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SELECTED SUMMARIES Table of Contents   
Year : 2009  |  Volume : 2  |  Issue : 2  |  Page : 179-181
Selected Summaries

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication12-Dec-2009

How to cite this article:
Talwar S, Choudhary SK, Airan B. Selected Summaries. Ann Pediatr Card 2009;2:179-81

How to cite this URL:
Talwar S, Choudhary SK, Airan B. Selected Summaries. Ann Pediatr Card [serial online] 2009 [cited 2021 Sep 23];2:179-81. Available from:

Right ventricle to pulmonary artery conduit augmentation compared with replacement in young children

Zachariah JPV, Pigula FA, Mayer JE, McElhinney DB

Ann Thorac Surg 2009;88:574-80

The increasing use of right ventricle (RV) to pulmonary artery (PA) conduits in neonates and younger children has generated a large cohort of patients who require multiple re-operations for conduit failure. The management of these patients is not yet standardized and there is no consensus on the optimal therapeutic strategy in this group of children. In an attempt to elucidate this issue, a retrospective study was done at the Children's Hospital, Boston. It consisted of a detailed cross-sectional analysis of 180 patients who were 10 years of age or less, and underwent a first conduit reoperation (conduit 2). 147 (82%) underwent conduit replacement and 33 (18%) underwent conduit augmentation. The analysis was limited to patients 10 years of age or younger to focus on patients who were generally unlikely to accommodate placement of an adult-sized conduit. The demographic profile of the patients in both the groups was similar.

The conduit augmentation procedure consisted of a longitudinal incision along the entire length of the anterior portion of the RV-PA conduit across both RV and PA anatomoses with excision of the homograft valve. An on-lay patch of expanded polytetrafluoroethylene (n=17) , polyethylene terephthalate fiber (Dacron, n=9), or homograft (n=7) was sewn into this incision to increase the diameter. Conduit augmentation was less likely to be performed when the original conduit was an aortic homograft compared with other conduits. Conduit replacement was carried out using aortic homograft (n= 89), pulmonary homograft (n=42) , a non-valved synthetic tube graft (n=13) or a valved synthetic graft (n=3).

The primary outcome was freedom from re-operation (conduit 3) after conduit 2. Secondary outcomes included survival and a composite outcome of freedom from conduit 3 or conduit dilation (freedom from conduit re-intervention) after conduit 2. At conduit re-operation, cardiopulmonary bypass time was longer in replacement patients (101 ± 35 versus 71 ± 34 minutes; P < 0.001); cardiac intensive care unit stay was similar (2.3 ± 3.6 days for replacement versus 1.8 ± 0.8 days; P = 0.23 for augmentation). Early mortality was 0.5%.

Median follow-up duration was 7.3 years with no difference between the two groups and overall 10-year survival was 95%. Transcatheter dilation or stenting of an obstructed RV-PA conduit was performed in 85 patients after conduit 2, 71 in the replacement group and 14 in the augmentation group. Fifty-two of these patients subsequently underwent conduit 3. 74 patients underwent conduit 3 for stenosis, 66 in the replacement group and 8 in the augmentation group. There were no differences between replacement and augmentation groups in indications for conduit 3. Freedom from reoperation was 80% at 5 years and 39% at 10 years, whereas freedom from re-intervention (reoperation or catheter intervention) was 55% at 5 years and 26% at 10 years. Aortic homograft as a first conduit and undersized conduits were associated with shorter freedom from reoperation and re-intervention. The authors concluded that patch augmentation is equally effective as compared to conduit replacement and is perhaps a more cost-effective alternative to conduit replacement for conduit reoperation in selected young children, especially in resource-poor settings. The important limitations of this study were that it was a retrospective analysis of data and surgeon bias always dictated the choice of either procedure; however it may still be worthwhile to consider conduit augmentation in younger patients in India specially when a later re-operation is imminent and the supply of homografts is limited.

Surgical Management of Supravalvular Aortic Stenosis: Does Brom Three-Patch Technique Provide Superior Results?

Metton O, Ali WB, Calvaruso D, Bonnet D, Sidi D, Raisky O, Vouhι PR

Ann Thorac Surg 2009;88:588-93

Supravalvular aortic stenosis (SVAS) is an uncommon condition and its repair is challenging with lack of unanimity on the optimal procedure. This study is from the University Paris Descartes and Sick Children Hospital, Paris, France. It was performed to evaluate the results of surgery for SVAS and to compare the symmetric three-patch repair (Brom procedure) with other methods of repair.

Between 1995 and 2007, 34 patients with SVAS underwent surgery at the authors institution. 14 of these had Williams syndrome. 24 patients had discreet SVAS, 10 had diffuse stenosis involving the ascending aorta (n=3) or the ascending and transverse aorta (n=7). The left ventricle to aorta peak gradient ranged between 70 and 145 mm Hg (mean 104 ± 21 mm Hg). Branch pulmonary arterial stenoses were present in 15 patients (44%). Surgical procedures consisted of Brom three-patch technique (n=23), one-patch repair (n=8), 3 patients (9%) had inverted bifurcated patch enlargement (Doty repair, n=3).

There was one early death due to diffuse signs of myocardial ischemia with left ventricular dysfunction after Brom repair. The mean left ventricle to aorta peak systolic gradient at hospital discharge was 21 ± 16 mm Hg; it was 37.5 ± 17 mm Hg with one-patch repair, 30 ± 15 mm Hg with Doty operation, and 14 ± 10 mm Hg after Brom procedure. Mean follow-up was 5.8 ± 4.3 years (range, 6 months to 12 years). One patient who underwent one-patch repair underwent reoperation for residual obstruction. At last follow-up, left ventricle to aorta peak gradient was 45 ± 28 mm Hg after one-patch repair, 30 ± 9 mm Hg after Doty operation, and 11 ± 18 mm Hg after Brom procedure which was associated with a low incidence of residual obstruction (n=2) and aortic insufficiency (n=1). Bicuspid aortic valve and type of operation were identified as incremental risk factors for higher gradients. The authors concluded that mid-term outcome after repair of SVAS is satisfactory and that results after three-patch repair are superior to those of one-patch reconstruction in terms of residual obstruction and development of aortic insufficiency. However, we will need to await longer follow-up of these patients and preferably, a larger number of patients with each technique.

Amiodarone as a First-Line Therapy for Postoperative Junctional Ectopic Tachycardia

Kovacikova L, Hakacova N, Dobos D, Skrak P, Zahorec M

Ann Thorac Surg 2009;88:616-22

Junctional ectopic tachycardia (JET) is a potentially life-threatening arrhythmia , which occurs in 1-11% patients after repair of congenital heart defects (CHD) and is often resistant to conventional therapy such as control of fever, correction of electrolyte abnormalities, anemia, and hypovolemia, optimizing sedation, and reducing use of inotropes. This study from Children's Cardiac Center, Bratislava, Slovakia evaluated the efficacy of amiodarone as the first-line treatment in such patients and assessed factors associated with failure of amiodarone therapy.

Over a 10 year period (January 1998 to December 2007) , 40 pediatric patients (median age 2 months, range, 3 days to 72 months) with postoperative JET following repair of CHD received intravenous amiodarone in 2-10mg/kg bolus and, if necessary, followed by continuous infusion (10 to 15 ΅g/kg/min), as the first-line therapy. Amiodarone therapy was considered successful if there was a restoration of sinus rhythm or slowing of JET to a rate that allowed atrial or atrioventricular sequential pacing. Failure of amiodarone therapy was defined as persistently rapid JET or late increases in the JET rate exceeding 170 bpm requiring escalation of therapy to hypothermia. Safety of amiodarone therapy was defined as absence of hemodynamic instability requiring intervention.

Treatment with amiodarone was effective in 18 patients (45%). Boluses of amiodarone with median dose of 3 mg/kg (range, 2 to 10 mg/kg) were effective in restoring sinus rhythm in 7 patients. In the remaining 11 patients, junctional rhythm persisted after amiodarone boluses of 8 mg/kg (range, 4 to 10 mg/kg) and continuous infusion of amiodarone was started for a duration of 23 hours (range, 8 to 55 hours). However, the rate decreased from 180 bpm (range, 173 to 200 bpm) to 142 bpm (range, 133 to 155 bpm; P < 0.0001) and allowed effective pacing with atrioventricular synchrony. Higher arteriovenous oxygen saturation difference (P = 0.007) and lower body temperature (P = 0.02) were associated with failure of amiodarone therapy. There were no deaths due to JET. During administration of amiodarone boluses, hypotension occurred in 28 patients, with good response to calcium or volume expansion in 23 and with a need to increase catecholamine support in 5 patients. No proarrhythmic effects of amiodarone, atrioventricular block, or bradycardia were encountered.

The authors concluded that amiodarone as the first-line treatment was effective in almost half of the patients with postoperative JET. Higher arteriovenous oxygen saturation difference and lower body temperature were associated with failure of amiodarone therapy, and their presence may suggest more aggressive initial approach consisting of amiodarone combined with hypothermia.

The strengths of this study are that it is prospective, single-institutional study with a consistent two-staged treatment protocol throughout the study period. The limitation was that different protocols of amiodarone treatment were not compared.

Anomalous origin of the left coronary artery from the pulmonary artery: late results with special attention to the mitral valve

Alia WB, Mettona O, Roubertiea F, Pouarda P, Sidib D, Raiskya O, Vouhιa PR

Eur J Cardiothorac Surg 2009;36:244-8

This is a large series of 62 patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) from the University Paris Descartes and Sick Children Hospital, Paris, France and a uniform approach to managing these patients is discussed.

Over a 21 year period (1986 to 2007), 62 children with ALCAPA (median age, 16 months range 10 days to 11 years), underwent surgery. The median preoperative left ventricular ejection fraction was 32% (range 10-75%). Thirty-six patients (58%) had a preoperative ejection fraction less than 30%. Preoperatively, the degree of mitral regurgitation (MR) was 0 to trivial in 4 patients (6.5%), mild in 28 (45%), moderate in 17 (27.5%) and severe in 13 cases (21%). The "uniform approach" consisted of (a) Immediate surgery at diagnosis (b) direct aortic reimplantation of the anomalous artery in 61 of 62 patients and (3) no concomitant mitral valve surgery, irrespective of the severity of severity of MR

There were six hospital deaths, due to ventricular arrhythmias (n = 2), neurologic damage (n = 1), multi-organ failure (n = 1) and intractable low cardiac output syndrome (n = 2). Predictors of hospital death were poor preoperative left ventricular ejection fraction (<30%) (P = 0.035), origin of ALCAPA from the left-handed facing pulmonary sinus (P = 0.026), operation before 1997 (P = 0.034) and use of left ventricular assist device (P = 0.043). The severity of preoperative mitral regurgitation was not identified as a potential risk factor. Median stay in the intensive care unit was 10.6 days (range 1-49 days). The median durations of ventilatory support and inotropic support were 7.2 days (range 0.5-41 days) and 7.6 days (range 1-48 days), respectively.

The mean follow-up was 9.7 years (range 3 months to 21 years) and was 98% complete. Mean left ventricular ejection fraction was 63 ± 10% (range 35-75%) (P < 0.00001 compared to preoperative). Mitral regurgitation was absent or trivial in 21 cases (40%), mild in 28 (53%) and moderate in 4 patients (7%). Five patients underwent reoperation for mitral valve repair (n = 3), surgical angioplasty of the reimplanted left coronary artery (n = 1) and mammary to left coronary bypass (n = 1). Reoperations were performed after a median delay of 86 months (range 8 months to 18 years). No patient died at reoperation.

The authors concluded that direct aortic reimplantation can be performed in the almost all children with ALCAPA and provides satisfactory long-term results. Early mortality is related to the severity of left ventricular dysfunction and should be decreased by a wise use of postoperative cardiac assist devices. Left ventricular function always improves and usually recovers to normal. Also, they feel that MR can always be left alone since it almost always improves postoperatively, however, it may require a re-operation. This recommendation is a little controversial as several studies have advocated aggressive repair of MR for an optimal early outcome.

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

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