Background: Several factors affect the long-term outcome of Fontan procedure, but a high pulmonary artery pressure is still one of the most important limitation for proceeding to a Fontan circulation. Herein, we present our experience in Fontan patients with high preoperative pulmonary artery pressures. Methods: A retrospective analysis was performed in order to evaluate Fontan patients with a preoperative pulmonary artery pressure > 15 mmHg between 2009 and 2020. Sixteen patients were operated on with a mean preoperative pulmonary artery pressure of 17.5 ± 2.1 mmHg. Results: Mean age at the time of Fontan procedure was 7.8 ± 5.6 years. All of the patients had stage II cavopulmonary anastomosis prior to Fontan completion, with a mean interstage period of 4 ± 2.6 years. Fontan completion was achieved with a polytetrafluorethylene (PTFE) tubular conduit, two of which were intra-extracardiac. Fenestration was performed in 4 (25%) cases. Postoperative pulmonary artery pressures and arterial oxygen saturation levels were 11.2 ± 2.8 mmHg and 97.8 ± 2, respectively. Mean duration of pleural drainage was 3.9 ± 5.3 days. Any morbidity and mortality were not encountered during a mean follow up period of 4.8 ± 7.7 years. Conclusions: The mid-term results of stage III Fontan completion in patients with pulmonary artery >15 mmHg are encouraging. Pulmonary vascular resistance, not only pulmonary artery pressure may help to identify high risk patients before Fontan completion.
COVID-19 and nuclear cardiology: Introducing the ‘’forward” virtual visit Angelidis G, Valotassiou V, Psimadas D, Georgoulias PNuclear Medicine Laboratory, University of Thessaly, Larissa, GreeceWe read with great interest the recent review article by Kaushik A, et al. concerning the potential role of digital health applications in the present pandemic situation . As the authors noted, alternative tools are needed for the optimal management of cardiovascular patients, avoiding unnecessary visits to health care facilities. The severe acute respiratory syndrome – coronavirus – 2 (SARS-CoV-2) can invade the cardiovascular cells, potentially causing life-threatening cardiac impairment . In particular, patients with pre-existing cardiovascular diseases are characterized by a higher risk of adverse cardiovascular events. Therefore, most of those referred for nuclear cardiology techniques are expected to be at higher risk of developing serious coronavirus disease 2019 (COVID-19) complications. However, the performance of the individually required diagnostic and follow-up procedures is important .Telemedicine applications have been used in public health emergencies, leading to several advantages in terms of safety and efficacy. In the field of nuclear cardiology, the initial evaluation of patients’ history and clinical features can take place remotely (‘’forward” virtual visit). This approach seems to be patient-centred (permitting an adequate case assessment) and conducive to self-quarantine (protecting patients, healthcare professionals, and the community from viral exposure). Importantly, possible clinical presentations of COVID-19 may be evaluated during the ‘’forward” virtual visit, as well as information regarding travel and exposure histories. Moreover, local epidemiological information may be used to adjust screening pattern, and special measures could be developed (such as isolation in dedicated ‘’hot” rooms) for patients with high-risk features. After the performance of the examination, telemedicine applications could be also used for the consultation with the patients.Telemedicine applications may contribute to a better adjustment of nuclear cardiology services under the current demanding circumstances. Of course, no telemedicine programme can be created overnight, but this approach may be of value not only during the next months but also after the end of COVID-19 pandemic . For example, our nuclear medicine laboratory is located in central Greece providing services to inhabitants of mountain villages, and nearby small islands. Consequently, the use of telemedicine applications could aid our practice in the future as well, particularly during the winter months when travelling by car or sea travels may be extremely demanding.
Individuals with single-ventricle congenital heart disease who are palliated to a Fontan circulation are at risk for heart failure and liver disease, with recurrent ascites being one potentially debilitating cause of late morbidity. Although ascites associated with heart failure or liver failure is usually characterized by a high serum-ascites albumin gradient (SAAG), we have observed multiple instances of ascites in Fontan patients with low SAAG, suggesting an inflammatory process. We present three cases in which recalcitrant ascites severely and adversely impacted quality of life, and describe our initial experience with intraperitoneal corticosteroids in this setting.
COVID-19 has created challenges for society and the medical community. While the pandemic continues to unfold, the transplant community has had to pivot to keep recipients, donors, and transplant teams safe given these unprecedented times. This has resulted in a decrease in the number of transplants performed in the United States and an increased number of inactive patients on the UNOS waiting list.1 Waitlist and transplant recipients have an increased risk for acquiring COVID-19. It is speculated that this patient population is particularly vulnerable given their immunocompromised status and the high prevalence of comorbidities.2 Given the uncertainty surrounding the risk of transplant patients contracting COVID-19, there is interest in describing these cases in the literature.
Background: Differences in cardiac remodeling after mitral valve (MV) surgery between the sexes is poorly understood. Inferior outcomes for females undergoing MV surgery compared to males have been suggested in the literature, although causative factors behind this discrepancy have not been identified. Materials and Methods: In this propensity-matched, retrospective, single-center study, we sought to identify the impact that sex may have on cardiac remodeling and long-term outcomes to better inform clinical decision making in MV surgical intervention. Outcomes were compared between males and females undergoing MV replacement (MVR) between 2004 and 2018. The primary outcome was cardiac remodeling 1 year postoperatively. Secondary outcomes included mortality, stroke, myocardial infarction (MI), reoperation of the MV, and rehospitalization. Results: 314 males and 314 females were included after propensity matching. Males demonstrated a significant degree of improved left ventricular remodeling while females did not, and females showed a significant degree of left atrial remodeling while males did not. Mortality rates were relatively equivalent between the two groups, although males were more likely to develop sepsis and require rehospitalization due to MI. Conclusions: There has been little research exploring the differences in cardiac remodeling between the sexes after MVR. The results of this study have suggested that MVR is equally safe for both sexes and has demonstrated a difference in the heart’s ability to remodel after MVR. The significance of this difference has the potential to result in largely different clinical outcomes for males and females. Further study is necessary to fully elucidate this relationship.
Introduction - The impact of manufacturer labelled prosthesis size and predicted effective orifice area (EOA) on long term survival after aortic valve replacement is not clear although indexed effective orifice area (iEOA) has been associated with worse survival. Methods - Data was retrospectively collected from Jan 2000 – Dec 2019 for prosthesis type, model and size for isolated aortic valve replacements. Stratified survival was compared between groups and subgroups for labelled valve size, EOA and predicted PPM. Results – Total of 3444 patients were included. Moderate and severe PPM was 15.6% and 1.6% respectively. Cumulative life time hazard was worse for biological valves (mortality: biological 77.7% vs mechanical 64.8%, p=0.001). Mean survival was 132.7 months for biological versus 191.3 months for mechanical valves (p=0.001). Moderate prosthetic AS (EOA = 1-1.5 cm2) was12.1% and severe prosthetic AS (EOA≤1 cm2) was 0.8% respectively. Worse survival in the presence of moderate-severe prosthetic AS was seen in biological valves (115.2 months versus 133.7 months, p=0.001 for EOA≤1.5cm2 and >1.5cm2 respectively). There was a statistically significant correlation between survival and iEOA (Spearman’s rho=0.084, p=0.001, BCa bootstrap 95% CI;0.050, 0.120). Moderate to severe PPM (iEOA≤0.85cm2/m2) was a predictor of worse long term survival (HR 3.56; 95% CI: 1.37 - 9.25; p=0.009). Conclusion - Predicted prosthetic moderate to severe AS and moderate to severe PPM adversely affect long term survival. Smaller valves are associated with reduced survival in all groups.
Type A aortic dissection most often requires emergent surgery to prevent malperfusion, stroke, and/or rupture of aorta. The conduct of the surgery is mostly targeted at restoring true lumen flow. In this regard, institution of cardiopulmonary bypass and circulation management is key to allow adequate systemic flow, perfusion of brain and visceral organs and comprehensive systemic cooling to achieve circulatory arrest when needed. Different strategies have been used with varying success rates, with the most common being femoral cannulation. More recently axillary and central cannulation strategies have shown satisfactory results with the promise of antegrade flow. Cannulation approach should, therefore, depend on individual patient characteristics, presentation and true lumen anatomy.
Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.
OBJECTIVE. For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches in order to establish the possible gold standard. METHODS A systematic search was performed to identify all publications reporting the outcomes of four approach for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis. RESULTS There were 31 included studies with 9,663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA and 6.4% RRA; Early TR moderate-or-more was 9.6%, 4.8%, 4.6% and 3.8%; Late mortality was 22.5%, 18.2%, 11.9% and 11.9%; Late TR moderate-or-more was 27.9%, 18.3%, 14.3% and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (–85% vs. no TA; –64% vs. SA; –32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches, however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes. CONCLUSIONS. Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provides more stable FTR across time.
Background The role of percutaneous repair of functional mitral regurgitation (MR) is evolving. Left ventricle remodeling is known to be different between men and women; however, outcomes following percutaneous repair of functional MR have not considered the impact of sex. Methods Between 2012 and 2018, 175 patients underwent percutaneous repair of functional MR with the Mitra Clip NT/NTR (Abbott, Irvine CA) at our institution. Patients were assessed in a dedicated clinic with a follow-up that averaged 0.7±1.2 years and extended to 5.7 years. Results Men had a larger body surface area than women (p<0.001), whereas women were more likely than men to have diabetes preoperatively (p=0.02). There were no deaths or instances of single leaflet detachment. Immediate post-procedure MR was <2+ in 158 (90%) with a mean trans-mitral valve repair gradient of 3.4±1.0 and 3.5±2.1 mm Hg, respectively for women and men (p=0.8). One- and 2-year freedom from MR >3+ was 86.0±3.5% and 77.6±5.1%, respectively. After adjusting for differences between male and female patients, women were more likely to have recurrent MR >3+ (hazard ratio 4.7, 95% confidence interval 1.2-18.4, p=0.03). Upon adjusted analysis, there was also no association between gender and survival (p=0.2). One- and 2- year survival was 69.8±4.3% and 54.3±5.5%, respectively. Conclusion Women are more likely to have recurrent severe MR after percutaneous repair of functional MR. The mechanism for this remains undetermined.
We report a case of cardiac hibernoma, which is a very rare type of benign lipomatous tumour. They are usually asymptomatic and therefore remain undetected or are found incidentally. When symptomatic, they vary and depend on location of heart involved. The patient had a hibernoma on right atrial wall invading the intra-atrial groove and extending over superior vena cava (SVC), causing significant symptoms of SVC obstruction and tamponade. The patient therefore underwent emergency operation, in which the tumour was resected and the right atrium was reconstructed with Bovine pericardial patch. He was discharged home well.
Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for non-responders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR. Aim: To describe a single center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm. Methods: A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine association of patient and arrest characteristics with survival. Results: Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n=12). Twenty-six patients died on ECMO (55.3%) while 9 patients (19.1%) survived decannulation but died prior to discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status. Conclusions: Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multi-institutional studies are needed to determine evidenced based criteria for ECPR deployment.
BACKGROUND: COVID-19 has significantly impacted the healthcare landscape in the United States in a variety of ways including a nation-wide reduction in operative volume. The impact of COVID-19 on the availability of donor organs and the impact on solid organ transplant remains unclear. We examine the impact of COVID-19 on a single, large-volume heart transplant program. METHODS: A retrospective chart review was performed examining all adult heart transplants performed at a single institution between March 2020 and June 2020. This was compared to the same time frame in 2019. We examined incidence of primary graft dysfunction (PGD), continuous renal replacement therapy (CRRT) and 30-day survival. RESULTS: From March-June 2020, 43 orthotopic heart transplants were performed compared to 31 performed during 2019. Donor and recipient demographics demonstrated no differences. There was no difference in 30-day survival. There was a statistically significant difference in incidence of post-operative CRRT (9/31 v. 3/43; p = .01). There was a statistically significant difference in race (23W/8B/1AA v. 30W/13B; P=.029). CONCLUSION: We demonstrate that a single, large-volume transplant program was able to grow volume with little difference in donor variables and clinical outcomes following transplant. While multiple reasons are possible, most likely the reduction of volume at other programs allowed us to utilize organs to which we would not have previously had access. More significantly, our growth in volume was coupled with no instances of COVID-19 infection or transmission amongst patients or staff due to an aggressive testing and surveillance program.
A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supraannular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. As current data is limited, a literature review concerning subtle aortic dissection is provided.
Background: Expected beneﬁts of modified ultraﬁltration(MUF) include increased hematocrit, reduction of total body water & inﬂammatory mediators, improved left ventricular systolic function, & improved systolic blood pressure and cardiac index following cardiopulmonary bypass(CPB). This prospective randomized trial tested this hypothesis. Methods: 79 patients undergoing intracardiac repair of Tetralogy of Fallot(TOF) were randomized to MUF group(Group-M, n=39) or only conventional ultrafiltration(CUF) group(Group-C, n=40). Primary outcome was change in hematocrit. Secondary outcomes were changes in peak airway pressures, ventilatory support, blood transfusions, time to peripheral rewarming, mean arterial pressure, central venous pressure, inotrope score(IS) and cardiac index. Serum inflammatory markers were measured. Results: Following MUF, Group-M had higher hematocrit(44.3±0.98 g/dl) compared to Group-C(37.8±1.37g/dl),P=<0.001. Central venous pressure(mmHg) immediately following sternal closure was 9.27±3.12mmHg in Group-M & 10.52±2.2mmHg in Group-C(P=0.04). In the ICU, they were 11.52±2.20mmHg in Group-C and 10.84±2.78mmHg in Group-M(P=0.02). Time to peripheral rewarming was 6.30±3.91 hours in Group-M and 13.67±3.91hours in Group-C(P=0.06). Peak airway pressures in ICU were 17±2mmHg in Group-M & 20.55±2.97mmHg in Group-C, P<0.001. Duration of mechanical ventilation was 6.3±2.7 hours in Group-M compared to 14.7±3.5 hours in Group-C(P=0.002). IS was 11.52±2.20 in Group-C compared to 10.84±2.78 in Group-M. 8/39(20.5%) patients in Group-M had IS>10 compared to 22/40(55%) patients in Group-C(P=0.02). Serum Troponin-T and Interleukin-6 levels were lower in Group-M; TNF-α and CPK-MB were similar. ICU & hospital stay were similar. Conclusion: MUF group had higher post-operative hematocrit, decreased duration of mechanical ventilation, lower need for inotropes & lower Interleukin-6 & Troponin-T levels. MUF group had better post-operative outcomes.
Concomitant presence of acute type A dissection and coactation of aorta is rare (1). Levoatriocardinal vein has shown to be associated with left sided hypoplastic lesions as well as with normal hearts (2, 3 ). However, concurrent presence of levoatriocardinal vein with acute type A dissection, severe aortic regurgitation and Coarctation of aortic isthmus was not described. We here described a case of 20 year male presented to emergency department with acute chest pain radiating to back. On evaluation, he was found to have acute type A dissection with dilated aortic root, severe aortic regurgitation, normal mitral valve, severe coarctation of aorta and levoatriocardinal vein. Patient was managed successfully with composite valve conduit replacement of ascending aorta with ascending aortic to descending aortic graft (16mm graft) with levoatriocardinal vein ligation.