Reply to Buratto et al.

Reply to Buratto et al. 1296 Letters to the Editor / European Journal of Cardio-Thoracic Surgery Reply to Buratto et al. Predictors of right ventricular failure after a,b, a,b a,b implantation of left ventricular assist Meena Nathan *, Sitaram Emani and Pedro J. del Nido Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, devices USA Department of Surgery, Harvard Medical School, Boston, MA, USA a, b a c Orhan Gokalp *, Hasan Iner , Yuksel Besir and Gamze Gokalp Department of Cardiovascular Surgery, Faculty of Medicine, Izmir Katip Received 15 December 2017; accepted 18 December 2017 Celebi University, Izmir, Turkey Department of Cardiovascular Surgery, Adıyaman Education and Research Keywords: Unbalanced atrioventricular septal defects � Biventricular conver- Hospital, Adiyaman, Turkey sion � Outcomes Department of Paediatrics Emergency, Izmir Tepecik Education and Research Hospital, Izmir, Turkey We thank you for the opportunity to respond to the letter by Buratto et al. [1] Received 30 November 2017; accepted 29 December 2017 regarding our article on the mid-term outcomes in unbalanced complete atrioventricular septal defect [2]. Keywords: Right ventricular failure � Mechanical circulatory support � They raised the concern of survivor bias in our biventricular conversion/re- cruitment (BiVC/BiVR) cohort. We would like to point out that the reason we Ventricular assist device � Risk factors chose the date of BiVR or BiVC as the timing of entry into the study was be- cause these patients, particularly BiVC patients, had their initial surgery at out- Congratulations to Boegershausen et al. [1] on their study. As the authors have side institutions. Therefore, obtaining accurate survival data for all unbalanced noted, the incidence of right ventricular failure (RVF) development after im- complete atrioventricular septal defect cases from these institutions was not plantation of left ventricular assist devices (LVADs), which is the most import- feasible. Furthermore, for patients who were cared for from the neonatal ant treatment option for advanced stage heart failure, is not very low. In period at our centre, we were careful to include all patients in whom an ultim- 2–4 various series, this ratio is up to 50% [ ]. As can be seen, RVF development ate BiV circulation was planned in the BiVR group to avoid this bias. rates are extremely high. Even more important subject is the increased mortal- The premise of our article was to show that BiVC with or without BiVR ity rates when RVF develops after LVAD. Therefore, determining the RVF pre- could be achieved with a reasonably low mortality and morbidity, but with dictors after LVAD is frequently discussed as an important topic today. But, in increased rates of reintervention. This is particularly important in certain high- the literature, many different parameters have been emphasized with regard risk groups such as trisomy 21 and heterotaxy, which poorly tolerate single- to the predictive factors for the development of RVF after LVAD. For example, ventricle palliation. As depicted in our supplementary material, fig. S2, 13 of in this study, Boegershausen et al. report that only the basal longitudinal sys- 57 (23%) patients with heterotaxy in the single-ventricle group died when tolic strain of the right ventricular (RV) free wall (PSLSbasal) and the central compared with 3 of 32 (9%) in the BiVC/BiVR group and 4 of 101 (4%) patients venous pressure are predictive factors for RVF. Similarly, another study of in the primary BiV repair group. As we accrue more patients, we will be able 4428 patients reported that high central venous pressure and low right ven- to perform a matched analysis of the three cohorts in the future. 3–6 tricular stroke work index were predictive factors for RVF after LVAD [4]. But, As decision making in this complex cohort continues to evolve [ ], longitu- in the same study, unlike the study by Boegershausen et al., they reported that dinal data on this cohort would provide valuable information to further eluci- international normalized ratio, N-terminal pro-b-type natriuretic peptide, date therapy that is designed to meet the individual patient needs based on moderate-to-severe right ventricular dysfunction, increased right ventricular/ anatomical and physiological parameters. We agree that atrioventricular re- left ventricular ratio and preprocedural ventilator dependence were also pre- gurgitation remains the primary driver of reinterventions in unbalanced com- dictive factors for RVF after LVAD implantation. Another study [5] reported plete atrioventricular septal defect, whether it is single-ventricle palliation, that parameters such as increased pulmonary artery pressure, increased right primary BiV repair or BiVC/BiVR, as presented in table 6 of our article. atrial pressure, decreased stroke volume, preoperative severe tricuspid regur- Abnormalities in both valve morphology and ventricular morphology contrib- gitation and renal replacement therapy were risk factors for RFV, unlike the uted to atrioventricular valve regurgitation in this patient population and study by Boegershausen et al. It is, of course, it is possible to increase these therefore necessitate an individualized approach to repair. examples. However, it is clear that there is no single predictive factor for the development of RVF after LVAD. Another issue that we want to mention is that the main treatments applied by Boegershausen et al. for RVF after LVAD REFERENCES implantation are vasodilator inhalation, prolongation of inotropic treatment and right-sided extracorporeal membrane oxygenation. However, other ven- tricular support systems, such as a Levitronix CentriMag ventricular assist de- [1] Buratto E, Khoo B, Ye XT, Konstantinov IE. Does biventricular conversion vice for the right side, have never been used. How do authors explain the bring survival benefits to patients with an unbalanced atrioventricular sep- reason for this? We believe that sharing the authors’ ideas on this subject will tal defect. Eur J Cardiothorac Surg 2018;53:1295. add value to their study. [2] Nathan M, Emani S, IJsselhof R, Liu H, Gauvreau K, del Nido P. Midterm outcomes in unbalanced atrio ventricular septal defect: successful biven- tricular conversion from single ventricle palliation. Eur J Cardiothorac Surg 2017;52:565–72. REFERENCES [3] Nathan M, Liu H, Pigula FA, Fynn-Thompson F, Emani S, Baird CA et al. Biventricular conversion after single-ventricle palliation in unbalanced [1] Boegershausen N, Zayat R, Aljalloud A, Musetti G, Goetzenich A, Tewarie L atrioventricular canal defects. Ann Thorac Surg 2013;95:2086–95. et al. Risk factors for the development of right ventricular failure after left ven- [4] Herrin MA, Zurakowski D, Baird CW, Banka P, Esch JJ, del Nido PJ et al. tricular assist device implantation-a single-centre retrospective with focus on Hemodynamic parameters predict adverse outcomes following biventricu- deformation imaging. Eur J Cardiothorac Surg 2017;52:1069–76. lar conversion with single-ventricle palliation takedown. J Thorac [2] McIlvennan CK, Magid KH, Ambardekar AV, Thompson JS, Matlock DD, Cardiovasc Surg 2017;154:572–82. Allen LA. Clinical outcomes after continuous-flow left ventricular assist de- [5] Bacha E. Borderline left ventricle: trying to see the forest for the trees. vice: a systematic review. Circ Heart Fail 2014;7:1003–13. J Thorac Cardiovasc Surg 2017;154:570–1. [3] Lampert BC, Teuteberg JJ. Right ventricular failure after left ventricular as- [6] Delius RE. 2-V or not 2-V: that is the question.. .plus some musings on sist devices. J Heart Lung Transplant 2015;34:1123–30. thinking out of the box. J Thorac Cardiovasc Surg 2017;154:583–4. [4] Bellavia D, Iacovoni A, Scardulla C, Moja L, Pilato M, Kushwaha SS et al. Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta-analysis of observational studies. Eur J Heart *Corresponding author. Department of Cardiac Surgery, Boston Children’s Fail 2017;19:926–46. Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +1-617- [5] Kiernan MS, Grandin EW, Brinkley M Jr, Kapur NK, Pham DT, Ruthazer R 3557932; fax: +1-617-7300214; e-mail: meena.nathan@cardio.chboston.org et al. Early right ventricular assist device use in patients undergoing (M. Nathan). continuous-flow left ventricular assist device implantation: incidence and risk factors from the interagency registry for mechanically assisted circula- doi:10.1093/ejcts/ezx500 tory support. Circ Heart Fail 2017;10:e003863. Advance Access publication 19 January 2018 Downloaded from https://academic.oup.com/ejcts/article-abstract/53/6/1296/4818262 by Ed 'DeepDyve' Gillespie user on 20 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Abstract

1296 Letters to the Editor / European Journal of Cardio-Thoracic Surgery Reply to Buratto et al. Predictors of right ventricular failure after a,b, a,b a,b implantation of left ventricular assist Meena Nathan *, Sitaram Emani and Pedro J. del Nido Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, devices USA Department of Surgery, Harvard Medical School, Boston, MA, USA a, b a c Orhan Gokalp *, Hasan Iner , Yuksel Besir and Gamze Gokalp Department of Cardiovascular Surgery, Faculty of Medicine, Izmir Katip Received 15 December 2017; accepted 18 December 2017 Celebi University, Izmir, Turkey Department of Cardiovascular Surgery, Adıyaman Education and Research Keywords: Unbalanced atrioventricular septal defects � Biventricular conver- Hospital, Adiyaman, Turkey sion � Outcomes Department of Paediatrics Emergency, Izmir Tepecik Education and Research Hospital, Izmir, Turkey We thank you for the opportunity to respond to the letter by Buratto et al. [1] Received 30 November 2017; accepted 29 December 2017 regarding our article on the mid-term outcomes in unbalanced complete atrioventricular septal defect [2]. Keywords: Right ventricular failure � Mechanical circulatory support � They raised the concern of survivor bias in our biventricular conversion/re- cruitment (BiVC/BiVR) cohort. We would like to point out that the reason we Ventricular assist device � Risk factors chose the date of BiVR or BiVC as the timing of entry into the study was be- cause these patients, particularly BiVC patients, had their initial surgery at out- Congratulations to Boegershausen et al. [1] on their study. As the authors have side institutions. Therefore, obtaining accurate survival data for all unbalanced noted, the incidence of right ventricular failure (RVF) development after im- complete atrioventricular septal defect cases from these institutions was not plantation of left ventricular assist devices (LVADs), which is the most import- feasible. Furthermore, for patients who were cared for from the neonatal ant treatment option for advanced stage heart failure, is not very low. In period at our centre, we were careful to include all patients in whom an ultim- 2–4 various series, this ratio is up to 50% [ ]. As can be seen, RVF development ate BiV circulation was planned in the BiVR group to avoid this bias. rates are extremely high. Even more important subject is the increased mortal- The premise of our article was to show that BiVC with or without BiVR ity rates when RVF develops after LVAD. Therefore, determining the RVF pre- could be achieved with a reasonably low mortality and morbidity, but with dictors after LVAD is frequently discussed as an important topic today. But, in increased rates of reintervention. This is particularly important in certain high- the literature, many different parameters have been emphasized with regard risk groups such as trisomy 21 and heterotaxy, which poorly tolerate single- to the predictive factors for the development of RVF after LVAD. For example, ventricle palliation. As depicted in our supplementary material, fig. S2, 13 of in this study, Boegershausen et al. report that only the basal longitudinal sys- 57 (23%) patients with heterotaxy in the single-ventricle group died when tolic strain of the right ventricular (RV) free wall (PSLSbasal) and the central compared with 3 of 32 (9%) in the BiVC/BiVR group and 4 of 101 (4%) patients venous pressure are predictive factors for RVF. Similarly, another study of in the primary BiV repair group. As we accrue more patients, we will be able 4428 patients reported that high central venous pressure and low right ven- to perform a matched analysis of the three cohorts in the future. 3–6 tricular stroke work index were predictive factors for RVF after LVAD [4]. But, As decision making in this complex cohort continues to evolve [ ], longitu- in the same study, unlike the study by Boegershausen et al., they reported that dinal data on this cohort would provide valuable information to further eluci- international normalized ratio, N-terminal pro-b-type natriuretic peptide, date therapy that is designed to meet the individual patient needs based on moderate-to-severe right ventricular dysfunction, increased right ventricular/ anatomical and physiological parameters. We agree that atrioventricular re- left ventricular ratio and preprocedural ventilator dependence were also pre- gurgitation remains the primary driver of reinterventions in unbalanced com- dictive factors for RVF after LVAD implantation. Another study [5] reported plete atrioventricular septal defect, whether it is single-ventricle palliation, that parameters such as increased pulmonary artery pressure, increased right primary BiV repair or BiVC/BiVR, as presented in table 6 of our article. atrial pressure, decreased stroke volume, preoperative severe tricuspid regur- Abnormalities in both valve morphology and ventricular morphology contrib- gitation and renal replacement therapy were risk factors for RFV, unlike the uted to atrioventricular valve regurgitation in this patient population and study by Boegershausen et al. It is, of course, it is possible to increase these therefore necessitate an individualized approach to repair. examples. However, it is clear that there is no single predictive factor for the development of RVF after LVAD. Another issue that we want to mention is that the main treatments applied by Boegershausen et al. for RVF after LVAD REFERENCES implantation are vasodilator inhalation, prolongation of inotropic treatment and right-sided extracorporeal membrane oxygenation. However, other ven- tricular support systems, such as a Levitronix CentriMag ventricular assist de- [1] Buratto E, Khoo B, Ye XT, Konstantinov IE. Does biventricular conversion vice for the right side, have never been used. How do authors explain the bring survival benefits to patients with an unbalanced atrioventricular sep- reason for this? We believe that sharing the authors’ ideas on this subject will tal defect. Eur J Cardiothorac Surg 2018;53:1295. add value to their study. [2] Nathan M, Emani S, IJsselhof R, Liu H, Gauvreau K, del Nido P. Midterm outcomes in unbalanced atrio ventricular septal defect: successful biven- tricular conversion from single ventricle palliation. Eur J Cardiothorac Surg 2017;52:565–72. REFERENCES [3] Nathan M, Liu H, Pigula FA, Fynn-Thompson F, Emani S, Baird CA et al. Biventricular conversion after single-ventricle palliation in unbalanced [1] Boegershausen N, Zayat R, Aljalloud A, Musetti G, Goetzenich A, Tewarie L atrioventricular canal defects. Ann Thorac Surg 2013;95:2086–95. et al. Risk factors for the development of right ventricular failure after left ven- [4] Herrin MA, Zurakowski D, Baird CW, Banka P, Esch JJ, del Nido PJ et al. tricular assist device implantation-a single-centre retrospective with focus on Hemodynamic parameters predict adverse outcomes following biventricu- deformation imaging. Eur J Cardiothorac Surg 2017;52:1069–76. lar conversion with single-ventricle palliation takedown. J Thorac [2] McIlvennan CK, Magid KH, Ambardekar AV, Thompson JS, Matlock DD, Cardiovasc Surg 2017;154:572–82. Allen LA. Clinical outcomes after continuous-flow left ventricular assist de- [5] Bacha E. Borderline left ventricle: trying to see the forest for the trees. vice: a systematic review. Circ Heart Fail 2014;7:1003–13. J Thorac Cardiovasc Surg 2017;154:570–1. [3] Lampert BC, Teuteberg JJ. Right ventricular failure after left ventricular as- [6] Delius RE. 2-V or not 2-V: that is the question.. .plus some musings on sist devices. J Heart Lung Transplant 2015;34:1123–30. thinking out of the box. J Thorac Cardiovasc Surg 2017;154:583–4. [4] Bellavia D, Iacovoni A, Scardulla C, Moja L, Pilato M, Kushwaha SS et al. Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta-analysis of observational studies. Eur J Heart *Corresponding author. Department of Cardiac Surgery, Boston Children’s Fail 2017;19:926–46. Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +1-617- [5] Kiernan MS, Grandin EW, Brinkley M Jr, Kapur NK, Pham DT, Ruthazer R 3557932; fax: +1-617-7300214; e-mail: meena.nathan@cardio.chboston.org et al. Early right ventricular assist device use in patients undergoing (M. Nathan). continuous-flow left ventricular assist device implantation: incidence and risk factors from the interagency registry for mechanically assisted circula- doi:10.1093/ejcts/ezx500 tory support. Circ Heart Fail 2017;10:e003863. Advance Access publication 19 January 2018 Downloaded from https://academic.oup.com/ejcts/article-abstract/53/6/1296/4818262 by Ed 'DeepDyve' Gillespie user on 20 June 2018

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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Jan 19, 2018

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