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Selcuk A, Spurney C, Ozturk M, Haverty M, Tongut A, Desai M, Park IH, Mehta R, Yerebakan C, d'Udekem Y. Left Atrioventricular Valve Regurgitation After Atrioventricular Septal Defect Repair. Ann Thorac Surg 2024:S0003-4975(24)00583-6. [PMID: 39067630 DOI: 10.1016/j.athoracsur.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 06/14/2024] [Accepted: 07/15/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Whether patients with moderate left atrioventricular valve regurgitation (LAVVR) after surgical repair of complete atrioventricular septal defect (CAVSD) should be observed or undergo reoperation remains unclear. METHODS Moderate LAVVR was diagnosed in 87 of 220 patients who underwent CAVSD repair: 47 during the initial hospital stay and 40 after a median of 7 months (interquartile range, 2-18 months) after the initial operation. RESULTS Of these 87 patients who had moderate LAVVR, 15 died, for an overall mortality of 17%. The regurgitation became severe in 39 patients (45%) within a median of 2 months (interquartile range, 1-7 months) leading to 33 reoperations and 10 deaths. In 23 of 87 patients (26%), regurgitation remained at a moderate level over a median follow-up period of 8 months (interquartile range, 1-48 months). In 25 of 87 patients (29%), the regurgitation decreased to mild after a median of 9 months (interquartile range, 5-19 months). The only independent risk factor for increased severity of regurgitation and reoperation was the echocardiographic appearance of the jet centered around the cleft rather than central at the time of diagnosis of moderate regurgitation (odds ratio, 3.5; 95% CI, 1.5-9.0; P = .007). CONCLUSIONS Moderate LAVVR after CAVSD repair is often linked to death and reoperation, but regurgitation remains stable in one-quarter of patients and improves in one-third. The deterioration usually occurs within the first year after surgery. The initial observation of patients with residual or new moderate regurgitation for up to 1 year or until further deterioration seems reasonable, as long as the regurgitation is centrally located.
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Affiliation(s)
- Arif Selcuk
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Christopher Spurney
- Division of Cardiology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Mahmut Ozturk
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Mitchell Haverty
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Aybala Tongut
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Manan Desai
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - In Hye Park
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Rittal Mehta
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington DC.
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Day TG, Matthew J, Budd SF, Venturini L, Wright R, Farruggia A, Vigneswaran TV, Zidere V, Hajnal JV, Razavi R, Simpson JM, Kainz B. Interaction between clinicians and artificial intelligence to detect fetal atrioventricular septal defects on ultrasound: how can we optimize collaborative performance? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:28-35. [PMID: 38197584 DOI: 10.1002/uog.27577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/19/2023] [Accepted: 12/30/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Artificial intelligence (AI) has shown promise in improving the performance of fetal ultrasound screening in detecting congenital heart disease (CHD). The effect of giving AI advice to human operators has not been studied in this context. Giving additional information about AI model workings, such as confidence scores for AI predictions, may be a way of further improving performance. Our aims were to investigate whether AI advice improved overall diagnostic accuracy (using a single CHD lesion as an exemplar), and to determine what, if any, additional information given to clinicians optimized the overall performance of the clinician-AI team. METHODS An AI model was trained to classify a single fetal CHD lesion (atrioventricular septal defect (AVSD)), using a retrospective cohort of 121 130 cardiac four-chamber images extracted from 173 ultrasound scan videos (98 with normal hearts, 75 with AVSD); a ResNet50 model architecture was used. Temperature scaling of model prediction probability was performed on a validation set, and gradient-weighted class activation maps (grad-CAMs) produced. Ten clinicians (two consultant fetal cardiologists, three trainees in pediatric cardiology and five fetal cardiac sonographers) were recruited from a center of fetal cardiology to participate. Each participant was shown 2000 fetal four-chamber images in a random order (1000 normal and 1000 AVSD). The dataset comprised 500 images, each shown in four conditions: (1) image alone without AI output; (2) image with binary AI classification; (3) image with AI model confidence; and (4) image with grad-CAM image overlays. The clinicians were asked to classify each image as normal or AVSD. RESULTS A total of 20 000 image classifications were recorded from 10 clinicians. The AI model alone achieved an accuracy of 0.798 (95% CI, 0.760-0.832), a sensitivity of 0.868 (95% CI, 0.834-0.902) and a specificity of 0.728 (95% CI, 0.702-0.754), and the clinicians without AI achieved an accuracy of 0.844 (95% CI, 0.834-0.854), a sensitivity of 0.827 (95% CI, 0.795-0.858) and a specificity of 0.861 (95% CI, 0.828-0.895). Showing a binary (normal or AVSD) AI model output resulted in significant improvement in accuracy to 0.865 (P < 0.001). This effect was seen in both experienced and less-experienced participants. Giving incorrect AI advice resulted in a significant deterioration in overall accuracy, from 0.761 to 0.693 (P < 0.001), which was driven by an increase in both Type-I and Type-II errors by the clinicians. This effect was worsened by showing model confidence (accuracy, 0.649; P < 0.001) or grad-CAM (accuracy, 0.644; P < 0.001). CONCLUSIONS AI has the potential to improve performance when used in collaboration with clinicians, even if the model performance does not reach expert level. Giving additional information about model workings such as model confidence and class activation map image overlays did not improve overall performance, and actually worsened performance for images for which the AI model was incorrect. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T G Day
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Matthew
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - S F Budd
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - L Venturini
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - R Wright
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - A Farruggia
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - T V Vigneswaran
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - V Zidere
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Harris Birthright Research Centre, King's College London NHS Foundation Trust, London, UK
| | - J V Hajnal
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - R Razavi
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J M Simpson
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - B Kainz
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department Artificial Intelligence in Biomedical Engineering, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Germany
- Department of Computing, Faculty of Engineering, Imperial College London, London, UK
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Freeman K, Caris E, Schultz AH, Tressel W, Kronmal R, Buddhe S. Predictors of post-operative left atrioventricular valve regurgitation in pediatric patients with complete atrioventricular canal defects. Echocardiography 2024; 41:e15832. [PMID: 38796741 DOI: 10.1111/echo.15832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/12/2024] [Accepted: 04/30/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND In infants with complete atrioventricular canal (CAVC) defects, post-operative left atrioventricular valve regurgitation (LAVVR) is a known major cause of morbidity and mortality and a common indication for re-operation. However, there is scarce data to identify risk factors for poor outcomes. Our study aims to find echocardiographic characteristics that predict post-operative LAVVR at discharge and 1-year follow-up. METHODS Retrospective cohort study of patients with initial CAVC repair at our hospital who were followed for 1 year between 2013 and 2022. Patients with major co-morbid conditions were excluded. Serial echocardiograms were reviewed. Anatomic details, quantitative and qualitative measure of LAVVR including the number of regurgitant jets, regurgitant jet length and vena contracta width, and ventricular function were collected. The time points measured include pre-operative transthoracic echocardiogram (TTE), post-operative transesophageal echocardiogram (PO-TEE), routine protocol based post-operative day 1 (POD1) TTE, discharge TTE and 1-year post-operative (1yPO) TTE. Paired t-tests, chi-square analysis, and linear regression analysis were performed comparing measured variables to LAVVR outcomes. RESULTS Fifty-two patients were included; 92% had Trisomy 21. The majority were classified as Rastelli A (71%), others Rastelli C (29%). Only two patients had moderate or greater LAVVR pre-operatively. The mean age at repair was 125 ± 44 days. Pre-operative LAVVR was the only significant predictor of LAVVR severity at 1 year after backward stepwise regression. Of those with < moderate LAVVR on PO-TEE, 20% had worsening to ≥ moderate at discharge, but only 9% remained that way at 1 year. Of those with ≥ moderate LAVVR on PO-TEE, 40% improved to < moderate by 1 year. Two patients who worsened at 1 year, both secondary to likely cleft suture dehiscence. Only one patient required reoperation in the immediate post-operative period secondary to severe LAVVR due to suture dehiscence. Routine protocol-based POD1 echo did not have any association with altered outcomes. CONCLUSION Pre-operative LAVVR was the only significant predictor of LAVVR severity at 1 year. A significant percentage (40%) of patient with ≥ moderate LAVVR on PO-TEE improved to < moderate by 1 year. Furthermore, routine protocol-based POD1 echo did not have any association with altered outcomes.
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Affiliation(s)
- Kaitlyn Freeman
- Department of Pediatrics, Division of Cardiology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Caris
- Department of Pediatrics, Division of Cardiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amy H Schultz
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Tressel
- Department of Biostatistics, Collaborative Health Studies Coordinating Center, University of Washington, Seattle, Washington, USA
| | - Richard Kronmal
- Department of Biostatistics, Collaborative Health Studies Coordinating Center, University of Washington, Seattle, Washington, USA
| | - Sujatha Buddhe
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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In de Braekt T, Aben JP, Maussen M, van den Bosch HCM, Houthuizen P, Roest AAW, van den Boogaard PJ, Lamb HJ, Westenberg JJM. Fully Automated Valve Segmentation for Blood Flow Assessment From 4D Flow MRI Including Automated Cardiac Valve Tracking and Transvalvular Velocity Mapping. J Magn Reson Imaging 2024. [PMID: 38558490 DOI: 10.1002/jmri.29370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Automated 4D flow MRI valvular flow quantification without time-consuming manual segmentation might improve workflow. PURPOSE Compare automated valve segmentation (AS) to manual (MS), and manually corrected automated segmentation (AMS), in corrected atrioventricular septum defect (c-AVSD) patients and healthy volunteers, for assessing net forward volume (NFV) and regurgitation fraction (RF). STUDY TYPE Retrospective. POPULATION 27 c-AVSD patients (median, 23 years; interquartile range, 16-31 years) and 24 healthy volunteers (25 years; 12.5-36.5 years). FIELD STRENGTH/SEQUENCE Whole-heart 4D flow MRI and cine steady-state free precession at 3T. ASSESSMENT After automatic valve tracking, valve annuli were segmented on time-resolved reformatted trans-valvular velocity images by AS, MS, and AMS. NFV was calculated for all valves, and RF for right and left atrioventricular valves (RAVV and LAVV). NFV variation (standard deviation divided by mean NFV) and NFV differences (NFV difference of a valve vs. mean NFV of other valves) expressed internal NFV consistency. STATISTICAL TESTS Comparisons between methods were assessed by Wilcoxon signed-rank tests, and intra/interobserver variability by intraclass correlation coefficients (ICCs). P < 0.05 was considered statistically significant, with multiple testing correction. RESULTS AMS mean analysis time was significantly shorter compared with MS (5.3 ± 1.6 minutes vs. 9.1 ± 2.5 minutes). MS NFV variation (6.0%) was significantly smaller compared with AMS (6.3%), and AS (8.2%). Median NFV difference of RAVV, LAVV, PV, and AoV between segmentation methods ranged from -0.7-1.0 mL, -0.5-2.8 mL, -1.1-3.6 mL, and - 3.1--2.1 mL, respectively. Median RAVV and LAVV RF, between 7.1%-7.5% and 3.8%-4.3%, respectively, were not significantly different between methods. Intraobserver/interobserver agreement for AMS and MS was strong-to-excellent for NFV and RF (ICC ≥0.88). DATA CONCLUSION MS demonstrates strongest internal consistency, followed closely by AMS, and AS. Automated segmentation, with or without manual correction, can be considered for 4D flow MRI valvular flow quantification. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Thomas In de Braekt
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Marc Maussen
- Pie Medical Imaging BV, Maastricht, the Netherlands
| | | | - Patrick Houthuizen
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
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Wiggins LM, Wang S, Wells W, Starnes V, Cleveland JD. Anatomic considerations in the management of complete atrioventricular canal. Cardiol Young 2024; 34:754-758. [PMID: 37814959 DOI: 10.1017/s1047951123003323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
OBJECTIVE Patients with complete atrioventricular canal have a variable clinical course prior to repair. Many patients balance their circulations well prior to elective repair. Others manifest clinically significant pulmonary over circulation early in life and require either palliative pulmonary artery banding or complete repair. The objective of this study was to assess anatomic features that impact the clinical course of patients. METHODS In total, 222 patients underwent complete atrioventricular canal repair between 2012 and 2022 at a single institution. Twenty-seven (12%) patients underwent either pulmonary artery banding (n = 15) or complete repair (n = 12) at less than 3 months of age (Group 1). The remaining 195 (88%) underwent repair after 3 months of age (Group 2). Patient records and imaging were reviewed. RESULTS The median post-operative length of stay following complete repair was 25 [7,46] days for those patients in Group 1 and 7 [5,12] days for those in Group 2 (p < 0.0001). There was relative hypoplasia of left-sided structures in Group 1 versus Group 2. Mean z-score for the ascending aorta was -1.2 (±0.8) versus -0.3 (±0.9) (p < 0.0001), the aortic isthmus was -2.1 (±0.8) versus -1.4 (±0.8) (p = 0.005). The pulmonary valve to aortic valve diameter ratio was median 1.47 [1.38,1.71] versus 1.38 [1.17,1.53] (p 0.008). CONCLUSIONS Echocardiographic evaluation of the systemic and pulmonary outflow of patients with complete atrioventricular canal may assist in predicting the clinical course and need for early repair vs pulmonary artery banding.
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Affiliation(s)
- Luke M Wiggins
- Division of Pediatric Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Shuo Wang
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Winfield Wells
- Division of Pediatric Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Vaughn Starnes
- Division of Pediatric Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - John D Cleveland
- Division of Pediatric Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
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McGeoghegan PB, Lu M, Sleeper LA, Emani SM, Baird CW, Feins EN, Gellis LA, Friedman KG. Cleft closure and other predictors of contemporary outcomes after atrioventricular canal repair in patients with parachute left atrioventricular valve. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae048. [PMID: 38539038 PMCID: PMC11014788 DOI: 10.1093/icvts/ivae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVES Parachute left atrioventricular valve (LAVV) complicates atrioventricular septal defect (AVSD) repair. We evaluate outcomes of AVSD patients with parachute LAVV and identify risk factors for adverse outcomes. METHODS We evaluated all patients undergoing repair of AVSD with parachute LAVV from 2012 to 2021. The primary outcome was a composite of time-to-death, LAVV reintervention and development of greater than or equal to moderate LAVV dysfunction (greater than or equal to moderate LAVV stenosis and/or LAVV regurgitation). Event-free survival for the composite outcome was estimated using Kaplan-Meier methodology and competing risks analysis. Cox proportional hazards regression was used to identify predictors of the primary outcome. RESULTS A total of 36 patients were included with a median age at repair of 4 months (interquartile range 2.3-5.5 months). Over a median follow-up of 2.6 years (interquartile range 1.0-5.6 years), 6 (17%) patients underwent LAVV reintervention. All 6 patients who underwent LAVV reintervention had right-dominant AVSD. Sixteen patients (44%) met the composite outcome, and all did so within 2 years of initial repair. Transitional AVSD (versus complete), prior single-ventricle palliation, leaving the cleft completely open and greater than or equal to moderate preoperative LAVV regurgitation were associated with a higher risk of LAVV reintervention in univariate analysis. In multivariate analysis, leaving the cleft completely open was associated with the composite outcome. CONCLUSIONS Repair of AVSD with parachute LAVV remains a challenge with a significant burden of LAVV reintervention and dysfunction in medium-term follow-up. Unbalanced, right-dominant AVSDs are at higher risk for LAVV reintervention. Leaving the cleft completely open might independently predict poor overall outcomes and should be avoided when possible. CLINICAL TRIAL REGISTRATION NUMBER IRB-P00041642.
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Affiliation(s)
| | - Minmin Lu
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Lynn A Sleeper
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Christopher W Baird
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Eric N Feins
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Laura A Gellis
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
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Kobayashi Y, Kasahara S, Sano S, Suzuki H, Suzuki E, Yorifuji T, Kotani Y. Staged repair for complete atrioventricular septal defect in patients weighing less than 4.0 kg. J Thorac Cardiovasc Surg 2024; 167:1136-1144. [PMID: 37442338 DOI: 10.1016/j.jtcvs.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/14/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE This study compared the mortality, left atrioventricular valve-related reoperation, and left atrioventricular valve competence in symptomatic neonates and small infants who underwent staged repair incorporating pulmonary artery banding or primary repair for complete atrioventricular septal defect. METHODS Patients weighing less than 4.0 kg at the time of undergoing staged (n = 37) or primary (n = 23) repair for balanced complete atrioventricular septal defect between 1999 and 2022 were reviewed. The mean follow-up period was 9.1 years. Freedom from moderate or greater left atrioventricular valve regurgitation was estimated with the Kaplan-Meier method. RESULTS The staged group included smaller children (median weight, 2.9 vs 3.7 kg) and a higher proportion of neonates (41% vs 4%). All patients in the staged group survived pulmonary artery banding and underwent intracardiac repair (median weight, 6.8 kg). After pulmonary artery banding, the severity of left atrioventricular valve regurgitation improved in 10 of 12 patients (83%) without left atrioventricular valve anomaly who had mild or greater left atrioventricular valve regurgitation and a left atrioventricular valve Z score greater than 0. Although survival and freedom from left atrioventricular valve-related reoperation at 15 years (P = .195 and .602, respectively) were comparable between the groups, freedom from moderate or greater left atrioventricular valve regurgitation at 15 years was higher in the staged group (P = .026). CONCLUSIONS Compared with primary repair, staged repair for complete atrioventricular septal defect in children weighing less than 4.0 kg resulted in comparable survival and reoperation rates and better left atrioventricular valve competence. Pulmonary artery banding may mitigate secondary left atrioventricular valve regurgitation unless a structural valve abnormality exists. Selective deferred intracardiac repair beyond the neonatal and small-infancy period may still play an important role in low-weight patients.
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Affiliation(s)
- Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Shunji Sano
- Department of Pediatric Cardiac Surgery, Showa University Hospital, Tokyo, Japan
| | - Hiroyuki Suzuki
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Etsuji Suzuki
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan.
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Zhang QL, Chen YK, Lin SH, Du XW, Chen Q, Wang SM, Cao H. Tricuspid mechanical valve replacement for severe tricuspid stenosis in a child who underwent surgical correction of complete atrioventricular septal defect, a rare long-term complications. J Cardiothorac Surg 2024; 19:77. [PMID: 38336747 PMCID: PMC10858579 DOI: 10.1186/s13019-024-02580-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Complete atrioventricular septal defect is a complicated congenital heart malformations, and surgical correction is the best treatment, the severe tricuspid stenosis is a rare long-term complication after the surgery. CASE PRESENTATION We report a case with the complication of severe tricuspid stenosis 7 years after the surgical correction of complete atrioventricular septal defect in a child. Then the patient underwent tricuspid mechanical valve replacement, Glenn, atrial septostomy, and circumconstriction of the right pulmonary artery. CONCLUSIONS The patient recovered successfully with good short-term.
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Affiliation(s)
- Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yu-Kun Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shi-Hao Lin
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xin-Wei Du
- Department of Cardiac and Thoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shun-Min Wang
- Department of Cardiac and Thoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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Gellis L, McGeoghegan P, Lu M, Feins E, Sleeper L, Emani S, Friedman K, Baird C. Left atrioventricular valve repair after primary atrioventricular canal surgery: Predictors of durability. J Thorac Cardiovasc Surg 2023; 166:1168-1177. [PMID: 37160215 DOI: 10.1016/j.jtcvs.2023.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Acute outcomes after atrioventricular canal defects (AVCD) surgery in the current era are excellent; yet despite surgical advances, ∼15% of patients require future left atrioventricular valve (LAVV) repair. Among patients with AVC who undergo LAVV repair after primary AVC surgery, we sought to characterize the durability of these repairs. Specifically, we aimed to determine predictors for reintervention following an LAVV repair in patients with repaired AVCD, with a focus on postoperative transesophageal echocardiography (TEE). METHODS We reviewed all patients undergoing LAVV repair (after a primary AVCD surgery) at Boston Children's Hospital between 2010 and 2020. Competing risk analysis was performed to evaluate cumulative incidence of LAVV reinterventions. Predictors of LAVV reintervention were evaluated using multivariable Cox regression. RESULTS A total of 137 LAVV repairs following primary AVCD surgery were performed in 113 patients. Median age and weight at LAVV repair were 25 months (interquartile range, 12-76 months) and 11.1 kg (interquartile range, 7.8-19.4 kg). Original anatomy was complete AVCD in 87 (63%), transitional AVCD in 27 (20%), and partial AVCD in 23 (17%) cases. Over a median follow-up of 12 months (interquartile range, 1.3 months-4 years), 47 (34%) of the LAVV repairs required LAVV reintervention. Reinterventions included a total of 27 LAVV re-repairs and 20 LAVV replacements. In multivariable analysis, age at LAVV repair younger than 72 months, partial AVCD anatomy, left ventricle dysfunction, mean LAVV stenosis gradient ≥5 mm Hg, and multiple jets of regurgitation on postoperative LAVV repair TEE were associated with LAVV reintervention. Grade of LAVV regurgitation on postoperative TEE was not an independent risk factor, but reintervention rates were high when residual LAVV stenosis gradient was ≥5 mm Hg and residual mild LAVV regurgitation was present on postoperative TEE (47%) and even higher when residual LAVV stenosis gradient was ≥5 mm Hg and LAVV regurgitation was greater than mild (73%). CONCLUSIONS Reintervention rates remain high for LAVV repairs that occur after primary AVCD surgery, particularly for patients with LAVV stenosis gradient ≥5 mm Hg and mild or greater LAVV regurgitation on postoperative TEE.
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Affiliation(s)
- Laura Gellis
- Department of Cardiology, Children's Hospital Boston, Boston, Mass.
| | | | - Minmin Lu
- Department of Cardiology, Children's Hospital Boston, Boston, Mass
| | - Eric Feins
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass
| | - Lynn Sleeper
- Department of Cardiology, Children's Hospital Boston, Boston, Mass
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass
| | - Kevin Friedman
- Department of Cardiology, Children's Hospital Boston, Boston, Mass
| | - Christopher Baird
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass
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10
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Wright LK, Stallings EB, Cragan JD, Pabst LJ, Alverson CJ, Oster ME. Narrowing the Survival Gap: Trends in Survival of Individuals with Down Syndrome with and without Congenital Heart Defects Born 1979 to 2018. J Pediatr 2023; 260:113523. [PMID: 37244582 PMCID: PMC10538432 DOI: 10.1016/j.jpeds.2023.113523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 05/12/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the hypothesis that childhood survival for individuals with Down syndrome (DS) and congenital heart defects (CHDs) has improved in recent years, approaching the survival of those with DS without CHDs. STUDY DESIGN Individuals with DS born from 1979 to 2018 were identified through the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects surveillance system administered by the Centers for Disease Control and Prevention. Survival analysis was performed to evaluate predictors of mortality for those with DS. RESULTS The cohort included 1671 individuals with DS; 764 had associated CHDs. The 5-year survival in those with DS with CHD improved steadily among individuals born in the 1980s through the 2010s (from 85% to 93%; P = .01), but remained stable (96% to 95%; P = .97) in those with DS without CHDs. The presence of a CHD was not associated with mortality through 5 years of age for those born 2010 or later (hazard ratio, 2.63; 95% CI, 0.95-8.37). In multivariable analyses, atrioventricular septal defects were associated with early (<1 year) and late (>5 year) mortality, whereas ventricular septal defects were associated with intermediate (1-5 years) mortality and atrial septal defects with late mortality, when adjusting for other risk factors. CONCLUSIONS The gap in 5-year survival between children with DS with and without CHDs has improved over the last 4 decades. Survival after 5 years remains lower for those with CHDs, although longer follow-up is needed to determine if this difference lessens for those born in the more recent years.
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Affiliation(s)
- Lydia K Wright
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Heart Center, Nationwide Children's Hospital, Columbus, OH; National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Erin B Stallings
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Janet D Cragan
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura J Pabst
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Clinton J Alverson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
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11
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Kumar R, Halder V, Ghosh S, Thingnam S, Singh H, Mishra AK, Mahajan S, Aggarwal P, Dutta ARS, Mishra A. Early and Mid-Term Outcomes of Primary Repair After Atrioventricular Canal Defect: A Single-Center Eight-Year Experience. Cureus 2023; 15:e45304. [PMID: 37846269 PMCID: PMC10576971 DOI: 10.7759/cureus.45304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND/AIM Surgical repair techniques and management of patients with atrioventricular septal defect (AVSD) have progressed over the last few decades. Early and definitive interventions have become the choice of treatment for these patients. Based on this background, we aimed to review the early and mid-term outcomes of primary AVSD repair. METHODS A total of 53 patients with a mean age of 3.45 ± 5.67 years underwent definitive repair for AVSD between January 2014 and June 2021. The clinical data including age, type of defect, associated co-anomalies, symptoms, pulmonary hypertension, etc. were collected and assessed retrospectively. Mitral regurgitation (MR) as a clinical outcome was assessed at 0, 1, 2, and 5 years. RESULTS Among the recruited patients, 35 (66.1%) were male and 18 (33.9%) were female. Of 53 patients, repair for the complete defect was done in 38 (71.69%) patients, repair for intermediate/partial defect was done in 15 (23.1%) patients, and one patient underwent repair for incomplete type. Other associated co-anomalies were anterior mitral leaflet (12 (22.6%)), atrial and ventricular septal defect (VSD) (30 (56.6%)), and patent ductus arteriosus (PDA) (11 (20.8%)). Different procedures for surgical repair included patch closure, cleft repair, and polytetrafluoroethylene (PTFE) VSD closure. After repair, the mean follow-up period was 46.73 ± 27.37 months. Overall mortality was 3.78% (2/53), and two patients underwent reintervention due to symptomatic severe MR. CONCLUSIONS A definitive and timely correction of AVSD shows satisfactory early and mid-term results.
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Affiliation(s)
- Rupesh Kumar
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Vikram Halder
- Department of Cardiothoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, IND
| | - Soumitra Ghosh
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Shyam Thingnam
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Harkant Singh
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Anand K Mishra
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Sachin Mahajan
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Pankaj Aggarwal
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Aduri Raja S Dutta
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Amit Mishra
- Department of Cardiothoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, IND
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12
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Schumacher K, Marin Cuartas M, Meier S, Aydin MI, Borger MA, Dähnert I, Kostelka M, Vollroth M. Long-term results following atrioventricular septal defect repair. J Cardiothorac Surg 2023; 18:250. [PMID: 37612667 PMCID: PMC10463950 DOI: 10.1186/s13019-023-02355-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Atrioventricular septal defects (AVSD) represent 4-7% of congenital cardiac malformations. Definitive early repair is favored over prior pulmonary artery banding and delayed definitive repair in many centers. The aim of this study was to analyze long-term outcomes following AVSD repair over a 21-year period. METHODS A total of 202 consecutive patients underwent surgical AVSD correction between June 1999 and December 2020. Surgery was performed using the double-patch technique. The study data were prospectively collected and retrospectively analyzed. Primary outcomes were In-hospital mortality and overall long-term freedom from reoperation. RESULTS Median age at operation was 120 days (IQR 94-150), median weight was 5.0 kg (4.2-5.3). None of the patients died within the first 30 postoperative days. In-hospital mortality was 0.5% (1/202 patients). Median follow-up was 57 months (11-121). Overall freedom from reoperation at 5, 10 and 15 years was 91.8%, 86.9% and 86.9%, respectively. CONCLUSION AVSD repair with the double-patch technique is a safe and effective procedure with good early postoperative outcomes and low long-term reoperation rates.
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Affiliation(s)
- Katja Schumacher
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Mateo Marin Cuartas
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Sabine Meier
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Muhammed Ikbal Aydin
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Michael Andrew Borger
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Ingo Dähnert
- Department of Pediatric Cardiology, Leipzig Heart Center, Leipzig, Germany
| | - Martin Kostelka
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Marcel Vollroth
- Department of Cardiac Surgery, University, Leipzig Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany.
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13
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Daene M, De Pauw L, De Meester P, Troost E, Moons P, Gewillig M, Rega F, Van De Bruaene A, Budts W. Outcome of Down patients with repaired versus unrepaired atrioventricular septal defect. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2023. [DOI: 10.1016/j.ijcchd.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
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14
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Chandiramani A, Bader V, Finlay E, Lilley S, Young D, Peng E. The impact of surgical repair on left ventricular outflow tract in atrioventricular septal defect with common atrioventricular valve orifice. JTCVS OPEN 2023; 14:385-395. [PMID: 37425447 PMCID: PMC10328763 DOI: 10.1016/j.xjon.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/13/2022] [Accepted: 10/03/2022] [Indexed: 07/11/2023]
Abstract
Objective Although a narrow left ventricular outflow tract in atrioventricular septal defect is related to its intrinsic morphology, the contribution from the repair technique remains to be quantified. Methods A total of 108 patients with an atrioventricular septal defect with a common atrioventricular valve orifice were divided into 2 groups: 2-patch (N = 67) and modified 1-patch (N = 41) repair. The left ventricular outflow tract morphometric was analyzed by quantifying the degree of disproportion between subaortic and aortic annular dimensions (disproportionate morphometrics ratio was defined as ≤ 0.9). Z-scores (median, interquartile range) were further analyzed in a subset of 80 patients with immediate preoperative and postoperative echocardiography. A total of 44 subjects with ventricular septal defects served as controls. Results Before repair, 13 patients (12%) with an atrioventricular septal defect had disproportionate morphometrics (vs 6 [14%] ventricular septal defect P = .79), but the subaortic Z-score (-0.53, -1.07 to 0.06) was lower than the ventricular septal defect (0.07, -0.57 to 1.17; P < .001). After repair, both 2-patch (8 [12%] preoperatively vs 25 [37%] postoperatively; P = .001) and modified 1-patch (5 [12%] vs 21 [51%], P < .001) procedures showed a greater degree of disproportionate morphometrics. Both 2-patch (postoperatively -0.73, -1.56 to 0.08 vs preoperatively -0.43, -0.98 to 0.28; P = .011) and modified 1-patch (-1.42, -2.63 to -0.78 vs -0.70, -1.18 to -0.25; P = .001) procedures also demonstrated lower subaortic Z-scores postrepair. The postrepair subaortic Z-scores were lower in the modified 1-patch group (-1.42 [-2.63 to -0.78]) compared with the 2-patch group (-0.73 [-1.56 to 0.08]; P = .004). Low postrepair subaortic Z-scores (<-2) were observed in 12 patients (41%) in the modified 1-patch group and 6 patients (12%) in the 2-patch group (P = .004). Conclusions Surgical correction resulted in greater disproportionate morphometrics seen immediately postrepair. The impact on the left ventricular outflow tract was observed in all repair techniques, with a greater burden seen after modified 1-patch repair. Video Abstract This morphometric study in AVSD with common atrio-ventricular valve orifice confirmed further derangements of LV outflow tract morphometrics immediately after surgical repair.
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Affiliation(s)
- Ashwini Chandiramani
- Department of General (Internal) Medicine, Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom
| | - Vivian Bader
- Department of Paediatric Cardiac Surgery, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
| | - Emma Finlay
- Department of Cardiac Physiology and Echocardiography, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
| | - Stuart Lilley
- Department of Cardiac Physiology and Echocardiography, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
| | - David Young
- Department of Mathematics and Statistics, University of Strathclyde, Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom
| | - Ed Peng
- Department of Paediatric Cardiac Surgery, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
- College of Medical, Veterinary and Life Sciences, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland, United Kingdom
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15
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Wang B, Verrocchi J, Liew D, Zentner D. Does Down syndrome influence the outcomes of congenital cardiac surgery? A systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:240-248. [PMID: 35612980 DOI: 10.1093/ehjqcco/qcac028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND Congenital cardiac surgery for individuals with Down syndrome (DS) has historically occurred at a reduced frequency. Little data are available regarding long-term post-congenital cardiac surgical outcomes. Limited sample sizes and clinical heterogeneity require a pooled analysis approach. AIMS To compare long-term outcomes post-congenital heart surgery between adults with and without DS. METHODS Databases (Medline, Embase, and PubMed) were searched utilizing terms related to DS and congenital heart disease.Studies that enrolled adults (>18 years) with operated congenital heart disease and compared long-term outcomes with respect to DS presence were included. All study designs were included, but those with limited/peri-operative follow-up, non-English texts, case studies, and literature reviews were excluded.Blinded screening, data extraction, and quality assessment were independently conducted by two reviewers. QUIPS criteria were used for risk of bias analysis. Both random- and fixed-effects models were used for meta-analysis. RESULTS A total of 23 studies (n = 10 466) were included. Risk of bias was frequently high due to unblinded retrospective study designs and analyses limited in adjustment for other prognostic factors.Meta-analysis demonstrated no effect of DS on long-term mortality [hazard ratio (HR) 0.86, 95% confidence interval (95% CI) 0.6-1.23], to a maximum described follow-up of 38 years. Lower cardiac reoperation risk (HR 0.6, 95% CI 0.46-0.78) for individuals with DS was found on pooled analysis. Meta-analysis was limited by between-study variation. CONCLUSION DS does not affect post-congenital cardiac surgical survival in adulthood. Reduced reoperation may reflect challenges in assessing functional and symptomatic status and/or concerns regarding perceived reoperation difficulties or likely benefits.
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Affiliation(s)
- Benjamen Wang
- Cardiology Department, The Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia
| | - Justin Verrocchi
- Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Dominica Zentner
- Cardiology Department, The Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC 3010, Australia
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16
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Left Atrioventricular Transvalvular Pressure Gradients Derived from Intraoperative and Postoperative Echocardiograms following Atrioventricular Septal Defect Repair. Diagnostics (Basel) 2023; 13:diagnostics13050957. [PMID: 36900100 PMCID: PMC10001237 DOI: 10.3390/diagnostics13050957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Left atrioventricular valve (LAVV) stenosis following an atrioventricular septal defect (AVSD) repair is a rare but potentially life-threatening complication. While echocardiographic quantification of diastolic transvalvular pressure gradients is paramount in the evaluation of a newly corrected valve function, it is hypothesized that these measured gradients are overestimated immediately following a cardiopulmonary bypass (CPB) due to the altered hemodynamics when compared to postoperative valve assessments using awake transthoracic echocardiography (TTE) upon recovery after surgery. METHODS Out of the 72 patients screened for inclusion at a tertiary center, 39 patients undergoing an AVSD repair with both intraoperative transesophageal echocardiograms (TEE, performed immediately after a CPB) and an awake TTE (performed prior to hospital discharge) were retrospectively selected. The mean (MPGs) and peak pressure gradients (PPGs) were quantified using a Doppler echocardiography and other measures of interest were recorded (e.g., a non-invasive surrogate of the cardiac output and index (CI), left ventricular ejection fraction, blood pressures and airway pressures). The variables were analyzed using the paired Student's t-tests and Spearman's correlation coefficients. RESULTS The MPGs were significantly higher in the intraoperative measurements when compared to the awake TTE (3.0 ± 1.2 vs. 2.3 ± 1.1 mmHg; p < 0.01); however, the PPGs did not significantly differ (6.6 ± 2.7 vs. 5.7 ± 2.8 mmHg; p = 0.06). Although the assessed intraoperative heart rates (HRs) were also higher (132 ± 17 vs. 114 ± 21 bpm; p < 0.001), there was no correlation found between the MPG and the HR, or any other parameter of interest, at either time-point. In a further analysis, a moderate to strong correlation was observed in the linear relationship between the CI and the MPG (r = 0.60; p < 0.001). During the in-hospital follow-up period, no patients died or required an intervention due to LAVV stenosis. CONCLUSIONS The Doppler-based quantification of diastolic transvalvular LAVV mean pressure gradients using intraoperative transesophageal echocardiography seems to be prone to overestimation due to altered hemodynamics immediately after an AVSD repair. Thus, the current hemodynamic state should be taken into consideration during the intraoperative interpretation of these gradients.
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17
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Kobayashi Y, Kasahara S, Sano S, Kotani Y. Modified single-patch repair for atrioventricular septal defects results in good functional outcomes in the absence of deep ventricular septal defects. J Thorac Cardiovasc Surg 2023; 165:411-421. [PMID: 36115701 DOI: 10.1016/j.jtcvs.2022.07.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/03/2022] [Accepted: 07/21/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES We compared 2-patch repair (TP) with modified single-patch repair (MSP) for complete atrioventricular septal defects and evaluated their effect on the left atrioventricular valve (LAVV) competence. We also identified risk factors for unfavorable functional outcomes. METHODS This retrospective study included 118 patients with complete atrioventricular septal defects who underwent intracardiac repair from 1998 to 2020 (MSP: 69; TP: 49). The median follow-up period was 10.4 years. The functional outcome of freedom from moderate or greater LAVV regurgitation (LAVVR) was estimated using the Kaplan-Meier method. RESULTS The hospital mortality was 1.7% (2/118) and late mortality was 0.8% (1/118). Eight patients required LAVV-related reoperation (MSP: 4; TP: 4) and none required left ventricular outflow tract-related reoperation. In the MSP group without LAVV anomaly, the receiver operating characteristic curve analysis revealed that the ventricular septal defect (VSD) depth was strongly associated with moderate or greater postoperative LAVVR, with the best cutoff at 10.9 mm. When stratified according to the combination of intracardiac repair type and VSD depth, the MSP-deep VSD (VSD depth >11 mm) group showed the worst LAVV competence among the 4 groups (P = .002). According to multivariate analysis, weight <4.0 kg, LAVV anomaly, and moderate or greater preoperative LAVVR were independent risk factors for moderate or greater postoperative LAVVR, whereas MSP was not a risk factor. CONCLUSIONS Postoperative LAVVR remains an obstacle to improved functional outcomes. MSP provides LAVV competence similar to TP unless deep VSD is present. The surgical approach should be selected on the basis of anatomical variations, specifically VSD depth.
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Affiliation(s)
- Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Shunji Sano
- Pediatric Cardiothoracic Surgery, University of California, San Francisco, San Francisco, Calif
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan.
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Al-Wassia HK, Al-Radi OO, Maghrabi KA, Bayazeed MA, Qattan MM, Ebraheem DT, Gadi SU, Kattan MF, Alghamdi RA, Alzabidi SH, Dohain AM. The influence of age and weight on the outcomes of complete atrioventricular septal defect repair. Egypt Heart J 2022; 74:55. [PMID: 35849194 PMCID: PMC9294084 DOI: 10.1186/s43044-022-00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The appropriate age and weight for surgical repair of atrioventricular septal defect (AVSD) is an area of controversy. We aimed to study the effect of weight and age at the time of surgical repair for complete AVSD in children less than 2 years of age on postoperative outcomes. A retrospective data review was performed for patients who underwent the AVSD repair from 2012 to 2019 at our institutions. Our primary outcome was the postoperative in-hospital length of stay (LOS). Secondary outcomes included total positive pressure ventilation (PPV), ventilation time, maximum vasoactive–inotropic score (max VIS), and other postoperative complications.
Results
The study included fifty patients. The median age was 191 days, and the median weight was 4.38 kg at the time of surgery. Weight < 4 kg was associated with longer PPV time and postoperative in-hospital LOS (p value of 0.033 and 0.015, respectively). Additionally, they had higher max VIS at 24 h and 48 h than the other groups with bodyweight 4–5.9 kg or ≥ 6 kg (p value of 0.05 and 0.027, respectively). Patients with older age or lower weight at operation had a longer in-hospital LOS and total length of PPV after surgery. There were no postoperative in-hospital deaths.
Conclusions
Older age and lower weight at the time of surgical repair of atrioventricular septal defect could be independent predictors of prolonged postoperative in-hospital length of stay and total length of positive pressure ventilation.
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19
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Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
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20
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The effect of surgical technique, age, and Trisomy 21 on early outcome of surgical management of complete atrioventricular canal defect. Cardiol Young 2022; 32:869-873. [PMID: 34350818 DOI: 10.1017/s1047951121003139] [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: 11/06/2022]
Abstract
BACKGROUND The optimal timing, surgical technique, and the influence of Trisomy 21 on the outcome of surgical repair of Complete Atrioventricular Canal Defect remains uncertain. We reviewed our experience in the repair of CAVC to identify the influence of these factors on operative outcomes. METHODS A prospective study included 70 patients, who underwent repair of CAVC at our institute between July, 2016 and October, 2019. Primary endpoint was mortality and the secondary endpoint was a degree of left atrioventricular valve regurgitation. RESULTS No significant difference was noted between patients operated on, at the first 6 months of age versus later, regarding mortality or LAVV regurgitation. Surgical repair by modified single-patch technique showed a significant reduction in bypass time (71.13 ± 13.507 min versus 99.19 ± 27.092 min, p-value = 0.001). Compared to closure of cleft only, posterior annuloplasty used for repair of LAVV resulted in significant reduction in the occurrence of post-operative valve regurgitation during the early period (LAVV 2 + 43 versus 7 %, p-value = 0.03) and at 6 months of follow-up (LAVV 2 + 35.4 versus 0 %, p-value = 0.01), respectively. CONCLUSIONS Early intervention, in the first 6 months in patients with CAVC by surgical repair gives comparable acceptable results to later repair; Trisomy 21 was not found to be a risk factor for early intervention. Repair of common AV valve by cleft closure with posterior LAVV annuloplasty showed better results with a significant decrease in post-operative LAVV regurgitation and early mortality in comparison to the closure of cleft only.
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21
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Goutallier CS, Buratto E, Hu T, Lui A, Davies B, Konstantinov IE, Brizard CP. Repair of complete atrioventricular septal defect under 3.5 kilograms: defining the limits of safe repair. J Thorac Cardiovasc Surg 2022; 164:1167-1175. [DOI: 10.1016/j.jtcvs.2022.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 10/19/2022]
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22
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Akam-Venkata J, Ikemba CM, Martinez J, Pruszynski J, Heistein L, Pirolli TJ, Forbess JM. Single-Stage Surgical Management of Atrioventricular Septal Defects with Coarctation of the Aorta. Pediatr Cardiol 2022; 43:1645-1652. [PMID: 35637360 PMCID: PMC9150633 DOI: 10.1007/s00246-022-02895-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/24/2022] [Indexed: 01/28/2023]
Abstract
Surgical options for coarctation of aorta (CoA) with atrioventricular septal defect (AVSD) include single-stage repair vs. staged approach with neonatal CoA repair and delayed AVSD repair. The durability of left atrioventricular valve (LAVV) function after neonatal repair is questioned, and the optimal approach remains controversial. Eighteen CoA-AVSD patients who underwent single-stage repair 2005-2015 by a single surgeon were retrospectively analyzed. Fifteen patients had complete and three had partial AVSD. Birth weight was 3.19 kg (2.17-4.08). Age at surgery was 16 days (6-127). One- and ten-year survival were 80% and 69%. Freedom from reintervention was 60% and 40% at one and ten-year respectively. Reinterventions included relief of left ventricular outflow tract obstruction (LVOTO) (n = 4), repair of cleft LAVV (n = 3), and LAVV and aortic valve replacement (n = 1). Freedom from LAVV reintervention was 85.6% and 66% at 1 and 10 years respectively. There were four deaths: two post-operative and two following hospital discharge. Mortality was due to sepsis in three patients, and heart failure related to LVOTO and LAVV insufficiency in one. At 68-month (0.6-144) follow-up the majority had mild or less LAVV regurgitation, and all had normal LV dimension and systolic function. There was no recurrent arch obstruction. Single-stage surgical repair of CoA-AVSD is feasible and reasonable. Survival and freedom from reintervention in our cohort approximate those outcomes of two-stage repair with durable left AV valve function and no recurrent arch obstruction. These patients are frequently syndromic and demonstrate mortality risk from non-cardiac causes. Consideration of a single-staged approach is warranted for appropriate patients with CoA-AVSD.
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Affiliation(s)
- Jyothsna Akam-Venkata
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA. .,Division of Pediatric Cardiology, Department of Pediatrics, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, 39216, USA.
| | - Catherine M. Ikemba
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Joseph Martinez
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Jessica Pruszynski
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Lisa Heistein
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Timothy J. Pirolli
- Department of Pediatric Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Joseph M. Forbess
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
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23
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Long-Term Outcome Up To 40 Years after Single Patch Repair of Complete Atrioventricular Septal Defect in Infancy or Childhood. Thorac Cardiovasc Surg 2021; 69:e68-e75. [PMID: 34953470 PMCID: PMC8751973 DOI: 10.1055/s-0041-1740070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objectives Patients with repaired complete atrioventricular septal defect (CAVSD)
represent an increasing portion of grown-ups with congenital heart disease. For repair of
CAVSD, the single-patch technique has been employed first. This technique requires
division of the bridging leaflets, thus, among other issues, long-term function of the
atrioventricular valves is of particular concern. Methods Between 1978 and 2001, 100 consecutive patients with isolated CAVSD
underwent single-patch repair in our institution. Hospital mortality was 11%. Primary
endpoints were clinical status, atrioventricular valve function, and freedom from
reoperation in long term. Follow-up was obtained contacting the patient and/or caregiver,
and the referring cardiologist. Results Eighty-three patients were eligible for long-term follow-up (21.0 ± 8.7,
mean ± standard deviation [21.5; 2.1–40.0, median; min–max] years after surgical repair).
Actual long-term mortality was 3.4%. Quality of life (QoL; self- or caregiver-reported in
patients with Down syndrome) was excellent or good in 81%, mild congestive heart failure
was present in 16%, moderate in 3.6% as estimated by New York Heart Association
classification. Echocardiography revealed normal systolic left ventricular function in all
cases. Regurgitation of the right atrioventricular valve was mild in 48%, mild–moderate in
3.6%, and moderate in 1.2%. The left atrioventricular valve was mildly stenotic in 15% and
mild to moderately stenotic in 2%; regurgitation was mild in 54%, mild to moderate in 13%,
and moderate in 15% of patients. Freedom from left atrioventricular-valve-related
reoperation was 95.3, 92.7, and 89.3% after 5, 10, and 30 years, respectively. Permanent
pacemaker therapy, as an immediate result of CAVSD repair ( n = 7) or as a result
of late-onset sick sinus syndrome ( n = 5), required up to six reoperations in
single patients. Freedom from pacemaker-related reoperation was 91.4, 84.4, and 51.5%
after 5, 10, and 30 years, respectively. Conclusion Up to 40 years after single-patch repair of CAVSD, clinical status and
functional results are promising, particularly, in terms of atrioventricular valve
function. Permanent pacemaker therapy results in a life-long need for surgical
reinterventions.
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24
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Ivanov Y, Buratto E, Naimo P, Lui A, Hu T, d'Udekem Y, Brizard CP, Konstantinov IE. Incidence and management of the left ventricular outflow obstruction in patients with atrioventricular septal defects. Interact Cardiovasc Thorac Surg 2021; 34:604-610. [PMID: 34751750 PMCID: PMC8972236 DOI: 10.1093/icvts/ivab303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/10/2021] [Accepted: 09/26/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yaroslav Ivanov
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Edward Buratto
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Phillip Naimo
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Adrienne Lui
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Thomas Hu
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Yves d'Udekem
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, VIC, Australia
| | - Christian P Brizard
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Igor E Konstantinov
- Cardiac Surgery Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, VIC, Australia
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25
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Chandiramani AS, Bader V, Finlay E, Lilley S, McLean A, Peng E. The role of abnormal subaortic morphometry as a substrate for left ventricular outflow tract obstruction following atrioventricular septal defect repair. Eur J Cardiothorac Surg 2021; 61:545-552. [PMID: 34549774 DOI: 10.1093/ejcts/ezab397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 06/29/2021] [Accepted: 07/14/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although left ventricular outflow tract (LVOT) obstruction is a recognized risk after atrioventricular (AV) septal defect (AVSD) repair, quantitative assessments to define the substrate of the obstruction are lacking. METHODS Morphometric analyses were based on measurements from early 2-dimensional echocardiographic scans (within 3 months postoperatively) for 117 patients (82 CAVVO = common AV valve; 35 SAVVO = separate AV valve orifices), which were compared to 50 age/weight matched controls (atrial septal defect/ventricular septal defect). Late echocardiographic analyses were performed in 57 patients with AVSD (follow-up range, 1.2-10.7 years). RESULTS Adequate z scores (above -2.5) were observed in 109 (93%) patients with AVSD at the aortic annulus and in 89 (76%) with AVSD in the subaortic area. Compared to the control group, patients with AVSD had lower median z scores at the aortic annulus (-0.64 vs 0.60; P < 0.001) and the subaortic areas (-1.48 vs 0.59; P < 0.001), disproportionate subaortic/aortic annulus ratio <1.00 (67% vs 22%; P < 0.001), narrower annuloaortic-septal angle (94.0 vs 104.0; P < 0.001) and annuloaortic left AV valve angle (78.0 vs 90.0; P < 0.001). Compared to patients with CAVVO, those with SAVVO had narrower annuloaortic-septal angles (P = 0.022) that persisted at late analysis, with lower subaortic/aortic annular ratios (P = 0.039). In patients with CAVVO, lower early postoperative subaortic z scores were found following modified single-patch repairs (median -2.12 vs -1.02 in two-patch repairs; P = 0.004). A total of 6/117 (5%) patients (4 CAVVO, 5% and 2 SAVVO, 6%) required reoperations for LVOT obstruction (mean 6.9 years postoperatively), with no difference in morphology or types of operations. CONCLUSIONS Despite having adequate z scores, patients with AVSD demonstrated abnormal LVOT morphometrics early postoperatively. Besides intrinsic morphology, repair techniques may have an impact on postoperative LVOT morphometrics and requires further evaluation.
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Affiliation(s)
- Ashwini Suresh Chandiramani
- College of Medical, Veterinary and Life Sciences, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Vivian Bader
- Department of Paediatric Cardiac Surgery, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Emma Finlay
- Department of Paediatric Cardiology/Echocardiography, Royal Hospital for Children, Glasgow, UK
| | - Stuart Lilley
- Department of Paediatric Cardiology/Echocardiography, Royal Hospital for Children, Glasgow, UK
| | - Andrew McLean
- Department of Paediatric Cardiac Surgery, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Ed Peng
- College of Medical, Veterinary and Life Sciences, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.,Department of Paediatric Cardiac Surgery, Royal Hospital for Children Glasgow, Glasgow, UK
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26
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Callahan CP, Jegatheeswaran A, Barron DJ, Husain SA, Fuller S, Overman DM, McCrindle BW. Association of atrial septal fenestration with outcomes after atrioventricular septal defect repair. J Thorac Cardiovasc Surg 2021; 163:1142-1152.e6. [PMID: 34627603 DOI: 10.1016/j.jtcvs.2021.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/01/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE During repair of atrioventricular septal defect (AVSD), surgeons might leave an atrial level shunt when concerned about postoperative physiology, or as part of routine practice. However, the association of fenestration with outcomes is unclear. We sought to determine factors associated with mortality after biventricular repair of AVSD. METHODS We included 581 patients enrolled from 32 Congenital Heart Surgeons' Society institutions from January 1, 2012, to June 1, 2020 in the Congenital Heart Surgeons' Society AVSD cohort. Parametric multiphase hazard analysis was used to identify factors associated with mortality. A random effect model was used to account for possible intersite variability in mortality. RESULTS An atrial fenestration was placed during repair in 133/581 (23%) patients. Overall 5-year survival after repair was 91%. Patients who had fenestration had an 83% 5-year survival versus 93% for those not fenestrated (P < .001). Variables associated with mortality in multivariable hazard analysis included institutional diagnosis of ventricular unbalance (hazard ratio [HR], 2.7 [95% confidence interval (CI): 1.5-4.9]; P = .003), preoperative mechanical ventilation (HR, 4.1 [95% CI, 1.3-13.1]; P = .02), atrial fenestration (HR, 2.8 [95% CI, 1.5-4.9]; P < .001), and reoperation for ventricular septal defect (HR, 4.0 [95% CI, 1.3-13.1]; P = .002). There was no difference in measures of ventricular unbalance for comparisons of fenestrated with nonfenestrated patients. No significant interinstitution variability in mortality was observed on the basis of the random effect model (P = .7). CONCLUSIONS An atrial communication at biventricular repair of AVSD is associated with significantly reduced long-term survival after adjusting for other known associated factors, including unbalance. These findings might challenge the routine practice of fenestration.
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Affiliation(s)
- Connor P Callahan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, University of Utah/Primary Children's Medical Center, Salt Lake City, Utah
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pa
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Minneapolis, Minn; Mayo Clinic - Children's Minnesota Cardiovascular Collaborative, Rochester, Minn
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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27
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Buratto E, Lui A, Hu T, Naimo P, Ivanov Y, d'Udekem Y, Brizard CP, Konstantinov IE. Propensity score matched analysis of cleft closure in complete atrioventricular septal defect repair. Ann Thorac Surg 2021; 113:1553-1561. [PMID: 34487709 DOI: 10.1016/j.athoracsur.2021.07.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/02/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Repair of complete atrioventricular septal defect (cAVSD) is achieved with low mortality. However, there is a high rate of reoperation on the left atrioventricular valve (LAVV), which is often attributed to non-closure of the cleft. Although non-closure of the cleft has been reported to be a risk factor for reoperation, no randomized-controlled or propensity-matched trials have ever been performed. We investigated the effect of cleft closure on outcomes following cAVSD repair. METHODS We reviewed 455 patients who underwent cAVSD repair between 1990 and 2019. To determine the effect of cleft closure, propensity score matching was performed on risk factors for reoperation following cAVSD repair. RESULTS Median age was 3.6 months (mean 9.6±20.4), median weight was 4.3 kg (mean 4.7±4.3kg) and 41.9% (191/455) were male. Early mortality was 2.9% (13/455), and survival was 89.8±1.9% at 20 years. Early reoperation was a risk factor for mortality (p=0.004). Freedom from reoperation was 72.5±4.0% at 20 years. Freedom from LAVV reoperation was 74.1±4.0% at 20 years. Preoperative severe LAVV regurgitation (p<0.001) and early postoperative moderate or greater LAVV regurgitation (p=0.007) were risk factors for reoperation, while trisomy 21 (p=0.03) and recent era of surgery (p=0.02) were protective. Propensity score matching yielded 106 pairs. There were no differences in long-term survival (p=0.71) or reoperation (p=0.26) between the two groups. CONCLUSIONS Repair of cAVSD can be achieved with low mortality and good long-term survival, however, the reoperation rate remains high. Similar freedom from reoperation can be achieved with or without closure of the LAVV cleft.
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Affiliation(s)
- Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne; Heart Research Group, Murdoch Children's Research Institute, Melbourne
| | - Adrienne Lui
- Department of Paediatrics, University of Melbourne, Melbourne
| | - Thomas Hu
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne
| | - Phillip Naimo
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne; Heart Research Group, Murdoch Children's Research Institute, Melbourne
| | - Yaroslav Ivanov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne
| | - Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne; Heart Research Group, Murdoch Children's Research Institute, Melbourne; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne
| | - Christian P Brizard
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne; Heart Research Group, Murdoch Children's Research Institute, Melbourne; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne; Department of Paediatrics, University of Melbourne, Melbourne; Heart Research Group, Murdoch Children's Research Institute, Melbourne; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne.
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28
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Ramgren JJ, Zindovic I, Nozohoor S, Gustafsson R, Hakacova N, Sjögren J. Impact of concomitant complex cardiac anatomy in nonsyndromic patients with complete atrioventricular septal defect. J Thorac Cardiovasc Surg 2021; 163:1437-1444. [PMID: 34503843 DOI: 10.1016/j.jtcvs.2021.08.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We studied a cohort of patients with nonsyndromic complete atrioventricular septal defect with and without concomitant complex cardiac anatomy and compared the outcomes after surgical repair. METHODS Between 1993 and 2018, 62 nonsyndromic patients underwent complete atrioventricular septal defect repair. Sixteen patients (26%) had complex complete atrioventricular septal defect with variables representing concomitant cardiac anatomic complexity: tetralogy of Fallot, double outlet right ventricle, total anomalous pulmonary venous return, concomitant aortic arch reconstruction, multiple ventricular septal defects, staged repair of coarctation of the aorta, and a persisting left superior vena cava. The mean follow-up was 12.7 ± 7.9 years. Baseline variables were retrospectively evaluated and analyzed using univariable logistic regression. Survival was studied using Kaplan-Meier estimates, and group comparisons were performed using the log-rank test. A competing-risk analysis estimated the risk of reoperation with death as the competing event. A Gray's test was used to test equality of the cumulative incidence curves between groups. RESULTS The perioperative mortality was 3.2% (2/62). Actuarial survival was 100% versus 66.7% ± 14.9% at 10 years in the noncomplex and complex groups, respectively (P < .01). There was no significant difference in the overall reoperation rate between the noncomplex group (7/46; 15%) and the complex group (4/16; 25%) (odds ratio, 1.86; 95% confidence interval, 0.46-7.45; P = .30). The competing-risk analysis demonstrated no significant difference in reoperation between the groups (P = .28). CONCLUSIONS Our data show that nonsyndromic patients without complex cardiac anatomy have a good long-term survival and an acceptable risk of reoperation similar to contemporary outcomes for patients with complete atrioventricular septal defect with trisomy 21. However, the corresponding group of nonsyndromic patients with concomitant complex cardiac lesions are still a high-risk population, especially regarding mortality.
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Affiliation(s)
- Jens Johansson Ramgren
- Section for Pediatric Cardiac Surgery, Department of Pediatrics, Lund University and Children's Hospital, Skane University Hospital, Lund, Sweden.
| | - Igor Zindovic
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Ronny Gustafsson
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Nina Hakacova
- Department of Pediatrics, Lund University and Children's Hospital, Skane University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
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29
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Maurer SJ, Moosholzer L, Pujol C, Nagdyman N, Ewert P, Tutarel O. Complete Atrioventricular Septal Defects after the Age of 40 Years. J Clin Med 2021; 10:jcm10163665. [PMID: 34441962 PMCID: PMC8396930 DOI: 10.3390/jcm10163665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/27/2021] [Accepted: 08/18/2021] [Indexed: 12/03/2022] Open
Abstract
Background: There is an increasing number of adults with complete atrioventricular septal defects (cAVSD). However, data regarding older adults are lacking. The aim of this study is to analyze the outcome of adults with cAVSD over the age of 40 years. Methods: Patients with cAVSD who were ≥40 years of age at any point between 2005 until 2018 were included retrospectively. Data were retrieved from hospital records. The primary endpoint was a combination of death from any cause and unplanned hospitalizations due to cardiac reasons. Results: 43 patients (60.5% female, mean age 43.7 ± 6.0 years, genetic syndrome 58.1%) were included. At begin of follow-up, the majority of patients (n = 41, 95.3%) was in New York Heart Association (NYHA) class I or II. Out of the whole cohort 26 (60.5%) had undergone cardiac surgery. At baseline, at least one extracardiac comorbidity was present in 40 patients (93.0%). Median follow-up was 1.7 years (IQR 0.3–4.6). On univariate Cox analysis, NYHA class at begin of follow-up (hazard ratio: 1.96, CI 95%: 1.04–3.72, p < 0.05) was the only predictor for the primary endpoint. Conclusions: Significant morbidity and mortality is present in cAVSD patients over the age of 40 years. NYHA class is predictive for a worse outcome.
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Affiliation(s)
- Susanne J. Maurer
- Department of Electrophysiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, 80636 Munich, Germany;
| | - Lorena Moosholzer
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, 80636 Munich, Germany; (L.M.); (C.P.); (N.N.); (P.E.)
| | - Claudia Pujol
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, 80636 Munich, Germany; (L.M.); (C.P.); (N.N.); (P.E.)
| | - Nicole Nagdyman
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, 80636 Munich, Germany; (L.M.); (C.P.); (N.N.); (P.E.)
| | - Peter Ewert
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, 80636 Munich, Germany; (L.M.); (C.P.); (N.N.); (P.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80992 Munich, Germany
| | - Oktay Tutarel
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, 80636 Munich, Germany; (L.M.); (C.P.); (N.N.); (P.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80992 Munich, Germany
- Correspondence: or ; Tel.: +49-89-1218-2729
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30
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Basgoze S, Yildiz O, Ozturk E, Onan IS. Repair of complete atrioventricular canal defects: Early and midterm results and comparison of the left anterior leaflet augmentation technique with traditional technics. J Card Surg 2021; 36:2658-2668. [PMID: 33955056 DOI: 10.1111/jocs.15602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Complete atrioventricular septal defects (CAVSD) include a variable spectrum of congenital malformations with different forms of clinical findings. We examined early and midterm outcomes, the need for reoperation, postoperative residual AV valve regurgitation, and other risk factors after various CAVSD repairs. METHODS Between 2014 and 2018, we have performed 89 isolated CAVSD repairs. We retrospectively reviewed the patients' medical records. Patients were divided into three groups according to their repair techniques modified one patch repair (MP) (n = 16); two patch repair (TP) (n = 49); and left anterior leaflet augmentation (ALA) technique (n = 24). RESULTS Eighty patients (89.8%) survived hospital discharge. Early mortality rates were three (18.8%) in the group MP, five (10.2%) in the group TP, and one (4.2%) in the group ALA. Thirteen patients died during the follow-up period. Late mortality rates were three (18.8%) in the group MP, four (16.6%) in the group ALA, and six (12.2%) in the group TP. The mean follow-up time was 35.9 ± 22.97 months (range: 0.3-77 months). The morbidity and mortality results were similar between-group TP and ALA but worse in the MP group. Low body weight (<4 kg) and younger age at surgery (<4 months) were found to be risk factors on mortality by univariate and multivariate analysis. Surgical technic was not found to be an independent risk factor. CONCLUSION In our series, TP and ALA techniques had satisfactory results in early and midterm periods. Younger age and small bodyweight might increase early mortality and the need for reoperation.
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Affiliation(s)
- Serdar Basgoze
- Department of Cardiovascular Surgery, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Okan Yildiz
- Department of Pediatric Cardiovascular Surgery, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Erkut Ozturk
- Department of Pediatric Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ismihan Selen Onan
- Department of Pediatric Cardiovascular Surgery, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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31
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Peterson JK, Kochilas LK, Knight J, McCracken C, Thomas AS, Moller JH, Setty SP. Long-Term Survival and Causes of Death in Children with Trisomy 21 After Congenital Heart Surgery. J Pediatr 2021; 231:246-253.e3. [PMID: 33359302 PMCID: PMC8005470 DOI: 10.1016/j.jpeds.2020.12.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/12/2020] [Accepted: 12/17/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate long-term transplant-free survival and causes of death in the trisomy 21 (T21) population after surgery for congenital heart disease (CHD) in comparison with patients who are euploidic. STUDY DESIGN This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, enriched with prospectively collected data from the National Death Index and the Organ Procurement and Transplantation Network for patients with sufficient direct identifiers. Kaplan-Meier survival plots were generated and multivariable Cox proportional hazards models were used to examine risk factors for mortality between patients with T21 and 1:1 matched patients with comparable CHD who are euploidic. RESULTS A long-term survival analysis was completed for 3376 patients with T21 (75 155 person-years) who met inclusion criteria. The 30-year survival rate for patients with T21 ranged from 92.1% for ventricular septal defect to 65.3% for complex common atrioventricular canal. Of these, 2185 patients with T21 were successfully matched with a patient who was euploidic. After a median follow-up of 22.86 years (IQR, 19.45-27.14 years), 213 deaths occurred in the T21 group (9.7%) compared with 123 (5.6%) in the euploidic comparators. After adjustment for age, sex, era, CHD complexity, and initial palliation, the hazard ratio of CHD-related mortality was 1.34 times higher in patients with T21 (95% CI, 0.92-1.97; P = .127). CONCLUSIONS CHD-related mortality for patients with T21 after cardiac surgical intervention is comparable with euploidic comparators. Children with T21 require lifelong surveillance for co-occurring conditions associated with their chromosomal abnormality.
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Affiliation(s)
- Jennifer K. Peterson
- Johns Hopkins University School of Nursing, 525 North Wolfe Street, Baltimore, MD 21205
| | - Lazaros K. Kochilas
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA 30322,Children’s Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322
| | - Jessica Knight
- Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, 101 Buck Road, Athens, GA 30602
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA 30322
| | - Amanda S. Thomas
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA 30322
| | - James H. Moller
- Departments of Pediatrics and Medicine, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN 55455
| | - Shaun P. Setty
- Long Beach Memorial Heart and Vascular Institute, 2801 Atlantic Avenue, Long Beach, CA 90806,Children’s Heart Institute, MemorialCare Miller Children’s and Women’s Hospital, 2801 Atlantic Avenue, Long Beach, CA 90806
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32
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Tack P, Willems R, Annemans L. An early health technology assessment of 3D anatomic models in pediatric congenital heart surgery: potential cost-effectiveness and decision uncertainty. Expert Rev Pharmacoecon Outcomes Res 2021; 21:1107-1115. [PMID: 33475446 DOI: 10.1080/14737167.2021.1879645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Three-dimensional anatomic models have been used for surgical planning and simulation in pediatric congenital heart surgery. This research is the first to evaluate the potential cost-effectiveness of 3D anatomic models with the intent to guide surgeons and decision makers on its use.Method: A decision tree and subsequent Markov model with a 15-year time horizon was constructed and analyzed for nine cardiovascular surgeries. Epidemiological, clinical, and economic data were derived from databases. Literature and experts were consulted to close data gaps. Scenario, one-way, threshold, and probabilistic sensitivity analysis captured methodological and parameter uncertainty.Results: Incremental costs of using anatomical models ranged from -366€ (95% credibility interval: -2595€; 1049€) in the Norwood operation to 1485€ (95% CI: 1206€; 1792€) in atrial septal defect repair. Incremental health-benefits ranged from negligible in atrial septal defect repair to 0.54 Quality Adjusted Life Years (95% CI: 0.06; 1.43) in truncus arteriosus repair. Variability in the results was mainly caused by a temporary postoperative quality-adjusted life years gain.Conclusion: For complex operations, the implementation of anatomic models is likely to be cost-effective on a 15 year time horizon. For the right indication, these models thus provide a clinical advantage at an acceptable cost.
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Affiliation(s)
- Philip Tack
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Ghent, Belgium
| | - Ruben Willems
- Department of Public Health, Ghent University, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
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Schleiger A, Kramer P, Schafstedde M, Yigitbasi M, Danne F, Murin P, Cho MY, Photiadis J, Berger F, Ovroutski S. Can Left Atrioventricular Valve Reduction Index (LAVRI) Predict the Surgical Strategy for Repair of Atrioventricular Septal Defect? Pediatr Cardiol 2021; 42:898-905. [PMID: 33580286 PMCID: PMC8110484 DOI: 10.1007/s00246-021-02558-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/16/2021] [Indexed: 11/26/2022]
Abstract
Despite improved survival, surgical treatment of atrioventricular septal defect (AVSD) remains challenging. The optimal technique for primary left atrioventricular valve (LAVV) repair and prediction of suitability for biventricular approach in unbalanced AVSD are still controversial. We evaluated the ability of our recently developed echocardiographic left atrioventricular valve reduction index (LAVRI) in predicting LAVV reoperation rate and surgical strategy for unbalanced AVSD. Retrospective echocardiographic analysis was available in 352 of 790 patients with AVSD treated in our institution and included modified atrioventricular valve index (mAVVI), ventricular cavity ratio (VCR), and right ventricle/left ventricle (RV/LV) inflow angle. LAVRI estimates LAVV area after complete cleft closure and was analyzed with regard to surgical strategy in primary LAVV repair and unbalanced AVSD. Of the entire cohort, 284/352 (80.68%) patients underwent biventricular repair and 68/352 (19.31%) patients underwent univentricular palliation. LAVV reoperation was performed in 25/284 (8.80%) patients after surgical correction of AVSD. LAVRI was significantly lower in patients requiring LAVV reoperation (1.92 cm2/m2 [IQR 1.31] vs. 2.89 cm2/m2 [IQR 1.37], p = 0.002) and significantly differed between patients receiving complete and no/partial cleft closure (2.89 cm2/m2 [IQR 1.35] vs. 2.07 cm2/m2 [IQR 1.69]; p = 0.002). Of 82 patients diagnosed with unbalanced AVSD, 14 were suitable for biventricular repair (17.07%). mAVVI, LAVRI, VCR, and RV/LV inflow angle accurately distinguished between balanced and unbalanced AVSD and predicted surgical strategy (all p < 0.001). LAVRI may predict surgical strategy in primary LAVV repair, LAVV reoperation risk, and suitability for biventricular approach in unbalanced AVSD anatomy.
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Affiliation(s)
- Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marie Schafstedde
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Mustafa Yigitbasi
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Friederike Danne
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Peter Murin
- Department of Congenital Heart Surgery/Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery/Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery/Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Pediatrics, Division of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Olariu IC, Popoiu A, Ardelean AM, Isac R, Steflea RM, Olariu T, Chirita-Emandi A, Stroescu R, Gafencu M, Doros G. Challenges in the Surgical Treatment of Atrioventricular Septal Defect in Children With and Without Down Syndrome in Romania-A Developing Country. Front Pediatr 2021; 9:612644. [PMID: 34307243 PMCID: PMC8292620 DOI: 10.3389/fped.2021.612644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Atrioventricular septal defect (AVSD) is a cardiac malformation that accounts for up to 5% of total congenital heart disease, occurring with high frequency in people with Down Syndrome (DS). We aimed to establish the surgical challenges and outcome of medical care in different types of AVSD in children with DS compared to those without DS (WDS). Methods: The study included 62 children (31 with DS) with AVSD, evaluated over a 5 year period. Results: Complete AVSD was observed in 49 (79%) children (27 with DS). Six children had partial AVSD (all WDS) and seven had intermediate types of AVSD (4 with DS). Eight children had unbalanced complete AVSD (1 DS). Median age at diagnosis and age at surgical intervention in complete AVSD was not significantly different in children with DS compared to those WDS (7.5 months vs. 8.6). Median age at surgical intervention for partial and transitional AVSDs was 10.5 months for DS and 17.8 months in those without DS. A large number of patients were not operated: 13/31 with DS and 8/31 WDS. Conclusion: The complete form of AVSD was more frequent in DS group, having worse prognosis, while unbalanced AVSD was observed predominantly in the group without DS. Children with DS required special attention due to increased risk of pulmonary hypertension. Late diagnosis was an important risk factor for poor prognosis, in the setting of suboptimal access to cardiac surgery for patients in Romania. Although post-surgery mortality was low, infant mortality before surgery remains high. Increased awareness is needed in order to provide early diagnosis of AVSD and enable optimal surgical treatment.
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Affiliation(s)
- Ioana-Cristina Olariu
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
| | - Anca Popoiu
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
| | - Andrada-Mara Ardelean
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
| | - Raluca Isac
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
| | - Ruxandra Maria Steflea
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania
| | - Tudor Olariu
- Department of Organic Chemistry, Faculty of Pharmacy, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Adela Chirita-Emandi
- Department of Microscopic Morphology Genetics Discipline, Center of Genomic Medicine Timisoara, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Regional Centre of Medical Genetics Timis, "Louis Turcanu" Emergency Hospital for Children Timisoara, Part of ERN ITHACA, Timisoara, Romania
| | - Ramona Stroescu
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
| | - Mihai Gafencu
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
| | - Gabriela Doros
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Pediatrics, "Louis Turcanu" Emergency Hospital for Children, Timisoara, Romania
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Ijsselhof R, Gauvreau K, Nido PD, Nathan M. Atrioventricular Valve Function Predicts Reintervention in Complete Atrioventricular Septal Defect. World J Pediatr Congenit Heart Surg 2020; 11:247-248. [PMID: 32093554 PMCID: PMC7045277 DOI: 10.1177/2150135119893648] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Technical performance score (TPS) has been associated with both early and late outcomes across a wide range of congenital cardiac procedures. A previous study has shown that the presence of residual lesions before discharge, as measured by TPS, is accurately able to identify patients who required postdischarge reinterventions after complete atrioventricular septal defect (CAVSD) repair. The aim of this study is to determine which subcomponents of TPS best predict postdischarge reinterventions after CAVSD repair. METHODS This was a single-center retrospective review of patients with CAVSD after repair between January 2000 and March 2016. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention before discharge for residua) based on subcomponent scores from discharge echocardiograms. Outcome of interest was postdischarge reintervention. RESULTS Among 344 patients, median age was 3.2 months (interquartile range [IQR], 2.4-4.2). There were 34 (10%) postdischarge reinterventions. Median follow-up was 2.6 years (IQR, 0.09-7.9). Trisomy 21 and concomitant procedure were associated with postdischarge reinterventions. After adjusting for these factors, among the subcomponents, left atrioventricular valve stenosis and regurgitation, right atrioventricular valve regurgitation, residual ventricular septal defect, and abnormal conduction at discharge were significantly associated with postdischarge reinterventions. CONCLUSIONS We demonstrated the ability of TPS to predict postdischarge reinterventions in patients who underwent CAVSD repair. Residual left and right atrioventricular valve regurgitation and abnormal conduction at discharge were among the subcomponents strongly associated with postdischarge reinterventions. Thus, TPS may aid clinicians in identifying children at higher risk for reintervention.
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Affiliation(s)
- Rinske Ijsselhof
- Department of Pediatric Cardiac Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Pedro Del Nido
- Department of Cardiology, Boston Children's Hospital, and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, and Department of Surgery, Harvard Medical School, Boston, MA, USA
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36
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Ramgren JJ, Nozohoor S, Zindovic I, Gustafsson R, Hakacova N, Sjögren J. Long-term outcome after early repair of complete atrioventricular septal defect in young infants. J Thorac Cardiovasc Surg 2020; 161:2145-2153. [PMID: 32919770 DOI: 10.1016/j.jtcvs.2020.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The long-term outcome after repair of complete atrioventricular septal defect in young infants is still not fully understood. The objective of this study was to evaluate data after repair for complete atrioventricular septal defect over a 25-year period to assess survival and identify risk factors for left atrioventricular valve-related reoperations. METHODS A total of 304 consecutive patients underwent surgical correction for complete atrioventricular septal defect between April 1993 and October 2018. The results for young infants (aged <3 months; n = 55; mean age 1.6 ± 0.6 months) were compared with older infants (aged >3 months; n = 249; mean age, 5.1 ± 5.2 months). Mean follow-up was 13.2 ± 7.8 years (median, 14.0 years; interquartile range, 7.0-20.0). The Kaplan-Meier method was used to assess overall survival and freedom from left atrioventricular valve-related reoperation. RESULTS Overall, 30-day mortality was 1.0% (3/304) with no difference between young and older infants (P = 1.0). Overall survival in the total population at 20-year follow-up was 95.1% (±1.3%). Independent risk factors for poor survival were the presence of an additional ventricular septal defect (P = .042), previous coarctation of the aorta (P < .001), persistent left superior vena cava (P = .026), and genetic syndromes other than Trisomy 21 (P = .017). Freedom from left atrioventricular valve-related reoperation was 92.6% (±1.7%) at 20 years. There was no significant difference in left atrioventricular valve-related reoperation in young infants compared with older infants (P = .084). CONCLUSIONS Our data demonstrated that excellent long-term survival could be achieved with early repair for complete atrioventricular septal defect, and the need for reoperations due to left atrioventricular valve regurgitation was low. Primary correction in patients aged less than 3 months is, when clinically necessary, well tolerated. Palliative procedures can be avoided in the majority of patients.
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Affiliation(s)
- Jens Johansson Ramgren
- Section for Pediatric Cardiac Surgery, Department of Pediatrics, Lund University and Children's Hospital, Skane University Hospital, Lund, Sweden.
| | - Shahab Nozohoor
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Ronny Gustafsson
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Nina Hakacova
- Department of Pediatric Cardiology, Lund University and Children's Hospital, Skane University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
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Single-ventricle palliation in children with atrioventricular septal defect and transposition of the great arteries: 45 years of experience. Cardiol Young 2020; 30:1165-1170. [PMID: 32594938 DOI: 10.1017/s1047951120001791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The association of atrioventricular septal defect and transposition of the great arteries is very rare. As a rule, these patients have unbalanced ventricles. However, there have been no studies describing the results of single-ventricle palliation in these children. METHODS All children who underwent surgery with a diagnosis of atrioventricular septal defect and transposition of the great arteries were included in the study. Data were obtained from medical records. RESULTS A total of 38 patients with atrioventricular septal defect and transposition of the great arteries underwent single-ventricle palliation at the study institution between 1971 and 2016. The mean follow-up was 12.4 years (median: 14.6 years, range 2-43.3 years). Most children had unbalanced atrioventricular septal defect (94.7%, 36/38). Survival was 67.6% (95% confidence interval [CI]: 50.0-80.2%) at 10 years and 57.8% (95% CI: 38.0-73.4%) at 20 years. By 10 years, 58.6% (95% CI: 40.8-72.7%) had progressed to Fontan completion, while 32.5% (95% CI: 18.2-47.6%) had died. In patients achieving Fontan completion, 20-year event-free survival was 73.3% (95% CI: 34.8-91.3%), while 5.0% (95% CI: 0.4-20.5%) had undergone cardiac transplantation and 21.7% (95% CI: 3.2-50.8%) had undergone takedown of the Fontan circulation. Freedom from atrioventricular valve surgery was 57.0% (95% CI: 37.2-72.7%) at 10 and 20 years. CONCLUSIONS The association of atrioventricular septal defect and transposition of the great arteries is very rare, and most of these children have unbalanced ventricles. Single-ventricle palliation results in 25-year overall survival of 50%. However, in patients, who had Fontan completion, survival was 75% at 25 years after Fontan operation.
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"Repair of common atrioventricular junction in isolation and when associated with other congenital heart defects". Indian J Thorac Cardiovasc Surg 2020; 37:54-66. [PMID: 33584027 DOI: 10.1007/s12055-020-00947-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022] Open
Abstract
Management of atrioventricular septal defects has grown leaps and bounds since the first correction of this malformation. Main reasons considered for the improvement are good understanding of lesion anatomy, precise preoperative diagnosis including imaging, progress in surgical technique, myocardial protection, and post-operative care. In this article we review the anatomy, pathophysiology, clinical features, associations, diagnosis, surgical therapy, complications, and results of atrioventricular septal defects.
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Thanh Xuan N, Xuan Hung N, Hoai An T, Dang Phuoc N, Huu Son N, Nhu Hiep P. <p>Treatment of Isolated Complete Atrioventricular Septal Defect: The Hue Central Hospital Experience</p>. OPEN ACCESS SURGERY 2020. [DOI: 10.2147/oas.s255267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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40
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Fong LS, Betts K, Bell D, Konstantinov IE, Nicholson IA, Winlaw DS, Orr Y, Hu T, Radford D, Alphonso N, Andrews D. Complete atrioventricular septal defect repair in Australia: Results over 25 years. J Thorac Cardiovasc Surg 2020; 159:1014-1025.e8. [DOI: 10.1016/j.jtcvs.2019.08.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 08/02/2019] [Accepted: 08/13/2019] [Indexed: 11/30/2022]
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Wang G, Ma K, Pang K, Hua Z, Zhang S, Qi L, Yang Y, Feng Z, Mao F, Zhang H, Li S. Modified Single Repair Technique for Complete Atrioventricular Septal Defect: A Propensity Score Matching Analysis. Pediatr Cardiol 2020; 41:615-623. [PMID: 31974717 DOI: 10.1007/s00246-020-02292-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/17/2020] [Indexed: 11/26/2022]
Abstract
There were controversies about the priority of modified single patch (MSP) technique compared with two-patch (TP) technique for patients with complete atrioventricular septal defect (CAVSD). From 2002 to 2013, patients who diagnosed as balanced CAVSD in our institution were retrospectively included. Patients with unbalanced ventricles or associated anomalies were excluded. The primary endpoint was all-cause mortality and the secondary endpoint consist of left atrioventricular dysfunction or left atrioventricular outflow tract obstruction (LVOTO). A total of 74 patients underwent MSP repair and 102 patients underwent TP repair. After 1:1 propensity matching, there were 46 Rastelli type A CAVSD patients in each group. Patients in MSP group had shorter cardiopulmonary bypass time [median (interquartile range) 73.5 (65.5-95.0) versus 105.0 (88.8-130.0) min, P < 0.001] and aortic cross-clamp time [105.5 (90.0-128.0) versus 143.0 (122.0-184.0) min, P < 0.001]. In total, the primary endpoint occurred in 12 patients, including 2/46 (4.3%) in MSP group and 10/46 (21.7%) in TP group. That 1-year, 3-year, 5-year survival rate can be calculated as 95.6%, 95.6%, 95.6% in MSP group and 92.6%, 80.4%, 78.2% in TP group, P = 0.015. No significant statistical difference found for the secondary endpoints that 7/46 (15.2%) patients occurred moderate or severe LAVVR in MSP group versus 11/46 (23.9%) patients in TP group, P = 0.293. No LVOTO occurred in both groups. Besides the simplicity of technique, MSP technique may be safer.
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Affiliation(s)
- Guanxi Wang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Kai Ma
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Kunjing Pang
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, The People's Republic of China
| | - Zhongdong Hua
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Sen Zhang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Lei Qi
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Yang Yang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Zicong Feng
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | | | - Hao Zhang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Shoujun Li
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China.
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Management of the bad atrioventricular valve in Fontan…time for a change. J Thorac Cardiovasc Surg 2019; 158:1643-1648. [DOI: 10.1016/j.jtcvs.2019.08.129] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/01/2019] [Accepted: 08/11/2019] [Indexed: 11/21/2022]
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Fong LS, Betts K, Kannekanti R, Ayer J, Winlaw DS, Orr Y. Modified-Single Patch vs Double Patch Repair of Complete Atrioventricular Septal Defects. Semin Thorac Cardiovasc Surg 2019; 32:108-116. [PMID: 31306766 DOI: 10.1053/j.semtcvs.2019.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/06/2019] [Indexed: 11/12/2022]
Abstract
Biventricular repair of complete atrioventricular septal defect (CAVSD) is largely achieved using the double-patch (DP) or modified single-patch (MSP) techniques in the current era; however, long-term results following MSP repair are not well defined. We aimed to compare long-term outcomes including reoperation and mortality after CAVSD repair using DP and MSP techniques, and identify the risk factors associated with adverse outcomes. A retrospective cohort study was performed including all patients who underwent CAVSD repair using DP and MSP techniques at our institution between 17 May 1990 and 14 December 2015. Demographic details, early (≤30 days) and late (>30 days) outcomes (reoperation, mortality) were studied. Competing risks analysis with cumulative incidence function was used for survival analyses. Overall, 273 consecutive patients underwent CAVSD repair (120 DP and 153 MSP) and 41 patients required reoperation during follow-up. Competing risks analysis showed no association between repair technique and reoperation (P = 1.0) or mortality (P = 0.9). Considering competing risks due to mortality, the cumulative incidence of reoperation at 5, 10, and 15 years was 14%, 17%, and 17% for DP and 12%, 13%, and 16% for MSP, respectively. Non-Down syndrome and moderate or greater left atrioventricular valve regurgitation were predictors for reoperation. Pulmonary artery banding was predictive of mortality, though strongly associated with earlier surgical era. Median follow-up duration was 8.0 years (interquartile range 3.9-20.8) for DP and 11.6 years (interquartile range 5.4-16.1) for MSP (P = 0.4). Event-free survival is similar after DP and MSP repair of CAVSD indicating either repair technique can be safely utilized.
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Affiliation(s)
- Laura S Fong
- Discipline of Child and Adolescent Health, Faculty of Health and Medicine, The University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Westmead, Australia.
| | - Kim Betts
- Curtin University School of Public Health, Perth, Australia
| | - Raviteja Kannekanti
- Heart Centre for Children, The Children's Hospital at Westmead, Westmead, Australia
| | - Julian Ayer
- Discipline of Child and Adolescent Health, Faculty of Health and Medicine, The University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Westmead, Australia
| | - David S Winlaw
- Discipline of Child and Adolescent Health, Faculty of Health and Medicine, The University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Westmead, Australia
| | - Yishay Orr
- Discipline of Child and Adolescent Health, Faculty of Health and Medicine, The University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Westmead, Australia
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Complete Atrioventricular Septal Defect: Evolution of Results in a Single Center During 50 Years. Ann Thorac Surg 2019; 107:1824-1830. [DOI: 10.1016/j.athoracsur.2019.01.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/01/2019] [Accepted: 01/09/2019] [Indexed: 11/17/2022]
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45
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Preoperative Clinical and Echocardiographic Factors Associated with Surgical Timing and Outcomes in Primary Repair of Common Atrioventricular Canal Defect. Pediatr Cardiol 2019; 40:1057-1063. [PMID: 31065759 DOI: 10.1007/s00246-019-02116-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Abstract
In complete atrioventricular canal defect (CAVC), there are limited data on preoperative clinical and echocardiographic predictors of operative timing and postoperative outcomes. A retrospective, single-center analysis of all patients who underwent primary biventricular repair of CAVC between 2006 and 2015 was performed. Associated cardiac anomalies (tetralogy of Fallot, double outlet right ventricle) and arch operation were excluded. Echocardiographic findings on first postnatal echocardiogram were correlated with surgical timing and postoperative outcomes using bivariate descriptive statistics and multivariable logistic regression. 153 subjects (40% male, 84% Down syndrome) underwent primary CAVC repair at a median age of 3.3 (IQR 2.5-4.2) months. Median postoperative length of stay (LOS) was 7 (IQR 5-15) days. Eight patients (5%) died postoperatively and 24 (16%) required reoperation within 1 year. On multivariable analysis, small aortic isthmus (z score < - 2) was associated with early primary repair at < 3 months (OR 2.75, 95% CI 1.283-5.91) and need for early reoperation (OR 3.79, 95% CI 1.27-11.34). Preoperative ventricular dysfunction was associated with higher postoperative mortality (OR 7.71, 95% CI 1.76-33.69). Other factors associated with mortality and longer postoperative LOS were prematurity (OR 5.30, 95% CI 1.24-22.47 and OR 5.50, 95% CI 2.07-14.59, respectively) and lower weight at surgery (OR 0.17, 95% CI 0.04-0.75 and OR 0.55, 95% CI 0.35-0.85, respectively). Notably, preoperative atrioventricular valve regurgitation and Down syndrome were not associated with surgical timing, postoperative outcomes or reoperation, and there were no echocardiographic characteristics associated with late reoperation beyond 1 year after repair. Key preoperative echocardiographic parameters helped predict operative timing and postoperative outcomes in infants undergoing primary CAVC repair. Aortic isthmus z score < - 2 was associated with early surgical repair and need for reoperation, while preoperative ventricular dysfunction was associated with increased mortality. These echocardiographic findings may help risk-stratified patients undergoing CAVC repair and improve preoperative counseling and surgical planning.
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46
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Atik E, Barreto AC, Binotto MA. Case 2 / 2019 - Complete Atrioventricular Septal Defect, with Down Syndrome, without Pulmonary Hypertension and Natural History at 33 Years of Age. Arq Bras Cardiol 2019; 112:319-320. [PMID: 30916196 PMCID: PMC6424048 DOI: 10.5935/abc.20190024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Edmar Atik
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Alessandra Costa Barreto
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Maria Angélica Binotto
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
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Schleiger A, Miera O, Peters B, Schmitt KRL, Kramer P, Buracionok J, Murin P, Cho MY, Photiadis J, Berger F, Ovroutski S. Long-term results after surgical repair of atrioventricular septal defect. Interact Cardiovasc Thorac Surg 2018; 28:789-796. [DOI: 10.1093/icvts/ivy334] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/31/2018] [Accepted: 11/07/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Björn Peters
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Katharina R L Schmitt
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Jelena Buracionok
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Peter Murin
- Department of Congenital Heart Surgery/Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery/Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery/Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- German Center of Cardiovascular Research, Partner Site, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
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Lehner A, Herrmann FE, Mehilli J, Haas NA. Edwards Sapien 3 transcatheter aortic valve implantation for management of severe aortic regurgitation in a teenage patient with corrected atrioventricular septal defect and progressive left ventricular dysfunction. Catheter Cardiovasc Interv 2018; 93:E244-E247. [DOI: 10.1002/ccd.27975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/02/2018] [Accepted: 10/19/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Anja Lehner
- Department of Pediatric Cardiology and Intensive CareMunich University Hospital, Ludwig Maximilians University Munich Germany
| | - Florian E. Herrmann
- Department of Cardiac SurgeryMunich University Hospital, Ludwig Maximilians University Munich Germany
| | - Julinda Mehilli
- DZHK (Center for Cardiovascular Research), Partner Site Munich Heart AllianceMunich University Hospital, Ludwig Maximilians University Munich Germany
- Department of CardiologyMunich University Hospital, Ludwig Maximilians University Munich Germany
| | - Nikolaus A. Haas
- Department of Pediatric Cardiology and Intensive CareMunich University Hospital, Ludwig Maximilians University Munich Germany
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49
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Long-term outcomes in patients who underwent surgical correction for atrioventricular septal defect. Anatol J Cardiol 2018; 20:229-234. [PMID: 30297581 PMCID: PMC6249524 DOI: 10.14744/anatoljcardiol.2018.39660] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: The follow-up results of patients operated for atrioventricular septal defect (AVSD) during 1996–2016 at Başkent University are presented. Methods: Data obtained from hospital records consists of preoperative echocardiographic and angiographic details, age and weight at surgery, operative details, Down syndrome presence, postoperative care details, early postoperative and latest echocardiographic findings and hospitalization for reintervention. Results: A total of 496 patient-files were reviewed including 314 patients (63.4%) with complete and 181 (36.6%) with partial AVSD (48.4% of all patients had Down syndrome). Atrioventricular (AV) valve morphology was Rastelli type A in 92.2%, B in 6.5%, and C in 1.3% of patients. The operative technique used was single-patch in 21.6% (108), double-patch in 25.8% (128), and modified single-patch (Wilcox) in 52.5% (260) of patients. The follow-up time was 37.79±46.70 (range, 0–198) months. A total of 64 patients (12.9%) had arrhythmias while in the intensive care unit; pacemaker was implanted in 12 patients. A total of 78 patients (15.7%) were treated for pulmonary hypertensive crisis. The early morbidity and mortality in the postoperative first month were calculated as 38% and 10%, and the late morbidity and mortality (>1 month) were calculated as 13.1% and 1.9%, respectively. The rate of reoperation in our cohort was 8.9%. Conclusion: Although the early morbidity and mortality are low in AVSD operations, the rate of reoperations for left AV valve insufficiency are still high. Although Down syndrome is not a risk factor for early mortality, the co-morbid factors, such as longer postoperative mechanical ventilator or inotropic support, lead to higher risk for morbidity. The frequency of pulmonary hypertension and consequent complications are also high.
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50
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Mery CM, Zea-Vera R, Chacon-Portillo MA, Zhu H, Kyle WB, Adachi I, Heinle JS, Fraser CD. Contemporary Outcomes After Repair of Isolated and Complex Complete Atrioventricular Septal Defect. Ann Thorac Surg 2018; 106:1429-1437. [PMID: 30009807 DOI: 10.1016/j.athoracsur.2018.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Contemporary outcomes of complete atrioventricular septal defect (CAVSD) repair, particularly for defects with associated abnormalities, is unclear. The goal of this study is to report an all-inclusive experience of CAVSD repair using a consistent surgical approach. METHODS All patients undergoing CAVSD repair between 1995 and 2016 at our institution were included. Patients were divided into 2 groups: isolated and complex (tetralogy of Fallot, aortic arch repair, double outlet right ventricle, and total anomalous pulmonary venous return). Survival and reoperation were analyzed using log-rank test and Gray's test, respectively. Multivariable analysis was performed with Cox regression. RESULTS Overall, 406 patients underwent repair: 350 (86%) isolated and 56 (14%) complex CAVSD (tetralogy of Fallot: 34, double outlet right ventricle: 7, aortic arch repair: 12, total anomalous pulmonary venous return: 3). Median age at repair was 5 months (range, 10 days to 16 years); 339 (84%) had trisomy 21. A 2-patch repair was used in 395 (97%) and the zone of apposition was completely closed in 305 (75%). Perioperative mortality was 2% and 4% in the isolated and complex groups, respectively. Perioperative mortality since 2006 was 0.9%. Median follow-up was 7 years. Overall 10-year survival and incidence of any reoperation were 92% and 11%, respectively. Complex anatomy was not a risk factor for mortality (p = 0.35), but it was for reoperation (hazard ratio [HR]: 2.6; p < 0.01). Risk factors for left atrioventricular valve reoperation were a second bypass run (HR: 2.7) and preoperative moderate or worse regurgitation (HR: 2.3). CONCLUSIONS Mortality after CAVSD repair is low, yet reoperation remains a significant problem. Repair of complex CAVSD can be performed with similar mortality rates.
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Affiliation(s)
- Carlos M Mery
- Division of Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas.
| | - Rodrigo Zea-Vera
- Division of Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Martin A Chacon-Portillo
- Division of Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Huirong Zhu
- Outcomes and Impact Service, Texas Children's Hospital, Houston, Texas
| | - William B Kyle
- Division of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Charles D Fraser
- Division of Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
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