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Background: Patients with an open ventricular septal defect (VSD) after repair of pulmonary atresia (PA), VSD, and major aortopulmonary collaterals (MAPCAs) are the most vulnerable subgroup. We analyzed the impact of concomitant versus delayed VSD closure on survival and intermediate-term right ventricular (RV) function., Methods: Between October 1996 and February 2017, 96 patients underwent a pulmonary flow study-aided repair of PA/VSD/MAPCAs. For patients who underwent either concomitant or delayed intracardiac repair, echocardiographic RV systolic function was retrospectively calculated to assess (1) RV fractional area change (RVFAC) and (2) two-dimensional RV longitudinal strain (RVLS) of the free wall of the right ventricle. QLAB cardiac analysis software version 10.3 (Philips Medical Systems, Andover, MA) was used for analysis., Results: A total of 64 patients underwent concomitant VSD closure at the time of unifocalization, and 16 patients underwent delayed VSD closure at a median of 2.3 years (range: 3 days to 7.4 years). At a median follow-up of 8.1 years (range: 0.1 to 19.5 years) for the concomitant repair group versus 7.4 years (range: 0.01 to 15.3 years) for the delayed repair group, no differences in RVFAC and RVLS were observed (RVFAC: 41.0% ± 6.2% versus 41.2% ± 7.6%, p = 0.91; RVLS: -18.7 ± 4.3 versus -18.9 ± 4.0, p = 0.87)., Conclusions: Patients (83%) with PA/VSD/MAPCAs underwent complete repair at intermediate-term follow-up with preserved RV function. Delayed VSD closure was accomplished in 50% of the patients initially deemed unsuitable for repair. Delayed VSD closure did not affect survival and did not portend impaired RV systolic function., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to identify predictors of postoperative respiratory failure after surgical tracheoplasty for congenital tracheal stenosis., Methods: Between February 2011 and April 2017, 16 infants underwent congenital tracheal stenosis repair. Preoperative computed tomography evaluation of the trachea and mainstem bronchi was performed. The primary outcome was midterm freedom from postoperative respiratory failure defined as persistent need for mechanical ventilation or surgical tracheobronchial reoperation. Bronchial mismatch, defined as [1 - (smaller bronchus diameter / larger bronchus diameter)] × 100, was analyzed in relation to the primary outcome., Results: Median age was 106 days (range, 1 to 406) and median weight was 5.3 kg (range, 2.6 to 8 kg). Four patients were neonates (25%) and 6 had genetic abnormalities (37.5%). There were no early nor late deaths. Median ventilation time was 5.5 days (range, 3 to 45). Mean follow-up time was 2.2 years (range, 0.1 to 4.5). Four patients with bronchial mismatch greater than 20% had postoperative respiratory failure (p = 0.002). Two of them underwent tracheostomy and were discharged with ventilation home care support. One underwent successful reoperation consisting of bilateral bronchial plasty with autologous cartilage rib grafts, and the other underwent successful right bronchial and tracheal reconstruction. One patient with bilateral bronchial hypoplasia underwent slide tracheoplasty associated with preemptive bilateral bronchial plasty and made a full recovery., Conclusions: Surgical treatment of congenital tracheal stenosis in neonates and infants portends a good outcome. Bronchial mismatch greater than 20% can identify a subset of patients at increased risk for surgical reintervention and chronic respiratory failure. Slide tracheoplasty with preemptive bronchial reconstruction may prevent postoperative respiratory failure., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Acute failure of the Fontan circulation is rare but remains associated with high morbidity and mortality rates. Little is known about the long-term outcome of patients who underwent Fontan takedown to an intermediate palliative circulation and their potential candidacy for redo Fontan completion., Methods: Patients followed up at a single institution who underwent takedown of a Fontan circulation to an intermediate palliative circulation within 2 months of extracardiac Fontan completion were reviewed., Results: Between October 1990 and December 2015, 18 patients underwent Fontan takedown to a superior cavopulmonary connection (with or without an additional shunt) at a median age of 3.3 years (range, 1.8 to 8.0) and median weight of 13.8 kg (range, 8.0 to 27.0 kg). Takedown was required during the Fontan procedure itself in 2 patients, and within the first 2 postoperative months in 16 patients (median time to takedown, 3 days). Seventeen patients survived the post-takedown period and 3 ultimately underwent successful redo Fontan. Four patients required heart transplantation, with 2 deaths. In patients with extended intermediate palliation, median arterial oxygen saturation was 84% (range, 76% to 92%) at a median follow-up of 6.3 years (range, 0.7 to 25.9)., Conclusions: Takedown to a superior cavopulmonary connection is an effective treatment option and, in some patients, acts as a bridge to subsequent redo Fontan completion or heart transplantation. An extended intermediate palliative circulation is tolerated for several years with reasonable oxygen saturation levels at rest. In our experience, an early takedown strategy to a superior cavopulmonary connection is the treatment of choice for acute Fontan failure., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the accuracy of the pulmonary flow study in (1) predicting the feasibility of concomitant intracardiac repair after one-stage unifocalization; and in (2) predicting long-term survival and the onset of right ventricular dysfunction after surgery., Methods: Between October 1996 and July 2015, a flow study was obtained in 95 patients undergoing complete one-stage unifocalization for pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals. The ability to achieve 100% flow (approximately 2.5 L · min -1 · m -2 ) into the pulmonary bed at a mean pressure of 30 mm Hg or less was utilized as an indicator for acceptability of ventricular septal defect closure., Results: Overall survival was 78% ± 6% at 15 years. Sixty-four patients underwent successful one-stage intracardiac repair. The flow study accurately predicted suitability for VSD closure (area under the curve = 0.855). After one-stage ventricular septal defect closure, no difference in survival was observed after stratification according to flow study pressures (25 mm Hg or less versus greater than 25 mm Hg, log rank p = 0.20). At a median follow-up of 7 years, no association was found between flow study pressure and the onset of right ventricular dysfunction (p = 0.21). Overall, the inability to achieve final intracardiac repair was a strong predictor of death (hazard ratio 9.14, 95% confidence interval: 1.98 to 42.07, p < 0.0001)., Conclusions: Suitability for ventricular septal defect closure is reliably defined by the flow study with a cutoff of 30 mm Hg. Flow study pressure values do not affect long-term outcomes. The ability to obtain intracardiac repair (in either one or more stages) is the strongest predictor of survival., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We present the surgical implantation in mitral position of the Edwards Sapien 3 valve for prosthetic valve endocarditis in a severely ill child after multiple valve replacements. The procedure was safely performed and provided adequate hemodynamic results in the short term. This report highlights the excellent potential of Sapien 3 valve for the treatment of mitral valve disease in children with a mitral valve annulus of appropriate size. Of note, the use of the Sapien 3 valve should be considered when a bioprosthesis is required at the time of valve re-replacement., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Persistent left fifth aortic arch is a rare anomaly often associated with aortic coarctation. We report the case of a newborn presenting with signs of duct-dependent aortic coarctation. Echocardiography showed an interrupted fourth aortic arch, persistent left fifth aortic arch associated with aortic coarctation, and a restrictive arterial duct. Arch repair was accomplished using the fifth aortic arch as an in situ flap to enlarge the hypoplastic fourth aortic arch associated with coarctectomy and extended end-to-end anastomosis. We believe that this newly reported surgical approach is safe and effective and allows for adequate enlargement of the entire fourth aortic arch., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Recurrent prosthetic valve endocarditis, especially when characterized by annular abscess and aortic root destruction, remains a surgical challenge. A radical and aggressive surgical treatment is required preventing recurrent infection. Homograft implants are still thought to be the best surgical option, but they are not always available and their use in younger patient remains controversial. We propose an additional anatomical surgical technique, which consists in the implantation of a composite graft in the left ventricular outflow tract, well below the native aortic annulus, and then the direct reimplantation of coronary ostia., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We hypothesized that factors associated with an institution's residual risk unaccounted for by population-based models may be identifiable and used to enhance the value of population-based risk scores for quality improvement., Methods: From January 2000 to January 2010, 4,971 patients underwent aortic valve replacement (AVR), either isolated (n = 2,660) or with concomitant coronary artery bypass grafting (AVR+CABG; n = 2,311). Operative mortality and major morbidity and mortality predicted by The Society of Thoracic Surgeons (STS) risk models were compared with observed values. After adjusting for patients' STS score, additional and refined risk factors were sought to explain residual risk. Differences between STS model coefficients (risk-factor strength) and those specific to our institution were calculated., Results: Observed operative mortality was less than predicted for AVR (1.6% [42 of 2,660] vs 2.8%, p < 0.0001) and AVR+CABG (2.6% [59 of 2,311] vs 4.9%, p < 0.0001). Observed major morbidity and mortality was also lower than predicted for isolated AVR (14.6% [389 of 2,660] vs 17.5%, p < 0.0001) and AVR+CABG (20.0% [462 of 2,311] vs 25.8%, p < 0.0001). Shorter height, higher bilirubin, and lower albumin were identified as additional institution-specific risk factors, and body surface area, creatinine, glomerular filtration rate, blood urea nitrogen, and heart failure across all levels of functional class were identified as refined risk-factor variables associated with residual risk. In many instances, risk-factor strength differed substantially from that of STS models., Conclusions: Scores derived from population-based models can be enhanced for institutional level use by adjusting for institution-specific additional and refined risk factors. Identifying these and measuring differences in institution-specific versus population-based risk-factor strength can identify areas to target for quality improvement initiatives., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Neonates with hypoplastic left heart syndrome and high-risk factors for an open Norwood procedure may benefit from a hybrid stage I procedure. The presence of a giant patent ductus arteriosus prevents safe deployment of the ductus arteriosus stent. We describe a new technique that involves banding the patent ductus arteriosus, therefore allowing stent implantation during hybrid stage I palliation., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Low superior vena cava (SVC) blood flow has recently been identified as a marker for bidirectional superior cavopulmonary connection (SCPC) failure and death. Prior innominate vein occlusion is considered a significant anatomic risk factor for SCPC failure. We therefore evaluated the outcomes of infants who underwent SCPC with known upper-body venous obstruction., Methods: Between February 1995 and June 2014, SCPC was carried out in 8 patients who had either a single SVC with known prior occlusion of the innominate vein (n = 6) or bilateral SVCs without a bridging vein with occlusion of one SVC (n = 2). The cause of the occlusion was an indwelling catheter in 5 patients. These patients were compared with 8 patients with normal upper-body venous drainage who underwent SCPC. Patients were evaluated for preoperative risk factors (including SVC size, pulmonary artery size, Nakata index, pulmonary vascular resistance), operative factors, and clinical outcomes to determine the impact of prior upper-body venous occlusion on SCPC failure or death., Results: There were no significant differences in preoperative risk factors between the two groups, except for a significantly lower Nakata index in the study group with a trend toward smaller pulmonary artery branch size. There were no SCPC takedowns or mortalities. There was no significant difference in postoperative length of stay (median of 7 days [range, 5 to 32 days] versus 5 days [range, 4 to 32 days]; p = 0.17. Study patients had a lower mean systemic oxygen saturation at discharge, 81% versus 85% (p = 0.05). In the study group, at a median follow-up of 42 months, 3 patients underwent successful Fontan completion and 5 are still awaiting Fontan completion., Conclusions: Although patients with prior upper-body venous obstruction may have lower systemic oxygen saturations at hospital discharge, they do not demonstrate an increased SCPC failure or mortality rate. Innominate vein occlusion or its equivalent in patients with bilateral SVCs should not preclude the performance of SCPC. Physiologic rather than anatomic evaluation of preoperative systemic venous return may be more useful to predict outcome after SCPC., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Statins interact with multiple pathways involved in infection. Therefore, we examined the association between preoperative statin therapy and infections after cardiac operations and assessed whether statin therapy was associated with lower infection-related mortality., Methods: From January 2005 to January 2011, 12,741 patients underwent cardiac operations. Endpoints were (1) postoperative infections and (2) mortality after an infectious complication. A propensity score was developed on the probability of patients receiving statin therapy; patients were matched in part on this score. A multivariable logistic model was developed to examine mortality. Survival of infected patients was estimated using Kaplan-Meier and multiphase hazard function methodology., Results: A total of 6,113 patients (48%) were receiving statins and 6,628 (52%) were not. Five hundred fifteen patients had postoperative infections-260 (4.3%) in the statin group and 255 (3.8%) in the no-statin group. However, patients receiving statins were older with more comorbidities and less favorable operative characteristics. Among propensity-matched groups, postoperative infections were significantly lower in patients receiving statins (n = 102 [3.1%]) than in those who were not (n = 147 [4.5%]; p = 0.004). Among patients in whom infections developed, there was no significant difference in hospital mortality between the statin and no-statin groups either before or after propensity-score matching (odds ratio, 1.38; confidence limit [CL], 0.59, 3.22; p = 0.5)., Conclusions: We observed a protective effect of statin therapy against the development of infections after cardiac operations, but not on mortality from these infections. Prospective investigations are needed to determine optimal dose and duration of statin therapy and their relationship to infectious complications., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Mitral valve prolapse (MVP) represents a common degenerative disease, often requiring surgery. If untreated, MVP with considerable valve incompetence can lead to cardiovascular and systemic complications causing substantial morbidity and mortality. In contrast with the wide knowledge concerning clinical and physiological features, currently available data regarding its molecular bases are very limited. We review current knowledge concerning MVP biological mechanisms, focusing on specific aspects of haemostasis, platelet function, oxidative stress, extracellular matrix remodeling and genomics. In particular, available evidence supports the role played by tissue remodeling processes in determining MVP onset and progression. Moreover, even if a consistent although controversial perturbation of haemostatic system and alterations of the oxidative stress equilibrium have been proposed to influence disease development, it is unknown whether these changes precede or follow MVP occurrence. Consequently, the complete knowledge of all the biochemical pathways involved are far from complete. In addition, changes in the regulation pattern of adrenergic and renin-angiotensin-aldosterone systems have been described in MVP syndrome, a condition characterized by the association of MVP with other peculiar neurological and general symptoms, but it is unknown whether these abnormalities are shared by "traditional" MVP. In conclusion, MVP is probably a multi-factorial process, and many aspects still need to be clarified. As surgery can only correct the damaged valve but not the underlying mechanisms, a more complete knowledge of the involved molecular pathways is necessary, as it may allow the discovery of targeted therapeutic strategies aimed at modifying or slackening MVP natural course in the early phases., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to predict immediate outcomes after adult cardiac operations, but less than 30% of the cases used to develop this score were valve procedures. We studied EuroSCORE performance in valve procedures., Methods: We performed a meta-analysis of published studies reporting the assessment of discriminatory power of the EuroSCORE by receiver operating characteristics (ROC) curve analysis in adult valve operations. A comparison of observed and predicted mortality rates was also performed., Results: A literature search identified 37 potentially eligible studies, and 12 were selected for meta-analysis comprising 26,621 patients with 1250 events (mortality rate, 4.7%). Meta-analysis of these studies provided an average area under the curve (AUC) value of 0.730 (95% confidence interval [CI], 0.717 to 0.743). The same results were obtained when meta-analyses were performed separately in studies categorized on reliability of uncertainty estimation: in the seven studies reporting reliable uncertainty estimation (8175 patients with 358 events; mortality rate, 4.4%), the ROC curve provided an average AUC value of 0.724 (95% CI, 0.699 to 0.749). The five studies not reporting reliable uncertainty estimation (18,446 patients with 892 events; mortality rate, 4.8%) had an average AUC of 0.732 (95% CI, 0.717 to 0.747). We documented a constant trend to overpredict mortality by EuroSCORE, both in the additive and especially in the logistic form., Conclusions: The EuroSCORE has low discrimination ability for valve surgery, and it sensibly overpredicts risk. Alternative risk scoring algorithms should be seriously considered., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to determine whether, in recent years, sex differences in the type of care during coronary artery bypass graft surgery procedures occurred., Methods: Between 1995 and 2004, 5,935 consecutive patients (4,867 men and 1,068 women) underwent isolated coronary artery bypass graft surgery; propensity score matching was used to investigate whether sex adversely impacts standard care and early outcomes of coronary revascularization., Results: Of the 1,068 women undergoing isolated coronary artery bypass graft surgery, only 280 (26.2%) were matched on propensity scores with men. Distribution of preoperative variables among matched pairs was, on average, equal. Propensity-matched women received similar number of distal anastomoses as men (2.70 +/- 0.89 versus 2.82 +/- 0.97; p = 0.13), had similar rates of complete revascularization (82.5% versus 81.6%; p = 0.78), and of off-pump procedures (24.3% versus 27.5%; p = 0.39); also, the rate of utilization of arterial grafts (left internal mammary artery 98.5% versus 98.2%; p = 0.73; right internal mammary artery 3.2% versus 3.2%; p > 0.99; radial artery 8.2% versus 9.6%; p = 0.55), as well as the number of distal anastomoses performed with arterial grafts (1.11 +/- 0.36 versus 1.13 +/- 0.39; p = 0.47), were similar in women and men. No differences were detected in major complications (in-hospital mortality, perioperative myocardial infarction, and stroke) in propensity-matched pairs, whereas women had lower reexploration for bleeding and blood transfusion rates., Conclusions: The preoperative profiles of women and men were markedly different, as only one fourth of women could be matched. In the current era, after adjustment for preoperative variables, female patients received the same standard of care as men, with improved results in some minor early outcomes.

Background: The purpose of this study is to assess the effects of linear and geometric left ventricular aneurysm reconstruction on early postoperative outcomes., Methods: A search of computerized databases supplemented with manual bibliographic review was performed for all peer-reviewed English language publications concerning randomized and nonrandomized studies reporting the results of left ventricular reconstruction after both linear and geometric reconstruction techniques. Meta-analyses of several short-term outcomes were performed., Results: No randomized trial was identified. Eighteen nonrandomized trials were found with a total of 1,814 and 803 patients who underwent linear and geometric reconstruction, respectively. Meta-analysis of all studies (n = 18) revealed an increased risk of in-hospital death for patients undergoing linear reconstruction (relative risk = 1.59, 95% confidence interval: 1.12 to 2.26, p = 0.01). The subanalysis of studies in which linear reconstruction was adopted mainly in the first period of time, and geometric reconstruction was adopted in a later phase, still showed a significant advantage in terms of in-hospital mortality for patients undergoing geometric reconstruction (n = 11 studies, relative risk = 1.89, 95% confidence interval: 1.22 to 2.93, p = 0.004). By contrast, when the two surgical approaches were carried out in the same time lag, there was no difference between linear and geometric reconstruction techniques (n = 7 studies, relative risk = 1.04, 95% confidence interval: 0.57 to 1.92, p = 0.89). No differences in the other outcomes of interest were observed., Conclusions: The advantage for geometric reconstruction techniques in terms of in-hospital mortality shown in some studies can be an effect of learning curve or of improvement over time in management of these difficult patients. Further studies are required to clarify this issue.

Objectives: This study was undertaken to evaluate predictors and outcomes of octogenarians who underwent abdominal aortic aneurysm repair., Design: A prospective observational study., Materials and Methods: Between January 1st, 1997 and April 15th, 2005, 31 octogenarians were admitted to our Department with the diagnosis of abdominal aortic aneurysm. Mean follow-up time was 53.7+/-27.2 months. All patients were in good clinical condition and represented a selected healthy group of octogenarians., Results: The overall perioperative (30-days) mortality rate was 3.1%. The total in-hospital morbidity rate was 22.6%. Overall survival estimates at 48 and 96 months were 81+/-8% and 46+/-21%, respectively. The actuarial freedom from aneurysm-related death at 48 and 96 months was 96+/-4% and 96+/-4%, respectively. The actuarial freedom from aneurysm-unrelated death at 48 and 96 months was 84+/-7% and 48+/-21%. Only coronary artery disease was a significant predictor of survival using multivariate stepwise logistic regression analysis., Conclusions: In this series, AAA surgery was carried out in selected octogenarians without affecting long-term survival.