Preoperative Pulmonary Artery Research Articles

Notch ratio in pulmonary flow predicts long-term survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

Assessment of the pattern of the RV outflow tract Doppler provides insights into the hemodynamics of chronic thromboembolic pulmonary hypertension (CTEPH). We studied whether pre-operative assessment of timing of the pulmonary flow systolic notch by Doppler echocardiography is associated with long-term survival after pulmonary endarterectomy (PEA) for CTEPH. Fifty-nine out of 61 consecutive CETPH patients (mean age 53 ± 14 years, 34% male) whom underwent PEA between June 2002 and June 2005 were studied. Clinical, echocardiographic and hemodynamic variables were assessed pre-operatively and repeat echocardiography was performed 3 months after PEA. Notch ratio (NR) was assessed with pulsed Doppler and calculated as the time from onset of pulmonary flow until notch divided by the time from notch until end of pulmonary flow. Long-term follow-up was obtained between May 2021 and February 2022. Pre-operative mean pulmonary artery pressure (mPAP) was 45 ± 15 mmHg and pulmonary vascular resistance (PVR) was 646 ± 454 dynes.s.cm-5. Echocardiography before PEA showed that 7 patients had no notch, 33 had a NR < 1.0 and 19 had a NR > 1.0. Three months after PEA, echocardiography revealed a significant decrease in sPAP in long-term survivors with a NR < 1.0 and a NR > 1.0, while a significant increase in TAPSE/sPAP was only observed in the NR < 1.0 group. Mean long-term clinical follow-up was 14 ± 6 years. NR was significantly different between survivors and non-survivors (0.73 ± 0.25 vs. 1.1 ± 0.44, p < 0.001) but no significant differences were observed in mPAP or PVR. Long-term survival at 14 years was significantly better in patients with a NR < 1.0 compared to patients with a NR > 1.0 (83% vs. 37%, p = < 0.001). Pre-operative assessment of NR is a predictor of long-term survival in CTEPH patients undergoing PEA, with low mortality risk in patients with NR < 1.0. Long-term survivors with a NR < 1.0 and NR > 1.0 had a significant decrease in sPAP after PEA. However, the TAPSE/sPAP only significantly increased in the NR < 1.0 group. In the NR < 1.0 group, the 6-min walk test increased significantly between pre-operative and at 1-year post-operative follow-up. NR is a simple echocardiographic parameter that can be used in clinical decision-making for PEA.

A study on the outcome of preoperative pulmonary function tests on a patient undergoing rheumatic mitral valve surgery

Abstract Background and Aims: Evaluation of pulmonary function by spirometer in adult patients undergoing cardiac surgery is a simple test to assess pulmonary reserve that has important implications in operative morbidity. However, there is no established consensus regarding which patients should undergo preoperative pulmonary function tests (PFTs), including forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC). The primary aim was to evaluate the outcome of preoperative PFTs on patients undergoing rheumatic mitral valve surgery. Material and Methods: One hundred patients undergoing rheumatic mitral valve surgery, meeting the inclusion criteria, were included in this prospective observational study. The pulmonary function of the patients was assessed using a spirometer before surgery. Preoperative pulmonary artery systolic pressure (PASP) and arterial blood gas (ABG) analyses were also performed. The correlation of PFTs with early postsurgical outcome, comprising mortality within 30 days of surgery and morbidity defined as the existence of at least one of the postoperative complications, such as low cardiac output state indicated by increased requirement of inotropes, prolonged ventilation (&gt;24 hours), postoperative new-onset hemodynamically significant arrhythmias, renal dysfunction, and post-op infection, was assessed. Results: With the increasing New York Heart Association (NYHA) class of the patient, there was a decline of FEV1% and FVC%, which was statistically significant (P &lt; 0.0001). There was a significant positive correlation of FVC% with preoperative saturation of peripheral oxygen (SpO2) and preoperative saturation of peripheral carbon dioxide (PaO2) and FEV1% with preoperative SpO2 and preoperative PaO2. Patients who had postoperative prolonged ventilation had lower values of FVC% and FEV1%, which was statistically significant (P &lt; 0.001). The patients who expired had significantly lower values of FVC% and FEV1%. Conclusions: Preoperative lung function has an implication on intraoperative morbidity during cardiac surgery although a common consensus on its application is lacking. Preoperative spirometry can be one of the parameters for predicting postoperative morbidity and mortality in patients undergoing rheumatic mitral valve surgery. Spirometry might have a role to play in predicting patient outcomes in rheumatic mitral valve surgeries; however, larger well-powered studies are needed.

Relationship between fragmented QRS complex and early left ventricular dysfunction after mitral valve repair

BackgroundPreoperative left ventricular (LV) ejection fraction (PreLVEF) and preoperative LV end-systolic diameter (PreESD) are known predictors for postoperative LV dysfunction after mitral valve repair (MVR). Fragmented QRS (fQRS) evaluated in 12-derivation electrocardiography has widely been accepted as a sign of myocardial fibrosis.In the present study, we aimed to evaluate the relationship between fQRS in preoperative 12‑lead electrocardiography (ECG) and postoperative LV dysfunction that develop after MVR in patients with severe primary mitral regurgitation (MR) due to mitral valve prolapse (MVP). MethodsFrom 2019 to 2022, 49 patients who had undergone successful MVR surgery for severeMR caused by MVP were enrolled in the study. The preoperative and postoperative echocardiographic data were collected retrospectively. We analyzed the demographic, echocardiographic, operative and postoperative parameters to assess the relationship between fQRS and early postoperative LV dysfunction, defined as an LVEF<60%. ResultsPreLVEF of all patients were ≥ %65. A total of 22 patients had fQRS (44.9%) and postoperative LV dysfunction was found to be 36.7%. A significantly higher rate of fQRS was observed in the group with postoperative LV dysfunction compared to the group without (12 (66.7%) vs 10 (32.3%), p: 0.036). In multivariate analysis for fQRS, PreESD, preoperative pulmonary artery systolic pressure (PrePASP), preoperative atrial fibrillation (PreAF), and male gender, only fQRS was found to be a significant predictor of postoperative LV dysfunction (p: 0.003, OR: 4.28, 95% CI (1.15–15.96). ConclusionfQRS was found to be a predictor of postoperative LV dysfunction in the early period after MVR. fQRS may be a readily available and cost-effective test that can be used in clinical practice to predict postoperative LV dysfunction in patients undergoing MVR.

Impact of preoperative left pulmonary artery stenting on the Fontan procedure: a retrospective multicentre study.

Left pulmonary artery (LPA) or bifurcation stenoses at Fontan palliation can be very challenging to treat and may also require cardioplegia and aortic transection. Moreover, the low pressure of Fontan circulation and the bulkiness of the aorta increase the risk of a patch angioplasty collapse. Pre-Fontan LPA stenting of stenotic LPAs overcomes those drawbacks therefore the present study aimed to evaluate its advantageous impact on Fontan surgery. A multicentre retrospective analysis was performed on 304 consecutive Fontan patients. The study population was divided into 2 groups (LPA stented, n = 62 vs not stented, n = 242); pre-and postoperative data were compared. LPA-stented patients had a higher prevalence of systemic right ventricle (P = 0.01), hypoplastic left heart syndrome (P = 0.042), complex neonatal palliations (Norwood/Damus-Kaye-Stansel) and surgical LPA patch repair at Glenn (P < 0.001). No differences were found in cross-clamp rates, early (P = 0.29) and late survival (94.6% vs 98.4, P = 0.2) or complications (P = 0.14). Complex palliations on ascending aorta/aortic arch (P = 0.013) and surgical LPA repair at Glenn (P < 0.001) proved to be risk factors for LPA stenting before Fontan at multivariable analysis. The LPA-stented group showed similar outcomes in terms of survival and complications rate compared to patients without LPA stenosis; however, they significantly differ in their higher preoperative risk profile and in their more complex anatomy. Complex neonatal palliations involving ascending aorta or aortic arch may increase the risk of pulmonary branches stenosis requiring stenting; therefore, preoperative stenting of LPA stenoses could help to reduce the surgical risk of complex Fontan procedure by avoiding the need for cross-clamp or complex mediastinal dissections to perform a high-risk surgical repair.

Association Between Functional Tricuspid Regurgitation and Mortality Following Cardiac Surgery

BackgroundCurrent guidelines recommend concomitant repair of certain non-severe cases of tricuspid regurgitation (TR) in patients undergoing cardiac surgery, but the prognostic relevance and postsurgical impact of the TR remain uncertain. ObjectivesThe purpose of this study was to determine the prognostic impact of functional TR in patients undergoing diverse cardiac surgeries and to examine the effect-modifying role of patient characteristics in patients in whom TR confers a greater risk of adverse outcomes. MethodsPatients undergoing coronary artery bypass, aortic, and mitral valve surgery were included. Patients with severe TR, organic tricuspid valve pathology, undergoing tricuspid valve surgery or without a recent preoperative echocardiogram were excluded. Clinical variables were extracted from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. An independent cohort was used for external validation. ResultsOf 2,119 patients (mean age 67.4 years; 29% females), TR severity was moderate in 185 (9%), mild in 636 (30%), trivial in 1,126 (53%), and absent in 172 (8%). There were 238 deaths during the median follow-up period of 2.6 years. After adjusting for relevant factors, moderate TR was found to be independently associated with mid-term mortality (HR: 2.58; 95% CI: 1.22-5.47) and with in-hospital mortality or major morbidity (OR: 3.18; 95% CI: 1.37-7.42). The association between TR and mortality was apparent when preoperative pulmonary artery systolic pressure was <40 mm Hg but not ≥40 mm Hg (P for interaction = 0.036). ConclusionsIn this diverse cohort of contemporary cardiac surgery patients, moderate functional TR was associated with increased mortality and major morbidity, particularly in the absence of pulmonary hypertension.

Factors affecting the outcomes after bidirectional Glenn shunt: two decades of experience from a tertiary referral center

BackgroundDespite the improved management of patients with a single ventricle, the long-term outcomes are not optimal. We reported the outcomes of the bidirectional Glenn procedure (BDG) and factors affecting the length of hospital stay, operative mortality, and Nakata index before Fontan completion.ResultsThis retrospective study included 259 patients who underwent BDG shunt from 2002 to 2020. The primary study outcomes were operative mortality, duration of hospital stay, and Nakata index before Fontan. Mortality occurred in 10 patients after BDG shunt (3.86%). By univariable logistic regression analysis, postoperative mortality after BDG shunt was associated with high preoperative mean pulmonary artery pressure (OR: 1.06 (95% CI 1.01–1.23); P = 0.02). The median duration of hospital stay after BDG shunt was 12 (9–19) days. Multivariable analysis indicated that Norwood palliation before BDG shunt was significantly associated with prolonged hospital stay (β: 0.53 (95% CI 0.12–0.95), P = 0.01). Fontan completion was performed in 144 patients (50.03%), and the pre-Fontan Nataka index was 173 (130.92–225.34) mm2/m2. Norwood palliation (β: − 0.61 (95% CI 62.63–20.18), P = 0.003) and preoperative saturation (β: − 2.38 (95% CI − 4.49–0.26), P = 0.03) were inversely associated with pre-Fontan Nakata index in patients who had Fontan completion.ConclusionsBDG had a low mortality rate. Pulmonary artery pressure, Norwood palliation, cardiopulmonary bypass time, and pre-BDG shunt saturation were key factors associated with post-BDG outcomes in our series.

Postoperative vasoplegia in lung transplantation: incidence and relation to outcome in a single-centre retrospective study

BackgroundThe incidence and clinical importance of vasoplegia after lung transplantation remains poorly studied. We describe the incidence of vasoplegia and its association with complications after lung transplantation. MethodsPerioperative data of 279 lung transplant recipients operated on from 2015 to 2020 in a UK hospital were analysed retrospectively. ResultsVasoplegia occurred in 41.6% of patients after lung transplantation (mild, 31.0%; moderate, 55.2%; severe, 13.8%). Compared with non-vasoplegic patients, vasoplegic patients had a higher incidence of any acute kidney injury, defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria (78.5% vs 65%, P=0.015), renal replacement therapy (47.4% vs 24.5%, P<0.001), and delayed chest closure (18.4% vs 9.2%, P=0.025); were ventilated longer (70 [32–368] vs 34 [19–105] h, P<0.001); and stayed longer in the ICU (12.9 [5–30] vs 6.8 [3–20] days, P<0.001). Mortality at 30 days and 1 yr was higher in patients with vasoplegia (11.2% vs 5.5% and 20.7% vs 11.7%, P=0.039, respectively). Severe vasoplegia represented a predictor of longer-term mortality (hazard ratio=1.65, P=0.008). Underlying infectious disease, increased BMI, higher preoperative pulmonary artery systolic pressure and bilirubin levels, lower glomerular filtration rate, and increased fresh frozen plasma transfusion were predictors of vasoplegia severity. Neutrophilia, leucocytosis, and increased C-reactive protein were associated with vasoplegia, but release of the neutrophil activation markers myeloperoxidase and heparin-binding protein was similar between groups. ConclusionsInfluenced by preoperative status as well as procedural factors and inflammatory response, vasoplegia is a common and critical condition after lung transplantation with worse short-term outcomes and long-term survival.

Effect of preoperative pulmonary artery pressure on the prognosis of end-stage heart failure patients after heart transplantation

ObjectiveTo evaluate the effect of preoperative pulmonary artery pressure on perioperative outcome of end-stage heart failure patients undergoing heart transplantation.MethodsRetrospective analysis was undertaken on the clinical data of patients receiving heart transplantation in the Department of Cardiovascular Surgery of our hospital from March 2017 to March 2022. A ROC curve analysis was developed between mean pulmonary artery pressure (mPAP) and postoperative mortality using mPAP as diagnostic criteria. Patients were divided into groups based on this threshold to determine the best mPAP threshold value for predicting postoperative nosocomial mortality, and the differences in preoperative and intraoperative data, postoperative complications, and clinical prognosis of patients in the two groups were compared. Patients were followed up to draw the survival curve of patients in the two groups.ResultsThe study enlisted the participation of 105 patients. ROC curve research revealed that preoperative pulmonary artery pressure was substantially linked with death following heart transplantation, with mPAP = 30.5mmHg being the best threshold. The group with mPAP ≥ 30.5mmHg had a greater incidence of postoperative ECMO support (28.2% vs. 10.6%, P = 0.021) and a higher incidence of in-hospital mortality (15.4% vs. 1.5%, P = 0.019) than the group with mPAP < 30.5mmHg. The postoperative survival rates of 105 patients were 91.3%, 88.7%, 81.6%, and 77.5% at 1, 2, 3, and 4 years, respectively, however, there was no significant difference between the two groups of patients in the postoperative intermediate-far survival rate (P = 0.431).ConclusionsPreoperative pulmonary artery pressure in patients with end-stage heart failure is intimately correlated with perioperative prognosis of heart transplant recipients. The optimal cut-off mPAP value in predicting perioperative prognosis of heart transplant recipients is 30.5mmHg. In the high mPAP group, perioperative ECMO support rate and perioperative mortality rate are high, which do not affect the medium and long-term prognosis of the recipients undergoing heart transplantation.

Pre-operative pulmonary artery pulsatility index does not predict mortality post-cardiac transplantation.

The pulmonary artery pulsatility index (PAPi) is a novel haemodynamic marker that has previously been shown to predict right ventricular dysfunction and mortality in patients with pulmonary hypertension and advanced heart failure. Utility of the PAPi in predicting outcomes post-cardiac transplantation is unknown. The aim of this study was to compare the prognostic significance of PAPi against pulmonary vascular resistance (PVR) for the predication of morbidity and all-cause mortality post-transplantation. All patients who underwent cardiac transplantation over a 6year period were studied. Pre-operative right heart catheter data was obtained. The PAPi was calculated as follows: (systolic pulmonary artery pressure [sPAP]-diastolic pulmonary artery pressure [dPAP])/right atrial (RA) pressure. One hundred fifty-eight patients with a mean age of 49±14years were studied (43 with a pre-transplant left ventricular assist device [LVAD]). Three patients were excluded due to missing data. In the non-LVAD group, there was no significant difference in PAPi or PVR, nor was there any association with post-operative outcome (including stratification by natural history sub-type; all P>0.05). In the LVAD group, there was no association with PAPi and post-operative outcome; however, PVR was predictive of post-operative mortality (mortality: 2.8±1.3 WU vs. alive: 1.7±0.7 WU; P=0.005). The PAPi was not able to discriminate mortality outcomes for patients post-cardiac transplantation. Pulmonary vascular resistance remains a marker of mortality in an LVAD cohort bridged to transplant (central illustration).

Predictors of prolonged pleural effusion after Fontan operation.

Prolonged pleural effusion is a fairly common condition which has considerable impact on complicated and longer hospital stays after Fontan surgery. Identifying the patient population prone to have pleural effusions is still seeking for an answer. This study is to determine the variables that may predict prolonged pleural effusion according to the data of 69 patients who underwent Fontan operation between June 2018 and December 2020 and survived to date. Prolonged pleural effusion was defined as the need for a chest tube for more than 7 days. Two patient groups, with and without prolonged effusion, were compared in terms of pre-, peri-, and post-operative variables. The patients were subdivided into "high-risk" and "low-risk" groups based on the pre-operative catheterisation data. The most frequent main diagnosis was tricuspid atresia (n: 13, 19%). Among 69 patients, 28 (40%) had prolonged pleural effusion whereas 11 (16%) had effusions that lasted longer than 14 days. Ten patients among prolonged effusion group (35%) had pulmonary atresia coexistent with the main diagnosis. Fontan operation was performed in 6 patients (8.7%) over the age of 10, and 4 of these patients (67%) had prolonged pleural effusion. Among numerous variables, statistical significance between the two groups was achieved in pre-operative mean pulmonary artery pressure, post-operative albumin, C-reactive protein levels, length of hospital stay, duration of chest tube drainage, and amount of effusion per day. Early recognition and treatment strategies with routine medical protocol use remain to be the cornerstone for the management of post-operative prolonged pleural effusions after Fontan surgery.

Changes in pulmonary artery index and its relation to outcome after stage II palliation in patients with hypoplastic left heart syndrome.

This study aimed to prove if pulmonary artery (PA) size influences survival and if an additional aortopulmonary shunt (APS) promotes left PA growth after bidirectional cavopulmonary shunt (BCPS) in patients with hypoplastic left heart syndrome. The medical records of patients with hypoplastic left heart syndrome who underwent Norwood procedure and BCPS between 2007 and 2020 were reviewed. Right, left and total (right + left) PA indices were calculated according to Nakata and colleagues. A total of 158 patients were included in this study. The median age at Norwood and BCPS was 8 (7-11) days and 3.6 (3.1-4.6) months, respectively. There were 7 hospital deaths and 12 late deaths. Survival after BCPS was 90.3% at 1 year and 86.2% at 2 years. Total, right and left PA indices were 238 (195-316), 136 (101-185) and 102 (75-130) mm2/m2 at the time of BCPS, and they were 237 (198-284), 151 (123-186) and 86 (69-108) mm2/m2 at the time of Fontan. Left PA index decreased significantly between the time of BCPS and Fontan (P < 0.01). Nine patients needed partial takedown and additional APS due to failing BCPS, but the additional APS did not promote the PA growth significantly. Preoperative PA index did not affect the mortality after BCPS. The partial takedown and additional APS for failing BCPS were unable to improve left PA size.

Pulmonary Hypertension and Operative Risk in Mitral Valve and Coronary Surgery

IntroductionPulmonary hypertension (PHT) is a known risk factor for coronary artery bypass grafting (CABG), though less well understood for valve operations. We hypothesized PHT is associated with lower risk during mitral valve operations compared to CABG. MethodsPatients undergoing isolated mitral valve or CABG operations (2011-2019) in a regional Society of Thoracic Surgeons (STS) database were stratified by pulmonary artery systolic pressure (PASP). The association of PASP by procedure type was assessed by hierarchical regression modeling, adjusting for STS predicted risk scores. ResultsOf the 2542 mitral and 11,059 CABG patients, the mitral population had higher mean STS risk of mortality (3.6% versus 2.4%, P < 0.0001) and median PASP (42 mmHg versus 32 mmHg, P < 0.0001). PASP was independently associated with operative mortality and major morbidity in both mitral and CABG patients. However, for mitral patients a 10-mmHg increase in PASP was associated with lower odds of morbidity (odds ratio: 1.06 versus 1.13), mortality (odds ratio: 1.11 versus 1.18) and intensive care unit time (4.3 versus 7.6 h) compared with CABG patients (interaction terms P < 0.0001). Among mitral patients, median PASP was higher in stenotic versus regurgitant disease (57 mmHg versus 40 mmHg, P < 0.0001). However, there was no differential association of PASP on morbidity or mortality (interaction terms P > 0.05). ConclusionsAlthough mitral surgery patients tend to have higher preoperative pulmonary artery pressures, PHT was associated with a lower risk for mitral outcomes compared with CABG. Further research on the management and optimization of patients with PHT perioperatively is needed to improve care for these patients.

Temperature management of intraoperative cardiopulmonary bypass in valve replacement surgery: a retrospective analysis of the impact on postoperative organ function.

This study aimed to systematically analyze the effects of cardiopulmonary bypass (CPB) at different temperatures on the function of different organs in patients after heart valve replacement and to investigate its safety and feasibility. The data of 275 heart valve replacement surgery patients who underwent static suction compound anesthesia under CPB between February 2018 and October 2019 were retrospectively analyzed and divided into normothermic CPB anesthesia group (group 0), shallow hypothermic CPB anesthesia group (group 1), medium hypothermic CPB anesthesia group (group 2), and deep hypothermic CPB anesthesia group (group 3) according to the different intraoperative CPB temperatures. The basic preoperative conditions, cardiac resuscitation, number of defibrillations, postoperative ICU stay, postoperative hospital stay, and postoperative evaluation of different organ functions, such as heart, lung, and kidney functions, were analyzed and studied in each group. The comparison of preoperative and postoperative pulmonary artery pressure and left ventricular internal diameter (LVD) was statistically significant in each group (p < 0.05), and the postoperative pulmonary function pressure was statistically significant in group 0 compared with groups 1 and 2 (p < 0.05). The preoperative glomerular filtration rate (eGFR) and the eGFR on the first postoperative day were statistically significant in all the groups (p < 0.05), and the eGFR on the first postoperative day in groups 1 and 2 were statistically significant (p < 0.05). The control of appropriate temperature during CPB was associated with the recovery of organ function in patients after valve replacement. Intravenous compound general anesthesia with superficial hypothermic CPB might be more beneficial in recovering cardiac, pulmonary, and renal functions.

Albumin-Bilirubin Score: A Novel Mortality Predictor in Valvular Surgery.

The heart and liver are two organs that are closely related. The Albumin-Bilirubin (ALBI) score is a developed scoring system for assessing liver function. The aims of this study were to examine the correlation between preoperative ALBI score and pulmonary artery pressure and to investigate its ability to predict heart valve surgery mortality outcomes. The data of 872 patients who underwent isolated and combined heart valve surgery from 2014 to 2021 were retrospectively screened. In the preoperative period, 152 patients with laboratory tests including albumin and total bilirubin were found and analyzed retrospectively. Thirteen of these patients were excluded from the study. The remaining 139 patients were included in the analysis. Baseline demographic data, echocardiography data, performance status, laboratory data, operative data, and postoperative status were collected. The optimal cutoff value of preoperative ALBI score was calculated. The cutoff for ALBI scores was calculated as -2.44 to predict in-hospital mortality (sensitivity = 75.0%, specificity = 70%). Based on the cutoff value, 90 patients had a low ALBI score (≤ -2.44, 64.7%) and 49 patients had a high ALBI score (> -2.44, 35.3%). High ALBI score was associated with an increased incidence of acute kidney injury and in-hospital mortality, and a positive correlation was found between ALBI score and pulmonary artery pressure. In patients with valvular surgery, high ALBI score was an independent prognostic factor of in-hospital mortality and acute kidney injury. It is easily measurable and a cost-effective way to predict mortality.

Preoperative pulmonary artery hypertension as a risk factor: the tip of the iceberg

Preoperative pulmonary artery hypertension as a risk factor: the tip of the iceberg

A modified approach in the repair of type I and II truncus arteriosus to promote branch pulmonary arterial growth and limit early reoperation.

Maintaining adequate branch pulmonary arterial growth is critical in preventing early (<3years) right ventricular outflow tract reoperation after the repair of truncus arteriosus. We hypothesized that a modified truncus arteriosus repair keeping the branch pulmonary arteries in situ would promote branch pulmonary arterial growth and limit early right ventricular outflow tract reoperation. For infants requiring repair for type I and II truncus arteriosus, the truncal root was septated through a hockey stick incision keeping the branch pulmonary arteries in situ, the ventricular septal defect was closed, and a short aortic homograft was used to reconstruct the right ventricular outflow tract. Echocardiograms measured preoperative and follow-up branch pulmonary artery diameter. Between 1998 and 2020, 41 infants were repaired using the modified approach (type I, 28; type II, 13). With a median follow-up of 11.6 (interquartile range, 3.1-15.5) years, there was no significant change between preoperative left pulmonary artery and right pulmonary artery Z-scores and their corresponding follow-up measurement (left pulmonary artery: 0.97, interquartile range, 0.6-1.6 vs left pulmonary artery: 1.4, interquartile range, -0.3 to 1.9) (right pulmonary artery: 0.6, interquartile range, -0.4 to 1.7 vs right pulmonary artery: 0.3 interquartile range, 0.5-0.9). Only 7.3% (n=2) of follow-up right pulmonary artery Z-scores were less than 2.5 Z-scores below preoperative measurements. Four children (9.8%) required early right ventricular outflow tract reoperation. On multivariable analysis, larger conduit Z-scores were associated with greater time to right ventricular outflow tract reoperation (hazard ratio, 0.55, confidence interval, 0.307-0.984; P=.043). Maintaining the branch pulmonary arteries in situ at initial truncus arteriosus repair allows for branch pulmonary arterial growth, limiting early right ventricular outflow tract reoperation.

Abstract 11708: Giant Myxoma Causing Severe Pulmonary Hypertension

Introduction: Myxomas are the most common primary cardiac tumor, with clinical manifestations depending on tumor size and location. We present a case of giant left atrial (LA) myxoma causing functional mitral stenosis and associated severe pulmonary hypertension. Case: A 75-year-old woman with newly diagnosed heart failure and atrial fibrillation presented to the emergency department with 2-months of chest pain and shortness of breath. She had left-sided chest pain during exertion and at rest, dyspnea, and 3-pillow orthopnea. She was normothermic, blood pressure of 93/57 mm Hg, HR 63 bpm, respiratory rate of 21, and 91% oxygen saturation on room air. Cardiovascular exam revealed no murmurs, elevated JVD and bilateral lower extremity edema. Chest CT revealed a large mass, measuring 9x4 cm, in the LA extending into the left ventricle. TTE demonstrated a large mobile mass in the LA measuring 9.4x3.9 cm. The mass extended through the mitral valve into the left ventricle, causing functional mitral stenosis with mean inflow gradient of 10 mmHg. Severe tricuspid regurgitation was demonstrated with a peak regurgitant velocity of 4.89 m/s, with estimated right ventricular systolic pressure of 101 mmHg. Pre-operative pulmonary artery systolic pressure was 100 mmHg. She underwent surgical excision. Histology confirmed diagnosis of myxoma, and the mass measured 7.2 x 5.0 x 4.7 cm. At follow up, she had no heart failure symptoms or additional episodes of atrial fibrillation. Repeat TTE demonstrated normal RVSP. Discussion: Symptoms of myxoma include cardiovascular, embolic and constitutional symptoms. While obstructive symptoms are common in large myxomas, only 10% have severe functional mitral stenosis. Despite this, sequela of pulmonary hypertension and tricuspid regurgitation is not well documented. Diagnosis is made by TTE, which also allows assessment of valvular and hemodynamic changes. Treatment requires surgical resection, with low rates of recurrence.

Impact of Reintervention During Stage 1 Palliation Hospitalization: A National, Multicenter Study

BackgroundStage 1 palliation (S1P) for hypoplastic left heart syndrome remains associated with high morbidity and mortality. Previous studies on burden of reinterventions did not include patients who remain hospitalized before stage 2 palliation (S2P). This study described the rate of reintervention during S1P hospitalization and sought to determine the impact of reintervention on outcomes. MethodsAll participants enrolled in phase II of the National Pediatric Cardiology Quality Improvement Collaborative after S1P were included in this study. The primary outcome was the rate of reintervention during hospitalization after S1P and before hospital discharge or S2P. Reintervention was defined as 1 or more unplanned interventional cardiac catheterizations or surgical reoperations. ResultsBetween March 1, 2016 and October 1, 2019, 1367 participants underwent S1P and 339 (24.8%) had a reintervention; most commonly to address the source of pulmonary blood flow. Gestational age, weight at S1P, atrioventricular septal defect, heterotaxy, preoperative pulmonary artery bands, hybrid S1P, and an additional bypass run or early extracorporeal membrane oxygenation were significantly associated with reintervention. Participants in the reintervention group experienced higher rates of nearly all postoperative complications, were less likely to be discharged before S2P (57.1% vs 86%; P < .001), and more likely to experience in-hospital mortality (17% vs 5%; P < .001). ConclusionsUnplanned reintervention during hospitalization after S1P palliation occurred in 25% of participants in a large, registry-based national cohort. Participants who underwent reintervention were more likely to remain as inpatient and were less likely to survive to S2P. Reintervention was associated with a multitude of postoperative complications that affect survival and long-term outcome.

Notch ratio in pulmonary flow predicts long term prognosis after pulmonary endarterectomy for chronic thrombo-embolic pulmonary hypertension

Abstract Introduction The notch ratio (NR) in the pulmonary flow predicts in-hospital mortality after pulmonary endarterectomy (PEA) for chronic thrombotic pulmonary hypertension (CTEPH). Purpose We studied whether the echocardiographic parameter NR can also discriminate long term outcome. Methods All patients who underwent PEA between June 2002 and June 2005 were studied. Clinical, hemodynamic and echocardiographic variables were assessed pre-operatively and at 3 months post-PEA. Clinical follow up ended in March 2022. NR was the time from onset pulmonary flow until notch divided by the time from notch until end of pulmonary flow assessed with pulsed Doppler. Results A total of 59 patient are included in this analysis. Mean age was 53±14 years, 34% were male patients and 66% of patients were NYHA class III or IV. Pre-operative mean pulmonary artery pressure (mPAP) was 45±15 mmHg and calculated total pulmonary resistance (TPR) was 870±511 dynes s cm–5. Pre-operatively, 7 patients had no notch, 33 had NR &amp;lt;1.0 and 19 had NR &amp;gt;1. Six patients died in hospital and a total of 19 patients died during the follow up till March 2022. Between survivors and non-survivors, no significant differences were observed in 6-minute walking distance (409±114 m. vs. 364±110 m., p=0.22), plasma BNP (34±47 pmol/l vs. 57±52 pmol/l, p=0.10), mean PAP (43±14 mmHg vs. 49±15 mmHg, p=0.14), TPR (793±493 dynes s cm–5 vs. 1015±525 dynes s cm–5, p=0.13). NR was significant different between survivors and non-survivors (0.73±0.25 vs. 1.1±0.44, p&amp;lt;0.001). Mean very long term follow-up of 14±6 years. The 1, 5, 8 and 14 year survival for patients with a NR &amp;lt;1 was respectively 100%, 100%, 95% and 83% was significantly better (p≤0.001) then for patients with a NR &amp;gt;1 (1, 5, 8 and 14 year survival was 68%, 53%, 42% and 37%, respectively). For patients without a notch (1, 5 and 8 year survival was 100% and 14 year survival was 86%). Conclusion NR predicts in-hospital and long term mortality in CTEPH patients undergoing PEA. NR &amp;gt;1.0 is associated with a higher risk of mortality. NR is a simple echocardiographic parameter that can be used in clinical decision making for PEA. Funding Acknowledgement Type of funding sources: None.

Predictors of mitral valve hemodynamics after mitral valve repair for degenerative mitral regurgitation: a subanalysis of the CAMRA randomized trial

Abstract Introduction Intra-operative predictors of mid-to-late mitral valve dysfunction after surgical repair of mitral regurgitation (MR) caused by prolapse remain poorly characterized. This study aims to evaluate the effect of annuloplasty prosthesis size on post-operative MV hemodynamics at rest and during exercise, and to identify perioperative predictors of MV dysfunction. Methods 104 patients were randomly assigned to resection and preservation for surgical treatment of posterior leaflet prolapse in the Canadian Mitral Research Alliance CardioLink-2 study. Echocardiograms were performed at baseline and 1 year postoperatively. Intraoperative TEE was performed to assess immediate MV gradients. Exercise TTE was performed 1 year after repair. Linear regression analysis was used to identify associations between MV indices (rest and peak exercise gradients) at 12 months, and perioperative echocardiographic and clinical factors. Results Mean age of participants was 65±10 years, and 83% were male. Larger annuloplasty size was associated with lower transmitral gradients at rest and during peak exercise. In multivariable analysis, annuloplasty size ≥34mm was associated with lower mean and peak rest and exercise gradients at 12 months, after adjustment for repair type, age, sex, and BSA (p&amp;lt;0.001). Higher pre-operative pulmonary artery pressures were associated with reduced functional capacity post-operatively. Intra-operative TEE gradients predict resting and exercise MV hemodynamics at 1 year. Conclusion Annuloplasty size ≥34mm is associated with improved MV hemodynamics at rest and during peak exercise 1 year post MV repair. MV repair prior to onset of pulmonary hypertension confers favourable post operative functional capacity. Finally, intra-operative TEE can be used to identify patients at risk of mitral valve dysfunction within 1 year of repair. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): The Heart and StrokeFoundation of Ontario (GIA 16-00014666)