Luis E. De León

Risk factors for development of endocarditis and reintervention in patients undergoing right ventricle to pulmonary artery valved conduit placement

OBJECTIVE To determine the incidence and risk factors for endocarditis and reintervention in patients undergoing placement of right ventricle-to-pulmonary artery valve conduits. METHODS All right ventricle-to-pulmonary artery valved conduits placed between 1995 and 2014 were included. Freedom from endocarditis, reintervention, and replacement were analyzed using the Kaplan-Meier method and parametric survival regression models. RESULTS A total of 586 patients underwent placement of a total of 792 valved conduits, including 289 (36%) pulmonary homografts, 121 (15%) aortic homografts, 245 (31%) bovine jugular grafts, and 137 (17%) porcine heterografts. There were 474 (60%) primary placements and 318 (40%) replacements. The median duration of conduit follow-up was 7 years; 23 conduits developed endocarditis at a median of 5 years after surgery. The use of bovine jugular grafts was the sole significant risk factor associated with endocarditis (hazard ratio, 9.05; 95% confidence interval, 2.6-31.8 compared with homografts). The hazard was greater for bovine jugular grafts compared with the other conduit types and increased with time; however, bovine jugular grafts were associated with a lower risk for reintervention (P < .0001) and replacement (P = .0002). Factors associated with greater risk of both reintervention and replacement were younger age and smaller conduit size. In addition, a diagnosis of truncus arteriosus was associated with a greater risk for replacement (P = .03). CONCLUSIONS Bovine jugular grafts are associated with a significantly greater risk of late endocarditis but with lower reintervention rates compared with other valved conduits. The risk of endocarditis and durability must be balanced during conduit selection. Antibiotic prophylaxis and a high index of suspicion for endocarditis are warranted in patients with bovine jugular grafts.

Outcomes of surgical intervention for anomalous aortic origin of a coronary artery: A large contemporary prospective cohort study

Objective The purpose of this study was to prospectively analyze the outcomes of patients with anomalous aortic origin of a coronary artery undergoing surgical intervention according to a standardized management algorithm. Methods All patients aged 2 to 18 years undergoing surgical intervention for anomalous aortic origin of a coronary artery between December 2012 and April 2017 were prospectively included. Patients underwent stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and retrospectively electrocardiogram‐gated computed tomography angiography preoperatively. Patients were cleared for exercise at 3 months postoperatively if asymptomatic and repeat stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and computed tomography angiography showed normal results. Results A total of 44 patients, with a median age of 14 years (8‐18 years), underwent surgical intervention: 9 (20%) for the anomalous left coronary artery and 35 (80%) for the anomalous right coronary artery. Surgical procedures included unroofing in 35 patients (80%), translocation in 7 patients (16%), ostioplasty in 1 patient (2%), and side‐side‐anastomosis in 1 patient (2%). One patient who presented with aborted sudden cardiac death from an anomalous left coronary and underwent unroofing presented 1 year later with a recurrent episode and was found to have an unrecognized myocardial bridge and persistent compression of the coronary requiring reintervention. At last follow‐up, 40 patients (91%) are asymptomatic and 4 patients have nonspecific chest pain; 42 patients (95%) have returned to full activity, and 2 patients are awaiting clearance. Conclusions Surgical treatment for anomalous aortic origin of a coronary artery is safe and should aim to associate the coronary ostium with the correct sinus, away from the intercoronary pillar. After surgery, the majority of patients are cleared for exercise and remain asymptomatic. Longer follow‐up is needed to assess the true efficacy of surgery in the prevention of sudden cardiac death.

Routine preoperative laboratory testing in elective pediatric cardiothoracic surgery is largely unnecessary

Objective: Routine preoperative laboratory testing (RLT) is common practice in pediatric cardiothoracic surgery and is associated with significant cost burden to patients and families. We sought to examine the value of RLT in patients undergoing elective pediatric cardiothoracic surgery. Methods: We conducted a retrospective study of all scheduled elective pediatric cardiothoracic surgery at our institution from 2012 to 2014. Inpatients were excluded. Patient charts were reviewed to obtain preoperative laboratory values and determine relationship to case cancellation. RLT includes complete blood count, prothrombin time, partial thromboplastin time, urinalysis, 7 chemistry metabolic panel, electrocardiogram, and 2‐view chest radiograph. Results: RLT was completed for 1106 scheduled elective cases. Six (0.5%) cancellations were related to abnormal preoperative laboratory test results: 5 complete blood counts and 1 urinalysis. Hospital charge for RLT averaged

Aortic Arch Advancement and Ascending Sliding Arch Aortoplasty for Repair of Complex Primary and Recurrent Aortic Arch Obstruction

2064 per patient. Based on this incidence, we estimated that 184 routine preoperative laboratory tests, which generated a total hospital charge of

High Incidence of Late Infective Endocarditis in Bovine Jugular Vein Valved Conduits

379,776, were required to capture 1 abnormal test significant enough to cancel surgery. An estimated charge of

Cor triatriatum sinister with an intact interatrial septum and a decompressing vein in a toddler

2,169,552 was generated on prothrombin time, partial thromboplastin time, 7 chemistry metabolic panel, electrocardiogram, and 2‐view chest radiograph, and none of these tests resulted in a cancellation. Conclusions: RLT does not significantly impact decision‐making in elective pediatric cardiothoracic surgery. The decision to order a specific screening test should be clinically driven. Selective preoperative laboratory testing may have a positive impact on healthcare costs without affecting outcomes.

Malformaciones de la pared torácica en niños

The optimal treatment of patients with complex coarctation of the aorta and hypoplastic aortic arch is controversial. Children undergoing repair of obstructive arch lesions are at lifelong risk of recurrence. Multiple techniques have been described to address complex primary and recurrent coarctation. Our approach at Texas Childrens Hospital (Houston, TX) has been to address these lesions in an anatomic fashion via median sternotomy, under cardiopulmonary bypass using the techniques of aortic arch advancement and ascending sliding arch aortoplasty. Anatomic repair of complex primary or recurrent aortic obstruction is safe and produces a favorable repair with a low rate of recurrence. Both operations restore normal arch contour using native aortic tissue. The decision of which particular surgical strategy to use depends on the patients age, anatomy, and the elasticity of the tissue.

The Role of Echocardiography and Intracardiac Exploration in the Evaluation of Candidacy for Biventricular Repair in Patients With Borderline Left Heart Structures

Background Bovine jugular vein (BJV) grafts (Medtronic, Inc, Minneapolis, Minn) are used to restore right ventricle‐to‐pulmonary artery continuity. Recent studies have associated these grafts with the development of infective endocarditis. The purpose of this study was to report the incidence of endocarditis in BJV grafts. Methods All BJV grafts placed in the right ventricle‐to‐pulmonary artery position between 2001 and 2017 at our institution were included. Freedom from endocarditis was analyzed using the Kaplan–Meier method and parametric survival regression models. Results Overall, 228 patients underwent placement of 253 BJV grafts. The median duration of conduit follow‐up was 6 years (5 months to 14 years). Twenty‐five conduits developed endocarditis, yielding an incidence of 10% at a median of 7.5 years after surgery. Median duration of symptoms before the diagnosis of endocarditis was 21 days (3‐180 days). The most common infectious agents were viridans streptococci (n = 13; 52%). Freedom from endocarditis at 5 and 10 years was 97% and 77%, respectively. After controlling for confounders, BJV grafts had a higher incidence of endocarditis compared with homografts (P < .001). Twenty‐three (92%) of the conduits that developed endocarditis were managed surgically, with no mortality. Conclusions The incidence of late endocarditis affecting BJV is high. Increased surveillance and a high index of suspicion for endocarditis are warranted in patients who have undergone implantation of BJV grafts, especially if the graft has been in place for more than 7 years. When infective endocarditis has been diagnosed in these grafts, surgical replacement is recommended, with excellent outcomes.

Mid-Term Outcomes in Patients with Congenitally Corrected Transposition of the Great Arteries: A Single Center Experience

Cor triatriatum sinister is a very rare cardiac anomaly that may lead to pulmonary hypertension, right ventricular dilation, and eventually right heart failure. We report a case of a toddler who presented with respiratory distress and cardiomegaly and was found to have cor triatriatum sinister with a restrictive communication, decompressing vertical vein, pulmonary hypertension, severe tricuspid regurgitation, and severe right ventricular dysfunction. She underwent a successful surgical repair, with normalisation of right ventricular function and pulmonary artery pressure.

Descending Aortic Translocation for Relief of Distal Tracheal and Proximal Bronchial Compression

41 patients operated for deformities of the chest wall, 24 Pectus Excavatum, 14 Pectus Carinatum and3 Polands Syndrome are evaluated. In the first two deformities there was a higher frecueney of males (18/24 and 11/14). The anomaly was the only complaint in .38% of the patients. The other ones had additional symptoms as respiratory infections, sternal pain, dyspnea. In 85% of the patients the deformity was present from infancy. In several cases there were relatives with the same anomaly. The surgical correction is not only indicated because of cosmetic reasons, but also to prevent greater sternal deformities and pulmonary and cardiac diseases. The ideal age to perform it is between 2 and 5 years. We used Dr. M.M. Ravitchs surgical technique and (he results were in general good to excellent