Simultaneous Aortic and Pulmonary Valve Replacement in Repaired Congenital Heart Disease.

OBJECTIVES: Patients with congenital heart disease frequently require surgical or percutaneous interventional valve replacement after initial congenital heart defect (CHD) repair. In some of these patients, simultaneous replacement of both semilunar valves is necessary, resulting in increased procedural complexity, morbidity, and mortality. In this study, we analyze the outcomes of simultaneous aortic and pulmonary valve replacements following multiple surgical interventions for CHD. METHODS: This was a retrospective study of 24 patients who after initial repair of CHD underwent single-stage aortic and pulmonary valve replacement at our institution between 2003 and 2021. RESULTS: The mean age of the patients was 28 ± 13 years; the mean time since the last surgery was 15 ± 11 years. Decellularized valved homografts (DVHs) were used in nine patients, and mechanical valves were implanted in seven others. In eight patients, DVHs, biological, and mechanical valves were implanted in various combinations. The mean cardiopulmonary bypass time was 303 ± 104 minutes, and aortic cross-clamp time was 152 ± 73 minutes. Two patients died at 12 and 16 days postoperatively. At a maximum follow-up time of 17 years (mean 7 ± 5 years), 95% of the surviving patients were categorized as New York Heart Association heart failure class I. CONCLUSIONS: Single-stage aortic and pulmonary valve replacement after initial repair of CHD remains challenging with substantial perioperative mortality (8.3%). Nevertheless, long-term survival and clinical status at the latest follow-up were excellent. The valve type had no relevant impact on the postoperative course. The selection of the valves for implantation should take into account operation-specific factors-in particular reoperability-as well as the patients' wishes.

Idiopathic Aneurysm of the Aortic Arch in an Infant.

Congenital aortic aneurysms are rare disorders, usually associated with genetic aortic syndromes. Here, we describe the case of an idiopathic aortic arch aneurysm which had been diagnosed prenatally by fetal echocardiography. The diagnosis was confirmed after birth in the neonatal period and successful surgical resection of the aneurysm was performed at the age of 3 months. The idiopathic etiology of the aneurysm, its localization, and the early surgical resection render this case very unusual.

4D-flow cardiac magnetic resonance imaging after aortic root replacement with long-valved decellularized aortic homografts: comparison to valve-sparing aortic root replacement and healthy controls.

OBJECTIVES: Long-valved decellularized aortic homografts (DAH) may be used in young patients to treat aortic valve disease associated with aortic root dilatation, thereby eliminating the need for prosthetic material and anticoagulation. METHODS: Thirty-three male subjects in 3 equally sized cohorts were compared: patients following DAH implantation with a median age of 29 years [interquartile range (IQR) 27.5-37.5], patients post-valve-sparing aortic root replacement (VSARR), median 44 years (IQR 31.5-49) and healthy controls, median 33 years (IQR 28-40, P = 0.228). Time-resolved three-dimensional phase-contrast cardiac magnetic resonance imaging was performed to assess maximum blood flow velocity, pulse wave velocity, mechanical energy loss (EL), wall shear stress and flow patterns (vorticity, eccentricity, helicity) in 5 different planes of the aorta. RESULTS: The mean time between surgery and cardiovascular magnetic resonance was 2.56 ± 2.0 years in DAH vs 2.67 ± 2.1 in VSARR, P = 0.500. No significant differences in maximum velocity and pulse wave velocity were found between healthy controls and DAH across all planes. Velocity in the proximal aorta was significantly higher in VSARR (182.91 ± 53.91 cm/s, P = 0.032) compared with healthy controls. EL was significantly higher in VSARR in the proximal aorta with 1.85 mW (IQR 1.39-2.95) compared with healthy controls, 1.06 mW (0.91-1.22, P = 0.016), as well as in the entire thoracic aorta. In contrast, there was no significant EL in DAH in the proximal, 1.27 m/W (0.92-1.53, P = 0.296), as well as in the thoracic aorta, 7.7 m/W (5.25-9.90, P = 0.114), compared with healthy controls. There were no significant differences in wall shear stress parameters for all 5 regions of the thoracic aorta between the 3 groups. DAH patients, however, showed more vorticity, helicity and eccentricity in the ascending aorta compared with healthy controls (P < 0.019). CONCLUSIONS: Decellularized long aortic homografts exhibit near to normal haemodynamic parameters 2.5 years postoperatively compared with healthy controls and VSARR.

Pressure-compacted and spider silk-reinforced fibrin demonstrates sufficient biomechanical stability as cardiac patch in vitro.

OBJECTIVE: The generation of bio-/hemocompatible cardiovascular patches with sufficient stability and regenerative potential remains an unmet goal. Thus, the aim of this study was the generation and in vitro biomechanical evaluation of a novel cardiovascular patch composed of pressure-compacted fibrin with embedded spider silk cocoons. METHODS: Fibrin-based patches were cast in a customized circular mold. One cocoon of Nephila odulis spider silk was embedded per patch during the casting process. After polymerization, the fibrin clot was compacted by 2 kg weight for 30 min resulting in thickness reduction from up to 2 cm to <1 mm. Tensile strength and burst pressure was determined after 0 weeks and 14 weeks of storage. A sewing strength test and a long-term load test were performed using a customized device to exert physiological pulsatile stretching of a silicon surface on which the patch had been sutured. RESULTS: Fibrin patches resisted supraphysiological pressures of well over 2000 mmHg. Embedding of spider silk increased tensile force 1.8-fold and tensile strength 1.45-fold (p < .001), resulting in a final strength of 1.07 MPa and increased sewing strength. Storage for 14 weeks decreased tensile strength, but not significantly and suturing properties of the spider silk patches were satisfactory. The long-term load test indicated that the patches were stable for 4 weeks although slight reduction in patch material was observed. CONCLUSION: The combination of compacted fibrin matrices and spider silk cocoons may represent a feasible concept to generate stable and biocompatible cardiovascular patches with regenerative potential.

Pediatric urgent heart transplantation with age or weight mismatched donors: Reducing waiting time by enlarging donor criteria.

BACKGROUND: Despite considerable progress in heart transplantation, pediatric waiting list mortality is still high, and often patients do not have enough time to wait. We hypothesized that extending the donor criteria regarding age and weight mismatch does not significantly affect the early follow-up. METHODS: We retrospectively analyzed our pediatric heart transplantation patients operated on from 2014 to 2020 for high (>3.0) or low (<0.6) donor-recipient weight ratio (DRWR) or chronological age mismatches (donor organ >5 years older than recipient age). This patient cohort constituted "mismatched heart transplantations" (mHTX). We compared mHTX preoperative status, postoperative course, 1-year survival, and early clinical follow-up to standard pediatric heart transplantations (sHTX). RESULTS: We performed 20 pediatric heart transplantations-10 mHTX and 10 sHTX. The minimum DRWR was 0.44, the maximum was 5.60, and the maximum age mismatch was 42.6 years. Median days in the intensive care unit (p = .436) and time-to-first-rejection episode (p = .925) were comparable. Nine patients in each group were alive after 1 year, two patients were operated within 1 year of follow-up. One mHTX patient developed cardiac allograft vasculopathy after 15 months and died 648 days after transplantation (p = .237). All other patients were alive at the end of follow-up and in good clinical conditions (median follow-up for mHTX was 732.5 days, 1149.5 days for sHTX). CONCLUSION: Postoperative course and early follow-up after mHTX were comparable to sHTX. In urgent clinical situations, extended donor criteria may be considered an additional option for pediatric heart transplantation.