Long-Term Survival and Freedom From Coronary Artery Reintervention After Arterial Switch Operation for Transposition of the Great Arteries: A Population-Based Nationwide Study.

Background The aim of this study was to evaluate long-term survival and freedom from coronary artery reintervention after the arterial switch operation (ASO). Methods and Results This single-center nationwide retrospective study included consecutive children who underwent ASO between 1990 and 2016 (n=605). Long-term outcomes were obtained by cross-mapping individual data with the National Death Registry and the National Registry of Cardiovascular Interventions for adults. A control group was randomly retrieved at a 1:10 ratio from the National Birth and Death Registries. Early mortality was 3.3% and late mortality was 1.7% during a median follow-up of 10 (interquartile range, 5-16) years. The probability of overall survival at 20 years after ASO was 94.9% compared with 99.5% in the background population (hazard ratio [HR] 15.6; 95% CI, 8.9-27.5, P<0.001). Independent multivariable predictors of worse survival were an intramural coronary artery (HR, 5.2; 95% CI, 1.8-15.2, P=0.002) and period of ASO 1990 to 1999 (HR, 4.6; 95% CI, 1.5-13.6, P<0.001). Fourteen patients (2.3%) required 16 coronary artery reoperations. Freedom from coronary artery reintervention at 20 years after ASO was 96%. The only independent multivariable predictor associated with a higher hazard for coronary artery reintervention was an intramural coronary artery (HR, 33.9; 95% CI, 11.8-97.5, P<0.001). Conclusions Long-term survival after ASO is excellent. Coronary artery reinterventions are rare. An intramural coronary artery was an independent predictor associated with a higher risk for coronary artery reintervention and death, regardless of the surgical period.

COMPARISON OF LCP AND INTRAMEDULLARY NAIL OSTEOSYNTHESIS IN CALCANEAL FRACTURES.

OBJECTIVE: This study compared groups of patients with calcaneal fractures of Sanders types II and III. One group was treated with ORIF using an LCP (plate), while the second was treated with a minimally invasive method using a C-Nail. METHODS: The study included 217 patients in the ORIF group and 19 patients in the minimally invasive nail osteosynthesis group. RESULTS: In the LCP group, the outcomes were excellent for 35.7% of the patients; good, 38.9%; satisfactory, 19.7%; and poor, 5.7%. In the C-Nail group, the outcomes were excellent for 36.9% of the patients; good; 31.6%; satisfactory, 21%; and poor, 10.2%. The mean values of the restoration of Böhler's angle from post-injury were 6.8° to 32.3° in the LCP group and 7.1° to 33.3° in the C-Nail group. After 12 months, there was only a minimal decrease in Böhler's angle to 29.2° in both the LCP and C-Nail groups. CONCLUSION: The outcomes obtained with C-Nail fixation are statistically identical to those obtained with LCP fixation. We conclude that osteosynthesis with a C-Nail is suitable as the first-choice treatment for Sanders types II and III fractures. Level of evidence IV, retrospective observational study.

OBJETIVO: Comparar grupos de pacientes com fratura intra-articular do calcâneo tipos II e III de Sanders. MÉTODOS: Estudo retrospectivo que incluiu 217 pacientes no grupo tratado por redução aberta e fixação interna com placa de compressão (Grupo PC) e 19 pacientes que seguiram um método minimamente invasivo com C-Nail. RESULTADOS: No Grupo PC, os resultados foram excelentes em 35,7%, bons em 38,9%, satisfatórios em 19,17% e ruins em 5,7%. Os resultados registados no grupo que recebeu implante de unha foram excelentes em 36,9%, bons em 31,6%, satisfatórios em 21% e ruins em 10,2% Os valores médios do restauro do ângulo de Böhler desde o pós-ferimento variaram entre 6,8° e 32,3°, no Grupo PC, e entre 7,1° e 33,3°, no grupo tratado com C-Nail. Ao fim de 12 meses, apenas se observou redução mínima do ângulo de Böhler para 29,2° nos dois grupos. CONCLUSÃO: Os resultados do método recentemente introduzido de osteossíntese minimamente invasiva com C-Nail são estatisticamente idênticos aos obtidos pela redução aberta e fixação interna com placa de compressão. Assim, o novo tipo de osteossíntese com C-Nail é adequado como primeira escolha em fraturas do tipo Sanders II e III. Nível de evidência IV, Estudo retrospectivo de observação.

Comparison of lcp and intramedullary nail osteosynthesis in calcaneal fractures / Comparação entre placa de osteossíntese e haste intramedular em fratura do calcâneo

ABSTRACT Objective: This study compared groups of patients with calcaneal fractures of Sanders types II and III. One group was treated with ORIF using an LCP (plate), while the second was treated with a minimally invasive method using a C-Nail. Methods: The study included 217 patients in the ORIF group and 19 patients in the minimally invasive nail osteosynthesis group. Results: In the LCP group, the outcomes were excellent for 35.7% of the patients; good, 38.9%; satisfactory, 19.7%; and poor, 5.7%. In the C-Nail group, the outcomes were excellent for 36.9% of the patients; good; 31.6%; satisfactory, 21%; and poor, 10.2%. The mean values of the restoration of Böhler's angle from post-injury were 6.8° to 32.3° in the LCP group and 7.1° to 33.3° in the C-Nail group. After 12 months, there was only a minimal decrease in Böhler's angle to 29.2° in both the LCP and C-Nail groups. Conclusion: The outcomes obtained with C-Nail fixation are statistically identical to those obtained with LCP fixation. We conclude that osteosynthesis with a C-Nail is suitable as the first-choice treatment for Sanders types II and III fractures. Level of evidence IV, retrospective observational study.

RESUMO Objetivo: Comparar grupos de pacientes com fratura intra-articular do calcâneo tipos II e III de Sanders. Métodos: Estudo retrospectivo que incluiu 217 pacientes no grupo tratado por redução aberta e fixação interna com placa de compressão (Grupo PC) e 19 pacientes que seguiram um método minimamente invasivo com C-Nail. Resultados: No Grupo PC, os resultados foram excelentes em 35,7%, bons em 38,9%, satisfatórios em 19,17% e ruins em 5,7%. Os resultados registados no grupo que recebeu implante de unha foram excelentes em 36,9%, bons em 31,6%, satisfatórios em 21% e ruins em 10,2% Os valores médios do restauro do ângulo de Böhler desde o pós-ferimento variaram entre 6,8° e 32,3°, no Grupo PC, e entre 7,1° e 33,3°, no grupo tratado com C-Nail. Ao fim de 12 meses, apenas se observou redução mínima do ângulo de Böhler para 29,2° nos dois grupos. Conclusão: Os resultados do método recentemente introduzido de osteossíntese minimamente invasiva com C-Nail são estatisticamente idênticos aos obtidos pela redução aberta e fixação interna com placa de compressão. Assim, o novo tipo de osteossíntese com C-Nail é adequado como primeira escolha em fraturas do tipo Sanders II e III. Nível de evidência IV, Estudo retrospectivo de observação.

Histochemical and histological changes of paraspinal muscles in patients with thoracic and lumbar spine fractures treated with open and minimally invasive stabilisation.

BACKGROUND: Histological and histochemical analyses of muscle samples were used to determine the intensity of paraspinal muscle injury during open (OPEN) and minimally invasive (MIS) procedures due to spinal trauma. OBJECTIVE: A randomised prospective study design was chosen. According to our hypothesis, OPEN procedures will lead to more intensive microscopic changes than MIS. METHODS: Muscle samples were collected during the primary surgery - fracture surgery (FRS) from the left and during material extraction (EXS) from the right side. Complete samples were acquired from 17 OPEN and 18 MIS subjects. We compared them histochemically and histologically; muscle fibre typing and statistical analysis were performed. RESULTS: We statistically confirmed that the increase in fibrosis in the OPEN EXS sample was significantly higher than in the MIS EXS sample, with p< 0.05 (p= 0.000322453). Fibre types in MIS did not differ almost at all in both samples; the changes were statistically insignificant.In OPEN samples, the number of type I fibres differed significantly. In EXS, it was significantly lower (46.23%) than in FRS (60.63%), at a statistically significant level, p< 0.05 (p= 0.0234375000) especially with the increase of the type IIA fibres, less in IIB fibres. CONCLUSIONS: These microscopic findings provide a statistically significant confirmation that OPEN procedures in spinal fracture lead, in most cases, to significant changes in the structure of the corset muscle at the fracture site and surgical access point than MIS procedures.

Acute right ventricular resynchronization improves haemodynamics in children after surgical repair of tetralogy of Fallot.

Aims: Right bundle branch block is associated with right ventricular (RV) electromechanical dyssynchrony, which may contribute to acute haemodynamic impairment after repair of tetralogy of Fallot (ToF). We sought to evaluate the effects of RV resynchronization on haemodynamics and tissue oxygenation during the first 24 h after surgery. Methods and results: Arterial pressures, cardiac output, and tissue oxygenation were measured in 28 consecutive patients (median age 10.1 months) during baseline sinus rhythm with right bundle branch block and after RV resynchronization by atrial-triggered RV free wall pacing in complete fusion with spontaneous activation. Studied variables were compared in a crossover design in four 5-min intervals (baseline rhythm and stimulation, 2x each). Resynchronization reduced the QRS complex duration from median 110 to 70 ms (P < 0.001), increased significantly median arterial systolic, mean and pulse pressure, cardiac index, left ventricular maximum +dP/dT and decreased central venous pressure (P < 0.001 for all). Both cerebral and renal oxygenation improved (P < 0.001). Eleven of the 28 patients showed a clinically highly significant resynchronization effect defined as an increase in arterial pulse pressure of ≥ 10%. The q-RV interval (expressed as % of QRS duration) at the RV pacing site during baseline rhythm was the only predictor of resynchronization effect. Conclusions: RV resynchronization carried short-term improvement of haemodynamics in children early after surgery for ToF and might be a useful non-pharmacologic adjunct to the management of haemodynamically compromised patients. Resynchronization effect was maximized when pacing from area of the latest RV activation.

Permanent epicardial pacing in children: long-term results and factors modifying outcome.

AIMS: To evaluate the results of permanent epicardial pacing in children. METHODS AND RESULTS: All consecutive patients from one country (n = 119, period 1977-2009) undergoing permanent epicardial pacemaker implantation at <18 years of age (median 1.8 years, inter-quartile range 0.3-6.4 years) were studied retrospectively. Median patient follow up was 6.4 years (inter-quartile range 2.9-11.1 years); 207 generators, 89 atrial and 153 ventricular pacing leads were implanted. The probability of absence of any pacing system dysfunction was 70.1 and 47.2% at 5 and 10 years after implantation, respectively. Overall probability of continued epicardial pacing was 92.8 and 76.1% at 5 and 10 years, respectively, and increased in the recent implantation era (post-2000, P = 0.04). The use of steroid-eluting leads decreased the risk of exit block with a hazard ratio (HR) of 0.20 [95% confidence interval (CI) 0.09-0.44, P < 0.001)]. The use of bipolar Medtronic 4968 leads reduced the risk of surgical reintervention because of fracture, insulation break, outgrowth or exit block in comparison to the unipolar 4965 lead design (HR 0.12, 95% CI 0.04-0.40, P < 0.001). The AutoCapture™ feature (HR 0.08, 95% CI 0.02-0.36, P < 0.001) and steroid-eluting leads (HR 0.30, 95% CI 0.11-0.84, P = 0.021) decreased the risk of battery depletion. CONCLUSION: The probability of continued epicardial pacing in children was 76% at 10 years after implantation, increased for implantation in recent years, and allowed transvenous pacing to be deferred to a significantly greater age. The use of bipolar steroid-eluting leads and of a beat-to-beat capture tracking feature significantly increased pacing system longevity and decreased the need for surgical reinterventions.

Differential effects of the site of permanent epicardial pacing on left ventricular synchrony and function in the young: implications for lead placement.

AIMS: To analyse left ventricular (LV) synchrony and function with respect to the epicardial pacing site in the young. METHODS AND RESULTS: Left ventricular function and synchrony (M-mode, speckle tracking) were evaluated during mid-term follow-up in 32 children with complete non-surgical (n = 15) or surgical (n = 17) atrioventricular block (structural heart disease in 21/32) paced from LV apex (n = 19), right ventricular (RV) apex (n = 7), and RV free wall (n = 6), respectively. Data are in the following order: LV apical, RV apical, and RV free wall pacing. Septal to posterior wall motion delay (SPWMD) = median 0, 69, and 136 ms (P < 0.001), septal to lateral mechanical delay = 54 +/- 29, 73 +/- 24, and 129 +/- 70 ms (P = 0.001), apical to basal mechanical delay = 96 +/- 37, 106 +/- 50, and 79 +/- 18 ms (P NS), and LV ejection fraction (LVEF) = 57 +/- 9, 49 +/- 12, and 33 +/- 10% (P < 0.001), respectively. Left ventricular ejection fraction correlated negatively with SPWMD (R(2) = 0.454, P < 0.001) and septal to lateral mechanical delay (R(2) = 0.320, P < 0.001) but not with apical to basal mechanical delay. Right ventricular free wall pacing (P = 0.014) and SPWMD (P = 0.044) were negative multivariable predictors of LVEF. CONCLUSION: Compared with other sites, LV apical pacing preserves septal to lateral LV synchrony and systolic function and may be the preferred epicardial pacing site in the young.

Haemodynamic changes due to delayed sternal closure in newborns after surgery for congenital cardiac malformations.

BACKGROUND: Delayed sternal closure is used to prevent low cardiac output syndrome in selected newborns shortly after cardiac surgery for congenital cardiac defects. Sternal closure itself often causes haemodynamic and ventilatory instability that cannot be entirely assessed by standard monitoring means. Therefore, we used transpulmonary thermodilution technique for an exact evaluation of the haemodynamic changes. PATIENTS AND METHODS: Between April, 2006, and December, 2008, 23 neonates aged from 1 to 30 days, with a median of 7 days, and weighing from 1.9 to 4.2 kilograms, with a median of 3.25 kilograms, were studied after biventricular corrections. Residual intracardiac shunts were excluded by echocardiography. Haemodynamic and ventilatory parameters, along with those obtained by the transpulmonary thermodilution technique, were recorded before and immediately after the sternal closure, and then at 0.5, 1, 2, 6, 12, 24, and 48 hours. RESULTS: Chest closure caused significant decrease in systolic arterial pressure from 80.04 +/- 11.48 to 69.48 +/- 9.63 mmHg (p < 0.001), cardiac index from [median (25th/75th centile)] 2.640 (2.355/2.950) to 2.070 (1.860/2.420) l/min/m2 (p < 0.001), stroke volume index from 18.50 (16.00/20.00) to 14.00 (11.00/17.00) ml/m2 (p < 0.001), and dynamic lung compliance from 2.45 (2.31/3.00) to 2.30 (2.14/2.77) ml/cmH2O (p = 0.007). Stroke volume variation increased from 14.00 (9.25/16.75) to 18.00 (15.00/21.00) % (p < 0.001). The oxygenation index transitorily increased from 2.50 (2.14/3.15) to 3.36 (2.63/4.29) (p < 0.001). Serum lactate decreased from 1.40 (1.12/2.27) to 1.0 (0.8/1.3)mmol/l, p < 0.001 in coincidence with a haemodynamic stabilisation at a later time after chest closure. Cardiopulmonary instability caused by the sternal closure necessitated therapeutic intervention in 18 of 23 patients (78.3%). CONCLUSION: Delayed sternal closure causes a significant transitory decrease in stroke volume, cardiac output and arterial blood pressure. Also lung compliance and blood oxygenation are temporarily significantly compromised.

Predictors of left ventricular remodelling and failure in right ventricular pacing in the young.

AIMS: To identify risk factors for left ventricular (LV) dysfunction in right ventricular (RV) pacing in the young. methods and results: Left ventricular function was evaluated in 82 paediatric patients with either non-surgical (n = 41) or surgical (n= 41) complete atrioventricular block who have been 100% RV paced for a mean period of 7.4 years. Left ventricular shortening fraction (SF) decreased from a median (range) of 39 (24-62)% prior to implantation to 32 (8-49)% at last follow-up (P < 0.05). Prevalence of a combination of LV dilatation (LV end-diastolic diameter >+2z-values) and dysfunction (SF < 0.26) was found to increase from 1.3% prior to pacemaker implantation to 13.4% (11/82 patients) at last follow-up (P = 0.01). Ten of these 11 patients had progressive LV remodelling and 8 of 11 were symptomatic. The only significant risk factor for the development of LV dilatation and dysfunction was the presence of epicardial RV free wall pacing (OR = 14.3, P < 0.001). Other pre-implantation demographic, diagnostic, and haemodynamic factors including block aetiology, pacing variables, and pacing duration did not show independent significance. CONCLUSION: Right ventricular pacing leads to pathologic LV remodelling in a significant proportion of paediatric patients. The major independent risk factor is the presence of epicardial RV free wall pacing, which should be avoided whenever possible.

Long-term (up to 20 years) results of percutaneous balloon angioplasty of recurrent aortic coarctation without use of stents.

AIMS: To assess the efficacy, safety, and long-term results of the balloon angioplasty of recoarctation. METHODS AND RESULTS: The angioplasty was performed in 99 consecutive patients aged 36 days to 32.6 years (median 268 days). Recoarctation to descending aorta diameter ratio increased from 0.44 (0.35/0.50) to 0.66 (0.57/0.77), P < 0.001. Systolic gradient was reduced from 34.0 (26.0/44.75) to 15.0 (8.25/27.0) mmHg, P < 0.001. In seven patients (7.1%) the procedure was ineffective. One patient (1%) with heart failure died within 24 h after a successful angioplasty and in another (1%) an intimal abruption necessitated surgical revision. The follow-up ranged up to 20.7 years (median 8.1 years). Actuarial probability of survival 20.7 years after the procedure was 0.91, and of reintervention-free survival was 0.44. Older age at the angioplasty was associated with a higher incidence of reinterventions (hazard ratio 1.057; 95% confidence interval 1.012-1.103; P = 0.010). The type of surgery and the recoarctation anatomy did not influence the outcome. In 69 patients aneurysm formation was studied by high-sensitive methods with only one positive finding per 462 patient-years. CONCLUSION: Angioplasty is safe and effective regardless of the type of surgery used and the recoarctation anatomy. Older age at the angioplasty is associated with a higher incidence of reinterventions.