Single centre experience on primary correction of common arterial trunk: overall survival and freedom from reoperation after more than 15 years

Surgical outcomes of common arterial trunk repair beyond infancy

Background

The aim of this study is to analyze the clinical outcomes of common arterial trunk repair beyond infancy in terms of both early- and long-term outcomes.

Methods

Between January 2003 and December 2019, 56 patients underwent repair for common arterial trunk beyond infancy at our institute. Median age was 34.5 months, 51.8% were females, and 48.2% were males.

Results

48.2% were type 1, 46.4% were type 2, and 5.4% were type 3. 17.9% patients underwent direct connection technique for right ventricular outflow tract reconstruction; remaining received a conduit. The most common type of truncal valve anatomy was tricuspid (82.1%). Early mortality was 7%. Univariable analysis identified age (p = 0.003), weight (p = 0.04), duration of ventilation (p = 0.036), and pulmonary hypertensive crisis (p ≤ 0.001) as factors affecting early mortality. In our overall cohort of beyond infancy repair for common arterial trunk, at 10 years, the survival, freedom from reintervention for right ventricular outflow tract reconstruction, freedom from ≥ moderate conduit obstruction, freedom from impaired right ventricle function, and freedom from ≥ moderate truncal valve regurgitation were 76.7%, 89.7%, 74%, 88.6%, and 66.3%, respectively.

Conclusion

Repair for common arterial trunk in patients presenting beyond 1 year of age is challenging; however, it can be done with satisfactory early and late outcomes in terms of mortality and reintervention.

Long-term outcomes of truncus arteriosus repair: A modulated renewal competing risks analysis

OBJECTIVE

In this study, we sought to identify independent risk factors for mortality and reintervention after early surgical correction of truncus arteriosus using a novel statistical method.

METHODS

Patients undergoing neonatal/infant truncus arteriosus repair between January 1984 and December 2018 were reviewed retrospectively. An innovative statistical strategy was applied integrating competing risks analysis with modulated renewal for time-to-event modeling.

RESULTS

A total of 204 patients were included in the study. Mortality occurred in 32 patients (15%). Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were significantly associated with overall mortality (right ventricle to pulmonary artery conduit size: hazard ratio, 1.34; 95% confidence interval, 1.08-1.66, P = .008; truncal valve insufficiency: hazard ratio, 2.5; 95% confidence interval, 1.13-5.53, P = .024). truncal valve insufficiency at birth, truncal valve intervention at index repair, and number of cusps (4 vs 3) were associated with truncal valve reoperations (truncal valve insufficiency: hazard ratio, 2.38; 95%, confidence interval, 1.13-5.01, P = .02; cusp number: hazard ratio, 6.62; 95% confidence interval, 2.54-17.3, P < .001). Right ventricle to pulmonary artery conduit size 11 mm or less was associated with a higher risk of early catheter-based reintervention (hazard ratio, 1.54; 95% confidence interval, 1.04-2.28, P = .03) and reoperation (hazard ratio, 1.96; 95% confidence interval, 1.33-2.89, P = .001) on the right ventricle to pulmonary artery conduit.

CONCLUSIONS

Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were associated with overall mortality after truncus arteriosus repair. Quadricuspid truncal valve, the presence of truncal valve insufficiency at the time of diagnosis, and truncal valve intervention at index repair were associated with an increased risk of reoperation. The size of the right ventricle to pulmonary artery conduit at index surgery is the single most important factor for early reoperation and catheter-based reintervention on the conduit.

Surgery for Truncus Arteriosus: Contemporary Practice

Surgery for truncus arteriosus has an early mortality of 3% to 20%, with a long-term survival of approximately 75% at 20 years. Nowadays, truncus arteriosus repair is mostly done in the neonatal period together with a single-staged repair of concomitant cardiovascular anomalies. There are many challenging subgroups of patients with truncus arteriosus, including those with clinically significant truncal valve insufficiency, an interrupted aortic arch, or a coronary artery anomaly. In fact, truncal valve competency appears to be the most important factor influencing the outcomes after truncus arteriosus repair. The use of a conduit during truncus arteriosus repair invariably requires reoperation on the right ventricular outflow tract. Through improvements in perioperative techniques over time, many children are now living well into adulthood after repair of truncus arteriosus, albeit with a high rate of reoperation. Despite this, the long-term outcomes of truncus arteriosus repair are good, with many patients being asymptomatic and with a quality of life comparable to the general population.

Rare Association of an Intramural Coronary Artery and Truncus Arteriosus

The association of truncus arteriosus (TA) and an intramural coronary artery is rare. Seven (7) patients had TA and an intramural coronary artery at the Royal Children's Hospital, Melbourne between 1996 and 2018. Four (4) patients underwent concomitant unroofing of their intramural coronary artery. One (1) patient who did not undergo concomitant unroofing had a cardiac arrest on postoperative day 1 and subsequently underwent reoperation for coronary unroofing. Given the potential for serious complications, patients with TA and an intramural coronary artery may benefit from coronary unroofing with creation of a generous neo-ostium.

Truncus arteriosus repair: A 40-year multicenter perspective

OBJECTIVE

To examine the long-term surgical outcomes of patients who underwent truncus arteriosus (TA) repair.

METHODS

Between 1979 and 2018, a total of 255 patients underwent TA repair at 3 Australian hospitals. Data were obtained by review of medical records from initial admission until last cardiology follow-up.

RESULTS

At the time of TA repair, the median patient age was 44 days, and median weight was 3.5 kg. Early mortality was 13.3% (34 of 255), and overall survival was 76.8 ± 2.9% at 20 years. Neonatal surgery and low operative weight were risk factors for early mortality. Most deaths (82.5%; 47 of 57) occurred within the first year following repair. A coronary artery anomaly and early reoperation were identified as risk factors for late mortality. A total of 175 patients required at least 1 reoperation, with overall freedom of reoperation of 2.9 ± 1.5% at 20 years. Follow-up of survivors was 96% complete (191 of 198). The median duration of follow-up was 16.4 years. At the last follow-up, 190 patients were categorized as New York Heart Association class I/II, and 1 patient was class III.

CONCLUSIONS

TA repair during the neonatal period presents significant surgical challenges. Neonates with signs of overcirculation should be operated on promptly. A coronary artery anomaly is a risk factor for late mortality. Survival beyond the first year following repair is associated with excellent outcomes.

Surgical repair for persistent truncus arteriosus in neonates and older children

Objectives

Persistent truncus arteriosus represents less than 3% of all congenital heart defects. We aim to analyze mid-term outcomes after primary Truncus arteriosus repair at different ages and to identify the risk factors contributing to mortality and the need for intervention after surgical repair.

Methods

This retrospective cohort study included 36 children, underwent repair of Truncus arteriosus in the period from January 2011 to December 2018 in two institutions. We recorded the clinical and echocardiographic data for the patients preoperatively, early postoperative, 6 months postoperative, then every year until their last documented follow-up appointment.

Results

Thirty-six patients had truncus arteriosus repair during the study period. Thirty-one patients had open sternum post-repair, and two patients required extracorporeal membrane oxygenation. Bleeding occurred in 15 patients (41.67%), and operative mortality occurred in 5 patients (14.7%). Patients with truncus arteriosus type 2 (p = 0.008) and 3 (p = 0.001) and who were ventilated preoperatively (p < 0.001) had a longer hospital stay. Surgical re-intervention was required in 8 patients (22.86%), and 11 patients (30.56%) had catheter-based reintervention. Freedom from reintervention was 86% at 1 year, 75% at 2 years and 65% at 3 years. Survival at 1 year was 81% and at 3 years was 76%. High postoperative inotropic score predicted mortality (p = 0.013).

Conclusion

Repair of the truncus arteriosus can be performed safely with low morbidity and mortality, both in neonates, infants, and older children. Re-intervention is common, preferably through a transcatheter approach.

Single-centre 20-year experience with repair of truncus arteriosus

OBJECTIVES

We analysed a large series of truncus arteriosus repairs with a focus on early and late outcomes.

METHODS

Ninety-seven consecutive patients who underwent truncus arteriosus repair (1997-2017) were included retrospectively. Univariable analysis for mortality and reintervention was performed.

RESULTS

The early mortality rate decreased from 45% (1997-2007; 14/31) to 4.5% (2008-2017; 3/66) (P = 0.001). Repair beyond the neonatal period (P = 0.03) and direct connection for right ventricular outflow tract reconstruction (P = 0.001) were associated with early death by univariable analysis. Overall survival was 68 ± 6.0% at 15 years; a majority of the deaths (90%; 9/10) occurred within the first year after repair. Freedom from the first and second conduit reoperations at 10 years was 22.9% and 89%, respectively. Freedom from truncal valve (TrV) reoperation was 83.9% at 15 years. Initial TrV insufficiency ≥ moderate was associated with a TrV reoperation (P = 0.008) with freedom from TrV reoperation in this subgroup of 58.3% at 10 years. Freedom from TrV reoperation for quadricuspid and tricuspid TrVs was 66.8% and 93.8% at 10 years with 100% for bicuspid TrVs at 8 years. At the last follow-up, 98.5% (69/70) were in New York Heart Association functional class I-II.

CONCLUSIONS

In the current era, truncus arteriosus can be repaired with a low early mortality rate and a good long-term outcome. A significant reintervention burden still persists. Direct connection is associated with early mortality.

Impact of truncal valve surgery on the outcomes of the truncus arteriosus repair

OBJECTIVES

Preoperative moderate or greater truncal valve (TV) insufficiency is one of the most important factors influencing mortality in children with truncus arteriosus. We therefore sought to determine the impact of TV insufficiency and concomitant TV surgery on children who underwent truncus arteriosus repair at a single institution.

METHODS

We reviewed 180 patients who underwent truncus arteriosus repair between 1979 and 2016. Preoperative echocardiography demonstrated TV insufficiency in 80 patients (mild: 33.9%, 61/180; moderate: 9.4%, 17/180 and severe: 1.1%, 2/180).

RESULTS

Twenty-one patients had concomitant TV surgery with an early mortality of 19% (4/21) and overall survival of 70.8 ± 10.1% at 25 years. There were 60 neonates, 11 of whom had concomitant TV surgery with an early mortality of 27% (3/11) and overall survival of 62.3 ± 15.0% at 20 years. Concomitant TV repair (P = 0.5) was not a risk factor for death. TV reoperation was common in those who had concomitant TV surgery, with freedom from reoperation of 19.2 ± 14.9% at 20 years. In the remaining 159 patients, 14 required subsequent TV surgery, and the freedom from TV surgery was 84.0 ± 4.6% at 20 years. At a median follow-up of 18.5 years, TV insufficiency was none or trivial in 79.6% (109/137) and mild or less in 98.5% (135/137) of patients.

CONCLUSIONS

Most patients with mild TV insufficiency are free from TV surgery up to 25 years. The durability of TV repair is poor. Most patients with moderate or greater TV insufficiency and a quadricuspid TV will require TV surgery.

Repair of incompetent truncal valves: early and mid-term results

OBJECTIVES

To analyse the factors associated with in-hospital mortality and mid-term significant neoaortic valve regurgitation (AR) after truncal valve (TV) repair.

METHODS

Eleven children underwent TV repair at our institution from July 1999 to March 2012. All children presented significant preoperative TV regurgitation. Valve anatomy was quadricuspid in 7 (64%) patients and tricuspid in 4 (36%). The median age and weight at surgery were 29.6 (range 0.3-173.2) months and 12 (range 2.2-49) kg, respectively. Repair included bicuspidalization through the approximation of two leaflets associated with triangular resection of the opposite one (n = 2, 18%), or either bicuspidalization or tricuspidalization of the TV through excision of one leaflet and related sinus of Valsalva (n = 9, 82%). In 3 patients, repair was associated with coronary detachment before cusp removal, followed by coronary reimplantation.

RESULTS

In-hospital death occurred in 2 (18%) patients. Factors associated with hospital mortality were age <1 year (P = 0.05), weight <3 kg (P = 0.02) and longer cross-clamping time (P = 0.008). Follow-up was complete for all patients [median follow-up time: 52.2 (range 132.2-2.5) months]. Mid-term significant AR occurred in 4 patients (45%, moderate in 2 and severe in 2). One with severe AR underwent successful valve replacement 4 months postoperatively, leading to freedom from reintervention of 91%. Freedom from significant AR was 76.2 (33.2-93.5) and 60.9 (20.2-85.6) at 1 and 2 years, respectively. There was a trend towards longer freedom from mid-term significant AR for patients who underwent cusp removal compared with those who did not (P = 0.07).

CONCLUSIONS

TV repair in children can be performed safely with fairly good and durable results. Cusp removal might decrease the rate of severe AR on mid-term follow-up.

Mid-term results after correction of type I and type II persistent truncus arteriosus in older patients

OBJECTIVE

This study aims to analyze long-term results after correction of type I and type II truncus arteriosus in older patients operated in one institution over five years.

METHODS

Between 2006 and 2010, 12 patients, median age 4 years, underwent repair of truncus arteriosus. Repair with reconstruction of the right ventricular to pulmonary artery continuity was performed using a valved conduit in 12 patients.

RESULTS

There was no early mortality. All patients are alive with their original conduit 0.6 to 5 years after correction. No patients required reoperations for conduit dysfunction. Recent clinical examination was undertaken in all patients and they are in good condition.

CONCLUSIONS

Though mean age at operation was higher in this study than published results, the operation should be performed if the pulmonary vascular resistance is under 8 units.m(2) before operation.

Percutaneous pulmonary valve implantation: two-centre experience with more than 100 patients

AIMS

Dysfunction of valved conduits in the right ventricular outflow tract (RVOT) limits durability and enforces repeated surgical interventions. We report on our combined two-centre experience with percutaneous pulmonary valve implantation (PPVI).

METHODS AND RESULTS

One hundred and two patients with RVOT dysfunction [median weight: 63 kg (54.2-75.9 kg), median age: 21.5 years (16.2-30.1 years), diagnoses: TOF/PA 61, TAC 14, TGA 9, other 10, AoS post-Ross-OP 8] were scheduled for PPVI since December 2006. Percutaneous pulmonary valve implantation was performed in all patients. Pre-stenting of the RVOT was done in 97 patients (95%). The median peak systolic RVOT gradient decreased from 37 mmHg (29-46 mmHg) to 14 mmHg (9-17 mmHg, P < 0.001) and the ratio RV pressure/AoP decreased from 62% (53-76%) to 36% (30-42%, P < 0.0001). The median end-diastolic RV-volume index (MRI) decreased from 106 mL/m(2) (93-133 mL/m(2)) to 90 mL/m(2) (71-108 mL/m(2), P = 0.001). Pulmonary regurgitation was significantly reduced in all patients. One patient died due to compression of the left coronary artery. The incidence of stent fractures was 5 of 102 (5%). During follow-up [median: 352 days (99-390 days)] one percutaneous valve had to be removed surgically 6 months after implantation due to bacterial endocarditis. In 8 of 102 patients, a repeated dilatation of the valve was done due to a significant residual systolic pressure gradient, which resulted in a valve-in-valve procedure in four.

CONCLUSION

This study shows that PPVI is feasible and it improves the haemodynamics in a selected patient collective. Apart from one coronary compression, the rate of complications at short-term follow-up was low. Percutaneous pulmonary valve implantation can be performed by experienced interventionalists with similar results as originally published. The intervention is technically challenging and longer clinical follow-up is needed.

Minimally Invasive Options for Failing Homografts in the Pulmonary Position

Homograft implantation in the pulmonary position is usually part of initial repair in congenital heart defects with dysplasia or atresia of the pulmonary valve and at the time of the Ross operation. As part of reoperations, homografts are mainly required after nonvalved right ventricular outflow tract procedures. Due to an annual increase of homograft dysfunction, replacement is inevitable. Recently, percutaneous catheter-based valve implantations gain increasing acceptance. Even transventricular pulmonary valve implantation has been reported. Prior to decision making for any surgical or interventional therapy, the right ventricular outflow tract morphology together with additional pathologies need to be assessed. With the development of new prostheses and delivery modes, the demand for conventional surgery will further decrease.

Cardiac defects and results of cardiac surgery in 22q11.2 deletion syndrome

Specific types and subtypes of cardiac defects have been described in children with 22q11.2 deletion syndrome as well as in other genetic syndromes. The conotruncal heart defects occurring in patients with 22q11.2 deletion syndrome include tetralogy of Fallot, pulmonary atresia with ventricular septal defect, truncus arteriosus, interrupted aortic arch, isolated anomalies of the aortic arch, and ventricular septal defect. These conotruncal heart defects are frequently associated in this syndrome with additional cardiovascular anomalies of the aortic arch, pulmonary arteries, infundibular septum, and semilunar valves complicating cardiac anatomy and surgical treatment. In this review we describe the surgical anatomy, the operative treatment, and the prognostic results of the cardiac defects associated with 22q11.2 deletion syndrome. According to the current literature, in patients with tetralogy of Fallot with/without pulmonary atresia and truncus arteriosus, in spite of the complex cardiac anatomy, the presence of 22q11.2 deletion syndrome does not worsen the surgical prognosis. On the contrary in children with pulmonary atresia with ventricular septal defect and probably in those with interrupted aortic arch the association with 22q11.2 deletion syndrome is probably a risk factor for the operative treatment. The complex cardiovascular anatomy in association with depressed immunological status, pulmonary vascular reactivity, neonatal hypocalcemia, bronchomalacia and broncospasm, laryngeal web, and tendency to airway bleeding must be considered at the time of diagnosis and surgical procedure. Specific diagnostic, surgical, and perioperative protocols should be applied in order to provide appropriate treatment and to reduce surgical mortality and morbidity.

Severe Pregnancy-Induced Deterioration of Truncal Valve Regurgitation in an Adolescent Patient with Repaired Truncus Arteriosus

Truncus arteriosus, a rare and complex congenital heart disease, is hallmarked by a single great vessel (truncus) that arises over a large ventricular septal defect and provides both the pulmonary and systemic circulation. Pregnancy reports after repair for truncus arteriosus are scarce. Therefore, the maternal and offspring outcomes are unknown. We report the outcome of a pregnancy in an 18-year-old woman with repaired truncus arteriosus. Despite severe and symptomatic deterioration of truncal valve regurgitation, she successfully delivered a healthy child, and the valve function recovered within 2 weeks postpartum.

Anesthetic management of the adult patient with congenital heart disease

As the number of CHD repairs in adults continues to increase, these operations will be performed in a wider variety of institutions and systems. Unfortunately, not all of these centers will have an optimal environment for correcting CHD in adults. This type of surgery is best accomplished in a facility specifically designed for treating adults with CHD. Optimal care of these patients is provided by cardiologists who are trained and experienced in pediatric and adult cardiology, by surgeons who are trained and experienced in treating CHD, and by anesthesiologists who are experienced in caring for adults with CHD. Whatever the setting, cardiac anesthesiologists involved in these cases must be thoroughly aware of the anesthetic implications for the unique pathophysiology of each patient, and they must not rely on their "usual" expectations of either true pediatric CHD or acquired adult heart disease.

Truncus arteriosus repair: outcomes, risk factors, reoperation and management

OBJECTIVES

Truncus arteriosus (TA) continues to be associated with significant morbidity and mortality, but there have been clinically significant improvements with early repair.

METHODS

Sixty patients underwent physiological correction of TA between November 1978 and January 2000. The average age was 76 days (range, 3 days--20 months). Associated cardiac anomalies were frequently encountered, the most common being severe truncal valve regurgitation (n=7), interrupted aortic arch (n=6), coronary artery anomalies (n=6), non-confluent pulmonary arteries (n=4), and total anomalous pulmonary venous return (n=1). Truncal valve replacement was performed initially or subsequently in seven patients with severe regurgitation (mechanical prostheses in six patients and a cryopreserved aortic homograft in one patient). Right ventricle--pulmonary artery continuity was established with an aortic (n=16) or pulmonary homograft (n=32) in 48 patients, a Dacron polyester porcine valved conduit in five, a non-valved polytetrafluoroethylene (PTFE) tube in three, direct anastomosis to the right ventricle with anterior patch arterioplasty in three, and a bovine jugular venous valve conduit in one patient.

RESULTS

There were ten hospital deaths (17%; 70% confidence limit, 7--25%). Multivariate and univariate analyses demonstrated a relationship between hospital mortality and associated cardiac anomalies. In the 43 patients without these associated cardiac anomalies, the early survival was 91% (group I). In the 17 patients with one or more of these risk factors, the survival was 71% (group II, P=0.002). There was one late death. Twenty-three patients (46%) required reoperation for right ventricular outflow tract (RVOT) obstruction at a mean follow-up time of 59.1 months. In 23 patients, the RVOT reconstruction was performed with a PTFE monocusp, and six patients had of a variety of replacement conduits inserted. Postoperatively, there were 34 (68%) patients in New York Heart Association functional class I and 16 (32%) in class II. Twenty-eight surviving patients are reported as doing well without any medication. The freedom of reoperation in the 39 hospital survivors (group I) without risk factors was 64% at 7 years; and 36% at 10 years in the 11 patients (group II) surviving with risk factors.

CONCLUSIONS

Associated cardiac anomalies were risk factors for death after the repair of TA. In the absence of these associated lesions, TA can be repaired with an excellent surgical outcome in the neonatal and early infancy period.

Performance of allografts and xenografts for right ventricular outflow tract reconstruction

BACKGROUND

We compared the long-term durability of allografts and xenografts implanted for reconstruction of the right ventricular outflow tract.

METHODS

A total of 401 patients were studied from January 1974 to June 2000 (145 xeno- and 256 allografts), follow-up being 98% complete. We analyzed freedom from reoperation and allograft specific factors that may indicate degeneration.

RESULTS

The age at implantation was 2 days to 31 years (median 4.0 years). Conduit exchange rate was similar (p = 0.2) for conduit diameters less than 15 mm (41%+/-9% for allografts, 30%+/-6% for xenografts), but significantly different (p = 0.02) for diameters of 15 mm or larger (60%+/-8% for allografts, 30%+/-10% for xenografts). Diagnosis-related 20-year survival analysis showed a significantly (p = 0.01) better survival of patients with tetralogy of Fallot/pulmonary atresia (83%+/-5%) and Rastelli-type surgery (81%+/-8%) compared with patients with truncus arteriosus communis (69%+/-8%). ABO-compatibility, preservation method, and aortic or pulmonary allograft could not be identified as risk factors for allograft longevity.

CONCLUSIONS

For smaller diameters (less than 15 mm), allografts exhibit no advantage over xenografts, whereas in larger diameters (15 mm or larger) allografts are the conduit of choice for the right ventricular outflow tract.