Annals of Pediatric Cardiology
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SELECTED SUMMARIES Table of Contents   
Year : 2010  |  Volume : 3  |  Issue : 1  |  Page : 94-96
Selected Summaries


Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication12-Jun-2010
 

How to cite this article:
Talwar S, Choudhary SK, Airan B. Selected Summaries. Ann Pediatr Card 2010;3:94-6

How to cite this URL:
Talwar S, Choudhary SK, Airan B. Selected Summaries. Ann Pediatr Card [serial online] 2010 [cited 2019 Apr 18];3:94-6. Available from: http://www.annalspc.com/text.asp?2010/3/1/94/64352


Symptomatic Neonatal Tetralogy of Fallot: Repair or Shunt?

Kanter KR, Kogon BE, Kirshbom PM, Carlock PR

Ann Thorac Surg 2010;89:858-63.

The management of neonates with symptomatic tetralogy of Fallot (TOF) who require surgery in the first month of life has been a matter of debate and there is no consensus on whether a Blalock-Taussig shunt (BTS) or early primary repair is the best option. In this paper from the Emory University School of Medicine, the authors reviewed their experience with 37 symptomatic neonates (prostaglandin dependent or having unacceptable systemic arterial saturations or hypercyanotic spells) with TOF, undergoing either a BTS (n = 17) or primary repair (n = 20), between 2002 and 2008.

The choice of operation was based on the individual patient and the preference of the attending surgeon. In general, neonates who were smaller and required emergency operation were shunted; those with favorable anatomy and good-sized branch pulmonary arteries had primary repair. Patients undergoing BTS more commonly required emergency operation (24% vs. 0%; P = 0.036); otherwise, the two groups were similar.

One infant with preoperative bowel ischemia died one day postoperatively after emergency BTS. There were two late deaths 11 and 12 months postoperatively, both in primary repair patients, one each due to cardiac and respiratory failure. The 16 survivors of the BTS had TOF repair 216 ± 99 days after the original shunt. Patients undergoing BTS had shorter intensive care unit (4.1 ± 2.7 vs. 11.8 ± 12.1 days, P = 0.0173) and hospital (11.1 ± 11.2 21.1 ± 18.0 days, P = 0.055) stay for the first operation compared with those neonates undergoing primary repair. However, when the values for the subsequent intensive care unit and hospital stay at the time of complete repair were added to the initial values in the BTS group, these were no different. The primary repair patients more frequently had a transannular patch and a tendency to more frequent delayed sternal closure. Nineteen of the 20 primary repair patients had a transannular patch. Ten of the shunted patients had a transannular patch at the time of complete repair.

The authors concluded that BTS or primary repair of neonates with symptomatic TOF provides equivalent results with comparable mortality. Patients undergoing BTS may have a greater likelihood of avoiding a transannular patch at complete repair. Therefore, primary repair is not always the better approach and the choice of operation should be individualized according to the patient, surgeon and institutional factors.

Current Expectations for Surgical Repair of Isolated Ventricular Septal Defects

Scully BB, Morales DLS, Zafar F, McKenzie ED, Fraser Jr CD, Heinle JS

Ann Thorac Surg 2010;89:544-51.

With a growing enthusiasm in the percutaneous device closure of ventricular septal defect (VSD), it has become essential to review the results of surgical repair of this condition. This paper, from the Texas Children's Hospital, reports on 215 patients (age 20 days to 18 years, median 10 months) undergoing surgical repair of VSD between 2000 and 2006. The types of VSDs were perimembranous (n = 172, 80%), supracristal (n = 28, 13%), inlet (n = 6, 3%) and muscular (n = 9, 4%).

There was one in-hospital death (0.5%) in a 32-week premature infant with genetic abnormalities and respiratory failure. In the immediate postoperative period, six patients (2.8%) required reoperation mainly for bleeding and wound complications. No patient underwent reoperation for a residual VSD. None of the patients had complete heart block. The median intensive care unit length of stay was 2 days (range, 1-14 days). The median postoperative hospital length of stay was 5 days (range, 2-187 days). No patients were discharged on antiarrhythmic agents, had complete heart block or required permanent pacing. There were two late deaths (0.9%) due to non-cardiac causes. At mean follow-up of 2.1 ± 2.0 years, 99.5% (211 of 212) of the patients were asymptomatic and none had significant tricuspid or aortic regurgitation.

The authors concluded that surgical closure of isolated VSD is safe and effective and that the risk of death, complete heart block and reoperation is minimal. As new technologies for VSD closure evolve, results such as these should be considered when evaluating patients, choosing therapeutic options and counseling families.

Lateral Tunnel Fontan in the Current Era: Is It Still A Good Option?

Brown JW, Ruzmetov M, Deschner BW, Rodefeld MD, Turrentine MW

Ann Thorac Surg 2010;89:556-63.

Of late, there are numerous studies that have aimed at comparing the extracardiac Fontan (ECF) with the intra-atrial lateral tunnel Fontan (LTF) operation. In his study from the Indiana University School of Medicine, the authors reviewed the long-term outcomes after an LTF operation and compared them with recently published series using one or both techniques.

Between 1992 and 2008, 220 of 280 patients (median age, 2.5 years; range, 1-45 years) underwent a fenestrated or non-fenestrated LTF operation. The underlying cardiac diagnoses were hypoplastic left heart syndrome (n = 65), tricuspid atresia (n = 54), double-inlet left ventricle (n = 48), unbalanced atrioventricular septal defect (n = 22) and other complex cardiac defects (n = 31). Thirty-six patients (16%) did not have previous staged palliation (they received a single-stage hemi-Fontan and LTF), but 184 (84%) had previous cavopulmonary pulmonary anastomosis: hemi-Fontan (n = 155), right hemi-Fontan plus left bidirectional Glenn (n = 19), bidirectional Glenn only (n = 7) and left hemi-Fontan only (n = 3). During LTF, a fenestration was performed in 202 patients (92%). Eighteen patients (8%) were not fenestrated. The indication for fenestration included a diagnosis of hypoplastic left heart syndrome, preoperative mean pulmonary artery pressure more than 15 mmHg and any preoperative variable such as left ventricular hypertrophy or small pulmonary arteries that could potentially increase the pulmonary vascular resistance.

There was one early death (due to multiorgan dysfunction syndrome). Follow-up was 98% complete and averaged 6.7 ± 3.9 years. At last follow-up, the mean New York Heart Association (NYHA) functional class of the survivors was 1.7 ± 0.5; 201 patients (96%) were in NYHA class I/II and eight patients were in class III.

There were 10 late deaths due to low cardiac output (n = 4), arrhythmia (n = 2), pneumonia (n = 1), respiratory failure (n = 1), multiorgan failure (n = 1) and severe hepatic necrosis secondary to adenovirus (n = 1). Three patients required Fontan takedown because of low cardiac output (5 days postoperatively), protein-losing enteropathy (1 month postoperatively) and superior vena cava and right atrium dilation (9 years postoperatively). One patient underwent heart transplantation. Actuarial survival was 96% at 5 years and 95% at 10 and 15 years, and freedom from Fontan failure was 94% at 5 years and 93% at 10 years. Freedom from new supraventricular tachyarrhythmia was 98% at 5 years and 95% at 10 years and freedom from new bradyarrhythmia was 97% at 5 years and 96% at 10 years. Six patients developed protein-losing enteropathy. Freedom from this complication was 97% at 15 years. Risk factors for development of supraventricular tachyarrhythmia included atrioventricular valve abnormalities (P = 0.02) and preoperative bradyarrhythmia (P = 0.01). Risk factors for bradyarrhythmia included the need for early postoperative pacing (P = 0.001). The authors compared their results with other recent series of ECF and LTF and found that the type of the Fontan operation did not affect the early or late outcome.

The authors concluded that the LTF operation results in excellent midterm palliation with a low incidence of postoperative atrial tachyarrhythmia that is largely dependent on the underlying cardiac morphology and incidence of preoperative arrhythmia. In their opinion, the good midterm outcome after an LTF operation should serve as a basis for comparison with other surgical alternatives to complete the Fontan circulation.

Long-Term Results After Mitral Valve Repair in Children

Lee C, Lee CH, Kwak JG, Park CS, Kim SJ, Song JY, Shim WS

Eur J Cardiothorac Surg 2010;37:267-72.

Between 1988 and 2007, 139 children (<18 years) underwent mitral valve (MV) repair at the Sejong Heart Institute, Republic of Korea. The long-term results of this procedure were analyzed in this study.

The median age of presentation was 2.3 years (2 months to 17.6 years). Forty-seven (34%) of these patients were 1 year of age or less. The median body weight was 10.9 kg (range, 3.7-73.0 kg). Patients with atrioventricular septal defect, single ventricle or atrioventricular discordance were excluded. None of these patients had rheumatic heart disease. The predominant lesion was mitral regurgitation (MR, n = 125, 10%) and mitral stenosis (MS, n = 14, 10%). Severity of MR was grade IV in 47 patients, grade III in 44, grade II in 26 and grade I in eight. MS was severe (mean gradient >10 mmHg) in four patients, moderate (mean gradient 5-10 mmHg) in eight and mild (mean gradient <5 mmHg) in two.

Annulus dilatation and leaflet prolapse were most frequently present in patients with MR (93 of 125, 74%). Associated cardiac lesions were present in 111 patients (80%) and were addressed concurrently in 105 patients. Various surgical techniques were used according to the functional and pathologic findings of MV. In patients with MR, these included Wooler-Kay annuloplasty (n = 57, 45.6%), cleft repair (n = 22, 17.6%), strip annuloplasty (n = 18, 14.4%), ring annuloplasty (n = 14, 11.2%), artificial chordae (n = 12, 9.6%), chordae shortening (n = 10, 8%), posterior annulus plication (n = 9, 7.2%), papillary muscle splitting (n = 7, 5.6%), secondary chordae resection (n = 6, 5.6%), edge-to edge repair (n = 5, 4%), commissure obliteration (n = 5, 4%) and chordal transfer (n = 4, 3.2%). In patients with MS, surgical procedures were papillary muscle splitting (n = 11, 78.6%), commissorotomy (n = 4, 28.6%), resection of the supravalvar ring (n = 4, 28.6%), secondary chordae resection (n = 2, 14.3%), leaflet slicing (n = 1, 7.1%) and fenestration of chordae (n = 1, 7.1%).

There was no early death. The median follow-up was 8 years (2 months to 20 years, 78% complete). Among 122 survivors with MR, 102 patients (84%) underwent echocardiography during follow-up. Degree of MR was none in 42 patients, grade 1 in 36, grade 2 in 19 and grade 3 in five. All patients who underwent edge-to-edge repair showed mild MR and no MS. Among 14 survivors with MS, eight patients (57%) underwent echocardiography during follow-up. The median MS gradient was 2.8 mmHg (0-10 mmHg). All survivors were in the NYHA class I or II. Twenty-six patients required 29 MV reoperations; in 11 of these, MV replacement was performed and in 15 patients, rerepair was performed. At 15 years, freedom from MV reoperation and MV replacement was 77% and 90%, respectively. There were three late deaths and the overall survival was 97% at 15 years.

The authors concluded that MV repair in children showed excellent survival, acceptable reoperation rate and satisfactory valve function at long-term follow-up. In patients undergoing reoperation, rerepair was successful in more than half of the patients. The authors have also discussed the importance of avoiding a mechanical prosthetic valve and anticoagulants in this young subset of patients.

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Correspondence Address:
Sachin Talwar
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


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