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Biomedical subjects

Edward L Bove

Publications and source records attributed to Edward L Bove.

At least 19 recordsLinked to original sources
PubMed2006

Current outcomes and risk factors for the Norwood procedure.

OBJECTIVE: Tremendous strides have been made in the outcomes for hypoplastic left heart syndrome and other functional single-ventricle malformations over the past 25 years. This progress relates primarily to improvements in survival for patients undergoing the Norwood procedure. Previous reports on risk factors have been on smaller groups of patients or collected over relatively long periods of time, during which management has evolved. We analyzed our current results for the Norwood procedure with attention to risk factors for poor outcome. METHODS: A single-institution review of all patients undergoing a Norwood procedure for a single-ventricle malformation from May 1, 2001, through April 30, 2003, was performed. Patient demographics, anatomy, clinical condition, associated anomalies, operative details, and outcomes were recorded. RESULTS: Of the 111 patients, there were 23 (21%) hospital deaths. Univariate analysis revealed noncardiac abnormalities (genetic or significant extracardiac diagnosis, P = .0018), gestational age (P = .03), diagnosis of unbalanced atrioventricular septal defect (P = .017), and weight of less than 2.5 kg (P = .0072) to be related to hospital death. On multivariate analysis, only weight of less than 2.5 kg and noncardiac abnormalities were found to be independent risk factors. Patients with either of these characteristics had a hospital survival of 52% (12/23), whereas those at standard risk had a survival of 86% (76/88). CONCLUSIONS: Although improvements in management might have lessened the effect of some of the traditionally reported risk factors related to variations in the cardiovascular anatomy, noncardiac abnormalities and low birth weight remain as a future challenge for the physician caring for the patient with single-ventricle physiology.

Cardiac Surgical Procedures↗
PubMed2006

Bridge to transplant using the MicroMed DeBakey ventricular assist device in a child with idiopathic dilated cardiomyopathy.

We report the implantation of the MicroMed DeBakey left ventricular assist device (MDBVAD) in a 10-year-old girl with cardiogenic shock secondary to an idiopathic dilated cardiomyopathy. This was the first pediatric implant of the MDBVAD in the United States and the youngest patient worldwide. The patient recovered well and subsequently underwent successful heart transplantation after 84 days of support.

Cardiac Catheterization↗
PubMed2006

Management of congenital and acquired pulmonary vein stenosis.

BACKGROUND: Pulmonary vein (PV) stenosis, whether congenital or after repair of total anomalous pulmonary venous connection (TAPVC), continues to carry a poor prognosis. METHODS: A retrospective review identified 36 patients who underwent repair of PV stenosis between December 1989 and June 2003. Fourteen with congenital PV stenosis underwent scar excision and primary repair (n = 2), intraoperative stent placement (n = 4), or sutureless pericardial marsupialization (n = 8). Twenty-two with acquired PV stenosis after TAPVC repair underwent anastomotic revision and/or vein repair (n = 11) or sutureless pericardial marsupialization (n = 11). Follow-up ranged from 1 month to 14 years (median, 30 months). RESULTS: Among the 14 patients with congenital PV stenosis, 8 died (3 early deaths, 4 late deaths with restenosis, and 1 late noncardiac death). Among the six survivors, five (4 after marsupialization) have not developed restenosis. Among 11 of 22 patients with acquired PV stenosis undergoing anastomotic revision or vein repair, there were 5 deaths (2 early, 2 late with restenosis, and 1 late noncardiac death) and 1 of the six survivors has developed restenosis. Of the remaining 11 undergoing marsupialization, there was one late death (with restenosis) and 10 survivors have no restenosis. Congenital etiology, use of marsupialization technique, presence of associated defect, and extent of disease were identified as risk factors for poor outcome. CONCLUSIONS: Patients with pulmonary vein stenosis continue to have a guarded prognosis. Sutureless pericardial marsupialization was associated with satisfactory midterm results and appears superior to other conventional techniques.

Heart Defects, Congenital↗
PubMed2005

Risk factors for cerebrovascular events following fontan palliation in patients with a functional single ventricle.

The risk for cerebrovascular events (CVEs) is increased in children with functional single ventricles (FSVs). However, there are limited data indicating the prevalence of CVEs or the role of preventative therapy. To measure the prevalence of clinically evident CVEs in patients with FSVs, identify risk factors, and analyze the effect of aspirin on the risk for CVEs, a retrospective chart review was performed on all patients who underwent Fontan palliation at the University of Michigan from January 1, 1975, to June 30, 1998 (n = 402). Data collected included original anatomy, Fontan type, date of CVE, medications at the time of CVE, intraoperative placement of fenestration, and date of last follow-up. The overall mortality rate was 12%. There were 38 CVEs (9%), of which only 11 (3%, or 0.0036/patient-year) could not be attributed to a defined event (catheterization, extracorporeal membrane oxygenation, or cardiac arrest). Anticoagulation with aspirin was associated with a statistically significantly decreased risk for CVEs. Fontan type was not associated with the risk for CVEs. Thus, patients with FSVs are at increased risk for CVEs, although the de novo risk was low. Aspirin use is associated with a decreased risk for CVEs.

Aspirin↗
PubMed2005

Extended resection and end-to-end anastomosis for aortic coarctation in infants: results of a tailored surgical approach.

BACKGROUND: The surgical repair of aortic coarctation in infants has evolved over time. This study evaluates our current approach utilizing extended end-to-end anastomosis without prosthetic material to enlarge all areas of aortic arch hypoplasia. METHODS: The Michigan Congenital Heart Center database was reviewed for infants who underwent repair of isolated aortic coarctation from January 1, 1990, to January 1, 2000. RESULTS: Eighty-three infants underwent surgical repair of isolated coarctation during this decade. Median age at repair was 21 days (range, 2 to 365). Repair was performed through thoracotomy in 72 patients. Because of severe transverse arch hypoplasia, the remaining 11 infants underwent median sternotomy with circulatory arrest. There were 2 deaths: 1 due to pulmonary hypertension in a patient with alveolar capillary dysplasia and 1 late death due to pneumonia in a patient with noncardiac anomalies. Neither patient had residual coarctation. Technique-related complications of bronchial compression, chylothorax, and vocal cord paralysis were noted in 4 patients. Follow-up data were available for 66 patients (80%) with mean follow-up duration of 4.5 years (SD +/- 3.1). Reintervention was required in 4 patients (6%). One underwent reoperation after 1 month, and 3 underwent balloon angioplasty within 7 months of initial repair. The remaining 61 patients are asymptomatic, on no antihypertensive medications, and have aortic arch gradients less than 15 mm Hg. One developed subaortic stenosis necessitating resection. CONCLUSIONS: Tailored surgical repair for aortic coarctation has a low rate (6%) of residual and recurrent coarctation even when performed in infants. Mortality and morbidity are low.

Anastomosis, Surgical↗
PubMed2005

Superior durability of SynerGraft pulmonary allografts compared with standard cryopreserved allografts.

BACKGROUND: The ideal pulmonary valve replacement for children and adolescents remains elusive. Although favored by many surgeons, the cryopreserved pulmonary allograft tends to become rapidly incompetent and elicits an immune response. The SynerGraft process (Cryolife Inc, Kennesaw, GA) decellularizes a pulmonary allograft, leaving a scaffold of connective tissue. These grafts have been shown to decrease immune reactivity and become populated with host cells. Although theoretically these traits may improve durability, few data comparing SynerGraft-processed allografts (SynAs) (Cryolife Inc) with standard cryopreserved allografts are available. METHODS: A single institution review was performed for all SynAs implanted from their introduction in 2001 to January 2003. Twenty-six patients with SynAs and 26 age and diagnosis-matched controls receiving cryopreserved allografts were evaluated. Subjects were analyzed for demographics, survival, reintervention, and echocardiographic findings. RESULTS: There were no significant differences between groups in age, weight, valve diameter, orthotopic and heterotopic allograft position, or follow-up. On echocardiogram there was no difference in initial degree of allograft insufficiency or gradient. However, at mean follow-up of 19 +/- 13 months, SynAs were significantly less regurgitant than cryopreserved allografts (p = 0.017). Although all gradients were low, a significant difference between SynAs (7.6 +/- 14 mm Hg) and cryopreserved allografts (14.6 +/- 15.6 mm Hg; p = 0.012) had emerged. Survival was identical at 85% (22 of 26). Rates of reintervention were similar at 7% (2 of 26) for cryopreserved allografts and 3.8% (1 of 26) for SynAs (p = 0.98). CONCLUSIONS: At intermediate follow-up, the SynA demonstrated greater durability with less insufficiency and lower gradients. These characteristics are important to many patients with complex congenital heart disease; however, long-term effects on survival and reintervention remain unknown.

Case-Control Studies↗
PubMed2005

Multiscale modeling of the cardiovascular system: application to the study of pulmonary and coronary perfusions in the univentricular circulation.

The objective of this study is to compare the coronary and pulmonary blood flow dynamics resulting from two configurations of systemic-to-pulmonary artery shunts currently utilized during the Norwood procedure: the central (CS) and modified Blalock Taussig (MBTS) shunts. A lumped parameter model of the neonatal cardiovascular circulation and detailed 3-D models of the shunt based on the finite volume method were constructed. Shunt sizes of 3, 3.5 and 4 mm were considered. A multiscale approach was adopted to prescribe appropriate and realistic boundary conditions for the 3-D models of the Norwood circulation. Results showed that the average shunt flow rate is higher for the CS option than for the MBTS and that pulmonary flow increases with shunt size for both options. Cardiac output is higher for the CS option for all shunt sizes. Flow distribution between the left and the right pulmonary arteries is not completely balanced, although for the CS option the discrepancy is low (50-51% of the pulmonary flow to the right lung) while for the MBTS it is more pronounced with larger shunt sizes (51-54% to the left lung). The CS option favors perfusion to the right lung while the MBTS favors the left. In the CS option, a smaller percentage of aortic flow is distributed to the coronary circulation, while that percentage rises for the MBTS. These findings may have important implications for coronary blood flow and ventricular function.

Blood Flow Velocity↗
PubMed2004

Tricuspid valve repair in hypoplastic left heart syndrome.

OBJECTIVES: Currently, the survival for the Norwood procedure for hypoplastic left heart syndrome is approximately 90% in selected centers. However, the development of tricuspid regurgitation remains a significant obstacle to successful staged repair in a subset of these patients. The results of tricuspid valve repair in this challenging patient population remain largely unknown. METHODS: Twenty-eight patients with significant (3-4+) tricuspid regurgitation after the Norwood procedure required tricuspid valve repair from August 1995 through December 2002. The clinical and Doppler-echocardiographic data were reviewed to determine the efficacy of repair and patient outcome. RESULTS: Follow-up was 96% complete (27/28). Patients were divided into 2 groups on the basis of tricuspid regurgitation at late follow-up: those with a successful late outcome (0-2+) and those with a poor outcome (3-4+). There were 17 (63%) patients with a successful result and 10 (37%) with an adverse outcome. Age, weight, follow-up duration, valve anatomy, and stage of palliation were not significantly different between groups. Early postoperative 0 to 2+ regurgitation was associated with a durable result (P =.012) and preserved ventricular function (P =.04). Need for repair other than a partial annuloplasty was predictive of a poor outcome (P =.04). Overall survival was 67% (18/27). Survival was 94% (16/17) for patients with a successful late result versus 20% (2/10) for those with a poor outcome (P =.0002). CONCLUSIONS: Tricuspid valve repair can be accomplished in this challenging patient population with excellent results. Successful tricuspid valve repair is predictive of continued good valve function and preserved right ventricular function. Successful valve repair at late follow-up predicts excellent late survival.

Child↗
PubMed2004

Primary closure for postoperative mediastinitis in children.

OBJECTIVES: Mediastinitis affects approximately 1% of children undergoing median sternotomy. Conventional therapy involves debridement followed by open wound care with delayed closure, days to weeks of closed suction or antimicrobial irrigation, and vacuum-assisted closure or muscle flap closure. We hypothesized that primary closure without prolonged suction or irrigation is an effective, less traumatic treatment for mediastinitis in children. METHODS: From January 1986 to July 2002, 6705 procedures involving median sternotomy were performed at the C. S. Mott Children's Hospital, resulting in 57 cases of mediastinitis (0.85%). Cases were divided into 2 groups, with 42 cases treated with primary closure and 15 cases treated with delayed or muscle flap closure. The 42 cases of primary closure comprised the primary study group of this institutional review board-approved, retrospective analysis. Patient demographics, surgical variables, mediastinitis-related parameters, and outcomes were evaluated. RESULTS: One patient had recurrent mediastinitis for an overall infection eradication rate of 97% (40/41). Three patients (7%) required re-exploration for suspected ongoing infection. Of these re-explorations, 1 patient had evidence of continued mediastinitis. The remaining 2 patients with sepsis of unclear cause had no clinical or culture evidence of recurrent infection. One of these patients ultimately died of sepsis without active mediastinitis for a hospital survival of 97% (41/42). No significant differences could be detected between the treatment successes and failures in this small cohort of patients. CONCLUSIONS: Simple primary closure is an effective means to treat selected cases of postoperative mediastinitis in children. The results compare favorably with other more lengthy or debilitating treatments.

Child↗
PubMed2004

High systemic vascular resistance and sudden cardiovascular collapse in recovering Norwood patients.

BACKGROUND: Sudden death, remote from surgery, in patients with hypoplastic left heart syndrome (HLHS) after Norwood palliation is an important problem. The episodic nature of this syndrome has made its cause(s) difficult to ascertain. Observations made in hospitalized Norwood patients may afford insight into the pathophysiology of sudden death among these patients. METHODS: We conducted a retrospective chart review. RESULTS: Five patients with HLHS experiencing unremarkable recoveries from Norwood palliation, still hospitalized but extubated (only 1 in intensive care), had unexpected, acute decompensation 8 to 15 days postoperatively. All had acutely decreased peripheral perfusion; severe metabolic acidosis (mean HCO(3) = 9 mEq/L, range 6 to 11 mEq/L; mean arterial lactate = 16 mmol/L, range 10 to 20 mmol/L, normal less than 2 mmol/L); relatively high arterial pO(2), especially considering their low systemic perfusion (mean = 57 mm Hg, range 50 to 66 mm Hg on fraction of inspired oxygen (FiO(2)) less than 0.3 in 4 of 5 patients); and relatively high systolic blood pressure (mean systolic blood pressure = 91 mm Hg, range 78 to 116 mm Hg). During the preceding 24 hours, all had had systolic blood pressures of more than 85 mm Hg at multiple times. All were resuscitated with mechanical ventilation and administration of HCO(3) and intravenous inotropic agents or vasodilators (1 also required extracorporeal membrane oxygenation), with rapid resolution of their acidosis. After decompensating, all were treated with oral antihypertensive agents; 1 had an early hemi-Fontan. All survived to discharge. CONCLUSIONS: Increased systemic vascular resistance may be especially pernicious in Norwood patients-even remote from operation-as the condition increases myocardial work and O(2) consumption while diminishing systemic perfusion. Chronic and acutely increased systemic vascular resistance may account for some cases of sudden unexpected death in Norwood patients.

Cardiac Surgical Procedures↗
PubMed2004

Single-stage repair of tetralogy of Fallot with pseudoaneurysm: a unique approach.

Pseudoaneurysm is a potentially lethal complication after modified Blalock-Taussig shunt. This report describes a frequently misdiagnosed clinical presentation along with noninvasive diagnosis of pseudoaneurysm after a modified Blalock-Taussig shunt. We report a novel single-stage surgical management of the pseudoaneurysm with concomitant complete repair of tetralogy of Fallot.

Anastomosis, Surgical↗
PubMed2004

Comparison of right ventricle to pulmonary artery conduit and modified Blalock-Taussig shunt hemodynamics after the Norwood operation.

The Norwood procedure remains one of the highest-risk operations in congenital heart surgery. A significant contributor to this risk is thought to be the diastolic run-off into the modified Blalock-Taussig shunt (MBTS). In an effort to eliminate this risk, several groups have begun to utilize a right ventricle to pulmonary artery conduit (RVPAC), which decreases this diastolic "steal" of coronary blood flow. Whereas initial results with the RVPAC are encouraging, the postulated hemodynamic advantages are unproven. This case illustrates the positive hemodynamic changes by echocardiography after the replacement of a MBTS with a RVPAC in a patient after a Norwood procedure.

Anastomosis, Surgical↗
PubMed2004

Double intramural coronary arteries in D-transposition of the great arteries.

We report a rare case of D-transposition of the great arteries with intramural origin of both the left and right coronary arteries. The patient underwent a successful arterial switch operation at 7 days of life with an uneventful postoperative course. Regardless of challenging coronary anatomy, the arterial switch operation remains the optimal approach for repair of the transposition of the great arteries in the neonate.

Abnormalities, Multiple↗
PubMed2004

Hypoplastic left heart syndrome: conventional surgical management.

Surgical palliation for hypoplastic left heart syndrome has become standard therapy in many centers throughout the world. Significant improvements in management, from preoperative diagnosis and intraoperative technique to postoperative care, have resulted in a dramatic increase in survival. With this improved survival, however, come new challenges and unforeseen problems. The first stage of the reconstructive surgery remains the highest risk procedure for the reason that establishing a stable circulation that is dependent on a single, volume-overloaded right ventricle with the potential for jeopardized coronary blood flow remains a surgical challenge. In this review, current management strategies for the conventional reconstructive surgical approach are examined.

Cardiac Surgical Procedures↗