Atrioventricular Valve Insufficiency Research Articles

Predicting the Need for Neoaortic Arch Intervention in Infants with Hypoplastic Left Heart Syndrome Through the Glenn Procedure.

Neoaortic recoarctation is present in up to over one-third of patients having undergone the Norwood procedure for hypoplastic left heart syndrome. Some of these patients will require reintervention by catheterization or surgery through the time of the Glenn procedure. Echocardiography and catheterization are often utilized in this period to assess hemodynamics although no specific criteria have been identified to predict whether and when neoaortic arch reintervention will be needed. We sought to identify predictors, including but not limited to echocardiographic and catheterization gradients, to predict such intervention. A retrospective analysis was conducted including patients with hypoplastic left heart syndrome. Patients with significantly comorbid lesions such as isomerism, anomalous pulmonary venous connections, and significant atrioventricular valve insufficiency were excluded as were patients without interstage echocardiographic and catheterization data. Receiver operator curve analysis was performed to establish peak-value gradients by echocardiography and catheterization that were predictive of neoaortic reintervention from the time of the Norwood through the time of the Glenn. These values were then entered into a multivariate regression with several other factors to determine what factors were predictive of need for such intervention. Bland-Altman analysis was conducted to compare echocardiographic and catheterization gradients. A peak echocardiographic gradient of 26mmHg (100% sensitivity, 85% specificity) and a peak-to-peak catheterization gradient of 8.5mm Hg (83% sensitivity, 86% specificity) were found to be predictive of need for neoaortic arch reintervention after multivariate analysis. Echocardiographic and catheterization gradients were found to have poor correlation with one another. A peak gradient of 26mmHg or greater by echocardiography and a peak-to-peak gradient of 8.5mmHg or greater by catheterization after the Norwood but prior to the Glenn are predictive of need for neoaortic reintervention through the time of the Glenn hospitalization.

A Novel-Design Poly-L-Lactic Acid Biodegradable Device for Closure of Atrial Septal Defect: Long-Term Results in Swine

Objectives: The aim of this study is to evaluate the long-term effectiveness and safety of a self-expandable, double-disk biodegradable device made of poly-<smlcap>L</smlcap>-lactic acid (PLLA) for closure of atrial septal defects (ASDs) in swine. Methods: ASDs were created by transseptal needle puncture followed by balloon dilatation in 20 piglets. The experimental group comprised 18 animals, while the remaining 2 animals were used as controls. Effectiveness and safety were evaluated by rectal temperature, leukocyte count, chest radiography, electrocardiogram, transthoracic echocardiography (TTE), intracardiac echocardiography (ICE), and histologic studies. Animals were followed up at 1, 3, 6, and 12 months. Results: An ASD model was successfully created in 19 animals; 1 piglet died during the procedure. The ASD diameters that were created ranged from 5 to 6.4 mm. Devices were successfully implanted in 17 animals. No animal died during the follow-up studies. Rectal temperatures and electrocardiograms were normal at follow-up, while leukocyte counts transiently increased from 1 to 6 months. Radiography, TTE, ICE, and macroscopic studies demonstrated that PLLA occluders were positioned well, with no shifting, mural thrombus formation, or atrioventricular valve insufficiency. Histologic evaluations showed that PLLA devices were partially degraded in the follow-up study. Conclusions: ASD closure with the novel PLLA biodegradable device is safe and effective. Longer-term studies are needed to evaluate long-term biodegradability.

Clinical outcome following total cavopulmonary connection: a 20-year single-centre experience.

This study aims to evaluate the clinical outcome following total cavopulmonary connection (TCPC) and to identify factors affecting early and late outcome. Between May 1994 and March 2015, 434 patients underwent TCPC with 50 lateral tunnels and 374 extracardiac conduits. The clinical outcome, exercise capacity and liver examination results were retrospectively reviewed. Thirty-day survival was 98.2%, and the estimated survival rate at 15 years was 92.3%. Freedom from tachyarrhythmia at 15 years was 91.0%. Other late morbidities included bradyarrhythmia in 17, protein-losing enteropathy (PLE) in 15, thromboembolism in 3 and plastic bronchitis in 3 patients. At last follow-up, normal systemic ventricular function (ejection fraction >50%) was observed in 88.2%. Atrioventricular valve (AVV) regurgitation was mild or less in 90% of patients with systemic left ventricle, in 63% of those with systemic right ventricle and 58% of the patients with unbalanced atrioventricular septal defect or common inlet ventricles. Cardiopulmonary exercise capacity showed impaired peak oxygen uptake (71% of normal) in a sub-group of 120 patients at a mean of 9 years postoperatively. Biochemistry of 338 patients at last follow-up revealed a gamma-glutamyl transferase value beyond normal in 90 patients (26%), with a positive correlation between the level and the time after the initial operation (P < 0.01). Pre-TCPC high transpulmonary gradient emerged as a predictor for delayed hospital recovery (P = 0.002), late mortality (P = 0.016) and reoperation (P = 0.015) in multivariable analysis. Contemporary TCPC can be performed with low risk and provides excellent survival in the long-term. Classic morbidities of the original Fontan procedure, such as Fontan pathway revision, tachyarrhythmia and thromboembolism seem mitigated. However, exercise limitations, PLE and liver dysfunction remain an issue. AVV insufficiency and ventricular dysfunction are still a concern.

Abstract 17110: Risk Factors for Hepatic Fibrosis in Children and Adolescents After Fontan Operation

Introduction: Congestive hepatopathy is increasingly recognized as a complication of Fontan physiology. Prospective data regarding the incidence of hepatopathy and risk factors for its development are lacking. Methods: Liver biopsies were obtained as part of a routine program of comprehensive end-organ evaluation offered to all patients &gt;10 years after Fontan operation (FO) through the Single Ventricle Survivorship Program. Evaluation included cardiac catheterization and contemporaneous percutaneous liver biopsy. Quantitative determination of hepatic fibrosis was performed using Sirius red staining for collagen with automated calculation of percent positive staining per slide. Patient specific characteristics, echocardiographic findings, and hemodynamic measures were assessed and evaluated as potential risk factors for collagen deposition using Pearson correlation. Differences in collagen deposition (%CD) between subgroups were assessed using the student t-test. Results: The cohort consisted of 67 patients (36 male) at mean age of 17.3 ±4.5 years and mean time from Fontan of 14.9 ±4.5 years. Right ventricular morphology was present in 37 subjects; 30 with hypoplastic left heart syndrome. Mean %CD by Sirius red staining was 23.8 ±9.5% (range 8.7-49.4%) as compared to 2.6 ±0.3% in controls. There was significant correlation between time from Fontan and degree of Sirius red staining (r=0.33, p=0.006). Serum liver enzymes and platelet count did not correlate with %CD. The median inferior vena cava (IVC) pressure was 13 mmHg (range 6-24 mmHg) and did not correlate with %CD. There was no difference in %CD between those with a measured IVC pressure ≥13 mmHg versus those with a pressure &lt;13 mmHg. There was no difference in %CD based on ventricular morphology or severity of atrioventricular valve insufficiency. Conclusion: In this cohort of predominantly asymptomatic children and adolescents electively evaluated after FO, all exhibited evidence for hepatic fibrosis as measured by collagen deposition in the liver. Time from FO was the only factor in this cohort that was significantly associated with collagen. These findings demonstrate that liver fibrosis is an inherent feature of Fontan physiology and that the degree of fibrosis increases over time.

Current challenges in pediatric heart transplantation for congenital heart disease.

Pediatric heart transplantation is an established therapy for end-stage cardiac disease without suitable medical or surgical options. However, transplantation for congenital heart disease carries an incremental risk that challenges the pediatric transplant team on multiple levels. With improved outcomes following palliative and corrective congenital cardiac surgery, cardiac transplantation has decreased in recent years as a primary therapy. Nevertheless, congenital heart disease remains the most common indication for cardiac transplantation during infancy. Primary transplantation in infancy is selectively recommended for severe systemic ventricular dysfunction, severe atrioventricular valve insufficiency, and occlusive coronary artery anomalies, particularly with single ventricle physiology. Wait-list mortality remains highest for infants with prior palliative surgery and patients with failing Fontan physiology, both of whom have limited options for effective mechanical circulatory support. The sensitized patient carries an increased risk with prolonged wait times, although virtual cross-matches and single bead assays for donor-specific antigens have facilitated the transplant process. Early and late survival after transplantation for congenital heart disease remain inferior to cardiomyopathy, with prior Fontan procedure as a major risk factor. However, among survivors at 6 months, late outcomes are generally excellent. Major late causes of death include allograft vasculopathy, post-transplant lymphoproliferative disease, and acute rejection. Noncompliance with medications remains a major risk for teenage mortality. Despite the myriad of evolving challenges, pediatric heart transplantation for congenital heart disease enjoys routine short and long-term success at experienced centers for the vast majority of such patients without other options.

Modified Single Versus Double-Patch Technique for the Repair of Complete Atrioventricular Septal Defect.

We present our single center results of two commonly used surgical techniques, the modified single-patch and double-patch technique for the repair of the complete atrioventricular septal defect. We enrolled 49 patients with complete atrioventricular septal defect who were operated by a single surgeon between 2004 and 2014. The modified single-patch technique was performed in 32 cases (group S), whereas the defect was repaired with the double-patch technique in 17 patients (group D). The mean age at the time of operation was 7.7 ± 8.6 (range 1-48) months and 9.9 ± 12.5 (range 1.5-48) months, in groups S and D, respectively. Mean body weight was 6.7 ± 3 (range 3.5-15.5) kilograms and 7.2 ± 3.8 (range 4.3-14.5) kilograms in groups S and D, respectively. Cross-clamp and cardiopulmonary bypass times were shorter in the modified single-patch group (65.6 ± 16.3 vs. 98.7 ± 19.8 minutes, p = 0.0001; 88.9 ± 23.3 vs. 128.9 ± 28.0 minutes, p = 0.0001). Postoperative atrioventricular valve function was improved in both groups. Mean follow-up period was 4.4 ± 3.2 (range 1.2-9.9) years. One patient in each group underwent reoperation for left atrioventricular valve insufficiency. We encountered two early and one late mortalities in modified single-patch group. One early mortality was experienced in the unmodified group. The modified single-patch and two-patch techniques have comparable results; however, the modified single-patch technique is performed with significantly shorter cross-clamp and cardiopulmonary bypass times, therefore we have adopted this technique on a routine basis for the treatment of the complete atrioventricular septal defect in our institute.

Unusual presentation of congenitally corrected transposition of great arteries (CCTGAs) in a middle aged male

Congenitally corrected transposition of great arteries (CCTGAs) is a rare congenital heart disease. The literature review reveals that asymptomatic CCTGA is even rarer in elderly male. We report a case of a 54-year-old male, with no past significant medical history, who presented with angina type of chest pain. On examination, he had bradycardia, lower limb hypertension and grade 3 pansystolic murmur in the mitral area. Investigations revealed complete heart block in electrocardiograph, chest radiograph showed cardiomegaly, transthoracic echocardiography showed an apically located systemic atrio-ventricular (AV) valve, parallel arrangement of the great arteries, AV and ventriculoarterial discordance, hypertrophied right ventricle and significant systemic AV valve insufficiency with ejection fraction of 40%. These findings were consistent with congenitally corrected transposition of the great arteries with systemic AV valve insufficiency. Holter monitoring showed complete heart block, no significant pauses and one event of ill-sustained ventricular tachycardia (ventricular triplet) with the patient being asymptomatic during the study period. Need of internal cardioverter-defibrillator or pacemaker was deferred. The remaining hospital stay was uneventful. At the time of discharge, the patient was stable.

Results of Fontan operation in patients with atrioventricular valve regurgitation.

The influence of concomitant atrioventricular valve regurgitation on the results of Fontan operation remains disputable. The goal of this study was to compare early and late results of Fontan operation performed in patients with mild or moderate-to-severe atrioventricular valve regurgitation. For retrospective analysis, patients with atrioventricular valve insufficiency assessed by echocardiography were divided into three groups based on the severity of regurgitation and its repair or non-repair during Fontan operation: Group 1: unrepaired regurgitation 1-2+ (n = 33); Group 2: unrepaired regurgitation 3-4+ (n = 11); Group 3: repaired regurgitation 3-4+ (n = 35). Actuarial survival was estimated by the Kaplan-Meier method, followed by the log-rank test to compare survival curves between groups. Hospital mortality rates in Groups 1 through 3 reached 3, 27 and 14%, respectively (P = 0.015, Group 1 vs Group 2). The frequency of non-lethal complications did not significantly differ between groups. However, patients from Group 2 required significantly more intensive inotropic support, longer mechanical ventilation and had larger pleural effusion. Predicted survival after Fontan operation was the worst in Group 2 (P = 0.016, Group 2 vs Group 1). The frequency of non-lethal late complications was also the highest in Group 2 (50 vs 17 or 11%); however, the difference did not reach statistical significance (P = 0.13 and 0.069, respectively). The severity of atrioventricular valve regurgitation during the follow-up did not significantly change when compared with discharge after the repair in Group 2 or Group 3 (P = 0.19 and 0.52, respectively), and significantly increased in Group 1 (P = 0.003). However, this increase did not have clinical significance during the reported period of follow-up. If unrepaired, concomitant moderate-to-severe atrioventricular valve regurgitation significantly worsens the results of the Fontan procedure. Longer observation is needed to define the strategy in patients with mild atrioventricular valve regurgitation that remained unrepaired during Fontan operation.

Computational modeling of pathophysiologic responses to exercise in Fontan patients.

Reduced exercise capacity is nearly universal among Fontan patients. Although many factors have emerged as possible contributors, the degree to which each impacts the overall hemodynamics is largely unknown. Computational modeling provides a means to test hypotheses of causes of exercise intolerance via precisely controlled virtual experiments and measurements. We quantified the physiological impacts of commonly encountered, clinically relevant dysfunctions introduced to the exercising Fontan system via a previously developed lumped-parameter model of Fontan exercise. Elevated pulmonary arterial pressure was observed in all cases of dysfunction, correlated with lowered cardiac output (CO), and often mediated by elevated atrial pressure. Pulmonary vascular resistance was not the most significant factor affecting exercise performance as measured by CO. In the absence of other dysfunctions, atrioventricular valve insufficiency alone had significant physiological impact, especially under exercise demands. The impact of isolated dysfunctions can be linearly summed to approximate the combined impact of several dysfunctions occurring in the same system. A single dominant cause of exercise intolerance was not identified, though several hypothesized dysfunctions each led to variable decreases in performance. Computational predictions of performance improvement associated with various interventions should be weighed against procedural risks and potential complications, contributing to improvements in routine patient management protocol.

EARLY OUTCOME AFTER AORTIC VALVE REPLACEMENT ON PATIENTS WITH REDUCED LEFT VENTRICULAR EJECTION FRACTION

Background: To evaluate the early results of operation for partial atrioventricular septal defect. Methods: Twenty-sevent patients underwent surgical correction of partial atrioventricular septal defect from 1/2011 to 12/2013 at Cardiovascular Centre of Hue Central Hospital. There were 7 (25.9%) female patients and 20 (74.1%) male patients, 18.5% of patients aged &lt; 1 age, 55.6% of patients aged ≥ 1 to 15 years, and 25.9% of patients aged ≥ 16 to 60 years. Sevent (25.9%) had congestive heart failure. There was a primum atrial septal defect in 100% of patients. A cleft of the anterior mitral leaflet was diagnosed in 100% of patients. 92.6% of patients had either moderate or severe mitral incompetence prior to operation. The pulmonary artery systolic pressure exceeded 40 mmHg in 85,.2% of patients. Results: Atrial septal defects were closed with a pericardial patch in 100% of patients. The cleft in its anterior leaflet was closed in 100% of patients. Postoperatively, moderate mitral insufficiency developed in 14.8% of patients. 85.2% of patients have mild mitral incompetence. One patients (3.7%) needed a permanent pacemaker. There was no intraoperative mortality. At 6-9 months postoperatively, left atrioventricular valve insufficiency was moderate in 2 (7.4%) patients and mild in 25 (92.6%) patients who had had cleft closure alone. Conclusions: Repair of partial atrioventricular septal defect is safe and good. It is important to close the cleft in the left atrioventricular valve. The mitral valve should be repaired in a conservative manner. Intraoperative complications occur but are uncommon, suggesting that short-term follow is excellent.

Nitric Oxide Synthase-3 Promotes Embryonic Development of Atrioventricular Valves

Nitric oxide synthase-3 (NOS3) has recently been shown to promote endothelial-to-mesenchymal transition (EndMT) in the developing atrioventricular (AV) canal. The present study was aimed to investigate the role of NOS3 in embryonic development of AV valves. We hypothesized that NOS3 promotes embryonic development of AV valves via EndMT. To test this hypothesis, morphological and functional analysis of AV valves were performed in wild-type (WT) and NOS3−/− mice at postnatal day 0. Our data show that the overall size and length of mitral and tricuspid valves were decreased in NOS3−/− compared with WT mice. Echocardiographic assessment showed significant regurgitation of mitral and tricuspid valves during systole in NOS3−/− mice. These phenotypes were all rescued by cardiac specific NOS3 overexpression. To assess EndMT, immunostaining of Snail1 was performed in the embryonic heart. Both total mesenchymal and Snail1+ cells in the AV cushion were decreased in NOS3−/− compared with WT mice at E10.5 and E12.5, which was completely restored by cardiac specific NOS3 overexpression. In cultured embryonic hearts, NOS3 promoted transforming growth factor (TGFβ), bone morphogenetic protein (BMP2) and Snail1expression through cGMP. Furthermore, mesenchymal cell formation and migration from cultured AV cushion explants were decreased in the NOS3−/− compared with WT mice. We conclude that NOS3 promotes AV valve formation during embryonic heart development and deficiency in NOS3 results in AV valve insufficiency.

‘Crystal’ in the heart

A 35-year-old man presented to the emergency unit with progressive dyspnoea of two weeks’ duration. He had no previous medical history, and denied chest discomfort. During echocardiography, a severely impaired biventricular systolic function with severe atrioventricular valve insufficiency was found. The left ventricular end diastolic diameter (LVEDD) was 74 mm (Fig. 1A). There was no evidence of coronary artery disease (CAD), as shown in Figure 1B. On inquiry, he confessed to a weekly consumption of ‘crystal’ (methyl amphetamine) of about 0.5–1 g. Haemodynamic findings showed a decreased cardiac index of 1.7 L/min/m2. The patient had an intra-aortic balloon pump implanted as a bridge to recovery. However, haemodynamic and echocardiographic parameters did not improve, so he received a levosimendan infusion. Left ventricular endomyocardial biopsies were taken, and histological and immunohistological examinations revealed severe methamphetamine-induced chronic myocardial injury with degeneration of hypertrophied myocytes neighbouring small arterioles with medial hyperplasie in the presence of a mild inflammatory reaction (Fig. 1D). There was no evidence of acute or chronic myocarditis, amyloidosis or preexisting dilated or other primary cardiomyopathies. No viral genomes were detected by nested PCR analysis. The results were confirmed by cardiac magnetic resonance imaging (MRI) (Fig. 1C). Late gadolinium enhancement indicating myocardial fibrosis or necrosis was not obvious. The patient slowly recovered over the course of two weeks. Long-term ECG showed a non-sustained ventricular tachycardia of 18 beats. He left hospital with a wearable cardioverter-defibrillator (LifeVest®). Chronic use of methyl amphetamine may result in severe heart failure, malnutrition, infections and permanent psychiatric illness. The patient was discharged for outpatient drug rehabilitation.

Pathophysiological consequences of atrioventricular valve insufficiency in the equine patient

Pathophysiological consequences of atrioventricular valve insufficiency in the equine patient

Intra- or extracardiac Fontan operation? A simple strategy when to do what.

IntroductionThe complete Fontan circulation is the definite palliation for many complex congenital cardiac lesions. After bi-directional Glenn anastomosis (BDG), two well-established techniques – intracardiac tunneling and extracardiac prosthesis – are available for completion, although the choice of technique is still a matter of debate.Material and methodsWe retrospectively reviewed the surgical and clinical records of patients with single ventricle physiology, who underwent intracardiac (group I) or extracardiac (group II) Fontan palliation after BDG.ResultsComplete data were available in 72 patients. Thirty-eight patients received intracardiac (median weight: 12.6 kg) and 34 patients extracardiac repair (median weight: 15.6 kg). Patients with intracardiac tunneling had longer cardiopulmonary bypass (CBP) time (170 min vs. 104 min; p < 0.001), longer ventilatory (39 h vs. 21 h; p = 0.009) and longer inotropic support (48 h vs. 10 h; p < 0.001). Ventilatory and inotropic support were dependent on CPB (r = 0.69 and r = 0.637) and on aortic cross-clamping (r = 0.785 and r = 0.705 only group I), but not dependent on age, weight or pulmonary artery pressure (PAP).ConclusionsBoth techniques are feasible without perioperative mortality. Normally developed children with good hemodynamics after BDG received an elective extracardiac procedure without fenestration later. Patients with developmental retardation, severe progressive cyanosis, myocardial dysfunction, or moderate to severe atrio-ventricular valve insufficiency are scheduled for an earlier intracardiac baffle repair with routine fenestration, as they are at higher risk. Prolonged CPB and aortic cross-clamping times adversely impact the early postoperative course. Further strategies must be developed to avoid these effects, particularly in the patient group at higher imminent risk.

Repair of Left Atrioventricular Valve Cleft Defects With Patch Augmentation

Operations for left atrioventricular valve insufficiency after repair of an atrioventricular septal defect can be challenging. Repair techniques largely depend on closure of the residual cleft in the anterior leaflet in conjunction with a posterior annuloplasty. Profound deficiencies in anterior leaflet tissue can make primary cleft closure impractical. A simplified technique, in which cleft closure is supported by triangular-shaped patch material, is presented along with results in 13 patients.

Risk factors for postoperative arrhythmia in patients with physiologic univentricular hearts undergoing Fontan procedure

Advanced age, dilated right atrium, increased preoperative pulmonary artery pressure, increased right atrial pressure, technique of operation, and poor ventricular function were reported to be risk factors for postoperative arrhythmia. Aim of this study is to determine the risk factor for postoperative arrhythmia after Fontan operation with regard to ventricle dominancy and hemodynamic parameters. In this retrospective study, the data of the patients including age, weight, dominant ventricle, type of cardiac anomaly, previous operations, duration of cardiopulmonary bypass (CPB), duration of aortic clamping, cardiac rhythm, pulmonary artery pressure, the Nakata Index, systemic atrioventricular (AV) valve insufficiency were obtained from the hospital records, the echocardiographic files, and cardiac catheterization records. Patients were assigned to dominant left ventricle or dominant right ventricle groups. Statistical analysis was performed using the Mann-Whitney U test. Arrhythmia was observed in 21 (52.5%) patients in the postoperative period. No postoperative arrhythmia was observed in patients with a right atrial pressure of <5 mmHg, whereas postoperative arrhythmias were observed in patients with a right atrial pressure of ≥5 mmHg (p<0.05). When the effects of preoperative and postoperative pulmonary artery pressures on postoperative arrhythmia were evaluated, postoperative arrhythmia was determined in only 2 (12.5%) of 8 patients with a preoperative mean pulmonary artery pressure of ≤9 mmHg, whereas postoperative arrhythmia was observed in 19 (59.3%) of 32 patients with a preoperative pulmonary artery pressure of ≥10 mmHg. A preoperative mean pulmonary artery pressure of >10 mmHg increased the risk of postoperative arrhythmia (p<0.02). Postoperative arrhythmia was determined in 8 (53%) of 15 patients with a dominant right ventricle, and in 13 (52%) of 25 patients with a dominant left ventricle (p>0.05). While a preoperative mean pulmonary artery pressure of >10 mmHg and a preoperative right atrial pressure of >5 mmHg were the risk factors for postoperative arrhythmia in patients undergoing Fontan procedure, the right or left ventricular dominance was not a risk factor.

Does the surgical technique used in the orthotopic heart transplant affect the results regarding the rhythm

The aim of this study was to compare the requirement for temporary and permanent pacemaker insertion and the incidence of the problems regarding the rhythm following heart transplantation with the bicaval or biatrial technique in the early postoperative period. Sixty-one patients underwent orthotopic heart transplantation between the dates of September 1989 and December 2008 in our clinics were included to the study. The study was designed as retrospective analysis, and all data were collected from hospital records. The transplantation was performed by using standard biatrial method in 28 of the patients, by using bicaval anastomosis method in 33 of the patients. Statistical analyses were performed using Chi-square, Fischer's exact and Mann-Whitney U tests. Predictors of temporary and permanent pacemaker insertion were analyzed using logistic regression analysis. In the biatrial group, the temporary pacemaker requirement (p<0.05), left bundle branch block (LBBB) (p<0.01) and atrioventricular block (AV block) (p<0.05) were observed statistically significantly more than in bicaval anastomosis group. In addition, in the biatrial group, one patient needed implantation of permanent pacemaker and one patient-implantable cardioverter defibrillator. On the postoperative echocardiographic evaluation, in the patients operated with the bicaval technique, the tricuspid (p<0.01) and mitral insufficiency (p<0.01) were observed significantly less. In the logistic regression analysis, hypertension (OR: 1.053, 95% CI: 1.019-1.176, p<0.05), donor age (OR: 1.016, 95% CI: 1.023-1.038, p<0.05) and application of the operation with the biatrial technique (OR: 10.287, 95% CI: 1.298-91.278, p<0.01) were determined as the risk factors requiring the temporary pacemaker usage. In the bicaval group, arrhythmia (ventricular and atrial premature beats) and atrioventricular valve insufficiency were observed less, the rhythm returned to normal in an earlier period. Biatrial surgical technique, donor age and hypertension were determined as significant predictors of temporary pacemaker insertion in the orthotopic heart transplantation. Atrioventricular block, left bundle branch block, and arrhythmia frequency was significantly less in the bicaval group. In terms of factors affecting morbidity, the bicaval technical results were found superior than biatrial technique.

La rhinite allergique au Maroc : à propos de 1450 cas

Operations for left atrioventricular valve insufficiency after repair of an atrioventricular septal defect can be challenging. Repair techniques largely depend on closure of the residual cleft in the anterior leaflet in conjunction with a posterior annuloplasty. Profound deficiencies in anterior leaflet tissue can make primary cleft closure impractical. A simplified technique, in which cleft closure is supported by triangular-shaped patch material, is presented along with results in 13 patients.

Risk Factor Analysis for Second-Stage Palliation of Single Ventricle Anatomy

Single ventricle hearts can be surgically palliated by a series of operations culminating in the Fontan procedure, which establishes a total cavopulmonary connection. The second-stage procedure creates a physiologic connection between the superior vena cava and the pulmonary artery. From 1998 to 2010, 557 patients with single ventricle heart disease underwent second-stage surgical palliation. This cohort was retrospectively analyzed to assess patient outcome by a number of anatomic, physiologic, and procedural factors. The analysis excluded patients undergoing hybrid first-stage procedures. The median age at operation was 165 days (range, 59 days to 49 years). The most common anatomic subtypes were hypoplastic left heart syndrome (52%), tricuspid atresia (12%), unbalanced atrioventricular septal defect (10%), double inlet left ventricle (9%), or other (17%). Left ventricular hypoplasia was present in 70%. A hemi-Fontan procedure was done in 89%, and 11% received a bidirectional Glenn. Concomitant atrioventricular valve repair was necessary in 9%. Early mortality was 4.7%, and 5.9% died after discharge but before Fontan. No early or late deaths occurred in patients with tricuspid atresia and double inlet left ventricle. Multivariate analysis demonstrated ventricular dysfunction, atrioventricular valve regurgitation, and unbalanced atrioventricular septal defect were significant adverse risk factors for survival to Fontan. Second-stage palliation can be performed at low risk for patients with left ventricular dominance, but significant risk remains for patients with left ventricular hypoplasia and unbalanced atrioventricular septal defect. Atrioventricular valve insufficiency is a persistent problem that has not been neutralized by repair strategies.

Abstract 17418: Vector Velocity Imaging: A Reliable Tool to Quantify Myocardial Function and Predict Clinical Outcomes in Single Ventricle Patients

Background: Ventricular function is one of the factors that correlate with survival to second stage surgical palliation in single ventricle (SV) patients. Standard 2D echocardiography (2DE) has limitations in evaluating right ventricular function. Myocardial function can be reliably determined using Vector Velocity Imaging (VVI), which is an angle independent method of evaluating myocardial mechanics using conventional 2DE images. HYPOTHESIS: VVI provides a valid and reproducible measure of ventricular function in SV patients compared to standard 2DE with direct correlation to clinical outcomes. Methods: Medical records and 2DE's were retrospectively reviewed on 72 patients with SV's (37 systemic right ventricles, 35 systemic left ventricles. VVI analysis was performed offline using Siemens Syngo software. When feasible, 2D and Doppler parameters of ventricular function were performed. Using VVI on a 4 chamber image longitudinal velocity (LVel), strain (S), strain rate (SR) were obtained. Ventricular function was measured pre and post stage 1 palliation and compared to normals. Results: Fifty seven patients survived to stage 2 palliation (79%). Of the 15 deceased, 10 survived to hospital discharge; 10 had a single RV and 5 had single LV. Heterotaxy, post operative ECMO, sepsis, atrioventricular valve insufficiency and chylothorax were factors associated with death. Using 2DE, ventricular function was qualitatively normal in all but 3 patients pre-stage 1 and in 9 patients post stage 1. Other quantitative parameters were not consistently employed through the study period. LVel, S, and SR were depressed compared to normal hearts in all study patients. There was a statistical difference in the LVel between the survivors and non-survivors (p 0.017). Conclusions: Despite qualitatively normal ventricular function, VVI shows significantly decreased myocardial function in both single left and right ventricles when compared to normal hearts. In the absence of traditional quantitative measures of SV function, VVI is a reliable tool to evaluate myocardial mechanics and serves as an adjunct to prognosticate clinical outcomes.