High-Risk Anatomic Subsets in Hypoplastic Left Heart Syndrome

Despite overall improvements in outcomes for patients with hypoplastic left heart syndrome, there remain anatomic features that can place these patients at higher risk throughout their treatment course. These include severe preoperative obstruction to pulmonary venous return, restrictive atrial septum, coronary fistulae, severe tricuspid regurgitation, smaller ascending aorta diameter (especially if <2 mm), and poor ventricular function. The risk of traditional staged palliation has led to the development of alternative strategies for such patients. To further improve the outcomes, we must continue to diligently examine and study anatomic details in HLHS patients.

Plasmalyte-A Based del Nido Cardioplegia Versus Plain Ringer Based del Nido Cardioplegia: Double-Blind Randomized Trial

Background: In this prospective randomized controlled trial, we compared the standard del Nido cardioplegia solution (SDN) with the modified del Nido cardioplegia solution (MDN) in which the base solution was the plain Ringer solution. Methods: A total of 80 patients aged < 12 years undergoing intracardiac repair of Tetralogy of Fallot were randomized into SDN (n = 39) or MDN (n = 41) groups. The primary outcome was a change in cardiac index (CI). Secondary outcomes were ventricular arrhythmias after the release of aortic-cross clamp, postoperative inotropic score (IS), time to peripheral rewarming, duration of mechanical ventilation, intensive care unit (ICU) length of stay, and hospital length of stay, and electron microscopic differences between the 2 groups. Cardiac Troponin-I, inflammatory markers tumor necrosis factor-α (TNF-α), and interleukin-L (IL-6) were measured. Results: Applying the noninferiority confidence interval approach, the difference between the changes in CI between the 2 groups was -0.093 L/min/m2 (95% CI: -0.46-0.27 L/min/m2) which was within the noninferiority threshold of -0.5 indicating that CI was similar in both SDN and MDN. Ventricular arrhythmias postclamp release (P = .91), IS (P = .09), duration of mechanical ventilation (P = .27), ICU length of stay (P = .50), hospital length of stay (P = .57), IL-6 (P = .19), TNF-α (P = .17), Troponin-I (P = .15), electron microscopy changes (P > .05) were not different between groups. Conclusion: MDN was shown to be noninferior to the SDN cardioplegia in terms of preservation of cardiac index. In addition, other metrics indicative of myocardial protection were similar between groups. In developing nations where SDN is not available or is expensive, MDN cardioplegia is an acceptable alternative.

Mitral valve repair with the edge-to-edge technique: A 20 years single-center experience

OBJECTIVES

For tailored treatment of primary mitral regurgitation (MR), surgeons developed different repair techniques. One of them, the edge-to-edge repair has recently seen a revival, especially for Barlow's disease.

METHODS

This study was designed to assess the outcomes of the edge-to-edge technique in mitral valve (MV) repair. Preoperative, periprocedural, and postoperative data were prospectively collected in a dedicated database and analyzed retrospectively.

RESULTS

Between March 1999 and July 2019, a total of 152 patients (mean age: 60 ± 13) received an edge-to-edge repair combined with annuloplasty for degenerative MR at our institution. MR resulted from posterior leaflet prolapse in 23 patients (15.1%), anterior leaflet prolapse in 19 (12.5%), and bileaflet prolapse in 110 (72.4%). Of those who had a bileaflet prolapse, 91 (82.7%) had Barlow's disease. Follow-up was complete in 97.4% (6.4 ± 5.7 years). Echocardiographic assessment was achieved in 85.5% (5.1 ± 5.6 years). Overall survival after 10 years was 73.7 ± 5.0%. Twelve patients required valve-related reoperations due to ring dehiscence (n = 2), leaflet suture dehiscence (n = 2), progression of native valve disease (n = 6), or due to device failure (ring fracture) (n = 2). The cumulative incidence of valve-related reoperation at 10 years was 8.4 ± 3.0% (5.2 ± 4.1% in patients with Barlow's disease). At latest follow-up, echocardiography revealed excellent valve function with no or mild MR in 93 patients (88.6%). The mean gradient was 2.9 ± 1.3 mmHg at discharge and decreased to 2.4 ± 1.3 mmHg. Three patients (2.8%) had more than moderate MR.

CONCLUSION

Edge-to-edge MV repair is a simple method with excellent results in terms of valvular function and durability especially in patients with Barlow's disease.

The World Database for Pediatric and Congenital Heart Surgery: Update

Following several years of planning and design, the World Database for Pediatric and Congenital Heart Surgery (WDPCHS) went live on January 1, 2017. The first operational year of this valuable database has proven very successful. As of February 28, 2018, more than 4,500 patients have been submitted from 39 centers; participation currently spans 19 countries over 6 continents, with 120 more centers in the enrollment pipeline. This update, the first in a series, is intended to provide World Society for Pediatric and Congenital Heart Surgery members and others who care for children with congenital heart disease with a broad overview of current progress and ongoing activities surrounding the WDPCHS.

The Relationship between Intra-Operative Transfusions and Nadir Hematocrit on Post-Operative Outcomes after Cardiac Surgery

Uncertainty exists regarding the optimal strategy for the management of anemia in the setting of cardiac surgery. We sought to improve our understanding of the role of intra-operative hematocrit (HCT) and transfusions on peri-operative outcomes following cardiac surgery. A total of 18,886 patients undergoing on-pump cardiac surgery were identified from a multi-institutional registry including surgical and perfusion data. Patients were divided into four groups based on their intra-operative nadir HCT (<21 or ≥21) and whether or not they received intra-operative red blood cell (+RBC or -RBC) transfusions. Outcomes were adjusted for the Society of Thoracic Surgeons predicted risk of mortality (PROM), pre-operative HCT, and medical center. Regardless of nadir HCT cohort, those who received a transfusion had higher PROM relative to patients who did not receive a transfusion. The mean PROM was significantly higher among those HCT ≥21 + RBC (5.3%) vs. HCT ≥ 21 - RBC (1.9%), p < .001. Similarly, the PROM was significantly higher among HCT <21 + RBC (5.1%) vs. those HCT <21 - RBC (3.1%), p < .001. Adjusted outcomes demonstrated an increased impact of RBC transfusions on adverse outcomes irrespective of nadir HCT including stroke (p < .001), renal failure (p < .001), prolonged ventilation (p < .001), and mortality (p < .001). This study demonstrates that transfusions have a more profound effect on post-operative cardiac surgery outcomes than anemia.

Left ventricular and mitral valve function long after repair of left anomalous coronary artery from the pulmonary artery: recovery years after severe ischemia

BACKGROUND

The study evaluates the long-term results of surgery for anomalous left coronary artery from the pulmonary artery (ALCAPA) with special attention on the left ventricular (LV) function and mitral regurgitation.

METHODS

Twenty-one children underwent surgery for ALCAPA over 23 years (1987-2010). All patients underwent establishment of a two-coronary system, by direct reimplantation (n = 13) or by intrapulmonary tunnel technique (n = 8), with concomitant mitral valve repair in one. The follow-up echocardiograms were evaluated to assess LV function and mitral regurgitation.

RESULTS

Five patients died. The age of the nonsurvivors was lower, 4.2 ± 1.3 versus 22.7 ± 29.4 months, P = .04. All nonsurvivors had moderate or severe mitral regurgitation preoperatively and higher LV diameter z score than the survivors: 11.8 (9-14.6) versus 4.6 (1.9-13.1), P = .01. At last follow-up, all survivors were asymptomatic; the diastolic LV diameter was normal, with z scores: 0.3 (0.1-1.9) versus 7 (1.9-14.6) preoperatively, P = .001, as was the LV ejection fraction: 66% (61%-78%) versus 38% (16%-70%) preoperatively, P = .001. Fifteen patients had moderate or severe mitral regurgitation at initial presentation and it eventually regressed to insignificant in all survivors (P = .001). No subsequent interventions on the coronary arteries or the mitral valve were needed. Four patients with intrapulmonary tunnel had mild suprapulmonary obstruction with Doppler peak gradients between 20 and 30 mm Hg.

CONCLUSIONS

In our experience, establishment of a two-coronary circulation without mitral valve repair leads to normalization of LV dimension and systolic function and to improvement of mitral regurgitation in the surviving patients. Mortality is related to low age and to the associated higher degree of LV dysfunction.