Mark Ruzmetov

Objective: There are limited studies that compare the outcomes of injection laryngoplasty (IL) versus observation in pediatric cardiac surgery patients with vocal fold immobility (VFI). The current study compares outcomes of VFI in pediatric cardiac surgery patients who undergo observation versus those who receive IL treatments. Methods: This is a retrospective case study of 41 pediatric cardiac surgery patients (observation 29 vs IL 12) who had postoperative VFI diagnosed by flexible laryngoscopy from January 1, 2015 to February 1, 2024. The resolution of VFI was based on subsequent normal flexible laryngoscopy and/or modified barium swallow study. The primary outcomes were the rates of gastrostomy tube placement and VFI resolution. Secondary outcomes were time from diagnosis to VFI resolution and time on tube feeds. The two cohorts were compared using two-tailed unpaired t-test, Fisher's exact test, and Mann-Whitney U test as appropriate. Results: There were no statistically significant differences in preoperative and intraoperative characteristics between the two groups. The overall rate of resolution of VFI was 78% (32/41) (observation 83% [24/29] and IL 67% [8/12] [ P = .41]). The mean time to VFI resolution was 13.8 months for the IL cohort and 9.9 months for the observation cohort ( P = .45). The overall gastrostomy tube placement rate was 44% (18/41) (observation 38% [11/29] vs IL 58% [7/12]% [ P = .31]). The mean time on tube feeds for each cohort was the following: observation 13.1 months versus IL 14.9 months ( P = .73). Conclusion: There were no statistically significant differences in outcomes between pediatric cardiac surgery patients with VFI who were observed and those who had IL.

Objective: Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly resulting in myocardial ischemia, global left ventricular (LV) dysfunction, and mitral regurgitation (MR). Surgical placement of a pulmonary artery band (PAB) at ALCAPA repair may assist with recovery of patients with severe LV dysfunction. We assessed the outcomes of patients with ALCAPA and severe dysfunction treated with, and without a PAB. Methods: We performed a retrospective analysis of cases presented to our center between January 2007 and December 2023. Baseline and follow-up data were collected from records. Ventricular function was assessed by standardized transthoracic echocardiogram. Results: Twenty-six patients underwent ALCAPA repair at a median age of 4 months (range 19 days-8 years). Surgery was performed by direct coronary reimplantation in all patients. Beginning in 2017, we have placedan adjustable PAB in 5 patients with severe LV dysfunction (Conclusion: There is marked improvement of MR grade and LV function, and no mortality during a 10-year period in the group with EF > 25%. Patients with EF < 25% treated with a PAB demonstrated an improved trajectory toward EF improvement, achieving normal function earlier than those without PA band. Temporary adjustable PAB may be beneficial in ALCAPA patients with severe dysfunction.

Purpose: Some centers including ours have used glutaraldehyde-treated pericardium for reconstruction of coronary button defects at the arterial switch operation (ASO). This may impact the incidence of pulmonary stenosis and prevent primary closure of the pericardium. We report a series where 2-ply extracellular matrix (Tyke) was used to reconstruct the neopulmonary root. Methods: Since May 2016, all patients (n = 38) were repaired using Tyke for reconstruction of the coronary button defects. We measured the incidence of pulmonary stenosis and insufficiency at the main pulmonary artery (MPA) and branch pulmonary arteries by echocardiogram and compared these measurements with the historical cohort where pericardium (some treated with glutaraldehyde, some fresh) was used. Results: Mean follow-up was 3.0 ± 2.4 years (range, 1 month to 8 years). The mean gradient at the neopulmonary valve was 6.8 ± 7 mm Hg in the Tyke group versus 23.7 ± 16.1 in the pericardium group ( P < .01). The mean gradient at the distal MPA was 8.9 ± 2.9 mm Hg for the Tyke group and 44.5 ± 40.1 in the historical group ( P < .01). The mean gradient at the proximal left and right branch pulmonary arteries was 29 ± 19 and 32 ± 16 mm Hg in the Tyke group and 33 ± 16 and 36 ± 26 (NSD). At the last follow-up, six of 38 patients (18%) in the Tyke group had a pulmonary reintervention: five patients had a balloon dilation of branch pulmonary arteries, and one patient had dilation of the MPA. No patients underwent surgical intervention on the pulmonary valve or the reconstructed MPA. Conclusion: Tyke is a reasonable alternative material for reconstruction of the coronary button defects during the ASO within the follow-up period.

Background: Patients with bicuspid aortic valves (BAVs) tend to develop dilation of the ascending aorta. The aim of this study was to analyze the impact of leaflet fusion pattern on aortic root diameter and outcomes in patients undergoing surgery for BAV vs tricuspid aortic valve (TAV) disease. Methods: This is a retrospective review of 90 patients with aortic valve disease (mean [SD] age, 51.5 [8.2] years) who underwent aortic valve replacement for BAV (n = 60) and TAV (n = 30). Fusion of right-left (R/L) coronary cusps was identified in 45 patients, whereas the remaining 15 patients had right-noncoronary (R/N) cusp fusion. Aortic diameter was measured at 4 levels, and Z values were computed. Results: There were no significant differences between the BAV and TAV groups for age, weight, aortic insufficiency grade, or size of implanted prostheses. However, a higher preoperative peak gradient at the aortic valve was significantly associated with R/L fusion (P = .02). Preoperative Z values of ascending aorta and sinotubular junction diameter were significantly higher in patients with R/N fusion than with the R/L (P < .001 and P = .04, respectively) and TAV (P < .001 and P < .05, respectively) subgroups. During the follow-up period (mean [SD], 2.7 [1.8] years), 3 patients underwent a redo procedure. At the last follow-up, the sizes of ascending aorta were similar among all 3 patient groups. Conclusion: This study suggests that preoperative dilation of the ascending aorta is more common in patients with R/N fusion than in patients with R/L and TAV but is not significantly different between all groups in the early follow-up period. R/L fusion was associated with an increased risk of preoperative presence of aortic stenosis.

Background: Surgical pulmonary artery banding (PAB) has been limited in practice because of later requirement for surgical removal or adjustment. The aim of this study is to describe our experience creating a dilatable PAB via transcatheter balloon dilation (TCBD) in congenital heart disease (CHD) patients. Methods: Retrospective chart review of adjustable PAB—outline anatomical variants palliated and patient outcomes. Results: Sixteen patients underwent dilatable PAB—median age 52 days (range 4-215) and weight 3.12 kg (1.65-5.8). Seven (44%) of the patients were premature, 11 (69%) had ventricular septal defect(s) with pulmonary over-circulation, four (25%) atrioventricular septal defects, and four (25%) single ventricle physiology. Subsequent to the index procedure: five patients have undergone intracardiac complete repair, six patients remain well palliated with no additional intervention, and four single ventricles await their next palliation. One patient died from necrotizing enterocolitis (unrelated to PAB) and one patient required a pericardiocentesis postoperatively. Five patients underwent TCBD of the PAB without complication—Two had one TCBD, two had two TCBD, and another had three TCBD. The median change in saturation was 14% (complete range 6-22) and PAB diameter 1.7 mm (complete range 1.1-5.2). Median time from PAB to most recent outpatient follow-up was 868 days (interquartile range 190-1,079). Conclusions: Our institution has standardized a PAB technique that allows for transcatheter incremental increases in pulmonary blood flow over time. This methodology has proven safe and effective enough to supplant other institutional techniques of limiting pulmonary blood flow in most patients—allowing for interval growth or even serving as the definitive palliation.

Background In addition to being associated with aortopathy, a bicuspid aortic valve (BAV) has been posed to be a risk factor for the dilation of the pulmonary autograft in the aortic position. The aim of this study is to assess the association between the subtype of native aortic valve leaflet fusion (right and noncoronary leaflets [R/N] vs right and left leaflets [R/L]) and autograft dilation and valve dysfunction after the Ross procedure. Methods We performed a retrospective review of 43 patients with BAV who underwent a Ross procedure in our center from 1993 to 2013. Serial transthoracic echocardiography was used to measure changes in autograft and ascending aortic diameter over time. The aortic diameter was measured at four levels, and Z values were computed. Aortic dilation was defined as a Z value greater than 3. Results The mean age at the time of the Ross procedure was 13.5 ± 9.2 years. R/L was the most prevalent native aortic valve subtype (R/L, n = 26, 61% vs R/N, n = 17, 39%). PreRoss procedure, aortic dilation was more frequent in patients with R/N fusion (P = .02), whereas the initial aortic valve gradient and grade of aortic insufficiency (AI) did not differ between the subgroups. At follow‐up, (mean = 9.6 ± 4.3 years) dilation of the autograft and ascending aorta was seen more often in patients with R/N leaflet fusion (P = .03). Conversely, the prevalence of more than moderate AI was significantly higher in patients with R/L leaflet fusion (P = .03). There was no significant difference between groups among numbers of late reintervention on the aortic valve or root (P = .75); however the type of intervention varied by morphologic subtype. Patients with R/L fusion underwent more aortic valve replacements (AVRs) while patients with R/N fusion underwent more valve‐sparing aortic root replacements. Conclusions After Ross procedure, both groups of patients were likely to have a combination of dilation of the aortic root and the tubular portion of the ascending aorta at follow‐up. Patients with R/L fusion were more likely to have a prevalence of root dilation, while patients with R/N fusion were more likely to have tubular ascending aorta dilation. The R/L phenotype is associated with a slightly more rapid dilation at follow‐up and is more likely to have postoperative autograft insufficiency. This information may serve to guide patient and procedure selection for AVR.

Objective: Custodiol is an intracellular, crystalloid cardioplegia solution that is a single-dose alternative to multi-dose cold blood cardioplegia; however, there is scarce data regarding its use in infants and children. The objective of this study was to compare its impact on myocardial function in infants. Methods: Single-center retrospective review including 132 patients <12 months old undergoing biventricular repair. There were 106 patients who received single-dose Custodiol and 27 patients who received multi-dose blood cardioplegia. Demographic and echocardiographic data were compared between the two groups. Results: Patients receiving Custodiol were slightly younger (100 ± 62 days) and lower weight (4.7 ± 1.3 kg) compared to 152 ± 86 days and 5.2 ± 1.3 kg for blood cardioplegia (p < 0.05). The Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery Congenital Heart Surgery score was similar between both groups. Average cardiopulmonary bypass time was similar between both groups (Custodiol 93 ± 54 minutes vs. blood 81 ± 44 minutes, p = 0.46) as was aortic cross-clamp time (Custodiol 58 ± 33 minutes vs. cold blood 53 ± 33 minutes, p = 0.62). Pre-operative left ventricular ejection fraction was similar for blood 73 ± 8% versus Custodiol 70 ± 9%, p = 0.21. There was also no intergroup difference in left ventricular ejection fraction 24 hours post op (blood 64 ± 9% vs. Custodiol 65 ± 12%, p = 0.53) or at discharge (blood 66 ± 10% vs. Custodiol 66 ± 11%, p = 0.95). The pre-operative right ventricle function by fractional area change was also similar in blood cardioplegia (46 ± 13%) versus Custodiol (48 ± 9%, p = 0.38) and showed similar drops in parameters in the two groups 24 hours after surgery and at discharge. Conclusion: Single-dose Custodiol is as safe as blood cardioplegia for myocardial protection in congenital cardiac surgery for the cross-clamp times evaluated in this study. Evaluation at longer cross-clamp times would be helpful to determine if there is a greater benefit to single-dose Custodiol versus more repeated doses of blood cardioplegia for longer cross-clamp times.