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Background and Objectives: The incidence of distant metastases in patients with head and neck cancer (HNC) is approximately 10%. Pulmonary metastases are the most frequent distant location, with an incidence of 70–85%. The standard treatment options are chemo-, immuno- and radiotherapy. Despite a benefit for long-term survival for patients with isolated pulmonary metastases, pulmonary metastasectomy (PM) is not the treatment of choice. Furthermore, many otorhinolaryngologists are not sufficiently familiar with the concept of PM. This work reviews the recent studies of pulmonary metastatic HNC and the results after pulmonary metastasectomy. Materials and Methods: PubMed, Medline, Embase, and the Cochrane library were checked for the case series’ of patients undergoing metastasectomy with pulmonary metastases published since 1 January 2000. Results: We included the data of 15 studies of patients undergoing PM. The 5-year survival rates varied from 21% to 59%, with median survival from 10 to 77 months after PM. We could not identify one specific prognostic factor for long-term survival after surgery. However, at least most studies stated that PM should be planned if a complete (R0) resection is possible. Conclusions: PM showed reliable results and is supposedly the treatment of choice for patients with isolated pulmonary metastases. Patients not suitable for surgery may benefit from other non-surgical therapy. Every HNC patient with pulmonary metastases should be discussed in the multidisciplinary tumor board to optimize the therapy and the outcome.

OBJECTIVES Bovine and porcine pericardial patches are frequently used in cardiothoracic and vascular surgery. There are no guidelines recommending the usage of these patches for particular surgical approaches. However, these 2 materials supposedly possess different properties. The clinical advantage of porcine compared with bovine patches remains controversial. In this experimental study, we analysed the incorporation and vascularization of bovine and porcine pericardial patches during the initial phase after implantation. METHODS Bovine and porcine pericardial patches were implanted into the dorsal skinfold chamber of C57BL/6 mice (n = 8 per group) to study vascularization and inflammation at the implantation site using repetitive intravital fluorescence microscopy over a 14-day period. At the end of the in vivo experiments, CD-31-positive cells were determined to evaluate the vascularization by immunohistochemistry. Furthermore, cell proliferation and apoptosis were analysed immunohistochemically. RESULTS Implanted bovine patches exhibited an enhanced vascularization, as indicated by a significantly higher number of CD-31-positive cells and micro-vessels (23.2 ± 4.3 vs 16.5 ± 5.8 mm−2; P = 0.001). Furthermore, bovine patches showed a slightly but not significantly higher functional capillary density. Both patches induced a moderate leukocytic inflammatory host tissue response, and neither bovine nor porcine patches significantly affected apoptosis and cell proliferation at the implantation site. CONCLUSIONS Bovine and porcine pericardial patches are similarly suitable for surgery. Bovine patches exhibited an improved vascularization during the first 14 days after implantation. This may result in a quicker and improved incorporation into the surrounding tissue compared with porcine pericardial patches.

Recent studies have shown that blood vessel invasion (V1) influences the long-term survival of patients with Non-Small Cell Lung Cancer (NSCLC). The aim of the present study was to emphasize V1 as an independent risk factor. We evaluated the effects of V1 on the survival of NSCLC patients with UICC stages I, II, and III after surgery.This retrospective study includes 747 consecutive patients with NSCLC who underwent anatomic resection and radical lymphadenectomy at our institution between January 2012 and December 2020. V1- were compared to V0-patients (no blood vessel invasion). All patients received adjuvant therapy according to European guidelines when indicated. After excluding patients with detection of lymphangiosis carcinomatosa, tumor-cells at the resection margin, distant metastases and those, that received neoadjuvant therapy, 1-, 3- and 5- year survival rates were assessed by Kaplan-Meier method. To proof V1 as an independent risk factor, a propensity score matched (PSM) analysis was performed regarding age, gender, UICC-stage, lymph-node involvement, and comorbidities.A total of 461 patients (V0: 440; V1: 21) were included in this analysis. Baseline characteristics did not show any significant difference. Mean age in V0-group was 65.7 ± 10.5 years and 64.1 ± 8.6 years in V1-group (p-value = 0.5). In the V0-group 54.8% were male, whereas in the V1-group this number was 66.7% (p-value = 0.37). Mean survival in V1-group was significantly shorter compared to V0-group (V1: 45.8 ± 9.3 months; V0: 81.1 ± 1.1 months; p-value0.001). This was confirmed after applying a propensity score matched analysis (V0: 99.9 ± 4.9 months; V1: 45.8 ± 9.3 months; p-value0.001) - V1 is a prognostic marker independent of UICC stage. The 1-, 3- and 5-year survival rates were significantly shorter for V1-patients (1-year: V0: 100%; V1: 70.6%; p-value = 0.012) (3-year: V0: 95.2%; V1: 46.2%; p-value = 0.002) (5-year: V0: 90.5%; V1: 36.4%; p-value = 0.003).As we have shown with our investigations, V1 has a major impact on long-term survival in NSCLC patients and furthermore, acts as an independent risk factor. Due to our small but specified sample size, our statement should be confirmed by a multicenter study. In the meantime, we suggest making the implementation of the V0/V1 specification mandatory in the tumor classification.

Sublobar resection is frequently performed for Non-Small Cell Lung Cancer (NSCLC) patients with ≤2 cm nodules. Frequently, both proper staging and radical lymphadenectomy are omitted in these operations. Therefore, we decided to evaluate the number of lymph node metastases and the number of postoperative nodal upstaging in patients undergoing pulmonary resection due to NSCLC with tumors ≤2 cm at our institution.Nodal upstaging, lymphangiosis- (L1), and hemangiosis carcinomatosa (V1) were analyzed. pN0 patients were compared to patients with postoperative nodal upstaging. One-, three, and five-year survival rates were measured. Survival was also assessed by the Kaplan-Meier method.747 patients underwent surgery for NSCLC at our institution between 2012 and 2020. We retrospectively reviewed data of 236 NSCLC patients with ≤2 cm tumors. The mean tumor size was 1.4 cm ± 0.39 in our cohort. Of our patients, 14% showed a cT1a tumor, and 86% of patients cT1b. 24.0 ± 12.3 lymph nodes were dissected and analyzed per patient, and 0.7 ± 2.0 of those were affected. Of our patients, 16.1% showed L1 affection, and 7.6% a V1 affection. Lymph node involvement was diagnosed in 11(4.7%) patients preoperatively. 39(16.5%) patients were upstaged due to lymph node involvement postoperatively (p 0.001). Upstaged patients showed significantly worse 3- (upstaged: 60.6% vs. pN0: 83.2%; p = 0.01) and 5-year (upstages: 38% vs. pN0 71.5%; p = 0.02) survival rates.16.5% of patients with ≤2 cm NSCLC were nodal upstaged postoperatively. These results underline that lymphadenectomy and proper staging are crucial for NSCLC patients irrespective of the tumor size and the surgical approach.

Purpose: Sublobar resection is a frequently performed surgical approach for Non-Small Cell Lung Cancer (NSCLC) patients with Methods: 747 patients underwent surgery for NSCLC at our institution between 2012 and 2020. We retrospectively reviewed data of NSCLC patients with Results: Mean tumor size was 1.4cm±0.39 in our cohort. Of our patients, 14% showed a cT1a tumor and 86% of patients cT1b. 24.0±12.3 lymph nodes were dissected and analyzed per patient, and 0.7±2.0 of those were affected. Of our patients, 16.1% showed an L1 affection and 7.6% a V1 affection. Lymph node involvement was diagnosed in 11(4.7%) patients preoperatively. 39(16.5%) patients were upstaged due to lymph node involvement postoperatively (pConclusion: Of our patients with

Extracorporeal membrane oxygenation or extracorporeal life support (ECLS) in patients after cardiac surgery and postcardiotomy cardiogenic shock (PCS) is known to be associated with high mortality. Especially in patients after coronary artery bypass grafting (CABG) and PCS, ECLS is frequently established. The aim of this analysis was to evaluate factors associated with in-hospital mortality in patients treated with ECLS due to PCS after CABG.Between August 2006 and January 2017, 92 consecutive patients with V-A ECLS due to PCS after isolated CABG were identified and included in this retrospective analysis. Patients were divided into survivors (S) and non-survivors (NS) and analyzed with risk factors of in-hospital mortality.In-hospital mortality added up to 61 patients (66%). Non-survivors were significantly older (60 ± 812 (S) vs. 67 ± 10 (NS); p = 0.013). Bilateral internal mammary artery graft was significantly more frequently used in S (23% (S) vs. 2% (NS); p = 0.001). After 24 h of ECLS support, median lactate levels were significantly higher in NS (1.9 (1.3; 3.5) mmol/L (S) vs. 3.5 (2.1; 6.3) mmol/L (NS); p = 0.001). NS suffered more often acute kidney injury requiring dialysis (42% (S) vs. 74% (NS); p = 0.002).Mortality in patients with refractory PCS after CABG and consecutive ECLS support remains high. Failing end-organ recovery under ECLS despite optimized concomitant medical therapy is an indicator of adverse outcomes in this specific patient cohort. Moreover, total-arterial revascularization might be beneficial for cardiac recovery in patients suffering PCS after CABG and following ECLS.

Nowadays, an increasing number of neonatal and pediatric patients with severe heart failure benefits from extracorporeal membrane oxygenation (ECMO) support. A total of 39 pediatric patients needed venoarterial ECMO (vaECMO) support in our department between January 2008 and December 2016. Patients were retrospectively divided in two groups: 30-day survivor group (17 patients) and 30-day nonsurvivor group (22 patients). Outcome and factors predictive for 30-day mortality and mid- as well as long-term survival up to 7-year follow-up were analyzed by univariate analysis and Kaplan-Meier survival estimation. Basic demographics and preoperative characteristics did not differ between groups (P > 0.05). 67% of patients were successfully weaned off ECMO and 44% survived 30-day after ECMO application. After 7-year follow-up 28% of pediatric patients were alive. Thirty-day survivors were significantly more likely to undergo elective cardiac surgery (P = 0.001), whereas significantly more 30-day nonsurvivors underwent urgent surgery (P = 0.004). Odds of incidence of catecholamine refractory circulatory failure, failed myocardial recovery, and cerebral edema was significantly higher in 30-day nonsurvivor group (41.6-fold, 16-fold, and 2.5-fold, respectively). Kaplan-Meier survival estimation analysis revealed significant differences in terms of mid- and long-term survival among neonates, infants, toddlers, and preadolescents (Breslow P = 0.037 and Log-Rank P = 0.028, respectively). vaECMO provides an efficient therapy option for life-threatening heart disorders in neonates and pediatric patients being at high risk for myocardial failure leading to circulatory arrest. Urgency of surgery effected on higher mortality, but there was no difference in terms of mortality in 30-day survivor group in comparison to 30-day nonsurvivor group among neonates, infants, toddlers, and preadolescents.

BACKGROUND: Mortality and morbidity after surgical repair for complex congenital heart defects and severe cardiopulmonary failure on extracorporeal membrane oxygenation (ECMO) support remain high despite significant advances in medical management and technological improvements. We report on outcomes and factors after using ECMO in our surgical pediatric population including short- and long-term survival. METHODS: A total of 45 neonatal and pediatric patients were identified who needed ECMO in our department between January 2008 and December 2016. In 41 cases (91%) a vaECMO (ECLS) was implemented, whereas 4 patients (9%) received vvECMO treatment for respiratory failure. In 33 cases vaECMO was implanted following cardiac surgery for congenital heart disease (CHD), whereas in 8 patients ECMO was utilized by means of extracorporeal cardiopulmonary resuscitation (eCPR) following refractory cardiac arrest. The primary endpoint of the present study was survival to discharge and long-term survival free from neurological impairments. Univariate and bivariate analysis was performed to address predictors for outcome. Kaplan-Meier survival analysis was used to address mid- and long-term survival. RESULTS: Median [IQR] duration of ECMO support was 3 [2, 5] days (range, 1–17 days). Median age at ECMO implantation was 128 [14, 1,813] days, median weight of patients was 5.4 [3.3, 12] kg. Totally 10 patients included in this study were diagnosed with concomitant genetic conditions. A total of 20 (44%) patients were successfully weaned off ECMO (survived >24 h after ECMO explantation), whereas 15 (33%) of them survived to discharge. Single ventricle (SV) repair was performed in 14, biventricular repair in 19 patients. Neonates (

Contains fulltext : 208423.pdf (Publisher’s version ) (Closed access) We describe a Fontan patient with severe heart failure who was successfully treated with biventricular cardiac resynchronization therapy (CRT). Our case shows that strain imaging might play a crucial role in guiding placement of pacing leads and in characterizing the electromechanical substrate associated with a favorable CRT response. Furthermore, we demonstrate for the first time that ventriculo-ventricular interdependency seems an important mechanical concept, which can be utilized to augment cardiac performance in failing Fontan patients with a functional hypoplastic ventricle.

Objectives: We report the first use of a biorestorative valved conduit (Xeltis pulmonary valve–XPV) in children. Based on early follow-up data the valve design was modified; we report on the comparative performance of the two designs at 12 months post-implantation.Methods: Twelve children (six male) median age 5 (2 to 12) years and weight 17 (10 to 43) kg, had implantation of the first XPV valve design (XPV-1, group 1; 16 mm (n = 5), and 18 mm (n = 7). All had had previous surgery. Based on XPV performance at 12 months, the leaflet design was modified and an additional six children (five male) with complex malformations, median age 5 (3 to 9) years, and weight 21 (14 to 29) kg underwent implantation of the new XPV (XPV-2, group 2; 18 mm in all). For both subgroups, the 12 month clinical and echocardiographic outcomes were compared.Results: All patients in both groups have completed 12 months of follow-up. All are in NYHA functional class I. Seventeen of the 18 conduits have shown no evidence of progressive stenosis, dilation or aneurysm formation. Residual gradients of >40 mm Hg were observed in three patients in group 1 due to kinking of the conduit (n = 1), and peripheral stenosis of the branch pulmonary arteries (n = 2). In group 2, one patient developed rapidly progressive stenosis of the proximal conduit anastomosis, requiring conduit replacement. Five patients in group 1 developed severe pulmonary valve regurgitation (PI) due to prolapse of valve leaflet. In contrast, only one patient in group 2 developed more than mild PI at 12 months, which was not related to leaflet prolapse.Conclusions: The XPV, a biorestorative valved conduit, demonstrated promising early clinical outcomes in humans with 17 of 18 patients being free of reintervention at 1 year. Early onset PI seen in the XPV-1 version seems to have been corrected in the XPV-2, which has led to the approval of an FDA clinical trial.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02700100 and NCT03022708.

Adenocarcinoma (AC) is the number one pathological entity of lung cancer with approximately 30-40% of cases. It is known to be heterogeneous and has 5 histopathological growth patterns. We evaluated the long-term survival rates of patients with predominant subtypes.290 patients with AC underwent pulmonary resection between 2012 and 2017 at our institution. We excluded all patients with lymph node involvement and distant metastases. Hence, 163 patients were included for further analysis. Predominant growth pattern was defined if more than 10% of cells showed a growth pattern. 1, 3, and 5-year survival rates were evaluated. Survival was assessed by Kaplan-Meier curves and the Cox proportional hazards model was used to identify prognostic factors for overall survival.Predominant growth patterns10% were compared to10% growth patterns of the same subtype. 1-year, 3-year, and 5-year overall survival rates of patients with predominant solid tumor growth10% differed significantly from patients with10% (88.4% vs. 97.6%, p = 0.04; 65.8% vs. 87.4% p = 0.001, 36.4% vs. 65.9% p = 0.01). Survival rates did not differ between10% papillary and acinar growth compared to10%. Kaplan-Meier curves showed reduced overall survival for patients with solid tumor growth10% (log-rank 0.002). Solid tumor growth10% was an independent prognostic factor for worse long-term survival (Hazard ratio: 3.05, p = 0.01).Our study demonstrates that the presence of a predominant solid pattern in pulmonary adenocarcinoma is a factor for an unfavorable prognosis. This should be kept in mind in daily clinical practice.

Background: Application of extracorporeal membrane oxygenation in pediatric patients with severe heart failure steadily increases. Differentiation of outcomes and survival of diverse pediatric groups is of interest for adequate therapy. Methods: Between January 2008 and December 2016, a total of 39 pediatric patients needed veno-arterial extracorporeal membrane oxygenation support in our department. Patients were retrospectively divided into three groups: neonates (30 days/1 year). Early outcomes as well as mid- and long-term survival up to 7-year follow-up were analyzed. Results: Basic demographics significantly differed in terms of age, height, and weight among the groups in accordance with the intended group categorization (p Conclusion: Veno-arterial extracorporeal membrane oxygenation is a lifesaving therapeutic chance for pediatric patients in the setting of either failure to wean from cardiopulmonary bypass or failed resuscitation from cardiac arrest. A fair part of patients could be saved by using this technology. Survival rate among the groups was similar.

Background and Objectives: Pediatric extracorporeal membrane oxygenation (ECMO) support is often the ultimate therapy for neonatal and pediatric patients with congenital heart defects after cardiac surgery. The impact of lactate clearance in pediatric patients during ECMO therapy on outcomes has been analyzed. Materials andMethods: We retrospectively analyzed data from 41 pediatric vaECMO patients between January 2006 and December 2016. Blood lactate and lactate clearance have been recorded prior to ECMO implantation and 3, 6, 9 and 12 h after ECMO start. Receiver operating characteristic (ROC) analysis was used to identify cut-off levels for lactate clearance. Results: Lactate levels prior to ECMO therapy (9.8 mmol/L vs. 13.5 mmol/L, p = 0.07) and peak lactate levels during ECMO support (10.4 mmol/L vs. 14.7 mmol/L, p = 0.07) were similar between survivors and nonsurvivors. Areas under the curve (AUC) of lactate clearance at 3, 9 h and 12 h after ECMO start were significantly predictive for mortality (p = 0.017, p = 0.049 and p = 0.006, respectively). Cut-off values of lactate clearance were 3.8%, 51% and 56%. Duration of ECMO support and respiratory ventilation was significantly longer in survivors than in nonsurvivors (p = 0.01 and p &lt, 0.001, respectively). Conclusions: Dynamic recording of lactate clearance after ECMO start is a valuable tool to assess outcomes and effectiveness of ECMO application. Poor lactate clearance during ECMO therapy in pediatric patients is a significant marker for higher mortality.

Aims. Induced pluripotent stem cell-derived cardiomyocytes (iPS-CMs) have become a promising tool in cardiovascular safety pharmacology. Immaturity of iPS-CMs remains an ongoing concern. We compared electrophysiological and contractile features of cardiac bodies (hiPS-CBs) derived from human-induced pluripotent stem cells and human neonatal and infantile myocardial slices relevant for drug screening. Methods and Results. Myocardial tissue slices were prepared from biopsies obtained from patients undergoing surgery for hypoplastic left heart syndrome (HLHS) and tetralogy of Fallot (TOF). Electrophysiological features and response to Ik,r blockade as well as contractile properties were investigated using microelectrodes and isometric force measurements and were compared to hiPS-CBs. Both native myocardial tissue slices as well as hiPS-CBs showed action potential prolongation after Ik,r blockade, but early afterdepolarisations could be observed in native myocardial tissue slices only. The force-frequency relationship (FFR) varied at lower frequencies and was negative throughout at higher frequencies in hiPS-CBs. In contrast, native myocardial tissue slices exhibited positive, negative, and biphasic FFRs. In contrast to native myocardial tissue slices, hiPS-CBs failed to show an inotropic response to ß-adrenergic stimulation. Although all groups showed ß-adrenergic induced positive lusitropy, the effect was more pronounced in myocardial tissue slices. Conclusion. hiPS-CBs were able to reproduce AP prolongation after Ik,r blockade, but to a lesser extent compared to human neonatal and infantile myocardial tissue slices. Early afterdepolarisations could not be induced in hiPS-CBs. Contractile force was differently regulated by β-adrenergic stimulation in hiPS-CBs and the native myocardium. If used for cardiotoxicity screening, caution is warranted as hiPS-CBs might be less sensitive to pharmacologic targets compared to the native myocardium of neonates and infants.

Background Double-chambered right ventricle is a partial separation of the right ventricle by pathological tissue. This anomaly is described in infants and children but can also be diagnosed in young adults. Case Description A 47-year-old patient presented with chest pain and exercise intolerance. Further evaluation revealed a double-chambered right ventricle. During the surgical procedure, fibrotic tissue was transected, and a pulmonary valve replacement including enlargement of the main pulmonary artery was performed. Conclusion Subpulmonary obstruction of the right ventricle can be related to double-chambered right ventricle even in adulthood. Treatment options include surgical resection with pulmonary valve replacement.

Background The postnatal development of myofibrillar mechanics, a major determinant of heart function, is unknown in pediatric patients with tetralogy of Fallot and related structural heart defects. We therefore determined the mechanical properties of myofibrils isolated from right ventricular tissue samples from such patients in relation to the developmental changes of the isoforms expression pattern of key sarcomere proteins involved in the contractile process. Methods and Results Tissue samples from the infundibulum obtained during surgery from 25 patients (age range 15 days to 11 years, median 7 months) were split into half for mechanical investigations and expression analysis of titin, myosin heavy and light chain 1, troponin‐T, and troponin‐I. Of these proteins, fetal isoforms of only myosin light chain 1 ( ALC ‐1) and troponin‐I (ssTnI) were highly expressed in neonates, amounting to, respectively, 40% and 80%, while the other proteins had switched to the adult isoforms before or around birth. ALC ‐1 and ssTnI expression subsequently declined monoexponentially with a halftime of 4.3 and 5.8 months, respectively. Coincident with the expression of ssTnI, Ca 2+ sensitivity of contraction was high in neonates and subsequently declined in parallel with the decline in ssTnI expression. Passive tension positively correlated with Ca 2+ sensitivity but not with titin expression. Contraction kinetics, maximal Ca 2+ ‐activated force, and the fast phase of the biphasic relaxation positively correlated with the expression of ALC ‐1. Conclusions The developmental changes in myofibrillar biomechanics can be ascribed to fetal‐to‐adult isoform transition of key sarcomeric proteins, which evolves regardless of the specific congenital cardiac malformations in our pediatric patients.

Background: In selected neonates and infants, primary palliative stent implantation may be indicated for coarctation of the aorta. We describe our experience with this approach in five consecutive patients. Methods: Five neonates and infants (age range 6 to 68 days, gestation 33 to 38 weeks, weight range at procedure of between 1650 to 4000 g) underwent palliative stent implantation as primary therapy for coarctation of the aorta. Indications for primary stent implantation were varied. All procedures were performed by elective surgical cut down of the axillary artery. Standard coronary stents (diameter 4.5 to 5 mm, length 12 to 16 mm) were delivered via a 4F sheath. The axillary artery was repaired after removal of the sheath. Results: All procedures were acutely successful, and without procedural complications. All patients survived to hospital discharge. Four patients have subsequently undergone elective stent removal and surgical repair of the arch, at between 38 and 83 days following stent implantation. Complete stent removal was achieved in three patients. Over a follow-up ranging between 8 weeks and 36 months, none of the patients has had any further complications. Conclusions: This palliative approach is warranted in carefully selected patients. Long-term follow-up is required.

IntroductionStenoses in the pulmonary arterial system can have a significant negative impact on the early postoperative course in infants. Early recognition and aggressive management are mandatory.Patients and methodsWe describe our experience with 8 infants, with ages ranging from 3 to 9 months, weighing from 4.5 to 7.7 kilograms, who presented in the up to 18 days following construction of a shunt from the superior caval vein to the pulmonary arteries with clinical symptoms of obstructed pulmonary flow. We include also 2 infants in whom pulmonary arterial stents were implanted in the operating room. Cardiac catheterization showed significant stenoses or occlusion of the left pulmonary arteries in 9 infants, the right pulmonary arteries in 2, or the superior caval vein in 1, the investigation being prompted by the findings of supraphysiological superior caval venous pressures and systemic hypoxaemia. We implanted a variety of stents mounted on balloons ranging in diameter from 6 to 13 millimetres, with 7 placed across a newly created surgical anastomotic site.ResultsAll stenoses were crossed successfully, and stents implanted satisfactorily in all patients, albeit that 1 infant suffered an acute tear of the left pulmonary artery, requiring immediate reoperation. This patient died 72 hours later due to a diffuse coagulopathy. All other patients demonstrated sustained clinical improvement following the procedure. At follow-up, 7 of the 9 survivors have progressed to completion of the Fontan circulation. Redilation of the stents was required in the interim, prior to completion of the Fontan circulation, in 4 of them. In 2 patients, the previously implanted stents were incised during the Fontan completion, permitting placement of the extracardiac Goretex conduit from the inferior caval vein to the pulmonary arteries.ConclusionsStents can successfully be implanted perioperatively in the pulmonary arterial system during infancy, and redilated, with improvement in clinical outcome in the majority of those with clinically relevant obstruction.

There are few data on successful recanalization of acutely occluded modified aortopulmonary shunts in infants in whom the major component of pulmonary flow is shunt-dependent.Seven infants (age range 6 days to 7 months) with modified (polytetrafluoroethylene) aortopulmonary shunts (central shunt n = 6, modified Blalock-Taussig shunt n = 1), in whom acute shunt occlusion was documented following surgery (interval from shunt surgery 2-6 days) underwent emergency cardiac catheterization with a view to reopening the shunt. Anterograde right ventricle to pulmonary artery flow was present in three patient; two other had additional aortopulmonary collateral vessels, and intravenous prostaglandin E (PGE1) infusion was restarted in three infants to achieve or maintain ductal patency. All occluded shunts could be crossed with a 4F endhole catheter and various guidewire combinations. Balloon dilation was performed using a balloon with the same nominal diameter as the shunt (5 or 6 mm).All shunts were successfully recanalized. Two infants with recurrent cyanotic episodes underwent stent implantation in the right ventricular outflow tract (RVOT) during the same procedure. One infant required shunt revision 24 h following balloon angioplasty, during which a small clot was evacuated from the distal end of the shunt. An immediate improvement in oxygen saturation could be documented in all patients. In the remaining six infants, shunt patency was confirmed at follow-up, until further definitive repair. One infant died of non-cardiac causes, while awaiting definitive repair.This small series demonstrates that acutely occluded shunts can be successfully recanalized, and that patency can be maintained until further definitive surgery in the majority of infants.

The Mustard operation for transposition of the great arteries is associated with good long-term survival. Typical complications at follow-up include progressive loss of sinus node function requiring permanent pacemaker implantation, and systemic venous pathway obstruction often precluding a transvenous approach to pacing. We report on 7 patients (median age 14.1; range 5-19) with bradyarrhythmia requiring permanent pacemaker implantation with associated stenosis (n = 6) or occlusion (n = 1) of the superior vena cava, in whom stent implantation relieved the obstruction and facilitated subsequent transvenous permanent pacing. In five of them stenting and pacemaker implantation were performed during a single procedure; two patients underwent elective pacemaker implantation 6 weeks later. In one patient the pacemaker had to be explanted due to pacemaker pocket infection. In the others the follow-up has been uneventful, with excellent chronic pacing thresholds and appropriate sensing. Two patients have had their generator replaced electively.We conclude that stenting of the SVC stenosis allows implantation of transvenous pacemaker leads with good intermediate term results in patients with a Mustard operation for transposition of the great arteries.

BackgroundDespite meticulous investigation of bypass techniques for deep hypothermic circulatory arrest, unfavorable long-term neurologic deficits have been well documented. Our aim was to improve brain perfusion by reducing platelet plugging with a glycoprotein IIb/IIIa inhibitor (eptifibatide) in an experimental model of deep hypothermic circulatory arrest–reperfusion in pigs.MethodsTwo groups of 12 piglets each (eptifibatide group [eptifibatide + unfractionated heparin] vs UFH group [only unfractionated heparin]) underwent 10 minutes of normothermic bypass, 40 minutes of cooling during cardiopulmonary bypass (hematocrit, 30%; cardiopulmonary bypass flow, 100 mL·kg−1·min−1), 60 minutes of circulatory arrest at 15°C, and a 40-minute rewarming period. Intravital fluorescence microscopy of pial vessels at set intervals was performed.ResultsDuring the cooling period, there was a tendency toward reduced functional capillary density values without statistical significance in both groups. During reperfusion, the eptifibatide group demonstrated a significantly decreased platelet adhesion and aggregation (at 30 minutes of reperfusion: functional capillary density, 104% ± 3% vs 77% ± 4% relative to baseline, P = .02; red blood cell velocity, 0.65 vs 0.30 mm/s, P < .004). A more rapid recovery of tissue oxygenation (P < .001) was documented. Furthermore, a significant microvascular permeability reduction was achieved compared with that seen in the UFH group (P < .02). The use of eptifibatide resulted in fewer ultrastructural changes in hippocampal tissue, which is demonstrated by histologic examination.ConclusionsPlatelet plugging reduction with the glycoprotein IIb/IIIa inhibitor eptifibatide improves cerebral capillary blood flow and reduces cerebral ischemia in the setting of deep hypothermic circulatory arrest. Furthermore, significant endothelial cell injury and perivascular edema reduction can be achieved.

Background The purpose of this study was to develop a specific postoperative score for intensive care unit (ICU) cardiac surgical patients for assessment of organ dysfunction and survival. Methods This prospective study consisted of all consecutive adult patients admitted after cardiac surgery to our ICU over a period of 3 years. Evaluation of variables was performed using the first year patients who stayed in the ICU for at least 24 hours. The reproducibility was then tested in two validation sets using all patients. Performance was assessed with the Hosmer-Lemeshow (χ 2 statistics) goodness-of-fit test and receiver operating characteristic (ROC) curves and compared with the Acute Physiology and Chronic Health Evaluation (APACHE II) and Multiple Organ Dysfunction Score (MODS). Results A total of 3,230 patients were admitted to the ICU after cardiac surgery. Mean χ 2 values for the new score were 5.8 (APACHE II, 11.3; MODS, 9.7) for the construction set, 7.2 (APACHE II, 8.0; MODS, 4.5) for the validation set I, and 5.9 for the validation set II. The mean area under the ROC curve was 0.91 (APACHE II, 0.86; MODS, 0.84) for the new score in the construction set, 0.88 (APACHE II, 0.84; MODS, 0.84) in the validation set I, and 0.92 in the validation set II. Conclusions Our new 10-variable risk index performs very well, with calibration and discrimination very high, better than general severity systems; and it is an appropriate tool for daily risk stratification in ICU cardiac surgery patients. Thus, it may serve as an "expert system" for diagnosing organ failure, decision making, resource evaluation, and predicting mortality among ICU cardiac surgical patients.

Das Ziel dieser Studie war die Entwicklung eines spezifischen Schweregradklassifizierungssystems fur die Beurteilung und Vorhersage von Organfunktionsstorungen und Uberleben bei herzchirurgischen Intensivpatienten. Hierzu wurden konsekutiv alle erwachsenen Patienten nach einem herzchirurgischen Eingriff unter Einsatz der Herzlungenmaschine uber einen Zeitraum von 3 Jahren in die Studie aufgenommen. Im Konstruktionsset erfolgte die Auswahl der Variablen mit Hilfe der Patienten, die mindestens 24 Stunden auf der Intensivstation verbrachten. Die Ergebnisse wurden dann in zwei Validierungssets mit allen Intensivpatienten uberpruft. Die Qualitat des Scores wurde mit dem Hosmer-Lemeshow-Test (HL) sowie der ROC-Analyse beurteilt, und mit dem APACHE-II- und dem MODS-Score verglichen. Insgesamt wurden 3230 Patienten uber einen Zeitraum von 3 Jahren auf unserer Intensivstation aufgenommen. Die HL-Werte fur den neuen Score waren 5,8 (APACHE-II: 11,3; MODS: 9,7) fur das Konstruktionsset, 7,2 (APACHE-II: 8,0; MODS: 4,5) fur das Validierungsset I und 5,9 fur das Validierungsset II. Die Flache unter der ROC-Kurve war 0,91 (APACHE-II: 0,86; MODS: 0,84) fur den neuen Score im Konstruktionsset, 0,88 (APACHE-II: 0,84; MODS: 0,84) in dem Validierungsset I, und 0,92 in dem Validierungsset II. Der neue CASUS (Cardiac Surgery Score) zeigt fur herzchirurgische Intensivpatienten eine exzellente Kalibrierung und Diskriminierung bezuglich der 30-Tage-Letalitat. Die Variablen des CASUS sind einfach, reproduzierbar und werden routinemasig in herzchirurgischen Intensivstationen erfasst. Der CASUS konnte als Expertensystem fur das Diagnostizieren von Organfunktionsstorungen, der Entscheidungsfindung, der Ressourcenauswertung und Vorhersage der Letalitat fur herzchirurgische Intensivpatienten dienen.

We describe transcatheter therapy for early onset occlusion or stenoses of extracardiac conduits in three children who had undergone Fontan completion. Successful stent implantation was associated with complete resolution of symptoms.

A 10-month-old infant with severe tricuspid valve disease due to staphylococcal bacterial endocarditis, underwent surgical replacement of the valve. The new valve was fashioned using an autologous pericardial patch. Over 3 years of follow-up, the new valve has functioned satisfactorily, with moderately elevated right atrial pressure.

ObjectiveA variety of devices are available for transcatheter closure of unwanted shunts. We describe our experience with the use of the Amplatzer vascular plug IV in a consecutive series of infants.MethodsA total of eight consecutive infants – all born preterm at gestational ages ranging from 24 to 35 weeks – undergoing transcatheter closure of unwanted shunts – persistently patent arterial duct in five patients, an aorta to right atrium fistula in one, multiple aortopulmonary collateral vessels in one, and an azygos vein to left atrium connection in one – are described. Their age, from birth, ranged between 3 and 11 months, and weight between 2.6 and 11.3 kilograms. All devices were delivered using percutaneous arterial or venous vascular access via a large lumen (0.038 inch) 4-French delivery catheter.ResultsAll lesions could be successfully occluded using one or more devices. Device diameters ranged between 4 and 8 millimetres, and exceeded the minimum diameter of the target vessel by 1 to 2 millimetres. Successful occlusion was confirmed either directly at angiography or on follow-up echocardiography. Of the infants who were mechanically ventilated prior to the procedure, three could be successfully weaned following closure of the shunt. There were no procedure-related complications.ConclusionsThe new vascular plug IV is cheap and efficacious in closing a variety of shunts in young infants, and warrants further extended clinical application.

In this study we investigated the postnatal developmental changes in sarcomeric protein expression in parallel with contractile parameters in myofibrils isolated from small resections from the right ventricular (RV) outflow tract in 25 patients with Tetralogy of Fallot and related congenital heart diseases (CHD). These CHDs are associated with RV hypertrophy and outflow tract obstruction. The age of the patients ranged from 4 days to 38 months. The resections were procured during surgical correction of the cardiac malformation and would have been otherwise discarded. In the neonate (4 days old), the expression of slow skeletal TnI (ssTnI) and atrial light chain (ALC-1) was ∼82% and ∼50% respectively and declined to respectively < ∼8% and ∼3% at the age of 38 months. This down-regulation in ssTnI and ALC-1 expression correlated (p

Little is known about the outcome of acute thrombotic occlusion of segments of the cavopulmonary connections (CPC) in infants and children with univentricular hearts. Early recognition and aggressive therapy may result in successful salvage of some of these patients. Five consecutive patients (age range 4-8 months) presenting with acute occlusion of a CPC segment underwent emergency cardiac catheterization. After angiographic confirmation, the occluded segment was crossed using an endhole catheter and guidewire combination. Serial balloon dilation and stent implantation (ten stents in total) were undertaken to recanalize the occlusion. The stents used were mounted on balloons ranging in diameter from 6 mm to 8 mm, depending on the size of the native vessel. The sites of occlusion were the left pulmonary artery (n=4), and the left-sided superior caval vein (n=3). All occlusions could be successfully recanalized. In three patients, early reocclusion necessitated either surgery or repeat catheterization and angioplasty. There were two early deaths, due to recurrent thrombotic obstruction confirmed either at autopsy or angiography. The remaining patients are alive and well; the majority of survivors have undergone completion of the Fontan operation. A high index of clinical suspicion combined with aggressive therapy can result in successful recanalization in some infants with acutely occluded CPC segments, with acceptable long-term outcome.

A neonate weighing 2.8 kilograms underwent the staged hybrid procedure for palliation of hypoplastic left heart syndrome. Within 6 hours following placement of a stent to retain patency of the interatrial communication, the infant developed second degree atrioventricular block, which resolved within 24 hours. Four days later, the patient developed complete atrioventricular dissociation. Removal of the stent was followed by recovery of atrioventricular conduction.

Severe myocardial dysfunction after blunt head injury is a rare but potentially lethal complication. We describe remarkable myocardial recovery after severe hemodynamic deterioration in a young man with brain injury, due to extracorporeal membrane oxygenation support. Because of the severity of brain damage, the patient succumbed after diagnosis of brain death. Postmortem histopathological examination of the heart showed severe myocardial necrosis.

Neurological impairments following cardio-pulmonary bypass (CPB) during open heart surgery can result from microembolism and ischaemia. Here we present results from monitoring cerebral hemodynamics during CPB with near infrared spatially resolved spectroscopy. In particular, the study has the objective (a) to monitor oxy- and deoxyhemoglobin concentrations (oxy-Hb, deoxy-Hb) and their changes during CPB surgery and (b) to develop and test algorithms for the calculation of these parameters from broad band spectroscopy. For this purpose a detection system was developed based on a lens imaging spectrograph designed to optimise sensitivity of recorded reflectance spectra for wavelengths between 600 and 1000 nm. Two independent detector channels for both cerebral hemispheres each with three source-detector distances are used. It is demonstrated that the system does record cerebral oxygenation parameters during CPB in infants with a significant decrease in oxygen saturation SO2 during cardiac arrest. The methodological focus is on an error estimation of the haemoglobin concentrations and separation of cerebral from skin signals. The depth sensitivity profile of the set-up is estimated with a layered structure model of tissue and Monte Carlo methods for the description of the photon propagation.

Percutaneous replacement of the tricuspid valve with a bovine jugular venous valve (melody valve) was successfully undertaken in a 9-year-old boy. The patient had a previous history of bacterial endocarditis of the native tricuspid valve in infancy. Initially, a pericardial patch valve was created, followed by surgical replacement of the valve using a biological tissue valve at 4 years of age. Progressive stenosis and regurgitation of the biological valve, with severe venous congestion and resulting hepatic dysfunction prompted percutaneous valve replacement.