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St Louis JD, Bhat A, Carey JC, Lin AE, Mann PC, Smith LM, Wilfond BS, Kosiv KA, Sorabella RA, Alsoufi B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Recommendation for the care of children with trisomy 13 or trisomy 18 and a congenital heart defect. J Thorac Cardiovasc Surg 2024; 167:1519-1532. [PMID: 38284966 DOI: 10.1016/j.jtcvs.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Recommendations for surgical repair of a congenital heart defect in children with trisomy 13 or trisomy 18 remain controversial, are subject to biases, and are largely unsupported with limited empirical data. This has created significant distrust and uncertainty among parents and could potentially lead to suboptimal care for patients. A working group, representing several clinical specialties involved with the care of these children, developed recommendations to assist in the decision-making process for congenital heart defect care in this population. The goal of these recommendations is to provide families and their health care teams with a framework for clinical decision making based on the literature and expert opinions. METHODS This project was performed under the auspices of the AATS Congenital Heart Surgery Evidence-Based Medicine Taskforce. A Patient/Population, Intervention, Comparison/Control, Outcome process was used to generate preliminary statements and recommendations to address various aspects related to cardiac surgery in children with trisomy 13 or trisomy 18. Delphi methodology was then used iteratively to generate consensus among the group using a structured communication process. RESULTS Nine recommendations were developed from a set of initial statements that arose from the Patient/Population, Intervention, Comparison/Control, Outcome process methodology following the groups' review of more than 500 articles. These recommendations were adjudicated by this group of experts using a modified Delphi process in a reproducible fashion and make up the current publication. The Class (strength) of recommendations was usually Class IIa (moderate benefit), and the overall level (quality) of evidence was level C-limited data. CONCLUSIONS This is the first set of recommendations collated by an expert multidisciplinary group to address specific issues around indications for surgical intervention in children with trisomy 13 or trisomy 18 with congenital heart defect. Based on our analysis of recent data, we recommend that decisions should not be based solely on the presence of trisomy but, instead, should be made on a case-by-case basis, considering both the severity of the baby's heart disease as well as the presence of other anomalies. These recommendations offer a framework to assist parents and clinicians in surgical decision making for children who have trisomy 13 or trisomy 18 with congenital heart defect.
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Affiliation(s)
- James D St Louis
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga.
| | - Aarti Bhat
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - John C Carey
- Department of Pediatrics, University of Utah Health and Primary Children's Hospital, Salt Lake City, Utah
| | - Angela E Lin
- Department of Pediatrics, Mass General Hospital for Children, Boston, Mass
| | - Paul C Mann
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga
| | - Laura Miller Smith
- Department of Pediatrics, Oregon Health and Science University, Portland, Ore
| | - Benjamin S Wilfond
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - Katherine A Kosiv
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Robert A Sorabella
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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Deptula J, Olshove V, Oldeen M, Kozik D, Alsoufi B. Normalizing Anti-Thrombin III for heparin management during routine cardiopulmonary bypass for congenital cardiothoracic surgery: A single institution practice review. Perfusion 2024:2676591241239819. [PMID: 38503431 DOI: 10.1177/02676591241239819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Over the past decade, there has been an increase in the use of recombinant Anti-Thrombin III (AT-III) administration during neonatal and pediatric short- and long-term mechanical support for the replacement of acquired deficiencies. Recombinant AT-III (Thrombate) administration is an FDA licensed drug indicated primarily for patients with hereditary deficiency to treat and prevent thromboembolism and secondarily to prevent peri-operative and peri-partum thromboembolism. Herein we propose further use of Thrombate for primary AT-III deficiency of the newborn as well as for acquired dilution and consumption secondary to cardiopulmonary bypass (CPB). METHODOLOGY All patients undergoing CPB obtain a preoperative AT-III level. Patients with identified deficiencies are normalized in the OR using recombinant AT-III as a patient load, in the CPB prime, or both. Patient baseline Heparin Dose Response (HDR) is assessed using the Heparin Management System (HMS) before being exposed to AT-III. If a patient load of AT-III is given, a second HDR is obtained and this AT-III Corrected HDR is used as the primary goal during CPB. Once CPB is initiated, an AT-III level is obtained with the first patient blood analysis. A subtherapeutic level results in an additional dose of AT-III. During the rewarm period, a final AT-III level is obtained and AT-III treated once again if subtherapeutic. A retrospective, matched analysis review of practice analyzing two groups, a Study Group (Repeat HDR, May 2022 onward) and Matched Group (Without Repeat HDR, July 2019 to April 2022), for age (D), weight (Kg) and operation was conducted. The focus of the study was to determine any change in heparin sensitivity identified post AT-III patient bolus load in the HDR (U/mL), Slope (U/mL/s), ACT (s), and total amount of heparin on CPB (U) and protamine (mg) used in each group. RESULTS No significance was seen in Baseline AT-III (%), post heparin load HDR (U/mL), first CPB ACT (s), first CPB HDR (U/mL), or total CPB heparin (u/Kg) between the two groups. Statistical significance was seen in Baseline ACT (s), Baseline HDR (U/mL), Baseline Slope (U/mL/s), Post Heparin Load ACT (s), first CPB AT-III (%), and Protamine (mg/Kg) (p < .05). No statistical significance was seen in the Study Intragroup between pre versus post AT-III patient load baseline sample in ACT (s), however significance was seen in HDR (U/mL) and Slope (U/mL/s) (p < .05). CONCLUSION Implementation of AT-III monitoring and therapy before and during CPB in conjunction with the HMS allows patients to maintain a steady state of anticoagulation with overall less need for excessive heparin replacement and potentially thrombin activation. The result is obtaining a steady state of anticoagulation, a reduced fluctuation in the heparin and ACT levels and a potential for lower co-morbidities associated with prolonged CPB times.
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Affiliation(s)
- Joseph Deptula
- Pediatric Perfusion, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Vincent Olshove
- Pediatric Perfusion, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Molly Oldeen
- Pediatric Perfusion, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, School of Medicine and Norton Children's Hospital, University of Louisville, Louisville, Kentucky, USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, School of Medicine and Norton Children's Hospital, University of Louisville, Louisville, Kentucky, USA
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Deptula J, Olshove V, Oldeen M, Kozik D, Alsoufi B. A novel approach to retrograde autologous priming for infant, pediatric and adult populations undergoing congenital heart surgery. Perfusion 2024:2676591241239820. [PMID: 38498943 DOI: 10.1177/02676591241239820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Retrograde Autologous Priming (RAP) of cardiopulmonary bypass (CPB) circuits is an effective way to reduce prime volume, commonly through the transfer of prime into separate reservoirs or circuit manipulation. We describe a simple and safe technique for RAP without the need for any circuit modifications or manipulations. METHODS For this technique, a separate roller pump for ultrafiltration (UF) is used. After adequate heparinization and arterial cannulation, the UF pump is initiated slowly, removing prime through the effluent of the UF, replacing with the patient's blood from the aortic cannula. Once the arterial line and UF circuit are autologous primed, the arterial head displaces reservoir crystalloid toward the UF circuit at a flow rate equal to the UF pump, displacing the crystalloid prime with blood from the UF circuit, autologous priming the boot and oxygenator with blood, crystalloid again being removed by the effluent. After venous cannulation, the venous line prime is replaced with autologous blood, the crystalloid removed by the effluent of the UF circuit via the arterial head. During RAP, if the patient becomes hypovolemic, either autologous volume is transfused back to the patient, or CPB is initiated, without the need for circuitry modifications. RESULTS The patient population in this sample consisted of 63 patients ranging between 6.1 kg and 115.6 kg. The smaller the patient, the less blood volume available for RAP and therefore the less prime volume able to be removed. Overall percent removal increases as our patients size increases compared to total circuit volume. CONCLUSION This RAP technique is a safe and effective way to achieve a standardized asanguinous prime for many regardless of patient or circuit size in the absence of contraindications such as low starting hematocrit, emergency surgery or physiologic instability. Most importantly, this potentially reduces the amount of hemodilution patients see from CPB initiation and therefore the lowest nadir hematocrit and consequently the amount of required homologous blood products needed during surgery.
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Affiliation(s)
- Joseph Deptula
- Department of Pediatric Perfusion, Norton Children's Hospital, Louisville, KY, USA
| | - Vincent Olshove
- Department of Pediatric Perfusion, Norton Children's Hospital, Louisville, KY, USA
| | - Molly Oldeen
- Department of Pediatric Perfusion, Norton Children's Hospital, Louisville, KY, USA
| | - Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, School of Medicine and Norton Children's Hospital, University of Louisville, Louisville, KY, USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, School of Medicine and Norton Children's Hospital, University of Louisville, Louisville, KY, USA
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Alsoufi B, Kozik D, Perrotta M, Wilkens S, Lambert AN, Deshpande S, Slaughter M, Trivedi J. Trends and outcomes of heart transplantation in adults with congenital heart disease. Eur J Cardiothorac Surg 2024; 65:ezae086. [PMID: 38447194 DOI: 10.1093/ejcts/ezae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES Heart transplantation for adult congenital heart disease is complicated and associated with challenging pretransplant support, long waiting and high early post-transplant mortality. We explored if surgical and medical advances and allocation system changes have affected outcomes. METHODS From United Network for Organ Sharing database, adults with congenital heart disease listed for heart transplantation were queried. To explore practice and outcome trends, patients were divided into 4 eras (eras 1-3: nearly 3 equal periods from 1992 to 2018, era 4: after 2018, corresponding with new allocation system). Univariate and multivariable analysis was performed to evaluate outcomes. RESULTS A total of 2737 patients were listed. There was gradual increase in listed and transplanted patients, along with significant increase in use of mechanical support, simultaneous kidney and liver transplantation. While proportion of transplanted remained constant, there was decrease in proportion delisted/died after listing (P = 0.01) and waiting list duration (P = 0.01), especially in era 4. Thirty-day post-transplant mortality remains high; however, it has significantly improved starting era 3 (P = 0.01). Current survival at 1-year and 5-years is 85% and 65%, with improvement mainly related to decreased early death. On multivariable analysis, factors associated with survival were lower glomerular filtration rate (hazard ratio = 0.99, P = 0.042), bilirubin (hazard ratio = 1.17, P<0.001) and mechanical ventilation (hazard ratio = 2.3, P=0.004). CONCLUSIONS Heart transplantation in adults with congenital heart disease is increasing, along with added complexity, higher usage of pretransplant mechanical support and simultaneous organ transplantation. Despite that, more complex patients do not experience worse outcomes. Early mortality improved but remains high. New donor allocation system allowed shorter waiting time and higher proportion transplanted without altering early mortality.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Deborah Kozik
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Melissa Perrotta
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Sarah Wilkens
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Andrea Nicole Lambert
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Shriprasad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - Mark Slaughter
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
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Skaff AM, Lambert AN, Alsoufi B. Ventricular dysfunction in a low birthweight, premature neonate. J Thorac Cardiovasc Surg 2024; 167:1147-1151. [PMID: 37295644 DOI: 10.1016/j.jtcvs.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/12/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Adam M Skaff
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, Ky
| | - A Nicole Lambert
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, Ky
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky.
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Eberly LM, Alsoufi B. Heart transplant for adult congenital heart disease: a battle to overcome early mortality. Eur J Cardiothorac Surg 2024; 65:ezae033. [PMID: 38331408 DOI: 10.1093/ejcts/ezae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/06/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Logan M Eberly
- Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
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Johnsrude C, Dasgupta S, Sobczyk W, Alsoufi B, Kozik D. Implantation of a transmural atrial pacing lead in an adult with postoperative congenital heart disease and delayed chest closure. JTCVS Tech 2024; 23:49-51. [PMID: 38352017 PMCID: PMC10859665 DOI: 10.1016/j.xjtc.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 02/16/2024] Open
Affiliation(s)
- Christopher Johnsrude
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Walter Sobczyk
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Bahaaldin Alsoufi
- Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Deborah Kozik
- Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
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Desai MH, Trivedi JR, Gerhard EF, Sinha P, Alsoufi B, Deshpande SR. Perioperative Morbidity and Outcomes in Pediatric Patients Transitioned From Extracorporeal Membrane Oxygenation to Ventricular Assist Device Support: A Study of the Society of Thoracic Surgeons Congenital Heart Surgery Database. ASAIO J 2024; 70:75-80. [PMID: 37815257 PMCID: PMC10749675 DOI: 10.1097/mat.0000000000002052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
As a bridge to transplant strategy, children transitioned from extracorporeal membrane oxygenation (ECMO) to ventricular assist device (VAD) have higher waitlist mortality compared with those who receive de novo VAD. However, the contribution of the immediate perioperative period and differences in the two groups are not well studied. We performed a nested case-control study between children receiving de novo VAD (group 1) and those transitioned from ECMO to VAD (group 2) between 2014 and 2019 using The Society of Thoracic Surgeons (STS) database. A total of 735 children underwent VAD placement with 498 in group 1 and 237 in group 2. Patients in group 2 were significantly younger, smaller, and significantly sicker, were twice as likely to transition to biventricular VAD and need unplanned reoperations. Overall mortality was 16% for group 1 and 34% for group 2 ( p < 0.01). Regression analysis showed that ECMO use (odds ratio [OR], 2.17 [1.3-3.4]), ventilator need (OR, 2.2 [1.3-3.9]), and cardiogenic shock (OR, 1.8 [1.2-2.8]) were all independent preoperative predictors of VAD mortality while dialysis need (OR, 25.5 [8.6-75.3]), stroke (OR, 6.2 [3.1-12.6]), and bleeding (OR, 1.9 [1.1-3.4]) were independent postoperative predictors of VAD mortality within 30 days (all p < 0.05). The study demonstrated significant baseline differences between the two cohorts, warranting avoidance of comparison. Early elective VAD placement in this cohort of patients should be sought to avoid interim ECMO and high post-VAD mortality.
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Affiliation(s)
- Manan H. Desai
- From the Division of Pediatric Cardiac Surgery, Children’s National Hospital, Washington, District of Columbia
| | - Jaimin R. Trivedi
- Division of Thoracic and Cardiovascular Surgery, University of Louisville, Louisville, Kentucky
| | - Eleanor F. Gerhard
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Pranava Sinha
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Bahaaldin Alsoufi
- Division of Thoracic and Cardiovascular Surgery, Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Shriprasad R. Deshpande
- Department of Pediatric Cardiology, Children’s National Hospital, Washington, District of Columbia
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Alsoufi B, Kozik D, Lambert AN, Deshpande S, Wilkens S, Austin E, Trivedi J. Associated Factors and Impact of Persistent Renal Dysfunction in Pediatric Heart Transplantation. Ann Thorac Surg 2024; 117:136-142. [PMID: 36634833 DOI: 10.1016/j.athoracsur.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 12/12/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND We evaluated the impact of significant renal dysfunction (SRD) on listing and pediatric heart transplantation (PHT) outcomes. METHODS The United Network of Organ Sharing registry was queried. Our cohort included 11,625 children listed for PHT (2000-2020). At listing, 1494 (13%) had SRD, defined as an estimated glomerular filtration rate of <45 mL/min/1.73 m2 and/or dialysis requirement. Characteristics of children with and without SRD were compared. SRD impact on outcomes was examined. Factors associated with waiting list mortality, persistent SRD at PHT, and post-PHT survival with and without simultaneous heart-kidney transplantation were assessed. RESULTS Compared with children with an estimated glomerular filtration rate >45 mL/min/1.73 m2, those with SRD had higher waiting list death (37% vs 14%, P < .01) and lower transplantation rate (51% vs 71%, P < .01). On multivariable analysis, SRD was associated with waiting list death (hazard ratio, 3.016; P < .0001). Among 767 children with SRD who received PHT, 361 (47%) had persistent SRD at the time of PHT. On multivariable analysis, factors associated with persistent SRD were older age (odds ratio [OR], 1.147 per year; 95% CI, 1.046-1.258 per year; P = .0035), bilirubin (OR, 1.127 per 1-mg/dL; 95% CI, 1.061-1.197 per 1-mg/dL; P < .0001), dialysis (OR, 1.839; 95% CI, 1.017-3.326; P = .0115), mechanical ventilation (OR, 1.972; 95% CI, 1.336-2.911; P = .0006), extracorporeal membrane oxygenation (OR, 1.747; 95% CI, 1.074-2.842; P = .0247), and not using a ventricular assist device (VAD) (OR, 0.498 [VAD use]; 95% CI, 0.277-0.895 VAD use; P = .0198). Post-PHT survival was 72%, 70%, and 56% (P < .01) at 8 years for PHT alone with improved renal function, simultaneous heart-kidney transplantation (n = 69), and PHT alone with persistent SRD, respectively. CONCLUSIONS SRD is associated with high waiting list death and decreased transplantation rate. Timely proper pre-PHT support with VAD could enhance kidney recovery. Simultaneous heart-kidney transplantation neutralized persistent SRD effect on survival and might be considered in high-risk patients such as those on dialysis, mechanical ventilation, or extracorporeal membrane oxygenation support.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Kentucky.
| | - Deborah Kozik
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Kentucky
| | - Andrea Nicole Lambert
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, Kentucky
| | - Shriprasad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC
| | - Sarah Wilkens
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, Kentucky
| | - Erle Austin
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Kentucky
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Kentucky
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Alsoufi B, Kozik D, Lambert AN, Wilkens S, Trivedi J, Deshpande S. Increasing donor-recipient weight mismatch in infant heart transplantation is associated with shorter waitlist duration and no increased morbidity or mortality. Eur J Cardiothorac Surg 2023; 64:ezad316. [PMID: 37701977 DOI: 10.1093/ejcts/ezad316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/01/2023] [Accepted: 09/12/2023] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVES Infants awaiting paediatric heart transplantation (PHT) experience long waitlist duration and high mortality due to donor shortage. Using the United Network for Organ Sharing database, we explored if increasing donor-recipient weight ratio (DRWR) >2.0 (recommended cutoff) was associated with adverse outcomes. METHODS Between 2007 and 2020, 1392 infants received PHT. We divided cohort into 3 groups: A (DRWR ≤1.0, n = 239, 17%), B (DRWR 1.0-2.0, n = 947, 68%), C (DRWR >2.0, n = 206, 15%). Group characteristics and PHT outcomes were analysed. RESULTS DRWR ranged between 0.5 and 4.1. Underlying pathology (congenital versus cardiomyopathy), gender, race, renal function and mechanical circulatory support were comparable between groups. Group C patients were more likely to be ventilated, to receive ABO blood group (ABO)-incompatible heart and to have longer donor ischaemic time. Waitlist duration was significantly shorter for group C (33 vs 50 days, P < 0.1). Early outcomes for groups A, B and C were the following (respectively): operative death (6%, 4%, 3%, P = 0.29), primary graft dysfunction (5%, 3%, 3%, P = 0.30), renal failure (10%, 7%, 7%, P = 0.42) and stroke (3%, 4%, 1%, P = 0.36). The DRWR group was not associated with operative death in either congenital (odds ratio (OR) = 0.819, 95% confidence interval (CI) = 0.523-1.282) or cardiomyopathy (OR = 1.221, 95% CI = 0.780-1.912) patients and only significant factor was pre-PHT extracorporeal membrane oxygenation (OR = 4.400, 95% CI = 2.761-7.010). Additionally, survival at 1 year (87%, 87%, 85%, P = 0.80) and 5 years (76%, 78%, 77%, P = 0.80) was comparable between the DRWR groups. CONCLUSIONS Infants who received PHT with DRWR >2.0, up to 4.1, experienced shorter waitlist duration with no demonstrable increase in peri-transplant complications, operative or late mortality. Historic practice to avoid DRWR > 2.0 due to complications (e.g. hypertension-related stroke, graft dysfunction, death) is not currently supported in infants and stretching DRWR acceptance criteria would decrease PHT waitlist duration and potentially improve waitlist complications and mortality.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Deborah Kozik
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Andrea Nicole Lambert
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Sarah Wilkens
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Shriprasad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
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Argo MB, Barron DJ, Bondarenko I, Eckhauser A, Gruber PJ, Lambert LM, Paramananthan T, Rahman M, Winlaw DS, Yerebakan C, Alsoufi B, DeCampli WM, Honjo O, Kirklin JK, Prospero C, Ramakrishnan K, St Louis JD, Turek JW, O'Brien JE, Pizarro C, Anagnostopoulos PV, Blackstone EH, Jacobs ML, Jegatheeswaran A, Karamlou T, Stephens EH, Polimenakos AC, Haw MP, McCrindle BW. Hybrid palliation versus nonhybrid management for a multi-institutional cohort of infants with critical left heart obstruction. J Thorac Cardiovasc Surg 2023; 166:1300-1313.e2. [PMID: 37164059 DOI: 10.1016/j.jtcvs.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To compare patient characteristics and overall survival for infants with critical left heart obstruction after hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) versus nonhybrid management (eg, Norwood, primary transplantation, biventricular repair, or transcatheter/surgical aortic valvotomy). METHODS From 2005 to 2019, 1045 infants in the Congenital Heart Surgeons' Society critical left heart obstruction cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent nonhybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the 2 groups was adjusted by applying balancing scores to nonparametric estimates. RESULTS Compared with the nonhybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, noncardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all P values < .03). Unadjusted 12-year survival after hybrid palliation and nonhybrid management, was 55% versus 69%, respectively. After matching, 12-year survival after hybrid palliation versus nonhybrid management was 58% versus 63%, respectively (P = .37). Among matched infants born weighing <2.5 kg, 2-year survival after hybrid palliation versus nonhybrid management was 37% versus 51%, respectively (P = .22). CONCLUSIONS Infants born with critical left heart obstruction who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo nonhybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus nonhybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower-birth-weight infants.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Igor Bondarenko
- Division of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | - Aaron Eckhauser
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Peter J Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Tharini Paramananthan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David S Winlaw
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Ky
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - Carol Prospero
- Division of Pediatric Cardiology, Nemours Children's Hospital Delaware, Wilmington, Del
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tenn
| | - James D St Louis
- Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - James E O'Brien
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, M
| | - Christian Pizarro
- Cardiothoracic Surgery, Nemours Children's Hospital Delaware, Wilmington, Del
| | - Petros V Anagnostopoulos
- Division of Pediatric Cardiothoracic Surgery, University of Wisconsin Health American Family Hospital, Madison, Wis
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Anastasios C Polimenakos
- Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga
| | - Marcus P Haw
- Department of Pediatric Cardiovascular Surgery, Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Alsoufi B. The Konno-Rastan procedure in children and young adults: efficiency versus effectiveness. Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad171. [PMID: 37847656 PMCID: PMC10599977 DOI: 10.1093/icvts/ivad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Norton Children’s Hospital, Louisville, KY, USA
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14
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Argo MB, Barron DJ, Eghtesady P, Yerebakan C, DeCampli WM, Alsoufi B, Honjo O, Jacobs JP, Paramananthan T, Rahman M, Lambert LM, Jegatheeswaran A, Carrillo SA, Husain SA, Ramakrishnan K, Caldarone CA, Karamlou T, Nelson J, Mannie C, Romano JC, Turek JW, Blackstone EH, Galantowicz ME, Kirklin JK, Mitchell ME, McCrindle BW. Outcomes After Hybrid Palliation for Infants With Critical Left Heart Obstruction. J Am Coll Cardiol 2023; 82:1427-1441. [PMID: 37758438 DOI: 10.1016/j.jacc.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/02/2023] [Accepted: 07/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) is an initial management strategy for infants with critical left heart obstruction and serves as palliation until subsequent operations are pursued. OBJECTIVES This study sought to determine patient characteristics and factors associated with subsequent outcomes for infants who underwent hybrid palliation. METHODS From 2005 to 2019, 214 of 1,236 prospectively enrolled infants within the Congenital Heart Surgeons' Society's critical left heart obstruction cohort underwent hybrid palliation across 24 institutions. Multivariable hazard modeling with competing risk methodology was performed to determine risk and factors associated with outcomes of biventricular repair, Fontan procedure, transplantation, or death. RESULTS Preoperative comorbidities (eg, prematurity, low birth weight, genetic syndrome) were identified in 70% of infants (150 of 214). Median follow-up was 7 years, ranging up to 17 years. Overall 12-year survival was 55%. At 5 years after hybrid palliation, 9% had biventricular repair, 36% had Fontan procedure, 12% had transplantation, 35% died without surgical endpoints, and 8% were alive without an endpoint. Factors associated with transplantation were absence of ductal stent, older age, absent interatrial communication, smaller aortic root size, larger tricuspid valve area z-score, and larger left ventricular volume. Factors associated with death were low birth weight, concomitant genetic syndrome, cardiopulmonary bypass use during hybrid palliation, moderate to severe tricuspid valve regurgitation, and smaller ascending aortic size. CONCLUSIONS Mortality remains high after hybrid palliation for infants with critical left heart obstruction. Nonetheless, hybrid palliation may facilitate biventricular repair for some infants and for others may serve as stabilization for intended functional univentricular palliation or primary transplantation.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
| | - Williams M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tharini Paramananthan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - S Adil Husain
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tennessee, USA
| | | | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer Nelson
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Chelsea Mannie
- Division of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark E Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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15
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Argo MB, Barron DJ, Eghtesady P, Alsoufi B, Honjo O, Yerebakan C, DeCampli WM, Jacobs JP, Carrillo SA, Jegatheeswaran A, Karamlou T, Paramananthan T, Rahman M, Lambert LM, Nelson J, Caldarone CA, Husain SA, Galantowicz ME, Ramakrishnan K, Kirklin JK, Turek JW, Mannie C, Blackstone EH, Mitchell ME, McCrindle BW. Norwood operation versus comprehensive stage II after bilateral pulmonary artery banding palliation for infants with critical left heart obstruction. J Thorac Cardiovasc Surg 2023; 166:943-954.e1. [PMID: 36804212 DOI: 10.1016/j.jtcvs.2023.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/15/2022] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine patient characteristics and outcomes after Norwood versus comprehensive stage II (COMPSII) for infants with critical left heart obstruction who had prior hybrid palliation (bilateral pulmonary artery banding ± ductal stent). METHODS From 23 Congenital Heart Surgeons' Society institutions (2005-2020), 138 infants underwent hybrid palliation followed by either Norwood (n = 73, 53%) or COMPSII (n = 65). Baseline characteristics were compared between Norwood and COMPSII groups. Parametric hazard model with competing risk methodology was used to determine risk and factors associated with outcomes of Fontan, transplantation, or death. RESULTS Infants who underwent Norwood versus COMPSII had a higher prevalence of prematurity (26% vs 14%, P = .08), lower birth weight (median 2.8 vs 3.2 kg, P < .01) and less frequent ductal stenting (37% vs 99%; P < .01). Norwood was performed at a median age of 44 days and median weight of 3.5 kg, versus COMPSII at 162 days and 6.0 kg (both P < .01). Median follow-up was 6.5 years. At 5 years after Norwood and COMPSII, respectively; 50% versus 68% had Fontan (P = .16), 3% versus 5% had transplantation (P = .70), 40% versus 15% died (P = .10), and 7% versus 11% are alive without transition, respectively. For factors associated with either mortality or Fontan, only preoperative mechanical ventilation occurred more frequently in the Norwood group. CONCLUSIONS Higher prevalence of prematurity, lower birth weight, and other patient-related characteristics in the Norwood versus COMPSII groups may influence differences in outcomes that were not statistically significant for this limited risk-adjusted cohort. The clinical decision regarding Norwood versus COMPSII after initial hybrid palliation remains challenging.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, St. Louis, Mo
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Ky
| | - Osami Honjo
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tharini Paramananthan
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jennifer Nelson
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, Mo
| | | | - S Adil Husain
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Mark E Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tenn
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - Chelsea Mannie
- Division of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, St. Louis, Mo
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wis
| | - Brian W McCrindle
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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16
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Kozik D, Alsoufi B. Pediatric mechanical circulatory support - a review. Indian J Thorac Cardiovasc Surg 2023; 39:80-90. [PMID: 37525715 PMCID: PMC10386992 DOI: 10.1007/s12055-023-01499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
The history of mechanical circulatory support began in 1953, as the first heart-lung machine enabled surgeons to perform complex open heart surgery. Heart failure is more prevalent in adults than pediatric patients which has led to the development of devices for adults with end-stage heart failure at a faster pace. Pediatric mechanical circulatory support has been derived from adult durable devices and subsequently applied in the adolescent population. The application of adult devices in children is inherently problematic due to size mismatch, especially in smaller patients. There has been an increasing interest in developing durable pumps that are appropriate for children for several reasons, with the primary factor being the number of children with end-stage heart failure far exceeding the number of potential donors. Mechanical circulatory support (MCS) for children can be divided into short-term temporary support and long-term durable support. The goal of this review is to discuss the devices available for the pediatric population and review the options for support in complex patients including single-ventricle anatomy, biventricular support, and total artificial heart options. We will also briefly discuss the Pumps for Kids, Infants, and Neonates (PumpKIN) Trial and MCS registries, including the Advanced Cardiac Therapies Improving Outcomes Network (ACTION).
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Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
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17
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Alsoufi B, Anagnostopoulos PV. Commentary: Regionalization of congenital heart surgery. If you don't know where you are going, you'll end up someplace else. J Thorac Cardiovasc Surg 2023; 165:1551-1553. [PMID: 35811141 DOI: 10.1016/j.jtcvs.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
| | - Petros V Anagnostopoulos
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine, American Family Children's Hospital, Madison, Wis
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18
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Alsoufi B, Sizemore J, Wilkens S, Furlong-Dillard J, Kozik D, Lambert A, Trivedi J. Outcomes of Heart Transplantation in Children with Previously Palliated Hypoplastic Left Heart Syndrome. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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19
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Alsoufi B. Hybrid First-stage Palliation and Other Strategies to Achieve Biventricular Repair in High-Risk Neonates With Complex Heart Anomalies and Aortic Arch Obstruction. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2023; 26:40-49. [PMID: 36842797 DOI: 10.1053/j.pcsu.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Medical and surgical advances have allowed single-stage total repair in neonates born with complex congenital heart anomalies and aortic arch obstruction. Nonetheless, total repair might be too complex or high risk in certain neonates with demographic, clinical or morphologic risk factors. Alternative management strategies might offer these neonates better outcomes with superior anatomic repair, shorter hospitalization, reduced morbidity, and improved survival. Alternative initial surgical strategies might include aortic arch repair and pulmonary artery band with or without cardiopulmonary bypass, extracardiac repair only and pulmonary artery band, Norwood operation, and hybrid first-stage palliation; all deferring complex biventricular intra-cardiac repair to later stage. The strategy choice should be personalized to each patient, taking into consideration the morphologic and clinical state, and the existent goals of care.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky.
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20
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Berul CI, Dasgupta S, LeGras MD, Peer SM, Alsoufi B, Sherwin ED, Desai M, Yerebakan C, Johnsrude C. Tiny pacemakers for tiny babies. Heart Rhythm 2023; 20:766-769. [PMID: 36822482 DOI: 10.1016/j.hrthm.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/31/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Charles I Berul
- Children's National Hospital, George Washington University School of Medicine, Washington, DC.
| | - Soham Dasgupta
- Norton Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Marc D LeGras
- Pediatric Cardiology Center of Oregon, Portland, Oregon
| | - S Murfad Peer
- Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Bahaaldin Alsoufi
- Norton Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Elizabeth D Sherwin
- Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Manan Desai
- Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Can Yerebakan
- Children's National Hospital, George Washington University School of Medicine, Washington, DC
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21
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Ceremuga B, Kozik D, Sobczyk W, Alsoufi B, Settles D, Raheja P, Ganzel B, Pahwa S. Double-Chambered Right Ventricle:An Intraoperative Surprise. J Cardiothorac Vasc Anesth 2023; 37:784-787. [PMID: 36828709 DOI: 10.1053/j.jvca.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Bradley Ceremuga
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY
| | - Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY
| | - Walter Sobczyk
- Department of Pediatric Cardiology, University of Louisville, Louisville, KY
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY
| | - Dana Settles
- Department of Cardiovascular Anesthesia, University of Louisville, Louisville, KY
| | - Prafull Raheja
- Department of Cardiology, University of Louisville, Louisville, KY
| | - Brian Ganzel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY
| | - Siddharth Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY.
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22
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Dasgupta S, Alsoufi B. Systemic To Pulmonary Artery Shunt Stenosis: Prevention Is Better Than Cure. Eur J Cardiothorac Surg 2022; 62:6772514. [DOI: 10.1093/ejcts/ezac501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Soham Dasgupta
- University of Louisville, Norton Children’s Hospital Division of Pediatric Cardiology, Department of Pediatrics, , Louisville, Kentucky, USA
| | - Bahaaldin Alsoufi
- University of Louisville, Norton Children’s Hospital Department of Cardiovascular and Thoracic Surgery, , Louisville, Kentucky, USA
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23
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Deshpande SR, Alsoufi B. Ventricular Assist Device Support In Children: Better, But Not Perfect. Eur J Cardiothorac Surg 2022; 62:6675457. [PMID: 36005890 DOI: 10.1093/ejcts/ezac424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
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24
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Alsoufi B. Coronary artery bypass grafting in infants and young children: default or alternative choice? Interact Cardiovasc Thorac Surg 2022; 35:6625660. [PMID: 35775945 PMCID: PMC9270863 DOI: 10.1093/icvts/ivac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine , Louisville, KY, USA
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Kupferschmid JP, Turek JW, Hughes GC, Austin EH, Alsoufi B, Smith JM, Scholl FG, Rankin JS, Badhwar V, Chen JM, Nuri MA, Romano JC, Ohye RG, Si MS. Early Outcomes of Patients Undergoing Neoaortic Valve Repair Incorporating Geometric Ring Annuloplasty. World J Pediatr Congenit Heart Surg 2022; 13:304-309. [PMID: 35446224 DOI: 10.1177/21501351221079523] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES During congenital heart surgery, the pulmonary valve and root may be placed into the systemic position, yielding a "neoaortic" valve. With the stress of systemic pressure, the pulmonary roots can dilate, creating aneurysms and/or neoaortic insufficiency (neoAI). This report analyzes the early outcomes of patients undergoing neoaortic valve repair incorporating geometric ring annuloplasty. METHODS Twenty-one patients underwent intended repair at six centers and formed the study cohort. Thirteen had previous Ross procedures, five had arterial switch operations, and three Fontan physiology. Average age was 21.7 ± 12.8 years (mean ± SD), 80% were male, and 11 (55%) had symptomatic heart failure. Preoperative neoAI Grade was 3.1 ± 1.1, and annular diameter was 30.7 ± 6.5 mm. RESULTS Valve repair was accomplished in 20/21, using geometric annuloplasty rings and leaflet plication (n = 13) and/or nodular release (n = 7). Fourteen had neoaortic aneurysm replacement (13 with root remodeling). Two underwent bicuspid valve repair. Six had pulmonary conduit changes, one insertion of an artificial Nodulus Arantius, and one resection of a subaortic membrane. Ring size averaged 21.9 ± 2.3 mm, and aortic clamp time was 171 ± 54 minutes. No operative mortality or major morbidity occurred, and postoperative hospitalization was 4.3 ± 1.4 days. At discharge, neoAI grade was 0.2 ± 0.4 (P < .0001), and valve mean gradient was ≤20 mm Hg. At average 18.0 ± 9.1 months of follow-up, all patients were asymptomatic with stable valve function. CONCLUSIONS Neoaortic aneurysms and neoAI are occasionally seen late following Ross, arterial switch, or Fontan procedures. Neoaortic valve repair using geometric ring annuloplasty, leaflet reconstruction, and root remodeling provides a patient-specific approach with favorable early outcomes.
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Affiliation(s)
| | | | - G Chad Hughes
- 22957Duke University Medical Center, Durham, NC, USA
| | | | | | | | - Frank G Scholl
- Joe Dimaggio 24931Children's Hospital, Hollywood, FL, USA
| | | | | | - Jonathan M Chen
- 24931Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Muhammad A Nuri
- 24931Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Black AK, Alsoufi B. Invited Commentary: Computational Flow Dynamics: The Future of Fontan Conduit Selection and Operative Planning? World J Pediatr Congenit Heart Surg 2022; 13:302-303. [PMID: 35446216 DOI: 10.1177/21501351221091341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Allison K Black
- Departments of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
| | - Bahaaldin Alsoufi
- Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
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Alsoufi B, Kozik D, Sparks J, Wilkens S, Austin E, Trivedi J. Increasing Donor-Recipient Weight Mismatch is Associated with Shorter Waitlist Duration and No Increased Morbidity or Mortality. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Alsoufi B, Knight JH, St. Louis J, Raghuveer G, Kochilas L. Outcomes Following Aortic Valve Replacement in Children With Conotruncal Anomalies. World J Pediatr Congenit Heart Surg 2022; 13:178-186. [PMID: 35238703 PMCID: PMC9205217 DOI: 10.1177/21501351211072476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Conotruncal anomalies can develop aortopathy and/or aortic valve (AV) disease and AV replacement (AVR) is occasionally needed. We report long-term results and examine factors affecting survival following AVR in this group. METHODS We queried the Pediatric Cardiac Care Consortium (PCCC, US database for interventions for congenital heart diseases) to identify patients with repaired conotruncal anomalies and AVR. Long-term outcomes were provided by the PCCC, the US National Death Index, and Organ Procurement and Transplantation Network. Competing risks analysis examined outcomes following AVR (death/transplantation, reoperation) and multivariable regression analysis assessed significant factors. RESULTS One hundred six children with repaired conotruncal anomalies underwent AVR (1982-2003). Underlying anomaly was truncus (n = 40), d-transposition (n = 22), type-B interrupted arch (n = 16), double-outlet right ventricle (n = 12), pulmonary atresia with ventricular septal defect (n = 9), tetralogy of Fallot (n = 6), corrected transposition (n = 1). 18 (17%) had prior aortic valvuloplasty (surgical = 12, percutaneous = 6). Median age at AVR was 6.9 years (interquartile range = 2.5-12.4). AV pathophysiology was regurgitation (n = 83, 78%), stenosis (n = 9, 9%), and mixed (n = 14, 15%). AVR type was mechanical (n = 72, 68%), homograft (n = 21, 20%), and Ross (n = 13, 12%). Operative mortality was 13(12%). Infant age at AVR was risk factor (odds ratio = 55, 95% confidence interval [CI] = 6-539, P = .0006). On competing risks analysis, five years after AVR, 6% died or received transplantation, 20% had reoperation. Twenty-five years transplant-free survival was 53%. Factors associated with death after hospital discharge included mitral surgery (hazards ratio [HR] = 11, 95% CI = 3-39, P = .0002), underlying defect (HR = 2, 95% CI = 1-5, P = .446). Twenty years transplant-free survival in conotruncal anomalies group was inferior to matched children undergoing AVR for congenital non-conotruncal disease (61% vs 82%, P = .0012). CONCLUSIONS Long-term survival following AVR in children with conotruncal anomalies is inferior to that of isolated congenital AV disease and is linked to an underlying cardiac defect. Although valve type was not associated with survival, infant age was a risk factor for operative mortality. Continuous attrition and high reoperation warrant vigilant monitoring.
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Alsoufi B. Commentary: A new Fontan commandment? J Thorac Cardiovasc Surg 2022; 164:781-782. [PMID: 35120760 DOI: 10.1016/j.jtcvs.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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Alsoufi B, Knight JH, St. Louis J, Raghuveer G, Kochilas L. Are Mechanical Prostheses Valid Alternatives to the Ross Procedure in Young Children Under 6 Years Old? Ann Thorac Surg 2022; 113:166-173. [PMID: 33359723 PMCID: PMC8219808 DOI: 10.1016/j.athoracsur.2020.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used. METHODS We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n = 84) or MP (n = 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes. RESULTS Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P = .24) or 15-year transplant-free survival (94.1% vs 87.5%, P = .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P = .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P = .78] vs 6.0 [95% confidence interval, 0.6-63.1; P = .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P = .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement. CONCLUSIONS Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.
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Affiliation(s)
| | - Jessica H. Knight
- Department of Epidemiology and Biostatistics, University of Georgia College of Public Health
| | - James St. Louis
- Department of Pediatrics, University of Missouri-Kansas City
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Alsoufi B. Commentary: Heart Transplantation Listing In Children With Significant Renal Insufficiency: The Need For Paradigm Shift. J Thorac Cardiovasc Surg 2022; 164:2032-2033. [DOI: 10.1016/j.jtcvs.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 12/25/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
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Kozik D, Alsoufi B. Commentary: Length of stay as measure of quality: A misty strategy that might backfire. J Thorac Cardiovasc Surg 2021; 163:1616-1617. [PMID: 34906397 DOI: 10.1016/j.jtcvs.2021.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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Alsoufi B. Commentary: When perfect is not the enemy of good. J Thorac Cardiovasc Surg 2021; 163:2194-2195. [PMID: 34893325 DOI: 10.1016/j.jtcvs.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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Knight JH, Sarvestani AL, Ibezim C, Turk E, McCracken CE, Alsoufi B, St Louis J, Moller JH, Raghuveer G, Kochilas LK. Multicentre comparative analysis of long-term outcomes after aortic valve replacement in children. Heart 2021; 108:940-947. [PMID: 34611043 DOI: 10.1136/heartjnl-2021-319597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/09/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The ideal valve substitute for surgical intervention of congenital aortic valve disease in children remains unclear. Data on outcomes beyond 10-15 years after valve replacement are limited but important for evaluating substitute longevity. We aimed to describe up to 25-year death/cardiac transplant by type of valve substitute and assess the potential impact of treatment centre. Our hypothesis was that patients with pulmonic valve autograft would have better survival than mechanical prosthetic. METHODS This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional US-based registry of paediatric cardiac interventions, linked with the National Death Index and United Network for Organ Sharing through 2019. Children (0-20 years old) receiving aortic valve replacement (AVR) from 1982 to 2003 were identified. Kaplan-Meier transplant-free survival was calculated, and Cox proportional hazard models estimated hazard ratios for mechanical AVR (M-AVR) versus pulmonic valve autograft. RESULTS Among 911 children, the median age at AVR was 13.4 years (IQR=8.4-16.5) and 73% were male. There were 10 cardiac transplants and 153 deaths, 5 after transplant. The 25-year transplant-free survival post AVR was 87.1% for autograft vs 76.2% for M-AVR and 72.0% for tissue (bioprosthetic or homograft). After adjustment, M-AVR remained related to increased mortality/transplant versus autograft (HR=1.9, 95% CI=1.1 to 3.4). Surprisingly, survival for patients with M-AVR, but not autograft, was lower for those treated in centres with higher in-hospital mortality. CONCLUSION Pulmonic valve autograft provides the best long-term outcomes for children with aortic valve disease, but AVR results may depend on a centre's experience or patient selection.
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Affiliation(s)
- Jessica H Knight
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Amber Leila Sarvestani
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Chizitam Ibezim
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Elizabeth Turk
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Courtney E McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - James St Louis
- Department of Surgery, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - James H Moller
- School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Geetha Raghuveer
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Lazaros K Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Altin F, Alsoufi B, Kanter K, Deshpande SR. Systemic Venous Reconstructions During Pediatric Heart Transplantation. World J Pediatr Congenit Heart Surg 2021; 12:583-588. [PMID: 34597211 DOI: 10.1177/21501351211020699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Congenital heart disease continues to be an important indication for pediatric heart transplantation (HT) and is often complicated by systemic venous anomalies. The need for reconstruction, surgical technique used, as well as the outcomes of these have limited documentation. METHODS Descriptive, retrospective study of patients transplanted at Emory University between 2006 and 2017. We reviewed surgical data, follow-up, and interventions for patients necessitating venous reconstruction during transplantation. RESULTS A total of 179 transplants were performed during the time period of which 74 (41%) required systemic venous reconstruction. Mean age at transplant was 6.3 (±6.16) years, and 74.3% of these patients carried a diagnosis of single ventricle; 51 (68.9%) of 74 patients required pulmonary artery reconstruction at the time of HT. Forty patients required superior vena caval reconstruction, while 22 patients required inferior vena caval reconstruction due to prior palliation or anomaly. Venous anomalies along with other anatomic features necessitated biatrial transplantation in four patients. Posttransplant evaluation revealed systemic venous stenosis in 14 (18.9%) of 74 patients. Eight (10.8%) patients required 12 interventions for the systemic veins. Patients with bilateral Glenn anastomosis prior to transplant were at high risk for the development of stenosis and needing interventions. Systemic venous complications were uncommon in those with native systemic veins without Glenn or Fontan procedure. CONCLUSION Systemic venous reconstruction needs are high in pediatric HT. Posttransplant stenosis and the need for interventions are relatively common. Current techniques for systemic venous reconstruction for complex congenital heart disease patients may deserve further review to optimize these outcomes.
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Affiliation(s)
- Firat Altin
- Department of Pediatric Cardiac Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Training and Research Hospital, Istanbul, Turkey
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
| | - Kirk Kanter
- Cardiothoracic Surgery, Emory University, Children's Healthcare of Atlanta, GA, USA
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Alsoufi B, Trivedi J, Rycus P, Sinha P, Deshpande S. Repeat Extracorporeal Membrane Oxygenation Support Is Appropriate in Selected Children With Cardiac Disease: An Extracorporeal Life Support Organization Study. World J Pediatr Congenit Heart Surg 2021; 12:597-604. [PMID: 34597210 DOI: 10.1177/21501351211025004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Children requiring multiple consecutive extracorporeal membrane oxygenation (ECMO) runs likely have ongoing cardiac pathology (eg, residual lesions, myocardial dysfunction) and are exposed to increased complications and end-organ failure. Often, repeat back-to-back ECMO is suggested to be futile due to poor reported survival. METHODS Using Extracorporeal Life Support Organization (ELSO) data (2011-2019), we evaluated children (n = 669) who received multiple cardiac ECMO runs (≥2) within 30 days interval. Factors associated with hospital mortality were evaluated using multivariable regression analysis. RESULTS Median ECMO runs was 2 (range: 2-5) including 294 (44%) patients who received extracorporeal cardiopulmonary resuscitation (ECPR). There were 250 (37%) hospital survivors. Survivors were more likely older, Caucasian, and less likely to have hypoplastic left heart syndrome, require >2 runs, receive longer support duration, require inotropes or have acidosis while on ECMO, or develop renal and neurological complications. On multivariable analysis, factors associated with death included neonates (odds ratio [OR] = 3.6, 95% CI = 1.8-7.5, P = .0002), African Americans (OR = 2.7, 95% CI = 1.4-4.9, P = .0307), longer ECMO duration (OR = 1.1, 95% CI = 1.05-1.11, P < .0001, per 10 hours), central cannulation at initial run (OR = 1.7, 95% CI = 1.1-2.8, P = .0285), renal failure (OR = 3.0, 95% CI = 1.9-4.6, P < .0001), and neurological complications (OR = 3.8, 95% CI = 2.2-6.8, P < .0001). CONCLUSIONS In selected children with cardiac pathology, multiple back-to-back ECMO and/or ECPR runs are associated with 37% hospital survival. Although registry data limit the ability to clearly determine selection criteria for repeat ECMO, our findings suggest that in properly selected patients, repeat ECMO support is not futile. Ongoing assessment of support adequacy, end-organ function, and cardiopulmonary recovery is necessary as longer support and emerging complications are associated with poor survival.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville, KY, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville, KY, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Hospital, Washington, DC, USA
| | - Shriprassad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
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Alsoufi B. Commentary: Another way to skin a cat, hardly ever. JTCVS Tech 2021; 9:121-123. [PMID: 34647078 PMCID: PMC8501252 DOI: 10.1016/j.xjtc.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
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Alsoufi B. The challenge of assuming clinical relevance from statistical significance. J Card Surg 2021; 36:4139-4140. [PMID: 34449101 DOI: 10.1111/jocs.15930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky, USA
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Thomas AS, Chan A, Alsoufi B, Vinocur JM, Kochilas L. Long-term Outcomes of Children Operated for Anomalous Left Coronary Artery from the Pulmonary Artery. Ann Thorac Surg 2021; 113:1223-1230. [PMID: 34419434 DOI: 10.1016/j.athoracsur.2021.07.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND We examined the outcomes of children (<18 years) operated for anomalous left coronary artery from the pulmonary artery (ALCAPA). METHODS We linked patients undergoing ALCAPA repair between 1982 and 2003 in the Pediatric Cardiac Care Consortium with the National Death Index and the Organ Procurement and Transplantation Network, to examine their outcomes through 2019. RESULTS We identified 228 children (median age 6.0 months) operated for ALCAPA. At time of repair, 38.6% had severe mitral regurgitation (MR) and 71.4% severe left ventricular (LV) dysfunction. Repair included primarily coronary reimplantation (n=173) and Takeuchi procedure (n=34); concurrently, 18 underwent mitral valve (MV) surgery. In-hospital death occurred in 31 (13.6%) and was not associated with MR severity (p=0.846); however, among patients with moderate or severe MR, risk of death was 28% lower when undergoing MV surgery (p=0.033). After adjustment for other risk factors, only infant surgery reached statistical significance for in-hospital death (aOR=12.99; 95% CI: 1.61, 104.59, p=0.016). Among those discharged alive with long-term data available (n=155), the 30-year transplant-free survival reached 95.5% (95% CI: 92.3-98.8) and was not associated with degree of pre-operative MR or LV dysfunction. Coronary reimplantation was associated with better long-term survival compared to other surgical techniques (aOR=0.11; 95% CI 0.02-0.74, p=0.023). CONCLUSIONS Favorable long-term outcomes can be expected after coronary artery reimplantation for ALCAPA even in cases with severe LV dysfunction at presentation. MV surgery predicted decreased risk for in-hospital mortality in patients with moderate/severe MR, but MR severity predicted neither in-hospital nor longer-term outcomes.
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Affiliation(s)
- Amanda S Thomas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Alice Chan
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY
| | - Jeffrey M Vinocur
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Lazaros Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA.
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Deshpande S, Sparks JD, Alsoufi B. Pediatric heart transplantation: Year in review 2020. J Thorac Cardiovasc Surg 2021; 162:418-421. [PMID: 34045058 DOI: 10.1016/j.jtcvs.2021.04.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Shriprassad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC
| | - Joshua D Sparks
- Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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Jegatheeswaran A, Alsoufi B. Anomalous aortic origin of a coronary artery: 2020 year in review. J Thorac Cardiovasc Surg 2021; 162:353-359. [PMID: 34120742 DOI: 10.1016/j.jtcvs.2021.04.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Ky
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Affiliation(s)
- Shriprasad R Deshpande
- From the Pediatric Cardiology, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Marvin J Slepian
- Department of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine and Norton Children's Hospital, Louisville, Ky
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Deshpande S, Alsoufi B. Meeting needs-pushing boundaries: Mechanical circulatory support in children; year in review. J Thorac Cardiovasc Surg 2021; 162:400-404. [PMID: 33994204 DOI: 10.1016/j.jtcvs.2021.04.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Shriprassad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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Alsoufi B. The Challenges of Swimming Against the Tide. World J Pediatr Congenit Heart Surg 2021; 12:527-528. [PMID: 34278868 DOI: 10.1177/21501351211013707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, 24931Norton Children's Hospital, Louisville, KY, USA
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Alsoufi B. Commentary: Is The Vanishing Conduit The Answer For The Lack Of Ideal Conduit? Semin Thorac Cardiovasc Surg 2021; 34:992-993. [PMID: 34004288 DOI: 10.1053/j.semtcvs.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital.
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Alsoufi B. Commentary: There are no facts, only interpretations. J Thorac Cardiovasc Surg 2021; 163:411-412. [PMID: 34020805 DOI: 10.1016/j.jtcvs.2021.04.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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Das B, Trivedi JR, Sinha P, Ramakrishnan K, Alsoufi B, Deshpande SR. Interplay between donor and recipient factors impacts outcomes after pediatric heart transplantation: An analysis from the united network for organ sharing database. Pediatr Transplant 2021; 25:e13912. [PMID: 33245837 DOI: 10.1111/petr.13912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Donor utilization rates continue to be low for pHT, however, efforts to expand the donor acceptance criteria have shown mixed results in single-institution studies in pediatric and adult transplantation. Purpose of this study is to assess impact of individual and cumulative donor risk factors on transplant outcomes as well as the interplay between donor and recipient risk factors as it relates to transplant outcomes. METHOD We analyzed pHT UNOS data (2008-2018) to compare the recipient characteristics, donor characteristics, and outcomes based on donor ejection fraction of less than 50% (low EF) and or ischemic time of greater than 4 hours (prolonged IT). RESULTS A total of 4345 pHT were performed of which 1309 (30.1%) were with prolonged IT and 122 (2.8%) in low EF. Additionally, 58 (1.3%) were performed with both low EF and prolonged IT (combined risk). Rest (2856 patients, 65.7%) was considered low risk. Recipients of combined risk were more likely to be younger, have post-surgical congenital heart disease, be on ECMO or ventilator but less likely on VAD (all P < .01) compared with any other group. Waitlist time was significantly lower for low EF (mean 39 days, 15-109) or combined risk group (36 days, range 15-80) compared with other groups (60 days, range 23-125) (P = .01). 1-year mortality was 8% in low-risk group, 12% in prolonged IT, 14% in reduced EF, and 28% in combined risk patients (P < .01). Number of treated rejections in one year were significantly higher in prolonged IT and combined risk group compared to other groups (P < .01). When stratified by recipient risk, there was no difference in outcomes for low risk, prolonged IT, or low EF groups; however, there were significant survival differences for high-risk recipient versus low-risk recipient in each donor group. CONCLUSION Lower EF donors performed similar to prolonged IT donor, but were uncommonly used. Acceptance of risk was common in recipients deemed higher risk for waitlist mortality and led to shorter wait times. Caution should be used in accepting combined risk transplants. The recipient risk factors have significant impact on outcomes across all donor risk groups and further analysis will help balance the waitlist mortality with post-transplant outcomes.
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Affiliation(s)
- Bibhuti Das
- Pediatric Cardiology, Texas Children's Hospital, Austin, TX, USA
| | - Jaimin R Trivedi
- Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Hospital, Washington, DC, USA
| | - Karthik Ramakrishnan
- Department of Cardiovascular Surgery, Children's National Hospital, Washington, DC, USA
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
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Konstantinov IE, Backer CL, Yerebakan C, Alsoufi B. At the forefront of congenital cardiothoracic surgery: 2020-2021. J Thorac Cardiovasc Surg 2021; 162:178-182. [PMID: 33972113 DOI: 10.1016/j.jtcvs.2021.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Department of Paediatrics, University of Melbourne, Heart Research Group, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Heart Institute and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Can Yerebakan
- Cardiac Surgery, Children's National Heart Institute, Washington, DC
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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Alsoufi B. Curb Your Enthusiasm for the Ozaki Procedure in Small Children. Ann Thorac Surg 2021; 113:378-379. [PMID: 33839137 DOI: 10.1016/j.athoracsur.2021.03.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Ste-1200, Louisville, KY 40202; Department of Cardiothoracic Surgery, Norton Children's Hospital, Louisville, Kentucky.
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