Neonatal quadricuspid truncal valve repair with left coronary artery unroofing

State of the Art Review: Aortic Valve Repair in Infants and Children

BACKGROUND

Congenital aortic and truncal valve disease is challenging in infants and children given the lack of available prostheses in very small sizes and the limited durability of homograft aortic valve replacement.

METHODS

A comprehensive literature search was performed using the PubMed database. Studies were included either if the report included patients less than 1 year of age or if the technique was tailored to accommodate for somatic growth.

RESULTS

Techniques for aortic and truncal valve repair addressing each aspect of the aortic valve complex-the aorta, aortic annulus, commissures, and cusps-were reviewed. The incidence of reoperation after aortic or truncal valve repair is significant at 10 years and ranges from 30% to 70% depending on the underlying diagnosis and the repair technique used. A significant challenge in interpreting the published literature relates to the lack of anatomic data available in the publications, thus limiting both the ability to make direct comparisons among operative techniques and the ability to draw conclusions regarding these techniques as applied to varied causes.

CONCLUSIONS

A comprehensive understanding of the aortic valve complex is necessary to achieve adequate results in pediatric aortic valve repair given the high variability in these valves.

Surgical repair of severely incompetent quadricuspid truncal valve

The surgical management of truncus arteriosus poses a constant challenge for the cardiac team treating the patient. A correct diagnosis, surgical therapy and post-operative management are crucial for the survival of the patient. Almost 30% of the patients show an abnormal number of leaflets in the truncal valve (TV), the majority being quadricuspid valves. Additionally, around 25% of the patients show some degree of TV incompetence. We demonstrate an effective way to reconstruct incompetent, quadricuspid valves with good post-operative outcome.

Long-term outcomes following repair of truncus arteriosus and interrupted aortic arch

OBJECTIVES

We aim to evaluate the long-term outcomes following repair of truncus arteriosus with an interrupted aortic arch.

METHODS

We reviewed all children (n = 24) who underwent repair of truncus arteriosus and an interrupted aortic arch between 1979 and 2018 in a single institution. The morphology of the interrupted aortic arch was type A in 5, type B in 18 and type C in 1.

RESULTS

The median age at repair was 10 days and the median weight was 3.1 kg. Direct end-to-side anastomosis of the ascending and descending aorta was performed in 16 patients (67%, 16/24), patch augmentation in 5 patients (21%, 5/24) and direct anastomosis with the use of an interposition graft to the descending aorta in 2 patients (8%, 2/24). One patient, the first in the series, underwent interrupted aortic arch repair via subclavian flap aortoplasty prior to truncus repair. A period of deep hypothermic circulatory arrest was used in 16 patients, and isolated cerebral perfusion was used in 8 patients. The early mortality rate was 17% (4 out of 24 patients). There were no late deaths and overall survival was 83 ± 8% [95% confidence interval (CI) 61-93] at 20 years. Freedom from any reoperation was 33 ± 11% (95% CI 14-54) at 5 years and 13 ± 9% (95% CI 2-34) at 10 years. Six patients underwent 10 aortic reoperations. Freedom from aortic arch reoperation was 69 ± 11% (95% CI 42-85) at 10 and 20 years. Follow-up was 95% complete (19/20), with a median follow-up time of 20 years. At last follow-up, no clinically significant aortic arch obstruction was identified in any patient, and all patients were in New York Heart Association Class I/II.

CONCLUSIONS

Repair of truncus arteriosus with an interrupted aortic arch with direct end-to-side anastomosis results in good survival beyond hospital discharge. Although the long-term functional state of patients is good, reoperation rates are high.

Long-Term Fate of the Truncal Valve

Background Long-term survival in patients with truncus arteriosus is favorable, but there remains significant morbidity associated with ongoing reinterventions. We aimed to study the long-term outcomes of the truncal valve and identify risk factors associated with truncal valve intervention. Methods and Results We retrospectively reviewed patients who underwent initial truncus arteriosus repair at our institution from 1985 to 2016. Analysis was performed on the 148 patients who were discharged from the hospital and survived ≥30 days postoperatively using multivariable competing risks Cox regression modeling. Median follow-up time was 12.6 years (interquartile range, 5.0-22.1 years) after discharge from full repair. Thirty patients (20%) underwent at least one intervention on the truncal valve during follow-up. Survival at 1, 10, and 20 years was 93.1%, 87.0%, and 80.9%, respectively. The cumulative incidence of any truncal valve intervention by 20 years was 25.6%. Independent risk factors for truncal valve intervention included moderate or greater truncal valve regurgitation (hazard ratio [HR], 4.77; P<0.001) or stenosis (HR, 4.12; P<0.001) before full truncus arteriosus repair and moderate or greater truncal valve regurgitation at discharge after full repair (HR, 8.60; P<0.001). During follow-up, 33 of 134 patients (25%) progressed to moderate or greater truncal valve regurgitation. A larger truncal valve root z-score before truncus arteriosus full repair and during follow-up was associated with worsening truncal valve regurgitation. Conclusions Long-term rates of truncal valve intervention are significant. At least moderate initial truncal valve stenosis and initial or residual regurgitation are independent risk factors associated with truncal valve intervention. Larger truncal valve root z-score is associated with significant truncal valve regurgitation and may identify a subset of patients at risk for truncal valve dysfunction over time.

Surgery for Truncus Arteriosus: Contemporary Practice

Surgery for truncus arteriosus has an early mortality of 3% to 20%, with a long-term survival of approximately 75% at 20 years. Nowadays, truncus arteriosus repair is mostly done in the neonatal period together with a single-staged repair of concomitant cardiovascular anomalies. There are many challenging subgroups of patients with truncus arteriosus, including those with clinically significant truncal valve insufficiency, an interrupted aortic arch, or a coronary artery anomaly. In fact, truncal valve competency appears to be the most important factor influencing the outcomes after truncus arteriosus repair. The use of a conduit during truncus arteriosus repair invariably requires reoperation on the right ventricular outflow tract. Through improvements in perioperative techniques over time, many children are now living well into adulthood after repair of truncus arteriosus, albeit with a high rate of reoperation. Despite this, the long-term outcomes of truncus arteriosus repair are good, with many patients being asymptomatic and with a quality of life comparable to the general population.

Rare Association of an Intramural Coronary Artery and Truncus Arteriosus

The association of truncus arteriosus (TA) and an intramural coronary artery is rare. Seven (7) patients had TA and an intramural coronary artery at the Royal Children's Hospital, Melbourne between 1996 and 2018. Four (4) patients underwent concomitant unroofing of their intramural coronary artery. One (1) patient who did not undergo concomitant unroofing had a cardiac arrest on postoperative day 1 and subsequently underwent reoperation for coronary unroofing. Given the potential for serious complications, patients with TA and an intramural coronary artery may benefit from coronary unroofing with creation of a generous neo-ostium.

Truncus arteriosus repair: A 40-year multicenter perspective

OBJECTIVE

To examine the long-term surgical outcomes of patients who underwent truncus arteriosus (TA) repair.

METHODS

Between 1979 and 2018, a total of 255 patients underwent TA repair at 3 Australian hospitals. Data were obtained by review of medical records from initial admission until last cardiology follow-up.

RESULTS

At the time of TA repair, the median patient age was 44 days, and median weight was 3.5 kg. Early mortality was 13.3% (34 of 255), and overall survival was 76.8 ± 2.9% at 20 years. Neonatal surgery and low operative weight were risk factors for early mortality. Most deaths (82.5%; 47 of 57) occurred within the first year following repair. A coronary artery anomaly and early reoperation were identified as risk factors for late mortality. A total of 175 patients required at least 1 reoperation, with overall freedom of reoperation of 2.9 ± 1.5% at 20 years. Follow-up of survivors was 96% complete (191 of 198). The median duration of follow-up was 16.4 years. At the last follow-up, 190 patients were categorized as New York Heart Association class I/II, and 1 patient was class III.

CONCLUSIONS

TA repair during the neonatal period presents significant surgical challenges. Neonates with signs of overcirculation should be operated on promptly. A coronary artery anomaly is a risk factor for late mortality. Survival beyond the first year following repair is associated with excellent outcomes.

The quadricuspid truncal valve: Surgical management and outcomes

OBJECTIVE

To determine the outcomes of patients with a quadricuspid truncal valve (TV) and durability of TV repair.

METHOD

We reviewed 56 patients with truncus arteriosus and a quadricuspid TV who underwent complete repair between 1979 and 2018.

RESULTS

TV insufficiency was present in 39 patients (mild, n = 22; moderate, n = 14; and severe, n = 3). Fourteen patients had concomitant TV surgery. Early mortality in patients who had concomitant TV surgery was 14% (2 out of 14 patients) and overall survival was 77.1% ± 11.7% at 15 years. Freedom from TV reoperation was 30.3% ± 14.6% at 15 years. Early mortality in patients who did not undergo concomitant TV surgery was 9.5% (4 out of 42 patients) and overall survival was 74.9% ± 6.9% at 15 years. Progression of TV insufficiency requiring TV surgery occurred in 16.7% (7 out of 42 patients). Freedom from TV reoperation was 77.1% ± 7.8% at 15 years. The most common method of repair was tricuspidization of the TV. Freedom from TV reoperation was 64.3% ± 21.0% at 10 years after tricuspidization and 0% at 6 years after other types of TV surgery. Overall follow-up was 97.6% (41 out of 42 patients) complete for survivors with median follow-up of 16.6 years. At last follow-up there was no TV insufficiency in 16 patients, mild insufficiency in 24 patients, and moderate insufficiency in 1 patient.

CONCLUSIONS

More than one-third of patients with a quadricuspid TV require TV surgery. Tricuspidization of the quadricuspid TV appears to be a durable repair option with good long-term outcomes.