No abstract

This study presents the first European clinical experience with the Medos DeltaStream DP1, a new pulsatile flow pump, in neonates and infants. Between January 2002 and December 2004, 420 patients at our institution underwent congenital heart surgery on cardiopulmonary bypass. During this period, 10 patients required extracorporeal membrane oxygenation (ECMO) support for acute postcardiotomy heart failure. Seven patients (median age 7 days, range 1-70 days), were supported by a nonpulsatile Biomedicus centrifugal pump, whereas three patients (aged 1 month, 1 year, and 12 years) were supported by a pulsatile Medos DP1. The DP1 is an extracorporeal rotary blood pump. The pump features a diagonal-flow impeller, and can be used for both continuous and pulsatile output. Special characteristics include a small priming volume of approximately 30 ml and a high pumping capacity. A temperature sensor and speed sensors are integrated in the pump. The pump has a delivery rate of up to 8 l/min and a speed range of 100-10,000 rpm. Overall mortality was 40% (4 of 10 patients), and all four deaths were in the nonpulsatile Biomedicus group. In the nonpulsatile group, the median support duration was 95 hours with a range of 48-140 hours. Two patients assisted with the pulsatile pump system were successfully weaned after 36 and 53 hours, respectively; the 12-year-old patient was successfully transplanted on the eighth postimplant day and discharged from the hospital on the 32nd posttransplant day. Although this preliminary experience doesn't allow for statistical analysis, clinically it was possible to observe a better performance in pulsatile flow recipients with faster lactate recovery, reduced need for inotropic support, reduced assistance duration in bridge-to-recovery settings, and smoother intensive care management. ECMO for postcardiotomy heart failure in neonates and infants still carries high mortality and morbidity rates. Pulsatile flow with the Medos DeltaStream DP1 pump system improves results by producing more physiologic hemodynamics, reducing the duration of support in the case of bridge to recovery, and improving end-organ function.

OBJECTIVES Italy has been one of the countries most severely affected by the coronavirus disease 2019 (COVID-19). The Italian government was forced to introduce quarantine measures quickly, and all elective health services were stopped or postponed. This emergency has dramatically changed the management of paediatric and adult patients with congenital heart disease. We analysed data from 14 Italian congenital cardiac surgery centres during lockdown, focusing on the impact of the pandemic on surgical activity, patients and healthcare providers and resource allocation. METHODS Fourteen centres participated in this study. The period analysed was from 9 March to 4 May. We collected data on the involvement of the hospitals in the treatment of patients with COVID-19 and on limitations on regular activity and on the contagion among patients and healthcare providers. RESULTS Four hospitals (29%) remained COVID-19 free, whereas 10 had a 39% reduction in the number of beds for surgical patients, especially in the northern area. Two hundred sixty-three surgical procedures were performed: 20% elective, 62% urgent, 10% emergency and 3% life-saving. Hospital mortality was 0.4%. Compared to 2019, the reduction in surgical activity was 52%. No patients operated on had positive test results before surgery for severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19. Three patients were infected during the postoperative period. Twenty-nine nurses and 12 doctors were infected. Overall, 80% of our infected healthcare providers were in northern centres. CONCLUSIONS Our study shows that the pandemic had a different impact on the various Italian congenital cardiac surgery centres based on the different patterns of spread of the virus across the country. During the lockdown, the system was able to satisfy all emergency clinical needs with excellent results.

OBJECTIVES Repair of Tetralogy of Fallot (TOF) has currently excellent results with either transventricular or transatrial approach. However, it is unclear as to which has better late outcomes and what role of residual pulmonary valve (PV) regurgitation in the long term is. We report on late clinical outcomes after repair in a large series of patients with TOF, focusing on the type of surgical technique. METHODS This analysis is a retrospective multicentre study on patients undergoing TOF repair in infancy. The exclusion criteria of the study were TOF with pulmonary atresia or absent PV. RESULTS We selected 720 patients who had undergone TOF repair (median age 5.7 months, interquartile range 3.7–11.7). Preoperative cyanotic spells occurred in 18%. A transatrial repair was performed in 433 (60.1%) patients. The PV was preserved in 249 (35%) patients, while the right ventricular outflow tract was reconstructed with a transannular patch (60.4%) or a conduit (4.6%) in the rest of the patients. At a median follow-up of 4 years (range 1–21, 86% complete), 10 (1.6%) patients died, while 39 (6.3%) patients required surgical reoperation and 72 (11.7%) patients required an interventional procedure. The propensity match analysis showed that the incidence of postoperative complications and adverse events at follow-up were significantly increased in patients undergoing transventricular approach repair with transannular patch (P = 0.006) and PV preservation was a significant protective factor against postoperative complications (P = 0.009, odds ratio 0.5) and late adverse events (P = 0.022). CONCLUSIONS Surgical repair of TOF in infancy is a safe procedure, with good late clinical outcomes. However, transatrial approach and PV preservation at repair are associated with lower early and late morbidity.

Anomalous origin of the pulmonary arteries from the ascending aorta is a rare, but severe clinical entity necessitating a scrupulous evaluation. Either the right or the left pulmonary arteries can arise directly from the ascending aorta while the other pulmonary artery retains its origin from the right ventricular outflow tract. Such a finding can be isolated or can coexist with several congenital heart lesions. Direct intrapericardial aortic origin, however, must be distinguished with origin through a persistently patent arterial duct. In the current era, clinical manifestations usually become evident in the newborn rather than during infancy, as used to be the case. They include respiratory distress or congestive heart failure due to increased pulmonary flow and poor feeding. The rate of survival has now increased due to early diagnosis and prompt surgical repair, should now be expected to be at least 95%. We have treated four neonates with this lesion over the past 7 years, all of whom survived surgical repair. Right ventricular systolic pressure was significantly decreased at follow-up. Our choice of treatment was to translocate the anomalous pulmonary artery in end-to-side fashion to the pulmonary trunk. Our aim in this report is to update an Italian experience in the diagnosis and treatment of anomalous direct origin of one pulmonary artery from the aorta, adding considerations on the lessons learned from our most recent review of the salient literature.