Midterm Results of Arterial Switch Operation in Older Patients With Severe Pulmonary Hypertension

The efficacy of the treat-repair-treat strategy for severe pulmonary arterial hypertension associated with congenital heart disease: a meta-analysis

BACKGROUND

This meta-analysis was conducted to evaluate the efficacy of the treat-repair-treat (TRT) strategy in the treatment of severe pulmonary arterial hypertension with congenital heart disease (PAH-CHD).

METHODS

PubMed, EMBASE, Cochrane and Web of Science online databases were searched by two independent investigators for studies that used the TRT strategy for PAH-CHD, and the retrieved studies were reviewed by a third investigator. The main outcomes were pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), 6-minute walk distance (6MWD), and transcutaneous oxygen saturation (SpO2). The changes were compared between follow-up and baseline. Stata version 14.0 was used for data analysis. A random-effects model was selected for meta-analysis. Subgroup analysis and meta-regression were used to find the source of heterogeneity.

RESULTS

A total of 335 patients from 9 single-arm studies were included. Meta-analysis showed significant reductions in PAP and PVR and improvements in 6MWD and SpO2 (PAP: SMD -2.73 95% CI -2.97, - 2.50 p = < 0.001; PVR: SMD -1.27 95% CI -1.53, - 1.02 p = < 0.001; 6MWD: SMD 1.88 95% CI 1.49, 2.27 p = < 0.001; SpO2: SMD 3.72 95% CI 3.13, 4.32 p = < 0.001). Subgroup analysis showed that younger patients had better efficacy, and the change in SpO2 was an indication for patient selection. The combined mortality rate was 5% at follow-up.

CONCLUSIONS

In this meta-analysis, we demonstrated that the TRT strategy may have positive effects on haemodynamics and cardiac function in patients with severe PAH-CHD at short-term follow-up. Our analysis suggests that changes in age and SpO2 may be related to patient prognosis.

TRIAL REGISTRATION

The protocol was registered on the PROSPERO website with the registration number CRD42022366552. The relevant registration information can be obtained from the website https://www.crd.york.ac.uk/prospero/#searchadvanced .

Mid-Term Outcomes of Primary Arterial Switch Operation for Taussig-Bing Anomaly

To identify risk factors associated with mortality and reintervention on primary arterial switch operation for Taussig-Bing anomaly in 225 cases over a 16-year period. From 2002 to 2017, 225 children with Taussig-Bing anomaly received a primary arterial switch operation at the Shanghai Children's Medical Center. Perioperative data and follow-up results were collected. Univariate and multivariable analysis was used to explore risk factors associated with early mortality. The competing risk analysis was used to identify risk factors related to reintervention. Early mortality was 12.9% (29/225) with a satisfactory long-term survival rate (10-year survival rate 85.0%). The median age at repair was 77 days (interquartile range, IQR, 48-139). The median duration of follow-up was 4.6 (range 0.1-18.3) years. 87 children (38.7%) received concomitant aortic arch repair. Prolonged cardiopulmonary bypass time (a-OR 1.18, 95% confidence interval [CI], 1.09-1.28, p < 0.001) is found to be an independent risk factor for early death. Larger weight at repair tends to be a protective factor (a-OR 0.66, 95% CI, 0.425-1.02, p = 0.060) and intramural coronary artery (a-OR 4.81, 95% CI, 0.927-24.9, p = 0.062) tends to be a risk factor for early mortality. The cumulative incidence rate of overall reintervention was 18.9% (95% CI, 10.3%-27.4%) at 5 years and 32.3% (95% CI, 17,0%-47.6%) at 10 years. No independent risk factors were identified for long-term overall reintervention. Prolonged aortic-cross clamp time was an independent risk factor for long-term right-sided reintervention (adjusted hazard ratio [a-HR] 1.12, 95% CI 1.005-1.25, p = 0.041). Neo-aortic regurgitation was a concern with an incidence rate of moderate or greater neo-AR of 16.1 % (95% CI 7.6%-24.7%) at 10 years. Intramural coronary artery remains a surgical challenge in primary arterial switch operation for the Taussig-Bing anomaly. Larger weight at ASO tends to be a protective factor for early death. Reintervention is frequently necessary but can be performed with satisfactory results.

Clinical comparative analysis of histidine-tryptophan-ketoglutarate solution and St. Thomas crystalloid cardioplegia: A 12-year study from a single institution

Cardioplegic reperfusion during a long-term ischemic period interrupts cardiac surgery and increases cellular edema due to repeated administration. The present clinical study compared the protective effects of histidine-ketoglutarate-tryptophan (HTK) solution and St. Thomas crystalloid cardioplegia. Clinical experiences of the myocardial protection induced by one single perfusion with HTK were reviewed in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease. This retrospective study included 88 high-risk patients (aortic cross-clamp time, >120 min) between March 2001 and July 2012. The cohort was divided into two groups according to the technique used. Either myocardial protection was performed with one single perfusion with HTK solution (HTK group) or with conventional St. Thomas crystalloid cardioplegia (St group). The duration of cardiopulmonary bypass did not differ between the two groups. The mortality, morbidity, intensive care unit (ICU) stay, postoperative hospitalization, and transfusions of HTK group are significantly lower than those of the St group (P<0.05). Univariate and multivariate analysis demonstrated that HTK is a statistically significant independent predictor of decreased early mortality and morbidity (P<0.05). In conclusion, the present findings suggested that HTK solution decreases mortality, morbidity, ICU stay, postoperative hospitalization, and transfusions in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease.

Midterm results of "treat and repair" for adults with non-restrictive ventricular septal defect and severe pulmonary hypertension

BACKGROUND

A non-restrictive ventricular septal defect (VSD) can cause intracardiac left to right shunt, which leads to increased pulmonary vascular resistance (PVR) and pulmonary hypertension causes bi-directional or even right-left shunt, namely the Eisenmenger's syndrome. For patients with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger's syndrome, traditional VSD repair carries high mortality and poor prognosis. Recently, targeted drug therapy was used to decrease pulmonary circulation resistance in these patients before they receive defect repair surgery, namely "treat and repair" strategy, however, there is few reports about the midterm result of this strategy in adults with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger's syndrome.

METHODS

In this study, we used this strategy to treat 41 adult VSD patients who received bosentan as the targeted therapy to decrease their PVR before and after repair surgery.

RESULTS

A total of 39 patients were followed up for an average of 37 months. None of the patients died during follow-up. Among them, 36 cases continued targeted drug therapy, whose mean pulmonary artery pressure (mPAP) was significantly reduced, including 31 cases with mPAP <50 mmHg, and the valve of tap hole was closed. Besides, the SpO2 was significantly elevated.

CONCLUSIONS

These results demonstrated that "treat-and-repair" strategy may be a viable approach for the adults with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger's syndrome.

Factors associated with prolonged recovery after the arterial switch operation for transposition of the great arteries in infants

This study aimed specifically to identify the predictors of prolonged recovery after the arterial switch operation for transposition of the great arteries in infants. The clinical records of all infants admitted to the surgical intensive care unit (SICU) between January 2000 and March 2011 after an arterial switch operation were retrospectively reviewed. The cohort was divided into a prolonged recovery group that included all patients who exceeded the 75th percentile for duration of SICU stay and a standard recovery group that included all the remaining patients. Of the 102 patients in the final analysis, 31 experienced prolonged recovery. The median SICU stay was 18 days (range, 14-58 days) for the patients in the prolonged recovery group and only 8 days (range, 5-13 days) for the patients in the standard recovery group. After univariate analysis, a stepwise logistic regression model analysis was used to compare the demographic data as well as the pre-, intra-, and postoperative variables between the two groups. Of all the variables analyzed, high postbypass serum lactate level [odds ratio (OR), 2.610; 95 % confidence interval (CI), 1.464-4.653; p = 0.039], need for larger volume of resuscitation fluid (OR, 3.154; 95 % CI, 1.751-5.682; p = 0.018), and noninfectious pulmonary complication (OR, 2.844; 95 % CI, 1.508-5.363; p = 0.025) were identified as independent risk factors for prolonged recovery among infants undergoing an arterial switch operation for transposition of the great arteries.

Clinical and pathologic comparison of simple left-to-right shunt congenital heart disease and transposition of the great arteries with ventricular septal defect

BACKGROUND

This study aimed to compare clinical and pathologic data for selected patients with congenital heart disease (CHD) and severe pulmonary hypertension (PH) treated with a diagnostic-treatment-and-repair strategy and to compare results for patients with pulmonary vascular disease (PVD) with simple left-to-right shunt CHD with patients with transposition of the great arteries (TGA) and ventricular septal defect (VSD).

METHODS

Group I comprised 38 patients with simple left-to-right shunt CHD and severe PH; group II included 11 older patients with TGA with VSD and severe PH; and group III comprised 6 autopsy cases of individuals with a normal circulation. The nature of the pulmonary arteries was determined by the Heath-Edwards classification system. All specimens were quantitatively analyzed.

RESULTS

Group I showed 31 patients with a change to grade I, 3 patients were grade II, 3 patients were grade III, and only 1 patient was grade IV. Group II showed 7 patients with a change to grade I, 2 patients were grade II, 1 patient was grade III, and only 1 patient was grade IV. The media wall thickness percentage (%MT), the media wall area percentage (%MS), and arteriole density were significantly higher in groups I and II than in group III. %MS was significantly higher in group II than in group I; no significant differences in %MT and arteriole density could be found between groups I and II.

CONCLUSIONS

The PVD in these selected patients with CHD and severe PH who were cared for with a diagnostic-treatment-and-repair strategy is generally reversible, and the changes in PVD in the patients with TGA and VSD were similar to those in the patients with simple left-to-right shunt CHD.