Interactive CardioVascular and Thoracic Surgery (2017) 1–7 ORIGINAL ARTICLE

doi:10.1093/icvts/ivx148

Cite this article as: Lee J-H, Lee J-E, Shin J, Song I-K, Kim H-S, Kim C-S et al. Clinical implications of hypothermic ventricular fibrillation versus beating-heart technique
during cardiopulmonary bypass for pulmonary valve replacement in patients with repaired tetralogy of Fallot. Interact CardioVasc Thorac Surg 2017; doi:10.1093/
icvts/ivx148.

ADULT CARDIAC
Clinical implications of hypothermic ventricular fibrillation
versus beating-heart technique during cardiopulmonary bypass
for pulmonary valve replacement in patients with repaired
tetralogy of Fallot
Ji-Hyun Leea, Ji-Eun Leea, Jungho Shina, In-Kyung Songa, Hee-Soo Kima, Chong-Sung Kima,
Woong-Han Kimb and Jin-Tae Kima,*
a
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
b
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea

* Corresponding author. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, # 101 Daehakno, Jongnogu, Seoul 110-744, Republic
of Korea. Tel: +82-2-20723295; fax: +82-2-7455587; e-mail: jintae73@gmail.com (J.-T. Kim).

Received 2 November 2016; received in revised form 16 March 2017; accepted 21 March 2017

Abstract
OBJECTIVES: This study aimed to compare the effects of hypothermic ventricular fibrillation and beating-heart techniques during cardio-
pulmonary bypass (CPB) on postoperative outcomes after simple pulmonary valve replacement in patients with repaired tetralogy of
Fallot (TOF).
METHODS: We retrospectively reviewed the data of 47 patients with repaired tetralogy of Fallot at a single institution, who received pul-
monary valve replacement under the ventricular fibrillation or beating-heart technique without cardioplegic cardiac arrest during CPB
between January 2005 and April 2015.
RESULTS: The patients were divided into fibrillation (n = 32) and beating-heart (n = 15) groups. On comparing these groups, the fibrillation
group had a larger sinotubular junction (27.1 ± 4.6 vs 22.1 ± 2.4 mm), had a longer operation duration (396 ± 108 vs 345 ± 57 min), required
more postoperative transfusions (2.1 ± 2.6 vs 5.0 ± 6.3 units) and had a higher vasoactive–inotropic score at intensive care unit admission
(8.0 vs 10, all P < 0.05). Echocardiographic data indicated that the systolic internal diameter of the left ventricle was larger in the fibrillation
group than in the beating-heart group immediately after surgery and at the 1-year follow-up. Major adverse cardiac events occurred in 3
cases, all from the fibrillation group. Among 7 patients from the fibrillation group with transoesophageal echocardiography data during
CPB, 6 had fully opened aortic valves during fibrillation, causing flooding into the left ventricle and left ventricle distension.
CONCLUSIONS: The postoperative outcomes are worse with the ventricular fibrillation technique than with the beating-heart technique
during CPB for pulmonary valve replacement in patients with repaired tetralogy of Fallot.
Keywords: Cardiopulmonary bypass • Pulmonary valve replacement • Tetralogy of Fallot • Ventricular distension • Ventricular
fibrillation

INTRODUCTION A recent retrospective study showed that a non-cardioplegic

Management of the heart during cardiopulmonary bypass (CPB)
for cardiac surgery varies according to the institution and the sur-
gical plan selected. There are cardioplegic methods (blood or
crystalloid cardioplegia, antegrade or retrograde infusion of car-
dioplegia) and non-cardioplegic methods (ventricular fibrillation
or beating-heart technique) [1–3]. Beating-heart and hypother-
mic ventricular fibrillation techniques can be used in procedures,
such as pulmonary valve replacement (PVR) without aorta cross-
clamping, when there is no definite intracardiac defect [3–5].
method was preferred with good clinical outcomes after coro-
nary artery bypass surgery [3]. However, there have been contro-
versies regarding myocardial ischaemia between the ventricular
fibrillation and beating-heart techniques [6, 7]. Hypothermic ven-
tricular fibrillation during cardiac surgery has some benefits [8],
including maintenance of continuous coronary perfusion and
easy control of the surgical field by the surgeon, which can help
avoid flooding from the right ventricle (RV) by contraction when
the pulmonary artery is open. However, there may be a concern
about increased myocardial energy consumption in ventricular

C The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V
2 J.-H. Lee et al. / Interactive CardioVascular and Thoracic Surgery
fibrillation, because it involves a hyperactive state when com-
pared with the beating-heart condition.
We assumed that the beating-heart and ventricular fibrillation
techniques during CPB have similar influences on myocardial
oxygen consumption in an empty heart. However, when the left
ventricle (LV) is inadequately decompressed, the balance of oxy-
gen supply and demand in the myocardium would be more
impaired with the ventricular fibrillation technique than with the
beating-heart technique, because the LV is continuously dis-
tended in ventricular fibrillation. LV distension is associated with
increased intraventricular pressure and impaired myocardial
perfusion.
The progression of pulmonary regurgitation and RV dilation
are common indications for PVR after early surgical repair in
patients with tetralogy of Fallot (TOF) [9]. Aortic root dilatation,
with progressive aortic insufficiency, is a common late postoper-
ative complication of TOF [10]. Geometric deformation of the
aortic valve during implantation of an artificial pulmonary valve
can cause an increase in the volume of aortic regurgitation dur-
ing CPB, leading to LV distension and myocardial ischaemia.
There are limited data on the effects of hypothermic ventricu-
lar fibrillation and beating-heart techniques during CPB on clini-
cal outcomes after PVR. The purpose of this study was to
compare the effects of these 2 techniques during CPB on postop-
erative outcomes after simple PVR in patients with repaired TOF.
MATERIALS AND METHODS
Study population
This study was approved by our local Institutional Review Board
(approval no.: H1605-025-760), and the requirement for written
informed consent was waived. We reviewed the medical records
of all patients who underwent TOF repair in infancy and were
admitted to our institution for PVR between January 2005 and
April 2015. We included patients who received simple PVR
because of moderate-to-severe pulmonary regurgitation. The
timing of PVR in patients with pulmonary regurgitation was usu-
ally determined when there was an increased RV end-diastolic
volume index (>150–170 ml/m2 as measured using magnetic res-
onance imaging), decreased RV and LV function, recurrent
arrhythmia or symptoms, such as exercise intolerance and dysp-
noea, following discussions among attending paediatric cardiolo-
gists and cardiac surgeons. We excluded patients who underwent
other complex procedures, such as replacement of the RV out-
flow tract conduit, extensive pulmonary artery angioplasty, and
excision of the infundibulum. Patients with preoperative infective
endocarditis were also excluded.
Intraoperative strategy including surgical and
cardiopulmonary bypass technique
A sternotomy was performed and CPB was instituted with single-
venous and ascending aortic cannulation. CPB was conducted with
non-pulsatile flow and mild-to-moderate hypothermia (28–32 C)
during the beating-heart or ventricular fibrillation condition for
myocardial protection [1]. Ventricular fibrillation occurred sponta-
neously during hypothermia, or it was induced using a fibrillator.
Patients were divided into the following 2 groups according to
the CPB strategy: the beating-heart group and the fibrillation
group. If ventricular fibrillation was left or induced, we included
the patient in the fibrillation group. If a spontaneous fibrillating
heart was defibrillated immediately and returned to normal sinus
rhythm, we included the patient in the beating-heart group.
A bioprosthetic valve (Hancock II, Medtronic, Minneapolis,
MN, USA) was implanted for PVR using multiple interrupted 3-0
Ethibond suture. The incised main pulmonary artery was wid-
ened with a Gore-Tex patch using 4-0 Gore-Tex continuous
suture at the level of the pulmonary annulus. When the pulmo-
nary valve was completely implanted, temperature was gradually
increased and defibrillation was performed in the fibrillating
heart, if necessary. Routinely, the surgeons inserted a vent cathe-
ter through the pulmonary vein or left atrium directly for PVR
under hypothermic ventricular fibrillation. However, when severe
adhesion was noted and major bleeding was expected owing to
adhesiolysis, a vent catheter was not used. No vent catheter was
used in the beating-heart group.
Data collection and definitions
Two experts who performed paediatric cardiac anaesthesia
reviewed the following electronic medical records and intraoper-
ative transoesophageal echocardiography (TOE) data during CPB:
type of operation; preoperative echocardiographic and cardiac
magnetic resonance imaging data; duration of operation and
CPB; duration of fibrillation; intraoperative peak lactate level;
postoperative echocardiographic data and cardiac magnetic res-
onance imaging results, including left ventricle internal diameter
(LVID); amount of transfused blood; duration of mechanical ven-
tilation (MV); duration of stay in the intensive care unit; and post-
operative major adverse cardiac events, including non-fatal
cardiac arrest, myocardial infarction, congestive heart failure,
new cardiac arrhythmia and death [11].
The use of inotropic and vasoactive medications was also
recorded. The vasoactive–inotropic score (VIS) was calculated as fol-
lows [12]: (dopamine dose, mg/kg/min + dobutamine dose, mg/kg/
min + 100) x (epinephrine dose, mg/kg/min + 10) x (milrinone dose,
mg/kg/min + 10,000) x (vasopressin dose, U/kg/min + 100) x (norepi-
nephrine dose, mg/kg/min). The VIS score at 0, 24, 48 and 72 h after
surgery was recorded in all patients.
Statistical analysis
Data are presented as means (standard deviations) or medians
(interquartile ranges). For each comparison, we used the
Kolmogorov–Smirnov test to determine whether the data were
normally distributed, and then, we used the Student’s t-test or
Mann-Whitney U-test to evaluate the differences between
groups. Categorical data were analysed using Fisher’s exact test.
All statistical analyses were performed using SPSS, ver. 19 (SPSS,
Inc., Chicago, IL, USA). A P-value <0.05 was considered statisti-
cally significant.
RESULTS
Between January 2005 and April 2015, 114 patients at our institu-
tion underwent simple PVR because of pulmonary regurgitation
after repair of TOF in infancy. We excluded 67 patients (56 who
underwent operation under cardioplegic cardiac arrest and 11
whose medical records regarding the CPB strategy were unclear).
 J.-H. Lee et al. / Interactive CardioVascular and Thoracic Surgery 3

We finally analysed the data of 47 patients (32 in the fibrillation that the diastolic LVID and the change in the systolic LVID were
group and 15 in the beating-heart group). significantly greater in the fibrillation group than in the beating-
heart group. Additionally, the 1-year follow-up echocardio-
graphic findings showed that the systolic LVID and the change in

Clinical outcomes
The beating-heart and fibrillation groups showed no significant
differences in patient characteristics (Table 1). Patients had no
other cardiac anomaly, such as an atrial or ventricular septal
defect. A vent was inserted in 11 patients from the fibrillation
group. The mean size of the sinotubular junction was significantly
larger in the fibrillation group than in the beating-heart group
(P = 0.006), although the 2 groups had no differences in the size
of the aortic annulus and sinus of Valsalva. The 2 groups had sim-
ilar presence and grade of aortic regurgitation (AR), which was
considered trivial. Additionally, there were no significant differen-
ces in preoperative ventricular ejection fraction, RV end-diastolic
volume and size of the systolic and diastolic LVID.
Table 2 shows the intraoperative and postoperative variables
in the beating-heart and fibrillation groups. The lowest intraoper-
ative body temperature was significantly lower in the fibrillation
group than in the beating-heart group (P = 0.029). The 2 groups
had similar durations of CPB, but the operative time was longer
in the fibrillation group than in the beating-heart group
(P = 0.039). The mean duration of fibrillation was 77.1 ± 34.5 min.
The amount of blood received during the postoperative period
was significantly higher in the fibrillation group than in the
beating-heart group (P = 0.03). According to postoperative 1-year
echocardiography data, the degree of AR did not change. Only 1
patient from the fibrillation group showed trivial mitral regurgita-
tion (MR), whereas other patients had no significant MR after
surgery.
All patients received inotropic and vasoactive support intrao-
peratively and postoperatively. The VIS score at intensive care
unit admission was significantly higher in the fibrillation group
than in the beating-heart group (P = 0.008). The immediate post-
operative transthoracic echocardiographic findings indicated
ADULT CARDIAC
the systolic and diastolic LVID were significantly greater in the
fibrillation group than in the beating-heart group.
During hospitalization, 3 patients from the fibrillation group
had major adverse cardiac events (1 patient had intermittent
desaturation requiring reintubation and bagging with an artificial
manual breathing unit and 2 patients had newly developed arrhyth-
mia requiring cardioversion). The fibrillation and beating-heart
groups had similar durations of MV and intensive care unit stay, and
there were no cases of postoperative mortality in either group.
Because a vent catheter was only used in the fibrillation group,
we additionally compared data between the fibrillation group
with a vent catheter and that without a vent catheter. However,
there were no significant differences in baseline and intraopera-
tive characteristics, and postoperative clinical outcomes between
these groups (all P > 0.05).
Intraoperative transoesophageal echocardiography
TOE was performed intraoperatively in all patients. All of the
patients showed moderate or severe pulmonary regurgitation with
increased RV volume before PVR. Among the patients, TOE images
during CPB were available in 10 patients who underwent surgery
after October 2012 (3 in the beating-heart group and 7 in the
fibrillation group). TOE images during CPB were not obtained
before October 2012, because we had no specific interest in ven-
tricular fibrillation during CPB. The TOE images during CPB
showed LV distension during fibrillation in 6 of the 7 patients from
the fibrillation group and in no patient from the beating-heart
group. TOE confirmed that the aortic valve fully opened during
fibrillation, resulting in flooding into the LV and LV distension
(Fig. 1, Videos 1 and 2). Among the 6 patients with LV distension,

Table 1: Preoperative characteristics of the beating-heart and fibrillation groups

Beating heart (n = 15) Fibrillation (n = 32) P-value

Age (years) 15.7 ± 6.2 17.7 ± 5.9 0.091

Height (cm) 153.1 ± 14.9 159.5 ± 16.2 0.222
Weight (kg) 45.6 ± 16.2 51.5 ± 15.6 0.120
Sex (M/F) 9/6 8/24 0.315
No. of previous cardiac surgeries 1.5 (1.0–2.25) 1.0 (1.0–2.0) 0.541
Preoperative echocardiography and MRI data
Incidence of aortic regurgitation 6 12 0.592
Aortic annulus diameter (mm) 23.2 ± 3.6 24.3 ± 4.2 0.417
Aortic sinus diameter (mm) 32.5 ± 4.2 34.6 ± 5.0 0.272
Sinotubular junction size (mm) 22.1 ± 2.4 27.1 ± 4.6 0.006
PR fraction (%) 39 ± 9 36 ± 13 0.519
RV EF (%) 40.2 ± 7.5 35.3 ± 11.0 0.185
RV EDV (ml/m2) 163 ± 46 186 ± 55 0.240
LV EF (%) 58 ± 9 63 ± 11 0.150
Systolic LVID (mm) 27.2 ± 6.4 25.8 ± 5.8 0.470
Diastolic LVID (mm) 40.3 ± 7.3 40.3 ± 5.9 0.970

Numerical data are presented as means ± standard deviations or as medians (interquartile ranges). Patients in the beating-heart group had beating hearts dur-
ing CPB; patients in the fibrillation group had hypothermic ventricular fibrillation during CPB.
PR: pulmonary regurgitation; RV: right ventricle; EF: ejection fraction; EDV: end-diastolic volume; LV: left ventricle; LVID: LV internal diameter.
4 J.-H. Lee et al. / Interactive CardioVascular and Thoracic Surgery

Table 2: Intraoperative and postoperative characteristics of the beating-heart and fibrillation groups

Beating heart (n = 15) Fibrillation (n = 32) P-value

Lowest body temperature during CPB ( C) 29.3 ± 2.0 27.5 ± 2.6 0.029
Intraoperative transfusion (units)a 11.2 ± 6.3 10.8 ± 5.8 0.820
Postoperative transfusion (units)a 2.1 ± 2.6 5.0 ± 6.3 0.030
Operation time (min) 345 ± 57 396 ± 108 0.039
CPB time (min) 129 ± 30 140 ± 50 0.458
Intraoperative peak lactate (mmol/l) 3.7 ± 2.7 4.0 ± 3.1 0.747
VIS, 0 h 8.0 (5.2–9.4) 10.0 (7.9–11.8) 0.008
VIS, 24 h 0.0 (0.0–8.1) 3.0 (0.0–7.5) 0.590
VIS, 48 h 0.0 (0.0–0.0) 0.0 (0.0–6.7) 0.067
VIS, 72 h 0.0 (0.0–0.0) 0.0 (0.0–2.0) 0.144
Total MV time (h) 9.5 (7.6–13.9) 14.2 (7.0–19.3) 0.304
ICU stay (h) 44.1 (21.2–44.1) 46.6 (23.2–91.7) 0.240
Hospital stay (days) 9.0 (8.0–13.0) 11.0 (9.0–18.8) 0.088
Number of MACEs 0 3 0.210
Immediate postoperative echocardiographic data
LV EF (%) 58 ± 9 63 ± 10 0.677
Systolic LVID (mm) 26.9 ± 6.0 29.0 ± 4.9 0.275
Diastolic LVID (mm) 39.9 ± 6.7 43.4 ± 3.8 0.044
Changes of systolic LVID (mm)b 0.6 ± 2.8 2.8 ± 6.4 0.028
Changes of diastolic LVID (mm)b 0.9 ± 3.6 2.1 ± 6.9 0.095
One-year follow-up echocardiographic data
LV EF (%) 61 ± 6 62 ± 10 0.677
Systolic LVID (mm) 29.5 ± 4.6 31.9 ± 6.3 0.043
Diastolic LVID (mm) 43.6 ± 4.8 47.0 ± 4.6 0.236
Changes of systolic LVID (mm)b 1.8 ± 5.9 5.8 ± 5.2 0.039
Changes of diastolic LVID (mm)b 2.5 ± 6.4 6.9 ± 5.6 0.043

All values are presented as means ± standard deviations or medians (interquartile ranges).
a
Values are the sums of all blood products (packed red blood cells, platelets, cryoprecipitate and fresh frozen plasma).
b
Values are changes from preoperative measurements.
CPB: cardiopulmonary bypass; VIS: vasoactive–inotropic scores; ICU: intensive care unit; MV: mechanical ventilation; MACE: major adverse cardiac event; LV:
left ventricle; EF: ejection fraction; LVID: LV internal diameter.

Figure 1: Representative transoesophageal echocardiographic images of ventricular fibrillation during cardiopulmonary bypass. (A) Mid-oesophageal aortic valve
long-axis view and (B) mid-oesophageal 4-chamber view. During ventricular fibrillation, an opened aortic valve results in flooding into the LV. This figure and accom-
panying video clips demonstrate that the aortic valve remains opened with a floating leaflet, resulting in LV distension. AV: aortic valve; LA: left atrium; MV: mitral
valve; RV:right ventricle; LV: left ventricle.

3 patients had trivial aortic regurgitation, while the other 3 patients
showed no aortic valve abnormality preoperatively.
We detected MR during ventricular fibrillation in 3 of the 7
patients from the fibrillation group. Continuous-wave Doppler
imaging indicated that the MR velocity was approximately 3.5 m/
s and the aorta perfusion pressure was 58–72 mmHg (Fig. 2).
DISCUSSION
The major result of our study is that hypothermic ventricular
fibrillation was associated with postoperative LV dilatation and a
large amount of transfusion in the postoperative period.
Additionally, patients receiving PVR under ventricular fibrillation
 J.-H. Lee et al. / Interactive CardioVascular and Thoracic Surgery 5

ADULT CARDIAC
Video 1: Mid-oesophageal long-axis view from transoesophageal echocardiog-
raphy. During ventricular fibrillation, the aortic valve remains open, leading to
flooding into the left ventricle in 6 of 7 patients with LV distension. AV: aortic
valve, LA: left atrium, LV: left ventricle, MV: mitral valve.

Video 2: An opened AV with a floating leaflet in the sinus of Valsalva during

ventricular fibrillation. (A) long axis of AV; (B) short axis of AV. AV: aortic valve.

during CPB required more inotropic and vasoactive support in

the immediate postoperative period.
There are limited data regarding the influence of heart man-
agement during CPB for PVR on clinical outcomes. The results of
our study suggest that myocardial injury is more common in the
fibrillation group. There were 3 major adverse cardiac event
cases in the fibrillation group and no such case in the beating-
heart group. In terms of VIS, the median value was 8.0 in the
beating-heart group and 10.0 in the fibrillation group, as milri-
none and dopamine were administered after weaning from CPB
in patients who showed decreased right ventricular function. The
doses of inotropes were gradually decreased according to ven- Figure 2: Representative continuous-wave Doppler images of MR during fibril-
tricular function evaluated using TOE. The VIS score has been lation of 3 patients (A, B and C). All MR velocities were 3.5 m/s. The pressure
shown to predict morbidity and mortality after cardiac surgery gradient between the left atrium and left ventricle was calculated as
50 mmHg, using the simplified Bernoulli equation.
[12–14]. None of the patients in the beating-heart group required
inotropic or vasoactive support at 48 h and 72 h after surgery,
while some patients of fibrillation group required inotropic sup- of a high-perfusion pressure during CPB are required to improve
port at that time. The fibrillation group also received more post- LV function after hypothermic ventricular fibrillation.
operative transfusions, possibly because of lower body Theoretically, the aortic valve should be closed during CPB,
temperatures during CPB. even during ventricular fibrillation, because the aortic pressure is
According to a previous report, although myocardial oxygen greater than the left intraventricular pressure. We thought that
consumption was lower in a cold fibrillating-heart technique than the influence of preoperative AR on the risk of LV distension dur-
in a beating-heart technique, myocardial wall tension was higher ing ventricular fibrillation in our cohort would be insignificant
in the fibrillating-heart technique [6]. Therefore, even in moderate because the degree of AR was trivial. However, we observed that
hypothermia, a longer fibrillation time can result in imbalance of the aortic valve remained open and was floating during ventricu-
myocardial oxygen delivery and consumption. In addition, a lar fibrillation in some of our TOF patients. In such a situation,
decrease in perfusion pressure from 100 mmHg to 50 mmHg backward pressure from the aorta is delivered to the LV, leading
caused a 63% reduction in subendocardial oxygen delivery [15]. to severe LV distension. When the aortic valve is fully open, the
Therefore, minimization of the fibrillation time and maintenance systemic pressure is directly delivered to the endocardium,
6 J.-H. Lee et al. / Interactive CardioVascular and Thoracic Surgery
thereby impairing myocardial perfusion. TOE can easily detect
this phenomenon.
Our available TOE data during CPB indicated that 6 of the 7
patients from the fibrillation group had LV distension, with a
wide open aortic valve during ventricular fibrillation. We believe
that this phenomenon may be common in patients with repaired
TOF who are receiving PVR under the condition of ventricular
fibrillation. However, it is difficult for the surgeon to detect LV dis-
tension and a fully opened aortic valve in the surgical field.
Additionally, this phenomenon is associated with an immediate
adverse postoperative outcome. Therefore, we recommend TOE
monitoring for the detection of LV distension with the aortic valve
opened when ventricular fibrillation develops during CPB [16].
For patients with LV distension during fibrillation, the intraven-
tricular pressure can be estimated using the following simplified
Bernoulli equation [17]: pressure gradient = 4 x (velocity)2. If the
velocity of mitral regurgitation approaches 3.5 m/s during fibrilla-
tion, we can assume that the intraventricular pressure would
be more than 49 mmHg when the perfusion pressure was 58–
72 mmHg. The estimated subendocardial perfusion pressure (dif-
ference of intraventricular pressure and aortic pressure) was
below 20 mmHg. Considering the range of aortic blood pressure
needed to maintain autoregulation of coronary blood flow (45–
150 mmHg in healthy subjects [18]), myocardial ischaemia and
delayed recovery of ventricular function would have occurred in
these patients.
We suggest some possible explanations for the phenomenon,
a wide open aortic valve during ventricular fibrillation. First, a
portion of the physiologic shunt, such as that involving the bron-
chial artery and the Thebesian veins, which drain to the left side
of the heart, might cause an increase in LV pressure, LV dis-
tention and opening of the aortic valve. If a vent is not inserted,
the LV pressure would increase and the aortic valve would open.
Therefore, insertion of a vent is highly recommended in the ven-
tricular fibrillation technique. Second, the geometry of the aortic
root might change when the surgeon retracts the ascending aorta
for better exposure of the pulmonary root during PVR. This may
interrupt normal coaptation of the valve and aggravate aortic
regurgitation because of the distorted aorta. After the aortic valve
opens, the LV pressure increases further, and valve closure then
becomes difficult. Third, a change in flow mechanics in the sinus,
associated with aortopathy, may be responsible. This effect
appears to be associated with the larger size of the sinotubular
junction in the fibrillation group. Aortic root and sinus dilation,
media abnormality of the aorta and reduced wall compliance are
common in adults with repaired TOF [19], and these can change
the flow mechanics through the aortic valve. The closing force of
the aortic valve is associated with sinus cavity pressure, which is
related with fluid vortices, the relationship between sinus ridge
and cavity pressure and flow patterns, such as pulsatile and
steady flow, through the aortic valve [20]. Although the extent of
pathologic change in aortic structures may be related to aortic
valve opening during ventricular fibrillation, further research is
needed to clarify the exact mechanism.
Changes in LVID are also important. The beating-heart and
fibrillation groups had similar preoperative LVID, but the immedi-
ate postoperative diastolic LVID and 1-year postoperative systolic
LVID were significantly longer in the fibrillation group than in the
beating-heart group. Importantly, only the fibrillation group had
significant increases in the immediate postoperative systolic LVID,
1-year postoperative systolic LVID and diastolic LVID. This could
be due to ventricular distension during fibrillation and post-
fibrillation ventricular remodelling. Ventricular remodelling refers
to changes in ventricular size, shape and function associated with
mechanical, neurohormonal and genetic factors [21]. A previous
study indicated that the extent of myocardial injury is related to
the extent of chamber remodeling over time [22]
Limitations
There were some limitations in our study. First, we retrospectively
analysed a small unevenly matched group of patients. Therefore,
there might have been bias from uncontrolled factors, and thus,
a definite conclusion is difficult to make. Second, we could not
compare the extent of myocardial damage in the beating-heart
and fibrillation groups, because cardiac enzyme levels are not
checked routinely after congenital cardiac surgery in our centre.
Third, TOE data during CPB were only available for 10 patients,
and we could not reliably evaluate the incidence of ventricular
distension during CPB and its association with fibrillation. Fourth,
the sample size was small, and this may be the reason for the
absence of differences between the groups with regard to some
variables, such as 48 h and 72 h VIS, MV time and the number of
major adverse cardiac events. Finally, the operation time
appeared to be longer in our centre than in other centres. The
operative time was prolonged because of teaching and reopera-
tion difficulties.
CONCLUSION
In summary, our results indicate that the ventricular fibrillation
technique, rather than the beating-heart technique, during CPB
for PVR in patients with repaired TOF is associated with unfav-
ourable postoperative outcomes. In our centre, considering the
findings and the phenomenon of ventricular distension with an
opened aortic valve during hypothermic ventricular fibrillation,
we prefer the cardioplegic or beating-heart method during CPB.
As ventricular distension can occur at ventricular fibrillation dur-
ing CPB, TOE monitoring is essential during CPB.
Conflict of interest: none declared.
REFERENCES
[1] Saad H, Aladawy M. Temperature management in cardiac surgery. Glob
Cardiol Sci Pract 2013;2013:44–62.
[2] Yamamoto H, Yamamoto F. Myocardial protection in cardiac surgery: a
historical review from the beginning to the current topics. Gen Thorac
Cardiovasc Surg 2013;61:485–96.
[3] Antunes PE, Ferrao de Oliveira J, Prieto D, Coutinho GF, Correia P,
Branco CF et al. Coronary artery bypass surgery without cardioplegia:
hospital results in 8515 patients. Eur J Cardiothorac Surg
2016;49:918–25.
[4] Mitropoulos F, Kanakis M, Davlouros P, Dellos C. Beating heart replace-
ment of the pulmonary valve in a patient with surgically corrected tetral-
ogy of fallot. Hellenic J Cardiol 2006;47:180–3.
[5] Ramanan S, Doll N, Boethig D, Tafer N, Horke A, Roques X et al.
Pulmonary-valve replacement in adults: results with the medtronic free-
style valve. Ann Thorac Surg 2015;100:1047–53.
[6] Buckberg GD, Brazier JR, Nelson RL, Goldstein SM, McConnell DH,
Cooper N. Studies of the effects of hypothermia on regional myocardial
blood flow and metabolism during cardiopulmonary bypass. I. The
adequately perfused beating, fibrillating, and arrested heart. J Thorac
Cardiovasc Surg 1977;73:87–94.
 J.-H. Lee et al. / Interactive CardioVascular and Thoracic Surgery
[7] Kawachi Y, Tominaga R, Yoshitoshi M, Tokunaga K, Nakamura M.
Relationship between perfusion pressure and myocardial microcircula-
tion in the beating empty or spontaneously fibrillating heart. Jpn J Surg
1985;15:379–86.
[8] Akins CW. Hypothermic fibrillatory arrest for coronary artery bypass
grafting. J Card Surg 1992;7:342–7.
[9] Villafane J, Feinstein JA, Jenkins KJ, Vincent RN, Walsh EP, Dubin AM
et al. Hot topics in tetralogy of fallot. J Am Coll Cardiol
2013;62:2155–66.
[10] Nagy CD, Alejo DE, Corretti MC, Ravekes WJ, Crosson JE, Spevak PJ et al.
Tetralogy of fallot and aortic root dilation: a long-term outlook. Pediatr
Cardiol 2013;34:809–16.
[11] Lurati Buse GA, Bolliger D, Seeberger E, Kasper J, Grapow M, Koller MT
et al. Troponin t and brain natriuretic peptide after on-pump cardiac
surgery: prognostic impact on 12-month mortality and major cardiac
events after adjustment for postoperative complications. Circulation
2014;6:007253.
[12] Gaies MG, Gurney JG, Yen AH, Napoli ML, Gajarski RJ, Ohye RG et al.
Vasoactive-inotropic score as a predictor of morbidity and mortality in
infants after cardiopulmonary bypass. Pediatr Crit Care Med
2010;11:234–8.
[13] Barge-Caballero E, Segovia-Cubero J, Gonzalez-Vilchez F, Delgado-
Jimenez J, Perez-Villa F, Almenar-Bonet L et al. Evaluation of the preop-
erative vasoactive-inotropic score as a predictor of postoperative out-
comes in patients undergoing heart transplantation. Int J Cardiol
2015;185:192–4.
7
[14] Garcia RU, Walters HL 3rd, Delius RE, Aggarwal S. Vasoactive inotropic
score (vis) as biomarker of short-term outcomes in adolescents after car-
diothoracic surgery. Pediatr Cardiol 2016;37:271–7.
[15] Brazier JR, Cooper N, McConnell DH, Buckberg GD. Studies of the effects
ADULT CARDIAC
of hypothermia on regional myocardial blood flow and metabolism dur-
ing cardiopulmonary bypass. III. Effects of temperature, time, and perfu-
sion pressure in fibrillating hearts. J Thorac Cardiovasc Surg
1977;73:102–9.
[16] Hensely FA, Martin DE, Gravlee GP. A Practical Approach to Cardiac
Anesthesia. Philadelphia, PA: Lippincott Williams & Wilkins, A Wolters
Kluwer Business, 2013, 601–2.
[17] Giardini A, Tacy TA. Non-invasive estimation of pressure gradients in regurgi-
tant jets: an overdue consideration. Eur J Echocardiogr 2008;9:578–84.
[18] Feliciano L, Henning RJ. Coronary artery blood flow: physiologic and
pathophysiologic regulation. Clin Cardiol 1999;22:775–86.
[19] Niwa K. Aortic root dilatation in tetralogy of fallot long-term after
repair–histology of the aorta in tetralogy of fallot: evidence of intrinsic
aortopathy. Int J Cardiol 2005;103:117–9.
[20] Bellhouse BJ, Reid KG. Fluid mechanics of the aortic valve. Br Heart J
1969;31:391.
[21] Sutton MG, Sharpe N. Left ventricular remodeling after myocardial
infarction: pathophysiology and therapy. Circulation 2000;101:2981–8.
[22] Chung H, Yoon J-H, Yoon YW, Park CH, Ko EJ, Kim JY et al. Different
contribution of extent of myocardial injury to left ventricular systolic
and diastolic function in early reperfused acute myocardial infarction.
Cardiovasc Ultrasound 2014;12:6.