Preoperative Mean Pulmonary Artery Pressure Research Articles

Predicting the Necessity for Extracorporeal Circulation During Lung Transplantation: A Feasibility Study

The factors leading to the implementation of unplanned extracorporeal circulation during lung transplantation are poorly defined. Consequently, the authors aimed to identify patients at risk for unplanned extracorporeal circulation during lung transplantation. Retrospective data analysis. Single-center university hospital. A development data set of 170 consecutive patients and an independent validation cohort of 52 patients undergoing lung transplantation. The authors investigated a cohort of 170 consecutive patients undergoing single or sequential bilateral lung transplantation without a priori indication for extracorporeal circulation and evaluated the predictive capability of distinct preoperative and intraoperative variables by using automated model building techniques at three clinically relevant time points (preoperatively, after endotracheal intubation, and after establishing single-lung ventilation). Preoperative mean pulmonary arterial pressure was the strongest predictor for unplanned extracorporeal circulation. A logistic regression model based on preoperative mean pulmonary arterial pressure and lung allocation score achieved an area under the receiver operating characteristic curve of 0.85. Consequently, the authors developed a novel 3-point scoring system based on preoperative mean pulmonary arterial pressure and lung allocation score, which identified patients at risk for unplanned extracorporeal circulation and validated this score in an independent cohort of 52 patients undergoing lung transplantation. The authors showed that patients at risk for unplanned extracorporeal circulation during lung transplantation could be identified by their novel 3-point score.

Extracorporeal Support During Bilateral Sequential Lung Transplantation in Patients With Pulmonary Hypertension: Risk Factors and Outcomes

To identify preoperative predictors of extracorporeal support in patients with pulmonary hypertension (PH) undergoing bilateral sequential lung transplantation (LTx), and to examine outcomes associated with the use of extracorporeal support. Retrospective, observational study. Single organ transplantation and tertiary care university medical center. Adults with PH (preoperative mean pulmonary artery pressure (mPAP)≥25 mmHg) who underwent primary bilateral sequential LTx during 2007 to 2013. Of 262 patients with PH undergoing LTx, extracorporeal support was initiated intraoperatively in 149 (57%). Preoperative severe right ventricle (RV) dysfunction and moderate or severe tricuspid regurgitation (TR) were associated with extracorporeal support. In the remaining 208 patients without those factors, increasing preoperative oxygen requirement (odds ratio [OR] 1.30 per 1 L/min, 95% confidence intervals [CI] 1.11-1.52, p = 0.001), presence of RV dilation (OR 2.77, 95% CI 1.28-6.02, p = 0.010), and mPAP (OR 1.33 per 5-mmHg increase in mPAP, 95% CI 1.04-1.70, p = 0.021) were associated independently with extracorporeal support in the multivariable model. Analysis of 49 propensity-matched pairs showed longer intensive care unit (5 v 14 days, p = 0.006) and hospital stays (27 v 39 days, p = 0.016) and increased need for tracheostomy (16% v 41%, p = 0.017) in patients exposed to extracorporeal support but no differences in 30-day mortality, stroke, myocardial infarction, or dialysis. Severity of RV dysfunction, TR, RV dilatation, increasing oxygen requirement, and increasing mPAP showed significant associations with the need for extracorporeal support during LTX in patients with PH. Extracorporeal support was associated with increased length of stay and tracheostomy but not with mortality or other complications. © 2016 Elsevier Inc. All rights reserved.

Outcomes of total cavopulmonary connection for single ventricle palliation.

The aim of this study was to review the early and mid-term outcomes of the total cavopulmonary connection (TCPC) procedure and evaluate risk factors for prolonged pleural effusions. The clinical records of 82 consecutive patients, who underwent a TCPC operation between January 2008 and December 2013, were reviewed for incidence of prolonged pleural effusions, duration of ventilation time and pleural drainage, length of intensive care unit (ICU) stay, and early and mid-term morbidity and mortality. The median age at surgery was 3.0 years. The main single ventricle diagnoses included 18 cases of a double-inlet single ventricle, 17 cases of heterotaxy, 16 cases of tricuspid atresia, 4 cases of mitral atresia, 12 cases of unbalanced complete atrioventricular canal (CAVC), 5 cases of double-outlet right ventricle (DORV) combined with ventricular septal defect (VSD) and pulmonary stenosis (PS), 4 cases of transposition of the great arteries (TGA) combined with VSD and PS, 4 cases of corrected transposition of great arteries (cTGA) combined VSD and PS, and 2 cases of criss-cross heart. Preoperative mean pulmonary artery pressure (mPAP) was 13.66±2.21 mmHg with 23.2% (n=19) higher than 15 mmHg. A total of 61 (74.4%) patients underwent a fenestration. The perioperative mortality was 4.9%. The median duration of pleural effusion was 10 days (range, 3-80 days), and prolonged pleural effusions occurred in 16 (19.5%) patients. Multivariable analysis revealed that mPAP >15 mmHg was independently associated with prolonged pleural effusions (OR, 8.33; 95% CI, 2.33-29.74; P=0.001), and creation of a fenestration was associated with decreased odds of effusion (OR, 0.21; 95% CI, 0.06-0.74; P=0.015). Five-year estimated Kaplan-Meier survival of two-stage TCPC was significantly higher than that of one-stage group(96.7% vs. 79.7%, P=0.023). Patients with heterotaxy or obstructed totally anomalous pulmonary venous connection (TAPVC) had significantly worse mid-term survival. Staged TCPC improved the early and mid-term survival of patients with a single ventricle. mPAP >15 mmHg was independently associated with prolonged pleural effusions and a fenestration significantly associated with a lower odds of effusion.

Outcomes of Surgical Repair for Persistent Truncus Arteriosus from Neonates to Adults: A Single Center's Experience.

ObjectiveThis study aimed to report our experiences with surgical repair in patients of all ages with persistent truncus arteriosus.MethodsFrom July 2004 to July 2014, 50 consecutive patients with persistent truncus arteriosus who underwent anatomical repair were included in the retrospective review. Median follow-up time was 3.4 years (range, 3 months to 10 years).ResultsFifty patients underwent anatomical repair at a median age of 19.6 months (range, 20 days to 19.1 years). Thirty patients (60%) were older than one year. The preoperative pulmonary vascular resistance and mean pulmonary artery pressure were 4.1±2.1 (range, 0.1 to 8.9) units.m2 and 64.3±17.9 (range, 38 to 101) mmHg, respectively. Significant truncal valve regurgitation was presented in 14 (28%) patients. Hospital death occurred in 3 patients, two due to pulmonary hypertensive crisis and the other due to pneumonia. Three late deaths occurred at 3, 4 and 11 months after surgery. The actuarial survival rates were 87.7% and 87.7% at 1 year and 5 years, respectively. Multivariate analysis identified significant preoperative truncal valve regurgitation was a risk factor for overall mortality (odds ratio, 7.584; 95%CI: 1.335–43.092; p = 0.022). Two patients required reoperation of truncal valve replacement. One patient underwent reintervention for conduit replacement. Freedom from reoperation at 5 years was 92.9%. At latest examination, there was one patient with moderate-to-severe truncal valve regurgitation and four with moderate. Three patients had residual pulmonary artery hypertension. All survivors were in New York Heart Association class I-II.ConclusionsComplete repair of persistent truncus arteriosus can be achieved with a relatively low mortality and acceptable early- and mid-term results, even in cases with late presentation. Significant preoperative truncal valve regurgitation remains a risk factor for overall mortality. The long-term outcomes warrant further follow-up.

Pathologic markers for evaluation of reversibility in pulmonary hypertension related to congenital heart disease

To assess the pathologic markers for evaluation of reversibility in pulmonary hypertension (PAH) related to congenital heart disease. Twenty-eight patients with congenital heart disease complicated by PAH were subclassified into reversible pulmonary hypertension (RPAH) and irreversible pulmonary hypertension (IPAH), according to post-operative mean pulmonary artery pressure (MPAP). Pulmonary vascular lesion was analyzed according to Ruan's method. Mean medium thickness percent, mean medium area percent and pulmonary arteriolar density were measured by quantitative morphometry. Immunohistochemical study for transgelin and filamin A was carried out. Amongst the 28 cases studied, 24 were RPAH and 4 were IPAH. Of the 24 patients with RPAH, 13 (54.2%, 13/24) had pulmonary vascular lesion of grade 0, 9 (37.5%, 9/24) of grade 1 and 2 (8.3%, 2/24) of grade 2. Of the 4 patients with IPAH, 1 had lesion of grade 1, 1 of grade 2 and 2 of grade 3. Both preoperative and postoperative MPAP were higher in IPAH patients than that in RPAH patients[(53.3±23.4) mmHg versus (34.1±12.7) mmHg, P=0.020 and (35.0±8.8) mmHg versus (17.8±3.9) mmHg, P<0.01]. Compared to patients with pulmonary vascular lesion of grades 0 and 1, the preoperative MPAP in patients with grades 2 and 3 showed no significant difference, but the postoperative MPAP was higher (P<0.05 or 0.01). Compared to control group, mean medium thickness percent and mean medium area percent were significantly higher in RPAH and IPAH categories (12.0±3.5, 8.5±2.0 versus 5.7±1.0, P<0.01 and 55.8±11.1, 49.0±9.4 versus 34.0±5.5, P<0.01). Mean medium thickness percent was significantly higher in IPAP group than that in RPAH group (12.0±3.5 versus 8.5±2.0, P=0.001). Correlation analysis demonstrated that mean medium thickness percent and mean medium area percent had positive correlation with preoperative and postoperative MPAP. There was no correlation between grading of pulmonary vascular lesion and reversibility. Transgelin and filamin A had stronger staining in pulmonary vascular smooth muscle cells in IPAH than those in RPAH and controls(P<0.05). Pathologic assessment of lung biopsy remains the gold standard for evaluation of the reversibility in PAH related to congenital heart disease. Mean medium thickness percent, mean medium area percent and immunoreactivity for transgelin and filamin A are useful parameters.

Operative and Functional Outcome After Pulmonary Endarterectomy for Advanced Thromboembolic Pulmonary Hypertension.

To evaluate the midterm hemodynamic and functional outcome of pulmonary endarterectomy (PEA) for patients with advanced chronic thromboembolic pulmonary hypertension (CTEPH). Thirty-eight consecutive patients underwent PEA for CTEPH from May 2004 to March 2012. All patients were followed prospectively at six months postoperatively and annually thereafter. Each patient underwent serial cardiopulmonary exercise testing (CPET) and transthoracic echocardiography, and were followed for up to four years. Overall, 31.5% (12/38) of patients had Jamieson class II disease while 65.8% (25/38) had class III disease. There were three in-hospital mortalities (7.9%), all of which had baseline pulmonary vasculature resistance (PVR) greater than 1400 dynes-sec-cm(-5) . Preoperative PVR and mean pulmonary artery pressure were 1209 ± 723 dynes-sec-cm(-5) and 50 ± 14 mmHg, respectively, signifying a high-risk operative group. Ninety-seven percent of patients were in NYHA class III or IV preoperatively. At median follow-up of 29 months 89.5% (17/19) of patients were in NYHA class I or II. CPET revealed a progressive increase in peak oxygen consumption from 16.5 ± 4.1 ml/kg/min at first follow-up, to a plateau of 20.2 ± 5.6 ml/kg/min (p = 0.032) at two years. CPET can be used to quantify progress in functional capacity post-CTEPH, although improvements in peak oxygen consumption plateau at two years.

Inflammation and congenital heart disease associated pulmonary hypertension.

Increased blood flow may trigger pulmonary arterial wall inflammation, which may influence progression of pulmonary artery hypertension in patients with congenital heart disease. In this study, we aimed to investigate the correlation between preoperative inflammation markers and pulmonary arterial hypertension. A total of 201 patients with pulmonary hypertension were enrolled in this study retrospectively; they had undergone open heart surgery between January 2012 and December 2013. Patients' preoperative C-reactive protein (CRP), neutrophil to lymphocyte ratio, red blood cell distribution width, pulmonary pressures, and postoperative outcomes were evaluated. Patient age, neutrophil to lymphocyte ratio, red blood cell distribution width, and CRP were found to be significantly correlated with both preoperative peak and mean pulmonary artery pressures. These data were entered into a linear logistic regression analysis. Patient age, neutrophil to lymphocyte ratio, and CRP were found to be independently correlated with peak pulmonary pressure (P &lt; .001, P &lt; .001, and P = .004) and mean pulmonary artery pressure (P &lt; .001, P &lt; .001, and P = .001), whereas preoperative mean pulmonary artery pressure was found to be independently correlated with intensive care unit stay (P &lt; .001). No parameter was found to be significantly correlated with extubation time and mortality. Eighteen patients had experienced pulmonary hypertensive crisis; in this subgroup, patients' mean pulmonary artery pressure and neutrophil to lymphocyte ratio were found to be significant (P = .047, P = .003). Preoperative inflammation markers may be correlated with the progression of pulmonary hypertensive disease, but further studies with larger sample size are needed to determine the predictive role of these markers for postoperative outcomes.

Human lung microRNA profiling in pulmonary arterial hypertension secondary to congenital heart defect.

Although several microRNAs were reported to play essential roles in pulmonary artery hypertension due to hypoxia or monocrotaline, their potential role in pulmonary arterial hypertension secondary to congenital heart disease is largely unknown. This study aimed to indentify microRNAs implicated in pulmonary arterial hypertension secondary to congenital heart disease in children. Using microRNAs microarray, we profiled the microRNAs in the lung specimen from 12 congenital heart disease patients, (6 with pulmonary arterial hypertension and the others without). We validated the microRNAs expression using RT-PCR experiments. Then, we predicted the target genes of the promising microRNAs by bioinformatical analysis and verified its regulating role by luciferase assay and western blot experiments. All the 12 patients were uneventfully recovered from cardiac surgery. Comparing to the non-pulmonary arterial hypertension lung tissue, 62 microRNAs were significantly up-regulated and 12 were significantly de-regulated in the pulmonary arterial hypertension lung tissue. Among them 27 microRNAs reached P values ≤ 0.05, we validated the up-regulation of microRNA-27b by RT-PCR experiments and found the expression level of microRNA-27b was correlated with preoperative mean pulmonary arterial pressure. In vitro, overexpression of microRNA-27b decreased the protein expression of NOTCH1 and significantly reduced luciferase activity. The current study revealed for the first time that microRNAs may be important regulators in pulmonary arterial hypertension secondary to congenital heart disease, and demonstrated the correlation between microRNA-27b and pulmonary arterial hypertension with the implication of NOTCH1.

(542) - The Impact of Perioperative Bleeding on Long-Term Outcomes of Mechanical Circulatory Support

s S203 since April 2010. ECMO may be instituted a priori or upon hemodynamic (or other) indication, which we aim to avoid if possible. Here we identify risk factors for intraoperative indication ECMO and compare results with those patients transplanted without ECMO support. Methods: Patients transplanted between April 2010 and February 2014 were retrospectively reviewed. Patients requiring intraoperative indication ECMO formed Group A, patients transplanted off-pump formed Group B. Patients with preoperative ECMO, idiopathic pulmonary artery hypertension or requiring a concomitant cardiac procedure, where intraoperative ECMO was employed a priori, were excluded. Results: Among 481 patients undergoing bilateral sequential lung transplantation, 67 (14%, Group A) underwent intraoperative indication ECMO implant and 328 (68%) patients (Group B) did not. Eighty-six (18%) patients, where ECMO was used a priori, were excluded from the study. Among group A patients, decision for using ECMO was set at clamping of the first (mostly right) pulmonary artery in 37 (55%) patients and later during the procedure in the remaining 30 (45%) patients. Veno-arterial ECMO was used in all 67 patients and was implanted emergently in only 10 (15%) of these. At multivariate analysis, pulmonary fibrosis (OR 2.5, 95%CI: 1.3-4.7, p= 0.004) and preoperative mean pulmonary artery pressure greater than 24mmHg (OR 2.3, 95%CI: 1.3-4.1, p= 0.005) were identified as risk factors for intraoperative indication ECMO. Postoperatively, more Group A than B patients showed primary graft dysfunction (35%vs.12%, p< 0.01), required revision for bleeding (13%vs.4%, p< 0.01), required intermittent dialysis (19%vs.4%, p< 0.01), or died in-hospital (13%vs.3%, p< 0.01). In Group A and B patients, at 1and 3-year follow-up, overall survival (%) was 82±5vs.92±1 and 73±6vs.78±3, respectively (p= 0.32). Conclusion: Pulmonary fibrosis and secondary pulmonary artery hypertension are predictors for the need of intraoperative indication ECMO. Of interest, 68% of the patients can safely be transplanted off-pump with excellent results and a further 18% may be assigned to an a priori ECMO cohort.

Prediction of hemodynamic improvement after pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension using non-invasive imaging.

Pulmonary endarterectomy (PEA) is the recommended treatment in chronic thromboembolic pulmonary hypertension (CTEPH). Prediction of outcome after PEA remains challenging. In search for pre-operative predictors we evaluated non-invasive parameters measured by chest CT-scan and echocardiography. Between May 2004 and January 2009, 52 consecutive patients with CTEPH who underwent PEA (59.6% female, mean age 58.9±13.4years) were included. Prior to surgery, pulmonary artery (PA) diameter indices were calculated by chest CT scan and different echocardiographic measurements to evaluate pulmonary hypertension were obtained. Hemodynamic improvement after PEA was defined as a pulmonary vascular resistance (PVR) <500dynscm(-5) and a mean pulmonary artery pressure <35mmHg 3days after PEA. Mortality was evaluated at day 30. Mean pulmonary artery pressure (PAP)at baseline was 40.1±8.5mmHg, with a PVR of 971±420dynscm(-5). Persistent pulmonary hypertension was observed in 15 patients (28.8%). Gender, pre-operative mean PAP, PA diameter indices, and tricuspid annular plane systolic excursion were all predictors for hemodynamic improvement after PEA. The indexed PA diameter on CT was the only independent predictor for hemodynamic improvement: 19.4±2.4 versus 22.9±4.9mm/m(2) in those without improvement (OR 0.76: 95% CI 0.58-0.99, p=0.04). All patients who died within 30days (9.6%) had persistent pulmonary hypertension, with a post-operative mean PAP of 51.6±14.1mmHg and PVR of 692±216 dynscm(-5). The pre-operative PA diameter indexed for body surface area is the only independent predictor for hemodynamic improvement after PEA in CTEPH patients. In all patients who died within 30days after PEA, persistent pulmonary hypertension was present.

Tricuspid Regurgitation after Cardiac Transplantation Does Not Affect Long Term Survival

Purpose Tricuspid regurgitation (TR) after orthotopic heart transplantation (OHT) may be associated with right ventricular dysfunction and increased mortality. This study addresses the fate of postoperative TR and its impact on long term survival. Methods and Materials Between 2002 and 2006, 118 patients were identified who underwent OHT at our institution. Detailed retrospective case-note review was undertaken. Data collected included demographic, perioperative and echocardiographic details. Patients were divided into two groups based on the degree of TR identified on echocardiography early postoperatively. Results Of the 118 pts, 23 (19%) had at least moderate TR in the early postoperative period. The two groups were otherwise similar with respect to age and sex, however the TR group had significantly higher preoperative mean pulmonary artery and capillary wedge pressure (33.4 vs. 25.6, p figure 1 ] Of the 23 patients with significant early postoperative TR, 17 (74%) demonstrated significant reduction in the grade of TR on serial annual echocardiographic follow-up. TR almost completely disappeared in 15 patients (65%) at 1-year follow-up. Conclusions This study reports no significant impact of early TR on long-term survival following OHT. In addition, in a significant proportion of patients the degree of TR improves significantly on follow-up echocardiography without any further intervention.

Outcome of univentricular repair in patients with Down syndrome

Total cavopulmonary connection (TCPC) is rarely performed for a functional single ventricle in children with Down syndrome; therefore, the postsurgical outcomes are not well known. We evaluated mortality and related factors after TCPC in children with Down syndrome. Between January 2004 and March 2010 we identified 8 patients with Down syndrome among 235 patients who had undergone TCPC. The preoperative clinical course, preoperative data, and postoperative clinical course were evaluated. In addition, clinical parameters and postoperative clinical course were compared between children with Down syndrome (n=8) and a non-Down syndrome group (n=227). The median age at the time of TCPC was 4.1 years (range, 3.4-5.5 years), and the preoperative mean pulmonary artery pressure was 13.9±1.81 mm Hg. We observed respiratory complications in 2 patients, surgical site infection in 3 patients, and chylothorax in 2 patients. No significant difference was observed in preoperative data and mortality rate (1 of 8 patients [12.5%] in the Down syndrome group; 5 of 227 patients [2.2%] in the non-Down syndrome group) between the groups of children with and without Down syndrome. However, when the postoperative clinical course was examined, the durations of intensive care unit stay (P=.009) and hospital stay (P=.007) were found to be significantly prolonged in the Down syndrome group. Patients with Down syndrome tend to show prolonged recovery after TCPC. However, as opposed to previous reports, the mortality rate of patients undergoing TCPC is lower with no significant difference from that of children without Down syndrome.

Does the Society of Thoracic Surgeons risk score accurately predict operative mortality for patients with pulmonary hypertension?

This study assessed the impact of pulmonary hypertension (PH) on morbidity and mortality after the most common cardiac operations and evaluated the accuracy of the Society of Thoracic Surgeons (STS) risk model for patients with PH. At a single center between 1994 and 2010, all adult cardiac operations performed with recorded preoperative mean pulmonary arterial pressure (MPAP) and STS predicted mortality were reviewed. MPAP was defined as normal (<25 mm Hg) or as mild (25-34 mm Hg), moderate (35-44 mm Hg), or severe (≥ 45 mm Hg) PH. Multivariate analysis was performed to elucidate the contribution of PH to morbidity and mortality. In all, 3343 patient records were reviewed. Coronary artery bypass grafting (CABG) was the most common procedure (67.5%), followed by aortic valve replacement (24.9%) and mitral valve procedures (6.3%). Postoperative complications and mortality increased with increasing MPAP. Multivariable analysis found that both moderate (odds ratio, 7.17; P < .001) and severe (odds ratio, 13.73; P < .001) PH were significantly associated with increased mortality, even after accounting for STS risk. A subset analysis of isolated CABG cases revealed markedly increased mortality for all categories of PH (mild odds ratio, 1.99; moderate odds ratio, 11.5; severe odds ratio, 38.9; P < .001). Morbidity and mortality were independently associated with PH. Observed mortality was significantly higher than predicted by the STS model for patients with moderate and severe PH, particularly in isolated CABG. Addition of PH to the STS risk model should be considered, or alternative tools should be used to assess risk in these patients.

Pulmonary Artery Haemodynamic Properties in Patients with Pulmonary Hypertension Secondary to Rheumatic Mitral Stenosis

We sought to explore the pulmonary haemodynamic changes in rheumatic mitral stenosis patients with secondary pulmonary hypertension. The pulmonary artery resistance and compliance of 35 patients with rheumatic mitral stenosis and 12 controls without cardiopulmonary vascular disease were evaluated by using an improved method, which is based on making calculations with parameters obtained from right heart catheterisation. The results are as follows: (1) pulmonary artery compliance in patients with secondary pulmonary hypertension was significantly lower than that of the control group (P<0.01); (2) linear correlation analyses showed that preoperative mean pulmonary artery pressure (mPAP) closely correlated with zero-pressure compliance in the mitral stenosis group (r=-0.745, P<0.05); (3) PAP and pulmonary vascular resistance decreased significantly in both groups with mitral stenosis after infusing 0.5 μg kg(-1) min(-1) of sodium nitroprusside (P<0.01). The pulmonary zero pressure compliance and mean pressure compliance increased significantly in the group with mild pulmonary hypertension; whereas in the severe group, the mean compliance changed with significance as the mPAP decreased (1.51 ± 0.59 vs 1.81 ± 0.77 ml/mmHg), however no significant change occurred in the pulmonary zero pressure compliance (2.35 ± 1.24 ml/mmHg vs. 2.24 ± 1.53 ml/mmHg, P>0.05) The walls of pulmonary artery vessels in patients with pulmonary hypertension secondary to rheumatic mitral stenosis appeared to be remodelled by varying degrees as indicated by their haemodynamic properties. Structural remodelling may be a factor affecting preoperative pulmonary artery pressure. Mitral stenosis patients with severe pulmonary hypertension have significantly lower responses to sodium nitroprusside possibly due to aggradation and deposition of collagen in the artery walls, decreasing constriction and dilation, or atrophy of smooth muscle cells.

Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation

The study objective was to compare the incidence of short- and intermediate-term arrhythmias among 3 different surgical modifications of the Fontan procedure. We performed a retrospective review of all patients who underwent the Fontan operation at a single institution between January 2004 and May 2010 for preoperative, perioperative, and follow-up variables. Three surgical modifications were studied: intra/extracardiac conduit with limited atriotomy, standard extracardiac conduit, and lateral tunnel. Rhythm was classified as normal or abnormal. A rhythm dysfunction grading was devised and used to identify worsening of rhythm for patients with abnormal rhythm preoperatively. Multivariable logistic regression was used to determine predictors of abnormal rhythm. To eliminate confounding effects of transient immediate postoperative arrhythmias, data were analyzed for abnormal rhythm within the first 2 weeks and for more than 2 weeks after surgery. Of the 134 patients (n = 50 with intra/extracardiac conduit with limited atriotomy, n = 19 with standard extracardiac conduit, n = 65 with lateral tunnel) (median follow-up, 36 months; interquartile range, 22-50 months; 2 operative deaths and 6 late deaths), rhythm data for more than 2 weeks postoperatively were available in 88 (40 with lateral tunnel, 14 with standard extracardiac conduit, 34 with intra/extracardiac conduit with limited atriotomy). These patients constituted the study groups. Patients in the lateral tunnel group were relatively younger at the time of the Fontan operation (P < .001) and had a longer follow-up (P < .001). Multivariable logistic regression confirmed that greater than moderate atrioventricular valve regurgitation was the only independent predictor of abnormal rhythm during the first 2 postoperative weeks. Older age at Fontan (odds ratio, 1.20; 95% confidence interval, 1.05-1.38; P = .012) and higher preoperative mean pulmonary artery pressure (odds ratio, 1.2; 95% confidence interval, 1.03-1.44; P = .026) were predictors of abnormal rhythm more than 2 weeks postoperatively. Intra/extracardiac conduit with limited atriotomy Fontan modification was associated with a significantly lower incidence of abnormal rhythm after 2 weeks postoperatively compared with lateral tunnel modification (odds ratio, 0.28; 95% confidence interval, 0.10-0.84; P = .015). Intra/extracardiac conduit with limited atriotomy Fontan modification has a significantly lower risk of abnormal rhythm postoperatively in the short and intermediate term when compared with the lateral tunnel.

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.

Fontan Operation. Hemodynamic Factors Associated With Postoperative Outcomes

Introduction and objectivesThe Fontan operation is usually the final palliative procedure in patients with univentricular heart. The objectives of this study were, firstly, to describe the clinical and haemodynamic characteristics of a group of patients with univentricular physiology who had previously been palliated with a bidirectional Glenn procedure and, secondly, to identify risk factors that can influence postoperative outcomes after the Fontan operation. MethodsRetrospective study with 32 patients who underwent a Fontan operation between March 2000 and December 2009. Clinical characteristics, catheterization data, type and duration of surgery were revised and analyzed as predictors of postoperative outcome. ResultsHospital mortality was 3%. After a median follow-up of 44 months (interquartile range, 32-79), survival was 90%. Preoperative mean pulmonary arterial pressure (measured during catheterization) was correlated with late mortality. Of the remaining variables analyzed, the Nakata and McGoon indices, and duration of cardiopulmonary bypass showed the highest correlations with postoperative outcomes. Interventional catheterization before the Fontan operation was performed in 42% of patients. ConclusionsHospital mortality after the Fontan operation was very low. The performance of a haemodynamic study before the Fontan operation made it possible to select high-risk patients for surgery as well as permitting the performance of interventional procedures that could improve postoperative outcome in these patients.

Operación de Fontan. Estudio de los factores hemodinámicos asociados a la evolución postoperatoria

Introduction and objectivesThe Fontan operation is usually the final palliative procedure in patients with univentricular heart. The objectives of this study were, firstly, to describe the clinical and haemodynamic characteristics of a group of patients with univentricular physiology who had previously been palliated with a bidirectional Glenn procedure and, secondly, to identify risk factors that can influence postoperative outcomes after the Fontan operation. MethodsRetrospective study with 32 patients who underwent a Fontan operation between March 2000 and December 2009. Clinical characteristics, catheterization data, type and duration of surgery were revised and analyzed as predictors of postoperative outcome. ResultsHospital mortality was 3%. After a median follow-up of 44 months (interquartile range, 32-79), survival was 90%. Preoperative mean pulmonary artery pressure (measured during catheterization) was correlated with late mortality. Of the remaining variables analyzed, the Nakata and McGoon indices, and duration of cardiopulmonary bypass showed the highest correlations with postoperative outcomes. Interventional catheterization before the Fontan operation was performed in 42% of patients. ConclusionsHospital mortality after the Fontan operation was very low. The performance of a haemodynamic study before the Fontan operation made it possible to select high-risk patients for surgery as well as permitting the performance of interventional procedures that could improve postoperative outcome in these patients.Full English text available from:www.revespcardiol.org

Outcomes after Bidirectional Glenn Operation in Single Ventricular Anatomy: A Single Centre Experience

Outcomes after Bidirectional Glenn Operation in Single Ventricular Anatomy: A Single Centre Experience Maqsood M. Elahi 1,∗, Hong C. Chew1, Hari Ravindranathan2, Alan Farnsworth1, Graham R. Nunn1, David Winlaw1, Peter W. Grant 1 1Department of Cardiothoracic Surgery, Sydney Children’s Hospital, Barker Street, Randwick, NSW, Australia 2 Department of Neonatal & Children’s Intensive Care, Sydney Children’s Hospital, Barker Street, Randwick, NSW, Australia Objective: The bidirectional Glenn (BDG) procedure is a well-established procedure. Numerous studies have highlighted its potential benefits in the single-ventricle palliation pathway. We report our experience for predictive variables and outcomes associated with BDG procedures. Methods: Demographics, age at the time of the BDG procedure, associated procedures, length of hospital stay, duration ofmechanical ventilation, length of ICU stay, and primary diagnoses for 29 consecutive patients undergoing the BDG procedure was collected. All data were analysed with Kaplan–Meier survival analysis and the Cox proportional hazard regression test to assess the probability of survival after the BDG procedure. A stepwise regression analysis was performed for identification of independent factors for postoperative oxygen saturation at hospital discharge. and demonstrate that performing BDG procedure at sixmonths of age is feasible and safe. doi:10.1016/j.hlc.2010.11.057 Surgery vs Percutaneous Valvuloplasty for Neonatal and Infant Critical Aortic Stenosis Fountas Nikolas ∗, Cole Andrew, Roberts Philip, Chard Richard ∗ Optimal management for critical aortic stenosis in neonatal and infantpopulations ispoorlyunderstood.This study sought to evaluate outcomes of percutaneous transcatheter balloon valvuloplasty versus surgical therapy. Thirty-nine neonates and 37 infants (mean age 10 days and 4.3 months respectively) underwent treatment for critical aortic stenosis at the Children’s Hospital Westmead between 1998 and 2010. Valvuloplasty was done in 37 (95%) neonates and 37 (100%) infants. Aortic valvotomy, Konno, or Ross-Konno procedures were performed in 12 (31%) neonates and seven (19%) infants. Ten patients had surgery for concomitant aortic coarctation repair (nine), mitral valvotomy/repair (two), or ASD closure (one). Four neonate mortalities occurred (10%); all balloon valvuloplasty related.Re-interventions, either catheteror surgery, occurred in 15 (38%) neonates andnine (24%) infants. Four patients (three neonate, one infant) required both catheter Results: All patients in our study except two required initial palliation with either BT shunt or PA banding in early postnatal care. The mean period from initial surgery to BDG surgerywas approximately 11months. At the time of the BDG procedure, the youngest patient was fivemonths old, and the oldest patient was 4.5 years old. There was an equal distribution of patients with right-sided or leftsided single ventricle anatomy. The postoperative oxygen saturations at discharge (all on room air) were positively associated with previous antegrade flow defined as any flow through the native pulmonary artery and pulmonary valve (P< 0.005) and negatively associated with preoperative end-diastolic ventricular pressure (P< 0.005). Age at the time of the BDG procedure was not associated with worse postoperative oxygen saturations at discharge. There was only one late death (3.4%). Time to Fontan procedure was 23± 4.5 months. The significant independent variables for morbidity in Fontan completion after the BDG procedure were preoperative mean pulmonary artery pressure, bypass time and postoperative oxygen saturations. Conclusion: Our results demonstrated that low mortality in single ventricle anatomy. We found that the post-BDG oxygen saturations at hospital discharge were associated with previous native antegrade flow. We hypothesise that antegrade native pulmonary flow include promotion of normal pulmonary artery growth andmaintenance of pulmonary artery endothelial function for a better outcome towards Fontan completion. Our results support the international trend towards BDG procedure in younger age and surgical re-interventions. Children requiring intervention for congenital critical aortic stenosis as neonates fared worse than infants in mortality and re-intervention rates, and surgery was safe and effective when catheter intervention was unsuccessful. doi:10.1016/j.hlc.2010.11.058 Effect of Physical Activity on Continuous-Flow Left Ventricular Assist Device Function in Outpatients Sharon Hu1,2,3,∗, Anne Keogh1,2, Peter Macdonald1,2, Eugene Kotlyar 1, Desiree Robson1, Michelle Harkess 1, Paul Jansz1,3, Phillip Spratt 1,3, Chris Hayward1,2 1Heart Failure and Transplant Unit, St Vincent’s Hospital, Sydney, Australia 2 Faculty of Medicine, The University of New South Wales, Sydney, Australia 3 Department of Cardiothoracic Surgery, St Vincent’s Hospital, Sydney, Australia Introduction: Left ventricular assist devices (LVADs) augment the heart’s pumping action in patientswithmedically refractory heart failure. Pump flow in continuousflow LVADs have been shown to increase with graded exercise testing [1,2]. However, data on pump behaviour during activities of daily living where cardiac output requirements vary are lacking. Purpose: To observe whether LVAD flow changes with everyday physical activity without active alterations in pump settings.

Predictors of postoperative outcome after pulmonary endarterectomy from a 14-year experience with 279 patients

Postoperative outcome after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is difficult to predict. We sought to analyze specific preoperative findings to predict mortality, shorter mechanical ventilation, and hemodynamic improvement after PEA. A total of 279 patients with CTEPH (57 ± 14 years old, 57% male), who underwent PEA between 1995 and 2009, were reviewed retrospectively. Preoperative pulmonary hemodynamic parameters, spirometry data, laboratory data, cardiac co-morbidities, clinical stage, and number of desobliterated segments were analyzed using a logistic regression model to identify independent predictors for early mortality, shorter duration of mechanical ventilation, and hemodynamic improvement. There were 31 early deaths (11.1%, last three years: 6.7%). Among 16 significant predictors for early mortality, preoperative arterial oxygenation was the only significant predictor in multivariate analysis (P < 0.05). A total of 147 patients (52.7%) could be extubated within 48 h postoperatively. Out of 16 significant predictors in univariate analysis for mechanical ventilation less than 48 h, only higher forced expiratory volume in 1s FEV1.0 (P < 0.05) and higher preoperative cardiac index (P < 0.05) were significant in multivariate analysis. In 185 patients (66.3%), postoperative pulmonary vascular resistance (PVR) was reduced to lower than 400 dyn s(-1) cm(-5) at 48 h after PEA. Male gender (P < 0.05), lower preoperative mean pulmonary arterial pressure (PAP) (P < 0.05), and more intra-operative desobliterated segments (P < 0.01) were identified as significant predictors for this hemodynamic response with sensitivity of 77.5% and specificity of 67.9%. Using Pearson's correlation coefficient, PVR at 48 h after PEA could be estimated as PVR = 123.266+135.471 × creatinine-22.053 × desobliterated segments + 3.248 × systolic PAP (P < 0.01, R(2) = 0.401, 95% confidence interval = 0.464-0.830). Preoperative factors can primarily predict postoperative outcome after PEA. Patients with underlying parenchymal lung disease will have increased risk for early mortality and prolonged mechanical ventilation. The extent of desobliterated segments as well as preoperative hemodynamic severity play a key role in predicting good hemodynamic responders.