Preoperative Echocardiographically Derived Mean dP/dTic Predicts Early Post-operative Dysfunction in Children Undergoing Mitral Valve Surgery.

Mean dP/dtic is a quantitative measurement of ventricular function that can be obtained noninvasively by echocardiography. In adults with mitral regurgitation (MR), it has been shown to be a more sensitive predictor of postoperative left ventricular ejection fraction (EF). The utility of dP/dtic in pediatric congenital heart diseases with MR has been underexplored. Patients (0 to ≤ 19 years) with MR who underwent mitral valve (MV) repair or replacement from 2015 to 2021 were included. Echocardiographically derived mean dP/dtic, Tei index, and EF were used to assess and compare ventricular function prior to, shortly after, and late after MV surgery. Study cohort included 61 patients (age 4.5 [IQR 0.14, 18.7] years, 89% MV repair, 11% MV replacement). Median time intervals between surgery and preoperative, early postoperative, and late postoperative echocardiograms were 6 days, 6 days, and 350 days, respectively. Median EF was 62% (z-score - 0.40) preoperatively, 56% (z-score - 1.40) early postoperatively, and 61% (z-score - 0.60) late postoperatively. Median dP/dtic was 1393 (IQR 1029, 1775) mmHg/s preoperatively, 1178 (IQR 886, 1946) mmHg/s early postoperatively, and 1270 (IQR 791, 1765) mmHg/s late postoperatively. Preoperative median dP/dtic correlated with early and late postoperative EF. Preoperative EF was not significantly correlated with early postoperative EF, but was correlated with late postoperative EF. Mitral valve intervention in pediatric patients is associated with an initial decline but subsequent recovery of systolic function. Non-invasively derived mean dP/dtic may offer advantages over other preoperative echocardiographic indices to predict postoperative systolic function.

Early and long-term outcomes following cardiac surgery for patients with heterotaxy syndrome.

Objective: Heterotaxy syndrome is a complex multisystem abnormality historically associated with high morbidity and mortality. We sought to evaluate the early and long-term outcomes after cardiac surgery in heterotaxy syndrome. Methods: This is a single-center retrospective review of patients with heterotaxy syndrome undergoing single-ventricle palliation or primary or staged biventricular repair from 1998 to 2018. Patients were stratified by single ventricle versus biventricular physiology, and the severity of atrioventricular valve regurgitation. Demographics, anatomic characteristics, and early and late outcomes, including the length of stay, mortality, and surgical or catheter reinterventions, were analyzed. Results: Among 250 patients, 150 (60%) underwent biventricular repair. In-hospital mortality was 7.6% (n = 19). Median follow-up was 5.2 (range, 0-16) years. Among survivors to discharge, mortality was 19% (n = 44) and reintervention was 52% (n = 120). Patients with moderate/severe atrioventricular valve regurgitation were older (32 vs 16 months, P = .02), were more likely to experience adverse events during their index surgical admission (72% vs 46%, P < .001), and had longer in-hospital length of stay (20 vs 12 days, P = .009). Among patients with moderate to severe atrioventricular valve regurgitation, single-ventricle palliation is associated with a greater risk of unplanned reintervention compared with patients undergoing biventricular repair (hazard ratio, 2.13; CI, 1.10-4.12; P = .025). Conclusions: There was no significant difference in early or late outcomes in single-ventricle versus biventricular repair strategies in heterotaxy. In the subgroup of patients with moderate/severe atrioventricular valve regurgitation, patients who underwent single-ventricle palliation were 2.5 times more likely to need a late reintervention compared with those undergoing biventricular repair.

Impact of pre-bypass ultrafiltration on prime values and clinical outcomes in neonatal and infant cardiopulmonary bypass.

BACKGROUND: A standard blood prime for cardiopulmonary bypass (CPB) in congenital cardiac surgery may possess non-physiologic values for electrolytes, glucose, and lactate. Pre-bypass Ultrafiltration (PBUF) can make these values more physiologic and standardized prior to bypass initiation. We aimed to determine if using PBUF on blood primes including packed red blood cells and thawed plasma would make prime values more predictable and physiologic. Additionally, we aimed to evaluate whether the addition of PBUF had an impact on outcome measures. METHODS: Retrospective review of consecutive patients ≤ 1 year of age undergoing an index cardiac operation on CPB between 8/2017 and 9/2021. As PBUF was performed at the perfusionists' discretion, a natural grouping of patients that received PBUF vs. those that did not occur. Differences in electrolytes, glucose, and lactate were compared at specific time points using Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Clinical outcomes were also assessed. RESULTS: In both cohorts, the median age at surgery was 3 months and 47% of patients were female; 308/704 (44%) of the PBUF group and 163/414 (39%) of the standard prime group had at least one preoperative risk factor. The proportion of PBUF circuits which demonstrated more physiologic values for glucose (318 [45%]), sodium (434, [62%]), potassium (688 [98%]), lactate (612 [87%]) and osmolality (595 [92%]) was significantly higher when compared to standard prime circuit levels for glucose (8 [2%]), sodium (13 [3%], potassium (150 [36%]), lactate (56 [13%]) and osmolality (23 [6%]) prior to CPB initiation. There were no differences in clinical outcomes or rates of major adverse events between the two cohorts. CONCLUSIONS: PBUF creates standardized and more physiologic values for electrolytes, glucose, and lactate before the initiation of bypass without significant impacts on in-hospital outcomes.

Prospective randomized controlled trial of the safety and feasibility of a novel mesenchymal precursor cell therapy in hypoplastic left heart syndrome.

Objective: To assess the safety and feasibility of low-dose, novel, allogenic mesenchymal precursor cell (MPC) therapy as an adjunct to left ventricular (LV) recruitment for patients with hypoplastic left heart syndrome (HLHS) and borderline left ventricles. MPC injections into the hypoplastic left ventricle may stimulate neovascularization and beneficial LV remodeling and may improve the likelihood of achieving biventricular (BiV) or 1.5 ventricle (1.5V) circulation. Methods: Children <5 years with prior single ventricle palliation undergoing LV recruitment surgery at a single center were randomized to MPC injections into the LV endocardium/papillary muscles (MPCs) or standard-of-care (controls) and followed for 24 months. The primary endpoint was safety, including (serious) adverse events (S/AEs), and panel reactive antibodies (PRAs). Secondary endpoints included BiV/1.5V conversion and LV size and function. Results: Nineteen subjects were enrolled, including 9 MPC recipients and 10 controls. Fourteen patients (74%) had >1 AE, and 2 patients had SAEs, both deemed unrelated to the trial product. AE severity and frequency were similar in the 2 groups. Baseline PRA levels were high, with no difference between the groups at 12 months. The overall probability of BiV/1.5V conversion was 0.16 (95% confidence interval [CI], 0.05 to 0.41) at 12 months and 0.52 (95% CI, 0.31 to 0.77) at 24 months. For patients with imaging data at both time points, increases in LV volumes from baseline to 12 months were larger in the MPC group by 3-dimensional echocardiography and cardiac magnetic resonance imaging. For children who successfully underwent BiV conversion (n = 12), full BiV conversion was achieved at 24 months in 5 of 5 (100%) MPC-treated children compared with 4 of 7 (57%) controls. Conclusions: MPC injections were considered safe and feasible in HLHS patients. More than 50% of subjects underwent BiV/1.5V conversion within 2 years. Larger trials are needed to investigate the therapeutic potential of MPCs in this population.

Trends in surgical management of anomalous aortic origin of the coronary artery over 2 decades.

Objective: To evaluate outcomes of patients undergoing surgery for anomalous aortic origin of the coronary artery (AAOCA) at a tertiary care center and determine the influences of a coronary artery program on management strategies and outcomes. Methods: This retrospective review of consecutive surgical patients who had isolated AAOCA at a tertiary care center between August 1, 1999, and October 31, 2022, compared patient characteristics, interventional timing, and surgical strategies before and after program inception in 2018. Comparisons between time periods and anatomical subgroups were performed using Fisher exact and Wilcoxon rank-sum tests. Results: Of 149 surgical AAOCA patients, 102 (69%) had AAO of the right coronary artery. Compared with AAO of the left coronary artery (AAOLCA), AAO of the right coronary artery (AAORCA) was associated with greater athletic participation (intramural, varsity, and college-level) (74% vs 43%; P < .001) and preoperative functional imaging (72% vs 49%; P = .01), but were less likely to have ischemic changes on functional imaging (5% vs 23%; P = .03) or any postoperative complications (7% vs 19%; P = .04). Moderate or greater aortic insufficiency occurred postoperatively in 1 (1%) of AAORCA and 1 (3%) of AAOLCA patients. After the coronary artery program inception, there was an increase among patients with AAOCA undergoing preoperative computed tomography angiography (pre-2018: 39 out of 98 [40%] vs post-2018: 48 out of 51 [94%]; P < .001) and a decrease in isolated AAOCA unroofing procedures performed (30 [31%] vs 5 [10%]; P = .004). Conclusions: Surgical management of AAOCA evolved over time, and can be achieved with low instance of postoperative aortic insufficiency. Establishment of a coronary artery program has streamlined care.