Sunday, October 22nd, 2017
Session I: Basic Science/Translational Research
Moderators:
- Christopher A. Caldarone
- Christian Pizarro
A1. Looking from Within: Virtual Reality in Congenital Heart Surgery
Syed Faaz Ashraf, T-Y Hsia
Great Ormond Street Hospital for Children, London, United Kingdom
Objective: 3D printed models can assist preoperative planning in complex congenital heart defects, but they remain time consuming and costly to make and do not render easy viewing of the intracardiac structures/anatomy. Advanced virtual reality (VR) interface can now allow for multi-plane visualization of all aspects of the intracardiac anatomy in 3D space. We developed a fast and low cost VR interface as a tool to assist perioperative management in congenital heart surgery.
Methods: A virtual world was created in a game engine Unity along with Google Virtual Reality Software Development Kit. MRI/CT scans of various congenital cardiac defects were segmented into 3D models and inserted into VR application. Transferring the application to an Android mobile phone allowed viewing with a Head Mounted Device (HDM).
Results: The VR application miniaturizes the viewer and allows him/her to ‘walk’ within the heart and great vessels in a 360-degree virtual world, with complete freedom of movement and visualization. After segmentation, time taken to VR viewing was 4-10 minutes (vs 2-6 hours for 3D printing). Set-up cost for VR application includes a mobile phone ($200-800) and a HMD ($5-80), without additional running costs. In contrast, a 3D printed heart model ranged between $50–100 each and requires a dedicated 3D printer.
Conclusion: Virtual reality offers a new and potentially superior method for preoperative surgical planning and postoperative assessment in complex congenital heart defects. This modality allows the viewer to move within the heart, and holds promise as a cost-effective tool to assist surgical decision making.
A2. Progress on the “Self-Powered Fontan” Model
William DeCampli1,2, Marcus Ni2, Giovanna Rodriguez2, Rachael Quinn2, Ray Prather2, Kyle Beggs2, Eduardo Divo3, Mark Fogel4, Alain Kassab2
1Heart Center at Arnold Palmer Hospital for Children, Orlando, FL, USA, 2University of Central Florida, Orlando, FL, USA, 3Embry Riddle Aeronautical University, Daytona, FL, USA, 4The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
William DeCampli1,2, Marcus Ni2, Giovanna Rodriguez2, Rachael Quinn2, Ray Prather2, Kyle Beggs2, Eduardo Divo3, Mark Fogel4, Alain Kassab2
1Heart Center at Arnold Palmer Hospital for Children, Orlando, FL;2University of Central Florida, Orlando, FL; 3Embry Riddle Aeronautical University, Daytona, FL; 4The Childrens Hospital of Philadelphia, Philadelphia, PA
Introduction: We previously reported on the concept of using a bifurcating aorto-pulmonary graft with directed “injection jets” (IJ) to augment pulmonary blood flow while reducing Fontan pressure in the “at risk” Fontan patient. Conceptually, the IJ would achieve objective similar to that of external pumps, expcept that it would be powered by the ventricle itself. We now report results of a multi-scale model.
Methods: We constructed a multi-scale Fontan in a manner similar to published methodologies. The IJ graft consists of an 8mm graft sewn to the aorta or branch, that bifurcates into two flanged branches terminating in 3mm nozzles. Each branch is sewn into a branch pulmonary artery on the edges of the cavopulmonary connection, so the jets are directed nearly parallel to the branch PA flow (Fig 1). Graft geometry is tailored to provide Qp/Qs < 1.5.
Results: Baseline model for a 4 year old patient had cardiac index (CI) = 2.2 l/min/m2, Fontan pressure (FP) = 16.4 mm Hg, and systemic oxygen delivery (SO2D) = 2.37 ml O2/sec. Addition of the IJ resulted in CI = 3.2 l/min/m2, FP = 13.5 mm Hg, SO2D = 2.9 mlO2/sec. Entrainment of ambient flow by the IJ was evident (Figs 2,3).
Conclusions: We have demonstrated the IJ effect in a full multi-scale model of the Fontan. An increase in oxygen delivery and decrease in Fontan pressure can be achieved with a Qp/Qs < 1.5.
A3. Improvement of Electrophysiological and Morphological Characteristics of 3D Bioprinted Human Induced Pluripotent Stem Cell-Derived Cardiac Patches by Defined Factors*
Chin Siang Ong1,2, Takuma Fukunishi1, Huaitao Zhang1, Chen Yu Huang2, Adriana Blazeski3, Deborah DiSilvestre2, Luca Vricella1, Leslie Tung3, Gordon Tomaselli2, Narutoshi Hibino1*
1Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA, 2Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA, 3Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
Objectives: Cardiac tissue engineering is essential as an alternative treatment for heart failure. We have successfully created beating electrically-connected 3D-bioprinted cardiac patches using human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs), but the tissue remains developmentally immature. Maturation of hiPSC-CMs is important to achieve the biomechanical properties of adult cardiomyocytes. We have thus developed a method of hiPSC-CM maturation and the purpose of this study is to examine whether this maturation method improves the electrophysiological and morphological properties of 3D-bioprinted cardiac patches.
Methods: hiPSC-CMs were co-cultured with human umbilical vein endothelial cells, and human cardiac fibroblasts in ultra-low attachment 96-well plates to form spheroids.
Defined factors were added: Triiodothyronine hormone, dexamethasone, insulin-like growth factor-1 (TDI). Spheroids were placed in a needle array using a 3D bioprinter. 3D-bioprinted cardiac patches were subsequently decannulated and subjected to electrophysiological tests and imaging using confocal microscopy.
Results: 3D-bioprinted patches treated with TDI have higher conduction velocities (treated 11.8±1.2 cm/s vs untreated 2.4±0.3 cm/s, p<0.0001), lower action potential durations at 30% repolarization (treated 66±2 ms, untreated 119±11 ms, p=0.0014) and 80% repolarization (treated 99±5 ms, untreated 228±7 ms, p<0.0001). Sarcomere length increased in biomaterial-free 3D-bioprinted cardiac patches treated with TDI by 30.6%±1.9% (p<0.0001), compared to untreated patches. All these changes suggested that TDI treatment promoted maturation of 3D-bioprinted cardiac patches.
Conclusion: Treatment with TDI significantly improves the electrophysiological and morphological properties of 3D-bioprinted cardiac patches, and creates an environment that promotes the development of working adult myocardium. This intervention has significant potential for the field of cardiac tissue regeneration.
A4. Right Ventricular Outflow Tract Replacement: From Innovative Chemical Concepts to The Development of a Tissue-Engineered Biofunctionalized Bioresorbable Valved Tube
David Kalfa1, Paul Hommes-Schattmann2, Margaux Pontailler3, Bilal Ahmad4, Axel Neffe2, Pierre Pouponneau5, Marilys Blanchy6, Gareth Williams4, Philippe Menasché3,7, Andreas Lendlein2
1TEH-Tube Scientific Coordinator, Department of Paediatric Cardiac Surgery, Columbia University, New York, NY, USA, 2Institute of Biomaterial Science and Berlin-Brandenburg Centre for Regenerative Therapies, 3Hôpital Européen Georges Pompidou, 4University College London, 5Statice SAS, 6Rescoll, 7University Paris Descartes
Objective – Conduits currently used to reconstruct the right ventricular outflow tract (RVOT) have no growth potential and require reoperations. To date, all available materials fail to display the chemical, mechanical and biological features matching the requirements to develop a growing valved tube for children. We investigated the in vitro and in vivo impact of innovative new-generation degradable polymers on the development of a tissue-engineered biofunctionalized bioresorbable valved tube.
Methods – Polyester-based degradable new-generation polymers were synthetized based on innovative chemical concepts and processed by electrospinning. In vitro fibre morphology, mechanical properties and crystallinity were analysed. Patches of electrospun polymers were implanted in the inferior vena cava of 90 rats: group 1: new-generation non-functionalized polymer (n=30); group 2: new-generation functionalized polymer (n=30); group 3: blends of off-the-shelf polymers (polyurethane/polycaprolactone) serving as controls (n=30). In vivo results were analyzed by echography, histology and immunohistochemistry at 3 months.
Results – Electrospinning of new-generation polymers led to the formation of highly organized fibres. Mechanical properties were tailorable by fine-tuning electrospinning settings, molecular weight and polymer composition. This new-generation polymer showed a trend towards a better in-situ tissue regeneration (less stenosis, better endothelial function, elastin-enriched extracellular matrix). Mechanical properties tended to replicate those of the native tissue. An advanced design of the valved tube based on computer-assisted designing techniques allowed for the production of second-generation polymeric tubes.
Conclusions – Compared to off-the-shelf polymers, the specific synthesis of innovative new-generation biodegradable polymers was beneficial to the development of cell-free tissue-engineered bioresorbable growing valved tube.
A5. Designing Customized 3D Printed Models For Surgical Planning in Repair of Congenital Heart Defects
Sarah Chen1, Juan Garcia1, Luca Vricella2, Narutoshi Hibino2
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Johns Hopkins Hospital, Baltimore, MD
Advances in diagnostic imaging and 3D printing technology have enabled the creation of patient-specific models. This research sought to establish a workflow for creating 3D printed congenital heart defect models, focusing specifically on creating aortic arch models optimized for surgical planning for hypoplastic left heart syndrome (HLHS) stage I palliation. Using this workflow, the objectives were to create a life-sized 3D printed model of pre-operative HLHS anatomy, an approximation of the desired post-operative anatomy, and a customized homograft patch designed for optimal aortic arch reconstruction. To create the models, specialized segmentation software was used to isolate aortic arch anatomy from HLHS CT scans. 3D modeling software was used to optimize the exported segmented model, and to design the shape of the homograft patch customized to allow for the desired post-operative result. The models were printed on a Stratasys PolyJet printer in a clear, flexible material to allow surgical suturing to assess the homograft patch, which was determined to be a successful fit. In addition, methods were established for creating aortic arch models from 3D ultrasound, to utilize a safe, cost-effective, and accessible imaging modality. Accordingly, proof-of-concept 3D printed models were created from 3D aortic arch ultrasound as well as 3D fetal cardiac ultrasound data. Creating models from fetal imaging could allow surgeons more time for pre-procedural planning. The resulting workflow promotes a novel method for producing patient-specific 3D printed cardiac models as well as a method to custom design surgical patches, which have the potential to improve treatment planning and outcomes.
A6. The Therapeutic Advantage of Neonatal Cardiac Progenitor Cells and Their Potential for in Utero Administration*
Gregory J Bittle1, Sudhish Sharma1, Rachana Mishra1, Progyaparamita Saha1, Sonying Cao2, Penghua Yang2, Wei-Bin Shen2, K. Barry Deatrick1, Peixin Yang2, Sunjay Kaushal1
1Department of Surgery, Division of Cardiac Surgery and 2Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
The Therapeutic Advantage of Neonatal Cardiac Progenitor Cells and Their Potential for In Utero Administration
Gregory J Bittle1, Sudhish Sharma1, Rachana Mishra1, Progyaparamita Saha1, Sonying Cao2, Penghua Yang2, Wei-Bin Shen2, K. Barry Deatrick1, Peixin Yang2, Sunjay Kaushal1
1Department of Surgery, Division of Cardiac Surgery and 2Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
Objectives: This study examines the mechanisms by which human neonatal c-kit+ cardiac progenitor cells (nCPCs) orchestrate positive myocardial remodeling, and evaluates the feasibility of in utero CPC administration as a basis for studying the behavior of nCPCs in the fetal heart.
Methods: Human CPCs were isolated from neonates (nCPCs) or adults (aCPCs). These were then characterized in vitro, and their in vivo effectiveness was evaluated in a rat model of myocardial infarction followed by serial echocardiography for 4 weeks – a well-established regenerative model. These experiments were repeated using nCPC total conditioned medium (nTCM) and the exosomal fraction of nTCM (nEXO). Finally, in utero, intramyocardial, microultrasound-guided CPC administration was performed in a mouse cardiomyopathy model at multiple time points between E9-E16 (single injection per fetus).
Results: Compared to aCPCs, nCPCs exhibit better functional recovery and reduced fibrosis after MI. nTCM was more effective than nCPCs in promoting improved function and positive tissue-level remodeling; nEXO and nCPCs were similarly effective in these regards. In utero CPC administration was feasible after E9, with the lowest peri-procedural mortality between E9-E11. Exogenous cells were confirmed in the myocardium of selected fetuses immediately after injection.
Conclusions: nCPCs possess superior capacity to induce positive remodeling compared to aCPCs in a model of myocardial injury and regeneration, and this effect is mediated by paracrine mechanisms. Having established a reliable method for in utero CPC administration, we intend to further investigate the therapeutic potential of nCPCs and their products to rescue rodent models of congenital cardiomyopathy and structural heart disease.
A7. Donor Cell Free DNA (Dcf-DNA) as a Non-Invasive Indicator of Rejection Following Pediatric Cardiac Transplantation
Steven Kindel1, Karl Stamm1, Mary Goetsch1, Donna Mahnke1, Mats Hidestrand1, Pip Hidestrand1, Gail Stehndahl1, Ronit Katz2, Aoy Mitchell1, Steven Zangwill3, Michael Mitchell1
1Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA,2University of Washington, Seattle, WA, USA 3Phoenix Children’s, Phoenix, AZ, USA
Session II: Videos
Moderators:
- Christopher Mascio
- Luca A. Vricella
V1. A Patient-Specific, 3-D Printed, Bioresorbable Splint for the Treatment of Tracheobronchomalacia
Richard G. Ohye1, Scott J. Hollister2, Andrea S. Les1, Ayishwariya Premanathan3,Glenn E. Green1
1University of Michigan, Ann Arbor, MI, USA, 2Georgia Institute of Technology, Atlanta, GA, USA, 3Materialise, Leuven, Belgium
Severe tracheobronchomalacia (TBM) remain a challenge with mortality rates of 20-50%. Surgical options, including stenting, aortopexy, and reconstruction, have high complication and failure rates. We have developed a customizable, 3-D printed, bioresorbable splint to treat TBM. The splint has been successfully used in seven infants and children and in one adolescent (non-resorbable) at our institution. An additional patient was treated successfully in Spain. This video will highlight the splint, the implantation and the current results of this innovated solution.
V2. 360 Degree Cone Reconstruction for Ebstein’s Anomaly
Michael E. Mitchell1, Peter Kouretas2, Viktor Hraska1
1Children’s Hospital of Wisconsin, Milwaukee, WI, USA, 2UCSF, San Francisco, CA, USA
Several modifications of the Cone procedure as first described by da Silva have been reported. We have employed a complete 360° leaflet detachment coupled with a 60 degree counterclockwise rotation in performing the Cone procedure in infants and adults with excellent results. We feel that this complete mobilization coupled with the counterclockwise rotation provides for both better alignment of the leaflets and subvalvar apparatus as well as a more symmetrical distribution of tension following leaflet reattachment potentially resulting in better valve function and longevity of repair.
V3. Arterial Switch with Intraarterial Tunnel for TFA with Intramural Single Coronary Artery
Christian Pizarro, Majeed Bhat, Daborah Davis. Daniel Duncan
Alfred DuPont Hospital for Children, Wilmington, DE, USA
The video illustrates an arterial switch procedure using an intra arterial tunnel (Takeuchi)in a patient with transposition of the great arteries with intact ventricular septum and single intramural coronary artery. This technique provides an effective option for arterial switch with out the need to move a single coronary button with a proximal intramural course. The nature of the pathway incorporating native tissue allows for future growth and patency is demonstrated by angiography several years later
V4. Transposition of the Great Arteries with Intact Ventricular Septum and Type 1 Aortopulmonary Window
Ziyad M. Binsalamah1, Luis E. De León1, Gurpreet S. Dhillon2, Caraciolo J. Fernandes2, Asra Khan2, Keila N. Lopez2, Jeffrey S. Heinle1
1Congenital Heart Surgery, 2Pediatric Cardiology, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
Aortopulmonary window is a rare form of congenital heart disease that can be seen in isolation or with associated other complex cardiac lesions. We demonstrate the successful repair of transposition of the great arteries with an associated aortopulmonary window in a neonate. The repair consisted of an arterial switch operation, and repair of the aortopulmonary window. Repair of transposition of the great arteries in association with an aortopulmonary window can be successfully achieved in the neonatal period, with excellent outcomes. Timing of surgical intervention depends on its size and location, as well as the associated complex congenital heart lesion.
V5. Techniques I learned from Dr Hanley? How I do a Unifocalization
Ali Ibrahimiye, James Hammel
Children’s Hospital and Medical Center Omaha, Nebraska, USA
Objective: This video demonstrates the techniques utilized to expose and dissect MAPCA’s without going on cardiopulmonary bypass
Methods: Patient is a 3 month old 4.5 kg infant with TOF/PA/MAPCA x3. We dissect MAPCA’s and unifocalize right lung off pump.
Results: We performed a complete repair. Cross clamp and bypass times were 36 min and 152min respectively. Mean PA pressure was 11.
Conclusion: We are showing that MAPCAs can be safely exposed and dissected without going on bypass which we believe is very critical for a successful unifocalization.
Pizza Dinner & Poster Session
P1. High Risk For Infective Endocarditis With Use Of Bovine Jugular Vein Valved Conduits (“Contegra”)
Ziv Beckerman, Luis E. De Leon, Carlos M. Mery, Ziyad M. Binsalamah, Charles D. Fraser, Jr.
Division of Congenital Heart Surgery, Texas Children’s Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
Objective(s): We recently reported our outcomes and incidence of late endocarditis in patients undergoing right ventricle (RV) to pulmonary artery (PA) conduit placement. The use of a bovine jugular vein (BJV) conduit was found to be the sole significant risk factor for late endocarditis (HR, 9.05; 95% CI, 2.6–31.8 compared with homografts). The purpose of this study is to update our report on the incidence with BJV endocarditis.
Methods: All RV–to–PA valved conduits placed between 1995 and 2017 were included. Freedom from endocarditis was analyzed using the Kaplan-Meier method and parametric survival regression models.
Results: A total of 228 patients underwent placement of a total of 253 BJV conduits. The median duration of conduit follow-up was 5y (6d-16y). 24 (9.5%) patients developed endocarditis of their BJV at a median of 7.5y (34d-14y) after the surgery. Freedom from endocarditis at 1y, 2y, 5y, 8y, 10y was 99%, 98%, 97%, 85%, 78% respectively (Figure 1.). Over our previously reported follow-up period (2001-2014), 14 patients with BJV developed endocarditis (6%), while over the last 2.5 years, additional 10 patients developed endocarditis, raising the incidence of endocarditis to 9.5%. 22 patients (92%) underwent surgical replacement of their conduits, with no mortality.
Conclusions: The incidence of late endocarditis (9.5% at a median of 7.5years) affecting BJV is high. These concerning findings call into question the continued use of these conduits. Surgical replacement of an infected conduit is recommended, with excellent survival.
P2. Bridge to Lung Transplant With Paracorporeal Lung Assist Device (PLAD) in 1-Year Old Patients: Lessons Learned
David Morales, Farhan Zafar, Christopher Towe, Chet Villa, Angela Lorts, David Cooper, Jami Johnson, James Reagor, Marc Schecter, Roosevelt Bryant 3rd1
The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Introduction: Refractory pulmonary hypertension(PHtn) leading to cardiac dysfunction in children occasionally requires mechanical support. We report two infants who were successfully bridged-to-lung transplantation(LTx) with the use of pLADs.
Methods/Results: A 20-month-old female(7kg)(patient-1) and an 8-month-old male(8kg)(patient-2) had been critically ill for six and three months with PHtn refractory to medical management. Both patients were initially supported with a Quadrox-Pediatric pLAD using 6mm EXCOR cannulas in the main pulmonary artery and left atrial(LA) appendage (no exposed cannula in the LA to avoid stroke). Patient-1 had primary pulmonary vein stenosis, underwent a device exchange due to “failing” oxygenator(day-9), an addition of a centrifugal pump into the circuit due to progressive right heart failure(day-19), and then was transplanted(day-44). She died 110-days post-transplant from an overwhelming RSV viremia. Patient-2 had a history of viral infection, VA-ECMO and unremitting pneumothoraces. He was transitioned to the NovaLung(day-14) and transplanted(day-31) 7mos ago and continues to rehabilitate. On the pLAD, both patients could extubate, re-socialize and begin physical/nutritional rehabilitation. Amongst other technical/care details, we learned that the pressure-drop of the pediatric-Quadrox is 38mmHg at 1.5LPM (retains heater/cooling capabilities) compared to the NovaLung’s 4mmHg at 1.5LPM. NovaLung has a larger surface area requiring more flow to avoid thrombus. Anticoagulation was with heparin/high-dose aspirin and resulted in no stroke, device thrombosis or bleeding events.
Conclusion: pLADs may be a safe bridge-to-LTx for smaller children with the potential for physical, social and nutritional rehabilitation. Shared learning is essential to improve the outcomes of these complex pediatric patients supported with novel device strategies.
P3. Impact of Fenestration on Postoperative Complications Following A Fontan Procedure: Systematic Review and Meta-Analysis
Bouhout Ismail1, Ben-Ali Walid1, Khairy Paul2, Poirier Nancy1
1Department of Cardiac Surgery, Montreal Heart Institute and CHU Sainte Justine, University of Montreal, Canada, 2Department of electrophysiology, Montreal
Objective: A systematic review and meta-analysis of studies were performed comparing fenestrated and nonfenestrated Fontan procedures.
Methods: Medline and Embase were searched with the following strategy: ([Fenestration OR Fenestrated] AND [Fontan OR cavopulmonary connection) from 1990 to 2017. A total of 413 papers were screened by two independent reviewers (IB and BW). The primary endpoint was Fontan failure defined as in-hospital mortality or Fontan take down. Secondary endpoints were in-hospital mortality, reduction in postoperative pulmonary pressure, prolonged chest tube drainage (> 10 days), intensive care unit (ICU) and hospital length of stay. Data were pooled using Rev Man 5. A random effect analysis was used when the heterogeneity was more than mild (I2? 25%).
Results: Seventeen studies with a total of 4769 patients were included. There was a tendency towards a lower Fontan failure rate in the fenestrated group (OR: 0.74 [0.54-1.02], p=0.06, I2=20%). In contrast, the in-hospital mortality was similar between the two groups (OR: 1.10 [0.57-2.12], p=0.78, I2=49%). The postoperative pressures was significantly lower after a fenestrated Fontan (SMD -0.99 [-1.68-0.30] mmHg, p=0.005, I2=95%). The incidence of prolonged chest tube drainage was lower in the fenestrated Fontan (OR: 0.41 [0.23-0.75], p=0.004, I2=71%). However, the ICU and hospital length of stay were similar in the two groups (SMD: 0.69 [-0.24-1.62], p=0.14, I2=95% and -0.84 [-5.04-3.36] days, p=0.70, I2=98%; respectively)
Conclusions: The fenestrated Fontan reduces postoperative chest tube drainage, is more effective in reducing postoperative pulmonary pressures and may mitigate the risk of Fontan failure.
P4. An Appraisal of Materials and Value for Patch Reconstruction of the Pulmonary Arteries
William Hollabaugh1, Michael McGinnis2, William K. Johnson1, Michael E. Mitchell1, James S. Tweddell3, Ronald K. Woods1
1Medical College of Wisconsin, Children’s Hospital of WI, Milwaukee, WI, USA, 2Wayne State School of Medicine, Detroit, MI, USA, 3Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, OH, USA
Methods: Retrospective single-institution review spanning the interval 1990-2015 of patients undergoing main or branch PA reconstruction. Five patch materials were analyzed: CM – porcine submucosal matrix; BovP – bovine pericardium; BPH – branch patch pulmonary homograft; G – goretex; and AutP – autologous pericardium. Primary outcome was re-intervention on the reconstructed PA site. Median follow-up was 5.3 years (IQR 2.5-9.5).OBJECTIVE(S) – We sought to evaluate quality (re-intervention) and cost of various patch materials used for main and branch pulmonary artery (PA) patch reconstruction.
Results: The cohort included 341 patients and 442 patch reconstruction sites. Median age (IQR) and weight were 0.53 yrs (0.3-1.4) and 6.9kg (5.1-8.9). TOF/PS and other biventricular repair constituted 54.3% of the cohort. Patch sites included main PA (w/wo) extension to branch for 143 patches (32.4%); L PA and hilar for 90 (20.4%); R PA and hilar for 105 (23.8%); and both branches for 65 (14.7%). Table 1 lists re-intervention and unit cost per type of patch material, demonstrating wide variability in cost and non-inferior quality of the least expensive material.
Conclusions: Selection of patch material for PA reconstruction has the potential to substantially improve value by reducing cost.
P5. Preserved Left Recurrent Laryngeal and Phrenic Nerve Function With Use of Ferromagnetic Dissection When Compared With Monopolar Electrocautery
Jessica Noel-Morgan1, Christina Namakydoost1, Carlos del Rio2, Shaylyn Bennett1, Pawel Kwiatkowski1, Patrick McConnell1
1Nationwide Children’s Hospital, Columbus, OH, USA, 2QTest Labs, Columbus, OH, USA
Objectives: Recurrent laryngeal nerve (RLN) injury is a significant morbidity after many congenital heart surgeries. We sought to determine the relative impact of stretch, and ferromagnetic (FM) dissection or monopolar electrocautery (EC) on the function of the recurrent laryngeal (RLN) and phrenic (PN) nerves in a swine model.
Methods: Eleven pigs were intubated with EMG endotracheal tubes. Following left thoracotomy, the proximal vagus, PN and RLN were isolated and instrumented with nerve stimulator. RLN was stretched at 5mm for 10 minutes. Pigs received two-second insults at 50mm, 5mm and 2mm from the RLN with FM (max=60, n=6) or EC (20/20, n=5). EMGs were obtained before and after each insult. PN function was monitored by hemidiaphragm developed force (DF) via stimulation sequences before and after FM or EC insults.
Results: RLN stretch generated 58 ± 12g of force and reduced amplitudes by 35 ± 24% (4.0mA, P=NS). At 2 mm from RLN, EC insult resulted in complete loss of transmission (4.0mA, P<0.001 vs. Stretch and FM) while FM insult decreased amplitudes by 28 ± 24% (4.0mA, P=NS vs. Stretch). Following PN insult, EC reduced DF by 92 ± 9% (4.0mA, P<0.001 vs. Baseline) and FM reduced DF by 23 ± 21% (4.0mA, P=NS vs. Baseline).
Conclusions: RLN stretch had minimal effect on function. Low voltage EC, when used within 2mm of the RLN or PN, resulted in severe injury to PN and complete loss of function to the RLN. FM cautery had no significant effect to either nerve at the highest energy setting.
P6. The Rastelli Procedure with Our New Modification (Rastelli with Straightening Aortoplasty) in an Attempt to Improve the Hemodynamic State of Left Ventricular Outflow Tract and Aorta**
Mohammed K. Al-Jughiman, Maryam A. Al-Omair
Prince Sultan Cardiac Center, Al-Ahsa, Saudi Arabia
Background: The mal-aligned LVOT that results after Rastelli procedure has been a concern. Our study was undertaken to confirm three hypothesises. First, the flow pattern in the ascending aorta (not only the LVOT) is not as laminar as in normal heart because the relationship between LV and aorta is different after Rastelli. Second, the aorto-patch angle after Rastelli represents the aorto-septal angle in normal heart. So, the steeper this angle, the more turbulent flow across LVOT. Third, minimizing that steep angle by performing our modification (straightening aortoplasty) will produce less turbulence in both LVOT and aorta which may eventually retard subaortic growth that has been associated with subaortic turbulence.
Methods: Computational Fluid Dynamics simulations of the Rastelli and “Modified” Rastelli have been split up into multiple developmental streams. Comparisons were made of multiple post-processing analyses to evaluate flow patterns.
Results: In both procedures, the turbulent kinetic energy (TKE) in the ascending aorta was around 80% of TKE in the LVOT which confirmed our first hypothesis. “Modified” Rastelli has shown less TKE and less wall shear stress in the LVOT. Pressure drop (indicative of energy loss) between LVOT and aortic valve was less in “Modified” Rastelli. Both procedures have large flow separation in the ascending aorta but that separation was significantly less in the “Modified” Rastelli,(Figure.1.A). Separation is associated with pressure drop and insufficiency. As a result, the aortic systolic pressure at 0.01s of systole was 43mmHg in Rastelli and 65.7mmHg in “Modified” Rastelli,(Figure.1.B).
Conclusion: “Modified” Rastelli has produced more favorable hemodynamics in both LVOT and Aorta.
P7. Withdrawn
P8. Brain Injury to Cardiac Procurement Interval And Relationship To Outcomes Of Pediatric Cardiac Transplantation
Craig Grosshuesch, William K. Johnson, Nick DeVogel, Tao Wang, Steven J. Kindel, Ronald K. Woods
Medical College of Wisconsin, Children’s Hospital of WI, Milwaukee, WI, USA
Objective(s): Severe brain injury and brain death are associated with pathophysiological changes unfavorable to the heart. Limited single-center studies evaluating interval from brain death to cardiac procurement have produced conflicting results. We sought to analyze the relationship between the interval from primary central nervous system event to cardiac procurement with major outcomes after pediatric cardiac transplantation using a large national registry.
Methods: We retrospectively evaluated a pediatric cohort from the UNOS registry over the interval 2005-2014 including only recipients who received donor hearts from patients with a primary CNS event. Time from donor admission to donor aortic clamp defined the brain interval (BI) which was categorized into 4 intervals – < 2 days, 2-4 days, 4-6 days, and > 6 days. Primary outcomes were recipient and graft survival. Logistical regression modeling was used for multi-variable analysis.
Results: The cohort included 2,731 recipients. BI was not related to time to patient death or rejection, nor death or cardiac rejection prior to discharge (Table 1). Additional sub-analyses of various age groups and recipient diagnoses didn’t alter these findings. Defined from the time of brain death declaration (as echo data was not available prior), longer time interval was associated with fewer hearts accepted for transplant – 62.8% for > 5 days versus 74.1% to 85.0% for shorter intervals (p<0.0001).
Conclusions: Based on UNOS data, there was no relationship between BI and major outcomes after pediatric cardiac transplantation. Extended donor management intervals may reduce the number of hearts deemed acceptable for transplantation.
P9. Vivien Thomas and His Contributions to Congenital Heart Surgery
Osama M. Eltayeb1,2 Carl L. Backer1,2
1Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Background: More than 70 years have passed since the first systemic-to-pulmonary artery shunt was performed to treat cyanotic heart disease at Johns Hopkins University in 1944. The collaboration of Blalock, Taussig, and Thomas to develop an operation to treat Tetralogy of Fallot has been well documented in the medical literature. Although Vivien Thomas’ contribution as a full partner in this endeavor was originally unrecognized, several articles and the modern media have recently illustrated the importance of Thomas’ role in ushering in the modern era of cardiac surgery.
Methods: Literature search was conducted using PubMed, Ovid, and the autobiography of Vivien Thomas, Pioneering Research in Surgical Shock and Cardiovascular Surgery.
Results: Following the success of the systemic-to-pulmonary artery shunt Thomas carried out research on arterial implants in the left ventricle, interventricular septal defects, and mitral and pulmonary insufficiency. He oversaw the experiments that led to the first operation for transposition of the great arteries and developed surgical instruments such as the vascular clamp. Most importantly he trained and mentored many surgical residents who went on to become chiefs of pediatric cardiac surgery at many institutions throughout the United States such as Texas Children’s Hospital, University of Pittsburgh, and Johns Hopkins.
Conclusions: Vivien Thomas’ contributions to congenital heart surgery were extensive well beyond the development of the “Blue Baby” operation. The “Blalock-Taussig shunt” should more appropriately be called the “Blalock-Taussig-Thomas shunt.”
P10. Comprehensive Interstage Cardiac Care Program from Fetus to Glenn Results in Improved Survival for Complex Single Ventricle Infants
Haleh Heydarian, Dennis Wells, Samuel Hanke, James Cnota, Bryan Goldstein, Roosevelt Bryant 3rd, James Tweddell, David Morales
The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
Session III: My Worst Nightmare Cases
Moderators:
- Emile A. Bacha
- Scott M. Bradley
A8. Mitral Valve Excision in Pediatric VADs: Not as Benign as One Thinks*
Yusuke Terasaki, Narutoshi Hibino, Kristin Nelson-McMillan, Todd Crawford, Alejandro Suarez, Luca Vricella
Johns Hopkins Hospital, Baltimore, MD
A9. The Enemy of Good Defined
Joshua Hermsen1, Eric Krieger1, Jonathan Chen2
1University of Washington Medical Center, Seattle, WA, USA, 2Seattle Children’s Hospital, Seattle, WA, USA
We converted a 24 yo male with D-TGA/VSD/PS, who had undergone Fontan palliation because of straddling mitral chordae, to a 1.5V circulation. Pre-operatively the patient was asymptomatic with Fontan pressures of 8mmHg and VO2 max 27.8ml/kg/min (62% predicted). Initial operative results were no VSD, no MR, 20mmHg peak LVOT gradient and <1/2 systemic RV pressures. The right ventriculotomy was somewhat constrained by a large acute marginal coronary.
A patch margin VSD developed on POD 3 and endovascular closure was successful. Near systemic RV hypertension was noted after closure. The patient was re-intubated for pneumonia POD 6 and suffered circulatory arrest. Central VA ECMO was initiated following 90 minutes of CPR. The RV-PA conduit was unsuccessfully revised on ECMO day 5 and successfully revised via ventriculotomy enlargement on ECMO day 7 with resultant RV pressures of 40mmHg allowing ECMO weaning. Renal function recovered after 22d of hemodialysis support. The chest was closed via rectus flap and split-thickness skin grafting. The patient discharged home on POD 92 ambulatory and grossly neurologically intact following inpatient rehabilitation.
In follow-up the patient has required high dose diuretics and RHC at 5 months shows: RA pressure 21, RV 49/20, PA 27/19 (23), PCW 22.
In an attempt to avoid future Fontan morbidity this patient was harmed. The key mistake of limiting the size and inferior extent of the right ventriculotomy led to a cascade of untoward events from which he narrowly escaped. Fontan conversion to 1.5 or 2V circulation is high risk and demands technical perfection.
A10. Ross-Konno Operation with Associated AAORCA Repair in an Infant with Quadricusp Pulmonary Valve
Christopher J. Knott-Craig, Umar Boston, TK Susheel Kumar, Ken-Michael Bayle, Ranjit Philip
Le Bonheur Children’s Hospital and University of Tennessee Health Sciences Center, Memphis, TN, USA
A neonate with mitral stenosis, bicuspid aortic valve, posterior malaigned VSD, ASD, and interrupted aortic arch underwent complete biventricular repair. At 3 months left-sided structures had normalized in size but the infant had developed significant LVOTO (gradient 60 mmHg). At reoperative surgery, a Ross-Konno operation was done. The surgery was complicated by presence of AAORCA, with the coronary ostia arising very close to each other from the left facing sinus. In a addition, the pulmonary valve was a quadricuspid valve, making coronary transfer even more difficult. Video of anatomy and surgical repair.
A11. Why won’t the Left Ventricle Beat? The Perils of an Undiagnosed Anomalous Left Coronary Artery
S. Adil Husain, John H. Calhoon
University of Texas Health – San Antonio
Objective: We describe a failing Left Ventricle (LV) following Complete Atrioventricular Canal Defect (CAVC) repair.
Methods: A 5 month-old underwent CAVC with subsequent severe LV dysfunction. An anomalous left coronary artery was identified off the right pulmonary artery (ALCARPA).
Results: Post operative extracorporeal membrane oxygenation support (ECMO) was required following a cardiac arrest. Reoperation was required due to mitral valve regurgitation and a ventricular septal defect due to suture dehiscence.
Conclusions: In unknown ALCARPA, cardioplegia delivery to the left heart is inadequate. Novel reparative techniques and post-operative mechanical circulatory support may be required.
Monday, October 23rd, 2017
Scientific Session IV
(8 minute talk and 7 minute discussion)
Moderators:
- Carl L. Backer
- Harold M. Burkhart
~ John A. Hawkins Top Scoring Abstract Award ~
A12. Airway Compression After Complete Unifocalization in Patients With Pulmonary Atresia, Ventricular Septal Defect, and Major Aortopulmonary Collaterals
Shuhua Luo1,2, Glen Van Arsdell1, Osami Honjo1
1Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Canada, 2Department of Cardiovascular Surgery, West China Hospital Sichuan University, Chengdu, China
Objective: We hypothesized that reconstructed pulmonary artery(PA) size and post-repair PA pressure are associated with postoperative airway compression (AC) following complete unifocalization for pulmonary atresia (PA), ventricular septal defects (VSD), and major aortopulmonary collaterals(MAPCAs).
Methods: Forty-eight consecutive patients underwent completed unifocalization between 2000 and 2016. Clinical course and outcome were reviewed, and potential factors associated with AC were analyzed.
Results: Fourteen(29.2%) of 48 patients developed AC. The median duration of follow up was 2.6 years. AC was caused by branch PA and aorta(n=4), branch PA and conduit(n=2), conduit(n=2), arch(n=2), conduit and aorta(n=4). Surgical treatment was required eight(57%) patients[Conduit downsizing(n=1) and suspension of branch PA(n=2), conduit+aorta(n=2), conduit(n=2), aorta(n=1), aorta+trachea(n=1)]. Four(28%) patients required additional airway stent. RV Systolic Pressure/LV Systolic Pressure(RVSP/LVSP)(p=0.04), RV-PA conduit size index(p=0.0001), and Nakata index of neo-PA(p=0.003) were significantly higher in patients with AC. The majority of AC occurred in patients with high RVSP/LVSP(>65%) and large Nakata index (>200mm2/m2). The patients with AC had significantly worse 3-year survival (no compression 88.2% vs. compression 64.2%, p=0.03). Binary logistic regression identified large RV-PA conduit size index (p=0.03) and Nakata index of neo-PA (p=0.004) as the predictors for AC.
Conclusion: AC early after PA/VSD/MAPCAs repair is a common complication associated with high mortality and morbidity. Excessive enlargement of the central PA and high pressure are important mechanisms of developing airway compression in this entity. Appropriate design of the size and geometrical arrangement of branch PA and conduit may reduce the incidence of AC in the high-risk group of the patients with high post-repair PA pressure.
A13. Effect of Atrioventricular Valve Repair on Outcomes of Single Ventricle Palliation
Bahaaldin Alsoufi, Raina Sinha, Kirk Kanter, Dean McKenzie
Emory University School of Medicine
Objectives: The presence of significant atrioventricular valve (AVV) regurgitation results in unfavorable conditions that affect the success of single ventricle (SV) multistage palliation. We report our AVV repair experience.
Methods: We examined the need of AVV repair in 604 infants who underwent initial palliation surgery (2002-12), explored patients’ characteristics and anatomic details associated with outcomes.
Results: Fifty-seven patients received AVV repair during first-stage(n=8), Glenn(n=30), Fontan(n=19) stages. Median age at time of AVV repair was 6.6 months (IQR4.2-24.1). Underlying SV anomaly was HLHS(n=29), atrial isomerism(n=14), other(n=14). The AVV was tricuspid(n=30), mitral(n=8), common(n=19). Pre-operatively, 55(97%) had AVV regurgitation ≥ moderate and 8(14%) had ventricular dysfunction ≥ moderate. Post-repair, AVV regurgitation was none or trivial (n=21,37%), mild (n=19,33%), moderate (n=17,30%). Competing risks analysis showed that 10-years following AVV repair, 15 % had died, 15% had received transplantation, 14% had undergone AVV reoperation and 56% were alive without transplantation or AVV reoperation. Overall survival and transplant-free survival at 10-years following AVV repair was 78% and 68%. Factors affecting transplant-free survival were AVV repair at first-stage surgery (HR1.8(0.6-5.6),p=0.005) and post-repair ventricular dysfunction ≥ moderate (HR5.4(1.5-19.8),p=0.036). Comparison with a matched control group, transplant-free survival was lower in AVV repair cohort (68%vs.87%,p=0.013).
Conclusions: The presence of significant AVV regurgitation affects SV palliation survival. This is especially evident in patients who require AVV repair at first-stage surgery and those with diminished ventricular function. Different approaches are warranted in these high-risk patients and those might implicate the mode of initial palliation, timing of AVV repair and listing for transplantation.
A14. In Vitro Hemodynamic Comparison of the St Jude Medical 15mm Mechanical Heart Valve to the Melody Deployed at 16mm
James Hammel1, Jacob Quint2, Amber Stettnichs2, Kevin Cole2
1Children’s Hospital, Omaha, NE, USA, 2University of Nebraska School of Engineering, Lincoln, NE, USA
Objective: When reconstruction is not possible, options for atrioventricular valve replacement in infants are limited. A 15 mm mechanical heart valve (St. Jude Medical) is available on a compassionate use basis. The Melody transcatheter pulmonary valve (Medtronic) has been used off-label as a mitral and tricuspid replacement. The hemodynamic performance of neither valve has been published. We sought to measure and compare the open-mode flow potential of the two prosthetic valves.
Method: Testing was performed with a ViVitro pulse duplicator system using blood analogue and physiologic infant flows and pressures. Custom valve mounts were created. The Melody valve was deployed within a 16 mm sleeve, whereas the SJM valve was mounted over a 15mm orifice. A conventional mechanical valve (OnX, 19mm) was tested as control. Transvalve pressure gradient was measured at a range of flows and the effective orifice area (EOA) was calculated from the most linear part of the pressure/flow relationship.
Results: Measured EOA of the control valve agreed with published values. EOA of the SJM 15mm mechanical valve was 1 cm2, whereas the EOA of the Melody deployed at 16 mm was only 0.65 cm2.
Conclusion: At similar annular dimensions, the hemodynamic potential of the SJM 15mm mechanical valve exceeds that of the Melody valve significantly. These data may help guide surgeons in the application of both valves.
A15. Perioperative Outcome of Stage 1 Norwood Palliation with Dual Arterial Cannulation
Ali Ibrahimiye, Joby Varghese, Rebecca Siecke, Kim Duncan, James Hammel
Children’s Hospital and Medical Center Omaha, Nebraska, USA
Objective: Norwood reconstruction using direct cannulation of the innominate artery and descending aorta (DAC) can be performed under mild hypothermia and with uninterrupted flow to the brain and viscera throughout the procedure. The heart is arrested for the proximal neoaortic root reconstruction. We sought to report outcomes of this procedure with regard to survival, blood transfusion, inotropic support, and duration of mechanical ventilation.
Methods: Retrospective review of all patients with HLHS who underwent Norwood stage 1 palliation at our institution by a single surgeon, since adoption of the DAC technique in 2009.
Results: 40 neonates with HLHS underwent Norwood operation with DAC. 36 survived to second stage operation (90%). Duration of crossclamp and cardiopulmonary bypass (med, IQR) were 31 (23, 57) minutes and 110 (95, 146) minutes respectively. All patients received washed red cells in the circuit prime. 12 patients (30%) required no additional transfusion for hemostasis. 28 patients received platelets, of whom 3 also received cryoprecipitate and 1 received FFP. Six patients (15%) were treated with open chest. Duration of mechanical ventilation was 3 (1, 4) days. Duration of ICU stay was 9 (5, 19) days. The mean inotrope score (dopamine + milrinone x10 + epinephrine x100) was 6.74.
Conclusion: Stage 1 palliation for HLHS can be performed safely with DAC under mild hypothermia. Survival is similar to reported series from highly experienced centers. Inotrope score, blood transfusion, length of stay, and duration of ventilation compare favorably to national benchmarks.
A16. Post-Transplant Survival in Heart and Lung Transplant Recipients: Poor Outcomes Extend Beyond the Standard Adolescent Age Group
David Morales, Scott Baker, Raheel Rizwan, Ivan Wilmot, Christopher Towe, Farhan Zafar, Roosevelt Bryant III
The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Introduction: Adolescents are known to have worse survival for heart (HTx) and lung (LTx) transplantation compared to recipients ? 18 years of age. We sought to determine if this survival disadvantage extended beyond the standard definition of adolescent age (12-18y).
Methods: All heart and lung transplant recipients 8 to 49 years of age were identified in the UNOS database (2001-2015). Five and ten-year Kaplan-Meier survival was assessed in 1-year units. The inflection point for increased and deceased survival was determined. Based on the inflection point, patients were divided into 3 age groups for HTx (8 -14 years, 15 -29 years, 30 – 49 years) and LTx (8 – 11 years, 12 – 27 years, 28 – 49 years).
Results: 11,429 HTx and 6,457 LTx recipients were identified. The inflection point for increased mortality was 15-years and 12-years for HTx and LTx respectively. The inflection point for decreased mortality was 30-years and 28-years for HTx and LTx respectively. Ages 15 to 29 years had worse survival compared to other age groups for HTx. Ages 12 to27 years had worse survival compared to other age groups for LTx. [Figure]
Conclusion: Adolescent and young adult HTx and LTx recipients have worse survival compared to younger children and middle aged-patients. Grouping patient survival/outcomes by the accepted/legal definitions unfavorably categorizes a young HTx (12 – 15 years) cohort whose survival is actually similar to the younger cohort and misses a vulnerable young adult recipient population in need of additional scrutiny and care for both HTx and LTx.
A17. CT Scan Results of Coronary Unroofing
Andrada R. Popescu, Osama M. Eltayeb, Michael C. Monge, Cynthia K. Rigsby, Carl L. Backer
Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
Background: Coronary unroofing is currently our standard operation for patients with anomalous aortic origin of a coronary artery (AAOCA). Our protocol is that if the postoperative coronary orifice is widely patent by CT scan, the patient can be cleared for all activity. We evaluated the results of postoperative coronary CTA on our patients who had coronary artery unroofing.
Methods: Retrospective analysis of 65 patients who underwent AAOCA unroofing between 2006 and 2016 and had postoperative coronary CTA. The postoperative coronary CTAs were assessed for patency of the unroofed ostium and the diameter of the proximal repaired coronary artery.
Results: All patients had widely patent neo-ostium by CT assessment. Two of 65 (3%) patients had mild-to-moderate narrowing of the proximal repaired coronary artery. Based on the results of these scans all patients were cleared for unrestricted sports activity. Of these 65 patients, only 1 (0.65%) had postoperative symptoms. The patient had heart block and syncope on postoperative day #11 prior to postoperative coronary CTA. Emergency cardiac catheterization showed a patent coronary artery and operative re-exploration confirmed a patent coronary orifice. The diagnosis was thrombus from one of the sutures causing temporary right ventricular ischemia.
Conclusion: Coronary CTA clearly defines the coronary ostium and proximal course following coronary unroofing for AAOCA. All patients scanned postoperatively had a patent coronary orifice. Based on these results we continue to utilize coronary unroofing as our procedure of choice for these patients, and postoperative imaging as a screening tool to clear patients for sports activity.
A18. A Table Mounted Cardiopulmonary Bypass System for Pediatric Cardiac Surgery
Ana Costa, Darren Parham, Justin Ashley, Khanh H. Nguyen
Mount Sinai Medical Center, New York, NY
There have been efforts to miniaturize the cardiopulmonary bypass circuits in pediatric cardiac surgery. We are presenting a modified cardiopulmonary bypass set up with a priming volume of 90 ml. The whole assembly is mounted on the operating table next to the patient. This set up maintains all features of a full sized cardiopulmonary bypass machine. Miniaturized circuit reduces the need for blood priming and pump induced inflammations.The table mounted system also provides extra safety during table’s position adjustment as it is our common practice to have the tubings at minimal length.
Scientific Session V: CHSS Data Center Report
Moderators:
- William M. DeCampli – CHSS Data Center, Orlando, FL
- James K. Kirklin – CHSS Research Committee Chair, Birmingham, AL
Member Business Meeting and Report of the President
Carl L. Backer, MD, President
Emile A. Bacha, MD, Secretary-Treasurer
Keynote Lecture
Public Reporting and Regionalization; What the US Can Learn From the UK
Professor Martin Elliott, MD, FRCS, FRSA
The Great Ormond Street Hospital for Children NHS FT, London, England
STS Congenital Heart Surgery Database
Jeffrey Jacobs, MD, Saint Petersburg, FL, USA
Marshall Jacobs, MD, Philadelphia, PA, USA
Scientific Session VI
Moderators:
- Joseph A. Dearani
- Jennifer C. Romano
A19. Characterizing Congenital Heart Surgery Care Current Referral Patterns in the US: Where Are Patients Coming From and Where Are They Going?
Tara Karamlou1, Sara K. Pasquali2, Paul Lin2, Carl L. Backer3, David M. Overman4, Jennifer C. Hirsch2, Jeffrey P. Jacobs5, Karl F. Welke6
1Phoenix Children’s Hospital, Phoenix AZ, 2Mott Children’s Hospital, Ann Arbor, MI, 3Ann & Robert Lurie Children’s Hospital, Chicago, Il, 4Children’s Hospital Minnesota, Minnesota, MO, 5Johns Hopkins All Children’s Heart Institute, St. Petersburg, Fl, 6Children’s Hospital of Illinois, Peoria, Il
Objectives: Regionalization of care may provide a rational congenital heart surgery (CHS) model. We: 1) describe US CHS center distribution; 2) demonstrate referral patterns; and 3) characterize the demographic traveling for CHS and incurred travel burden.
Methods: State Inpatient Databases from 2012 for patients ?18 characterized current CHS network. Complexity-stratification used RACHS-1 method, with RACHS-1 level 4 or higher defined as high complexity. Hospital volume was stratified by 50 case quartile increments. Results: 18,817 operations at 149 hospitals from 38 states performed ?RACHS-1 classifiable case. Hospital distribution paralleled population density, with California, Texas, and New York having the highest number and 3 states having no center. Median annual case volume was 126 (range 1–797). 54 centers performed ?50 cases and 46 performed >150 cases. Case mix varied, with 107(72%) centers performing high complexity cases. Of centers performing high complexity cases, 36(33%) performed ?10 cases/year. Unadjusted overall mortality rate was 3.5%(N=664) and was lowest at highest-volume programs. Patients already travel for CHS, with most traveling to higher-volume programs (Figure). 3729(24%) of patients travel ?100 miles, and 8027(52%) bypass their nearest CHS center. Neither complexity nor age importantly increased median travel distance. Self-pay insurance patients traveled least (Table).
Conclusions: Many CHS centers are small-volume programs located in close proximity. Higher complexity is concentrated in large-volume hospitals, but important numbers of complex cases are performed at very low-volume hospitals. Patients already travel long distances to high-volume, perceived high-quality centers. These referral patterns appear unrelated to patient age, complexity, or insurance status.
A20. Deterioration of Functional Abilities in Children Surviving the Fontan Operation
Florencia Ricci1, Billie-Jean Martin2, Ari Joffe3, Gonzalo Garcia Guerra3, Irina Dinu4, Ivan Rebeyka2, Charlene Robertson1
1Division of Developmental Pediatrics, Department of Pediatrics, 2Division of Cardiac Surgery, Department of Surgery, 3Division of Pediatric Critical Care, Department of Pediatrics, 4School of Public Health, University of Alberta, Edmonton, Canada
Introduction: Deficits in functional abilities impact the ability of a child to function independently in life. Hypothesis: deterioration in functional abilities(DFA) is not uncommon after the Fontan; stroke is often the event leading to DFA. Objectives: to determine: 1)frequency of DFA post-Fontan; 2)frequency of peri-Fontan stroke among those with and without DFA; 3)potentially modifiable acute care predictors that may lead to reduction of DFA.
Methods: From 1996-2016, 192 children prospectively registered in The Western Canadian Complex Pediatric Therapies Follow-up Program underwent a Fontan operation. At age 2(pre-Fontan) and 4.5 years(post-Fontan), children received multidisciplinary assessment; the Adaptive Behavior Assessment System-II general adaptive composite(GAC) was determined. DFA: defined as a 1SD decrease in GAC from pre- to post-Fontan scores. Stroke diagnosis: confirmed through retrospective chart review. Predictors of DFA: analyzed using multiple logistic regression analysis.
Results: Post-Fontan, DFA occurred in 34/133(25.6%) of assessed survivors. In those with DFA, mean GAC at 2 years: 96.2(17.5) vs. 74.5(16.6) at 4.5 years. Evidence of peri-Fontan stroke was found in 10/34(29.4%) of children with DFA vs. 8/99(8.1%) of children without DFA(p=0.002). Mean post-Fontan GAC in children with stroke was 76.9(21) vs. 90.1(18.3) among those without stroke(p=0.01). Independent predictors of DFA are: peri-Fontan stroke, Odds Ratio(OR) 5 (95%CI:1.74,14.36 )(p=0.003), and age at Fontan (years), OR 1.67(95%CI 1.02, 2.73)(p=0.04).
Conclusions: It is essential to assess the longitudinal trajectory of functional abilities as more than 25% surviving children show DFA. Efforts to prevent peri-Fontan stroke and complete the Fontan operation at an earlier age may lead to reduction of DFA
A21. Delayed Sternal Closure in Neonatal Cardiac Surgery Using a Negative Pressure Wound Vacuum System on Closed Surgical Incisions
Brenda Sefton, Barbara Rhodes, Kaitlin Ward, David Hoganson, Luis Quinonez
Boston Children’s Hospital, Boston, MA, USA
Delayed sternal closure after neonatal cardiac surgery has a high risk of wound complications, including infection. To decrease complications, a negative pressure wound system (PrevenaTM) was applied to closed skin incisions to evacuate fluid, maintain edge approximation and provide a barrier to contamination. We report our clinical experience in neonatal delayed sternal closure using negative pressure wound therapy.
Methods: All neonates undergoing delayed sternal closure, December 2015 -2016 were evaluated. Negative pressure therapy (50-75 mm Hg) was applied with continuous, low intensity. A comparison group, consisted of standard delayed sternal closure without wound therapy. The groups were similar in age, gender, BMI, weight and cardiac lesions. All patient wounds were assessed at discharge or before 30 days.
Results: 84 neonates with a median age of 5 days (range, 1-28). PrevenaTM was used in 34 patients at median of 3 days (range, 1-13) and removed after a median of 5 days (range, 3-10).The therapy group had no infections and one partial dehiscence. There were no hemodynamic, respiratory or skin injury events related to negative pressure. 50 control patients had standard delayed sternal closure at a median 3 days (range, 1-10). Eight of these patients had wound complications: 6 superficial wound infections (12% vs. 0%) (p = 0.08), including 1 re-operation; and 2 skin dehiscences. No difference in hospital LOS between the two groups.
Conclusions: Negative pressure wound therapy using the PrevenaTM system applied to neonates after delayed sternal closure may reduce wound complications, including infection.
A22. Evaluation of Differential Pulmonary Perfusion Using Tc99m Macroaggregated Albumin (MAA) after Fontan Procedure
Sachin Talwar, Lakshmi Sankhayan, Chetan Patel, Shiv Kumar Choudhary, Balram Airan
All India Institute of Medical Sciences, New Delhi, India
Objectives: Fontan procedure (FO) is the final palliation for patients with univentricular physiology. We studied differential perfusion ratio and percentage uptake of radiotracer in different zones of each lung following FO.
Patients and methods: Between July 2015 and March 2017, 45 patients underwent Tc99m Macroaggregated Albumin (MAA) lung perfusion scan at mean follow up of 49.326.1 days following FO. Differential perfusion ratios and percentage uptake of radiotracer in upper, middle & lower zones of each lung was calculated.
Results: Post superior vena cava (SVC) injection, mean radionuclide count of right lung was marginally higher compared to left (403.5217.3 kct vs 332.4163.6 kct, P=0.082). However, mean differential perfusion to right lung was more than left (53.918.60% vs 44.7419.63%, P=0.025). Following IVC injection, mean radionuclide count and mean percentage of total flow to right lung was more than left (189.592.2 kct vs 173.3128.5 kct and 52.018.7% vs 47.9218.7%, P>0.05). Total lower zone mean perfusion was higher than upper zone following both SVC and IVC injection (34.15.3% vs 17.84.1% and 33.55.0% vs 17.54.1%, p=0.0001). Mean radionuclide count and percentage contribution of SVC was more than IVC in right lung (403.5217.3kct vs 189.592.2 and 66.112.8% vs 33.8%) and left lung (332.4163.6kct vs 173.7128.5kct and 65.414.0% vs 34.514.0%, P=0.001)
Conclusion: Following FO, SVC blood flowed preferentially to right lung. Of the total caval flow, SVC contribution was significantly more in each lung. Lower zone was perfused more than upper zone. Modifying the caval offset may lead to a more uniform blood flow in these patients.
A23. Interrupted Right Aortic Arch, Right Descending Thoracic Aorta with a Large Gap between Proximal and Distal Arch Portions
Ali Dodge-Khatami1, Miguel Urencio1, Chris E. Greenleaf1, Craig A. Mathis1, Jorge D. Salazar2
1University of Mississippi Medical Center, Jackson, MS 2Boston Children’s Hospital, Boston, MA, USA
Video of repair for Interrupted Aortic Arch with a wide gap between ascending and descending aortic portions. The ascending aorta is split from the sino-tubular junction to the arch origin, sliding the flap of native tissue posteriorly with anastomosis to the distal arch, and patch completion. There was no peri-operative mortality in 8 neonates/infants. Wide interruption gaps between proximal and distal aortic portions do not preclude a tension-free reconstruction with the “ascending aortic slide” technique. The native tissue bridge has potential for growth, and is a scaffold for patch augmentation in biventricular hearts, or for Norwood stage I in uni-ventricular palliation.
A24. Aortico-Left Ventricular Tunnel: The Impact of the Computed Tomography Fly Through
Michael C. Monge1,2, Cynthia K. Rigsby1,2, Osama M. Eltayeb1,2, Neale r. Zingle1, Carl L. Backer1,2
1Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA, 2Northwestern University Feinberg School of Medicine, Chicago, IL, USA
A 7-day-old. 2.8 kg neonate underwent transaortic closure of a Type II aortico-left ventricular tunnel. Echocardiograni showed origin of the right coronary artery (RCA) from the tunnel. Preoperative computed tomographic angiography “fly through” defined the relationship of the RCA to the tunnel to insure correct placement of the patch to close the tunnel without compromising the origin of the RCA from the tunnel, The child did well and was discharged one week postoperatively with normal left ventricular function, no residual tunnel, and no aortic insufficiency. We will show a video of the computed tomography “fly-through” and the operation.
A25. Robotic Totally Endoscopic Repair of Isolated Left Partial Anomalous Pulmonary Venous Drainage
Brian Mitzman, Mackenzie Mcrorey, Brooke Patel, Amit Patel, Gerhard Ziemer, Husam Balkhy
University of Chicago, Chicago, IL, USA
Program Director: Mark Ferguson A 50 year old obese female presented with isolated left partial anomalous pulmonary venous return to the innominate vein. There was no atrial septal defect. Left to right shunt was 1.7:1. She underwent a robotic totally endoscopic on-pump beating heart repair. The operation was successful with short length of stay, quick recovery, and minimal postoperative pain. Our video demonstrates that a totally endoscopic repair is technically feasible by showing all steps, along with pre and post operative 3D anatomic CT reconstructions.