Outcomes of surgery for the spectrum of atrioventricular septal defects

© 2019 Dr Edward James BurattoAtrioventricular septal defects (AVSDs) are a spectrum of diseases affecting the atrioventricular septum, junction and valves. Disease severity varies from mild, in the form of partial AVSD, to severe in the form of unbalanced AVSD. Regardless of the severity, all patients require surgery in childhood to improve long-term survival. At each end of the spectrum, research has been relatively limited compared to the amount of attention focused on the commonest form, complete AVSD. Partial AVSD (pAVSD) has been considered a relatively minor defect, often grouped with secundum atrial septal defects, but this ignores the fact that pAVSD shares much of the anatomical complexity of other forms of AVSD. Unbalanced AVSD (uAVSD) is frequently not amenable to complete repair, requiring staged palliation resulting in a Fontan circulation. Early results of palliative strategies in these patients were very poor, and there has been relatively little attention paid to the single ventricle palliation strategy in recent years. This project focuses on these two less studied forms of AVSD, in order to determine current results, and risk factors for poor outcomes. For each condition we have followed the largest series of patients ever reported in the literature, with over 30 years of follow-up. In children with partial AVSD, we have demonstrated that survival is excellent, yet there is a very high rate of reoperation in the long-term. We found that closing the cleft of the left atrioventricular valve (LAVV) improved outcomes, even when that valve was not incompetent. Reoperation in this group was shown to be mostly due to LAVV regurgitation, and we demonstrated that improved rates of repair could be achieved with a novel patch augmentation technique. While some groups have advocated performing repair in infancy, we demonstrated, in a propensity score matched analysis, that better survival was achieved with repair after one year of age. In children with unbalanced AVSD, we found that, although there was a high attrition rate, children who achieved Fontan completion had much better outcomes than previously thought possible. We demonstrated that atrioventricular valve (AVV) regurgitation was a major cause of reoperation and morbidity and that outcomes were very poor in children in whom repair failed. Importantly, we found that mechanical prosthetic replacement may be preferable if an adequate repair cannot be achieved. Finally, we examined the impact of pulmonary artery banding in children with complex AVSD, and demonstrated that it did not worsen AVV regurgitation and allowed the majority of patients to progress to delayed complete repair or Fontan completion

Single vs double antiplatelet therapy in acute coronary syndrome: Predictors of bleeding after coronary artery bypass grafting

To investigate the contribution of anti-platelet therapy and derangements of pre-operative classical coagulation and thromboelastometry parameters to major bleeding post-coronary artery bypass grafting (CABG)

T-Remodeling of the Pulmonary Artery Bifurcation for Pulmonary Artery Origin Stenosis

BACKGROUND: Various surgical techniques are utilized for reconstructing hypoplastic pulmonary arteries (PAs) in patients with conotruncal anomalies and at times, may be susceptible to restenosis and reoperation. We reviewed our experience with a simple technique of T-shaped remodeling of the PA bifurcation. METHODS: Between 2005 and 2019, 31 patients underwent T-remodeling of central PAs by a single cardiac surgeon. The PA bifurcation was opened cranially, and the opening was augmented with an oval-shaped patch effectively transforming the V-shaped bifurcation into a T-shaped bifurcation. Both origins of the PAs were enlarged, even in the instance of single PA origin stenosis. RESULTS: Median age at time of T-remodeling was 17 months (range: 7 weeks to 14 years). The following cardiac morphologies were observed: tetralogy of Fallot (n = 12, 39%), pulmonary atresia with ventricular septal defect (VSD) and major aortopulmonary collateral arteries (n = 8, 26%), truncus arteriosus (n = 6, 19%), pulmonary atresia with VSD (n = 3, 9.7%), and transposition of the great arteries (n = 2, 6.5%). Thirteen patients (42%) had previous central shunt, and eight patients (26%) had previous modified Blalock-Taussig shunt. There were no operative mortalities. Immediately after T-remodeling, echocardiographic estimates of right ventricle to PA gradient decreased from 42 [interquartile range 28-58] mm Hg to 20 [12-36] mm Hg ( = .03). Freedom from reoperation on the PA bifurcation for the entire cohort was 100% at one year, 88% (95% CI 68%-96%) at five years and 82% (57%-93%) at ten years. CONCLUSIONS: T-remodeling for PA origin stenosis is a safe procedure with excellent freedom from reoperation that is easily reproducible and applicable to patients with all cardiac morphologies

Predicting adverse outcomes in elective coronary artery bypass graft surgery using pre-operative troponin I levels

Background: Cardiac troponins are frequently measured as part of the pre-operative work-up of patients prior to coronary artery bypass graft surgery (CABG). The utility of measuring these levels in elective patients, and the clinical implication of an abnormal result are unclear. The following study investigates the relationship between cardiac troponin I (cTnI) measured as part of a routine pre-operative work-up and outcomes following CABG. Methods: From January 2010 to December 2012, 378 patients underwent isolated, elective CABG and had cTnI measured prospectively, as part of their pre-operative work-up. Patients were divided into normal (Group I) and elevated (Group II) cTnI groups. Pre-operative, operative and post-operative data were obtained from our institution's prospectively collected database. Results: Elevated cTnI was present in 47 patients (12.4%) pre-operatively. Intra-operative variables did not differ between the elevated cTnI and control groups. Both 30-day mortality (Group I: 0.9% v Group II: 6.4%, p=0.03) and cardiac arrest (Group I: 1.5% v Group II: 8.5%, p=0.01) were significantly more frequent in the elevated cTnI group. In multivariable analysis, elevated cTnI remained a predictor for cardiac arrest (OR 5.8, 95% CI 1.2 – 29.2). Conclusions: Patients presenting for elective CABG frequently have elevated cTnI on pre-operative work-up. These patients may be at a greater risk of 30-day mortality and cardiac arrest. Routine pre-operative measurement of cTnI may alert clinicians to a higher operative risk