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Gotor CA, García E, Arias FJ, Granados MA, Montañes E, Mendoza A, Garcia MT, Boni L. One-stage neonatal Yasui procedure: Presentation of our surgical experience and a new decision-making algorithm. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Abstract
BACKGROUND Yasui procedure is surgical repair intended to preserve biventricular function for patients with left ventricle outflow tract obstruction associated with aortic arch lesions and ventricular septal defect. METHODS Retrospective chart review analysis of all patients who had Yasui procedure (2008-2020) comparing midterm outcome of one versus two stage repair. RESULTS Twenty patients (70% female) underwent Yasui procedure in our center. Eight patients (40%) had left ventricle outflow tract obstruction /interrupted aortic arch, 7 patients (35%) had left ventricle outflow tract obstruction /coarctation of aorta, 3 patients (15%) had double outlet ventricle and ventricular septal defect that were unattainable for tunneling to one of the semilunar valves without creating obstruction, and 2 patients (10%) had aortic atresia with hypoplastic aortic arch. All patients had associated ventricular septal defect. Fifteen patients (75%) had one-stage repair and 5 patients (25%) had two-stage repair. Means age and weight for one and two-stage repair were 1.3 ± 2 months, 13.4 ± 11.5 months and 3.3 ± 0.6 kg, 7.8 ± 3.4 kg, respectively. During follow up, 8 patients (40%) required re- intervention, mainly for right ventricle-pulmonary artery conduit either dilation or replacement. The average duration of follow up was 5 years with nil mortality. CONCLUSION Yasui procedure is effective approach for children who have left ventricle outflow tract obstruction associated with aortic arch anomalies and ventricular septal defect. Survival rate with single or staged repair is comparably good. During the first 5 year of follow up, nearly 40% of operated patients required re-intervention.
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Tracey M. Congenital Cardiac Defects That Are Borderline Candidates for Biventricular Repair. Crit Care Nurse 2019; 38:e7-e13. [PMID: 30275070 DOI: 10.4037/ccn2018679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This article discusses congenital heart defects that are marginal candidates for biventricular repair and highlights the anatomic considerations upon which the surgical decision is based. Specifically, the article reviews the importance of capacitance and compliance of the ventricles and their associated atrioventricular valves. For each of the defects discussed, the imaging modalities used to diagnose a marginal ventricle are reviewed and the surgical decision-making process is outlined. The article also reviews immediate postoperative treatment of these patients and when to consider biventricular repair of a marginal lesion to be a failure.
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Affiliation(s)
- Megan Tracey
- Megan Tracey is a nurse practitioner in the cardiovascular intensive care unit and the advanced practice provider manager in the Heart Center at Lucile Packard Children's Hospital, Palo Alto, California.
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Abarbanell G, Border WL, Schlosser B, Morrow G, Kelleman M, Sachdeva R. Preoperative echocardiographic measures in interrupted aortic arch: Which ones best predict surgical approach and outcome? CONGENIT HEART DIS 2018. [PMID: 29520990 DOI: 10.1111/chd.12599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE It is unclear whether neonates with interrupted aortic arch (IAA) and a smaller left ventricular outflow tract may have improved outcomes with a Yasui operation (ventricular outflow bypass procedure) over a primary complete repair. This study sought to identify preoperative echocardiographic parameters to differentiate which neonates may have improved outcomes with a primary vs Yasui operation. DESIGN Patient demographics, cardiac surgery type, complications, need for reoperation and/or interventional catheterization, and date of last follow-up were collected on neonates who underwent a biventricular repair for IAA from 2003 to 2014. Preoperative echocardiograms were analyzed for: IAA type, valve annulus size, aortic valve morphology, ventricular size and aortic arch anatomy. RESULTS Seventy-seven neonates underwent IAA repair between 2003 and 2013. 60 neonates had a primary repair and 17 a Yasui operation. Neonates that underwent a Yasui operation had significantly smaller mitral and aortic valves with aortic arch hypoplasia. Within the primary repair group, a decreasing aortic root z-score on univariate analysis increased the odds of reoperation by twofold [OR = 1.98, 95% CI: (1.15-3.42), P = .014]. A significant interaction between repair type and aortic root z-score was identified on multivariable analysis (P = .039), for neonates with aortic root z-scores less than -2.5, the probability of reoperation during the follow up time period [mean 4.5 years (3.3 months-10 year)] was significantly higher in the primary repair group compared to the Yasui group (64.3% vs 37.5%). CONCLUSIONS Neonates with IAA and an aortic root z-score less than -2.5 have lower odds of subsequent reoperations with a Yasui operation compared to a primary repair over the follow up period. These findings suggest a Yasui operation should be considered if the preoperative aortic root z-score is less than -2.5. Careful evaluation of these morphologic predictors on preoperative echocardiograms can be helpful in surgical planning in neonates with IAA.
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Affiliation(s)
- Ginnie Abarbanell
- Department of Pediatrics, Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - William L Border
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Brian Schlosser
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Gemma Morrow
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Michael Kelleman
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Ritu Sachdeva
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Atlanta, Georgia, USA
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Hirano Y, Inamura N, Kawazu Y, Aoki H, Kayatani F, Iwai S, Kawata H. Evaluation of Factors Associated With Achievement of Biventricular Repair After Bilateral Pulmonary Artery Banding in Patients With Interrupted Aortic Arch. World J Pediatr Congenit Heart Surg 2018; 9:54-59. [PMID: 29310563 DOI: 10.1177/2150135117737685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND At our institution, we perform bilateral pulmonary artery banding (BPAB) as the first-stage palliation for interrupted aortic arch (IAA) with low birth weight or severe subaortic stenosis (SAS). The present study aimed to identify factors that may influence the decision regarding the type of second-stage operation, that is, univentricular palliation or biventricular repair, in these patients. METHODS Cardiac catheterization and angiographic data of nine patients with IAA who underwent initial BPAB and subsequent univentricular or biventricular repair were retrospectively analyzed. RESULTS Between 2004 and 2014, of nine patients with IAA who underwent initial BPAB, biventricular repair was subsequently performed in six patients (group B) and univentricular repair in three patients (group U). All patients survived. There was no significant intergroup difference in IAA classification, location of ventricular septal defect, presence of 22q11.2 deletion, presence of aberrant right subclavian artery, band diameter, or post-BPAB pulmonary artery pressure and index. Timing of BPAB and the body weight at the time of BPAB, however, differed significantly between the groups ( P = .02). Catheter data before BPAB were not significantly different between the groups, with the exception of the degree of subaortic stenosis (or hypoplasia of the left ventricular outflow tract) expressed as percentage of the normal end-systolic aortic valve annular diameter for patient body surface area. This metric (%SAS before BPAB) was significantly higher in group B (60%-68%) than in group U (47%-60%; P = .04). Among patients for whom baseline %SAS was < 60%, the %SAS did not increase after BPAB. CONCLUSION The most important factor that allowed biventricular repair was not the pulmonary artery pressure or diameter but the degree of SAS. Patients who initially had more severe SAS ultimately underwent univentricular repair due to lack of substantial improvement in dimensions of the left ventricular outflow tract after BPAB.
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Affiliation(s)
- Yasuhiro Hirano
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Noboru Inamura
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan.,2 Department of Pediatrics, Kinki University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Yukiko Kawazu
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Hisaaki Aoki
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Futoshi Kayatani
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Shigemitsu Iwai
- 3 Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Hiroaki Kawata
- 3 Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
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Shihata M, El-Zein C, Wittle K, Husayni T, Ilbawi M. Staged biventricular repair for neonates with left ventricular outflow tract obstruction, ventricular septal defect, and aortic arch obstruction. Ann Thorac Surg 2014; 98:1394-7. [PMID: 25149049 DOI: 10.1016/j.athoracsur.2014.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/17/2014] [Accepted: 05/27/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate clinical outcomes of neonates who underwent a Norwood operation as a first step of a planned biventricular repair and the impact of associated risk factors. METHODS A retrospective cohort study was performed on all neonates (n = 44) undergoing the Norwood operation as the first stage of a biventricular (Norwood-Rastelli) repair from January 2000 to December 2012 at a single center. Multivariable analysis was performed to identify predictors of survival. RESULTS Stage one mortality was 9%. The interstage survival for nonsyndromic and syndromic patients was 100% versus 46%, respectively (p < 0.001). Twenty-four patients (55%) underwent biventricular completion repair with no mortality. Freedom from reintervention after biventricular completion was 53% at 6 years. The overall survival for nonsyndromic patients versus syndromic patients was 86% versus 43%, respectively (p = 0.01). Genetic syndromes and prematurity were significant predictors of interstage mortality on multivariable analysis. CONCLUSIONS Staged biventricular repair for patients with complex left ventricular outflow tract obstruction, ventricular septal defect, and aortic arch obstruction can be achieved with excellent outcomes for neonates without genetic syndromes. The staged approach is associated with longer time to reintervention after the biventricular completion.
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Affiliation(s)
- Mohammad Shihata
- Madinah Cardiac Center, Taibah University, Madinah, Saudi Arabia.
| | - Chawki El-Zein
- Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Katie Wittle
- Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Tarek Husayni
- Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Michel Ilbawi
- Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, Illinois
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Qureshi MY, Burkhart HM, Hagler DJ. Biventricular repair after stage II univentricular surgery: palliation is not a one-way path. Ann Thorac Surg 2013; 96:e119-20. [PMID: 24182509 DOI: 10.1016/j.athoracsur.2013.04.138] [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: 02/14/2013] [Revised: 04/23/2013] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
Abstract
Surgical decision in mild forms of hypoplastic left heart syndrome can be challenging. Once a univentricular pathway has been chosen, it can be difficult to reconsider a biventricular repair. A commitment to a palliative pathway is usually considered irreversible after initial univentricular repair. We present this case as an example in which the primary surgical palliation pathway was altered, and eventually a successful biventricular repair was performed in a mild variant of hypoplastic left heart syndrome, despite the fact that maneuvers to promote left ventricular growth were not recruited at the time of initial surgery.
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Kalish BT, Banka P, Lafranchi T, Tworetzky W, del Nido P, Emani SM. Biventricular Conversion After Single Ventricle Palliation in Patients With Small Left Heart Structures: Short-Term Outcomes. Ann Thorac Surg 2013; 96:1406-1412. [DOI: 10.1016/j.athoracsur.2013.05.060] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/14/2013] [Accepted: 05/17/2013] [Indexed: 12/20/2022]
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Tomoyasu T, Oka N, Miyamoto T, Kitamura T, Itatani K, Inoue N, Ishii M, Miyaji K. Surgical strategy for severe aortic hypoplasia and aortic stenosis with ventricular septal defect and normal left ventricle. Pediatr Cardiol 2013; 34:1107-11. [PMID: 23250649 DOI: 10.1007/s00246-012-0611-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 11/30/2012] [Indexed: 12/01/2022]
Abstract
At our institution, the strategy for patients with bicuspid aortic valve, aortic valve stenosis (<5 mm), and aortic hypoplasia [hypoplastic aortic arch, coarctation of the aorta (CoA), or interrupted aortic arch (IAA)] with ventricular septal defects (VSDs) as well as normal left ventricular (LV) volume and mitral valve size consists of two parts. The Norwood operation is applied as the first palliation for this group of patients. Second, the decision whether the patients are to undergo the Rastelli operation or a univentricular repair is made depending on the size of the right ventricle after the Norwood operation. This study aimed to examine whether the aforementioned surgical strategy for this group of patients is adequate or not. Seven patients undergoing the Norwood operation as the first palliation for bicuspid aortic valve, aortic valve stenosis (<5 mm), and aortic hypoplasia with VSDs as well as normal LV volume and mitral valve size between February 2005 and March 2010 at Kitasato University Hospital and the Gunma Children's Medical Center were reviewed. Postoperative serum B-type natriuretic peptide (BNP) and central venous pressure (CVP) were measured in the patients undergoing the staged Norwood-Rastelli operation to assess whether the authors' right ventricular end-diastolic volume index (RVEDVI) cutoff (80 % of normal) is adequate. At this writing, all seven patients are alive after a mean follow-up period of 58.8 ± 17.8 months. They all had aortic valve stenosis of <5 mm and a bicuspid aortic valve. Four patients had a diagnosis of CoA with VSD, and three patients had IAA with VSD. Six patients underwent biventricular repair, and one patient had univentricular repair due to the small RVEDVI (74 % of normal). The patients with 80-90 % of normal RVEDVI had higher BNP and higher CVP than those with more than 90 % of normal RVEDVI after the Rastelli operation, whereas the patient undergoing the Fontan operation had a low BNP level. In conclusion, the described strategy for patients with severe aortic hypoplasia and aortic stenosis with VSD as well as normal LV and mitral valve size is reasonable.
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Affiliation(s)
- Takahiro Tomoyasu
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara 252-0374, Japan
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Emani SM, del Nido PJ. Strategies to maintain biventricular circulation in patients with high-risk anatomy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:37-42. [PMID: 23561816 DOI: 10.1053/j.pcsu.2013.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Although hypoplasia of left heart structures presents with a spectrum of severity, management decisions are typically dichotomous: single-ventricle palliation or biventricular repair. Since the long-term outcomes of single-ventricle palliation are sub-optimal, strategies to aggressively pursue biventricular circulation in patients with borderline left heart structures have been developed. Recent strategies and surgical techniques to rehabilitate the left heart in patients with borderline left heart are described.
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Affiliation(s)
- Sitaram M Emani
- Department of Cardiac Surgery, Children's Hospital Boston, Boston, MA, USA
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Aortic valve replacement in neonates and infants: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg 2012; 144:1084-89. [DOI: 10.1016/j.jtcvs.2012.07.060] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 07/11/2012] [Accepted: 07/26/2012] [Indexed: 11/23/2022]
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Biventricular Repair With the Yasui Operation (Norwood/Rastelli) for Systemic Outflow Tract Obstruction With Two Adequate Ventricles. Ann Thorac Surg 2012; 93:1999-2005; discussion 2005-6. [DOI: 10.1016/j.athoracsur.2012.02.050] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 02/06/2012] [Accepted: 02/08/2012] [Indexed: 11/20/2022]
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Hoashi T, Bove EL, Devaney EJ, Hirsch JC, Ohye RG. Intermediate-term clinical outcomes of primary biventricular repair for left ventricular outflow tract obstruction and ventricular septal defect. J Thorac Cardiovasc Surg 2011; 141:200-6. [DOI: 10.1016/j.jtcvs.2010.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 04/02/2010] [Accepted: 06/06/2010] [Indexed: 10/19/2022]
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Intermediate-Term Results of the Ross Procedure in Neonates and Infants. Ann Thorac Surg 2010; 89:1827-32; discussion 1832. [DOI: 10.1016/j.athoracsur.2010.02.107] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 02/17/2010] [Accepted: 02/22/2010] [Indexed: 11/21/2022]
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Biventricular Repair After Modified Norwood Operation. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0096-5] [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]
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Nathan M, Rimmer D, del Nido PJ, Mayer JE, Bacha EA, Shin A, Regan W, Gonzalez R, Pigula F. Aortic atresia or severe left ventricular outflow tract obstruction with ventricular septal defect: results of primary biventricular repair in neonates. Ann Thorac Surg 2006; 82:2227-32. [PMID: 17126139 DOI: 10.1016/j.athoracsur.2006.05.124] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 05/16/2006] [Accepted: 05/18/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aortic atresia or severe aortic stenosis and left ventricular outflow tract obstruction is a frequent component of complex congenital heart disease. Aortic atresia or severe aortic stenosis and left ventricular outflow tract obstruction with two adequate ventricles is sometimes treated by Norwood palliation followed by late biventricular repair. We reviewed our experience with primary biventricular repair in this group of neonates. METHODS Retrospective review identified 17 neonates (10 males) with aortic atresia or severe left ventricular outflow tract obstruction with ventricular septal defect and an adequate left ventricle undergoing primary biventricular repair between 1986 and 2002. Mean age was 7.7 +/- 2.9 days, weight 3.3 +/- 0.7 kg, and body surface area 0.21 +/- 0.04 kg/m2. Associated anomalies included arch hypoplasia, 7 (41%); aortic atresia, 7 (41%); and coarctation, 5 (29%). Results are reported as mean +/- standard deviation. RESULTS Median follow-up was 6 years (range, 1 to 17.7 years). Three of the 17 (18%) died within 30 days. There were no deaths in this series since 1992. Nine patients (38.9%) required one reoperation, 7 of which were for conduit stenosis, 1 for left ventricular outflow tract obstruction, and 1 for residual ventricular septal defect with left ventricle-to-right atrium shunt. Freedom from death at 10 years was 82% by Kaplan-Meier estimate. CONCLUSIONS Excellent long-term survival can be achieved by primary biventricular repair as corroborated by our survival rate of 82%. Primary biventricular repair is an effective operation for aortic atresia and severe left ventricular outflow tract obstruction with adequate sized left ventricle that avoids interstage attrition associated with Norwood palliation and is our procedure of choice.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Harvard Medical School, Children's Hospital Boston, Boston, Massachusetts 02115, USA
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McCrindle BW, Tchervenkov CI, Konstantinov IE, Williams WG, Neirotti RA, Jacobs ML, Blackstone EH. Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: A Congenital Heart Surgeons Society study. J Thorac Cardiovasc Surg 2005; 129:343-50. [PMID: 15678045 DOI: 10.1016/j.jtcvs.2004.10.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to determine the prevalence of outcomes and associated patient and management factors for neonates with interrupted aortic arch. METHODS From 1987 to 1997, a total of 472 neonates were enrolled prospectively from 33 institutions. Competing risks methodology was used to determine simultaneous risk and associated incremental risk factors for death, initial and subsequent left ventricular outflow tract procedures, and arch reinterventions. RESULTS Overall survival was 59% at 16 years after study entry but improved with successive birth cohort. In general, risk factors for death in each of the competing risks analyses included lower birth weight, younger age at study entry, type B interrupted aortic arch, and major associated cardiac anomalies. Of 453 patients who had interrupted aortic arch repair, after 16 years 33% had died and 28% had undergone an arch reintervention. Reintervention was more likely for those who had truncus arteriosus repair, interrupted aortic arch repair by a method other than direct anastomosis with patch augmentation, and the use of polytetrafluoroethylene as either an interposition graft or a patch. From study entry, competing risks after 16 years showed that 28% had died and 34% had undergone an initial left ventricular outflow tract procedure. Initial left ventricular outflow tract procedure was more likely for those with single ventricle, type B interrupted aortic arch, bicuspid aortic valve, or anomalous right subclavian artery. Among those who had undergone an initial left ventricular outflow tract procedure, after 16 years 37% had died and 28% had undergone a second procedure. CONCLUSION Anatomic features affect mortality and initial left ventricular outflow tract procedures, whereas characteristics of the arch repair affect arch reintervention.
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Affiliation(s)
- Brian W McCrindle
- Division of Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Tchervenkov CI, Jacobs JP, Sharma K, Ungerleider RM. Interrupted aortic arch: Surgical decision making. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:92-102. [PMID: 15818364 DOI: 10.1053/j.pcsu.2005.01.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interrupted aortic arch (IAA) is defined as the loss of luminal continuity between the ascending and descending aorta. It is associated with a multitude of lesions ranging from isolated ventricular septal defects to complex ones. Although results have improved in the modern era, repair of IAA is associated with a significant mortality and morbidity. In recent years, the move to a one-stage repair has become well established, and the optimal technique for aortic repair seems to be partial direct anastomosis with patch augmentation. Left ventricular outflow tract obstruction (LVOTO) continues to be an important factor affecting survival and re-intervention rates after IAA repair. Great variability exists with regard to definition and diagnosis of LVOTO. To guide the decision for left ventricular outflow tract (LVOT) intervention and which type to use, we propose a simple formula based on the baby's weight. We advocate a conservative approach when the LVOT diameter is greater than the baby's weight + 2 mm and a LVOT bypass procedure (Yasui or Norwood) if the LVOT diameter is less than the baby's weight in millimeters. If the LVOT diameter falls in between, no definitive recommendation can be made, and the surgical approach is based on the surgeon's experience and overall philosophy.
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Affiliation(s)
- Christo I Tchervenkov
- Division of Pediatric Cardiovascular Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montréal, Quebec, Canada
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Abstract
BACKGROUND In general, neonates with severe left ventricular outflow tract obstruction, aortic valvar stenosis or atresia, and arch hypoplasia with either interruption or coarctation, and a small left ventricle undergo Norwood palliation followed classically by a bidirectional cavopulmonary shunt and eventual modified Fontan. However, a subset of patients, usually neonates with a ventricular septal defect, may have adequate left ventricle and mitral valve sizes making them candidates for future biventricular repair (BVR). In view of the long-term advantage of BVR, the feasibility and outcome of this approach was studied. Additionally, echocardiographic data were reviewed in an attempt to develop objective prognostic criteria for selection of patients suitable for BVR. METHODS During a 4-year period, 8 of 58 infants undergoing Norwood palliation were identified as potential two-ventricle candidates. Their mean age was 6 days. Diagnoses included aortic atresia (n = 1), or aortic valve stenosis and subaortic stenosis (n = 7), with an interrupted aortic arch in 3 and coarctation in 4. All patients had a ventricular septal defect and a left ventricle that was considered to be apex forming. Mean mitral valve size was 11 mm (z-score = -1.7). Mean aortic valve size was 4.1 mm (mean z-score = -8.4). RESULTS All 8 patients survived Norwood palliation. Six subsequently underwent BVR with ventricular septal defect closure and a right ventricle to pulmonary artery conduit at a mean age of 7 months. One patient is awaiting repair, and 1 underwent a cavopulmonary shunt. At the time of BVR, mean mitral valve z-score was essentially unchanged at -1.4 (14 mm). No early deaths or late deaths occurred during a mean follow-up of 32 months. CONCLUSIONS A small subset of patients requiring Norwood palliation as newborns may be candidates for eventual BVR with low risk. In general, patients suitable for BVR have a mitral valve z-score of more than -3 and a normal-sized left ventricle. Recognition of neonatal BVR candidates enables consideration of complete neonatal repair. However, single-stage repair needs to be compared with the excellent results obtainable with the staged approach.
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Affiliation(s)
- Jeffrey M Pearl
- Department of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, OSB-3, Cincinnati, OH 45229, USA.
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