Journal of Heart and Lung Transplantation, Apr 1, 2021
Introduction This is a case of a 16-year-old male with ccTGA who underwent systemic RVAD (HeartMa... more Introduction This is a case of a 16-year-old male with ccTGA who underwent systemic RVAD (HeartMate III) implantation for severe systemic RV dysfunction. Case Report Based on suboptimal transesophageal (TEE) and epicardial ECHO imaging, the inflow cannula was to be placed anterior and lateral to the true apex of the systemic RV. The ventriculotomy created by a coring device overrode into the ventricular septum and was hidden underneath the inflow cannula ring (Fig 1A). After VAD support was initiated, patient became severely hypoxic with a PO2 of 45-50 mmHg. CPB was re-initiated and the inflow cannula was removed, revealing a large iatrogenic VSD at the cannula insertion point. VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the VAD sewing ring (Fig 1B). After CPB was weaned again, patient initially remained cyanotic and imaging identified possible tiny VSD patch leak with right to left shunting as a potential cause of hypoxia. Pursuing residual VSD closure was deemed unsafe. Rescue nitric oxide (NO) infusion dramatically corrected the desaturation. Summary Iatrogenic VSD in the setting of systemic RVAD causes significant hypoxia but can be effectively repaired by patch closure. Determining the favourable positioning of the inflow cannula in ccTGA is a technical challenge. Using a combination of TEE and epicardial ECHO offers superior guidance for cannula insertion, but can still be inadequate in preventing iatrogenic injury. Furthermore, even small residual VSDs or septal suture holes can be a source of hemodynamically significant right to left shunting due to the high negative pressure from the inflow cannula. In these situations, medical optimization may be the solution. Rationale for the remarkable effect of NO in our case is somewhat unclear, but perhaps explained by improved ventricular ejection and decompression from the subpulmonary LV. Figure 1. ECHO of A) iatrogenic VSD hidden by sewing ring and B) RV after VSD patch closure and lateral repositioning of inflow cannula.=
Additional file 1: Supplemental Fig. 1. Country of data collected for anesthesia-related interven... more Additional file 1: Supplemental Fig. 1. Country of data collected for anesthesia-related interventions tested in multicentre randomized controlled trials.
In the last decade, there has been a discrepancy between the increasing recognition for research ... more In the last decade, there has been a discrepancy between the increasing recognition for research involvement in medical training and the stagnation in the number physician-scientists. Health research funding cutbacks, inadequate mentorship, heavy schedules, and unfamiliarity with scientific methodology are obstacles that limit research interest amongst junior medical learners and cause attrition of promising physician-scientist in training. This article outlines five strategies to promote and facilitate the development of physician-scientists with the understanding that research is integral to clinical excellence. Some of the ways the undergraduate and postgraduate medical curricula can better lend themselves to producing clinicians with the skillset to address clinical uncertainties through an evidence-based approach are: partnerships between healthcare and academia, increasing admission to MD/PhD and Clinical Investigator programs, establishing fundamentals of scientific thinking,...
The commonly used central shunt (i.e. direct connection of the divided main pulmonary artery to t... more The commonly used central shunt (i.e. direct connection of the divided main pulmonary artery to the ascending aorta) to facilitate the growth of the diminutive branch pulmonary artery in patients with pulmonary atresia with major aortopulmonary collateral arteries can cause main pulmonary artery distortion, and subsequent disproportional branch pulmonary artery flow and growth. This report describes a novel technique of shunt construction to minimize pulmonary artery torque and tension by using a modified central shunt constructed from autologous pericardium that is anastomosed in an end-to-side fashion to the lateral aspect of the ascending aorta. This shunt will serve as an intermediary conduit to facilitate the main pulmonary artery anastomosis while minimizing torque and tension on the main pulmonary artery. The tension-free connection between the main pulmonary artery and the aorta enabled by the modified central shunt supports proportional pulmonary artery flow and growth in p...
Congenitally corrected transposition of the great arteries (ccTGAs) represents a complex form of ... more Congenitally corrected transposition of the great arteries (ccTGAs) represents a complex form of congenital heart disease that is associated with several cardiac complications. Herein is a case series of three children with ccTGA and ventricular assist device (VAD) inserted for systemic right ventricle failure at a single institution. All patients remained hemodynamically stable postimplant and were successfully discharged from the intensive care unit to undergo postoperative rehabilitation. All three patients received an orthotopic heart transplant with uneventful posttransplant courses. This case series provides insight into the medical management and technical feasibility of VAD support in children with ccTGA with end-stage heart failure.
Journal of Heart and Lung Transplantation, Apr 1, 2021
Introduction This is a case of a 16-year-old male with ccTGA who underwent systemic RVAD (HeartMa... more Introduction This is a case of a 16-year-old male with ccTGA who underwent systemic RVAD (HeartMate III) implantation for severe systemic RV dysfunction. Case Report Based on suboptimal transesophageal (TEE) and epicardial ECHO imaging, the inflow cannula was to be placed anterior and lateral to the true apex of the systemic RV. The ventriculotomy created by a coring device overrode into the ventricular septum and was hidden underneath the inflow cannula ring (Fig 1A). After VAD support was initiated, patient became severely hypoxic with a PO2 of 45-50 mmHg. CPB was re-initiated and the inflow cannula was removed, revealing a large iatrogenic VSD at the cannula insertion point. VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the VAD sewing ring (Fig 1B). After CPB was weaned again, patient initially remained cyanotic and imaging identified possible tiny VSD patch leak with right to left shunting as a potential cause of hypoxia. Pursuing residual VSD closure was deemed unsafe. Rescue nitric oxide (NO) infusion dramatically corrected the desaturation. Summary Iatrogenic VSD in the setting of systemic RVAD causes significant hypoxia but can be effectively repaired by patch closure. Determining the favourable positioning of the inflow cannula in ccTGA is a technical challenge. Using a combination of TEE and epicardial ECHO offers superior guidance for cannula insertion, but can still be inadequate in preventing iatrogenic injury. Furthermore, even small residual VSDs or septal suture holes can be a source of hemodynamically significant right to left shunting due to the high negative pressure from the inflow cannula. In these situations, medical optimization may be the solution. Rationale for the remarkable effect of NO in our case is somewhat unclear, but perhaps explained by improved ventricular ejection and decompression from the subpulmonary LV. Figure 1. ECHO of A) iatrogenic VSD hidden by sewing ring and B) RV after VSD patch closure and lateral repositioning of inflow cannula.=
Additional file 1: Supplemental Fig. 1. Country of data collected for anesthesia-related interven... more Additional file 1: Supplemental Fig. 1. Country of data collected for anesthesia-related interventions tested in multicentre randomized controlled trials.
In the last decade, there has been a discrepancy between the increasing recognition for research ... more In the last decade, there has been a discrepancy between the increasing recognition for research involvement in medical training and the stagnation in the number physician-scientists. Health research funding cutbacks, inadequate mentorship, heavy schedules, and unfamiliarity with scientific methodology are obstacles that limit research interest amongst junior medical learners and cause attrition of promising physician-scientist in training. This article outlines five strategies to promote and facilitate the development of physician-scientists with the understanding that research is integral to clinical excellence. Some of the ways the undergraduate and postgraduate medical curricula can better lend themselves to producing clinicians with the skillset to address clinical uncertainties through an evidence-based approach are: partnerships between healthcare and academia, increasing admission to MD/PhD and Clinical Investigator programs, establishing fundamentals of scientific thinking,...
The commonly used central shunt (i.e. direct connection of the divided main pulmonary artery to t... more The commonly used central shunt (i.e. direct connection of the divided main pulmonary artery to the ascending aorta) to facilitate the growth of the diminutive branch pulmonary artery in patients with pulmonary atresia with major aortopulmonary collateral arteries can cause main pulmonary artery distortion, and subsequent disproportional branch pulmonary artery flow and growth. This report describes a novel technique of shunt construction to minimize pulmonary artery torque and tension by using a modified central shunt constructed from autologous pericardium that is anastomosed in an end-to-side fashion to the lateral aspect of the ascending aorta. This shunt will serve as an intermediary conduit to facilitate the main pulmonary artery anastomosis while minimizing torque and tension on the main pulmonary artery. The tension-free connection between the main pulmonary artery and the aorta enabled by the modified central shunt supports proportional pulmonary artery flow and growth in p...
Congenitally corrected transposition of the great arteries (ccTGAs) represents a complex form of ... more Congenitally corrected transposition of the great arteries (ccTGAs) represents a complex form of congenital heart disease that is associated with several cardiac complications. Herein is a case series of three children with ccTGA and ventricular assist device (VAD) inserted for systemic right ventricle failure at a single institution. All patients remained hemodynamically stable postimplant and were successfully discharged from the intensive care unit to undergo postoperative rehabilitation. All three patients received an orthotopic heart transplant with uneventful posttransplant courses. This case series provides insight into the medical management and technical feasibility of VAD support in children with ccTGA with end-stage heart failure.
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