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OBJECTIVES Left superior vena cava (LSVC)-related obstruction of mitral inflow is a rare finding in patients with complex cardiac anomalies like hypoplastic left heart complex. We report our experience by establishing a left superior to right superior caval vein continuity (innominate vein creation by direct LSVC–right superior vena cava end-to-side-anastomosis), and coronary sinus unroofing if indicated for LSVC-related mitral inflow obstruction. METHODS Nineteen patients (median age: 1.0 ± 0.3 years; range: 7 days–4.8 years) underwent anatomical correction of LSVC without the use of foreign material in conjunction with repair or palliation of congenital anomalies in a single centre between April 2015 and November 2019. Indications for the procedure were LSVC-related obstruction of left ventricular inflow due to a dilated coronary sinus. Additional procedures included mitral (n = 7) or atrioventricular (n = 3) valve surgery, right ventricular to pulmonary artery conduit (n = 3), first stage palliation (n = 3) or biventricular repair (n = 5) of hypoplastic left heart complex. Three patients needed secondary mitral valve replacement (n = 3). RESULTS All LSVC or coronary sinus-related obstructions were effectively relieved. No patient died early, 2 patients died late after the procedure. One patient needed stenting of the superior vena cava below the unobstructed cephalad vein anastomosis at the former right superior vena cava-cannulation-site. Follow-up was complete and demonstrated an 89.5% survival after 2.5 ± 0.4 years. Innominate vein patency was 100% documented by echocardiography (n = 19), cardiac catheterization (n = 6) or both. Mean mitral valve z-scores before the operation were −1.7 ± 0.2 (range −3.8 to 0.3) and increased to 0.7 ± 0.2 (range −0.7 to 1.9) after LSVC repair. CONCLUSIONS Anatomical correction by surgical creation of an innominate vein is an effective method to relieve LSVC-related obstructions and promotes mitral valvar growth. Mitral ring sizes were at least normalized after surgery at the time of discharge. Further prospective follow-up studies to evaluate the growth potential of left-sided heart structures by reporting cardiac z-scores are needed to evaluate the true impact of coronary sinus unroofing.

Objective: The longevity of valved right ventricle to pulmonary artery (RV-PA) conduits is limited due to calcification and degeneration of nonviable structures. Xenografts are commonly used because of the restricted availability of cryopreserved homografts. Tissue-engineered (decellularised) pulmonary valves (TEPVs) were thought to be a valuable alternative to cryopreserved pulmonary homografts due to postoperative seeding with viable autologous vascular endothelial cells. Methods: From July 2007 to December 2008, xenogenous TEPV (Matrix P plus#) were implanted in 16patients in the rightventricular outflowtract for differentindications, relatedto congenitalheart disease.Mean age at operation was 14 11 years, including three patients younger than 1 year. The median conduit size was 22 mm (range: 13—26 mm). Results: The early and late survival rates were 100%. At a median follow-up of 10 months (range: 2—17 months), six patients (38%) had to be re-operated upon due to obstructed grafts. Five of these patients were older than 13 years (range: 13—26 years); one patient was younger than 1 year. On echocardiography before re-operation, mean systolic gradient in the main PA was 66 18 mmHg. In explanted conduits, we found a predominantly peripheral conduit narrowing without leaflet calcification. Histological examination revealed stenosis formation, due to inflammatory infiltration and severely fibrogenic pseudo-intimal reaction. Conclusions: On the basis of our short-term results, the Matrix P plus# de-cellularised tissueengineered pulmonary valve cannot be regarded as an ideal conduit for right ventricular outflow tract reconstruction, as the widespread use of these grafts may increase the possibility of frequent early conduit failures. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: To evaluate the influence of high colloid oncotic pressure (COP) priming of cardiopulmonary bypass (CPB) on fluid balances, haemofiltration, capillary leakage and renal function in neonates and infants. Methods: Twenty neonates or infants underwent heart surgery using CPB and were randomised in two groups. For group 1 (FFP-group) a blood priming with fresh frozen plasma (FFP, low oncotic pressure) was chosen,forgroup2(HA-group)a bloodprimingcontainingFFPandhumanalbumin20%(HA)torealisehigheroncoticpressureswassubstituted.All patients were monitored before, during and 6 h after CPB. We measured weights, fluid balances, transfusion volumes, colloid oncotic pressures, inflammatory parameters (c-reactive protein, interleukin-6, interleukin-8, thrombocytes, leucocytes) and renal function (creatinine clearances, renal protein losses). Results: Patient’s demographics and operational procedures were comparable in both groups with no further differences in operation procedures regarding palliation or correction. Colloid oncotic pressures of the priming solutions were higher in the HA-group (28 mmHg 4.9) than in the FFP-group (6 mmHg 1.3, p < 0.001). Relative weight gain as a marker of capillary leakage in the HA-group (2% 4.5) was significantly lower 6 h post CPB than in the FFP-group (8% 8.0, p = 0.015). Haemofiltration rates were higher in the HA-group (569 ml 197 vs 282 ml 157, p = 0.002) on CPB. There were no differences of creatinine clearances 6 h after the end of CPB. Renal protein losses were elevated in both groups without any inter-group differences during and 6 h after CPB. Conclusion: Addition of concentrated human albumin to priming fluids in paediatric cardiac surgery leads to less weight gain even after CPB. Supplementing paediatric patients undergoing cardiac surgery with concentrated human albumin does not affect renal function more severely than in paediatric patients undergoing cardiac surgery on CPB with blood priming. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objectives: To assess the impact of balanced ultrafiltration and peritoneal dialysis (PD) on plasma and urinary cytokines and renal dysfunction after cardiopulmonary bypass (CPB) surgery in newborns and infants. Methods: Twenty-three newborns and infants weighing less than 7 kg and scheduled for operation on congenital malformation were enrolled in this descriptive open clinical study. All patients received conventional ultrafiltration in the CPB rewarming period. Eleven newborns underwent Tenckhoff-catheter implantation in the operation theatre as a routine institutional procedure and received PD after admission to the ICU (the PD [+] group). No PD was used in another 12 patients (the PD [- ] group). Interleukins (IL) 6 and 8 were measured four times pre- and post-operatively. Kidney function was assessed by creatinine clearances and urine protein and enzyme analyses. Results: All patients had an uneventful clinical course. Age (10 ± 2 days, PD [+] vs. 96 ± 19 days, PD [-]), CPB duration (215 ± 23 vs. 143 ± 20 min), and degree of hypothermia (26 ± 1.3 vs. 31 ± 0.1 °C) differed significantly between the groups. Age, CPB duration and ultrafiltration influenced post-operative IL-levels in an analysis of variance. While there were few differences immediately after the end of ultrafiltration, post-operative levels of IL-6 and IL-8 were higher and more sustained in the newborns (PD [+]) than in the older infants (PD [- ]). The median amount of IL-6 and IL-8 removed by ultrafiltration came to 28 and 59% compared to the amount of IL-6 and IL-8 remaining in the blood at the end of CPB. IL-clearance by ultrafiltration was more than 1000-fold and by PD more than 100-fold as effective as IL-clearance by the kidney. While the kidneys showed an unselective mixed glomerular and tubular pattern of injury, during CPB higher serum IL-concentrations correlated with lower urinary IL-clearances in both study groups. Conclusions: Ultrafiltration and PD are highly effective in removing proinflammatory cytokines. Impaired kidney function was associated with proinflammatory IL-serum concentrations. Thus, we raise the hypothesis that glomerular-filtered proinflammatory ILs damage the proximal tubular cells of the kidney in newborns and infants, thus contributing to post-operative renal dysfunction. Conversely, we conclude that removing proinflammatory ILs by ultrafiltration and PD acts renoprotectively. A future prospective randomised study could demonstrate whether this can indeed improve clinical outcome.