Cone versus conventional repair for Ebstein's anomaly

OBJECTIVES

We aimed to investigate tricuspid valve function and adverse events after conventional repair and valve replacement for Ebstein's anomaly and compare them with cone repair.

METHODS

The medical records of 151 patients (mean age, 25 years; 62% were female) who underwent operation in a single center from 1985 to 2018 were retrospectively analyzed. To determine tricuspid valve regurgitation during follow-up, serial echocardiographic examination was used (n = 2397, tricuspid regurgitation grades were graphed for every patient).

RESULTS

Thirty-nine patients underwent cone repair, 107 patients underwent other repair techniques, and 5 patients underwent valve replacement. The operative mortality was 1.3% (n = 2). Failed valve repair (defined as in-hospital death, conversion to replacement, or in-hospital reoperation) was less frequent after cone repair than after other repair techniques (5%, n = 2 vs 20%, n = 21, P = .039). Mean follow-up was 12.3 years (cone repair: 3.7 years). The 5-year cumulative incidence of moderate or greater recurrent tricuspid regurgitation was lower after cone repair than after other repair techniques (8% vs 32%, P = .03). Among the patients undergoing other repair techniques, the 15-year cumulative incidence of moderate or greater recurrent tricuspid regurgitation, severe tricuspid regurgitation, and reoperation was 58%, 37%, and 31%, respectively. During follow-up, 18 patients died (13 of cardiac and 5 of noncardiac causes). Among patients who died of cardiac causes, 10 of 13 had all 3 characteristics-moderate or greater tricuspid regurgitation, atrial fibrillation, and New York Heart Association classification III and IV-at their last medical evaluation.

CONCLUSIONS

Before cone repair, recurrent tricuspid regurgitation was considerable. Cone repair provided a higher rate of successful repair and a lower incidence of moderate or greater recurrent tricuspid regurgitation at the midterm follow-up.

Impact of Characteristics at Stage-2-Palliation on Outcome Following Fontan Completion

The optimal timing of stage-2-palliation (S2P) in single left ventricle is not clear. The aim of this study was to identify S2P related factors associated with outcomes after total cavopulmonary connection (TCPC), particularly relative to the dominant systemic ventricle. A total of 405 patients who underwent both S2P and TCPC at our institute between 1997 and 2017 was included. Patients were divided into two groups, dominant right ventricle (RV type, n = 235) and dominant left ventricle (LV type, n = 170). S2P related factors associated with mortality, postoperative ventricular function, and late exercise capacity following TCPC, were analyzed. The median age at S2P was 4 [3-7] and 6 [3-11] months in RV and LV type patients, respectively (p = 0.092). Survival after TCPC was similar in RV and LV type patients (p = 0.280). In those with RV type, risk factors for mortality following TCPC were older age (p < 0.001), heavier weight (p = 0.001), higher PAP (p < 0.001), higher TPG (p = 0.010), and lower SO2 (p = 0.008) at S2P. In those with LV type, no risk factor was identified. Risk factors for postoperative impaired ventricular function were older age and higher weight at S2P in both RV and LV type patients. Older age at S2P was also identified as a risk for inferior peak oxygen uptake (VO2) years after TCPC both in RV and LV type patients. Older age at S2P was associated with higher mortality after Fontan completion only in RV type patients. However, it was associated with postoperative ventricular dysfunction and lower exercise capacity after TCPC in both RV and LV type patients.

Reasons for Failure of Systemic-to-Pulmonary Artery Shunts in Neonates

BACKGROUND

Systemic-to-pulmonary artery shunt placement is an established palliative procedure for congenital heart disease. Although it is thought to be a simple operation, it is associated with significant morbidity and mortality.

METHODS

Data for all neonates who underwent surgery for a systemic-to-pulmonary artery shunt between 2000 and 2016 were reviewed. The study endpoints were shunt failure and shunt-related mortality. Shunt failure was defined as a shunt dysfunction because of thrombosis or stenosis requiring intervention or reoperation; shunt mortality was defined as death because of a shunt dysfunction.

RESULTS

A total of 305 shunts (central shunt, n = 135; Blalock-Taussig shunt, n = 170) were implanted in 280 patients. The median patients' age at the time of surgery was 9 days (1-31 days). The median shunt size was 3.5 mm (3-4 mm). Twenty-four patients (8%) were diagnosed with a shunt failure, with a median time of 7 days (0-438 days). Freedom from shunt failure at 1 year was 91.6% ± 2%. A shunt-related mortality was ascertained for 12 patients (4%). Freedom from shunt-related mortality at 1 year was 96% ± 1%. Perioperative platelet transfusion (p = 0.01), central shunt (p = 0.02), 3-mm shunt size (p = 0.02), and postoperative extra corporeal membrane oxygenation (ECMO) (p < 0.01) were identified as risk factors for shunt failure. Platelet transfusion (p = 0.04) and postoperative ECMO (p < 0.01) were further identified as risk factors for shunt mortality.

CONCLUSION

Based on these data, we recommend implanting a modified Blalock-Taussig shunt of at least 3.5 mm in neonates. Perioperative platelet transfusion and postoperative ECMO increase the risk of shunt failure.

Kawasaki disease and hepatobiliary involvement: report of two cases

Background

Kawasaki disease (KD) without affection of the coronary artery system is rare. Optic nerve pathology together with KD has not been described earlier.

Case presentation

We present one case of KD in a 12-year-old girl predominantly with prolonged cholestasis, and a second case of multiple recurrent KD in a 9-year-old boy with hepatomegaly and ischemic optic nerve neuropathy. The coronary artery system was not involved in either case.

Conclusions

KD warrants rapid diagnosis and immediate specific treatment in order to prevent the high risk of coronary artery aneurysm and stenosis.

Effect of body position on ventilation distribution during PEEP titration in a porcine model of acute lung injury using advanced respiratory monitoring and electrical impedance tomography

Background

Lung failure after acute lung injury remains a challenge in different clinical settings. Various interventions for restoration of gas exchange have been investigated. Recruitment of collapsed alveoli by positive end expiratory pressure (PEEP) titration and optimization of ventilation-perfusion ratio by prone positioning have been extensively described in animal and clinical trials. This animal study was conducted to investigate the effects of PEEP and positioning by means of advanced respiratory monitoring including gas exchange, respiratory mechanics, volumetric capnography and electrical impedance tomography.

Methods

After induction of acute lung injury by oleic acid and lung lavage, 12 domestic pigs were studied in randomly assigned supine or prone position during a PEEP titration trial with maximal PEEP of 30 mbar.

Results

Induction of lung injury resulted in significant deterioration of oxygenation [partial pressure of arterial oxygen/inspiratory fraction of oxygen (PaO₂/FiO₂): p = 0.002] and ventilation [partial pressure of arterial carbon dioxide (PaCO₂): p = 0.002] and elevated alveolar dead-space ratios (Valv/Vte: p = 0.003) in both groups. Differences in the prone and the supine group were significant for PaCO₂ at incremental PEEP 10 and 20 and at decremental PEEP 20 (20d) and 10 (10d), for PaO₂/FiO₂ at PEEP 10 and 10d and for alveolar dead space at PEEP 10d. Electrical impedance tomography revealed homogenous ventilation distribution in prone position during PEEP 20, 30 and 20d.

Conclusions

Prone position leads to improved oxygenation and ventilation parameters in a lung injury model. Respiratory monitoring with measurement of alveolar dead space and electrical impedance tomography may visualize optimized ventilation in a PEEP titration trial.

Re-sternotomy as an unwelcome side-effect of unknown effervescent tablet intake?

Four hours after surgery for aortic valve stenosis and tricuspid valve regurgitation, an unknown foreign body was present on the routine chest X-ray. We performed re-sternotomy in order to retrieve this foreign body. The foreign body was easy to move on fluoroscopy but we could not extract it. We concluded that the foreign body was in a subdiaphragmatic location. As a consequence, we performed gastroscopy. A white, frothy mass (similar to an undissolved effervescent tablet) within an ulcerated lesion was seen and partially extracted.

Systolic right ventricular function in children and young adults with pulmonary artery hypertension secondary to congenital heart disease and tetralogy of Fallot: tricuspid annular plane systolic excursion (TAPSE) and magnetic resonance imaging data

OBJECTIVE

  The tricuspid annular plane systolic excursion (TAPSE), as echocardiographic index to assess right ventricular (RV) systolic function, has not been investigated thoroughly in children and young adults with tetralogy of Fallot (TOF) and pulmonary artery hypertension secondary to congenital heart disease (PAH-CHD).

PATIENTS

  TAPSE values of 49 patients with PAH-CHD and 156 patients with TOF were compared with age-matched normal subjects. TAPSE values were also compared with RV ejection fraction (RVEF) and RV indexed end-diastolic volume (RVEDVi) determined by magnetic resonance imaging in PAH-CHD and TOF patients.

RESULTS

  Patients with a PAH-CHD showed a positive correlation between TAPSE with RVEF (r= 0.81; P < 0.001) and a negative correlation between TAPSE with RVEDVi (r=-0.67; P < 0.001). Similarly, in our TOF patients, a positive correlation between TAPSE with RVEF (r= 0.65; P < 0.001) and a negative correlation between TAPSE with RVEDVi (r=-0.42; P < 0.001) was seen.

CONCLUSIONS

  Significant pressure overload in PAH-CHD patients and volume overload in TOF patients lead to a decreased systolic RV function, determined by TAPSE and magnetic resonance imaging and to increased RVEDVi values, determined by MRI, with time.

Accurate preoperative echocardiography has more impact on prediction of long-term mortality than intra-operatively measured flow in coronary bypass grafts

OBJECTIVE

Our study aimed to analyze the predictive value of intra-operative bypass graft flow measurements for long-term mortality.

METHODS

A total of 1593 consecutive coronary artery bypass graft (CABG) patients routinely underwent intra-operative bypass graft flow measurements with the transit-time flow meter (TTFM: Cardiomed(®)). The results of the flow measurements and the demographics were analyzed retrospectively.

RESULTS

The mean follow-up was 3.8 years (0.5-8.8 years) with no losses to follow-up. Overall mortality was 10.1%. The preoperative left ventricular ejection fraction (LVEF) (echocardiograph) was the highest independent predictor of long-term survival (hazard ratio 0.97, p = 0.004) in all groups. The univariate analysis for the CABG I group showed that besides LVEF, female gender (hazard ratio 3.6, p = 0.02) was also significant. For the CABG II group, additive EuroSCORE (European System for Cardiac Operative Risk) (ES) (hazard ratio 1.4, p = 0.0001) and age (hazard ratio 1.1, p = 0.001) were significant. In the CABG III group, ES (hazard ratio 1.2, p < 0.0001), age (hazard ratio 1.04, p = 0.001), IMA (hazard ratio 0.5, p < 0.0001) and concomitant aortic valve replacement (AVR) (hazard ratio 2.1, p = 0.03) were significant, in addition to the LVEF.

CONCLUSION

With quality-controlled surgeons checked by intra-operative TTFM, accurate quantification of preoperative LVEF significantly predicts long-term outcome. Effective bypass graft flows failed to predict outcome in CABG patients, regardless of the degree of coronary artery disease (CAD) and concomitant AVR.

Primary cardiac undifferentiated sarcoma of the right atrium presenting with cardiac tamponade

This report illustrates the serial imaging of a primary cardiac undifferentiated sarcoma of the right atrium using echocardiography, chest X-ray, and computed tomography. Transthoracic echocardiography on presentation showed an extensive mass of the right atrial free wall with an impending cardiac tamponade. Symptoms were controlled with pericardiocentesis, pericardial window, and radiotherapy but recurred 8 months later with pleural effusion and tumor spread to the great arteries. Primary cardiac sarcoma (PSC) is a rare and aggressive malignancy that is usually diagnosed late due to its nonspecific symptoms. Cytology and cardiac biopsy may be negative, and suspicion for the tumor is warranted in recurrent pericardial effusion. Analogous to parietal pleural biopsy in lung tumors with pleural effusion, parietal pericardial biopsy may be positive in PSC of the right atrium with pericardial effusion. Echocardiography is the major diagnostic tool and aids pericardiocentesis. Pericardial window may be useful for recurrent pericardial effusion but does not preclude its reaccumulation. There is no proven effective treatment for PSC, and treatments include surgical resection, cardiac transplant, chemotherapy, and radiotherapy. Despite its poor prognosis, symptomatic relief is important and attainable.