Assessing the recently noted surgical outcome of isolated total anomalous pulmonary venous connection repair: A single-secondary center experience

Predicting the Need for Pulmonary Venous Reintervention in Total Anomalous Pulmonary Venous Connection: The Role of Preoperative Echocardiographic Metrics

PURPOSE

Development of postoperative obstruction in total anomalous pulmonary venous connection (TAPVC) is a major cause of morbidity and mortality. Although preoperative echocardiography has often been cited as prognostic of postoperative outcome, its predictive value has not been fully evaluated. Pulmonary venous variability index (PVVI) is an echocardiographic metric developed at our center and previously shown to correlate with preoperative clinical markers and catheterization findings of obstruction. We hypothesized that preoperative PVVI would be superior to maximum and mean velocity for prediction of postsurgical outcome in TAPVC.

METHODS

We performed a retrospective review of TAPVC patients repaired at our center. Preoperative echocardiograms were reviewed for clinical read, and measures of pulmonary venous obstruction including maximum, mean, and minimum velocity and PVVI ([maximum velocity-minimum velocity]/mean velocity) were calculated from spectral Doppler of the pulmonary venous pathway. The outcome was time to surgical or catheter-based pulmonary vein reintervention.

RESULTS

In total, 162 patients were included and 33 (20%) underwent reintervention. On univariate Cox proportional hazards model, single ventricle status, mixed-type TAPVC, and PVVI ≤ 0.5 were predictive of reintervention (hazard ratios of 2.7, p = 0.01; 3.2, p = 0.01; and 2.2, p = 0.03, respectively). Absolute echocardiographic velocities were not associated with the outcome. On multivariate analysis, single ventricle status and mixed-type TAPVC remained significant predictors of reintervention, while PVVI did not.

CONCLUSIONS

Though preoperative PVVI was associated with an increased risk of postoperative reintervention in TAPVC by univariate analysis, multivariate analysis suggests that single ventricle status and TAPVC subtype are the strongest drivers of postoperative outcomes. Preoperative velocities are not predictive of outcome in TAPVC.

Emergency surgery without stabilization prior to surgical repair for total anomalous pulmonary venous connection reduces duration of mechanical ventilation without reducing survival

Background

To examine two different operation timing for treating patients with a total anomalous pulmonary venous connection (TAPVC) who need emergency surgery and to summarize the effects of the two operation strategies.

Methods

A retrospective review of 54 patients with TAPVC who underwent operations within 72 h of presentation between December 2010 and July 2019 at a single institution was conducted. All patients exhibited respiratory or hemodynamic instability that required mechanical ventilation and inotropic support. Forty-four patients received emergency operations between 24 to 72 h due to stabilization of the patient’s condition. Stable hemodynamics were achieved, and a stable internal milieu was maintained before the operation. These patients comprised the Stable group (SG). Rather than being subjected to efforts to obtain stable hemodynamics and maintain a stable internal milieu, ten patients received emergency operations immediately within 24 h of diagnosis or an emergency operation is performed immediately due to uncorrectable acidosis or progressive cardiovascular collapse. These patients comprised the Unstable group (UG). The hospital course, operative data, and outpatient records were reviewed.

Results

In SG group, there were 23 exhibited the supracardiac type, 15 exhibited the cardiac type, 4 exhibited the cardiac type, and 2 exhibited the mixed cardiac type,3 patients were premature, the rest was term infant, PDA was the most common comorbidities (28 patients), the next is severe tricuspid valve regurgitation (21 patients). In UG group, there were 3 exhibited the supracardiac type, 4 exhibited the cardiac type, 3 exhibited the cardiac type, and no patient exhibited the mixed cardiac type, only 1 patient was premature, the rest were term infant. PDA (6 patients) and severe tricuspid valve regurgitation (5 patients) were the top two comorbidities. The median weight, median age at surgery, mean cardiopulmonary bypass (CPB) duration and mean aortic cross-clamp (ACC) duration were not significantly different between the two groups. The median postoperation durations of ventilator support were 8.1 ± 4.6 (2–13) days in the SG group and 4.9 ± 2.1 (2–18) days in the UG group, resulting in a significant difference (p = 0.008), the Post-op days in ICU and Days of hospitalization were 8.64 ± 4.04 days and 19.9 ± 4.27 days in the SG group and 5.6 ± 2.01 days and 14.7 ± 1.75 days in the UG group (P = 0.026 and 0.002). There were 12 hospital mortalities (27.3%) in the SG group and 2 hospital mortalities (20%) in the UG group, resulting in no significant difference in mortality (p = 0.636). Postoperative complications, such as low cardiac output and arrhythmia, were not significantly different between the two groups. The survival rates in the UG and SG groups at 5 years were 87.5 and 89.9%, respectively. There was no difference in survival between the two groups at the latest follow-up (SG group 89.9% versus UG group 87.5%, p = 0.8115).

Conclusion

An emergency operation should be performed immediately without any delay, it can reduce duration of mechanical ventilation and Days of hospitalization without reducing mortality.

Venous Flow Variation Predicts Preoperative Pulmonary Venous Obstruction in Children with Total Anomalous Pulmonary Venous Connection

BACKGROUND

Identifying preoperative pulmonary venous obstruction in total anomalous pulmonary venous connection is important to guide treatment planning and risk prognostication. No standardized echocardiographic definition of obstruction exists in the literature. Definitions based on absolute velocities are affected by technical limitations and variations in pulmonary venous return. The authors developed a metric to quantify pulmonary venous blood flow variation: pulmonary venous variability index (PVVI). The aim of this study was to demonstrate its accuracy in defining obstruction.

METHODS

All patients with total anomalous pulmonary venous connection at a single institution were identified. Echocardiograms were reviewed, and maximum (V_max), mean (V_mean), and minimum (V_min) velocities along the pulmonary venous pathway were measured. PVVI was defined as (V_max - V_min)/V_mean. These metrics were compared with pressures measured on cardiac catheterization. Echocardiographic measures were then compared between patients with and without clinical preoperative obstruction (defined as a need for preoperative intubation, catheter-based intervention, or surgery within 1 day of diagnosis), as well as pulmonary edema by chest radiography and markers of lactic acidosis. One hundred thirty-seven patients were included, with 22 having catheterization pressure recordings.

RESULTS

V_max and V_mean were not different between patients with catheter gradients ≥ 4 and < 4 mm Hg, while PVVI was significantly lower and V_min higher in those with gradients ≥ 4 mm Hg. The composite outcome of preoperative obstruction occurred in 51 patients (37%). Absolute velocities were not different between patients with and without clinical obstruction, while PVVI was significantly lower in patients with obstruction. All metrics except V_max were associated with pulmonary edema; none were associated with blood gas metrics.

CONCLUSIONS

The authors developed a novel quantitative metric of pulmonary venous flow, which was superior to traditional echocardiographic metrics. Decreased PVVI was highly associated with elevated gradients measured by catheterization and clinical preoperative obstruction. These results should aid risk assessment and diagnosis preoperatively in patients with total anomalous pulmonary venous connection.