Short-term effect of monocuspid valves on pulmonary insufficiency and clinical outcome after surgical repair of tetralogy of fallot

AbstractIn the surgical repair of tetralogy of Fallot, monocuspid valves are sometimes inserted within a transannular patch to prevent pulmonary insufficiency. To determine whether this monocuspid valve prevents short-term postoperative pulmonary insufficiency and improves clinical outcome, we reviewed clinical data and preoperative and postoperative echocardiographic variables from 61 patients who underwent one of three different procedures for repair of tetralogy of Fallot between August 1992 and March 1994. We compared features from 24 patients who had undergone transannular patch repair with a monocuspid valve (patch-valve) with those from 17 patients who had undergone patch repair without a monocuspid valve (patch) and 20 patients who had undergone repair without a transannular patch (no patch). We used the ratio of pulmonary valve insufficiency jet width to pulmonary artery diameter, as measured by color-flow Doppler flowmetry, as an index of severity of pulmonary insufficiency. Moderate to severe pulmonary insufficiency was arbitrarily defined as a ratio of at least 0.50. We found no significant differences in ratios among the patch-valve group (0.73 ± 0.25, mean ± standard deviation), the patch group (0.79 ± 0.20), and the no patch group (0.59 ± 0.23). The percentages of patients with moderate to severe pulmonary insufficiency did not differ among the three groups (patch-valve 80%, patch 90%, no patch 64%). Clinical data (including mortality, number of reoperations, intensive care unit and hospital lengths of stay, and postoperative hemodynamics) were similar in the three groups. We conclude that insertion of a monocuspid valve in repair of tetralogy of Fallot does not prevent short-term postoperative pulmonary insufficiency and does not improve immediate postoperative outcome for these patients. (J Thorac Cardiovasc Surg 1996;112:33-7

Echocardiographic evaluation of partial anomalous pulmonary venous drainage

AbstractObjectives. This study was undertaken to determine the accuracy of routine echocardiography in the detection of partial anomalous pulmonary venous drainage.Background. Although there are occasional case reports of the echocardiographic appearance of partial anomalous pulmonary venous drainage, no large series have addressed the accuracy of this technique in a large cohort of patients.Methods. Between January 1983 and December 1993, 50 patients with partial anomalous pulmonary venous drainage (with or without an associated atrial septal defect as the only other significant intracardiac defect) were identified from the data base at the Hospital For Sick Children, Toronto. Routine echocardiographic reports were reviewed, and the results were compared with surgical or catheterization findings. Risk factors related to diagnostic errors were sought using a Fisher exact test, chi square analysis, ttest and Kruskal-Wallis analysis of variance.Results. Confirmation of the diagnosis was available in 45 patients whose data were subsequently used for risk factor analysis. The median age at echocardiography was 4.1 years (range 1 month to 18 years). Right-sided drainage was present in 43 patients (86%), with left-sided drainage in 7 (14%). Thirteen patients had an intact atrial septum, 7 a patent foramen ovale and 30 a secundum atrial septal defect. Right ventricular dilation was observed in 46 patients. Two had normal dimensions (two not assessed). The diagnosis was missed by echocardiography in 15 (33%) of the 45 patients with a confirmed diagnosis. Year of study and use of color flow mapping were the only significant variables related to detection rate (7% missed diagnosis with vs. 62% without the use of color flow, p < 0.0005). The median year of missed diagnosis was 1985 versus 1990 (p < 0.002). Transesophageal echocardiography accurately defined the site of drainage in all three patients in whom it was utilized.Conclusions. Two-dimensional echocardiography in conjunction with color flow mapping is a valuable tool for the diagnosis of partial anomalous pulmonary venous drainage

Balloon angioplasty of native coarctation: clinical outcomes and predictors of success

AbstractOBJECTIVESWe sought to investigate the clinical impact of balloon angioplasty for native coarctation of the aorta (CoA) and determine predictors of outcome.BACKGROUNDBalloon dilation of native CoA remains controversial and more information on its long-term impact is required.METHODSHemodynamic, angiographic and follow-up data on 69 children who underwent balloon angioplasty of native CoA between 1988 and 1996 were reviewed. Stretch, recoil and gain of CoA circumference and area were calculated and related to outcomes.RESULTSInitial systolic gradients (mean ± SD, 31 ± 12 mm Hg) fell by −74 ± 27% (p < 0.001), with an increase in mean CoA diameters of 128 ± 128% in the left anterior oblique and 124 ± 87% in the lateral views (p < 0.001). Two deaths occurred, one at the time of the procedure and one 23 months later, both as a result of an associated cardiomyopathy. Seven patients had residual gradients of >20 mm Hg. One patient developed an aneurysm, stable in follow-up, and four patients had mild dilation at the site of the angioplasty. Freedom from reintervention was 90% at one year and 87% at five years with follow-up ranging to 8.5 years. Factors significantly associated with decreased time to reintervention included: a higher gradient before dilation, a smaller percentage change in gradient after dilation, a small transverse arch and a greater stretch and gain, but not recoil.CONCLUSIONBalloon dilation is a safe and efficient treatment of native CoA in children. Greater stretch and gain are factors significantly associated with reintervention, possibly related to altered elastic properties and vessel scarring

Paediatric Obesity Research in Early Childhood and the Primary Care Setting: The TARGet Kids! Research Network

Primary paediatric health care is the foundation for preventative child health. In light of the recent obesity epidemic, paediatricians find themselves at the frontline of identification and management of childhood obesity. However, it is well recognized that evidence based approaches to obesity prevention and subsequent translation of this evidence into practice are critically needed. This paper explores the role of primary care in obesity prevention and introduces a novel application and development of a primary care research network in Canada—TARGet Kids!—to develop and translate an evidence-base on effective screening and prevention of childhood obesity

Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: A Congenital Heart Surgeons Society study

ObjectiveWe sought to determine the prevalence of outcomes and associated patient and management factors for neonates with interrupted aortic arch.MethodsFrom 1987 to 1997, a total of 472 neonates were enrolled prospectively from 33 institutions. Competing risks methodology was used to determine simultaneous risk and associated incremental risk factors for death, initial and subsequent left ventricular outflow tract procedures, and arch reinterventions.ResultsOverall survival was 59% at 16 years after study entry but improved with successive birth cohort. In general, risk factors for death in each of the competing risks analyses included lower birth weight, younger age at study entry, type B interrupted aortic arch, and major associated cardiac anomalies. Of 453 patients who had interrupted aortic arch repair, after 16 years 33% had died and 28% had undergone an arch reintervention. Reintervention was more likely for those who had truncus arteriosus repair, interrupted aortic arch repair by a method other than direct anastomosis with patch augmentation, and the use of polytetrafluoroethylene as either an interposition graft or a patch. From study entry, competing risks after 16 years showed that 28% had died and 34% had undergone an initial left ventricular outflow tract procedure. Initial left ventricular outflow tract procedure was more likely for those with single ventricle, type B interrupted aortic arch, bicuspid aortic valve, or anomalous right subclavian artery. Among those who had undergone an initial left ventricular outflow tract procedure, after 16 years 37% had died and 28% had undergone a second procedure.ConclusionAnatomic features affect mortality and initial left ventricular outflow tract procedures, whereas characteristics of the arch repair affect arch reintervention

Kawasaki Disease Shock Syndrome vs Classical Kawasaki Disease: A Meta-analysis and Comparison With SARS-CoV-2 Multisystem Inflammatory Syndrome.

BACKGROUND: The emergence of increasing reports worldwide of a severe inflammatory process and shock in pediatric patients resembling Kawasaki disease (KD) and more specifically Kawasaki disease shock syndrome (KDSS), prompted us to explore KDSS in a preamble of a systematic comparison between the two conditions. METHODS: We completed a systematic review of KDSS and performed a meta-analysis comparison between reported KDSS cases and KD controls. RESULTS: A total of ten case-control series were included in the meta-analysis. KDSS patients were older (38.4 ± 30.6 vs. 21.9±19.5 months; P<0.001) compared to standard KD with equal sex distribution and completeness of clinical diagnostic criteria. KDSS present higher CRP (59.4±29.2 mg/dL vs. 20.8±14.8 mg/dL; p<0.001), lower albumin (2.7±0.5 g/dL vs. 3.3±0.5 g/dL; p<0.01), and lower platelets (255±149 109/L vs. 394±132 109/L; p<0.001) but only borderline higher WBC's (p=0.06). Differences in ALT, AST and ESR were non-significant. The odds of IVIG resistance (44.4% vs. 9.6%; (p<0.001) and the hospital length of stay (10.9±5.8 vs. 5.0±3.0 days; p<0.001) were higher in KDSS as were the odds of coronary artery abnormalities (33.9% vs. 8.6%; p<0.001). CONCLUSION: This first meta-analysis on KDSS versus KD represents a basis for future works on KDSS and opens the opportunity for future multicenter studies in the search of causal relationships between presenting elements and the eventual complications of KDSS. The similarities between SARS-CoV-2 multisystem inflammatory syndrome in children (MIS-C) and KDSS open new horizons to the understanding of the etiology and pathophysiology related to KDSS

Foetal echocardiographic assessment of borderline small left ventricles can predict the need for postnatal intervention

Abstract Background We sought to prospectively determine foetal echocardiographic factors associated with neonatal interventions in borderline hypoplastic left ventricles. Methods Foetuses were included who had a left ventricle that was 2-4 standard deviations below normal for length or diameter and had forward flow across the mitral and aortic valves. Factors associated with an intervention in the first month of life or no need for intervention were sought using univariate and multivariate logistic regression models. Results From 2005 to 2008, 47 foetuses meeting the criteria had an additional diagnosis (+foetal coarctation/+transverse arch hypoplasia): atrioventricular septal defect 7 (+2/+0), double outlet right ventricle 2 (+0/+0), Shone's complex 19 (+9/+4), and ventricular disproportion 19 (+13/+11; 4 both). There were seven pregnancies terminated, three foetal demises, and five had compassionate care. There were 32 livebirths that either had a biventricular repair (n = 20, n = 2 dead), univentricular palliation (n = 2, both alive), or no intervention (n = 9). Overall survival of livebirths to 6 months of age was 79%. Factors associated with early intervention on first foetal echocardiogram were: obstructed or retrograde arch flow (p = 0.08, odds ratio 3.3), coarctation (p = 0.05, odds ratio 11.4), and left ventricle outflow obstruction (p = 0.05, odds ratio 12.5). Neonatal factors included: Shone's diagnosis (p = 0.02, odds ratio 4.9), bicuspid aortic valve (p = 0.005, odds ratio 11.7), and larger tricuspid valve z-score (p = 0.05, odds ratio 3.6). A neonatal factor associated with no intervention was a larger mitral valve z-score (mean −3.8 versus −4.2 intervention group, p = 0.04, odds ratio 2.8). Discussion The need for early intervention in foetuses with borderline hypoplastic left ventricle can be predicted by foetal echocardiograph

Case complexity scores in congenital heart surgery: A comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system

ObjectiveThe Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery system were developed by consensus to compare outcomes of congenital cardiac surgery. We compared the predictive value of the 2 systems.MethodsOf all index congenital cardiac operations at our institution from 1982 to 2004 (n = 13,675), we were able to assign an Aristotle Basic Complexity score, a Risk Adjustment in Congenital Heart Surgery score, and both scores to 13,138 (96%), 11,533 (84%), and 11,438 (84%) operations, respectively. Models of in-hospital mortality and length of stay were generated for Aristotle Basic Complexity and Risk Adjustment in Congenital Heart Surgery using an identical data set in which both Aristotle Basic Complexity and Risk Adjustment in Congenital Heart Surgery scores were assigned. The likelihood ratio test for nested models and paired concordance statistics were used.ResultsAfter adjustment for year of operation, the odds ratios for Aristotle Basic Complexity score 3 versus 6, 9 versus 6, 12 versus 6, and 15 versus 6 were 0.29, 2.22, 7.62, and 26.54 (P < .0001). Similarly, odds ratios for Risk Adjustment in Congenital Heart Surgery categories 1 versus 2, 3 versus 2, 4 versus 2, and 5/6 versus 2 were 0.23, 1.98, 5.80, and 20.71 (P < .0001). Risk Adjustment in Congenital Heart Surgery added significant predictive value over Aristotle Basic Complexity (likelihood ratio χ2 = 162, P < .0001), whereas Aristotle Basic Complexity contributed much less predictive value over Risk Adjustment in Congenital Heart Surgery (likelihood ratio χ2 = 13.4, P = .009). Neither system fully adjusted for the child’s age. The Risk Adjustment in Congenital Heart Surgery scores were more concordant with length of stay compared with Aristotle Basic Complexity scores (P < .0001).ConclusionsThe predictive value of Risk Adjustment in Congenital Heart Surgery is higher than that of Aristotle Basic Complexity. The use of Aristotle Basic Complexity or Risk Adjustment in Congenital Heart Surgery as risk stratification and trending tools to monitor outcomes over time and to guide risk-adjusted comparisons may be valuable