Average Cardiopulmonary Bypass Time Research Articles

Results of using thoraflextm hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital

Background: The aim of this study was to introduce and evaluate the early results after the frozen elephant trunk (FET) procedure with ThoraflexTM Hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital. Methods: This is a retrospective descriptive study of all acceptable patients after the frozen elephant trunk (FET) procedure with ThoraflexTM Hybrid prothesis at Viet Duc University Hospital from January 2021 to May 2023. Results: There were 21 patients with a male rate of 85.7% and an average age 58.2±10 years old (range 40–73). History of patients with hypertension: 19 (90.5%); post-dissection aortic aneurysm: 2 (9.5%) patients. By cause, the number of patients with thoracic aortic aneurysm was 03 (14.3%), acute aortic dissection type A was 16 (76.1%), and aortic dissection type B was 02 (9.5%). In which there were 16 cases of emergency surgery (76.1%). Replacement of the aortic arch was performed under moderate hypothermic (280 °C on average) circulatory arrest and bilateral selective antegrade cerebral perfusion with permanent monitoring of cerebral tissue oxygenation by the MASIMO machine. Average cardio-pulmonary bypass time, aortic cross clamp time, distal hypothermic circulatory arrest time, and operating time were 137,5±22,9 minutes; 86,3±17,6 minutes; 25,2±8,9 minutes; and 7,7±10,3 hours. The average ventilation time, length of intensive care unit stay, and hospital stay were 7,2±9,7 days, 18,8±20,7 days, and 19,9 ± 6,5 days. There was one patient with post-operative cerebrospinal fluid drainage. No patient had bleeding complications, recurrent nerve palsy, reoperation, or in-hospital mortality. Conclusion: The initial results after the frozen elephant trunk procedure with ThoraflexTM Hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital were safe, good, and feasible.

1053 An Insight into Cardiac Tumours Using Over 20 Years of Up-to-Date Historical Data.

Abstract Aim Cardiac tumours are uncommon and frequently incidental findings. The study aims at analysing the demographics, presentation, histological prevalence and outcomes for cardiac tumours over the past 21 years. Method An observational retrospective data analysis on an SCTS database of all patients undergoing cardiac surgery at 3 different centres in the UK was performed. Further data was collected through operative summaries, pathology reports and outpatient letters. Results 207 patients underwent an operation for a cardiac tumour between 2001 and 2022, 66.2% were female and 33.8% male. Mean age was 62 years (17- 86 years). 62.3% were urgent procedures, 21.3% elective and 16.4% emergencies. 44 patients presented with chest pain, 29 stroke, 18 palpitations/arrhythmias, 15 shortness of breath and 7 syncope. In 51 patients the finding was incidental. Average cardiopulmonary bypass time was 80 minutes, and the average cross clamp time was 52 minutes. In 80.2% of cases the left chamber was involved, 10.6% right atrium, 1% left ventricle and 0.5% right ventricle. The final pathological specimen was reported as myxoma in 80.2% of cases, fibroelastoma in 3.9%, thrombus in 7%, sarcoma in 2.9 % and 1% calcified mass. Other histologies included osteosarcoma, lymphoma, granulation tissue, infected mass, cardiac fibroma, and lipoma. In-hospital mortality was 1.5%. Conclusions Despite the rarity of cardiac tumours and the lack of presenting symptoms, the study demonstrated that surgical mortality is low and although the overwhelmingly the commonest histology was confirmed to be myxoma, sarcoma is also an important differential as are the other histologies, which may be surprising.

Experience of the Postoperative Intensive Care Treatment of Stanford Type A Aortic Dissection.

To summarize the experience of the postoperative intensive care treatment of Stanford type A aortic dissection (STAAD) following Sun's procedure. A total of 124 patients with STAAD who underwent Sun's procedure from January 2014 to December 2021 at the General Hospital of Ningxia Medical University were retrospectively analyzed. All patients were admitted to the cardiac surgery intensive care unit (ICU) after surgery. According to the perioperative characteristics of the patients with STAAD, intensive care treatment was given to actively prevent the occurrence of postoperative complications. In all the cases enrolled in this study, the causes of aortic dissection comprised hypertension (105 cases), trauma (six cases), Marfan's syndrome (six cases), and aorto-arteritis (seven cases). The history of past illnesses comprised hypertension (105 cases), coronary disease (25 cases), diabetes mellitus (16 cases), and chronic obstructive pulmonary disease (six cases). There were some preoperative complications, such as cardiac insufficiency, acute liver insufficiency, acute renal insufficiency, pleural effusion, pericardial effusion, pulmonary infection, lower limb ischemia, mesenteric arterial embolism, and digestive tract hemorrhage. The average cardiopulmonary bypass time was 186 ± 32.1 min, the aortic clamp time was 74 ± 12.8 min, the deep hypothermic circulatory arrest time was 21 ± 2.6 min, and the mechanical ventilation time was 34 ± 2.8 h. The average ICU and hospital residence times were 7 ± 1.6 days and 12 ± 3.6 days, respectively. Postoperative complications comprised hypoxemia (34 cases), pulmonary infections (22 cases), tracheostomy (four cases), cerebral hemorrhage (four cases), cerebral infarction (four cases), transient delirium (eight cases), secondary thoracotomies due to bleeding (two cases), alimentary tract hemorrhage (eight cases), and acute renal insufficiency (38 cases). There was no occurrence of hoarseness or chylothorax. There were 15 cases of death, and the total mortality rate was 12.1%. In four cases, the cause of death was one postoperative complication (3.2%), and in 11 cases, the cause of death was multiple postoperative complications (8.9%). The other patients were discharged from the hospital with a good prognosis for full recovery. Postoperative intensive care treatment was an important part of the successful surgical treatment of STAAD.

Robotic mitral valve repair in National Taiwan University Hospital: 10-year results.

With the help of robotic surgical systems and their 3-dimensional, high-resolution imaging, mitral repair with long shaft instruments and endo-wrist functionality has become a feasible reality. Patients benefit from maintained thoracic cage integrity, reduced surgical trauma, and faster return to normal functional activity. We describe National Taiwan University Hospital's 10-year experience with robotic-assisted mitral valve repair procedures for repairing mitral regurgitation. We performed a retrospective observational cohort study of patients undergoing robotic-assisted mitral valve repair for severe mitral regurgitation at National Taiwan University Hospital. Between January 2012 and September 2022, 450 consecutive patients underwent robotic mitral valve repair with or without additional cardiac procedures. All procedures were completed by a single surgical team. Four hundred and fifty patients, with 272 (60.4%) isolated mitral repairs and 178 (39.6%) combined additional (one or more) cardiac procedures were performed. The Euroscore II estimate mortality was 3.1%±2.7%. The average cardiopulmonary bypass (CPB) time was 124±42 minutes, and the average operation time was 165±51 minutes. Perioperative and 30-day mortality was observed in one (0.22%) patient. Mean intensive care unit stay was 26.5±26.0 hours. Postoperative stroke was observed in one (0.22%) patient and new-onset atrial fibrillation was observed in 71 (15.78%) patients. All patients were in less than mild mitral regurgitation and 422 (93.78%) had none or trace regurgitation at discharge. Freedom from moderate mitral regurgitation was 97.6%, and freedom from mitral valve reoperation was 98% at 10 years. With standardized robotic procedures and non-compromised repair techniques, excellent short-term outcomes and long-term valve repair durability can be achieved in experienced centers.

Application of primary sutureless repair for obstructed total anomalous of pulmonary venous connection at the Vietnam National Children's Hospital

Objectives: This study evaluates the results of applying primary sutureless technique in surgical repair of total anomalous pulmonary venous connection at Children Heart Center, Vietnam National Children's Hospital. Methods: A retrospective study was conducted to evaluate the short-term outcomes of primary sutureless repair for all patients diagnosed with obstructed total anomalous venous connection (TAPVC) from July 2015 to December 2016. Results: There were 25 patients undergoing primary sutureless repair during the study period. The mean age and the mean weight are 77.00 ± 23.26 days and 3.93 ± 1.16 kg, respectively. There were 19/25 (76%) cases with preoperative respiratory failure with 14 cases (56%) requiring mechanical ventilation before surgery, of which 9 patients (36%) had life-threatening acute pulmonary edema from before emergency surgical repair. There were 17 cases admitted to the hospital with cardiogenic shock. Evaluation of transthoracic echocardiography showed 15 cases of supracardiac TAPVC, 5 cases of infracardiac TAPVC, 2 cases of intracardiac, 2 cases of mixed, and 1 case of partial TAPVC. The mean aortic cross-clamp time was 65.40 ± 23.34 minutes, the average cardiopulmonary bypass time was 119.72 ± 34.85 minutes, the mean surgery time was 200.04 ± 39.42 minutes. 9 cases underwent circulatory arrest and 7 cases underwent low-flow bypass during surgery. 3 patients died in the postoperative period, of which 2 from septic shock and multi-organ failure, 1 patient from respiratory failure after extubation due to laryngomalacia. The reoperation rate was 2/25 as a consequence of recurrent pulmonary vein stenosis. Conclusions: The primary sutureless repair for obstructed anomalous pulmonary venous connection is safe and favorable. Long-term outcomes follow-up are essentially required.

Hundred plus Minimally Access Cardiac Surgery: Our Experience

Background: Minimally invasive procedures lead to less scarring resulting in better cosmetic outcomes. This has resulted in increased patient interest in such procedures and this has motivated surgeons to pursue newer and improved techniques for Minimally invasive cardiac surgery (MICS). Obviously, with the advent of MICS the techniques to achieve it also needed to be changed and upgraded which includes access for cannulation for cardiopulmonary bypass (CPB). Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels with minithoracotomy/ministernotomy proves to be a safe and effective tool in patients with body weight of above 20 kg for minimally access cardiac surgery. We use this technique for Atrial septal defect (ASD) closure, aortic valve replacement (AVR), redo Tricuspid valve replacement (TVR) and mitral valve replacement (MVR). Here, we describe our experience with minimally invasive approach using total peripheral cannulation and an anterior mini-thoracotomy (6 cm or less) incision for ASD closure, AVR, TVR and MVR. Methods: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive ASD closure, AVR, TVR and MVR with total peripheral cannulation were collected and analyzed. Results: Between May 2014 to May 2019 we performed minimally invasive closure of atrial septal defects, AVR, TVR and MVR with total peripheral cannulation in 103 patients. There were 64 females and 39 males Mean age was 25 years (range 8 - 58 years), Spectrum of procedures include ASD closure in 81 patients (78.6%), AVR via minithoracotomy in 13 patients (12.6%) and AVR via ministernotomy in 3 patients (2.9%), redo TVR in 5 (4.8%), MVR in 1 patient (0.97%). Average cardiopulmonary bypass (CPB) time was 46 minutes (range 22 - 78 min) and average aortic cross-clamp time (AoX) 26 min (range 12 - 45 min) in ASD closure group. In AVR group average CPB time was 91 min (range 72 - 120 min) and AoX time 76.5 min (range 65 - 109 min). In TVR group average CPB time 54 min (range 45 - 67 min) on beating heart. Only one MVR done in this period and CPB time was 82 min and AoX time was 65 min. The mean length of stay in intensive care unit was 1.8 days in ASD closure, 2 days in AVR group when in TVR group 3.5 days, and hospital stay was 3 days in ASD closure group, 4 days in AVR group and 7 days in TVR group. The only one patient who underwent MVR died in 12th post operative day from sepsis. There was one late mortality in AVR group after reoperation for prosthetic valve endocarditis at 3 months from first operation. Conclusion: ASD closure, AVR, TVR and MVR with mini invasive approach is safe with very few manageable preoperative complications and good patient satisfaction.

Hundred plus Minimally Access Cardiac Surgery: Our Experience

Background: Minimally invasive procedures lead to less scarring resulting in better cosmetic outcomes. This has resulted in increased patient interest in such procedures and this has motivated surgeons to pursue newer and improved techniques for Minimally invasive cardiac surgery (MICS). Obviously, with the advent of MICS the techniques to achieve it also needed to be changed and upgraded which includes access for cannulation for cardiopulmonary bypass (CPB). Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels with minithoracotomy/ministernotomy proves to be a safe and effective tool in patients with body weight of above 20 kg for minimally access cardiac surgery. We use this technique for Atrial septal defect (ASD) closure, aortic valve replacement (AVR), redo Tricuspid valve replacement (TVR) and mitral valve replacement (MVR). Here, we describe our experience with minimally invasive approach using total peripheral cannulation and an anterior mini-thoracotomy (6 cm or less) incision for ASD closure, AVR, TVR and MVR. Methods: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive ASD closure, AVR, TVR and MVR with total peripheral cannulation were collected and analyzed. Results: Between May 2014 to May 2019 we performed minimally invasive closure of atrial septal defects, AVR, TVR and MVR with total peripheral cannulation in 103 patients. There were 64 females and 39 males Mean age was 25 years (range 8 - 58 years), Spectrum of procedures include ASD closure in 81 patients (78.6%), AVR via minithoracotomy in 13 patients (12.6%) and AVR via ministernotomy in 3 patients (2.9%), redo TVR in 5 (4.8%), MVR in 1 patient (0.97%). Average cardiopulmonary bypass (CPB) time was 46 minutes (range 22 - 78 min) and average aortic cross-clamp time (AoX) 26 min (range 12 - 45 min) in ASD closure group. In AVR group average CPB time was 91 min (range 72 - 120 min) and AoX time 76.5 min (range 65 - 109 min). In TVR group average CPB time 54 min (range 45 - 67 min) on beating heart. Only one MVR done in this period and CPB time was 82 min and AoX time was 65 min. The mean length of stay in intensive care unit was 1.8 days in ASD closure, 2 days in AVR group when in TVR group 3.5 days, and hospital stay was 3 days in ASD closure group, 4 days in AVR group and 7 days in TVR group. The only one patient who underwent MVR died in 12th post operative day from sepsis. There was one late mortality in AVR group after reoperation for prosthetic valve endocarditis at 3 months from first operation. Conclusion: ASD closure, AVR, TVR and MVR with mini invasive approach is safe with very few manageable preoperative complications and good patient satisfaction.

Survival Outcome of Combined Heart and Lung Transplantation: Single Center vs. UNOS Data

Purpose Following a combined heart/lung transplant (HLTx), UNOS reports a survival rate of 68% at year 1, 58% at year 2, and 53% at year 3. This study aims to compare the survival outcome following HLTx from our medical center with UNOS registry data. Methods We retrospectively studied 12 patients that underwent HLTx at our center between 2012-2020 to assess long-term survival. We analyzed included recipient's age, sex, etiology, lung allocation score (LAS), cardiopulmonary bypass (CPB) time, total/warm ischemic time, procedural approach, induction, donor age/sex, length of stay (LOS), and cause of death. We then assessed the survival outcome of our patients and compared that with the UNOS registry data (n=1295) using a Kaplan-Meier curve and log-rank test (p Results Out of our 12 patients, 8 were male and 4 were female, with the average age 53 ± 10 yrs. From the donors, 7 were male and 5 were female, with an average age of 37 ± 14 yrs. Etiology included PF (50%), sarcoidosis (17%), and pulmonary HTN (17%). Pre-Txp, 2 patients were placed on VA ECMO (1 on ventilation), 1 on VV ECMO, 1 on RVAD, and 1 on HM III. The average LAS was 65 ± 21. All of our patients were put on CPB during operation with an average CPB time of 186 ± 37 min, total ischemic time of 243 ± 68 min for right and 194 ± 60 min for left, and warm ischemic time of 36 ± 10 min for right and 47 ± 11 min for left. In total, 9 had a median sternotomy incision and 3 had a clamshell incision. Campath induction was performed on 7 patients while 5 had Simulect induction. Post-Txp, 2 patients required ECMO. Median LOS was 45 days and mean survival time was 757 ± 945 days. A total of 3 patients died due to infection, MSOF, and bleeding. The log-rank test between the patients from our center compared to the national average showed no significant difference in survivability (p=0.292). Conclusion Although not significant, our HLTx survival outcome was slightly better than the national UNOS survival data. Surgical techniques and careful management may contribute to better survival outcomes in selected patients.

Single-stage repair for coarctation with ventricular septal defect: results of 100 cases at a single centre.

The outcomes of the single-stage surgical repair of aortic arch hypoplasia (AAH) and/or coarctation of the aorta (CoA) associated with ventricular septal defect (VSD) remain controversial, especially in a lower middle-income country. This study reports the results of a single-stage repair protocol at our institution for AAH/CoA with VSD using selective cerebral perfusion. This retrospective study included 100 consecutive patients who underwent single-stage repair via median sternotomy using selective cerebral perfusion for AAH/CoA with VSD from July 2010 to March 2017. The patients consisted of 65 males and 35 females. The median age of the patients was 67 days (range 4-2266 days); the median weight was 3.8 kg (range 2.1-15 kg). The average cardiopulmonary bypass time was 132 ± 28 min, the aortic cross-clamp time was 92 ± 23 min and the selective cerebral perfusion time was 33 ± 10 min. The survival rate of all patients was 94.7 ± 2.3%, with an in-hospital mortality of 5% and no late mortality at a median follow-up of 37 months (range 4-96 months). Four patients required reoperation due to recoarctation. The overall event-free survival rate following surgery was 87.1%. The median pressure gradient across the anastomosis at the last follow-up was 8.3 ± 2.8 mmHg. Multivariate logistic regression analysis revealed proximal aortic arch obstruction as a predictor of mortality (odds ratio = 3.8). The aortic isthmus diameter was identified as a predictor for reintervention by Cox regression (hazard ratio = 6.7). Single-stage repair for AAH/CoA with VSD is safe and feasible in a developing country.

Early clinical outcomes of thoracoscopic mitral valvuloplasty: a clinical experience of 100 consecutive cases.

We reported our experience of 100 consecutive cases of thoracoscopic mitral valvuloplasty in the early period. Between September 2017 and December 2019, 100 consecutive cases (aged 49.2±14.7 years; 56% male) of thoracoscopic mitral valvuloplasty had been completed in our institution. The safety and feasibility of this technique was evaluated by its early clinical outcomes. Mitral valve (MV) repair was performed by means of Carpentier techniques, including leaflet folding in 5 cases, cleft suture in 10, commissuroplasty in 15 including 2 commissurotomy, edge to edge in 1, artificial chordae implantation in 76 cases with an average of 2.5±1.6 (1 to 4) pairs, and prosthetic annuloplasty in all cases. Intraoperative transoesophageal echocardiography (TEE) revealed no mitral regurgitation (MR) in 95 cases and a mild in 2 cases with all coaptation length more than 5 mm. The rest 3 cases with moderate or more MR were successfully reconstructed during a second pump-run. The average cardiopulmonary bypass (CPB) time was 164.4±51.0 min and aortic clamping time was 119.7±39.1 min, and the latest 10 cases were 140.2±45.3 and 96.3±25.4 min, respectively (P<0.05). There was only one operative death from avulsion of left atrial suture after operation and 2 intraoperative re-exploration through a conversion to sternotomy for bleeding. Severe MR was observed in 2 patients 3 months after operation, and MV replacement (MVR) was performed through median sternotomy. Totally thoracoscopic mitral valvuloplasty was technically feasible, safe, effective, and reproducible in clinical practice after crossing the learning curve.

Conversion of prior univentricular repairs to septated circulation: Case selection, challenges, and outcomes.

Complex congenital heart defects that present earlier in life are sometimes channelled in the single ventricle pathway, because of anatomical or logistic challenges involved in biventricular correction. Given the long-term functional and survival advantage, and with the surgeons' improved understanding of the cardiac anatomy, we have consciously explored the feasibility of a biventricular repair in these patients when they presented later for Fontan completion. We present a single institution's 10-year experience in achieving biventricular septation of prior univentricular repairs, the technical and physiological challenges and the surgical outcomes. Between June 2010 and December 2019, 246 patients were channelized in the single ventricle pathway, of which 32 patients were identified as potential biventricular candidates at the time of evaluation for Fontan palliation, considering their anatomic feasibility. The surgical technique involves routing of the left ventricle to the aorta across the ventricular septal defect, ensuring an adequate sized right ventricular cavity, establishing right ventricle-pulmonary artery continuity and taking down the Glenn shunt with rerouting of the superior vena cava to the right atrium. This is a retrospective study where we reviewed the unique physiological and surgical characteristics of this subset of patients and analysed their surgical outcomes and complications. Biventricular conversion was achieved in all cases except in 3 patients, who had the Glenn shunt retained leading to a one and a half ventricle repair. The average age of the patients was 4.9years of whom 18 were male. The average cardiopulmonary bypass time was 371min with an average cross clamp time of 162min. There was one mortality in a patient with corrected transposition of great arteries (c-TGA) with extensive arterio-venous malformations (AVMs). At a median follow-up of 60months, all patients remained symptom free except two with NYHA II symptoms, one being treated for branch pulmonary artery stenosis with balloon dilatation and the other with multiple AVMs who needed coil closure. One patient with branch pulmonary artery (PA) stenosis required balloon dilatation and stent placement. The possibility of achieving the surgical goal in this unique subset of patients evolves with the progressive experience of the congenital heart surgeon. Case selection is a crucial aspect in achieving the desired outcome, and this 'borderline' substrate is often recognized at the time of evaluation for the Fontan completion. A comprehensive preoperative imaging and planning helps in achieving the surgical septation and reconnection to achieve the desired physiological circulation. Though technically challenging, the surgery has excellent short- and mid-term outcomes as evidenced by our 10-year experience.

Outcomes of the Warden Procedure for Partial Anomalous Pulmonary Venous Drainage.

Partial anomalous pulmonary venous drainage (PAPVD) is a common congenital heart disease. If the insertion of an anomalous pulmonary vein (PV) is high into the superior vena cava (SVC), the traditional 1-patch or 2-patch surgical repair might be challenging. Unlike patch procedures, the cavoatrial anastomosis technique (Warden procedure) theoretically reduces complications such as sinus node dysfunction and venous obstruction. We investigate outcomes of the Warden procedure (WP) at a single institution. A total of 67 patients (42 males and 25 females) with PAPVD who underwent the WP between January 2011 and December 2018 were consecutively enrolled. The median age was 2.8years (3-61years old). 52 cases were younger than 18years old. perioperative and follow-up clinical data were collected. In addition, we selected possible risk factors (a total of 18 risk factors) of SVC stenosis or obstruction. Univariate and multivariate analyses were conducted to confirm the independent risk factors. The average Cardiopulmonary bypass (CPB) time was 132.3 ± 46.3min, and the aortic cross-clamp time was 85.2 ± 35.7min. One patient died postoperatively in hospital. The mean follow-up time of the remaining patients (n = 66) was 15.8 ± 14.5months (3-64months). No abnormal cardiac function or sinus node dysfunction cases were identified during the follow-up. Of the survival patients, no venous obstruction was presented before the discharge. Numbers of patients identified with mild PV and SVC stenosis were 1 (1.5%) and 7 (10.6%, 4 of them turned negative eventually) at discharge. At the last follow-up, no PV obstruction was identified, whereas, 4 cases (6%) had SVC obstruction. Numbers of PV and SVC stenosis cases were 3 (4.5%) and 8 (12%). Univariate and multivariate analyses showed that only the diameter of SVC less than 10mm was an independent risk factor for SVC stenosis or obstruction at the last follow-up. Warden procedure can effectively treat PAPVD (anomalous drainages into SVC), with satisfactory early and mid-term postoperative results. Different modifications of the Warden procedure may be selected according to the anatomic characteristics. The diameter of SVC less than 10mm predicts SVC stenosis or obstruction after Warden procedure.

Custodiol cardioplegia solution compared to cold blood cardioplegia in pediatric cardiac surgery: a single-institution experience.

Custodiol is an intracellular, crystalloid cardioplegia solution that is a single-dose alternative to multi-dose cold blood cardioplegia; however, there is scarce data regarding its use in infants and children. The objective of this study was to compare its impact on myocardial function in infants. Single-center retrospective review including 132 patients <12 months old undergoing biventricular repair. There were 106 patients who received single-dose Custodiol and 27 patients who received multi-dose blood cardioplegia. Demographic and echocardiographic data were compared between the two groups. Patients receiving Custodiol were slightly younger (100 ± 62 days) and lower weight (4.7 ± 1.3 kg) compared to 152 ± 86 days and 5.2 ± 1.3 kg for blood cardioplegia (p < 0.05). The Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery Congenital Heart Surgery score was similar between both groups. Average cardiopulmonary bypass time was similar between both groups (Custodiol 93 ± 54 minutes vs. blood 81 ± 44 minutes, p = 0.46) as was aortic cross-clamp time (Custodiol 58 ± 33 minutes vs. cold blood 53 ± 33 minutes, p = 0.62). Pre-operative left ventricular ejection fraction was similar for blood 73 ± 8% versus Custodiol 70 ± 9%, p = 0.21. There was also no intergroup difference in left ventricular ejection fraction 24 hours post op (blood 64 ± 9% vs. Custodiol 65 ± 12%, p = 0.53) or at discharge (blood 66 ± 10% vs. Custodiol 66 ± 11%, p = 0.95). The pre-operative right ventricle function by fractional area change was also similar in blood cardioplegia (46 ± 13%) versus Custodiol (48 ± 9%, p = 0.38) and showed similar drops in parameters in the two groups 24 hours after surgery and at discharge. Single-dose Custodiol is as safe as blood cardioplegia for myocardial protection in congenital cardiac surgery for the cross-clamp times evaluated in this study. Evaluation at longer cross-clamp times would be helpful to determine if there is a greater benefit to single-dose Custodiol versus more repeated doses of blood cardioplegia for longer cross-clamp times.

External suture annuloplasty for mild to moderate and moderate aortic regurgitation due to an isolated type Ic lesion.

Whether mild to moderate and moderate aortic regurgitation should be corrected surgically during other cardiovascular surgeries remains controversial. We evaluated the effectiveness of external suture annuloplasty in such cases. Among 95 patients undergoing aortic valve repair between December 2013 and March 2018, five patients with mild to moderate and moderate aortic regurgitation due to aortic annulus dilatation (type Ic lesion) underwent surgery for mitral regurgitation and/or thoracic aortic aneurysm. Aortic valves were repaired with external suture annuloplasty alone with a mean Hegar dilator size of 20.4 ± 0.8 (20.0-22.0)mm at the same time and were followed up echocardiographically. There were no cases of mortality or major morbidity. Intraoperative direct measurement revealed ventriculoaortic junction size of 25.0 ± 0.8 (24.0-27.0)mm. The average cardiopulmonary bypass time and aortic cross-clamping time were 139 ± 46 (76-205)min and 105 ± 38 (58-172)min, respectively. Postoperative transthoracic echocardiogram during hospitalization showed trivial aortic regurgitation in all cases, with average ventriculoaortic junction size, aortic valve area, and peak and mean transvalvular gradient of 19.1 ± 0.7 (18.0-20.3)mm, 2.24 ± 0.48 (1.60-3.00)cm2, 6.4 ± 1.9 (4.0-9.2)mmHg, and 3.5 ± 1.1 (2.1-5.2)mmHg, respectively. Ventriculoaortic junction size was significantly decreased (P < 0.05). There have been no changes in ventriculoaortic junction size (P = 0.32) or other echocardiographic findings for 24 ± 6 (17-36)months after surgery. Although concomitant with other cardiac surgeries, mild to moderate and moderate aortic regurgitation could be repaired without clinically relevant additional surgical duration. External suture annuloplasty is a useful, safe, and secure treatment choice for type Ic lesion-induced aortic regurgitation.

Mid-term outcomes of individualized surgeries in patients with Ebstein's anomaly.

The variable anatomy of Ebstein's anomaly leads to its various surgical procedures. The long-term outcomes of different operations were not well established. Thirty-five patients with Ebstein's anomaly who underwent operations from 2006 to 2018 in our department were retrospectively reviewed. Individualized surgical plans were performed according to the preoperative echocardiography and surgeons' preference. Tricuspid repair, either Danielson's or Carpentier's technique, was the primary choice in patients who had sufficient tricuspid leaflets and adequate right ventricle, while tricuspid replacement was used when a reliable repair is not achievable. Additional bidirectional cavopulmonary shunt was performed in those who had unstable hemodynamics despite of high central venous pressure after separation from cardiopulmonary bypass. The perioperative and follow-up data were collected. The age was 26.9 (0.6-54) years [16 children (age <14, and 19 adults (age ≥14)]. Preoperative tricuspid regurgitation was severe in 30, moderate in 4, and mild in the remaining 1 patient. Preoperative cardiac-associated malformations include 20 atrial septal defects, 2 ventricular septal defects, 2 pulmonary stenosis, and 1 sub aortic ridge, and these were operated simultaneously. Among all the surgical patients, 2 needed additional reoperation during the same admission, and ultimately, 29 patients had biventricular repair, including 21 tricuspid repair and 8 replacements. The other 6 patients had cavopulmonary connection and achieved 1.5 ventricular repair (3 tricuspid repair and 3 replacements). In all the 24 tricuspid repair patients, Danielson's procedure was used in 17, while Carpentier's technique was used in the other 7 patients. The average cardiopulmonary bypass time was 90 ± 28min and cross-clamp time was 48 ± 24min. There were 2 perioperative deaths (5.7%) and no third-degree atrioventricular block. The postoperative in hospital stay was 13.7 ± 9.6days. In the 33 survivors who were followed up at a median of 29.2months, 6 patients had severe tricuspid regurgitation, and 2 of them underwent tricuspid replacement. The 5-year freedom from severe tricuspid dysfunction or reoperation was 78.5%, and no difference was found between children and adults, neither between different surgical choices. The surgeries of Ebstein's anomaly were variable, and individualized operation achieved reasonable short- and mid-term results. However, severe tricuspid regurgitation during the follow-up was not neglectable, and reoperation in such cases also achieved good outcomes. New repair strategy such as cone repair may be considered.

Comparison of conventional and primary sutureless surgery for repairing supracardiac total anomalous pulmonary venous drainage

ObjectiveThe efficacy of using a sutureless approach in order to surgically manage postoperative pulmonary vein stenosis following total anomalous pulmonary venous drainage (TAPVD) has been reported, though outcomes of primary treatment of supracardiac TAPVD remain unclear. We retrospectively reviewed our cardiac center experience, and compared the differences in mid-term outcomes for those patients that received conventional surgery and those that underwent sutureless technique for the primary repair of supracardiac TAPVD.MethodsA total of 43 patients (median age, 199 days; range, 35 days to 1572 days) with supracardiac TAPVD underwent surgical treatment at our cardiac center from 2014 to 2018 were studied retrospectively. Primary sutureless repair was conducted in 20 cases (46.5%). The pulmonary vein scores, left ventricular ejection fraction (LVEF), baseline of the included patients, postoperative, and outcomes data were analyzed between the two groups.ResultsThe pulmonary vein scores, indicating the stenosis degree, of two groups were 0.1 ± 0.3 and 0.1 ± 0.3, left ventricular ejection fraction (LVEF) (%) were separately 66.2 ± 12.1 and 67.1 ± 13.6. The average cardiopulmonary bypass time of sutureless techniques group was much longer than conventional group (96.2 ± 32.6 min vs 75.6 ± 28.2 min, P < 0.05), but there was no difference in aortic cross-clamp time between the two groups. Followed up from 0.1 to 4 years, 3 cases died overall, with 1 (5.0%) individual dying from postoperative pulmonary venous obstruction (PVO) in sutureless group, and 2 (8.6%) dying in the conventional group respectively for postoperative infection and post-PVO. There were no differences in the length of stay in the ICU, grades of PVS after surgery, LVEF and reoperation rate between the two groups.ConclusionsThe mortality, post-PVO, follow up results of supracadiac TAPVD showed no differences between sutureless and conventional techniques. Post-PVO supposed to be the main reason for postoperative mortality.

Technique of Complete Heart Isolation with Continuous Cardiac Perfusion During Cardiopulmonary Bypass: New Opportunities for Gene Therapy

Cardiopulmonary bypass (CPB) featuring complete heart isolation and continuous cardiac perfusion is a very promising approach for solving the problem of efficient gene delivery. In the technique presented here, separate pumps are used for the systemic and cardiac circuits. This system permits continuous isolated arrested heart perfusion through optimizing a number of delivery parameters including temperature, flow rate, driving pressure, ionic composition, and exposure time to the cardiac vessels. During complete cardiac isolation, the blood vector concentration trended from 11.51 ± 1.73 log genome copies (GCs)/cm3 to 9.84 ± 1.65 log GC/cm3 (p &gt; .05). Despite restructuring a very high concentration to the heart, GCs were detectable in the systemic circuit. These values over time were near negligible by comparison but detectable 1.66 ± .26 during 20 minutes of recirculation and did not change (p &gt; .05). After the completion of the recirculation interval and subsequent washing procedure, the initial systemic blood vector GC concentration slightly increased to 2.08 ± .38 log GCs/cm3 (p &gt; .05). During the recirculation period, we supported flow via the cardiac circuit around 300 mL/min. In this technique of heart isolation with continuous cardiac perfusion, &gt;99% of the vector remains in coronary circulation during recirculation period. The animal’s non recirculation blood, or that in the system, was routinely tested during and after recirculation to contain much less than 1% of the original dose obtained via logging concentration of therapeutic over time. All of the sheep in this group recovered from anesthesia and received critical postoperative care, including all organ function, in the first 24–36 hours. Twenty-one sheep (84%) survived to euthanasia at 12 weeks. Average CPB time was 107 ± 19.0 minutes and cross-clamp time was 49 ± 7.9 minutes. This technology readily provides multiple pass recirculation of genes through the heart with minimal side effects of collateral expression of other organs.

Vitamin D and Postoperative Vasopressor Use in Cardiopulmonary Bypass.

The use of cardiopulmonary bypass (CPB) in cardiac surgery often leads to a systemic inflammatory response. Up to 25% of patients undergoing CPB for cardiac surgery are reported to develop vasoplegic syndrome in the acute postoperative period, in which the patients are refractory to vasopressors. The purpose of this study is to assess vitamin D deficiency as a risk factor for vasoplegia after using CPB. We performed a retrospective review of 1322 patients undergoing adult cardiac surgery requiring CPB. Forty-six patients with previously recorded 25-hydroxy vitamin D (25(OH)D) levels within 6 months of surgery met the conditions of this study. The mean level of 25(OH)D was 32.7 ng/mL (standard deviation [SD] = 15.1). The mean age of patients was 67 (SD = 10.1) years old, most were male (63%) and white (78%). Average CPB time was 140 ± 44 minutes. Postoperative vasopressor use was compared to individual preoperative 25(OH)D levels. As a secondary end point, postoperative vasopressor use and vasoplegia were analyzed between 3 groups: Vitamin D deficient defined as 25(OH)D ≤20 ng/mL (n = 7), vitamin D insufficient defined as 25(OH)D between 20 and 29 ng/mL (n = 15), and vitamin D sufficient defined as 25(OH)D ≥30 ng/mL (n = 24). There was no correlation between vitamin D levels and postoperative vasopressor use. The mean doses of postoperative vasopressor use were 0.088 µg/kg/min (standard error of the mean [SEM] = 0.032), 0.085 µg/kg/min (SEM = 0.037), and 0.072 µg/kg/min (SEM = 0.024) of norepinephrine equivalents for the vitamin D deficient, insufficient, and sufficient groups, respectively. Incidence of vasoplegia for each group was the following: 0.143 for vitamin D deficient, 0.067 for vitamin D insufficient, and 0.125 for vitamin D sufficient. In this pilot study, there does not appear to be a relationship between vitamin D and vasopressor use following cardiac surgery utilizing CPB; however, there appears to be a trend toward an increased vasopressor usage in patients with decreased vitamin D levels. A larger sample size and a prospective analysis are warranted to further assess the significance of the relationship between vasoplegia and vitamin D deficiency. With further investigation, vitamin D has the potential to become a low-cost, low-risk therapeutic for improving outcomes in CPB surgery.

Selective Cerebro-Myocardial Perfusion in Complex Neonatal Aortic Arch Pathology: Midterm Results.

Aortic arch repair in newborns and infants has traditionally been accomplished using a period of deep hypothermic circulatory arrest. To reduce neurologic and cardiac dysfunction related to circulatory arrest and myocardial ischemia during complex aortic arch surgery, an alternative and novel strategy for cerebro-myocardial protection was recently developed, where regional low-flow perfusion is combined with controlled and independent coronary perfusion. The aim of the present retrospective study was to assess short-term and mid-term results of selective and independent cerebro-myocardial perfusion in neonatal aortic arch surgery. From April 2008 to August 2015, 28 consecutive neonates underwent aortic arch surgery under cerebro-myocardial perfusion. There were 17 male and 11 female, with median age of 15 days (3-30 days) and median body weight of 3 kg (1.6-4.2 kg), 9 (32%) of whom with low body weight (<2.5 kg). The spectrum of pathologies treated was heterogeneous and included 13 neonates having single-stage biventricular repair (46%), 7 staged biventricular repair (25%), and 8 single-ventricle repair (29%). All operations were performed under moderate hypothermia and with a "beating heart and brain." Average cardiopulmonary bypass time was 131 ± 64 min (42-310 min). A period of cardiac arrest to complete intra-cardiac repair was required in nine patients (32%), and circulatory arrest in 1 to repair total anomalous pulmonary venous connection. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 30 ± 11 min (15-69 min). Renal dysfunction, requiring a period of peritoneal dialysis was observed in 10 (36%) patients, while liver dysfunction was noted only in 3 (11%). There were three (11%) early and two late deaths during a median follow-up of 2.9 years (range 6 months-7.7 years), with an actuarial survival of 82% at 7 years. At latest follow-up, no patient showed signs of cardiac or neurologic dysfunction. The present experience shows that a strategy of selective and independent cerebro-myocardial perfusion is safe, versatile, and feasible in high-risk neonates with complex congenital arch pathology. Encouraging outcomes were noted in terms of cardiac and neurological function, with limited end-organ morbidity.

Results of the Fontan operation with no early mortality in 248 consecutive patients.

The Fontan operation has undergone several modifications and today is the primary way to treat a broad spectrum of congenital heart defects. The purpose of this study is to present the results of treatment of children with a single ventricle operated by the same surgical team and managed according to a uniform strategy. In the years 2007-2015, in 248 children aged 3.7 ± 2.6 years and weighing 14.6 ± 6.1 kg with a single ventricle, Fontan surgery was performed. In 56 (22.6%) children surgery was based on the creation of an intra-atrial lateral tunnel, and in 192 (77.4%) patients extracardiac modification was performed. In most patients, the operation was carried out with the normothermic cardiopulmonary bypass, on a "beating heart" without aortic cross-clamp. The average cardiopulmonary bypass time was 53.9 ± 23.9 min. The most common indication for surgery was hypoplastic left heart syndrome (53.6%). All patients with a single ventricle referred to our hospital for the Fontan procedure were enrolled into the surgery programme. All patients survived the operation and were discharged home. Thirty-six (14.5%) patients were extubated in the operating room, in other patients the mean duration of the mechanical ventilation was 9.7 ± 16.1 h (median 7 h). The average time of hospitalisation in the whole study group was 17.5 ± 18.5 days (median 15 days). After surgery, in four children transient seizures occurred, and three patients had an ischaemic stroke. Developing and obeying a fixed perioperative protocol is crucial for low mortality and small number of complications after Fontan operation.