Reoperations in adults with congenital heart disease: analysis of early outcome

Outcomes following multivalve reoperation in adults with congenital heart disease: A 30-year, single-center study

OBJECTIVE

As patients with congenital heart disease increasingly live into adulthood, reoperative surgery is frequently required. Although half of these are valve-related procedures, little is known regarding early and late outcomes, and factors associated with adverse outcomes.

METHODS

From 1993 to 2022, a total of 1960 adult patients with congenital heart disease underwent repeat median sternotomy at our institution. Of these, 502 patients (26%) underwent intervention on 2 or more valves and constituted the study cohort.

RESULTS

The median age was 39 (27-51) years, and 275 patients (55%) were female. A second sternotomy was performed in 265 patients (53%), a third sternotomy was performed in 135 patients (27%), a fourth sternotomy was performed in 75 patients (15%), and a fifth or more sternotomy was performed in 27 patients (5%). Interventions were performed on 2 valves in 436 patients (87%), 3 valves in 62 patients (12%), and 4 valves in 4 patients (1%). The most common combinations were pulmonary and tricuspid in 241 patients (48%), followed by mitral and tricuspid in 85 patients (17%), aortic and pulmonary in 42 patients (8%), and aortic and mitral in 41 patients (8%). Early mortality was 4.2% overall and 2.7% for elective operations. Nonelective operations and congenital heart disease of major complexity were independently associated with early mortality. Median follow-up was 14 years. One, 5-, and 10-year survivals were 93.6%, 89.3%, and 79.5%, respectively. Factors independently associated with overall mortality were age, ventricular dysfunction, coronary artery disease, renal failure, double valve replacement, nonelective operations, and bypass time.

CONCLUSIONS

Multiple valve interventions are common and confer low early mortality in the elective setting. Referral before ventricular dysfunction and in an elective setting optimizes outcomes.

Risk factors and early outcomes of repeat sternotomy in 1960 adults with congenital heart disease: A 30-year, single-center study

OBJECTIVE

Patients with congenital heart disease (CHD) increasingly live into adulthood, often requiring cardiac reoperation. We aimed to assess the outcomes of adults with CHD (ACHD) undergoing repeat sternotomy at our institution.

METHODS

Review of our institution's cardiac surgery database identified 1960 ACHD patients undergoing repeat median sternotomy from 1993 to 2023. The primary outcome was early mortality, and the secondary outcome was a composite end point of mortality and significant morbidity. Univariable and multivariable logistic regression models were used to determine factors independently associated with outcomes.

RESULTS

Of the 1960 ACHDs patient undergoing repeat sternotomy, 1183 (60.3%) underwent a second, third (n = 506, 25.8%), fourth (n = 168, 8.5%), fifth (n = 70, 3.5%), and sixth sternotomy or greater (n = 33, 1.6%). CHD diagnoses were minor complexity (n = 145, 7.4%), moderate complexity (n = 1380, 70.4%), and major complexity (n = 435, 22.1%). Distribution of procedures included valve (n = 549, 28%), congenital (n = 625, 32%), aortic (n = 104, 5.3%), and major procedural combinations (n = 682, 34.7%). Overall early mortality was 3.1%. Factors independently associated with early mortality were older age at surgery, CHD of major complexity, preoperative renal failure, preoperative ejection fraction, urgent operation, and postoperative blood transfusion. In addition, sternotomy number and bypass time were independently associated with the composite outcome.

CONCLUSIONS

Despite the increase in early mortality with sternotomy number, sternotomy number was not independently associated with early mortality but with increased morbidity. Improvement strategies should target factors leading to urgent operations, early referral, along with operative efficiency including bypass time and blood conservation.

Surgical strategies to address re-operative complex left ventricular outflow tract and thoracic aortic pathology: Cleveland Clinic children's experience

BACKGROUND

Complex patients requiring operations on the left ventricular outflow tract, aortic valve, or thoracic aorta after previous repair of aortopathy constitute a challenging group, with limited information guiding decision-making. We aimed to use our institutional experience to highlight management challenges and describe surgical pearls to address them.

METHODS

Forty-one complex patients with surgery on the left ventricular outflow tract, aortic valve, or aorta at Cleveland Clinic Children's between 2016 and 2021 following previous repair of aortic pathology were retrospectively reviewed. Patients with known connective tissue disease or single ventricle circulation were excluded.

RESULTS

Median age at index procedure was 23 years (range 0.25-48) with median of 2 prior sternotomies. Previous aortic operations included subvalvular (n = 9), valvular (n = 6), supravalvular (n = 13), and multi-level surgeries (n = 13). Four deaths occurred in median follow-up of 2.5 years. Mean left ventricular outflow tract gradients improved significantly for patients with obstruction (34.9 ± 17.5 mmHg versus 12.6 ± 6.0 mmHg; p < 0.001). Technical pearls include the following: 1) liberal use of anterior aortoventriculoplasty with valve replacement; 2) primarily anterior aortoventriculoplasty following the subpulmonary conus in contrast to more vertical incision for post-arterial switch operation patients; 3) pre-operative imaging of mediastinum and peripheral vasculature for cannulation and sternal re-entry; and 4) proactive use of multi-site peripheral cannulation.

CONCLUSIONS

Operation to address the left ventricular outflow tract, aortic valve, or aorta following prior congenital aortic repair can be accomplished with excellent outcomes despite high complexity. These procedures commonly include multiple components, including concomitant valve interventions. Cannulation strategies and anterior aortoventriculoplasty in specific patients require modifications.

An In Vitro Characterization of a PCL-Fibrin Scaffold for Myocardial Repair

Each year in the United States approximately 10,000 babies are born with a complex congenital heart defect (CHD) requiring surgery in the first year of after birth. Several of these operations require the implantation of a full-thickness heart patch; however, the current patch materials available to pediatric heart surgeons are exclusively non-living and non-degradable, which do not grow with the patient and are prone to fail due to an inability to integrate with the heart. In this work, the goal was to develop a full-thickness, tissue engineered myocardial patch (TEMP) that is made from biodegradable components, strong enough to withstand the mechanical forces of the heart wall, and able to integrate with the heart and drive neotissue formation. Here, a thick and porous electrospun PCL scaffold filled with high-salt PEGylated fibrin was developed. The scaffold was found to be mechanically sufficient for heart wall repair. Vascular cells were able to infiltrate more than halfway through the scaffold in static culture within three weeks. The scaffold maintained pluripotent stem cells for at least four days, supports viable iPSC-derived cardiomyocytes, and fostered tissue thickening in vitro. The TEMP developed here and tested in vitro is promising for the repair of structural CHD and will next be assessed in situ.

Multimodality Imaging Assessment of Tetralogy of Fallot: From Diagnosis to Long-Term Follow-Up

Tetralogy of Fallot (TOF) is the most common complex congenital heart disease with long-term survivors, demanding serial monitoring of the possible complications that can be encountered from the diagnosis to long-term follow-up. Cardiovascular imaging is key in the diagnosis and serial assessment of TOF patients, guiding patients' management and providing prognostic information. Thorough knowledge of the pathophysiology and expected sequalae in TOF, as well as the advantages and limitations of different non-invasive imaging modalities that can be used for diagnosis and follow-up, is the key to ensuring optimal management of patients with TOF. The aim of this manuscript is to provide a comprehensive overview of the role of each modality and common protocols used in clinical practice in the assessment of TOF patients.

Impact of severe valvular heart disease in adult congenital heart disease patients

BACKGROUND

The clinical impact of valvular heart disease (VHD) in adult congenital heart disease (ACHD) patients is unascertained. Aim of our study was to assess the prevalence and clinical impact of severe VHD (S-VHD) in a real-world contemporary cohort of ACHD patients.

MATERIALS AND METHODS

Consecutive patients followed-up at our ACHD Outpatient Clinic from September 2014 to February 2021 were enrolled. Clinical characteristics and echocardiographic data were prospectively entered into a digitalized medical records database. VHD at the first evaluation was assessed and graded according to VHD guidelines. Clinical data at follow-up were collected. The study endpoint was the occurrence of cardiac mortality and/or unplanned cardiac hospitalization during follow-up.

RESULTS

A total of 390 patients (median age 34 years, 49% males) were included and S-VHD was present in 101 (25.9%) patients. Over a median follow-up time of 26 months (IQR: 12-48), the study composite endpoint occurred in 76 patients (19.5%). The cumulative endpoint-free survival was significantly lower in patients with S-VHD vs. patients with non-severe VHD (Log rank p < 0.001). At multivariable analysis, age and atrial fibrillation at first visit (p = 0.029 and p = 0.006 respectively), lower %Sat O2, higher NYHA class (p = 0.005 for both), lower LVEF (p = 0.008), and S-VHD (p = 0.015) were independently associated to the study endpoint. The likelihood ratio test demonstrated that S-VHD added significant prognostic value (p = 0.017) to a multivariate model including age, severe CHD, atrial fibrillation, %Sat O2, NYHA, LVEF, and right ventricle systolic pressure > 45 mmHg.

CONCLUSION

In ACHD patients, the presence of S-VHD is independently associated with the occurrence of cardiovascular mortality and hospitalization. The prognostic value of S-VHD is incremental above other established prognostic markers.

Surgery for Adult Patients with Congenital Heart Disease: Results from the European Database

Adults with congenital heart disease (ACHD) represent a growing population. To evaluate frequency, type and outcomes of cardiac surgery in ACHD, we gathered data from the European Congenital Heart Surgeons Association Database of 20,602 adult patients (≥18 years) with a diagnosis of congenital heart disease who underwent cardiac surgery, between January 1997 and December 2017. We demonstrated that overall surgical workload (as absolute frequencies of surgical procedures per year) for this specific subset of patients increased steadily during the study period. The most common procedural groups included septal defects repair (n = 5740, 28%), right-heart lesions repair (n = 5542, 27%) and left-heart lesions repair (n = 4566, 22%); almost one-third of the procedures were re-operations (n = 5509, 27%). When considering the year-by-year relative frequencies of the main procedural groups, we observed a variation of the surgical scenario during the last two decades, characterized by a significant increase over time for right and left-heart lesions repair (p < 0.0001, both); while a significant decrease was seen for septal defects repair (p < 0.0001) and transplant (p = 0.03). Overall hospital mortality was 3% (n = 622/20,602 patients) and was stable over time. An inverse relationship between mortality and the number of patients operated in each center (p < 0.0001) was observed.

Grown-up Congenital Heart Surgery in 1093 Consecutive Cases: A "Hidden" Burden of Early Outcome

BACKGROUND

Surgery in grown-ups with congenital heart disease (GUCH) is characterized by complex anatomy, comorbidities, reoperations, and technical challenges. Although 30-day postoperative mortality is low, this measure might be insufficient to reflect adverse outcome monitoring. Our study aimed to establish whether prolonged intensive care unit (ICU) stay (≥7 days) and 6-month mortality were more clinically meaningful measures than 30-day mortality and to identify predictors of adverse outcome.

METHODS

All consecutive GUCH patients from 1998 to 2015 were identified. Perioperative characteristics, diagnoses, and postoperative data were collected retrospectively. Predictors of 30-day and 6-month mortality and prolonged ICU stay were determined with logistic regression. Era effect was tested for quality assurances by dividing the cohort into 4 time intervals.

RESULTS

Within 17 years, 1093 consecutive cardiac surgical procedures were identified in 1026 GUCH patients. During the study period, 30-day mortality improved significantly, with an overall 30-day mortality of 1.5%; 6-month mortality and prolonged ICU stay were 2.4% and 6.7%, respectively. Despite a decreased number of preoperative patients in New York Heart Association Functional Classification III or higher, prolonged ICU stay increased over the eras. Predictors of adverse outcome were New York Heart Association class III or higher, preoperative renal failure, disease of great complexity, preoperative ventilator support, cardiopulmonary bypass time, and concomitant procedures.

CONCLUSIONS

In the current era of low 30-day mortality, extended 6-month mortality and prolonged ICU stay reporting may be more realistic measures of adverse outcomes for counseling GUCH patients at risk.

Impact of Non-cardiac Comorbidities in Adults with Congenital Heart Disease: Management of Multisystem Complications

The prevalence and impact of non-cardiac comorbidities in adult patients with congenital heart disease increase over time, and these complications are often specifically a consequence of the long-term altered cardiovascular physiology or sequelae of previous therapies. For the ACHD patient admitted to the intensive care unit (ICU) for either surgical or medical treatment, an assessment of the burden of multisystem disease, as well as an understanding of the underlying cardiovascular pathophysiology, is essential for optimal management of these complex patients. This chapter takes an organ-system-based approach to reviewing common comorbidities in the ACHD patient, focusing on conditions that are directly related to ACHD status and may significantly impact ICU care.

Cardiac surgery in adults with high-surgical complexity CHD: results of a network collaborative programme

BACKGROUND

Adults with CHD often exhibit complex cardiac abnormalities, whose management requires specific clinical and surgical expertise. To enable easier access of these patients to highly specialised care, we implemented a collaborative programme that incorporates medical and surgical specialists belonging to both paediatric and adult cardiovascular institutions.

OBJECTIVES

The objective of this study was to review the experience gained and to analyse the surgical outcome of major cardiac surgery.

METHODS

We retrospectively reviewed all consecutive patients admitted for major cardiac surgery using our network between January, 2010 and December, 2013. Analysis of surgical outcome was performed in patients selected for major cardiac surgery with cardiopulmonary bypass. Early and late outcomes were evaluated.

RESULTS

Out of a total of 433 inward patients, 86 were selected for surgery. The median age was 25.5 years, -64 patients (74.4%) had previously undergone heart surgery, and -55 patients (64%) had been subjected to at least one sternotomy. Abnormalities of the left ventricular and right ventricular outflow tract were the most frequent (37.2% and 30.2%, respectively), and despite high-surgical complexity only one death occurred (in-hospital mortality 1.1%). On a median follow-up time of 4 years no deaths and no heart-failure events have occurred; one patient underwent further cardiac surgery programmed at the time of discharge.

CONCLUSIONS

Low mortality and morbidity rates can be obtained in high-surgical complexity adults with CHD populations when paediatric and adult cardiac specialists operate in the same multidisciplinary environment.

Twenty Years of Adult Congenital Heart Surgery: A Single-Center African Experience

BACKGROUND

Lack of data exists on the surgical management of adult congenital heart disease on the African continent. This study was undertaken to describe the clinical profile and surgical outcome of adult patients with congenital heart disease undergoing surgery in a single-center African study population.

METHODS

A retrospective medical chart review of consecutive adult patients (≥18 years) undergoing congenital heart surgery between October 1995 and December 2015 at our institution was undertaken. We described cardiac diagnosis, diagnostic complexity, risk profile, and surgical morbidity and mortality.

RESULTS

Data were collected of 233 surgical procedures performed in 219 patients (45.6% males). The most common diagnostic category was septal defects (41.2%), followed by right heart lesions (17.2%), left heart lesions (12.4%), thoracic arteries (9.0%), and conduit failure (6.9%). Twenty-four percent of patients presented in functional class III or IV, and 46% of patients met the criteria for the simple Bethesda diagnostic class. Preoperative risk factors were identified in 19.8% of patients. Corrective surgery was performed in 71.7% of cases, reoperative surgery in 27.6%, and palliative surgery in 0.8%. Right ventricle to pulmonary artery conduit placement comprised 53.1% of reoperations. The overall hospital mortality was 1.7%. Postoperative complications occurred in 26.3% of cases.

CONCLUSIONS

This study presents a detailed description of this emerging population in a developing world context. Our outcomes data suggest that adult congenital heart disease surgery is feasible in a Southern African tertiary referral center with low operative mortality and acceptable morbidity.

Chance of surgery in adult congenital heart disease

Background Young patients with congenital heart disease reaching adulthood face mandatory transition to adult cardiology. Their new cardiologist needs to assess the chances of major future events such as surgery. Using a large national registry, we assessed if patient characteristics at the age of 18 years could predict the chance of congenital heart surgery in adulthood. Design and methods Of 10,300 patients from the CONCOR national registry, we used general patient characteristics at age 18 years, underlying congenital heart defect, history of complications, and interventions in childhood as potential predictors of congenital heart surgery occurring from age 18 years up to age 40 and 60 years. Cox regression was used to calculate hazard ratios with 95% confidence intervals. Analyses were performed separately for all congenital heart surgery and for valvular surgery alone. Results Altogether 2427 patients underwent congenital heart surgery after age 18 years, 1389 of whom underwent valvular surgery. Underlying heart defect, male sex, multiple defects, childhood endocarditis, supraventricular arrhythmia, aortic complications and paediatric cardiovascular surgery, independently predicted adult congenital heart surgery. The mean chance of congenital heart surgery was 22% up to age 40 and 43% up to age 60 years; individual chances spanned from 9-68% up to age 40 and from 19-93% up to age 60 years. Conclusion At the time of transition from paediatric to adult cardiology, an easily obtainable set of characteristics of patients with congenital heart disease can meaningfully inform cardiologists about the patient's individual chance of surgery in adulthood. Our findings warrant validation in other cohorts.

Nineteen Years of Adult Congenital Heart Surgery in a Single Center

BACKGROUND

Adults with congenital heart disease are a growing population. We describe surgical interventions, short- and long-term mortality and morbidity, and risk factors for adverse events in a population-based cohort.

METHODS

Patients over or equal to 18 years with congenital heart disease who underwent cardiac surgery at Aarhus University Hospital, Denmark, from 1994 to 2012 were included in the study. Diagnoses, surgical procedures, postoperative complications, and survival were identified in hospital databases, medical records, and the Danish Civil Registration System.

RESULTS

Four hundred seventy-four surgeries were performed in 445 adults (50% men). The median age was 39 years (range 18-83). Thirty-nine percent had previous surgical or catheter-based interventions. Thirty-day and in-hospital mortality were 1.1%. Postoperative complications occurred in 50% of cases, most were minor such as temporary arrhythmias and pneumonia. Major complications included postoperative bleeding necessitating intervention (6%), stroke (2%), and acute temporary renal failure (1%). Multivariate analysis identified RACHS-1 categories over or equal to 3 compared to category 1 (odds ratio (OR) = 2.3; 95% confidence interval (CI): 1.5-3.7), New York Heart Association functional class III and IV compared to class I (OR = 2.2; 95% CI: 1.3-3.7) and age at surgery (OR = 1.03, 95% CI: 1.01-1.04), as risk factors for adverse events. Survival during a median follow-up of 7.8 years (range 0 days-21.4 years) was 85% (95% CI: 80%-89%).

CONCLUSION

Adults with congenital heart disease constitute a growing population with the need for cardiac surgery. Postoperative complications are frequent but early and late mortality are low.

Short-Term Costs and Hospitalization Rates in Patients With Adult Congenital Heart Disease After Pulmonic Valve Replacement

In the adult congenital heart disease (ACHD) population, pulmonary valve replacement (PVR) is a common intervention, its benefit, however, has been incompletely investigated. This study investigates short- and intermediate-term outcomes after PVR in ACHD. Using State Inpatient Databases from the Healthcare Cost and Utilization Project, we investigated both hospitalization rate and financial burden accrued over the 12-month period after PVR compared with the 12 months before. Among 202 patients who underwent PVR, per patient-year hospitalization rates doubled in the year after PVR compared with the year before (0.16 vs 0.36, p = 0.006). With the exception of postprocedural complications, the most common reasons for hospitalization were unchanged after surgery: 22% of patients were admitted with equal or greater frequency after PVR. These patients experienced higher inpatient costs both at index admission and in the year after PVR (p = 0.004 and p <0.001, respectively). Univariate predictors of increased hospitalizations after PVR were age ≥50 years (p = 0.016), transposition of the great arteries, or conotruncal abnormalities (p <0.001), lipid disorders (p = 0.025), hypertension (p = 0.033), and number of chronic conditions ≥4 (p = 0.004). Multivariate analysis identified transposition of the great arteries or conotruncal abnormalities as an independent risk factor for increased hospitalization and cost post-PVR (p ≤0.001). In conclusion, short-term costs and hospitalization rates increase after PVR in a small group of patients with ACHD.

Factors determining outcomes in grown up patients operated for congenital heart diseases

Background:

The number of grown ups with congenital heart diseases (GUCHs) is steadily increasing.

Aims:

To analyze factors predicting early cardiac morbidity following cardiac surgery in GUCH at a tertiary care center.

Setting and Design:

Retrospective study at a multispeciality tertiary referral center.

Methods:

Between January 2004 and December 2014, 1432 patients ≥13 years of age (acyanotic defects: 843, cyanotic defects: 589) underwent surgery for congenital heart defects. Factors associated with early cardiac morbidity were analyzed.

Statistical Analysis:

Univariable and multivariable analysis of all factors affecting outcomes.

Results:

On multivariate analysis, previous sternotomy, aortic cross-clamp time >45 min, cyanosis, and emergency procedure were independent predictors of early morbidity with respective odds ratios (ORs) of 12.4, 3.6, 2.6, and 8.1. For more precise estimation, a risk score was generated. Taking the log odds with each of these four as respective weights, a score was generated. The variables were previous sternotomy (2.5), aortic cross-clamp >45 min (1.3), emergency procedure (2.1), and cyanosis (0.9), if the respective condition is present, zero otherwise. The score ranged from 0 to 4.5. The average value of the score based on the four variables was significantly higher in cases with morbidity (1.85 ± 1.17) vs. (0.75 ± 0.88), P < 0.001. Distribution of scores was significantly different between patients with and without morbidity. Sixty-seven percent patients without any morbidity had score <1 compared to 24.6% with morbidity. Only 0.9% patients without morbidity had score of ≥3 compared to 16.4% patients with morbidity. Compared with patients having score <1, patients with scores 1-2 had OR of 3.4, 2-3 had OR of 6.0, and >3 had OR of 48.7.

Conclusion:

GUCH can be safely operated when adequate caution is taken in the presence of independent predictors such as previous sternotomy, aortic clamp time >45 min, cyanosis, and emergency procedure.

Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease

BACKGROUND

Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover.

METHODS

We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013.

RESULTS

During the study period, 2264 (mean age 39.1 years, females ∼54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors.

CONCLUSIONS

Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.

Reoperative double ventricular outflow tract reconstruction in grown-up congenital heart disease patients with conotruncal anomalies

OBJECTIVE

Surgical experiences of the reoperative double ventricular outflow tract reconstruction long after the successful repair of conotruncal anomalies were reviewed.

METHODS

Ten adult patients with conotruncal anomalies (6 females, 22.9 ± 5.5 years old) underwent the reoperative double ventricular outflow tract reconstruction. Primary diagnosis was pulmonary atresia with ventricular septal defect in 6 patients, truncus arteriosus in 3, and double-outlet right ventricle in 1. The indication for the left ventricular outflow tract reconstruction was the left ventricular dilatation and dysfunction derived from moderate or greater systemic semilunar valve insufficiency. The indication for the right ventricular outflow tract reconstruction was severe pulmonary insufficiency in all patients, and concomitant right ventricular outflow tract obstruction in 7.

RESULTS

The systemic semilunar valve replacement was performed in all patients. The right ventricular outflow tract patching was performed in 4 patients, and the revision of extra-cardiac conduit in 6. Within a mean follow-up of 9.0 ± 7.0 years, there was no mortality. The left ventricular end-diastolic volume index improved from 147 ± 37 to 108 ± 19 ml/m(2) (p = 0.005), and the peak pressure gradient across right ventricular outflow tract improved from 43 ± 17 mmHg to 9 ± 2 at 1 year after (p = 0.02). The plasma brain natriuretic peptide level improved from 83 ± 57 to 34 ± 32 pg/ml (p = 0.03).

CONCLUSIONS

Reoperative double ventricular outflow tract reconstruction long after the repair of conotruncal anomalies was safely performed, and provided the ventricular reverse remodeling and improvement of serum BNP level.

Determination of reference values for tricuspid annular plane systolic excursion in healthy Turkish children

Objective:

Tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic measurement used for evaluating right ventricular systolic function. While established reference values of TAPSE exist for the adult population, only a limited number of studies have attempted to evaluate reference values for the pediatric population. The aim of the present study was to determine the reference values for TAPSE in healthy children in Turkey.

Methods:

A total of 765 healthy children aged between 0 and 18 years, all of whom were referred to our clinic with cardiac murmurs, were evaluated prospectively. Patients with no cardiac pathologies or other disorders were excluded from the study. The measurement of TAPSE was obtained using a 2D-guided M-mode technique with echocardiography, and the relationship between age and surface area with TAPSE was investigated. The statistical analysis was carried out using the SPSS 20.0 software package (SPSS Inc., Chicago, IL, USA, 2012).

Results:

The mean TAPSE value was found to be 19.56±5.54 mm, and no significant difference was identified between male and female children. TAPSE values showed a positive correlation with increasing age and surface area. The mean TAPSE value was 9.09±1.36 mm in newborns and 25.91±3.60 mm in the 13-18 years age group. A negative correlation was seen between TAPSE and heart rate.

Conclusion:

In the present study, the reference values for TAPSE in healthy Turkish children were presented in percentile tables and the corresponding z-scores were determined. These reference values may be useful in daily practice for the evaluation of right ventricular systolic function in children.

[Risk factors for surgery of congenital heart disease in adults: twenty-two years of experience. Who should operate them?]

OBJECTIVE

To assess the association between mortality in surgery of congenital heart disease in adults, and factors related to patients and operations.

METHOD

Descriptive study of operations performed by specialized surgeons in congenital heart surgery (238), adult acquired surgery (117), and specialty residents (108). The association of mortality with surgical risk and complexity, specialization of surgeon, cardiopulmonary by-pass and aortic cross clamping was assessed fitting logistic regression models.

RESULTS

A total of 463 operations were included (442 with cardiopulmonary by-pass) in the study performed between 1991 and 2012. Median age at surgery: 34; 52.8% were women. First surgery: 295, reoperation: 168. Median score of Aristotle was 6.8, with significantly higher complexity since 2001, after restructuring the Unit. Overall hospital mortality was 3.9%. Mortality was significantly associated to number of previous surgeries (OR: 5.02; 95%CI: 1.44-17.52), operations by acquired heart disease surgeons (OR: 3.53; 95%CI: 1.14-10.98), higher Aristotle (OR: 1,64; 95%CI: 1.18-2.29), and high cardiopulmonary by-pass time (OR: 1.13; 95%CI: 1.07-1.19).

CONCLUSIONS

Surgery of congenital heart disease in adults has been performed with low mortality. High complexity interventions, prolonged cardiopulmonary by-pass times and multiple reoperations were associated to higher mortality. Participation of cardiac surgeons specialized in congenital heart disease is associated with better outcomes.

Red cell transfusion management for patients undergoing cardiac surgery for congenital heart disease

BACKGROUND

Congenital heart disease is the most commonly diagnosed neonatal congenital condition. Without surgery, only 30% to 40% of patients affected will survive to 10 years old. Mortality has fallen since the 1990s with 2006 to 2007 figures showing surgical survival at one year of 95%. Patients with congenital heart disease are potentially exposed to red cell transfusion at many points in the surgical pathway. There are a number of risks associated with red cell transfusion that may be translated into increased patient morbidity and mortality.

OBJECTIVES

To evaluate the effects of red cell transfusion on mortality and morbidity on patients with congenital heart disease at the time of cardiac surgery.

SEARCH METHODS

We searched 11 bibliographic databases and three ongoing trials databases including the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (Ovid, 1950 to 11 June 2013), EMBASE (Ovid, 1980 to 11 June 2013), ClinicalTrials.gov, World Health Organization (WHO) ICTRP and the ISRCTN Register (to June 2013). We also searched references of all identified trials, relevant review articles and abstracts from between 2006 and 2010 of the most relevant conferences. We did not limit the searches by language of publication.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing red cell transfusion interventions in patients undergoing cardiac surgery for congenital heart disease. We included participants of any age (neonates, paediatrics and adults) and with any type of congenital heart disease (cyanotic or acyanotic). We excluded patients with congenital heart disease undergoing non-cardiac surgery. No co-morbidities were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We identified 11 trials (862 participants). All trials were in neonatal or paediatric populations. The trials covered only three areas of interest: restrictive versus liberal transfusion triggers (two trials), leukoreduction versus non-leukoreduction (two trials) and standard versus non-standard cardiopulmonary bypass (CPB) prime (seven trials). Owing to the clinical diversity in the participant groups (cyanotic (three trials), acyanotic (four trials) or mixed (four trials)) and the intervention groups, it was not appropriate to pool data in a meta-analysis. No study reported data for all the outcomes of interest to this review. Risk of bias was mixed across the included trials, with only attrition bias being low across all trials. Blinding of study personnel and participants was not always possible, depending on the intervention being used.Five trials (628 participants) reported the primary outcome: 30-day mortality. In three trials (a trial evaluating restrictive and liberal transfusion (125 participants), a trial of cell salvage during CPB (309 participants) and a trial of washed red blood cells during CPB (128 participants)), there was no clear difference in mortality at 30 days between the intervention arms. In two trials comparing standard and non-standard CPB prime, there were no deaths in either randomised group. Long-term mortality was similar between randomised groups in one trial each comparing restrictive and liberal transfusion or standard and non-standard CPB prime.Four trials explored a range of adverse effects following red cell transfusion. Kidney failure was the only adverse event that was significantly different: patients receiving cell salvaged red blood cells during CPB were less likely to have renal failure than patients not exposed to cell salvage (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.09 to 0.79, 1 study, 309 participants). There was insufficient evidence to determine whether there was a difference between transfusion strategies for any other severe adverse events.The duration of mechanical ventilation was measured in seven trials (768 participants). Overall, there was no consistent difference in the duration of mechanical ventilation between the intervention and control arms.The duration of intensive care unit (ICU) stay was measured in six trials (459 participants). There was no clear difference in the duration of ICU stay between the intervention arms in the transfusion trigger and leukoreduction trials. In the standard versus non-standard CPB prime trials, one trial examining the impact of washing transfused bypass prime red blood cells showed no clear difference in duration of ICU stay between the intervention arms, while the trial assessing ultrafiltration of the priming blood showed a shorter duration of ICU stay in the ultrafiltration group.

AUTHORS' CONCLUSIONS

There are only a small number of small and heterogeneous trials so there is insufficient evidence to assess the impact of red cell transfusion on patients with congenital heart disease undergoing cardiac surgery accurately. It is possible that the presence or absence of cyanosis impacts on trial outcomes, which would necessitate different clinical management of two groups. Further adequately powered, specific, high-quality trials are warranted to assess this fully.

[Intensive care management of critically ill adults with congenital heart disease]

Due to improvements in cardiac surgery and perioperative care the number of adults with congenital heart disease is continuously growing. The perioperative and intensive care management of these patients is a challenge due to the variety of pathologies and surgical options as well as the complex pathophysiology. Many patients develop organ dysfunction with time and many require multiple cardiac operations as well as non-cardiac interventions during adulthood. While these patients are best treated in dedicated tertiary centers that provide a multidisciplinary expertise, basic knowledge of this population is important for everyone involved in acute medical care. This review will discuss some general aspects of adults with congenital heart disease such as pulmonary hypertension, Eisenmenger syndrome, cyanosis, pregnancy and perioperative care, with a special focus on the management of critically ill patients.

Midterm results of surgery for adults with congenital heart disease centralized to a Swedish cardiothoracic center

OBJECTIVE

The surgical management of adults with congenital heart disease (ACHD) offers a great challenge, with a large number of anomalies with complex pathophysiology necessitating specific treatments. Pre- and postoperative morbidity has been relatively high, and the influencing factors are not completely identified. We sought to evaluate the incidence and predictors of postoperative complications following surgery for ACHD centralized to a Swedish cardiothoracic center.

DESIGN

Between April 2003 and May 2012, 191 consecutive patients with ACHD underwent 192 surgical procedures at our department. Pre-, intra-, and postoperative data were prospectively entered in a clinical database and retrospectively reviewed. Multivariate analysis was used to identify determinants of postoperative complications as a composite end point.

RESULTS

The 30-day mortality was 0.5%. Overall survival was 98.3% ± 1.0 at 1 year and 98.3% ± 1.0 at 5 years postoperatively. Repeat sternotomy had to be performed in 94 patients (49%). New onset atrial fibrillation or flutter was the most prevalent (13%, n = 17/135) postoperative complication. Independent risk factors for major postoperative complications were age (odds ratio [OR] 1.81/10 year increment, P = 0.001; 95% confidence interval [CI] 1.29-2.53), reduced (<50%) systemic left ventricle ejection fraction (OR 3.61, P = 0.031; 95% CI 1.13-11.6), and the duration of cardiopulmonary bypass (OR 3.34/60 minute increase, P < 0.001; 95% CI 2.03-5.49).

CONCLUSIONS

Our present data suggest that surgery in ACHD can be performed in centralized units with an excellent early and midterm survival. The incidence of postoperative complications was relatively low consisting mainly of supraventricular arrhythmias. In our opinion, ACHD surgery should be performed in centralized units with experienced surgeons in a dedicated multidisciplinary team for optimized postoperative management.

Risk factors associated with morbidity and mortality after pulmonary valve replacement in adult patients with previously corrected tetralogy of Fallot

Patients with palliated tetralogy of Fallot (TOF) often require pulmonary valve replacement in adulthood, yet the data regarding their outcomes are scarce. This study aimed to identify risk factors associated with postoperative complications in these patients and to establish long-term survival data for this patient group. A retrospective cohort study investigated 153 consecutive patients with a history of TOF repair who underwent pulmonary valve replacement at a single large academic center between March 1996 and March 2010. In part 1 of the study, logistic models were constructed to assess demographic, medical, and surgical risk factors for operative mortality; occurrence of a major adverse event (stroke, renal failure, prolonged ventilation, deep sternal infection, reoperation, or operative mortality); and prolonged hospital stay (>7 days). Risk factors with a p value less than 0.10 by univariate analysis were included in the subsequent multivariate analysis. In part 2 of the study, long-term, all-cause mortality was determined by construction of a Kaplan-Meier curve for the cohort. Seven patients died (4.5%). Significant risk factors for mortality in the multivariable analysis included age older than 40 years (odds ratio (OR) 9.89) and concomitant surgery (OR 6.65). A major adverse event occurred for 22 patients (14.4%). The only significant risk factor in the multivariable analysis for an adverse event was concomitant surgery (OR 6.42). The hospital stay was longer than 7 days for 31 patients (20.3%). The significant risk factors for a prolonged hospital stay included the presence of preoperative arrhythmias (OR 4.17), New York Heart Association class 3 (OR 4.35), and again, concomitant surgery (OR 4.2). Among the 146 hospital survivors, only 5 patients died in the intervening period. The predicted survival rates were 98.5% at 1 year, 96.7% at 5 years, and 93.5% at 10 years. Pulmonary valve replacement in adults with palliated TOF is a safe procedure with excellent long-term survival, but there remain important risk factors for postoperative mortality, prolonged hospital stay, and major adverse events. Awareness and modification of important risk factors may help to improve outcomes.

Outcome of complex adult congenital heart surgery in the developing world

BACKGROUND

There is scanty information on the outcome of adult congenital heart disease surgery from the developing world.

METHODS

This was a retrospective chart review of the surgical outcome of 153 adults with congenital heart disease over a 5-year period. Surgical atrial septal defect closure was considered "simple" while all other surgeries were considered "complex."

RESULTS

  There were 102 patients in the "simple" group and 51 in the "complex" group. Only three (2%) patients had prior operations. The "complex" group had longer bypass time and cross clamp time. Intensive care unit stay, ventilation time, and inotrope administration were longer. Major complications were more common and there were two deaths in the "complex" group. Age more than 30 years, cyanosis, and New York Heart Association class more than II were predictors of longer stay in the intensive care unit. Surgical repair of Tetralogy of Fallot in adults tended to have a longer ventilation time and intensive care unit stay with a mortality of 4%. At follow up, all patients were in New York Heart Association class I or II. Improvement of the functional class with negligible adverse events was noted in both groups.

CONCLUSIONS

  A retrospective evaluation of 153 adults with congenital heart disease who underwent open heart surgery at a single center in India showed strikingly fewer reoperations compared with large European studies. There was a similar prevalence of complex lesions. Surgical mortality was low, and long-term functional outcome was gratifying.

Ten-year experience with surgical treatment of adults with congenital cardiac disease

The number of adults with congenital cardiac disease continues to increase, and adult patients are now more numerous than paediatric patients. We sought to identify risk factors for perioperative death and report our results with surgical management of adult patients with congenital cardiac disease. We retrospectively analysed in-hospital data for 244 consecutive adult patients who underwent surgical treatment of congenital cardiac disease in our centre between January, 1998 and December, 2007. The mean patient age was 27.2 plus or minus 11.9 years, 29% were in functional class III or IV, and 25% were cyanosed. Of the patients, half were operated on for the first time. A total of 61% of patients underwent curative operations, 36% a reoperation after curative treatment, and 3% a palliative operation. Overall mortality was 4.9%. Predictive factors for hospital death were functional class, cyanosis, non-sinus rhythm, a history of only palliative previous operation(s), and an indication for palliative treatment. Functional class, cyanosis, type of initial congenital cardiac disease (single ventricle and double-outlet right ventricle), and only palliative previous operation were risk factors for prolonged intensive care stay (more than 48 hours). The surgical management of adult patients with congenital cardiac disease has improved during recent decades. These generally young patients, with a complex pathology, today present a low post-operative morbidity and mortality. Patients having undergone palliative surgery and reaching adulthood without curative treatment present with an increased risk of morbidity and mortality. Univentricular hearts and double-outlet right ventricles were associated with the highest morbidity.

Hypoxia in early life is associated with lasting changes in left ventricular structure and function at maturity in the rat

BACKGROUND

There is a growing population of adults with repaired cyanotic congenital heart disease. These patients have increased risk of impaired cardiac health and premature death. We hypothesized that hypoxia in early life before surgical intervention causes lasting changes in left ventricular structure and function with physiological implications in later life.

METHODS

Sprague-Dawley rats reared initially hypoxic conditions (FiO(2)=0.12) for days 1-10 of life were compared to rats reared only in ambient air. Cellular morphology and viability were compared among LV cardiomyocytes and histological analyses were performed on LV myocardium and arterioles. Intracellular calcium transients and cell shortening were measured in freshly-isolated cardiomyocytes, and mitochondrial hexokinase 2 (HK2) expression and activity were determined. Transthoracic echocardiography was used to assess LV function in anesthetized animals.

RESULTS

Cardiomyocytes from adult animals following hypoxia in early life had greater cellular volumes but significantly reduced viability. Echocardiographic analyses revealed LV hypertrophy and diastolic dysfunction, and alterations in cardiomyocyte calcium transients and cell shortening suggested impaired diastolic calcium reuptake. Histological analyses revealed significantly greater intima-media thickness and decreased lumen area in LV arterioles from hypoxic animals. Alterations in mitochondrial HK2 protein distribution and activity were also observed which may contribute to cardiomyocyte fragility.

CONCLUSIONS

Hypoxia in early life causes lasting changes in left ventricular structure and function that may negatively influence myocardial and vascular responses to physiological stress in later life. These data have implications for the growing population of adults with repaired or palliated cyanotic congenital heart disease.

The changing epidemiology of congenital heart disease

Congenital heart disease is the most common congenital disorder in newborns. Advances in cardiovascular medicine and surgery have enabled most patients to reach adulthood. Unfortunately, prolonged survival has been achieved at a cost, as many patients suffer late complications, of which heart failure and arrhythmias are the most prominent. Accordingly, these patients need frequent follow-up by physicians with specific knowledge in the field of congenital heart disease. However, planning of care for this population is difficult, because the number of patients currently living with congenital heart disease is difficult to measure. Birth prevalence estimates vary widely according to different studies, and survival rates have not been well recorded. Consequently, the prevalence of congenital heart disease is unclear, with estimates exceeding the number of patients currently seen in cardiology clinics. New developments continue to influence the size of the population of patients with congenital heart disease. Prenatal screening has led to increased rates of termination of pregnancy. Improved management of complications has changed the time and mode of death caused by congenital heart disease. Several genetic and environmental factors have been shown to be involved in the etiology of congenital heart disease, although this knowledge has not yet led to the implementation of preventative measures. In this Review, we give an overview of the etiology, birth prevalence, current prevalence, mortality, and complications of congenital heart disease.

Aortic valve surgery in congenital heart disease: a single-center experience

The optimal treatment of congenital aortic valve lesions is a controversial issue. This study was performed to evaluate the outcome after surgical treatment of aortic valve lesions in congenital aortic valve disease. Between the years of 2000 and 2008, 61 patients (mean age: 12.6 +/- 9.6 years, range: 1 day to 40 years) underwent aortic valve surgery for congenital aortic valve disease. Twenty-four patients had undergone previous cardiovascular operations. Indications for surgery were aortic regurgitation in 14.7% (n = 9), aortic stenoses in 26.2% (n = 16), and mixed disease in 59.1% (n = 36). The Ross procedure was performed in 37.7% (n = 23), aortic valve replacement with biological or mechanical prostheses in 29.5% (n = 18). Concomitant procedures were performed in 91.8% (n = 56) due to associated congenital cardiac defects. The overall mortality rate was 5%. Six patients needed reoperation. Implantation of permanent pacemakers occurred in six patients for permanent atrioventricular block. At the latest clinical evaluation, all survivors are in New York Heart Association class I-II and are living normal lives. Aortic valve surgeries in patients with congenital heart disease have had low mortality and morbidity rates in our series. Surgical technique as well as timing should be tailored for each patient. Aortic valve replacement should be delayed until the implantation of an adult-sized prosthesis is possible.

Pregnancy does not accelerate biological valve degeneration

BACKGROUND

Pregnancy in women with biological heart valve prosthesis might lead to a faster degeneration of the prosthesis. We analyzed the rate of prosthesis replacement and the outcome of pregnancies in women with biological valve prosthesis.

METHODS

Between 1976 and 2006, 100 female patients aged 18-40 years at time of the study, underwent a valve replacement with a bioprosthesis or a homograft. At a mean interval of 10.8±8 years, 87 patients were evaluated by a questionnaire.

RESULTS

A biological prosthesis was implanted in 45 patients (52%), while 42 patients (48%) received a homograft. After valve replacement, 33 patients (38%) had a total of 56 pregnancies with a live-birth rate of 77% (n=43). There were 9 (16%) miscarriages, 4 (7%) therapeutic abortions and no stillbirths. There was no maternal death, thromboembolic event or structural valve deterioration during pregnancy. Out of 87 patients, 31 (36%) required a valve re-replacement at a mean time of 9.5±5 years. Neither age, valve type, valve position nor pregnancy were a risk factor for a valve re-replacement. The freedom from valve re-replacement at 5 and 10 years, was 96±3% and 73±9%, respectively for patients after a pregnancy compared to 93±4% and 52±10%, respectively for patients without a pregnancy (p=0.2).

CONCLUSIONS

Pregnancy does not accelerate the risk for replacement of a biological heart valve prosthesis. Pregnancy in women with biological heart valves can be carried out without increased morbidity related to the implanted valve.

Morbidity and mortality risk factors in adults with congenital heart disease undergoing cardiac reoperations

BACKGROUND

Reoperations represent relatively frequent events in adults with congenital heart disease (ACHD). Cardiac operations in these patients present major difficulties in management and technique. Although reoperations in ACHD are becoming increasingly frequent, limited knowledge exists regarding perioperative risk factors.

METHODS

The study included 164 ACHD patients who underwent cardiac reoperations between January 2002 and December 2007 at our institution. Preoperative and intraoperative data were analyzed to identify morbidity and mortality risk factors.

RESULTS

Reoperations included pulmonary valve implantation or conduit replacement in 60, aortic valve/root procedures in 36, residual atrial or ventricular septal defect closure in 19, and Fontan operation/conversion in 19. Hospital mortality was 3.6%. The mean mechanical ventilation time was 26 hours. Mean intensive care unit stay was 3.1 days. Severe postoperative complications occurred in 24 (15.1%). Cardiopulmonary bypass time (p = 0.001), Fontan operation/conversion (p = 0.001), preoperative hematocrit (p = 0.004), previous number of operations (p = 0.001), and preoperative congestive heart failure (p = 0.021) were associated with severe morbidity. No factor was associated with death.

CONCLUSIONS

Reoperations in ACHD are mostly due to right ventricular outflow tract lesions and were associated with a low mortality rate if performed in a center with a considerable activity and a dedicated program. Severe morbidity is relatively frequent and is generally associated with the preoperative (high hematocrit due to cyanosis, congestive heart failure, and the number of previous operations) and operative (Fontan operation/conversion and cardiopulmonary bypass duration) conditions of the patient.

Association of neonatal hypoxia with lasting changes in left ventricular gene expression: an animal model

OBJECTIVE

Innovations in pediatric cardiovascular surgery have resulted in significant improvements in survival for children with congenital heart disease. In adults with such disease, however, surgical morbidity and mortality remain significant. We hypothesized that hypoxemia in early life causes lasting changes in gene expression in the developing heart and that such changes may persist into later life, affecting the physiology of the adult myocardium.

METHODS

Microarray expression analyses were performed with left ventricular tissue from 10- and 90-day-old rats exposed to hypoxia (inspired oxygen fraction 0.12) for the first 10 days after birth then subsequently reared in ambient air and with tissue from age-matched rats reared entirely in ambient air. Changes in expression of selected genes were confirmed with real-time reverse transcriptase polymerase chain reaction. Left ventricular cardiomyocytes were isolated from adult animals in both groups, and cellular morphology and viability were compared.

RESULTS

Microarray analyses revealed significant changes in 1945 and 422 genes in neonates and adults, respectively. Changes in genes associated with adaptive vascular remodeling and energy homeostasis, as well as regulation of apoptosis, were confirmed by real-time reverse transcriptase polymerase chain reaction. The viability of cardiomyocytes isolated from hypoxic animals was significantly lower than in those from control animals (36.7% +/- 13.3% vs 85.0% +/- 2.9%, P = .024).

CONCLUSIONS

Neonatal hypoxia is associated with significant changes in left ventricular gene expression in both neonatal and adult rats. This may have physiologic implications for the adult myocardium.

Initial experience with the amplatzer membranous septal occluder in adults

OBJECTIVES

Most perimembranous ventricular septal defects (pmVSD) that are still patent in adult life are small, hemodynamically and clinically unimportant, and do not require any intervention. However, surgery in adulthood for those that need to be closed carries significant morbidity. A trans-catheter technique for closing pmVSDs has been developed, and this paper describes our initial experience using the Amplatzer membranous septal occluder (AMSO).

PATIENTS/METHODS

Twelve patients, 9 female and 3 male, median age 34.5 years (range: 21-67) underwent catheterization for attempted pmVSD closure. Ten of the defects were native and 2 were post-operative residual defects. Transcatheter VSD closure was performed as previously described, under general anesthesia and with trans-esophageal echocardiographic (TEE) monitoring. Patients had a moderate to large left to right shunt (mean Qp/Qs = 2.0+/-0.4) with mild left heart volume overload and near normal pulmonary pressure. All 10 native pmVSDs were closed successfully, 9 with AMSO and one with an Amplatzer muscular VSD occluder, after failure to implant the AMSO. There was one post procedural complication--self-limiting retroperitoneal bleeding. Three patients had a residual leak. Attempted VSD closure in the 2 patients with post surgery residual shunt was unsuccessful.

CONCLUSION

We conclude that transcatheter mVSD closure with the AMSO is an efficient and safe alternative to surgery in carefully selected adult patients with native pmVSDs.

Midterm results of surgical intervention for congenital heart disease in adults: an Italian multicenter study

OBJECTIVE

We have analyzed, in a clinical multicenter study, the effect of cardiac surgery in adults with congenital heart disease in Italy.

METHODS

We collected clinical data from 856 patients aged 19 years or older who underwent surgical intervention from January 1, 2000, to December 31, 2004. Patients were divided into 3 surgical groups: group 1, palliation (3.1%); group 2, repair (69.7%); and group 3, reoperation (27.4%).

RESULTS

Preoperatively, 34.6% of patients were in New York Heart Association class I, 48.4% were in class II, 14.2% were in class III, and 2.8% were in class IV. Sinus rhythm was present in 83%. There were 1179 procedures performed in 856 patients (1.37 procedures per patient), with a hospital mortality of 3.1%. Overall mean intensive care unit stay was 2.3 days (range, 1-102 days). Major complications were reported in 247 (28.8%) patients, and postoperative arrhythmias were the most frequent. At a mean follow-up of 22 months (range, 1 month-5.5 years; completeness, 87%), late death occurred in 5 (0.5%) patients. New York Heart Association class was I in 79.3%, II in 17.6%, and III in 2.9%, and only 1 (0.11%) patient was in class IV. Overall survival estimates are 82.6%, 98.9%, and 91.8% at 5 years for groups 1, 2, and 3, respectively. Freedom from adverse events at 5 years is 91% for acyanotic patients versus 63.9% for preoperative cyanotic patients (P < .0001).

CONCLUSIONS

Surgical intervention for congenital heart disease in adults is a safe and low-risk treatment. However, patients presenting with preoperative cyanosis show a higher incidence of late adverse events and complications.

Update in adult congenital cardiac surgery

The number of grown-up patients with congenital heart disease (GUCH) is constantly increasing and will equal the number of children requiring surgery for congenital heart disease (CHD). Specialized centers dealing with the medical and paramedical problems of these patients are required. GUCH patients can be divided into the following groups: (1) patients with minor cardiac malformations presenting at adult age for first treatment; (2) patients presenting for correction as adults because they are either naturally balanced or were surgically palliated; (3) patients presenting for expected reoperations after correction in childhood; (4) patients requiring repair of residual defects after correction; (5) patients developing heart failure after correction or palliation of CHD requiring thoracic transplantation; and (6) patients developing acquired heart disease in addition to CHD. Special aspects of malformations frequently occurring in GUCH patients are discussed in detail. Acquired heart disease in this patient population is expected to increase in the coming decades as survivors of CHD grow old.