Risk Factors of Long-Term Sequelae After Transcatheter Closure of Perimembranous Ventricular Septal Defect in Young Children.

BACKGROUND: Complications arising from transcatheter closure of perimembranous ventricular septal defects (pmVSD) in children, such as residual shunts and aortic regurgitation (AR), have been observed. However, the associated risk factors remain unclear. This study identified risk factors linked with residual shunts and AR following transcatheter closure of pmVSD in children aged 2-12 years.Methods and Results: The medical records of 63 children with pmVSD and a pulmonary-to-systemic blood flow ratio <2.0 who underwent transcatheter closure between 2011 and 2018 were analyzed with a minimum 3-year follow-up. The success rate of transcatheter closure was 98.4%, with no emergency surgery, permanent high-degree atrioventricular block, or mortality. Defects ≥4.5 mm had significantly higher odds of persistent residual shunt (odds ratio [OR] 6.85; P=0.03). The use of an oversize device (≥1.5 mm) showed a trend towards reducing residual shunts (OR 0.23; P=0.06). Age <4 years (OR 27.38; 95% confidence interval [CI] 2.33-321.68) and perimembranous outlet-type VSD (OR 11.94, 95% CI 1.10-129.81) were independent risk factors for AR progression after closure. CONCLUSIONS: Careful attention is crucial for pmVSDs ≥4.5 mm to prevent persistent residual shunts in transcatheter closure. Assessing AR risk, particularly in children aged <4 years, is essential while considering the benefits of pmVSD closure.

Impact of Previous Conventional Cardiac Surgery on the Clinical Outcomes After Heart Transplantation.

The impact of the type, purpose, and timing of prior surgery on heart transplantation (HT) remains unclear. This study investigated the influence of conventional cardiac surgery (PCCS) on HT outcomes. This study analyzed HTs performed between 1999 and 2019 at a single institution. Patients were categorized into two groups: those with and without PCCS. Short-term outcomes, including post-transplant complications and mortality rates, were evaluated. Cox proportional and Kaplan-Meier survival analyses were used to identify risk factors for mortality and assess long-term survival, respectively. Of 368 patients, 29% had PCCS. Patients with PCCS had a higher incidence of post-transplant complications. The in-hospital and 1 year mortality rates were higher in the PCCS group. PCCS and cardiopulmonary bypass time were significant risk factors for 1 year mortality (hazard ratios = 2.485 and 1.005, respectively). The long-term survival rates were lower in the PCCS group, particularly in the first year. In sub-analysis, patients with ischemic cardiomyopathy and PCCS had the poorest outcomes. The era of surgery and timing of PCCS in relation to HT did not significantly impact outcomes. In conclusion, PCCS worsen the HT outcomes, especially in patients with ischemic etiology. However, the timing of PCCS and era of HT did not significantly affect this concern.

Validation of the European system for cardiac operative risk evaluation II in a large Taiwan cardiac surgical centre.

BACKGROUND: The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established scoring system for predicting mortality in cardiac surgery. This system was derived predominantly from a European patient cohort; however, no validation of this system has been conducted in Taiwan. We sought to assess the performance of EuroSCORE II at a tertiary centre. METHODS: The 2161 adult patients receiving cardiac surgery between 2017 and 2020 in our institution were included. RESULTS: Overall, the in-hospital mortality rate was 7.89%. The performance of EuroSCORE II was assessed using the area under the receiver operator curve (AUC) for discrimination and the Hosmer-Lemeshow (H-L) test for calibration. Data were analysed for type of surgery, risk stratification, and status of the operation. EuroSCORE II had good discriminative power (AUC=0.854, 95% Confidence Interval (CI): 0.822-0.885) and good calibration (χ2=5.19, p=0.82) for all types of surgery except ventricular assist devices (AUC=0.618, 95% CI: 0.497-0.738). EuroSCORE II also showed good calibration for most types of surgery except coronary artery bypass surgery (CABG) combined procedure (P=0.033), heart transplantation (HT) (P=0.017), and urgent operation (P=0.041). EuroSCORE II significantly underestimated the risk for CABG combined procedure and urgent operations, and overestimated the risk for HT. CONCLUSION: EuroSCORE II had satisfactory discrimination and calibration power to predict surgical mortality in Taiwan. However, the model is poorly calibrated for CABG combined procedure, HT, urgent operation, and, likely, lower- and higher-risk patients.

Total Anomalous Pulmonary Venous Connection: Surgical Outcomes and Risk Factors for Postoperative Pulmonary Vein Obstruction.

Background: Total anomalous pulmonary venous connection (TAPVC) is a fatal congenital cardiac anomaly that requires urgent surgical intervention. The development of postoperative pulmonary vein obstruction (PVO) negatively impacts long-term survival. Objectives: The present study aimed to evaluate the surgical outcomes of TAPVC repair and risk factors associated with postoperative PVO. Methods: Patients who underwent primary TAPVC repair at our institute between 2004 and 2022 were retrospectively enrolled, and those with right atrial isomerism and single ventricle physiology were excluded. Factors associated with survival and postoperative PVO were analyzed. Results: A total of 116 patients were enrolled in the present study. The early mortality rate was 6.9%. Nineteen patients (16.4%) developed postoperative PVO within a median time of 59 days of the primary repair, of whom 10 were successfully relieved without any recurrent obstruction. In long-term follow-up, patients with postoperative PVO had significantly lower long-term survival rates than those without postoperative PVO [57.9%, 95% confidence interval (CI) = 34.8-79.5%; vs. 90.4%, 95% CI = 83-96.6% at 10 years, p < 0.001]. Risk factors for postoperative PVO development included lower body weight, younger age, preoperative mechanical ventilation, preoperative inotrope use, and emergency operation. Conclusions: Postoperative PVO was significantly associated with a higher long-term mortality rate after primary TAPVC repair, with the risk being higher in patients with critical preoperative status. The long-term outcome was good for patients in whom the obstruction was successfully relieved. Early detection and prompt intervention for postoperative PVO after TAPVC repair can improve overall survival in these patients.

Biventricular Repair for Aortic Atresia, Ventricular Septal Defect, and Type C Interrupted Aortic Arch.

Interrupted aortic arch is a rare congenital heart defect. Among patients with interrupted aortic arch, an interruption between the innominate artery and left common carotid artery (type C) is the rarest. Herein, we report the case of a neonate with aortic atresia, ventricular septal defect, type C interrupted aortic arch, and aberrant right subclavian artery who underwent Norwood stage I operation and staged biventricular repair. Due to aortic atresia, coronary artery perfusion was retrograde from the right common carotid artery. The surgical technique and special considerations for cardiopulmonary bypass are presented.

Role of percutaneous pulmonary artery cannulation in extracorporeal life support for acute cardiac failure: A single-center case series.

BACKGROUND: Pulmonary artery (PA) cannulation is an effective extracorporeal life support (ECLS) management for left ventricular (LV) decompression or right ventricular (RV) support. This case series explores the results of PA cannulation during ECLS for acute cardiac failure. METHODS: Patients receiving percutaneous PA cannulation between January 2017 and December 2020 in a single institution were retrospectively reviewed. Patients receiving PA cannulation by a surgical cutdown method were excluded. Based on the hemodynamic needs of the patients, percutaneous PA cannulation was applied with ECLS for LV unloading and/or RV support. The primary endpoint was the successful weaning from circulatory support. The secondary endpoints included 30-day or in-hospital mortality, significant periprocedural complications, and successful hospital discharge without major complications. RESULTS: Fifteen patients (13 men, age range 11.2-70.8 years) presented acute heart failure and were initially managed by conventional ECLS mode. Percutaneous PA cannulation was performed for LV unloading in 13 patients (86.67%) and isolated RV circulatory support in two patients (13.33%). Weaning from circulatory support was achieved in 11 patients (73.33%). No significant periprocedural complication, including bleeding, infection, or vascular event requiring surgical exploration, was reported. The 30-day or in-hospital mortality rate was 33.33%. Eight cases (53.33%) were successfully discharged without major complications, including permanent stroke or the need for long-term hemodialysis. CONCLUSIONS: PA cannulation, especially percutaneously performed, was effective and safe for LV unloading and/or RV support during ECLS. Further investigation is required to confirm the efficacy and safety of our approach and management in a larger patient population.

Outcomes of pediatric patients supported with ventricular assist devices single center experience.

BACKGROUND: There has been a remarkable increase in the number of pediatric ventricular assist device (VAD) implanted over the past decade. Asian pediatric heart centers had not participated in the multicenter registries among the Western countries. This article aimed to report the outcomes of pediatric VAD in our hospital. METHODS: The study enrolled all patients aged <18 years at the time of VAD implantation in our institution between 2008 and 2021. RESULTS: There were 33 patients with diagnosis of acute fulminant myocarditis (n = 9), congenital heart disease (n = 5), dilated cardiomyopathy (n = 16), and others. Paracorporeal continuous-flow pump was the most frequently implanted (n = 27). Most of the devices were implanted in patients with INTERMACS profile 1 (n = 24). The median duration on VAD was 22 days (range 2-254). The proportion of patients attaining positive outcomes (alive on device, bridge to transplantation or recovery) was 72.7% at 1 month, 67.7% at 3 months, and 67.7% at 6 months. Most of the deaths on device occurred within the first month post-implant (n = 9), with neurological complications being the most frequent cause of death. All recovered cases were successfully weaned off the device within the first month of implantation. CONCLUSION: We demonstrated a favorable outcome in pediatric patients supported with VAD at our institution.

Extreme size mismatch: bronchus compression by an oversized donor heart in small children.

Studies have suggested that a more liberal criterion of donor-recipient weight ratio (DRWR) is associated with superior waitlist survival without compromising posttransplant outcomes in selected critically ill patients. Successful transplantation of an extremely oversized donor heart into a small recipient is herein described. A 2-year-old girl accepted a size-mismatched adult donor heart offer (DRWR of 4.4) due to frequent complications with a left ventricular assist device. During the immediate postoperative period, spatial constraints within the thoracic cavity compromised graft function. Computed tomography revealed severe compression of the left bronchus due to the oversized allograft with lobar collapse of the left lung. With temporary extracorporeal membrane oxygenation support, graft function improved within 1 month after transplantation. Subsequent adaptive size remodeling of the transplanted heart with concomitant left bronchus re-expansion was observed within 6 months after transplantation. Despite a complicated posttransplant recovery, the patient was discharged home with minimal respiratory sequelae. Our report describes an alternative strategy for managing early morbidities related to an oversized graft and supports extending the criteria of size matching in pediatric heart transplantations.

Microrna-486-5P Regulates Human Pulmonary Artery Smooth Muscle Cell Migration via Endothelin-1.

Pulmonary arterial hypertension (PAH) is a fatal or life-threatening disorder characterized by elevated pulmonary arterial pressure and pulmonary vascular resistance. Abnormal vascular remodeling, including the proliferation and phenotypic modulation of pulmonary artery smooth muscle cells (PASMCs), represents the most critical pathological change during PAH development. Previous studies showed that miR-486 could reduce apoptosis in different cells; however, the role of miR-486 in PAH development or HPASMC proliferation and migration remains unclear. After 6 h of hypoxia treatment, miR-486-5p was significantly upregulated in HPASMCs. We found that miR-486-5p could upregulate the expression and secretion of ET-1. Furthermore, transfection with a miR-486-5p mimic could induce HPASMC proliferation and migration. We also found that miRNA-486-5p could downregulate the expression of SMAD2 and the phosphorylation of SMAD3. According to previous studies, the loss of SMAD3 may play an important role in miRNA-486-5p-induced HPASMC proliferation. Although the role of miRNA-486-5p in PAH in in vivo models still requires further investigation and confirmation, our findings show the potential roles and effects of miR-486-5p during PAH development.

Impact of duration of mechanical support on heart transplantation: Hasty transplantation may not have a good long-term outcome.

BACKGROUND: Mechanical circulatory support (MCS) has been widely utilized in critically ill cardiac transplant candidates. Few studies have investigated the impact of duration of MCS before heart transplantation (HTx) on long-term patient survival. METHODS: A retrospective HTx database was reviewed between 2009 and 2019. Patients who did not or did undergo MCS before HTx were categorized into two groups: (1) A (did not) and (2) B (did), respectively. A receiver operating characteristic (ROC) curve was plotted to assess the cutoff level of MCS duration before HTx in evaluating 5-year survival. RESULT: A total of 270 HTx patients (group A: 120, group B: 150) were analyzed. Group B patients had a higher percentage of blood type O, a higher incidence of resuscitation, a shorter listing duration, and a higher likelihood of having United Network for Organ Sharing (UNOS) 1A status than group A. The ROC curve revealed 24 days as a good cut-off level for determining the best MCS before HTx timing. Group B was categorized into two subgroups: (1) B1 (MCS < 24 days, n = 65) and (2) B2 (MCS > 24 days, n = 85). B2 had a higher incidence of cardiopulmonary resuscitation (CPR), hemodialysis, longer waiting time after MCS, and better ventricular assist device implantation than B1. However, the survival curves showed that B1 outcomes were significantly worse than in groups A and B2. Groups A and B2 had similar survival curves without an increased incidence of infection. CONCLUSION: The preliminary data demonstrated that a longer duration of MCS may be associated with better outcomes than urgent HTx.

Impact of pre-transplant bloodstream infection on clinical outcomes after heart transplantation.

BACKGROUND: Active bloodstream infection (BSI) is a contraindication for heart transplantation (HT). However, some critical patients with BSI may undergo HT as a life-saving procedure. We aimed to investigate the impact of pre-transplant BSI on the clinical outcomes after HT. METHODS: We enrolled 511 consecutive patients who underwent HT between 1999 and 2019. Patients were divided into two groups based on the presence of BSI within 30 days preoperatively. Forty-three patients (8.4%) with BSI who were clinically stable and had no metastatic infection were considered for HT on an individual basis. In-hospital mortality, incidence of early postoperative BSI, length of postoperative hospital stays, and long-term survival were compared between the groups. Logistic and Cox regression analyses were performed to identify risk factors for in-hospital and 1-year mortality. RESULTS: Patients with pre-transplant BSI had a high incidence of previous cardiopulmonary resuscitation, pre-transplant ventilator use, mechanical circulatory support use, renal replacement therapy, United Network for Organ Sharing status 1A, and a prolonged preoperative hospital waiting period. The in-hospital mortality rate was higher in patients with pre-transplant BSI (21% vs. 12%, p = .081), and the mortality rate was very high (33.3%) for those with BSI 0-15 days before HT. In addition, patients with pre-transplant BSI had a significantly longer postoperative hospital stay than patients in the control group. However, long-term survival was similar in both groups. CONCLUSIONS: Although pre-transplant BSI was associated with higher in-hospital mortality and prolonged postoperative hospital stay, patients who survived the early period had a similar long-term prognosis.

Malignant granular cell tumour at the interventricular septum.

Granular cell tumours are usually benign with a 1-2% incidence of malignancy. They are less sensitive to radiotherapy and chemotherapy and are treated by surgical excision. We report a case of a malignant granular cell tumour located at the interventricular septum.

Outcome of urgent desensitization in sensitized heart transplant recipients.

BACKGROUND/PURPOSE: Sensitization, the presence of preformed anti-human antibody in recipients, restricts access to ABO-compatible donors in heart transplant. Desensitization therapy works by reducing preformed antibodies to increase the chances of a negative crossmatch or permit safe transplantation across positive crossmatch. There is no consensus regarding the desensitization protocol in cardiac patients, and the outcome of desensitization remains under debate. METHODS: Twenty-five consecutive sensitized heart transplant recipients received perioperative desensitization in our institution from 2012 to 2019. One-year patient survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients. RESULTS: Within the first year after transplant, patient survival in sensitized recipients was 76%. Infection was the major cause of death. The cumulative incidence of rejection was 8% for antibody-mediated rejection and 16% for acute cellular rejection. No significant difference in 1-year survival or rejection rate could be demonstrated between sensitized and nonsensitized recipients. CONCLUSION: Acceptable early outcomes in patient survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity crossmatch- or panel-reactive antibody-directed urgent immunomodulation strategies, while infection remains the major concern.

Impact of the Pre-Transplant Circulatory Supportive Strategy on Post-Transplant Outcome: Double Bridge May Work.

BACKGROUND: The number of waitlisted patients requiring mechanical circulatory support (MCS) as a bridge to heart transplantation is increasing. The data concerning the results of the double-bridge strategy are limited. We sought to investigate the post-transplant outcomes across the different bridge strategies. METHODS: We retrospectively reviewed a heart transplantation database from Jan 2009 to Jan 2019. Intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD) were the MCS that we investigated. The pre- and post-transplant characteristics and variables of patients bridged with the different types of MCS were collected. The post-transplant survival was compared using Kaplan-Meier survival analysis. RESULTS: A total of 251 heart transplants were reviewed; 115 without MCS and 136 with MCS. The patients were divided to five groups: Group 1 (no MCS): n = 115; Group 2 (IABP): n = 15; Group 3 (ECMO): n = 33; Group 4 (ECMO-VAD): double-bridge (n = 59); Group 5 (VAD): n = 29. Survival analysis demonstrated that the 3-year post-transplant survival rates were significantly different among the groups (Log-rank p < 0.001). There was no difference in survival between group 4(ECMO-VAD) and group 1(no MCS)1 (p = 0.136), or between group 4(ECMO-VAD) and group 5(VAD) (p = 0.994). Group 3(ECMO) had significantly inferior 3-year survival than group 4(ECMO-VAD) and group 5(VAD). CONCLUSION: Double bridge may not lead to worse mid-term results in patients who could receive a transplantation. Initial stabilization with ECMO for critical patients before implantation of VAD might be considered as a strategy for obtaining an optimal post-transplant outcome.

Prognostic factors for heart recovery in adult patients with acute fulminant myocarditis and cardiogenic shock supported with extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an effective support method for acute fulminant myocarditis (AFM) with cardiogenic shock. However, deciding whether to bridge to a left ventricular assist device (LVAD) or to maintain ECMO support until heart recovery is still controversial. MATERIAL AND METHODS: This was a retrospective observational study from a single center. Eighty-eight adults with AFM and ECMO support between 2006 and 2018 were included. The primary endpoint was heart recovery without heart transplantation or long-term LVAD support. RESULTS: The heart recovery group contained 43 patients, of whom 41 were discharged after being weaned off ECMO and the other two after LVAD. Five patients with heart transplants and one with long-term LVAD support were discharged, accounting for an overall survival of 55.7%. Multivariate logistic regression revealed that peak CK-MB level, severe intraventricular conduction disturbance (asystole) and malignant arrhythmia (VT or VF) were prognostic factors for nonrecovery (P = .027 and 0.017, respectively), while early intravenous immunoglobulin (IVIG) use before ECMO was highly likely to have a protective effect with a trend toward statistical significance (P = .079). A risk score was developed: 4 points for VT/VF/asystole, 1 point for every 100 µg/L increase in the peak CK-MB level, up to a maximum of 5 points, and -3 points for early IVIG use. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.818. CONCLUSION: High CK-MB levels and VT/VF/asystole in patients with AFM are associated with poor heart recovery. Early IVIG use shows a potentially protective effect.

Impact of MELD score and cardiopulmonary bypass duration on post-operative hypoxic hepatitis in patients with liver cirrhosis undergoing open heart surgery.

BACKGROUND: The outcome of open-heart surgery for patients with liver cirrhosis (LC) varies widely, indicating multifactorial influences on liver injury after cardiopulmonary bypass (CPB). METHODS: This observational single center study evaluated adult LC patients receiving open heart surgery with CPB during 2007 and 2017. The primary endpoint was post-operative hypoxic hepatitis (POHH), defined by post-operative serum glutamate oxaloacetate transaminase and glutamate pyruvate transaminase more than 10 times the pre-operative value. RESULTS: In total, 61 patients were included in the study, of whom 14 (18.7%) developed POHH. Hospital mortality of non-POHH group (4.3%) was similar to that estimated using Euroscore II (4.0%), but that of the POHH group (21.4%) was 2.7 times as that estimated using Euroscore II (8.0%). Model for End-Stage Liver Disease (MELD) score and CPB duration were found as independent risk factors for POHH by multivariate logistic regression. POHH incidence was 0.0% if MELD <5 and 80.0% of MELD >20 regardless of CPB duration. For those with MELD between 5 and 20, POHH incidence increases as CPB duration increases. CONCLUSION: For LC patients undergoing cardiac surgery with CPB, the incidence of POHH is highly associated with MELD score and CPB duration. To prevent POHH, the CPB duration should be shortened for those with MELD score between 5 and 20, and CPB be avoid for those with MELD >20.

Excessive Tracheal Length in Patients With Congenital Tracheal Stenosis.

BACKGROUND: Slide tracheoplasty is the preferred approach for treating long-segment congenital tracheal stenosis (CTS). However, little research has been conducted on the tracheobronchial anatomy before and after slide tracheoplasties in patients with CTS. METHODS: We reviewed 23 patients with CTS who received slide tracheoplasties. We measured the intrathoracic tracheal length and the carina angle from computed tomography images. To account for each patient's body size, we divided the intrathoracic tracheal length by the length of the thorax to obtain the trachea-thorax ratio (TTR). These measurements were used to compare patients before and after slide tracheoplasties as well as normal control subjects. RESULTS: Two patients had upper tracheal CTS and 21 patients had lower tracheal CTS. For the 21 patients with lower tracheal stenosis, their TTRs before slide tracheoplasty were 0.42 ± 0.04, which were significantly larger than those of the control subjects (0.32 ± 0.04; p < 0.0001). After slide tracheoplasty, the TTR was 0.32 ± 0.04, similar to the control TTRs (p = 0.94). The carina angle was significantly wider in the 21 patients than in the control subjects (120.7 ± 11.7 degrees versus 86.4 ± 13.1 degrees; p < 0.0001). After slide tracheoplasty, the carina angle was significantly narrower (from 120.7 ± 11.7 degrees to 92.2 ± 15.2 degrees; p < 0.0001), which was similar to control subjects. CONCLUSIONS: The trachea was longer and the carina angle wider in patients with lower tracheal CTS than in control subjects. Excessive tracheal length is favorable for slide tracheoplasty. Slide tracheoplasty not only corrects CTS, but also restores tracheobronchial morphology.