Surgical Age and Morbidity After Arterial Switch for Transposition of the Great Arteries

Arterial Switch for Transposition of the Great Arteries: Treatment Timing, Late Outcomes, and Risk Factors

Background

Reports of long-term mortality and reintervention after transposition of the great arteries with intact ventricular septum treatment, although favorable, are mostly limited to single-center studies. Even less is known about hospital resource utilization (days at hospital) and the impact of treatment choices and timing on outcomes.

Objectives

The purpose of this study was to describe survival, reintervention and hospital resource utilization after arterial switch operation (ASO) in a national dataset.

Methods

Follow-up and life status data for all patients undergoing ASO between 2000 and 2017 in England and Wales were collected and explored using multivariable regressions and matching.

Results

A total of 1,772 patients were identified, with median ASO age of 9.5 days (IQR: 6.5-14.5 days). Mortality and cardiac reintervention at 10 years after ASO were 3.2% (95% CI: 2.5%-4.2%) and 10.7% (95% CI: 9.1%-12.2%), respectively. The median time spent in hospital during the ASO spell was 19 days (IQR: 14, 24). Over the first year after the ASO patients spent 7 days (IQR: 4-10 days) in hospital in total, decreasing to 1 outpatient day/year beyond the fifth year. In a subgroup with complete risk factor data (n = 652), ASO age, and balloon atrial septostomy (BAS) use were not associated with late mortality and reintervention, but cardiac or congenital comorbidities, low weight, and circulatory/renal support at ASO were. After matching for patient characteristics, BAS followed by ASO and ASO as first procedure, performed within the first 3 weeks of life, had comparable early and late outcomes, including hospital resource utilization.

Conclusions

Mortality and hospital resource utilization are low, while reintervention remains relatively frequent. Early ASO and individualized use of BAS allows for flexibility in treatment choices and a focus on at-risk patients.

Effect of Chronic Heart Failure Complicated with Type 2 Diabetes Mellitus on Cognitive Function in the Elderly

Objective

To explore the effect of chronic heart failure complicated with type 2 diabetes mellitus on cognitive function in the elderly.

Methods

600 patients with chronic heart failure were selected from January 2018 to January 2021. All patients were divided into observation group (A) and control group (B). A was chronic heart failure complicated with type 2 diabetes mellitus group. B was chronic heart failure group. The clinical effects of the two groups were observed.

Results

Compared with the clinical indexes during and after operation, there were differences in operation time, postoperative recovery time, and treatment cost between A and B, but the difference is not significant (all P > 0.05). LVEF cardiac function index score, LVEF score of A compared with B, the difference was statistically significant (P < 0.05). The MMSE score and MoCA score of the two groups were compared. Before operation, the MMSE score and MoCA score of A were lower than those of B, and the difference was statistically significant (P < 0.05). After operation, the MMSE score and MoCA score in B were significantly higher than those in B, but the increasing trend of MMSE score and MoCA score in B was significantly higher than that in A (P < 0.05). Comparison of HAMA score and HAMD score: before operation, the HAMA score and HAMD score were higher in A, but the difference is not significant (P > 0.05). After operation, the scores of HAMA and HAMD in A and B decreased significantly, but the difference is not significant (P > 0.05). Multivariate analysis showed that the fasting blood glucose and glycosylated hemoglobin were the risk factors of cognitive impairment.

Conclusion

Type 2 diabetes mellitus in elderly patients with chronic heart failure will further aggravate cognitive impairment, and type 2 diabetes is an important independent risk factor affecting cognitive function, which accelerates cognitive impairment and significantly reduces the executive ability of elderly patients with chronic heart failure, resulting in a significant decline in patients' ability to understand and apply information.

Association of Preterm Singleton Birth With Fertility Treatment in the US

IMPORTANCE

Preterm birth is a global health issue. The association between fertility treatment and preterm singleton births has not been clarified.

OBJECTIVE

To examine the association between fertility treatment and preterm birth.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used birth data that were submitted by 50 states and the District of Columbia to the National Vital Statistics System database. All mothers in the database who had a singleton live birth from January 1, 2016, to December 31, 2019, were included. Those who had preexisting hypertension or diabetes were excluded.

EXPOSURES

Fertility treatment categorized as assisted reproductive technology (ART) or non-ART treatment.

MAIN OUTCOMES AND MEASURES

The main outcome was a diagnosis of preterm birth, which was defined as birth before 37 complete weeks (<259 days) of gestation. Gestational age was calculated by obstetric estimation at delivery and was collected from the database.

RESULTS

The final sample consisted of 14 370 920 mothers (mean [SD] age, 28.79 [5.79] years) with singleton live births. Of these women, 122 944 (0.9%) conceived by ART and 71 176 (0.5%) received non-ART treatment. The prevalence of preterm birth was 7.6% (n = 1 071 994) in natural conception, 10.7% (n = 13 205) in ART, and 9.3% (n = 6629) in non-ART groups. Compared with neonates who were naturally conceived, newborns who were conceived with ART (adjusted risk difference [aRD], 3.10% [95% CI, 2.93%-3.27%]; adjusted odds ratio [aOR], 1.49 [95% CI, 1.46-1.52]; P < .001) and non-ART treatment (aRD, 2.22% [95% CI, 2.00%-2.44%]; aOR, 1.35 [95% CI, 1.31-1.38]; P < .001) had significantly higher risk for preterm birth after full adjustment. These associations were similar in subgroups of participants as defined by baseline characteristics.

CONCLUSIONS AND RELEVANCE

This study found that singleton neonates who were conceived by fertility treatment had higher rates of preterm birth. Further investigations are warranted into the association between ART or non-ART treatment and the risk of preterm birth in singleton neonates.

The Impact of Prematurity on Morbidity and Mortality in Newborns with Dextro-transposition of the Great Arteries

Prematurity is a risk factor for adverse outcomes after arterial switch operation in newborns with D-TGA (D-TGA). In this study, we sought to investigate the impact of prematurity on postnatal and perioperative clinical management, morbidity, and mortality during hospitalization in neonates with simple and complex D-TGA who received arterial switch operation (ASO). Monocentric retrospective analysis of 100 newborns with D-TGA. Thirteen infants (13.0%) were born premature. Preterm infants required significantly more frequent mechanical ventilation in the delivery room (69.2% vs. 34.5%, p = 0.030) and during the preoperative course (76.9% vs. 37.9%, p = 0.014). Need for inotropic support (30.8% vs. 8.0%, p = 0.035) and red blood cell transfusions (46.2% vs. 10.3%, p = 0.004) was likewise increased. Preoperative mortality (23.1% vs 0.0%, p = 0.002) was significantly increased in preterm infants, with necrotizing enterocolitis as cause of death in two of three infants. In contrast, mortality during and after surgery did not differ significantly between the two groups. Cardiopulmonary bypass times were similar in both groups (median 275 vs. 263 min, p = 0.322). After ASO, arterial lactate (34.5 vs. 21.5 mg/dL, p = 0.007), duration of mechanical ventilation (median 175 vs. 106 h, p = 0.038), and venous thrombosis (40.0% vs. 4.7%, p = 0.004) were increased in preterm, as compared to term infants. Gestational age (adjusted unit odds ratio 0.383, 95% confidence interval 0.179-0.821, p = 0.014) was independently associated with mortality. Prematurity is associated with increased perioperative morbidity and increased preoperative mortality in D-TGA patients.

Lessons learned from ECMO support in pediatric patients with D-transposition of the great arteries: preoperative, intraoperative and postoperative

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) support on D-transposition of the great arteries (D-TGA) carries formidable challenges.

METHODS

A retrospective study was performed on pediatric patients with D-TGA supported by ECMO from July 2007 to December 2019. This study summarized the clinical experience of ECMO support in pediatric patients with D-TGA preoperative, intraoperative, and postoperative.

RESULTS

Overall, 16 children with D-TGA received ECMO support during this period. Two (2 of 16) were supported before cardiac surgery, 3 (3 of 16) were supported postoperatively in the intensive care unit, and 11 (11 of 16) failed to wean off cardiopulmonary bypass. Two cases of preoperative ECMO support for patients with D-TGA with an intact ventricular septum and restrictive atrial septum due to severe hypoxemia died. In this study, D-TGA with coronary artery malformation and other complicated deformities died (8 of 14), whereas uncomplicated D-TGA without coronary artery malformation all survived (6 of 14). The wean-off rate of ECMO patients supported in D-TGA was 62.5% (10 of 16), while the 30-day survival rate was 44% (7 of 16).

CONCLUSION

Although a promising ECMO weaning rate was obtained, 30-day survival of this population was frustrating, mainly attributed to the original anatomy of coronary arteries and the concomitant deformities.

Risk Factors for Reoperation After Arterial Switch Operation

OBJECTIVE

The timing and nature of and risk factors for reoperation after the arterial switch operation in the setting of d-transposition of the great arteries requires further elucidation.

METHODS

A total of 403 patients who underwent arterial switch operation from 1986 to 2017 were reviewed. Institutional preference was for pulmonary artery reconstruction using a pantaloon patch of fresh autologous pericardium. The targets for coronary artery reimplantation were identified by intermittent root distension. Multivariable analysis was used to identify risk factors for reoperation.

RESULTS

Median follow-up was 8.6 years (interquartile range [IQR]: 2-16.9). Pulmonary arterioplasty was the most common reoperation (n = 11, 2.7%) at 3.3 years (IQR: 1.4-11.4) postoperatively. Subvalvar right ventricular outflow tract reconstruction (RVOTR) was required in nine (2.2%) patients at 2.5 years (IQR: 1.1-5.3) postoperatively. Aortic valve repair or replacement (AVR/r) was required in seven (1.7%) patients at 13.6 years (IQR: 10.0-15.8) postoperatively. Aortic root replacement (ARR) and Coronary Artery Bypass Graft/coronary patch arterioplasty were required in five (1.2%) patients each at 13.6 years (IQR: 11.0-15.3) and 11.3 years (IQR: 2.3-13.6) postoperatively, respectively. Taussig-Bing anomaly was a risk factor for any reoperation (P = .034). Risk factors for specific reoperations included ventricular septal defect for AVR/r (P = .038), Taussig-Bing anomaly for RVOTR (P = .004), and pulmonary artery banding for ARR (P = .028).

CONCLUSIONS

Pantaloon patch pulmonary artery reconstruction and intermittent neo-aortic root distension during coronary reimplantation have minimized respective outflow tract reoperations. Certain anatomic subsets carry different risks for late reoperation, and pulmonary artery and/or RVOT reinterventions tend to occur sooner than aortic reinterventions. Special attention to these higher risk subpopulations will be critical to optimizing lifelong outcomes.