Anesthesia for noncardiac procedures for children with a Berlin Heart EXCOR Pediatric Ventricular Assist Device: a case series

Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk

The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.

Pediatric ventricular assist devices: Bridge to a new era of perioperative care

Pediatric ventricular assist devices (VADs) are evolving as a standard therapy for end stage heart failure in children. Major recent developments include the increased use of continuous flow (CF) devices in children and increased experience with congenital heart disease (CHD) and outpatient management. In the current and future era anesthesiologists will encounter more children presenting for VAD implantation, subsequent procedures and heart transplantation. Successful perioperative management requires an understanding of the interaction between the patient's physiology and the device and a framework to troubleshoot problems. This review focuses on CF devices, VAD support for CHD and perioperative management of pulsatile and CF devices in the pediatric population.

Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association

Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients.

Anesthesia for the patient with congenital heart disease presenting for noncardiac surgery

PURPOSE OF REVIEW

To summarize recent publications emphasizing the changes in the population of patients with congenital heart disease and trends in the anesthetic and perioperative care of these patients presenting for noncardiac procedures.

RECENT FINDINGS

It has been reported that children with congenital heart disease presenting for noncardiac surgery are at an increased anesthetic risk. This risk has become better defined. The patients at highest risk are infants with a functional single ventricle and patients with suprasystemic pulmonary hypertension, left ventricular outflow tract obstruction or dilated cardiomyopathy. Familiarity with the physiology and perioperative implications of the stages of single ventricle palliation is critical. The anesthetic approach, monitoring, conduct of surgery and postoperative care and outcomes are variable in this patient population. Recent literature reflects the growing number of children with ventricular assist devices and the management of these patients for noncardiac procedures. Cardiac imaging modalities provide diagnostic information, and strategies for reducing anesthetic risk for these procedures are of great interest. Pharmacologic trends and the application of technology are reviewed.

SUMMARY

The identification of high-risk patients, multidisciplinary decision-making and planning and careful anesthetic management and monitoring are critical for optimizing outcomes in children with congenital heart disease presenting for noncardiac procedures.

Can we improve the outcomes of pediatric congenital heart disease survivors?

Appreciating the complexity and evolving pathophysiology after palliation of CHD is critical to improving the outcome. Despite a growing patient population because of greater survival over the years, detailed data on the long-term outcomes of these patients is surprisingly sparse. The establishment in 2001 of the Pediatric Heart Network by the National Heart, Lung and Blood Institute has provided a collaborative multicenter platform to conduct large trials in CHD and to characterize outcomes. This chapter has emphasized how CHD care spans the continuum from fetal life to adulthood. Current research efforts aspire to better characterize short-term and long-term outcomes, continue advancement of technologies to better diagnose and treat CHD, and to elucidate the role of genetics and biomarkers in predicting outcome. Focused studies on variations in perioperative practice and quality will help us provide better clinical outcomes for CHD survivors.

Safety of Berlin Heart EXCOR pump changes in the PICU

OBJECTIVE

To describe whether Berlin Heart EXCOR Pediatric pump changes in the ICU are associated with infection, hemodynamic and ventilatory instability, and neurologic injury.

DESIGN

Retrospective, descriptive chart review.

SETTING

PICU in a quaternary care children's hospital.

PATIENTS

Eight patients were supported on Berlin Heart EXCOR Pediatric pumps due to cardiomyopathy or cardiogenic shock. Two patients were supported with left ventricular assist devices, five had biventricular assist devices, and one required a univentricular assist device.

INTERVENTIONS

A team of cardiac surgeons, pediatric intensivists, and operating room nurses conducted sixteen pump changes in the pediatric intensive care unit. Patients were monitored for deleterious effects for 5 days following the change.

MEASUREMENT AND MAIN RESULTS

For the first 48 hrs following the EXCOR pump change, no patients exhibited acute neurologic deficits or escalation of hemodynamic or ventilatory support. Over the first 5 days, no blood cultures were positive for microbes.

CONCLUSIONS

Berlin Heart EXCOR Pediatric pump changes in the pediatric intensive care unit appear to be a safe procedure when conducted by a highly specialized team.

Diagnosis and management of circulatory arrest in pediatric ventricular assist device patients: presentation of two cases and suggested guidelines

INTRODUCTION

Pediatric patients supported by ventricular assist devices (VADs) are becoming more common. No guidelines exist to provide an approach to diagnosis or management of circulatory arrest in these patients. We present two case reports of apparent circulatory arrest in pediatric VAD-supported patients at our institution.

DISCUSSION

Diagnosis of circulatory arrest in VAD-supported patients can be challenging, especially with non-pulsatile flow devices. Traditional methods of diagnosis, such as pulse check and blood pressure, may be unreliable. Etiology may be primary device failure though other etiologies need to be considered. Treatment of the circulatory arrest depends on the etiology and type of VAD device being used.

CONCLUSION

In the absence of strong literature on the approach to these patients, we present these case reports and our local institutional guidelines as a starting point for discussion.

Ventricular-assist device therapy in children

Mechanical circulatory support is an important modality in the management of paediatric patients with circulatory failure. The field of ventricular assist device (VAD) is particularly evolving. We review the currently available and developing VADs in the paediatric population, and the anaesthetic management of patients presenting for VAD implantation and with VADs for non-cardiac surgery.

Perioperative management of pediatric patients on mechanical cardiac support

The population of children with end-stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short- and long-term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.