Rodrigo Zea-Vera

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

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.

Endovascular management of inferior vena cava filter thrombotic occlusion

Objective Inferior vena cava occlusion is a potentially life-threatening complication related to caval filters. We present our experience with filter-induced inferior vena cava occlusion in order to assess the feasibility, safety, and effectiveness of endovascular management. Methods A retrospective review of all patients undergoing inferior vena cava filter placement over a 60-month study period was performed. From this cohort, a total of 10 cases of inferior vena cava occlusion after filter placement were identified. Demographics, clinical data, procedures, and outcomes were extracted. Patients were followed to the last clinic visit or until they died. Results One-hundred eighty filters were placed by our group practice during the study period. Of those, a total of 10 patients were identified. Overall, there were 7 males; the mean age was 57.1 years (25–78 years). The median time between inferior vena cava filter placement and filter occlusion was 105 days (range 5–4745 days). All patients were clinically symptomatic at the time of their presentation. Nine out of 10 patients were successfully managed endovascularly. Trellis™-8 thrombectomy was the most common endovascular strategy performed (nu2009=u20099). Four patients had balloon angioplasty, two of those with stent placement for chronically occluded inferior vena cava/iliac veins. No thromboembolic complications developed during a median follow-up period of 233 days (range 4–1083 days). Conclusions Endovascular management of inferior vena cava occlusion is feasible, safe, and effective in decreasing thrombus burden in the presence of an inferior vena cava filter. Further studies evaluating long-term inferior vena cava patency and optimal surveillance regimen after endovascular management of filter-related inferior vena cava occlusion are warranted.

Ventricular Assist Device Support: Single Pediatric Institution Experience Over Two Decades

BACKGROUNDnWe reviewed our single institutional experience with pediatric ventricular assist device (VAD) support over the last 2 decades, with an aim to improve our current management and gain an insight into the future direction.nnnMETHODSnA retrospective review was conducted on all patients that had undergone VAD support between 1996 and 2017. Outcomes were analyzed based on the type of VADs, whether temporary or durable devices. Primary end points were positive outcomes, including bridge-to-transplantation, bridge-to-recovery, alive on device, and bridge-to-bridge to another VAD, or negative outcomes, including death during VAD support or in-hospital death after bridge-to-recovery. The Pediatric Interagency Registry for Mechanical Circulatory Support definition was used to classify adverse events.nnnRESULTSnOverall, 201 VADs were implanted in 159 patients, with 82 (41%) and 119 (59%) being temporary and durable support, respectively. There has been a trend toward an increasing annual implant volume both with temporary and durable VADs. Positive outcomes were achieved in 80% (66 of 82) of those with temporary support, with bridge-to-recovery (53% [35 of 66]) and bridge-to-bridge to another VAD (38% [25 of 66]) being the predominant outcomes. Of those on durable support, 84% (100 of 119) achieved positive outcomes, with bridge-to-transplant (66% [78 of 119]) being the leading destination. The most notable change during the study period was the introduction of implantable continuous-flow VADs, resulting in outpatient management becoming a routine practice. No patients were discharged on VAD support before 2004, but 85% were discharged on VADs with discharge capability afterxa02013.nnnCONCLUSIONSnThe present study has demonstrated the evolutional changes of pediatric VAD support and their effect on clinical outcomes over the last 2 decades.

Contemporary Outcomes after Repair of Isolated and Complex Complete Atrioventricular Septal Defect

BACKGROUNDnContemporary outcomes of complete atrioventricular septal defect (CAVSD) repair, particularly for defects with associated abnormalities, is unclear. The goal of this study is to report an all-inclusive experience of CAVSD repair using a consistent surgical approach.nnnMETHODSnAll patients undergoing CAVSD repair between 1995 and 2016 at our institution were included. Patients were divided into 2 groups: isolated and complex (tetralogy of Fallot, aortic arch repair, double outlet right ventricle, and total anomalous pulmonary venous return). Survival and reoperation were analyzed using log-rank test and Grays test, respectively. Multivariable analysis was performed with Cox regression.nnnRESULTSnOverall, 406 patients underwent repair: 350 (86%) isolated and 56 (14%) complex CAVSD (tetralogy of Fallot: 34, double outlet right ventricle: 7, aortic arch repair: 12, total anomalous pulmonary venous return: 3). Median age at repair was 5 months (range, 10 days to 16 years); 339 (84%) had trisomy 21. A 2-patch repair was used in 395 (97%) and the zone of apposition was completely closed in 305 (75%). Perioperative mortality was 2% and 4% in the isolated and complex groups, respectively. Perioperative mortality since 2006 was 0.9%. Median follow-up was 7 years. Overall 10-year survival and incidence of any reoperation were 92% and 11%, respectively. Complex anatomy was not a risk factor for mortality (pxa0= 0.35), but it was for reoperation (hazard ratio [HR]: 2.6; p < 0.01). Risk factors for left atrioventricular valve reoperation were a second bypass run (HR: 2.7) and preoperative moderate or worse regurgitation (HR: 2.3).nnnCONCLUSIONSnMortality after CAVSD repair is low, yet reoperation remains a significant problem. Repair of complex CAVSD can be performed with similar mortality rates.

Cervical left aortic arch with distal tortuosity causing coarctation and aneurysmal formation in a child

We present a case of a 10‐year‐old female with a cervical aortic arch and distal transverse arch tortuosity causing coarctation and aneurysmal formation and describe the surgical repair of this rare congenital anomaly.

Acute humoral rejection in an infant without risk factors after heart transplantation

Graft rejection is the most common factor that limits graft survival after transplantation. During infancy, the humoral immune system is partially suppressed and humoral rejection of a cardiac allograft has not been reported in the absence of risk factors such as prior transplantation, blood transfusions, ventricular assist devices, and elevation of panel reactive antibodies. We present a case of an infant with dilated cardiomyopathy who developed multiple episodes of acute humoral rejection after heart transplantation in the absence of risk factors.

Pulsatile Glenn as long-term palliation for single ventricle physiology patients

OBJECTIVEnThere are limited studies analyzing pulsatile Glenn as a long-term palliation strategy for single ventricle patients. This study sought to determine their outcomes at a single institution.nnnDESIGNnA retrospective review was performed.nnnSETTINGnStudy performed at a single pediatric hospital.nnnPATIENTSnAll single ventricle patients who underwent pulsatile Glenn from 1995 to 2016 were included.nnnOUTCOME MEASURESnPulsatile Glenn failure was defined as takedown, transplant, or death. Further palliation was defined as Fontan, 1.5, or biventricular repair. Risk factors were assessed by Cox multivariable competing risk analyses.nnnRESULTSnSeventy-eight patients underwent pulsatile Glenn at age 9xa0months (interquartile range, 5-14). In total, 28% had heterotaxy, 18% had a genetic syndrome, and 24% had an abnormal inferior vena cava. There were 3 (4%) perioperative mortalities. Further palliation was performed in 41 (53%) patients with a median time-to-palliation of 4xa0years (interquartile range, 3-5). Pulsatile Glenn failure occurred in 10 (13%) patients with 8 total mortalities. Five- and 10-year transplant-free survival were 91% and 84%, respectively. At a median follow-up of 6xa0years (interquartile range, 2-8), 27 patients (35%) remained with PG (age 7xa0years [interquartile range, 3-11], oxygen saturation 83%xa0±xa04%). Preoperative moderate-severe atrioventricular valve regurgitation (AVVR) (hazard ratio 7.77; 95% confidence interval 1.80-33.43; P =.005) and higher pulmonary vascular resistance (hazard ratio 2.59; 95% confidence interval 1.08-6.15; P =.031) were predictors of pulsatile Glenn failure after adjusting for covariates. Reaching further palliation was less likely in patients with preoperative moderate-severe AVVR (hazard ratio 0.22, 95% confidence interval 0.08-0.59; P =.002).nnnCONCLUSIONnPulsatile Glenn can be an effective tool to be used in challenging circumstances, these patients can have a favorable long-term prognosis without reducing their suitability for further palliation.