Primary correction of total anomalous pulmonary venous return with a modified sutureless technique

OBJECTIVES The objective was to evaluate primary sutureless repair of total anomalous pulmonary venous return (TAPVR) in neonates using a modified technique that minimizes hypothermia and circulatory arrest times. METHODS From 2009 to 2011, seven consecutive patients underwent primary sutureless repair for the treatment of TAPVR, by which the prepared posterior pericardium was sutured to an opening in the left atrium. Three patients had the obstructed infracardiac type, and four patients had the unobstructed supracardiac type of TAPVR. Moderate hypothermia was used in all patients with a median temperature of 28°C (26-32). Circulatory arrest was not used except for the opening of the collector, which lasted between 3 and 5 min. The connecting vein was ligated in all seven patients (five during repair and two early postoperatively). The follow-up was 100% complete, with a median duration of 652 (range 370-1023) days. RESULTS There was no operative mortality and no late death. No patient required reoperation. Postoperative echocardiography showed unobstructed pulmonary venous flow in all patients. Recurrent pulmonary venous stenosis was not seen during the follow-up in any patient. CONCLUSIONS The sutureless technique is an effective technique with potential advantages even for the primary correction of TAPVR. With the described technique, the need for circulatory arrest is substantially reduced. Not handling the pulmonary venous collector by avoiding a direct anastomosis may contribute to better compliance, better growth and the absence of subsequent stenosi

Simplified surgical-hybrid Melody® valve implantation for paediatric mitral valve disease

Children suffering from left atrioventricular valve (LAVV) disease not amenable to repair represent a significant challenge. The results of surgical reconstruction are not optimal. Valve replacement as an alternative is associated with poor results. The surgical-hybrid approach with implantation of a stented biological valve (bovine jugular vein graft, Melody® valve) seems to represent a new therapeutic option. Here we demonstrate our case, the consideration and the approach to extreme clinical findings in a small child. We describe a simplified surgical-hybrid Melody valve implantation in a LAVV position. The technique of implantation is relatively simple and the immediate postoperative result very goo

Melody valve to replace the mitral valve in small children: Lessons learned

Objective Infants requiring mitral valve replacement have few viable options. Recently, stented bovine jugular vein graft (Melody) has been surgically implanted in such cases. Herein, we report our experience, elaborating on evolution of implantation technique, pitfalls, as well as long-term outcome (including late dilatability). Methods Seven Melody valves were implanted (2013-2019). The median patient age and weight were 6.7 (1.8-30.5) months and 5.8 (4.6-9.5) kg, respectively. The indications for implantation were mitral stenosis and/or regurgitation postatrioventricular septal defect (AVSD) repair (5), congenital mitral valve dysplasia (1), and Shone's complex (1). Operative technique involved shortening the valve and creating a neo-sewing ring at 2/3 (atrial)-1/3 (ventricular) junction. Implantation was followed by intraoperative balloon dilatation. Results Five out of seven patients survived the perioperative period (one death due to technical failure and the other due to acute respiratory distress syndrome postcardiopulmonary bypass). Two out of five medium-term survivors got transplanted (1) or died due to acute myeloid leukemia (1). No valves were replaced. The mean echo gradient at discharge was a median 4 (2-6) mmHg. None of the patients showed left ventricular outflow tract or pulmonary venous obstruction. Two Melody valves were dilated late (5 months and 3 years postoperatively), resulting in decreasing mean gradients from 6 to 1 and from 17 to 4 mmHg. At last follow-up, surviving Melody had a mean gradient of 4 (1-9) mmHg. Conclusions Mitral valve replacement with a Melody valve is feasible in infants, is reproducible, shows good immediate results, and offers the possibility of later dilatation. This technique offers a better solution compared to the existing alternatives for infants requiring a prosthetic mitral valve

Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves

Objective: To evaluate the early results of a new method to repair malfunctioning bicuspid aortic valves by creating a tricuspid valve with a crown-like (i.e. anatomic) annulus. Material and methods: Twelve patients (ages from 10 to 27 years) with chronic regurgitation (and flow-dependent stenosis) of a bicuspid aortic valve underwent repair with the principle of creating a tricuspid valve and a crown-like annulus. The fused leaflets were trimmed and reinserted underneath the existing aortic annulus to create one new native cusp. The third leaflet was fashioned out of a xenopericard patch and was inserted underneath the existing annulus as well to restore the crown-like anatomy of a normal aortic annulus. A tricuspid aortic valve with a morphologically normal annulus was thus created, which resulted in improved coaptation of the leaflets. The repair was immediately assessed by transesophageal echocardiography (TEE) with the heart loaded at 50%. In two patients, a second run helped fine-tune the repair. Median cross-clamping time was 82 min. Follow-up ranged from 3 to 46 months (median 13 months). Results: No significant complication occurred. The function of the aortic valve was excellent with trivial or mild regurgitation in 11 patients and moderate regurgitation in 1 patient. There was no stenosis across the valve. The repair remained stable over time. Remodelling of the left ventricle occurred as expected. Conclusions: Aortic valve repair is feasible in some dysfunctioning bicuspid aortic valves. Tricuspidisation of the valve can result in excellent systolic and diastolic functions. The creation of a crown-like annulus results in improved coaptation of the cusps and could lead to more reliable outcome. Although long-term results are needed, this anatomic correction seems to be a good alternative to valvular replacement in certain sub-groups of patient

Absent left main coronary artery in a case of pulmonary atresia-intact ventricular septum and right ventricle-dependent coronary circulation

Right ventricle-dependent coronary circulation coexisting with left main coronary atresia in the setting of pulmonary atresia-intact ventricular septum is rare. In the case described, the left coronary artery (LCA) origin from the aorta could not be found on conventional angiography or cardiac magnetic resonance imaging. During surgery, multiple LCA branches originating from the finger-like continuum of the primitive right ventricular sinusoidal network were observed. A Damus-Kaye-Stansel anastomosis and an aortopulmonary shunt operation were performed. Shunt takedown and a bidirectional Glenn anastomosis followed at 3 months of age. At 18 months follow-up, the child is thriving with stable hemodynamics and a saturation of 85%. Awareness about this rare coronary artery anomaly is necessary to prevent catastrophic consequences. The challenges, complications, and lessons learned while treating this rare variant are discussed

Realignment of the ventricular septum using partial direct closure of the ventricular septal defect in Tetralogy of Fallot

Objective: The aim is to describe our technique of partial direct closure of the ventricular septal defect (VSD) in Tetralogy of Fallot (TOF), and assess its influence on the realignment and remodeling of the left ventricular outflow tract. Methods: Between 2004 and 2010, 32 non-consecutive patients with TOF underwent a direct or partial direct closure of VSD. Median age and weight were 5.2 months and 6.7kg, respectively. An approach through the right atrium was used in 30 patients and through the infundibulum in two patients. The conal septum was mobilized by transecting the hypertrophic trabeculae to facilitate the approximation of the VSD. The membranous part of the VSD was closed (in the later part of the series) with a small xenopericardial patch to avoid tension on the suture line traversing the area of risk to the bundle of His. Follow-up was complete, with a median duration of 46.9 (range 12-75.3) months. Results: The VSD could be closed successfully in all patients. A residual VSD was partly responsible for one early postoperative re-operation. There were no early or late deaths. At follow-up, all patients were in sinus rhythm. Three patients showed a small residual VSD. Thirty patients had none, one showed trivial, and one had mild aortic regurgitation. The left ventricular outflow showed a good realignment of the ventricular septum in all the patients. Conclusions: Partial direct closure of the VSD corrects the primary defect in TOF, that is, the malalignment of the septum. It results in a straight, wide open left ventricular outflow tract and brings better support to the aortic roo

Postoperative arrhythmia in patients with bidirectional cavopulmonary anastomosis

OBJECTIVES Bidirectional cavopulmonary anastomosis (BDCPA) is part of the staged Fontan palliation for congenital heart defects with single-ventricle morphology. The aim of this study was to describe incidence and characteristics of early postoperative arrhythmias in patients undergoing BDCPA. METHODS Retrospective analysis of 60 patients undergoing BDCPA at the age of <12 months from 2001 to 2008 at a single centre. Arrhythmias were subclassified in sinus bradycardia, premature atrial/ventricular contraction, supraventricular tachycardia and atrioventricular block. The groups were compared according to age at operation and diagnosis. Postoperative follow-up data were included until Fontan completion. RESULTS Postoperative arrhythmia was observed in 20 patients: 12 temporary and 8 persisting until hospital discharge. Sinus bradycardia is a common postoperative arrhythmia and occurred in 16 patients (9 transient, 7 persistent until hospital discharge). One patient undergoing BDCPA and a Damus-Kaye-Stansel procedure had a persisting first-degree atrioventricular block. The occurrence of a postoperative arrhythmia was independent of age and diagnostic group (hypoplastic left heart vs non-hypoplasic left heart). After hospital discharge, five of the eight arrhythmia resolved spontaneously resulting in 2 patients with sinus bradycardia and 1 patient with a first-degree AV block immediately before the Fontan completion was undertaken. CONCLUSIONS Postoperative arrhythmias in patients with BDCPA occur early after surgery and are temporary. Severe and life-threatening arrhythmias are rare although the interventions are complex and the patients very young. The most common arrhythmia is sinus bradycardi