Anesthesia and the pediatric cardiac catheterization suite: a review

European Pediatric Cardiac Anesthesia Fellowship Program: A First Proof of Concept

The Pediatric Cardiac Anesthesia (PCA) fellowship is a demanding training program in Europe and the United States. Successful completion of the program requires years of training in anesthesiology, a thorough understanding of cardiovascular anatomy and physiology, and extensive experience in the perioperative management of neonates and children with heart disease. In the context of the first candidate to successfully complete the PCA program in Europe, this article presents excerpts from the design and structure of the European PCA program. The PCA program is evaluated critically by both external and internal reviewers, and points are highlighted that could be included in the next version of the program.

Preliminary Experience With Remimazolam for Procedural Sedation and as an Adjunct to General Anesthesia During Diagnostic and Interventional Cardiac Procedures

Background

Remimazolam is a benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5 - 10 min, a limited context sensitive half-life, and rapid recovery when the infusion is discontinued.

Methods

Following the Institutional Review Board (IRB) approval, we performed a retrospective chart review of patients who received remimazolam in the cardiac catheterization, cardiac magnetic resonance imaging (MRI), and electrophysiology suites. The primary objective was to assess efficacy and safety. The secondary objective was to describe bolus and infusion dosing of remimazolam and the need for adjunctive agents to optimize procedural sedation conditions.

Results

The study cohort included 26 patients with a median age of 18 years and a total of 33 anesthetic encounters. The most common procedures were endomyocardial biopsy or isolated hemodynamic assessment (right or left heart catheterization). Remimazolam was the primary agent for sedation in 82% of the procedures. The majority of cases (25 encounters, 76%) included a bolus dose of remimazolam prior to the start of an infusion. For those patients who received a starting bolus dose, dosing typically ranged between 30 and 110 µg/kg. Continuous infusion rates of remimazolam varied from 5 to 20 µg/kg/min. No adverse hemodynamic or respiratory effects were noted. Midazolam, fentanyl, and dexmedetomidine were the most frequently used adjunctive agents. One patient required transition to general anesthesia due to the need for a surgical intervention based on the findings of the cardiac catheterization. All other patients were effectively sedated.

Conclusions

Our preliminary experience demonstrates that remimazolam effectively provided sedation for diagnostic and therapeutic cardiovascular procedures. Future studies are needed to further define dosing parameters for both bolus dosing and continuous infusion as well as to compare remimazolam to other commonly used for procedural sedation in patients with congenital and acquired heart disease.

Adverse Events in the Pediatric Cardiac Catheterization Suite: Does Having Pediatric Cardiac Anesthesiologists Make a Difference?

INTRODUCTION

It has been suggested that anesthesiologists with subspecialty expertise in pediatric cardiac anesthesia are best qualified to care for patients with complex congenital cardiac anomalies and manage the complex physiology frequently encountered in the pediatric cardiac catheterization lab. We evaluated the incidence of adverse events in our pediatric cardiac catheterization lab, comparing care provided by cardiac and noncardiac pediatric attending anesthesiologists.

METHODS

Data were collected on each anesthetic in the pediatric cardiac catheterization lab from January 1, 2016 to December 31, 2019. A generalized linear mixed effect model was used to identify associations between pediatric cardiac and noncardiac anesthesiologists and the presence of adverse events adjusting for age, American Society of Anesthesiologists physical status, emergency status, and interventional versus diagnostic procedures.

RESULTS

A total of 3,761 procedures involving 1,729 patients were included in the study. There was no significant difference between noncardiac and cardiac anesthesia attendings for overall adverse events (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.82 to 1.75 P=0.349). Specific respiratory adverse events (OR, 1.22; 95%, CI 0.73 to 2.03 P=0.443) or cardiac adverse events (OR, 1.26; 95% CI, 0.64 to 2.48 P=0.502) were also not significantly different with respect to noncardiac compared with cardiac attending anesthesiologists.

CONCLUSIONS

In our analysis, the incidence of adverse events in the pediatric cardiac catheterization lab during the study period was not statistically different, whether anesthesia care was provided by a cardiac or a noncardiac anesthesiologist.

Do COVID-19 pandemic-related behavior changes affect perioperative respiratory adverse events in children undergoing cardiac interventional catheterization?

BACKGROUND

The novel coronavirus disease (COVID-19) suddenly broke out in China in December 2019. Pandemic-related behavioral changes can cause perioperative respiratory adverse events in children with congenital heart disease (CHD). Here, we compared the incidence of perioperative respiratory adverse events (PRAEs) in CHD children with and without upper respiratory infection (URI) undergoing the cardiac catheterization before and during the COVID-19 pandemic.

METHODS

This prospective observational single-center study was based at a tertiary care center in Shanghai, China. A total of 359 children with CHD with and without recent URI were included between January 2019 and March 2021. The overall incidence of PRAEs (laryngospasm, bronchospasm, coughing, airway secretion, airway obstruction, and oxygen desaturation) in non-URI and URI children undergoing elective cardiac catheterization was compared before and during the COVID-19 pandemic. A logistic regression model was fitted to identify the potential risk factors associated with PRAEs.

RESULTS

Of the 564 children enrolled, 359 completed the study and were finally analyzed. The incidence of URIs decreased substantially during the COVID-19 pandemic (14% vs. 41%, P < 0.001). Meanwhile, the overall PRAEs also significantly declined regardless of whether the child had a recent URI (22.3% vs. 42.3%, P = 0.001 for non-URI and 29.2% vs. 58.7%, P = 0.012 for URI, respectively). Post-operative agitation in children without URI occurred less frequently during the pandemic than before (2.3% vs. 16.2%, P = 0.001). Behaviors before the COVID-19 pandemic (odds ratio = 2.84, 95% confidence interval [CI] 1.76-4.58) and recent URI (odds ratio = 1.79, 95% CI 1.09-2.92) were associated with PRAEs.

CONCLUSIONS

COVID-19 pandemic-related behavioral changes were associated with a reduction in PRAEs in non-URI and URI children undergoing elective therapeutic cardiac catheterization.

Severe Complications after General Anesthesia versus Sedation during Pediatric Diagnostic Cardiac Catheterization for Ventricular Septal Defect

Pediatric cardiac catheterization requires unconsciousness and immobilization through general anesthesia or sedation. This study aimed to compare the occurrence of severe complications in pediatric diagnostic cardiac catheterization for ventricular septal defect between general anesthesia and sedation performed under similar institutional environments. Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified pediatric patients (aged <2 years) who underwent diagnostic cardiac catheterization for ventricular septal defect between July 2010 and March 2019. The composite outcome was the occurrence of severe complications, including catecholamine use and intensive care unit admission, within seven days after catheterization. Overlap weighting based on propensity scores was used to adjust for patient- and hospital-level confounding factors. We identified 3159 patients from 87 hospitals, including 930 under general anesthesia and 2229 under sedation. The patient- and hospital-level baseline characteristics differed between the groups. After adjustment, the proportion of patients with severe complications was significantly higher in the general anesthesia group than in the sedation group (2.4% vs. 0.6%; risk difference, 1.8% [95% confidence interval, 0.93−2.6%]). Severe complications occurred more frequently in the general anesthesia group than in the sedation group. Further research on anesthetic methods is necessary to assess the safety and accuracy of pediatric diagnostic cardiac catheterization.

A retrograde approach for transcatheter valvotomy procedure in infants with pulmonary atresia intact ventricular septum (PA-IVS): retrograde versus antegrade approach

INTRODUCTION

This study evaluates the retrograde approach compared to the antegrade approach in infants with PA-IVS who underwent transcatheter pulmonary valvotomy procedure at National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

MATERIAL AND METHOD

This is a single-centre retrospective study conducted from January 2017 to June 2019 consisting of infants undergoing transcatheter pulmonary valvotomy procedures from our centre.

RESULTS

Among 3733 records of cardiac catheter procedure in paediatric patients during the last 3 years, there were 12 subjects with PA-IVS, where five subjects were done by antegrade approach and seven by retrograde approach. The retrograde approach is shown to excel the antegrade approach in terms of procedural time by 58.64 minutes (CI 95 % 32.97-84.29, p = 0.008) and PA-RV crossing time by 27 minutes (CI 95 % 14.01-39.99, p = 0.02). There was no significant difference in contrast used (120.23 ± 25.77 versus 150.27 ± 39.26 ml/BSA, p = 0.518), and right ventricle to pulmonary artery systolic pressure gradient after valvotomy (39.571 ± 5.814 versus 53.52 ± 29.15, p = 0.329) between the retrograde and the antegrade approach.

CONCLUSION

The retrograde approach offered shorter procedural time and comparably satisfying results than the antegrade approach. The shorter procedural time was preferred due to the shorter duration of general anaesthesia, which may decrease the risk of neurodevelopmental deficits in the patient.

Estimating filling pressures in paediatric heart transplant recipients using echocardiographic parameters and B-type natriuretic peptide

BACKGROUND

Longitudinal evaluation of allograft diastolic function in paediatric heart transplant recipients is important for early detection of acute rejection, cardiac allograft vasculopathy, and graft dysfunction. Mean diastolic right atrial and pulmonary capillary wedge pressures obtained at catheterisation are the reference standards for assessment. Echocardiography is non-invasive and more suitable for serial surveillance, but individual parameters have lacked accuracy. This study aimed to identify covariates of post-transplant mean right atrial and pulmonary capillary wedge pressures, including B-type natriuretic peptide and certain echocardiographic parameters.

METHODS

A retrospective review of 143 scheduled cardiac catheterisations and echocardiograms from 56 paediatric recipients transplanted from 2007 to 2011 was performed. Samples with rejection were excluded. Univariate and multivariate linear regression models using backward selection were applied to a database consisting of B-type natriuretic peptide, haemodynamic, and echocardiographic data.

RESULTS

Ln B-type natriuretic peptide, heart rate z-score, left ventricular end-diastolic dimension z-score, mitral E/e', and percent interventricular septal thickening in systole were independently associated with mean right atrial pressure. Ln B-type natriuretic peptide, heart rate z-score, left ventricular end-diastolic dimension z-score, left ventricular mass (observed/predicted), and mitral E/e' were independently associated with mean pulmonary capillary wedge pressure. Covariates of B-type natriuretic peptide included mean pulmonary artery and pulmonary capillary wedge pressures, height, haemoglobin, fractional shortening, percent interventricular septal thickening in systole, and pulmonary vascular resistance index.

CONCLUSIONS

B-type natriuretic peptide and echocardiographic indices of diastolic function were independently related to post-transplant mean right atrial and pulmonary capillary wedge pressures in paediatric heart transplant recipients without rejection.

Utility of Computed Tomographic Angiography for Pulmonary Hypertension Assessment in a Cohort of West Highland White Terriers With or Without Canine Idiopathic Pulmonary Fibrosis

West Highland white terriers (WHWTs) affected with canine idiopathic pulmonary fibrosis (CIPF) are at risk of developing precapillary pulmonary hypertension (PH). In humans, thoracic computed tomography angiography (CTA) is commonly used to diagnose and monitor patients with lower airway diseases. In such patients, CTA helps to identify comorbidities, such as PH, that could negatively impact prognosis. Diameter of the pulmonary trunk (PT), pulmonary trunk-to-aorta ratio (PT/Ao), and right ventricle-to-left ventricle ratio (RV/LV) are CTA parameters commonly used to assess the presence of PH. Pulmonary vein-to-right pulmonary artery ratio (PV/PA) is a new echocardiographic parameter that can be used in dogs to diagnose PH. The primary aim of this study was to evaluate the use of various CTA parameters to diagnose PH. An additional aim was to evaluate the correlation of RV/LV measurements between different CTA planes. CTA and echocardiography were prospectively performed on a total of 47 WHWTs; 22 affected with CIPF and 25 presumed healthy control dogs. Dogs were considered to have PH if pulmonary vein-to-right pulmonary artery ratio (PV/PA) measured on 2D-mode echocardiography was less than to 0.7. WHWTs affected with CIPF had higher PT/Ao compared with control patients. In WHWTs affected with CIPF, PT size was larger in dogs with PH (15.4 mm) compared with dogs without PH (13 mm, p = 0.003). A cutoff value of 13.8 mm predicted PH in WHWTs affected with CIPF with a sensitivity of 90% and a specificity of 87% (AUC = 0.93). High correlations were observed between the different CTA planes of RV/LV. Results suggest that diameter of the PT measured by CTA can be used to diagnose PH in WHWTs with CIPF.

Anesthesia Management for Pediatrics with Congenital Heart Diseases Who Undergo Cardiac Catheterization in China

Objectives

The goal of this study was to summarize anesthesia management for pediatrics with congenital heart diseases who undergo cardiac catheterization procedure in China.

Methods

The relevant articles were identified through computerized searches in the CNKI, Wanfang, VIP, and PubMed databases through May 2020, using different combinations of keywords: “congenital heart diseases,” “pediatric,” “children,” “anesthesia,” “cardiac catheterization,” “interventional therapy,” “interventional treatment,” “interventional examination,” and “computed tomography.”

Results

The database searches identified 48 potentially qualified articles, of which 25 (9,738 patients in total) were determined to be eligible and included. The authors collect data from the article information. Anesthesia methods included endotracheal intubation or laryngeal mask ventilation general anesthesia, monitored anesthesia care, and combined with sacral canal block. Anesthesia-related complications occurred in 7.41% of the patients and included dysphoria, respiratory depression, nausea, vomiting, cough, increased respiratory secretion, and airway obstruction. The incidence of procedure-related complications was 12.14%, of which the most common were arrhythmia and hypotension.

Conclusions

For pediatric patients with congenital heart diseases who undergo cardiac catheterization procedures in China, arrhythmia and hypotension are the most common procedure-related complications. Monitored anesthesia care is the commonly used anesthesia methods, and dysphoria, cough, nausea, vomiting, and respiratory depression are frequent complications associated with anesthesia.

Recovery profile of sugammadex versus neostigmine in pediatric patients undergoing cardiac catheterization: A randomized double-blind study

Background:

Sugammadex is a selective reversal agent which has the ability to reverse deep neuromuscular blockade. However, there are still controversial results as regard sugammadex effects on the quality of recovery. We hypothesized that Sugammadex may have better recovery profile compared to neostigmine in pediatric patients with congenital heart diseases undergoing cardiac catheterization.

Patients and Methods:

This prospective randomized double-blind study included 50 pediatric patients aged <2 years who were divided into two groups according to the reversal agent used; Group S (Sugammadex) and Group N (Neostigmine). Both groups received the same anesthetic technique during cardiac catheterization, and basic hemodynamic monitoring was ensured in both groups. After the procedure, reversal was done using 4 mg.kg^‒1 sugammadex or 0.04 mg. kg^‒1 neostigmine plus 0.02 mg. kg^‒1 atropine according to the group allocation. Recovery time and side effects were recorded.

Results:

The two groups showed comparable findings regarding demographics. Nonetheless, the total time of anesthesia had mean values of 91.06 and 101.25 min in the two groups, respectively (P = 0.003), while recovery time had mean values of 1.61 and 9.23 min in the same groups, respectively (P < 0.001). Hemodynamic profile (heart rate and mean arterial pressure) was better after reversal with sugammadex. Blood sugar levels and side effects showed no significant difference between both groups.

Conclusion:

Sugammadex can be a more rapid and effective alternative to neostigmine for reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing cardiac catheterization.

Sedation and anaesthesia for cardiac catheterisation

Since the introduction of cardiac catheterisation for Paediatric Cardiology in 1947, the subspecialty has seen dramatic changes. The advancement of non-invasive imaging techniques such as echocardiography, CT and cardiac MRI has shifted the focus for paediatric cardiac catheterisations from a primarily diagnostic tool (to define anatomy, assess haemodynamics and calculate shunts) to an important treatment option for various congenital heart defects.

Assessment of hemodynamic responses to exercise in aortic coarctation using MRI-ergometry in combination with computational fluid dynamics

In patients with aortic coarctation it would be desirable to assess pressure gradients as well as information about blood flow profiles at rest and during exercise. We aimed to assess the hemodynamic responses to physical exercise by combining MRI-ergometry with computational fluid dynamics (CFD). MRI was performed on 20 patients with aortic coarctation (13 men, 7 women, mean age 21.5 ± 13.7 years) at rest and during ergometry. Peak systolic pressure gradients, wall shear stress (WSS), secondary flow degree (SFD) and normalized flow displacement (NFD) were calculated using CFD. Stroke volume was determined based on MRI. On average, the pressure gradient was 18.0 ± 16.6 mmHg at rest and increased to 28.5 ± 22.6 mmHg (p < 0.001) during exercise. A significant increase in cardiac index was observed (p < 0.001), which was mainly driven by an increase in heart rate (p < 0.001). WSS significantly increased during exercise (p = 0.006), whereas SFD and NFD remained unchanged. The combination of MRI-ergometry with CFD allows assessing pressure gradients as well as flow profiles during physical exercise. This concept has the potential to serve as an alternative to cardiac catheterization with pharmacological stress testing and provides hemodynamic information valuable for studying the pathophysiology of aortic coarctation.

The effect of the duration of the procedure on the risk of complications during pediatric cardiac catheterization

Background

This study aims to evaluate the frequency of and associated risk factors for adverse events caused by cardiac catheterization procedures in pediatric patients.

Methods

Between January 2009 and January 2012, a total of 599 pediatric patients (320 males, 279 females; mean age 5.4±4.7 years; range, 1 day to 21 years) who underwent cardiac catheterization in our cardiac catheterization laboratory were retrospectively analyzed. Demographic and clinical data of the patients including the duration of the procedure, management of anesthesia, the American Society of Anesthesiologists class, and Catheterization Risk Score for Pediatrics, and procedure-related serious adverse events were recorded.

Results

The incidence of procedure-related serious adverse events was 9.18%. Potential risk factors associated with serious adverse events were identified as interventional heart catheterization, high scores obtained from the Catheterization Risk Score for Pediatrics, the use of endotracheal tube in airway control, and prolonged procedural duration.

Conclusion

Our study results suggest that prolonged duration of catheterization is a potential risk factor for procedure-related adverse events and the duration of the procedure needs to be included as a variable in the Catheterization Risk Score for Pediatrics scoring system for predicting procedure-related adverse events.

Anesthesia timing for children undergoing therapeutic cardiac catheterization after upper respiratory infection: a prospective observational study

BACKGROUND

We aimed to analyze anesthesia timing and perioperative respiratory adverse event (PRAE) risk factors in children undergoing therapeutic cardiac catheterization after upper respiratory tract infection (URI).

METHODS

We prospectively included children for elective therapeutic cardiac catheterization. Parents or legal guardians were asked to complete a questionnaire on the child's demographics, tobacco exposure, and URI symptoms. PRAEs (laryngospasm, bronchospasm, coughing, airway secretion, airway obstruction, and oxygen desaturation) as well as details of anesthesia management were recorded.

RESULTS

Of 332 children, 201 had a history of URI in the preceding eight weeks. The occurrence rate of PRAEs in children with URI≤two weeks reached the highest proportion, which was higher than that in children without URI (66.3% vs. 46.6%, P=0.007). The overall incidence of PRAEs in children with URI in 3-8 weeks was significantly lower than that in children with URI in the recent ≤two weeks (49.0% vs. 66.3%, P=0.007), and similar to that in the control group (49.0% vs. 46.6%). Multivariate analysis showed association between PRAEs and type of congenital heart disease (CHD) (P<0.001), anesthesia timing (P=0.007), and age (P=0.021). Delayed schedule (two weeks after URI) minimized the risk of PRAEs to the level comparable to that observed in children without URI (OR, 1.11; 95% CI: 0.64-1.91; P=0.707).

CONCLUSIONS

If treatment is not urgent, a pediatric patient at a high risk of PRAEs will be benefit from the postponement of an interventional operation by at least two weeks after URI.

Anesthesia for high-risk procedures in the catheterization laboratory

Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.

Fellowship Training in Pediatric Cardiac Anesthesia: History, Maturation, and Current Status

Pediatric cardiac anesthesia as a discipline has evolved over the years to become a well recognized sub-specialty. Education and training in the field has also continued to change and develop. In this review, the author outline the changes in the field over the years and suggest a structure for an organized fellowship training process.

Congenital heart diseases and anaesthesia

Patients with congenital heart diseases (CHDs) are at increased risk of developing complications during anaesthesia. Improvements in medical and surgical management in recent decades have resulted in significantly more children with CHD surviving to adulthood. The aim of this article is to focus on broad classification of CHD and to provide an updated review on the current perioperative anaesthetic management of CHD patients in different settings such as (a) interventional cardiac procedures that have dominated the field, (b) uncorrected patients for non-cardiac surgery and (c) corrected patients for non-cardiac surgery. The complexity of the defects along with a variety of non-cardiac surgery makes it impossible to have one single-anaesthesia technique. Search on Ovid, PubMed, Google Scholar and Medline were done with MeSH terms such as 'congenital heart disease', 'cardiac catheterisation', 'anaesthetic management' and 'non-cardiac surgery' mainly focusing on review articles and controlled studies for preparing the article.

Efficacy and Safety of Radiofrequency Catheter Ablation of Tachyarrhythmias in 123 Children Under 3 Years of Age

BACKGROUND

The risk-benefit ratio of radiofrequency catheter ablation (RFCA) in infants and toddlers remains controversial. Experience with RFCA in these patients is limited. This work is intended to describe the efficacy and safety of RFCA in children under 3 years of age with tachycardia complicated by drug resistance, drug intolerance, or tachycardia-induced cardiomyopathy.

METHODS

We retrospectively reviewed data from 123 consecutive children under 3 years of age (mean, 2.3 ± 0.8 years; weight, 13.6 ± 2.8 kg) with tachycardia complicated by drug resistance, drug intolerance, or tachycardia-induced cardiomyopathy; the children underwent an electrophysiology study between 1994 and 2014 at our center. Fifteen children had congenital heart disease, and 27 children were under 1 year of age. Among the 109 children who underwent RFCA, acute success rate (no inducible arrhythmia before procedure completion), 2-year rate of symptomatic tachyarrhythmia recurrence, and complication rate were assessed.

RESULTS

Among the 123 children studied, 76.4% had atrioventricular reentrant tachycardia, 5.7% had atrioventricular nodal reentrant tachycardia, 2.4% had focal atrial tachycardia, 6.5% had atrial flutter, and 4.1% had idiopathic left ventricular tachycardia. For RFCA, the acute success rate was 94.5%, and the 2-year recurrence rate was 6.8%, without any major complications.

CONCLUSION

RFCA appears to be an effective and safe therapeutic option in selected small children with tachycardia resistant to conventional medical management, tachycardia complicated by drug intolerance, or tachycardia-induced cardiomyopathy.

Noteworthy Literature in 2015

This article is a review of the literature published during the 12 months of 2015, which is of interest to the congenital cardiac anesthesiologist. While the review is not exhaustive, it identifies 7 themes in the literature for 2015 and cites 78 peer-reviewed publications.