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1.
Cardiol Young ; 30(5): 698-709, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32364090

RESUMO

OBJECTIVE: Protein-losing enteropathy is an infrequent but severe condition occurring after Fontan procedure. The multifactorial pathogenesis remains unclear and no single proposed treatment strategy has proven universally successful. Therefore, we sought to describe different treatment strategies and their effect on clinical outcome and mortality. MATERIAL AND METHODS: We performed a retrospective observational study. From the total cohort of 439 Fontan patients treated in our institution during the study period 1986-2019, 30 patients (6.8%) with protein-losing enteropathy were identified. Perioperative, clinical, echocardiographic, laboratory, and invasive haemodynamic findings and treatment details were analysed. RESULTS: Median follow-up after disease onset was 13.1 years [interquartile range 10.6]. Twenty-five patients received surgical or interventional treatment for haemodynamic restrictions. Medical treatment, predominantly pulmonary vasodilator and/or systemic anti-inflammatory therapy with budesonide, was initiated in 28 patients. In 15 patients, a stable remission could be achieved by medical or surgical procedures (n = 3 each), by combined multimodal therapy (n = 8), or ultimately by cardiac transplantation (n = 1). Phrenic palsy, bradyarrhythmia, Fontan pathway stenosis, and absence of a fenestration were significantly associated with development of protein-losing enteropathy (p = 0.001-0.48). Ten patients (33.3%) died during follow-up; 5-year survival estimate was 96.1%. In unadjusted analysis, medical therapy with budesonide and pulmonary vasodilator therapy in combination was associated with improved survival. CONCLUSIONS: Protein-losing enteropathy is a serious condition limiting survival after the Fontan procedure. Comprehensive assessment and individual treatment strategies are mandatory to achieve best possible outcome. Nevertheless, relapse is frequent and long-term mortality substantial. Cardiac transplantation should be considered early as treatment option.

2.
Cardiol Young ; 30(5): 629-632, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32279698

RESUMO

OBJECTIVES: The aim of our study was to compare post-operative outcome after total cavopulmonary connection between patients operated during winter and summer season. METHODS: We retrospectively studied 211 patients who underwent extracardiac total cavopulmonary connection completion at our institution between 1995 and 2015 (median age 4 (1-42) years). Seventy (33%) patients were operated during winter (November to March) and 141 (67%) patients during summer season (April to October). RESULTS: Patients operated during winter and summer season showed no difference in early mortality (7% versus 5%, p = 0.52) and severe morbidity like need for early Fontan takedown (1% versus 1%, p = 0.99) and need for mechanical circulatory support (9% versus 4%, p = 0.12). The post-operative course and haemodynamic outcome were comparable between both groups of patients (ICU (4 versus 3 days, p = 0.44) and hospital stay (15 versus 14 days, p = 0.28), prolonged pleural effusions (36% versus 31%, p = 0.51), need for dialysis (16% versus 11%, p = 0.37), ascites (37% versus 33%, p = 0.52), supraventricular tachyarrhythmia (16% versus 13%, p = 0.56) and chylothorax (26% versus 16%, p = 0.12), change of antibiotic treatment (47% versus 36%, p = 0.06), prolonged inotropic support (24% versus 14%, p = 0.05), intubation time (15 versus 12 hours, p = 0.33), and incidence of fast-track extubation (11% versus 22%, p = 0.06). CONCLUSION: Outcomes after total cavopulmonary connection completion during winter and summer season were comparably related to mortality, severe morbidity, or longer hospital stay in the early post-operative period. These results suggest that total cavopulmonary connection completion during winter season is as safe as during summer season.

3.
Eur J Cardiothorac Surg ; 58(1): 171-176, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32236473

RESUMO

OBJECTIVES: In revised 2018 American Heart Association/American College of Cardiology guideline for the management of adults with congenital heart disease (ACHD), the committee introduced a classification that combines lesion anatomy and physiological status: ACHD anatomic physiological (AP) classification. Anatomy is described as of simple (I), moderate (II) or great (III) complexity, whereas physiology is listed in 4 categories of increasing severity (A, B, C and D). Can this classification predict early postoperative mortality? METHODS: ACHD AP classification was determined for 339 adults who underwent open-heart surgery between September 2012 and August 2018. In addition, the adult congenital heart surgery (ACHS) and Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery (STAT) mortality scores were calculated. A model based on binary logistic regression was applied. The event was early postoperative death. Mortality scores were estimated for each ACHD AP class. RESULTS: All patients could be categorized by the ACHD AP classification. The 354 procedures were performed with an early mortality of 3.4% (12/354). The mortality risk for the new mortality score, simply called ACAP score, ranged from 0.2% (95% confidence interval 0.08-0.41%) for ACHD AP class IA to 20% (16.04-24.64%) for IIID class. Observed over expected ratios of early mortality amounted to 0.87, 1.54 and 1.14, whereas areas under the curve of receiver operator characteristic were found to be 0.78, 0.64 and 0.88 for STAT, ACHS and ACAP scores, respectively. CONCLUSIONS: ACHD AP classification could embrace all procedures. In our setting, the ACAP score was more predictive of early mortality than the ACHS and STAT mortality scores. It should be validated by further studies and other centres.

4.
Pediatr Crit Care Med ; 21(6): e316-e324, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32343108

RESUMO

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation in children with refractory cardiac arrest has been shown to improve survival, however, risk factors associated with mortality and neurologic impairments are not well defined. We analyzed our recent institutional experience with pediatric extracorporeal cardiopulmonary resuscitation to identify variables associated with survival and neurocognitive outcome. DESIGN: Retrospective observational study. SETTING: Pediatric cardiology and congenital heart surgery departments of a tertiary referral heart center. PATIENTS: Seventy-two consecutive children (median age, 0.3 yr [0.0-1.9 yr]) who underwent extracorporeal cardiopulmonary resuscitation at our institution during the study period from 2005 to 2016. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Median duration of resuscitation was 60 minutes (42-80 min) and median extracorporeal support duration was 5.4 days (2.2-7.9 d). Forty-three (59.7%) extracorporeal cardiopulmonary resuscitation events occurred during off-hours, however, neither duration of resuscitation (65 min [49-89 min] vs 51 min [35-80 min]; p = 0.16) nor survival (34.9% vs 37.9%; p = 0.81) differed significantly compared to working hours. Congenital heart disease was present in 84.7% of the patients. Survival to hospital discharge was 36.1%; younger age, higher lactate levels after resuscitation, acute kidney injury, renal replacement therapy, hepatic injury, and complexity of prior cardiothoracic surgical procedures were significantly associated with mortality. At mid-term follow-up (median, 4.1 yr [3.7-6.1 yr]), 22 patients (84.6% of discharge survivors) were still alive with 77.3% having a favorable neurologic outcome. High lactate levels, arrest location other than ICU, and requirement for renal replacement therapy were associated with unfavorable neurologic outcome. Interestingly, longer duration of resuscitation did not negatively impact survival or neurologic outcome. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation is a valuable tool for the treatment of children with refractory cardiac arrest and a favorable neurologic outcome can be achieved in the majority of survivors even after prolonged resuscitation. Mortality after extracorporeal cardiopulmonary resuscitation in postcardiac surgery children is associated with procedural complexity.

5.
Thorac Cardiovasc Surg ; 68(1): 2-14, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31679152

RESUMO

Priming the cardiopulmonary bypass (CPB) circuit without the addition of homologous blood constitutes the basis of blood-saving strategies in open-heart surgery. For low-weight patients, in particular neonates and infants, this implies avoidance of excessive hemodilution during extracorporeal circulation. The circuit has to be miniaturized and tubing must be cut as short as possible to reduce the priming volume to prevent unacceptable hemodilution with initiating CPB. During perfusion, measures should be taken to prevent blood loss from the primary circuit to avoid replacement by additional volume. Favorable factors such as mild hypothermia/normothermia and high heparin concentrations during extracorporeal circulation promote earlier hemostasis after coming off bypass.Lower mortality score, first chest entry, higher hemoglobin concentration before going on bypass, and shorter CPB duration support transfusion-free CPB procedure. Reduced postoperative morbidity and mortality were observed when CPB was performed without blood transfusion. In our experience, this can be achieved in at least 70% of CPBs, even in low-weight patients.Bloodless CPB circuit priming should become a widespread reality, even in neonates and young infants, in any open-heart procedure.

6.
Thorac Cardiovasc Surg ; 68(1): 59-67, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30602177

RESUMO

BACKGROUND: We routinely start cardiopulmonary bypass (CPB) for pediatric congenital heart surgery without homologous blood, due to circuit miniaturization, and blood-saving measures. Blood transfusion is applied if hemoglobin concentration falls under 8 g/dL, or it is postponed to after coming off bypass or after operation. How this strategy impacts on postoperative mortality and morbidity, in infants weighing ≤ 7 kg? METHODS: Six-hundred fifteen open-heart procedures performed from January 2014 to June 2018 were selected. One-hundred sixty-three patients (26.5%) were transfused on CPB (group 1), while 452 (73.5%) patients were not transfused on CPB (group 2). Operative risk and complexity were similar in both groups. Postoperative mortality and morbidity were compared. Multiple logistic regression was used to detect factors independently associated with outcome. RESULTS: Observed mortality in nontransfused group (0.7% = 3/452) was significantly lower than expected (4.2% = 19/452): p = 0.0007, and much lower than in transfused group (6.7% = 11/163): p < 0.0001. CPB transfusion (p = 0.001) was independently associated with mortality, either acting as the sole factor or in combination with the Society of Thoracic Surgeons morbidity score (p = 0.013). Patients not transfused during CPB required less frequently vasoactive inotropic drugs (p = 0.011) and duration of their mechanical ventilation was shorter (93 ± 134 hours) than for transfused patients (142 ± 170 hours): p = 0.0003. CPB transfusion was an independent determinant factor for morbidity (p = 0.05), together with body weight (p < 0.0001), vasoactive inotropic score (p < 0.0001), CPB duration (p = 0.001), and postoperative transfusion (p = 0.009). CONCLUSION: The strategy of transfusion-free CPB course, feasible in most patients ≤ 7kg, was associated with improved outcome. Asanguineous priming of CPB circuit should become standard, even in neonates and infants.

7.
Thorac Cardiovasc Surg ; 68(1): 30-37, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30609447

RESUMO

BACKGROUND: This study reports midterm results of high-risk patients with hypoplastic left ventricle treated with initial bilateral pulmonary artery banding (PAB) before secondary Norwood procedure (NP). METHODS: Retrospective study of 17 patients admitted between July 2012 and February 2017 who underwent this treatment strategy because diagnosis or clinical status was associated with high risk for NP. Survival was compared with that of patients who underwent primary NP. RESULTS: Mean Aristotle comprehensive complexity score for NP would have been 19.7 ± 2.6. Risk factors included obstructed pulmonary venous return (n = 9), body weight < 2.5 kg (n = 7), total anomalous pulmonary venous connection (n = 3), and necrotizing enterocolitis (n = 1). Ten patients had a score ≥ 19.5. Early survival after PAB was 82.4% (14/17). NP was performed in 14 patients after improvement of clinical condition at a median age of 56 days and a weight ≥2,500 g. There was no 30-day mortality, but one interstage death. One patient died later after Glenn operation. One-year survival after primary PAB followed by NP was 70.6 ± 11.1%. During the same period, 35 patients with overall lower risk factors underwent primary NP; early postoperative survival and 1-year survival were 88.6 ± 5.4% and 68.6 ± 7.8%, respectively. There was no significant difference in survival between the two groups (p = 0.83) despite higher risk in the secondary Norwood group (p <0.0001). CONCLUSIONS: PAB before NP in high-risk patients constituted salvage management. Primary PAB provided enough time for stabilization and control of most risk factors. It allowed midterm survival equivalent to the survival after primary NP in lower risk neonates.

8.
Eur J Cardiothorac Surg ; 56(6): 1170-1177, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31504392

RESUMO

OBJECTIVES: Different types of patch materials are used for aortic valve repair in children with congenital aortic valve disease to avoid early valve replacement. CardioCel© (Admedus, Toowong, QLD, Australia) consists of bovine pericardium treated with the ADAPT method (Admedus' proprietary tissue engineering process). METHODS: Our goal was to describe tissue reactions in 12 explanted aortic valve leaflet specimens (augmented or replaced with CardioCel patch material) (11 explanted surgically, 1 autopsy). Explantation was performed during reoperation after aortic valve repair, necessitated by aortic valve stenosis in 5, aortic valve insufficiency in 2, combined aortic valve lesions in 3 patients and endocarditis in 1 patient. One patient died of sudden left heart failure 28 months after aortic valve repair. At the last documented follow-up of this patient at 22 months, he showed mild aortic valve stenosis and insufficiency. Implantation time (time between implantation and explantation) of CardioCel patches was a median of 25 (range 11-47) months. Explants were examined using a uniform protocol with methylmethacrylate and/or paraffin embedding after fixation in formalin. Besides standard histological staining, von Kossa (for identification of calcifications) and immunohistochemical stains were applied with antibodies specific for muscular, inflammatory and connective tissue component antigens. Findings regarding the extent of appositional growth on top of the patch consisting of fibroblasts and extracellular matrix components, calcification, and inflammation were rated using a 4-grade scale (G0 no/G1 few/G2 moderate/G3 massive). RESULTS: Superficial endothelialization was demonstrated in all patients by immunohistochemical analysis. Nine specimens showed mild inflammatory cell infiltration (G1) (G2: n = 3). Significant appositional growth on top of the patch due to addition of fibroblasts and extracellular matrix components, was seen in all specimens (G1: n = 1; G2: n = 7; G3: n = 4). Ten of 12 samples with implant times of 23 months or longer revealed calcifications (G1: n = 6; G2: n = 3; G3: n = 1). Two specimens with the shortest implant times (11 and 20 months) showed no calcifications (G0). Thrombus apposition with granulocyte infiltration was demonstrated in the specimen of the patient with endocarditis. CONCLUSIONS: In our cohort, all CardioCel patches used for aortic valve repair in patients with congenital heart disease demonstrated appositional growth of fibroblasts and extracellular matrix components, and calcification after an implant time of at least 23 months.

9.
Interact Cardiovasc Thorac Surg ; 28(5): 789-796, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30590597

RESUMO

OBJECTIVES: We analysed our 29-year experience of surgical repair of atrioventricular septal defect (AVSD) to define risk factors for mortality and reoperation. METHODS: Between 1988 and 2017, 508 patients received AVSD repair in our institution; 359 patients underwent surgery for complete AVSD, 76 for intermediate AVSD and 73 for partial AVSD. The median age of the patients was 6.1 months (interquartile range 10.3 months), and the median weight was 5.6 kg (interquartile range 3.2 kg). The standard AVSD repair was performed using 2-patch technique (n = 347) and complete cleft closure (n = 496). The results were divided into 2 surgical eras (early era 1986-2004 and late era 2004-2017). Risk factors were analysed to determine the impact of patient age, weight, the presence of trisomy 21 and complex AVSD on mortality and reoperation rate. RESULTS: In-hospital mortality decreased from 10.2% (n = 26) in early surgical era to 1.6% (n = 4) in late surgical era (P < 0.001). Seventy-seven patients required reoperation. Freedom from reoperation was 84.4% after 25 years. The main indication for reoperation was left atrioventricular valve regurgitation (13.8%). The multivariable Cox regression analysis revealed reoperation of the left AV valve, early surgical era, patient age <3.0 months and complex AVSD to be independent risk factors for mortality. Age <3.0 months, complex AVSD and moderate/severe left AV valve regurgitation at discharge predicted reoperation. CONCLUSIONS: AVSD repair can be performed with low mortality and reoperation rate. Age <3 months, complex AVSD and moderate/severe regurgitation of the left AV valve at discharge were predictors for reoperation. Reoperation of the left AV valve was the strongest risk factor for mortality.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Previsões , Defeitos dos Septos Cardíacos/cirurgia , Feminino , Seguimentos , Alemanha/epidemiologia , Defeitos dos Septos Cardíacos/diagnóstico , Defeitos dos Septos Cardíacos/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Lactente , Masculino , Alta do Paciente , Reoperação , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento
11.
J Heart Lung Transplant ; 37(12): 1459-1466, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30292432

RESUMO

BACKGROUND: The majority of children supported with ventricular assist devices (VADs) are bridged to heart transplantation. Although bridge to recovery has been reported, low recovery patient numbers has precluded systematic analysis. The aim of this study was to delineate recovery rates and predictors of recovery and to report on long-term follow-up after VAD explantation in children. METHODS: Children bridged to recovery at our institution from January 1990 to May 2016 were compared with a non-recovery cohort. Clinical and echocardiographic data before and at pump stoppages and after VAD explantation were analyzed. Kaplan‒Meier estimates of event-free survival, defined as freedom from death or transplantation after VAD removal, were determined. RESULTS: One hundred forty-nine children (median age 5.8 years) were identified. Of these, 65.2% had cardiomyopathy, 9.4% had myocarditis, and 24.8% had congenital heart disease. The overall recovery rate was 14.2%, and was 7.1% in patients with dilated cardiomyopathy. Predictors of recovery were age <2 years (recovery rate 27.8%, odds ratio [OR] 5.64, 95% confidence interval [CI] 2.0 to 16.6) and diagnosis of myocarditis (rate 57.1%; OR 17.56, 95% CI 4.6 to 67.4). After a median follow-up of 10.8 years, 15 patients (83.3%) were in Functional Class I and 3 (16.7%) in were in Class II. Mean left ventricular ejection fraction was 53% (range 28% to 64%). Ten- and 15-year event-free survival rates were both 84.1 ± 8.4%. CONCLUSIONS: Children <2 years of age and those diagnosed with myocarditis have the highest probability of recovery. Long-term survival after weaning from the VAD was better than after heart transplantation, as demonstrated in the excellent long-term stability of ejection fraction and functional class.


Assuntos
Transplante de Coração , Coração Auxiliar , Complicações Pós-Operatórias/etiologia , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Transplante de Coração/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Complicações Pós-Operatórias/mortalidade , Intervalo Livre de Progressão , Fatores de Risco
12.
Cardiol Young ; 28(10): 1141-1147, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30033907

RESUMO

We currently perform open-heart procedures using bloodless priming of cardiopulmonary bypass circuits regardless of a patient's body weight. This study presents results of this blood-saving approach in neonates and infants with a body weight of up to 7 kg. It tests with multivariate analysis factors that affect perioperative transfusion. A total of 498 open-heart procedures were carried out in the period 2014-2016 and were analysed. Priming volume ranged from 73 ml for patients weighing up to 2.5 kg to 110 ml for those weighing over 5 kg. Transfusion threshold during cardiopulmonary bypass was 8 g/dl of haemoglobin concentration. Transfusion factors were first analysed individually. Variables with a p-value lower than 0.2 underwent logistic regression. Extracorporeal circulation was conducted without transfusion of blood in 335 procedures - that is, 67% of cases. Transfusion-free operation was achieved in 136 patients (27%) and was more frequently observed after arterial switch operation and ventricular septal defect repair (12/18=66.7%). It was never observed after Norwood procedure (0/33=0%). Lower mortality score (p=0.001), anaesthesia provided by a certain physician (p=0.006), first chest entry (p=0.013), and higher haemoglobin concentration before going on bypass (p=0.013) supported transfusion-free operation. Early postoperative mortality was 4.4% (22/498). It was lower than expected (6.4%: 32/498). In conclusion, by adjusting the circuit, cardiopulmonary bypass could be conducted without donor blood in majority of patients, regardless of body weight. Transfusion-free open-heart surgery in neonates and infants requires team cooperation. It was more often achieved in procedures with lower mortality score.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Peso Corporal , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Cardiopatias Congênitas/cirurgia , Transfusão de Sangue , Feminino , Seguimentos , Humanos , Recém-Nascido , Masculino , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
13.
Eur J Cardiothorac Surg ; 54(5): 953-958, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29718154

RESUMO

OBJECTIVES: Strict patient selection, short cardiopulmonary bypass (CPB) time and short mechanical ventilation are well-recognized aspects of optimizing the postoperative course after total cavopulmonary connection. In this study, we evaluated the influence of our early postoperative extubation strategy in our population of Fontan patients over the past 2 decades. METHODS: Early postoperative course was evaluated retrospectively in 211 consecutive patients, who were selected for total cavopulmonary connection in our institution between 1995 and 2015. We analysed postoperative haemodynamic parameters and early outcome after surgery (mortality and length of hospital stay) according to preoperative patient characteristics, duration of CPB and duration of mechanical ventilation. To investigate the influence of mechanical ventilation, the cohort was subdivided into a 'fast-track' extubation group (≤6 h ventilation, n = 59) and a prolonged ventilation group (>6 h ventilation, n = 152). RESULTS: In the entire cohort, duration of CPB did not correlate with duration of mechanical ventilation (P = 0.1), and it did not differ between both groups (P = 0.3). Patients in the fast-track group showed significantly better haemodynamics with higher mean arterial pressure and lower mean pulmonary artery pressure at 6, 24 and 48 h postoperatively when compared with the prolonged ventilation group (P = 0.02-0.001). In multivariable analysis, longer mechanical ventilation, but not duration of CPB, was independently associated with length of hospital stay. CONCLUSIONS: Early weaning from mechanical ventilation correlates with improved early Fontan haemodynamics, whereas early outcome is unrelated to duration of CPB. This indicates that early extubation may represent a principal strategy for improving early results after total cavopulmonary connection.


Assuntos
Ponte Cardiopulmonar/métodos , Técnica de Fontan/métodos , Cardiopatias Congênitas/cirurgia , Adolescente , Adulto , Extubação , Criança , Pré-Escolar , Feminino , Técnica de Fontan/efeitos adversos , Hemodinâmica , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Desmame do Respirador/estatística & dados numéricos , Adulto Jovem
14.
Eur J Cardiothorac Surg ; 54(6): 986-992, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29718178

RESUMO

OBJECTIVES: The search for an optimal patch material for aortic valve reconstruction (AVR) is an ongoing challenge. In this study, we report our experience of AVR using decellularized bovine pericardial patch material in congenital heart surgery. METHODS: Data of 40 consecutive patients who underwent AVR using the CardioCel® patch (Admedus Regen Pty Ltd, Perth, WA, Australia) between February 2014 and August 2016 were retrospectively reviewed. The median age of the patients at operation was 9 (2-34) years, and 18 patients were younger than 7 years. Twenty-six patients initially presented with aortic valve insufficiency (AI) and 14 with stenosis. Clinical and echocardiographic data were available until August 2017 for a median postoperative follow-up (FU) of 22 (6-42) months. RESULTS: Nine of 40 (23%) patients experienced an event during FU (death: n = 1, 2.5%; reoperation: n = 8, 20%). Overall, the probability of freedom from reoperation or death was 97 ± 3%, 76 ± 9% and 57 ± 12% at 12, 24 and 36 months of FU, respectively. Reason for reoperation was stenosis in 3 (37.5%) patients, insufficiency in 4 (50%) patients and 1 (12.5%) patient was diagnosed with aortic valve endocarditis. Of the remaining 31 patients, 2 patients are scheduled for reoperation (aortic valve stenosis: n = 1 and AI: n = 1) and 9 patients exhibit worsening of aortic valve function with moderate AI. Freedom from developing combined end point [death/reoperation/moderate degree of aortic valve dysfunction (aortic valve stenosis, AI)] after AVR was 92 ± 5%, 55 ± 9% and 28 ± 9% at 12, 24 and 36 months, respectively. CONCLUSIONS: AVR using decellularized bovine pericardial patch material in patients with congenital aortic valve disease show unsatisfactory results within the first 3 years of FU.


Assuntos
Valva Aórtica , Bioprótese , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Pericárdio/transplante , Adolescente , Adulto , Animais , Valva Aórtica/anormalidades , Valva Aórtica/cirurgia , Bovinos , Criança , Pré-Escolar , Feminino , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Humanos , Masculino , Estudos Retrospectivos , Adulto Jovem
15.
Interact Cardiovasc Thorac Surg ; 27(2): 264-268, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29534193

RESUMO

OBJECTIVES: The technique of subcoronary autograft implantation for the Ross procedure has shown excellent durability of aortic valve function in adults. However, its use in children with hypoplastic aortic annulus or multilevel left ventricular outflow tract obstruction (LVOTO) was traditionally precluded. We combined this technique with a Konno incision and evaluated LVOTO relief and durability of the autograft function in growing patients. METHODS: Between January 2012 and January 2017, 13 patients with severe LVOTO and hypoplastic aortic annulus underwent Ross-Konno procedure with subcoronary autograft implantation. The median age at operation was 14 months. Six were infants. Concomitant procedures included resection of endocardial fibroelastosis (n = 9), mitral valvuloplasty (n = 2) and aortic arch repair (n = 1). The Konno incision was enlarged with a patch. The autograft was implanted beneath the ostia of the coronary arteries, retaining external support by the native aortic annulus. RESULTS: A newborn with hypoplastic left heart complex and Turner syndrome died in hospital: early mortality of 7.7%. No residual LVOTO or autograft regurgitation was observed at discharge. At a median follow-up of 20 months, no death had occurred. No catheter or surgical reintervention on the aortic valve or any LVOT site was needed. All peak pressure gradients across the LVOT were <10 mmHg. No autograft regurgitation was detected. CONCLUSIONS: The Ross procedure using subcoronary implantation technique combined with LVOT Konno enlargement is feasible even in patients with multilevel LVOTO and marked size discrepancy between the autograft and native aortic annulus. Longer follow-up is indicated to confirm the expected durability of the autograft function.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Obstrução do Fluxo Ventricular Externo/cirurgia , Adolescente , Adulto , Valva Aórtica/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Ferida Cirúrgica , Transplante Autólogo , Resultado do Tratamento
16.
Interact Cardiovasc Thorac Surg ; 27(3): 417-421, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-29579223

RESUMO

OBJECTIVES: To assess our practice according to the Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery (STS-EACTS) Mortality Score and to the new concept of unit performance. METHODS: All main procedures carried out in the years 2012-2016 were analysed. The STS-EACTS model-based mortality risk procedure was used to calculate expected mortality. Surgical performance was estimated as the Aristotle complexity score multiplied by hospital survival. Unit performance was defined as surgical performance multiplied by the number of procedures. RESULTS: In total, 2435 procedures were analysed. One hundred and two deaths (95% confidence interval 71-135 deaths) were expected; 43 patients died after operation. Observed mortality divided by expected mortality was 0.42. The ratio ranged from 0.23 (year 2014) to 0.59 (year 2013) and was <0.6 in all STS-EACTS mortality categories. The difference between observed and expected mortality was highly significant: 1.8% vs 4.2% (P-value <0.0001). Observed surgical and unit performances were, higher than expected performances every year. Achieved surgical performance was the highest in year 2012 (7.28 ± 2.54) and the lowest in year 2014 (7.04 ± 2.52). The highest figure of unit performance was achieved in year 2016: 3980 points. CONCLUSIONS: The STS-EACTS score, currently recognized as a sound instrument to assess mortality after congenital heart surgery, overestimated postoperative mortality. If these results are confirmed by other centres, the model should be recalibrated to match the current surgical practice. Although surgical performance can evaluate outcome quality, it does not include case volume activity. Unit performance provides this information, and it integrates quality and quantity into a single value.


Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Cardiopatias Congênitas/cirurgia , Garantia da Qualidade dos Cuidados de Saúde , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cardiopatias Congênitas/mortalidade , Mortalidade Hospitalar , Humanos , Estudos Retrospectivos , Medição de Risco
18.
Interact Cardiovasc Thorac Surg ; 25(6): 887-891, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29049673

RESUMO

OBJECTIVES: Left ventricular assist device implantation is an established therapy for paediatric patients with end-stage heart failure. Early right ventricular dysfunction (RVD) after implantation still remains a challenge in the postoperative period. This study sought to determine the incidence of RVD and to identify echocardiographic predictors of RVD in paediatric patients, as well describing associated clinical outcome. METHODS: Prospectively collected preoperative echocardiographic, haemodynamic, demographic and biochemical data from 48 patients scheduled for left ventricular assist device implantation were evaluated. Incidence of high central venous pressure, decreased central venous saturation, high inotropic support requirements or need for mechanical support of the right ventricle during the first 48 h after implantation were used to define RVD. Echocardiographic assessments of right ventricular geometry, function using linear dimensions, areas and tricuspid annular plane systolic excursion (TAPSE) were performed preoperatively and the relative relationships between these parameters were evaluated. RESULTS: We included 48 consecutive paediatric patients (median age 5 years, range 0-17; median weight 15.9 kg, range 3.6-91). According to our criteria, 24 (50%) patients developed RVD. TAPSE as the parameter for assessment of longitudinal systolic function was significantly lower in this group (P = 0.01). The difference became even more pronounced after normalization to the RV end-diastolic diameter in long axis with P = 0.003. The odds ratio for patients with TAPSE/RV end-diastolic diameter in long axis <17.1% to develop RVD was 7.7 (P = 0.002). CONCLUSIONS: RVD occurs frequently in paediatric patients after left ventricular assist device. TAPSE, normalized to the RV end-diastolic diameter, may help to identify patients at risk for RVD. The predictive value of this parameter supports decision making to plan for adequate pharmacological support or consider early upgrading to mechanical RV support.


Assuntos
Ecocardiografia sob Estresse/métodos , Ecocardiografia Transesofagiana/métodos , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Coração Auxiliar/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Disfunção Ventricular Direita/epidemiologia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Alemanha/epidemiologia , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/fisiopatologia , Ventrículos do Coração/fisiopatologia , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Fatores de Tempo , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/fisiopatologia
19.
Interact Cardiovasc Thorac Surg ; 25(5): 687-689, 2017 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29049743

RESUMO

OBJECTIVES: Oxygenator failure during cardiopulmonary bypass constitutes a life-threatening event, especially when perfusion is conducted under normothermia. An alternative solution to emergency oxygenator changeover is described. METHODS: A supplementary oxygenator is added in the venous line without interrupting perfusion. De-airing is achieved through the cardiotomy reservoir. Oxygen supply is adapted to ensure physiologic partial oxygen pressure. RESULTS: On 5 occasions in the past 4 years, Capiox Baby FX 05 oxygenator (n = 4) and Capiox FX15 (n = 1) failed to exchange blood gases after bypass run ranging from 290 min to 563 min. Hypoxia ensued with partial oxygen pressure values of 49-79 mmHg with a fraction of inspired oxygen of 1. An additional veno-venous Terumo Capiox FX 05 oxygenator immediately improved oxygenation with resulting partial oxygen pressure increasing to at least 291 mmHg. CONCLUSIONS: An additional veno-venous oxygenator effectively corrects failing oxygenator during cardiopulmonary bypass. The method does not require circulation arrest. It does not carry the risk of air embolism. It can be carried out without any help from a second perfusionist or member of operation team.


Assuntos
Ponte Cardiopulmonar/métodos , Embolia Aérea/prevenção & controle , Cardiopatias Congênitas/cirurgia , Oxigenadores de Membrana , Guias de Prática Clínica como Assunto , Gasometria , Criança , Pré-Escolar , Desenho de Equipamento , Feminino , Cardiopatias Congênitas/sangue , Máquina Coração-Pulmão , Humanos , Masculino
20.
Ann Thorac Surg ; 104(2): e143-e145, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28734437

RESUMO

A 31-year-old patient with a univentricular heart and double-inlet left ventricle, moderate pulmonary stenosis, and severe mitral valve regurgitation experienced irreversible heart failure after mitral valve replacement. "Biventricular" mechanical circulatory support was initiated. The systemic circulation was supported using the HeartWare ventricular assist device (HVAD) (HeartWare, Framingham, MA) pump in the usual manner. The second pump was inserted into the right atrium and connected to the pulmonary artery after closure of the pulmonary valve and atrial separation. This solution allowed optimal circulatory support, reduction of pulmonary resistance, and normal peripheral oxygen saturation. Thus the patient was listed for heart transplantation.


Assuntos
Cardiopatias Congênitas/cirurgia , Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/cirurgia , Coração Auxiliar , Função Ventricular/fisiologia , Adulto , Ecocardiografia , Feminino , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/diagnóstico , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Ventrículos do Coração/anormalidades , Ventrículos do Coração/fisiopatologia , Humanos , Imageamento Tridimensional , Tomografia Computadorizada por Raios X
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