Pulmonary valve replacement in tetralogy of Fallot - who and how?

BACKGROUND AND AIM: Pulmonary regurgitation is the most common complication in repaired tetralogy of Fallot patients. Severe chronic pulmonary regurgitation can be tolerated for decades, but if not treated, it can progress to symptomatic, irreversible right ventricular dilatation and dysfunction. We investigated clinical associations with pulmonary valve replacement among patients with significative pulmonary regurgitation and how interventional developments can change their management. METHODS: All adult patients with repaired tetralogy of Fallot who were followed at an adult CHD Clinic at a single centre from 1980 to 2022 were included on their first outpatient visit. Follow-up was estimated from the time of correction surgery until one of the following events occurred first: pulmonary valve replacement, death, loss to follow-up or conclusion of the study. RESULTS: We included 221 patients (116 males) with a median age of 19 (18-25). At a median age of 33 (10) years old, 114 (51%) patients presented significant pulmonary regurgitation. Among patients with significant pulmonary regurgitation, pulmonary valve replacement was associated with male gender, older age at surgical repair, and longer QRS duration in adulthood. Pulmonary valve replacement was performed in 50 patients, including four transcatheter pulmonary valve implantations, at a median age of 34 (14) years. CONCLUSION: Pulmonary regurgitation affects a large percentage of tetralogy of Fallot adult patients, requiring a long-term clinical and imaging follow-up. Sex, age at surgical repair and longer QRS are associated with the need of PVR among patients with significative pulmonary regurgitation. Clinical practice and current literature support TPVI as the future gold standard intervention.

Changes in cerebral autoregulation and vasoreactivity after surgical aortic valve replacement: a prospective study.

NEW FINDINGS: What is the central question of this study? How are dynamic cerebral autoregulation and brain vasoreactivity influenced by severe aortic stenosis and its surgical treatment? What are the main findings and their importance? Dynamic cerebral autoregulation is preserved in the long term in patients with severe aortic stenosis and does not change after surgical aortic valve replacement. However, carbon dioxide vasoreactivity is impaired in these patients. ABSTRACT: Surgical aortic valve replacement (SAVR) alters the natural course of severe aortic stenosis (AS). In this study, we aimed to determine the effects of the disease on dynamic cerebral autoregulation and vasoreactivity (VR) and to assess their changes after SAVR. We recruited 23 patients diagnosed with severe AS eligible for SAVR and 15 healthy matched controls. AS patients had lower mean VR to CO2 (P = 0.005) than controls, but dynamic cerebral autoregulation was preserved. Cerebral haemodynamics showed no significant change after SAVR. Patients with smaller baseline aortic valve areas presented with smaller low frequency phase changes after surgery (P = 0.016). Severe AS does not seem to impact dynamic cerebral autoregulation but does reduce VR to CO2 . SAVR does not alter cerebral autoregulation nor vasoreactivity.

A Unique Shunt For Treatment Of A Postoperative Chylothorax.

Postoperative chylothorax can be a serious complication. We report on the case of a neonate who had a postoperative chylothorax immediately after esophageal surgery that did not respond to conservative measures or the first two attempts of surgical management of chylothorax. Lastly, a successful pleuroperitoneal shunt was placed and the patient was discharge at 3-months-old. A pleuroperitoneal shunt is usually the last surgical option but may be a curative measure.

Large congenital pulmonary airway malformation with mucinous cell clusters - a case report.

We report the clinical case of a 38 weeks gestational age neonate, antenatally diagnosed with a left large macrocystic pulmonary malformation conditioning dextrocardia. At birth, he presented with respiratory distress requiring non-invasive ventilation with high-flow nasal cannula (HFNC). A left inferior lobectomy was performed via thoracotomy on day 21 of life. Histological features of the lesion were compatible with congenital pulmonary airway malformation (CPAM) type I with muci- nous cell clusters. No surgical complications were reported and the neonate was discharged six days after surgery. Follow-up two months after surgery was unremarkable.

The role of the hepatic factor on the improvement of arterial oxygenation after a Kawashima procedure: A case report.

BACKGROUND: Anomalies of the systemic venous return to the heart are infrequent, occurring more often in patients with congenital heart disease. CASE REPORT: We present a patient with heterotaxy, univentricular circulation, and hemiazygos return who underwent a Kawashima procedure at 3 years of age. Fourteen years later, she developed increased cyanosis and tiredness. The symptoms clearly improved after an off-pump derivation of the hepatic drainage from the common atrium to the hemiazygos system. CONCLUSIONS: This rare case report addresses the surgical challenges imposed by patients with complex congenital heart disease combined with anomalies in systemic venous return. Although improvement in arterial oxygenation after redirecting hepatic flow to the hemiazygos system in patients previously submitted to a Kawashima procedure has already been reported, the existence of a hepatic factor remains to be recognized.

THORACIC SURGERY IN A COVID-19 FRONTLINE HOSPITAL. ARE THE PATIENTS SAFE?

INTRODUCTION AND OBJECTIVES: COVID-19 pandemic forced a change in health care resources and provision due to the emergence of a new group of patients, requiring extraordinary protective measures and the adoption of new organization for the treatment of urgent or priority COVID-19 negative patients. We reviewed our practice during the first pandemic period to evaluate our surgical outcomes and identify if patients COVID-19 negative submitted to thoracic surgery had an increased risk of being infected or die. METHODS: We retrospectively reviewed our surgical results between 11th March and 15th May 2020. Thirty patients underwent thoracic surgery at the Department of Cardiothoracic Surgery of Centro Hospitalar Universitário de São João. RESULTS: None of the patients was COVID-19 positive and cross-transmission of the disease was not recognized. The majority of patients were admitted from home, with a high priority indication, namely an oncological disease. There was only one case of in-hospital mortality. CONCLUSION: During the first wave of the pandemic it was safe to be admitted and submitted to thoracic surgery at CHUSJ. Our patients, including oncological patients, received the adequate surgical treatment without an increase of risk of death or infection.

A DECEITFUL RIGHT ATRIAL MASS.

This large atrial mass was removed from a 33-yearold patient admitted to the emergency department for severe venous congestion. Its hard texture, grayish discolouration and wall infiltration prompted radical excision and partial atrial reconstruction. Histopathology was compatible with a thrombus, discarding malignancy.

Cardiothoracic surgery during the Covid-19 pandemic: Perioperative care, safety, and surgical results.

BACKGROUND: Covid-19 was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. Responses to this crisis integrated resource allocation for the increased amount of infected patients while maintaining an adequate response to other severe and life-threatening diseases. Though cardiothoracic patients are at high risk for Covid-19 severe illness, postponing surgeries would translate to increased mortality and morbidity. We reviewed our practice during the initial time of the pandemic, with emphasis on safety protocols. METHODS: From 11 March to 15 May 2020, 148 patients underwent surgery at the Department of Cardiothoracic Surgery of Centro Hospitalar Universitário de São João. The clinical characteristics of the patients were retrospectively registered, along with novel containment and infection prevention measures targeting the new coronavirus. RESULTS: The majority of adult cardiac patients were operated on an emergency basis. Hospital mortality was 1.9% (n = 2 patients). Most adult thoracic patients were admitted from home, with a diagnosis of neoplastic disease in 60% of patients. Hospital mortality was 3.3% (1 patient). Fifteen children underwent cardiothoracic surgery. There was no mortality. The infection prevention procedures applied, totally excluded the transmission of Covid-19 in the department. CONCLUSION: While guaranteeing a prompt response to emergent, urgent, and high priority cases, novel safety measures in individual protection, patients circuits, and preoperative diagnoses of symptomatic and asymptomatic infection were adopted. The surgical results corroborate that it was safe to undergo cardiothoracic surgery during the initial time of the Covid-19 pandemic. The new policies will be maintained while the virus stays in the community.

Pulmonary Sequestration Supplied By The Circumflex Artery - A Rare Case Report.

Pulmonary sequestration (PS) is a rare congenital malformation, even more when its arterial supply is a coronary artery. We present a case of a 68-year-old man admitted in the emergency room with an acute coronary syndrome and no evidence of significant coronary disease. Instead, he had an abnormal branch from the circumflex coronary artery nourishing a mass in the left lower pulmonary lobe. A coronary steal phenomenon was proposed to explain the clinical presentation. An anterior left thoracotomy with ligation of the abnormal branch and atypical resection of the lung segment comprising the sequestration was performed.

Early and mid-term haemodynamic performance and clinical outcomes of St. Jude Medical Trifecta™ valve.

BACKGROUND: New models of aortic bioprostheses have proven excellent early haemodynamic profile, but their mid and long-term performance warrants further systematic assessment. The aim of this study is to report clinical and haemodynamic performance of St. Jude Medical Trifecta bioprosthesis during 5 years of implantation. METHODS: We performed a single centre, retrospective, observational and descriptive study including all 556 individuals who underwent aortic valve replacement (AVR) with the Trifecta bioprosthesis (between July of 2011 and June of 2016). Survival and re-intervention were censored in February 2017. Postoperative ambulatory echocardiographic data was available for 490 patients. A complete clinical follow-up was available in 463 individuals (mean follow-up time, 27±17 months). RESULTS: In our sample the mean age was 73±9 years, 57.6% were male and median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 2.9 (interquartile range, 1.6-5.8). There were 301 (54.1%) combined procedures, mostly coronary artery bypass grafting in 170 (30.6%). Overall 30-days mortality was 5.4% (n=30) and cumulative survival at 5-years was 72.3%. There were 23 (4.3%) permanent pacemaker implantations. During follow-up, 5 (0.9%) patients presented non-structural valve dysfunction (NSVD) and 4 (0.8%) underwent reoperation due to prosthesis endocarditis. At the first ambulatory evaluation transvalvular mean gradient and effective orifice area (EOA) were 10.9±4.1 mmHg and 2.0±0.5 cm2, respectively. Severe patient-prosthesis mismatch (PPM) was observed in 5 (1.1%) individuals and moderate in 52 (11.3%). CONCLUSIONS: In a "real-world" clinical setting, our findings support the good overall mid-term haemodynamic and safety profile of the Trifecta bioprosthesis.

Freedom Solo® versus Trifecta® bioprostheses: clinical and haemodynamic evaluation after propensity score matching.

OBJECTIVES: The goal of this study was to compare the stentless Freedom Solo® (FS) and the stented Trifecta® (TF) aortic bioprostheses with regard to haemodynamic profile, left ventricular mass regression and early and late postoperative outcomes and survival. METHODS: A longitudinal cohort study of consecutive patients undergoing aortic valve replacement (2009-16) with either the FS or TF at 1 centre was performed. Local databases and national records were queried. Prosthesis haemodynamics and left ventricular dimensions were obtained from postoperative echocardiograms. After propensity score matching (21 covariates), the Kaplan-Meier and competing risk analyses were performed for survival and the combined outcome of structural valve deterioration and endocarditis, respectively. Haemodynamics and mass regression were assessed by a mixed-effects model including propensity score as a covariate. RESULTS: From a total sample of 397 patients with the FS and 525 TF bioprostheses with a median follow-up time of 4.0 (2.2-6.0) and 2.4 (1.4-3.7) years, respectively, a matched sample of 329 pairs was obtained. Matched groups showed no differences in survival (hazard ratio = 1.04, 95% confidence interval = 0.69-1.56) or cumulative hazards of combined outcome (subdistribution hazard ratio = 0.54, 95% confidence interval = 0.21-1.39). Although the TF showed an improved haemodynamic profile, no difference was found in mass regression. Patients with TF bioprostheses had higher rates of prolonged mechanical ventilation, whereas patients with the FS bioprosthesis showed higher rates of thrombocytopenia. CONCLUSIONS: The TF showed an improved haemodynamic profile compared to the FS, but this did not translate into further reverse remodelling. Postoperative outcomes and survival rates were comparable for both bioprostheses. Long-term follow-up is needed for comparisons with classical bioprosthesis models.

Freedom Solo Versus Trifecta Bioprotheses: Clinical and Hemodynamic Evaluation after Propensity Score Matching.

INTRODUCTION: To compare stentless Freedom Solo and stented Trifecta aortic bioprostheses regarding hemodynamic profile, left ventricular mass regression, early and late postoperative outcomes and survival. METHODS: Longitudinal cohort study of consecutive patients undergoing aortic valve replacement (from 2009 to 2016) with either Freedom Solo or Trifecta at one centre. Local databases and national records were queried. Postoperative echocardiography (3-6 months) was obtained for hemodynamic profile (mean transprosthetic gradient and effective orifice area) and left ventricle mass determination. After propensity score matching (21 covariates), Kaplan-Meier analysis and cumulative incidence analysis were performed for survival and combined outcome of structural valve deterioration and endocarditis, respectively. Hemodynamics and left ventricle mass regression were assessed by a mixed- -effects model including propensity score as a covariate. RESULTS: From a total sample of 397 Freedom Solo and 525 Trifecta patients with a median follow-up time of 4.0 (2.2- 6.0) and 2.4 (1.4-3.7) years, respectively, a matched sample of 329 pairs was obtained. Well-balanced matched groups showed no difference in survival (hazard ratio=1.04, 95% confidence interval=0.69-1.56) or cumulative hazards of combined outcome (subhazard ratio=0.54, 95% confidence interval=0.21-1.39). Although Trifecta showed improved hemodynamic profile compared to Freedom Solo, no differences were found in left ventricle mass regression. CONCLUSION: Trifecta has a slightly improved hemodynamic profile compared to Freedom Solo but this does not translate into differences in the extent of mass regression, postoperative outcomes or survival, which were good and comparable for both bioprostheses. Long-term follow-up is needed for comparisons with older models of bioprostheses.

[Carcinoid syndrome. A clinical report]. / Síndrome Carcinóide: Caso Clínico.

The carcinoid syndrome is a rare clinical entity, coursing with a slow evolution. Patients typically present flush, diarrhea and acute asthma attacks, which often delays the diagnostic until there is cardiac involvement, with more pronounced symptoms. We report the clinical case of a 62 years-old male, with a known significant tricuspid valve disorder. While waiting for cardiac surgery, he presented with an acute abdominal condition, which allowed the detection of a carcinoid syndrome. He underwent surgical excision of the primary tumor (right hemicolectomy), removal of hepatic metastases, and tricuspid valve replacement.