Tyson A. Fricke

Outcomes of the Arterial Switch Operation for Transposition of the Great Arteries: 25 Years of Experience

BACKGROUND Studies on long-term outcomes of the arterial switch operation (ASO) for transposition of the great arteries (TGA) are uncommon. Thus, we sought to determine the long-term outcomes for patients after ASO performed at a single institution over a 25-year period. METHODS From 1983 to 2009, 618 patients underwent the ASO for TGA and were reviewed retrospectively. RESULTS Overall early mortality was 2.8%. Risk factors for early death on multivariate analysis were resection of left ventricular outflow tract obstruction at time of ASO (p = 0.001), weight less than 2.5 kg at time of ASO (p < 0.001), associated aortic arch obstruction (p = 0.043), and the need for postoperative extracorporeal membrane oxygenation (p < 0.001). Mean follow-up time was 10.6 years (range 2 months to 26.1 years). Late mortality was 0.9%. Reintervention was significantly higher (p < 0.001) in patients with ventricular septal defect or arch obstruction versus those without them (25.2% and 23.4% vs 5.9% at 15- year follow-up). Risk factors for late reintervention were left ventricular outflow tract obstruction at time of ASO (p < 0.001) and a greater circulatory arrest time (p < 0.001). Freedom from at least moderate neoaortic valve regurgitation for the entire cohort was 98.7% (95% confidence interval 96.8 to 99.5%) at 20 years. Mild neoaortic regurgitation was seen in 25.6% of patients at mean follow-up. All patients were free of arrhythmia and heart failure symptoms at last follow-up. CONCLUSIONS The ASO can be performed with good long-term results. Patients with associated ventricular septal defect and aortic arch obstruction warrant close follow-up.

Aortic dissection and rupture in adolescents after tetralogy of Fallot repair

Lobectomy pT2N1M0, IIB Wild type None Bone metastasis (6 mo), DWD (1 y, 5 mo) Lobectomy pT1N0M0, IA Exon 19 (del) None Brain metastasis (2 mo), AWD (3 y, 6 mo) Left pneumonectomy Pathologic CR Exon 19 (del)* Gefitinib (2 y) Brain metastasis (2 y, 4 mo), AWD (2 y, 7 mo) Bilobectomy pT1N1M0, IIA Exon 19 (del) Gefitinib (11 mo) AWOD (11 mo) Lobectomy pT1N2M0, IIIA Unknown None Brain metastasis (5 mo), AWD (2 y) Left extrapleural pneumonectomy pT4N2M0, IIIB Exon 19 (del) Gefitinib (3 mo) Brain metastasis (3 mo), DWD (1 y, 7 mo)

Outcomes of the Arterial Switch Operation in Patients With Taussig-Bing Anomaly

BACKGROUND The arterial switch operation (ASO) is associated with poorer outcomes in patients with Taussig-Bing anomaly (TBA) compared with transposition of the great arteries (TGA). We describe the outcomes after ASO in patients with TBA at a single institution. METHODS Between 1983 and 2009, 57 patients with TBA underwent the ASO at the Royal Childrens Hospital in Melbourne. RESULTS Hospital mortality was 5.3% (3 of 57). Larger weight at operation (p=0.015), pulmonary artery banding prior to ASO (p=0.049) and concurrent pulmonary artery banding (p=0.049) were risk factors of early death. Actuarial survival was 94% at 15 years. Follow-up was 84% complete with a mean follow-up of 9.8±6.7 years (range, 6 days to 19.1 years). There was no late mortality. Reintervention was required in 24.4% (11 of 45). Longer cross-clamp time (p=0.027) was a risk factor for reintervention. Freedom from reintervention was 75.3% at 15 years. After ASO, 2.2% (1 of 45) presented with sub-neopulmonary obstruction and 13.3% (6 of 45) had moderate or more neoaortic insufficiency (neo-AI). Surgery prior to ASO was a risk factor for sub-neopulmonary obstruction (p=0.049) and moderate or more neo-AI (p=0.016). Freedom from moderate or more neo-AI was 91.1% at 10 years. CONCLUSIONS Early mortality has improved over time with no mortality occurring in the last decade. Although patients are doing well on late follow-up, many patients require reintervention and show progression of neo-AI. Close long-term follow-up is warranted as patients are likely to require further reintervention in the second decade after TBA repair.

Outcomes of Truncus Arteriosus Repair in Children: 35 Years of Experience From a Single Institution

We evaluated the long-term outcomes following repair of truncus arteriosus (TA) from a single institution. We conducted a retrospective review of children (n = 171) who underwent TA repair between 1979 and 2014. Early mortality rate was 11.7% (20/171). There were 19 late deaths. Most deaths (74%, 29/39) occurred within the first year following surgery. The 1-year mortality rate in 1979-2004 was 18% (25/136) and decreased to 11% (4/35) in 2005-2014. The overall survival rate was 73.6% at 30 years. Multivariate analysis identified postoperative extracorporeal membrane oxygenation (P = 0.003), operative weight <2.5kg (P = 0.012), prior surgical intervention (P = 0.018), and coronary artery anomaly (P = 0.037) as risk factors for early mortality. A Cox regression model identified DiGeorge syndrome (P = 0.008) as a risk factor for late mortality. Freedom from right ventricular outflow tract reoperation was 4.6% at 20 years. Concomitant truncal valve (TV) repair or replacement was undertaken in 20 patients. Additionally, 14 patients underwent late TV repair or replacement. The overall survival rate in patients who underwent TV operation was 76.9% at 20 years. A total of 19 patients had concomitant interrupted aortic arch with a survival rate of 89.5% at 20 years. Median follow-up was 19 years (mean = 17 years, range: 1-34 years). All patients were in New York Heart Association Class I/II at last follow-up. Following repair of TA, patients had good long-term functional status but had high reoperation rates. Repair of interrupted aortic arch and TV were not risk factors for mortality. Postoperative extracorporeal membrane oxygenation, operative weight <2.5kg, prior surgical intervention, and coronary artery anomaly were risk factors for early death. DiGeorge syndrome was associated with late death, most commonly from infection.

Arterial switch operation in children with interrupted aortic arch: Long-term outcomes

have reported minimally invasive VATS using ECMO. The use of ECMO, however, has a potential problem with bleeding, especially when pleural adhesion exists. In the present case, we selected VATS under local and epidural anesthesia with preparation of ECMO, expecting less bleeding during the operation and early recovery after the operation. The procedure was well tolerated and the air leakage was completely controlled. The patient was discharged on day 4 after the operation. VATS procedures under local and epidural anesthesia have been reported in patients with spontaneous pnemothorax and secondary pneumothorax after lung transplantation. In a small randomized study, Pompeo and collegues reported that awake VATS bullectomy with pleural abrasion for spontaneous pneumothorax was feasible and provided equivalent outcome to procedures with the patient under general anesthesia. Thoracoscopic operations with the patient awake, however, have limitations. First, effective epidural anesthesia is indispensable and general anesthesia has to be induced when effective analgesia cannot be obtained. Second, total lung collapse cannot be obtained, especially in patients with limited contralateral pulmonary function, and thus lesions close to the hilum would not be adequately treated. Bearing these limitations in mind, we

Long-term results of anatomic correction for congenitally corrected transposition of the great arteries: A 19-year experience

Objective: The surgical indication, timing, strategy, and surgical technique for anatomic correction of congenitally corrected transposition of the great arteries are challenging. We evaluated the long‐term results at The Royal Childrens Hospital Melbourne. Methods: Review of 32 successive anatomic corrections between 1996 and 2015. Results: Twenty‐one double‐switch (66%), 6 Senning/Bex‐Nikaidoh (19%), and 5 Senning/Rastelli (16%) procedures were performed (median age, 1.9 years). Median follow‐up was 5.4 years with 4 deaths and 1 heart transplant. Cumulative incidence of late reoperation was 8%, 29%, and 59% at 1, 5, and 10 years, respectively. Twenty‐six patients had full follow‐up with native hearts. Nineteen had normal left ventricle (LV) function. Late LV dysfunction, mostly mild, was not related to needing a pacemaker (P = .4) or a pulmonary artery band (PAB) (P = .08). Previous PAB was linked to the need for aortic valve surgery or neoaortic regurgitation moderate or greater (P = .03). Six required Senning revision. The introduction of the Shumacker modification of the Senning has generated stable pulmonary venous pathways. Six patients developed postoperative iatrogenic atrioventricular block dependent on a permanent pacemaker. Conclusions: Anatomic correction is a surgical challenge. It provides excellent functional outcomes in survivors with a significant need for reoperation and a definite risk of death or transplantation. Normal LV function should be expected in most patients. LV dysfunction was not linked to PAB or pacemaker requirement but surgery without LV training had better long‐term LV function. The Shumacker modification provided stable venous pathways. Iatrogenic atrioventricular block remains a challenge.

Translocation of a single coronary artery from the nonfacing sinus in the arterial switch operation: Long-term patency of the interposition graft

In the current era, a single coronary artery originating from one of the facing sinuses is no longer a risk factor for the arterial switch operation (ASO) in high-volume units. Although an anterior looping or a commissural malalignment increases the distance between the original coronary orifice and neoaorta, both anatomic variations can still be managed successfully by means of tube reconstruction of the single coronary artery with autologous pericardium or aorta. However, a single coronary artery originating from a nonfacing sinus presents a rare yet significant problem, often making ASO impossible. Herein we describe a successful translocation of the single coronary artery with an interposition graft, with a documented patency at 20 years of follow-up.

Long-term outcomes of complete vascular ring division in children: a 36-year experience from a single institution.

Objectives Complete vascular rings are rare and cause tracheoesophageal compression. Following surgical division, some patients have persisting tracheomalacia. We aim to assess the long-term outcomes of complete vascular ring division. Methods All patients (n = 132) who underwent surgical division of a complete vascular ring between 1978 and 2014 were identified from the hospital database and retrospectively reviewed. Results Complete vascular rings consisted of a double aortic arch (n = 80), right aortic arch with an aberrant subclavian artery and left ligamentum arteriosum (n = 50), right aortic arch with mirror image branching and left ligamentum arteriosum (n = 1), and a left aortic arch with right descending aorta and right ligamentum arteriosum (n = 1). Kommerells diverticulum was identified in 10 patients. Preoperative tracheomalacia was identified via bronchoscopy in 25 patients. Concomitant tracheal reconstruction was not performed in any patient. Kommerells diverticulum was resected in 1 patient. The hospital mortality rate was 1.5% (2/132). There were no late deaths. The overall survival rate was 98.3 ± 1.2% (95% CI: 93.4, 99.6) at 20 years. Postoperatively, persistent tracheal compression was reported in 3 patients, and tracheomalacia in 16 patients. The rate of freedom from reoperation was 88.6 ± 4.0% (95% CI: 77.9, 94.3) at 20 years. No patient required tracheal surgery during the follow-up period. Follow-up was 92% (121/132) complete, with a median follow-up of 11.4 years (range 44 days to 36 years). At the last follow-up, 7 patients had mild tracheomalacia. Conclusions Outcomes of division of a complete vascular ring are excellent. Tracheomalacia often improves following division of the vascular ring. Respiratory symptoms following complete vascular ring division are uncommon.

From cellular senescence to regeneration: A quest for the holy grail for the next generation of surgeons?

From the Department of Cardiothoracic Surgery, The Royal Children’s Hospital, The University of Melbourne and the Murdoch Children’s Research Institute, Melbourne, Victoria, Australia. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 28, 2017; accepted for publication May 11, 2017. Address for reprints: Igor E. Konstantinov, MD, PhD, FRACS, The Royal Children’s Hospital, Flemington Rd, Parkville, Melbourne, Victoria 3029, Australia (E-mail: igor.konstantinov@rch.org.au). J Thorac Cardiovasc Surg 2017;-:1-2 0022-5223/

The History of Experimental Heterotopic and Orthotopic Heart Transplantation Before Cardiopulmonary Bypass

36.00 Crown Copyright 2017 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.05.036 Accumulation of senescent, senescence-associated b-galactosidase–positive, cells appears to play a key role in the initiation of regeneration processes. Improving immune clearance of senescent cells may result in regeneration of the damaged tissue.