REOPERATIVE CARDIAC SURGERY IN ADULT CONGENITAL HEART DISEASE PATIENTS



Bassem N. Mora, M.D., Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA

Objectives: To discuss the spectrum of anomalies which require reoperative cardiac surgery in the adult congenital heart disease (ACHD) patient.

Background: There are >1,000,000 ACHD patients in North America. Cardiac surgery in those is divided into cases involving great complexity (e.g. cyanotic lesions, single ventricle, double-outlet ventricle), moderate complexity (e.g. anomalous pulmonary venous drainage, atrioventricular septal defects, coarctation, Ebstein’s, right ventricular (RV) or left ventricular (LV) outflow tract obstruction, non-secundum atrial septal defect (ASD), pulmonary regurgitation (PR) or stenosis, tetralogy of Fallot, complicated ventricular septal defect (VSD)), and simple complexity (e.g. isolated congenital valve stenosis or insufficiency, simple VSD, secundum ASD).

Results: The majority of reoperations for ACHD patients involve reoperative valve replacement, especially in the pulmonary position. Often, more than one valve is addressed at reoperation, the most common being pulmonary valve replacement and tricuspid valve repair. Pulmonary valve replacement is indicated for severe PR with symptoms, RV dysfunction/enlargement, arrhythmias, or significant tricuspid insufficiency. Indications for reoperative valve repair or replacement include worsening CHD valvar stenosis or regurgitation, which should undergo valve therapy as in patients with non-congenital valve disease. Patients may also present with subaortic stenosis, and should undergo resection if operative criteria are met. Other operations include reoperations on the RV outflow tract for obstruction from severe valvar obstruction who require surgery if percutaneous therapy is contraindicated. Subvalvar stenosis, supravalvar stenosis and double-chambered RV require surgery. Only a minority of single ventricle patients will require reoperation in adulthood, most commonly either implantation of an epicardial pacemaker/defibrillator, or heart transplantation.

Conclusions: Reoperative cardiac surgery for ACHD patients involves a wide spectrum of lesions with established indications and reasonable morbidity and mortality. As more CHD patients survive into adulthood, the variety of reoperative cardiac surgical repairs will increase in complexity.