Atrioventricular Valve Surgery Research Articles

Atrioventricular valve surgery in patients with univentricular heart and two separate atrioventricular valves.

Atrioventricular valve regurgitation in patients with univentricular heart is a well-known risk factor for adverse outcomes and atrioventricular valve repair remains a particular surgical challenge. We reviewed all surgical atrioventricular valve procedures in patients with univentricular heart and two separate atrioventricular valves who underwent surgical palliation. Endpoints of the study were reoperation-free survival and cumulative incidence of reoperation. Between 1994 and 2021, 202 patients with univentricular heart and two separate atrioventricular valve morphology underwent surgical palliation, with 15.8% (32/202) requiring atrioventricular valve surgery. Primary diagnoses were double inlet left ventricle (n = 14, 43.8%), double outlet right ventricle (n = 7, 21.9%), and congenitally corrected transposition of the great arteries (n = 7, 21.9%). Median weight at valve surgery was 10.6 kg (interquartile range, 7.9-18.9). Isolated left or right atrioventricular valve surgery was required in nine (28.1%) and 22 patients (68.8%), respectively. Concomitant left and right atrioventricular valve surgery was performed in one patient (3.1%). Closure of the left valve was conducted in four patients (12.5%) and closure of the right valve in three (9.4%). Operative and late mortality were 3.1% and 9.7%, respectively. Reoperation-free survival and cumulative incidence of reoperation at 10 years after surgery were 62.3% (standard error of the mean: 6.9) and 30.9% (standard error of the mean: 9.6), respectively. In patients with univentricular heart and two separate atrioventricular valves, surgical intervention on these valves is required in a minority of patients and is associated with low mortality but high incidence of reoperation.

Systemic Atrioventricular Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Vessels.

Limited data exist regarding the long-term outcomes of systemic atrioventricular valve (SAVV) intervention (morphologic tricuspid valve) in congenitally corrected transposition (ccTGA). The goal of this study was to evaluate the mid- and long-term outcomes of SAVV surgery in ccTGA. We performed a retrospective review of 108 ccTGA patients undergoing SAVV surgery from 1979 to 2022. The primary outcome was a composite endpoint of mortality, cardiac transplantation, or ventricular assist device implantation. The secondary outcome was long-term systemic right ventricular ejection fraction (SVEF). Cox proportional hazard and linear regression models were used to analyze survival and late SVEF data. The median age at surgery was 39.5 years (Q1-Q3: 28.8-51.0 years), and the median preoperative SVEF was 39% (Q1-Q3: 33.2%-45.0%). Intrinsic valve abnormality was the most common mechanism of SAVV regurgitation (76.9%). There was 1 early postoperative mortality (0.9%). Postoperative complete heart block occurred in 20 patients (18.5%). The actuarial 5-, 10-, and 20-year freedom from death or transplantation was 92.4%, 79.1%, and 62.9%. The 10- and 20-year freedom from valve reoperation was 100% and 93% for mechanical prosthesis compared with 56.6% and 15.7% for bioprosthesis (P< 0.0001). Predictors of postoperative mortality were age at operation (P=0.01) and preoperative SVEF (P=0.04). Preoperative SVEF (P< 0.001), complex ccTGA (P=0.02), severe SAVV regurgitation (P=0.04), and preoperative creatinine (P=0.003) were predictors of late postoperative SVEF. SAVV surgery remains a valuable option for the treatment of patients with ccTGA, with low early mortality and satisfactory long-term outcomes, particularly in those with SVEF≥40%. Timely referral and accurate patient selection are the keys to better long-term outcomes.

Invited commentary to: Long-term follow-up of atrioventricular valve function in Fontan patients: effect of atrioventricular valve surgery.

Invited commentary to: Long-term follow-up of atrioventricular valve function in Fontan patients: effect of atrioventricular valve surgery.

Catheter-based serratus anterior plane block vs. continuous wound infiltration for postoperative pain control following minimally invasive atrioventricular valve surgery : a randomized, prospective trial

Background: Minimally invasive cardiac surgery via mini-thoracotomy reduces surgical trauma compared to full sternotomy. However, thoracotomy can cause severe postoperative pain. Managing postoperative pain is challenging but critical for fast rehabilitation and avoidance of chronic pain. Our objective was to compare the efficacy of analgesia of a bolus in combination with continuous local anaesthetics using a serratus anterior plane block (SAPB) catheter versus a wound infiltration catheter (CWI) in patients after minimally invasive cardiac surgery. Design and setting: We conducted a monocentric, prospective, randomized controlled trial between January 2021 and August 2022. The study was performed at Ghent University Hospital, Belgium. Methods: Patients scheduled for minimally invasive cardiac surgery via thoracoscopy and mini-thoracotomy were randomized to receive either a SABP or a CWI catheter. Postoperatively, continuous ropivacaine 0.2% was started at 10ml/h, and a supplementary bolus of 30ml ropivacaine 0.5% was administered one hour before detubation. The catheter remained in place for at least 24 hours. The primary endpoint was opioid consumption during the first 48 hours postdetubation. Secondary endpoints were anti-emetic consumption, Numerical Analogue Score for 48 hours, length of stay in the Intensive Care Unit and hospital, and incidence of chronic pain. Qualitative data were compared using the Chi – Square test, quantitative data were analyzed with the Student’s t-test. Results: During the study period, a total of 21 patients received a SAPB catheter and 26 patients received a CWI catheter. No statistical significant differences were seen in baseline characteristics. In the first 48 hours postdetubation, morphine equivalent consumption was similar in both groups (p= 0.52), with no differences observed in the early, mid- or late postoperative phases. The total morphine equivalent dose was 21.8 mg in the SAPB and 18.6 mg in the CWI group. There were no significant differences in postoperative vomiting and nausea, length of stay in the Intensive Care Unit and in the hospital and chronic thoracic pain (23% and 33% for the SAPB and CWI group, respectively, p=0.54). Conclusion: This prospective study found no significant difference in postoperative opioid consumption between patients who received a serratus anterior plane block catheter and those who received a wound catheter with bolus and continuous ropivacaine, following minimally invasive cardiac surgery via right thoracoscopy and mini-thoracotomy.

Long-term follow-up of atrioventricular valve function in Fontan patients: effect of atrioventricular valve surgery.

The aim of this study was to evaluate the relationship between atrioventricular valve and ventricular function in Fontan survivors, including the effect of atrioventricular valve surgery. Analysis focused on transplant-free survival and the need for atrioventricular valve surgery in single ventricle patients after Fontan completion. Longitudinal echocardiographic examination of long-term valve and ventricular function was performed. Fontan completion was performed in 113 patients, having a right univentricular morphology in 33.6%, a left ventricle morphology in 62.8% and ambiguous in 3.6%. Perioperative mortality was 2.7% (n = 3). Within a median follow-up of 16.3 years (interquartile range 10.6-23.6), transplant-free survival was 96.1 ± 1.9% and 90.4 ± 5.8% at 10-25 years. Twenty AV valve procedures were performed in 14 (12.4%) children, respectively, pre-Fontan (n = 10), per-Fontan (n = 8) and post-Fontan (n = 2), resulting in a cumulative incidence of AV valve surgery is 5.7 ± 2.2% and 12.3 ± 3.2% at 1-5 years. Atrio-ventricular valve function deteriorated over time [hazard ratio (HR) 1.112, 95% confidence interval (CI) 1.089-1.138, P < 0.001], without difference for valve morphology (P = 0.736) or ventricular dominance (P = 0.484). AV valve dysfunction was greater in patients requiring AV valve surgery (HR 20.383, 95% CI 6.223-36.762, P < 0.001) but showed a comparable evolution since repair to those without valve surgery (HR 1.070, 95% CI 0.987-1.160, P = 0.099). Progressive time-related ventricular dysfunction was observed (HR 1.141, 95% CI 1.097-1.182, P < 0.001), significantly less in left ventricle-dominance (HR 0.927, 95% CI 0.860-0.999, P = 0.047) but more after AV valve surgery (HR 1.103, 95% CI 1.014-1.167, P = 0.022). In a homogeneously treated Fontan population, 25-year transplant-free survival is encouraging. Atrio-ventricular valve surgery was necessary in 12.4%, resulting mostly in a durable valve function. However, a slow time-related decline of atrioventricular valve function as of ventricular function is worrisome, evoking a role for additional heart failure therapy.

Surgical Considerations for the Mitral Valve in Congenitally Corrected Transposition

BackgroundSystemic atrioventricular valve (morphologic tricuspid valve [TV]) regurgitation has been implicated in the development of systemic ventricular failure in congenitally corrected transposition of the great arteries (ccTGA), leading to timely referral for valve replacement. However, the surgical management of subpulmonary atrioventricular valve (morphologic mitral valve [MV]) regurgitation and outcomes has not been well studied. MethodsOf 108 ccTGA patients undergoing atrioventricular valve surgery from 1979 to 2022, 22 patients (20%) underwent MV surgery. Demographics, etiology of valve regurgitation, operative details, and outcomes of these 22 patients were retrospectively reviewed. Follow-up at 1, 5, and 10 years was available for 18 (82%), 13 (59%), and 11 patients (50%), respectively. ResultsMedian age was 37 years (interquartile range, 29-57 years). Intrinsic MV pathology was present in 18 individuals (82%). Operations included repair in 16 patients (73%), replacement in 6 (27%), and concomitant replacement of TV in 16 (73%). There was 1 perioperative death (5%) in a patient undergoing an emergent operation for severe acute-on-chronic heart failure due to worsening TV regurgitation. During a median follow-up of 12 years (interquartile range, 2-19 years), 7 patients (32%) died. Among the 16 patients who underwent repair, recurrent moderate or greater regurgitation was seen in 15%, 29%, and 43% of repairs in patients with annular, leaflet, and lead-induced regurgitation, respectively. ConclusionsConcomitant TV and MV disease occur much less frequently than isolated TV disease in ccTGA. Intrinsic MV disease is most commonly observed but appears less amenable to successful repair compared with mitral repair in the systemic position and suggests MV replacement may be preferred in ccTGA patients.

Technical aspects and outcomes of using homografts in atrioventricular valve surgery: a systematic review

Objective: To summarize and critically appraise the world experience with homografts in mitral and tricuspid valve surgery.Methods: We conducted a systematic review according to the PRISMA criteria. We searched the following terms in available databases, such as PubMed (National Center for Biotechnology Information), Cochrane Library, Web of Science (Clarivate), and Google Scholar: ((mitral homograft) OR (tricuspid homograft) OR (homograft) AND (valve replacement) OR (valve repair)).Results: We recruited 3 specialists to search the information matching our inclusion and exclusion criteria and selected 23 publications covering the period 1988-2021 for analysis. The mean follow-up period was 15 [6-60] months. Survival at the end of the follow-up period was 100% [90.7%-100.0%]; freedom from graft dysfunction was 100%, and freedom from reoperation was 100% [79%-100%].Conclusion: The world experience with homografts in atrioventricular valve surgery is limited to small case series with inconclusive surgical aspects and a heterogeneous follow-up period. The immediate results suggest that homografts could be used as an alternative valve substitute for a wide spectrum of diseases both in primary and revision surgery. Received 19 April 2023. Revised 14 May 2023. Accepted 15 May 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: M.D. Nuzhdin, R.N. KomarovData collection and analysis: M.D. Nuzhdin, D.A. Matsuganov, I.Yu. Melnikov, A.V. TsaregorodtsevStatistical analysis: D.A. MatsuganovDrafting the article: M.D. NuzhdinCritical revision of the article: R.N. Komarov, M.D. NuzhdinFinal approval of the version to be published: M.D. Nuzhdin, R.N. Komarov, D.A. Matsuganov, I.Yu. Melnikov, A.V. Tsaregorodtsev

Anterior Pathway for Epicardial Left Atrial Appendage Clip Occlusion During Minimally Invasive Atrioventricular Valve Surgery.

The left atrial appendage occlusion (LAAO) by endocardial suture is sometimes inadequate and thrombogenic with uncertain electrical competence. Moreover, epicardial LAAO clip placement through the transverse sinus can be technically challenging during minimally invasive atrioventricular valve surgery. Here, we describe our new endoscopic technique via an anterior access pathway in 5 patients with concomitant atrial fibrillation using an epicardial clip device (AtriClip Pro 1 or AtriClip Pro 2, AtriCure, Mason, OH, USA) for LAAO. The LAAO was successful in all patients without residual perfusion and surgical complications. Epicardial LAAO by clip via the anterior access pathway represents a novel and feasible endoscopic technique for minimally invasive atrioventricular valve surgery.

Long-Term Outcomes of Cardiovascular Operations in Children With Connective Tissue Disorders

Connective tissue disorders can be associated with significant cardiovascular morbidity needing cardiac surgery during childhood. In this retrospective study, we used the Pediatric Cardiac Care Consortium, a multicenter United States-based registry of pediatric cardiac interventions, to describe the long-term outcomes of patients who underwent their first surgery for connective tissue-related cardiovascular conditions aged <21 years. Between 1982 and 2003, a total of 103 patients were enrolled who underwent cardiac surgery for a connective tissue-related cardiovascular disorder, including 3 severe infantile cases operated on within the first year of life. Most patients underwent aortic site surgery (n = 85) as a composite graft (n = 50), valve-sparing (n = 33), or other aortic surgery (n = 2). The remaining patients underwent atrioventricular valve surgery (mitral 17, tricuspid 1). Of the 99 patients surviving to discharge, 80 (including the 3 infantile) had adequate identifiers for tracking long-term outcomes through 2019 through linkage with the National Death Index and the Organ Procurement. Over a median period of 19.5 years (interquartile range 16.0 to 23.1), 29 deaths and 1 transplant occurred in the noninfantile group, whereas all 3 infantile patients died before the age of 4 years. The postdischarge survival for the noninfantile group was 92.2%, 68.2%, and 56.7% at 10, 20, and 25 years, respectively. Cardiovascular-related pathology contributed to all deaths in the infantile and 89% (n = 27) of deaths for the noninfantile cases after hospital discharge. The significant late attrition from cardiovascular causes emphasizes the need for close monitoring and ongoing management in this population.

Impact of hypoxemia and re-interventions on clinical outcomes after bidirectional cavopulmonary shunt.

We sought to investigate the impact of early postoperative low arterial oxygen saturation on mortality and morbidity after bidirectional cavopulmonary shunt (BCPS). The medical records of all patients who underwent BCPS between 2013 and 2018 were reviewed. A total of 164 patients were included in this study. Forty-seven patients underwent reintervention during hospital stay at median 7 days after BCPS. Before reintervention, 30 patients were intubated or had SpO2 of <75%. All re-interventions for Glenn pathway obstruction and 4 out of 5 venovenous coil embolization resulted in hospital discharge, while high mortality was observed after other re-interventions (atrioventricular valve surgery, thrombolysis, systemic ventricular outflow obstruction relief, extracorporeal membrane oxygenation implantation and diaphragmatic plication). Additional aortopulmonary shunt with pulmonary artery discontinuation was performed in 8 patients who showed severe cyanosis with median SpO2 of 59% under maximal ventilation support. In the univariable Cox regression analysis, the associated factors for mortality before total cavopulmonary connection were reduced ventricular function [hazard ratio (HR) 6.89, 95% confidence interval (CI) 1.76-26.9, P-value 0.006], greater than moderate atrioventricular valve regurgitation (HR 5.89, 95% CI 1.70-20.4, P-value 0.005), SpO2 1 h after extubation (HR 0.87, 95% CI 0.80-0.96, P-value 0.004) and mean pulmonary artery pressure 1 h after extubation (HR 1.14, 95% CI 1.02-1.26, P-value 0.016). After BCPS, unacceptable cyanosis persisted with various aetiologies. Low arterial oxygen saturation within 1 h after extubation is significantly associated with high mortality after BCPS.

Atrioventricular septal defect in Fontan circulation: Right ventricular dominance, not valve surgery, adversely affects survival

ObjectiveThe effect of ventricular dominance and previous atrioventricular valve (AVV) surgery on patient outcomes after Fontan operation remains unclear. We sought to determine the effect of ventricular dominance and previous AVV surgery on transplantation-free survival and long-term AVV competency in patients with atrioventricular septal defect (AVSD) and Fontan circulation. MethodsWe conducted a retrospective study of 1703 patients in the Australia and New Zealand Fontan Registry, who survived Fontan operation between 1987 and 2021. ResultsOf 174 patients with AVSD, 60% (105/174) had right ventricular (RV) dominance and 40% (69/174) had left ventricular (LV) dominance. The cumulative incidence of moderate or greater AVV regurgitation at 25 years after Fontan operation in patients with LV dominance was 56% (95% CI, 35%-72%), compared with 54% (95% CI, 40%-67%) in patients with RV dominance (P = .6). Nonetheless, transplantation-free survival at 25 years in patients with LV dominance was 94% (95% CI, 86%-100%), compared with 67% (95% CI, 52%-87%) in patients with RV dominance (hazard ratio, 5.9; 95% CI, 1.4-25.4; P < .01). Of note, transplantation-free survival was not different in patients who underwent AVV surgery before or at Fontan completion compared with those who did not (15 years: 81% [95% CI, 62%-100%] vs 88% [95% CI, 81%-95%]; P = .3). ConclusionsIn patients with AVSD and Fontan circulation the rate of moderate or greater common AVV regurgitation is similar in those with LV and RV dominance. RV dominance, rather than previous AVV surgery, is a risk factor for death or transplantation.

Relationships between coronary arteries and atrioventricular annuli: surgical and percutaneous implications.

Atrioventricular valve surgery poses a risk of myocardial infarction due to the proximity of the coronary arteries. Percutaneous techniques also present a risk of coronary injury. Our objective was to identify, on the mitral and the tricuspid annuli, the zones of high risk given their proximity to the circumflex artery and the right coronary artery, respectively. We dissected the courses of the circumflex artery and the right coronary artery in 25 explanted hearts. The distances were measured at reference points according to a clock-face model. Proximity was "very high", "high", or "relative" for distances of less than 5mm, between 5 and 10mm, or more than 10mm, respectively. The mitral annulus zone of "high" proximity was located between "7:30" and "10:00" (minimum 6.5mm at "9:30"). The tricuspid annulus zone of "very high" proximity was located between "1:30" and "3:00" (minimum 4.0mm at "2:00"). The circumflex artery seemed closer to the mitral annulus in the hearts with left coronary dominance (n = 2), emphasizing the importance of the preoperative coronary angiography. Zones at risk of coronary damage were identified on the mitral and the tricuspid annuli between "7:30" and "10:00", and between "1:30" and "3:00", respectively. Knowing them can help interventionists avoid ischemic complications. Based on an innovative clock-face orientation scheme in which the distance data were collected at multiple reference points on a superimposed template, our study provides an intuitive and detailed overview of the critical distances between valves and arteries.

Long-Term Outcomes of Atrioventricular Valve Surgery in Patients with Functional Single Ventricle: Should We Avoid Valve Replacement?

Atrioventricular valve regurgitation (AVVR) is associated with increased morbidity and mortality in patients with single ventricle physiology. The purpose of this study was to evaluate the long-term results of the surgical management of AVVR and to analyze the effects of AV valve replacement. The medical records of 38 single ventricle patients who underwent atrioventricular valve surgery more than once between January 2001 and March 2018 were retrospectively reviewed. We analyzed and compared clinical data of patients who underwent valve replacement as an initial treatment (n = 8) for AVVR with patients who initially underwent valve repair (n = 30). The median follow-up duration was 98.1months (range, 0.9-209.6months). There was one early mortality and seven late mortalities. Freedom from reoperation between the two groups at 15years of follow-up was significantly different: 18.3% in the repair group and 100% in the replacement group (p = 0.013). The replacement group showed a better overall survival rate (100%) at 15years than the repair group (68.5%) without statistical significance (p = 0.097). All mortalities occurred in the repair group. Nine patients in the repair group (30%) and one patient in the replacement group (12.5%) showed preoperative ventricular dysfunction. RV-type single ventricle with atrioventricular (AV) valve annular dilatation was found out as a risk factor of AVV replacement both in univariate (p = 0.04) and multivariate (p = 0.004) analysis. AV valve replacement might be considered as a primary treatment option for patients who have an annular dilation with an RV-type single ventricle rather than repeated valvuloplasty.

Common atrioventricular valve surgery in children with functional single ventricle.

A common atrioventricular valve (CAVV) is considered to be a risk factor for early and late deaths in patients with functional single ventricle (FSV). CAVV surgery in patients with FSV is challenging and there is limited knowledge of the outcomes of CAVV repair with univentricular physiology. We reviewed all CAVV surgical procedures in patients with FSV who underwent univentricular palliation. End points of the study were survival after CAVV surgery and cumulative incidence of reoperation. Between 1984 and 2019, 66 children with CAVV and FSV underwent single-ventricle palliation, of whom 45.5% (30/66) required CAVV surgery. Indication for surgery was moderate CAVV regurgitation in 40% (12/30) and severe CAVV regurgitation in 60% (18/30). CAVV repair was performed in 93.3% (28/30) and CAVV replacement in 6.7% (2/30). The median age and weight at surgery were 0.9 years (interquartile range 0.3-1.8) and 6.5 kg (interquartile range 3.9-8.7), respectively. Operative and late mortality were 23.3% and 8.7%, respectively. Survival and cumulative incidence of reoperation at 4 years after CAVV surgery were 68.9% [standard deviation (SD): 8.7] and 35.8% (SD: 9.1), respectively. Fontan completion was achieved in 60% (18/30). Survival at 4 years after birth was 69.7% (SD: 8.5) in 30 patients with CAVV surgery, whereas it was 83% (SD: 6.3) in 36 patients without CAVV surgery (P = 0.32). CAVV surgery in patients with FSV is associated with substantial mortality and a high incidence of reoperation.

Risk factors for Takotsubo syndrome following cardiac surgery: A case-control study.

Takotsubo syndrome following cardiac surgery is a rare occurrence. However, early diagnosis is essential to prevent treatment which could increase the left ventricular outflow tract pressure gradient in patients with Takotsubo syndrome, and lead to cardiogenic shock. Therefore, our study aimed to identify the incidence of Takotsubo syndrome after cardiopulmonary bypass and the associated risk factors and prognosis. We retrospectively studied 5773 patients who underwent cardiopulmonary bypass between February 2007 and July 2017. Among these, Takotsubo syndrome was diagnosed in 52 (0.9%). To evaluate the risk factors for Takotsubo syndrome, 104 of the remaining 5721 patient were randomly selected as the control group (1:2 ratio). Univariate and multivariate logistic regression analyses were used for risk factor analysis. Majority of patients (69.2%) in the Takotsubo syndrome group underwent mitral valve surgery, compared with 32.7% in the control group. The following risk factors of Takotsubo syndrome were identified: atrio-ventricular valve surgery (odds ratio (OR) 10.5; 95% confidence interval (CI), 2.6-42.5; p = 0.001); and the immediate postoperative use of epinephrine (OR, 3.3; 95% CI, 1.0-10.7; p = 0.05) and dobutamine (OR, 4.8; 95% CI, 1.72-13.3; p = 0.003). Hypertension was a significant protective factor against Takotsubo syndrome following cardiac surgery (OR, 0.22; 95% CI, 0.06-0.73; p = 0.01). Takotsubo syndrome following cardiac surgery is rare. Immediate postoperative use of epinephrine and doputamine, as well as atrio-ventricular valve surgery were factors associated with the development of Takotsubo syndrome.

Growth of hypoplastic mitral valves in hypoplastic left heart complex and similar constellations after anatomical left superior vena cava correction

OBJECTIVES Left superior vena cava (LSVC)-related obstruction of mitral inflow is a rare finding in patients with complex cardiac anomalies like hypoplastic left heart complex. We report our experience by establishing a left superior to right superior caval vein continuity (innominate vein creation by direct LSVC–right superior vena cava end-to-side-anastomosis), and coronary sinus unroofing if indicated for LSVC-related mitral inflow obstruction.METHODSNineteen patients (median age: 1.0 ± 0.3 years; range: 7 days–4.8 years) underwent anatomical correction of LSVC without the use of foreign material in conjunction with repair or palliation of congenital anomalies in a single centre between April 2015 and November 2019. Indications for the procedure were LSVC-related obstruction of left ventricular inflow due to a dilated coronary sinus. Additional procedures included mitral (n = 7) or atrioventricular (n = 3) valve surgery, right ventricular to pulmonary artery conduit (n = 3), first stage palliation (n = 3) or biventricular repair (n = 5) of hypoplastic left heart complex. Three patients needed secondary mitral valve replacement (n = 3).RESULTSAll LSVC or coronary sinus-related obstructions were effectively relieved. No patient died early, 2 patients died late after the procedure. One patient needed stenting of the superior vena cava below the unobstructed cephalad vein anastomosis at the former right superior vena cava-cannulation-site. Follow-up was complete and demonstrated an 89.5% survival after 2.5 ± 0.4 years. Innominate vein patency was 100% documented by echocardiography (n = 19), cardiac catheterization (n = 6) or both. Mean mitral valve z-scores before the operation were −1.7 ± 0.2 (range −3.8 to 0.3) and increased to 0.7 ± 0.2 (range −0.7 to 1.9) after LSVC repair.CONCLUSIONSAnatomical correction by surgical creation of an innominate vein is an effective method to relieve LSVC-related obstructions and promotes mitral valvar growth. Mitral ring sizes were at least normalized after surgery at the time of discharge. Further prospective follow-up studies to evaluate the growth potential of left-sided heart structures by reporting cardiac z-scores are needed to evaluate the true impact of coronary sinus unroofing.

Single-ventricle palliation in children with atrioventricular septal defect and transposition of the great arteries: 45 years of experience.

The association of atrioventricular septal defect and transposition of the great arteries is very rare. As a rule, these patients have unbalanced ventricles. However, there have been no studies describing the results of single-ventricle palliation in these children. All children who underwent surgery with a diagnosis of atrioventricular septal defect and transposition of the great arteries were included in the study. Data were obtained from medical records. A total of 38 patients with atrioventricular septal defect and transposition of the great arteries underwent single-ventricle palliation at the study institution between 1971 and 2016. The mean follow-up was 12.4 years (median: 14.6 years, range 2-43.3 years). Most children had unbalanced atrioventricular septal defect (94.7%, 36/38). Survival was 67.6% (95% confidence interval [CI]: 50.0-80.2%) at 10 years and 57.8% (95% CI: 38.0-73.4%) at 20 years. By 10 years, 58.6% (95% CI: 40.8-72.7%) had progressed to Fontan completion, while 32.5% (95% CI: 18.2-47.6%) had died. In patients achieving Fontan completion, 20-year event-free survival was 73.3% (95% CI: 34.8-91.3%), while 5.0% (95% CI: 0.4-20.5%) had undergone cardiac transplantation and 21.7% (95% CI: 3.2-50.8%) had undergone takedown of the Fontan circulation. Freedom from atrioventricular valve surgery was 57.0% (95% CI: 37.2-72.7%) at 10 and 20 years. The association of atrioventricular septal defect and transposition of the great arteries is very rare, and most of these children have unbalanced ventricles. Single-ventricle palliation results in 25-year overall survival of 50%. However, in patients, who had Fontan completion, survival was 75% at 25 years after Fontan operation.

The impact of cardiopulmonary bypass management on outcome: a propensity matched comparison between minimally invasive and conventional valve surgery.

Research concerning cardiopulmonary bypass (CPB) management during minimally invasive cardiac surgery (MICS) is scarce. We investigated the effect of CPB parameters such as pump flow, haemoglobin concentration and oxygen delivery on clinical outcome and renal function in a propensity matched comparison between MICS and median sternotomy (MS) for atrioventricular valve surgery. A total of 356 patients undergoing MICS or MS for atrioventricular valve surgery between 2006 and 2017 were analysed retrospectively. Propensity score analysis matched 90 patients in the MS group with 143 in the MICS group. Logistic regression analysis was performed to investigate independent predictors of cardiac surgery-associated acute kidney injury in patients having MICS. In MICS, CPB (142.9 ± 39.4 vs 101.0 ± 38.3 min; P < 0.001) and aortic cross-clamp duration (89.9 ± 30.6 vs 63.5 ± 23.0 min; P < 0.001) were significantly prolonged although no differences in clinical outcomes were detected. The pump flow index was lower [2.2 ± 0.2 vs 2.4 ± 0.1 l⋅(min⋅m2)-1; P < 0.001] whereas intraoperative haemoglobin levels were higher (9.25 ± 1.1 vs 8.8 ± 1.2; P = 0.004) and the nadir oxygen delivery was lower [260.8 ± 43.5 vs 273.7 ± 43.7 ml⋅(min⋅m2)-1; P = 0.029] during MICS. Regression analysis revealed that the nadir haemoglobin concentration during CPB was the sole independent predictor of cardiac surgery-associated acute kidney injury (odds ratio 0.67, 95% confidence interval 0.46-0.96; P = 0.029) in MICS but not in MS. Specific cannulation-related issues lead to CPB management during MICS being confronted with flow restrictions because an average pump flow index ≤2.2 l/min/m2 is achieved in 40% of patients who have MICS compared to those who have a conventional MS. This study showed that increasing the haemoglobin level might be helpful to reduce the incidence of cardiac surgery-associated acute kidney injury after minimally invasive mitral valve surgery.

Minimally invasive atrioventricular valve surgery – current status and future perspectives

We are currently witnessing rapid evolution in minimally invasive and catheter-based atrioventricular valve interventions as acceptable alternatives to classic sternotomy access (CSA). Collectively, minimally invasive atrioventricular valve surgery (MIAS) is associated with significant learning curves and its routine application is met with varying degrees of enthusiasm in view of strict quality control, clinical governance and outcome reporting. Whether the reported potential benefits and comparable efficacy across a range of long-term outcome measures reported by experienced MIAS centres can be translated into general international surgical practice, are not well defined. This paper describes the historic evolution of MIAS, the contemporary clinical outcomes of MIAS compared with CSA, and the application of MIAS in “real-life” general practice.

A case of 15-year misdiagnosed heart failure: congenitally corrected transposition of the great arteries.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare condition, accounting for about 1% of all congenital heart diseases1, and more than 90% of patients have associated anomalies like ventricular septal defect, pulmonary stenosis, and systemic atrioventricular valve anomalies2. European Society of Cardiology (ESC) guidelines recommend systemic atrioventricular valve surgery for severe regurgitation before systemic ventricular function deteriorates (before right ventricular ejection fraction <45%)1.