Home Journal Watch Safe Decompression of the Right Ventricle for PAIVS in Neonates with Coronary Fistulae: Including the selective Use of fistula ligation to avoid coronary steal

Safe Decompression of the Right Ventricle for PAIVS in Neonates with Coronary Fistulae: Including the selective Use of fistula ligation to avoid coronary steal

florinef 100 mg Noveen Davidson, MBBS, MCh, Fiona Doig, MBBS, M.S, Eliazar Dimpalapang, BA, MStat, John Stirling, MB, ChB, FCP, (SA) (Paed), Thomas Gentles, MB, ChB, FRACP, Nigel Wilson, MB, ChB, FRACP, John Artrip, MD, FRACS, Kirsten Finucane, MB, ChB, FRACS

buy me a boat lyrics World Journal for Pediatric and Congenital Heart Surgery, 12(2), 185-194. https://doi.org/10.1177/2150135120974395

Abstract

buy modafinil canada Background: There are a number of surgical and interventional treatment options for infants with pulmonary atresia with intact ventricular septum (PAIVS). In our practice, we characterize coronary fistulae and interruptions with angiography in the newborn and have developed a strategy to safely decompress the right ventricle in association with ligation of fistulae if necessary.

how to order Pregabalin taper Methods: All infants operated for PAIVS at age < 60 days from 1999 to 2018 were retrospectively studied. Pre- and postoperative variables were collected, angiograms were reviewed, and a territory score was created to grade the severity of coronary abnormalities. This study focused on the subgroup of patients who had early surgical decompression of the right ventricle.

Results: A total of 77 patients were included, with a mean follow-up of 8.6 years. Of these, 55 (71%) had coronary fistulae, including 28 (36%) with coronary artery interruption. Right ventricular decompression (RVD) was performed in 47 (60.5%) patients. There was no 30-day mortality in those who underwent RVD, whereas 6 (20%) without RVD died within 30 days (P = .003). Ten-year survival was 97.8% and 73.3% for RVD and non-RVD, respectively. In order to prevent coronary steal, 17 patients underwent coronary fistula ligation as their RV was decompressed with 100% early and late survival.

Conclusion: Early and late survival in infants with PAIVS is better if the RV can be decompressed. Coronary fistula ligation with RVD has been introduced without an adverse outcome in selected patients with large fistulae.

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Commentary

The authors present a very nice single center, retrospective review of patients with Pulmonary Atresia and Intact Ventricular Septum (PAIVS) that underwent surgery with and without right ventricular decompression and coronary fistula ligation.  The authors present an excellent clinical algorithm describing their institutional management of neonates with this diagnosis (Figure #1). The overall results and survival were excellent. There were six patients with atresia of more than one coronary artery ostium, of which four died. The authors point to the inability to provide transplantation in their country for this population. The literature and personnel experience has clearly supported the benefit of cardiac transplantation in this sub-set of patients with PAIVS.  This should be include in any algorithm describing the management of this defect during the neonatal period. Also, authors refer to a still controversial theory concerning growth of the right ventricle following the depression of the outflow tract.  A word of cautions should be provide when attempting to place patient down this pathway.  Although there is some evidence that this phenomenon may occur, there is a potential for a profound negative impact on other organ systems.  This may be as a result of increase central venous pressure, often greater then we see with functional single ventricle palliation.  Just a word of caution.

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