Publications (26) View all
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Article: Tetralogy of Fallot and Aortic Root Dilation: A Long-Term Outlook.
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ABSTRACT: Dilation of the sinus of Valsalva (SoV) has been increasingly observed after repaired tetralogy of Fallot (TOF). We estimate the prevalence of SoV dilation in adults with repaired TOF and analyze possible factors related to aortic disease. Adults with TOF [n = 109, median age 33.2 years (range 18.1 to 69.5)] evaluated at Johns Hopkins Hospital from 2001 to 2009 were reviewed in an observational retrospective cohort study. Median follow-up was 27.3 (range 0.1-48.8) years. SoV dilation was defined as >95 % confidence interval adjusted for age and body surface area (z-score > 2). The prevalence of SoV dilation was 51 % compared with that of a normal population with a mean z-score of 2.03. Maximal aortic diameters were ≥4 cm in 39 % (42 of 109), ≥4.5 cm in 21 % (23 of 109), ≥5 cm in 8 % (9 of 109), and ≥5.5 cm in 2 % (2 of 109). There was no aortic dissection or death due contributable to aortic disease. Aortic valve replacement was performed in 1.8 % and aortic root or ascending aorta (AA) replacement surgery in 2.8 % of patients. By multivariate logistic regression analysis, aortic regurgitation (AR) [odds ratio (OR) = 3.09, p = 0.005], residual ventricular septal defect (VSD) (OR = 4.14, p < 0.02), and TOF with pulmonary atresia (TOF/PA) (OR = 6.75, p = 0.03) were associated with increased odds of dilated aortic root. SoV dilation after TOF repair is common and persists with aging. AR, residual VSD, and TOF/PA are associated with increased odds of dilation. AA evaluation beyond the SoV is important. Indexed values are imperative to avoid bias on the basis of age and body surface area.Pediatric Cardiology 10/2012; · 1.30 Impact Factor -
Article: Valve-sparing aortic root replacement in Loeys-Dietz syndrome.
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ABSTRACT: Loeys-Dietz syndrome (LDS) is a recently recognized aggressive aortic disorder characterized by root aneurysm, arterial tortuosity, hypertelorism, and bifid uvula or cleft palate. The results of prophylactic root replacement using valve-sparing procedures (valve-sparing root replacement [VSRR]) in patients with LDS is not known. We reviewed all patients with clinical and genetic (transforming growth factor-β receptor mutations) evidence of LDS who underwent VSRR at our institution. Echocardiographic and clinical data were obtained from hospital and follow-up clinic records. From 2002 to 2009, 31 patients with a firm diagnosis of LDS underwent VSRR for aortic root aneurysm. Mean age was 15 years, and 24 (77%) were children. One (3%) patient had a bicuspid aortic valve. Preoperative sinus diameter was 3.9±0.8 cm (z score 7.0±2.9) and 2 (6%) had greater than 2+ aortic insufficiency. Thirty patients (97%) underwent reimplantation procedures using a Valsalva graft. There were no operative deaths. Mean follow-up was 3.6 years (range, 0 to 7 years). One patient required late repair of a pseudoaneurysm at the distal aortic anastomosis, and 1 had a conversion to a David reimplantation procedure after a Florida sleeve operation. No patient suffered thromboembolism or endocarditis, and 1 (3%) patient experienced greater than 2+ late aortic insufficiency. No patient required late aortic valve repair or replacement. Loeys-Dietz syndrome is an aggressive aortic aneurysm syndrome that can be addressed by prophylactic aortic root replacement with low operative risk. Valve-sparing procedures have encouraging early and midterm results, similar to those in Marfan syndrome, and are an attractive option for young patients.The Annals of thoracic surgery 08/2011; 92(2):556-60; discussion 560-1. · 3.74 Impact Factor -
Article: Society of Thoracic Surgeons Risk Score predicts hospital charges and resource use after aortic valve replacement.
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ABSTRACT: The impact of Society of Thoracic Surgeons predicted mortality risk score on resource use has not been previously studied. We hypothesize that increasing Society of Thoracic Surgeons risk scores in patients undergoing aortic valve replacement are associated with greater hospital charges. Clinical and financial data for patients undergoing aortic valve replacement at The Johns Hopkins Hospital over a 10-year period (January 2000 to December 2009) were reviewed. The current Society of Thoracic Surgeons formula (v2.61) for in-hospital mortality was used for all patients. After stratification into risk quartiles, index admission hospital charges were compared across risk strata with rank-sum and Kruskal-Wallis tests. Linear regression and Spearman's coefficient assessed correlation and goodness of fit. Multivariable analysis assessed relative contributions of individual variables on overall charges. A total of 553 patients underwent aortic valve replacement during the study period. Average predicted mortality was 2.9% (±3.4) and actual mortality was 3.4% for aortic valve replacement. Median charges were greater in the upper quartile of patients undergoing aortic valve replacement (quartiles 1-3, $39,949 [interquartile range, 32,708-51,323] vs quartile 4, $62,301 [interquartile range, 45,952-97,103], P < .01]. On univariate linear regression, there was a positive correlation between Society of Thoracic Surgeons risk score and log-transformed charges (coefficient, 0.06; 95% confidence interval, 0.05-0.07; P < .01). Spearman's correlation R-value was 0.51. This positive correlation persisted in risk-adjusted multivariable linear regression. Each 1% increase in Society of Thoracic Surgeons risk score was associated with an added $3000 in hospital charges. This is the first study to show that increasing Society of Thoracic Surgeons risk score predicts greater charges after aortic valve replacement. As competing therapies, such as percutaneous valve replacement, emerge to treat high-risk patients, these results serve as a benchmark to compare resource use.The Journal of thoracic and cardiovascular surgery 04/2011; 142(3):650-5. · 3.41 Impact Factor -
Article: Impact of the viral respiratory season on postoperative outcomes in children undergoing cardiac surgery.
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ABSTRACT: To compare postoperative outcomes in children undergoing cardiac surgery during the viral respiratory season and nonviral season at our institution. This was a retrospective cohort study and secondary matched case-control analysis. The setting was an urban academic tertiary-care children's hospital. The study was comprised of all patients <18 years of age who underwent cardiac surgery at Johns Hopkins Hospital from October 2002 through September 2007. Patients were stratified by season of surgery, complexity of cardiac disease, and presence or absence of viral respiratory infection. Measurements included patient characteristics and postoperative outcomes. The primary outcome was postoperative length of stay (LOS). A total of 744 patients were included in the analysis. There was no difference in baseline characteristics or outcomes, specifically, no difference in postoperative LOS, intensive care unit (ICU) LOS, and mortality, among patients by seasons of surgery. Patients with viral respiratory illness were more likely to have longer postoperative LOS (p < 0.01) and ICU LOS (p < 0.01) compared with matched controls. We identified no difference in postoperative outcomes based on season in patients undergoing cardiac surgery. Children with viral respiratory infection have significantly worse outcomes than matched controls, strengthening the call for universal administration of influenza vaccination and palivizumab to appropriate groups. Preoperative testing for respiratory viruses should be considered during the winter months for children undergoing elective cardiac surgery.Pediatric Cardiology 04/2011; 32(6):801-6. · 1.30 Impact Factor -
Article: Valve-sparing aortic root replacement in children: intermediate-term results.
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ABSTRACT: Valve-sparing root replacement (VSRR) is an attractive option for aortic aneurysm in children with low-operative risk, but mid- and late-term results are not yet known. Between 1997 and 2009, 56 children (mean age 11.5 years) underwent VSRR at our institution. Twenty-six (46.4%) had Marfan syndrome and 24 (42.8%) had Loeys-Dietz syndrome. Mean preoperative max sinus diameter was 4.2±0.8 cm (Z-score 7.7±2.9). Five (8.9%) had >2+ aortic insufficiency (AI). Two (3.6%) underwent David I reimplantation with a straight-tube, 12 (21.4%) had a Yacoub remodeling procedure, and 42 (75.0%) had reimplantation using a Valsalva-graft. There were one (1.8%) operative and three (5.4%) late deaths. One patient required reoperation for bleeding and one required late repair of a distal pseudoaneurysm. Mean follow-up was 5.2 years (range 0-12 years). No patients suffered thromboembolic events or had endocarditis. Of the 12 remodeling patients, four (33.3%) developed >2+ AI and required aortic valve repair or replacement. No patient developed >2+ AI after reimplantation. VSRR in children is a safe alternative to aortic root replacement with mechanical or biological prostheses. In this particular group of patients with connective tissue disorders and proclivity toward annular dilation and late AI, reimplantation is superior to remodeling.Interactive cardiovascular and thoracic surgery 11/2010; 12(3):415-9, discussion 419.
