Explore the vast range of titles available.

Background and Clinical Significance: Papillary Fibroelastoma is a benign primary cardiac tumor, commonly located in a valvular position, predominantly on the aortic valve. Case Presentation: We present a 73-year-old male patient with a medical history of chronic lymphatic leukemia, kidney failure, diabetes, and obstructive sleep apnea. In a routinely performed echocardiogram an abnormal structure in the left ventricle was found. The patient presented completely asymptomatically at the time of examination. A cardiac magnetic resonance-scan provided further information about the size and localization of the tumor in the left ventricle, which seemed to be attached to a papillary muscle and was about 1.6 cm in diameter. Due to visible scarring of the myocardia, which was identified in the scan, a cardiac catheter examination was performed. A coronary artery disease was detected with a severe stenosis in three vessels. During an elective bypass-operation, the removal of the structure was performed with an approach through the left atrium, passing the mitral valve using a valve sizer for better exposure. The tumor of 1 cm presented macroscopically with an anemone-like shape. The histopathological examination confirmed the intraoperative assumption of a papillary fibroelastoma, found in an aberrant location. Conclusions: Unexpectedly challenging surgical removals of structures in the left ventricle require innovative techniques with available instruments for better exposure.

Background/Objectives: Obstruction of the Fontan pathway is a severe morbidity after total cavopulmonary connection (TCPC). This study aimed to evaluate the incidence and location of TCPC pathway obstruction and corresponding interventions. Methods: In all patients undergoing TCPC between 1994 and 2023, postoperative interventions for TCPC pathway obstruction were evaluated. Risk factors for TCPC pathway interventions were identified, and the impact of TCPC pathway interventions on late outcomes was analyzed. Results: Among 650 patients, 136 (21%) needed catheter/surgical interventions for TCPC pathway obstructions during the median duration of 0.2 (0.03–6.1) years postoperatively. Interventions comprised 128 catheters and 10 surgeries. Catheter intervention included 107 left pulmonary arteries (PA), 8 right PAs, and 27 extracardiac conduits. Surgery included eight conduit revisions, four PA enlargements, and two SVC enlargements. Freedom from interventions at 1, 3, 5, and 10 years was 87.7, 85.3, 83.6, and 78.5%, respectively. Previous Norwood procedure (HR: 2.228, p = 0.003), previous ductal stent (HR: 2.574, p < 0.001), previous PA interventions (HR: 2.514, p < 0.001), and high PA pressure before TCPC (HR: 1.161, p = 0.004) were risk factors. Patients requiring interventions had a higher incidence of protein-losing enteropathy (16.0 vs. 2.0%, p < 0.001), plastic bronchitis (8.3 vs. 0.8%, p < 0.001), and failing Fontan (28.6 vs. 7.6%, p < 0.001), compared to those who did not. Conclusions: Interventions for Fontan pathway obstruction were needed in 21% of patients. The left-PA stenosis was the main lesion, most cases of which were treated by stent implantation. Norwood procedure, ductal stent, pre-TCPC PA intervention, and high pre-TCPC PA pressure were identified as risks factors.

Background/Objectives: After years of work in the field of aortic arch surgery, the technique has evolved, making this procedure relatively safe, with lasting results. Due to the increasing long-term survival and overall aging of the patient population, more patients require aortic arch reoperation. In the present study, the safety of aortic arch reoperations was analyzed in the long term, focusing on risk factors for mortality. Methods: Between 1999 and 2023, 108 patients were included in our study who underwent reoperation on aortic arch after prior operation on the aorta, the aortic valve, or a combination of both. The exclusion criteria were being aged under 18 years and transcatheter aortic valve implantation as a previous intervention. The principal outcome was the incidence of mortality, and additional outcomes of interest included cardiac re-reoperation, bleeding, a new aortic type B dissection, infective endocarditis, readmission due to a cardiac cause, coronary intervention and neurovascular complications, pacemaker implantation, and temporary mechanical circulatory support. Results: The mean age was 56 ± 14 years, and 75% (81/108) of patients were male. In our study, we found age (p ≤ 0.01) and history of coronary artery disease (p = 0.01) to be preoperative risk factors for adverse outcomes. The mean time between the index operation and reoperation was 6.84 years (1.61–14.94). Indications for reoperation included dilatation (HR = 0.49, p = 0.05), rupture or false aneurysm (HR = 2.08, p= 0.08), dissection (HR = 1.41, p = 0.30), and endocarditis (HR = 1.49, p = 0.41). A main risk factor was the need for a salvage reoperation (p ≤ 0.01). Also, a longer operation (p = 0.04), cardiopulmonary bypass (p ≤ 0.01), and ventilation time (p ≤ 0.01), bleeding complications (p ≤ 0.01), and requiring temporary mechanical circulatory support (p = 0.04) were linked to higher mortality. The overall survival was 82% after 1 year, 73% after 5 years, and 56% after 10 years. In the multivariate Cox regression analysis, age (HR = 1.04, p ≤ 0.01), the need for a salvage operation (HR = 5.38, p = 0.01), a prolonged ventilation time (HR = 1.08, p = 0.04), and bleeding complications (HR = 3.76, p = 0.03) were associated with higher mortality. In the ROC analysis, an age over 57.5 years was associated with significantly lower overall survival (p ≤ 0.01). Conclusions: Aortic arch reoperations can be performed with acceptable long-term outcomes, but perioperative factors significantly influence early mortality. Salvage operations, bleeding complications, and prolonged ventilation were strong predictors of adverse outcomes. Older age, particularly >57.5 years, was independently associated with increased mortality risk.

Objective: Over the last ten years, aortic surgery has transitioned from a high-risk procedure to a well-established operation, offering favorable outcomes and survival when performed by experienced hands. Advances in surgical techniques and evolving technologies allow treatment of older and more complex patients with reoperations. However, outcome data are limited. This study aims to identify risk factors for adverse outcomes after reoperation on the aortic root. Methods: This retrospective study included patients who received aortic root reoperation from 1999 to 2023 in a high-volume center, with a history of previous surgery on the thoracic aorta or aortic valve. Patients under the age of 18 or those with transcatheter aortic valve implantation as an index procedure were excluded. Results: A total of 192 patients were analyzed. Mean age was 57 ± 13 years, and 77.6% were men. The main procedure was Bentall (88.5%). An elective operation was performed in 54.7% of the patients. The mean time between the index operation and reoperation was 8.61 (3.01–16.05) years. Mortality at 30 days was 13%. Survival rates at one, five, and ten years were 84%, 81%, and 71%, respectively. Female gender, non-elective surgery, concomitant procedures, and combined procedures on the aortic root and arch were associated with worse survival. In the Cox regression, age (HR = 3.98, p < 0.01), EuroSCORE II (HR = 1.46, p < 0.01), concomitant procedures at reoperation (HR = 2.53, p = 0.01), prolonged cardiopulmonary bypass time (HR = 1.01, p < 0.01), bleeding complications (HR = 6.11, p < 0.01), and need for temporary mechanical circulatory support (HR = 4.86, p = 0.01) were significantly associated with a higher mortality. Analysis of the receiver operating characteristic curve revealed that age > 60 years at reoperation is a strong predictor for poor outcomes (AUC = 0.712, p < 0.01). Conclusions: Mortality following aortic root reoperation is primarily driven by baseline patient risk and perioperative complications. Reduced survival was observed in patients over 60 years of age, females, those having non-elective surgery, combined root and arch operations, and procedures with additional concomitant operations. Bleeding events, the use of temporary mechanical circulatory support, and concomitant interventions at reoperation emerged as independent predictors of mortality.

Failing Fontan poses a significant clinical challenge. This study aims to improve patients' outcomes by comprehensively understanding the incidence, pathophysiology, risk factors, and treatment of failing Fontan after total cavopulmonary connection. We performed a retrospective analysis of patients who underwent total cavopulmonary connection at the German Heart Center Munich between 1994 and 2022. The onset of failing Fontan was defined as: protein-losing enteropathy, plastic bronchitis, NYHA class IV, NYHA class III for > one year, unscheduled hospital admissions for heart failure symptoms, and evaluation for heart transplantation. Among 634 patients, 76 patients presented with failing Fontan, and the incidence was 1.48 per 100 patient-years. Manifestations included protein-losing enteropathy (n = 34), hospital readmission (n = 28), NYHA III (n = 18), plastic bronchitis (n = 16), evaluation for heart transplantation (n = 14), and NYHA IV (n = 4). Risk factors for the onset of failing Fontan were dominant right ventricle (p = 0.010) and higher pulmonary artery pressure before total cavopulmonary connection (p = 0.004). A total of 72 interventions were performed in 59 patients, including balloon dilatation/stent implantation in the total cavopulmonary connection pathway (n = 49) and embolization of collaterals (n = 24). Heart transplantation was performed in four patients. The survival after the onset of Fontan failure was 77% at 10 years. Patients with failing Fontan revealed significantly higher zlog-NT-proBNP levels after onset compared to those without (p = 0.021). The incidence of Fontan failure was 1.5 per 100 patient years. Dominant right ventricle and higher pulmonary artery pressure before total cavopulmonary connection were significant risks for the onset of failing Fontan. Zlog-NT-proBNP is only a late marker of Fontan failure.

To identify early postoperative haemodynamic and laboratory parameters predicting outcomes following total cavopulmonary connection. Patients who underwent total cavopulmonary connection between 2012 and 2021 were evaluated. Serial values of mean pulmonary artery pressure, mean arterial pressure, peripheral oxygen saturation, and lactate levels were collected. The influence of these variables on morbidities was analyzed. Cut-off values were calculated using the receiver operating characteristic analysis. A total of 249 patients were included. All patients had previous bidirectional cavopulmonary shunt. Median age and weight at total cavopulmonary connection were 2.2 (1.8-2.7) years and 11.7 (10.7-13.4) kg, respectively. All patients were extubated in the ICU at a median of 3 (2-5) hours after ICU admission. Postoperative pulmonary artery pressure, around 12 hours after extubation, was significantly associated with chest tube drainage (p = 0.048), chylothorax (p = 0.021), ascites (p = 0.016), and adverse events (p = 0.028). Receiver operating characteristic analysis revealed a cut-off value of 13-15 mmHg for chest tube drainage and chylothorax and 17 mmHg for ascites and adverse events. Mean arterial pressure 1 hour after extubation was associated with prolonged chest tube drainage (p = 0.015) and adverse events (p = 0.008). Peripheral oxygen saturation 6 hours after extubation (p = 0.003) was associated with chest tube duration and peripheral oxygen saturation 1 hour after extubation (p < 0.001) was associated with ascites. Lactate levels on 2 postoperative day (p = 0.022) were associated with ascites and lactate levels on 1 postoperative day (p = 0.009) were associated with adverse events. Higher pulmonary artery pressure, lower mean arterial pressure, lower peripheral oxygen saturation, and higher lactate in early postoperative period, around 12 hours after extubation, predicted in-hospital and post-discharge adverse events following total cavopulmonary connection.

Brady-arrhythmia requiring pacemaker implantation remains one of the Fontan-specific complications before and after total cavopulmonary connection. A retrospective analysis of 620 patients who underwent total cavopulmonary connection between 1994 and 2021 was performed to evaluate the incidence of brady-arrhythmia and the outcomes after pacemaker implantation. Factors associated with the onset of brady-arrhythmia were identified. A total of 52 patients presented with brady-arrhythmia and required pacemaker implantation. Diagnosis included 16 sinus node dysfunctions, 29 atrioventricular blocks, and 7 junctional escape rhythms. Pacemaker implantation was performed before total cavopulmonary connection (n = 16), concomitant with total cavopulmonary connection (n = 8), or after total cavopulmonary connection (n = 28, median 1.8 years post-operatively). Freedom from pacemaker implantation following total cavopulmonary connection at 10 years was 92%. Twelve patients needed revision of electrodes due to lead dysfunction (n = 9), infections (n = 2), or dislocation (n = 1). Lead energy thresholds were stable, and freedom from pacemaker lead revision at 10 years after total cavopulmonary connection was 78%. Congenitally corrected transposition of the great arteries (odds ratio: 6.6, confidence interval: 2.0-21.5, p = 0.002) was identified as a factor associated with pacemaker implantation before total cavopulmonary connection. Pacemaker rhythms for Fontan circulation were not a risk factor for survival (p = 0.226), protein-losing enteropathy/plastic bronchitis (p = 0.973), or thromboembolic complications (p = 0.424). In our cohort of patients following total cavopulmonary connection, freedom from pacemaker implantation at 10 years was 92% and stable atrial and ventricular lead energy thresholds were observed. Congenitally corrected transposition of the great arteries was at increased risk for pacemaker implantation before total cavopulmonary connection. Having a pacemaker in the Fontan circulation had no adverse effect on survival, protein-losing enteropathy/plastic bronchitis, or thromboembolic complications.

This study aims to assess the surgical outcome of borderline hypoplastic left ventricle before and after the induction of the left ventricle rehabilitation strategy. A retrospective review investigated patients with borderline hypoplastic left ventricle who underwent surgical intervention between 2012 and 2022. The patient cohort was stratified into two groups based on the initiation of left ventricle rehabilitation: an early-era group (E group, 2012-2017) and a late-era group (L group, 2018-2022). Left ventricle rehabilitation was defined as palliation combined with other procedures aimed at promoting left ventricular growth such as restriction of atrial septal defect, relief of inflow/outflow obstructive lesions, and resection of endocardial fibroelastosis. A total of 58 patients were included. Primary diagnosis included 12 hypoplastic left heart syndromes, 11 critical aortic valve stenosis, and others. A total of 9 patients underwent left ventricle rehabilitation, 8 of whom underwent restriction of atrial septal defect. As for clinical outcomes, 9 of 23 patients achieved biventricular repair in the E group, whereas in the L group, 27 of 35 patients achieved biventricular repair (39% vs. 77%, = 0.004). Mortality did not differ statistically between the two groups (log-rank test = 0.182). As for the changes after left ventricle rehabilitation, left ventricular growth was observed in 8 of 9 patients. The left ventricular end-diastolic volume index (from 11.4 to 30.1 ml/m , = 0.017) and left ventricular apex-to-right ventricular apex ratio (from 86 to 106 %, = 0.014) significantly increased after left ventricle rehabilitation. The introduction of the left ventricle rehabilitation strategy resulted in an increased proportion of patients achieving biventricular repair without a concomitant increase in mortality. Left ventricle rehabilitation was associated with enhanced left ventricular growth and the formation of a well-defined left ventricle apex. Our study underscores the significance of left ventricle rehabilitation strategies facilitating successful biventricular repair. The data suggest establishing restrictive atrial communication may be a key factor in promoting left ventricular growth.

We have left antegrade pulmonary blood flow (APBF) at bidirectional cavopulmonary shunt (BCPS) only for high-risk patients. This study evaluates the indication and the outcomes of patients with APBF, compared to those without APBF. Patients with APBF after BCPS were identified among patients who underwent BCPS between 1997 and 2022. Outcomes of patients with and without APBF after BCPS were compared. APBF was open in 38 (8.2%) of 461 patients. Median age (7.7 versus 6.3 months, p = 0.55) and weight (5.6 versus 6.1 kg, p = 0.75) at BCPS were similar in both groups. The most frequent indication for APBF was high pulmonary artery pressure (PAP) in 14 patients, followed by hypoxaemia in 10, and hypoplastic left pulmonary artery in 8. The source of APBF was the pulmonary trunk in 10 patients and the aortopulmonary shunt in 28. Median hospital stay after BCPS was longer (22 versus 14 days, p = 0.018) and hospital mortality was higher (10.5 versus 2.1%, p = 0.003) in patients with APBF compared to those without APBF. However, 448 hospital survivors showed similar survival after discharge following BCPS (p = 0.224). Survival after total cavopulmonary connection (TCPC) was similar between the groups (p = 0.753), although patients with APBF were older at TCPC compared to those without (3.9 versus 2.2 years, p = 0.010). APBF was left in 8% following BCPS in high-risk patients, mainly due to preoperative high PAP. Hospital survivors after BCPS demonstrated comparable survival in patients with and without APBF. Adding APBF at BCPS might be a useful option for high-risk patients.

The purpose of this study is to evaluate the incidence and outcomes regarding tachyarrhythmia in patients after total cavopulmonary connection. A retrospective analysis of 620 patients who underwent total cavopulmonary connection between 1994 and 2021 at our institution was performed. Incidence of tachyarrhythmia was depicted, and results after onset of tachyarrhythmia were evaluated. Factors associated with the onset of tachyarrhythmia were identified. A total of 52 (8%) patients presented with tachyarrhythmia that required medical therapy. Onset during hospital stay was observed in 27 patients, and onset after hospital discharge was observed in 32 patients. Freedom from late tachyarrhythmia following total cavopulmonary connection at 5, 10, and 15 years was 97, 95, and 91%, respectively. The most prevalent late tachyarrhythmia was atrial flutter (50%), followed by supraventricular tachycardia (25%) and ventricular tachycardia (25%). Direct current cardioversion was required in 12 patients, and 7 patients underwent electrophysiological study. Freedom from Fontan circulatory failure after onset of tachyarrhythmia at 10 and 15 years was 78% and 49%, respectively. Freedom from occurrence of decreased ventricular systolic function after the onset of tachyarrhythmia at 5 years was 85%. Independent factors associated with late tachyarrhythmia were dominant right ventricle (hazard ratio, 2.52, p = 0.02) and weight at total cavopulmonary connection (hazard ratio, 1.03 per kilogram; p = 0.04). Type of total cavopulmonary connection at total cavopulmonary connection was not identified as risk. In our large cohort of 620 patients following total cavopulmonary connection, the incidence of late tachyarrhythmia was low. Patients with dominant right ventricle and late total cavopulmonary connection were at increased risk for late tachyarrhythmia following total cavopulmonary connection.