Papers by Massimo Padalino
European Journal of Echocardiography, 2021
Many centers have recently adopted pulmonary valve (PV) preservation procedures to prevent the de... more Many centers have recently adopted pulmonary valve (PV) preservation procedures to prevent the detrimental long-term effects of chronic pulmonary regurgitation after tetralogy of Fallot (ToF) repair. The aim of our study was to investigate pulmonary valve (PV) and right ventricular function by echocardiography in paediatric patients with repaired Tetralogy of Fallot (ToF), comparing PV preservation surgical strategies to standard transannular patch (TAP) repair. All patients undergoing transatrial-transpulmonary repair for ToF at our institution between January 2007 and May 2020 were reviewed retrospectively. Patients were divided into 2 main groups, according to the different techniques used: patients undergoing a PV preservation strategy and patients undergoing TAP repair. All patients underwent standard echo-Doppler study including RV end-diastolic area (RVEDA), end-systolic area (RVESA), fractional area change (FAC) and TAPSE; PR was assessed by Color Doppler, continuous-wave (CW) Doppler and derived parameters such as pressure half time (PHT) and pulmonary regurgitation (PR) index. By speckle tracking we measured also, in a subgroup of patients, right atrial strain (RAS), RV and left ventricle (LV) global longitudinal strain (RVGLS, LVGLS) and their time to peak (TTP) values. Overall, 82 patients underwent a successful PV preservation strategy while 34 underwent a standard TAP repair. At index surgery, BSA (0.31 ± 0.1 m2, P = 0.3), age (4.8 ± 0.3 months, P = 0.5) and preoperative PV Z-score (-3.20 ± 0.1, P = 0.1) did not different between groups. Five-year actuarial freedom from moderate/severe PV regurgitation was significantly higher in the PV preservation group compared to the TAP (61.3% [95% CI: 48-73%] vs 25.9% [95% CI: 12-43%], respectively; p = 0.02). After adjusting for age, gender, BSA, and type of PV, the use of a TAP was still significantly associated with an increased risk for PV regurgitation at follow up (HR: 1.85, 95% CI: 1.09, 3.15; p = 0.02). At a mean follow-up of 6.9 ± 0.3 years, patients undergoing PV preservation showed an increased right ventricular fractional area change (46.9 ± 0.8% vs 42.5 ± 1.7%, P < 0.001) and tricuspid annular plane systolic excursion (TAPSE) z-score (-3.36 ± 0.3% vs -4.7 ± 0.4%, P = 0.005), while maintaining better PV competence in terms of pulmonary regurgitation index (87.9 ± 1.2% vs 82.7 ± 2.4%, P = 0.02). At speckle tracking subanalysis, patients undergoing PV preservation (n= 23), compared to the TAP group (n = 13) showed also higher values of RAS (37.5 ± 6.0% vs 29.3 ± 8.2% , P < 0.006), shorter right TTP (319 ± 39ms vs 357.5 ± 45.2 ms, P < 0.01) and higher values of LVGLS (-20,6 ± 4,2% vs -17.5 ± 3.0, P < 0.03). CONCLUSIONS: Surgical repair of ToF with PV preservation provides excellent outcomes in terms of PV competence and right ventricular function and should be advocated whenever possible.
Interactive Cardiovascular and Thoracic Surgery, Mar 24, 2020
OBJECTIVES: This study aimed to evaluate the outcomes and feasibility of different techniques of ... more OBJECTIVES: This study aimed to evaluate the outcomes and feasibility of different techniques of reconstruction of the right ventricular outflow tract (RVOT) in surgical repair of truncus arteriosus. We retrospectively reviewed all consecutive patients with truncus arteriosus who underwent successful surgical repair in our centre between 1994 and 2017. We analysed late results according to the type of RVOT repair. We collected data from 29 survivors after truncus arteriosus repair. Six (20%) of them were affected by DiGeorge syndrome. The RVOT reconstruction was achieved using a valved conduit in 58.6%, while a direct right ventricle-pulmonary artery (RV-PA) anastomosis, with or without the interposition of the left atrial appendage, was performed in the remaining. At a median follow-up time of 7.9 years (interquartile range 1.8-13.1), 6 patients (3 affected by DiGeorge syndrome) died. Between the 2 groups, there were no differences in terms
European Heart Journal, Oct 3, 2017
Treatment decisions in patients with scimitar syndrome (SS) are often challenging, especially in ... more Treatment decisions in patients with scimitar syndrome (SS) are often challenging, especially in patients with isolated SS who are often asymptomatic and who might be diagnosed accidentally. We queried a large multiinstitutional registry of SS patients to evaluate the natural history of this condition and to determine the efficacy of surgical treatment in terms of survival and clinical status.
Giornale italiano di cardiologia, 2020
European Journal of Cardio-Thoracic Surgery, Jul 11, 2022
OBJECTIVES Many centres have recently adopted pulmonary valve (PV) preservation (PVP) during tetr... more OBJECTIVES Many centres have recently adopted pulmonary valve (PV) preservation (PVP) during tetralogy of Fallot (ToF) repair. We sought to identify the midterm functional outcomes and risk factors for pulmonary regurgitation after this procedure. METHODS All patients undergoing PVP during transatrial–transpulmonary repair for ToF with PV stenosis at our institution between January 2007 and December 2020 were reviewed. RESULTS Overall, 73 patients were included. At the index surgery, the body surface area was 0.31 ± 0.04 m2, the age was 4.9 ± 2.9 months and the preoperative PV z-score was -3.02 ± 1.11. At a mean follow-up of 5.3 ± 2.7 years, the fractional area change of the right ventricle (RV) was 47.1 ± 5.2%, and the tricuspid annular plane systolic excursion z-score was -3.31 ± 1.89%. The 5-year freedom from moderate/severe PV regurgitation was 61.3% [95% confidence interval (CI): 48, 73%]. There was a significant correlation between RV function and moderate/severe PR at follow-up (R2: 0.08; P = 0.03). A comparison with a group of patients undergoing a transannular patch procedure (N = 33) showed superior outcomes for patients with PVP. The preoperative PV z-score and the degree of PR at discharge were risk factors for the early development of moderate/severe PR at follow-up [hazard ratio (HR): 0.64; 95% CI: 0.48, 0.86, P = 0.01 and HR: 2.31; 95% CI: 1.00, 5.36, P = 0.04, respectively]. A preoperative PV annulus z-score ≤ -2.85 was found to be predictive for moderate/severe PR at 5 years after PVP (HR: 2.56; 95% CI: 1.31, 5.01, P = 0.002). CONCLUSIONS A pulmonary valve preservation strategy during tetralogy of Fallot repair should always be attempted. However, a preoperative PV annulus z-score &lt; -2.85 and moderate/severe regurgitation upon discharge are risk factors for midterm pulmonary regurgitation.
European Journal of Cardio-Thoracic Surgery, Oct 23, 2021
OBJECTIVES Fontan patients are known to suffer from clinical attrition over the years, which ha... more OBJECTIVES Fontan patients are known to suffer from clinical attrition over the years, which has been characterized as Fontan failure. We sought to evaluate the clinical outcomes of such Fontan patients undergoing surgical management in a 25-year, single-centre experience. METHODS A retrospective single-centre analysis of patients undergoing surgical treatment for failing Fontan between 1995 and 2020, including any reoperations when ventricular function was preserved, or a heart transplant (HTx), when ventricular contractility was impaired. We analysed survival, indications for surgery and early and late complication rates. RESULTS We collected 30 patients (mean age 24.7 years) who required surgery after a mean time of 19.3 years from the original Fontan procedure: Fontan conversion in 21 (70%, extracardiac conduit in 19, lateral tunnel in 2), a HTx in 4 (13.3%) and other reoperations in 5 (16.7%). The most common indications for surgery were tachyarrhythmias (63.3%) and severe right atrial dilatation (63.3%). Overall survival at the 1-, 5-, 10- and 20-year follow-up examinations were 75.9% [95% confidence interval (CI): 91.4–60.4%], 75.9% (95% CI: 91.4–60.4%), 70% (95% CI: 78–52%) and 70% (95% CI: 78–52%), respectively. The most frequent complications were postoperative tachyarrhythmias (50%) and late Fontan-associated liver disease (56.5%). HTx and Fontan conversion provided comparably good outcomes compared to other reoperations (P = 0.022). CONCLUSIONS Surgery for failing Fontan can be performed effectively with overall good long-term survival. However, early and late morbidities are still a significant burden. Because other reoperations performed when patients presented with contraindications for a HTx have carried high mortality, close clinical follow-up is mandatory, and an earlier indication for Fontan conversion or a HTx is advisable to optimize outcomes.
The Journal of Thoracic and Cardiovascular Surgery, Apr 1, 2012
Extracorporeal membrane oxygenation (ECMO) is commonly used in children to allow recovery from po... more Extracorporeal membrane oxygenation (ECMO) is commonly used in children to allow recovery from post-cardiac surgical heart failure that is refractory to medical therapy or resuscitation. The overall survival after ECMO has been reported to be between 35% and 51% in institutions where a dedicated 24-hour in-house ECMO team is part of the surgical program. In pediatric cardiac centers with average volumes, however, a specialized ECMO team is often not available and a greater effort must be made to provide the best outcome for patients requiring mechanical circulatory support. We describe an easy and reproducible technical solution for weaning patients from ECMO support. This method proved to be a safe and an effective solution in our institution, where a dedicated 24-hour in-house ECMO team is lacking.
Journal of Cardiovascular Medicine, Nov 1, 2018
Background and aim: To determine whether the right ventricle outflow tract (RVOT) type of reconst... more Background and aim: To determine whether the right ventricle outflow tract (RVOT) type of reconstruction is correlated to different outcomes in long term results in patients who survived after surgical repair of truncus arteriosus (TA). Methods: We retrospectively reviewed the outcomes of 30 patients with TA who underwent successful surgical repair in our center between 1994–2017. We analyzed late results according to the type of RVOT repair. Results: Among 30 survivors after TA repair, 6 (20%) were affected by DiGeorge syndrome. The RVOT reconstruction was achieved by means of a conduit (Contegra or Homograft) in 53.6%. In the remaining group of patients, a direct right ventricle-pulmonary artery anastomosis ± interposition of left atrial appendage (LAA) was performed. At a median follow-up time of 12 years (range 4 months-23 years, 93% complete), 6 patients (3 affected by DiGeorge syndrome) died late. Between RVOT groups, there was no difference in terms of late mortality; however, the use of a conduit was significantly associated with a higher risk for reoperation (p 0.021; OR 8.80, 1.35–57.4, Figure 1). Conclusions: Post surgical history of patients with TA is characterized by a higher incidence of late adverse events when RVOT is reconstructed by means of a conduit. Reconstruction of the RVOT with a direct anastomosis and/or left atrial appendage interposition reduces effectively the need for reoperation in long term.
The Annals of Thoracic Surgery, Mar 1, 2016
Journal of Clinical Medicine, Jan 6, 2023
Objectives: The surgical technique for right partial anomalous pulmonary venous return (PAPVR) de... more Objectives: The surgical technique for right partial anomalous pulmonary venous return (PAPVR) depends on the location of the anomalous pulmonary veins (PVs). With this in mind, we sought to evaluate the impact of 3D heart segmentation and reconstruction on preoperative surgical planning. Methods: A retrospective study was conducted on all patients who underwent PAPVR repair at our institution between January 2018 and October 2021; three-dimensional segmentations and reconstructions of all the heart anatomies were performed. A score (the PAPVR score) was established and calculated using two anatomical parameters (the distance between the most cranial anomalous PV and the superior rim of the sinus venosus defect/the sum of the latter and the distance between the PV and the azygos vein) to predict the type of correction. Results: A total of 30 patients were included in the study. The PAPVR score was found to be a good predictor of the type of surgery performed. A value > 0.68 was significantly associated with a Warden procedure (p < 0.001) versus single/double patch repair. Conclusions: Three-dimensional heart segmentations and reconstructions improve the quality of surgical planning in the case of PAPVR and allow for the introduction of a score that may facilitate surgical decisions on the type of repair required.
Journal of Cardiovascular Development and Disease, Sep 23, 2021
Fontan-associated liver disease (FALD) is an arising clinical entity that can occur long after a ... more Fontan-associated liver disease (FALD) is an arising clinical entity that can occur long after a successful Fontan operation for correction of single ventricle (SV) congenital heart disease (CHD). Occurrence of FALD is characterized by liver cirrhosis and other hepatic complications, and determinates an increased morbidity and mortality. Currently, there is no consensus on how to stage FALD. We report here our experience by an observational study in 52 patients with SV-CHD after Fontan operation that were recruited through a period of 36 ± 9.3 months. All cases underwent lab tests and liver and cardiac imaging evaluation, including liver stiffness (LS) measurement by transient elastography (TE) (FibroScan ® ). According to selective criteria for liver disease, we identified 23/43 (53.5%) cases with advanced FALD that showed: older age (p < 0.05), larger hepatic and cava veins diameter (p < 0.05), worsened NYHA class (p < 0.05), abnormal lymphocytes (p < 0.01), platelet count (p < 0.05), and GGT, prothrombin time (INR), albumin and cystatin C levels (p < 0.05), with respect to cases without advanced FALD. LS values were significantly increased in cases with advanced FALD, at cut-off values higher than 22 kPa (p < 0.001). LS, and its combined score with spleen diameter and platelet count (LSPS) successfully helped to detect 100% of cases with portal hypertension (p < 0.001). In conclusion, LS can be effective to stage FALD and to uncover cases with severe risk of complications, avoiding higher morbidity and mortality related to advanced FALD.
Journal of Cardiac Surgery, Apr 12, 2016
Background and Aim of the Study: Congenital mitral valve (MV) dysplasia is a relatively rare and ... more Background and Aim of the Study: Congenital mitral valve (MV) dysplasia is a relatively rare and highly complex cardiac disease. We present our results and illustrate the techniques used to repair these valves. Methods: Between 1972 and 2014, 100 consecutive patients underwent surgical repair of congenital MV dysplasia at our institution. Predominant MV regurgitation was present in 53 patients (53%) whereas mitral stenosis was prevalent in 47 (47%). Results: There were five early (5%) and eight late deaths (9%). Actuarial survival was 95%, 94%, and 93% at 5, 10, and 20 years, respectively. Sixteen patients (18%) required reintervention due to subsequent MV dysfunction. Actuarial freedom from reintervention for MV dysfunction was 95%, 92%, and 89% at 5, 10, and 20 years, respectively. Conclusions: The mechanism underlying the valve dysfunction in congenital mitral valve dysplasia is multifactorial and requires the application of a variety of surgical techniques for repair.
Pacing and Clinical Electrophysiology, Mar 4, 2015
BackgroundClinical utility of remote monitoring of implantable cardiac devices has been previousl... more BackgroundClinical utility of remote monitoring of implantable cardiac devices has been previously demonstrated in several trials in the adult population. The aim of this study was to assess the clinical utility of remote monitoring in a pediatric population undergoing pacemakers implantation.MethodsThe study population included 73 consecutive pediatric patients who received an implantable pacemaker. The remote device check was programmed for every 3 months and all patients had a yearly out‐patient visit. Data on device‐related events, hospitalization, and other clinical information were collected during remote checks and out‐patient visits.ResultsDuring a mean follow‐up of 18 ± 10 months, 470 remote transmissions were collected and analyzed. Two deaths were reported. Eight transmissions (1.7%) triggered an urgent out‐patient visit. Twenty percent of transmissions reported evidence of significant clinical or technical events. All young patients and their families were very satisfied when using remote monitoring to replace out‐patient visits.ConclusionsThe ease in use, together with satisfaction and acceptance of remote monitoring in pediatric patients, brought very good results. The remote management of our pediatric population was safe and remote monitoring adequately replaced the periodic out‐patient device checks without compromising patient safety.
European Journal of Cardio-Thoracic Surgery, Mar 20, 2019
We sought to describe early and late outcomes in a large surgical series of patients with anomalo... more We sought to describe early and late outcomes in a large surgical series of patients with anomalous aortic origin of coronary arteries. We performed a retrospective multicentre study including surgical patients with anomalous aortic origin of coronary arteries since 1991. Patients with isolated high coronary takeoff and associated major congenital heart disease were excluded. We collected 156 surgical patients (median age 39.5 years, interquartile range 15-53) affected by anomalous right (67.9%), anomalous left (22.4%) and other anatomical abnormalities (9.6%). An interarterial course occurred in 86.5%, an intramural course in 62.8% and symptoms in 85.9%. The operations included coronary unroofing (56.4%), reimplantation (19.2%), coronary bypass graft (15.4%) and other (9.0%). Two patients with preoperative cardiac failure died postoperatively (1.3%). All survivors were discharged home in good clinical condition. At a median follow-up of 2 years (interquartile range 1-5, 88.5% complete), there were 3 deaths (2.2%), 9 reinterventions in 8 patients (5 interventional, 3 surgical); 91.2% are in New York Heart Association functional class < _ II, but symptoms persisted in 14.2%; 48.1% of them returned to sport activity. On Kaplan-Meier analysis, event-free survival at follow-up was 74.6%. Morbidity was not significantly different among age classes, anatomical variants and types of surgical procedures. Furthermore, return to sport activity was significantly higher in younger patients who participated in sports preoperatively.
European Journal of Cardio-Thoracic Surgery, Dec 1, 2002
The publisher regrets that when the above article was printed, there were a series of errors in t... more The publisher regrets that when the above article was printed, there were a series of errors in the text and in Table . The full correct article is printed on the following pages.
Cardiology in The Young, Mar 17, 2023
Journal of Clinical Medicine
Pediatric heart failure (HF) is an important clinical condition with high morbidity and mortality... more Pediatric heart failure (HF) is an important clinical condition with high morbidity and mortality. Compared to adults, pediatric HF shows different etiologies characterized by different physiology, a different clinical course, and deeply different therapeutic approaches. In the last few years, new drugs have been developed and new therapeutic strategies have been proposed with the goal of identifying an individualized treatment regimen. The aim of this article is to review the new potential drugs and non-pharmacological therapies for pediatric heart failure in children.
European Heart Journal
Objectives the physio-pathological role of the morphological ventricular dominance (left, FSLV; r... more Objectives the physio-pathological role of the morphological ventricular dominance (left, FSLV; right, FSRV), and the hemodynamic contribute of an accessory ventricular chamber (AVC), in patients with functional single ventricle (FSV) after Fontan operation are still uncertain due to conflicting data. We analyzed a cohort of Fontan patients to assess and correlate such anatomical features to late clinical outcomes. Methods We enrolled all patients after a Fontan procedure who underwent a cardiac magnetic resonance (CMR) and a cardiopulmonary exercise test (CPET) in the previous 3 years. Clinical, CMR and CPET data from the last follow-up visit were retrieved to analyze whether the size of any AVC and the morphological ventricular dominance (FSLV vs FSRV) were correlated with clinical outcomes (NYHA, need for reinterventions or cardiac transplantation, mortality, arrhythmias, liver disease and protein-losing enteropathy) and functional parameters (including FSV ejection fraction and ...
The International Journal of Artificial Organs
Management of end-stage heart failure (ESHF) in children with congenital heart disease is challen... more Management of end-stage heart failure (ESHF) in children with congenital heart disease is challenging. We report a step-by-step hybrid procedure (transcatheter pulmonary valve and left mechanical assist device implantations) in a child with ESHF after repair of tetralogy of Fallot, as an effective bridge to transplant strategy.
Circulation, 2020
Introduction: Many centers have recently adopted pulmonary valve (PV) preservation procedures to ... more Introduction: Many centers have recently adopted pulmonary valve (PV) preservation procedures to prevent the detrimental long-term effects of chronic pulmonary regurgitation after tetralogy of Fallot (ToF) repair. Hypothesis: Here, we investigated PV and right ventricular function after PV preservation surgical strategies compared to standard transannular patch (TAP) repair. Methods: All patients undergoing transatrial-transpulmonary repair for ToF with PV stenosis at our institution between January 2007 and May 2020 were reviewed retrospectively. Patients were divided into 2 main groups, according to the different techniques used: patients undergoing a PV preservation strategy and patients undergoing TAP repair. Results: Overall, 82 patients underwent a successful PV preservation strategy while 34 underwent a standard TAP repair. At index surgery, BSA (0.31±0.1 m 2 , P=0.3), age (4.8±0.3 months, P=0.5) and preoperative PV Z-score (-3.20±0.1, P=0.1) did not differ between groups. Fi...
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Papers by Massimo Padalino