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Mashali MH, Yousef AA, Elmahrouk AF, Ba-Atiyah W, Rasol MA, Arafa MA, Shihata MS, Jamjoom AA, Hamouda TE. Reintervention after repair of tetralogy of Fallot: a one-decade single-center experience. THE CARDIOTHORACIC SURGEON 2023. [DOI: 10.1186/s43057-023-00096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Abstract
Background
Reinterventions after tetralogy of Fallot repair (TOF) remains a common clinical problem. The objective of this study was to evaluate types of reintervention after TOF repair and identify the risk factors for reinterventions.
Methods
This retrospective study was conducted from 2010 to 2022 and included 171 patients with complete TOF repair. Patients were grouped according to the occurrence of reintervention into two groups: patients who did not have reintervention (n = 138) and those who required reintervention (n = 33).
Results
Median follow-up was 36 (13–67) months. The first reintervention was required in 33 patients. Freedom from the first reintervention at 1, 3, 5, and 7 years was 91%, 85%, 81%, and 76%, respectively. Surgical reintervention was required in 12 patients and transcatheter intervention in 21 patients. Second reinterventions were required in 11 patients; 4 had surgery, and 7 had a transcatheter intervention. Third reinterventions were performed on two patients; one had surgery, and one had a transcatheter intervention. The most common interventions were performed at the level of pulmonary arteries (n = 17), followed by the pulmonary valve and the right ventricular outflow tract (n = 15). The risk of reintervention was associated with the low weight (HR: 0.65 (95% CI: 0.48–0.88); P = 0.005) and small LPA diameter (HR: 0.36 (95% CI: 0.21–0.60); P < 0.001) at the time of the primary intervention and the nonuse of the transannular patch (HR: 0.27 (95% CI: 0.08–0.85); P = 0.026).
Conclusions
The risk of reintervention is high after tetralogy of Fallot repair. In our experience, the smaller the left pulmonary artery and weight at the repair time increased the risk of reintervention. Using a transannular patch in our series was associated with a lower risk of reintervention.
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Miller JR, Stephens EH, Goldstone AB, Glatz AC, Kane L, Van Arsdell GS, Stellin G, Barron DJ, d'Udekem Y, Benson L, Quintessenza J, Ohye RG, Talwar S, Fremes SE, Emani SM, Eghtesady P. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot. J Thorac Cardiovasc Surg 2023; 165:221-250. [PMID: 36522807 DOI: 10.1016/j.jtcvs.2022.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice. METHODS The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement. RESULTS In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation. CONCLUSIONS Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.
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Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Andrew B Goldstone
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Andrew C Glatz
- Division of Pediatrics, Department of Pediatric Cardiology, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Glen S Van Arsdell
- Division of Cardiothoracic Surgery, Department of Surgery, UCLA Mattel Children's Hospital, Los Angeles, Calif
| | - Giovanni Stellin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Lee Benson
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Quintessenza
- Department of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Sachin Talwar
- Department of Cariothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass.
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
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Toubat O, Wells WJ, Starnes VA, Kumar SR. Fate of the Right Ventricular Outflow Tract Following Valve-Sparing Repair of Tetralogy of Fallot. Semin Thorac Cardiovasc Surg 2022; 36:242-249. [PMID: 36567048 PMCID: PMC10287841 DOI: 10.1053/j.semtcvs.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Valve-sparing repair (VSR) of tetralogy of Fallot (TOF) tends to result in higher residual right ventricular outflow tract (RVOT) gradients. We evaluated the progression and clinical implications of RVOT gradients following VSR of TOF. Demographic, clinical, and operative data were retrospectively collected from consecutive TOF patients who underwent VSR at our institution between 01/2010 and 06/2021. RVOT gradient, pulmonary valve annulus (PVA) diameter and Boston Z-scores were recorded from serial echocardiograms. Data are presented as median and interquartile range or number and percentage. A total of 156 children (boys 92, 59%) underwent VSR at 6.5 (4.9-8.4) months of age and 6.6 kg (5.6- 7.7) weight. There was 1 (0.6%) operative mortality. The remaining 155 patients were followed for 69.4 months (4-106.2). RVOT gradient was 2.4m/s (1.7-2.9) at discharge. It transiently increased, then declined and stabilized during follow-up. PVA Z-score was -1.7 (-3.1 to 0.5) at discharge and 'grew' to -0.8 (-1.7 to 0.4) at last follow-up. Freedom from RVOT re-intervention was 97%, 94% and 91% at 1, 5 and 10-year follow-up. Among 67 (43%) patients with PVA Z-score < -2, a similar RVOT gradient pattern was observed and freedom from RVOT re-intervention was 97%, 95% and 95% at 1, 5 and 8-year follow-up. Following VSR of TOF, RVOT gradients transiently increase and then fall as PVA growth catches up, resulting in durable intermediate outcomes. Patients with PVA Z-score < -2 demonstrated a similar pattern of hemodynamics in the RVOT and excellent freedom from reintervention.
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Affiliation(s)
- Omar Toubat
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Winfield J Wells
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Vaughn A Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Subramanyan Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
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Samal S, Sharma R, Minhas HS, G G, Agarwal S, Naqvi SEH, Geelani MA. Role of great artery annulus ratio to predict transannular patch enlargement in repair of tetralogy of Fallot. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Traditionally, the pulmonary valve annulus (PVA) z-score is used to predict the requirement of transannular patch enlargement (TAPE) of right ventricular outflow tract (RVOT) and main pulmonary artery (MPA) in repair of tetralogy of Fallot (TOF). PVA z-score is highly variable and many other parameters are being reported to be accurate in predicting need of TAPE. In this study, we analyze the role of great artery annulus ratio (pulmonary valve annulus to aortic valve annulus ratio, PVA/AVA) to be used as a predictor for TAPE.
Methods
We analyzed 90 patients of TOF retrospectively who underwent repair between January 2021 and December 2021. The patients were divided as TAPE group who required TAPE of RVOT and MPA and non-TAPE group who did not have TAPE. Their baseline parameters, PVA Z-score, and cut-off great artery annulus ratio were compared.
Results
Total 44 (48.9%) patients had transannular patch (TAPE) repair and 46 (51.1%) patients had non-transannular patch repair. The great artery annulus ratio and PVA z-score was lower in case of TAPE group with statistical significance. Receiver operating characteristic curve analysis showed great artery annulus ratio as more accurate predictor of TAPE.
Conclusion
Great artery annulus ratio can be used as a simple and accurate predictor for transannular patch enlargement along with PVA z-score during repair of TOF.
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Yi K, Wang D, Xu J, Zhang X, Wang W, Gao J, Wang W, You T, Tian J. Surgical Strategies for Preservation of Pulmonary Valve Function in a Radical Operation for Tetralogy of Fallot: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:888258. [PMID: 35911536 PMCID: PMC9326161 DOI: 10.3389/fcvm.2022.888258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo evaluate the efficacy and safety of different surgical strategies to preserve pulmonary valve function. Surgical procedures evaluated include intraoperative balloon pulmonary valvuloplasty (IBPV), pulmonary valve reconstruction, and commissurotomy and pulmonary cusp augmentation (PCA) in patients who underwent a radical operation for Tetralogy of Fallot (ToF).Materials and MethodsThe five databases searched in the current study included the Cochrane Library, PubMed, China National Knowledge Infrastructure, VIP, and WanFang data. A systematic search for control trials was performed in each database from the start date of each database until December 2021. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of included studies.ResultsA total of 15 retrospective studies with a total number of 1,396 participants were included in this study. In subgroup 1 (IBPV vs. TAP), patients undergoing IBPV had a less degree of regurgitation at 1–2 years after the surgery. The reintervention rate increased in the IBPV group at 5 years. In subgroup 2 (pulmonary valve reconstruction vs. TAP), the degree of regurgitation decreased in the pulmonary valve reconstruction group at 1 month after the surgery. In subgroup 3 (valve-sparing operation vs. TAP), the comparison demonstrated decreased rates for surgical mortality and reintervention at 5–10 years after the surgery.ConclusionWe proposed that pulmonary valve function in a radical operation for ToF was preserved. IBPV, pulmonary valve reconstruction, and commissurotomy and PCA can be performed during the surgical procedure based on the developmental status and anatomical characteristics of the right ventricular outflow tract (RVOT), pulmonary valve, and pulmonary artery.Systematic Review Registration[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022300987].
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Affiliation(s)
- Kang Yi
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
| | - Dan Wang
- Department of Geriatric Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jianguo Xu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xin Zhang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenxin Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jie Gao
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Wei Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Tao You
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- Tao You,
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
- *Correspondence: Jinhui Tian,
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Guariento A, Schiena CA, Cattapan C, Avesani M, Doulamis IP, Padalino MA, Castaldi B, di Salvo G, Vida V. Pulmonary valve preservation during tetralogy of Fallot repair: midterm functional outcomes and risk factors for pulmonary regurgitation. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6644955. [PMID: 35848949 DOI: 10.1093/ejcts/ezac365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Many centres have recently adopted pulmonary valve (PV) preservation (PVP) during tetralogy of Fallot (ToF) repair. We sought to identify the midterm functional outcomes and risk factors for pulmonary regurgitation after this procedure. METHODS All patients undergoing PVP during transatrial-transpulmonary repair for ToF with PV stenosis at our institution between January 2007 and December 2020 were reviewed. RESULTS Overall, 73 patients were included. At the index surgery, the body surface area was 0.31 ± 0.04 m2, the age was 4.9 ± 2.9 months and the preoperative PV z-score was -3.02 ± 1.11. At a mean follow-up of 5.3 ± 2.7 years, the fractional area change of the right ventricle (RV) was 47.1 ± 5.2%, and the tricuspid annular plane systolic excursion z-score was -3.31 ± 1.89%. The 5-year freedom from moderate/severe PV regurgitation was 61.3% [95% confidence interval (CI): 48, 73%]. There was a significant correlation between RV function and moderate/severe PR at follow-up (R2: 0.08; P = 0.03). A comparison with a group of patients undergoing a transannular patch procedure (N = 33) showed superior outcomes for patients with PVP. The preoperative PV z-score and the degree of PR at discharge were risk factors for the early development of moderate/severe PR at follow-up [hazard ratio (HR): 0.64; 95% CI: 0.48, 0.86, P = 0.01 and HR: 2.31; 95% CI: 1.00, 5.36, P = 0.04, respectively]. A preoperative PV annulus z-score ≤ -2.85 was found to be predictive for moderate/severe PR at 5 years after PVP (HR: 2.56; 95% CI: 1.31, 5.01, P = 0.002). CONCLUSIONS A pulmonary valve preservation strategy during tetralogy of Fallot repair should always be attempted. However, a preoperative PV annulus z-score < -2.85 and moderate/severe regurgitation upon discharge are risk factors for midterm pulmonary regurgitation.
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Affiliation(s)
- Alvise Guariento
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Chiara A Schiena
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Claudia Cattapan
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Martina Avesani
- Pediatric Cardiology Unit, Departments of Women's and Children's Health, University of Padua, Padua, Italy
| | - Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Massimo A Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Biagio Castaldi
- Pediatric Cardiology Unit, Departments of Women's and Children's Health, University of Padua, Padua, Italy
| | - Giovanni di Salvo
- Pediatric Cardiology Unit, Departments of Women's and Children's Health, University of Padua, Padua, Italy
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
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7
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Waqar T, Ansari MZA, Khan K. Clinical outcome of right ventricle outflow tract management for repair of Tetralogy of Fallot with three contemporary surgical strategies. Pak J Med Sci 2021; 37:1313-1318. [PMID: 34475904 PMCID: PMC8377931 DOI: 10.12669/pjms.37.5.3961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/04/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare the early operative outcome of TOF repair with three contemporary repair strategies of RVOTO repair i.e. TAP, Mono-cusp construction (MC) in TAP and pulmonary valve repair. Methods: Study is performed at Punjab Institute of Cardiology, Lahore from May 2016 to April 2020. Retrospective analysis of data was performed for patient who underwent TOF repair by three different strategies of RVOT repairs during TOF surgery based on z scoring for pulmonary valve annulus. Group-I underwent trans-annular patch repair, while Group-II and III underwent Mono-cusp repair with autologous pericardium and pulmonary valve repair respectively. Analysis of Variance (ANOVA) and Pearson Chi-Square (PCS) statistics were used to compare the three groups for numeric and categorical variables respectively. Post-hoc t-test and Bonferroni correction were performed for numeric data to compare two groups with each other. Chi-square test was used to perform comparison between groups for categorial variables. Results: ANOVA for aortic cross clamp time, total CPB time, Post-operative mechanical ventilation time, ICU stay and hospital stay showed statistical difference among all three group with p-value less than 0.05 however post hoc T-test showed this variation is limited to post-operative mechanical ventilation only when groups compared with each other. PCS showed there was difference for incidence of difficult weaning from CPB when all three groups compared while there was no difference in operative mortality with p-value of 0.15. However, Group-II comparison with Group-I showed that weaning from CPB was superior in-Group-II with p-value of 0.016. Group-III showed the best statistics for all operative outcome variables among all three groups. Comparison of incidence of post-operative moderate pulmonary regurgitation before discharge between Group-II and Group-III showed significant difference with p-value of 0.0052. Conclusion: PV repair strategy should be employed for RVOT repair of TOF whenever feasible. MC repair showed fewer hours of postoperative mechanical ventilation and higher incidence of easy weaning from CPB when compared to TAP, however its impacts over ICU stay, Hospital stay and operative mortality is not profound in our TOF repair population.
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Affiliation(s)
- Tariq Waqar
- Tariq Waqar, (FCPS, FRCS), Associate Professor, Pediatric Cardiac Surgery, Punjab Institute of Cardiology, Lahore, Pakistan
| | - M Zubair Ahmed Ansari
- M. Zubair Ahmed Ansari, (FCPS), Assistant Professor, Cardiac Surgery, Cardiac Centre, Bahawalpur, QMC, Bahawalpur, Pakistan
| | - Kamran Khan
- Kamran Khan, (MS), Medical Officer, Punjab Institute of Cardiology, Lahore, Pakistan
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Yu H, Del Nido PJ, Geva T, Yang C, Wu Z, Rathod RH, Huang X, Billiar KL, Tang D. A Novel Pulmonary Valve Replacement Surgery Strategy Using Contracting Band for Patients With Repaired Tetralogy of Fallot: An MRI-Based Multipatient Modeling Study. Front Bioeng Biotechnol 2021; 9:638934. [PMID: 34095094 PMCID: PMC8170134 DOI: 10.3389/fbioe.2021.638934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/08/2021] [Indexed: 11/21/2022] Open
Abstract
Patients with repaired Tetralogy of Fallot (ToF), a congenital heart defect which includes a ventricular septal defect and severe right ventricular outflow obstruction, account for the majority of cases with late-onset right ventricle (RV) failure. Current surgery procedures, including pulmonary valve replacement (PVR) with right ventricle remodeling, yield mixed results. PVR with active band insertion was hypothesized to be of clinical usage on improving RV function measured by ejection fraction (EF). In lieu of risky open-heart surgeries and experiments on animal and human, computational biomechanical models were adapted to study the impact of PVR with five band insertion options. Cardiac magnetic resonance (CMR) images were acquired from seven TOF patients before PVR surgery for model construction. For each patient, five different surgery plans combined with passive and active contraction band with contraction ratio of 20, 15, and 10% were studied. Those five plans include three single-band plans with different band locations; one plan with two bands, and one plan with three bands. Including the seven no-band models, 147 computational bi-ventricle models were constructed to simulate RV cardiac functions and identify optimal band plans. Patient variations with different band plans were investigated. Surgery plan with three active contraction bands and band active contraction ratio of 20% had the best performance on improving RV function. The mean ± SD RV ejection fraction value from the seven patients was 42.90 ± 5.68%, presenting a 4.19% absolute improvement or a 10.82% relative improvement, when compared with the baseline models (38.71 ± 5.73%, p = 0.016). The EF improvements from the seven patients varied from 2.87 to 6.01%. Surgical procedures using active contraction bands have great potential to improve RV function measured by ejection fraction for patients with repaired ToF. It is possible to have higher right ventricle ejection fraction improvement with more bands and higher band active contraction ratio. Our findings with computational models need to be further validated by animal experiments before clinical trial could become possible.
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Affiliation(s)
- Han Yu
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States.,Department of Surgery, Harvard Medical School, Boston, MA, United States
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Chun Yang
- Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA, United States
| | - Zheyang Wu
- Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA, United States
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Xueying Huang
- School of Mathematical Sciences, Xiamen University, Xiamen, China
| | - Kristen L Billiar
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, United States
| | - Dalin Tang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China.,Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA, United States
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9
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Lyu Z, Jin M, Yang Y. Value of pulmonary annulus index in predicting transannular patch in tetralogy of Fallot repair. J Card Surg 2021; 36:2197-2203. [PMID: 33749928 DOI: 10.1111/jocs.15500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/07/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE It is very important to accurately assess the transannular patch (TAP) in the surgical treatment of tetralogy of Fallot (TOF). The pulmonary annulus index (PAI; the actual pulmonary annulus diameter divided by the expected pulmonary annulus diameter), GA ratio (the ratio of pulmonary annulus and aortic annulus), PAAI (the ratio of pulmonary annulus cross-section and aortic annulus cross-section), and pulmonary annulus Z score (PA Z score) were compared. This study aimed to analyze and explore the application value of PAI in predicting the need for TAP in children undergoing TOF repair. METHODS In total, 130 patients who were diagnosed with TOF and underwent TOF repair in Beijing Anzhen Hospital affiliated to Capital Medical University from December 2018 to December 2019 were retrospectively studied. In total, 112 cases were included in this study and 18 cases were excluded, of which 16 cases were aged above 18 years and 2 cases suffered from Down syndrome. They were divided into TAP group and no TAP group; the values of the pulmonary annulus and aortic annulus were measured. GA ratio, PAI, PAAI, the pulmonary annulus Z score, and main pulmonary artery (MPA) Z score were calculated to perform statistical analysis. RESULTS A total of 112 patients were included in the study, aged 4-177 months, with an average of 22.87 ± 30.21 months; 66 males and 46 females; weighing 5.3-29 kg, with an average of 9.94 ± 4.08 kg; three cases died, one case died of sepsis caused by pulmonary infection, one case died of low cardiac output syndrome, and one case died of multiple organ failure. In total, 62 cases (55.8%) did not undergo TAP and 50 cases (44.2%) underwent TAP. The pulmonary annulus Z score, main pulmonary artery Z score, and PAI in the TAP group were smaller than those in the no TAP group (p < .05). Receiver operating curve (ROC) analysis showed that when the cut-off value of pulmonary annulus was -1.98, the area under the curve (AUC) was 0.88, the sensitivity was 80%, and the specificity was 71%; when the cut-off value of PAI was 0.53, AUC was 0.85, the sensitivity was 75%, and the specificity was 80%; when the cut-off value of GA ratio was 0.55, AUC was 0.85, the sensitivity was 76%, and the specificity was 80%. The area under the PAAI curve was 0.85, the sensitivity was 76%, and the specificity was 79%. When the pulmonary valve Z score, PAI, GA ratio, PAAI, and MPA Z score were all greater than the dividing value, TAP was avoided in more than 90% of children with TOF. When the pulmonary valve Z score, PAI, GA ratio, PAAI, and the main pulmonary artery Z score were all below the dividing value, more than 90% of children with TOF needed TAP. CONCLUSION The predictive effect of PAI as a simple and effective predictor of TAP in TOF radical operation is the same as that of pulmonary annulus Z score, and combining it with the main pulmonary artery Z score was the most accurate method of prediction.
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Affiliation(s)
- Zhenyu Lyu
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Mei Jin
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yifei Yang
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Kwon MH, Bacha EA. Pulmonary Valve-Sparing Techniques for Tetralogy of Fallot: A Systematic Approach for Maximizing Success and Minimizing Risk. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:24-28. [PMID: 32354543 DOI: 10.1053/j.pcsu.2020.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/01/2020] [Accepted: 02/07/2020] [Indexed: 11/11/2022]
Abstract
Valve-sparing techniques for the treatment of Tetralogy of Fallot with pulmonary stenosis have evolved over the past few decades. This article will discuss the rationale for a more aggressive approach to sparing the pulmonary valve, the various techniques available (including commissurotomy, leaflet thinning and debridement, balloon dilation, and finally modified monocusp repair), as well as a systematic approach for employing these techniques based on individual patient anatomy in a manner that takes full advantages of the benefits of the valve-sparing approach while mitigating the risks involved.
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Affiliation(s)
- Michael H Kwon
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian/Columbia University Medical Center, Morgan Stanley Children's Hospital of New York, Columbia University College of Physicians and Surgeons, New York, New York
| | - Emile A Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian/Columbia University Medical Center, Morgan Stanley Children's Hospital of New York, Columbia University College of Physicians and Surgeons, New York, New York.
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11
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Emani SM. Commentary: Tetralogy of Fallot-in pursuit of perfection. J Thorac Cardiovasc Surg 2021; 162:1321-1322. [PMID: 33785215 DOI: 10.1016/j.jtcvs.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass.
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12
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O'Byrne ML, DeCost G, Katcoff H, Savla JJ, Chang J, Goldmuntz E, Groeneveld PW, Rossano JW, Faerber JA, Mercer-Rosa L. Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database. J Am Heart Assoc 2020; 9:e016581. [PMID: 32691679 PMCID: PMC7792257 DOI: 10.1161/jaha.120.016581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes. Methods and Results We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each. Conclusions This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Grace DeCost
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jill J Savla
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Joyce Chang
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Division of Rheumatology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
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13
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Hancock Friesen CL, Jaquiss RDB. Is the Die Cast by Surgeon's Choice or Patient's Anatomy? Late Outcomes in Tetralogy of Fallot. Can J Cardiol 2020; 37:184-185. [PMID: 32621889 DOI: 10.1016/j.cjca.2020.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
| | - Robert D B Jaquiss
- University of Texas Southwestern, Children's Health Dallas, Dallas, Texas, USA
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14
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Choi SJ, Kwon JE, Roh DE, Hyun MC, Jung H, Lee YO, Cho JY, Kim YH. Importance of pulmonary valve morphology for pulmonary valve preservation in tetralogy of Fallot surgery: comparison of the echocardiographic parameters. Clin Exp Pediatr 2020; 63:189-194. [PMID: 32024330 PMCID: PMC7254174 DOI: 10.3345/kjp.2019.01060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/06/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The decision to use transannular patching (TAP) during tetralogy of Fallot (TOF) repair depends on the pulmonary valve annulus size; the z score of the pulmonary annulus is the most commonly used predictor. However, definitive results are not obtained with z scores as different z score data sets are used for different parameters. PURPOSE This study aimed to identify the echocardiographic and other key factors that warranted a change in the surgical method during TOF surgery. METHODS Sixty-two patients were enrolled and divided into a pulmonary valve (PV) preservation group and a TAP group. Their medical records were reviewed. RESULTS The z score for PV annulus (PVA), ratio of the PVA to aortic annulus size, and ratio of PVA to descending aorta (DAO) size were significantly different between the PV preservation and TAP groups (-1.72±1.52 vs. -3.07±1.94, P=0.004; 0.62±0.12 vs. 0.50±0.14, P=0.002; and 1.32±0.32 vs. 1.07±0.36, P= 0.008, respectively). For TAP repair, the PVA z score had a sensitivity of 65.4% and specificity of 73.1%, ratio of PVA to aortic annulus size had a sensitivity of 73.1% and specificity of 65.4%, and ratio of PVA to DAO size had a sensitivity of 69.2% and specificity of 57.7%. The TAP group showed more monocuspid PVs (P=0.011), while the PV preservation group showed more tricuspid PVs (P=0.027). Commissurotomy was more frequently performed in the PV preservation group than in the TAP group (P=0.001). Of patients with commissurotomy, 58% showed a PV z score<-2. CONCLUSION Although various echocardiographic parameters may serve as predictors for determining surgical methods for TOF patients, the PV morphology and tissue characteristics should also be considered.
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Affiliation(s)
- Su Jin Choi
- Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children's Hospital, Daegu, Korea
| | - Jung Eun Kwon
- Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children's Hospital, Daegu, Korea
| | - Da Eun Roh
- Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children's Hospital, Daegu, Korea
| | - Myung Chul Hyun
- Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children's Hospital, Daegu, Korea
| | - Hanna Jung
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Ok Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Joon Yong Cho
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yeo Hyang Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children's Hospital, Daegu, Korea
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Repaired Congenital Heart Disease in Older Children and Adults: Up-to-Date Practical Assessment and Characteristic Imaging Findings. Radiol Clin North Am 2020; 58:503-516. [PMID: 32276700 DOI: 10.1016/j.rcl.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Because of a recent increase in survival rates and life expectancy of patients with congenital heart disease (CHD), radiologists are facing new challenges when imaging the peculiar anatomy of individuals with repaired CHD. Cardiac computed tomography and magnetic resonance are paramount noninvasive imaging tools that are useful in assessing patients with repaired CHD, and both techniques are increasingly performed in centers where CHD is not the main specialization. This review provides general radiologists with insight into the main issues of imaging patients with repaired CHD, and the most common findings and complications of each individual pathology and its repair.
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16
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Romeo JL, Etnel JR, Takkenberg JJ, Roos-Hesselink JW, Helbing WA, van de Woestijne P, Bogers AJ, Mokhles MM. Outcome after surgical repair of tetralogy of Fallot: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020. [DOI: 10.1016/j.jtcvs.2019.08.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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17
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Lozano-Balseiro M, Garcia-Vieites M, Martínez-Bendayán I, García-Hernández I, Cuenca-Castillo JJ, Rueda-Núñez F, Bautista-Hernandez V. Valve-Sparing Tetralogy of Fallot Repair With Intraoperative Dilation of the Pulmonary Valve. Mid-Term Results. Semin Thorac Cardiovasc Surg 2019; 31:828-834. [DOI: 10.1053/j.semtcvs.2019.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/15/2019] [Indexed: 01/15/2023]
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18
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Mouws EMJP, de Groot NMS, van de Woestijne PC, de Jong PL, Helbing WA, van Beynum IM, Bogers AJJC. Tetralogy of Fallot in the Current Era. Semin Thorac Cardiovasc Surg 2018; 31:496-504. [PMID: 30395964 DOI: 10.1053/j.semtcvs.2018.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/30/2018] [Indexed: 11/11/2022]
Abstract
Only few studies have reported long-term outcome of the transatrial-transpulmonary approach in the current era of management of tetralogy of Fallot (ToF). We investigated 15-year outcome of correction via a transatrial-transpulmonary approach in a large cohort of successive patients operated in the 21st century. All infant ToF patients undergoing transatrial-transpulmonary ToF correction between 2000 and 2015 were included (N = 177, 106 male, median follow-up 7.1 (interquartile range 3.0-10.9) years. Data regarding postoperative complications, reinterventions, development of atrial and ventricular arrhythmia, cardiac function, and survival were evaluated. Prior shunting was performed in 10 patients (6%). The transatrial-transpulmonary approach resulted in valve-sparing surgery in 57 patients (32%). Postoperative surgical complications included junctional ectopic tachycardia (N = 12, 7%), pericardial (N = 10, 6%) or pleural effusion (N = 7, 3%), chylothorax (N = 7, 4%), bleeding requiring reoperation (N = 4, 3%), and superficial wound infection (N = 1). Fifty-one patients underwent 68 reinterventions, mainly due to pulmonary restenosis (PS) (N = 57). ToF correction at age <2 months and double outlet or double-chambered right ventricle variants of the ToF spectrum were independent predictors for reintervention. Patients undergoing valve-sparing ToF correction had a significant longer PR-free survival than those with a transannular patch (8.5 [95% confidence interval 6.8-10.3] years vs 1.1 [95% confidence interval 0.8-1.5] years; P < 0.001). Overall mortality was 2.8%; mortality rates were higher in premature/dysmature newborns (0.7% vs 9.5%; P < 0.001). Although the 15-year outcome of the transatrial-transpulmonary approach in terms of postoperative complications and mortality rates is excellent, the high incidence of moderate and severe PR is worrisome. Valve-sparing surgery was associated with a substantially lower incidence of PR, yet was surgically not possible in the majority of patients.
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Affiliation(s)
- Elisabeth M J P Mouws
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Peter L de Jong
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wim A Helbing
- Department of Pediatric Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ingrid M van Beynum
- Department of Pediatric Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Singh NM, Loomba RS, Gudausky TM, Mitchell ME. Monocusp valve placement in children with tetralogy of Fallot undergoing repair with transannular patch: A functioning pulmonary valve does not improve immediate postsurgical outcomes. CONGENIT HEART DIS 2018; 13:935-943. [PMID: 30260077 DOI: 10.1111/chd.12670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/05/2018] [Accepted: 08/07/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In patients with tetralogy of Fallot (TOF), use of transannular patch (TAP) may be required in order to relieve significant right ventricular outflow tract obstruction, subsequently resulting in pulmonary insufficiency (PI). The monocusp valve has been used to temporarily reduce insufficiency in hopes to improve short and midterm outcomes. The purpose of this study was to assess for potential benefits of the monocusp valve in this subset of patients. DESIGN Between 2005 and 2016, 119 patients with TOF with pulmonary stenosis who underwent repair with TAP were analyzed, 43 (36.1%) had a monocusp valve placed. Immediate outcomes were assessed by postoperative echocardiograms, ICU data including time to extubation, chest tube duration, reintervention, length of stay, and mortality. RESULTS Median age of repair was similar for monocusp group at 143.5 days and nonmonocusp at 137.0 days (P = .93). Peak preoperative right ventricular outflow tract obstruction was higher in the monocusp group (80 mm Hg vs. 70 mm Hg, P ≤ .01). Patients who had monocusp placed had longer bypass time. There was less PI for monocusp group immediately after repair and at discharge (P ≤ .01). There was no difference in days of intubation, chest tube duration, length of hospitalization, reintervention rates, or mortality. CONCLUSION Decreasing the degree of PI with a monocusp valve in patients undergoing repair for TOF repair with TAP does not improve clinical outcomes in the immediate postoperative period.
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Affiliation(s)
- Nikki M Singh
- Division of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute at Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Rohit S Loomba
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Todd M Gudausky
- Division of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute at Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Medical College of Wisconsin, Herma Heart Institute at Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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20
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Bacha EA. Intraoperative balloon dilation in tetralogy of Fallot: Is there a "secret sauce"? J Thorac Cardiovasc Surg 2018; 156:782. [PMID: 30011769 DOI: 10.1016/j.jtcvs.2018.02.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/28/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Emile A Bacha
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University, New York, NY
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Awori MN, Mehta NP, Mitema FO, Kebba N. Optimal Use of Z-Scores to Preserve the Pulmonary Valve Annulus During Repair of Tetralogy of Fallot. World J Pediatr Congenit Heart Surg 2018; 9:285-288. [DOI: 10.1177/2150135118757991] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: The size of the pulmonary annulus measured as a z-score is often used to determine when to insert a transannular patch (TAP). Multiple “cutoffs” are quoted in the literature; this could lead to inappropriate insertion. We aimed to determine whether the use of z-scores derived from different populations may have contributed to the varied “cutoffs” quoted. Methods: PubMed was searched using the terms: “tetralogy,” “Fallot,” “transannular,” “patch,” “mortality,” and “death.” Studies published between January 1, 2005, and October 5, 2017, were included; studies without participants under the age of 18 years and studies that did not describe the operative procedure were excluded. Results: Of 52 papers retrieved, 19 were included representing 2,500 repaired patients; 1,371 (54.8%) had a TAP. Five (26.3%) papers representing 638 patients (25.5%) quoted a z-score “cutoff” and what data set was used; “cutoffs” ranged from −2 to −4 and were derived from 2 different data sets. Three studies quoted a data set that has been shown in previous work to be problematic; the only quoted “cutoffs” of −4 were from two of these studies. Conclusions: Surprisingly few (26.3%) studies mention what pulmonary annulus size “cutoff” was used to decide when to insert a TAP. Z-scores derived from different populations were used by different studies and it is possible that this may have contributed to the varied “cutoffs’ quoted. Recommendations to perform valve-sparing surgery in pulmonary annuli as small as −4 may not be warranted. Future papers should record “cutoffs” employing recommended z-score data set.
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Affiliation(s)
- Mark Nelson Awori
- Kenyatta National Hospital, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Nikita P. Mehta
- Kenyatta National Hospital, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Frederick O. Mitema
- Kenyatta National Hospital, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Naomi Kebba
- Kenyatta National Hospital, University of Nairobi College of Health Sciences, Nairobi, Kenya
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Valve-sparing repair with intraoperative balloon dilation in tetralogy of Fallot: Midterm results and therapeutic implications. J Thorac Cardiovasc Surg 2018; 155:1163-1173.e4. [DOI: 10.1016/j.jtcvs.2017.08.147] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/23/2017] [Accepted: 08/28/2017] [Indexed: 11/18/2022]
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23
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Arafat AA, Elatafy EE, Elshedoudy S, Zalat M, Abdallah N, Elmahrouk A. Surgical strategies protecting against right ventricular dilatation following tetralogy of Fallot repair. J Cardiothorac Surg 2018; 13:14. [PMID: 29357937 PMCID: PMC5778645 DOI: 10.1186/s13019-018-0702-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/17/2018] [Indexed: 11/30/2022] Open
Abstract
Background Right ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia. Methods From 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from − 2 to − 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5). Results All repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%). Conclusion Pulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.
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Affiliation(s)
- Amr A Arafat
- Cardiothoracic Surgery Department, Tanta University, Al-Geish Street, Tanta, 31527, Gharbya, Egypt.
| | - Elatafy E Elatafy
- Cardiothoracic Surgery Department, Tanta University, Al-Geish Street, Tanta, 31527, Gharbya, Egypt
| | | | - Mahmoud Zalat
- Cardiothoracic Surgery Department, Misr Children Hospital, Cairo, Egypt
| | | | - Ahmed Elmahrouk
- Cardiothoracic Surgery Department, Tanta University, Al-Geish Street, Tanta, 31527, Gharbya, Egypt
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Parikh KN, Shah NC, Clark JB, Myers JL. Pulmonary valve restitution following transannular patch repair of tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2017; 25:985-986. [PMID: 29049532 DOI: 10.1093/icvts/ivx215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/30/2017] [Indexed: 11/13/2022] Open
Abstract
Chronic pulmonary insufficiency following transannular patch repair of tetralogy of Fallot may mandate restoration of a competent pulmonary valve. Pulmonary valve leaflets that are preserved at initial surgery may grow and develop normal morphology and subsequent valve repair may be possible. We reviewed our experience with native pulmonary valve restitution following transannular patch repair (2001-15). The cohort included 9 patients with a median age of 18.7 (range 10.6-31.3) years. Operative technique involved reapproximation of the anterior commissure of the pulmonary valve. Median length of stay was 3 days, and there were no deaths. At median follow-up of 2.0 (0.4-13.5) years, pulmonary insufficiency was graded as ≤mild (n = 4), mild-moderate or moderate (n = 4) and moderate-severe (n = 1); pulmonary stenosis was ≤mild (n = 8) and moderate (n = 1), with median peak gradient of 21 (16-64) mmHg. No patient required reintervention. At reoperation to treat pulmonary insufficiency in repaired TOF, if residual leaflets are found with favourable anatomy, restitution of the native valve should be considered. This valve-preserving technique avoids the certain failure of a bioprosthesis and is associated with favourable early outcomes. The viability of this option may influence surgeons to leave the pulmonary leaflets in situ at the time of initial repair.
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Affiliation(s)
- Khushboo N Parikh
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Nishant C Shah
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Joseph B Clark
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - John L Myers
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Children's Hospital, Hershey, PA, USA
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25
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A functional pulmonary valve after tetralogy of Fallot repair: A fool's errand? J Thorac Cardiovasc Surg 2017; 155:1161-1162. [PMID: 29110953 DOI: 10.1016/j.jtcvs.2017.09.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/22/2022]
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Bhagra CJ, Hickey EJ, Van De Bruaene A, Roche SL, Horlick EM, Wald RM. Pulmonary Valve Procedures Late After Repair of Tetralogy of Fallot: Current Perspectives and Contemporary Approaches to Management. Can J Cardiol 2017; 33:1138-1149. [PMID: 28843325 DOI: 10.1016/j.cjca.2017.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 11/18/2022] Open
Abstract
Few topics in adult congenital heart disease have approached the level of scrutiny bestowed on pulmonary valve replacement (PVR) strategies late after tetralogy of Fallot (TOF) repair. Despite the successes of primary surgery for TOF, there is a growing group of adults with residual right ventricular outflow tract and pulmonary valve dysfunction. Patients with residual chronic pulmonic regurgitation as a consequence of earlier surgery can later develop symptoms of exercise intolerance and complications including heart failure, tachyarrhythmias, and sudden cardiac death. Optimal timing of PVR has sparked debate, which has catalyzed increasing research efforts over the past decade. Although performance of PVR in the absence of symptoms is currently on the basis of the rationale that achievement of complete reverse remodelling is highly desirable, whether this approach results in improvement in patient outcomes in the long-term has yet to be shown. Surgical PVR and percutaneous pulmonary valve intervention are different techniques with specific advantages and disadvantages that require careful consideration for each individual patient, alongside the need for requisite reinterventions over the course of a patient's lifetime. Criteria pertaining to referral strategies are ever being refined as newer technologies for percutaneous therapies continue to evolve. In this article we review the literature surrounding the indications for, the optimal timing of, and the approaches to pulmonary valve procedures in adults with previously repaired TOF.
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Affiliation(s)
- Catriona J Bhagra
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Cambridge University and Papworth NHS Foundation Trusts, Cambridge, United Kingdom
| | - Edward J Hickey
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alexander Van De Bruaene
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - S Lucy Roche
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eric M Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rachel M Wald
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
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27
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Karamichalis JM. The Right Ventricular Outflow Tract Reconstruction: A Challenge in Tetralogy of Fallot Repair. Is There a Right Way of Doing It? An Art or a Science? Semin Thorac Cardiovasc Surg 2017; 28:471-472. [PMID: 28043463 DOI: 10.1053/j.semtcvs.2016.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2016] [Indexed: 11/11/2022]
Affiliation(s)
- John M Karamichalis
- Division of Pediatric Cardiac Surgery, The Children's Hospital at Saint Francis, Tulsa, OK; University of California San Francisco, San Francisco, California.
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28
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Bacha E. Valve-Sparing or Valve Reconstruction Options in Tetralogy of Fallot Surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:79-83. [PMID: 28007071 DOI: 10.1053/j.pcsu.2016.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 09/14/2016] [Indexed: 06/06/2023]
Abstract
This review deals with a relatively new field in congenital heart surgery, valve preservation or, in cases of more severe pulmonary valve stenosis or dysplasia, valve reconstruction during tetralogy of Fallot repair. We describe the stepwise approach utilized, starting with simple maneuvers such as commissurotomy and valve dilation for mild pulmonary stenosis to commissurotomy and intraoperative balloon dilation for moderate stenosis, and finally transection of the annulus and valve reconstruction using a patch that acts as a modified monocusp. Results are presented and have been gratifying.
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Affiliation(s)
- Emile Bacha
- Columbia University College of Physicians and Surgeons, Congenital and Pediatric Cardiac Surgery, New York, NY; and New York-Presbyterian Morgan Stanley Children's Hospital (CHONY), New York, NY.
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Kim YY, Ruckdeschel E. Approach to residual pulmonary valve dysfunction in adults with repaired tetralogy of Fallot. Heart 2016; 102:1520-6. [DOI: 10.1136/heartjnl-2015-309067] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 05/23/2016] [Indexed: 12/28/2022] Open
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