Search

Objectives: The goal of this study was to develop a device for percutaneous replacement of the tricuspid valve in animals.Background: Percutaneous valve replacement has recently been introduced, and early clinical experience has been reported. To date, this technique is limited to the replacement of pulmonary and aortic valves in selected patients.Methods: A newly designed nitinol stent, forming two large disks separated by a cylinder with a diameter of 18 mm, was specially designed for the purpose of this study. An 18-mm bovine valve was mounted in the central part of the stent, and a polytetrafluoroethylene membrane was sutured onto the ventricular disk. Eight ewes were equally divided into two groups (group 1, acute study; group 2, killed at one month).Results: Seven of eight devices were successfully delivered in the desired position. In one animal, the device was trapped in tricuspid cordae, leading to its incomplete opening. A significant paravalvular leak was noticed in one animal of group 2. Mean right atrial pressure increased from 5 to 7 mm Hg and did not change during the follow-up. At autopsy, examination confirmed the good position of devices in successfully implanted animals.Conclusions: Implantation of a semi-lunar valve in the tricuspid position is possible in ewes through a transcatheter approach. A disk-based nitinol stent is needed to allow valve implantation in the atrioventricular position. These studies open new perspectives into tricuspid as well as mitral valve replacement. [ABSTRACT FROM AUTHOR]

This article presents information on a medical case related to secondary collapse of a Palmaz stent implanted for native aortic coarctation. A 21 year old woman was referred for native aortic coarctatiori. At 6 months of age she had had a repair of an aorto-pulmonary window, at 12 months a surgical closure of an atrial septal defect, and at 7 years a left pneumonectomy. At presentation she had systemic hyper-tension and superior-inferior limb gradient of 30 mm Hg. The risk of surgical repair of coarctation was considered to be elevated, thus, redilation of the stent was attempted, utilising a 18 mm balloon.

Background: Recent evidence shows an association between coronavirus disease 2019 (COVID-19) infection and a severe inflammatory syndrome in children. Cardiovascular magnetic resonance (CMR) data about myocardial injury in children are limited to small cohorts. The aim of this multicenter, international registry is to describe clinical and cardiac characteristics of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 using CMR so as to better understand the real extent of myocardial damage in this vulnerable cohort., Methods and Results: Hundred-eleven patients meeting the World Health Organization criteria for MIS-C associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), having clinical cardiac involvement and having received CMR imaging scan were included from 17 centers. Median age at disease onset was 10.0 years (IQR 7.0-13.8). The majority of children had COVID-19 serology positive (98%) with 27% of children still having both, positive serology and polymerase chain reaction (PCR). CMR was performed at a median of 28 days (19-47) after onset of symptoms. Twenty out of 111 (18%) patients had CMR criteria for acute myocarditis (as defined by the Lake Louise Criteria) with 18/20 showing subepicardial late gadolinium enhancement (LGE). CMR myocarditis was significantly associated with New York Heart Association class IV (p = 0.005, OR 6.56 (95%-CI 1.87-23.00)) and the need for mechanical support (p = 0.039, OR 4.98 (95%-CI 1.18-21.02)). At discharge, 11/111 (10%) patients still had left ventricular systolic dysfunction., Conclusion: No CMR evidence of myocardial damage was found in most of our MIS-C cohort. Nevertheless, acute myocarditis is a possible manifestation of MIS-C associated with SARS-CoV-2 with CMR evidence of myocardial necrosis in 18% of our cohort. CMR may be an important diagnostic tool to identify a subset of patients at risk for cardiac sequelae and more prone to myocardial damage., Clinical Trial Registration: The study has been registered on ClinicalTrials.gov, Identifier NCT04455347, registered on 01/07/2020, retrospectively registered., (© 2021. The Author(s).)

The Fontan operation has been the final palliation for patients born with congenital heart defects with a functional single ventricle for more than 4 decades. The "normal" Fontan physiology is characterized by the loss of the sub-pulmonary ventricle with consequent elevated pressure in the caval system, non-pulsatile blood flow in the pulmonary circulation and at least mild reduction of the systemic output. When successful, this procedure is associated with a range of benefits including improved arterial saturation and abolishment of chronic volume overload, allowing a fairly normal life to the majority of patients through early adulthood. As we enter the 5th decade of caring for patients palliated with the Fontan procedure, it is evident that adult survivors face significant morbidity due to multiorgan dysfunction, early mortality and need for heart transplantation. Several late complications may occur: ventricular dysfunction, arrhythmia, cyanosis, exercise intolerance, elevated pulmonary vascular resistance, protein-losing enteropathy, plastic bronchitis, hepatic and renal complications. The mechanism of late Fontan failure is multifactorial and not completely understood, it depends on interactions between the ventricle, the pulmonary vascular bed, the venous and lymphatic compartments. Conclusions: the aim of this review is to describe the pathophysiology of Fontan circulation and the clinical and hemodynamic characteristics of early and late failing Fontan survivors, their association with morbidity and mortality, and the strategies for their management.

A comprehensive description of morbidity and mortality as well as risk factors of interventional cardiac catheterization performed in neonatal age was reported in our paper recently published on the International Journal of Cardiology ( IJCA28502; PII: S0167-5273(20)30384-3; DOI: 10.1016/j.ijcard.2020.04.013 ). Eight Italian high-volume centres of Paediatric Cardiology were involved in this observational, retrospective data collection and analysis. In this dataset, clinical and procedural characteristics of 1423 newborns submitted to 1551 interventional cardiac catheterization procedures were analyzed. Primary outcomes were considered procedure and in-hospital mortality as well as major adverse event and procedural failure rates. Secondary outcomes were considered minor adverse events and need for blood transfusion. Targets of this data analysis were: 1) to evaluate the overall major risk factors of interventional cardiac catheterization; 2) to identify the most hazardous interventional procedures; 3) to assess possible trends of individual procedures as well as their outcome over time; 4) to find possible relationships between the volume activity of any centre and the procedure and follow-up outcome. In particular, this Data in Brief companion paper aims to report the specific statistic highlights of the multivariable analysis (binary logistic regression) used to assess the impact of any potential risk factors on the type of procedure over a short-term follow-up., (© 2020 The Authors.)

A comprehensive description of morbidity and mortality in patients affected by mutations in genes encoding for signal transducers of the RAS-MAPK cascade (RASopathies) was performed in our study recently published in the International Journal of Cardiology. Seven European cardiac centres participating to the CArdiac Rasopathy NETwork (CARNET), collaborated in this multicentric, observational, retrospective data analysis and collection. In this study, clinical records of 371 patients with confirmed molecular diagnosis of RASopathy were reviewed. Cardiac defects, crude mortality, survival rate of patients with 1) hypertrophic cardiomyopathy (HCM) and age <2 years or young adults; 2) individuals with Noonan syndrome and pulmonary stenosis carrying PTPN11 mutations; 3) biventricular obstruction and PTPN11 mutations; 4) Costello syndrome or cardiofaciocutaneous syndrome were analysed. Mortality was described as crude mortality, cumulative survival and restricted estimated mean survival. In particular, with this Data In Brief (DIB) paper, the authors aim to report specific statistic highlights of the multivariable regression analysis that was used to assess the impact of mutated genes on number of interventions and overall prognosis.

Objectives: To evaluate the effects of endothelin inhibitors (ERAs) on hemodynamic and functional parameters in patients post-Fontan procedure with high pulmonary vascular resistance (PVR)., Methods: Among our cohort of patients with Fontan circulation, 8 children, 8 adolescents, and 8 adults had PVR ≥2 WU*m 2 . These patients were treated with ERAs (minors with bosentan, adults with macitentan) and reevaluated after 6 months. Pre- and posttreatment hemodynamic variables were assessed by cardiac catheterization. Functional capacity was evaluated by cardiopulmonary exercise testing (CPET). Our primary endpoint was to obtain a reduction of PVR; the secondary endpoint was to obtain an improvement of functional capacity., Results: Under treatment, New York Heart Association class improved for adolescents and adults. PVR decreased (P = .01) in all groups: in children from the median value 2.3 (interquartile range 2.0-3.1) to 1.9 (1.4-2.3) WU*m 2 , in adolescents from 2.3 (2.1-2.4) to 1.7 (1.4-1.8) WU*m 2 , and in adults from 2.8 (2.0-4.7) to 2.1 (1.8-2.8)WU*m 2 . In 71% of patients, PVR fell to less than 2 WU*m 2 . Cardiac index increased in adolescents from 2.6 (2.4-3.3) to 3.6 (3.4-4.3) L/min/m 2 , P = .04, and in adults from 2.1 (2.0-2.3) to 2.8 (2.3-4.7) L/min/m 2 , P = .03. CPET showed that only adolescents displayed a significant functional improvement. Anaerobic threshold improved from 17 (13-19) to 18 (13-20) mL/kg/min, P = .03; oxygen consumption and VO 2 max increased from 1.3 (1.0-1.6) to 1.7 (1.1-1.9) L/min, P = .02 and from 25 (21-28) to 28 (26-31) L/min, P = .02, respectively. Oxygen pulse increased from 7.9 (5.7-10.4) to 11.2 (8.2-13.0) L/beat, P = .01., Conclusions: This is the first study that assesses by cardiac catheterization and CPET the effects of ERA in patients with Fontan circulation with increased PVR. These results suggest that ERAs might provide most pronounced hemodynamic and functional improvement in adults and adolescents., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Hepatic damage in Fontan circulation setting is well known. Mainly represented by fibrosis, it is still poorly understood. Transient hepatic elastography (Fibro-Scan) is a useful tool to test liver stiffness and is commonly used in the evaluation of liver fibrosis. Unfortunately, the increase of inferior vena cava pressure consequent to total cavopulmonary connection can probably interfere with Fibro-Scan evaluation altering the result evaluation with the conventional scale. To verify this hypothesis and to quantify the impact of venous pressure on Fibro-Scan results, we checked perioperative liver stiffness changes in patients undergoing total cavopulmonary connection., Methods: A prospective observational study was carried out on 9 patients undergoing extracardiac total cavopulmonary connection. Mean age at operation was 4.3 ± 0.6 years, and mean weight 14 ± 2.4 kg. Hepatic stiffness was analysed with Fibro-Scan evaluation immediately before and 4 months after surgery. Results were matched with several perioperative data: pulmonary pressures, conduit size, fenestration, hepatic enzymes and coagulation setting., Results: Preoperative hepatic stiffness was 6.2 ± 1.5 kPa, with a significant increase to 11.2 ± 4 kPa at a mean follow-up of 4 months (P < 0.01). Mean alanine aminotransferase was 16.9 ± 8.3 mg/dl preoperatively and 16.3 ± 8.7 mg/dl at discharge. Both values showed a significant correlation with liver stiffness raise, their Pearson Correlation Indexes being 0.8 and 0.7, respectively (P < 0.01). Mean aspartate aminotransferase/alanine aminotransferase ratio at discharge was 1.7 ± 0.5 and showed a significant negative correlation with liver stiffness raise, its Pearson Correlation Index being -0.7 (P < 0.01)., Conclusions: Liver stiffness increases rapidly after total cavopulmonary connection and perioperative variations in some liver enzymes appear to correlate with this change. Since a true anatomical damage is known to develop gradually with Fontan circulation, early liver stiffness raise is likely due to parenchymal congestion only. Fibro-Scan can easily recognize and assess the entity of such a change. For these reasons, this diagnostic tool must be considered useful only to monitor liver stiffness changes and evolution with time, but a conventional evaluation of results, like in other acquired hepatic fibrosis, can be misleading., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The arterial switch operation (ASO) for transposition of the great arteries requires transfer of the coronary arteries from the aorta to the proximal pulmonary artery (neoaorta). This is complicated by variable coronary anatomy before transfer. In 8% to 10% of cases, there is evidence of late coronary stenosis and/or occlusion, often with catastrophic clinical consequences. The mechanism of such complications has not been well studied., Methods and Results: We analyzed 190 consecutive high-resolution computed tomographic scans from the ASO procedure (patients aged 5-16 years) and found 17 patients with significant (>30% up to occlusion) coronary lesions (8.9%); all were later confirmed by conventional angiography. The left main coronary artery was abnormal in 9 patients (ostium in all), the left anterior descending artery in 3, the circumflex in 2, and the right coronary artery in 3 patients. Using multiplanar and 3-dimensional reconstructions of the coronary arteries, aorta, and pulmonary artery, we identified the commonest mechanisms of coronary abnormalities. For the left main and left anterior descending artery, anterior positioning of the transferred left coronary artery (between 12 and 1 o'clock on the neoaorta) appeared to predispose to a tangential course of the proximal left coronary artery promoting stenosis. All circumflex lesions occurred in Yacoub type D coronaries where a long initially retroaortic artery was stretched by its new positioning behind an enlarged neoaorta. Right coronary artery lesions occurred only in cases in which the reimplantation site was very high above the right coronary sinus with potential compression from the main pulmonary artery bifurcation immediately above., Conclusions: Thus detailed multiplanar computed tomographic scanning can elucidate the mechanisms of late coronary complications after the ASO. Understanding these aspects could help to improve surgical technique to minimize the risk of late coronary obstructions., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Congenital mitral regurgitation is rare and usually part of complex cardiac anomalies. When needed, early surgery represents a great challenge. In small babies avoiding valve replacement is desirable, but valve repair may be extremely complex. We describe an isolated congenital mitral regurgitation, successfully treated with conservative surgery about 1 h after birth. In a 30-year-old pregnant woman, fetal echocardiography revealed mitral annular dilatation with massive regurgitation, functional aortic atresia and a very small patent foramen ovale. Realizing that the baby had a poor chance of survival after birth, a cesarean section was scheduled at 37 weeks of pregnancy. The procedure was performed in the operating room next to the cardiac surgery theatre, where the newborn was urgently transferred. After an unsuccessful attempt of percutaneous atrial septostomy, a rescue surgical mitral repair was performed. To avoid mitral replacement, moderate residual regurgitation was accepted. Postoperative hospital stay was 57 days and the baby was discharged in good clinical condition. Residual mitral regurgitation was moderate at discharge and decreased thereafter. During a five-year follow-up the child remained asymptomatic with normal growth. Preserved ventricular function and progressive volume reduction of left heart chambers were observed.

Aim: To evaluate the information provided by echocardiography and cardiac catheterization in patients with partial cavopulmonary connection (PCPC) with or without additional pulmonary blood flow (PBF) in whom total cavopulmonary connection (TCPC) was planned., Methods: We retrospectively evaluated the results provided by echocardiography and cardiac catheterization in 110 consecutive patients with PCPC (35 with isolated PCPC, 38 with associated antegrade PBF, 37 with associated retrograde PBF) in whom TCPC was planned., Results: Eight patients had superior vena cava syndrome; all others suffered from cyanosis and fatigue. Pulmonary artery size could be determined in 54% of patients without additional PBF, in 47% of those with associated retrograde PBF and in 68% of those with associated PBF (p=0.20). Concomitant clinical signs of increased central venous pressure and echocardiographic signs of ventricular dysfunction and/or hypoplastic pulmonary arteries identified four patients in whom TCPC was not low-risk. PAP exceeding 16 mmHg was found in 9% of patients without and 16% of those with associated PBF (p=0.38). The Nakata index was higher in patients with associated antegrade PBF than in those without associated PBF (p=0.004) or in those with associated retrograde PBF (p=0.002). Of the 16 patients who needed concomitant interventional catheterization, 10 had associated retrograde PBF (p<0.05). In 11 patients (nine with and two without additional PBF), TCPC was contraindicated., Conclusion: Cardiac catheterization is still necessary before TCPC, mostly in patients with additional PBF, to identify those at risk and those needing interventional catheterization.

Background: Occlusion of the femoral veins is a frequent complication of cardiac catheterization in small children. If the venous femoral approach is not available, a jugular approach is generally used for catheterization of the right heart., Aims: To describe and evaluate an alternative retrograde approach for catheterization of the right heart in small children with a ventricular septal defect or single ventricle., Methods: Between January 2004 and January 2007 we attempted retrograde catheterization of the right heart via the femoral artery using a 4 French sheath in eight children with occluded femoral veins. The procedure was planned under awake sedation., Results: Median age was five months (range 4-60) and median weight was 5 kg (range 4-10). Diagnoses were as follows: single ventricle (n = 6); pulmonary atresia and ventricular septal defect (n = 1); complex transposition of the great arteries (n = 1). The procedure was successful in six patients, enabling measurement of pulmonary arterial pressure and pulmonary angiography. The procedure was abandoned in two patients because of ventricular arrhythmias. One patient had concomitant dilatation of aortic recoarctation and one had embolization of aortopulmonary collaterals. With the exception of transient ventricular arrhythmias, no acute or late complications occurred. In particular, transient or permanent atrioventricular block, occurrence of new aortic insufficiency, and acute or late thrombosis of the femoral artery were not observed., Conclusion: Retrograde catheterization of the right heart in small children is feasible and relatively safe. This technique can be performed without general anaesthesia and avoids a jugular approach.

Objectives: We investigated the accuracy of 64-slice computed tomography (CT) angiography, as compared to invasive angiography, to evaluate reimplanted coronary arteries in children after arterial switch operation (ASO) for transposition of the great arteries (TGA)., Background: Assessment of the integrity of reimplanted coronary arteries is crucial for long-term outcome after ASO for TGA. Noninvasive tests have limited accuracy for detecting significant coronary lesions, and invasive coronary angiography is usually required in this setting., Methods: One hundred thirty consecutive children, after ASO for TGA (age 5.6 +/- 1.1 years), underwent conventional invasive coronary angiography and coronary CT angiography using a 64-slice scanner. The ability of CT to detect significant coronary stenoses (>30% diameter reduction) of the coronary ostia and proximal segments, and other abnormalities of the coronary arteries was analyzed by blinded comparison to the invasive coronary angiogram., Results: The CT was fully evaluable in 126 of 130 patients (97%), allowing assessment of ostia and proximal segments of all coronary arteries. The CT correctly detected all 12 patients (9.2%) in whom invasive coronary angiography had identified significant coronary lesions, with a sensitivity, specificity, and negative predictive value of 100%. In addition, CT showed nonsignificant coronary lesions (<30% luminal narrowing) in 6 patients and allowed determination of the underlying reasons for coronary luminal narrowing, such as stretching or compression of the re-implanted coronary arteries caused by their anatomic relationship to the adjacent great vessels., Conclusions: 64-slice CT coronary angiography performs as well as invasive angiography for detecting significant coronary lesions in the majority of children who have undergone the arterial switch procedure for TGA. CT also provides information on the underlying mechanism of coronary luminal narrowing.

Objective: We assessed the contribution of acute aortic arch angulation and enhanced systolic pulse wave reflection to dilatation of the ascending aorta and aortic regurgitation late after the arterial switch operation for transposition of the great arteries., Methods: We performed aortography, radial artery applanation tonometry, and transthoracic echocardiography in 47 children (aged 5-6 years) who underwent the arterial switch operation and in 20 matched healthy controls. The aortic arch angle, ratio of ascending/descending aortic diameter, degree of aortic regurgitation, central pulse pressure, aortic augmentation pressure, and augmentation index were measured., Results: The aortic arch angle was more acute (55 +/- 6.5 degrees vs 68 +/- 5 degrees, respectively, P < .001) and the ratio of the ascending/descending aorta diameter was significantly greater (1.98 +/- 0.4 vs 1.55 +/- 0.06, respectively, P < .001) in the patients who underwent the arterial switch operation compared with controls. Augmentation pressure and augmentation index were higher in the patients who underwent the arterial switch operation than in controls (7.5 +/- 4.6 vs 3.4 +/- 5.8, respectively P = .04; 21 +/- 10 vs 8 +/- 13, respectively, P = .005). A more acute aortic angle was associated with a higher aortic augmentation index (r = 0.41, P < .01), a greater ratio of the ascending to descending aorta (r = -0.6, P < .001), and the degree of aortic regurgitation (r = 0.39, P < .01)., Conclusion: Sharper angulation of the aortic arch is associated with early pulse wave reflection, dilatation of the ascending aorta, and aortic regurgitation late after the arterial switch operation for transposition of the great arteries.

Objective: To evaluate the results of surgical revascularization in children with coronary artery lesions following neonatal arterial switch operation (ASO)., Methods: Among 755 neonates who underwent ASO, there were 713 late survivors (94%). Coronary lesions were detected in 34 patients (5%). Coronary revascularization was carried out in 19 children (mean age: 5.6+/-3.2 years) in whom myocardial ischemia was demonstrated by myocardial perfusion imaging studies. Coronary lesions involved the left main coronary artery in 14 cases, the left anterior descending artery in 3, and the right coronary artery in 2. Sixteen patients had coronary angioplasty (left main coronary artery in 11, left anterior descending artery in 3, right coronary artery in 2). Two patients underwent a mammary bypass and one had a saphenous vein proximal bypass., Results: There was no mortality or coronary event. Mean follow-up was 6.3+/-2.8 years. Patency of coronary repair was demonstrated in all patients; however, in one child with angioplasty of the left main coronary artery, there was a residual stenosis of the left anterior descending artery, and reoperation with a mammary bypass was required. Myocardial perfusion imaging was performed in 18 patients; myocardial perfusion was normal in 16 and 2 had minimal residual perfusion defects. Treadmill exercise testing was performed in 11 patients and was normal in all., Conclusions: (1) Following ASO, coronary lesions are not uncommon and they are progressive. Routine and sequential coronary evaluation is necessary. (2) Coronary revascularization can be achieved using coronary angioplasty in most cases. Mammary bypass may be used in selected circumstances. Normal myocardial perfusion is restored in most patients.

Background: The objective of this study was to review our institutional experience concerning neonatal aortic commissurotomy and to identify predictors of outcome., Methods: From January 1, 1990, to January 1, 2005, 65 neonates were referred for critical aortic stenosis. Among these 36 consecutive patients underwent surgical valvotomy by the same surgeon and 16 patients had balloon valvotomy. We examined clinical records to establish determinants of outcome and illustrate long-term results., Results: In the surgical group 6 patients had nonstenotic parachute mitral valve, 6 had aortic coarctation, 13 had endocardial fibroelastosis; and 15 had depressed fractional shortening. In the balloon valvotomy group most infants had associated mitral stenosis (n = 7), small aortic annulus (n = 5), multiple anomalies (n = 2), endocardial fibroelastosis (n = 9), and depressed fractional shortening (n = 13). In the surgical group global mortality was 19%; 47% in infants with depressed fractional shortening and 0% in infants with normal fractional shortening. Mortality in the balloon valvotomy group was 56%. Low fractional shortening, low mean aortic gradient, endocardial fibroelastosis, and small aortic annulus were associated with fatal outcome. In the surgical group 6 patients needed Ross operation at a median interval of 4 years from commissurotomy. In the balloon valvotomy group 3 patients needed early mitral replacement and 5 aortic valve surgery. At a median follow-up of 6 years, all children are in New York Heart Association class I, all have a normal ventricular function, 2 have aortic restenosis, and 5 have at least moderate aortic incompetence., Conclusions: In a selected population of neonates with isolated aortic stenosis, surgical valvotomy offers an excellent long-term outcome to patients with a normokinetic left ventricle, while patients with a hypokinetic left ventricle have a poor outcome. Balloon valvotomy offers poor results when performed in patients with complex anomalies.

Ligation of the left anterior descending coronary artery (LAD) is used to induce experimental myocardial infarction (MI). Most previous studies have focused on the early postoperative period, while data on mid-term follow-up are scanty. This study examined the mid-term effects of LAD ligation in 95 MI rats and 28 controls. The following parameters were evaluated: systemic blood pressure (SBP), heart rate (HR), and plasma brain natriuretic peptide (BNP) level. In addition, M-mode and B-mode echocardiography, histologic examinations, and cardiac hydroxyproline assays were performed. Forty-seven perioperative and 5 late deaths were recorded. Left ventricular dilation, observed 1 mo after MI, did not progress with time. Septal thickening was similar in the 2 groups, while wall thickening was lower in the MI rats at 1 mo only. Stroke volume was diminished in MI rats, while cardiac output was depressed only at 1 and 2 mo, due to increased heart rate. SBP was unchanged and plasma BNP level was similar in the 2 groups. The infarcted area (mean +/- SD) was 35 +/- 10%. The ventricles in MI rats were heavier and had increased hydroxyproline content. In conclusion, these data show that LAD ligation is not only a model of acute MI, but at mid-term it provides a model of chronic ischemic dilated cardiomyopathy.

Background: Pulmonary artery banding is proposed as a first palliation in infants with complex congenital heart disease and high pulmonary blood flow. In addition, it may be used to retrain the left ventricle. Optimal tightening may be difficult to obtain, leading to reoperation. An implantable device for pulmonary artery banding with telemetric control was recently developed allowing for repeated adjustments, but it is presently limited to patients weighing less than 20 kg. In large animals, we tested an off-label adjustable gastric banding system for pulmonary artery banding., Methods and Results: Fourteen ewes weighing 50 to 75 kg underwent implantation of the Lap-Band device (BioEnterics Corp, Santa Barbara, Calif) around the main pulmonary artery through a left thoracotomy. All had functional evaluation with progressive occlusion and opening of the device at implantation and every 2 weeks until sacrifice immediately after implantation (group 1, n = 8), at 1 month (group 2, n = 3), at 3 months (group 3, n = 3), or death. Invasive pressure measurements in the right ventricle and aorta were carried out each time. Devices were easily implanted in all animals. Progressive occlusion and reopening were possible in all animals during each time point. Two animals died of right heart failure related to excessive tightening of the band. Retrieval of the device without any major damage was possible in 12 of 14 animals., Conclusion: With this implantable device, we were able to adjust the pulmonary artery diameter in animals. Patients requiring left ventricle retraining and weighing more than 30 kg would benefit from the device's use in humans.

Objective: The main cause of long-term morbidity and mortality after a successful arterial switch operation for transposition of the great arteries is complications at the ostial segments, proximal segments, or both of the retransferred coronary arteries. The purpose of this study was to investigate the clinical usefulness of multislice computed tomographic angiography in detecting ostial and proximal coronary lesions in children having undergone the arterial switch operation for transposition of the great arteries., Methods: Forty-nine children (aged 8.5 +/- 3.9 years) operated on for transposition of the great arteries with the arterial switch operation (follow-up, 8.3 +/- 3.6 years) underwent systematic selective conventional and multislice computed tomographic angiography. The ability of multislice computed tomography in detecting stenosis and other modifications of the coronary arteries' course was analyzed by 2 independent investigators., Results: Multislice computed tomography, as compared with selective conventional coronary angiography, permitted assessment of ostial and proximal coronary segments in every patient. It correctly detected the 4 (8.1%) patients with significant coronary lesions (1 with ostial and 3 with proximal coronary stenosis) that had been identified by means of conventional angiography. Multislice computed tomography clearly showed an abnormal course of the coronary artery between the great arteries with compression of the ostial (1 patient) and proximal (3 patients) segments of the retransferred coronary arteries., Conclusion: These results indicate that multislice computed tomographic angiography is fully accurate in detecting ostial coronary artery stenoses, proximal coronary artery stenoses, or both in pediatric patients having undergone the arterial switch operation for transposition of the great arteries. Our results suggest that multislice computed tomography could be used as a screening technique for detecting coronary complications in the follow-up of the arterial switch operation before having recourse to conventional angiography.

The arterial switch operation is the procedure of choice for correction of transposition of the great arteries. Although offering excellent long term results, this procedure is burdened by the risk of acute and subacute coronary occlusion. No guide-lines exist for the management of acute or chronic ischemia in this setting. We briefly review the literature and present the results of our institution.

Background: Percutaneous pulmonary valve replacement has recently been introduced and is under investigation in humans. This technique is, however, limited to patients with a right ventricular outflow tract that does not exceed 22 mm in diameter. We report our experience of off-pump pulmonary valve replacement using a hybrid approach in animals with large right ventricular outflow tracts., Methods: Eight ewes were included in the protocol and were equally divided into 2 groups. A left thoracotomy was first performed, and the main pulmonary artery was banded by using 2 radiopaque rings with a diameter of 18 mm that allowed for further pulmonary valve replacement. We then intended to implant a valved stent either percutaneously (group 1) or through a transventricular approach (group 2). All animals were killed after valve implantation. The operation allowed the pulmonary diameter to be reduced from 30 to 17.6 mm., Results: The right ventricular pressure did not significantly increase after reduction of the pulmonary artery diameter (25 vs 36 mm Hg). Subsequent pulmonary valve replacement through a percutaneous or a transventricular approach was always possible without any requirement for extracorporeal circulation. All devices were successfully delivered inside the pulmonary artery banding and were functioning perfectly at early evaluation., Conclusions: Implantation of a pulmonary valve is possible in ewes through a hybrid approach when the right ventricular outflow tract exceeds 22 mm in diameter. This involves both surgeons and interventionists and allows for a staged procedure in which the valvulation is performed percutaneously or, for a combined hybrid approach, in which the valve is implanted off pump transventricularly during the same operation.