Background. Increasing numbers of the very old are presenting for cardiac surgical procedures. There is little information about quality of life after hospital discharge in this group.
Methods. From ...March 1995 to February 1997, 127 patients older than 80 years at operation (mean age, 83 ± 2.5 years; range, 80 to 92 years) were entered into the cardiac surgery database and analyzed retrospectively. The RAND SF-36 Health Survey and the Seattle Angina Questionnaire were used to assess quality of life by telephone interview (mean follow-up, 15.7 ± 6.9 months). No patient was lost to follow-up.
Results. Operations included coronary artery bypass grafting (65.4%), coronary artery bypass grafting plus valve replacement (15.8%), and isolated valve replacement (14.2%). Preoperatively, 63.8% were in New York Heart Association class IV. Thirty-day mortality was 7.9%, and actuarial survival was 83% (70% confidence interval, 79% to 87%) at 1 year and 80% (70% confidence interval, 75% to 85%) at 2 years. Preoperative renal failure significantly increased the risk of early death (relative risk, 3.96) as did urgent or emergent operation (relative risk, 6.70). In addition, cerebrovascular disease (relative risk, 3.54) and prolonged ventilation (relative risk, 3.82) were risk factors for late death. Ninety-five patients (92.2%) were in New York Heart Association class I or II at follow-up. Seattle Angina Questionnaire scores for anginal frequency (92.3 ± 18.9), stability (94.4 ± 16.5), and exertional capacity (86.8 ± 25.1) indicated good relief of symptoms. SF-36 scores were equal to or better than those for the general population of age greater than 65 years. Of the survivors, 83.7% were living in their own home, 74.8% rated their health as good or excellent, and 82.5% would undergo operation again in retrospect.
Conclusion. Octogenarians can undergo cardiac surgical procedures at a reasonable risk and show remarkable improvement in their symptoms. Elderly patients benefit from improved functional status and quality of life.
Repair of neonatal tetralogy of Fallot (TOF) has low mortality. Debate continues regarding the initial management of cyanotic or duct-dependent infants with TOF and adverse risk factors. While repair ...can and has been performed in these patients, it is associated with increased morbidity.
We review the effectiveness of right ventricular outflow tract (RVOT) stenting in the symptomatic young infant with TOF.
Clinical, echocardiographic, angiographic and haemodynamic data were reviewed for nine patients who underwent 11 RVOT stenting procedures from October 1994 to August 2007.
The pulmonary valve was deemed unsalvageable in all patients (median valve diameter 3.7 mm (range 2.7-4.2), Z-score -6.7 (range -9.7 to -5.4). RVOT stenting improved arterial oxygen saturation from a median of 73% (60-85%) to 94% (90-98%) (p = 0.008). Median Z-score for the left pulmonary artery increased from -4.9 (-7.8 to -2.4) before stent implantation to -1.5 (-4.2 to -0.2) (p = 0.02) before surgical repair. Median Z-score for the right pulmonary artery increased from -3.7 (-6.8 to -1.9) to -0.8 (-2.5 to 0.1) (p = 0.008). Median Nakata index increased from 56 mm(2)/m(2) (21-77) to 150 mm(2)/m(2) (123-231) (p = 0.008). There were no procedural complications. Six patients have undergone successful repair. There were no deaths.
In the symptomatic young infant with TOF, stenting of the RVOT provides a safe and effective management strategy, improving arterial oxygen saturation and encouraging pulmonary artery growth.
Abstract Background Compliance with the April 2007 American Heart Association (AHA) infective endocarditis (IE) guidelines is not well described. We sought to evaluate the impact of these guidelines ...on the clinical practices of pediatric and adult congenital cardiologists. Methods We conducted a 2-centre retrospective cohort study, including patients who had at least 1 outpatient cardiology visit after April 1, 2008 and had 1 of 11 prespecified high- or low-risk congenital cardiac lesions. High-risk lesions required prophylaxis per the AHA guidelines; low-risk patients no longer required prophylaxis. Cardiology clinic letters were reviewed to determine if antibiotic prophylaxis and oral hygiene were addressed and whether prophylaxis was recommended. Comparisons were made before April 2007 vs at least 1 year after guideline publication. Results We included 238 high-risk and 201 low-risk patients. IE prophylaxis was recommended for all study patients before April 2007. After April 2008, IE prophylaxis recommendations were reduced by 44.9% for low-risk patients ( P < 0.0001) and 9.3% for high-risk patients ( P = 0.0156). IE prophylaxis recommendations were documented in the medical record of 92% of patients (95% confidence interval, 88%-95%) before April 2007 vs 81% (77%-84%) after April 2008. Oral hygiene was emphasized for only 44% and 28% of patients before and after guideline revision ( P = 0.0005). Conclusions The 2007 AHA guidelines resulted in significantly fewer recommendations for IE prophylaxis in low-risk patients. However, cardiologists continue to recommend prophylaxis for some low-risk patients and advise some high-risk patients against prophylaxis. These findings suggest disagreement or uncertainty within the cardiology community regarding current IE guidelines.
Abstract Congenital heart disease is the most common congenital malformation and approximately 3 in 1000 newborns have critical congenital heart disease (CCHD). Timely diagnosis affects morbidity, ...mortality, and disability, and newborn pulse oximetry screening has been studied to enhance detection of CCHD. In this position statement we present an evaluation of the literature for pulse oximetry screening. Current detection strategies including prenatal ultrasound examination and newborn physical examination are limited by low diagnostic sensitivity. Pulse oximetry screening is safe, noninvasive, easy to perform, and widely available with a high specificity (99.9%) and moderately high sensitivity (76.5%). When an abnormal saturation is obtained, the likelihood of having CCHD is 5.5 times greater than when a normal result is obtained. The use of pulse oximetry combined with current strategies has shown sensitivities of up to 92% for detecting CCHD. False positive results can be minimized by screening after 24 hours, and testing the right hand and either foot might further increase sensitivity. Newborns with abnormal screening results should undergo a comprehensive assessment and echocardiography performed if a cardiac cause cannot be excluded. Screening has been studied to be cost neutral to cost effective. We recommend that pulse oximetry screening should be routinely performed in all healthy newborns to enhance the detection of CCHD in Canada.
Abstract Background Neonates with certain forms of severe congenital heart disease (CHD) diagnosed prenatally might have better outcomes in comparison with those diagnosed after birth. The proportion ...of prenatally detected neonates with severe CHD and the effect of prenatal diagnosis on clinical outcomes have not been previously investigated in Canada. Methods We retrospectively studied infants in Alberta, Canada, who required surgical or catheter intervention for CHD at younger than 1 year of age, between January 2007 and December 2010, and pregnancy terminations affected by CHD. Results Of the 374 subjects identified (327 infants, 47 pregnancies with termination), 188 (50%) were detected prenatally. Failure of prenatal diagnosis was associated with anomalies not involving the 4-chamber view on ultrasound (odds ratio, 1.86; 95% confidence interval, 1.48-2.35; P < 0.001) and region of residence ( P = 0.04). Prenatal detection was associated with fewer days to hospital admission ( P < 0.001), fewer days to surgery ( P = 0.003), and greater use of prostaglandins ( P = 0.001). Infants diagnosed prenatally who underwent surgery within 15 days of age had higher preductal O2 saturations ( P = 0.04), fewer days to admission ( P = 0.03), and less frequently required preoperative intubation ( P = 0.004), and inotropes ( P = 0.001). Pregnancy termination occurred among 49% of fetuses detected before 24 weeks' gestation. Conclusions Only 50% of fetuses and/or neonates with severe CHD managed in Alberta have a prenatal diagnosis. The likelihood of prenatal detection is influenced by the status of the 4-chamber view on ultrasound and the region of maternal residence indicating heterogeneous access to fetal echocardiography within Alberta. Prenatal detection might improve clinical outcomes for neonates with severe CHD.
Few congenital heart malformations have raised as many surgical, ethical, social and economic issues as the therapy for infants diagnosed with hypoplastic left heart syndrome. Before the 1980s, this ...complex malformation was associated with 95% mortality within the first month of life. In the past two decades, palliative surgery and cardiac transplantation have become management options, in addition to comfort care for the infant. These innovations have forced parents and physicians to make difficult decisions because the long term results of the additional treatment options are not known. This article describes the current risk factors, diagnosis, treatment and outcome of infants with hypoplastic left heart syndrome. Prenatal diagnosis provides families with time for counselling and for becoming more informed about management options. Surgical therapy provides hope for the survival of these infants, but their long term outcomes are not well defined. Comfort care in either the home or hospital remains an acceptable management option. More investigations to determine the long term outcome following palliative surgery and transplantation are needed before they become the standards of care.
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