Ventricule Unique & Fuite de la Valve Atrioventriculaire: Quand Intervenir? Emre Belli Massy

Transcription

1 Ventricule Unique & Fuite de la Valve Atrioventriculaire: Quand Intervenir? Emre Belli Massy

2 CHD Atr ioventr icular valve r epair in patients with functional single-ventr icle physiology: Impact of ventr icular and valve function and morphology on survival and reintervention Ventricule Osami Honjo, MD, PhD, Unique Cori R. Atlin, BA, Luc & Mertens, Fuite MD, PhD, de Osman la O. Al-Radi, Valve MD, MSc, AV Andrew N. Redington, MD, Christopher A. Caldarone, MD, and Glen S. Van Arsdell, MD Obj ective: This study was to determine whether atrioventricular valve repair modifies natural history of single-ventricle patients with atrioventricular valve insufficiency and to identify factors predicting survival Chirurgie des valvulopathies congénitales and reintervention. Ø prothèse Prise en charge des VU analysis used case-matched controls. VU & Fuite valve AV 10-25%; interaction Qp/Qs? Anatomique, fonctionnelle, les 2 Facteur de risque events, including failed repair. Onjo et al. M ethods: Fifty-seven (13.5%) of 422 single-ventricle patients underwent atrioventricular valve repair. Valve morphology, regurgitation mechanism, and ventricular morphology and function were analyzed for effect on survival, transplant, and reintervention with multivariate logistic and Cox regression models. Comparative Results: Atrioventricular valvewastricuspid in 67% and common in 28%. Ventricular morphology wasright in 83%. Regurgitation mechanisms were prolapse (n ¼ 24, 46%), dysplasia (n ¼ 18, 35%), annular dilatation (n ¼ 8, 15%), and restriction or cleft (n ¼ 2, 4%). Postrepair insufficiency was none or trivial in 14 (26%), mild in 33 (61%), and moderate in 7 (13%). Survival in repair group was lower than in matched controls (78.9% vs 92.7% at 1 year, 68.7% vs 90.6% at 3 years, P ¼.015). Patients with successful repair and normal ventricular function had equivalent survival to matched controls (P ¼.36). Independent predictors for death or transplant included increased indexed annular size(p ¼.05), increased cardiopulmonary bypass time(p ¼.04), and decreased postrepair ventricular function (P ¼.01). Ventricular dilation was a time-related factor for all Conclusions: Survival waslower in single-ventricle patients operated on for atrioventricular valveinsufficiency than in case-matched controls. Patients with little postoperative residual regurgitation and preserved ventricular function had equivalent survival to controls. Lower gradeventricular function and ventricular dilation correlated with death and repair failure, suggesting that timing of intervention may affect outcome. (J Thorac Cardiovasc Surg 2011;142:326-35)

3 Ventricule Unique & Fuite de la Valve AV Quand faut-il intervenir Anatomie Projet biventriculaire? Gravité de la fuite Tolérance clinique? Fonction VU

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6 INTRODUCTION AND OBJECTIVE Objective: Single-center experience of AVV repair with focus on midterm outcomes after surgery by evaluation of risk factors for death/tx and AVV reoperation. Retrospective study: consecutive patients with UVH undergoing AV repair at any time of univentricular palliation for moderate/severe AVV regurgitation

7 MATERIAL AND METHODS Surgical techniques: 3 senior surgeons over 16 years «Nothing but repair strategy» with 3-step approach: Kalfa JTCS 2014, Pontailler EJCS subvalvular rehabilitation 2. plication/reenforcement of the annulus 3. leaflet augmentation by fresh autologous pericardium Employed surgical techniques for 1 st AVV repair : No (%) or median (ranges) Operatives techniques cleft closure (interrupted suture line) 12 (39) annuloplasty* (interrupted suture line on pledgets) 11 (35) commissuroplasty (separated points on pledgets) 7 (23) chordal repair (Goretex neo-chordae) 4 (13) edge-to-edge repair 2 (6) patch augmentation (by fresh autologous pericardium) 2 (6) * 5 adolescents with rings: Carpentier (1), Sovering (2), Uniring (2) All patients benefited from one or more techniques at AVV repair.

8 RESULTS STUDY POPULATION Number of patients n = 31; 38 surgical procedures median age at operation: 3.6 years median weight: 14 kg M:F 0,8 Preoperative patient variables Anatomic caracteristics No (%) or median (range) single ventricle : dominant RV 14 (45) single ventricle : dominant LV 13 (42) biventricular anatomy 4 (13) common AVV 10 (32) two AVV 8 (26) dominant tricuspid valve 7 (22) dominant mitral valve 6 (19) transposed great vessels 15 (48) right heart obstruction 15 (48) left heart obstruction 8 (26) Specific cardiac anatomy Double inlet ventricle with hypoplasia/atresia of one AVV or common AVV 6 (19) Double inlet ventricle with two AVV 5 (16) DORV-AVSD 5 (16) Unbalanced atrioventricular septal defect 4 (13) Unbalanced double outlet right ventricle 4 (13) Hypoplastic Left Heart Syndrome 2 (6) Tricuspid atresia 2 (6) Others 3 (10) Timing of 1st AVV repair before BCPC at BCPC before TCPC Clinical caracteristics: at TCPC Oxygen saturation: 81% NYHA III-IV: 31% Ventricular dysfunction: 16% Moderate AVVR: 71% Severe AVVR: 29% after TCPC

9 RESULTS EARLY MORBIDITY AND EARLY OUTCOME No (%) or median (range) Perioperatives variables cardiopulmonary bypass time 95 min (57-269) aortic cross clamp time 47 min (8-131) chest tube drainage time 5 d (2-46) Intensive care stay 4 d (1-27) postoperative hospital stay 21 d (7-150) supraventricular tachycardia 3 (9) renal insufficiency 1 (3) thromboembolic event 5 (16) pacemaker implantation 2 (6) Residual AV regurgitation at discharge none or trivial 9 (29) mild 16 (52) moderate 6 (19) severe 0 (0) Univentricular function at discharge normal 25 (81) moderate dysfunction 6 (19) severe dysfunction 1 (3)

10 RESULTS:OUTCOME FOR MORTALITY AND TRANSPLANTATION Causes of death: Severe univentricular dysfunction + AVVR Severe bronchiolitis Failing Fontan (protein-loosing enteropathy) Causes of Tx: Univentricular dysfunction after BCPC Postoperative uncontrolled endocarditis No early mortality 3 late deaths (median delay: 1 year [ ]) 3 transplantations Mean FU: 4,5 y (SD +/- 4,6) with univentricular dysfunction Failing Fontan Univariate risk Freedom factors from death/tx: for death/transplantation: 5 years: 84% 10 years: 84% Longer intensive At last visit: care stay (p= 0.022) Longer postoperative 92% NYHA I-II hospital with trivial/mild stay AVVR (p= 0.047) 28% univentricular dysfunction Higher total all number patients are of on surgeries chronic cardiac medication(p= 0.039) Higher preoperative 80% have completed mean pulmonary Fontan pressure (p= 0.047) Trend for failed AVV repair (p= 0.057) Trend for dominant tricuspid valve (p= 0.089) Multivariate risk factors: Failed AV repair: HR 5.93 (CI: ); p=0.057

11 RESULTS:VALVULAR REINTERVENTIONS 6/31 patients (19%) had seven AVV reoperations: Median delay: 1.8 years (range: ) Median age: 3.8 years (range: ) All patients had successful second AVV repair but one AVV closure No valve replacement at first or second procedure Univariate risk factors for reintervention: Masculine gender (p= 0.032) Transposed great vessels (p= ) Need for valve Freedom repair before from reoperation: BCPC 5 years: (p= 0.012) 76% 10 years: 66% Failed 1st AVV repair (p= 0.006) Multivariate risk factors: Failed 1st AVV repair: HR:11.37 (CI 95%: ,8); p= Masculine gender: HR: (CI 95%: ); p= 0.032

12 DISCUSSION Paper Morphology Mortality Survival after AVV repair Author Year n Timing RV TV CAVV Early Late 1 year 5 year 10 year 1 Imai /99 repair at Fontan 46% 12% 4% 84% 2 Mahle /576 at BCPC 55% 22% 7% 86% 76% 3 Sallehudin /340 at Fontan 4 Mavroudis /80 at Fontan 16% 1.2% 5% 5 Ando all stages 69% 75% 75% 6 Kerendi at Fontan 52% 0% 4,8% 7 Kwak /39 repair all stages 58% 5.5% 5,5% 90% 86% 8 Nakata all stages 61.5% 30% 54% 18.4% 8% 79% 70% inf < 3 m 59% 34% 9 Ando /103 repair BCPC/TCPC 43.5% 42% 47% 15% 90% 10 Honjo /422 all stages 83% 67% 28% 14% 15% 70% 11 Wong all stages 62% 56% 32% 17% 20% 72% 61% 12 Kotani /66 all stages 84% 67% 24% excluded 19% 90% 79% 76% 13 Sano all stages 81% 9.4% 87.5% 6.3% 28% 86% 57% 14 Yamagishi at BCPC 24% 49% 2.7% 2.7% 15 This study all stages 45% 22% 32% 0% 9% 84% 84% Important risk factor for death/tx/reintervention: residual postoperative AVV regurgitation Other risk factors for death: (Honjo et al., Garnreiter et al.) low body weight (Nakata et al.) early need for surgery (Wong et al.) postoperative dysfunction (Honjo et al., Kontani et al., Mavroudis et al., Imai et al.)

13 CONCLUSION AVV repair was mostly feasible in UVH despite the need for subsequent procedures in some patients (20%) Early results were good with no early mortality, no valve replacement at initial procedure and no postoperative deterioration of univentricular function Midterm results of this difficult UVH patient group were favorable Residual postoperative AVV regurgitation was the main risk factor for death/transplantation as well as for AVV reintervention AVV repair seems mandatory for all patients with significant AVVR at any stage/time of univentricular palliation

14 Ventricule Unique & Fuite de la Valve AV Quand faut-il intervenir Anatomie Projet biventriculaire? Gravité de la fuite Tolérance clinique? Fonction VU

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