Residual VSD Research Articles

Outcomes of Total Surgical Correction for Tetralogy of Fallot in Benghazi

Tetrology of Fallot (TOF) is the most common cyanotic congenital heart disease, accounting for 10% of all types of congenital heart disease. Despite decreased mortality rates by improvement in surgery and post-cardiac intensive care, there continues to be late postoperative complications. This study aimed to evaluate the outcomes after total repair of tetralogy of Fallot, including 44 children who underwent complete surgical repair between 2000 to 2018. Data were collected from medical records and directly from patients during their visit to the clinic, that included: history, clinical examination, gender, age at operation, results of ECG, Holter monitoring, echocardiography, cardiac catheterization, cardiac CT scan. Follow-up ranged from 6 months to18 years. Results revealed that the M/F ratio was 1.4:1. Also, two patients had a previous palliative systemic artery to PA shunt. A TAP was inserted in 22 (50%) patients. Postoperative complications were: severe PR 29%, small residual VSD 18.1%, and two patients had significant VSD which needed surgical intervention, residual RVOT 8.1%, RBBB 97.7%, There was three death (6.8%), and 36.3% of patients will need surgical intervention in the future. It was concluded that follow-ups up to adulthood to monitor potential complications are necessary. QRS duration is used for monitoring ventricular arrhythmia and sudden death. Echocardiography is a non-invasive tool in diagnosis, before and at the time of surgery, as well as in follow-ups.

The Destiny of Postoperative Residual Ventricular Septal Defects After Surgical Repair in Infants and Children.

Residual ventricular septal defects (rVSDs) of small size are commonly seen on transesophageal echocardiography after surgical repair. This study aimed to determine the destiny of rVSD found on intraoperative echocardiogram. Patients undergoing surgical repair of VSD as the primary procedure with available intraoperative and discharge echocardiograms between 2007 and 2017 were reviewed. Presence of an rVSD on intraoperative echo triggered review of discharge echo and of subsequent follow-up echocardiograms. One hundred four patients were analyzed. The mean age and weight for the entire cohort were 1.4 ± 2.9 years (median, 5.4 months; range, 29 days to 14 years) and 8.8 ± 9.9 kg (median, 5.1 kg; range, 2.7-58 kg), respectively. Sixty (57%) patients had rVSD at discharge, with mean size of residual VSD of 1.38 ± 0.92 mm (mode, 0.6; median, 2.2 mm; range, 0.5-3.9 mm). The mean follow-up time was 3.7 ± 3.1 years (range, 1 month to 9.3 years). Among those with rVSD at discharge, a residual shunt persisted in 73% at one-month follow-up. On follow-up at three years postdischarge, of the 60 patients with early rVSD, 6 had a persistent rVSD (10%) with a mean diameter of 3.0 ± 0.8 mm (range, 2.4-3.9 mm). Residual VSD after surgical repair is detected frequently on postoperative echocardiogram. The presence of rVSD was not associated with any preoperative, intraoperative, or postoperative factors. By three years of follow-up, only six patients continued to demonstrate rVSD with a mean diameter of 3 mm, suggesting that defects 3 mm or greater may be less likely to close spontaneously after three years.

Early outcome of total correction in adult tetralogy of fallot patients.

Objectives: To detect the early outcome of total correction of Tetralogy of Fallot (TOF) in adult patients of age 16 years or above. Study Design: Retrospective descriptive case series. Setting: Paediatric Cardiac Surgery Department of Faisalabad Institute of Cardiology, Faisalabad. Period: October 2016 to June 2019. Material & Methods: All consecutive patients of age 16 years or above who underwent total correction for TOF during study period were included. Surgical procedure and early outcome measures were recorded and analyzed. Results: Sixty nine patients underwent total correction for TOF during the study period. Majority of patients (n=55, 79.7%) were between16 to 25years of age. Male dominated the study population (56.5%, n=39) with male to female ratio 1.3: 1. Nine patients (13%) had coiling of MAPCA before surgery while prior palliation with Blalock Taussig shunt (BT Shunt) was seen in 5.8 % patients (n=4). All patients were operated with trans-atrial trans-pulmonary approach (n=69, 100%). Pulmonary artery was augmented with pericardial patch in 22 cases (32%) while left pulmonary artery (LPA) augmentation was done in two patients. Pulmonary valve annulus divided in 22 % of patients (n=15), RVOT was reconstructed with trans-annular pericardial patch in 10.1% patients (n=7) while Pulmonary valve was replaced with tissue valve in 7 patients (10.1%). In one patient RV to PA continuity was established with contegra. Post operatively Inotropic support was given for initial 39 ±45 hours, mean ICU stay was 39±75 hours, mean chest drainage 1086±741 ml and mean requirement for blood transfusion was 2.2 ±2.4 units. As regard early complications, six patients had tiny to small residual VSD (8.7%) while no patient developed complete heart block. Two patients had neurological damage (2.9%), one patient developed renal failure (1.45%) while chest reopening was done in two patients due to postoperative bleeding and/ or tamponade (2.9%). There was death of two patients (2.9%), one had renal failure due to low cardiac output (LCOS) and the other had stroke. Conclusion: The early outcome of complete repair of TOF in patients 16 years and above is good with a negligible mortality and limited number of complications.

Transatrial approach for total correction of tetralogy of Fallot: our centre experience over three years

Background: The objective of this study was to evaluate the early and mid-term outcome of total correction of tetralogy of Fallot (TOF) done through transatrial approach avoiding ventriculotomy with or without transannular patching.Methods: Of 210 patients undergoing total correction for TOF between January 2016 and January 2019, 180 patients were operated via transatrial approach. The ventricular septal defect closure, infundibular resection and pulmonary valvotomy were performed through the right atrium. Age ranged from 12 months to 44 years (mean, 2.6 years), 104 patients were male and 76 patients were females.Results: Three patients (1.67%) died in early post-operative period. Pulmonary complications were seen in 8 (4.44%), septicemia in 1 (0.55%), low output syndrome in 2 (1.10%) and temporary arrhythmias in 6 (3.33%) patients. Reintubation was needed in 3 (1.67%) patients. Early reoperation was needed in 3 (1.67%) patients in view of post-operative bleeding. There were no mediastinal or deep sternal wound infections. None of our patient had complete heart block. There were no late deaths or late reoperations. Echocardiography before discharge did not reveal significant residual VSD in any patient. The mean right ventricular outflow tract pressure gradient was 28 mmHg (range of 20 to 44 mmHg) which decreased on follow-up echocardiography to 16 mmHg (range of 14 to 24 mmHg) at mean follow up of 23 months. None of our patient had severe pulmonary or tricuspid regurgitation or severe right ventricular dysfunction on follow up.Conclusions: Transatrial repair of TOF is associated with remarkably low morbidity and mortality in our early experience.

P1500 Reptilian heart in a man

Abstract 40 year old man admitted to hospital due to tachycardia episode. His normal ECG was consistent with RBBB with a QRS duration of 200msec. He had undergone a VSD operation when he was 6. He had a 3/6 systolic murmor . On TTE, there was a VSD patch and a residual tiny VSD with a L-R shunt. The maximum systolic gradient of VSD shunt was measured as 92mmHg .There was also moderate tricuspid regurgitation (TR) with a peak velocity of 5.1m/sec and estimated sPAP of 103mmHg. Considering the measured sPAP and the VSD shunt gradients, his systolic blood pressure (SBP)should approximately be equal to sum of those two ( 103+ 92 = 195mmHg). However his BP was 140/90mmHg.When we examined his heart for a possible explanation for this inconsistency, we noticed a systolic aliasing inside the RV with a maximum velocity of 3.1m/sec and systolic gradient of 38mmHg. However the chamber with lower pressure (P) was the one to which the VSD shunt was directed, and this chamber was in direct continuity with pulmonary artery. So to confirm the P in this chamber we also used pulmonary regurgitation flow and measured a peak diastolic velocity of 3.8m/sec, meaning a mean PAP of 60mmHg .Cardiac catheterization also confirmed a sPAP of 116mmHg and mPAP of 65mmHg. The systolic aortic P was 145mmHg and systolic LV P was 152mmHg. So the unexpectedly high gradient of VSD shunt was still a mystery for us. While searching the literature to explain this , we noticed that the patients’ heart was resembling the reptilian heart model. The reptilian heart has two atria and one ventricle with 3 segments seperated via muscular ridges. In our patients’ heart ,the small chamber with high P in the RV was the cavum venosum, the larger chamber of RV with VSD was the cavum pulmonale, and the left ventricle was the cavum arteriosum. (Fig) The reptilian hearts typically have noncompacted myocardium which was actually the case in our patient. The reptilian hearts also have unique conduction system with no AV node and His bundle, and slow depolarization of ventricle from left to right. When we performed EPS, we found that the patient had no AV node and His bundle. Bringing together all these findings, we conclude that the patient has a reptilian heart with all anatomical, electrical and physiological features. And the answer to the mystery of inconsistent P recordings was hidden in ECG. The RBBB with very long QRS duration causes a delay between contraction of ventricles resulting in a dynamic P gradient between ventricles. We demonstrated this dinamic bidirectional shunt on CW recording when we obtained a more optimal recording of the shunt flow.This case demonstrates us one more evidence of human evolution; arising from single cell and developing to fish, to reptiles and to mammals. The evolution takes place again and again during neonatal life. If there is an embryological arrest, as occured in our patient, we can easily see the clues of this amazing human evolution. Abstract P1500 Figure

Incidence of Aortic Regurgitation in Association with Type of Ventricular Septal Defects and its Immediate and Intermediate Outcome after Surgical Closure.

IntroductionVentricular septal defect (VSD) is one of the more common congenital heart defects, and aortic regurgitation (AR) is its major complication if it remains unrepaired. We aim to determine the AR incidence in various types of VSD, its immediate and intermediate six to 12-month post-VSD repair outcomes of AR.MethodsWe conducted a retrospective review of medical records of all children aged 18 years or younger who were diagnosed with single VSD at our institution from 2016 to 2018. VSD was classified according to its location and relation to the tricuspid annulus and semilunar valve. AR severity grading was done according to the American Society of Echocardiography, and vena contracta width (VC) was taken as the main parameter for severity. We defined trivial-to-mild AR as VC width less than 0.3 cm, moderate AR was 0.3-0.6 cm VC width, and severe AR was VC width of more than 0.6 cm. Immediate and intermediate outcomes of surgical closure, such as residual VSD and AR, were observed.ResultsOne hundred ninety patients with isolated single VSD were included in the study. Of those, 114 patients had perimembranous VSD (60.0%), 64 patients had muscular VSD (33.7%), and 12 patients had supracristal VSD (6.3%). The median age of our study cohort was six months, with a male to female ratio of 1.3:1. Aortic valve prolapse (28.9%; n = 55) and AR (23.2%; n = 44) were the most common findings on echocardiographic evaluation of VSD patients. Most cases of VSD with AR had trivial-to-mild AR, (68.2%; n = 30). AR was most commonly seen in supracristal VSD (83.3%; n = 10) followed by perimembranous VSD (28.9%; n = 33). VSD closed spontaneously in 34 patients (17.9%) and 98 patients (51.6%) patients underwent surgery. Residual VSD after surgical closure was present in 57.1% (56) and 17.3% (17) of the patients immediate postoperatively and six- to 12-month postoperative follow-up, respectively. Similarly, residual AR after surgical closure of VSD was present in 32.7% (32) and 15.3% (15) of the patients immediate postoperatively and six- to 12-month postoperative follow-up, respectively.ConclusionThe incidence of AR with VSD was very high in our study; AR was most commonly associated with supracristal VSD. After surgical repair, mild AR decreased with time. Early corrective surgery of VSD can prevent this complication and help improve outcomes.

Outcome ventricular septal defect Closure using the Nit-O

Introduction The main goal is to study outcome ventricular septal defect Closure using the Nit-Occlud Le VSD-Coil. Methodology Following IRB approval from KAIMRC with number RC17/285/R, a retrospective chart review analysis were conducted of all pediatric patients with VSD who underwent transcatheter closure of VSD at King Abdul-Aziz Cardiac Center during the period from 2011till 2016. Demographic data, diagnosis, intraprocedure and post-procedure events were reviewed. Results The patients referred for VSD interventional closure are 46 patients, 29 cases fulfill the criteria for VSD closure using Nit-Occlud Le VSD-Coil, twenty-four patients of them had successful interventional closure of VSD with successful rate of 83% and 5 cases were referred to surgery due to device not fit or hemolysis. In this study, age group from 2 years up to 18 years. Ninety percent of VSD is the perimembranous (PM) type, 26 patients, and 3 patients (10%) with muscular VSD. From the 26 PM VSD cases 10 with TV accessory tissue partially covering the VSD defects. Immediate closure of the defect was achieved in 11/24 patients (45%); in five patients, there was tiny residual and 8 with small residual, at 6 months follow up only 6 patients with tiny residual VSD defect. Conclusion The Nit-Occlud”-Le VSD coil device with high safety level used for selected cases of VSDs. The device has minimal effects on the aortic and tricuspid valve, and there was no permanent AV block especially in patients with PM VSDs. Patients with a residual shunt should be followed, especially for the hemolysis.

Management of post-myocardial infarction ventricular septal defects: A critical assessment.

Post-myocardial infarction (MI) ventricular septal defects (PIVSD) are an uncommon but life-threatening complication of acute MI. Although surgical closure has been the standard of care, mortality, and recurrence of VSD remain high even after emergent surgery. Transcatheter VSD closure (TCC) devices have become an alternative or adjunct to surgical closure. Online database search was performed for studies that included adults with PIVSD who underwent medical treatment (MT) alone, surgical closure (SC) (early or late), and TCC (early, late, or for post-surgical residual VSD). Twenty-six studies were included with a total of 737 patients who underwent either MT (N = 100), SC (early (n = 167), late (n = 100)), and TCC (early (n = 176), late (n = 115), or post-surgical residual VSD (n = 79)). The 30-day mortality among MT group was 92 ± 6.3%, among SC was 61 ± 22.5% (early 56 ± 23%, late 41 ± 30%), and for all TCC patients was 33 ± 24% (early 54 ± 32.7%, late 16 ± 26%), and TCC for post-surgical residual VSD 11 ± 34.9%. The mortality among overall SC, overall TCC and early TCC groups was significantly lower as compared with the MT (P < 0.001 for all comparisons). The overall mortality among all TCC, and late TCC groups was significantly lower when compared with the late SC (P < 0.0001, P < 0.0001, respectively). Closure of PIVSD decreases mortality as compared with MT alone and should be attempted as early as possible after diagnosis. Selection of TCC versus SC should be based on factors including complexity of the defect, availability of closure devices, expertise of the operator, and clinical condition of patient.

Right ventricular workload assessed by FDG-PET in a patient with residual VSD and infundibular pulmonary stenosis after repair of tetralogy of Fallot

Right ventricular workload assessed by FDG-PET in a patient with residual VSD and infundibular pulmonary stenosis after repair of tetralogy of Fallot

The role of intraoperative epicardial echocardiography in pediatric cardiac surgery.

Our aim was to evaluate the findings and the role of intraoperative epicardial echocardiography (IEE) in the management of pediatric cardiac surgery patients. Patients evaluated with IEE between December 2015 and December 2017 were analyzed retrospectively. Demographic data, preoperative transthoracic echocardiography (TTE), and IEE reports were evaluated. A total of 410 patients evaluated by IEE were included in the study. Of these, 52% were women, and 48% were men. The median age was 8.5months (range: 1month-7years), and median body weight was 7.1kg (range: 3.3-61kg). The most common diagnoses were tetralogy of Fallot (TOF; n=148), ventricular septal defect (VSD; n=117), atrial septal defect (ASD; n=57), and complete atrioventricular septal defect (AVSD; n=48). There were minor residual lesions not requiring reestablishment of cardiopulmonary bypass (CPB) in 16.6% (n=68), while major residual lesions requiring return to CPB were determined in 5.1% (n=21). Major residual lesions were detected in 7 patients with TOF (4 severe right ventricular outflow tract obstructions, 2 pulmonary artery stenosis, 1 residual VSD shunt), 6 patients with VSD (hemodynamically significant residual shunts), and 5 patients with complete AVSD (3 left atrioventricular valve regurgitations, 1 right atrioventricular valve regurgitation, 1 left ventricular outflow tract obstruction). Transient bradycardia was observed in 5 patients. Intraoperative epicardial echocardiography provides good guidance during congenital heart surgery. IEE helps to clarify the surgical planning and decreases morbidity and mortality due to unnecessary invasive procedures, especially for pathologies involving the pulmonary artery and its branches, as well as for apical ventricular septal defects.

Total Repair of Tetralogy of Fallot: Trans-Atrial Trans-Pulmonary Approach Versus Trans-Ventricular Approach

1. Abstract 1.1. Background: <span style=font-size:10.0pt; font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Tetralogy of Fallot (TOF) is one of the common cyanoticheart diseases.Now total repair is spreading to save children at younger age and lower body weight.The aim of this study was to evaluate the results of the two different surgical techniques used for total repair of tetralogy of Fallot:transatrial-transpulmonary approach and transventricular approach with special emphasis on preoperative and intraoperative risk factors that affecting the prognosis of patients,and with analysis of postoperative short-term results. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.2. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Patients and Methods: Between January 2014 and December 2016,sixty patients withTOF were randomly collected in a prospective study. Children divided into two groups,GroupAincluded 30 patients repaired through transatrial-transpulmonary approach.GroupBincluded30 patients repaired through transventricular approach. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman;letter-spacing:= -.3pt=>1.3. Results: <span style=font-size:10.0pt; font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Preoperative characteristics and variables of patients were similar.As regard to cardiopulmonary bypass time,cross-clamp timethere were no significant differences(p>0.05).There were significant differences in ventilation time(p 0.023),inotropic support(p 0.001)and duration of stay in the ICU(p0.001).The incidence of arrhythmia2 patients (6.7%)vs.5 patients (16.7%)]with non- <span style=font-size: 10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:arial;= mso-font-width:99%=>significant difference.There is significant difference in right/left ventricular pressure ratio(p At follow up,Comparisons between both groups showed no significantdifferences as regard to RV pressure and PG across the RVOT(P>0.05).None of our children needed reintervention for residual VSD or significant RVOTO.There were three mortalities(5%),one in group A due to RV dysfunction and two in group B due toventricular arrhythmia and RV dysfunction. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.4. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Conclusion: Total repair is the primary choice for management of FallotTetralogy.We encourage transatrial-transpulmonary repair to avoid ventricular incisions, otherwise a limited ventriculotomy is sufficient rather than extended ventriculotomy with transannular repair. 2. Keywords: Congenital Heart Disease; Surgical Techniques; Tetralogy of Fallot

Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Single-Center Intermediate-Term Experience.

We present our experience for patients who have undergone an anatomic repair (AR) for congenitally corrected transposition of the great arteries (CCTGA) at the Children's Hospitalof Wisconsin. A retrospective chart review of patients who underwent AR for CCTGA from 2001 to 2015 was performed. The cohort consisted of 15 patients (74% male). Median age of anatomic repair was 15months (range 4.5-45.6months). Four patients had a bidirectional Glenn (BDG) prior to AR. At the time of AR,-9 (60%) underwent Senning/Rastelli procedure, 4 (26.6%) had double switch operation, and 2 (13.3%) underwent only Senning with VSD closure. Median duration of follow-up was 5.5years (0.05-14years). Reoperations prior to discharge included BDG, revision of pulmonary venous baffle, closure of residual VSD, and pacemaker placement. Late reoperations included left ventricular outflow tract obstruction repair, conduit replacement, melody valve placement, and pacemaker implantation. At their most recent follow-up, no patient had heart failure symptoms and only 1 had severely diminished function that improved with cardiac resynchronization therapy. Moderate mitral regurgitation was noted in 15% (2/13), and severe in 7% (1/13). Moderate tricuspid regurgitation was noted in 15% (2/13). One patient, 7% (1/13), developed moderate aortic insufficiency. There was a 100% survival at the time of the most recent follow-up. Patients with CCTGA who have undergone AR have excellent functional status and mid-term survival but reinterventions are common. Longer term studies are needed to determine both the extent and spectrum of reinterventions as well as long term survival.

85 Post operative complications in adult congenital heart disease

IntroductionIncreasing numbers of adults with congenital heart disease (ACHD) are undergoing redo or primary surgical procedures. There is little available data relating to post-operative mortality and morbidity in this group.MethodsWe...

Tetralogy of Fallot repair in patients presenting after Infancy: A single surgeon experience.

Objective:To determine the early surgical outcomes of Tetralogy of Fallot (TOF) repair in children and young adults operated after the age of one year.Methods:In this retrospective study, 307 cases of primary repair of Tetralogy of Fallot were done between September 2012 to February 2017, at CPE Institute of cardiology, Multan. Out of 307 operated patients, 4 (1.3%) patients had previous modified Blalock Taussig shunts, 2 (0.6%) associated ASD with TOF, 3 (0.9%) co-association of TOF with PDA, 2 (0.6%) had large conal arterial branch crossing the annulus, 3 (0.9%) had dextrocardia with situs inversus, 12 (3.9%) TOF with double outlet right ventricle (DORV), 2 (0.6%) were associated with complete AV canal defect, 8 (2.60%) with absent pulmonary valve syndrome, 15 (5.5%) with left pulmonary artery stenosis. Data of post-operative complications and operative parameters was recorded for all patients.Results:Mean age of operated patients was 9.56±4.89 years. Post-operative complications occurred in 7.8% of patients. Most common post-operative complications were pleural effusion with a frequency of 12(3.9%) patients, and complete heart block in one patient. Insignificant small residual VSD was diagnosed in 8 (2.6%) patients. One moderately large VSD was closed surgically after one year of 1st surgery. Moderate to severe pulmonary valve regurgitation was diagnosed in 114 (37.1%) patients. Mild to moderate tricuspid regurgitation in 15 (4.8%) patients and moderate right ventricular outflow tract obstruction (RVOT) in 16 (5.2%) patients. Thirty-day mortality was only four (1.3%).Conclusion:Surgical correction of Tetralogy of Fallot (TOF) in children after one year carries good operative outcomes with minimum morbidity and mortality.

心室中隔欠損症に対する再手術 30 例の検討

心室中隔欠損症に対する再手術 30 例の検討

Echocardiography for residual VSD.

Echocardiography for residual VSD.

0362: Tetralogy of Fallot complete repair: humanitarian chains versus French native children

French humanitarian chains promote surgery for children with congenital heart diseases coming from developing countries. We assessed the results following complete repair of tetralogy of Fallot (TOF) in relation to the origin of patients. A 4-years retrospective review of 73 consecutive patients with TOF repair was performed. Children were divided into two groups: French children (group A, n=38) and children from developing countries (group B, n=35). Preoperative status differed between the two groups. Children from group B were older (0.82 vs 7.18 year-old, p<0.001), with a lower BMI (16 vs 14 kg/m2, p<0.001). They were more symptomatic with lower oxygen saturation (90% vs 83%, p=0.007) combined with a higher level of plasmatic hemoglobin (13.1 vs 16.1 g/dl, p<0.001). Proportion of preoperative palliative surgery was higher although not significant in group A (18% vs 6%, p=0.156). There wasn’t any irregular form due to coronary abnormality in the two groups. Preoperative echography showed no difference concerning the rate of pulmonary annulus Z-Score < - 3 (39% vs 43%, p=0.956). Results of surgery showed no differences in terms of aortic cross clamping time (65 vs 60 min, p=0.235) or rate of trans-annular patch insertion (37% vs 31%, p=0.810). Postoperative course didn’t significantly differ between the two groups. There was no death, two early reoperations (one for bleeding and one for residual VSD) and one late reintervention for residual supra-valvular stenosis in group A after a median follow-up time of 1.8 years. There was one early death (2.8%) and one early reoperation for bleeding in group B after a median follow-up time of 30 days. All were in sinus rhythm. Elective surgery for TOF repair carries low risk of morbimortality. Despite worst preoperative status, children from humanitarian chains can be treated safely by complete repair. Palliative surgery must be reserved for children presenting a marked cachexia profile.

Tetralogy of Fallot complete repair: Humanitarian chains versus French native children

French humanitarian chains promote surgery for children with congenital heart diseases coming from developing countries. We assessed the results following complete repair of tetralogy of Fallot (TOF) in relation to the origin of patients. A 4-year retrospective review of 73 consecutive patients with TOF repair was performed. Children were divided into two groups: French children (group A, n = 38) and children from developing countries (group B, n = 35). Preoperative status differed between the two groups. Children from group B were older (0.82 vs 7.18 year-old, P < 0.001), with a lower BMI (16 vs 14 kg/m 2 , P < 0.001). They were more symptomatic with lower oxygen saturation (90% vs 83%, P = 0.007) combined with a higher level of plasmatic hemoglobin (13.1 vs 16.1 g/dL, P < 0.001). Proportion of preoperative palliative surgery was higher although not significant in group A (18% vs 6%, P = 0.156). There wasn’t any irregular form due to coronary abnormality in the two groups. Preoperative echography showed no difference concerning the rate of pulmonary annulus Z Score < –3 (39% vs 43%, P = 0.956). Results of surgery showed no differences in terms of aortic cross-clamping time (65 vs 60 min, P = 0.235) or rate of trans-annular patch insertion (37% vs 31%, P = 0.810). Postoperative course didn’t significantly differ between the two groups. There was no death, two early reoperations (one for bleeding and one for residual VSD) and one late reintervention for residual supra-valvular stenosis in group A after a median follow-up time of 1.8 years. There was one early death (2.8%) and one early reoperation for bleeding in group B after a median follow-up time of 30 days. All were in sinus rhythm. Elective surgery for TOF repair carries low risk of morbi-mortality. Despite worst preoperative status, children from humanitarian chains can be treated safely by complete repair. Palliative surgery must be reserved for children presenting a marked cachexia profile.

Impact of perioperative transesophageal echocardiography on tetralogy of fallot total repair

Introduction Previous studies have suggested that in cardiac surgical patients, TEE provides essential information before and after cardiopulmonary bypass regarding cardiac performance, valve function, and congenital anomalies. Significant residual abnormalities may be missed during TOF surgical repair. The result is often post-operative morbidity and mortality and sometimes the need for reoperation. Objectives To determine impact and accuracy of perioperative TEE in assessment of patients undergoing TOF total repair. Methods The study included 50 patients with TOF referred to Cardiothoracic Surgery Department Ain Shams University Hospitals for total repair. Each patient was subjected to history taking, clinical examination, routine preoperative investigations, preoperative TTE, perioperative TEE and Post recovery TTE. Results Our study population included 45 (90%) pediatric patients and 5(10%) adults. Youngest was 1year 2 months old and oldest was 25 years old. Their weight ranged from 8 to 85 Kg. TEE was feasible in 49 cases (98%) while the pediatric probe failed to be introduced in only one patient. TEE was able to visualize LM coronary artery in 96% of cases, and visualized RCA in 70% of cases. TEE newly detected a case with separate ostea of LAD and LCX. Only one patient developed non sustained runs of SVT There was significant difference between TEE and TTE as regard IAS visualization (P value 0.0001). All our patients had only subaortic VSD except 4 patients. Three had doubly commited subarterial VSD seen by both TTE and TEE, while one patient had subaortic VSD with inlet extension, which was visualized only by TEE. Postoperative TEE detected residual small VSD in 29 cases of whom 14 cases had the VSD closed spontaneously by the time of TTE. TEE missed small residual VSD in 3 cases. In one case postoperative TEE showed a serpignous mid muscular VSD which was not detected preoperatively. There was moderate agreement between TEE and TTE regarding overriding of aortic valve (weighted Kappa 0.580). There was strong agreement between TTE and TEE in assessment of postoperative PR (r o.8594, P 0.0001). Preoperative TEE showed major impact in 2 cases (4%). In one case total repair was decided instead of shunt operation. While in the other TEE newly detected TV chordae attached to IVS crest with inlet extension of VSD. Preoperative TEE had minor impact in 29 cases (59%) by adding new information which did not alter surgical plan, as visualization of coronaries and IAS. TEE showed major postoperative impact in 2 cases (4%) in the form of second run of CPB and RVOT reconstruction. Minor impact in the form of detection of relieved RVOT obstruction, absence of residual shunts, preserved biventricular function in 47 cases (94%). Conclusion TEE imaging is a safe, feasible, and accurate tool for anatomical, hemodynamic, and functional assessment in patients with TOF during surgical repair. TEE offers the advantage of permitting visualization of the operative procedure in real time and provides guidance for the surgeon in making decisions inside the operating room.

Transcatheter closure of ventricular septal defects with nitinol wire occluders of type patent ductus arteriosus.

Ventricular septal defects closure (VSD) depending on the anatomy and clinical setting can be performed surgically or by a hybrid and transcatheter approach. Two cases of children with VSD will be presented. Patients’ defects were closed with various types of occluders made of nitinol wire mesh occluder, patent ductus arteriosus (PDA) type. The first case was a 2.5-year-old boy after cardiosurgical correction of tetralogy of Fallot (TOF). After the procedure, a significant haemodynamic residual VSD was observed, which was not successfully closed during the subsequent reoperation. Despite pharmacological treatment, symptoms of heart failure were observed in this patient. In echocardiographic images the residual VSD was presented as a tunnel-like dissection of the ventricular septum (length 6 mm and diameter 3.4 mm). The defect was closed via arterial access with an Amplatzer Duct Occluder II (ADO II). The procedure was successfully performed without any medical complications. In this child, a significant shunt reduction and a noticeable improvement in the patient's clinical status and diminished symptoms of heart failure were noticed. The second patient was a 4-year-old girl suffering from a multi-perforated perimembranous VSD accompanied by a ventricular septal defect with aneurysm. The defect was closed by a venous approach with a PDA Cardio-O-Fix occluder (very similar to ADO I). No short-term or long-term complications were visible during or after the procedure. Only a mild residual shunt through the VSD was observed 6 months afterwards. Transcatheter VSD closure with a proper morphology, with occluders of type Amplatzer Duct Occluder ADO I or ADO II, constitutes a safe and effective therapeutic alternative.