Reintervention for arch obstruction after stage 1 reconstruction does not adversely affect survival or outcome at Fontan completion
ABSTRACT To determine the effect of reintervention for coarctation after stage 1 reconstruction for hypoplastic left heart syndrome and variants on survival, suitability for Fontan, and morbidity at Fontan.
A retrospective review of echocardiograms, catheterizations, hospital records of patients who underwent stage 1 reconstruction from January 2002 to May 2005, with a cross-sectional analysis of hospital survivors, was performed. Kaplan-Meier curves were derived for patients alive more than 30 days after stage 1 reconstruction.
A total of 176 patients underwent stage 1 reconstruction. Forty-three patients (23%) underwent balloon angioplasty (n = 43) or surgical intervention (n = 4) for re-coarctation. Median time to intervention was 123 (1-316) days. Seven of 43 patients (16%) underwent more than 1 balloon angioplasty. Thirty-nine patients underwent intervention before stage 2 reconstruction, and 4 patients had intervention between stage 2 reconstruction and Fontan. Kaplan-Meier curves showed no difference in freedom from death or transplant between patients who did and did not undergo intervention for re-coarctation. Fontan completion was performed in 107 patients. By echocardiogram, the prevalence of moderate to severe ventricular dysfunction between groups was similar at Fontan; however, significant atrioventricular valve regurgitation was more common in patients who required intervention (28/33 vs 40/65, P = .02). Overall Fontan mortality was 2% and not different between groups. Length of stay was not different between patients with and without re-coarctation.
Reintervention for coarctation after stage 1 reconstruction is common. Hemodynamic differences between groups did not affect Fontan completion, mortality, or hospital length of stay. Follow-up is necessary to determine the impact of re-coarctation on longer-term mortality and morbidity.
SourceAvailable from: Meryl S Cohen[Show abstract] [Hide abstract]
ABSTRACT: Recoarctation of the aorta (RCoA) is a major cause of morbidity and mortality after the Norwood procedure. We sought to identify transthoracic echocardiographic (TTE) indices associated with RCoA and to develop a highly sensitive and specific diagnostic score for accurate diagnosis. All subjects who underwent a Norwood procedure from 12/2005 to 12/2009 were identified. Subjects were excluded if they did not undergo a TTE within one month of an outcome-defining event (cardiac catheterization, autopsy, or surgery). RCoA was defined as arch intervention at catheterization or surgery, or findings of RCoA at autopsy. Of 113 subjects included for analysis, RCoA occurred in 19 (17%). All TTE indices were significantly associated with RCOA in univariate testing. In the final multivariate model, peak isthmus velocity >2.5 m/sec (p<0.001), coarctation index (CI), defined as the ratio of narrowest region of the descending thoracic aorta to the distal descending thoracic aorta diameter <0.7 (p<0.01), and decrease in ventricular systolic performance (p=0.03) were all significantly associated with RCoA. A composite score was developed using a peak velocity >2.5 m/sec (2 points), CI <0.7 (1 point) and a decrease in ventricular systolic performance (1 point). A score > 2 diagnosed RCoA with 100% sensitivity and 85% specificity. The score performed equally well regardless of shunt type. In conclusion, a composite score of TTE indices accurately discriminates RCoA in patients who have undergone the Norwood procedure.The American journal of cardiology 07/2014; 114(1). DOI:10.1016/j.amjcard.2014.04.014 · 3.58 Impact Factor
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ABSTRACT: Objectives We evaluated the use of, and outcomes associated with, balloon angioplasty (BA) for recurrent coarctation in single ventricle (SV) and two ventricle (2V) patients following a Norwood-type aortic arch reconstruction (NTAR). Background Extended patch augmentation of the aorta, a NTAR, is utilized in SV patients undergoing the Norwood procedure (NP) as well as 2V patients with a diffusely hypoplastic aorta. While many studies have evaluated recurrent coarctation following the NP, the incidence of recurrent coarctation and outcomes associated with BA in 2V patients following NTAR are unclear. MethodsA retrospective review was performed of all neonates who underwent a NTAR at our institution between 2000 and 2010. The incidence of recurrent coarctation requiring intervention and factors associated with successful BA were evaluated. ResultsA NTAR was performed in 361 SV patients and 88 2V patients. The incidence of recurrent coarctation requiring intervention was 19.3% in 2V vs. 9.7% in SV patients (P=0.01) at a median of 0.5 (interquartile range 0.3-1.2) years from initial surgery. BA was successful in 25 SV patients (81%) and 10 2V patients (71%; P=0.70). Of the characteristics evaluated, lower initial peak-to-peak gradient (P=0.02), larger balloon size for angioplasty (P=0.02) and larger diameter of the descending aorta (P=0.01) were associated with BA success. Conclusions Recurrent coarctation following NTAR is more common in 2V patients than in SV patients. BA for recurrent coarctation has similar success in both groups and should continue to be utilized in this population. (c) 2013 Wiley Periodicals, Inc.Catheterization and Cardiovascular Interventions 06/2014; 83(7). DOI:10.1002/ccd.25318 · 2.51 Impact Factor
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ABSTRACT: Objective We sought to review and analyze the hemodynamic derangements during prograde transcatheter aortic intervention (PTAI) in single ventricle patients.Background Although PTAI for postsurgical recurrent coarctation in single ventricle patients has been described; hemodynamic instability during the intervention is variably reported.Methods Pre-, intra-, and postprocedural records and outcomes of patients with SVP undergoing PTAI for post-Norwood aortic coarctation were retrospectively reviewed. The full disclosure waveform review was used to further categorize hemodynamic derangements during the intervention.ResultsA total of 26 PTAIs were performed in 11 patients between October 2007 and December 2013. The median age and weight was 4.2 (2.3–43) months and 5.3 (3.2–15.7) kg. PTAI included balloon angioplasty (BA) in 73% of procedures (n = 19) and stent implantation (SI) in 27% (n = 7). Hemodynamic derangement was more severe in the SI group compared with the BA group. Two of seven (29%) of the SI group required cardiopulmonary resuscitation.Conclusions Hemodynamic instability during PTAI is common in patients with SVP and more profound during SI. These findings have important implications for informed consent, anesthetic considerations, inotropic support, additional central venous access, and extracorporeal support/surgical backup.Congenital Heart Disease 05/2014; 10(1). DOI:10.1111/chd.12181 · 1.01 Impact Factor