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Background: The dynamic behavior of the aortic sinuses has an important function in the specific characteristics of coronary blood flow. Several publications have confirmed suboptimal myocardial perfusion after the Norwood procedure. Our study was undertaken to confirm four hypotheses. First, we hypothesized that there is more resistance to coronary flow due to coronary attachments to hypoplastic aortic root and sinuses. Also, as the amalgamation of the ascending aorta with the pulmonary artery occurs above the aortic root, the coronary blood flow is not fully in antegrade pattern. Second, performing the Norwood with our modification i.e., coronary transfer to the well-developed sinuses of the pulmonary root will result in less resistance to flow and a full antegrade flow pattern. This may eventually improve the long term ventricular and survival outcomes. Third, our modification is applicable to all procedures where the pulmonary root supplies the systemic circulation e.g., Norwood, Damus–Kaye–Stansel (DKS), and Yasui operations, whether applied to single or biventricular repair. Fourth, with our modification, the effect of the type of shunt; Sano vs. Blalock Taussig (BT shunt) on the coronary flow after the Norwood will be mitigated. This will give the surgeon more freedom to which shunt to use, and may make the surgeon keener to perform the BT shunt in order to avoid the ventricular scar associated with the Sano shunt which will negatively impact the ventricular function. Methods: Computational fluid dynamic (CFD) simulations were performed to evaluate flow streamlines and to quantify flow distribution and total pressure drop in the coronary branches in both Norwood (pre-transfer) and modified Norwood (post-transfer) models. Comparisons between the two models were performed. Results: The systolic flow rate in all coronary branches was higher in the post-transfer model in the proportions of: left main 5%, left anterior descending (LAD) 6%, left circumflex (LCx) 3.5%, and right coronary artery (RCA) 7.2% higher flow rates. In diastole, pressure drop from the aortic inlet to distal left main and distal right main was substantially less in the post-transfer model. Conclusion: Post-transfer model has produced more favorable coronary hemodynamics in all coronary branches. As a result, performing our modification could potentially improve the long term ventricular and survival outcomes.

Objectives To evaluate the durability of aortic valve (AoV) repair relative to other strategies for children with significant aortic insufficiency (AI). Methods From 2001 to 2012, 90 children with greater than or equal to moderate AI underwent surgery. Resulting procedures were classified according to final operative outcome: AoV repair (repair; n = 46, 51%), Ross procedure (Ross; n = 21, 23%) or replacement with mechanical or tissue prosthesis [aortic valve replacement (AVR); n = 23, 26%]. Repeated measures (n = 1081 echocardiograms) mixed-model analysis and parametric multiphase risk-adjusted hazard analysis were used to evaluate haemodynamic parameters and durability of operations. Results Mean age at operation was similar for repair and Ross groups, but slightly higher for the AVR group (10.6, 11 and 13.2, respectively; P = 0.04). Baseline annular dimensions were similar among groups. Of 46 repairs, 85% involved pericardial leaflet extensions (commonly with leaflet shaving and/or commisuroplasty). The remaining repairs were commissuroplasties. On multivariable analysis, repair was associated with increased early (∼1-2 years) AI and increased outflow tract peak pressure gradients relative to Ross and AVR procedures. On univariate analysis, repairs tended to have a larger annulus size compared with Ross or AVR; however, this was not significant on multivariable analysis. There were 25 reinterventions (surgical reoperation = 16; transcatheter intervention = 9) for 22 children. Freedom from surgical reoperation was 64, 100 and 51% at 6 years for repairs, Ross and AVR, respectively (P = 0.05); however, three of five reoperations after AVR were for failed bioprosthetic devices. The freedom from reintervention was not significantly influenced by the type of AoV operation (P = 0.43). Conclusions Durability of aortic valve repair for children is limited by recurrence of AI and/or stenosis, often within the first few years. After repair, reoperation should be anticipated within ∼7 years.

Several procedures have been introduced to manage this complex congenital heart malformation. It is not clear that any one approach is best for all patients. Decision-making for a given patient may be influenced by multiple patient factors. There is little doubt that surgeon and institutional experience and preference also play a role. We have focused our survey on three procedures, i.e., the Rastelli, Nikaidoh (aortic root translocation), and réparation à l'étageventriculaire (REV) procedures. The questionnaire was directed to all Congenital Heart Surgeon Society member surgeons. A total of 61 clinical practitioners responded to our survey. Of them, 45 (73.8 %) were staff congenital heart surgeons, 11 (18 %) were staff pediatric cardiologists, 1 (1.6 %) was a staff adult congenital cardiologist, 1 (1.6 %) was a fellow pediatric cardiologist, 2 (3.3 %) were fellow or resident congenital heart surgeons, and 1 (1.6 %) was a nurse practitioner. Most respondents believe that the Rastelli procedure should be considered the first option (n = 28, 45.9 %), while 24 (39.3 %) respondents believe that the Nikaidoh procedure should be considered the first option. Asked "To which surgeon do you prefer to refer your patient" (one who will perform Rastelli, Nikaidoh, or REV), all staff cardiologists (n = 12, 100 %) responded "doesn't matter." This survey revealed a wide diversity among clinical practitioners in terms of management of patients with TGA/VSD/LVOTO and preferred surgical approaches. A multi-institutional study of surgical management of TGA/VSD/LVOTO may help to define principles for optimal matching of procedures to patients.

Objective Primary coronary artery bypass grafting (CABG) is performed routinely in elderly patients with good results. However, the risk profile and outcomes of reoperative CABG in elderly patients are not well defined. Our purpose was to study the risk profile and hospital outcomes of isolated reoperative CABG in elderly patients (75 years and older) compared to isolated primary CABG in the same age group. Methods Between January 1990 and December 2010, 3483 elderly patients (age ≥ 75 years) underwent isolated CABG at our institution. Of these, 129 (3.7%) underwent reoperative CABG. Data were prospectively collected in a computerized database. Independent predictors of hospital mortality were determined by multivariable logistic regression. Results Hospital mortality was 3.2% and 8.5% (p

Primary coronary artery bypass grafting (CABG) is performed routinely in elderly patients with good results. However, the risk profile and outcomes of reoperative CABG in elderly patients are not well defined. Our purpose was to study the risk profile and hospital outcomes of isolated reoperative CABG in elderly patients (75 years and older) compared to isolated primary CABG in the same age group.Between January 1990 and December 2010, 3483 elderly patients (age ≥ 75 years) underwent isolated CABG at our institution. Of these, 129 (3.7%) underwent reoperative CABG. Data were prospectively collected in a computerized database. Independent predictors of hospital mortality were determined by multivariable logistic regression.Hospital mortality was 3.2% and 8.5% (p 0.001) in elderly patients in the primary group and reoperative group, respectively. Perioperative myocardial infarction (MI) occurred in 2.9% and 8.5% (p 0.001), and low cardiac output syndrome (LCOS) occurred in 6.2% and 20.9% (p 0.001) of patients in the primary group and reoperative group, respectively. The prevalence of perioperative MI was threefold higher in elderly patients undergoing reoperative CABG with antegrade cardioplegia alone (11.5%) compared to combined antegrade/retrograde cardioplegia (3.9%). Additionally, mortality was higher in elderly patients undergoing reoperative surgery with use of antegrade cardioplegia alone (12.8% vs. 2%, p = 0.03). Combined use of antegrade and retrograde cardioplegia was independently protective from mortality in the reoperative group (OR = 0.10; p = 0.03).Elderly patients undergoing reoperative CABG have an approximately threefold increase in the risk of mortality compared to elderly patients undergoing primary CABG. The higher risk of mortality is primarily driven by a higher rate of perioperative MI and LCOS. Combined use of antegrade and retrograde cardioplegia was associated with lower perioperative MI and lower mortality.

In this report we present a 43-year-old male with achondroplastic dwarfism who presented with acute Type A aortic dissection with aortic insufficiency. The patient underwent successful Bentall and hemiarch repair. Anesthetic, perfusion-related, and surgical planning and execution are presented.

BACKGROUND: In older children with severe aortic insufficiency (AI), a strategy of aortic valve REPAIR is often pursued in order to delay ROSS procedure or aortic valve replacement with a mechanical/bioprosthetic device (AVR). We aimed to test this strategy of valve REPAIR by evaluating its durability. METHODS: From 2001-2012, 90 children with severe AI underwent: REPAIR (N1⁄446, 51%), ROSS (N1⁄421, 23%) or AVR (N1⁄423, 26%). Repeated measures (N1⁄41081 echos) mixed model analysis were used to evaluate haemodynamic outcomes. RESULTS: Mean age at operation was identical for REPAIR and ROSS (11 years), but slightly older for AVR (13 years). Annular dimensions were largest for REPAIR versus either AVR or ROSS (P1⁄4.01, figure). Cardiopulmonary bypass times were significantly shorter for REPAIRS versus either ROSS or AVR (figure, P