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Loomba RS, Dyamenahalli U, Savorgnan F, Acosta S, Villarreal E, Farias JS, Wong J, Flores S. Association of Immediate Postoperative Hemodynamic and Laboratory Values in Predicting Norwood Admission Outcomes. Pediatr Cardiol 2024; 45:1232-1241. [PMID: 36350339 DOI: 10.1007/s00246-022-03044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022]
Abstract
The primary objective of this study was to determine whether or not hemodynamic parameters and laboratory values at the time of admission to the pediatric cardiac intensive care unit after the Norwood operation were associated with a composite outcome of either need for extracorporeal membrane oxygenation or inpatient mortality. This was a single-center retrospective study of infants with functionally univentricular hearts admitted to intensive care after the Norwood procedure from January 2011 to January 2020. Data were obtained at a single point (after a Norwood procedure) and then compared between two subsets of patients based on the presence or not of the composite outcome of interest. In univariate and multiple regression analyses, a series of receiver operator curves were generated to assess the relationship between the variables of interest and the composite outcome. Eight (7.6%) experienced the composite outcome out of a total of 104 patients. Those who experienced the composite endpoint had significantly higher oxygen extraction ratio (0.43 vs. 0.31, p = 0.01), lower systemic blood flow (2.5 L/min versus 3.1 L/min, p = 0.01), and higher systemic vascular resistance (20.2 indexed woods units versus 14.8 indexed woods units, p = 0.01). Those with systemic blood flow of less than 2.5 L/min/m2 had a 17% risk of experiencing the composite endpoint AUC = 0.79. Those with systemic vascular resistance of greater than 19 indexed woods units had a 22% risk of experiencing the composite endpoint AUC 0.80. Systemic blood flow and systemic vascular resistance are independently associated with this composite outcome.
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Affiliation(s)
- Rohit S Loomba
- Department of Pediatrics, Advocate Children's Hospital, The Heart Institute, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Oak Lawn, Illinois, USA
| | - Umesh Dyamenahalli
- Department of Pediatrics, Advocate Children's Hospital, The Heart Institute, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Oak Lawn, Illinois, USA
| | - Fabio Savorgnan
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Sebastian Acosta
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Enrique Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Monterrey, Nuevo Leon, Mexico
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Monterrey, Nuevo Leon, Mexico
| | - Joshua Wong
- Department of Pediatrics, Advocate Children's Hospital, The Heart Institute, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Oak Lawn, Illinois, USA
| | - Saul Flores
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Ferrari F, Nacoti M, Carobbio A, Favarato M, Di Dedda GB, Bonanomi E. The impact of a standardized perioperative management on hospital mortality after the Norwood procedure in a low volume center: results and perspectives. Minerva Pediatr (Torino) 2024; 76:498-506. [PMID: 34128601 DOI: 10.23736/s2724-5276.21.06133-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mortality of newborns with Hypoplastic Left Heart Syndrome (HLHS) is mainly concentrated after Norwood procedure (NP) stage 1 palliation (S1P) and between S1P and stage 2 palliation (S2P). Standardized management of these patients may help to control hospital mortality. Aim of the study was to evaluate the impact on hospital mortality of a standardized perioperative management (SPM) for newborns requiring S1P in a low volume center for NP. METHODS A consecutive series of patients undergoing S1P from January 1, 2002 to December 31, 2006 were retrospectively compared, by a "before and after" design, with those receiving a SPM (i.e. use of selective cerebral perfusion, near infrared spectroscopy, delayed sternal closure, modified ultrafiltration) from January 1st, 2007 to December 31st, 2018. Demographic, intraoperative and postoperative characteristics were collected. Univariate and multivariate analyses assessed differences before and after SPM. RESULTS Ninety-one newborns underwent S1P in the considered period; of 74 eligible patients, 25 did not receive SPM, while 49 received SPM. Hospital mortality after S1P was 31% (CI 21-44%). The introduction of a SPM did not affect hospital mortality both at the univariate-(28% vs. 29%, P=0.959) and at the multivariate analysis (HR 1.85, P=0.62). Mortality was 12% (CI 6-25%) between hospital discharge after S1P and S2P and 8% (CI 3-22%) between S2P and S3P. CONCLUSIONS The use of a SPM for HLHS newborns requiring S1P was not effective in reducing hospital mortality in a low volume center. We suggest a collaboration between Italian Pediatric Cardiac Centers to manage HLHS patients.
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Affiliation(s)
- Floriana Ferrari
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy -
| | - Mirco Nacoti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Moreno Favarato
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giovanni B Di Dedda
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ezio Bonanomi
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
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Iskander C, Nwankwo U, Kumanan KK, Chiwane S, Exil V, Lowrie L, Tan C, Huddleston C, Agarwal HS. Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review. J Clin Med 2024; 13:4244. [PMID: 39064284 PMCID: PMC11277754 DOI: 10.3390/jcm13144244] [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: 04/30/2024] [Revised: 06/20/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.
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Affiliation(s)
- Christopher Iskander
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Ugonna Nwankwo
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Krithika K. Kumanan
- Advanced Data Health Institution, Saint Louis University, Saint Louis, MO 63104, USA;
| | - Saurabh Chiwane
- Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Vernat Exil
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Lia Lowrie
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| | - Corinne Tan
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Charles Huddleston
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Hemant S. Agarwal
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
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Salavitabar A, Armstrong AK, Carrillo SA. Hybrid Interventions in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:399-408. [PMID: 38839172 DOI: 10.1016/j.iccl.2024.02.005] [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] [Indexed: 06/07/2024]
Abstract
Hybrid interventions in congenital heart disease (CHD) embody the inherent collaboration between congenital interventional cardiology and cardiothoracic surgery. Hybrid approaches to complex and common lesions provide the opportunity to circumvent the limitations of patient size, vascular access, severity of illness, and anatomy that would otherwise be prohibitive to surgical and percutaneous techniques alone. This review describes several important hybrid approaches to interventions in CHD.
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Affiliation(s)
- Arash Salavitabar
- The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Aimee K Armstrong
- The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Sergio A Carrillo
- The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
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Mustafa HJ, Aghajani F, Jawwad M, Shah N, Abuhamad A, Khalil A. Fetal cardiac intervention in hypoplastic left heart syndrome with intact or restrictive atrial septum, systematic review, and meta-analysis. Prenat Diagn 2024; 44:747-757. [PMID: 37596875 DOI: 10.1002/pd.6420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023]
Abstract
To investigate outcomes of fetuses with hypoplastic left heart syndrome (HLHS) with an intact or restrictive atrial septum (I/RAS) managed expectantly or with fetal atrial septal intervention (FASI PubMed, Scopus, and Web of Science were searched systematically from inception until April 2023. Outcomes were classified by those who had FASI and those who had expectant management (EM). To estimate the overall proportion of each endpoint, a meta-analysis of proportions was employed using a random-effects model. Heterogeneity was assessed using the I2 value. Thirty-two studies reporting on 746 fetuses with HLHS and I/RAS met our inclusion criteria. Eleven studies (123 fetuses) were in the FASI group and 21 studies (623 fetuses) were in the EM group. Among the 123 FASI cases, 107 (87%) were reported to be technically successful. The mean gestational age (GA) at diagnosis was comparable between the groups (26.2 weeks FASI vs. 24.4 weeks EM group). The mean GA at FASI was 30.4 weeks (95% CI 28.5, 32.5). The mean GA at delivery was also comparable (37.7 weeks FASI vs. 38.1 weeks EM group). Neonatal outcomes, including live birth, neonatal death, and survival to hospital discharge pooled proportions, were also comparable between groups (live birth: 92% (95% CI 64, 99) FASI versus 93% (95% CI 79, 98) in EM, neonatal death: 32% (95% CI 11, 65) FASI versus 30% (95% CI 21, 41) EM, survival to hospital discharge: 37% (95% CI 25, 52) FASI versus 52% (95% CI 42, 61) EM). Age at neonatal death was higher in the FASI group (mean: 17 days FASI vs. 7.2 days EM group). There was a lower rate of postnatal atrial restrictive septum in the FASI group 38% (95% CI 17, 63) compared to the EM group 88% (95% CI 57, 98). Our review shows variations across centers in the selection criteria and techniques used for FASI. Although survival including livebirth, neonatal death, and survival to hospital discharge did not differ between groups, the procedure may translate into a less restrictive septum at birth. Future multicenter studies are needed to better identify the subset of cases that might have improved outcomes, use standardized definitions, unified techniques, utilize core outcome set, and assess long-term benefits.
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Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- The Fetal Center at Riley Children's and Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Faezeh Aghajani
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
| | - Mohammad Jawwad
- Department of Medicine and Surgery, Dow University of Health Sciences, Karachi, Pakistan
| | - Nensi Shah
- Department of Internal Medicine, College of Medical Sciences, Bharatpur, Nepal
| | - Alfred Abuhamad
- Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Bucholz EM, Lu M, Sleeper L, Vergales J, Bingler MA, Ronai C, Anderson JB, Bates KE, Lannon C, Reynolds L, Brown DW. Risk Factors for Death or Transplant After Stage 2 Palliation for Single Ventricle Heart Disease. JACC. ADVANCES 2024; 3:100934. [PMID: 38939642 PMCID: PMC11198479 DOI: 10.1016/j.jacadv.2024.100934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/30/2023] [Accepted: 01/25/2024] [Indexed: 06/29/2024]
Abstract
Background For infants with single ventricle heart disease, the time after stage 2 procedure (S2P) is believed to be a lower risk period compared with the interstage period; however, significant morbidity and mortality still occur. Objectives This study aimed to identify risk factors for mortality or transplantation referral between S2P surgery and the first birthday. Methods Retrospective cohort analysis of infants in the National Pediatric Cardiology Quality Improvement Collaborative who underwent staged single ventricle palliation from 2016 to 2022 and survived to S2P. Multivariable logistic regression and classification and regression trees were performed to identify risk factors for mortality and transplantation referral after S2P. Results Of the 1,455 patients in the cohort who survived to S2P, 5.2% died and 2.3% were referred for transplant. Overall event rates at 30 and 100 days after S2P were 2% and 5%, respectively. Independent risk factors for mortality and transplantation referral included the presence of a known genetic syndrome, shunt type at stage 1 procedure (S1P), tricuspid valve repair at S1P, longer time to extubation and reintubation after S1P, ≥ moderate tricuspid regurgitation prior to S2P, younger age at S2P, and the risk groups identified in the classification and regression tree analysis (extracorporeal membrane oxygenation after S1P and longer S2P cardiopulmonary bypass time without extracorporeal membrane oxygenation). Conclusions Mortality and transplantation referral rates after S2P to 1 year of age remain high ∼7%. Many of the identified risk factors after S2P are similar to those established for interstage factors around the S1P, whereas others may be unique to the period after S2P.
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Affiliation(s)
- Emily M. Bucholz
- Section of Cardiology, Department of Pediatrics, Children’s Hospital of Colorado and the University of Colorado School of Medicine, Denver, Colorado, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn Sleeper
- Department of Cardiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Vergales
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | - Christina Ronai
- Department of Cardiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey B. Anderson
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine E. Bates
- Congenital Heart Center, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Carole Lannon
- Congenital Heart Center, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Lindsey Reynolds
- Department of Cardiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - David W. Brown
- Department of Cardiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
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Rao PS. Therapy of Patients with Cardiac Malposition. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040739. [PMID: 37189988 DOI: 10.3390/children10040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Positional abnormalities per se do not require treatment, but in their place, the accompanying pulmonary pathology in dextroposition patients and pathophysiologic hemodynamic abnormalities resulting from multiple defects in patients with cardiac malposition should be the focus of treatment. At the time of the first presentation, treating the pathophysiologic aberrations caused by the defect complex, whether it is by improving the pulmonary blood flow or restricting it, is the first step. Some patients with simpler or single defects are amenable to surgical or transcatheter therapy and should be treated accordingly. Other associated defects should also be treated appropriately. Biventricular or univentricular repair dependent on the patient's cardiac structure should be planned. Complications in-between Fontan stages and after conclusion of Fontan surgery may occur and should be promptly diagnosed and addressed accordingly. Several other cardiac abnormalities unrelated to the initially identified heart defects may manifest in adulthood, and they should also be treated.
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, Children's Memorial Hermann Hospital, McGovern Medical School, University of Texas-Houston, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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Yagi H, Lo CW. Left-Sided Heart Defects and Laterality Disturbance in Hypoplastic Left Heart Syndrome. J Cardiovasc Dev Dis 2023; 10:jcdd10030099. [PMID: 36975863 PMCID: PMC10054755 DOI: 10.3390/jcdd10030099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a complex congenital heart disease characterized by hypoplasia of left-sided heart structures. The developmental basis for restriction of defects to the left side of the heart in HLHS remains unexplained. The observed clinical co-occurrence of rare organ situs defects such as biliary atresia, gut malrotation, or heterotaxy with HLHS would suggest possible laterality disturbance. Consistent with this, pathogenic variants in genes regulating left-right patterning have been observed in HLHS patients. Additionally, Ohia HLHS mutant mice show splenic defects, a phenotype associated with heterotaxy, and HLHS in Ohia mice arises in part from mutation in Sap130, a component of the Sin3A chromatin complex known to regulate Lefty1 and Snai1, genes essential for left-right patterning. Together, these findings point to laterality disturbance mediating the left-sided heart defects associated with HLHS. As laterality disturbance is also observed for other CHD, this suggests that heart development integration with left-right patterning may help to establish the left-right asymmetry of the cardiovascular system essential for efficient blood oxygenation.
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Affiliation(s)
- Hisato Yagi
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15201, USA
| | - Cecilia W Lo
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15201, USA
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Rao PS. Double-Inlet Left Ventricle. CHILDREN 2022; 9:children9091274. [PMID: 36138583 PMCID: PMC9497213 DOI: 10.3390/children9091274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022]
Abstract
Double-inlet left ventricle (DILV) is most frequent among univentricular atrioventricular connections. In DILV, there is a single functioning ventricle, most commonly with left ventricular structure. This chamber receives both atrioventricular valves and is connected to an outlet chamber with morphologic features of the right ventricle. The great vessels are often transposed, and pulmonary stenosis is seen in two-thirds of patients. The anatomy and pathophysiology can be defined by echo-Doppler studies with a rare need for other imaging studies. The management is mostly related to the nature of associated heart defects and the degree of pathophysiological abnormality. When the infants present initially, treatment to address the hemodynamic issues is undertaken. Subsequently, these babies need staged total cavo-pulmonary connection, i.e., the Fontan procedure which is undertaken in three stages; these stages are described in this review. The existence of inter-stage mortality and post-Fontan complications is recognized and was reviewed. The paper concludes that DILV can be successfully diagnosed with echo-Doppler studies and this heart anomaly can be effectively treated with the currently prevailing medical, catheter interventional, and surgical treatment practices.
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, Children's Memorial Hermann Hospital, McGovern Medical School, University of Texas-Houston, Houston, TX 77030, USA
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Leftward and Posterior Deviation of the Septum Primum Predicts Morbidity in Patients with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2022; 43:1365-1372. [PMID: 35316357 DOI: 10.1007/s00246-022-02860-w] [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: 11/09/2021] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
Leftward posterior deviation of the atrial septum primum (LDSP) has been reported in up to 64% of patients with hypoplastic left heart syndrome (HLHS) but there are no published data on its impact on neonatal outcomes. We reviewed the prevalence of LDSP and its correlation with neonatal outcomes in our institution. This was a single-center retrospective study of neonates with HLHS from 2001 to 2019. Echocardiograms were reviewed and the presence or absence of LDSP was noted. To quantify the degree of deviation in patients with LDSP, a new measurement, the deviation index (DI) was calculated using both the subcostal long and short-axis views. Of ninety-four patients with HLHS, fifty-seven (61%) patients were noted to have LDSP. There was no statistically significant difference in gestational age (GA), birth weight (BW), or mortality between patients with and without LDSP. Patients with LDSP had an increased incidence of unplanned reoperation (p < 0.01), post-operative cardiac catheterization (p < 0.05), and post-operative infection (p < 0.05). After correction for GA, BW, HLHS subtype, and type of surgery, LDSP predicted reoperation (OR = 3.6, p < 0.01), catheterization (OR = 2.7, p = 0.05), and infection (OR = 3.4, p < 0.05). Higher degree of deviation predicted reoperation (DI > 0.17), catheterization (DI > 0.07), and infection (DI > 0.12). There was excellent inter-observer reproducibility of the DI (ICCabsolute-agreement = 0.82, ICCconsistency = 0.90). Patients with LDSP have a higher prevalence of post-operative morbidity. The degree of deviation was found to be predictive of post-operative complications. Pre-operative echocardiographic evaluation of LDSP in patients with HLHS may be helpful in risk stratification and counseling.
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Mitral Atresia with Normal Aortic Root. CHILDREN 2022; 9:children9081148. [PMID: 36010040 PMCID: PMC9406580 DOI: 10.3390/children9081148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022]
Abstract
Mitral atresia with normal aortic root is a rare complex congenital heart defect (CHD) and constitute less than 1% of all CHDs. In this anomaly, the mitral valve is atretic, a patent foramen ovale provides egress of the left atrial blood, either a single ventricle or two ventricles with left ventricular hypoplasia are present, and the aortic valve/root are normal by definition. Clinical, roentgenographic and electrocardiographic features are non-distinctive, but echo-Doppler studies are useful in defining the anatomic and pathophysiologic components of this anomaly with rare need for other imaging studies. Treatment consists of addressing the pathophysiology resulting from defect and associated cardiac anomalies at the time of initial presentation, usually in the early infancy. These children eventually require staged total cavo-pulmonary connection (Fontan) in three stages. Discussion of each of these stages were presented. Complications are observed in-between the stages of Fontan surgery and following completion of Fontan procedure. Attempts to monitor for early detection of these complications and promptly addressing the complications are recommended.
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Alpha-blockade during congenital heart surgery admissions: analysis from national database. Cardiol Young 2022; 32:1136-1142. [PMID: 34530952 DOI: 10.1017/s1047951121003875] [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] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The effects of alpha-blockade on haemodynamics during and following congenital heart surgery are well documented, but data on patient outcomes, mortality, and hospital charges are limited. The purpose of this study was to characterise the use of alpha-blockade during congenital heart surgery admissions and to determine its association with common clinical outcomes. MATERIALS AND METHODS A cross-sectional study was conducted using the Pediatric Health Information System database. De-identified data for patients under 18 years of age with a cardiac diagnosis who underwent congenital heart surgery were obtained from 2004 to 2015. Patients were subdivided on the basis of receiving alpha-blockade with either phenoxybenzamine or phentolamine during admission or not. Continuous and categorical variables were analysed using Mann−Whitney U-tests and Fisher exact tests, respectively. Characteristics between subgroups were compared using univariate analysis. Regression analyses were conducted to determine the impact of alpha-blockade on ICU length of stay, hospital length of stay, billed charges, and mortality. RESULTS Of the 81,313 admissions, 4309 (5.3%) utilised alpha-blockade. Phentolamine was utilised in 4290 admissions. In univariate analysis, ICU length of stay, total length of stay, inpatient mortality, and billed charges were all significantly higher in the alpha-blockade admissions. However, regression analyses demonstrated that other factors were behind these increased. Alpha-blockade was significantly, independently associated with a 1.5 days reduction in ICU length of stay (p < 0.01) and a 3.5 days reduction in total length of stay (p < 0.01). Alpha-blockade was significantly, independently associated with a reduction in mortality (odds ratio 0.8, 95% confidence interval 0.7−0.9). Alpha-blockade was not independently associated with any significant change in billed charges. CONCLUSIONS Alpha-blockade is used in a subset of paediatric cardiac surgeries and is independently associated with significant reductions in ICU length of stay, hospital length of stay, and mortality without significantly altering billed charges.
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Abstract
OBJECTIVES Superior vena cava oxygen saturation (SVC O 2 ) monitoring is well described for early detection of hemodynamic deterioration after neonatal cardiac surgery but inferior vena cava vein oxygen saturation (IVC O 2 ) monitoring data are limited. DESIGN Retrospective cohort study of 118 neonates with congenital heart disease (52 single ventricle) from February 2008 to January 2014. SETTING Pediatric cardiac ICU. PATIENTS Neonates (< 30 d) with concurrent admission IVC O 2 and SVC O 2 measurements after cardiac surgery with cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary aim was to correlate admission IVC O 2 and SVC O 2 . Secondary aims included: correlate flank or cerebral near-infrared spectroscopy with IVC O 2 and SVC O 2 , respectively, and exploratory analysis to evaluate associations between oximetry data and a composite adverse outcome defined as any of the following: increasing serum lactate or vasoactive support at 2 hours post-admission, cardiac arrest, or mortality. Admission IVC O 2 and SVC O 2 correlated ( r = 0.54; p < 0.001). However, IVC O 2 measurements were significantly lower than paired SVC O 2 (mean difference, -6%; 95% CI, -8% to -4%; p < 0.001) with wide variability in sample agreement. Logistic regression showed that each 12% decrease in IVC O 2 was associated with a 12-fold greater odds of the composite adverse outcome (odds ratio [OR], 12; 95% CI, 3.9-34; p < 0.001). We failed to find an association between SVC O 2 and increased odds of the composite adverse outcome (OR, 1.8; 95% CI, 0.99-3.3; p = 0.053). In an exploratory analysis, the area under the receiver operating curve for IVC O 2 and SVC O 2 , and the composite adverse outcome, was 0.85 (95% CI, 0.77-0.92) and 0.63 (95% CI, 0.52-0.73), respectively. Admission IVC O 2 had strong correlation with concurrent flank near-infrared spectroscopy value ( r = 0.74; p < 0.001). SVC O 2 had a weak association with cerebral near-infrared spectroscopy ( r = 0.22; p = 0.02). CONCLUSIONS In postoperative neonates, admission IVC O 2 and SVC O 2 correlate. Lower admission IVC O 2 may identify a cohort of postsurgical neonates at risk for low cardiac output and associated morbidity.
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Abstract
INTRODUCTION AND BACKGROUND Mortality between stages 1 and 2 single-ventricle palliation is significant. Home-monitoring programmes are suggested to reduce mortality. Outcomes and risk factors for adverse outcomes for European programmes have not been published. AIMS To evaluate the performance of a home-monitoring programme at a medium-sized United Kingdom centre with regards survival and compare performance with other home-monitoring programmes in the literature. METHODS All fetal and postnatal diagnosis of a single ventricle were investigated with in-depth analysis of those undergoing stage 1 palliation and entered the home-monitoring programme between 2016 and 2020. The primary outcome was survival. Secondary outcomes included multiple parameters as potential predictors of death or adverse outcome. RESULTS Of 217 fetal single-ventricle diagnoses during the period 2016-2020, 50.2% progressed to live birth, 35.4% to stage 1 and 29.5% to stage 2. Seventy-four patients (including 10 with postnatal diagnosis) entered the home-monitoring programme with six deaths making home-monitoring programme mortality 8.1%. Risk factors for death were the hybrid procedure as the only primary procedure (OR 33.0, p < 0.01), impaired cardiac function (OR 10.3, p < 0.025), Asian ethnicity (OR 9.3, p < 0.025), lower mean birth-weight (2.69 kg versus 3.31 kg, p < 0.01), and lower mean weight centiles during interstage follow-up (mean centiles of 3.1 versus 10.8, p < 0.01). CONCLUSION Survival in the home-monitoring programme is comparable with other home-monitoring programmes in the literature. Hybrid procedure, cardiac dysfunction, sub-optimal weight gain, and Asian ethnicity were significant risk factors for death. Home-monitoring programmes should continue to raise awareness of these factors and seek solutions to mitigate adverse events. Future work to generalise home-monitoring programme and single-ventricle fetus to stage 2 outcomes in the United Kingdom will require multi-centre collaboration.
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Abbas Q, Hussain MZH, Shahbaz FF, Siddiqui NUR, Hasan BS. Performance of a Risk Analytic Tool (Index of Tissue Oxygen Delivery "IDO2") in Pediatric Cardiac Intensive Care Unit of a Developing Country. Front Pediatr 2022; 10:846074. [PMID: 35722489 PMCID: PMC9203960 DOI: 10.3389/fped.2022.846074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/16/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the performance of a commercially available risk analytic tool (IDO2) to estimate the risk for SVO2 < 40% in patients admitted in cardiac intensive care unit (CICU). METHODS Medical and T3 records of all patients (aged 1 day to 12 years, weight >2 kg) who received care in the CICU between October 1st, 2019 and October 1st, 2020, had SvO2 lab(s) drawn during CICU course and whose data was transmitted to T3, were included. The average IDO2 Index was computed in the 30-min period immediately prior to each SvO2 measurement and used as a predictor score for SvO2 < 40%. RESULTS A total of 69 CICU admissions from 65 patients, median age 9.3 months (interquartile range 20.8) were identified. Surgical and medical patients were 61 (88%) and 8 (12%) respectively; 4 (5.7%) patients had single ventricle physiology. Tetralogy of Fallot n = 23 (33.3%) and ventricular septal defects 17 (24.6%) were major cardiac diagnosis. Sixty-one (89.9%) of the admissions were successfully discharged from the hospital. Of the 187-total included SvO2 labs, 17 (9%) were <40%. The AUC of estimating SvO2 < 40% IDO2 was 0.87 [confidence interval (CI): 0.79-0.94]. Average IDO2 above 75 had the highest absolute risk (42.11, CI: 20.25-66.50) and highest RR (4.63, CI: 2.31-9.28, p-value < 0.0001) of SvO2 < 40%. CONCLUSION IDO2 performed well in estimating low SvO2 (<40%) in pediatric patients presenting to a CICU in a low resource setting. Future work is needed to determine the effect of this risk analytic tool on clinical outcomes in such a setting.
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Affiliation(s)
- Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Babar S Hasan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6550760. [DOI: 10.1093/ejcts/ezac129] [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] [Received: 09/27/2021] [Revised: 01/28/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
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Morell E, Miller MK, Lu M, Friedman KG, Breitbart RE, Reichman JR, McDermott J, Sleeper LA, Blume ED. Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease. J Am Heart Assoc 2021; 10:e018488. [PMID: 33442989 PMCID: PMC7955315 DOI: 10.1161/jaha.120.018488] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision‐making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease. Methods and Results A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1‐year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1–5), 39% had single‐ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis “extremely well” or “well,” 28% of physicians thought parents understood the prognosis only “a little,” “somewhat,” or “not at all.” Better parent‐reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4–21.7, P=0.02). There was poor parent–physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy. Conclusions Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent‐reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient‐reported outcomes, parent education, and physician communication tools may be beneficial.
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Affiliation(s)
- Emily Morell
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles Los Angeles CA
| | | | - Minmin Lu
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | | | | | - Julie McDermott
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Lynn A Sleeper
- Department of Cardiology Boston Children's Hospital Boston MA
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Hoffman GM, Scott JP, Ghanayem NS, Stuth EA, Mitchell ME, Woods RK, Hraska V, Niebler RA, Bertrandt RA, Mussatto KA, Tweddell JS. Identification of Time-Dependent Risks of Hemodynamic States After Stage 1 Norwood Palliation. Ann Thorac Surg 2020; 109:155-162. [DOI: 10.1016/j.athoracsur.2019.06.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/05/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022]
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19
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Impact of Right Ventricular Geometry and Left Ventricular Hypertrophy on Right Ventricular Mechanics and Clinical Outcomes in Hypoplastic Left Heart Syndrome. J Am Soc Echocardiogr 2019; 32:1350-1358. [PMID: 31351794 DOI: 10.1016/j.echo.2019.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Right ventricular (RV) function is a major determinant of survival in hypoplastic left heart syndrome (HLHS). However, the relation of RV geometry to myocardial mechanics and their relation to transplant-free survival are incompletely characterized. METHODS We retrospectively studied 48 HLHS patients from the Hospital for Sick Children, Toronto, (median age, 2.2; interquartile range, 3.62 years) at different surgical stages. Patients were grouped by the presence (n = 23) or absence (n = 25) of RV "apical bulging" defined as a sigmoid-shaped septum with the RV leftward apical segment contiguous with the left ventricular (LV) lateral wall. Regional and global RV strain were measured using speckle-tracking echocardiography, and regional strains were analyzed for patterns and peak values. These were compared between HLHS anatomical subtypes and between patients with versus without apical bulging. We further investigated the association between RV geometry and dysfunction with the outcomes of heart failure, death, or transplant. RESULTS RV global (-7.3% ± 2.8% vs -11.2% ± 4.4%; P = .001), basal septal (-3.8% ± 3.2% vs -11.4% ± 5.8%; P = .0001) and apicolateral (-5.1% ± 3.5% vs -8.0% ± 5.8%, P = .001) longitudinal strain were lower in patients with versus without apical bulging, respectively. Apical bulging was equally prevalent in all HLHS anatomical variants. Twenty of 22 (91%) patients with apical bulging displayed hypertrophy of the LV apical and lateral segments. Death or transplantation were approximately equal in both groups but related to reduced RV global strain in patients with (seven of seven) and not in those without apical bulging (two of eight; P = .022). CONCLUSIONS These results suggest that the finding of apical bulging is related to the presence of a hypertrophied hypoplastic LV, with a negative impact on regional and global RV function. Therefore, analysis of RV and LV geometry and mechanics may aid in the assessment and prognostication of this high-risk population.
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Wolfe KR, Brinton J, Di Maria MV, Meier M, Liptzin DR. Oxygen saturations and neurodevelopmental outcomes in single ventricle heart disease. Pediatr Pulmonol 2019; 54:922-927. [PMID: 30919581 DOI: 10.1002/ppul.24275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/20/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate whether the degree of hypoxemia following stage-I and stage-II palliative surgeries predicts neurodevelopmental outcomes at 14 months of age in children with single ventricle congenital heart disease (SVCHD). DESIGN We analyzed longitudinal data from two Pediatric Heart Network (PHN) randomized controlled trials, with a total of 328 subjects. Oxygen saturations, measured via pulse oximetry, at time of discharge from stage-I and stage-II surgeries were the primary predictors of interest, and Bayley Scales of Infant Development-II (BSID-II) scores at 14 months old were the primary outcome measure. Relevant covariates from previously-published PHN studies were also included in regression models. RESULTS Oxygen saturations at time of discharge from stage-I and stage-II surgeries were not related to BSID-II scores. Having one or more oxygen saturation measurements below 80% was also not associated with BSID-II scores, and neither was change in oxygen saturations over time. These relationships were not altered by inclusion of relevant covariates. CONCLUSIONS In this large cohort of children with SVCHD, oxygen saturations post-stage-I and post-stage-II palliation surgeries as measured via pulse oximetry were not associated with neurodevelopmental outcomes at 14 months of age. The relationship between oxygen saturations and neurodevelopment in SVCHD is likely complex, and neurodevelopment is known to be affected by a number of factors. Pulse oximetry may also be an insufficient proxy for cerebral oxygen delivery. Clinically, pulse oximetry readings during the interstage and post-stage-II surgery periods are not a reliable predictor of future neurodevelopmental risk.
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Affiliation(s)
- Kelly R Wolfe
- Pediatric Neurology, University of Colorado School of Medicine and Children's Hospital, Aurora, Colorado
| | - John Brinton
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Michael V Di Maria
- Heart Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Maxene Meier
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Deborah R Liptzin
- Pediatric Pulmonary Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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Zielonka B, Snarr BS, Liu MY, Zhang X, Mascio CE, Fuller S, Gaynor JW, Spray TL, Rychik J. Resource Utilization for Prenatally Diagnosed Single-Ventricle Cardiac Defects: A Philadelphia Fetus-to-Fontan Cohort Study. J Am Heart Assoc 2019; 8:e011284. [PMID: 31140350 PMCID: PMC6585367 DOI: 10.1161/jaha.118.011284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Healthcare resource utilization is substantial for single‐ventricle cardiac defects (SVCD), with effort commencing at time of fetal diagnosis through staged surgical palliation. We sought to characterize and identify variables that influence resource utilization for SVCD from fetal diagnosis through death, completed staged palliation, or cardiac transplant. Methods and Results Patients with a prenatal diagnosis of SVCD at our institution from 2004 to 2011 were screened. Patients delivered with intent to treat who received cardiac care exclusively at our institution were included. Primary end points included the total days hospitalized and the numbers of echocardiograms and cardiac catheterizations. Subanalysis was performed on survivors of completed staged palliation on the basis of Norwood operation, dominant ventricular morphology, and additional risk factors. Of 202 patients born with intent to treat, 136 patients survived to 6 months after completed staged palliation. The median number of days hospitalized per patient‐year was 25.1 days, and the median numbers of echocardiograms and catheterizations per patient‐year were 7.2 and 0.7, respectively. Mortality is associated with increased resource utilization. Survivors had a cumulative length of stay of 57 days and underwent a median of 21 echocardiograms and 2 catheterizations through staged palliation. Right‐ventricle–dominant lesions requiring Norwood operation are associated with increased resource utilization among survivors of staged palliation. Conclusions For fetuses with SVCD, those with dominant right‐ventricular morphology requiring Norwood operation demand increased resource utilization regardless of mortality. Our findings provide insight into care for SVCD, facilitate precise prenatal counseling, and provide information about the resources utilized to successfully manage SVCD.
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Affiliation(s)
- Benjamin Zielonka
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Brian S Snarr
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Michael Y Liu
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Xuemei Zhang
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher E Mascio
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Stephanie Fuller
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - J William Gaynor
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Thomas L Spray
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Jack Rychik
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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Yoon S, Jang EJ, Kim GH, Kim DH, Lim TY, Lee H, Ryu HG. Adult lung transplantation case-volume and in-hospital and long-term mortality in Korea. J Cardiothorac Surg 2019; 14:19. [PMID: 30674327 PMCID: PMC6343357 DOI: 10.1186/s13019-019-0849-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/17/2019] [Indexed: 11/17/2022] Open
Abstract
Background The inverse relationship between case-volume and surgical mortality has been reported in complex surgical procedures. The aim of this study was to evaluate the effect of case-volume on mortality after lung transplantation in Korea. Methods The National Health Insurance Service data was used to analyse all adult lung transplantations in Korea between 2007 and 2016. Institutions were categorized into low-volume (< 5 lung transplantations/year) centers or high-volume (≥ 5 lung transplantations/year) centers. Risk-adjusted in-hospital mortality and long-term survival according to case-volume was evaluated. Results A total of 315 adult recipients underwent lung transplantation at 7 centers. The odds ratio for in-hospital mortality in low-volume centers was similar to high-volume centers (OR, 1.496; 95% CI, 0.81–2.76; p = 0.197). Log-rank analysis of Kaplan-Meier curves according to case-volume also did not show a difference in long-term survival between high- and low-volume centers (p = 0.052). Conclusions There was no association between case-volume and in-hospital mortality after lung transplantation in Korea, although there was a tendency towards better long-term survival associated with high-volume centers.
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Affiliation(s)
- Susie Yoon
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, 1375 Gyeongdong-ro, Andong-si, Gyeongsangbuk-do, 36729, South Korea
| | - Ga Hee Kim
- Department of Statistics, Kyungpook National University, 80 Daehak-ro, Buk-gu, Daegu, 41566, South Korea
| | - Dal Ho Kim
- Department of Statistics, Kyungpook National University, 80 Daehak-ro, Buk-gu, Daegu, 41566, South Korea
| | - Tae-Yoon Lim
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hannah Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ho Geol Ryu
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Rai V, Mroczek T, Szypulski A, Pac A, Gładki M, Dudyńska M, Skalski J. Outcome of Norwood operation for hypoplastic left heart syndrome. Indian J Thorac Cardiovasc Surg 2018; 34:337-344. [PMID: 33060891 PMCID: PMC7525726 DOI: 10.1007/s12055-017-0603-1] [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: 06/01/2017] [Revised: 09/26/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE The Norwood procedure, the first surgical step of staged palliation for hypoplastic left heart syndrome (HLHS), is also applied for other complex single ventricle lesions. This study aimed to evaluate the outcome of the Norwood operation in a single center over 4 years and to identify clinical and anatomic risk factors for overall mortality. METHODS A retrospective review of the pediatric cardiovascular surgery database was performed to identify infants with HLHS who underwent NP (Norwood procedure) at our institution between January 2007 and December 2011. Our study population consisted of 85 patients with HLHS. RESULTS Early mortality (30 days postoperative period) between January 2007 and December 2011 for Norwood operation was 7 (8.2%) out of 85 patient, and overall mortality was 24 (28.2%). CONCLUSION Our single-center experience shows that the Norwood operation can be performed for complex single ventricle lesions with similarly good early outcomes regardless of the underlying anatomy.
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Affiliation(s)
- Vivek Rai
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Krakow, Poland
| | - Tomasz Mroczek
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Krakow, Poland
| | - Aleksander Szypulski
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Krakow, Poland
| | - Agnieszka Pac
- Department of Epidemiology and Public Health, Jagiellonian University, Krakow, Poland
| | - Marcin Gładki
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Krakow, Poland
| | - Mirosława Dudyńska
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Krakow, Poland
| | - Janusz Skalski
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Krakow, Poland
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Lin LQ, Conway J, Alvarez S, Goot B, Serrano-Lomelin J, Colen T, Tham EB, Kutty S, Li L, Khoo NS. Reduced Right Ventricular Fractional Area Change, Strain, and Strain Rate before Bidirectional Cavopulmonary Anastomosis is Associated with Medium-Term Mortality for Children with Hypoplastic Left Heart Syndrome. J Am Soc Echocardiogr 2018; 31:831-842. [PMID: 29655509 DOI: 10.1016/j.echo.2018.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ventricular dysfunction is associated with increased morbidity and mortality in children with hypoplastic left heart syndrome. The aim of this study was to assess the diagnostic performance of conventional and speckle-tracking echocardiographic measures of right ventricular (RV) function before bidirectional cavopulmonary anastomosis palliation in predicting death or need for heart transplantation (HTx). METHODS RV fractional area change (RVFAC) and longitudinal and circumferential strain and strain rate (SR) were measured in 64 prospectively recruited patients with hypoplastic left heart syndrome from echocardiograms obtained before bidirectional cavopulmonary anastomosis surgery. The composite end point of death or HTx was examined. Receiver operating characteristic analysis was performed, and cutoff values optimizing sensitivity and specificity were derived. RESULTS At a median follow-up of 5.0 years (interquartile range, 2.8-6.4 years), 13 patients meeting the composite end point had lower longitudinal strain and SR, circumferential SR, and RVFAC compared with survivors (n = 51). The conventional cutoff of RVFAC < 35% was specific for death or HTx (86%) but had poor sensitivity (46%), with an area under the curve of 0.73. Speckle-tracking echocardiographic variables showed similar areas under the curve (range, 0.69-0.79), with negative predictive values >90%. Addition of speckle-tracking echocardiographic variables to RVFAC < 35% showed no added benefit. However, in a subpopulation of patients with RVFAC ≥ 35% (n = 44), those meeting the composite end point (n = 7) had lower longitudinal SR (median, -1.0 1/sec [interquartile range, -0.8 to -1.1 1/sec] vs -1.21/sec [interquartile range, -1.0 to -1.3 1/sec], P = .03). Interobserver reproducibility was superior for longitudinal strain and SR (intraclass correlation coefficient > 0.92) compared with RVFAC (intraclass correlation coefficient = 0.75). CONCLUSIONS Children with hypoplastic left heart syndrome with normal RVFAC and ventricular deformation before bidirectional cavopulmonary anastomosis have a low likelihood of death or HTx in the medium term. In the presence of reduced RVFAC, speckle-tracking echocardiography does not provide additional prognostic value. However, in patients with "normal" RVFAC, it may have a role in improving outcome prediction and warrants further investigation.
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Affiliation(s)
- Lily Q Lin
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Jennifer Conway
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Silvia Alvarez
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin Goot
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Timothy Colen
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Edythe B Tham
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Shelby Kutty
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Ling Li
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Nee Scze Khoo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Nicolau GO, Nigro Neto C, Bezerra FJL, Furlanetto G, Passos SC, Stahlschmidt A. Vasodilator Agents in Pediatric Cardiac Surgery with Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2018; 32:412-422. [DOI: 10.1053/j.jvca.2017.07.007] [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: 04/18/2017] [Indexed: 11/11/2022]
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Abstract
OBJECTIVE To evaluate differences in interstage growth of pulmonary arteries between use of polytetrafluoroethylene and femoral vein homograft as Sano shunt during stage-I Norwood palliation. METHODS A retrospective review of all patients who survived to the second stage following Norwood-Sano operation at two institutions was performed. Either polytetrafluoroethylene or the valved segment of femoral vein homograft was used for construction of the Sano shunt. The size of pulmonary arteries was compared at pre-Glenn catheterisation. RESULTS A total of 48 neonates with the diagnosis of hypoplastic left heart syndrome or its variants comprised the study population. Femoral vein homograft of 5-6 mm diameter was used in 14 and polytetrafluoroethylene graft of 5 mm was used in 34 patients. The two groups were comparable in terms of preoperative demographics and age at time of pre-Glenn catheterisation (3.9±0.7 versus 3.4±0.8 months, p=0.06). Patients who received femoral vein homograft demonstrated a significantly higher pre-Glenn Nakata index [264 (130-460) versus 165 (108-234) mm2/m2, p=0.004]. The individual branch pulmonary arteries were significantly larger in the femoral vein group (right, 7.8±3.6 versus 5.0±1.2, p=0.014; left, 7.2±2.1 versus 5.6±1.9, p=0.02). There were no differences in cardiac index, Qp:Qs, ventricular end-diastolic pressure or systemic oxygen saturations. CONCLUSIONS Utilisation of a valved segment of femoral vein homograft as right ventricle to pulmonary artery conduit during Norwood-Sano operation confers better interstage growth of the pulmonary arteries. Further studies are needed to evaluate the impact of femoral vein homograft on single ventricle function.
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Kabagambe SK, Lee CJ, Goodman LF, Chen YJ, Vanover MA, Farmer DL. Lessons from the Barn to the Operating Suite: A Comprehensive Review of Animal Models for Fetal Surgery. Annu Rev Anim Biosci 2017; 6:99-119. [PMID: 29237141 DOI: 10.1146/annurev-animal-030117-014637] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The International Fetal Medicine and Surgery Society was created in 1982 and proposed guidelines for fetal interventions that required demonstrations of the safety and feasibility of intended interventions in animal models prior to application in humans. Because of their short gestation and low cost, small animal models are useful in early investigation of fetal strategies. However, owing to the anatomic and physiologic differences between small animals and humans, repeated studies in large animal models are usually needed to facilitate translation to humans. Ovine (sheep) models have been used the most extensively to study the pathophysiology of congenital abnormalities and to develop techniques for fetal interventions. However, nonhuman primates have uterine and placental structures that most closely resemble those of humans. Thus, the nonhuman primate is the ideal model to develop surgical and anesthetic techniques that minimize obstetrical complications.
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Affiliation(s)
- Sandra K Kabagambe
- University of California, Davis Health, Sacramento, California 95817, USA; , , , , ,
| | - Chelsey J Lee
- University of California, Davis Health, Sacramento, California 95817, USA; , , , , ,
| | - Laura F Goodman
- University of California, Davis Health, Sacramento, California 95817, USA; , , , , ,
| | - Y Julia Chen
- University of California, Davis Health, Sacramento, California 95817, USA; , , , , ,
| | - Melissa A Vanover
- University of California, Davis Health, Sacramento, California 95817, USA; , , , , ,
| | - Diana L Farmer
- University of California, Davis Health, Sacramento, California 95817, USA; , , , , ,
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Behandlung der chronischen Herzinsuffizienz im Kindesalter. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0370-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cutrì E, Meoli A, Dubini G, Migliavacca F, Hsia TY, Pennati G. Patient-specific biomechanical model of hypoplastic left heart to predict post-operative cardio-circulatory behaviour. Med Eng Phys 2017; 47:85-92. [DOI: 10.1016/j.medengphy.2017.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/02/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
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Abstract
PURPOSE OF REVIEW Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the mitral valve, left ventricle, and aorta and is ultimately palliated with a single-ventricle repair. Universally fatal in infancy prior to the advent of modern surgical techniques, the majority of HLHS patients will now reach adulthood. However, despite improvements in early survival, the HLHS population continues to face significant morbidity and early mortality. This review delineates common sources of patient morbidity and highlights areas in need of additional research for this growing segment of the adult congenital heart disease population. RECENT FINDINGS It has become increasingly clear that palliated adult single ventricle patients, like those with HLHS, face significant life-long morbidity from elevated systemic venous pressures as a consequence of the Fontan procedure. Downstream organ dysfunction secondary to elevated Fontan pressures has the potential to significantly impact long-term management decisions, including strategies of organ allocation. Because of the presence of a morphologic systemic right ventricle, HLHS patients may be at even higher risk than other adult patients with a Fontan. Because the adult HLHS population continues to grow, recognition of common sources of patient morbidity and mortality is becoming increasingly important. A coordinated effort between patients and providers is necessary to address the many remaining areas of clinical uncertainty to help ensure continued improvement in patient prognosis and quality of life.
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Haller C, Chetan D, Saedi A, Parker R, Van Arsdell GS, Honjo O. Geometry and growth of the reconstructed aorta in patients with hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2017; 153:1479-1487.e1. [DOI: 10.1016/j.jtcvs.2017.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 01/12/2017] [Accepted: 02/04/2017] [Indexed: 10/20/2022]
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Riveros Perez E, Riveros R. Mathematical Analysis and Physical Profile of Blalock-Taussig Shunt and Sano Modification Procedure in Hypoplastic Left Heart Syndrome: Review of the Literature and Implications for the Anesthesiologist. Semin Cardiothorac Vasc Anesth 2017; 21:152-164. [PMID: 28118786 DOI: 10.1177/1089253216687857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The first stage of surgical treatment for hypoplastic left heart syndrome (HLHS) includes the creation of artificial systemic-to-pulmonary connections to provide pulmonary blood flow. The modified Blalock-Taussig (mBT) shunt has been the technique of choice for this procedure; however, a right ventricle-pulmonary artery (RV-PA) shunt has been introduced into clinical practice with encouraging but still conflicting outcomes when compared with the mBT shunt. The aim of this study is to explore mathematical modeling as a tool for describing physical profiles that could assist the surgical team in predicting complications related to stenosis and malfunction of grafts in an attempt to find correlations with clinical outcomes from clinical studies that compared both surgical techniques and to assist the anesthesiologist in making decisions to manage patients with this complex cardiac anatomy. Mathematical modeling to display the physical characteristics of the chosen surgical shunt is a valuable tool to predict flow patterns, shear stress, and rate distribution as well as energetic performance at the graft level and relative to ventricular efficiency. Such predictions will enable the surgical team to refine the technique so that hemodynamic complications be anticipated and prevented, and are also important for perioperative management by the anesthesia team.
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A Novel Electrocardiogram Algorithm Utilizing ST-Segment Instability for Detection of Cardiopulmonary Arrest in Single Ventricle Physiology: A Retrospective Study. Pediatr Crit Care Med 2017; 18:44-53. [PMID: 27755397 PMCID: PMC5466171 DOI: 10.1097/pcc.0000000000000980] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluated ST-segment monitoring to detect clinical decompensation in infants with single ventricle anatomy. We proposed a signal processing algorithm for ST-segment instability and hypothesized that instability is associated with cardiopulmonary arrests. DESIGN Retrospective, observational study. SETTING Tertiary children's hospital 21-bed cardiovascular ICU and 36-bed step-down unit. PATIENTS Twenty single ventricle infants who received stage 1 palliation surgery between January 2013 and January 2014. Twenty rapid response events resulting in cardiopulmonary arrests (arrest group) were recorded in 13 subjects, and nine subjects had no interstage cardiopulmonary arrest (control group). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arrest data were collected over the 4-hour time window prior to cardiopulmonary arrest. Control data were collected from subjects with no interstage arrest using the 4-hour time window prior to cardiovascular ICU discharge. A paired subgroup analysis was performed comparing subject 4-hour windows prior to arrest (prearrest group) with 4-hour windows prior to discharge (postarrest group). Raw values of ST segments were compared between groups. A 3D ST-segment vector was created using three quasi-orthogonal leads (II, aVL, and V5). Magnitude and instability of this continuous vector were compared between groups. There was no significant difference in mean unprocessed ST-segment values in the arrest and control groups. Utilizing signal processing, there was an increase in the ST-vector magnitude (p = 0.02) and instability (p = 0.008) in the arrest group. In the paired subgroup analysis, there was an increase in the ST-vector magnitude (p = 0.05) and instability (p = 0.05) in the prearrest state compared with the postarrest state prior to discharge. CONCLUSIONS In single ventricle patients, increased ST instability and magnitude were associated with rapid response events that required intervention for cardiopulmonary arrest, whereas conventional ST-segment monitoring did not differentiate an arrest from control state.
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Hill GD, Rudd NA, Ghanayem NS, Hehir DA, Bartz PJ. Center Variability in Timing of Stage 2 Palliation and Association with Interstage Mortality: A Report from the National Pediatric Cardiology Quality Improvement Collaborative. Pediatr Cardiol 2016; 37:1516-1524. [PMID: 27558553 DOI: 10.1007/s00246-016-1465-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/16/2016] [Indexed: 11/27/2022]
Abstract
For infants with single-ventricle lesions with aortic arch hypoplasia, the interstage period from discharge following stage 1 palliation (S1P) until stage 2 palliation (S2P) remains high risk. Significant variability among institutions exists around the timing of S2P. We sought to describe institutional variation in timing of S2P, determine the association between timing of S2P and interstage mortality, and determine the impact of earlier S2P on hospital morbidity and mortality. The National Pediatric Cardiology Quality Improvement Collaborative registry was queried. Centers were divided based on median age at S2P into early (n = 15) and late (n = 16) centers using a cutoff of 153 days. Groups were compared using Chi-squared or Wilcoxon rank-sum test. Multivariable logistic regression was used to determine risk factors for interstage mortality. The final cohort included 789 patients from 31 centers. There was intra- and inter-center variability in timing of S2P, with the median age by center ranging from 109 to 214 days. Late centers had a higher mortality (9.9 vs. 5.7 %, p = 0.03) than early centers. However, the event rate (late: 8.2 vs. early: 5.8 deaths per 10,000 interstage days) was not different by group (p = 0.26). Survival to hospital discharge and hospital length of stay following S2P were similar between groups. In conclusion, in a large multi-institution collaborative, the median age at S2P varies among centers. Although optimal timing of S2P remains unclear, centers performing early S2P did not experience worse S2P outcomes and experienced less interstage mortality.
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Affiliation(s)
- Garick D Hill
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Nancy A Rudd
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David A Hehir
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Peter J Bartz
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
- Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Mills KI, Kaza AK, Walsh BK, Bond HC, Ford M, Wypij D, Thiagarajan RR, Almodovar MC, Quinonez LG, Baird CW, Emani SE, Pigula FA, DiNardo JA, Kheir JN. Phosphodiesterase Inhibitor-Based Vasodilation Improves Oxygen Delivery and Clinical Outcomes Following Stage 1 Palliation. J Am Heart Assoc 2016; 5:JAHA.116.003554. [PMID: 27806964 PMCID: PMC5210357 DOI: 10.1161/jaha.116.003554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systemic vasodilation using α-receptor blockade has been shown to decrease the incidence of postoperative cardiac arrest following stage 1 palliation (S1P), primarily when utilizing the modified Blalock-Taussig shunt. We studied the effects of a protocol in which milrinone was primarily used to lower systemic vascular resistance (SVR) following S1P using the right ventricular to pulmonary artery shunt, measuring its effects on oxygen delivery (DO2) profiles and clinical outcomes. We also correlated Fick-based assessments of DO2 with commonly used surrogate measures. METHODS AND RESULTS Neonates undergoing S1P were treated according to best clinical judgment prior to (n=32) and following (n=24) implementation of a protocol that guided operative, anesthetic, and postoperative management, particularly as it related to SVR. A majority of the subjects (n=51) received a modified right ventricular to pulmonary artery shunt. In a subset of these patients (n=21), oxygen consumption (VO2) was measured and used to calculate SVR, DO2, and oxygen debt. Neonates treated with the protocol had significantly lower SVR (P=0.02), serum lactate (P<0.001), and Sa-vO2 difference (P<0.001) and a lower incidence of CPR requiring extracorporeal membrane oxygenation (E-CPR, P=0.02) within the first 72 postoperative hours. DO2 was closely associated with SVR (r2=0.78) but correlated poorly with arterial (SaO2) and venous (SvO2) oxyhemoglobin concentrations, the Sa-vO2 difference, and blood pressure. CONCLUSIONS A vasodilator protocol utilizing milrinone following S1P effectively decreased SVR, improved serum lactate, and decreased postoperative cardiac arrest. DO2 correlated more closely with SVR than with Sa-vO2 difference, highlighting the importance of measuring VO2 in this population. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184169.
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Affiliation(s)
- Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Brian K Walsh
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Hilary C Bond
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Mackenzie Ford
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Melvin C Almodovar
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Luis G Quinonez
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Sitaram E Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Frank A Pigula
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA .,Department of Pediatrics, Harvard Medical School, Boston, MA
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Creating Opportunities for Optimal Nutritional Experiences for Infants With Complex Congenital Heart Disease. J Pediatr Health Care 2016; 30:599-605. [PMID: 27666504 DOI: 10.1016/j.pedhc.2016.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION To our knowledge, successful breastfeeding in the population with single ventricle congenital heart disease has not been reported in the literature, particularly during the interstage period. METHOD A retrospective case study including inpatient nutrition and a complete history of daily logs with the home surveillance monitoring program was performed. RESULTS Successful full breastfeeding (exceeding prescribed weight growth goals) after Stage I surgery was achieved during the interstage period. The infant was discharged at 3.41 kg, not consistently breastfeeding, and progressed to 7.05 kg at 5 months of age, fully breastfeeding. CONCLUSION Supporting breastfeeding for infants who have undergone repairs for single ventricle anatomy can be challenging but can be accomplished. It requires a concerted team effort, clear communication, and collaboration among caregivers, the mother, and her supporters.
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Abstract
OBJECTIVES In this review, we discuss hemodynamic monitoring modalities, including their application, the interpretation of data, limitations, and impact on outcomes. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS One of the tenets of critical care medicine is to ensure adequate tissue oxygenation. This assessment must be timely and accurate to optimize outcomes. The clinical assessment of cardiac function, cardiac output, and tissue oxygenation based on the physical examination and standard hemodynamic variables, although an indispensable part of this exercise, has significant limitations. The use of adjunctive hemodynamic monitoring modalities provides a much more objective, accurate, and timely assessment of the patient's hemodynamic profile and is invaluable for assessing the patient's clinical status, clinical trajectory, and response to interventions.
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Marino BS, Cassedy A, Drotar D, Wray J. The Impact of Neurodevelopmental and Psychosocial Outcomes on Health-Related Quality of Life in Survivors of Congenital Heart Disease. J Pediatr 2016; 174:11-22.e2. [PMID: 27189685 DOI: 10.1016/j.jpeds.2016.03.071] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/04/2016] [Accepted: 03/28/2016] [Indexed: 01/30/2023]
Affiliation(s)
- Bradley S Marino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dennis Drotar
- Division of Behavioral Medicine and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jo Wray
- Critical Care and Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Chorna O, Baldwin HS, Neumaier J, Gogliotti S, Powers D, Mouvery A, Bichell D, Maitre NL. Feasibility of a Team Approach to Complex Congenital Heart Defect Neurodevelopmental Follow-Up: Early Experience of a Combined Cardiology/Neonatal Intensive Care Unit Follow-Up Program. Circ Cardiovasc Qual Outcomes 2016; 9:432-40. [PMID: 27220370 DOI: 10.1161/circoutcomes.116.002614] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 03/29/2016] [Indexed: 11/16/2022]
Abstract
Infants with complex congenital heart disease are at high risk for poor neurodevelopmental outcomes. However, implementation of dedicated congenital heart disease follow-up programs presents important infrastructure, personnel, and resource challenges. We present the development, implementation, and retrospective review of 1- and 2-year outcomes of a Complex Congenital Heart Defect Neurodevelopmental Follow-Up program. This program was a synergistic approach between the Pediatric Cardiology, Cardiothoracic Surgery, Pediatric Intensive Care, and Neonatal Intensive Care Unit Follow-Up teams to provide a feasible and responsible utilization of existing infrastructure and personnel, to develop and implement a program dedicated to children with congenital heart disease. Trained developmental testers administered the Ages and Stages Questionnaire-3 over the phone to the parents of all referred children at least once between 6 and 12 months' corrected age. At 18 months' corrected age, all children were scheduled in the Neonatal Intensive-Care Unit Follow-Up Clinic for a visit with standardized neurological exams, Bayley III, multidisciplinary therapy evaluations and continued follow-up. Of the 132 patients identified in the Cardiothoracic Surgery database and at discharge from the hospital, a total number of 106 infants were reviewed. A genetic syndrome was identified in 23.4% of the population. Neuroimaging abnormalities were identified in 21.7% of the cohort with 12.8% having visibly severe insults. As a result, 23 (26.7%) received first-time referrals for early intervention services, 16 (13.8%) received referrals for new services in addition to their existing ones. We concluded that utilization of existing resources in collaboration with established programs can ensure targeted neurodevelopmental follow-up for all children with complex congenital heart disease.
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Affiliation(s)
- Olena Chorna
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - H Scott Baldwin
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - Jamie Neumaier
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - Shirley Gogliotti
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - Deborah Powers
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - Amanda Mouvery
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - David Bichell
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.)
| | - Nathalie L Maitre
- From the Center for Perinatal Research at Nationwide Children's Hospital, Columbus, OH (O.C., N.L.M.); Department of Cell and Developmental Biology (H.S.B.), Division of Cardiology, Department of Pediatrics (H.S.B.), Department of Pediatric Rehabilitation (J.N., S.G., D.P., A.M., D.B.), Department of Pediatric Cardiac Surgery (D.B.), Vanderbilt University, Nashville, TN; and Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN (N.L.M.).
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Brown KL, Wray J, Knowles RL, Crowe S, Tregay J, Ridout D, Barron DJ, Cunningham D, Parslow R, Franklin R, Barnes N, Hull S, Bull C. Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWhile early outcomes of paediatric cardiac surgery have improved, less attention has been given to later outcomes including post-discharge mortality and emergency readmissions.ObjectivesOur objectives were to use a mixed-methods approach to build an evidenced-based guideline for postdischarge management of infants undergoing interventions for congenital heart disease (CHD).MethodsSystematic reviews of the literature – databases used: MEDLINE (1980 to 1 February 2013), EMBASE (1980 to 1 February 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1981 to 1 February 2013), The Cochrane Library (1999 to 1 February 2013), Web of Knowledge (1980 to 1 February 2013) and PsycINFO (1980 to 1 February 2013). Analysis of audit data from the National Congenital Heart Disease Audit and Paediatric Intensive Care Audit Network databases pertaining to records of infants undergoing interventions for CHD between 1 January 2005 and 31 December 2010. Qualitative analyses of online discussion posted by 73 parents, interviews with 10 helpline staff based at user groups, interviews with 20 families whose infant either died after discharge or was readmitted urgently to intensive care, and interviews with 25 professionals from tertiary care and 13 professionals from primary and secondary care. Iterative multidisciplinary review and discussion of evidence incorporating the views of parents on suggestions for improvement.ResultsDespite a wide search strategy, the studies identified for inclusion in reviews related only to patients with complex CHD, for whom adverse outcome was linked to non-white ethnicity, lower socioeconomic status, comorbidity, age, complexity and feeding difficulties. There was evidence to suggest that home monitoring programmes (HMPs) are beneficial. Of 7976 included infants, 333 (4.2%) died postoperatively, leaving 7634 infants, of whom 246 (3.2%) experienced outcome 1 (postdischarge death) and 514 (6.7%) experienced outcome 2 (postdischarge death plus emergency intensive care readmissions). Multiple logistic regression models for risk of outcomes 1 and 2 had areas under the receiver operator curve of 0.78 [95% confidence interval (CI) 0.75 to 0.82] and 0.78 (95% CI 0.75 to 0.80), respectively. Six patient groups were identified using classification and regression tree analysis to stratify by outcome 2 (range 3–24%), which were defined in terms of neurodevelopmental conditions, high-risk cardiac diagnosis (hypoplastic left heart, single ventricle or pulmonary atresia), congenital anomalies and length of stay (LOS) > 1 month. Deficiencies and national variability were noted for predischarge training and information, the process of discharge to non-specialist services including documentation, paediatric cardiology follow-up including HMP, psychosocial support post discharge and the processes for accessing help when an infant becomes unwell.ConclusionsNational standardisation may improve discharge documents, training and guidance on ‘what is normal’ and ‘signs and symptoms to look for’, including how to respond. Infants with high-risk cardiac diagnoses, neurodevelopmental conditions or LOS > 1 month may benefit from discharge via their local hospital. HMP is suggested for infants with hypoplastic left heart, single ventricle or pulmonary atresia. Discussion of postdischarge deaths for infant CHD should occur at a network-based multidisciplinary meeting. Audit is required of outcomes for this stage of the patient journey.Future workFurther research may determine the optimal protocol for HMPs, evaluate the use of traffic light tools for monitoring infants post discharge and develop the analytical steps and processes required for audit of postdischarge metrics.Study registrationThis study is registered as PROSPERO CRD42013003483 and CRD42013003484.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The National Congenital Heart Diseases Audit (NCHDA) and Paediatric Intensive Care Audit Network (PICANet) are funded by the National Clinical Audit and Patient Outcomes Programme, administered by the Healthcare Quality Improvement Partnership (HQIP). PICAnet is also funded by Welsh Health Specialised Services Committee; NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, National Office of Clinical Audit Ireland, and HCA International. The study was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Sonya Crowe was supported by the Health Foundation, an independent charity working to continuously improve the quality of health care in the UK.
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Affiliation(s)
- Katherine L Brown
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rachel L Knowles
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Jenifer Tregay
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - David J Barron
- Cardiac Surgery Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research, University College London, London, UK
| | - Roger Parslow
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiac Unit, Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Nick Barnes
- Department of Paediatrics, Northampton General Hospital NHS Trust, Northampton, UK
| | - Sally Hull
- Primary Care Department, Queen Mary University of London, London, UK
| | - Catherine Bull
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Oster ME, Kelleman M, McCracken C, Ohye RG, Mahle WT. Association of Digoxin With Interstage Mortality: Results From the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use Dataset. J Am Heart Assoc 2016; 5:e002566. [PMID: 26764412 PMCID: PMC4859374 DOI: 10.1161/jaha.115.002566] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/18/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Mortality for infants with single ventricle congenital heart disease remains as high as 8% to 12% during the interstage period, the time between discharge after the Norwood procedure and before the stage II palliation. The objective of our study was to determine the association between digoxin use and interstage mortality in these infants. METHODS AND RESULTS We conducted a retrospective cohort study using the Pediatric Heart Network Single Ventricle Reconstruction Trial public use dataset, which includes data on infants with single right ventricle congenital heart disease randomized to receive either a Blalock-Taussig shunt or right ventricle-to-pulmonary artery shunt during the Norwood procedure at 15 institutions in North America from 2005 to 2008. Parametric survival models were used to compare the risk of interstage mortality between those discharged to home on digoxin versus those discharged to home not on digoxin, adjusting for center volume, ascending aorta diameter, shunt type, and socioeconomic status. Of the 330 infants eligible for this study, 102 (31%) were discharged home on digoxin. Interstage mortality for those not on digoxin was 12.3%, compared to 2.9% among those on digoxin, with an adjusted hazard ratio of 3.5 (95% CI, 1.1-11.7; P=0.04). The number needed to treat to prevent 1 death was 11 patients. There were no differences in complications between the 2 groups during the interstage period. CONCLUSIONS Digoxin use in infants with single ventricle congenital heart disease is associated with significantly reduced interstage mortality.
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Affiliation(s)
- Matthew E. Oster
- Children's Healthcare of AtlantaGA
- Emory University School of MedicineAtlantaGA
| | | | | | | | - William T. Mahle
- Children's Healthcare of AtlantaGA
- Emory University School of MedicineAtlantaGA
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Tabbutt S, Ghanayem N. Unanticipated Readmissions During the Interstage Period in Patients With Hypoplastic Left Heart Syndrome: Can the Numbers be Safely Reduced? Semin Thorac Cardiovasc Surg 2016; 28:815-816. [DOI: 10.1053/j.semtcvs.2016.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2016] [Indexed: 11/11/2022]
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Abstract
Hypoplastic left heart syndrome has the greatest mortality rate among all CHDs and without palliation is uniformly fatal. Despite noble efforts, the aetiology of this syndrome is unknown and a cure remains elusive. The genetic and anatomic heterogeneity of hypoplastic left heart syndrome supports a rethinking of old hypotheses and warrants further investigation into the histological and vascular variations recognised with this syndrome. In an effort to elucidate the pathogenesis of hypoplastic left heart syndrome, this review will focus on its unique myocardial and coronary pathology as well as evaluate the association of hypoplastic left heart syndrome with the endocardial fibroelastosis reaction.
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Abstract
PURPOSE OF REVIEW The focus of postoperative care in the pediatric patient with congenital heart disease has become a reduction in length of stay and morbidity. This review will discuss strategies to achieve this goal and recent studies to support current practices. RECENT FINDINGS Most agree that prolongation of the length of stay following a cardiac surgery contributes to morbidity. Postoperative feeding difficulty, hyperglycemia, acute kidney injury, fluid overload, and prolonged intubation contribute significantly to length of stay. SUMMARY Postoperative care of the neonate and child following a cardiac surgery remains challenging with limited data to drive our practices. Patients remain at risk for significant morbidity, and future studies should focus on recognizing predictors of morbidity, prevention, and treatment.
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Anderson JB, Beekman RH, Kugler JD, Rosenthal GL, Jenkins KJ, Klitzner TS, Martin GR, Neish SR, Brown DW, Mangeot C, King E, Peterson LE, Provost L, Lannon C. Improvement in Interstage Survival in a National Pediatric Cardiology Learning Network. Circ Cardiovasc Qual Outcomes 2015; 8:428-36. [DOI: 10.1161/circoutcomes.115.001956] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/05/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey B. Anderson
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Robert H. Beekman
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - John D. Kugler
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Geoffrey L. Rosenthal
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Kathy J. Jenkins
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Thomas S. Klitzner
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Gerard R. Martin
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Steven R. Neish
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - David W. Brown
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Colleen Mangeot
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Eileen King
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Laura E. Peterson
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Lloyd Provost
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
| | - Carole Lannon
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.B.A., R.H.B.); Children’s Hospital & Medical Center, Omaha, NE (J.D.K.); University of Maryland School of Medicine, Baltimore (G.L.R.); Boston Children’s Hospital Medical Center, Boston, MA (K.J.J., D.W.B.); Mattel Children’s Hospital at University of California, Los Angeles (T.S.K.); Children’s National Medical Center, Washington, DC (G.R.M.); University of Texas Health Center, San Antonio (S.R.N.); Division of
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Unexpected deaths and unplanned re-admissions in infants discharged home after cardiac surgery: a systematic review of potential risk factors. Cardiol Young 2015; 25:839-52. [PMID: 25547262 DOI: 10.1017/s1047951114002492] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Babies with CHDs are a particularly vulnerable population with significant mortality in their 1st year. Although most deaths occur in the hospital within the early postoperative period, around one-fifth of postoperative deaths in the 1st year of life may occur after hospital discharge in infants who have undergone apparently successful cardiac surgery. Aim To systematically review the published literature and identify risk factors for adverse outcomes, specifically deaths and unplanned re-admissions, following hospital discharge after infant surgery for life-threatening CHDs. METHODS A systematic search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and PsycINFO electronic databases, supplemented by manual searching of conference abstracts. RESULTS A total of 15 studies were eligible for inclusion. Almost exclusively, studies were conducted in single US centres and focussed on children with complex single ventricle diagnoses. A wide range of risk factors were evaluated, and those more frequently identified as having a significant association with higher mortality or unplanned re-admission risk were non-Caucasian ethnicity, lower socio-economic status, co-morbid conditions, age at surgery, operative complexity and procedure type, and post-operative feeding difficulties. CONCLUSIONS Studies investigating risk factors for adverse outcomes post-discharge following diverse congenital heart operations in infants are lacking. Further research is needed to systematically identify higher risk groups, and to develop interventions targeted at supporting the most vulnerable infants within an integrated primary and secondary care pathway.
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Laranjo S, Costa G, Freitas I, Ferreira Martins JD, Bakero L, Trigo C, Fragata I, Fragata J, F Pinto F. The hybrid approach for palliation of hypoplastic left heart syndrome: Intermediate results of a single-center experience. Rev Port Cardiol 2015; 34:347-55. [PMID: 25956411 DOI: 10.1016/j.repc.2014.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/15/2014] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome. METHODS We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014. RESULTS Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%. CONCLUSIONS In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.
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Affiliation(s)
- Sérgio Laranjo
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal.
| | - Glória Costa
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
| | - Isabel Freitas
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
| | | | - Luís Bakero
- Serviço de Cirurgia Cardio-Torácica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
| | - Conceição Trigo
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
| | - Isabel Fragata
- Serviço de Anestesiologia, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
| | - José Fragata
- Serviço de Cirurgia Cardio-Torácica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
| | - Fátima F Pinto
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta - CHLC, EPE, Lisboa, Portugal
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Laranjo S, Costa G, Freitas I, Ferreira Martins JD, Bakero L, Trigo C, Fragata I, Fragata J, F. Pinto F. The hybrid approach for palliation of hypoplastic left heart syndrome: Intermediate results of a single-center experience. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2015.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Yuki K, DiNardo JA. Comparison of actual oxygen delivery kinetics to those predicted by mathematical modeling following stage 1 palliation just prior to superior cavopulmonary anastomosis. Paediatr Anaesth 2015; 25:174-9. [PMID: 25164862 DOI: 10.1111/pan.12517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimizing systemic oxygen delivery (DO2) and hemodynamics in children with hypoplastic left heart syndrome (HLHS) is a clinical challenge. Mathematical modeling of the HLHS circulation has been used to determine the relationship between oxygen kinetic parameters and DO2 and to determine how DO2 might be optimized. The model demonstrates that neither arterial oxygen saturation (SaO2) nor mixed venous oxygen saturation (SvO2) alone accurately predicts DO2. OBJECTIVES Oxygen delivery kinetics predicted by previously described mathematical modeling were compared with actual patients' hemodynamic data. We sought to determine which patient derived parameters correlated best with DO2. METHODS Patients with HLHS who underwent cardiac catheterization prior to surgery to create a superior cavopulmonary anastomosis from 2007 to 2011 were identified. Hemodynamic data obtained were compared with the data derived from the mathematical model. Correlations between SaO2, SvO2, SaO2-SvO2, SaO2/(SaO2-SvO2), pulmonary-to-systemic blood flow ratio (Qp/Qs), and DO2 were evaluated using both linear and nonlinear analyses, and R(2) was calculated. RESULTS/CONCLUSIONS Patients' data fit most aspects of the mathematical model. DO2 had the best correlation with SaO2/(SaO2-SvO2; R(2) = 0.8755) followed by SaO2 -SvO2 (R(2) = 0.8063), while SaO2 or SvO2 alone did not demonstrate a significant correlation as predicated by the mathematical model (R(2) = 0.09564 and 0.4831, respectively). SaO2/(SaO2 -SvO2) would be useful clinically to track changes in DO2 that occur with changes in patient condition or with interventions.
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Affiliation(s)
- Koichi Yuki
- Cardiac Anesthesia Division, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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