Long-term outcomes of the classic Konno-Rastan procedure in paediatric and adult patients: impact of aortic annulus size on patient outcomes.

OBJECTIVES: The classic Konno-Rastan procedure may yield different outcomes regarding aortic annulus diameters ≤15 mm and larger. Focusing on the effect of the diameter of the aortic annulus, we described the long-term outcomes of our patients. METHODS: The outcomes of paediatric and adult patients who underwent surgery from 2000 to 2021 were studied retrospectively. The patient population was divided into 2 groups with aortic annulus diameters ≤15 mm and >15, and the outcomes were compared between the 2 groups. RESULTS: A total of 48 patients, with a mean age of 12.24 ± 9.42 years (2-53 years) and a median follow-up duration of 8 years (7 months to 20 years) with an IQR of 5.5, were enrolled. The mean peak instantaneous pressure gradient was 78.97 ± 25.29 mmHg, which decreased to 21.43 mmHg (P-value = 0.012). The maximum left ventricular outflow tract gradient at the last follow-up was 28.21 mmHg, with the exception of 1 case with a gradient of 68.45 mmHg. The mean diameter of the aortic annulus was 15.34 ± 3.87 mm (8-23 mm), and the mean prosthetic valve size was 20.31 mm, which was 5 mm (33%) larger than the native annulus diameter. The overall mortality rate was 6.3%, with 1 death in the hospital and 2 in the first year after the surgery. The major complication rate, including mortality, heart block and reintervention, was higher in patients with ≤15 mm annulus (P-value = 0.028.) However, there was no difference between the 2 groups in follow-up. Four (8%) late cardiac reoperations were performed, none of which were related to our surgeries. CONCLUSIONS: Kono-Rastan surgery for patients with aortic valve diameter of ≤15 mm can be performed with acceptable long-term outcomes.

Does the postoperative quality of reduction, regardless of the surgical method used in treating a calcaneal fracture, influence patients' functional outcomes?

BACKGROUND: The extensile lateral approach (ELA) and sinus tarsi approach (STA) are commonly utilized for surgically treating calcaneal fractures. This study compared the outcomes of ELA and STA in the management of calcaneal fractures and assessed the influence of postoperative quality of reduction on functional and pain scores. METHODS: The study included 68 adults with Sanders type-II and type-III calcaneal fractures who underwent either ELA or STA surgery. Pre- and postoperative radiographs and computed tomography scans were analyzed, and functional and pain scores were evaluated using the Manchester Oxford Foot Questionnaire (MOXFQ), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and Visual Analogue Score (VAS) during follow-up visits. RESULTS: Out of the total patients, 50 underwent ELA surgery while 18 underwent STA surgery. The anatomic (excellent) reduction was achieved in 33 (48.5%) patients. There were no significant differences between the ELA and STA groups concerning functional scores, pain scores, the proportion of excellent reduction, and complications. Additionally, anatomic reduction, compared to near or non-anatomic (good, fair, or poor) reduction, demonstrated a decrease in MOXFQ (unstandardized ß coefficient: -13.83, 95% CI: -25.47 to -2.19, p = 0.021), an increase in AOFAS (unstandardized ß coefficient: 8.35, 95% CI: 0.31 to 16.38, p = 0.042), and a reduction in VAS pain (unstandardized ß coefficient: -0.89, 95% CI: -1.93 to -0.16, p = 0.095) scores. CONCLUSION: In conclusion, we found no significant differences regarding complications, excellent reduction, and functional scores between STA and ELA surgeries. Therefore, STA may be an effective alternative for the treatment of calcaneal fractures in Sanders type II and type III calcaneal fractures. Furthermore, the anatomic reduction of the posterior facet correlated with improved functional scores, emphasizing the importance of achieving it for restoring foot function regardless of surgery type or time between injury and surgery.

Minimally invasive versus sternotomy approach for double-patch repair of partial anomalous pulmonary venous connection and sinus venosus defect in pediatric and adult patients: Mid to long-term outcomes.

BACKGROUND: Several surgical techniques have been proposed to repair right partial anomalous pulmonary venous connection (PAPVC) along with sinus venosus defect (SVD). This study aimed to compare the perioperative data and outcomes of double-patch repair using a minimally invasive approach versus conventional sternotomy in pediatric and adult patients. METHODS: This retrospective study was conducted on 48 minimally invasive cases and 35 sternotomy cases, undergoing surgery by a single surgeon between July 2002 and August 2020. For all patients, repair was performed using the double-patch technique. In the minimally invasive approach, right mini-thoracotomy was performed with central cannulation for children and with peripheral cannulation for adults. The patients were classified into two pediatric and adult groups, and each group was categorized into minimally invasive and sternotomy approaches. They were followed-up by transthoracic echocardiography and electrocardiography before and early after surgery, 3 and 6 months after surgery, and then annually. The relative data were compared between the two approaches in terms of perioperative findings, postoperative pulmonary vein or superior vena cava (SVC) stenosis, and sinus node dysfunction. RESULTS: This study included 25 minimally invasive cases and 19 sternotomy cases in the pediatric group (mean age, 4.99 ± 4.28 and 6.10 ± 4.39 years, respectively) and 23 minimally invasive cases and 16 sternotomy cases in the adult group (mean age, 35.73 ± 8.06 and 32.62 ± 9.80 years, respectively). The mean and median follow-ups were 6.31 ± 4.92 years and 6 years (range: 6 month-18 year) in the pediatric group and 6.15 ± 4.53 years and 5 years (range: 6 month-18 year) in the adult group, respectively. The mean chest tube drainage was significantly lower in the minimally invasive pediatric group (p = .03), and the mean blood transfusion volume was significantly lower in the minimally invasive adult group compared to the other groups (p = .03). No stenosis occurred in the pulmonary veins. Mild SVC stenosis occurred in one patient in the minimally invasive pediatric group, with no need for reintervention. All patients had a normal sinus rhythm, except for the mentioned case with a transient, first-degree atrioventricular block, which spontaneously reverted to the normal sinus rhythm. CONCLUSIONS: The minimally invasive approach can be a safe and practical alternative for the double-patch repair of PAPVC and SVD. It ensures a repair with comparable quality to sternotomy, but with better cosmetic and psychological outcomes.

Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results.

OBJECTIVES: The prevention of pulmonary insufficiency (PI) is a crucial part of the tetralogy of Fallot repair. Many techniques have been introduced to construct valves from different materials for the right ventricular outflow tract, including the most commonly constructed monocusp valves. We are introducing a new bicuspid valve made intraoperatively using the autologous right atrial appendage (RAA) to prevent PI in these patients. METHODS: The RAA valve was constructed and used in 21 patients with tetralogy of Fallot. The effective preservation of the native valve was impossible in all patients because of either a severe valve deformity or a small annulus. The RAA valve was created after ventricular septal defect closure and right ventricular outflow tract myectomy and was covered with a bovine transannular pericardial patch. The perioperative data were evaluated, and the echocardiography results were assessed immediately after operations and in follow-up with a median of 10.5 months. The data were retrospectively compared with 10 other patients with similar demographic data but with only transannular patches. RESULTS: The mean age of the patients was 13.3 months. No mortality or related morbidity occurred after repair using the RAA valve. The PI severity early after the operation was trivial or no PI in 18 patients, and mild PI was observed in 3 patients, which progressed to moderate PI in one of them in the mean 12-month follow-up period. Fifteen patients had mild or no pulmonary stenosis, while moderate pulmonary stenosis was observed in 6 others. Compared with the other 10 patients with only transannular patches, the RAA valve patients had prolonged operative and clamping times, but no difference in postoperative course and shorter hospital stays. The degree of PI was, of course, significantly less in the RAA valve patients, but pulmonary stenosis was the same. CONCLUSIONS: The RAA valve construction is a safe and effective technique to prevent PI after the tetralogy of Fallot repair, at least in terms of short- and mid-term results. A longer follow-up period is needed to confirm if this new valve can eliminate or significantly delay the need for pulmonary valve replacement in these patients.

Clinical and Functional Outcomes of Ulnar Lengthening in the Treatment of Masada Type I Forearm Deformities in Hereditary Multiple Osteochondromas.

PURPOSE: Forearm deformity is common in hereditary multiple osteochondromas (HMO). The results of ulnar lengthening and osteochondroma excision are generally favorable, both clinically and radiographically. This study aimed to assess the clinical, radiographic, and functional results of forearm reconstruction in patients with Masada type I deformity (osteochondroma in the distal ulna with radial bowing, without radial head dislocation). METHODS: A retrospective review was performed on patients with HMO who underwent surgical reconstruction for a Masada type I forearm deformity over a 10-year period. Eleven forearms in 10 patients underwent gradual ulnar lengthening with an external fixator. Age at the time of surgery was 5 to 12 years. Radiographic evaluation included ulnar shortening, radial articular angle, and carpal slip. Clinical evaluation included range of motion of the elbow and wrist. Functional outcomes were evaluated with the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short Form-36 survey. RESULTS: At an average follow-up of 37.5 months, significant improvement was observed in ulnar shortening, the radial articular angle, and carpal slip. Preoperative average Disabilities of the Arm, Shoulder, and Hand score of 24.2 improved to 17.3. Significant improvement was observed in 3 measures of the Short Form-36 survey: general health, social functioning, and health change. CONCLUSIONS: In agreement with the literature, surgical reconstruction yielded favorable clinical and radiographic results in Masada type I forearm deformities. The main functional improvement was observed in scales of mental health. The baseline physical impairment was minimal in the absence of radial head dislocation, but although it improved with treatment, it was not necessarily clinically relevant. This study can assist surgeons and families in setting realistic goals and expectations for surgery. There may also be additional long-term benefits to forearm lengthening in HMO, including prevention of radial head dislocation, improved range of motion, and better cosmesis, which future research may help to clarify. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Noninvasive Assessment of Pulmonary Artery Pressure in Patients with Extracardiac Conduit Total Cavopulmonary Connection.

To assess quantitative measurement of mean pulmonary artery pressure (PAP) in extracardiac total cavopulmonary connection (TCPC) patients by noninvasive echocardiographic inferior vena cava collapsibility index (IVC-CI) and also correlation between the peripheral vein pressure and mean PAP. In 19 TCPC patients with at least 1-year follow-up after completion of TCPC, complete echocardiography including IVC-CI was recorded. All patients underwent cardiac catheterization for mean PAP pressure, peripheral vein pressure (PVP) and contrast study. Different cutoff points of mean PAP were analyzed, and based on the highest cutoff point, patients were categorized into two groups: mean PAP < 17 mmHg (acceptable) and > = 17 mmHg (high) for comparison analysis. Between 2006 and 2015, from 43 patients who had undergone TCPC, nineteen patients with a mean age 12.9 ± 6.6 years and mean follow-up time of 3.4 ± 1.9 years were included in this study. Mean PAP was 14.6 ± 3.97 (range 8-22 mmHg). Thirteen (68 %) patients had PAP < 17 mmHg. No significant statistical difference was detected with respect to age, sex, type of congenital heart disease and fenestration between these two groups. But, right ventricular dominancy was more prevalent in the high PAP group (50 % vs. 7.7 % P value 0.03). IVC-CI had a correlation with mean PAP (r 0.67, P < 0.001). IVC-CI < 21.8 % can predict PAP > = 17 mmHg with 83 % sensitivity and 100 % specificity. Regression analysis proposed an equation for PAP measurement: PAP (mmHg) = 20.2097-0.1796 × (IVC-CI), (r2 = 0.56). Peripheral vein pressure measurement also showed a good correlation with mean PAP and may be used to estimate PAP with the following equation: PAP (mmHg) = 0. 8675 × PVP, (r 0.90, P < 0.0001). In conclusion, IVC-CI as noninvasive and peripheral vein pressure measurement as a minimal invasive method may be useful for quantitative estimation of PAP in patients with extracardiac TCPC.

Prevalence of substance use among offspring of opioid addicts.

AIMS: This study assessed the prevalence of substance use in sons and daughters of opioids addicts in Iran. MEASUREMENTS: A confidential semistructured interview and DSM-IV criteria were used. Data were gathered from 500 subjects (225 men and 275 women). These subjects were selected randomly from sons and daughters of 500 opioids addicts (out of 1500 opioids addicts) who sought treatment in 2000. RESULTS: Of these subjects, 33.8% were in the age range of 20-29, 33.1% in 30-39, 28% were >40, and 7.1% were <20 years; of them, 81.6% were married and 18.4% were single. The majority (36.2%) used cigarettes, 19% used opium, 18.2% used alcohol, 2.6% used hashish, and 1.6% used marijuana once or more at some time in their lives. Nobody used cocaine or psychedelics. Of the current substance dependents, using DMS-IV criteria, 46.7% of men and 5.5% of women were nicotine dependent, 12.9% of men and 1.1% of women were opium dependent, and 0.9% of men and 0.7% of women were heroin dependent. (Some used or were using more than one substance.) Enjoyment (56.8%) was the first and modeling (49.6%) was the second most common reason reported for substance use. CONCLUSIONS: Substance use was significantly higher in men, in single, and also in illiterate subjects. There was a nonsignificant relation between age group and substance use. Cultural attitudes toward drug use quite likely affect the type and amounts of use. These findings can be considered when planning preventive programs.