Optimal Use of Z-Scores to Preserve the Pulmonary Valve Annulus During Repair of Tetralogy of Fallot

2018 ◽  
Vol 9 (3) ◽  
pp. 285-288 ◽  
Author(s):  
Mark Nelson Awori ◽  
Nikita P. Mehta ◽  
Frederick O. Mitema ◽  
Naomi Kebba
Keyword(s):  
Pulmonary Valve ◽  
Operative Procedure ◽  
Data Sets ◽  
Z Score ◽  
Data Set ◽  
Death Studies ◽  
Transannular Patch ◽  
Z Scores ◽  
Different Populations ◽  
Valve Annulus

Objective: The size of the pulmonary annulus measured as a z-score is often used to determine when to insert a transannular patch (TAP). Multiple “cutoffs” are quoted in the literature; this could lead to inappropriate insertion. We aimed to determine whether the use of z-scores derived from different populations may have contributed to the varied “cutoffs” quoted. Methods: PubMed was searched using the terms: “tetralogy,” “Fallot,” “transannular,” “patch,” “mortality,” and “death.” Studies published between January 1, 2005, and October 5, 2017, were included; studies without participants under the age of 18 years and studies that did not describe the operative procedure were excluded. Results: Of 52 papers retrieved, 19 were included representing 2,500 repaired patients; 1,371 (54.8%) had a TAP. Five (26.3%) papers representing 638 patients (25.5%) quoted a z-score “cutoff” and what data set was used; “cutoffs” ranged from −2 to −4 and were derived from 2 different data sets. Three studies quoted a data set that has been shown in previous work to be problematic; the only quoted “cutoffs” of −4 were from two of these studies. Conclusions: Surprisingly few (26.3%) studies mention what pulmonary annulus size “cutoff” was used to decide when to insert a TAP. Z-scores derived from different populations were used by different studies and it is possible that this may have contributed to the varied “cutoffs’ quoted. Recommendations to perform valve-sparing surgery in pulmonary annuli as small as −4 may not be warranted. Future papers should record “cutoffs” employing recommended z-score data set.

Optimal Z-Score Use in Surgical Decision-Making in Pulmonary Atresia With Intact Ventricular Septum

2017 ◽  
Vol 8 (3) ◽  
pp. 385-388 ◽  
Author(s):  
Mark Nelson Awori ◽  
Nikita P. Mehta ◽  
Frederick O. Mitema ◽  
Naomi Kebba
Keyword(s):  
Tricuspid Valve ◽  
Pulmonary Atresia ◽  
Ventricular Septum ◽  
Data Sets ◽  
Intact Ventricular Septum ◽  
Z Score ◽  
Biventricular Repair ◽  
Tricuspid Valve Annulus ◽  
Z Scores ◽  
Valve Annulus

Objectives: In the surgical treatment of pulmonary atresia with intact ventricular septum, the size of the tricuspid valve annulus (as measured by z-scores) has emerged as a significant factor in deciding which repair to perform. Various tricuspid valve annulus z-scores are reported as “cutoffs” for successful biventricular repair. We aimed to determine whether the use of different z-score data sets contributed to the gross variation in “cutoffs” for successful biventricular repair reported in the literature. Methods: A single search was made of PubMed using the “advanced” setting with the following search terms: pulmonary, atresia, intact, septum, z, and score. The filters “title” and “title/abstract” were used for the first four and last two terms, respectively; the instruction “AND” combined all terms. Articles that identified which z-score data set was used in patients with biventricular repairs were included. Results: From 13 articles, 1,392 patients were studied, 410 (29.5%) of which achieved biventricular repair. Three z-score data sets were quoted; mean tricuspid valve annulus z-scores in biventricular repair patients ranged between −0.53 and −5.1. After correcting for discrepancies between z-score data sets, no study reported a mean tricuspid valve annulus z-score <−2.8 in biventricular repair patients and 83.3% reported mean tricuspid valve annuli z-scores >−1.7. Conclusion: The use of varied tricuspid valve annuli z-score data sets may have contributed to gross variations in reported “cutoffs” for successful biventricular repair. This could lead to inappropriate surgical pathway allocation.

Echocardiographic factors discriminating biventricular versus univentricular approach in the foetus with borderline left ventricle

2014 ◽  
Vol 25 (5) ◽  
pp. 941-950 ◽  
Author(s):  
David W. Jantzen ◽  
Sarah K. Gelehrter ◽  
Sunkyung Yu ◽  
Janet E. Donohue ◽  
Carlen G. Fifer
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Single Ventricle ◽  
Left Ventricular ◽  
Z Score ◽  
Biventricular Repair ◽  
Z Scores ◽  
Valve Annulus ◽  
Single Ventricle Palliation ◽  
Dimension Ratio

AbstractBackground: The term “borderline left ventricle” describes a small left heart that may be inadequate to provide systemic cardiac output and implies the potential need for a single-ventricle palliation. The aim of this study was to identify foetal echocardiographic features that help discriminate which infants will undergo single-ventricle palliation versus biventricular repair to aid in prenatal counselling. Methods: The foetal database at our institution was searched to identify all foetuses with borderline left ventricle, as determined subjectively by a foetal cardiologist, from 2000 to 2011. The foetal images were retrospectively analysed for morphologic and physiologic features to determine which best predicted the postnatal surgical choice. Results: Of 39 foetuses identified with borderline left ventricle, 15 were planned for a univentricular approach, and 24 were planned for a biventricular approach. There were significant differences between the two outcome groups in the Z-scores of the mitral valve annulus, left ventricular end-diastolic dimension, aortic valve annulus, and ascending aorta diameter (p<0.05). With respect to discriminating univentricular outcomes, cut-offs of mitral valve Z-score ⩽−1.9 and tricuspid:mitral valve ratio ⩾1.5 were extremely sensitive (100%), whereas a right:left ventricular end-diastolic dimension ratio ⩾2.1 provided the highest specificity (95.8%). Conclusion: In foetuses with borderline left ventricle, a mitral valve Z-score ⩾−1.9 or a tricuspid:mitral valve ratio ⩽1.5 suggests a high probability of biventricular repair, whereas a right:left ventricular end-diastolic dimension ratio ⩾2.1 confers a likelihood of single-ventricle palliation.

scholarly journals Comparison between the Early Outcome of Fallot Repair with Preservation of the Pulmonary Valve Annulus versus Transannular Patch Repair

2019 ◽  
Vol 87 (12) ◽  
pp. 5065-5073
Author(s):  
MOHAMED ATTYA, M.D.; AMR BASTAWISY, M.D. ◽  
WALEED ISMAIL, M.D. MICHEAL W. REFAAT, M.B.B.Ch.
Keyword(s):  
Pulmonary Valve ◽  
Patch Repair ◽  
Early Outcome ◽  
Transannular Patch ◽  
Valve Annulus

scholarly journals Total Correction of Tetralogy of Fallot: Effect of Transannular Patch on Early Outcome

2018 ◽  
Vol 10 (2) ◽  
pp. 194-200 ◽  
Author(s):  
Md Azizul Islam Khan ◽  
Kazi Abul Hasan ◽  
ABM Abdus Salam ◽  
Quazi Abul Azad ◽  
Sadia Sajmin Siddiqua ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Tetralogy Of Fallot ◽  
Pulmonary Valve ◽  
Total Correction ◽  
Early Outcome ◽  
Transannular Patch ◽  
Group A ◽  
Valve Annulus ◽  
Z Value ◽  
Group B

Background: It is arguable whether presence of transannular patch is itself a risk factor for adverse outcome at total correction(repair) of tetralogy of Fallot (TOF).This study intended to compare early outcome of intact pulmonary valve annulus with transannular patching at repair of TOF.Methods: This prospective observational study was conducted from July 2015 to January 2017.40 patients were enrolled in 2 groups- A & B.In group A,14 patients with intact pulmonary valve annulus& in group B, 26 patients with transannular patch. The diameter of pulmonary valve annulus was measured with Hegar dilator and Z value of the measured diameter were calculated from an established published nomogram. Transannular patch was placed if Z value of annular diameter < -3 or post repair operative room right ventricle/left ventricle pressure ratio (P RV/LV)> 0.7.Patients were monitored in the intensive care unit(ICU) and followed up for 3 months following discharge from hospital.Results: Patients of group B were younger and smaller body surface area. There were no significant difference of preoperative variables in terms of peripheral arterial oxygen saturation(SpO2%), haematocrit (%),NYHA functional class, right ventricular hypertrophy, and level & severity of right ventricular out flow tract obstruction. Early out come in terms of duration of ventilation time, inotrope support & ICU stay; post operative morbidity & mortality were more in group B than group A patients. Pulmonary regurgitation & right ventricular dysfunction following transannular patch at repair of TOF plays important role for adverse outcome.Conclusion: Transannular patch is associated with higher morbidity and mortality in total correction of Tetralogy of Fallot.Cardiovasc. j. 2018; 10(2): 194-200

scholarly journals Predictors of Transannular Patch Enlargement in Tetralogy of Fallot Repair; a Single Center Experience

2021 ◽  
pp. 1-10
Author(s):  
Petronila N. Tabansi ◽  
Sanjukta Bose Barghava ◽  
Atul Prabhu ◽  
Uchenna Onubogu ◽  
Prashant Takhur ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Tetralogy Of Fallot ◽  
Pulmonary Valve ◽  
Heart Diseases ◽  
Univariate Analysis ◽  
Surgical Techniques ◽  
Categorical Variables ◽  
Z Score ◽  
Transannular Patch ◽  
Aortic Valve Diameter

Introduction: Tetralogy of Fallot (ToF) accounts for 5% to 10% of all congenital heart diseases (CHD) and is the commonest cyanotic heart disease beyond the neonatal period. Surgical repair is directed at relieving the right ventricular outflow tract obstruction (RVOTO) and has evolved over time from the frequent use of transannular patch enlargement (TAPE) of the pulmonary valve annulus (PVA), to the more recent trend of conservation of the PVA using valve-sparing surgical techniques. This is latter technique is preferred to avoid serious and progressive complications associated with TAPE. The decision on TAPE is primarily base on the PVA z-score which is subject to variability across different surgeons and centers; as such, other parameters have been proposed and some determined to be better predictors of TAPE in ToF surgeries. Aim: To determine the predictors of transannular patch enlargement in ToF surgeries in a CHD specialist center.  Methods: This was a retrospective analysis of all patient with ToF who presented at a major CHD center - the Sri Sathya Sai Sanjeevani Hospital (SSSSH), in Raipur India between July 2018 to April 2019. Parameters sought and obtained included patients’ demographics, anthropometry and echocardiographic parameters. The z-scores and other derivable variables were calculated and entered into a data base. Analysis using SPSS was done. Descriptive statistics was used to represent continuous variables in means, medians and ranges while categorical variables were represented in bar chats. Analysis of variance was done among group means. Results: There were 135 patients with age range from 7months to 199 months, with more males 89 (65.9%). TAPE was done in 36(26.7%). The aortic valve diameter (18.3 Vs 20mm, p=0.037), Pulmonary valve diameter (10.1 vs 12.0mm, P=0.003), and pulmonary valve Z-score (-2.48 vs -1.47, p=0.011) were significantly smaller for the group that received TAPE. Univariate analysis of the great artery ratio (PVA/AoV) did not significantly predict TAPE use. However, a GA ratio of < 0.54 was significantly associated with a higher likelihood of having TAPE, odds ratio 2.37(CI: 1.47 to 3.9). Multivariate logistic for use of TAPE in TOF explained 15% (R2) of the variance seen in the use of TAPE and correctly predicted 70.8% of the children with TOF who received TAPE. The area under curve for predictability of who received TAPE was 65% (95% CI 53.5% to 76.6. Conclusion: The PVA diameter, Aortic valve diameter and PVA z-score are predictors of TAPE. A GA ratio < 0.54 increases the likelihood of TAPE. Clinical parameters are not useful as determinants of TAPE.

scholarly journals The effect of Z-Score standardization (normalization) on binary input due the speed of learning in back-propagation neural network

2019 ◽  
Vol 1 (3) ◽  
pp. 42-48
Author(s):  
Mohammed Z. Al-Faiz ◽  
Ali A. Ibrahim ◽  
Sarmad M. Hadi
Keyword(s):  
Neural Network ◽  
Input Data ◽  
Back Propagation ◽  
Large Data ◽  
Back Propagation Neural Network ◽  
Data Sets ◽  
Z Score ◽  
Data Set ◽  
The Neural Network ◽  
Time Required

The speed of learning in neural network environment is considered as the most effective parameter spatially in large data sets. This paper tries to minimize the time required for the neural network to fully understand and learn about the data by standardize input data. The paper showed that the Z-Score standardization of input data significantly decreased the number of epoochs required for the network to learn. This paper also proved that the binary dataset is a serious limitation for the convergence of neural network, so the standardization is a must in such case where the 0’s inputs simply neglect the connections in the neural network. The data set used in this paper are features extracted from gel electrophoresis images and that open the door for using artificial intelligence in such areas.

Applicability and Durability of Valve-Sparing Tetralogy of Fallot Repair

2021 ◽  
Vol 12 (5) ◽  
pp. 628-634
Author(s):  
Elizabeth H. Stephens ◽  
Brian L. Wolfe ◽  
Abhinav A. Talwar ◽  
Angira Patel ◽  
Joseph A. Camarda ◽  
...  
Keyword(s):  
Tetralogy Of Fallot ◽  
Pulmonary Valve ◽  
Demographic Data ◽  
Right Ventricular Outflow Tract ◽  
Patch Repair ◽  
Transannular Patch ◽  
Z Scores ◽  
Valve Sparing ◽  
Tetralogy Of Fallot Repair

Background: Although valve-sparing repair remains ideal for patients with tetralogy of Fallot, the durability of valve-sparing repair and which patients may have been better served with a transannular patch remain unclear. Methods: Retrospective review was performed of tetralogy of Fallot operations at our institution from January 2008 to December 2018. Standard demographic data were collected, including echocardiographic parameters, operative details, and clinical outcomes. Statistical analysis was performed comparing the transannular patch and valve-sparing repair groups. Results: Sixty-seven patients underwent tetralogy of Fallot repair with a median age of 4.5 (3.2-6.0) months and weight of 5.8 (5.2, 6.7) kg. Seventeen (25%) patients underwent transannular patch repair and 50 (75%) patients underwent valve-sparing repair. There was no difference in age or weight between patients who underwent a transannular patch repair and those who underwent a valve-sparing repair. At last follow-up (median 42 months), there was a trend of a higher peak pulmonary valve/right ventricular outflow tract gradient ( P = .06) in the valve-sparing group, but no difference in the pulmonary valve annulus z-scores. Additionally, the pulmonary valve z-scores in the valve-sparing group decreased from −2.3 ± 1.0 on predischarge echocardiogram of to −1.2 ± 1.6 on last follow-up, with the peak gradient on predischarge 23 (0-37) mm Hg remaining stable on last follow-up at 18 (0-29) mm Hg. There was one reoperation: pulmonary valve replacement six years after a transannular patch. Conclusions: Obtaining a postrepair pulmonary valve z-score of −2 yields satisfactory, stable valve-sparing repair with pulmonary valve growth, acceptable gradients, minimal regurgitation, and high freedom from reintervention during follow-up.

Abstract 14576: Durability of Valve-sparing Tetralogy of Fallot Repair

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Elizabeth H Stephens ◽  
Bryan L Wolfe ◽  
Abhinav A Talwar ◽  
Angira Patel ◽  
Joseph Camarda ◽  
...  
Keyword(s):  
Tetralogy Of Fallot ◽  
Pulmonary Valve ◽  
Pulmonary Regurgitation ◽  
Pulmonary Valve Replacement ◽  
Patch Repair ◽  
Transannular Patch ◽  
Z Scores ◽  
Valve Sparing ◽  
Tetralogy Of Fallot Repair

Introduction: While valve-sparing repair is ideal for Tetralogy of Fallot (TOF), it’s durability and which patients may benefit from a transannular patch remains unclear. To this end, we reviewed our experience with valve-sparing TOF repair. Methods: Retrospective review was performed of all primary TOF operations at our institution from 1/2008 to 12/2018. Standard demographic, operative, and echo data were collected, along with clinical outcomes. Transannular patch and valve-sparing repair groups were then compared. Results: Sixty-eight patients underwent TOF repair with a mean age of 4.1±2.2 months and weight of 5.7±1.8 kg. There was no difference in age or weight between patients who underwent a transannular patch repair and valve-sparing repair (Table). There was also no difference in the frequency of hypercyanotic spells or beta-blocker use. As expected the pre-operative pulmonary valve size and z-score were significantly different between groups. Bypass times were longer in the transannular patch group (176±40 vs. 144±40 minutes, p=0.005). There were no differences in post-operative complications. At last follow-up (median 41.5 months) there was a trend of a higher peak pulmonary valve gradient (p=0.07) in the valve-sparing group, but no difference in pulmonary valve annulus z-scores. Additionally, the pulmonary valve z-scores in the valve-sparing group decreased from -2.3±1.0 on pre-discharge echocardiogram to -1.2±1.6 on last follow-up, with the peak gradient on pre-discharge 20 (33) mmHg stable on last follow-up at 18 (29) mmHg and degree of pulmonary regurgitation stable. There was one reoperation in the cohort: a pulmonary valve replacement in a patient who had undergone a transannular patch repair 6 years prior. Conclusions: Valve-sparing TOF patients demonstrated stable repairs with pulmonary valve growth, acceptable gradients, minimal regurgitation, and high freedom from re-intervention during follow-up.

scholarly journals Validity of Pulmonary Valve Z-Scores in Predicting Valve-Sparing Tetralogy Repairs—Systematic Review †

Children ◽  
2019 ◽  
Vol 6 (5) ◽  
pp. 67
Author(s):  
Raina Sinha ◽  
Vasu Gooty ◽  
Subin Jang ◽  
Ali Dodge-Khatami ◽  
Jorge Salazar
Keyword(s):  
Pulmonary Valve ◽  
Pulmonary Arteries ◽  
Pulmonary Atresia ◽  
Right Ventricular Outflow Tract ◽  
Ventricular Outflow Tract ◽  
P Value ◽  
Complete Relief ◽  
Z Score ◽  
Z Scores ◽  
Valve Sparing

There is a lack of consensus regarding the preoperative pulmonary valve (PV) Z-score “cut-off” in tetralogy of Fallot (ToF) patients to attempt a successful valve sparing surgery (VSS). Therefore, the aim of this study was to review the available evidence regarding the association between preoperative PV Z-score and rate of re-intervention for residual right ventricular outflow tract (RVOT) obstruction, i.e. successful valve sparing surgery. A systematic search of studies reporting outcomes of VSS for ToF was performed utilizing PubMed, EMBASE, and Scopus databases. Patients with ToF variants such as pulmonary atresia, major aortopulmonary collaterals, absent pulmonary valve, associated atrioventricular septal defect, and discontinuous pulmonary arteries were excluded. Out of 712 screened publications, 15 studies met inclusion criteria. A total of 1091 patients had surgery at a median age and weight of 6.9 months and 7.2 kg, respectively. VSS was performed on the basis of intraoperative PV assessment in 14 out of 15 studies. The median preoperative PV Z-score was −1.7 (0 to −4.9) with a median re-intervention rate of 4.7% (0–36.8%) during a median follow-up of 2.83 years (1.4–15.8 years). Quantitatively, there was no correlation between decreasing preoperative PV Z-scores and increasing RVOT re-intervention rates with a correlation coefficient of −0.03 and an associated p-value of 0.91. In observational studies, VSS for ToF repair was based on intraoperative evaluation and sizing of the PV following complete relief of all levels of obstruction of the RVOT, rather than pre-operative echocardiography derived PV Z-scores.

scholarly journals Importance of pulmonary valve morphology for pulmonary valve preservation in tetralogy of Fallot surgery: comparison of the echocardiographic parameters

2020 ◽  
Vol 63 (5) ◽  
pp. 189-194
Author(s):  
Su Jin Choi ◽  
Jung Eun Kwon ◽  
Da Eun Roh ◽  
Myung Chul Hyun ◽  
Han Na Jung ◽  
...  
Keyword(s):  
Tetralogy Of Fallot ◽  
Pulmonary Valve ◽  
Aortic Annulus ◽  
Data Sets ◽  
Key Factors ◽  
Descending Aorta ◽  
Surgical Methods ◽  
Echocardiographic Parameters ◽  
Valve Annulus ◽  
Tissue Characteristics

Background: The decision to use transannular patching (TAP) during tetralogy of Fallot (TOF) repair depends on the pulmonary valve annulus size; the <i>z</i> score of the pulmonary annulus is the most commonly used predictor. However, definitive results are not obtained with <i>z</i> scores as different <i>z</i> score data sets are used for different parameters.Purpose: This study aimed to identify the echocardiographic and other key factors that warranted a change in the surgical method during TOF surgery.Methods: Sixty-two patients were enrolled and divided into a pulmonary valve (PV) preservation group and a TAP group. Their medical records were reviewed.Results: The <i>z</i> score for PV annulus (PVA), ratio of the PVA to aortic annulus size, and ratio of PVA to descending aorta (DAO) size were significantly different between the PV preservation and TAP groups (-1.72±1.52 vs. -3.07±1.94, <i>P</i>=0.004; 0.62±0.12 vs. 0.50±0.14, <i>P</i>=0.002; and 1.32±0.32 vs. 1.07±0.36, <i>P</i>= 0.008, respectively). For TAP repair, the PVA <i>z</i> score had a sensitivity of 65.4% and specificity of 73.1%, ratio of PVA to aortic annulus size had a sensitivity of 73.1% and specificity of 65.4%, and ratio of PVA to DAO size had a sensitivity of 69.2% and specificity of 57.7%. The TAP group showed more monocuspid PVs (<i>P</i>=0.011), while the PV preservation group showed more tricuspid PVs (<i>P</i>=0.027). Commissurotomy was more frequently performed in the PV preservation group than in the TAP group (<i>P</i>=0.001). Of patients with commissurotomy, 58% showed a PV <i>z</i> score<-2.Conclusion: Although various echocardiographic parameters may serve as predictors for determining surgical methods for TOF patients, the PV morphology and tissue characteristics should also be considered.

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