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Egbe AC, Salama AA, Miranda WR, Karnakoti S, Anderson JH, Jain CC, Burchill LJ, Connolly HM. Right Heart Reverse Remodeling and Prosthetic Valve Function After Transcatheter vs Surgical Pulmonary Valve Replacement. JACC Cardiovasc Interv 2024; 17:248-258. [PMID: 38267139 DOI: 10.1016/j.jcin.2023.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND There are limited data about postprocedural right heart reverse remodeling and long-term prosthesis durability after transcatheter pulmonary valve replacement (TPVR) and how these compare to surgical pulmonary valve replacement (SPVR). OBJECTIVES This study sought to compare right heart reverse remodeling, pulmonary valve gradients, and prosthetic valve dysfunction after TPVR vs SPVR. METHODS Patients with TPVR were matched 1:2 to patients with SPVR based on age, sex, body surface area, congenital heart lesion, and procedure year. Right heart indexes (right atrial [RA] reservoir strain, RA volume index, RA pressure, right ventricular [RV] global longitudinal strain, RV end-diastolic area, and RV systolic pressure) were assessed at baseline (preintervention), 1 year postintervention, and 3 years postintervention. Pulmonary valve gradients were assessed at 1, 3, 5, 7, and 9 years postintervention. RESULTS There were 64 and 128 patients in the TPVR and SPVR groups, respectively. Among patients with TPVR, 46 (72%) and 18 (28%) received Melody (Medtronic) vs SAPIEN (Edwards Lifesciences) valves, respectively. The TPVR group had greater postprocedural improvement in RA reservoir strain and RV global longitudinal strain at 1 and 3 years. The TPVR group had a higher risk of prosthetic valve dysfunction mostly because of a higher incidence of prosthetic valve endocarditis compared to SPVR but a similar risk of pulmonary valve reintervention because some of the patients with endocarditis received medical therapy only. Both groups had similar pulmonary valve mean gradients at 9 years postintervention. CONCLUSIONS These data suggest a more favorable right heart outcome after TPVR. However, the risk of prosthetic valve endocarditis and prosthetic valve dysfunction remains a major concern.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA.
| | - Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Snigdha Karnakoti
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
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Abozied O, Miranda W, Younis A, Burchill L, Jain C, Connolly H, Dearani J, Stephens EH, Egbe AC. Outcomes after implantation of right-sided mechanical valve prostheses in congenital heart disease. Heart 2023; 109:1765-1771. [PMID: 37407219 DOI: 10.1136/heartjnl-2023-322666] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Bioprosthetic valves are often used for pulmonary valve replacement (PVR) and tricuspid valve replacement (TVR) because of concerns about mechanical valve thrombosis in the right heart. The purpose of this study was to assess prosthetic valve function and outcomes (prosthetic valve dysfunction, reoperations and major bleeding events) after mechanical PVR and TVR and to compare these to bioprostheses implanted in the same positions. METHOD Case-control study of adults with congenital heart disease that underwent mechanical TVR or PVR (2003-2021) at Mayo Clinic Rochester, Minnesota. For each mechanical prosthesis, we identified two patients that received bioprosthesis in the same position (1:2 matching). RESULTS We identified 48 consecutive patients that underwent mechanical PVR (n=39, age 32 (26-38) years, men 22 (56%)) and/or mechanical TVR (n=17, age 36 (31-42) years, men 9 (53%)), as control group of 78 patients (age 30 (24-36) years, men 44 (56%)) and 34 patients (age 34 (29-39) years, men 18 (53%)) that underwent bioprosthetic PVR and TVR, respectively. The most common diagnoses in patients that received mechanical prosthesis were: tetralogy of Fallot (n=14, 19%), aortic stenosis status post Ross operation (n=11, 23%), truncus arteriosus (n=5, 11%), atrioventricular canal defect (n=4, 8%), Ebstein anomaly (n=3, 6%), double outlet right ventricle (n=2, 4%), valvular pulmonic stenosis (n=2, 4%). Compared with the bioprosthesis group, the mechanical prosthesis group had lower temporal increase in Doppler systolic mean gradient after PVR (∆ -1±2 vs 3±2 mm Hg, p<0.001) and Doppler diastolic mean gradient after TVR (∆ 0±1 vs 2±1 mm Hg, p=0.005). The mechanical prosthesis group also had lower risk of prosthetic valve dysfunction after PVR (1.0% vs 2.8% /year, p=0.02) and after TVR (2.6% vs 4.3% /year, p=0.008), but higher risk of major bleeding events (2.2% vs 0.1% /year, p<0.001). CONCLUSIONS Patients that received right-sided mechanical valve prostheses had lower temporal increase in valve gradient, lower risk of prosthetic valve dysfunction, but higher risk of bleeding complications compared with those that underwent right-sided bioprosthetic valve implantation.
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Affiliation(s)
- Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - William Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Luke Burchill
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Heidi Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Elizabeth H Stephens
- Department of Cardiovascular Surgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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Slouha E, Trygg G, Tariq AH, La A, Shay A, Gorantla VR. Pulmonary Valve Replacement Timing Following Initial Tetralogy of Fallot Repair: A Systematic Review. Cureus 2023; 15:e49577. [PMID: 38156158 PMCID: PMC10754298 DOI: 10.7759/cureus.49577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Pulmonary valve replacement (PVR) is a critical aspect of surgical management for patients with tetralogy of Fallot (ToF). Determining an optimal timeframe for intervention is imperative, as it directly impacts long-term outcomes and the risk of complications in ToF patients. Ventriculotomy with the transannular patch is currently indicated for right ventricular outflow tract obstruction, but the patch itself can lead to pulmonary regurgitation (PR), dyspnea, and cyanosis, among other complications. This investigation seeks to establish an evidence-based timeline to enhance the overall quality of care for individuals with this congenital heart condition. From 2002 to 2022, 21,935 articles regarding the PVR timing for ToF were examined and filtered. The publications were screened using PRISMA guidelines, and 32 studies were included for analysis and review. Among the studies, PVR was strongly indicated for patients who had developed severe PR, especially in asymptomatic patients and those experiencing fatigue and exercise intolerance. Severe PR was associated with arrhythmias such as right bundle branch block, atrioventricular block, and prolonged QRS intervals, in which male sex and high right ventricular end-diastolic volume (RVEDV) were significant predictors of long preoperative QRS duration. Most physicians found RVEDV necessary for making surgical referrals despite a lack of correlation between PR severity and RVEDV or indexed right ventricular end-systolic volume (RVESVi). However, asymptomatic ToF patients with preoperative RVESVi benefited from PVR. Except for some variations in QRS intervals among studies, arrhythmias tended to persist post-op, yet NYHA functional class and RV size improved significantly following PVR. Older age at PVR was found to be associated with adverse cardiac events, whereas early PVR presented with appropriately short QRS intervals. Cardiac function tended to be significantly worse in patients undergoing late PVR versus early PVR, with timelines ranging from one to three decades following initial ToF repair. Choosing the best timeline for PVR largely depends on the patient's baseline cardiopulmonary presentation, and additional quantitative deformation analysis can help predict an appropriate timeline for ToF patients.
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Affiliation(s)
- Ethan Slouha
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Genevieve Trygg
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Abdul Hadi Tariq
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Anthony La
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Allison Shay
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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Marchini F, Meossi S, Passarini G, Campo G, Pavasini R. Pulmonary Valve Stenosis: From Diagnosis to Current Management Techniques and Future Prospects. Vasc Health Risk Manag 2023; 19:379-390. [PMID: 37416511 PMCID: PMC10320808 DOI: 10.2147/vhrm.s380240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023] Open
Abstract
Pulmonary stenosis (PS) is mainly a congenital defect that accounts for 7-12% of congenital heart diseases (CHD). It can be isolated or, more frequently, associated with other congenital defects (25-30%) involving anomalies of the pulmonary vascular tree. For the diagnosis of PS an integrated approach with echocardiography, cardiac computed tomography and cardiac magnetic resonance (CMR) is of paramount importance for the planning of the interventional treatment. In recent years, transcatheter approaches for the treatment of PS have increased however, meaning surgery is a possible option for complicated cases with anatomy not suitable for percutaneous treatment. The present review aims to summarize current knowledge regarding diagnosis and treatment of PS.
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Affiliation(s)
- Federico Marchini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Sofia Meossi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Giulia Passarini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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Lawley CM, Tanous D, O'Donnell C, Anderson B, Aroney N, Walters DL, Shipton S, Wilson W, Celermajer DS, Roberts P. Ten Years of Percutaneous Pulmonary Valve Implantation in Australia and New Zealand. Heart Lung Circ 2022; 31:1649-1657. [PMID: 36038469 DOI: 10.1016/j.hlc.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 04/28/2022] [Accepted: 07/12/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study sought to investigate the characteristics, morbidity (including the rate of infective endocarditis and valve replacement) and mortality of individuals undergoing percutaneous pulmonary valve implantation in Australia and New Zealand since the procedure has been performed. BACKGROUND The outcomes of percutaneous pulmonary valve implantation in Australia and New Zealand have not been evaluated. Recent international data, including patients from New Zealand, suggests the rate of infective endocarditis is not insignificant. METHODS A retrospective multi-site cohort study was undertaken via medical record review at the centres where percutaneous pulmonary valve implantation has been performed. All procedures performed from 2009-March 2018 were included. Individuals were identified from local institution databases. Data was collected and analysed including demographics, details at the time of intervention, haemodynamic outcome, post procedure morbidity and mortality. Multi-site ethics approval was obtained. RESULTS One hundred and seventy-nine (179) patients attended the cardiac catheter laboratory for planned percutaneous pulmonary valve implantation. Of these patients, 172 underwent successful implantation. Tetralogy of Fallot and pulmonary atresia were the most common diagnoses. The median age at procedure was 19 years (range 3-60 yrs). There was a significant improvement in the acute haemodynamics in patients undergoing percutaneous pulmonary valve implantation for stenosis. Seven (7) patients (3.9%) experienced a major procedural/early post procedure complication (death, conversion to open procedure, cardiac arrest), including two deaths. The annualised rates of infective endocarditis and valve replacement were 4.6% and 3.8% respectively. There was one death related to infective endocarditis in follow-up. CONCLUSIONS Percutaneous pulmonary valve replacement is a relatively safe method of rehabilitating the right ventricular outflow tract.
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Affiliation(s)
- Claire M Lawley
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW, Australia; The University of Sydney Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - David Tanous
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Clare O'Donnell
- Green Lane Paediatric and Congenital Cardiac Service, Starship/Auckland City Hospitals, Starship Children's Hospital, Auckland, New Zealand
| | - Benjamin Anderson
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Qld, Australia
| | - Nicholas Aroney
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - Darren L Walters
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; The University of Queensland, Brisbane, Qld, Australia
| | - Stephen Shipton
- Children's Cardiac Centre, Perth Children's Hospital, Perth, WA, Australia
| | - William Wilson
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Philip Roberts
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW, Australia
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Zhuang B, Yu S, Feng Z, He F, Jiang Y, Zhao S, Lu M, Li S. Left ventricular strain derived from cardiac magnetic resonance can predict outcomes of pulmonary valve replacement in patients with repaired tetralogy of Fallot. Front Cardiovasc Med 2022; 9:917026. [PMID: 36061553 PMCID: PMC9433663 DOI: 10.3389/fcvm.2022.917026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeSeveral adults with repaired tetralogy of Fallot (rToF) undergo pulmonary valve replacement (PVR) to reduce the right ventricular volume and retain right ventricular function. However, there is currently no consensus on the ideal time for PVR surgery in asymptomatic patients with rTOF with pulmonary regurgitation (PR). Clinical outcomes after PVR are also indeterminate. Recently, myocardial strain and strain rate derived from cardiac magnetic resonance (CMR) feature tracking were found to be more sensitive to right ventricular dysfunction than conventional parameters and therefore may add prognostic value in patients with rToF. We aimed to analyze whether pre-PVR left ventricular (LV) strain and strain rate detected by CMR feature tracking are associated with midterm outcomes after PVR in patients with rToF.MethodsSeventy-eight asymptomatic patients with rToF who required PVR due to moderate or severe PR were prospectively enrolled between January 2014 and June 2020. CMR cine sequences were obtained, and feature tracking parameters were measured preoperatively. Adverse events were documented during the follow-up. Receiver operating characteristic analysis was performed to determine the cutoff value. Kaplan–Meier curves were drawn with log-rank statistics; moreover, univariate and multivariate Cox proportional hazards regression analyses and Harrel C-indices were analyzed.ResultsDuring 3.6 ± 1.8 years of follow-up, 25 adverse events were recorded. Kaplan–Meier survival curves and univariate Cox analysis verified that patients with significantly reduced radial strain (RS), circumferential strain (CS), longitudinal strain (LS), RS rate at systole and diastole (RSRs and RSRe), and circumferential and LS rates at diastole (CSRe and LSRe) had worse event-free survival. After multivariate correction, only LS and LSRe remained significantly associated with adverse outcomes (hazard ratio = 1.243 [1.083–1.428] and 0.067 [0.017–0.258], respectively, all p < 0.05). The cutoff values of LS and LSRe were −12.30 (%) and 1.07 (s–1), respectively.ConclusionThe LV strain and strain rate prior to PVR are important prognostic factors for adverse events after PVR in rToF.
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Affiliation(s)
- Baiyan Zhuang
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shiqin Yu
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zicong Feng
- Pediatric Cardiac Surgery Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengpu He
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Yong Jiang
- Department of Echocardiography, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Echocardiography, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Minjie Lu,
| | - Shoujun Li
- Pediatric Cardiac Surgery Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Shoujun Li,
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Congenital heart disease: pathology, natural history, and interventions. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Al Mosa AFH, Madathil S, Bernier PL, Tchervenkov C. Long-Term Outcome Following Pulmonary Valve Replacement in Repaired Tetralogy of Fallot. World J Pediatr Congenit Heart Surg 2021; 12:616-627. [PMID: 34597203 DOI: 10.1177/21501351211027857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Late pulmonary valve replacement following repair of tetralogy of Fallot may become necessary in patients with chronic pulmonary insufficiency. There is limited information on the long-term outcome of these prostheses, which is the focus of this study. METHODS We conducted a retrospective study of patients with repaired tetralogy of Fallot who underwent pulmonary valve replacement from 1990 to 2015 in our institution. We investigated imaging and clinical parameters including mortality and late adverse events (reintervention [surgical or transcatheter]), infective endocarditis, or arrhythmias requiring device implantation or ablation. RESULTS There were 69 patients divided into 3 groups: Carpentier-Edwards (n = 14), Contegra (n = 40), and pulmonary homograft (n = 15). The mean age at the time of pulmonary valve replacement was 21 ± 12 years. The mean follow-up was 8.5 ± 4.7 years. The mean preoperative and postoperative right ventricular end-diastolic volume index was 210 ± 42 and 120 ± 24 mL/m2, respectively. There were no mortalities. Late adverse events were observed in 23 (33%) patients: 15 (22%) reintervention (surgical or transcatheter), 11 (16%) endocarditis, and 11 (16%) arrhythmias. Overall, 1-, 5-, and 10-year freedom from surgical reintervention was 98.5%, 93.6%, and 79.3%, respectively. The Contegra group had significantly higher pulmonary valve gradients, a higher risk of developing late adverse events compared to Carpentier-Edwards (P = .046) and pulmonary homograft (P = .055) in multivariate analysis and increased risk for reintervention in the univariate analysis (hazard ratio: 3.4; 95% CI: 0.92-13; P value.066). CONCLUSION Pulmonary valve replacement in patients with repaired tetralogy of Fallot has acceptable short- and intermediate-term outcomes. Contegra prosthesis had a higher risk of late adverse events with higher pulmonary valve gradients.
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Affiliation(s)
- Alqasem Fuad H Al Mosa
- Cardiovascular Surgery, 54473McGill University Health Center (MUHC), Montreal, Quebec, Canada
| | | | - Pierre-Luc Bernier
- Cardiovascular Surgery, Montreal Children's Hospital (MCH), 5620McGill University Health Center (MUHC), Quebec, Canada
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Chungsomprasong P, Somkittithum P, Chanthong P, Vijarnsorn C, Durongpisitkul K, Soongswang J, Subtaweesin T, Sriyodchartti S. Risk factors and long-term outcomes after tetralogy of Fallot repair at an Asian tertiary referral center. Asian Cardiovasc Thorac Ann 2021; 30:433-440. [PMID: 34424057 DOI: 10.1177/02184923211039795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Tetralogy of Fallot is the most common type of cyanotic congenital heart disease. More postoperative tetralogy of Fallot patients grow up than in the past, and these patients need to be followed-up. OBJECTIVE To investigate the survival and long-term outcomes of patients who underwent total repair of tetralogy of Fallot, and to identify the risk factors for reoperation with pulmonic valve replacement. METHOD A total of 403 patients who underwent total tetralogy of Fallot repair at our center during 1997 to 2016 were retrospectively included. Demographic, clinical, treatment, outcome, and follow-up data were collected and analyzed. RESULTS Median age and body weight at the time of tetralogy of Fallot repair was 4.41 years (range: 0.85-55.28) and 13.58 kg (range: 5.5-68), respectively. The median follow-up was 9.0 years, and overall mortality was 3.2%. The actuarial survival rates at 10 and 20 years were 96.4% and 95.2%, respectively, and the freedom from pulmonic valve replacement was 93.4% and 57.4%, respectively. The median time to indicate pulmonic valve replacement was 13.9 years (range: 6.2-20.5). Multivariate analysis revealed transannular patch technique (hazard ratio: 3.023, 95% confidence interval: 1.34-6.83; p = 0.008) and palliative shunt (hazard ratio: 2.39, 95% confidence interval: 1.16-4.91; p = 0.018) to be independent risk factors for reoperation with pulmonic valve replacement. CONCLUSION The rates of overall survival and freedom from pulmonic valve replacement were both high in this study, and both were comparable to the rates reported from other studies. Overall mortality was as low as 3.47%. The need for a transannular patch or palliative shunt should be considered risk factors for a consequent reoperation.
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Affiliation(s)
- Paweena Chungsomprasong
- Division of Pediatric Cardiology, Department of Pediatrics, 546354Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Pimonrat Somkittithum
- Division of Pediatric Cardiology, Department of Pediatrics, 546354Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Prakul Chanthong
- Division of Pediatric Cardiology, Department of Pediatrics, 546354Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Chodchanok Vijarnsorn
- Division of Pediatric Cardiology, Department of Pediatrics, 546354Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Kritvikrom Durongpisitkul
- Division of Pediatric Cardiology, Department of Pediatrics, 546354Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Jarupim Soongswang
- Division of Pediatric Cardiology, Department of Pediatrics, 546354Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Thaworn Subtaweesin
- Division of Cardiothoracic Surgery, Department of Surgery, 65106Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Somchai Sriyodchartti
- Division of Cardiothoracic Surgery, Department of Surgery, 65106Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
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Abstract
BACKGROUND The adult population of repaired tetralogy of Fallot is increasing and at risk of pre-mature death and arrhythmia. This study evaluates risk factors for adverse outcome and the effect of pulmonary valve replacement within a national cohort. METHODS A retrospective cohort study of 341 adult repaired tetralogy of Fallot (16-72 years) managed through a single national service was undertaken incorporating over 1200 patient-years of follow-up. Demographics, cardiopulmonary exercise testing, cardiac magnetic resonance, reintervention (including pulmonary valve replacement), and clinical events were analysed. The influence of these parameters on a primary outcome (death or arrhythmia) was evaluated. RESULTS Compared with an age-/gender-matched population, patients experienced a reduced survival, particularly males over 55 years (standardised mortality ratio : 6.12, 95% CI: 1.64-15.66, p = 0.004). Cox proportional hazards modelling identified increased indexed right ventricle (RV) end-diastolic volume (hazard ratio (HR): 2.86, 95% CI: 1.4-5.85, p = 0.004) and female gender (HR (male): 0.37, 95% CI: 0.14-0.98, p = 0.045) to be predictors significantly associated with the primary outcome. Pulmonary valve replacement undertaken at indexed RV end-diastolic volume = 145 ml/m2 reduced RV volumes and QRS duration but did not improve cardiopulmonary exercise testing nor NYHA class. Pulmonary valve replacement during cohort period was associated with increased risk of primary outcome (HR: 2.82, 95% CI: 1.36-5.86, p = 0.005). CONCLUSIONS Although the majority of adult tetralogy of Fallot were asymptomatic in NYHA 1, cardiopulmonary exercise testing revealed important deficits. Tetralogy of Fallot survival was reduced compared to the general population. Female gender and increasing RV end-diastolic volume predicted adverse events. Pulmonary valve replacement reduced RV volumes and QRS duration but did not improve primary outcome.
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11
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Lee C, Choi ES, Lee CH. Long-term outcomes of pulmonary valve replacement in patients with repaired tetralogy of Fallot. Eur J Cardiothorac Surg 2021; 58:246-252. [PMID: 32047919 DOI: 10.1093/ejcts/ezaa030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/30/2019] [Accepted: 01/09/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate long-term outcomes of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (TOF) and to identify the factors associated with adverse clinical events (ACEs). METHODS A total of 190 patients who underwent PVR between 1998 and 2015 after repair of TOF were retrospectively analysed. ACE was defined as all-cause death, heart transplantation or new-onset sustained arrhythmia. Univariable Cox proportional hazards regression analysis was used to identify the factors associated with ACE after PVR. RESULTS The median age at PVR was 19 years. Preoperative magnetic resonance imaging (MRI) was performed in 143 (75%) patients, and the median right ventricular (RV) end-diastolic and end-systolic volume index was 164 and 82 ml/m2, respectively. The follow-up completeness was 94%, and the median follow-up duration was 9.8 years. The transplantation-free survival and freedom from ACE at 15 years was 95% and 90%, respectively. The factors associated with ACE were older age at PVR, older age at TOF repair, New York Heart Association functional class III or IV, presence of tachyarrhythmias, longer cardiopulmonary bypass time and concomitant arrhythmia surgery. In a subgroup analysis of 143 patients with preoperative MRI data, larger RV end-systolic volume index, larger left ventricular end-systolic volume index and lower left ventricular ejection fraction were associated with ACE. CONCLUSIONS Long-term outcomes of PVR in patients with repaired TOF were satisfactory. Proactive PVR before the onset of advanced symptoms, tachyarrhythmias and ventricular dysfunction may further improve the long-term survival of this patient population.
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Affiliation(s)
- Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Seok Choi
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Republic of Korea
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12
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Forsch N, Govil S, Perry JC, Hegde S, Young AA, Omens JH, McCulloch AD. Computational analysis of cardiac structure and function in congenital heart disease: Translating discoveries to clinical strategies. JOURNAL OF COMPUTATIONAL SCIENCE 2021; 52:101211. [PMID: 34691293 PMCID: PMC8528218 DOI: 10.1016/j.jocs.2020.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Increased availability and access to medical image data has enabled more quantitative approaches to clinical diagnosis, prognosis, and treatment planning for congenital heart disease. Here we present an overview of long-term clinical management of tetralogy of Fallot (TOF) and its intersection with novel computational and data science approaches to discovering biomarkers of functional and prognostic importance. Efforts in translational medicine that seek to address the clinical challenges associated with cardiovascular diseases using personalized and precision-based approaches are then discussed. The considerations and challenges of translational cardiovascular medicine are reviewed, and examples of digital platforms with collaborative, cloud-based, and scalable design are provided.
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Affiliation(s)
- Nickolas Forsch
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | - Sachin Govil
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | - James C Perry
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Sanjeet Hegde
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Alistair A Young
- Department of Biomedical Engineering, King’s College London, London, UK
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, NZ
| | - Jeffrey H Omens
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
- Deparment of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Andrew D McCulloch
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
- Deparment of Medicine, University of California San Diego, La Jolla, CA, USA
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13
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Lee C. Pulmonary Valve Replacement in Patients with Repaired Tetralogy of Fallot: What Are the Benefits? Korean Circ J 2021; 51:373-375. [PMID: 33821588 PMCID: PMC8022028 DOI: 10.4070/kcj.2021.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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14
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Dang Van S, Pavy C, Guimbretière G, Boulanger J, Maminirina P, Guerin P, Baron O. Results of large pulmonary homograft implantation for right ventricular outflow tract reconstruction. J Card Surg 2021; 36:442-448. [PMID: 33319937 DOI: 10.1111/jocs.15184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/22/2020] [Accepted: 10/20/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND To evaluate the long-term results of implantation of homogeneous large size of pulmonary homograft (PH) for reconstruction of the right ventricular outflow tract (RVOT). METHODS Between January 2000 and December 2017, 107 patients were implanted with PH for reconstruction of the RVOT. Data were collected retrospectively in this single-center study. PH failure was defined as a peak of gradient greater than 40 mmHg and/or as a pulmonary regurgitation greater than Grade 2. Primary endpoint was the reoperation of the RVOT during follow-up. Secondary endpoints were overall survival, occurrence of PH failure and the rate of reoperation for all cause. RESULTS Mean age of the recipients was 26.1 ± 13.6 years. Median follow-up interval was 2.99 years (interquartile range [IQR]: 6.2). Mean size of PH was 24.9 ± 1.9 mm. Reoperation of the RVOT occurred in eight patients (7.8%). Time before reoperation was 2.74 years (IQR: 6.4). Freedom from reoperation for RVOT at 5 and 10 years was respectively 95.7% and 90.0%. Overall survival at 10 years was 95.2%. PH failure occurred in 13 patients (12.0%). Median time before PH failure was 6.7 years (IQR: 9.6). Freedom from PH failure at 10 years was 81.6%. Reoperation for PH failure occurred in four patients (3.9%). Concomitant tricuspid surgery (p = .01; 95% confidence interval [CI]: 1.9-319.6) and undersized PH (p = .01; 95% CI: 2.06-719.8) were independent risk factors of late reoperation. CONCLUSION Implantation of large PH for RVOT reconstruction provides excellent midterm results in terms of reoperation.
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Affiliation(s)
- Simon Dang Van
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
| | - Carine Pavy
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
| | - Guillaume Guimbretière
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
| | - Julie Boulanger
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
| | - Pierre Maminirina
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
| | - Patrice Guerin
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
| | - Olivier Baron
- Department of Pediatric and Congenital Cardiac Surgery, University Hospital of Nantes, France
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15
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Risk Factors for Mortality and Ventricular Tachycardia in Patients With Repaired Tetralogy of Fallot: A Systematic Review and Meta-analysis. Can J Cardiol 2020; 36:1815-1825. [DOI: 10.1016/j.cjca.2020.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022] Open
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16
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Burkhart HM, Phillips SD. Commentary: Pulmonary valve bioprosthesis: Longevity and reintervention. J Thorac Cardiovasc Surg 2020; 161:364-365. [PMID: 32859415 DOI: 10.1016/j.jtcvs.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Harold M Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla.
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17
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Commentary: The conundrum of pulmonary valve substitutes. J Thorac Cardiovasc Surg 2020; 160:488-489. [DOI: 10.1016/j.jtcvs.2020.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 11/20/2022]
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18
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Duarte VE, Graf JA, Marshall AC, Economy KE, Valente AM. Transcatheter Pulmonary Valve Performance During Pregnancy and the Postpartum Period. JACC Case Rep 2020; 2:847-851. [PMID: 34317364 PMCID: PMC8302026 DOI: 10.1016/j.jaccas.2020.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
Abstract
Increasing numbers of women with congenital heart disease are undergoing pregnancy after transcatheter pulmonary valve replacement (TPVR). We present the course of 9 pregnancies in 7 women with TPVR, noting pre-pregnancy, antepartum, and postpartum gradients, as well as maternal cardiac, obstetric, and neonatal outcomes. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Valeria E Duarte
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Julia A Graf
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Katherine E Economy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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19
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Perri G, Galletti L. Commentary: Looking for the ideal pulmonary valve. J Thorac Cardiovasc Surg 2020; 160:485-486. [PMID: 32532504 DOI: 10.1016/j.jtcvs.2020.04.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Gianluigi Perri
- Pediatric Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children Hospital, Rome, Italy
| | - Lorenzo Galletti
- Pediatric Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children Hospital, Rome, Italy.
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20
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Egbe AC, Vojjini R, Banala K, Najam M, Khalil F, Osman K, Badawy M, Anderson JH, Taggart NW. Determinants and Prognostic Implications of Left-Heart Filling Pressures in Tetralogy of Fallot. Can J Cardiol 2020; 36:1491-1498. [PMID: 32247704 DOI: 10.1016/j.cjca.2019.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/15/2019] [Accepted: 10/30/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Elevated pulmonary artery wedge pressure (PAWP) is the hallmark of left-heart failure and is responsible for heart failure symptoms and mortality. Although PAWP typically correlates with right atrial pressure (RAP), it is primarily dependent on left-heart myocardial properties and volume status. As right-heart disease can occur in the absence of left-heart disease in patients with tetralogy of Fallot (TOF), we hypothesized that RAP was the primary determinant of PAWP in this population. METHODS A cohort study of adults with TOF that underwent right-heart catheterization at Mayo Clinic Rochester (1990 to 2017) to determine the relationship among RAP, PAWP, and mortality. RESULTS Among 213 patients (male 105; age 37 ± 14 years), the mean PAWP was 14 ± 5 mm Hg, and RAP was 11 ± 5 mm Hg. RAP was the strongest predictor of PAWP (β = 0.68, standard error = 0.06, P < 0.001), independent of left-heart disease and atherosclerotic cardiovascular risk factors. The patients with high PAWP also had normal tissue Doppler velocities, suggesting normal left-ventricular myocardial properties. PAWP was an independent predictor of death/transplant (hazard ration [HR] 1.11, 95% confidence interval [CI], 1.03-1.20, P = 0.004). However, when RAP was incorporated into the regression model, RAP (and not PAWP) became the independent predictor of outcomes (HR 1.14, 95% CI, 1.06-1.22, P = 0.001). CONCLUSIONS The current study showed that RAP was the primary determinant of PAWP and accounts, to some extent, for the mortality in patients with TOF and high PAWP. The data provide new insight in the pathophysiology of disease progression for symptomatic patients with TOF.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Rahul Vojjini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Keerthana Banala
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maria Najam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fouad Khalil
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Karim Osman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamed Badawy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason H Anderson
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
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21
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Cochran CD, Yu S, Gakenheimer-Smith L, Lowery R, Lu JC, Mahani MG, Agarwal PP, Dorfman AL. Identifying Risk Factors for Massive Right Ventricular Dilation in Patients With Repaired Tetralogy of Fallot. Am J Cardiol 2020; 125:970-976. [PMID: 31964501 DOI: 10.1016/j.amjcard.2019.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/28/2022]
Abstract
In repaired tetralogy of Fallot (rTOF), pulmonary insufficiency results in varying degrees of right ventricle (RV) dilation. A subset of patients is diagnosed at initial cardiac magnetic resonance imaging (CMR) with a massively dilated RV, far beyond pulmonary valve replacement (PVR) criteria, which is unlikely to return to normal size after PVR. This study aimed to identify risk factors for massive RV dilation at initial CMR. This nested case-control study included all patients at our institution with rTOF and massive RV dilation (indexed RV end-diastolic volume [RVEDVi] ≥200 ml/m2) on initial CMR. Patients were matched by age at first CMR, gender, and type of repair with rTOF controls with RVEDVi<200 ml/m2. In 39 cases (median RVEDVi 227 ml/m2, interquartile range [IQR] 213 to 250) and 73 controls (median RVEDVi 155 ml/m2, IQR 130 to 169), repair at >6 months of age, longer QRS duration, and non-Caucasian race were significantly associated with massive RV dilation on univariate analysis. In multivariate analysis, repair at >6 months of age (adjusted odds ratio [AOR] 2.90, 95% confidence interval [CI] 1.12 to 7.55, p = 0.03), longer QRS duration (AOR = 1.03, 95% CI 1.01 to 1.05, p = 0.005), and non-Caucasian race (AOR = 7.84, 95% CI 1.76 to 34.8, p = 0.01) remained independently associated with massive RV dilation. Era of repair, history of systemic to pulmonary shunt palliation, genetic anomaly, and additional cardiac lesions did not differ between groups. In conclusion, these risk factors identify a subset of patients who may benefit from earlier CMR evaluation to avoid massive irreversible RV dilation.
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Affiliation(s)
- Clinton D Cochran
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Maryam Ghadimi Mahani
- Section of Cardiothoracic Radiology, Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Prachi P Agarwal
- Section of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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22
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Predicting the Future: Tetralogy of Fallot Will Be Primarily Treated with Catheter Based Intervention Within Two Decades. Surgeon's Perspective. Pediatr Cardiol 2020; 41:546-552. [PMID: 32198582 DOI: 10.1007/s00246-020-02298-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/17/2020] [Indexed: 10/24/2022]
Abstract
Interventional cardiology has made extraordinary advances over recent years, but most are still limited to addressing single intracardiac or valvular lesions. This debate considers whether complete interventional repair of more complex congenital defects might become achievable. Tetralogy of Fallot (ToF) is probably the first candidate where complete interventional repair might be achieved-given that various components of the defect have already been successfully addressed-albeit as either a palliative intervention (RVOT stenting) or to address the sequelae of standard surgery (percutaneous PVR). This article considers the challenges that would need to be overcome in terms of the morphology of the condition, the age limitations, and the necessary technological advancements that would be required-while setting these against the benchmark of current surgical outcomes and the parallel progress that is being developed in surgical correction. While complete interventional repair of ToF may still be beyond current techniques, a hybrid approach between surgeons and intentional cardiologists can strive to create a life-long paradigm of care that minimizes the need for surgery and focuses on the maintenance of a healthy right ventricle, such that patients born with ToF can achieve normal life expectancy.
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23
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He F, Feng Z, Chen Q, Jiao Y, Hua Z, Zhang H, Yang K, Pang K, Lu M, Ma K, Zhang S, Qi L, Wang G, Li S. Whether Pulmonary Valve Replacement in Asymptomatic Patients With Moderate or Severe Regurgitation After Tetralogy of Fallot Repair Is Appropriate: A Case-Control Study. J Am Heart Assoc 2020; 8:e010689. [PMID: 30587056 PMCID: PMC6405720 DOI: 10.1161/jaha.118.010689] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Although right ventricular (RV) volume was significantly decreased in symptomatic patients with repaired tetralogy of Fallot (rTOF) after pulmonary valve replacement (PVR), RV size was still enlarged along with RV dysfunction. Methods and Results A prospective case‐control study was conducted in a tertiary hospital; 81 asymptomatic repaired tetralogy of Fallot patients with moderate or severe pulmonary regurgitation were enrolled. The enrolled cohort was divided into 2 groups: PVR group (n=41) and medication group (n=40). Cardiac magnetic resonance, transthoracic echocardiography, and electrocardiography were scheduled after recruitment and 6 months after PVR or recruitment. Adverse events were recorded during follow‐up. Three deaths, 1 heart transplantation, 3 PVRs, and 2 symptomatic heart failures in medication group and 1 redo PVR in the PVR group were observed during follow‐up. Compared with the medication group, the PVR group had significantly lower adverse events rate (P=0.023; odds ratio, 0.086; 95% CI, 0.010–0.716), and RV function was significantly improved (P<0.05). Binary logistic regression analysis identified preoperative RV end‐systolic volume index (10‐mL/m2 increment, P=0.009; odds ratio, 0.64; 95% CI, 0.457–0.893) was an independent predictor of normalization of RV size after PVR. A preoperative RV end‐systolic volume index cut‐off value of 120 mL/m2 (area under curve, 0.819; sensitivity, 90.3%; specificity, 70%) was analyzed by receiver operating characteristic curves for normalized RV size after PVR. Conclusions PVR in asymptomatic repaired tetralogy of Fallot patients is appropriate and effective in reducing right ventricular size and preserving right ventricular function. The recommended criterion of RV end‐systolic volume index for PVR is 120 mL/m2.
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Affiliation(s)
- Fengpu He
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Zicong Feng
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Qiuming Chen
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Yiping Jiao
- 2 Psychological Teaching and Research Department Hangzhou Armed Police Officer School Hangzhou China
| | - Zhongdong Hua
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Hao Zhang
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Keming Yang
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Kunjing Pang
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Minjie Lu
- 3 Department of Magnetic Resonance Imaging National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Kai Ma
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Sen Zhang
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Lei Qi
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Guanxi Wang
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Shoujun Li
- 1 Pediatric Cardiac Surgery Center National Center for Cardiovascular Disease and Fuwai Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
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Egbe AC, Vallabhajosyula S, Connolly HM. Trends and outcomes of pulmonary valve replacement in tetralogy of Fallot. Int J Cardiol 2020; 299:136-139. [DOI: 10.1016/j.ijcard.2019.07.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/10/2019] [Accepted: 07/17/2019] [Indexed: 01/10/2023]
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25
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Egbe AC, Banala K, Vojjini R, Osman K, Afzal A, Jain V, Thotamgari S, Ammash NM. The applications and potential limitations of right ventricular volumes as surrogate marker in tetralogy of fallot. IJC HEART & VASCULATURE 2019; 26:100430. [PMID: 31763442 PMCID: PMC6864123 DOI: 10.1016/j.ijcha.2019.100430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 11/17/2022]
Abstract
Cardiac magnetic resonance imaging derived right ventricular (RV) volumes are often necessary for optimal timing of pulmonary valve replacement in patients with tetralogy of Fallot (TOF). This practice is based on previous studies that reported preoperative RV volumetric thresholds that predicted postoperative RV remodeling. As a result, pulmonary valve replacements are being performed even in asymptomatic patients based on RV volumetric thresholds that predict complete postoperative RVOT remodeling. Hence, RV volumes are now being used as surrogate markers/endpoints for future cardiovascular outcomes. Unfortunately, there are no studies showing survival benefit for performing pulmonary valve replacement at smaller RV volumes. This review underscores some of the limitations of using RV volumes as surrogate markers for clinical outcomes, and also highlights knowledge gaps about the pathophysiologic mechanism of cardiovascular death in the TOF population.
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Affiliation(s)
- Alexander C. Egbe
- Corresponding author at: Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, United States.
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26
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Outcomes of Bioprosthetic Valves in the Pulmonary Position in Adults With Congenital Heart Disease. Ann Thorac Surg 2019; 108:1410-1415. [DOI: 10.1016/j.athoracsur.2019.05.068] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/23/2022]
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Wijayarathne PM, Skillington P, Menahem S, Thuraisingam A, Larobina M, Grigg L. Pulmonary Allograft Versus Medtronic Freestyle Valve in Surgical Pulmonary Valve Replacement for Adults Following Correction of Tetralogy of Fallot or Its Variants. World J Pediatr Congenit Heart Surg 2019; 10:543-551. [DOI: 10.1177/2150135119859853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Following corrective surgery in infancy/childhood for tetralogy of Fallot (TOF) or its variants, patients may eventually require pulmonary valve replacement (PVR). Debate remains over which valve is best. We compared outcomes of the Medtronic Freestyle valve with that of the pulmonary allograft valve following PVR. Methods: A retrospective study was undertaken from a single surgical practice of adult patients undergoing elective PVR between April 1993 and March 2017. The choice of valve was at the surgeon’s discretion. There was a trend toward the almost exclusive use of the more readily available Medtronic Freestyle valve since 2008. Results: One hundred fifty consecutive patients undergoing 152 elective PVRs were reviewed. Their mean age was 33.8 years. Ninety-four patients had a Medtronic Freestyle valve, while 58 had a pulmonary allograft valve. There were no operative or 30-day mortality. The freedom from reintervention at 5 and 10 years was 98% and 98% for the pulmonary allograft and 99% and 89% for the Medtronic Freestyle. There was no significant difference in the rate of reintervention, though this was colored by higher pulmonary gradients across the Medtronic Freestyle despite its shorter follow-up. Conclusions: Pulmonary valve replacement following previous surgical repair of TOF or its variants was found to be safe with no significant differences in mortality or reintervention between either valve. Although the Medtronic Freestyle valve had a greater tendency toward pulmonary stenosis, additional follow-up is needed to further document its long-term outcomes.
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Affiliation(s)
| | - Peter Skillington
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Cardiothoracic Surgery, Melbourne Private Hospital, Parkville, Victoria, Australia
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia
| | - Samuel Menahem
- Department of Cardiology, Epworth and Melbourne Private Hospital, Melbourne, Victoria, Australia
- School of Clinical Sciences, Monash Health, Monash University, Clayton, Victoria, Australia
| | - Amalan Thuraisingam
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Marco Larobina
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Cardiothoracic Surgery, Melbourne Private Hospital, Parkville, Victoria, Australia
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia
| | - Leeanne Grigg
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Mongeon FP, Ben Ali W, Khairy P, Bouhout I, Therrien J, Wald RM, Dallaire F, Bernier PL, Poirier N, Dore A, Silversides C, Marelli A. Pulmonary Valve Replacement for Pulmonary Regurgitation in Adults With Tetralogy of Fallot: A Meta-analysis-A Report for the Writing Committee of the 2019 Update of the Canadian Cardiovascular Society Guidelines for the Management of Adults With Congenital Heart Disease. Can J Cardiol 2019; 35:1772-1783. [PMID: 31813508 DOI: 10.1016/j.cjca.2019.08.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/11/2019] [Accepted: 08/16/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There is no systematic evidence review of the long-term results of surgical pulmonary valve replacement (PVR) dedicated to adults with repaired tetralogy of Fallot (rTOF) and pulmonary regurgitation. METHODS Our primary objective was to determine whether PVR reduced long-term mortality in adults with rTOF compared with conservative therapy. Secondary objectives were to determine the postoperative incidence rate of death, the changes in functional capacity and in right ventricular (RV) volumes and ejection fraction after PVR, and the postoperative incidence rate of sustained ventricular arrhythmias. A systematic search of multiple databases for studies was conducted without limits. RESULTS No eligible randomized controlled trial or cohort study compared outcomes of PVR and conservative therapy in adults with rTOF. We selected 10 cohort studies (total 657 patients) reporting secondary outcomes. After PVR, the pooled incidence rate of death was 1% per year (95% confidence interval [CI] 0-1% per year) and the pooled incidence rate of sustained ventricular arrhythmias was 1% per year (95% CI 1%-2% per year). PVR improved symptoms (odds ratio for postoperative New York Heart Association functional class > II 0.08, 95% CI 0.03-0.24). Indexed RV end-diastolic (-61.29 mL/m2, -43.64 to -78.94 mL/m2) and end-systolic (-37.20 mL/m2, -25.58 to -48.82 mL/m2) volumes decreased after PVR, but RV ejection fraction did not change (0.19%, -2.36% to 2.74%). The effect of PVR on RV volumes remained constant regardless of functional status. CONCLUSION Studies comparing PVR and conservative therapy exclusively in adults with rTOF are lacking. After PVR, the incidence rates of death and ventricular tachycardia are both 1 per 100 patient-years. Pooled analyses demonstrated an improved functional status and a reduction in RV volumes.
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Affiliation(s)
- François-Pierre Mongeon
- Adult Congenital Heart Center, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
| | - Walid Ben Ali
- Department of surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Paul Khairy
- Adult Congenital Heart Center, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Ismail Bouhout
- Department of surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Judith Therrien
- Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Rachel M Wald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Frederic Dallaire
- Division of Pediatric and Fetal Cardiology, Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Pierre-Luc Bernier
- Department of surgery, McGill University Health Center, McGill University, Montréal, Québec, Canada
| | - Nancy Poirier
- Department of surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Department of surgery, CHU-Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Annie Dore
- Adult Congenital Heart Center, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Candice Silversides
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease (MAUDE Unit), McGill University, Montréal, Québec, Canada
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Armstrong AK, Berger F, Jones TK, Moore JW, Benson LN, Cheatham JP, Turner DR, Rhodes JF, Vincent JA, Zellers T, Lung T, Eicken A, McElhinney DB. Association between patient age at implant and outcomes after transcatheter pulmonary valve replacement in the multicenter Melody valve trials. Catheter Cardiovasc Interv 2019; 94:607-617. [DOI: 10.1002/ccd.28454] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric CardiologyDeutsches Herzzentrum Berlin Berlin Germany
- German Center of Cardiovascular Research Berlin Germany
| | - Thomas K. Jones
- Department of CardiologySeattle Children's Hospital Seattle Washington
| | - John W. Moore
- Division of Cardiology, Department of PediatricsRady Children's Hospital and University of California San Diego San Diego California
| | - Lee N. Benson
- The Division of Cardiology, The Labatt Family Heart CenterThe Hospital for Sick Children Toronto Canada
| | | | - Daniel R. Turner
- Division of Cardiology, Carman and Ann Adams Department of PediatricsChildren's Hospital of Michigan Detroit Michigan
| | - John F. Rhodes
- Department of Pediatric CardiologyMedical University of South Carolina Charleston South Carolina
| | - Julie A. Vincent
- Division of Pediatric CardiologyColumbia University Medical Center New York New York
| | - Thomas Zellers
- Division of Cardiology, Department of PediatricsUniversity of Texas Southwestern and the Heart Center at Children's Health Dallas Texas
| | - Te‐Hsin Lung
- Coronary and Structural Heart Clinical Department Santa Rosa California
| | - Andreas Eicken
- Deutsches Herzzentrum München, Klinik für Kinderkardiologie und angeborene HerzfehlerTechnische Universität München Munich Germany
| | - Doff B. McElhinney
- Department of Cardiothoracic Surgery, Lucille Packard Children's HospitalStanford University School of Medicine Palo Alto California
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Gnanappa GK, Celermajer DS, Zhu D, Puranik R, Ayer J. Severe right ventricular dilatation after repair of Tetralogy of Fallot is associated with increased left ventricular preload and stroke volume. Eur Heart J Cardiovasc Imaging 2019; 20:1020-1026. [DOI: 10.1093/ehjci/jez035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/11/2018] [Accepted: 02/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Pulmonary regurgitation (PR) and right ventricular (RV) dilatation are common in repaired tetralogy of Fallot (rTOF). Left ventricular (LV) dysfunction is an important risk factor in rTOF. The effect of PR/RV dilatation on LV performance and RV-LV interactions in rTOF are incompletely understood. We examined LV responses and exercise capacity in rTOF, both before and after pulmonary valve replacement (PVR).
Methods and results
Cardiac magnetic resonance imaging scans in 126 rTOF patients (age 17.3 ± 7.6 years) were analysed, comparing subjects with indexed RV end-diastolic volume (RVEDVi) <170 mL/m2 (mild/moderate dilatation, n = 95) and RVEDVi ≥170 mL/m2 (severe dilatation, n = 31). Indexed PR volume (PRVi), RV end-systolic (RVESVi), RV end-diastolic (RVEDVi), RV stroke volume (RVSVi), net pulmonary forward flow (NPFFi), LV end-diastolic (LVEDVi), LV end-systolic (LVESVi), LV stroke volume (LVSVi), RV and LV ejection fraction (EF), and diastolic septal curvature were obtained. Peak aerobic capacity (VO2 max) was measured. In a subset (n = 30), measures were obtained pre-and-post surgical PVR. Compared to those with mild/moderate RV dilatation, patients with severe RV dilation had greater PRVi (38 ± 12 vs. 24 ± 9 mL/m2, P < 0.0001), NPFFi (53 ± 9 vs. 44 ± 11 mL/m2, P < 0.0001), LVEDVi (87 ± 14 vs. 73 ± 13 mL/m2, P < 0.0001), LVESVi (39 ± 12 vs. 30 ± 8 mL/m2, P < 0.0001), and LVSVi (48 ± 7 vs. 43 ± 8 mL/m2, P = 0.002) but lower RV ejection fraction (46 ± 8 vs. 53 ± 7%, P < 0.0001). Septal curvature and VO2 max were similar in both groups. After PVR, there was no change in LVEDVi, LVSVi, septal curvature, or VO2 max.
Conclusions
Chronic PR with severe RV dilatation is associated with increased NPFFi, LVEDVi, and LVSVi. This may potentially explain preserved exercise capacity in rTOF with severe PR and RV dilatation.
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Affiliation(s)
- Ganesh Kumar Gnanappa
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
| | - David S Celermajer
- Department of Cardiology, The Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Danyi Zhu
- School of Electrical and Information Technology, University of Sydney, Maze Crescent, Darlington, New South Wales 2006, Australia
| | - Rajesh Puranik
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
- Department of Cardiology, The Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
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31
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Egbe AC, Vallabhajosyula S, Akintoye E, Connolly HM. Trends and Outcomes of Infective Endocarditis in Adults With Tetralogy of Fallot: A Review of the National Inpatient Sample Database. Can J Cardiol 2019; 35:721-726. [PMID: 31151707 DOI: 10.1016/j.cjca.2019.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/06/2019] [Accepted: 02/10/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Lesion complexity and prosthetic valves are known risk factors for infective endocarditis in patients with congenital heart disease. Tetralogy of Fallot (TOF) is the most common complex/cyanotic congenital heart disease and often requires prosthetic valve implantation. Population-based risk of endocarditis in TOF patients is unknown. METHODS We reviewed the National Inpatient Sample (NIS) and identified admissions in TOF patients (>18 years), 2000 to 2014. The primary outcome was to describe incidence of endocarditis-related admissions. To assess trends, we divided the study period into tertiles: early (2000 to 2004), mid (2005 to 2009) and late (2010 to 2014) eras. The secondary outcome was to compare in-hospital mortality, complications, and health care resource utilization between admissions with and without endocarditis. RESULTS There were 393 (2.1%) endocarditis-related admissions among 18,353 admissions, and the incidence of endocarditis-related admissions increased over time: 1.9% (early era) vs 2.2% (mid-era) vs 2.4% (late era), P < 0.001. Overall in-hospital mortality was 6%. In addition to previously described risk factors for endocarditis, such as previous pacemaker/defibrillator or prosthetic valve implantation, we observed an association between endocarditis-related admissions and male gender, black race, and lower socioeconomic class. In comparison with admissions without endocarditis, the endocarditis-related admissions had higher in-hospital mortality, complications, and health care resource utilization measured by length of stay, inflation-adjusted hospitalization cost, and type of hospital discharge. CONCLUSIONS Incidence of endocarditis-related admissions increased over time and was associated with higher mortality, complications, and health care resource utilization. Further studies are required to investigate the observed temporal increase in incidence of endocarditis and explore new strategies to improve outcomes.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Emmanuel Akintoye
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinic, Iowa City, Iowa, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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32
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Egbe AC, Miranda WR, Ammash NM, Said SM, Missula VR, Abdelsamid MF, Kothapalli S, Connolly HM. Use of mechanical valve prostheses in adults with tetralogy of Fallot. Int J Cardiol 2019; 291:45-49. [PMID: 30803889 DOI: 10.1016/j.ijcard.2019.02.028] [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] [Received: 09/27/2018] [Revised: 11/03/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND There are limited data about the outcomes mechanical prostheses in adults with tetralogy of Fallot (TOF). The purpose of the study was to describe the incidence of mechanical valve related adverse events (MVRAE), reoperation and all-cause mortality in TOF patients with mechanical valve prostheses. METHODS We reviewed the MACHD (Mayo Adult Congenital Heart Disease) database and identified all adult TOF patients with mechanical valve prostheses, 1990-2017. MVRAE was defined as valve thrombosis, endocarditis, embolic stroke or major bleeding complications. RESULTS A total of 44 prostheses were implanted in 29 patients (age 44 ± 13 years; men 18 [62%]), and 10 (36%) patients received multiple mechanical prostheses. The median number of prior sternotomies was 3 (range 2-7). Target intentional normalized ratio (INR) was 2.0-3.0 for patients with isolated mechanical aortic prostheses (n = 12, 41%), 2.5-4.0 for mechanical prostheses in non-aortic positions. There were no surgical deaths, and 10 MVRAE (endocarditis [n = 4], major bleeding complications [n = 5] and valve thrombosis [n = 1]) occurred in 7 (24%) patients during a median follow-up of 11 (5 18) years. The 10-year survival and freedom from reoperation were 87% and 95% respectively. CONCLUSIONS Surgical mortality and valve thrombosis for mechanical valve prostheses are low presumably due to appropriate patient selection and meticulous anticoagulation. Endocarditis and bleeding complications are major concerns. Further studies are required to determine the appropriate target INR that provides the optimal balance between preventing valve thrombosis and avoiding major bleeding complications mechanical valve prostheses in different positions.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Naser M Ammash
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Venkata R Missula
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | | | - Srikanth Kothapalli
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
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33
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Baggen VJ, Venema E, Živná R, van den Bosch AE, Eindhoven JA, Witsenburg M, Cuypers JA, Boersma E, Lingsma H, Popelová JR, Roos-Hesselink JW. Development and validation of a risk prediction model in patients with adult congenital heart disease. Int J Cardiol 2019; 276:87-92. [DOI: 10.1016/j.ijcard.2018.08.059] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/09/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022]
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34
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Townsley MM, Windsor J, Briston D, Alegria J, Ramakrishna H. Tetralogy of Fallot: Perioperative Management and Analysis of Outcomes. J Cardiothorac Vasc Anesth 2019; 33:556-565. [DOI: 10.1053/j.jvca.2018.03.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 12/14/2022]
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35
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Zahn EM. Self-Expanding Pulmonary Valves for Large Diameter Right Ventricular Outflow Tracts. Interv Cardiol Clin 2018; 8:73-80. [PMID: 30449423 DOI: 10.1016/j.iccl.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Congenital heart defects that involve obstruction to the right ventricular outflow tract are common. Surgical repair involves early relief of right ventricular outflow tract obstruction, which typically results in pulmonary regurgitation and large irregularly shaped "native" right ventricular outflow tract. This type of anatomy represents the majority of patients who could potentially benefit from transcatheter pulmonary valve therapy. Currently approved balloon-expandable devices were not designed for this application and the unique anatomy of these patients presents tremendous challenges for designing a valve that is. This article explores those challenges and the newest self-expanding devices designed to treat this challenging population.
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Affiliation(s)
- Evan Michael Zahn
- Guerin Family Congenital Heart Program, Cedars Sinai Medical Center, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
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36
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Englert JAR, Gupta T, Joury AU, Shah SB. Tetralogy of Fallot: Case-Based Update for the Treatment of Adult Congenital Patients. Curr Probl Cardiol 2018; 44:46-81. [PMID: 30172549 DOI: 10.1016/j.cpcardiol.2018.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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37
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Matsuo K, Kabasawa M, Asano S, Tateno S, Kawasoe Y, Okajima Y, Hayashida N, Murayama H. Surgical treatment for adult congenital heart disease: consideration for indications and procedures. Gen Thorac Cardiovasc Surg 2017; 66:57-64. [PMID: 29119450 DOI: 10.1007/s11748-017-0861-2] [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: 08/23/2017] [Accepted: 10/28/2017] [Indexed: 11/29/2022]
Abstract
The number of the adult patients with congenital heart diseases (ACHD) continues to grow owing to improvement of surgical results and medical management. Corrective surgery for complex CHD does not always mean complete cure. It is not rare that the patients will visit the cardiology institutes because of secondary lesions due to residua or sequela in adults. Some patients with CHD remain unrepairable with different degree of heart failure and pulmonary arterial hypertension. Association of arrhythmias is common in ACHD patients and sometimes critical. We experienced 265 surgical procedures for ACHD patients at our center between 1999 and 2015. Of these procedures, palliative surgery was performed in 3%, palliation to corrective surgery in 6%, primary repair in 57%, and redo surgery in 34%. Hospital mortality within 30 days in this period was 1.1%. Surgery for ACHD patients is safe, beneficial and low-risk treatment; however, tailored procedures for the individual patient are essential to obtain the optimal quality. A comprehensive multidisciplinary approach is required to fulfill this goal.
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Affiliation(s)
- Kozo Matsuo
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan.
| | - Masashi Kabasawa
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Soichi Asano
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Shigeru Tateno
- Section of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Yasutaka Kawasoe
- Section of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Yoshitomo Okajima
- Section of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Naoki Hayashida
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Hirokazu Murayama
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
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38
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Li HF, Wu Y, Wang M, Grunkemeier GL. A Stopping Guideline for Pulmonary Heart Valve Premarket Approval Studies. Semin Thorac Cardiovasc Surg 2017; 30:81-84. [PMID: 28987280 DOI: 10.1053/j.semtcvs.2017.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Hsin-Fang Li
- Medical Data Research Center, Providence Health and Service, Portland, Oregon.
| | - YingXing Wu
- Medical Data Research Center, Providence Health and Service, Portland, Oregon
| | - Mansen Wang
- Medical Data Research Center, Providence Health and Service, Portland, Oregon
| | - Gary L Grunkemeier
- Medical Data Research Center, Providence Health and Service, Portland, Oregon
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39
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Mechanical valves in the pulmonary position: An international retrospective analysis. J Thorac Cardiovasc Surg 2017; 154:1371-1378.e1. [DOI: 10.1016/j.jtcvs.2017.04.072] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 03/23/2017] [Accepted: 04/12/2017] [Indexed: 12/21/2022]
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40
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Stroke Volume Ratio Predicts Redilatation of the Right Ventricle After Pulmonary Valve Replacement. Ann Thorac Surg 2017; 104:698-703. [DOI: 10.1016/j.athoracsur.2016.12.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/29/2016] [Accepted: 12/20/2016] [Indexed: 11/21/2022]
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41
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Abstract
PURPOSE OF REVIEW Procedural technique and short-term outcomes of transcatheter pulmonary valve implantation (TPVI) have been widely described. The purpose of this article is to provide an update on current valve technology, and to focus on recent data surrounding TPVI in the dilated right ventricular outflow tract (RVOT), hybrid interventions, significant outcomes, and procedural costs. RECENT FINDINGS Transcatheter valve technology has expanded with current trials evaluating self-expandable valves that can be implanted in dilated RVOTs. Until those valves are widely available, hybrid techniques have been shown to offer a potential alternative in these patients, as well as in patients of small size. Although medium-term results of TPVI have shown 5-year freedom from reintervention or replacement of 76%, new data have underlined some concerns relating to bacterial endocarditis after the procedure. Procedural costs remain a concern, but vary greatly between institutions and healthcare systems. SUMMARY TPVI has emerged as one of the most innovative procedures in the treatment of patients with dysfunctional RVOT and pulmonary valves. Further device development is likely to expand the procedure to patients of smaller size and with complex, dilated RVOTs.
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42
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Yang HS. Three-dimensional echocardiography in adult congenital heart disease. Korean J Intern Med 2017; 32:577-588. [PMID: 28704916 PMCID: PMC5511944 DOI: 10.3904/kjim.2016.251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 06/16/2017] [Indexed: 12/27/2022] Open
Abstract
Congenital heart disease (CHD) is now more common in adults than in children due to improvements in fetal echo, neonatal and pediatric care, and surgical techniques leading to dramatically increased survivability into adulthood. Adult patients with CHD, regardless of prior cardiac surgery, experience further cardiac problems or therapeutic challenges; therefore, a non-invasive, easily accessible echocardiographic examination is an essential follow-up tool. Among echocardiographic modalities, three-dimensional (3D) echocardiography provides better delineation of spatial relationships in complex cardiac geometries and more accurate volumetric information without geometric assumptions. For atrial septal defects, an en face view of the tissue defect allows better decisions on device closure. For tricuspid valve malformations, an en face view provides diagnostic information that is difficult to obtain from routine 2D tomography. In repaired tetralogy of fallot with pulmonary regurgitation, preoperative 3D echocardiography- based right ventricular volume may be used to determine the timing of a pulmonary valve replacement in conjunction with cardiovascular magnetic imaging. For optimal adult CHD care, 3D echocardiography is an important complement to routine 2D echocardiography.
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Affiliation(s)
- Hyun Suk Yang
- Correspondence to Hyun Suk Yang, M.D. Division of Cardiovascular Medicine, Department of Internal Medicine, Konkuk University Medical Center, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea Tel: +82-2-2030-7519 Fax: +82-2-2030-7748 E-mail:
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43
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Hemolytic Anemia due to Right Ventricular to Pulmonary Artery Conduit Stenosis. J Pediatr Hematol Oncol 2017; 39:e290-e292. [PMID: 28267085 DOI: 10.1097/mph.0000000000000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hemolytic anemia is a well-recognized complication in patients with left-sided mechanical heart valves. It is rare to see hemolysis with a bioprosthetic valve in the right ventricular outflow tract. We report a 4-year-old-girl with history of truncus arteriosus status-post repair who developed hemolytic anemia as a result of a calcified and obstructed bioprosthetic right ventricular to pulmonary artery-valved conduit. The hemolysis was alleviated by replacing the obstructed conduit with a larger valved conduit.
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44
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Bhagra CJ, Hickey EJ, Van De Bruaene A, Roche SL, Horlick EM, Wald RM. Pulmonary Valve Procedures Late After Repair of Tetralogy of Fallot: Current Perspectives and Contemporary Approaches to Management. Can J Cardiol 2017; 33:1138-1149. [PMID: 28843325 DOI: 10.1016/j.cjca.2017.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 11/18/2022] Open
Abstract
Few topics in adult congenital heart disease have approached the level of scrutiny bestowed on pulmonary valve replacement (PVR) strategies late after tetralogy of Fallot (TOF) repair. Despite the successes of primary surgery for TOF, there is a growing group of adults with residual right ventricular outflow tract and pulmonary valve dysfunction. Patients with residual chronic pulmonic regurgitation as a consequence of earlier surgery can later develop symptoms of exercise intolerance and complications including heart failure, tachyarrhythmias, and sudden cardiac death. Optimal timing of PVR has sparked debate, which has catalyzed increasing research efforts over the past decade. Although performance of PVR in the absence of symptoms is currently on the basis of the rationale that achievement of complete reverse remodelling is highly desirable, whether this approach results in improvement in patient outcomes in the long-term has yet to be shown. Surgical PVR and percutaneous pulmonary valve intervention are different techniques with specific advantages and disadvantages that require careful consideration for each individual patient, alongside the need for requisite reinterventions over the course of a patient's lifetime. Criteria pertaining to referral strategies are ever being refined as newer technologies for percutaneous therapies continue to evolve. In this article we review the literature surrounding the indications for, the optimal timing of, and the approaches to pulmonary valve procedures in adults with previously repaired TOF.
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Affiliation(s)
- Catriona J Bhagra
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Cambridge University and Papworth NHS Foundation Trusts, Cambridge, United Kingdom
| | - Edward J Hickey
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alexander Van De Bruaene
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - S Lucy Roche
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eric M Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rachel M Wald
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Affiliation(s)
- Erle H Austin
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Norton Children's Hospital, Louisville, Ky.
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Dobbels B, Herregods MC, Troost E, Van De Bruaene A, Rega F, Budts W, De Meester P. Early versus late pulmonary valve replacement in patients with transannular patch-repaired tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2017; 25:427-433. [DOI: 10.1093/icvts/ivx118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/25/2017] [Indexed: 01/18/2023] Open
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García Vieites M, Portela Torrón F, Bautista Hernández V, Fernández Arias L, Vásquez Echeverri D, Martínez Bendayán I, Bouzas Zubeldía B, Cuenca Castillo JJ. Resultados del recambio valvular pulmonar según el tipo de prótesis implantada. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.10.010] [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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¿Funcionan igual las prótesis pulmonares porcinas en menores de edad que en adultos? Una llamada a la prudencia. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Prótesis pulmonar porcina versus yugular bovina para reparar el tracto de salida del ventrículo derecho en menores con cardiopatía congénita. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Ottaviani G, Buja LM. Update on congenital heart disease and sudden infant/perinatal death: from history to future trends. J Clin Pathol 2017; 70:555-562. [DOI: 10.1136/jclinpath-2017-204326] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/05/2017] [Accepted: 03/08/2017] [Indexed: 11/04/2022]
Abstract
During the 20th century, expert pathologists contributed an in-depth characterisation of the anatomical pathology and associated pathophysiology of congenital heart disease (CHD). Starting in the 1970s, the reported CHD birth prevalence has been increasing, owing to advances in diagnostic methods. Over the years, surgical treatments have been associated with an enormous reduction of CHD mortality. Advances also have been made in understanding the developmental biology and molecular pathogenesis of CHD. In developed countries, sudden infant death syndrome (SIDS) is the most frequent form of death during the first year of life, with a death rate of 0.42 every 1000 births. Unexpected stillbirth has a six- to eightfold greater incidence than that of SIDS and remains unexplained in 40–80% of cases even after autopsy. Specific environmental risk factors, such as maternal smoking, air and water pollution, food contamination, pesticides, etc, can interact with the genetic constitution in complex ways, which may lead to polymorphisms and/or mutations of specific genes, such as polymorphisms in the serotonin transporter gene 5-HTT, the regulator of the synaptic serotonin concentration. Current directions of research in this area are reviewed.
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