Medical City Dallas is a hospital located at 7777 Forest Lane, just west of North Central Expressway (US 75), in north Dallas, Texas (USA).
BACKGROUND:Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical aortic valve replacement for symptomatic severe aortic stenosis, but long-term, comparative clinical outcomes and echocardiography data are lacking. OBJECTIVES:Our goal was to compare 10-year clinical and echocardiographic outcomes after balloon-expandable TAVR or surgery in intermediate-risk surgical patients in the PARTNER 2A randomized trial. METHODS:Between 2011 and 2013, patients with severe, symptomatic aortic stenosis at intermediate surgical risk were randomized at 57 centers to TAVR with the balloon-expandable SAPIEN XT system (Edwards Lifesciences) or to surgery. Randomization was stratified by anatomical suitability for transfemoral (TF) or transthoracic (transapical/transaortic [TA/TAo]) access. Ten-year outcomes were evaluated in the valve implant population and included all-cause mortality, aortic valve reintervention, and core laboratory-adjudicated echocardiographic outcomes. To obtain 10-year data, patient reconsent at 5 years was required, and vital status sweeps were implemented to improve data completeness for all-cause mortality. RESULTS:Among 1,910 randomized patients who received a valve, 974 underwent TAVR (TF: 749/974 [76.9%]) and 936 had surgery. Mean patient age was 81.6 years, 45.4% were women, and the mean Society of Thoracic Surgeons score was 5.8%. At 10 years, vital status was available for 881 of 974 patients (90.5%) and 838 of 936 patients (89.5%). All-cause 10-year mortality with vital status sweeps was 86.1% after TAVR and 82.8% after surgery (HR: 1.13; 95% CI: 1.02-1.25; P = 0.02). When stratified by access route, rates of all-cause mortality for TAVR and surgery in the TF group were similar (83.9% vs 82.1%, respectively; P = 0.27), whereas mortality was higher for TAVR in the TA/TAo group (93.2% vs 85.1%; P < 0.01; P for interaction = 0.03). Cumulative incidence rates of aortic valve reintervention at 10 years were 6.3% for TAVR and 1.6% for surgery (P < 0.001). Of the 24 TAVR and 35 surgical patients with available echocardiographic data at 10 years, mean gradients were 12.6 mm Hg and 12.7 mm Hg, respectively. CONCLUSIONS:At the 10-year follow-up, TAVR in intermediate-risk patients with the SAPIEN XT prosthesis compared with surgery was associated with lower survival rates, with differences predominantly observed in the TA/TAo access cohort. TAVR with the XT valve was also associated with significantly higher rates of aortic valve reintervention. (PARTNER II Trial: Placement of AoRTic TraNscathetER Valves II - XT Intermediate and High Risk [PII A]; NCT01314313).
Infradiaphragmatic total anomalous pulmonary venous return is a rare CHD often requiring emergent cardiac surgery. Options are limited for premature infants. We describe successful transcatheter palliation of a premature infant utilising stenting of the ductus venosus followed by transhepatic portal venous access for stent placement in an obstructed vertical vein with hepatic tract closure using the VASCADE Vascular Closure System (Cardiva Medical Inc., Santa Barbara, CA).
BACKGROUND:Craniosynostosis studies typically focus on perioperative outcomes. Because surgical intervention can negatively affect cranial growth, earlier reviews may overestimate long-term benefit and produce spuriously favorable results. The purpose of this review is to evaluate long-term outcomes following cranial vault remodeling for single-suture craniosynostosis with a focus on skeletal maturity. METHODS:A retrospective review was performed of all consecutive patients with single-suture craniosynostosis undergoing remodeling procedures by a single surgeon. RESULTS:Of 924 reviewed patients, 752 underwent primary and 172 secondary corrections. The median length of stay was 2 days, the allogeneic blood transfusion rate was 7.5%, and the complication rate was 0.7%. Among patients receiving primary repairs, 3.4% underwent secondary correction at a mean age of 5.5 years, with this rate rising to 20% by skeletal maturity. Delaying primary surgical intervention and applying overcorrection were associated with a reduction in the secondary correction rate from 2.2% to 0.6%, despite comparable follow-up durations. The odds ratio suggests that for every month of delay in initial correction, there is an expected 15% reduction in secondary procedures. In a cohort of 835 individuals, gross developmental outcomes fell within the normal range, with only 12% demonstrating mild to moderate delays. CONCLUSIONS:This review of 924 single-suture craniosynostosis remodeling procedures revealed a predominantly benign perioperative course. The overall secondary surgery rate was 3.4%, rising to 20% by skeletal maturity, suggesting that outcomes cannot be fully appreciated until completion of skeletal growth. Focused analyses suggest that delaying primary interventions and performing overcorrections could reduce secondary correction rates. Most of the affected children exhibited developmental trajectories similar to those of unaffected individuals.
BACKGROUND:Neonates with hypoplastic left heart syndrome variants with an intact or highly restrictive atrial septum (HLH-IAS) require immediate postnatal intervention to survive. Emergent left atrial decompression (LAD) via a percutaneous or hybrid approach is standard, but the comparative effectiveness and outcomes of these approaches remain underexplored. METHODS:A multicenter retrospective analysis of all neonates with HLH-IAS who underwent LAD in the first 36 hours of life from January 2009 to March 2020 at 14 North American congenital cardiac programs was conducted. Patient and procedural characteristics and patient outcomes were compared between hybrid and percutaneous LAD. RESULTS:Among 128 patients with HLH-IAS, 105 (80%) underwent percutaneous LAD and 23 (17%) hybrid LAD. No significant differences were observed in preprocedural characteristics such as birth weight (3.1±0.6 versus 3.2±0.6 kg; P=0.453), presence of a baseline interatrial communication (66% versus 61%; P=0.659), interatrial communication gradient (14.4±6.9 versus 12.7±4.6 mm Hg; P=0.456), or lowest pH (7.13±0.14 versus 7.09±0.15; P=0.193). Hybrid LAD resulted in a shorter time from birth to procedure (120 versus 52 minutes; P=0.005) and to atrial septal defect creation (55 versus 29 minutes; P=0.002). All hybrid LAD were technically successful, although 11 (10%) percutaneous LAD were unsuccessful with 7 requiring conversion to surgical septectomy. There was a trend toward fewer serious adverse events with hybrid LAD (36% versus 17%; P=0.141). Most patients (67%) who underwent hybrid LAD had simultaneous pulmonary artery band placement and 21% of patients with percutaneous LAD required reoperation for pulmonary artery band. Long-term survival rates were comparably low between groups, with a 30% transplant-free survival at a median 8-month follow-up. CONCLUSIONS:In patients with HLH-IAS, hybrid LAD allows for faster atrial septal defect creation, has a higher technical success rate, and potentially fewer procedural serious adverse events compared with percutaneous LAD, alongside facilitating simultaneous pulmonary artery band. Our findings underscore the poor prognosis for patients with HLH-IAS despite intervention, highlighting the need for better treatment strategies.
