Impact of hepatopathy in pediatric patients after surgery for complex congenital heart disease

Conjugated hyperbilirubinemia is associated with increased morbidity and mortality after neonatal heart surgery

BACKGROUND

Cholestasis characterised by conjugated hyperbilirubinemia is a marker of hepatobiliary dysfunction following neonatal cardiac surgery. We aimed to characterise the incidence of conjugated hyperbilirubinemia following neonatal heart surgery and examine the effect of conjugated hyperbilirubinemia on post-operative morbidity and mortality.

METHODS

This was a retrospective study of all neonates who underwent surgery for congenital heart disease (CHD) at our institution between 1/1/2010 and 12/31/2020. Patient- and surgery-specific data were abstracted from local registry data and review of the medical record. Conjugated hyperbilirubinemia was defined as perioperative maximum conjugated bilirubin level > 1 mg/dL. The primary outcome was in-hospital mortality. Survival analysis was conducted using the Kaplan-Meier survival function.

RESULTS

Conjugated hyperbilirubinemia occurred in 8.5% of patients during the study period. Neonates with conjugated hyperbilirubinemia were more likely to be of younger gestational age, lower birth weight, and non-Caucasian race (all p < 0.001). Patients with conjugated hyperbilirubinemia were more likely to have chromosomal and non-cardiac anomalies and require ECMO pre-operatively. In-hospital mortality among patients with conjugated hyperbilirubinemia was increased compared to those without (odds ratio 5.4). Post-operative complications including mechanical circulatory support, reoperation, prolonged ventilator dependence, and multi-system organ failure were more common with conjugated hyperbilirubinemia (all p < 0.04). Patients with higher levels of conjugated bilirubin had worst intermediate-term survival, with patients in the highest conjugated bilirubin group (>10 mg/dL) having a 1-year survival of only 6%.

CONCLUSIONS

Conjugated hyperbilirubinemia is associated with post-operative complications and worse survival following neonatal heart surgery. Cholestasis is more common in patients with chromosomal abnormalities and non-cardiac anomalies, but the underlying mechanisms have not been delineated.

Evaluation of perioperative risk factors in pediatric patients with left ventricle outflow tract obstruction

Introduction

Left ventricular outflow tract obstructions (LVOTO) presents as complex cardiac diseases accompanied by other cardiac anomalies in the pediatric age group. Postoperative complications, especially cardiac, pulmonary, and renal complications, that may develop after pediatric cardiac surgery can become life-threatening. If the perioperative risk factors for these complications are known in pediatric patients with LVOTO, anesthesiologists and surgeons may take precautions to eliminate undesirable outcomes.

Aim

To evaluate the perioperative risk factors that may contribute to the development of postoperative complications in pediatric patients operated on for LVOTO in a pediatric cardiac surgery clinic.

Material and methods

The study retrospectively investigated 58 patients who were operated on for LVOTO in a pediatric cardiac surgery clinic. The patients were divided into two groups, those with and without postoperative complications. Preoperative laboratory test results, anesthesia time, operation time, aortic cross-clamp time, cardiopulmonary bypass (CPB) time, postoperative inotropes, first postoperative laboratory tests, intraoperative and postoperative complications, mechanical ventilation time, intensive care unit stay, and hospital stay were recorded.

Results

The most common postoperative complications were endocrine complications, followed by hepatic complications. The preoperative lymphocyte count was significantly higher (p < 0.05), and the neutrophil-to-lymphocyte ratio (NLR) was significantly lower (p < 0.05) in the group with postoperative complications. The postoperative pH, glucose, creatinine, and aspartate aminotransferase (AST) levels were significantly lower (p < 0.05), and the postoperative calcium level was significantly higher (p < 0.05) in the group without postoperative complications. Intraoperative platelet transfusion rate was found to be significantly lower (p < 0.05) in the group with postoperative complications.

Conclusions

It is critical to identify predictive factors to prevent postoperative complications in pediatric patients undergoing surgery for LVOTO. Preoperative NLR, intraoperative platelet transfusion, and postoperative calcium, glucose, pH and AST levels may help in the prediction of complications.