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Background: The increasing complexity of congenital cardiac surgery has led to greater utilization of extracorporeal membrane oxygenation (ECMO) support for children post‐surgery. This study aims to identify risk factors for mortality and brain injury in pediatric patients requiring post‐cardiotomy ECMO and to evaluate their neurological outcomes. Methods: This retrospective study includes pediatric patients with congenital heart diseases who required ECMO after surgery. Risk factors for in‐hospital mortality and brain injury were assessed. Neurodevelopmental status was determined using the Pediatric Cerebral Performance Category (PCPC) Scale at discharge and during follow‐up. Results: Between October 2014 and May 2021, 2651 pediatric patients underwent cardiac surgery, with 90 (3.4%) requiring ECMO. The mean age was 0.6 years, ranging from 1 day to 13 years and 7 months. ECMO was implemented for 45 patients due to CPB weaning failure (NW‐CPB), 24 due to postoperative low‐cardiac output syndrome (LCOS), and 21 for extracorporeal cardiopulmonary resuscitation (E‐CPR). ECMO weaning was achieved in 73 patients (81%), with an overall mortality rate of 36%. Pre‐implant lactate levels (OR: 1.13, 95% CI: 1.03–1.25; p = 0.009) and peak bilirubin levels (OR: 1.04, 95% CI: 0.87–1.24; p = 0.69) were risk factors for in‐hospital mortality. Survival rates were 79% for LCOS, 60% for NW‐CPB, and 48% for E‐CPR. Brain injury incidence was 33%, with E‐CPR being a significant risk factor (p = 0.006) and NW‐CPB being protective (p = 0.001). Follow‐up in November 2023 showed significant improvement in neurodevelopmental status (p < 0.001). Conclusion: Elevated pre‐implant lactate and elevated bilirubin levels during ECMO are major risk factors for mortality. E‐CPR is the primary risk factor for brain injury. Follow‐up revealed significant improvements in neurodevelopmental outcomes. [ABSTRACT FROM AUTHOR]

This article discusses the use of cardiac magnetic resonance (CMR) imaging with the late gadolinium enhancement (LGE) technique to assess the presence of a myocardial scar in patients with an anomalous right coronary artery originating from the left sinus of Valsalva (R-ACAOS). The study included 48 patients with R-ACAOS, and 21% of them showed an ischaemic pattern of LGE. These patients were older and had high-risk anatomical features. Although most patients were asymptomatic and had negative provocative tests, the presence of an ischaemic scar suggests a potential risk for sudden cardiac death. CMR may be a useful tool for risk stratification in R-ACAOS patients. [Extracted from the article]

BACKGROUND: Anomalous aortic origin of coronary artery (AAOCA) with intramural segment is associated with risk of sudden cardiac death, probably related to a compressive mechanism exerted by the aorta. However, the intramural compression occurrence and magnitude during the cardiac cycle remain unknown. We hypothesized that (1) in end diastole, the intramural segment is narrower, more elliptic, and has greater resistance than extramural segment; (2) the intramural segment experiences a further compression in systole; and (3) morphometry and its systolic changes vary within different lumen cross-sections of the intramural segment. METHODS: Phasic changes of lumen cross-sectional coronary area, roundness (minimum/maximum lumen diameter), and hemodynamic resistance (Poiseuille law for noncircular sections) were derived from intravascular ultrasound pullbacks at rest for the ostial, distal intramural, and extramural segments. Data were obtained for 35 AAOCA (n=23 with intramural tract) after retrospective image-based gating and manual lumen segmentation. Differences between systolic and end-diastolic phases in each section, between sections of the same coronary, and between AAOCA with and without intramural tract were assessed by nonparametric statistical tests. RESULTS: In end diastole, both the ostial and distal intramural sections were more elliptical (P<0.001) than the reference extramural section and the correspondent sections in AAOCA without intramural segment. In systole, AAOCA with intramural segment showed a flattening at the ostium (−6.76% [10.82%]; P=0.024) and a flattening (−5.36% [16.56%]; P=0.011), a narrowing (−4.62% [11.38%]; P=0.020), and a resistance increase (15.61% [30.07%]; P=0.012) at the distal intramural section. No-intramural sections did not show morphological changes during the entire cardiac cycle. CONCLUSIONS: AAOCA with intramural segment has pathological segment-specific dynamic compression mainly in the systole under resting conditions. Studying AAOCA behavior with intravascular ultrasound during the cardiac cycle may help to evaluate and quantify the severity of the narrowing. [ABSTRACT FROM AUTHOR]

Background Isolated coronary arteriovenous fistulas are extremely rare, accounting for 0.08–0.4% of all congenital heart disease. Closure of the fistula is recommended in cases of large dimensions, relevant left–right shunt, or ischaemic events. Thrombosis of the coronary aneurysms may occur as a postoperative complication. Case summary We report a case of a coronary fistula between the circumflex artery and coronary sinus with giant aneurysm. After a failed percutaneous closure attempt, the patient was surgically treated without major postoperative complications. Despite therapeutic anticoagulation and antiplatelet therapy, she presented at clinical follow-up with thrombosis of the dilated coronary artery without signs or symptoms of ischaemia. Discussion Management of coronary artery fistula may be challenging in cases in which initial percutaneous closure is unsuccessful. This particular case also highlights the importance of close follow-up, despite optimal therapy, to detect potentially lethal complications related to the low flow in the dilated coronary aneurysm. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES: Tricuspid valve (TV) surgery in the adult with congenital heart disease (ACHD) is a frequently performed procedure. The aim of this study was to analyse postoperative and medium-term outcomes. METHODS: We conducted a single-centre retrospective study of patients with ACHD who underwent TV surgery (January 2000–December 2016); patients with Ebstein's anomalies were excluded. Operative and clinical records were reviewed. Outcomes considered were survival, grade of insufficiency/stenosis and TV reoperation at follow-up. RESULTS: A total of 128 patients with ACHD had TV surgery for functional regurgitation (n  = 95), dysplasia (n  = 23) and systemic TV (n  = 10). Median age was 40.8 years [interquartile range (IQR) 25.3]; 55.5% were men. Preoperative regurgitation was classified as mild (n  = 8), moderate (n  = 47) and severe (n  = 70). The TV was repaired in 109 as follows: ring annuloplasty (n  = 43), de Vega annuloplasty (n  = 29), Wooler annuloplasty (n  = 13), commissural plasty (n  = 9), Kay annuloplasty (n  = 7) and others (n  = 8). The TV was replaced in 19 patients with biological (n  = 10) and mechanical (n  = 9) prostheses. The median hospital stay was 12 days (IQR 10). The overall mortality rate was 8.6% (n  = 11): 2 hospital deaths (1.6%) and 9 late deaths. Survival was 93% [95% confidence interval (CI) 85–97%] at 5 years and 83% (95% CI 70–91%) at 10 years. The median follow-up period was 4.95 years (IQR 7.7) with 1 TV reoperation. Echocardiographic assessment showed ≥moderate regurgitation in 34 (34.3%) patients. Suture plasty had a significantly higher incidence of TV regurgitation ≥moderate compared to ring annuloplasty (48.9% vs 26.3%; P  = 0.033). CONCLUSIONS: TV surgery in the ACHD is frequently associated with other main procedures. Stabilizing the TV annulus with a prosthetic ring guarantees lower recurrence of moderate to severe regurgitation compared to suture plasty repair. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES: We sought to describe early and late outcomes in a large surgical series of patients with anomalous aortic origin of coronary arteries. METHODS: We performed a retrospective multicentre study including surgical patients with anomalous aortic origin of coronary arteries since 1991. Patients with isolated high coronary takeoff and associated major congenital heart disease were excluded. RESULTS: We collected 156 surgical patients (median age 39.5 years, interquartile range 15–53) affected by anomalous right (67.9%), anomalous left (22.4%) and other anatomical abnormalities (9.6%). An interarterial course occurred in 86.5%, an intramural course in 62.8% and symptoms in 85.9%. The operations included coronary unroofing (56.4%), reimplantation (19.2%), coronary bypass graft (15.4%) and other (9.0%). Two patients with preoperative cardiac failure died postoperatively (1.3%). All survivors were discharged home in good clinical condition. At a median follow-up of 2 years (interquartile range 1–5, 88.5% complete), there were 3 deaths (2.2%), 9 reinterventions in 8 patients (5 interventional, 3 surgical); 91.2% are in New York Heart Association functional class ≤ II, but symptoms persisted in 14.2%; 48.1% of them returned to sport activity. On Kaplan–Meier analysis, event-free survival at follow-up was 74.6%. Morbidity was not significantly different among age classes, anatomical variants and types of surgical procedures. Furthermore, return to sport activity was significantly higher in younger patients who participated in sports preoperatively. CONCLUSIONS: Surgical repair of anomalous aortic origin of coronary arteries is effective and has few complications. Unroofing and coronary reimplantation are safe and are the most common procedures. The occurrence of late adverse events is not negligible, and long-term surveillance is mandatory. Most young athletes can return to an unrestrained lifestyle. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Life expectancy of patients with repaired tetralogy of Fallot is normal until adulthood, when it becomes burdened by major complications such as cardiac arrhythmias and heart failure. Ventricular tachycardia (VT), associated with electrical conduction abnormalities in anatomical isthmuses, is the most common complication and is refractory to medical therapy. The arrhythmogenic sources can be surgically ablated during reoperations for pulmonary valve incompetence. The purpose of our study is to evaluate the safety and effectiveness of surgical radiofrequency ablation during PVR and its long-term impact on the occurrence of cardiac events. METHODS A total of 118 patients with repaired tetralogy of Fallot underwent reoperation for pulmonary valve regurgitation in IRCCS-Policlinico San Donato between January 2002 and February 2016. Twenty patients with risk factors for ventricular arrhythmia underwent EP testing and were found positive. The mean QRS duration was 178 ms. Right ventricular dysfunction was present in all the patients, and 20% had associated tricuspid regurgitation. The cohort (N = 20), with positive EP study, underwent pulmonary valve replacement and concomitant intraoperative ventricular surgical radiofrequency ablation, targeting the slow conducting isthmuses identified during preoperative electroanatomical mapping. All patients were reviewed at 1 month, 3 months and 6 months with clinical evaluation, echocardiography, ECG and implantable cardioverter-defibrillator interrogation. At 6 months, a postoperative electrophysiological study was performed in all patients, and a cardioverter defibrillator was implanted as primary preventive measure in patients with residual inducible VT. RESULTS Pulmonary valve replacement and surgical ventricular radiofrequency ablation were performed in all cases. One patient died while on V-V extracorporeal membrane oxygenation (ECMO) due to respiratory failure. There was no late mortality. Follow-up was complete with a median of 6.5 years. During the postoperative EPS study, inducible VT was found in 15.7% of patients who received an implantable cardioverter-defibrillator, whereas VT could no longer be induced in the remaining patients. No procedure-related complication was observed, and freedom from ventricular arrhythmia was 94% and 89.5% at 1 year and 5 years, respectively. CONCLUSIONS Pulmonary regurgitation and right ventricular dysfunction correlate with VT and SCD, but valve replacement alone does not reduce the risk of ventricular tachyarrhythmias. Intraoperative ventricular ablation during reoperation for pulmonary regurgitation prevents the occurrence of ventricular arrhythmias in the early and medium term. Accordingly, this technique may be proposed as a safe associated procedure in selected patients. [ABSTRACT FROM AUTHOR]

The double check occurs during a chess game when 1 player obtains a check with 2 pieces simultaneously. Bellsham-Revell I et al. i [[1]], in their article, seem to have found such a strategic move in the treatment of HLHS, putting the interstage mortality under double check using simultaneously preoperative computed tomography (CT) and anticipation of superior cavopulmonary connection (SCPC). [Extracted from the article]