Eline F. Bruggemans

Thirty-Year Experience With the Arterial Switch Operation

BACKGROUND We evaluated the results of the arterial switch operation (ASO) being performed at our institution for more than 30 years and identified risk factors for mortality and reoperation. METHODS Clinical outcome of 332 consecutive patients with transposition of the great arteries undergoing ASO was retrospectively analyzed, using surgical reports, medical charts, and latest follow-up echocardiography. Statistical analysis was performed using the Kaplan-Meier method and univariable and multivariable binary logistic and Cox regression analyses. RESULTS In-hospital mortality was 11.4%. At 15 years, estimated overall survival was 85.2%, and estimated freedom from reoperation was 74.0%. Cross-clamp time (p=0.001) and absence of the Lecompte maneuver (p=0.001) were identified as independent risk factors for in-hospital mortality, whereas coronary problems during surgery (p=0.009) and postoperative pacemaker implantation (p<0.001) were independent risk factors for late mortality. Independent risk factors for reoperation were higher age at the time of the ASO (p=0.002), presence of arch abnormalities (p<0.001), coronary problems during surgery (p=0.005), and duration of ventilation (p<0.001). At latest echocardiography, moderate or severe neoaortic regurgitation was present in 3.4% of the patients. CONCLUSIONS Overall, 30 years of experience with the ASO shows good survival and event-free survival rates. Coronary transfer problems during surgery were found to be an important risk factor for late mortality and reoperation. However, coronary anatomy other than 1LCx-2R and an intramural course of the left coronary artery or left anterior descending artery were not risk factors for mortality or reoperation. Neoaortic regurgitation does not seem to form a major problem.

More Than 30 Years' Experience With Surgical Correction of Atrioventricular Septal Defects

BACKGROUND Outcome of surgical correction of atrioventricular septal defects (AVSD) still varies despite enhanced results. We reviewed our 30-year experience with AVSD repair and identified risk factors for mortality and reoperation. METHODS Between 1975 and 2006, 312 patients underwent surgery for complete AVSD (n = 209; 67.0%), partial AVSD (n = 76; 24.4%), or intermediate AVSD (n = 27; 8.6%). Mean age was 2.4 ± 3.9 years; 142 patients (45.5%) were younger than 6 months. Follow-up was 99.0% complete. RESULTS There were 26 in-hospital deaths (8.3%) and 6 late deaths (2.1% of 283). Estimated overall survival for the total study population was 91.3%, 90.6%, and 88.6% at 1, 5, and 15 years, respectively. In the multivariable logistic regression analysis, surgical era 1975 to 1995 (p < 0.001) and younger age (p = 0.004) were found to be independent risk factors for early mortality, whereas preoperative AV valve insufficiency showed a tendency toward statistical significance (p = 0.052). Of the hospital survivors, 43 patients required a late reoperation. Estimated freedom from late reoperation was 96.4%, 89.3%, and 81.8% at 1, 5, and 15 years, respectively. Multivariable Cox regression analysis showed associated cardiovascular anomalies (p < 0.001), left AV valve dysplasia (p < 0.001), and absence of cleft closure (p = 0.003) to be independent risk factors for late reoperation. CONCLUSIONS AVSD repair can be accomplished with good long-term results. Early surgical era, associated cardiovascular anomalies, left AV valve dysplasia, and absence of cleft closure negatively influence survival and risk of reoperation.

Tranexamic acid and aprotinin in low- and intermediate-risk cardiac surgery: a non-sponsored, double-blind, randomised, placebo-controlled trial §

OBJECTIVE Tranexamic acid has been suggested to be as effective as aprotinin in reducing blood loss and transfusion requirements after cardiac surgery. Previous studies directly comparing both antifibrinolytics focus on high-risk cardiac surgery patients only or suffer from methodological problems. We wanted to compare the effectiveness of tranexamic acid versus aprotinin in reducing postoperative blood loss and transfusion requirements in the patient group representing the majority of cardiac surgery patients: low- and intermediate-risk patients. METHODS We conducted a non-sponsored, double-blind, randomised, placebo-controlled trial in which 298 patients scheduled for low- or intermediate-risk (mean logistic EuroSCORE 4.1) first-time heart surgery with use of cardiopulmonary bypass were randomised to receive either tranexamic acid, high-dose aprotinin, or placebo. All patients had preoperative normal renal function. End points of the study were monitored from the time of surgery until patient discharge. This trial was executed between June 2004 and October 2006. RESULTS Both antifibrinolytics significantly reduced blood loss and transfusion requirements when compared with placebo. Aprotinin was about twice as effective as tranexamic acid in reducing total postoperative blood loss (estimated median difference 155 ml, 95% confidence interval (CI) 60-260; p < 0.001). Accordingly, aprotinin reduced packed red blood cell transfusions more than tranexamic acid, although the difference did not reach statistical significance. Only aprotinin significantly reduced the proportion of transfused patients when compared with placebo (mean difference -20.9%, 95% CI 7.3-33.5; p = 0.013), and only aprotinin completely abolished bleeding-related re-explorations (mean difference 6.8%, 95% CI 1.6-13.4%; p = 0.004). Neither antifibrinolytic agent increased the incidence of mortality (mean difference tranexamic acid -0.4%, 95% CI -4.6 to 4.4; p = 0.79, mean difference aprotinin -1.3%, 95% CI -6.2 to 3.5; p = 0.62) or other serious adverse events when compared with placebo. CONCLUSION Aprotinin has clinically significant advantages over tranexamic acid in patients with normal renal function scheduled for low- or intermediate-risk cardiac surgery.

28 Years' Experience With Transatrial-Transpulmonary Repair of Atrioventricular Septal Defect With Tetralogy of Fallot

BACKGROUND The outcome of surgical correction of atrioventricular septal defect and tetralogy of Fallot has improved in recent years but is still reported to be associated with high mortality. Controversy exists about the need of a right ventriculotomy or a right ventricular to pulmonary artery conduit. The purpose of this study was to evaluate our results of atrioventricular septal defect and tetralogy of Fallot repair by transatrial-transpulmonary approaches. METHODS Between 1979 and 2007, 20 consecutive patients underwent correction of atrioventricular septal defect and tetralogy of Fallot. Five patients had undergone prior palliative shunts. In all patients, a transatrial-transpulmonary approach was used and repair was accomplished without a conduit. The two-patch technique was used to correct the atrioventricular septal defect. Clinical data were obtained by retrospective review of inpatient and outpatient clinical charts. RESULTS There was no in-hospital mortality and one late, noncardiac death. Six patients required eight reoperations, six for left atrioventricular valve insufficiency (repair: n = 4; replacement: n = 2), one for residual ventricular septal defect, and one for pulmonary artery branch obstruction. Follow-up was complete for all patients (median, 17 years; range, 1.5 to 28 years). All 19 survivors were in good clinical condition at last control, without medication, and in New York Heart Association class I (n = 18) or II (n = 1). Transesophageal echocardiography revealed good right ventricular function, low right ventricular outflow tract gradients (mean, 9 +/- 7.4 mm Hg), and trace pulmonary valve insufficiency (n = 11). CONCLUSIONS Atrioventricular septal defect and tetralogy of Fallot can be repaired with low mortality by the transatrial-transpulmonary approach without the use of a conduit.

Long-Term Results of Reoperation for Left Atrioventricular Valve Regurgitation After Correction of Atrioventricular Septal Defects

BACKGROUND Long-term results of reoperation for left atrioventricular valve regurgitation (LAVVR) after previous correction of atrioventricular septal defect (AVSD) are scarce. We evaluated long-term outcome of reoperation for LAVVR and identified risk factors for reoperation. METHODS Between December 1976 and July 2006, 45 of 312 patients with correction of different AVSDs underwent reoperation for LAVVR. The cohort of 267 patients who did not need reoperation for LAVVR allowed for the identification of risk factors for reoperation and evaluation of overall survival after primary AVSD repair in a competing risk scenario. Clinical data were obtained by retrospective review. RESULTS The left atrioventricular valve (LAVV) was repaired in 31 patients (68.9%) and replaced in 14 (31.1%). There were 3 in-hospital deaths (6.7%) and 2 late deaths (4.4%). Estimated overall survival was 88.1% at 15 years after the reoperation, and estimated incidence of death after reoperation in the total patient cohort was 2% at 15 years after the primary AVSD repair. Overall survival was significantly higher after LAVV repair than after replacement (p=0.010). Ten patients with LAVV repair required a second reoperation for LAVVR. At follow-up, survivors were in New York Heart Association functional class I (n=36) or II (n=4). Independent risk factors for first reoperation for LAVVR were associated cardiovascular anomalies (p<0.001), LAVV dysplasia (p<0.001), and nonclosure of the cleft (p=0.027). CONCLUSIONS After previous correction of AVSD, LAVVR can usually be corrected by valve repair. A very dysplastic valve may necessitate replacement. Overall survival is higher after repair than after replacement. In general, overall survival of patients reoperated on for LAVVR is favorable. The overall mortality rate after primary repair of AVSD is explained only for a small part by mortality after reoperation for LAVVR.

Stentless bioprostheses: a versatile and durable solution in extensive aortic valve endocarditis

OBJECTIVES Infective endocarditis of the aortic valve with local aortic root destruction requires radical resection of infected tissues and subsequent reconstruction of periannular structures and the left ventricular outflow tract (LVOT). Homografts or stentless bioprostheses are recommended for use in this specific patient group. The Freestyle stentless bioprosthesis is a porcine aortic root prosthesis, which approaches the surgical versatility of the homograft, but has the advantage of ready availability and uniform quality. We assessed clinical and echocardiographic outcome following the use of this prosthesis in extensive aortic valve endocarditis. METHODS Between June 2000 and December 2014, 55 Freestyle prostheses were implanted for aortic valve endocarditis involving the root in 54 patients (74% male). The mean age at operation was 61 ± 13 years. The mean EuroSCORE II was 20.1 ± 13.5. Twenty-nine (54%) patients had prosthetic valve endocarditis. The median follow-up time after surgery was 3.5 years, ranging from 0 to 15 years. RESULTS Early and late mortality were 11% (6 patients) and 14% (7 patients), respectively. Estimated overall survival at 1 and 5 years was 83 and 70%, respectively. There was no survival difference between patients with native or prosthetic valve endocarditis. One patient underwent reoperation for recurrent endocarditis 2.3 years after the initial procedure. No other prosthesis failure occurred. At a median follow-up of 3.3 years, mean gradient over the prosthesis was 4.3 ± 2.3 mmHg. No patient had more than mild aortic regurgitation. CONCLUSIONS The Freestyle stentless bioprosthesis is a valuable option to reconstruct the LVOT after debridement in extensive aortic valve endocarditis. It is readily available with a versatility and clinical outcome comparable with that of homografts. Although early mortality remains considerable in this high-risk group of patients, late survival is good with low rates of recurrence of endocarditis, immediate local control and good haemodynamic performance on echocardiography.

More Than 25 Years of Experience in Managing Pulmonary Atresia With Intact Ventricular Septum

BACKGROUND Management of pulmonary atresia with intact ventricular septum (PAIVS) is challenging and depends on the individual patients morphologic characteristics. We evaluated outcomes of 25 years of experience in morphologically driven management of PAIVS. METHODS Between January 1985 and December 2011, 60 patients were treated for PAIVS. Patients were retrospectively categorized into mild (n=27), moderate (n=18), and severe (n=15) right ventricular (RV) hypoplasia subgroups based on morphologic characteristics at first presentation. Tricuspid valve (TV) annulus z score increases were analyzed in patients who underwent biventricular repair and in patients who underwent 1.5-ventricular repair. Median follow-up time was 9.8 years (range, 0-25 years). One patient was lost to follow-up. RESULTS Fifty-nine (98.3%) patients underwent operation. There were 7 early postprocedure deaths and 1 late death. Estimated overall survival was 86.5% at 10 years after initial admission for the total group, and 96.3%, 77.8%, and 79.4% for the subgroups, respectively. In the respective subgroups, biventricular repair was achieved in 24 (88.9%), 3 (16.7%), and 0 patients. In the patients who underwent biventricular repair, there was a significant increase of the TV annulus z score. At latest follow-up, mean New York Heart Association (NYHA) class was 1.3 for the total group and 1.1, 1.2, and 1.5 for the patients who underwent biventricular, 1.5-ventricular, and univentricular repair, respectively. CONCLUSIONS Our individualized management approach to PAIVS showed good early and long-term results. Early decision on the management goal, determined by individual morphologic characteristics at presentation, is of paramount importance. In specific patients, however, taking into account RV development at a later point in time may improve outcome.

Results of surgical repair of atrioventricular septal defect with double-orifice left atrioventricular valve

OBJECTIVE The outcome of surgical correction of atrioventricular septal defect with double-orifice left atrioventricular valve has improved in recent years but is still reported to be associated with high mortality and reoperation rates. Controversy exists about the management of the accessory orifice. We evaluated our results with correction of atrioventricular septal defect with double-orifice left atrioventricular valve. METHODS Between 1975 and 2006, 21 patients underwent correction of atrioventricular septal defect with double-orifice left atrioventricular valve. Clinical data were obtained by means of retrospectively reviewing inpatient and outpatient medical records. To evaluate the influence of double-orifice left atrioventricular valve on mortality and the need for reoperation, a comparison was made with 291 consecutive patients who, during the same period, underwent correction of atrioventricular septal defect without double-orifice left atrioventricular valve. RESULTS None of the 21 patients with double-orifice left atrioventricular valve had undergone a previous operation. The accessory orifice was managed with different techniques depending on the severity of the regurgitation. There was no in-hospital mortality, and there were 3 late deaths. Seven patients required 12 reoperations, 7 for left atrioventricular valve insufficiency. Double-orifice left atrioventricular valve had no influence on mortality but was a significant predictor for reoperation compared with repair of atrioventricular septal defect without double-orifice left atrioventricular valve. At the latest follow-up, all 18 survivors were in New York Heart Association functional class capital I, Ukrainian without medication. Only 1 patient showed residual mild left atrioventricular valve insufficiency. CONCLUSION Atrioventricular septal defect with double-orifice left atrioventricular valve can be repaired with low mortality. However, double-orifice left atrioventricular valve is a predictor for reoperation. The accessory orifice is often competent and should then be left untouched. If regurgitation of the accessory orifice is present, this is best managed with suture or patch closure.

A single-centre 37-year experience with reoperation after primary repair of atrioventricular septal defect

OBJECTIVES To evaluate our experience with patients reoperated after primary repair of atrioventricular septal defect (AVSD) and identify predictors of poor outcome. METHODS Between 1976 and 2014, 69 patients were reoperated after primary repair of partial (n = 28), intermediate (n = 15) or complete (n = 26) AVSD. RESULTS Median age at first reoperation was 62.4 (range, 1.6-845) months, median interval to first reoperation was 22.3 (range, 0.2-598) months. Main indications for first reoperation included left atrioventricular valve (LAVV) pathology (66%), residual septal defect (19%) and left ventricle outflow tract obstruction (LVOTO; 4%). Procedures to address LAVV pathology included various valvuloplasties in 47 (77%) patients and valve replacement in 14 (23%) patients. A second, third, fourth and fifth reoperation was required in 27, 12, 4 and 1 patient, respectively. Most common procedures were LAVV replacement (LAVVR), LVOTO relief, pacemaker implantation and right atrioventricular valve procedure. Freedom from reoperation after LAVV valvuloplasty (LAVVP) was 84 and 62% at 1 and 10 years, respectively. There were 10 early and 4 late deaths. Estimated overall survival at 1, 5 and 10 years was 87, 83 and 83%, respectively. Double orifice LAVV (DOLAVV) was a risk factor for in-hospital and overall mortality [odds ratio (OR) = 14.5; 95% confidence interval (CI) = 1.2-178.7; P = 0.037 and hazard ratio (HR) = 6.8; 95% CI = 1.5-31.7; P = 0.015, respectively]. Patients with LAVVP and LAVVR differed significantly in overall survival (P = 0.014). At the last follow-up (median, 9.8; range, 0-34 years), 84% survivors were in New York Heart Association Class I or II. CONCLUSIONS Many patients reoperated after primary AVSD repair needed surgical reintervention. LAVV pathology was the most common indication for reoperation. DOLAVV was a risk factor for mortality. Particular AVSD type did not appear to be a risk factor for mortality or LAVVP failure. There is some evidence for the close relationship between LAVV pathology and LVOTO in subjects undergoing reoperation after primary AVSD repair as some patients with initial LAVV problems needed LVOTO repair later on and vice versa.

Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection?: A Multicenter Randomized Trial

Background— A Dutch online patient decision aid to support prosthetic heart valve selection was recently developed. A multicenter randomized controlled trial was conducted to assess whether use of the patient decision aid results in optimization of shared decision making in prosthetic heart valve selection. Methods and Results— In a 5-center randomized controlled trial, patients were allocated to receive either standard preoperative care (control group) or additional access to the patient decision aid (intervention group). Legally capable adult patients accepted for elective isolated or combined aortic and mitral valve replacement were included. Primary outcome was preoperative decisional conflict (Decisional Conflict Scale); secondary outcomes included patient knowledge, involvement in valve selection, anxiety and depression, (valve-specific) quality of life, and regret. Out of 306 eligible patients, 155 were randomized (78 control and 77 intervention). Preoperative decisional conflict did not differ between the groups (34% versus 33%; P=0.834). Intervention patients felt better informed (median Decisional Conflict Scale informed subscore: 8 versus 17; P=0.046) and had a better knowledge of prosthetic valves (85% versus 68%; P=0.004). Intervention patients experienced less anxiety and depression (median Hospital Anxiety and Depression Scale score: 6 versus 9; P=0.015) and better mental well-being (mean Short Form Health Survey score: 54 versus 50; P=0.032). Three months postoperatively, valve-specific quality of life and regret did not differ between the groups. Conclusions— A patient decision aid to support shared decision making in prosthetic heart valve selection does not lower decisional conflict. It does result in more knowledgeable, better informed, and less anxious and depressed patients, with a better mental well-being. Clinical Trial Registration— http://www.trialregister.nl. Unique identifier: NTR4350.