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Original article
One-stage neonatal Yasui procedure: Presentation of our surgical experience and a new decision-making algorithm
Procedimiento Yasui neonatal en una etapa: presentación de nuestra experiencia quirúrgica y un nuevo algoritmo de toma de decisiones
Consuelo A. Gotora, Enrique Garcíaa,
Corresponding author
enrique_huc@hotmail.com

Corresponding author.
, Francisco J. Ariasa, Miguel A. Granadosb, Elena Montañesb, Alberto Mendozab, María T. Garciac, Lorenzo Bonia
a Children's Congenital Cardiac Surgery Unit, 12 de Octubre University Hospital, Madrid, Spain
b Pediatric Cardiology Unit, 12 de Octubre University Hospital, Madrid, Spain
c Cardiac Surgery Perfusion, 12 de Octubre University Hospital, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Interrupted aortic arch is a rare&#44; but highly lethal anomaly in early infancy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Interruption usually occurs between the left common carotid and the left subclavian arteries &#40;interrupted aortic arch type B&#41;&#44; but can occur distal to the left subclavian artery &#40;interrupted aortic arch type A&#41; or between the innominate artery and left common carotid artery &#40;interrupted aortic arch type C&#41;&#44; and is usually associated with a large&#44; non-restrictive ventricular septal defect&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Interrupted aortic arch may be associated with critical aortic atresia or stenosis&#44; and a reasonably well-developed apex-forming left ventricle&#44; due to the presence of the ventricular septal defect&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> The degree of left ventricle hypoplasia and possible dysfunction determines whether neonates with critical left ventricular outflow tract obstruction are managed with univentricular palliation or biventricular repair&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The first report of primary biventricular repair by Yasui in 2 neonates with interrupted aortic arch and severe aortic stenosis was published in 1987&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;3&#44;5</span></a> This procedure consist&#44; in general terms&#44; in that the left ventricular outflow tract is rerouted to the native pulmonary valve through an intra-cardiac baffle arising from the ventricular septal defect&#59; the two great arteries roots are then joined through a Damus&#8211;Kaye&#8211;Stansel anastomosis&#59; pulmonary blood flow is provided by a right ventricle-pulmonary artery valved conduit&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> This combines a Norwood type arch reconstruction with a Rastelli type operation establishing a biventricular repair&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The purpose of this study is to present our experience with three patients with very similar anatomical characteristics that underwent a neonatal Yasui procedure&#44; as well as to expose the general management of these patients in our center using a new decision making algorithm&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a series of three neonates who underwent a Yasui operation at &#8220;12 de Octubre&#8221; Hospital between 2017 and 2022&#46; Patients were identified through the cardiac database&#44; and the medical records were subsequently reviewed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first and second patients we present had an interrupted aortic arch type B associated with aortic stenosis and non-restrictive ventricular septal defect&#46; The third patient had aortic atresia&#44; with an ascending aorta of approximately 2<span class="elsevierStyleHsp" style=""></span>mm in diameter and a mild-restrictive ventricular septal defect&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All patients underwent a primary Yasui procedure before 2 weeks of age&#44; at a median weight of 3&#46;1<span class="elsevierStyleHsp" style=""></span>kg&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The characteristics and echocardiographic measurements before the Yasui operation are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with this congenital anomaly&#44; who are born in our hospital or are referred from other centers&#44; are discussed in a multidisciplinary session to decide the management and therapeutic strategy&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Maintaining ductal patency by infusion of prostaglandin E1 represents the first step in the medical resuscitation of the neonate with interrupted aortic arch&#46; Because the lower half of the body is dependent on perfusion through the ductus&#44; and because blood in the ductus can also pass into the pulmonary circulation&#44; it is important that pulmonary and systemic circulations are well balanced&#46; This can be achieved by avoiding a high level of inspired oxygen &#40;usually room air is appropriate&#41;&#44; as well as avoiding respiratory alkalosis caused by hyperventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> On the other hand&#44; systemic vasodilators are used to optimize systemic pressures&#46; Metabolic acidosis should be aggressively treated&#46; Because myocardial function is likely to be depressed somewhat at the time of presentation&#44; and it may be necessary for the heart to handle a moderate volume load &#40;depending on the balance between pulmonary and systemic circulations&#41;&#44; an inotropic agent is used on certain occasions&#46; Intensive medical treatment is usually maintained for a few days before surgery&#46; It should be avoided to take a child to the operating room with any abnormalities of acid&#8211;base&#44; renal&#44; or hepatic indices&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The typical anatomy of patients who underwent a Yasui procedure is shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">After discharge from the hospital&#44; the patients continued with the corresponding follow-up adapted to their evolution&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Operation</span><p id="par0065" class="elsevierStylePara elsevierViewall">The concept of the Yasui operation is a combination of aortic arch reconstruction&#44; redirection of left ventricle outflow through the ventricular septal defect to both semilunar valves &#40;joined by a Damus&#8211;Kaye&#8211;Stansel anastomosis&#41; and establishment of right ventricle-pulmonary artery continuity using a valved conduit<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Cannulation strategies</span><p id="par0070" class="elsevierStylePara elsevierViewall">In patient 1 &#40;interrupted aortic arch&#41;&#44; arterial perfusion was established with a 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm polytetrafluoroethylene graft &#40;Gore-Tex&#174;&#41; anastomosed to the origin of the right carotid artery&#46; The graft was cannulated with an 8-French cannula &#40;cerebral perfusion&#41;&#46; The descending aorta was cannulated directly through the proximal ductus arteriosus also with an 8-French cannula &#40;systemic perfusion&#41; and the 2 cannulae were connected to the arterial perfusion line&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In patient 2 &#40;interrupted aortic arch&#41;&#44; arterial perfusion was established with a 6-French cannula in the ascending aorta &#40;cerebral perfusion&#41;&#46; The descending aorta was cannulated directly through the proximal ductus arteriosus with an 8-French cannula &#40;systemic perfusion&#41; and the 2 cannulae were connected to the arterial perfusion line&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In patient 3 &#40;aortic atresia and hypoplasia of ascending aorta&#41;&#44; arterial perfusion was established with a 6-French cannula in the aortic arch&#44; proximal to the right carotid artery &#40;cerebral perfusion&#41;&#46; The descending aorta was cannulated directly through the proximal ductus arteriosus with an 8-French cannula &#40;systemic perfusion&#41; and the 2 cannulae were connected to the arterial perfusion line&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In all patients venous return was established with bicaval cannulation&#44; and extracorporeal circulation was performed in hypothermia at 26&#176; C&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aortic reconstruction</span><p id="par0090" class="elsevierStylePara elsevierViewall">In recent years in our center&#44; during aortic arch surgery&#44; we use myocardial perfusion in addition to selective cerebral perfusion&#44; thus reducing cardiac ischemia times&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Reconstruction of the aortic arch&#44; in the first two patients&#44; was performed by end-to-end anastomosis of the posterior wall of the descending thoracic aorta to the ascending aorta&#44; and anterior enlargement with an autologous pericardium patch in patient 1 and a pulmonary</p><p id="par0100" class="elsevierStylePara elsevierViewall">homograft patch in patient 2&#46; With adequate mobilization of the ascending and descending aortas&#44; this is easily performed without tension&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The third patient had no interruption of the aortic arch&#44; so reconstruction of the aortic arch and ascending aorta consisted of an anterior enlargement with a CardioCel&#174; 3D patch&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Subsequently&#44; the Damus&#8211;Kaye&#8211;Stansel connection was made between the proximal pulmonary trunk and the ascending aorta&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Intraventricular rerouting</span><p id="par0115" class="elsevierStylePara elsevierViewall">A vertical right ventricular outflow tract incision was made just below the pulmonary valve to the right of and parallel to the left anterior descending coronary artery&#46; This ventriculotomy exposed the perimembranous ventricular septal defect&#46; In all cases&#44; a bovine pericardium patch was used to baffle the left ventricle outflow through the ventricular septal defect to the pulmonary artery&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In patient 3&#44; ventricular septal defect enlargement was performed &#40;due to an original restrictive defect&#41;&#44; achieving a diameter of approximately 8<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right ventricle to pulmonary artery connection</span><p id="par0125" class="elsevierStylePara elsevierViewall">A right ventricle to pulmonary artery connection was established using a Hancock conduit &#40;14<span class="elsevierStyleHsp" style=""></span>mm&#41; in patient 1&#44; and a Contegra conduit &#40;12<span class="elsevierStyleHsp" style=""></span>mm&#41; in patients 2 and 3&#44; according to surgeon preference&#46;</p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical considerations</span><p id="par0130" class="elsevierStylePara elsevierViewall">Given the characteristics of the article&#44; approval by the Ethics Committee or Institutional Review Board is not required&#44; nor is the request of informed consent for publication&#46; Written informed consent for surgery was obtained from the patient&#8217;s parents&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0135" class="elsevierStylePara elsevierViewall">Operative details are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">In the first two patients&#44; concomitant myocardial perfusion was used during 26 and 25<span class="elsevierStyleHsp" style=""></span>min respectively&#46; In the third patient&#44; due to the characteristics of the diminutive aorta&#44; myocardial perfusion was not possible during reconstruction of the aortic arch&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The duration of cardiopulmonary bypass was 275&#44; 249 and 391<span class="elsevierStyleHsp" style=""></span>min&#44; and myocardial ischemia was 150&#44; 126 and 179<span class="elsevierStyleHsp" style=""></span>min&#44; in patient 1&#44; 2 and 3&#44; respectively&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Patient 1 presented the right subclavian artery originating from the right pulmonary branch&#44; and for this reason this artery was reimplanted in the ascending aorta during the intervention&#46; This justifies the longer surgical times compared to the second patient &#40;similar anatomy&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The sternum was left open in all three cases and subsequently closed in the Intensive Care Unit&#44; as is usual practice in complex neonatal cases&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Patient 1&#44; during his stay in the Intensive Care Unit&#44; required surgical revision due to postoperative cardiac tamponade&#46; The thorax could be closed 5 days after surgery&#46; He presented episodes of junctional tachycardia that required antiarrhythmic treatment with amiodarone&#46; Peritoneal dialysis was required during the first postoperative days&#46; Extubation could be performed 11 days postoperatively&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In patient 2&#44; the thorax was closed 24<span class="elsevierStyleHsp" style=""></span>h after admission to the Intensive Care Unit&#46; Five days after surgery she was extubated&#44; but a few hours later she had to be intubated again due to inspiratory stridor associated with respiratory work&#46; Treatment with dexamethasone was started&#44; allowing definitive extubation on the seventh postoperative day&#46; Fibrobronchoscopy was performed&#44; showing a left vocal cord paresis with partial collapse of the right intermediate bronchus&#46; She developed acute renal insufficiency which resolved progressively with the optimization of the treatment&#46; She needed antibiotic treatment due to a sepsis caused by Enterococcus faecalis&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Patient 3&#44; during his stay in the Intensive Care Unit&#44; in the context of right ventricular failure&#44; required peritoneal dialysis associated with diuretic treatment&#46; Thoracic closure was performed 3 days postoperatively&#46; He developed complete atrioventricular block requiring definitive epicardial pacemaker implantation two weeks after surgery&#46; Thirty-six hours after pacemaker implantation&#44; the patient was extubated&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Intensive Care Unit stay of patient 1&#44; 2 and 3 was 29&#44; 22 and 24 days&#44; respectively&#59; total hospital stay was 65&#44; 64 and 43 days&#44; respectively&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The follow-up time has been 59 months in patient 1&#44; 49 months in patient 2 and 10 months in patient 3&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">At 6 months of follow-up&#44; patient 1 required a stent implantation in the right pulmonary branch&#44; and at 42 months he underwent angioplasty of the previously implanted stent&#44; and a stent implantation in the right ventricle-pulmonary artery conduit was performed&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Patient 2 progressively developed stenosis of the right ventricle-pulmonary artery conduit during follow-up&#44; so 16 months after the first surgery&#44; a 14<span class="elsevierStyleHsp" style=""></span>mm Hancock valved conduit was implanted&#46; In addition&#44; during this intervention a moderate-severe obstruction of the left ventricular outflow tract was observed and repaired in the same surgical act&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In the out-patient postoperative cardiac examinations of the third patient&#44; a residual ventricular septal defect of approximately 3<span class="elsevierStyleHsp" style=""></span>mm was observed&#46; Moreover&#44; at the level of the aortic arch there was an area of coarctation distal to the take-off of the supra-aortic trunks with a minimum diameter of 2&#46;8<span class="elsevierStyleHsp" style=""></span>mm and a maximum gradient of 90&#8211;100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; without clear diastolic extension&#46; In addition&#44; stenosis was observed at the junction of the ascending aorta with the arch&#44; with a maximum gradient of 40<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The first therapeutic option was balloon angioplasty&#44; which was performed 3 months after initial surgery&#44; without significant changes&#46; In view of this situation&#44; elective priority surgery was indicated to repair the arch and close the ventricular septal defect&#46; During the surgery&#44; we found a severe endovascular reaction to the aortic arch patch&#44; with formation of a 2<span class="elsevierStyleHsp" style=""></span>mm thick fibrous tissue covering circumferentially the entire portion of the previously augmented aortic arch &#40;from Damus&#8211;Kaye&#8211;Stansel anastomosis to post-ductal aorta&#41;&#44; leaving only a 4&#8211;5<span class="elsevierStyleHsp" style=""></span>mm patent lumen&#46; This reaction was also observed on the external surface of the patch&#46; Contegra&#39;s conduit was normofunctioning&#46; The residual ventricular septal defect was localized at the level of the septal leaflet of the tricuspid valve&#46; We performed an aortic arch augmentation with heterologous bovine pericardial patch and we closed the residual ventricular septal defect with simple U stitches&#46; The intraoperative epicardial echocardiography showed an adequate arch enlargement&#44; and no residual intracardiac lesions&#46; The thorax was closed primarily&#44; and the patient was transferred to the Intensive Care Unit&#46; During his stay in the Intensive Care Unit there was a tendency to arterial hypertension which required aggressive intravenous treatment&#46; The patient was extubated at 48<span class="elsevierStyleHsp" style=""></span>h from admission to the Intensive Care Unit&#46; On the fourth postoperative day&#44; he was discharged from Intensive Care Unit to the hospital ward&#44; and on postoperative day 16 he was discharged home&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">All patients are alive and doing well at last follow-up&#44; with adequate objective echocardiographic biventricular function&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">The Yasui operation is a useful approach for the management of patients with interrupted aortic arch and critical left ventricular outflow tract obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> Since its publication in 1987&#44; several case reports or small series have described the utility of this operation&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;8&#8211;21</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The Yasui procedure does have an advantage compared with a Norwood single-ventricle approach for two important physiologic reasons&#46; First&#44; a two-ventricle repair results in normalization of the circulation&#46; Secondly&#44; the Yasui repair also results in fully saturated blood going to the systemic circulation&#46; In contradistinction&#44; the Norwood procedure creates a &#8220;parallel circulation&#44;&#8221; which has proven to be a far more tenuous physiology&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Biventricular repair in this spectrum of patients can be performed in a single stage &#40;primary Yasui procedure&#41; or in different stages&#44; and both procedures have advantages and disadvantages&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Initial palliation for staged patients consists of a Norwood type aortic arch reconstruction&#44; which includes a Damus&#8211;Kaye&#8211;Stansel anastomosis&#46; Pulmonary blood flow is provided by a modified Blalock&#8211;Taussig shunt or a right ventricle-pulmonary artery shunt&#46; The following stage would consist in channeling the ventricular septal defect to the semilunar valves &#40;joined by a Damus&#8211;Kaye&#8211;Stansel anastomosis&#41; with enlargement of the ventricular septal defect &#40;if necessary&#41; and creation of right ventricle-pulmonary artery continuity with a valved conduit &#40;and removal of the previous shunt&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The approach of performing a multistage repair has certain advantages&#58; the intracardiac part of the surgery &#40;ventricular septal defect closure&#41; would be performed in older &#40;and bigger&#41; patients&#44; away from the fragile neonatal period&#46; It also gives us the possibility of inserting a larger conduit between the Right ventricle and the pulmonary artery&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> This strategy avoids the initial surgical complexity of primary corrective surgery&#44; and allows a period of growth prior to final biventricular repair&#44; which may facilitate better selection of candidates&#44; as there may be some patients who will benefit from a univentricular physiology and who could not otherwise have been identified&#44; which is especially important in the case of impaired left ventricular function&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> On the other side&#44; we can identify a few disadvantages&#46; First of all&#44; this physiology is associated with significant operative and short-medium term mortality&#44; which reflects that these patients present a more complex postoperative period&#59; secondly&#44; we leave them longer time with a &#8220;parallel circulation&#8221;&#44; with desaturated blood reaching the systemic circulation&#46; There is no evidence in the literature to support the idea that this physiology is better tolerated in patients with two adequately formed ventricles&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The advantage of the single-stage approach is the early normalization of the circulation&#44; creating a two-ventricle system with fully saturated blood going to the systemic circulation&#46; This approach also increases the interval to the next reoperation compared with an initial Norwood procedure&#46; Disadvantages of the single-stage approach include a more technically demanding operation&#44; with prolongation of the crossclamp and bypass times&#44; insertion of small conduit sizes&#44; and possibly a higher risk for surgically induced heart block&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The placement of a neonatal conduit implies the replacement of the conduit within 3&#8211;4 years&#46; Therefore&#44; with either approach&#44; these patients are likely to undergo at least two operations in their first 3 years of life&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">For the above reasons&#44; in recent years we have chosen to perform the Yasui procedure in a single stage&#46; In addition&#44; different series have been published evaluating the results of a primary Yasui procedure&#44; with excellent results&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;21&#44;23&#44;24</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Another surgical option that could be used for patients with critical aortic stenosis&#47;atresia&#44; interrupted or hypoplastic aortic arch&#44; ventricular septal defect&#44; and a normal-sized left ventricle&#44; is the neonatal Ross&#8211;Konno operation with aortic arch repair&#46; This option would result in a two-ventricle system&#44; and thus confer the same physiologic advantages as the Yasui with respect to normalization of the circulation&#46; But the Ross&#8211;Konno option does not circumvent the issues associated with right ventricular outflow tract conduits&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> A point in favor of the Yasui operation&#44; is the added technical difficulty of coronary harvesting and reimplantation in the Ross&#8211;Konno operation in neonates with diminutive ascending aorta&#46; When there is a large size discrepancy between the pulmonary and aortic annulus&#44; reimplanted coronary arteries may end-up in an unusual position&#44; which can result in coronary insufficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">In our opinion&#44; the arterial translocation that must be performed in these patients to perform a Ross procedure involves a very short distance mobilization&#44; which&#44; together with the great difficulty of translocating the coronary ostium in a patient with a diminutive aorta&#44; does not justify the complexity of performing such an operation&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The benefits of the Yasui procedure compared with alternative treatment strategies are difficult to evaluate because of the relative rarity and heterogeneity of this heart defect&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">In certain circumstances the left ventricle instead of being small&#44; globular and underdeveloped&#44; is rather flattened or even crescentic&#44; compressed by a dilated right ventricle with overloaded pressure and volume&#46; In such conditions of distorted left ventricle geometry&#44; small preoperative left ventricle volumes may not accurately predict the feasibility of biventricular repair&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> The septum should adopt a normal position after the operation normalizes the loading conditions&#46; Therefore&#44; the postoperative capacity can best be predicted by the preoperative left ventricle potential volume&#44; which is the volume if the septal position were normal&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> and this is what we consider as the &#8220;potential Bullet&#8221;&#46; Several studies have now demonstrated that 15&#8211;20<span class="elsevierStyleHsp" style=""></span>ml&#47;m<span class="elsevierStyleSup">2</span> is the minimal left ventricle volume necessary to support the systemic circulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">If we obtain a potential Bullet volume greater than 20<span class="elsevierStyleHsp" style=""></span>ml&#47;m<span class="elsevierStyleSup">2</span> and the mitral annulus has a <span class="elsevierStyleItalic">z</span>-score greater than &#8722;3&#44; we consider a biventricular repair in our patient&#46; Like us&#44; other authors set a mitral annulus with a <span class="elsevierStyleItalic">z</span>-score greater than &#8722;3 as the limit for considering a biventricular repair&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">After assessing the possibility of biventricular repair&#44; the next step would be to decide on the best surgical strategy&#46; If the patient has aortic atresia&#44; the indication is to perform a Yasui procedure &#40;this would be the case of our third patient&#41;&#46; If the patient has aortic stenosis&#44; we must assess the size of the aortic annulus&#46; If the aortic annulus has a <span class="elsevierStyleItalic">z</span>-score of less than &#8722;3&#44; we perform a Yasui procedure&#46; If the <span class="elsevierStyleItalic">z</span>-score is greater than &#8722;3&#44; we consider conventional repair of arch interruption&#47;hypoplasia and ventricular septal defect closure &#40;<span class="elsevierStyleItalic">z</span>-scores were calculated according to the data from of Pettersen et al&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The size of the aortic annulus to consider performing a Yasui procedure varies from one author to another&#46; Carrillo et al&#46; perform this procedure when the subaortic and valvular area &#40;measured in millimeters&#41; is less than the patient&#39;s weight &#40;measured in kilograms&#41;&#44; or when the aortic valve has a <span class="elsevierStyleItalic">z</span>-score of less than &#8722;3&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> Kanter et al&#46; perform Yasui when the diameter of the left ventricular outflow tract &#40;valvular or subaortic region&#41; is less than 4<span class="elsevierStyleHsp" style=""></span>mm&#59; when it is between 4&#8211;4&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; both a Yasui procedure and conventional repair are considered&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows a schematic representation of our above mentioned protocol&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0285" class="elsevierStylePara elsevierViewall">In patients with critical aortic stenosis&#47;atresia&#44; interrupted or hypoplastic aortic arch&#44; ventricular septal defect&#44; and a normal-sized left ventricle&#44; we advocate for primary neonatal repair with the Yasui operation&#44; as we believe that the sooner the infant reaches a normal physiologic state&#44; the better will be the long-term outcome&#46; In addition&#44; the immediate postoperative course of patients with a complete repair is less complicated than in those with an initial palliative procedure&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">We can conclude that in experienced centers&#44; primary Yasui repair can be performed in neonatal period with satisfactory results&#44; low mortality and good left ventricular function in the short-medium term&#46; Current series with a larger number of patients and long-term follow-up are needed to demonstrate the superiority of the Yasui procedure over other treatment alternatives&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Financial support</span><p id="par0295" class="elsevierStylePara elsevierViewall">This research received no specific grant from any funding agency&#44; commercial or not-for-profit sectors&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to present our experience with three patients who underwent a neonatal Yasui procedure&#44; and to show the new decision-making algorithm&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a series of three neonates operated on at our hospital between 2017 and 2022&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All the patients underwent a primary Yasui&#46; The duration of cardiopulmonary bypass was 275&#44; 249 and 391<span class="elsevierStyleHsp" style=""></span>min&#44; in patient 1&#44; 2 and 3&#44; respectively&#46; After surgery&#44; the Intensive Care Unit stay of patients 1&#44; 2 and 3 was 29&#44; 22 and 24 days&#44; respectively&#46; The patients were discharged in good condition&#46; Subsequent complications during follow-up included the need for percutaneous intervention in patient 1 for the implantation of a stent in the right pulmonary branch &#40;at 6 months postoperatively&#41; and a stent in the right ventricle-pulmonary artery conduit &#40;at 42 months&#41;&#46; Patient 2 required right ventricle-pulmonary artery conduit replacement and repair of moderate-severe left ventricular outflow tract obstruction at 16 months postoperatively&#46; Patient 3 needed a reoperation at 3 months postoperatively due to aortic arch stenosis at different levels and a residual ventricular septal defect&#46; Currently&#44; all patients are alive with adequate echocardiographic biventricular function&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In experienced centers&#44; primary Yasui repair can be performed in the neonatal period with satisfactory results&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es presentar nuestra experiencia con tres pacientes sometidos a un procedimiento de Yasui neonatal&#44; y mostrar el nuevo algoritmo de toma de decisiones&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se trata de una serie de tres neonatos&#44; operados en nuestro hospital entre 2017 y 2022&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes fueron sometidos a un Yasui primario&#46; La duraci&#243;n del <span class="elsevierStyleItalic">bypass</span> cardiopulmonar fue de 275&#44; 249 y 391 minutos&#44; en los pacientes 1&#44; 2 y 3&#44; respectivamente&#46; Tras la cirug&#237;a&#44; la estancia en la Unidad de Cuidados Intensivos de los pacientes 1&#44; 2 y 3 fue de 29&#44; 22 y 24 d&#237;as&#44; respectivamente&#46; Los pacientes fueron dados de alta en buenas condiciones&#46; Las complicaciones posteriores durante el seguimiento incluyeron&#44; la necesidad de intervenci&#243;n percut&#225;nea en el paciente 1 para la implantaci&#243;n de un <span class="elsevierStyleItalic">stent</span> en la rama pulmonar derecha &#40;a los seis meses del posoperatorio&#41;&#44; y un <span class="elsevierStyleItalic">stent</span> en el conducto ventr&#237;culo-pulmonar derecho &#40;a los 42 meses&#41;&#46; El paciente 2&#44; requiri&#243; la sustituci&#243;n del conducto ventr&#237;culo-pulmonar derecho&#44; y la reparaci&#243;n de la obstrucci&#243;n moderada-grave del tracto de salida del ventr&#237;culo izquierdo&#44; a los 16 meses del posoperatorio&#46; El paciente 3&#44; necesit&#243; una reoperaci&#243;n a los tres meses del posoperatorio&#44; debido a una estenosis del arco a&#243;rtico a diferentes niveles&#44; y a una comunicaci&#243;n interventricular residual&#46; Actualmente&#44; todos los pacientes est&#225;n vivos con una funci&#243;n biventricular ecocardiogr&#225;fica adecuada&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En centros con experiencia&#44; se puede realizar la reparaci&#243;n primaria de Yasui en el periodo neonatal con resultados satisfactorios&#46;</p></span>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; IAA&#44; interrupted aortic arch&#59; AS&#44; aortic stenosis&#59; AA&#44; aortic atresia&#59; HAA&#44; hypoplasia of ascending aorta&#59; VSD&#44; ventricular septal defect&#46;</p>"
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                  \t\t\t\t">4&#8211;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#8211;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#8722;3&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; DKS&#44; Damus&#8211;Kaye Stansel&#59; VSD&#44; ventricular septal defect&#59; RVOTR&#44; right ventricular outflow tract reconstruction&#59; CPB&#44; cardiopulmonary bypass&#59; SCP&#44; selective cerebral perfusion&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yasui primary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yasui primary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yasui primary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Size &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Body weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aortic reconstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DKS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>patch augmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DKS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>patch augmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DKS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>patch augmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VSD enlargement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RVOTR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hancock conduit &#91;14<span class="elsevierStyleHsp" style=""></span>mm&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contegra conduit &#91;12<span class="elsevierStyleHsp" style=""></span>mm&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contegra conduit &#91;12<span class="elsevierStyleHsp" style=""></span>mm&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CPB time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">275&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">249&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">391&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-clamp time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SCP time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ICU &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total hospital stay &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Result&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Survived&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Survived&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Survived&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Current clinical status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3504630.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Perioperative data of the Yasui operation&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Geggel RL&#46; Cardiac causes of cyanosis in the newborn&#46; UptoDate 2020&#46; Available from&#58; <a target="_blank" href="https://www.uptodate.com/contents/cardiac-causes-of-cyanosis-in-the-newborn">https&#58;&#47;&#47;www&#46;uptodate&#46;com&#47;contents&#47;cardiac-causes-of-cyanosis-in-the-newborn</a> &#91;accessed 18&#46;7&#46;22&#93;&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biventricular repair with the Yasui operation &#40;Norwood&#47;Rastelli&#41; for systemic outflow tract obstruction with two adequate ventricles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46;R&#46; Kanter"
                            1 => "P&#46;M&#46; Kirshbom"
                            2 => "B&#46;E&#46; Kogon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.athoracsur.2012.02.050"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "2012"
                        "volumen" => "93"
                        "paginaInicial" => "1999"
                        "paginaFinal" => "2006"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22520828"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Primary repair of interrupted aortic arch and severe aortic stenosis in neonates"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Yasui"
                            1 => "H&#46; Kado"
                            2 => "E&#46; Nakano"
                            3 => "K&#46; Yonenaga"
                            4 => "A&#46; Mitani"
                            5 => "Y&#46; Tomita"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Thorac Cardiovasc Surg"
                        "fecha" => "1987"
                        "volumen" => "93"
                        "paginaInicial" => "39"
                        "paginaFinal" => "45"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ross and Yasui operations for complex biventricular repair in infants with critical left ventricular outflow tract obstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;J&#46; Hickey"
                            1 => "T&#46; Yeh"
                            2 => "J&#46;P&#46; Jacobs"
                            3 => "C&#46;A&#46; Caldarone"
                            4 => "C&#46;I&#46; Tchervenkov"
                            5 => "B&#46;W&#46; McCrindle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejcts.2009.06.060"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Cardiothorac Surg"
                        "fecha" => "2010"
                        "volumen" => "37"
                        "paginaInicial" => "279"
                        "paginaFinal" => "288"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19762251"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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Article information
ISSN: 11340096
Original language: English
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