Impact of obesity on post-operative arrhythmias after congenital heart surgery in children and young adults

Background: Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery. Methods: Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2–20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5–85, overweight 85–95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis. Results: There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive–inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias. Conclusion: Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.

COMPARISON OF TRANS-RIGHT ATRIAL VERSUS COMBINED (TRANS-RIGHT ATRIAL, TRANS-RIGHT VENTRICULAR) APPROACH FOR INTRA-CARDIAC REPAIR OF TETRALOGY OF FALLOT: SINGLE-CENTER EXPERIENCE

Background and Objective: We compared trans-right atrial (t-RA) versus combined (trans-right-atrial and trans-ventricular (t-RA/RV) approaches for intra-cardiac repair of Tetralogy of Fallot (TOF) for the pre-operative and post-operative right ventricular (RV) function. The RV function was calculated using a tricuspid annular plane systolic excursion (TAPSE) using two-dimensional (2-D) echocardiography. Materials and Methods: This was a retrospective study. Fifty-three patients operated for the intra-cardiac repair of TOF between August 2019 and March 2021 were included in the study and divided into two groups based on the approach for repair as follows: t-RA or combined (t-RA/RV) approach. The first group (t-RA) had twenty-one patients, and the second group (combined t-RA/RV approach) had thirty-two patients. The assessment of pre-operative and post-operative RV function was done using TAPSE. Records of follow-up at 1 month and 3 months were evaluated. Results: Age, body surface area (BSA), preoperative saturation, cardiopulmonary bypass time, aortic cross?clamp time, postoperative intensive care unit (ICU) stay, and hospital stay were similar in both groups. However, t?RA/RV group had more pleural effusions (9 vs. 1 patients, P < 0.05), but had more improvements in Right Ventricular outflow tract (RVOT) gradients. There were no differences in arrhythmias in either group. Pre-operative TAPSE for both groups was similar (1.46 ± 0.27 vs. 1.61 ± 0.31, P > 0.05) and so was the post?operative TAPSE at discharge (1.54 ± 0.31 vs. 1.49 ± 0.33, P > 0.05), at 1 months (1.64 ± 0.25 vs. 1.48 ± 0.32, P > 0.05) and 3months (1.75 ± 0.19 vs. 1.7 ± 0.15, P > 0.05). Conclusion: Both approaches provide adequate palliation with effective improvements in RVOT gradients for patients with TOF. A limited right ventriculotomy does not adversely affect early RV function or increase the incidence of arrhythmias at the immediate post-operative period and early follow-up. More extensive studies with prospective randomized design and longer follow-ups are needed to address these issues further. Keywords: Tetralogy of Fallot, transatrial approach, intracardiac repair.

Postoperative Early Outcomes of Conventional versus Minimally Invasive Multivessel Coronary Artery Bypass Surgery: Retrospective Study

Minimally invasive coronary artery bypass grafting (CABG) is a new technique developed in recent years apart from the conventional method. Our first objective is to compare the postoperative early outcomes of conventional and minimally invasive multivessel (MIM) CABG methods, and second objective is to compare perioperative differences between two surgical techniques. This retrospective, comparative study was conducted at a university hospital with 100 patients, who underwent CABG surgery from November, 1 2019 to June, 1 2020. The data of 50 patients, who underwent MIM CABG (Group M), was certain. Among the patients operated with the conventional method (Group C), 50 patients were randomly selected from the same time period. Examination of early postoperative outcomes revealed that Group C had significantly higher intensive care unit (ICU) stay (p=0.013), significantly higher mechanical ventilation time in ICU (p<0.001), and significantly higher isolated systolic blood pressure (p=0.013). Examination of perioperative variables revealed that Group C had significantly shorter duration of surgery (p<0.001), significantly shorter aortic cross-clamp time (p<0.001), significantly shorter cardiopulmonary bypass (CPB) time (p<0.001), significantly lesser graft numbers (p<0.001), significantly lesser left internal mammary artery use (p<0.05), and significantly lesser inotropic support after CPB was discontinued (p<0.05). In the light of these results, MIM CABG was associated with enhanced postoperative early outcomes with prolonged surgery time compared to conventional method.

AORTIC VALVE RECONSTRUCTION SURGERY USING AUTOLOGOUS PERICARDIUM: THE EXPERIENCE IN VIETNAM

Objective: The study aimed to evaluate the indications and describe the aortic valve reconstruction techniques by Ozaki’s procedure in Vietnam and report mid-term outcomes of this technique in Vietnam. Methods: Between June 2017 and December 2019, 72 patients diagnosed with isolated aortic valve disease, with a mean age of 52.9 (19 – 79 years old), and a male:female ratio of 3:1 underwent aortic valve reconstruction surgery by Ozaki’s technique at Cardiovascular Center, E Hospital, Vietnam. Results: The aortic valve diseases consisted of aortic stenosis (42%), aortic regurgitation (28%), and a combination of both (30%). In addition, the proportion of aortic valves with bicuspid morphology and small annulus (≤ 21 mm) was 28% and 38.9%, respectively. The mean aortic cross-clamp time was 106 ± 13.8 minutes, mean cardiopulmonary bypass time was 136.7 ± 18.5 minutes, and 2.8% of all patients required conversion to prosthetic valve replacement surgery. The mean follow-up time was 26.4 months (12- 42 months), the survival rate was 95.8%, the reoperation rate was 2.8%, and rate of postoperative moderate or higher aortic valve regurgitation was 4.2%. Postoperative valvular hemodynamics was favorable, with a peak pressure gradient of 16.1 mmHg and an effective orifice area index of 2.3 cm . Conclusions: This procedure was safe and effective, with favorable valvular hemodynamics and a low rate of valvular degeneration. However, more long-term follow-up data are needed.

Emergency surgical treatment of total anomalous pulmonary venous connection

Background: This study explores the strategy and effect of emergency surgical treatment for total anomalous pulmonary venous connection (TAPVC). Methods: From March 2009 to February 2020, 78 patients with TAPVC underwent emergency surgical correction. There were 51 males and 27 females. The median age was 39.5 days, and the median weight was 4.0 kg. The preoperative percutaneous oxygen saturation was 80.8±4.5%. Results: Of the cases investigated, seven died during the perioperative period, 16 had delayed chest closure, 19 had early pulmonary vein obstruction, two had secondary tracheal intubation, one had a brain complication, and one had third-degree atrioventricular block. Low weight, younger age, cardiopulmonary bypass time, and aortic cross-clamp time were identified as risk factors for early mortality. During the follow-up from four to 137 months, 12 cases did not respond to follow up. Ten patients died within one to six months after discharge. One patient underwent reoperation due to pulmonary vein obstruction. The longer hospital stays after operation and intensive care unit time were identified as risk factors for late mortality. Conclusions: Emergency surgery for severe TAPVC patients after admission had achieved good results in the near future. Prenatal diagnosis should be strengthened to save more patients. The higher late mortality rate indicates that such patients should strengthen post-discharge management to reduce the occurrence of post-discharge deaths.

Kết quả phẫu thuật điều trị bệnh lý gián đoạn quai động mạch chủ tại Bệnh viện Nhi Trung ương

TÓM TẮT Mục tiêu: Đánh giá kết quả tạo hình quai động mạch chủ trong phẫu thuật một thì điều trị bệnh lý GĐQĐMC tại Bệnh Viện Nhi Trung Ương từ năm 2012 đến 2019. Phương pháp: Nghiên cứu hồi cứu 53 bệnh nhân được phẫu thuật sửa chữa một thì bệnh tim bẩm sinh GĐQĐMC từ tháng 01 năm 2012 đến tháng 12 năm 2019. Kết quả: Bệnh nhân gồm 32 nam và 21 nữ. Tuổi trung bình là 43 ± 53 ngày, cân nặng trung bình khi phẫu thuật 3.4 ± 0.7 kg. Trung bình thời gian chạy máy tim phổi nhân tạo (TPNT) là 128 ± 28 phút, thời gian cặp chủ 92 ± 18 phút và thời gian tưới máu não chọn lọc là 34 ± 11 phút. Tử vong sớm sau mổ có 9 bệnh nhân (16.9%). Thời gian theo dõi trung bình 37 ± 21 [8-95] tháng. Tỷ lệ sống sót chung sau phẫu thuật là 83% tại thời điểm 8 năm. Tỷ lệ sống sót không phải can thiệp lại do tái hẹp quai ĐMC là 97.6% tại thời điểm 8 năm, không có bệnh nhân tử vong trong quá trình theo dõi. Kết luận: Phẫu thuật một thì sửa chữa bệnh lý GĐQĐMC ở Bệnh viện Nhi Trung ương là hoàn toàn khả thi và có thể thực hiện được ở lứa tuổi sơ sinh và nhũ nhi với tỷ lệ tử vong thấp. Từ khóa: Gián đoạn quai động mạch chủ, thông liên thất, hẹp đường ra thất trái, cửa sổ chủ phế. ABSTRACT OUTCOMEOF SURGICAL REPAIR FOR INTERRUPTED AORTIC ARCH IN NATIONAL CHILDREN’S HOSPITAL, HANOI Objective: The objective was to determine outcomes of aortic arch reconstruction in one-stage repair of interrupted aortic arch in Nation Hospital of Pediatrics from 2012 to 2019. Methods: Records of 53 consecutive patients undergoing interrupted aortic arch repair between January 2012 to December 2019 were reviewed. Single-stage repair was performed in all of the patients. Results: The patients consisted of 32 males and 21 females. Mean age of the patients was 43 ± 53 days and mean weight was 3.4 ± 0.7 kg. The average cardiopulmonary bypass time was 128 ± 28 minutes, the aortic cross-clamp time was 92 ± 18 minutes and the selective cerebral perfusion time was 34 ± 11 minutes. Early mortality was 16.9%. Mean follow-up was 37 ± 21 [8-95] months. Actuarial survival including early death was 83% at 8 years. The freedom from reintervention of recurrent aortic arch obstruction was 97.6% at 8 years. No late death occurred. Conclusions: Single-stage repair of interrupted aortic arch with intracardiac defects is safe and feasible with newborn and infant in National Hospital of Pediatrics. Keyword: Interrupted aortic arch, ventricular septal defect, left ventricular outflow tract obstruction, aortopulmonary window

Toward Routine Minimally Invasive Ventricular Septal Defect Closure Via Right Lateral Minithoracotomy

Background: Improving the surgical results and recent advancement of transcatheter techniques for closure of ventricular septal defect (VSD) increased the demand for minimally invasive approaches. In this study, we analyzed the results of the patients who underwent VSD closure with right lateral minithoracotomy (RLMT).Methods: Between September 2014 and February 2021, 24 patients underwent minimally invasive VSD closure with RLMT. The median age of the patients was 16 months (range, 4-84 months). Fifteen patients (62.5%) were female. The median weight of the patients was 9.75 kg (range, 4.6-30 kg). The types of VSD were perimembranous in 19 patients, subaortic in three patients, inlet in one patient, and subpulmonic in one patient. Five patients had low-lying pulmonary stenosis in addition to VSD.Results: No perioperative death or major complication occurred during follow-up. All defects were repaired through RLMT. The median cardiopulmonary bypass time was 81 min (range, 44-163 min), and the aortic cross-clamp time was 65 min (range, 33-131 min). The median hospital stay was 6 days (range, 5-21 days). One patient had minimal (2 mm) residual left-to-right shunt. All families were satisfied with the cosmetic results during the follow-up.Conclusions: The RLMT method is a safe and effective alternative to standard median sternotomy for VSD closure and can be performed with favorable cosmetic and clinical results.

A Novel Plug-Based Vascular Closure Device for Percutaneous Femoral Artery Closure in Patients Undergoing Minimally-Invasive Valve Surgery

Objectives: Surgical exposure of groin vessels to establish cardiopulmonary bypass (CPB) for minimally-invasive valve surgery (MIS) is standard of care but may result in postoperative wound healing disorders or seroma formation. Therefore, adaption of transcatheter techniques for fully percutaneous insertion of CPB cannulae may improve clinical results. We herein analyze a single center experience with a novel plug-based vascular closure device for MIS.Methods: Between 03/2020 and 02/2021 MIS using the MANTA™ (Teleflex Medical Inc., Wayne, PA, USA) vascular closure device was performed in 28 consecutive patients (58.8 ± 10.6 years, 60.3% male, logEuroSCORE II 1.1 ± 0.8%) receiving mitral and/or tricuspid valve repair/replacement. Concomitant procedures were left atrial appendage occlusion and cryoablation for atrial fibrillation in 21.4% (6/28) and 10.7% (3/28) of patients, respectively. Data were retrospectively analyzed in accordance with standardized M-VARC definitions. MANTA™ device success and early safety was defined as absence of any access site or access related vascular injury and major and life-threatening bleeding complications.Results: MANTA™ device success with immediate hemostasis and early safety were 96.4% (27/28). In one case, device failure necessitated surgical cut down without further complications. Mean aortic cross clamp time and cardiopulmonary bypass were 96.5 ± 24.2 min and 150.2 ± 33.6 min. Stroke, renal failure or myocardial infarction were not observed. Intensive care unit and total hospital stay were 1.7 ± 0.8 days and 10.1 ± 5.7 days. Overall 30-day mortality was 0%. Post-procedure echocardiography presented one case of residual moderate tricuspid regurgitation and competent valves in all other cases.Conclusions: The MANTA™ device is safe and effective in MIS. Its ease of use and effectiveness to achieve immediate hemostasis have further simplified MIS.

Initial results of aortic valve reconstruction using autologous pericardium (Ozaki's procedure)

Introduction: This study report the clinical characteristics, surgical indications, surgical technique and initial outcomes of autologous pericardial aortic valve reconstruction using Ozaki’s procedure. Methods: The study included consecutive patients with isolated aortic valve disease who underwent Ozaki’s procedure between June 2017 and December 2019. Aortic valve cups were reconstructed by autologous pericardium using Ozaki’s procedure. Results: Seventy-two patients were enrolled (mean age 52.9 ± 13 years; 53 males) and consisted of 30 aortic stenosis cases, 20 aortic regurgitation cases, and 22 patients with a combination of both 72 patients, a bicuspid aortic valve was present in 20, and 7 patients had infective endocarditis. Surgery was performed via a full or partial sternotomy. The procedure was successful in 70 case, and two patients were converted to prosthetic valve replacement. The aortic cross-clamp time was 106.3 ± 13.8 minutes, cardiopulmonary bypass time was 136.7 ± 18.5 minutes. One patient died of cardiac tamponade in hospital, and two patients underwent reoperation due to bleeding and sternal infection, respectively, were observed during the follow-up period of 30 days. 1-month postoperative echocardiography revealed that one patient had moderate aortic valve regurgitation, max trans-valvular pressure gradient was 16.1 ± 2.3 mmHg, and aortic valve area was 2.5 ± 0.2 cm ². Conclusions: Aortic valve reconstruction using autologous pericardium by Ozaki’s procedure was feasible, good hemodynamics, and can be applied to all lesions of the aortic valve.

Totally endoscopic resection of atrial myxoma: early results of 26 patients in E hospital

Objective: Myxoma is the most common form of non-malignant tumor that arises from connective tissue. Totally endoscopic surgery without robotic assistance can resect the entire atrial myxoma. This study aim to evaluate the early results of this surgical method. Methods: From January 2019 to April 2021, 26 patients (20 females, 6 males, mean age 49.5 ± 14.3) were diagnosed with atrial myxoma. All tumors of those patients were resected by totally endoscopic surgery. We evaluated the early outcome of this method based on the following criteria: mortality rates, conversion to open surgery, cardiopulmonary bypass time, aortic cross-clamp time, postoperative time. Results: Totally endoscopic surgery to resect atrial myxoma was successfully performed in all patients with surgical ports on the thoracic wall. The largest incision was not more than 1.5 cm in diameter. Mean cardiopulmonary bypass time was 134 ± 39 minutes, aortic cross-clamp time was 81.4 ± 26.4 minutes, mechanical ventilation time was 10.5 ± 4.6 hours, ICU length of stay was 2.1 ± 0.9 days, postoperative time was 6.9 ± 5.4 days. We had one case in which the excision of myxoma was performed contemporaneously with mitral valve annuloplasty. Conclusions: Initial outcomes of totally endoscopic surgery to resect atrial myxomas were satisfactory. However, to fully evaluate the effectiveness of this method, we need to conduct a long-term follow-up of these patients.