Artery Shunt Research Articles

Comparative characteristics of minimally invasive and classical (median sternotomy) methods of coronary artery bypass grafting

Objective. To analyze the results and comparative characteristics of minimally invasive and classical coronary artery bypass grafting in multivessel coronary artery disease and the presence of critical stenosis. Materials and Methods. Over the past two years, the National Scientific Center of Surgery and Transplantation named after O. O. Shalimov performed mini­invasive coronary artery bypass grafting for multivessel lesions of the coronary arteries in 27 patients (group 1). The comparative study also included 27 patients operated on using the classical method (group 2). The average age of patients was (53.1 ± 3.9) years. There were 46 men (85.2%) and 8 women (14.8%). According to the main indicators, including the number of affected coronary arteries, age, physiological parameters, etc., the groups did not differ statistically significantly. The main methods of the study were coronary angiography, multislice computed tomography of the coronary arteries with 3D reconstruction of the architecture of the great vessels, chest and heart. Results. During the follow­up of patients in both groups for up to a year after the operation, no clinical manifestations of angina and heart failure were noted, which gives reason to state the good function of the shunts. Intra­ and postoperative complications in group 1 occurred in 2 patients: the need for conversion due to cardiac rhythm and hemodynamics (1) and repeated thoracotomy due to bleeding from the arterial shunt (1). In group 2, complications also occurred in 2 patients: sternal diastasis requiring sternoplasty (1) and surgical wound exudation requiring the installation of a vacuum device for 4 days with subsequent secondary suturing (1). Conclusions. Minimally invasive coronary artery bypass grafting is a safe method of myocardial revascularization in multivessel coronary artery disease and critical stenosis. The technique allows for rapid rehabilitation and shorter hospital stays, which is economically beneficial for the hospital. Minimally invasive coronary artery bypass grafting can be considered as an alternative to the classical method of coronary artery bypass grafting with midline sternotomy.

Current outcomes of systemic-to-pulmonary artery shunt in patients with biventricular circulation

ObjectiveThis study investigated the outcomes after systemic-to-pulmonary artery shunt (SPS) in patients with biventricular circulation. MethodsBetween January 2014 and June 2023, among 406 patients who underwent SPS, 223 patients pursuing biventricular repair were included. Primary outcome of interest was major adverse shunt-related event (MASE) which was defined as the composite of cardiopulmonary resuscitation, extracorporeal membrane oxygenation, and shunt-related intervention. ResultsThe median age and body weight were 30 days and 3.5 kg, respectively. Median ratio of shunt diameter to body weight (mm/kg) was 1.0. The origin of SPS was the subclavian artery in 118 (52.9%), and the innominate artery in 93 patients (41.7%). There were 4 early deaths (1.8%), all of which were preceded by in-hospital MASE resulting from pulmonary overcirculation. There were two interstage deaths (0.9%). Competing risk analysis showed that the probability of biventricular repair at 24 months after SPS was 94.2%. In-hospital MASE occurred in 17 patients, with most cases (n=14, 82.4%) resulting from pulmonary overcirculation. In multivariable analysis, associated genetic or extracardiac anomalies (odds ratio [OR] 4.78; p=0.019), transposition of the great arteries (OR 6.42; p=0.012) and use of cardiopulmonary bypass (OR 7.39; p=0.001) were identified as risk factors for in-hospital MASE. Among 10 cases of inter-stage MASE, 9 cases were successfully managed up to biventricular repair. ConclusionsIn the current era, SPS is a safe and useful option for patients with biventricular circulation. In patients with risk factors for in-hospital MASE, meticulous efforts should be directed towards preventing pulmonary overcirculation to further enhance outcomes.

Combined Norwood and Modified Left-Sided Starnes Procedures for Congenitally Corrected Transposition of the Great Arteries.

The combination of congenitally corrected transposition of the great arteries (ccTGA), Ebstein anomaly of the systemic atrioventricular valve, and critical systemic ventricular outflow tract obstruction is extremely rare. Management of a neonate with these lesions in cardiogenic shock is quite challenging. Tricuspid valve exclusion has been increasingly and successfully used to manage neonatal Ebstein anomaly patients. We extended this idea of tricuspid valve exclusion (modified Starnes) combined with a Norwood Stage 1 operation with a modified systemic to pulmonary artery shunt to successfully manage a neonate with ccTGA, severe systemic atrioventricular valve regurgitation, and critical ventricular outflow tract obstruction.

Consolidation in the right middle lobe in pediatric bronchial-pulmonary artery shunt: radiology's Aunt Minnie?

By retrospectively studying the chest computed tomography (CT) data of children with bronchial artery (BA)-pulmonary artery fistula, this study summarizes the characteristic imaging features of the disease and provides imaging support for the diagnosis and clinical treatment of these children. Digital subtraction angiography and CT angiography data were collected from 74 children with pulmonary hemorrhage following BA embolization. Bronchial-pulmonary shunt was present in 30 cases. Of the 74 children with pulmonary hemorrhage in this study, seven exhibited signs of consolidation in the middle lobe of the right lung, and bronchial-pulmonary shunt existed in all of them. A total of 30 children with BA-pulmonary artery shunt (PAS) had BA tortuosity and thickening. Regarding primary BA-PAS, the middle lobe and lower lobe of the right lung were involved in 94.1% (16) of the children. Those with a fistula located in the middle lobe of the right lung accounted for 58.8% (10 cases), of which 40.0% (four cases) presented consolidation. In this study, 41.2% (seven) of the children with primary BA-PAS exhibited no abnormal changes on chest CT, and 58.8% (10 cases) exhibited abnormal changes in the unilateral lung. For children with pulmonary hemorrhage who have consolidation in the right middle lobe, the formation of BA-PAS should be anticipated. The possibility of primary BA-PAS should not be disregarded in children with pulmonary hemorrhage with tortuosity and dilation of BAs, despite no apparent abnormalities on lung CT, or ground-glass density or consolidation on only one side. The chest CT of patients with pulmonary hemorrhage showed consolidation of the right middle lobe of the lung, which was highly likely to indicate BA-PAS.

Operations for increasing the pulmonary blood flow in newborns with cyanotic congenital heart defects: results and features of outpatient postoperative monitoring

Background. In patients with cyanotic congenital heart defects, pulmonary blood flow is maintained by a functio­ning patent ductus arteriosus (PDA). Most patients with complex ductal-dependent cyanotic defects require intermediate staged treatment before radical correction of the defect. Timely and comprehensive outpatient monitoring by a pediatrician and pediatric cardiologist are important for patient survival following palliative treatment, along with determining optimal timing for consultations at specialized cardiac surgical centers. Objective: to present the outcomes of using two methods for increasing pulmonary blood flow (systemic-to-pulmonary artery shunt (SPAS) and PDA sten­ting), as well as the features of outpatient cardiological observation and treatment in these patients. Materials and methods. From 2000 to February 2024, 22 patients underwent SPAS, and 25 — PDA stenting at the State Institution “Scientific and Practical Medical Center of Pediatric Cardiology and Cardiac Surgery” of the Ministry of Health of Ukraine. Results. After interventions, the mean arterial oxygen saturation (SatO2) increased in both groups, significantly higher in the PDA stenting group (p < 0.05). The ave­rage length of stay in the intensive care unit in the SPAS group was 19.6 ± 11.1 (range: 5 to 91) days compared to 12.8 ± 6.3 (range: 4 to 37) days in those with PDA stenting (p = 0.05). The duration of artificial lung ventilation in the SPAS group was 290.3 ± 215.3 (range: 63 to 751) hours, and in the PDA stenting group, it was shorter, 151.8 ± 75.5 (range: 39 to 549) hours (p < 0.05). Early (30-day) postoperative mortality in the SPAS group was 13.6 % (3/22 patients), with a late mortality of 18 % (4/22). In contrast, there was not early (30-day) postoperative mortality in the PDA stenting group, and late mortality was 8 % (2/25). Before the subsequent stage of surgical correction, sufficient growth of pulmonary artery branches was noted (Nakata index increased from 156.9 ± 33.3 mm2/m2 to 277.0 ± 35.9 mm2/m2 in the SPAS group and from 142.7 ± 55.2 mm2/m2 to 289.1 ± 149.2 mm2/m2 in the PDA stenting group), and the left ventricular end-diastolic index has increased (from 51.2 ± 32.4 mm2/m2 to 67.5 ± 15.5 mm2/m2 in the SPAS group and from 50.8 ± 24.9 mm2/m2 to 56.7 ± 28.5 mm2/m2 in the PDA stenting group). Thirteen patients in the SPAS group underwent the next stage of surgical correction (Glenn shunt or total repair of the congenital heart defect), while in the PDA stenting group — 17 patients. Conclusions. For cyanotic congenital heart defects, which have ductus-dependent pulmonary blood flow, both described methods are quite effective.

Effects of Dexmedetomidine in Improving Oxygenation and Reducing Pulmonary Shunt in High-Risk Pediatric Patients Undergoing One-Lung Ventilation for Thoracic Surgery: A Double-Blind Randomized Controlled Trial.

Background and objectives Pediatric thoracic surgery has unique considerations due to the immaturity of the respiratory system anatomically and physiologically, which presents technical and pharmacological considerations, including the very common technique of one-lung ventilation (OLV), which causes serious complications in children. Therefore, we investigated the effects of dexmedetomidine on oxygenation and pulmonary shunt fraction (Qs/Qt) in high-risk pediatric patients undergoing OLV for thoracic surgery. This randomized controlled trial aimed to investigate dexmedetomidine's effect on the partial pressure of arterial oxygen (PaO2) and pulmonary shunt fraction (Qs/Qt). Methods A total of 63 children underwent thoracic surgery with OLV and were divided into two groups. The dexmedetomidine group (group Dex, n = 32) received dexmedetomidine (0.4 μg/kg/hour), and the placebo group (group placebo, n = 31) received normal saline. Two arterial and central venous blood samples were taken for arterial and venous blood gas analysis at four time points: T1 (10 minutes after mechanical ventilation of total lung ventilation), T2 (10 minutes after OLV), T3 (60 minutes after OLV), and T4 (20 minutes after the end of OLV). At these intervals, the following parameters were measured: PaO2, Qs/Qt, mean arterial pressure (MAP), heart rate (HR), and peak inspiratory pressure (PIP). Results The two groups had no significant differences in FEV1/FVC and baseline pulmonary shunt fraction (Qs/Qt). Dexmedetomidine significantly improved PaO2 compared with placebo during OLV (T2 and T3). There was a significant decrease in Qs/Qt compared with placebo during OLV (T2, T3, and T4). There was a decrease in PIP compared with placebo during OLV (T2 and T3). No statistically significant differences in MAP or HR were observed between the groups. Conclusion Infusion of dexmedetomidine during OLV in high-risk pediatric thoracic surgery reduces shunt and pulmonary shunt fraction Qs/Qt, improves PaO2 and body oxygenation, reduces PIP and pressure load, and maintains hemodynamic stability (MAP, HR).

Optimal Shunt Type for Norwood Procedure: Predicted Adverse Impact of Discordant Surgical Approach

BackgroundThe Single Ventricle Reconstruction (SVR) trial compared survival after Norwood procedure with either modified Blalock Taussig shunt (MBTS) or right ventricle pulmonary artery shunt (RVPAS). MethodsData from all 549 participants in the SVR trial were used to develop the MBTS TFSA algorithms, which predict the transplantation-free survival advantage (TFSA) after MBTS vs RVPAS at 1 and 6 years after Norwood procedure. Linear regression analysis of the MBTS TFSA values was performed to identify factors related to more optimal outcomes with MBTS at each timepoint. The impact of discordant management (ie, predicted shunt type did not equal the one actually received) on outcomes and the extent of inconsistencies between predictions were evaluated. ResultsThe MBTS TFSA algorithm favored MBTS over RVPAS for only 6.2% of participants at 1 year and for 27.0% at 6 years. In terms of both 1- and 6-year outcomes, MBTS was favored with younger age at Norwood procedure and pre-Norwood intubation, while RVPAS was favored with younger gestational age and metrics indicating larger right ventricle size in the parasternal echocardiographic views. Other predictors were timepoint-specific. MBTS TFSA based allocation could have led to an absolute risk reduction in heart transplantation and mortality of 8.0% at 1 year and 16.8% at 6 years, mostly by preventing discordant MBTS management. Notably, separate predictions from the 1-year and 6-year algorithms produced discordant predictions for 136 participants (24.8%). ConclusionsThe incorporation of data-derived patient-specific factors for selection of shunt type for the Norwood procedure may produce more optimal transplantation free survival. These precision medicine algorithms require prospective validation.

Elective open repair with the debranch, perfuse, reconstruct technique to treat suprarenal or type IV thoracoabdominal aortic aneurysms

BackgroundOpen surgical repair of suprarenal abdominal aortic aneurysm (SRAAA) and type IV thoracoabdominal aortic aneurysm (TAAA) remains a surgical challenge because of the inducted intraoperative visceral and renal ischemia. We report a novel three-step technique named debranch, perfuse, reconstruct (DPR), using debranching and passive arterial shunt to decrease these ischemic complications. The main aim of this study was to evaluate the 30-day and 1-year mortality rates associated with these DPR technique. The secondary aim was to evaluate the impact on renal function and the primary patency of the repaired arteries. MethodsThis retrospective study included all consecutive patients who underwent elective surgery for SRAAA or type IV TAAA using the DPR technique between January 2011 and June 2022. In debranching, using partial side clamping, a multibranch graft was implanted side-to-end into the descending thoracic aorta. The left renal artery was anastomosed end-to-end to the graft. As needed, the superior mesenteric artery (SMA), the celiac trunk, and the right renal artery could also be anastomosed to the graft. In the perfusion step, cannulas were connected to the last branch of the multibranch graft to perfuse other arteries during aortic cross-clamping. For repair, a tube or bifurcated graft was used for the aortic repair. The branch used as a passive temporary arterial shunt was ligated at the end of the intervention. Clinical, radiological, and biological preoperative and postoperative factors were reviewed using a standardized database. Procedural complications and reinterventions were analyzed, as well as artery patency. ResultsThere were 40 patients who underwent DPR technique. The mean patient age was 67 ± 13 years and two were women. Twenty-three patients presented with a SRAAA and 17 with a type IV TAAA. The 30-day and 1-year mortality rates were 2.5% (one patient). Two respiratory complications (5%) and three mesenteric ischemic complications (7%) have been recorded. No patient developed signs of cardiac or spinal cord dysfunction. We did not observe a significant change in postoperative renal function. The celiac trunk, superior mesenteric artery, left renal artery, and right renal artery bypass patency rates at 1 year were 95%, 100%, 90%, and 100%, respectively. ConclusionsThe SRAAA and type IV TAAA repair with DPR technique provides short visceral and renal ischemia times with a low mortality rate. This technique could be an option to consider for visceral and renal protection during open surgical repair.

Comparison of Blalock-Taussig-Thomas Shunts With Patent Ductus Arteriosus Ligated Versus Left Open.

The optimal approach to patent ductus arteriosus management during systemic-to-pulmonary artery shunt placement is currently unknown. The purpose of this study is to examine the outcomes of variable strategies for patent ductus arteriosus management during Blalock-Taussig-Thomas shunt surgery. A retrospective cohort study of infants who underwent shunt placement was performed, comparing those who had the ductus ligated with those who had the ductus left open. Indicators of low cardiac output syndrome, development of necrotizing enterocolitis, and secondary outcomes such as resuscitation events were examined. Thirty-six infants were included all of whom had their shunt placed via median sternotomy. Twenty infants had their ductus ligated at the time of the shunt, and they were compared with 16 infants whose ductus was left open. There was no statistical difference in preoperative baseline characteristics, including corrected gestational age, age in days, weight, mechanical ventilation, vasoactive use, heterotaxy, and gastrointestinal anomalies. There was also no statistical difference in postoperative indicators of low cardiac output, including urine production, total fluids given, renal injury, maximum lactate, and vasoactive-inotropic score. Three patients had postoperative renal injury, and all were in the ligated duct group. There was also no statistical difference in any secondary outcomes, including the development of necrotizing eneterocolitis, resuscitation events, reinterventions, length of intubation, total length of stay, and mortality. This study provides evidence that variable management of the ductus during shunt placement does not significantly impact outcomes. Leaving the ductus open allows for a potential rescue source of pulmonary blood flow and does not appear to increase the risk of postoperative low cardiac output.

Pulmonary Flow Management by Combination Therapy of Hemostatic Clipping and Balloon Angioplasty for Right Ventricular-Pulmonary Artery Shunt in Hypoplastic Left Heart Syndrome.

Controlling pulmonary blood flow in patients who have undergone Norwood palliation, especially early postoperatively, is challenging due to a change in the balance of systemic and pulmonary vascular resistance. We applied a combination therapy of clipping and balloon angioplasty for right ventricle-pulmonary artery (RV-PA) shunt to control pulmonary blood flow, but the influence of the combination therapy on the PA condition is uncertain. Retrospectively analysis was conducted of all infants with hypoplastic left heart syndrome who had undergone Norwood palliation with RV-PA shunt at Okayama University Hospital from January 2008 to September 2022. A total of 50 consecutive patients underwent Norwood palliation with RV-PA shunt in this study period. Of them, 29 patients underwent RV-PA shunt flow clipping, and the remaining 21 had unclipped RV-PA shunt. Twenty-three patients underwent balloon angioplasty for RV-PA shunt with clips. After balloon angioplasty, oxygen saturation significantly increased from 69 (59-76)% to 80 (72-86)% (p < 0.001), and the narrowest portion of the clipped conduit significantly improved from 2.8 (1.8-3.4) to 3.8 (2.9-4.6) mm (p < 0.001). In cardiac catheterizations prior to Bidirectional cavo-pulmonary shunt (BCPS), there were no significant differences in pulmonary-to-systemic flow ratio (Qp/Qs), ventricular end-diastolic pressure, Nakata index, arterial saturation, mean pulmonary artery pressure and pulmonary vascular resistance index. On the other hand, in Cardiac catheterizations prior to Fontan, Nakata index was larger in the clipped group (p = 0.02). There was no statistically significant difference in the 5-year survival between the two groups (clipped group 96%, unclipped group 74%, log-rank test: p = 0.13). At least, our combination therapy of clipping and balloon angioplasty for RV-PA shunt did not negatively impact PA growth. Although there is a trend toward better but not statistically significant difference in outcomes in the clipped group compared to the non-clipped group, this treatment strategy may play an important role in improving outcomes in hypoplastic left heart syndrome.

Autonomous Fontan pump: Computational feasibility study

ObjectiveAfter Fontan palliation, patients with single-ventricle physiology are committed to chronic circulatory inefficiency for the duration of their lives. This is due in large part to the lack of a subpulmonary ventricle. A low-pressure rise cavopulmonary assist device can address the subpulmonary deficit and offset the Fontan paradox. We investigated the feasibility of a Fontan pump that is self-powered by tapping reserve pressure energy in the systemic arterial circulation. MethodsA double-inlet, double-outlet rotary pump was designed to augment Fontan flow through the total cavopulmonary connection. Pump power is supplied by a systemic arterial shunt and radial turbine, with a closed-loop shunt return to the common atrium (QP:QS 1:1). Computational fluid dynamic analysis and lumped parameter modeling of pump impact on the Fontan circulation was performed. ResultsFindings indicate that a pump that can augment all 4 limbs of total cavopulmonary connection flow (superior vena cava/inferior vena cava inflow; left pulmonary artery/right pulmonary artery outflow) using a systemic arterial shunt powered turbine at a predicted cavopulmonary pressure rise of +2.5 mm Hg. Systemic shunt flow is 1.43 lumped parameter model, 22% cardiac output. Systemic venous pressure is reduced by 1.4 mm Hg with improved ventricular preload and cardiac output. ConclusionsIt may be possible to tap reserve pressure energy in the systemic circulation to improve Fontan circulatory efficiency. Further studies are warranted to optimize, fabricate, and test pump designs for hydraulic performance and hemocompatibility. Potential benefits of an autonomous Fontan pump include durable physiologic shift toward biventricular health, freedom from external power, autoregulating function and exercise responsiveness, and improved quality and duration of life.

PATENT DUCTUS ARTERIOSUS STENTING IN NEWBORNS AND INFANTS WITH CYANOTIC CONGENITAL HEART DEFECTS: EXPERIENCE AND OUTCOMES

Background. Among all congenital heart defects (CHD), one-third are cyanotic defects with duct-dependent pulmonary blood flow. Palliative interventions are necessary for children with complex cyanotic CHD, premature infants, and children with complex comorbidities. Ensuring a reliable source of pulmonary blood flow adequate for arterial oxygenation and native pulmonary artery branches growth are the primary goals of staged interventions. The classic approach to providing adequate pulmonary blood flow before total repair is systemic-to-pulmonary artery shunting. Currently, there is a growing trend towards the use of an alternative method - transcatheter patent ductus arteriosus (PDA) stenting. Aim: Demonstrate the experience of PDA stenting, immediate and long-term outcomes in newborns and infants. Materials and Methods. From 2009 to April 2024, PDA stenting was performed in 66 patients at the UCC. Among the all cohort, 49 (74.2%) were newborns (Group I), and 17 (25.7%) were infants (Group II). The average age was: Group I - 7.4±5.9 days (range 1 to 28 days), and Group II - 105.2±54.78 days (range 42 to 280 days). The average weight was: Group I - 3.0±0.49 kg (range 1.9 to 4.4 kg), and Group II - 5.2±1.4 kg (range 2.7 to 9 kg). This study analyzed pre-, intra-, and postoperative parameters including age, weight, presence of concomitant/genetic pathology, saturation level, pulmonary artery branches diameter, Nakata index, PDAs size, origin and type, duration of staying in the intensive care unit, duration of artificial lung ventilation and inotropic support, early and late postoperative complications, 30-day and inter-stage mortality rates in the two patient groups. Results. All cases of transcatheter stent implantation were performed by transfemoral access. The average ICU stay duration for Group I was 13.8±9.52 days (range 2 to 119 days), and for Group II was 6.4±3.64 days (range 2 to 20 days). The duration of artificial lung ventilation in Group I was 185.8±165.28 hours (range 2 to 2066 hours), and in Group II was 67.5±46.15 hours (range 4 to 248 hours). Inotropic support - on average for Group I - 151.6±81.06 hours (range 0 to 720 hours), and for Group II - 82.4±47 hours (range 0 to 211 hours). Saturation increased from an average of 65.7±11.03% to 85.2±5.7% in Group I (p&lt;0.05), and from 66.8±10.9% to 87.4±4.24% in Group II (p&lt;0.05). Early postoperative complications were observed in 34.6% (17/49) of Group I patients and 23.5% (4/17) of Group II patients. The early 30-day mortality rate was 8.1% (4/49) for Group I. The next stage of surgical treatment wasperformed on average after 12.9±10.2 months by 51% (25/49) of Group I patients and by 88% (15/17) of Group II patients, on average after 14.98±12 months post-stenting. The interstage (late) mortality rate was 6.1% (3/49) for Group I and 5.8% (1/17) for Group II. Conclusion. Considering the outcomes after PDA stenting in our cohort of patients, this procedure appears to be an effective operation for providing a reliable source of pulmonary blood flow in various anatomical variants of cyanotic CHD in both newborns and infants.

Experience of Performing Systemic-to-Pulmonary Artery Shunt in Patients with Univentricular Heart Physiology and Depleted Pulmonary Blood Flow

Among patients with congenital heart disease diagnosed in infancy, 7.7% of infants have anatomical variants with functional single ventricle physiology which is often accompanied by depleted pulmonary blood flow. The type of these defects is clinically associated with cyanosis, in most cases caused not by mixing of blood at the level of the heart chambers, but by the presence of ductal-dependent pulmonary blood flow, which requires urgent surgical intervention. The aim. To evaluate the immediate and long-term outcomes of hemodynamic correction in patients with single-ventricle heart physiology with depleted pulmonary blood flow. Materials and methods. In the period from 2010 to 2022, 114 patients with reduced pulmonary blood flow underwent systemic-pulmonary anastomosis at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. Among these, 64 patients had biventricular circulation and subsequently underwent radical correction. The other 50 patients had single-ventricular heart physiology and underwent placement of systemic-pulmonary anastomosis as the first stage of the hemodynamic strategy according to Fontaine, so their data became the main material of this study. Results. Hospital mortality after systemic-pulmonary anastomosis was 8% (4 patients). An uncomplicated course of the early postoperative period was observed in 38 (76%) patients, and 16 complications were observed in the remaining 12 (24%) patients. The median follow-up period was 40 [3; 160] months. During the follow-up period, 2 (4.3%) patients died due to anastomosis thrombosis as a result of self-discontinuation of anticoagulant therapy, 3 (6.5%) patients were lost to follow-up and did not come for examination. The second stage of hemodynamic correction in the form of bidirectional cavopulmonary anastomosis was performed in 41 (82%) patients of the study group. Conclusions. Patients with single-ventricular heart physiology with depleted pulmonary blood flow are a group of extremely complex children who require an individual approach at all stages of hemodynamic correction, and early diagnosis and palliative systemic-pulmonary anastomosis continues to be a reliable alternative for these children, despite the fact that mortality after the first stage remains quite high.

Comparison of Ductal Stent Versus Surgical Shunt as Initial Intervention for Neonates with Pulmonary Atresia with Intact Ventricular Septum.

Data comparing surgical systemic-to-pulmonary artery shunt and patent ductus arteriosus (PDA) stent as the initial palliation procedure for patients with pulmonary atresia with intact ventricular septum (PA-IVS) are limited. We sought to compare characteristics and outcomes in a multicenter cohort of patients with PA-IVS undergoing surgical shunts versus PDA stents. We retrospectively reviewed neonates with PA-IVS from 2009 to 2019 in 19 United States centers. Bivariate comparisons and multivariable logistic regression analysis were performed to determine the relationship between initial palliation strategy and outcomes including major adverse cardiovascular events (MACE): stroke, mechanical circulatory support, cardiac arrest, or death. Included were 187 patients were included: 38 PDA stents and 149 surgical shunts. Baseline characteristics did not differ statistically between groups. Post-procedural MACE occurred in 4 patients (11%) with PDA stents versus 38 (26%) with surgical shunts, p = 0.079. Overall, the initial palliation strategy was not significantly associated with MACE (aOR:0.37; 95% CI,0.13-1.02). In patients with moderate-to-severe right ventricle hypoplasia, PDA stents were significantly associated with decreased odds of MACE (aOR:0.36; 95% CI,0.13-0.99). PDA stents were associated with lower vasoactive inotrope scores (median 0 versus 5, p < 0.001), greater likelihood to be extubated at the end of their procedure (37% versus 4%, p < 0.001), and shorter duration of mechanical ventilation (median 24 versus 96h, p < 0.001). PDA stents were associated with significantly more unplanned reinterventions for hypoxemia compared to surgical shunts (42% vs. 20%, p = 0.009). In this multicenter study, neonates with PA-IVS who underwent PDA stenting received less vasoactive and ventilatory support postoperatively compared to those who had surgical shunts. Furthermore, patients with the most severe morphology had decreased odds of MACE.

PULMONARY HYPERTENSION AND CONGENITAL HEART DISEASE: THE CLINIC BEYOND THE EVIDENCE

Abstract Eisenmenger syndrome (ES), first described by Victor Eisenmenger, was defined by Paul Wood in pathophysiologic terms as “pulmonary hypertension (PH) at systemic level, caused by a high pulmonary vascular resistance (PVR), with reversed or bidirectional shunt at aorto–pulmonary, ventricular, or atrial level.” It represents the most severe hemodynamic phenotype of pulmonary arterial hypertension (PAH) in association with congenital heart disease (CHD) and develops in the presence of large, unrepaired atrial or ventricular septal defects, arterial shunts, or complex forms of CHD. Although therapeutic management has rapidly advanced in recent years, these patients were not included in randomized controlled trials for specific pulmonary arterial hypertension drugs, except for bosentan. However, in clinical practice we apply treatment strategies combining drugs targeting multiple pathobiological pathways. The clinical case we describe is that of a 44–year–old patient, suffering from Down syndrome, with ES due to subaortic VSD and a a patency of Botallo duct, followed in our PH clinic of the "Ruggi D‘Aragona" University Hospital for about 9 years. The patient, on dual therapy with Macitentan 10 mg and Sildenafil 60 mg, was in the intermediate–high risk class, stationary. During the last two checks, there was a progressive worsening of the hemodynamic parameters, walking distance of only 100 meters, with SpO2 at baseline 90% and desaturation during the 6mwt. On cardiac color Doppler ultrasound evidence of TAPSE 18 mm, PAPS 100 mmHg, RAA 20 cm²; TAPSE/PAPS 0.18. The patient presented in WHO class 3. The only RCTs currently available concern the use of bosentan, but in clinical practice, initial monotherapy with an endothelin receptor antagonist or a phosphodiesterase type 5 inhibitor for symptomatic patients is proposed. Reassess and consider escalation to a double combination therapy in case of clinical worsening or inadequate clinical response. Consider uptitration with the addition of prostanoids when inadequate response and timely assess the eligibility for transplantation. For our patient therefore, in consideration of the impossibility of surgery, although there is little evidence on prospective observational studies based on cohorts of a few patients, we added selexipag 200 ug x 2/day to titrate therapy.This case opens the door to still unclear scenarios in which unfortunately the only weapon available remains the clinician‘s judgment and experience.

The American Association for Thoracic Surgery (AATS) 2024 expert consensus document: Management of neonates and infants with Ebstein anomaly

ObjectivesSymptomatic neonates and infants with Ebstein anomaly (EA) require complex management. A group of experts was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic focusing on risk stratification and management. MethodsThe EA Clinical Congenital Practice Standards Committee is a multinational and multidisciplinary group of surgeons and cardiologists with expertise in EA. A citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to EA. The search was restricted to the English language and the year 2000 or later and yielded 455 results, of which 71 were related to neonates and infants. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of members votes with at least 75% agreement on each statement. ResultsWhen evaluating fetuses with EA, those with severe cardiomegaly, retrograde or bidirectional shunt at the ductal level, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or fetal hydrops should be considered high risk for intrauterine demise and postnatal morbidity and mortality. Neonates with EA and severe cardiomegaly, prematurity (<32 weeks), intrauterine growth restriction, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or cardiogenic shock should be considered high risk for morbidity and mortality. Hemodynamically unstable neonates with a circular shunt should have emergent interruption of the circular shunt. Neonates in refractory cardiogenic shock may be palliated with the Starnes procedure. Children may be assessed for later biventricular repair after the Starnes procedure. Neonates without high-risk features of EA may be monitored for spontaneous closure of the patent ductus arteriosus (PDA). Hemodynamically stable neonates with significant pulmonary regurgitation at risk for circular shunt with normal right ventricular systolic pressure should have an attempt at medical closure of the PDA. A medical trial of PDA closure in neonates with functional pulmonary atresia and normal right ventricular systolic pressure (>20-25 mm Hg) should be performed. Neonates who are hemodynamically stable without pulmonary regurgitation but inadequate antegrade pulmonary blood flow may be considered for a PDA stent or systemic to pulmonary artery shunt. ConclusionsRisk stratification is essential in neonates and infants with EA. Palliative comfort care may be reasonable in neonates with associated risk factors that may include prematurity, genetic syndromes, other major medical comorbidities, ventricular dysfunction, or sepsis. Neonates who are unstable with a circular shunt should have emergent interruption of the circular shunt. Neonates who are unstable are most commonly palliated with the Starnes procedure. Neonates who are stable should undergo ductal closure. Neonates who are stable with inadequate pulmonary flow may have ductal stenting or a systemic-to-pulmonary artery shunt. Subsequent procedures after Starnes palliation include either single-ventricle palliation or biventricular repair strategies.

Surgical outcomes of the systemic-to-pulmonary artery shunt: risk factors of post-operative acute events and effectiveness of regulation of pulmonary blood flow with metal clips.

The aim of this study was to analyze the risk factors for acute events after systemic-to-pulmonary shunt (SPS) and to investigate the effectiveness of pulmonary blood flow regulation with a metal clip. The case histories of 116 patients (78 biventricular [BV] and 38 single ventricle [SV] physiology) who underwent SPS between 2010 and 2021 were retrospectively reviewed. Our strategy was to delay SPS until 1month of age; pulmonary blood flow (PBF) regulation by partial clipping of the graft, if needed. Cases of aortic cross-clamping were excluded from this study. CPB was used in 49 (42%) patients: the median age at SPS was 1month (2days to 16years), and the sternotomy approach in 65. Discharge survival was 98.3% (114/116); hospital death occurred in 1.7% due to coronary ischemia. Inter-stage mortality occurred in 1.7% (shunt thrombosis, 1; pneumonia, 1). Pre-discharge acute events occurred in 7 patients (6.0%): thrombosis 3, pulmonary over-circulation 2, and coronary ischemia 2. Multiple logistic regression analysis revealed that pulmonary atresia with intact ventricular septum (PA/IVS) (p = 0.0253) was an independent risk factor for acute events. Partial clipping of the graft was performed in 24 patients (pulmonary atresia 15) and clip removal was performed by catheter intervention in 9 patients; no coronary ischemic events and graft injury occurred in these patients. Surgical outcomes after SPS were acceptable and metal clip regulation of pulmonary blood flow appears to be safe and effective. PA/IVS was still a significant risk factor for acute events.

More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury.

Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.

Continuous positive airway pressure combined with small-tidal-volume ventilation on arterial oxygenation and pulmonary shunt during one-lung ventilation in patients undergoing video-assisted thoracoscopic lobectomy: A randomized, controlled study.

One-lung ventilation (OLV) is frequently applied during video-assisted thoracoscopic surgery (VATS) airway management to collapse and isolate the nondependent lung (NL). OLV can give rise to hypoxemia as a result of the pulmonary shunting produced. Our study aimed to assess the influence of continuous positive airway pressure (CPAP) combined with small-tidal-volume ventilation on improving arterial oxygenation and decreasing pulmonary shunt rate (QS/QT) without compromising surgical field exposure during OLV. Forty-eight patients undergoing scheduled VATS lobectomy were enrolled in this research and allocated into three groups at random: C group (conventional ventilation, no NL ventilation intervention was performed), LP group (NL was ventilated with lower CPAP [2 cmH2O] and a 40-60 mL tidal volume [TV]), and HP group (NL was ventilated with higher CPAP [5 cmH2O] and a 60-80 mL TV). Record the blood gas analysis data and calculate the QS/QT at the following time: at the beginning of the OLV (T0), 30 min after OLV (T1), and 60 min after OLV (T2). Surgeons blinded to ventilation techniques were invited to evaluate the surgical fields. The demography data of the three groups were consistent with the surgical data. At T1, PaO2 in the HP group was substantially higher compared to the C group (P < 0.05), while there was no significant difference in the LP group (P > 0.05). At T1-T2, PaCO2 in the LP and HP groups was significantly less than that in the C group (P < 0.05). At T1, the QS/QT values of groups C, LP, and HP were 29.54 ± 6.89%, 22.66 ± 2.08%, and 19.64 ± 5.76%, respectively, and the QS/QT values in the LP and HP groups markedly reduced (P < 0.01). The surgical field's evaluation by the surgeon among the three groups was not notable (P > 0.05). CPAP combined with small-tidal-volume ventilation effectively improved arterial oxygenation and reduced QS/QT and PaCO2 without compromising surgical field exposure during OLV. Among them, 5 cmH2O CPAP + 60-80 ml TV ventilation had a better effect on improving oxygenation.

Anesthesia Management in Blalock-Taussig Shunt Procedure

Background: The systemic to pulmonary artery shunts are done as palliative procedures for complex cyanotic congenital heart diseases. Blalock-Taussig shunt (BT shunt) provide regulated blood flow to the lungs allowing growth of pulmonary arteries until the patient reaches proper age and body weight suitable for definitive corrective repair. BT shunts are first line management in patients with critical cyanotic conditions.Case: A 12-month-old boy diagnosed with PA-VSD subaortic, L-R shunt PDA and critical PDA stenosis experienced a recurrent spell condition with the lowest oxygen saturation 40%, underwent urgent BT shunt surgery. Oxygen saturation increases to 80-85% after shunt procedure.Discussion: Anesthesia management includes optimizing preoperative condition and patient hydration state, providing balance anesthesia during surgery, maintaining balance of pulmonary and systemic blood flow. High oxygen fraction can be given to maintain oxygen saturation before BT shunt anastomosis. Mechanical ventilation, heart rate with sinus rhythm, preload and contractility is maintained to obtain normal cardiac output. After BT shunt anastomosis, the oxygen fraction is reduced with a saturation target of 70–85%. Postoperative management includes anticoagulant administration and monitoring postoperative complications. The patient developed complications of increased pulmonary blood flow postoperatively and was admitted to the PICU for 3 days. The patient was discharged in good condition from ward on day 7.Conclusion: Understanding the physiology of heart defects and perioperative management determine the success of BT shunt surgery, reducing patient morbidity and mortality. Optimizing intraoperative and postoperative oxygen delivery with oxygenation targets PaO2 40-45 mmHg and saturation 70-80% reflects the balance of pulmonary blood flow and systemic blood flow (Qp:Qs=0.7-1.5:1).