Bovine jugular vein conduit versus pulmonary homograft in the Ross operation.

OBJECTIVES: The Ross procedure involves using the native pulmonary valve for aortic valve replacement then replacing the pulmonary valve with an allograft or xenograft. We aimed to compare our age-matched experience with the bovine jugular vein conduit and the pulmonary homograft for pulmonary valve replacement during the Ross procedure in children. METHODS: Between 1998 and 2016, 15 patients <18 years of age underwent a Ross procedure using the bovine jugular vein conduit (Ross-Bovine Jugular Vein Conduit) at our institution. These patients were age-matched with 15 patients who had the Ross operation with a standard pulmonary homograft for right ventricular outflow tract reconstruction (Ross-Pulmonary Homograft). Paper and electronic medical records were retrospectively reviewed. RESULTS: The median age of the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft patients were 4.8 years (interquartile range 1.1-6.6) and 3.3 years (interquartile 1.2-7.6), respectively (p = 0.6). The median follow-up time for the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft groups were 1.7 years (interquartile range 0.5-4.9) and 6.8 years (interquartile range 1.9-13.4), respectively (p = 0.03). Overall, 5-year survival, freedom from redo aortic valve replacement, and freedom from pulmonary valve replacement were similar between groups. CONCLUSION: The bovine jugular vein conduit and pulmonary homograft have favourable mid-term durability when used for right ventricular outflow tract reconstruction for the Ross operation. The bovine jugular vein conduit may be a suitable replacement for appropriately sized patients undergoing a Ross aortic valve replacement, though longer follow-up is needed.

Early conversion of classic Fontan conversion may decrease term morbidity: single centre outcomes.

BACKGROUND: The initial classic Fontan utilising a direct right atrial appendage to pulmonary artery anastomosis led to numerous complications. Adults with such complications may benefit from conversion to a total cavo-pulmonary connection, the current standard palliation for children with univentricular hearts. METHODS: A single institution, retrospective chart review was conducted for all Fontan conversion procedures performed from July, 1999 through January, 2017. Variables analysed included age, sex, reason for Fontan conversion, age at Fontan conversion, and early mortality or heart transplant within 1 year after Fontan conversion. RESULTS: A total of 41 Fontan conversion patients were identified. Average age at Fontan conversion was 24.5 ± 9.2 years. Dominant left ventricular physiology was present in 37/41 (90.2%) patients. Right-sided heart failure occurred in 39/41 (95.1%) patients and right atrial dilation was present in 33/41 (80.5%) patients. The most common causes for Fontan conversion included atrial arrhythmia in 37/41 (90.2%), NYHA class II HF or greater in 31/41 (75.6%), ventricular dysfunction in 23/41 (56.1%), and cirrhosis or fibrosis in 7/41 (17.1%) patients. Median post-surgical follow-up was 6.2 ± 4.9 years. Survival rates at 30 days, 1 year, and greater than 1-year post-Fontan conversion were 95.1, 92.7, and 87.8%, respectively. Two patients underwent heart transplant: the first within 1 year of Fontan conversion for heart failure and the second at 5.3 years for liver failure. CONCLUSIONS: Fontan conversion should be considered early when atrial arrhythmias become common rather than waiting for severe heart failure to ensue, and Fontan conversion can be accomplished with an acceptable risk profile.

Regulation of myocardial stromal cell-derived factor 1α/CXCL12 by tumor necrosis factor signaling.

BACKGROUND: Global myocardial ischemia-reperfusion (I/R) occurs during cardiac operations. This I/R injury leads to increased production of tumor necrosis factor α (TNF) instantly and upregulated expression of stromal cell-derived factor 1 α (SDF-1). On the basis of the published data from our laboratory and other groups, locally produced TNF contributes to cardiac dysfunction mainly via binding to its receptor (tumor necrosis factor receptor 1 [TNFR1]), whereas ischemia-induced myocardial SDF-1 mediates cardioprotection. Although TNF has been shown to work as an upstream initiator for induction of other cytokines and chemokines, there is no information regarding the interaction among TNF, TNFRs, and myocardial SDF-1 expression. In this study, given that TNF downregulated SDF-1 in vascular endothelial cells, we therefore hypothesized that TNF would have a negative effect on myocardial SDF-1 production, which is attributable to TNFR-initiated actions. METHODS: Using a Langendorff model, isolated male mouse hearts were infused with TNF for 45 min. Male adult mouse hearts from wild type, TNFR1 knockout (TNFR1KO), TNFR2KO, and TNFR1/2KO were subjected to global I/R. H9c2 cells with small interfering RNA transfection were used as an in vitro model. The levels of SDF-1 (protein and messenger RNA) were detected by enzyme-linked immunosorbent assay and quantitative reverse transcription-polymerase chain reaction . Protein kinases of IκB (nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor α) and c-jun N-terminal kinase were also determined using Western blot assay. RESULTS: TNF infusion downregulated myocardial SDF-1 production in a dose-dependent manner in the hearts. In addition, using TNF significantly decreased SDF-1 expression in cardiomyoblasts (H9c2 cells), which was associated with reduced IκB level. Knockdown of TNFR1 or TNFR2 by small interfering RNAs neutralized TNF-suppressed SDF-1 in H9c2 cells. Furthermore, deletion of TNFR1/2 or TNFR2 increased SDF-1 production in the hearts after I/R. CONCLUSIONS: Our study represents the initial evidence showing that TNF plays an inhibitory role in modulating myocardial SDF-1 production and blockade of TNF signaling by ablation of TNFR1 and TNFR2 genes increased SDF-1 expression in the heart. These data expand on TNF signaling-initiated mechanisms in myocardium, which may lend a more complete understanding of SDF-1 and TNFR-derived actions in hopes of advancing ischemic heart injury treatments.

Training Patterns and Lifetime Career Achievements of US Academic Cardiothoracic Surgeons.

BACKGROUND: We aimed to investigate the impact of taking dedicated time for research (DTR) during training and/or getting a PhD on subsequent career achievements of US academic cardiothoracic surgeons. METHODS: Online resources (institutional Web sites, CTSNet, Scopus, NIH RePORTER) were queried to collect training information (timing of medical school/residency/fellowship graduation, DTR, PhD) and academic metrics (publications, citations, research funding) for 694 academic cardiothoracic surgeons practicing at 56 premiere US institutions. RESULTS: Excluding missing data, 464 (75 %) surgeons took DTR and 156 (25 %) did not; 629 (91 %) were MD only and 65 (9 %) also had a PhD. DTR was associated with higher number of ongoing publications (~5.6/year vs. ~3.8/year), with no difference for accrued number of total citations. History of DTR was more prevalent among surgeons with versus without NIH funding (87 vs. 71 %; p < 0.001), but no difference was seen across academic ranks and among those who were division/department chiefs. No overall increase in publications/citations, academic rank advancement, NIH funding, or leadership roles was found for those with a PhD. CONCLUSIONS: Among cardiothoracic surgeons, devoting time during the training years exclusively to research might be associated with higher career-long academic productivity in terms of annual number new publications and ability to get NIH funding, but without significant impact in terms of academic rank or institutional role advancement. No significant difference was found between those with versus without a PhD in terms of career-long number of publications/citations, academic rank, NIH funding, or leadership role, even though sample size might have been insufficient to identify any such potential difference.

Academic Productivity of US Cardiothoracic Surgical Centers.

BACKGROUND AND AIM: We investigated which metrics represent valid correlates of the academic productivity of cardiothoracic (CT) surgical centers. METHODS: We collected data from 57 US academic CT surgical groups (663 surgeons), including H index and institutional role of each surgeon, ranking by US News & World Report (USNWR) and NIH funding, and designation as department versus division. RESULTS: Academic productivity (median H-index of each group) was significantly different across institutions (p < 0.001). Several USNWR hospital categories ("Honor Roll", "Adult Cardiology and Heart Surgery", "Adult Pulmonology", "Adult Cancer") and medical school ranking for research were associated with differences in academic productivity, while ranking by NIH funding or designation as department versus division was not. Groups with chairperson's individual H-index ≥50 were overall more productive than those with chairperson's H-index <50 (median H-index: 18 vs. 14; p = 0.005). CONCLUSIONS: USNWR rankings provide a good representation of academic productivity, while NIH funding ranking or designation as department versus division does not. The individual productivity of the chairperson is correlated with that of the whole group. doi: 10.1111/jocs.12773 (J Card Surg 2016;31:423-428).

Prospective trial of a pediatric ventricular assist device.

BACKGROUND: Options for mechanical circulatory support as a bridge to heart transplantation in children with severe heart failure are limited. METHODS: We conducted a prospective, single-group trial of a ventricular assist device designed specifically for children as a bridge to heart transplantation. Patients 16 years of age or younger were divided into two cohorts according to body-surface area (cohort 1, <0.7 m(2); cohort 2, 0.7 to <1.5 m(2)), with 24 patients in each group. Survival in the two cohorts receiving mechanical support (with data censored at the time of transplantation or weaning from the device owing to recovery) was compared with survival in two propensity-score-matched historical control groups (one for each cohort) undergoing extracorporeal membrane oxygenation (ECMO). RESULTS: For participants in cohort 1, the median survival time had not been reached at 174 days, whereas in the matched ECMO group, the median survival was 13 days (P<0.001 by the log-rank test). For participants in cohort 2 and the matched ECMO group, the median survival was 144 days and 10 days, respectively (P<0.001 by the log-rank test). Serious adverse events in cohort 1 and cohort 2 included major bleeding (in 42% and 50% of patients, respectively), infection (in 63% and 50%), and stroke (in 29% and 29%). CONCLUSIONS: Our trial showed that survival rates were significantly higher with the ventricular assist device than with ECMO. Serious adverse events, including infection, stroke, and bleeding, occurred in a majority of study participants. (Funded by Berlin Heart and the Food and Drug Administration Office of Orphan Product Development; ClinicalTrials.gov number, NCT00583661.).

Berlin Heart EXCOR pediatric ventricular assist device for bridge to heart transplantation in US children.

BACKGROUND: Recent data suggest that the Berlin Heart EXCOR Pediatric ventricular assist device is superior to extracorporeal membrane oxygenation for bridge to heart transplantation. Published data are limited to 1 in 4 children who received the device as part of the US clinical trial. We analyzed outcomes for all US children who received the EXCOR to characterize device outcomes in an unselected cohort and to identify risk factors for mortality to facilitate patient selection. METHODS AND RESULTS: This multicenter, prospective cohort study involved all children implanted with the Berlin Heart EXCOR Pediatric ventricular assist device at 47 centers from May 2007 through December 2010. Multiphase nonproportional hazards modeling was used to identify risk factors for early (<2 months) and late mortality. Of 204 children supported with the EXCOR, the median duration of support was 40 days (range, 1-435 days). Survival at 12 months was 75%, including 64% who reached transplantation, 6% who recovered, and 5% who were alive on the device. Multivariable analysis identified lower weight, biventricular assist device support, and elevated bilirubin as risk factors for early mortality and bilirubin extremes and renal dysfunction as risk factors for late mortality. Neurological dysfunction occurred in 29% and was the leading cause of death. CONCLUSIONS: Use of the Berlin Heart EXCOR has risen dramatically over the past decade. The EXCOR has emerged as a new treatment standard in the United States for pediatric bridge to transplantation. Three-quarters of children survived to transplantation or recovery; an important fraction experienced neurological dysfunction. Smaller patient size, renal dysfunction, hepatic dysfunction, and biventricular assist device use were associated with mortality, whereas extracorporeal membrane oxygenation before implantation and congenital heart disease were not.

Midterm survival of infants requiring postoperative extracorporeal membrane oxygenation after Norwood palliation.

This study reports the mid-term survival for neonates undergoing extracorporeal membrane oxygenation (ECMO) after Norwood palliation at a single center. Limited data exist on the mid-term survival of patients undergoing ECMO after Norwood palliation. We reviewed our ECMO experience from July 1994 to October 2008 and compared two groups: patients who required ECMO after Norwood palliation and patients who underwent Norwood palliation without ECMO. We analyzed 30-day survival, survival to hospital discharge, and survival to most recent follow-up. One hundred sixty patients underwent Norwood palliation for hypoplastic left heart syndrome (HLHS) and its variants. A total of 32 patients (20%) required postoperative ECMO. Using Kaplan-Meier analysis, the predicted survival rates for Norwood/non-ECMO patients to 30 days, 1 year, and 3 years after the procedure are 87.6% (CI 79.5-91.5%), 62.5% (CI 54.3-71.0%), and 59.9% (CI 50.8-67.8%), respectively. Survival to 30 days, 1 year, and 3 years after Norwood was significantly decreased in Norwood/ ECMO patients, with predicted survival rates of 50.0% (CI 31.9-65.7%), 24.6% (CI 11.4-40.4), and 13.2% (CI 3.9-28.3%), respectively (p < 0.0001). Risk factors for hospital mortality included nonelective or emergency placement onto ECMO, longer duration of ECMO support, and the development of acute renal failure while on ECMO. Of the original Norwood/ECMO hospital survivors, only half of these patients survived a mean of nearly 4 years. ECMO after Norwood palliation is associated with significant mortality. Our data suggest that neonates who require ECMO after Norwood palliation are prone to continued attrition once discharged from the hospital.

The Ross full root replacement in adults with bicuspid aortic valve disease.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve disease (BAVD) is the most common congenital cardiac lesion causing aortic stenosis in adults. This lesion can be associated with a histological abnormality of the aortic wall and dilated or aneurysmal ascending aorta. In younger patients, the Ross operation offers several advantages over conventional aortic valve replacement (AVR); however, the rationale of performing this procedure on adults in the face of BAVD have been questioned. METHODS: Between 1994 and 2009, a total of 101 adult patients (mean age 36 years; range: 18-61 years) with BAVD underwent the Ross full root replacement at the authors' institution. Of these patients, 23 (23%) had an aneurysmal ascending aorta (4.0-5.2 cm) associated with BAVD which was resected at the time of, or subsequent to, a Ross AVR. The end point of the study was freedom from Ross autograft dilatation > 4.0 cm, dysfunction, or valve repair or replacement. RESULTS: The mean follow up was 6.0 +/- 3.9 years. At the latest follow up, 19 patients (19%) had a dilated ascending aorta with a mean size 45.1 mm (range: 40-64 mm). Eight patients (8%) required a redo operation on the autograft. Three of seven patients undergoing reoperation had their autograft valve preserved; the remaining four underwent a modified Bentall root replacement. One patient had a repair of a left ventricular pseudoaneurysm below the Ross valve. Only three patients with preoperative ascending aorta dilation developed late autograft dilation. Freedom from autograft dilatation > 4.0 cm, dysfunction, repair or replacement was 80% at 10 years. CONCLUSION: Mid-term results indicate that Ross AVR in adults with BAVD had good outcomes, with a low incidence of autograft-related complications. In almost half of the patients undergoing reoperation, the autograft valve was preserved. The incidence of autograft valve insufficiency and dilatation might be further reduced by: (i) aggressively treating any postoperative systemic hypertension; (ii) externally fortifying the annulus and sinotubular junction of the autograft with Dacron strips; and/or (iii) replacing a dilated ascending aorta with a Dacron interposition graft. The preoperative diagnosis of BAVD and/or aneurysmal ascending aorta is not predictive of late autograft dilatation or failure.

Cefuroxime pharmacokinetics in pediatric cardiovascular surgery patients undergoing cardiopulmonary bypass.

OBJECTIVES: The objective of this study was to determine the pharmacokinetics of cefuroxime in children undergoing cardiopulmonary bypass (CPB) for cardiovascular surgery. DESIGN: A prospective study. SETTING: A tertiary pediatric teaching hospital. PARTICIPANTS: Infants and children undergoing CPB were enrolled in the study. INTERVENTION: An initial dose (mean, 24.2 ± 1.6 mg/kg) of cefuroxime was administered before surgical incision, and a second dose (mean, 14.4 ± 7.9 mg/kg) was administered in the CPB prime solution. Serial blood samples were obtained before, during, and after the CPB process. Samples were shipped on dry ice to the analytic laboratory and concentrations determined by a validated high-performance liquid chromatography method. A 2-compartment pharmacokinetic model was fitted to the data using maximum a priori-Bayesian estimation, with weight as a covariate. Monte Carlo simulations of a single-dose (25 mg/kg pre-CPB) approach and a 2-dose (25 mg/kg pre- and 12.5-mg/kg prime solution dose) approach were performed. MEASUREMENTS AND MAIN RESULTS: Fifteen subjects (9 males/6 females) were enrolled in the study, with median (range) age and weight of 11 (3-34) months and 9.5 (4.5-15.4) kg, respectively. The median (range) duration of CPB was 136 (71-243) minutes. Median and range cefuroxime pharmacokinetic parameters were as follows: maximum concentration (Cmax) dose, 1: 328 (150-512) µg/mL; systemic clearance, 0.050 (0.041-0.058) L/h/kg; steady-state volume of distribution, 0.213 (0.081-0.423) L/kg; volume of distribution in the central compartment, 0.081 (0.046-0.162) L/kg; and elimination half-life, 3.76 (1.03-6.81) hours. The median 8-hour post-dose-simulated cefuroxime concentrations were 26.5 and 16.0 mg/L for the 2-dose and single-dose regimens, respectively. CONCLUSION: Manufacturers recommend that pediatric doses of cefuroxime (25-50 mg/kg) can be used in infants and children undergoing CPB to maintain adequate serum concentrations for surgical-site infection prophylaxis. A second intraoperative dose, administered through the CPB circuit, provides no additional prophylactic advantage.

Outcomes following surgery for primary mediastinal nonseminomatous germ cell tumors in the cisplatin era.

OBJECTIVE: Treatment of primary mediastinal nonseminomatous germ cell tumors involves cisplatin-based chemotherapy followed by surgery to remove residual disease. We undertook a study to determine short and long-term outcomes. METHODS: A retrospective analysis of patients with primary mediastinal nonseminomatous germ cell tumors who underwent surgery at our institution from 1982 to 2017 was performed. RESULTS: A total of 255 patients (mean age, 29.2 years) were identified. Acute respiratory distress syndrome occurred postoperatively in 27 patients (10.9%), which was responsible for all 11 (4.3%) postoperative deaths. Of patients who developed acute respiratory distress syndrome, more patients received bleomycin-containing chemotherapy (25 out of 169; 14.8%) than non-bleomycin regimens (2 out of 77; 2.6%) (P = .004). With respect to variables independently predictive of long-term survival, evidence of choriocarcinoma before chemotherapy (n = 12) was determined to be an adverse factor (P = .006). In contrast, biopsy-proven elements of seminoma (n = 34) were predictive of improved survival (P = .04). The worst pathology identified in the residual mediastinal mass after chemotherapy was necrosis in 61 patients (25.0%), teratoma in 84 patients (34.4%), and malignant (persistent germ cell or non-germ cell cancer) in 97 patients (39.8%), which influenced overall survival (P < .001). Additionally, teratoma with stromal atypia (n = 18) demonstrated decreased survival compared with teratoma without atypia (n = 66; P = .031). Patients with malignancy involving >50% of the residual mass (n = 47) had a 2.3-fold increased risk of death compared with ≤50% malignancy (n = 45; P = .008). Finally, elevated postoperative serum tumor markers (n = 40) was significantly predictive of adverse survival (P < .001). CONCLUSIONS: In the treatment of primary mediastinal nonseminomatous germ cell tumors, avoiding bleomycin-containing chemotherapy is important. Pre- and postchemotherapy pathology and postoperative serum tumor markers are independent predictors of long-term survival.

Risk Factors for Reoperation After Arterial Switch Operation.

OBJECTIVE: The timing and nature of and risk factors for reoperation after the arterial switch operation in the setting of d-transposition of the great arteries requires further elucidation. METHODS: A total of 403 patients who underwent arterial switch operation from 1986 to 2017 were reviewed. Institutional preference was for pulmonary artery reconstruction using a pantaloon patch of fresh autologous pericardium. The targets for coronary artery reimplantation were identified by intermittent root distension. Multivariable analysis was used to identify risk factors for reoperation. RESULTS: Median follow-up was 8.6 years (interquartile range [IQR]: 2-16.9). Pulmonary arterioplasty was the most common reoperation (n = 11, 2.7%) at 3.3 years (IQR: 1.4-11.4) postoperatively. Subvalvar right ventricular outflow tract reconstruction (RVOTR) was required in nine (2.2%) patients at 2.5 years (IQR: 1.1-5.3) postoperatively. Aortic valve repair or replacement (AVR/r) was required in seven (1.7%) patients at 13.6 years (IQR: 10.0-15.8) postoperatively. Aortic root replacement (ARR) and Coronary Artery Bypass Graft/coronary patch arterioplasty were required in five (1.2%) patients each at 13.6 years (IQR: 11.0-15.3) and 11.3 years (IQR: 2.3-13.6) postoperatively, respectively. Taussig-Bing anomaly was a risk factor for any reoperation (P = .034). Risk factors for specific reoperations included ventricular septal defect for AVR/r (P = .038), Taussig-Bing anomaly for RVOTR (P = .004), and pulmonary artery banding for ARR (P = .028). CONCLUSIONS: Pantaloon patch pulmonary artery reconstruction and intermittent neo-aortic root distension during coronary reimplantation have minimized respective outflow tract reoperations. Certain anatomic subsets carry different risks for late reoperation, and pulmonary artery and/or RVOT reinterventions tend to occur sooner than aortic reinterventions. Special attention to these higher risk subpopulations will be critical to optimizing lifelong outcomes.

Two Decades Using Stentless Porcine Aortic Root in Right Ventricular Outflow Tract Reconstruction.

BACKGROUND: The stentless porcine aortic root prosthesis (SPAR) has been described as a suitable valve for right ventricular outflow tract reconstruction (RVOTR). Indiana University Methodist Hospital in Indianapolis, Indiana began using this valve for RVOTR in 1998. This study reports medium-term to late- term outcomes of the valve in the pulmonary position. METHODS: A retrospective chart review was conducted of patients older than 18 years of age who underwent RVOTR with a SPAR between April 2000 and October 2019. Primary outcomes included survival and freedom from any valvular reintervention. Secondary outcomes included endocarditis and conduit dysfunction detected by routine echocardiography or cardiac magnetic resonance imaging. RESULTS: A total of 135 patients underwent RVOTR with a SPAR at a median age of 32.4 years (range, 18 to 71 years). Of these patients, 129 had previous surgery. Indications included pulmonary insufficiency (90.4%), stenosis (34.8%), endocarditis (7.4%), and carcinoid (4.4%). Median follow-up was 2.97 years (interquartile range, 0.6 to 8.0 years). Overall survival was 93.3%, with 3 perioperative death and 6 late deaths. Endocarditis developed in 4 patients (2.9%), 2 of whom required reoperation. Progressive conduit degradation was evident at 10 years, with 22.2% and 7.7% having moderate stenosis and insufficiency, respectively. Eight (5.9%) reinterventions included 2 surgical replacements, 3 percutaneous replacements, and 3 balloon valvuloplasties at means of 8.5, 7.4, and 2.2 years, respectively. Overall freedom from reintervention at 1, 5, and 10 years was 99.1%, 94.7% and 90.7%, respectively. CONCLUSIONS: In this large, single-institution experience with a long follow-up period, use of the SPAR demonstrated excellent midterm to long-term durability, low rates of endocarditis, and high freedom from reintervention.

Surgical Valvuloplasty Versus Balloon Dilation for Congenital Aortic Stenosis in Pediatric Patients.

BACKGROUND: For children with congenital aortic stenosis (AS) who are candidates for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). We aimed to evaluate the longer term outcomes of SAV versus BAD at our institution. METHODS: We retrospectively reviewed the outcomes of 2 months to 18 years old patients who underwent SAV or BAD at our institution between January 1990 and July 2018. Baseline and follow-up characteristics were assessed by echocardiography. Long-term survival, freedom from reintervention, freedom from aortic valve replacement (AVR), and aortic regurgitation were evaluated. RESULTS: A total of 212 patients met inclusion criteria (SAV = 123; BAD = 89). Age, sex, aortic insufficiency (AI), and aortic valve gradient were similar between the groups. At 10 years, 27.9% (19/68) of SAV patients and 58.3% (28/48) of BAD patients had moderate or worse AI (P = .001), and reintervention occurred in 39.2% (29/74) of SAV patients and 78.6% (44/56) of BAD patients (P < .001). Kaplan-Meier analysis revealed overall survival was 96.8% (119/123) for SAV and 95.5% (85/89) for SAV (P = .87). At 10 years, 35% (23/66) of SAV patients and 54% (23/43) of BAD patients underwent AVR (P = .213). CONCLUSIONS: Surgical aortic valvuloplasty demonstrated greater gradient reduction, less postoperative and long-term AI, and a lower reintervention rate at 10 years than BAD. There was no difference in survival or AVR reintervention rate. Surgical aortic valvuloplasty is a durable and efficacious intervention and should continue to be considered a favorable choice for palliation of valvular AS.

Right Ventricular Outflow Tract Reconstruction in Infant Truncus Arteriosus: A 37-year Experience.

BACKGROUND: Multiple conduits for right ventricular outflow tract reconstruction exist, although the ideal conduit that maximizes outcomes remains controversial. We evaluated long-term outcomes and compared conduits for right ventricular outflow tract reconstruction in children with truncus arteriosus. METHODS: Records of patients who underwent truncus arteriosus repair at our institution between 1981 and 2018 were retrospectively reviewed. Primary outcomes included survival and freedom from catheter reintervention or reoperation. Secondary analyses evaluated the effect of comorbidity, operation era, conduit type, and conduit size. RESULTS: One hundred patients met inclusion criteria. Median follow-up time was 15.6 years (interquartile range, 5.3-22.2). Actuarial survival at 30 days, 5 years, 10 years, and 15 years was 85%, 72%, 72%, and 68%, respectively. Early mortality was associated with concomitant interrupted aortic arch (hazard ratio, 5.4; 95% confidence interval, 1.7-17.4; P = .005). Median time to surgical reoperation was 4.6 years (interquartile range, 2.9-6.8; n = 58). Right ventricle to pulmonary artery continuity was established with an aortic homograft (n = 14), pulmonary homograft (n = 41), or bovine jugular vein conduit (n = 36) in most cases. Multivariate analysis revealed longer freedom from reoperation with the bovine jugular vein conduit compared with the aortic homograft (hazard ratio, 3.1; 95% confidence interval, 1.3-7.7; P = .02) with no difference compared with the pulmonary homograft. Larger conduit size was associated with longer freedom from reoperation (hazard ratio, 0.7; 95% confidence interval, 0.6-0.9; P < .001). CONCLUSIONS: The bovine jugular vein conduit is a favorable conduit for right ventricular outflow tract reconstruction in patients with truncus arteriosus. Concomitant interrupted aortic arch is a risk factor for early mortality.

Rastelli Operation for D-Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Stenosis.

OBJECTIVES: Our preferred approach for the surgical treatment of patients with D-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis has been the Rastelli operation. We herein evaluate our 30-year experience with this procedure. METHODS: Clinical records for patients who underwent the Rastelli operation between 1988 and 2017 at our institution were retrospectively reviewed. Primary outcomes included freedom from death or cardiac transplantation and freedom from conduit reintervention. RESULTS: Forty-seven patients met inclusion criteria. Mean follow-up was 11.7 ± 6.8 years. Forty-three (91.5%) patients received a palliative systemic-to-pulmonary artery shunt and/or atrial septostomy prior to the Rastelli procedure. Five (10.6%) patients required ventricular septal defect enlargement at the time of the Rastelli procedure. The overall mean right ventricle-to-pulmonary artery conduit size was 17.0 mm. Mortalities included one early and three late deaths. Freedom from death or cardiac transplantation was 93% and 84% at 5 and 25 years, respectively. Seven patients required pacemaker placement, two immediately postoperatively and five late. Freedom from conduit replacement was 85% and 25% at 5 and 15 years, respectively. Seven (14.9%) patients required a second conduit intervention. Forty-one (87.2%) patients were New York Heart Association class I or II at the most recent follow-up. CONCLUSIONS: The Rastelli operation for D-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis offers excellent mid- to long-term survival. The need for conduit replacement remains the most common indication for reintervention, and further study of the optimal choice of conduit will be useful.

Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery.

BACKGROUND: Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS: We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS: We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION: Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.

Intermediate Outcomes of Staged Tetralogy of Fallot Repair.

BACKGROUND: The optimal surgical strategy for tetralogy of Fallot (TOF) repair in neonates and young infants requiring early surgical intervention remains controversial. Our surgical center follows the uniform strategy of a staged approach with initial systemic-to-pulmonary artery shunt the majority of time when early surgical intervention is required. We characterized a contemporary cohort of patients with TOF with pulmonary stenosis (PS) undergoing staged repair in order to determine the rate of pulmonary valve-sparing repair (PVSR), growth of the pulmonary valve annulus and pulmonary arteries, postoperative morbidity and mortality, and need for reintervention. METHODS: We retrospectively studied patients with TOF/PS who underwent staged repair from 2000 to 2017. Surgical details, postoperative course, and reinterventions were noted. Echocardiographic measurements and Z-score values of pulmonary valve annulus, main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA) diameters were evaluated. RESULTS: Of the 59 patients with staged TOF/PS, PVSR was performed in 25 (42%). There was a 5% incidence of postoperative arrhythmia. The Z-scores of MPA, RPA, and LPA were significantly higher before complete repair when compared to before palliative shunt. The 5 and 10-year survival rates were both 93%, and the probability of freedom from reoperation at 5 and 10 years was 87% and 82%, respectively. CONCLUSIONS: Staged repair of TOF in young symptomatic infants results in 42% receiving PVSR, pulmonary artery growth, low incidence of postoperative arrhythmia, and relatively low rate of reoperations.

Reoperative right ventricular outflow tract conduit reconstruction: risk analyses at follow up.

BACKGROUND AND AIM OF THE STUDY: Right ventricular-to-pulmonary artery (RV-PA) conduits are implanted in the right ventricular outflow tract (RVOT) of children, with the knowledge that future reoperation will likely be required. The authors' experience of conduit RVOT reconstruction was reviewed in order to assess the frequency of conduit replacement and to determine risk factors for conduit dysfunction and failure. METHODS: Between January 1980 and April 2007, a total of 261 patients (mean age 8.7 +/- 11.7 years) underwent primary RVOT reconstruction with an RV-PA conduit at the authors' institution. There were 19 (7%) early deaths. Among the survivors, 84 (35%) underwent conduit explant at the implanting hospital with insertion of a second conduit at a mean of 6.0 +/- 3.7 years (range: 7 months to 22 years) after the first implantation. The primary operation and reoperation patient groups were compared with regard to the incidence of early death, late death, conduit-related intervention without explant, and conduit explant. RESULTS: Six risk factors for mortality were significant on univariate analyses: surgery before 1992 (p = 0.005), age <3 months (p = 0.001), diagnosis of truncus arteriosus (p <0.001), reconstruction with allografts (p = 0.05), association with interrupted aortic arch (p = 0.05) and with truncal valve insufficiency (p = 0.05). Of these six factors, only the diagnosis of truncus arteriosus (p = 0.001) and surgery before 1992 (p = 0.05) remained significant by multivariate analysis. Univariable analysis was performed for multiple factors, of which the following were found to be significant: body weight (p <0.003), age (p = 0.002), conduit diameter (p <0.0001), conduit type (p = 0.006), and diagnosis of truncus arteriosus (p <0.0001). Multivariable analysis of significant univariable risks revealed small allograft diameter (p <0.001) and diagnosis of truncus arteriosus (p <0.001) to be significant risk-factors for need of replacement. CONCLUSION: Most RVOT conduits placed in children will eventually require replacement. Patient survival for conduit replacement is comparable to that for primary conduit placement. Reoperative conduit RVOT reconstruction is possible, with low morbidity and mortality.

Bovine Jugular Vein Conduit: A Mid- to Long-Term Institutional Review.

BACKGROUND: Since 1999, we have used the bovine jugular vein conduit for right ventricular outflow tract reconstruction in infants and children. Herein, we review their mid- to long-term outcomes. METHODS: Between 1999 and 2016, 315 bovine jugular vein conduits were implanted in 276 patients. Patients were grouped by age at bovine jugular vein conduit implant: group 1: 0 to 1 years (N = 65), group 2: one to ten years (N = 132), and group 3: older than ten years (N = 118). For survival and hemodynamic analysis, additional group stratification was done based on conduit size. Group small: 12 and 14 mm (N = 75), group medium: 16 and 18 mm (N = 84), and group large: 20 and 22 mm (N = 156). RESULTS: Mean follow-up for groups 1, 2, and 3 was 4.0, 4.9, and 5.9 years, respectively. Early mortality was 9%, 0%, and 1% for groups 1, 2, and 3, respectively ( P < .001). Late mortality was 5%, 2%, and 2% for groups 1, 2, and 3, respectively ( P = .337). Group 1 had the lowest ten-year freedom from conduit failure at 13%, versus 53% and 69% for groups 2 and 3, respectively ( P < .001). A total of 21 (6.6%) patients developed endocarditis, 11 (3.5%) patients required reoperation, and 10 (3.2%) patients required antibiotic therapy alone. CONCLUSIONS: The bovine jugular vein conduit is a useful option for right ventricular outflow tract reconstruction given its easy implantability and acceptable midterm durability.