Right ventricle to pulmonary artery conduit: a comparison of long-term graft-related events between bovine jugular vein conduit, aortic homograft, and porcine-valved conduits

Background

The optimal conduit for right ventricle to pulmonary artery (RV-PA) reconstruction does not exist. Reinterventions are common due to conduit stenosis and endocarditis. Tailoring conduit choice according to patients' characteristics could improve the outcomes. The study aimed to compare graft-related events (infective endocarditis, transcatheter pulmonary valve replacement (PVR), transcatheter conduit dilatation, surgical conduit replacement, and transcatheter pulmonary branch intervention for RV-PA reconstruction using bovine jugular vein, aortic homograft, and porcine-valved conduits.

Methods

In a retrospective cohort study, 155 patients with 193 procedures that were done in King Faisal Specialist Hospital and Research Center-Jeddah (KFSHRC JED) for implanting RV-PA conduits from 1999 to 2021 were included. The patients were grouped according to the type of conduit into 3 groups; Group 1 (n=153) received bovine jugular vein (BJVs) grafts, Group 2 (n=29) received aortic homografts, Group 3 (n=11) received porcine-valved conduits. Factors associated with graft-related events were evaluated using stepwise Cox regression analysis.

Results

Patients with BJVs were significantly younger than those with porcine-valved conduits 3 (P=0.009). The weight of BJVs patients was significantly lower than homografts (P=0.002) and porcine-valved conduits patients 3 (P<0.001). The conduit size was as expected significantly lower in BJVs patients than patients who received porcine-valved conduits (P<0.001) and patients who received aortic homografts (P<0.001). There was no difference between Group 2 and 3 (P=0.084). Operative mortality occurred in 13 patients: 12 (7.84%) with BJV conduit and 1 (9.09%) with porcine valved conduit (P=0.351). Male gender [odds ratio (OR): 10.04; 95% confidence interval (CI): 1.28-78.86; P=0.028] and smaller conduit size (OR: 0.78; 95% CI: 0.61-0.99; P=0.048) were associated with increased operative mortality. Freedom from graft-related events at 5 and 10 years was 67% and 52% in BJVs patients, 74% and 36% in patients who received aortic homografts, and 53% in patients who received porcine-valved conduits. Factors associated with increased graft-related events were male gender (HR: 1.58; 95% CI: 1.004-2.50, P=0.048) and younger age (HR: 0.995; 95% CI: 0.991-0.999, P=0.041).

Conclusions

RV-PA reconstruction was associated with low mortality, unrelated to the conduit type. Reinterventions for graft-related events were common. The durability and graft-related events might be comparable among BJV grafts, aortic homografts, and porcine-valved conduits. Factors associated with increased graft-related events in this study were male gender and younger age.

Patent ductus arteriosus stenting versus modified Blalock-Taussig shunt for palliation of duct-dependent pulmonary blood flow lesions

BACKGROUND

Patent ductus arteriosus (PDA) stenting is an alternative to modified Blalock-Taussig shunt (MBTS) as first-stage palliation of duct-dependent lesions. The superiority of one approach over the other is still controversial. Our objective was to compare PDA  stent versusMBTS for palliation in regard to safety, efficacy, and efficiency.

METHODS

From 2010 to 2021, 134 patients had first-stage palliation with either PDA stent (n = 83) or MBTS (n = 51). Twenty-seven patients failed the primary treatment and were converted to the other group. The study endpoints were hospital outcomes, interstage reintervention, and concomitant procedures at the second-stage palliation.

RESULTS

Patients with PDA stent were significantly younger. The prevalence of antegrade pulmonary blood flow (PBF) was higher in patients who had MBTS and graft thrombosis was higher in the PDA stent. Hospital stay was significantly longer in patients who had MBTS. Predictors of prolonged mechanical ventilation were low-weight, MBTS, and conversion. Intensive care unit stay significantly increased with conversion, low-weight, and antegrade PBF. The interstage intervention was required more frequently in PDA-stent group. Predictors of reintervention were conversion and pulmonary atresia with the intact interventricular septum. Pulmonary artery plasty was required more frequently during the second-stage palliation in PDA-stent group.

CONCLUSION

PDA stent is an alternative to MBTS for first-stage palliation. It is associated with shorter hospital stays and avoidance of surgery at the expense of a high rate of stent thrombosis and interstage reintervention. Conversion increased the risk of the procedure. More studies are needed to determine factors that affect PDA-stent outcomes and patient selection criteria.

Recanalization of arterial duct is feasible, effective and its potential risks are treatable

BACKGROUND

Recanalization of arterial duct (AD) is rarely needed.

OBJECTIVE

The aim of this study is to report our experience regarding the feasibility and effectiveness of arterial duct recanalization in three infants and review the relevant literature.

METHODS AND RESULTS

We report on three patients with decreased pulmonary blood flow after initial palliation. The first patient had pulmonary atresia (PA) and an intact ventricular septum. He needed recanalization of the AD after pulmonary valve perforation and dilatation. The second patient had PA and ventricular septal defect (VSD). His AD originated from the left subclavian artery. He required AD recanalization after palliation with a central shunt and clipping of the duct. During intervention he developed a thrombus in the stent, which was treated successfully using thrombolytic treatment. The third patient had PA and VSD. The arterial duct originated from the left subclavian artery and was recanalized after spontaneous closure despite prostaglandin infusion. During the procedure the patient had severe desaturation and bradycardia requiring resuscitation fortwo minutes. All infants had successful arterial duct recanalization and stenting. Additionally, they were clinically stable during follow-up.

CONCLUSION

Arterial duct recanalization and stenting is a feasible and effective procedure in selected cases, and its risks are treatable. Long-term studies are required.

Cardiac rhabdomyoma mimicking haemodynamics of hypoplastic left heart syndrome

Cardiac rhabdomyomas are rare and often regress spontaneously. However, the management of rhabdomyoma with severe inflow and outflow obstructions is a challenge. An infant with a massive left ventricular rhabdomyoma mimicking the haemodynamics of hypoplastic left heart syndrome is reported. Surgery could not be contemplated because the mitral valve leaflets and chordae were imbedded in the tumour mass. The arterial duct (AD) was kept open to perfuse the systemic circulation and palliations with pulmonary artery branch banding and AD stenting were planned. However; while waiting for spontaneous regression of the tumour, the child died of circulatory collapse when 4 weeks old.

Successful percutaneous closure of a secundum atrial septal defect through femoral approach in a patient with interrupted inferior vena cava

Percutaneous closure of secundum atrial septal defect (ASD II) is considered the treatment of choice in the majority of cases. Interrupted inferior vena cava with azygos continuation can make delivery of the occluder difficult or not possible. Transjugular, transhepatic approach or surgery can be the alternative. We present the case of a 53-year-old woman with ASD II and interrupted inferior vena cava, and describe successful atrial septal defect closure under transesophageal echocardiography guidance through transfemoral approach using a modification of the standard technique.

Stent angioplasty: an effective alternative in selected infants with critical native aortic coarctation

Management of native aortic coarctation during early months of life poses therapeutic challenges, and there is no consensus among medical professionals regarding a management plan. Much can be argued about the benefits, limitations, and/or complications of transcatheter versus surgical intervention in such cases. Occasionally, the complexity of the lesions limits management options. Therefore, each patient requires individual management decisions because there is no one therapeutic plan that satisfies all patients. In this report, four critically ill infants who had complex native coarctation are presented. Surgical repair was not possible because of relative contraindications. The patients underwent transcatheter stent implantation (six procedures and seven stents) as a nondefinitive procedure with acceptable results. Three patients improved. One patient did not survive, mainly due to other major complications. Multiple reexpansions of the stents were carried out when indicated. After a mean follow-up of 45 months (range, 41-49), the three survivors were doing fine and had gained an average weight of 9.7 kg (range, 6.6-13.3). At the time of reporting, the relative contraindications no longer exist and the final surgical repair can be carried out. Our experience suggests that in certain situations and in critically ill infants with complex form of coarctation, stent angioplasty can be used as a life-saving palliative procedure. Further reexpansions can be done when required. This may serve as a bridge to major surgical repair in the future.

Resternotomy for a retrosternal cardiac pseudoaneurysm in a 1.5-year- old child: a case report

Cardiac pseudoaneurysm is a contained rupture of the myocardium that can occur after cardiac surgery, chest trauma, and endocarditis. The wall of the pseudoaneurysm consists of fibrous tissue and lacks the structural elements found in a normal cardiac wall, and it is contained by the pericardial adhesions or the epicardial wall. Early surgery is recommended even for asymptomatic patients due to the propensity for rupture and fatal outcome. We report our experience with the surgical approach of a child with a cardiac pseudoaneurysm who had undergone a biventricular repair of a double outlet right ventricle with non-committed ventricular septal defect in the form of intraventricular tunneling.

Phentolamine as a treatment for poor mixing in transposition of the great arteries with adequate intraatrial communication

Patients with transposition of the great arteries often show poor mixing for different reasons, even after adequate balloon atrial septostomy. We present a patient with such a lesion whose clinical status improved dramatically after phentolamine was applied. We believe this improvement is due to reduction in afterload caused by the alpha(2) blocker and also possibly as a response to a presumptive effect of the drug on the diastolic function of the right ventricle, allowing more left-to-right shunt across the atrial septal defect. Both phenomena can improve cardiac output in such a situation.

Transcatheter occlusion of a large left coronary artery to right superior vena cava fistula using the Amplatzer duct occluder device

Transcatheter embolization has become the therapy of choice for most coronary artery fistula. We report a 5.9-kg infant with a coronary artery fistula from the left coronary artery to the right superior vena cava with significant congestive heart failure. The infant underwent successful complete occlusion using the Amplatzer duct occluder.

Balloon dilation of native aortic coarctation in infancy

Balloon dilation of aortic coarctation in neonates and infants remains controversial. Between 2/1985 and 8/1999, 80 patients <12 months of age, with native aortic coarctation underwent balloon dilation. The systolic pressure gradient across the stenosed area was reduced significantly acutely from a mean of 45.6+/-19.4 mmHg to 17.9+/-13.8 mmHg. In 55 (68.8%) patients, the procedure was initially successful with a residual gradient of <20 mmHg. In 12.5% of patients, intimal tears were detected after dilation. In 21.3% of patients, obstruction of the femoral artery occurred, which responded to heparin or streptokinase in all. Two patients developed aneuryms immediately after the first intervention. In 1 case, surgery was performed with a successful aneurysmectomy. Severe complications or death in relation to the procedure were not detected. Long-term follow-up was obtained in 66 of 80 (82.5%) patients in a period between 6 to 174 months (median 29 months). In 22/66 (33%) of the infants, within a mean period of 10.9+/-15.2 months after first intervention, a redilation was necessary. Sixteen of 22 were successful procedures. In the remaining six patients, surgery was performed electively. A total of 30/66 who had follow-up (45%) patients remained free from reintervention or surgery after the first procedure. Further analysis of the data according to age showed that neonates and infants < or =3 months of age had a 90% and 62% higher residual stenosis rate, respectively, than infants >3 months. In this young age group, balloon dilation can only be recommended as palliation in young infants with severe left venticular dysfunction or in the case surgery is prohibitive for other reasons.

Use of low-dose ketamine and/or midazolam for pediatric cardiac catheterization

Ketamine and midazolam are commonly used in children undergoing cardiac catheterization. However, there is controversy regarding the safety of administering these agents in the absence of an anesthesiologist. We retrospectively reviewed pediatric cardiac catheterization procedures at our institution between 1996 and 1997. A total of 154 patients (0.3-192 months) underwent a total of 205 procedures. They received ketamine (n = 79, 1.05 +/- 0.88 mg/kg/hr), midazolam (n = 35, 0.14 +/- 0.09 mg/kg/hr), or both (n = 91; ketamine, 1.13 +/- 0.84 mg/kg/hr; midazolam, 1.57 +/- 1.03 mg/kg//hr). In 18.5% of patients there were complex cardiac lesions. Mean procedure time was 79 +/- 36.2 minutes. Pre- and postprocedure systolic and diastolic mean blood procedure 72 +/- 14 and 68 +/- 12 mmHg, respectively. Pre- and postprocedure O2 saturation was 93.19 +/- 8.72 and 93.63 +/- 8.3, respectively. One patient required intubation, and 15% required oxygen therapy. The mortality rate was zero. The anesthesiologist's assistance was requested by the cardiologist in 21 procedures (group A) and not requested in 184 procedures (group B). The two groups were not different in relation to the drug used (p = 0.283) or the complexity of the cardiac lesions (p = 0.051). However, there was significant difference between the two regarding the need for supporting drugs (3/21 vs 3/184, p = 0.02) or oxygen treatment (7/21 vs 26/184, p = 0.014). No patients in group B required intubation, whereas 14% and 1.6% required oxygen therapy and supporting drugs, respectively. We conclude that low-dose ketamine and midazolam can be administered safely to most pediatric patients by the cardiologist, who can safely predict the need for an anesthesiologist.

Accessory mitral valve tissue in combination with subaortic membrane and significant impairment of left ventricular function

A 6-year-old girl was found to have a combination of accessory mitral valve tissue and subaortic membrane. The association caused left ventricular outflow tract obstruction leading to severe left ventricular dysfunction. Surgical relief of the obstruction resulted in immediate improvement of ventricular function.

Comparison between the safety profile and clinical results of the Cook detachable and Gianturco coils for transcatheter closure of patent ductus arteriosus in 272 patients

OBJECTIVES

We evaluated the occlusion rate and safety of Cook detachable coils versus Gianturco coils in transcatheter closure of patent ductus arteriosus (PDA).

BACKGROUND

The Cook detachable coil recently was introduced in an attempt to improve the safety of transcatheter closure of PDA.

METHODS

Between January 1994 and September 1998, 272 patients underwent transcatheter PDA closure. Cook detachable coils were used in 137 patients, with a mean age of 43.9 months and weight of 13.8 kg. In 135 patients, Gianturco coils were used, with a mean age of 56.8 months and weight of 17.8 kg. The mean narrowest diameter of the PDA in the Cook detachable coil group was 2.85 mm versus 2.32 mm for the Gianturco coil group.

RESULTS

The Cook detachable coil group was younger and weighed less than the Gianturco group (P < 0.05 and 0.02, respectively). Their narrowest PDA diameter was larger (P < 0.01). Embolization rate was significantly lower in the Cook coil group (9[6.5%] of 137 vs 22 (16.3%) of 135; P = < 0.013). The mean follow-up for the Cook coil group was significantly shorter (0.55 years) than for the Gianturco coil group (1.18 years; P < 0.001). On an intention-to-treat basis, complete occlusion by echocardiography was achieved in 99 (72.3%) of 137 patients in the Cook detachable coil group, which was significantly less than the Gianturco coil group (114 [84.4%] of 135; P = 0.008).

CONCLUSION

Cook detachable coils for transcatheter closures of the PDA are safer than Gianturco coils. Hence, children with large ductal can be treated earlier in life. Short-term complete occlusion rate was lower in the Cook detachable coil group. This rate can be explained by a shorter follow-up time, larger ductal diameter, and the different materials used for the detachable coils.

Recanalization of an occluded modified Blalock-Taussig shunt by balloon angioplasty within 12 hours of its construction

An infant developed severe desaturation within a few hours of construction of a modified Blalock-Taussig shunt. Echocardiography revealed that the shunt had become occluded, and this was confirmed angiographically. At catheterisation, therefore, we passed a 0.014" percutaneous transluminal coronary angioplasty wire through the occluded shunt into the right pulmonary artery and then dilated the shunt successfully using a 5 mm coronary angioplasty balloon. Six weeks later, the shunt remained patent.

Radiographic characteristics of Cook detachable and Gianturco coils as well as clinical results of transcatheter closure of the patent ductus arteriosus

PURPOSE

To describe the radiographic appearance of the Gianturco and the Cook detachable coils and present the clinical results in patients who underwent transcatheter closure of patent ductus arteriosus.

MATERIALS AND METHODS

Between January 1994 and June 1997, eighty-two patients underwent closure of patent ductus arteriosus (PDA) using either Gianturco or Cook detachable coils. The chest x-ray and echocardiography of all patients were reviewed and the following parameters were evaluated: 1) the size of the heart (cardiothoracic ratio), 2) the position and the type of the coils in the postero-anterior and the lateral projection, 3) the number of coils used, 4) the existence of residual ductal flow, 5) Doppler velocity in the left pulmonary artery.

RESULTS

Complete occlusion was achieved in 94%, and cardio-thoracic ratio regressed from 0.57 to 0.53 (p < 0.01), after a mean follow-up of 1.2 years. The identification of the different coils on the chest radiograph was successful in only 47% of cases, difficulties arising especially, when multiple coils were used. In 55 patients (67%) the coil position was judged to be optimal, in 27 patients (33%) suboptimal. The latter correlates with the presence of residual shunt. Multiple coils correlated more with a left pulmonary artery flow velocity exceeding 1.5 m/s.

CONCLUSION

Coil-occlusion of patent ductus arteriosus is effective and leads to reduced cardio-thoracic ratio. Radiographic coil identification is possible but may be difficult if multiple coils are deployed. Suboptimal coil position led more often to residual PDA shunt. Multiple coils are more commonly associated with increased LPA velocities, but hemodynamic significant obstruction to flow is rare.

Peri-operative complications following surgical closure of atrial septal defect type II in 232 patients--a baseline study

This study intends to provide a detailed overview of the types and rates of peri-operative complications after surgical correction of an isolated ASD II. The transvenous approach to the occlusion of atrial septal defects has yielded promising results during its first 5 years of clinical trials, but before it can be established as a routine measure, definite proof is needed to demonstrate that its rate of serious complications does at least not exceed that of the surgical closure. Between 1985 and 1992, 232 consecutive patients underwent surgical closure of a secundum atrial septal defect. Among the patients 118 were children (< 18 years; 79 girls and 39 boys) with a mean age of 8.9 +/- 5.2 years (4 months-17 years) and 114 adults (74 women and 40 men) with a mean age of 28.5 +/- 10.8 years (18-69 years). Pre-operatively eight children (6.8%) and eight adults (7%) were treated for right heart failure. Mean pulmonary artery pressure was 20.4 +/- 10.4 mmHg for the children and 19.3 +/- 7 mmHg for the adults. The average pulmonary artery to systemic flow ratios were 2.9:1 and 3:1 for children and adults, respectively. Thirty children (25.4%) and 15 adults (13.2%) underwent patch closure while direct suture was the method used for the remaining patients. Average cardiopulmonary bypass time was 35.7 +/- 17.9 min for the children and 41.5 +/- 19.9 min for the adults. The length of the procedure (skin to skin) was a mean of 116 min in the young group, and 141 min in the adult group.(ABSTRACT TRUNCATED AT 250 WORDS)