Jin Young Song

Outcomes of Pulmonary Valve Replacement in 170 Patients With Chronic Pulmonary Regurgitation After Relief of Right Ventricular Outflow Tract Obstruction: Implications for Optimal Timing of Pulmonary Valve Replacement

OBJECTIVES The objectives of this study were to evaluate outcomes of pulmonary valve replacement (PVR) in patients with chronic pulmonary regurgitation (PR) and to better define the optimal timing of PVR. BACKGROUND Although PVR is effective in reducing right ventricular (RV) volume overload in patients with chronic PR, the optimal timing of PVR is not well defined. METHODS A total of 170 patients who underwent PVR between January 1998 and March 2011 for chronic PR were retrospectively analyzed. To define the optimal timing of PVR, pre-operative and post-operative cardiac magnetic resonance imaging (MRI) data (n = 67) were analyzed. RESULTS The median age at the time of PVR was 16.7 years. Follow-up completeness was 95%, and the median follow-up duration was 5.9 years. Overall and event-free survival at 10 years was 98% and 70%, respectively. Post-operative MRI showed significant reduction in RV volumes and significant improvement in biventricular function. Receiver-operating characteristic curve analysis revealed a cutoff value of 168 ml/m(2) for non-normalization of RV end-diastolic volume index (EDVI) and 80 ml/m(2) for RV end-systolic volume index (ESVI). Cutoff values for optimal outcome (normalized RV volumes and function) were 163 ml/m(2) for RV EDVI and 80 ml/m(2) for RV ESVI. Higher pre-operative RV ESVI was identified as a sole independent risk factor for suboptimal outcome. CONCLUSIONS Midterm outcomes of PVR in patients with chronic PR were acceptable. PVR should be considered before RV EDVI exceeds 163 ml/m(2) or RV ESVI exceeds 80 ml/m(2), with more attention to RV ESVI.

Transcatheter closure of perimembranous ventricular septal defect using Amplatzer ductal occluder.

To show that transcatheter closure of perimembranous ventricular septal defect (PMVSD) with the Amplatzer ductal occluder (ADO, AGA Medical Corp, Plymouth, Minnesota) is a safe and effective treatment option.

Permanent Epicardial Pacing in Pediatric Patients: 12-Year Experience at a Single Center

BACKGROUND Permanent cardiac pacing is not often done in children, and when done is usually accomplished through epicardial pacing. We reviewed a 12-year experience with the implantation of epicardial pacemakers by our clinical group. METHODS Fifty-three patients who underwent their first implantation of an epicardial pacemaker before the age of 18 years and between 1997 and 2009 were included in our study. The mean age of the patients at the time of first pacemaker implantation was 5.7±4.8 years. Indications for pacemaker implantation included postoperative or congenital atrioventricular block and sinus node dysfunction. The patients underwent 105 operations for the replacement of pacemaker pulse generators and 75 operations for the replacement of pacemaker leads. The most commonly used generator mode was the rate-responsive accelerometer-based (DDDR) mode, which was used in 40.9% of the patients. We used more non-steroid-eluting leads (70.1%) than steroid-eluting leads (29.1%). RESULTS The overall duration of follow-up in the study was 8.0±4.5 years (range, 2.1 months to approximately 17.0 years). Freedom from the need for generator replacement was 98.0%, 60.7%, and 11.1% at 1, 5, and 8 years, respectively. A tendency toward early generator exhaustion was observed among younger patients (p=0.058). The generator mode used for pacing did not significantly affect generator longevity. Freedom from the need for lead replacement was 98.3%, 83.8%, and 63.6% at 1, 5, and 10 years, respectively. The mean longevity of the leads used in the study was 10.8±0.8 years. Neither patient age at the time of lead implantation nor type of lead significantly affected lead longevity. CONCLUSIONS Lead longevity was sufficiently long and did not vary significantly according to type of lead. Generator longevity was not affected by lead type, generator mode, or patient age at the time of pacemaker implantation.

Long-term results after mitral valve repair in children

OBJECTIVE We analysed the long-term results of mitral valve (MV) repair in children. METHODS We reviewed clinical records of 139 children (<18 years) who underwent MV repair between 1988 and 2007. Patients with atrioventricular septal defect, single ventricle or atrioventricular discordance were excluded. Median age was 2.3 years (2 months to 17.6 years), and 47 children (34%) were infants. Mitral regurgitation (MR) was predominant in 125 patients (90%), and 91 (73%) of these showed MR grade > or = 3. Mitral stenosis (MS) was predominant in 14 patients (10%), and median mean pressure gradient across the MV was 9.0 mmHg (0-20 mmHg). Associated cardiac lesions were present in 111 patients (80%) and were addressed concurrently in 105 patients. Various surgical techniques were used according to the functional and pathologic findings of MV. RESULTS There was no early death. Median follow-up was 8 years (2 months to 20 years, 78% complete). Twenty-six patients required 29 MV re-operations, and 11 of these required MV replacements. At 15 years, freedom from MV re-operation and MV replacement was 77% and 90%, respectively. Diagnosis of MS and MV status on discharge (MR grade > or =3 or MS gradient > or =10 mmHg) were significant risk factors for re-operation. There were three late deaths, and the overall survival was 97% at 15 years. Among 122 survivors with MR, 102 patients (84%) underwent echocardiography during follow-up. The degree of MR decreased significantly and only five patients showed MR grade 3. Among 14 survivors with MS, eight patients (57%) underwent echocardiography during follow-up. The degree of MS decreased significantly and median MS gradient was 2.8 mmHg (0-10 mmHg). All survivors remain in the NYHA class I or II. CONCLUSIONS MV repair in children showed excellent survival, acceptable re-operation rate and satisfactory valve function at long-term follow-up. Residual MV dysfunction was a significant risk factor for re-operation, but re-repair was successful in more than half of the patients who underwent re-operation.

Clinical outcomes of slide tracheoplasty in congenital tracheal stenosis

OBJECTIVES Treatment of long-segment congenital tracheal stenosis (CTS) remains challenging. Recently, slide tracheoplasty has become the standard approach in many centres. The aim of this study was to evaluate the clinical outcomes of slide tracheoplasty. METHODS Between 2004 and 2011, 18 patients underwent slide tracheoplasty in our centre. The median patient age was 2.5 months (range, 18 days-4 years) and the median body weight was 4.2 (range, 2.2-17.7) kg at operation. Eleven (61%) patients were on a mechanical ventilator prior to surgery. The median stenotic segment estimated by a computed tomography scan was 52% of the length of total trachea (range, 18-84%). Five (28%) patients had proximal bronchial stenosis, 3 (17%) had tracheal bronchus, 2 (11%) had tracheobronchomalacia and 1 (6%) had agenesis of the right lung. Thirteen (72%) patients had a combined cardiac anomaly, including 8 patients with a pulmonary artery sling. Ten (56%) patients had associated extracardiac anomalies. Slide tracheoplasty was performed on cardiopulmonary bypass in all patients, and cardiac lesions were corrected. RESULTS There was no early death. The patient with agenesis of the right lung died of left bronchial stenosis 3 months after the surgery. Two (11%) patients were reoperated on for tracheal restenosis. In the other 15 patients, the median duration of ventilator support was 8 (range, 5-34) days and the median duration of hospitalization was 31 (range, 12-79) days. During the follow-up (median duration of 17 months; range, 2-77 months), 13 (72%) patients were symptom-free and 2 (11%) underwent tracheostomy for tracheomalacia. CONCLUSIONS Based on this study, slide tracheoplasty seems to be an effective technique for CTS. However, shortening of the trachea after reconstruction may give rise to recurrent obstruction.

Bicuspid pulmonary valve implantation using polytetrafluoroethylene membrane: early results and assessment of the valve function by magnetic resonance imaging

OBJECTIVES The durability of bioprosthetic valves in the pulmonary position is suboptimal. The objectives of this study were to evaluate the early results of polytetrafluoroethylene (PTFE) bicuspid pulmonary valve (PV) implantation and to better define the function of this valve by magnetic resonance imaging (MRI). METHODS Fifty-six patients who underwent PTFE bicuspid PV implantation between June 2009 and August 2011 were retrospectively analysed. The median age was 17.5 years and median valve size was 26 mm. Fundamental diagnoses were tetralogy of Fallot (n = 38), pulmonary atresia with ventricular septal defect (n = 8), double outlet right ventricle (n = 7) and absent PV syndrome (n = 3). Thirty-two patients with pulmonary regurgitation (PR) underwent MRI preoperatively and 22 of them underwent follow-up MRI at a median of 6.7 months postoperatively. RESULTS There was one early death. Postoperative echocardiography (n = 53) showed no or trivial PR in 49 patients and mild PR in 4. Median follow-up duration was 15.2 months. There was no late death or reoperation. Follow-up echocardiography (n = 41) performed at a median of 7.5 months postoperatively showed no or trivial PR in 33 patients and mild PR in 8 patients. Follow-up MRI showed a significant reduction in right ventricular volumes and improvement in biventricular function. The median PR fraction of this valve was 10%. CONCLUSIONS Early results of bicuspid PV implantation using PTFE membrane were satisfactory. PTFE bicuspid PV demonstrated excellent performance for the short term as evidenced by echocardiography and MRI. Long-term follow-up is mandatory to determine the durability of this valve.

Early Surgical Correction of Atrioventricular Valvular Regurgitation in Single-Ventricle Patients

BACKGROUND The purpose of this study is to evaluate the effectiveness of early surgical correction for atrioventricular valve regurgitation (AVVR) in single-ventricle patients. METHODS The medical records of 39 single-ventricle patients who underwent atrioventricular surgery more than once between 1996 and 2008 were reviewed. RESULTS The mean preoperative grade of AVVR was 2.6 ± 0.7. Four patients underwent valvular operations at first palliative surgery, 3 patients before bidirectional cavopulmonary connection, 13 at bidirectional cavopulmonary connection, 6 in the interstage between bidirectional cavopulmonary connection and Fontan, 10 at Fontan, and 3 after Fontan procedure. Surgical techniques for valve were edge-to-edge sutures for bridging leaflets, leaflet cleft repair, partial or complete annuloplasty with strip, or artificial valve implantation. Although there was no statistical significance, the patients who underwent early operation (AVVR grade less than 2) showed a tendency toward better atrioventricular valvular function during the postoperative follow-up (57.1 months, range: 2 ∼ 129 months). None of the patients whose preoperative AVVR grade less than 2 showed an AVVR more than 2 at the final echocardiography. There were 4 deaths overall due to sepsis, Fontan failure, and sudden cardiac arrest. Final echocardiographic findings showed a mean AVVR of 1.6 ± 0.8 and acceptable cardiac function. All living patients were in a good New York Heart Association functional class (1.07 ± 0.2). CONCLUSIONS Even though we could not find statistically significant evidence of benefit for early correction of AVVR in single-ventricle patients, the patients undergoing early valvular operation for regurgitation showed a tendency toward better atrioventricular valvular function at midterm.

Percutaneous Closure of the Acquired Gerbode Shunt Using the Amplatzer Duct Occluder in a 3-Month Old Patient

The Gerbode shunt, known as the left ventricle to the right atrial communication, is a rather rare finding, following surgical closure of septal defects. Even though the surgical closure is accepted as a treatment of choice, we report a successful percutaneous transcatheter closure of the Gerbode shunt in a 3-months old baby who weighed 3 kilograms.

The hybrid perventricular closure of apical muscular ventricular septal defect with Amplatzer duct occluder

Purpose Apical muscular ventricular septal defects (MVSDs), especially in small infants, can be difficult to manage using surgical and percutaneous closure. An intraoperative perventricular procedure is a good option for closing apical MVSDs in small children with or without associated cardiac anomalies. We evaluated the results of hybrid perventricular closure of apical MVSDs performed using an Amplatzer duct occluder (ADO). Methods We retrospectively reviewed the medical records of 5 patients who underwent hybrid perventricular closure of MVSDs with ADOs, from March 2006 to May 2011. The median patient age at the time of the procedure was 12 months (range, 25 days to 25 months), and the median body weight was 9.1 kg (range, 4.3 to 15 kg). Two patients had multiple ventricular septal defects (VSDs; additional perimembranous VSD in 1 patient and multiple MVSDs in the other) and 3 patients had associated cardiac anomalies; complete transposition of the great arteries in 1 patient and an atrial septal defect in 2 patients. All the procedures were performed on beating hearts, exception in 1 case. The ADO selected for the aortic side was at least 1 to 2 mm larger than the largest VSD in the left ventricle side. Results The procedure was successful in all patients and each device was well positioned. During the median follow-up of 2.4 years, a small residual VSD was noted in 2 patients who had multiple VSDs and no leakage was seen in the other 3 patients. Conclusion Perventricular closure of MVSD with an ADO is a good option for patients with apical MVSD. However, careful manipulation is important, especially in the case of small infants.

Tension pneumopericardium after cardiac surgery: a rare but lethal problem.

A 13-month-old girl who had no medical history uneventfully underwent patch closure of an atrial septal defect under mild hypothermic cardiopulmonary bypass. An immediately postoperative chest radiograph did not show any unusual findings (the Figure, A), and the process of weaning her from the ventilator was started. Just before extubation (6 hours after transfer to the intensive care unit), a sudden desaturation occurred, and a massive bloody secretion drained through the endotracheal tube. Echocardiography showed that the interventricular septal motion was slightly paradoxical, but ventricular contractility was normal. Chest radiograph revealed an unexpected …