One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection

Background. The guidelines for performing a one and a half ventricle repair with pulsatile bidirectional Glenn remains controversial. This retrospective report summarizes the experience of a single institution, with an attempt at providing an answer.

Methods. Fifty consecutive patients, aged 4 months to 42 years, underwent intracardiac repair along with a superior cavopulmonary connection. Twenty-seven of the patients had had previous surgical palliation. Repair consisted of patch closure of the ventricular septal defect (n = 25), tricuspid valve repair (n = 26), reconstruction of the right ventricular outflow tract (n = 34), transpulmonary annular patch (n = 34), right ventricle to pulmonary artery homograft conduit (n = 4), and concomitant repair of atrioventricular canal (n = 9). Ten patients were left with a fenestration in the atrial septum.

Results. There were six hospital deaths (12%) and two late deaths (4.5%). Forty-two survivors were followed from 8 months to 116 months. Eighty-eight percent are in functional class I. Actuarial survival at 97 months was 74%.

Conclusions. Moderate right heart hypoplasia constitutes a safe anatomic category for a pulsatile bidirectional Glenn. It is advisable not to proceed with a one and a half ventricle repair if postoperative residual pulmonary artery hypertension is anticipated. Patients requiring an intricate intracardiac repair and those with concomitant right heart hypoplasia may be better suited for a Fontan type of repair to reduce the complexity of the procedure.     

Paediatric myocardial protection-strategies, controversies and recent developments

During the last two decades, there has been a phenomenal rise in the number of patients undergoing early primary repair for congenital heart defects. Repair of these intracardiac defects usually requires open heart surgery that necessitates cardiopulmonary bypass, aortic cross clamping and administered cardiac arrest. To achieve this goal, cardioplegia is administered at predetermined intervals to ensure a quiescent heart and protection of the myocardium from ischaemia at the same time. Cardioplegia administration is usually done in conjunction with hypothermia to decrease the metabolic demands of the arrested heart as hypothermia alone is inferior to the combination of hypothermia and cardioplegia in providing adequate myocardial protection. The types and methods of cardioplegia in use today are as diverse as individual surgeons; and most institutions have over time developed their own preferred myocardial protection techniques that have proven to be safe and effective. Most of the available literature and concepts in pediatric myocardial protection today have been borrowed from observations in adults and ex- vivo and in-vivo animal models. The extrapolation of these concepts to pediatric myocardium is inappropriate as immature myocardium is not simply a “small adult heart”. It has unique differences and susceptibilities. This review provides a synopsis of pediatric myocardial protection including types, mechanisms, composition and comparative features of pediatric cardioplegia solutions currently in use all over the world. As of now, there is no evidence favoring one technique or strategy over the other. Pediatric myocardial protection protocols in general are currently experience based.     

Giant pulmonary artery aneurysm with right ventricular outflow tract obstruction

Aneurysm of the main pulmonary artery is rare. Its natural history is not well understood and there are no clear guidelines regarding its optimal treatment. We present a case of a huge saccular aneurysm of the main pulmonary artery which was associated with infundibular and valvular pulmonary stenosis. It was repaired using a pericardial patch with concomitant pulmonary valvotomy and infundibular resection. Postoperative recovery was uneventful and the patient is doing well. Follow-up echocardiogram revealed good repair.     

Extra cardiac Fontan without cardiopulmonary bypass: techniques and early results

Extracardiac Fontan is currently the preferred final palliation for patients with a univentricular heart. The operation is commonly performed on Cardiopulmonary bypass on a beating heart. In this review, we discuss a protocol for successfully performing this operation without cardiopulmonary bypass. The advantages and pitfalls of this technique are briefly discussed.     

A Prospective Randomized Clinical Trial Comparing 3D and Standard Miniplates in Treatment of Mandibular Symphysis and Parasymphysis Fractures

Purpose

To compare the efficacy of the 3D miniplates to standard miniplates in the osteosynthesis of mandibular symphysis and parasymphysis fractures on the basis of clinical parameters and radiographic evaluation.

Patients and Methods

A prospective randomized clinical trial was conducted to treat consecutive mandibular symphysis and parasymphysis fractures. The patients were randomly divided into 2 groups. The patients underwent osteosynthesis in group A with 3D titanium miniplates and in group B with conventional titanium miniplates. The cause of trauma, the number of days from injury to surgery, average age and gender were all reviewed. The assessment of the patients was done at 1, 3, and 6 weeks and 3 months using the clinical parameters and radiographic evaluation.

Results

Eighty patients with isolated symphysis or parasymphysis fracture met the inclusion criteria. In our study, a statistically significant difference was not found in the clinical parameters such as pain, swelling, infection, paresthesia, hardware failure, and mobility between the fracture segments. Similarly Radiological evaluation did not show any statistically significant difference in reduction between the 2 groups. 3D plates are difficult to adapt and use sometimes, but operative time is less with them in treatment of symphysis and parasymphysis fractures.

Conclusion

The use of 3D miniplates for symphysis and parasymphysis fracture fixation was efficacious enough to bear the masticatory load during osteosynthesis of the fracture. Although 3D miniplate system is difficult to adapt and difficult to use in cases of fractures involving the mental nerve, they provide the advantage of less operative time and less implant material in treatment of symphysis and parasymphysis fracture, with clinical results almost similar to those seen with conventional miniplate osteosynthesis.