Bidirectional glenn surgery without palliative pulmonary artery banding in univentricular heart with unrestricted pulmonary flow. Retrospective multicenter experience

BACKGROUND

Although pulmonary artery banding (PAB) has been generally acknowledged as an initial palliative treatment for patients having single ventricle (SV) physiology and unrestrictive pulmonary blood flow (UPBF), it may result in unfavorable outcomes. Performing bidirectional Glenn (BDG) surgery without initial PAB in some selected cases may avoid the complications associated with PAB and reduce the number of operative procedures for these patients. This research aimed to assess the outcome of BDG surgery performed directly without doing initial PAB in patients with SV-UPBF.

METHODS

This Multicenter retrospective cohort includes all patients with SV-UPBF who had BDG surgery. Patients were separated into two groups. Patients in Group 1 included patients who survived till they received BDG (20 Patients) after initial PAB (28 patients), whereas patients in Group 2 got direct BDG surgery without first performing PAB (16 patients). Cardiac catheterization was done for all patients before BDG surgery. Patients with indexed pulmonary vascular resistance (PVRi) ≥ 5 WU.m2 at baseline or > 3 WU.m2 after vasoreactivity testing were excluded.

RESULTS

Compared with patients who had direct BDG surgery, PAB patients had a higher cumulative mortality rate (32% vs. 0%, P = 0.016), with eight deaths after PAB and one mortality after BDG. There were no statistically significant differences between the patient groups who underwent BDG surgery regarding pulmonary vascular resistance, pulmonary artery pressure, postoperative usage of sildenafil or nitric oxide, intensive care unit stay, or hospital stay after BDG surgery. However, the cumulative durations in the intensive care unit (ICU) and hospital were more prolonged in patients with BDG after PAB (P = 0.003, P = 0.001respectively).

CONCLUSION

Direct BDG surgery without the first PAB is related to improved survival and shorter hospital stays in some selected SV-UPBF patients.

Percutaneous closure of postoperative residual ventricular septal defects, including dehiscence of surgical patches

Background

Percutaneous closure of residual ventricular septal defects (VSDs) after congenital heart surgery may provide a safer and more efficient alternative to redo surgery. This study aimed to evaluate the outcome of transcatheter closure of residual postoperative VSD.

Methods

This multicenter retrospective cohort study was conducted at the tertiary care institutions of King Faisal Specialist Hospital and King Abdulaziz University Hospital, Saudi Arabia, from March 2012 to March 2022. All patients who underwent transcatheter closure of postoperative residual VSD were included. As catheter closure of VSD related to surgical patches is challenging, patients were divided into two groups. Group 1 comprised patients with VSD related to the surgical patches, while Group 2 included residual muscular VSD. Various occluders and approaches were utilized based on the patient's weight and the VSD type, size, and proximity to the cardiac valves. Demographic, echocardiographic, catheterization, and outcome data were collected and analyzed using descriptive and comparative statistics.

Results

Thirty-three patients underwent 37 VSD catheter closure procedures. Twenty-two procedures were done to close residual VSD related to the surgical patch, while fifteen were done for additional muscular VSD. The median age of the patients was 3.3 years, and the interquartile range (IQR) ranged between 9 months and 7 years. The median weight was 13.1 kilograms, with an IQR of 5.1 to 16.8 kilograms. The median pulmonary to systemic flow ratio (QP/QS) was 1.6 with an IQR of 1.5 to 2.44; the median systolic pulmonary pressure was 46 mmHg with an IQR of 32 to 54 mmHg. The median procedure duration was 120 minutes, with an IQR of 90 to 160 minutes. Patients in Group 1 were older and had a lower mean pulmonary pressure than Group 2 (P=0.02, P=0.007, respectively). Of the 37 procedures, 35 (94.6%) were done successfully, while two patients had redo surgery due to failed procedures (one had device embolization). Ten successful catheterizations were performed for infants weighing ≤5 kilograms. The functional heart failure class improved significantly after the closure of the residual VSD. There were three documented mortalities, none related to the procedure. No significant difference between patient groups regarding hospital stay or survival (P=0.660, P=0.791, respectively).

Conclusions

After congenital heart surgery, transcatheter closure of residual VSD may be a safe and effective alternative to surgical closure. It can be applied to various residual VSD using a variety of occluders with satisfactory results. Moreover, using specific approaches can close residual VSD, even in small infants.

Percutaneous coronary stent implantation in children and young infants following surgical repair of congenital heart disease

Background

Coronary artery stent implantation (CSI) in the pediatric population is rare. Only a few reports were published on managing postoperative coronary artery obstruction using coronary stents following surgical repair of congenital heart diseases (CHD). This study aimed to analyze the feasibility, indications, procedural technique, risk factors, and short-term outcomes of CSI after pediatric cardiac surgery.

Methods

In this retrospective cohort study, we reviewed all pediatric patients who underwent surgical repair of CHD requiring postoperative CSI in two cardiac centers (King Abdulaziz University Hospital and King Faisal Specialist Hospital and Research Center) between 2012 and 2022. Survival to hospital discharge was the study's primary outcome. The secondary outcomes included procedural success, duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, need for coronary reintervention, and late mortality. A descriptive analysis was performed for the collected data from the patients' medical records.

Results

Eleven patients who underwent postoperative CSI were identified. The most common anatomic diagnosis was congenital aortic valve stenosis. All patients underwent cardiac catheterization on extracorporeal membrane oxygenation support except one patient, who presented with chest pain after cardiac surgery. Procedural success was achieved in all patients with excellent revascularization documented by post-procedural angiograms. Both patients who had late coronary events after cardiac surgery survived hospital discharge. There was no in-hospital mortality among the two patients who required stenting of only the right coronary artery. The four patients who required more than 120 minutes to complete the procedure had early mortality. After CSI, the median duration of mechanical ventilation and ICU stay was 12 and 17 days, respectively. Six patients (54.5%) survived hospital discharge post-CSI; they did not require re-intervention during the follow-up period (38-1,695 days).

Conclusions

CSI in pediatric patients can be performed with excellent procedural success for treating coronary artery stenosis after cardiac surgery. It could be considered a potential treatment strategy for this population.

Factors affecting the outcomes after bidirectional Glenn shunt: two decades of experience from a tertiary referral center

BACKGROUND

Despite the improved management of patients with a single ventricle, the long-term outcomes are not optimal. We reported the outcomes of the bidirectional Glenn procedure (BDG) and factors affecting the length of hospital stay, operative mortality, and Nakata index before Fontan completion.

RESULTS

This retrospective study included 259 patients who underwent BDG shunt from 2002 to 2020. The primary study outcomes were operative mortality, duration of hospital stay, and Nakata index before Fontan. Mortality occurred in 10 patients after BDG shunt (3.86%). By univariable logistic regression analysis, postoperative mortality after BDG shunt was associated with high preoperative mean pulmonary artery pressure (OR: 1.06 (95% CI 1.01-1.23); P = 0.02). The median duration of hospital stay after BDG shunt was 12 (9-19) days. Multivariable analysis indicated that Norwood palliation before BDG shunt was significantly associated with prolonged hospital stay (β: 0.53 (95% CI 0.12-0.95), P = 0.01). Fontan completion was performed in 144 patients (50.03%), and the pre-Fontan Nataka index was 173 (130.92-225.34) mm²/m². Norwood palliation (β: - 0.61 (95% CI 62.63-20.18), P = 0.003) and preoperative saturation (β: - 2.38 (95% CI - 4.49-0.26), P = 0.03) were inversely associated with pre-Fontan Nakata index in patients who had Fontan completion.

CONCLUSIONS

BDG had a low mortality rate. Pulmonary artery pressure, Norwood palliation, cardiopulmonary bypass time, and pre-BDG shunt saturation were key factors associated with post-BDG outcomes in our series.

The influence of age and weight on the outcomes of complete atrioventricular septal defect repair

Background

The appropriate age and weight for surgical repair of atrioventricular septal defect (AVSD) is an area of controversy. We aimed to study the effect of weight and age at the time of surgical repair for complete AVSD in children less than 2 years of age on postoperative outcomes. A retrospective data review was performed for patients who underwent the AVSD repair from 2012 to 2019 at our institutions. Our primary outcome was the postoperative in-hospital length of stay (LOS). Secondary outcomes included total positive pressure ventilation (PPV), ventilation time, maximum vasoactive–inotropic score (max VIS), and other postoperative complications.

Results

The study included fifty patients. The median age was 191 days, and the median weight was 4.38 kg at the time of surgery. Weight < 4 kg was associated with longer PPV time and postoperative in-hospital LOS (p value of 0.033 and 0.015, respectively). Additionally, they had higher max VIS at 24 h and 48 h than the other groups with bodyweight 4–5.9 kg or ≥ 6 kg (p value of 0.05 and 0.027, respectively). Patients with older age or lower weight at operation had a longer in-hospital LOS and total length of PPV after surgery. There were no postoperative in-hospital deaths.

Conclusions

Older age and lower weight at the time of surgical repair of atrioventricular septal defect could be independent predictors of prolonged postoperative in-hospital length of stay and total length of positive pressure ventilation.

Combined Norwood and cavopulmonary shunt as the first palliation in late presenters with hypoplastic left heart syndrome and single-ventricle lesions

OBJECTIVE

A primary cavopulmonary shunt as a component of the initial Norwood palliation could be an option in patients with hypoplastic left heart syndrome and single-ventricle lesions. We present our initial experience with this approach in carefully selected patients with unrestricted pulmonary blood flow and low pulmonary vascular resistance.

METHODS

The study included 16 patients; the mean age was 137.9 ± 84.2 days. All patients underwent a Norwood palliation consisting of atrial septectomy, Damus-Kaye-Stansel connection, and arch augmentation in addition to the cavopulmonary shunt as the initial palliation.

RESULTS

The mean preoperative pulmonary to systemic blood flow (Qp/Qs) ratio on room air (n = 9) and with 100% oxygen (n = 8) was 5.3 ± 3.2 and 8.6 ± 4.3, respectively. The mean pulmonary vascular resistance on room air (n = 10) and 100% oxygen (n = 9) was 4.8 ± 3.1 and 1.7 ± 0.97 WU/m², respectively. Delayed chest closure was needed in 12 patients, and 6 patients required postoperative inhaled nitric oxide. One patient underwent takedown of the cavopulmonary shunt and construction of the right ventricle to pulmonary artery conduit after 1 month. The mean intensive care unit stay was 18.9 ± 15.4 days. There were 2 in-hospital deaths (48 hours and 8 days after surgery) and 2 postdischarge deaths (6 months and 2 years after hospital discharge). Seven patients have undergone the Fontan completion successfully, and 5 patients await further surgery.

CONCLUSIONS

First-stage Norwood palliation with cavopulmonary shunt for patients with hypoplastic left heart syndrome or single-ventricle lesions is feasible in late presenters with low pulmonary vascular resistance.

Clinical characteristics and outcomes of children with COVID-19 in Saudi Arabia

Objectives:

To determine the demographic and clinical characteristics, underlying comorbidities, and outcomes of children with coronavirus disease 2019 (COVID-19) infection.

Methods:

In this retrospective study, we reported 62 pediatric patients (age <14 years) with confirmed COVID-19 between March 2 and July 1, 2020, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

Results:

Comorbid conditions, including cardiac, neurological, respiratory, and malignant disorders, were reported in 9 patients (14.5%). The most prominent presenting complaints were fever (80.6%) and cough (48.4%). Most of our patients (80.6%) had mild disease, 11.3% had moderate disease, and 8.1% exhibited severe and critical illness. Twenty-one patients (33.9%) were hospitalized, with 4 patients (6.5%) admitted to the pediatric intensive care unit, and 3 (4.8%) patients died.

Conclusion:

All pediatric age groups are susceptible to COVID-19, with no gender difference. COVID-19 infection may result in critical illness and even mortality in subsets of pediatric patients.

Functional recovery of cardiomyopathy induced by atrial tachycardia in children: Insight from cardiac strain imaging

AIM

To evaluate systolic and diastolic cardiac function in children who had cardiomyopathy induced by ectopic atrial tachycardia (EAT).

METHODS

Twenty-two pediatric patients who had cardiomyopathy induced by EAT and 25 age-matched controls were recruited in this case-control study. The patients were examined after rhythm control and normalization of their left ventricular systolic function. Different echocardiographic modalities including tissue Doppler imaging and two-dimension speckle tracking echocardiography were utilized to assess the ventricular and atrial function.

RESULTS

The patients' median age was 51 months (interquartile range: 28.5-84 months). The median time interval required for normalization of left ventricular ejection fraction (EF) among patients was 1.5 months (interquartile range: 1.5-2.12 months). Compared to controls, patients had a significantly higher median left ventricular myocardial performance index (MPI) at the interventricular septum (0.44 vs. 0.38, p = .001) and left ventricular lateral wall (0.46 vs. 0.32, p = .0001). The median right ventricular MPI of the patients' group was significantly higher when compared to the control group (0.34 vs. 0.26, p = .0001). The median right atrial (RA) reservoir function in patients was significantly reduced compared to controls (30% vs. 36.63%, p = .007).

CONCLUSIONS

Shortly after rhythm normalization and restoration of left ventricular EF, using tissue Doppler imaging and two-dimension speckle tracking echocardiography, children who had cardiomyopathy induced by EAT continue to have left ventricular diastolic dysfunction, right ventricular dysfunction, and reduced RA reservoir function.

Impact of coronavirus disease 2019 in a child who underwent ventricular septal defect device closure: a case report

Background

Studies about the incidence and severity of coronavirus disease 2019 (COVID-19) in children are still significantly lower than those in adults. Moreover, data on the effect of COVID-19 in children with congenital heart disease (CHD) are limited. To the best of our knowledge, this study first reported mortality in a child with CHD who acquired COVID-19.

Case summary

A 16-month-old boy presented to the emergency department due to shortness of breath, fever, cough, and poor oral intake. He tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He required mechanical ventilation for rapidly progressing respiratory failure. The patient had a large mid-muscular ventricular septal defect (VSD) that was closed percutaneously at the age of 13 months. Moreover, we followed his hospital sequelae from admission to death.

Discussion

This child had multiple risk factors, including malnutrition and persistent pulmonary hypertension (PH) after late closure of the VSD. The pre-existing PH could have been aggravated by the lung condition associated with COVID-19 and the respiratory failure triggered by SARS-CoV-2 infection. The patient presented with ventricular systolic dysfunction, elevated troponin serum levels and newly developed trifascicular block, which were indicative of myocardial injury. The elevated inflammatory markers and multi-organ dysfunction seem to corroborate multisystem inflammatory syndrome in children, which was described recently among paediatric patients with COVID-19.

Cardiac catheterization addressing early post-operative complications in congenital heart surgery-a single-center experience

BACKGROUND

Cardiac catheterization after congenital heart surgery may play an important role in the diagnosis and management of patients with a complicated or unusual post-operative course. The main objective of this study was to evaluate the safety, efficacy, and outcome of cardiac catheterization performed in the early post-operative period following congenital heart surgery. All patients who underwent cardiac catheterization after congenital heart surgery during the same admission of cardiac surgery from November 2015 to May 2018 were included in the study.

RESULTS

Thirty procedures were performed for 27 patients (20 interventional and 10 diagnostic). The median age of the patients was 15 months (15 days to 20 years), median weight was 8.2 kg (3.4 to 53 kg), and median time from surgery was 3 days (0-32 days). Eleven procedures were performed for 11 patients on extracorporeal membrane oxygenation (ECMO) support. The main indications for catheterization included the inability to wean from ECMO (10 procedures) and cyanosis (10 procedures). Interventional procedures included angioplasty using stents (10 procedures, success rate of 90%), angioplasty using only balloons (2 procedures, success rate of 50%), and occlusion for residual shunts (8 procedures, success rate of 100%). No mortality was recorded during any procedure. Vasoactive-inotropic score had significantly decreased 48 h after catheterization when compared to pre-catheterization scores (p = 0.0001). Moreover, 72% of patients connected to ECMO support were successfully weaned from ECMO after catheterization. Procedural complications were recorded in 3 interventional procedures. Survival to hospital discharge was 55.5% and overall survival was 52%. Patients on ECMO support had a higher mortality than other patients.

CONCLUSION

Cardiac catheterization can be performed safely in the early post-operative period, and it could improve the outcome of the patient (depending on the complexity of the cardiac lesions involved).

The outcomes of bidirectional Glenn before and after 4 months of age: A comparative study

OBJECTIVE

We aim to present our experience with the bidirectional Glenn (BDG) in patients less than 4 months of age and to compare their outcomes with the patients who underwent BDG after the age of 4 months.

METHODS

A retrospective review of data was performed for patients who underwent the BDG procedure from 2002 to 2018 at our institutions. We reviewed the patients' demographics, echocardiographic findings, cardiac catheterization data, operative details, postoperative data, and outcome variables.

RESULTS

The study was conducted on 213 patients. At the time of the BDG operation, 32 patients were younger than 4 months (younger group) and 181 patients were older than 4 months (older group). The preoperative mean pulmonary artery pressure was significantly higher in the younger group (p = .035) but there were no significant differences between both groups in Qp/Qs, ventricular end-diastolic pressure, indexed pulmonary vascular resistance, and preoperative oxygen saturation. However, the initial postoperative oxygen saturation of the younger group was lower than the older group (p = .007). The duration of mechanical ventilation, duration of pleural drainage, ICU stay, and hospital stay after BDG were significantly longer in the younger group compared to the older group. The early mortality was higher in the younger group, but this difference did not reach statistical significance (p = .283).

CONCLUSION

Performing BDG procedure in infants less than 4 months of age is safe, with favorable outcomes. Early BDG is associated with a less-smooth postoperative course without a significant increase in early or late mortality.

Outcomes of biventricular repair for shone's complex

BACKGROUND

Shone's complex is a rare lesion affecting the mitral valve (MV) and left ventricular outflow tract (LVOT). The objective of this study is to report the outcomes after Shone's complex repair, the growth of mitral and aortic valve and LVOT, and long-term survival.

METHODS

This retrospective study included all patients diagnosed with Shone's complex, who underwent biventricular repair. Data including patients' characteristics, type of the MV lesion and the associated lesions were collected. Patients were followed up regularly with echocardiography, and the changes in mitral and aortic valve z-score and LVOT z-score were recorded.

RESULTS

Thirty-seven patients were included in the study, the median age was 3.4 months, and 11 patients (30.6%) had pulmonary hypertension. The main procedure performed during the first surgical intervention was coarctation repair in 26 patients (70%). Twelve patients had MV repair, and five had MV replacement. Operative mortality occurred in 1 patient (2.7%), median follow up was 52 (25-75th percentile: 22-84) months. Survival at 1, 5, and 10 years was 94.4%, 90%, and 76.9%, respectively. Reoperation was required in 13 patients, mainly for LVOT repair (n = 8). Reoperation was significantly associated with associated aortic valve lesion (p = .044). The growth of the MV z-score was 0.35 per year; p < .001, aortic valve z-score 0.086 per year; p = 0.422, and the LVOT z-score was 0.53 per year; p = .01.

CONCLUSION

Biventricular repair of Shone's complex has good outcomes. Reoperation is frequently encountered, especially with low aortic valve z-score. The MV and LVOT have significant growth following Shone's complex repair.

Surgical repair for persistent truncus arteriosus in neonates and older children

Objectives

Persistent truncus arteriosus represents less than 3% of all congenital heart defects. We aim to analyze mid-term outcomes after primary Truncus arteriosus repair at different ages and to identify the risk factors contributing to mortality and the need for intervention after surgical repair.

Methods

This retrospective cohort study included 36 children, underwent repair of Truncus arteriosus in the period from January 2011 to December 2018 in two institutions. We recorded the clinical and echocardiographic data for the patients preoperatively, early postoperative, 6 months postoperative, then every year until their last documented follow-up appointment.

Results

Thirty-six patients had truncus arteriosus repair during the study period. Thirty-one patients had open sternum post-repair, and two patients required extracorporeal membrane oxygenation. Bleeding occurred in 15 patients (41.67%), and operative mortality occurred in 5 patients (14.7%). Patients with truncus arteriosus type 2 (p = 0.008) and 3 (p = 0.001) and who were ventilated preoperatively (p < 0.001) had a longer hospital stay. Surgical re-intervention was required in 8 patients (22.86%), and 11 patients (30.56%) had catheter-based reintervention. Freedom from reintervention was 86% at 1 year, 75% at 2 years and 65% at 3 years. Survival at 1 year was 81% and at 3 years was 76%. High postoperative inotropic score predicted mortality (p = 0.013).

Conclusion

Repair of the truncus arteriosus can be performed safely with low morbidity and mortality, both in neonates, infants, and older children. Re-intervention is common, preferably through a transcatheter approach.

Evolution of ventricular function in children with permanent right ventricular pacing after tetralogy of Fallot repair: A midterm follow-up

OBJECTIVE

We aim to evaluate the midterm effect of chronic apical right ventricular (RV) pacing on right and left ventricular (LV) function using different modalities of echocardiography including conventional echocardiography, tissue Doppler imaging and two-dimension speckle tracking echocardiography.

METHODS

This case-control study enrolled 49 patients divided into two groups: a paced group and a nonpaced group. The paced group included 23 patients that underwent tetralogy of Fallot (TOF) repair and required permanent pacemaker insertion for postoperative complete heart block. The nonpaced group included 26 patients that had TOF repair at the same period.

RESULTS

The median age for the paced and nonpaced groups was 6 and 8 years, respectively (P = .169). The follow-up duration after TOF surgical repair was 4 years for the paced patients and 5 years for nonpaced patients (P = .411). In the nonpaced group, the QRS duration increased and LV global longitudinal strain (GLS) decreased significantly with increasing duration after TOF repair, P value was .006 and .042, respectively. In the paced group, tricuspid annular systolic plane excursion (TAPSE) was significantly correlated with age (r = .578; P = .004) and duration following TOF correction (r = .724; P < .001).

CONCLUSION

Chronic RV apical pacing in children after TOF repair was associated with better clinical status, preservation of RV systolic function, and prevention of progressive QRS prolongation. RV pacing was not associated with progressive deterioration of LV systolic function with increasing the time interval following TOF repair. Therefore, RV pacing can be beneficial in corrected TOF patients presenting with RV failure.

Excess nonhemorrhagic pleural drainage after surgery for congenital heart diseases: Single center experience

OBJECTIVE

Chylothorax after surgery for congenital heart disease is an uncommon but serious complication that adversely affects surgical outcomes. The aim of our study was presenting our experience for the management of postoperative chylothorax and excess nonhemorrhagic pleural drainage.

METHODS

Medical records of patients with excess nonhemorrhagic pleural drainage were retrospectively reviewed and the collected data included demographics, surgical procedures, drainage characteristics, methods of postoperative management, and outcome.

RESULTS

From March 2011 to May 2018, 52 patients with excess postoperative pleural drainage were identified from a total of 816 pediatric patients operated upon for congenital cardiac disease, giving an incidence of 63.7%. Tetralogy of Fallot and single ventricle morphology were the most common cardiac pathology. The serum triglyceride level was checked and found elevated in 30 patients (53.5%). The maximum daily drainage was 136.25 ± 109.7 mL/day and the mean duration of drainage was 32.23 ± 35.7 days. Medium-chain triglyceride formula was given for 27 patients (51.9%), octreotide for 22 (42.3%) for a mean duration of 8.07 ± 28.3 days. Total parenteral nutrition was needed for 11 patients (21.1%) for a mean duration of 3.13 ± 7.63 days. The success rate for conservative management was 94.2%. Thoracic duct ligation performed for three patients. The mean duration of mechanical ventilation was 7.4 ± 3.6 days, mean intensive care unit stay was 29.6 ± 35.1 days, and mean total hospital stay was 20.9 ± 17.5 days. We had six cases of hospital mortality (11.53%).

CONCLUSION

Initiation of a stepwise approach for excess nonhemorrhagic pleural drainage based on the amount and rate of drainage achieve a favorable outcomes.