Fatih Özdemir

Coronary artery bypass grafting (CABG) is an exceedingly rare procedure in pediatric cardiac surgery, primarily due to the low incidence of coronary artery disease in this population. However, when indicated, the use of the internal thoracic artery (ITA) as a graft is crucial for ensuring long-term success. This case report describes a patient with a coronary artery anomaly where the right coronary artery is taking its origin from the left main coronary artery and transversing along the right ventricle outflow tract. The patient experienced late coronary compression after Rastelli operation, highlighting the critical role of ITA grafts in the surgical treatment.

Background: In this study, we present our early and mid-term results using two different types of handmade polytetrafluoroethylene (PTFE) valved conduits in patients who require right ventricular outflow reconstruction. Methods: Between March 2021 and May 2024, 72 patients (30 males and 42 females; median age: 69 (IQR: 26–123) months) who underwent implantation of a handmade bicuspid or tricuspid valve PTFE conduit for right ventricular outflow reconstruction were retrospectively analyzed. Preoperative, postoperative, and follow-up echocardiograms were also evaluated. Results: The first postoperative echocardiography revealed that 11 (36.7%) patients had mild regurgitation, and 3 (10%) patients had moderate regurgitation in the bicuspid group initially, while only 7 (16.7%) of the patients in the tricuspid group had mild regurgitation (p = 0.004). None of the patients required reintervention in the early postoperative period because of conduit dysfunction. In the mid-term follow-up, the mean follow-up duration was 22.4 ± 11 months. PTFE-valved conduit dysfunction was observed in three patients in the bicuspid group, while no dysfunction was observed in the tricuspid group (p = 0.049). Even if the median peak gradient was found to be slightly higher in the tricuspid group [15 (IQR: 0–25) vs. 0 (IQR: 0–15)] (p = 0.032), no conduit dysfunction was reported during follow-up. Kaplan–Meier analysis demonstrated that the tricuspid conduit group maintained 100% freedom from dysfunction during the 24-month follow-up period. In contrast, the bicuspid group had rates of 90%, 87%, and 83% at 6, 12, and 24 months, respectively (log-rank p = 0.016). Conclusions: The ePTFE valved conduits provide significant advantages in terms of durability, biocompatibility, cost-effectiveness, and hemodynamic performance for right ventricular outflow tract reconstruction in pediatric cardiac surgery. The findings of our study suggest that tricuspid valve design offers better potential for preventing conduit dysfunction.

Öz Amaç: Ciddi aortopulmoner çap uyumsuzluğu arteryel switch operasyonu sırasında karşılaşılan bir problemdir. Sinotubuler bileşke geometrisini bozarak postoperatif neoaortik kapak yetmezliğine neden olabilir. Bu çalışmada aortopulmoner çap uyumsuzluğunu gidermek için uyguladığımız cerrahi teknikleri ve bu prosedürün sonuçlarını inceledik. Materyal ve metod: Hastanemizde Aralık 2017-Mayıs 2023 tarihleri arasında büyük arter transpozisyonu (BAT) tanısı ile opere edilen hastalar arasından pulmoner arter / aort çap uyuşmazlığını gidermeye yönelik cerrahi prosedür uygulanan hastalar çalışmaya alındı. Hastalar nonkoroner sinüs plikasyonu yapılanlar ve diğer teknikler uygulananlar olarak iki gruba ayrıldı. Pulmoner arter / aort çap uyuşmazlığı sinotubuler bileşkede pulmoner arter çapının aorta çapının iki katından fazla olması olarak tanımlandı. Bulgular: Arteryel switch operasyonu yapılan 127 hastadan 23’ünde (%18,1) aortopulmoner çap uyumsuzluğu mevcuttu. Aortopulmoner çap uyumsuzluğu olan hastaların 15’ine (%65,2) nonkoroner sinüs plikasyonu, 5’ine (%21,7) aort anterior duvarına longitudinal insizyon ile genişletme, 2’sine (%8,7) pulmoner arterden doku rezeksiyonu ve 1’ine (%4,4) aort anterior duvarda otolog perikard yama ile genişletme yapıldı. Hastaların 15’i erkek, ortanca yaşı 14 gün ve ortanca ağırlığı 3,3 kg olarak saptandı. Hastaların 9’u basit BAT iken 10 hastada büyük arter transpozisyonuna ventriküler septal defekt, 4 hastada Taussig-Bing anomalisi, 4 hastada aortik ark patolojisi eşlik ediyordu. İki hasta sol ventrikül disfonksiyonu nedeniyle ve bir hasta sepsis nedeniyle yaşamını yitirdi. Gruplar arasında perioperatif veriler açısından anlamlı farklılık bulunmadı. Takipte hafif neoaortik kapak yetmezliği oranı nonkoroner sinüs plikasyonu yapılan hastalarda %33,3 (n=5), diğer tekniklerin uygulandığı hastalarda %37,5 (n=3) bulundu. Hiçbir hastada neoaortik kapak darlığı veya orta/ciddi neoaortik kapak yetmezliği saptanmadı. Sonuç: Nonkoroner sinüs plikasyonu arteryel switch operasyonlarında aortopulmoner çap uyumsuzluğunu gidermeye yönelik basit, düşük riskli ve uygulaması kolay bir prosedürdür. Bu teknik kullanılarak aort ve pulmoner arter arasındaki asimetri ortadan kaldırılabilir ve daha doğal bir anatomi oluşturulması sağlanabilir.

Background: This second harvest of the Congenital Heart Surgery Database intended to compare current results with international databases. Methods: This retrospective study examined a total of 4007 congenital heart surgery procedures from 15 centers in the Congenital Heart Surgery Database between January 2018 and January 2023. International diagnostic and procedural codes were used for data entry. STAT (Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery) mortality scores and categories were used for comparison of the data. Surgical priority status was modified from American Society of Anesthesiologist guidelines. Centers that sent more than 5 cases to the database were included to the study. Results: Cardiopulmonary bypass and cardioplegic arrest were performed in 2,983 (74.4%) procedures. General risk factors were present in 22.6% of the patients, such as genetic anomaly, syndrome, or prematurity. Overall, 18.9% of the patients had preoperative risk factors (e.g., mechanical ventilation, renal failure, and sepsis). Of the procedures, 610 (15.2%) were performed on neonates, 1,450 (36.2%) on infants, 1,803 (45%) on children, and 144 (3.6%) on adults. The operative timing was elective in 56.5% of the patients, 34.4% were urgent, 8% were emergent, and 1.1% were rescue procedures. Extracorporeal membrane oxygenation support was used in 163 (4%) patients, with a 34.3% survival rate. Overall mortality in this series was 6.7% (n=271). Risk for mortality was higher in patients with general risk factors, such as prematurity, low birth weight neonates, and heterotaxy syndrome. Mortality for patients with preoperative mechanical ventilation was 17.5%. Pulmonary hypertension and preoperative circulatory shock had 11.6% and 10% mortality rates, respectively. Mortality for patients who had no preoperative risk factor was 3.9%. Neonates had the highest mortality rate (20.5%). Intensive care unit and hospital stay time for neonates (median of 17.8 days and 24.8 days, respectively) were also higher than the other age groups. Infants had 6.2% mortality. Hospital mortality was 2.8% for children and 3.5% for adults. Mortality rate was 2.8% for elective cases. Observed mortality rates were higher than expected in the fourth and fifth categories of the STAT system (observed, 14.8% and 51.9%; expected, 9.9% and 23.1%; respectively). Conclusion: For the first time, outcomes of congenital heart surgery in Türkiye could be compared to the current world experience with this multicenter database study. Increased mortality rate of neonatal and complex heart operations could be delineated as areas that need improvement. The Congenital Heart Surgery Database has great potential for quality improvement of congenital heart surgery in Türkiye. In the long term, participation of more centers in the database may allow more accurate risk adjustment.

Background: In this study, we present our early results with the Ozaki procedure in the treatment of congenital aortic valve disease. Methods: Between July 2021 and July 2023, a total of 14 patients (10 males, 4 females; median age: 13.9 years; range, 8.5 to 15 years) who underwent neoaortic valve reconstruction of three leaflets using Ozaki procedure were retrospectively analyzed. Preoperative, postoperative, and follow-up echocardiogram images were evaluated. Results: Preoperative indications were aortic regurgitation (n=3) or combined aortic stenosis and regurgitation (n=11). The median aortic annular diameter was 23 (range, 19.5 to 25) mm on preoperative echocardiography. The median preoperative peak systolic aortic valve gradient for patients with aortic stenosis was 60 (range, 45 to 93) mmHg. The median preoperative aortic valve regurgitation grade was 4 (range, 3 to 4). Autologous pericardium and bovine pericardium were used in 12 and two patients, respectively. There was no conversion to valve replacement, myocardial infarction, or mortality in the early postoperative period. The median follow-up time was 8.5 (range, 6 to 19) months. One patient who performed the Ozaki procedure with bovine pericardium underwent valve replacement eight months later. Conclusion: The Ozaki procedure can be performed safely and effectively in congenital aortic valve stenosis and insufficiency with promising early results.

Infants who undergo cardiac surgery frequently have complications that may advance to multiple organ failure and result in mortality. This study aims to compare three different multiple organ dysfunction scoring systems: the Neonatal Multiple Organ Dysfunction (NEOMOD) score, the modified NEOMOD score, and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in predicting postoperative 30-day mortality in neonates undergoing cardiac surgery. This retrospective cohort study was conducted between January 2019 and February 2021 in a single unit on neonates operated on due to congenital heart disease in the first 28 days of life. Patients who underwent off-pump surgeries were excluded from the study. The NEOMOD, modified NEOMOD, and PELOD-2 scores were calculated for each of the first 3 days following surgery. A total of 138 patients were included. All scores had satisfactory goodness-of-fit and at least good discriminative ability on each day. The modified NEOMOD score consistently demonstrated the best prediction among these three scores after the first day, reaching its peak performance on day 2 (area under curve: 0.824, CI: 0.75–0.89). Our findings suggest that NEOMOD and modified NEOMOD scores in the first 72 h could potentially serve as a predictor of mortality in this population.

Background: In this study, we aimed to analyze the predictors and risk factors of mortality in patients who underwent Norwood I procedure with the diagnosis of hypoplastic left heart syndrome. Methods: Between January 2009 and December 2020, a total of 139 patients (95 males, 44 females) who underwent Norwood I procedure with the diagnosis of hypoplastic left heart syndrome in our center were retrospectively analyzed. Results: The median birth weight was 3,200 (range, 3,000 to 3,350) g and the median age at the time of operation was seven (range, 5 to 10) days. Pulmonary flow was achieved with a Sano shunt in the majority (72%) of patients. Survival rate was 41% after the first stage. Reoperation for bleeding (p=0.017), reoperation for residual lesion (p=0.011), and postoperative peak lactate level (p=0.029), were associated with in-hospital mortality. Nineteen (33%) of 57 patients died before the second stage. Thirty-three (58%) patients underwent second stage, and survival after the second stage was 94%. Thirteen patients underwent third stage, and survival after the third stage was 85%. Estimated probability of survival at six months, and one, two, three, and four years were 33%, 33%, 25%, 25%, and 22% respectively. Conclusion: Hospital and inter-stage mortality rates are still high and this seems to be the most challenging period in term of survival efforts of the patients with hypoplastic left heart syndrome. Early recognition and reintervention of anatomical residual defects, close follow-up in the inter-stage period, and the accumulation of multidisciplinary experience may help to improve the results to acceptable limits.