Background The Blalock-Taussig shunt (BTS) was introduced 68 years ago before open repair of cyanotic congenital heart disease (CHD) was possible. The originally described technique has undergone ...many modifications but remains an integral component of the management of cyanotic CHD. We report our contemporary, single institution experience with the BTS. Study Design We performed a retrospective review of all patients treated with a BTS from June 1995 to December 2011. Results There were 730 BTS performed in 712 patients; 727 (99.6%) by interposition graft (modified). The BTS was predominantly right-sided (n = 657, 90%). Median age and weight at palliation were 8 days (range 0 days to 18.5 years) and 3.2 kg (1.5 to 51 kg). Median hospital length of stay was 16 days (range 0 to 347 days). There were 241 (33%) BTS performed as initial palliation for ultimate 2-ventricle (2V) circulation, 471 (65%) as part of staged palliation for patients with functionally univentricular lesions (1V), 6 (1%) as a part of 1.5-ventricle palliation, and 12 (1%) for Ebstein's anomaly. There were 473 (65%) BTS placed via sternotomy and the most common site of BTS was the right subclavian to right pulmonary artery (PA; n = 452, 62%). Hospital mortality was higher for BTS in 1V patients (1V 15% vs 2V 3%, p < 0.0001). Overall, 536 (73%) patients were bridged to complete repair or the second stage of 1V palliation after a median duration of 6.5 months (0 days to 15.3 years). Multivariable regression showed that sternotomy approach, use of cardiopulmonary bypass, innominate artery-PA shunt, and diagnosis of Ebstein's were risk factors for in-hospital mortality (p < 0.05). Conclusions Although the BTS remains an important component of the surgical treatment of cyanotic congenital heart disease, patients with single ventricle circulation still face significant ongoing risk of mortality.
Surgical pulmonary valve replacement: A benchmark for outcomes comparisons McKenzie, E. Dean, MD; Khan, Muhammad S., MD; Dietzman, Thomas W., BS ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
10/2014, Letnik:
148, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Background Patients with right heart obstructive lesions develop residual or recurrent right ventricle outflow tract pathology as a result of native or implanted pulmonary valve (PV) dysfunction. ...Until recently, the standard of care has been surgical placement of a PV or valved right ventricle to pulmonary artery conduit. Catheter-based options are being increasingly applied in patients with PV dysfunction. The purpose of our study was to evaluate outcomes of surgical pulmonary valve/conduit replacement (PVR) at a large pediatric hospital to provide contemporary benchmark data for comparison with developing technologies. Methods Retrospective review of patients undergoing PVR not associated with complex concomitant procedures from July 1995 to December 2010 was completed. Inclusion criteria were designed to generally match those applied to patients promoted for catheter-based valve replacement based on age and weight (age ≥5 years and weight ≥30 kg). Results There were 148 PVRs with all patients having undergone ≥ 1 previous interventions (tetralogy of Fallot 53% and pulmonary atresia 17%). Surgical indications were PV insufficiency (60%), PV stenosis (26%), and both (13%). Valves used included bioprosthetic (n = 108; 73%) and homografts (n = 40; 27%). Time-to-extubation, intensive care unit stay, and hospital length of stay were <1 day (interquartile range, 0-1 day), 2 days (interquartile range, 1-2 days), and 5 days (interquartile range, 4-6 days), respectively, with no hospital deaths. Freedom from PV reintervention at 1, 3, and 5 years was 99%, 99%, and 94%, respectively. Multivariable analysis showed age <13 years ( P = .003), and smaller valve size ( P = .025) were associated with increased risk of valve reintervention. Patient survival at follow-up (mean, 5.0 ± 3.9 years) was 99%. Conclusions Surgical PVR is safe with low in-hospital and midterm follow-up mortality and reoperation rates. These outcomes provide a useful benchmark for treatment strategy comparisons.
Background We sought to evaluate the impact of the evolution of a pediatric mechanical circulatory support (MCS) program on outcomes of children listed for heart transplantation at our institution. ...Methods All patients listed for isolated heart transplantation from 1995 to 2013 were included. The use of MCS while on the wait-list was recorded. Wait-list and posttransplant outcomes were compared before and after 2005, which was when we became capable of providing long-term MCS without size limitation. Results In total, 259 patients were listed for transplant and 201 (78%) reached transplant. The use of MCS was significantly increased between the eras (13% and 37%, p = 0.0001). Wait-list mortality was significantly decreased (25% and 11%, p = 0.0006). Among transplant recipients, the proportion of patients who underwent MCS was significantly increased (13% and 37%, p = 0.0002). Of these MCS patients, the use of long-term devices was significantly increased (50% and 98%, p = 0.0004). Median duration of MCS was significantly increased (12 and 78 days, p = 0.004). Kaplan-Meier estimates showed a trend ( p = 0.08) toward improved survival after bridge-to-transplant both at 1 year (70% in the early era and 88% in the late era) and at 5 years (60% and 78%, respectively). Conclusions Outcomes of pediatric heart transplantation have significantly improved over the last 2 decades. We believe such improvement is, at least in part, attributable to maturation of MCS strategy, characterized by avoiding the use of temporary devices such as extracorporeal membrane oxygenation as a bridge-to-transplant and a more aggressive use of long-term devices.
Abstract Background Few data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failure–related hospitalizations ...increased over time but that mortality decreased. Factors associated with mortality and length of stay were also assessed. Methods and Results A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for pediatric (age ≤18 years) heart failure–related hospitalizations for the years 1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153 (95% confidence interval CI 8,898–13,409) in 2003 to 13,892 (95% CI 11,528–16,256) in 2006. Hospital length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5–15.2) to 2006 (mean 19.4 days, 95% CI 18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9–8.0) and did not vary significantly between years; however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis. Conclusions Heart failure–related hospitalizations occur in 11,000–14,000 children annually in the United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.
Institutional operative volume has been shown to impact outcomes of various procedures including lung transplantation (LTx). We sought to determine whether this holds true with pediatric LTx by ...comparing outcomes of adult centers (with larger overall volume) to those of pediatric centers (with smaller volume but more pediatric-specific experience).
A retrospective analysis of the Organ Procurement and Transplant Network data was performed. Centers were categorized as either adult (LTx volume predominantly in adult patients), high-volume pediatric (HVP, ≥4 LTxs/year), or low-volume pediatric (LVP, <4 LTxs/year). Outcomes were compared in "younger children" (<12 years) and "older children and adolescents" (12 to 17 years).
In total, 1,046 pediatric LTxs were performed between 1987 and 2012 at 62 centers (adult 51 82%, HVP 3 5%, LVP 8 13%). Although adult centers had larger overall LTx volume, their pediatric experiences were severely limited (median 1/year). In younger children, HVP centers were significantly better than LVP centers for patient survival (half-life: 7.3 vs 2.9 years, p = 0.002). Similarly, in older children and adolescents, HVP centers were significantly better than adult centers for patient survival (half-life: 4.6 vs 2.5 years, p = 0.001). Of note, even LVP centers tended to have longer patient survival than adult centers (p = 0.064). Multivariable analysis identified adult centers as an independent risk factor for graft failure (hazard ratio: 1.5, p < 0.001) as with LVP (hazard ratio: 1.3, p = 0.0078).
Despite larger overall clinical volume, outcomes among pediatric LTx recipients in adult centers are not superior to those of pediatric centers. Not only center volume but pediatric-specific experience has an impact on outcomes in pediatric LTx.
Abstract Objective To determine the incidence and risk factors for endocarditis and reintervention in patients undergoing placement of right ventricle-to-pulmonary artery valve conduits. Methods All ...right ventricle–to–pulmonary artery valved conduits placed between 1995 and 2014 were included. Freedom from endocarditis, reintervention, and replacement were analyzed using the Kaplan-Meier method and parametric survival regression models. Results A total of 586 patients underwent placement of a total of 792 valved conduits, including 289 (36%) pulmonary homografts, 121 (15%) aortic homografts, 245 (31%) bovine jugular grafts, and 137 (17%) porcine heterografts. There were 474 (60%) primary placements and 318 (40%) replacements. The median duration of conduit follow-up was 7 years; 23 conduits developed endocarditis at a median of 5 years after surgery. The use of bovine jugular grafts was the sole significant risk factor associated with endocarditis (hazard ratio, 9.05; 95% confidence interval, 2.6–31.8 compared with homografts). The hazard was greater for bovine jugular grafts compared with the other conduit types and increased with time; however, bovine jugular grafts were associated with a lower risk for reintervention ( P < .0001) and replacement ( P = .0002). Factors associated with greater risk of both reintervention and replacement were younger age and smaller conduit size. In addition, a diagnosis of truncus arteriosus was associated with a greater risk for replacement ( P = .03). Conclusions Bovine jugular grafts are associated with a significantly greater risk of late endocarditis but with lower reintervention rates compared with other valved conduits. The risk of endocarditis and durability must be balanced during conduit selection. Antibiotic prophylaxis and a high index of suspicion for endocarditis are warranted in patients with bovine jugular grafts.
Objective The present study sought to determine the long-term quality of life (QOL) of children who required long-term ventricular assist device (VAD) support as a bridge to transplantation (BTT) ...compared with children who underwent heart transplantation without VAD support. Currently, 20% of children undergoing heart transplantation have required a VAD as a BTT. Few data have been published assessing how children requiring a VAD as a BTT will fair in terms of their long-term QOL. Methods The present study used a cross-sectional design, using the Core and Cardiac modules of the Pediatric Quality of Life Inventory survey. In a secondary analysis, the factors associated with worse QOL outcomes among the VAD patients were also investigated. Results At follow-up (median, 4.2 years), between the 21 children who required a VAD as a BTT and 42 who went straight to transplantation, no significant differences were found in the QOL as measured using the Psychosocial Health Summary Score, Physical Health Summary Score, or Total Score in the survey's Core Module, nor were any differences found in the outcomes assessed using the survey's Cardiac Module. Of the patients who required a VAD, only the presence of a neurologic complication was associated with worse QOL, which was demonstrated by decreased Physical Health Summary and Cardiac Communication scores. Conclusions Over the long term, surviving children who required a long-term VAD as a BTT experience a similar QOL as those who went straight to transplantation.
The results of bridging patients with cardiac allograft failure to retransplantation (ReTx) with mechanical circulatory support (MCS) have not been well studied. The United Network of Organ Sharing ...(UNOS) database was used to analyze outcomes of patients successfully bridged with MCS to cardiac ReTx.
Of 1,690 cardiac ReTx identified in the UNOS database from October 1987 to July 2011, 149 (8.8%) were bridged to ReTx with MCS.
Patients bridged to ReTx with MCS had a poorer survival than patients not bridged (p < 0.0001). ReTx after ventricular assist device (VAD) support had better survival than ReTx after extracorporeal membrane oxygenation (ECMO; half-life, 3.9 years vs 61 days, p = 0.026). For patients bridged to ReTx, graft survival was 40% for ReTx within 1 year of primary Tx vs 64% (p = 0.003). When ReTx was performed 1 year after cardiac Tx, survival was similar in patients bridged with a VAD and those not bridged (mean, 7.5 vs 8.7 years; p = 0.8). Survival for patients bridged to ReTx with ECMO was consistently worse (p ≤ 0.05) in all analyses. The 1-year survival of ReTx after VAD performed in 2003 to 2011 (67%) was better than in the earlier era of 1987 to 2002 (37%, p = 0.005).
Bridging patients to ReTx with ECMO at any time is not advisable. Bridging patients with MCS to ReTx within 1 year of primary cardiac Tx is not advisable. Survival after ReTx for patients bridged by VAD has improved considerably over time. Patients who survive the first year after cardiac Tx can be bridged by VAD to ReTx with an expectation that outcomes can be similar to ReTx patients who did not require MCS.
Background There is a paucity of data on the current outcomes of surgical intervention for recurrent aortic arch obstruction (RAAO) after initial aortic arch repair in children. The goal of this ...study is to report the long-term results in these patients. Methods All patients undergoing surgical intervention for RAAO at Texas Children's Hospital from 1995 to 2012 were included. The cohort was divided into four groups based on initial procedure: (1) simple coarctation repair, (2) Norwood procedure, (3) complex congenital heart disease, and (4) interrupted aortic arch. Results A total of 48 patients age 9 months (range, 22 days to 36 years) underwent 49 procedures for RAAO. All patients had an anatomic repair consisting of either patch aortoplasty (n = 27, 55%), aortic arch advancement (n = 8, 16%), sliding arch aortoplasty (n = 6, 12%), placement of an interposition graft (n = 2, 17%), reconstruction with donor allograft (n = 4, 8%), extended end-to-end anastomosis (n = 1, 2%), or redo Norwood-type reconstruction (n = 1, 2%). Most procedures (n = 46, 94%) were performed through a median sternotomy using cardiopulmonary bypass. At a median follow-up of 6.1 years (range, 9 days to 17 years), only 2 patients required surgical or catheter-based intervention for RAAO. Hypertension was present in 10% of patients at last follow-up. There were no neurologic or renal complications. There was 1 perioperative death after an aortic arch advancement in group 1. Four other patients have died during follow-up, none of the deaths related to RAAO. Conclusions Anatomic repair of RAAO is a safe procedure associated with low morbidity and mortality, and low long-term reintervention rates.
Introduction In lung transplantation (LTx), the arterial partial pressure of oxygen (PaO2 ) is traditionally regarded as critical information for assessment of donor lung function. Each center sets ...its own thresholds; by convention, a donor PaO2 of less than 300 mm Hg has been considered disqualifying. Limited literature exists to support such a practice. We analyzed all LTxs performed in the United States over a 9-year period to assess the effect of donor PaO2 on graft survival. Methods The United Network for Organ Sharing (UNOS) database was queried for LTx (January 2000–November 2009). Of 12,545 LTx performed, 12,045 (96%) had donor PaO2 data on a fraction of inspired oxygen of 1.0, recorded at the time of procurement. Results Mean donor PaO2 was 407 ± 140 mm Hg. The majority of LTxs had a donor PaO2 greater than 300 mm Hg (9593 (80%) whereas PaO2 was 200 mm Hg or less in 1830 (15%) and 201 to 300 in 582 (5%) donors. Use of donors with a PaO2 of less than 200 increased over time from 5% (45) in 2000 to 21% (295) in 2009 ( P = .002). Kaplan-Meier survival analysis showed no difference in graft survival with differing donor PaO2 s, irrespective of whether patients had a single or double LTx. A Cox multivariable analysis of 21 donor characteristics demonstrated that donor PaO2 had no association with graft survival. Conclusions Donor PaO2 levels did not affect graft survival. The use of donors with lower PaO2 s could substantially increase the donor pool. We are not suggesting that donor PaO2 is not important when assessing potential lung donors but its level of importance in regard to other criteria appears less than previously believed.
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