Ross-Konno and Endocardial Fibroelastosis Resection After Hybrid Stage I Palliation in Infancy: Successful Staged Left-Ventricular Rehabilitation and Conversion to Biventricular Circulation After Fetal Diagnosis of Aortic Stenosis

We report a patient who presented during fetal life with severe aortic stenosis, left-ventricular dysfunction, and endocardial fibroelastosis (evolving hypoplastic left heart syndrome). Management involved in utero and postnatal balloon aortic valvuloplasty for partial relief of obstruction and early postnatal hybrid stage I palliation until recovery of left-ventricular systolic function had occurred. The infant subsequently had successful conversion to a biventricular circulation by combining resection of endocardial fibroelastosis with single-stage Ross-Konno, aortic arch reconstruction, hybrid takedown, and pulmonary artery reconstruction

Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork: A Scientific Study from the American Heart Association

The cardiac surgical operating room (OR) is a complex environment in which highly trained subspecialists interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Indeed, both mortality and morbidity for coronary artery bypass surgery have decreased during the past decade. Nonetheless, the highly skilled and dedicated personnel in cardiac ORs are human and will make errors. Refined techniques, advanced technologies, and enhanced coordination of care have led to significant improvements in cardiac surgery outcomes

Outcomes of the bidirectional Glenn procedure in patients less than 3 months of age

Objective: The bidirectional Glenn procedure is a well-established procedure performed as part of the single-ventricle palliation pathway. Numerous studies have highlighted the potential benefits of an 'early' BDG procedure. The ideal age to perform the BDG procedure, however, remains uncertain. We report our experience with the BDG procedure in patients younger than 3 months. Methods: One hundred sixty-nine consecutive patients from 1998 to 2007 undergoing the BDG procedure were divided into 2 groups: younger than 3 months (n = 20) and older than 3 months. The groups were compared for 26 variables. All data were analyzed with Kaplan-Meier survival analysis and the Cox proportional hazard regression test to assess the probability of survival after the BDG procedure in both groups. A stepwise regression analysis was performed for identification of independent factors for postoperative oxygen saturation at hospital discharge. Results: The groups were comparable, with an equal distribution of patients with right-sided or left-sided single-ventricle anatomy. Although intensive care unit length of stay, ventilation time, and hospital length of stay were longer in the younger group, room air oxygen saturations at discharge, both early and late mortality, and time to the Fontan procedure were similar between groups. The independent variables found for death after the BDG procedure were preoperative mean pulmonary artery pressure, atrioventricular valve regurgitation, and postoperative oxygen saturations at hospital discharge. Survival in patients with hypoplastic left heart syndrome was comparable between groups after 5 years of follow-up. Conclusion: The BDG procedure is feasible and safe in patients as young as 2 months of age, with early and late mortality equivalent to that seen in older patients. (J Thorac Cardiovasc Surg 2010; 139: 562-8)139356256

Expression of the thymus leukemia antigen in mouse intestinal epithelium.

The Qa and Tla regions of the mouse major histocompatibility complex contain a series of genes encoding proteins with structural similarity to the class I transplantation antigens of the same complex. In contrast to the genes encoding the transplantation antigens, the Qa and Tla genes show very little polymorphism. Function(s) of the proteins encoded by the Qa and Tla loci remain an enigma. Recently, the protein products of the Qa and Tla loci, often referred to as class Ib major histocompatibility complex molecules, have been proposed to present antigen to gamma delta T cells. In mice, gamma delta T cells have been found concentrated in several epithelial barriers and in the skin; yet, expression of serologically detectable Tla antigens is believed restricted to thymocytes, activated T lymphocytes, and some T-cell leukemias. Here we report that luminal epithelial cells of the mouse small intestine express the thymus leukemia antigen (TLA). We also find that, unlike T cells in Peyer's patches, a significant fraction of intestinal epithelial lymphocytes also express TLA. RNA prepared from intestinal cells contains transcripts of the T18d gene, which encodes TLA. These data extend the known expression profile of TLA molecules to mature lymphocytes and to nonhematopoietic cells. These data also demonstrate the specific expression of TLA on antigen-presenting cells in a site enriched for T cells that express gamma delta T-cell antigen receptor

Myocardial function after fetal cardiac bypass in an ovine model

Objective: Fetal cardiac surgery might improve the prognosis of certain complex congenital heart defects that have significant associated mortality and morbidity in utero or after birth. An important step in translating fetal cardiac surgery is identifying potential mechanisms leading to myocardial dysfunction after bypass. The hypothesis was that fetal cardiac bypass results in myocardial dysfunction, possibly because of perturbation of calcium cycling and contractile proteins. Methods: Midterm sheep fetuses (n = 6) underwent 30 minutes of cardiac bypass and 120 minutes of monitoring after bypass. Sonomicrometric and pressure catheters inserted in the left and right ventricles measured myocardial function. Cardiac contractile and calcium cycling proteins, along with calpain, were analyzed by means of immunoblotting. Results: Preload recruitable stroke work (slope of the regression line) was reduced at 120 minutes after bypass (right ventricle: baseline vs 120 minutes after bypass, 38.6 +/- 6.8 vs 20.4 +/- 4.8 [P = .01]; left ventricle: 37 +/- 7.3 vs 20.6 +/- 3.9, respectively [P = .01]). Tau (in milliseconds), a measure of diastolic relaxation, was increased in both ventricles (right ventricle: baseline vs 120 minutes after bypass, 32.7 +/- 4.5 vs 67.8 +/- 9.4 [P < .01]); left ventricle: 26.1 +/- 3.2 vs 63.2 +/- 11.2, respectively [P = .01]). Cardiac output was lower and end-diastolic pressures were higher in the right ventricle, but not in the left ventricle, after bypass compared with baseline values. Right ventricular troponin I was degraded by increased calpain activity, and protein levels of sarco(endo) plasmic reticulum calcium ATPase were reduced in both ventricles. Conclusions: Fetal cardiac bypass was associated with myocardial dysfunction and disruption of calcium cycling and contractile proteins. Minimizing myocardial dysfunction after cardiac bypass is important for successful fetal surgery to repair complex congenital heart defects. (J Thorac Cardiovasc Surg 2011;141:961-8)1414961U37

Erythropoietin protects the systolic function of neonatal hearts against ischaemia/reperfusion injury

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)The effect of erythropoietin (EPO) on neonatal hearts is not well understood. The current hypothesis is that EPO has protective effects against ischaemia-reperfusion when administered prior to ischaemia induction. Systolic and diastolic indices, as well as the Akt and extracellular-regulated kinase (Erk) signalling pathways, were studied in vivo using a neonatal pig heart model. Regional ischaemia was induced for 45 min by the ligation of the left anterior descending artery, followed by 90 min of reperfusion. The treatment groups consisted of: (i) untreated controls, (ii) treatment with EPO 3 min prior to ischaemia and (iii) treatment with EPO 24 h before ischaemia. Sophisticated myocardial contractility indices were assessed by pressure/volume loops of the left ventricle. The Akt and Erk pathways were evaluated via a western blot. Elastance was found to be higher in the group receiving EPO 3 min prior to ischaemia. In addition, preload recruitable stroke work was higher for both groups receiving EPO prior to ischaemia when compared with controls. The time constant of the isovolumic relaxation and end-diastolic pressure-volume relationship did not differ between the three groups after 90 min of reperfusion. Furthermore, EPO treatment enhanced phosphorylation of Akt, but not Erk, and EPO-treated animals showed lower levels of apoptosis-related proteins. EPO had a protective effect on neonatal systolic function after ischaemia/reperfusion injury, but no effect on diastolic function. This cardioprotective effect might be mediated by the activation of the Akt pathway.431156162Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)FAPESP [2009/09583-3

Use of modified ultrafiltration in adults undergoing coronary artery bypass grafting is associated with inflammatory modulation and less postoperative blood loss: A randomized and controlled study

Objectives: Modified ultrafiltration (MUF) has been shown to decrease the postcardiac surgery inflammatory response and to improve respiratory function and cardiac performance in pediatric patients; however, this approach has not been well established in adults. The present study hypothesized that MUF could decrease the postsurgical inflammatory response, leading to improved respiratory and cardiac function in adults undergoing coronary artery bypass grafting. Methods: Sixty patients undergoing coronary artery bypass grafting were randomized to the MUF or control group (n = 30 each). MUF was performed for 15 minutes at the end of bypass. The following data were recorded at the beginning of anesthesia, end of bypass, end of experimental treatment, and 24 and 48 hours after surgery: alveolar-arterial oxygen gradient, red blood cell units transfused, chest tube drainage, hemodynamic parameters, and cytokine levels (interleukin-6, P-selectin, intercellular adhesion molecule, and soluble tumor necrosis factor receptor). Results: The MUF group displayed less chest tube drainage than the control group after 48 hours (598 +/- 123 mL vs 848.0 +/- 455 mL; P = .04) and less red blood cell transfusions (0.6 +/- 0.6 units/patient vs 1.6 +/- 1.1 units/patient; P = .03). Hematocrit level was higher in the MUF group than in the control group at the end of bypass (37.8% +/- 1.1% vs 34.1% +/- 1.1%; P < .05), but the levels were comparable at 48 hours. Similar values for interleukin-6 and P-selectin were observed at all stages. Plasma levels of intercellular adhesion molecule were higher in the MUF group than in the control group, particularly in the first sampling after experimental treatment (P = .01). Plasma levels of soluble tumor necrosis factor receptor were higher in the MUF group than in the control group at 48 hours. Hemodynamic and oxygen transport parameters were similar in both groups throughout the observation period. There were no differences in other clinical outcomes. Conclusions: Use of MUF was associated with increased inflammatory response, reduced blood loss, and less blood transfusions in adults undergoing coronary artery bypass grafting. (J Thorac Cardiovasc Surg 2012;144:663-70)1443663670Fundacao de Amparo a Pesquisa de Sao Paulo Sao Paulo, Brazi

Risk Factors For Mortality And Morbidity After The Neonatal Blalock-taussig Shunt Procedure.

Perioperative advances have led to significant improvements in outcomes after many complex neonatal open heart procedures. Whether similar improvements have been realized for the modified Blalock-Taussig shunt, the most common palliative neonatal closed-heart procedure, is not known. Data were abstracted from The Society of Thoracic Surgeons Congenital Heart Surgery Database (2002 to 2009). Inclusion criteria were all neonates who received a modified Blalock-Taussig shunt with or without cardiopulmonary bypass, and with or without concomitant ligation of a patent ductus arteriosus. Discharge mortality was the primary end point. A composite morbidity end point one or more of the following: postoperative extracorporeal membrane oxygenation, low cardiac output, or unplanned reoperation. Associations with patient and procedural variables were assessed with univariable and multivariable analyses. The inclusion criteria were met by 1273 patients. The discharge mortality rate was 7.2%, and composite morbidity, as defined, was 13.1%. Primary diagnoses were classified as (1) those potentially amenable to biventricular repair (62%), (2) functionally univentricular hearts (22%), and (3) pulmonary atresia with intact ventricular septum (PA/IVS; 14%), and miscellaneous (2%). Discharge mortality stratified by primary diagnoses was PA/IVS (15.6%), functionally univentricular hearts (7.2%), and diagnoses potentially amenable to biventricular repair (5.1%). Need for preoperative ventilatory support, diagnosis of PA/IVS or functionally univentricular hearts, and any weight less than 3 kg, were risk factors for death. Preoperative acidosis or shock (resolved or persistent) and diagnosis of PA/IVS or functionally univentricular hearts were predictors of composite morbidity. Nearly 33% of the deaths occurred within 24 hours postoperatively, and 75% within the first 30 days. The mortality rate after the neonatal modified Blalock-Taussig shunt remains high, particularly for infants weighing less than 3 kg and those with the diagnosis of PA/IVS.92642-51; discussion 651-