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To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery. Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared. Of 717 infants (median age: 4 months, Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P <.01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P <.01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P <.01; and tendency toward lower early mortality: 0% versus 2.8%, P =.08. Reintubation rate did not differ between the groups (P =.7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P <.01), resulting in 27% less reimbursement in the FT group. FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group system s reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately. FT concept of early extubation. Graphical describes the methodology of the study with 717 infants <7 kg undergoing open heart surgery on cardiopulmonary bypass. Group FT (N = 182) was extubated within the first 8 hours after surgery, group non-FT (N = 535) was extubated at a later point. After propensity score matching 1:1, we received 123 matched pairs. Group FT demonstrated shorter ICU/hospital stay, lower VIS, and transfusion rates; however, also 27% less reimbursement. FT , Fast-track; ICU , intensive care unit; VIS , vasoactive-inotropic score; CPB , cardiopulmonary bypass. [Display omitted] [ABSTRACT FROM AUTHOR]

Right ventricular hypertrophy and failure are major causes of cardiac morbidity and mortality. A key event in the progression to right ventricular hypertrophy and failure is cardiomyocyte apoptosis due to mitochondrial dysfunction. We sought to determine whether localized intramyocardial injection of autologous mitochondria from healthy muscle treats heart failure. Mitochondria transplanted from different sources were initially tested in cultured hypertrophic cardiomyocytes. A right ventricular hypertrophy/right ventricular failure model created through banding of the pulmonary artery in immature piglets was used for treatment with autologous mitochondria (pulmonary artery banded mitochondria injected/treated n = 6) from calf muscle, versus vehicle (pulmonary artery banded vehicle injected/treated n = 6) injected into the right ventricular free-wall, and compared with sham-operated controls (sham, n = 6). Animals were followed for 8 weeks by echocardiography (free-wall thickness, contractility), and dp/dt max was measured concomitantly with cardiomyocyte hypertrophy, fibrosis, and apoptosis at study end point. Internalization of mitochondria and adenosine triphosphate levels did not depend on the source of mitochondria. At 4 weeks, banded animals showed right ventricular hypertrophy (sham: 0.28 ± 0.01 cm vs pulmonary artery banding: 0.4 ± 0.02 cm wall thickness; P =.001), which further increased in pulmonary artery banded mitochondria injected/treated but declined in pulmonary artery banded vehicle injected/treated (0.47 ± 0.02 cm vs 0.348 ± 0.03 cm; P =.01). Baseline contractility was not different but was significantly reduced in pulmonary artery banded vehicle injected/treated compared with pulmonary artery banded mitochondria injected/treated and so was dp/dtmax. There was a significant difference in apoptotic cardiomyocyte loss and fibrosis in sham versus hypertrophied hearts with most apoptosis in pulmonary artery banded vehicle injected/treated hearts (sham: 1 ± 0.4 vs calf muscle vs vehicle: 13 ± 1.7; P =.001 and vs pulmonary artery banded mitochondria injected/treated: 8 ± 1.9, P =.01; pulmonary artery banded vehicle injected/treated vs pulmonary artery banded mitochondria injected/treated, P =.05). Mitochondrial transplantation allows for prolonged physiologic adaptation of the pressure-loaded right ventricular and preservation of contractility by reducing apoptotic cardiomyocyte loss. Mitochondrial transplantation allows for prolonged physiologic adaptation of the pressure-loaded RV and preservation of contractility. [Display omitted] [ABSTRACT FROM AUTHOR]

Endothelial-to-mesenchymal transition (EndMT) has been identified as the underlying mechanism of endocardial fibroelastosis (EFE) formation. The purpose of this study was to determine whether hemodynamic alterations due to valvar defects promote EndMT and whether age-specific structural changes affect ventricular diastolic compliance despite extensive surgical resection of EFE tissue. We analyzed EFE tissue from 24 patients with hypoplastic left heart syndrome (HLHS) who underwent left ventricular (LV) rehabilitation surgery at Boston Children's Hospital between December 2011 and March 2018. Six patients with flow disturbances across the aortic valve and/or mitral valve but no HLHS diagnosis and macroscopic appearance of "EFE-like tissue" in the LV were included for comparison. All samples were examined for amount of collagen/elastin production and degradation, and presence of active EndMT by histologic analysis. EFE tissue from patients with and without HLHS consisted predominantly of elastin and collagen fibers. There was no alteration in degradation activity for collagen or elastin as shown by in situ zymography. Active EndMT was found in all patients with and without HLHS with flow disturbances ("EFE-like"). In patients with HLHS, EFE infiltrated into the underlying myocardium with increasing age. Patients with and without HLHS with flow disturbances due to stenotic or incompetent valves develop EndMT-derived fibrotic tissue covering the LV. When EFE recurs, it is directly associated with flow disturbances and switches to an infiltrative growth pattern with increasing age, leading to increased diastolic stiffness of the LV. [ABSTRACT FROM AUTHOR]

We sought to develop an instrument that would enable the delivery of artificial chordae tendineae (ACT) using optical visualization of the leaflet inside the beating heart. A delivery instrument was developed together with an ACT anchor system. The instrument incorporates an optically clear silicone grasping surface in which are embedded a camera and LED for direct leaflet visualization during localization, grasping, and chordal delivery. ACTs, comprised of T-shaped anchors and an expanded polytetrafluoroethylene chordae, were fabricated to enable testing in a porcine model. Ex vivo experiments were used to measure the anchor tear-out force from the mitral leaflets. In vivo experiments were performed in which the mitral leaflets were accessed transapically using only optical guidance and ACTs were deployed in the posterior and anterior leaflets (P2 and A2 segments). In 5 porcine ex vivo experiments, the mean force required to tear the anchors from the leaflets was 3.8 ± 1.2 N. In 5 porcine in vivo nonsurvival procedures, 14 ACTs were successfully placed in the leaflets (9 in P2 and 5 in A2). ACT implantation took an average of 3.22 ± 0.83 minutes from entry to exit through the apex. Optical visualization of the mitral leaflet during chordal placement is feasible and provides direct feedback to the operator throughout the deployment sequence. This enables visual confirmation of the targeted leaflet location, distance from the free edge, and successful deployment of the chordal anchor. Further studies are needed to refine and assess the device for clinical use. [ABSTRACT FROM AUTHOR]

The study aim was to compare Fontan patients undergoing lateral tunnel (LT) versus extracardiac conduit (ECC) technique. Fontan patients (LT vs ECC) from January 2000 to December 2017 were analyzed retrospectively. Baseline characteristics were analyzed as covariates. Primary outcomes (ie, mortality, Fontan failure, thrombosis, and pacemaker implantation) were compared using time-to-event models. Subgroup analysis including only initially fenestrated cases and propensity score matching were performed. Eight hundred one Fontan patients: LT (n = 638) versus ECC (n = 163) were included. Median follow-up time was 4.8 years (range, 1.1-10.8 years). Baseline characteristics were similar except for age: LT versus ECC: 2.6 years (range, 2.2-3.2 years) versus 3.1 years (range, 2.6-4.7 years) (P <.01) and mean pulmonary artery pressure: LT versus ECC: 12 mm Hg (11-15 mm Hg) versus 11 mm Hg (10-13 mm Hg) (P <.05). Early mortality was significantly higher in ECC versus LT group (3.1%; vs 0.5%; P <.05). Freedom from death, heart transplantation and Fontan failure were significantly longer in LT vs ECC (P <.01). After correcting for age, diagnosis, surgical technique, surgeon, mean pulmonary artery pressure, and fenestration, the ECC group showed worse freedom from death (hazard ratio, 2.8; P <.01) and Fontan failure (hazard ratio, 3.0; P <.01). No difference in pacemaker implantation rate was demonstrated (P =.25). Early fenestration closure was associated with higher risk of early (hazard ratio, 30.5) and late mortality (hazard ratio, 3.5). After matching, log-rank tests showed significant differences between the 2 groups for Fontan failure at 5 and 10 years (P <.01) and mortality at 5 years (P =.02). When compared with ECC, LT Fontan is associated with better short and midterm outcomes. Spontaneous fenestration closure is an independent risk factor for early/late mortality. LT versus ECC at Boston Children's Hospital. This figure describes the methods of this retrospective study including a total of 801 Fontan patients (ECC = 163, LT = 638) at Boston Children's Hospital. It then summarizes the major findings of this study with the LT technique being superior in terms of early and midterm mortality rates and exercise performance but having longer operating times and equal pacemaker rates than ECC Fontan technique, which tends to have higher early fenestration closure rates. In conclusion, these findings indicate that LT technique should be reconsidered for third-stage palliation in patients with univentricular morphology. [ABSTRACT FROM AUTHOR]