Surgical Closure Research Articles

VSD Surgical Closure in Colombia in Children with Secondary Pulmonary Hypertension. Does Altitude Influence Postoperative Pulmonary Pressure?

A retrospective, cross-sectional, descriptive, observational study was carried out to describe the history of pulmonary hypertension in pediatric patients living at different altitudes following surgical correction of ventricular septal defect. Data from 40 patients who underwent surgery in La Fundacion Cardioinfantil was collected and used for our analysis. Bivariate analysis showed no significant relationship between altitude and pulmonary hypertension after ventricular septal defect closure. Unrelated to the main objective of our study, our investigation revealed that our population underwent surgical correction of VSD at older ages than expected. While previous publications demonstrate the benefit of intervention at 4years of age or younger (19, 20), the average age in our studied population was found to be 7.8years old. These patients had unfavorable hemodynamic parameters for ventricular septal defect closure, but our study showed that our patients benefited from surgery with an immediate satisfactory postoperative result. Patients transitioned from parameters indicating severe PH to mild PH within the first 24-48h after surgery.

The Analysis Study of Diagnosis and Management of Giant Omphaloceles: A Comprehensive Systematic Review

Background: Giant omphalocele (GO) is a severe form of omphalocele, characterized by a defect larger than 5 cm, often including the liver. Management strategies include staged surgical closure and non-operative delayed closure, with the latter focusing on neo-epithelialization and secondary operations. This study aims to explore diagnosis and management during neonatal care. Methods: This systematic review exclusively examined full-text articles published in English between 2014 and 2024, adhering to the PRISMA 2020 guidelines. Result: The study conducted a thorough review of more than 300 publications that were obtained from reputable databases, such as ScienceDirect, SagePub, and PubMed. Eight publications were identified as necessitating a more comprehensive examination subsequent to an initial screening. As a result, a comprehensive review of these selected studies was conducted to guarantee an exhaustive and rigorous assessment. Conclusion: Giant omphaloceles management involves a multifaceted approach, including primary closure, staged surgical closure, and nonoperative delayed closure. Synthetic materials and biological meshes promote granulation tissue formation and gradual closure, but further research is needed to reduce morbidity and mortality.

Abstract 4135311: Cryptogenic stroke associated with a double interatrial septum treated with surgical closure

Introduction: A double atrium septum is a rare congenital anomaly characterized by a double-walled atrial septum with persistent interatrial space. This could be an asymptomatic presentation but also serve as a nidus of thromboembolic complications. We hereby present a case of a 57-year-old female with a cryptogenic stroke found to have a patent foramen ovale and double atrial septum. Case Description: A 57 year-old-female with a past medical history of hypertension presented with acute complaints of word-finding difficulty, left-sided neck pain and lightheadedness after a head strike while swimming. She was found to have a right-sided cerebellar stroke. A carotid artery ultrasound showed no evidence of atherosclerotic disease. Her lipid profile was normal. A transthoracic echocardiogram showed a patent foramen ovale with a positive bubble study revealing a large right to left shunt with Valsalva. A transesophageal echocardiogram confirmed a patent foramen ovale with an incidental finding of a double atrial septum with extreme redundancy of septal issue. The patient had a surgical closure of the interatrial septum and resection of the accessory interatrial septum tissue. She developed chronic post-sternotomy pain and subsequently had sternal wire removal. Discussion: A double atrial septum is a rare congenital anomaly seen as two parallel interatrial septa accompanied by a distinct echo-lucent midline space that expands during systole and contracts during diastole. It can happen embryologically by either the abnormal development of the septum secundum, resorption failure of the superior portion of the septum primum, or the persistence of the left venous valve of the sinus venosus. Typically, individuals with double atrial septum are asymptomatic, but they may encounter cardioembolic events due to the potential thrombi formation in the interatrial space. Communication between the septa increases the likelihood of such events. Unlike atrial fibrillation/flutter, there are currently no established criteria for initiating anticoagulation therapy for double atrial septum, primarily due to its rarity. Some options include antiplatelet agents, oral anticoagulation therapy, and percutaneous or surgical PFO closure. Surgical closure provides a permanent closure of the defect, thereby preventing future paradoxical emboli without the potential risks associated with long-term anticoagulation.

Abstract 4118882: Decompensated Heart Failure Secondary to a Non-Coronary Sinus of Valsalva to Right Atrium Fistula: A Case Report

Introduction: Sinus of Valsalva aneurysm (SVA) accounts for 3.5% of all congenital cardiac anomalies. Rupture occurs in 35% of cases and can lead to life-threatening fistulas, predominantly involving the right ventricle or right atrium. Description of Case: 62-year-old female with hypertension and hypothyroidism presented to the ER with progressively worsening dyspnea over the past week. She also reported worsening lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea. Chest X-ray showed large pleural effusions. Her ejection fraction was 66% ejection fraction with a fistula between the right sinus of Valsalva and the right atrium on transthoracic echocardiogram (TTE) which was also seen on transesophageal echocardiogram (TEE). Her heart failure was due to the fistula as she had no coronary artery disease on coronary angiogram. She had cardiothoracic surgery for fistula repair. Postoperatively, she developed complete heart block requiring a permanent pacemaker. She had no further complications and was discharged home in good condition. Discussion: SVA affects the right sinus (94%), with the non-coronary (5%) and left sinus (1%) being less commonly involved. Aneurysm rupture typically forms a fistula into the right ventricle (60%), right atrium (29%), left atrium (6%), or left ventricle (4%), and rarely into the pericardial cavity (1%). Symptoms vary by rupture size and location. TTE is the initial diagnostic tool but has limited sensitivity (50%) for detecting fistulas, whereas TEE has a 90% sensitivity. Cardiac MRI and CT can further refine diagnoses, and cardiac catheterization assesses coronary arteries preoperatively. Surgical closure with a patch is the primary treatment for ruptured SVA, significantly improving survival rates compared to non-surgical management.

Abstract 4113301: A Rare Cause of Recurrent Heart Failure Exacerbations After Transcatheter Aortic Valve Replacement: Ventricular Septal Defect and Significant Paravalvular Leak

Introduction: Ventricular septal defects (VSD) have been reported in <1% of cases following transcatheter aortic valve replacement (TAVR). A retrospective record review of VSD cases occurring after all TAVRs performed between January 2012 and September 2020 at one urban US tertiary hospital showed 0.37% incidence of these complications, mostly with small and restrictive VSD. Case Description: An 80-year-old woman with history of hypertension, HFpEF, and TAVR 8 months prior for severe aortic stenosis (AS) at an outside hospital presented with worsening dyspnea and peripheral edema over the past month. Blood pressure was 148/53mmHg, heartrate 83bpm, oxygen saturation 98% and auscultation revealed a harsh holosystolic murmur 4/6 loudest at left sternal border and bibasilar rales. Chest X-ray showed pulmonary edema and bilateral pleural effusions. NT-proBNP was 17,000pg/ml and troponin-I was negative. Echocardiogram showed EF55-60%, a membranous VSD, severe pulmonary hypertension, and moderate paravalvular leak (PVL). Coronary angiogram showed non-obstructive disease. Right heart catheterization confirmed significant left to right shunting. Treatment/Outcomes: Cardiothoracic surgery was consulted for multidisciplinary evaluation, and joint recommendation was for surgical aortic valve replacement and VSD closure which was successfully performed. One month follow-up echocardiogram showed normal aortic valve gradient without PVL and normal right ventricular pressure. Discussion/Conclusion: Numerous potential risks such as severe and uneven calcification of the native valve, an elliptic aortic annulus, excessive valve sizing, or elevated valve placement can lead to VSD. A recurrent element in many of these instances involves direct trauma to the septum caused by the implanted valve, exacerbated by subsequent annulus dilation. The presence of PVL is common post-TAVR and is an established independent prognostic factor, while VSD post-TAVR is uncommon, but may be associated with low implantation position relative to the aortic annulus or post-implantation balloon dilatation. Rarely, worsening VSD may require operative management. In this case, the improvement of heart failure symptoms and echocardiogram parameters after transthoracic surgery confirmed successful repair.

Percutaneous Closure of Postmyocardial Infarction Ventricular Septal Rupture – A Single Center Experience from the Eastern Part of India

Abstract Background: Postinfarction ventricular septal rupture (VSR) is a rare but lethal mechanical complication of an acute myocardial infarction (AMI). It results in 90%–95% mortality within 2 months of diagnosis without any kind of intervention. Given high surgical mortality, transcatheter closure has emerged as a potential strategy and as an alternative to high-risk surgical closure. Indian data on percutaneous device closure of post-AMI VSR are limited; hence, we report our resource-limited single-center experience with different kinds of occluder devices for closure of post-AMI VSR. Methods and Results: In this single-center, retrospective cohort study, patients who underwent transcatheter closure of postmyocardial infarction (MI) VSR between 2018 and 2024 at Health World Hospitals in Durgapur, West Bengal, were included. The primary outcome was a mortality rate of 30 days. The study population was eleven primary cases of post-MI VSR. The mean age of the population was 61 years. The majority of the patients had anterior wall MI (54.5%), and the remaining had inferior wall MI. Different kinds of devices (Amplatzer atrial septal occlude, post-MI VSD device, and Konar-Multifunctional Occluder) were used to close VSR. Successful closure was performed in 9 patients (81%) with minimal residual shunt in 2 patients. Of 9 cases, 3 patients expired; one was lost to follow-up, and the rest are doing well at 30-day follow-up. Conclusion: Transcatheter closure of PMI VSRs can be performed with different kinds of devices with high technical success, relatively low procedural complication rates, and a good 30-day survival even in a setup outside the metropolis with limited availability of devices, as an alternative to very high-risk surgical closure.

Innovative Surgical Left Atrial Appendage Closure Technique: Early Experience of Inverted Spiral Closure Technique.

Simultaneous closure of the left atrial appendage (LAA) during cardiac procedures has become a common preventive measure against cardiogenic embolic events associated with atrial fibrillation. However, this strategy encounters limitations during minimally invasive mitral valve surgery through a right minithoracotomy because access to the LAA is limited. The use of endocardial sutures for surgical exclusion of the LAA is also well established but has a notable rate of closure failure. We introduced a new surgical LAA closure technique called the inverted spiral closure technique (ISCT). Between July 2020 and August 2021, 26 patients underwent LAA closure with ISCT concomitant to mitral valve surgery in our hospital. Early postoperative outcomes and any stroke or thromboembolic event during the follow-up were evaluated. Transthoracic or transesophageal echocardiography (TEE) was used to assess LAA patency. The ISCT procedure was performed successfully in all cases. No significant persistent flow between the left atrium and LAA was observed on intraoperative TEE. During a median follow-up of 1.1 years, no patients experienced stroke, myocardial infarction, or death. Postoperative echocardiography showed no significant residual flow within the LAA. One patient was incidentally found to have recanalization between the left atrium and LAA several months after surgery on an enhanced computed tomography scan during coronary evaluation. The ISCT can be performed reliably through the same left atriotomy for mitral valve surgery and is a useful and effective technique for surgical LAA exclusion. There are still not enough patients and modalities for postoperative evaluation.

Device closure via minimally invasive left intercostal incision in children with perimembranous ventricular septal defect

When treating perimembranous ventricular septal defect, median sternotomy leads to unsightly scar, right subaxillary thoracotomy requires cardiopulmonary bypass, and transcatheter device closure constrained by vascular condition. Using small left intercostal incision, we employed transthoracic device closure to get around these issues. During this study, right subaxillary thoracotomy was used for surgical repair in 117 patients (Surgical group), whereas small left intercostal incision was used for transthoracic device closure in 131 patients (Device group). Retrospective data collection and analysis were conducted. The success rate was comparable (117/117 vs. 130/131, P = 1.000). The device group experienced notably reduced operating time, mechanical ventilation duration, ICU stay, and postoperative hospital stay (All P < 0.001). Given that the device group’s incision was much smaller than the surgical group’s (1.1 ± 0.3 vs. 6.8 ± 1.6 cm, P < 0.001), blood transfusion or drainage tube was not needed. The device group observed a lower frequency of complications, with the exception of small residual shunt. It is feasible and safe to perform transthoracic device closure in children with perimembranous ventricular septal defects via small left intercostal incision. It can be a good minimally invasive substitute for surgical closure when utilized properly.

Foix-Alajouanine syndrome: a comprehensive overview of rare but relevant diagnosis.

Foix-Alajouanine syndrome (FAS) is an uncommon neurological disorder marked by the gradual development of spinal cord congestion. First documented by Foix and Alajouanine in 1926. Although it is infrequent, delayed or misdiagnosis is nonetheless prevalent, resulting in inadequate therapy and unfavorable results. Using the PubMed database, MEDLINE, and EMBASE, we collected data on FAS patients and conducted a pooled analysis. The term 'FAS' was used to search for related articles. Our search was restricted to previous clinical case reports or series that were published in English. Non-English articles were excluded. We included the articles in the period from 1974 to 2024. Articles were eligible if the radiographic and clinical findings were indicative of FAS. A thorough research analysis was performed, examining case reports that specifically addressed this issue. This study examines the clinical symptoms, difficulties in diagnosis, methods of treatment, and outcomes related to FAS. FAS predominantly impacts the elderly population. A total of 26 patients were diagnosed with FAS. The median age of affected individuals was 53 (SD ±15.96). The ratio of males to females is roughly 5:1. The clinical manifestations encompass gradual muscle weakness and sensory impairments. The diagnosis is dependent on radiological evaluations, specifically MRI and digital subtraction angiography. Possible treatments include endovascular therapy, surgical closure of arteriovenous fistula, or a combination of the two. Significant improvements in neurological impairments can be achieved by early intervention. The diagnosis of FAS continues to be difficult due to its infrequency and varied clinical manifestations. Prompt and precise diagnosis is essential for proper intervention, typically utilizing endovascular or surgical methods. Additional research is required to determine prognostic markers and enhance long-term care techniques for this rare neurological condition.

The incidence of atrial fibrillation in patients with interatrial shunt: is it reduced after surgical or transcatheter closure of the shunt?

Abstract Background Atrial fibrillation (AF) is a prevalent diagnosis among individuals with interatrial shunts, and the prevalence increases with age (1). Since the 1990s, interventionists have introduced transcatheter techniques, to close interatrial shunts, while surgical procedures reserved in cases of technical complexity (2). Despite the potential reduction in AF incidence post interatrial shunt closure, discernible modifications in the cardiac conduction system may persist (3). Notwithstanding, reports indicate an incidence of new-onset AF in approximately 10-25% of patients after interatrial shunt closure, with a pronounced prevalence among elderly (4). This study aims to delineate the incidence of AF subsequent to interatrial shunt, surgical och transcatheter, closure within a national cohort in Sweden. Methods The study includes all patients diagnosed with an interatrial shunt, atrial septal defect and patent foramen ovale, classified using the International Classification of Diseases, 10th edition (ICD-10), as documented in the Swedish National Patient Register, along with data sourced from the Cause of Death Register. Patients with multiple diagnoses of other congenital heart diseases are excluded, and interventions performed between 1997 and 2017 are identified using the NOMESCO surgical classification. Comorbidities such as chronic ischemic heart disease, myocardial infarction, heart failure, hypertension, and diabetes are considered, with the primary endpoint being the incidence of AF post-intervention. Results A total of 3,426 patients with interatrial shunts underwent intervention between 1997 and 2017, with a mean follow-up duration of 6.2 years. Among these, 49% (n=1,725) underwent transcatheter closure, while 41 patients underwent both transcatheter and surgical procedures. The mean age was 36 years, with 9% presenting with heart failure at baseline. Before the intervention, 14% (n=483) had AF, increasing to 22% (n=755) post-intervention. Of those developing AF post-intervention, 16% (n=119) experienced the AF event within 60 days, evenly distributed between transcatheter and surgical procedures. Over 40% of patients with post-intervention AF had an average age of 62. The incidence of AF post-intervention was 1.6 per 100 patient-years (see Figure). Stroke incidence was 3.6 per 100 patient-years and the mortality rate was 7% (n=257) during follow up (see Table). Conclusions Patients with interatrial shunts exhibit a high incidence of AF, which further escalates following closure of the interatrial shunt, not only within the first few days post-intervention, particularly among the elderly population. This can relate to high incidence of ischemic stroke.Figure

Outcome of pregnancy in women with unrepaired atrial septal defect - study of a single tertiary centre

Abstract Background Patients with unrepaired atrial septal defect (ASD) are prone to develop arrhythmia, right heart failure and to suffer paradoxical embolism. The risk might be even bigger during pregnancy due to the hemodynamic changes combined with the hypercoagulable state. Purpose To evaluate maternal, foetal, and neonatal outcome of pregnancy in women with unrepaired ASD. Methods A retrospective study of 43 pregnancies in 24 women with unrepaired ASD was performed in our tertiary centre from 2004. Previous maternal cardiovascular events and events during pregnancy (maternal, neonatal, and obstetric) were documented. Results 24 women with unrepaired ASD (median age: 27.5 ± 6.2) had 43 pregnancies resulting in one termination, 4 miscarriages and 38 live births. 55% were primigravida and 2 twin pregnancies were documented. At baseline 2 women (10.5%) were in NYHA functional class II and signs of right ventricle (RV) volume overload were detected on echocardiography in 18 cases (47%). 2 women had a history of supraventricular tachycardia. Median gestation at delivery was 39 ± 2.6 weeks. No thromboembolic events, pulmonary hypertension, or desaturation occurred during pregnancy. However maternal cardiovascular complications all affected women with RV volume overload: 2 cases (5.2%) of supraventricular tachycardia, 2 (5.2%) cases with NYHA functional class deterioration and 1 case (2.6%) of syncope were documented. Only one obstetric event; preeclampsia occured. Neonatal complications were as follows: premature delivery in 3 cases (7.9%) and recurrence of congenital heart disease (CHD) in 4 pregnancies (10.5%). After the pregnancy device or surgical closure of the ASD was indicated for 11 women (45.8%). Since then, five already underwent device closure, one had surgical repair, while five women are still waiting for intervention. Conclusions Our results align with the mWHO classification. Pregnancy with an unrepaired ASD is well tolerated and has a low risk of neonatal and maternal cardiovascular events. However, women with right ventricle volume overload are prone to develop arrhythmia or right heart failure during pregnancy. Therefore, cardiology follow-up during pregnancy should be decided on an individual basis. In our cohort no thromboembolic events were documented during pregnancy, however the prevalence of congenital heart disease in the foetus was higher compared to the literature.

The ventricular septal defect in tetralogy of Fallot: A multi-centre morphological and statistical shape analysis study

Abstract Background Ventricular septal defects (VSDs) in Tetralogy of Fallot (TOF) are often thought to be ‘large and unrestricted’ but experience suggests they have a more heterogenous morphology. Understanding the morphological variations and dimensions is the first step in modifying surgical closure or optimising potential device design. Purpose The objective of this study was to perform a comprehensive multi-center morphological analysis of the characteristics of the VSD in TOF. Additionally, we sought to perform a preliminary 2D shape analysis and principal component analysis (PCA) on standardised photos of the VSDs. Through this multi-dimensional approach, we aim to elucidate the morphological variations and structural characteristics of the VSD in TOF as a basis for future 3D shape analysis. Methods Of 495 specimens analysed, 460 were included in the morphological analysis. Standardised protocol was applied to assess the characteristics of the VSD: basic measurements of the height, width, inferior limb, and length of the inferior fibrous rim (if perimembranous) were taken and indexed to ventricular length. The degree of aortic override and presence of aorto-mitral continuity were also documented with double outlet right ventricle (DORV) being defined as more than 50% of aorta supported by the right ventricle. Statistical analysis was performed to assess variations in TOF morphology across different age groups and disease phenotypes. Standardised photographs of 130 VSDs were taken from the right ventricle and traced for PCA, in order to assess shape variations among the VSDs. Results Both the length of the inferior limb of the PM VSD and the length of the fibrous rim increased with ventricular length but the rate of change was lower for the fibrous rim. A chi-square analysis comparing the presence of double outlet right ventricle and the presence of a fibrous continuity between the aortic and mitral valves showed no association between these features (p = 0.89). The results of PCA in the indexed datasets showed that the largest variation was in the size of the VSD and then from the shape of the VSD where two distinct morphologies emerged: a classic V-shaped VSD and wide but shallow variant. Discussion Our study challenges conventional definitions and assumptions regarding the morphological characteristics of the VSD in TOF and suggests that components may change size at differing rates. Our study conclusively shows that DORV and TOF can co-exist and the definition of DORV should be made independently of the presence of aorto-mitral continuity. Contrary to the traditional view of TOF featuring large unrestricted VSDs, our findings suggest wide shallow VSDs are common. These findings challenge paradigms and underscore a necessity for the continuing morphological re-evaluation of TOF utilising large datasets with a diverse phenotypic spread.

Transcatheter closure of patent ductus arteriosus: review of author’s experiences and observations

Patent ductus arteriosus (PDA) is a congenital cardiac defect (CCD) and comprises 8% to 10% of all CCDs. Following the description of surgical closure by Gross and colleagues in the 1930s, it has become a standard mode of therapy and remained so until the description of transcatheter techniques to occlude PDA by Porstmann, Rashkind and their associates in the late 1960s. This review paper discusses transcatheter occlusion techniques with buttoned devices, Giantuco coils , and Amplatzer devices with particular attention to author’s contributions to these methods.

Cardiac arrest in pregnancy with successful stabilization and delivery on veno-arterial extracorporeal membrane oxygenation: a case report

Abstract Background Cardiac arrest in pregnancy is rare. Clinicians need to adapt management to the altered anatomy and physiology of pregnancy, and the well-being of two patients (mother and foetus) may come into consideration. The medical literature has limited reports on outcomes following extracorporeal membrane oxygenation (ECMO) in pregnancy. Case summary We report the evaluation, management, and outcome of a woman with cardiac arrest and severe left ventricle (LV) dysfunction in mid-trimester of pregnancy. The previously well woman had tolerated two prior term pregnancies without complication. At 25 weeks of gestation, she presented to the hospital with breathlessness and vomiting after a pre-syncopal episode at home. She then had in-hospital cardiac arrest, managed initially with cardiopulmonary resuscitation. The LV was dilated, thin walled, and severely impaired (LV ejection fraction 14%), and there was a secundum atrial septal defect (ASD). She was supported with veno-arterial ECMO. Planned birth occurred 5 days post-arrest for maternal indication. Coronary angiography demonstrated 99% proximal left anterior descending artery stenosis and aneurysm, raising the possibility of previous subclinical Kawasaki disease. She underwent surgical revascularization and ASD closure. Both mother and infant made a good recovery. Discussion We report a case of cardiac arrest in pregnancy as first presentation of severe LV dysfunction. The case highlights the role of ECMO for cardiac arrest in pregnancy and outlines specific interventions and management concepts in this setting.

Role of MMP-2, MMP-9, TIMP-1, and TIMP-2 in children with ventricular septal defect.

Ventricular septal defect (VSD) is the second most common congenital heart anomaly. In most cases, it closes spontaneously in the first year of life, but it sometimes requires surgical closure due to the risk of serious complications. This is why it is important to identify markers that could help predict its course. Findings that matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) play an important role in the cleavage of the extracellular matrix were the reasons to investigate their role in cardiogenesis.In prior studies on this topic, their concentrations were studied in the blood.The aim of this prospective study was to investigate the role of MMP-2, MMP-9, TIMP-1, and TIMP-2 in the etiology and pathophysiology of VSD using urine samples, as an innovative non-invasive approach, and the ELISA method. It involved fifty-two children with isolated VSD and twenty healthy children up to one year of age. We found that these MMPs and TIMPs are significantly (P = 0.000) higher in children with VSD, and the correlations between their concentrations and the size of the defect are positive, especially for MMP-9 and TIMP-1. MMP-9 was significantly (P = 0.044) higher in cases in which VSD didn't close in the first year of life compared to cases in which it closed. Our results suggest the role of MMP-2, MMP-9, TIMP-1, and TIMP-2 in the aetiopathogenesis of VSD and that their urinary concentrations, especially of MMP-9, in combination with echocardiographic and clinical monitoring, could be useful in predicting its natural course.

Surgical Closure of Multiple Muscular Ventricular Septal Defects in Children Using 3D-Printed Models.

Multiple muscular ventricular septal defects (VSDs) are often difficult to visualize and access surgically. The main challenge is identifying all defects intraoperatively, without which residual defects are inevitable. Patient-specific three-dimensional (3D) printed models can help accurately demonstrate intracardiac anatomy. We present our experience using this technology to surgically close multiple muscular VSDs . Data of all patients with multiple VSDs in whom a 3D-printed model was used to aid surgical planning between September 2021 and July 2023 was collected retrospectively. Our approach involved generating a 3D model from a preoperative computerized tomography scan for each patient, which was then used to precisely identify the location of the multiple VSDs and plan surgical intervention. Six patients underwent closure of multiple VSDs using a 3D model. The mean age at surgery was 3.5 years (SD ± 2.8 years). Five (83.3%) patients had previously undergone pulmonary artery banding. The VSDs were approached through the right atrium in three (50%) and the right ventricle in three (50%) patients. Mean cardiopulmonary bypass and myocardial ischemia times were 185.2 min (SD ± 94.8 min) and 147.5 min (SD ± 86 min), respectively. There was no postoperative heart block or a hemodynamically significant residual VSD. All six patients had normal biventricular function at a median follow-up duration of 1.7 months (interquartile range: 1.2-7.4 months). 3D printing to aid closure of multiple VSDs is safe, reliable, and reproducible. We recommend adding 3D printing to surgeons' armamentarium when faced with the challenge of closing multiple muscular VSDs in children.

Assessing chiasm perfusion and postoperative visual function with superior hypophyseal artery indocyanine green angiograms during endoscopic endonasal surgery.

To date, there are no validated intraoperative tools to predict postoperative visual function following endoscopic endonasal surgery (EES). Assessment of post-surgical vision during surgery can help in postoperative planning and disposition and inform surgical decisions in real-time. The objective of this study was to evaluate the capability of intraoperative endoscopic indocyanine green (ICG) angiography to measure optic chiasm perfusion and determine its relationship with postoperative visual function. A retrospective review was performed on patients undergoing EES for sellar andsuprasellar lesions. ICG was injected prior to surgical closure at a time when the optic chiasm and anterior circulation were visible. Luminescence of the superior hypophyseal artery (SHA) branches enveloping the optic chiasm was registered 10seconds after ICG penetration into the anterior cerebral arteries (ACAs). Pre and post-operative visual acuity and field exams were used to assess visual function. Patients with and without new deficits were compared to examine statistical association with intraoperative ICG findings. Twenty patients were included (mean age 49years, 55% female). Eighteen patients displayed stable or improved vision after resectionand demonstrated luminescence of all chiasmatic branches within 10s of ACA fluorescence. Two patients experienced new postoperative visual deficits. Upon review, their ICG administrations showed no fluorescence of the SHA branches enveloping the chiasm. A lack of chiasm fluorescence within ten seconds of ACA fluorescence was associated with new postoperative vision deficits (p = 0.005). This study shows that the lack of ICG fluorescence of SHA branches at the chiasm correlates with ischemic changes and new post-operative bitemporal hemianopsia. Lack of chiasm fluorescence after 10seconds of observation reflects compromised chiasm perfusion and likely new post-surgical visual deficits.

A Report of Inadvertent Narrowing of Coronary Sinus Ostium During Surgical Closure of Ostium Secundum Atrial Septal Defect, Identified Perioperatively Using Transesophageal Echocardiography.

A Report of Inadvertent Narrowing of Coronary Sinus Ostium During Surgical Closure of Ostium Secundum Atrial Septal Defect, Identified Perioperatively Using Transesophageal Echocardiography.

Combined local flap placement and negative-pressure wound therapy for the management of critical peritracheostomal pharyngocutaneous fistula

ObjectivePeritracheostomal pharyngocutaneous fistula (PCF), a direct connection between the PCF and tracheal stoma due to a skin defect, is among the most problematic complications after total laryngectomy or pharyngolaryngectomy. Peritracheostomal PCFs can cause lethal complications, including severe pneumonia or carotid blowout, secondary to salivary leakage directly into the tracheal stoma, and their management is challenging without early invasive surgical closure. We aimed to evaluate the utility of our novel and minimally invasive combined local skin flap placement and negative-pressure wound therapy (NPWT) method for the management and conservative closure of peritracheostomal PCFs. MethodsWe retrospectively enrolled patients who developed a peritracheostomal PCF from July 2015 to September 2021 at our institution and affiliated hospitals. Postoperative PCFs were all initially managed with appropriate wound bed preparation. Subsequently, a small local flap of healthy, lower neck skin was elevated and transferred anterior to the PCF to replace the peritracheostomal skin defect. The flap served to provide a sufficient surface for film dressing attachment and facilitated airtight sealing during NPWT. We initiated NPWT after confirming the local skin flap was firmly sutured to the tracheal mucosa. A flexible hydrocolloid dressing was applied to the peritracheostomal skin flap, and a film dressing was placed on the flexible hydrocolloid dressing and surrounding cervical skin. We inserted the NPWT foam shallowly into the fistula tract and applied negative pressure (73.5–125 mmHg). NPWT was continued until the PCF was closed or became so small that salivary leakage was minimal and could be managed by conventional compression dressings. ResultsWe enrolled six patients [male, n = 6; mean age, 66.5 years (range, 57–80 years)]. NPWT was applied for an average of 18.2 days (range, 2–28 days). During NPWT, air leakage occurred once (2 cases), only a few times (2 cases), or not at all (2 cases). In all patients, complete fistula closure was achieved in an average of 28.2 days (range, 15–55 days) after the start of NPWT, and no patient required further surgical intervention. There were no lethal complications (e.g., severe pneumonia) during treatment. ConclusionOur method of combined local flap placement and NPWT enabled effective management of salivary aspiration and accelerated wound healing, which allowed conservative fistula closure in all patients. We believe combined local flap placement and NPWT should be considered a first-line treatment for intractable peritracheostomal PCF.

Closure of small fenestrations without optimal rims with a PDA coil far from primary atrial septal defects: a new approach.

An ostium secundum atrial septal defect (ASD) is a CHD that can be treated percutaneously since 1974, mostly cases with only one main defect. In cases with fenestrations close to the main defect, a single occluder can be used for treatment because the discs extend beyond the waist of the device. In some cases where the defects are far from each other, they may require either more than one device or surgical closure. We present two patients in whom we observed fenestrations far from the primary defect. Initially, the main ASDs were closed with an ASD occluder, and then the fenestrations were closed with a patent ductus arteriosus (PDA) coil, resulting in complete closure of both defects. This shows that closing small fenestrations that are far away from the primary interatrial defect without rims and using other devices instead, such as a PDA coil, is feasible and can avoid the need for an open-heart surgical procedure; moreover, it is important to note that leaving these fenestrations open can have the same physiology as a patent foramen oval.