Several perioperative risk factors influence outcomes after repair of complete atrioventricular s... more Several perioperative risk factors influence outcomes after repair of complete atrioventricular septal defects. This study was conducted to determine their association with perioperative mortality and need for reoperation. Between July 1982 and February 1995, 363 children underwent defect repair (median age, 8.3 months; mean, 17.4+/-1.3). Tetralogy of Fallot was present in 21 patients, double-outlet right ventricle in 4, subaortic stenosis in 8, ventricular hypoplasia in 8, coarctation in 5, atrial isomerism in 2, and other congenital anomalies in 9. Down's syndrome was present in 235 (65%). One-patch technique was applied in 99, two-patch in 243. During repair, the anterior bridging leaflet was divided in 12, the posterior bridging leaflet in 31, both leaflets in 71, and neither in 249. Left atrioventricular valve (LAVV) cleft was closed partially in 181 and completely in 112. Early mortality was 10.5%; 10-year survival, 83% (95% confidence interval, 0.79 to 0.87). At 10 years,...
Background. The assessment of anomalous coronary arteries (AAOCA) remains controversial without a... more Background. The assessment of anomalous coronary arteries (AAOCA) remains controversial without an optimal stress modality for ischemia. We evaluated the value of PET-CT myocardial perfusion imaging in these patients and subsequent management. Methods and results. AAOCA patients (n = 82) undergoing PET-CT from 2015 to 2021 were retrospectively chart reviewed. Multivariable analyses performed to assess relevant clinical and imaging factors associated with ischemia on PET and AAOCA surgery. Key characteristics include mean age 45 ± 20 years, 30 (37%) female, 45 (55%) with chest pain, 19 (23%) anomalous left main coronary artery, 58 (71%) anomalous right coronary artery, 26 (32%) with objective ischemia on PET-CT, and 37 (45%) who underwent AAOCA surgery. Adverse outcomes over mean follow-up of 2.2 ± 1.8 years included one death and two myocardial infarctions. Anomalous left main was independently associated with ischemia on PET-CT, odds ratio (95% confidence intervals) 4.15 (1.31-13.1), P = .006. Chest pain and ischemia on PET-CT were independently associated with and provided incremental prognostic value for surgery, odds ratio 9.73 (2.78-34.0), P < .001 and 6.79 (1.99-23.2), P = .002, respectively.
The Journal of Thoracic and Cardiovascular Surgery, 2021
OBJECTIVES Improved durability and preference to avoid anticoagulation have led to increasing use... more OBJECTIVES Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement. METHODS From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients. RESULTS Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group. CONCLUSIONS Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.
Background: Sinus of Valsalva aneurysm is a rare entity, and has multiple causes including post-s... more Background: Sinus of Valsalva aneurysm is a rare entity, and has multiple causes including post-surgical, trauma, infection, and inflammatory disease with the most common cause being a congenital defect in the aortic media. Most common sites for rupture of sinus of Valsalva aneurysm is into the right atrium and right ventricle. This can result in significant mortality if not recognized. This is the cause of sudden symptomatic aortic regurgitation and should be considered in an ill patient with new onset murmur.
World Journal for Pediatric and Congenital Heart Surgery, 2021
The optimal training of the highly specialized congenital heart surgeon is a long and complex pro... more The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve th...
The Journal of Thoracic and Cardiovascular Surgery, 2021
OBJECTIVES To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternot... more OBJECTIVES To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest. METHODS From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect. RESULTS Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2). CONCLUSIONS Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.
The presence of severe pectus excavatum at the time of redo cardiac surgery presents unique chall... more The presence of severe pectus excavatum at the time of redo cardiac surgery presents unique challenges for sternal re-entry and reconstruction. We present the case of a 14 year-old boy with tetralogy of Fallot, prior transannular patch repair, and severe pectus excavatum, who presented for pulmonary valve replacement and pectus repair. A modified Ravitch procedure with subperichondrial resection of the costal cartilages allowed for sternal mobilization, safe reentry, and excellent reconstruction. This is a safe and reproducible technique for dealing with the challenging scenario of severe pectus excavatum in patients undergoing redo cardiac surgery.
The Journal of Thoracic and Cardiovascular Surgery, 2019
Supplemental material is available online. Feature Editor's Note-One of the most important congen... more Supplemental material is available online. Feature Editor's Note-One of the most important congenital heart surgery studies conducted in the past decade was the Single Ventricle Reconstruction (SVR) trial, the results of which were first published in 2010. This randomized, prospective study compared the outcomes of the modified BlalockÀTaussig shunt with the Sano right ventricle-topulmonary artery conduit modification for neonates with hypoplastic left heart syndrome undergoing first-stage palliation. It is truly amazing to reflect on the massive number of publications that have now originated from the original SVR trial. One of those is the very important SVR extension study, or SVR II. Newberger and colleagues have just recently reported their 6-year follow-up of the initial SVR cohort. We at the Journal have asked Karamlou and colleagues to provide us with a summary of the very interesting findings from SVR II. Their careful analysis and summary of SVR II discusses overall survival versus transplant-free survival, addresses practice variation among and within centers, and touches on the concept of regionalization of care to perceived centers of excellence. The analysis also discusses the deployment of alternative initial therapies, such as primary transplantation or hybrid palliation. Finally, the analysis notes the definite benefits of longitudinal surveillance and targeted intervention through interstage home-monitoring programs and how they have improved outcomes. Karamlou and colleagues have beautifully summarized the statistical analysis of SVR II. The frequent use of the word ''sobering'' in their analysis should cause readers to pay attention. Given the great insights provided by SVR II, one can only wonder what SVR III, SVR IV, and so on will bring! William Harvey said, ''All we know is infinitely less than all that remains unknown,'' 1 a statement that, despite the enormous body of literature, encapsulates the current understanding of hypoplastic left heart syndrome (HLHS). The first report from the Single Ventricle Reconstruction II (SVR Extension Study), which was recently published in Circulation by Newburger and colleagues, 2 details outcomes at 6 years following enrollment in the initial SVR trial. The authors reported on transplant-free survival, catheter interventions, right ventricular function, and adverse clinical events in 331 (60%) of the original study subjects at a mean of 7.1 AE 1.6 years following initial Norwood palliation. Three time intervals were investigated, given the hypothesis that treatment effect (ie, shunt type) may vary with palliated stage: before stage II surgery, between stage II surgery and Fontan, and after Fontan. Multivariable Cox proportional-hazard regression and
Journal of the American College of Cardiology, 2019
Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical pres... more Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical presentation may be insidious and associated with a number of cardiopulmonary anomalies. Case: A 47 year old male presented with progressive exertional dyspnea, palpitations, and a new systolic murmur in the setting of known dextrocardia. He underwent TTE which showed mildly reduced biventricular function, dilated RV, and moderate TR. Decision-making: Given the suspicion for underlying congenital disease, he underwent cardiac MRI, X-ray, and CTA (Figure 1) which confirmed dextrocardia with evidence of Scimitar syndrome with all right sided pulmonary veins draining into the IVC, a Qp/Qs of 1.6:1, and concomitant dilation of the RA, RV, and PA. Additional findings included an anomalous single coronary artery originating from the right coronary cusp, aortic root dilation (5 cm) and moderate TR. Surgical repair was performed with in-situ pericardial repair of scimitar vein routing to the LA, repair of the TV, and repair of the noncoronary aortic sinus with CardioCel. On follow up, the patient reported resolution of dyspnea on exertion and improved functional capacity. Conclusion: This unique case highlights dextrocardia with Scimitar Syndrome, aortopathy, and anomalous single coronary artery. This congenital complex went undiagnosed for nearly five decades with only mild symptom burden. Multimodality cardiac imaging played a crucial role in the diagnosis and surgical planning of this case.
A 10-month-old male presented with persistent hypoxemia and oxygen requirement of 1.5 L throughou... more A 10-month-old male presented with persistent hypoxemia and oxygen requirement of 1.5 L throughout the day. He had a fetal diagnosis of large secundum atrial septal defect (ASD), pulmonary stenosis (PS), and mildly hypoplastic right ventricle (RV). Additionally, he had multiple comorbidities including tethered cord, bilateral chronic subdural hematomas status post ventriculo-peritoneal shunt placement, and laryngeal web status post multiple tracheal dilations. He had undergone balloon pulmonary valvuloplasty at 4 months of age with reportedly good result, despite which he continued to have persistent oxygen requirement. On clinical examination, he was cyanosed with oxygen saturations in the 80s, despite supplemental oxygen therapy. He had a normal cardiac examination without the presence of
Objectives: Mitral valve replacement with either a bioprosthetic or a mechanical valve is the tre... more Objectives: Mitral valve replacement with either a bioprosthetic or a mechanical valve is the treatment of choice for severe mitral stenosis. However, choosing a valve implant type is still a subject of debate. This study aimed to evaluate and compare the early and late outcomes of mitral valve replacement [mechanical (MMV) vs. bioprosthetic (BMV)] for severe mitral stenosis. Methods: A retrospective cohort study was performed on data involving mitral stenosis patients who have undergone mitral valve replacement with either BMV (n = 50) or MMV (n = 145) valves from 1999 to 2012. Data were collected from the patients' records and follow-up through telephone calls. Data were analyzed for early and late mortality, New York Heart Association (NYHA) functional classes, stroke, pre-and postoperative echocardiographic findings, early and late valve-related complications, and survival. Chi-square test, logistic regression, Kaplan-Meier curve, and dependent proportions tests were some of the tests employed in the analysis. Results: A total of 195 patients were included in the study with a 30-day follow-up echocardiogram available for 190 patients (97.5%), while 103 (53%) were available for follow-up over the telephone. One patient died early postoperatively; twelve patients died late in the postoperative period, six in the bioprosthesis group and six in the mechanical group. The late mortality had a significant association with postoperative stroke (p < 0.001) and postoperative NYHA Classes III and IV (p = 0.002). Postoperative NYHA class was significantly associated with age (p = 0.003), pulmonary disease (p = 0.02), mitral valve implant type (p = 0.01), and postoperative stroke (p = 0.02); 14 patients had strokes in the mechanical (9) and in the bioprosthetic (5) groups. NYHA classes were significantly better after the replacement surgeries (p < 0.001). BMV were significantly associated with worse survival (p = 0.03), worse NYHA postoperatively (p = 0.01), and more reoperations (p = 0.006). Survival was significantly better with MMV (p = 0.03). When the two groups were matched for age and mitral regurgitation, the analysis revealed that BMV were significantly associated with reoperations (p = 0.02) but not significantly associated with worse survival (p = 0.4) or worse NYHA (p = 0.4). Conclusion: MMV replacement in mitral stenosis patients is associated with a lower reoperation rate, but there was no difference in survival compared with BMV replacement.
We report the case of a five-year-old girl with plastic bronchitis after repaired complex congeni... more We report the case of a five-year-old girl with plastic bronchitis after repaired complex congenital heart disease, who became asymptomatic after a short course of Augmentin. We report the disease regression as response either to antibiotic or as coincidental with spontaneous resolution.
Journal of the Saudi Heart Association began using the plagiarism detection software, iThenticate... more Journal of the Saudi Heart Association began using the plagiarism detection software, iThenticate (http://www.ithenticate.com/). Every paper which we consider for publication in JSHA will be checked through this software for plagiarism and/or duplicate submission. In addition to this, JSHA is a registered journal with the Committee on Publication Ethics (COPE) (http://publicationethics.org/) and actively follows the COPE Code of Conduct and Best Practice for Journal Editors. We would like to take the opportunity to outline some of the major principles of publication ethics, as we realize that adherence to publication ethics is often not rooted in malicious intent, but a lack of education and awareness.
To assess the level of resting heart rate (RHR) in an outpatient population presenting with stabl... more To assess the level of resting heart rate (RHR) in an outpatient population presenting with stable coronary artery disease (CAD) as well as to measure its association with current therapeutic management strategies for cardiovascular events. A multi-center cross-sectional survey was carried out in Saudi Arabia and Egypt over a three month period (between January 2007 and April 2007). 2049 patients with CAD without clinical heart failure (HF) were included in this study through "cluster sampling". RHR was measured by manual palpitation. Mean age of CAD patients was 56.7 ± 10.4 and the mean RHR was 78.9 ± 13.9 b/m. 1686 patients (83.1%) were on β-blockers for whom the RHR was 78.5 ± 14.0 b/m (95.5% had RHR ⩾ 60 b/m, which is higher than recommended by the guidelines). 1094 (73.5%) of patients on β-blockers were on a lower dose, probably to avoid the complications associated with such a class. Among those not on β-blockers (16.9%), RHR was 80.9 ± 13.0 b/m. Moreover, 98 patient...
Arterial-line filters used during extracorporeal circulation continue to rely on the physical pro... more Arterial-line filters used during extracorporeal circulation continue to rely on the physical properties of a wetted micropore and reductions in blood flow velocity to affect air separation from the circulating blood volume. Although problems associated with air embolism during cardiac surgery persist, a number of investigators have concluded that further improvements in filtration are needed to enhance air removal during cardiopulmonary bypass procedures. This article reviews theoretical principles of micropore filter technology and outlines the development of a new arterial-line filter concept using computational fluid dynamics analysis. Manufacturer-supplied data of a micropore screen and experimental results taken from an ex vivo test circuit were used to define the inputs needed for numerical modeling of a new filter design. Flow patterns, pressure distributions, and velocity profiles predicted with computational fluid dynamics software were used to inform decisions on model re...
Modern management of extracorporeal circulation, especially during long-term support of post-card... more Modern management of extracorporeal circulation, especially during long-term support of post-cardiac surgical patients, remains challenging and requires optimal care of the patient's fluid balance and coagulation hemostasis for its successful outcome. The activated clotting time assay is one of the tests used to manage extracorporeal circulation and is available in a low- and high-range level. The question of which assay is more appropriate for procedures that require low to moderate heparin dosing is still unclear. We report our experience with a neonate diagnosed with hypoplastic left heart syndrome who needed emergent extracorporeal membrane oxygenation support for 13 days after Norwood stage I palliation using a Sano shunt. Although successful, bleeding complications prompted us to review our strategy for management of coagulation hemostasis.
There was no difference the echo parameters whether the DTB time was <90 or >90 min and whether t... more There was no difference the echo parameters whether the DTB time was <90 or >90 min and whether the call to ER time was <12 or >12 h. pPCI is an effective R for STEMI pts. In our study cohort, the echo data shows that there is significant improvement in the EF during 3-6 months follow up but with no evidence of reverse remodeling. These changes were independent of the time delay to pPCI.
Several perioperative risk factors influence outcomes after repair of complete atrioventricular s... more Several perioperative risk factors influence outcomes after repair of complete atrioventricular septal defects. This study was conducted to determine their association with perioperative mortality and need for reoperation. Between July 1982 and February 1995, 363 children underwent defect repair (median age, 8.3 months; mean, 17.4+/-1.3). Tetralogy of Fallot was present in 21 patients, double-outlet right ventricle in 4, subaortic stenosis in 8, ventricular hypoplasia in 8, coarctation in 5, atrial isomerism in 2, and other congenital anomalies in 9. Down's syndrome was present in 235 (65%). One-patch technique was applied in 99, two-patch in 243. During repair, the anterior bridging leaflet was divided in 12, the posterior bridging leaflet in 31, both leaflets in 71, and neither in 249. Left atrioventricular valve (LAVV) cleft was closed partially in 181 and completely in 112. Early mortality was 10.5%; 10-year survival, 83% (95% confidence interval, 0.79 to 0.87). At 10 years,...
Background. The assessment of anomalous coronary arteries (AAOCA) remains controversial without a... more Background. The assessment of anomalous coronary arteries (AAOCA) remains controversial without an optimal stress modality for ischemia. We evaluated the value of PET-CT myocardial perfusion imaging in these patients and subsequent management. Methods and results. AAOCA patients (n = 82) undergoing PET-CT from 2015 to 2021 were retrospectively chart reviewed. Multivariable analyses performed to assess relevant clinical and imaging factors associated with ischemia on PET and AAOCA surgery. Key characteristics include mean age 45 ± 20 years, 30 (37%) female, 45 (55%) with chest pain, 19 (23%) anomalous left main coronary artery, 58 (71%) anomalous right coronary artery, 26 (32%) with objective ischemia on PET-CT, and 37 (45%) who underwent AAOCA surgery. Adverse outcomes over mean follow-up of 2.2 ± 1.8 years included one death and two myocardial infarctions. Anomalous left main was independently associated with ischemia on PET-CT, odds ratio (95% confidence intervals) 4.15 (1.31-13.1), P = .006. Chest pain and ischemia on PET-CT were independently associated with and provided incremental prognostic value for surgery, odds ratio 9.73 (2.78-34.0), P < .001 and 6.79 (1.99-23.2), P = .002, respectively.
The Journal of Thoracic and Cardiovascular Surgery, 2021
OBJECTIVES Improved durability and preference to avoid anticoagulation have led to increasing use... more OBJECTIVES Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement. METHODS From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients. RESULTS Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group. CONCLUSIONS Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.
Background: Sinus of Valsalva aneurysm is a rare entity, and has multiple causes including post-s... more Background: Sinus of Valsalva aneurysm is a rare entity, and has multiple causes including post-surgical, trauma, infection, and inflammatory disease with the most common cause being a congenital defect in the aortic media. Most common sites for rupture of sinus of Valsalva aneurysm is into the right atrium and right ventricle. This can result in significant mortality if not recognized. This is the cause of sudden symptomatic aortic regurgitation and should be considered in an ill patient with new onset murmur.
World Journal for Pediatric and Congenital Heart Surgery, 2021
The optimal training of the highly specialized congenital heart surgeon is a long and complex pro... more The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve th...
The Journal of Thoracic and Cardiovascular Surgery, 2021
OBJECTIVES To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternot... more OBJECTIVES To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest. METHODS From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect. RESULTS Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2). CONCLUSIONS Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.
The presence of severe pectus excavatum at the time of redo cardiac surgery presents unique chall... more The presence of severe pectus excavatum at the time of redo cardiac surgery presents unique challenges for sternal re-entry and reconstruction. We present the case of a 14 year-old boy with tetralogy of Fallot, prior transannular patch repair, and severe pectus excavatum, who presented for pulmonary valve replacement and pectus repair. A modified Ravitch procedure with subperichondrial resection of the costal cartilages allowed for sternal mobilization, safe reentry, and excellent reconstruction. This is a safe and reproducible technique for dealing with the challenging scenario of severe pectus excavatum in patients undergoing redo cardiac surgery.
The Journal of Thoracic and Cardiovascular Surgery, 2019
Supplemental material is available online. Feature Editor's Note-One of the most important congen... more Supplemental material is available online. Feature Editor's Note-One of the most important congenital heart surgery studies conducted in the past decade was the Single Ventricle Reconstruction (SVR) trial, the results of which were first published in 2010. This randomized, prospective study compared the outcomes of the modified BlalockÀTaussig shunt with the Sano right ventricle-topulmonary artery conduit modification for neonates with hypoplastic left heart syndrome undergoing first-stage palliation. It is truly amazing to reflect on the massive number of publications that have now originated from the original SVR trial. One of those is the very important SVR extension study, or SVR II. Newberger and colleagues have just recently reported their 6-year follow-up of the initial SVR cohort. We at the Journal have asked Karamlou and colleagues to provide us with a summary of the very interesting findings from SVR II. Their careful analysis and summary of SVR II discusses overall survival versus transplant-free survival, addresses practice variation among and within centers, and touches on the concept of regionalization of care to perceived centers of excellence. The analysis also discusses the deployment of alternative initial therapies, such as primary transplantation or hybrid palliation. Finally, the analysis notes the definite benefits of longitudinal surveillance and targeted intervention through interstage home-monitoring programs and how they have improved outcomes. Karamlou and colleagues have beautifully summarized the statistical analysis of SVR II. The frequent use of the word ''sobering'' in their analysis should cause readers to pay attention. Given the great insights provided by SVR II, one can only wonder what SVR III, SVR IV, and so on will bring! William Harvey said, ''All we know is infinitely less than all that remains unknown,'' 1 a statement that, despite the enormous body of literature, encapsulates the current understanding of hypoplastic left heart syndrome (HLHS). The first report from the Single Ventricle Reconstruction II (SVR Extension Study), which was recently published in Circulation by Newburger and colleagues, 2 details outcomes at 6 years following enrollment in the initial SVR trial. The authors reported on transplant-free survival, catheter interventions, right ventricular function, and adverse clinical events in 331 (60%) of the original study subjects at a mean of 7.1 AE 1.6 years following initial Norwood palliation. Three time intervals were investigated, given the hypothesis that treatment effect (ie, shunt type) may vary with palliated stage: before stage II surgery, between stage II surgery and Fontan, and after Fontan. Multivariable Cox proportional-hazard regression and
Journal of the American College of Cardiology, 2019
Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical pres... more Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical presentation may be insidious and associated with a number of cardiopulmonary anomalies. Case: A 47 year old male presented with progressive exertional dyspnea, palpitations, and a new systolic murmur in the setting of known dextrocardia. He underwent TTE which showed mildly reduced biventricular function, dilated RV, and moderate TR. Decision-making: Given the suspicion for underlying congenital disease, he underwent cardiac MRI, X-ray, and CTA (Figure 1) which confirmed dextrocardia with evidence of Scimitar syndrome with all right sided pulmonary veins draining into the IVC, a Qp/Qs of 1.6:1, and concomitant dilation of the RA, RV, and PA. Additional findings included an anomalous single coronary artery originating from the right coronary cusp, aortic root dilation (5 cm) and moderate TR. Surgical repair was performed with in-situ pericardial repair of scimitar vein routing to the LA, repair of the TV, and repair of the noncoronary aortic sinus with CardioCel. On follow up, the patient reported resolution of dyspnea on exertion and improved functional capacity. Conclusion: This unique case highlights dextrocardia with Scimitar Syndrome, aortopathy, and anomalous single coronary artery. This congenital complex went undiagnosed for nearly five decades with only mild symptom burden. Multimodality cardiac imaging played a crucial role in the diagnosis and surgical planning of this case.
A 10-month-old male presented with persistent hypoxemia and oxygen requirement of 1.5 L throughou... more A 10-month-old male presented with persistent hypoxemia and oxygen requirement of 1.5 L throughout the day. He had a fetal diagnosis of large secundum atrial septal defect (ASD), pulmonary stenosis (PS), and mildly hypoplastic right ventricle (RV). Additionally, he had multiple comorbidities including tethered cord, bilateral chronic subdural hematomas status post ventriculo-peritoneal shunt placement, and laryngeal web status post multiple tracheal dilations. He had undergone balloon pulmonary valvuloplasty at 4 months of age with reportedly good result, despite which he continued to have persistent oxygen requirement. On clinical examination, he was cyanosed with oxygen saturations in the 80s, despite supplemental oxygen therapy. He had a normal cardiac examination without the presence of
Objectives: Mitral valve replacement with either a bioprosthetic or a mechanical valve is the tre... more Objectives: Mitral valve replacement with either a bioprosthetic or a mechanical valve is the treatment of choice for severe mitral stenosis. However, choosing a valve implant type is still a subject of debate. This study aimed to evaluate and compare the early and late outcomes of mitral valve replacement [mechanical (MMV) vs. bioprosthetic (BMV)] for severe mitral stenosis. Methods: A retrospective cohort study was performed on data involving mitral stenosis patients who have undergone mitral valve replacement with either BMV (n = 50) or MMV (n = 145) valves from 1999 to 2012. Data were collected from the patients' records and follow-up through telephone calls. Data were analyzed for early and late mortality, New York Heart Association (NYHA) functional classes, stroke, pre-and postoperative echocardiographic findings, early and late valve-related complications, and survival. Chi-square test, logistic regression, Kaplan-Meier curve, and dependent proportions tests were some of the tests employed in the analysis. Results: A total of 195 patients were included in the study with a 30-day follow-up echocardiogram available for 190 patients (97.5%), while 103 (53%) were available for follow-up over the telephone. One patient died early postoperatively; twelve patients died late in the postoperative period, six in the bioprosthesis group and six in the mechanical group. The late mortality had a significant association with postoperative stroke (p < 0.001) and postoperative NYHA Classes III and IV (p = 0.002). Postoperative NYHA class was significantly associated with age (p = 0.003), pulmonary disease (p = 0.02), mitral valve implant type (p = 0.01), and postoperative stroke (p = 0.02); 14 patients had strokes in the mechanical (9) and in the bioprosthetic (5) groups. NYHA classes were significantly better after the replacement surgeries (p < 0.001). BMV were significantly associated with worse survival (p = 0.03), worse NYHA postoperatively (p = 0.01), and more reoperations (p = 0.006). Survival was significantly better with MMV (p = 0.03). When the two groups were matched for age and mitral regurgitation, the analysis revealed that BMV were significantly associated with reoperations (p = 0.02) but not significantly associated with worse survival (p = 0.4) or worse NYHA (p = 0.4). Conclusion: MMV replacement in mitral stenosis patients is associated with a lower reoperation rate, but there was no difference in survival compared with BMV replacement.
We report the case of a five-year-old girl with plastic bronchitis after repaired complex congeni... more We report the case of a five-year-old girl with plastic bronchitis after repaired complex congenital heart disease, who became asymptomatic after a short course of Augmentin. We report the disease regression as response either to antibiotic or as coincidental with spontaneous resolution.
Journal of the Saudi Heart Association began using the plagiarism detection software, iThenticate... more Journal of the Saudi Heart Association began using the plagiarism detection software, iThenticate (http://www.ithenticate.com/). Every paper which we consider for publication in JSHA will be checked through this software for plagiarism and/or duplicate submission. In addition to this, JSHA is a registered journal with the Committee on Publication Ethics (COPE) (http://publicationethics.org/) and actively follows the COPE Code of Conduct and Best Practice for Journal Editors. We would like to take the opportunity to outline some of the major principles of publication ethics, as we realize that adherence to publication ethics is often not rooted in malicious intent, but a lack of education and awareness.
To assess the level of resting heart rate (RHR) in an outpatient population presenting with stabl... more To assess the level of resting heart rate (RHR) in an outpatient population presenting with stable coronary artery disease (CAD) as well as to measure its association with current therapeutic management strategies for cardiovascular events. A multi-center cross-sectional survey was carried out in Saudi Arabia and Egypt over a three month period (between January 2007 and April 2007). 2049 patients with CAD without clinical heart failure (HF) were included in this study through "cluster sampling". RHR was measured by manual palpitation. Mean age of CAD patients was 56.7 ± 10.4 and the mean RHR was 78.9 ± 13.9 b/m. 1686 patients (83.1%) were on β-blockers for whom the RHR was 78.5 ± 14.0 b/m (95.5% had RHR ⩾ 60 b/m, which is higher than recommended by the guidelines). 1094 (73.5%) of patients on β-blockers were on a lower dose, probably to avoid the complications associated with such a class. Among those not on β-blockers (16.9%), RHR was 80.9 ± 13.0 b/m. Moreover, 98 patient...
Arterial-line filters used during extracorporeal circulation continue to rely on the physical pro... more Arterial-line filters used during extracorporeal circulation continue to rely on the physical properties of a wetted micropore and reductions in blood flow velocity to affect air separation from the circulating blood volume. Although problems associated with air embolism during cardiac surgery persist, a number of investigators have concluded that further improvements in filtration are needed to enhance air removal during cardiopulmonary bypass procedures. This article reviews theoretical principles of micropore filter technology and outlines the development of a new arterial-line filter concept using computational fluid dynamics analysis. Manufacturer-supplied data of a micropore screen and experimental results taken from an ex vivo test circuit were used to define the inputs needed for numerical modeling of a new filter design. Flow patterns, pressure distributions, and velocity profiles predicted with computational fluid dynamics software were used to inform decisions on model re...
Modern management of extracorporeal circulation, especially during long-term support of post-card... more Modern management of extracorporeal circulation, especially during long-term support of post-cardiac surgical patients, remains challenging and requires optimal care of the patient's fluid balance and coagulation hemostasis for its successful outcome. The activated clotting time assay is one of the tests used to manage extracorporeal circulation and is available in a low- and high-range level. The question of which assay is more appropriate for procedures that require low to moderate heparin dosing is still unclear. We report our experience with a neonate diagnosed with hypoplastic left heart syndrome who needed emergent extracorporeal membrane oxygenation support for 13 days after Norwood stage I palliation using a Sano shunt. Although successful, bleeding complications prompted us to review our strategy for management of coagulation hemostasis.
There was no difference the echo parameters whether the DTB time was <90 or >90 min and whether t... more There was no difference the echo parameters whether the DTB time was <90 or >90 min and whether the call to ER time was <12 or >12 h. pPCI is an effective R for STEMI pts. In our study cohort, the echo data shows that there is significant improvement in the EF during 3-6 months follow up but with no evidence of reverse remodeling. These changes were independent of the time delay to pPCI.
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Papers by Hani Najm