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Tucker DL, Lee LJ, Ahmad M, Shaheen N, Gupta S, Najm HK, Hammoud MS, Tretter JT, Karamlou T. Surgical strategies to address re-operative complex left ventricular outflow tract and thoracic aortic pathology: Cleveland Clinic children's experience. Cardiol Young 2023; 33:2559-2566. [PMID: 37013896 DOI: 10.1017/s1047951122003936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Complex patients requiring operations on the left ventricular outflow tract, aortic valve, or thoracic aorta after previous repair of aortopathy constitute a challenging group, with limited information guiding decision-making. We aimed to use our institutional experience to highlight management challenges and describe surgical pearls to address them. METHODS Forty-one complex patients with surgery on the left ventricular outflow tract, aortic valve, or aorta at Cleveland Clinic Children's between 2016 and 2021 following previous repair of aortic pathology were retrospectively reviewed. Patients with known connective tissue disease or single ventricle circulation were excluded. RESULTS Median age at index procedure was 23 years (range 0.25-48) with median of 2 prior sternotomies. Previous aortic operations included subvalvular (n = 9), valvular (n = 6), supravalvular (n = 13), and multi-level surgeries (n = 13). Four deaths occurred in median follow-up of 2.5 years. Mean left ventricular outflow tract gradients improved significantly for patients with obstruction (34.9 ± 17.5 mmHg versus 12.6 ± 6.0 mmHg; p < 0.001). Technical pearls include the following: 1) liberal use of anterior aortoventriculoplasty with valve replacement; 2) primarily anterior aortoventriculoplasty following the subpulmonary conus in contrast to more vertical incision for post-arterial switch operation patients; 3) pre-operative imaging of mediastinum and peripheral vasculature for cannulation and sternal re-entry; and 4) proactive use of multi-site peripheral cannulation. CONCLUSIONS Operation to address the left ventricular outflow tract, aortic valve, or aorta following prior congenital aortic repair can be accomplished with excellent outcomes despite high complexity. These procedures commonly include multiple components, including concomitant valve interventions. Cannulation strategies and anterior aortoventriculoplasty in specific patients require modifications.
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Affiliation(s)
- Dominique L Tucker
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Leah J Lee
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Munir Ahmad
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Naseeb Shaheen
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sohini Gupta
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Miza Salim Hammoud
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Implications of Transfusion in Adults with Congenital Heart Disease Undergoing Cardiac Surgery. Pediatr Cardiol 2023; 44:218-227. [PMID: 35963890 DOI: 10.1007/s00246-022-02981-2] [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: 04/05/2022] [Accepted: 07/21/2022] [Indexed: 01/24/2023]
Abstract
The number of adults with congenital heart disease (CHD) requiring cardiovascular (CV) surgery is increasing rapidly in today's era. We hypothesized that exposure to perioperative blood products is associated with worse outcomes in adults. All adults (≥ 18 years old) undergoing CV surgery with Cardio-Pulmonary Bypass (CPB) between 2015 and 2020 were reviewed retrospectively. Associations between transfusion and outcomes were studied by univariable logistic regression and Wilcoxon rank sum tests. Cox/ logistic regression was used to assess (a) postoperative ventilation time and length of stay, and (b) major complications, respectively. Of 323 patients, 170 (53%) received blood products perioperatively. The median age was 27 (interquartile range [IQR]: 22-36) years, there were 181 (46%) males, and 16 (5%) patients had single ventricle anatomy. Patients receiving products experienced more complications (OR: 6.6, 95% CI: [2.9, 14.7], p < 0.001) specifically, cardiac arrest (OR: 8.8, 95% CI: [1.1, 71.9], p = 0.04). Transfusion was associated with greater frequency of thrombosis ((OR: 7.8, 95% CI: [1.8, 34.7], p = 0.01)), longer ventilation time (HR: 3.0, 95% CI: [2.4, 3.9], p < 0.001), and longer hospital length of stay (HR: 2.7, 95% CI: [2.1, 3.4], p < 0.001). Longer CPB time (OR: 1.0, 95% CI: [1.0, 1.1], p < 0.001) and prior cardiac surgery (OR: 1.6, 95% CI: [1.3, 2.1], p < 0.001) were independent predictors of perioperative blood product transfusion. Adults who received perioperative blood products experienced more complications and worse in-hospital outcomes. Future research on optimizing blood product transfusion based on risk prediction is needed to optimize outcomes in adults with CHD.
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Harrison JH, Dhawan R, Essandoh MK, Dalia AA, Cotter EK, Stoops S, Chaney MA. Complex Reoperation in a Patient With DiGeorge Syndrome. J Cardiothorac Vasc Anesth 2020; 34:1655-1662. [PMID: 32144064 DOI: 10.1053/j.jvca.2020.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 11/11/2022]
Affiliation(s)
- John-Henry Harrison
- Department of Anesthesiology, School of Medicine & Public Health, University of Wisconsin-Madison, Madison, WI
| | - Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Michael K Essandoh
- Cardiovascular Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Division of Cardiac Anesthesiology, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Elizabeth K Cotter
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Shea Stoops
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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Sfyridis PG, Mylonas KS, Kalangos A. Abdominal Vessel Cannulation Before Resternotomy in Complex Congenital Heart Surgery. Ann Thorac Surg 2019; 109:e219-e221. [PMID: 31589855 DOI: 10.1016/j.athoracsur.2019.08.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/01/2022]
Abstract
Repeat cardiac operations are common among patients with complex congenital heart disease. Inadvertent cardiotomy during redo sternotomy can increase intraoperative time and mortality. Establishing extracorporeal circulation before resternotomy may render redo congenital cardiac surgery cases safer and more expeditious. In the present report, we describe the technique of preemptive cannulation of the abdominal aorta (or right common iliac artery) and inferior vena cava. This approach may be a useful when femoral vessels are occluded owing to many catheterizations or prior cannulations. In our practice, no reentry injuries or other complications related to abdominal vessel cannulation have occurred.
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Affiliation(s)
| | | | - Afksendiyos Kalangos
- Department of Pediatric Cardiac Surgery, Mitera Children's Hospital, Athens, Greece
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Warnes CA. Adult congenital heart disease: the challenges of a lifetime. Eur Heart J 2018; 38:2041-2047. [PMID: 28011704 DOI: 10.1093/eurheartj/ehw529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
The growing population of adults with congenital heart disease (CHD) poses challenges for cardiac surgeons, general cardiologists and CHD sub specialists. The patients themselves, often believing themselves to be 'totally corrected' following operative repair, also face challenges with re-operations and lifelong cardiac problems. This review examines the challenges of the past, present and future for both medical providers and patients.
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Affiliation(s)
- Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Gu X, Zhang Q, Sun H, Fei J, Zhang X, Kutryk MJ. Transcatheter Closure Versus Repeat Surgery for the Treatment of Postoperative Left-to-Right Shunts: A Single Center 15-Year Experience. Cardiol Res 2018; 8:286-292. [PMID: 29317971 PMCID: PMC5755660 DOI: 10.14740/cr629e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/05/2017] [Indexed: 11/28/2022] Open
Abstract
Background Repeat surgery and the percutaneous approach (transcatheter closure (TCC)) have been used for the management of postoperative left-to-right shunts. In this study, we described our 15 years of experience in treating postoperative left-to-right shunts with these two approaches. Methods From February 2002 to February 2017, 50 patients with residual left-to-right shunts, following cardiac surgery, were treated using TCC or repeat surgery. Clinical examination, standard 12-lead electrocardiography, chest X-ray, and a transthoracic echocardiogram were performed before hospital discharge and at all follow-ups. Results The closure rate was 100% in both groups and there was no procedure-related mortality. Patients with TCC had few complications. The procedure time and duration of hospital stay for TCC patients were 58.9 ± 27.7 min and 6.1 ± 0.8 days, respectively. Eleven out of 19 patients receiving reoperation suffered serious complications after surgery, e.g., bleeding and nosocomial infections. The operation time and duration of hospital stay for reoperation patients were 256.7 ± 60.5 min and 17.0 ± 4.0 days, respectively. No other serious complications were seen at all follow-up visits for both groups. Conclusions In conclusions, TCC is safe and effective for the management of postoperative left-to-right shunts, and is associated with few complications, which can be the favored closure strategy over repeat surgery for the management of postoperative left-to-right shunts.
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Affiliation(s)
- Xinghua Gu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan 250012, China
| | - Qiuwang Zhang
- Division of Cardiology, Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Hourong Sun
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan 250012, China
| | - Jianchun Fei
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan 250012, China
| | - Xiquan Zhang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan 250012, China
| | - Michael J Kutryk
- Division of Cardiology, Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Villa-Hincapie CA, Carreno-Jaimes M, Obando-Lopez CE, Camacho-Mackenzie J, Umaña-Mallarino JP, Sandoval-Reyes NF. Risk Factors for Mortality in Reoperations for Pediatric and Congenital Heart Surgery in a Developing Country. World J Pediatr Congenit Heart Surg 2017; 8:435-439. [PMID: 28696882 DOI: 10.1177/2150135117704657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The survival of patients with congenital heart disease has increased in the recent years, because of enhanced diagnostic capabilities, better surgical techniques, and improved perioperative care. Many patients will require reoperation as part of staged procedures or to treat grafts deterioration and residual or recurrent lesions. Reoperations favor the formation of cardiac adhesions and consequently increase surgery time; however, the impact on morbidity and operative mortality is certain. The objective of the study was to describe the risk factors for mortality in pediatric patients undergoing a reoperation for congenital heart disease. METHODS Historic cohort of patients who underwent reoperation after pediatric cardiac surgery from January 2009 to December 2015. Operations with previous surgical approach different to sternotomy were excluded from the analysis. RESULTS In seven years, 3,086 surgeries were performed, 481 were reoperations, and 238 patients fulfilled the inclusion criteria. Mean number of prior surgeries was 1.4 ± 0.6. Median age at the time of reoperation was 6.4 years. The most common surgical procedures were staged palliation for functionally univentricular heart (17.6%). Median cross-clamp time was 66 minutes. Younger age at the moment of resternotomy, longer cross-clamp time, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery (STAT) Mortality Categories risk category greater than three were risk factors for mortality. The number of resternotomies was not associated with mortality. Mortality prior to hospital discharge was 4.6%, and mortality after discharge but prior to 30 days after surgery was 0.54%. Operative mortality was 5.1%. CONCLUSIONS Resternotomy in pediatric cardiac surgery is a safe procedure in our center.
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Affiliation(s)
- Carlos A Villa-Hincapie
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Marisol Carreno-Jaimes
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia
| | - Carlos E Obando-Lopez
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Jaime Camacho-Mackenzie
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Juan P Umaña-Mallarino
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Nestor F Sandoval-Reyes
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
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Holst KA, Said SM, Nelson TJ, Cannon BC, Dearani JA. Current Interventional and Surgical Management of Congenital Heart Disease: Specific Focus on Valvular Disease and Cardiac Arrhythmias. Circ Res 2017; 120:1027-1044. [PMID: 28302746 DOI: 10.1161/circresaha.117.309186] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 01/15/2023]
Abstract
Successful outcome in the care of patients with congenital heart disease depends on a comprehensive multidisciplinary team. Surgery is offered for almost every heart defect, despite complexity. Early mortality for cardiac surgery in the neonatal period is ≈10% and beyond infancy is <5%, with 90% to 95% of patients surviving with a good quality of life into the adult years. Advances in imaging have facilitated accurate diagnosis and planning of interventions and surgical procedures. Similarly, advances in the perioperative medical management of patients, particularly with intensive care, has also contributed to improving outcomes. Arrhythmias and heart failure are the most common late complications for the majority of defects, and reoperation for valvar problems is common. Lifelong surveillance for monitoring of recurrent or residual structural heart defects, as well as periodic assessment of cardiac function and arrhythmia monitoring, is essential for all patients. The field of congenital heart surgery is poised to incorporate new innovations such as bioengineered cells and scaffolds that will iteratively move toward bioengineered patches, conduits, valves, and even whole organs.
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Affiliation(s)
- Kimberly A Holst
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Sameh M Said
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Timothy J Nelson
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Bryan C Cannon
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN.
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Strange G, Brizard C, Karl TR, Neethling L. An evaluation of Admedus' tissue engineering process-treated (ADAPT) bovine pericardium patch (CardioCel) for the repair of cardiac and vascular defects. Expert Rev Med Devices 2014; 12:135-41. [PMID: 25431988 DOI: 10.1586/17434440.2015.985651] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Tissue engineers have been seeking the 'Holy Grail' solution to calcification and cytotoxicity of implanted tissue for decades. Tissues with all of the desired qualities for surgical repair of congenital heart disease (CHD) are lacking. An anti-calcification tissue engineering process (ADAPT TEP) has been developed and applied to bovine pericardium (BP) tissue (CardioCel, AdmedusRegen Pty Ltd, Perth, WA, Australia) to eliminate cytotoxicity, improve resistance to acute and chronic inflammation, reduce calcification and facilitate controlled tissue remodeling. Clinical data in pediatric patients, and additional pre-market authorized prescriber data demonstrate that CardioCel performs extremely well in the short term and is safe and effective for a range of congenital heart deformations. These data are supported by animal studies which have shown no more than normal physiologic levels of calcification, with good durability, biocompatibility and controlled healing.
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