Background and aim: On the basis of previously published accounts, coupled with our own experience, we have assessed the surgical approaches to patients with isomeric atrial appendages. Methods: We reviewed pertinent published studies on surgical treatment of individuals with isomeric atrial appendages, with the pertinent surgical details provided by most of the manuscripts. Results: Half of patients with right isomerism, and two-thirds of those with left isomerism have bilateral superior caval veins. Azygos extension of the inferior caval vein is reported in three-quarters of those with left isomerism. The coronary sinus is universally absent in right isomerism, along with totally anomalous pulmonary venous connection, and is absent in two-fifths of those with left isomerism.. Univentricular atrioventricular connections are expected in up to three-quarters of those with right isomerism. Atrioventricular septal defect is reported in up to four-fifths, more frequently in right isomerism, with such patients typically having discordant ventriculoatrial connections or double outlet right ventricle. Reported mortalities extend to 85% for those with right, and 50% for those with left isomerism. In right isomerism, mortality is up to 54% for systemic-to-pulmonary arterial shunting, up to 75% for univentricular repair, and up to 95% for repair of totally anomalous pulmonary venous connection itself. No more than one-quarter had undergone Fontan completion, with reported mortalities of 21%. Conclusion: Early surgical results are satisfactory in patients with left isomerism, but disappointing for those with right. Recent advances in cardiac and liver transplantation may offer improved survival.

Background: Expected benefits of modified ultrafiltration(MUF) include increased hematocrit, reduction of total body water & inflammatory mediators, improved left ventricular systolic function, & improved systolic blood pressure and cardiac index following cardiopulmonary bypass(CPB). This prospective randomized trial tested this hypothesis. Methods: 79 patients undergoing intracardiac repair of Tetralogy of Fallot(TOF) were randomized to MUF group(Group-M, n=39) or only conventional ultrafiltration(CUF) group(Group-C, n=40). Primary outcome was change in hematocrit. Secondary outcomes were changes in peak airway pressures, ventilatory support, blood transfusions, time to peripheral rewarming, mean arterial pressure, central venous pressure, inotrope score(IS) and cardiac index. Serum inflammatory markers were measured. Results: Following MUF, Group-M had higher hematocrit(44.3±0.98 g/dl) compared to Group-C(37.8±1.37g/dl),P=<0.001. Central venous pressure(mmHg) immediately following sternal closure was 9.27±3.12mmHg in Group-M & 10.52±2.2mmHg in Group-C(P=0.04). In the ICU, they were 11.52±2.20mmHg in Group-C and 10.84±2.78mmHg in Group-M(P=0.02). Time to peripheral rewarming was 6.30±3.91 hours in Group-M and 13.67±3.91hours in Group-C(P=0.06). Peak airway pressures in ICU were 17±2mmHg in Group-M & 20.55±2.97mmHg in Group-C, P<0.001. Duration of mechanical ventilation was 6.3±2.7 hours in Group-M compared to 14.7±3.5 hours in Group-C(P=0.002). IS was 11.52±2.20 in Group-C compared to 10.84±2.78 in Group-M. 8/39(20.5%) patients in Group-M had IS>10 compared to 22/40(55%) patients in Group-C(P=0.02). Serum Troponin-T and Interleukin-6 levels were lower in Group-M; TNF-α and CPK-MB were similar. ICU & hospital stay were similar. Conclusion: MUF group had higher post-operative hematocrit, decreased duration of mechanical ventilation, lower need for inotropes & lower Interleukin-6 & Troponin-T levels. MUF group had better post-operative outcomes.