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Trisauvapak T, Bongkotwilawan N, Ekawaravong S. Challenges of managing anomalous mitral arcade with severe mitral regurgitation and hydrops fetalis in infants. BMJ Case Rep 2024; 17:e259272. [PMID: 38866580 PMCID: PMC11177271 DOI: 10.1136/bcr-2023-259272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/14/2024] Open
Abstract
Anomalous mitral arcade (MA) is a rare congenital anomaly. We report a case of MA in a newborn who presented with hydrops fetalis due to severe mitral regurgitation. After birth, he developed severe respiratory failure, congestive heart failure and airway obstruction because an enlarged left atrium from severe mitral regurgitation compressed the distal left main bronchus. There is limited experience in surgical management of this condition in Thailand, and the patient's mitral valve was too small for replacement. Therefore, he was treated with medication to control heart failure and supported with positive pressure ventilation to promote growth. We have followed the patient until the current time of writing this report at the age of 2 years, and his outcome is favourable regarding heart failure symptoms, airway obstruction, growth and development. This case describes a challenging experience in the non-surgical management of MA with severe regurgitation, which presented at birth.
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Affiliation(s)
- Tienake Trisauvapak
- Pediatrics, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Bang phli, Thailand
| | - Nitiroj Bongkotwilawan
- Pediatrics, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Bang phli, Thailand
| | - Suparat Ekawaravong
- Pediatrics, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Bang phli, Thailand
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2
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Xu Q, Hou K, Lv B, Xing Q, Chen R. Application of Foley balloon catheter in palliative surgery for pulmonary atresia with an intact ventricular septem, with additional cases of pulmonary atresia with ventricular septal defect and tetralogy of Fallot. BMC Cardiovasc Disord 2023; 23:547. [PMID: 37940877 PMCID: PMC10634058 DOI: 10.1186/s12872-023-03587-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/29/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Pulmonary atresia and tetralogy of Fallot can require palliative surgery in the neonatal period due to severe hypoxia; however, limitations of established techniques include high failure rate and need for cardiopulmonary bypass. Herein, right ventricular outflow tract reconstruction on a beating heart using a Foley balloon catheter is described. METHODS A retrospective review of patients who underwent right ventricular outflow tract reconstruction on a beating heart using a Foley balloon catheter at our institution between September 2018 and March 2022 was completed. During the procedure, a Foley balloon catheter was used to occlude the blood from the right ventricular inflow tract. RESULTS Eight patients with pulmonary atresia and intact ventricular septum underwent an off-pump right ventricular outflow tract reconstruction. One patient with pulmonary atresia and ventricular septal defect, and two patients with tetralogy of Fallot underwent an on-pump right ventricular outflow tract reconstruction on a beating heart. The procedures were successful in all patients. Patent ductus arteriosus ligation without modified Blalock-Taussig shunt placement was performed in three patients with pulmonary atresia with intact ventricular septum and two patients with tetralogy of Fallot, ductus arteriosus was left open in four patients with pulmonary atresia with intact ventricular septum. All patients remained clinically well without serious complications. CONCLUSIONS Right ventricular outflow tract reconstruction on a beating heart using a Foley balloon catheter for pulmonary atresia and tetralogy of Fallot is a feasible alternative to catheter-based interventions or traditional surgical treatment, especially in patients with muscular infundibular stenosis or hypoplastic pulmonary annulus. Further studies with more cases are needed to verify feasibility and superiority of this approach.
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Affiliation(s)
- Qiteng Xu
- Medical College, Qingdao University, Qingdao, China
| | - Kefeng Hou
- Heart Center, Qingdao Women and Children's hospital, 6 Tongfu Road , Qingdao, 266000, China
| | - Bei Lv
- Heart Center, Qingdao Women and Children's hospital, 6 Tongfu Road , Qingdao, 266000, China
| | - Quansheng Xing
- Heart Center, Qingdao Women and Children's hospital, 6 Tongfu Road , Qingdao, 266000, China
| | - Rui Chen
- Heart Center, Qingdao Women and Children's hospital, 6 Tongfu Road , Qingdao, 266000, China.
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3
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Kerstein JS, Klepper CM, Finnan EG, Mills KI. Nutrition for critically ill children with congenital heart disease. Nutr Clin Pract 2023; 38 Suppl 2:S158-S173. [PMID: 37721463 DOI: 10.1002/ncp.11046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/19/2023] Open
Abstract
Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.
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Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| | - Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Emily G Finnan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
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4
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AbuHassan HR, Arafat AA, Albabtain MA, Alwadai AH, AlArwan KM, Ali AA, Rasheed S, Babikr NB, Shaikh SF. Postcardiotomy extracorporeal membrane oxygenation in patients with congenital heart disease; the effect of place of initiation. Perfusion 2023:2676591231177898. [PMID: 37232567 DOI: 10.1177/02676591231177898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Postcardiotomy extracorporeal membrane oxygenation (ECMO) in pediatric patients can be affected by the place of initiation, either in the operating room (OR) or the pediatric cardiac intensive care unit (PCICU). This study aimed to characterize and compare patients who had postcardiotomy ECMO initiation in the OR or PCICU and evaluate risk factors for hospital mortality. METHODS This retrospective study included 103 patients who required postcardiotomy ECMO support after the repair of congenital cardiac lesions from 2010 to 2022. Patients were grouped according to the place of ECMO insertion into two groups. Group 1 (n = 69) had ECMO insertion in the OR, and Group 2 (n = 34) had ECMO insertion in the PCICU. RESULTS Cardiac arrest occurred significantly more often in patients with ECMO insertion in the PCICU (21 (61.76%) vs. 13 (18.84%); p < 0.001). Pre-ECMO lactate levels, pH, VIS, base deficit, and PaO2 did not differ between the groups. Re-exploration for bleeding was significantly higher in Group 1 (32 (46.38%) vs. 8 (23.53%); p = 0.03). Cannula repositioning (4 (11.76%) v. 2 (2.90%); p = 0.09) and mechanical ventilation time were nonsignificantly higher in Group 2 (19.5 (10-31) vs. 11 (5-25) days; p = 0.07). No difference in mortality was found between groups (42 (60.87%) vs. 23 (67.65%), p = 0.50). By multivariable analysis, elevated lactate on ECMO and low pH before ECMO were associated with mortality. CONCLUSIONS ECMO insertion in the OR has a comparable mortality rate to PCICU insertion. Pre-ECMO low pH and high lactate during ECMO could predict mortality.
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Affiliation(s)
- Hanan R AbuHassan
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiac Research Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Abdullah H Alwadai
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Khaled M AlArwan
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Amira A Ali
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Sadia Rasheed
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Nida B Babikr
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Shawana F Shaikh
- Pediatric Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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Alsoufi B. Hybrid First-stage Palliation and Other Strategies to Achieve Biventricular Repair in High-Risk Neonates With Complex Heart Anomalies and Aortic Arch Obstruction. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2023; 26:40-49. [PMID: 36842797 DOI: 10.1053/j.pcsu.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Medical and surgical advances have allowed single-stage total repair in neonates born with complex congenital heart anomalies and aortic arch obstruction. Nonetheless, total repair might be too complex or high risk in certain neonates with demographic, clinical or morphologic risk factors. Alternative management strategies might offer these neonates better outcomes with superior anatomic repair, shorter hospitalization, reduced morbidity, and improved survival. Alternative initial surgical strategies might include aortic arch repair and pulmonary artery band with or without cardiopulmonary bypass, extracardiac repair only and pulmonary artery band, Norwood operation, and hybrid first-stage palliation; all deferring complex biventricular intra-cardiac repair to later stage. The strategy choice should be personalized to each patient, taking into consideration the morphologic and clinical state, and the existent goals of care.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky.
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Henmi S, Essa Y, Öztürk M, Tongut A, Desai M, Yerebakan C, d'Udekem Y. Cardiovascular surgery in very low birth weight (≤1500 g) neonates. Eur J Cardiothorac Surg 2022; 63:6873741. [PMID: 36469322 DOI: 10.1093/ejcts/ezac552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/08/2022] [Accepted: 12/02/2022] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Soichiro Henmi
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Yasin Essa
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Mahmut Öztürk
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Aybala Tongut
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Manan Desai
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Can Yerebakan
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Yves d'Udekem
- Department of Pediatric Cardiac Surgery, Heart Institute, Children's National Hospital, George Washington University, Washington, DC, USA
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Al-Wassia HK, Al-Radi OO, Maghrabi KA, Bayazeed MA, Qattan MM, Ebraheem DT, Gadi SU, Kattan MF, Alghamdi RA, Alzabidi SH, Dohain AM. The influence of age and weight on the outcomes of complete atrioventricular septal defect repair. Egypt Heart J 2022; 74:55. [PMID: 35849194 PMCID: PMC9294084 DOI: 10.1186/s43044-022-00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The appropriate age and weight for surgical repair of atrioventricular septal defect (AVSD) is an area of controversy. We aimed to study the effect of weight and age at the time of surgical repair for complete AVSD in children less than 2 years of age on postoperative outcomes. A retrospective data review was performed for patients who underwent the AVSD repair from 2012 to 2019 at our institutions. Our primary outcome was the postoperative in-hospital length of stay (LOS). Secondary outcomes included total positive pressure ventilation (PPV), ventilation time, maximum vasoactive–inotropic score (max VIS), and other postoperative complications.
Results
The study included fifty patients. The median age was 191 days, and the median weight was 4.38 kg at the time of surgery. Weight < 4 kg was associated with longer PPV time and postoperative in-hospital LOS (p value of 0.033 and 0.015, respectively). Additionally, they had higher max VIS at 24 h and 48 h than the other groups with bodyweight 4–5.9 kg or ≥ 6 kg (p value of 0.05 and 0.027, respectively). Patients with older age or lower weight at operation had a longer in-hospital LOS and total length of PPV after surgery. There were no postoperative in-hospital deaths.
Conclusions
Older age and lower weight at the time of surgical repair of atrioventricular septal defect could be independent predictors of prolonged postoperative in-hospital length of stay and total length of positive pressure ventilation.
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Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
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9
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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Burgos CM, Frenckner B, Broman LM. Premature and Extracorporeal Life Support: Is it Time? A Systematic Review. ASAIO J 2022; 68:633-645. [PMID: 34593681 DOI: 10.1097/mat.0000000000001555] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Early preterm birth < 34 gestational weeks (GA) and birth weight (BW) <2 kg are relative contraindications for extracorporeal membrane oxygenation (ECMO). However, with improved technology, ECMO is presently managed more safely and with decreasing complications. Thus, these relative contraindications may no longer apply. We performed a systematic review to evaluate the existing literature on ECMO in early and late (34-37 GA) prematurity focusing on survival to hospital discharge and the complication intracranial hemorrhage (ICH). Data sources: MEDLINE, PubMed, Web of Science, Embase, and the Cochrane Database. Only publications in the English language were evaluated. Of the 36 included studies, 23 were related to ECMO support for respiratory failure, 10 for cardiac causes, and four for congenital diaphragmatic hernia (CDH). Over the past decades, the frequency of ICH has declined (89-21%); survival has increased in both early prematurity (25-76%), and in CDH (33-75%), with outcome similar to late prematurity (48%). The study was limited by an inherent risk of bias from overlapping single-center and registry data. Both the risk of ICH and death have decreased in prematurely born treated with ECMO. We challenge the 34 week GA time limit for ECMO and propose an international task force to revise current guidelines. At present, gestational age < 34 weeks might no longer be considered a contraindication for ECMO in premature neonates.
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Affiliation(s)
- Carmen Mesas Burgos
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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11
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Freud LR, Seed M. Prenatal Diagnosis and Management of Single Ventricle Heart Disease. Can J Cardiol 2022; 38:897-908. [DOI: 10.1016/j.cjca.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 12/18/2022] Open
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12
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Altered erythropoiesis in newborns with congenital heart disease. Pediatr Res 2022; 91:606-611. [PMID: 33531673 DOI: 10.1038/s41390-021-01370-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fetal hypoxia has been implicated in fetal growth restriction in congenital heart disease (CHD) and leads to stress erythropoiesis in utero. The objective is to assess erythropoiesis and its association with growth in newborns with CHD. METHODS Fetuses with prenatally diagnosed CHD from 2013 to 2018 were retrospectively reviewed. Pregnancies with multiple gestation, genetic abnormalities, major extra-cardiac anomalies, and placental abruption were excluded. Complete blood count tests at birth were compared to published normative values. Spearman correlation assessed associations of red blood cell (RBC) indices with birth anthropometrics and prenatal Doppler measures. RESULTS A total of 160 newborns were included. Median gestational age was 38.3 (37.3, 39.0) weeks. Infants ≥37 weeks gestation had lower hemoglobin (Hgb), hematocrit, and elevated nucleated RBC (nRBC), mean corpuscular volume, and mean corpuscular hemoglobin compared to reference. No differences in RBC indices were observed in infants <34 and 34-37 weeks gestation. There was no difference in Hgb and nRBC between CHD subgroups. Neither Hgb nor nRBC were associated with birth anthropometrics or Doppler patterns. CONCLUSIONS Term infants with CHD demonstrated multiple alterations in erythrocyte indices suggesting ineffective stress erythropoiesis in late gestation resulting in lower Hgb at birth. Altered erythropoiesis was not correlated to growth or Doppler patterns. IMPACT Newborns with congenital heart disease (CHD) born at term gestation demonstrated altered erythropoiesis. Term newborns with CHD have decreased hemoglobin levels despite having red blood cell indices consistent with stress erythropoiesis, suggesting an incomplete compensatory response to in utero physiologic disturbances associated with CHD. The etiology is unknown; however, it may be influenced by multiple risk factors during pregnancy in the maternal-fetal dyad. Alterations in red blood cell indices were not associated with outcomes of fetal growth.
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13
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Kozik D, Alsoufi B. Commentary: Length of stay as measure of quality: A misty strategy that might backfire. J Thorac Cardiovasc Surg 2021; 163:1616-1617. [PMID: 34906397 DOI: 10.1016/j.jtcvs.2021.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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14
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Kim M, Okunowo O, Ades AM, Fuller S, Rintoul NE, Naim MY. Single-Center Comparison of Outcomes Following Cardiac Surgery in Low Birth Weight and Standard Birth Weight Neonates. J Pediatr 2021; 238:161-167.e1. [PMID: 34214588 DOI: 10.1016/j.jpeds.2021.06.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/19/2021] [Accepted: 06/23/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare outcomes between low birth weight (LBW; <2.5 kg) and standard birth weight neonates undergoing cardiac surgery. STUDY DESIGN A single-center retrospective study of neonates undergoing cardiac surgery with cardiopulmonary bypass from 2012 to 2018. LBW neonates were 1:2 propensity score-matched to standard birth weight neonates (n = 93 to n = 186) using clinical characteristics. The primary and secondary outcomes were survival to hospital discharge and postoperative complications, respectively. After matching, regression analyses were conducted to compare outcomes. RESULTS The LBW group had a higher proportion of premature neonates than the standard birth weight group (60% vs 8%; P < .01) and were less likely to survive to hospital discharge (88% vs 95%; OR, 0.39; 95% CI, 0.15-0.97). There was no difference in unplanned cardiac reoperations or catheter-based interventions, cardiac arrest, extracorporeal membrane oxygenation, infection, and end-organ complications between the groups. Among LBW infants, survival was improved at weight >2 kg. CONCLUSIONS LBW is a risk factor for decreased survival. LBW neonates weighing >2 kg have survival comparable to those weighing >2.5 kg.
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Affiliation(s)
- Minso Kim
- Division of Newborn Medicine, Department of Pediatrics, Mount Sinai Kravis Children's Hospital, New York, NY.
| | - Oluwatimilehin Okunowo
- Data Science & Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne M Ades
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Maryam Y Naim
- Division of Cardiac Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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15
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Zeng X, Hu Y, Shu L, Li J, Duan H, Shu Q, Li H. Explainable machine-learning predictions for complications after pediatric congenital heart surgery. Sci Rep 2021; 11:17244. [PMID: 34446783 PMCID: PMC8390484 DOI: 10.1038/s41598-021-96721-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
The quality of treatment and prognosis after pediatric congenital heart surgery remains unsatisfactory. A reliable prediction model for postoperative complications of congenital heart surgery patients is essential to enable prompt initiation of therapy and improve the quality of prognosis. Here, we develop an interpretable machine-learning-based model that integrates patient demographics, surgery-specific features and intraoperative blood pressure data for accurately predicting complications after pediatric congenital heart surgery. We used blood pressure variability and the k-means algorithm combined with a smoothed formulation of dynamic time wrapping to extract features from time-series data. In addition, SHAP framework was used to provide explanations of the prediction. Our model achieved the best performance both in binary and multi-label classification compared with other consensus-based risk models. In addition, this explainable model explains why a prediction was made to help improve the clinical understanding of complication risk and generate actionable knowledge in practice. The combination of model performance and interpretability is easy for clinicians to trust and provide insight into how they should respond before the condition worsens after pediatric congenital heart surgery.
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Affiliation(s)
- Xian Zeng
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China.,The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yaoqin Hu
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China
| | - Liqi Shu
- Department of Neurology, Rhode Island Hospital, Brown University, Providence, USA
| | - Jianhua Li
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China
| | - Huilong Duan
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Qiang Shu
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China.
| | - Haomin Li
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China.
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16
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Ota N, Tachimori H, Hirata Y, Miyata H, Suzuki T, Uchita S, Takamoto S, Izutani H. Contemporary patterns of the management of truncus arteriosus (primary versus staged repair): outcomes from the Japanese National Cardiovascular Database. Eur J Cardiothorac Surg 2021; 61:787-794. [PMID: 34329388 DOI: 10.1093/ejcts/ezab348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Although primary repair in early infancy has for decades been the prevalent strategy for management of truncus arteriosus (TA), recent concerns about the levels of morbidity and mortality have led to consideration of a staged surgical approach. Our goal was to describe recent patterns of management, to characterize patients who underwent primary or staged repair and to evaluate risk factors associated with operative mortality in a contemporary multicentre cohort. METHODS In the Japanese Cardiovascular Surgery Database, we identified all cases of TA undergoing an initial surgical procedure from 2008 to 2018. Operative mortality was defined as death within 30 days of an operation or in-hospital death regardless of the length of hospital stay. The hospital volume was defined by the average volume of TA repairs per year. RESULTS The total number of patients undergoing initial surgery for TA was 286. Sixty-eight (24%, 68/286) underwent primary repair (primary repair group). The remaining 218 (76%, 218/286) underwent initial bilateral pulmonary artery banding as part of a planned staged approach (staged repair group). One hundred sixty-two patients out of 218 initially banded patients underwent the repair of TA during this study period. Concomitant diagnoses in the entire cohort included interrupted aortic arch repair in 36 patients and truncal valve regurgitation in 32. No centres handling an average of ≥2 truncus cases/year of the repair of TA were identified in this cohort. A total of 30% (85/286) of the cases were performed at centres that handled an average of ≥1 and <2 cases/year. The remaining 70% were at centres with <1 case/year. Overall, 37 patients (12.9%; 37/286) died. The operative mortality rates in the primary and staged repair groups were similar: that for the primary repair group was 16.2% (11/68) versus 11.9% for the staged repair group (26/218; P = 0.41). With multivariable logistic regression analysis, the factors most strongly associated with operative mortality were preoperative heart failure requiring catecholamine support (odds ratio, 4.18; 95% confidence interval 1.96-8.96) and the repeat bilateral pulmonary artery banding (odds ratio, 3.89; 95% confidence interval 1.08-14.07). CONCLUSIONS The staged repair of TA has emerged as the preferred option for surgical timing at most of the centres participating in the Japanese Cardiovascular Surgery Database. The management outcomes of the patients with TA were favourable, even for the patients at low-volume centres.
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Affiliation(s)
- Noritaka Ota
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Division of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shunji Uchita
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Shinichi Takamoto
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
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17
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Sinha R, Altin HF, McCracken C, Well A, Rosenblum J, Kanter K, Kogon B, Alsoufi B. Effect of Atrioventricular Valve Repair on Multistage Palliation Results of Single-Ventricle Defects. Ann Thorac Surg 2021; 111:662-670. [DOI: 10.1016/j.athoracsur.2020.03.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
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18
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Mori Y, Nakashima Y, Kaneko S, Inoue N, Murakami T. Risk Factors for Cardiac Adverse Events in Infants and Children with Complex Heart Disease Scheduled for Bi-ventricular Repair: Prognostic Value of Pre-operative B-Type Natriuretic Peptide and High-Sensitivity Troponin T. Pediatr Cardiol 2020; 41:1756-1765. [PMID: 32808054 DOI: 10.1007/s00246-020-02437-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/07/2020] [Indexed: 11/26/2022]
Abstract
Few reports have described the prognostic value of measuring both B-type natriuretic peptides (BNP) and high-sensitivity troponin T (hs-TnT) in pediatric patients with complex congenital heart disease (CHD) undergoing surgery. We assessed demographic, hemodynamic, and laboratory data, including BNP and hs-TnT levels, for the prediction of cardiac adverse events in 85 patients. Cardiac adverse events were defined as death, cardiac arrest, worsening heart failure requiring inotropic agents and/or respiratory support, and unscheduled surgery/intervention either within or after 12 months of surgery. There were 17 cardiac adverse events. Of the demographic variables, low birth weight (< 2500 g: Odds ratio [OR], 5.97; 95% confidential interval [CI] 1.48-24.0; p = 0.001) and Ross/New York Heart Association [NYHA] class (≥ 2.0) (OR 12.7; 95% CI 3.08-52.7; p = 0.0004) were strongly association with cardiac adverse events. Among hemodynamic and laboratory variables, preoperative BNP (OR 14.04; 95% CI 2.15-91.7; p = 0.001) and hs-TnT levels (OR 16.66; 95% CI 2.27-122; p = 0.002) were found to be independent risk factors. Receiver operating characteristic analysis determined BNP and hs-TnT levels of 60.9 pg/mL and 0.025 ng/mL, respectively, to be markers of high risk. Kaplan-Meier analysis demonstrated significant differences in the freedom from cardiac adverse events between Group A (BNP or hs-TnT elevated, n = 26) and Group B (both biomarkers elevated, n = 19; log-rank, p < 0.001). In conclusion, low birth weight (< 2500 g) and Ross/NYHA class ≥ 2.0 are strongly associated with cardiac adverse events. Preoperative BNP and hs-TnT also provide prognostic information in patients with complex CHD scheduled for surgery. Using both markers in combination predicts cardiac adverse events better than using either separately.
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Affiliation(s)
- Yoshiki Mori
- Division of Pediatric Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan.
| | - Yasumi Nakashima
- Division of Pediatric Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Sachie Kaneko
- Division of Pediatric Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Nao Inoue
- Division of Pediatric Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Tomotaka Murakami
- Division of Pediatric Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
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19
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Alsoufi B. Commentary: It's not that we can't find a solution, it's that we can't isolate the problem. J Thorac Cardiovasc Surg 2020; 160:e69-e70. [DOI: 10.1016/j.jtcvs.2020.04.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 11/29/2022]
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20
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Ross FJ, Radman M, Jacobs ML, Sassano-Miguel C, Joffe DC, Hill KD, Chiswell K, Feng L, Jacobs JP, Vener DF, Latham GJ. Associations between anthropometric indices and outcomes of congenital heart operations in infants and young children: An analysis of data from the Society of Thoracic Surgeons Database. Am Heart J 2020; 224:85-97. [PMID: 32353587 DOI: 10.1016/j.ahj.2020.03.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with congenital heart disease are at risk for growth failure due to inadequate nutrient intake and increased metabolic demands. We examined the relationship between anthropometric indices of nutrition (height-for-age z-score [HAZ], weight-for-age z-score [WAZ], weight-for-height z-score [WHZ]) and outcomes in a large sample of children undergoing surgery for congenital heart disease. METHODS Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having index cardiac surgery at age 1 month to 10 years were included. Indices were calculated by comparing patients' weight and height to population norms from the World Health Organization and Centers for Disease Control and Prevention. Outcomes included operative mortality, composite mortality or major complication, major postoperative infection, and postoperative length of stay. For each outcome and index, the adjusted odds ratio (aOR) (for mortality, composite outcome, and infection) and adjusted relative change in median (for postoperative length of stay) for a 1-unit decrease in index were estimated using mixed-effects logistic and log-linear regression models. RESULTS Every unit decrease in HAZ was associated with 1.40 aOR of mortality (95% CI 1.32-1.48), and every unit decrease in WAZ was associated with 1.33 aOR for mortality (95% CI 1.25-1.41). The relationship between WHZ and outcome was nonlinear, with aOR of mortality of 0.84 (95% CI 0.76-0.93) for 1-unit decrease when WHZ ≥ 0 and a nonsignificant association for WHZ < 0. Trends for other outcomes were similar. Overall, the incidence of low nutritional indices was similar for 1-ventricle and 2-ventricle patients. Children between the age of 1 month and 1 year and those with lesions associated with pulmonary overcirculation had the highest incidence of low nutritional indices. CONCLUSIONS Lower HAZ and WAZ, suggestive of malnutrition, are associated with increased mortality and other adverse outcomes after cardiac surgery in infants and young children. Higher WHZ over zero, suggestive of obesity, is also associated with adverse outcomes.
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Affiliation(s)
- Faith J Ross
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA.
| | - Monique Radman
- Critical Care, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Marshall L Jacobs
- Cardiac Surgery, Johns Hopkins School of Medicine, 1800 Orleans St, Zayed Tower 7107, Baltimore, MD
| | - Claudia Sassano-Miguel
- Clinical Nutrition, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Denise C Joffe
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Kevin D Hill
- Pediatrics, Duke University, DUMC Box 3090, Durham, NC; Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Liqi Feng
- Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Jeffrey P Jacobs
- Cardiothoracic Surgery, Johns Hopkins All Children's Heart Institute, 501 6th Ave S, OCC Suite 607, JHACH Box 6500000606, St Petersburg, FL
| | - David F Vener
- Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, 6651 Main St, Houston, TX
| | - Gregory J Latham
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
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21
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Hames DL, Mills KI, Thiagarajan RR, Teele SA. Extracorporeal Membrane Oxygenation in Infants Undergoing Truncus Arteriosus Repair. Ann Thorac Surg 2020; 111:176-183. [PMID: 32335016 DOI: 10.1016/j.athoracsur.2020.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Infants undergoing truncus arteriosus (TA) repair suffer one of the highest mortality rates of all congenital heart defects. Extracorporeal membrane oxygenation (ECMO) can support patients undergoing TA repair, but little is known about factors contributing to mortality in this cohort. The objective of this study was to identify risk factors for mortality in infants with TA requiring perioperative ECMO. METHODS Data from the Extracorporeal Life Support Organization from 2002 to 2017 for infants less than 60 days old undergoing TA repair were analyzed. Demographics, clinical characteristics, and ECMO characteristics and complications were compared between survivors and nonsurvivors. Multivariable logistic regression was used to evaluate independent risk factors for mortality. RESULTS Of 245 patients analyzed, 92 (37.6%) survived to discharge. Nonsurvivors had a lower weight and a longer ECMO duration. A higher proportion of nonsurvivors suffered complications on ECMO, including mechanical complications, circuit thrombus, bleeding, and need for renal replacement therapy. In multivariable analysis lower weight (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.95), duration of ECMO (OR, 1.1; 95% CI, 1.02-1.18), need for renal replacement therapy (OR, 3.23; 95% CI, 1.68-6.2), cardiopulmonary resuscitation on ECMO (OR, 11.52; 95% CI, 1.3-102.33), and infection on ECMO (OR, 4.47; 95% CI, 1.2-16.64) were independently associated with mortality. CONCLUSIONS Many factors associated with mortality for infants requiring perioperative ECMO with TA repair are related to complications suffered on ECMO. Thoughtful patient selection and meticulous ECMO management to prevent complications are essential in improving outcomes for these infants.
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Affiliation(s)
- Daniel L Hames
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Kimberly I Mills
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi R Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah A Teele
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Ergün S, Yildiz O, Güneş M, Akdeniz HS, Öztürk E, Onan İS, Güzeltaş A, Haydin S. Use of extracorporeal membrane oxygenation in postcardiotomy pediatric patients: parameters affecting survival. Perfusion 2020; 35:608-620. [PMID: 31971070 DOI: 10.1177/0267659119897746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM We aimed to investigate the risk factors affecting survival after extracorporeal membrane oxygenation use in pediatric postcardiotomy patients. METHODS One hundred thirty-three consecutive patients who underwent surgery for congenital heart disease who needed extracorporeal membrane oxygenation support were retrospectively analyzed. RESULTS In all, 3,082 patients were operated, of which 140 patients (4.54% of the total number of operations) needed extracorporeal membrane oxygenation. Eighty (60.1%) patients were successfully weaned and 51 (38.3%) patients were discharged. Of the 50 patients discharged during the mean follow-up period of 34.8 (0-192.4) months, 6 (12%) patients died. The extracorporeal membrane oxygenation support was instituted in 29 (21.8%) patients for extracorporeal membrane oxygenation cardiopulmonary resuscitation, in 44 (33.1%) patients due to the inability to be separated from cardiopulmonary bypass, in 19 (14.3%) patients due to respiratory failure, and in 41 patients due to low cardiac output syndrome. Eighty patients (60.2%) were successfully weaned from extracorporeal membrane oxygenation support. The remaining 53 (39.8%) patients died on extracorporeal membrane oxygenation. Mortality was observed in 29 (21.8%) of the 80 patients in the successful weaning group, while the remaining 51 (38.3%) patients were discharged from the hospital. Multivariate analysis showed that double-ventricular physiology increased the rate of successful weaning (odds ratio: 3.4, 95% confidence interval lower: 1.5 and upper: 8, p = 0.004) and prolonged extracorporeal membrane oxygenation durations were a risk factor in successful weaning (odds ratio: 0.9, 95% confidence interval lower: 0.8 and upper: 0.9, p = 0.007). The parameters affecting mortality were the presence of syndrome (odds ratio: 3.8, 95% confidence interval lower: 1.0 and upper: 14.9, p = 0.05), single-ventricular physiology (odds ratio: 5.3, 95% confidence interval lower: 1.8 and upper: 15.3, p = 0.002), and the need for a second extracorporeal membrane oxygenation (odds ratio: 12.9, 95% confidence interval lower: 1.6 and upper: 104.2, p = 0.02). While 1-year survival was 15.2% and 3-year survival was 12.1% in patients with single-ventricular physiology, the respective survival rates were 43.9% and 40.8%. CONCLUSION Parameters affecting mortality after extracorporeal membrane oxygenation support in pediatric postcardiotomy patient group were the presence of a syndrome, multiple runs of extracorporeal membrane oxygenation, and single-ventricular physiology. Timing of extracorporeal membrane oxygenation initiation, appropriate patient selection, appropriate reintervention or reoperation for patients with correctable pathology, the use of an appropriate cannulation strategy in single-ventricle patients, management of shunt flow, and appropriate interventions to reduce the incidence of complications play key roles in improving survival.
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Affiliation(s)
- Servet Ergün
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Okan Yildiz
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Güneş
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Halil Sencer Akdeniz
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - İsmihan Selen Onan
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Güzeltaş
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Sertaç Haydin
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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23
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Tanem J, Rudd N, Rauscher J, Scott A, Frommelt MA, Hill GD. Survival After Norwood Procedure in High-Risk Patients. Ann Thorac Surg 2019; 109:828-833. [PMID: 31520639 DOI: 10.1016/j.athoracsur.2019.07.070] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multiple single-ventricle populations are noted to be at increased risk for mortality after the Norwood procedure. Preoperative risk factors include low birth weight, restrictive/intact atrial septum, obstructed pulmonary veins, ventricular dysfunction, and atrioventricular valve regurgitation. We report outcomes of the Norwood procedure in standard- and high-risk patients in the recent era. METHODS All patients born with hypoplastic left heart syndrome between 2006 and 2016 who underwent a Norwood procedure at our institution were included. Patient data were retrospectively reviewed, and Kaplan-Meier analysis was used to evaluate survival between groups. RESULTS The cohort included 177 patients. Fifty patients were determined high-risk preoperatively: low birth weight (n = 18), ventricular dysfunction/atrioventricular valve regurgitation (n = 13), intact or restrictive atrial septum/obstructed anomalous pulmonary venous return (n = 14), and multiple factors (n = 5). There were 2 (1.6%) deaths before Glenn in the standard-risk group, with a total of 10 (20%) from the high-risk groups (P < .0001). Survival at 1 year differed greatly between groups, with highest being standard risk at 89% and lowest in the intact septum/obstructed veins group at 54%. The difference between groups in long-term survival was significant (P < .001). CONCLUSIONS Outcomes after the Norwood procedure have improved for standard-risk patients. Those with preoperative risk factors account for most of the early deaths after the Norwood procedure. This high-risk status does not resolve after Glenn, because longer-term survival continues to diverge from the standard-risk group.
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Affiliation(s)
- Jena Tanem
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Nancy Rudd
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Rauscher
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ann Scott
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michele A Frommelt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Garick D Hill
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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24
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Graupner O, Helfrich F, Ostermayer E, Lobmaier SM, Ortiz JU, Ewert P, Wacker-Gussmann A, Haller B, Axt-Fliedner R, Enzensberger C, Abel K, Karge A, Oberhoffer R, Kuschel B. Application of the INTERGROWTH-21st chart compared to customized growth charts in fetuses with left heart obstruction: late trimester biometry, cerebroplacental hemodynamics and perinatal outcome. Arch Gynecol Obstet 2019; 300:601-613. [PMID: 31139902 DOI: 10.1007/s00404-019-05198-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/17/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Birth weight (BW) is crucial for surgical outcome in children with left heart obstruction (LHO). Head circumference (HC) is believed to correlate with the neurocognitive outcome in LHO. Our aim was to investigate the application of international standardized growth charts from the INTERGROWTH-21st project in comparison to customized growth charts in fetal LHO. METHODS This is a retrospective cohort study consisting of 60 singleton pregnancies complicated by fetal LHO. For the z score calculation of estimated fetal weight (EFW) and biometric parameters, the INTERGROWTH-21st calculator was used as well as algorithms of customized growth charts. Antenatal measurements were compared to newborn biometry and the association with fetal Doppler results (MCA PI: middle cerebral artery pulsatility index and CPR: cerebroplacental ratio) was examined. Furthermore, the ability of each antenatal chart to predict adverse perinatal outcome was evaluated. RESULTS At a mean gestational age of 37 weeks, all assessment charts showed significantly smaller mean values for antenatal head circumference (HC) z scores. Highest detection rate for restricted HC growth antenatally was achieved with Hadlock charts. MCA PI and CPR were not associated with neonatal HC. A significant association was observed between EFW and 1-year survival, independent of the considered growth chart. CONCLUSIONS Growth chart independently, antenatal HC did tend to be smaller in LHO fetuses. A significant association was observed between EFW and 1-year survival rate. Prospective investigations in CHD fetuses should be carried out with internationally standardized growth charts to better examine their prognostic value in this high-risk population.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Franziska Helfrich
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Eva Ostermayer
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Silvia M Lobmaier
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Javier U Ortiz
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Defects, German Heart Centre Munich, Munich, Germany
| | - Annette Wacker-Gussmann
- Department of Pediatric Cardiology and Congenital Heart Defects, German Heart Centre Munich, Munich, Germany.,Department of Sport and Health Sciences, Technical University of Munich, München, Germany
| | - Bernhard Haller
- Institute for Medical Informatics, Statistics and Epidemiology (IMedIS), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roland Axt-Fliedner
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Christian Enzensberger
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Kathrin Abel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Anne Karge
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Renate Oberhoffer
- Department of Pediatric Cardiology and Congenital Heart Defects, German Heart Centre Munich, Munich, Germany.,Department of Sport and Health Sciences, Technical University of Munich, München, Germany
| | - Bettina Kuschel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Manuel V, Morais H, Turquetto ALR, Miguel G, Miana LA, Pedro A, Nunes MAS, Leon G, Magalhães MP, Martins T, Júnior APF. Single Ventricle Palliation in a Developing Sub-Saharan African Country: What Should be Improved? World J Pediatr Congenit Heart Surg 2019; 10:164-170. [DOI: 10.1177/2150135118822671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Single ventricle physiology management is challenging, especially in low-income countries. Objective: To report the palliation outcomes of single ventricle patients in a developing African country. Methods: We retrospectively studied 83 consecutive patients subjected to single ventricle palliation in a single center between March 2011 and December 2017. Preoperative data, surgical factors, postoperative results, and survival outcomes were analyzed. The patients were divided by palliation stage: I (pulmonary artery banding [PAB] or Blalock–Taussig shunt [BTS]), II (Glenn procedure), or III (Fontan procedure). Results: Of the 83 patients who underwent palliation (stages I-III), 38 deaths were observed (31 after stage I, six after stage II, and one after stage III) for an overall mortality of 45.7%. The main causes of operative mortality were multiple organ dysfunction due to sepsis, shunt occlusion, and cardiogenic shock. Twenty-eight survivors were lost to follow-up (22 after stage I, six after stage II). Thirteen stage II survivors are still waiting for stage III. The mean follow-up was 366 ± 369 days. Five-year survival was 28.4 % for PAB and 30.1% for BTS, while that for stage II and III was 49.8% and 57.1%, respectively. Age (hazard ratio, 0.61; 95% confidence interval: 0.47-0.7; P = .000) and weight at surgery (hazard ratio, 0.45; 95% confidence interval: 0.31-0.64; P = .002) impacted survival. Conclusion: A high-mortality rate was observed in this initial experience, mainly in stage I patients. A large number of patients were lost to follow-up. A task force to improve outcomes is urgently required.
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Affiliation(s)
- Valdano Manuel
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Division of Cardiovascular Surgery, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Humberto Morais
- Cardiology Department, Hospital Militar Principal/Instituto Superior, Luanda, Angola
| | - Aida L. R. Turquetto
- Division of Cardiovascular Surgery, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Gade Miguel
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
| | - Leonardo A. Miana
- Division of Cardiovascular Surgery, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Albino Pedro
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Pediatric Cardiology Department, Cardiac Surgery Department, Portuguese Red Cross Hospital, Lisbon, Portugal
| | - Maria A. S. Nunes
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Pediatric Cardiology Department, Cardiac Surgery Department, Portuguese Red Cross Hospital, Lisbon, Portugal
| | - Gilberto Leon
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
| | - Manuel Pedro Magalhães
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Pediatric Cardiology Department, Cardiac Surgery Department, Portuguese Red Cross Hospital, Lisbon, Portugal
| | - Telmo Martins
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
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26
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Alsoufi B. Commentary: Assessing risk factors after truncus arteriosus repair-The devil is in the details. J Thorac Cardiovasc Surg 2019; 157:2399-2401. [PMID: 30846262 DOI: 10.1016/j.jtcvs.2019.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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27
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Prognostic Risk Analyses for Postcardiotomy Extracorporeal Membrane Oxygenation in Children: A Review of Early and Intermediate Outcomes. Pediatr Cardiol 2019; 40:89-100. [PMID: 30132053 DOI: 10.1007/s00246-018-1964-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
We evaluated the morbidity and mortality of children requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) to determine independent factors affecting early and intermediate outcomes. Between January 2002 and December 2015, 79 instances of ECMO after cardiac surgery in 73 children were retrospectively reviewed. Follow-up was completed in December 2016. Predictive risk analyses were employed concerning weaning of ECMO, hospital discharge, and mortality after discharge. Age and weight were 14.9 ± 25.6 months and 7.0 ± 5.3 kg, respectively. Median support time was 8.3 ± 4.4 days. Sixty-seven (85%) were successfully weaned off ECMO and 48 (61%) survived to hospital discharge. Multi-variate logistic regression analysis identified the first day to obtain negative fluid balance after initiation of support (adjusted odds ratio = 0.42), high serum lactate levels (0.97), and high total bilirubin (0.84) during support as significant independent factors associated with successful separation from ECMO. The first day of negative fluid balance (0.65) after successful decannulation was an independent risk factor for survival to hospital discharge. After hospital discharge, actuarial 1-year, 5-year, and 10-year survival rates were 94%, 78%, and 78%, respectively. Low weight increased the risk of death after hospital discharge by a multi-variate Cox hazard model. High serum lactate, high serum bilirubin, and unable to obtain early negative fluid balance during support impacted mortality of decannulation. Obtaining a late negative fluid balance in post-ECMO were independent risk factors for death after successful weaning. Low weight affected intermediate outcomes.
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Melekoglu AN, Baspinar O. Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience. J Int Med Res 2018; 47:615-625. [PMID: 30373426 PMCID: PMC6381459 DOI: 10.1177/0300060518806111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures. Methods This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD. Results Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures. Conclusions Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.
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Affiliation(s)
- Asli Nuriye Melekoglu
- 1 Department of Paediatrics, Division of Neonatology, Malatya Training and Research Hospital, Malatya, Turkey
| | - Osman Baspinar
- 2 Department of Paediatrics, Division of Paediatric Cardiology, Faculty of Medicine, The University of Gaziantep, Gaziantep, Turkey
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Alsoufi B, McCracken C, Kochilas LK, Clabby M, Kanter K. Factors Associated With Interstage Mortality Following Neonatal Single Ventricle Palliation. World J Pediatr Congenit Heart Surg 2018; 9:616-623. [DOI: 10.1177/2150135118787723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Several advances have led to improved hospital survival following neonatal palliation (NP) of single ventricle (SV) anomalies. Nonetheless, a number of patients continue to suffer from interstage mortality (ISM) prior to subsequent Glenn. We aim to study patients’ characteristics and anatomic, surgical, and clinical details associated with ISM. Methods: A total of 453 SV neonates survived to hospital discharge following NP. Competing risk analysis modeled events after NP (Glenn, transplantation, or death) and examined variables associated with ISM. Results: Competing risk analysis showed that one year following NP, 10% of patients had died, 87% had progressed to Glenn, 1% had received heart transplantation, and 2% were alive without subsequent surgery. On multivariable analysis, factors associated with ISM were as follows: weight ≤2.5 kg (hazard ratio, HR = 2.4 [1.2-4.6], P = .013), premature birth ≤36 weeks (HR = 2.0 [1.0-4.0], P = .05), genetic syndromes (HR = 3.2 [1.7-6.1], P < .001), unplanned cardiac reoperation (HR = 2.1 [1.0-4.4], P = .05), and prolonged intensive care unit (ICU) stay >30 days following NP (HR = 2.5 [1.4-4.5], P < .001). Palliative surgery type (shunt, Norwood, band) was not associated with ISM, although aortopulmonary shunt circulation after Norwood was (HR = 5.4 [1.5-19.2] P = .01). Of interest, underlying SV anatomy was not associated with ISM (HR = 1.1 [0.6-2.2], P = .749). Conclusions: In our series, ISM following NP occurred in 10% of hospital survivors. As opposed to hospital death, underlying SV anomaly was not associated with ISM. Conversely, several patient factors (prematurity, low weight, and genetic syndromes) and clinical factors (unplanned reoperation and prolonged ICU stay following NP) were associated with ISM. Vigilant outpatient management that is individualized to specific clinical and social needs, taking into account all associated factors, is warranted to improve survival in high-risk patients.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Lazaros K. Kochilas
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha Clabby
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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30
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Alsaied T, Tseng S, King E, Hahn E, Divanovic A, Habli M, Cnota J. Effect of fetal hemodynamics on growth in fetuses with single ventricle or transposition of the great arteries. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:479-487. [PMID: 29057564 DOI: 10.1002/uog.18936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 08/19/2017] [Accepted: 09/29/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES As birth weight is a critical predictor of outcome in neonates with congenital heart defect (CHD), the common problem of poor fetal growth in this population is clinically important. However, it is not well understood and the impact of fetal hemodynamics on fetal growth and birth weight in those with CHD has not been assessed. In this study, we sought to evaluate the association between combined cardiac output (CCO) and fetal middle cerebral artery (MCA) and umbilical artery (UA) pulsatility indices (PIs) and fetal growth in different subgroups of CHD, and to study the effects of fetal hemodynamics on late gestational weight gain. We hypothesized that fetuses with CHD will have lower CCO and be smaller at birth. METHODS This was a retrospective review of fetal echocardiograms from 67 fetuses diagnosed with hypoplastic left heart syndrome (HLHS, n = 30), non-HLHS single ventricle (SV) (n = 20) or dextrotransposition of the great arteries (d-TGA, n = 17), compared with normal controls (n = 42). CCO was calculated using valvar area, velocity-time integral and heart rate and indexed to estimated fetal weight. MCA- and UA-PI were calculated using systolic, diastolic and mean velocities. Fetal biometry was recorded. Regression models were used to study trends in CCO, MCA- and UA-PI and fetal biometry over gestational age. To evaluate fetal weight gain in late gestation, Z-scores of estimated fetal weight at 30 weeks and birth weight were compared. Regression analysis was used to determine the associations of CCO, indexed CCO and MCA- and UA-PI at 30 weeks with birth weight, length and head circumference Z-scores, in addition to weight gain late in gestation. The gestational age of 30 weeks was chosen based on previous studies that found evidence of poor weight gain in fetuses with CHD in late gestation, starting at around that time. RESULTS CCO increased with gestation in all four groups but the rate was slower in fetuses with HLHS and in those with SV. MCA-PI was lower in fetuses with HLHS compared with in those with non-HLHS-SV throughout gestation, suggesting different cerebral blood distribution. At the end of gestation, rate of fetal weight gain slowed in those with HLHS and in those with SV (similar to CCO curves), and head circumference growth rate slowed in all groups but controls. CCO, indexed CCO and MCA- and UA-PI did not correlate with any of the birth measurements or with weight gain late in gestation in fetuses with CHD. CONCLUSIONS We found no associations of CCO or MCA- and UA-PI with late gestational weight gain or biometry at birth in fetuses with CHD. This does not support fetal hemodynamics as the primary driver of suboptimal fetal growth in fetuses with SV. Future research could further explain genetic and placental abnormalities that may affect fetal growth in those with CHD. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- T Alsaied
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Tseng
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - E King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - E Hahn
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A Divanovic
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - M Habli
- Division of Maternal Fetal Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Cnota
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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31
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Alsoufi B, McCracken C, Oster M, Shashidharan S, Kanter K. Genetic and Extracardiac Anomalies Are Associated With Inferior Single Ventricle Palliation Outcomes. Ann Thorac Surg 2018; 106:1204-1212. [DOI: 10.1016/j.athoracsur.2018.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 04/10/2018] [Accepted: 04/18/2018] [Indexed: 12/20/2022]
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32
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Rawal RB, Farquhar DR, Kilpatrick LA, Drake AF, Zdanski CJ. Considering a Weight Criterion for Neonatal Tracheostomy: An Analysis of the ACS NSQIP-P. Laryngoscope 2018; 129:500-505. [PMID: 30194839 DOI: 10.1002/lary.27272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Neonates weighing < 2.5 kg have known higher rates of surgical mortality and morbidity, but this remains unexamined specifically for tracheostomy. We present outcomes of neonates undergoing tracheostomy stratified by weight. METHODS Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric from 2012 to 2014. Patients undergoing tracheostomy were included. Thirty-day mortality and major/minor complication rates were stratified by weight (group 1: < 2.5 kg; group 2: ≥ 2.5 kg and < 4 kg; group 3: ≥ 4 kg). Patient comorbidities were assessed for independent risk factors of morbidity and mortality. RESULTS Of 183,233 patients, 543 underwent tracheostomy. Forty-four patients were group 1 (mean: 2.2 kg ± 0.25); 170 patients were group 2 (mean: 3.31 kg ± 0.42); and 329 patients were group 3 (mean: 6.4 kg ± 2.7). Between groups 1 and 2, there were no significant differences in mortality (P = 0.47), major complication rates (P = 0.99), or minor complication rates (P = 0.64). In comparing all three groups, there were no significant differences in mortality (P = 0.47), major complication rates (P = 0.80), or minor complication rates (P = 0.77). The overall 30-day mortality for all patients was 4.24%. In a multivariate logistical regression model, weight group did not change the odds of all negative outcomes (group 1: odds ratio [OR] of 0.71; 95% confidence interval [CI], 0.33-1.53 and group 2: OR of 0.78; 95% CI, 0.50-1.22). Bronchopulmonary dysplasia was the only independent significant predictor of major complications (OR, 1.69; 95% CI, 1.02-2.79) (P = 0.04). CONCLUSION Our data indicate that 30-day mortality and morbidity outcomes for neonatal tracheostomy are not affected by weight. Overall 30-day mortality should be discussed with caregivers preoperatively. LEVEL OF EVIDENCE 4 Laryngoscope, 129:500-505, 2019.
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Affiliation(s)
- Rounak B Rawal
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Douglas R Farquhar
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Lauren A Kilpatrick
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Amelia F Drake
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Carlton J Zdanski
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
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33
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Alsaied T, Tseng S, King E, Hahn E, Divanovic A, Habli M, Cnota J. Hemodynamic adaptation to suboptimal fetal growth in patients with single ventricle physiology. Echocardiography 2018; 35:1378-1384. [PMID: 29886568 DOI: 10.1111/echo.14047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In fetuses with structurally normal heart and suboptimal fetal growth (SFG), umbilical artery vascular resistance increases as measured by umbilical artery pulsatility index (UA-PI). The objective of this study is to compare hemodynamic responses to SFG in fetuses with single ventricle (SV) and controls with structurally normal heart. METHODS Fetal echocardiograms around 30 weeks of gestation were reviewed. UA-PI and middle cerebral artery pulsatility index (MCA-PI) were calculated. SFG was defined as a birth weight below 25th percentile for gestational age. RESULTS Studies from 92 fetuses were reviewed-SV (n = 50) and controls (n = 42). The prevalence of SFG was higher in SV compared to controls (46% vs 21%, P = .02). In patients with normal heart and SFG, UAPI was significantly higher than normal controls (P = .003) suggesting increased placental vascular resistance. In SV with SFG there was no difference in UAPI compared to SV without SFG. There was no difference in MCA-PI between the groups. CONCLUSIONS The hemodynamic response to SFG in SV varies from fetuses with structurally normal heart. The mechanism of SFG and the placental pathology may be distinct in SV.
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Affiliation(s)
- Tarek Alsaied
- Boston Children's Hospital, Boston Children's Heart Center, Boston, MA, USA.,Cincinnati Children's Hospital Medical Center, Children's Heart Institute, Cincinnati, OH, USA
| | - Stephanie Tseng
- Cincinnati Children's Hospital Medical Center, Children's Heart Institute, Cincinnati, OH, USA
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eunice Hahn
- Cincinnati Children's Hospital Medical Center, Children's Heart Institute, Cincinnati, OH, USA
| | - Allison Divanovic
- Cincinnati Children's Hospital Medical Center, Children's Heart Institute, Cincinnati, OH, USA
| | - Mounira Habli
- Division of Maternal Fetal Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James Cnota
- Cincinnati Children's Hospital Medical Center, Children's Heart Institute, Cincinnati, OH, USA
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34
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Multimodal imaging and three-dimensional cardiac computational modelling in the management of congenital heart disease: The secret to getting ahead is to get started. Arch Cardiovasc Dis 2018; 111:395-398. [DOI: 10.1016/j.acvd.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 11/23/2022]
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35
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Hoxha S, Abbasciano RG, Sandrini C, Rossetti L, Menon T, Barozzi L, Linardi D, Rungatscher A, Faggian G, Luciani GB. Selective Cerebro-Myocardial Perfusion in Complex Neonatal Aortic Arch Pathology: Midterm Results. Artif Organs 2018; 42:457-463. [PMID: 29508410 DOI: 10.1111/aor.13128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/06/2018] [Accepted: 01/09/2018] [Indexed: 01/13/2023]
Abstract
Aortic arch repair in newborns and infants has traditionally been accomplished using a period of deep hypothermic circulatory arrest. To reduce neurologic and cardiac dysfunction related to circulatory arrest and myocardial ischemia during complex aortic arch surgery, an alternative and novel strategy for cerebro-myocardial protection was recently developed, where regional low-flow perfusion is combined with controlled and independent coronary perfusion. The aim of the present retrospective study was to assess short-term and mid-term results of selective and independent cerebro-myocardial perfusion in neonatal aortic arch surgery. From April 2008 to August 2015, 28 consecutive neonates underwent aortic arch surgery under cerebro-myocardial perfusion. There were 17 male and 11 female, with median age of 15 days (3-30 days) and median body weight of 3 kg (1.6-4.2 kg), 9 (32%) of whom with low body weight (<2.5 kg). The spectrum of pathologies treated was heterogeneous and included 13 neonates having single-stage biventricular repair (46%), 7 staged biventricular repair (25%), and 8 single-ventricle repair (29%). All operations were performed under moderate hypothermia and with a "beating heart and brain." Average cardiopulmonary bypass time was 131 ± 64 min (42-310 min). A period of cardiac arrest to complete intra-cardiac repair was required in nine patients (32%), and circulatory arrest in 1 to repair total anomalous pulmonary venous connection. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 30 ± 11 min (15-69 min). Renal dysfunction, requiring a period of peritoneal dialysis was observed in 10 (36%) patients, while liver dysfunction was noted only in 3 (11%). There were three (11%) early and two late deaths during a median follow-up of 2.9 years (range 6 months-7.7 years), with an actuarial survival of 82% at 7 years. At latest follow-up, no patient showed signs of cardiac or neurologic dysfunction. The present experience shows that a strategy of selective and independent cerebro-myocardial perfusion is safe, versatile, and feasible in high-risk neonates with complex congenital arch pathology. Encouraging outcomes were noted in terms of cardiac and neurological function, with limited end-organ morbidity.
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Affiliation(s)
- Stiljan Hoxha
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Riccardo Giuseppe Abbasciano
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | | | - Lucia Rossetti
- Division of Cardiology, University of Verona, Verona, Italy
| | - Tiziano Menon
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Luca Barozzi
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Daniele Linardi
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Alessio Rungatscher
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
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36
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Chen JM. Don't Just Do Something, Stand There! Semin Thorac Cardiovasc Surg 2018; 30:79-80. [PMID: 29501562 DOI: 10.1053/j.semtcvs.2018.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan M Chen
- Congenital Cardiac Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington.
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37
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Alsoufi B, McCracken C, Kanter K, Shashidharan S, Kogon B. Current Results of Single Ventricle Palliation of Patients With Double Inlet Left Ventricle. Ann Thorac Surg 2017; 104:2064-2071. [DOI: 10.1016/j.athoracsur.2017.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/08/2017] [Accepted: 04/12/2017] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Numerous advances in surgical techniques and understanding of single-ventricle physiology have resulted in improved survival. We sought to determine the influence of various demographic, perioperative, and patient-specific factors on the survival of single-ventricle patients following stage 1 palliation at our institution. METHODS We conducted a retrospective study of all single-ventricle patients who had undergone staged palliation at our institution over an 8-year period. Data were collected from the Society of Thoracic Surgeons Congenital Heart Surgery database and from patient charts. Information on age, weight at stage 1 palliation, prematurity, genetic abnormalities, non-cardiac anomalies, ventricular dominance, and type of palliation was collected. Information on mortality and unplanned reinterventions was also collected. RESULTS A total of 72 patients underwent stage 1 palliation over an 8-year period. There were 12 deaths before and one death after stage 2 palliation. There was no hospital mortality following Glenn or Fontan procedures. On univariate analysis, low weight at the time of stage 1 palliation and prematurity were found to be risk factors for mortality following stage 1 palliation. However, multivariable Cox regression analysis revealed weight at stage 1 palliation to be a strong predictor of mortality. The type of stage 1 palliation did not have any influence on the outcome. No difference in survival was noted following the Glenn procedure. CONCLUSION Low weight has a deleterious impact on survival following stage 1 palliation. This is mitigated by stage 2 palliation. The type of stage 1 palliation itself has no bearing on the outcome.
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Alsoufi B, McCracken C, Shashidharan S, Deshpande S, Kanter K, Kogon B. The Impact of 22q11.2 Deletion Syndrome on Surgical Repair Outcomes of Conotruncal Cardiac Anomalies. Ann Thorac Surg 2017; 104:1597-1604. [PMID: 28669502 DOI: 10.1016/j.athoracsur.2017.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 04/09/2017] [Accepted: 04/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aim to describe the impact of 22q11.2 deletion syndrome (22q11DS) on clinical characteristics, postoperative course, and early and late outcomes of neonates undergoing surgery for conotruncal anomalies. METHODS A retrospective review was performed (2002 to 2012) of 224 neonates who underwent surgery for interrupted aortic arch (n = 67), truncus arteriosus (n = 85), or ductal-dependent pulmonary atresia and ventricular septal defect (n = 72). Patients were divided into three groups: group 1, n = 119, no genetic syndrome; group 2, n = 64, 22q11DS; and group 3, n = 41, other genetic syndrome. Adjusted analysis to compare outcomes was performed. RESULTS In comparison with group 1, group 2 had longer mechanical ventilation duration (148 versus 102 hours, p = 0.008), intensive care unit stay (268 versus 159 hours, p < 0.001), and hospital stay (19.3 versus 11.5 days, p < 0.001). On adjusted analysis, there was an insignificant increase in unplanned reoperation (odds ratio [OR] 2.4, 95% confidence interval [CI]: 0.7 to 8.4, p = 0.167) but no increased extracorporeal membrane oxygenation use (OR 1.5, 95% CI: 0.3 to 6.1, p = 0.612), hospital mortality (OR 0.6, 95% CI: 0.1 to 3.3, p = 0.570), or decreased late survival (hazard ratio 0.9, 95% CI: 0.4 to 2.1, p = 0.822). In comparison with group 1, group 3 had longer mechanical ventilation duration (190 versus 102 hours, p < 0.001), intensive care unit stay (236 versus 159 hours, p = 0.007), and hospital stay (21.5 versus 11.5 days, p < 0.001); and increased unplanned reoperation (OR 3.7, 95% CI: 1.1 to 12.5, p = 0.032), extracorporeal membrane oxygenation use (OR 4.4, 95% CI: 1.1 to 17.6, p = 0.038), hospital mortality (OR 4.2, 95% CI: 1.2 to 14.5, p = 0.021), and diminished late survival (hazard ratio 4.0, 95% CI: 2.1 to 8.1, p < 0.001). CONCLUSIONS In neonates with conotruncal anomalies, 22q11DS is associated with prolonged recovery and increased resource utilization. However, despite a small increase in unplanned reoperation, there is no significant impact on early or late survival. In comparison, other genetic syndromes are associated with increased unplanned reoperation, extracorporeal membrane oxygenation use, hospital mortality, and diminished late survival. These findings are important for family counseling and risk stratification.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
| | - Courtney McCracken
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Subhadra Shashidharan
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Shriprasad Deshpande
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
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Chittithavorn V, Duangpakdee P, Rergkliang C, Pruekprasert N. Risk factors for in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functionally univentricular heart undergoing a modified Blalock–Taussig shunt†. Interact Cardiovasc Thorac Surg 2017; 25:407-413. [DOI: 10.1093/icvts/ivx147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 04/14/2017] [Indexed: 12/13/2022] Open
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Ednie AC, Amram O, Schuurman N, Yanchar NL. Comparing pyloromyotomy outcomes across Canada. J Pediatr Surg 2017; 52:739-743. [PMID: 28238307 DOI: 10.1016/j.jpedsurg.2017.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 01/23/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Changing patterns of referral and management of hypertrophic pyloric stenosis (HPS) in North America have recently been described. Comfort with perioperative management, anesthesia, and corrective surgery have been cited as reasons for these changes. Our primary objective was to assess pyloromyotomy outcomes between different hospital types across Canada. The secondary objective was to geospatially map all pyloromyotomies to identify regions of higher HPS incidence across Canada. METHODS Data of all pyloromyotomies done between 2011 and 2013 were acquired from Canadian Institute for Health Information (CIHI). Complication rates and length of hospital stay (LOS) were analyzed. Postal codes for each patient were used to geospatially map regions of higher HPS incidence. RESULTS A total of 1261 pyloromyotomies were assessed. There was no difference in LOS or complication rates between different hospital types or surgeon group. Open pyloromyotomies were done in 75% of the cases. Several regions of higher HPS incidence were identified across Canada. CONCLUSION This study found no difference in complication rate or LOS stay between hospital type and surgeon type across Canada. This may reflect a previously identified referral trend in the United States towards pediatric centers. Several regions of higher HPS incidence were identified, and may aid in identifying genetic elements causing HPS. LEVEL OF EVIDENCE 2c.
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Affiliation(s)
- Alexander C Ednie
- Dalhousie University, Division of General Surgery, QEII Health Sciences Centre, 8-813 VG Site, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.
| | - Ofer Amram
- Simon Fraser University, Department of Geography, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Nadine Schuurman
- Simon Fraser University, Department of Geography, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Natalie L Yanchar
- Dalhousie University, Division of General Surgery, QEII Health Sciences Centre, 8-813 VG Site, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada; IWK Health Centre, Division of Pediatric Surgery, 5980 University Ave, Halifax, NS, B3K 6R8, Canada
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Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals. J Thorac Cardiovasc Surg 2017; 153:1519-1526. [PMID: 28259455 DOI: 10.1016/j.jtcvs.2016.12.042] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/20/2016] [Accepted: 12/30/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. METHODS We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within-center correlation. RESULTS The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18% had major extracardiac anomalies, and 74% underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95% confidence interval, 1.4-6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in-hospital mortality (8% vs 2%, P = .002). CONCLUSIONS This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4-fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes.
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Talbot LJ, Sinyard RD, Rialon KL, Englum BR, Tracy ET, Rice HE, Adibe OO. Influence of weight at enterostomy reversal on surgical outcomes in infants after emergent neonatal stoma creation. J Pediatr Surg 2017; 52:35-39. [PMID: 27916444 DOI: 10.1016/j.jpedsurg.2016.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (< 2.5kg) is associated with poor surgical outcomes. METHODS Patients who underwent enterostomy reversal from 2005 to 2013 at less than 6months old were identified in our institutional database. Only patients who underwent emergent enterostomy creation (i.e. for necrotizing enterocolitis or spontaneous perforation) were included. Demographics, disease process, comorbidities, stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of p<0.05. The primary outcome examined was major morbidity, defined as the presence of anastomotic leak, obstruction, hernia, EC fistula, perforation, wound infection, sepsis, or death. RESULTS Eighty-nine patients met inclusion criteria. Demographics (sex, ethnicity, surgical disease process, reversal indication, and ASA score) were similar. The lowest weight group had lower gestational age (p<0.001) and birth weight (p=0.005), and contained a higher proportion of jejunostomies to ileostomies (p=0.013). On univariable analysis, only incisional hernia was significantly different as a complication between weight groups. On multivariable analysis controlling for gestational age and ASA, there was no significant difference in odds of major operative morbidity between groups. CONCLUSIONS Enterostomy reversal at lower weight may not be associated with increased risk of perioperative complications. Early stoma reversal may be acceptable when required for progression of neonatal care. LEVEL OF EVIDENCE Level III, Treatment Study (Retrospective comparative study).
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Affiliation(s)
| | - Robert D Sinyard
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kristy L Rialon
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Henry E Rice
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Obinna O Adibe
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
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Rhee YJ, Han SJ, Chong YY, Kang MW, Kang SK, Yu JH. Extracorporeal Membrane Oxygenation in a 1,360-g Premature Neonate after Repairing Total Anomalous Pulmonary Venous Return. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:379-382. [PMID: 27733999 PMCID: PMC5059125 DOI: 10.5090/kjtcs.2016.49.5.379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/01/2015] [Accepted: 11/03/2015] [Indexed: 12/02/2022]
Abstract
With advancements in complex repairs in neonates with complicated congenital heart diseases, extracorporeal membrane oxygenation (ECMO) has been increasingly used as cardiac support. ECMO has also been increasingly used for low birth weight (LBW) or very low birth weight (VLBW) neonates. However, since prematurity and LBW are risk factors for ECMO, the appropriate indications for neonates with LBW, especially VLBW, are under dispute. We report a case of ECMO performed in a 1,360-g premature infant with VLBW due to cardiopulmonary bypass weaning failure after repairing infracardiac total anomalous pulmonary venous return.
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Affiliation(s)
- Youn Ju Rhee
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Sung Joon Han
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Yoo Young Chong
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Min-Woong Kang
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Shin Kwang Kang
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Jae-Hyeon Yu
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
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Left Upper Lobectomy for Congenital Lobar Emphysema in a Low Weight Infant. Case Rep Surg 2016; 2016:4182741. [PMID: 27597924 PMCID: PMC5002461 DOI: 10.1155/2016/4182741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 06/26/2016] [Accepted: 07/21/2016] [Indexed: 11/22/2022] Open
Abstract
Congenital lobar emphysema (CLE) is a rare lung congenital malformation. Differential diagnosis of the disease remains challenging in an infant with acute respiratory distress. We report a case of a 3-week-old female infant with a weight of 2.1 kg who presented respiratory distress related to CLE. Left upper lobectomy was performed and she had an uneventful recovery.
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Palliation Outcomes of Neonates Born With Single-Ventricle Anomalies Associated With Aortic Arch Obstruction. Ann Thorac Surg 2016; 103:637-644. [PMID: 27592600 DOI: 10.1016/j.athoracsur.2016.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/07/2016] [Accepted: 06/13/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The two most common surgical strategies for the treatment of neonates born with single-ventricle anomalies associated with aortic arch obstruction are the Norwood operation and pulmonary artery banding plus coarctation repair (PAB+COA). We reviewed characteristics and outcomes of neonates who underwent those two surgical strategies at our institution. METHODS Between 2002 and 2012, 94 neonates with a single ventricle and aortic arch obstruction (excluding hypoplastic left heart syndrome) underwent Norwood (n = 65) or PAB+COA (n = 29). Outcomes were parametrically modeled, and risk factors associated with early and late death were analyzed. RESULTS Competing-risks analysis showed that, at 2 years after the operation, 24% of patients had died or received transplantation and 75% had undergone a Glenn shunt. At 5 years after the Glenn shunt, 10% of patients had died or received transplantation, 62% had undergone Fontan, and 28% were alive awaiting Fontan. Overall 8-year survival was 70%. Outcomes after Norwood included extracorporeal membrane oxygenation use in 9 (14%), unplanned reoperation in 13 (20%), hospital death in 10 (15%), and interstage death in 8 (12%), with 8-year survival of 66%. Outcomes after PAB+COA included extracorporeal membrane oxygenation use in 1 (3%), unplanned reoperation in 9 (30%), hospital death in 1 (3%), and interstage death in 3 (10%), with 8-year survival of 76%. There was an association trend between underlying anatomy and survival (hazard ratio [HR], 2.1; 95% confidence interval [CI], 0.9 to 4.7; p = 0.087). On multivariable analysis, factors associated with death were extracorporeal membrane oxygenation use (HR, 5.5; 95% CI, 1.9 to 15.9; p = 0.002), genetic syndromes/extracardiac anomalies (HR, 3.5; 95% CI, 1.5 to 8.2; p = 0.003), and weight of 2.5 kg or less (HR, 3.0; 95% CI, 1.3 to 7.2; p = 0.012). CONCLUSIONS Anatomic and patient characteristics influence palliation outcomes in neonates born with single-ventricle anomalies associated with aortic arch obstruction. Although the Norwood operation is applicable in most of these patients, the PAB+COA strategy is a valid alternative in well-selected patients.
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Is there a limit to how far we should push the envelope in pediatric cardiac surgery? J Thorac Cardiovasc Surg 2016; 152:707-8. [DOI: 10.1016/j.jtcvs.2016.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 05/26/2016] [Indexed: 11/22/2022]
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Outcomes of neonates requiring prolonged stay in the intensive care unit after surgical repair of congenital heart disease. J Thorac Cardiovasc Surg 2016; 152:720-727.e1. [DOI: 10.1016/j.jtcvs.2016.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/08/2016] [Accepted: 04/13/2016] [Indexed: 12/31/2022]
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Loomba RS, Nijhawan K, Anderson R. Impact of Era, Type of Isomerism, and Ventricular Morphology on Survival in Heterotaxy: Implications for Therapeutic Management. World J Pediatr Congenit Heart Surg 2016; 7:54-62. [PMID: 26714995 DOI: 10.1177/2150135115601831] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heterotaxy has been demonstrated to reduce survival. There are several different subgroups of patients, however, and no single study has had a large number of patients and analyzed survival across the different subgroups such as patients born in different eras, patients with right and left isomerism, and patients with biventricular or functionally univentricular hearts. This study pools previously reported data from Kaplan-Meier curves and performs such subgroup analysis. METHODS A systematic review of the literature was performed to identify studies reporting survival of patients with the so-called "heterotaxy" by means of Kaplan-Meier survival curves. Data were extracted from these survival curves and then pooled together. A polynomial regression was then used to generate a pooled survival curve. This was done for all patients, those born in a more recent era, those with right and left isomerism, and those with biventricular or functionally univentricular hearts. RESULTS Those born in the more recent era (after 2000) had increased survival compared to the overall cohort. Those with left isomerism tended to have a survival benefit compared to those with right isomerism until about 16 years of age, beyond which those with right isomerism developed a survival benefit. Those with biventricular hearts had a survival benefit compared to those with left isomerism. CONCLUSION Survival in the so-called heterotaxy syndrome is based on several factors, which include era of birth, sidedness of isomerism, and whether the heart is biventricular or functionally univentricular.
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Affiliation(s)
- Rohit S Loomba
- Division of Cardiology, Children's Hospital of Wisconsin/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Karan Nijhawan
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Robert Anderson
- Institute of Genetic Medicine, Newcastle University, United Kingdom
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Alsoufi B, Gillespie S, Kim D, Shashidharan S, Kanter K, Maher K, Kogon B. The Impact of Dominant Ventricle Morphology on Palliation Outcomes of Single Ventricle Anomalies. Ann Thorac Surg 2016; 102:593-601. [DOI: 10.1016/j.athoracsur.2016.04.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 11/16/2022]
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