Publications by authors named "Charles D Fraser"

273 Publications

Unusual presentation of an obstructing cardiac myxoma.

JTCVS Tech 2020 Sep 24;3:234-235. Epub 2020 Jun 24.

Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Tex.

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http://dx.doi.org/10.1016/j.xjtc.2020.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303053PMC
September 2020

Commentary: Very nice study…what are we to do with it?

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2021 May 1. Epub 2021 May 1.

Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Hospital, Austin, Tex; Division of Cardiovascular Surgery, University of Texas-Dell Medical School, Austin, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.04.069DOI Listing
May 2021

Risk stratification and surgery for anomalous aortic origin of a coronary artery: Onward through the fog.

J Thorac Cardiovasc Surg 2021 May 9;161(5):1584-1586. Epub 2021 Mar 9.

Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School, Dell Children's Medical Center, Austin, Tex; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico.

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http://dx.doi.org/10.1016/j.jtcvs.2019.06.131DOI Listing
May 2021

Discussion.

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2021 Feb 10. Epub 2021 Feb 10.

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http://dx.doi.org/10.1016/j.jtcvs.2020.12.115DOI Listing
February 2021

Acquired Sinus of Valsalva Fistula and Turner Syndrome.

Ann Thorac Surg 2021 Jan 29. Epub 2021 Jan 29.

Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas; Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, Texas. Electronic address:

A 21-year old female with a history of Turner syndrome presented with a diastolic heart murmur, dizziness, dyspnea, and intermittent chest pain. Preoperative imaging revealed a fistula from the right sinus of Valsalva into the right atrium. Turner syndrome is associated with both aortopathy and congenital heart malformations. Acquired sinus of Valsalva fistula is a rare disorder and has not been previously reported in association with Turner syndrome.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.066DOI Listing
January 2021

The intraoperative use of recombinant activated factor VII in arterial switch operations.

Cardiol Young 2021 Mar 19;31(3):386-390. Epub 2020 Nov 19.

Texas Children's Hospital, Houston, TX, USA.

Background: The rate of bleeding complications following arterial switch operation is too low to independently justify a prospective randomised study for benefit from recombinant factor VIIa. We aimed to evaluate factor VIIa in a pilot study.

Methods: We performed a retrospective cohort study of patients undergoing arterial switch operation from 2012 to 2017. Nearest-neighbour propensity score matching on age, gender, weight, and associated cardiac defects was used to match 27 controls not receiving recombinant factor VIIa to 30 patients receiving recombinant factor VIIa. Fisher's exact test was performed to compare categorical variables. Wilcoxon's rank-sum test was used to compare continuous variables between cohorts.

Results: Post-operative thrombotic complications were not associated with factor VIIa administration (Odds Ratio (OR) 0.28, 95% CI 0.005-3.77, p = 0.336), nor was factor VIIa administration associated with any re-explorations for bleeding. No intraoperative transfusion volumes were different between the recombinant factor VIIa cohort and controls. Post-operative prothrombin time (10.8 [10.3-12.3] versus 15.9 [15.1-17.2], p < 0.001) and international normalised ratio (0.8 [0.73-0.90] versus 1.3 [1.2-1.4], p < 0.001]) were lower in recombinant factor VIIa cohort relative to controls.

Conclusions: In spite of a higher post-bypass packed red blood cell transfusion requirement, patients receiving recombinant factor VIIa had a similar incidence of bleeding post-operatively. With no difference in thrombotic complications, and with improved post-operative laboratory haemostasis, a prospective randomised study is warranted to evaluate recombinant factor VIIa.
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http://dx.doi.org/10.1017/S1047951120004072DOI Listing
March 2021

Evaluation of Extracorporeal Membrane Oxygenation Therapy as a Bridging Method.

Ann Thorac Surg 2021 07 22;112(1):68-74. Epub 2020 Oct 22.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) before transplantation.

Methods: The United Network for Organ Sharing database was queried for all adult patients (aged 18 years or more) who required support with ECMO before heart transplantation from 2001 to 2018. Patients were stratified into patients who did not require ECMO before transplantation, who were weaned off ECMO before transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to a left ventricular assist device (LVAD) before transplantation. Demographics and outcomes including 1-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared.

Results: Overall, 29,370 patients did not require ECMO before transplantation, 101 patients were weaned off ECMO before transplantation, 118 were bridged from ECMO directly to transplantation, and 55 patients were successfully bridged from ECMO to LVAD before transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in 1-year survival for patients who were bridged from ECMO to transplantation compared with patients who were bridged to LVAD before subsequent transplantation (P < .001).

Conclusions: Our study suggests bridging ECMO patients to an LVAD before transplantation will result in improved 1-year survival compared with patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.041DOI Listing
July 2021

Commentary: The challenge of postoperative diaphragmatic paralysis in patients with functionally univentricular circulation: A data-driven strategy.

J Thorac Cardiovasc Surg 2020 11 19;160(5):1297-1299. Epub 2020 Jul 19.

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.003DOI Listing
November 2020

Sickle Cell-Related Complications in Patients Undergoing Cardiopulmonary Bypass.

World J Pediatr Congenit Heart Surg 2020 09;11(5):565-571

Texas Center for Pediatric and Congenital Heart Disease, 441903University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA.

Background: We aimed to describe our experience with patients with sickle cell trait (SCT) and undergoing surgery on cardiopulmonary bypass (CPB).

Methods: Data on all patients with SCT or sickle-α thalassemia who underwent surgery on CPB were collected (1996-2017).

Results: Overall, 46 patients were included, 37 (80%) had SCT and 9 (20%) had sickle-α thalassemia. A total of 4 (9%) developed a potential sickle cell-related complication. Patients with sickle cell-related complications were significantly older (median 14 years vs 14 months, = .037) and heavier (median 54 kg vs 9 kg, = .041). Complications occurred, although without statistical significance, in patients who underwent longer median CPB times (249 minutes vs 137 minutes, = .069), lower median temperature (31.7 °C vs 33.3 °C, = .094), and a higher percentage underwent deep hypothermic circulatory arrest (50% vs 7%, = .053). A total of 30 (65%) patients underwent exchange transfusion (ET) pre-bypass. Patients who underwent ET were significantly older (median 4 years vs 7 months, = .003) and heavier (median 16 kg vs 6 kg, = .015) than patients who did not undergo ET. The incidence of complications was comparable between patients who underwent ET (10%) and those who did not (6%).

Conclusions: In this retrospective, single-center study, it has been shown that cardiac surgery requiring CPB in patients with SCT and sickle-α thalassemia had a low risk for sickle cell-associated complications. In this cohort of patients, older age, longer CPB times, lower median temperature, and the utilization of deep hypothermic circulatory arrest appear to play an important role in the development of complications.
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http://dx.doi.org/10.1177/2150135120926991DOI Listing
September 2020

Discussion.

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2020 Sep;160(3):769-771

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http://dx.doi.org/10.1016/j.jtcvs.2020.01.115DOI Listing
September 2020

Commentary: Coronary origins after the arterial switch operation: Let's think of it like anomalous aortic origin of the coronaries.

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2021 04 13;161(4):1406-1407. Epub 2020 Jul 13.

Texas Center for Pediatric and Congenital Heart Disease, The University of Texas - Dell Medical School, Dell Children's Hospital, Austin, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.020DOI Listing
April 2021

Diaphragm Paralysis After Pediatric Cardiac Surgery: An STS Congenital Heart Surgery Database Study.

Ann Thorac Surg 2021 07 5;112(1):139-146. Epub 2020 Aug 5.

Division of Pediatric Cardiac Surgery, University of Chicago, Chicago, Illinois.

Background: Previous single-center studies of diaphragm paralysis (DP) after pediatric cardiac surgery report incidence of 0.3% to 12.8% and associate DP with respiratory complications, prolonged ventilation and length of stay, and mortality. To better define incidence and associations between DP and various procedures and outcomes, we performed a multicenter study.

Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried to identify children who experienced DP after cardiac surgery (2010-2018; 126 centers). Baseline characteristics and postoperative outcomes were compared between patients with and without DP as well as between patients who underwent plication and those who did not. Associations between center volume and center rates of DP and use of plication were also explored.

Results: A total of 2214 of 191,463 (1.2%) patients experienced DP. Postoperative DP portended worse outcomes, including mortality (5.6% vs 3.5%; P < .001), major morbidity (37.2% vs 10.7%; P < .001), tracheostomy (7.1% vs 0.9%; P < .001), prolonged mechanical ventilation (38.0% vs 7.8%; P < .001), and 30-day readmission (22.0% vs 10.6%; P < .001). A total of 1105 of 2214 (49.9%) patients with DP underwent plication. Patients who underwent plication were younger, were smaller, had more risk factors, and underwent more complex surgeries. Plication rates varied widely across centers. There was no correlation between center volume and center risk-adjusted rates of DP (r = .05, P = .5), nor frequency of plication (r = .08, P = .4).

Conclusions: DP complicating pediatric heart surgery is rare but portends significantly worse outcomes. One-half of patients underwent plication. Center-level risk-adjusted rates of DP and plication are not associated with case volume. Significant variability in plication practices suggests a target for quality improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.175DOI Listing
July 2021

We should reframe the discussion/debate about neonatal repair of tetralogy of Fallot.

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2021 Apr 10;161(4):1421-1425. Epub 2020 Jun 10.

Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, Surgery and Pediatrics, University of Texas, Dell Medical School, Austin, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.093DOI Listing
April 2021

Long-term Survival After Heart Transplantation: A Population-based Nested Case-Control Study.

Ann Thorac Surg 2021 03 31;111(3):889-898. Epub 2020 Jul 31.

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Heart transplantation is the mainstay of treatment for patients in end-stage heart failure. This study sought to contrast survival after transplantation with that of the general population to quantify standardized mortality rates using a nested case-control study design.

Methods: Control subjects were noninstitutionalized inhabitants of the United States identified through the National Longitudinal Mortality study. Case subjects were adults who underwent heart transplantation between 1990 and 2007 and identified through the Organ Procurement and Transplantation Network. Propensity-matching (5:1, nearest neighbor, caliper = 0.1) was utilized to identify suitable control subjects based on age, sex, race, and state of permanent residency. The primary study endpoint was 10-year survival.

Results: In all, 31,883 heart transplant recipients were matched to 159,415 noninstitutionalized residents of the United States. The 10-year survival of heart transplant recipients was 53%. The population expected mortality rate was 15.9 deaths per 100 person-years with an observed rate of 45.1 deaths per 100 person-years (standardized mortality rate [SMR] 2.84; 95% confidence interval, 2.82 to 2.87). The broadest gaps between observed and expected survival were evident in female (SMR 3.63), black (SMR 3.67), and Hispanic (SMR 4.12) recipients. Standardized mortality ratios declined over time (1990 to 1995, 3.09; 1996 to 2000, 2.90; 2001 to 2007, 2.58). The long-term standardized survival of older recipients was closest to that expected for their age.

Conclusions: Heart transplant recipients have considerable long-term survival and have a threefold higher standardized long-term mortality rate than that of the noninstitutionalized population. Long-term mortality rates have consistently declined over time and will likely continue to decrease.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.163DOI Listing
March 2021

Left Ventricular Assist Device Exchange Increases Heart Transplant Wait-List Mortality.

J Surg Res 2020 11 20;255:277-284. Epub 2020 Jun 20.

Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The new heart transplant allocation criteria prioritize inpatients who require temporary mechanical circulatory support and give lower urgency to candidates on a durable left ventricular assist device (LVAD) who require a device exchange. This study explores whether the latter group should warrant higher priority to reduce wait-list mortality.

Methods: This is a retrospective observational study of 13,113 adult heart transplant candidates in the Organ Procurement and Transplantation Network database who underwent LVAD implantation between 2007 and 2017. It evaluates the impact of LVAD exchange on the composite endpoint of death or removal from the wait list owing to worsening medical condition 1 y after device implantation.

Results: There were 1085 pump exchanges in 954 patients (7% of candidates), of which 22% were women. The pump exchange rate was 5.92 events per 100 patient-years. One-year survival was lower for those who required a pump exchange (76.3% versus 88.5%, logrank P < 0.001). This was congruent with the risk-adjusted mortality 1-y after implantation (hazards ratio: 2.56, 95% confidence interval: 2.18-3.00, P < 0.001).

Conclusions: These findings indicate that among candidates awaiting heart transplantation with a durable LVAD, undergoing pump exchange doubles the risk of 1-y mortality. Giving priority to these candidates may reduce wait-list mortality.
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http://dx.doi.org/10.1016/j.jss.2020.05.062DOI Listing
November 2020

Commentary: I guess I'm just confused…isn't this information sobering?

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2020 09 14;160(3):775-776. Epub 2020 Feb 14.

Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Hospital, The University of Texas - Dell Medical School, Austin, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.02.020DOI Listing
September 2020

Anomalous Aortic Origin of a Coronary Artery: Surgical Emergency?

Ann Thorac Surg 2020 10 30;110(4):e257-e259. Epub 2020 Mar 30.

Coronary Anomalies Program, Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, Austin, Texas; Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, Texas. Electronic address:

Anomalous aortic origin of a coronary artery is a congenital condition associated with sudden cardiac death. There are no current recommendations for the acute management and urgency for this patient population. This manuscript describes and discusses two patients who presented with an acute coronary event and needed emergent intervention despite initial clinical stabilization and improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.052DOI Listing
October 2020

Conditional Survival in Heart Transplantation: An Organ Procurement and Transplantation Network Database Analysis.

Ann Thorac Surg 2020 10 12;110(4):1339-1347. Epub 2020 Mar 12.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Survival after heart transplantation is typically reported only in terms of overall survival. Conditional survival may provide prognostic information for patients after surviving a given period. This study sought to provide an analysis of conditional survival in heart transplantation.

Methods: Data from 29,000 patients who underwent heart transplantation between 2002 and 2016 were analyzed from the Organ Procurement and Transplantation Network database, and 5-year conditional survival rates were calculated according to age, sex, race, renal function, and hepatic function at transplantation.

Results: As time from transplantation increased from 0 to 5 years, the 5-year observed conditional survival changed from 74% to 82% for ages younger than 40 years, 79% to 82% for ages 40 to 49, 79% to 78% for ages 50 to 60, and 75% to 70% for ages older than 60 at transplantation. Conditional survival peaked at 1 and 2 years after transplantation for most subgroups. In recipients younger than 40 years, men had slightly higher conditional survival than women (absolute difference, 3%-4%). In recipients older than 60 years, women had slightly higher conditional survival (absolute difference, 1%-4%). Black recipients had lower survival than white and Hispanic recipients for nearly all time points. Recipients younger than 40 years with the worst renal (65% to 88%) and hepatic function (66% to 83%) at transplantation experienced the largest increase in conditional survival.

Conclusions: The conditional survival of patients who undergo heart transplantation changes substantially over time. The largest increases in conditional survival are in young patients with impaired renal and hepatic function. Conditional survival can provide more accurate prognostic information for heart recipients who survive a given period after transplantation.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.014DOI Listing
October 2020

Myocardial Ischemia in Children With Anomalous Aortic Origin of a Coronary Artery With Intraseptal Course.

Circ Cardiovasc Interv 2020 03 27;13(3):e008375. Epub 2020 Feb 27.

Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston.

Background: Intraseptal anomalous aortic origin of a coronary artery is considered a benign condition. However, there have been case reports of patients with myocardial ischemia, arrhythmia, and sudden cardiac death. The purpose of this study was to determine the clinical presentation, myocardial perfusion on provocative stress testing, and management of children with anomalous aortic origin of a coronary artery with an intraseptal course in a prospective cohort.

Methods: Patients with anomalous aortic origin of a coronary artery and intraseptal course were prospectively enrolled from December 2012 to May 2019, evaluated, and managed following a standardized algorithm. Myocardial perfusion was assessed using stress imaging. Fractional flow reserve was performed in patients with myocardial hypoperfusion on noninvasive testing. Exercise restriction, β-blockers, and surgical intervention were discussed with the families.

Results: Eighteen patients (female 6, 33.3%), who presented with no symptoms (10, 55.6%), nonexertional (4, 22.2%), and exertional symptoms (4, 22.2%), were enrolled at a median age of 12.4 years (0.3-15.9). Perfusion imaging was performed in 14/18 (77.8%) and was abnormal in 7/14 (50%); fractional flow reserve was positive in 5/8 (62.5%). All 4 patients with exertional symptoms and 3/10 (30%) with no or nonexertional symptoms had myocardial hypoperfusion. Coronary artery bypass grafting was performed in a 4-year-old patient; β-blocker and exercise restriction were recommended in 4 patients not suitable for surgery. One patient had nonexertional chest pain and 17 were symptom-free at median follow-up of 2.5 years (0.2-7.1).

Conclusions: Up to 50% of patients with intraseptal anomalous aortic origin of a coronary artery had inducible myocardial hypoperfusion during noninvasive provocative testing. Long-term follow-up is necessary to understand the natural history of this rare anomaly.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008375DOI Listing
March 2020

Commentary: TEE in TOF Surgery: Looking for the Pearls.

Authors:
Charles D Fraser

Semin Thorac Cardiovasc Surg 2020 20;32(2):290-291. Epub 2020 Feb 20.

Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2020.02.017DOI Listing
June 2020

Increased Use of Multiorgan Transplantation in Heart Transplantation: Only Time Will Tell.

Ann Thorac Surg 2020 10 20;110(4):1308-1315. Epub 2020 Feb 20.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The utilization of multiorgan transplantation in cardiac transplantation has steadily increased over the past several years. We sought to characterize the trends and outcomes in simultaneous heart and other organ transplantation compared with heart transplantation alone.

Methods: The United Network for Organ Sharing database was queried for all adult patients (age ≥ 18 y) who underwent isolated heart transplantation or simultaneous heart-lung or heart-kidney transplantation from 1987-2016. Patients were stratified into 3 equal time intervals. Demographics and postoperative outcomes were compared.

Results: A total of 58,060 patients were identified with a distribution based on era. Dual organ recipients had more factors associated with increased operative risk including higher rates of diabetes, pulmonary hypertension, intensive care unit admissions, and dialysis prior to transplantation. Heart-lung and heart-kidney recipients had decreased 1-year survival compared with isolated heart recipients from 2007-2016. However, heart-kidney recipients had significantly increased 5-year post-transplantation survival compared with isolated heart recipients with impaired renal function. For isolated heart transplants and heart-lung transplants, 5-year survival rates improved over time, whereas 5-year survival for heart-kidney recipients did not improve with time.

Conclusions: We found a significantly increased 5-year survival rate for heart-kidney transplant recipients compared with isolated heart transplant recipients with renal impairment. Lack of improvement in 5-year postoperative outcomes for heart-kidney recipients in the setting of higher-risk pretransplant clinical characteristics suggests decreased selectivity regarding heart-kidney recipients. Continued scrutiny and evaluation of postoperative outcomes are required to ensure just and appropriate utilization of organs.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.081DOI Listing
October 2020

Outcomes in Anomalous Aortic Origin of a Coronary Artery Following a Prospective Standardized Approach.

Circ Cardiovasc Interv 2020 02 13;13(2):e008445. Epub 2020 Feb 13.

Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin (C.M.M., C.D.F.).

Background: Anomalous aortic origin of a coronary artery (CA) is the second leading cause of sudden cardiac death in young athletes. Management is controversial and longitudinal follow-up data are sparse. We aim to evaluate outcomes in a prospective study of anomalous aortic origin of CA patients following a standardized algorithm.

Methods: Patients with anomalous aortic origin of a CA were followed prospectively from December 2012 to April 2017. All patients were evaluated following a standardized algorithm, and data were reviewed by a dedicated multidisciplinary team. Assessment of myocardial perfusion was performed using stress imaging. High-risk patients (high-risk anatomy-anomalous left CA from the opposite sinus, presence of intramurality, abnormal ostium-and symptoms or evidence of myocardial ischemia) were offered surgery or exercise restriction (if deemed high risk for surgical intervention). Univariate and multivariable analyses were used to determine predictors of high risk.

Results: Of 201 patients evaluated, 163 met inclusion criteria: 116 anomalous right CA (71%), 25 anomalous left CA (15%), 17 single CA (10%), and 5 anomalous circumflex CA (3%). Patients presented as an incidental finding (n=80, 49%), with exertional (n=31, 21%) and nonexertional (n=32, 20%) symptoms and following sudden cardiac arrest/shock (n=5, 3%). Eighty-two patients (50.3%) were considered high risk. Predictors of high risk were older age at diagnosis, black race, intramural course, and exertional syncope. Most patients (82%) are allowed unrestrictive sports activities. Forty-seven patients had surgery (11 anomalous left CA and 36 anomalous right CA), 3 (6.4%) remained restricted from sports activities. All patients are alive at a median follow-up of 1.6 (interquartile range, 0.7-2.8) years.

Conclusions: In this prospective cohort of patients with anomalous aortic origin of a CA, most have remained free of exercise restrictions. Development of a multidisciplinary team has allowed a consistent approach and may have implications in risk stratification and long-term prognosis.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008445DOI Listing
February 2020

Commentary: Overpromised, understudied: The slippery slope of pediatric cardiac device development.

Authors:
Charles D Fraser

J Thorac Cardiovasc Surg 2020 10 20;160(4):e221-e222. Epub 2019 Nov 20.

University of Texas Dell Medical School, Dell Children's Medical Center, Austin, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.10.171DOI Listing
October 2020

Twenty-Three-Year Experience With the Arterial Switch Operation: Expectations and Long-Term Outcomes.

Semin Thorac Cardiovasc Surg 2020 Summer;32(2):292-299. Epub 2020 Jan 17.

Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

We aimed to describe the short- and long-term outcomes of patients after an arterial switch operation (ASO) at a single institution during a 23-year period. A retrospective chart review of all patients <18 months of age who underwent an ASO between January 1995 and March 2018 at Texas Children's Hospital, Houston, TX was performed. Primary endpoints include mortality and reintervention. Perioperative mortality was defined as mortality occurring in-hospital and/or <30 days after surgery. Survival and freedom-from-reintervention were analyzed using Kaplan-Meier method, log-rank tests, and Cox regression models. The cohort included 394 patients. Diagnoses included 204 patients (52%) with intact ventricular septum, 137 (35%) with a ventricular septal defect, 17 (4%) with a ventricular septal defect and left ventricular outflow tract obstruction (LVOTO), and 36 (9%) with Taussig-Bing anomaly. Median age at surgery was 8 days (range: 1 day to 17 months) and median weight was 3.4 (range: 0.8-12.0) kg. Overall perioperative mortality was 1.3% (n = 5), 0.3% (n = 1) since 1999. Overall survival at 5, 10, and 15 years was 98.2%, 97.8%, and 97.8%, respectively. Perioperative morality was associated with prematurity (P = 0.012), <2.5 kg (P< 0.001), and longer circulatory arrest (P = 0.024) after univariate analysis. Reintervention was associated with a longer cross-clamp time (P < 0.001), <2.5 kg (P = 0.009), LVOTO resection (P = 0.047), and genetic syndrome (P= 0.011) after multivariable analysis. Current ASO expectations should include a perioperative mortality risk of <1% and good long-term survival. Reinterventions are more frequent in patients <2.5 kg, concomitant LVOTO resection, a genetic syndrome, and longer cross-clamp time.
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http://dx.doi.org/10.1053/j.semtcvs.2020.01.004DOI Listing
September 2020

Infundibular sparing versus transinfundibular approach to the repair of tetralogy of Fallot.

Congenit Heart Dis 2019 Nov;14(6):1149-1156

Section of Pediatric Cardiology, Stanford University, Palo Alto, California.

Introduction: The right ventricular infundibular sparing approach (RVIS) to the repair of tetralogy of Fallot (TOF) avoids a full-thickness ventricular incision, typically utilized in the transinfundibular (TI) method.

Methods: We performed a retrospective, age-matched cohort study of patients who underwent RVIS at Texas Children's Hospital or TI at Children's Hospital Medical Center in Nebraska and subsequently underwent cardiac magnetic resonance imaging (CMR). We compared right ventricular end-diastolic and systolic volumes indexed to body surface area (RVEDVi and RVESVi) and right ventricular ejection fraction (RVEF) as primary endpoints. Secondary endpoints were indexed left ventricular diastolic and systolic volume (LVEDVi and LVESVi), left ventricular ejection fraction (LVEF), right ventricular (RV) sinus ejection fraction (EF) and RV outflow tract EF (RVOT EF).

Results: Seventy-nine patients were included in the analysis; 40 underwent RVIS and 39 underwent TI repair. None of the patients in the TI repair group had an initial palliation with a systemic to pulmonary arterial shunt compared to seven (18%) in the RVIS group (P < .01). There was no appreciable difference in RVEDVi (122 ± 29 cc/m vs 130 ± 29 cc/m , P = .59) or pulmonary regurgitant fraction (40 ± 13 vs 37 ± 18, P = .29) between the RVIS and TI groups. Compared to the TI group, the RVIS group had higher RVEF (54 ± 6% vs 44 ± 9%, P < .01), lower RVESV (57 ± 17 cc/m vs 67 ± 25 cc/m , P = .03), higher LVEF (61 ± 11% vs 54 ± 8%, P < .01), higher RVOT EF (47 ± 12% vs 41 ± 11%, P = .03), and higher RV sinus EF (56 ± 5% vs 49 ± 6%, P < .01) CONCLUSIONS: In this selected cohort, patients who underwent RVIS repair for TOF had higher right and left ventricular ejection fraction compared to those who underwent TI repair.
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http://dx.doi.org/10.1111/chd.12863DOI Listing
November 2019

Contemporary Outcomes following Redo Autogenous Infrainguinal Bypass.

Ann Vasc Surg 2020 Jul 31;66:537-542. Epub 2019 Oct 31.

Division of Vascular Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD.

Background: Revascularization after lower extremity bypass failure poses many challenges. Despite nearly 7 decades of experience with lower extremity revascularization, there is little data on the success of redo bypass particularly when autogenous conduit is utilized. The purpose of this study is to review outcomes of redo infrainguinal bypass constructed solely of autogenous vein.

Methods: All patients who underwent redo infrainguinal bypass at a single institution by a single surgeon were retrospectively reviewed. Bypasses were categorized into 3 groups: femoral-popliteal, femoral-distal, and popliteal-distal bypasses. Since the repeat bypasses were all done for limb salvage, freedom from above or below knee amputation (FFA) was primary outcome, which was defined as the number of days from redo bypass to subsequent amputation or the most recent follow-up.

Results: From 2006 to 2016, 100 limbs underwent redo bypass. Fifty-nine (59.0%) limbs had undergone one previous bypass while 41 (41.0%) had undergone 2 or more. The redo configurations consisted of 23 (23.0%) femoral-popliteal, 70 (70.0%) femoral-distal, and 7 (7.0%) popliteal-distal bypasses. Ninety-seven (97.0%) underwent redo using autologous vein grafts including 41 (95.5%) of those who had 2 or more previous bypasses. The 3 patients who ultimately underwent prosthetic bypass had bilateral great and small saphenous veins and bilateral basilic and cephalic veins previously harvested. Nine (9.0%) limbs were subsequently amputated: 2 (2.0%) above knee and 7 (7.0%) below knee amputations. Of these, all had had 2 or more previous bypasses and 2 of the 3 patients who ultimately received prosthetic bypasses were in this group. In patients with one previous bypass, FFA was 775 days (IQR: 213-1,626 days). In patients with 2 or more previous bypasses, FFA was 263 days (IQR: 106-1,148 days). No patients with femoral-popliteal bypasses suffered amputation while 7 (10.0%) of the femoral-distal and 2 (28.6%) of the popliteal-distal bypasses suffered subsequent amputations (P = 0.067).

Conclusions: Redo infrainguinal bypass is effective in salvaging threatened lower extremities. Furthermore, once a patient is deemed a bypass candidate, revascularization with autologous vein can be achieved. A significant FFA rate is achieved with redo bypass, although patients with more distal disease are harder to salvage.
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http://dx.doi.org/10.1016/j.avsg.2019.10.070DOI Listing
July 2020

Effects of Systemic and Device-Related Complications in Patients Bridged to Transplantation With Left Ventricular Assist Devices.

J Surg Res 2020 02 9;246:207-212. Epub 2019 Oct 9.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The use of left ventricular assist devices (LVADs) as a bridge to heart transplantation has increased rapidly over the last 2 decades. We aim to explore the effect of pretransplant systemic and device-related complications on posttransplant survival for patients bridged with LVADs.

Materials And Methods: The United Network of Organ Sharing (Organ Procurement and Transplantation Network) database was queried for all adult heart transplant recipients (aged ≥ 18 y) transplanted from April 1, 2015, to June 31, 2018. Device-related complications included thrombosis, device infection, device malfunction, life-threatening arrhythmia, and other device complications. Systemic complications included a new dialysis need or ventilator dependence between the time of listing and transplantation, transfusion, or systemic infection requiring treatment with intravenous antibiotics within 2 wk of transplantation.

Results: A total of 2131 patients were identified as requiring LVAD support before transplantation. LVAD patients had high rates of preoperative systemic complications (53%) and high rates of device-related complications (42.7% experienced at least one device-related complication). Kaplan-Meier analysis revealed a significantly decreased 1-y survival for LVAD patients bridged to transplantation who experienced a pretransplant systemic complication (P = 0.041). Interestingly, preoperative device-related complications had no effect on 1-y posttransplantation survival (P = 0.93). Multivariate Cox modeling revealed that systemic complications were associated with a significantly increased risk of posttransplant mortality for LVAD patients (hazard ratio 1.45; P = 0.033).

Conclusions: Recipients who suffered a systemic complication while awaiting heart transplantation experienced higher short-term mortality rates. Device-related complications do not appear to impact posttransplantation outcomes.
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http://dx.doi.org/10.1016/j.jss.2019.08.016DOI Listing
February 2020

Reoperation after isolated subaortic membrane resection.

Cardiol Young 2019 Nov 26;29(11):1391-1396. Epub 2019 Sep 26.

Division of Congenital Heart Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.

Background: The resection of a subaortic membrane remains far from a curative operation. We sought to examine factors associated with reoperation and the degree of aortic valve regurgitation as a potential long-term source for reoperation.

Methods: All patients who underwent resection of an isolated subaortic membrane between 1995 and 2018 were included. Patients who underwent other procedures were excluded. Paired categorical data were compared using McNemar's test. Univariate time-to-event analyses were performed using Kaplan-Meier methods with log-rank tests for categorical variables and univariate Cox models for continuous variables.

Results: A total of 84 patients (median age 6.6, 31% females) underwent resection of isolated subaortic membrane. At a median follow-up of 9.3 years (interquartile range 0.6-22.5), 12 (14%) patients required one reoperation and 1 patient required two reoperations. Median time to first reoperation was 4.6 years. The degree of aortic valve regurgitation improved post-operatively from pre-operatively (p = 0.0007); however, the degree of aortic valve regurgitation worsened over the course of follow-up (p = 0.010) to equivalence with pre-operative aortic valve regurgitation (p = 0.18). Performance of a septal myectomy was associated with longer freedom from reoperation (p = 0.004).

Conclusions: In patients with isolated subaortic membranes, performance of a septal myectomy can minimise risk for reoperation. Patients should be serially monitored for degradation of the aortic valve, even if aortic regurgitation is not present post-operatively.
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http://dx.doi.org/10.1017/S1047951119002336DOI Listing
November 2019

Impact of the New Pulmonary Hypertension Definition on Heart Transplant Outcomes: Expanding the Hemodynamic Risk Profile.

Chest 2020 01 22;157(1):151-161. Epub 2019 Aug 22.

Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC. Electronic address:

Background: At the recent 6th World Symposium on Pulmonary Hypertension (PH), the definition of PH was redefined to include lower pulmonary artery pressures in the setting of elevated pulmonary vascular resistance (PVR). However, the relevance of this change to subjects with PH due to left-heart disease as well as the preoperative assessment of heart transplant (HT) recipients is unknown.

Methods: The United Network for Organ Sharing database was queried to identify adult recipients who underwent primary HT from 1996 to 2015. Recipients were subdivided into those with mean pulmonary artery pressure (mPAP) < 25 mm Hg and ≥ 25 mm Hg. Exploratory univariable analysis was undertaken to identify candidate risk factors associated with 30-day and 1-year survival (conditional on 30-day survival) in recipients with mPAP < 25 mm Hg, and subsequently, parsimonious multivariable Cox proportional hazards models were constructed to assess the independent association with PVR.

Results: Over the study period, 32,465 patients underwent HT, including 12,257 (38%) with mPAP < 25 mm Hg. The median age was 55 years (interquartile range, 47-62) and the median PVR was 1.5 Wood units (WU) (interquartile range, 1-2.2) in recipients with mPAP < 25 mm Hg. After controlling for confounders, PVR was independently associated with increased risk for 30-day mortality (hazard ratio, 1.16; 95% CI, 1.05-1.27; P < .01), but not conditional 1-year mortality (hazard ratio, 1.03; 95% CI, 0.94-1.12; P = .55). PVR ≥ 3 WU was associated with an absolute 1.9% increase in 30-day mortality in those with mPAP < 25 mm Hg, a similar risk to recipients with PVR ≥ 3 WU and mPAP ≥ 25 mm Hg.

Conclusions: Elevated PVR remains associated with a significant increase in the hazard for 30-day mortality after cardiac transplantation, even in the setting of lower pulmonary artery pressures. These data support the validity of the new definition of pulmonary hypertension.
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http://dx.doi.org/10.1016/j.chest.2019.07.028DOI Listing
January 2020

Rare Presentation of Endocarditis and Mycotic Brain Aneurysm.

Ann Thorac Surg 2020 03 16;109(3):e179-e181. Epub 2019 Aug 16.

Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Dell Children's Medical Center, Austin, Texas.

Bartonella endocarditis can be an elusive diagnosis. The clinical manifestations can vary and, at times, include multiorgan involvement. This case report describes 2 patients who presented with multiorgan failure, cerebral mycotic aneurysms, and valvular endocarditis secondary to Bartonella infection. The complex diagnosis, decision making, and surgical management are described.
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http://dx.doi.org/10.1016/j.athoracsur.2019.06.073DOI Listing
March 2020
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