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Background and Aim: We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes, including reinterventions, for each subset., Methods: We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, associated anomalies, and the effect of severe pulmonary hypertension., Results: Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between 0% and 14.2%, with morbidity estimated between 6% and 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with the need for reoperation being over four times higher. Perventricular hybrid approaches are useful for the closure of high anterior or apical defects. Overall, the results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical subsets., Conclusions: We have addressed the approaches, and the results, of therapeutic treatment in terms of coexisting discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects., (© 2022 Wiley Periodicals LLC.)

The present perspective is a synthesis of published investigations in the setting of anomalous connection of the right superior caval vein to the morphologically left atrium or biatrial drainage of the right caval vein. We identified 57 suitable cases from 97 investigations, reviewing the clinical presentation, diagnostic modalities utilized, surgical techniques used, and their outcomes. Clinical presentation, radiographic findings, saline contrast echocardiography, computed tomographic angiocardiography, radionuclide perfusion scan, magnetic resonance imaging, and angiocardiography provided the diagnostic information and were used to define the disease entities before surgery. We have also addressed several issues concerning the influence of the so-called heterotaxy: the establishment of the diagnosis, the variation in clinical presentation, and subsequent management. For the overall group of patients undergoing either surgical intervention or transcatheter treatment with an Amplatzer vascular plug, the operative mortality remains high at 9.5%. We submit that an increased appreciation of these disease entities will contribute to improved future surgical management.

Continuously growing patient's demand, technological innovation, and surgical expertise have led to the widespread popularity of minimally invasive cardiac surgery (MICS). Patient's demand is being driven by less surgical trauma, reduced scarring, lesser pain, substantially lesser duration of hospital stay, and early return to normal activity. In addition, MICS decreases the incidence of postoperative respiratory dysfunction, chronic pain, chest instability, deep sternal wound infection, bleeding, and atrial fibrillation. Widespread media coverage, competition among surgeons and hospitals, and their associated brand values have further contributed in raising awareness among patients. In this process, surgeons and anesthesiologist have moved from the comfort of traditional wide incision surgeries to more challenging and intensively skilled MICS. A wide variety of cardiac lesions, techniques, and approaches coupled with a significant learning curve have made the anesthesiologist's job a challenging one. Anesthesiologists facilitate in providing optimal surgical settings beginning with lung isolation, confirmation of diagnosis, cannula placement, and cardioplegia delivery. However, the concern remains and it mainly relates to patient safety, prolonged intraoperative duration, and reduced surgical exposure leading to suboptimal treatment. The risk of neurological complications, aortic injury, phrenic nerve palsy, and peripheral vascular thromboembolism can be reduced by proper preoperative evaluation and patient selection. Nevertheless, advancement in surgical instruments, perfusion practices, increasing use of transesophageal echocardiography, and accumulating experience of surgeons and anesthesiologist have somewhat helped in amelioration of these valid concerns. A patient-centric approach and clear communication between the surgeon, anesthesiologist, and perfusionist are vital for the success of MICS.

Background: B-type natriuretic peptide has been extensively studied in patients with cardiovascular disease, but its impact on the perioperative outcome of patients with cyanotic congenital heart defects is still unclear. We assessed the perioperative changes in B-type natriuretic peptide levels and their correlation with preoperative factors and clinical outcomes in a large homogenous group of patients with tetralogy of Fallot undergoing definitive repair at a tertiary care center., Methods: A prospective study was undertaken in the cardiac operating room and intensive care unit at a single institution; 250 patients with tetralogy of Fallot undergoing intracardiac repair under cardiopulmonary bypass were studied. B-type natriuretic peptide levels were taken at 3 time points and correlated with clinical variables., Results: Baseline B-type natriuretic peptide levels correlated with the degree of cyanosis in all 4 groups. B-type natriuretic peptide levels at 24 h after admission to the intensive care unit correlated with mortality in the adult subset of patients. B-type natriuretic peptide levels > 290 pg mL(-1) in the intensive care unit predicted an increased probability of adverse clinical outcomes., Conclusions: We demonstrated a rise in serum B-type natriuretic peptide levels in patients with tetralogy of Fallot undergoing definitive repair on cardiopulmonary bypass. B-type natriuretic peptide levels may be monitored to identify patients with cyanosis at increased risk of an augmented inflammatory response to cardiopulmonary bypass., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Improved cosmetic appearance, reduced pain and duration of post-operative stay have intensified the popularity of minimally invasive cardiac surgery (MICS); however, the increased risk of stroke remains a concern. In conventional cardiac surgery, surgeons can visualize and feel the cardiac structures directly, which is not possible with MICS. Transesophageal echocardiography (TEE) is essential during MICS in detecting problems that require immediate correction. Comprehensive evaluation of the cardiac structures and function helps in the confirmation of not only the definitive diagnosis, but also the success of surgical treatment. Venous and aortic cannulations are not under the direct vision of the surgeon and appropriate positioning of the cannulae is not possible during MICS without the aid of TEE. Intra-operative TEE helps in the navigation of the guide wire and correct placement of the cannulae and allows real-time assessment of valvular pathologies, ventricular filling, ventricular function, intracardiac air, weaning from cardiopulmonary bypass and adequacy of the surgical procedure. Early detection of perioperative complications by TEE potentially enhances the post-operative outcome of patients managed with MICS.

Background: The widespread off-label use of recombinant activated factor VII for the control of refractory postoperative hemorrhage continues despite a warning from the Food and Drug Administration. Although effective in reducing the need for transfusion of blood and blood products, safety concerns still prevail., Objective: To compare the dosing and efficacy of recombinant activated factor VII between pediatric and adult patients, and in the operating room and intensive care unit., Methods: The records of 69 patients (33 children and 36 adults) who underwent cardiovascular surgery and received recombinant activated factor VII were reviewed retrospectively. The dose of recombinant activated factor VII, mediastinal drainage, use of blood and blood products, incidence of thrombosis, and 28-day mortality were studied., Results: the efficacy of recombinant activated factor VII was comparable in adults and children, despite the lower dose in adults. Prophylactic use of recombinant activated factor VII decreased the incidence of mediastinal exploration and the duration of intensive care unit stay. A 4.3% incidence of thrombotic complications was observed in this study., Conclusion: The efficacious dose of recombinant activated factor VII is much less in adults compared to children. Prophylactic use of recombinant activated factor VII decreases the dose required, the incidence of mediastinal exploration, and intensive care unit stay, with no survival benefit.

Indications for extra corporeal membrane oxygenation (ECMO) after pediatric cardiac surgery have been increasing despite the absence of encouraging survival statistics. Modification of ECMO circuit led to the development of integrated ECMO cardiopulmonary bypass (CPB) circuit at the author's institute, for children undergoing repair of transposition of great arteries among other congenital heart diseases (CHD). In this report, they analyzed the outcome of children with CHD, undergoing surgical repair and administered ECMO support in the last 10 years. The outcome was analyzed with reference to the timing of intervention, use of integrated ECMO-CPB circuit, indication for ECMO support, duration of ECMO run and the underlying CHD. The results reveal a significantly improved survival rate with the use of integrated ECMO-CPB circuit and early time of intervention rather than using ECMO as a last resort in the management. The patients with reactive pulmonary artery hypertension respond favorably to ECMO support. In all scenarios, early intervention is the key to survival.

Indian patients undergoing cardiac surgery have different demographics, clinical profile as well as risk profile, compared to the western population. The purpose of this study was to validate the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification model in Indian patients undergoing cardiac surgery in a single cardiac center. Data from 1000 consecutive adult patients undergoing cardiac surgery (coronary artery bypass grafting or valve surgery) were prospectively collected as per the EuroSCORE model. The model's validity was assessed on the basis of its calibration power (Hosmer-Lemeshow test) and discriminatory power [area under receiver operating characteristic curve]. The patients were divided into three risk groups on the basis of their EuroSCORE. The Hosmer-Lemeshow test revealed a good calibration power (P = 0.73) and the area under the ROC curve was 0.8278, suggesting a good discriminative power. The predicted mortality was similar to observed mortality in low- and moderate-risk patients but the observed mortality in high-risk patients (15.6%) was double that of predicted mortality (7.5%). The risk factors prevalent in European population were not observed in Indian population. EuroSCORE accurately predicts mortality in low and moderate-risk Indian patients undergoing cardiac surgery but is less predictive for high-risk Indian patients. Updating and improvisation of EuroSCORE by incorporation of risk factors associated with rheumatic valvular heart disease which is more prevalent in India, may enable it to accurately predict mortality in high-risk patients also.

Introduction: This study was designed to elucidate the trends in cerebral venous oxygen saturation in cyanotics and acyanotics undergoing normothermic and hypothermic cardiopulmonary bypass (CPB) and its relationship to perfusion flow rates., Methods: Five hundred and forty-eight patients (253 cyanotics) undergoing first surgical correction using CPB were included in this prospective study. One hundred and seventy-two patients underwent surgical correction under normothermic CPB (34-36 degrees C) - group I; 142 patients were operated under moderately hypothermic CPB - group II; and 234 patients were operated under deep hypothermic CPB - group III. The perfusion flow rates were adjusted to maintain the internal jugular venous oxygen saturation (IJVO2) between 70-80% in both cyanotics and non-cyanotics., Results: The prevalence of preoperative cerebral venous desaturation was 17.4% and 5.1% in cyanotic and acyanotic groups, respectively. All patients undergoing hypothermic CPB had IJVO 2 >75% at the recommended perfusion flow rate. During surgery, 87.2% of group I patients undergoing normothermic CPB and 88.5% of group II and III patients undergoing hypothermic CPB had IJVO 2 <75% during re-warming and required an increased perfusion flow rate to maintain IJVO2 >75%. The cyanotics demonstrated a higher incidence of cerebral desaturation in all three groups. Patients aged <4 years had almost the same prevalence of cerebral desaturation compared to the older patients., Conclusions: We conclude that patients undergoing normothermic CPB are at greater risk of cerebral desaturation. The cyanotics are at greater risk compared to acyanotics during normothermic CPB and during the re-warming phase of hypothermic CPB and require an individualised increased perfusion flow rate.