Outcome of low body weight (<2.2 kg) infants undergoing cardiac surgery

Comparison of Levosimendan Versus Milrinone After the Arterial Switch Operation for Infants ≤3 kg

Background: Various inotropes and inodilators have been utilized to treat low cardiac output syndrome after the arterial switch operation. The use of levosimendan, a calcium sensitizer has been limited in this setting. This study compares the effects of levosimendan with milrinone in managing low cardiac output after the arterial switch operation. Methods: A retrospective, comparative study was conducted in a tertiary care hospital on patients weighing up to 3 kg undergoing the arterial switch operation between January 2017 and January 2022. Patients received a loading dose followed by continuous infusion of either levosimendan or milrinone. Echocardiographic, hemodynamic and biochemical parameters were compared. Results: Forty-three patients received levosimendan and 42 patients received milrinone as the primary test drug. Cardiac index of less than 2.2 L/min/m2 on postoperative day 1 and 2 was found in 9.3% and 2.3% of patients receiving levosimendan versus 26.2% and 11.9% in those receiving milrinone, respectively (P = .04 and .08, respectively). Early lactate-clearance and better central venous oxygen saturations were noted in the levosimendan group. Prevalence of acute kidney injury was higher in the milrinone group (50% vs 28%; P = .03). Use of peritoneal dialysis in the milrinone group versus levosimendan was 31% and 16.3%, respectively (P = .11). There was no difference in hospital mortality between the groups (milrinone, 3; levosimendan, 2, P = .62). Conclusions: Levosimendan is safe and as effective as milrinone to treat low cardiac output syndrome occurring in neonates after the arterial switch operation. In addition we found that levosimendan was renal protective when compared with milrinone.

Managing CHD in Tertiary NICU in Collaboration with a Cardiothoracic Center

Increasingly non-cardiac tertiary neonatal intensive care units (NCTNs) manage newborns with CHD prior to planned transfer to specialist cardiac surgical centres (SCSC). It improves patient flow in SCSCs, enables families to be nearer home, and improves psychological well-being Parker et al. (Evaluating models of care closer to home for children and young people who are ill: a systematic review, 2011). This practice has gradually increased as the number of SCSCs has decreased. This study examines the effectiveness of this expanding practice. The management provided, length of stay in the NCTN and outcomes are described for one UK NCTN situated at a significant distance from its SCSC. A retrospective observational study of cardiac-related admissions to a NCTN between January 2010 and December 2019 was conducted. 190 neonates were identified: 41 had critical CHD; 64 had major CHD. The cohort includes babies with a wide range of cardiac conditions and additional complexities. 23.7% (n = 45) required transfer to a specialist center after a period of stabilization and growth ranging from several hours to 132 days. 68% (n = 130) were discharged home or repatriated to a local NICU. Of the remaining 15 babies, 13 were transferred to other specialties including the hospice. Two died on NICU. The mortality was consistent with the medical complexity of the group Best and Rankin (J Am Heart Assoc 5:e002846, 2016), Laas et al. (BMC Pediatr 17:124, 2017). 8.9% (n = 17) died before age 2. Nine babies had care redirected due to an inoperable cardiac condition or life-limiting comorbidities. Our study demonstrates a complex neonatal cohort with CHD can be managed effectively in a NCTN, supporting the current model of care. The NCTN studied was well supported by pediatricians with expertise in cardiology alongside visiting pediatric cardiologists.

The Role of Early and Delayed Surgery for Infants with Congenital Brain Tumors

PURPOSE

The present study aimed to evaluate the role of early and delayed surgery in congenital brain tumors and analyze the clinical outcomes of infantile brain tumors.

MATERIALS AND METHODS

We performed a retrospective cohort study on 69 infantile brain tumors at a single institution from January 2008 to June 2023. Outcomes were assessed as early mortality (within 30 days following surgery) to evaluate the risk of early surgery in congenital brain tumors. Outcomes of recurrence and overall survival were analyzed in infantile brain tumors.

RESULTS

Surgery-related early mortality appeared to occur in young and low-body-weight patients. Cut-off values of age and body weight were found to be 1.3 months and 5.2 kg to avoid early mortality. Three patients (3/10, 30%) showed early mortality in the early surgery group, and early mortality occurred in one patient (1/14, 7.14%) in the delayed surgery group, whose tumor was excessively enlarged. Younger age at diagnosis (< 3 months of age; hazard ratios [HR], 7.1; 95% confidence intervals [CI], 1.4 to 35.6; p=0.018) and leptomeningeal seeding (LMS; HR, 30.6; 95% CI, 3.7 to 253.1; p=0.002) were significant independent risk factors for high mortality in infantile brain tumors.

CONCLUSION

We suggest delaying surgery until the patient reaches 1.3 months of age and weighs over 5.2 kg with short-term imaging follow-up unless tumors grow rapidly in congenital brain tumors. Younger ages and the presence of LMS are independent risk factors for high mortality in infantile brain tumors.

Analysis of Different Facets of the Rule of 10 for Cleft Lip Repair for Their Application in the Current Era

OBJECTIVE

To evaluate the relevance of the "rule of 10" as a deciding factor preoperatively for patients undergoing cleft lip repair in the Indian sub-continent.

DESIGN

A questionnaire survey was conducted.

SETTING

All tertiary cleft care centers in the Indian subcontinent participated in an online questionnaire survey with anesthetic and surgical professionals.

MAIN OUTCOME

The primary goal of this survey was to determine the relevance and applicability of various aspects of the rule of 10 as a preoperative guideline for determining the timing of cleft lip repair in ASA I infants. The survey also aids in understanding the systemic factors that need to be prioritized and factors that are no longer of primary relevance in defining the timeline to undertake cleft lip repair in infants in the current era.

RESULTS

Surgeons and anesthetists from 31 tertiary cleft centers in India responded to the questionnaire. Specifically, 64.5% do not apply the "rule of 10" for deciding the timing of cleft lip repair, and 77% of the centers reported that cleft lip repair can be taken up in infants with hemoglobin levels in the range of 9-10 g/dL and an average weight of 4.5 kg. The average blood loss in unilateral lip repair ranged between 5 and 10 mL and 10 and 40 mL in children with bilateral lip repair. Three to six months was the average age at which cleft lip repair was undertaken at most of the centers in India.

CONCLUSION

The rule of 10 is not considered a gold standard by most of the centers in India, and the decision-making was based on the overall physiological status of the patients, the experience of the surgeon, and the anesthetic and post-operative care facilities available at the center.

Right ventricular outflow tract stenting promotes pulmonary artery development in tetralogy of fallot

Background

Right ventricular outflow tract (RVOT) stenting seems to be suggested as a promising treatment option and an alternative to modified Blalock-Taussig shunt (mBTS) in the initial palliation of patients with Fallot-type lesions in recent years. This study sought to assess the effect of RVOT stenting on the growth of the pulmonary artery (PA) in patients with Tetralogy of Fallot (TOF).

Methods

Retrospective review analyzing 5 patients with Fallot-type congenital heart disease with small pulmonary arteries who underwent palliative with RVOT stenting and 9 patients underwent modified Blalock-Taussig shunt within 9 years period. Differential left PA (LPA) and right PA (RPA) growth was measured by Cardiovascular Computed Tomography Angiography (CTA).

Results

RVOT stenting improved arterial oxygen saturation from median of 60% (interquartile range [IQR]: 37% to 79%) to 95% (87.5% to 97.5%) (p = 0.028). The LPA diameter Z-score improved from -2.843 (-3.51-2.037) to -0.78 (-2.3305-0.19) (p = 0.03), the RPA diameter Z-score improved from median -2.843 (-3.51-2.037) to -0.477 (-1.1145-0.459) (p = 0.002), the Mc Goon ratio increased from median 1 (0.8-1.105) to 1.32 (1.25-1.98) (p = 0.017). There were no procedural complications and all 5 patients have undergone final repair in the RVOT stent group. In the mBTS group, the LPA diameter Z-score improved from -1.494 (-2.242-0.6135) to -0.396 (-1.488-1.228) (p = 0.15), the RPA diameter Z-score improved from median -1.328 (-2.036-0.838) to 0.088 (-0.486-1.223) (p = 0.007), and there were 5 patients occur different complications and 4 patients was not attained the standards of final surgical repair.

Conclusion

RVOT stenting, compared with mBTS, seems to better promote pulmonary artery growth, improve arterial oxygen saturations, and have less procedure complications in patients with TOF who being absolute contraindicated for primary repair due to high risks.

Cardiovascular surgery in very low birth weight (≤1500 g) neonates

OBJECTIVES

Low birth weight and prematurity are known risks of increased morbidity and mortality with undergoing cardiovascular surgery. Our aim was to review the outcomes of very low birth weight (≤1500 g) patients who have undergone cardiovascular surgery.

METHODS

A retrospective review was performed for 32 very low birth weight (≤1500 g) patients who underwent cardiovascular surgery from 2004 to 2021 in our institution.

RESULTS

Fifteen patients weighting ≤1500 g at surgery (≤1500-g group) were compared to 17 patients born with a weigh of ≤1500 g and weighting between 1500 and 2500 g at surgery (>1500- to ≤2500-g group) in this study. In-hospital mortality was 33% (5/15) in the ≤1500-g group and 24% (4/17) in the >1500- to ≤2500-g group (P = 0.55). All patients with simple biventricular lesion survived following full repair. The occurrence of postoperative intracerebral haemorrhage was significantly higher in those operated at weight ≤1500 g than those weighting >1500 to ≤2500 g (40% vs 0%; P = 0.01). The 1- and 3-year survival rates were 66.0 ± 12.4% and 46.2 ± 14.8% in the ≤1500-g group and 76.5 ± 10.3% and 70.6 ± 11.1% in the >1500- to ≤2500-g group (log-rank P = 0.12).

CONCLUSIONS

Cardiac surgery for a very low birth weight neonate resulted in a high early and late mortality. Early surgery is only acceptable for simple biventricular lesions if needed. Delayed surgery seems to provide better long-term outcomes in patients with complex lesions. Alternative strategies for neonatal cardiopulmonary bypass should be investigated in patients with complex biventricular and single ventricular lesions.

Stenting of patent ductus arteriosus in low birth weight newborns less than 2kg- procedural safety, feasibility and results in a retrospective study

Objective

Retrospective analysis of the feasibility, safety and results of patent ductus arteriosus (PDA) stenting in low birth weight babies weighing < 2 kg. Background: Stenting of patent ductus arteriosus is a well known palliative technique for several years as an alternative to shunt surgery in babies weighing > 2.5–3 kg. Ductal stenting in babies weighing less than 2 kg is not done routinely all around the world due to limited experience and concerns regarding its feasibility and safety in such small subset.

Methods

Records of patients who underwent PDA stenting at our institution from June 2014 to December 2016 were reviewed. In this period, we attempted to do PDA stenting using femoral artery approach in babies weighing < 2 kg. Echocardiography and colour Doppler were used for patient selection and assessment of procedural outcome.

Results

PDA stenting using femoral artery approach was successful in all 5 patients weighing < 2 kg. In this group, patient age ranged from 2 days to 16 days and weighed 1.8 kg to 1.97 kg. All patients had good post-procedure outcome. One patient had stent malposition from aortic end towards main pulmonary artery which was managed by an additional stent.

Conclusion

PDA stenting is feasible and safe with good end results in carefully selected low birth weight babies weighing < 2 kg.

Effect of Concomitant Birth Defects and Genetic Anomalies on Infant Mortality in Tetralogy of Fallot

BACKGROUND

A substantial proportion of infants born with tetralogy of Fallot (TOF) die in infancy. A better understanding of the heterogeneity associated with TOF, including extracardiac malformations and chromosomal anomalies is vital to stratifying risk and optimizing outcomes during infancy.

METHODS

Using the North Carolina Birth Defects Monitoring Program, infants diagnosed with TOF and born between 2003 and 2012 were included. Kaplan-Meier survival curves were used to estimate cumulative 1-year mortality, stratified by the presence of concomitant birth defects (BDs) and chromosomal anomalies. Multivariable logistic regression was used to estimate the direct effect of each concomitant BD, after adjusting for all others.

RESULTS

A total of 496 infants with TOF were included, and 15% (n = 76) died. The number of concomitant BD systems was significantly associated with the risk of death at 1-year, p < 0.0001. Specifically, the risk of mortality was 8% among infants with TOF with or without additional cardiac defects, 16% among infants with TOF and 1 extracardiac BD system, 19% among infants with 2 extracardiac BD systems, and 39% among infants with ≥ 3 extracardiac BD systems. After adjustment, concomitant eye and gastrointestinal defects were significantly associated increased with 1-year mortality, odds ratio 2.83 (95% confidence interval, 1.08-7.32) and odds ratio 4.43 (95% confidence interval, 1.57, 12.45), respectively. Infants with trisomy 13 or trisomy 18 were also significantly more likely to die, p < 0.0001.

CONCLUSION

Both concomitant BDs and genetic anomalies increase the risk of mortality among infants with TOF. Future studies are needed to identify the underlying genetic and socioeconomic risk factors for high-risk TOF infants. Birth Defects Research 109:1154-1165, 2017. © 2017 Wiley Periodicals, Inc.

Evaluating the Rule of 10s in Cleft Lip Repair: Do Data Support Dogma?

BACKGROUND

Cleft lip represents one of the most common birth defects in the world. Although the timing of cleft lip repair is contingent on a number of factors, the "rule of 10s" remains a frequently quoted safety benchmark. Initially reported by Wilhelmsen and Musgrave in 1966 and modified by Millard in 1976, this rule referred to performing surgery once patients had reached cutoffs in weight, hemoglobin, and age/leukocyte count. Despite significant advances in both surgical and anesthetic technique, the oft-quoted "rule of 10s" has not been systematically investigated since its inception.

METHODS

Patients who underwent primary cleft lip repair were identified from the National Surgical Quality Improvement Program Pediatric database. Multivariate logistic regression models were used to determine the independent effect of each rule of 10 metric or violation of the rule of 10s as a whole on postoperative complications, and to determine independent risk factors for complications in cleft lip surgery.

RESULTS

One thousand three hundred thirteen patients met inclusion criteria, with a 3.6 percent complication rate. Of the included patients, 151 (11.5 percent) violated at least one facet of the rule of 10s. Other than patient weight, neither the rule of 10s nor any individual metric was significantly predictive of postoperative complications.

CONCLUSIONS

Since its introduction nearly a half century ago, the risks associated with performing surgery in patients who violate the rule of 10s has undergone dramatic reductions. This analysis highlights the need to continually validate and evaluate dogma as the field continues to advance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Weight-for-age standard score - distribution and effect on in-hospital mortality: A retrospective analysis in pediatric cardiac surgery

OBJECTIVE

To study the distribution of weight for age standard score (Z score) in pediatric cardiac surgery and its effect on in-hospital mortality.

INTRODUCTION

WHO recommends Standard Score (Z score) to quantify and describe anthropometric data. The distribution of weight for age Z score and its effect on mortality in congenital heart surgery has not been studied.

METHODS

All patients of younger than 5 years who underwent cardiac surgery from July 2007 to June 2013, under single surgical unit at our institute were enrolled. Z score for weight for age was calculated. Patients were classified according to Z score and mortality across the classes was compared. Discrimination and calibration of the for Z score model was assessed. Improvement in predictability of mortality after addition of Z score to Aristotle Comprehensive Complexity (ACC) score was analyzed.

RESULTS

The median Z score was -3.2 (Interquartile range -4.24 to -1.91] with weight (mean±SD) of 8.4 ± 3.38 kg. Overall mortality was 11.5%. 71% and 52.59% of patients had Z score < -2 and < -3 respectively. Lower Z score classes were associated with progressively increasing mortality. Z score as continuous variable was associated with O.R. of 0.622 (95% CI- 0.527 to 0.733, P < 0.0001) for in-hospital mortality and remained significant predictor even after adjusting for age, gender, bypass duration and ACC score. Addition of Z score to ACC score improved its predictability for in-hosptial mortality (δC - 0.0661 [95% CI - 0.017 to 0.0595, P = 0.0169], IDI- 3.83% [95% CI - 0.017 to 0.0595, P = 0.00042]).

CONCLUSION

Z scores were lower in our cohort and were associated with in-hospital mortality. Addition of Z score to ACC score significantly improves predictive ability for in-hospital mortality.