Dearani, Joseph A.

Objective: To compare the safety and effectiveness of video-assisted thoracic surgery (VATS) versus conventional median sternotomy (open) in the repair of secundum atrial septal defect (ASD) or patent foramen ovale (PFO). Design: Among 415 consecutive patients undergoing open or VATS ASD/PFO closure between 1993 and October 2012, 153 patients were compared using 2:1 frequency matching (n = 102 open vs 51 VATS). Matching variables include age, gender, body surface area, past medical history of neurologic events, and need of patch closure. Median age was 43 years (3-71 years), and 67% were female. Results: There were no early deaths in either group. There were no conversions to open sternotomy. Although mean cross-clamp time (14.5 ± 7.6 vs 26.3 ± 13.2 minutes, P < .001) and bypass time (31.7 ± 13.8 vs 60.9 ± 20.9 minutes, P < .001) were longer in the VATS group, patients who underwent VATS had shorter postoperative ventilation time (7.5 ± 6.4 vs 4.4 ± 2.8 hours, P = .03) with 62.7% extubated in the operating room, along with shorter intensive care unit stay (26.7 ± 10.8 vs 19.1 ± 9.9 hours, P < .001) and hospital stay (5.2 ± 1.9 vs 3.5 ± 0.9 days, P < .001). At early follow-up (mean 1.5 years, maximum 4.2 years), there was no difference in need for reintervention. Of the 27 patients who underwent VATS ASD/PFO closure for a neurologic event, none had a recurrence. Conclusion: The use of VATS provides a safe, equally effective alternative to conventional sternotomy for ASD/PFO closure, using a less invasive approach.

Background: Nearly 90% of the children with heart disease in low- and middle-income countries (LMICs) cannot access cardiovascular (CV) services. Limitations include inadequate financial, human, and infrastructure resources. Nongovernmental organizations (NGOs) have played crucial roles in providing clinical services and infrastructure supports to LMICs CV programs; however, these outreach efforts are dispersed, inadequate, and lack coordination. Methods: A survey was sent to members of the World Society for Pediatric and Congenital Heart Society and PediHeart. Results: A clearinghouse was created to provide information on NGO structures, geographic reach, and scope of services. The survey identified 80 NGOs supporting CV programs in 92 LMICs. The largest outreach efforts were in South and Central America (42%), followed by Africa (18%), Europe (17%), Asia (17%), and Asia-Western Pacific (6%). Most NGOs (51%) supported two to five outreach missions per year. The majority (87%) of NGOs provided education, diagnostics, and surgical or catheter-based interventions. Working jointly with LMIC partners, 59% of the NGOs performed operations in children and infants; 41% performed nonbypass neonatal operations. Approximately a quarter (26%) reported that partner sites do not perform interventions in between missions. Conclusions: Disparity and inadequacy in pediatric CV services remain an important problem for LMICs. A global consensus and coordinated efforts are needed to guide strategies on the development of regional centers of excellence, a global outcome database, and a CV program registry. Future efforts should be held accountable for impacts such as growth in the number of independent LMIC programs as well as reduction in mortality and patient waiting lists.

The purpose of this case is to describe the complex perioperative management of a 30-year-old woman with congenital heart disease and multiple resternotomies presenting with pulmonary homograft dysfunction and evaluation for percutaneous pulmonary valve replacement. Transvenous, transcatheter Melody valve placement caused left main coronary artery occlusion and cardiogenic shock. An Impella ventricular assist device (VAD) provided rescue therapy during operating room transport for valve removal and pulmonary homograft replacement. ECMO support was required following surgery. Several days later during an attempted ECMO wean, her hemodynamics deteriorated abruptly. Transesophageal and epicardial echocardiography identified pulmonary graft obstruction, requiring homograft revision due to large thrombosis. This case illustrates a role for Impella VAD as bridge to definitive procedure after left coronary occlusion and describes management of complex perioperative ECMO support challenges.

Tetralogy of Fallot (TOF) is a cyanotic congenital heart defect typically diagnosed in infancy and treated with early surgical correction. We report a patient with TOF diagnosed at age 78. Successful surgical repair was performed at age 83, the oldest reported age of surgical correction of this condition. Despite a complicated surgical and postoperative course, the patient is doing well almost four years later.

Background— The clinical efficacy of alcohol septal ablation for obstructive hypertrophic cardiomyopathy (HCM) has been demonstrated, but the long-term effects of the procedure remain uncertain. This study examined the survival of patients after septal ablation performed in a tertiary HCM referral center. Methods and Results— We examined 177 patients (mean age, 64 years; 68% women) who underwent septal ablation at our institution. Over a follow-up of 5.7 years, survival free of all mortality was no different than the expected survival for a comparable general population, and similar to that of age- and sex-matched patients who underwent isolated surgical myectomy (8-year survival estimate, 79% versus 79%; P =0.64). For the end point of documented sudden cardiac death or unknown cause of death, the incidence per 100 person-year follow-up was 1.31 (95% confidence interval, 0.60–2.38). Residual left ventricular outflow tract gradient after ablation was an independent predictor of long-term survival free of any death. Conclusions— In this nonrandomized study of carefully selected patients undergoing septal ablation by experienced operators in a tertiary referral HCM center, long-term survival was favorable and similar to that of an age- and sex-matched general population, and to patients undergoing surgical myectomy, as well, without an increased risk of sudden cardiac death.