The long-term outcome after repair of tetralogy of Fallot (TOF) is critically dependent pulmonary valve competence that is compromised by trans-annular patch (TAP). We compared a new echocardiographic index [pulmonary annulus index (PAI)] to conventional methods of predicting need for TAP in infants undergoing TOF repair. Consecutive infants undergoing TOF repair were prospectively studied. Pre-operative aortic and pulmonary annuli and main pulmonary artery (MPA) diameters were measured and z scores determined. PAI was a ratio of observed to expected pulmonary annulus (PA) diameter. TAP was based on intra-operative sizing by surgeons blinded to PAI values. Receiver operator curves (ROC) were generated for all PAI, MPA z scores and pulmonary annulus z scores. Of 84 infants (8.6 ± 2.6 months; 7.5 ± 1.3 kg), 36 needed TAP (43%). All the three indices viz. PAI, Pulmonary annulus and MPA z scores performed similarly in predicting need for TAP (ROC curves ~ 80%). Combining cut-offs of MPA z scores (> - 3.83) with either PAI (> 0.73) or PA z score (> - 1.83) predicted avoidance of TAP with ~ 90% accuracy. When both PAI and MPA z scores were below the cut-offs there was an 80% likelihood of TAP. Failure to predict TAP was associated with unicommisural pulmonary valves. PAI was equal to PA z scores in predicting need for TAP during repair of TOF. Combining either with MPA z scores was the most accurate method of prediction. Failure of prediction was mainly due to presence of a unicommissural pulmonary valve.

ObjectiveWe sought to evaluate the association between low birth weight (LBW) and outcomes following neonatal cardiac surgery in a low-income and middle-income country setting where LBW prevalence is high and its impact on surgical outcomes is undefined.DesignSingle-centre retrospective cohort study.SettingReferral paediatric hospital in Southern IndiaPatientsAll neonatal cardiac surgical cases between January 2011 and December 2018. LBW was defined as <2.5 kg.Main outcome measuresPatient demographics, corrective versus palliative surgery and postoperative outcomes were collected from the institutional database which undergoes regular audit as part of International Quality Improvement Collaborative for Congenital Heart Disease. In-hospital mortality was the primary outcome measure.ResultsOf 569 neonatal cardiac operations, 123 (21.6%) had LBW (mean: 2.2±0.3 kg); 18.7% <2 kg and 21.1% were preterm (<37 weeks). Surgery type (corrective vs palliative) or non-cardiac anomalies were not associated with birth weight. Birth weight did not correlate with ICU length of stay (LOS) and mechanical ventilation but was lower in those with postoperative sepsis. Overall in-hospital mortality was 7.0%; LBW neonates had higher mortality (OR 2.16, 95% CI 1.09 to 4.29, p=0.025). Multivariable analyses revealed birth weight (OR per 100 g decrease in weight: 1.12; 95% CI 1.03 to 1.22), age at surgery (OR per day increase in age of 0.93; 95% CI 0.87 to 0.99) and palliative intervention (OR 4.46 (95% CI 1.91 to 10.44) as independent predictors of in-hospital mortality.ConclusionLBW adversely impacts in-hospital mortality outcomes following neonatal cardiac surgery in a resource-limited setting without increase in ICU or hospital LOS.

Background: In the treatment of simple congenital cardiac lesions, percutaneous and cosmetic surgical approaches have steadily gained prominence. Surgically, right vertical axillary approach is sparsely used despite superior cosmesis and less pain and blood product usage. Knowledge of potential pitfalls could lead to its more widespread acceptance. Methods: We retrospectively analyzed perioperative outcomes of 104 consecutive patients who underwent surgery by this technique between mid-2016 and December 2019, including ostium secundum (67), sinus venosus (34), coronary sinus (1), and ostium primum (1) atrial septal defects and hemianomalous pulmonary venous connection (1). Perioperative variables, surgical times, complications, and follow-up data were analyzed. Results: Patient weight ranged from 6.8 to 41 kg. Incision length ranged from 4 to 6 cm. There was no mortality. All cannulation was central. Difficulty in cannulation (inferior vena cava) was seen in two patients. Morbidity included pneumothorax in 2 (1.9%) patients and subcutaneous emphysema necessitating prolonged intercostal drain retention in 20 (19.2%) patients. Surgical time increased linearly (r = 0.567; P < .001) with increasing patient weight but cardiopulmonary bypass (CPB) time remained unaffected. No chest deformities or paresthesia were noted on follow-up. Scar size decreased in some patients. Conclusions: Right vertical axillary approach can be safely employed to treat simple congenital cardiac lesions with adequate awareness of potential pitfalls. Increasing patient weight increases the surgical time but does not affect CPB times. Incidence of pneumothorax and subcutaneous emphysema is similar to other thoracotomy approaches. It is cosmetically superior.

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Severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV) needing emergent mitral valve replacement is a rare complication. The unrelieved mitral stenosis is compounded by severe MR leading to acute rise in pulmonary hypertension and right ventricular afterload, decreased coronary perfusion, ischemia and right ventricular failure. Associated septal shift and falling left ventricular preload leads to a vicious cycle of myocardial ischemia and hemodynamic collapse and needs to be addressed emergently before the onset of end organ damage. In this report, we describe the pathophysiology of hemodynamic collapse and peri-operative management issues in a case of mitral valve replacement for acute severe MR following BMV.