Archives of Cardiovascular Diseases Supplements最新文献

Introduction

Congenital heart disease is the most common congenital malformation and affects nearly 1% of births. Surgery for congenital heart disease in adults has special characteristics that differentiate it from congenital heart surgery in children and heart surgery for acquired diseases in adults: the diversity of the anatomoclinical situations and the difficulty of the specific surgical techniques are the most important. The presence of multiorgan involvement is common in these patients, which complicates anesthesia and the postoperative period.

Objective

The main objective of our work was to evaluate the immediate and 6-month results of congenital heart diseases surgery in adulthood in terms of feasibility, morbidity and mortality.

Methods

It was a retrospective descriptive study conducted in the Cardiovascular Surgery Department of La Rabta Hospital over a 10 year period. We included patients who underwent surgical correction in adulthood (≥ 18 years). We excluded patients who files were not usable or who were lost to follow-up. We recruited 130 patients with congenital heart disease diagnoses on echocardiography and operated on in adulthood. According to the type of the congenital disease, these patients were subdivided into 2 groups according to cyanogenic or not heart disease.

Results/Expected results

The average age was 32 years old. A female predominance was objectified (72%). At diagnosis, 46% of our patients were symptomatic with dyspnea. At pre-surgical echocardiographic evaluation, LVEF was preserved in 125 patients (96%) with an average of 65.7 ± 10.4%. 85% of operations were under CPB. 46% of patients used vasoactive drugs upon discharge from CPB. Intra-hospital mortality was 5% and intra-hospital morbidity was 31%. The complications had a favorable evolution. This postoperative morbidity was the cause of a longer hospital stay.

Conclusion/Perspectives

Nowadays, some other techniques seek to register as less invasive alternatives to conventional surgery such as closure of septal defects percutaneously and totally computer-assisted endoscopic occlusion which offers an excellent aesthetic result.

Introduction

Low-profile stent implantation remains a rescue treatment for aortic coarctation and branch pulmonary arteries stenosis in small children. Stent re-expansion to cope with vascular growth remains problematic.

Objective

To evaluate ex-vivo feasibility and mechanical behavior of over-dilating BeSmooth peripheral stents (Bentley InnoMed, Germany).

Methods

Three BeSmooth stents in diameters of 7, 8, and 10 mm were dilated to nominal pressure and then 13atm. Test-1 (sequential up-sizing post-dilation without re-stenting): BeSmooth Ø7 × 23 mm was post-dilated using 12, 14, and 16 mm high-pressure balloons. Test-2 (post-dilation until plateau/breakpoint then re-stenting): BeSmooth Ø10 × 57 mm was post-dilated with 14 mm balloon until plateau/breakpoint and then with 48 mm bare-metal Optimus-XXL stent hand-mounted on 14 mm balloon. Test-3 (straightforward re-stenting): BeSmooth Ø8 × 57 mm was directly post-dilated with 48 mm bare-metal Optimus-XXL stent hand-mounted on 16 mm balloon. The stents’ diameter and length were measured. Balloon rupture and stent fracture patterns were closely evaluated.

Results/Expected results

Test-1: BeSmooth Ø7 × 23 mm was post-dilated to 10 mm diameter with a little shortening. Up-sizing the stent to 11 mm with the Ø14 mm balloon led to the stent shrinking to 3.2 mm. At 20atm pressure, BeSmooth Ø7 × 23 mm shortened to 2 mm forming a 12 mm diameter solid ring circle, and the 16 mm woven balloon ruptured radially. Test-2: The BeSmooth Ø10 × 23 mm reached a plateau diameter of 13 mm without shortening and the balloon did not rupture. Stent-in-stent re-expansion showed that at 10atm pressure, BeSmooth Ø10 × 57 mm fractured longitudinally in various dispatched breaking points at a diameter of 13 mm without shortening and ruptured the balloon with multiple pinholes. Test-3: At 10atm pressure, BeSmooth Ø8 × 57 mm fractured centrally at three different points at a diameter of 11.5 mm without shortening and the balloon broke radially in half.

Conclusion/Perspectives

In our benchmark tests, extreme shortening, severe balloon rupture, or unpredictable stent fracture patterns at small balloon diameters limits the safe post-dilation of BeSmooth stents beyond 13 mm. BeSmooth stents are not ideal candidates for off-label stent interventions in smaller patients.

Introduction

Pregnancies in patients with a Fontan circulation are high-to very high-risk pregnancies. European and American recommendations consider patients with any Fontan complications should be counseled against becoming pregnant.

Objective

This study sought to evaluate maternal complications in patients with Fontan circulation according to the modified WHO (mWHO) classification.

Methods

We performed a retrospective observational cohort study across 13 international centers. Maternal and fetal outcomes were reviewed according to baseline risk assessed as per the mWHO classification. Women with oxygen saturations < 85%, NYHA functional class IV, depressed ventricular function, moderate to severe atrioventricular valve regurgitation, refractory arrhythmia, plastic bronchitis, or protein-losing enteropathy (PLE) were considered at very high risk of complications (mWHO IV), those without any Fontan complication were classified at high risk (mWHO III). The risk of remaining patients who experienced other types of Fontan complications was classified as mWHO III–IV.

Results/Expected results

We analyzed 84 women (median age 27 years, interquartile range 23-30) with Fontan physiology undergoing 108 complete pregnancies, average gestation of 33 ± 5 weeks. Fifty-two (48%) pregnancies were classified as mWHO III, 45 (42%) mWHO III–IV, and 11 (10%) mWHO IV (Table 1). None patients had a previous history of PLE or plastic bronchitis. There was no maternal death. Cardiovascular complications occurred in 13 (25%), 16 (35%) and 4 (36%) pregnancies classified mWHO III, III–IV, and IV respectively (P = 0.74). Cardiovascular complication rates remained not significantly different when patients with any Fontan complications were compared to patients without (36% vs. 25%, P = 0.23; Table 1). There were high rates of fetal (n = 73, 68%) and obstetrical (n = 75, 69% including 38 bleeding events) complications without significant difference between the 3 risk groups.

Conclusion/Perspectives

Maternal cardiovascular complications occurred in one-third of pregnancies whatever the mWHO classification. Even if there is no reported maternal death, women with Fontan circulation should be carefully counseled on pregnancy risks.

Introduction

In native aortic coarctation, as well as recoarctation with appropriate anatomy, stenting has become the treatment of first choice according to European guidelines.

Objective

The objective of this study was to assess the safety as well as the short and long-term efficacy of percutaneous treatment of aortic coarctation/recoarctation in adults.

Methods

This study included all adult patients with a native or post-operative aortic coarctation treated percutaneously in a single center from March 2006 to December 2022. Baseline characteristics, intra-procedural and follow-up data were analyzed. The primary outcome was acute procedural success and secondary outcomes were intra-operative and late complications.

Results/Expected results

A total of 62 patients were included. The mean age was 35 years (range, 15–74), 33 (53.2%) patients were male. Thirty patients (48.3%) had a native aortic coarctation, 57 (91.9%) were hypertensive and 32 (51.6%) had a bicuspid aortic valve. Acute procedural success was achieved in all patients with a peak-to-peak gradient at the end of the procedure lower than 20 mmHg in 60 (96.7%) patients. Two (3.2%) patients had a non-fatal aortic rupture without sequelae and 2 (3.2%) had a false femoral aneurysm requiring intervention. At the follow-up visit, 55.3% patients had persistent arterial hypertension requiring medical treatment. Regarding late complications, 3 (4,8%) patients had aortic recoarctation that required a new percutaneous procedure, 1 (1,6%) patient had a type B aortic dissection that did not require invasive management, and 1 (1,6%) patient had a thrombosis of the right external iliac artery.

Conclusion/Perspectives

Percutaneous treatment with stenting of aortic coarctations in adults is safe and effective when performed in expert centers. Follow-up of this cohort will bring important data on very long-term outcomes associated with this technique.

Introduction

Since the disqualification of mortality as unique quality outcome after pediatric cardiac surgery, many quality outcomes have been proposed without any universal agreement.

Objective

To list the most used quality outcomes from a literature review and to analyze the behavior of these quality outcomes.

Methods

The study was restricted to Arterial Switch Operation (ASO) and Ventricular Septal Defects Closure (VSDC). Three criteria were used to qualify the quality outcomes: variation in time, variation between centers, and dependency on surgical severity. The analysis was performed using data extracted from an extensive review of the literature and from our local database. The categorial outcomes were automaticaly classified by a grouping algorithm. All the outcomes significantly described in the litterature were clustered. Programmation was performed in R.

Results/Expected results

The literature review identified 41 articles discussing quality outcomes of pediatric cardiac surgery. 18 quality outcomes were extracted. In total, 15 centers were found to have reported surgery early outcomes (nine for ASO and six for VSDC). The outcomes clusterisation is presented in Figure 1.

Conclusion/Perspectives

Three groups of outcomes were identified: 1/ Medical Hazards (mortality, resuscitation, extra corporeal membrane oxygenation, neurological events, atrio-ventricular block), 2/Expected events and preventive strategies (renal support, effusion, delayed sternal closure, length of stays, durations of amine/ventilation) and 3/ unwanted adverse events (reintervention/readmission, infectious event, reintubation). This list of outcomes could be used as a standard base for future reports.

Introduction

Systemic tricuspid valve regurgitation (TR) is often encountered in patients with atrial correction of transposition of the great arteries (acTGA) or congenitally corrected transposition of the great arteries (ccTGA). When at least moderate, it is related to impaired functional capacity, heart failure and mortality. Management is a matter of debate as medical management is limited and valvular surgery at risk. Among adults with severe and symptomatic systemic mitral regurgitation at high risk for surgery, percutaneous edge-to-edge repair is now proposed as a reasonable alternative.

Methods

We hypothetised that percutaneous management of systemic TR may be feasible and safe. A monthly national dedicated multidisciplinary meeting was therefore organized, including cardiologists and surgeons dedicated to adults with CHD. All concerned patients were evaluated and a decision was taken and thereafter offered to each patients.

Results/Expected results

So far, 9 patients, of whom 1 female, with a median age of 41 ± 14 years, were included, 4 with acTGA and 5 with ccTGA. The procedures were performed in 4 French tertiary CHD centers between May 2019 and June 2022, following institutional review board approval. The XTR MitraClip device (Abbott, Santa Clara, CA) was used, 1 MitraClip was used in 5 patients, 2 in 2 and 3 in 1. The procedure was not possible in 1 patient, because of impossibility to achieve appropriate orientation of the clip on the tricuspid valve. No complication was reported. At 6 months of follow-up, we noticed a decrease in the TR of at least 1 grade in 8 patients. NYHA functional class improved in 5 patients and diuretics doses decreased in 4.

Conclusion/Perspectives

Transcatheter edge-to-edge repair appears as a feasible and safe procedure in patients with significant systemic TR. Further studies need to be performed to precise the optimal position of percutaneous reduction of systemic TR in the management of these patients.

Introduction

Fetal aortic stenosis (FAS) has a poor prognosis. Fetal aortic valvuloplasty (FAV) has been proposed to improve post-natal outcome by promoting left ventricular (LV) growth. Data on long-term evolution of patients who received FAV are scarce.

Objective

Report our retrospective single center experience on FAV focusing on post-natal evolution of the patients.

Methods

All fetuses with FAV were retrospectively included. Fetal, FAV and neonatal data were recorded. Univentricular or biventricular strategies (UniV or BiV) at birth were collected as well as type of intervention. Causes of death and follow-up (FU) were reviewed.

Results/Expected results

Fifty-eight fetuses with critical AS received 63 FAV at a mean gestational age of 24.6 weeks between 2011 and 2022. At the time of FAV, LV end diastole Z-score varied from –3 to +3. Technical procedural success was reported in 50/58 fetuses. There were 9 in utero demises and 9 terminations of pregnancy (TOP). Thirty eight newborns were delivered at a mean gestational age of 38.1 weeks (8/38 preterms) and a mean weight of 2925 grams (1270–3220 grams). In total, 21 patients required prostaglandin. 9 patients had UniV at birth and 3 patients are still alive. The remaining 29 patients had BiV at birth with 3 univentricular conversion. In the 26 patients with BIV, 23 patients are alive at last FU. Three patients have never been operated on. Thirteen needed one intervention on the aortic valve: 10 had a surgical commissurotomy and 3 had a balloon valvuloplasty. Eleven had 2 interventions and 2 had 3 interventions. Mean age at last FU was 26 [8–112] months.

Conclusion/Perspectives

Severity of FAS is confirmed with 50% of the fetuses alive at last FU. A low incidence of UniV is reported because of high rate of TOP or palliative care at birth. Among patients with BiV, rate of reintervention is high but long-term survival is satisfactory.

Introduction

Infrahepatic interruption of the inferior vena cava (IVC) with azygos or hemiazygos continuation is a rare finding.

In this anatomic entity, the intrahepatic segment of the IVC is absent, and the hepatic veins empty directly into the right atrium. Venous blood flow from the lower body is directed from the IVC into the azygos system at the level of the renal veins, with resultant dilation of the azygos and/or hemiazygos veins.

Objective

We report the case of azygos continuation of the IVC. The diagnosis was made during a catheterization during a Percutaneous Transluminal Mitral Commissurotomy.

A 56 years old female, with the history of diabetes mellitus, blood hypertension, hypothyroidism, and a mitral valve stenosis of rheumatic origin dilated 20 years ago, presented with dyspnea NYHA II. The clinical findings were: a low-pitched diastolic murmur, no sign of right cardiac failure.

Transthoracic echocardiography Show a mitrale surface in 1,3 cm². During the procedure of mitral diltation it was impossible to cross the IVC. We performed an Aortic CT-SCAN revealing aninfrahepatic interruption of the inferior vena cava (IVC) with azygos continuation.

Conclusion/Perspectives

Anomalous inferior vena cava with azygos or hemiazygos continuation is best interpreted as interruption or failure of fusion of the hepatic and prerenal segments of the inferior vena cava, combined with persistence of either the right lumbar azygos vein or left lumbar hemiazygos vein. Thus, a better term for the anomaly would be infrahepatic interruption of the inferior vena cava with azygos (hemiazygos) continuation.

Introduction

Coronary artery fistulas (CAFs) are rare coronary anomalies and transcatheter closure remains debatable.

Objective

To evaluate our experience with transcatheter management of CAFs.

Methods

Retrospective clinical data review of all children in whom echocardiographically suspected CAFs were confirmed during cardiac catheterization from 2000 to 2022.

Results/Expected results

In total, 92 CAFs were identified in 76 patients (44% males) with a median age of 3.8 years (IQR, 0.8–7). 25 (32.9%) patients had concomitant congenital anomalies and 9 (11.8%) had coronary artery anomalies. 39/51 (76.5%) patients with isolated CAFs were asymptomatic at diagnosis. 27 (35.5%) patients had pre-procedural CT angiography. CAFs mainly originated from the left main coronary artery (42.4%) and right coronary artery (38.1%). Drainage sites were mainly the right cavities (80.4%). 23/76 (30.3%) patients with 35/92 (38%) small CAFs had no intervention with a benign clinical long-term follow-up. 8/76 (10.5%) patients with 9/92 (9.8%) CAFs not amenable to percutaneous closure were directly sent for surgery. 45/76 (59.2%) patients had percutaneous closure of 48/92 (52.2%) CAFs using microcoils (31.3%), device occluders (58.3%), or both (10.4%). Occlusion material was exchanged before release in 4 (8.9%) patients. Devices were deployed transvenously using a track wire loop in 19/48 (39.6%) CAFs. Closure approach was modified per-operatively in 4 (8.9%) patients. Percutaneous closure was unsuccessful in 3 (6.7%) patients of which 2 had surgical ligation. Twelve complications occurred including 7 transient ST–T wave changes, 2 asymptomatic coronary pseudo-stenosis, one coronary dissection, and one pulmonary edema. Repeat closure was needed in 3 (6.7%) patients for residual leak and was unsuccessful in 2 of them. One patient had trivial CAF recanalization with an asymptomatic 12-year follow-up.

Conclusion/Perspectives

Transcatheter closure of CAFs is feasible and effective in carefully selected patients. Complications are frequent but not permanent. Surgery is a valuable upfront option in large and technically complex CAFs or a bailout of failed percutaneous attempts.