Atrioventricular Valve Regurgitation Grade Research Articles

Predictors of Early Postoperative Supraventricular Tachyarrhythmias in Children After the Fontan Procedure.

Postoperative arrhythmias are a frequent and fatal complication after the Fontan operation. However, clinical evidence demonstrating early postoperative arrhythmias in children undergoing the Fontan operation is limited. This study aimed to evaluate the prevalence of arrhythmias and identify the predictors of early postoperative supraventricular tachyarrhythmias (SVTs) after the Fontan procedure.Data were analyzed from 80 pediatric patients who underwent Fontan procedures between April 2000 and December 2017 in a single-center retrospective study. Early postoperative SVTs were defined as arrhythmias within 30 days after the Fontan procedure. We divided the patients into two groups, with or without early postoperative arrhythmias, and the predictors of early postoperative arrhythmias were analyzed. A multivariate logistic regression analysis was performed to determine independent predictors of early postoperative SVTs after the Fontan procedure.Early postoperative SVTs were observed in 21 patients (26.3%). The most common arrhythmia was junctional ectopic tachycardia. After an adjustment, an atrioventricular valve regurgitation (AVVR) grade of ≥2 (odds ratio 10.54, 95% confidence interval 2.52 to 44.17, P = 0.001) and preoperative arrhythmias (odds ratio 26.49, 95% confidence interval 1.64 to 428.62, P = 0.021) were significant predictors of early postoperative SVTs after the Fontan operation.An AVVR grade ≥2 and preoperative arrhythmia were significant predictors associated with early postoperative SVTs. Intervention for AVVR may provide clinical benefit for preventing early postoperative arrhythmias after the Fontan operation.

Atrioventricular valve regurgitation in patients undergoing total cavopulmonary connection: Impact of valve morphology and underlying mechanisms on survival and reintervention

ObjectiveThe study objective was to determine the mechanisms of atrioventricular valve regurgitation in single-ventricle physiology and their influence on outcomes after total cavopulmonary connection. MethodsAmong 460 patients who underwent a total cavopulmonary connection, 101 (22%) had atrioventricular valve surgery before or coincident with total cavopulmonary connection. ResultsAtrioventricular valve morphology showed 2 separated in 33 patients, mitral in 11 patients, tricuspid in 41 patients, and common in 16 patients. Patients with a tricuspid and a common atrioventricular valve underwent atrioventricular valve surgery frequently, 27% and 36%, respectively. Atrioventricular valve regurgitation was due to 1 or more of the following mechanisms: dysplastic leaflet (62), prolapse (53), annular dilation (27), cleft (22), and chordal anomaly (14). Structural anomalies were observed in 89 patients (88%). The procedure was atrioventricular valve repair in 81 patients, atrioventricular valve closure in 16 patients, and atrioventricular valve replacement in 4 patients. Among 81 patients who underwent initial repair, repeat repair was required in 20 patients, atrioventricular valve replacement was required in 7 patients, and atrioventricular valve closure was required in 3 patients. Among patients undergoing atrioventricular valve surgery, overall survival after total cavopulmonary connection (88% vs 95% at 15 years, P = .01), freedom from atrioventricular valve reoperation after total cavopulmonary connection (75% vs 99% at 15 years, P < .01), and grade of atrioventricular valve regurgitation at a median follow-up of 6.6 years (P < .01) were worse than in those who did not require atrioventricular valve surgery. ConclusionsAtrioventricular valve regurgitation in univentricular heart is more frequently associated with a tricuspid or a common atrioventricular valve, and structural anomalies are the primary cause. Significant atrioventricular valve regurgitation requiring surgery influences survival after total cavopulmonary connection, especially when atrioventricular valve replacement was needed. Surgical management based on mechanisms of regurgitation is mandatory.

Improved Ventricular Function after TEE-guided Cardioversion of Atrial Arrhythmias in Patients after the Fontan Operation.

Atrial tachyarrhythmias frequently develop after the Fontan operation. Patients with Fontan physiology rely on atrial contribution to cardiac output, and thus control of atrial arrhythmias is important. Outcomes after cardioversion in patients after Fontan have not been reported. We sought to determine if cardioversion results in improved echocardiographic parameters or clinical symptomatology; and, discern risk factors for arrhythmia recurrence. We retrospectively analyzed the Mayo Clinic echocardiographic database to capture patients after the Fontan operation who underwent transesophageal echocardiography-guided electrical cardioversion from 2000-2015. Clinical and echocardiographic data were collected and compared at baseline and follow-up. Eight hundred ninety patients with prior Fontan operation underwent echocardiographic evaluation; 341 (38%) developed atrial arrhythmias. Thirty-six patients [20 males, median age 29 (12-51)] underwent transesophageal echocardiography-guided cardioversion of atrial arrhythmias [atrial flutter/intraatrial reentrant tachycardia (75%); atrial fibrillation (25%)]. At follow-up, improvements were noted in ejection fraction by 10% (P < .0001); atrioventricular valve regurgitation grade (39%) (P = .002); New York Heart Association (NYHA) class (61%) (P < .001); and resolution of spontaneous echo contrast in the Fontan circuit (65%) (P < .01). No embolic events occurred following cardioversion. Eighteen patients (50%) developed recurrent atrial arrhythmias at 15 (3-36) months after cardioversion. Five-year freedom from arrhythmia recurrence was 61%. Significant univariate predictors of arrhythmia recurrence were atrial flutter/intraatrial reentrant tachycardia (HR = 4.3, P = .02); NYHA ≥ II (HR = 4.1, P = .03); systemic right ventricle (HR = 5.2; P = .02); and ejection fraction ≤ 40% (HR = 2.8; P = .04). On multivariate analysis, only systemic right ventricle (HR = 3.7; P = .02) remained an independent predictor of arrhythmia recurrence. After the Fontan operation, cardioversion of atrial arrhythmias improves ventricular function, atrioventricular valve regurgitation grade, and NYHA class. Arrhythmia recurrence was common and patients with atrial flutter/intraatrial reentrant tachycardia, systemic right ventricle, or reduced ventricular function may be at risk of arrhythmia recurrence. Further studies are required to identify additional risk factors and protective factors for arrhythmia recurrence.

Forward Flow Through the Pulmonary Valve After Bidirectional Cavopulmonary Shunt Benefits Patients at Fontan Operation

The impact of additional pulmonary forward flow (APF) through the pulmonary valve at the time of bidirectional cavopulmonary shunt (BCPS) is unknown. Between 2000 and 2010, 276 patients had BCPS and 126 of them were selected, including 60 patients with APF via pulmonary valve and 66 patients, in whom the pulmonary valve was closed. We compared the length of hospital stay and duration of pleural drainage at BCPS and Fontan operations. We also compared the number of surgical interventions before BCPS, the number of operations between BCPS and Fontan operation, Nakata index prior to Fontan operation, grade of atrioventricular valve regurgitation (AVVR), and oxygen saturations prior to Fontan operation. Prior to BCPS, 20% (12 of 60) of patients with APF and none without APF had pulmonary artery (PA) banding. More patients without APF had systemic-to-PA shunts (p < 0.01). Fontan operation was completed in 58% (35 of 60) of patients with APF and in 68% (45 of 66) of patients without APF (p = 0.34). There was no difference in the length of hospital stay or duration of pleural drainage at BCPS. No significant difference was observed in the number of surgical procedures between BCPS and Fontan operation, grade of AVVR or oxygen saturations before Fontan operation. Children with APF had a higher Nakata index (p = 0.02) prior to Fontan operation, shorter duration of pleural drainage (p = 0.009) and shorter hospital stay (p = 0.009) after Fontan operation. Children with APF at BCPS had better developed PAs, shorter duration of pleural drainage, and shorter hospital stay after Fontan operation.

The Natural History of Atrioventricular Valve Regurgitation Throughout Fetal Life in Patients with Atrioventricular Canal Defects.

Atrioventricular valve regurgitation (AVVR) influences morbidity and mortality in the atrioventricular canal defect (AVC). Fetal cardiac structures are subject to hemodynamic changes, as well as growth and maturation during gestation, which may alter the degree of AVVR and affect prognosis. We sought to investigate the frequency of change in degree of AVVR documented by fetal echocardiography (echo) between different periods of gestational age. Subjects with AVC seen in the Fetal Heart Program between January 2008 and September 2010 were identified. Degree of AVVR was assessed by color Doppler imaging and categorized as Grade 0 (no AVVR), Grade 1 (hemodynamically insignificant AVVR = trivial or mild), and Grade 2 (hemodynamically important AVVR = ≥moderate). Levels of AVVR between periods were compared. Forty-three fetuses were analyzed. Overall, 60% had no change, 14% had a decrease, and 26% had an increase in AVVR grade. Two fetuses progressed from Grade 0 or 1 to Grade 2, while one fetus decreased from Grade 2 to Grade 0. Trisomy 21 and heterotaxy syndrome were not risk factors for AVVR progression. Transitional and incomplete canal defects may be more susceptible to AVVR progression. Sixty percent of fetuses with AVC will not exhibit progression of AVVR between the second and third trimesters of gestation. In those who exhibit change, it is most often within a hemodynamically insignificant range between none and mild regurgitation (Grades 0 and 1). These findings have implications for the counseling, follow-up, and delivery plans of the fetus with AVC defect.

Influence of Bidirectional Cavopulmonary Anastomosis and Concomitant Valve Repair on Atrioventricular Valve Annulus and Function

The relationship between atrioventricular valve regurgitation (AVVR) and valve annulus after bidirectional cavopulmonary anastomosis (BCPA) and adequate indications for valve repair are unclear. We evaluated the size of the valve annulus and the grade of AVVR before and immediately after BCPA, and at the most recent follow-up before the Fontan operation in 37 patients with a functional single ventricle. Nine patients underwent concomitant valve surgery. The mean z value of the valve annulus was significantly lower postoperatively than preoperatively in the 28 patients who were not treated by valve surgery (0.45 vs 1.51, p=0.01). However, mean regurgitation scores did not significantly change after BCPA (1.60 vs 1.78, p=0.08). The most recent assessment showed that the mean z value increased compared with that immediately after BCPA (1.36 vs 0.45, p=0.005). This increase was significant in the patients with moderate regurgitation. The mean z value of the valve annulus of the patients treated by concomitant valvuloplasty was significantly lower postoperatively than preoperatively (-0.25 vs 3.9, p=0.0001) and remained low at the latest evaluation. Mean regurgitation scores also significantly decreased after BCPA (2.25 vs 3.37, p=0.007). Unloading the systemic ventricle by BCPA leads to a decrease in the relative size of the atrioventricular valve. However, this decrease does not improve the degree of AVVR in the absence of concomitant valve repair. Concomitant valve repair is justified in patients with moderate or worse AVVR and an abnormal valve structure.

Atrioventricular Valve Regurgitation in the Fetus With Atrioventricular Canal Defect: Transition From Prenatal to Postnatal Life

Atrioventricular valve regurgitation (AVVR) is a clinically important element of the common atrioventricular canal defect. Cardiac preload and afterload increase from prenatal to postnatal life. These hemodynamic changes may increase the degree of regurgitation and affect management and prognosis. We sought to investigate the frequency of change in degree of AVVR from fetal to postnatal life in this patient population. Subjects who underwent both fetal and postnatal echocardiography within 4 weeks of life between January 2008 and September 2010 were included in the study. Degree of AVVR was assessed by color Doppler imaging and scored as 0 (no regurgitation), 1 (hemodynamically insignificant regurgitation), and 2 (hemodynamically important regurgitation). Forty-nine subjects were included. Mean gestational age at fetal echocardiogram was 34 ± 2.8 weeks; age at postnatal echocardiogram was a median of <24 h of age (range 0-24). After birth, 69 % subjects had no change, 8 % of subjects had a decrease, and 22 % subjects had an increase in AVVR grade. Five patients progressed from a fetal score 0 or 1 to postnatal score 2. Neither trisomy 21 nor heterotaxy syndrome were risk factors for progression of AVVR. In patients with AV canal defects, 90 % demonstrate no hemodynamically significant change in AVVR from fetal to postnatal life, whereas 10 % display a hemodynamically significant change. AVVR appreciated in utero is predictive of neonatal regurgitation in the majority of patients. These findings have implications for the counseling and management of the fetus with AV canal defect.

Long-Term Serial Aerobic Exercise Capacity and Hemodynamic Properties in Clinically and Hemodynamically Good, "Excellent", Fontan Survivors

The serial hemodynamics and predictors of long-term, good Fontan survivors remain unknown. Two hundred one patients who had undergone a Fontan operation before September 1998 were reviewed to compare their long-term clinical status with serial hemodynamics. During a mean follow-up of 18.7 years, 47 (30.1%) of the 156 survivors had no clinical events that required an unscheduled hospitalization. Of those, 18 survivors exhibited good serial hemodynamics and the respective mean values of central venous pressure (CVP, mmHg), cardiac index (CI, L·min(-1)·m(2)), and ventricular ejection fraction (EF, %) before and 1, 5, 10, and 15 years after the operation were as follows: 3.8, 9.0, 11.3, 10.6, and 10.1 (CVP); 3.6, 3.1, 2.8, 2.6, and 2.6, and 69 (CI); 57, 56, 58, 54, and 53 (EF). Serial values of CVP, ventricular end-diastolic pressure (EDP) and the grade of atrioventricular valve regurgitation (AVVR) were lower and the peak oxygen uptake was greater in the good patients (P<0.05 for all). A 1-year postoperative lower CVP and no history of AVVR repair during the Fontan operation independently predicted the good patients (P<0.05). A lower CVP and EDP, better atrioventricular valvular function, and greater exercise capacity characterize good Fontan survivors and an early postoperative low CVP without an AVVR repair predicts good survivors.

Pulmonary venous blood flow pattern in patients with univentricular hearts following total cavo-pulmonary connection.

The objective of the study was evaluation of the pulmonary venous blood flow (PVF) pattern and the influence of ventricular function and atrioventricular valve regurgitation on this flow in patients with univentricular hearts post total cavo-pulmonary connection (TCPC). Transthoracic or transoesophageal echocardiographic studies were performed in 24 children with normal hearts (group A) and in 24 patients with univentricular hearts (group B). Ventricular function and atrioventricular valve regurgitation was semiquantitatively assessed. Systolic/diastolic maximal velocities and velocity time integrals (VTI) were measured from PVF tracings. Ejection fraction was measured by radionuclide angiography in 11 patients. Twelve patients underwent heart catheterization and angiography. In group B the PVF showed a biphasic flow velocity curve. The systolic integrals were smaller and the diastolic integrals were larger than in group A (6.4 vs. 13.0 cm, P = 0.0001, and 13.9 vs. 10.0 cm, P = 0.005). The pulmonary venous systolic flow fraction in 13 patients with an open fenestration and/or atrioventricular valve regurgitation grade 2-3 was significantly lower than in those 11 patients without fenestration and none/small regurgitation (0.19 vs. 0.40, P = 0.05). In conclusion, the PVF pattern in children with univentricular hearts pallitated with TCPC is similar to the PVF pattern found in individuals with biventricular hearts showing a biphasic flow velocity curve despite the absence of pulsatile pulmonary artery flow. The PVF in patients with TCPC-palliated univentricular hearts is influenced by atrioventricular valve regurgitation and fenestration flow.