Becoming a congenital heart surgeon: the long and challenging road

Training in congenital cardiac surgery is potentially lengthier and more demanding than training in any other surgical field. The duration of training is proportional to the complexity of the specialization. The expertise of a wide range of procedures is required. There is no doubt that some individuals may acquire the requisite abilities with greater ease than others, but fundamentally, these are capabilities that can be taught and learnt. Moreover, congenital cardiac surgeons are required to have a detailed understanding of pathophysiology and morphology, in addition to the stamina and empathy required to manage these complex patients. A fellowship is just the start of such training and is followed by a long road eventually leading to a lifelong journey to become a qualified congenital cardiac surgeon. Effective mentorship is a prerequisite throughout training to guide surgeons on this journey.

Right ventricular function in Marfan patients remains stable despite (multiple) cardiac interventions

Background

Left-sided heart lesions, namely aortic root aneurysm, mitral valve prolapse and intrinsic left ventricular (LV) dysfunction are an essential part of the cardiovascular phenotype of Marfan syndrome (MFS). While recent data stresses the need for concomitant tricuspid valve repair (TVR) when addressing left-sided heart lesions in non-MFS patients, data on tricuspid valve disease and right ventricular (RV) function in MFS is scarce.

Purpose

We sought to determine changes in RV function, tricuspid valve regurgitation and need for TVR in MFS patients throughout their lifetime, from day of first contact.

Methods

We retrospectively analyzed 183 MFS patients fulfilling Ghent criteria seen at our institution between 1995 and 2019. In this patient population, 136 patients (74%) underwent 170 procedures with cardioplegic arrest. Aortic root surgery was performed in 90% and mitral valve surgery (MVR) in 19% of patients undergoing surgery. TVR was performed in 3.7% of all patients undergoing surgery and 18.5% of patients undergoing MVR. Mean age at time of first intervention was 37.8±14.4 years. Mean age in the group of patients without history of surgery was 20.6±17.5 years. Right ventricular function was evaluated using tricuspid annular plane systolic excursion (TAPSE) by echocardiographic assessment at baseline (defined as most recent exam before surgery, or first available exam in patients without history of surgery), and at last available follow-up (defined as last available exam after surgery, or last available exam prior to subsequent surgery). Mean follow-up (FU) was 7.2±7.1 years.

Results

Patients that underwent surgery with cardioplegic arrest did not experience a significant decrease in RV function over time (mean TAPSE at baseline 22.3±4.7 mm, mean difference −4.0±6.7 mm at last FU after surgery). The same was true for patients undergoing MVR with a mean TAPSE at baseline of 21.5±5.2 mm and a mean difference of −5.6±8.05 mm at last available FU (p=0.664). Freedom from impaired RV function (defined as TAPSE ≤15mm) at 5-, 10- and 15-years FU was 78%, 77%, 73%, respectively. Freedom from severe TR was 100% up to 15 years, and freedom from TVR at 5-, 10- and 15-years FU was 96%. Actuarial survival of all patients at 5-, 10- and 15-years FU was 95.6%, 94.5%, and 91.8%, respectively.

Conclusions

Current data suggests that right-sided heart lesions in MFS patients are rare. RV function remains stable over time despite (multiple) cardiac interventions. Furthermore, the need for TVR is low, independently of whether MVR was performed or not.

Funding Acknowledgement

Type of funding sources: None.

Hemodynamic performance of Edwards Intuity valve in a compliant aortic root model

Numerous designs of bioprosthetic valves exist. The sutureless surgical valve is a newer design concept which combines elements of the transcatheter valve technology with surgical valves. This design aims at shorter and easier implantation. It was the aim of this study to perform hemodynamic and kinematic measurements for this type of valves to serve as a baseline for following studies which investigate the effect of the aortic root on the valve performance. To this end, the Edwards Intuity aortic valve was investigated in a new in vitro flow loop mimicking the left heart. The valve was implanted in a transparent, compliant aortic root model, and the valve kinematics was investigated using a high speed camera together with synchronized hemodynamic measurements of pressures and flows. The valve closure was asynchronous (one by one leaflet), and the valve started to close before the deceleration of the fluid. The aortic root model showed a dilation of the sinuses which was different to the ascending aorta, and the annulus was found to move towards the left ventricle during diastole and towards the aorta during systole.