George Daicoff: A Pioneering Surgeon and Humanitarian of The Southern Thoracic Surgical Association.

George Daicoff was a true pioneer who excelled in patient care, research, teaching, and advocacy; he performed cardiac surgery on thousands. He trained at Mayo Clinic under the tutelage of John Kirklin in 1966. He served on the faculty at University of Florida from 1967 to 1977 and became Chief of Thoracic and Cardiovascular Surgery at University of Florida. He then served as Chief of Cardiovascular Surgery at All Children's Hospital from 1977 to 1998. In 1972, he was one of 13 founding members of the Congenital Heart Surgeons' Society (CHSS), and in 1973, he was one of 10 surgeons to attend the first meeting of CHSS. Dr Daicoff won the 1970 Southern Thoracic Surgical Association President's Award for best scientific paper, and the 1996 Southern Thoracic Surgical Association Osler Abbot Award. In 2015, the Southern Thoracic Surgical Association Congenital Heart Surgery President's Award was named the George Daicoff Award.

Heart Transplantation for Pediatric and Congenital Cardiac Disease: A Comparison of Two Eras over 23 Years and 188 Transplants at a Single Institution.

BACKGROUND: To assess changes in patterns of practice and outcomes over time, we reviewed all patients who underwent heart transplantation (HTx) at our institution and compared two consecutive eras with significantly different immunosuppressive protocols (cohort 1 [80 HTx, June 1995-June 2006]; cohort 2 [108 HTx, July 2006-September 2018]). METHODS: Retrospective study of 180 patients undergoing 188 HTx (June 1995-September 2018; 176 first time HTx, 10 second HTx, and 2 third HTx). In 2006, we commenced pre-HTx desensitization for highly sensitized patients and started using tacrolimus as our primary postoperative immunosuppressive agent. The primary outcome was mortality. Survival was modeled by the Kaplan-Meier method. Univariable and multivariable Cox proportional hazard models were created to identify prognostic factors for survival. RESULTS: Our 188 HTx included 18 neonates, 85 infants, 83 children, and 2 adults (>18 years). Median age was 260.0 days (range: 5 days-23.8 years). Median weight was 7.5 kg (range: 2.2-113 kg). Patients in cohort 1 were less likely to have been immunosensitized preoperatively (12.5% vs 28.7%, P = .017). Nevertheless, Kaplan-Meier analysis suggested superior survival in cohort 2 (P = .0045). Patients in cohort 2 were more likely to be alive one year, five years, and ten years after HTx. Multivariable analysis identified the earlier era (hazard ratio [HR] [95% confidence interval] for recent era = 0.32 [0.14-0.73]), transplantation after prior Norwood operation (HR = 4.44 [1.46-13.46]), and number of prior cardiac operations (HR = 1.33 [1.03-1.71]) as risk factors for mortality. CONCLUSIONS: Our analysis of 23 years of pediatric and congenital HTx reveals superior survival in the most recent 12-year era, despite the higher proportion of patients with elevated panel reactive antibody in the most recent era. This improvement was temporally associated with changes in our immunosuppressive strategy.

Risk Factors for Survival After Heart Transplantation in Children and Young Adults: A 22-Year Study of 179 Transplants.

BACKGROUND: This article reviews all patients who underwent heart transplantation (HTx) within a single institution (172 patients underwent 179 HTx [167 first-time HTxs, 10 second HTxs, 2 third HTxs]) to describe diagnostic characteristics, management protocols, and risk factors for mortality. METHODS: Descriptive analysis was performed for the entire cohort using mean, standard deviation, median, interquartile range, and overall range, as appropriate. Univariable and multivariable Cox proportional hazards models were performed to identify prognostic factors for outcomes over time. The primary outcome of interest was mortality, which was modeled by Kaplan-Meier analysis. RESULTS: Median age at HTx was 263 days (range, 5 days to 24 years; mean = 4.63 ± 5.95 years; 18 neonates, 79 infants). Median weight at HTx was 7.5 kg (range, 2.2-113 kg; mean = 19.36 ± 23.54). Diagnostic categories were cardiomyopathy (n = 62), primary transplantation for hypoplastic left heart syndrome (HLHS) or HLHS-related malformation (n = 33), transplantation after cardiac surgery for HLHS or HLHS-related malformation (n = 17), non-HLHS congenital heart disease (n = 55), and retransplant (n = 12). Operative mortality was 10.1% (18 patients). Cumulative total follow-up is 1,355 years. Late mortality was 18.4% (33 patients). Overall Kaplan-Meier five-year survival was 76.2%. One hundred twenty-one patients are alive with a mean follow-up of 7.61 ± 6.46 years. No survival differences were seen among the five diagnostic subgroups ( P = .064) or between immunosensitized patients (n = 31) and nonimmunosensitized patients (n = 141; P = .422). CONCLUSIONS: Excellent results are expected for children undergoing HTx with comparable results among diagnostic groups. Pretransplant mechanical circulatory support and posttransplant mechanical circulatory support are risk factors for decreased survival. Survival after transplantation for HLHS or HLHS-related malformation is better with primary HTx in comparison to HTx after prior cardiac surgery.

Anomalous Papillary Muscle Insertion Causing Dynamic Left Ventricular Outflow Tract Obstruction without Hypertrophic Obstructive Cardiomyopathy.

Anomalous papillary muscle insertion directly into the surface of the mitral valve leaflet is rare, especially in a subject without apparent evidence of hypertrophic cardiomyopathy. We present a case of this isolated congenital malformation producing two hemodynamic sequelae of dynamic left ventricular outflow tract obstruction and severe mitral regurgitation.

Noninferiority of closely monitored mechanical valves to bioprostheses overshadowed by early mortality benefit in younger patients.

BACKGROUND: Confidence in bioprosthetic durability without anticoagulation has led to a contemporary trend of offering tissue valves to younger patients. Close monitoring of mechanical valve patients at lower international normalized ratio (INR) thresholds may reduce anticoagulation morbidity. We prospectively compared results of bioprostheses (BP) and a bileaflet mechanical prosthesis (MP) monitored at low INR thresholds. METHODS: Patients received an isolated Carpentier-Edwards bovine or Medtronic porcine BP or the On-X MP. INR targets were 2.0 for MP recipients undergoing aortic valve replacement and 2.5 for mitral valve replacement, using point-of-care home monitoring. Operations consecutively performed between September 2003 and August 2007 were propensity matched using logistic regression by preoperative covariates of age, sex, valve position, New York Heart Association class, ejection fraction, atrial fibrillation, and creatinine. RESULTS: Of 469 operations consecutively performed, 172 patients were matched for analysis. Mean age was 56.2±9.6 years (range, 24 to 72 years). Median follow-up was 4.0 years (total follow-up, 667.0 patient-years). No late bleeding events occurred. The thromboembolic complication rates per patient-year were 0.77% for MP and 0.78% for BP (p=0.67). There were 9 BP deaths vs 4 MP (2.35% vs 1.41%/patient-year; BP hazard ratio, 0.60; 95% confidence interval, 0.13 to 2.15). Postoperative linearized mortality benefit of MP was observed as early as 5 years, reaching significance at 7.5 years (p=0.04). CONCLUSIONS: Patients aged 65 years or younger with MP and closely monitored anticoagulation display noninferiority to BP from bleeding and thromboembolic complications. MP valves begin to confer mortality benefit over BP as early as 7.5 years postoperatively. Because this predates the timeline of typical structural valve degeneration, equipoise is suggested when choosing a BP in a young patient with future expectations of valve-in-valve intervention.

Lessons learned from 119 consecutive cardiac transplants for pediatric and congenital heart disease.

BACKGROUND: This manuscript reviews all patients who underwent orthotopic heart transplantations (OHT) at our program (116 patients underwent 119 OHT) to describe their diagnostic characteristics and to assess risk factors for mortality. METHODS: Median age at OHT was 179 days (mean, 1,446.6 ± 188.9 days [4.0 ± 0.5 years]; range, 5 days to 7,125 days [19.5 years]; 15 neonates, 68 infants). Median weight at OHT was 5.5 kg (mean, 17.2 ± 2.1 kg; range, 2.2 to 113 kg). Diagnoses were cardiomyopathy (n = 37), primary transplantation for hypoplastic left heart syndrome (HLHS) or HLHS-related malformation (n = 29), transplantation after prior cardiac surgery for HLHS or HLHS-related malformation (n = 9), non-HLHS congenital heart disease (n = 39), and retransplant (n = 5). RESULTS: Overall Kaplan-Meier 5-year survival was 72.7%. Operative mortality was 12.6% (15 patients). Late mortality was 13.4% (16 patients). Eighty-five patients survived, with a mean follow-up of 5.76 ± 0.48 years (median, 5.1 years; range, 0.12 to 14.0 years). Total follow-up was 507.0 years. No survival difference was seen among the five diagnostic subgroups (p = 0.20). Univariate association between risk factors and survival was assessed for the following variables: age (p = 0.91), weight (p = 0.86), sex (p = 0.47), race (p = 0.40), insurance classification (p = 0.42), high PRA (p = 0.20), pretransplant mechanical circulatory support (p < 0.001), posttransplant mechanical circulatory support (p < 0.001), redo sternotomy (p = 0.07), heterotaxy (p = 0.02), cardiopulmonary bypass time (p = 0.01), and donor heart cross-clamp time (p = 0.02). CONCLUSIONS: Excellent results are expected for children undergoing OHT regardless of diagnostic classification. Pretransplant mechanical circulatory support, posttransplant mechanical circulatory support, cardiopulmonary bypass time, donor heart cross-clamp time, and heterotaxy are risk factors for decreased survival.

Pediatric cardiac transplantation in children with high panel reactive antibody.

BACKGROUND: Elevated panel reactive antibody (PRA) may be considered a risk factor precluding pediatric orthotopic heart transplantation. We retrospectively reviewed our management strategy and outcome data for children undergoing heart transplantation with high PRA (> 10%). METHODS: Sixty consecutive children (median age = 130.5 days) underwent heart transplantation. Diagnoses included hypoplastic left heart syndrome (HLHS) (30 patients), cardiomyopathy (18 patients), and postoperative complex congenital heart disease (CCHD) (12 patients). Standard induction immunosuppressive therapy included pulse steroids, gamma globulin, and polyclonal rabbit antithymocyte globulin. Initial immunosuppression is a calcinurin inhibitor and an antiproliferative agent. Eight children exhibited elevated PRA (group P). Fifty-two exhibited nonelevated PRA (group N). Immunosuppression was modified in group P as follows: preoperative intravenous immunoglobulin G (IVIG) and/or cyclophosphamide or mycophenolate mofetil and preoperative and postoperative exchange transfusions or plasmapheresis. In group P, cyclophosphamide was the initial antiproliferative agent. RESULTS: Group P = 4 HLHS patients (all status post [s/p] prior cardiac surgery) and 4 postoperative CCHD patients. Group N = 26 HLHS patients (4 patients s/p prior cardiac surgery), 18 cardiomyopathy patients, and 8 postoperative CCHD patients. Group P patients were older and weighed more than group N patients. Waiting time for donor heart, cardiac ischemic time, and length of hospital stay were similar in both groups. Thirty-day mortality for group P was 25% and for group N it was 7.9% (p = 0.178). Overall mortality for group P was 50% and for group N it was 15.4% (p = 0.043). CONCLUSIONS: Although heart transplantation can offer children with end-stage heart failure and elevated PRA their only chance of survival, these patients remain high risk despite aggressive immunosuppression.

Acute myocardial infarction in a 15-year old secondary to myxomatous embolisation.

We present a 15-year-old white male who presented with an acute myocardial infarction secondary to embolisation of tissue from a left atrial myxoma. He successfully underwent resection of the myxoma, and embolectomy of the fragments of tumour lodged in the coronary artery.

The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery and interventional cardiology coil occlusion.

BACKGROUND: In an effort to analyze our experience and develop treatment guidelines, we reviewed all our patients with patent ductus arteriosus (PDA) treated with video-assisted thoracoscopic surgery (VATS) or interventional cardiology coil occlusion. METHODS: One hundred patients underwent 102 cardiac catheterizations. Forty-five children underwent VATS. The entire cohort of patients is 141 because 4 patients underwent both catheterization and VATS. RESULTS: Successful PDA coil occlusion occurred in 91 patients (91 of 100; 91%); 8 had unsuccessful attempts at coil occlusion and 1 was referred for surgical ligation after catheterization without any attempt at coil placement. Thirty-nine children had successful VATS PDA closure. Six children required conversion to thoracotomy because of inadequate exposure during VATS. Hospital stay for children more than 45 days of age was as follows: VATS median stay, 1 day, mean, 1.4 days; thoracotomy median stay, 4 days, mean, 4.6 days. One patient treated with PDA coil occlusion developed a recurrent PDA and required reembolization. Three children underwent initial catheterization without successful coil placement with subsequent successful VATS. All VATS patients left the operating theater with echocardiography documenting no residual PDA. Two children who underwent successful VATS with no residual PDA at hospital discharge were found on outpatient follow-up to have developed tiny recurrent PDAs and both were successfully coil occluded; 1 of these 2 children is 1 of the 3 children initially evaluated by catheterization and then referred for VATS. CONCLUSIONS: Video-assisted thoracoscopic surgery and coil occlusion represent complementary techniques for PDA treatment. A rationale for selection of the appropriate treatment modality can be based upon the size and age of the patient and the size and morphology of the PDA.

Minimally invasive endoscopic repair of pectus excavatum.

OBJECTIVE: We report our initial 3 years 4 months' single institution experience in 31 consecutive patients with pectus excavatum treated with minimally invasive endoscopic pectus excavatum repair utilizing a modification of the 'Nuss' technique. METHODS: Under general anesthesia, a curved steel bar is individually shaped for each patient to match the ideal chest wall shape and is placed through an endoscopically created retrosternal tunnel between two bilateral midaxillary line 2-cm incisions. The tunnels initially go along the outside of the rib cage, under the pectoral muscles. At the level of the sternum, these tunnels go retrosternal and communicate with each other. The steel bar is passed with the convexity facing posteriorly, within a protective flat silastic drain. Under endoscopic guidance, the curved steel bar is passed through one tunnel, under the sternum, and out the other tunnel. Once positioned, the bar is turned over, thereby correcting the deformity. An epidural catheter provides perioperative pain relief. RESULTS: Minimally invasive endoscopic pectus excavatum repair has been performed on 31 patients (age: range 4.4-31.0 years, median 15.0 years, mean 14.5 years). Median hospital length of stay is 4 days (range 3-10 days, mean 4.6 days). Pneumothorax occurred in five patients requiring tube thoracostomy in three. One patient developed delayed bilateral pleural effusions requiring drainage. Two patients developed evidence of sterile seroma formation at the skin incision several months after minimally invasive repair of pectus excavatum. These seromas resolved with non-interventional conservative medical treatment. No other complications occurred. CONCLUSION: The minimally invasive endoscopic pectus repair is safe and effective and currently our procedure of choice for primary pectus excavatum in all ages. Endoscopic visualization facilitates the safe creation of the retrosternal tunnel. Short-term results have been excellent. Further follow-up will be necessary to determine long-term results.