Hélène Demanet

Early results of valved bovine jugular vein conduit versus bicuspid homograft for right ventricular outflow tract reconstruction

BACKGROUND Homograft conduits are preferable for right ventricular outflow tract reconstruction in children, but their limited availability remains a major concern. Recently, a valve-containing segment of bovine jugular vein (Contegra, Medtronic Inc, Minneapolis, MN) has been introduced as a potential alternative conduit. METHODS Early clinical and echocardiographic results of right ventricular outflow tract reconstruction were retrospectively compared between 41 children (mean age, 1.9 years), receiving a Contegra conduit and 36 patients (mean age, 2.7 years) with a size-reduced pulmonary homograft. RESULTS Clinical outcome was comparable with two early deaths in the homograft group and one in the Contegra group. There were no conduit-related complications in either population. Early echocardiographic assessment showed only trivial to mild regurgitation in 9 homografts versus 17 Contegra conduits. The peak gradient across the right ventricular outflow tract conduit was comparable for both groups, although a larger number of patients, treated with a downsized homograft, had a small gradient at the distal junction with the pulmonary arteries (12 versus 6 patients). None of the patients had a gradient at the valvar level. CONCLUSIONS The valved bovine jugular vein conduit offers a promising substitute for right ventricular outflow tract reconstruction in infants and children, with an early hemodynamic performance that compares favorably with downsized, bicuspid homografts. Clinical advantages are greater shelf availability and the natural continuity between valve and conduit, which allows proximal infundibular shaping without additional material. However, durability must be determined, even though most of these children will require right ventricular outflow tract reoperation after outgrowing the conduit.

Cardiac surgery with extracorporeal circulation in 23 infants weighing 2500 g or less: short and intermediate term outcome

OBJECTIVE AND METHODS From September 1990 to February 1997, 23 consecutive critically ill infants (12 males, 11 females) weighing 2500 g or less underwent cardiac surgery necessitating extracorporeal circulation (ECC). A retrospective study was carried out to evaluate short- and intermediate-term outcome. Mean weight at operation was 2265 g (range 1750-2500 g). Mean age at operation was 24 days. The indications for surgery were transposition of the great arteries (TGA; 7), ventricular septal defect (VSD; 4), aortic stenosis (AS; 3), univentricular heart (UVH; 2), tetralogy of Fallot (TOF; 2), interrupted aortic arch (IAA; 2), atrial septal defect (ASD; 1), atrioventicular septal defect (AVSD; 1) and total abnormal pulmonary venous return (TAPVR; 1). All patients were in NYHA class IV; 17 patients (74%) were intubated pre-operatively. RESULTS The mean aortic cross-clamping time was 40 min. Twelve patients required deep hypothermia (<20 degrees C) with total circulatory arrest (mean duration 19 min). All patients were successfully weaned from extracorporeal circulation (ECC). Five patients left the operating room with an open sternum (mean duration before closure: 3.5 days). Mean duration of artificial ventilation was 10.6 days; of inotropic support 6.7 days and of intensive care stay 17.8 days. Severe complications were observed in 19 patients (83%): cardiac failure requiring high inotropic support (13), sepsis (7), and acute renal insufficiency (5). One patient needed a ventricular assist device. Five patients (22%) died in the intensive care unit (ICU): 2 AS with fibroelastosis, 2 IAA with VSD. and 1 UVH with pulmonary atresia. At discharge from the ICU, 7 patients were receiving no treatment. Mean duration of follow-up was 32 months (range 2-80 months). We had 2 reoperations: 1 for right ventricular outflow tract obstruction 1 year after a switch operation and 1 for mitral valve replacement 1 year after total abnormal pulmonary venous return repair (death 30 days post mitral valve replacement). Survival at I year was 73%. At the last clinical examination 16 patients were in NYHA class I. CONCLUSION Despite the severity of pre-operative cardiac disease, early surgical repair with ECC in infants weighing 2500 g or less is feasible with tolerable mortality yet with significant early morbidity.

Ten-year experience with surgical treatment of adults with congenital cardiac disease

The number of adults with congenital cardiac disease continues to increase, and adult patients are now more numerous than paediatric patients. We sought to identify risk factors for perioperative death and report our results with surgical management of adult patients with congenital cardiac disease. We retrospectively analysed in-hospital data for 244 consecutive adult patients who underwent surgical treatment of congenital cardiac disease in our centre between January, 1998 and December, 2007. The mean patient age was 27.2 plus or minus 11.9 years, 29% were in functional class III or IV, and 25% were cyanosed. Of the patients, half were operated on for the first time. A total of 61% of patients underwent curative operations, 36% a reoperation after curative treatment, and 3% a palliative operation. Overall mortality was 4.9%. Predictive factors for hospital death were functional class, cyanosis, non-sinus rhythm, a history of only palliative previous operation(s), and an indication for palliative treatment. Functional class, cyanosis, type of initial congenital cardiac disease (single ventricle and double-outlet right ventricle), and only palliative previous operation were risk factors for prolonged intensive care stay (more than 48 hours). The surgical management of adult patients with congenital cardiac disease has improved during recent decades. These generally young patients, with a complex pathology, today present a low post-operative morbidity and mortality. Patients having undergone palliative surgery and reaching adulthood without curative treatment present with an increased risk of morbidity and mortality. Univentricular hearts and double-outlet right ventricles were associated with the highest morbidity.

Surgical treatment of coronary artery fistula with aneurysm.

Abstract Two operations for coronary artery aneurysm with fistula are reported. This rare congenital malformation can be associated with acute and chronic complications. Surgical treatment is generally recommended. The surgical strategy remains controversial and is discussed. Retrograde cardioplegic cardiac arrest and retrograde dissection of the fistula are favoured. Conservative treatment of the dilated coronary segments was adopted. In both cases, the postoperative course was uneventful and no residual shunts were diagnosed at postoperative echocardiography.

Redo valve surgery nowadays: What have we learned?

Abstract Re-operative valvular surgery is common nowadays. Increased mortality and morbidity are generally associated. Re-operations in cardiac surgery are technically more difficult because of adhesions and a more advanced cardiac status of the patient. Results reported 20 years ago carried a high mortality risk. Experience and technological evolution have produced a substantial reduction in postoperative mortality nowadays. The present review focuses on historical results of redo valve surgery, risks factors for postoperative mortality, technical progress and surgical strategies contributing to better results.

Endocarditis of bovine jugular vein conduit due to Q fever.

Contegra (Medtronic, Minneapolis, MN) conduits are routinely used in cases of right ventricular outflow tract reconstruction during congenital heart surgery. We report two cases of Q fever endocarditis involving Contegra conduits. Surgical treatment and distinct aspects of both unusual cases are described.

PREVALENCE OF EARLY POSTOPERATIVE ARRHYTHMIAS IN CHILDREN WITH DELAYED OPEN-HEART SURGERY FOR SEVERE CONGENITAL HEART DISEASE

Abstract Background. Our aim was to determine the incidence, risk factors and outcome of early postoperative arrhythmias in children with delayed treatment of severe congenital heart disease. Methods. A prospective study was conducted in 141 consecutive children with delayed referral from emerging countries, who underwent open-heart surgery. Results. Sinus node dysfunction was noted in 5 cases. Preoperative moderate extrasystoly was common and its incidence significantly increased in the postoperative phase. Overall, 9 patients required specific antiarrhythmic therapy: 6 for sustained atrioventricular reciprocating tachycardia, and 3 respectively for atrial flutter, atrial fibrillation and junctional ectopic tachycardia. Non-sustained atrioventricular and ventricular tachycardia required no therapy in respectively 6 and 1 case. Postoperative complete atrioventricular block was observed in 6 patients and remained permanent in 3. No major complications resulted from those arrhythmias. Preoperative low oxygen saturation, preoperative arrhythmias, as well as long cardiopulmonary bypass time and aortic cross-clamp time, were risk factors for early postoperative arrhythmias. Conclusions. Children with delayed surgery for congenital heart disease are at risk of developing early postoperative arrhythmias depending on the complexity of their disease and of its treatment. However, their prevalence (14%) is not higher than in the general population of cardiac children.

Pulmonary valve replacement after right ventricular outflow tract reconstruction with homograft vs Contegra®: A case control comparison of mortality and morbidity

BackgroundRepair of congenital heart defects involving the right ventricular outflow tract may require the implantation of a right ventricle to pulmonary artery conduit. This conduit is likely to be replaced during childhood. This study compares the operative outcomes of the replacement procedure of Contegra® and homografts in pulmonary position.MethodsFrom 1999 to 2016, 82 children underwent 87 right ventricle to pulmonary artery conduit replacements (60 Contegra® and 27 homografts). Demographics, operative and clinical data were obtained through a retrospective review of the medical records. The two groups were matched for comparison using propensity score matching. All the procedures were performed by the same team of surgeons.ResultsNo statistically significant difference was observed between the two groups when considering the operative data for anesthesia, surgery, cardiopulmonary bypass and aortic clamping durations. A peroperative complication rate of 13.47% and 15.36% in Contegra® and homograft replacement groups respectively (p value = 0.758) was observed. There was no difference regarding the blood loss and fluid input. No statistically significant difference was observed between the two groups for the post-operative morbidity. We considered the Pediatric Risk of Mortality (PRISM) score, the day of extubation, the day of withdrawal of inotropic drugs, the length of the intensive care unit stay and the length of hospital stay. The overall mortality is 2.3% but there is no statistically significant difference between the two groups.ConclusionRight ventricle to pulmonary artery conduit replacement procedure can be achieved with a low surgical morbidity or mortality, not influenced by the type of conduit that is replaced. Therefore, the choice between homograft or Contegra® for right ventricle to pulmonary artery reconstruction should not be influenced by the future surgical risk during the replacement procedure.Trial registrationNCT03048071. Registered 9 February 2017 (retrospectively registered).

Implantation of an Absorb bioresorbable vascular scaffold in the stenotic aortopulmonary collateral artery of a young child with Alagille syndrome

Stent implantation in children can be problematic due to the possibility of growth incapacity and difficulties during later surgery. For these reasons, bioresorbable stents may be a good alternative to conventional stents. We report our experience with implantation of an Absorb bioresorbable stent in the stenotic major aortopulmonary collateral artery (MAPCA) of a 1‐year‐old girl born with pulmonary atresia with ventricular septal defect.

Contegra 12 mm: How Long Can It Last?

Since the year 2000, we have used Contegra conduits for right ventricular outflow tract reconstruction in infants and newborns. Published reports of early and late results from multiple centers have included variable and inconsistent findings. Concerns about the durability of small conduits placed in younger infants have been expressed. We report an interesting experience with a 12-mm Contegra conduit that we explanted 16 years after implantation in the course of repair of truncus arteriosus (common arterial trunk) in an infant.