Publications by authors named "George M Alfieris"

47 Publications

De Novo Damaging Variants, Clinical Phenotypes, and Post-Operative Outcomes in Congenital Heart Disease.

Circ Genom Precis Med 2020 08 30;13(4):e002836. Epub 2020 Jun 30.

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital (C.E.S.), Harvard Medical School, MA.

Background: De novo genic and copy number variants are enriched in patients with congenital heart disease, particularly those with extra-cardiac anomalies. The impact of de novo damaging variants on outcomes following cardiac repair is unknown.

Methods: We studied 2517 patients with congenital heart disease who had undergone whole-exome sequencing as part of the CHD GENES study (Congenital Heart Disease Genetic Network).

Results: Two hundred ninety-four patients (11.7%) had clinically significant de novo variants. Patients with de novo damaging variants were 2.4 times more likely to have extra-cardiac anomalies (=5.63×10). In 1268 patients (50.4%) who had surgical data available and underwent open-heart surgery exclusive of heart transplantation as their first operation, we analyzed transplant-free survival following the first operation. Median follow-up was 2.65 years. De novo variants were associated with worse transplant-free survival (hazard ratio, 3.51; =5.33×10) and longer times to final extubation (hazard ratio, 0.74; =0.005). As de novo variants had a significant interaction with extra-cardiac anomalies for transplant-free survival (=0.003), de novo variants conveyed no additional risk for transplant-free survival for patients with these anomalies (adjusted hazard ratio, 1.96; =0.06). By contrast, de novo variants in patients without extra-cardiac anomalies were associated with worse transplant-free survival during follow-up (hazard ratio, 11.21; =1.61×10) than that of patients with no de novo variants. Using agnostic machine-learning algorithms, we identified de novo copy number variants at 15q25.2 and 15q11.2 as being associated with worse transplant-free survival and 15q25.2, 22q11.21, and 3p25.2 as being associated with prolonged time to final extubation.

Conclusions: In patients with congenital heart disease undergoing open-heart surgery, de novo variants were associated with worse transplant-free survival and longer times on the ventilator. De novo variants were most strongly associated with adverse outcomes among patients without extra-cardiac anomalies, suggesting a benefit for preoperative genetic testing even when genetic abnormalities are not suspected during routine clinical practice. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01196182.
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http://dx.doi.org/10.1161/CIRCGEN.119.002836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439931PMC
August 2020

Intraoperative Cortical Asynchrony Predicts Abnormal Postoperative Electroencephalogram.

Ann Thorac Surg 2021 02 6;111(2):645-654. Epub 2020 Jun 6.

Department of Surgery, University of Rochester Medical Center, Rochester, New York.

Background: Postoperative electroencephalograms (EEGs) can identify seizure activity and neurologic dysfunction in high-risk neonates requiring cardiac surgical procedures. Although intraoperative EEG monitoring is uncommon, variations in cerebral blood flow and temperature during antegrade cerebral perfusion (ACP) can manifest as cortical asynchrony during EEG monitoring. We hypothesized that intraoperative EEG cortical asynchrony would identify neonates at risk for abnormal postoperative EEG tracings.

Methods: Neonates requiring ACP for cardiac repair or palliation had continuous baseline, intraoperative, and postoperative hemodynamic and EEG monitoring. Synchronous and asynchronous cortical bursts were quantified during (1) cooling before ACP, (2) ACP, and (3) rewarming. Asynchronous bursts were defined as interhemispheric variations in electrical voltage or frequency. Neonates were divided into 2 groups, those with and without an abnormal postoperative EEG, which was defined as either persistent asynchrony for more than 2 hours or seizure activity on EEG.

Results: Among 40 neonates, 296 asynchronous bursts were noted, most commonly during rewarming. Eight (20%) neonates had an abnormal postoperative EEG (seizure activity, n = 3; persistent asynchrony, n = 5). Baseline demographics and intraoperative hemodynamics were similar between the groups. However, the total number of intraoperative asynchronous bursts was greater in neonates with an abnormal postoperative EEG (17 [11, IQR:24] vs 3 [IQR:1, 7]; P < .001). Multivariate analysis confirmed that the number of asynchronous bursts was independently associated with an abnormal postoperative EEG (odds ratio,1.35; confidence interval,:1.10, 1.65; P = .004).

Conclusions: Neonates with a greater number of intraoperative asynchronous cortical bursts had an abnormal postoperative EEG.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.090DOI Listing
February 2021

Commentary: The static use of the transannular patch in the repair of tetralogy of Fallot.

J Thorac Cardiovasc Surg 2019 Sep 23. Epub 2019 Sep 23.

Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY.

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http://dx.doi.org/10.1016/j.jtcvs.2019.09.036DOI Listing
September 2019

Neurodevelopmental Delay After the Neonatal Repair of Coarctation and Arch Obstruction.

Ann Thorac Surg 2019 11 14;108(5):1416-1422. Epub 2019 Jun 14.

Department of Surgery, University of Rochester Medical Center, Rochester, New York. Electronic address:

Background: Although single ventricle physiology and cyanosis are known risk factors for neurodevelopmental delay (NDD), the impacts of isolated coarctation (Iso CoA) repair or arch reconstruction (AR) are less understood.

Methods: The Vineland Adaptive Behavior Scales, third edition, prospectively evaluated children without a genetic syndrome. An overall composite score, normalized to age and sex, was generated from individual domain scores. NDD was defined as a composite or domain score at least 1 SD less than the established mean. Iso CoA was repaired using a left thoracotomy, whereas AR was performed using a sternotomy and cardiopulmonary bypass. Children with a structurally normal heart and without previous surgery were used as control patients.

Results: Of 60 children, 50 required neonatal repair (12 for Iso CoA, 38 for AR), and 10 were control patients. From the entire cohort of children who required neonatal coarctation repair (Iso CoA + AR) composite (93.9 ± 15.9 vs 105.0 ± 7.4; P = .004) and all domain scores were significantly lower than control patients. NDD was present in 25 of 50 children after repair and in 0 of 10 control patients (P = .003). Similarly, the prevalence of NDD was significantly greater after Iso CoA repair (58.3% vs 0%; P = .005) and AR (47.3% vs 0%; P = .007) than in the control population, but no significant difference was found between the Iso CoA and AR groups (P = .74).

Conclusions: In this small cohort, half of the neonates who required either Iso CoA repair or AR exhibit NDD at an intermediate-term follow-up.
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http://dx.doi.org/10.1016/j.athoracsur.2019.04.088DOI Listing
November 2019

Met-Hemoglobin Is a Biomarker for Poor Oxygen Delivery in Infants Following Surgical Palliation.

World J Pediatr Congenit Heart Surg 2019 07 29;10(4):485-491. Epub 2019 May 29.

3 Department of Pediatrics, University of Rochester, Rochester, NY, USA.

Background: Infants with cyanotic congenital heart disease demonstrate wide fluctuations in hemoglobin (Hb), oxygen saturation, and cardiac output following palliation. Methemoglobin (Met-Hb), the product of Hb oxidation, may represent a compensatory mechanism during hypoxia and may be utilized as a biomarker.

Methods: Arterial and venous Met-Hb levels were obtained from infants requiring palliation. The primary outcome was to describe the relationship between Met-Hb and other indices of tissue oxygenation (venous saturation, estimated arteriovenous oxygen difference [Est AV-Diff], and lactate). Secondary outcomes were to determine the impact of elevated Met-Hb levels ≥1.0% and the effect of red blood cell (RBC) transfusion on Met-Hb levels.

Results: Fifty infants and 465 Met-Hb values were studied. Venous Met-Hb levels were significantly higher than arterial levels (venous: 0.84% ± 0.36% vs arterial: 0.45% ± 0.18%; < .001). Venous Met-Hb demonstrated a significant inverse relationship with venous oxygen saturation ( = -0.6; < .001) and Hb ( = -0.3, < .001) and a direct relationship with the Est AV-Diff ( = 0.3, < .001). A total of 129 (29.6%) venous Met-Hb values were elevated (≥1.0%) and were associated with significantly lower Hb and venous saturation levels and higher Est AV-Diff and lactate levels. Methemoglobin levels decreased significantly following 65 RBC transfusions (0.94 ± 0.40 vs 0.77 ± 0.34; < .001). Linear mixed models demonstrated that higher venous Met-Hb levels were associated with lower measures of tissue oxygenation and not related to any preoperative clinical differences.

Conclusion: Methemoglobin may be a clinically useful marker of tissue oxygenation in infants following surgical palliation.
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http://dx.doi.org/10.1177/2150135119852327DOI Listing
July 2019

Serial Follow-Up of Two Surgical Strategies for the Repair of Tetralogy of Fallot.

Semin Thorac Cardiovasc Surg 2019 5;31(3):515-523. Epub 2019 Jan 5.

University of Rochester Medical Center, Division of Cardiac Surgery, Department of Surgery, Rochester, New York. Electronic address:

Adverse events following tetralogy of Fallot repair include arrhythmia, reoperation, and death. While limiting the right ventriculotomy mitigates these events over the short and intermediate term, the impact over the long term is unknown. Children requiring tetralogy of Fallot repair were divided into 2 groups: extended right ventriculotomy vs limited right ventriculotomy with transatrial ventricular septal defect closure. Follow-up office ECGs and Holter monitoring, exercise stress tests, and echocardiograms were obtained in the first, second, and third postoperative decades. The primary outcome was cumulative events defined as reoperation, arrhythmia, or death. The extended and limited right ventriculotomy techniques were used in 21 and 17 children, respectively. Cumulative survival was 93.6% at 30 years and was not different between groups. While 10-year (42.9% vs 5.9%, P = 0.02) event rates favored the limited ventriculotomy technique, there were no significant differences at 20 or 25 years. Cox proportional hazard analysis demonstrated that the limited ventriculotomy technique was independently associated with lower events at 10 years (hazard ratio 0.03, 95% confidence interval 0.0016, 0.5697, P = 0.01). The limited ventriculotomy group had greater exercise capacity in the second decade but not the third. Right ventricular end-diastolic diameter Z score was not different at 10 or 20 years, but was significantly smaller in the limited ventriculotomy group at 30 years (5.55 ± 1.69 vs 4.14 ± 0.63, P = 0.03). Limiting the right ventriculotomy during tetralogy of Fallot repair limits 10-year events, improves exercise capacity at 20 years, and attenuates late right ventricular dilation.
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http://dx.doi.org/10.1053/j.semtcvs.2019.01.006DOI Listing
January 2020

Damus-Kaye-Stansel procedure avoids coronary obstruction in complex D-transposition.

J Card Surg 2018 Nov 25;33(11):756-758. Epub 2018 Oct 25.

Department of Surgery, University of Rochester Medical Center, Rochester, New York.

Although all coronary anatomy in D-transposition of the great arteries may be "switchable," there are reports in the literature of early and late coronary obstruction following the arterial switch operation. The Damus-Kaye-Stansel procedure does not risk injury to the coronary arteries, and unlike the atrial switch, commits the left ventricle to the systemic circulation. We present a series of four neonates over 22 years with D-transposition of the great arteries and a concomitant coronary artery anomaly precluding arterial switch that were repaired using a Damus-Kaye-Stansel procedure and right ventricle to pulmonary artery conduit.
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http://dx.doi.org/10.1111/jocs.13937DOI Listing
November 2018

Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients.

Transfusion 2018 07 30;58(7):1631-1639. Epub 2018 Mar 30.

Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York.

Background: There are data suggesting that free hemoglobin (Hb), heme, and iron contribute to infection, thrombosis, multiorgan failure, and death in critically ill patients. These outcomes may be mitigated by haptoglobin.

Study Design And Methods: 164 consecutively treated children undergoing surgery for congenital heart disease were evaluated for associations between free Hb and haptoglobin and clinical outcomes, physiologic metrics, and biomarkers of inflammation RESULTS: Higher perioperative free Hb levels (and lower haptoglobin levels) were associated with mortality, nosocomial infection, thrombosis, hours of intubation and inotropes, increased interleukin-6, peak serum lactate levels, and lower nadir mean arterial pressures. The median free Hb in patients without infection (30 mg/dL; 29 interquartile range [IQR], 24-52 mg/dL) was lower than in those who became infected (39 mg/dL; IQR, 33-88 mg/ 31 dL; p = 0.0046). The median mechanical ventilation requirements were 19 (IQR, 7-72) hours in patients with higher levels of haptoglobin versus 48 (IQR, 18-144) hours in patients with lower levels (p = 0.0047). Transfusion dose, bypass duration, and complexity of surgery were all significantly correlated with Hb levels and haptoglobin levels. Multivariate analyses demonstrated that these variables were independently and significantly associated with outcomes.

Conclusions: Elevated pre- and postoperative levels of free Hb and decreased levels of haptoglobin were associated with adverse clinical outcomes, inflammation, and unfavorable physiologic metrics. Transfusion, RACHS score, and duration of bypass were associated with increased free Hb and decreased haptoglobin. Further investigation of the role of hemolysis and haptoglobin as potential mediators or markers of outcomes is warranted.
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http://dx.doi.org/10.1111/trf.14601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105435PMC
July 2018

Modified Repair of Type I and II Truncus Arteriosus Limits Early Right Ventricular Outflow Tract Reoperation.

Semin Thorac Cardiovasc Surg 2018 8;30(2):199-204. Epub 2018 Feb 8.

Department of Surgery, University of Rochester Medical Center, Rochester, New York; Department of Pediatrics, University of Rochester Medical Center, Rochester, New York; Pediatric Cardiac Consortium of Upstate New York. Electronic address:

Repair of truncus arteriosus often requires early right ventricular outflow tract (RVOT) reoperation. Using a modified repair, the branch pulmonary arteries are left in situ, which may avoid earlier RVOT reoperation. We hypothesized that our modified repair for type I and II truncus arteriosus would extend the time to RVOT reoperation. Infants with truncus arteriosus were divided into 2 groups: (1) traditional technique where the branch pulmonary arteries are excised from the truncal root, or (2) modified repair where the branch pulmonary arteries are left in situ and septated from the truncal root. Regardless of the approach, a bioprosthetic conduit or homograft was used to establish right ventricular to pulmonary artery continuity. Follow-up pulmonary artery angiograms were used to assess for branch pulmonary artery stenosis. From 54 infants (modified repair: 33, traditional technique: 21), there were no significant differences in age at repair, gender, or type of truncus arteriosus. With 100% follow-up, use of the modified repair resulted in a lower rate of branch pulmonary artery stenosis, and greater freedom from surgical branch pulmonary arterioplasty. Five- and 10-year freedom from RVOT reoperation (5 years: modified-81.5% vs traditional-30.5%, P = 0.004; 10 years: modified-53.3% vs traditional-30.5%, P = 0.01) favored the modified repair. Cox regression analysis demonstrated that the modified repair was associated with an independently lower risk for RVOT reoperation (hazard ratio: 0.08, confidence interval: 0.01, 0.75, P = 0.02). Thus, maintaining the branch pulmonary artery architecture resulted in greater freedom from RVOT reoperation.
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http://dx.doi.org/10.1053/j.semtcvs.2018.02.003DOI Listing
November 2018

Transfer of Neonates with Critical Congenital Heart Disease Within a Regionalized Network.

Pediatr Cardiol 2017 Oct 15;38(7):1350-1358. Epub 2017 Jul 15.

Pediatric Cardiac Consortium of Upstate New York, New York, USA.

Regionalization of pediatric cardiac surgical care varies between and within states. In most geographic regions, at least some neonates with critical heart disease are transferred from their birth hospital to a different hospital for surgery. The impact of neonatal transfer for surgery, particularly over a considerable distance (>10 miles), has been largely unexplored. We sought to examine the impact of transferring neonates for cardiac surgery. We queried the New York State Cardiac Surgery database (2005-2014) from a single institution to identify neonates born within the cardiac surgery center and those transferred for surgery. Outcomes were compared between groups, with subgroup analysis of neonates with single ventricle anatomy. 113 surgical neonates were born at the cardiac surgery center, and 268 were transferred to the cardiac surgery center. Median transfer distance was 91 (IQR 73, 94) miles. Age at operation and the need for preoperative ventilation were significantly lower in neonates born at the cardiac surgery center. In addition, single ventricle anatomy was more prevalent among those born at the cardiac surgery center (48.7 vs. 31.3%; p = 0.001). However, postoperative outcomes were the same-30-day survival was similar across groups (birth: 89% vs. transfer: 90%; p = 0.7), and for those with single ventricle palliation (birth: 81% vs. transfer: 81%; p = 0.9). Within our regionalized network, we found no difference in 30-day survival between neonates either born or transferred to a cardiac surgery center, which supports the use of a regionalized network of hospitals to the care of children with congenital heart disease.
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http://dx.doi.org/10.1007/s00246-017-1668-8DOI Listing
October 2017

A modified LVAD technique to augment caval and pulmonary arterial blood flow in the "failing Fontan" circulation.

J Card Surg 2017 Feb 9;32(2):126-132. Epub 2017 Jan 9.

Department of Surgery, University of Rochester Medical Center, Rochester, New York.

Background: There are minimal circulatory support options for patients with a failing Fontan. The Heartmate II (HMII) left ventricular assist device (Thoratec, Bedford, MA) in its packaged state cannot augment caval/pulmonary arterial blood flow.

Aim: We hypothesized that a modified HMII pump could augment caval and pulmonary arterial blood flow.

Methods: A bifurcated ringed Gore-Tex graft (W. L. Gore & Associates, Flagstaff, AZ) was sewn to the HMII inflow, and the outflow graft transected and tapered from 16 mm to 8 mm in diameter. In three sheep, the inflow and outflow grafts were anastomosed end-to-side to both cava and the pulmonary artery.

Results: Following baseline measurements, the pump speed was increased to 8000 revolutions per minute (RPMs). Compared to baseline, at 8000 RPMs, there were no significant differences in mean arterial, central venous, or pulmonary arterial pressure. However, there was a significant decrease in right ventricular diastolic diameter (3.1 ± 0.1 vs. 1.8 ± 0.2 cm, R = 0.6, p = 0.02) and similarly a decrease in pulmonary arterial pulse pressure (8.5 ± 2.1 vs. 2.1 ± 2.9 mmHg, p = 0.01). As pump speed increased, there was a corresponding increase in pump flow and power, with a decrease in pulsatility index.

Conclusions: These findings suggest that the HMII may be modified to provide caval/pulmonary circulatory support for the failing Fontan circulation.
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http://dx.doi.org/10.1111/jocs.12931DOI Listing
February 2017

The Initial Glimpse at Long-term Outcomes Following the Repair of Truncus Arteriosus.

Semin Thorac Cardiovasc Surg 2016 11;28(2):512-513. Epub 2016 Aug 11.

University of Rochester Medical Center, Rochester, New York.

The article by Naimo and colleagues (outcomes of truncus arteriosus repair in children: 35 years of experience from a single center) provides the initial glimpse at long-term outcomes following truncus arteriosus repair. Although survival has improved over the past decade, the morbidity resulting from subsequent re-operations now comprises a significant area for improvement in the ensuing decade.
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http://dx.doi.org/10.1053/j.semtcvs.2016.08.001DOI Listing
August 2017

Sustained Improvement in Right Ventricular Chamber Dimensions 10 Years Following Xenograft Pulmonary Valve Replacement.

World J Pediatr Congenit Heart Surg 2017 01;8(1):39-47

1 University of Rochester Medical Center, Rochester, NY, USA.

Background: The goals following pulmonary valve replacement (PVR) are to optimize right ventricular hemodynamics and minimize the need for subsequent reoperations on the right ventricular outflow tract. We hypothesized PVR using a xenograft valved conduit would result in superior freedom from reoperation with sustained improvement in right ventricular chamber dimensions.

Methods: Xenograft valved conduits placed in patients aged >16 years were reviewed from 2000 to 2010 to allow for a 5-year minimum follow-up. Preoperative, one-year, and the most recent echocardiograms quantified right ventricular chamber dimensions, corresponding Z scores, and prosthetic valve function. Magnetic resonance imaging (MRI) studies compared preoperative and follow-up right ventricular volumes.

Results: A total of 100 patients underwent PVR at 24 (19-34) years. Freedom from reintervention was 100% at 10 years. At most recent follow-up, only one patient had greater than mild pulmonary insufficiency. The one-year (17.3 ± 7.2 mm Hg; P < .01) and most recent follow-up (18.6 ± 9.8 mm Hg; P < .01) Doppler-derived right ventricular outflow tract gradients remained significantly lower than preoperative measurements (36.7 ± 27.0 mm Hg). Similarly, right ventricular basal diameter, basal longitudinal diameter, and the corresponding Z scores remained lower at one year and follow-up from preoperative measurements. From 34 MRI studies, the right ventricular end-diastolic indexed volume (161.7 ± 58.5 vs 102.9 ± 38.3; P < .01) and pulmonary regurgitant fraction (38.0% ± 15.9% vs 0.8% ± 3.3%; P < .01) were significantly lower at 7.1 ± 3.4 years compared to the preoperative levels.

Conclusion: Use of a xenograft valved conduit for PVR results in excellent freedom from reoperation with sustained improvement in right ventricular dimensions at an intermediate-term follow-up.
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http://dx.doi.org/10.1177/2150135116670632DOI Listing
January 2017

Continuous Cardiopulmonary Bypass During the Repair of Total Anomalous Pulmonary Venous Return.

World J Pediatr Congenit Heart Surg 2016 11;7(6):750-752

Pediatric Cardiac Consortium of Upstate New York, NY, USA

Circulatory arrest (CA) is traditionally utilized during the repair of total anomalous pulmonary venous return (TAPVR). Since 2005, we have exclusively repaired all types of TAPVR using continuous cardiopulmonary bypass. We present our technique using continuous cardiopulmonary bypass throughout the duration of the repair, by temporarily occluding the vertical vein and placing a pump sucker within the pulmonary venous confluence. This technique has been used on 29 consecutive patients and resulted in limited morbidity and absence of pulmonary vein stenosis from most recent follow-up.
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http://dx.doi.org/10.1177/2150135116663699DOI Listing
November 2016

Left Main Coronary Artery Atresia in an Infant With Inclusion-Cell Disease.

World J Pediatr Congenit Heart Surg 2018 03 12;9(2):246-250. Epub 2016 Sep 12.

1 Division of Pediatric Cardiology, Department of Pediatrics, University of Rochester Medical Center, Golisano Children's Hospital, Rochester, NY, USA.

A 2-month-old male with dysmorphic facies, neonatal thrombocytopenia, left congenital cataract, and long bone abnormalities became hypotensive with ST depression on induction of anesthesia for congenital cataract repair. Echocardiogram demonstrated decreased left ventricular function (ejection fraction 46%), mild mitral valve regurgitation (MR), and regional wall motion abnormalities. The left coronary artery could not be visualized. Subsequent cardiac catheterization confirmed atresia of the left main coronary artery. The patient underwent cardiac surgery with coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery. His postoperative course was uncomplicated, his ventricular function normalized, and he was discharged home. Over the next few months, he developed progressive, severe MR refractory to medical management. Repeat cardiac catheterization revealed stenosis of the right proximal coronary artery, raising concern for progressive coronary involvement. In addition to dysmorphic features and failure to thrive, there were profound developmental delays and a finding of vacuolated lymphocytes on blood smear, which led to a diagnosis of mucolipidosis II (Inclusion [I]-cell disease). The patient was referred for mitral valve replacement, which was successful; however, ongoing respiratory issues attributed to the progression of I-cell disease led to a prolonged hospitalization with placement of a tracheostomy. Reports of coronary anomalies in patients with I-cell disease are rare. An association between mucopolysaccharidosis syndromes and coronary artery abnormalities has been established and is supported by this case report, highlighting the importance of considering the potential for coronary artery involvement with I-cell disease and other similar storage diseases.
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http://dx.doi.org/10.1177/2150135116664701DOI Listing
March 2018

Outcomes Using a Conservative Versus Liberal Red Blood Cell Transfusion Strategy in Infants Requiring Cardiac Operation.

Ann Thorac Surg 2017 Jan 3;103(1):206-214. Epub 2016 Aug 3.

Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York.

Background: The optimal hemoglobin for infants after cardiac operation is unknown. Red blood cells (RBCs) are commonly transfused to maintain high hemoglobin concentrations in the absence of a clinical indication. We hypothesized that infants can be managed with a postoperative conservative RBC transfusion strategy, resulting in lower daily hemoglobin concentrations, without evidence of impaired oxygen delivery (ie, lactate, arteriovenous oxygen difference [avOdiff]), or adverse clinical outcomes.

Methods: Infants weighing 10 kg or less undergoing biventricular repair or palliative (nonseptated) operation were randomly assigned to either a postoperative conservative or liberal transfusion strategy. Conservative group strategy was RBC transfusion for a hemoglobin less than 7.0 g/dL for biventricular repairs or less than 9.0 g/dL for palliative procedures plus a clinical indication. Liberal group strategy was RBC transfusion for hemoglobin less than 9.5 g/dL for biventricular repairs or less than 12 g/dL for palliative procedures regardless of clinical indication.

Results: After the operation of 162 infants (82 conservative [53 biventricular, 29 palliative], 80 liberal [52 biventricular, 28 palliative]), including 12 Norwood procedures (6 conservative, 6 liberal), daily hemoglobin concentrations were significantly lower within the conservative group than the liberal group by postoperative day 1 and remained lower for more than 10 days. The percentage of patients requiring a RBC transfusion, number of transfusions, and volume of transfusions were all significantly lower within the conservative group. Despite lower hemoglobin concentrations within the conservative group, lactate, avOdiff, and clinical outcomes were similar.

Conclusions: Infants undergoing cardiac operation can be managed with a conservative RBC transfusion strategy. Clinical indications should help guide the decision for RBC transfusion even in this uniquely vulnerable population. Larger multicenter trials are needed to confirm these results, and focus on the highest risk patients would be of great interest.
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http://dx.doi.org/10.1016/j.athoracsur.2016.05.049DOI Listing
January 2017

Use of a Dacron Annular Sparing Versus Limited Transannular Patch With Nominal Pulmonary Annular Expansion in Infants With Tetralogy of Fallot.

Ann Thorac Surg 2017 Jan 29;103(1):186-192. Epub 2016 Jul 29.

Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York. Electronic address:

Background: Repair of tetralogy of Fallot (ToF) using a transannular patch can result in severe pulmonary insufficiency (PI) and subsequent right ventricular (RV) dilation. Use of a Dacron (Maquet Cardiovascular LLC, Wayne, NJ) limited transannular patch with nominal pulmonary annular expansion (LTAP) attempts to limit PI. We sought to evaluate the degree of PI and RV dilation resulting from a LTAP or annular sparing (AS) approach.

Methods: Infants less than 1 year of age undergoing ToF repair between 2000 and 2010 were divided into 2 groups: LTAP and AS RV outflow tract patch. Echocardiograms were used to determine RV dimensions and corresponding Z-values.

Results: From 94 infants, 48 required a LTAP and 46 required an AS patch. The preoperative pulmonary valve annulus Z-value was significantly smaller in the LTAP versus AS group (-2.7 ± 1.4 versus -0.9 ± 1.5; p < 0.001). Mean follow-up was obtained at 7.9 ± 3.4 years. Ten-year freedom from severe pulmonary insufficiency was 78.5% versus 93.2% (p = 0.3) in the LTAP and AS groups, respectively. There was no significant difference in the diameter of the RV base Z-value between groups (LTAP: 0.9 ± 0.8 versus AS: 0.0 ± 2.3; p = 0.1). Further, the freedom from reoperation at 10 years was also not significantly different between the LTAP and AS groups (95.6% versus 91.8%; p = 0.5).

Conclusions: When required, a LTAP results in a similar change in RV chamber size and rate of reoperation at an intermediate-term follow-up.
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http://dx.doi.org/10.1016/j.athoracsur.2016.05.056DOI Listing
January 2017

Identification of differentially regulated genes in human patent ductus arteriosus.

Exp Biol Med (Maywood) 2016 12 28;241(18):2112-2118. Epub 2016 Jul 28.

1 Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY 14642, USA.

In order to identify differentially expressed genes that are specific to the ductus arteriosus, 18 candidate genes were evaluated in matched ductus arteriosus and aortic samples from infants with coarctation of the aorta. The cell specificity of the gene's promoters was assessed by performing transient transfection studies in primary cells derived from several patients. Segments of ductus arteriosus and aorta were isolated from infants requiring repair for coarctation of the aorta and used for mRNA quantitation and culturing of cells. Differences in expression were determined by quantitative PCR using the ΔΔCt method. Promoter regions of six of these genes were cloned into luciferase reporter plasmids for transient transfection studies in matched human ductus arteriosus and aorta cells. Transcription factor AP-2b and phospholipase A2 were significantly up-regulated in ductus arteriosus compared to aorta in whole tissues and cultured cells, respectively. In transient transfection experiments, Angiotensin II type 1 receptor and Prostaglandin E receptor 4 promoters consistently gave higher expression in matched ductus arteriosus versus aorta cells from multiple patients. Taken together, these results demonstrate that several genes are differentially expressed in ductus arteriosus and that their promoters may be used to drive ductus arteriosus-enriched transgene expression.
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http://dx.doi.org/10.1177/1535370216661778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102136PMC
December 2016

Long-Term Survival and Freedom From Reoperation After Placement of a Pulmonary Xenograft Valved Conduit.

Ann Thorac Surg 2016 Aug 4;102(2):602-7. Epub 2016 May 4.

Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan.

Background: The optimal choice for pulmonary valve replacement (PVR) remains controversial. This study hypothesized that xenografts used for PVR would result in prolonged long-term survival and freedom from reoperation.

Methods: Children and adults with congenital heart disease requiring PVR using a xenograft from 1980 to 1985 were reviewed. In all cases, the xenograft valve was either sewn or manufactured into a Dacron conduit, and the conduit was sewn to the pulmonary artery bifurcation. Clinical data were analyzed, and survival and freedom from reoperation were determined using Kaplan-Meier analysis.

Results: Twenty-four patients received a xenograft for PVR at 14.6 ± 5.6 years. Conduit size ranged from 21 to 27 mm. Most patients received a Carpentier-Edwards valved conduit (n = 17), followed by a Hancock valved conduit (n = 5) and an Ionescu-Shiley valve sewn into a Dacron graft (n = 2). No perioperative deaths occurred. Reoperation was required mainly for pulmonary stenosis (72.7%), followed by pulmonary insufficiency (18.2%), or both stenosis and insufficiency (9%). Freedom from reoperation was 90%, 56%, 43%, and 14% at 10, 20, 25, and 30 years, respectively. At most recent follow-up the was only death, which was related to severe biventricular failure 25 years after conduit implant.

Conclusions: PVR using a xenograft valved conduit results in prolonged freedom from reoperation and excellent long-term survival. These data, which provide long-term follow-up information on xenograft valves after PVR.
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http://dx.doi.org/10.1016/j.athoracsur.2016.02.045DOI Listing
August 2016

Neurodevelopmental outcomes after neonatal cardiac surgery: Role of cortical isoelectric activity.

J Thorac Cardiovasc Surg 2016 Apr 27;151(4):1137-42. Epub 2015 Oct 27.

Department of Surgery, University of Rochester Medical Center, Rochester, NY.

Objectives: Neonates with congenital heart disease are at risk for impaired neurodevelopment after cardiac surgery. We hypothesized that intraoperative EEG activity may provide insight into future neurodevelopmental outcomes.

Methods: Neonates requiring surgery had continuous intraoperative EEG and hemodynamic monitoring. The level of EEG suppression was classified as either: slow and continuous; moderate burst suppression; severe burst suppression; or isoelectric (no brain activity for >3 minutes). Follow-up neurodevelopmental outcomes were assessed using the Vineland Adaptive Behavior Scale II (Vineland-II).

Results: Twenty-one neonates requiring cardiac surgery developed a slow and continuous EEG pattern after general anesthesia. Ten neonates (48%) maintained continuous brain electrical activity with moderate burst suppression as the maximum level of EEG suppression. Eleven neonates (52%) developed severe burst suppression that progressed into an isoelectric state during the deep hypothermic period required for circulatory arrest. However, the duration of this state was significantly longer than circulatory arrest times (111.1 ± 50 vs 22.3 ± 17 minutes; P < .001). At a mean follow-up at 5.6 ± 1.0 years, compared with neonates with continuous brain electrical activity, neonates who developed an isoelectric state had lower Vineland-II scores in communication. There was an inverse relationship between composite Vineland-II scores and duration of isoelectric activity (R = -0.75, P = .01). Of neonates who experienced an isoelectric state, durations of >90 minutes were associated with the lowest Vineland-II scores (125.0 ± 2.6 vs 81.1 ± 12.7; P < .01).

Conclusions: The duration of cortical isoelectric states seems related to neurodevelopmental outcomes. Strategies using continuous EEG monitoring to minimize isoelectric states may be useful during complex congenital heart surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2015.10.065DOI Listing
April 2016

Successful surgical palliation of a triple-outlet right ventricle: a rare congenital cardiac malformation.

Cardiol Young 2016 Feb 2;26(2):403-5. Epub 2015 Jul 2.

3Department of Pediatrics,Division of Pediatric Cardiology,University of Rochester Medical Center,Rochester,New York,United States of America.

Most commonly, hearts have either a single arterial trunk or two arterial trunks; however, rare reports exist of a "tritruncal" heart, a heart with three outflow tracts. Here, we present one of the first reports of successful surgical palliation of a triple-outlet right ventricle.
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http://dx.doi.org/10.1017/S1047951115001237DOI Listing
February 2016

Distal Transverse Arch to Left Carotid Artery Ratio Helps to Identify Infants With Aortic Arch Hypoplasia.

Ann Thorac Surg 2015 Sep 23;100(3):1004-11; discussion 1011-2. Epub 2015 Jul 23.

Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York.

Background: Aortic coarctation (CoA) with concomitant aortic arch hypoplasia (AAH) is associated with an increased risk of hypertension after surgical repair. The differentiation of CoA with or without AAH may be critical to delineate the ideal surgical approach that best ameliorates postoperative hypertension. Since 2000, we have defined CoA with AAH when the diameter of the distal transverse aortic arch is equal to or less than the diameter of the left carotid artery. We hypothesized that, based on our definition, aortic tissue from infants having CoA with AAH would demonstrate distinct genetic expression patterns as compared with infants having CoA alone.

Methods: From 6 infants (AAH, 3; CoA, 3), an Affymetrix 1.0 genome array identified genes in the coarctation/arch region that were differentially expressed between infants having CoA with AAH versus CoA alone. Reverse transcription polymerase chain reaction validated genetic differences from a cohort of 21 infants (CoA with AAH, 10; CoA, 11). To evaluate the clinical outcomes based on our definition of CoA with AAH, we reviewed infants repaired using this algorithm from 2000 to 2010.

Results: Microarray data demonstrated genes differentially expressed between groups. Reverse transcription polymerase chain reaction confirmed that CoA with AAH was associated with an increased expression of genes involved in cardiac and vascular development and growth, including hepsin, fibroblast growth factor-18, and T-box 2. The clinical outcomes of 79 infants (AAH, 26; CoA, 53) demonstrated that 90.1% were free of hypertension at 13 years when managed with this surgical strategy.

Conclusions: These findings provide evidence that the ratio of the diameter of the distal transverse arch to the left carotid artery may be helpful to identify CoA with AAH and, when used to delineate the surgical approach, may minimize hypertension.
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http://dx.doi.org/10.1016/j.athoracsur.2015.04.107DOI Listing
September 2015

Pharmacokinetics of ε-Aminocaproic Acid in Neonates Undergoing Cardiac Surgery with Cardiopulmonary Bypass.

Anesthesiology 2015 May;122(5):1002-9

From the Departments of Anesthesiology (M.P.E., D.M.S.), Surgery (G.M.A., R.E.A.), Pediatrics (J.M.C.), and Neurology, Center for Human Experimental Therapeutics (C.V.), University of Rochester School of Medicine and Dentistry, Rochester, New York; and Department of Anaesthesiology, University of Auckland, Auckland, New Zealand (B.A.).

Background: Antifibrinolytic medications such as ε-aminocaproic acid (EACA) are used in pediatric heart surgery to decrease surgical bleeding and transfusion. Dosing schemes for neonates are often based on adult regimens, or are simply empiric, in part due to the lack of neonatal pharmacokinetic information. The authors sought to determine the pharmacokinetics of EACA in neonates undergoing cardiac surgery and to devise a dosing regimen for this population.

Methods: Ten neonates undergoing cardiac surgery with cardiopulmonary bypass were given EACA according to standard practice, and blood was drawn at 10 time points to determine drug concentrations. Time-concentration profiles were analyzed using nonlinear mixed effects models. Parameter estimates (standardized to a 70-kg person) were used to develop a dosing regimen intended to maintain a target concentration shown to inhibit fibrinolysis in neonatal plasma (50 mg/l).

Results: Pharmacokinetics were described using a two-compartment model plus an additional compartment for the cardiopulmonary bypass pump. First-order elimination was described with a clearance of 5.07 l/h × (WT/70). Simulation showed a dosing regimen with a loading dose of 40 mg/kg and an infusion of 30 mg · kg · h, with a pump prime concentration of 100 mg/l maintained plasma concentrations above 50 mg/l in 90% of neonates during cardiopulmonary bypass surgery.

Conclusions: EACA clearance, expressed using allometry, is reduced in neonates compared with older children and adults. Loading dose and infusion dose are approximately half those required in children and adults.
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http://dx.doi.org/10.1097/ALN.0000000000000616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882606PMC
May 2015

Longer RBC storage duration is associated with increased postoperative infections in pediatric cardiac surgery.

Pediatr Crit Care Med 2015 Mar;16(3):227-35

1Department of Pediatrics, University of Rochester, Rochester, NY. 2Department of Medicine, University of Rochester, Rochester, NY. 3Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, NY. 4Congenital Cardiac Surgery, University of Rochester, Rochester, NY. 5Department of Environmental Medicine, University of Rochester, Rochester, NY. 6Department of Anesthesiology, University of Rochester, Rochester, NY.

Objectives: Infants and children undergoing open heart surgery routinely require multiple RBC transfusions. Children receiving greater numbers of RBC transfusions have increased postoperative complications and mortality. Longer RBC storage age is also associated with increased morbidity and mortality in critically ill children. Whether the association of increased transfusions and worse outcomes can be ameliorated by use of fresh RBCs in pediatric cardiac surgery for congenital heart disease is unknown.

Interventions: One hundred and twenty-eight consecutively transfused children undergoing repair or palliation of congenital heart disease with cardiopulmonary bypass who were participating in a randomized trial of washed versus standard RBC transfusions were evaluated for an association of RBC storage age and clinical outcomes. To avoid confounding with dose of transfusions and timing of infection versus timing of transfusion, a subgroup analysis of patients only transfused 1-2 units on the day of surgery was performed.

Measurements And Main Results: Mortality was low (4.9%) with no association between RBC storage duration and survival. The postoperative infection rate was significantly higher in children receiving the oldest blood (25-38 d) compared with those receiving the freshest RBCs (7-15 d) (34% vs 7%; p = 0.004). Subgroup analysis of subjects receiving only 1-2 RBC transfusions on the day of surgery (n = 74) also demonstrates a greater prevalence of infections in subjects receiving the oldest RBC units (0/33 [0%] with 7- to 15-day storage; 1/21 [5%] with 16- to 24-day storage; and 4/20 [20%] with 25- to 38-day storage; p = 0.01). In multivariate analysis, RBC storage age and corticosteroid administration were the only predictors of postoperative infection. Washing the oldest RBCs (> 27 d) was associated with a higher infection rate and increased morbidity compared with unwashed RBCs.

Discussion: Longer RBC storage duration was associated with increased postoperative nosocomial infections. This association may be secondary in part, to the large doses of stored RBCs transfused, from single-donor units. Washing the oldest RBCs was associated with increased morbidity, possibly from increased destruction of older, more fragile erythrocytes incurred by washing procedures. Additional studies examining the effect of RBC storage age on postoperative infection rate in pediatric cardiac surgery are warranted.
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http://dx.doi.org/10.1097/PCC.0000000000000320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4351137PMC
March 2015

Regression of left ventricular hypertrophy in children following the Ross procedure.

Interact Cardiovasc Thorac Surg 2014 May;18(5):607-10

Department of Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY, USA.

Objectives: Left ventricular hypertrophy (LVH) frequently accompanies the progression of aortic valve disease in children. The extent of LVH regression following surgical relief of aortic valve disease in children has not been clearly elucidated. We hypothesized that significant regression of LVH will occur in children following the Ross procedure.

Methods: We examined LVH over time in children <18 years of age who underwent the Ross procedure. Left ventricular mass index (LVMI) and corresponding z scores were calculated based on height, age and gender. Left ventricular hypertrophy was defined as an LVMI of > 39 g/m(2.7) and a z score of >1.6.

Results: Twenty-five children underwent the Ross procedure. The left ventricular mass increased proportionally with the growth of the child from baseline to the latest follow-up at 7.3 ± 2.9 years (121.1 ± 81.5 vs 133.1 ± 79.8 g, P = 0.4). However, 96% (24/25) of children demonstrated LVMI regression from baseline. Mean LVMI decreased from 70.8 ± 31.2 to 41.8 ± 16.6 g/m(2.7) (P < 0.001). Similarly, LVMI z scores decreased from 2.2 ± 1.2 to 0.2 ± 1.9 (P < 0.001). Freedom from LVH was 83% at 10 years. Examination of LVMI and z scores over time demonstrated that the largest decrease occurred after the first year, with continued gradual decline over 10 years of follow-up.

Conclusions: The Ross procedure is effective in reversing LVH in children with aortic valve disease.
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http://dx.doi.org/10.1093/icvts/ivt462DOI Listing
May 2014

Intraoperative electroencephalography predicts postoperative seizures in infants with congenital heart disease.

Pediatr Neurol 2014 Apr 19;50(4):313-7. Epub 2013 Dec 19.

Department of Neonatology, University of Rochester Medical Center, Rochester, New York.

Background: During the surgical repair of infants with congenital cardiac defects, there can be periods of decreased cerebral blood flow, particularly during deep hypothermic circulatory arrest. As a result, these infants are at increased risk for seizures and long-term neurodevelopmental difficulties.

Methods: Thirty-two infants with congenital heart disease had continuous video-electroencephalographic (EEG) monitoring pre-, intra-, and postoperatively for 48 hours after surgery.

Results: For patients requiring deep hypothermic circulatory arrest (n = 17) the EEG pattern for all patients became suppressed and eventually isoelectric below 25 °C. Two of the 32 infants had electrical seizures within the 48-hour monitoring period. Both required deep hypothermic circulatory arrest, and the burst pattern during recovery had rhythmic, sharp components that were high amplitude and often asynchronous between the hemispheres. The interval between the onset of seizure activity and initiation of the sharp burst pattern during surgery was 29 and 40 hours. This pattern was not observed during isoelectric recovery from infants who did not develop postoperative seizures.

Conclusions: The EEG in infants during deep hypothermic circulatory arrest displayed predictable changes. We identified an electroencephalographic pattern following the isoelectric period that may predict seizure development in the subsequent 48 hours.
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http://dx.doi.org/10.1016/j.pediatrneurol.2013.12.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203305PMC
April 2014

Aortic aneurysm with a ruptured dissection in a 15-year-old boy with hypoplastic left heart syndrome.

J Thorac Cardiovasc Surg 2014 Apr 18;147(4):e35-6. Epub 2013 Dec 18.

Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Strong Memorial Hospital and Golisano Children's Hospital, Rochester, NY.

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http://dx.doi.org/10.1016/j.jtcvs.2013.11.034DOI Listing
April 2014

Right ventricular outflow tract obstruction after sinus of valsalva aneurysm repair.

J Card Surg 2014 May 22;29(3):317-9. Epub 2013 Oct 22.

Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York.

Sinus of Valsalva aneurysm (SVA) is a rare cardiac lesion especially in the western countries and older population. We report an unusual case of a 60-year-old Caucasian male with SVA, acute decompensation, and a pressurized prolapsed aortic leaflet cystic remnant via a small supracristal VSD causing recurrent right ventricular outflow tract obstruction following a Bentall procedure
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http://dx.doi.org/10.1111/jocs.12219DOI Listing
May 2014

Risk factors for a positive neoaortic arch gradient after stage I palliation for hypoplastic left heart syndrome.

Ann Thorac Surg 2013 Aug 16;96(2):645-50. Epub 2013 Jun 16.

Division of Cardiac Surgery, Strong Memorial Hospital, Rochester, New York.

Background: Providing unobstructed systemic blood flow is one goal of stage I palliation for hypoplastic left heart syndrome. Although clinically significant obstruction is defined when the arch gradient exceeds 15 mm Hg, any positive gradient constitutes obstruction, which may impair ventricular function. We sought to identify risk factors before stage I palliation that result in a positive neoaortic arch gradient before bidirectional Glenn.

Methods: Reviewed were 51 neonates who underwent stage I palliation and subsequent bidirectional cavopulmonary anastomosis procedures for hypoplastic left heart syndrome. Echocardiograms before stage I palliation were reviewed for aortic dimensions. Cardiac catheterization before bidirectional cavopulmonary anastomosis determined the aortic arch gradient and degree of right ventricular dysfunction.

Results: Of the 51 patients, 24 (47%) had a negative or absent arch gradient. Patients with a positive gradient had a median gradient of 5 mm Hg (range, 1 to 60 mm Hg). The diameter of the ascending aorta and proximal transverse arch indexed to the descending thoracic aorta (0.5 ± 0.2 vs 0.7 ± 0.4 and 0.4 ± 0.2 vs 0.6 ± 0.2 mm, p = 0.02 and p = 0.01) and lower birth weight (3.1 ± 0.5 vs 3.4 ± 0.4 kg, p = 0.03) were risk factors of a positive neoaortic arch gradient. Further, the degree of arch obstruction was inversely related to the degree of right ventricular function (odds ratio, 1.08; p < 0.01).

Conclusions: Lower birth weight and a smaller aortic diameter confer a higher risk of developing a positive neoaortic arch gradient, resulting in reduced right ventricular function.
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http://dx.doi.org/10.1016/j.athoracsur.2013.04.046DOI Listing
August 2013

Hypertensive changes within the aortic arch of infants and children with isolated coarctation.

Ann Thorac Surg 2013 Jul 31;96(1):190-5. Epub 2013 May 31.

Pediatric Cardiac Consortium of Upstate New York, Rochester, New York, USA.

Background: Despite repair, a significant proportion of patients with coarctation of the aorta (CoA) present with late hypertension. Increased gene expression of aortic wall collagen and vascular smooth muscle cell markers occurs in the presence of hypertension. Before repair, a patent ductus arteriosus (PDA) limits hypertension proximal to the coarctation. We hypothesize that preoperative collagen and vascular smooth muscle expression from the aortic arch in children is variable, depending on the presence or absence of a PDA.

Methods: We analyzed the expression patterns of collagen and vascular smooth muscle cell markers in 25 children with CoA using a quantitative polymerase chain reaction. Aortic arch tissue proximal to the CoA was normalized to descending aortic tissue distal to the coarctation. Collagen-I, transforming growth factor-β, elastin, and calponin were analyzed.

Results: At repair, 19 patients were aged younger than 3 months (14 with a PDA, 5 with a ligamentum arteriosum), and the remaining 6 were older than 1 year. There was no difference in age or weight between infants with or without a PDA. Infants without a PDA had the greatest difference in collagen-I expression compared with infants with a PDA (7.0 ± 1.6-fold vs 0.8 ± 1.1-fold, p = 0.01). Expression of transforming growth factor-β (4.3 ± 1.4 vs 2.6 ± 2.3, p = 0.01) and calponin (3.7 ± 0.7 vs 0.6 ± 1.1, p = 0.05) was lower from infants with vs without a PDA.

Conclusions: Our findings provide evidence of preoperative changes in the aortic arch before repair, particularly in the absence of a PDA.
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http://dx.doi.org/10.1016/j.athoracsur.2013.04.007DOI Listing
July 2013