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Resumen: El drenaje venoso pulmonar anómalo total (DVPAT) es una cardiopatía congénita poco frecuente que se caracteriza por la ausencia de conexión entre todas las venas pulmonares y la aurícula izquierda. En este defecto, las venas pulmonares llegan a un confluente detrás de la aurícula izquierda que conecta con el retorno venoso sistémico a través de una vena vertical. Existen cuatro tipos anatómicos (supracardiaco, cardiaco, infracardiaco y mixto), siendo el supracardiaco el más frecuente. Cuando existe una obstrucción al retorno venoso pulmonar constituye una auténtica emergencia quirúrgica. El objetivo de la reparación es conseguir un drenaje de los efluentes pulmonares a la aurícula izquierda sin obstrucción. Se ha descrito la suplementación de la anastomosis con parche de pericardio, así como la utilización de suturas reabsorbibles para minimizar el riesgo de estenosis de la conexión durante el seguimiento.Presentamos un caso de DVPAT supracardiaco y obstructivo que requirió de tratamiento quirúrgico emergente neonatal. La reparación se llevó a cabo a los dos días de vida mediante anastomosis directa con sutura reabsorbible entre las venas pulmonares y la cara posterior de la aurícula izquierda. La porción derecha del confluente y la aurícula izquierda fueron suplementadas con un parche de pericardio. El postoperatorio transcurrió sin incidencias significativas y el paciente fue dado de alta el 20° día postoperatorio. Seis años tras la cirugía, este se encuentra asintomático, ha tenido un desarrollo neurológico normal y no existen signos de obstrucción en el drenaje venoso por ecocardiografía. Abstract: Total anomalous pulmonary venous return (TAPVR) is a rare congenital heart disease that is characterized by lack of conection between all four pulmonary veins and the left atrium. In this defect, the pulmonary veins make a confluence behind the left atrium which connects with the systemic venous return. Four anatomic subtypes (supracardiac, cardiac, infracardiac and mixed) exist, being the supracardiac the most common one. Obstruction of the pulmonary venous return constitutes a surgical emergency. The goal of surgical repair is to get unobstructed egress from the pulmonary veins int the left atrium. Patch supplementation of the anastomosis as well as use of bioabsorbible sutures have been reported to minimize the risk of stenosis of the conection through follow-up.We present a case of supracardiac and obstrictive TAPVR who required emergent neonatal surgical treatment. Repair was undertaken at two days of life by means of direct anastomosis with bioabsorbable suture between the pulmonary veins and the posterior wall of the left atrium. The anastomosis was supplemeted with a pericardial patch. Postoperative course was uneventful and the patient was discharged home on the 20th postoperative day. Six years after surgery, our patient is asymptomatic, with a normal neurologic development and shows no signs of obstruction on the venous return by echocardiography.

Resumen: La realización exitosa de una cirugía combinada de reparación de una cardiopatía congénita y trasplante pulmonar ha sido descrita raramente. Presentamos el caso de un paciente pediátrico con hipertensión pulmonar grave y cardiopatía congénita al que se le realizó un trasplante pulmonar bilateral combinado con corrección de su cardiopatía. Un año tras la cirugía el paciente se encuentra asintomático y en excelente clase funcional. Específicamente nos centramos en describir el protocolo y la técnica quirúrgica empleados en el procedimiento. Hasta donde sabemos, este podría ser el primer caso de estas características realizado con éxito en nuestro medio. Abstract: Successful completion of the combined repair of congenital heart disease and lung transplant has been rarely reported. The case is presented of a paediatric patient with severe pulmonary hypertension and congenital heart disease, who had a bilateral lung transplant combined with repair of his congenital heart defect. One year after surgery, the patient is asymptomatic and in excellent functional class. Specifically, focus was made on the surgical protocol and technique used to undertake the procedure. As far as we know, this could be the first case of its kind successfully carried out in our country. Palabras clave: Trasplante pulmonar, Hipertensión pulmonar grave, Cardiopatía congénita, Keywords: Lung transplant, Severe pulmonary hypertension, Congenital heart disease

The impact of age-associated disorders is increasing as the life expectancy of the population increments. Cardiovascular diseases and neurodegenerative disorders, such as Parkinson’s disease, have the highest social and economic burden and increasing evidence show interrelations between them. Particularly, dysfunction of the cardiovascular nervous system is part of the dysautonomic symptoms of Parkinson’s disease, although more studies are needed to elucidate the role of cardiac function on it. We analyzed the dopaminergic system in the nigrostriatal pathway of Parkinsonian and dyskinetic monkeys and the expression of some key proteins in the metabolism and synthesis of catecholamines in the heart: total and phosphorylated (phospho) tyrosine hydroxylase (TH), and membrane (MB) and soluble (S) isoforms of catechol-O-methyl transferase (COMT). The dopaminergic system was significantly depleted in all MPTP-intoxicated monkeys. MPTP- and MPTP+L-DOPA-treated animals also showed a decrease in total TH expression in both right (RV) and left ventricle (LV). We found a significant increase of phospho-TH in both groups (MPTP and MPTP+L-DOPA) in the LV, while this increase was only observed in MPTP-treated monkeys in the RV. MB-COMT analysis showed a very significant increase of this isoform in the LV of MPTP- and MPTP+L-DOPA-treated animals, with no significant differences in S-COMT levels. These data suggest that MB-COMT is the main isoform implicated in the cardiac noradrenergic changes observed after MPTP treatment, suggesting an increase in NA metabolism. Moreover, the increase of TH activity indicates that cardiac noradrenergic neurons still respond despite MPTP treatment.

Nonrevascularizable coronary artery disease is a frequent cause of hibernating myocardium leading to heart failure (HF). Currently, there is a paucity of therapeutic options for patients with this condition. There is a lack of animal models resembling clinical features of hibernating myocardium. Here we present a large animal model of hibernating myocardium characterized by serial multimodality imaging. Yucatan minipigs underwent a surgical casein ameroid implant around the proximal left anterior descending coronary artery (LAD), resulting in a progressive obstruction of the vessel. Pigs underwent serial multimodality imaging including invasive coronary angiography, cardiac magnetic resonance (CMR), and hybrid 18F-Fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT). A total of 43 pigs were operated on and were followed for 120 ± 37 days with monthly multimodality imaging. 24 pigs (56%) died during the follow-up. Severe LAD luminal stenosis was documented in all survivors. In the group of 19 long-term survivors, 17 (90%) developed left ventricular systolic dysfunction [median LVEF of 35% (IQR 32.5-40.5%)]. In 17/17, at-risk territory was viable on CMR and 14 showed an increased glucose uptake in the at-risk myocardium on 18FDG-PET/CT. The present pig model resembles most of the human hibernated myocardium characteristics and associated heart failure (systolic dysfunction, viable myocardium, and metabolic switch to glucose). This human-like model might be used to test novel interventions for nonrevascularizable coronary artery disease and ischemia heart failure as a previous stage to clinical trials. his study has been partially funded by the Horizon 2020 European Research Area Network on Cardiovascular Diseases (ERA-CVD) Joint Transnational Call “AC16/00021: FAT-4HEART,” by the Spanish Society of Cardiology through a “Translational Research grant 2019,” and by the Instituto de Salud Carlos III (ISCIII) and the European Regional Development Fund (ERDF) through a FIS grant (Ref # PI16/02110). Imaging phenotyping was partially supported by the Comunidad de Madrid (S2017/BMD-3867 RENIM-CM) and cofunded with European structural and investment funds. The CNIC is supported by the ISCIII, the Ministerio de Ciencia e Innovación and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505). Sí

Resumen: Introducción: El cierre quirúrgico del ductus arterioso persistente en el prematuro es una técnica agresiva y no exenta de complicaciones. Diseñamos un estudio con el objetivo de describir nuestra experiencia con una técnica menos invasiva, el abordaje extrapleural vía minitoracotomía posterior, y de comparar sus resultados con los del abordaje clásico transpleural. Pacientes y métodos: Estudio de cohortes retrospectivo de los neonatos prematuros a los que se les realizó cierre quirúrgico del ductus en un periodo de 10 años (marzo de 2005-marzo de 2015). Se compararon las complicaciones agudas, los resultados al alta y en el seguimiento entre los grupos de abordaje extrapleural y abordaje clásico transpleural. Se incluyó a 48 pacientes, 30 en el grupo de abordaje clásico y 18 en el grupo extrapleural. Resultados: Las características demográficas y preoperatorias fueron similares en ambos grupos. No se encontraron diferencias entre los 2 grupos en la incidencia de complicaciones postoperatorias agudas (56,6 vs. 44,4%), en la dependencia de oxígeno a las 36 semanas (33,3 vs. 55,5%), ni en la mortalidad hospitalaria (10 vs. 16,6%). En la evolución a corto plazo, el grupo extrapleural precisó menos días hasta la retirada del oxígeno suplementario (36,3 vs. 28,9) y hasta el alta hospitalaria (67,5 vs. 53,2), aunque solo el tiempo hasta la extubación alcanzó una diferencia estadísticamente significativa (11,5 vs. 2,7, p = 0,03). Conclusiones: El abordaje extrapleural por minitoracotomía posterior para el cierre quirúrgico del ductus en el prematuro es factible y podría conllevar algunos beneficios clínicos a corto plazo. Abstract: Introduction: Surgical closure of patent ductus arteriosus in premature neonates is an aggressive technique and is not free of complications. A study was designed with the aim of describing our experience with a less invasive technique, the extra-pleural approach via a posterior minithoracotomy, and to compare the results with the classic transpleural approach. Patients and methods: A retrospective cohort study was conducted on premature neonates on whom surgical closure of the ductus was performed during a ten-year period (March 2005 to March 2015). A comparison was made of the acute complications, the outcomes on discharge, and follow-up, between the extra-pleural approach and the classic transpleural approach. The study included 48 patients, 30 in the classical approach and 18 in the extra-pleural group. Results: The demographic and pre-operative characteristics were similar in both groups. No differences were found between the 2 groups in the incidence of acute post-operative complications (56.6 vs. 44.4%), on the dependence on oxygen at 36 weeks (33.3 vs. 55.5%), or in hospital mortality (10 vs. 16.6%). As regards the short-term progress, the extra-pleural group required fewer days until the withdrawal of supplementary oxygen (36.3 vs. 28.9) and until hospital discharge (67.5 vs. 53.2), although only the time until extubation achieved a statistically significant difference (11.5 vs. 2.7, P=.03). Conclusions: The extra-plural approach by posterior minithoracotomy for the surgical closure of ductus in the premature infant is viable and could bring some clinical benefits in the short-term.

Resumen: Desde que Norwood et al. efectuaron la primera paliación exitosa en 1983, ha habido cambios sustanciales en el diagnóstico, el manejo y el pronóstico del síndrome de corazón izquierdo hipoplásico. La supervivencia en el estadio i de la paliación quirúrgica ha aumentado hasta el 90% en muchas instituciones, con la posibilidad de sobrevivir hasta la vida adulta. No obstante, la morbimortalidad asociada continúa siendo sustancial.Aunque la premisa de la paliación quirúrgica por etapas del síndrome de corazón izquierdo hipoplásico está bien establecida, hay variaciones significativas en la técnica quirúrgica y el manejo entre distintos centros, y varios aspectos controvertidos siguen sin resolverse. En esta revisión resumimos las opciones quirúrgicas y de manejo disponibles actualmente para neonatos con síndrome de corazón hipoplásico, así como sus resultados. Abstract: Since the first successful palliation was performed by Norwood et al. in 1983, there have been substantial changes in diagnosis, management, and outcomes of hypoplastic left heart syndrome, Survival for stage 1 palliation has increased to 90% in many centres, with patients potentially surviving into adulthood. However, the associated morbidity and mortality remain substantial.Although the principles of staged surgical palliation of hypoplastic left heart syndrome are well established, there is significant variability in surgical procedure and management between centres, and several controversial aspects remain unresolved. In this review, we summarize the current surgical and management options for newborns with hypoplastic left heart syndrome and their outcomes.

Objective: The aim of our study is to report our initial results with rapid deployment aortic valve replacement within the Spanish RADAR Registry, especially focusing on the incidence of patient-pr...

Aim The underlying pathophysiologic mechanisms of aortic stenosis are not clear. Mitochondrial dysfunction plays a role in many pathological conditions including cardiac diseases. We aimed to analyze the mitochondrial DNA haplogroups in a group of patients undergoing valve replacement surgery due to severe aortic stenosis. Methods Mitochondrial DNA haplogroups were assessed in 176 patients with severe aortic stenosis and 308 control subjects. Cardiovascular risk factors and demographics were similar in both groups. Results Patients carrying haplogroup Uk had a lower risk of developing aortic stenosis, especially compared to patients carrying haplogroup H (odds ratio = 0.507; 95% confidence interval: 0.270–0.952, p = 0.035). Conclusions Mitochondrial DNA haplogroups could be involved in the development of severe aortic stenosis. Specifically, haplogroup H could be a risk factor and Uk a protective factor for severe aortic stenosis in a population from Spain.

Objective(s) To assess the impact of univentricular versus biventricular pacing (BiVP) on systemic ventricular function in patients with congenitally corrected transposition of the great arteries (ccTGA). Methods We performed a retrospective review of all patients with a diagnosis of ccTGA who underwent pacemaker insertion. From 1993 to 2014, 53 patients were identified from the cardiology database and surgical records. Results Overall mortality was 7.5% (n = 4). One patient required transplantation and 3 late deaths occurred secondary to end-stage heart failure. Median follow-up was 3.7 years (range, 4 days to 22.5 years). Twenty-five (47%) underwent univentricular pacing only, of these, 8 (32%) developed significant systemic ventricular dysfunction. Twenty-eight (53%) received BiVP, 17 (26%) were upgraded from a dual-chamber system, 11 (21%) received primary BiVP. Fourteen (82%) of the 17 undergoing secondary BiVP demonstrated systemic ventricular dysfunction at the time of pacer upgrade, with 7 (50%) demonstrating improved systemic ventricular function after pacemaker upgrade. Overall, 42 (79%) patients underwent univentricular pacing, with 22 (52%) developing significant systemic ventricular dysfunction. In contrast, the 11 (21%) who received primary BiVP had preserved systemic ventricular function at latest follow-up. Conclusions Late-onset systemic ventricular dysfunction is a major complication associated with the use of univentricular pacing in patients with ccTGA. All patients with ccTGA who develop heart block should undergo primary biventricular pacing, as this prevents late systemic ventricular dysfunction. Preemptive placement of BiVP leads at the time of anatomical repair or other permanent palliative procedure will facilitate subsequent BiVP should heart block develop.

ResumenIntroducción y objetivosLa técnica de miniesternotomía inferior se ha utilizado ampliamente para la corrección de defectos congénitos, aunque su uso en nuestro medio ha sido más limitado. Nuestro objetivo es comunicar los resultados quirúrgicos y cosméticos de 100 pacientes con cardiopatía congénita que fueron intervenidos a través de una miniesternotomía inferior.MétodosDe enero del 2010 a septiembre del 2013, 100 pacientes (60 mujeres y 23 adultos) con una edad mediana de 4 años (rango 0,3-79,1) recibieron una intervención cardiaca mediante miniesternotomía inferior. Los procedimientos quirúrgicos realizados fueron: cierre de CIA OS (n=57), cierre de CIV (n=23), reparación de canal AV (n=9), cierre de CIA seno venoso (n=5), cierre de CIA OS y plastia tricuspídea con anillo (n=4), reemplazo valvular mitral (n=1) y reparación de cor triatriatum (n=1). Los resultados cosméticos y de satisfacción se evaluaron en aquellos pacientes intervenidos hasta diciembre del 2012 mediante la escala de PSAS y un cuestionario. Los datos intrahospitalarios y de seguimiento clínico y ecocardiográfico se obtuvieron para identificar complicaciones y defectos residuales. Se excluyó del estudio a 2 pacientes que fueron reconvertidos a esternotomía media.ResultadosNo ha habido muertes, reoperaciones por sangrado, complicaciones de la herida u otras morbilidades mayores. No se observan defectos residuales en las ecocardiografías de seguimiento (mediana 11 meses, rango 3 a 36). La evaluación sistemática de la cicatriz demostró excelente resultados. Además, 52 pacientes (82,5%) dieron la puntuación máxima al resultado del proceso quirúrgico.DiscusiónLa miniesternotomía inferior permite una reparación segura y precisa de una selección de defectos cardiacos congénitos. Este abordaje también proporciona un resultado cosmético y una satisfacción del paciente excelentes y podría ser de elección para esta población.AbstractIntroduction and objectivesLower ministernotomy has been widely used, although it has been seldom used for the repair of congenital heart defects in our country. The aim of our study is to present the surgical and cosmetic results as well as satisfaction of patients with congenital heart disease undergoing lower mini-sternotomy.MethodsFrom January 2010 through September 2013, 100 patients (60 female and 23 adults) with a median age of 4 years (range 0.3 to 70.1) underwent reparative cardiac surgery through lower mini-sternotomy. Operative techniques used were OS ASD closure (n=57), VSD closure (n=23), AV canal repair (n=9), SV ASD closure (n=5), OS ASD closure and tricuspid valve ring annuloplasty (n=4), mitral valve replacement (n=1) and cor triatriatum repair (n=1). Two adult patients were converted to median sternotomy and were excluded from the study. Cosmetic results and patients’ satisfaction were evaluated with the PSAS Scar Scales and a separate questionnaire. In-hospital and follow-up clinical and echocardiographic data were also recorded looking at complications and residual defects.ResultsThere have been no deaths, reoperation for bleeding, wound complications or other major morbidities in our series. No significant residual defects are shown at most recent follow-up echocardiogram (median 0.96 years). Systematic evaluation of the scar showed excellent scores. Moreover, 52 patients (82.5%) gave the maximum score possible to their overall surgical outcome.DiscussionLower mini-sternotomy allows for safe and accurate repair of selected congenital heart defects. This approach also provides excellent cosmetic outcomes and patients’ satisfaction and could be of choice in this population.

Background: The durability of bioprostheses in the pulmonary position in patients with congenital heart disease remains suboptimal. The new INSPIRIS Resilia aortic valve is characterized by a peric...

Objective Early results for anatomic repair of congenitally corrected transposition of the great arteries (ccTGA) are excellent. However, the development of left ventricular dysfunction late after repair remains a concern. In this study we sought to determine factors leading to late left ventricular dysfunction and the impact of cardiac resynchronization as a primary and secondary (upgrade) mode of pacing. Methods From 1992 to 2012, 106 patients (median age at surgery, 1.2 years; range, 2 months to 43 years) with ccTGA had anatomic repair. A retrospective review of preoperative variables, surgical procedures, and postoperative outcomes was performed. Results In-hospital deaths occurred in 5.7% (n = 6), and there were 3 postdischarge deaths during a mean follow-up period of 5.2 years (range, 7 days to 18.2 years). Twelve patients (12%) developed moderate or severe left ventricular dysfunction. Thirty-eight patients (38%) were being paced at latest follow-up evaluation. Seventeen patients had resynchronization therapy, 9 as an upgrade from a prior dual-chamber system (8.5%) and 8 as a primary pacemaker (7.5%). Factors associated with left ventricular dysfunction were age at repair older than 10 years, weight greater than 20 kg, pacemaker implantation, and severe neo-aortic regurgitation. Eight of 9 patients undergoing secondary cardiac resynchronization therapy (upgrade) improved left ventricular function. None of the 8 patients undergoing primary resynchronization developed left ventricular dysfunction. Conclusions Late left ventricular dysfunction after anatomic repair of ccTGA is not uncommon, occurring most often in older patients and in those requiring pacing. Early anatomic repair and cardiac resynchronization therapy in patients requiring a pacemaker could preclude the development of left ventricular dysfunction.

ResumenLa tetralogía de Fallot es la cardiopatía cianógena más frecuente. En el siguiente manuscrito, describiremos las características anatómicas, fisiopatológicas y de diagnóstico, así como las diferentes técnicas de reparación quirúrgica de esta malformación, destacando el parche transanular, el parche monocúspide y la dilatación intraoperatoria de la válvula pulmonar. Con respecto al abordaje quirúrgico, enfatizaremos el momento propicio de la reparación, así como las técnicas encaminadas a la preservación de la válvula pulmonar y a minimizar los efectos deletéreos de la insuficiencia pulmonar crónica.AbstractTetralogy of Fallot constitutes the most common congenital heart disease presenting with cyanosis. In the next manuscript we’ll describe the anatomic, pathophysiology and diagnostic features, as well as the different techniques of surgical repair, highlighting the transannular patch, the monocusp patch and the intraoperative dilation of the pulmonary valve. With respect to the surgical approach we’ll emphazise the timing of repair and the surgical techniques aimed at preserving the pulmonary valve and thus, minimizing the deleterious effects of chronic pulmonary regurgitation.

[Abstract] OBJECTIVES: The enlargement of the left atrium has been identified as a marker of chronically increased left ventricular filling pressure and left ventricular diastolic dysfunction. This study aims to evaluate the association of indexed left atrial diameter with stroke, cardiovascular mortality, the combined event, and all-cause mortality in patients who underwent aortic valve surgery. METHODS: Indexed left atrial diameter was measured in 2011 adult patients (mean age, 70.9 ± 10.8 years; 58.7% were men) who underwent aortic valve surgery between January 2008 and March 2016. RESULTS: On the basis of the criteria of the American Society of Echocardiography, indexed left atrial diameter was normal in 64% of patients, mildly enlarged in 12.4% of patients, moderately enlarged in 9.2% of patients, and severely enlarged in 14.3% of patients. Over a mean follow-up period of 3.2 ± 2.1 years, there were 334 deaths and 97 strokes. Cardiovascular mortality survival at 5 years among patients with normal, mild, moderate, and severe left atrial enlargement was 91.6%, 86.8%, 77.9%, and 77.4%, respectively (P < .001). After covariable adjustment, Cox regression analysis showed indexed left atrial diameter as an independent predictor of all-cause mortality (hazard ratio per 1-cm/m2 increment, 1.545; 95% confidence interval, 1.252-1.906, P < .001), cardiovascular death (hazard ratio per 1-cm/m2 increment, 1.971; 95% confidence interval, 1.541-2.520; P < .001), and the combined event (hazard ratio per 1-cm/m2 increment, 1.673; 95% confidence interval, 1.321-2.119; P < .001). CONCLUSIONS: Indexed left atrial diameter is a strong predictor of long-term outcomes in patients with aortic valve diseases who undergo surgery.

Objetivo: Determinar la incidencia de deterioro valvular estructural (DVE) entre todos los modelos de bioprótesis aórtica Mitroflow (A12/LX/DL), así como definir los factores de riesgo implicados y el posible papel protector del tratamiento anticalcificación phospholipid reduction treatment (PRT) del modelo DL. Métodos: Estudio retrospectivo de 1.023 pacientes consecutivos operados de recambio valvular aórtico con bioprótesis Mitroflow entre 2001 y 2014. Resultados: El seguimiento medio fue de 5,4 ± 3,1 años. La incidencia acumulada global de DVE fue 0,48% a un año, 2,1% a 5 años y 6,8% a 10 años. El grupo PRT mostró menor incidencia acumulada de DVE (0,2% vs. 1,2% a 4 años) (p = 0,04). El análisis de regresión de riesgos competitivos confirmó: edad < 70 años (HR = 2,98 [1,5-5,89], p = 0,002), tamaño valvular de 19 mm (HR = 4,7 [2,29-9,64], p 30 mmHg en postoperatorio precoz (HR = 10,3 [5,3-19,9], p

Aortic dissection is a life-threatening condition that is very rare in neonates and children. We present here an iatrogenic aortic dissection in relation to umbilical artery catheterization in a preterm neonate, presenting as acute renal failure. In our case, a conservative non-surgical approach with antihypertensive therapy and management of renal injury was effective and led to a satisfactory outcome.

Background— The outcome of the surgical repair in congenital heart disease correlates with the degree of myocardial damage. In this study, we determined whether mitochondrial DNA depletion is a sensitive marker of right ventricular (RV) damage and whether impaired mitochondrial DNA (mtDNA) replication contributes to the transition from compensated hypertrophy to failure. Methods and Results— RV samples obtained from 31 patients undergoing cardiac surgery were compared with 5 RV samples from nonfailing hearts (control). Patients were divided into compensated hypertrophy and failure groups, based on preoperative echocardiography, catheterization, and/or MRI data. Mitochondrial enzyme activities (citrate synthase and succinate dehydrogenase) were maintained during hypertrophy and decreased by ≈40% ( P P Conclusions— Impaired mtDNA replication causes early and progressive depletion of mtDNA in the RV of the patients with congenital heart disease during the transition from hypertrophy to failure. Decreased mtDNA content probably is a sensitive marker of mitochondrial injury in this patient population.

OBJECTIVE: To estimate the degree of association between domestic violence -physical, verbal or sexual- with suicidal behavior among university students. MATERIAL AND METHODS: A matched case-control study was done with students attending the University of Colima, Mexico. The cases were 235 teenagers who presented both suicidal ideation and suicide attempt; the controls were 470 individuals of the same age and sex. RESULTS: Sexual abuse showed the highest degree of association with suicidal behavior (OR= 27.4), followed by verbal violence (OR= 9.28), drug use (OR= 8.6), physical violence (OR= 5.5) and smoking (OR= 3.6). Multivariate logistic regression showed that verbal violence was associated with suicidal behavior independently of the other variables, while physical violence, sexual abuse, smoking and drug use seem to depend on verbal violence. CONCLUSIONS: Domestic violence, particularly verbal or sexual, is strongly associated with suicidal behavior in adolescents and should be considered in suicide prevention programs.

Background The efficacy of extracorporeal membrane oxygenation (ECMO) in bridging children with unrepaired heart defects to a definitive or palliative surgical procedure has been rarely reported. The goal of this study is to report our institutional experience with ECMO used to provide preoperative stabilization after acute cardiac or respiratory failure in patients with congenital heart disease before cardiac surgery. Methods A retrospective review of the ECMO database at Children's Hospital Boston was undertaken. Children with unrepaired congenital heart disease supported with ECMO for acute cardiac or respiratory failure as bridge to a definitive or palliative cardiac surgical procedure were identified. Data collection included patient demographics, indication for ECMO, details regarding ECMO course and complications, and survival to hospital discharge. Results Twenty-six patients (18 male, 8 female) with congenital heart disease were bridged to surgical palliation or anatomic repair with ECMO. Median age and weight at ECMO cannulation were, respectively, 0.12 months (range, 0 to 193) and 4 kg (range, 1.8 to 67 kg). Sixteen patients (62%) survived to hospital discharge. Variables associated with mortality included inability to decannulate from ECMO after surgery (p = 0.02) and longer total duration of ECMO (p = 0.02). No difference in outcomes was found between patients with single and biventricular anatomy. Conclusions Extracorporeal membrane oxygenation, used as a bridge to surgery, represents a useful modality to rescue patients with failing circulation and unrepaired complex heart defects.

The aim of this study was to determine the effect of thiamine pyrophosphate (TPP) on serum lactate levels, maximum oxygen consumption (Vo2max) and heart rate in male athletes performing aerobic activity. A double-blind, randomized, crossover study was performed in which lactate levels, Vo2max and heart rates in 27 male athletes were compared at rest and after exercise, following administration of placebo (sodium chloride 0.9%) or TPP (1 mg/kg). At rest, serum lactate levels after placebo or TPP were similar; however, after exercise, the levels were lower in the athletes after taking TPP than after placebo. During exercise, Vo2max in athletes on TPP was higher than on placebo. At rest, heart rate after taking placebo or TPP was similar but, after exercise, heart rate was lower after taking TPP than after placebo. It is concluded that TPP caused serum lactate levels and heart rate to be lower than placebo and Vo2max to be higher in athletes performing aerobic physical activity.

Parachute left atrioventricular (AV) valve can complicate repair of common atrioventricular canal (CAVC), and single-ventricle palliation is sometimes preferred. The goal of this study is to review our single institutional experience in biventricular repair in this patient group.The demographic, procedural and outcome data were obtained for all children who underwent biventricular repair for complete CAVC with parachute [single left ventricular (LV) papillary muscle] or forme fruste parachute left AV valve (closely spaced LV papillary muscles) from 2001 to 2012. Primary outcomes were survival, freedom from left AV valve stenosis (defined as an inflow gradient ≥7 mmHg and post-capillary pulmonary hypertension) and freedom from left AV valve replacement.A total of 24 patients were included (21 parachutes, 3 forme frustes). There was 1 early death (4.2%). At discharge, no patient had more-than-mild regurgitation and 1 had stenosis. During a median follow-up of 3.7 years (IQR 4 months to 5 years), there were 2 late deaths (8.3%), 6 patients (25%) presented significant left AV valve stenosis and 2 patients (8.3%) required valve replacement. Freedom from stenosis was 95 ± 4.9% at 1 year, 83.1 ± 8.9% at 3 years, 64.7 ± 13.5% at 5 years and 51.7 ± 15.8% at 10 years. Complete cleft closure was not associated with a significantly different freedom from left AV valve reoperation (log-rank test, P = 0.89) or significant stenosis (P = 0.47).Biventricular repair in parachute left AV valve and CAVC is feasible with acceptable mortality and freedom from stenosis. The burden of reoperation remains significant in this patient group.

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty.

Objectives The goal of our study was to report our intermediate-term results with aortic root translocation plus arterial switch for d-transposition of the great arteries with left ventricular outflow tract obstruction. Background A d-transposition of the great arteries with left ventricular outflow tract obstruction represents a difficult surgical problem. The Rastelli procedure is the usual approach to this condition. However, recurrent left ventricular outflow tract obstruction and early conduit obstruction as well as arrhythmias and troublesome late mortality are significant limitations. Methods From 1993 to 2005, 11 children (8 male, 3 female) ages 1 month to 11 years (median age 7 months) have undergone aortic root autograft translocation plus arterial switch to correct d-transposition of the great arteries with left ventricular outflow tract obstruction. The native aortic root was excised from the right ventricle infundibulum and inserted into the left ventricular outflow, enlarging the outflow tract by resecting the outlet septum and an appropriate-size ventricular septal defect patch. After coronary artery reimplantation, right ventricular outflow reconstruction was achieved with a homograft. Results There were no early or late deaths. With a median follow-up of 59 months (range 2 to 137 months), 5 patients required 6 conduit replacement procedures at a median time of 53 months. Two patients required an implantable defibrillator for ventricular arrhythmias. None of the patients have developed left ventricular outflow tract obstruction. Conclusions Aortic root autograft plus arterial switch procedure is a good option for the surgical management of infants and children with d-transposition of the great arteries and left ventricular outflow tract obstruction and results in a more anatomic repair compared with Rastelli operation. Intermediate-term results indicate good relief of left ventricular outflow tract obstruction and need for conduit replacement compares favorably with the Rastelli procedure for this lesion.

Introduction: Surgical closure of patent ductus arteriosus in premature neonates is an aggressive technique and is not free of complications. A study was designed with the aim of describing our experience with a less invasive technique, the extra-pleural approach via a posterior minithoracotomy, and to compare the results with the classic transpleural approach. Patients and methods: A retrospective cohort study was conducted on premature neonates on whom surgical closure of the ductus was performed during a ten-year period (March 2005 to March 2015). A comparison was made of the acute complications, the outcomes on discharge, and follow-up, between the extra-pleural approach and the classic transpleural approach. The study included 48 patients, 30 in the classical approach and 18 in the extra-pleural group. Results: The demographic and pre-operative characteristics were similar in both groups. No differences were found between the 2 groups in the incidence of acute post-operative complications (56.6 vs. 44.4%), on the dependence on oxygen at 36 weeks (33.3 vs. 55.5%), or in hospital mortality (10 vs. 16.6%). As regards the short-term progress, the extra-pleural group required fewer days until the withdrawal of supplementary oxygen (36.3 vs. 28.9) and until hospital discharge (67.5 vs. 53.2), although only the time until extubation achieved a statistically significant difference (11.5 vs. 2.7, p = .03). Conclusions: The extra-plural approach by posterior minithoracotomy for the surgical closure of ductus in the premature infant is viable and could bring some clinical benefits in the short-term. Resumen: Introducción: El cierre quirúrgico del ductus arterioso persistente en el prematuro es una técnica agresiva y no exenta de complicaciones. Diseñamos un estudio con el objetivo de describir nuestra experiencia con una técnica menos invasiva, el abordaje extrapleural vía minitoracotomía posterior, y de comparar sus resultados con los del abordaje clásico transpleural. Pacientes y métodos: Estudio de cohortes retrospectivo de los neonatos prematuros a los que se les realizó cierre quirúrgico del ductus en un periodo de 10 años (marzo de 2005-marzo de 2015). Se compararon las complicaciones agudas, los resultados al alta y en el seguimiento entre los grupos de abordaje extrapleural y abordaje clásico transpleural. Se incluyó a 48 pacientes, 30 en el grupo de abordaje clásico y 18 en el grupo extrapleural. Resultados: Las características demográficas y preoperatorias fueron similares en ambos grupos. No se encontraron diferencias entre los 2 grupos en la incidencia de complicaciones postoperatorias agudas (56,6 vs. 44,4%), en la dependencia de oxígeno a las 36 semanas (33,3 vs. 55,5%), ni en la mortalidad hospitalaria (10 vs. 16,6%). En la evolución a corto plazo, el grupo extrapleural precisó menos días hasta la retirada del oxígeno suplementario (36,3 vs. 28,9) y hasta el alta hospitalaria (67,5 vs. 53,2), aunque solo el tiempo hasta la extubación alcanzó una diferencia estadísticamente significativa (11,5 vs. 2,7, p = 0,03). Conclusiones: El abordaje extrapleural por minitoracotomía posterior para el cierre quirúrgico del ductus en el prematuro es factible y podría conllevar algunos beneficios clínicos a corto plazo.

OBJECTIVES Lower mini-sternotomy represents a minimally invasive surgical technique that has been utilized for the repair of a wide variety of congenital heart defects with excellent surgical and cosmetic outcomes. However, clinical improvements provided for this technique beyond cosmetic results are controversial. The aim of our study is to report our results with lower mini-sternotomy for the repair of congenital heart malformations and compare them with a matched group with a full median sternotomy approach. METHODS From 2010 through 2013, 105 consecutive congenital patients (81 paediatric) underwent lower mini-sternotomy at our centre (Group 1). We analysed in-hospital and follow-up outcomes, and compare them with an age-sex-diagnosis-type of surgery-matched group (Group 2). Both groups were managed following the same clinical protocols. RESULTS In Group 1, age at the time of surgery was 12 ± 17 years (range from 0.2 to 64.6 years). In this group, 81 patients were paediatric and 62 were female. Operative techniques were atrial septal defect (n = 72), ventricular septal defect (n = 24) and atrioventricular canal repairs (n = 9). There were no deaths or major in-hospital complications. Two adult patients required conversion to full median sternotomy. For a medium follow-up of 1.5 years (range from 1 month to 5 years), there were no deaths, reinterventions or reoperations and no significant residual defects were found. Compared with Group 2, patients in Group 1 had longer cardiopulmonary bypass times (58.71 ± 19.08 vs 45.39 ± 20.45, P < 0.001) and cross-clamp times (32.75 ± 13.11 vs 23.22 ± 13.93, P < 0.001), higher rate of early extubation (96 vs 85%, P = 0.018) and lower rate of postoperative complications (11.6 vs 22.3%, P = 0.034). CONCLUSIONS At our centre, lower mini-sternotomy represents a safe alternative for the repair of congenital heart defects in paediatric and adult populations. Cardiopulmonary bypass and cross-clamp times were longer in the mini-sternotomy group. However, these patients showed earlier extubation and less postoperative complications when compared with patients with a full sternotomy approach. Combined with improved cosmetic outcomes, lower mini-sternotomy could represent the technique of choice for these populations.

Background Early results for anatomic repair of congenitally corrected transposition of the great arteries are excellent with respect to right ventricular and tricuspid valve function. However, development of left ventricular (systemic ventricle) dysfunction late after repair remains a concern. In this study we sought to determine factors leading to late impairment in left ventricular performance. Methods From August 1992 to July 2005, 44 patients (median age at surgery, 1.6 years; range, 0.6 to 39.6 years) with congenitally corrected transposition of the great arteries had anatomic repair. Left ventricular function and mitral regurgitation were evaluated by echocardiography at follow-up. Twenty-three patients had a Rastelli procedure, and 21 underwent an arterial switch. Twelve patients (27%) were pacemaker dependent at latest follow-up. Results Early mortality was 4.5% (n = 2) with 1 late death as a result of leukemia. Median follow-up was 3.0 years (range, 7 days to 12.4 years). Left ventricular function remained unchanged (normal) in 35 patients, improved in 1 patient, and deteriorated in 8 patients (18%). Mitral regurgitation was unchanged in 30 patients, improved in 6 patients, and worsened in 8 patients (18%). Development of left ventricular dysfunction was significantly associated with pacemaker implantation ( p = 0.005) and a widened QRS (>20% > 98% percentile of normal; p = 0.03). Conclusions Anatomic repair of congenitally corrected transposition can be performed with low operative mortality. However, late left ventricular dysfunction is not uncommon, with higher incidence in those requiring pacing and with a prolonged QRS. Resynchronization may be of value in patients requiring a pacemaker.

To the Editor: Atrioventricular (AV) valve repair for regurgitation has been shown to be preferable to valve replacement in young children ([1][1]). Besides valvuloplasty technique, annulus reduction and stabilization with a ring have been demonstrated to be necessary to maintain effective leaflet

A 69-year-old man with no history of chest trauma was admitted to our institution complaining of blunt and severe central chest pain of cataclysmic onset radiating to the back. His medical history was remarkable only for a chronic atrial fibrillation treated with warfarin and amiodarone. On arrival, his ECG showed atrial fibrillation at 120 bpm with no signs of myocardial ischemia. Laboratory examination was uneventful except for an international normalized ratio of 7. With the presumptive diagnosis of acute aortic syndrome, a thoracoabdominal high-resolution contrast-enhanced computed tomography scan was performed that showed a large mass at the level of the left atrium (LA) and a moderate pericardial effusion (Figure 1 and Movie I in the online-only Data Supplement). Linear attenuation coefficients of the LA mass and pericardial fluid were suggestive of acute clot and blood (60 and 50 Hounsfield units, respectively). No signs of malignancy, pulmonary embolism, or aortic disease were found. During evaluation, our patient's clinical condition …

Association of d-transposition of the great arteries and complete atrio-ventricular canal constitutes an uncommon and complex cardiac anomaly usually associated with poor prognosis. We report our experience on one-stage neonatal repair for d-transposition of the great arteries and complete atrio-ventricular canal. Between August 1997 and 2005, four patients (two males and two females) underwent anatomical correction for d-transposition of the great arteries and complete atrio-ventricular canal using an arterial switch procedure and two-patch repair. Mean age and weight at operation were 20 days (range from 3 to 28 days) and 3.2kg (range from 2.7 to 3.5kg), respectively. None of the patients received preoperative palliative procedure. Associated lesions were left outflow tract obstruction in three patients and multiple muscular ventricular septal defects in two patients. All four patients survived the operation. There was one in-hospitality death due to fungal sepsis. One patient required late re-operation for left ventricular outflow tract obstruction and left atrio-ventricular valve regurgitation. For a mean follow-up of 67 months (range from 51 to 90 months) all patients are asymptomatic and with no residual defects. Corrective repair of d-transposition of the great arteries and complete atrio-ventricular canal can be successfully achieved in this very challenging population during the neonatal period.

Q fever is characterized by its clinical polymorphism. Cardiac involvement in acute Q fever is rare. We report a case of pleuro-pericarditis that rapidly evolved to pericardial constriction during an acute episode of Coxiella burnetii infection. Constrictive pericarditis was confirmed by hemodynamic measurements, echocardiography, and magnetic resonance. Indirect immunofluorescence assay revealed positive serology for acute Q fever. The patient underwent a successful pericardiectomy and was given antibiotics. The histopathologic study of the excised pericardium showed C. burnetii in a large cluster of organisms. After a 6-month follow-up period, the individual was asymptomatic.

Background The optimal age and duration of left ventricular (LV) training in congenitally corrected transposition (ccTGA) with an unprepared LV is unknown. The objective of this study was to review the effect of age at pulmonary artery banding (PAB) and duration of ventricular training on LV function and aortic regurgitation (AR) after anatomic repair. Methods The medical records of all patients who underwent PA banding for LV training between 1998 and 2011 were retrospectively reviewed. The primary end points were moderate or more LV dysfunction and moderate or more AR after anatomic repair. Results During the study period, 25 patients with ccTGA underwent PAB for LV preparation. There was 1 early death. Eighteen patients underwent anatomic repair at a median of 10 months (range, 2 weeks to 11 years) from PAB. At the most recent follow-up after anatomic repair, moderate AR developed in 1 patient, and moderate or more LV dysfunction developed in 4. LV dysfunction developed in 4 of 6 patients banded after 2 years of age, compared with 0 of 12 patients banded before 2 years ( p = 0.005). After anatomic repair, LV dysfunction developed in 4 of 7 patients repaired after age 3 years compared with 0 of 11 repaired before 3 years ( p = 0.01). Conclusions Early PAB strategy is associated with favorable LV and neoaortic valve function after anatomic repair for ccTGA with an unprepared LV. Candidates for anatomic repair who require LV training should be referred early in infancy for consideration of appropriate timing of PAB.

Objetivo Estudiamos nuestra forma de correccion en los ultimos 5 anos para conocer el impacto de respetar el anillo pulmonar sobre la incidencia de reoperacion y el desarrollo de insuficiencia pulmonar. Material y metodos Treinta y seis ninos corregidos empleando cuatro grupos de tecnicas segun se respete o no el anillo pulmonar, y el abordaje de la comunicacion interventricular (CIV): a) CIV por auricula + anillo intacto (6p); b) CIV por infundibulo + anillo intacto (17p); c) CIV por auricula y minima apertura anular desde tronco pulmonar (6p), y d) CIV por infundibulo y parche transanular (7p). Resultados Ocho reoperaciones para desobstruccion del tracto de salida de ventriculo derecho (TSVD). Dos de ellas por insuficiente reseccion muscular en grupo 1. Seis reoperaciones estuvieron en relacion con el anillo pequeno (17% de la serie global, 26% en pacientes con anillo intacto). Dos de estas ultimas para interponer conducto por DA cruzando el TSVD, y 4 se coloco parche transanular. Ningun paciente en los grupos 3 y 4 se reoperaron para ampliar TSVD. El Z score medio del anillo pulmonar de los reoperados fue de –3,4 frente a –1,7 en no reoperados en los grupos 1 y 2 (anillo intacto). La incidencia de insuficiencia pulmonar grave inicial fue menor en los grupos con anillo intacto (8,7 vs 58,3%). En el seguimiento aumento al 22% en los grupos 1 y 2, debido a las reoperaciones para colocar parche transanular. Conclusiones Respetar el anillo conduce a mayor incidencia de reoperacion por obstruccion, pero menor incidencia de insuficiencia pulmonar inicial y en el seguimiento.

In his letter to the editor, Dr. Jaakko L.O. Pohjoismaki expressed his concern about our recent publication “Impaired Mitochondrial Biogenesis Precedes Heart Failure in Right Ventricular Hypertrophy in Congenital Heart Disease,”1 regarding the relationship between age and mtDNA copy number. Specifically, he suggested that the reported decrease of mtDNA levels in cardiac hypertrophy could be explained by the age differences of the patient groups rather than the status of the disease. We appreciate the thoughtfulness of Dr. Pohjoismaki. Indeed, the median age of the control group in our study was older than the patient group, and …

Combined aortic and pulmonic stenosis is a very rare condition, with only a few patients reported in the literature.1 Moreover, most of those cases are children and young adults, and thus, the pathogenesis has been often considered congenital.2,3 We report an 81-year-old man with a diagnosis of severe aortic and pulmonic stenosis who underwent successful aortic and pulmonic valve replacement, and we comment on the echocardiographic and pathological findings and speculate on the most likely cause. To the best of our knowledge, this is the first report of this condition in an octogenarian patient. An 81-year-old man with a medical history of smoking, arterial hypertension, dyslipidemia, mild renal …

Background Pulmonary valve replacement (PVR) is a common therapy for chronic pulmonary regurgitation. However, the use of this strategy is mostly based on the studies performed on patients with tetralogy of Fallot (TOF) and not in patients with pulmonary atresia/intact ventricular septum (PA/IVS). The aim of this study is to evaluate our experience with PVR in patients with PA/IVS and compare them with a matched cohort of TOF patients. Methods Between 1995 and 2009, 13 patients with PA/IVS underwent a late PVR. Matched TOF control subjects were identified for 12 of these patients. Before and after PVR echocardiographic, magnetic resonance imaging, exercise test, Holter, and electrocardiographic data were compared between groups. Results There was no mortality in either group. The PVR improved pulmonary regurgitant fraction and right ventricular volumes in all patients. Patients with PA/IVS had more significant tricuspid regurgitation (TR [at least moderate]) by echocardiography and magnetic resonance imaging before PVR (n = 11 [85%] versus n=1 [8%]; p = 0.003) and had more tricuspid valve repairs than TOF patients (n = 9 [69%] versus n=1 [8%]; p = 0.004). Repair was undertaken by a combination of techniques. Although TR was improved early postoperatively, only 2 of 9 patients (22%) were free from significant TR at most recent follow-up (median 2.5 years; range, 0.1 to 10.9). No patient underwent reoperation at latest follow-up. Conclusions Patients with PA/IVS can undergo a late PVR with excellent results. Significant TR and repair are more commonly observed among patients with PA/IVS compared with TOF patients. Although tricuspid valve repair improves regurgitation early, TR tends to recur, suggesting the need for further refinement of current surgical techniques.

Valved conduits are frequently used in congenital heart surgery to establish continuity between the right ventricle and the pulmonary arteries. The Contegra bovine jugular vein (Medtronic Inc, Minneapolis, MN) is a conduit that incorporates a tri-leaflet valve and affords off-the-shelf availability, good handling characteristics, and excellent hemodynamics. However, complications related to the use of this device have been reported, with conduit failure occurring mainly as a consequence of stenosis, conduit thrombosis, and valve regurgitation. We present a case of aneurysmal conduit failure of a 14-mm Contegra conduit used to reconstruct the right ventricular outflow tract.

Anatomic repair is the standard surgical approach to congenitally corrected transposition of the great arteries. However, timing to perform the procedure remains controversial. We present 2 cases of congenitally corrected transposition of the great arteries and Ebstein's-like anomaly of the tricuspid valve presenting with heart failure. Both cases had successful anatomic repair during the neonatal period.

The goal of our study was to report our intermediate-term results with aortic root translocation plus arterial switch for d-transposition of the great arteries with left ventricular outflow tract obstruction.A d-transposition of the great arteries with left ventricular outflow tract obstruction represents a difficult surgical problem. The Rastelli procedure is the usual approach to this condition. However, recurrent left ventricular outflow tract obstruction and early conduit obstruction as well as arrhythmias and troublesome late mortality are significant limitations.From 1993 to 2005, 11 children (8 male, 3 female) ages 1 month to 11 years (median age 7 months) have undergone aortic root autograft translocation plus arterial switch to correct d-transposition of the great arteries with left ventricular outflow tract obstruction. The native aortic root was excised from the right ventricle infundibulum and inserted into the left ventricular outflow, enlarging the outflow tract by resecting the outlet septum and an appropriate-size ventricular septal defect patch. After coronary artery reimplantation, right ventricular outflow reconstruction was achieved with a homograft.There were no early or late deaths. With a median follow-up of 59 months (range 2 to 137 months), 5 patients required 6 conduit replacement procedures at a median time of 53 months. Two patients required an implantable defibrillator for ventricular arrhythmias. None of the patients have developed left ventricular outflow tract obstruction.Aortic root autograft plus arterial switch procedure is a good option for the surgical management of infants and children with d-transposition of the great arteries and left ventricular outflow tract obstruction and results in a more anatomic repair compared with Rastelli operation. Intermediate-term results indicate good relief of left ventricular outflow tract obstruction and need for conduit replacement compares favorably with the Rastelli procedure for this lesion.