Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization.

BACKGROUND: Aortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo. METHODS: Data-available consecutive 38 patients (median age, 77; interquartile range, 72.8-82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling. RESULTS: The Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling. CONCLUSIONS: Low global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.

Prediction of Pulmonary to Systemic Flow Ratio in Patients With Congenital Heart Disease Using Deep Learning-Based Analysis of Chest Radiographs.

Importance: Chest radiography is a useful noninvasive modality to evaluate pulmonary blood flow status in patients with congenital heart disease. However, the predictive value of chest radiography is limited by the subjective and qualitive nature of the interpretation. Recently, deep learning has been used to analyze various images, but it has not been applied to analyzing chest radiographs in such patients. Objective: To develop and validate a quantitative method to predict the pulmonary to systemic flow ratio from chest radiographs using deep learning. Design, Setting, and Participants: This retrospective observational study included 1031 cardiac catheterizations performed for 657 patients from January 1, 2005, to April 30, 2019, at a tertiary center. Catheterizations without the Fick-derived pulmonary to systemic flow ratio or chest radiography performed within 1 month before catheterization were excluded. Seventy-eight patients (100 catheterizations) were randomly assigned for evaluation. A deep learning model that predicts the pulmonary to systemic flow ratio from chest radiographs was developed using the method of transfer learning. Main Outcomes and Measures: Whether the model can predict the pulmonary to systemic flow ratio from chest radiographs was evaluated using the intraclass correlation coefficient and Bland-Altman analysis. The diagnostic concordance rate was compared with 3 certified pediatric cardiologists. The diagnostic performance for a high pulmonary to systemic flow ratio of 2.0 or more was evaluated using cross tabulation and a receiver operating characteristic curve. Results: The study included 1031 catheterizations in 657 patients (522 males [51%]; median age, 3.4 years [interquartile range, 1.2-8.6 years]), in whom the mean (SD) Fick-derived pulmonary to systemic flow ratio was 1.43 (0.95). Diagnosis included congenital heart disease in 1008 catheterizations (98%). The intraclass correlation coefficient for the Fick-derived and deep learning-derived pulmonary to systemic flow ratio was 0.68, the log-transformed bias was 0.02, and the log-transformed precision was 0.12. The diagnostic concordance rate of the deep learning model was significantly higher than that of the experts (correctly classified 64 of 100 vs 49 of 100 chest radiographs; P = .02 [McNemar test]). For detecting a high pulmonary to systemic flow ratio, the sensitivity of the deep learning model was 0.47, the specificity was 0.95, and the area under the receiver operating curve was 0.88. Conclusions and Relevance: The present investigation demonstrated that deep learning-based analysis of chest radiographs predicted the pulmonary to systemic flow ratio in patients with congenital heart disease. These findings suggest that the deep learning-based approach may confer an objective and quantitative evaluation of chest radiographs in the congenital heart disease clinic.

Aortic valve replacement for infective endocarditis in an adult with uncorrected tetralogy of Fallot and pulmonary atresia.

Infective endocarditis is one of the complications encountered in patients with uncorrected tetralogy of Fallot; however, there have been only limited reports on surgical treatment of this condition. A 38-year-old man with uncorrected tetralogy of Fallot with pulmonary atresia previously palliated with modified Blalock-Taussig shunt was diagnosed with aortic valve infective endocarditis and developed severe aortic regurgitation. He underwent urgent aortic valve replacement, during which intermittent hypothermic circulatory arrest was necessary to achieve adequate myocardial protection and bloodless surgical field due to massive arterial return into the left ventricle from the collateral pulmonary circulation.

Novel aortic arch reconstruction using a modified Norwood procedure based on hypoplastic left heart syndrome-specific anatomical malformations.

OBJECTIVES: Postoperative left pulmonary artery (PA) or bronchus compression occasionally follows narrowing of the retroaortic space after the Norwood procedure. We examined hypoplastic left heart syndrome (HLHS)-specific anatomical malformations and hypothesized that a long main pulmonary arterial trunk might contribute to a larger retroaortic space. In this study, we introduced a modified Norwood procedure [pulmonary artery trunk-saving method (PATS)] and evaluated the results. METHODS: HLHS-specific anatomical malformations were examined using computed tomographic data from 23 consecutive patients who underwent bilateral pulmonary banding. Fourteen patients had HLHS or associated conditions (Group H), and 9 patients had other complex cardiac defects and underwent biventricular repair (Group B). Five consecutive HLHS patients underwent PATS as a modified Norwood operation, and 6 controls underwent a conventional Norwood procedure. We used computed tomography to measure the lengths of the aorta and PA and the angle of both pulmonary branches to evaluate the effect of PATS. RESULTS: Preoperative examination confirmed HLHS-specific right PA branching adjacent to the pulmonary valve and a trend towards a shorter main pulmonary arterial trunk with the conventional Norwood procedure. Also, both right and left pulmonary arterial branching from the dorsal aspect of the main pulmonary arterial trunk and the PA branch angle were minimal in HLHS patients. Postoperative data showed the retroaortic space behind the reconstructed neoaorta was significantly wider in PATS patients than in conventional Norwood patients. Longitudinal measurements (between the aortic arch and pulmonary valve) and sagittal measurements (ascending aorta to descending aorta) were larger in PATS patients, and no left PA or airway obstruction was observed following PATS. CONCLUSIONS: PATS resulted in a wider aortopulmonary space without left pulmonary arterial stenosis or bronchus obstruction. HLHS-specific anatomical malformations suggested that PATS may avoid extrinsic compression of the left PA and bronchus by the neoaorta and can be an alternative for HLHS patients.

[A Case of Aortic Cannula Malposition Detected by Prolonged Desaturation of Regional Cerebral Oxygen Index (rcSO2)].

A sixteen-year-old female patient with congenital aortic stenosis underwent Ross procedure. We monitored bilateral regional cerebral saturation of oxygen (rcSO2) on the forehead at the right and left of the midline. After aortic and bicavel cannulation, cardiopulmonary bypass was instituted. On the mor- row of aortic cross clamping, the rcSO2 fell from approximately 55% to below 30%. We searched the cause of this phenomenon, and detected that the tip of aortic cannula was inserted to the left subclavian artery. After repositioning, the bilateral rcSO2 increased to above 65%. We felt keenly that the monitoring of rcSO2 is useful to recognize corrective adjustment of the cannula ori- entation, and the avoidance of cerebral hypoperfusion during the cardiopulmonary bypass period.

Ventricular Tachycardia Rotating a Scar of a Total Right Ventricular Exclusion.

We describe a 15-year-old postoperative girl who underwent surgical 3-dimensional mapping and ablation of hemodynamically unstable ventricular tachycardia (VT) with an on-pump beating heart surgical technique. She had previously received a tricuspid valve closure, entire right ventricular free wall resection, and finally Fontan operation with an extracardiac conduit to treat a severe Ebstein's anomaly. Activation mapping revealed a VT rotating around a large right ventricular free wall incisional scar with a narrow conduction channel between the scar and a tricuspid annulus (TA). A linear radiofrequency ablation connecting the scar and the TA terminated the VT.