Open supra-aortic revascularization and arch reconstruction after previous TEVAR in a complex arch anatomy

We propose a technique to minimize the neurological and systemic risks involved in rerouting the blood flow toward the brain in a “single remaining vessel” configuration with a 90% stenosis by means of complete hypothermic cerebral protection associated with normothermic systemic blood flow with a “restitutio ad integrum” of the supra-aortic trunks flow. The perfusion of the brain and the arms was almost completely separated from the systemic perfusion by the deployment 1 year before of a thoracic endoprosthesis in association with complete chronic occlusion of the brachiocephalic trunk and a functioning carotid-subclavian bypass. The Free Flow of the prosthesis, which acted as a hook, moved the calcium toward the left carotid ostium, creating a 90% stenosis with intermittent acute cerebral hypoperfusion and amaurosis. We achieved an optimal result: The patient was discharged on postoperative day 7 with no neurological problems and with patency and direct blood flow in all the supra-aortic trunks.

Evaluation of Optimization of Pulmonary and Systemic Blood Flow in Children after Bidirectional Cavapulmonary Anastomosis

In patients after bidirectional cavapulmonary anastomosis, blood flow through the superior vena cava (SVC), providing effective pulmonary blood flow, is the most important factor influencing blood oxygen saturation. Blood flow through the inferior vena cava recirculates into the systemic bloodstream. The study of the ratio of these flows will provide better understanding of the physiology of blood circulation after anastomosis and determine systemic oxygen saturation of blood and optimal time to perform surgery. The aim. To determine volumetric blood flow in the SVC, calculate pulmonary to systemic blood flow ratio in children after bidirectional cavapulmonary anastomosis, and evaluate its contribution to cardiac output and oxygen saturation in systemic blood flow. Materials and methods. In the period from January 2010 to June 2021, 51 patients with congenital heart defects with depleted pulmonary blood flow underwent hemodynamic correction at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. There were 29 male patients (57%) and 22 female patients (43%). The mean age of the patients at the time of the surgery was 34 ± 18.2 months (2 to 120 months), the mean age of patients at the time of examination was 43.5 ± 28.4 months (12 to 134 months). The main method of diagnosis in determining the defect and assessing the immediate and long-term results was echocardiographic examination and probing of the heart cavities. To evaluate the optimization of pulmonary/systemic blood flow we used equations obtained using the Fick method. Pulmonary to systemic blood flow ratio was calculated separately for 35 patients. Among the examined 35 patients, 18 children were older than 2.5 years, so all the examined patients were conveniently divided into 2 age groups: I group (n = 17) up to 2.5 years, II group (n = 18) older than 2.5 years to assess the contribution of SVC to the systemic circulation depending on age. Results. Pulmonary to systemic blood flow ratio was calculated for 35 patients Qp/Qs = (82% – 66%) / (97% – 66%) = 0.52. The calculated cardiac index according to echocardiography was 4.0 ± 0.85 L/min/m2 which corresponds to the SVC saturation (r = 0.60, p = <0.001). The flow in the superior vena cava = 2.08 L/min/m2. There was a very interesting trend towards decrease in the average rate of systemic saturation in patients after bidirectional cavapulmonary anastomosis depending on age and duration of surgery. Thus, in 17 patients of group I, the calculated Qp/Qs was (84% – 67%) / (97% – 67%) = 0.57. In patients of group II, the average systemic oxygen saturation was 78 ± 2% (from 65% to 81%). Calculated Qp/Qs for 18 patients of group II = (78% – 66%) / (97% – 66%) = 0.39, which indicates a decrease in pulmonary to systemic ratio with the growth of the child. Decreased systemic saturation after bidirectional cavapulmonary anastomosis in patients with increasing age and body surface area is associated with a decrease in the proportional flow from the superior vena cava. Therefore, in our clinical material, we confirmed the phenomenon of change in pulmonary to systemic ratio depending on age, which was described by Salim et al. according to a study conducted on healthy babies. Conclusions. The contribution of SVC flow to total cardiac output after bidirectional cavapulmonary anastomosis is directly associated with the patient’s age and gradually decreases in older patients, as indicated by a decrease in systemic saturation, so the clinical effect of bidirectional cavapulmonary anastomosis may be significantly better when performing surgery in early childhood.

OCT and OCT-angiography parameters of intraocular blood flow in healthy adults

PURPOSE.To identify the relationship between the parameters of choroidal and retinal blood flow by optical coherence tomography (OCT) and OCT angiography (OCT-A), and the structural, hydrodynamic and systemic hemodynamic parameters in healthy adults.METHODS.The study included 42 male subjects aged 54.43±4.1 years without signs of local or systemic pathologies. The following parameters were evaluated on the RTVue-XR tomograph (USA): structural and microcirculatory parameters of the optic disc (OD) — peripapillary retinal nerve fiber layer (pRLNF) and radial peripapillary capillary plexus (RPCP); the macula — thickness, superficial capillary plexus (SCP), deep vascular complex (DVC), foveolar avascular zone (FAZ); the choroid — thickness, structure. Blood pressure was determined using the Riva–Rocci method; tonometry — by the Maklakov method. The parameters of bidirectional corneal applanation were evaluated, and perfusion and tolerance pressure were calculated.RESULTS.Negative correlations were revealed between intraocular pressure, pRNFL and capillary density of RCP (R= −0.58… −0.73); between choroid thickness, systemic blood flow, and tolerant pressure (R= −0.56… −0.72); between the thickness of the choroid and the volume of focal losses (FLV, %), as well as the OCT-A parameters of FAZ (area, perimeter, and density of foveolar vessels) (R= −0.45… −0.58). Positive correlations were found between perifoveal thickness (including ganglion complex) with the pRNFL (R=0.58–0.71), as well as with the thickness of the choroid (R=0.41–0.65). The confidence level was p≤0.001.CONCLUSION. The relationship of retinal, choroidal, micro hemodynamics parameters by OCT (choroid thickness) and OCT-A (RCC) (HD Angio Disc 4.5 protocol); area, perimeter, and vascular density of FAZ (Angio Retina 3.0 protocol) with the parameters of systemic blood flow in healthy subjects can likely be considered as hemodynamic biomarkers in the diagnosis, monitoring, and evaluation of treatment effectiveness of any intraocular vascular process (including glaucoma).

Multiple renal injuries lead to death in postoperative cardiac surgery even with precocious hemodiafiltrations

We present the case of a newborn diagnosed with perinatal asphyxia and secondary renal injuries, transposition of the great vessels and low systemic blood flow, treated with Prostaglandin, atrioseptostomy, followed by arterial switch surgery After the cardiac surgery the patient is oliguric and requires hemodiafiltration for 12 days, after which renal function is restored. In evolution, however, AVB (atrioventricular block) grade III occurs, followed by implantation of permanent pacemaker, but another postoperative complication – chylothorax – leads to stopping electrical stimulation followed by severe cardiac dysfunction and, consequently, recurrent renal injury and anuria. Re-establishing hemodiafiltration for another 7 days without recovery of renal function. Perinatal asphyxia, cardiac heart disease with low systemic blood flow, prostaglandin, atrioseptostomy, cardiac rhythms disturbances, chylothorax, sepsis, cardiac arrest are intriguing factors that bring renal injury. Their association greatly decreases the chance of survival even if the patient benefits from supportive treatment and early hemodiafiltration.

Functional activity of the endothelium and immune status in atherosclerotic lesions of the aorto-iliac segment and revascularization

Objective. The aim of the study is the evaluation of endothelial functional activity and immune status in systemic and local blood flow in atherosclerotic lesions of the aorto-iliac segment after open and endovascular interventions and establishing the relationship with the lesion class. Materials and methods. The study included 190 patients with lesions of the aorto-iliac segment. Depending on the type of surgical intervention, patients were divided into two groups: group I (n=97) - patients who underwent aorto-femoral bypass surgery, group II (n=93) - patients who underwent TRANS-balloon angioplasty with stenting of the iliac arteries. Results. Violations of the functional state of the endothelium and the immune status in the systemic and local blood flow, which do not correlate with the TASC II lesion class (TransAtlantic Inter-Society Consensus II), were revealed. There were differences in the factors of endothelial damage (in patients of group II before surgery, the level of homocysteine in the systemic blood flow, oxidized low-density lipoproteins in the systemic and local blood flow), hemostatic form of endothelial dysfunction (in group I, inhibitor of tissue plasminogen activator type I (PAI-1) in the systemic and tissue plasminogen activator (t-PA) in the local blood flow) and apoptosis (higher in group I in the systemic and local blood flow). During revascularization of the aorto-iliac segment, there were violations of the hemostatic form of endothelial dysfunction in group II with an increase in PAI-1 by 14.8% (p<0.001) in the systemic blood flow and by 1.9 times (p<0.001) in the revascularized arterial segment compared to group I. In group II after revascularization was significantly higher the immunoglobulins (Ig) class A in system and the circulating immune complexes, interleukins 1 (IL-1) in local blood flow and lower levels of IgM, interleukins 6 (IL-6), IL-1 in system and IgA, IgM, IL-6 in local blood flow compared with I group. Conclusion. The study of the features of the functional state of the endothelium and the immune status will optimize the management strategies of patients after various types of revascularization interventions on the aorto-iliac segment.

Abstract 15805: Longitudinal Changes in Univentricular Patients Pre-Bidirectional Cavopulmonary Connection and Pre-Fontan

Background: Little is known about serial changes in the physiology of single ventricle (SV) patients during staged palliation and if HLHS patients differ from the rest. Methods: We analyzed SV patients who had a combined cath with CMR at both the preBCPC and preFontan studies from 2016-2019. Flow contrast mapping used to calculate pulmonary arterial (Qpa) and venous (Qpv) flow. Systemic blood flow (Qs) calculated using [superior vena cava (SVC) flow + descending aortic flow at the level diaphragm]. Cerebral vascular resistance (CVRi) calculated using [ascending aortic pressure (AoP)-right atrial pressure (RAP)/SVC flow]. Systemic vascular resistance (SVR) calculated using [(AoP-RaP)/Qs]. Pulmonary vascular resistance (PVR) was calculated using [(mean PAP - LAP)/Qpv]. Results: 30 patients were found, 10 with HLHS. The BCPC unloaded the heart, EDVi fell from preBCPC to preFontan. From preBCPC to preFontan(Table1): PA flow fell, but was compensated by increased APC flow to keep QpQs~1, PApressure and PVRi fell. Compared to others, the HLHS patients had larger hearts (EDVi) and lower PA but higher APC flow at both preBCPC(Table2)and preFontan(Table3). By preFontan, HLHS patients had worse function: higher ESVi, lower EF. Conclusion: QpQs ~1 is maintained by increase in APC flow. HLHS hearts are larger and deteriorate progressively.

Abstract 12971: Oxidative Stress in Children With Left to Right Shunt Congenital Heart Disease

Background: Oxidative stress has recently been noted as a factor involved in myocardial remodeling and has been reported to be a predictor of heart failure severity and cardiac death in adults. However, its relevance in the pediatric field is unclear. Objective: This study aimed to investigate the reference range of oxidative stress dynamics and evaluate the role of oxidative stress in children with left to right shunt congenital heart disease (CHD). Methods: The subjects consisted of 40 patients (CHD group) with left to right shunt CHD who underwent cardiac catheterization at Hamamatsu University Hospital and 105 healthy children. The oxidative stress markers were measured in blood derivatives of reactive oxygen metabolites (ROM; adult reference value 250-300 U. CARR). We examined the dynamics of ROM in healthy children and then compared the various parameters, including ROM, in 40 age- and sex-matched healthy controls (control group). Results: The median age of the CHD group (21 boys and 19 girls) was 9.5 months (interquartile range: 2.8-32.0 months). CHD consisted of 27 cases of ventricular septal defect, 8 cases of atrial septal defect, 4 cases of patent ductus arteriosus, and 1 case of atrioventricular septal defect. In the healthy children, ROM showed a significant positive correlation with age (r = 0.482, p <0.001). The blood ROM of the CHD group (292 ± 84 U.CARR) was significantly higher (p <0.001) than that in the control group (199 ± 82 U.CARR), and the ROM showed a significant positive correlation with the pulmonary-to-systemic blood flow ratio (r = 0.333, p = 0.022), the percentage of left ventricular end diastolic volume (r = 0.503, p <0.001), and the percentage of right ventricular end diastolic volume (r = 0.771, p <0.001). The area under ROC curve of ROM for pulmonary-to-systemic-blood-flow ratio > 1.5 was 0.741 (95% CI: 0.576-0.906, p=0.026), with a cut-off value of 293 U.CARR. Conclusions: ROM, an indicator of oxidative stress, showed a gradual upward trend with age in childhood, and this transition was confirmed to differ from that of NT-proBNP, which decreases to a steady state after marked elevation in the early neonatal period. These findings suggest that ROM is a biological marker reflecting at least the volume load in left to right shunt CHD.

Plasma NT-proBNP and pulmonary to systemic blood flow ratio in congenital heart defects with left-to-right shunts

Background Cardiac left-to-right shunts changes to the pulmonary-to-systemic blood flow ratio (Qp/Qs ratio). This ratio can be used to monitor the hemodynamics of the heart. Left-to right-shunts cause the release of amino terminal proB-ty natriuretic peptide (NT-proBNP) that can be utilized as a specific marker for the presence of heart failure in children with congenital heart defects (CHDs). Early intervention such as defect closure in CHD is important to prevent heart failure. Objective To assess for a correlation between the level of NT pro-BNP and Qp/Qs ratio in CHD patients with left-to-right shunts. Methods This cross-sectional, analytical study was conducted in 32 children who underwent cardiac catheterization at Sanglah General Hospital, Denpasar, Bali, and were recruited by consecutive sampling. NT-proBNP levels were measured by ELISA with a two-step sandwich assay system; Qp/Qs ratio using Fick rules. Statistical analyses included Shapiro-Wilk test, descriptive analysis for subject characteristics, and Pearson’s correlation analysis. A P value of <0.05 was considered to be statistically significant. Age and defect size were analyzed as confounding factors by partial correlation test. Results The correlation value between NT-proBNP and Qp/Qs ratio was r=0.384 (P<0.05), after controlling for age and defect size as cofounding factors. Conclusion There is a weak positive correlation between NT-proBNP levels and pulmonary-to-systemic blood flow ratio in patients with left-to-right shunt, after controlling for age and defect size as confounding factors.