1512 Letters to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 15091516
Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardio-
Fig 1. Complication risk associated with superior venous oximetry. CPR, car-
diopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation.
than a fixed threshold. An increase in serum lactate >0.75
mmol/L/h or an inability for lactate clearance <6.76 mmol/L
within the first postoperative day was considered critical.7,8
However, it must be remembered that, especially in pediatric
cardiac surgery patients, serum lactate levels reflect inadequate
tissue perfusion and are also influenced by increased glycoly-
sis, reflecting a stressed state (type B hyperlactatemia).9 Addi-
tionally, the metabolic storage burden of transfused red blood
cells must be recognized as a contributing factor, particularly
in the early perioperative period, even with a short storage
time (4 days).10 Processing circuit volume with cell-saver
systems or using washed red blood cells attenuates this
effect.11
We, therefore, propose that a structured protocol be imple-
mented to assess the need for ECMO support when hemody-
namics remain borderline despite efforts to optimize
oxygenation and tissue perfusion.11 In addition to an SvO2
<45% as the key parameter, significant tricuspid regurgitation
and continuously rising serum lactate levels or the failure to
lower lactate levels within the first postoperative day, and dis-
cussion of preemptively deploying ECMO should precede the
collapse of this complex and highly vulnerable hemodynamic
state. After initiating ECMO, once hemodynamics have stabi-
lized and bleeding has stopped, cardiac catheterization should
be considered. Because patients with hypoplastic left heart
syndrome often have additional complex malformations, resid-
ual lesions can be found in many patients, and outcomes
improve with timely intervention.12
Conflict of Interest
None.
References
1 Zaleski KL, Valencia E, Matte GS, et al. How we would treat our own
hypoplastic left heart syndrome neonate for stage 1 surgery. J Cardiothorac
Vasc Anesth 2023;37:504–12.
2 Alphonso N, Angelini A, Barron DJ, et al. Guidelines for the management
of neonates and infants with hypoplastic left heart syndrome: The Euro-
pean Association for Cardio-Thoracic Surgery (EACTS) and the Associa-
tion for European Paediatric and Congenital Cardiology (AEPC)
thorac Surg 2020;58:416–99.
3 Pisesky A, Shah S, Seed M, et al. Standardisation of management after
Norwood operation has not improved 1-year outcomes. Cardiol Young
2021;31:105–13.
4 Photiadis J, Sinzobahamvya N, Fink C, et al. Optimal pulmonary to sys-
temic blood flow ratio for best hemodynamic status and outcome early
after Norwood operation. Eur J Cardiothorac Surg 2006;29:551–6.
5 Hoffman GM, Ghanayem NS, Kampine JM, et al. Venous saturation and
the anaerobic threshold in neonates after the Norwood procedure for hypo-
plastic left heart syndrome. Ann Thorac Surg 2000;70:1515–20.
6 Feinstein JA, Benson DW, Dubin AM, et al. Hypoplastic left heart syn-
drome: Current considerations and expectations. J Am Coll Cardiol
2012;59(1 Suppl):S1–42.
7 Murtuza B, Wall D, Reinhardt Z, et al. The importance of blood lactate
clearance as a predictor of early mortality following the modified Norwood
procedure. Eur J Cardiothorac Surg 2011;40:1207–14.
8 Charpie JR, Dekeon MK, Goldberg CS, et al. Serial blood lactate measure-
ments predict early outcome after neonatal repair or palliation for complex
congenital heart disease. J Thorac Cardiovasc Surg 2000;120:73–80.
9 Stephens EH, Epting CL, Backer CL, Wald EL. Hyperlactatemia: An
update on postoperative lactate. World J Pediatr Congenit Heart Surg
2020;11:316–24.
10 Paglia G, D’Alessandro A, Rolfsson O,  et al. Biomarkers defining the
metabolic age of red blood cells during cold storage. Blood 2016;128:
e43–50.
11 Mills KI, Kaza AK, Walsh BK, et al. Phosphodiesterase inhibitor-based
vasodilation improves oxygen delivery and clinical outcomes following
stage 1 palliation. J Am Heart Assoc 2016;5:e003554.
12 Brown KL, Thiruchelvam T, Kostolny M. Extracorporeal membrane oxy-
genation after the Norwood operation: Making the best of a tough situa-
tion. Eur J Cardiothorac Surg 2022;62:ezac221.
Gabor Erdoes, MD*,1
Andreas Koster, MDy
Alexander Kadner, MDz
Eugen Sandica, MDx
*
Department of Anesthesiology and Pain Medicine, Inselspital, Bern Univer-
sity Hospital, University of Bern, Bern, Switzerland
y
Institute of Anesthesiology and Pain Therapy, Heart, and Diabetes Center
NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
z
Department of Cardiac Surgery, Inselspital, Bern University Hospital, Uni-
versity of Bern, Bern, Switzerland
x
Pediatric Heart Center and Center for Surgery Congenital Heart Defects,
Heart, and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen,
Germany
https://doi.org/10.1053/j.jvca.2023.03.010
An Unusual Mass in the Right Atrium After a
Staged Extracardiac Total Cavopulmonary
Connection in a Case of Tricuspid Atresia
To the Editor:
Total cavopulmonary connection is a final-stage palliative
procedure performed to treat single-ventricular lesions that are
not amenable to biventricular repair.1 It usually is done after a
bidirectional Glen procedure in which the superior vena cava
is anastomosed to the pulmonary artery.1 The extracardiac
modification of the Glen shunt includes the placement of a
tube graft from the inferior vena cava to the pulmonary artery.1
We observed a mass in the right atrium due to hemodynamic
 Letters to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 15091516
Fig 1. (A) Postcardiopulmonary bypass transesophageal echocardiographic midesophageal 4-chamber view (probe turned right) shows a pedunculated mass in the
right atrium (red arrow). (B) Postcardiopulmonary bypass transesophageal echocardiographic midesophageal right ventricular inflow-outflow view shows a round
mass in the right atrium (red arrow). CPB, cardiopulmonary bypass; ME, midesophageal; RV, right ventricle; TEE, transesophageal echocardiography.
changes associated with the placement of the extracardiac
graft.
A 5-year-old boy with tricuspid atresia (type 1b) presented
for final-stage total cavopulmonary connection surgery. He
underwent a bidirectional Glen procedure and an atrial septec-
tomy at 6 months of age. Preoperative transthoracic echocardi-
ography showed an 11-mm atrial septal defect, laminar flow in
the bidirectional Glen circuit, and preserved ventricular func-
tion without mitral regurgitation. Intraoperative transesopha-
geal echocardiography confirmed the preoperative diagnosis.
An extracardiac total cavopulmonary connection without fen-
estration was performed during cardiopulmonary bypass. Lam-
inar flow in the extracardiac graft was observed after bypass.
However, we noticed a well-defined pedunculated mass in the
right atrium in multiple transesophageal echocardiography
views (Figs 1, A and B; Video 1). We were concerned about a
possible thrombus, but inspection of the surgical field showed
that the right atrium was nearly collapsed and the right atrial
wall was invaginating into the chamber. After placement of
the extracardiac graft, the right atrium received blood from
only the left atrium through the atrial septal defect. Because
there was tricuspid atresia, the right atrium received minimal
blood and did not fill completely.2 As a result, the right atrium
was underfilled, and the right atrial wall was invaginated into
the chamber, mimicking a mass.
Video 1. Postcardiopulmonary bypass transesophageal
echocardiographic examination shows a pedunculated mass in
the right atrium in the midesophageal 4-chamber view and a
round mass in the midesophageal right ventricular inflow-out-
flow view. CPB, cardiopulmonary bypass; LA, left atrium,
LV, left ventricle; ME, midesophageal; RA, right atrium; RV,
right ventricle; SV, single ventricle; TA, tricuspid atresia;
TEE, transesophageal echocardiography.
Declaration of Competing Interest
None.
1513
Supplementary materials
Supplementary material associated with this article can be
found in the online version at doi:10.1053/j.jvca.2023.04.016.
References
1 Petit CJ. Staged single-ventricle palliation in 2011: Outcomes and expecta-
tions. Congenit Heart Dis 2011;6:406–16.
2 Sumal AS, Kyriacou H, Mostafa AMHAM. Tricuspid atresia: Where are we
now? J Card Surg 2020;35:1609–17.
Hari Dev JJ, MD, DM
Saravana Babu, MS, MD, DM, FTEE
Divya Jacob, MD, DM
Thomas Koshy, MBBS, DA, MD, PDCC, FRCP
Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal
Institute for Medical Sciences and Technology, Trivandrum, India
https://doi.org/10.1053/j.jvca.2023.04.016
Cerebral Fungal Infections as a Cause of Stroke
in Cardiac Surgery Patients: Be Cautious!!
To the Editor:
Neurologic dysfunction in the postoperative period after
cardiac surgery is most commonly attributed to thrombo-
embolism or an intracranial bleed.1 Fungal infection is a
rare cause of cerebral infarction and hemiparesis in an oth-
erwise healthy patient. Cerebral Aspergillus infections are
common in immunocompromised patients,2 and are not
considered the first-line differential diagnosis of cerebral
infarcts in a cardiac surgery patient. The infection is usu-
ally secondary to the lung, paranasal sinuses, or the heart,
and forms microthrombi in large- or medium-sized cerebral
vessels.3,4 The previously reported postoperative cases of
cerebral aspergillosis occurred in patients on extracorporeal
membrane oxygenation.5 It was postulated that the