Adriano Carotti

Ospedale Pediatrico Bambino Gesù, Roma, Latium, Italy

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Publications (71)192.46 Total impact

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    ABSTRACT: Children undergoing Ross operation were expected to have longer autograft, but shorter homograft durability compared with adults. In order to define the outcome in the second decade after Ross operation in children, a nationwide review of 23 years of experience was undertaken.
    Heart (British Cardiac Society) 07/2014; · 5.01 Impact Factor
  • The Journal of thoracic and cardiovascular surgery. 07/2014; 148(1):363-4.
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    ABSTRACT: PurposeOur aim is to compare new non-invasive imaging modalities in the evaluation of vascular ring (VR) and pulmonary artery sling (PAS) and to understand the role of bronchoscopy in comparison with them in assessing tracheobronchial tree.Methods We have retrospectively analyzed the data from 41 patients with a VR or a PAS diagnosed at Bambino Gesù Children's Hospital of Rome, between 2008 and 2012. Age, gender, presenting symptoms, clinical history, comorbidities, imaging modalities used for diagnosis (cardiac magnetic resonance [CMR], computed tomography [CT], tracheobronchoscopy [TB]) and surgical treatment were recorded.ResultsThe vascular anatomy was completely defined in all patients, whether evaluated by CMR or CT, with a diagnostic accuracy of 100% based on surgical observation. All CT exams were performed without sedation with a mean dose-length product (DLP32) of 29 ± 9 and an effective dose of 1.56 ± 0.6 mSv, range 0.5–2.5 mSv. CMR required general anesthesia in all patients but involved no exposure to ionizing radiation. CT performed better than CMR in assessing tracheal stenosis when compared to TB. It detected complete tracheal cartilage rings in 2/3 patients with PAS, besides tracheomalacia and/or bronchomalacia in 54% of patients.Conclusions Both cross-sectional imaging modalities (CT and CMR) can reliably and accurately diagnose these congenital vascular anomalies. While CT involves exposure to ionizing radiation, it avoids the risks related to anesthesia needed for CMR, and provides a more accurate assessment of tracheobronchial anatomy. TB remains a fundamental tool in tracheomalacia diagnosis in VR symptomatic patients and PAS. Pediatr Pulmonol. © 2014 Wiley Periodicals, Inc.
    Pediatric Pulmonology 06/2014; · 2.38 Impact Factor
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    ABSTRACT: Haemolysis is known to occur during surgery on cardiopulmonary bypass (CPB) and to be responsible for kidney injury. The aim of this study was to assess, in a cohort of infants, the reference levels of free haemoglobin (fHb) and their change over time postoperatively; the predicting variables of haemolysis in the intraoperative phase; and the association between fHb and renal function. A retrospective analysis in infants undergoing surgery on CPB was conducted. Children with preoperative renal dysfunction and need for extracorporeal membrane oxygenation support were excluded. fHb was sampled before and after CPB and on the first 2 postoperative days (POD). Twenty-two patients with a median (interquartile) age of 111 (63-184) days and Aristotle score of 8 (6.4-9) were enrolled. fHb had a baseline value of 29 (24-41) mg/dl, peaked to 75 (65-109) mg/dl at CPB weaning and returned to 35 (30-55) mg/dl on POD 2 (P <0.0001). The median normalized index of haemolysis was 0.15 (0.09-0.19) g of fHb per 100 l of pumped blood. A multivariable regression model showed that, at CPB weaning, fHb levels were independently associated with left atrial venting flow (P = 0.02), and that CPB time remained the only independent variable (P = 0.034), when left atrial venting was excluded from the analysis. Acute kidney injury (AKI) occurred in 10 patients (45%). fHb levels in the 48 post-CPB hours were not significantly different between AKI and non-AKI patients: However, a significant correlation was present between creatinine on POD1 and CPBw-fHb (r = 0.48; P = 0.045); and between cystatin C on POD1 and CPBw-fHb (r = 0.58; P = 0.02). A high rate of fHb is released during paediatric surgery with CPB in infants. fHb mainly depends on the left atrial venting flow rate and CPB duration. However, such peaks of fHb levels were not associated with renal dysfunction.
    Interactive Cardiovascular and Thoracic Surgery 05/2014; · 1.11 Impact Factor
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    ABSTRACT: To investigate the clinical manifestations at diagnosis and during follow-up in patients with 22q11.2 deletion syndrome to better define the natural history of the disease. A retrospective and prospective multicenter study was conducted with 228 patients in the context of the Italian Network for Primary Immunodeficiencies. Clinical diagnosis was confirmed by cytogenetic or molecular analysis. The cohort consisted of 112 males and 116 females; median age at diagnosis was 4 months (range 0 to 36 years 10 months). The diagnosis was made before 2 years of age in 71% of patients, predominantly related to the presence of heart anomalies and neonatal hypocalcemia. In patients diagnosed after 2 years of age, clinical features such as speech and language impairment, developmental delay, minor cardiac defects, recurrent infections, and facial features were the main elements leading to diagnosis. During follow-up (available for 172 patients), the frequency of autoimmune manifestations (P = .015) and speech disorders (P = .002) increased. After a median follow-up of 43 months, the survival probability was 0.92 at 15 years from diagnosis. Our data show a delay in the diagnosis of 22q11.2 deletion syndrome with noncardiac symptoms. This study provides guidelines for pediatricians and specialists for early identification of cases that can be confirmed by genetic testing, which would permit the provision of appropriate clinical management.
    The Journal of pediatrics 03/2014; · 4.02 Impact Factor
  • Enrico Cetrano, Angelo Polito, Adriano Carotti
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    ABSTRACT: An intrapericardial vacuolated mass compressing and displacing the heart was diagnosed by echocardiography in a foetus of 22 weeks gestation. The birth was induced for early signs of foetal distress at 29 weeks and, after two initial pericardial evacuation procedures, the tumour was resected radically 7 days after birth at a weight of 1.55 kg. Mass histology showed teratoma associated with yolk sac tumour. We comment on the overall approach adopted after foetal diagnosis and the histopathological features of the tumour, and try to draw conclusions on patient outcome data.
    Cardiology in the Young 01/2014; · 0.95 Impact Factor
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    ABSTRACT: Bleeding during and after cardiac surgery is a major issue in pediatric patients. A prospective cohort study was conducted to evaluate the effect of a commercially available prothrombin complex (Confidex) administered in cardiac surgery after weaning from cardiopulmonary bypass of infants with nonsurgical bleeding. In this study, 14 patients younger than 1 year received a Confidex bolus and were matched with 11 patients of a similar age who did not receive the drug. The preoperative coagulation profile was similar in the two groups. No side effects, including anaphylaxis or thrombotic events, were observed. The numbers of units of packed red blood cells and fresh frozen plasma administered both intra- and postoperatively were similar. The postoperative coagulation examination results and thromboelastographic parameters did not differ significantly between the two groups. However, the Confidex patients bled significantly less than the control subjects during the first 24 postoperative hours. The median volume of drained blood was 0.0 ml/kg h (range 0-1.9 ml/kg h) compared with 1.9 ml/kg h (range 1-3 ml/kg h) (p = 0.009). At least one unit of packed red blood cells in the postoperative phase was required by 2 patients (14 %) in the Confidex group and six patients (54 %) in the control group (odds ratio [OR], 0.13; 95 % confidence interval [CI], 0.02-0.9; p = 0.03). The median duration of mechanical ventilation was 3 days (range 2-4 days) in the Confidex group and 4 days (range 0-8 days) in the control group (p = 0.66). The median stay in the intensive care unit was 6 days (range 5-9 days) in the Confidex group and 7 days (range 4-12 days) in the control group (p = 0.88). The use of Confidex for infants undergoing cardiac surgery was safe and effective. It reduced postoperative bleeding and allowed fewer units of packed red blood cells to be infused in the postoperative phase without major side effects.
    Pediatric Cardiology 07/2013; · 1.20 Impact Factor
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    ABSTRACT: The combination of right aortic arch with aberrant left brachiocephalic artery and aortic coarctation is very rare. Here, we report the case of a 3.1-kg neonate with multiple malformations who received detailed preoperative anatomical definition by chest computed tomography (CT) scan and eventually underwent one-stage repair at the age of 17 days. The surgical technique included left brachiocephalic artery detachment and its end-to-end anastomosis to the branch of a monofurcated pulmonary homograft used to treat the aortic arch coarctation simultaneously. Postoperative control chest CT scan performed 3 months postoperatively revealed optimal repair. Considerations on imaging and surgical technique are reported.
    Interactive Cardiovascular and Thoracic Surgery 05/2013; · 1.11 Impact Factor
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    ABSTRACT: OBJECTIVE:: Modified ultrafiltration is commonly used in pediatric cardiac surgery. Although its clinical benefits are currently debated, modified ultrafiltration has proved to improve mean arterial pressure in the first postoperative hours. Aim of our study was to measure cardiac index, stroke volume index, and mean arterial pressure modification before and after modified ultrafiltration by means of Pressure Recording Analytical Method. DESIGN:: Single-center prospective observational cohort study. SETTING:: Pediatric cardiac surgery operating room. PATIENTS:: Children below 20 kg that are included in the "pediatric" mode of Pressure Recording Analytical Method. MEASUREMENTS AND MAIN RESULTS:: Forty patients were enrolled in this study. Median age, weight, and body surface area at surgery were 3 months (interquartile range, 10 days to 3.5 years), 5.6 (3.1-15) kg, and 0.31 (0.21-0.56), respectively. During the modified ultrafiltration procedure, a median volume of 17 mL/kg (11-25) was ultrafiltered and a median volume of 11 mL/kg (6-17) was reinfused with a median final modified ultrafiltration balance of -0.15 mL/kg (-4.0 to 0.1). By univariate analyses, there was a 10% increase in postmodified ultrafiltration mean, systolic and diastolic pressures (p = 0.01), stroke volume index (p = 0.02), and cardiac index (p = 0.001) without significant changes in heart rate, central (left and right) venous pressures, stroke volume variation, and inotropic score. By multivariate analysis, when controlling for cardiopulmonary bypass time and age at surgery, cardiac index variation was independently associated with lower preoperative body surface area (beta coefficient -5.5, p = 0.04). CONCLUSIONS:: According to Pressure Recording Analytical Method assessment, modified ultrafiltration acutely improves myocardial function, as shown by a 10% increase of systemic arterial pressure, stroke volume index, and cardiac index. This effect is more pronounced in smaller sized patients.
    Pediatric Critical Care Medicine 04/2013; · 2.35 Impact Factor
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    ABSTRACT: Injury of structures, leading to a major bleeding during chest opening, is a severe and potentially life-threatening complication, especially in redo cardiac surgery, both in adults and children. In three paediatric redo operations performed via midline sternotomy, we managed this complication successfully and uneventfully by using an inflated Fogarty catheter to plug the blood leak from the injured vessel before repairing the lesion under direct vision in a bloodless surgical field. Herein we report in detail the technique used and a comment on our experience.
    Interactive Cardiovascular and Thoracic Surgery 03/2013; · 1.11 Impact Factor
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    ABSTRACT: OBJECTIVES To analyse the factors associated with in-hospital mortality and mid-term significant neoaortic valve regurgitation (AR) after truncal valve (TV) repair.METHODS Eleven children underwent TV repair at our institution from July 1999 to March 2012. All children presented significant preoperative TV regurgitation. Valve anatomy was quadricuspid in 7 (64%) patients and tricuspid in 4 (36%). The median age and weight at surgery were 29.6 (range 0.3-173.2) months and 12 (range 2.2-49) kg, respectively. Repair included bicuspidalization through the approximation of two leaflets associated with triangular resection of the opposite one (n = 2, 18%), or either bicuspidalization or tricuspidalization of the TV through excision of one leaflet and related sinus of Valsalva (n = 9, 82%). In 3 patients, repair was associated with coronary detachment before cusp removal, followed by coronary reimplantation.RESULTSIn-hospital death occurred in 2 (18%) patients. Factors associated with hospital mortality were age <1year (P = 0.05), weight <3 kg (P = 0.02) and longer cross-clamping time (P = 0.008). Follow-up was complete for all patients [median follow-up time: 52.2 (range 132.2-2.5) months]. Mid-term significant AR occurred in 4 patients (45%, moderate in 2 and severe in 2). One with severe AR underwent successful valve replacement 4 months postoperatively, leading to freedom from reintervention of 91%. Freedom from significant AR was 76.2 (33.2-93.5) and 60.9 (20.2-85.6) at 1 and 2 years, respectively. There was a trend towards longer freedom from mid-term significant AR for patients who underwent cusp removal compared with those who did not (P = 0.07).CONCLUSIONTV repair in children can be performed safely with fairly good and durable results. Cusp removal might decrease the rate of severe AR on mid-term follow-up.
    Interactive Cardiovascular and Thoracic Surgery 03/2013; · 1.11 Impact Factor
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    ABSTRACT: OBJECTIVE: This study reviews a single-center experience with the Ross procedure in infants and young children. METHODS: From November 1993 to March 2012, 55 children aged less than 17 years underwent a Ross procedure. The patients ranged in age from 2 days to 17 years (median, 5.9 years). Thirteen patients were infants, and 18 patients were preschool children. The predominant indication for the Ross procedure was aortic stenosis. Twenty-seven patients (49%) with left ventricular outflow tract obstruction underwent a modified Ross-Konno procedure. Twenty-five patients (45%) had undergone 40 previous cardiac procedures. Preoperatively, 3 patients showed severe left ventricular dysfunction, with 2 of the patients requiring intubation and inotropic support. Concomitant procedures were performed in 11 patients (20%). Nine patients underwent mitral valve surgery, and 2 patients underwent subaortic membrane resection. RESULTS: Patients were followed up for a median of 66 months (range, 3 months to 17 years). Overall survival at 1, 2, 5, and 10 years was 84.9%. Hospital mortality rate was 13% (7/55 patients). All deaths occurred in neonates or infants, except 1 who was aged less than 4 years. Freedom from reoperation for autograft failure was 100% at 1 year, 96.7% at 5 years, and 73.7% at 10 years. During follow-up, 7 patients required a reoperation on the autograft for dilatation and severe aortic insufficiency. Freedom from reoperation for the right ventricular outflow tract replacement was 56.1% at 10 years. CONCLUSIONS: The low rate of autograft failure demonstrates that the Ross procedure is an attractive option for the management of aortic valve disease and complex left ventricular outflow tract obstruction in the pediatric population. However, alternative options must be considered in adolescents and young adults.
    The Journal of thoracic and cardiovascular surgery 03/2013; · 3.41 Impact Factor
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    ABSTRACT: AIMS: Cardiac pacing is a difficult technique in children, particularly in patients with congenital heart defects (CHDs). Few studies to date have addressed this topic.METHODS AND RESULTS: We performed a retrospective analysis of the results of a single centre. Between 1982 and 2008, 287 patients with CHD, median age of 5 years (25-75%, 1-11) underwent cardiac pacing for sinus node dysfunction (SND) and atrioventricular block (AVB); 97% of patients underwent at least one heart surgery. Endocardial systems (Endo) were implanted in 117 patients, epicardial systems (Epi) in 170, with 595 leads (228 Endo, 367 Epi). Endocardial systems showed a significantly older age group with more frequent SND; Epi a younger age group, with more frequent AVB, greater number of surgical interventions. Perioperative complications were mortality 0.6% (Epi), pericardial effusion 0.6% (Epi), and haemothorax 3.4% (Endo). The median follow-up is 5 (2-10) years: the pacing system failed in 29% of patients, 13% Endo, and 40% Epi (P < 0.0001). Multivariate analysis showed a significantly higher risk of failure for Epi, a lower implant age, greater the number of leads implanted. The risk of malfunction of the leads increases significantly for Epi and the younger age when implanted. The steroid-eluting leads have a lower risk of malfunction (P = 0.05), steroid-eluting Endo leads provide significantly better outcomes than Epi.CONCLUSION: Cardiac pacing in paediatric patients with CHD shows satisfactory results in the long term. Endocardial systems show significantly better results than Epi systems. A younger age when implanted is a risk factor for complications at follow-up.
    Europace 02/2013; · 2.77 Impact Factor
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    ABSTRACT: The use of mechanical cardiac assistance is well established as a bridge to orthotopic heart transplantation (OHT) or to recovery for patients with congestive heart failure, however, the experience in single ventricle (SV) physiology is still limited. We report two cases of mechanical assistance in patients with SV physiology: a 2-year old male with hypoplastic left heart syndrome who underwent Norwood Stage I and II followed by HF and a 4-year old female with a univentricular heart who developed a severe right ventricular dysfunction 2 years after a cavopulmonary shunt. Mechanical support utilizing ventricular assist devices (VADs) is considered a valid tool to bridge patients with congestive heart failure to either OHT or to recovery. Increasing experience and improved outcomes utilizing this technology in children with biventricular hearts have led to considering employing these devices in failing SV treatment. We present 2 cases of terminally ill children with SV who were assisted with a VAD.
    Interactive Cardiovascular and Thoracic Surgery 01/2013; · 1.11 Impact Factor
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    ABSTRACT: Despite the remarkable advances with the use of ventricular assist devices (VAD) in adults, pneumatic pulsatile support in children is still limited. We report on our experience in the pediatric population. Retrospective review of 27 consecutive children offered mechanical support with Berlin Heart as a bridge to heart transplant, and Jarvik 2000 as a destination therapy from February 2002 to October 2011. The median patient age was 4.8 years (range = 75 days to 20.5 years). The median patient weight was 18.6 kg (range = 2.9-63 kg). We divided the patients in two groups, including in group I patients assisted for bridging to heart transplantation and in group II patients with Duchenne's dystrophy assisted as destination therapy. In the group I, 11 patients required biventricular mechanical support (BVAD), but in all other cases, a single left VAD proved sufficient (56%). The median duration of VAD support was 48 days (1 to 192 days). The median pre-VAD pulmonary vascular resistance index (Rpi) was 5.7 WU/m(2) (3.5 to 14.4 WU/m(2)). Twelve patients (48%) were successfully bridged to heart transplantation after a median duration of mechanical support of 63 days (range = 2-168 days). Ten deaths occurred (40%), three for neurological complications, two for sepsis, two for multiorgan failure, and three other for device malfunctioning. Since 2007, the survival rate of our patients has increased from 33% to 75%, and the need for BVAD has decreased from 89% to 23%. In the group II, two patients with mean age of 15.3 years were assisted with Jarvik 2000, and both of them are alive in a follow-up of 10.4 months. In two patients with Rpi > 10 WU/m(2), unresponsive to pulmonary vasodilatator therapy, Rpi dropped to 2.2 and 2 WU/m(2) after 40 and 23 days of BVAD support, respectively. Six patients (32%) required at least one pump change. Of 12 patients undergoing heart transplantation, five developed an extremely elevated (>60%) panel-reactive antibody by enzyme-linked immunosorbent assay, confirmed by Luminex. All of them experienced at least one acute episode of rejection in the first month after heart transplant, needing plasmapheresis. The survival rate after heart transplantation was 100% with a median follow-up of 34.4 months (45 days to 8.7 years). Mechanical support in children with end-stage heart failure is an effective strategy as a bridge to heart transplantation with a reasonable morbidity and mortality. BVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance. The total implantable system opens a future scenarios for patients not eligible for heart transplantation.
    Transplantation Proceedings 09/2012; 44(7):2007-12. · 0.95 Impact Factor
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    ABSTRACT: We discuss 4 cases of plastic bronchitis (PB) after Fontan procedure observed at our Institution, with the aim to identify an effective treatment and possible factors favoring the onset of PB. Plastic bronchitis is an uncommon disease characterized by recurrent formation of large pale bronchial casts obstructing the tracheobronchial tree. The treatment includes inhaled or systemic steroids, aerosolized mucolytics, bronchoscopic lavage, direct bronchoscopic extraction and, in few reports, aerosolized fibrinolytic and pulmonary vasodilators. Four cases of PB after Fontan procedure occurred in our center from January 2008 to January 2012. All patients showed preserved ventricle function and underwent embolization of systemic-pulmonary collaterals prior to a Fontan procedure and all had chylothorax in the perioperative period. Two patients died; 1 of massive thrombosis of the superior vena cava and right pulmonary artery and the other of acute asphyxiation and refractory cardiac failure. The exact causes of PB in Fontan patients remain unknown. An early diagnosis and a multiple therapy with steroids, mucolytics, pulmonary vasodilators, and aerosolized tissue plasminogen activator may be effective.
    The Annals of thoracic surgery 06/2012; 94(3):860-4. · 3.45 Impact Factor
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    ABSTRACT: Fetal cardiac surgery (FCS) represents a challenging issue for the in utero treatment of congenital heart defects. However, FCS has still not gained the sufficient reliability for clinical practice due to an incompletely elucidated fetal stress response. For example, blood sampling can contribute to its onset, leading to fetoplacental unit dysfunction, one of the main causes of failure of the surgical procedure. In order to address this issue, the role of the autonomic control system during an experimental procedure of cardiac bypass on ewe fetuses was investigated by means of recurrence quantification analysis (RQA), a well-recognized method for the analysis of nonlinear systems. RQA was applied to time series extracted from fetal arterial pressure recordings before and after the cardiac bypass established by means of an extracorporeal circuit, including an axial blood pump, and taking advantage of the capability of the placenta to work as a natural oxygenator. Statistically significant correlations were found among RQA-based metrics and fetal blood gas data, suggesting the possibility to infer the clinical status of the fetus starting from its hemodynamic signals.This study shows the relevance of RQA as a complementary tool for the monitoring of the fetal status during cardiac bypass.
    The International journal of artificial organs 06/2012; 35(5):376-84. · 1.76 Impact Factor
  • Enrico Cetrano, Adriano Carotti
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    ABSTRACT: A 33-day-old neonate with transposition of the great arteries, ventricular septal defect, and intramural course of both coronary arteries underwent successful arterial switch repair. At a follow-up time of 36 months, left ventricular function and coronary arterial anatomy at angiography were normal. Optimal treatment of such rare coronary arterial abnormality may allow functional and anatomic results comparable to usual coronary arterial patterns in transposition of the great arteries.
    The Annals of thoracic surgery 03/2012; 93(3):986-7. · 3.45 Impact Factor
  • Adriano Carotti
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2012; 42(1):40-1. · 2.40 Impact Factor
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    ABSTRACT: To identify factors associated with the surgical outcome in patients undergoing right ventricular outflow tract reconstruction (RVOTR) using decellularized tissue-engineered pulmonary valve conduits (TEPVc) and to study their safety and longevity. From April 2006 to April 2010, 93 patients underwent either palliative or corrective RVOTR using Matrix P (37) and Matrix P Plus (56) xenogenic decellularized TEPVc (size range 11-27 mm). Median age and weight at operation were 20 (0.16-290) months and 10.15 (2.65-86) kg respectively. Primary and redo surgery occurred in 40 and 60% of cases, respectively. Eighty-eight patients (94.6%) received conduit implantation in the framework of corrective surgery, whereas in 5 (5.4%) a palliative procedure was undertaken. Follow-up was complete in 91% of patients, with a median duration of 12 months (range: 2 days-51 months). Data analysis included diagnosis, type of surgery (palliative vs. corrective) and age at surgery. Predetermined primary outcomes were represented by conduit failure or dysfunction. Two patients with Matrix P and two with Matrix P Plus died in the early post-operatively phase (4.3%). None of the deaths were conduit-related. One patient died at conduit replacement. Thirty-three patients (35.5%) experienced conduit failure whereas conduit dysfunction occurred in 27 patients (29%). Two-year freedom from conduit failure and dysfunction was 60.2% (95% CI: 50.1-69.6) and 77.4% (95% CI: 67.9-84.7), respectively. Reasons for failure were conduit stenosis in 20 cases (61%), pseudoaneurysm in 3 (9%), conduit dilatation (>50% of original diameter) in 2 (6%), stenosis of distal anastomosis involving pulmonary bifurcation in 6 (18%) and allograft dissection in 2 (6%). Histological examination showed inflammatory giant-type cells in the presence of a poor autologous cell seeding in all explanted specimens. Univariate and multivariate analyses showed an association between age at surgery ≤1 year and conduit dysfunction (adjusted HR: 2.29; 95% CI: 1.01-5.20, P = 0.04). Compared with the other conduit for RVOTR Matrix conduits showed a high incidence of failure. Our results suggest that the use of Matrix conduits for RVOTR should be considered with caution.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2012; 41(6):1320-5. · 2.40 Impact Factor