Annals of Pediatric Cardiology
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Table of Contents   
Year : 2012  |  Volume : 5  |  Issue : 2  |  Page : 217-219
Selected summaries

1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiothoracic and Vascular Surgery, MIOT Hospital, 4/112, Mount Poonamalle Road, Manapakkam, Chennai, India

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Date of Web Publication11-Aug-2012

How to cite this article:
Talwar S, Singhi AK. Selected summaries. Ann Pediatr Card 2012;5:217-9

How to cite this URL:
Talwar S, Singhi AK. Selected summaries. Ann Pediatr Card [serial online] 2012 [cited 2022 Jan 22];5:217-9. Available from:

Surgical valvuloplasty versus balloon aortic dilation for congenital aortic stenosis: Are evidence-based outcomes relevant?

Brown JW, Rodfeld MD, Ruzmetov M, Eltayeb O, Yurdakok O, Turrentine MW

Ann Thorac Surg 2012;94:146-55.

In this retrospective study from the Indiana University School of Medicine, the authors compare the results of surgical aortic valvuloplasty (SAV) to transcatheter balloon aortic valvuloplasty (BAV) for children with congenital aortic stenosis (AS) who are candidates for a future biventricular repair.

Between December 1990 and November 2010, 89 pediatric patients who had initial SAV were compared with 69 patients receiving percutaneous BAV as the initial intervention. There were no significant differences in age, sex, body surface area, preoperative aortic valve peak gradients, or aortic valve anatomy. There was however, a higher incidence of mild pre-interventional aortic regurgitation (AR) in the BAV group. No patient in either group had moderate or severe AR. Standard surgical or interventional techniques were used in all patients. Follow-up was 93% in the surgical group and 97% in the balloon dilation cohort. For surgical valvuloplasty, the mean follow-up was 8.9 ± 6.5 years (6 months to 20 years, median 10 years). The mean follow-up for the balloon dilation group was significantly shorter at 5.2 ± 2.9 years (2 months to 10 years, median 6 years).

There was 1 early death in the balloon dilation group attributed to pulmonary hypertensive crisis. There were 2 late deaths in the surgical valvuloplasty group, one after 2 years due to unexplained reasons and the other after 4 years following re-operation for AI. Multivariate analysis for the predictors of both early and late death was inconclusive. The peak systolic pressure gradient across the aortic valve after the initial intervention decreased significantly in both groups, but the difference in gradient reduction between the groups was significant at discharge (surgical, 25.0 ± 8.8 mm Hg versus balloon, 49.5 ± 16.0 mm Hg; P < 0.0001). For 45 patients in the surgical group (51%) followed out to 20 years and 43 patients in the balloon group (63%) followed out to only 10 years, the systolic pressure gradient across the aortic valve increased over the follow-up interval and was not significantly different between the groups at the latest follow-up. After BAV, 40% of patients' AR grades progressed (60% progressed to mild from none/trace and 15% progressed from mild to moderate), whereas only 8% had progression in the SAV group. Seventy-five percent of the SAV group patients had none/trivial AR after SAV, with 6% progressing from none/trivial to mild and 2% progressing to moderate AR. The time between the initial procedure and subsequent re-intervention was a mean 8.6 ± 4.9 years (range, 6 months-20 years) in the surgical group and a mean of 2.5 ± 2.5 years (range, 4 months-10 years) in the balloon group (P < 0.0001). Freedom from any re-intervention on aortic valve was 72% in the surgical group and 53% in the balloon group at 10 years (P = 0.02). The time to re-intervention in surgical patients was nearly 4 times longer than for patients who underwent BAV (8.6 ± 4.9 years versus. 2.5 ± 2.5 years; P < 0.001). The authors concluded that BAV yields less gradient reduction, more post procedural AI, and a shorter interval between initial and subsequent re-intervention than does SAV. The limitations of this study are its retrospective nature, differences of era as BAV was introduced later and also the fact that there was a significantly longer follow-up in the surgical group compared to the BAV group.

Pulmonary artery banding as 'open end' palliation of systemic right ventricles: an interim analysis

Cools B, Brown SC, Louw J, Heying R, Meyns B, Gewilling M

Eur J Cardiothorac Surg 2012;41:913-8.

Current surgical strategies to deal with a failing systemic RV consist of anatomical repair (double-switch) and cardiac transplant. Anatomical repair is considered as the 'best' option of palliation provided that the left ventricle (LV) is trained, which is the case in infants and neonates or after PAB in childhood.

Pulmonary artery banding (PAB) has been used as an interim measure either to prevent pulmonary hypertension, stabilize TR or to train the LV. However, the use of a fixed band during childhood may force the physician to proceed to early anatomical repair if the band becomes too tight, even in the presence of good RV function. In this retrospective review from Leuven, Belgium, the authors present their intermediate results and outcome of pulmonary artery banding (PAB) in an open-ended strategy for systemic right ventricles. Patients were banded because of RV dysfunction, hoping that RV function would improve sufficiently to stabilize or improve the patients and to have the LV trained for double-switch operation if required.

Between April 1985 to January 2011, PAB was performed in 20 patients (median age 4.3 years, range: 0.9-14.9 years) who had systemic RV's. The patients were divided into 3 groups: (a) Group 1 (n = 5, RV dysfunction after Senning), (b) Group 2 (n = 6, CTGA with large VSD) and Group 3 (n = 9, asymptomatic cTGA). Early in the series, PAB was performed using standard surgical technique in nine patients. In 11 patients, a dilatable band was placed after late 2004. Except for those with a large VSD, a mild band was placed to accommodate for growth, with the aim to result in subsystemic LV pressures when fully grown. The immediate aim was to achieve a gradient of ~20-40 mmHg without LV dysfunction on transoesophageal echocardiography.

There were no early or late deaths. Median follow-up was 86 months (range: 0.5-379 months). The gradient over the LV outflow tract showed a mild but non-significant increase over time.). RV function and dilation and tricuspid regurgitation showed no significant deterioration during the follow-up period. RV function improved in one patient in Group 1 and one in Group 2. At last follow-up, 90% (18/20) have adequate ongoing palliation with PAB. One patient underwent a double-switch operation and one received an additional bidirectional Glenn shunt. A dilatable band was redilated with improvement in percutaneous saturation and in another the procedure was abandoned due to development of transient atrioventricular block. Functional class remained either unchanged or improved. The authors concluded that the PAB can be performed with no mortality and low morbidity. PAB in these heterogeneous patients provides true 'open ended palliation' by allowing left ventricular training in those going for anatomical repair, stabilizing or improving RV function and TR in others, thereby delaying surgery. It can also be left in place as long-term palliation. The addition of a dilatable band allows manipulation of pulmonary flows, but longer follow-up is required to provide data on best management strategies for these complex patients.

Percutaneous atrial septal occluder devices and cardiac erosion: A review of the literature

Crawford GB, Brindis RG, Krucoff MW, Mansalis BP, Carroll JD

Catheter Cardiovasc Interv 2012 May 2. doi: 10.1002/ccd.24347.

Device closure of Ostium Secundum Atrial Septal defect is well established with infrequent complications. Cardiac erosion is one of the few rare complications which has of late raised concern. Crawford et al. systematically reviewed the literature on cardiac erosion associated with Atrial Septal Defect (ASD) Occluder devices using MEDLINE database. Over a span of ~10 years (March 2002-June 2011) they found 25 articles which reported erosion events associated with the AMPLATZER Septal Occluder (ASO) device. Twenty independent, surgically confirmed cases of erosion and one suspected event have been reported in the literature after percutaneous septal defect closure using the ASO. Additional 79 distinct events were reported in case series and review articles. Few cases (3) of non FDA approved device related aortic erosions were reported. The quality of documentation for these additional cases varied substantially; many were not confirmed surgically or at autopsy. In view of unavailable denominator and numerator (of the number implanted Atrial septal Occluder) the exact incidence of erosion was difficult to calculate. The possible incidence is 0.1-0.3% as reported by the authors. Erosion events associated with the Atrial septal Occluder device have occurred at the roof of the right or left atrium or at the atrial junction with the aorta, causing hemopericardium, tamponade or aortic fistula. The possible causes of erosions were related with factors which increases the chance of contact between the device and the atrial wall like absent or deficient superior-anterior rim, oversizing of device. Erosion was assumed to be related to an abrasive mechanical force between the device and human tissue rather than an inflammatory mediated weakening of the wall. The authors opined about abrasive potential of the ASO device related to the nitinol thread. Some patients might have the susceptibility for getting injury. The examples of possible vulnerable group mentioned are: structural defects (Marfan syndrome), age related changes in tissue composition and thickness, and spatial variations in tissue strength and ability to resist abrasive forces. Over-sizing of the device may lead to contact between the edges of the ASO device and the walls of susceptible tissue of the aorta and roof of the atria. No report of cardiac erosion was found after HELEX Occluder except a case of AML perforation by wire. The authors concluded that the incidence of cardiac erosion after device closure of ASD is a rare but serious complication ascribed to device over-sizing or deficient retro- aortic rims. The consensus and evidence for a cogent risk factor(s) is lacking. The authors felt that we are not making progress in understanding the incidence, cause, and prevention of erosion by the on-going case reports. They mentioned about the limited progress in understanding the context of erosion safety concerns and suggested the need of further studies for the assessment of the root cause of erosion and true incidence of this complication.

Long-term effects of sildenafil in a rat model of chronic mitral regurgitation: Benefits of ventricular remodeling and exercise capacity

Kim KH, Kim YJ, Ohn JH, Yang J, Lee SE, Lee SW, Kim HK, Seo JW, Sohn DW

Circulation 2012;125:1390-401

Medical therapy for chronic mitral regurgitation(MR) is a contentious issue. Presently an effective medical therapy is not available to prevent left ventricular (LV) remodeling and deterioration of exercise capacity and thus delay the need for surgery in case of chronic MR. Sildenafil, a known and established pulmonary vasodilator was investigated for its possible beneficial effects in chronic MR. In this study from Seoul, Korea, the authors have studied the long-term effects of sildenafil in a chronic mitral regurgitation model in rats. The authors tested the hypothesis that chronic treatment with sildenafil attenuates left ventricular (LV) remodeling and prevents exercise intolerance in chronic MR. In an experimental model, MR was created in 11- week old Sprague-Dawley rats by making a hole on the mitral leaflet under the guidance of transesophageal echocardiography using intracradiac echocardiography catheter. Two weeks later, MR and LV dilatation were confirmed by echocardiography, and rats were randomly assigned to sildenafil treatment (MR sildenafil group; 50 mg/kg PO twice a day; n ~ 16) or normal saline only (MR group; n ~ 16) and continued for 4 months. The treatment was continued for 14 weeks. The MR was assessed by an expert echocardiographer. The rats were subjected to treadmill in a rotating drum. Systolic and diastolic blood pressures were measured in conscious rats via the tail-cuff method. After 4 months, LV size was smaller in the MR sildenafil compared with the MR group (LV end-systolic dimension, 4.7 ± 0.3 for sham versus 5.9 ± 0.3 for MR sildenafil versus 7.4 ± 0.5 mm for MR; P < 0.05; LV end-diastolic dimension, 8.3 ± 0.4 versus 10.5 ± 0.2 versus 11.7 ± 0.61 mm, respectively; P < 0.05). LV ejection fraction was greater in the MR sildenafil group than in the MR group (70.2 ± 2.2% for sham versus 67.0 ± 4.2% for MR sildenafil versus 58.9 ± 2.5% for MR; P < 0.01). Serial treadmill test revealed that exercise capacity was reduced in the MR but not in the MR sildenafil group. The histology of the cardiomyocyte and the genetic arrangement of both the rat cohort were also studied in detail. Transcriptional profiling of cardiac apical tissues revealed that gene sets related to inflammatory response, DNA damage response, cell cycle checkpoint, and cellular signaling pathways were significantly enriched by genes with reciprocal changes. Pathological analysis showed that perivascular fibrosis was more prominent in the MR than in the MR sildenafil group and that the percentage of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling-positive cells was 2-fold greater in the MR compared with the MR sildenafil group. The treatment group had significant beneficial effect on MR by attenuation of LV remodeling and prevention of exercise intolerance which was attributed to anti apoptotic, anti-inflammatory effects of sildenafil. The authors concluded that sildenafil significantly attenuated the LV remodeling and prevented exercise intolerance in a rat model of chronic MR. However, the dosages used in this experimental study were inordinately high compared to the clinically used dosages. The authors also cited creation of hole in AML a limitation of the study, as it does not represent exactly the human model of MR.

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

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