Risk factors for morbidity in infants undergoing tetralogy of fallot repair

Primary versus staged repair for tetralogy of Fallot in symptomatic neonates: systematic review and meta-analysis

The choice between primary repair and staged repair strategy for Tetralogy of Fallot remains a subject of debate in clinical practice. This review aims to compare the outcomes and efficacy of two surgical approaches in managing Tetralogy of Fallot among neonatal populations. Literature search was conducted across seven databases, identifying a total of 1393 relevant studies. Inclusion criteria encompassed comparative studies focusing on primary repair and staged repair for Tetralogy of Fallot in neonates. Quality of included studies was assessed using The Newcastle-Ottawa Scale for retrospective cohort studies. Data synthesis involved the extraction of post-operative outcomes. Meta-analysis was performed where feasible, pooling effect sizes to determine the overall impact of each repair strategy. Eight studies were selected for full-text appraisal. A total of 4464 Tetralogy of Fallot patients underwent surgical correction. The pooled mean patient age was 8.68 (±7.38) and 8.56 (±6.8) days for primary repair and staged repair, respectively. The primary repair was associated with a higher cardiac complications rate (odds ratio 1.50, 95% confidence interval 1.07 to 2.10) and transannular patch usage (odds ratio 2.62, 95% CI confidence interval 2.02 to 3.40). In contrast, staged repair was associated with longer hospital (mean difference 11.84, 95% confidence interval 9.59 to 14.10) and ICU (mean difference 3.06, 95% confidence interval 1.64 to 4.47) length of stay. However, no substantial differences were observed in terms of mortality and reintervention rates between these two approaches. The findings highlight the need for well-designed research and emphasise the importance of personalised approaches to address the intricate nature of Tetralogy of Fallot management in this population. Adjusting surgical approach to patient features may be necessary to maximise surgical outcomes.

Primary surgical repair of tetralogy of fallot at the Uganda Heart Institute: a ten-year review of 30day mortality and morbidity

BACKGROUND

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) worldwide. It accounts for 7% of CHD cases in Uganda and leads to fatal outcomes in the long term without surgery. Surgery is often delayed in developing countries like Uganda due to limited resources.

OBJECTIVE

This study aimed to determine the early surgical outcomes of patients with TOF who underwent primary intracardiac repair at the Uganda Heart Institute (UHI) and to identify factors associated.

METHODOLOGY

This retrospective chart review evaluated outcomes of primary TOF repair patients at UHI from February 2012 to October 2022. Patient outcomes were assessed from surgery until 30 days post-operation.

RESULTS

Out of the 104 patients who underwent primary TOF repair at UHI, records of 88 patients (84.6%) were available for review. Males accounted for 48.9% (n = 43). The median age at the time of operation was 4 years (with an interquartile range of 2.5-8.0 years), ranging from 9 months to 16 years. Genetic syndromes were present in 5/88 (5.7%). These included 2 patients with trisomy 21, 2 with Noonan's, and 1 with 22q11.2 deletion syndrome. Early postoperative outcomes for patients included: residual ventricular septal defects in 35/88 (39.8%), right ventricular dysfunction in 33/88 (37.5%), residual pulmonary regurgitation in 27/88 (30.7%), residual right ventricular outflow tract obstruction in 27/88 (30.0%), pleural effusion in 24/88 (27.3%), arrhythmias in 24/88(27.3%), post-operative infections in 23/88(26.1%) and left ventricular systolic dysfunction in 9/88 (10.2%). Out of the children who underwent surgery after one year of age, 8% (7 children) died within the first 30 days. There was a correlation between mortality and post-operative ventilation time, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, preoperative oxygen saturations, RV and LV dysfunction and the operating team.

CONCLUSION

The most frequent outcomes after surgery were residual ventricular septal defects and right ventricular failure. In our study, the 30-day mortality rate following TOF repair was 8%. Deceased patients had lower pre-operative oxygen levels, longer CPB and cross-clamp times, longer post-operative ventilation, RV/LV dysfunction, and were more likely operated by the local team.

Risk Factors Associated With Prolonged Mechanical Ventilation and Length of Stay After Repair of Tetralogy of Fallot

BACKGROUND

This study examined preoperative, intraoperative, and postoperative data to identify factors that are associated with prolonged mechanical ventilation (PMV) and prolonged intensive care unit length of stay (ICU LOS) in tetralogy of Fallot (TOF) patients undergoing repair surgery.

METHODS

A retrospective study was carried out after approval from the institutional review board. All patients (age 0-52 years) who underwent TOF repair from January 2016 to September 2022 were included. Prolonged mechanical ventilation was defined as >24 h of ventilation, while prolonged ICU LOS was defined as ICU stay >3 days.

RESULTS

A total of 922 patients were included, among whom 288 (31.2%) were intubated for >24 h and 222 (24.1%) stayed in ICU for >3 days. Younger age (odds ratio [OR] = 2, 95% confidence interval [CI] 1.2-3.3, P = .007), lower weight (OR = 2.1, 95% CI 1.2-3.5, P = .003), and residual lesion (OR = 3.27, 95% CI 1.2-8.7, P = .017) were associated with PMV. Moreover, independent risk factors for prolonged ICU LOS are similar to PMV risk factors, including younger age (OR = 2.3, 95% CI 1.28-4.12, P = .005), lower weight (OR = 2.83, 95% CI 1.58-5, P < .001), underweight status (OR = 1.7, 95% CI 1.12-2.57, P = .012), and residual lesion (OR = 3.79, 95% CI 1.43-10.05, P = .007). Both aortic cross-clamp and cardiopulmonary bypass times did not exhibit clinically significant risk factors toward PMV and prolonged ICU LOS.

CONCLUSIONS

The risk factors for PMV and prolonged ICU LOS were residual lesion, younger age, and lower weight. Nutritional status contributed to the risk of prolonged ICU LOS, but not PMV. Consideration of these factors may provide optimal care to improve the outcome following TOF corrective surgery.

Predictors of Post-Operative Hospital Length of Stay Following Complete Repair of Tetralogy of Fallot in a Pediatric Cohort in the North of England

We sought to estimate the median post-operative length of stay (PLOS) and predictors of PLOS following tetralogy of Fallot (ToF) repair at a specialist surgical center in the North of England. The local National Congenital Heart Disease Audit dataset was used to identify patients aged < 2 years who underwent surgical repair for ToF between 1 January 1986 and 13 May 2022. Coefficients representing the median change in PLOS (days) according to predictors were estimated using Quantile regression. There were 224 patients (59.4% male, median age = 9 months, interquartile range (IQR) 5-13 months) with a median PLOS of 9 days (IQR 7-13). In the univariable regression, age (months) and weight (kg) at operation (β =  - 0.17, 95% CI: - 0.33, - 0.01) and (β =  - 0.53, 95% CI: - 0.97, - 0.10), previous (cardiac or thoracic) procedure (β = 5, 95% CI:2.38, 7.62), procedure urgency (elective vs urgent) (β = 2.8, 95% CI:0.39, 5.21), bypass time (mins) (β = 0.03, 95% CI:0.01, 0.05), cross-clamp time (mins) (β = 0.03, 95% CI:0.01, 0.06) and duration of post-operative intubation (days) (β = 0.81, 95% CI:0.67, 0.96), were significantly associated with PLOS. Previous procedure and intubation time remained significant in multivariable analyses. Some patient and operative factors can predict PLOS following complete ToF repair. Information on PLOS is important for health professionals to support parents in preparing for their child's discharge and to make any necessary practical arrangements. Health commissioners can draw on evidence-based guidance for resource planning. The small sample size may have reduced the power to detect small effect sizes, but this regional study serves as a foundation for a larger national study.

Impact of pulmonary valve replacement on left and right ventricular function using strain analysis, in children with repaired tetralogy of Fallot

BACKGROUND

In repaired Tetralogy of Fallot (rTOF), pulmonary regurgitation and resulting right ventricular (RV) and left ventricular (LV) dysfunction are associated with adverse clinical outcomes. We performed an echocardiographic assessment of LV and RV function using Global Longitudinal Strain (GLS) and conventional echo method prior to and following Pulmonary Valvular Replacement (PVR) to help inform proper timing of operation.

RESULTS

A total of 30 rTOF patients (12.17 ± 2.5 years, 70% male) were included. Regarding to LV function, the study revealed a significant reverse correlation between LV GLS (absolute value) and early (mean = 10.4 days) and late (mean = 7.4 months) postop LVEF. Paired T-Test showed significant difference between GLS of LV and RV before and late after operation (op), however, without significant changes early postop. Late postop significant improvements occurred in other conventional echo indices of LV and RV function as well. There was also a significant correlation between echo-measured LVEF & Fraction Area Change (RV FAC) and MRI-derived LVEF & RVEF, respectively.

CONCLUSION

In this cross-sectional study in rTOF patients, RV and LV GLS as well as conventional echocardiographic indices regarding LV and RV function improved significantly after 6 months (mean = 7.4mo) following PVR.

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot

OBJECTIVE

Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.

METHODS

The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.

RESULTS

In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.

CONCLUSIONS

Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.

Pulmonary valve replacement: a new paradigm with tissue engineering

Prevalence of congenital heart diseases worldwide is around 9 per 1000 newborns, 20% of which affect the pulmonary valve or right ventricular outflow tract. As survival after surgical repair of these defects has improved over time, there is the need to address the long-term issues of older children and young adults with "repaired" congenital heart diseases. In recent decades, the most used types of valves are the mechanical and bioprosthetic valves. Despite improving patients' quality of life, these effects are suboptimal due to their limitations, such as the inability to grow and adapt to hemodynamic changes. These issues have led to the search for living valve solutions through tissue engineering to respond to these challenges. This review aims to review the performance of traditional pulmonary valves and understand how tissue engineering-based valves can improve the management of these patients.

Mortality Risk Factors in Tetralogy of Fallot Patients Undergoing Total Correction

A total correction is a preferred treatment for Tetralogy of Fallot patients in every part of the world. However, the mortality in developing countries was as high as 6.9% to 15.3%. This was a retrospective analytic study that analyzed pre and post-operative risk factors that affected mortality on TOF patients that were performed total correction in Indonesia. A total of 47 TOF patients that were performed total correction from January 2016 to September 2019 were enrolled in this study based on the inclusion criteria. Preoperative and post-operative data were obtained from medical records. In this research, the majority of mortality was found in male patients (39.3%), while the female’s rate was lower (36.8%). Overall mortality was 38.3% and one operative death was found. The average age of patients was 84.12 months (12-210 months), whereas the average height (85.56 ± 36.17cm vs. 112.93 ± 21.73) and weight (17.22kg vs. 28.21kg) were lower for mortality patients. Some significant preoperative variables were identified as mortality risk factors such as: age below 60 months (p=0.047), smaller weight and height (p=0.008; p=0.002), abnormal hematocrit (p=0.002), and oxygen saturation below 75% (p=0.018). Significant post-operative risk factors included: temperature above 38.5⁰C (p=0.000), and ventilator time of more than 48 hours (p=0.033). In conclusion, the mortality of TOF patients undergoing a total correction in developing countries was quite high. It was associated with some risk factors, such as younger age, lower weight and height, low oxygen saturation, post-operative fever, and prolonged ventilator time.

Impact of pulmonary valve replacement on left ventricular rotational mechanics in repaired tetralogy of Fallot

BACKGROUND

In repaired tetralogy of Fallot (rTOF), abnormal left ventricular (LV) rotational mechanics are associated with adverse clinical outcomes. We performed a comprehensive analysis of LV rotational mechanics in rTOF patients using cardiac magnetic resonance (CMR) prior to and following surgical pulmonary valve replacement (PVR).

METHODS

In this single center retrospective study, we identified rTOF patients who (1) had both a CMR ≤ 1 year before PVR and ≤ 5 years after PVR, (2) had no other intervening procedure between CMRs, (3) had a body surface area > 1.0 m2 at CMR, and (4) had images suitable for feature tracking analysis. These subjects were matched to healthy age- and sex-matched control subjects. CMR feature tracking analysis was performed on a ventricular short-axis stack of balanced steady-state free precession images. Measurements included LV basal and apical rotation, twist, torsion, peak systolic rates of rotation and torsion, and timing of events. Associations with LV torsion were assessed.

RESULTS

A total of 60 rTOF patients (23.6 ± 7.9 years, 52% male) and 30 healthy control subjects (20.8 ± 3.1 years, 50% male) were included. Compared with healthy controls, rTOF patients had lower apical and basal rotation, twist, torsion, and systolic rotation rates, and these parameters peaked earlier in systole. The only parameters that were correlated with LV torsion were right ventricular (RV) end-systolic volume (r = - 0.28, p = 0.029) and RV ejection fraction (r = 0.26, p = 0.044). At a median of 1.0 year (IQR 0.5-1.7) following PVR, there was no significant change in LV rotational parameters versus pre-PVR despite reductions in RV volumes, RV mass, pulmonary regurgitation, and RV outflow tract obstruction.

CONCLUSION

In this comprehensive study of CMR-derived LV rotational mechanics in rTOF patients, rotation, twist, and torsion were diminished compared to controls and did not improve at a median of 1 year after PVR despite favorable RV remodeling.

Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results

OBJECTIVES

The prevention of pulmonary insufficiency (PI) is a crucial part of the tetralogy of Fallot repair. Many techniques have been introduced to construct valves from different materials for the right ventricular outflow tract, including the most commonly constructed monocusp valves. We are introducing a new bicuspid valve made intraoperatively using the autologous right atrial appendage (RAA) to prevent PI in these patients.

METHODS

The RAA valve was constructed and used in 21 patients with tetralogy of Fallot. The effective preservation of the native valve was impossible in all patients because of either a severe valve deformity or a small annulus. The RAA valve was created after ventricular septal defect closure and right ventricular outflow tract myectomy and was covered with a bovine transannular pericardial patch. The perioperative data were evaluated, and the echocardiography results were assessed immediately after operations and in follow-up with a median of 10.5 months. The data were retrospectively compared with 10 other patients with similar demographic data but with only transannular patches.

RESULTS

The mean age of the patients was 13.3 months. No mortality or related morbidity occurred after repair using the RAA valve. The PI severity early after the operation was trivial or no PI in 18 patients, and mild PI was observed in 3 patients, which progressed to moderate PI in one of them in the mean 12-month follow-up period. Fifteen patients had mild or no pulmonary stenosis, while moderate pulmonary stenosis was observed in 6 others. Compared with the other 10 patients with only transannular patches, the RAA valve patients had prolonged operative and clamping times, but no difference in postoperative course and shorter hospital stays. The degree of PI was, of course, significantly less in the RAA valve patients, but pulmonary stenosis was the same.

CONCLUSIONS

The RAA valve construction is a safe and effective technique to prevent PI after the tetralogy of Fallot repair, at least in terms of short- and mid-term results. A longer follow-up period is needed to confirm if this new valve can eliminate or significantly delay the need for pulmonary valve replacement in these patients.

Impact of Perioperative Tachydysrhythmias on Mortality and Length of Stay in Complete Repair of Tetralogy of Fallot: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System

INTRODUCTION

Tachydysrhythmias (TDS) frequently occur after complete repair of tetralogy of Fallot (TOF). However, not much is known about the effect of TDS on morbidity and mortality after TOF repair. We sought to assess the associations between TDS and mortality and morbidity after repair of TOF using a multicentre database.

MATERIALS AND METHODS

We identified all children aged 0-5 years in the Pediatric Health Information System who underwent TOF repair between 2004 and 2015. Codes for TDS were used to identify cases. Outcome variables were inpatient mortality and total length of stay (LOS). Univariate and multiple logistic and linear regression analyses were used to identify the effects of multiple risk factors, including TDS, on mortality and LOS.

RESULTS

A total of 7,749 patients met inclusion criteria, of which 1,493 (19%) had codes for TDS. There was no association between TDS and inpatient mortality. However, TDS were associated with 1.1 days longer LOS and accounted for 2% of the variation observed in LOS.

CONCLUSION

After complete repair of TOF, TDS were not associated with mortality and appeared to have only a modest effect on LOS.

Risk factors for severe pulmonary regurgitation after repair of tetralogy of Fallot with transannular patch

BACKGROUND

Severe pulmonary regurgitation may result in right ventricular volume overload and decreased right ventricular function. Severe pulmonary regurgitation can be predicted prior to repair of tetralogy of Fallot. The aim of this study was to determine the risk factors for severe pulmonary regurgitation in repaired tetralogy of Fallot with transannular patch.

METHODS

This was a cross-sectional study in 43 patients with repaired tetralogy of Fallot using transannular patch. This study was carried out in Dr. Cipto Mangunkusumo hospital during 2015 to 2018. Participants were followed up for routine examination using echocardiography. We used bivariate and multivariate logistic regression using STATA 12.1 to identify risk factors for severe pulmonary regurgitation in this population.

RESULTS

A total of 43 patients composed of 22 boys and 21 girls with repaired tetralogy of Fallot using transannular patch were enrolled in the study. Median age of participants was 6 years at admission (2.1-18.5 years) and 3.4 years (1-17 years) at repair. Median length of follow-up was 2.1(1-4.3) years. Risk factors associated with severe pulmonary regurgitation after tetralogy of Fallot repair were McGoon ratio > 1.8 (odds ratio = 6.9; 95% confidence interval = 1.6-30) and follow-up duration >1.9 years (odds ratio = 3.6; 95% confidence interval = 0.9-15.2).

CONCLUSION

McGoon ratio > 1.8 and follow-up duration > 1.9 years are associated with severe pulmonary regurgitation after tetralogy of Fallot repair.

Predictors of a complicated course after surgical repair of tetralogy of Fallot

Background

In this study, we aimed to evaluate the patient and surgical factors affecting prolonged hospital stay and major adverse events after surgical repair of tetralogy of Fallot and to identify the predictors of a complicated course after surgical repair.

Methods

A total of 170 consecutive patients (96 males, 74 females; median age 12 months; range, 1 to 192 months) who underwent surgical repair of tetralogy of Fallot between January 2015 and April 2018 were retrospectively reviewed. A mechanical ventilation duration of >24 h, an intensive care unit stay of >3 days, and a hospital stay of >7 days were considered as prolonged. Unplanned reoperation, complete heart block requiring a permanent pacemaker implantation, renal failure, diaphragmatic paralysis, neurological deficit, sudden circulatory arrest, need for extracorporeal membrane oxygenation, and death were considered as major adverse events.

Results

The median time to hospital discharge was 8.0 (range, 5.0 to 40.0) days. Higher preoperative hematocrit levels prolonged the length of hospital stay (odds ratio: 1.12, 95% confidence interval 1.1-1.2, p<0.001). A total of 28 major adverse events were observed in 17 patients (10%). Lower pulmonary artery annulus Z-score (odds ratio: 0.5, 95% confidence interval 0.3-0.9, p=0.01) and residual ventricular septal defects (odds ratio: 54.6, 95% confidence interval 1.6-1,874.2, p=0.03) were found to increase mortality. Residual ventricular septal defect was also a risk factor for major adverse events (odds ratio: 12.4, 95% confidence interval 1.5-99.9, p=0.02).

Conclusion

Preoperative and operative factors such as high preoperative hematocrit, low preoperative oxygen saturation, low pulmonary annulus Z-score, Down syndrome, residual ventricular septal defects, and the use transannular patch were found to be associated with prolonged length of hospital stay, prolonged mechanical ventilation, prolonged intensive care unit stay, and increased development of major adverse events.

Postnatal Cardiac Development and Regenerative Potential in Large Mammals

The neonatal capacity for cardiac regeneration in mice is well studied and has been used to develop many potential strategies for adult cardiac regenerative repair following injury. However, translating these findings from rodents to designing regenerative therapeutics for adult human heart disease remains elusive. Large mammals including pigs, dogs, and sheep are widely used as animal models of humans in preclinical trials of new cardiac drugs and devices. However, very little is known about the fundamental cardiac cell biology and the timing of postnatal cardiac events that influence cardiomyocyte proliferation in these animals. There is emerging evidence that external physiological and environmental cues could be the key to understanding cardiomyocyte proliferative behavior. In this review, we survey available literature on postnatal development in various large mammal models to offer a perspective on the physiological and cellular characteristics that could be regulating cardiomyocyte proliferation. Similarities and differences between developmental milestones, cardiomyocyte maturational events, as well as environmental cues regulating cardiac development, are discussed for various large mammals, with a focus on postnatal cardiac regenerative potential and translatability to the human heart.

A Case Report Examining Early Extubation Following Congenital Heart Surgery in a Low Resource Setting

This case report aims to critically analyse the evidence surrounding early extubation in the post-operative phase following complex congenital cardiac surgery. Child A was an 8 year old female who had undergone complex congenital cardiac surgery during an international surgical charity mission. On admission to the paediatric intensive care unit Child A appeared to be in good condition and no major complications had occurred intra-operatively. This was considered alongside the situational pressures of resource limitations and the mission's aim to offer surgery to as many children as possible during the available time frame. The decision was made by the team that Child A was a suitable candidate for 'early extubation.' Some members of the team were uncomfortable with this approach and felt it could lead to poorer outcomes for patients. Current evidence surrounding early extubation both within international surgical mission trips to low-income and middle-income countries and established cardiac centres within high-income countries is examined and discussed alongside the context of resource limitation. Although the process and implications of early extubation following cardiac surgery needs further research, on the basis of the evidence currently available clinicians could potentially encourage the use of early extubation within clinical practice (for appropriately selected patients) through the utilisation of a multidisciplinary approach, both within the UK and during international surgical charity missions to low-income and middle-income countries.

Short-term clinical and echocardiographic outcomes after use of polytetrafluoroethylene bicuspid pulmonary valve during the repair of tetralogy of Fallot

Background:

Application of transannular patch (TAP) during the repair of tetralogy of Fallot (TOF) leads to the development of pulmonary regurgitation (PR). This PR is known to cause right ventricular (RV) volume overload and dysfunction which in turn leads to increase in both morbidity and mortality both in immediate and long-term periods. Here, we sought to analyze the effects of polytetrafluoroethylene (PTFE) pulmonary bicuspid valve on the early outcome of patients with TOF repair where TAP is needed.

Subjects and Methods:

This is a retroprospective, observational study where PTFE bicuspid pulmonary valve was incorporated in all consecutive patients undergoing repair of TOF involving the application of TAP. Postoperative inhospital course was assessed, and patients were followed till 6 months for the status of PR and peak RV outflow tract (RVOT) gradient.

Results:

38 patients were enrolled in the study. The mean age of participants was 53.66 ± 78.67 months. Extubation in operating room was done in 31 (81.58%) patients. Duration of ventilator support was 10.48 ± 24.22 h, and duration of hospital stay was 7.95 ± 3.08 days. These data were compared with three recent studies where only TAP was applied. Extubation in operating room, mechanical ventilation time, and hospital stay were significantly improved in the present study. Out of 37 live patients, four (10.81%) patients had no PR, 28 (75%) had mild, 1 (2.7) had moderate, and 4 (10.81%) had severe PR. Average RVOT peak gradient was 18.8 ± 8.1 mmHg.

Conclusion:

Incorporation of PTFE bicuspid pulmonary valve during the repair of TOF appears to facilitate early extubation and thus reduces ventilator-associated comorbidities. Study needs further long-term follow-up to look for behavior of PTFE bicuspid valve.

Impact of surgical pulmonary valve replacement on ventricular strain and synchrony in patients with repaired tetralogy of Fallot: a cardiovascular magnetic resonance feature tracking study

BACKGROUND

In patients with repaired tetralogy of Fallot (TOF), a better understanding of the impact of surgical pulmonary valve replacement (PVR) on ventricular mechanics may lead to improved indications and outcomes. Therefore, we used cardiovascular magnetic resonance (CMR) feature tracking analysis to quantify ventricular strain and synchrony in repaired TOF patients before and after PVR.

METHODS

Thirty-six repaired TOF patients (median age 22.4 years) prospectively underwent CMR a mean of 4.5 ± 3.8 months before PVR surgery and 7.3 ± 2.1 months after PVR surgery. Feature tracking analysis on cine steady-state free precession images was used to measure right ventricular (RV) and left ventricular (LV) circumferential strain from short-axis views at basal, mid-ventricular, and apical levels; and longitudinal strain from 4-chamber views. Intraventricular synchrony was quantified using the maximum difference in time-to-peak strain, the standard deviation of the time-to-peak, and cross correlation delay (CCD) metrics; interventricular synchrony was assessed using the CCD metric.

RESULTS

Following PVR, RV end-diastolic volume, end-systolic volume, and ejection fraction declined, and LV end-diastolic volume and end-systolic volume both increased with no significant change in the LV ejection fraction. LV global basal and apical circumferential strains, and basal synchrony improved. RV global circumferential and longitudinal strains were unchanged, and there was a varied impact on synchrony across the locations. Interventricular synchrony worsened at the midventricular level but was unchanged at the base and apex, and on 4-chamber views.

CONCLUSIONS

Surgical PVR in repaired TOF patients led to improved LV global strain and no change in RV global strain. LV and RV synchrony parameters improved or were unchanged, and interventricular synchrony worsened at the midventricular level.

Effect of Weight Extremes on Ventricular Volumes and Myocardial Strain in Repaired Tetralogy of Fallot as Measured by CMR

Pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (rTOF-TAP) is often based on cardiac MRI (CMR) right ventricular (RV) volumes indexed to body surface area (BSA). Weight extremes result in increased patient morbidity and affect indexed measurements. We hypothesized that patients with rTOF-TAP at extremes of weight have (1) over- or underestimated indexed volumes and (2) altered parameters of cardiac function. CMRs in patients with rTOF-TAP were retrospectively reviewed; analysis included right and left ventricular (LV) volumes and ejection fractions (EF) and peak global LV circumferential strain (ε _cc) from myocardial tagged images. Indexed volumes were recalculated using ideal BSA. Weight categories were assigned: underweight, appropriate weight, overweight, and obese. Linear regression models with weight category, spline of age, and gender were created to assess the association of weight and parameters of volume and function. When RV volumes were corrected for ideal BSA, 11 (31%) additional overweight and obese patients met published criteria for PVR and 3 (38%) underweight patients no longer met criteria. Obese and overweight patients had larger absolute LV and RV diastolic volumes, but no difference in volumes indexed to ideal BSA. Modeling demonstrated no difference in LVEF or RVEF by weight categories but significant differences in global LV ε _cc. Extremes of body weight may result in inappropriate timing of PVR. Extremes of weight lead to abnormalities in global LV ε _cc. Although clinical implications of abnormal ε _cc are unclear, these patients may be at higher risk for early ventricular dysfunction.

Healthcare Disparities in Outcomes of a Metropolitan Congenital Heart Surgery Center: The Effect of Clinical and Socioeconomic Factors

OBJECTIVE

The purpose of this study is to identify the impact of demographic, socioeconomic, and clinical factors on congenital heart surgery outcomes.

STUDY DESIGN

This retrospective cohort study included 234 congenital heart surgery patients from 2011 through 2015, in a racially/ethnically diverse metropolitan children's hospital. Outcomes included length of stay (LOS), age at first echocardiogram, length of mechanical ventilation, and incidence of complications.

RESULTS

Compared to others, black children underwent their first echocardiogram at a later age (median 23 versus 2 days, p = 0.014) and were more likely to be diagnosed with congenital heart disease in the emergency room (p = 0.026). Hispanic children were more likely to have major non-cardiac congenital anomalies (p = 0.045). Increased LOS during elective admissions was associated with higher surgical complexity (STAT category 4 and 5 Estimate 3.905 days, p = 0.001), compared to STAT category 1, and number of complications (Estimate = 2.306 days per complication, p < 0.001). Increased LOS in non-elective admissions was associated with the number of complex chronic conditions (Estimate = 15.446 days, p = 0.045) and the number of complications (Estimate = 11.591 days per complication, p < 0.001). However, in multivariate analysis, race and ethnicity was not associated with increased LOS or age at first echocardiogram.

CONCLUSION

In this diverse setting, race/ethnicity was not associated with increased LOS, age at first echocardiogram, length of ventilation, or complications. Surgical complexity, chronic conditions, and complications were associated with increased LOS. We discuss some interventions to reduce disparities in congenital heart surgery outcomes.

Factors affecting perioperative mortality in tetralogy of Fallot

BACKGROUND

We evaluated the preoperative, operative and postoperative risk factors affecting early mortality in patients who underwent total correction of tetralogy of Fallot (TOF).

METHODS

One hundred and twenty-two TOF patients who underwent reparative surgery between January 2010 and November 2013 were enrolled in the study.

RESULTS

Mean patient age and weight was 2.3 ± 2.5 years and 11.3 ± 6.4 kg, respectively. Cardiac catheterization was performed in 101 patients (83%),and coronary anomalies were found in 11 patients. Mean McGoon index, pulmonary annulus z-score, main pulmonary artery z-score, left pulmonary artery z-score and right pulmonary artery z-score were 2.0 ± 0.4, -1.85 ± 1.54, -2.84 ± 2.06, 1.17 ± 1.73, and 0.74 ± 1.57, respectively. Total reparative surgery with a transannular patch was performed in 97 patients (79.6%); the rest underwent valve-sparing surgery. Median duration of postoperative mechanical ventilation, intensive care and hospital stay were 19 h, 3 days and 9 days, respectively. Extracorporeal membrane oxygenation (ECMO) was required in 10 patients in the postoperative early period. Arrhythmias occurring in the early postoperative period were junctional ectopic tachycardia (n = 13), complete atrioventricular block(n = 10; permanent epicardial pacemaker implanted in four) and ventricular tachycardia (n = 4). Nine patients died in the early postoperative period (7.3%). Parameters found to be associated with increased mortality were low preoperative oxygen saturation; high right ventricular/aortic pressure ratio immediately after surgery; presence of coronary anomaly; requirement of postoperative ECMO; and pacemaker (P = 0.02, P = 0.04, P = 0.01, P = 0.0001, P = 0.03, respectively).

CONCLUSIONS

Poor preoperative oxygenation, presence of coronary anomaly, complete AV block in the early postoperative period, high RV pressure and requirement of ECMO appear to be the most significant factors that affect early mortality in the surgical treatment of TOF. Appropriate preoperative assessment, correct surgical strategies and attentive intensive care monitoring are required in order to reduce mortality.

Intramural Ventricular Septal Defect Is a Distinct Clinical Entity Associated With Postoperative Morbidity in Children After Repair of Conotruncal Anomalies

BACKGROUND

Intramural ventricular septal defects (VSDs) are interventricular communications through right ventricular free wall trabeculations that can occur after repair of conotruncal anomalies. We assessed the prevalence of residual intramural VSDs and their effect on postoperative course.

METHODS AND RESULTS

Children who underwent biventricular repair of a conotruncal anomaly from January 1, 2006, to June 30, 2013, and had a postoperative transthoracic echocardiogram were included. Images were reviewed for residual intramural or nonintramural VSDs. The primary outcome was a composite of mortality, extracorporeal membrane oxygenation use, and need for subsequent catheter or surgical VSD closure. The secondary outcome was postoperative hospital length of stay. A residual VSD was present in 256 of the 442 subjects (58%), of which 231 (90%) were <2 mm in size. Forty-nine patients (11%) had intramural VSDs, and 207 (47%) had nonintramural VSDs. Patients with intramural VSDs were more likely to reach the primary composite outcome compared with those with nonintramural VSDs or no residual VSD (14 of 49 [29%] versus 15 of 207 [7%] versus 6 of 186 [3%]; P<0.0001). In addition, those with intramural VSDs had longer postoperative hospital length of stay compared with those with nonintramural VSDs or no residual VSD (20 days [interquartile range, 11-42 days] versus 7 days [interquartile range, 5-14 days] versus 6 days [interquartile range, 4-11 days]; P=0.0001). These associations remained significant after adjustment for known risk factors for poor outcomes, including residual VSD size and operative complexity.

CONCLUSIONS

Among residual VSDs after repair of conotruncal anomalies, intramural VSDs are uniquely associated with postoperative morbidity, mortality, and longer postoperative hospital length of stay. It is important to recognize intramural VSDs in the postoperative period.

Bilateral persistent pupillary membrane with tetralogy of fallot: a case report and review of the literature

Case Report. A 15-year-old boy presented to the Fatih Sultan Mehmet Education and Research Hospital with the complain of bilateral vision blurring associated with severe glare and photophobia. On ophthalmological examination, uncorrected visual acuity was 20/200 in the right eye and 20/100 in the left eye, and there was no improvement with pinhole testing. The slit-lamp examination showed persistent pupillary membranes (PPM) in both eyes. According to the history obtained from his parents, he had received cardiac surgery for tetralogy of Fallot (TOF) 8 years ago. Conclusion. This patient is unique because this is the first reported case of bilateral PPM with congenital heart anomaly in the literature. Bilaterality of the eye anomaly strengthens the possibility of an uncommon association between PPM and TOF, rather than local failure in embryonic development.