Search Results (99)

Introduction: The radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) originating from the right ventricular outflow tract (RVOT) is a well-established therapy. Traditionally, RFCA is guided using electroanatomical 3D mapping systems involving manual catheter navigation within cardiac chambers. While effective, this approach may be time-consuming, and it carries a potential risk of cardiac wall perforation. Although the risk is low, it cannot be underestimated. Therefore, alternative mapping methods are sought to reduce procedural times and improve the overall efficiency of RVOT-VAs ablation. Aim: To evaluate the safety, feasibility, and efficacy of a universal RVOT 3D model implementation for the ablation of idiopathic RVOT-VAs. Methods: Consecutive patients undergoing VA ablation supported with a universal RVOT 3D model (3D-MODEL group) were included in the study. The RVOT universal model in this group was created by processing DICOM images for the improved segmentation of anatomical structures, followed by production using 3D printing technology. Patients who underwent classic endocardial electroanatomical mapping served as controls (EAM group). Results: A total of 228 patients were included in the study (143 women, age 50 ± 17 years): 149 in the 3D-MODEL group and 79 in the EAM group. The acute complete elimination of clinical VAs was achieved for 133 (89%) of patients in the 3D-MODEL group vs. 65 (82%) in the EAM group (p = 0.14). The procedural time was significantly shorter in the 3D-MODEL group compared to the EAM group (38 ± 14 min vs. 80 ± 39 min, p < 0.001). A significant difference was also observed in the radiofrequency time between the 3D-MODEL and EAM groups (251 ± 176 s vs. 503 ± 425 s, p < 0.001). No significant difference in fluoroscopy time was found between the groups (284 ± 167 s vs. 260 ± 327 s, p = 0.49). Two cases of cardiac tamponade occurred, both in patients from the EAM group. During follow-up, lasting 14 ± 10 months, 87% of patients in the 3D-MODEL group and 75% in the EAM group remained arrhythmia-free (p = 0.45). Conclusions: The use of universal RVOT 3D modeling is a feasible, safe, and effective alternative to classic electroanatomical mapping in the ablation of idiopathic RVOT-VAs. Full article

Background and Objectives: Risk stratification in acute heart failure (AHF) remains challenging, particularly in settings where biomarker availability is limited. Echocardiography offers valuable hemodynamic insights, but no single parameter fully captures the complexity of biventricular dysfunction and pressure overload. This study aimed to evaluate a novel echocardiographic index (ViRTUE Index–VTI-RVRA-TAPSE Unified Evaluation) integrating a peak systolic gradient between the right ventricle and right atrium (RV-RA gradient), tricuspid annular plane systolic excursion (TAPSE), the velocity–time integral in the left ventricular outflow tract (VTI LVOT), NT-proBNP (N-terminal pro–B-type Natriuretic Peptide) levels, and in-hospital mortality among patients with AHF. Materials and Methods: We retrospectively analyzed 123 patients admitted with AHF. Echocardiographic evaluation at admission included TAPSE, VTI LVOT, and the RV-RA gradient. An index was calculated as ${\displaystyle \frac{RV-RA gradient }{TAPSE x VTI LVOT}}$. NT-proBNP levels and in-hospital outcomes were recorded. Statistical analysis included correlation, logistic regression, and ROC curve evaluation. Results: The proposed index showed a significant positive correlation with NT-proBNP values (r = 0.543, p < 0.0001) and good discriminative ability for elevated NT-proBNP (AUC = 0.79). It also correlated with in-hospital mortality (r = 0.193, p = 0.032) and showed moderate prognostic performance (AUC = 0.68). Higher index values were associated with greater mortality risk. Conclusions: This novel index, based on standard echocardiographic measurements, reflects both systolic dysfunction and pressure overload in AHF. Its correlation with NT-proBNP and in-hospital mortality highlights its potential as a practical, accessible bedside tool for early risk stratification, particularly when biomarker testing is unavailable or delayed. Full article

Background: Iron deficiency (ID) is a prevalent comorbidity of heart failure (HF), affecting up to 59% of patients, regardless of the presence of anaemia. Although its negative impact on left ventricular (LV) function is well documented, its effect on right ventricular (RV) function remains unclear. This study assessed the effects of ID on RV global longitudinal strain (RV-GLS) in patients diagnosed with acute decompensated HF (ADHF). Methods: This study included data from 100 patients hospitalised with ADHF irrespective of LV ejection fraction (LVEF) value. ID was defined according to the European Society of Cardiology HF guidelines as serum ferritin <100 ng/mL or ferritin 100–299 ng/mL, with transferrin saturation <20%. Anaemia was defined according to World Health Organization criteria as haemoglobin level <12 g/dL in women and <13 g/dL in men. RV systolic function was assessed using parameters including RV ejection fraction (RVEF), tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), peak systolic tissue Doppler velocity of the RV annulus (RV TDI S′), acceleration time of the RV outflow tract, and RV free wall GLS. Results: The mean (±SD) age of the study population (64% male) was 70 ± 10 years. The median LVEF was 35%, with 66% of patients classified with HF with reduced ejection fraction, 6% with HF with mid-range ejection fraction, and 28% with HF with preserved ejection fraction. Fifty-eight percent of patients had ID. There were no significant differences between patients with and without ID regarding demographics, LVEF, RV FAC, RV TDI S′, or systolic pulmonary artery pressure. However, TAPSE (15.6 versus [vs.] 17.2 mm; p = 0.05) and RV free wall GLS (−14.7% vs. −18.2%; p = 0.005) were significantly lower in patients with ID, indicating subclinical RV systolic dysfunction. Conclusions: ID was associated with subclinical impairment of RV systolic function in patients diagnosed with ADHF, as evidenced by reductions in TAPSE and RV-GLS, despite the preservation of conventional RV systolic function parameters. Further research validating these findings and exploring the underlying mechanisms is warranted. Full article

This technical report presents a compelling case for the use of very-high-power, very-short-duration (VHPSD) radiofrequency ablation as a promising and efficient strategy for treating symptomatic premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT). The patient with frequent, symptomatic PVCs and a 24% burden underwent successful ablation using a 90 W/4 s recipe via the QDOT MICRO™ catheter. The procedure resulted in immediate and sustained elimination of PVCs, with only 4 s of ablation time, near-zero fluoroscopy, no complications, and no PVC recurrence at 6 months. VHPSD ablation, though originally developed for atrial fibrillation, demonstrated remarkable procedural efficiency, precision, and lesion efficacy in this case. Compared to standard power, long-duration (SPLD) ablation, VHPSD offers the potential to significantly reduce procedural time, minimize tissue edema, and lower complication risk, particularly advantageous in anatomically challenging areas or in situations where maintaining stable catheter contact for extended periods is difficult or unfeasible. This technical report suggests the transformative potential of VHPSD as a first-line ablation strategy for RVOT-PVCs, provided careful mapping and appropriate technique are used. It underscores the need for further prospective studies to validate its broader safety, efficacy, and role in PVC management, particularly in cases involving intramural origins. Full article

Background: In patients undergoing surgical aortic valve replacement due to severe aortic valve stenosis (AS), the presence of right ventricular damage markers (RVDMs) determined by echocardiography is a poor prognostic indicator. However, such data is not available in patient groups who have undergone transcatheter aortic valve replacement (TAVI). The aim of this study is to investigate the prognostic value of RVDM determined by computed tomography (CT) in a patient group undergoing TAVI. Material and Method: This multicentre, prospective study included 184 patients who underwent TAVI. In basal CT, the pulmonary artery (PA) diameter and right ventricular outflow tract myocardial thickness (RVOTMT) in mid-systole and maximal right and left ventricular diameter (RVD/LVD) ratios in mid-diastole were measured as indicators of RVDM before the TAVI procedure. The primary endpoint of the study was 1-year mortality. Results: The primary endpoint of the study was observed in 42 patients (22%). Among the CT parameters, the PA diameter, RVOTMT, and maximal RVD/LVD ratio were observed to be higher in the mortality group (p < 0.001). In the ROC analysis, a PA diameter of 30.5 and above had a 78% sensitivity and 82% specificity (AUC: 0.87 95% CI 0.82–0.93, p < 0.001), an RVOTMT of 4 mm and above had 90% sensitivity and 87% specificity (AUC: 0.93 95% CI 0.87–0.99, p < 0.001), and a maximal RVD/LVD ratio of 0.91 and above showed 90% sensitivity and 92% specificity (AUC: 0.94 95% CI 0.89–0.99, p < 0.001) to predict one-year mortality. In the Cox regression analysis, the RVOTMT and maximal RVD/ LVD ratios were found to be the best independent parameters showing 1-year mortality. Conclusion: This study showed that RVDMs determined by CT are strong predictors of 1-year mortality in severe AS patients treated with TAVI. Full article

Background/Objectives: Bovine pericardial valve conduits (PVCs) are commonly used for right ventricular outflow tract reconstruction in both pediatric and adult patients. Calcification, particularly prevalent in children and young adults, is a leading cause of conduit failure and is affected by the chemical composition of the treated biomaterials. In this study, we aimed to compare the structural changes in diepoxy-treated (DE-PVCs) and glutaraldehyde-treated PVCs (GA-PVCs) and to identify factors contributing to tissue mineralization in a large animal model. Methods: Pulmonary artery replacement was performed in minipigs (33–88 kg) using twelve DE-PVCs and four GA-PVCs. After six months, the animals were euthanized, and the explanted PVCs underwent macroscopic and microscopic examination. Results: Large calcium deposits formed along conduit joining suture (CJS) lines in all PVCs, regardless of the cross-linking agent. Mineral clusters surrounded the multifilament braided thread, and its fibers were encrusted with hydroxyapatite crystals. In DE-PVCs, no mineralization occurred outside the suture lines, and they showed successful integration and graft vitalization with a uniform neointima and well-developed endothelial monolayer. GA-PVCs developed a rigid external capsule, foci of collagen fiber calcification within the walls, and neointimal hyperplasia with limited endothelial coverage. Conclusions: In PVCs, calcification predominantly occurs along the CJS lines, where the multifilament suture acts as a nucleation site for hydroxyapatite crystals. DE treatment prevents collagen mineralization, unlike GA, and offers better integration, reduced neointimal hyperplasia, and a well-developed endothelial layer. These findings suggest that DE-PVCs may be a superior option for pediatric cardiac surgery by reducing calcification and improving conduit durability. Overall, the results will help optimize PVC manufacturing strategies to lower the risk of conduit failure. Full article

Tetralogy of Fallot (ToF) with pulmonary atresia (PA) and complete right ventricular outflow tract obstruction (RVOTO) represents one of the most critical forms of congenital heart disease in neonates. These cases require complex and timely interventions to ensure survival and optimize long-term outcomes. While surgical correction offers a favorable prognosis, the period from birth to surgery is often marked by significant hemodynamic, respiratory and nutritional challenges, particularly in neonatal intensive care units (NICUs). This study aims to outline a structured, physiology-guided approach to the preoperative management of neonates with ToF and complete RVOTO, emphasizing stabilization strategies, hemodynamic support, ventilatory management and nutritional optimization. We performed a focused literature review of practices in neonatal ToF management and illustrated our experience through two case reports highlighting divergent outcomes in infants with the same anatomical diagnosis. The management strategies covered include delivery room stabilization, the use of prostaglandins, mechanical ventilation techniques, nutritional interventions and the timing of surgical intervention. A phased, physiology-guided management strategy is the key to the successful preoperative treatment of ToF with pulmonary atresia. Optimizing hemodynamics, ensuring adequate pulmonary blood flow and supporting nutritional needs are the main drivers for growth and may reduce the time from diagnosis to surgical correction. Full article

Neural crest cells (NCCs) play a significant role in the development of ventricular outflow tracts (OFTs), and cardiac neural crest cells (cNCCs) are involved in the development of the embryonic conus, suggesting that these cell lineages may be a teratogenic target for the development of cardiopathies in offspring conceived under a hyperglycemic environment. We evaluate the effect of the hyperglycemic intrauterine environment on the morphological and anatomical changes in the conal ridges along with the alterations in the spatiotemporal expression of AP2α in offspring hearts at 13, 15, and 17 DPC. The anatomical and histological analysis of the hearts in the experimental group presented smaller dimensions compared to the control group in the offspring at the three ages studied. Consequently, this resulted in a hyperglycemic environment that altered the immunostaining of AP2α in the hearts of the offspring at the three ages studied. Thus, the hyperglycemic intrauterine environment in offspring caused important morphological alterations in the development of conal ridges and promoted the generation of conotruncal heart defects in which the double outlet of the right ventricle, the atrioventricular (AV) canal, predominated. Therefore, knowing that exposing the offspring to more glucose potentially can lead to complications during organogenesis of the circulatory and central nervous systems. Full article

Aortic valve disease accounts for approximately 5% of all congenital heart defects in children. Choosing the optimal valve replacement in this population is challenging, as it must ensure durability, accommodate growth, and minimize the need for long-term anticoagulation. Biological valves do not require anticoagulation but lack durability and growth potential, leading to frequent reoperations. Mechanical valves offer longevity but necessitate lifelong anticoagulation and do not grow with the child. Among the available surgical options, the Ross procedure has emerged as a preferred approach due to its favorable hemodynamic performance, growth potential, and freedom from anticoagulation. First described in 1967, this technique involves replacing the diseased aortic valve with a pulmonary autograft and reconstructing the right ventricular outflow tract using a human or non-human valve substitute. Despite its advantages, the procedure is technically demanding, has a considerable learning curve, and transforms a single-valve pathology into a bivalvular condition. This narrative review provides an updated perspective on the Ross procedure in children, focusing on long-term survival, reoperation rates, and the role of percutaneous valve replacement in delaying surgical reintervention. By synthesizing the latest evidence, we aim to clarify the current standing of the Ross procedure as a durable and effective solution for pediatric aortic valve disease. Full article

Background/Objectives: The arterial switch operation (ASO) has been performed in the neonatal period as an anatomical correction for d-transposition of the great arteries since the 1980s. As the population of adult congenital heart disease patients grows, it is essential for healthcare providers across various disciplines to comprehend the complexities of these patients. We report on outcomes up to the third decade after ASO. Methods: All patients who underwent ASO from May 1985 to December 2020 were included, and a retrospective chart review with follow-up until December 2021 was conducted. Additionally, vital status verification (90.3% complete) was performed through the national health insurance. Survival analysis and competing risk analysis were performed to determine outcomes in the third decade after ASO. Results: One-hundred-ninety-five patients (72.3% male; median age at surgery 6 days; median weight at surgery 3.4 kg) underwent ASO from May 1985 to December 2020. Patients with a prenatal diagnosis showed a lower rate of preoperative cardiac decompensation (p = 0.017). Early in-hospital mortality was 8.7%, and no early in-hospital deaths occurred in the study era from 2006 to 2020. Four late deaths occurred, and the Kaplan–Meier estimated survival of the 178 hospital survivors was 98.3% ± 1.2% at 10 years, 96.8% ± 1.9% at 20 years and 92.4% ± 4.7 at 30 years. The cumulative incidence of left ventricular outflow tract (LVOT) reoperation after ASO was 1.3% at 10 years, 3.4% at 20 years and 11.3% at 30 years. The cumulative incidence of right ventricular outflow tract (RVOT) reoperation after ASO was 7.2% at 10 years and 17.5% at 20 and 30 years. Conclusions: Overall long-term survival of the hospital survivors is good. The reoperation rate on the LVOT is favorable. Percutaneous interventions, if feasible after the Lecompte maneuver, might pose an option to delay the more common reoperations on the RVOT, though further studies are needed to determine their long-term impact. Full article

Pulmonary disfunction is frequent in repaired congenital heart diseases. Both pulmonary regurgitation and pulmonary stenosis are possible complications over time. In the past, the surgical approach was the only feasible management but exposed the patient to a redo-surgery with its consequent risks. Nowadays, the development of novel devices and techniques has made possible a transcatheter pulmonary valve implantation. The Melody Transcatheter Pulmonary Valve (TPV) (Medtronic Inc., Minneapolis, MN, USA) and the Edwards Sapien XT and S3 Transcatheter Heart Valve (Edwards Lifesciences LLC, Irvine, CA, USA) are balloon-expandable valvular bioprostheses approved for pulmonary position. Venus P-Valve (Venus Medtech, Shanghai, China) and Harmony TPV (Medtronic Inc., Minneapolis, MN, USA) are self-expandable pulmonary valves. Alterra Adaptive Prestent (Edwards Lifesciences LLC, Irvine, CA, USA) is an hourglass self-expandable stent that reduces the size of large right ventricular outflow tracts, creating a suitable landing zone to implant an Edwards Sapien S3 THV 29 mm. Novel stents and percutaneous valves are being planned and experimented with to widen the field of transcatheter approach. The aim of this review is to describe both the current approaches, strategies, and techniques as well as the future perspective to deal with the patients with significant pulmonary stenosis and/or regurgitation. Full article

The Ross procedure introduced a new technique for aortic valve replacement by utilizing a pulmonary autograft to replace the diseased aortic valve. This approach provides a living, dynamic valve substitute capable of growth and adaptation to systemic pressures while addressing the limitations of mechanical valves, which require lifelong anticoagulation, and bioprosthetic valves, which lack durability and growth potential. The Ross procedure offers superior hemodynamic performance and freedom from anticoagulation. While initially popular, utilization declined due to its technical complexity and concerns regarding the potential for the failure of two valves, requiring additional operations. Advances in surgical techniques, such as reinforced autografts, improved myocardial protection, and better homograft preservation, coupled with evidence of favorable long-term outcomes, have renewed interest in the procedure. Preoperative imaging with echocardiography, cardiac magnetic resonance imaging, and computed tomography angiography ensures optimal patient selection and preparation. Intraoperatively, precise autograft harvesting, accurate implantation, and meticulous right ventricular outflow tract reconstruction are critical for success. Blood conservation techniques, such as acute normovolemic hemodilution and retrograde autologous priming, are employed to minimize transfusion-related complications. The anesthesiologist plays a critical role, including meticulous monitoring of myocardial function and hemodynamics, with intraoperative transesophageal echocardiography being essential for assessing valve integrity and ventricular function. Recent studies suggest that the Ross procedure can restore life expectancy in appropriately selected patients, reinforcing its value as a surgical option for managing aortic valve disease. Full article

Background: Severe pulmonary regurgitation (PR) often occurs after treatment of tetralogy of Fallot with a valve ring patch, leading to enlargement and diverse morphological characteristics of the native right ventricular outflow tract (nRVOT), which increases the difficulty of transcatheter pulmonary valve replacement (TPVR). The purpose of this study was to use the TPVR simulator to help doctors improve their surgical skills by simulating the surgical process in vitro. Methods: The TPVR simulator was developed using three-dimensional (3D) printing technology under computer-aided design. In this study, the TPVR simulator was used for preoperative simulation training and teaching. First, 10 specialists were equally divided into a 3D-printed group and a non-3D-printed group, each performing one TPVR; then, another six specialists and six young surgeons were selected to complete three TPVR simulations. Results: For the 3D-printed simulation group, the over-flap time (5.22 min (range: 4.85–5.87 min) vs. 6.72 min (range: 6.12–7.70 min), p = 0.016), fluoroscopy time (15.00 min (range: 13.50–16.50 min) vs. 19.00 min (range: 17.50–21.50 min), p = 0.012), and total operative time for the five surgeons (57.00 min (range: 54.00–62.50 min) vs. 67.00 min (range: 62.00–69.50 min), p = 0.036) were shorter. In addition, the results showed significant reductions in the median over-flap time and total time required in both the expert panel and young surgeon groups (all p < 0.05). Conclusions: The reliability and validity of the TPVR simulator was initially demonstrated and has the potential to be a teaching and training tool for surgeons. Full article

Background: In this study, we present our early and mid-term results using two different types of handmade polytetrafluoroethylene (PTFE) valved conduits in patients who require right ventricular outflow reconstruction. Methods: Between March 2021 and May 2024, 72 patients (30 males and 42 females; median age: 69 (IQR: 26–123) months) who underwent implantation of a handmade bicuspid or tricuspid valve PTFE conduit for right ventricular outflow reconstruction were retrospectively analyzed. Preoperative, postoperative, and follow-up echocardiograms were also evaluated. Results: The first postoperative echocardiography revealed that 11 (36.7%) patients had mild regurgitation, and 3 (10%) patients had moderate regurgitation in the bicuspid group initially, while only 7 (16.7%) of the patients in the tricuspid group had mild regurgitation (p = 0.004). None of the patients required reintervention in the early postoperative period because of conduit dysfunction. In the mid-term follow-up, the mean follow-up duration was 22.4 ± 11 months. PTFE-valved conduit dysfunction was observed in three patients in the bicuspid group, while no dysfunction was observed in the tricuspid group (p = 0.049). Even if the median peak gradient was found to be slightly higher in the tricuspid group [15 (IQR: 0–25) vs. 0 (IQR: 0–15)] (p = 0.032), no conduit dysfunction was reported during follow-up. Kaplan–Meier analysis demonstrated that the tricuspid conduit group maintained 100% freedom from dysfunction during the 24-month follow-up period. In contrast, the bicuspid group had rates of 90%, 87%, and 83% at 6, 12, and 24 months, respectively (log-rank p = 0.016). Conclusions: The ePTFE valved conduits provide significant advantages in terms of durability, biocompatibility, cost-effectiveness, and hemodynamic performance for right ventricular outflow tract reconstruction in pediatric cardiac surgery. The findings of our study suggest that tricuspid valve design offers better potential for preventing conduit dysfunction. Full article

The combination of hypertrophic cardiomyopathy with outflow tract obstruction, severe pre-capillary and post-capillary pulmonary hypertension, and severe primary mitral regurgitation is rare and presents distinct management challenges. Background and Clinical Significance: Pulmonary hypertension is an independent predictor of all-cause mortality in patients with hypertrophic cardiomyopathy managed medically and often precludes patients from undergoing cardiopulmonary bypass due to increased surgical morbidity and mortality. In studies specifically evaluating surgical myectomy, however, survival is favorable in patients with moderate-to-severe pulmonary hypertension. Case Presentation: We present a case of a 74-year-old male with six months of dyspnea with minimal exertion. A diagnostic work-up with transthoracic echocardiogram showed asymmetric left ventricular hypertrophy, left ventricular outflow tract obstruction with a peak gradient of 200 mmHg, right ventricular systolic pressure of 99 mmHg, systolic anterior motion of the mitral valve and flail anterior mitral leaflet. The patient was evaluated by a multi-disciplinary team and underwent extended septal myectomy and mitral valve repair with significant improvement in functional capacity post-operatively. Conclusions: While pulmonary hypertension increases the risk of morbidity and mortality during cardiopulmonary bypass, moderate-to-severe pulmonary hypertension in hypertrophic cardiomyopathy with outflow tract obstruction is a unique indication for septal reduction therapy that may not be associated with higher surgical mortality. Full article