A simple-to-use nomogram for predicting prolonged mechanical ventilation for children after Ebstein anomaly corrective surgery: a retrospective cohort study

BACKGROUND

Prolonged mechanical ventilation (PMV) after pediatric cardiac surgery imposes a great burden on patients in terms of morbidity, mortality as well as financial costs. Ebstein anomaly (EA) is a rare congenital heart disease, and few studies have been conducted about PMV in this condition. This study aimed to establish a simple-to-use nomogram to predict the risk of PMV for EA children.

METHODS

The retrospective study included patients under 18 years who underwent corrective surgeries for EA from January 2009 to November 2021. PMV was defined as postoperative mechanical ventilation time longer than 24 hours. Through multivariable logistic regression, we identified and integrated the risk factors to develop a simple-to-use nomogram of PMV for EA children and internally validated it by bootstrapping. The calibration and discriminative ability of the nomogram were determined by calibration curve, Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic (ROC) curve.

RESULTS

Two hundred seventeen children were included in our study of which 44 (20.3%) were in the PMV group. After multivariable regression, we obtained five risk factors of PMV. The odds ratios and 95% confidence intervals (CI) were as follows: preoperative blood oxygen saturation, 0.876(0.805,0.953); cardiothoracic ratio, 3.007(1.107,8.169); Carpentier type, 4.644(2.065,10.445); cardiopulmonary bypass time, 1.014(1.005,1.023) and postoperative central venous pressure, 1.166(1.016,1.339). We integrated the five risk factors into a nomogram to predict the risk of PMV. The area under ROC curve of nomogram was 0.805 (95% CI, 0.725,0.885) and it also provided a good discriminative information with the corresponding Hosmer-Lemeshow p values > 0.05.

CONCLUSIONS

We developed a nomogram by integrating five independent risk factors. The nomogram is a practical tool to early identify children at high-risk for PMV after EA corrective surgery.

The Role of Novel Transcatheter Procedures in Patients With Congenital Heart Disease

The development of percutaneous structural interventions in patients with acquired heart disease is happening at an exponential rate, and some of this technology is being used to treat patients with congenital heart disease. This review describes the pathophysiology of valvular abnormalities specific to congenital heart disease and discusses the application of structural procedures in this population. Although the overall experience has been encouraging, especially in high-risk patients, this article will highlight the reasons that a cautious approach to adoption of this technology is necessary in these patients.

Ebstejn's anomaly in patients perioperative period during a non-cardiac surgery operation

Introduction: Ebstein anomaly, a congenital heart defect characterized by a morphological and functional abnormality of the tricuspid valvula while moving the mouth of the tricuspid valvula towards the apex of the right chamber. Case report: A patient aged 39 years on the Department of Surgery was admitted under the image of an acute abdomen and the need for emergency surgical treatment. Routine preoperative preparation, laboratory treatment, examination of internist and examination of anesthesiologist on the part of the part was carried out. He has a history of occasional breathing problems during respiratory infection, a smoker. Clinical status, other than primary problems, is orderly. Operational treatment passed neatly, on the fourth postoperative day the patient complained of suffocation, lack of air and chest pain, translated into intensive care monitored (spo2 87% f about 110/min TA 90/60), blood gas analysis done and laboratory treatment (fibrinogen, D dimer) due to suspected pulmonary thromboembolia consulted cardiologist, dilation of the right atrium seen by ultrasound. Discussion: Non-cardiac surgeries in patients with pre-existing congenital heart defects are high-risk surgeries with increased mobility and mortality in the perioperative period. In accordance with the accompanying pathoanatomical and pathophysiological changes that define the congenital heart defect, a detailed plan must be made - anesthesiological management for each patient separately. Hemodynamic and respiratory stability with avoidance of hypoxia and paradoxical arrhythmias are the basic postulates in patients with Ebstein's anomaly.

Current perspectives on treatment of perioperative hemodynamic instability and hypotension

Overall, there are numerous causes of hypotension in the perioperative period. The approach to definitive treatment must be tailored to the child's unique anatomy and physiology, as well as the current factors presumed to be eliciting the hypotensive state. It is imperative to consider both routine and lesion-specific etiologies to the current hypotensive episode. Lastly, when employing pharmacologic therapy for hypotension, there are often multiple combinations of medications that can reasonably be used to achieve the desired hemodynamic effects.

Nerve distribution in myocardium including the atrial and ventricular septa in late stage human fetuses

Few information had been reported on deep intracardiac nerves in the myocardium of late human fetuses such as nerves at the atrial-pulmonary vein junction and in the atrial and ventricular septa. We examined histological sections of the heart obtained from 12 human fetuses at 25–33 weeks. A high density of intracardiac nerves was evident around the mitral valve annulus in contrast to few nerves around the tricuspid annulus. To the crux at the atrioventricular sulcus, the degenerating left common cardinal vein brought abundant nerve bundles coming from cardiac nerves descending along the anterior aspect of the pulmonary trunk. Likewise, nerve bundles in the left atrial nerve fold came from cardiac nerves between the ascending aorta and pulmonary artery. Conversely, another nerves from the venous pole to the atrium seemed to be much limited in number. Moreover, the primary atrial septum contained much fewer nerves than the secondary septum. Therefore, nerve density in the atrial wall varied considerably between sites. As ventricular muscles were degenerated from the luminal side for sculpturing of papillary muscles and trabeculae, deep nerves became exposed to the ventricular endothelium. Likewise, as pectineal muscles were sculptured, nerves were exposed in the atrial endothelium. Consequently, a myocardial assembly or sculpture seemed to be associated with degeneration and reconstruction of early-developed nerves. A failure in reconstruction during further expansion of the left atrium might be connected with an individual variation in anatomical substrates of atrial fibrillation.

Noteworthy Literature in 2015

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