The late development of heart block in paediatric patients following device closure of a perimemb... more The late development of heart block in paediatric patients following device closure of a perimembranous ventricular septal defect may be a cause for concern.
Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual, 2006
Doubly committed subarterial ventricular septal defect complicated by severe aortic regurgitation... more Doubly committed subarterial ventricular septal defect complicated by severe aortic regurgitation caused by a prolapsed aortic cusp still represents a challenging surgical problem. We report on our "two-patch" technique, were the ventricular septal defect is closed through the aortic valve by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed to the aortic wall. Since May 1990, 15 patients with a mean age of 12 years underwent repair of this cardiac malformation with the "two-patch" technique. The aortic regurgitation was severe in all patients. All patients survived. In a mean follow-up of 10 years, two patients were successfully reoperated for progression of the aortic regurgitation. All the remaining patients were in NYHA functional class I. In conclusion, the "two-patch" technique is simple, easily reproducible, and can be a valid surgical option for this complex car...
Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual, 1999
The Fontan procedure by means of an extracardiac conduit was initially proposed for patients pres... more The Fontan procedure by means of an extracardiac conduit was initially proposed for patients presenting with anomalies of intra-atrial anatomy. We extended this technique to all patients with functional anatomic single ventricle. Between 1988 and 1998, 206 patients with complex cardiacanomalies underwent a total extracardiac cavopuolmonary connection. In 202 patients we used a conduit, in 4 patients we performed an IVC to pulmonary artery direct anastomosis. Ten patients underwent Conversion of a filing atriopulmonary Fontan procedure to a total extracardiac cavopulmonary connection. Early deaths occurred in 10% of patients and the extracardiac conduit was taken down in 3 additional patients. The cause of death was myocardial failure in 13 patients. Pulmonary distortion or hypoplasia in 6. No deaths have occurred in our last 45 patients. We observed no cases of conduit obstruction and thrombosis. Arrthymias were present in 16 patients. Ten patients underwent conversion of a formed m...
Congenital aortopulmonary window is a rare inborn cardiac malformation that should be surgically ... more Congenital aortopulmonary window is a rare inborn cardiac malformation that should be surgically treated as soon as the diagnosis is made usually during infancy. We report a successful surgical treatment of a 23-year-old male patient with a big type III aortopulmonary window.
Near Infrared Spectroscopy (NIRS) is an emerging technique for brain oxygenation monitoring in ne... more Near Infrared Spectroscopy (NIRS) is an emerging technique for brain oxygenation monitoring in newborns complicated by acute and chronic hypoxia. However, data regarding cerebral oxygenation normal values are still lacking and matter of debate. Therefore, we investigate whether NIRS parameters in healthy preterm/term infants are gestational age and delivery modalities dependent and correlate with standard monitoring parameters. From January to December 2007, 100 healthy newborns with gestational age from 30 to 42 weeks' gestation were evaluated. Routine laboratory variables, daily clinical and neurological evaluation and ultrasound imaging were performed. The regional cerebral oxygen saturation (rSO2) and fractional cerebral tissue oxygen extraction (FTOE) were measured by NIRS in the first 6-hours after birth. Data were recorded by MetaVision ICU X-Edition software and analyzed by SPSS statistical package. rSO2 and FTOE correlated (R=-0.77; R=0.41; P<0.01, for both) with gestational age. Highest rSO2 and the lowest FTOE peaks (P<0.001, for all) were found at 30-33 wks when compared with other monitoring periods. From 34 wks onwards, rSO2 progressively decreased and FTOE increased reaching their lower dip/peak (P<0.001, for all) at 38-39 weeks. rSO2 and FTOE values were significantly different (P<0.05, for both) between preterm and term newborns when corrected for delivery modality. rSO2 correlated (P<0.001 for all) with heart (r=0.63), respiratory (r=-0.58) rate, and with arterial oxygen saturation (r=0.65). In conclusion, in the first 6-hours after birth cerebral oxygenation in healthy newborns is gestational age-dependent and correlated with routine parameters. NIRS reference curve could be particularly useful in sick newborns brain monitoring.
Journal of Maternal-Fetal and Neonatal Medicine, 2009
Hypoxia-ischemia (H-I) constitutes the main phenomenon responsible for brain-blood barrier permea... more Hypoxia-ischemia (H-I) constitutes the main phenomenon responsible for brain-blood barrier permeability modifications leading to cerebral vascular auto-regulation loss in newborns. Hypotension, cerebral ischemia, and reperfusion are the main events involved in vascular auto-regulation loss leading to cell death and tissue damage. Reperfusion could be critical since organ damage, particularly of the brain, may be amplified during this period. An exaggerated activation of vasoactive agents, of calcium mediated effects could be responsible for reperfusion injury (R-I), which, in turns, leads to cerebral hemorrhage and damage. These phenomena represent a common repertoire in newborns complicated by perinatal acute or chronic hypoxia treated by risky procedures such as mechanical ventilation, nitric oxide supplementation, brain cooling, and extracorporeal membrane oxygenation (ECMO). Despite accurate monitoring, the post-insult period is crucial, as clinical symptoms and standard monitoring parameters may be silent at a time when brain damage is already occurring and the therapeutic window for pharmacological intervention is limited. Therefore, the measurement of circulating biochemical markers of brain damage, such as vasoactive agents and nervous tissue peptides is eagerly awaited in clinical practice to detect high risk newborns. The present review is aimed at investigating the role of biochemical markers such as adrenomedullin, a vasoactive peptide; S100B, a calcium binding protein, activin A, a glycoprotein, in the cascade of events leading to I-R injury in newborns complicated by perinatal asphyxia.
Aims: To summarise data from studies comparing surgical (SC) versus percutaneous closure (PC) of ... more Aims: To summarise data from studies comparing surgical (SC) versus percutaneous closure (PC) of atrial septal defects (ASDs).
Journal of Maternal-Fetal and Neonatal Medicine, 2012
Low cardiac output syndrome (LCOS) remains a major perioperative complications in infants subject... more Low cardiac output syndrome (LCOS) remains a major perioperative complications in infants subjected to open-heart surgery with cardiopulmonary bypass (CPB). The present study investigated whether perioperative blood assessment of a potent vasoactive peptide namely adrenomedullin (AM) can predict the risk of LCOS. We measured AM levels in 48 patients (LCOS: n = 9; controls: n = 39) undergone to open-heart surgery with CPB at five predetermined time points before, during and after the surgery. Clinical, laboratory and perioperative data were analyzed by a multiple logistic regression model. AM significantly decreased (p < 0.01) during and after the surgical procedure exhibiting a dip at the end of the CPB. Multivariable analysis demonstrated significant correlations among LCOS, AM measured at the end of CPB (p < 0.001), and cooling duration (p < 0.05). AM at 27 pg/L cutoff achieved a sensitivity of 100% and a specificity of 64.1%, while cooling at 11-min cutoff combined a sensitivity of 55.6% and a specificity of 92.3% for LCOS prediction. This study suggests that AM can constitute, alone or combined with standard parameters, a promising predictor of LCOS in infants subjected to open-heart surgery with CPB.
Intrauterine infection is suggested to cause perinatal brain white matter injury. In the current ... more Intrauterine infection is suggested to cause perinatal brain white matter injury. In the current study, we evaluated whether S100B, a brain damage marker, may be also assessed in maternal bloodstream after white matter injury induced by fetal intravenous application of lypopolisaccharide (LPS) endotoxin. Fourteen fetal sheeps were chronically catheterized at a mean gestational age of 107 days. Three days after surgery, fetuses (n = 7) received 500 ng of LPS or 2 mL 0.9% saline (n = 7) intravenously (IV). Lypopolisaccharide and placebo groups were monitored by continuous hemodynamic data recordings and at 6 predetermined time points (control value; 3, 6, 24, 48, and 72 hours after LPS/placebo administration) blood was drawn for laboratory parameters and S100B assessment. Brain damage was evaluated by light microscopy after Klüver-Barrera staining. Selected areas of the periventricular white matter were also examined by electron microscopy. White matter injury was detected in all LPS-treated fetuses, whereas no abnormalities were seen in control animals or in LPS-treated mothers. Maternal and fetal S100B protein levels were significantly higher in the LPS group than in the control group at all monitoring time points (P < .001). The highest fetal-maternal S100B levels were observed at 3-hour time-point (P < .001). We found that S100B protein is increased in the maternal district in presence of fetal periventricular brain white matter injury induced by endotoxin. The present data offer additional support for S100B assessment in the maternal circulation in pregnancies complicated by intrauterine infection at risk of white matter injury.
Background: Neonatal death in full-term infants who suffer from perinatal asphyxia (PA) is a majo... more Background: Neonatal death in full-term infants who suffer from perinatal asphyxia (PA) is a major subject of investigation, since few tools exist to predict patients at risk of ominous outcome. We studied the possibility that urine S100B measurement may identify which PA-affected infants are at risk of early postnatal death.
Thousands of children live in developing countries with untreated but correctable congenital hear... more Thousands of children live in developing countries with untreated but correctable congenital heart disease (CHD), and most of them will die simple because they live in poor countries that do not have suitable medical/surgical facilities. The aim of the Association of Children with Heart Disease in the World is to support the operatory and teaching activities of a group of voluntary doctors engaged in the management of children with CHD in developing countries. Since 1992, the association has obtained 160 grants for foreign doctors who have been trained in our hospitals; performed 75 missions abroad, with more than 2150 cases evaluated and 404 cardiac operations performed; obtained millions of dollars worth of donated medical equipment; and constructed two cardiac surgery departments in Syria and Cameroon. Many efforts have been made, but much more can be done as we attain more experience and develop better coordination and collaboration between the international groups engaged in this emerging social need.
The Journal of Thoracic and Cardiovascular Surgery, 2004
The ultimate goal of surgical therapy for pulmonary atresia with ventricular septal defect and ma... more The ultimate goal of surgical therapy for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries is to create unobstructed and separate in series pulmonary and systemic circuits. Our preference has been a 1-stage complete unifocalization technique, avoiding collateral anastomosis with either the native pulmonary arteries or other aortopulmonary collateral vessels.
The Journal of Thoracic and Cardiovascular Surgery, 2000
Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients wit... more Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients with dysfunction of a prior Fontan connection. Thirty-one patients (19.9 +/- 8.8 years) underwent revision of a previous Fontan connection to total extracardiac cavopulmonary anastomosis at four institutions. Complications of the previous Fontan connection included atrial tachyarrhythmias (n = 20), progressive heart failure (n = 17), Fontan pathway obstruction (n = 10), effusions (n = 10), pulmonary venous obstruction by an enlarged right atrium (n = 6), protein-losing enteropathy (n = 3), right atrial thrombus (n = 2), subaortic stenosis (n = 1), atrioventricular valve regurgitation (n = 3), and Fontan baffle leak (n = 5). Conversion to an extracardiac cavopulmonary connection was performed with a nonvalved conduit from the inferior vena cava to the right pulmonary artery, with additional procedures as necessary. There have been 3 deaths. Two patients died in the perioperative period of heart failure and massive effusions. The third patient died suddenly 8 months after the operation. All surviving patients were in New York Heart Association class I (n = 20) or II (n = 7), except for 1 patient who underwent heart transplantation. Early postoperative arrhythmias occurred in 10 patients: 4 required pacemakers, and medical therapy was sufficient in 6. In 15 patients, pre-revision arrhythmias were improved. Effusions resolved in all but 1 of the patients in whom they were present before revision. The condition of 2 patients with protein-losing enteropathy improved within 30 days. Conversion of a failing Fontan connection to extracardiac cavopulmonary connection can be achieved with low morbidity and mortality. Optimally, revision should be undertaken early in symptomatic patients before irreversible ventricular failure ensues.
Background: Brain hyperthermia, accompanying the rewarming phase of cardiopulmonary bypass (CPB),... more Background: Brain hyperthermia, accompanying the rewarming phase of cardiopulmonary bypass (CPB), has been involved in the genesis of postoperative brain damage. Blood SlOOB levels are emerging as a marker of brain distress, and could offer a reliable monitoring tool at different times during and after open heart surgery. Methods: Thirty-two patients undergoing repair of congenital heart disease with CPB and deep hypothermic circulatory arrest (DHCA) were monitored by SlOOB blood levels and middle cerebral artery Doppler velocimetry pulsatility index (MCA PI) before, during, and after surgical procedure a t five predetermined time-points. Results: Both SlOOB and MCA PI significantly increased, MCA PI values exhibiting a peak at t h e end of surgery time-point (p > 0.051, while SlOOB blood levels were increased a t the end of CPB (p c 0.05). Multivariate analysis, with SlOOB levels measured at the end of CPB as dependent variable, showed a positive significant correlation with MCA PI (p = 0.041, with the CPB and the rewarming duration (p = 0.03 and p = 0.009, respectively). Conclusions: The present results show a significant correlation between a biochemical marker of brain damage and an index of increased cerebrovascular resistance, with higher levels during the rewarming CPB phase in pediatric open heart surgery. 17.279-284) Several parameters such as hemodynamic changes due to the duration of the operative stress during cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), have
Background: The Ross operation has been applied t o various aortic valve pathologies, particularl... more Background: The Ross operation has been applied t o various aortic valve pathologies, particularly when somatic growth is an issue. However, associated cardiac disease and technical problems may limit its use with regard t o associated procedures and issues of right ventricular outflow reconstruction. Materials and Methods: From December 1992 t o March 1998,24 patients underwent aortic pulmonary autograft implantation. There were 14 males and 10 females, 15 2 10 years of age (mean f SD) (range 1 t o 50 years), weighing 42.8 f 20 kg (mean 2 SD) (range 8 t o 78 kg). Aortic insufficiency was Present in 15 (62.5%) patients, stenosis in 8 (33.3%) patients, and valvar stenosis associated with left ventricular outflow tract obstruction in 1 (4.1%) patient. Etiology was rheumatic in 17 patients and congenital in 7. The Ross procedure was accompanied by a partial-Konno left ventricular Outflow enlargement in one patient, and mitral valve annuloplasty, mitral commissurotomy, and tricuspid valve replacement in three other patients, respectively. The right ventricular outflow was reconstructed with a valved pulmonary homograft in 14 patients and with a Shelhigh No-React@ Porcine Pulmonary conduit in 10 patients. Evaluation was done by New York Heart Association (NYHA) Class and by echocardiography at a follow-up of 22.8 2 24 months (mean 2 SD) (range 3 t o 63 months). Results: There were no operative mortalities and no postoperative arrhythmias. One (4.1%) patient required intra-aortic balloon pump (IABP) support for 3 days, one (4.1%) patient died 2 Years later of probable arrhythmia, and one (4.1%) patient required mechanical aortic valve replacement 2 Years later for severe autograft insufficiency. Left ventricular ejection fraction was unchanged (preoperative 62.4% 2 30%, postoperative 64.2% 2 30% [mean f SD], [p = NSI) and no significant gradient was documented by echocardiographic Doppler in the right and left ventricular outflow tracts. The aortic insufficiency scale decreased from a mean of 3.9 2 0.2 t o a mean of 1 f 0 (p < 0.01). NYHA Class decreased t o I in all patients, from 111 (10) and II (14).
Supraventricular and ventricular arrhythmias are a major cause of morbidity and mortality in adul... more Supraventricular and ventricular arrhythmias are a major cause of morbidity and mortality in adult patients with congenital heart disease (CHD). Intraoperative ablation offers an alternative to the complex surgical Cox-Maze procedure for these patients. We present the results of our preliminary experience with intraoperative monopolar irrigated radiofrequency ablation (IRA) in adults with CHD undergoing elective cardiac surgery. Since September 2002, 50 adults with a mean age of 39 years with CHD underwent IRA during cardiac surgery. We performed 31 right-sided Maze procedures, 13 Cox-Maze III procedures and 6 right ventricular ablations. In addition, we implanted a pace-maker into 14 patients. Two patients died (2 of 50; 4%) of causes not related to the intraoperative ablation. Over an average follow-up period of 28 months the remaining 48 patients are alive in NYHA class I or II. All patients were discharged on antiarrhythmic oral treatment for 3 months. All patients underwent Holter testing 3 and 6 months after the ablation procedure and five underwent programmed ventricular tachycardia stimulation 6 months postoperatively. Forty-three patients are still in spontaneous sinus rhythm, two are in sinus rhythm on chronic oral antiarrhythmic treatment for recurrence of atrial fibrillation, two are in stable atrial fibrillation, and one has pacemaker rhythm. There were no complications from the IRA. Intraoperative IRA is a safe and effective procedure to control arrhythmic problems in adults with CHD. This procedure should be taken into consideration when transcatheter ablation fails or when elective cardiac surgery is planned.
Methods and results Between January 2000 and June 2005, among 140 patients who underwent percutan... more Methods and results Between January 2000 and June 2005, among 140 patients who underwent percutaneous closure of an mVSD or a pmVSD, 88 were aged lt;12. Two different Amplatzer devices were used: the mVSD occluder and the pmVSD occluder. Mean age and weight ...
The late development of heart block in paediatric patients following device closure of a perimemb... more The late development of heart block in paediatric patients following device closure of a perimembranous ventricular septal defect may be a cause for concern.
Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual, 2006
Doubly committed subarterial ventricular septal defect complicated by severe aortic regurgitation... more Doubly committed subarterial ventricular septal defect complicated by severe aortic regurgitation caused by a prolapsed aortic cusp still represents a challenging surgical problem. We report on our "two-patch" technique, were the ventricular septal defect is closed through the aortic valve by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed to the aortic wall. Since May 1990, 15 patients with a mean age of 12 years underwent repair of this cardiac malformation with the "two-patch" technique. The aortic regurgitation was severe in all patients. All patients survived. In a mean follow-up of 10 years, two patients were successfully reoperated for progression of the aortic regurgitation. All the remaining patients were in NYHA functional class I. In conclusion, the "two-patch" technique is simple, easily reproducible, and can be a valid surgical option for this complex car...
Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual, 1999
The Fontan procedure by means of an extracardiac conduit was initially proposed for patients pres... more The Fontan procedure by means of an extracardiac conduit was initially proposed for patients presenting with anomalies of intra-atrial anatomy. We extended this technique to all patients with functional anatomic single ventricle. Between 1988 and 1998, 206 patients with complex cardiacanomalies underwent a total extracardiac cavopuolmonary connection. In 202 patients we used a conduit, in 4 patients we performed an IVC to pulmonary artery direct anastomosis. Ten patients underwent Conversion of a filing atriopulmonary Fontan procedure to a total extracardiac cavopulmonary connection. Early deaths occurred in 10% of patients and the extracardiac conduit was taken down in 3 additional patients. The cause of death was myocardial failure in 13 patients. Pulmonary distortion or hypoplasia in 6. No deaths have occurred in our last 45 patients. We observed no cases of conduit obstruction and thrombosis. Arrthymias were present in 16 patients. Ten patients underwent conversion of a formed m...
Congenital aortopulmonary window is a rare inborn cardiac malformation that should be surgically ... more Congenital aortopulmonary window is a rare inborn cardiac malformation that should be surgically treated as soon as the diagnosis is made usually during infancy. We report a successful surgical treatment of a 23-year-old male patient with a big type III aortopulmonary window.
Near Infrared Spectroscopy (NIRS) is an emerging technique for brain oxygenation monitoring in ne... more Near Infrared Spectroscopy (NIRS) is an emerging technique for brain oxygenation monitoring in newborns complicated by acute and chronic hypoxia. However, data regarding cerebral oxygenation normal values are still lacking and matter of debate. Therefore, we investigate whether NIRS parameters in healthy preterm/term infants are gestational age and delivery modalities dependent and correlate with standard monitoring parameters. From January to December 2007, 100 healthy newborns with gestational age from 30 to 42 weeks&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; gestation were evaluated. Routine laboratory variables, daily clinical and neurological evaluation and ultrasound imaging were performed. The regional cerebral oxygen saturation (rSO2) and fractional cerebral tissue oxygen extraction (FTOE) were measured by NIRS in the first 6-hours after birth. Data were recorded by MetaVision ICU X-Edition software and analyzed by SPSS statistical package. rSO2 and FTOE correlated (R=-0.77; R=0.41; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01, for both) with gestational age. Highest rSO2 and the lowest FTOE peaks (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001, for all) were found at 30-33 wks when compared with other monitoring periods. From 34 wks onwards, rSO2 progressively decreased and FTOE increased reaching their lower dip/peak (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001, for all) at 38-39 weeks. rSO2 and FTOE values were significantly different (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05, for both) between preterm and term newborns when corrected for delivery modality. rSO2 correlated (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001 for all) with heart (r=0.63), respiratory (r=-0.58) rate, and with arterial oxygen saturation (r=0.65). In conclusion, in the first 6-hours after birth cerebral oxygenation in healthy newborns is gestational age-dependent and correlated with routine parameters. NIRS reference curve could be particularly useful in sick newborns brain monitoring.
Journal of Maternal-Fetal and Neonatal Medicine, 2009
Hypoxia-ischemia (H-I) constitutes the main phenomenon responsible for brain-blood barrier permea... more Hypoxia-ischemia (H-I) constitutes the main phenomenon responsible for brain-blood barrier permeability modifications leading to cerebral vascular auto-regulation loss in newborns. Hypotension, cerebral ischemia, and reperfusion are the main events involved in vascular auto-regulation loss leading to cell death and tissue damage. Reperfusion could be critical since organ damage, particularly of the brain, may be amplified during this period. An exaggerated activation of vasoactive agents, of calcium mediated effects could be responsible for reperfusion injury (R-I), which, in turns, leads to cerebral hemorrhage and damage. These phenomena represent a common repertoire in newborns complicated by perinatal acute or chronic hypoxia treated by risky procedures such as mechanical ventilation, nitric oxide supplementation, brain cooling, and extracorporeal membrane oxygenation (ECMO). Despite accurate monitoring, the post-insult period is crucial, as clinical symptoms and standard monitoring parameters may be silent at a time when brain damage is already occurring and the therapeutic window for pharmacological intervention is limited. Therefore, the measurement of circulating biochemical markers of brain damage, such as vasoactive agents and nervous tissue peptides is eagerly awaited in clinical practice to detect high risk newborns. The present review is aimed at investigating the role of biochemical markers such as adrenomedullin, a vasoactive peptide; S100B, a calcium binding protein, activin A, a glycoprotein, in the cascade of events leading to I-R injury in newborns complicated by perinatal asphyxia.
Aims: To summarise data from studies comparing surgical (SC) versus percutaneous closure (PC) of ... more Aims: To summarise data from studies comparing surgical (SC) versus percutaneous closure (PC) of atrial septal defects (ASDs).
Journal of Maternal-Fetal and Neonatal Medicine, 2012
Low cardiac output syndrome (LCOS) remains a major perioperative complications in infants subject... more Low cardiac output syndrome (LCOS) remains a major perioperative complications in infants subjected to open-heart surgery with cardiopulmonary bypass (CPB). The present study investigated whether perioperative blood assessment of a potent vasoactive peptide namely adrenomedullin (AM) can predict the risk of LCOS. We measured AM levels in 48 patients (LCOS: n = 9; controls: n = 39) undergone to open-heart surgery with CPB at five predetermined time points before, during and after the surgery. Clinical, laboratory and perioperative data were analyzed by a multiple logistic regression model. AM significantly decreased (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) during and after the surgical procedure exhibiting a dip at the end of the CPB. Multivariable analysis demonstrated significant correlations among LCOS, AM measured at the end of CPB (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and cooling duration (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). AM at 27 pg/L cutoff achieved a sensitivity of 100% and a specificity of 64.1%, while cooling at 11-min cutoff combined a sensitivity of 55.6% and a specificity of 92.3% for LCOS prediction. This study suggests that AM can constitute, alone or combined with standard parameters, a promising predictor of LCOS in infants subjected to open-heart surgery with CPB.
Intrauterine infection is suggested to cause perinatal brain white matter injury. In the current ... more Intrauterine infection is suggested to cause perinatal brain white matter injury. In the current study, we evaluated whether S100B, a brain damage marker, may be also assessed in maternal bloodstream after white matter injury induced by fetal intravenous application of lypopolisaccharide (LPS) endotoxin. Fourteen fetal sheeps were chronically catheterized at a mean gestational age of 107 days. Three days after surgery, fetuses (n = 7) received 500 ng of LPS or 2 mL 0.9% saline (n = 7) intravenously (IV). Lypopolisaccharide and placebo groups were monitored by continuous hemodynamic data recordings and at 6 predetermined time points (control value; 3, 6, 24, 48, and 72 hours after LPS/placebo administration) blood was drawn for laboratory parameters and S100B assessment. Brain damage was evaluated by light microscopy after Klüver-Barrera staining. Selected areas of the periventricular white matter were also examined by electron microscopy. White matter injury was detected in all LPS-treated fetuses, whereas no abnormalities were seen in control animals or in LPS-treated mothers. Maternal and fetal S100B protein levels were significantly higher in the LPS group than in the control group at all monitoring time points (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). The highest fetal-maternal S100B levels were observed at 3-hour time-point (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). We found that S100B protein is increased in the maternal district in presence of fetal periventricular brain white matter injury induced by endotoxin. The present data offer additional support for S100B assessment in the maternal circulation in pregnancies complicated by intrauterine infection at risk of white matter injury.
Background: Neonatal death in full-term infants who suffer from perinatal asphyxia (PA) is a majo... more Background: Neonatal death in full-term infants who suffer from perinatal asphyxia (PA) is a major subject of investigation, since few tools exist to predict patients at risk of ominous outcome. We studied the possibility that urine S100B measurement may identify which PA-affected infants are at risk of early postnatal death.
Thousands of children live in developing countries with untreated but correctable congenital hear... more Thousands of children live in developing countries with untreated but correctable congenital heart disease (CHD), and most of them will die simple because they live in poor countries that do not have suitable medical/surgical facilities. The aim of the Association of Children with Heart Disease in the World is to support the operatory and teaching activities of a group of voluntary doctors engaged in the management of children with CHD in developing countries. Since 1992, the association has obtained 160 grants for foreign doctors who have been trained in our hospitals; performed 75 missions abroad, with more than 2150 cases evaluated and 404 cardiac operations performed; obtained millions of dollars worth of donated medical equipment; and constructed two cardiac surgery departments in Syria and Cameroon. Many efforts have been made, but much more can be done as we attain more experience and develop better coordination and collaboration between the international groups engaged in this emerging social need.
The Journal of Thoracic and Cardiovascular Surgery, 2004
The ultimate goal of surgical therapy for pulmonary atresia with ventricular septal defect and ma... more The ultimate goal of surgical therapy for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries is to create unobstructed and separate in series pulmonary and systemic circuits. Our preference has been a 1-stage complete unifocalization technique, avoiding collateral anastomosis with either the native pulmonary arteries or other aortopulmonary collateral vessels.
The Journal of Thoracic and Cardiovascular Surgery, 2000
Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients wit... more Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients with dysfunction of a prior Fontan connection. Thirty-one patients (19.9 +/- 8.8 years) underwent revision of a previous Fontan connection to total extracardiac cavopulmonary anastomosis at four institutions. Complications of the previous Fontan connection included atrial tachyarrhythmias (n = 20), progressive heart failure (n = 17), Fontan pathway obstruction (n = 10), effusions (n = 10), pulmonary venous obstruction by an enlarged right atrium (n = 6), protein-losing enteropathy (n = 3), right atrial thrombus (n = 2), subaortic stenosis (n = 1), atrioventricular valve regurgitation (n = 3), and Fontan baffle leak (n = 5). Conversion to an extracardiac cavopulmonary connection was performed with a nonvalved conduit from the inferior vena cava to the right pulmonary artery, with additional procedures as necessary. There have been 3 deaths. Two patients died in the perioperative period of heart failure and massive effusions. The third patient died suddenly 8 months after the operation. All surviving patients were in New York Heart Association class I (n = 20) or II (n = 7), except for 1 patient who underwent heart transplantation. Early postoperative arrhythmias occurred in 10 patients: 4 required pacemakers, and medical therapy was sufficient in 6. In 15 patients, pre-revision arrhythmias were improved. Effusions resolved in all but 1 of the patients in whom they were present before revision. The condition of 2 patients with protein-losing enteropathy improved within 30 days. Conversion of a failing Fontan connection to extracardiac cavopulmonary connection can be achieved with low morbidity and mortality. Optimally, revision should be undertaken early in symptomatic patients before irreversible ventricular failure ensues.
Background: Brain hyperthermia, accompanying the rewarming phase of cardiopulmonary bypass (CPB),... more Background: Brain hyperthermia, accompanying the rewarming phase of cardiopulmonary bypass (CPB), has been involved in the genesis of postoperative brain damage. Blood SlOOB levels are emerging as a marker of brain distress, and could offer a reliable monitoring tool at different times during and after open heart surgery. Methods: Thirty-two patients undergoing repair of congenital heart disease with CPB and deep hypothermic circulatory arrest (DHCA) were monitored by SlOOB blood levels and middle cerebral artery Doppler velocimetry pulsatility index (MCA PI) before, during, and after surgical procedure a t five predetermined time-points. Results: Both SlOOB and MCA PI significantly increased, MCA PI values exhibiting a peak at t h e end of surgery time-point (p > 0.051, while SlOOB blood levels were increased a t the end of CPB (p c 0.05). Multivariate analysis, with SlOOB levels measured at the end of CPB as dependent variable, showed a positive significant correlation with MCA PI (p = 0.041, with the CPB and the rewarming duration (p = 0.03 and p = 0.009, respectively). Conclusions: The present results show a significant correlation between a biochemical marker of brain damage and an index of increased cerebrovascular resistance, with higher levels during the rewarming CPB phase in pediatric open heart surgery. 17.279-284) Several parameters such as hemodynamic changes due to the duration of the operative stress during cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), have
Background: The Ross operation has been applied t o various aortic valve pathologies, particularl... more Background: The Ross operation has been applied t o various aortic valve pathologies, particularly when somatic growth is an issue. However, associated cardiac disease and technical problems may limit its use with regard t o associated procedures and issues of right ventricular outflow reconstruction. Materials and Methods: From December 1992 t o March 1998,24 patients underwent aortic pulmonary autograft implantation. There were 14 males and 10 females, 15 2 10 years of age (mean f SD) (range 1 t o 50 years), weighing 42.8 f 20 kg (mean 2 SD) (range 8 t o 78 kg). Aortic insufficiency was Present in 15 (62.5%) patients, stenosis in 8 (33.3%) patients, and valvar stenosis associated with left ventricular outflow tract obstruction in 1 (4.1%) patient. Etiology was rheumatic in 17 patients and congenital in 7. The Ross procedure was accompanied by a partial-Konno left ventricular Outflow enlargement in one patient, and mitral valve annuloplasty, mitral commissurotomy, and tricuspid valve replacement in three other patients, respectively. The right ventricular outflow was reconstructed with a valved pulmonary homograft in 14 patients and with a Shelhigh No-React@ Porcine Pulmonary conduit in 10 patients. Evaluation was done by New York Heart Association (NYHA) Class and by echocardiography at a follow-up of 22.8 2 24 months (mean 2 SD) (range 3 t o 63 months). Results: There were no operative mortalities and no postoperative arrhythmias. One (4.1%) patient required intra-aortic balloon pump (IABP) support for 3 days, one (4.1%) patient died 2 Years later of probable arrhythmia, and one (4.1%) patient required mechanical aortic valve replacement 2 Years later for severe autograft insufficiency. Left ventricular ejection fraction was unchanged (preoperative 62.4% 2 30%, postoperative 64.2% 2 30% [mean f SD], [p = NSI) and no significant gradient was documented by echocardiographic Doppler in the right and left ventricular outflow tracts. The aortic insufficiency scale decreased from a mean of 3.9 2 0.2 t o a mean of 1 f 0 (p < 0.01). NYHA Class decreased t o I in all patients, from 111 (10) and II (14).
Supraventricular and ventricular arrhythmias are a major cause of morbidity and mortality in adul... more Supraventricular and ventricular arrhythmias are a major cause of morbidity and mortality in adult patients with congenital heart disease (CHD). Intraoperative ablation offers an alternative to the complex surgical Cox-Maze procedure for these patients. We present the results of our preliminary experience with intraoperative monopolar irrigated radiofrequency ablation (IRA) in adults with CHD undergoing elective cardiac surgery. Since September 2002, 50 adults with a mean age of 39 years with CHD underwent IRA during cardiac surgery. We performed 31 right-sided Maze procedures, 13 Cox-Maze III procedures and 6 right ventricular ablations. In addition, we implanted a pace-maker into 14 patients. Two patients died (2 of 50; 4%) of causes not related to the intraoperative ablation. Over an average follow-up period of 28 months the remaining 48 patients are alive in NYHA class I or II. All patients were discharged on antiarrhythmic oral treatment for 3 months. All patients underwent Holter testing 3 and 6 months after the ablation procedure and five underwent programmed ventricular tachycardia stimulation 6 months postoperatively. Forty-three patients are still in spontaneous sinus rhythm, two are in sinus rhythm on chronic oral antiarrhythmic treatment for recurrence of atrial fibrillation, two are in stable atrial fibrillation, and one has pacemaker rhythm. There were no complications from the IRA. Intraoperative IRA is a safe and effective procedure to control arrhythmic problems in adults with CHD. This procedure should be taken into consideration when transcatheter ablation fails or when elective cardiac surgery is planned.
Methods and results Between January 2000 and June 2005, among 140 patients who underwent percutan... more Methods and results Between January 2000 and June 2005, among 140 patients who underwent percutaneous closure of an mVSD or a pmVSD, 88 were aged lt;12. Two different Amplatzer devices were used: the mVSD occluder and the pmVSD occluder. Mean age and weight ...
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Papers by Raul Abella