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Favela JG, Argo MB, McAllister J, Waldrop CL, Huerta S. Gastric Outlet Obstruction from Stomach-Containing Groin Hernias: Case Report and a Systematic Review. J Clin Med 2023; 13:155. [PMID: 38202162 PMCID: PMC10779582 DOI: 10.3390/jcm13010155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
Most abdominopelvic structures can find their way to a groin hernia. However, location, and relative fixation are important for migration. Gastric outlet obstruction (GOO) from a stomach-containing groin hernia (SCOGH) is exceedingly rare. In the current report, we present a 77-year-old man who presented with GOO from SCOGH to our facility. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) of patients presenting with SCOGH since it was first reported in 1802. Ninety-one cases of SCOGH were identified (85 inguinal and six femoral) over the last two centuries (1802-2023). GOO from SCOGH occurred in 48% of patients in one review and 18% in our systematic analysis. Initial presentation ranged from a completely asymptomatic patient to peritonitis. Management varied from entirely conservative treatment to elective hernia repair to emergent laparotomy. Only one case of laparoscopic management was documented. Twenty-one deaths from SCOGH were reported, with most occurring in early manuscripts (1802-1896 [n = 9] and 1910-1997 [n = 10]). In the recent medical era, outcomes for patients with this rare clinical presentation are satisfactory and treatment ranging from conservative, non-operative management to surgical repair should be tailored towards patients' clinical presentation.
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Affiliation(s)
- Juan G. Favela
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI 53792, USA; (J.G.F.); (M.B.A.)
| | - Madison B. Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI 53792, USA; (J.G.F.); (M.B.A.)
| | - Jared McAllister
- Department of Surgery, VA North Texas Health Care System, Dallas, TX 75216, USA; (J.M.); (C.L.W.)
| | - Caitlyn L. Waldrop
- Department of Surgery, VA North Texas Health Care System, Dallas, TX 75216, USA; (J.M.); (C.L.W.)
| | - Sergio Huerta
- Department of Surgery, VA North Texas Health Care System, Dallas, TX 75216, USA; (J.M.); (C.L.W.)
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Argo MB, Barron DJ, Bondarenko I, Eckhauser A, Gruber PJ, Lambert LM, Paramananthan T, Rahman M, Winlaw DS, Yerebakan C, Alsoufi B, DeCampli WM, Honjo O, Kirklin JK, Prospero C, Ramakrishnan K, St Louis JD, Turek JW, O'Brien JE, Pizarro C, Anagnostopoulos PV, Blackstone EH, Jacobs ML, Jegatheeswaran A, Karamlou T, Stephens EH, Polimenakos AC, Haw MP, McCrindle BW. Hybrid palliation versus nonhybrid management for a multi-institutional cohort of infants with critical left heart obstruction. J Thorac Cardiovasc Surg 2023; 166:1300-1313.e2. [PMID: 37164059 DOI: 10.1016/j.jtcvs.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To compare patient characteristics and overall survival for infants with critical left heart obstruction after hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) versus nonhybrid management (eg, Norwood, primary transplantation, biventricular repair, or transcatheter/surgical aortic valvotomy). METHODS From 2005 to 2019, 1045 infants in the Congenital Heart Surgeons' Society critical left heart obstruction cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent nonhybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the 2 groups was adjusted by applying balancing scores to nonparametric estimates. RESULTS Compared with the nonhybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, noncardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all P values < .03). Unadjusted 12-year survival after hybrid palliation and nonhybrid management, was 55% versus 69%, respectively. After matching, 12-year survival after hybrid palliation versus nonhybrid management was 58% versus 63%, respectively (P = .37). Among matched infants born weighing <2.5 kg, 2-year survival after hybrid palliation versus nonhybrid management was 37% versus 51%, respectively (P = .22). CONCLUSIONS Infants born with critical left heart obstruction who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo nonhybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus nonhybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower-birth-weight infants.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Igor Bondarenko
- Division of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | - Aaron Eckhauser
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Peter J Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Tharini Paramananthan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David S Winlaw
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Ky
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - Carol Prospero
- Division of Pediatric Cardiology, Nemours Children's Hospital Delaware, Wilmington, Del
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tenn
| | - James D St Louis
- Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - James E O'Brien
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, M
| | - Christian Pizarro
- Cardiothoracic Surgery, Nemours Children's Hospital Delaware, Wilmington, Del
| | - Petros V Anagnostopoulos
- Division of Pediatric Cardiothoracic Surgery, University of Wisconsin Health American Family Hospital, Madison, Wis
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Anastasios C Polimenakos
- Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga
| | - Marcus P Haw
- Department of Pediatric Cardiovascular Surgery, Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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3
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Argo MB, Barron DJ, Eghtesady P, Yerebakan C, DeCampli WM, Alsoufi B, Honjo O, Jacobs JP, Paramananthan T, Rahman M, Lambert LM, Jegatheeswaran A, Carrillo SA, Husain SA, Ramakrishnan K, Caldarone CA, Karamlou T, Nelson J, Mannie C, Romano JC, Turek JW, Blackstone EH, Galantowicz ME, Kirklin JK, Mitchell ME, McCrindle BW. Outcomes After Hybrid Palliation for Infants With Critical Left Heart Obstruction. J Am Coll Cardiol 2023; 82:1427-1441. [PMID: 37758438 DOI: 10.1016/j.jacc.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/02/2023] [Accepted: 07/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) is an initial management strategy for infants with critical left heart obstruction and serves as palliation until subsequent operations are pursued. OBJECTIVES This study sought to determine patient characteristics and factors associated with subsequent outcomes for infants who underwent hybrid palliation. METHODS From 2005 to 2019, 214 of 1,236 prospectively enrolled infants within the Congenital Heart Surgeons' Society's critical left heart obstruction cohort underwent hybrid palliation across 24 institutions. Multivariable hazard modeling with competing risk methodology was performed to determine risk and factors associated with outcomes of biventricular repair, Fontan procedure, transplantation, or death. RESULTS Preoperative comorbidities (eg, prematurity, low birth weight, genetic syndrome) were identified in 70% of infants (150 of 214). Median follow-up was 7 years, ranging up to 17 years. Overall 12-year survival was 55%. At 5 years after hybrid palliation, 9% had biventricular repair, 36% had Fontan procedure, 12% had transplantation, 35% died without surgical endpoints, and 8% were alive without an endpoint. Factors associated with transplantation were absence of ductal stent, older age, absent interatrial communication, smaller aortic root size, larger tricuspid valve area z-score, and larger left ventricular volume. Factors associated with death were low birth weight, concomitant genetic syndrome, cardiopulmonary bypass use during hybrid palliation, moderate to severe tricuspid valve regurgitation, and smaller ascending aortic size. CONCLUSIONS Mortality remains high after hybrid palliation for infants with critical left heart obstruction. Nonetheless, hybrid palliation may facilitate biventricular repair for some infants and for others may serve as stabilization for intended functional univentricular palliation or primary transplantation.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
| | - Williams M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tharini Paramananthan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - S Adil Husain
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tennessee, USA
| | | | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer Nelson
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Chelsea Mannie
- Division of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark E Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Jegatheeswaran A, Argo MB, Devlin PJ, Callahan CP, Meza JM, Wilder TJ, Hickey EJ, Karamlou T. The Congenital Heart Surgeons' Society Kirklin/Ashburn Fellowship: The Fellows' Perspective. World J Pediatr Congenit Heart Surg 2023; 14:575-586. [PMID: 37737596 DOI: 10.1177/21501351231190087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Since its establishment in 2001, the Congenital Heart Surgeons' Society John W. Kirklin/David Ashburn Fellowship has contributed substantially to the field of congenital heart surgery research while simultaneously training the next generation of surgeon- scientists. To date, ten fellows (and counting) have successfully completed this rigorous training, producing over 40 published articles focused on longitudinal outcomes from the various Congenital Heart Surgeons' Society cohorts. As the Kirklin/Ashburn Fellowship expands and additional fellows matriculate, its legacy, the network of support, and the contribution to congenital heart surgery research will undoubtedly hold strong.
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Affiliation(s)
- Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, UK
- Children's Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul J Devlin
- Division of Cardiac Surgery and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Connor P Callahan
- Division of Pediatric Cardiothoracic Surgery, University Hospitals Rainbow Babies and Children's, Cleveland, OH, USA
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Travis J Wilder
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Edward J Hickey
- Department of Cardiothoracic Surgery, Texas Children's Hospital, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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5
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Argo MB, Barron DJ, Eghtesady P, Alsoufi B, Honjo O, Yerebakan C, DeCampli WM, Jacobs JP, Carrillo SA, Jegatheeswaran A, Karamlou T, Paramananthan T, Rahman M, Lambert LM, Nelson J, Caldarone CA, Husain SA, Galantowicz ME, Ramakrishnan K, Kirklin JK, Turek JW, Mannie C, Blackstone EH, Mitchell ME, McCrindle BW. Norwood operation versus comprehensive stage II after bilateral pulmonary artery banding palliation for infants with critical left heart obstruction. J Thorac Cardiovasc Surg 2023; 166:943-954.e1. [PMID: 36804212 DOI: 10.1016/j.jtcvs.2023.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/15/2022] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine patient characteristics and outcomes after Norwood versus comprehensive stage II (COMPSII) for infants with critical left heart obstruction who had prior hybrid palliation (bilateral pulmonary artery banding ± ductal stent). METHODS From 23 Congenital Heart Surgeons' Society institutions (2005-2020), 138 infants underwent hybrid palliation followed by either Norwood (n = 73, 53%) or COMPSII (n = 65). Baseline characteristics were compared between Norwood and COMPSII groups. Parametric hazard model with competing risk methodology was used to determine risk and factors associated with outcomes of Fontan, transplantation, or death. RESULTS Infants who underwent Norwood versus COMPSII had a higher prevalence of prematurity (26% vs 14%, P = .08), lower birth weight (median 2.8 vs 3.2 kg, P < .01) and less frequent ductal stenting (37% vs 99%; P < .01). Norwood was performed at a median age of 44 days and median weight of 3.5 kg, versus COMPSII at 162 days and 6.0 kg (both P < .01). Median follow-up was 6.5 years. At 5 years after Norwood and COMPSII, respectively; 50% versus 68% had Fontan (P = .16), 3% versus 5% had transplantation (P = .70), 40% versus 15% died (P = .10), and 7% versus 11% are alive without transition, respectively. For factors associated with either mortality or Fontan, only preoperative mechanical ventilation occurred more frequently in the Norwood group. CONCLUSIONS Higher prevalence of prematurity, lower birth weight, and other patient-related characteristics in the Norwood versus COMPSII groups may influence differences in outcomes that were not statistically significant for this limited risk-adjusted cohort. The clinical decision regarding Norwood versus COMPSII after initial hybrid palliation remains challenging.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, St. Louis, Mo
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Ky
| | - Osami Honjo
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tharini Paramananthan
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Divisions of Cardiovascular Surgery and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jennifer Nelson
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, Mo
| | | | - S Adil Husain
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Mark E Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tenn
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - Chelsea Mannie
- Division of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, St. Louis, Mo
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wis
| | - Brian W McCrindle
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Meza JM, Blackstone EH, Argo MB, Thuita L, Lowry A, Rajeswaran J, Jegatheeswaran A, Caldarone CA, Kirklin JK, DeCampli WM, Pourmoghadam K, Gruber PJ, McCrindle BW. A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation. JTCVS Open 2023; 14:426-440. [PMID: 37425467 PMCID: PMC10329031 DOI: 10.1016/j.xjon.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/28/2023] [Indexed: 07/11/2023]
Abstract
Objective Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.
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Affiliation(s)
- James M. Meza
- Division of Cardiothoracic and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Madison B. Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Ashley Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - James K. Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - William M. DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Kamal Pourmoghadam
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Peter J. Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Brian W. McCrindle
- Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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7
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Howell AJ, Argo MB, Barron DJ. Aortic Atresia or Complex Left Outflow Tract Obstruction in the Presence of a Ventricular Septal Defect. World J Pediatr Congenit Heart Surg 2022; 13:624-630. [PMID: 36053110 PMCID: PMC9442629 DOI: 10.1177/21501351221114881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Severe left outflow tract obstruction (LVOTO) is not always associated with hypoplastic left heart syndrome (HLHS). Aortic valvar atresia or complex LVOTO in the presence of a large ventricular septal defect (VSD) are a rare group of lesions that offer the possibility of biventricular repair. The Yasui procedure is the commonest surgical approach which can be performed as a primary neonatal correction or as a staged procedure with a Norwood followed by a subsequent Rastelli. This article reviews the surgical outcomes and decision-making process. Both strategies are reasonable with the trend toward staged procedure in the setting of the additional interrupted arch, with neonatal survival of > 90% in the modern era and excellent long-term survival. Re-intervention is mostly related to conduit revision and the need for re-operation for LVOTO is rare. Deciding between conventional repair and the Yasui in cases of LVOTO/VSD can be difficult and there are no uniform accepted criteria. In a typical neonate, an aortic annulus < 4.5 mm is generally the limit of acceptability for a conventional repair. In selected cases of LVOTO/VSD, an alternative to the Yasui is the Ross-Konno. Retrospective comparisons between the 2 techniques are difficult due to differing patient characteristics (especially associated with mitral valve disease) but the neonatal Ross has been associated with higher early mortality.
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Affiliation(s)
- Allison J Howell
- Labatt Family Heart Centre, 7979Hospital for Sick Children, Toronto, Ontario, Canada
| | - Madison B Argo
- Labatt Family Heart Centre, 7979Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Labatt Family Heart Centre, 7979Hospital for Sick Children, Toronto, Ontario, Canada
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