Aggressive Patch Augmentation May Reduce Growth Potential of Hypoplastic Branch Pulmonary Arteries After Tetralogy of Fallot Repair Travis J. Wilder,

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Presentation transcript:

Aggressive Patch Augmentation May Reduce Growth Potential of Hypoplastic Branch Pulmonary Arteries After Tetralogy of Fallot Repair Travis J. Wilder, MD, Glen S. Van Arsdell, MD, Eric Pham-Hung, BS, Michael Gritti, BS, Sara Hussain, MD, Christopher A. Caldarone, MD, Andrew Redington, MD, Edward J. Hickey, MD The Annals of Thoracic Surgery Volume 101, Issue 3, Pages 996-1004 (March 2016) DOI: 10.1016/j.athoracsur.2015.11.040 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Drawings show management strategies of (A) limited extension arterioplasty to the proximal pulmonary artery (PA; EXTENSION), (B) expensive patch augmentation to the hilum (PATCH), and (C) unaugmented (NATIVE) branch PA (BPA) at the initial repair. Although only depicted as a bilateral arterioplasty, each PATCH arterioplasty could be extended into the left PA (LPA; n = 22), right PA (RPA; n = 9) or bilaterally (n = 21). (MPA = main pulmonary artery; RV = right ventricle; VSD = ventricular septal defect.) The Annals of Thoracic Surgery 2016 101, 996-1004DOI: (10.1016/j.athoracsur.2015.11.040) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Freedom from branch pulmonary artery (BPA) reintervention. (A) Unadjusted 10-year freedom from BPA reintervention for all 434 children after tetralogy of Fallot repair. The circles show nonparametric estimates at events (reinterventions), the solid lines show parametric determinants of continuous point estimates enclosed by 68% confidence intervals (dashed lines and bars), and the numbers in parentheses are children at-risk at the associated time. (B) Risk-adjusted, 10-year freedom from BPA reintervention for all 434 children stratified by BPA management strategy. (C) Nomogram plot depicts the effect of the baseline BPA z-score on the risk-adjusted, 5-year freedom from BPA reintervention for each respective group. The green curve shows 249 children with unaugmented BPAs (NATIVE), blue curve shows 133 children who had limited extension arterioplasty (EXTENSION), and the red curve shows 52 children who had a patch arterioplasty (PATCH). The solid lines are parametric estimates for the risk of death at 5 years. The estimated freedom from reintervention was based on median or values for BPA z-score (–2), open atrial septal defect (0.16), and fenestrated ventricular septal defect (0.02). The Annals of Thoracic Surgery 2016 101, 996-1004DOI: (10.1016/j.athoracsur.2015.11.040) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Branch pulmonary artery growth (BPA). (A) Postrepair growth of the smallest BPA (of either the right PA or left PA) as reported from 1,439 postrepair echocardiograms for 434 children. The time-related trends show an early phase (<2 years) of rapid growth, followed by a reduced rate of continued growth (late phase). When evaluated independently, the overall trends for the growth of the (B) right PA and (C) left PA were similar to the trends when evaluating the smallest of the BPAs. Each solid blue line represents the unadjusted estimate of temporal trend enclosed within 68% bootstrap percentile confidence limits. The black circles represent data grouped (without regard to repeated measurements) within time frames to provide crude verification of model fit. The Annals of Thoracic Surgery 2016 101, 996-1004DOI: (10.1016/j.athoracsur.2015.11.040) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Effect of branch pulmonary artery (BPA) strategy on PA growth and right ventricular systolic pressure (RVSP). Overall trends after tetralogy of Fallot repair for (Left) BPA growth and (Right) RVSP stratified by the strategy for BPA management. (Top) Unadjusted raw echocardiogram data for measurements (circles) for (A) BPA size and (B) RVSP. Each circle is an independent echocardiogram measurement for the unaugmented BPAs (NATIVE) group (green), limited extension arterioplasty (EXTENSION) group (blue), or patch arterioplasty (PATCH) group (red). The continuous lines are simple regression lines for the corresponding group, providing the best fit among BPA values without regard to repeated measurements. (Bottom) Relationship between risk-adjusted postrepair (C) BPA growth and (D) RVSP stratified by corresponding strategy for BPA management. Each curve represents a hypothetical patient stratified by strategy for BPA management with otherwise identical profiles. The estimated BPA growth is based on mean values of values of the baseline BPA z-score (–2) and body surface area at repair (0.4) and estimated peak RVSP is based on median values for the intraoperative RVSP measured by needle manometry (46 mm Hg) and the baseline pulmonary valve z-score (–4). The Annals of Thoracic Surgery 2016 101, 996-1004DOI: (10.1016/j.athoracsur.2015.11.040) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions