Isolated partial anomalous pulmonary venous connections in adults: twenty-year experience

OBJECTIVE

We sought to review our experience with isolated partial anomalous pulmonary veins as their management is controversial.

DESIGN

We reviewed all patients with isolated partial anomalous pulmonary veins >18 years attending the Congenital Clinic from 1988-2008.

RESULTS

Forty-three patients aged 20-73 years were included. Fifteen patients had no surgery, 11 of whom had a single anomalous pulmonary vein. Surgical repair was performed in 28 patients: 27 had right ventricular volume overload, 21 had more than one anomalous pulmonary vein, and 1 had stenosed pulmonary veins. Right ventricular systolic pressure was elevated (>35 mm Hg) in 12 patients. Eleven patients had anomalous left pulmonary veins: 10 had the pulmonary vein anastomosed to the left atrial appendage and one patient had anastomosis to the left lower pulmonary vein. One patient had bilateral anomalous pulmonary veins anastomosed directly to the left atrium. Sixteen patients had anomalous right pulmonary veins: fifteen had a baffle through a surgically-created atrial septal defect, while one had the anomalous pulmonary vein anastomosed to the left atrium. There was no early mortality. During mean echo follow-up of 2.7 years, 19 patients (68%) had reduced right ventricular size and five had improved right ventricular function. Seven patients with increased pulmonary pressure had a decrease post-operatively.

CONCLUSION

Partial anomalous pulmonary veins can cause symptoms, right ventricular volume overload, and pulmonary hypertension, particularly when more than one pulmonary vein is anomalous. Surgical repair can be accomplished with low morbidity and mortality, with improvement in the right ventricular size and pulmonary pressures in most.

Epicardial versus endocardial permanent pacing in adults with congenital heart disease

BACKGROUND

Permanent pacing (PM) in patients with congenital heart disease (CHD) presents unique challenges-with little known about the long-term outcomes.

METHODS

Pacemaker complications and reinterventions were reviewed over a 38-year period and were grouped by epicardial or endocardial approaches.

RESULTS

The average age at intervention was 37 ± 19 years for 106 patients and 259 PM procedures were performed (2.4 ± 2 per patient). From the first PM procedure, patients were followed for 11.6 ± 14 years. The most common indications for initial PM intervention were heart block (25%) and sinus node dysfunction (20%), yet reintervention was driven primarily by lead failure (49%). Endocardial systems were initially implanted in 73 patients (67%). Epicardial pacing was more common in patients with complex CHD (p = 0.006), cyanosis (p < 0.001), residual shunts (0.01), or Ebstein's anomaly (p = 0.01). Fifty-one devices (28%) developed lead or generator complications. Epicardial systems were most likely to develop lead failure (p < 0.0001), predominantly in the ventricular lead (p < 0.0001). Endocardial systems were found to be more durable than the epicardial systems (p = 0.023), and Ebstein's anomaly or an epicardial system was an independent predictor of lead failure.

CONCLUSIONS

Permanent pacing in CHD is associated with considerable morbidity and the need for repeat intervention, especially in those with Ebstein's anomaly. Epicardial pacing systems appear to have a higher incidence of lead failure and are significantly less durable in this group.

Adult congenital heart disease importance of the right ventricle

The right ventricle (RV) is of lesser importance in acquired heart disease, but its role is of increasing importance in congenital heart disease. It may function as a subpulmonary ventricle or as a subaortic (systemic) ventricle in transposition complexes. The RV has a remarkable ability to adapt to pressure and volume load, but its size and function are often overlooked. Patients usually develop symptoms only after RV dysfunction has occurred, and in many diverse clinical scenarios, late referral is common. Advanced RV enlargement and dysfunction are responsible for not only impaired functional capacity but also lethal ventricular arrhythmias and sudden death. Appropriate imaging of the size and function of the RV are important because timely surgery on the pulmonary and tricuspid valves may preserve RV size and function. Adults with congenital heart disease should be followed at centers where there is an understanding of these problems so that valvular surgery can be considered when appropriate.

Comparison of the outcome of porcine bioprosthetic versus mechanical prosthetic replacement of the tricuspid valve in the Ebstein anomaly

Our objective was to determine the relative merits of using a bioprosthetic porcine valve (BPV) versus a mechanical valve (MechV) when tricuspid valve (TV) replacement is required in patients with Ebstein anomaly. From 1972 to 2006, 333 patients received a BPV and 45 received a MechV. Patient records were reviewed, vital status ascertained, and all patients not known to be deceased were mailed a medical questionnaire or contacted by telephone. Early mortality was not statistically higher for patients who had a MechV (11%) than for those who had a BPV (5%) inserted in the TV position (p = 0.173). The only independent preoperative predictor of operative mortality was moderate to severe left ventricular dysfunction (odds ratio 3.1, p = 0.03); 20-year survival was better in patients who had a BPV (75%) than for those who had a MechV (43%, p = 0.003). On multivariate analysis, after adjusting for ablation of accessory pathways, sinus rhythm at dismissal, and concomitant repair of pulmonary valve stenosis, a BPV remained a predictor of late survival (hazard ratio 0.42, p = 0.004). Survival free of reoperation on the TV at 20 years postoperatively was similar for patients who had a MechV (49%) compared with those who had a BPV (42%) inserted (p = 0.941). A greater percentage of patients who had a MechV reported endocarditis (12% vs 2%), bleeding requiring hospitalization (6% vs 3%), and thrombosis (12% vs 6%); however, none of these differences were statistically significant. In conclusion, a BPV in the tricuspid position was an independent predictor of improved survival. This may be related to the higher incidence of bleeding and thrombotic complications in the patients with MechVs or may be related to differences between the 2 groups. A BPV may offer superior late survival when compared with a MechV when TV replacement is required in patients with Ebstein anomaly, but patient selection must be individualized.

Anesthetic management of parturients with congenitally corrected transposition of the great arteries: three cases and a review of the literature

Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity for congestive heart failure and cardiac dysrhythmias during pregnancy, labor, and delivery. We report the successful obstetric and anesthetic management of three women with CCTGA, review the pertinent medical literature, and discuss important issues surrounding the anesthetic management of parturients with CCTGA.

Effect of operation for Ebstein anomaly on left ventricular function

Our objective was to examine the outcomes of patients with left ventricular (LV) dysfunction who underwent operation for Ebstein anomaly. From April 1, 1972 to January 1, 2006, 539 patients with Ebstein anomaly underwent operation at Mayo Clinic. LV function was determined by echocardiography. Of the 495 patients with preoperative echocardiographic assessment of LV function, 50 had moderate or severe LV systolic dysfunction. In patients with LV dysfunction, the tricuspid valve (TV) was repaired in 12 patients and replaced in 36 patients; 1 patient had a 1.5 ventricle repair, and 1 patient had cardiac transplantation. There were 5 early deaths (10%). LV function improved in all but 4 patients after operation. In no patient did LV function worsen after operation. The 1-, 5-, and 10-year survival was 86%, 77%, and 67%, respectively. On univariate analysis, absence of sinus rhythm at dismissal (p = 0.003) was associated with greater overall mortality. For the entire cohort of 539 patients, LV dysfunction was independently predictive of late mortality (hazard ratio 3.76, p <0.001). At late follow-up (mean 6.9 years), 86% of patients were in New York Heart Association class I or II. In conclusion, LV systolic dysfunction occurs infrequently in patients with Ebstein anomaly and is a risk factor for increased late mortality. Although early mortality is greater in patients with LV dysfunction, the late results are favorable. Decreasing LV function should be an indication to promptly restore TV competence rather than a contraindication to TV operation.

Functional status after operation for Ebstein anomaly: the Mayo Clinic experience

OBJECTIVES

The objective of this study was to review the long-term functional outcome of patients with Ebstein anomaly who had cardiac operation at our institution.

BACKGROUND

Ebstein anomaly is a spectrum of tricuspid valvular and right ventricular dysplasia. Many patients will require operation in an attempt to improve quality of life.

METHODS

From April 1, 1972, to January 1, 2006, 539 patients with Ebstein anomaly underwent 604 cardiac operations at the Mayo Clinic in Rochester, Minnesota. Patient records were reviewed, and all patients known to still be alive were mailed a medical questionnaire or contacted by telephone.

RESULTS

At the initial operation at our institution, the mean age of the patients was 24 years (range 8 days to 79 years) and 53% were female patients. Survival at 5, 10, 15, and 20 years was 94%, 90%, 86%, and 76%, respectively. Survival free of late reoperation was 86%, 74%, 62%, and 46% at 5, 10, 15, and 20 years, respectively. Surveys were returned by 285 of 448 (64%) patients known to be alive at the time of this study. Two hundred thirty-seven (83%) patients were in New York Heart Association functional class I or II, and 34% were taking no cardiac medication. One hundred three patients (36%) reported an incident of atrial fibrillation or flutter, 5 patients (2%) reported having had endocarditis, and 1 patient (<1%) reported having a stroke. There were 275 pregnancies among 82 women. The recurrence of congenital heart disease was reported in 9 of 232 (3.9%) liveborn children.

CONCLUSIONS

Patients have good long-term survival and functional outcomes after undergoing surgery for Ebstein anomaly. Atrial arrhythmias are common both before and after surgery. Many patients have had one or more successful pregnancies with a low-recurrence risk of congenital heart disease.

Hysteroscopic sterilization in women with severe cardiac disease: experience at a tertiary center

OBJECTIVE

To determine the feasibility and effectiveness of hysteroscopic sterilization as a minimally invasive sterilization method for women with high-risk cardiac disease.

PARTICIPANTS AND METHODS

In a retrospective cohort study, 18 women with high-risk cardiac conditions that strictly contraindicated pregnancy were compared with a reference cohort of 157 women without cardiac disease. All underwent microinsert hysteroscopic sterilization at Mayo Clinic from January 2003 through February 2007. End points included successful placement, fallopian tube patency determined by hysterosalpingogram 3 months after the procedure, and pregnancy status.

RESULTS

Women in the cardiac cohort were younger than those in the reference cohort (median age, 25 vs 39 years; P<.001), had lower parity (median, 0 vs 2; P<.001), and had a higher proportion of patients categorized as American Society of Anesthesiologists' physical status 3 (severe systemic disease) and physical status 4 (systemic disease that is a constant threat to life) (83% vs 6%; P<.001). No significant differences were noted for use of general anesthesia (17% vs 27%; P=.41), successful bilateral device placement (100% vs 95%; P>.99), postoperative pain score (median, 0 for both groups; P=.87), or length of hospitalization (median, 6 vs 6 hours; P=.63). No intraoperative complications occurred. Follow-up hysterosalpingography showed high tubal occlusion rates in both cohorts (100% cardiac; 98% reference; P>.99). No pregnancies occurred during a median follow-up period of 20 months (interquartile range, 8-33 months).

CONCLUSION

For women with cardiac disease and strict contraindications for pregnancy, microinsert hysteroscopic sterilization provided minimally invasive, permanent, and reliable contraception.

Intermediate-term results of ascending–descending posterior pericardial bypass of complex aortic coarctation

OBJECTIVE

Extra-anatomic bypass of complex thoracic aortic disease through a median sternotomy has been reported as a safe alternative to thoracotomy. Our objective was to examine intermediate-term outcomes.

METHODS

We retrospectively reviewed 50 consecutive patients with congenital aortic coarctation or recurrent coarctation who underwent ascending-descending posterior pericardial aortic bypass between January 1985 and November 2005. Demographic data, in-hospital and postoperative morbidity and mortality, and resolution of hypertension were determined by examination of the medical record.

RESULTS

The mean age at operation was 42 years; 27 (54%) were men. There were no perioperative deaths. Upper-extremity blood pressure after coarctation repair with ascending-descending aortic bypass was significantly improved. Mean systolic blood pressure decreased from 158 +/- 25 mm Hg preoperatively to 123 +/- 14 mm Hg postoperatively (P < .001). There were no graft-related deaths or complications in follow-up extending up to 20 years.

CONCLUSIONS

The ascending-descending aortic bypass through a posterior pericardial approach is a safe operation and is effective in relieving obstruction and improving hypertension.

Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics

Prevention of congenital cardiovascular defects has been hampered by a lack of information about modifiable risk factors for abnormalities in cardiac development. Over the past decade, there have been major breakthroughs in the understanding of inherited causes of congenital heart disease, including the identification of specific genetic abnormalities for some types of malformations. Although relatively less information has been available on noninherited modifiable factors that may have an adverse effect on the fetal heart, there is a growing body of epidemiological literature on this topic. This statement summarizes the currently available literature on potential fetal exposures that might alter risk for cardiovascular defects. Information is summarized for periconceptional multivitamin or folic acid intake, which may reduce the risk of cardiac disease in the fetus, and for additional types of potential exposures that may increase the risk, including maternal illnesses, maternal therapeutic and nontherapeutic drug exposures, environmental exposures, and paternal exposures. Information is highlighted regarding definitive risk factors such as maternal rubella; phenylketonuria; pregestational diabetes; exposure to thalidomide, vitamin A cogeners, or retinoids; and indomethacin tocolysis. Caveats regarding interpretation of possible exposure-outcome relationships from case-control studies are given because this type of study has provided most of the available information. Guidelines for prospective parents that could reduce the likelihood that their child will have a major cardiac malformation are given. Issues related to pregnancy monitoring are discussed. Knowledge gaps and future sources of new information on risk factors are described.

Transposition of the great arteries

Many patients with ventriculoarterial discordance have survived to adulthood. Those with complete transposition of the great arteries have often had an atrial switch procedure (Mustard or Senning operation) performed, which leaves the morphological right ventricle (RV) supporting the systemic circulation. RV failure and tricuspid regurgitation are common. Some patients may ultimately require cardiac transplantation. Sinus node dysfunction is increasingly common with longer follow-up, and some patients need pacemaker implantation. Atrial arrhythmias are frequent, and atrial flutter may be a marker for sudden death. Patients with an arterial switch procedure are also surviving to adulthood. Long-term problems include coronary stenoses, distortion of the pulmonary arteries, dilatation of the neoaortic root, and aortic regurgitation. Patients with congenitally corrected transposition have both atrioventricular and ventriculoarterial discordance and therefore also have a morphological RV and delicate tricuspid valve in the systemic circulation. Associated defects, such as abnormalities of the tricuspid valve, ventricular septal defect, and pulmonary stenosis, occur in the majority of patients. Heart block occurs with increasing age. Atrial arrhythmias occur frequently, and their occurrence should prompt a search for a hemodynamic problem. Progressive tricuspid regurgitation occurs with age and is associated with deterioration of RV function. Surgical treatment should be considered at the earliest sign of RV dilatation or dysfunction. All patients should be seen periodically in a center where expertise in the clinical evaluation, imaging, and hemodynamic assessment of adult congenital heart disease is available.

Early and Late Results of the Modified Fontan Operation for Heterotaxy Syndrome

OBJECTIVES

We sought to evaluate the early and late results of the modified Fontan operation for patients with heterotaxy syndrome, assess variables traditionally known to correlate with poor outcome, and assess current health status of survivors after the Fontan procedure.

BACKGROUND

The natural history of unoperated cardiac lesions in heterotaxy is known to be poor. Therefore, the Fontan operation has been proposed to improve survival.

METHODS

Patients with heterotaxy were identified from the Mayo Clinic Fontan database. Hospital and outpatient records were abstracted for preoperative, operative, and postoperative clinical and hemodynamic data. All patients not known to be deceased were sent health status questionnaires.

RESULTS

A total of 142 patients with heterotaxy syndrome had a modified Fontan operation. Asplenia was present in 76 patients (54%). Median age at operation was 9 years (range 2 to 35 years). Median follow-up was 4 years (range 0 to 23 years). There were a total of 61 deaths (43%), with 32 (23%) within 30 days of operation or before hospital discharge. The 5-, 10-, and 15-year survival was 64%, 57%, and 53%, respectively. In the modern era (1995 to 2004) early mortality was 10%. Of the 81 survivors, questionnaires were available from 41 (51%). Eighty percent reported having no or mild symptoms. However, 19 (46%) had arrhythmias, 5 (12%) had a thromboembolic event, and 1 (2%) developed protein-losing enteropathy.

CONCLUSIONS

Early survival has improved for heterotaxy patients after the Fontan operation; however, late morbidity and mortality remain substantial. Better strategies for long-term treatment of this high-risk group need to be identified.

Report of the National Heart, Lung, and Blood Institute Working Group on Research in Adult Congenital Heart Disease

The Working Group on research in adult congenital heart disease (ACHD) was convened in September 2004 under the sponsorship of National Heart, Lung, and Blood Institute (NHLBI) and the Office of Rare Diseases, National Institutes of Health, Department of Health and Human Services, to make recommendations on research needs. The purpose of the Working Group was to advise the NHLBI on the current state of the science in ACHD and barriers to optimal clinical care, and to make specific recommendations for overcoming those barriers. The members of the Working Group were chosen to provide expert input on a broad range of research issues from both scientific and lay perspectives. The Working Group reviewed data on the epidemiology of ACHD, long-term outcomes of complex cardiovascular malformations, issues in assessing morphology and function with current imaging techniques, surgical and catheter-based interventions, management of related conditions including pregnancy and arrhythmias, quality of life, and informatics. After research and training barriers were discussed, the Working Group recommended outreach and educational programs for adults with congenital heart disease, a network of specialized adult congenital heart disease regional centers, technology development to support advances in imaging and modeling of abnormal structure and function, and a consensus on appropriate training for physicians to provide care for adults with congenital heart disease.

Sinus Venosus Atrial Septal Defect

Background— Sinus venosus atrial septal defect (SVASD) differs from secundum atrial septal defect by its atrial septal location and its association with anomalous pulmonary venous connection (APVC). Data on long-term outcome after surgical repair are limited.

Methods and Results— We reviewed outcomes of 115 patients (mean age±SD 34±23 years) with SVASD who had repair from 1972 through 1996. APVC was present in 112 patients (97%). Early mortality was 0.9%. Complete follow-up was obtained for 108 patients (95%) at 144±99 months. Symptomatic improvement was noted in 83 patients (77%), and deterioration was noted in 17 patients (16%). At follow-up, 7 (6%) of 108 patients had sinus node dysfunction, a permanent pacemaker, or both, and 15 (14%) of 108 patients had atrial fibrillation. Older age at repair was predictive of postoperative atrial fibrillation ( P =0.033). No reoperations were required during follow-up. Survival was not different from expected for an age- and sex-matched population. Clinical improvement was more common with older age at surgery ( P =0.014). Older age at repair ( P =0.008) and preoperative New York Heart Association class III or IV ( P =0.038) were independent predictors of late mortality.

Conclusions— Operation for SVASD is associated with low morbidity and mortality, and postoperative subjective clinical improvement occurs irrespective of age at surgery. Postoperative atrial fibrillation appears to be related to older age at operation. SVASD repair achieves survival similar to that of a matched population and should be considered whenever repair may impact survival or symptoms.

Ebstein's anomaly - review of a multifaceted congenital cardiac condition

Ebstein's anomaly (EA) is a rare but fascinating congenital heart disorder accounting for <1% of all congenital heart defects. Since its description in 1866, dramatic advances in diagnosis and therapy have been made. In this review, we describe current diagnostic criteria and classification, natural history, clinical features, and prognosis, typical echocardiographic features and pathologic findings, and the spectrum of associated cardiac malformations including left heart anomalies associated with EA. Differences between Ebstein-like changes associated with congenitally corrected transposition and EA are described. The spectrum of typical ECG and conduction system changes, arrhythmias including accessory pathways and ectopic atrial tachycardias related to EA are also reviewed. Differential diagnosis of EA is discussed including tricuspid valve dysplasia and prolapse as well as arrhythmogenic right ventricular cardiomyopathy. The review describes management options in EA including catheter interventions, indication for operation and surgical options including tricuspid valve repair and replacement. Overall, EA is a complex congenital anomaly with a broad pathologic-anatomical and clinical spectrum and no two patients are alike. Therefore, precise knowledge of the different anatomic and hemodynamic variables, associated malformations and management options are essential. Management of EA patients is complex. Thus it is important that these patients are regularly seen by a cardiologist with expertise in congenital heart disease.