Search

Background: Survival prospects for adults with repaired tetralogy of Fallot (TOF) are now excellent. Attention should therefore shift to assessing and improving functional health status and quality of life. We aimed to assess late functional health status of adults surviving TOF repair by matched comparison to their healthy siblings. Methods: All 1,693 TOF repairs performed at our institution between 1946 and 1990 were reviewed. A matched comparison was undertaken whereby presumed survivors and their healthy sibling were contacted and asked to complete the Ontario Health Survey 1990 and the 36-Item Short Form Health Survey (SF-36) questionnaire. Results: Both questionnaires were completed by 224 adult survivors and their sibling closest in age. Adults with repaired TOF had lower scores for self-perceived general health status ( p < 0.001), were less likely to rate their health as good or excellent ( p < 0.001), and had lower SF-36 scores for physical functioning and general health ( p = 0.001) than their siblings. However, patients reported similar satisfaction with their lives, similar levels of social participation and support, and were as likely to be in long-term partnerships. Worse physical and mental health scores were associated with older age at surgery and at time of questionnaire completion and recent requirement for noncardiac medication. Conclusions: Although reporting lower functional health status then their siblings, quality of life and life satisfaction for adults who underwent surgery for TOF during childhood is comparable to that of their siblings without heart defects. Follow-up of younger adults is required to understand current health outcomes attributable to improvements in the management of TOF. [ABSTRACT FROM AUTHOR]

Background: Percutaneous closure of patent foramen ovale/atrial septal defect (PFO/ASD) is an increasingly common procedure perceived as having minimal risk. There are no population-based estimates of in-hospital adverse event rates of percutaneous PFO/ASD closure. Methods: We used nationally representative data from the 2001-2005 Nationwide Inpatient Sample to identify patients ≥20 years old admitted to an acute care hospital with an International Classification of Diseases, Ninth Revision code designating percutaneous PFO/ASD closure on the first or second hospital day. Variables analyzed included age, sex, number of comorbidities, year, same-day use of intracardiac or other echocardiography, same-day left heart catheterization, hospital size and teaching status, PFO/ASD procedural volume, and coronary intervention volume. Outcomes of interest included length of stay, charges, and adverse events. Results: The study included 2,555 (weighted to United States population: 12,544 ± 1,987) PFO/ASD closure procedures. Mean age was 52.0 ± 0.4 years, and 57.3% ± 1.0% were women. Annual hospital volume averaged 40.8 ± 7.7 procedures (range, 1-114). Overall, 8.2 ± 0.8% of admissions involved an adverse event. Older patients and those with comorbidities were more likely to sustain adverse events. Use of intracardiac echocardiography was associated with fewer adverse events. The risk of adverse events was inversely proportional to annual hospital volume (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86-0.96, per 10 procedures), even after limiting the analysis to hospitals performing ≥10 procedures annually (OR 0.91, 95% CI 0.85-0.98). Adverse events were more frequent at hospitals in the lowest volume quintile as compared with the highest volume quintile (13.3% vs 5.4%, OR 2.42, 95% CI 1.55-3.78). Conclusions: The risk of adverse events of percutaneous PFO/ASD closure is inversely correlated with hospital volume. This relationship applies even to hospitals meeting the current guidelines, performing ≥10 procedures annually. [Copyright &y& Elsevier]

Background: Late cardiac outcomes in women with aortic stenosis (AS) who have undergone pregnancy have not been well defined. Methods: We examined 51 consecutive women with congenital AS who underwent 70 pregnancies. Late cardiac events (pulmonary edema, cardiac arrhythmia, cardiac death, cardiac interventions >1 year since baseline evaluation) were the outcome of interest. The frequency of late cardiac events in the postpregnant group were compared to age- and lesion-matched women with congenital AS who have never been pregnant. Results: During the follow-up period (6 + 4 years), 43% of women underwent cardiac interventions which comprised all late cardiac events. Independent baseline predictors of late cardiac events were (1) moderate or severe AS (hazard ratio = 4.5, P = .045) and (2) New York Functional Class II (hazard ratio = 4.6, P = .014). When outcomes in 26 women from the postpregnant group were compared to 26 age- and lesion-matched women who have never been pregnant, the postpregnant group had a higher late cardiac event rate than the never-pregnant group (31% vs 0%, P = .021). Conclusion: Women with moderate or severe AS and symptomatic during pregnancy are at high likelihood of requiring cardiac interventions late after pregnancy. Women with congenital AS who have undergone pregnancy have a higher frequency of late cardiac events compared to those who have never been pregnant. Late cardiac outcomes after pregnancy should be considered in the counseling of women with AS who are contemplating pregnancy. [Copyright &y& Elsevier]

Objectives: To examine the results of aortic valve sparing for aortic root aneurysm. Methods: Two hundred twenty consecutive patients who had aortic valve sparing for aortic root aneurysm were prospectively studied with annual clinical assessments and echocardiography. Their mean age was 46 ± 15 years, 40% had Marfan syndrome, 17% had aortic dissection, and 7% had bicuspid aortic valve. Reimplantation of the aortic valve was performed in 167 patients and remodeling of the aortic root in 53. Aortic cusp repair was performed in 80 patients, and reinforcement of the free margin of one of the cusps with a fine polytetrafluoroethylene (Gore-Tex) suture in 48. The mean follow-up was 5.2 ± 3.7 years and it was complete. Results: There were 3 operative and 13 late deaths. Patients’ survival at 10 years was 88% ± 3%. Age older than 65 years, advanced functional class, and ejection fraction less than 40% were independent predictors of death. Moderate aortic insufficiency developed in 7 patients and severe insufficiency in 6. Freedom from moderate or severe aortic insufficiency at 10 years was 85% ± 5% for all patients, but it was 94% ± 4% after reimplantation and 75% ± 10% after remodeling (P = .04). Five patients required aortic valve replacement; the freedom from valve replacement at 10 years was 95% ± 3%. One case of endocarditis developed 11 years postoperatively. At the latest follow-up, 88% of the patients were in functional class I, and 10% were in class II. Conclusions: Aortic valve-sparing operation is associated with low rates of valve-related complications. The probability of late aortic insufficiency was lower after the reimplantation procedure than after remodeling in our experience. [Copyright &y& Elsevier]

Background: We evaluated outcomes in patients requiring late reoperation after tetralogy of Fallot (ToF) repair to identify risk factors for arrhythmia and determine whether arrhythmia surgery decreased the risk of subsequent death or recurrent arrhythmia. Methods: Review was performed of all ToF patients from 1969 to 2005 undergoing reoperation late (>1 year) after repair. Patients with associated lesions, except pulmonary atresia, were included. A total of 249 patients had 278 reoperations. Procedures at initial reoperation included pulmonary valve replacement (PVR) in 217, ablation in 63, and tricuspid valve repair/replacement in 46. Pre-reoperative arrhythmias were present in 75, including supraventricular tachycardia (SVT) in 31, ventricular tachycardia (VT) in 34, and SVT+VT in 10 patients. Results: Median age at reoperation was 23 years (range, 1 to 63). Ten-year survival after reoperation was 93%, and was independent of arrhythmia status (p = 0.86). Arrhythmia patients were characterized by older age at initial repair and at late reoperation, tricuspid and pulmonary regurgitation, and longer QRS duration (p < 0.001 for all). Risk factors for post-reoperative recurrent arrhythmia were longer QRS duration and not having PVR. Longer QRS duration, with a cut-point of more than 160 msec, was associated with recurrent SVT (p = 0.004). Supraventricular tachycardia ablation improved arrhythmia-free survival (75% versus 33%, p < 0.001) but VT ablation did not (96% versus 95%, p = 0.50). However, recurrent VT occurred in only 3 patients (10%). Conclusions: Late mortality in patients undergoing reoperation after ToF repair is not impacted by pre-reoperative arrhythmia. Prolongation of QRS identifies patients at risk for recurrent VT and SVT, but recurrent VT is uncommon. Early PVR, and surgical ablation in patients with SVT, decreases arrhythmic risk. [Copyright &y& Elsevier]

: BackgroundPalliative atrial switch (PAS) procedures that reroute pulmonary and systemic venous drainage and leave a ventricular septal defect (VSD) open have been used in the treatment of deeply cyanotic patients who have severe pulmonary vascular obstructive disease (PVOD). Palliative atrial switch is beneficial for patients with transposition of the great arteries or other complex lesions with VSD who show higher arterial oxygen saturation in the pulmonary artery than in the aorta (transposition hemodynamics/unfavorable streaming). We reviewed the early and late results of PAS (Mustard, n = 25; Senning, n = 3) in patients at two institutions.: MethodsBetween April 1965 and March 2000, PAS was performed in 28 cyanotic patients (18 male, 10 female). Median age was 10 years (range, 1 to 27). Mean preoperative pulmonary arterial pressure was 68 mm Hg (range, 30 to 121 mm Hg). Mean systemic arterial oxygen saturation was 65% (range, 47% to 80%). The majority of patients (95%) were in New York Heart Association (NYHA) functional class III or IV preoperatively.: ResultsOverall early mortality was 21%; for patients after 1972 (n = 23), the early mortality was 8.7%. Mean follow-up was 8.3 years (maximum 20). Mean postoperative systemic arterial oxygen saturation was increased significantly to 88% (p < 0.0001). Late survival for early survivors at 5, 10, and 15 years respectively was 84% (59%, 97%), 64% (39%, 88%), and 54% (15%, 72%). The NYHA functional class was significantly improved; 94% of late survivors (n = 17) were in functional class I or II (p = 0.002).: ConclusionsThe PAS operation significantly improves systemic arterial oxygen saturation and quality of life in selected patients with transposition hemodynamics, VSD, and severe PVOD. [Copyright &y& Elsevier]

Background: A study was conducted to determine the long-term results of aortic valve reimplantation to treat aortic root aneurysm. Methods: Prospective follow-up with clinical assessments and echocardiography was done of 167 consecutive patients who had reimplantation of the aortic valve as treatment of aortic root aneurysm. Their mean age was 45 ± 15 years, 78% were men, 38% had Marfan syndrome, 14% had aortic dissection, and 7% had bicuspid aortic valve. The aortic valve was reimplanted into a straight Dacron (Dupont, Wilmington, DE) tube in 89 patients and in a Dacron tube with creation of neoaortic sinuses in 78. Aortic cusp repair was performed in 66 patients, and the free margin was reinforced with a fine Gore-Tex suture (W.L. Gore & Assoc, Flagstaff, AZ) in 36. The mean follow-up was 5.1 ± 3.8 years and was 100% complete. Results: There were two operative and six late deaths. Survival at 10 years was 92% ± 3%. Moderate aortic insufficiency developed in 3 patients, and severe developed in 2. Freedom from moderate or severe aortic insufficiency was 94% ± 4% at 10 years. Two patients required aortic valve replacement. Freedom from aortic valve replacement was 95% ± 4% at 10 years. At the latest follow-up, 90% of the patients were in New York Heart Association functional class I and 10% were in class II. Conclusions: Reimplantation of the aortic valve to treat patients with aortic root aneurysm is associated with excellent long-term survival and low rates of valve-related complications. Reimplantation of the aortic valve is a durable type of aortic valve repair. [Copyright &y& Elsevier]

: BackgroundAortic valve-sparing operations are an alternative to aortic root replacement in patients with aortic root aneurysms, or aortic valve replacement and supracoronary replacement of the ascending aorta in patients with ascending aorta aneurysms and dilated sinotubular junctions with consequent aortic insufficiency.: MethodsFrom 1988 to 2001, 230 patients underwent aortic valve-sparing operations for aortic root aneurysms (151 patients) or ascending aortic aneurysms with aortic insufficiency (79 patients). Two types of aortic valve-sparing operations were performed in patients with aortic root aneurysms: reimplantation of the aortic valve and remodeling of the aortic root. Mean follow-up was 3.8 ± 2.8 years.: ResultsPatients with aortic root aneurysms were younger, had less severe aortic insufficiency, less extensive vascular disease, and better left ventricular function than patients with ascending aorta aneurysms. The 8-year survival was 83% ± 5% for the first group and 36% ± 14% for the second. The freedom from aortic valve reoperation at 8 years was 99% ± 1% for the first group and 97% ± 2% for the second. In patients who had aortic root aneurysms, 3 developed severe aortic insufficiency (AI), and 15 developed moderate AI, for an 8-year freedom from significant AI of 67% ± 7%. But freedom from AI was 90% ± 3% after the technique of reimplantation, and 55% ± 6% after the technique of remodeling (p = 0.02). In patients with ascending aortic aneurysms, the freedom from AI greater than 2+ at 8 years was 67% ± 11%.: ConclusionsThe long-term results of aortic valve sparing for aortic root aneurysms are excellent, and reimplantation of the aortic valve may provide a more stable repair of the aortic valve than remodeling of the aortic root. [Copyright &y& Elsevier]