Anesthetic Management of the Resection of a Kommerell’s Diverticulum.

Anesthetic Management of the Resection of a Kommerell’s Diverticulum.

Bhandary SP, Papadimos TJ, Svensson LG, Sale S.

J Cardiothorac Vasc Anesth. 2015 Feb;29(1):142-5. doi: 10.1053/j.jvca.2013.08.010. Epub 2013 Dec 13. No abstract available.

PMID: 24332920 [PubMed – in process]

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Comment from Dr. Hafil B. Abdulgani (Indonesia), section editor of Congenital Heart Surgery Journal Watch: The Kommerell’s diverticulum is an abnormal remnant of the left aortic arch and presents itself as an aneurysmal dilation of the proximal aberrant left or right subclavian artery. It is associated with congenital anomalies of the aortic arch such as a double aortic arch, left-sided arch with aberrant right subclavian or right-sided arch with aberrant left subclavian artery. A right-sided arch is formed by the right fourth pharyngeal arch and abnormal persistence of the right dorsal aorta. In this case report, incomplete regression of the distal left aortic arch between the left common carotid and the left subclavian artery represents the Kommerell’s diverticulum with an aberrant left subclavian artery taking off (described by cartoon drawing below).

FIG4_DEVELOP_NORMAL AORTA_

 

Comprehensive preoperative anesthetic evaluation for coexisting cardiac anomalies along with perioperative anesthetic concerns, such as the airway, lung isolation, and extubation were described. Airway evaluation should include lower airway anatomy with potential chronic external compressive effects. Secondary bronchomalacia might exist and posed difficulties in lung isolation and extubation. It was advisable to perform bronchoscopy under anesthesia after induction to ascertain distal airway compression and formulate a plan for airway management. The authors’ approach is to use a double-lumen tube (DLT) if there is minimal compression with a patent mainstem bronchus opposite of the incision side. An endobronchial blocker can be used if significant airway compression precludes the use of DLT, and precautions should be taken that minimize the occlusive volume that is maintained to isolate the lung. Prolonged compressive effects on the airway could result in bronchomalacia with difficulty in extubation postoperatively due to dynamic collapse of the airway. Options such as postoperative, noninvasive ventilation and airway stenting could help in managing this difficult situation. An invasive arterial catheter should be placed in the non-aberrant subclavian artery and the femoral artery to monitor perfusion pressures proximally and distally. The authors routinely place large-bore intravenous access to facilitate rapid volume infusion in the event of significant bleeding. Arterial catheters needed to be placed on either side of the repair not only to look for the identification of post-repair coarctation but also to assist with distal perfusion while on cardiopulmonary bypass. In this patient, arterial blood pressure monitoring was done using the right brachial and left femoral arterial catheter. Right upper extremity arterial pressure monitoring was instituted to determine the perfusion pressure proximal to the clamp, i.e., to the brain and in the lower extremity pressure to monitor the perfusion distal to the clamp. In conclusion, the anesthesiologist must remain vigilant and recognize situations in which there may be a need to modify the anesthetic management based on patient stability, surgical preference, and/or institutional practice.

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B-type natriuretic peptide as prognostic marker in tetralogy of Fallot surgery.

B-type natriuretic peptide as prognostic marker in tetralogy of Fallot surgery.

Kapoor PM, Subramanian A, Malik V, Kiran U, Velayoudham D.

Asian Cardiovasc Thorac Ann. 2015 Feb;23(2):146-52. doi: 10.1177/0218492314534247. Epub 2014 May 13.

PMID: 24823381 [PubMed – in process]

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Comment from Dr. Hafil B. Abdulgani (Indonesia), section editor of Congenital Heart Surgery Journal Watch: B-type natriuretic peptide (BNP) is a well-known 32-amino acid polypeptide hormone, with diuretic, natriuretic, and vasoactive properties, that is used as a biomarker for the management of cardiac disease in both adult and pediatric patients. BNP levels predict the development of both low cardiac output syndrome (LCOS) and prolonged mechanical ventilation in children and neonates with congenital heart defects amenable to surgical repair. This prospective, observational study was to assess 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. Patients with preexisting congestive cardiac failure, coagulopathy, renal failure, hepatic dysfunction, immune or central nervous system dysfunction, local or systemic infection or inflammation (fever, leukocytosis), those on immunosuppressive or anti-inflammatory therapy and lack of complete data were excluded. 250 patients were divided into group 1 (infants <1-year old), group 2 (children 1- to 12-years old), group 3 (adolescents aged 12–18 years), and group 4 (adults >18 years of age). The result revealed that baseline B-type natriuretic peptide levels correlated with the degree of cyanosis in all 4 groups. B-type natriuretic peptide levels at 24h after admission to the intensive care unit correlated with mortality in the adult subset of patients. B-type natriuretic peptide levels >290pg mL−1 in the intensive care unit predicted an increased probability of adverse clinical outcomes.

This study concluded that B-type natriuretic peptide levels may be monitored to identify patients with cyanosis at increased risk of an augmented inflammatory response to cardiopulmonary bypass.

surg 6.1

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Fifteen-year Single Center Experience with the “Giessen Hybrid” Approach for Hypoplastic Left Heart and Variants: Current Strategies and Outcomes.

Fifteen-year Single Center Experience with the “Giessen Hybrid” Approach for Hypoplastic Left Heart and Variants: Current Strategies and Outcomes.

Schranz D, Bauer A, Reich B, Steinbrenner B, Recla S, Schmidt D, Apitz C, Thul J, Valeske K, Bauer J, Müller M, Jux C, Michel-Behnke I, Akintürk H.

Pediatr Cardiol. 2015 Feb;36(2):365-73. doi: 10.1007/s00246-014-1015-2. Epub 2014 Sep 2.

PMID: 25179460 [PubMed – in process] Free PMC Article

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Comment from Dr. Hafil B. Abdulgani (Indonesia), section editor of Congenital Heart Surgery Journal Watch: This study presented the overall single institutional 15-year experience with an unselected cohort of hypoplastic left heart syndrome (HLHS) and hypoplastic left heart complex (HLHC: borderline/obstructive left heart structures, duct-dependent circulation of the lower body, and antegrade flow to the ascending aorta) patients who underwent a Hybrid procedure as initial palliation providing their mid- and long-term outcome. The “Giessen Hybrid” approach consisted of surgical bilateral pulmonary banding (bPAB), percutaneous duct stenting and atrioseptostomy optionally with stent placement as necessary.  The patients were grouped according their neonatal appraisal to undergo univentricular palliation (HLHS-group A) and biventricular repair (HLHC-group B). A small group of patients (group C) received Hybrid stage I procedure for primary listing to orthotopic heart transplantation (HTX) or comfort care after hybrid stage I. Retrospective data collection included variables at admission, operative and postoperative parameters, as well as follow-up information during a 15-year observational period. Risk adjustment was calculated for each patient of the HLHS and variants group A via comprehensive Aristotle score. Flow-chart a, b, c shows all patients treated by Hybrid approach:

surg 5.1

 

BVR biventricular repair, HLHC hypoplastic left heart complex, HLHS hypoplastic left heart syndrome, HTX heart transplantation

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Kaplan–Meier actuarial survival curve of all (n = 154) patients treated by hybrid approach, differentiated by birth weight less than 2.5 kg

surg 5.3

 

Kaplan–Meier actuarial survival curve: a HLH-LS (MA/AA/MS/AA, MA/AS, MS/AS + variants): candidates for Norwood I Giessen experience June 1998–June 2013. b All patients of group A differentiated by birth weight less than 2.5 kg. c Patients of group A (n = 107), differentiated in term of aortic atresia (AA, n = 58) and stenosis (AS, n = 49).

AA aortic atresia, AS aortic stenosis, MA mitral atresia, MS mitral stenosis

surg 5.4

 

Kaplan–Meier actuarial survival curve: Patients of group A (n = 107), differentiated in term of left pulmonary artery stenting (LPA, n = 38) and stenosis (AS, n = 49)

 

This study showed fifteen-year survival rate for HLHS and variants was 77%, with no significant impact of birth weight of less than 2.5 kg. The authors concluded that, “Giessen Hybrid” stage I fulfilled the criteria of life-saving approach; and, replaced Norwood-staged palliation with a considerable mid- and long-term survival rate. Considerable inter-stage mortality revealed by this study indicates that close surveillance is mandated.

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Coronary artery bypass grafting in single-ventricle patients palliated with Fontan procedure: future consideration.

Coronary artery bypass grafting in single-ventricle patients palliated with Fontan procedure: future consideration.

Awad S, Abdelhady K.

Pediatr Cardiol. 2015 Feb;36(2):251-2. doi: 10.1007/s00246-014-1072-6. Epub 2014 Dec 16. No abstract available.

PMID: 25511664 [PubMed – in process]

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Select item 25500695

Comment from Dr. Hafil B. Abdulgani (Indonesia), section editor of Congenital Heart Surgery Journal Watch: This is a progressive editorial that raised the issue of coronary artery disease developing in adult patients with congenital heart disease following a Fontan procedure in their childhood. A common pre-Fontan procedure, to improve single ventricle performance, is to occlude aorto-pulmonary collateral arteries by coiling in the catheterization laboratory. In the future, coil occlusion may influence patency of distal feeder vessels, which commonly originate from the left and/or the right internal mammary arteries. Furthermore, coronary artery disease developing in this case may not be amenable to percutaneous coronary intervention by stenting. Therefore, coronary artery bypass surgery can be the ideal choice of treatment. A hybrid team, consisted of pediatric cardiology, adult cardiology and cardiac surgeon, shall be called upon to manage this complex problem in the near future.

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Outcomes Associated With Preoperative Use of Extracorporeal Membrane Oxygenation in Children Undergoing Heart Operation for Congenital Heart Disease: A Multi-institutional Analysis.

Outcomes Associated With Preoperative Use of Extracorporeal Membrane Oxygenation in Children Undergoing Heart Operation for Congenital Heart Disease: A Multi-institutional Analysis.

Gupta P, Robertson MJ, Beam BW, Rettiganti M.

Clin Cardiol. 2015 Feb;38(2):99-105. doi: 10.1002/clc.22358. Epub 2014 Dec 26.

PMID: 25545610 [PubMed – in process]

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Select item 25573638

Comment from Dr. Hafil B. Abdulgani (Indonesia), section editor of Congenital Heart Surgery Journal Watch: This is an observational analysis of a multicenter, administrative, national dataset obtained from using: the Pediatric Health Information System (PHIS) database. The PHIS database is powered by 43 children’s hospitals across the United States with the aim of improving quality, enhancing performance, and providing safe, effective, and efficient care. Institutions are affiliated with the Child Health Corporation of America (CHCA; Shawnee Mission, KS), a business alliance of children’s hospitals, and account for 20% of all tertiary-care children’s hospitals. This study demonstrated that patients requiring ECMO prior to their heart operation have significantly lower mortality compared with patients requiring ECMO after their heart operation.

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