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Geoffrion TR, Fuller SM. High-Risk Anatomic Subsets in Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2022; 13:593-599. [PMID: 36053102 DOI: 10.1177/21501351221111390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite overall improvements in outcomes for patients with hypoplastic left heart syndrome, there remain anatomic features that can place these patients at higher risk throughout their treatment course. These include severe preoperative obstruction to pulmonary venous return, restrictive atrial septum, coronary fistulae, severe tricuspid regurgitation, smaller ascending aorta diameter (especially if <2 mm), and poor ventricular function. The risk of traditional staged palliation has led to the development of alternative strategies for such patients. To further improve the outcomes, we must continue to diligently examine and study anatomic details in HLHS patients.
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Affiliation(s)
- Tracy R Geoffrion
- Division of Cardiothoracic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Cardiothoracic Surgery, Department of Surgery, 14640Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Caneo LF, Turquetto ALR, Neirotti RA, Binotto MA, Miana LA, Tanamati C, Penha JG, Silveira JBD, Alexandre e Silva TM, Jatene FB, Jatene MB. Lessons Learned From a Critical Analysis of the Fontan Operation Over Three Decades in a Single Institution. World J Pediatr Congenit Heart Surg 2017; 8:376-384. [DOI: 10.1177/2150135117701405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The Fontan operation (FO) has evolved and many centers have demonstrated improved results relative to those from earlier eras. We report a single-institution experience over three decades, describing the outcomes and evaluating risk factors. Methods: Successive patients undergoing primary FO were divided into era I (1984-1994), era II (1995-2004), and era III (2005-2014). Clinical and operative notes were reviewed for demographic, anatomic, and procedure details. End points included early and late mortality and a composite of death, heart transplantation (HTX), or Fontan takedown. Results: A total of 420 patients underwent 18 atriopulmonary connections, 82 lateral tunnels (LT), and 320 extracardiac conduit (EC) Fontan procedures. Forty-six (11%) patients died; early and late mortality were 7.9% and 3.1%, respectively. Eight (1.9%) patients underwent HTX, 11 (2.6%) underwent Fontan conversion to EC, and 1 (0.2%) takedown of EC to bidirectional Glenn shunt. Prevalence of concomitant valve surgery ( P < .001) and pulmonary artery reconstruction ( P < .001) differed over the eras. Preoperative valve regurgitation was associated with likelihood of early mortality (odds ratio [OR] = 3.5, P = .002). Embolic events (OR = 1.9, P = .047), preoperative valve regurgitation (OR = 2.3, P = .029), diagnosis of unbalanced atrioventricular canal defect (OR = 1.14, P = .03), and concomitant valve replacement (OR = 6.9, P = .001) during the FO were associated with increased risk of the composite end point (death, HTX, or takedown). Conclusion: Technical modifications did not result in improved results across eras, due in part to more liberal indications for surgery in the recent years. Valve regurgitation, unbalanced atrioventricular canal, embolic events, or concomitant valve replacement were associated with FO failure.
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Affiliation(s)
- Luiz Fernando Caneo
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Aida L. R. Turquetto
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rodolfo A. Neirotti
- Surgery and Pediatrics, Emeritus Michigan State University, East Lansing, MI, USA
| | - Maria A. Binotto
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Leonardo A. Miana
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carla Tanamati
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Juliano G. Penha
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - João B. D. Silveira
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Fabio B. Jatene
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo B. Jatene
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Laux D, Vergnat M, Lambert V, Gouton M, Ly M, Peyre M, Roussin R, Belli E. Atrio-ventricular valve regurgitation in univentricular hearts: outcomes after repair†. Interact Cardiovasc Thorac Surg 2015; 20:622-9; discussion 629-30. [PMID: 25690458 DOI: 10.1093/icvts/ivv011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/19/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim was to describe the early and mid-term outcome after atrio-ventricular valve (AVV) repair in patients with univentricular hearts (UVHs) and to identify risk factors for AVV reoperation and death. METHODS This study is a retrospective review of patients undergoing valve repair for AVV regurgitation at any stage of univentricular palliation from 1998 to 2014. Patient- and procedure-related variables were analysed. RESULTS A total of 31 consecutive patients underwent 38 procedures for ≥ moderate AVV regurgitation at a median age of 3.6 years. Thirty-two percent of patients had a common AVV, 26% had two AVVs, 22% had a dominant tricuspid valve and 19% had a dominant mitral valve. All patients underwent valve repair as a first procedure without early mortality. At discharge, patients preserved their ventricular function (fractional shortening <30%: preoperative 16% vs postoperative 22.5%, NS). In 19% (n = 6) of patients, the procedure was considered as failed because of significant residual regurgitation. There were three late deaths [median delay: 1 year (range 0.7-13.6)] and three heart transplantations. Six patients underwent seven AVV reoperations [median delay: 2 years (range 0.2-7.6)]. Longer intensive care stay (P = 0.022), longer total postoperative hospital stay (P = 0.039), higher total number of surgeries (P = 0.039), lower body mass index (P = 0.042) and higher preoperative mean pulmonary pressure (P = 0.047) were univariate risk factors for death/transplantation. Failed first AVV repair (P = 0.01), higher total number of surgeries (P = 0.026), lower body mass index (P = 0.031), male gender (P = 0.031) and need for valve repair before bidirectional cavopulmonary connection (P = 0.036) were univariate risk factors for AVV reoperation. In multivariate analysis, no univariate risk factor reached statistical significance. Freedom from death/transplantation was 84% (CI 95%: 70%-98%) at 5 and 10 years. Survival free from AVV reoperation was 72% (CI 95%: 52%-92%) at 5 years and 62% at 10 years (CI 95%: 36%-88%). Mean follow-up of survivors was 4.7 years (SD ± 4.3; range 0.2-15.6). At last visit, 96% of survivors were in NYHA Class I-II. Ninety-two percent had a ≤ mild residual regurgitation. CONCLUSIONS In patients with a UVH and ≥ moderate AVV regurgitation, AVV repair is feasible without postoperative deterioration of their ventricular function. Nevertheless, these patients remain at increased risk for death/transplantation and AVV reoperation.
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Affiliation(s)
- Daniela Laux
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Mathieu Vergnat
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Virginie Lambert
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Marielle Gouton
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Mohamed Ly
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Marianne Peyre
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Regine Roussin
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
| | - Emre Belli
- Department of Pediatric and Congenital Heart Disease-M3C, Marie Lannelongue Hospital, University Paris Sud, Le Plessis Robinson, France
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