Repair of truncus arteriosus: a considered approach to right ventricular outflow tract reconstruction

Truncus arteriosus from prenatal diagnosis to clinical outcome: a single-centre experience

BACKGROUND

The aim of this study was to review our institution's experience with truncus arteriosus from prenatal diagnosis to clinical outcome.

METHODS

and results: We conducted a single-centre retrospective cohort study for the years 2005-2020. Truncus arteriosus antenatal echocardiographic diagnostic accuracy within our institution was 92.3%. After antenatal diagnosis, five parents (31%) decided to terminate the pregnancy. After inclusion from referring hospitals, 16 patients were offered surgery and were available for follow-up. Right ventricle-to-pulmonary artery continuity was preferably established without the use of a valve (direct connection), which was possible in 14 patients (88%). There was no early or late mortality. Reinterventions were performed in half of the patients at latest follow-up (median follow-up of 5.4 years). At a median age of 5.5 years, 13 out of 14 patients were still without right ventricle-to-pulmonary artery valve, which was well tolerated without signs of right heart failure. The right ventricle demonstrated preserved systolic function as expressed by tricuspid annular plane systolic excursion z-score (-1.4 ± 1.7) and fractional area change (44 ± 12%). The dimensions and function of the left ventricle were normal at latest follow-up (ejection fraction 64.4 ± 6.2%, fractional shortening 34.3 ± 4.3%).

CONCLUSIONS

This study demonstrates good prenatal diagnostic accuracy of truncus arteriosus. There was no mortality and favourable clinical outcomes at mid-term follow-up, with little interventions on the right ventricle-to-pulmonary artery connection and no right ventricle deterioration. This supports the notion that current perspectives of patients with truncus arteriosus are good, in contrast to the poor historic outcome series. This insight can be used in counselling and surgical decision-making.

Outcomes in Primary Repair of Truncus Arteriosus with Significant Truncal Valve Insufficiency: A Systematic Review and Meta-analysis

Data regarding the effect of significant TVI on outcomes after truncus arteriosus (TA) repair are limited. The aim of this meta-analysis was to summarize outcomes among patients aged ≤ 24 months undergoing TA repair with at least moderate TVI. A systematic literature search was conducted in PubMed, Scopus, and CINAHL Complete from database inception through June 1, 2022. Studies reporting outcomes of TA repair in patients with moderate or greater TVI were included. Studies reporting outcomes only for patients aged > 24 months were excluded. The primary outcome was overall mortality, and secondary outcomes included early mortality and truncal valve reoperation. Random-effects models were used to estimate pooled effects. Assessment for bias was performed using funnel plots and Egger's tests. Twenty-two single-center observational studies were included for analysis, representing 1,172 patients. Of these, 232 (19.8%) had moderate or greater TVI. Meta-analysis demonstrated a pooled overall mortality of 28.0% after TA repair among patients with significant TVI with a relative risk of 1.70 (95% CI [1.27-2.28], p < 0.001) compared to patients without TVI. Significant TVI was also significantly associated with an increased risk for early mortality (RR 2.04; 95% CI [1.36-3.06], p < 0.001) and truncal valve reoperation (RR 3.90; 95% CI [1.40-10.90], p = 0.010). Moderate or greater TVI before TA repair is associated with an increased risk for mortality and truncal valve reoperation. Management of TVI in patients remains a challenging clinical problem. Further investigation is needed to assess the risk of concomitant truncal valve surgery with TA repair in this population.

Death, reoperation, and late cardiopulmonary function after truncus repair

Objective

To identify the late surgical outcomes of truncus arteriosus.

Methods

Fifty consecutive patients with truncus arteriosus who underwent surgery between 1978 and 2020 at our institute were enrolled in this retrospective, single institutional cohort study. The primary outcome was death and reoperation. The secondary outcome was late clinical status, including exercise capacity. The peak oxygen uptake was measured by a ramp-like progressive exercise test on a treadmill.

Results

Nine patients underwent palliative surgery, which resulted in 2 deaths. Forty-eight patients went on to truncus arteriosus repair, including 17 neonates (35.4%). The median age and body weight at repair were 92.5 days (interquartile range, 10-272 days) and 3.85 kg (interquartile range, 2.9-6.5 kg), respectively. The survival rate at 30 years was 68.5%. Significant truncal valve regurgitation (P = .030) was a risk factor for survival. Survival rates were similar between in the early 25 and late 25 patients (P = .452). The freedom from death or reoperation rate at 15 years was 35.8%. Significant truncal valve regurgitation was a risk factor (P = .001). The mean follow-up period in hospital survivors was 15.4 ± 12 years (maximum, 43 years). The peak oxygen uptake, which was performed in 12 long-term survivors at a median duration from repair of 19.7 years (interquartile range, 16.8-30.9 years), was 70.2% of predicted normal (interquartile range, 64.5%-80.4%).

Conclusions

Truncal valve regurgitation was a risk factor for both survival and reoperation, thus improvement of truncal valve surgery is essential for better life prognosis and quality of life. Slightly reduced exercise tolerance was common in long-term survivors.

Outcomes of truncal valve replacement in neonates and infants: a meta-analysis

BACKGROUND

Infants with truncus arteriosus typically undergo repair by repurposing the truncal valve as the neo-aortic valve and using a valved conduit homograft for the neo-pulmonary valve. In cases where the native truncal valve is too insufficient for repair, it is replaced, but this is a rare occurrence with a paucity of data, especially in the infant population. Here, we conduct a meta-analysis to better understand the outcomes of infant truncal valve replacement during the primary repair of truncus arteriosus.

METHODS

We systematically reviewed PubMed, Scopus, and CINAHL for all studies reporting infant (<12 months) truncus arteriosus outcomes between 1974 and 2021. Exclusion criteria were studies which did not report truncal valve replacement outcomes separately. Data extracted included valve replacement type, mortality, and reintervention. Our primary outcome was early mortality, and our secondary outcomes were late mortality and reintervention rates.

RESULTS

Sixteen studies with 41 infants who underwent truncal valve replacement were included. The truncal valve replacement types were homografts (68.8%), mechanical valves (28.1%), and bioprosthetic valves (3.1%). Overall early mortality was 49.4% (95% CI: 28.4-70.5). The pooled late mortality rate was 15.3%/year (95% CI: 5.8-40.7). The overall rate of truncal valve reintervention was 21.7%/year (95% CI: 8.4-55.7).

CONCLUSIONS

Infant truncal valve replacement has poor early and late mortality as well as high rates of reintervention. Truncal valve replacement therefore remains an unsolved problem in congenital cardiac surgery. Innovations in congenital cardiac surgery, such as partial heart transplantation, are required to address this.

Outcomes and occurrence of post-operative pulmonary hypertension crisis after late referral truncus arteriosus repair

Background

Truncus arteriosus (TA) is a rare congenital heart disease with a high rate of early mortality. The occurrence of post-operative pulmonary hypertension crisis (PHC), known to be a common and life-threatening complication, increases due to the irreversible development of pulmonary vascular resistance with age. We sought to figure out the risk factors for PHC and describe the surgical outcomes of TA patients with late referral (repair <1 month excluded).

Materials and methods

We retrospectively reviewed patients after TA repair between 2009 and 2021 at Shanghai Children’s Medical Center. The occurrence of PHC was defined according to post-operative Pp/Ps ≥ 1 and clinical manifestations. Risk factors for PHC and mortality were conducted by multivariable analysis.

Results

A total of 98 patients were treated, including 55 males and 43 females. The median age at repair was 121 (69, 245) days. Post-operative PHC occurred in 22 (22.4%) patients with a median age of 186 (122, 293) days. By multivariable analysis, patients with the sum of Z-score of pre-operative bilateral pulmonary artery (PA) diameters (OR: 1.6, 95% CI: 1.2–2.3, P = 0.01) was more likely to experience PHC. Longer CPB duration contributed to early death (OR: 1.0, 95% CI: 1.0–1.0, P = 0.01). Total survival at 10 years was 81.4%. In 4.5 (2.9, 7.5) years of follow-up, twenty-six patients received 30 reinterventions. Valved reconstruction of RVOT most predicted reinterventions (OR: 4.2, 95% CI: 1.4–13.0, P = 0.01).

Conclusion

Surgical repair of TA patients with late referral has resulted in comparatively favorable early and mid-term outcomes. PHC occurred more commonly in patients with overextended bilateral PA pre-operatively. Meanwhile, valved reconstruction of RVOT would more likely lead to early reintervention.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hospital Survival After Surgical Repair of Truncus Arteriosus with Interrupted Aortic Arch: Results from a Multi-institutional Database

Truncus arteriosus (TA) is a major congenital cardiac malformation that requires surgical repair in the first few weeks of life. Interrupted aortic arch (IAA) is an associated malformation that significantly impacts the complexity of the TA operation. The aim of this study was to (1) define the comorbid conditions associated with TA and (2) determine the hospital survival and morbidity of patients with TA with and without an IAA. Data was collected from the Vizient Clinical Database/Resource Manager, formerly University HealthSystem Consortium, which encompasses more than 160 academic medical centers in the United States. The database was queried for patients admitted from 2002 to 2016 who were ≤ 4 months of age at initial admission, diagnosed with TA, and underwent complete surgical repair during that hospitalization. Of the 645 patients with TA who underwent surgery, 98 (15%) had TA with an interrupted aortic arch (TA-IAA). Both TA and TA-IAA were associated with a high prevalence of comorbidities, including DiGeorge syndrome, prematurity, and other congenital malformations. There was no difference in mortality between TA and TA-IAA (13.7-18.4%, p value = 0.227). No comorbid conditions were associated with an increased mortality in either group. However, patients with TA-IAA had a longer post-operative length of stay (LOS) compared to those without IAA (30 versus 40.3 days, p value = 0.001) and this effect was additive with each additional comorbid condition. In conclusion, the addition of IAA to TA is associated with an increased post-operative LOS, but does not increase in-hospital mortality.

Twenty-Year Experience with Truncus Arteriosus Repair: Changes in Risk Factors in the Current Era

Although the clinical outcomes of truncus arteriosus (TA) repair have been improving, few data are available on long-term outcomes after truncus arteriosus repair in the current era. This study evaluated long-term outcome after repair of TA. Fifty-one patients underwent total correction from April 1982 to June 2018. Since 2003, perioperative strategy has changed to minimal priming volume, modified ultrafiltration, and early total repair (n = 26). Mortality and reoperation rates were analyzed before and after 2003. There were 8 hospital deaths after initial operation, all before 1997. During the mean follow-up of 9.8 years, there were 2 deaths. The Kaplan-Meier estimate of survival among all hospital survivors was 94.7% at 5 years and 88.0% at 20 years. A significant independent risk factor for early mortality was operation before 2003 (Hazard ratio (HR) 9.710, p = 0.041) and REV operation (HR 8.000, p = 0.028). Freedom from reoperation for conduit change and TV repair were 88.3% and 41% at 1 and 5 years, and 96.2% and 85.4% at 1 and 5 years, respectively. After 2003, younger age and conduit choice were risk factors for conduit-related reoperation. Initial preoperative TV regurgitation was independent risk factor for sequential TV repair. Patients with TA can undergo total repair of TA with excellent results, especially in current era. Most of the patients require conduit-related reoperations. Younger age and the methods of RVOT reconstruction were risk factors for conduit-related reoperations. TV repair is necessary in limited patients, and initial regurgitation was a risk factor.

Alternative techniques of right ventricular outflow tract reconstruction for surgical repair of truncus arteriosus

OBJECTIVES

This study aimed to evaluate the outcomes and feasibility of different techniques of reconstruction of the right ventricular outflow tract (RVOT) in surgical repair of truncus arteriosus.

METHODS

We retrospectively reviewed all consecutive patients with truncus arteriosus who underwent successful surgical repair in our centre between 1994 and 2017. We analysed late results according to the type of RVOT repair.

RESULTS

We collected data from 29 survivors after truncus arteriosus repair. Six (20%) of them were affected by DiGeorge syndrome. The RVOT reconstruction was achieved using a valved conduit in 58.6%, while a direct right ventricle-pulmonary artery (RV-PA) anastomosis, with or without the interposition of the left atrial appendage, was performed in the remaining. At a median follow-up time of 7.9 years (interquartile range 1.8-13.1), 6 patients (3 affected by DiGeorge syndrome) died. Between the 2 groups, there were no differences in terms of the late mortality and onset of adverse events. However, the use of a conduit seemed more prone to reintervention and onset of adverse events.

CONCLUSIONS

Different RVOT reconstruction techniques are safe and have similar late outcomes. However, use of a direct RV-PA anastomosis and left atrial appendage interposition may reduce the need for reoperation in the long term.

Outcomes after common arterial trunk repair: Impact of the surgical technique

OBJECTIVES

We compared the risk of mortality and reintervention after common arterial trunk (CAT) repair for different surgical techniques, in particular the reconstruction of the right ventricle outflow tract with left atrial appendage (LAA) without a monocusp.

METHODS

The study population comprised 125 patients with repaired CAT who were followed-up at our institution between 2000 and 2018. Statistical analysis included Cox proportional hazard models.

RESULTS

Median follow-up was 10.6 years. The 10-year survival rate was 88.2% (95% confidence interval [CI], 80.6-92.4) with the poorest outcome for CAT type IV (64.3%; 95% CI, 36.8-82.3; P < .01). In multivariable analysis, coronary anomalies (hazard ratio [HR], 11.63 [3.84-35.29], P < .001) and CAT with interrupted aortic arch (HR, 6.50 [2.10-20.16], P = .001) were substantial and independent risk factors for mortality. Initial repair with LAA was not associated with an increased risk of mortality (HR, 0.37 [0.11-1.24], P = .11). The median age at reintervention was 3.6 years [7.3 days-13.1 years]. At 10 years, freedom from reintervention was greater in the group with LAA repair compared with the valved conduit group, 73.3% (95% CI, 41.3-89.4) versus 17.2% (95% CI, 9.2-27.4) (P < .001), respectively. Using a valved conduit for repair (HR, 4.79 [2.45-9.39], P < .001), truncal valve insufficiency (HR, 2.92 [1.62-5.26], P < .001) and DiGeorge syndrome (HR, 2.01 [1.15-3.51], P = .01) were independent and clinically important risk factors for reintervention.

CONCLUSIONS

For the repair of CAT, the LAA technique for right ventricle outflow tract reconstruction was associated with comparable survival and greater freedom from reintervention than the use of a valved conduit.

Surgery for Truncus Arteriosus: Contemporary Practice

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

Truncus arteriosus repair: A 40-year multicenter perspective

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Single-centre 20-year experience with repair of truncus arteriosus

OBJECTIVES

We analysed a large series of truncus arteriosus repairs with a focus on early and late outcomes.

METHODS

Ninety-seven consecutive patients who underwent truncus arteriosus repair (1997-2017) were included retrospectively. Univariable analysis for mortality and reintervention was performed.

RESULTS

The early mortality rate decreased from 45% (1997-2007; 14/31) to 4.5% (2008-2017; 3/66) (P = 0.001). Repair beyond the neonatal period (P = 0.03) and direct connection for right ventricular outflow tract reconstruction (P = 0.001) were associated with early death by univariable analysis. Overall survival was 68 ± 6.0% at 15 years; a majority of the deaths (90%; 9/10) occurred within the first year after repair. Freedom from the first and second conduit reoperations at 10 years was 22.9% and 89%, respectively. Freedom from truncal valve (TrV) reoperation was 83.9% at 15 years. Initial TrV insufficiency ≥ moderate was associated with a TrV reoperation (P = 0.008) with freedom from TrV reoperation in this subgroup of 58.3% at 10 years. Freedom from TrV reoperation for quadricuspid and tricuspid TrVs was 66.8% and 93.8% at 10 years with 100% for bicuspid TrVs at 8 years. At the last follow-up, 98.5% (69/70) were in New York Heart Association functional class I-II.

CONCLUSIONS

In the current era, truncus arteriosus can be repaired with a low early mortality rate and a good long-term outcome. A significant reintervention burden still persists. Direct connection is associated with early mortality.

Clarifying the anatomy of common arterial trunk: a clinical study of 70 patients

Aims

Anatomic variations in hearts with common arterial trunk are well-known, although there is no large study of living patients. Detailed knowledge of the origins of the pulmonary and coronary arteries is vital for surgical management. We sought to clarify the variations using computed tomography.

Methods and results

We prospectively studied 70 consecutive patients using echocardiography and computed tomography. In 63 (90%) patients, there was aortic dominance, while 7 (10%) had dominance of the pulmonary component. In 27 (43%) patients with aortic dominance, part of the pulmonary segment arose from a truncal valvar sinus. A long confluent pulmonary channel was more common in patients with sinusal origin compared to those with non-sinusal origin of the pulmonary segment (19 vs. 0; P = 0.0005). Close proximity between the orifices of the coronary arteries and the pulmonary component was also more frequent with sinusal origin (21 vs. 6; P &lt; 0.001) with 5 (19%) patients having pulmonary flow obstructed by a truncal valvar leaflet.

Conclusion

Sinusal origin of the pulmonary component is common with aortic dominance, frequently in association with a long confluent pulmonary segment, which may be in close proximity to the origin of a coronary artery. One-fifth of patients with sinusal origin of pulmonary component have a truncal valvar leaflet obstructing the pulmonary orifice. These morpho-anatomic findings have important implications for management.

Impact of truncal valve surgery on the outcomes of the truncus arteriosus repair

OBJECTIVES

Preoperative moderate or greater truncal valve (TV) insufficiency is one of the most important factors influencing mortality in children with truncus arteriosus. We therefore sought to determine the impact of TV insufficiency and concomitant TV surgery on children who underwent truncus arteriosus repair at a single institution.

METHODS

We reviewed 180 patients who underwent truncus arteriosus repair between 1979 and 2016. Preoperative echocardiography demonstrated TV insufficiency in 80 patients (mild: 33.9%, 61/180; moderate: 9.4%, 17/180 and severe: 1.1%, 2/180).

RESULTS

Twenty-one patients had concomitant TV surgery with an early mortality of 19% (4/21) and overall survival of 70.8 ± 10.1% at 25 years. There were 60 neonates, 11 of whom had concomitant TV surgery with an early mortality of 27% (3/11) and overall survival of 62.3 ± 15.0% at 20 years. Concomitant TV repair (P = 0.5) was not a risk factor for death. TV reoperation was common in those who had concomitant TV surgery, with freedom from reoperation of 19.2 ± 14.9% at 20 years. In the remaining 159 patients, 14 required subsequent TV surgery, and the freedom from TV surgery was 84.0 ± 4.6% at 20 years. At a median follow-up of 18.5 years, TV insufficiency was none or trivial in 79.6% (109/137) and mild or less in 98.5% (135/137) of patients.

CONCLUSIONS

Most patients with mild TV insufficiency are free from TV surgery up to 25 years. The durability of TV repair is poor. Most patients with moderate or greater TV insufficiency and a quadricuspid TV will require TV surgery.

Characteristics and operative outcomes for children undergoing repair of truncus arteriosus: A contemporary multicenter analysis

OBJECTIVE

We sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort.

METHODS

We conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation, cardiopulmonary resuscitation, or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative extracorporeal membrane oxygenation, 26 (12%) received cardiopulmonary resuscitation, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus before discharge from the nursery (OR, 3.1; 95% CI, 1.3-7.4), cardiopulmonary bypass duration >150 minutes (OR, 3.5; 95% CI, 1.5-8.5), and right ventricle-to-pulmonary artery conduit diameter >50 mm/m² (OR, 4.7; 95% CI, 2.0-11.1).

CONCLUSIONS

In a contemporary multicenter analysis, 20% of children who underwent repair of truncus arteriosus experienced MACE. Early diagnosis, shorter duration of cardiopulmonary bypass, and use of smaller diameter right ventricle-to-pulmonary artery conduits represent potentially modifiable factors that could decrease morbidity and mortality in this fragile patient population.

Contemporary Outcomes and Factors Associated With Mortality After a Fetal or Postnatal Diagnosis of Common Arterial Trunk

BACKGROUND

Common arterial trunk (CAT) is a rare anomaly with a spectrum of pathology. We sought to identify current trends and factors associated with postnatal outcomes.

METHODS

This was a single-centre review including 153 live births with planned surgery. Patients were analyzed as 2 cohorts based on era of CAT diagnosis (1990 to 1999 vs 2000 to 2014) and complexity of disease (simple vs complex). "Complex" required the association with significant aortic arch obstruction, truncal valve (TV) stenosis/regurgitation, and/or branch pulmonary artery (PA) hypoplasia, respectively.

RESULTS

Sixteen (10%) died preoperatively, and this outcome was associated with significant TV stenosis (odds ratio [OR] 4.55; P = 0.01) and regurgitation (OR 3.17; P = 0.04); 130 (95%) of 137 operated infants underwent primary complete repair. Their survival rates to 1 year improved from 54% to 85% after 2000, although this outcome remained substantially lower for cases with a complex vs simple CAT repair (76% vs 95%; OR 6.46; P = 0.006). Other risk factors associated with decreased 1-year survival included diagnosis before 2000 (OR 4.48; P = 0.038) and a lower birth weight (OR 8.0 per kg weight; P = 0.001). Finally, of 93 survivors beyond year 1 of life, 76 (82%) had undergone a total of 224 reinterventions. Only 15 (16%) were alive without any surgical or catheter-based reintervention at study end.

CONCLUSIONS

Despite recent surgical improvements, postnatal mortality continues to be substantial if CAT is complicated by significant pathology of the TV, aortic arch, or branch PAs. Reoperations and catheter interventions are eventualities for most patients during childhood.

Perioperative and Anesthetic Considerations in Truncus Arteriosus

Truncus arteriosus is a congenital cardiac lesion in which failure of embryonic truncal septation results in a single semilunar valve and single arterial trunk providing both pulmonary and systemic circulations. Most patients with this lesion are symptomatic in the neonatal period with cyanosis and/or congestive heart failure and undergo complete repair in the first weeks of life. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with truncus arteriosus.

Surgery for truncus arteriosus

Truncus arteriosus (TA) is a congenital heart defect in which a common arterial trunk supplies systemic, pulmonary and coronary circulation. Associated cardiac anomalies are common. Without surgical treatment, most patients die within infancy. Various operative techniques have evolved over the past 50 years. More recently, many centres have adopted primary repair in the neonatal period or early infancy. The objective of this paper is to describe anatomy, diagnosis, natural history and the technique of operation of TA.

In search of a pediatric cardiac surgeon’s ‘Holy Grail’: the ideal pulmonary conduit

The limited lifespan of all currently available conduits leads to repeat operations and interventional procedures in many children. Each reoperation entails considerable risk to life, expenditure and compromised quality of life as the conduit degenerates. The ideal conduit should be available freely, inexpensive, require no anticoagulation, be resistant to infection, free from thromboembolism, have no gradients or regurgitation and have unlimited durability. This review explores various options as surgeons and researchers endeavor to develop the ideal conduit--which will fulfill all of the above-mentioned criteria. Various currently available conduits are analyzed. Special emphasis is given to tissue-engineered valves and percutaneous valve implantations.

Surgery for common arterial trunk

Surgery for common arterial trunk has evolved over the past 30 years. Current management involves total repair during the neonatal period with excellent expected results. The presence of truncal valve insufficiency or interrupted aortic arch may increase the surgical risk for morbidity and mortality. Current therapy and management continues to evolve.

Modified Lecompte procedure for repair of double-outlet left ventricle

A modification of the Lecompte procedure was used successfully for total correction in 2 boys aged 3 and 6 months with double-outlet left ventricle. The operative procedure and short-term results are evaluated.

Mid-term results after correction of type I and type II persistent truncus arteriosus in older patients

OBJECTIVE

This study aims to analyze long-term results after correction of type I and type II truncus arteriosus in older patients operated in one institution over five years.

METHODS

Between 2006 and 2010, 12 patients, median age 4 years, underwent repair of truncus arteriosus. Repair with reconstruction of the right ventricular to pulmonary artery continuity was performed using a valved conduit in 12 patients.

RESULTS

There was no early mortality. All patients are alive with their original conduit 0.6 to 5 years after correction. No patients required reoperations for conduit dysfunction. Recent clinical examination was undertaken in all patients and they are in good condition.

CONCLUSIONS

Though mean age at operation was higher in this study than published results, the operation should be performed if the pulmonary vascular resistance is under 8 units.m(2) before operation.

Early reintervention on the pulmonary arteries and right ventricular outflow tract after neonatal or early infant repair of truncus arteriosus using homograft conduits

Patients with truncus arteriosus often require pulmonary arterial (PA) and/or right ventricular outflow tract (RVOT) reintervention within the first year of repair. However, little is known about the risk factors for early reintervention on the PAs or RVOT in this population. The objective of the present retrospective cohort study was to determine the risk factors for early PA or RVOT reintervention after repair of truncus arteriosus in neonates and young infants. Of 156 patients ascertained (median age at repair 14 days; 143 early survivors), reinterventions on the RVOT and/or PAs were performed in 109. The first reintervention was catheter therapy in 73 patients (conduit dilation/stenting in 29, PA dilation/stenting in 31, both in 13) and conduit reoperation in 36 patients. The freedom from any RVOT or PA reintervention was 68 ± 4% at 1 year and 48 ± 5% at 2 years. The factors associated with early reintervention (shorter 1-year freedom from reintervention) on univariate analysis were repair quartile, neonatal repair, smaller weight at repair, and smaller implanted conduit size. On multivariable analysis, only smaller conduit size remained significant (multivariable hazard ratio 0.66/mm, range 0.53 to 0.83; p <0.001). The freedom from conduit reoperation was 92 ± 3% at 1 year and 76 ± 4% at 2 years. Overall, the left and right PA sizes were modestly larger than normal by the 1-sample t test, and PA Z scores and the PA area index were not associated with the risk of reintervention. Early reintervention for PA and/or RVOT conduit obstruction is common after neonatal and early infant repair of truncus arteriosus using homograft conduits. A smaller conduit size was associated with early RVOT/PA reintervention. The branch PA size was normal before surgery, suggesting that the PA stenosis in these patients resulted from factors other than intrinsic stenosis or hypoplasia.

Simple Versus Complex Truncus Arteriosus

This study examined simple versus complex forms of truncus arteriosus (TA) results in the current era with regard to mortality, reintervention, and resource utilization. From 1999 to 2008, 42 infants underwent primary repair of TA, including 22 simple forms of TA without associated anomalies and 20 complex forms with risk factors such as interrupted aortic arch (n = 8), coarctation (n = 1), significant truncal valve regurgitation (n = 6), discontinuous pulmonary arteries (n = 3), and truncal valve stenosis (n = 2). There were 4 early deaths (4/42, 9.5%), with no difference between simple TA (2/22, 9.1%) and complex TA (2/20, 10%). Early mortality decreased to 1 patient (1/23, 4%) in the most recent era: 2003-2008. Late mortality occurred in 4 (4/38, 10.5%). Reintervention was required in 12 patients, a median of 2 years postoperatively: for conduit reasons in 8 and combined conduit and truncal valve insufficiency in 4. Actuarial survival was 82% ± 7% at 5 years and freedom from reintervention was 52% ± 17% at 5 years, which are not different between complex and simple forms. Complex TA, age, and weight were not predictors on multivariable analysis for early or late death or reintervention. Complex TA had significantly longer ( P < .05) median length of stay (17 vs 13 days) and intensive care unit intubation times (8 vs 5 days) versus simple TA. Complex TA does not have a higher operative or late mortality risk or increased risk of reintervention compared with simple TA. However, complex patients can be expected to have increased resource utilization as compared with simple forms of TA.

Surgical repair of truncus arteriosus associated with interrupted aortic arch

The surgical repair of truncus arteriosus associated with an interrupted aortic arch (TAC-IAA) requires performing two major procedures at the same time. Due to the small number of patients, there is nearly no surgical learning curve. The surgical technique has greatly improved since the introduction of a homograft patch enlargement of the small ascending aorta. The association with a severe truncal regurgitation is a major risk factor as well as the presence of preoperative multiple organs failure. The series published by single centers are ≪10 patients, which make statistical analysis troublesome. The mortality varies from 0% to 50%. The multicentric study published in 2006 by the Congenital Heart Surgeons Society (CHSS) reports a 68% mortality (34/50). Nevertheless, the results can be excellent in experienced centers using a modern one stage surgical technique, undertaken in the first week of life.

Damus-Rastelli Procedure for Biventricular Repair of Aortic Atresia and Hypoplasia

BACKGROUND

Biventricular repair (BVR) can be achieved in aortic atresia with ventricular septal defect (VSD) by creating a double outlet left ventricle, Damus-Kaye-Stansel procedure and placement of a right ventricular-pulmonary artery conduit. This study is a review of 15 years experience with this "Damus-Rastelli" technique to assess clinical outcomes in comparison with a standard univentricular approach.

METHODS

A review of 16 patients with aortic atresia or complex left ventricular outflow tract obstruction who underwent BVR between 1990 and 2005; a comparison with outcomes for the Norwood I procedure over the same period.

RESULTS

Early mortality was 19% (3 patients) with no deaths in the last 12 years (13 patients). Twelve patients had associated aortic interruption (56%) or coarctation (19%). Anatomic subtype was not a risk for early death. Late age at operation was the only risk factor identified for early death (p = 0.01). Median follow-up was 32 (range, 4 to 190) months. Actuarial survival at one and five years was 60% and 53%, respectively. This compares with an early mortality of 29% (p < 0.01) and actuarial survival of 58% and 50% in the Norwood group. Freedom from reintervention was 68% and 20% at one and five years, respectively. One patient required balloon dilatation of recurrent coarctation, all others were balloon dilatation (n = 2) or surgical (n = 4) conduit replacement. All survivors are currently in New York Heart Association class I.

CONCLUSIONS

Biventricular repair of aortic atresia and VSD can be achieved with results that compare well with univentricular palliation. Despite the need for conduit change, the long-term benefit of a BVR would support this technique. Delay in performing the initial repair may increase mortality.

Truncus Arteriosus Communis: Early and Midterm Results of Early Primary Repair

BACKGROUND

Repair of truncus arteriosus communis (TAC) in the neonatal and early infant period has become standard practice in many centers. We report our experience on early primary repair of TAC, with a focus on early and midterm results.

METHODS

From July 1993 to December 2005, 29 patients with median age 28 days (range, 11 to 127), and median body weight 3.1 kg (range, 2.6 to 5.9 kg), underwent primary repair of TAC. The anatomical type of TAC was as follows: A1-2, 27; A3, 0; and A4, 2. Right ventricular outflow tract was reconstructed with an aortic (n = 7) or pulmonary homograft (n = 8), or a bovine (n = 11) or porcine valved xenograft (n = 3). Follow-up was complete for all patients.

RESULTS

Hospital mortality was 3.4% (1 death due to respiratory infection). At a mean follow-up of 74 months (range, 2 to 149), 1 patient died suddenly 2 months after surgery (6-year actuarial survival 93%). Of the 27 midterm survivors, 14 (52%) underwent 30 interventional procedures including percutaneous balloon dilation with or without stenting for right ventricular outflow tract or branch pulmonary artery obstruction. Eight of them were reoperated on for right ventricle-to-pulmonary artery conduit replacement (n = 8, 23%), and aortic valve regurgitation (n = 1, 3.4%). The overall freedom from any reintervention at 6 years was 50%. Aortic valve regurgitation was trace in 15 patients, mild in 8, moderate in 4. All midterm survivors but 1 (26 of 27) had good ventricular function.

CONCLUSIONS

Truncus arteriosus communis repair can be performed early with very low perioperative mortality and satisfactory midterm morbidity; the latter is mainly attributed to right ventricular outflow tract reconstruction. Interventional cardiac catheterization delays inevitable conduit replacement.

Repair of Truncus Arteriosus and Aortic Arch Interruption: Outcome Analysis

BACKGROUND

The excellent results for repair of truncus arteriosus reported in some centers have not applied to patients with associated interrupted aortic arch. This work aims at understanding the discrepancy of results in our own experience.

PATIENTS AND METHODS

Ten patients among 83 consecutive children with truncus arteriosus repaired from 1987 to September 2004 who had aortic arch interruption were analyzed, with particular emphasis on clinical presentation and outcome. The comprehensive Aristotle complexity score was calculated for each patient. The Kaplan-Meier method was used to estimate survivals.

RESULTS

Preoperative mechanical ventilation was necessary in 5 of the 10 patients; 2 of them were moribund. Associated major lesions were as follows: severe (n = 2) and moderate (n = 4) truncal valve regurgitation, coronary artery anomalies (n = 3) and Di-George's syndrome (n = 4). The comprehensive Aristotle score was at least 20 in 6 patients. There were 5 operative deaths (5 of 10); early mortality was 50% (95% confidence limits: 19% to 81%). These deaths occurred in patients with Aristotle score of 20 or greater (5 of 6 = 83%). All 4 patients who had no moderate or severe truncal valve regurgitation survived the intervention. Survival was a low 37.5% +/- 16.1% from 1 year on compared with a high 95.5% +/- 2.5% for the 73 patients without aortic arch interruption.

CONCLUSIONS

This study confirms the predictive value of the Aristotle score, hospital mortality being significantly correlated with the highest Aristotle score (p = 0.024). To improve outcome in these high-risk patients, preoperative management should be optimized, repair should not be delayed, and regurgitant truncal valve should be repaired or replaced.

The effect of repair technique on postoperative right-sided obstruction in patients with truncus arteriosus

OBJECTIVES

We reviewed our experience with repair of truncus arteriosus to assess the effect of type of right ventricular outflow tract reconstruction on perioperative morbidity, survival, and freedom from catheter-based interventions and reoperation.

METHODS

Patients undergoing repair of truncus arteriosus from June 1990 through February 2004 were evaluated on the basis of operative procedure regarding preoperative and postoperative variables, the need for postoperative catheter-based intervention or reoperation, and survival on the basis of univariate, multivariable, and actuarial analyses.

RESULTS

Of 54 study patients, 15 (28%) received a valved homograft, and 39 (72%) received a direct connection with a variety of hood materials. Five (9.1%) patients died. Valved homograft recipients were more likely to require reoperation than patients receiving direct connections (40% vs 15%, P = .046); however, valved homograft and direct connection recipients had a similar incidence of the combined end point of reoperation or catheter-based intervention (40.0% vs 37.5%, P = .865). Univariate and multivariable modeling demonstrated use of valved homografts or direct connections with an autologous pericardial hood to be predictive of the need for later catheter-based intervention or reoperation. Actuarial analysis demonstrated a trend toward improved outcomes in the direct connection group and within the direct connection cohort, a statistically significant difference on the basis of hood type.

CONCLUSIONS

Although the direct connection technique might not prevent later catheter-based intervention, it does reduce the need for reoperation. Outcomes among direct connection recipients were associated with hood type: polytetrafluoroethylene hoods (W. L. Gore & Associates, Inc, Tempe, Ariz) had the lowest rate of reintervention, and untreated autologous pericardial hoods had the highest rate of reintervention. We report excellent outcomes with primary repair of truncus arteriosus. Where anatomically appropriate, we advocate the direct connection technique.

Problems with the right ventricular outflow tract: a review of morphologic features and current therapeutic options

Repair of complex malformations that necessitate restoration of continuity between the right ventricle and the pulmonary arteries can now safely be performed with low morbidity and mortality. Major concerns still remain on the long-term outlook for these patients, and about the durability of the different prostheses used to restore that continuity, whether during initial correction or at the time of reintervention for failure of the conduit or pulmonary regurgitation. In this review, we discuss the salient morphologic features of the right ventricular outflow tract, and then focus on the indications for early and late intervention, current therapeutic options, and outcomes.

Conduit selection for right ventricular outflow tract reconstruction: contemporary options and outcomes

Reconstruction of the right ventricular outflow tract, with the establishment of an unobstructed pathway between the right ventricle and the pulmonary arteries, is a task that the congenital heart surgeon frequently faces. In situations where this outflow tract is congenitally absent, or the pulmonary valve has been used to replace a dysfunctional left ventricular outflow tract, a conduit is usually required to establish pulmonary blood flow. Cryopreserved homografts are currently favored for this, though these nonviable valved allografts have certain limitations. The following review will further define the problem of right ventricular outflow tract reconstruction, with an emphasis on conduit selection and possible alternatives to conduit repair.