Atrioventricular Valve Replacement Research Articles

A Novel Template and Cylinder Bioprosthetic Atrioventricular Valve: An Ex Vivo Study

PurposeThis ex vivo study aimed to develop and evaluate a novel cylinder bioprosthetic valve for mitral and tricuspid valve replacements, addressing concerns related to valve size, anticoagulation, and postoperative morbidity. DescriptionExisting bioprosthetic valves lack annulus–papillary muscle continuity. In contrast, our valve, which is crafted from autologous pericardium, maintains annulus–papillary muscle continuity, maximizes the orifice area when open, and closes in response to rising ventricular pressure, thus preserving mitral valve complexity. It also offers a comprehensive size range: implanted mitral valve diameters ranged from 13 to 26 mm, and implanted tricuspid valve diameters ranged from 15 to 28 mm. EvaluationAnimal models demonstrated satisfactory coaptation lengths and excellent valve performance without regurgitation. ConclusionsOur newly designed valve is a geometrically adaptable alternative to existing valves. Its autologous pericardium construction, open design position, and preservation of annulus–papillary muscle continuity address key limitations in existing implants. Moreover, with a broad size selection, this valve accommodates patients across all age groups. The innovative design and potential clinical benefits make this valve a breakthrough in atrioventricular valve replacement.

Mechanical atrioventricular valve replacement in patients with single ventricle palliation.

Atrioventricular valve (AVV) replacements in patients with single-ventricle circulations pose significant surgical risks and are associated with high morbidity and mortality. From 1997 to 2021, 16 consecutive patients with functionally single-ventricle physiology underwent mechanical AVV replacement. Primary outcome was transplant-free survival. Secondary outcomes included major postoperative morbidity. The median age of AVV replacement was 2 years old (interquartile range 0.6-3.8 years). All AVV replacements were performed with a St. Jude Medical mechanical valve, median 24 mm (range, 19-31mm). Extracorporeal membrane oxygenation (ECMO) was required in 4 patients. Operative mortality was 38% (6/16). There were 2 late deaths and 3 transplants. Transplant-free survival was 50% at 1 year, 37.5% at 5 years, and 22% at 10 years. Transplant-free survival was higher for patients with preserved ventricular function (P = 0.01). Difference in transplant-free survival at 1 year was 75% vs 25%, at 5 years was 62.5% vs 12.5% and at 10 years was 57% vs 0%. Three (19%) patients had complete heart block requiring permanent pacemaker insertion. 6 of 13 patients (46%) patients reached Fontan completion (3 patients operated at/after Fontan). Significant bleeding events occurred in 8 patients (50%) with 3 patients suffering major cerebrovascular accidents. There were 6 events of valve thrombosis in 5 patients, resulting in 2 deaths and 2 heart transplants. Mechanical valve replacement carries significant morbidity and mortality risk. While it successfully salvages about half of patients with preserved ventricular function, careful consideration of alternative options should be made before embarking upon mechanical valve replacement.

Modified atrioventricular valve replacement in children

One major challenge of atrioventricular valve replacement in children is the small size of the native valve annulus. In addition, in cases of atrioventricular septal defect, the atrioventricular node (AVN) shifts to a different location, making this condition difficult to treat. This report describes a technique that uses a trapezoid-shaped patch to separate the implanted valve suture-line from the AVN, which allows surgeons to implant larger valves while simultaneously preventing injury to the AVN.

Liver Cirrhosis After the Fontan Procedure: Impact of Atrioventricular Valve Failure

BackgroundLiver cirrhosis is now well recognized as a potential complication after the Fontan procedure, although associated risk factors and optimal timing of liver screening remain unclear. MethodsAll patients who underwent an extracardiac conduit Fontan procedure at The Royal Children’s Hospital, Melbourne, were identified using the Australia and New Zealand Fontan Registry. Cirrhosis was diagnosed based on liver biopsy, or a combination of imaging findings and clinical evaluation by a hepatologist. ResultsBetween 1997 and 2020, 398 patients underwent an extracardiac conduit Fontan procedure at our center, and 276 had ongoing follow-up in Victoria. Ninety-five patients (34%) underwent liver assessment at a mean age of 18.2 ± 6.7 years (11.8 ± 5.5 years post-Fontan). Fifteen patients (16%) were diagnosed with cirrhosis at a mean age of 22.7 ± 5.9 years (14.0 ± 5.2 years post-Fontan). The need for prior or concomitant atrioventricular valve repair or replacement was associated with an increased risk of cirrhosis (univariable hazard ratio [HR] 7.09, 95% confidence interval [CI] 2.13-23.61, P = .001). By multivariable analysis, factors associated with development of cirrhosis were atrioventricular valve failure prior to Fontan (HR 3.27, 95% CI 1.15-9.31, P = .026) and older age at Fontan operation (HR 1.13 per year increase, 95% CI 1.01-1.26, P = .034). The proportion of patients alive, nontransplanted, and without cirrhosis at 10, 15, and 20 years was 93.4% (95% CI 88.4%-98.7%), 79.6% (95% CI 69.7%-90.8%), and 64.6% (95% CI 51.0%-81.9%), respectively. ConclusionsEarly commencement of liver screening should be considered for patients with a history of atrioventricular failure during Fontan palliation.

Technical modification and safe explantation of the Melody valve in the mitral position in small children.

Technical modification and safe explantation of the Melody valve in the mitral position in small children.

Clinical Features and Outcomes in Adults With Childhood Repair of Partial Atrioventricular Septal Defect

BackgroundPartial atrioventricular septal defects (pAVSDs) are mostly repaired in childhood; however, there are limited data describing these patients in adulthood. ObjectivesThe objective of this study was to describe clinical course and associations with outcomes in adults with repaired pAVSDs. MethodsA retrospective review of adults (≥18 years) with pAVSDs repaired in childhood who presented to the Adult Congenital Heart Disease Clinic at our institution was conducted. ResultsOf 121 patients, the median age was 31 years (IQR: 22-43 years) and 71.9% were female. The median number of operations at the time of presentation was 1 (IQR: 1-2). Left atrioventricular valve (LAVV) replacement had been performed in 19.8% of patients. Among those with native LAVV, 41.2% had ≥ moderate regurgitation. Atrial arrhythmias were present in 34.7% and were associated with later age at repair (P = 0.02) and a high number of prior surgeries (P = 0.005). Estimated systolic pulmonary artery pressure >40 mmHg was seen in 19.8%. Over 4 (IQR: 1-12) years of follow-up, death occurred in 13 (10.7%) patients and reoperation was required in 39.7%. One-third had a LAVV prosthesis by the end of the study. Atrial fibrillation was independently associated with death or hospitalization on multivariable analysis. ConclusionsIn this cohort of adults with pAVSDs repaired in childhood, atrial fibrillation was common at a young age and associated with worse outcomes. Thus, more studies are needed evaluating the cause of this arrhythmia burden and possible associated atrial myopathy. While many require surgery in adulthood, more information is needed regarding indications for and impacts of LAVV intervention as one-third had an LAVV prosthesis by the end of follow-up.

Abstract 13727: Prediction of Pacemaker Implantation in Patients With Postoperative Heart Block: A Data Analytics Approach

Introduction: Current guidelines recommend observation for AV node recovery until postoperative days (POD) 7 to 10 for patients with complete heart block (CHB) after congenital cardiac surgery prior to permanent pacemaker (PPM) placement. We created a predictive tool to identify patients at high risk of requiring PPM before POD 7 to aid in surgical decision making. Methods: Postoperative CHB cases from August 2009 to January 2019 were identified. We collected demographic, anatomic, and surgical details. Random forest, logistic regression, and decision tree models were trained and evaluated using 5-fold cross validation, then prospectively validated on data from January 2019 to April 2021. Separate models were developed for all patients on POD 0 and those without recovery on POD 4. Results: Of 101 cases of CHB (22 in validation cohort), 60 (59%) required PPM. Median days [IQR] to AVN recovery was 3 [1-7] and PPM was 10 [7-13]. A decision tree model was used for its performance and interpretability, and included: (1) aortic valve replacement, subaortic stenosis repair, or Konno incision; (2) ventricular L-loop; (3) atrioventricular valve replacement; (4) use of preoperative antiarrhythmic agent (in POD 0 model only; figure 1). The POD 4 model (table 1) had a positive predictive value (PPV) of 0.94 [95% CI 0.81-0.98], which was stable in prospective validation (PPV 1.0). Conclusions: Our decision tool identified patients requiring PPM with high specificity and PPV. On POD 4, patients with left ventricular outflow tract repair, AV valve replacement, or ventricular L-Looping could be considered for PPM placement before POD 7 to reduce risks of temporary pacing and improve care efficiency.

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.

Ethical Issues in the Care of Emerging Adults in Pediatric Intensive Care Units.

Ethical Issues in the Care of Emerging Adults in Pediatric Intensive Care Units.

Effect of Earlier Atrioventricular Valve Intervention on Survival After the Fontan Operation

Whereas the prevalence and impact of atrioventricular valve (AVV) regurgitation in patients with single ventricle physiology has become increasingly apparent, the optimal timing for valve intervention is unclear. To investigate this, we performed a retrospective review of all 1,167 patients from the Mayo Clinic Fontan database. Thirteen percent (153 patients) had AVV repair or replacement during their staged single ventricle palliation. We found that patients with right ventricular morphology and common AVV were at increased risk for AVV intervention. Patients who underwent AVV intervention had increased risk of death/transplant compared with those who did not (hazards ratio [HR] = 1.75, 95% CI 1.37 to 2.23, p <0.001). With respect to valve intervention timing, whereas AVV intervention before Fontan presented similar risk for death/transplant compared with no AVV intervention (HR = 0.85, 95% CI 0.32 to 2.27, p = 0.74), intervention at time of Fontan had a significantly higher risk (HR = 1.46, 95% CI 1.09 to 1.97, p = 0.01), and intervention after Fontan had a much more substantial risk (HR = 3.83, 95% CI 2.54 to 5.79, p <0.001). AVV repair failure occurred in 11% of patients. In terms of relative risk of valve repair versus replacement, in post-Fontan AVV intervention patients, AVV replacement carried a 2.9 fold risk of death/transplant compared with AVV repair. In conclusion, AVV disease remains a considerable challenge for durable Fontan physiology. This data demonstrates that earlier intervention on valve pathology improves survival with the Fontan circulation. Continued surveillance of single ventricle patients and prompt referral of those with valve pathology can improve outcomes in this challenging population.

Cylinder mitral and tricuspid valve replacement in neonates and small children.

Atrioventricular valve replacement in small children is associated with high morbidity and mortality. There are no prostheses available with a diameter ˂15 mm. This study reports our initial experience with a cylinder valve for mitral and tricuspid valve replacement in infants and small children. Our cylinder valve was hand-made for patients requiring atrioventricuclar valve replacement with an annulus of <15 mm. A 12-mm Contegra valve was prepared and placed inside a 14-mm Gore-Tex tube graft and sutured on both extremities. Eight patients were included, with a median age of 6.9 months (range 1 day to 38 months). Four had mitral and 4 had tricuspid valve replacement. All implants were technically successful, with no significant regurgitation, no stenosis and no left ventricular outflow tract obstruction. There were 3 early deaths from low cardiac output, in patients with significant associated lesions (severe neonatal Ebstein's, pulmonary artery-intact ventricular septum, biventricular conversion from Norwood stage 1). Two patients required early reintervention: 1 for balloon dilatation for stenosis and 1 for reoperation for paravalvular leak. During follow-up, 2 patients had mitral valve replacement with a 16-mm mechanical valve at 9 and 20 months from the cylinder valve implantation. The remaining 2 patients are alive and well 2 years and 2 months after the procedure. Cylinder valve replacement of atrioventricular valves was feasible without any technical issues. It was successful in getting out of a difficult situation and allows for somatic growth and implantation of a reasonably-sized mechanical prosthesis on the annulus.

Outcomes of Supra-annular Mechanical Atrioventricular Valve Replacement with Polytetrafluoroethylene Graft in Infants and Children.

Despite improvements in valve repair techniques, conditions in which infants and children need for mechanical valve replacement (MVR) are still present. We analyzed supra-annular MVR outcomes in infants and children with small annulus and compared them with conventional annular MVR outcomes. Data were collected retrospectively from medical records of infants and children (weighing < 20kg) who underwent atrioventricular valve replacement with mechanical valve in Seoul National University Children's Hospital between December 1984 and January 2019. We identified 8 patients (median age 20months, median weight 10.2kg) who underwent supra-annular MVR with polytetrafluoroethylene graft (supra-annular group). The patients were diagnosed with congenital mitral valve malformation (5 patients), complete atrioventricular septal defect (2 patients), and functional single ventricle (1 patient). The implanted mechanical valve size ranged from 16 to 23mm. Thirty-three patients (median age 40months, median weight 13kg) underwent conventional annular MVR (annular group). The survival rate was not significantly different between the supra-annular and annular groups (75.0 vs 78.8%, P = 0.816). In patients with biventricular repair (7 patients with supra-annular MVR and 28 patients with annular MVR), mechanical valve-to-mitral valve annulus size ratio was higher in the supra-annular group than in the annular group (1.24 ± 0.30 vs 0.96 ± 0.22, P = 0.035). No coronary complication or heart block were observed in the supra-annular group. Supra-annular MVR with polytetrafluoroethylene graft may be a feasible surgical option in children with a small annulus when valve repair is unsuccessful.

Atrioventricular Valve Repair in Single Ventricle Physiology: Timing Matters.

Atrioventricular valve (AVV) regurgitation in patients with single ventricle (SV) physiology severely impacts prognosis; the appropriate timing for surgical treatment is unknown. We sought to study the results of surgical treatment of AVV regurgitation in SV patients and evaluate risk factors for mortality. Medical records of 81 consecutive patients with moderate or severe AAV regurgitation who were submitted to AVV repair or replacement during any stage of univentricular palliation between January 2013 and May 2017 were examined. We studied demographic data and perioperative factors looking for predictors that might have influenced the results. Binary logistic regression was used to assess the impact on postoperative ventricular dysfunction and mortality. Median age and weight were seven months (interquartile range [IQR]: 3-24) and 5.2 kg (IQR: 3.7-11.2), respectively. Seventy (86.4%) patients underwent AVV repair, and 11 (13.6%) patients underwent AVV replacement. There was an association between AVV repair effectiveness and timing of intervention (P = .004). Atrioventricular valve intervention at the time of initial surgical palliation was associated with more ineffective repairs (P = .001), while AVV replacement was more common between Glenn and Fontan procedures (P = .004). Overall 30-day mortality was 30.5% (25 patients). In-hospital mortality was 49.4%, and it was higher when AVV repair was performed concomitant with initial (stage 1) palliation (64.1% vs 35.7%; P = .01) and when an effective repair was not achieved (75% vs 41%; P = .008). Multivariable analysis identified timing concomitant with stage 1 palliation as an independent risk factor for mortality (P = .01); meanwhile, an effective repair was a protective factor against in-hospital mortality (P = .05). Univentricular physiology with AVV regurgitation is a high-risk group of patients. Surgery for AVV regurgitation at stage 1 palliation was associated with less effective repair and higher mortality in this initial experience. On the other hand, effective repair determined better outcomes, highlighting the importance of experience and the learning curve in the management of such patients.

THROMBOEMBOLISM IN THE ADULT FONTAN POPULATION: A MARKER OF FONTAN CIRCULATORY DYSFUNCTION?

The reported incidence of clinical and/or silent thromboembolism (TE) in Fontan patients varies in the literature from 10-35%. Clinical TE has been shown to be associated with increased mortality in the Fontan population. It is unknown whether clinical and/or silent TE is a marker of Fontan circulatory dysfunction or occurs in isolation and is of minimal clinical consequence. Our objective was to determine: 1) prevalence of clinical and silent Fontan or pulmonary artery thromboembolism (TE) in an adult Fontan population and its’ relationship with adverse cardiac events; and 2) the association of Fontan TE with extra-cardiac organ dysfunction. A retrospective study of adult Fontan patients actively followed at St. Paul’s Hospital, who underwent definitive assessment for TE with either cardiac CT or MRI between 2000 and 2018. Adverse cardiac event were defined as death, heart transplantation or surgery for Fontan conversion or atrioventricular valve replacement. Sixty seven patients were included. TE was present in 15 (22%) patients, of which 8 (53%) were silent. TE was present in 41% (7/17) with a classic Fontan and 16% (8/50) with a total cavopulmonary connection (TCPC). TE was associated with increased rates of adverse cardiac event compared to those without [27% (4/15) vs.8% (4/52), p=0.02]. There was also a lower albeit normal eGFR in the TE group (p=0.02). Liver enzymes, VAST score and protein losing enteropathy was similar between the two groups. The incidence of TE is higher in the classic Fontan compared with TCPC. TE is associated with more adverse cardiac events, although it appears to be a marker rather than a cause of abnormal cardiac hemodynamics. No clear relationship was seen between TE and extracardiac organ dysfunction, suggesting that TE is likely not a marker of overall Fontan circulatory dysfunction. Nearly half of the TE detected in our cohort was clinically silent, highlighting the need to consider regular screening of the Fontan circuit with multimodality imaging.

Clinical Importance of Fontan Circuit Thrombus in the Adult Population: Significant Association With Increased Risk of Cardiovascular Events

BackgroundThe impact of Fontan circuit thrombus is poorly understood. The objectives of this study were to determine (1) the incidence of Fontan circuit thrombus and proportion of silent thrombus; (2) any association between Fontan circuit thrombus and markers of Fontan circulatory dysfunction; and (3) the association of Fontan circuit thrombus with adverse cardiac outcomes. MethodsWe conducted a retrospective review of adult patients who underwent the Fontan procedure (aged > 18 years) followed at St. Paul’s Hospital who underwent cardiac computed tomography or magnetic resonance imaging assessment (n = 67). Fontan circulatory dysfunction markers included clinical heart failure, N-terminal pro-brain natriuretic peptide, ventricular dysfunction, atrioventricular valvular regurgitation, refractory arrhythmias, declining exercise capacity, and hepatic/renal dysfunction. Adverse cardiac outcomes were death, heart transplantation, or surgery for Fontan revision or atrioventricular valve replacement. ResultsFontan circuit thrombus was present in 15 of 67 patients (22%): 41% (7/17) classic/modified Fontan and 16% (8/50) total cavopulmonary connection. Incidence was 36% among those suspected to have Fontan circuit thrombus; 14% in those with no clinical/echocardiographic suspicion; and clinically silent in 40% diagnosed with Fontan thrombus. The time from Fontan surgery to Fontan circuit thrombus diagnosis was 22 ± 6 years in the classic/modified group vs 14 ± 8 years in the total cavopulmonary connection group (P = 0.03. Fontan circuit thrombus was associated with adverse cardiac outcomes (27% [4/15] vs 8% [4/52], P = 0.02), but there was no difference in Fontan circulatory dysfunction markers. ConclusionGiven the incidence of Fontan circuit thrombus and association with adverse cardiac outcomes, routine surveillance of the Fontan circuit should strongly be considered. The identification of thrombus should lead to anticoagulation implementation/optimization, along with screening/intervention for reversible Fontan circulatory issues in an attempt to prevent adverse cardiac outcomes.

Long-term results of ventricular septation for double-inlet left ventricle†

To review the long-term surgical outcomes of ventricular septation for double-inlet left ventricle and reconsider the possibility of ventricular septation as an option of surgical treatments. Between 1978 and 1994, 22 patients with double-inlet left ventricle underwent ventricular septation. The mean age at operation was 5.3 years (range 0-22 years). Follow-up was carried out in 20 of 22 patients (91%) and the mean follow-up period was 14.7 years (range 0-39 years). Actuarial survival and reoperation-free survival rates at 30 years were 49% and 21%, respectively. To date, 8 patients have been followed up. Among them, atrioventricular valve replacement and permanent pacemaker were required in 4 and 7 patients, respectively. Late cardiac catheter examination at 25.5 years after surgery showed that the median cardiac index was 2.6 l/min/m2 (range 2.1-3.4 l/min/m2), left ventricular end-diastolic pressure was 7 mmHg (range 4-11 mmHg), left ventricular ejection fraction was 50% (range 27-63%), right ventricular ejection fraction was 53% (range 31-66%) and central venous pressure was 6 mmHg (range 4-11 mmHg). At the latest follow-up, the New York Heart Association Functional Classification was I for 5 patients, II for 2 patients and III for 1 patient. The median peak oxygen uptake was 52.9% (range 44.1-93.5%). Some patients with double-inlet left ventricle were able to maintain low central venous pressure and a sufficient cardiac index long after ventricular septation. Although the single ventricle strategy remains a first-line treatment, ventricular septation can be a surgical treatment option.

Systemic Atrioventricular Valve Replacement in Patients With Functional Single Ventricle

To review the outcome after atrioventricular valve replacement in single ventricle patients. The medical records of 37 consecutive patients who underwent initial valve replacement between 2001 and 2016 were reviewed. Actuarial survival rates were 73%, 65%, and 59% at 1, 5, and 10 years, respectively. Multivariate analysis indicated body surface area <0.28 m2 (P = 0.007; hazard ratio, 31.1), preoperative inotropic support (P < 0.001; hazard ratio, 24.5), primary valve replacement (P = 0.044; hazard ratio, 6.1), oversized prosthesis (P = 0.001; hazard ratio, 14.5), and intra- or postoperative extracorporeal membrane oxygenation support (P < 0.001; hazard ratio, 53.2) were the risk factors for mortality. Cumulative incidences of redo replacement were 11%, 17%, and 17% at 1, 5, and 10 years, respectively. There was no risk factor for redo replacement. Among 11 patients undergoing valve replacement before or at the time of bidirectional cavopulmonary shunt, all 4 patients who reached Fontan completion survived. Among 13 patients undergoing valve replacement after bidirectional cavopulmonary shunt, only 3 patients reached Fontan completion. Among 11 patients undergoing valve replacement after Fontan completion, there were 3 operative mortalities and 2 late mortalities. For 7 of 8 hospital survivors, cardiac index improved from 2.2 L/min/m2 (interquartile range, 2.0-2.4) to 3.4 (2.8-3.7) (P = 0.002). Atrioventricular valve replacement was a reasonable choice of treatment for single ventricle patients. For small patients with impaired ventricular function who had no choice other than valve replacement, commercially available valves were oversized and outcomes remained poor.

Systemic atrioventricular valve replacement by mechanical prosthesis in children: Evolution in practice and predictors of long-term outcome

Systemic atrioventricular mechanical valve replacement (SAVR) in children is challenging particularly in the youngest because of poor long-term outcomes related to the fixed size of the prosthesis and the anticoagulation treatment. We reviewed the clinical and surgical records of 85 children who underwent SAVR at our institution between 2000 and 2017. The median age and the median weight at first operation were respectively 3.1 years (range: 1 month to 17 y) and 11.4 kg (range: 2.5 to 68 kg). Twenty-six patients (31%) were < 1-year-old. Median follow-up for operative survivors was 4.3 years (IQR: 2.3–9.5 y, up to 17.5 y, 98% complete). Global mortality was 18%. One-year, five-year and ten-year patient survival was respectively 87%, 82% and 78%. No significant predictive factor was associated with operative mortality. Among survivors, the 10-year freedom from reoperation was 74%. Complications after SAVR included heart block requiring pacemaker (13%) with a higher risk in case of atrioventricular canal ( P = 0.004), bleeding (7%), prosthesis thrombosis (3.5%), stroke (2%) and endocarditis (5%). By multivariate age-adjusted analysis, the surgical strategies were the most important contributors to the long-term outcome. While undergoing a prosthesis implantation in supra-annular position was at high risk of late complications (OR = 1.6, P = 0.017), using an inversed aortic prosthesis prevented them (OR = −2.3, P = 0.004). SAVR replacement remains a challenging procedure with high mortality but limited mortality related to anticoagulation. Modifications of the operative technics are one of the major causes of better long-term outcome.

Surgical management of atrioventricular valve regurgitation in functional single ventricle

Objective: To evaluate the early- and mid-term outcomes of surgical atrioventricular valve (AVV) intervention in patients with functional single ventricle (FSV). Methods: The clinical data of 40 consecutive FSV patients who underwent surgical AVV intervention between January 2008 and December 2017 at Department of Cardiac Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University were reviewed retrospectively. There were 25 male and 15 female patients. The median age at AVV intervention was 4.5 to 204.0 months (M(Q(R)): 42.5 (59.7) months), and the median body weight was 6.0 to 55.4 kg (M(Q(R)): 13.8 (8.1) kg). The systemic AVV morphology included common AVV in 21 patients, mitral valve in 7 patients, tricuspid valve in 3 patients, and both mitral and tricuspid valve in 9 patients. At first surgical intervention, 15 patients had severe, 25 patients had moderate AVV regurgitation. The timings of the initial surgical intervention were at the first palliative, Glenn, between Glenn and Fontan, and Fontan stage in 5, 23, 4, and 8 patients, respectively. The methods of the initial surgical intervention were AVV repair in 31 patients, AVV replacement in 9 patients. Actuarial survivals were estimated by the Kaplan-Meier method. Prognosis factors for atrioventricular valve reoperation were analyzed using the Cox regression hazard model. Results: There were 6 early deaths, with a mortality of 15.0%. Thirty-four survival patients received a follow-up of 1 to 117 months (M(Q(R)): 44 (34) months). Survival of patients after the initial surgical intervention were 85.0% (95% CI: 74.0% to 95.9%), 79.3% (95% CI: 66.6% to 92.0%), and 79.3% (95% CI: 66.6% to 92.0%) at 1 year, 5 years and 10 years, respectively. In all, only 13 patients completed the Fontan procedure. Six patients underwent 8 reoperations, including AVV replacement in 5 patients, redo AVV repair in 3 patients. Freedom from AVV reoperation at 1 and 5 years was 89.8% (95% CI: 78.8% to 100%) and 79.4% (95% CI: 64.7% to 94.1%), respectively. Multivariate Cox regression analysis revealed that common AVV (HR=3.53, 95% CI: 1.63-7.67, P=0.020) was the prognosis factors for AVV reoperation. Conclusions: The early- and mid-term outcomes of surgical AVV intervention in FSV patients are not satisfactory. The mortality and reoperation rate are still high, and common AVV predicts the AVV reoperation after the initial surgical intervention.

Dysrhythmias in patients with a complete atrioventricular septal defect: From surgery to early adulthood.

ObjectiveOutcomes after surgical repair of complete atrioventricular septal defect (cAVSD) have improved. With advancing age, the risk of development of dysrhythmias may increase. The aims of this study were to (1) examine development of sinus node dysfunction (SND), atrial and ventricular tachyarrhythmias, and (2) study progression of atrioventricular conduction abnormalities in young adult patients with repaired cAVSD.Study designIn this retrospective multicenter study, 74 patients (68% female) with a cAVSD repaired in childhood were included. Patients’ medical files were evaluated for occurrence of SND, atrioventricular conduction block (AVB), atrial and ventricular tachyarrhythmias.ResultsMedian age at repair was 6 months (interquartile range 3‐10) and median age at last follow‐up was 24 years (interquartile range 21‐28). SND occurred after a median of 17 years (interquartile range 11‐19) after repair in 23% of patients, requiring pacemaker implantation in two patients (12%). Regular supraventricular tachycardia was observed in three patients (4%). Atrial fibrillation and ventricular tachyarrhythmias were not observed. Twenty‐seven patients (36%) had first‐degree AVB, which was self‐limiting in 16 (59%) and persistent in 10 (37%) patients. One patient developed third‐degree AVB 7 days after left atrioventricular valve replacement. Spontaneous type II second‐degree AVB occurred in a 28‐year‐old patient. Both patients underwent pacemaker implantation.ConclusionsClinically significant dysrhythmias were uncommon in young adult patients after cAVSD repair. However, three patients required pacemaker implantation for either progression of SND or spontaneous type II second‐degree AVB. Longer follow‐up should point out whether dysrhythmias will progress or become more prevalent with increasing age.