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Smith J, Zampi JD, Balasubramanian S, Mosher B, Uzark K, Lowery R, Yu S, Romano JC. Use of Hybrid Stage I to Stratify Between Single Ventricle Palliation and Biventricular Repair. World J Pediatr Congenit Heart Surg 2024:21501351241247501. [PMID: 39118323 DOI: 10.1177/21501351241247501] [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: 08/10/2024]
Abstract
Background: Hybrid stage I palliation (HS1P) has been utilized for patients with single ventricle (SV) congenital heart disease (CHD). To date, reports on the use of HS1P for other indications including biventricular (BiV) CHD have been limited. Methods: We performed a single-center retrospective cohort study of patients who underwent HS1P with an anticipated physiologic outcome of BiV repair, or with an undetermined SV versus BiV outcome. Patient characteristics and outcomes from birth through definitive repair or palliation were collected and reported with descriptive statistics. Results: Nineteen patients underwent HS1P with anticipated BiV repair. Extracardiac and intracardiac risk factors (ICRF) were common. Ultimately, 13 (68%) patients underwent BiV repair, 1 (5%) underwent SV palliation, and 5 (26%) died prior to further palliation or repair. Resolution of ICRF tracked with BiV outcome (6/6, 100%), persistence of ICRF tracked with SV outcome or death (3/3, 100%). Twenty patients underwent HS1P with an undetermined outcome. Ultimately, 13 (65%) underwent BiV repair, 6 (30%) underwent SV palliation, and 1 (5%) underwent transplant. There were no deaths. Intracardiac risk factors were present in 15 of 20 patients (75%); BiV repair only occurred when all ICRF resolved (67%). Post-HS1P complications and reinterventions occurred frequently in both groups, through all phases of care. Conclusions: Hybrid stage 1 palliation can be used to defer BiV repair and to delay decision between SV palliation and BiV repair. Resolution of ICRF was associated with ultimate outcome. In this high-risk group, complications are common, and mortality especially in the marginal BiV patient is high.
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Affiliation(s)
- Justin Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester, Rochester, NY, USA
| | - Jeffrey D Zampi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sowmya Balasubramanian
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Bryan Mosher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Karen Uzark
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer C Romano
- Department of Cardiac Surgery and Pediatrics, Section of Pediatric Cardiovascular Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Pediatrics, Section of Pediatric Cardiovascular Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Eising JB, Bökenkamp R, Schneider AW, Kuipers IM, Hazekamp MG. Hybrid palliation to promote growth of left ventricle and left ventricular outflow tract. Eur J Cardiothorac Surg 2024; 66:ezae275. [PMID: 39037957 PMCID: PMC11288405 DOI: 10.1093/ejcts/ezae275] [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] [Received: 01/08/2024] [Revised: 04/30/2024] [Accepted: 07/19/2024] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVES In patients with borderline left hearts or a severe left ventricular outflow tract obstruction, hybrid palliation can be used to stabilize the patient and postpone biventricular repair (BVR). In this study, we analysed growth of left-sided structures and outcomes of these patients. METHODS We conducted a retrospective cohort study including patients who received hybrid palliation between January 2010 and September 2023. Echo measurements were collected at hybrid palliation, BVR and last follow-up. Growth of left ventricular structures were analysed. RESULTS In 38 patients, hybrid palliation was used to promote growth of left ventricular structures. In total, 15 patients received a Ross-Konno/Yasui procedure, while 23 patients received conventional BVR. In patients with a conventional BVR, a significant increase was found in left ventricular volume indexed by body surface area, Z-score of aortic valve and left ventricular outflow tract between hybrid palliation and BVR. Mitral valve Z-score did not increase significantly. After BVR until follow-up, only increase of the aortic valve Z-scores and left ventricular volume indexed by body surface area was found significant. Of all included patients (n = 38), additional surgical procedures were necessary in 8 patients during the interstage period and 15 patients after BVR. Additional catheter interventions were needed in 14 patients in the interstage period and 15 after BVR. Six patients died, with no mortality in the conventional BVR group. CONCLUSIONS Hybrid palliation as part of a staged BVR is a safe and effective initial step and promotes the growth of left ventricular structures in patients with small left-sided heart structures. Close follow-up is mandatory because extra catheter or surgical interventions are frequently needed.
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Affiliation(s)
- Jacobien B Eising
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Regina Bökenkamp
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Adriaan W Schneider
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Irene M Kuipers
- Department of Pediatric Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Mark G Hazekamp
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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Corno AF, Findley TO, Salazar JD. Narrative review of single ventricle: where are we after 40 years? Transl Pediatr 2023; 12:221-244. [PMID: 36891374 PMCID: PMC9986776 DOI: 10.21037/tp-22-573] [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: 11/05/2022] [Accepted: 01/10/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Key medical and surgical advances have been made in the longitudinal management of patients with "functionally" single ventricle physiology, with the principles of Fontan circulation applied to other complex congenital heart defects. The purpose of this article is to review all of the innovations, starting from fetal life, that led to a change of strategy for single ventricle. METHODS Our literature review included all full articles published in English language on the Cochrane, MedLine, and Embase with references to "single ventricle" and "univentricular hearts", including the initial history of the treatments for this congenital heart defects as well as the innovations reported within the last decades. KEY CONTENT AND FINDINGS All innovations introduced have been analyzed, including: (I) fetal diagnosis and interventions, in particular to prevent or reduce brain damages; (II) neonatal care; (III) post-natal diagnosis; (IV) interventional cardiology procedures; (V) surgical procedures, including neonatal palliations, hybrid procedures, bidirectional Glenn and variations, Fontan completion, biventricular repair; (VI) peri-operative management; (VII) Fontan failure, with Fontan take-down and conversion, and mechanical circulatory support; (VIII) transplantation, including heart, heart and lung, heart and liver; (IX) exercise; (X) pregnancy; (XI) adolescents and adults without Fontan completion; (XII) future studies, including experimental studies on animals, computational studies, genetics, stem cells and bioengineering. CONCLUSIONS These last 40 years have certainly changed the course of natural history for children born with any form of "functionally" single ventricle, thanks to the improvement in diagnostic and treatment techniques, and particularly to the increased knowledge of the morphology and function of these complex hearts, from fetal to adult life. There is still much left unexplored and room for improvement, and all efforts should be concentrated in collaborations among different institutions and specialties, focused on the same matter.
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Affiliation(s)
- Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Tina O Findley
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, TX, USA
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Corno AF, Koerner TS, Salazar JD. Innovative treatments for congenital heart defects. World J Pediatr 2023; 19:1-6. [PMID: 36481963 DOI: 10.1007/s12519-022-00654-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Antonio F Corno
- McGovern Medical School, Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health Science Center in Houston, 6410 Fannin Street, MSB 6.274, Houston, TX, 77030, USA.
| | - Taylor S Koerner
- McGovern Medical School, Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health Science Center in Houston, 6410 Fannin Street, MSB 6.274, Houston, TX, 77030, USA
| | - Jorge D Salazar
- McGovern Medical School, Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health Science Center in Houston, 6410 Fannin Street, MSB 6.274, Houston, TX, 77030, USA
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Akintürk H, Yörüker U, Müller M, Schranz D. Hypoplastic Left Ventricle: Left Ventricular Recruitment With Hybrid Approach. World J Pediatr Congenit Heart Surg 2022; 13:637-644. [PMID: 36053106 DOI: 10.1177/21501351221116274] [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
Decision-making for biventricular repair (BVR) or univentricular palliation is challenging in neonates with hypoplastic left heart complex (HLHC). Hybrid strategy can be used successfully to achieve BVR in some of these patients. Between June 1998 and January 2022, 342 patients with a diagnosis of HLHS/variants, ductal-dependent lower body circulation with two ventricles, or HLHC with borderline left ventricle (LV) underwent initial bilateral pulmonary artery banding and ductal stenting in our institution. Among these 342 patients, 224 patients were defined as HLHS/variants and underwent univentricular palliation. 118 patients were determined to have borderline LV and hypoplastic left ventricular structures (HLHC, n = 48) or ductal-dependent lower body circulation with two ventricles (n = 70) considered suitable for BVR. 48 patients had multilevel obstructions including both aortic and mitral valve hypoplasia, aortic arch hypoplasia, and borderline LV. These were considered to have HLHC. These 48 HLHC patients are the subject of this report. Neonatal hybrid palliation at a median age of seven days was performed in 48 patients and 46 patients underwent BVR at a median age of 156 days. In 46 patients who underwent BVR, hospital mortality was not observed. The median follow-up was 66 months, with no late mortality. Heart transplant-free survival at 5, 10, and 15 years was 95.7%. 12 patients (26%) required reoperation and 9 (19.5%) required catheter reinterventions. Hybrid palliation may increase the chances for biventricular circulation in patients with borderline LV and small left-sided structures. Giessen hybrid approach as a left ventricular recruitment strategy achieves excellent early and long-term results.
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Affiliation(s)
- Hakan Akintürk
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Uygar Yörüker
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Matthias Müller
- Department of Pediatric Cardiac Anestesiology, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Dietmar Schranz
- Department of Pediatric Cardiology, Goethe University, Frankfurt, Germany
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Intrauterine Valvuloplasty in Severe Aortic Stenosis-A Ten Years Single Center Experience. J Clin Med 2022; 11:jcm11113058. [PMID: 35683446 PMCID: PMC9181328 DOI: 10.3390/jcm11113058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/13/2022] [Accepted: 05/27/2022] [Indexed: 02/05/2023] Open
Abstract
Objective: To assess the course and outcome of fetal aortic valvuloplasty (FAV) in fetuses with severe aortic stenosis (SAS) in a single center. Methods: All fetuses with a prenatal diagnosis of SAS with subsequent FAV were retrospectively collected in one tertiary center for fetal medicine over a period of 10 years. In the study, period fetuses with SAS were considered suitable for FAV in the presence of markedly elevated left ventricular pressures (maximum velocity of mitral regurgitation (MR Vmax) >250 cm/s and/or maximum velocity of aortic stenosis (AS Vmax) >250 cm/s), retrograde flow in the transverse aortic arch and a left ventricular length Z-score >−1. Results: In the study period 29 fetuses with AS were treated with 38 FAV. If reinterventions are included 82.7% of fetuses received a technically successful FAV. Procedure related death occurred in three (10.3%) cases, spontaneous fetal death in 2 (6.9%), and termination of pregnancy was performed in 3 cases (10.3%). Among the 21 live births (72.4%), four died in infancy. Among the remaining survivors, 8/17 (47.1%) had a biventricular outcome at the age of one year, 8/17 (47.1%) were univentricular and one infant (5.9%) is biventricular at the age of eight months. Fetuses with biventricular outcome had significantly greater left ventricular (LV) length Z-scores (p = 0.031), and lower tricuspid to mitral valve (TV/MV) ratios (p = 0.003). Conclusions: FAV has a high technical success rate and a low rate of procedure related mortality if performed in experienced hands. The success rate of biventricular circulation at the age of one year is moderate and seems to depend rather on the center’s experience and postnatal surgical strategies than solely on prenatal selection criteria. In the absence of randomized controlled trials, FAV remains an experimental intervention.
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Greenleaf CE, Salazar JD. Biventricular Conversion for Hypoplastic Left Heart Variants: An Update. CHILDREN 2022; 9:children9050690. [PMID: 35626869 PMCID: PMC9139433 DOI: 10.3390/children9050690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022]
Abstract
Ongoing concerns with single-ventricle palliation morbidity and poor outcomes from primary biventricular strategies for neonates with borderline left heart structures have led some centers to attempt alternative strategies to obviate the need for ultimate Fontan palliation and limit the risk to the child during the vulnerable neonatal period. In certain patients who are traditionally palliated toward single-ventricle circulation, biventricular circulation is possible. This review aims to delineate the current knowledge regarding converting certain patients with borderline left heart structures from single-ventricle palliation toward biventricular circulation.
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Corno AF, Adebo DA, LaPar DJ, Salazar JD. Modern advances regarding interatrial communication in congenital heart defects. J Card Surg 2021; 37:350-360. [PMID: 34842296 DOI: 10.1111/jocs.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/12/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The interatrial communication, one of the most frequent congenital heart defects, represents an important intracardiac shunt between systemic and pulmonary circulations. Direction and magnitude of the interatrial shunting depends upon several features, including defect size, shape and location, pressure difference between right and left atrium, and difference in right and left ventricular compliance. METHODS In this review article, the presence or absence of interatrial communication, and its role, have been analyzed, as they can have a critical impact on the cardiovascular physiopathology, and the interatrial communication can prove to be either clinically harmful, useful or indispensable. Accordingly, the utility and role of the interatrial communication in modern congenital, pediatric and adult, disease has evolved, with modification of the indications to close, maintain patency, or create an interatrial communication. RESULTS The interatrial communication and shunting can be manipulated to maximize the oxygen delivery to the tissues, accordingly with the underlying congenital heart defect. While not always relevant to patients with bi-ventricular circulations, this becomes extremely important in children and adults with complex congenital heart defects. CONCLUSIONS With improving long-term survival for the vast majority of congenital heart patients, an advanced understanding of the role and utility of the interatrial communication, and of all the possibilities of its manipulation, is essential to improve the patient outcomes.
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Affiliation(s)
- Antonio F Corno
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Dilachew A Adebo
- Department of Pediatric and Congenital Cardiology, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Damien J LaPar
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Jorge D Salazar
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
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Corno AF, LaPar DJ, Li W, Salazar JD. A narrative review of modern approach and outcomes evaluation in congenital heart defects. Transl Pediatr 2021; 10:2114-2122. [PMID: 34584882 PMCID: PMC8429879 DOI: 10.21037/tp-21-163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/23/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The purpose of this review is to highlight critical advances and innovative approaches to the most challenging clinical situations in congenital heart surgery, to establish a new perspective from which to evaluate current clinical practice patterns and contemporary United States program ranking systems. BACKGROUND The past decades have witnessed substantial advances in the treatment of congenital heart defects. New strategies are deeply rooted in calculated risk-taking innovations. Pioneer surgeons developed, improved and refined critical operative skills and techniques to optimize cardiovascular physiology, decrease operative mortality and improve clinical outcomes. METHODS Unfortunately, in the modern surgical era, supportive environments to allow surgeons to make similar gains and innovative contributions remain scarce. In the current practice, overall procedure volume is prioritized to safeguard quality metrics, including hospital survival and length of stay, surgical complications, and neurocognitive outcomes. As a result, exceptional surgical results have become translated and defined by public ranking systems such as the US News and World Report Best Children's Hospital National Ranking (USNWR) and the Congenital Heart Surgery Database of the Society for Thoracic Surgeons (CHSD-STS), primary based upon early post-operative mortality. This reality places surgeons in a vulnerable position where pressure to achieve a high clinical ranking contrasts with a surgeon definition of "acceptable" surgical risk. Currently, the most frequently used risk stratification tools do not factor in important differences in strategies, such as staged palliation versus complete repair, or bi-ventricular versus uni-ventricular physiology. This favors hospitals pursuing multistage surgical approaches, even if the result is worse long-term morbidity, mortality and increased resource utilization. This economy of ranking-based decision-making causes surgeons either avoid operating altogether or accept less advantageous multi-staged treatment strategies for patients with elevated expected mortality. Such an environment also might present much farther-reaching negative impacts on the growth and development of junior surgeons and trainees, as well as on the pursuit of new surgical innovations to aid future generations of patients. CONCLUSIONS Risk aversive surgical behavior is creating an environment not favorable for the children born with truly complex congenital heart defects. KEYWORDS Biventricular conversion; congenital heart surgery; multidisciplinary approach; risk-stratification; surgical outcomes.
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Affiliation(s)
- Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Damien J LaPar
- Pediatric and Congenital Cardiac Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Wen Li
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
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