Preserving the pulmonary valve in Tetralogy of Fallot repair: Reconsidering the indication for valve-sparing.

BACKGROUND: Tetralogy of Fallot (TOF) repair is a frequent procedure, and although valve-sparing (VS) repair is preferred, determining which patients can successfully undergo this operation remains controversial. We sought to identify parameters to determine a selective, accurate indication for VS repair. METHODS: We reviewed 71 patients (82%) undergoing VS repair. We analyzed hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify acceptable indications. Patients requiring pulmonary valve (PV) reintervention versus no reintervention were compared. RESULTS: PV annulus size at repair was z-score of -2.0 (-5.3, 1.3). Approximately half (51%) had a z-score less than -2. Cox regression results showed this was not a risk factor for reintervention (p = .59). Overall, 1-, 3-, 5-, and 10-year freedom from PV reintervention rates were 95.8%, 92.8%, 91% and 77.8%, respectively. Residual pulmonary stenosis (PS) at initial repair was relatively higher in the reintervention group compared with no reintervention group (40 [28, 51] mmHg vs. 30 [22, 37] mmHg; p = .08). For patients with residual PS, pressure gradient (PG) was consistent over time across both groups (PV reintervention: -3 [-15, 8] mmHg vs. no reintervention: 0 [-9, 8] mmHg). The risk of PV reintervention is 3.7-fold higher when the PG from intraoperative TEE is greater than 45 mmHg (p = .04). CONCLUSIONS: Our review of the midterm outcomes of expanded indication for VS suggests intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg or RV pressure is higher than half of systemic pressure to prevent reintervention.

Pediatric aortic valve repair: Any development in the material for cusp extension valvuloplasty?

BACKGROUND: Aortic cusp extension is a technique for aortic valve (AV) repairs in pediatric patients. The choice of the material used in this procedure may influence the time before reoperation is required. We aimed to assess postoperative and long-term outcomes of patients receiving either pericardial or synthetic repairs. METHODS: We conducted a single-center, retrospective study of pediatric patients undergoing aortic cusp extension valvuloplasty (N = 38) with either autologous pericardium (n = 30) or CorMatrix (n = 8) between April 2009 and July 2016. Short- and long-term postoperative outcomes were compared between the two groups. Freedom from reoperation was compared using Kaplan-Meier analysis. Degree of aortic stenosis (AS) and aortic regurgitation (AR) were recorded at baseline, postoperatively, and at outpatient follow-up. RESULTS: At 5 years after repair, freedom from reoperation was significantly lower in the CorMatrix group (12.5%) compared to the pericardium group (62.5%) (p = .01). For the entire cohort, there was a statistically significant decrease in the peak trans-valvar gradient between preoperative and postoperative assessments with no significant change at outpatient follow-up. In the pericardium group, 28 (93%) had moderate to severe AR at baseline which improved to 11 (37%) postoperatively and increased to 21 (70%) at time of follow-up. In the biomaterial group, eight (100%) had moderate to severe AR which improved to three (38%) postoperatively and increased to seven (88%) at time of follow-up. CONCLUSION: In terms of durability, the traditional autologous pericardium may outperform the new CorMatrix for AV repairs using the cusp extension method.

Acute Effects of Vasopressin Arginine Infusion in Children with Congenital Heart Disease: Higher Blood Pressure Does Not Equal Improved Systemic Oxygen Delivery.

The use of vasopressin has been increased in recent years in children after congenital heart surgery. However, there is limited information regarding its effects on cardiac output, systemic oxygen delivery, and myocardial energetics. The purpose of this study is to characterize the effects of vasopressin infusions on hemodynamics and systemic oxygen delivery in children with congenital heart disease. A retrospective, single-center study of patients with congenital heart disease who received vasopressin infusions in a pediatric cardiac intensive care unit between January 2019 and May 2020. The measured values collected for study were systolic and diastolic blood pressure, heart rate, arterial oxygen saturation as determined by pulse oximetry, arterial pH, arterial partial pressure of oxygen, arterial partial pressure of carbon dioxide, serum lactate, serum sodium, and renal and cerebral oximetry based on near-infrared spectroscopy. The calculated values for this study were the difference between arterial and NIRS oximetry, the reno-cerebral near-infrared spectroscopy gradient and the vasoinotrope score. A Wilcoxon signed-rank test was utilized to compare values of paired continuous variables before and after initiation of the vasopressin infusion. Correlations were assessed using Spearman correlation analyses and stepwise regressions were completed. A total of 26 vasopressin infusions among 20 unique patients were included in the final analyses. Of these 26 vasopressin infusions, 18 were in patients with biventricular circulation and 8 were in patients with functionally univentricular circulation. The median vasopressin infusion dose at initiation was 0.4 (0.1-1) milliunits/kg/min. For the entire cohort 2 h after the initiation of vasopressin, systolic blood pressure increased to 8.4 mmHg, p < 0.01, but no significant correlation was found to markers of systemic oxygen delivery. Similar results were obtained when only those with biventricular circulation were considered. Those with functionally univentricular circulation were not found to have any statistically significant rise in blood pressure. Vasopressin infusions appear to statistically significantly increase systolic blood pressure in children with congenital heart disease who have a biventricular but not functionally univentricular circulation. Even when an increase in systolic blood pressure is present, systemic oxygen delivery did not improve.

Effects of Vasopressin Infusion After Pediatric Cardiac Surgery: A Meta-analysis.

Vasopressin has been used to augment blood pressure; however, cardiovascular effects after cardiac surgery have not been well established. The primary objective of this study was to survey the current literature and quantify the pooled effect of vasopressin on hemodynamic parameters in children after pediatric cardiac surgery. A systematic review was conducted to identify studies characterizing the hemodynamic effects of vasopressin after pediatric cardiac surgery. Studies were assessed and those of satisfactory quality with pre- and post-vasopressin hemodynamics for each patient were included in the final analyses. 6 studies with 160 patients were included for endpoints during the first 2 h of infusions. Patients who received vasopressin infusion had greater mean, systolic, and diastolic blood pressures and lower heart rates at 2 h after initiation. 8 studies with 338 patients were included for the effects at 24 h. Patients who received vasopressin infusion had lower central venous pressures and decreased lactate concentrations 24 h after initiation. A subset analysis for children with functionally univentricular hearts found significant decrease in inotrope score and central venous pressure. A subset analysis for neonates found significant decrease in inotrope score and fluid balance. Vasopressin leads to decrease in heart rate and increase in blood pressure in the first 2 h of initiation. Later effects include decrease in inotrope score, central venous pressure, fluid balance, and in lactate within the first 24 h. Findings vary in neonates and in those with functionally univentricular hearts although beneficial effects are noted in both.