Congenital Heart Surgery

Post-Fontan pulmonary artery growth in patients with a bidirectional cavopulmonary shunt with additional antegrade pulsatile blood flow

Post-Fontan pulmonary artery growth in patients with a bidirectional cavopulmonary shunt with additional antegrade pulsatile blood flow. Ferns SJ, Zein CE, Subramanian S, Husayni T, Ilbawi MN.Asian Cardiovasc Thorac Ann. 2020 Dec 25:218492320984095. doi: 10.1177/0218492320984095. Online ahead of print.PMID: 33356352   Take Home Points: The additional pulmonary flow in BCPS physiology facilitates the PA growth between Stage 2 and 3. PA growth are also shown after Fontan operation even if the additional flow was eliminated. No adverse effects, such as decreased ventricular function due to volume overload was shown even after Fontan operation. Commentary from Dr. Yasuhiro Kotani (Okayama, Japan), section editor of Congenital Heart Surgery Journal Watch:   Summary: Ferns and colleagues investigated the long-term effect of the additional antegrade pulmonary flow in 212 patients undergoing Fontan operation. The patients were divided into 2 groups based on the presence of additional flow (Pulsatile group (N=33) and Non-pulsatile group (N=70)). The key finding was that patients with an additional flow had a significant increase in PA size before Fontan and this continued after Fontan operation even eliminated an antegrade flow. They also showed an equivalent outcome between the groups, regarding with ventricular function, AVVR, and other complications.   Significance: It is still unclear that how the additional pulmonary flow affects PA growth between stage 2 and 3. This study clearly showed that Nakata index, i.e., PA size significantly increased in patients with an additional flow.   Comment: Previous reports describe both advantages and disadvantages of having the additional flow in BCPS. Advantages include better oxygen saturations, improved PA growth, and prevention of pulmonary arteriovenous malformations. Downsides include an elevated BCPS pressure and an increased ventricular volume overload. This study demonstrated the better PA growth even after Fontan operation and no adverse effects, such as impaired ventricular function was noted. However, it is important to know that the proportion of having HLHS in Non-pulsatile Group is much higher. In generally, patients with HLHS tends to have a smaller PA and a decreased ventricular function with significant AVVR, indicating this result should be carefully interpreted. Pulsatile Groups included more standard risk patients who are not likely to develop ventricular dysfunction and late complications and this may have affected the result of this study. An additional flow may not be a good option in patients with an impaired ventricular function, even non-HLHS. Therefore, indication of additional flow should be carefully considered in the group of single ventricle as they have a wide variety of anatomy and physiology and behave differently.   

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Impact of early Coronavirus Disease 2019 pandemic on pediatric cardiac surgery in China

Impact of early Coronavirus Disease 2019 pandemic on pediatric cardiac surgery in China. Shi G, Huang J, Pi M, Chen X, Li X, Ding Y, Zhang H; National Association of Pediatric Cardiology and Cardiac Surgery Working Group. J Thorac Cardiovasc Surg. 2020 Dec 1:S0022-5223(20)33146-9. doi: 10.1016/j.jtcvs.2020.11.074. Online ahead of print. PMID: 33419537   Take Home Message: The COVID 19 pandemic has decreased overall congenital surgical volume. There is an increased proportion of emergent and urgent operations (change in case-mix). Travel restrictions may affect access to congenital cardiac surgical care. Commentary from Dr. Luis Quinonez (Boston, MA, USA), section editor of Congenital Heart Surgery Journal Watch:   Summary: The objective of the study was to evaluate the impact of COVID-19 outbreak on the 1) congenital heart surgery programs and 2) the outcomes of patients with repaired lesions. This is a multicenter observational cohort study of 13 pediatric congenital heart disease surgical centers in China. The surgical cohort was divided into 3 groups: January to April 2018, 2019, and 2020 (COVID-19 era surgery). The follow-up cohort, was similarly divided: September to December 2017, 2018, and September 2019 to January 2020 (COVID-19 era follow-up). The authors used a daily migration scale index (MSI) to evaluate travel.   Overall surgical volume was decreased. The decrease in surgical volume did not correlate with the number of COVID-19 cases regionally or in each center, but was correlated with decreased MSI. In the surgical cohort, the proportions of symptomatic and emergent operations increased, while elective asymptomatic cases were not done during COVID-19 era. Nevertheless, mortality and need for ECMO was not affected. In the follow-up cohort, more patients received telephone or on-line follow-up during the COVID-19 era. The probability of death and unplanned admission was similar in the follow-up groups. Anxiety was greater in the COVID-19 era follow-up cohort.   The following graphic from the paper summarizes the main findings:     Comment: This is an interesting study that confirms what most of us perceive the impact of COVID-19 pandemic to be on congenital cardiac surgical care. The need to reallocate or restrict resources has led to decreased overall volume and prioritization of emergent, urgent and symptomatic cases. Despite this, outcomes seemed to have remained the same, as best as we can tell. However, the group that has not yet received attention is the asymptomatic, non-urgent, non-emergent cases. Will there be a negative impact on the outcomes of these patients when they eventually come to treatment? How about the patients that were unable to access care due to travel restrictions? The other group of patients that are vulnerable are those with virtual follow-up. It is unknown whether missed progression of disease will be important when physical examination could not be performed. It will take years before we can determine the true impact of the COVID-19 pandemic on our patients. We currently tend to focus on the sicker patients, but there is a greater number of “well” patients at risk.   

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Mitral Valve Repair in Children Below Age 10 Years: Trouble or Success?

Mitral Valve Repair in Children Below Age 10 Years: Trouble or Success? Mayr B, Vitanova K, Burri M, Lang N, Goppel G, Voss B, Lange R, Cleuziou J.Ann Thorac Surg. 2020 Dec;110(6):2082-2087. doi: 10.1016/j.athoracsur.2020.02.057. Epub 2020 Mar 30.PMID: 32240647   Take Home Message: Mitral valve conditions requiring surgical management before the age of 10 years are rare. Mortality associated with surgical management of these patients is not small. Even if the need for reoperation and valvular replacement is relatively high, most patients still benefit from surgical repair and attempting so is worth it.   Commentary from Dr. Frederic Jacques (Quebec City, QC, Canada), chief section editor of Congenital Heart Surgery Journal Watch:   In the December 2020 issue of Annals of Thoracic Surgery, Mayr et al. report on 50 patients who had surgical repair of their mitral valve before the age of 10 years from 1975 to 2017. Forty patients had congenital problems, while 10 other patients had acquired disease. The authors specifically looked at survival and cumulative incidence of reoperation. The median age at surgical repair was 1.2 years and 1.9 years for congenital and acquired conditions, respectively. Most patients had regurgitation. The mortality for congenital conditions was significant with an immediate operative mortality of 5% and a late mortality of another 10%. No death occurred for acquired problems. Among congenital patients, those experiencing regurgitation had a better outcome, compared to stenosis. At a 6-years follow-up, congenital patients had close to 40% need for reoperation. Ultimately, 10% of patients with initial repair required a synthetic prosthesis. Among the 20% who required a second surgical repair of the mitral valve, 50% ended up with a prosthesis.   This paper reminds us how rare and difficult to deal with are mitral valve problems in children before the age of 10. It shows how risky are these operations, however it is important to acknowledge that valvular surgical repair techniques have significantly changed (likely improved) over the course of the study period. Even though the risk of mortality, the need for reoperation and the need for prosthetic valvular replacement is not dismal, it is important to realize that 90% of these patients can be repaired with a sustainable result. Looking at this paper, pediatric cardiologists and surgeons should be encouraged to make every effort to keep the native valve whenever possible. Expectations of repair should also acknowledge how difficult this problem is, especially for congenital patients. The development of better surgical prosthesis both biological (see Emani et al.) and mechanical (see Ijsselhof et al., Annals of Thoracic Surgery, December 2020) will also improve the overall outcomes for these challenging patients.   

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