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Objectives: To determine the early, intermediate and long-term outcomes of pulmonary atresia with ventricular septal defect (PA/VSD) Types I, II and III initially palliated by a right ventricle to pulmonary artery (RVPA) connection., Methods: We performed a retrospective study from 2000 to 2014 that included 109 patients with PA/VSD who had undergone an RVPA connection (tetralogy of Fallot and PA/VSD Type IV excluded). The end-points of this strategy were adequate pulmonary artery tree post-palliation, second palliation, biventricular repair, right ventricular pressure post-biventricular repair and late reoperation. Mean follow-up was 5.4 years (1 day to 14-78 years)., Results: Early mortality after an RVPA connection was 2.7% (3 of 109). The interstage mortality rate was 6.6% (7 of 106). Eighty-four (77%) patients had a biventricular repair and 8 patients (7%) are awaiting repair. Overall survival was 90% at 1 year and 81% at 10 years. The RVPA connection allowed significant growth of the native pulmonary artery with a Nakata index of 101 mm2/m2 before the RVPA connection and 274 mm2/m2 after (P = 0.001). Twenty-nine reinterventions for restrictive pulmonary blood flow have been done (9 before 2 months and 20 after 2 months). Of the 84 patients who had a repair, 22 patients (26%) initially had a right ventricular pressure greater than 40 mmHg. Twenty-eight patients (33%) required late reoperation., Conclusions: Hospital deaths after the RVPA connection were low. The procedure allowed good growth of the native pulmonary artery. Biventricular repair was possible in a large number of cases. The late morbidity rate remains significant. Early reinterventions could be avoided by appropriate calibration. This technique appears to be suitable for any type of PA/VSD with central pulmonary arteries., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The presence of single coronary artery (CA) in the arterial switch operation (ASO) for neonatal treatment with transposition of the great arteries (TGA) has been reported to be an independent risk factor for early death after surgical repair and late reintervention. The study objective was to evaluate the mortality and the CA stenosis risk at early and long term in neonatal ASO for TGA and single CA., Methods: Between January 1987 and January 2010, 979 neonates underwent an ASO, of which 73 had a single CA (7.5% of all cohort): right ostium with posterior left CA loop was the most frequent pattern (63%), followed by left ostium with an anterior right CA loop (26%). Mean age at operation was 9.3 ± 5.7 days. Mean follow-up was 9.8 years (range: 1-20 years)., Results: Eight patients (11%) died, 6 of coronary-related death. Overall, survival was 90.1 ± 1.9% at 1 year and 88.6% ± 3.8% at 2, 5, 10 and 15 years, respectively. Independent risk factor for mortality was associated surgery before 2001. Freedom from coronary events was 91.6 ± 3.3% at 1 year and 88.7 ± 3.8% at 5, 10 and 15 years respectively. No patients required late reintervention for CA surgery or angioplasty., Conclusions: All coronary-related death occurred within the first 6 months after ASO, and all patients but 1 were operated before 2001. In our experience, it appears that a single CA is not any more a risk factor for early and late mortality after ASO for TGA. Mortality has drastically reduced since 2001 and is now close to that found in TGA with standard coronary patterns. The acquired experience shared between the surgeons and the institution offsets the undeniable surgical difficulty., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Right ventricle to pulmonary artery connection (RVPA connection) without prosthetic material has been our ideal strategy to palliate pulmonary atresia with ventricular septal defect (VSD) or severe tetralogy of Fallot for the last decade. We speculate that RVPA connection ensures adequate postoperative haemodynamics for symptomatic neonates and promotes pulmonary artery rehabilitation. The present study was undertaken to assess the outcome of this strategy., Methods: Between 2000 and 2010, among 107 patients who benefited from an RVPA connection, 57 were neonates. Forty-eight of these underwent autologous tissue reconstruction, 5 using left atrial appendage. Median weight was 2.9 kg (range 1.8-4.4). Median Nakata index was 100 mm2/m2 (range 17-185 mm2/m2); 12% had major aortopulmonary collaterals. All patients were reviewed retrospectively. End-points were death or complete repair; reintervention for restrictive pulmonary blood flow was considered as failure. At follow-up, we evaluated reintervention after complete repair, and quality of life., Results: There were 2 early deaths (RV hypoplasia and RV failure) and 3 late sudden deaths (range 3-6 months). Pulmonary blood flow required to be increased in 8 patients: 4 underwent shunt after a median delay of 1 month; RVPA connection enlargement was needed in 3; 1 patient had percutaneous angioplasty. Finally, 47 patients (81%) had a complete repair, of which 70% were performed without prosthetic material at a median age of 7 months (range 2-53), with a median Nakata index of 221 mm2/m2 (range 102-891). One patient died early and 1 was a failure with opening of the VSD after intracardiac repair. At last follow-up, 4 patients were still awaiting repair, with 1 late death and 5 who had required reintervention after intracardiac repair; there were 3 conduit replacements and 2 balloon dilatation patch enlargements., Conclusions: The neonatal RVPA connection approach (i) provides an acceptable survival rate with a satisfactory haemodynamic adaptation, (ii) facilitates rehabilitation of PAs and (iii) avoids the use of prosthetic graft at correction.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was as follows: is coronary artery bypass graft (CABG) surgery superior to percutaneous coronary intervention (PCI) in terms of in-hospital mortality and morbidity and long-term outcomes in patients with acute myocardial infarction (MI)? A total of 104 papers were returned using the selected search. Of these, six represented the best evidence to answer the clinical question. The selection criteria were comparative studies with only PCI and CABG groups in patients with acute MI. Case reports, reviews, recommendations and studies on a specific population or out of the context of acute MI were excluded. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Almost all PCI patients received stents. One study used drug-eluting stents (DES). Two randomized studies showed similar short- and mid-term morbidities and mortalities in patients with acute MI in the PCI and CABG groups but higher repeat revascularization rates after PCI. Three observational studies found comparable survival, but one of them found more periprocedural events with CABG and the other two found more recurrent ischaemia requiring repeat revascularization in the PCI group. In one cohort study, CABG appeared to be an independent risk factor for death in N-STEMI according to the European Society/American College of Cardiology 2000 definition. The results are strongly influenced by the definition of acute MI. In an institution offering the two techniques with an equivalent accessibility, the principal advantage of PCI is a lower incidence of periprocedural and short-term morbidities. CABG, on the other hand, offers a better durability with less mid-term repeat revascularization required, especially when compared with PCI with DES implantation. Choice had to weight up coronary artery anatomy, number and localization of coronary artery stenosis and accessibility of both PCI and CABG treatments. Medical and surgical discussion within the Heart Team is required to make the best medical decision for each patient.

Objectives: We report the safety and feasibility of various transcatheter techniques of cavocaval connection in principle for the completion of Fontan circulation in viable, chronic and ovine heart models. Surgically simulated preparations of both intracardiac and extracardiac cavocaval connections were studied., Methods: Sixteen sheep were divided into two groups per the type of surgical preparation. All animals underwent standard right thoracotomy with interposition of a 20-mm Gore-tex(®) conduit between the superior vena cava (SVC) and the right atrium (RA). Nitinol rings were placed around the SVC and the inferior vena cava (IVC). In Group I (intracardiac, n = 10), the SVC-RA junction was closed using a polytetrafluoroethylene (PTFE) membrane 1 cm below the SVC-Gore-tex(®) anastomosis. In Group II (extracardiac, n = 6), a 20-mm Gore-tex conduit de-aired and filled with heparinized saline was anastomosed to connect the SVC and the IVC. The IVC end was anastomosed in a termino-lateral fashion and the SVC end in a termino-terminal fashion; both the ends were occluded with a PTFE membrane. Animals were scheduled for transcatheter cavocaval connection after a variable healing period., Results: Four animals in Group I died; three early and one late after surgical preparation. After a median interim period of 1 month (0-9 months), five sheep from Group I and six from Group II underwent successful transcatheter cavocaval connection. Perforation of the PTFE membrane was successful in all animals. Covered stents were deployed precisely and with good stability ensured by the nitinol rings. All animals survived transcatheter completion and were sacrificed after a median follow-up of 4 months (0-8 months) per protocol. No stent migration, thromboembolic events, residual shunts or paraprosthetic leak was noticed on angiographic evaluation or at autopsy in any animal., Conclusions: Transcatheter techniques for completion of cavocaval connection in surgically simulated, chronic animal models is safe and feasible. Both techniques were equally successful with no failures or short-term complications. Such techniques should work in principle for completion of intracardiac and extracardiac Fontan circulation.

Objective: Long-term evaluation of the impact of bicuspid pulmonary valve on neoaortic valve regurgitation and aortic root dilatation (ARD) after arterial switch operation (ASO) for transposition of the great arteries (TGA)., Methods: Between January 1987 and March 2010, 980 neonates underwent ASO for TGA. A total of 40 patients (4.0%) had a pulmonary bicuspid valve with no significant left ventricular outflow tract obstruction. In this group, 11 patients (28%) had associated ventricular septal defect, three hypoplastic aortic arch, and three had a right ventricular hypoplasia. No pulmonary valvuloplasty was attempted. Mean follow-up was 7.7 ± 5.5 years. Echocardiography evaluations of neoaortic valve function and morphology and aortic root dimensions were performed., Results: There were two hospital deaths (5%) related to hypoplastic right ventricle and left ventricular dysfunction, and no late death yielding an actuarial survival to 95% SD at 1, 5, and 10 years. At last follow-up, five patients (12%) had mild-to-moderate aortic regurgitation (AR). None had aortic valve stenosis. ARD was noted in 28% of the patients (Z-score up to +3). One patient needed a Bentall procedure for significant AR and severe dilatation of the ascending aorta at 11 years of age. As many as four patients underwent reoperation (10%) for stenosis of the left coronary artery. Freedom from reoperation was 95% SD, 88% SD, and 75% SD at 1,5, and 10 years, respectively., Conclusions: ASO is a safe option for TGA associated with a well-functioning bicuspid pulmonary valve with low morbidity and mortality. Prevalence of AR was not particularly high. Even though ARD was frequent, neoaortic bicuspid valve did not represent a high risk for aortic reoperation. Long-term individual follow-up is mandatory to observe the potential risk of root dilatation and AR.

Flash pulmonary edema (FPE) is a severe renovascular disease that leads to acute recurring pulmonary edema and acute systemic hypertension. Though rarely reported in the literature, its incidence is probably underestimated secondary to misdiagnosis, especially in patients with normal left ventricular function. We report the case of an orthotopic heart transplant recipient who presented with FPE despite having normal left ventricular function and no signs or symptoms of transplant rejection. Discovery of severe bilateral atherosclerotic renal artery stenosis in this patient led to emergency hepatorenal bypass surgery and a favorable postoperative course.

Objective: Mid-term evaluation of an aggressive surgical management of isolated congenitally corrected transposition of the great arteries (ccTGA) by pulmonary artery (PA) banding in early infancy., Methods: Between 2001 and 2009, 11 asymptomatic patients (seven neonates and four infants) underwent a dilatable, partially adjustable, homemade PA banding for ccTGA with intact ventricular septum. PA band circumference was correlated to body weight (22 mm+1 mm kg(-1)) and ideally adjusted to obtain flat septal geometry. Mean age at operation was 1.5±1.4 months., Results: There was no hospital mortality. Mean ventilation time and intensive care unit (ICU) stay were 20±9 h and 2.6±1.5 days, respectively. Five patients required postoperative inotropic support. One late death occurred suddenly at 4 months; normal biventricular function and no tricuspid regurgitation were noted at last follow-up, 1 week before death. Mean follow-up was 21.5±26 months. Mean band velocity increased over time from 2.65±0.7 m s(-1) postoperatively to 3.7±0.3 at 6 months and 4.5±0.4 m s(-1) at 2 years. Tricuspid regurgitation remained stable in seven patients, decreased in three and worsened in one. Flat septal geometry was obtained in all patients after the third postoperative month. One patient underwent a double-switch procedure at 7 years due to suprasystemic morphologically left ventricular pressure. The postoperative course was uneventful., Conclusions: In neonates with isolated ccTGA, prophylactic PA banding is safe and carries a low morbidity. At mid-term evaluation, tricuspid valve function is stabilised or improved and systemic competence of the left ventricle is maintained, thus allowing double switch if indicated., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Biventricular assist device (BVAD) has been shown to be effective for bridge to heart transplantation with an acceptability low incidence of adverse effects in critically ill heart failure patients. We report the case of a 44-year-old man with severe acute ischemic heart failure who was supported with the Thoratec paracorporeal biventricular assist system. After an initial uneventful postoperative course the patient experienced a splenic rupture which required a splenectomy. The pathological mechanism of this outcome remains unclear. Two months after discharge, the patient underwent heart transplantation and had no postsplenectomy sepsis or thrombotic complications at the last follow-up.