Background Structural deterioration of allografts over time is believed to be at least partly related to an immune response mounted against human leukocyte antigen specific to the transplanted ...tissue. SynerGraft (SG) processing (CryoLife, Kennesaw, GA) is a technology that decellularizes an allograft leaving only connective tissue, therefore, reducing immunogenicity and potentially increasing durability of the implant. Methods We performed a retrospective review of 163 SG patients and 124 standard allograft controls from 3 medical centers. Patient demographics were tabulated, and conduit stenosis and insufficiency were measured by echocardiography. Results There were 28 deaths (15 of 163 9% SG patients vs 13 of 124 11% standard patients; p = 0.72), but no deaths were attributed to structural failure of the conduit. The actuarial survival for SG vs standard cohorts was not different at 5 and 10 years. Among the 274 hospital survivors, 17% SG vs 42% standard had evidence for significant conduit dysfunction at the most recent follow-up or before conduit replacement. Freedom from conduit dysfunction was significantly worse at 10 years in the standard group (58%) than in the SG group (83%, p < 0.001). Conclusions This study represents a multiinstitutional retrospective comparison of SG and standard cryopreserved allografts used in right ventricular outflow tract reconstruction in a broad range of patient ages. Our results demonstrate that at an intermediate-term to long-term follow-up, conduit dysfunction and pulmonary insufficiency and stenosis are higher among patients receiving standard allografts. We postulate that the improved durability of SG is related to decreased immunogenicity of the SG technology.
Background In the Ross aortic valve replacement (AVR), a pulmonary allograft normally replaces the autotransplanted pulmonary valve. Despite the Ross advantages vs other AVR procedures, there has ...been a small but unpredictable risk of early structural allograft valve deterioration, usually manifested by shrinkage and right ventricular outflow tract obstruction. This study analyzed our results of the Ross AVR using a new CryoValve SynerGraft (CryoLife Inc, Kennesaw, GA) decellularized pulmonary allograft (SGDPA) and compared it with the standard cryopreserved allograft (SCA) used during the same period. Methods Between 2000 and 2009, 29 patients received a SGDPA and 34 received the SCA during Ross AVR. Patients were a mean age at implant of 28.6 ± 16.0 years (range, 4 months to 58 years). Retrospective data included reported adverse events, and the most recent hemodynamic data were collected. Results No early or late deaths or significant morbid events occurred during the mean follow-up of 4.9 ± 2.7 years (range, 2 months to 9 years). No patient required conduit reoperation. The median peak gradient at discharge was 12 mm Hg and was not significant at last follow-up. No deterioration in conduit valve function occurred in the SGDPA group. Mild conduit regurgitation developed in several SCA patients, and one patient had moderate regurgitation. No patient reached our definition of conduit dysfunction (peak gradient: 40 mm Hg or >2+ regurgitation). Conclusions The SGDPA conduit is an alternative to the SCA for the Ross AVR. The early clinical and hemodynamic results are encouraging but were not significantly different from the SCA. SynerGraft technology may provide a more durable option for patients who need right ventricular outflow tract reconstruction. Further long-term follow-up is needed to see if this decellularization process improves long-term allograft durability.
Background This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. Methods From 1970 ...to 2010, 97 patients have undergone a total of 136 MVRs. Median age was 8 years (2 weeks to 18 years), 41 patients (42%) were less than 5 years, and 16 were infants (17%). Etiology was congenital in 65 patients (67%), rheumatic in 27 (28%), and endocarditis in 5 (5%). Regurgitation was the predominant lesion in 67 patients (69%), stenosis in 23 (24%), and mixed in 7 (7%) patients. Mechanical valves (ball, n = 11; or bileaflet disc, n = 66) and xenografts (porcine, n = 14; bovine, n = 2) were used in 93 initial MVR patients. Since 2002, 5 children have undergone Ross MVR with a pulmonary autograft in 3 and an aortic homograft in 2. Results Hospital mortality was 6% (6 of 97). There were 23 late deaths and 5 patients have required cardiac transplantation. Thirty-five year actuarial survival was 71%. Age less than 2 years, MVR prior to 1980, atrioventricular septal defect, univentricular heart, and additional left side obstructions were significant predictors of death. Mean follow-up was 12.8 ± 10.1 years (range, 2 months to 38 years). Seventeen patients with mechanical valves experienced systemic emboli in 9 (10%), valve thrombosis in 5 (6%), and bleeding requiring transfusion in 3 (3%) patients. Thirty-two patients required reoperations (35%) from 3 months to 14 years (mean, 6.5 ± 4.4 years) after initial MVR. Actuarial freedom from reoperation at 35 years was 63%. Variables associated with mitral re-replacement were younger age, small weight, valve diameter less than 23 mm, MVR prior to 1980, and type of implanted valves (xenograft, single-leaflet disk, ball-caged, or human valves). Conclusions Pediatric MVR can be performed with low initial mortality but should be reserved for medical and reconstruction failure because reoperation, valve-related complications, and late mortality are high. Bileaflet prostheses larger than 23 mm have the lowest reoperation risk. Ross MVR may offer select patients a durable tissue valve without lifelong anticoagulation and its associated complications.
The stentless porcine aortic root prosthesis (SPAR) has been described as a suitable valve for right ventricular outflow tract reconstruction (RVOTR). Indiana University Methodist Hospital in ...Indianapolis, Indiana began using this valve for RVOTR in 1998. This study reports medium-term to late- term outcomes of the valve in the pulmonary position.
A retrospective chart review was conducted of patients older than 18 years of age who underwent RVOTR with a SPAR between April 2000 and October 2019. Primary outcomes included survival and freedom from any valvular reintervention. Secondary outcomes included endocarditis and conduit dysfunction detected by routine echocardiography or cardiac magnetic resonance imaging.
A total of 135 patients underwent RVOTR with a SPAR at a median age of 32.4 years (range, 18 to 71 years). Of these patients, 129 had previous surgery. Indications included pulmonary insufficiency (90.4%), stenosis (34.8%), endocarditis (7.4%), and carcinoid (4.4%). Median follow-up was 2.97 years (interquartile range, 0.6 to 8.0 years). Overall survival was 93.3%, with 3 perioperative death and 6 late deaths. Endocarditis developed in 4 patients (2.9%), 2 of whom required reoperation. Progressive conduit degradation was evident at 10 years, with 22.2% and 7.7% having moderate stenosis and insufficiency, respectively. Eight (5.9%) reinterventions included 2 surgical replacements, 3 percutaneous replacements, and 3 balloon valvuloplasties at means of 8.5, 7.4, and 2.2 years, respectively. Overall freedom from reintervention at 1, 5, and 10 years was 99.1%, 94.7% and 90.7%, respectively.
In this large, single-institution experience with a long follow-up period, use of the SPAR demonstrated excellent midterm to long-term durability, low rates of endocarditis, and high freedom from reintervention.
Abstract Objectives We aimed to further validate the vasoactive-ventilation-renal score as a predictor of outcome in patients recovering from surgery for congenital heart disease. We also sought to ...determine the optimal time point within the early recovery period at which the vasoactive-ventilation-renal score should be measured. Methods We prospectively reviewed consecutive patients recovering from cardiac surgery within our intensive care unit between January 2015 and June 2015. The vasoactive-ventilation-renal score was calculated at 6, 12, 24, and 48 hours postoperatively as follows: vasoactive-ventilation-renal score = ventilation index + vasoactive-inotrope score + Δ creatinine change in serum creatinine from baseline*10. Primary outcome of interest was prolonged hospital length of stay, defined as length of stay in the upper 25%. Receiver operating characteristic curves were generated, and areas under the curve with 95% confidence intervals were calculated for all time points. Multivariable logistic regression modeling also was performed. Results We reviewed 164 patients with a median age of 9.25 months (interquartile range, 2.6-58 months). Median length of stay was 8 days (interquartile range, 5-17.5 days). The area under the curve value for the vasoactive-ventilation-renal score as a predictor of prolonged length of stay (>17.5 days) was greatest at 12 hours postoperatively (area under the curve = 0.93; 95% confidence interval, 0.89-0.97). On multivariable regression analysis, after adjustment for potential confounders, the 12-hour vasoactive-ventilation-renal score remained a strong predictor of prolonged hospital length of stay (odds ratio, 1.15; 95% confidence interval, 1.10-1.20). Conclusions In a heterogeneous population of patients undergoing surgery for congenital heart disease, the novel vasoactive-ventilation-renal score calculated in the early postoperative recovery period can be a strong predictor of prolonged hospital length of stay.
Multiple conduits for right ventricular outflow tract reconstruction exist, although the ideal conduit that maximizes outcomes remains controversial. We evaluated long-term outcomes and compared ...conduits for right ventricular outflow tract reconstruction in children with truncus arteriosus.
Records of patients who underwent truncus arteriosus repair at our institution between 1981 and 2018 were retrospectively reviewed. Primary outcomes included survival and freedom from catheter reintervention or reoperation. Secondary analyses evaluated the effect of comorbidity, operation era, conduit type, and conduit size.
One hundred patients met inclusion criteria. Median follow-up time was 15.6 years (interquartile range, 5.3-22.2). Actuarial survival at 30 days, 5 years, 10 years, and 15 years was 85%, 72%, 72%, and 68%, respectively. Early mortality was associated with concomitant interrupted aortic arch (hazard ratio, 5.4; 95% confidence interval, 1.7-17.4; P = .005). Median time to surgical reoperation was 4.6 years (interquartile range, 2.9-6.8; n = 58). Right ventricle to pulmonary artery continuity was established with an aortic homograft (n = 14), pulmonary homograft (n = 41), or bovine jugular vein conduit (n = 36) in most cases. Multivariate analysis revealed longer freedom from reoperation with the bovine jugular vein conduit compared with the aortic homograft (hazard ratio, 3.1; 95% confidence interval, 1.3-7.7; P = .02) with no difference compared with the pulmonary homograft. Larger conduit size was associated with longer freedom from reoperation (hazard ratio, 0.7; 95% confidence interval, 0.6-0.9; P < .001).
The bovine jugular vein conduit is a favorable conduit for right ventricular outflow tract reconstruction in patients with truncus arteriosus. Concomitant interrupted aortic arch is a risk factor for early mortality.
Background The Ross aortic valve replacement (AVR) has been the AVR of choice for children at our center since 1993. Absence or inadequate quality of the pulmonary valve or, less commonly, family or ...surgeon preference caused us to select an alternative AVR prosthesis for some children. This review compares the outcomes of 42 children who received a non-Ross AVR with 115 children undergoing Ross root replacement at our institution during the most recent 22 years. Methods A retrospective chart review of the 42 pediatric non-Ross AVRs was compared with 115 Ross AVRs. The mean age at AVR was 11.0 ± 6.5 years (range, 1 month to 18 years) for the non-Ross and 11.4 ± 5.5 years (range, 6 weeks to 18 years) for the Ross groups. Follow-up was 7.8 ± 6.2 years for the Ross group and 8.7 ± 6.5 years for the non-Ross group. The Ross AVR technique was modified in 2000; these modifications were applied to 72 patients (63%) of the total Ross AVR group. Results All-cause early and late mortality of the non-Ross AVR group was 17% compared with 4% for the Ross cohort ( p = 0.017). The actuarial survival rate at 20 years for the non-Ross AVR group was 81% compared with 94% for the Ross group ( p = 0.018). Reintervention rate was 29% (12/38) in the non-Ross group and 28% (32/115) in the entire Ross group (60% 26/43 before 2000, and 8% 6/72 after 2000). Thromboemboli, bleeding, and endocarditis occurred in 2.4%, 1.4%, and 10% in the non-Ross group compared with 0.9%, 2.6%, and 1.7% in the Ross AVR group ( p = 0.46, 0.01, and 0.02), respectively. Patients in the non-Ross group had a significantly higher recurrent or persistent aortic valve gradient (>20 mm Hg) than did patients in the Ross group at most recent follow-up ( p < 0.05). Conclusions Lower mortality, valve-related complications, and better hemodynamics were seen after the Ross AVR than with other types of AVR prostheses. The Ross AVR remains the treatment of choice for children who have an adequate pulmonary valve. Reoperation for Ross root dilatation, regurgitation, or both (only 6% since our modifications in 2000) has markedly reduced the main drawbacks of this AVR technique. The Ross AVR affords the growing child the advantages of a growing, autologous, viable valve substitute and eliminates the lifelong disadvantages of mechanical and xenograft valves.
Treatment of primary mediastinal nonseminomatous germ cell tumors involves cisplatin-based chemotherapy followed by surgery to remove residual disease. We undertook a study to determine short and ...long-term outcomes.
A retrospective analysis of patients with primary mediastinal nonseminomatous germ cell tumors who underwent surgery at our institution from 1982 to 2017 was performed.
A total of 255 patients (mean age, 29.2 years) were identified. Acute respiratory distress syndrome occurred postoperatively in 27 patients (10.9%), which was responsible for all 11 (4.3%) postoperative deaths. Of patients who developed acute respiratory distress syndrome, more patients received bleomycin-containing chemotherapy (25 out of 169; 14.8%) than non-bleomycin regimens (2 out of 77; 2.6%) (P = .004). With respect to variables independently predictive of long-term survival, evidence of choriocarcinoma before chemotherapy (n = 12) was determined to be an adverse factor (P = .006). In contrast, biopsy-proven elements of seminoma (n = 34) were predictive of improved survival (P = .04). The worst pathology identified in the residual mediastinal mass after chemotherapy was necrosis in 61 patients (25.0%), teratoma in 84 patients (34.4%), and malignant (persistent germ cell or non–germ cell cancer) in 97 patients (39.8%), which influenced overall survival (P < .001). Additionally, teratoma with stromal atypia (n = 18) demonstrated decreased survival compared with teratoma without atypia (n = 66; P = .031). Patients with malignancy involving >50% of the residual mass (n = 47) had a 2.3-fold increased risk of death compared with ≤50% malignancy (n = 45; P = .008). Finally, elevated postoperative serum tumor markers (n = 40) was significantly predictive of adverse survival (P < .001).
In the treatment of primary mediastinal nonseminomatous germ cell tumors, avoiding bleomycin-containing chemotherapy is important. Pre- and postchemotherapy pathology and postoperative serum tumor markers are independent predictors of long-term survival.
Diagnostic approach, treatments, short- and long-term outcomes of 255 patients with primary mediastinal nonseminomatous germ cell tumor (PMNSGCT). CT, Computed tomography; STM, serum tumor markers; FNA, fine need aspiration; dx, diagnosis; chemotx, chemotherapy; x, without; c, with; Op, operative. Display omitted
Background Persistence or recurrence of stenosis is a complication of coarctation repair and is associated with major long-term morbidity. The rate of recurrence varies significantly, depending on ...the age of the patient, technique at initial repair, and the arch anatomy. We reviewed our experience with surgical repair of recurrent coarctation of the aorta and compared it with our institutional experience with balloon aortoplasty. Methods We retrospectively reviewed our experience with 1,012 patients undergoing initial repair of coarctation between 1960 and 2008. During that time, 103 patients (10%) required reintervention. Median age at reintervention was 6.5 years (range, 2 weeks to 44 years) and median weight was 12 kg (range, 1.9 to 94 kg). Fifty-nine patients with recoarctation had surgical repair, and 44 patients were treated with balloon aortoplasty with or without stent placement. Results Ninety-five percent of patients have been followed up (median time, 14.2 years; range, 2 months to 42 years). There were 5 late deaths. Actuarial survival was 98% at 15 and 40 years in patients with surgical reintervention, and it was 91% ( p = 0.001) at 15 years in patients with balloon aortoplasty reintervention. A second redo coarctation of the aorta reintervention was performed in 12 patients: 8 patients after percutaneous intervention (nonsurgical) and 4 patients after surgical recoarctation repair. The median interval between first and second reintervention was 3.5 years (range, 1 month to 14 years). One patient who had two dilations underwent a third and fourth reintervention: patch enlargement and pseudoaneurysm resection. Freedom from reintervention in the surgical group was 96% at 15 years and 94% at 40 years, which was compared with actuarial freedom from reintervention for patients with percutaneous intervention (balloon/stent) at 15 years (82%; p < 0.001). Conclusions Our study demonstrates that surgical repair of recurrent coarctation of the aorta can be performed safely and with excellent results. The recurrence after surgical reintervention is low, and most patients to date have not required further intervention. Balloon aortoplasty as an alternative method of managing recoarctation is efficient and less invasive than surgery; however, well-described complications may occur. Recurrence rates with angioplasty are significantly higher than with surgery.
Background For children with congenital aortic stenosis (AS) who are selected for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter ...balloon aortic dilation (BAD). A retrospective study was undertaken to compare the effectiveness of BAD versus SAV, evaluating the long-term survival, incidence of aortic valve restenosis or aortic insufficiency (AI) or both, and freedom from reoperation for repeated valve repair or replacement. Neonates less than 2 months of age were excluded from this comparison. Methods We reviewed the outcomes of children undergoing repair by SAV (n = 89) and BAD (n = 69) at our institution during a recent 20-year period. Clinical and echocardiographic follow-up were analyzed. The patient groups were compared with regard to the persistence or recurrence of postoperative aortic gradients and valve insufficiency and valve-related reintervention, including aortic valve replacement (AVR). Results There was no significant difference between the groups with respect to mean age, body surface area, valve anatomy, sex, and preoperative gradients. Our data demonstrate that gradient reduction, AI, and the need for reintervention were worse for BAD. Aortic gradients at last follow-up were similar in both cohorts, but return of a significant gradient occurred sooner for patients who had BAD. Aortic gradient at discharge was significantly better for the patients who underwent SAV. Kaplan-Meier analysis showed that at 10 years, comparison of SAV and BAD was as follows: freedom from reintervention, 72% versus 53% ( p = 0.02) and freedom from AVR, 80% versus 75% ( p = 0.32). Conclusions BAD yields less gradient reduction, more postprocedural AI, and a shorter interval between initial and subsequent reintervention than does SAV. Our results demonstrate that SAV is safe and effective and that residual gradients and degree of AI are low. After SAV, the need for AVR can usually be delayed until the child is significantly older. The long-term functional stability after SAV is excellent. BAD in comparison is associated with an increased frequency and severity of AI and the need for earlier reintervention and valve replacement. SAV should be offered to all patients beyond the newborn period because it gives superior and longer lasting palliation.
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