Outcomes of Transannular Repair of Tetralogy of Fallot With a Contegra® Monocuspid Patch.

BACKGROUND: Surgical repair of tetralogy of Fallot (ToF) depends on the anatomical variations of the heart defect. A group of patients with a hypoplastic pulmonary valve annulus required a transannular patch. This study aimed to evaluate the early and late outcomes of ToF repair with a transannular Contegra® monocuspid patch in a single center. METHODS: A retrospective review of medical records was conducted. This study included 224 children with a median age of 13 months who underwent ToF repair with a Contegra® transannular patch in over 20 years of observation. The primary outcomes were hospital mortality and need for early reoperations. The secondary outcomes were late death and event-free survival. RESULTS: The hospital mortality in our group was 3.1%, whereas two patients required early reoperation. Three patients were excluded from the study because follow-up data were not available. In the remaining group of patients (212 patients), the median follow-up was 116 (range, 1-206) months. One patient died because of sudden cardiac arrest at home six months after surgery. Event-free survival was observed in 181 patients (85.4%), whereas the remaining 30 patients (14.1%) required graft replacement. The median time to reoperation was 99 (range, 4-183) months. CONCLUSIONS: Although surgical treatment of ToF has been performed for more than 60 years worldwide, the optimal approach in children with a hypoplastic pulmonary valve annulus remains debatable. Among options, the Contegra® monocuspid patch can be effectively used in transannular repair of ToF with good long-term results.

Surgical Outcomes of Total Anomalous Pulmonary Venous Connection Repair.

Background and Objectives: Over the years, surgical repair of total anomalous pulmonary venous connection (TAPVC) outcomes have improved, however, morbidity and mortality still remain significant. This study aims to assess the early and long-term outcomes of surgical treatment of TAPVC children, operated on between 2006 and 2016, in one pediatric center in Poland. Materials and Methods: Diagnostics, surgical treatment, and follow-up data from 83 patients were collected. In addition, survival and risk factor analyses, control echocardiographic, and electrocardiographic examinations were performed. Results: In the analyzed group (n = 83), there were seven hospital deaths (within 30 days after the operation) (8.4%) and nine late deaths (10.8%). The mean follow-up time was 5.5 years, and, for patients who survived, it was 7.1 years. The mean survival time in patients with completed follow-up (n = 70) was 10.3 years; the overall five-year survival rate was 78.4%. Independent mortality risk factors were type I TAPVC, single ventricle physiology, time from admission to operation, intensive care unit stay, postoperative hospital stay, and temporary kidney insufficiency requiring dialysis. Conclusions: The presence of single ventricle physiology and the supracardiac subtype of TAPVC might be negative prognostic factors, while normal heart physiology presents with good post-repair results. This study indicates that cardiac arrhythmias may occur. Morbidity and mortality, related to surgical TAPVC correction, still remain significant.

Pulmonary artery growth in univentricular physiology patients.

BACKGROUND: A Fontan-type operation, i.e. a connection of the systemic veins and pulmonary arteries without subpulmonary ventricle, with different surgical techniques, is nowadays the only treatment option for patients with a functionally univentricular heart (UVH). Understanding the development of pulmonary arteries in patients who are considered for the Fontan procedure is important clinically. AIM: To evaluate the development of pulmonary arteries in patients with univentricular circulation. METHODS: Between 1995 and 2007, 111 patients underwent a bidirectional Glenn procedure. In all patients, preoperative catheterisation was performed to assess the anatomy and haemodynamics of UVH, especially the size of the pulmonary arteries. Ninety nine patients were included in the bidirectional Glenn group; 62 of these underwent repeat catheterisation before Fontan completion. The late results, after one stage extracardiac total cavopulmonary anastomosis performed in 24 patients between 1992 and 2002, were reinvestigated (one-stage Fontan group). We assessed the changes in the McGoon ratio and Nakata index for the whole cohort of patients. McGoon ratio is the sum of the diameter of pulmonary arteries divided by the diameter of the aorta. Nakata index is the sum of the cross-sectional area of the pulmonary arteries divided by the body surface area. RESULTS: During cardiac catheterisation prior to Glenn procedure, the mean Nakata index was 351.9 (range 131.2-886) mm2/m2 and was higher in patients with increased pulmonary flow (p = 0.0135). Mean McGoon ratio was 2.5 (range 1.1-4.9). An average 40.3 months after Glenn procedure, the Nakata index and McGoon ratio decreased significantly to 226.4 ± 125 mm²/m² (p < 0.003), and to 2.14 ± 0.58 (p < 0.008) respectively. In the group of patients after one-stage Fontan in late follow-up, mean 7.4 years after procedure, the Nakata index decreased from 318.7 ± 159.1 mm²/m² to 120 ± 40 mm²/m² (p < 0.0001) and McGoon ratio from 2.4 ± 0.6 to 1.4 ± 0.27 (p < 0.0001). Only size of pulmonary arteries before Glenn procedure, in the bidirectional Glenn group, or before Fontan operation, in the one-stage Fontan group,were inversely correlated with the changes of size of pulmonary arteries (p = 0.0015 and p = 0.0012). CONCLUSIONS: The relative decrease of the size of pulmonary arteries in the inter-stage period (between bidirectional Glenn anastomosis and Fontan completion) and after Fontan completion may indicate that pulmonary artery sizes should probably not bean absolute limiting factor in the decision on treatment of functionally UVH patients, especially at the stage of Fontan approach.

Major infection after pediatric cardiac surgery: external validation of risk estimation model.

BACKGROUND: A multivariable risk estimation model, in which the primary outcome was major infection, was recently developed and published using The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database. We have applied this risk estimation model to our congenital heart surgery program over a 16-year time interval to validate this risk estimation model and verify its specific risk factors for major infection. METHODS: Using complete and verified data, we selected patients in whom major procedures had been classified using both Aristotle Basic Score and Risk Adjustment for Congenital Heart Surgery (RACHS-1) and created a multivariable model in which primary outcome was major infection (septicemia, mediastinitis, or endocarditis). We checked the STS risk estimation model for major infection. We also assessed the significance of the STS risk factors in our program. RESULTS: A total of 6,314 patients were analyzed. We identified 197 (3.1%) major infections (septicemia 3%, endocarditis 0.015%, mediastinitis 0.09%). Hospital mortality, ventilation time, and length of stay were greater in patients with major infections. The following preoperative risk factors identified by the STS risk estimation model were significant in multivariate analysis in our patients: young age, high complexity, medium complexity, previous operation, and preoperative ventilation (p<0.0001). Estimated infection risk ranged from 0.32% to 11.58%. The model discrimination was good (c index, 0.808). Risks of infections after most common congenital heart surgery procedures were similar in both studies (rs=0.952, p=0.0003). CONCLUSIONS: Our external validation study confirmed that the STS model can be used as a preoperative risk stratification tool for major infection risk at the single institutional level.

Evolving approach to aortic valve replacement in children and adolescents--a preliminary report.

BACKGROUND: Surgical treatment methods are still controversial in children with congenital or acquired aortic valve dysfunction. AIM: To evaluate treatment results in children after mechanical or biological valve implantation. METHODS: We analysed a group of 55 children after mechanical valve implantation (group A) and a group of 8 children after Freestyle biological valve implantation (group B). We evaluated in both groups: patient's age, type of valve dysfunctions, severity of heart failure symptoms, and quality of life. The parameters of physiological left ventricular (LV) remodelling were examined on the basis of echocardiographical signs of LV contractibility (%SF) and anatomical changes: LV diastolic diameter (LVDd), LV posterior wall thickness (LVPW), thickness of intra-ventricle septum (IVS) and pressure gradient between LV and aorta (LV-Ao). RESULTS: There were no hospital deaths in either group. There were two late deaths in children from group A. Thromboembolic (2), nonspecific bleeding complications (2), and infections (2) occurred in group A. There were two re-operations in children after mechanical valve implantation. The early postoperative period was good in groups A and B. Furthermore, late postoperative period was good in group B. Physiological LV remodelling occurred in children in groups A and B. Quality of life was good in both groups. CONCLUSIONS: Good clinical results, simplicity, repeatability and safety of surgical technique mean that mechanical valve implantation in the aortic position is still an attractive option for treatment in children and adults. However, absence of bleeding, thromboembolic and infection complications and improvement of durability mean that the Freestyle biological new generation valve could be a good option for future in children and adolescents who need aortic valve replacement.