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CD25, the alpha chain of the IL-2 receptor, is expressed on activated effector T cells that mediate immune graft damage. Induction immunosuppression is commonly used in solid organ transplantation and can include antibodies blocking CD25. However, regulatory T cells (Tregs) also rely on CD25 for their proliferation, survival, and regulatory function. Therefore, CD25-blockade may compromise Treg protective role against rejection. We analysed in vitro the effect of basiliximab (BXM) on the viability, phenotype, proliferation and cytokine production of Treg cells. We also evaluated in vivo the effect of BXM on Treg in thymectomized heart transplant children receiving BXM in comparison to patients not receiving induction therapy. Our results show that BXM reduces Treg counts and function in vitro by affecting their proliferation, Foxp3 expression, and IL-10 secretion capacity. In pediatric heart-transplant patients, we observed decreased Treg counts and a diminished Treg/Teff ratio in BXM-treated patients up to 6-month after treatment, recovering baseline values at the end of the 12-month follow up period. These results reveal that the use of BXM could produce detrimental effects on Tregs, and support the evidence suggesting that BXM induction could impair the protective role of Tregs in the period of highest incidence of acute graft rejection.

Background: Collaboration between cardiac surgeons and cardiologists can offer interventions that each specialist may not be able to offer on their own. This type of collaboration has been demonstrated with the hybrid Stage I in patients with hypoplastic heart syndrome. Since that time, a hybrid approach to cardiac interventions has been expanded to an incredible variety of potential indications.Methods: Seventy-one patients were scheduled for a hybrid procedure along 8 years. This was defined as close collaboration between surgeon and cardiologist working together in the same room, either cath-lab (27 patients) or theater (44 patients).Results: Six groups were arbitrarily defined. A: vascular cut-down in the cath-lab (27 neonates); B: bilateral banding (plus ductal stent) in hypoplastic left heart syndrome or alike (15 children); C: perventricular closure of muscular ventricular septal defect (10 cases); D: balloon/stenting of pulmonary branches along with major surgical procedure (12 kids); E: surgical implantation of Melody valve (six patients) and others (F, one case). Two complications were recorded: left ventricular free wall puncture and previous conduit tearing. Both drawbacks were successfully sort out under cardiopulmonary by-pass.Conclusion: Surgeon and cardiologist partnership can succeed where their isolated endeavors are not enough. Hybrid procedures keep on spreading, overcoming initial expectations. As a bridge to biventricular repair or transplant, bilateral banding plus ductal stent sounds interesting. Novel indications can be classified into different groups. Hybrid procedures are not complication-free.

Objectives We sought to determine the indications, type, and outcomes of reoperations on the aortic root after repair of tetralogy of Fallot (TOF). Methods Eleven centers belonging to the European Congenital Heart Surgeons Association contributed to the data collection process. We included 36 patients who underwent surgical procedures on the aortic root, including surgery on the aortic valve and ascending aorta, between January 1975 and December 2017. Original diagnoses included TOF-pulmonary stenosis (n = 18) and TOF-pulmonary atresia (n = 18). The main indications for reoperation were aortic insufficiency (n = 19, 53%), aortic insufficiency and dilatation of the ascending aorta (n = 10, 28%), aortic root dilatation (n = 4, 11%), and ascending aorta dilatation (n = 3, 8%). Results The median age at reoperation was 30.4 years (interquartile range 20.3-45.3 years), and mechanical aortic valve replacement was the most common procedure performed. Five patients died early after reoperation (14%), and larger ascending aorta diameters were associated with early mortality (P = .04). The median age at the last follow-up was 41.4 years (interquartile range 24.5-51.6 years). Late death occurred in five patients (5/31, 16%). Most survivors (15/26, 58%) were asymptomatic at the last clinical examination (New York Heart Association, NYHA class I). The remaining patients were NYHA class II (n = 7) and III (n = 3). The most common symptoms were fatigue (n = 5), dyspnea (n = 4), and exercise intolerance (n = 3). Conclusions Reoperations on the aortic root are infrequent but may become necessary late after TOF repair. The main indications for reoperation are aortic insufficiency, either isolated or associated with a dilatation of the ascending aorta. The surgical risk at reoperation was high and the presence of ascending aorta dilation is related to higher mortality.

Background: Mid-line sternotomy is the commonest incision for cardiac surgery. Alternative approaches are becoming fashionable in many centres, amidst some reluctance because of learning curves and overall complexity. Our recent experience in starting a new program on minimally invasive pediatric cardiac surgery is presented. The rationale for a stepwise onset and the short-medium term results for a three-year span are displayed. Methods: A three-step schedule is planned: First, an experienced surgeon (A) starts performing simple cases. Second, new surgeons (B, C, D, E) are introduced to the minimally invasive techniques according to their own proficiency and skills. Third, the new adopters are enhanced to suggest and develop further minimally invasive approaches. Two quality markers are defined: conversion rate and complications. Results: In part one, surgeon A performs sub-mammary, axillary and lower mini-sternotomy approaches for simple cardiac defects. In part two, surgeons B, C, D and E are customly introduced to such incisions. In part three, new approaches such as upper mini-sternotomy, postero-lateral thoracotomy and video-assisted mini-thoracotomy are introduced after being suggested and developed by surgeons B, C and E, as well as an algorithm to match cardiac conditions and age/weight to a given alternative approach. The conversion rate is one out of 148 patients. Two major complications were recorded, none of them related to our alternative approach. Four minor complications linked to the new incision were registered. The minimally invasive to mid-line sternotomy ratio rose from 20% in the first year to 40% in the third year. Conclusions: Minimally invasive pediatric cardiac surgery is becoming a common procedure worldwide. Our schedule to set up a program proves beneficial. The three-step approach has been successful in our experience, allowing a tailored training for every new surgeon and enhancing the enthusiasm in developing further strategies on their own. Recording conversion-rates and complications stands for quality standards. A twofold increase in minimally invasive procedures was observed in two years. The short-medium term results after three years are excellent.

We present the case studies of two adult patients with tetralogy of Fallot who were scheduled for surgery. After addressing the right ventricular outflow tract obstruction, the aorta was opened and the ventricular septal defect was approached in a straightforward manner as it was located just under the overriding aortic valve. The second patient presented with was a situs inversus, dextroapex Fallot. In this setting, the aortic approach simplified the repair expeditiously. After 2 years, both patients are in New York Heart Association class I, with no residual ventricular septal defect, no aortic regurgitation, and complete relief of right ventricular outflow tract obstruction.

A 2-kilogram child had a pacemaker implanted by a subxyphoid approach with the generator located under the rectus sheath. Days later, the battery eroded the abdominal wall and the peritoneum. The whole system was removed and a new one was implanted inside the pericardium on an emergent basis.

Right-sided lesions occur in 5-25% of patients after arterial switch operation (ASO) and percutaneous or surgical treatments are available (although they are not complication-free).

Orthotopic heart transplantation after univentricular palliation presents a difficult challenge due to the complex anatomy and prior surgeries.

A need persists for Fontan conversion (classical Fontan to total cavopulmonary connection (TCPC)) that provides alternative approaches for the individual anatomical challenges occurred in these unusual and complex congenital grown-up patients.

ResumenIntroducción y objetivosEl trasplante cardiaco tras un Fontan supone un reto quirúrgico. Presentamos a 10 pacientes, destacando las variantes técnicas en las anastomosis previas a la implantación del injerto.MétodosRecogemos 8 casos de Fontan y 2 «take-down» consecutivos durante 32 meses, con medianas de edad (9 años), peso (30 kg) e intervalo entre Fontan y trasplante de 3 años. Siete pacientes presentaban conducto extracardiaco (diámetro 18/20), 2 conexión aurículo-pulmonar y uno, túnel lateral. Tres niños desarrollaron enteropatía pierde-proteínas. Nueve «stents» fueron implantados previamente.ResultadosHubo modificaciones en las 5 anastomosis. Una vez en la aurícula izquierda (sutura en ambas aurículas del receptor), 2 en la aorta (hemiarco), 2 en vena cava superior (plastia en vena innominada), 7 veces en la arteria pulmonar (parche de aorta/pericardio donante de hilio a hilio tras retirada de «stents»), vena cava inferior en 7 ocasiones (manguito de conducto). El seguimiento fue completo con una mediana de 25 meses (rango 3-34). Un paciente falleció. Dos precisaron extracorporeal membrane oxygenation por hipertensión pulmonar. Tres pacientes requirieron cierre de colaterales en hemodinámica, incluyendo colocación de «stent» en cava superior (1) y aorta (1). Se resolvió la enteropatía pierde-proteínas en 2 pacientes.ConclusionesTrasplantar a pacientes con Fontan previo es un reto. Podemos anticipar variantes en cada una de las 5 anastomosis previstas. Es recomendable obtener tejido extra del donante (aorta y arco, vena cava superior e innominada, pericardio). Los resultados pueden superponerse a otras series de trasplante cardiaco.AbstractIntrodcution and objectivesHeart transplantation after a Fontan procedure poses a unique challenge from a surgical point of view. The cases of ten patients are presented, stressing the technical variations performed in the five anastomoses in order to match the graft in the recipient.MethodsEight Fontan and two takedown patients were included over 32 consecutive months. The median age was 9 years, median weight was 30 Kg, with a median time interval of 3 years between Fontan and transplant. An extra-cardiac conduit (size 18/20) was implanted in seven patients, whereas an atriopulmonary connection was found in two, and lateral tunnel in one. Three patients developed protein-losing enteropathy. Nine stents were previously implanted.ResultsThe five anastomoses underwent some changes. Left atrium once (enlargement with recipient both atria), aorta twice (hemi-arch repair), superior vena cava twice (innominate donor plasty), pulmonary branches seven times (hilum to hilum plasty with donor aorta/pericardium patch after complete stent removal), and inferior vena cava seven times (conduit sleeve anastomoses). The patients were followed-up for a median of 25 months (range 5-34). One patient died. Extracorporeal membrane oxygenation was needed in two cases due to pulmonary hypertension. Three patients had collateral vessels occluded in the catheter laboratory, and stents placed in superior vena cava (1) and aorta (1). The protein-losing enteropathy was resolved in two children.ConclusionsTransplant in Fontan patients is currently challenging. Variations in each of the five proposed anastomoses must be anticipated. Extra tissue from the donor (innominate vein, aortic arch, pericardium) is strongly advisable. Overall results can match other transplants cohorts.

IntroducciónDesde el inicio de la revascularización coronaria sin circulación extracorpórea (sin CEC) en nuestro servicio la presencia de estenosis significativa (> 50%) del tronco común (TC) se consideró como una contraindicación a dicho procedimiento. No obstante, a partir del año 2001 la lesión de TC no fue un factor de exclusión para la técnica.Material y métodoDesde enero de 2001 hasta noviembre de 2002 se han intervenido 125 pacientes afectos de estenosis significativa del TC, 59 bajo CEC y 66 sin CEC. Se han recogido datos preoperatorios y postoperatorios en las bases de datos PATS y Apollo. Los datos se han analizado mediante el programa SPSS.ResultadosAmbos grupos presentaban características preoperatorias similares: sexo 88,1 vs 83,3% varones, edad 64,56 vs 66,65 años, grado funcional (CCS) III–IV 63,6 vs 70%, revascularización urgente 44,8 vs 49,2%, factores de riesgo (tabaquismo, HTA, diabetes mellitus, dislipemia, insuficiencia respiratoria e insuficiencia renal) y fracción de eyección (64,93 vs 59,89%). No han existido diferencias significativas en cuanto a mortalidad hospitalaria (3,5 vs 6,1%), número de injertos/ paciente (2,59 vs 2,86), hemorragia postoperatoria (773 vs 798 ml), transfusión concentrado hematíes (2,39 vs 2,11 unidades), estancia en UCI (2,88 vs 3,57 días) y estancia hospitalaria (11,14 vs 9,89 días).ConclusionesLos resultados en ambos grupos han sido similares, por lo que, en la actualidad, la existencia de estenosis del TC no condiciona la técnica de revascularización miocárdica quirúrgica con o sin CEC, quedando su elección a criterio del cirujano.IntroductionThe presence of severe left main coronary (LMCA) stenosis (> 50%) has been considered a contraindication for off-pump surgical revascularization at our department. We have already changed this approach after January 2001.MethodsFrom January 2001 to November 2002, 125 consecutive patients with severe LMCA stenosis were operated on. Fifty-nine patients were operated on-pump and 66 off-pump. Pre-, intra- and postoperative variables were evaluated. The SPSS software was used for the study analyses.ResultsBoth groups had similar preoperative data: 88.1 vs. 83.3% males, age 64.65 vs. 66.65% years, functional status (CCS) III–IV 63.3 vs. 70%, urgent treatment 44.8 vs. 49.2%, risk factors (smoking, hypertension, diabetes mellitus, hypercholesterolemia, respiratory failure and renal failure) and ejection fraction (64.93 vs. 59.89%). Hospital mortality 3.5 vs. 6.1%, number of grafts/patient 2.59 vs. 2.86, blood loss 773 vs. 798 ml, blood transfusion requirement 2.39 vs. 2.11 units, intensive care unit stay 2.88 vs. 3.57 days and hospital stay 11.14 vs. 9.89 days, did not show any statistical significance.ConclusionsThe results have been very similar. In our experience severe LMCA lesion does not condition the surgical approach. The decision is left to the discretion of the surgeon.

ResumenEn este capítulo se realizará una revisión general sobre la patología cardíaca derivada de los defectos de septación simples a diferentes niveles (auricular, ventricular y grandes arterias) con cortocircuitos predominantemente izquierda-derecha.AbstractA systematic review will be done in this chapter about general aspects in the field of simple septation defects with predominant left-to-right shunt, at different anatomic levels (atrium, ventricle and great arteries)

ResumenLa atresia pulmonar es una cardiopatía congénita compleja caracterizada por la falta de continuidad entre el ventrículo derecho y la arteria pulmonar. Cuando se asocia a comunicación interventricular y arterias colaterales aortopulmonares mayores supone un reto quirúrgico que puede precisar diferentes vías de abordaje en distintos tiempos quirúrgicos, como el caso presentado.AbstractPulmonary atresia is a complex congenital heart disease characterized by the lack of continuity between the right ventricle and pulmonary artery. Pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries remain as a surgical challenge and may require staged surgical approaches, as in the case presented.