Non-transplant cardiac surgery for end-stage dilated cardiomyopathy in small children

Mitral valve surgery for severe mitral regurgitation and dilated cardiomyopathy--a bridge to transplant: case report and a review of literature

We report a child with myocardial necrosis, dilated cardiomyopathy, and severe mitral valve (MV) regurgitation following neonatal enteroviral myocarditis. He underwent MV annuloplasty at 18 months and MV replacement at 3 years of age. He remains asymptomatic on medical therapy at 8 years of age. Mitral valve surgery may stabilize the evolution of dilated cardiomyopathy and delay the ultimate need for heart transplant.

Usefulness of mitral regurgitation as a marker of increased risk for death or cardiac transplantation in idiopathic dilated cardiomyopathy in children

In adults with idiopathic dilated cardiomyopathy (IDC), mitral regurgitation (MR) is associated with adverse prognosis and is often addressed by surgery or intervention. MR is commonly found in children with IDC, but its prognostic relevance has not been defined, and interventions to reduce MR are not routinely performed in this population. In this study, it was hypothesized that MR is an independent risk factor for death or transplantation. This was a single-center, retrospective study of sequential patients with IDC or familial IDC (left ventricular end-diastolic dimension z score >2 and ejection fraction <50%). Patients with acute myocarditis or previous mitral surgery were excluded. MR severity was graded according to American Society of Echocardiography guidelines as mild, moderate, or severe on the basis of MR jet vena contracta width. Left ventricular end-diastolic volume, end-systolic volume, and ejection fraction were measured by biplane Simpson's method. Forty-two children with IDC were studied. The mean follow-up period was 25 months. At initial assessment, 34 children (82%) were taking angiotensin-converting enzyme inhibitors, 25 (60%) furosemide, 27 (65%) β blockers, and 7 (17%) intravenous inotropes. The mean indexed end-systolic volume was 91 ± 51 ml/m(2). The mean ejection fraction was 27 ± 16%. MR was mild in 42%, moderate in 19%, severe in 2%, and absent in 35% of patients. MR severity progressed from initial to last evaluation. MR severity was an independent risk factor for lower freedom from death or transplantation. Progression in MR severity increased the annual hazard of death or transplantation by a factor of 2.4 (p = 0.003). In conclusion, MR severity is independently associated with worse clinical status and decreased freedom from death or transplantation in children with IDC.

Special report: Nursing diagnoses and interventions for a child with dilated cardiomyopathy requiring intra-aortic balloon pump support--case report

OBJECTIVE

The study aims to identify the nursing diagnoses and interventions for a child requiring intra-aortic balloon pump support.

METHODS

This was a case study of a 7-year-old child. The nursing diagnoses and interventions were obtained by three cardiology and pediatric specialist nurses, familiar with NANDA-International and Nursing Intervention Classification taxonomies.

RESULTS

Many nursing diagnoses and interventions were identified, but the main diagnosis for this patient was decreased cardiac output.

CONCLUSIONS

The nursing care for a child with an intra-aortic balloon requires well-qualified professionals, prepared to handle the diagnoses and interventions identified in this study.

PRACTICAL IMPLICATIONS

The use of a standard language system is essential to guide professionals in the caring process, providing essential elements to optimize interpretations.

The efficacy of mitral valve surgery in children with dilated cardiomyopathy and severe mitral regurgitation

Severe mitral regurgitation predicts poor outcomes in adults with left ventricular dysfunction. Frequently, adult patients now undergo initial mitral valve surgery instead of heart transplant. Pediatric data are limited. This study evaluates the efficacy of mitral valve surgery for severe mitral regurgitation in children with dilated cardiomyopathy. This is a single-institution experience in seven children (range, 0.5-10.9 years) with severe mitral regurgitation and dilated cardiomyopathy who underwent mitral valve surgery between January 1988 and February 2005, with follow-up to January 2006. Children with dilated cardiomyopathy had a depressed fractional shortening preoperatively (24.4% +/- 6.1%) that remained depressed (22.9% +/- 7.6%) 1.3 +/- 1.2 years after surgery (p = 0.50). Left ventricular end-diastolic (6.5 +/- 1.5 to 4.8 +/- 1.8 z-scores, p < 0.01) and end-systolic (6.8 +/- 1.5 to 5.5 +/- 2.1 z-scores, p < 0.05) dimensions improved. Hospitalization frequency had a median decrease of 6.0 hospitalizations per year (p < 0.02). Three patients were transplanted 0.2, 2.4, and 3.5 years after surgery. There was no perioperative mortality. Mitral valve surgery in children with dilated cardiomyopathy was performed safely and improved symptoms, stabilizing ventricular dysfunction in most patients. Mitral valve surgery should be considered prior to heart transplant in children with dilated cardiomyopathy and severe mitral regurgitation.

Outcome for Pediatric Cardiac Transplantation With and Without Bridge Methods

Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. Due to the shortage of pediatric donor hearts, various bridge techniques have been used for pediatric recipients to prolong patient survival until a heart is available. This study evaluates long-term outcome of bridge and nonbridge support for pediatric heart transplantation. Between March 1995 and June 2004, 18 pediatric patients underwent heart transplantation. Six patients (33.3%) underwent biological or mechanical bridge techniques before transplantation. Eight patients (44.4%) required perioperatively extracorporeal membrane oxygenation (ECMO) support. Patient data and records were retrospectively reviewed. Causes of death and long-term outcome were analyzed. Five of eight patients in the ECMO group (62.5%) were successfully decannulated and discharged home with excellent functional classes. No differences in rejection rate, survival rate, and functional class existed between the bridged and nonbridged groups. Overall 1-year and 5-year survival rates were both 83.3% and all have a good functional class. Pediatric heart transplantation can be accomplished with excellent early survival despite multiple prior cardiac operations and relatively severe illness. For the variety in small, low-body-weight pediatric patients, mechanical circulatory support using ECMO is suitable for managing sudden collapse while waiting for heart transplantation, and graft dysfunction after cardiac transplantation. The mortality rate is acceptable in this very high-risk group of patients and long-term outcome is good.