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King G, Buratto E, Cordina R, Iyengar A, Grigg L, Kelly A, Bullock A, Ayer J, Alphonso N, d'Udekem Y, Konstantinov IE. Atrioventricular septal defect in Fontan circulation: Right ventricular dominance, not valve surgery, adversely affects survival. J Thorac Cardiovasc Surg 2023; 165:424-433. [PMID: 36008181 DOI: 10.1016/j.jtcvs.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The effect of ventricular dominance and previous atrioventricular valve (AVV) surgery on patient outcomes after Fontan operation remains unclear. We sought to determine the effect of ventricular dominance and previous AVV surgery on transplantation-free survival and long-term AVV competency in patients with atrioventricular septal defect (AVSD) and Fontan circulation. METHODS We conducted a retrospective study of 1703 patients in the Australia and New Zealand Fontan Registry, who survived Fontan operation between 1987 and 2021. RESULTS Of 174 patients with AVSD, 60% (105/174) had right ventricular (RV) dominance and 40% (69/174) had left ventricular (LV) dominance. The cumulative incidence of moderate or greater AVV regurgitation at 25 years after Fontan operation in patients with LV dominance was 56% (95% CI, 35%-72%), compared with 54% (95% CI, 40%-67%) in patients with RV dominance (P = .6). Nonetheless, transplantation-free survival at 25 years in patients with LV dominance was 94% (95% CI, 86%-100%), compared with 67% (95% CI, 52%-87%) in patients with RV dominance (hazard ratio, 5.9; 95% CI, 1.4-25.4; P < .01). Of note, transplantation-free survival was not different in patients who underwent AVV surgery before or at Fontan completion compared with those who did not (15 years: 81% [95% CI, 62%-100%] vs 88% [95% CI, 81%-95%]; P = .3). CONCLUSIONS In patients with AVSD and Fontan circulation the rate of moderate or greater common AVV regurgitation is similar in those with LV and RV dominance. RV dominance, rather than previous AVV surgery, is a risk factor for death or transplantation.
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Affiliation(s)
- Gregory King
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Edward Buratto
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Cardiac Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; Heart Research Institute, Newtown, Sydney, Australia
| | - Ajay Iyengar
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Health, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Leeanne Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew Kelly
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia; Faculty of Health and Medical Sciences, Department of Paediatrics, The University of Adelaide, Adelaide, Australia
| | - Andrew Bullock
- Department of Cardiology, Perth Children's Hospital, Perth, Australia; Division Cardiovascular Medicine, Adult Congenital Cardiology, Sir Charles Gardiner Hospital, Perth, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nelson Alphonso
- Department of Cardiac Surgery, Queensland Children's Hospital, Brisbane, Australia; Queensland Paediatric Cardiac Research, Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - Yves d'Udekem
- The Division of Cardiovascular Surgery, Children's National Heart Institute, Washington, DC
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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Ota N, Tachibana T, Asai H, Ikarashi J, Asou T, Izutani H. Outcomes of bidirectional cavopulmonary shunt in patients younger than 4 months of age. Eur J Cardiothorac Surg 2020; 57:937-944. [DOI: 10.1093/ejcts/ezz373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Bidirectional cavopulmonary shunt (BCPS) has played an important role in the staged Fontan approach; however, the timing remains controversial, especially in younger patients. Therefore, we examined the outcomes of BCPS in infants younger than 3 months of age.
METHODS
From 2004 to 2018, 120 patients underwent BCPS at <4 months of age (younger group). For reference, we also reviewed the data from 204 patients who had undergone the BCPS procedure during the same period at more than 4 months of age (older group).
RESULTS
The median age and body weight at the time of the BCPS were 102 days and 4.2 kg for the younger group versus 196 days and 6.3 kg for the older group, respectively. Forty-eight patients (14.8%, 48 of 324; 16 in the younger group, 32 in the older group) had primary BCPS; the remaining 276 (104 in younger group, 172 in older group) had various forms of single-ventricle palliation before the BCPS procedure. Although preoperatively, 7 patients required extracorporeal membrane oxygenation (ECMO) support due to haemodynamic instability, they were successfully weaned from ECMO through haemodynamic benefits after BCPS. The 10-year actual survival rate (Kaplan–Meier) was 89% in the younger group and 86% in the older group (P = 0.55). Atrioventricular valve regurgitation (AVVR) was identified as a factor associated with hospital deaths in the younger group (P = 0.009), and much older age at BCPS was associated with late deaths in the older group (P = 0.027).
CONCLUSIONS
In this study population, early performance of BCPS is applicable for patients who have undergone prior palliation and for those in whom primary BCPS is the first surgical intervention, even for patients with haemodynamic instabilities.
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Affiliation(s)
- Noritaka Ota
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Hidetsugu Asai
- Department of Cardiovascular Surgery, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Jin Ikarashi
- Department of Cardiovascular Surgery, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Toshihide Asou
- Department of Cardiovascular Surgery, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
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Concurrent right atrial isomerism, complete atrioventricular septal defect, and single ventricle in an L-transposition of great arteries patient complicated by brain abscess. Cardiol Young 2019; 29:999-1001. [PMID: 31237225 DOI: 10.1017/s1047951119001288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present a case of an 11-year-old Indonesian female who was referred to our facility after surgical excision of brain abscess. The patient has been previously diagnosed with right atrial isomerism, complete atrioventricular septal defect, and L-Transposition of great arteries. Multiple staged surgeries are required for the management of this condition.
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Kido T, Kawata H, Iwai S, Nishigaki K, Ueno T, Ozawa H, Sawa Y. Clinical standard for valve area after common atrioventricular valve plasty for a single ventricle. Interact Cardiovasc Thorac Surg 2017; 25:727-733. [PMID: 28575209 DOI: 10.1093/icvts/ivx156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/20/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine a clinical standard for post-repair common atrioventricular valve orifice area based on mid- to long-term valve function in patients with a functional single ventricle. METHODS The medical records of 19 single-ventricle patients who underwent common atrioventricular valve plasty from July 1988 to January 2013 were retrospectively reviewed. Bivalvation valvuloplasty was performed in 7 patients with relatively hypoplastic leaflets. The relationship between the orifice area of the repaired common atrioventricular valve measured intraoperatively and valve function and ventricular volume in the early postoperative period (median, 9.5 months) and at mid- to long-term follow-up (median, 4 years) were analysed. RESULTS Post-repair valve area was significantly positively correlated with valve regurgitation severity in the early postoperative period (P = 0.001, r = 0.69) and at mid- to long-term follow-up (P = 0.02, r = 0.57). Patients who did not undergo bivalvation had favourable valve function at mid- to long-term follow-up and in the early postoperative period when the post-repair valve area was 96-136% of the normal mitral valve area. Bivalvation patients had significantly more valve regurgitation in the early postoperative period than patients without bivalvation, despite equivalent repaired valve area (P = 0.02). CONCLUSIONS The post-repair orifice area of the common atrioventricular valve is significantly related to postoperative valve function. The clinical standard of post-repair valve orifice area might be 96-136% of the normal mitral valve area in patients undergoing repair without bivalvation. Patients undergoing bivalvation require greater reduction to obtain favourable mid- to long-term valve function.
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Affiliation(s)
- Takashi Kido
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroaki Kawata
- Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Murodocho, Izumi, Osaka, Japan
| | - Shigemitsu Iwai
- Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Murodocho, Izumi, Osaka, Japan
| | - Kyoichi Nishigaki
- Department of Pediatric Cardiovascular Surgery, Osaka City General Hospital, Miyakojimaku, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideto Ozawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | | | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Yan S, Jianpeng W, Xin Q, Minghui Z, Li Z, Hao W. Right atrial isomerism in children older than 3 years. SPRINGERPLUS 2016; 5:1372. [PMID: 27606160 PMCID: PMC4992477 DOI: 10.1186/s40064-016-3007-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 08/05/2016] [Indexed: 12/02/2022]
Abstract
Background There is a high mortality in infants with right atrial isomerism (RAI). However, less is known about outcome in older children with RAI. This study sought to evaluate those patients with RAI who survived older than 3 years of age without surgical intervention. Results A total of 33 consecutive patients (20 males) were enrolled in the study, mean age 6 years (range 3–32). None of the patients had surgical intervention for the RAI before age 3. Cardiac abnormalities include altered cardiac position (39 %), atrioventricular valve anomaly (87 %), single or functional single ventricle (55 %), pulmonary/subpulmonary obstruction (97 %), abnormal origin of the aorta (100 %), bilateral superior vena cava (67 %), and anomalous pulmonary venous drainage (66 %). Surgical intervention was performed after 3 years of age in 20 patients (61 %). None of them planned or had biventricular repair performed. 10 patients underwent the total cavopulmonary connection procedure, including four (40 %) who had atrioventricular valve (AVV) repair at the same time [all with common atrioventricular valve (CAVV)]. One patient died the day after the operation. A total of 69 % of patients with a CAVV had moderate or severe regurgitation, while 27 % with a single atrioventricular valve had moderate or severe regurgitation. Conclusion Patients with RAI who have survived to early childhood without surgical intervention have complex cardiac abnormalities. Survival after single stage total cavopulmonary connection is good but AVV repair is common.
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Affiliation(s)
- Sun Yan
- Department of Echocardiography, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 167, Bei Li Shi Road, Xicheng District, Beijing, 100037 China
| | - Wang Jianpeng
- Department of Echocardiography, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 167, Bei Li Shi Road, Xicheng District, Beijing, 100037 China
| | - Quan Xin
- Department of Echocardiography, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 167, Bei Li Shi Road, Xicheng District, Beijing, 100037 China
| | - Zhang Minghui
- Department of Echocardiography, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 167, Bei Li Shi Road, Xicheng District, Beijing, 100037 China
| | - Zhang Li
- Department of Echocardiography, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 167, Bei Li Shi Road, Xicheng District, Beijing, 100037 China
| | - Wang Hao
- Department of Echocardiography, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 167, Bei Li Shi Road, Xicheng District, Beijing, 100037 China
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Naito Y, Hiramatsu T, Kurosawa H, Agematsu K, Sasoh M, Nakanishi T, Imai Y, Yamazaki K. Long-Term Results of Modified Fontan Operation for Single-Ventricle Patients Associated With Atrioventricular Valve Regurgitation. Ann Thorac Surg 2013; 96:211-8. [DOI: 10.1016/j.athoracsur.2013.02.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 01/29/2013] [Accepted: 02/06/2013] [Indexed: 11/30/2022]
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Ota N, Fujimoto Y, Murata M, Tosaka Y, Ide Y, Tachi M, Ito H, Sugimoto A, Sakamoto K. Improving outcomes of the surgical management of right atrial isomerism. Ann Thorac Surg 2011; 93:832-8; discussion 838-9. [PMID: 22112795 DOI: 10.1016/j.athoracsur.2011.05.110] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 05/25/2011] [Accepted: 05/31/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with right atrial isomerism (RAI) have several cardiac malformations historically resulting in significant morbidity and mortality. We sought to assess whether current surgical strategies have improved the outcomes of patients with RAI. METHODS A retrospective review of our database from 1997 to 2010 identified 60 consecutive patients with RAI who underwent initial palliation at Mt. Fuji Shizuoka Children's Hospital. All of the patients had a functional single ventricle. Of the 60 patients, 33 patients (51.7%) had obstructed total anomalous pulmonary venous drainage (TAPVD), 23 patients (40.3%) had significant (more than moderate) atrioventricular valvular regurgitation (AVVR), 7 patients (12.3%) had hiatus hernia, and 4 patients (6.7%) had major aortopulmonary collateral arteries. Pulmonary outflow atresia was present in 39 of the patients (65%), and 46 patients had systemic-to-pulmonary artery shunts. Of the 33 patients with TAPVD, 18 underwent repair of the condition at initial palliation, 9 others at the time of a Glenn operation, 2 more through a Fontan operation, and 4 at the interstage between palliative surgeries. Eight of the 23 patients with significant AVVR underwent atrioventricular valve repair at initial palliation, 8 others at the time of Glenn operation, 4 others at the time of Fontan operation, and 3 during the interstage between operations. An initial neonatal surgical procedure was performed in 30 patients (50%). The mean follow-up period for patients in the study was 53.1 months. RESULTS Operative mortality after initial palliation was 15.4% (4 of 26 patients) before 2003 and 17.6% (6 of 34 patients) after 2004 (p=NS). Five-year survival was 53.8% before 2003 and 81.7% after 2004 (p=0.035, log-rank test). A multivariate analysis identified persistent AVVR of more than moderate degree (p=0.04) as a factor associated with late mortality. CONCLUSIONS The outcomes of surgery for RAI are improving. Neonatal palliative surgery for RAI carries a high operative risk of early mortality, and persistent significant AVVR remains a risk factor for late mortality.
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Affiliation(s)
- Noritaka Ota
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
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8
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Nakata T, Fujimoto Y, Hirose K, Tosaka Y, Ide Y, Tachi M, Sakamoto K. Atrioventricular valve repair in patients with functional single ventricle. J Thorac Cardiovasc Surg 2010; 140:514-21. [DOI: 10.1016/j.jtcvs.2010.05.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 04/24/2010] [Accepted: 05/14/2010] [Indexed: 10/19/2022]
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9
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Yoshida M, Yamaguchi M, Yoshimura N, Murakami H, Matsuhisa H, Okita Y. Appropriate additional pulmonary blood flow at the bidirectional Glenn procedure is useful for completion of total cavopulmonary connection. Ann Thorac Surg 2006; 80:976-81. [PMID: 16122468 DOI: 10.1016/j.athoracsur.2005.03.090] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 03/14/2005] [Accepted: 03/21/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The role and effect of additional pulmonary blood flow at the time of bidirectional Glenn procedure (BDG) is controversial. We assessed our experiences to clarify the effects of controlled additional pulmonary blood flow on outcomes after BDG. METHODS Thirty-eight patients who underwent BDG (2.1 +/- 2.1 years of age) were enrolled in this study. In group A (n = 29) additional pulmonary blood flow was controlled by the banding of the pulmonary trunk, or the previously created Blalock-Taussig shunt, to keep the central venous pressure equal to or less than 16 mm Hg at BDG. In group B (n = 9), BDG was the only source of pulmonary blood flow. RESULTS One operative death occurred in group B. In group A, 24 patients underwent total cavopulmonary connection (TCPC) 14 +/- 6 months after BDG, and the remaining 5 patients are waiting for TCPC in good condition. In group B, 6 patients underwent TCPC 8 +/- 7 months after BDG. One patient is awaiting TCPC and the remaining patient is considered unsuitable for TCPC. Cardiac catheterization performed in 32 patients showed significant decrease of pulmonary artery (Nakata) index from 307 +/- 73 to 215 +/- 45 mm2/m2 after BDG in group B (p < 0.05). On the other hand, the Nakata index stayed in higher range from 316 +/- 115 to 287 +/- 74 mm2/m2 in group A, and there was a significant correlation between the Nakata index and the percentage of its difference (Y = 40.823 - 0.144 X; n = 26, R = 0.740, p < 0.0001). CONCLUSIONS Appropriate additional pulmonary blood flow is useful for the completion of TCPC by means of suppressing the decrease in the size of the pulmonary artery, especially in patients with underdeveloped pulmonary arteries.
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Affiliation(s)
- Masahiro Yoshida
- Department of Cardiothoracic Surgery, Kobe Childre's Hospital, Kobe, Hyogo, Japan.
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10
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Hsu JY, Wang JK, Lin MT, Wu ET, Chiu SN, Chen CA, Lue HC, Wu MH. Clinical Implications of Major Aortopulmonary Collateral Arteries in Patients With Right Isomerism. Ann Thorac Surg 2006; 82:153-7. [PMID: 16798206 DOI: 10.1016/j.athoracsur.2006.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Revised: 02/02/2006] [Accepted: 02/06/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND The presence of major aortopulmonary collateral arteries (MAPCA) in patients with right isomerism may alter the prognosis, which is still unclear. METHODS From 1994 to 2003, 138 out of 155 patients (89%) with right isomerism had pulmonary stenosis or pulmonary atresia and constituted the study population. RESULTS Two groups of patients were identified, one with MAPCA and the other without. The MAPCA originating from descending thoracic aorta or aortic arch was noted in 9 patients (6.5%), with a median number of MAPCA being 3 (range, 2 to 4). Patients with MAPCA commonly had congestive heart failure (8/9, 89%) and frequent lower airway infection (6/9, 67%). In comparison with patients with MAPCA and without, the intrapericardial pulmonary artery was more frequently absent (2 of 9 vs 1 of 129, p < 0.001), and the pulmonary arterial size was smaller (McGoon ratio <1.5, 8 of 9 vs 57 of 129, p = 0.009) in the MAPCA group. The mean pulmonary arterial pressure measured was often higher than the suggested limit for Fontan circulation. Major aortopulmonary collateral arteries were addressed at a median of 6 months old (2 to 19 months old) in 5 patients. Although surgical mortality was not different for first-stage palliation and Glenn shunt in both groups, total cavopulmonary connection could only be performed in one patient with MAPCA with poor results. However, the 5-year survival of patients with and without MAPCA was not statistically different (74.1% vs 55.2%, p = 0.19). CONCLUSIONS The presence of MAPCA was uncommon but still noted in patients with right isomerism. It may cause heart failure and a less favorable pulmonary vasculature for a complete Fontan-type operation.
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MESH Headings
- Abnormalities, Multiple/mortality
- Abnormalities, Multiple/pathology
- Abnormalities, Multiple/physiopathology
- Abnormalities, Multiple/surgery
- Adolescent
- Adult
- Aorta/abnormalities
- Arteriovenous Shunt, Surgical
- Blood Pressure
- Body Patterning
- Child
- Child, Preschool
- Cohort Studies
- Collateral Circulation
- Embolization, Therapeutic
- Female
- Fontan Procedure
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/surgery
- Heart Failure/etiology
- Humans
- Hypertension, Pulmonary/etiology
- Infant
- Infant, Newborn
- Life Tables
- Male
- Palliative Care
- Postoperative Complications/etiology
- Postoperative Complications/mortality
- Prevalence
- Pulmonary Artery/abnormalities
- Pulmonary Artery/surgery
- Pulmonary Atresia/pathology
- Pulmonary Atresia/physiopathology
- Pulmonary Atresia/surgery
- Pulmonary Circulation
- Pulmonary Valve Stenosis/pathology
- Pulmonary Valve Stenosis/physiopathology
- Pulmonary Valve Stenosis/surgery
- Pulmonary Veins/abnormalities
- Retrospective Studies
- Treatment Outcome
- Venae Cavae/abnormalities
- Venae Cavae/surgery
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Affiliation(s)
- Jui-Yu Hsu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
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11
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Yun TJ, Al-Radi OO, Adatia I, Caldarone CA, Coles JG, Williams WG, Smallhorn J, Van Arsdell GS. Contemporary management of right atrial isomerism: effect of evolving therapeutic strategies. J Thorac Cardiovasc Surg 2006; 131:1108-13. [PMID: 16678597 DOI: 10.1016/j.jtcvs.2005.11.036] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 11/10/2005] [Accepted: 11/16/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Infants with right atrial isomerism have poor outcomes because of a complex combination of cardiac anomalies. Aggressive management of total anomalous pulmonary venous drainage might have a positive effect on the prognosis. METHODS Outcomes of all children with right atrial isomerism from 1994 to the present were reviewed. Management of total anomalous pulmonary venous drainage evolved from no repair or conventional surgical technique to primary sutureless repair on initial palliation. Cox survival models were used to identify variables associated with reduced survival. RESULTS There were 55 children enrolled in the study. The median age at the initial visit was 2 days. Fifty-one patients had total anomalous pulmonary venous drainage (obstructive in 22 patients). Withdrawal of treatment occurred in 11 (20%) of 55 patients during an interval of institutional bias toward no treatment. Thirteen (24%) of 55 patients had palliations without total anomalous pulmonary venous drainage repair, and 3 (23%) of 13 survived. Thirty-one (56%) of 55 patients had operations that included total anomalous pulmonary venous drainage repair, of whom 13 (42%) of 31 underwent primary sutureless repair for total anomalous pulmonary venous drainage. Sixteen (52%) of 31 survived, and their current status 1 to 10 years (median, 5.8 years) after repair is post-Fontan (7/16 [44%]), postbidirectional Glenn (6/16 [38%]), and others (3 [20%]). In patients who underwent total anomalous pulmonary venous drainage repair (n = 31), 2 risk factors of decreased survival were identified: drainage site obstruction and infracardiac or mixed-type total anomalous pulmonary venous drainage. After adjustment, sutureless repair appeared to be associated with improved survival (hazard ratio, 0.43), but this beneficial effect did not reach significance (P = .19). CONCLUSIONS Mortality continues to be high; however, aggressive total anomalous pulmonary venous drainage repair for right atrial isomerism has resulted in improved survival. The role of primary sutureless repair for total anomalous pulmonary venous drainage remains to be defined.
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Affiliation(s)
- Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan, Ulsan, Republic of Korea
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12
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Kawahira Y, Kishimoto H, Kawata H, Ikawa S, Ueda H, Nakajima T, Kayatani F, Inamura N, Mori T. New indicator for the Fontan operation: diameters of the pulmonary veins in patients with univentricular heart. J Card Surg 1999; 14:259-65. [PMID: 10874610 DOI: 10.1111/j.1540-8191.1999.tb00990.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Operative survival after the Fontan procedure is good; however, there are some patients with disappointing results, especially those with atrial isomerism. OBJECTIVES We tested whether the diameter of the pulmonary veins, which is reported as a useful indicator of pulmonary blood flow, predicts operative results after the Fontan operation. PATIENTS AND METHODS We evaluated 30 consecutive patients undergoing either the bidirectional Glenn anastomosis (BDG) or the Fontan operation. Age at operation ranged from 3 to 81 months (mean 30). Diagnosis was right or left isomeric heart in 15 patients, double-outlet right ventricle in 4 and various other malformations in 11. BDG was performed in 16 patients and the Fontan operation in 14 patients. The diameters of the pulmonary veins were measured proximal to the entrance into the atrium in the late phase of a pulmonary arteriogram. The pulmonary vein (PV) index (in mm2/m2) was calculated from the sum of the cross-sectional areas of these veins divided by the body surface area. RESULTS Of the patients undergoing BDG (+/- ancillary procedures), 12 had successful results and 4 had unsuccessful results. The PV index for hemodynamically successful patients was 361 +/- 153 and 275 +/- 60 mm2/m2 (mean +/- SD) for unsuccessful patients (p = 0.30). Of the patients who underwent the Fontan operation, 13 had successful and 1 had unsuccessful results. The PV index for successful patients was > 285 mm2/m2 and 137 mm2/m2 for the nonsuccessful patients. The new pulmonary vascular resistance (PVR) calculated by using the PV index (mean pressure difference between the pulmonary artery and the atrium/PV index) for BDG patients with successful or unsuccessful results was 2.0 +/- 0.5 or 3.5 +/- 0.2 mmHg/mm2 per m2, respectively (p < 0.01). The new PVR for Fontan patients with successful results was < 2.0 mmHg/mm2 per m2, while that for the patient with an unsuccessful result was 4.4. The new PVR completely separated patients into successful and unsuccessful groups, while conventionally calculated PVR did not (p = 0.63). CONCLUSIONS PV index appears to be a useful morphological indicator of pulmonary blood flow and "new" PVR may improve the decision-making strategy for patients presenting with univentricular heart, especially those associated with isomeric heart.
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Affiliation(s)
- Y Kawahira
- Department of Cardiovascular Surgery, Osaka Medical Center, Japan.
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Francalanci P, Marino B. Morphology of the atrioventricular valve in patients with right atrial isomerism. Pediatr Cardiol 1998; 19:501. [PMID: 9770584 DOI: 10.1007/s002469900370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Kawahira Y, Kishimoto H, Kawata H, Ikawa S, Ueda H, Nakajima T, Kayatani F, Inamura N, Mori T. New Indicator for the Fontan Operation: Diameters of the Pulmonary Veins in Patients with Univentricular Heart. Echocardiography 1985. [DOI: 10.1111/j.1540-8175.1985.tb01287.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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