Division Of Vascular Ring Research Articles

Long-term Outcomes Following Thoracoscopic Division of Vascular Rings

ObjectivesWe evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center. MethodsAll pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007–12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews. Results60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time. ConclusionDivision of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings. Level of EvidenceLevel IV.

The Impact of Prenatal Diagnosis on Clinical Outcomes of Isolated Vascular Rings From a Statewide Paediatric Cardiology Tertiary Service.

Vascular rings, including right aortic arch with aberrant left subclavian artery (RAA-ALSCA), double aortic arch (DAA) and pulmonary artery sling (PAS), are congenital anomalies that may cause airway and oesophageal compression. As prenatal detection has improved, literature comparing clinical outcomes of antenatally versus postnatally diagnosed cases continues to emerge. The aim is to define a statewide tertiary paediatric institution's clinical profile and outcomes of prenatal versus postnatally diagnosed isolated vascular rings. A retrospective single-centre review of isolated RAA-ALSCA, DAA and PAS between 1 January 1999 and 31 December 2020 was conducted. Clinical characteristics, surgical and follow-up information were collected. Antenatal and postnatally diagnosed groups were compared. Out of 123 cases diagnosed with isolated vascular rings, 98 (79.7%) cases had RAA-ALSCA, 21 (17.1%) with DAA, 4 (3.3%) with PAS. The antenatal detection rate was 73.6% in the past decade; 20.3% had a genetic disorder, of which 48% had 22q11.21 microdeletion. Of prenatally diagnosed cases, 31.3% developed symptoms, commonly stridor and dysphagia, at a median age of 2.0 months (IQR 0.0-3.0), compared to a median age of diagnosis for the postnatal cohort of 9 months (IQR 1.0-40.7). Postnatally diagnosed cases were more likely to present with symptoms, primarily respiratory distress, than prenatally diagnosed cases (p=0.006). Fifty-nine (59) cases (50% antenatally diagnosed) required vascular ring division; 6.8% had residual symptoms following surgery. Antenatal diagnosis has improved and leads to better parental awareness and more timely, appropriate intervention. Postnatally diagnosed patients were older, more likely to be symptomatic, underwent more investigations and were commenced on more medications for symptom management prior to diagnosis. One in five cases of isolated vascular ring anomalies carried a genetic diagnosis, which has important implications on prenatal counselling and genetic testing.

External airway splint placement for severe pediatric tracheobronchomalacia

ObjectiveTo present external airway splinting with bioabsorbable airway supportive devices (ASD) for severe, life-threatening cases of pediatric tracheomalacia (TM) or tracheobronchomalacia (TBM). MethodsA retrospective cohort was performed for 5 pediatric patients with severe TM or TBM who underwent ASD placement. Devices were designed and 3D-printed from a bioabsorbable material, polycaprolactone (PCL). Pre-operative planning included 3-dimensional airway modeling of tracheal collapse and tracheal suture placement using nonlinear finite element (FE) methods. Pre-operative modeling revealed that triads along the ASD open edges and center were the most effective suture locations for optimizing airway patency. Pediatric cardiothoracic surgery and otolaryngology applied the ASDs by suspending the trachea to the ASD with synchronous bronchoscopy. Respiratory needs were trended for all cases. Data from pediatric patients with tracheostomy and diagnosis of TM or TBM, but without ASD, were included for discussion. ResultsFive patients (2 Females, 3 Males, ages 2–9 months at time of ASD) were included. Three patients were unable to wean from respiratory support after vascular ring division; all three weaned to room air post-ASD. Two patients received tracheostomies prior to ASD placement, but continued to experience apparent life-threatening events (ALTE) and required ventilation with supraphysiologic ventilator settings. One patient weaned respiratory support successfully after ASD placement. The last patient died post-ASD due to significant respiratory co-morbidity. ConclusionASD can significantly benefit patients with severe, unrelenting tracheomalacia or tracheobronchomalacia. Proper multidisciplinary case deliberation and selection are key to success with ASD. Pre-operative airway modeling allows proper suture placement to optimally address the underlying airway collapse.

Paediatric tracheobronchomalacia: Incidence, patient characteristics, and predictors of surgical intervention

ObjectivesTracheobronchomalacia (TBM), a condition where an abnormality of the tracheal walls causes collapse during the respiratory cycle, is a common cause of airway obstruction in childhood. TBM can present with a large spectrum of disease severity and underlying pathologies that may be managed medically and surgically, and it is not always clear which patients would most benefit from surgical intervention. We aim to describe the incidence, patient characteristics, and predictors of surgical intervention in a large cohort of paediatric patients. MethodsWe performed a retrospective review of all children diagnosed with TBM to a paediatric Otolaryngology unit in the west of Scotland between 2010 and 2020. Odds ratios for clinical predictors of surgery were calculated using logistic regression with uni- and multivariate analysis. Results249 patients were identified of which 219 proceeded to data collection. Primary malacia was noted in 161 (73.5%) and secondary in 58 (26.5%). Causes of secondary malacia included compression by the innominate artery (11%) and vascular rings (7.8%). Surgical interventions were performed in 28 patients (12.8%) including division of vascular ring, aortopexy, and surgical tracheostomy. Multivariate analysis showed secondary TBM, acute life-threatening events, and difficulty weaning from mechanical ventilation were independent risk factors for surgical intervention. ConclusionsTBM can present with a myriad of airway symptoms and is frequently associated with other airway and mediastinal pathologies necessitating multiple interventions. Children aged <1 year present with a more severe form of the disease and the presence of particular independent risk factors may indicate a need for surgical intervention. Level of evidence4

Feeding Difficulties Following Vascular Ring Repair: A Contemporary Narrative Review.

Vascular rings are congenital abnormalities of the aortic arch vascular system that compress the trachea and esophagus. A review of long-term outcomes suggests that chronic feeding difficulties can persist following surgical repair of vascular rings. Previous reports of postoperative vascular ring division outcomes indicate that chronic esophageal symptoms may persist following repair, though most available data focuses on persistent respiratory symptoms. It is therefore the aim of this article to summarize and organize recent evidence reporting the frequency, presentation, and management of feeding difficulties following vascular ring repair in pediatric patients. Pathophysiologic mechanisms for postoperative esophageal symptoms may include residual compression from an unresected diverticulum of Kommerell or delayed repair leading to chronic esophageal dysmotility despite correction of esophageal compression. Guidance on the management of feeding difficulties following vascular ring repair is limited. The authors describe success in one case with nasogastric tube feeding and interdisciplinary evaluation. Consensus regarding the management of feeding difficulty following vascular ring repair is needed.

Long-term outcomes in children undergoing vascular ring division: a multi-institution experience.

OBJECTIVESVascular rings are rare anomalies of congenital heart disease that cause respiratory and gastrointestinal symptoms. This study assessed the long-term outcomes of patients with vascular ring division.METHODSA multi-institution retrospective review of 371 patients with vascular rings undergoing surgical division at 3 paediatric cardiac institutions between November 2007 and October 2019 was performed.RESULTSThe complete vascular rings consisted of a double aortic arch (24.5%), right aortic arch with left ligamentum arteriosum (36.7%) and left aortic arch, with right ligamentum arteriosum (0.5%). The incomplete vascular rings consisted of a pulmonary artery sling (22.9%), left aortic arch with aberrant right subclavian artery (15.1%) and innominate artery compression syndrome (0.3%). Respiratory symptoms included stridor (71.4%), wheezing (49.1%), coughing (31.5%), gastrointestinal symptoms included choking (12.4%), dysphagia (3.2%) and emesis (1.9%). Only one patient died after discharge, yielding a late mortality rate of 0.3% (1/360). The 10-year overall survival rate was 96.8%. Postoperative complications were reported in 51 patients, 15 of whom required reoperation. The 10-year freedom from reoperation rate was 95.9%. Follow-up was completed in 95.4% (354/371) of patients, with a mean follow-up time of 4.3 ± 2.9 years (range from 1 to 13 years). Twenty patients (5.6%) experienced residual symptoms during long-term follow-up.CONCLUSIONSThe outcomes of vascular ring division are excellent. A Kommerell diverticulum >1.5 times the aberrant left subclavian artery origin is an operative indication for primary resection. Tracheomalacia is a risk factor for reoperation and residual symptoms, and preoperative fibrobronchoscopy is important for evaluation.

RING AROUND THE RESPIRATORY SYNCYTIAL VIRUS: A WINTER CASE OF A 10-MONTH-OLD IN RESPIRATORY DISTRESS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: We aim to highlight a case where respiratory syncytial virus (RSV) bronchiolitis, Haemophilus influenzae (H. flu) pneumonia, and reactive airway disease (RAD) simultaneously masked and unmasked the diagnosis of a complete vascular ring in a critically ill infant. CASE PRESENTATION: A 10-month-old term, previously healthy female presented with hypoxic/hypercapnic respiratory failure secondary to RSV bronchiolitis and H. flu pneumonia. She was intubated, started on antibiotics, and required pulmonary toilet for secretions and RAD. Over the following five days, she had progressively worsening ventilation, bronchospasm, and shock. By the morning of day six she reached maximal medical management of multiple inhaled and intravenous agents for bronchospasm (continuous albuterol, terbutaline, aminophylline then theophylline, ketamine, inhaled sevoflurane, a paralytic, and heliox), stress-dose steroids, and pressor support. Despite this, she continued to decompensate into the evening. It was noted that her peak pressures were consistently elevated despite intervention; the ECMO team was mobilized. Prior to cannulation, there was an abrupt inability to manually bag which suggested mechanical obstruction; arterial blood gases peaked (pH 6.74, pCO2 >250mmHg). Suspecting mucus plugging of the endotracheal tube (ETT), it was emergently exchanged with instantaneous ventilatory improvement: peak pressures and arterial blood gas normalized within thirty minutes (pH 7.45, pCO2 41mmHg). Inspection of the old ETT revealed no defect, so a CT chest with contrast was completed; it revealed a double aortic arch forming a complete vascular ring around trachea and esophagus. DISCUSSION: Vascular rings comprise 1% of congenital cardiac defects. In the first year of life approximately 87% of rings present with wheezing, stridor, or recurrent respiratory infections. The literature on vascular rings primarily focuses on raising suspicion because it is rare and often misdiagnosed. There was low suspicion in this case because of confirmed diagnoses of RSV, H. flu, and RAD. However, these diagnoses could not entirely explain her decompensation: chest x-ray was unimpressive compared to her clinical picture, and her high peak pressures and abrupt obstruction during manual bagging were inexplicable. The preceding events were likely explained by a precariously placed ETT that eventually slipped proximal to the ring, allowing complete obstruction (inability to manually bag). Re-intubation distal to the ring allowed for the correlating almost instantaneous clinical improvement. CONCLUSIONS: This case illustrates that one proper diagnosis does not exclude additional contributory diagnoses; therefore, we should not let our cognitive biases delay broadening differential when conventional treatment elicits inadequate response or does not align with what we understand of hemodynamic and pulmonary physiology. Reference #1: Leonardi B, Secinaro A, Cutrera R, et al. Imaging modalities in children with vascular ring and pulmonary artery sling. Pediatric Pulmonology. 2015;50(8):781-788. http://onlinelibrary.wiley.com/doi/10.1002/ppul.23075/abstract. https://doi.org/10.1002/ppul.23075. Reference #2: Naimo PS, Fricke TA, Donald JS, et al. Long-term outcomes of complete vascular ring division in children: A 36-year experience from a single institution. Interactive CardioVascular and Thoracic Surgery. 2016:ivw344. https://doi.org/10.1093/icvts/ivw344. Reference #3: Tola H, Ozturk E, Yildiz O, et al. Assessment of children with vascular ring. Pediatrics International. 2017;59(2):134-140. http://onlinelibrary.wiley.com/doi/10.1111/ped.13101/abstract. https://doi.org/10.1111/ped.13101. DISCLOSURES: No relevant relationships by Ashley Choe, source=Web Response No relevant relationships by Kerry Shum, source=Web Response No relevant relationships by Heather Slusser, source=Web Response

Outcomes following thoracotomy or thoracoscopic vascular ring division in children and young adults

ObjectiveTo determine the short- and intermediate-term outcomes following vascular ring division by video-assisted thoracoscopic (VATS) or thoracotomy approach. MethodsThis study is a retrospective review of patients with double aortic arch or right aortic arch with aberrant left subclavian artery and left ligamentum (RAA with LSCA/LL) who underwent division via left thoracotomy or VATS approach at a single institution. Outcome measures included operation duration (OR time), hospital length of stay (LOS), postoperative complications, and freedom from reintervention. ResultsA total of 200 patients underwent vascular ring division by VATS (n = 115) or thoracotomy (n = 85). Of 200 patients, 125 (56%) displayed respiratory symptoms at presentation, 29 (11%) displayed digestive tract symptoms, and 41 (32%) displayed both. Median follow-up was 2.1 years (interquartile range: 1 month to 7.1 years). Overall cohort mortality was 1 (0.5%) of 200 at 11 years after surgery. Fifteen (7.5%) experienced immediate postoperative complications. At follow-up visit within 1 month after surgery, 92 (74%) of 125 patients reported improvement in symptoms. Freedom from reintervention was 96% and 90% at 5 years and 10 years, respectively. Among patients with RAA with LSCA/LL (n = 113), VATS was associated with shorter LOS compared with thoracotomy (1.2 vs 3.4 days; P < .001), but rates of complications were not significantly different (9% vs 4%, P = .68). ConclusionsVascular ring division by either thoracotomy or VATS can be performed with low rates of complication and need for reintervention. Compared with thoracotomy, VATS is associated with shorter operative duration and hospital LOS among patients with RAA with LSCA/LL.

Long-term outcomes of complete vascular ring division in children: a 36-year experience from a single institution.

Complete vascular rings are rare and cause tracheoesophageal compression. Following surgical division, some patients have persisting tracheomalacia. We aim to assess the long-term outcomes of complete vascular ring division. All patients (n = 132) who underwent surgical division of a complete vascular ring between 1978 and 2014 were identified from the hospital database and retrospectively reviewed. Complete vascular rings consisted of a double aortic arch (n = 80), right aortic arch with an aberrant subclavian artery and left ligamentum arteriosum (n = 50), right aortic arch with mirror image branching and left ligamentum arteriosum (n = 1), and a left aortic arch with right descending aorta and right ligamentum arteriosum (n = 1). Kommerell's diverticulum was identified in 10 patients. Preoperative tracheomalacia was identified via bronchoscopy in 25 patients. Concomitant tracheal reconstruction was not performed in any patient. Kommerell's diverticulum was resected in 1 patient. The hospital mortality rate was 1.5% (2/132). There were no late deaths. The overall survival rate was 98.3 ± 1.2% (95% CI: 93.4, 99.6) at 20 years. Postoperatively, persistent tracheal compression was reported in 3 patients, and tracheomalacia in 16 patients. The rate of freedom from reoperation was 88.6 ± 4.0% (95% CI: 77.9, 94.3) at 20 years. No patient required tracheal surgery during the follow-up period. Follow-up was 92% (121/132) complete, with a median follow-up of 11.4 years (range 44 days to 36 years). At the last follow-up, 7 patients had mild tracheomalacia. Outcomes of division of a complete vascular ring are excellent. Tracheomalacia often improves following division of the vascular ring. Respiratory symptoms following complete vascular ring division are uncommon.

Thoracoscopic Management of Patent Ductus Arteriosus and Vascular Rings in Infants and Children.

Both patent ductus arteriosus (PDA) and vascular rings often require surgical treatment to prevent complications and alleviate symptoms, respectively. Management in infants and children has traditionally required an open thoracotomy. However, given the known advantages of the thoracoscopic approach, increased technical experience, and improved instrumentation, the minimally invasive technique to repair these thoracic vascular anomalies has grown in popularity. We report our experience with thoracoscopic PDA ligation and vascular ring division at a single institution. From October 1993 to March 2014, 78 patients underwent thoracoscopic PDA ligation, and 13 patients presented with vascular rings. Ages ranged from 2 days to 17 years (mean, 18 months), and weights ranged from 2 to 60 kg (mean, 8.5 kg) for the thoracoscopic PDA group, whereas ages ranged from 6 weeks to 13 years (mean, 19 months), and weights ranged from 3.6 to 38 kg (mean, 10 kg) for the thoracoscopic vascular ring division group. In the thoracoscopic PDA group, the mean operative time was 36 minutes. Complications consisted of one death not related to the procedure, one conversion to open for a torn ductus, one recurrence requiring re-operative thoracoscopic repair, and one residual PDA requiring cardiac catheterization with occlusion. In the vascular ring group, one procedure was unable to be completed thoracoscopically and was converted to open. In 2 cases, thoracoscopic exploration revealed no significant compression from the vascular ring, and dissection was stopped. Thoracoscopic closure of PDA and division of vascular rings are safe and effective techniques that minimize physiologic and cosmetic adverse effects.

Successful Robotic-Assisted Division of Symptomatic Vascular Ring

Successful Robotic-Assisted Division of Symptomatic Vascular Ring

Video-assisted Thoracoscopic Surgery: Is It a Superior Technique for the Division of Vascular Rings in Children?

The use of video-assisted thoracoscopic surgery (VATS) is becoming increasingly common in the treatment of congenital heart defects, particularly for the division of vascular rings. We compare the short-term outcomes of vascular ring division by VATS as opposed to open thoracotomy and discuss new issues raised by VATS division of vascular rings. Over a 3-year period, 47 pediatric patients underwent isolated division of a vascular ring. We reviewed preoperative, operative, and postoperative data. For patients whose vascular ring contained a ligamentous or atretic segment, comparisons were made between operations performed by open thoracotomy and by VATS. For the 47 patients, diagnoses included right aortic arch/aberrant left subclavian artery/left ligamentum arteriosum (25), double aortic arch/right dominant (19), and double aortic arch/left dominant (3). At the time of repair, ages ranged from 1.4 to 207 months (median 15.0) and weights ranged from 2.8 to 54.0 kg (median 11.0). The 29 patients with a vascular ring containing a ligamentous or atretic segment were included in the comparison between open thoracotomy and VATS. This included 25 patients with a right aortic arch, aberrant left subclavian artery, and ligamentum arteriosum, and 4 patients with a right dominant double aortic arch in which the left arch was atretic. Patients with patent rings requiring clamping and oversewing of the vessels were not included in the comparison. Thoracoscopic division was successful in 14/16 (88%) patients. There was no significant difference in the procedure time (P = .48) with the thoracoscopic approach. There were also similar times for intensive care unit stay (P = .25) and total length of hospital stay (P = .22). The division of vascular rings by VATS shows similar outcomes compared with the open thoracotomy approach. It is expected that, with an increase in comfort level and further improvements in technology, the use of VATS can be extended to include patients with other congenital heart defects.

Decade of Experience With Vascular Rings at a Single Institution

Over the past decade, the diagnostic workup of vascular rings has changed at our institution. Despite surgical intervention, we have observed long-term aerodigestive issues in some patients. In an effort to better characterize these pre- and postoperative issues, we reviewed a decade of experience at our institution. We performed a complete chart review of all patients identified as having surgical intervention for vascular ring between January 1993 and December 2003. A questionnaire was mailed to the family of each patient to ascertain a subjective assessment of long-term postoperative issues. Thirty-eight patients were reviewed and categorized as to specific arch anomaly. Associated cardiac anomalies were present in 29% of patients. Chronic feeding difficulties persisted in 18% of patients, and airway issues remained in nearly half of the patients. Patients with underlying genetic syndromes had less resolution of symptoms compared with nonsyndromic children. Chronic respiratory symptoms were present in 80% of patients operated <6 months, 15% if operated between 6 months and 3 years, and 42% of patients operated after 3 years of age. Aerodigestive issues may persist after vascular ring division despite initial improvement. Accurate preoperative anatomic imaging is imperative to surgical planning.

Totally Endoscopic Robotic-Assisted Repair of Patent Ductus Arteriosus and Vascular Ring in Children

This study reports on our initial experience with robotically assisted patent ductus arteriosus (PDA) closure and vascular ring division in children. From April 2002 to May 2004, 15 patients underwent PDA closure (n = 9) and vascular ring repair (n = 6) by a totally endoscopic approach, utilizing the Da Vinci robotic system. The mean age of the patients was 8.3 +/- 4.7 years (range, 3 to 18) and the mean weight, 35.5 +/- 19.0 kg (range, 14.1 to 77.0 kg). Three thoracoscopic trocars were used to accommodate the endoscopic camera and two surgical instruments with an additional small incision for lung retraction. After dissection by the surgeon seated at the master console, PDA ligation with clips or division of the atretic arch and ductal ligament was performed. Total operative times were 170 +/- 46 minutes (PDA) and 167 +/- 48 minutes (vascular ring). One patient with vascular ring was converted to thoracotomy because of dense adhesions due to previous surgery. Precise and easy surgical maneuver was possible with the articulated surgical instruments and three-dimensional visualization in 14 patients. Intraoperative transesophageal echocardiography confirmed no persistent shunt in all PDA patients. No laryngeal nerve injury and hemorrhage were noted. All patients were extubated in the operating room. Median length of postoperative hospital stay was 1.5 days. Robotically assisted PDA closure and vascular ring division is a feasible and safe procedure. Future technologic improvement, including smaller instrument size and incorporation of tactile feedback, may permit application of this technique to even younger infants and intracardiac repairs.

Resection of Kommerell's diverticulum and left subclavian artery transfer for recurrent symptoms after vascular ring division.

A Kommerell's diverticulum in patients with a right aortic arch may become aneurysmal and be an independent cause of tracheoesophageal compression, even after ligation and division of a left ligamentum. We review the indications for and results of Kommerell's diverticulum resection and left subclavian artery transfer in children with a right aortic arch who previously underwent vascular ring (ligamentum) division. From 1998 through 2001, eight children have been referred with recurrent respiratory symptoms (n=8) and/or recurrent dysphagia (n=4) after vascular ring division. Each child had a right aortic arch with a left ligamentum and had undergone division of the ligamentum elsewhere. All had a Kommerell's diverticulum that was not addressed at the initial operation. All patients had a repeat left thoracotomy with resection of the diverticulum. Five patients had division and reimplantation of the left subclavian artery into the left carotid artery to relieve the sling-like effect of the retroesophageal left subclavian artery on the right aortic arch. One other patient had primary Kommerell's diverticulum resection and transfer of the left subclavian artery to the left carotid artery. The mean age at the initial operation was 1.7+/-0.9 years, and the mean age at reoperation was 8.0+/-3.7 years. In all patients postoperative bronchoscopy confirmed relief of the tracheal compression. There were no complications related to the subclavian artery transfer. Two patients developed postoperative chylothorax, one requiring thoracic duct ligation. The median hospital stay was 5 days. All patients had dramatic resolution of their preoperative symptoms. Kommerell's diverticulum is an important anatomic structure that can cause recurrent symptoms in patients with a right aortic arch after ligamentum division. In selected patients, reoperation with resection of the Kommerell's diverticulum and transfer of a retroesophageal left subclavian artery results in relief of symptoms. This technique has become our procedure of choice as a primary operation for children with a right aortic arch and a significant Kommerell's diverticulum.

Hypoxemia During Thoracoscopic Interruption of Patent Ductus Arteriosus

In Response: We would like to thank Dr. Azzam for his interest in our study [1]. We do not think that temporary atrial right-left (R-L) shunt was the cause of transient desaturation in our patients. Of the 12 patients who presented with brief desaturation, 6 did not have lesions associated with increased pulmonary blood flow (one case each: collateral vein division, pacemaker wire insertion, diagnostic thoracoscopy, pericardial effusion drainage, vascular ring division, and thoracic duct interruption). Of the remaining six, five had a patent ductus arteriosus (PDA), and one had an aortopulmonary collateral, which might be considered to have a pathophysiology similar to PDA. In all of these the patients, desaturation occurred before interruption of the PDA or collateral. It is conceivable that, regardless of the underlying lesion, retraction of the lung and consequent hypoventilation, hypocarbia, and increased pulmonary vascular resistance induced R-L atrial shunting in the presence of a patent foramen ovale. Any attempt to compare the patients of Marshall et al. [2] with those of our study must be done with caution. The patients reported by Marshall et al. were uniformly small premature infants with PDA. Second, the cause of desaturation in these patients was never defined. Although the fall in transcutaneous PO2 (tCO2) occurred after ligation of the PDA in these patients, it also required left lung inflation to resolve. Finally, these premature infants did not receive any anesthetic or analgesic drug beyond local infiltration of the skin. Therefore, it is likely that their stress response to the procedure was significant. The use of fentanyl in preterm infants undergoing PDA ligation has been shown to attenuate the perioperative stress response, reduce ventilatory requirements, and decrease metabolic and circulatory complications [3]. It is also possible that the desaturation in Marshall et al.'s patients was at least in part caused by increased right-sided cardiac filling pressures (and, hence, R-L atrial shunting) due to elevated PVR and shifting of circulating blood volume from the systemic to the pulmonary circulation caused by elevated blood catecholamine concentrations [4]. Josee Lavoie, MD, FRCP Department of Anaesthesia; Montreal Children's Hospital; Montreal, Quebec, H3H 1P3, Canada Frederick A. Burrows, MD Department of Anesthesia; Arkansas Children's Hospital; Little Rock, AR 72202 Dolly D. Hansen, MD Department of Anesthesia; Children's Hospital; Boston, MA 02115

Video-Assisted Thoracoscopic Surgery for the Treatment of Congenital Cardiac Defects in the Pediatric Population

Recent technologic advances have contributed to a renewed interest in thoracoscopic surgery.In our institution, thoracoscopy through video-assisted technology has been successfully applied to congenital heart surgery. We reviewed the charts of 45 consecutive patients (ASA physical status II-IV) who underwent video-assisted thoracoscopic surgery (VATS) for various congenital heart defects. The mean age of the patients was 2.65 yr and the mean weight was 11.78 kg. The surgical procedures included patent ductus arteriosus interruption (n = 28) and vascular ring division (n = 8), and 9 patients had miscellaneous procedures. The most commonly used anesthetic regimen consisted of isoflurane, pancuronium, fentanyl, air, and oxygen. Seven patients were managed with one-lung ventilation, the remainder by two-lung ventilation with surgical lung retraction. Intraoperative desaturation occurred in 12 patients (26.7%) but resolved quickly with brief reexpansion of the lungs. Postoperative complications included: pleural effusions (n = 3), chylothorax (n = 2), right upper lobe atelectasis (n = 1), small pneumothorax (n = 1), and vocal cord paralysis (n = 1). Seven patients (15.5%) required conversion to a thoracotomy for insufficient exposure (n = 4) or due to concern over bleeding (n = 3). This experience with VATS in pediatric patients with congenital heart disease may provide a database for comparison with others who work with the VATS technique. (Anesth Analg 1996;82:563-67)

Video-Assisted Thoracoscopic Surgery for the Treatment of Congenital Cardiac Defects in the Pediatric Population

Recent technologic advances have contributed to a renewed interest in thoracoscopic surgery. In our institution, thoracoscopy through video-assisted technology has been successfully applied to congenital heart surgery. We reviewed the charts of 45 consecutive patients (ASA physical status 11-IV) who underwent video-assisted thoracoscopic surgery (VATS) for various congenital heart defects. The mean age of the patients was 2.65 yr and the mean weight was 11.78 kg. The surgical procedures included patent ductus arteriosus interruption (n = 28) and vascular ring division (n = 8), and 9 patients had miscellaneous procedures. The most commonly used anesthetic regimen consisted of isoflurane, pancuronium, fentanyl, air, and oxygen. Seven patients were managed with one-lung ventilation, the remainder by two-lung ventilation with surgical lung retraction. Intraoperative desaturation occurred in 12 patients (26.7%) but resolved quickly with brief reexpansion of the lungs. Postoperative complications included: pleural effusions (n = 3), chylothorax (n = 2), right upper lobe atelectasis (n = 1), small pneumothorax (n = 1), and vocal cord paralysis (n = 1). Seven patients (15.5%) required conversion to a thoracotomy for insufficient exposure (n = 4) or due to concern over bleeding (n = 3). This experience with VATS in pediatric patients with congenital heart disease may provide a database for comparison with others who work with the VATS technique.

Video-assisted thoracoscopic vascular ring division in infants and children

This study evaluated our early experience with video-assisted thoracoscopic vascular ring division and compared this approach with division by means of a conventional open thoracotomy. Video-assisted thoracoscopic techniques reduce surgical trauma and have been applied to several adult thoracic procedures; however, pediatric applications have been limited. We developed instruments and techniques for video-assisted thoracoscopic vascular ring division in the pediatric population. We compared patient characteristics, operative results and postoperative hospital courses of all patients undergoing vascular ring division by a video-assisted approach with a historical control group of all patients undergoing division by an open thoracotomy between January 1991 and December 1992. Eight patients (median age 5 months, range 40 days to 5.5 years; median weight 6.2 kg, range 1.8 to 17.1) underwent video-assisted thoracoscopic vascular ring division. Four had a double aortic arch with an atretic left arch and a left ligamentum, and four had a right aortic arch with aberrant left subclavian artery and a left ligamentum. All eight had successful ring division with symptomatic relief and no mortality. A limited thoracotomy was performed in three patients to divide patent vascular structures, and the hospital period was prolonged in one because of chylothorax. These eight patients were compared with a historical cohort of eight pediatric patients having vascular ring division performed by a conventional thoracotomy. The two groups did not differ in age, weight, intensive care unit or postoperative hospital stay, duration of intubation or thoracostomy tube or hospital charges. Total operating room time was longer for the group undergoing video-assisted operation. Early results for video-assisted thoracoscopic vascular ring division are comparable to those of the conventional surgical approach. With further refinement in technique and instrumentation, video-assisted surgical intervention may become a viable alternative to open thoracotomy for management of the symptomatic vascular ring.

Video-assisted thoracoscopic surgery for congenital heart disease

Video-assisted endoscopic techniques have reduced operative trauma in adult thoracic and general surgery, but applications in children with congenital heart disease have been limited. We report the development of video-assisted thoracic surgery procedures for neonates and infants with cardiovascular disease. Endoscopic instruments and techniques for pediatric cardiovascular procedures were designed and tested in the animal laboratory. Forty-eight operations were subsequently performed in 46 pediatric patients ranging in age from 2 hours to 14 years (median 9 months), weighing from 575 grams to 54 kg (median 8.5 kg). Clinical applications included seven different procedures: patent ductus ateriosus interruption in infants ( n = 26) and premature neonates ( n = 5), vascular ring division ( n = 8), pericardial drainage and resection ( n = 3), arterial and venous collateral interruption ( n = 2), thoracic duct ligation ( n = 2), epicardial pacemaker lead insertion ( n = 1), and diagnostic thoracoscopy ( n = 1), and diagnostic thoracoscopy ( n = 1). there was no operative mortality. Technical success, defined as a video-assisted procedure completed without incising chest wall muscle or spreading the ribs, was achieved in 39 of 48 procedures (82%), with thoracotomy required to complete nine procedures. Most patients (22/25, 88%) undergoing elective ductus ligation were extubated in the operating room and discharged from the hospital within 48 hours of the operation. Eight of the last 10 patients having ductus ligation were discharged on the first postoperative day. Residual ductal flow was assessed by (1) transesophageal echocardiography in the operating room (incidence: 0/25, 0%, 70% CL 0% to 7.3%); (2) discharged auscultation (incidence: 1/30, 3%, 70% CL 0.5% to 10.8%); and (3) follow-up Doppler echocardiography (incidence: 1/30, 3%, 70% CL 5.4% to 22.6%). Video-assisted thoracoscopic techniques can be safely applied to pediatric patients with patent ductus arteriosus and vascular rings and may become an effective addition to the staged management of more complex forms of congenital heart disease. (J T HORAC C ARDIOVASC S URG 1995; 109: 499-508)