Two-Stage Liver Transplantation and Tricuspid Valve Replacement After Blunt Trauma in a Pediatric Patient

In cases of uncontrollable hepatic hemorrhage or acute hepatic failure after trauma, liver transplantation can be a lifesaving procedure. Traumatic tricuspid valve injuries are rare, and symptoms can range from indolent to acute right heart failure. When concomitant, traumatic liver transplant and tricuspid injuries have significant physiologic interplay and management implications. We present a 14-year-old male injured in an all-terrain vehicle accident, who sustained a devastating disruption of the common bile duct and celiac artery injury, leading to acute hepatic failure, necessitating a two-stage liver transplantation. He was subsequently found to have a severe traumatic tricuspid injury, which required tricuspid valve replacement. At 4 years post-injury, he is without major complications. This is the first case presentation of the cooccurrence of these complex pathologies. Importantly, we demonstrate the complex decision-making surrounding traumatic liver transplantation and timing of subsequent tricuspid valve repair, weighing the complex interplay of these 2 pathologies.

Coronary artery dilation associated with bicuspid and unicuspid aortic valve disease in children: a series of 17 patients

INTRODUCTION

Coronary artery dilation associated with bicuspid/unicuspid aortic valves is described in adults with limited data in children. We aimed to describe the clinical course of children with bicuspid/unicuspid aortic valves and coronary dilation including coronary Z-score changes over time, association of coronary changes with aortic valve anatomy/function, and complications.

MATERIALS AND METHODS

Institutional databases were searched for children ≤18 years with both bicuspid/unicuspid aortic valves and coronary dilation (1/2006-6/2021). Kawasaki disease and isolated supra-/subvalvar aortic stenosis were excluded. Statistics were descriptive with associations measured by Fisher's exact test and overlapping 83.7% confidence intervals.

RESULTS

Of 17 children, bicuspid/unicuspid aortic valve was diagnosed at birth in 14 (82%). Median age at coronary dilation diagnosis was 6.4 years (range: 0-17.0). Aortic stenosis was present in 14 (82%) [2 (14%) moderate, 8 (57%) severe]; 10 (59%) had aortic regurgitation; 8 (47%) had aortic dilation. The right coronary was dilated in 15 (88%), left main in 6 (35%), and left anterior descending in 1 (6%) with no relationship between leaflet fusion pattern or severity of aortic regurgitation/stenosis on coronary Z-score. Follow-up evaluations were available for 11 (mean 9.3 years, range 1.1-14.8) with coronary Z-scores increasing in 9/11 (82%). Aspirin was used in 10 (59%). There were no deaths or coronary artery thrombosis.

DISCUSSION

In children with bicuspid/unicuspid aortic valves and coronary dilation, the right coronary artery was most frequently involved. Coronary dilation was observed in early childhood and frequently progressed. Antiplatelet medication use was inconsistent, but no child died nor developed thrombosis.

Short-Term Left Ventricular Reverse Remodeling after Transcatheter Aortic Valve Replacement in Children

BACKGROUND

There are no published data on left ventricular (LV) reverse remodeling after transcatheter aortic valve replacement (TAVR) in children. The aim of this study was to assess changes in LV echocardiographic parameters 6 months after TAVR in children.

METHODS

This single-center, retrospective study included all 22 patients (age < 21 years) who underwent TAVR. The median age was 14.7 years (interquartile range, 13.3-15.9 years), median weight was 57 kg (interquartile range, 46.0-66.3 kg), and 59% of patients were male. Demographics, type and duration of aortic valve dysfunction, symptom and treatment data, and preprocedural and 6-month follow-up echocardiographic data (LV volume, mass, end-diastolic dimension, end-systolic dimension, ejection fraction [EF], sphericity, and longitudinal strain) were collected. Failure to reverse remodel at 6 months was defined as meeting at least two of the following: Z score ≥ 2 that was unchanged or increased from baseline for LV volume, mass, end-diastolic dimension, or end-systolic dimension; abnormally high sphericity index that was unchanged or increased; and abnormally low EF or longitudinal strain. Median, interquartile range, and range are reported for continuous variables, and pre- and post-TAVR data were compared using the Wilcoxon signed rank test.

RESULTS

Eight patients (36%) had isolated aortic stenosis, four (18%) had isolated regurgitation, and 10 had (46%) mixed disease. Twelve (55%) had symptoms and 20 (91%) had prior surgical or catheter valve interventions. The primary complication was left bundle branch block, occurring in four children (18%). At 6 months, LV volume, mass, end-diastolic dimension, end-systolic dimension, and sphericity index improved. EF and strain were normal at baseline and at follow-up. Of three patients who failed to reverse remodel, two had left bundle branch block. Of three patients with persistent symptoms, one had failure of reverse remodeling.

CONCLUSIONS

Most pediatric patients had evidence of reverse LV remodeling 6 months after TAVR, suggesting a possible alternative to surgical aortic valve replacement in this population. Functional parameters (EF and strain) were normal at baseline and follow-up. Future studies are needed to determine optimal timing of TAVR and to explore the association of postprocedural left bundle branch block on failed reverse remodeling and outcomes in this population.

Transcatheter and Surgical Aortic Valve Implantation in Children, Adolescents, and Young Adults With Congenital Heart Disease

Transcatheter aortic valve implantation (TAVI) is common in adults but rare in children and adolescents. Since 2014, our institution has incorporated a transcatheter approach as an option for aortic valve replacement in this population. The purpose of this study was to compare short-term outcomes of TAVI with surgical aortic valve replacement (SAVR). This single-center, retrospective study included patients aged 10 to 21 years who had a native SAVR or TAVI between January 2010 to April 2020. Comparative analysis of baseline characteristics and a composite outcome (stroke within 6 months, readmission within 30 days, death) between SAVR and TAVI were made using chi-square test or Wilcoxon rank sum test, as appropriate. Of the 77 patients who underwent native aortic valve implantation during the study period (60 SAVR, 17 TAVI), 46 were aged 10 to 21 years (30 SAVR, 16 TAVI). Median follow-up was 3.8 years (interquartile range 1.5 to 4.9) for the SAVR group and 1.5 years (interquartile range 1.1 to 1.2) for the TAVI group. There was no difference in the composite outcome between groups. Patients in the SAVR group were more likely to have undergone concomitant surgical intervention and have longer intensive care unit and hospital stays. In conclusion, our study suggests similar short-term outcomes between SAVR and TAVI in children and young adults aged 10 to 21 years. Longer-term studies are essential to understand the utility of TAVI and to better consider the option of a transcatheter approach as an alternative to SAVR in the pediatric population.

Successfully Reducing Fat-modified Diet Duration for Treating Postoperative Chylothorax in Children

BACKGROUND

Medical management, primarily a fat-modified diet (FMD), is the mainstay of treatment for the majority of patients with chylothorax. Duration of FMD is traditionally reported as 6 weeks, but no studies demonstrate the shortest effective duration that prevents recurrence of chylothorax. Our aim was to decrease FMD duration to 2 weeks in children with postoperative chylothorax without a significant increase in recurrence.

METHODS

Our single-center study included pediatric (<18 years of age) patients that developed chylothorax within 30 days of cardiac surgery. Patients with cavopulmonary anastomoses were excluded. The pre-intervention cohort was 19 patients diagnosed between 2/2014-6/2015, and the post-intervention cohort was 98 patients from 7/2015-12/2019. FMD duration was decreased from 6 weeks to 4 weeks in May 2016, and to 2 weeks in June 2018. Recurrence was defined as a return of a chylous effusion requiring chest tube placement or hospital readmission within 30 days of resuming a regular diet.

RESULTS

The median duration of FMD decreased from 42 days (interquartile range: 30,43) in the pre-intervention cohort to 26 days (interquartile range: 14,29) post-intervention, with no recurrence of chylothorax in any group. Compliance to the FMD duration instruction in the 6-week, 4-week, and 2-week groups was 100%, 84% and 67% respectively. Compared to the first 6 months, compliance to the 2-week FMD instruction during the final 12 months increased from 40% (6/15) to 79% (26/33).

CONCLUSIONS

At our center, FMD duration decreased from 6 weeks to 2 weeks without any recurrence of chylothorax.

Time-related risk of pulmonary conduit re-replacement: a Congenital Heart Surgeons' Society Study

BACKGROUND

Patients receiving a right ventricle-to-pulmonary artery conduit in infancy will require successive procedures or replacements, each with variable longevity. We sought to identify factors associated with time-related risk of a subsequent surgical replacement (PC3) or transcatheter pulmonary valve insertion (TPVI) after a second surgically-placed PC (PC2).

METHODS

From 2002 to 2016, 630 patients from 29 Congenital Heart Surgeons' Society member institutions survived to discharge after initial valved PC insertion (PC1) at age < 2 years. Of those, 355 had undergone surgical replacement (PC2) of that initial conduit. Competing risk methodology and multiphase parametric hazard analyses were used to identify factors associated with time-related risk of PC3 or TPVI.

RESULTS

Of 355 PC2 patients (median follow-up of 5.3 years), 65 underwent PC3 and 41 TPVI. Factors at PC2 associated with increased time-related risk of PC3 were smaller PC2 Z score (Hazard Ratio [HR] 1.6, p<0.001), concomitant aortic valve intervention (HR 7.6, p=0.009), aortic allograft (HR 2.2, p=0.008), younger age (HR 1.4, p<0.001), and larger Z score of PC1 (HR 1.2, p=0.04). Factors at PC2 associated with increased time-related risk of TPVI were aortic allograft (HR: 3.3, p=0.006), porcine unstented conduit (HR 4.7, p<0.001), and older age (HR 2.3, p=0.01).

CONCLUSIONS

Aortic allograft as PC2 was associated with increased time-related risk of both PC3 and TPVI. Surgeons may reduce risk of these subsequent procedures by not selecting an aortic homograft at PC2, and by oversizing the conduit when anatomically feasible.

Implications of Left Ventricular Dysfunction at Presentation for Infants with Coarctation of the Aorta

Infants with aortic coarctation may present with left ventricular (LV) dysfunction which may complicate the postoperative course and lead to increased healthcare costs. We aimed to define the prevalence of moderate to severe left ventricular (LV) systolic dysfunction, evaluate time to recovery, and compare health care costs. Single-center retrospective cohort study at a tertiary care hospital was conducted. Infants < 6 months old at diagnosis with aortic coarctation were identified using surgical codes for coarctation repair between January 2010 and May 2018. Moderate to severe dysfunction was defined as ejection fraction (EF) < 40%. Of 160 infants studied, 18 (11%) had moderate to severe LV dysfunction at presentation. Compared to those with better LV function, infants with moderate to severe LV dysfunction were older at presentation (12 vs. 6 days, p = 0.004), had more postoperative cardiac intensive care unit (ICU) days (5 vs. 3, p < 0.001), and more ventilator days (3.5 vs. 1, p < 0.001). The median time to normal LV EF (≥ 55%) was 6 days postoperatively (range 1-230 days). Infants presenting with moderate to severe LV dysfunction had higher index hospitalization costs ($90,560 vs. $59,968, p = 0.02), but no difference in cost of medical follow-up for the first year following discharge ($3,078 vs. $2,568, p = 0.46). In the current era, > 10% of infants with coarctation present with moderate to severe LV dysfunction that typically recovers. Those with moderate to severe dysfunction had longer duration of mechanical ventilation and postoperative cardiac ICU stays, likely driving higher costs of index hospitalization.

The Benefits and Bias in Neurodevelopmental Evaluation for Children with Congenital Heart Disease

Neurodevelopmental (ND) impairment is common in children with congenital heart disease (CHD). While routine ND surveillance and evaluation of high-risk patients has become the standard-of-care, capture rate, barriers to referral, and potential patient benefits remain incompletely understood. Electronic data warehouse records from a single center were reviewed to identify all eligible and evaluated patients between July 2015 and December 2017 based on current guidelines for ND screening in CHD. Diagnoses, referring provider, and payor were considered. Potential benefit of the evaluation was defined as receipt of new diagnosis, referral for additional evaluation, or referral for a new service. Contingencies were assessed with Fisher's exact test. In this retrospective, cohort study, of 3434 children identified as eligible for ND evaluation, 135 were evaluated (4%). Appropriate evaluation was affected by diagnostic bias against coarctation of the aorta (CoArc) and favoring hypoplastic left heart syndrome (HLHS) (1.8 vs. 11.9%, p<0.01). Referrals were disproportionally made by a select group of cardiologists, and the rate of ND appointment non-compliance was higher in self-pay compared to insured patients (78% vs 27%, p<0.01). Potential benefit rate was 70-80% amongst individuals with the three most common diagnoses requiring neonatal surgery (CoArc, transposition of the great arteries, and HLHS). Appropriate ND evaluation in CHD is impacted by diagnosis, provider, and insurance status. Potential benefit of ND evaluation is high regardless of diagnosis. Strategies to improve access to ND evaluations and provider understanding of the at-risk population will likely improve longitudinal ND surveillance and clinical benefit.

Value-driven cardiac surgery: Achieving "perfect care" after coronary artery bypass grafting

OBJECTIVE

The objective of this study was to determine if the implementation of a value-driven outcomes tool comprising modifiable quality and utilization metrics lowers cost and improves value of coronary artery bypass grafting (CABG) postoperative care.

METHODS

Ten metrics were defined for CABG patients in 2 temporally separated phases. Clinical care protocols were designed and implemented to increase compliance with these metrics. Clinical outcomes and cost data were harvested from the electronic medical record using a proprietary value-driven outcomes tool and verified by a data management team. "Perfect care" was defined as achieving all 10 metrics per patient episode.

RESULTS

Over a 45-month period, data of 467 consecutive patients who underwent isolated CABG were analyzed. "Perfect care" was successfully achieved in 304 patients (65.1%). There were no observed differences in mortality between patient groups. Linear regression analysis showed a negative correlation between percent compliance with "perfect care" and mean cost. When multivariate analysis was used to adjust for preoperative risk score, mean cost for patients with "perfect care" was 37.0% less than for those without "perfect care."

CONCLUSIONS

In the context of focused institution-specific interventions to target quality and utilization metrics for CABG care, clinical care pathways and protocols informed by innovative tools that link automated tracking of these metrics to cost data might simultaneously promote quality and decrease costs, thereby enhancing value. This descriptive study provides preliminary support for a systematic approach to define, measure, and modulate the drivers of value for cardiothoracic surgery patients.

Resource Utilization for Initial Hospitalization in Pediatric Heart Transplantation in the United States

Pediatric heart transplantation (HT) is resource intensive. Event-driven pediatric databases do not capture data on resource use. The objective of this study was to evaluate resource utilization and identify associated factors during initial hospitalization for pediatric HT. This multicenter retrospective cohort study utilized the Pediatric Health Information Systems database (43 children's hospitals in the United States) of children ≤19 years of age who underwent transplant between January 2007 and July 2013. Demographic variables including site, payer, distance and time to center, clinical pre- and post-transplant variables, mortality, cost, and charge were the data collected. Total length of stay (LOS) and charge for the initial hospitalization were used as surrogates for resource use. Charges were inflation adjusted to 2013 dollars. Of 1,629 subjects, 54% were male, and the median age at HT was 5 years (IQR [interquartile range] 0 to 13). The median total and intensive care unit LOS were 51 (IQR 23 to 98) and 23 (IQR 9 to 58) days, respectively. Total charge and cost for hospitalization were $852,713 ($464,900 to $1,609,300) and $383,600 ($214,900 to $681,000) respectively. Younger age, lower volume center, southern region, and co-morbidities before transplant were associated with higher resource use. In later years, charges increased despite shorter LOS. In conclusion, this large multicenter study provides novel insight into factors associated with resource use in pediatric patients having HT. Peritransplant morbidities are associated with increased cost and LOS. Reducing costs in line with LOS will improve health-care value. Regional and center volume differences need further investigation for optimizing value-based care and efficient use of scarce resources.

Indications for intervention in asymptomatic children with chronic mitral regurgitation

Based on outcome data, surgery is recommended for asymptomatic adults with chronic mitral regurgitation (MR) and systolic dysfunction, marked left ventricular (LV) dilation, pulmonary hypertension, atrial fibrillation, or high likelihood of successful repair; but indications for children are poorly defined. We sought to determine predictors of postoperative LV dysfunction in asymptomatic children with chronic MR. The surgical database was searched for all children who underwent mitral valve surgery for chronic MR (2000-2012). Exclusion criteria were preoperative symptoms, acute MR, cardiomyopathy, or other defects affecting LV size. Preoperative and latest follow-up clinical and echocardiographic data were obtained. LV dysfunction was defined as ejection fraction (EF) ≤55% or shortening fraction (SF) ≤28%. Associations between preoperative factors and late LV dysfunction were determined using univariate Poisson regression. For the 25 children who met criteria, preoperative median LV end systolic Z score (LVESZ) was 5.3, EF was 65%, and SF was 34%. At follow-up (median 3.9 years), nine patients (36%) had LV dysfunction. Lower preoperative SF (OR 0.6, p < 0.001) and higher LVESZ (OR 1.7, p < 0.01) were associated with late LV dysfunction. LVESZ ≥ 5 combined with SF ≤ 33% had a sensitivity of 89%, specificity of 88%, and negative predictive value of 93% for late LV dysfunction. Only 1/14 patients with preoperative SF > 33% had late LV dysfunction. For asymptomatic children with chronic MR, surgery should be considered before LVESZ exceeds five and SF falls below 33%. Patients with SF > 33% may be followed with serial echocardiographic measurements.

Transthoracic echocardiographic predictors of left atrial hypertension in patients on venoarterial extracorporeal membrane oxygenation

Decompression of the left heart in patients supported with extracorporeal membrane oxygenation (ECMO) is often warranted to protect the myocardium and facilitate recovery. We studied the ability of standard echocardiographic parameters to predict left atrial hypertension by reviewing 3 cardiac patients supported with ECMO who subsequently underwent left atrial decompression. We found that standard echocardiographic parameters poorly predict the need for left atrial decompression on ECMO. Following a more specific diagnostic algorithm to estimate left-sided filling pressure in patients with depressed ejection fraction may significantly improve the ability of echocardiography to accurately predict left atrial hypertension and the need for decompression.

Repair of traumatic aortoinnominate disruption using CorMatrix

Blunt traumatic injuries to the innominate artery are rare but potentially devastating injuries. Patients with an innominate injury who survive typically have an isolated intimal tear with an intact adventitia. There are multiple case reports and series describing off-pump repair of innominate injuries using synthetic grafts, and even reports of successful endovascular stenting. We report the first successful case of innominate artery disruption and repair using CorMatrix (CorMatrix Alpharetta, GA) extracellular matrix.

Body composition and energy metabolism following Roux-en-Y gastric bypass surgery

Roux-en-Y gastric bypass (RYGB) surgery has become an accepted treatment for excessive obesity. We conducted a longitudinal study to assess regional body composition, muscle proteolysis, and energy expenditure before RYGB, and 6 and 12 months after RYGB. Whole-body and regional fat mass (FM) and lean mass (LM) were assessed via dual energy X-ray absorptiometry (DXA), and myofibrillar protein degradation was estimated by urinary 3-methylhistidine (3-MeH) in 29 subjects. Energy expenditure and substrate oxidation were also determined using a whole-room, indirect calorimeter in 12 of these subjects. LM loss constituted 27.8 +/- 10.2% of total weight loss achieved 12 months postoperatively, with the majority of LM loss (18 +/- 6% of initial LM) occurring in the first 6 months following RYGB. During this period, the trunk region contributed 66% of whole-body LM loss. LM loss occurred in the first 6 months after RYGB despite decreased muscle protein breakdown, as indicated by a decrease in 3-MeH concentrations and muscle fractional breakdown rates. Sleep energy expenditure (SEE) decreased from 2,092 +/- 342 kcal/d at baseline to 1,495 +/- 190 kcal/day at 6 months after RYGB (P < 0.0001). Changes in both LM and FM had an effect on the reduction in SEE (P < 0.001 and P = 0.005, respectively). These studies suggest that loss of LM after RYGB is significant and strategies to maintain LM after surgery should be explored.

Surgical removal of omental fat does not improve insulin sensitivity and cardiovascular risk factors in obese adults

BACKGROUND & AIMS

Visceral adipose tissue (VAT) is an important risk factor for the metabolic complications associated with obesity. Therefore, a reduction in VAT is considered an important target of obesity therapy. We evaluated whether reducing VAT mass by surgical removal of the omentum improves insulin sensitivity and metabolic function in obese patients.

METHODS

We conducted a 12-month randomized controlled trial to determine whether reducing VAT by omentectomy in 22 obese subjects increased their improvement following Roux-en-Y gastric bypass (RYGB) surgery in hepatic and skeletal muscle sensitivity to insulin study 1. Improvement was assessed by using the hyperinsulinemic-euglycemic clamp technique. We also performed a 3-month, longitudinal, single-arm study to determine whether laparoscopic omentectomy alone, in 7 obese subjects with type 2 diabetes mellitus (T2DM), improved insulin sensitivity study 2. Improvement was assessed by using the Frequently Sampled Intravenous Glucose Tolerance Test.

RESULTS

The greater omentum, which weighed 0.82 kg (95% confidence interval: 0.67-0.97), was removed from subjects who had omentectomy in both studies. In study 1, there was an approximate 2-fold increase in muscle insulin sensitivity (relative increase in glucose disposal during insulin infusion) and a 4-fold increase in hepatic insulin sensitivity 12 months after RYGB alone and RYGB plus omentectomy, compared with baseline values (P<.001). There were no significant differences between groups (P>.87) or group x time interactions (P>.36). In study 2, surgery had no effect on insulin sensitivity (P=.844) or use of diabetes medications.

CONCLUSIONS

These results demonstrate that decreasing VAT through omentectomy, alone or in combination with RYGB surgery, does not improve metabolic function in obese patients.

Assessing Body Fat Changes during Moderate Weight Loss with Anthropometry and Bioelectrical Impedance

BACKGROUND/OBJECTIVES: Monitoring changes in total fat mass and abdominal adiposity are important in understanding the impact of different types of weight loss interventions on health risks. Our objective was to assess the usefulness of anthropometry and bioelectrical impedance analysis (BIA) in predicting fat mass changes during moderate weight loss. SUBJECTS/METHODS: Fat mass changes were assessed in 34 overweight adults (24 females, 10 males) after a 12-week supervised weight loss induced by caloric restriction (-30% of requirement) using BIA and DXA. Agreement between BIA and DXA measurements were assessed by Bland-Altman plots. Linear regression modeling was used to predict body and truncal fat mass from anthropometric measures. RESULTS: Diet intervention resulted in a significant decrease in body weight (- 7.86 ± 2.87 kg), body mass index (BMI - 2.69 ± 0.98 kg/m(2)), total body fat (- 5.22 ± 2.32 kg), truncal fat (- 2.80 ± 1.94 kg) and waist circumference (- 5.52 ± 3.57 cm). BMI and body weight were highly correlated with body fat (0.83 and 0.92 in females and 0.94 and 0.92 in males respectively) and truncal fat (0.75 and 0.87 in females; 0.90 and 0.84 in males respectively) during weight loss. Waist circumference was more correlated with truncal fat in males than females (0.94 vs. 0.85 in females). Compared to DXA, BIA underestimated total body fat changes in males (- 8.8 kg, p<0.001) and overestimated total body fat changes in females (+ 2.1 kg, p< 0.001). CONCLUSIONS: Body mass index, body weight, and waist circumference provide simple and more accurate than BIA estimates of relative changes in total and truncal fat during moderate weight loss in adults.

Phosphodiesterase 5 inhibition improves beta-cell function in metabolic syndrome

OBJECTIVE

This study tested the hypothesis that phosphodiesterase 5 inhibition alone or in combination with ACE inhibition improves glucose homeostasis and fibrinolysis in individuals with metabolic syndrome.

RESEARCH DESIGN AND METHODS

Insulin sensitivity, beta-cell function, and fibrinolytic parameters were measured in 18 adults with metabolic syndrome on 4 separate days after a randomized, crossover, double-blind, 3-week treatment with placebo, ramipril (10 mg/day), tadalafil (10 mg o.d.), and ramipril plus tadalafil.

RESULTS

Ramipril decreased systolic and diastolic blood pressure, ACE activity, and angiotensin II and increased plasma renin activity. Ramipril did not affect insulin sensitivity or beta-cell function. In contrast, tadalafil improved beta-cell function (P = 0.01). This effect was observed in women (331.9 +/- 209.3 vs. 154.4 +/- 48.0 32 micro x mmol(-1) x l(-1), respectively, for tadalafil treatment vs. placebo; P = 0.01) but not in men. There was no effect of any treatment on fibrinolysis. CONCLUSIONS Phosphodiesterase 5 inhibition may represent a novel strategy for improving beta-cell function in metabolic syndrome.