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Published on: December 11, 2017
Long-term outcomes after atrioventricular valve operations in patients undergoing single-ventricle palliation
Daniel J Wong1, Ajay J Iyengar, Gavin R Wheaton
1Department of Cardiac Surgery, Royal Children's Hospital, and Department of Pediatrics, University of Melbourne, Melbourne, Australia.
Insights
Atrioventricular (AV) valve regurgitation in single ventricle patients poses significant risks, with high early mortality and long-term complications. Outcomes highlight the need for careful management and further research in this vulnerable population.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Adult Congenital Heart Disease
Background:
- Outcomes following atrioventricular (AV) valve operations in patients with functional single ventricles are not well-established.
- AV valve regurgitation presents a significant challenge in single ventricle physiology, particularly in young patients.
Purpose of the Study:
- To evaluate the outcomes of atrioventricular (AV) valve operations in patients with functional single ventricles.
- To identify predictors of mortality and morbidity after AV valve surgery in this population.
Main Methods:
- A retrospective review of 76 consecutive patients with single ventricles who underwent AV valve operations for regurgitation between 1988 and 2010.
- Procedures included valve replacements, repairs, and closures. Kaplan-Meier survival and freedom from reoperation/thromboembolic events were analyzed.
Main Results:
- Hospital mortality was 17%, with 1- and 10-year survival rates of 72% and 61%, respectively.
- Independent predictors of mortality included common AV valve, need for mechanical circulatory support, and timing of operation relative to bidirectional cavopulmonary shunt (BCPS).
- Long-term morbidity included moderate to severe regurgitation in 23% of survivors, pacemaker implantation in 6 patients, and decreased Fontan completion rates.
Conclusions:
- AV valve regurgitation is a substantial burden in single ventricle patients, associated with significant early mortality and long-term morbidity.
- The study identified key risk factors for adverse outcomes, emphasizing the complexity of managing these patients.
- Survival and functional outcomes, including Fontan completion, are impacted by AV valve operations in single ventricle physiology.
Background:
Outcomes after atrioventricular (AV) valve operations in patients with functional single ventricles are unclear.
Methods:
From 1988 to 2010, 76 consecutive patients with single ventricles underwent AV valve operations for regurgitation at a single institution. Five replacements, 66 repairs, and 5 valve closures were performed at a median age of 1 year (range, 1 day-14 years) on 43 tricuspid, 9 mitral, and 24 common AV valves.
Results:
Hospital mortality was 17% (13/76). The follow-up was 100% complete. There were 15 late deaths. There were 48 survivors with a mean follow-up of 8.3±6 years. One- and 10-year Kaplan-Meier survival after AV valve operations was 72% (95% confidence interval [CI], 60%-81%) and 61% (95% CI, 48%-71%), respectively. Independent predictors of overall mortality were presence of a common AV valve (p=0.03), requirement for postoperative mechanical circulatory support (p=0.02), and timing of valve operations between initial palliation and performance of a bidirectional cavopulmonary shunt (BCPS) (p=0.047). Ten-year freedom from valve reoperation and from thromboembolic events of hospital survivors was 56% (95% CI, 38%-70%) and 70% (95% CI, 56%-80%), respectively. At last follow-up, 11 of 48 surviving patients (23%) had moderate to severe regurgitation, and pacemaker implantation was required in 6 patients. Only 34 patients reached the stage of Fontan completion.
Conclusions:
AV valve regurgitation is a considerable burden for the patient with a single ventricle, especially when appearing at a young age. A quarter of patients died within the first year after operation, and they had considerable morbidity in terms of reoperation, thromboembolic events, and pacemaker implantation. Their chances of reaching Fontan completion seemed decreased.
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