ABSTRACT
Transcatheter patent ductus arteriosus (PDA) closure (TCPC) utilizing transthoracic echocardiogram (TTE) as the sole imaging guide could simplify care. This single-center study compares PDA dimensions obtained from the TTE and angiogram images of patients who underwent attempted TCPC at Stead Family Children's Hospital from 10/01/2019 to 10/31/2020. Blinded investigators measured these dimensions solely for this study and had no impact on clinical care. Also, a hypothetical Piccolo device size was chosen based on the TTE dimensions and another on the angiographic dimensions, and then the correlation was analyzed. Sixty-two patients underwent TCPC attempts. TTE tends to overestimate the PDA narrowest dimension and underestimate the PDA length and aortic end dimension. Linear regression analysis revealed a weak correlation between the length and aortic diameter (R = 0.37 and 0.21, respectively). A modest correlation was observed for the smallest dimension without color Doppler (R = 0.57) and with color Doppler, which was utilized when needed (R = 0.6). Bland-Altman analysis revealed a smaller mean difference between the TTE and angiogram measurements of the narrowest diameter without color Doppler (0.4 mm) and with color Doppler (used as needed) (0.4 mm). However, the mean difference is larger for the aortic end (- 1.64 mm) and the length (- 1.73 mm). TTE accurately predicted the Piccolo device size in 43 (72%) patients and overestimated the size in 17 (28%) patients to the next size. Our findings should be verified with further studies, and additional development of protocols is needed to use TTE to guide TCPC without fluoroscopy.
ABSTRACT
Adult congenital heart disease (ACHD) continues to rapidly increase worldwide. With an estimated 1.5 million adults with ACHD in the USA alone, there is a growing need for better education in the management of these complex patients and multiple knowledge gaps exist. This manuscript comprehensively reviewed the recent (2020) updated European Society of Cardiology Guidelines for the management of ACHD created by the Task Force for the management of adult congenital heart disease of the European Society of Cardiology, with perioperative implications for the adult cardiac anesthesiologist and intensivist who may be called upon to manage these complex patients.
Subject(s)
Cardiology , Heart Defects, Congenital , Adult , Advisory Committees , Cardiology/education , Heart Defects, Congenital/diagnosis , Heart Defects, Congenital/surgery , HumansABSTRACT
Adult congenital heart disease (ACHD) is a rising concern for the current healthcare system, with a prevalence that is anticipated to steadily increase through the year 2050. It is estimated that there are >1.4 million adults in the United States living with a congenital heart defect. Despite significant advances in medical and surgical therapy, most of these patients progress to advanced heart failure due to the unique anatomic, physiological, and hemodynamic abnormalities associated with the disease. Patient awareness of the disease coupled with advances in the diagnosis and treatment has led to a significant increase in the surgical treatment of CHD in adults. The authors aim to summarize and critically appraise the current literature on the morbidity, mortality, and risk scores associated with ACHD.
Subject(s)
Heart Defects, Congenital , Heart Failure , Adult , Heart Defects, Congenital/complications , Heart Defects, Congenital/diagnosis , Heart Defects, Congenital/surgery , Heart Failure/surgery , Humans , Morbidity , Risk Assessment , Risk Factors , United StatesABSTRACT
BACKGROUND AND AIM OF THE STUDY: Minimally invasive aortic valve replacement via ministernotomy (ministernotomy-AVR) or minithoracotomy (minithoracotomy-AVR) is gaining popularity. To date, a direct comparison of ministernotomy-AVR versus minithoracotomy-AVR is lacking. The study aim was to compare these two procedures from a cost-benefit perspective. METHODS: Eight reports from the United States were selected from amongst 33,494 literature citations based on sample size and data completeness. Perioperative variables were collected for each surgical approach. Fixed and variable costs were estimated as cost per case in excess of full sternotomy AVR procedures. RESULTS: Ministernotomy-AVR patients were of a significantly lower mean age (59.8 years versus 67.9 years), ejection fraction (50.4-51.6% versus 56.1-57.8%), shorter cardiopulmonary bypass time (97.2 min versus 125.6 min) and cross-clamp time (69.9 min versus 87.9 min), a lower rate of blood transfusion (25.9% versus 64.4%), and a shorter length of hospital stay (5.7 versus 6.2 days). There were no significant inter-group differences in 30-day mortality, conversion to sternotomy, neurologic events, arrhythmia, wound infection, or postoperative bleeding. Assuming a volume of 50 cases per year, the added operative cost per case for a minithoracotomy-AVR was US$ 4,254 compared to US$ 290 for a ministernotomy-AVR. The added costs per case, assuming 200 cases per year, were US$ 4,209 and US$ 290, respectively. A minithoracotomy-AVR program performing 50 cases per year adds US$ 1,063,665 of operative costs over five years, compared to US$ 72,500 for a ministernotomy-AVR program. CONCLUSION: The present analysis suggested that the clinical benefits of ministernotomy-AVR are comparable or better than those of minithoracotomy-AVR, and at lower costs. Healthcare delivery organizations should consider the results of cost-benefit examinations when developing surgical valve replacement programs.
Subject(s)
Aortic Valve/surgery , Delivery of Health Care/economics , Heart Valve Prosthesis Implantation/economics , Hospital Costs , Process Assessment, Health Care/economics , Sternotomy/economics , Thoracotomy/economics , Adult , Aged , Aged, 80 and over , Aortic Valve/physiopathology , Blood Loss, Surgical/prevention & control , Blood Transfusion/economics , Cost Savings , Cost-Benefit Analysis , Female , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Heart Valve Prosthesis Implantation/mortality , Humans , Length of Stay/economics , Male , Middle Aged , Models, Economic , Operative Time , Sternotomy/adverse effects , Sternotomy/methods , Sternotomy/mortality , Thoracotomy/adverse effects , Thoracotomy/methods , Thoracotomy/mortality , Time Factors , Treatment Outcome , United StatesSubject(s)
Antihypertensive Agents/administration & dosage , Epoprostenol/administration & dosage , Heart Septal Defects, Atrial/surgery , Nitric Oxide/administration & dosage , Administration, Inhalation , Anesthesia, Inhalation/instrumentation , Drug Therapy, Combination , Female , Humans , Infant, Newborn , Intraoperative Care/methodsSubject(s)
Disease Management , Fontan Procedure/methods , Heart Defects, Congenital/surgery , Palliative Care/methods , Perioperative Care/methods , Heart Defects, Congenital/diagnosis , Heart Defects, Congenital/physiopathology , Humans , Postoperative Complications/diagnosis , Postoperative Complications/physiopathology , Postoperative Complications/prevention & control , Pulmonary Circulation/physiology , Treatment OutcomeSubject(s)
Antifibrinolytic Agents/administration & dosage , Antifibrinolytic Agents/adverse effects , Cardiac Surgical Procedures/trends , Postoperative Complications/chemically induced , Blood Loss, Surgical/prevention & control , Cardiac Surgical Procedures/adverse effects , Humans , Orthopedic Procedures/adverse effects , Orthopedic Procedures/trends , Postoperative Complications/blood , Postoperative Complications/prevention & controlABSTRACT
Background Until recently, a large right ventricle outflow tract interfered with the feasibility of standard transcatheter pulmonary valve replacement (PVR). We are describing our experience using a hybrid approach for PVR using a left anterior thoracotomy approach to allow for plication of the main pulmonary artery followed by a transcatheter PVR using a Sapien S3 valve. Methods and Results This is a single-center, retrospective review of patients who were evaluated to be appropriate for a hybrid PVR approach. The patients' demographics, procedure details, and follow-up data were collected. Between May 2018 and April 2021, a total of 11 patients presented for hybrid transcatheter PVR. The median age and weight were 24 years (interquartile range, 19-43 years) and 81.8 kg (interquartile range, 69-91 kg), respectively. Nine out of 11 patients received a transcatheter PVR after main pulmonary artery plication. There were no procedurally related deaths. One major complication was encountered in which the valve was malpositioned requiring successful surgical PVR. Minor complications included acute kidney injury (n=1) and a broken rib (n=1). The median length of stay was 4 days (interquartile range, 2-4 days), with median follow-up of 7 months (interquartile range, 3-18 months). A well-functioning pulmonary valve was observed in all patients at the last follow-up. Conclusions A hybrid approach using left anterior thoracotomy with pulmonary artery plication followed by transcatheter Sapien S3 PVR provides a less-invasive option for patients with an enlarged right ventricular outflow tract. Preliminary results demonstrated this to be a safe option with good short-term outcomes.
Subject(s)
Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Pulmonary Valve Insufficiency , Pulmonary Valve , Tetralogy of Fallot , Cardiac Catheterization/adverse effects , Heart Valve Prosthesis/adverse effects , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Heart Ventricles , Humans , Pulmonary Artery/diagnostic imaging , Pulmonary Artery/surgery , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/surgery , Retrospective Studies , Tetralogy of Fallot/surgery , Thoracotomy/adverse effects , Treatment OutcomeABSTRACT
Background Prolonged exposure to a hemodynamically significant patent ductus arteriosus (PDA) is associated with major morbidity, particularly in infants born at <27 weeks' gestation. High-frequency jet ventilation (HFJV) is a standard of care at our center. There are no data about transcatheter PDA closure while on HFJV. The aim of this study was to assess the feasibility, safety, and outcomes of HFJV during transcatheter PDA closure. Methods and Results This is a retrospective cohort study of premature infants undergoing transcatheter device closure on HFJV. The primary outcome was successful device placement. Secondary outcomes included procedure time, fluoroscopy time and dose, time off unit, device complications, need for escalation in respiratory support, and 7-day survival. Subgroup comparative evaluation of patients managed with HFJV versus a small cohort of patients managed with conventional mechanical ventilation was performed. Thirty-eight patients were included in the study. Median age and median weight at PDA device closure for the HFJV cohort were 32 days (interquartile range, 25.25-42.0 days) and 1115 g (interquartile range, 885-1310 g), respectively. There was successful device placement in 100% of patients. There were no device complications noted. The time off unit and the procedure time were not significantly different between the HFJV group and the conventional ventilation group. Infants managed by HFJV had shorter median fluoroscopy times (4.5 versus 6.1 minutes; P<0.05) and no increased risk of adverse respiratory outcomes. Conclusions Transcatheter PDA closure in premature infants on HFJV is a safe and effective approach that does not compromise device placement success rate and does not lead to secondary complications.
Subject(s)
Ductus Arteriosus, Patent , High-Frequency Jet Ventilation , Cardiac Catheterization/methods , Ductus Arteriosus, Patent/surgery , Feasibility Studies , High-Frequency Jet Ventilation/adverse effects , Humans , Infant , Infant, Newborn , Infant, Premature , Retrospective Studies , Treatment OutcomeABSTRACT
Mechanical circulatory support in failing Fontan patients with Fontan circuit failure remains challenging. Herein, we describe a failing fenestrated Fontan patient who underwent systemic ventricular assist device support leaving the fenestration open. Perioperative course and hemodynamics during mechanical support are described in detail.
Subject(s)
Fontan Procedure , Heart-Assist Devices , Hemodynamics/physiology , Hypoplastic Left Heart Syndrome/surgery , Protein-Losing Enteropathies/surgery , Cardiac Catheterization , Child, Preschool , Fatal Outcome , Humans , Hypoplastic Left Heart Syndrome/complications , Male , Perioperative Period , Protein-Losing Enteropathies/complications , Shock, Septic , StentsSubject(s)
Aortic Valve/diagnostic imaging , Echocardiography, Three-Dimensional/standards , Heart Valve Prosthesis Implantation/methods , Heart Valve Prosthesis , Aged , Aortic Valve/surgery , Female , Heart Valve Prosthesis/adverse effects , Heart Valve Prosthesis Implantation/adverse effects , Humans , Reoperation/methodsABSTRACT
Aortic and mitral valve replacement with division and reconstruction of the inter-valvular fibrous body has been described in clinical situations involving infective endocarditis, extensive annular calcifications and diminutive valve annuli. Herein, we describe a combined transaortic and trans-septal approach with division of the inter-valvular fibrosa for combined aortic and mitral valve replacement. The reconstruction of the inter-valvular fibrous body, atrial walls and aortic root was carried out using a 'three-patch' technique with bovine pericardium.
Subject(s)
Cardiac Surgical Procedures/methods , Heart Valve Diseases/surgery , Ventricular Outflow Obstruction/surgery , Aorta/surgery , Aortic Valve/surgery , Heart Septum/surgery , Heart Valve Diseases/complications , Heart Valve Prosthesis Implantation/methods , Humans , Mitral Valve/surgery , Pericardium/transplantation , Treatment Outcome , Ventricular Outflow Obstruction/complicationsABSTRACT
Annuloplasty ring or band dehiscence is a possible complication of mitral valve repair surgery. It may be due to increased tension on the annuloplasty sutures, especially in ischemic mitral pathology in which a circumferential ring is used. Herein, we describe a technique for alternative suture placement in mitral annuloplasty using pledgeted sutures that may reduce the risk for ring or band dehiscence.
Subject(s)
Mitral Valve Annuloplasty/methods , Mitral Valve Insufficiency/surgery , Suture Techniques/instrumentation , Sutures , Equipment Design , HumansABSTRACT
INTRODUCTION: Acquired hemophilia A is a rare bleeding disorder with a high mortality rate. Diagnosis and treatment of this disorder can be very challenging to anesthesiologists because of lack of a personal or familial abnormal bleeding history. CASE PRESENTATION: We report a 60-year-old woman who presented to the operating room for an urgent fasciotomy. She was initially diagnosed to have compartment syndrome of her left upper extremity secondary to an expanding hematoma after multiple unsuccessful venipuncture attempts. After surgical intervention, she developed recurrent intramuscular hematomas, became severely anemic, and required surgical re-exploration and multiple blood product transfusions. Ultimately, she was found to have an elevated activated partial thromboplastin time (aPTT), very low FVIII activity, and high FVIII inhibitor titers consistent with the diagnosis of acquired hemophilia A. CONCLUSIONS: Treatment strategies in acquired hemophilia are based on two major objectives. During the acute stage, effective control of bleeding is critical. The ultimate therapeutic goal during the subacute phase is the elimination of the inhibitors targeting factor VIII. Here, we present this case and will review current literature regarding therapeutic approaches to this rare condition in the operating room setting and postoperative course.