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Yuerek M, Rossano JW, Mascio CE, Shaddy RE. Postoperative management of heart failure in pediatric patients. Expert Rev Cardiovasc Ther 2015; 14:201-15. [PMID: 26560361 DOI: 10.1586/14779072.2016.1117388] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25-65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.
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Affiliation(s)
- Mahsun Yuerek
- a Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Joseph W Rossano
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Christopher E Mascio
- c Division of Pediatric Cardiothoracic Surgery, Department of Surgery , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Robert E Shaddy
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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Shi WY, Li S, Collins N, Cottee DB, Bastian BC, James AN, Mejia R. Peri-operative Levosimendan in Patients Undergoing Cardiac Surgery: An Overview of the Evidence. Heart Lung Circ 2015; 24:667-72. [PMID: 25862519 DOI: 10.1016/j.hlc.2015.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
Levosimendan, a calcium sensitiser, has recently emerged as a valuable agent in the peri-operative management of cardiac surgery patients. Levosimendan is a calcium-sensitising ionodilator. By binding to cardiac troponin C and reducing its calcium-binding co-efficient, it enhances myofilament responsiveness to calcium and thus enhances myocardial contractility without increasing oxygen demand. Current evidence suggests that levosimendan enhances cardiac function after cardiopulmonary bypass in patients with both normal and reduced left ventricular function. In addition to being used as post-operative rescue therapy for low cardiac output syndrome, a pre-operative levosimendan infusion in high risk patients with poor cardiac function may reduce inotropic requirements, the need for mechanical support, the duration of intensive care admissions as well as post-operative mortality. Indeed, it is these higher-risk patients who may experience a greater degree of benefit. Larger, multicentre randomised trials in cardiac surgery will help to elucidate the full potential of this agent.
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Affiliation(s)
- William Y Shi
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia; Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia; The University of Melbourne, Australia.
| | - Sheila Li
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Nicholas Collins
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - David B Cottee
- Department of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
| | - Bruce C Bastian
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Allen N James
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Ross Mejia
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia
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Elahi MM, Chuang A, Ewing MJ, Choi CH, Grant PW, Matata BM. One problem two issues! Left ventricular systolic and diastolic dysfunction in aortic stenosis. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:10. [PMID: 25332986 DOI: 10.3978/j.issn.2305-5839.2013.06.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 06/19/2013] [Indexed: 01/19/2023]
Abstract
Reports suggested that immediate post-aortic valve replacement (AVR); left ventricular (LV) dysfunction may be an important risk for morbidity and mortality in patients requiring positive inotropic support. Several factors have been identified as significant prognostic factors i.e., LV systolic dysfunction, LV diastolic dysfunction (LV-DD), heart failure and myocardial infarction (MI). Specific to pathophysiological changes associated with AS, markers of systolic LV function (e.g., LVEF) have been extensively studied in management, yet only a few studies have analysed the association between LV-DD and immediate post-operative LV dysfunction This review brings together the current body of evidence on this issue.
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Affiliation(s)
- Maqsood M Elahi
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Anthony Chuang
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Michael J Ewing
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Charles H Choi
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Peter W Grant
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Bashir M Matata
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
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Hyldebrandt JA, Frederiksen CA, Heiberg J, Rothmann S, Redington AN, Schmidt MR, Ravn HB. Inotropic therapy for right ventricular failure in newborn piglets: effect on contractility, hemodynamics, and interventricular interaction. Pediatr Crit Care Med 2014; 15:e327-33. [PMID: 25080150 DOI: 10.1097/pcc.0000000000000202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the effect of right ventricular stunning on interventricular relationships in newborn piglets and to determine the effect of three commonly used inotropic treatment strategies. DESIGN Randomized, placebo-controlled animal study. SETTING Aarhus University Hospital, animal laboratory. SUBJECTS Twenty-eight newborn (4-d old) farm-bred piglets. INTERVENTIONS Acute right ventricular failure was induced by 10 cycles of alternating 3 minutes of ischemia and reperfusion of the right coronary artery. After right ventricular failure was induced, treatment with epinephrine + milrinone, dopamine + milrinone, dobutamine, or control (saline) was initiated, and the animals were observed for 180 minutes. MEASUREMENTS AND MAIN RESULTS Right and left ventricular systolic and diastolic variables were measured using pressure-volume loops recorded by conductance catheters. Arterial and central venous pressures were recorded, and cardiac index was determined by placing a flow probe around the pulmonary artery. Whole-body perfusion was evaluated by measuring pH and lactate in arterial blood samples. Induction of right ventricular stunning resulted in decreased ejection fraction (51% ± 4% vs 40% ± 12%, p = 0.0004); caused an interventricular septum deviation, decreased mean arterial pressure (49 ± 10 mm Hg vs 43 ± 11 mm Hg, p = 0.03), and increased blood lactate (1.85 ± 0.6 mM vs 5.79 ± 3.16 mM, p < 0.00001); and led to a decrease in blood pH (7.37 ± 0.08 vs 7.23 ± 0.13, p < 0.00001). A mortality rate greater than 50% was observed in the control group. All inotropic interventions increased contractility significantly in both the left and right ventricle. The effect of dobutamine on right ventricular failure decreased after 30 minutes and was indistinguishable from the control group after 3 hours. Dobutamine-treated animals had lower perfusion pressures and blood pH compared with epinephrine + milrinone and dopamine + milrinone groups. CONCLUSIONS In newborn piglets, dobutamine had a nonsustained effect on right ventricular failure, resulting in decreased contractility and impaired perfusion compared with both dopamine and epinephrine administered in combination with milrinone.
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Affiliation(s)
- Janus A Hyldebrandt
- 1Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark. 2Department of Clinical Medicine, Aarhus University, Aarhus, Denmark. 3Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark. 4The Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada. 5Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Jiang G, Li B, Zhang G, Xu E, Liu Y, Xu Z. Effects of sildenafil on prognosis in patients with pulmonary hypertension after left-sided valvular surgery. Heart Lung Circ 2014; 23:680-5. [PMID: 24613188 DOI: 10.1016/j.hlc.2013.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sildenafil (Viagra, Pfizer) is being used to treat pulmonary hypertension (PH). However, there are limited data on the effects of sildenafil on patients with PH after left-sided valvular surgery. The purpose of this study was to determine the optimal dosage and the effects of sildenafil on prognosis of patients with PH after left-sided valvular surgery. METHODS This randomised controlled trial, double-blind study enrolled patients with PH undergoing left-sided valvular surgery in our hospital from January to December, 2010. Ninety patients were enrolled. And 0.5 mg/kg sildenafil citrate or placebo was administered through nasogastric tubes, the haemodynamics changes in the 0.5/1/2/4 hours were assessed. The sildenafil citrate/placebo was continued to the discharges and the early prognoses of these patients were compared. RESULTS Compared with placebo, a 0.5 mg/kg dose of sildenafil significantly reduced the time of mechanical ventilation, stay-in-ICU and hospitalisation duration. CONCLUSIONS Sildenafil might be beneficial to the early prognosis of patients with PH after left-sided valvular surgery.
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Dobson GP, Faggian G, Onorati F, Vinten-Johansen J. Hyperkalemic cardioplegia for adult and pediatric surgery: end of an era? Front Physiol 2013; 4:228. [PMID: 24009586 PMCID: PMC3755226 DOI: 10.3389/fphys.2013.00228] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/05/2013] [Indexed: 12/16/2022] Open
Abstract
Despite surgical proficiency and innovation driving low mortality rates in cardiac surgery, the disease severity, comorbidity rate, and operative procedural difficulty have increased. Today's cardiac surgery patient is older, has a "sicker" heart and often presents with multiple comorbidities; a scenario that was relatively rare 20 years ago. The global challenge has been to find new ways to make surgery safer for the patient and more predictable for the surgeon. A confounding factor that may influence clinical outcome is high K(+) cardioplegia. For over 40 years, potassium depolarization has been linked to transmembrane ionic imbalances, arrhythmias and conduction disturbances, vasoconstriction, coronary spasm, contractile stunning, and low output syndrome. Other than inducing rapid electrochemical arrest, high K(+) cardioplegia offers little or no inherent protection to adult or pediatric patients. This review provides a brief history of high K(+) cardioplegia, five areas of increasing concern with prolonged membrane K(+) depolarization, and the basic science and clinical data underpinning a new normokalemic, "polarizing" cardioplegia comprising adenosine and lidocaine (AL) with magnesium (Mg(2+)) (ALM™). We argue that improved cardioprotection, better outcomes, faster recoveries and lower healthcare costs are achievable and, despite the early predictions from the stent industry and cardiology, the "cath lab" may not be the place where the new wave of high-risk morbid patients are best served.
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Affiliation(s)
- Geoffrey P. Dobson
- Department of Physiology and Pharmacology, Heart and Trauma Research Laboratory, James Cook UniversityTownsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Jakob Vinten-Johansen
- Cardiothoracic Research Laboratory of Emory University Hospital Midtown, Carlyle Fraser Heart CenterAtlanta, GA, USA
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Change in regional (somatic) near-infrared spectroscopy is not a useful indicator of clinically detectable low cardiac output in children after surgery for congenital heart defects. Pediatr Crit Care Med 2012; 13:529-34. [PMID: 22596064 DOI: 10.1097/pcc.0b013e3182389531] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Near-infrared spectroscopy correlation with low cardiac output has not been validated. Our objective was to determine role of splanchnic and/or renal oxygenation monitoring using near-infrared spectroscopy for detection of low cardiac output in children after surgery for congenital heart defects. DESIGN Prospective observational study. SETTING Pediatric intensive care unit of a tertiary care teaching hospital. PATIENTS Children admitted to the pediatric intensive care unit after surgery for congenital heart defects. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We hypothesized that splanchnic and/or renal hypoxemia detected by near-infrared spectroscopy is a marker of low cardiac output after pediatric cardiac surgery. Patients admitted after cardiac surgery to the pediatric intensive care unit over a 10-month period underwent serial splanchnic and renal near-infrared spectroscopy measurements until extubation. Baseline near-infrared spectroscopy values were recorded in the first postoperative hour. A near-infrared spectroscopy event was a priori defined as ≥20% drop in splanchnic and/or renal oxygen saturation from baseline during any hour of the study. Low cardiac output was defined as metabolic acidosis (pH <7.25, lactate >2 mmol/L, or base excess ≤-5), oliguria (urine output <1 mL/kg/hr), or escalation of inotropic support. Receiver operating characteristic analysis was performed using near-infrared spectroscopy event as a diagnostic test for low cardiac output. Twenty children were enrolled: median age was 5 months; median Risk Adjustment for Congenital Heart Surgery category was 3 (1-6); median bypass and cross-clamp times were 120 mins (45-300 mins) and 88 mins (17-157 mins), respectively. Thirty-one episodes of low cardiac output and 273 near-infrared spectroscopy events were observed in 17 patients. The sensitivity and specificity of a near-infrared spectroscopy event as an indicator of low cardiac output were 48% (30%-66%) and 67% (64%-70%), respectively. On receiver operating characteristic analysis, neither splanchnic nor renal near-infrared spectroscopy event had a significant area under the curve for prediction of low cardiac output (area under the curve: splanchnic 0.45 [95% confidence interval 0.30-0.60], renal 0.51 [95% confidence interval 0.37-0.65]). CONCLUSIONS Splanchnic and/or renal hypoxemia as detected by near-infrared spectroscopy may not be an accurate indicator of low cardiac output after surgery for congenital heart defects.
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Age- and chamber-specific differences in oxidative stress after ischemic injury. Pediatr Cardiol 2012; 33:322-31. [PMID: 22057242 PMCID: PMC3287060 DOI: 10.1007/s00246-011-0137-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
Each year, tens of thousands of children undergo cardiopulmonary bypass (CPB) to correct congenital heart defects. Although necessary for surgery, CPB involves stopping the heart and exposing it to ischemic conditions. On reoxygenation, the heart can experience effects similar to that of acute myocardial infarction. Although much is known about adult injury, little is known about the effects of global ischemia on newborn ventricles. We studied newborn (2 to 4 days old) and adult (>8 weeks old) rabbit hearts subjected to ischemia-reperfusion (30 min of ischemia and 60 min of reperfusion). Our data demonstrated chamber- and age-specific changes in oxidative stress. During ischemia, hydrogen peroxide (H(2)O(2)) increased in both right-ventricular (RV) and left-ventricular (LV) myocytes of the newborn, although only the RV change was significant. In contrast, there was no significant increase in H(2)O(2) in either RV or LV myocytes of adults. There was a fivefold increase in H(2)O(2) formation in newborn RV myocytes compared with adults (P = 0.006). In whole-heart tissue, superoxide dismutase activity increased from sham versus ischemia in the left ventricle of both adult and newborn hearts, but it was increased only in the right ventricle of the newborn heart. Catalase activity was significantly increased after ischemia in both adult ventricles, whereas no increase was seen in newborn compared with sham hearts. In addition, catalase levels in newborns were significantly lower, indicating less scavenging potential. Nanoparticle-encapsulated ebselen, given as an intracardiac injection into the right or left ventricle of newborn hearts, significantly increased functional recovery of developed pressure only in the right ventricle, indicating the potential for localized antioxidant therapy during and after pediatric surgical procedures.
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Elahi MM, Lam J, Asopa S, Matata BM. Levosimendan Versus an Intra-aortic Balloon Pump in Adult Cardiac Surgery Patients With Low Cardiac Output. J Cardiothorac Vasc Anesth 2011; 25:1154-62. [DOI: 10.1053/j.jvca.2011.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Indexed: 11/11/2022]
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Székely A, Breuer T, Sápi E, Székely E, Szatmári A, Tóth M, Hauser B, Gál J. Transpulmonary thermodilution in neonates undergoing arterial switch surgery. Pediatr Cardiol 2011; 32:125-30. [PMID: 21061004 DOI: 10.1007/s00246-010-9828-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Accepted: 09/24/2010] [Indexed: 01/05/2023]
Abstract
Measurement of the global end-diastolic volume index (GEDI) by transpulmonary thermodilution (TPTD) has become a useful technique for measuring preload in adults. This study aimed to investigate the hemodynamic changes in neonates during the postoperative period after arterial switch surgery. Over a 13-month period, the postoperative data of 12 neonates with transposition of the great arteries were retrospectively investigated. Arterial and central venous blood pressures were monitored, Cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI), GEDI, and extravascular lung water index (ELWI) were measured by thermodilution. The CI was significantly correlated with the SVRI only in the closed chest condition (r = -0.92; P < 0.001). The CI and SVI values were significantly lower and the ELWI and SVRI values significantly higher in both the open and closed chest conditions than the postextubation values. The relationship between change in GEDI and change in CI was stronger in the open chest condition (r = 0.93; P < 0.006) than in the closed chest condition (r = 0.75; P = 0.055). However, the latter just missed statistical significance. According to the findings, TPTD seems to be a useful tool for assessing cardiac function after neonatal arterial switch surgery. Establishment of normal values will be essential for proper guidance of therapy for this population using volumetric parameters.
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Affiliation(s)
- Andrea Székely
- Department of Anesthesia and Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Haller u. 29, Budapest, 1096, Hungary.
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Chakravarti SB, Mittnacht AJ, Katz JC, Nguyen K, Joashi U, Srivastava S. Multisite Near-Infrared Spectroscopy Predicts Elevated Blood Lactate Level in Children After Cardiac Surgery. J Cardiothorac Vasc Anesth 2009; 23:663-7. [DOI: 10.1053/j.jvca.2009.03.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Indexed: 11/11/2022]
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Abstract
OBJECTIVE To define the modes of presentation, incidence of major organ dysfunction, predictors of hospital mortality, and adverse outcomes in neonates with critical heart disease admitted to a tertiary care center. DESIGN Retrospective chart review. SETTING A tertiary care pediatric cardiac intensive care unit and neonatal intensive care unit. PATIENTS The medical records for all neonates (< or = 30 days of age) with heart disease admitted to the cardiac intensive care unit or neonatal intensive care unit between October 1, 2002, and September 30, 2003, were reviewed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 190 neonates met inclusion criteria during this 1-yr period, of which 146 (77%) had at least one surgical procedure. Single ventricle heart disease was present in 42%. The most common mode of presentation was following a prenatal diagnosis (53%), followed by diagnosis in the newborn nursery (38%) and diagnosis after newborn hospital discharge (8%). The most common presenting findings in the newborn nursery were isolated murmur (38%) or cyanosis (32%), while circulatory collapse (38%) was the most common presentation after discharge. For the entire study cohort, 13% had a known genetic syndrome, 23% had a major noncardiac congenital anomaly, and 16% weighed < 2.5 kg. The hospital mortality for the entire cohort was 7.4%. Risk factors associated with an increased risk of hospital mortality included younger age at admission, higher number of cardiopulmonary bypass runs, and need for postoperative cardiopulmonary resuscitation. Total hospital length of stay was > 1 month in 17% of neonates. CONCLUSIONS In patients with complex congenital heart disease, including nearly half with single ventricle heart disease, neonatal hospital mortality was 7%. These patients have a high frequency of multiple congenital anomalies, genetic syndromes, low birth weight, and prolonged length of stay.
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Chakravarti S, Srivastava S, Mittnacht AJC. Near Infrared Spectroscopy (NIRS) in Children. Semin Cardiothorac Vasc Anesth 2008; 12:70-9. [DOI: 10.1177/1089253208316444] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Near infrared spectroscopy (NIRS) is a noninvasive method for the in vivo monitoring of tissue oxygenation. Originally used predominantly to assess cerebral oxygenation, NIRS has gained widespread popularity in many clinical settings in all age groups. Changes in regional tissue oxygenation as detected by NIRS may reflect the delicate balance between oxygen delivery and consumption in more than one organ system. However, more studies are required to establish the ability of NIRS monitoring to improve patient outcome. This review provides a comprehensive description of NIRS in children.
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Bograd AJ, Mital S, Schwarzenberger JC, Mosca RS, Quaegebeur JM, Addonizio LJ, Hsu DT, Lamour JM, Chen JM. Twenty-year experience with heart transplantation for infants and children with restrictive cardiomyopathy: 1986-2006. Am J Transplant 2008; 8:201-7. [PMID: 17973960 DOI: 10.1111/j.1600-6143.2007.02027.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Idiopathic restrictive cardiomyopathy (RCM) is a rare cardiomyopathy in children notable for severe diastolic dysfunction and progressive elevation of pulmonary vascular resistance (PVR). Traditionally, those with pulmonary vascular resistance indices (PVRI) >6 W.U. x m(2) have been precluded from heart transplantation (HTX). The clinical course of all patients transplanted for RCM between 1986 and 2006 were reviewed. Preoperative, intraoperative and postoperative variables were evaluated. A total of 23 patients underwent HTX for RCM, with a mean age of 8.8 +/- 5.6 years and a mean time from listing to HTX of 43 +/- 60 days. Preoperative and postoperative (114 +/- 40 days) PVRI were 5.9 +/- 4.4 and 2.9 +/- 1.5 W.U. x m(2), respectively. At time of most recent follow-up (mean = 5.7 +/- 4.6 years), the mean PVRI was 2.0 +/- 1.0 W.U. x m(2). Increasing preoperative mean pulmonary artery pressure (PA) pressure (p = 0.04) and PVRI > 6 W.U. x m(2) (chi(2)= 7.4, p < 0.01) were associated with the requirement of ECMO postoperatively. Neither PVRI nor mean PA pressure was associated with posttransplant mortality; 30-day and 1-year actuarial survivals were 96% and 86%, respectively. Five of the seven patients with preoperative PVRI > 6 W.U. x m(2) survived the first postoperative year. We report excellent survival for patients undergoing HTX for RCM despite the high proportion of high-risk patients.
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Affiliation(s)
- A J Bograd
- Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Breuer T, Sápi E, Skoumal R, Tóth M, Ala-Kopsala M, Vuolteenaho O, Leppäluoto J, Ruskoaho H, Szatmári A, Székely A. N-terminal probrain natriuretic peptide level inversely correlates with cardiac index after arterial switch operation in neonates. Paediatr Anaesth 2007; 17:782-8. [PMID: 17596223 DOI: 10.1111/j.1460-9592.2007.02256.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Natriuretic peptide levels are associated with cardiac output and ventricular function. We hypothesized that concomitant measurement of the peptide fragments and the hemodynamic parameters could elucidate the associations of these parameters after pediatric cardiac surgery. METHODS After approval of the institutional review board and parents' informed consent, we investigated the clinical data of eight neonates undergoing correction of transposition of the great arteries. We measured the level of N-terminal fragments of prohormones of atrial and brain natriuretic peptides (NT-proANP, NT-proBNP) preoperatively, postoperatively and 12, 24, 48, and 72 h after arrival in the intensive care unit. The hemodynamic status was assessed by transpulmonary thermodilution at the same time points. Creatinine and other laboratory values were analyzed in the first 48 h postoperatively. RESULTS NT-proBNP levels were inversely correlated with cardiac index (CI, r = -0.47, P = 0.030), stroke volume index (r = -0.65, P = 0.005), and global end-diastolic volume index (GEDI; r = -0.63, P = 0.011). There was strong inverse correlation between the change of NT-proBNP levels and the change of CI between two consecutive measurements during the postoperative period (r = -0.79, P = 0.001). The NT-proBNP level 12 h after surgery was strongly correlated with the creatinine level of the postoperative 24th hour (r = 0.81, P = 0.014). CONCLUSIONS NT-proBNP correlated with the hemodynamic parameters and with the severity of renal dysfunction. Therefore, NT-proBNP is a reliable indicator of the circulatory state and the severity of a low output syndrome after arterial switch operation in neonates.
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Affiliation(s)
- Tamás Breuer
- Research Department, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
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Raja SG, Danton MD, MacArthur KJ, Pollock JC. Effects of Escalating Doses of Sildenafil on Hemodynamics and Gas Exchange in Children With Pulmonary Hypertension and Congenital Cardiac Defects. J Cardiothorac Vasc Anesth 2007; 21:203-7. [PMID: 17418732 DOI: 10.1053/j.jvca.2006.02.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Sildenafil (Viagra, Pfizer) is being increasingly used to treat pulmonary hypertension in children. However, there are limited data available to suggest dosage regimens. The purpose of this study was to determine the effects of escalating doses of sildenafil on hemodynamics and gas exchange in children with pulmonary hypertension because of congenital cardiac defects. DESIGN Prospective, observational study. SETTING Pediatric intensive care unit in a tertiary care children's hospital. PARTICIPANTS Ten children with pulmonary hypertension because of congenital cardiac defects who were in the intensive care unit and on nitric oxide after cardiac surgery. INTERVENTION Patients received sildenafil every 4 hours via a gastric tube in incremental doses of 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, and 2.0 mg/kg along with nitric oxide during their stay in the intensive care unit until they were extubated. Hemodynamic and arterial blood gas measurements were taken before (baseline) and 60 minutes after the administration of sildenafil. MEASUREMENTS AND MAIN RESULTS All doses of sildenafil caused significant reduction in pulmonary artery pressure with no significant effect on systemic arterial and central venous pressures. Arterial partial pressure of oxygen was decreased after a 2.0 mg/kg dose of sildenafil but not significantly. No significant differences were found among the 4 doses. CONCLUSION For the treatment of pulmonary hypertension in children with congenital cardiac defects, a 0.5 mg/kg dose of sildenafil every 4 hours is therapeutically as effective as a 2.0 mg/kg dose every 4 hours. However, a large dose-ranging and pharmacokinetic study of sildenafil in children with pulmonary hypertension because of congenital cardiac defects is needed to validate the safety and efficacy of the dose-range and dosing interval suggested by this study.
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MESH Headings
- Analysis of Variance
- Blood Gas Analysis
- Bronchodilator Agents/therapeutic use
- Cardiac Surgical Procedures
- Child
- Child, Preschool
- Dose-Response Relationship, Drug
- Female
- Heart Defects, Congenital/blood
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/surgery
- Heart Rate/drug effects
- Humans
- Hypertension, Pulmonary/blood
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Male
- Nitric Oxide/therapeutic use
- Phosphodiesterase Inhibitors/administration & dosage
- Piperazines/administration & dosage
- Piperazines/pharmacology
- Prospective Studies
- Pulmonary Gas Exchange/drug effects
- Pulmonary Wedge Pressure/drug effects
- Purines/administration & dosage
- Purines/pharmacology
- Research Design
- Sildenafil Citrate
- Sulfones/administration & dosage
- Sulfones/pharmacology
- Treatment Outcome
- United Kingdom
- Vasodilator Agents/administration & dosage
- Vasodilator Agents/pharmacology
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, UK.
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Raja SG, Rayen BS. Levosimendan in Cardiac Surgery: Current Best Available Evidence. Ann Thorac Surg 2006; 81:1536-46. [PMID: 16564321 DOI: 10.1016/j.athoracsur.2005.08.073] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 08/22/2005] [Accepted: 08/25/2005] [Indexed: 11/21/2022]
Abstract
Recent upsurge in referral of patients with high perioperative risk or compromised left ventricular function for cardiac surgery has lead to an increasing use of pharmacologic support in the form of vasodilator and inotropic therapy to achieve improvement of tissue perfusion in the perioperative period or to support weaning from cardiopulmonary bypass. Traditionally, perioperatively used inotropic agents, epinephrine, dobutamine, and milrinone, are limited by significant increases in myocardial oxygen consumption, proarrhythmia, or neurohormonal activation. Levosimendan, a new inodilator for the treatment of decompensated heart failure, has also shown promise in elective therapy of cardiac surgical patients with high perioperative risk or compromised left ventricular function, as well as in rescue therapy of patients with difficult weaning from cardiopulmonary bypass. This review article briefly discusses the pharmacology of levosimendan and evaluates current best available evidence to assess the safety and efficacy of levosimendan usage in cardiac surgery.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, United Kingdom.
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Duggal B, Pratap U, Slavik Z, Kaplanova J, Macrae D. Milrinone and low cardiac output following cardiac surgery in infants: is there a direct myocardial effect? Pediatr Cardiol 2005; 26:642-5. [PMID: 16193374 DOI: 10.1007/s00246-005-0881-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We assessed the effect of milrinone on myocardial function in pediatric patients with postoperative low cardiac output syndrome by index of myocardial performance in a prospective, open-label, nonrandomized, consecutive study. Fifteen patients with low cardiac output syndrome following cardiac surgical treatment were studied in the tertiary cardiothoracic pediatric intensive care unit between April 2001 and November 2003 (age range, 0.2-16 months; median, 7; weight, 2.7-11.8 kg; median, 5). Echocardiographic, Doppler-derived, time interval-based index of myocardial performance (Tei index) was used to study cardiac function prior to and while on intravenous milrinone treatment for 18-24 hours. Treatment with milrinone led to improvement in biventricular myocardial function [mean right ventricular index from 0.521 (SD-0.213) to 0.385 (SD-0.215), p = 0.003; mean left ventricular index from 0.636 (SD-0.209) to 0.5 (SD-0.171), p = 0.012). No difference was found in the values of heart rate corrected right or left ventricular ejection time prior to and while on treatment with milrinone (right ventricle: mean, 1.23 (SD-0.42) and 1.14 (SD-0.48), p = 0.29; left ventricles: mean, 1.17 (SD-0.51) and 1.13 (SD-0.48), p = 0.66) Our data support the direct myocardial effect of milrinone as part of the mechanism behind its already proven benefit in children with low cardiac output syndrome following cardiac surgery.
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Affiliation(s)
- B Duggal
- Paediatric Intensive Care Unit, Royal Brompton & Harefield NHS Trust, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Inhalative Vasodilatatoren in der kardiochirurgischen Intensivmedizin. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2005. [DOI: 10.1007/s00398-005-0497-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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21
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Egan JR, Festa M, Cole AD, Nunn GR, Gillis J, Winlaw DS. Clinical assessment of cardiac performance in infants and children following cardiac surgery. Intensive Care Med 2005; 31:568-73. [PMID: 15711976 DOI: 10.1007/s00134-005-2569-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2004] [Accepted: 01/20/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare clinical assessment of cardiac performance with an invasive method of haemodynamic monitoring. DESIGN AND SETTING Prospective observational study in a 16-bed tertiary paediatric intensive care unit. PATIENTS AND PARTICIPANTS Infants and children undergoing cardiopulmonary bypass and surgical repair of congenital heart lesions. INTERVENTIONS Based on physical examination and routinely available haemodynamic monitoring in the paediatric intensive care unit, medical and nursing staff assessed cardiac index, systemic vascular resistance index and volume status. Clinical assessment was compared with cardiac index, systemic vascular resistance index and global end diastolic volume index, obtained by femoral artery thermodilution. MEASUREMENTS AND RESULTS A total of 76 clinical estimations of the three parameters were made in 16 infants and children undergoing biventricular repair of congenital heart lesions. Agreement was poor between clinical and invasive methods of determining all three studied parameters of cardiac performance. Cardiac index was significantly underestimated clinically; mean difference was 0.71 l min(-1) m(-2) (95% range of agreement +/-2.7). Clinical estimates of systemic vascular resistance (weighted kappa=0.15) and volume status (weighted kappa=0.04) showed poor levels of agreement with measured values and were overestimated clinically. There was one complication related to a femoral arterial catheter and one device failure. CONCLUSIONS Routine clinical assessment of parameters of cardiac performance agreed poorly with invasive determinations of these indices. Management decisions based on inaccurate clinical assessments may be detrimental to patients. Invasive haemodynamic monitoring using femoral artery thermodilution warrants cautious further evaluation as there is little agreement with clinical assessment which is presently standard accepted care in this patient population.
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Affiliation(s)
- Jonathan R Egan
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, 2145 Westmead, NSW, Australia.
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Raja SG. Milrinone for pulmonary hypertension: Additional benefits, concerns, and caution. J Cardiothorac Vasc Anesth 2005; 19:134-5; author reply 135. [PMID: 15747287 DOI: 10.1053/j.jvca.2004.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kulasekaran K, Sargent PH, Flenady V. Milrinone for the treatment of cardiac dysfunction in neonates. Hippokratia 2004. [DOI: 10.1002/14651858.cd004952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Philip H Sargent
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Brisbane Queensland Australia 4101
| | - Vicki Flenady
- Mater Mothers' Hospital, Women's and Children's Health Service; Centre for Clinical Studies-Women's and Children's Health; Raymond Terrace South Brisbane Queensland Australia 4101
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