Bilateral pulmonary arterial banding results in an increased need for subsequent pulmonary artery interventions.

OBJECTIVE: Despite increasing use of bilateral branch pulmonary artery banding (bPAB), both as a temporary stabilizing treatment and as part of comprehensive hybrid management of hypoplastic left heart syndrome, little is known about the long-term outcomes of the pulmonary arteries (PAs) in banded patients. PATIENTS AND METHODS: We conducted a retrospective review of all patients with ductal-dependent systemic circulation (2001-2013) undergoing bPAB placement at a single institution (bPAB, n = 50); patients who underwent a stage I Norwood procedure (Norwood, n = 53) were used for comparison. The need for PA interventions (surgical arterioplasty, balloon angioplasty, and stent implantation) and PA growth were assessed. RESULTS: Bands were in place for a median of 76 days. PA growth and size were similar between groups, but bPAB patients required more interventions (1.4 ± 2.9 vs 0.5 ± 1.2, P = .01). In competing risks analysis, only 20% of bPAB patients were alive and free from intervention at 5 years after bPAB removal. Multivariable Cox proportional hazards regression of operative interventions within the bPAB group demonstrated the following risk factors: subsequent 2-ventricle repairs (hazard ratio [HR], 2.2; 95% confidence interval [CI], 0.7-6.7), smallest band diameter (HR per additional millimeter, 0.059; 95% CI, 0.004-0.849), and duration of band placement more than 90 days (HR, 3.5; 95% CI, 1.0-12.6). Hemodynamics and Fontan candidacy did not differ between groups. CONCLUSIONS: Patients with bPAB require additional interventions at earlier time points than Norwood patients. Patients with smaller bands and longer duration of banding are at high risk. Despite stenoses requiring additional interventions, Fontan candidacy is maintained.

Hard choices for high-risk patients with critical left ventricular outflow obstruction: contemporary comparison of hybrid versus surgical strategy.

Surgical management of high-risk newborns with critical left ventricular outflow tract obstruction (LVOTO) involves difficult decision making and complex procedures associated with significant morbidity and mortality. We sought to compare the outcomes of the hybrid and surgical strategies for the management of neonates with critical LVOTO considered at high risk in a contemporary nonrandomized cohort. This is a retrospective review of all patients undergoing management of critical LVOTO between January 2001 and December 2008. High-risk conditions included prematurity, low birth weight, and genetic or associated cardiac and noncardiac pathology. Analysis was performed based on intention to treat. Primary and secondary outcomes were operative and 6-month mortality. The cohort included 55 patients (21 hybrid and 34 surgical [31 Norwood, 3 biventricular repair]). The cohort had a median age of 4 (range, 1-62) days, mean weight of 2.7 ± 0.5 kg, and Aristotle comprehensive score of 18.6 ± 2.9. Low birth weight (P = .0007), prematurity (P = .004), and organ dysfunction (P = .04) were risk factors for operative death. Six-month mortality was associated with need for reintervention (P = .017) in the surgical group and history of organ dysfunction (P = .02) or aortic atresia (P = .03) in the hybrid group. Logistic regression identified low birth weight (P = .05; odds ratio [OR], 5.6 [0.9-34.6]), organ dysfunction (P = .05; OR, 4.7 [0.9-22.5]), and non-hypoplastic left heart syndrome (HLHS) diagnosis (P = .03; OR, 0.06 [0.005-0.93]) as predictors of mortality for the entire cohort. No differences in operative and 6-month mortality were detected between management strategies. Although initial surgical insult is lessened by the hybrid palliation, important interstage mortality and ongoing morbidity result in similar 6-month survival with either strategy. Patient-related factors have a larger influence on outcome than the management strategy chosen.

Mapeo electroanatómico 3D y ablación percutánea transtorácica de taquicardia auricular en pacientes post cirugía de Fontan / Electro anatomic 3-D mapping and percutaneous transthoracic ablation of atrial tachycardia after Fontan surgery

Introducción: La incidencia de taquicardias auriculares (TA) luego de la operación de Fontan es alta. El acceso a la aurícula pulmonar (AuP) requiere de una punción transeptal o acceso aórtico retrógrado. Se presentan resultados iniciales con una técnica percutánea que permite el acceso a la AuP para mapeo y ablación por radiofrecuencia (ARF). Métodos: Seis EEF con mapeo 3D electroanatómico (CARTO) y ARF se efectuaron en 5 pacientes (1.2 a 17 años). Todos tenían un Fontan (túnel lateral) y TA. Vía transtoráxica se posicionó en la AuP un catéter Navistar para mapeo, estimulación y ARF. Se indujo TA con estimulación programada e isoproterenol. La secuencia de activación, áreas de bloqueo eléctrico y anatómico, y la ubicación del electrograma de His fueron definidas con mapeo 3D electroanatómico. Las zonas de interés fueron estudiadas con técnicas de “entrainment”. Luego de la ARF, el éxito se definió como la imposibilidad de reinducir TA. Resultados: Se encontró taquicardia por reentrada auricular en 5 casos y taquicardia ectópica en uno. La ARF fue exitosa en todos ellos. Hubo 1 pneumotórax y hemotórax en dos casos. En un paciente se observó recurrencia de la TA a los 3 meses, que requirió una segunda ARF, sin nueva recidiva. Ningún paciente esta recibiendo tratamiento antiarrítmico. Resumen: El acceso transtorácico percutáneo a la AuP parece apropiado para mapear y tratar las taquicardias auriculares en pacientes con cirugía de Fontan.