Outcomes After Repair of Pulmonary Atresia With Ventricular Septal Defect and Major Aortopulmonary Collateral Arteries: A Tailored Approach in a Developing Setting

Pulmonary flow-study can predict in-hospital prognosis of unifocalization and corrective repair of pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries

Objectives

With the development of perioperative treatment, the results of the unifocalization and corrective repair of pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries have been significantly improved. However, the in-hospital recovery is quite different individually. Therefore, it is essential to find prognostic indicators to avoid unsatisfactory recovery.

Design

This was a case-control study.

Setting

The study was conducted in the national center for cardiovascular diseases in China.

Participants

Pediatric patients between 2014 and 2022.

Interventions

None.

Measurements & main results

A total of 19 patients were included. The possible prognostic indicators included were commonly used clinical data. Unsatisfactory postoperative recovery was defined as mechanical ventilation≥ 7 days and/or in-hospital death. Satisfactory postoperative recovery was defined as mechanical ventilation<7 days and survival at discharge. We separated patients into two groups and compared the peri-operative data through univariable analysis. There were 8 patients in unsatisfactory recovery group (including 1 death) and 11 patients in satisfactory recovery group. Among all the possible prognostic indicators, through univariable analysis, pulmonary arterial pressure in pulmonary flow study was statistically different (p = 0.027 < 0.05). The ROC curve showed that the area under curve and cut-off values in predicting satisfactory recovery were 0.841 and 22 mmHg; the corresponding sensitivity and specificity were 100% and 72.7%. There was no statistical difference between the two groups in ventricular septal fenestration and pulmonary hypertension targeting drugs.

Conclusion

A pulmonary arterial pressure <22 mmHg in pulmonary flow study may avoid unsatisfactory in-hospital recovery after unifocalization and corrective repair of pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries.

Outcomes of Rehabilitation Strategies for Pulmonary Atresia with Ventricular Septal Defect: A Single Center's Experience

Background

Both systemic-to-pulmonary shunt and right ventricle-pulmonary artery (RV-PA) connection are extensively applied to initially rehabilitate the pulmonary artery in pulmonary atresia with the ventricle septal defect (PA/VSD). However, which of these options is the most ideal for promoting pulmonary artery development and improving outcomes remains controversial.

Methods

A total of 109 PA/VSD patients undergoing initial rehabilitative surgery at Guangdong Provincial People's Hospital from 2010 to 2020 were enrolled in this study. A series of clinical data were collected to compare the perioperative and postoperative outcomes between systemic-to-pulmonary and RV-PA connection.

Results

The mean duration of follow-up was 61.1 months in the systemic-to-pulmonary shunt group and 70.3 months in the RV-PA connection group (p > 0.05). The RV-PA connection technique resulted in a significantly higher PaO 2 , lower red blood cells (RBC), lower hemoglobin, and lower hematocrit (Hct) (p < 0.05). The cumulative incidence curve estimated a cumulative complete repair rate of 56 ± 7% after 5 years in the RV-PA connection group, significantly higher than 36 ± 7% after 5 years in the systemic-to-pulmonary shunt group (p < 0.05). The Kaplan-Meier curve revealed a similar estimated survival rate between the two groups (p = 0.73). The RV-PA connection was identified as an independent predictor for complete repair in the multivariable analysis (HR = 2.348, 95% CI = 1.131-4.873).

Conclusions

The RV-PA connection is a more ideal initial rehabilitative technique than systemic-to-pulmonary shunt in treating PA/VSD as a consequence of comparable probability of survival but improved definitive complete repair rate.

Current treatment outcomes of congenital heart disease and future perspectives

China has the largest number of individuals with congenital heart disease (CHD) in the world and a heavy burden of CHD. Therefore, understanding current CHD treatment outcomes and patterns in China will contribute to global progress in CHD treatment and be a valuable experience. Generally, CHD treatment in China has satisfactory outcomes owing to the joint efforts by all relevant stakeholders across the country. However, efforts are needed to overcome the remaining challenges: management of mitral valve disease and paediatric end-stage heart failure needs to be improved; cohesive paediatric cardiology teams should be established and collaboration between hospitals enhanced; CHD-related medical resources need to be more accessible and equitable; and nationwide CHD databases should be enhanced. In the second paper of this Series, we aim to systematically summarise the current CHD treatment outcomes in China, discuss potential solutions, and provide future perspectives.

Current development of bovine jugular vein conduit for right ventricular outflow tract reconstruction

Right ventricular outflow tract (RVOT) reconstruction is a common surgical method to treat congenital cardiac lesions, and bovine jugular vein conduit (BJVC) has become a prevalent candidate of prosthetic material for this procedure since 1999. Although many clinical studies have shown encouraging results on BJVCs, complications such as stenosis, aneurysmal dilatation, valve insufficiency, and infective endocarditis revealed in other clinical outcomes still remain problematic. This review describes the underlying mechanisms causing respective complications, and summarizes the current technological development that may address those causative factors. Novel crosslinking agents, decellularization techniques, conduit coatings, and physical reinforcement materials have improved the performances of BJVCs. The authors expect that the breakthroughs in the clinical application of BJVC may come from new genetic research findings and advanced characterization apparatuses and bioreactors, and are optimistic that the BJVC will in the future provide sophisticated therapies for next-generation RVOT reconstruction.

A Novel 3D Visualized Operative Procedure in the Single-Stage Complete Repair With Unifocalization of Pulmonary Atresia With Ventricular Septal Defect and Major Aortopulmonary Collateral Arteries

Objectives

Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) is a relatively rare, complex, and heterogeneous congenital heart disease. As one of the effective treatments, the midline unifocalization strategy still remains complicated and challenging due to the diverse forms of MAPCAs and pulmonary arteries. The purpose of this study is to summarize our experience of a novel three-dimensional (3D) visualized operative procedure in the single-stage complete repair with unifocalization and to clarify the benefits it may bring to us.

Methods

We described our experience of the 3D visualized operative procedure such as 3D printing, virtual reality (VR), and mixed reality (MR) technology in patients with PA/VSD/MAPCAs who underwent a single-stage complete repair with unifocalization. The data from the patients who underwent this procedure (3D group) and those who underwent the conventional procedure (conventional group) were compared.

Results

The conventional and 3D groups included 11 patients from September 2011 to December 2017 and 9 from January 2018 to March 2021, respectively. The baseline characteristics such as age, body weight, preoperative saturation, the anatomy of the pulmonary arteries and MAPCAs, the Nakata index, and TNPAI had no statistical significance. All 9 patients in the 3D group were operated only through a median sternotomy, while 8 cases (72.7%) in the conventional group needed another posterolateral thoracotomy (p = 0.001). In the 3D group, the CPB time was shorter (93.2 ± 63.8 vs. 145.1 ± 68.4 min, p = 0.099), and the median pre-CPB time per MAPCAs was significantly shorter [25.7 (14.0, 46.3) vs. 65 (41.3, 75.0) min, p = 0.031]. There was no early death in the 3D group, while there were 3 in the conventional group (0 vs. 27.3%, p = 0.218).

Conclusion

The novel 3D visualized operative procedure may help improve the performance of the single-stage complete repair with the midline unifocalization of PA/VSD/MAPCAs and help shorten the dissecting time of the MAPCAs. It may promote the routine and successful application of this strategy in more centers.