Palliative procedures for congenital heart defects

Palliative surgery: state of the science and future directions

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.

Impact of Down Syndrome on Survival Among Patients With Congenital Heart Disease

BACKGROUND

Increasing survival among patients with congenital heart disease (CHD) has recently been reported. However, the impact of Down syndrome (DS) in patients with CHD is still debated. We aimed to estimate survival in patients with CHD with versus without DS compared with matched controls from the general population without CHD or DS.

METHODS AND RESULTS

We linked data from Swedish health registries to identify patients with CHD born between 1970 and 2017. Data from the Total Population Register were used to match each patient with CHD by sex and birth year with 8 controls without CHD or DS. A Cox proportional regression model was used to estimate mortality risk, and Kaplan-Meier curves were analyzed for the survival analysis. We identified 3285 patients with CHD-DS, 64 529 patients with CHD without DS, and 26 128 matched controls. The mortality risk was 25.1 times higher (95% CI, 21.3-29.5) in patients with CHD-DS versus controls. The mortality rate was 2 times higher (95% CI, 1.94-2.31) for patients with CHD with versus without DS. Lower mortality was found during the second versus first birth periods in patients with CHD-DS compared with controls; hazard ratio: 46.8 (95% CI, 29.5-74.0) and 17.7 (95% CI, 12.8-24.42) in those born between 1970 and 1989 versus 1990 and 2017, respectively.

CONCLUSIONS

In this retrospective cohort study, the mortality risk among patients with CHD-DS was 25 times higher compared with matched controls and 2 times higher compared with patients with CHD without DS. Survival was higher in patients with CHD-DS born after versus before 1990, coinciding with the modern era of congenital heart care.

Biological Scaffolds for Congenital Heart Disease

Congenital heart disease (CHD) is the most predominant birth defect and can require several invasive surgeries throughout childhood. The absence of materials with growth and remodelling potential is a limitation of currently used prosthetics in cardiovascular surgery, as well as their susceptibility to calcification. The field of tissue engineering has emerged as a regenerative medicine approach aiming to develop durable scaffolds possessing the ability to grow and remodel upon implantation into the defective hearts of babies and children with CHD. Though tissue engineering has produced several synthetic scaffolds, most of them failed to be successfully translated in this life-endangering clinical scenario, and currently, biological scaffolds are the most extensively used. This review aims to thoroughly summarise the existing biological scaffolds for the treatment of paediatric CHD, categorised as homografts and xenografts, and present the preclinical and clinical studies. Fixation as well as techniques of decellularisation will be reported, highlighting the importance of these approaches for the successful implantation of biological scaffolds that avoid prosthetic rejection. Additionally, cardiac scaffolds for paediatric CHD can be implanted as acellular prostheses, or recellularised before implantation, and cellularisation techniques will be extensively discussed.

The Experience of Uncertainty in Mothers Caring for Children at Home after Palliative Heart Surgery

Objectives

Palliative heart surgery is a compelling option for some children with congenital heart disease for which corrective heart surgery is not yet possible due to its complexity. As primary caregivers, mothers have the challenge of providing optimal care to their children at home post-surgery. This study aims to explore the experiences of mothers who are caring for children recovering from palliative heart surgery at home. The research applied descriptive, qualitative and phenomenology design.

Material and Methods

This study was conducted in Jakarta. The participants were 15 mothers of palliative heart surgery patients from seven provinces in Indonesia; Jakarta, Aceh, Bali, North Sumatra, West Java, Central Java and Banten. Data were collected using semi-structured interviews through the WhatsApp video call application and analysed using the Colaizzi method.

Results

Mothers often felt uncertain about how to provide the best care and felt that their needs for hospital services to assist them went unmet. Conclusions: This study has implications for the development of nursing services related to discharge planning for palliative heart surgery patients.

Complex adult congenital heart disease on cross-sectional imaging: an introductory overview

Congenital heart disease is the most common group of congenital pathology. Over the past few decades, advances in surgical treatment have resulted in a rising population of adult patients with repaired complex congenital heart disease. Although the quality of life has greatly improved, a significant proportion of morbidities encountered in clinical practice is now seen in adults rather than in children. These patients often have significant haemodynamic pathophysiology necessitating repeat intervention. CT and MRI are excellent imaging modalities, which help elucidate potential complications that may need urgent management. Although imaging should be performed in specialised centres, occasionally patients may present acutely to emergency departments in hospitals with little experience in managing potentially complex patients. The purpose of this article is to provide an introductory overview to the radiologist who may not be familiar with complex congenital heart disease in adult patients. This educational review has three main sections: (1) a brief overview of the post-operative anatomy and surgical management of the most common complex conditions followed by (2) a discussion on CT/MRI protocols and (3) a review of the various complications and their CT/MRI findings.

Limited upper mini-sternotomy approach for closed heart surgery in the newborns and infants

BACKGROUND

The mini-sternotomy has become a common approach of choice for a wide range of congenital defects requiring minimally invasive surgery. Here, we aimed to present closed heart surgery results via limited upper mini-sternotomy in the newborn and infants.

METHODS

A total of 46 infants who underwent pulmonary artery banding, patent ductus arteriosus ligation, and aortopexy via limited upper mini-sternotomy between December 2017 and October 2020 were enrolled. Patients included 26 males and 20 females with ages ranging from 2 days to 12 months (median age 3.25 ± 0.9 months). The weight ranged from 0.7 kg to 8 kg (median weight 3.6 ± 1.8 kg). These patients were evaluated retrospectively in terms of clinical, preoperative, intraoperative, and postoperative parameters.

RESULTS

Closed heart surgery procedures were corrected successfully without adverse events intraoperatively. The median operation time was 32 min (32 ± 7 min). The limited upper mini-sternotomy was performed on 46 patients, including the pulmonary banding (18 patients), PDA ligation (16 patients), and aortopexy (12 patients). No patients required conversion to full sternotomy or to extend the incision. Re-intervention to adjust the tightness of the band was required in 1 patient. There were 4 cases of mortality (8.6%). All four death cases had comorbidity and low birth weight (2500 g or less).

CONCLUSION

Limited upper mini-sternotomy is a technically feasible, safe, and effective approach that providing an adequately surgical view in closed heart surgery to reduce the invasiveness of the closed heart surgical repair via median sternotomy or thoracotomy approach.

Introduction of precordial Doppler ultrasound to confirm correct peripheral venous access during general anesthesia in children: A preliminary study

Background

Delayed identification of infiltration and dysfunction of peripheral intravenous (PIV) access can lead to serious consequences during general anesthesia in children. This preliminary study aimed to describe the application of precordial Doppler ultrasound during general anesthesia in children to detect and confirm the correct PIV access and to evaluate the accuracy of this method.

Methods

This was a single-center, preliminary study that was conducted in children (<18 years) who were scheduled for elective surgeries between October 2019 and March 2020. Rater anesthesiologists judged the change in precordial Doppler sound (S test) before and after injection of 0.5 mL/kg of normal saline (NS) via PIV. Blood flow velocity before and after NS injection was recorded, and multiple cutoff points were set to analyze the accuracy of detecting the infiltration and dysfunction of PIV catheter (V test).

Results

The total incidence of peripheral infiltration and dysfunction of PIV catheter was 7/512 (1.4%). In the S test, the sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver-operating characteristic curves (AUCs) were 5/7 (71.4%; 95% confidence interval [CI], 29.0%–96.3%), 490/505 (97.0%; 95% CI, 95.1%–98.3%), 24.0, 0.29, and 0.84, respectively. The V test showed that the reasonable threshold of blood flow velocity change was 1.0 m/s, with sensitivity, specificity, positive and negative likelihood ratios, and AUC of 4/7 (57.1%; 95% CI, 18.4%–90.1%), 489/505 (96.8%; 95% CI, 94.9%–98.2%), 18.0 and 0.44, and 0.84, respectively.

Conclusions

This preliminary study demonstrated that precordial Doppler ultrasound is a feasible, easy-to-use, and noninvasive technique with good accuracy to confirm the correct PIV access during general anesthesia in children. However, its accuracy requires further evaluation.

Applying the Self-determination Theory to Health-related Quality of Life for Adolescents with Congenital Heart Disease

PURPOSE

The purpose of this study is to examine the relationship among the three innate needs of Self-Determination Theory (SDT), self-management of care and adherence to treatment, and the relationship to health-related quality of life (HRQOL) for adolescents with congenital heart disease (CHD).

DESIGN AND METHODS

A non-experimental, cross-sectional, correlational design was conducted in a sample of 92 participants with CHD, ages 13 to 18 years. For data analysis, Pearson's correlations were used to explore associations between variables, and the hypotheses were tested using multiple linear regression.

RESULTS

Demographic and clinical data were collected: 15 ± 1.6 yrs; 59% male; 65% White; 43% mild CHD; 25% severe CHD. After controlling for covariates, regression analyses revealed relatedness (β = 0.64) and competence (β = 0.79) contributed significant variance to HRQOL, R² = 0.56, p < .001; however, autonomy and self-management of care and treatment adherence did not contribute significant variance to HRQOL.

CONCLUSIONS

This study found that relatedness and competence were significantly associated with HRQOL in adolescents with CHD; however, autonomy and self-management of care and adherence to treatment were not. These findings demonstrate the importance of further examining relatedness and competence in adolescents with CHD.

PRACTICE IMPLICATIONS

Nursing care should focus on the improvement of social support systems and interventions to increase self-efficacy for adolescents with CHD.

Adults With Complex Congenital Heart Disease: Cerebrovascular Considerations for the Neurologist

As infant and childhood mortality has decreased in congenital heart disease, this population is increasingly reaching adulthood. Adults with congenital heart disease (ACHD) represent a group with increased risk of stroke, silent brain infarcts, and vascular cognitive impairment. Cyanotic and other complex cardiac lesions confer the greatest risk of these cerebrovascular insults. ACHD patients, in addition to having an increased risk of stroke from structural cardiac issues and associated physiological changes, may have an accelerated burden of conventional vascular risk factors, including hypertension and impaired glucose metabolism. Adult neurologists should be aware of the risks of clinically evident and subclinical cerebrovascular disease in this population. We review the existing evidence on primary and secondary stroke prevention in individuals with complex congenital heart disease, and identify knowledge gaps in need of further research, including treatment of acute stroke in this population. Multisystemic genetic syndromes are outside the scope of this review.

Attitudes of clinicians toward cardiac surgery and trisomy 18

Trisomy 18 is an autosomal trisomy condition characterized by minor to major birth defects, severe disabilities, and high rates of pre- and postnatal mortality. Interventions for these infants have traditionally been withheld with focus instead on palliative support. The issues and attitudes surrounding corrective surgery of congenital heart defects, which is a birth defect that occurs in approximately 90% of infants with trisomy 18, is of our study's interest as recent literature has indicated that cardiac surgery is being performed and may lead to improved survival compared to palliative care. Thus, our study aimed to describe clinician attitudes toward cardiac surgery and trisomy 18. We surveyed 378 clinicians from multiple specialties, including genetic counselors, involved in the pre- and postnatal care of infants with trisomy 18. Descriptive statistics were performed to describe all clinicians' responses, and a secondary analysis with stratifications by clinician type was also performed. Forty-eight percent (n = 378) of clinicians felt it was appropriate to discuss the option of cardiac surgery. Ethical concerns and insufficient outcome data were the most agreed upon reasons for not offering cardiac surgery. Trisomy 18 not being uniformly lethal and expressed parental wishes were the most agreed upon justifications for offering surgery. Clinicians felt the discussion of the option of cardiac surgery is appropriate, however are hesitant due to ethical concerns and insufficient outcome data. Results from this study aim to promote discussion and collaboration among clinicians to improve consistency in patient care.

Feasibility of lung ultrasound to assess pulmonary overflow in congenital heart disease children

BACKGROUND

Pulmonary overflow (PO) is one of the most common complications in congenital heart disease (CHD) children with an incidence of 48-60% approximately. This study explored the feasibility of using lung ultrasound (LUS) to assess pulmonary overcirculation in CHD children and compare the diagnostic performance of LUS and chest radiography (CXR) for the detection of pulmonary overcirculation.

METHOD

The upper anterior area, lower anterior area, upper lateral area, and lower posterior area, in each hemithorax were scanned in 59 children in the supine position. A-lines, B-lines in each scanned region were recorded, and the worst LUS abnormality in the video clip was considered to characterize the examined region. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of LUS and CXR were compared using computed tomography (CT) as a standard criterion.

RESULTS

PO was diagnosed in 53% (31/59), 63% (37/59), and 51% (30/59) children with CT, CXR, and LUS, respectively. The sensitivity, specificity, and diagnostic accuracy of PO were 96%, 94%, and 95% for LUS and 74%, 50%, and 63% for CXR. The percentage of mild, moderate, and severe PO diagnosed via LUS were 31% (18/59), 19% (11/59), and 2% (1/59), respectively. Furthermore, the PO incidence diagnosed by LUS in CHD children less than 1 year old were significantly higher than those beyond 1 year old.

CONCLUSION

LUS is a noninvasive and useful tool for the detection and assessment of PO in CHD children at the operating room, and is better than CXR in sensitivity and specificity, comparable to CT.

Outcome of neonatal palliative procedure for pulmonary atresia with ventricular septal defect or tetralogy of Fallot with severe pulmonary stenosis: experience in a single tertiary center

Purpose

The present study aimed to evaluate progression and prognosis according to the palliation method used in neonates and early infants aged 3 months or younger who were diagnosed with pulmonary atresia with ventricular septal defect (PA VSD) or tetralogy of Fallot (TOF) with severe pulmonary stenosis (PS) in a single tertiary hospital over a period of 12 years.

Methods

Twenty with PA VSD and 9 with TOF and severe PS needed initial palliation. Reintervention after initial palliation, complete repair, and progress were reviewed retrospectively.

Results

Among 29 patients, 14 patients underwent right ventricle to pulmonary artery (RV-PA) connection, 11 palliative BT shunt, 2 central shunt, and 2 ductal stent insertion. Median age at the initial palliation was 13 days (1–98 days). Additional procedure for pulmonary blood flow was required in 5 patients; 4 additional BT shunt operations and 1 RV-PA connection. There were 2 early deaths among patients with RV-PA connection, one from RV failure and the other from severe infection. Finally, 25 patients (86%) had a complete repair. Median age of total correction was 12 months (range, 2–31 months). At last follow-up, 2 patients had required reintervention after total correction; 1 conduit replacement and 1 right ventricular outflow tract (RVOT) patch enlargements.

Conclusion

For initial palliation of patients with PA VSD or TOF with severe PS, not only shunt operation but also RV-PA connection approach can provide an acceptable outcome. To select the most proper surgical strategy, we recommend thorough evaluation of cardiac anomalies such as RVOT and PA morphologies and consideration of the patient’s condition.

Outcomes of palliative right ventricle to pulmonary artery connection for pulmonary atresia with ventricular septal defect

OBJECTIVES

To determine the early, intermediate and long-term outcomes of pulmonary atresia with ventricular septal defect (PA/VSD) Types I, II and III initially palliated by a right ventricle to pulmonary artery (RVPA) connection.

METHODS

We performed a retrospective study from 2000 to 2014 that included 109 patients with PA/VSD who had undergone an RVPA connection (tetralogy of Fallot and PA/VSD Type IV excluded). The end-points of this strategy were adequate pulmonary artery tree post-palliation, second palliation, biventricular repair, right ventricular pressure post-biventricular repair and late reoperation. Mean follow-up was 5.4 years (1 day to 14-78 years).

RESULTS

Early mortality after an RVPA connection was 2.7% (3 of 109). The interstage mortality rate was 6.6% (7 of 106). Eighty-four (77%) patients had a biventricular repair and 8 patients (7%) are awaiting repair. Overall survival was 90% at 1 year and 81% at 10 years. The RVPA connection allowed significant growth of the native pulmonary artery with a Nakata index of 101 mm2/m2 before the RVPA connection and 274 mm2/m2 after (P = 0.001). Twenty-nine reinterventions for restrictive pulmonary blood flow have been done (9 before 2 months and 20 after 2 months). Of the 84 patients who had a repair, 22 patients (26%) initially had a right ventricular pressure greater than 40 mmHg. Twenty-eight patients (33%) required late reoperation.

CONCLUSIONS

Hospital deaths after the RVPA connection were low. The procedure allowed good growth of the native pulmonary artery. Biventricular repair was possible in a large number of cases. The late morbidity rate remains significant. Early reinterventions could be avoided by appropriate calibration. This technique appears to be suitable for any type of PA/VSD with central pulmonary arteries.

Nurses' Perceptions of Quality of Life for Adolescents with Congenital Heart Disease

The purpose of this study was to understand nurses' perceptions and experiences regarding Quality of Life (QOL) of adolescents with complex congenital heart disease (CHD). Interpretive, hermeneutic, phenomenology was used to explore the perceptions and experiences of nurses who care for adolescents with complex CHD. The participants included 6 female registered nurses with experience taking care of adolescents with complex CHD. Data were collected using semi-structured interviews. Data analysis revealed 4 themes: QOL depends on how the psychological and social issues are interwoven with the physical; finding that balance between overprotection and too much freedom; setting goals to envision a future; and not being defined by a CHD. These results indicate that understanding nurses' perspectives and experiences may contribute to effective guidance for adolescents with complex CHD transitioning into adulthood.

Two problems and a single solution: Covered stent implantation to close an anterograde pulmonary flow and treat hypoplastic left pulmonary artery after Fontan operation

Several issues may impact on the function of a Fontan circulation including accessory source of pulmonary blood flow and pulmonary artery anatomy. Here we report on a 5.5-year-old boy who showed failing Fontan circulation due to left pulmonary artery stenosis/hypoplasia and significant forward pulmonary blood flow through the native pulmonary artery. Successful implantation of a 34-mm CP covered stent in the left pulmonary artery in a Fontan patient was useful for simultaneous successful treatment of residual antegrade flow from the systemic ventricle to the pulmonary artery and enlargement of hypoplastic left pulmonary artery. © 2015 Wiley Periodicals, Inc.

Exercise capacity in the Bidirectional Glenn physiology: Coupling cardiac index, ventricular function and oxygen extraction ratio

In Bi-directional Glenn (BDG) physiology, the superior systemic circulation and pulmonary circulation are in series. Consequently, only blood from the superior vena cava is oxygenated in the lungs. Oxygenated blood then travels to the ventricle where it is mixed with blood returning from the lower body. Therefore, incremental changes in oxygen extraction ratio (OER) could compromise exercise tolerance. In this study, the effect of exercise on the hemodynamic and ventricular performance of BDG physiology was investigated using clinical patient data as inputs for a lumped parameter model coupled with oxygenation equations. Changes in cardiac index, Qp/Qs, systemic pressure, oxygen extraction ratio and ventricular/vascular coupling ratio were calculated for three different exercise levels. The patient cohort (n=29) was sub-grouped by age and pulmonary vascular resistance (PVR) at rest. It was observed that the changes in exercise tolerance are significant in both comparisons, but most significant when sub-grouped by PVR at rest. Results showed that patients over 2 years old with high PVR are above or close to the upper tolerable limit of OER (0.32) at baseline. Patients with high PVR at rest had very poor exercise tolerance while patients with low PVR at rest could tolerate low exercise conditions. In general, ventricular function of SV patients is too poor to increase CI and fulfill exercise requirements. The presented mathematical model provides a framework to estimate the hemodynamic performance of BDG patients at different exercise levels according to patient specific data.

Stem cell therapy and tissue engineering for correction of congenital heart disease

This review article reports on the new field of stem cell therapy and tissue engineering and its potential on the management of congenital heart disease. To date, stem cell therapy has mainly focused on treatment of ischemic heart disease and heart failure, with initial indication of safety and mild-to-moderate efficacy. Preclinical studies and initial clinical trials suggest that the approach could be uniquely suited for the correction of congenital defects of the heart. The basic concept is to create living material made by cellularized grafts that, once implanted into the heart, grows and remodels in parallel with the recipient organ. This would make a substantial improvement in current clinical management, which often requires repeated surgical corrections for failure of implanted grafts. Different types of stem cells have been considered and the identification of specific cardiac stem cells within the heterogeneous population of mesenchymal and stromal cells offers opportunities for de novo cardiomyogenesis. In addition, endothelial cells and vascular progenitors, including cells with pericyte characteristics, may be necessary to generate efficiently perfused grafts. The implementation of current surgical grafts by stem cell engineering could address the unmet clinical needs of patients with congenital heart defects.

Radiofrequency energy for vascular closure: a novel technique with multiple applications

Vascular stricture is a known complication of radiofrequency ablation. We used this potential of radiofrequency for voluntary restriction and closure of a pulmonary artery branch in a sheep.

Diagnostic, prognostic and therapeutic relevance of B-type natriuretic hormone and related peptides in children with congenital heart diseases

The aim of this article is to review the diagnostic and prognostic relevance of measurement of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in pediatric patients with congenital cardiac diseases (CHD). A computerized literature search in the National Library of Medicine using the keywords "BNP assay" and "NT-proBNP assay"+neonate/s and newborn/s was performed. Next, we refined the analysis to include only the studies specifically designed to evaluate the clinical usefulness of BNP and NT-proBNP measurements in children with CHD. Several authors suggested that BNP/NT-proBNP is clinically helpful as a diagnostic and prognostic marker for children with suspected CHD. BNP values are age dependent, even in paediatric populations. Unfortunately, accurate reference values for BNP and NT-proBNP for neonatal ages have only recently become available. As a result, the lack of homogenous and accurate decisional levels in the neonatal period greatly limits the clinical impact of the BNP assay, and also contributed to the production of conflicting results. Regardless of age, there is great variability in BNP/NT-proBNP values among CHD characterized by different hemodynamic and clinical conditions. In particular, cardiac defects characterized by left ventricular volume and pressure overload usually show a higher BNP response than CHD which is characterized by right ventricular volume or pressure overload. BNP and NT-proBNP may be considered helpful markers in the integral clinical approach for patients with CHD. Measurement of BNP cannot replace cardiac imaging (including echocardiography, angiography and magnetic resonance), but provide independent, low cost and complementary information for the evaluation of cardiac function and clinical status.

[Modern therapy of congenital heart defects]

Modern therapy of congenital heart defects consists of interventional and surgical procedures. The following report provides information about the most common congenital heart defects and the corresponding therapeutic options. Furthermore, the combined application of interventional and surgical procedures, so-called hybrid procedures, is described in detail as well as the latest developments in percutaneous valve replacement therapy.