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Schlein J, Wollmann F, Kaider A, Wiedemann D, Gabriel H, Hornykewycz S, Base E, Michel-Behnke I, Laufer G, Zimpfer D. Long-term outcomes after surgical repair of subvalvular aortic stenosis in pediatric patients. Front Cardiovasc Med 2022; 9:1033312. [DOI: 10.3389/fcvm.2022.1033312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
ObjectivesSubvalvular aortic stenosis (SAS) can occur as discrete or tunnel-like obstruction of the left ventricular outflow tract and as progressive disease often leads to aortic valve regurgitation. We report our 30-year single-center experience after surgical repair of SAS.MethodsA retrospective chart review of all patients aged < 18 years, who underwent surgical repair of SAS from May 1985 to April 2020, was conducted. Mortality was cross-checked with the national health insurance database (93.8% complete mortality follow-up in April 2020). Survival and competing risks analysis were used to analyze the primary endpoints survival and incidence of reoperations.ResultsFrom May 1985 until April 2020 103 patients (median age 5.5 years) underwent surgical repair of SAS. Survival was 90.8% at 10 years and 88.7% at 20 and 30 years. Age < 1 year at time of surgery, Shone’s complex, mitral stenosis and concomitant mitral valve surgery were associated with mortality. The cumulative incidence of reoperation for SAS was 21.6% at 10 years, 28.2% at 20 and 30 years. The incidence of reoperation for SAS did not differ between the myectomy, membrane resection and combined myectomy and membrane resection groups. The cumulative incidence of reoperation on the aortic valve was 13.5% at 20 years.ConclusionRecurrence rate of SAS is not to be neglected, though surgical repair of subaortic stenosis has good long-term results. Patients who needed a combined membrane resection and septal myectomy are not more prone to recurrence than patients who underwent solitaire myectomy or membrane resection.
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Managing uncertainty in decision-making of common congenital cardiac defects. Cardiol Young 2022; 32:1705-1717. [PMID: 36300500 DOI: 10.1017/s1047951122003316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Decision-making in congenital cardiac care, although sometimes appearing simple, may prove challenging due to lack of data, uncertainty about outcomes, underlying heuristics, and potential biases in how we reach decisions. We report on the decision-making complexities and uncertainty in management of five commonly encountered congenital cardiac problems: indications for and timing of treatment of subaortic stenosis, closure or observation of small ventricular septal defects, management of new-onset aortic regurgitation in ventricular septal defect, management of anomalous aortic origin of a coronary artery in an asymptomatic patient, and indications for operating on a single anomalously draining pulmonary vein. The strategy underpinning each lesion and the indications for and against intervention are outlined. Areas of uncertainty are clearly delineated. Even in the presence of "simple" congenital cardiac lesions, uncertainty exists in decision-making. Awareness and acceptance of uncertainty is first required to facilitate efforts at mitigation. Strategies to circumvent uncertainty in these scenarios include greater availability of evidence-based medicine, larger datasets, standardised clinical assessment and management protocols, and potentially the incorporation of artificial intelligence into the decision-making process.
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De Wolf R, François K, Bové T, Coomans I, De Groote K, De Wilde H, Panzer J, Vandekerckhove K, De Wolf D. Paediatric subaortic stenosis: long-term outcome and risk factors for reoperation. Interact Cardiovasc Thorac Surg 2021; 33:588-596. [PMID: 34002231 DOI: 10.1093/icvts/ivab121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Surgical repair of subaortic stenosis (SAS) is associated with a substantial reoperation risk. We aimed to identify risk factors for reintervention in relation to discrete and tunnel-type SAS morphology. METHODS Single-centre retrospective study of paediatric SAS diagnosed between 1992 and 2017. Multivariable Cox regression analysis was performed to identify reintervention risk factors. RESULTS Eighty-five children [median age 2.5 (0.7-6.5) years at diagnosis] with a median follow-up of 10.1 (5.5-16.4) years were included. Surgery was executed in 83% (n = 71). Freedom from reoperation was 88 ± 5% at 5 years and 82 ± 6% at 10 years for discrete SAS, compared to, respectively, 33 ± 16% and 17 ± 14% for tunnel-type SAS (log-rank P < 0.001). Independent risk factors for reintervention were a postoperative gradient >20 mmHg [hazard ratio (HR) 6.56, 95% confidence interval (CI) 1.41-24.1; P = 0.005], tunnel-type SAS (HR 7.46, 95% CI 2.48-22.49; P < 0.001), aortic annulus z-score <-2 (HR 11.07, 95% CI 3.03-40.47; P < 0.001) and age at intervention <2 years (HR 3.24, 95% CI 1.09-9.86; P = 0.035). Addition of septal myectomy at initial intervention was not associated with lesser reintervention. Fourteen children with a lower left ventricular outflow tract (LVOT) gradient (P < 0.001) and older age at diagnosis (P = 0.024) were followed expectatively. CONCLUSIONS Children with SAS remain at risk for reintervention, despite initially effective LVOT relief. Regardless of SAS morphology, age <2 years at first intervention, a postoperative gradient >20 mmHg and presence of a hypoplastic aortic annulus are independent risk factors for reintervention. More extensive LVOT surgery might be considered at an earlier stage in these children. SAS presenting in older children with a low LVOT gradient at diagnosis shows little progression, justifying an expectative approach.
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Affiliation(s)
- Rik De Wolf
- Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium
| | - Katrien François
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Thierry Bové
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ilse Coomans
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Katya De Groote
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Hans De Wilde
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Joseph Panzer
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Daniël De Wolf
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium.,Department of Paediatric Cardiology, University Hospital of Brussels, Brussels, Belgium
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A Novel Approach for Transcatheter Management of Perimembranous Ventricular Septal Defect with a Subaortic Ridge. J Interv Cardiol 2021. [DOI: 10.1155/2021/6329273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction. Surgical closure of the perimembranous ventricular septal defect (PM VSD) and resection of the subaortic ridge are the standard methods of management, but there is no definitive agreement regarding the timing of surgery. Objectives. To evaluate the safety and efficacy of the management of patients with PM VSD and subaortic ridge with or without AR via transcatheter closure of the defect and compressing the ridge against the ventricular septum using Amplatzer ductal occluder type I (ADO-I). Patients and Methods. We introduced a new approach for transcatheter management of PM VSD and subaortic ridge by closing the VSD and capturing or compressing the ridge against the interventricular septum (IVS) using the ADO-I device. Thirty-eight (9.5%) of 398 patients with a PM VSD were found to have subaortic ridge and were enrolled in this study from August 1, 2014, to February 1, 2018, at the Ibn Albitar Center for Cardiac Surgery, Baghdad, Iraq. Results. The ages and weights of patients ranged from 1.5 to 25 years and 7 to 73 kg, respectively. The male-to-female ratio was 2.2 : 1. The VSD sizes ranged from 4 to 8 mm, and the median distance of the ridge from the proximal edge of the VSD was 2.5 mm. Prior to closure, 13 patients (34.2%) had mild and mild-to-moderate aortic regurgitation (AR), and nine patients (23.7%) had mild-to-moderate left ventricular outflow tract (LVOT) obstruction. The mean AR pressure half-time increased significantly after intervention (from 385 ± 38 ms to 535 ± 69 ms (significant
value, 0.001)), and the mean of the peak pressure gradient across the LVOT decreased from 33 ± 7 mmHg to 15 ± 2.4 mmHg (significant
value, 0.001). Successful procedures were achieved in 33 patients (86.8%). Conclusion. Transcatheter management of patients with PM VSD and subaortic ridges with or without AR is feasible and effective.
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Abushaban L, Uthaman B, Selvan JP, Al Qbandi M, Sharma PN, Mariappa TV. Long-term follow-up and outcomes of discrete subaortic stenosis resection in children. Ann Pediatr Cardiol 2019; 12:212-219. [PMID: 31516277 PMCID: PMC6716322 DOI: 10.4103/apc.apc_120_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Studies of long-term outcomes of discrete subaortic stenosis (DSS) are rare. Therefore, we reviewed the long-term outcomes of subaortic membrane resection in children with isolated DSS over 16 years from a single institution. Materials and Methods We retrospectively reviewed the records of patients (n = 27) who underwent resection of DSS between 2000 and 2017. Patients with major concomitant intracardiac anomalies were excluded. Indications for surgery were mean left ventricular outflow tract (LVOT), Doppler gradient >30 mmHg, and/or progressive aortic insufficiency. Results The mean age at diagnosis was 3.77 ± 3.49 years (range, 0.25-13 years) and the mean age at surgery was 6.36 ± 3.69 years (range, 1-13 years). All patients underwent resection of subaortic membrane. The mean LVOT Doppler gradient decreased from 40.52 ± 11.41 mmHg preoperatively to 8.48 ± 5.06 mmHg postoperatively (P < 0.001). The peak instantaneous LVOT Doppler gradient decreased from 75.41 ± 15.22 mmHg preoperatively to 18.11 ± 11.44 mmHg postoperatively (P < 0.001). At the latest follow-up, the peak gradient was 17.63 ± 8.93 mmHg. The mean follow-up was 7.47 ± 3.53 years (median 6.33 years; range 2.67-16 years). There was no operative mortality or late mortality. Recurrence of subaortic membrane occurred in 7 (25.92%, 7/27) patients who underwent primary DSS operation. Four (14.81%, 4/27) patients required reoperation for DSS recurrence at a median time of 4.8 years (3.1-9.1 years) after the initial repair. Risk factors for reoperation were age <6 years at initial repair. Eighteen (66.66%, 18/27) patients had AI preoperatively and progression of AI occurred in 70.37% (19/27). This included 4 (22.22%, 4/18) patients who had worsening of their preoperative AI. Short valve-to-membrane distance was found to be prognostically unfavorable. One (3.7%, 1/27) patient had an iatrogenic ventricular septal defect, and 2 (7.4%, 2/27) patients had complete AV block following membrane resection. Conclusions Resection of subaortic membrane in children is associated with low mortality. Higher LVOT gradient, younger age at initial repair, and shorter valve-to-membrane distance were found to be associated with adverse outcome. Recurrence and reoperation rates are high, and progression of aortic insufficiency following subaortic membrane resection is common. Therefore, these patients warrant close follow-up into adult life.
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Affiliation(s)
- Lulu Abushaban
- Department of Pediatrics, Chest Diseases Hospital, Kuwait City, Kuwait.,Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Babu Uthaman
- Department of Pediatrics, Chest Diseases Hospital, Kuwait City, Kuwait.,Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - John Puthur Selvan
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| | - Mustafa Al Qbandi
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| | - Prem N Sharma
- Health Sciences Center, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Thinakar Vel Mariappa
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
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Massé DD, Shar JA, Brown KN, Keswani SG, Grande-Allen KJ, Sucosky P. Discrete Subaortic Stenosis: Perspective Roadmap to a Complex Disease. Front Cardiovasc Med 2018; 5:122. [PMID: 30320123 PMCID: PMC6166095 DOI: 10.3389/fcvm.2018.00122] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is a congenital heart disease that results in the formation of a fibro-membranous tissue, causing an increased pressure gradient in the left ventricular outflow tract (LVOT). While surgical resection of the membrane has shown some success in eliminating the obstruction, it poses significant risks associated with anesthesia, sternotomy, and heart bypass, and it remains associated with a high rate of recurrence. Although a genetic etiology had been initially proposed, the association between DSS and left ventricle (LV) geometrical abnormalities has provided more support to a hemodynamic etiology by which congenital or post-surgical LVOT geometric derangements could generate abnormal shear forces on the septal wall, triggering in turn a fibrotic response. Validating this hypothetical etiology and understanding the mechanobiological processes by which altered shear forces induce fibrosis in the LVOT are major knowledge gaps. This perspective paper describes the current state of knowledge of DSS, articulates the research needs to yield mechanistic insights into a significant pathologic process that is poorly understood, and proposes several strategies aimed at elucidating the potential mechanobiological synergies responsible for DSS pathogenesis. The proposed roadmap has the potential to improve DSS management by identifying early targets for prevention of the fibrotic lesion, and may also prove beneficial in other fibrotic cardiovascular diseases associated with altered flow.
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Affiliation(s)
- Danielle D Massé
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - Jason A Shar
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - Kathleen N Brown
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.,Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | | | - Philippe Sucosky
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
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Nawaytou HM, Mercer-Rosa L, Channing A, Cohen MS. Intraoperative transesophageal echocardiographic predictors of recurrent left ventricular outflow tract obstruction in children undergoing subaortic stenosis resection. Echocardiography 2018; 35:678-684. [PMID: 29437237 DOI: 10.1111/echo.13827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Intraoperative transesophageal echocardiography (iTEE) is used to assess for residual left ventricular outflow tract obstruction (LVOTO) after surgical resection of subaortic membrane causing subaortic stenosis (sub-AS). We aimed to identify the iTEE features associated with recurrence of LVOTO. METHODS We conducted a retrospective study of children undergoing sub-AS resection from June 2006 to June 2014. Doppler assessment of the flow velocity and the anatomical features of the left ventricular outflow tract were analyzed from stored echocardiograms. Recurrent LVOTO was defined as an increase in the mean pressure gradient across the left ventricular outflow tract of > 15 mm Hg on the most recent follow-up echocardiogram from the mean pressure gradient on the predischarge echocardiogram or as doubling of the mean pressure gradient to a value ≥20 mm Hg. RESULTS Thirty-five patients were included, with median age at surgery was 8.1 years (range: 0.7-29 years) and median follow-up was 47 months (2-91 months). Ten patients (29%) had recurrent LVOTO, which was associated with a shorter distance between the narrowest diameter of the outflow tract and the aortic valve on iTEE [median 0.59 cm (range 0.39-0.74) vs 0.98 cm (0.75-1.5), P = .03]. No patients with more than mild residual LVOTO on iTEE regressed to mild or no LVOTO on follow-up echocardiograms. CONCLUSIONS LVOTO recurrence after sub-AS resection is common, and residual LVOTO remains the same or increases over time. Proximity of the LVOTO to the aortic valve is a risk factor for recurrent LVOTO. These findings may be useful in counseling patients and to guide the frequency of postoperative follow-up.
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Affiliation(s)
- Hythem M Nawaytou
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laura Mercer-Rosa
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra Channing
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Meryl S Cohen
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Outcomes of Subaortic Obstruction Resection in Children. Heart Lung Circ 2017; 26:179-186. [DOI: 10.1016/j.hlc.2016.05.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/12/2016] [Accepted: 05/25/2016] [Indexed: 11/18/2022]
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9
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Bhatia A, Mehta TH, Manning P, Kuvin JT. Adults With Left-Sided Pressure Loading Lesions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:55. [DOI: 10.1007/s11936-015-0416-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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10
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Etnel JR, Takkenberg JJ, Spaans LG, Bogers AJ, Helbing WA. Paediatric subvalvular aortic stenosis: a systematic review and meta-analysis of natural history and surgical outcome. Eur J Cardiothorac Surg 2014; 48:212-20. [DOI: 10.1093/ejcts/ezu423] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 09/02/2014] [Indexed: 11/14/2022] Open
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van der Linde D, Takkenberg JJM, Rizopoulos D, Heuvelman HJ, Budts W, van Dijk APJ, Witsenburg M, Yap SC, Bogers AJJC, Silversides CK, Oechslin EN, Roos-Hesselink JW. Natural history of discrete subaortic stenosisin adults: a multicentre study. Eur Heart J 2012; 34:1548-56. [DOI: 10.1093/eurheartj/ehs421] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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