Alexander Kadner

Objectives: Patients with congenitally corrected transposition of the great arteries (ccTGA) may undergo physiologic repair, leaving the right ventricle systemic, or anatomic repair, correcting the double discordance. We compared both strategies in an international study using propensity-score matching. Methods: Patients from 12 European centres, aged <18 years, who underwent either physiologic or anatomic repair between 1990 and 2010 were included (n = 266). Patients were matched by optimal pair matching on ventricular septal defect, subpulmonary left ventricular outflow tract obstruction, ≥mild systemic tricuspid valve regurgitation, age, and gender, resulting in a 1:1 matched cohort of 162 patients. The resulting groups were compared for long-term survival, reoperations, and function of the systemic ventricle and atrioventricular valve. Results: Transplant-free survival at 10 and 15 years was 87 ± 4%, 95% confidence interval (CI) [79%-95%] and 80 ± 6% [68%-93%] for the physiologic group and 85 ± 5% [78%-96%] and 85 ± 5% [78%-96%] for the anatomic group (P = .568). Freedom from cardiac reoperation at 10 and 15 years was 73 ± 6% [62%-85%] and 56 ± 8% [41%-75%] for the physiologic group and 61 ± 8% [47%-76%] and 36 ± 9% [26%-62%] for the anatomic group (P = .279). Tricuspid valve regurgitation at final follow-up was present in 57% (27/47) vs 17% (12/72), respectively (P < .001). Conclusions: Long-term survival and reoperation rates are similar in comparable patients following physiologic and anatomic repair of ccTGA in childhood. Tricuspid valve function may deteriorate when left in the systemic position following physiologic repair. In contrast, patients with tricuspid regurgitation may benefit from anatomic repair, with improved function in the subpulmonary position.

Background: Minimally invasive thoracotomies to repair selected congenital heart defects are considered only a cosmetic alternative approach by many; however, they represent the routine alternative in centers of expertise. Methods: Pooled institutional data from the European Congenital Heart Surgeons Association using mini-thoracotomy approaches were analyzed since the beginning of their respective experiences until an inclusion surgical date of January 31, 2024, allowing at least six months postoperative follow-up. Results: From 1999 to 2024, 3,007 patients from 11 centers underwent surgery. Age and weight ranged from 4 days to 73 years and 3.1 to 106 kg, respectively. Repaired defects included atrial and ventricular septal defects, partial anomalous pulmonary venous return, partial and complete atrioventricular septal defects, double-chambered right ventricle, cor triatriatum, scimitar syndrome, subaortic stenosis, and total anomalous pulmonary venous return (TAPVR). There was no surgical mortality or intraoperative conversion to sternotomy. Complications included wound infections (0.59%), pacemaker requirement (0.23%), phrenic nerve injury (0.26%), bleeding requiring exploration (0.13%), and neurologic injury (0.29%). Early or late reoperations were needed in 0.73%. Conclusion: Minimally invasive thoracotomies are the preferred approach for selected congenital heart defects in the participating pediatric heart centers. Mini-thoracotomy incisions allow safe access to an ever-expanding spectrum of quality repairs, low morbidity, superior cosmetics, and early return to functionality in infants, children, and adults.

We hypothesized that ultrasound-assisted thrombolysis (USAT) is non-inferior to surgical pulmonary embolectomy (SPE) to improve right ventricular (RV) function in patients with acute pulmonary embolism (PE). In a single-centre, non-inferiority trial, we randomly assigned 27 patients with intermediate-high or high-risk acute PE to undergo either USAT or SPE stratified by PE risk. Primary and secondary outcomes were the baseline-to-72-h difference in right-to-left ventricular (RV/LV) ratio and the Qanadli pulmonary occlusion score, respectively, by contrast-enhanced chest-computed tomography assessed by a blinded CoreLab. The trial was prematurely terminated due to slow enrolment. Mean age was 62.6 (SD 12.4) years, 26% were women, and 15% had high-risk PE. Mean change in RV/LV ratio was −0.34 (95% CI −0.50 to −0.18) in the USAT and −0.53 (95% CI −0.68 to −0.38) in the SPE group (mean difference: 0.152; 95% CI 0.032–0.271; P_{non-inferiority} = 0.80; P_superiority = 0.013). Mean change in Qanadli pulmonary occlusion score was −7.23 (95% CI −9.58 to −4.88) in the USAT and −11.36 (95% CI −15.27 to −7.44) in the SPE group (mean difference: 5.00; 95% CI 0.44–9.56, P = 0.032). Clinical and functional outcomes were similar between the 2 groups up to 12 months. In patients with intermediate-high and high-risk acute PE, USAT was not non-inferior when compared with SPE in reducing RV/LV ratio within the first 72 h. In a post hoc superiority analysis, SPE resulted in greater improvement of RV overload and reduction of thrombus burden.

OBJECTIVES: This study aims to describe the outcomes of surgical correction for anomalous aortic origin of coronary artery (AAOCA) with regard to symptom relief. METHODS: We performed a retrospective multicentre study including surgical patients who underwent correction for AAOCA between 2009 and 2022. Patients who underwent concomitant cardiac procedures were also included. However, to analyse symptom relief, we only assessed the subgroup of symptomatic patients who underwent isolated correction for AAOCA. RESULTS: A total of 71 consecutive patients (median age 55, range 12–83) who underwent surgical correction for AAOCA were included in the study. Right-AAOCA was present in 56 patients (79%), left-AAOCA in 11 patients (15%) and single coronary ostium AAOCA in 4 patients (6%). Coronary unroofing was performed in 72% of the patients, coronary reimplantation in 28% and an additional neo-ostium patchplasty in 13% of the patients. In 39% of the patients, a concomitant cardiac procedure was performed. During follow-up, no cardiovascular-related death was observed. Three patients (4.2%) had a myocardial infarction and underwent postoperative coronary artery bypass grafting. Six patients (8.5%) needed postoperative temporary mechanical circulatory support. Among the 34 symptomatic patients who underwent isolated AAOCA correction, 70% were completely asymptomatic after surgery, 12% showed symptom improvement and no symptom improvement was observed in 18% of the patients (median follow-up 3.5 years, range 0.3–11.1). CONCLUSIONS: Correction for AAOCA can be safely performed with or without concomitant cardiac procedures. Performing AAOCA correction leads to a significant improvement in symptoms for most patients.

Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are a challenge because of their various anatomic and clinical presentation. Although the prevalence is low, the absolute numbers of detected ACAOS are increasing because of the growing use of noninvasive anatomical imaging for ruling out coronary artery disease. As evidence‐based guidelines are lacking, treating physicians are left in uncertainty for the optimal management of such patients. The sole presence of ACAOS does not justify surgical correction, and therefore a thorough anatomic and hemodynamic assessment is warranted. Invasive and noninvasive multimodality imaging provides information to the clinical question whether the presence of ACAOS is an innocent coincidental finding, is responsible for the patient’s symptoms, or even might be a risk for sudden cardiac death. Based on recent clinical data, focusing on the pathophysiology of patients with ACAOS, myocardial ischemia is dependent on both the extent of fixed and dynamic components, represented by anatomic high‐risk features. These varying combinations should be considered individually in the decision making for the different therapeutic options. This state‐of‐the‐art review focuses on the advantages and limitations of the common contemporary surgical, interventional, and medical therapy with regard to the anatomy and pathophysiology of ACAOS. Further, we propose a therapeutic management algorithm based on current evidence on multimodality invasive and noninvasive imaging findings and highlight remaining gaps of knowledge.

Aims: Continuous-flow left ventricular assist devices (CF-LVADs) have become a standard of care in end-stage heart failure. Limited data exist comparing outcomes of HeartMate3 (HM3) and HeartWare HVAD (HW). We aimed to compare midterm outcomes of these devices. Methods and results: Investigator-initiated retrospective-observational comparative analysis of all patients who underwent primary LVAD implantation of either HM3 or HW at our centre between January 2010 and December 2020. Data were derived from a prospective registry. Primary endpoints were all-cause mortality and heart transplantation. Secondary endpoints included device-related major adverse cardiac and cerebrovascular events, which included major bleeding, major neurological dysfunction (defined as persisting neurological impairment for ≥24 h), device-related major infection (excluding driveline infections), major device malfunctions leading to re-intervention or partial device exchange (pump failure, outflow-graft twist or failure, controller failure, battery failure, patient cable failure, but excluding pump thrombosis), and pump thrombosis. Further secondary endpoints included right heart failure, gastrointestinal bleeding, driveline infections, and surgical re-interventions. The secondary outcomes were analysed not only for the first event but also for recurrent events. The analysis included competing risks analysis and recurrent event regression analysis, with adjustment for confounders age, gender, body mass index (BMI), and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Out of 106 primary CF-LVAD implantations, 36 (34%) received HM3 and 70 (66%) received HW. Median follow-up was 1.48 years [interquartile range 0.67, 2.41]. HM3 was more often implanted in men (91.7% vs. 72.9%, P = 0.024); patients were older (median 61 years [54, 66.5] vs. 52.5 years [43, 60], P < 0.001), had a higher BMI (median 26.7 kg/m2 [23.4, 29.0] vs. 24.3 kg/m2 [20.7, 27.4], P = 0.013), had more comorbidities, and were more likely targeted for destination therapy (36.1% vs. 14.3%, P = 0.010). Death occurred in 33.3% of HM3 patients, compared with 22.9% of HW patients, P = 0.247 (probability of survival at 4 years, 54.7% vs. 74.1%, P = 0.296). After adjustment for confounders, we observed a significant six-fold risk increase in device malfunctions for HW [hazard ratio (HR) 6.49, 95% confidence interval (CI) [1.89, 22.32], P = 0.003], but no significant differences in pump thrombosis (P = 0.173) or overall survival (P = 0.801). Conclusions: Comparing midterm outcomes between HM3 and HW for LVAD support from a prospective registry, HW patients had a significantly higher risk of device malfunctions. No significant differences were evident between devices in overall survival and in respect to most outcomes.