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Ann Thorac Surg 2000;69:857
© 2000 The Society of Thoracic Surgeons
Discussion
DR KIT V. AROM (Minneapolis, MN): Since given the large number of Mustard patients who are doing extremely well, which of these patients are likely to benefit from this therapy?
DR MAVROUDIS: There are many patients with Mustard baffles who are doing reasonably well and may in fact have been lost to follow-up. In light of the varied clinical outcomes, it is important for pediatric cardiologists to return these patients and evaluate them for symptoms and exercise intolerance.
In those patients who did not have symptoms, a diagnostic inquiry may reveal developed subpulmonic stenosis, which may represent an opportunity for a one-stage arterial switch conversion, even in the absence of symptoms. This approach admittedly is quite involved but successful in those patients who are well prepared. Thank you very much for your question.
DR ROSS M. UNGERLEIDER (Durham, NC): Gus, I appreciated having had the opportunity to review your manuscript. It is extremely well written and I think the readers of the Annals will enjoy having the opportunity to look at all the data. You have clearly made a career of showing all of us that very complex and difficult patients can be treated successfully and you continue to make wonderful contributions to the field.
I think that there are two contributions from your experience with this difficult group of patients. One is to recognize the problems that they have with neoaortic insufficiency, clearly a problem that was demonstrated in the era when patients received pulmonary artery bands before going to switch, and you have shown us ways to deal with that. You have also addressed the other major issue that brings patients late after atrial baffle operations to medical attention, and that is the development of arrhythmias, and you have added some very sophisticated treatment of that.
As we leave here we have to have a protocol in mind of what to do with these patients, and there is a bit of a conundrum, because it seems that as patients get older, they are worse candidates for conversion with pulmonary artery banding, and I would like to have you address what you would do with these older patients.
Patients over 16 years of age in particular have less likelihood of being able to successfully convert to being candidates for an arterial switch, yet if you think about the era that we are in, there are very few patients in the past 16 years who have received atrial baffle operations. And so in a way you have developed a series of treatments for patients that none of us are likely to see anymore. It is unlikely that we will see younger patients with failed atrial baffle operations who will be good candidates for this. So what do you do in your practice when you see a patient over the age of 16, the patients we are most likely to encounter, the ones who are most likely to be bad candidates for this, what is your protocol? Do you band them anyhow in the hopes that you may occasionally be able to convert one to an atrial switch or do you give them a transplant?
DR MAVROUDIS: Thank you for your question. You are quite right that age over 16 years in these patients has been determined to be a risk factor for death. Left ventricular function may be an important prognostic indicator for survival both before and after the pulmonary artery band and should be critically evaluated despite the patient’s age. Of course, the only subsequent alternative is cardiac transplantation, which will be a significant part of the therapy in these patients.
DR W. STEVES RING (Dallas, TX): My question is really an extension of Ross’s. For patients who present with severe right heart failure, often with severe tricuspid or systemic AV valve insufficiency, how do you decide which patients to band and switch versus transplant?
DR MAVROUDIS: I think that we would look at left ventricular function in these patients. If left ventricular function were favorable, then we would proceed with the pulmonary artery band despite the degree of right ventricular dysfunction and tricuspid regurgitation. Of course, we can then evaluate the effect of pulmonary artery banding on left ventricular function and proceed accordingly. Thus far, we have had no mortality from pulmonary artery band and we believe that our approach is reasonable.
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