Surgical Conduit Research Articles

Performance and Failure of Right Ventricle to Pulmonary Artery Conduit in Congenital Heart Disease

Surgical implantation of a right ventricle to pulmonary artery (RV-PA) conduit is an important component of congenital heart disease (CHD) surgery, but with limited durability, leading to re-intervention. The present single-center, retrospective, cohort study reports the results of surgically implanted RV-PA conduits in a consecutive series of children and adults with CHD. Patients with CHD referred for RV-PA conduit surgical implantation (from October 1997 to January 2022) were included. The primary outcome was conduit failure, defined as a peak gradient above 64 mm Hg, severe regurgitation, or the need for conduit-related interventions. Longitudinal echocardiographic studies were available for mixed-effects linear regression analysis. A total of 252 patients were initially included; 149 patients were eligible for follow-up data collection. After a median follow-up time of 49 months, the primary study end point occurred in 44 (29%) patients. A multivariable Cox regression model identified adult age (>18 years) at implantation and pulmonary homograft implantation as protective factors (hazard ratio 0.11, 95% confidence interval [CI] 0.02 to 0.47 and hazard ratio 0.34, 95% CI 0.16 to 0.74, respectively). Fever within 7 days of surgical conduit implantation was a risk factor for early (within 24 months) failure (odds ratio 4.29, 95% CI 1.41 to 13.01). Long-term use of oral anticoagulants was independently associated with slower progression of peak echocardiographic gradient across the conduits (mixed-effects linear regression p = 0.027). In patients with CHD, the rate of failure of surgically implanted RV-PA conduits is higher in children and after nonhomograft conduit implantation. Early fever after surgery is a strong risk factor for early failure. Long-term anticoagulation seems to exert a protective effect.

An International Consensus Survey among Pediatric Surgeons on the Role of Appendectomy in Malrotation.

Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

Right ventricle to pulmonary artery conduit: a comparison of long-term graft-related events between bovine jugular vein conduit, aortic homograft, and porcine-valved conduits.

The optimal conduit for right ventricle to pulmonary artery (RV-PA) reconstruction does not exist. Reinterventions are common due to conduit stenosis and endocarditis. Tailoring conduit choice according to patients' characteristics could improve the outcomes. The study aimed to compare graft-related events (infective endocarditis, transcatheter pulmonary valve replacement (PVR), transcatheter conduit dilatation, surgical conduit replacement, and transcatheter pulmonary branch intervention for RV-PA reconstruction using bovine jugular vein, aortic homograft, and porcine-valved conduits. In a retrospective cohort study, 155 patients with 193 procedures that were done in King Faisal Specialist Hospital and Research Center-Jeddah (KFSHRC JED) for implanting RV-PA conduits from 1999 to 2021 were included. The patients were grouped according to the type of conduit into 3 groups; Group 1 (n=153) received bovine jugular vein (BJVs) grafts, Group 2 (n=29) received aortic homografts, Group 3 (n=11) received porcine-valved conduits. Factors associated with graft-related events were evaluated using stepwise Cox regression analysis. Patients with BJVs were significantly younger than those with porcine-valved conduits 3 (P=0.009). The weight of BJVs patients was significantly lower than homografts (P=0.002) and porcine-valved conduits patients 3 (P<0.001). The conduit size was as expected significantly lower in BJVs patients than patients who received porcine-valved conduits (P<0.001) and patients who received aortic homografts (P<0.001). There was no difference between Group 2 and 3 (P=0.084). Operative mortality occurred in 13 patients: 12 (7.84%) with BJV conduit and 1 (9.09%) with porcine valved conduit (P=0.351). Male gender [odds ratio (OR): 10.04; 95% confidence interval (CI): 1.28-78.86; P=0.028] and smaller conduit size (OR: 0.78; 95% CI: 0.61-0.99; P=0.048) were associated with increased operative mortality. Freedom from graft-related events at 5 and 10 years was 67% and 52% in BJVs patients, 74% and 36% in patients who received aortic homografts, and 53% in patients who received porcine-valved conduits. Factors associated with increased graft-related events were male gender (HR: 1.58; 95% CI: 1.004-2.50, P=0.048) and younger age (HR: 0.995; 95% CI: 0.991-0.999, P=0.041). RV-PA reconstruction was associated with low mortality, unrelated to the conduit type. Reinterventions for graft-related events were common. The durability and graft-related events might be comparable among BJV grafts, aortic homografts, and porcine-valved conduits. Factors associated with increased graft-related events in this study were male gender and younger age.

Pulmonary Homograft vs Handmade Polytetrafluoroethylene-Valved Conduits After the Ross Procedure

BackgroundThis study aimed to longitudinally compare expanded polytetrafluoroethylene (ePTFE)–valved conduits vs pulmonary homograft (PH) conduits after right ventricular outflow tract reconstruction in the Ross procedure. MethodsPatients undergoing a Ross procedure from June 2004 to December 2021 were identified. Echocardiographic data, catheter-based interventions, or conduit replacements, as well as time to first reintervention or replacement, were comparatively assessed between handmade ePTFE-valved conduits and PH conduits. ResultsA total of 90 patients were identified. The median age and weight were 13.8 years (interquartile range [IQR], 8.08-17.80 years) and 48.3 kg (IQR, 26.8-68.7 kg), respectively. There were 66% (n = 60) ePTFE-valved conduits and 33% (n = 30) PHs. The median size was 22 mm (IQR, 18-24 mm) for ePTFE-valved conduits and 25 mm (IQR, 23-26 mm) for PH conduits (P < .001). Conduit type had no differential effect in the gradient evolution or the odds of presenting with severe regurgitation in the last follow-up echocardiogram. Of the 26 first reinterventions, 81% were catheter-based interventions, without statistically significant differences between the groups (69% PH vs 83% ePTFE). The overall surgical conduit replacement rate was 15% (n = 14), and it was higher in the homograft group (30% vs 8%; P = .008). However, conduit type was not associated with an increased hazard for reintervention or reoperation after adjusting for covariates. ConclusionsRight ventricular outflow tract reconstruction using handmade ePTFE-valved conduits after a Ross procedure provides encouraging midterm results, without a differential effect in hemodynamic performance or valve function compared with PH conduits. These results are reassuring about the use of handmade valved conduits in pediatric and young adult patients. Longer follow-up of tricuspid conduits will complement valve competency assessment.

Cardiac MRI: State of the Art.

Cardiac MRI plays an important role in the evaluation of cardiovascular diseases (CVDs), including ischemic heart disease, cardiomyopathy, valvular disease, congenital disease, pericardial disease, and masses. Large multicenter trials have shown the positive impact of MRI-based management on outcomes in several CVDs. These results have made MRI an indispensable technique in the evaluation of these diseases, and cardiac MRI has an important role in multisociety guidelines. MRI is the reference standard for quantification of ventricular volumes and function. Flow imaging enables accurate quantification of flow and velocities through valves, shunts, and surgical conduits or baffles. Late gadolinium enhancement and parametric mapping techniques enable tissue characterization and yield prognostic information. In the past decade, cardiac MRI technology has seen rapid advances in both hardware and sequences. Multiple novel sequences, such as parametric mapping and four-dimensional flow, are increasingly being incorporated into routine clinical practice. Acceleration strategies have matured, allowing faster acquisition of cardiac MRI sequences in patients with arrhythmia and poor breath holding. Challenges of cardiac MRI at high-field-strength magnets and in patients with indwelling cardiac devices or severe renal dysfunction have been mitigated. Artificial intelligence techniques are decreasing the complexity of MRI acquisition and postprocessing. This article reviews the current state of the art and emerging techniques in cardiac MRI.

Intravascular Lithotripsy Versus Open Surgical Conduit in the Management of Complex Access Vessels During Advanced Endovascular Aortic Repair

Intravascular Lithotripsy Versus Open Surgical Conduit in the Management of Complex Access Vessels During Advanced Endovascular Aortic Repair

SCAI Position Statement on Best Practices for Percutaneous Axillary Arterial Access and Training.

Axillary artery access has become increasingly widespread as an alternative to the femoral route for large-bore transcatheter aortic valve replacement (TAVR), endovascular aortic repair (EVAR), and mechanical circulatory support (MCS) procedures. Advantages of percutaneous access include avoidance of a surgical incision, general anesthesia, and conduit graft infection. This statement aims to review the anatomic considerations and risks for percutaneous axillary artery access, suggest best practices for access techniques, hemostasis/closure strategies, and complication management, and recommend options for training and privileging.

A \u201ccat\u201d-astrophic case of Bartonella infective endocarditis causing secondary cryoglobulinemia: a case report

BackgroundCulture-negative infective endocarditis (IE) constitutes approximately 10% of all cases of IE. Bartonella endocarditis is a common cause of culture-negative endocarditis and is associated with a high mortality rate. To date, no cases of Bartonella IE has been reported in association with cryoglobulinemia in the UK. We present a unique case of Bartonella IE causing secondary cryoglobulinemia in a young female.Case presentationA 17-year-old female with a background of pulmonary atresia and ventricular septal defect repaired with a cardiac conduit at the age of 4, presented with a one-year history of weight loss (from 53 to 39 kg) and poor appetite. She subsequently developed a vasculitic rash and haematoproteinuria with decline in renal function, requiring urgent hospital admission. Initial blood tests showed a near normal creatinine, but a raised cystatin C. Renal biopsy showed focal necrotizing glomerulonephritis with no acute tubular necrosis or chronic change. Subsequent blood tests supported a diagnosis of cryoglobulinaemic vasculitis (high rheumatoid factor, low complement, polyclonal gammopathy, Type 3 cryoglobulin). A weak positive PR3 meant there was some uncertainty about whether this could be a primary ANCA-associated vasculitis (AAV). Initial workup for an infectious cause, including multiple blood cultures, were negative. However, an echocardiogram showed definite vegetations on her surgical conduit. The patient did not respond to empirical antimicrobials and so was referred for surgical revision of her conduit. Tissue samples obtained intra-operatively demonstrated Bartonella species. With targeted antimicrobials post-operatively, she improved with resolution of immunologic abnormalities and at last review had a normal renal profile. On reviewing her social history, she had adopted several stray cats in the preceding year; and thus, the cause of the Bartonella infection was identified.ConclusionThis is the first reported case of Bartonella endocarditis causing secondary cryoglobulinemia reported in the UK. The key learning points from this case include that Bartonella endocarditis can present as a cryoglobulinaemic vasculitis and should be considered in any differential when the cause of cryoglobulinaemia is not clear and to enquire about relevant exposures especially when culture-negative endocarditis is suspected.

External validation of Pentafecta in patients undergoing laparoscopic radical cystectomy: results from a high-volume center

BackgroundTo investigate whether Pentafecta is suitable for bladder cancer patients receiving laparoscopic radical cystectomy (LRC).MethodsFrom November 2013 to December 2020, muscle invasive Bladder Cancer (MIBC) and non-muscle invasive Bladder Cancer (NMIBC) patients who received LRC and urinary diversion were retrospectively analyzed. Pentafecta was defined as meeting five criteria: negative soft margin, ≥ 16 lymph nodes (LNs) removed, major complications free, urinary diversion related sequelae free and clinical recurrence free within 1 year. Analyze the achievement of five criteria and compare the overall survival (OS) of Pentafecta group with non-attainment group. Multivariable Cox’s regression was performed to evaluate the impact of Pentafecta on OS. Multivariable logistic regression was performed to explore the effect of surgical experience on Pentafecta attainment.ResultsA total of 340 patients were included, negative soft margin, ≥ 16 lymph nodes (LNs) removed, major complications free, urinary diversion related sequelae free and clinical recurrence free within 1 year were observed in 95.3%, 30.3%, 83.8%, 75.0% and 85.6% of patients, respectively. Pentafecta group had a significantly longer OS than the non-attainment group (P = 0.027). The group with 10–15 LNs removed and meeting the other four criteria had a similar OS to group with ≥ 16 LNs removed (Pentafecta group) (5-year OS: 67.3% vs 72.7%, P = 0.861). Pentafecta (HR = 0.33, P = 0.011), positive lymph nodes (HR = 2.08, P = 0.028) and MIBC (HR = 3.70, P < 0.001) were all significant predictors of OS in multivariable Cox’s regression. Surgical experience (OR = 1.05, P < 0.001), conduit (OR = 2.09, P = 0.047) and neobladder (OR = 2.47, P = 0.048) were all independent predictors of Pentafecta attainment in multivariable logistic regression.ConclusionsPentafecta is suitable for bladder cancer patients receiving LRC and has the potential to be a valuable tool for evaluating the quality of LRC. Based on Pentafecta analysis, removing 10 LNs instead of 16 LNs as the one of the five criteria may be more appropriate for bladder cancer patients.

Congenitally Corrected Transposition of the Great Arteries with pulmonary atresia s/p left ventricle to pulmonary artery surgical conduit with trans-catheter pulmonary valve replacement-acrylic on canvas (36"x36")

Congenitally Corrected Transposition of the Great Arteries with pulmonary atresia s/p left ventricle to pulmonary artery surgical conduit with trans-catheter pulmonary valve replacement-acrylic on canvas (36"x36")

Assessment of the clinical outcomes and patient satisfaction when using bilateral radial artery as surgical conduits in coronary artery bypass grafting

IntroductionThe need for use of the bilateral radial artery has emerged since we faced patients in our institute with severe uncontrolled diabetes, bilateral leg elephantiasis, and left main disease that needs surgical revascularization.Patients and methodsWe reviewed the outcomes from our institute with retrospective analysis of prospectively collected clinical data from our local clinical database and identified 30 consecutive patients who underwent coronary artery revascularization requiring the use of bilateral radial harvest. Patient satisfaction was assessed using a quality-of-life questionnaire with the descriptors on a Likert Scale (table A). The patients were followed up both clinically and by ECG and echocardiography every 6 months for 2 years postoperatively to follow up their ejection fraction and for the assessment of any new segmental wall motion abnormalities.ResultsOnly three (12.5%) patients out of 24 reported 'rarely' or sometimes arm pain or discomfort, while all the others (87.5%) were asymptomatic. The median score for arm and sensory and neurological complications was 5. Three (12.5%) patients reported long-term permanent sensory deficit, while six (25%) patients had some other less-significant sensory loss. Only one (4.2%) patient reported significant motor dysfunction, while five (20.8%) patients reported milder forms of motor deficit. Thirteen (54.1%) patients considered the appearance of radial harvest site as excellent, while 23 (95.8%) patients considered it to be at least acceptable. One (4.2%) patient reported a 'moderate' functional change otherwise, the remaining patients reported 'minimal' (12.5%) or 'no change' (83%). The functional outcomes from our series of patients remain favorable with minimal functional decline in the majority of our patients. Both clinical ECG and echocardiographic follow-up revealed stability of all followed patients without the need for CCU admission or repeat revascularization in this time period.ConclusionsUsing bilateral radial artery as surgical conduits in coronary artery bypass grafting is acceptable to patients when alternatives are not favorable for surgical revascularization.

Improved perioperative mortality after secondary aortoenteric fistula repair and lessons learned from a 20-year experience

Secondary aortoenteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes. We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints. A total of 57 patients (63% male; n= 36) presented with SAEF (median age, 69years; interquartile range [IQR], 61-74years). Median follow-up time was 10months (interquartile range, 3-21months. The most common presenting symptoms were gastrointestinal bleeding (60%; n= 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n= 17) underwent extra-anatomic bypass with aortic ligation, 30% (n= 17) rifampin-soaked Dacron graft, 26% (n= 15) femoral vein (eg, neoaortoiliac system), and 14% (n= 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n= 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n= 35). Thirty-day mortality was 35% (n= 20) with no significant difference between 90days (39%; n= 22) and 180days (42%; n= 24). Morbidity was 70% (n= 40), with gastrointestinal (30%; n= 17; leak [9%]), pulmonary (25%; n= 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n= 32). One-year and 3-year survival was 54%± 6% and 48%± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P= .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P= .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome. In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy

ABSTRACT Introduction Trans-valvular micro-axial flow pumps such as Impella are increasingly utilized in patients with cardiogenic shock [CS]. A number of different Impella devices are now available providing a wide range of cardiac output. Among these, the Impella 5.0 and recently introduced Impella 5.5 pumps can provides 5.55 L/min of flow, enabling complete left ventricular support with more favorable hemodynamic effects on myocardial oxygen consumption and left ventricular unloading. These devices require placement of a surgical conduit graft for endovascular delivery, but are increasingly being used in patients with CS due to acutely decompensated heart failure [ADHF], acute myocardial infarction [AMI] and after cardiac surgery as a bridge to transplant or durable ventricular assist device surgery or myocardial recovery. Areas Covered This review focuses on the device profile and use of the Impella 5.0 and 5.5 systems in patients with CS. Specifically; we reviewed the published literature for Impella 5.0 device to summarize data regarding safety and efficacy. Expert Opinion The Impella 5.0 and 5.5 are trans-valvular micro-axial flow pumps for which the current data suggest excellent safety and efficacy profiles as approaches to provide circulatory support, myocardial unloading, and axillary placement enabling patient mobilization and rehabilitation. Abbreviations pMCS, Percutaneous mechanical circulatory support devices; CS, Cardiogenic shock; ADHF, Acute decompensated heart failure; AMI, Acute myocardial infarction; LVAD, Left ventricular assist deviceI; ABP, Intra-aortic balloon pump; VA-ECLS, Veno-arterial extracorporeal life support

Efficacy of Rivaroxaban and Aspirin in Patients With Peripheral Artery Disease With Venous and Prosthetic Surgical Bypass Conduits: Insights from the VOYAGER PAD Trial

Patients with peripheral artery disease (PAD) requiring surgical lower extremity revascularization (LER) are at heightened risk of adverse limb complications, including acute limb ischemia (ALI). VOYAGER PAD demonstrated that rivaroxaban significantly reduces this risk. Bypass is a major component of surgical LER, and procedural success is dependent on quality and type of conduit. The risk of ALI and efficacy of rivaroxaban for VOYAGER PAD surgical patients receiving vein or prosthetic conduit have not been described.

Evaluation and Management of Pulmonic Valve Disease

The goal of this review is to provide information about the causes, consequences, exam, echocardiographic findings, and guideline-based treatment options for pulmonic valve lesions. Balloon pulmonic valvuloplasty and surgical valve replacement are the primary treatment options for hemodynamically significant stenosis and regurgitation, respectively. Transcatheter pulmonic valve replacement has emerged as a treatment option for select native valve lesions or dysfunctional surgical conduits. Symptoms of pulmonic valve disease can be overlooked, and long-term effects on right ventricular function may be irreversible. An understanding of the pathophysiology and treatment of pulmonic disease is important, and consultation with a congenital heart disease specialist is warranted.

Coronary Artery Bypass: Review of Surgical Techniques and Impact on Long-Term Revascularization Outcomes.

Coronary revascularization for multivessel disease remains a common and costly source of hospitalizations in the United States. Surgical techniques influence outcomes for coronary bypass and also affect the need for percutaneous coronary intervention in the future. As more radial access has been used for coronary angiography, consideration for use of the radial artery as a surgical conduit remains unclear. Saphenous vein grafts are commonly used for coronary bypass, however long-term patency remains suboptimal, and is also associated with a higher risk of adverse events with percutaneous coronary intervention. Thus, understanding the interplay between coronary bypass techniques and percutaneous coronary intervention has become increasingly important.

Complications after Liver Transplant Related to Preexisting Conditions: Diagnosis, Treatment, and Prevention.

Diagnostic imaging after orthotopic liver transplant focuses primarily on depicting complications related to surgical hepatic vascular and biliary anastomoses. Less common preexisting vascular conditions include congenital anatomic variants, atherosclerosis, chronic portal venous thrombosis, splenic artery and variceal steal phenomena, and transarterial embolization (TAE) for hepatocellular carcinoma (HCC). If unappreciated or left untreated preoperatively, these conditions negatively impact the transplant by impairing hepatic arterial or portal vascular inflow. Many of the complications related to preexisting vascular conditions can be prevented or mitigated by proper performance and careful evaluation of preoperative imaging studies. The authors describe the diagnosis and treatment of complications arising from narrowing of the celiac axis by atherosclerosis and the median arcuate ligament, variant anatomy of the hepatic artery, insufficiency of the portal vein requiring surgical conduits, and large varices or an enlarged splenic artery and spleen that may steal blood and compromise hepatic arterial or venous inflow. While preoperative evaluation primarily involves CT and MRI, postoperative diagnosis involves screening with sonography and confirmation with other modalities. We propose the use of a preoperative checklist of vascular status and measurements in patients undergoing liver transplant. Reports of imaging studies in recipients after transplant should include details of surgical vascular anastomoses and conduits, any history of HCC and preoperative TAE, details of the preoperative α-fetoprotein levels, and any unusual procedures or pathologic findings in the explanted liver that may affect postoperative surveillance. The authors review the pretransplant imaging evaluation of vascular and HCC issues that may affect surgical outcomes and methods to help recognize complications after transplant that can arise from these conditions.©RSNA, 2020.

P4164Transcatheter pulmonary valve implantation versus surgical pulmonary conduit replacement in corrected tetralogy of Fallot with pulmonary atresia: a propensity matched comparison

Abstract Background Tetralogy of Fallot with pulmonary artesia (PA-VSD) complete repair includes the placement of a right ventricle to pulmonary artery conduit. As more and more patients survive past childhood, the need for conduit replacement has increased. Transcatheter pulmonary valve implantation (TPVI) has emerged as an alternative to the surgical pulmonary valve replacement (SPVR) in conduit failure, but comparative data are lacking. Purpose We aim to use data from a national procedural audit database to compare TPVI and SPVR in operated PA-VSD with conduit failure. Method All patients with surgically corrected PA-VSD undergoing TPVI or SPVR between 2006–2012 were included (SPVR n=103, TPVI n=31). A propensity score matching algorithm based on age, gender, known genetic mutations, MAPCAs presence of endocarditis, preoperative mechanical support, operation year and follow-up time was used and resulted in balanced groups. Results Median age at TPVI and SPVR were 23 years (11–51) and 12 years (0.3–55) respectively. Median follow-up was 3.7 years (1 day-12.5 years) in SPVR and 2 years (0.3–10.6) in TPVI. There were slightly more females in the TPVI group (64% vs 49% in SPVR p=0.1). There were no significant differences in procedure era (77% after 2005), MAPCAs (31%) or known genetic conditions (17%). All cases of preoperative endocarditis (n=6) and mechanical support (n=4) were in the SPVR group. Survival, freedom from pulmonary valve replacement (PVR) and PVR free survival before and after matching at 5 years are shown in Table. After matching survival tended to be lower in TPVI (p=0.4), but without reaching statistical significance, while freedom from PVR (p=0.004, Figure) and PVR free survival (0.02) were significantly lower after TPVI, compared to SPVR. Relative mortality by age increments Before matching After matching TPVI SPVR TPVI SPVR p value Survival at 5 years (%) 87 92 87 94 0.4 Freedom from PVR at 5 years (%) 83 96 83 100 0.004 PVR free survival at 5 years (%) 72 88 72 94 0.02 Conclusions In our study TPVI showed comparable midterm survivable with SPVR, but significantly lower freedom from PVR, resulting in a lower PVR free survival. Further studies with longer follow-up and a prospective design are needed to investigate the factors influencing these outcomes.

Surgical Mesoportal Bypass and Portosystemic Shunt Interventions

AbstractExtrahepatic portal vein obstruction is defined by obstruction of the extrahepatic portal vein with or without involvement of the intrahepatic veins and does not include isolated thrombosis of the splenic vein or superior mesenteric vein. The etiology may be congenital versus acquired and acute versus chronic. Historically, surgical intervention has been reserved for patients with symptoms refractory to medical or endoscopic management. Over time, however, advances in surgical technique and research have caused a shift in practice. The interventionalists' role is primarily to address clinically significant shunt dysfunction, including shunt stenosis and thrombosis. In this article, the authors discuss the classification and indications of surgical portosystemic conduits, pre-and postoperative imaging, and clinical signs, and endovascular techniques to address shunt dysfunction.

Catheterization Performed in the Early Postoperative Period After Congenital Heart Surgery in Children.

The aim of this study was to describe pediatric patients who underwent early postoperative cardiac catheterization after congenital heart surgery, their clinical indications, findings, interventions, and complications in a cardiovascular center. A descriptive retrospective study was performed. All catheterizations performed within 6weeks after congenital heart surgery between January 2004 and December 2014 were reviewed. We analyzed 101 early postoperative catheterizations. They were performed on median postoperative day five (IQR: 0-39); the median age was 64days (IQR: 22-240). The most common diagnoses were single ventricle (53%), left heart obstruction (12%), and tetralogy of fallot or pulmonary atresia with ventricular septal defect (11%). Most common indications were persistent cyanosis (53%), low cardiac output (24%), and residual defect on echocardiogram (20%). Most frequent findings during the catheterization were pulmonary artery stenosis (29%), surgical conduit obstruction (12%), and coarctation or hypoplasia of the aorta (11%). Forty-six (45%) procedures involved intervention. Most frequent interventions were pulmonary artery, aorta, and Blalock-Taussig fistula angioplasty with or without stent implantation. There were adverse effects in 11 cases (11%), and 30-day mortality was 28% (28 patients) with the majority unrelated to the catheterization directly. Although early postoperative catheterizations are high-risk procedures, they are currently a very good option to solve acute problems in critically ill patients. This study provides relevant information for a better understanding and approach to this complex group of patients.