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The Journal of Thoracic and... Apr 2024Neo-aortic root dilatation and valve regurgitation are emerging problems late after arterial switch operation (ASO). We sought to evaluate the prevalence and outcomes of...
BACKGROUND
Neo-aortic root dilatation and valve regurgitation are emerging problems late after arterial switch operation (ASO). We sought to evaluate the prevalence and outcomes of neo-aortic root or valve reoperation after ASO.
METHODS
All patients with biventricular circulation who underwent an ASO between 1983 and 2015 were included at a single institution.
RESULTS
In our cohort of 782 late ASO survivors, the median duration of follow-up was 18.1 years (interquartile range [IQR], 11.3-25.6 years). During follow-up, 47 patients (6.0%) underwent 60 reoperations on the neo-aortic valve/root. The first neo-aortic valve/root reoperation occurred at a median of 15.2 years (IQR, 7.8-18.4 years) after ASO. Operations included mechanical Bentall (31.9%; n = 15), aortic valve repair (25.5%; n = 12), mechanical aortic valve replacement (AVR) (21.3%; n = 10), valve-sparing root replacement (19.1%; n = 9), and the Ross procedure (2.1%; n = 1). There was 1 late death (2.1%). Multivariable predictors of neo-aortic valve/root reoperation were bicuspid valve (hazard ratio [HR], 4.8; 95% confidence interval [CI], 2.1-10.7; P < .001), Taussig-Bing anomaly (HR, 3.0; 95% CI, 1.2-7.4; P < .02), previous pulmonary artery band (HR, 2.8; 95% CI, 1.2-6.3; P < .01) and left ventricular outflow tract obstruction before ASO (HR, 2.4; 95% CI, 1.0-5.8; P < .04). Freedom from neo-aortic valve or root reoperation was 98.0% (95% CI, 96.7%-98.8%) at 10 years, 93.3% (95% CI, 90.8%-95.2%) at 20 years, and 88.5% (95% CI, 84.1%-91.8%) at 30 years after ASO. Among the 47 patients who underwent neo-aortic reoperation, freedom from AVR was 82.3% (95% CI, 67.7%-90.7%) at 10 years, 58.0% (95% CI, 41.8%-71.2%) at 20 years, and 43.2% (95% CI, 27.0%-58.3%) at 25 years after ASO.
CONCLUSIONS
The need for neo-aortic valve or root reoperation surpasses 10% by 30 years post-ASO. Evolving understanding of the mechanisms of neo-aortic valve insufficiency and techniques of neo-aortic valve repair may decrease the need for AVR.
Topics: Humans; Arterial Switch Operation; Aortic Valve; Transposition of Great Vessels; Retrospective Studies; Double Outlet Right Ventricle; Aortic Valve Insufficiency; Reoperation; Follow-Up Studies; Treatment Outcome
PubMed: 37757970
DOI: 10.1016/j.jtcvs.2023.09.038 -
Journal of the American College of... Oct 2023Hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) is an initial management strategy for infants with critical left heart obstruction...
BACKGROUND
Hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) is an initial management strategy for infants with critical left heart obstruction and serves as palliation until subsequent operations are pursued.
OBJECTIVES
This study sought to determine patient characteristics and factors associated with subsequent outcomes for infants who underwent hybrid palliation.
METHODS
From 2005 to 2019, 214 of 1,236 prospectively enrolled infants within the Congenital Heart Surgeons' Society's critical left heart obstruction cohort underwent hybrid palliation across 24 institutions. Multivariable hazard modeling with competing risk methodology was performed to determine risk and factors associated with outcomes of biventricular repair, Fontan procedure, transplantation, or death.
RESULTS
Preoperative comorbidities (eg, prematurity, low birth weight, genetic syndrome) were identified in 70% of infants (150 of 214). Median follow-up was 7 years, ranging up to 17 years. Overall 12-year survival was 55%. At 5 years after hybrid palliation, 9% had biventricular repair, 36% had Fontan procedure, 12% had transplantation, 35% died without surgical endpoints, and 8% were alive without an endpoint. Factors associated with transplantation were absence of ductal stent, older age, absent interatrial communication, smaller aortic root size, larger tricuspid valve area z-score, and larger left ventricular volume. Factors associated with death were low birth weight, concomitant genetic syndrome, cardiopulmonary bypass use during hybrid palliation, moderate to severe tricuspid valve regurgitation, and smaller ascending aortic size.
CONCLUSIONS
Mortality remains high after hybrid palliation for infants with critical left heart obstruction. Nonetheless, hybrid palliation may facilitate biventricular repair for some infants and for others may serve as stabilization for intended functional univentricular palliation or primary transplantation.
Topics: Infant; Humans; Hypoplastic Left Heart Syndrome; Treatment Outcome; Fontan Procedure; Heart Ventricles; Tricuspid Valve Insufficiency; Heart Block; Palliative Care; Retrospective Studies
PubMed: 37758438
DOI: 10.1016/j.jacc.2023.07.020 -
JACC. Cardiovascular Imaging Jun 2024Conflicting results from 2 randomized clinical trials of transcatheter mitral valve edge-to-edge repair in secondary mitral regurgitation (SMR) have led to the... (Review)
Review
Conflicting results from 2 randomized clinical trials of transcatheter mitral valve edge-to-edge repair in secondary mitral regurgitation (SMR) have led to the recognition that SMR is a heterogeneous disease entity presenting with different functional and morphological phenotypes. This review summarizes the current knowledge on SMR caused primarily by atrial secondary mitral regurgitation (aSMR) and ventricular SMR pathology. Although aSMR is generally characterized by severe left atrial enlargement in the setting of preserved left ventricular anatomy and function, different patterns of mitral annular distortion cause different phenotypes of aSMR. In ventricular SMR, the relation of SMR severity to left ventricular dilation as well as the degree of pulmonary hypertension and right ventricular dysfunction are important phenotypic characteristics, which are key for a better understanding of prognosis and treatment response.
Topics: Mitral Valve Insufficiency; Humans; Phenotype; Mitral Valve; Echocardiography, Transesophageal; Predictive Value of Tests; Severity of Illness Index; Ventricular Function, Left; Randomized Controlled Trials as Topic; Treatment Outcome; Cardiac Catheterization; Heart Valve Prosthesis Implantation
PubMed: 38551534
DOI: 10.1016/j.jcmg.2024.01.012 -
The American Journal of Cardiology Oct 2023Patients with repaired tetralogy of Fallot are at elevated risk for ventricular arrhythmia and sudden cardiac death. Over the past decade, the pathogenesis and natural...
Rationale and Design of the Multicenter Catheter Ablation of Ventricular Tachycardia Before Transcatheter Pulmonary Valve Replacement in Repaired Tetralogy of Fallot Study.
Patients with repaired tetralogy of Fallot are at elevated risk for ventricular arrhythmia and sudden cardiac death. Over the past decade, the pathogenesis and natural history of ventricular tachycardia has become increasingly understood, and catheter ablation has emerged as an effective treatment modality. Concurrently, there has been great progress in the development of a versatile array of transcatheter valves that can be placed in the native right ventricular outflow tract for the treatment of long-standing pulmonary regurgitation. Although such valve platforms may eliminate the need for repeat cardiac operations, they may also impede catheter access to the myocardial substrates responsible for sustained macro-reentrant ventricular tachycardia. This manuscript provides the rationale and design of a recently devised multicenter study that will examine the clinical outcomes of a uniform, preemptive strategy to eliminate ventricular tachycardia substrates before transcatheter pulmonary valve implantation in patients with tetralogy of Fallot.
Topics: Humans; Tetralogy of Fallot; Pulmonary Valve; Tachycardia, Ventricular; Arrhythmias, Cardiac; Pulmonary Valve Insufficiency; Treatment Outcome; Catheter Ablation; Heart Valve Prosthesis Implantation
PubMed: 37536198
DOI: 10.1016/j.amjcard.2023.07.087 -
Paediatrics and International Child... May 2024Rheumatic carditis is the leading cause of permanent disability caused by damage of the cardiac valve. This study aimed to determine the outcome and predictors of valve...
BACKGROUND
Rheumatic carditis is the leading cause of permanent disability caused by damage of the cardiac valve. This study aimed to determine the outcome and predictors of valve surgery in patients with acute rheumatic fever (ARF) and recurrent rheumatic fever (RRF).
METHODS
This was a retrospective study of patients diagnosed with ARF and RRF between 2006 and 2021. The predictors of valve surgery were analysed using multivariable Cox proportional regression.
RESULTS
The median age of patients with ARF and RRF (92) was 11 years (range 5-18). Seventeen patients (18%) were diagnosed with RRF. The most common presenting symptoms included clinical carditis (87%), heart failure (HF) (63%), fever (49%) and polyarthralgia (24%). Patients with moderate-to-severe rheumatic carditis (88%) were given prednisolone. After treatment, the severity of valvular regurgitation was reduced in 52 patients (59%). Twenty-three patients (25%) underwent valve surgery. The incidence of HF, RRF, severe mitral regurgitation on presentation, left ventricular enlargement and pulmonary hypertension was greater in the surgical group than in the non-surgical group. Recurrent rheumatic fever (hazard ratio 7.9, 95% CI 1.9-33.1), tricuspid regurgitation (TR) gradient ≥ 42 mmHg (HR 6.3, 95%CI 1.1-38.7) and left ventricular end-diastolic dimension (LVEDD) ≥6 cm (HR 8.7, 95% CI 2.1-35.9) were predictors of valve surgery (multivariable Cox proportional regression analysis).
CONCLUSION
Clinical carditis was the most common presenting symptom in patients with ARF and RRF. The majority of patients responded positively to prednisolone. These findings highlight the predictors of valve surgery following ARF, including RRF, TR gradient ≥ 42 mmHg and LVEDD ≥ 6 cm. ARF: acute rheumatic fever; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GAS: group A beta-haemolytic Streptococcus; HF: heart failure; HR: hazard ratio; LVEDD: left ventricular end-diastolic dimension; MR: mitral regurgitation; RHD: rheumatic heart disease; RRF: recurrent rheumatic fever; TR: tricuspid regurgitation.
Topics: Humans; Child, Preschool; Child; Adolescent; Rheumatic Fever; Mitral Valve Insufficiency; Tricuspid Valve Insufficiency; Myocarditis; Retrospective Studies; Rheumatic Heart Disease; Heart Failure; Prednisolone
PubMed: 38363075
DOI: 10.1080/20469047.2024.2313330 -
Pediatric Radiology Aug 2023Pulmonary valve replacement is recommended in patients with repaired tetralogy of Fallot based on cardiac magnetic resonance imaging (MRI) criteria. This procedure is...
Surgical and transcatheter pulmonary valve replacement in patients with repaired tetralogy of Fallot: cardiac magnetic resonance imaging characteristics and morphology of right ventricular outflow tract.
BACKGROUND
Pulmonary valve replacement is recommended in patients with repaired tetralogy of Fallot based on cardiac magnetic resonance imaging (MRI) criteria. This procedure is performed by surgical or transcatheter approaches.
OBJECTIVE
We aimed to investigate the differences in preprocedural MRI characteristics (volume, function, strain) and morphology of the right ventricular outflow tract and branch pulmonary arteries in patients for whom surgical or transcatheter pulmonary valve replacement was planned.
MATERIALS AND METHODS
Cardiac MRI of 166 patients with tetralogy of Fallot were analyzed. Of these, 36 patients for whom pulmonary valve replacement was planned were included. Magnetic resonance imaging characteristics, right ventricular outflow tract morphology, branch pulmonary artery flow distribution and diameter were compared between surgical and transcatheter groups. Spearman correlation and Kruskal-Wallis tests were performed.
RESULTS
Circumferential and radial MRI strain for the right ventricle were lower in the surgical group (P=0.045 and P=0.046, respectively). The diameter of the left pulmonary artery was significantly lower (P=0.021) and branch pulmonary artery flow and diameter ratio were higher (P=0.044 and P = 0.002, respectively) in the transcatheter group. There was a significant correlation between right ventricular outflow tract morphology and right ventricular end-diastolic volume index and global circumferential and radial MRI strain (P=0.046, P=0.046 and P= 0.049, respectively).
CONCLUSION
Preprocedural MRI strain, right-to-left pulmonary artery flow, diameter ratio and morphological features of the right ventricular outflow tract were significantly different between the two groups. A transcatheter approach may be recommended for patients with branch pulmonary artery stenosis, since both pulmonary valve replacement and branch pulmonary artery stenting can be performed in the same session.
Topics: Humans; Heart Ventricles; Pulmonary Valve; Tetralogy of Fallot; Pulmonary Valve Insufficiency; Magnetic Resonance Imaging; Treatment Outcome; Retrospective Studies
PubMed: 37010546
DOI: 10.1007/s00247-023-05645-2 -
Circulation. Cardiovascular... Sep 2023Transcatheter pulmonary valve replacement (TPVR) in patients with a congenital or acquired abnormality resulting in enlarged right ventricular outflow tract (RVOT) is...
BACKGROUND
Transcatheter pulmonary valve replacement (TPVR) in patients with a congenital or acquired abnormality resulting in enlarged right ventricular outflow tract (RVOT) is challenging and may preclude treatment with dedicated devices. We describe a technique using a physician-modified endograft to facilitate TPVR.
METHODS
Six patients underwent physician-modified endograft-facilitated TPVR for severe symptomatic pulmonary insufficiency with enlarged RVOT. The fenestration was created in a commercially available endograft before implantation, which was then deployed from the dominant branch pulmonary artery into the RVOT, with the fenestration aligned with the ostium of the nondominant pulmonary artery. A covered stent was placed through the fenestration into the nondominant branch pulmonary artery, and a transcatheter heart valve was deployed within the endograft at the level of the original pulmonary valve.
RESULTS
Four patients had tetralogy of Fallot, 1 had pulmonary atresia, and 1 had rheumatic valve disease. The RVOT/main pulmonary artery was severely enlarged (diameter, 44.2 [43.5-50.6] mm). All patients had reduced right ventricular (RV) function and dilated RVs (RV end-diastolic volume, 314 [235-316] mL). Successful endograft, covered stent, and transcatheter heart valve deployment were achieved in all cases without stent/valve embolization, vascular complications, or bleeding complications. At 30 days, 1 patient had mild pulmonary insufficiency, while others had none. The RV size measured by echocardiography was significantly reduced after TPVR (RV area, 34.4 [baseline] versus 29.0 [pre-discharge] versus 25.3 [30 days] cm; =0.03). During median follow-up of 221.5 (range, 29-652) days, there were no deaths or need for pulmonary valve reintervention. One patient developed severe tricuspid regurgitation due to entrapment of the anterior tricuspid leaflet by the endograft. The patient underwent successful tricuspid replacement and resection of the offending endograft with preservation of the pulmonary valve prosthesis.
CONCLUSIONS
Simple fenestration of an off-the-shelf endograft and associated covered stent placement through the fenestration allows TPVR for patients with dysfunctional native or patch-repaired pulmonary valves and RVOT enlargement.
Topics: Humans; Pulmonary Valve; Heart Valve Prosthesis Implantation; Cardiac Catheterization; Treatment Outcome; Heart Valve Prosthesis; Pulmonary Valve Insufficiency; Stents; Retrospective Studies; Prosthesis Design
PubMed: 37577788
DOI: 10.1161/CIRCINTERVENTIONS.123.013123 -
Indian Journal of Thoracic and... May 2024is a well-known cause of blood culture-negative endocarditis; however, pulmonary valve involvement is rare. The case of a 40-year-old African male who presented to the...
UNLABELLED
is a well-known cause of blood culture-negative endocarditis; however, pulmonary valve involvement is rare. The case of a 40-year-old African male who presented to the Emergency Department with chest pain, cardiac failure, and a 2-week history of fever is presented. Transoesophageal echocardiography confirmed an atrial septal defect, severe pulmonary insufficiency with large vegetations, severe mitral regurgitation due to anterior leaflet prolapse, and right ventricular dysfunction. Empirical antibiotic therapy was started, and urgent surgical intervention was decided. There were vegetations on the three pulmonary valve leaflets and the mitral valve. Closure of the atrial septal defect, mitral and tricuspid valve repair, pulmonary valve replacement with a biological prosthesis, and infundibuloplasty of the right ventricle were performed. The postoperative course was uneventful. Preoperative blood cultures were negative, and was detected through 16S rRNA gene amplification and sequencing in mitral and pulmonary implants. Serology showed positive titers of 1/1260 for both and . Ceftriaxone and gentamicin were administered for 10 days, followed by oral doxycycline for 12 weeks. A one-year echocardiogram showed normal functioning of the pulmonary prosthesis and the mitral and tricuspid repair. Infection caused by is a rare cause of endocarditis with negative blood cultures, and multivalvular and pulmonary valve involvement is exceptional.
SUPPLEMENTARY INFORMATION
The online version contains supplementary material available at 10.1007/s12055-024-01727-4.
PubMed: 38827541
DOI: 10.1007/s12055-024-01727-4 -
Seminars in Thoracic and Cardiovascular... 2023
Topics: Humans; Pulmonary Valve; Treatment Outcome; Cardiac Surgical Procedures; Heart Defects, Congenital; Heart Valve Prosthesis Implantation; Cardiac Catheterization; Heart Valve Prosthesis; Pulmonary Valve Insufficiency
PubMed: 35259489
DOI: 10.1053/j.semtcvs.2022.02.009 -
Circulation May 2024Tricuspid valve disease is an often underrecognized clinical problem that is associated with significant morbidity and mortality. Unfortunately, patients will often... (Review)
Review
Tricuspid valve disease is an often underrecognized clinical problem that is associated with significant morbidity and mortality. Unfortunately, patients will often present late in their disease course with severe right-sided heart failure, pulmonary hypertension, and life-limiting symptoms that have few durable treatment options. Traditionally, the only treatment for tricuspid valve disease has been medical therapy or surgery; however, there have been increasing interest and success with the use of transcatheter tricuspid valve therapies over the past several years to treat patients with previously limited therapeutic options. The tricuspid valve is complex anatomically, lying adjacent to important anatomic structures such as the right coronary artery and the atrioventricular node, and is the passageway for permanent pacemaker leads into the right ventricle. In addition, the mechanism of tricuspid pathology varies widely between patients, which can be due to primary, secondary, or a combination of causes, meaning that it is not possible for 1 type of device to be suitable for treatment of all cases of tricuspid valve disease. To best visualize the pathology, several modalities of advanced cardiac imaging are often required, including transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, to best visualize the pathology. This detailed imaging provides important information for choosing the ideal transcatheter treatment options for patients with tricuspid valve disease, taking into account the need for the lifetime management of the patient. This review highlights the important background, anatomic considerations, therapeutic options, and future directions with regard to treatment of tricuspid valve disease.
Topics: Humans; Tricuspid Valve; American Heart Association; United States; Heart Valve Diseases; Tricuspid Valve Insufficiency; Heart Valve Prosthesis Implantation
PubMed: 38660790
DOI: 10.1161/CIR.0000000000001232