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1.
JAMA Netw Open ; 4(7): e2118141, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34313740

RESUMO

Importance: The choice of the right surgical technique for correction of tetralogy of Fallot (TOF) is contentious for patients with a moderate to severe right outflow tract obstruction. The use of a transannular patch (TAP) exposes patients to chronic pulmonary regurgitation, while valve-sparing (VS) procedures may incompletely relieve pulmonary obstruction. Objective: To compare 30-year outcomes of TOF repair after a VS procedure vs TAP. Design, Setting, and Participants: This retrospective population-based cohort study was conducted among all patients with TOF born in the province of Quebec, Canada, from 1980 to 2015 who underwent complete surgical repair. Patients who received a TAP or VS procedure were matched using a propensity score based on preoperative factors in a 1:1 ratio. Data were analyzed from March 2020 through April 2021. Exposures: The study groups were individuals who received TAP and those who received VS. The VS group was further stratified by the presence of residual pulmonary stenosis. Main Outcomes and Measures: The primary outcome was all-cause mortality, with 30-year survival evaluated using Cox proportional-hazards models. Secondary outcomes included the cumulative mean number of cardiovascular interventions, pulmonary valve replacements (PVRs), and cardiovascular hospitalizations were evaluated using marginal means/rates regressions. Results: Among 683 patients with TOF (401 patients who underwent TAP [58.7%] and 282 patients who underwent a VS procedure [41.3%]), adequate propensity score matching was achieved for 528 patients (264 patients who underwent a VS procedure and 264 patients who underwent TAP). Among this study cohort, 307 individuals (58.1%) were men. The median (interquartile range [IQR]) follow-up was 16.0 (8.1-25.4) years, for a total of 8881 patient-years, including 63 individuals (11.9%) followed up for more than 30 years. Individuals who received a VS procedure had an increased 30-year survival of 99.1% compared with 90.4% for individuals who received TAP (hazard ratio [HR], 0.09 [95% CI, 0.02-0.41]; P = .002). Patients who underwent TAP had an increased 30-year cumulative mean number of cardiovascular interventions compared with patients who underwent a VS procedure without residual pulmonary stenosis (2.0 interventions [95% CI, 1.5-2.7 interventions] vs 0.7 interventions [95% CI, 0.5-1.1 interventions]; mean ratio [MR], 0.36 [95% CI, 0.25-0.50]; P < .001) and patients who underwent a VS procedure with at least moderate residual stenosis (1.3 interventions [95% CI, 0.9-1.9 interventions]; MR, 0.65 [0.45-0.93]; P = .02). Results were similar for PVR, with a 30-year cumulative mean 0.3 PVRs [95% CI, 0.1-0.7 PVRs] for patients who underwent a VS procedure without residual pulmonary stenosis (MR, 0.22 [95% CI, 0.12-0.43]; P < .001) and 0.6 PVRs (95% CI, 0.2-1.5 PVRs) for patients with at least moderate residual stenosis (MR, 0.44 [95% CI, 0.21-0.93]; P = .03), compared with 1.4 PVRs (95% CI, 0.8-2.5 PVRs) for the TAP group. No statistically significant difference was found for cardiovascular hospitalizations. Conclusions and Relevance: This study found that patients who underwent a VS procedure had increased 30-year survival, fewer cardiovascular reinterventions, and fewer PVRs compared with individuals who underwent TAP, even in the presence of significant residual pulmonary stenosis. These findings suggest that it is beneficial to perform a VS procedure when possible, even in the presence of moderate residual stenosis, compared with the insertion of a TAP.


Assuntos
Anuloplastia da Valva Cardíaca/mortalidade , Tratamentos com Preservação do Órgão/mortalidade , Complicações Pós-Operatórias/mortalidade , Estenose da Valva Pulmonar/mortalidade , Tetralogia de Fallot/cirurgia , Adulto , Idoso , Anuloplastia da Valva Cardíaca/métodos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/etiologia , Estenose da Valva Pulmonar/cirurgia , Quebeque , Reoperação/métodos , Reoperação/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Tetralogia de Fallot/complicações , Tetralogia de Fallot/mortalidade , Resultado do Tratamento
2.
Int J Cardiovasc Imaging ; 36(10): 1973-1982, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32462447

RESUMO

The hemodynamic impact of residual pulmonary regurgitation (PR) in repaired Tetralogy of Fallot (rTOF) has been well demonstrated. However, markers driving the decision making process to indicate the ideal timing of pulmonary valve replacement (PVR) are still uncertain. Furthermore, very few studies have included the right atrium (RA) dilatation as a preoperative risk factor for post-PVR clinical adverse outcome. The aim of this study was to investigate the impact of pre-PVR right atrial dilation on adverse outcomes in rTOF. We retrospectively reviewed from our CMR database all rTOF patients who underwent CMR study before and after PVR. Detailed clinical and surgical history were collected, in addition to imaging data. The composite primary and secondary post-PVR end points were also recorded. The study cohort consisted of 41 patients (mean age at PVR repair 27.4 ± 10 years). As expected, end-diastolic and end-systolic right ventricle (RV) volumes significantly decreased after PVR (p < 0.001). The RV reverse remodeling, defined by ΔRVEDVi and ΔRVESVi, was associated with both pre-PVR RVEDVi and RVESVi. The higher the pre-PVR RV volumes, more the RV reverse remodeling will be obtained post-surgery. Patients who experienced an adverse outcome were older at pre-PVR, they had a higher Nt-ProBNP, worse VO2/kg/min, more significant tricuspid regurgitation and more dilated RA. The association with the RA dilatation persists and becomes even more significant if we exclude patients who had tricuspid repair beside RVOT surgical reconstruction. Besides RV volumes and function, RA dimensions may play a pivotal role in the decision making of TOF patients.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Átrios do Coração/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca/efeitos adversos , Imageamento por Ressonância Magnética , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Função do Átrio Direito , Remodelamento Atrial , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Átrios do Coração/fisiopatologia , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Humanos , Masculino , Valor Preditivo dos Testes , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tetralogia de Fallot/mortalidade , Tetralogia de Fallot/fisiopatologia , Resultado do Tratamento , Função Ventricular Direita , Remodelação Ventricular , Adulto Jovem
3.
J Thorac Cardiovasc Surg ; 160(2): 476-484, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32014323

RESUMO

OBJECTIVES: The long-term durability of the 2 most commonly used types of bioprosthetic valves in the pulmonic position, the porcine and pericardial valves, is unclear. We compared the long-term durability of the pericardial (Carpentier-Edwards PERIMOUNT [CE]) and porcine (Hancock II) valves in the pulmonic position in patients with congenital cardiac anomalies. METHODS: We retrospectively reviewed the medical records of 258 cases (248 patients) of pulmonary valve implantation or replacement using CE (129 cases, group CE) or porcine (129 cases, group H) valves from 2 institutions between 2001 and 2009. RESULTS: The patients' age at pulmonary valve implantation was 14.9 ± 8.7 years. No significant differences in perioperative characteristics were observed between groups CE and H. Follow-up data were complete in 219 cases (84.9%) and the median follow-up duration was 10.5 (interquartile range, 8.4∼13.0) years. Ten mortalities (3.9%) occurred. Sixty-four patients underwent reoperation for pulmonary valve replacement due to prosthetic valve failure; 10 of these 64 patients underwent reoperation during the study period. Patients in group CE were significantly more likely to undergo reoperation (hazard ratio, 2.17; confidence interval, 1.26-3.72; P = .005) than patients in group H. Patients in group CE showed had a greater prosthetic valve dysfunction (moderate-to-severe pulmonary regurgitation or pulmonary stenosis with ≥3.5 m/s peak velocity through the prosthetic pulmonary valve) rate (hazard ratio, 1.83; confidence interval, 1.07-3.14; P = .027) than patients in group H. CONCLUSIONS: Compared with the pericardial valve, the porcine valve had long-term advantages in terms of reduced reoperation rate and prosthetic valve dysfunction in the pulmonic position in patients with congenital cardiac anomalies.


Assuntos
Bioprótese , Cardiopatias Congênitas/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Animais , Bovinos , Criança , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/fisiopatologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Xenoenxertos , Humanos , Masculino , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Falha de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/mortalidade , Estenose da Valva Pulmonar/fisiopatologia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Seul , Sus scrofa , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
4.
J Thorac Cardiovasc Surg ; 159(6): 2383-2392.e2, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31585750

RESUMO

OBJECTIVES: Pulmonary valve (PV) regurgitation (PR) is common after intervention for a hypoplastic right ventricular outflow tract. Secondary PV repair is an alternative to replacement (PVR), but selection criteria are not established. We sought to elucidate preoperative variables associated with successful PV repair and to compare outcomes between repair and PVR. METHODS: Patients who underwent surgery for secondary PR from 2010 to 2017 by a single surgeon were studied. The PV annulus and leaflets were measured on the preoperative echocardiogram and magnetic resonance images, and the primary predictor variable was leaflet area indexed to ideal PV annulus area (iPLA) by magnetic resonance imaging. PV repair and PVR groups were compared using multivariable logistic regression, and with a conditional inference tree. Freedom from PV dysfunction and from reintervention were assessed with Kaplan-Meier survival analyses. RESULTS: Of 85 patients, 31 (36%) underwent PV repair. By multivariable analysis, longer PV total leaflet length (cm/m2) (ß = 3.00, standard error [SE] = 0.82, P < .001), larger PV z score (ß = 1.34, SE = 0.39, P = .001), and larger iPLA (ß = 8.13, SE = 2.62, P = .002) were associated with repair. iPLA of 0.90 or greater was 91% sensitive and 83% specific for achieving PV repair. At a median of 4.1 years follow-up, there was greater freedom from significant PR in the PV repair group (log rank P = .008). CONCLUSIONS: Patients with an iPLA >0.9, and those with an iPLA between 0.7 and 0.9 with a PV annulus z score >0 should be considered for a native PV repair. At midterm follow-up, patients with a PV repair were not more likely to develop PR or to require reintervention when compared with patients undergoing PVR.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiopatias Congênitas/cirurgia , Pericárdio/transplante , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Técnicas de Sutura , Adolescente , Adulto , Autoenxertos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Criança , Pré-Escolar , Doença Crônica , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Seleção de Pacientes , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Técnicas de Sutura/efeitos adversos , Técnicas de Sutura/mortalidade , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
5.
World J Pediatr Congenit Heart Surg ; 10(2): 197-205, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30841830

RESUMO

BACKGROUND: Postcongenital heart surgery pulmonary regurgitation requires subsequent pulmonary valve replacement. We sought to compare the outcomes of pulmonary valve replacement after using bioprosthetic valves, porcine versus pericardial bioprosthesis. METHOD: Retrospective single-center study of consecutive pulmonary valve replacement in patients with pulmonary regurgitation following initial congenital cardiac surgery. From 2004 to 2016, 82 adult patients (53 males, 29 females) underwent pulmonary valve replacement at a mean age of 28.7 ± 8 years (range 18-52 years) with a mean time to pulmonary valve replacement of 24 ± 7 years (range 13-43 years). Porcine bioprosthetic valves (group 1, n = 32) and pericardial valves (group 2, n = 50) were used. Cardiac magnetic resonance imaging was performed (n = 54) at a mean of 18 ± 13 months before and 24 ± 21 months after pulmonary valve replacement. RESULTS: No significant difference was seen between the groups except that the mean follow-up was longer for group 1 (5.02 ± 2.06 vs 4.08 ± 3.21 years). In-hospital mortality was 1.1%. Follow-up completeness was 100% with no late death. Mean right ventricular end-systolic and end-diastolic volumes reduced significantly in both the groups ( P < .001), whereas right ventricular ejection fraction remained unchanged (group 1, P = .129; group 2, P = .675) . Only the left ventricular end-diastolic volume increased in both the groups, but the increase was significant for group 2 only (group 1, P = .070; group 2, P = .015), whereas the left ventricular end-systolic and ejection fraction remained unchanged in both the groups. There was no reoperation for pulmonary valve replacement. Freedom from intervention was 93.8% (group 1) and 100% (group 2) at eight years after pulmonary valve replacement ( P = .407). CONCLUSION: Midterm outcomes of pulmonary valve replacement in our adult cohort were satisfactory. Both types of bioprosthetic valves performed comparably for eight years and were a good option in adults.


Assuntos
Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Adulto , Animais , Ecocardiografia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Estudos Retrospectivos , Suínos , Resultado do Tratamento , Adulto Jovem
6.
Cardiovasc Revasc Med ; 20(7): 553-558, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30201480

RESUMO

BACKGROUND/PURPOSE: Percutaneous pulmonic valve implantation (PPVI) is an alternative treatment strategy to surgical pulmonic valve implantation (SPVI) for right ventricular outflow tract (RVOT) dysfunction. This study sought to compare outcomes of both treatment strategies. METHODS: The study population was extracted from the 2014 Nationwide Readmissions Database (NRD) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for PPVI and SPVI. Study outcomes included all-cause in-hospital mortality, length of index hospital stay (LOS), post-procedural bleeding, mechanical complications of heart valve prosthesis, vascular complications (VC), infective endocarditis (IE), total hospitalization charges, and 30-day readmission rates. RESULTS: A total of 975 patient discharges (176 in PPVI and 799 in SPVI group) were identified (average age 25.7 years; 57.5% male). PPVI was associated with significantly shorter median LOS (1 versus 5 days, p < 0.01), lower risk of bleeding (4.6% versus 26.4%, p < 0.01), and lower total hospitalization charges ($169,551.7 versus $210,681.8, p = 0.02). There was no significant difference between both groups in terms of all-cause in-hospital mortality (0% versus 1.4%, p = 0.12), mechanical complications of heart valve prosthesis (1.7% versus 2.0%, p = 0.78), VC (2.3% versus 2.0%, p = 0.82), IE (1.7% versus 3.1%, p = 0.31), or 30-day readmission rates (4.4% versus 7.6%, p = 0.16). CONCLUSION: Compared with SPVI, PPVI was associated with shorter LOS, lower bleeding, and lower total charges. There was no significant difference between the two strategies in terms of all-cause in-hospital mortality, mechanical complications of heart valve prosthesis, VC, IE, or 30-day readmission rates.


Assuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Obstrução do Fluxo Ventricular Externo/cirurgia , Adolescente , Adulto , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/economia , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/economia , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Preços Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Readmissão do Paciente , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/economia , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Obstrução do Fluxo Ventricular Externo/economia , Obstrução do Fluxo Ventricular Externo/mortalidade , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Adulto Jovem
7.
Semin Thorac Cardiovasc Surg ; 31(3): 496-504, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30395964

RESUMO

Only few studies have reported long-term outcome of the transatrial-transpulmonary approach in the current era of management of tetralogy of Fallot (ToF). We investigated 15-year outcome of correction via a transatrial-transpulmonary approach in a large cohort of successive patients operated in the 21st century. All infant ToF patients undergoing transatrial-transpulmonary ToF correction between 2000 and 2015 were included (N = 177, 106 male, median follow-up 7.1 (interquartile range 3.0-10.9) years. Data regarding postoperative complications, reinterventions, development of atrial and ventricular arrhythmia, cardiac function, and survival were evaluated. Prior shunting was performed in 10 patients (6%). The transatrial-transpulmonary approach resulted in valve-sparing surgery in 57 patients (32%). Postoperative surgical complications included junctional ectopic tachycardia (N = 12, 7%), pericardial (N = 10, 6%) or pleural effusion (N = 7, 3%), chylothorax (N = 7, 4%), bleeding requiring reoperation (N = 4, 3%), and superficial wound infection (N = 1). Fifty-one patients underwent 68 reinterventions, mainly due to pulmonary restenosis (PS) (N = 57). ToF correction at age <2 months and double outlet or double-chambered right ventricle variants of the ToF spectrum were independent predictors for reintervention. Patients undergoing valve-sparing ToF correction had a significant longer PR-free survival than those with a transannular patch (8.5 [95% confidence interval 6.8-10.3] years vs 1.1 [95% confidence interval 0.8-1.5] years; P < 0.001). Overall mortality was 2.8%; mortality rates were higher in premature/dysmature newborns (0.7% vs 9.5%; P < 0.001). Although the 15-year outcome of the transatrial-transpulmonary approach in terms of postoperative complications and mortality rates is excellent, the high incidence of moderate and severe PR is worrisome. Valve-sparing surgery was associated with a substantially lower incidence of PR, yet was surgically not possible in the majority of patients.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Obstrução do Fluxo Ventricular Externo/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/mortalidade , Estenose da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/mortalidade , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/mortalidade , Obstrução do Fluxo Ventricular Externo/fisiopatologia
8.
J Thorac Cardiovasc Surg ; 158(1): 99-107.e2, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30527716

RESUMO

OBJECTIVE: Carcinoid heart disease is characterized by tricuspid valve regurgitation and varying degrees of pulmonary valve regurgitation or stenosis. Valve replacement procedures may be complicated by systemic effects of carcinoid syndrome, as well as hepatic dysfunction and right heart failure. This study was performed to identify factors that might be associated with improving early mortality rates and late outcomes. METHODS: Between November 1985 and January 2018, 240 adult patients underwent surgery for carcinoid heart disease at the Mayo Clinic. We analyzed the association of multiple clinical and echocardiographic variables on early mortality and late survival. RESULTS: The median (interquartile range) age of patients was 63 years (55-69), and 117 patients (49%) were male. Before operation, 157 patients (70%) had New York Heart Association class III or IV limitation. Somatostatin analogs were used in 221 patients (92%), and long-acting somatostatins were used in 130 patients (54%). Loop diuretic therapy was used preoperatively in 125 patients (52%). Early mortality rate was 29% (9/22) between 1985 and 1994, but decreased to 7% (6/81) during 1995 to 2004, and to 5% (7/128) from 2005 onward. Overall survival estimates at 1, 3, and 5 years were 69%, 48%, and 34%, respectively. Older age, advanced New York Heart Association class, and a nonlinear effect of creatinine were independently associated with overall mortality. CONCLUSIONS: Valve replacement for carcinoid heart disease has acceptable short-term mortality, and early risk has decreased in the current era. Earlier intervention may improve overall survival.


Assuntos
Doença Cardíaca Carcinoide/complicações , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/cirurgia , Insuficiência da Valva Tricúspide/cirurgia , Idoso , Doença Cardíaca Carcinoide/mortalidade , Doença Cardíaca Carcinoide/fisiopatologia , Bases de Dados Factuais , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/etiologia , Estenose da Valva Pulmonar/mortalidade , Estenose da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/mortalidade , Insuficiência da Valva Tricúspide/fisiopatologia
9.
JACC Cardiovasc Interv ; 11(19): 1920-1929, 2018 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-30286853

RESUMO

OBJECTIVES: This study provides the 3-year follow-up results of the COMPASSION (Congenital Multicenter Trial of Pulmonic Valve Regurgitation Studying the SAPIEN Transcatheter Heart Valve) trial. Patients with moderate to severe pulmonary regurgitation and/or right ventricular outflow tract conduit obstruction were implanted with the SAPIEN transcatheter heart valve (THV). BACKGROUND: Early safety and efficacy of the Edwards SAPIEN THV in the pulmonary position have been established through a multicenter clinical trial. METHODS: Eligible patients were included if body weight was >35 kg and in situ conduit diameter was ≥16 and ≤24 mm. Adverse events were adjudicated by an independent clinical events committee. Three-year clinical and echocardiographic outcomes were evaluated in these patients. RESULTS: Fifty-seven of the 63 eligible patients were accounted for at the 3-year follow-up visit from a total of 69 implantations in 81 enrolled patients. THV implantation was indicated for pulmonary stenosis (7.6%), regurgitation (12.7%), or both (79.7%). Twenty-two patients (27.8%) underwent implantation of 26-mm valves, and 47 patients received 23-mm valves. Functional improvement in New York Heart Association functional class was observed in 93.5% of patients. Mean peak conduit gradient decreased from 37.5 ± 25.4 to 17.8 ± 12.4 mm Hg (p < 0.001), and mean right ventricular systolic pressure decreased from 59.6 ± 17.7 to 42.9 ± 13.4 mm Hg (p < 0.001). Pulmonary regurgitation was mild or less in 91.1% of patients. Freedom from all-cause mortality at 3 years was 98.4%. Freedom from reintervention was 93.7% and from endocarditis was 97.1% at 3 years. There were no observed stent fractures. CONCLUSIONS: Transcatheter pulmonary valve replacement using the Edwards SAPIEN THV demonstrates excellent valve function and clinical outcomes at 3-year follow-up.


Assuntos
Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Obstrução do Fluxo Ventricular Externo/cirurgia , Adolescente , Adulto , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Criança , Ensaios de Uso Compassivo , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/mortalidade , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Adulto Jovem
10.
JACC Cardiovasc Interv ; 11(19): 1909-1916, 2018 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-30219326

RESUMO

OBJECTIVES: The aim of this study was to describe and analyze data from patients treated in France with the Edwards SAPIEN transcatheter heart valve (Edwards Lifesciences LLC, Irvine, California) in the pulmonary position. BACKGROUND: The Edwards SAPIEN valve has recently been introduced for percutaneous pulmonary valve implantation (PPVI). METHODS: From April 2011 to May 2017, 71 patients undergoing PPVI were consecutively included. RESULTS: The median age at PPVI was 26.8 years (range 12.8 to 70.1 years). Primary underlying diagnoses were conotruncal malformations (common arterial trunk, tetralogy of Fallot and variants; n = 45), Ross procedure (n = 18), and other diagnoses (n = 8). PPVI indication was pure stenosis in 33.8% of patients, pure regurgitation in 28.1%, and mixed lesions in 38.1%. PPVI was successfully implemented in 68 patients (95.8%). Pre-stenting of the right ventricular outflow tract was performed in 70 patients (98.6%). Early major complications occurred in 4 subjects (5.6%), including 1 death, 1 coronary compression, and 2 pulmonary valve embolizations. Three of the 4 major complications occurred in the first 15 operated patients. No significant regurgitation was recorded after the procedure. Transpulmonary gradient was significantly reduced from 34.5 to 10.5 mm Hg (p < 0.0001). No patient died during a 1-month follow-up period. At 1-year follow-up, the death rate was 2.9%, and 3 patients had undergone surgical reintervention (44%). CONCLUSIONS: Early results with the Edwards SAPIEN valve in the pulmonary position demonstrate an ongoing high rate of procedural success.


Assuntos
Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Adulto , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Criança , Feminino , França , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Desenho de Prótese , Valva Pulmonar/anormalidades , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/mortalidade , Estenose da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
11.
J Thorac Cardiovasc Surg ; 155(4): 1434-1444, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29395212

RESUMO

BACKGROUND: Patients who undergo the Ross procedure are at increased risk of pulmonary valve (PV) homograft dysfunction. For those who require reintervention on the homograft, transcatheter PV replacement (tPVR) provides a less invasive therapeutic option than surgical PVR (sPVR). We examined the outcomes following tPVR versus sPVR in a cohort of patients who underwent the Ross procedure. METHODS: We performed a retrospective analysis of Ross patients age ≥14 years who underwent tPVR (n = 47) or sPVR (n = 41) at our institution. The patients' clinical and echocardiographic data were reviewed. RESULTS: Baseline parameters, including demographic data and left ventricular and right ventricular (RV) systolic function, were similar in the 2 groups. The mean follow-up was 56 ± 24 months for the tPVR group and 89 ± 46 months for the sPVR group (P < .001). No procedure-related mortality was noted in either group. At 6-year follow-up, there was no significant between-group difference in event-free survival (tPVR, 79% ± 7% vs sPVR, 91% ± 4%; P = .15) or PV reintervention (tPVR, 26% ± 9% vs sPVR, 8% ± 5%; P = .31). PV-associated infective endocarditis (IE) was significantly more common with tPVR (tPVR, 13% vs sPVR, 0%; P = .04), with an annualized rate of 2.98% per patient-year. In addition, there was a trend toward more valve dysfunction following sPVR (sPVR, 67% ± 8% vs tPVR, 35% ± 8%; P = .08). CONCLUSIONS: In Ross patients who require reintervention on the PV homograft, both tPVR and sPVR provide low procedural mortality and comparable midterm outcome with no significant difference in mortality or PV reintervention. However, IE is more common following tPVR. A larger randomized study is needed to determine the role of each procedure in patient management.


Assuntos
Bioprótese , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Falha de Prótese , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Adulto , Aloenxertos , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Ecocardiografia Doppler em Cores , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Humanos , Masculino , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
12.
Heart ; 104(9): 738-744, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29092913

RESUMO

OBJECTIVE: To determine the association of pulmonary valve replacement (PVR) with death and sustained ventricular tachycardia (VT) in patients with repaired tetralogy of Fallot (rTOF). METHODS: Subjects with rTOF and cardiac magnetic resonance from an international registry were included. A PVR propensity score was created to adjust for baseline differences. PVR consensus criteria were predefined as pulmonary regurgitation >25% and ≥2 of the following criteria: right ventricular (RV) end-diastolic volume >160 mL/m2, RV end-systolic volume >80 mL/m2, RV ejection fraction (EF) <47%, left ventricular EF <55% and QRS duration >160 ms. The primary outcome included (aborted) death and sustained VT. The secondary outcome included heart failure, non-sustained VT and sustained supraventricular tachycardia. RESULTS: In 977 rTOF subjects (age 26±15 years, 45% PVR, follow-up 5.3±3.1 years), the primary and secondary outcomes occurred in 41 and 88 subjects, respectively. The HR for subjects with versus without PVR (time-varying covariate) was 0.65 (95% CI 0.31 to 1.36; P=0.25) for the primary outcome and 1.43 (95% CI 0.83 to 2.46; P=0.19) for the secondary outcome after adjusting for propensity and other factors. In subjects (n=426) not meeting consensus criteria, the HR for subjects with (n=132) versus without (n=294) PVR was 2.53 (95% CI 0.79 to 8.06; P=0.12) for the primary outcome and 2.31 (95% CI 1.07 to 4.97; P=0.03) for the secondary outcome. CONCLUSION: In this large multicentre rTOF cohort, PVR was not associated with a reduced rate of death and sustained VT at an average follow-up of 5.3 years. Additionally, there were more events after PVR compared with no PVR in subjects not meeting consensus criteria.


Assuntos
Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Taquicardia Ventricular/etiologia , Tetralogia de Fallot/cirurgia , Adulto , Feminino , Próteses Valvulares Cardíacas , Humanos , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Pontuação de Propensão , Insuficiência da Valva Pulmonar/mortalidade , Taquicardia Ventricular/mortalidade , Tetralogia de Fallot/mortalidade , Fatores de Tempo , Resultado do Tratamento
13.
Circ Cardiovasc Interv ; 10(9)2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28851718

RESUMO

BACKGROUND: Transcatheter pulmonary valve replacement (TPVR) is an established therapy for dysfunctional right ventricular (RV) outflow tract conduits. TPVR in patients with congenitally corrected transposition of the great arteries, subpulmonary left ventricle, and left ventricular outflow tract (LVOT) conduit dysfunction has not been studied. Unique anatomic and physiological aspects of this population may contribute to distinct risks and outcomes. METHODS AND RESULTS: Across 10 US centers, 27 patients with a dysfunctional LVOT conduit were evaluated in the catheterization laboratory between December 2008 and August 2015 with the intent to perform TPVR. TPVR was successful in 23 patients (85%). Five serious adverse events occurred in 4 cases (15%), including pulmonary hemorrhage, hypotension requiring vasoactive support, conduit disruption requiring covered stent (n=2), and acute RV dysfunction with flash pulmonary edema. After TPVR, the LVOT peak systolic ejection gradient decreased from median of 35 to 17 mm Hg (P<0.001); pulmonary insufficiency was trivial/none in all but 1 patient, where it was mild. Worsening of systemic RV dysfunction or tricuspid regurgitation was seen in 12 patients (57%) and was associated with a significantly lower post-TPVR LVOT peak systolic ejection gradient (median 17 versus 21 mm Hg; P=0.02) and higher post-TPVR RV sphericity index (median 0.88 versus 0.52; P=0.004). Post-TPVR, there were 2 late deaths because of RV failure and 1 cardiac transplantation because of progressive RV dysfunction and tricuspid regurgitation. CONCLUSIONS: TPVR in dysfunctional LVOT conduits is feasible but associated with an important rate of TPV nonimplantation and procedural serious adverse events. Worsening systemic RV function and tricuspid regurgitation may develop after LVOT TPVR.


Assuntos
Bioprótese , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Ventrículos do Coração/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Transposição dos Grandes Vasos/cirurgia , Função Ventricular Esquerda , Adolescente , Adulto , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Criança , Transposição das Grandes Artérias Corrigida Congenitamente , Estudos de Viabilidade , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Ventrículos do Coração/anormalidades , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Transposição dos Grandes Vasos/diagnóstico por imagem , Transposição dos Grandes Vasos/mortalidade , Transposição dos Grandes Vasos/fisiopatologia , Resultado do Tratamento , Estados Unidos , Função Ventricular Direita , Adulto Jovem
14.
Heart ; 103(18): 1455-1460, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28351873

RESUMO

OBJECTIVES: To identify predictors of morbidity and mortality in patients undergoing either transcatheter pulmonary valve replacement (TPVR) or surgical pulmonary valve replacement (SPVR) in an effort to quantify any early benefit of TPVR over SPVR. METHODS: Using a risk-adjusted propensity score model, we compare early major morbidity and mortality between patients undergoing SPVR and TPVR at our institution between January 2006 and January 2014. RESULTS: 145 patients in the SPVR cohort and 78 patients in the TPVR cohort were included. Primary pulmonary regurgitation was more common in the SPVR group (76.6% vs 23.1%, p<0.001) and primary pulmonary stenosis was more common in the TPVR group (9.7% vs 44.9%, p< 0.001). In unadjusted analysis, major morbidity and mortality occurred in 11.7% of SPVR patients versus 3.8% of TPVR patients (p=0.04). However, following risk adjustment and inclusion of a propensity score, no significant difference was seen between the two modalities. A larger right ventricular end-diastolic dimension (RVEDVI) was the only preoperative variable associated with the primary end point (OR 1.013/10 mL/m2 increase, p=0.03). Hospital length of stay was significantly longer in patients undergoing SPVR (6.9±1.0 days SPVR vs 1.2±0.3 days TPVR, p<0.0001), with similar hospital costs between groups (mean: US$44 660±5071 SPVR vs US$48 355±1000 TPVR, p=0.7). CONCLUSIONS: Following risk adjustment, no significant differences were observed between SPVR and TPVR strategies. TPVR was associated with a shorter hospitalisation; however, total hospitalisation costs were similar between groups.


Assuntos
Implante de Prótese de Valva Cardíaca/métodos , Complicações Pós-Operatórias/epidemiologia , Estenose da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adulto , Cateterismo Cardíaco/métodos , Ecocardiografia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Imagem Cinética por Ressonância Magnética , Masculino , Pontuação de Propensão , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/diagnóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
Heart ; 102(19): 1520-6, 2016 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-27329296

RESUMO

Residual right ventricular outflow tract and pulmonary valve disease is common in adults with repaired tetralogy of Fallot. Chronic severe pulmonary regurgitation as a result of surgical repair can lead to myriad complications including right ventricular dysfunction, decreased exercise tolerance, right heart failure and symptomatic arrhythmias. The aim of restoring pulmonary valve integrity is to preserve right ventricular size and function with the intent of mitigating the development of symptoms and poor long-term outcomes. Right ventricular size thresholds by cardiac MRI have emerged beyond which reverse right ventricular remodelling after pulmonary valve replacement is less likely. Though pulmonary valve replacement has been shown to improve right ventricular dimensions and symptoms, no consistent improvement in right ventricular ejection fraction or objective measures of exercise capacity have been demonstrated. Furthermore, there are no long-term studies showing that normalisation of right ventricular size results in improved clinical outcomes. New transcatheter techniques of percutaneous pulmonary valve replacement have emerged with good short-term and mid-term outcomes, further adding to the complexity in determining 'when' and 'how' right ventricular outflow tract and pulmonary valve intervention should occur. With improved survival of these patients, the trend towards earlier pulmonary valve replacement at smaller right ventricular size and rapidly evolving transcatheter pulmonary valve techniques, the clinician must balance the goals of preserving right ventricular size and function in an attempt to prevent untoward outcomes with risks of multiple interventions in a patient's lifetime.


Assuntos
Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Tetralogia de Fallot/terapia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Doença Crônica , Tolerância ao Exercício , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Seleção de Pacientes , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Tetralogia de Fallot/mortalidade , Tetralogia de Fallot/fisiopatologia , Tetralogia de Fallot/cirurgia , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Função Ventricular Direita
16.
Ann Thorac Surg ; 102(2): 602-7, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27154149

RESUMO

BACKGROUND: The optimal choice for pulmonary valve replacement (PVR) remains controversial. This study hypothesized that xenografts used for PVR would result in prolonged long-term survival and freedom from reoperation. METHODS: Children and adults with congenital heart disease requiring PVR using a xenograft from 1980 to 1985 were reviewed. In all cases, the xenograft valve was either sewn or manufactured into a Dacron conduit, and the conduit was sewn to the pulmonary artery bifurcation. Clinical data were analyzed, and survival and freedom from reoperation were determined using Kaplan-Meier analysis. RESULTS: Twenty-four patients received a xenograft for PVR at 14.6 ± 5.6 years. Conduit size ranged from 21 to 27 mm. Most patients received a Carpentier-Edwards valved conduit (n = 17), followed by a Hancock valved conduit (n = 5) and an Ionescu-Shiley valve sewn into a Dacron graft (n = 2). No perioperative deaths occurred. Reoperation was required mainly for pulmonary stenosis (72.7%), followed by pulmonary insufficiency (18.2%), or both stenosis and insufficiency (9%). Freedom from reoperation was 90%, 56%, 43%, and 14% at 10, 20, 25, and 30 years, respectively. At most recent follow-up the was only death, which was related to severe biventricular failure 25 years after conduit implant. CONCLUSIONS: PVR using a xenograft valved conduit results in prolonged freedom from reoperation and excellent long-term survival. These data, which provide long-term follow-up information on xenograft valves after PVR.


Assuntos
Bioprótese , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/mortalidade , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Cateterismo Cardíaco , Criança , Ecocardiografia , Feminino , Seguimentos , Xenoenxertos , Humanos , Masculino , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/mortalidade , Reoperação , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estudos de Tempo e Movimento , Estados Unidos/epidemiologia
17.
Semin Thorac Cardiovasc Surg ; 28(2): 463-470, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28043462

RESUMO

In patients with tetralogy of Fallot (TOF), pulmonary atresia (PA), and other congenital right ventricular outflow tract (RVOT) malformations, polytetrafluoroethylene (PTFE) monocusp outflow tract patches (MOTP) relieve obstruction and provide pulmonary valve competence. The purpose of this study was to determine whether our PTFE-MOTP was an acceptable short- and mid-term remedy for patients with TOF or PA as assessed by freedom from severe pulmonary regurgitation and freedom from reoperation. From 1994-2014, 171 patients (mean age 1.5 ± 1.5 years; median 1.1 years) with TOF or PA underwent initial right ventricular outflow tract (RVOT) reconstruction with a PTFE-MOTP. Patients were studied intraoperatively and serially postoperatively using echocardiography and cardiac magnetic resonance imaging (CMR) to determine pulmonary valve dysfunction defined as a peak gradient >40mmHg or valve regurgitation>moderate. The mean follow-up duration was 10.9 ± 5.8 years (range: 1 month-20 years). There were 5 late deaths and 1 early death. There was a significant difference between the preoperative and postoperative peak RVOT gradients (74.0 vs 25.2mmHg). Of the 171 patients, 25 were lost to follow-up, and 42 have required replacement of their monocusp valves 10.1 ± 5.0 years (range: 5 months-19 years) after original monocusp insertion. At 10-year follow-up, severe pulmonary regurgitation was seen in less than 25% of patients, and severe pulmonary stenosis was seen in less than 10% of patients. Since 2007, CMR was used in 44 patients to characterize cardiac function in patients under consideration for PTFE-MOTP replacement. The average right ventricular-to-left ventricular (RV/LV) ratio on CMR was 1.7 ± 0.5 in these patients. CMR also showed that RV ejection fraction (52 ± 9%) and left ventricular ejection fraction (58 ± 7%) were both preserved in most patients. The PTFE-MOTP is an excellent short-term and mid-term option for initial RVOT reconstruction, particularly in children with TOF with nonsalvageable pulmonary valve or PA-ventricular septal defect.


Assuntos
Defeitos dos Septos Cardíacos/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Politetrafluoretileno , Atresia Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Obstrução do Fluxo Ventricular Externo/cirurgia , Criança , Pré-Escolar , Ecocardiografia Doppler , Feminino , Defeitos dos Septos Cardíacos/diagnóstico por imagem , Defeitos dos Septos Cardíacos/mortalidade , Defeitos dos Septos Cardíacos/fisiopatologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Lactente , Estimativa de Kaplan-Meier , Imageamento por Ressonância Magnética , Masculino , Desenho de Prótese , Falha de Prótese , Atresia Pulmonar/diagnóstico por imagem , Atresia Pulmonar/mortalidade , Atresia Pulmonar/fisiopatologia , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/mortalidade , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda , Função Ventricular Direita , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/mortalidade , Obstrução do Fluxo Ventricular Externo/fisiopatologia
18.
Semin Thorac Cardiovasc Surg ; 27(3): 310-8, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26708375

RESUMO

The purpose of this study was to assess the outcomes of bioprosthetic pulmonary valve replacement (PVR) in children. This is a retrospective review of all bioprosthetic PVR in children (≤ 20-year old) between 1992 and 2013 at a single institution. Most outcomes studied included pulmonary valve reintervention and bioprosthetic valve function. A total of 136 bioprosthetic PVRs were identified for 123 patients. The median age and body weight at the time of operation were 13.2 years and 48.4 kg. There were 1 early death and 3 late deaths during the median follow-up of 7.2 years (0-22.0 years). The actuarial transplant-free survival was 97.6% at 10 years. There were 43 bioprosthesis reinterventions with 29 reoperations and 14 catheter-based interventions. The freedom from bioprosthesis reintervention was 89.6% and 55.0% at 5 and 10 years, respectively. Echocardiographic bioprosthesis dysfunction (≥ moderate bioprosthesis insufficiency, ≥ 50 mmHg peak gradient through bioprosthesis, or bioprosthesis endocarditis with vegetation) was found in 57 bioprostheses. The freedom from bioprosthesis dysfunction was 74.0% and 32.8% at 5 and 10 years, respectively. Results from the Cox proportional hazards models showed that age had significant association with freedom from bioprosthesis reintervention and freedom from bioprosthesis dysfunction (P < 0.001 and P = 0.03), whereas bioprosthesis type had nonsignificant association with freedom from bioprosthesis dysfunction (P = 0.068). Bioprosthetic PVR in children had excellent early outcomes but rapidly deteriorating midterm outcomes. Careful and close follow-up are necessary for children with bioprosthesis in the pulmonary position.


Assuntos
Bioprótese , Previsões , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/epidemiologia , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Arkansas/epidemiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Incidência , Lactente , Masculino , Desenho de Prótese , Insuficiência da Valva Pulmonar/mortalidade , Reoperação , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Adulto Jovem
19.
Am J Cardiol ; 115(1): 118-24, 2015 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-25456860

RESUMO

Operative correction of tetralogy of Fallot frequently results in pulmonary insufficiency and chronic volume overload, which have been linked to increased risk for adverse outcomes. No consensus recommendations for the timing of pulmonary valve replacement (PVR) exist. The aim of this study was to examine the pattern of PVR in the United States from 2004 to 2012. The Pediatric Health Information Systems database was used to perform an observational study of children and adults ≥10 years of age with diagnoses of tetralogy of Fallot who underwent PVR at 35 centers in the United States from 2004 and 2012, to assess the rate of PVR and the age at which is performed. Mixed-effects multivariate regression was used to account for patient-level covariates and center-level covariance. Additional analyses assessed for trends in cost, hospital length of stay (LOS), intensive care unit LOS, and in-hospital mortality over the study period. In total, 799 subjects at 35 centers underwent PVR over the study period. The number of PVRs performed per year increased significantly over the study period. There was significant between-center heterogeneity in age at PVR (p <0.001). Age at PVR, intensive care unit LOS, hospital LOS, and cost did not change over the study period. In conclusion, PVR in patients with tetralogy of Fallot is being performed more frequently, without an accompanying change in the age at PVR or other measurable outcomes. There is significant variability in the age at which PVR is performed among centers across the United States. This highlights the need for additional research guiding the optimal timing of PVR.


Assuntos
Implante de Prótese de Valva Cardíaca/tendências , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Criança , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência da Valva Pulmonar/complicações , Insuficiência da Valva Pulmonar/mortalidade , Tetralogia de Fallot/complicações , Tetralogia de Fallot/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
20.
Circ Arrhythm Electrophysiol ; 8(1): 110-6, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25416756

RESUMO

BACKGROUND: Most patients with repaired tetralogy of Fallot require pulmonary valve replacement (PVR), but the evaluation for and management of ventricular arrhythmia remain unclear. This study is aimed at clarifying the optimal approach to this potentially life-threatening issue at the time of PVR. METHODS AND RESULTS: A retrospective analysis was performed on 205 patients with repaired tetralogy of Fallot undergoing PVR at our institution between 1988 and 2010. Median age was 32.9 (range, 25.6) years. Previous ventricular tachycardia occurred in 16 patients (8%) and 37 (16%) had left ventricular dysfunction, defined as left ventricular ejection fraction <50%. Surgical right ventricular outflow tract cryoablation was performed in 22 patients (10.7%). The primary outcome was a combined event including ventricular tachycardia, out-of-hospital cardiac arrest, appropriate implantable cardioverter defibrillator therapy, and sudden cardiac death. Freedom from the combined event at 5, 10, and 15 years was 95%, 90%, and 79%, respectively. In the first year after PVR, 2 events occurred. Conversely, in the 22 patients who underwent surgical cryoablation, a single event occurred 7 years after PVR. A history of ventricular tachycardia and left ventricular dysfunction was associated with higher risk for the combined event (hazard ratio, 4.7; P=0.004 and hazard ratio, 0.8; P=0.02, respectively). CONCLUSIONS: Patients with repaired tetralogy of Fallot undergoing PVR with history of ventricular tachycardia or left ventricular dysfunction appear to be associated with a higher risk of arrhythmic events after operation. Events in the first year after PVR are rare, and in select high-risk patients, surgical cryoablation does not seem to increase arrhythmic events and may be protective.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Taquicardia Ventricular/etiologia , Tetralogia de Fallot/cirurgia , Adulto , Procedimentos Cirúrgicos Cardíacos/mortalidade , Criança , Pré-Escolar , Criocirurgia , Morte Súbita Cardíaca/etiologia , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/etiologia , Parada Cardíaca Extra-Hospitalar/mortalidade , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/mortalidade , Insuficiência da Valva Pulmonar/fisiopatologia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Volume Sistólico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/cirurgia , Tetralogia de Fallot/diagnóstico , Tetralogia de Fallot/mortalidade , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Adulto Jovem
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