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Hazekamp MG, Barron DJ, Dangel J, Homfray T, Jongbloed MRM, Voges I. Consensus document on optimal management of patients with common arterial trunk. Eur J Cardiothorac Surg 2021; 60:7-33. [PMID: 34017991 DOI: 10.1093/ejcts/ezaa423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 01/12/2023] Open
Affiliation(s)
- Mark G Hazekamp
- Department of Cardiothoracic Surgery, University Hospital Leiden, Leiden, Netherlands
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Joanna Dangel
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Tessa Homfray
- Department of Medical Genetics, Royal Brompton and Harefield hospitals NHS Trust, London, UK
| | - Monique R M Jongbloed
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Inga Voges
- Department for Congenital Cardiology and Pediatric Cardiology, University Medical Center of Schleswig-Holstein, Kiel, Germany
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Multicenter Analysis of Truncal Valve Management and Outcomes in Children with Truncus Arteriosus. Pediatr Cardiol 2020; 41:1473-1483. [PMID: 32620981 DOI: 10.1007/s00246-020-02405-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
Truncal valve management in patients with truncus arteriosus is a clinical challenge, and indications for truncal valve intervention have not been defined. We sought to evaluate truncal valve dysfunction and primary valve intervention in patients with truncus arteriosus and determine risk factors for later truncal valve intervention. We conducted a retrospective cohort study of children who underwent truncus arteriosus repair at 15 centers between 2009 and 2016. Multivariable competing risk analysis was performed to determine risk factors for later truncal valve intervention. We reviewed 252 patients. Forty-two patients (17%) underwent truncal valve intervention during their initial surgery. Postoperative extracorporeal support, CPR, and operative mortality for patients who underwent truncal valve interventions were statistically similar to the rest of the cohort. Truncal valve interventions were performed in 5 of 64 patients with mild insufficiency; 5 of 16 patients with mild-to-moderate insufficiency; 17 of 35 patients with moderate insufficiency; 5 of 9 patients with moderate-to-severe insufficiency; and all 10 patients with severe insufficiency. Twenty patients (8%) underwent later truncal valve intervention, five of whom had no truncal valve intervention during initial surgical repair. Multivariable analysis revealed truncal valve intervention during initial repair (HR 11.5; 95% CI 2.5, 53.2) and moderate or greater truncal insufficiency prior to initial repair (HR 4.0; 95% CI 1.1, 14.5) to be independently associated with later truncal valve intervention. In conclusion, in a multicenter cohort of children with truncus arteriosus, 17% had truncal valve intervention during initial surgical repair. For patients in whom variable truncal valve insufficiency is present and primary intervention was not performed, late interventions were uncommon. Conservative surgical approach to truncal valve management may be justifiable.
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Naimo PS, Konstantinov IE. Surgery for Truncus Arteriosus: Contemporary Practice. Ann Thorac Surg 2020; 111:1442-1450. [PMID: 32828754 DOI: 10.1016/j.athoracsur.2020.06.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/24/2020] [Accepted: 06/03/2020] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Phillip S Naimo
- Department of Cardiothoracic Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Igor E Konstantinov
- Department of Cardiothoracic Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne Center for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Victoria, Australia.
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Abstract
OBJECTIVES Early surgical management of common arterial trunk is well established and has good prognosis. Late diagnosis is less common. We reviewed late-diagnosed common arterial trunk management and prognosis for children in developing countries. We also discuss the need for prior catheterisation. Material and methods We reviewed all common arterial trunk patients managed by our humanitarian organization since 1996. RESULTS A total of 41 children with common arterial trunk were managed at a mean age of 3 years old. The lack of adequate facilities in developing countries explains the late management. The decision to proceed with surgery was based on clinical and radiological symptoms of persistent shunt, particularly a high cutaneous saturation level, regardless of catheterization - not carried out systematically. Eight children had to be withdrawn and 33 (80.5%) received operation - mean saturation 91%. The postoperative course was marked by pulmonary arterial hypertension requiring specific treatment in 30% of cases. The operative mortality was 1/33. The 32 children returned home without treatment after a mean post operative stay of 49 days and were followed up (mean FU 3.4 years, none lost to follow-up). At last contact, 1 child died six months after surgery, 1 child had a massive truncal valve insufficiency, 5 had a significant stenosis of the RV-PA tube, and 2 have had further surgery for tube replacement. CONCLUSIONS Late management and surgery of common arterial trunk is possible with good long-term results without prior hemodynamic examination up to an advanced childhood when signs of left-to-right shunt persist. A high saturation level (above 88%) seems to be a good operability criterion.
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Role of computed tomography angiography in the differentiation of feline truncus arteriosus communis from pulmonary atresia with ventricular septal defect. J Vet Cardiol 2017; 19:514-522. [DOI: 10.1016/j.jvc.2017.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/11/2017] [Accepted: 09/21/2017] [Indexed: 01/12/2023]
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Justice L, Ellis M, St George-Hyslop C, Donnellan A, Trauth A, Drouillard B, Watt C, Callow L. Utilizing the PCICS Nursing Guidelines in Managing the CICU Patient. World J Pediatr Congenit Heart Surg 2016; 6:604-15. [PMID: 26467875 DOI: 10.1177/2150135115593131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Pediatric Cardiac Intensive Care Society (PCICS) Nursing Guidelines were developed to provide an evidence-based resource for bedside cardiac intensive care unit nursing care. Guideline topics include postoperative care, hemodynamic monitoring, arrhythmia management, and nutrition. These evidence-based care guidelines were presented at the 10th International Meeting of PCICS and have been utilized in the preparation of this article. They can be accessed at http://www.pcics.org/resources/pediatric-neonatal/. Utilization of these guidelines in practice is illustrated for single ventricle stage 1 palliation, Fontan operation, truncus arteriosus, and atrioventricular septal defect.
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Affiliation(s)
- Lindsey Justice
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Misty Ellis
- Department of Pediatric Critical Care, University of Louisville, Kosair Children's Hospital, Louisville, KY, USA
| | - Cecilia St George-Hyslop
- Department of Cardiac Critical Care. Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amy Donnellan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amiee Trauth
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Brenda Drouillard
- Department of Cardiac Critical Care. Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Claire Watt
- Department of Cardiac Critical Care. Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Louise Callow
- Michigan Congenital Heart Center, University of Michigan, CS Mott Children's Hospital, Ann Arbor, MI, USA
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Patrick WL, Mainwaring RD, Carrillo SA, Ma M, Reinhartz O, Petrossian E, Selamet Tierney ES, Reddy VM, Hanley FL. Anatomic Factors Associated With Truncal Valve Insufficiency and the Need for Truncal Valve Repair. World J Pediatr Congenit Heart Surg 2015; 7:9-15. [DOI: 10.1177/2150135115608093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Truncus arteriosus is a complex and heterogeneous form of congenital heart defect. Many of the risk factors from several decades ago, including late repair and interrupted aortic arch, have been mitigated through better understanding of the entity and improved surgical techniques. However, truncal valve dysfunction remains an important cause of morbidity and mortality. The purpose of this study was to evaluate the anatomic factors associated with truncal valve dysfunction and the need for truncal valve surgery. Methods: This was a retrospective review of 72 infants who underwent repair of truncus arteriosus at our institution. The median age at surgery was nine days, and the median weight was 3.1 kg. Preoperative assessment of truncal valve insufficiency by echocardiography revealed no or trace insufficiency in 30, mild in 25, moderate in 10, and severe in 7. The need for truncal valve surgery was dictated by the severity of truncal valve insufficiency. Results: Sixteen (22%) of the 72 patients undergoing truncus arteriosus repair had concomitant truncal valve surgery. Anatomic factors associated with the need for truncal valve surgery included an abnormal number of truncal valve cusps ( P < .005), presence of valve dysplasia ( P < .005), and the presence of an anomalous coronary artery pattern ( P < .005). Fifteen (94%) of the sixteen patients who underwent concomitant surgery had two or all three of these anatomic factors (sensitivity = 94%, specificity = 85%). Conclusion: This study demonstrates that the presence of specific anatomic factors was closely associated with the presence of truncal valve insufficiency and the need for concomitant truncal valve surgery. Preoperative evaluation of these anatomic factors may provide a useful tool in determining who should undergo concomitant truncal valve surgery.
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Affiliation(s)
- William L. Patrick
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Richard D. Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Sergio A. Carrillo
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Michael Ma
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Olaf Reinhartz
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
- Division of Pediatric Cardiac Surgery, Oakland Children’s Hospital, Oakland, CA, USA
| | - Edwin Petrossian
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
- Division of Pediatric Cardiac Surgery, Central Valley Children’s Hospital, Madera, CA, USA
| | - Elif Seda Selamet Tierney
- Division of Pediatric Cardiology, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - V. Mohan Reddy
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Frank L. Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
- Division of Pediatric Cardiac Surgery, Oakland Children’s Hospital, Oakland, CA, USA
- Division of Pediatric Cardiac Surgery, Central Valley Children’s Hospital, Madera, CA, USA
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Variation in Use of Pediatric Cardiology Subspecialty Care: A Total Population Study in California, 1983 to 2011. J Am Coll Cardiol 2015; 66:37-44. [PMID: 26139056 DOI: 10.1016/j.jacc.2015.04.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 04/21/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND American Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD). OBJECTIVES This study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011. METHODS We performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program. RESULTS There were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period. CONCLUSIONS California's inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.
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Sandrio S, Rüffer A, Purbojo A, Glöckler M, Dittrich S, Cesnjevar R. Common arterial trunk: current implementation of the primary and staged repair strategies. Interact Cardiovasc Thorac Surg 2015; 21:754-60. [PMID: 26362626 DOI: 10.1093/icvts/ivv261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/11/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In this study, we report our experience on the primary and staged surgical approaches for common arterial trunk (CAT) repair. METHODS Between August 2003 and February 2015, 16 consecutive patients underwent CAT repair in our institution. Two different approaches have been followed: group 'primary repair' (PR) consists of patients suitable for straightforward CAT repair, who underwent surgery electively at 1-3 months of age (n = 13); group 'staged repair' (SR) consists of critically ill neonates with CAT and poor preoperative status or coexisting interrupted aortic arch (n = 3). They underwent staged CAT repair with aortic arch repair and right ventricular-to-pulmonary artery (RV-PA) shunt within the neonatal period, followed by an intracardiac repair later in infancy. RESULTS Median age at initial surgical treatment was 8 days (range: 7-21 days) in group SR and 34 days (range: 14-91 days) in group PR (P = 0.03). Mean Aristotle Comprehensive Complexity score was 11 ± 0.6 (range: 11-13) in group PR and 18 ± 3.1 (range: 15-21) in group SR (P < 0.01). Follow-up was completed with a median duration of 3.6 years (range: 8 months to 11 years). There was neither early nor late mortality in both groups. In group SR, the median interval to second stage surgery was 216 days (range: 216-260 days). Seven patients (54%) in group PR required reoperation for RV-PA conduit failure (n = 4), truncal valve repair/replacement (n = 2) or both (n = 1). After initial surgery, Kaplan-Meier freedom from reoperation after 1, 2 and 8 years was 77 ± 12, 68 ± 13 and 20 ± 17% in group PR, and 0% in group SR (log-rank P < 0.01). Although all patients in group SR required reoperation to complete the anatomical correction (second stage procedure), there was no surgical reintervention of truncal valve and aortic arch thereafter. CONCLUSIONS Routine elective CAT repair could be safely performed at 1-3 months of age. However, neonatal CAT repair could be associated with a higher mortality especially in the presence of an interrupted aortic arch. In such cases, a staged CAT repair seems to be associated with favourable postoperative course and improved hospital survival, despite the inevitable need for reoperation, which can be performed at a relatively low risk.
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Affiliation(s)
- Stany Sandrio
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - André Rüffer
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Ariawan Purbojo
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Martin Glöckler
- Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Robert Cesnjevar
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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