1
|
Kara KA, Arslanoglu E, Yigit F, Arkan C, Ozcan E, Akardere OF, Cine N, Tuncer E, Cetiner N, Ceyran H. The prognostic significance of early troponin levels in patients undergoing aortic ridge surgery. Cardiol Young 2024; 34:301-307. [PMID: 37381824 DOI: 10.1017/s1047951123001737] [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: 06/30/2023]
Abstract
Subaortic stenosis is a CHD that can lead to left ventricular hypertrophy, heart failure, and aortic valve damage if left untreated. The gold standard treatment for subaortic stenosis is septal myectomy. However, there is no clear consensus on the surgical margins required for adequate muscle resection. In this retrospective study, we reviewed the records of 83 patients who underwent subaortic stenosis surgery between 2012 and 2020 to investigate the effect of early troponin levels on prognosis. We excluded patients with additional cardiac pathologies, hypertrophic obstructive cardiomyopathy, and valvular aortic stenosis.Troponin levels were recorded in the early post-operative period, and patients were monitored for complications such as ventricular arrhythmia, left ventricular systolic dysfunction, infective endocarditis, and pacemaker implantation. The troponin levels were significantly higher in the patients who had septal myectomy. The degree of myectomy affected the risk of complications in the early post-operative period and recurrence in the later period. However, when the gradient was substantially or completely removed by myectomy, patients experienced significant symptom improvement in the early post-operative period, and their late survival was equivalent to that of healthy individuals of the same age.Our findings suggest that monitoring troponin levels in patients undergoing septal myectomy may be beneficial in predicting the risk of complications. However, further studies are needed to establish the optimal surgical technique and extent of muscle resection required for subaortic stenosis treatment. Our study adds to the existing knowledge of the benefits and risks associated with septal myectomy as a treatment option for subaortic stenosis.
Collapse
Affiliation(s)
- Kenan Abdurrahman Kara
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Ergin Arslanoglu
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Fatih Yigit
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Cuneyt Arkan
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Esra Ozcan
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Omer Faruk Akardere
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Nihat Cine
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Eylem Tuncer
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| | - Nilufer Cetiner
- Pediatric Cardiology Department, Kosuyolu High Specialization Training and Research Hospital, Istanbul, Turkey
| | - Hakan Ceyran
- Pediatric Cardiovascular Surgery Department, Kosuyolu High Specialization Training And Research Hospital, Istanbul, Turkey
| |
Collapse
|
2
|
Ross F, Everhart K, Latham G, Joffe D. Perioperative and Anesthetic Considerations in Pediatric Valvar and Subvalvar Aortic Stenosis. Semin Cardiothorac Vasc Anesth 2023; 27:292-304. [PMID: 37455142 DOI: 10.1177/10892532231189933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Aortic stenosis (AS) is a common form of left ventricular outflow tract obstruction (LVOTO) in children with congenital heart disease. This review specifically considers the perioperative features of valvar (VAS) and subvalvar AS (subAS) in the pediatric patient. Although VAS and subAS share some clinical features and diagnostic approaches, they are distinct clinical entities with separate therapeutic options, which range from transcatheter intervention to surgical repair. We detail the pathophysiology of AS and highlight the range of treatment strategies with a focus on anesthetic considerations for the care of these patients before, during, and after intervention.
Collapse
Affiliation(s)
- Faith Ross
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Kelly Everhart
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Greg Latham
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Denise Joffe
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| |
Collapse
|
3
|
Bandara D, Salve GG, Marathe SP, Betts KS, Cole AD, Ayer JG, Nicholson IA, Orr Y. Mid- and long-term outcomes after surgical correction of subaortic stenosis: a 27-year experience. Eur J Cardiothorac Surg 2023; 64:ezad314. [PMID: 37707826 DOI: 10.1093/ejcts/ezad314] [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: 02/17/2023] [Revised: 08/31/2023] [Accepted: 09/12/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVES We reviewed the mid- and long-term surgical outcomes of patients with subaortic stenosis (SAS). METHODS Patients operated for SAS from April 1990 to August 2016 were reviewed retrospectively. Patients with major associations such as aortic arch obstruction were excluded. Time to reintervention and predictors of recurrence were assessed using Kaplan-Meier analysis, log-rank test and uni/multivariable Cox regression. RESULTS 120 patients at a median age of 4.7 years (interquartile range 2.9, 8.1) underwent primary operation (median peak preoperative left ventricular outflow tract gradient 52.5 mmHg, interquartile range 40, 70) involving fibrous tissue excision (n = 120) with septal myectomy (93%; n = 112) as the procedure of choice.At median follow-up of 13 years (interquartile range 7, 18), freedom from reintervention at 1, 3, 5 and 10 years was 99% (95% confidence interval 94%, 99%), 94% (87%, 97%), 93% (86%, 96%) and 90% (82%, 94%), respectively. Recurrence occurred in 18% (n = 20) with 15 patients undergoing reinterventions, 13 of whom required radical reoperation. Multivariable analysis revealed higher preoperative peak left ventricular outflow tract gradient (hazard risk 1.06, confidence interval 1.03, 1.09, P < 0.001), and presence of bicuspid aortic valve (hazard risk 14.13, confidence interval 3.32, 60.1, P < 0.001) as predictors for reintervention. Mild/moderate aortic regurgitation occurred in 49% (n = 55) of patients at the most recent follow-up. CONCLUSIONS Reintervention for recurrent SAS is common, predicted by higher preoperative peak left ventricular outflow tract gradient, and presence of bicuspid aortic valve, and frequently involves a radical procedure. Aortic regurgitation is a major consequence of SAS, but its severity usually remains low. CLINICAL REGISTRATION NUMBER SCHN HREC reference number 2019/ETH02729, approved on 09 July 2019.
Collapse
Affiliation(s)
- Dushan Bandara
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
| | - Gananjay G Salve
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
| | - Supreet P Marathe
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
| | - Kim S Betts
- School of Public Health, Curtin University, Perth, Australia
| | - Andrew D Cole
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
| | - Julian G Ayer
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian A Nicholson
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Yishay Orr
- Heart Centre for Children, The Children's Hospital at Westmead & The Sydney Children's Hospital at Randwick, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
4
|
Crofton AE, Kovacs SL, Stern JA. Subvalvular Aortic Stenosis: Learning From Human and Canine Clinical Research. Cardiol Res 2023; 14:319-333. [PMID: 37936623 PMCID: PMC10627371 DOI: 10.14740/cr1547] [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: 07/12/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
Subvalvular aortic stenosis (SAS) is the most common congenital heart disease (CHD) in dogs and is also prevalent in human children. A fibrous ridge below the aortic valve narrows the left ventricular outflow tract (LVOT) and increases blood flow velocity, leading to devastating side effects in diseased patients. Due to the similarities in presentation, anatomy, pathophysiology, cardiac development, genomics, and environment between humans and dogs, canine SAS patients represent a critical translational model of human SAS. Potential adverse outcomes of SAS include arrhythmias, left-sided congestive heart failure, endocarditis, exercise intolerance, syncope, and sudden cardiac death. The greatest divergence between canine and human SAS clinical research has been the standard of care regarding treatment of these outcomes, with pharmacological intervention dominating best practices in veterinary medicine and surgical intervention comprising the standard practice for human SAS patients. Regardless of the species, the field has yet to identify a treatment option to prevent disease progression or permanently remove the fibrous ridge, but historical leaps in SAS research support a continued translational approach as the most promising method for achieving this goal.
Collapse
Affiliation(s)
- Amanda E. Crofton
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, Davis, CA 95616, USA
| | - Samantha L. Kovacs
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California Davis, Davis, CA 95616, USA
| | - Joshua A. Stern
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
| |
Collapse
|
5
|
Schlein J, Wollmann F, Kaider A, Wiedemann D, Gabriel H, Hornykewycz S, Base E, Michel-Behnke I, Laufer G, Zimpfer D. Long-term outcomes after surgical repair of subvalvular aortic stenosis in pediatric patients. Front Cardiovasc Med 2022; 9:1033312. [DOI: 10.3389/fcvm.2022.1033312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
ObjectivesSubvalvular aortic stenosis (SAS) can occur as discrete or tunnel-like obstruction of the left ventricular outflow tract and as progressive disease often leads to aortic valve regurgitation. We report our 30-year single-center experience after surgical repair of SAS.MethodsA retrospective chart review of all patients aged < 18 years, who underwent surgical repair of SAS from May 1985 to April 2020, was conducted. Mortality was cross-checked with the national health insurance database (93.8% complete mortality follow-up in April 2020). Survival and competing risks analysis were used to analyze the primary endpoints survival and incidence of reoperations.ResultsFrom May 1985 until April 2020 103 patients (median age 5.5 years) underwent surgical repair of SAS. Survival was 90.8% at 10 years and 88.7% at 20 and 30 years. Age < 1 year at time of surgery, Shone’s complex, mitral stenosis and concomitant mitral valve surgery were associated with mortality. The cumulative incidence of reoperation for SAS was 21.6% at 10 years, 28.2% at 20 and 30 years. The incidence of reoperation for SAS did not differ between the myectomy, membrane resection and combined myectomy and membrane resection groups. The cumulative incidence of reoperation on the aortic valve was 13.5% at 20 years.ConclusionRecurrence rate of SAS is not to be neglected, though surgical repair of subaortic stenosis has good long-term results. Patients who needed a combined membrane resection and septal myectomy are not more prone to recurrence than patients who underwent solitaire myectomy or membrane resection.
Collapse
|
6
|
Leighton J, Gandy J, Sermeño J, Weiner K. Transthoracic Echocardiography Findings in an Adolescent With Late-Detection Subaortic Membrane and Patent Ductus Arteriosus: Impact of Surgical Intervention. CASE 2022; 6:377-381. [PMID: 36247376 PMCID: PMC9556927 DOI: 10.1016/j.case.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Left ventricular dilation may return toward normal after surgical correction of a large PDA. PH may normalize after surgical correction of a large PDA. PDA should be included in the differential diagnosis of cardiomyopathy in an adolescent.
Collapse
|
7
|
Chhabra A, Shinde P, Shetty V, Ganatra A. Anaesthetic management of a patient with sub-valvular aortic stenosis for emergency lower segment caesarean section: A case report. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_48_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
8
|
Cao Y, Yang S, Li W, Li L, Su J, Fan X. Surgical repair of subaortic stenosis resection: 10 years of single-center experience in 65 patients. J Card Surg 2021; 36:3593-3598. [PMID: 34339531 DOI: 10.1111/jocs.15886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/26/2021] [Accepted: 07/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Subaortic stenosis (SAS) was a rare congenital heart disease of left ventricular outflow tract (LVOT), ranging from "isolated" lesions to "tunnel" or "diffuse" lesions. We conducted a retrospective study to describe the characteristics of patients with different lesions and analyze the risk factors for reoperation. METHODS In this study, we examined a single-center retrospective cohort of SAS patients undergoing resection from 2010 to 2019. Patients were classified as simple lesion group (n = 37) or complex lesion group (n = 28). Demographics, perioperative findings, and clinical data were analyzed. RESULTS The surgical effect of the two groups was significantly lower than that before the operation (p < .05). The median age at operation was 6 (3-11.8) years. There was no operative mortality. In complex lesion group, cardiopulmonary bypass time (CPB time), aortic cross-clamping time (ACC time), mechanical ventilation time, and intensive care unit (ICU) stay time were longer. The median follow-up period was 2.8 years (range: 1-3.8), with two late death. Six patients (9.2%) required reoperation due to restenosis or severe aortic insufficiency. The freedom from reoperation rates at 5 years was 66.7% for simple lesion but only 52.3% for complex lesion (p = .036). CONCLUSIONS Although the lesions include many forms, SAS resection was still satisfactory. However, the reoperation after initial surgical treatment was not infrequent, especially in patients with complex lesion.
Collapse
Affiliation(s)
- Yuefeng Cao
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuang Yang
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenxiu Li
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lei Li
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junwu Su
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiangming Fan
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
De Wolf R, François K, Bové T, Coomans I, De Groote K, De Wilde H, Panzer J, Vandekerckhove K, De Wolf D. Paediatric subaortic stenosis: long-term outcome and risk factors for reoperation. Interact Cardiovasc Thorac Surg 2021; 33:588-596. [PMID: 34002231 DOI: 10.1093/icvts/ivab121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Surgical repair of subaortic stenosis (SAS) is associated with a substantial reoperation risk. We aimed to identify risk factors for reintervention in relation to discrete and tunnel-type SAS morphology. METHODS Single-centre retrospective study of paediatric SAS diagnosed between 1992 and 2017. Multivariable Cox regression analysis was performed to identify reintervention risk factors. RESULTS Eighty-five children [median age 2.5 (0.7-6.5) years at diagnosis] with a median follow-up of 10.1 (5.5-16.4) years were included. Surgery was executed in 83% (n = 71). Freedom from reoperation was 88 ± 5% at 5 years and 82 ± 6% at 10 years for discrete SAS, compared to, respectively, 33 ± 16% and 17 ± 14% for tunnel-type SAS (log-rank P < 0.001). Independent risk factors for reintervention were a postoperative gradient >20 mmHg [hazard ratio (HR) 6.56, 95% confidence interval (CI) 1.41-24.1; P = 0.005], tunnel-type SAS (HR 7.46, 95% CI 2.48-22.49; P < 0.001), aortic annulus z-score <-2 (HR 11.07, 95% CI 3.03-40.47; P < 0.001) and age at intervention <2 years (HR 3.24, 95% CI 1.09-9.86; P = 0.035). Addition of septal myectomy at initial intervention was not associated with lesser reintervention. Fourteen children with a lower left ventricular outflow tract (LVOT) gradient (P < 0.001) and older age at diagnosis (P = 0.024) were followed expectatively. CONCLUSIONS Children with SAS remain at risk for reintervention, despite initially effective LVOT relief. Regardless of SAS morphology, age <2 years at first intervention, a postoperative gradient >20 mmHg and presence of a hypoplastic aortic annulus are independent risk factors for reintervention. More extensive LVOT surgery might be considered at an earlier stage in these children. SAS presenting in older children with a low LVOT gradient at diagnosis shows little progression, justifying an expectative approach.
Collapse
Affiliation(s)
- Rik De Wolf
- Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium
| | - Katrien François
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Thierry Bové
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ilse Coomans
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Katya De Groote
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Hans De Wilde
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Joseph Panzer
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Daniël De Wolf
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium.,Department of Paediatric Cardiology, University Hospital of Brussels, Brussels, Belgium
| |
Collapse
|
10
|
Moafa H, Alnasef M, Diraneyya OM, Alhabshan F. Subaortic Membrane and Patent Ductus Arteriosus in Rare Association-Case Series. J Saudi Heart Assoc 2020; 32:410-414. [PMID: 33299784 PMCID: PMC7721455 DOI: 10.37616/2212-5043.1199] [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: 02/22/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The combination of subaortic membrane (SAM) and patent ductus arteriosus is very rare. Subaortic stenosis is the second most common form of left ventricular outflow tract (LVOT) obstruction after valvular aortic stenosis. We are reporting the largest case series of SAM and PDA. METHODS We included all patients that were diagnosed with the combination of SAM and PDA at our cardiac center. We have reviewed patients echocardiographic studies, cardiac catheterizations, surgical notes and all the outpatients notes. RESULTS We have a total of 7 patients. The age at presentation was in the early childhood with 3 patients diagnosed in infancy. Four patients had severe and moderate LVOT obstruction with SAM being very close to the aortic valve and all required surgical intervention. The last three patients had mild LVOT obstruction 2 of them with the SAM being > 4mm away from the aortic valve. Six out of the seven patients had intervention while the last one is under clinical follow up currently. PDA closure did not change the outcome. There were no other postoperative complication like developing new AI or developing complete heart block. There was no relation between gender, height, weight or age at diagnosis to the SAM clinical course. CONCLUSION SAM and PDA association is very rare. The underlying pathophysiology is not well understood. When the SAM is closer to aortic valve (≤ 4mm), it carries higher risk of progressive LVOT obstruction. The interventions for SAM and PDA were safe procedures.
Collapse
Affiliation(s)
- Hussain Moafa
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Alnasef
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Obayda M. Diraneyya
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - F Alhabshan
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
11
|
Abushaban L, Uthaman B, Selvan JP, Al Qbandi M, Sharma PN, Mariappa TV. Long-term follow-up and outcomes of discrete subaortic stenosis resection in children. Ann Pediatr Cardiol 2019; 12:212-219. [PMID: 31516277 PMCID: PMC6716322 DOI: 10.4103/apc.apc_120_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Studies of long-term outcomes of discrete subaortic stenosis (DSS) are rare. Therefore, we reviewed the long-term outcomes of subaortic membrane resection in children with isolated DSS over 16 years from a single institution. Materials and Methods We retrospectively reviewed the records of patients (n = 27) who underwent resection of DSS between 2000 and 2017. Patients with major concomitant intracardiac anomalies were excluded. Indications for surgery were mean left ventricular outflow tract (LVOT), Doppler gradient >30 mmHg, and/or progressive aortic insufficiency. Results The mean age at diagnosis was 3.77 ± 3.49 years (range, 0.25-13 years) and the mean age at surgery was 6.36 ± 3.69 years (range, 1-13 years). All patients underwent resection of subaortic membrane. The mean LVOT Doppler gradient decreased from 40.52 ± 11.41 mmHg preoperatively to 8.48 ± 5.06 mmHg postoperatively (P < 0.001). The peak instantaneous LVOT Doppler gradient decreased from 75.41 ± 15.22 mmHg preoperatively to 18.11 ± 11.44 mmHg postoperatively (P < 0.001). At the latest follow-up, the peak gradient was 17.63 ± 8.93 mmHg. The mean follow-up was 7.47 ± 3.53 years (median 6.33 years; range 2.67-16 years). There was no operative mortality or late mortality. Recurrence of subaortic membrane occurred in 7 (25.92%, 7/27) patients who underwent primary DSS operation. Four (14.81%, 4/27) patients required reoperation for DSS recurrence at a median time of 4.8 years (3.1-9.1 years) after the initial repair. Risk factors for reoperation were age <6 years at initial repair. Eighteen (66.66%, 18/27) patients had AI preoperatively and progression of AI occurred in 70.37% (19/27). This included 4 (22.22%, 4/18) patients who had worsening of their preoperative AI. Short valve-to-membrane distance was found to be prognostically unfavorable. One (3.7%, 1/27) patient had an iatrogenic ventricular septal defect, and 2 (7.4%, 2/27) patients had complete AV block following membrane resection. Conclusions Resection of subaortic membrane in children is associated with low mortality. Higher LVOT gradient, younger age at initial repair, and shorter valve-to-membrane distance were found to be associated with adverse outcome. Recurrence and reoperation rates are high, and progression of aortic insufficiency following subaortic membrane resection is common. Therefore, these patients warrant close follow-up into adult life.
Collapse
Affiliation(s)
- Lulu Abushaban
- Department of Pediatrics, Chest Diseases Hospital, Kuwait City, Kuwait.,Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Babu Uthaman
- Department of Pediatrics, Chest Diseases Hospital, Kuwait City, Kuwait.,Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - John Puthur Selvan
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| | - Mustafa Al Qbandi
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| | - Prem N Sharma
- Health Sciences Center, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Thinakar Vel Mariappa
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| |
Collapse
|
12
|
Mukadam S, Gordon BM, Olson JT, Newcombe JB, Hasaniya NW, Razzouk AJ, Bailey LL. Subaortic Stenosis Resection in Children: Emphasis on Recurrence and the Fate of the Aortic Valve. World J Pediatr Congenit Heart Surg 2018; 9:522-528. [DOI: 10.1177/2150135118776931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Recurrence after surgical resection of discrete subvalvar aortic stenosis in children often requires repeat operation. Risk factors for recurrence are poorly understood. We sought to determine potential risk factors for recurrence and postoperative comorbidities in the long term. Methods: Retrospective chart review was performed on all pediatric patients who underwent surgical resection of discrete subaortic stenosis at our institution. Demographics, perioperative findings, and clinical data were analyzed for predisposing factors. Results: From 1991 to 2015, a total of 104 patients underwent primary surgical resection of discrete subaortic stenosis. There were no postoperative deaths. Three (2.9%) patients required pacemaker implantation. Nine (8.4%) patients required repeat resection for recurrence of subaortic membrane over a median follow-up of 8.5 years (interquartile range: 5.9-13.5 years). Actuarial freedom from repeat resection was 100%, 94%, and 82% at one, five, and ten years, respectively. Repeat resection occurred more frequently in patients with genetic disease (37.5% vs 10.7%; P = .033) and preoperative mitral regurgitation (MR; 25% vs 1.2%; P < .001). Postoperative aortic insufficiency (AI) that was moderate or worse was associated with older age at the time of first resection (relative risk [RR]: 1.54, P < .05), moderate or severe preoperative AI (RR: 1.84, P = .002), and repeat resection of subaortic stenosis (RR: 1.90, P < .001). Conclusion: The majority of children who undergo surgical resection of subaortic stenosis will not experience recurrence in childhood and those who do require repeat resection may have a higher incidence of genetic disease and preoperative MR. Postoperative AI is associated with repeat resection, older age at the time of surgery, and degree of preoperative AI.
Collapse
Affiliation(s)
- Shireen Mukadam
- Division of General Pediatrics, Department of Pediatrics, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Brent M. Gordon
- Division of Pediatric Cardiology, Department of Pediatrics, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Jeffrey T. Olson
- Division of General Pediatrics, Department of Pediatrics, Loma Linda University Hospital, Loma Linda, CA, USA
- Department of Medicine, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Jennifer B. Newcombe
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Nahidh W. Hasaniya
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Anees J. Razzouk
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Leonard L. Bailey
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| |
Collapse
|
13
|
Anderson BR, Tingo JE, Glickstein JS, Chai PJ, Bacha EA, Torres AJ. When Is It Better to Wait? Surgical Timing and Recurrence Risk for Children Undergoing Repair of Subaortic Stenosis. Pediatr Cardiol 2017; 38:1106-1114. [PMID: 28508142 PMCID: PMC5987763 DOI: 10.1007/s00246-017-1622-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
Recurrence of subaortic stenosis (SAS) after surgery is common in children. The effects of patient characteristics and surgical timing on disease recurrence are largely unknown. We performed a retrospective study, assessing the relative effects of patient age and left ventricular outflow tract (LVOT) gradient on the need for reoperation for recurrent SAS. We included all children <20 years of age who underwent initial surgical resection of SAS at our center, January 2003-December 2013. Stratified logistic regression was performed, considering the effects of patient demographics, clinical characteristics, echocardiographic parameters, and operative technique, and clustering standard errors by surgeon. The multivariable model was used to simulate predicted probabilities of recurrent SAS for children at varying ages and baseline LVOT gradients. Sixty-three patients (38 males) underwent initial operation for SAS. Patients were followed for a median of 3.7 years (IQR 1.2-7.1). Twenty-one percent of patients (n = 13) underwent reoperation for SAS. Twelve were male. For every 10 mmHg increase in preoperative peak gradient in boys, the odds of reoperation for SAS doubled (OR 2.01, CI 1.5-2.72, p < 0.001), and for every additional 6 months of age, the odds of reoperation decreased by 14% (OR 0.86, CI 0.84-0.88, p < 0.001). Both younger age and higher preoperative outflow tract gradient are independently associated with risk of reoperation. Clinicians should consider the age and rate of LVOT gradient change-and not just the absolute gradient-in determining initial surgical timing.
Collapse
Affiliation(s)
- Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA.
| | - Jennifer E Tingo
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| | - Julie S Glickstein
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA
| | - Alejandro J Torres
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| |
Collapse
|
14
|
Boettcher BT, Mungara C, Manupipatpong KK, Freed JK, Kaiser M, Pagel PS. An Unexpected Finding During Repair of An Ascending Aortic Aneurysm. J Cardiothorac Vasc Anesth 2017; 32:600-602. [PMID: 28552298 DOI: 10.1053/j.jvca.2017.02.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI.
| | - Charan Mungara
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Markus Kaiser
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| |
Collapse
|
15
|
Outcomes of Subaortic Obstruction Resection in Children. Heart Lung Circ 2017; 26:179-186. [DOI: 10.1016/j.hlc.2016.05.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/12/2016] [Accepted: 05/25/2016] [Indexed: 11/18/2022]
|
16
|
Qureshi A, Awuor S, Martinez M. Adult Presentation of Subaortic Stenosis: Another Great Hypertrophic Cardiomyopathy Mimic. Heart Lung Circ 2015; 24:e7-e10. [DOI: 10.1016/j.hlc.2014.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/08/2014] [Indexed: 10/24/2022]
|
17
|
Etnel JR, Takkenberg JJ, Spaans LG, Bogers AJ, Helbing WA. Paediatric subvalvular aortic stenosis: a systematic review and meta-analysis of natural history and surgical outcome. Eur J Cardiothorac Surg 2014; 48:212-20. [DOI: 10.1093/ejcts/ezu423] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 09/02/2014] [Indexed: 11/14/2022] Open
|
18
|
Ezon DS. Fixed subaortic stenosis: a clinical dilemma for clinicians and patients. CONGENIT HEART DIS 2013; 8:450-6. [PMID: 23947905 DOI: 10.1111/chd.12127] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
Subaortic stenosis carries considerable morbidity and mortality. In most cases, patients have an underlying left ventricular outflow tract morphology that promotes turbulence at the outflow tract, which induces the development of subaortic fibromuscular tissue. A subset of patients will progress to develop severe stenosis and aortic regurgitation, but it has been difficult to determine which patients are at risk. While resection of the subaortic tissue improves immediate outcome, many patients have recurrence of both stenosis and regurgitation, questioning the efficacy of surgical intervention in asymptomatic patients. This review article describes the current understanding of the etiology, treatment, and prognosis of subaortic stenosis.
Collapse
Affiliation(s)
- David S Ezon
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| |
Collapse
|