Greater Regurgitation Research Articles

Prognostic utility of a risk prediction model for predischarge major residual lesions or unplanned reinterventions following congenital mitral valve repair

ObjectiveWe sought to develop a risk prediction model for predischarge major mitral valve (MV) residual lesions or unplanned MV reinterventions following congenital MV repair. MethodsPatients who underwent congenital MV repair (excluding primary repair, but including secondary repair, of canal-type defects) at a single institution from January 2000 to December 2020 and survived to discharge were retrospectively reviewed. The primary outcome was major MV residua (mean gradient >6 mm Hg or moderate or greater regurgitation on the discharge echocardiogram) or predischarge unplanned MV reintervention. Risk factors of interest included age, single-ventricle physiology, preoperative and intraoperative postrepair MV stenosis and regurgitation severity, MV annular diameter z score, systemic ventricle ejection fraction, unfavorable anatomy, concomitant left-heart procedure, and various technique-related categories. Logistic regression was used to develop a weighted risk score for the primary outcome. Internal validation using bootstrap-resampling was performed. ResultsOf 866 patients who underwent congenital MV repair at a median age of 2.7 years (interquartile range, 0.7-9.1 years), 202 (23.3%) patients developed the primary outcome. The final risk prediction model had a C-statistic of 0.82 (95% confidence interval, 0.78-0.85). A weighted risk score was formulated per the variables in this model. The median risk score was 8 (interquartile range, 6-11) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score ≥16) risk. The probability of the primary outcome was 5.0 ± 1.7%, 15.2 ± 6.7%, 45.9 ± 12.6%, and 76.7 ± 8.8% for low-, medium-, high-, and very-high-risk patients, respectively. ConclusionsOur risk prediction model may guide prognostication of patients following congenital MV repair.

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.

Impact of Aortic Atresia After Fontan Operation in Patients With Hypoplastic Left Heart Syndrome

BackgroundPatients with aortic atresia have the worst prognosis in the spectrum of hypoplastic left heart syndrome. It remains unknown whether patients with aortic atresia continue to do poorly after Fontan operation. This study aimed to determine the association between aortic atresia and atrioventricular valve (AVV) function and clinical outcomes after Fontan operation in patients with hypoplastic left heart syndrome. MethodsWe performed a retrospective study of 1731 patients who survived the Fontan operation from the Australia and New Zealand Fontan Registry between 1975 and 2020. ResultsWe identified 188 patients with hypoplastic left heart syndrome, including 99 (53%) with aortic atresia. Overall transplant-free survival and freedom from failure of Fontan circulation at 15 years was 91% (95% CI, 86%-96%) and 79% (95% CI, 71%-88%), respectively. The cumulative incidence of AVV operation at 15 years of age for patients with aortic atresia and aortic stenosis was 28% (95% CI, 19%-38%) and 14% (95% CI, 7%-22%; P = .03), respectively. The cumulative incidence of AVV failure (moderate or greater regurgitation or AVV operation) at 15 years of age for patients with aortic atresia and aortic stenosis was 50% (95% CI, 37%-61%) and 30% (95% CI, 19%-42%; P = .01). Patients with AVV failure were at increased risk of having moderately, or worse, decreased systolic ventricular function (odds ratio 6.7; 95% CI, 1.7-33; P = .01) and failure of Fontan circulation (hazard ratio 3.7; 95% CI, 1.5-9.1; P < .01). ConclusionsIn patients with hypoplastic left heart syndrome, there is no significant difference in transplant-free survival after Fontan operation between patients with aortic atresia and patients with aortic stenosis. However, patients with aortic atresia have a much higher burden of AVV failure than patients with aortic stenosis. Atrioventricular valve failure is associated with failure of Fontan circulation.

Adjuvant combined therapy with trastuzumab in patients with HER2‑ positive breast cancer and cardiac alterations: implications for optimal cardio‑oncology care.

Recently, the prognosis of patients with HER2‑positive breast cancer (BC) has improved significantly owing to the use of combined treatment modalities. However, systemic treatment is as-sociated with increased risk of cardiotoxicity. We aimed to assess subclinical cardiac alterations during the final stage of adjuvant com-bined therapy, that is, trastuzumab therapy (TT), as potential predictors of late cardiac complications in patients with HER2‑positive BC. We enrolled 251 patients with HER2‑positive BC treated with a radical local therapy, adjuvant chemotherapy (anthracyclines or anthracyclines + taxanes), and immunotherapy (trastuzumab). Patients underwent 6 echocardiographic examinations: at baseline, during TT, and after TT, with assessment of left ventricular ejection fraction (LVEF), degree of valvular regurgitation, and cardiac chamber diameters. Valvular fibrosis (28.4% of patients) was associated with older age, hypertension at baseline, and a higher degree of regurgitation during TT. Reduced LVEF, greater regurgitation, and larger cardiac chamber diameters were noted during TT. The patients who received higher anthracycline doses showed a greater degree of aortic insufficiency and a larger right ventricular diameter. Reduced LVEF during TT was associated with radiotherapy or chemotherapy and the degree of valvular regurgitation. Significantly larger diameters were observed in older patients and in those with comorbidities at baseline, high body mass index, and regurgitation. Asymptomatic subclinical cardiac alterations during TT may predict late cardiac complica-tions; however, longer follow‑up is necessary to confirm this hypothesis. Patients with HER2‑positive BC should be closely monitored for possible cardiac alterations during and after therapy to ensure optimal care and guide therapeutic decision‑making.

Right Heart Morphology of Candidate Patients for Transcatheter Tricuspid Valve Interventions

PurposeThis study quantitatively evaluated the phasic right heart morphology of candidate patients for a transcatheter tricuspid valve intervention (N=32) and of subjects with trace to no tricuspid regurgitation (N = 14).MethodsCardiac computed tomography angiography (CCTA) and transthoracic/transesophageal echocardiography (TTE/TEE) images were analyzed using dedicated research and clinical software. Using CCTA, the phasic right atrial and ventricular volumes, annulus dimensions, annulus-to-right coronary artery (RCA) distances, circumferential topography of the annular tissue shelf, vena cava dimensions (inferior and superior), vena cava positions, axis angles, and annular excursions were quantified. Using TTE/TEE, leaflet geometry, regurgitation, hemodynamics, and heart function were quantified. Measurements within and between groups were quantitatively compared with regression analyses to explore relationships between right heart features.ResultsThe phasic position and orientation of the vena cava and the circumferential topography of the annular tissue shelf were quantitatively presented for the first time. The candidate patient group exhibited greater chamber dimensions, enlarged vena cava, distended vena cava positions, positional shallowing of the annular tissue shelf, geometric annular distortion, leaflet distention, moderate or greater regurgitation, and impaired ventricular function. Atrial volume correlated strongly with directional vena cava positions as well as with annular dimensions. Annulus-to-RCA distances and annular excursions were comparable between groups.ConclusionsThis study provides new and further insight to the right heart morphology and functional characteristics of candidate patients for a transcatheter tricuspid valve intervention. These data provide a platform from which these patients can continue to be better understood for further improving transcatheter system design and use.

Impact of Pre-Existing Mitral Regurgitation Following Left Ventricular Assist Device Implant

Optimal management of significant mitral regurgitation (SMR) during left ventricular assist device (LVAD) placement remains uncertain. This study evaluates the effect of untreated preop SMR on outcomes following LVAD implant. Adults undergoing primary LVAD placement from April 2004 to May 2017 were included. Most recent preop transthoracic echocardiogram (TTE) was used to divide patients into an SMR group with moderate or greater regurgitation, and a group without SMR. Patients underwent LVAD implant without correction of SMR. Primary endpoint was 3-year postoperative survival, with secondary endpoints of length of stay (LOS), resolution of SMR following LVAD on postdischarge (30 day) TTE, and 1-year TTE. LVAD placement was performed in 270 patients, 172 (63.7%) without SMR and 98 (36.3%) with SMR. There were no differences in comorbidities including diabetes, hypertension, and renal disease. Preop ejection fraction was similar, but a higher pulmonary vascular resistance was recorded in the SMR group (3.6 vs 3.0 Wood Units, P = 0.048). There was no difference in 3-year mortality between the 2 cohorts (log-rank P = 0.0.803). The SMR group had decreased LOS (median 19.5 vs 22 days, P = 0.009). Of the 98 SMR patients, 91 (92.9%) had resolution of SMR to less than moderate at 30 days. At 1 year, 15% of those with preoperative SMR had recurrent SMR. Patients undergoing LVAD placement with preop SMR experience no differences in mortality, and a majority experience resolution of MR after implant. Longer-term SMR recurrence and need for mitral intervention with LVAD implant warrant further investigation.

Magnetic resonance phase contrast velocity mapping for flow quantification in irregular heart rhythms using radial k-space ultrashort echo time imaging

BackgroundPhase contrast velocity mapping sequences utilising ultrashort echo time (UTE) radial k-space sequences have been used to reduce intravoxel dephasing at high velocities. We evaluated the accuracy of the UTE flow sequence for mitral regurgitation (MR) quantification, including patients with atrial fibrillation. MethodsForty patients underwent cardiac MRI for indirect MR quantification by assessment of aortic flow using a UTE phase contrast sequence (TE 0.65 ms) combined with left ventricular stroke volume. Retrospective ECG-gating was used in sinus rhythm (30 patients), prospective ECG-triggering in atrial fibrillation (10). MR was also quantified by a standard phase contrast sequence (TE 2.85 ms, standard flow method) and by comparing stroke volumes (volumetric method). ResultsUTE flow-derived MR measurement showed modest agreement in sinus rhythm (95% limits of agreement: ±38.2 ml; ±29.8%) and atrial fibrillation (±33.7 ml; ±30.3%) compared to standard flow assessment. There was little systematic bias in sinus rhythm (mean offset −4.4 ml /−3.5% compared to standard flow assessment), but a slight bias towards greater regurgitation in atrial fibrillation (+15.2 ml /+14.0%). There were wider limits of agreement between the UTE flow method and volumetric method than between the regular flow method and the volumetric method in sinus rhythm (±48.4 ml; ±36.4%; mean offset: −12.2 ml /−9.0%) and similar limits of agreement in atrial fibrillation (±29.6 ml; 25.8%; +12.0 ml /+10.3%). ConclusionsUTE flow imaging is inferior to conventional flow techniques for MR assessment in patients with sinus rhythm as well as atrial fibrillation. However, the number of atrial fibrillation patients in this initial study is small.

Atrioventricular Valve Failure in Fontan Palliation

BackgroundAtrioventricular valve failure (moderate or greater regurgitation, or valve operation) is a risk factor for adverse outcomes in patients undergoing Fontan palliation. ObjectivesThis study determined the incidence of atrioventricular valve failure and its clinical impact on patients undergoing Fontan palliation. MethodsA retrospective cohort longitudinal study was conducted using patient data extracted from an existing bi-national, population-based registry. ResultsA total of 1,468 patients who underwent Fontan palliation were identified; complete follow-up data were available for 1,199 patients. Six hundred eighty-six patients had 2 atrioventricular valves, 286 had a single mitral valve, 130 had a common atrioventricular valve, and 97 had a single tricuspid valve. A total of 132 repairs were performed in 110 patients, and 15 replacements were performed in 13 patients. The cumulative incidence of atrioventricular valve failure at 25 years of age for patients with a common atrioventricular, single tricuspid, single mitral, and 2 atrioventricular valves was 56% (95% confidence interval [CI]: 46% to 67%), 46% (95% CI: 31% to 61%), 8% (95% CI: 4% to 12%), and 26% (95% CI: 21% to 30%), respectively. In patients without valve failure, freedom from Fontan failure at 10 and 20 years post-Fontan palliation was 91% (95% CI: 89% to 93%) and 77% (95% CI: 73% to 81%), respectively, compared with 77% (95% CI: 69% to 85%) and 54% (95% CI: 42% to 68%), respectively, in patients with valve failure (hazard ratio: 2.43; 95% CI: 1.74 to 3.39; p < 0.001). ConclusionsAtrioventricular valve failure occurs frequently in patients undergoing Fontan palliation. Patients with valve failure are twice as likely to have their Fontan circulation fail than those without valve failure.

Contemporaneous management of valvular heart disease and aortopathy in aircrew.

Valvular heart disease (VHD) is highly relevant in the aircrew population as it may limit appropriate augmentation of cardiac output in high-performance flying and predispose to arrhythmia. Aircrew with VHD require careful long-term follow-up to ensure that they can fly if it is safe and appropriate for them to do so. Anything greater than mild stenotic valve disease and/or moderate or greater regurgitation is usually associated with flight restrictions. Associated features of arrhythmia, systolic dysfunction, thromboembolism and chamber dilatation indicate additional risk and will usually require more stringent restrictions. The use of appropriate cardiac imaging, along with routine ambulatory cardiac monitoring, is mandatory in aircrew with VHD.Aortopathy in aircrew may be found in isolation or, more commonly, associated with bicuspid aortic valve disease. Progression rates are unpredictable, but as the diameter of the vessel increases, the associated risk of dissection also increases. Restrictions on aircrew duties, particularly in the context of high-performance or solo flying, are usually required in those with progressive dilation of the aorta.

A meta-analysis of reduced leaflet motion for surgical and transcatheter aortic valves: Relationship to cerebrovascular events and valve degeneration.

Reduced leaflet motion (RLM) of transcatheter aortic valves (TAV) is observed in up to 4% of cases with similar frequency in surgical valves, with an overall incidence that differs based on prosthesis type and size. This phenomenon likely represents subclinical leaflet thrombosis. Herein we sought to analyze the existing reported literature to assess whether or not RLM is associated with subsequent valve degeneration or cerebrovascular events. We searched PubMed, and EMBASE (2008-2017) to identify relevant studies. Studies with <1-year follow-up, studies not evaluating RLM, and/or clinical outcomes were excluded. Our co-primary endpoints were the incidence of cerebrovascular events (stroke and/or transient ischemic attack-TIA) or structural valvular degeneration defined as moderate or greater regurgitation and/or a mean gradient ≥20 mm Hg. The literature search yielded 30 potential studies. Of these, six observational studies with a total population of 1704 patients met our selection criteria. RLM was associated with an increased risk of stroke or TIA (adjusted OR 2.60, 95% CI 1.56 to 4.34, p = 0.004). At one year, RLM was associated with an increased risk of structural valve degeneration (adjusted OR 2.51, 95% CI 1.47 to 4.30, p = 0.006). The association between RLM and clinical endpoints remained even after limiting analysis to transcatheter aortic valve replacement (TAVR) patients only. In patients with bio prosthetic aortic valve, presence of RLM is associated with increased risk of stroke or TIA as well as structural valvular degeneration. These findings support ongoing surveillance efforts and evaluation of pharmacotherapies to address RLM in effort to minimize subsequent clinical events.

Common atrioventricular valve failure during single ventricle palliation†.

To determine the risk of atrioventricular valve failure (valve intervention or moderate or greater regurgitation) during the lifetime of patients with single ventricle physiology and common atrioventricular valve. Patients' data were extracted from an existing bi-national, population based registry. A retrospective review of their medical records was undertaken to determine the incidence of atrioventricular valve repair/replacement or moderate or greater regurgitation. From a registry of 1468 Fontan survivors, 136 patients with common atrioventricular valve were identified. Complete echocardiographic follow-up was available for 114 patients. Median length of follow-up was 10.2 years (interquartile range 5-15 years). Twenty-five year survival and freedom from Fontan failure were 94% [95% confidence interval (CI), 88-100%] and 74% (95% CI, 64-87%), respectively. Twenty-eight patients underwent 24 initial repairs and 4 replacements. The 24 patients undergoing repair subsequently needed 6 re-repairs, 2 replacements and 8 had moderate or greater regurgitation at last follow-up. Four-year freedom from atrioventricular valve repair failure was 50% (95% CI, 34-75%). An additional 30 patients developed moderate or greater atrioventricular valve regurgitation (6 New York Heart Association ≥3, 10 Fontan failures, 0 deaths). Cumulative incidence of the composite endpoint of atrioventricular valve failure at 28 years was 62% (95% CI, 49-74%). Patients with single ventricle physiology and common atrioventricular valve experience a continuous decline in valve function. The majority of patients experience valve failure in the first 30 years of life.

Regurgitant valvular disease prevalence and progression found on echocardiogram in military aviators.

The prevalence, progression rates, and outcomes affecting aviator valvular heart disease have not been extensively studied. The U.S. Air Force (USAF) School of Aerospace Medicine's Clinical Sciences Database was used to determine prevalence and progression rates for regurgitant valvular disease. A subset of the initial population was further evaluated for risk factors that increased the likelihood of progression. Descriptive statistical analysis, analysis of variance, and t-test calculations were completed. There were 8475 unique aviators with some degree of valvular regurgitation for an overall prevalence of 3.0%. The mitral and aortic valves were most likely to have mild and moderate or greater regurgitation, respectively. Progression rates from mild to moderate were 8% in the aortic valve, 2% in the mitral valve, and less than 1% in the pulmonic and tricuspid valves. Progression rates from moderate to severe were over 20% for both the mitral and aortic valves. The only risk factors correlating to progression of valvular disease were lower levels of high-density lipoproteins in the mitral and aortic valves and triglycerides in the mitral valve. In USAF aviators, progression rates for mild or greater aortic valve regurgitation and moderate or greater mitral valve regurgitation are significant and should be followed closely. Classic risk factors of age, tobacco use, elevated blood pressure, and hyperlipidemia have no association with increased risk of valvular progression or rate of progression. Study outcomes validate the current USAF policy for valvular heart disease in aviators.

Valve-sparing aortic root replacement and remodeling with complex aortic valve reconstruction in children and young adults with moderate or severe aortic regurgitation

The durability of valve-sparing aortic root procedures with aortic regurgitation due to leaflet disease is questioned. Here, we review our experience in combined aortic root and valve reconstruction in children and young adults. All valve-sparing aortic root procedures from 2000 to 2012 were reviewed, and patients with aortic valve repair beyond resuspension were included. Root procedures were classified as replacement with reimplantation, root remodeling, or aortic annular and sinotubular junction stabilization. The primary end point was structural valve deterioration, a composite of aortic valve reoperation and/or moderate or greater regurgitation at follow-up. Thirty-four patients were included during the study period. The surgery consisted of reimplantation in 13 patients, remodeling in 16 patients, and annular and sinotubular junction stabilization in 5 patients. Valve repair consisted of leaflet procedures in 26 patients and subannular reduction in 15 patients. During a median follow-up of 4.2 months (range, 2 weeks-8 years), there were 5 reoperations for aortic valve replacement due to aortic regurgitation, and 2 patients presented with moderate or greater regurgitation. Freedom from structural valve deterioration was 70.1% ± 10.3% at 1 year and remained stable thereafter, although it was significantly worse in the reimplantation group (P = .039). A more severe degree of preoperative aortic regurgitation (P = .001) and smaller graft to aortic annulus ratio (P = .003) were predictors of structural valve deterioration. Valve-sparing root and valve reconstruction can be done with low operative risk and allows valve preservation in most patients. These data should question the assumption that reimplantation is superior when associated with complex valve reconstruction.

Abstract 18101: Three-Dimensional Echocardiography Identify Mechanisms of Early Post Operative Valve Failure in Pediatric and Congenital Heart Disease

Background: Three-dimensional echocardiography (3DE) is an accurate and informative imaging modality routinely used in pre-operative assessment for surgical planning. There is however little information on 3DE role in early post-operative valve failure assessment. This is a report on our 5 years experience of 3DE in early post-operative mitral/left atrioventricular valve (MV/LAVV) failure assessment, its impact on our understanding of its mechanism and the clinical decision for returning to the operating theatre for re-repair. Methods and results: We retrospectively reviewed all patients chart and echo with MV/LAVV surgery between 2008 and 2012, excluding primary repair of atrioventricular septal defect (AVSD) and primary valve replacement. Early valve failure (EVF) is defined as moderate or greater MV/LAVV regurgitation within 30 days post repair. There were 132 MV/LAVV surgeries consisting of repaired complete AVSD (n=85), congenital MV abnormality (n= 17) and primum AVSD (n= 16). Pre operative moderate or greater regurgitation was present in 55 (42%) and post op EVF in 33 patients (25%). 3DE were performed in 22 (67%) of 33 EVF with 8 patients returning to the operating room for re-repair due to poor clinical progress in intensive care unit. Six of 8 re-repair were infants. 3DE accurately identified the mechanism of regurgitation such as suture dehiscence at base of cleft, leaflet tears and patch failure (see Figure). Four of 8 patients MV/LAVV regurgitation improved to mild or less regurgitation at follow-up (median 2 months), 3 remained unchanged and 1 subsequently died from intractable heart failure despite MV/LAVV regurgitation improving from severe to moderate. Conclusion: Although patient returning for re-repair of EVF were mainly driven by poor clinical progress in intensive care. 3DE accurately identified the mechanism of early post-operative valve failure thus facilitating surgical planning and decision for re-repair.

Durability of Truncal Valve Repair

Truncus arteriosus associated with truncal valve dysfunction has been shown to increase the mortality and morbidity associated with repair and the various techniques employed for truncal valve repair continue to evolve. We sought to examine the durability of truncal valve repair in truncus arteriosus. We reviewed all patients who underwent truncal valve repair at our institution from 1995 to 2008. Repair techniques included leaflet delamination, bicuspidization, commissuroplasty, annuloplasty, and leaflet augmentation. We examined long-term valve durability, function and need for valve replacement. A total of 17 patients underwent truncal valve repair, including 3 for predominant stenosis (>70 mm Hg gradient), 2 for mixed moderate stenosis (40 mm Hg gradient) and moderate regurgitation, and 12 for moderate or greater regurgitation. Of these, 14 patients (14 of 17, 82%) underwent valvuloplasty at the time of the initial truncus arteriosus repair. The median age at truncal valve repair was 24 days (range, 4 days to 42 years). Thirteen patients had 1 valvuloplasty, 3 patients had 2 valvuloplasties, and 1 patient had 3 valvuloplasties before undergoing a prosthetic valve replacement at age 13 years. Actuarial freedom from repeat truncal valve operation was 70% at 5 years and 50% at 7 years. Freedom from truncal valve replacement was 100% at 10 years. To date, only 1 patient (6%) has required a prosthetic valve. Echocardiography at 48 ± 33 (mean ± SD) months postoperatively showed a peak gradient of 11 ± 13 mm Hg; 6 patients have moderate regurgitation, and the rest have mild or less regurgitation. Truncal valve repair is a durable option with an acceptable reoperation rate, good function, and a low likelihood of needing truncal valve replacement. This is one of the largest series of truncal valve repairs and emphasizes that valve repair should remain the primary option.

Midterm Results of Size-Reduced Cryopreserved Homografts for Right Ventricular Outflow Tract Reconstruction

Size reduction of valved homografts has been investigated for right ventricular outflow tract reconstruction because of limited supply of small-sized grafts. However, follow-up results are lacking. From 1997 to 2007, 45 patients underwent placement of 34 pulmonary and 11 aortic, size-reduced bicuspid homografts for right ventricle to pulmonary artery connection, which was part of a Rastelli-type operation (n = 35; 78%), redo right ventricular outflow tract reconstruction (n = 5; 11%), double-switch operation (n = 3; 7%), or palliative right ventricle to pulmonary artery connection (n = 2; 4%). Mean age at surgery was 20.0 +/- 24.4 months. Twenty patients (44%) were younger than 1 year old. Mean body weight was 9.6 +/- 7.1 kg. Diameter of the bicuspid conduit was 15.0 +/- 1.5 mm (z value, 3.4 +/- 1.9). Graft dysfunction was defined as pressure gradient greater than 50 mm Hg or moderate or greater regurgitation on follow-up echocardiography. Survival, freedom from graft explantation, and freedom from graft dysfunction were estimated by the Kaplan-Meier method. Risk factor for graft dysfunction was evaluated by multivariate analysis. There were 2 (4.4%) early deaths. During a mean follow-up of 49.4 +/- 37.2 months, 13 patients showed graft dysfunction. Five of them had their grafts explanted. Freedom from graft explantation was 100% at 1 year after implantation, 97.4% +/- 2.5% at 3 years, and 89.0% +/- 6.2% at 5 years. Freedom from graft dysfunction was 92.4% +/- 4.2% at 1 year, 78.8% +/- 7.3% at 3 years, and 52.9% +/- 10.9% at 5 years. Diagnosis of truncus arteriosus was identified as a factor for graft dysfunction (p = 0.028). Size-reduced homografts may provide an alternative for right ventricular outflow tract reconstruction when an appropriately sized homograft is unavailable.

Patent Foramen Ovale Closure

Setting aside the controversial questions of whether closing a patent foramen ovale (PFO) is indicated or effective for the prevention of recurrent stroke or the treatment of migraine headaches, what is the physiological impact of implanting a transcatheter device in the atrial septum? In this issue of Circulation , Wohrle and his colleagues address 1 aspect of this question, reporting the results of a study in which they assessed atrioventricular and semilunar valve function in 102 patients before and after transcatheter PFO closure.1 The authors evaluated valvar competence before, the day following, and 12 months after PFO closure and found no significant change in aortic regurgitation (AR) or regurgitation of the other cardiac valves. On their own, these findings might be passed off as predictable and modestly novel. Viewed in the context of a recent article by Schoen et al in Heart , however, they are noteworthy.2 Accordingly, to appreciate the study by Wohrle et al fully, it should be read as a counterpoint to the report by Schoen et al, which was a surprise to many in its description of new or increased AR in 10% of 170 patients who underwent transcatheter closure of a PFO and 9% of 70 in whom a device was placed to close an atrial septal defect.2 Article see p 3002 Before simply accepting the apparently contradictory findings of these 2 studies, however, it is worth acknowledging several basic methodological differences. The first difference is the means by which valvar regurgitation was assessed. In contrast to Schoen et al, who evaluated valvar function with transesophageal echocardiography 3, 6, and 12 months after catheterization, Wohrle et al assessed the function of the aortic and other valves with cardiac magnetic resonance imaging. Schoen et al graded AR according to a standard ordinal scale, …

Evaluation of downsized homograft conduits for right ventricle–to–pulmonary artery reconstruction

Although homograft conduits are frequently used to establish right ventricle-to-pulmonary artery continuity, the limited availability of small-size homografts is a significant constraint in pediatric cardiac surgery. We compared the performance of standard homograft conduits with that of surgically reduced bicuspid homograft conduits in patients undergoing repair of truncus arteriosus. Forty infants undergoing complete repair of truncus arteriosus with either standard homografts (n = 26) or reduced-size bicuspid homografts (n = 14) were evaluated. The median downsized conduit diameter (13 mm) was similar to the standard homograft diameter (12 mm, P = .52). There were 6 early deaths and 5 late deaths, representing an overall 30-day mortality of 15% and a 5-year mortality of 25%. No deaths were directly related to homograft dysfunction. Four (29%) downsized conduits and 8 (31%) standard conduits required replacement at a median interval of 18.5 months and 42.4 months, respectively. Catheter-based interventions were required in 5 (36%) patients in the downsized group and in 3 (12%) patients in the standard group. There was no difference in freedom from surgical or catheter-based reintervention between the 2 groups (P = .42). Freedom from conduit failure (severe conduit stenosis, moderate or greater regurgitation) was 55.9% and 17.2% at 3 years in the downsized and standard groups, respectively. The surgically downsized homograft is an excellent option when an appropriate-sized homograft is not available and might prevent morbidity associated with the use of an oversized conduit.

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Early Results of a Simplified Method of Mitral Valve Annuloplasty

We hypothesized that a simple, unmeasured posterior annuloplasty technique (two thirds of a 27-mm Duran ring) offered advantages of standardization and ease of insertion. A consecutive series of all patients (n = 418; median age, 67 years) having mitral valve repair performed by two surgeons was analyzed to determine the outcome of three different annuloplasty techniques: commissural annuloplasty (n = 124), complete ring annuloplasty (n = 113), and an unmeasured, posterior, partial ring annuloplasty (n = 181). Intraoperatively, before repair, severity of mitral regurgitation as measured by double sampling dye curves and transesophageal echocardiography was similar in all three groups; after mitral valve repair, intraoperative assessment showed a similar degree of reduction in regurgitation in the three annuloplasty groups. Before hospital dismissal, transthoracic echocardiography demonstrated that the mean mitral valve areas and gradients were similar in the three groups; more patients having commissural annuloplasty were classified as having grade II or greater regurgitation. Mortality (n = 7, 1.7%) and need for reoperation (n = 8, 1.9%) was low in all groups despite the fact that additional procedures were performed in 48.8% of patients. Durations of cardiopulmonary bypass and aortic cross-clamping were significantly less in patients having commissural or posterior annuloplasties compared with those receiving a complete ring annuloplasty. These early results indicate that the posterior annuloplasty method is reproducible and expeditious. Postoperative valve function as assessed by degree of regurgitation, transvalvular gradient, and valve area was similar to that obtained by measured, complete ring annuloplasty and superior to that found in patients having commissural annuloplasty.