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Hussain AM, Younes MA. Early outcomes of experience warm surgery in children undergoing complete repair of tetralogy of Fallot in developing countries. BMC Pediatr 2024; 24:499. [PMID: 39097678 PMCID: PMC11297559 DOI: 10.1186/s12887-024-04976-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
OBJECTIVES While significant evidence supports the benefits of normothermic cardiopulmonary bypass (NCPB) over hypothermic techniques, many institutions in developing countries, including ours, continue to employ hypothermic methods. This study aimed to assess the early postoperative outcomes of normothermic cardiopulmonary bypass (NCPB) for complete surgical repair via the Tetralogy of Fallot (TOF) within our national context. METHODS We conducted this study in the Pediatric Cardiac Intensive Care Unit (PCICU) at the University Children's Hospital. One hundred patients who underwent complete TOF repair were enrolled and categorized into two groups: the normothermic group (n = 50, temperature 35-37 °C) and the moderate hypothermic group (n = 50, temperature 28-32 °C). We evaluated mortality, morbidity, and postoperative complications in the PCICU as outcome measures. RESULTS The demographic characteristics were similar between the two groups. However, the cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were notably longer in the hypothermic group. The study recorded seven deaths, yielding an overall mortality rate of 7%. No significant differences were observed between the two groups concerning mortality, morbidity, or postoperative complications in the PCICU. CONCLUSIONS Our findings suggest that normothermic procedures, while not demonstrably effective, are safe for pediatric cardiac surgery. Further research is warranted to substantiate and endorse the adoption of this technique.
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Affiliation(s)
- Alaa Mohamad Hussain
- University Children's Hospital, Damascus University, Damascus, Syrian Arab Republic.
| | - Mohammad Ali Younes
- University Children's Hospital, Damascus University, Damascus, Syrian Arab Republic.
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2
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Singh M, Roubertie F, Ozturk C, Borchiellini P, Rames A, Bonnemain J, Gollob SD, Wang SX, Naulin J, El Hamrani D, Dugot-Senant N, Gosselin I, Grenet C, L'Heureux N, Roche ET, Kawecki F. Hemodynamic evaluation of biomaterial-based surgery for Tetralogy of Fallot using a biorobotic heart, in silico, and ovine models. Sci Transl Med 2024; 16:eadk2936. [PMID: 38985852 DOI: 10.1126/scitranslmed.adk2936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/12/2024] [Accepted: 06/20/2024] [Indexed: 07/12/2024]
Abstract
Tetralogy of Fallot is a congenital heart disease affecting newborns and involves stenosis of the right ventricular outflow tract (RVOT). Surgical correction often widens the RVOT with a transannular enlargement patch, but this causes issues including pulmonary valve insufficiency and progressive right ventricle failure. A monocusp valve can prevent pulmonary regurgitation; however, valve failure resulting from factors including leaflet design, morphology, and immune response can occur, ultimately resulting in pulmonary insufficiency. A multimodal platform to quantitatively evaluate the effect of shape, size, and material on clinical outcomes could optimize monocusp design. This study introduces a benchtop soft biorobotic heart model, a computational fluid model of the RVOT, and a monocusp valve made from an entirely biological cell-assembled extracellular matrix (CAM) to tackle the multifaceted issue of monocusp failure. The hydrodynamic and mechanical performance of RVOT repair strategies was assessed in biorobotic and computational platforms. The monocusp valve design was validated in vivo in ovine models through echocardiography, cardiac magnetic resonance, and catheterization. These models supported assessment of surgical feasibility, handling, suturability, and hemodynamic and mechanical monocusp capabilities. The CAM-based monocusp offered a competent pulmonary valve with regurgitation of 4.6 ± 0.9% and a transvalvular pressure gradient of 4.3 ± 1.4 millimeters of mercury after 7 days of implantation in sheep. The biorobotic heart model, in silico analysis, and in vivo RVOT modeling allowed iteration in monocusp design not now feasible in a clinical environment and will support future surgical testing of biomaterials for complex congenital heart malformations.
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Affiliation(s)
- Manisha Singh
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - François Roubertie
- IHU Liryc, Electrophysiology and Heart Modeling Institute, F-33604 Pessac, France
- Congenital Heart Diseases Department, CHU de Bordeaux, F-33604 Pessac, France
| | - Caglar Ozturk
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Paul Borchiellini
- University of Bordeaux, INSERM, BioTis, U1026, F-33000 Bordeaux, France
| | - Adeline Rames
- University of Bordeaux, INSERM, BioTis, U1026, F-33000 Bordeaux, France
| | - Jean Bonnemain
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Samuel Dutra Gollob
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Sophie X Wang
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Jérôme Naulin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, F-33604 Pessac, France
| | - Dounia El Hamrani
- IHU Liryc, Electrophysiology and Heart Modeling Institute, F-33604 Pessac, France
| | - Nathalie Dugot-Senant
- Plateforme d'histopathologie, TBMcore INSERM US005-CNRS 3427, F-33000 Bordeaux, France
| | - Isalyne Gosselin
- Plateforme d'histopathologie, TBMcore INSERM US005-CNRS 3427, F-33000 Bordeaux, France
| | - Célia Grenet
- University of Bordeaux, INSERM, BioTis, U1026, F-33000 Bordeaux, France
| | - Nicolas L'Heureux
- University of Bordeaux, INSERM, BioTis, U1026, F-33000 Bordeaux, France
| | - Ellen T Roche
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Fabien Kawecki
- University of Bordeaux, INSERM, BioTis, U1026, F-33000 Bordeaux, France
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Khainza RE, Oketcho M, Aliku T, Namuyonga J, Ndagire E, Mwambu T, Muhoozi RM, Obongnyinge B, Tumwebaze H, Mbabazi N, Akech T, Nakato A, Killen A, Ofumbi GO, Lwabi P, Omagino J, Lubega S. Primary surgical repair of tetralogy of fallot at the Uganda Heart Institute: a ten-year review of 30day mortality and morbidity. BMC Cardiovasc Disord 2024; 24:322. [PMID: 38918721 PMCID: PMC11202334 DOI: 10.1186/s12872-024-03991-z] [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] [Received: 12/24/2023] [Accepted: 06/19/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) worldwide. It accounts for 7% of CHD cases in Uganda and leads to fatal outcomes in the long term without surgery. Surgery is often delayed in developing countries like Uganda due to limited resources. OBJECTIVE This study aimed to determine the early surgical outcomes of patients with TOF who underwent primary intracardiac repair at the Uganda Heart Institute (UHI) and to identify factors associated. METHODOLOGY This retrospective chart review evaluated outcomes of primary TOF repair patients at UHI from February 2012 to October 2022. Patient outcomes were assessed from surgery until 30 days post-operation. RESULTS Out of the 104 patients who underwent primary TOF repair at UHI, records of 88 patients (84.6%) were available for review. Males accounted for 48.9% (n = 43). The median age at the time of operation was 4 years (with an interquartile range of 2.5-8.0 years), ranging from 9 months to 16 years. Genetic syndromes were present in 5/88 (5.7%). These included 2 patients with trisomy 21, 2 with Noonan's, and 1 with 22q11.2 deletion syndrome. Early postoperative outcomes for patients included: residual ventricular septal defects in 35/88 (39.8%), right ventricular dysfunction in 33/88 (37.5%), residual pulmonary regurgitation in 27/88 (30.7%), residual right ventricular outflow tract obstruction in 27/88 (30.0%), pleural effusion in 24/88 (27.3%), arrhythmias in 24/88(27.3%), post-operative infections in 23/88(26.1%) and left ventricular systolic dysfunction in 9/88 (10.2%). Out of the children who underwent surgery after one year of age, 8% (7 children) died within the first 30 days. There was a correlation between mortality and post-operative ventilation time, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, preoperative oxygen saturations, RV and LV dysfunction and the operating team. CONCLUSION The most frequent outcomes after surgery were residual ventricular septal defects and right ventricular failure. In our study, the 30-day mortality rate following TOF repair was 8%. Deceased patients had lower pre-operative oxygen levels, longer CPB and cross-clamp times, longer post-operative ventilation, RV/LV dysfunction, and were more likely operated by the local team.
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Affiliation(s)
- Rebecca Esther Khainza
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda.
- Department of paediatrics, Mulago National Referral Hospital, Kampala, Uganda.
| | - Michael Oketcho
- Department of Cardiovascular and Thoracic Surgery UHI, Kampala, Uganda
| | - Twalib Aliku
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
- Uganda Christian University School of Medicine, Mukono, Uganda
| | - Judith Namuyonga
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
- Department of Paediatrics, Makerere University, Kampala, Uganda
| | - Emma Ndagire
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | - Tom Mwambu
- Department of Cardiovascular and Thoracic Surgery UHI, Kampala, Uganda
| | | | - Bernard Obongnyinge
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | - Hilda Tumwebaze
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | - Nestor Mbabazi
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
- Department of paediatrics, Mulago National Referral Hospital, Kampala, Uganda
| | - Teddy Akech
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | - Aisha Nakato
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | - Angelline Killen
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | | | - Peter Lwabi
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
| | - John Omagino
- Department of Cardiovascular and Thoracic Surgery UHI, Kampala, Uganda
| | - Sulaiman Lubega
- Department of Paediatric Cardiology, Uganda Heart Institute (UHI), Kampala, Uganda
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Flores-Umanzor E, Alshehri B, Keshvara R, Wilson W, Osten M, Benson L, Abrahamyan L, Horlick E. Transcatheter-Based Interventions for Tetralogy of Fallot Across All Age Groups. JACC Cardiovasc Interv 2024; 17:1079-1090. [PMID: 38749587 DOI: 10.1016/j.jcin.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 05/26/2024]
Abstract
Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. Palliative procedures, either surgical or transcatheter, aim to improve oxygen saturation, affording definitive procedures at a later stage. Transcatheter interventions have been used before and after surgical palliative or definitive repair in children and adults. This review aims to provide an overview of the different catheter-based interventions for TOF across all age groups, with an emphasis on palliative interventions, such as patent arterial duct stenting, right ventricular outflow tract stenting, or balloon pulmonary valvuloplasty in infants and children and transcatheter pulmonary valve replacement in adults with repaired TOF, including the available options for a large, dilated native right ventricular outflow tract.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Bandar Alshehri
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - William Wilson
- Royal Melbourne Hospital Cardiology, Parkville, Victoria, Australia
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Lee Benson
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; The Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children, The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
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5
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Ishigami S, Ye XT, Buratto E, Ivanov Y, Chowdhuri KR, Fulkoski N, Robertson T, Davies B, Brizard CP, Konstantinov IE. Long-term outcomes of tetralogy of Fallot repair: A 30-year experience with 960 patients. J Thorac Cardiovasc Surg 2024; 167:289-302.e11. [PMID: 37169063 DOI: 10.1016/j.jtcvs.2023.04.015] [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: 02/14/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE This study evaluates the long-term results of tetralogy of Fallot repair and assesses the risk factors for adverse outcomes. METHODS This retrospective study included 960 patients who underwent transatrial transpulmonary tetralogy of Fallot repair between 1990 and 2020. RESULTS A transannular patch was placed in 722 patients, and pulmonary valve preservation was achieved in 233 patients. The median age at tetralogy of Fallot repair was 9.4 (interquartile range, 6.2-14.2) months. The median follow-up duration was 10.6 (interquartile range, 5.4-16.3) years. There were 8 early deaths (0.8%) and 20 late deaths (2.1%). Genetic syndrome and pulmonary valve annulus Z score less than -3 were risk factors for mortality. The survival was 97.7% (95% confidence interval, 96.4-98.5) and 94.5% (95% confidence interval, 90.9-96.7) at 10 and 30 years, respectively. Freedom from any reoperation was 86.4% (95% confidence interval, 83.6-88.7) and 65.4% (95% confidence interval, 59.8-70.4) at 10 and 20 years, respectively. Postoperative right ventricular outflow tract peak gradient of 25 mm Hg or greater correlated with reoperation. Propensity score-matched analysis demonstrated that freedom from pulmonary valve replacement at 15 years was higher in the pulmonary valve preservation group compared with the transannular patch group (98.2% vs 78.4%, P = .004). Freedom from reoperation for right ventricular outflow tract obstruction at 15 years was lower in the pulmonary valve preservation group compared with the transannular patch group (P = .006). CONCLUSIONS The long-term outcomes of tetralogy of Fallot repair are excellent. A postoperative right ventricular outflow tract peak gradient less than 25 mm Hg appears to be optimal to prevent reoperation. If the pulmonary valve size is suitable, pulmonary valve preservation reduces the risk of pulmonary valve replacement, yet increases the reoperation rate for right ventricular outflow tract obstruction.
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Affiliation(s)
- Shuta Ishigami
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Xin Tao Ye
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Yaroslav Ivanov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kuntal Roy Chowdhuri
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nick Fulkoski
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Terry Robertson
- Department of Cardiology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Ben Davies
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; The Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; The Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; The Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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6
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Henmi S, Ryan JA, Mehta R, Haverty MC, Hovis IW, Puente BN, Ozturk M, Desai M, Tongut A, Yerebakan C, d'Udekem Y. A uniform strategy of primary repair of tetralogy of Fallot: Transventricular approach results in low reoperation rate in the first decade. J Thorac Cardiovasc Surg 2023; 166:1731-1738.e3. [PMID: 37301251 DOI: 10.1016/j.jtcvs.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To review outcomes after a uniform strategy of transventricular repair of tetralogy of Fallot. METHODS A total of 244 consecutive patients underwent transventricular primary repair of tetralogy of Fallot from 2004 to 2019. Median age at operation was 71 days; 57 (23%) patients were premature; 57 (23%) patients had low birth weight (<2.5 kg), and 40 (16%) had genetic syndromes. The diameter of pulmonary valve annulus, right pulmonary artery (PA), and left PA were 6.0 ± 1.8 mm (z score, -1.7 ± 1.3), 4.3 ± 1.4 mm (z score, -0.9 ± 1.2) and 4.1 ± 1.5 mm (z score, -0.5 ± 1.3). RESULTS Three (1.2%) operative deaths were recorded. Ninety patients (37%) underwent transannular patching. Postoperative echocardiographic peak right ventricular outflow tract gradient decreased from 72 ± 27 mm Hg to 21 ± 16 mm Hg. Median intensive care unit and hospital stay were 3 and 7 days. The survival rate at 10 years was 94.6% ± 1.8%. Reintervention was required 86 times (55 catheter interventions) in 56 patients following tetralogy of Fallot repair. The freedom from all-cause reintervention rate at 10 years was 70.5% ± 3.6%. Cyanotic spells (hazard ratio, 2.14; 95% CI, 1.22-3.90; P < .01) and smaller pulmonary valve annulus z score (hazard ratio, 1.26; 95% CI, 1.01-1.59; P = .04) were associated with increasing risk of all reinterventions. Freedom from redo surgery for right ventricular outflow tract obstruction and right ventricular dilatation at 10 years were, respectively, 85.0% ± 3.1% and 98.7% ± 0.9%. Freedom from valve implantation was 96.7% ± 1.5% at 10 years. CONCLUSIONS A uniform strategy of primary repair of tetralogy of Fallot through a transventricular approach resulted in low reoperation rate in the first decade. The need of pulmonary valve implantation was limited to <4% at 10 years.
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Affiliation(s)
- Soichiro Henmi
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Julia A Ryan
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Rittal Mehta
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Mitchell C Haverty
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Ian W Hovis
- Division of Cardiology, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Bao Nguyen Puente
- Division of Cardiac Critical Care Medicine, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Mahmut Ozturk
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Manan Desai
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Aybala Tongut
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Can Yerebakan
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC
| | - Yves d'Udekem
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Science, Washington, DC.
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7
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Moore JP, Shannon KM, Khairy P, Waldmann V, Bessière F, Burrows A, Su J, Shivkumar K. Sinus rhythm QRS morphology reflects right ventricular activation and anatomical ventricular tachycardia isthmus conduction in repaired tetralogy of Fallot. Heart Rhythm 2023; 20:1689-1696. [PMID: 37598989 DOI: 10.1016/j.hrthm.2023.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Patients with repaired tetralogy of Fallot (TOF) are at risk for ventricular tachycardia (VT) related to well-described anatomical isthmuses. OBJECTIVE The purpose of this study was to explore QRS morphology as an indicator of anatomical isthmus conduction. METHODS Patients with repaired TOF and complete right bundle branch block referred for transcatheter pulmonary valve replacement (PVR) or presenting with sustained VT underwent comprehensive 3-dimensional mapping in sinus rhythm. Electrocardiographic characteristics were compared to right ventricular (RV) activation and anatomical isthmus conduction properties. RESULTS Twenty-two patients (19 pre-pulmonary valve replacement and 3 clinical VT) underwent comprehensive 3-dimensional mapping (median 39 years; interquartile range [IQR] 27-48 years; 12 [55%] male). Septal RV activation (median 40 ms; IQR 34-46 ms) corresponded to the nadir in lead V1 and free wall activation (median 71 ms; IQR 64-81 ms) to the transition point in the upstroke of the R' wave. Patients with isthmus block between the pulmonary annulus and the ventricular septal defect patch and between the ventricular septal defect patch and the tricuspid annulus (when present), were more likely to demonstrate lower amplitude R' waves in lead V1 (5.8 mV vs 9.4 mV; P = .005), QRS fragmentation in lead V1 (15 [94%] vs 2 [13%]; P < .001), and terminal S waves in lead aVF (15 [94%] vs 6 [40%]; P < .001) than those with intact conduction. During catheter ablation, these QRS changes developed during isthmus block. CONCLUSION For patients with repaired TOF, the status of septal isthmus conduction was evident from sinus rhythm QRS morphology. Low-amplitude, fragmented R' waves in lead V1 and terminal S waves in the inferior leads were related to septal isthmus conduction abnormalities, providing a mechanistic link between RV activation and common electrocardiographic findings.
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Affiliation(s)
- Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California.
| | - Kevin M Shannon
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Victor Waldmann
- Université Paris Cité, Inserm, PARCC, Paris, France; Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, Paris, France; M3C-Necker, Hôpital Universitaire Necker-Enfants malades, APHP, Paris, France
| | - Francis Bessière
- Cardiac Electrophysiology Unit, European Georges Pompidou Hospital, Paris, France; Louis Pradel Hospital, Hospices Civils de Lyon, Université Lyon 1 Claude Bernard, Lyon, France
| | - Austin Burrows
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Jonathan Su
- Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
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8
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Wasiak A, Jaworski R, Pastuszko A, Birbach M, Kozlowski M, Mirkowicz-Malek M, Friedman-Gruszczynska J, Maruszewski B, Kansy A. Outcomes of Transannular Repair of Tetralogy of Fallot With a Contegra ® Monocuspid Patch. World J Pediatr Congenit Heart Surg 2023; 14:427-432. [PMID: 37097897 DOI: 10.1177/21501351231162902] [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: 04/26/2023]
Abstract
BACKGROUND Surgical repair of tetralogy of Fallot (ToF) depends on the anatomical variations of the heart defect. A group of patients with a hypoplastic pulmonary valve annulus required a transannular patch. This study aimed to evaluate the early and late outcomes of ToF repair with a transannular Contegra® monocuspid patch in a single center. METHODS A retrospective review of medical records was conducted. This study included 224 children with a median age of 13 months who underwent ToF repair with a Contegra® transannular patch in over 20 years of observation. The primary outcomes were hospital mortality and need for early reoperations. The secondary outcomes were late death and event-free survival. RESULTS The hospital mortality in our group was 3.1%, whereas two patients required early reoperation. Three patients were excluded from the study because follow-up data were not available. In the remaining group of patients (212 patients), the median follow-up was 116 (range, 1-206) months. One patient died because of sudden cardiac arrest at home six months after surgery. Event-free survival was observed in 181 patients (85.4%), whereas the remaining 30 patients (14.1%) required graft replacement. The median time to reoperation was 99 (range, 4-183) months. CONCLUSIONS Although surgical treatment of ToF has been performed for more than 60 years worldwide, the optimal approach in children with a hypoplastic pulmonary valve annulus remains debatable. Among options, the Contegra® monocuspid patch can be effectively used in transannular repair of ToF with good long-term results.
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Affiliation(s)
- Aleksandra Wasiak
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Radoslaw Jaworski
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Andrzej Pastuszko
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Mariusz Birbach
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Michal Kozlowski
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | | | | | - Bohdan Maruszewski
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Kansy
- Department of Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
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9
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Khan MS, Jan A, Ahmed H, Khan M, Khan AD, Shakil R, Khan B, Aman Z, Ali WS, Mahmood A. Outcomes of Surgical Repair of Tetralogy of Fallot: A Comparison Between the Adult and Pediatric Population. Cureus 2023; 15:e41467. [PMID: 37546072 PMCID: PMC10404136 DOI: 10.7759/cureus.41467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Early detection and timely treatment have provided successful repair of the anomaly in the developed world. However, in the developing world, there is still a burden of uncorrected TOF patients reaching adulthood. The goal of this study is to determine whether there is any difference in postoperative complications between adult and pediatric populations following surgical correction for TOF. Methods This study involved all those patients who received primary or secondary surgical repair for TOF in our facility between January 2017 and December 2020. The patients were split according to their age into the pediatric group if they were under 18 years and the adult group if they were 18 years or older. Patients with absent pulmonary valve or pulmonary atresia were not included in this study. Patients with large major aortopulmonary collateral arteries (MAPCA) were also excluded from this study. All patients underwent total correction through a median sternotomy approach. The ventricular septal defect was closed with a Bard knitted fiber patch. The right ventricular outflow tract (RVOT) was augmented by excising muscle bands or fibrous bands in the RVOT. If the annulus was smaller than the 3.5 z score, then a transannular patch was done using an autologous pericardium. The main pulmonary artery was augmented in every surgery using an autologous pericardial patch. All patients were shifted to the ICU on the ventilator and were extubated after fulfillment of the extubation criteria. Postoperative complications measured included re-opening, re-intubation, prolonged ventilation (>24 hours), and mortality within the index hospital admission. The clinical data of all patients were prospectively collected and analyzed using the chi-square test and t-test. A p-value of less than or equal to 0.05 was considered significant. Results The total number of patients was 134. This included 83 males (60.1%). A total of 114 patients who were aged below 18 years were included in the pediatric group, and 20 patients aged equal to or more than 18 years were included in the adult group. The mean average perfusion time in minutes in the adult group was 125.8 and in the pediatric group, it was 98.79. Similarly, the mean average of the cross-clamp time was also longer in the adult group at 89.55 minutes versus 69.63 minutes in the pediatric group. Overall, in the adult group, three (15%) patients had postoperative complications, while in the pediatric group, a total of 14 (11.9%) patients had postoperative complications (p = 0.001). However, there was no significant difference in the number of re-openings (8.5% vs. 10%; p = 0.8). The total mortality observed was 16 (11.59%). This included 14 (11.9%) in the pediatric group and two (10%) in the adult group. There was no significant difference between the two groups (p = 0.8). Conclusions Surgical repair of TOF can be performed in both adult and pediatric populations with acceptable outcomes. The mortality rate was found to be slightly greater in the pediatric population compared to the adults. However, it can be seen that the number of postoperative complications is greater in adults. Further research is needed to optimize outcomes for both pediatric and adult patients with TOF.
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Affiliation(s)
| | - Azam Jan
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Haseeb Ahmed
- Cardiothoracic and Vascular Surgery, Rehman Medical Institute, Peshawar, PAK
| | | | - Ahmad D Khan
- Endodontics, Sardar Begum Dental College, Peshawar, PAK
| | - Rafat Shakil
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Bahauddin Khan
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Zarkesha Aman
- Ophthalmology, Hayatabad Medical Complex, Peshawar, PAK
| | - Waleed S Ali
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Ahmad Mahmood
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
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10
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Gröning M, Smerup MH, Nielsen DG, Nissen H, Munk K, Mortensen UM, Andersen H, Engholm M, Bjerre J, Vejlstrup N, Juul K, Søndergaard EV, Jensen AS, Jørgensen TH, Thyregod HGH, Andersen HØ, Jøns C, Helvind M, Sondergaard L. Temporal changes in the surgical management of patients with tetralogy of Fallot in Denmark: a nationwide cohort study. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2023; 63:6972777. [PMID: 36617167 DOI: 10.1093/ejcts/ezad007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/02/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess temporal changes in the surgical management of patients with tetralogy of Fallot including the timing of interventions, surgical techniques, reinterventions and survival in a nationwide cohort. METHODS Patients with tetralogy of Fallot in Denmark were divided into 3 eras based on their year of birth: early (1977-1991), intermediate (1992-2006) and late (2007-2021). RESULTS The cohort consisted of 745 patients. Median follow-up was 21.2 years (13.7-30.5). There was a temporal trend towards less shunt palliation (-0.3% per year, 95% CI -0.05 to -0.1). Median age at intracardiac repair was 2.9 years (1.8-5.0), 0.8 years (0.5-1.3) and 0.5 years (0.4-0.7) (P < 0.001) in the early, intermediate and late era, respectively. There was a temporal trend towards less valve-sparing repair (-0.7% per year, 95% CI -0.5 to -1.0) and more repair with transannular patches (0.7% per year, 95% CI 0.5-1.0). Survival at 10 years was 79% (64-76), 90% (87-93) and 95% (92-98) (P < 0.001) and pulmonary valve replacement within the first 10 years after intracardiac repair was performed in 3% (1-6), 12% (8-16) and 21% (13-29) (P < 0.001) in the early, intermediate and late era, respectively. CONCLUSIONS There was a temporal trend towards less shunt palliation and intracardiac repair at a younger age with more use of transannular patches. While survival throughout childhood and adolescence has improved, more patients undergo pulmonary valve replacement during the first 10 years after intracardiac repair.
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Affiliation(s)
- Mathis Gröning
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Holdgaard Smerup
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Cardio-Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Henrik Nissen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Kim Munk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Helle Andersen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Morten Engholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Bjerre
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Klaus Juul
- Department of Pediatrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | | | | - Henrik Ørbæk Andersen
- Department of Cardio-Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Jøns
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Helvind
- Department of Cardio-Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Sondergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Offen S, Puranik R, Baker D, Cordina R, Chard R, Celermajer DS. Prevalence and determinants of tricuspid regurgitation after repair of tetralogy of Fallot. Int J Cardiol 2023; 372:55-59. [PMID: 36436685 DOI: 10.1016/j.ijcard.2022.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prevalence and determinants of tricuspid regurgitation (TR) in patients with repaired Tetralogy of Fallot (rTOF) remain incompletely understood. OBJECTIVES To explore the prevalence of and factors associated with TR in patients with rTOF, specifically, the relationship of right ventricular (RV) dilatation with TR severity. METHODS Patients (≥17 yrs) with rTOF referred to our service (2000-2019) were identified. Those with severe pulmonary stenosis, significant shunt, or previous tricuspid valve surgery were excluded. Using standard cardiac MRI protocols, RV, right atrial (RA) and tricuspid valve (TV) parameters were measured and compared. RESULTS 68 consecutively eligible patients with rTOF were included in the study (27 ± 9 yrs., 35% female). Despite substantial RV volume overload (mean RVEDVi 153 mL/m2), the majority of the cohort (78%) had no or only mild TR. RA volumes, tenting height/area and annular diameter were normal (4.9 ± 2.0 mm, 1.1 ± 1.0 cm2 and 32.4 ± 6.2 mm, respectively). There was no significant correlation of TR fraction with RVEDVi (r = 0.13; p = 0.30), RVEF (r = 0.09; p = 0.44) or tricuspid annular diameter (r = 0.07; p = 0.62). Only RAVi showed a weak but significant correlation with TR fraction (0.29; p = 0.03). In a pooled cohort analysis, including both rTOF patients and adults with a dilated RV from pre-tricuspid shunt lesions, only rTOF was independently associated with higher TR fraction (p = 0.017). CONCLUSION Despite substantial RV dilatation in a cohort with rTOF, there was surprisingly little TR. We found poor correlation between RVEDVi, RA volumes, tricuspid annular dilatation and the presence of significant TR. These findings question commonly held notions regarding the pathophysiology of functional TR in these patients.
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Affiliation(s)
- Sophie Offen
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Raj Puranik
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - David Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Rachael Cordina
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Richard Chard
- Department of Cardiology, Westmead Hospital, Australia
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia; Heart Research Institute, Australia.
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Miller JR, Stephens EH, Goldstone AB, Glatz AC, Kane L, Van Arsdell GS, Stellin G, Barron DJ, d'Udekem Y, Benson L, Quintessenza J, Ohye RG, Talwar S, Fremes SE, Emani SM, Eghtesady P. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot. J Thorac Cardiovasc Surg 2023; 165:221-250. [PMID: 36522807 DOI: 10.1016/j.jtcvs.2022.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice. METHODS The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement. RESULTS In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation. CONCLUSIONS Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.
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Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Andrew B Goldstone
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Andrew C Glatz
- Division of Pediatrics, Department of Pediatric Cardiology, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Glen S Van Arsdell
- Division of Cardiothoracic Surgery, Department of Surgery, UCLA Mattel Children's Hospital, Los Angeles, Calif
| | - Giovanni Stellin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Lee Benson
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Quintessenza
- Department of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Sachin Talwar
- Department of Cariothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass.
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
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13
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An In Vitro Circulatory Loop Model of the Pediatric Right Ventricular Outflow Tract as a Platform for Valve Evaluation. Cardiovasc Eng Technol 2022; 14:217-229. [PMID: 36456745 DOI: 10.1007/s13239-022-00648-w] [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] [Received: 06/28/2022] [Accepted: 11/11/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Tetralogy of Fallot and other conditions affecting the right ventricular outflow tract (RVOT) are common in pediatric patients, but there is a lack of quantitative comparison among techniques for repairing or replacing the pulmonary valve. The aim of this study was to develop a robust in vitro system for quantifying flow conditions after various RVOT interventions. METHODS An infant-sized mock circulatory loop that includes a 3D-printed RVOT anatomical model was developed to evaluate flow conditions after different simulated surgical repairs. Physiologically correct flow and pressure were achieved with custom compliant tubing and a tunable flow restrictor. Pressure gradient, flow regurgitation, and coaptation height were measured for two monocusp leaflet designs after tuning the system with a 12 mm Hancock valved conduit. RESULTS Measurements were repeatable across multiple samples of two different monocusp designs, with the wider leaflet in the 50% backwall model consistently exhibiting lower pressure gradient but higher regurgitation compared to the leaflet in the 40% backwall model. Coaptation height was measured via direct visualization with endoscopic cameras, revealing a shorter area of contact for the wider leaflet (3.3-4.0 mm) compared to the narrower one (4.3 mm). CONCLUSION The 3D-printed RVOT anatomical model and in vitro pulmonary circulatory loop developed in this work provide a platform for planning and evaluating surgical interventions in the pediatric population. Measurements of regurgitation, pressure gradient, and coaptation provide a quantitative basis for comparison among different valve designs and positions.
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14
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Arya N, Schievano S, Caputo M, Taylor AM, Biglino G. Relationship between Pulmonary Regurgitation and Ventriculo-Arterial Interactions in Patients with Post-Early Repair of Tetralogy of Fallot: Insights from Wave-Intensity Analysis. J Clin Med 2022; 11:6186. [PMID: 36294505 PMCID: PMC9604580 DOI: 10.3390/jcm11206186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate the effect of pulmonary regurgitation (PR) on left ventricular ventriculo-arterial (VA) coupling in patients with repaired tetralogy of Fallot (ToF). It was hypothesised that increasing PR severity results in a smaller forward compression wave (FCW) peak in the aortic wave intensity, because of right-to-left ventricular interactions. The use of cardiovascular magnetic resonance (CMR)-derived wave-intensity analysis provided a non-invasive comparison between patients with varying PR degrees. A total of n = 201 patients were studied and both hemodynamic and wave-intensity data were compared. Wave-intensity peaks and areas of the forward compression and forward expansion waves were calculated as surrogates of ventricular function. Any extent of PR resulted in a significant reduction in the FCW peak. A correlation was found between aortic distensibility and the FCW peak, suggesting unfavourable (VA) coupling in patients that also present stiffer ascending aortas. Data suggest that VA coupling is affected by increased impedance.
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Affiliation(s)
- Nikesh Arya
- Faculty of Mathematical and Physical Sciences, University College London, London WC1E 6BT, UK
| | - Silvia Schievano
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
- Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3HJ, UK
| | - Massimo Caputo
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol BS8 1TH, UK
- Bristol Heart Institute, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, BS2 8HW, UK
| | - Andrew M. Taylor
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
- Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3HJ, UK
| | - Giovanni Biglino
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol BS8 1TH, UK
- National Heart and Lung Institute, Imperial College London, London SW7 2BX, UK
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Manuel V, Miana LA, Guerreiro GP, Turquetto A, Santos RM, Fernandes N, Tenório DF, Caneo LF, Jatene FB, Jatene MB. Preoperative Neutrophil-Lymphocyte Ratio Can Predict Outcomes for Patients Undergoing Tetralogy of Fallot Repair. Braz J Cardiovasc Surg 2021; 36:607-613. [PMID: 34236799 PMCID: PMC8597611 DOI: 10.21470/1678-9741-2020-0408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/18/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Elevated neutrophil-lymphocyte ratio (NLR) has been associated with poorer outcomes in cyanotic patients undergoing single ventricle palliation. Little is known about this biomarker on patients with tetralogy of Fallot (TOF), the most common cyanotic congenital heart disease. Our objective is to study the impact of preoperative NLR on outcomes of TOF patients undergoing total repair. METHODS This retrospective study included 116 consecutive patients between January 2014 and December 2018. Preoperative NLR was measured from the last complete blood count test before the surgery. Using the cutoff value of 0.80, according to the receiver-operating characteristic (ROC) curve, the sample was divided into two groups (NLR < 0.80 and ≥ 0.80). The primary endpoint was hospital length of stay (LOS). RESULTS ROC curves showed that higher preoperative NLR was associated with longer hospital LOS, with an area under the curve of 0.801±0.040 (95% confidence interval 0.722 - 0.879; P<0.001). High preoperative NLR was also associated with long intensive care unit (ICU) LOS (P=0.035). Preoperative NLR predicted longer hospital LOS with a sensitivity of 63% and a specificity of 81.4%. CONCLUSION Higher preoperative NLR was associated with long ICU and hospital LOS in patients undergoing TOF repair.
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Affiliation(s)
- Valdano Manuel
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
| | - Leonardo A. Miana
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Gustavo Pampolha Guerreiro
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Aida Turquetto
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Rômullo Medeiros Santos
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Natália Fernandes
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Davi Freitas Tenório
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luiz Fernando Caneo
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Fabio B. Jatene
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Marcelo Biscegli Jatene
- Division of Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
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Liu J, Jiang X, Peng B, Li S, Yan J, Wang Q, Liu Z. Association of Pulmonary Valve Morphology Differences With Outcomes in Tetralogy of Fallot Repair With Right Ventricular Outflow Tract Incision. Front Cardiovasc Med 2021; 8:695876. [PMID: 34422925 PMCID: PMC8372408 DOI: 10.3389/fcvm.2021.695876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Current observational studies may not have large samples to investigate the relationship between pulmonary valve (PV) morphology differences and outcomes after complete repair for tetralogy of Fallot (TOF) by right ventricular outflow tract (RVOT) incision. This study aimed to assess the impact of PV morphology differences on outcomes after complete repair for TOF. Methods: This is a retrospective cohort study. Consecutive patients who underwent TOF repair with RVOT incision at Fuwai Hospital from January 2012 to December 2017 were included and compared according to PV morphology differences (unicuspid or bicuspid was abnormal morphology, while the tricuspid valve was normal morphology). The primary outcome was defined as a composite of death, or reintervention, or significant annular peak gradient (APG), or significant pulmonary regurgitation (PR), whichever occurred first. Multivariable Cox model analysis was used to assess the relationships between PV morphology differences and outcomes. Subgroup analysis and Propensity-score analysis were performed as sensitivity analyses to assess the robustness of our results. Results: The cohort included a total of 1,861 patients with primary diagnosis of TOF, with 1,688 undergoing CR-TOF with RVOT incision. The median age was 318 days [interquartile range (IQR): 223-534 days], a median weight of 8.9 kg (IQR: 7.6-10.5 kg) and 60.0% (1,011) were male. Complete follow-up data were available for 1,673 CR-TOF patients with a median follow-up duration of 49 months. Adjusted risks for the primary outcome and significant APG were lower for patients with normal PV morphology at follow up [adjusted hazard ratio (HR): 0.68; 95% CI: 0.46-0.98; adjusted HR: 0.22; 95% CI: 0.07-0.71, respectively]. The trend for the primary outcome during follow-up remained unchanged, even in subgroups and propensity score matching analyses. Conclusions: In this analysis of data from a large TOF cohort, patients with normal tricuspid PVs were associated with a decreased risk of the primary outcome and a lower risk of significant APG, as compared with patients with abnormal unicuspid or bicuspid PVs.
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Affiliation(s)
- Jinyang Liu
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianchao Jiang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Peng
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yan
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Wang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Beijing, China
| | - Zhimin Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Jiang X, Peng B, Liu J, Zhang H, Li S, Yan J, Wang Q. Impact of operator experience and volume on outcomes after complete repair for tetralogy of Fallot. Eur J Cardiothorac Surg 2021; 60:105-112. [PMID: 33724399 DOI: 10.1093/ejcts/ezab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the impact of individual operator experience on outcomes after complete repair for tetralogy of Fallot. METHODS This is a retrospective cohort study. Consecutive patients who underwent TOF repair at a single institution were included and compared according to whether the primary operator was an experienced, high-volume operator (defined as an operator who performed at least 20 surgical procedures for congenital heart disease defined as complex by the Risk Adjustment for Congenital Heart Surgery classification per year for at least 3 consecutive years). The primary outcome was defined as a composite of death, or reintervention, or significant annular peak gradient, or significant pulmonary regurgitation. Multivariable logistic regression and Cox proportional-hazards model analyses were used to assess the relationships between operator experience and outcomes. RESULTS From January 2012 to December 2017, a total of 1760 patients with primary diagnosis of TOF underwent TOF repair by 37 operators. Of these, 5 operators (13.5%) were considered experienced, and 32 (86.5%) were considered less experienced. Complete follow-up data were available for 1728 complete repair for TOF patients with a median follow-up duration of 49 months; in 611 patients (35.4%), the surgery was performed by experienced operators, and in 1117 patients (64.6%), the surgery was performed by less experienced operators. Adjusted risks for the primary outcome and significant pulmonary regurgitation were lower for patients who were treated by experienced operators, both at discharge [adjusted odds ratio 0.67, 95% confidence interval (CI) 0.50-0.90; adjusted odds ratio 0.54, 95% CI 0.37-0.78, respectively] and at follow-up (adjusted hazard ratio 0.82, 95% CI 0.68-0.97; adjusted hazard ratio 0.70, 95% CI 0.56-0.87, respectively). The trend for the primary outcome during follow-up remained unchanged, even in most subgroups. CONCLUSIONS Increased surgeon experience is associated with improved risk-adjusted outcomes. These results have potentially important implications for individual training, quality improvement and hospital programmes in the context of complete repair for TOF. REGISTRATION NUMBER http://www.chictr.org.cn number, ChiCTR2000033234.
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Affiliation(s)
- Xianchao Jiang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Peng
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinyang Liu
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Heng Zhang
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yan
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Wang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
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Clark JB. Making a Case for Late Repair of Tetralogy of Fallot. Ann Thorac Surg 2021; 113:1582. [PMID: 33939970 DOI: 10.1016/j.athoracsur.2021.02.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/07/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joseph B Clark
- Division of Pediatric Cardiac Surgery, Department of Pediatrics, Penn State Children's Hospital, 500 University Dr, H085, Hershey, PA 17033.
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Kobayashi Y, Kotani Y, Kuroko Y, Kawabata T, Sano S, Kasahara S. Staged Repair of Tetralogy of Fallot: A Strategy for Optimizing Clinical and Functional Outcomes. Ann Thorac Surg 2021; 113:1575-1581. [PMID: 33771498 DOI: 10.1016/j.athoracsur.2021.01.087] [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] [Received: 08/03/2020] [Revised: 11/28/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study evaluated the impact of a staged surgical strategy incorporating a modified Blalock-Taussig shunt (BTS) for tetralogy of Fallot (TOF) on pulmonary valve annulus (PVA) growth, the rate of valve-sparing repair (VSR) at the time of intracardiac repair (ICR), and long-term functional outcomes. METHODS This retrospective study included 330 patients with TOF who underwent ICR between 1991 and 2019, including 57 patients (17%) who underwent BTS. The mean follow-up period was 15.0±7.3 years. We compared the data of patients who underwent BTS and those who did not undergo BTS before ICR. RESULTS The median age and body weight before BTS were 71 (28-199) days and 4.3 (3.3-6.8) kg respectively. There were no in-hospital or interstage deaths after BTS. The PVA Z-scores of patients with BTS revealed significant growth after BTS (from -4.2±1.8 to -3.0±1.7, P<0.001). VSR was eventually performed in 207 (63%) patients, including 26 (46%) patients who underwent staged repair. The overall freedom from pulmonary regurgitation-related reintervention were 99.7%, 99.1%, and 95.8% at 1, 5, and 20 years, respectively. CONCLUSIONS A staged surgical strategy incorporating BTS as the first palliation for symptomatic patients resulted in no mortality. BTS may have contributed to the avoidance of primary transannular patch repair (TAP) and facilitated PVA growth; therefore, approximately half of the symptomatic neonates and infants were recruited for VSR. Staged repair may have led to functionally-reliable delayed TAP repair, thereby resulting in less surgical reinterventions.
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Affiliation(s)
| | | | - Yosuke Kuroko
- Cardiovascular Surgery, Okayama University Hospital, Japan
| | | | - Shunji Sano
- Pediatric Cardiothoracic Surgery, University of California, San Francisco
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Jiang X, Liu J, Peng B, Zhang H, Li S, Yan J, Wang Q. Impact of Annulus-Sparing on Surgical Adequacy of Pulmonary Valve in Complete Repair of Tetralogy of Fallot with Right Ventricular Outflow Tract Incision. Pediatr Cardiol 2021; 42:379-388. [PMID: 33156379 DOI: 10.1007/s00246-020-02493-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/30/2020] [Indexed: 11/24/2022]
Abstract
Today, strategy of repair remains controversial and rare analyses on annular integrity associated with outcomes in complete repair by RVOT incision were performed in a large TOF cohort in China. This is a retrospective cohort study involving patients with TOF who had undergone complete repair by RVOT incision between January 2012 and December 2017 in Fuwai hospital. The primary outcome was a composite of reintervention, significant pulmonary regurgitation (PR) and significant annular peak gradient (APG). Multivariate Cox proportional-hazards model analyses were used to assess the relationships between annular integrity and outcomes. In total, 1673 survival patients with the median age of 318 days were included, and 1002 were male. During a median follow-up of 49 months, 538 participants developed the primary outcome (27 reinterventions). Multivariate Cox analyses showed that compared with AS, TAP was associated with an increased risk of primary outcome (adjusted HR, 1.94 [95% CI 1.60-2.37]) and the results remained unchanged even in most subgroups defined. In secondary outcomes analyses, TAP is associated with a higher risk of reintervention (adjusted HR, 3.32 [95% CI 1.25-8.79]) and significant PR (adjusted HR, 2.51 [95% CI 2.00-3.16]). However, TAP is not associated with a decreased risk of significant APG (adjusted HR, 1.33 [95% CI 0.94-1.88]). PVA integrity preservation is important in complete repair of TOF with RVOT incision. TAP is associated with a higher risk of reintervention and significant PR, and with a similar risk of significant APG. Significant APG in AS patients at discharge has a downtrend over time.
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Affiliation(s)
- Xianchao Jiang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Jinyang Liu
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Bo Peng
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Heng Zhang
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Jun Yan
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Qiang Wang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China. .,Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China.
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21
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Well A, Mery CM. Commentary: The many roads traveled in tetralogy of Fallot repair. J Thorac Cardiovasc Surg 2020; 159:237-238. [PMID: 31635875 DOI: 10.1016/j.jtcvs.2019.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 09/07/2019] [Accepted: 09/10/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Andrew Well
- Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, Tex; Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Tex
| | - Carlos M Mery
- Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, Tex; Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Tex.
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22
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Alfieris GM, Swartz MF, Algahim M. Commentary: The static use of the transannular patch in the repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2019; 159:239-240. [PMID: 31635859 DOI: 10.1016/j.jtcvs.2019.09.036] [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: 09/04/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/20/2022]
Affiliation(s)
- George M Alfieris
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Michael F Swartz
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mohamed Algahim
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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