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Majani N, Sharau G, Mlawi V, Kalezi Z, Mongella S, Letara N, Nkya D, Kubhoja S, Chillo P, Slieker M, Janabi M, Grobbee D, Kisenge P. Early surgical outcome for Tetralogy Of Fallot In An African Setting; A Tanzanian experience using retrospective analysis of hospital data. BMC Cardiovasc Disord 2024; 24:493. [PMID: 39277731 PMCID: PMC11401386 DOI: 10.1186/s12872-024-04183-5] [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: 05/15/2024] [Accepted: 09/10/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND Tetralogy of Fallot (TOF) is typically treated in infancy but often done late in many resource-limited countries, jeopardizing surgical outcomes. This study examined the early results of children undergoing primary complete TOF repair at the Jakaya Kikwete Cardiac Institute (JKCI) in Tanzania, an emerging cardiac center in Eastern Africa. METHODS A retrospective cohort study of children ≤ 18 years undergoing primary TOF complete repair between 2019 and 2021 was conducted. Patients with complex TOF and those with obvious genetic syndrome were excluded. Data on socio-demography, pre-and postoperative cardiac complications, Intensive Care Unit (ICU) and hospital stay, and in-hospital and 30-day mortality were analyzed. Logistic regressions were employed to find the factors for mortality, ICU, and hospital stays. RESULTS The I02 children underwent primary TOF complete repair were majority male (65.7%; n = 67), with a median age of 3.0 years (IQR: 2-6), ranging from 3 months to 17 years.Only 20 patients (19.6%) were below one year of age. Almost all (90%; n = 92) were underweight, with a mean BMI of 14.6 + 3.1 kg/m2 Haematocrits were high, with a median of 48.7 (IQR: 37.4-59.0). The median oxygen saturation was 81% (IQR:72-93). Over a third of patients (38.2%; n = 39) needed Trans annular patch (TAP) during surgery. The median ICU stay was 72 h (IQR:48-120), with ICU duration exceeding three days for most patients. The median hospital stay was 8.5 days (IQR:7-11), with 70 patients (68.2%)experiencing an extended hospital stay of > 7 days. Bacterial sepsis was more common than surgical site infection (5.6%; n = 6 vs. 0.9%;n = 1). No patient needed re-operation for the period of follow up. The in-hospital mortality rate was 5.9%, with no deaths occurring in children less than one year of age nor after discharge during the 30-day follow-up period. No statistically significant differences were observed in outcomes in relation to age, sex, levels of hematocrit and saturations, presence of medical illnesses, and placement of TAP. CONCLUSION TOF repairs in this African setting at a national cardiac referral hospital face challenges associated with patients' older age and compromised nutritional status during the surgery. Perioperative mortality rates and morbidity for patients operated at an older age remain elevated. It's important to address these issues to improve outcomes in these settings.
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Affiliation(s)
- Naizihijwa Majani
- Department of Pediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania.
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands.
| | - Godwin Sharau
- Department of Pediatric Cardiac Surgery, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Vivienne Mlawi
- Department of Pediatric Cardiac Surgery, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Zawadi Kalezi
- Department of Pediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Stella Mongella
- Department of Pediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Nuru Letara
- Department of Pediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Deogratias Nkya
- Department of Pediatrics, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Sulende Kubhoja
- Department of Pediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Pilly Chillo
- Faculty of Medicine, Department of Internal Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Martijn Slieker
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Mohamed Janabi
- Department of Adult Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
- Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Diederick Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands
| | - Peter Kisenge
- Department of Adult Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
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Kesumarini D, Widyastuti Y, Boom CE, Dinarti LK. Risk Factors Associated With Prolonged Mechanical Ventilation and Length of Stay After Repair of Tetralogy of Fallot. World J Pediatr Congenit Heart Surg 2024; 15:81-88. [PMID: 37769605 DOI: 10.1177/21501351231191456] [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] [Indexed: 10/03/2023]
Abstract
BACKGROUND This study examined preoperative, intraoperative, and postoperative data to identify factors that are associated with prolonged mechanical ventilation (PMV) and prolonged intensive care unit length of stay (ICU LOS) in tetralogy of Fallot (TOF) patients undergoing repair surgery. METHODS A retrospective study was carried out after approval from the institutional review board. All patients (age 0-52 years) who underwent TOF repair from January 2016 to September 2022 were included. Prolonged mechanical ventilation was defined as >24 h of ventilation, while prolonged ICU LOS was defined as ICU stay >3 days. RESULTS A total of 922 patients were included, among whom 288 (31.2%) were intubated for >24 h and 222 (24.1%) stayed in ICU for >3 days. Younger age (odds ratio [OR] = 2, 95% confidence interval [CI] 1.2-3.3, P = .007), lower weight (OR = 2.1, 95% CI 1.2-3.5, P = .003), and residual lesion (OR = 3.27, 95% CI 1.2-8.7, P = .017) were associated with PMV. Moreover, independent risk factors for prolonged ICU LOS are similar to PMV risk factors, including younger age (OR = 2.3, 95% CI 1.28-4.12, P = .005), lower weight (OR = 2.83, 95% CI 1.58-5, P < .001), underweight status (OR = 1.7, 95% CI 1.12-2.57, P = .012), and residual lesion (OR = 3.79, 95% CI 1.43-10.05, P = .007). Both aortic cross-clamp and cardiopulmonary bypass times did not exhibit clinically significant risk factors toward PMV and prolonged ICU LOS. CONCLUSIONS The risk factors for PMV and prolonged ICU LOS were residual lesion, younger age, and lower weight. Nutritional status contributed to the risk of prolonged ICU LOS, but not PMV. Consideration of these factors may provide optimal care to improve the outcome following TOF corrective surgery.
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Affiliation(s)
- Dian Kesumarini
- Department of Anesthesia and Intensive Therapy, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
- Doctoral Programme, Faculty of Medicine and Public Health University of Gadjah Mada, Yogyakarta, Indonesia
| | - Yunita Widyastuti
- Department of Anesthesia and Intensive Therapy, Universitas Gadjah Mada/Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Cindy Elfira Boom
- Department of Anesthesia and Intensive Therapy, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Lucia Kris Dinarti
- Department of Cardiology and Vascular Medicine, Universitas Gadjah Mada/Dr Sardjito Hospital, Yogyakarta, Indonesia
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Adesanya AM, Best KE, Coats L, Rankin J. Predictors of Post-Operative Hospital Length of Stay Following Complete Repair of Tetralogy of Fallot in a Pediatric Cohort in the North of England. Pediatr Cardiol 2024; 45:92-99. [PMID: 37698700 PMCID: PMC10776676 DOI: 10.1007/s00246-023-03287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/25/2023] [Indexed: 09/13/2023]
Abstract
We sought to estimate the median post-operative length of stay (PLOS) and predictors of PLOS following tetralogy of Fallot (ToF) repair at a specialist surgical center in the North of England. The local National Congenital Heart Disease Audit dataset was used to identify patients aged < 2 years who underwent surgical repair for ToF between 1 January 1986 and 13 May 2022. Coefficients representing the median change in PLOS (days) according to predictors were estimated using Quantile regression. There were 224 patients (59.4% male, median age = 9 months, interquartile range (IQR) 5-13 months) with a median PLOS of 9 days (IQR 7-13). In the univariable regression, age (months) and weight (kg) at operation (β = - 0.17, 95% CI: - 0.33, - 0.01) and (β = - 0.53, 95% CI: - 0.97, - 0.10), previous (cardiac or thoracic) procedure (β = 5, 95% CI:2.38, 7.62), procedure urgency (elective vs urgent) (β = 2.8, 95% CI:0.39, 5.21), bypass time (mins) (β = 0.03, 95% CI:0.01, 0.05), cross-clamp time (mins) (β = 0.03, 95% CI:0.01, 0.06) and duration of post-operative intubation (days) (β = 0.81, 95% CI:0.67, 0.96), were significantly associated with PLOS. Previous procedure and intubation time remained significant in multivariable analyses. Some patient and operative factors can predict PLOS following complete ToF repair. Information on PLOS is important for health professionals to support parents in preparing for their child's discharge and to make any necessary practical arrangements. Health commissioners can draw on evidence-based guidance for resource planning. The small sample size may have reduced the power to detect small effect sizes, but this regional study serves as a foundation for a larger national study.
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Affiliation(s)
- Adenike M Adesanya
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle Upon Tyne, NE2 4AX, UK.
| | - Kate E Best
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Louise Coats
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle Upon Tyne, NE2 4AX, UK
- Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Judith Rankin
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle Upon Tyne, NE2 4AX, UK
- NIHR Applied Research Collaboration North East and North Cumbria, Newcastle Upon Tyne, UK
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Pinheiro PDS, Azevedo VMP, Rocha G. Predicting Factors of Surgical Mortality in Children and Adolescents Undergoing Correction of Tetralogy of Fallot. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20200394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Ho PSY, Quigley MA, Tucker DF, Kurinczuk JJ. Risk factors for hospitalisation in Welsh infants with a congenital anomaly. BMJ Paediatr Open 2022; 6:e001238. [PMID: 36053619 PMCID: PMC8845320 DOI: 10.1136/bmjpo-2021-001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate risk factor associated with hospitalisation of infants with a congenital anomaly in Wales, UK. DESIGN A population-based cohort study. SETTING Data from the Welsh Congenital Anomaly Register and Information Service linked to the Patient Episode Database for Wales and livebirths and deaths from the Office for National Statistics. PATIENTS All livebirths between 1999 and 2015 with a diagnosis of a congenital anomaly, which was defined as a structural, metabolic, endocrine or genetic defect, as well as rare diseases of hereditary origin. MAIN OUTCOME MEASURES Adjusted OR (aOR) associated with 1 or 2+ hospital admissions in infancy versus no admissions were estimated for sociodemographic, maternal and infant factors using multinomial logistic regression for the subgroups of all, isolated, multiple and cardiovascular anomalies. RESULTS 25 523 infants affected by congenital anomalies experienced a total of 50 705 admissions in infancy. Risk factors for ≥2 admissions were younger maternal age ≤24 years (aOR: 1.17; 95% CI 1.06 to 1.30), maternal smoking (aOR: 1.20; 1.10 to 1.31), preterm birth (aOR: 2.52; 2.25 to 2.83) and moderately severe congenital heart defects (aOR: 6.25; 4.47 to 8.74). Girls had an overall decreased risk of 2+ admissions (aOR: 0.84; 0.78 to 0.91). Preterm birth was a significant risk factor for admissions in all anomaly subgroups but the effect of the other characteristics varied according to anomaly subgroup. CONCLUSIONS Over two-thirds of infants with an anomaly are admitted to hospital during infancy. Our findings identified sociodemographic and clinical characteristics contributing to an increased risk of hospitalisation of infants with congenital anomalies.
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Affiliation(s)
- Peter S Y Ho
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Maria A Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Policy Research Unit- Maternal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David F Tucker
- Public Health Wales, Public Health Knowledge & Research, Congenital Anomaly Register & Information Service for Wales, Public Health Wales, Swansea, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Policy Research Unit- Maternal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Ahmed A, Prodhan P, Spray BJ, Bolin EH. Impact of Perioperative Tachydysrhythmias on Mortality and Length of Stay in Complete Repair of Tetralogy of Fallot: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System. Cardiology 2021; 146:368-374. [PMID: 33735878 DOI: 10.1159/000512777] [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] [Received: 05/12/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Tachydysrhythmias (TDS) frequently occur after complete repair of tetralogy of Fallot (TOF). However, not much is known about the effect of TDS on morbidity and mortality after TOF repair. We sought to assess the associations between TDS and mortality and morbidity after repair of TOF using a multicentre database. MATERIALS AND METHODS We identified all children aged 0-5 years in the Pediatric Health Information System who underwent TOF repair between 2004 and 2015. Codes for TDS were used to identify cases. Outcome variables were inpatient mortality and total length of stay (LOS). Univariate and multiple logistic and linear regression analyses were used to identify the effects of multiple risk factors, including TDS, on mortality and LOS. RESULTS A total of 7,749 patients met inclusion criteria, of which 1,493 (19%) had codes for TDS. There was no association between TDS and inpatient mortality. However, TDS were associated with 1.1 days longer LOS and accounted for 2% of the variation observed in LOS. CONCLUSION After complete repair of TOF, TDS were not associated with mortality and appeared to have only a modest effect on LOS.
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Affiliation(s)
- Aziez Ahmed
- Children's Heart Center, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, Connecticut, USA,
| | - Parthak Prodhan
- Department of Pediatrics, Section of Pediatric Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
| | - Beverly J Spray
- Biostatistics Core, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
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Wolter A, Gebert M, Enzensberger C, Kawecki A, Stessig R, Degenhardt J, Ritgen J, Thul J, Khalil M, Herrmann J, Axt-Fliedner R. Outcome and Associated Findings in Individuals with Pre- and Postnatal Diagnosis of Tetralogy of Fallot (TOF) and Prediction of Early Postnatal Intervention. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:504-513. [PMID: 30453353 DOI: 10.1055/a-0753-0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE The aim of our retrospective evaluation was to compare the outcome of patients with prenatal and postnatal diagnosis of Tetralogy of Fallot (TOF) and to analyze prenatal echocardiographic parameters predicting intervention within 30 days postnatal. MATERIALS AND METHODS We evaluated 142 patients in our pediatric heart center and prenatal diagnosis center and prenatal practice Praenatal plus in Cologne between 01/08-06/16. RESULTS Within the prenatal diagnosis group, 6/74 fetuses (8.1 %) had TOF with pulmonary atresia (TOF-PA), and 6 (8.1 %) had absent pulmonary valve syndrome (TOF-APVS). 14 (18.9 %) had an abnormal karyotype including 9/14 (64.3 %) with microdeletion 22q11.2. 25 (33.8 %) had extracardiac malformation. 4 (5.4 %) had agenesis of ductus arteriosus (DA), 22 (29.7 %) had right aortic arch (RAA) and 9 (12.2 %) had major aortopulmonary collateral arteries (MAPCAs). Within the postnatal diagnosis group, no patient had TOF-PA, 4/68 (5.9 %) had TOF-APVS. 12 (17.6 %) had extracardiac malformations, 9 (13.2 %) had an abnormal karyotype including 2/9 with microdeletion 22q11.2. 10 (14.7 %) had RAA, 9 (13.2 %) had MAPCAs. There were no cases with agenesis of DA. Increasing z-score values of the left/right pulmonary artery (LPA/RPA) prenatally were associated with a lower probability for early postnatal intervention (RPA: p = 0.017; LPA: p = 0.013). Within the prenatal diagnosis group, 12 of 41 (29.3 %) live-born patients with follow-up and intention to treat needed early intervention versus 7 (10.3 %) in the postnatal diagnosis group (p = 0.02). Within the postnatal diagnosis group, there were no deaths, while 2 (4.9 %) post-intervention deaths occurred in the prenatal diagnosis group. CONCLUSION There are no significant differences concerning post-intervention survival in the prenatal diagnosis group versus the postnatal diagnosis group. Complex cases may be underrepresented in the postnatal diagnosis group. Smaller RPA/LPA values prenatally seem to be associated with early postnatal intervention.
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Affiliation(s)
- Aline Wolter
- Department of OB&GYN, Justus-Liebig-University and UKGM, Division of Prenatal Medicine, Giessen, Germany
| | - Marie Gebert
- Department of OB&GYN, Justus-Liebig-University and UKGM, Division of Prenatal Medicine, Giessen, Germany
| | - Christian Enzensberger
- Department of OB&GYN, Justus-Liebig-University and UKGM, Division of Prenatal Medicine, Giessen, Germany
| | - Andrea Kawecki
- Department of OB&GYN, Justus-Liebig-University and UKGM, Division of Prenatal Medicine, Giessen, Germany
| | | | | | | | - Josef Thul
- Department of Paediatric Cardiology, Justus-Liebig-University and UKGM, Giessen, Germany
| | - Markus Khalil
- Department of Paediatric Cardiology, Justus-Liebig-University and UKGM, Giessen, Germany
| | | | - Roland Axt-Fliedner
- Department of OB&GYN, Justus-Liebig-University and UKGM, Division of Prenatal Medicine, Giessen, Germany
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Awori MN, Awori JA, Mehta NP, Makori O. Monocusp Valves Do Not Improve Early Operative Mortality in Tetralogy of Fallot: A Meta-Analysis. World J Pediatr Congenit Heart Surg 2020; 11:619-624. [PMID: 32853082 DOI: 10.1177/2150135120934763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Monocusp valves are thought to reduce early operative mortality and morbidity associated with pediatric tetralogy of Fallot repair. As there are no published randomized clinical trials comparing outcomes with and without a monocusp valve, we performed a meta-analysis of observational studies in accordance with established protocols. After systematically searching PubMed, the Cochrane Library, and Google Scholar, 12 studies were included. The operative mortality was compared in 695 patients, and we found no difference between patients with and patients without a monocusp valve. Monocusp valves may not improve operative mortality of tetralogy of Fallot repair in pediatric patients.
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Affiliation(s)
- Mark N Awori
- Department of Surgery, School of Medicine, 108330University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Jonathan A Awori
- Department of Pediatrics, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Nikita P Mehta
- Department of Surgery, School of Medicine, 108330University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Obed Makori
- Department of Surgery, School of Medicine, 108330University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
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Predictors of a complicated course after surgical repair of tetralogy of Fallot. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:264-273. [PMID: 32551156 DOI: 10.5606/tgkdc.dergisi.2020.18829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/12/2020] [Indexed: 11/21/2022]
Abstract
Background In this study, we aimed to evaluate the patient and surgical factors affecting prolonged hospital stay and major adverse events after surgical repair of tetralogy of Fallot and to identify the predictors of a complicated course after surgical repair. Methods A total of 170 consecutive patients (96 males, 74 females; median age 12 months; range, 1 to 192 months) who underwent surgical repair of tetralogy of Fallot between January 2015 and April 2018 were retrospectively reviewed. A mechanical ventilation duration of >24 h, an intensive care unit stay of >3 days, and a hospital stay of >7 days were considered as prolonged. Unplanned reoperation, complete heart block requiring a permanent pacemaker implantation, renal failure, diaphragmatic paralysis, neurological deficit, sudden circulatory arrest, need for extracorporeal membrane oxygenation, and death were considered as major adverse events. Results The median time to hospital discharge was 8.0 (range, 5.0 to 40.0) days. Higher preoperative hematocrit levels prolonged the length of hospital stay (odds ratio: 1.12, 95% confidence interval 1.1-1.2, p<0.001). A total of 28 major adverse events were observed in 17 patients (10%). Lower pulmonary artery annulus Z-score (odds ratio: 0.5, 95% confidence interval 0.3-0.9, p=0.01) and residual ventricular septal defects (odds ratio: 54.6, 95% confidence interval 1.6-1,874.2, p=0.03) were found to increase mortality. Residual ventricular septal defect was also a risk factor for major adverse events (odds ratio: 12.4, 95% confidence interval 1.5-99.9, p=0.02). Conclusion Preoperative and operative factors such as high preoperative hematocrit, low preoperative oxygen saturation, low pulmonary annulus Z-score, Down syndrome, residual ventricular septal defects, and the use transannular patch were found to be associated with prolonged length of hospital stay, prolonged mechanical ventilation, prolonged intensive care unit stay, and increased development of major adverse events.
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RACHS-1 score as predictive factor for postoperative ventilation time in children with congenital heart disease. Cardiol Young 2020; 30:213-218. [PMID: 31948508 DOI: 10.1017/s1047951120000025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Congenital heart disease is the most frequent malformation in newborns. The postoperative mortality of these patients can be assessed with the Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) score. This study evaluates whether the RACHS-1 score can also be used as a predictor for the length of postoperative ventilation and what is the influence of age. MATERIAL AND METHODS In a retrospective study over the period from 2007 to 2013, all patient records were evaluated: 598 children with congenital heart disease and cardiac surgery were identified and 39 patients have been excluded because of additional comorbidities. For evaluation of mortality, 559 patients could be analysed, after exclusion of 39 deceased patients, 520 cases remained for analysis of postoperative ventilation. RESULTS Overall mortality was 7% with a dependency on RACHS-1 categories. The median length of postoperative ventilation rose according to the RACHS-1 categories: RACHS-1 category 1: 9 hours (interquartile range (IQR) 7-13 hours), category 2: 30 hours (IQR 12-85 hours), category 4: 58 hours (IQR 13-135 hours), category 4: 71 hours (IQR 29-165 hours), and category 6: 189 hours (IQR 127-277 hours). Some of the RACHS-1 subgroups differed significantly from the categories, especially the repair of tetralogy of Fallot with a longer ventilation time and strong variability. Younger age was an independent factor for longer postoperative ventilation. CONCLUSION RACHS-1 is a good predictor for the length of postoperative ventilation after cardiac surgery with the exception of some subgroups. Younger age is another independent factor for longer postoperative ventilation. These data provide better insight into ventilation times and allow better planning of operations in terms of available intensive care beds.
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Romeo JL, Etnel JR, Takkenberg JJ, Roos-Hesselink JW, Helbing WA, van de Woestijne P, Bogers AJ, Mokhles MM. Outcome after surgical repair of tetralogy of Fallot: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020. [DOI: 10.1016/j.jtcvs.2019.08.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Bailey J, Elci OU, Mascio CE, Mercer-Rosa L, Goldmuntz E. Staged Versus Complete Repair in the Symptomatic Neonate With Tetralogy of Fallot. Ann Thorac Surg 2019; 109:802-808. [PMID: 31783017 DOI: 10.1016/j.athoracsur.2019.10.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/08/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The optimal management of tetralogy of Fallot (TOF) in symptomatic neonates remains unknown. We compared outcomes for those undergoing palliation vs complete repair in the neonatal period. METHODS In a retrospective cohort study of symptomatic neonates with TOF who had a neonatal complete repair (group 1, n = 112) or staged repair (group 2, n = 26) from 2000 to 2013, we compared outcomes at 4 time points: neonatal complete repair vs palliation (group 1 vs 2A), neonatal vs later complete repair (group 1 vs 2B), the single vs combined admissions to achieve a complete repair (group 1 vs group 2A + 2B), and cumulative events 2 years after complete repair for both groups. RESULTS Demographics, anatomy, comorbidities, surgical approach, and mortality were similar between groups 1 and 2. Group 1 had a longer duration of cardiopulmonary bypass and deep hypothermic circulatory arrest and more postprocedure cardiac events compared with group 2A; a longer duration of intubation, intensive care, and postprocedure hospital stay compared with groups 2A and 2B; and a longer total hospital stay compared with group 2B. With combined admissions for group 2, there was no difference in the total duration of intensive care, total hospital stay, or reinterventions compared with group 1. CONCLUSIONS Both management options result in similar survival; however, early morbidity was greater with neonatal complete repair. The impact of increased neonatal exposures, such as cardiopulmonary bypass, deep hypothermic circulatory arrest, and intensive care, on neurocognitive development requires further study but should be considered when choosing an optimal strategy.
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Affiliation(s)
- Jennifer Bailey
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Okan U Elci
- Biostatistics and Data Management Core-Westat, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Congenital Heart Surgical Admissions in Patients with Trisomy 13 and 18: Frequency, Morbidity, and Mortality. Pediatr Cardiol 2019; 40:595-601. [PMID: 30556105 DOI: 10.1007/s00246-018-2032-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/11/2018] [Indexed: 10/27/2022]
Abstract
Congenital heart defects are common among patients with trisomy 13 and 18; surgical repair has been controversial and rarely studied. We aimed to assess the frequency of cardiac surgery among admissions with trisomy 13 and 18, and evaluate their associations with resource use, complications, and mortality compared to admissions without these diagnoses. We evaluated congenital heart surgery admissions of ages < 18 years in the 1997, 2000, 2003, 2006, and 2009 Kids' Inpatient Database. Bivariate and multivariate analyses examined the adjusted association of trisomy 13 and 18 on resource use, complications, and inpatient death following congenital heart surgery. Among the 73,107 congenital heart surgery admissions, trisomy 13 represented 0.03% (n = 22) and trisomy 18 represented 0.08% (n = 58). Trisomy 13 and 18 admissions were longer; trisomy 13: 27 days vs. 8 days, p = 0.003; trisomy 18: 16 days vs. 8 days, p = 0.001. Hospital charges were higher for trisomy 13 and 18 admissions; trisomy 13: $160,890 vs. $87,007, p = 0.010; trisomy 18: $160,616 vs. $86,999, p < 0.001. Trisomy 18 had a higher complication rate: 52% vs. 34%, p < 0.006. For all cardiac surgery admissions, mortality was 4.5%; trisomy 13: 14% and trisomy 18: 12%. In multivariate analysis, trisomy 18 was an independent predictor of death: OR 4.16, 95% CI 1.35-12.82, p = 0.013. Patients with trisomy 13 and 18 represent 0.11% of pediatric congenital heart surgery admissions. These patients have a 2- to 3.4-fold longer hospital stay and double hospital charges. Patients with trisomy 18 have more complications and four times greater adjusted odds for inpatient death.
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14
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Martins IF, Doles IC, Bravo-Valenzuela NJM, Santos AORD, Varella MSP. When is the Best Time for Corrective Surgery in Patients with Tetralogy of Fallot between 0 and 12 Months of Age? Braz J Cardiovasc Surg 2019; 33:505-510. [PMID: 30517260 PMCID: PMC6257527 DOI: 10.21470/1678-9741-2018-0019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 02/05/2018] [Indexed: 11/23/2022] Open
Abstract
Objective To identify the best time for corrective surgery of tetralogy of Fallot (TF)
in children aged 0-12 months and to report the most frequent complications
during the first 3 years postoperatively. Methods Systematic review of studies published between 2000 and 2017 on corrective
surgery for TF. Articles were selected through search of electronic
databases (PubMed, SciELO, Scopus, Lilacs, Google Scholar, and Cochrane).
Length of stay in intensive care unit, duration of mechanical ventilation,
and peri/postoperative complications were analyzed for data discussion and
research interpretation. Conclusion Definitive corrective surgery is the best alternative, and the earlier it is
performed, the lower the occurrence of harmful effects and the greater the
chances of cardiorespiratory recovery. This systematic review suggests that
the best time to perform definitive corrective surgery for TF in the first
year of life is during 3-6 months of age in children with no or mild
symptoms. Children with severe symptoms should undergo surgery
immediately.
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Affiliation(s)
| | - Iara C Doles
- Universidade de Taubaté (UNITAU), Taubaté, SP, Brazil
| | - Nathalie J M Bravo-Valenzuela
- Universidade de Taubaté (UNITAU), Taubaté, SP, Brazil.,Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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15
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Postoperative feeding problems in patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals undergoing unifocalisation surgery. Cardiol Young 2018; 28:1329-1332. [PMID: 30070195 DOI: 10.1017/s1047951118001270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals are at risk for prolonged hospitalisation after unifocalisation. Feeding problems after congenital heart surgery are associated with longer hospital stay. We sought to determine the impact of baseline, intra-operative, and postoperative factors on the need for feeding tube use at the time of discharge. METHODS We included patients with the aforementioned diagnosis undergoing unifocalisation from ages 3 months to 4 years from 2010 to 2016. We excluded patients with a pre-existing feeding tube. Patients discharged with an enteric tube were included in the feeding tube group. We compared the feeding tube group with the non-feeding-tube group by univariable and multi-variable logistic regression. RESULTS Of the 56 patients studied, 41% used tube feeding. Median age and weight z-score were similar in the two groups. A chromosome 22q11 deletion was associated with the need for a feeding tube (22q11 deletion in 39% versus 15%, p=0.05). Median cardiopulmonary bypass time in the feeding tube group was longer (335 versus 244 minutes, p=0.04). Prolonged duration of mechanical ventilation was associated with feeding tube use (48 versus 3%, p=0.001). On multi-variable analysis, prolonged mechanical ventilation was associated with feeding tube use (odds ratio 10.2, 95% confidence intervals 1.6; 63.8). CONCLUSION Among patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals who were feeding by mouth before surgery, prolonged mechanical ventilation after unifocalisation surgery was associated with feeding tube use at discharge. Anticipation of feeding problems in this population and earlier feeding tube placement may reduce hospital length of stay.
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16
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Rothman A, Dosani K, Evans WN, Galindo A. Stenting of the ductus arteriosus originating from the innominate or left subclavian artery in patients with a right aortic arch. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Mercer-Rosa L, Elci OU, Pinto N, Tanel R, Goldmuntz E. 22q11.2 Deletion Status and Perioperative Outcomes for Tetralogy of Fallot with Pulmonary Atresia and Multiple Aortopulmonary Collateral Vessels. Pediatr Cardiol 2018. [PMID: 29520463 PMCID: PMC5959773 DOI: 10.1007/s00246-018-1840-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Deletion of 22q11.2 (del22q11) is associated with adverse outcomes in patients with tetralogy of Fallot (TOF). We sought to investigate its contribution to perioperative outcome in patients with a severe form of TOF characterized by pulmonary atresia (PA) or severe pulmonary stenosis (PS) and major aortopulmonary collateral arteries (MAPCAS). We conducted a retrospective review of patients with TOF/MAPCAS who underwent staged surgical reconstruction between 1995 and 2006. Groups were compared according to 22q11.2 deletion status using t-tests or the Wilcoxon Rank sum test. We included 26 subjects, 24 of whom survived the initial operation. Of those, 21 subjects had known deletion status and constitute the group for this analysis [15 with no deletion present (ND) and 6 del22q11 subjects]. There was no difference with respect to occurrence of palliative procedure prior to initial operation, or to timing of closure of the ventricular septal defect (VSD). Other than higher prevalence of prematurity (50%) in the del22q11 group versus no prematurity in the ND, the groups were comparable in terms of pre-operative characteristics. The intra- and post-operative course outcomes (length of cardiopulmonary bypass, use of vasopressors, duration of intensive care and length of hospital stay, tube-feeding) were also comparable. Although the del22q11 had longer mechanical ventilation than the ND, this difference was not significant [68 h (range 4-251) vs. 45 h (range 3-1005), p = 0.81]. In this detailed comparison of a small patient cohort, 22q11.2 deletion syndrome was not associated with adverse perioperative outcomes in patients with TOF, PA, and MAPCAS when compared to those without 22q11.2 deletion syndrome. These results are relevant to prenatal and neonatal pre-operative counseling and planning.
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Affiliation(s)
- Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, 34th and Civic Center Blvd, Suite 8NW35, Philadelphia, PA, 19104, USA.
| | - Okan U. Elci
- Division of Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Nelangi Pinto
- Westat-Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ronn Tanel
- Division of Pediatric Cardiology, UCSF Benioff Children’s Hospital, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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18
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Mercer-Rosa L, Elci OU, DeCost G, Woyciechowski S, Edman SM, Ravishankar C, Mascio CE, Kawut SM, Goldmuntz E. Predictors of Length of Hospital Stay After Complete Repair for Tetralogy of Fallot: A Prospective Cohort Study. J Am Heart Assoc 2018; 7:JAHA.118.008719. [PMID: 29769202 PMCID: PMC6015346 DOI: 10.1161/jaha.118.008719] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background We sought to identify patient and surgical factors associated with time to hospital discharge in patients undergoing complete repair for tetralogy of Fallot. Methods and Results We performed a prospective cohort study of patients with tetralogy of Fallot admitted for complete repair between May 1, 2012 and June 2, 2017 at Children's Hospital of Philadelphia with detailed demographic, clinical, and operative characteristics. The primary outcome was time to hospital discharge. Cox proportional hazards models were used to identify patient and operative predictors of time to hospital discharge. We enrolled 151 subjects, 62.8% male, 65.6% non‐Hispanic white, and 9.9% non‐Hispanic black. The median time to hospital discharge was 7 days (interquartile range 4, 12). Five patients died in the hospital, all of whom underwent tetralogy of Fallot repair beyond the neonatal period. Greater birth weight was associated with higher rate of hospital discharge (hazard ratio [HR]=1.35, 95% confidence interval (CI) =1.11, 1.64), while absent pulmonary valve versus pulmonary stenosis (HR=0.27, 95% CI=0.08, 0.91), pulmonary valve atresia versus pulmonary stenosis (HR=0.57, 95% CI=0.33, 0.97), presence of aortopulmonary collaterals (HR=0.44, 95% CI=0.24, 0.84), complete repair performed in the neonatal period (<30 days of life) (HR=0.45, 95% CI=0.27, 0.75), more than 1 cardiopulmonary bypass run (HR=0.33, 95% CI=0.18, 0.61), and longer aortic cross‐clamp time (HR [per 10 minutes]=0.88, 95% CI=0.79, 0.97) were associated with lower rate of hospital discharge. Conclusions Postoperative hospital stay after complete repair of tetralogy of Fallot is in part determined by patient and operative factors. Some (eg, surgical strategy for the symptomatic neonate) may be modifiable. These results may impact patient counseling, choice of surgical approach, and postoperative care.
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Affiliation(s)
- Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Okan U Elci
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, PA
| | - Grace DeCost
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stacy Woyciechowski
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sharon M Edman
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christopher E Mascio
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven M Kawut
- Department of Medicine and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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19
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Wang Q, Wang Z, Wu C, Pan Z, Xiang L, Liu H, Jin X, Tong K, Fan S, Jin X. Potential association of long noncoding RNA HA117 with tetralogy of Fallot. Genes Dis 2018; 5:185-190. [PMID: 30258948 PMCID: PMC6148707 DOI: 10.1016/j.gendis.2018.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/01/2018] [Indexed: 02/01/2023] Open
Abstract
Tetralogy of Fallot (TOF) is a congenital heart disease characterized by abnormal cardiomyocyte differentiation in the right ventricular outflow tract (RVOT), and HA117 is a novel long noncoding RNA (lncRNA) with anti-differentiation roles. To investigate the potential association of HA117 with TOF, we collected 84 RVOT tissues from patients with TOF. We determined the expression of HA117 in RVOT samples from TOF patients and collected clinical data to conduct a cross-sectional and short-term follow-up study. McGoon ratio, Nakata index, and left ventricular end-diastolic volume index (LVEDVI) were negatively correlated with the expression of HA117 based on subgroup analysis, correlation analysis and logistic regression analysis. Additionally, cardiopulmonary bypass (CPB) time and ICU stay were longer in patients with higher expression of HA117 than in patients with lower expression of HA117. Furthermore, percentage improvement in SPO2 was significantly reduced in patients with increased HA117 expression at 6 months after surgery. Our results suggested that the increased expression of the novel lncRNA HA117 is a risk factor for unfavorable McGoon ratio, Nakata index and LVEDVI in TOF patients. Additionally, an increased expression of HA117 might lead to adverse short-term outcomes in TOF patients.
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Affiliation(s)
- Quan Wang
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhili Wang
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chun Wu
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengxia Pan
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Xiang
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hang Liu
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xin Jin
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Kerong Tong
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Shulei Fan
- Renal Department and Nephrology Institute, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xianqing Jin
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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20
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas RA, Sinha P. Optimal Timing for Elective Early Primary Repair of Tetralogy of Fallot: Analysis of Intermediate Term Outcomes. Ann Thorac Surg 2016; 103:845-852. [PMID: 27692918 DOI: 10.1016/j.athoracsur.2016.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 06/14/2016] [Accepted: 07/05/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We have previously demonstrated that early primary repair of tetralogy of Fallot with pulmonary stenosis (TOF) can be safely performed without increase in hospital resource utilization or compromise to surgical technical performance scores (TPS). We sought to identify the optimal timing for elective early primary repair of TOF with respect to intermediate-term reintervention. METHODS Retrospective review of all patients with TOF undergoing elective primary repair between September 2004 and December 2013 was performed. Patients were stratified into reintervention group or no reintervention group. Multivariable Cox regression analysis identified independent predictors of reintervention. Youden's J-index in receiver operating characteristic analysis identified optimal age cutoff predictive of reintervention. Kaplan-Meier analysis with the log-rank test compared reintervention rates stratified by age and TPS. RESULTS A total of 129 patients with median (interquartile range) age and weight of 78 days (56 to 111) and 5 kg (4.1 to 5.7), respectively, underwent primary repair. After a median (interquartile range) follow-up of 2.3 years (0.1 to 4.6), 18 patients (14%) required a total of 22 reinterventions. Youden's J-index revealed significantly lower risk of intermediate-term reintervention when repaired after 55 days of age (8% for >55 days old versus 31% for ≤55 days of age). Multivariable Cox regression identified age 55 days and younger (hazard ratio [HR] 4.5, 95% confidence interval [CI] 1.6 to 12.8, p = 0.004), valve sparing repair (HR 15.3, 95% CI 1.8 to 128.5, p < 0.001), residual right ventricular outflow tract (RVOT) gradient (HR 1.11, 95% CI 1.1 to 1.2, p < 0.001), and inadequate TPS (HR 21.5, 95% CI 7.4 to 63, p < 0.001) as independent predictors of overall intermediate-term reintervention. CONCLUSIONS Elective repair in patients greater than 55 days of age, irrespective of size of the patient, can be safely performed without any increase in reintervention rates. Both residual peak RVOT gradient and TPS are effective in identifying patients at increased risk of reintervention.
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Affiliation(s)
- Michael E A Cunningham
- Department of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard A Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia.
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21
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas R, Sinha P. Influence of Age and Weight on Technical Repair of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:864-869. [PMID: 27154147 DOI: 10.1016/j.athoracsur.2016.02.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/21/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND We have previously shown that early primary repair of tetralogy of Fallot can be performed without increased morbidity or resource utilization. The technical performance score (TPS) is a self-assessment tool used to identify patients at risk of poor postoperative outcomes. We hypothesized that adequate technical repair can be obtained regardless of the patient's preoperative age or size. METHODS A retrospective review of all tetralogy of Fallot patients repaired between September 2004 and December 2013 was performed. The postoperative predischarge echocardiogram was reviewed to assign a TPS rating of optimal, adequate, or inadequate. The TPS groups were compared by univariate analysis using the Kruskal-Wallis test for continuous variables and χ(2) analysis for categoric variables. Multivariable logistic regression analysis was performed to identify independent predictors of inadequate TPS. RESULTS Among 167 patients (1 operative mortality), TPS was optimal in 88, adequate in 62, and inadequate in 17. Patients with worse TPS had longer ventilation time (p = 0.031), hospital length of stay (p = 0.036), and higher hospital charges (p = 0.005). Multivariable regression analysis revealed discontinuous branch pulmonary arteries (odds ratio 18.24, 95% confidence interval: 1.42 to 234, p = 0.015) as the only independent predictor of inadequate TPS. Younger age at repair (p = 0.245) and smaller weight (p = 0.260) were not associated with inadequate TPS. CONCLUSIONS Technical adequacy of tetralogy of Fallot repair is affected by anatomic subsets (discontinuous branch pulmonary arteries) and not by the patient's age or size. Worse TPS is associated with higher postoperative morbidity and hospital charges. Younger age and size should not be a deterrent for early primary repair.
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Affiliation(s)
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, DC
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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22
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Galicia-Tornell M, Reyes-López A, Ruíz-González S, Bolio-Cerdán A, González-Ojeda A, Fuentes-Orozco C. Tratamiento de la tetralogía de Fallot con parche transanular. Seguimiento a 6 años. CIR CIR 2015; 83:478-84. [DOI: 10.1016/j.circir.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 05/14/2015] [Indexed: 11/16/2022]
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23
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Patel JK, Glatz AC, Ghosh RM, Jones SM, Natarajan S, Ravishankar C, Mascio CE, Spray TL, Cohen MS. Intramural Ventricular Septal Defect Is a Distinct Clinical Entity Associated With Postoperative Morbidity in Children After Repair of Conotruncal Anomalies. Circulation 2015; 132:1387-94. [PMID: 26246174 DOI: 10.1161/circulationaha.115.017038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/30/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intramural ventricular septal defects (VSDs) are interventricular communications through right ventricular free wall trabeculations that can occur after repair of conotruncal anomalies. We assessed the prevalence of residual intramural VSDs and their effect on postoperative course. METHODS AND RESULTS Children who underwent biventricular repair of a conotruncal anomaly from January 1, 2006, to June 30, 2013, and had a postoperative transthoracic echocardiogram were included. Images were reviewed for residual intramural or nonintramural VSDs. The primary outcome was a composite of mortality, extracorporeal membrane oxygenation use, and need for subsequent catheter or surgical VSD closure. The secondary outcome was postoperative hospital length of stay. A residual VSD was present in 256 of the 442 subjects (58%), of which 231 (90%) were <2 mm in size. Forty-nine patients (11%) had intramural VSDs, and 207 (47%) had nonintramural VSDs. Patients with intramural VSDs were more likely to reach the primary composite outcome compared with those with nonintramural VSDs or no residual VSD (14 of 49 [29%] versus 15 of 207 [7%] versus 6 of 186 [3%]; P<0.0001). In addition, those with intramural VSDs had longer postoperative hospital length of stay compared with those with nonintramural VSDs or no residual VSD (20 days [interquartile range, 11-42 days] versus 7 days [interquartile range, 5-14 days] versus 6 days [interquartile range, 4-11 days]; P=0.0001). These associations remained significant after adjustment for known risk factors for poor outcomes, including residual VSD size and operative complexity. CONCLUSIONS Among residual VSDs after repair of conotruncal anomalies, intramural VSDs are uniquely associated with postoperative morbidity, mortality, and longer postoperative hospital length of stay. It is important to recognize intramural VSDs in the postoperative period.
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MESH Headings
- Cardiac Catheterization/statistics & numerical data
- Extracorporeal Membrane Oxygenation/statistics & numerical data
- Female
- Heart Defects, Congenital/surgery
- Heart Septal Defects, Ventricular/diagnostic imaging
- Heart Septal Defects, Ventricular/epidemiology
- Heart Septal Defects, Ventricular/etiology
- Heart Septal Defects, Ventricular/surgery
- Heart Septum/diagnostic imaging
- Humans
- Infant
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/surgery
- Length of Stay/statistics & numerical data
- Male
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/epidemiology
- Postoperative Complications/etiology
- Postoperative Complications/surgery
- Prevalence
- Reoperation/statistics & numerical data
- Risk Factors
- Treatment Outcome
- Truncus Arteriosus/abnormalities
- Truncus Arteriosus/surgery
- Ultrasonography
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Affiliation(s)
- Jyoti K Patel
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Andrew C Glatz
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Reena M Ghosh
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shannon M Jones
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shobha Natarajan
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chitra Ravishankar
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher E Mascio
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thomas L Spray
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Meryl S Cohen
- From Departments of Pediatrics (J.K.P., A.C.G., R.M.G., S.M.J., S.N., C.R., M.S.C.) and Surgery (C.E.M., T.L.S.), The Children's Hospital of Philadelphia, Philadelphia, PA
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Beg KA, Haq A, Amanullah M, Laique SN, Sadqani S, Aslam N, Rehmat AW, Hasan BS. Distinctive Hemodynamics in the Immediate Postoperative Period of Patients with a Longer Cardiac Intensive Care Stay Post-Tetralogy of Fallot Repair. CONGENIT HEART DIS 2015; 10:346-53. [PMID: 25864454 DOI: 10.1111/chd.12259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE After complete surgical repair the majority of tetralogy of Fallot (ToF), patients stay ≤2 days in the Cardiac Intensive Care Unit (CICU) while some may stay longer. We undertook this study to investigate the factors associated with shorter vs. longer length of stay in the CICU to help manage resources effectively. DESIGN Patients who underwent ToF repair at Aga Khan University, Pakistan, between July 2006 and December 2011 were studied in a case-control design. Clinical parameters were compared between short stay group (SSG) (≤2 days) and long stay group (LSG) (>2 days). Odds ratios were calculated, and regression was performed. RESULTS Ninety-eight patients (LSG 65, SSG 33) were included. Patients with lower preoperative saturation were 2.67 times more likely to be in the LSG group (P = .02). At 4 hours postoperatively, patients with a higher inotropic score (odds ratio [OR] = 3.03, confidence interval [CI] = 1.19-7.7, P = .02), higher central venous pressure (OR = 3.04, CI = 1.27-7.32, P = .013), and significant tachycardia at 4 hours (OR = 3.5, CI = 1.19-10.3. P = .02) were at risk for having a prolonged CICU stay. On multivariate analysis, significant postoperative tachycardia at 4 hours (z-score ≥3) was highly specific (sensitivity = 38.5%, specificity = 84.9%) for predicting the chances of being in the LSG. Other predictors included preop O(2) saturation ≤82.5% (sensitivity = 61.1%, specificity = 63.0%) and CVP ≥10 mm Hg at 4 hours (sensitivity = 55.4%, specificity = 71.9%). CONCLUSION Patients who end up staying longer in the CICU have features that are distinctive in the immediate postoperative period, and this can help clinicians in identifying patients who may need more support.
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Affiliation(s)
- Kisha A Beg
- Medical College, The Aga Khan University, Karachi, Pakistan
| | - Anwarul Haq
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Muneer Amanullah
- Section of Cardiothoracic Surgery, The Aga Khan University, Karachi, Pakistan
| | - Sobia N Laique
- Medical College, The Aga Khan University, Karachi, Pakistan
| | - Saleem Sadqani
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Nadeem Aslam
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Amina Wali Rehmat
- Cardiac Intensive Care Unit, The Aga Khan University, Karachi, Pakistan
| | - Babar S Hasan
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
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Early Primary Repair of Tetralogy of Fallot Does Not Lead to Increased Postoperative Resource Utilization. Ann Thorac Surg 2014; 98:2173-9; discussion 2179-80. [DOI: 10.1016/j.athoracsur.2014.07.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 06/24/2014] [Accepted: 07/23/2014] [Indexed: 11/20/2022]
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Li S, Zhang Y, Li S, Wang X, Zhang R, Lu Z, Yan J. Risk Factors Associated with Prolonged Mechanical Ventilation after Corrective Surgery for Tetralogy of Fallot. CONGENIT HEART DIS 2014; 10:254-62. [PMID: 25059746 DOI: 10.1111/chd.12205] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study examined early postoperative results to identify perioperative factors that are associated with prolonged mechanical ventilation (PMV) in tetralogy of Fallot (TOF) patients undergoing corrective surgery. METHODS We retrospectively examined the role of perioperative variables in determining the period of mechanical ventilatory support in TOF patients undergoing corrective surgery. A total of 821 patients were included in the study. The cohort was divided into a PMV group that included patients with >90th percentile for duration of mechanical ventilation and a non-PMV group which included all other patients. RESULTS Non-PMV group consisted of 751 patients (454 males, 297 females; median age 12 months, interquartile range 8-19 months; mean weight 9.60 ± 2.98 kg). PMV group consisted of 70 patients (51 males, 19 females; median age 8 months, interquartile range 6.75-13 months; mean weight 8.64 ± 1.95 kg). No patients died in the non-PMV group compared with two deaths due to acute respiratory distress syndrome in the PMV group. Univariate risk factors for PMV included age, weight, left ventricular end-diastolic volume index (LVEDVI), McGoon ratio, Nakata index, previous palliative operations, cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, preoperative major aortopulmonary collateral arteries (MAPCAs) occlusion by coils in hybrid procedure, postoperative right ventricular/left ventricular systolic pressure ratio, central venous pressure (CVP), left atrial pressure (LAP), endotracheal reintubation, vasoactive-inotropic score (VIS), renal replacement therapy, and early-onset ventilator-associated pneumonia (VAP). In a multivariable model, age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, blood returning to left atrium during surgery as a surrogate marker for significant aortopulmonary collateral presence, and early-onset VAP were the independent risk factors for PMV. CONCLUSIONS The risk factors for PMV were age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, VIS, LAP, blood returning to left atrium during surgery, and early-onset VAP.
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Affiliation(s)
- Shengli Li
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Yajuan Zhang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Shoujun Li
- Department of Cardiovascular Surgery, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xu Wang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Rongyuan Zhang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Zhongyuan Lu
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jun Yan
- Department of Cardiovascular Surgery, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
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Egbe AC, Nguyen K, Mittnacht AJ, Joashi U. Predictors of Intensive Care Unit Morbidity and Midterm Follow-up after Primary Repair of Tetralogy of Fallot. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:211-9. [PMID: 25207217 PMCID: PMC4157470 DOI: 10.5090/kjtcs.2014.47.3.211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 12/27/2013] [Accepted: 12/31/2013] [Indexed: 11/25/2022]
Abstract
Background Our objectives were to review our institutional early and midterm experience with primary tetralogy of Fallot (TOF) repair, and identify predictors of intensive care unit (ICU) morbidity. Methods We analyzed perioperative and midterm follow-up data for all cases of primary TOF repair from 2001 to 2012. The primary endpoint was early mortality and morbidity, and the secondary endpoint was survival and functional status at follow-up. Results Ninety-seven patients underwent primary repair. The median age was 4.9 months (range, 1 to 9 months), and the median weight was 5.3 kg (range, 3.1 to 9.8 kg). There was no early surgical mortality. The incidence of junctional ectopic tachycardia and persistent complete heart block was 2% and 1%, respectively. The median length of ICU stay was 6 days (range, 2 to 21 days), and the median duration of mechanical ventilation was 19 hours (range, 0 to 136 hours). By multiple regression analysis, age and weight were independent predictors of the length of ICU stay, while the surgical era was an independent predictor of the duration of mechanical ventilation. At the 8-year follow-up, freedom from death and re-intervention was 97% and 90%, respectively. Conclusion Primary TOF repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery remain significant predictors of morbidity.
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Affiliation(s)
- Alexander C Egbe
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, NY, USA
| | - Khanh Nguyen
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, NY, USA
| | | | - Umesh Joashi
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, NY, USA
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Bove T, Vandekerckhove K, Bouchez S, Wouters P, Somers P, Van Nooten G. Role of myocardial hypertrophy on acute and chronic right ventricular performance in relation to chronic volume overload in a porcine model: Relevance for the surgical management of tetralogy of Fallot. J Thorac Cardiovasc Surg 2014; 147:1956-65. [DOI: 10.1016/j.jtcvs.2013.10.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/03/2013] [Accepted: 10/11/2013] [Indexed: 11/27/2022]
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Egbe AC, Mittnacht AJ, Nguyen K, Joashi U. Risk factors for morbidity in infants undergoing tetralogy of fallot repair. Ann Pediatr Cardiol 2014; 7:13-8. [PMID: 24701079 PMCID: PMC3959054 DOI: 10.4103/0974-2069.126539] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Primary repair of tetralogy of Fallot (TOF) has low surgical mortality, but some patients still experience significant postoperative morbidity. Aim: To review our institutional experience with primary TOF repair, and identify predictors of intensive care unit (ICU) morbidity. Settings and Design: Medium-sized pediatric cardiology program. Retrospective study. Subjects and Methods: We retrospectively reviewed all the patients with TOF and pulmonic stenosis who underwent primary repair in infancy at our institution from January 2001 to December 2012. Preoperative, operative, and postoperative demographic and morphologic data were analyzed. ICU morbidity was defined as prolonged ICU stay (≥7 days), and/or prolonged duration of mechanical ventilation (≥48 h). Statistical Analysis Used: Multiple logistic regression analysis. Results: Ninety-seven patients underwent primary surgical repair during the study period. The median age was 4.9 months (1-9 months) and the median weight was 5.3 kg (3.1-9.8 kg). There was no early surgical mortality. Incidence of junctional ectopic tachycardia (JET) and persistent complete heart block was 2 and 1%, respectively. The median length of ICU stay was 6 days (2-21 days) and median duration of mechanical ventilation was 19 h (0-136 h). By multiple regression analysis, age and weight were independent predictors of length of ICU stay, while surgical era was an independent predictor of duration of mechanical ventilation. Conclusion: Primary TOF repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery remain significant predictors of morbidity.
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Affiliation(s)
- Alexander C Egbe
- Division of Pediatric Cardiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY
| | - Alexander J Mittnacht
- Division of Pediatric Cardiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY
| | - Khanh Nguyen
- Division of Pediatric Cardiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY
| | - Umesh Joashi
- Division of Pediatric Cardiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY
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d'Udekem Y, Galati JC, Rolley GJ, Konstantinov IE, Weintraub RG, Grigg L, Ramsay JM, Wheaton GR, Hope S, Cheung MH, Brizard CP. Low Risk of Pulmonary Valve Implantation After a Policy of Transatrial Repair of Tetralogy of Fallot Delayed Beyond the Neonatal Period. J Am Coll Cardiol 2014; 63:563-8. [DOI: 10.1016/j.jacc.2013.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/25/2013] [Accepted: 10/01/2013] [Indexed: 11/17/2022]
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Egbe AC, Uppu SC, Mittnacht AJC, Joashi U, Ho D, Nguyen K, Srivastava S. Primary tetralogy of Fallot repair: Predictors of intensive care unit morbidity. Asian Cardiovasc Thorac Ann 2013; 22:794-9. [DOI: 10.1177/0218492313513773] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Primary repair of tetralogy of Fallot has low surgical mortality, but some patients still experience significant postoperative morbidity. Our objectives were to review our institutional experience with primary tetralogy of Fallot repair, and identify predictors of intensive care unit morbidity. Methods We reviewed all patients with tetralogy of Fallot who underwent primary repair in infancy from 2001 to 2012. Preoperative, operative, and postoperative demographic and morphologic data were analyzed. Intensive care unit morbidity was defined as prolonged intensive care unit stay (≥7 days) and/or prolonged duration of mechanical ventilation (≥48 h). Results 97 patients who underwent primary surgical repair during the study period were included in the study. The median age was 4.9 months (range 1–9 months) and the median weight was 5.3 kg (range 3.1–9.8 kg). There was no early surgical mortality. The incidence of junctional ectopic tachycardia and persistent complete heart block was 2% and 1%, respectively. The median intensive care unit stay was 6 days (range 2–21 days) and the median duration of mechanical ventilation was 19 h (range 0–136 h). Age and weight were independent predictors of intensive care unit stay, while surgical era predicted the duration of mechanical ventilation. Conclusion Primary tetralogy of Fallot repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery were significant predictors of morbidity.
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Affiliation(s)
- Alexander C Egbe
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, USA
| | - Santosh C Uppu
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, USA
| | | | - Umesh Joashi
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, USA
| | - Deborah Ho
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, USA
| | - Khanh Nguyen
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, USA
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McKenzie ED, Maskatia SA, Mery C. Surgical management of tetralogy of fallot: in defense of the infundibulum. Semin Thorac Cardiovasc Surg 2013; 25:206-12. [PMID: 24331142 DOI: 10.1053/j.semtcvs.2013.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 11/11/2022]
Abstract
Surgical treatment of the Tetralogy of Fallot (ToF) is one of the great successes of medicine and also a topic of controversy. Different strategies have been proposed, including age-based (neonatal) management strategies as well as anatomic-based management strategies. Regardless of the management strategy entailed, the surgical management of ToF has considerably evolved over the years. As a result, patients can now expect excellent early results with survival approaching 100% for those without genetic syndromes. The goals of current surgical therapy should be to mitigate the late right ventricular (RV) dysfunction that may occur by minimizing the extent of surgical injury during the intial repair. As the surgical techniques continue to advance, the outcomes will continue to improve.
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Affiliation(s)
- E Dean McKenzie
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas..
| | - Shiraz A Maskatia
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Carlos Mery
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Kirsch RE, Glatz AC, Gaynor JW, Nicolson SC, Spray TL, Wernovsky G, Bird GL. Results of elective repair at 6 months or younger in 277 patients with tetralogy of Fallot: a 14-year experience at a single center. J Thorac Cardiovasc Surg 2013; 147:713-7. [PMID: 23602127 DOI: 10.1016/j.jtcvs.2013.03.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 02/15/2013] [Accepted: 03/20/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report practice and outcomes in infants undergoing elective repair of tetralogy of Fallot. METHODS A review of a retrospective cohort of elective complete repair of infants age 6 months or younger from 1995 to 2009 was performed. Patients were excluded because of previous interventions, hypercyanotic episodes, intensive care admissions, additional major cardiac defects, or if they were not discharged after birth. Length of stay, mortality, and complications were recorded. Association was determined using logistic or linear regression models and univariate testing determined the multivariate model. RESULTS There were 277 patients included. The hospital mortality rate was zero. A total of 87.4% of patients were discharged home within 7 days of repair, and 21.6% of patients were discharged on or before the third postoperative day. The postoperative course was uncomplicated in 245 patients (88.4%). Longer support time was associated independently with increased odds of complications (P < .001). Longer support time, younger age, chromosomal abnormality, and presence of a complication were associated independently with a longer hospital stay (all P < .001). Patients younger than 3 months (n = 110) had a longer median hospital stay (4 vs 3 days; P < .001) and longer support times (77.3 ± 35.1 min vs 66.4 ± 34 min; P < .01). CONCLUSIONS Elective tetralogy of Fallot repair was performed at 6 months or younger with low morbidity, no hospital mortality, and an 11.6% complication rate. Longer support times, lower weight, chromosomal abnormalities, and complications were associated with a significantly increased duration of hospital stay.
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Affiliation(s)
- Roxanne E Kirsch
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Pediatric Surgery, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Pediatric Surgery, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Gil Wernovsky
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa; Division of Cardiology, Department of Pediatrics, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Geoffrey L Bird
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa; Division of Cardiology, Department of Pediatrics, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa
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Tetralogy of Fallot with atrioventricular septal defect: surgical strategies for repair and midterm outcome of pulmonary valve-sparing approach. Pediatr Cardiol 2013; 34:861-71. [PMID: 23104595 DOI: 10.1007/s00246-012-0558-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/04/2012] [Indexed: 01/25/2023]
Abstract
Repair for tetralogy of Fallot (TOF) with complete atrioventricular septal defect (CAVSD) has been reported with good early and intermediate outcomes. Morbidity, however, remains significantly high. To date, repair of CAVSD/TOF using a pulmonary valve-sparing technique (PVS) and freedom from valve reoperation are not well defined. A study was undertaken to investigate outcomes. This study was conducted in as a retrospective investigation. Between January 1988 and December 2008, 13 consecutive patients with CAVSD/TOF were identified, and their records were reviewed retrospectively. Of these 13 patients, 9 had Rastelli type C CAVSD. Trisomy 21 was present in 9 cases (69 %; 7 with type C). Five patients had received a systemic-to-pulmonary shunt (SPS) before complete repair at a mean age 1.7 ± 0.6 months. All the patients survived until complete repair. At complete CAVSD/TOF repair, AVSD was corrected with a two-patch technique in all patients. For eight patients (61.5 %), PVS was used. The remaining five patients had transannular patch (TAP) repair. The mean age at complete repair was 6.3 ± 2.4 months. At complete repair, the mean cardiopulmonary bypass time was 173.5 ± 30.6 min, and the cross-clamp time was 134.7 ± 28.8 min. There was one hospitalization and no late deaths. The median follow-up period was 9.2 years [interquartile range (IQR), 4.7-13.3 years]. The actuarial survival was 90.0 ± 9.5 % at 1 year, 90 ± 9.5 % at 5 years, and 90 ± 9.5 % at 8 years. Of the 12 survivors, 6 had some reintervention during the follow-up period. Within the first 11 years after complete repair, two patients underwent left atrioventricular (AV) valve repair, and one patient had right AV valve repair. Two patients had residual VSD closure. Four patients underwent the first right ventricular outflow tract (RVOT) reintervention for critical insufficiency or stenosis at a mean interval of 6 ± 21) months. One patient had a second RVOT reoperation. Findings showed that CAVSD/TOF with PVS was related to significantly higher freedom from RVOT reintervention (100 % at 1, 5, and 8 years compared with 80 ± 17.9 % at 1 year, 60 ± 21.9 % at 5 years, and 40 ± 21.9 % at 8 years for CAVSD/TOF using TAP; P < 0.05). No patient who underwent PVS had left ventricular outflow tract obstruction requiring reoperation. Overall freedom from any reintervention was 90.9 ± 8.6 % at 1 year, 71.6 ± 14.0 % at 5 years, and 53.7 ± 8.7 % at 8 years in this group of patients. Correction of TOF with CAVSD can be performed at low risk with favorable intermediate-term survival and satisfactory freedom from reoperation. Use of TAP can be avoided in almost two thirds of patients and may influence freedom from early RVOT reintervention.
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d'Udekem Y. Tetralogy of Fallot: a larger infundibular incision in a transatrial repair eliminates the risk of a reoperation for a right ventricular outflow tract obstruction. Eur J Cardiothorac Surg 2013; 43:342-3. [PMID: 23319488 DOI: 10.1093/ejcts/ezs292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia.
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Mercer-Rosa L, Pinto N, Yang W, Tanel R, Goldmuntz E. 22q11.2 Deletion syndrome is associated with perioperative outcome in tetralogy of Fallot. J Thorac Cardiovasc Surg 2013; 146:868-73. [PMID: 23312975 DOI: 10.1016/j.jtcvs.2012.12.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/01/2012] [Accepted: 12/10/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to investigate the impact of 22q11.2 deletion on perioperative outcome in tetralogy of Fallot. METHODS We conducted a retrospective review of patients with tetralogy of Fallot who underwent complete surgical reconstruction at The Children's Hospital of Philadelphia between 1995 and 2006. Inclusion criteria included diagnosis of tetralogy of Fallot and known genotype. Fisher exact and Mann-Whitney tests were used for categoric and continuous variables, respectively. Regression analysis was used to determine whether deletion status predicts outcome. RESULTS We studied 208 subjects with tetralogy of Fallot, 164 (79%) without and 44 (20%) with 22q11.2 deletion syndrome. There were no differences in sex, race, gestational age, age at diagnosis, admission weight, and duration of mechanical ventilation. Presenting anatomy, survival, complications and reoperations were also comparable between patients with and without 22q11.2 deletion syndrome. Those with 22q11.2 deletion syndrome had more aortopulmonary shunts preceding complete surgical repair (21% vs 7%, P = .02). This association was present after adjustment for presenting anatomy (stenosis, atresia, or absence of pulmonary valve and common atrioventricular canal) and surgical era. In addition, those with 22q11.2 deletion syndrome had longer cardiopulmonary bypass time (84 vs 72 minutes, P = .02) and duration of intensive care (6 vs 4 days, P = .007). CONCLUSIONS Genotype affects early operative outcomes in tetralogy of Fallot resulting, in particular, in longer duration of intensive care. Future studies are required to determine factors contributing to such differences in this susceptible population.
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Affiliation(s)
- Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
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Escribano D, Herraiz I, Granados M, Arbues J, Mendoza A, Galindo A. Tetralogy of Fallot: prediction of outcome in the mid-second trimester of pregnancy. Prenat Diagn 2011; 31:1126-33. [PMID: 21928295 DOI: 10.1002/pd.2844] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 07/20/2011] [Accepted: 07/24/2011] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the usefulness of fetal echocardiography in the mid-second trimester in predicting postnatal outcome of tetralogy of Fallot (ToF), focusing on the need for early intervention (EI) and surgery type: pulmonary valve-sparing surgery (PVSS) versus placement of transannular patch (TAP). METHODS Assessment of cardiac morphological and functional parameters in 23 live-born fetuses with isolated ToF was performed at 19 to 22 and 34 to 38 weeks. Comparisons were made between outcome groups (EI vs non-EI and PVSS vs TAP). EI was considered as requirement either of palliative procedure or corrective surgery before three months. RESULTS Overall survival was 96%. EI was required in 32% of cases and TAP in 50%. At 19 to 22 weeks, a pulmonary valve peak systolic velocity (PVPSV) ≥87.5 cm/s predicted EI with 100% sensitivity and 93.3% specificity (p < 0.01). At 34 to 38 weeks, the size of the pulmonary valve, pulmonary valve/aortic valve and main pulmonary artery/ascending aorta were significantly different, but the PVPSV again yielded the best performance: all cases undergoing EI and/or TAP were selected using cut-off of ≥144.5 cm/s. CONCLUSION The postnatal outcome of fetuses with ToF may be established using PVPSV from the mid-second trimester. This may be useful in providing the most appropriate perinatal management and accurate parental counselling.
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Affiliation(s)
- D Escribano
- Department of Obstetrics and Gynaecology, Hospital Universitario '12 de Octubre', Madrid, Spain
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Remadevi KS, Vaidyanathan B, Francis E, Kannan BRJ, Kumar RK. Balloon pulmonary valvotomy as interim palliation for symptomatic young infants with tetralogy of Fallot. Ann Pediatr Cardiol 2011; 1:2-7. [PMID: 20300231 PMCID: PMC2840727 DOI: 10.4103/0974-2069.41049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objectives: To describe the case selection, technique and immediate and short-term results of balloon pulmonary valvotomy (BPV) in young infants with tetralogy of Fallot (TOF). Background: Symptomatic young infants with TOF can either undergo corrective surgery or Blalock-Taussig (BT) shunt. Corrective surgery in early infancy is associated with significant morbidity and is not a realistic option in many centers. BT shunt carries the risk of branch pulmonary artery distortion and shunt occlusion. Methods: Infants less than three months with a significant valvar pulmonary stenosis (with or without associated infundibular and annular component) and oxygen saturation ≤80% were offered BPV. The right ventricular outflow tract (RVOT) was crossed with 4F Judkin's right coronary catheter and the valve was crossed with 0.014” coronary guide wire. Serial balloon dilatations were done with over the wire coronary balloons (3-4 mm) and Mini Tyshak balloons up to a balloon annulus ratio of 2:1, depending upon the improvement in saturation and formation of annular waist. Results: Seventeen infants less than three months of age with tetralogy of Fallot (median age: 33 days, range: 10-90 days, weight: 3.47 ± 0.87 kg, pulmonary annulus Z score: -5.59 ± 1.04) including eight neonates underwent palliative BPV between May 2004 and March 2007. The mean balloon annulus ratio was 1.4 ± 0.28 and fluoroscopy time was 26.18 ± 20.2 minutes. The mean oxygen saturation increased significantly from 73 ± 7% to 90 ± 3.68% following BPV (p = 0.0001). The only major complication was RVOT perforation and pericardial tamponade in one infant. The mean follow-up period was 23 ± 12 months. Two babies developed significant desaturation requiring surgery in the six months following BPV. There was a significant increase in pulmonary annulus. The z score for the pulmonary annulus improved from -5.59 ±1.04 before BPV to - 4.31 ± 1.9 at the time of last follow-up (p = 0.018). The mean Z score of hilar right pulmonary artery (RPA) increased significantly from -1.19 ± 1.78 before BPV to 0.7 ± 0.91 after BPV (p = 0.001). The mean Z score of hilar left pulmonary artery (LPA) increased significantly from -1.28 ± 1.41 to 0.03 ± 1.29 after BPV (p = 0.005). Eight patients underwent corrective surgery. Conclusions: Balloon pulmonary valvotomy is safe and effective. It significantly improves the growth of pulmonary annulus and branch pulmonary arteries. Thus it can be considered as an interim palliative procedure for symptomatic young infants with TOF and predominant valvar pulmonary stenosis.
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Affiliation(s)
- K S Remadevi
- Division of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Kochi, India
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Park CS, Kim WH, Kim GB, Bae EJ, Kim JT, Lee JR, Kim YJ. Symptomatic Young Infants with Tetralogy of Fallot: One-stage versus Staged Repair. J Card Surg 2010; 25:394-9. [DOI: 10.1111/j.1540-8191.2010.01053.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Morales DL, Zafar F, Fraser CD. Tetralogy of Fallot repair: the Right Ventricle Infundibulum Sparing (RVIS) strategy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009; 12:54-58. [PMID: 19349014 DOI: 10.1053/j.pcsu.2009.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Despite the excellent operative survival for tetralogy of Fallot (TOF) repair, well-documented long-term complications and reduced life expectancy remain challenges for these patients and their clinicians. In an attempt to change the natural history of repaired TOF, we at Texas Children's Hospital (Houston, TX) have developed a management strategy not focused on age, but rather focused on preserving the right ventricular (RV) infundibulum. The RV infundibulum sparing (RVIS) repair of TOF consists of a transatrial and transpulmonary approach to close the ventricular septal defect and resect RV infundibular muscle coupled with a mini (< 5 mm) transannular patch or no ventricular incision. This strategy is applied with the ambition of decreasing the well-documented, long-term complications of TOF repair with large right ventriculotomies such as RV dilation, arrhythmias, need for pulmonary valve replacement, and RV failure. The RVIS strategy is an attempt based on our current knowledge and experience to optimize the time of repair so that we can not only maximize the early operative results but the long-term effects of this approach as these children mature into adolescents and adults. We have uniformly applied the RVIS strategy since 1995, which includes over 320 isolated TOF patients. We are currently reviewing this cohort in hopes that it will strengthen our beliefs and known results as well as give us more insight into whether the RVIS strategy can change the natural history of repaired TOF.
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Affiliation(s)
- David L Morales
- Michael E. DeBakey Department of Surgery, Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, TX, USA.
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Plasma angiopoietin-2 levels increase in children following cardiopulmonary bypass. Intensive Care Med 2008; 34:1851-7. [PMID: 18516587 DOI: 10.1007/s00134-008-1174-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 05/13/2008] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The aim was to investigate the effects of cardiopulmonary bypass (CPB) on plasma levels of the vascular growth factors, angiopoietin (angpt)-1, angpt-2, and vascular endothelial growth factor (VEGF). DESIGN The design was a prospective, clinical investigation. SETTING The setting was a 12-bed pediatric cardiac intensive care unit of a tertiary children's medical center. PATIENTS The patients were 48 children (median age, 5 months) undergoing surgical correction or palliation of congenital heart disease who were prospectively enrolled following informed consent. INTERVENTIONS There were no interventions in this study. MEASUREMENTS AND RESULTS Plasma samples were obtained at baseline and at 0, 6, and 24 h following CPB. Angpt-1, angpt-2, and VEGF levels were measured via commercial ELISA. Angpt-2 levels increased by 6 h (0.95, IQR 0.43-2.08 ng mL(-1) vs. 4.62, IQR 1.16-6.93 ng mL(-1), P < 0.05) and remained significantly elevated at 24 h after CPB (1.85, IQR 0.70-2.76 ng mL(-1); P < 0.05). Angpt-1 levels remained unchanged immediately after CPB, but were significantly decreased at 24 h after CPB (0.64, IQR 0.40-1.62 ng mL(-1) vs. 1.99, IQR 1.23-2.63 ng mL(-1), P < 0.05). Angpt-2 levels correlated significantly with cardiac intensive care unit (CICU) length of stay (LOS) and were an independent predictor for CICU LOS on subsequent multivariate analysis. CONCLUSIONS Angpt-2 appears to be an important biomarker of adverse outcome following CPB in children.
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Karamlou T, McCrindle BW, Williams WG. Surgery Insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. ACTA ACUST UNITED AC 2006; 3:611-22. [PMID: 17063166 DOI: 10.1038/ncpcardio0682] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 06/19/2006] [Indexed: 11/09/2022]
Abstract
Biventricular correction of tetralogy of Fallot was devised more than 50 years ago. Current short-term outcomes are excellent. The potential for late complications is, however, an important concern for the growing number of postrepair survivors. Progressive pulmonary valve regurgitation leading to right heart failure and arrhythmia are centrally important problems faced by these patients. New techniques are, however, likely to change the future outcomes for postrepair survivors. These techniques include percutaneous valve replacement, arrhythmia ablation surgery, and strategies that emphasize preservation of the pulmonary valve even at the cost of leaving some residual valvular stenosis. The objectives of this Review are to outline the major complications that arise late after repair of tetralogy of Fallot, to describe the surgical approaches that have been developed to avoid and manage arising complications, and to briefly explore how novel treatment paradigms could change the future long-term outlook for patients following tetralogy repair.
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Affiliation(s)
- Tara Karamlou
- Division of Cardiovascular Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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Pozzi M, Quarti A, Corno AF. Tetralogy of fallot. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2005.001487. [PMID: 24413328 DOI: 10.1510/mmcts.2005.001487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The optimal management of patients with tetralogy of Fallot has to consider the individual intra-cardiac anatomy as the most important variable, together with the age and the body weight of the patient. In any case the potential advantages of a primary early repair should be weighted against the experience and expertise of the individual centre and/or surgical team in dealing with tetralogy of Fallot and with neonates and infants. The best results are achieved by very carefully adapting the surgical technique to the individual morphology of the right ventricular outflow tract and of the pulmonary arteries. The details of the established surgical management for each component of the surgical repair are analysed and described. Over a period of 12 years (from 1993 to 2005) 318 consecutive patients with tetralogy of Fallot underwent repair with one hospital death (1/318=0.3% mortality).
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Affiliation(s)
- Marco Pozzi
- Alder Hey Royal Children Hospital, Cardiac Unit, Eaton Road, Liverpool, L12 2AP, UK
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Stewart RD, Backer CL, Young L, Mavroudis C. Tetralogy of Fallot: Results of a Pulmonary Valve-Sparing Strategy. Ann Thorac Surg 2005; 80:1431-8; discussion 1438-9. [PMID: 16181883 DOI: 10.1016/j.athoracsur.2005.04.016] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Revised: 04/05/2005] [Accepted: 04/06/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Our surgical strategy for repair of tetralogy of Fallot has focused on preserving the pulmonary valve. The purpose of this review was to identify pulmonary valve characteristics that mark the limits of this strategy. METHODS From 1997 through 2004, 102 consecutive patients underwent repair of tetralogy of Fallot at a median age of 5.9 months. Twenty-five patients had a prior shunt. Eighty-two patients (80%) had pulmonary valve-sparing procedures, predominantly through a transatrial and transpulmonary approach (n = 52). Twenty patients had a transannular patch (20%). Intraoperative measurements included the pulmonary valve annulus size and the postoperative pressure ratio between the right and left ventricles. RESULTS Eighty of 85 (94%) patients with z-score greater than -4 had a pulmonary valve-sparing procedure compared with 2 of 17 patients (12%) with pulmonary valve annulus z-scores less than -4 (p < 0.0001). All patients with a tricuspid pulmonary valve (n = 26) had a pulmonary valve-sparing procedure compared with 56 of 76 (74%) patients with a bicuspid pulmonary valve (p = 0.0016). Five patients with initial pulmonary valve-sparing operations required reoperation for residual stenoses; 4 pulmonary valve-sparing right ventricular outflow tract resections and 1 transannular patch. The only death occurred after reoperation elsewhere. Three of 9 patients (33%) who had a postoperative pressure ratio between the right and left ventricles greater than 0.7 after their initial pulmonary valve-sparing procedure required reoperation compared with 2 of 73 with postoperative pressure ratio between the right and left ventricles less than 0.7 (3%; p = 0.008). Fifteen of 25 patients (60%) with prior shunts had pulmonary valve-sparing procedures. CONCLUSIONS A pulmonary valve-sparing approach to the repair of tetralogy of Fallot was applied successfully in 80% of patients. Significant markers for success were a measured pulmonary annulus z-score of -4 or larger, a tricuspid pulmonary valve, and a postoperative pressure ratio between the right and left ventricles less than 0.7.
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Affiliation(s)
- Robert D Stewart
- Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Chicago, Illinois 60614, USA
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Liang CM, Hwang B, Lu JH, Lee PC, Weng ZC, Ho TY, Meng CCL. Risk factors of prolonged postoperative pleural effusion after repair of tetralogy of Fallot. J Chin Med Assoc 2005; 68:406-10. [PMID: 16187596 DOI: 10.1016/s1726-4901(09)70155-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and total correction is the definitive treatment. Chest tube drainage of pleural effusion (PE) is essential after surgery. Prolonged PE (> 7 days) is one of the complications; it may increase hospital stay and the risks of morbidity and mortality. The aim of this study was to investigate and analyze the possible risk factors for prolonged PE after total correction of TOF. METHODS Thirty-seven patients who received total correction of TOF between July 1999 and April 2001 were included in this study. They were divided into 2 groups according to the duration of chest tube drainage for postoperative PE: Group I had postoperative PE < or = 7 days; Group II had postoperative PE > 7 days. Detailed records were taken on patients' demographic characteristics, blood parameters, surgery, electrocardiographic and radiologic data, and angiographic and echocardiographic findings. The data of the 2 groups were compared using the Wilcoxon rank-sum test and Fisher's exact test. Risk factors were analyzed by logistic regression and model selection. RESULTS Of the 37 patients, 16 were male and 21 were female. There were 32 patients (86.5%) in Group I and 5 (13.5%) in Group II. Mean patient age at repair was 1.82 +/- 1.29 years (range, 0.53-3.11 years). Significant differences (p < 0.05) between the 2 groups were noted for gender, age at repair, body weight, presence of wound infection, duration on heart-lung machine (bypass time), oxygen saturation before surgery, duration of endotracheal intubation, length of hospital stay, and Nakata index. These risk factors were analyzed by logistic regression and model selection. Two models were set up: Model 1--oxygen saturation before surgery, presence of wound infection, age at repair; Model 2--oxygen saturation before surgery, presence of wound infection. CONCLUSION Prolonged PE is a significant morbidity after TOF repair. The risk factors for prolonged PE are gender, age at repair, body weight, bypass time, low oxygen saturation before surgery, wound infection after surgery, duration of endotracheal intubation, length of hospital stay, and Nakata index. Oxygen saturation before surgery and wound infection were major risk factors while age at repair was a confounder.
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Affiliation(s)
- Chi-Ming Liang
- Division of Pediatric Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
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