Atrial Septal Defect Repair Research Articles

Heart rate variability is markedly abnormal following surgical repair of atrial and ventricular septal defects in pediatric patients

BackgroundAbnormalities in heart rate variability (HRV) have been associated with increased morbidity and mortality. Adults with a history of successful correction of atrial septal defects (ASDs) and ventricular septal defects (VSDs) have clinically relevant abnormalities in HRV. The etiology of these abnormalities is unknown as is when they occur in the natural history of these lesions. We sought to determine whether the abnormalities described in adult patients are identifiable in pediatric patients. Materials and methodsEighty-five ASD patients, 105 VSD patients, and 142 non-cardiac surgical comparison patients aged 0–18 years were studied during post-operative admission to the critical care unit using continuously monitored bedside electrocardiographic (ECG) data. ResultsASD and VSD patients had statistically significantly lower time-domain heart rate variability parameters, i.e., standard deviation of NN interval duration, and lower frequency-domain heart rate variability parameters, i.e., power in the high frequency band and power in the low frequency band, compared to the comparison cohort. The lower frequency band to high frequency band power ratio was lower in ASD patients and higher in VSD patients compared to the comparison cohort. The abnormalities identified correlate well with patterns described in adult patients. ConclusionPost-surgical ASD and VSD patients have markedly abnormal heart rate variability patterns indicative of reduced parasympathetic activity and predominance of sympathetic activity. The HRV abnormalities described in adult patients are identifiable as early as the postoperative period in childhood. This finding warrants prospective study to identify drivers of this phenomenon.

Successful aspiration thrombectomy of large right atrial thrombus attached to atrial septal defect repair patch

Successful aspiration thrombectomy of large right atrial thrombus attached to atrial septal defect repair patch

Surgical Repair of Atrial Septal Defect and Lung Lobe Resection for Pulmonary Sequestration and Cystic Malformation in One Stage: A Case Report

Incidence of congenital cystic malformation of lungs ranges from 1 in 11,000 to 1 in 35,000 live birth. Concurrence of Congenital Pulmonary Airway Malformation (CPAM) with congenital heart disease is even infrequent. Even rarer, is the incidence of congenital pulmonary vascular and cystic parenchymal lesions with cardiac defects. The non functioning lung tissue is separated from bronchial tree and vascularised by aberrant artery from the systemic circulation. Simultaneous repair of cardiac and pulmonary defects, though challenging, but are preferable because of surgery being done in single stage with better cosmesis. A 10-yearold female child presented to the hospital with recurrent chest infections and respiratory distress while running since five years of age. The patient underwent atrial septal defect closure and right lower lobectomy for CPAM in one stage through midline sternotomy. We conclude that such complex cases can be managed successfully with meticulous planning and multidisciplinary team approach.

Groin Complications After Femoral Artery Cannulation in Minimally Invasive Cardiac Surgery

Background: Femoral cannulation is commonly used during minimally invasive cardiac surgery. We evaluated the occurrence of postoperative groin complications after femoral cannulation in minimally invasive cardiac surgery.
 Methods: This retrospective study included 140 patients who had minimally invasive surgery with femoral cannulation. One hundred twelve patients (80%) had mitral valve surgery, 24 patients (17.1%) had atrial septal defect repair, and four patients (2.9%) had myxoma excision. Their mean age was 41.47± 11.71 years, and 60% were females (n= 84).
 Results: Groin complications occurred in 14 patients (10%); seroma developed in 11 patients (7.9%), two had femoral artery hematoma (1.4%), and 1 (0.7%) patient had femoral arterial dissection, which was primarily repaired. There were no differences in the preoperative data between patients with and without groin complications. Patients with groin complications had non-significantly longer cardiopulmonary bypass time (155± 43.6 vs. 129.8± 35.7 min, P= 0.2) and longer hospital stay (13±3.8 vs. 11.6±4.3 days, P= 0.2)
 Conclusions: Groin complications are relatively uncommon in minimally invasive procedures and are usually simple to manage.

Abstract 13987: Efficacy and Safety of Surgical Repair of Atrial Septal Defect in Asymptomatic Children Less Than 3 Years of Age

Background: Elective surgical closure of atrial septal defect (ASD) in asymptomatic children is commonly performed at 3 to 6 years of age when catheter-guided closure is not feasible. However, a recommended timing of surgical closure is not based on recent evidence. Hypothesis: Surgical ASD closure can be done safely in any age group. Methods: Asymptomatic patients with surgically closed isolated ASDs who were not indicated for catheter-guided closure in our cardiac center from 2002 to 2019 were studied. The patients were divided into 4 groups based on the age at surgery (<3 years, ≥3 to <6 years, ≥ 6 to >10 years, and ≥ 10 years). Demographic data, type of ASD, cardiopulmonary bypass time (CPBT), intensive care unit (ICU) stay, total hospitalization days, post-operative adverse events, and readmission rate were studied. Effects of creation of pericardial window (PW) was also examined. Data are shown as mean ± standard deviation. Results: Total 163 patients were studied (Table). There was no statistically significant difference in CPBT, ICU stay, or total hospitalization days among the 4 groups. There were no mortalities. Incidence of adverse events during hospitalization was low in < 6 years (1.9 to 4.2%) but higher in older ages (10.8 to 13.5%). Readmission rate was higher in younger groups: 18.6% in < 3 years old, 13.2% in ≥ 3 and < 6 years old, 8.0% in ≥ 6 and < 10 years, and 10.8% in ≥ 10 years, which was mainly due to pericardial effusion (PE). Total 18 patients developed PE postoperatively, 14 of whom were readmitted for treatment. With the creation of PW at the time of initial surgery, the incidence of PE and readmission rate were significantly reduced compared with without PW, especially in younger children. There was no complication due to PW. Conclusion: Surgical ASD closure can be performed safely even in younger children with ages <3 years, especially with creation of PW. Routine application of PW markedly reduced postoperative adverse events in surgical ASD closure.

Comparison of the safety and efficacy between minimally invasive cardiac surgery and median sternotomy in a low-risk mixed Asian population in Singapore.

Minimally invasive cardiac surgery (MICS) has attracted increasing attention, with institutions increasingly adopting this approach over conventional median sternotomy (MS). This study aimed to describe the outcomes of minimally invasive cardiac surgery in our institution as the only centre with an established MICS programme in Singapore. Patients who had undergone cardiac procedures such as heart valve replacement or repair, coronary artery bypass grafting or atrial septal defect repair were included in the study. We analysed 4063 patients who had undergone MS and 390 patients who had undergone MICS between January 2009 and February 2020. Over the years, the number of MICS procedures performed increased, along with an increase in MICS operations with two or more concomitant cardiac procedures and a decrease in postoperative length of stay. Compared with patients who underwent MS, those who underwent MICS had shorter length of postoperative hospital stay (P < 0.001). On multivariate analysis, patients who underwent MICS had lower rates of atrial fibrillation (P = 0.021), reoperation (P = 0.028) and prolonged ventilation (P < 0.001). However, the rates of other postoperative complications were comparable between patients who underwent MICS and those who underwent MS. In our institution, MICS is a safe, reproducible and efficacious technique that yields superior outcomes compared with conventional MS procedures, in some aspects. The results of this study provide further evidence and support towards adopting the minimally invasive approach to cardiac surgery in a carefully selected group of cardiac patients in Singapore.

A single center experience with minimally invasive approaches in congenital cardiac surgery.

BackgroundCardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved.MethodsWe performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range).ResultsBetween September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14–47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7–37.8) than those who were not (24.2, 20.8–29.3) (P=0.009).ConclusionsMinimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.

Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

BackgroundTo compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs).MethodsThe PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates.ResultsA total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001).ConclusionsIn the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

Experience of Minimal Invasive Cardiac Surgery for repair of Atrial Septal Defects- A Single Center Study

Background: Atrial Septal Defects (ASD) can be closed surgically using conventional midline sternotomy or minimal invasive technique. This study was done to evaluate the outcome and safety of the minimal invasive cardiac surgical (MICS) approach using right vertical infra axillary incision (RVAI) for the repair of ASD. Methods: We performed a prospective observational cross-sectional analysis on 50 patients who were diagnosed as ASD of various types and not amenable to device closure. Their surgery was done RVAI using central cardiopulmonary bypass. Outcome of the study was evaluated using the following variables: length of the incision, satisfaction of patients, mortality, infection of surgical site, blood transfusion, duration of total operation, intensive care unit (ICU) stay, mechanical ventilation, hospital stay and aortic occlusion. Operations were done between December 2013 to December 2020. All the recruited patients were treated through RVAI as per patient’s choice. Results: Mean age was 11.4± 6.4 years. 18(36%) were male and 32(64%) were female. Body weight ranged from 10 to 65 kg. Mean length of incision was 6.2±0.8 cm. Mean aortic occlusion time was 42±14 min. ASD closed directly, using autologous treated pericardial patch or dacron patch. Mean total operation time was 4.08±0.6 hours and mean mechanical ventilation time was 8.3±5 hours. Average ICU stay was 35.6±6 hours and total hospital stay was 7.2±0.9 days. There was no significant blood loss. Only 10 patients required intravenous (IV) analgesics in the post-operative period. One patient required re-exploration, one conversion to median sternotomy and one suffered from superficial skin infection. There were no operative or late mortalities. Patient satisfaction was excellent. Conclusions: MICS technique using RVAI for surgical repair of ASD revealed a safe procedure and could be performed with excellent cosmetic and clinical outcomes. It provided a good alternative to the standard median sternotomy. Cardiovasc j 2021; 14(1): 37-43

Sinus venosus atrial septal defect in adults: Where we are and where we go? Initial experience of percutaneous repair

Percutaneous repair of sinus venosus atrial septal defect (SV ASD) has emerged with promising preliminary results. We sought to expose the modified management strategy for this pathology in our tertiary center. Since March 2020, date of the first percutaneous procedure, therapeutic strategy for SV ASD patients has changed and was based on cardiac CT and 3D STL models for anatomic analysis in all patients. Flow-MRI and 3D printing were produced in selected cases to upgrade anatomic understanding and strategy decision ( Fig. 1 ). Forecast success and issues were studied based on anatomic findings. Safety, efficiency and follow-up with both technics were noticed for decision making. From March 2020 to March 2021, 18 adults patients were reffered for SV ASD closure. Median age was 47 years old (18 to 84 years old) ( Fig. 2 ). Surgical correction was performed in 5 patients (27.8%) using patch baffle (3/5) or Warden technique (2/5). Length of hospital stay was 8 ± 3 days and no major event occurred. Immediate surgical results were excellent in all cases. Percutaneous closure was performed in 4 cases (22.2%). Procedures were simulated on 3D printed models in all cases. Procedures were guided using transesophageal echocardiography, fusion between fluoroscopy and echography, and fusion between CT scan and fluoroscopy. One residual shunt occurred but disappeared on the cath control at month 3. Stents used were covered CP10Z80, CP10Z70, CP 10Z60, and Bentley begraft aortic in one case. In two cases, covered stents were stabilized by adding bare metal stents. All 4 patients were discharged at day 3 with acetylsalicylic acid therapy. Eight of nine pending patients for percutaneous closure will be planned in 2021. Percutaneous management of SVASD was safe and efficient in selected cases. Pre-procedural multimodality imaging including 3D modeling appears to be a necessary condition for a tailored patient's selection.

Electrical storm after correction of an uncomplicated congenital atrial septal defect in an adult: a case report

BackgroundThere is a paucity of published literature describing electrical storm after the correction of uncomplicated atrial septal defect (ASD) in an adult.Case presentationWe present a 49-year-old woman with a congenital ASD combined with mild tricuspid regurgitation who denied any history of arrhythmia or other medical history. She suffered from electrical storm (≥ 3 episodes of ventricular tachycardias or ventricular fibrillations) in the early stage after ASD repair with combined tricuspid valvuloplasty. During electrical storm, her electrolytes were within normal ranges and no ischemic electrocardiographic changes were detected, which suggested that retained air embolism or acute coronary thrombosis were unlikely. Additionally, echocardiographic findings and her central venous pressure (5–8 mmHg during the interval between attacks) failed to support the diagnosis of pericardial tamponade. After a thorough discussion, the surgeons conducted an emergent re-exploration and repeated closure of the ASD with combined DeVega's annuloplasty. Eventually, the patient recovered uneventfully, without reoccurring arrhythmias during follow-up. Although we fail to determine the definite cause, we speculate that the causes probably are iatrogenic injury of the conduction system due to a rare anatomic variation, poor intraoperative protection, latent coronary distortion during tricuspid valvuloplasty, or idiopathic or secondary abnormalities of the conduction system.ConclusionsFor most surgeons, performing re-exploration without a known etiology is a difficult decision to make. This case illustrates that re-exploration could be an option when electrical storm occurs in the early stage postoperatively. Nevertheless, surgeons should assess the benefit-risk ratio when taking this unconventional measure.

Safety of perioperative period in robot-assisted atrial septal defect repair under hyperkalemic arrest

BackgroundVarious attempts have been made to meet patient desires, especially among younger and otherwise healthy individuals, for cosmetically satisfying incision with atrial septal defect (ASD) repair. One of procedures was a robotic-assisted totally endoscopic ASD repair via only two ports under hyperkalemic arrest without aortic cross-clamping. This study investigated perioperative management and safety for robotic-assisted total endoscopic ASD repair surgery under hyperkalemic arrest.MethodsWe retrospectively reviewed perioperative management of thirty patients who underwent total endoscopic robot-assisted ASD repair under hyperkalemic arrest. All procedures were performed under general anesthesia using robotic-assisted total endoscopic for ASD repair via two or three ports under hyperkalemic arrest without aortic cross-clamping.ResultsA total of 30 patients (mean age 45 ± 17 years, 8 male, 22 female) underwent successful ASD repair with the total endoscopic robotic-assisted procedures under hyperkalemic arrest.Hyperkalemic arrest was achieved and maintained by intravenous administration of mean potassium dose of 91±32 mEq (1.4±0.6 mEq/kg) with the lowest bladder temperature was 31.9±1.4 °C during hyperkalemic arrest.In all cases, serum potassium concentration was <5.0 mEq/L after weaning from cardiopulmonary bypass, although two cases who developed hyperkalemia >6 mEq/L after operation. At other time points, no patient exceeded 6 mEq/L of serum potassium concentration. At admission to the intensive care unit, mean serum creatine phosphokinase-MB level was 32±7mg/dL. There were no cases of arrhythmia or other cardiac complications during recovery.ConclusionsPerioperative management of robotic-assisted total endoscopic ASD repair under hyperkalemic arrest is safe and is not associated with fatal arrhythmia due to hyperkalemia.

First Harvest of Pediatric and Congenital Heart Surgery Multicenter Database in Turkey: Novel Application of Real-Time Online Reporting.

A new congenital heart surgery database (CKCV) with real-time online reporting function was recently developed in Turkey. All standard international parameters were used, but Aristotle Comprehensive Complexity score was modified. In this study, the first analysis of the CKCV Database is reported. The CKCV Database included 2307 procedures from 12 centers between January 2018 and March 2020. All parameters, including 10 real-time online reports, which represent the number of centers, number and mortality rates of all procedures, number of extracorporeal membrane oxygenation (ECMO) and results, details of postoperative complications, age-group statistics, analysis for priority status, mean intensive care and hospital stay durations of the procedures, results of Aristotle Basic, Modified Aristotle Comprehensive (MACC) and Society of Thoracic Surgeons-European Association (STAT) Score Categories, comparison of centers were analyzed. Most common 10 procedures were ventricular septal defect (VSD) repair (n = 273), tetralogy of Fallot (TOF) repair (n = 243), atrial septal defect (ASD) repair (n = 181), complete AVSD repair (n = 95), cavopulmonary anastomosis (n = 81), systemic to pulmonary shunt (n = 79), modified Fontan (n = 71), subaortic resection, (n = 66) PA banding (n = 66), and arterial switch operation (n = 66). Cardiopulmonary bypass was used in 84.6% of the procedures. Overall mortality rate was 6.0%. A total of 618 major and 570 minor complications were observed in 333 and 412 patients, respectively. According to six MACC categories, number of the patients and mortality rates were I (293; 0.3%); II (713; 1.4%); III (601; 3.3%); IV (607; 12%); V (84; 35.7%); and VI (9; 55.6%), respectively. Analysis of five STAT Categories showed 0.7, 3.8, 5.4, 14.9, and 54.7% mortality rates. CKCV Database has a great potential for nationwide quality improvement studies. Users could instantly analyze and compare their results to national and international aggregate data using a real-time online reporting function. This is the first multicenter congenital database study in Turkey.

Totally endoscopic mitral valve surgery: early experience in 188 patients

IntroductionTotally endoscopic technique has been widely used in cardiac surgery, and minimally invasive totally endoscopic mitral valve surgery has been developed as an alternative to median sternotomy for many patients with mitral valve disease. In this study, we describe our experience about a modified minimally invasive totally endoscopic mitral valve surgery and reported the preliminary results of totally endoscopic mitral valve surgery. The aim of this retrospective study is to evaluate the results of totally endoscopic technique in mitral valve surgery.Material and methodsWe retrospectively reviewed the profiles of 188 patients who were treated for mitral valve disease by modified totally endoscopic mitral valve surgery at our institution between January 2019 and December 2020. The procedure was performed under endoscopic right minithoracotomy and with femoro-femoral cannulation using the single two-stage venous cannula.ResultsA total of 188 patients underwent total endoscopic mitral valve surgery. Fifty-six patients had concomitant tricuspid valvuloplasty, 11 patients underwent concomitant ablation of atrial fibrillation and atrial septal defect repair was performed in three patients. Only one patient postoperatively died of multi-organ failure. Two patients were converted to median sternotomy. Except for one patient underwent operation to stop the bleeding from the incision site, no other serious complications nor reintervention occurred during the follow-up period.ConclusionsThe modified totally endoscopic mitral valve surgery performed at our institution is technically feasible and safe with the same efficacy as reported studies.

False Negative Critical Congenital Heart Disease Screening Result Arising from a Complex Cardiac Disease with Duct Dependent Systemic Circulation

Background: Critical congenital heart disease (CCHD) encompasses congenital structural heart defects that cause significant morbidity and mortality in the first few weeks of life unless treated and/or require surgery or catheter intervention within the 1st year of life. Since these deteriorate acutely due to their cardiac condition, they may be misdiagnosed as septicemia or perinatal asphyxia, especially in resource-poor settings. The American Academy of Pediatrics recommends universal screening with pulse oximetry after 24 h of life by a simple screening protocol. Although specificity is high, CCHD may be missed. We present a case who screened negative became symptomatic on day 10 of life and was finally diagnosed with a CCHD. Clinical Description: A full-term baby with uneventful postnatal course and negative CCHD screening was discharged on day 2 of life. He returned on day 10 with cardiogenic shock. Echocardiography confirmed interrupted aortic arch with large ventricular septal defect (VSD), moderate-sized atrial septal defect (ASD), and a small, restrictive patent ductus arteriosus (PDA). The initial false-negative result was attributed to the presence of large VSD that leads to equalization of preductal and postductal oxygen saturations. Management: The baby was stabilized with prostaglandin infusion and ventilatory support. He underwent staged repair with end-to-end anastomosis of interrupted segment and PDA ligation in the first sitting. The postoperative course was uneventful, and the patient was discharged home at day 25 of life. He is planned for VSD and ASD repair in follow-up. Conclusion: Complex heart diseases may behave unusually due to complicated inter-related hemodynamics arising from the various lesions. Primary health-care personnel should recognize the limitations of CCHD screening protocol and learn to counsel parents accordingly.

Our results of cardiac surgery performed with a right infra axillary mini thoracotomy

Aim: The aim of the study is to share the technique and results of heart surgery performed with right infra axillary mini thoracotomy.&#x0D; Materyal and Method: Between March 2013 and July 2014, 16 heart operations were performed with right infra axillary mini torocotomy incision. Patient data were analyzed retrospectively. These are 6 mitral valve replacement (MVR), 3 aortic valve replacement (AVR), 2 AVR + MVR, 2 atrial septal defect (ASD) repair, 1 myxoma excision. One of them is AVR + tricuspid ring annuloplasty operation and MVR performed due to reoperation. Radiofrequency (RF) ablation was also applied to 1 patient who underwent MVR due to atrial fibrillation.&#x0D; In these operations, thoracotomy was performed through the right anterior infra axillary line. A parabolic incision of 6-8 cm was made at the 3rd intercostal space (ICA) for aortic valve interventions and at the 4th ICA level for other valve interventions. No special surgical instruments were used in the operations except standard surgical instruments. All cannulation procedures were carried out through the existing thoracotomy incision.&#x0D; Results: No mortality or morbidity was observed as a result of the operations. The mean extracorporeal circulation (ECC) time was 95±11 minutes, and the mean cross clamp (CC) time was 61±9 minutes. There was an average of 380±35 cc drainage. Extubation time was 7±2.3 hours on average. All patients were taken to the service after 1±0.5 day of intensive care treatment. They were discharged from the hospital in an average of 6±1.5 days. Incision site infection was not observed in any patient. No patients were revised due to bleeding. One patient who was ablated for atrial fibrillation (AF) developed postoperative AF again. He was discharged with medical treatment and speed control. &#x0D; Conclusion: In this study, we think that heart surgeries with right infraaxillary mini thoracotomy incision may be a good alternative to standard sternotomy and other minimally invasive methods in heart surgery.. With standard surgical instruments and cannulation through a single incision, not only the mitral valve but also the aortic valve, tricuspid valve and other cardiac pathologies can be easily intervened. However, very good results are obtained in patients cosmetically.

158 Management of Atrial Fibrillation in Patients with Cerebral Amyloid Angiopathy: Multidisciplinary Neuro-Cardiology Approach

Abstract We present two cases that highlight the clinical challenge of anti coagulation in patients with intracerebral haemorrhage (ICH) due to Cerebral Amyloid Angiopathy (CAA) and co-existent non-valvular Atrial Fibrillation (AF). Case 1 78 -Years right-handed functionally independent gentleman presented with right parietal intracerebral haemorrhage (ICH) on Dabigatran that required reversal. He had a background history of hypertension, persistent AF and a previous ICH on warfarin. Post atrial septal defect repair, he had multiple unsuccessful cardioversions for AF, and a failed catheter ablation after the first stroke. Magnetic Resonance Imaging (MRI) brain showed Cerebral Amyloid Angiopathy (CAA), the cause of his recurrent bleeds. Anticoagulation was not started due to severe CAA on imaging and recurrent bleeds. He was referred for left atrial closure device. Case 2 79-Years female presented with left parietal haemorrhage and new onset atrial fibrillation. Work up for ICH showed normal BP readings and clotting profile. Her MRI brain showed a large lobar bleed with mild small vessel disease and evidence of no other imaging features suggestive of CAA. As optimal timing to start anticoagulation after ICH is unknown, she was suggested to take part in a clinical trial. Her family declined the offer of clinical trial and also anti coagulation due to few falls. Her CHAD-VaSc and HAS-BLED score were 4 and 2 respectively. She was then referred to tertiary centre for left atrial appendage closure device. Conclusion Safety and timing to initiate DOAC for AF in this group is not established yet, understanding hemorrhagic risk using Boston Criteria for CAA diagnosis should be considered in addition to HAS-BLED score. Shared decision making and comprehensive discussions with cardiologist are of paramount importance. Non pharmacological intervention studies WATCHMAN and PREVAIL have proven procedural efficacy, however, in elderly population, decision making is complex due to frailty, dementia and co-morbidities.

Wide QRS complex tachycardia after surgical repair of an isolated atrial septal defect: What is the mechanism?

Macroreentrant atrial tachycardia within the right atrium is the dominant mechanism in patients with prior surgical repair of atrial septal defects, with dual-loop circuits much more common than single-loop circuits. This case highlights the importance of clinical history for predicting arrhythmia mechanisms. Considering prior cardiac surgery may assist in preprocedural preparations and discussions regarding potential risks and benefits of catheter ablation.

An early health technology assessment of 3D anatomic models in pediatric congenital heart surgery: potential cost-effectiveness and decision uncertainty

ABSTRACT Background: Three-dimensional anatomic models have been used for surgical planning and simulation in pediatric congenital heart surgery. This research is the first to evaluate the potential cost-effectiveness of 3D anatomic models with the intent to guide surgeons and decision makers on its use. Method: A decision tree and subsequent Markov model with a 15-year time horizon was constructed and analyzed for nine cardiovascular surgeries. Epidemiological, clinical, and economic data were derived from databases. Literature and experts were consulted to close data gaps. Scenario, one-way, threshold, and probabilistic sensitivity analysis captured methodological and parameter uncertainty. Results: Incremental costs of using anatomical models ranged from −366€ (95% credibility interval: −2595€; 1049€) in the Norwood operation to 1485€ (95% CI: 1206€; 1792€) in atrial septal defect repair. Incremental health-benefits ranged from negligible in atrial septal defect repair to 0.54 Quality Adjusted Life Years (95% CI: 0.06; 1.43) in truncus arteriosus repair. Variability in the results was mainly caused by a temporary postoperative quality-adjusted life years gain. Conclusion: For complex operations, the implementation of anatomic models is likely to be cost-effective on a 15 year time horizon. For the right indication, these models thus provide a clinical advantage at an acceptable cost.

Does Myocardial Oxygen Extraction Depend on Preoperative Functional Class in Beating Heart Atrial Septal Defect Repair

Does Myocardial Oxygen Extraction Depend on Preoperative Functional Class in Beating Heart Atrial Septal Defect Repair