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Geoffrion TR, Aronowitz DI, Mangeot C, Ittenbach RF, Lodge AJ, Fuller SM, Chen JM, Gaynor JW. Contemporary outcomes for functional single ventricle with total anomalous pulmonary venous connection. J Thorac Cardiovasc Surg 2024; 167:2177-2185.e1. [PMID: 37778502 DOI: 10.1016/j.jtcvs.2023.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE In 2004, we reported improved early survival for patients with functional single ventricle anatomy and total anomalous pulmonary venous connection. This study sought to discover if outcomes have been ameliorated in the contemporary era. METHODS This was a single-center review of patients with single ventricle anatomy and total anomalous pulmonary venous connection who were admitted from 1984 to 2021. The cohort was divided into similarly sized groups by date of admission: Era 1: 1984 to 1992, Era 2: 1993 to 2007, and Era 3: 2008 to 2021. Survival was compared, and Cox proportional hazards models were used to evaluate the likelihood of mortality. RESULTS We included 190 patients with single ventricle anatomy and total anomalous pulmonary venous connection. Unbalanced atrioventricular canal defect (70%) was the most common primary diagnosis. The most common type of total anomalous pulmonary venous connection was supracardiac (49%). Approximately one-third (32%) of patients had pulmonary venous obstruction. There were no significant differences in patient characteristics across eras. Early survival after initial palliative operation improved between Eras 1 and 2, and then remained stable in Era 3. Overall survival improved from Era 1 to Eras 2 and 3 (P < .001), but not between Era 2 and 3. Survival to 10 years by Eras 1 to 3 was 15%, 51%, and 54%, respectively. The anatomic features associated with worse survival were hypoplastic left heart syndrome diagnosis (hazard ratio, 1.60; 1.04-2.57) and pulmonary venous obstruction (hazard ratio, 1.80; 1.24-2.69). CONCLUSIONS Overall survival for patients with single ventricle anatomy and total anomalous pulmonary venous connection has plateaued since the early 2000s. Even in the most recent era, survival to age 10 years remains less than 60%. Risk factors for mortality include the diagnosis of hypoplastic left heart syndrome and pulmonary venous obstruction. Further studies should focus on identification of the pathophysiological factors underlying the increased mortality.
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Affiliation(s)
- Tracy R Geoffrion
- Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wis.
| | | | - Colleen Mangeot
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa; Division of Cardiothoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Jonathan M Chen
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa; Division of Cardiothoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa; Division of Cardiothoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
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Puia-Dumitrescu M, Sullivan LN, Tanaka D, Fisher K, Pittman R, Kumar KR, Malcolm WF, Gustafson KE, Lodge AJ, Goldberg RN, Hornik CP. Survival, Morbidities, and Developmental Outcomes among Low Birth Weight Infants with Congenital Heart Defects. Am J Perinatol 2021; 38:1366-1372. [PMID: 32485756 DOI: 10.1055/s-0040-1712964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Prematurity and low birth weight (LBW) are risk factors for increased morbidity and mortality in infants with congenital heart defects (CHDs). We sought to describe survival, inhospital morbidities, and 2-year neurodevelopmental follow-up in LBW infants with CHD. STUDY DESIGN We included infants with birth weight (BW) <2,500 g diagnosed with CHD (except isolated patent ductus arteriosus) admitted January 2013 to March 2016 to a single level-IV academic neonatal intensive care unit. We reported CHD prevalence by BW and gestational age; selected in-hospital morbidities and mortality by infant BW, CHD type, and surgical intervention; and developmental outcomes by Bayley's scales of infant and toddler development, third edition (BSID-III) scores at age 2 years. RESULTS Among 420 infants with CHD, 28 (7%) underwent cardiac surgery. Median (25th and 75th percentiles) gestational age was 30 (range: 27-33) weeks and BW was 1,258 (range: 870-1,853) g. There were 134 of 420 (32%) extremely LBW (<1,000 g) infants, 82 of 420 (20%) were small for gestational age, and 51 of 420 (12%) multiples. Most common diagnosis: atrial septal defect (260/420, 62%), followed by congenital anomaly of the pulmonary valve (75/420, 18%). Most common surgical procedure: pulmonary artery banding (5/28, 18%), followed by the tetralogy of Fallot corrective repair (4/28, 14%). Survival to discharge was 88% overall and lower among extremely LBW (<1,000 g, 81%) infants and infants undergoing surgery (79%). Comorbidities were common (35%); retinopathy of prematurity and bronchopulmonary dysplasia were most prevalent. BSID-III scores were available on 148 of 176 (84%); any scores <85 were noted in 73 of 148 (49%), with language being most commonly affected. CONCLUSION Among LBW infants with congenital heart disease, hospital mortality varied by BW and cardiac diagnosis. KEY POINTS · In low birth weight infants with congenital heart disease, survival varied by birth weight and cardiac diagnosis.. · Overall survival was higher than previously reported.. · There were fewer morbidities than previously reported.. · Bayley's scale-III scores at 2 years of age were <85 for nearly half..
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Affiliation(s)
| | - Laura N Sullivan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David Tanaka
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Kimberley Fisher
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Rick Pittman
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Karan R Kumar
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - William F Malcolm
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Kathryn E Gustafson
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Andrew J Lodge
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ronald N Goldberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Christoph P Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.,Division of Quantitative Sciences, Duke Clinical Research Institute, Durham, North Carolina
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Prabhu NK, Zhu A, Meza JM, Hill KD, Fleming GA, Chamberlain RC, Lodge AJ, Turek JW, Andersen ND. Transition to Ductal Stenting for Single Ventricle Patients Led to Improved Survival: An Institutional Case Series. World J Pediatr Congenit Heart Surg 2021; 12:518-526. [PMID: 34278866 DOI: 10.1177/21501351211007808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of systemic-to-pulmonary shunts (SPS) in neonates with single ventricle heart defects and ductal-dependent pulmonary blood flow (ddPBF) was historically associated with high morbidity and mortality at our center. As a result, we transitioned to the preferential use of ductus arteriosus stents (DS) when feasible. This report describes our initial results with this strategy. METHODS A single-center study of single ventricle patients that received DS or SPS from 2015 to 2019 was performed to assess whether DS was associated with decreased in-hospital morbidity and increased survival to stage II palliation. RESULTS A total of 34 patients were included (DS = 11; SPS = 23). Underlying cardiac anomalies were similar between groups and included pulmonary atresia, unbalanced atrioventricular septal defect, and tricuspid atresia. Procedure success was similar between groups (82% vs 83%). Two DS patients were converted to SPS, due to ductal vasospasm or pulmonary artery obstruction, and four SPS patients required surgical shunt revision. In DS patients, postprocedure mechanical ventilation duration was shorter (one vs three days, P = .009) and fewer required postprocedure extracorporeal membrane oxygenation (9% vs 39%, P = .11). A higher proportion of DS patients survived to stage II palliation (100% vs 64%, P = .035), and the probability of one-year survival was higher in DS patients (100% vs 61%, P = .02). CONCLUSIONS At our center, patients with single ventricle heart defects and ddPBF that received DS experienced reduced in-hospital morbidity and increased survival to stage II palliation compared to SPS.
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Affiliation(s)
- Neel K Prabhu
- Congenital Heart Surgery Research and Training Program, 22957Duke University Medical Center, Durham, NC, USA.,22957Duke University School of Medicine, Durham, NC, USA
| | - Alexander Zhu
- Congenital Heart Surgery Research and Training Program, 22957Duke University Medical Center, Durham, NC, USA.,22957Duke University School of Medicine, Durham, NC, USA
| | - James M Meza
- Congenital Heart Surgery Research and Training Program, 22957Duke University Medical Center, Durham, NC, USA.,Division of Cardiovascular and Thoracic Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Kevin D Hill
- Division of Pediatric Cardiology, Department of Pediatrics, 22957Duke University Medical Center, Durham, NC, USA
| | - Gregory A Fleming
- Division of Pediatric Cardiology, Department of Pediatrics, 22957Duke University Medical Center, Durham, NC, USA
| | - Reid C Chamberlain
- Division of Pediatric Cardiology, Department of Pediatrics, 22957Duke University Medical Center, Durham, NC, USA
| | - Andrew J Lodge
- Congenital Heart Surgery Research and Training Program, 22957Duke University Medical Center, Durham, NC, USA.,Division of Cardiovascular and Thoracic Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Congenital Heart Surgery Research and Training Program, 22957Duke University Medical Center, Durham, NC, USA.,Division of Cardiovascular and Thoracic Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Nicholas D Andersen
- Congenital Heart Surgery Research and Training Program, 22957Duke University Medical Center, Durham, NC, USA.,Division of Cardiovascular and Thoracic Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
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Lodge AJ. Commentary: Coagulation Testing in Children Before Cardiac Surgery - A Long Run for a Short Slide. Semin Thorac Cardiovasc Surg 2021; 34:289-290. [PMID: 33737152 DOI: 10.1053/j.semtcvs.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/04/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew J Lodge
- Duke Pediatric and Congenital Heart Center, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina.
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5
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Overbey DM, Lodge AJ. Commentary: Neonatal heart transplant: A good option in a bad situation. J Thorac Cardiovasc Surg 2021; 162:1371-1372. [PMID: 33712240 DOI: 10.1016/j.jtcvs.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Douglas M Overbey
- Cardiothoracic Surgery Residency Program, Durham, NC; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrew J Lodge
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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6
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Ranney DN, Habermann AC, Meza JM, Turek JW, Lodge AJ, Vesel TP, Kirmani S, Schroder JN, Andersen ND. Implantation of a HeartMate 3 ventricular assist device in a 21-kg pediatric patient with Fontan failure. J Card Surg 2020; 35:3634-3637. [PMID: 33040377 DOI: 10.1111/jocs.15088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022]
Abstract
AIMS The HeartMate 3 (HM3) ventricular assist device (VAD) is gaining popularity in adults due to a favorable risk profile. However, reports of HM3 use in children are limited, potentially due to concerns with device size. MATERIALS AND METHODS Here we report the successful use of an HM3-VAD as a bridge to transplantation in a 21 kg (BSA 0.84), an 8-year-old male child with Fontan failure on home inotropes. RESULTS Urgent VAD implantation was performed. The standard adult sewing ring was used. The tricuspid valve and papillary muscles were completely excised from the ventricular cavity to prevent inflow obstruction. The pump was placed in the left pleural space. Outflow graft and driveline implantation were routine. VAD function appeared excellent with a reduction in Fontan pressures and improved kidney and liver function. Reoperation was required once to rule out tamponade and twice to evacuate a recurrent right hemothorax. The patient was discharged 3 months later in good condition and underwent successful heart transplantation 10 months after VAD placement. DISCUSSION This report demonstrates the feasibility of HM3-VAD implantation in a 21-kg Fontan patient, suggesting HM3 size is not a prohibitive limitation at this weight.
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Affiliation(s)
- David N Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Alyssa C Habermann
- Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph W Turek
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew J Lodge
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Travis P Vesel
- Department of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Sonya Kirmani
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Kang L, Lodge AJ. Commentary: Epic Supra Valve Just as Good for Pulmonary Valve Replacement - But is it Good Enough? Semin Thorac Cardiovasc Surg 2020; 33:193-194. [PMID: 32858215 DOI: 10.1053/j.semtcvs.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 07/21/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Lillian Kang
- Duke University Medical Center, Department of Surgery, Durham North Carolina
| | - Andrew J Lodge
- Duke Pediatric and Congenital Heart Center, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Durham North Carolina.
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8
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Lodge AJ, Siffring T. Commentary: Taking the next step in cardiopulmonary bypass management. JTCVS Tech 2020; 2:100-101. [PMID: 34317767 PMCID: PMC8299037 DOI: 10.1016/j.xjtc.2020.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Andrew J Lodge
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC
| | - Travis Siffring
- Department of Perfusion Services, Duke University Medical Center, Durham, NC
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9
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Drysdale ND, Andersen ND, Meza JM, Lodge AJ, Rankin JS, Turek JW. Initial Application of a Bicuspid Aortic Annuloplasty Ring in Pediatric Cardiac Surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2020; 23:29-33. [PMID: 32354544 DOI: 10.1053/j.pcsu.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 06/11/2023]
Abstract
Aortic stenosis and aortic insufficiency (AI) are common valvular conditions that may necessitate repair or replacement of the aortic valve. Aortic valve replacement is associated with higher long-term complications and thus, a consistent, reliable method of repair is needed. This is especially true in the pediatric population where lifelong anticoagulation and development of recurrent aortic stenosisor aortic insufficiency are especially problematic. The Hemispherical Aortic Annuloplasty Reconstruction Technology ring has been developed and used for annular stabilization in adults with success, though its efficacy in the pediatric population has yet to be demonstrated. Herein, we discuss the use of a geometric ring in aortic valve repair for the pediatric patient.
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Affiliation(s)
- Nicolas D Drysdale
- Duke University School of Medicine, Durham, North Carolina; Duke Congenital Heart Surgery Research & Training Laboratory, Durham, North Carolina
| | - Nicholas D Andersen
- Duke University School of Medicine, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Thoracic & Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina
| | - James M Meza
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Congenital Heart Surgery Research & Training Laboratory, Durham, North Carolina
| | - Andrew J Lodge
- Duke University School of Medicine, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Thoracic & Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina; Duke Congenital Heart Surgery Research & Training Laboratory, Durham, North Carolina
| | | | - Joseph W Turek
- Duke University School of Medicine, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Thoracic & Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina; Duke Congenital Heart Surgery Research & Training Laboratory, Durham, North Carolina.
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10
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Lodge AJ. Commentary: Another look at stage I Norwood outcomes from a different perspective. J Thorac Cardiovasc Surg 2019; 159:1049-1050. [PMID: 31677888 DOI: 10.1016/j.jtcvs.2019.07.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Andrew J Lodge
- Pediatric and Congenital Heart Center, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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11
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Reed CR, McCoy CC, Nag U, Nixon AB, Otto J, Lawson JH, Lodge AJ, Turek JW, Tracy ET. Proteomic Analysis of Infants Undergoing Cardiopulmonary Bypass Using Contemporary Ontological Tools. J Surg Res 2019; 246:83-92. [PMID: 31562990 DOI: 10.1016/j.jss.2019.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/08/2019] [Accepted: 08/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is essential for the repair of many congenital cardiac defects in infants but is associated with significant derangements in hemostasis and systemic inflammation. As a result, hemorrhagic complications and thrombosis are major challenges in the management of children requiring CPB or extracorporeal membrane oxygenation. Conventional clinical laboratory tests capture individual hemostatic derangements (low platelets, elevated fibrinogen) but fail to describe the complex, overlapping interactions among the various components of coagulation, including cellular interactions, contact activation, fibrinolysis, and inflammation. Given recent advances in analytic tools for identifying protein-protein interactions in the plasma proteome, we hypothesized that an unbiased proteomic analysis would help identify networks of interacting proteins for further investigation in pediatric CPB. MATERIALS AND METHODS Infants up to 1 y of age were enrolled. Plasma samples were collected at 0, 1, 4, and 24 h after CPB. Mass spectrometry was used to identify proteins undergoing changes in concentration after CPB, and STRING and ToppGene tools were used to identify biological networks. Two-dimensional difference gel electrophoresis identified changes in protein concentrations. Inflammatory markers were assessed by enzyme-linked immunosorbent assay at the same time points. RESULTS Ten infants with cardiac anomalies requiring surgery and CPB were enrolled; no major complications were recorded (median age, 127.5 d; interquartile range, 181.25 d). Using two-dimensional difference gel electrophoresis, >1400 individual protein spots were observed, and 89 proteins demonstrated change in concentration >30% with P < 0.02 when comparing 1, 4, or 24 h to baseline. Among protein spots with significant changes in concentration after CPB, 29 were identified with mass spectrometry (33%). In our interrogation of functional associations among these differentially expressed proteins, our results were dominated by the acute phase response, coagulation, and cell signaling functional categories. Among cytokines analyzed by enzyme-linked immunosorbent assay, IL-2, IL-8, and IL-10 were elevated at 4 h but normalized by 24 h, whereas IL-6 was persistently elevated. CONCLUSIONS Infants manifest a robust response to CPB that includes overlapping, complex pathways. Further investigation of interactions among immune, coagulation, and cell signaling systems may lead to novel therapeutics or biomarkers useful in the management of infants requiring CPB.
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Affiliation(s)
| | | | - Uttara Nag
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew B Nixon
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - James Otto
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Andrew J Lodge
- Section of Pediatric Cardiac Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph W Turek
- Section of Pediatric Cardiac Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Abstract
PURPOSE OF REVIEW This paper will discuss current cannulation strategies for infant aortic arch repair and compare them to more traditionally used techniques. RECENT FINDINGS Aortic arch reconstruction in infants has traditionally involved deep hypothermic circulatory arrest which results in total body ischemia. This has been associated with an increased risk of morbidity including bleeding, renal dysfunction, and neurologic injury. Advances in perfusion techniques have allowed for preserved perfusion to the brain during arch repair. Current techniques have further evolved that allow for continuous perfusion of the heart and even the lower body during arch reconstruction. With current techniques, aortic arch reconstruction in infants can be performed with continuous perfusion to the brain, heart, and lower body. Further technical refinements will be helpful, and study is necessary to evaluate the benefit of these strategies.
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Affiliation(s)
- Andrew J Lodge
- Duke University Medical Center, Pediatric and Congenital Heart Center, Division of Cardiovascular and Thoracic Surgery, Box 3340, Durham, NC, 27710, USA.
| | - Nicholas D Andersen
- Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
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13
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Al-Subu AM, Hornik CP, Cheifetz IM, Lodge AJ, Ofori-Amanfo G. Correlation between Regional Cerebral Saturation and Invasive Cardiac Index Monitoring after Heart Transplantation Surgery. J Pediatr Intensive Care 2018; 7:196-200. [PMID: 31073494 PMCID: PMC6506669 DOI: 10.1055/s-0038-1660788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/30/2018] [Indexed: 10/14/2022] Open
Abstract
The present study assessed the correlations between cerebral regional saturation detected by near infrared spectroscopy (NIRS) and cardiac index (CI) measured by pulmonary artery catheter. This was a retrospective cohort study conducted in the cardiac intensive care unit in a tertiary care children's hospital. Patients younger than 18 years of age who underwent heart transplantation and had a pulmonary artery catheter on admission to the pediatric cardiac intensive care unit between January, 2010, and August, 2013, were included. There were no interventions. A total of 10 patients were included with median age of 14 years (range, 7-17). Indications for transplantation were dilated cardiomyopathy ( n = 9) and restrictive cardiomyopathy ( n = 1). Mixed venous oxygen saturation (SvO 2 ), cerebral regional tissue saturation (rSO 2 ), and CI were recorded hourly for 8 to 92 hours post-transplantation. Spearman's rank correlation coefficient was used to assess correlations between SvO 2 and cerebral rSO 2 and between CI and cerebral rSO 2 . A total of 410 data points were collected. Median, 25th and 75th percentiles of cerebral rSO 2 , CI, and SvO 2 were 65% (54-69), 2.9 L/min/m 2 (2.2-4.0), and 75% (69-79), respectively. The correlation coefficient between cerebral rSO 2 and CI was 0.104 ( p = 0.034) and that for cerebral rSO 2 and SvO 2 was 0.11 ( p = 0.029). The correlations between cerebral rSO 2 and CI and between cerebral rSO 2 and SvO 2 were weak. Cerebral rSO 2 as detected by NIRS may not be an accurate indicator of CI in critically ill patients.
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Affiliation(s)
- Awni M. Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, The University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, United States
| | - Christoph P. Hornik
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina, United States
| | - Ira M. Cheifetz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina, United States
| | - Andrew J. Lodge
- Division of Pediatric Cardiac Surgery, Duke Children's Hospital, Durham, North Carolina, United States
| | - George Ofori-Amanfo
- Division of Pediatric Critical Care, Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, New York, United States
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Jooste EH, Scholl R, Wu YH, Jaquiss RDB, Lodge AJ, Ames WA, Homi HM, Machovec KA, Greene NH, Donahue BS, Shah N, Benkwitz C. Double-Blind, Randomized, Placebo-Controlled Trial Comparing the Effects of Antithrombin Versus Placebo on the Coagulation System in Infants with Low Antithrombin Undergoing Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:396-402. [PMID: 30072263 DOI: 10.1053/j.jvca.2018.05.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine whether precardiopulmonary bypass (CPB) normalization of antithrombin levels in infants to 100% improves heparin sensitivity and anticoagulation during CPB and has beneficial effects into the postoperative period. DESIGN Randomized, double-blinded, placebo-controlled prospective study. SETTING Multicenter study performed in 2 academic hospitals. PARTICIPANTS The study comprised 40 infants younger than 7 months with preoperative antithrombin levels <70% undergoing CPB surgery. INTERVENTIONS Antithrombin levels were increased with exogenous antithrombin to 100% functional level intraoperatively before surgical incision. MEASUREMENTS AND MAIN RESULTS Demographics, clinical variables, and blood samples were collected up to postoperative day 4. Higher first post-heparin activated clotting times (sec) were observed in the antithrombin group despite similar initial heparin dosing. There was an increase in heparin sensitivity in the antithrombin group. There was significantly lower 24-hour chest tube output (mL/kg) in the antithrombin group and lower overall blood product unit exposures in the antithrombin group as a whole. Functional antithrombin levels (%) were significantly higher in the treatment group versus placebo group until postoperative day 2. D-dimer was significantly lower in the antithrombin group than in the placebo group on postoperative day 4. CONCLUSION Supplementation of antithrombin in infants with low antithrombin levels improves heparin sensitivity and anticoagulation during CPB without increased rates of bleeding or adverse events. Beneficial effects may be seen into the postoperative period, reflected by significantly less postoperative bleeding and exposure to blood products and reduced generation of D-dimers.
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Affiliation(s)
- Edmund H Jooste
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Rebecca Scholl
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Robert D B Jaquiss
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Medical Center, Dallas, TX
| | - Andrew J Lodge
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham
| | - Warwick A Ames
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - H Mayumi Homi
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kelly A Machovec
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathaniel H Greene
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian S Donahue
- Division of Pediatric Cardiac Anesthesiology, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Nirmish Shah
- Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, NC
| | - Claudia Benkwitz
- Department of Anesthesia and Perioperative Care, UCSF Benioff Children's Hospital, San Francisco, CA
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Tew S, Fontes ML, Greene NH, Kertai MD, Ofori-Amanfo G, Jaquiss RDB, Lodge AJ, Ames WA, Homi HM, Machovec KA, Jooste EH. Natural history of nonimmune-mediated thrombocytopenia and acute kidney injury in pediatric open-heart surgery. Paediatr Anaesth 2017; 27:305-313. [PMID: 28098429 DOI: 10.1111/pan.13063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Thrombocytopenia and acute kidney injury (AKI) are common following pediatric cardiac surgery with cardiopulmonary bypass (CPB). However, the relationship between postoperative nadir platelet counts and AKI has not been investigated in the pediatric population. Our objective was to investigate this relationship and examine independent predictors of AKI. DESIGN After IRB approval, we performed a retrospective review of the institution's medical records and database. SETTING This study was performed at a single institution over a 5-year period. PATIENTS We included patients <21 years of age undergoing cardiac surgery with CPB. INTERVENTIONS Demographics, laboratory, and surgical characteristics were captured, and clinical event rates were recorded. MEASUREMENTS Descriptive statistics were used to evaluate platelet and creatinine distributions. T-tests and chi-squared tests were used to compare characteristics among Acute Kidney Injury Network groups. Multivariable logistic and ordinal logistic regression models were used to determine the association of our predictor of interest, postoperative nadir platelet count and AKI. RESULTS Eight hundred and fourteen patients (23% infants and 23% neonates) were included in the analysis. Postoperative platelet counts decreased 48% from baseline reaching a mean nadir value of 150 × 109 ·l-1 on postoperative day 3. AKI occurred in 37% of patients including 13%, 17%, and 6% with Acute Kidney Injury Network stages 1, 2, and 3, respectively. The magnitude of nadir platelet counts correlated with the severity of AKI. Independent predictors of severity of AKI include nadir platelet counts, CPB time, Aristotle score, patient weight, intra-operative packed red blood cell transfusion, and having a heart transplant procedure. CONCLUSIONS In pediatric open-heart surgery, thrombocytopenia and AKI occur commonly following CPB. Our findings show a strong association between nadir platelet counts and the severity of AKI.
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Affiliation(s)
- Shannon Tew
- Camelback Anesthesiology Consultants, Tempe, AZ, USA
| | - Manuel L Fontes
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Nathaniel H Greene
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miklos D Kertai
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - George Ofori-Amanfo
- Division of Critical Care, Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, NY, USA
| | - Robert D B Jaquiss
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Andrew J Lodge
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Warwick A Ames
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Hercilia Mayumi Homi
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Kelly A Machovec
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Edmund H Jooste
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Lodge AJ. Kicking the habit of routine preoperative laboratory testing in children undergoing cardiac surgery. J Thorac Cardiovasc Surg 2016; 153:686-687. [PMID: 27993366 DOI: 10.1016/j.jtcvs.2016.10.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 10/27/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew J Lodge
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Gulack BC, Benrashid E, Jaquiss RDB, Lodge AJ. Pulmonary Valve Replacement With a Trifecta Valve Is Associated With Reduced Transvalvular Gradient. Ann Thorac Surg 2016; 103:655-662. [PMID: 27570156 DOI: 10.1016/j.athoracsur.2016.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Outcomes after surgical pulmonary valve replacement (PVR) in patients with congenital cardiac disease are limited by long-term valve deterioration, which may be hastened by turbulent flow. The use of the Trifecta valve (St. Jude Medical, Little Canada, MN) at our institution (Duke University Medical Center, Durham, NC) appears to result in low postimplantation transvalvular gradients. This study was performed to compare the early transvalvular gradient associated with the Trifecta valve with that associated with two other valves commonly used for PVR. METHODS We performed a single institution review of patients undergoing PVR with the Perimount valve (Edwards Lifesciences, Irvine, CA), the Biocor valve (St. Jude Medical), or the Trifecta valve between November 1993 and January 2014. Multivariable linear regression modeling was used to determine the adjusted association between valve type and transvalvular gradient as determined by early postoperative echocardiography. RESULTS A total of 186 patients met study criteria; 54 (29%) received a Biocor valve, 87 (47%) received a Perimount valve, and 45 (24%) received a Trifecta valve. There were no baseline differences among the groups, but the peak transvalvular gradient was significantly decreased among patients with the Trifecta valve. After adjustment for age, valve size, patients' weight, and time to the assessment, as compared with the Trifecta valve, the Biocor valve was associated with a 57% higher peak valve gradient (p < 0.01), whereas the Perimount valve was associated with a 26% higher peak valve gradient (p = 0.04). CONCLUSIONS PVR for congenital heart disease with the Trifecta bioprosthetic valve is associated with a reduced early transvalvular gradient. This finding may be associated with reduced valve deterioration over time.
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Affiliation(s)
- Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ehsan Benrashid
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Robert D B Jaquiss
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Andrew J Lodge
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
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Erhunmwunsee L, Flanagan RP, Jaquiss RDB, Lodge AJ. Atrial Rhabdomyoma Resection With Extracellular Matrix Reconstruction of the Right Atrial Free Wall in an Infant. World J Pediatr Congenit Heart Surg 2016; 7:769-772. [DOI: 10.1177/2150135115610718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/09/2015] [Indexed: 11/15/2022]
Abstract
A neonate was diagnosed with a mediastinal mass after presenting with bradycardia. At surgery, she was found to have a 4-cm mass replacing most of the right atrial free wall. After tumor resection, the right atrium was reconstructed with an extracellular matrix biomaterial that supports native tissue regeneration. Her pathology revealed rhabdomyoma, which is rare in patients without tuberous sclerosis. The procedure was well tolerated but was complicated by narrowing of the superior vena cava that required dilation postoperatively.
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Affiliation(s)
- Loretta Erhunmwunsee
- Division of Thoracic Surgery, Department of Surgery, City of Hope, Duarte, CA, USA
| | - Ryan P. Flanagan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Robert D. B. Jaquiss
- Division of Pediatric Cardiology, Department of Pediatrics, Womack Army Medical Center, Fort Bragg, NC, USA
| | - Andrew J. Lodge
- Division of Pediatric Cardiology, Department of Pediatrics, Womack Army Medical Center, Fort Bragg, NC, USA
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Machovec KA, Jaquiss RD, Kaemmer DD, Ames WA, Homi HM, Walczak RJ, Lodge AJ, Jooste EH. Cardiopulmonary Bypass Strategy for a Cyanotic Child With Hemoglobin SC Disease. Ann Thorac Surg 2016; 101:2373-5. [DOI: 10.1016/j.athoracsur.2015.09.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/03/2015] [Accepted: 09/15/2015] [Indexed: 10/21/2022]
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20
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Machovec KA, Smigla G, Ames WA, Schwimer C, Homi HM, Dhakal IB, Jaquiss RDB, Lodge AJ, Jooste EH. Reduction in blood transfusion in a cohort of infants having cardiac surgery with cardiopulmonary bypass after instituting a goal-directed transfusion policy. Perfusion 2016; 31:598-603. [PMID: 27015916 DOI: 10.1177/0267659116640866] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Current trends in pediatric cardiac surgery and anesthesiology include goal-directed allogeneic blood transfusion, but few studies address the transfusion of platelets and cryoprecipitate. We report a quality improvement initiative to reduce the transfusion of platelets and cryoprecipitate in infants having cardiac surgery with cardiopulmonary bypass (CPB). METHODS Data from 50 consecutive patients weighing four to ten kilograms having cardiac surgery with CPB were prospectively collected after the institution of a policy to obtain each patient's platelet and fibrinogen levels during the rewarming phase of CPB. Data from 48 consecutive patients weighing four to ten kilograms having cardiac surgery with CPB prior to the implementation of the policy change were retrospectively collected. Demographics, laboratory values and blood product transfusion data were compared between the groups, using the Chi-square/Fisher's exact test or the T-Test/Wilcoxon Rank-Sum test, as appropriate. RESULTS The results showed more total blood product exposures in the control group during the time from bypass through the first twenty-four post-operative hours (median of 2 units versus 1 unit in study group, p=0.012). During the time period from CPB separation through the first post-operative day, 67% of patients in the control group received cryoprecipitate compared to 32% in the study group (p=0.0006). There was no difference in platelet exposures between the groups. CONCLUSION Checking laboratory results during the rewarming phase of CPB reduced cryoprecipitate transfusion by 50%. This reproducible strategy avoids empiric and potentially unnecessary transfusion in this vulnerable population.
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Affiliation(s)
- Kelly A Machovec
- Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA
| | - Gregory Smigla
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA
| | - Warwick A Ames
- Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA
| | - Courtney Schwimer
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA
| | - H Mayumi Homi
- Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA
| | - Ishwori B Dhakal
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Robert D B Jaquiss
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA
| | - Andrew J Lodge
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA
| | - Edmund H Jooste
- Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA
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Jooste EH, Machovec KA, Einhorn LM, Ames WA, Homi HM, Jaquiss RDB, Lodge AJ, Levy JH, Welsby IJ. 3-Factor Prothrombin Complex Concentrates in Infants With Refractory Bleeding After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:1627-1631. [PMID: 27236492 DOI: 10.1053/j.jvca.2016.01.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Edmund H Jooste
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC.
| | - Kelly A Machovec
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Lisa M Einhorn
- Department of Anesthesiology, Duke University, Durham, NC
| | - Warwick A Ames
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Hercilia M Homi
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Robert D B Jaquiss
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Andrew J Lodge
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Jerrold H Levy
- Department of Anesthesiology, Division of Adult Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, NC
| | - Ian J Welsby
- Department of Anesthesiology, Division of Adult Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, NC
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Machovec KA, Jooste EH, Walczak RJ, Homi HM, Jaquiss RDB, Lodge AJ, Ames WA. A change in anticoagulation monitoring improves safety, reduces transfusion, and reduces costs in infants on cardiopulmonary bypass. Paediatr Anaesth 2015; 25:580-6. [PMID: 25530420 DOI: 10.1111/pan.12591] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND An immature coagulation system coupled with the hypothermia and hemodilution associated with cardiopulmonary bypass (CPB) in infants makes the activated clotting time (ACT) an ineffective monitor for anticoagulation in this population. The Medtronic HMS Plus Hemostasis Management System (HMS; Medtronic, Inc., Minneapolis, MN, USA) is shown to decrease thrombin generation and blood product requirements. AIM We conducted a quality improvement initiative to test our hypothesis that the use of HMS results in reduced incidence of subtherapeutic ACT values, blood product usage, and operating room time for infants undergoing cardiac surgery. METHODS Fifty consecutive patients weighing <10 kg having cardiac surgery requiring CPB had anticoagulation managed by the HMS. Data were compared to that of 50 consecutive patients weighing <10 kg having cardiac surgery who had their anticoagulation monitored by the ACT alone. Comparisons between categorical variables were performed with chi-square tests. Comparisons between continuous variables were performed with the Wilcoxon rank-sum test. Statistical significance was defined as two-tailed P value < 0.05. RESULTS The HMS group had a 61% decrease in incidence of ACT values <480 s and elimination of ACT values < 400 s at any time on bypass. The HMS group received fewer blood products and spent fewer minutes in the operating room after protamine administration, translating to fewer donor exposures and a savings of $403 in transfusion costs and $440 in operating room time costs. CONCLUSION Our findings highlight the benefits of individualized heparinization for pediatric patients undergoing CPB with a monitored heparinization system.
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Affiliation(s)
- Kelly A Machovec
- Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
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Lodge AJ. Invited commentary. Ann Thorac Surg 2014; 98:102-3. [PMID: 24996700 DOI: 10.1016/j.athoracsur.2014.04.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 04/27/2014] [Accepted: 04/30/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew J Lodge
- Department of Surgery and Pediatrics, Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC27710.
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Torok RD, Wei B, Kanter RJ, Jaquiss RDB, Lodge AJ. Thoracoscopic resection of the left atrial appendage after failed focal atrial tachycardia ablation. Ann Thorac Surg 2014; 97:1322-7. [PMID: 24462413 DOI: 10.1016/j.athoracsur.2013.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/30/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND This case series describes 3 patients with the unusual location of focal atrial tachycardia in the left atrial appendage who failed catheter ablation but were successfully treated by left atrial appendage resection by a totally thoracoscopic surgical technique. METHODS In all 3 cases, left atrial appendage resection was carried out by video-assisted thoracoscopic surgery using only 3 5- to 10-mm incisions, eliminating the need for median sternotomy or thoracotomy. An endoscopic stapler was used to resect the left atrial appendage at its base, successfully eliminating the source of the patients' focal atrial tachycardia. RESULTS The mean operative time was 84 minutes. All 3 patients tolerated the procedure without any complications and were discharged on postoperative day 3. At an average follow-up of 4.5 years, all patients remained asymptomatic and with normal ambulatory rhythm monitoring off all antiarrhythmic medications. CONCLUSIONS Surgical resection of the left atrial appendage using a totally thoracoscopic approach is a safe and successful treatment option for patients who have failed endocardial catheter ablation. This novel approach utilizes smaller incisions and shorter operative times than the more invasive surgical techniques previously described in the literature.
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Affiliation(s)
- Rachel D Torok
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Wei
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ronald J Kanter
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Robert D B Jaquiss
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew J Lodge
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Stern JA, Tou SP, Barker PC, Hill KD, Lodge AJ, Mathews KG, Keene BW. Hybrid cutting balloon dilatation for treatment of cor triatriatum sinister in a cat. J Vet Cardiol 2013; 15:205-10. [DOI: 10.1016/j.jvc.2013.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/20/2013] [Accepted: 03/25/2013] [Indexed: 11/29/2022]
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Crews KA, Kaiser SL, Walczak RJ, Jaquiss RD, Lodge AJ. Bridge to Transplant With Extracorporeal Membrane Oxygenation Followed by HeartWare Ventricular Assist Device in a Child. Ann Thorac Surg 2013; 95:1780-2. [DOI: 10.1016/j.athoracsur.2012.09.088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 09/12/2012] [Accepted: 09/28/2012] [Indexed: 10/26/2022]
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Turek JW, Andersen ND, Lawson DS, Bonadonna D, Turley RS, Peters MA, Jaggers J, Lodge AJ. Outcomes before and after implementation of a pediatric rapid-response extracorporeal membrane oxygenation program. Ann Thorac Surg 2013; 95:2140-6; discussion 2146-7. [PMID: 23506632 DOI: 10.1016/j.athoracsur.2013.01.050] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Revised: 01/11/2013] [Accepted: 01/27/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Rapid-response extracorporeal membrane oxygenation (RR-ECMO) has been implemented at select centers to expedite cannulation for patients placed on ECMO during extracorporeal cardiopulmonary resuscitation (ECPR). In 2008, we established such a program and used it for all pediatric venoarterial ECMO initiations. This study was designed to compare outcomes before and after program implementation. METHODS Between 2003 and 2011, 144 pediatric patients were placed on venoarterial ECMO. Records of patients placed on ECMO before (17 ECPR and 62 non-ECPR) or after (14 ECPR and 51 non-ECPR) RR-ECMO program implementation were retrospectively compared. RESULTS The peak performance of the ECMO team was assessed by measuring ECMO initiation times for the ECPR patient subgroup (n = 31). There was a shift toward more ECPR initiations achieved in less than 40 minutes (24% pre-RR-ECMO versus 43% RR-ECMO; p = 0.25) and fewer requiring more than 60 minutes (47% pre-RR-ECMO versus 21% RR-ECMO; p = 0.14) after program implementation, although these changes did not reach statistical significance. After multivariable risk adjustment, RR-ECMO was associated with a 52% reduction in neurologic complications for all patients (adjusted odds ratio, 0.48; 95% confidence interval, 0.23 to 0.98; p = 0.04), but the risk of in-hospital death remained unchanged (adjusted odds ratio, 0.99; 95% confidence interval, 0.50 to 1.99; p = 0.99). CONCLUSIONS Implementation of a pediatric RR-ECMO program for venoarterial ECMO initiation was associated with reduced neurologic complications but not improved survival during the first 3 years of program implementation. These data suggest that development of a coordinated system for rapid ECMO deployment may benefit both ECPR and non-ECPR patients, but further efforts are required to improve survival.
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Affiliation(s)
- Joseph W Turek
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University of Iowa Children's Hospital, Iowa City, Iowa, USA
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Hill KD, Lodge AJ, Forsha D, Fleming GA, Green AS, Rhodes JF. A strategy for atrial septal defect closure in small children that eliminates long-term wall erosion risk. Catheter Cardiovasc Interv 2012; 81:654-9. [DOI: 10.1002/ccd.24500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/20/2012] [Indexed: 11/09/2022]
Affiliation(s)
- Kevin D. Hill
- Division of Pediatric Cardiology; Department of Pediatrics; Duke University Medical Center; Durham; North Carolina
| | - Andrew J. Lodge
- Division of Pediatric Cardiology; Department of Pediatrics; Duke University Medical Center; Durham; North Carolina
| | - Daniel Forsha
- Division of Pediatric Cardiology; Department of Pediatrics; Duke University Medical Center; Durham; North Carolina
| | - Gregory A. Fleming
- Division of Pediatric Cardiology; Department of Pediatrics; Duke University Medical Center; Durham; North Carolina
| | - Amanda S. Green
- Division of Pediatric Cardiology; Department of Pediatrics; Duke University Medical Center; Durham; North Carolina
| | - John F. Rhodes
- Division of Pediatric Cardiology; Department of Pediatrics; Duke University Medical Center; Durham; North Carolina
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Chen XJ, Smith PB, Jaggers J, Lodge AJ. Bioprosthetic pulmonary valve replacement: contemporary analysis of a large, single-center series of 170 cases. J Thorac Cardiovasc Surg 2012; 146:1461-6. [PMID: 23122698 DOI: 10.1016/j.jtcvs.2012.09.081] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 08/10/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The present study was designed to compare stented porcine and bovine pericardial valves used for pulmonary valve replacement to better define valve performance and postoperative quality of life. METHODS A retrospective review of all patients who underwent pulmonary valve replacement with a stented bioprosthesis from 1992 to 2008 was conducted. The medical records, imaging results, and quality of life questionnaires were analyzed. Differences in reintervention by valve type were determined using Cox proportional hazards models, controlling for subject age. RESULTS A total of 170 consecutive pulmonary valve replacements (73 stented porcine, group 1; 97 bovine pericardial, group 2) were reviewed. No significant differences were seen in patient age or implanted valve size between the groups. Surgical mortality was 1.2%. The median follow-up was 48.2 months and was longer for group 2. No significant difference was seen in the risk of reintervention by valve type (hazard ratio, 0.64; 95% confidence interval, 0.18-2.34; P = .51). After 39 months of follow-up, pulmonary stenosis and pulmonary insufficiency that was moderate or worse were more common in patients who had undergone pulmonary valve replacement at younger than 15 years (pulmonary stenosis, 30.9% vs 10.0%, P = .003; pulmonary insufficiency, 46.2% vs 3.8%, P < .001), regardless of valve type. All patients performed well mentally and physically on the quality of life surveys. CONCLUSIONS The present large series of stented bioprosthetic pulmonary valve replacements has demonstrated good results, particularly in adults, at intermediate follow-up. Freedom from reintervention was similar for the porcine and pericardial valves, and our finding did not clearly demonstrate the superiority of 1 type of valve. However, the stented bioprosthetic valves were less durable in younger patients.
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Affiliation(s)
- Xu-Jun Chen
- Department of Cardiothoracic Surgery, Shanghai Tongji Hospital, Tongji University, Shanghai, China; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Chen DF, Jaquiss RD, Lodge AJ, Carboni MP. 82-P. Hum Immunol 2012. [DOI: 10.1016/j.humimm.2012.07.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Affiliation(s)
- Nicholas D Andersen
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Box 3340, Durham, NC 27710, USA
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Tabbutt S, Ghanayem N, Ravishankar C, Sleeper LA, Cooper DS, Frank DU, Lu M, Pizarro C, Frommelt P, Goldberg CS, Graham EM, Krawczeski CD, Lai WW, Lewis A, Kirsh JA, Mahony L, Ohye RG, Simsic J, Lodge AJ, Spurrier E, Stylianou M, Laussen P. Risk factors for hospital morbidity and mortality after the Norwood procedure: A report from the Pediatric Heart Network Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144:882-95. [PMID: 22704284 DOI: 10.1016/j.jtcvs.2012.05.019] [Citation(s) in RCA: 240] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 03/21/2012] [Accepted: 05/09/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to identify risk factors for mortality and morbidity during the Norwood hospitalization in newborn infants with hypoplastic left heart syndrome and other single right ventricle anomalies enrolled in the Single Ventricle Reconstruction trial. METHODS Potential predictors for outcome included patient- and procedure-related variables and center volume and surgeon volume. Outcome variables occurring during the Norwood procedure and before hospital discharge or stage II procedure included mortality, end-organ complications, length of ventilation, and hospital length of stay. Univariate and multivariable Cox regression analyses were performed with bootstrapping to estimate reliability for mortality. RESULTS Analysis included 549 subjects prospectively enrolled from 15 centers; 30-day and hospital mortality were 11.5% (63/549) and 16.0% (88/549), respectively. Independent risk factors for both 30-day and hospital mortality included lower birth weight, genetic abnormality, extracorporeal membrane oxygenation (ECMO) and open sternum on the day of the Norwood procedure. In addition, longer duration of deep hypothermic circulatory arrest was a risk factor for 30-day mortality. Shunt type at the end of the Norwood procedure was not a significant risk factor for 30-day or hospital mortality. Independent risk factors for postoperative renal failure (n = 46), sepsis (n = 93), increased length of ventilation, and hospital length of stay among survivors included genetic abnormality, lower center/surgeon volume, open sternum, and post-Norwood operations. CONCLUSIONS Innate patient factors, ECMO, open sternum, and lower center/surgeon volume are important risk factors for postoperative mortality and/or morbidity during the Norwood hospitalization.
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Affiliation(s)
- Sarah Tabbutt
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Forsha D, Rhodes JF, Williams DA, Lodge AJ, Li JS. A Rare Coronary Collateral in Pulmonary Atresia and Intact Septum With Coronary Sinusoids. World J Pediatr Congenit Heart Surg 2012; 3:255-9. [DOI: 10.1177/2150135111430515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A neonate with pulmonary atresia and intract ventricular septum, ventriculocoronary sinusoids, bilateral coronary ostial atresia, and a rare collateral vessel between the descending thoracic aorta and the coronary system is described. The clinical course in this infant included extracorporeal life support and coil occlusion of the collateral in order to manage multiple ischemic events.
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Affiliation(s)
- Daniel Forsha
- Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - John F. Rhodes
- Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Derek A. Williams
- Department of Pediatrics, Brenner Children’s Hospital, Durham, NC, USA
| | - Andrew J. Lodge
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jennifer S. Li
- Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Division of Cardiology, Department of Pediatrics, Duke Clinical Research Institute, Durham, NC, USA
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Jaquiss RDB, Lodge AJ. Pediatric Ventricular Assist Devices: The Future (as of 2011). World J Pediatr Congenit Heart Surg 2012; 3:82-6. [PMID: 23804689 DOI: 10.1177/2150135111423277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last decade, there have been enormous advances in the field of pediatric-specific mechanical circulatory support. In the past, small children requiring bridge to transplant or recovery were limited to extracorporeal membrane oxygenation. Now, in various stages of development, there are several devices that offer the promise of the same quality of support enjoyed by older teenagers and adolescents, with the potential to substantially reduce transplant waiting list mortality and optimize transplant outcomes. Advances have been driven by both industry and, for the first time, by funding from the US National Institutes of Health.
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Affiliation(s)
- Robert D B Jaquiss
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Piacentino V, Troupes CD, Ganapathi AM, Blue LJ, Mackensen GB, Swaminathan M, Felker GM, Stafford-Smith M, Lodge AJ, Rogers JG, Milano CA. Clinical impact of concomitant tricuspid valve procedures during left ventricular assist device implantation. Ann Thorac Surg 2011; 92:1414-8; discussion 1418-9. [PMID: 21958790 DOI: 10.1016/j.athoracsur.2011.05.084] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 05/12/2011] [Accepted: 05/16/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Almost 50% of patients referred for implantable left ventricular assist device (LVAD) have significant tricuspid regurgitation (TR). Preoperative TR is associated with negative outcomes but the clinical benefit of concomitant tricuspid valve procedures has not been extensively studied. METHODS One hundred fifteen patients, undergoing implantable LVADs, were identified as having significant TR by echocardiography prior to their surgical procedure. Patients underwent either LVAD alone (n = 81) versus LVAD plus concomitant tricuspid procedures (n = 34) (29 annuloplasty ring repairs and 5 bioprosthetic replacements.) Preoperative characteristics and hemodynamics, as well as TR severity and clinical outcomes were retrospectively determined from chart and database review and compared for the two groups. RESULTS Preoperative characteristics and hemodynamics were similar for the two groups. Postoperative TR was markedly reduced for the group undergoing concomitant procedures versus LVAD alone. A temporary right ventricular assist device was required for only one of the 34 cases in which concomitant tricuspid procedures were performed; for patients undergoing LVAD alone, 8 of 81 required right ventricular assist devices. Mean duration of postoperative inotrope utilization was increased for the LVAD alone group versus the group with concomitant tricuspid procedures (10.0 vs 8.0 days, respectively, p = 0.04). The incidence of postoperative renal dysfunction was increased for the LVAD alone group (39%) versus concomitant procedures (21%) (p = 0.05). The LVAD alone group also had a greater mean postimplant length of hospitalization versus the concomitant procedures group (26.0 vs 19.0 days, p = 0.02). Finally, there was a trend toward improved survival for the group with concomitant tricuspid procedures versus LVAD alone. CONCLUSIONS For patients with significant TR undergoing implantable LVAD procedures, concomitant tricuspid procedures are associated with improved early clinical outcomes.
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Turner II, Turek JW, Jaggers J, Herlong JR, Lawson DS, Lodge AJ. Anomalous Aortic Origin of a Coronary Artery: Preoperative Diagnosis and Surgical Planning. World J Pediatr Congenit Heart Surg 2011; 2:340-5. [DOI: 10.1177/2150135111406938] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Anomalous aortic origin of a coronary artery (AAOCA), the anomalous coronary artery arises from an inappropriate coronary sinus and travels between the aorta and pulmonary artery. Proper surgical management depends upon correct diagnosis and accurate characterization of the origin and course of the coronary artery. Transthoracic echocardiography (TTE) has been the mainstay for diagnosis, but magnetic resonance imaging (MRI) and computed tomographic angiography (CTA) have been increasingly utilized. In this study, we report the largest series of surgically repaired AAOCA and accuracy of preoperative diagnostic studies. Methods: A review of 53 consecutive patients (mean age 13.9 years, range 4-65 years) undergoing repair of an AAOCA from 1995 to 2009 was performed. In all, 40 patients were identified with an anomalous right coronary artery (ARCA) from the left sinus of Valsalva, 13 patients had an anomalous left coronary artery (ALCA) arising from the opposite sinus. Symptoms of angina or syncope were present in 58% and 46% of cases with ARCA and ALCA, respectively. Results of preoperative diagnostic testing were compared to actual surgical findings to determine the accuracy of the tests. Results: Lack of an intramural course was observed intraoperatively in 7 cases (5 ARCA and 2 ALCA). Preoperative TTE accurately predicted whether the AAOCA was intramural or extramural in 49 (92.5%) of 53 cases. Magnetic resonance imaging was predictive in 5 (83.3%) of 6 patients and CTA in 11 (64.7%) of 17. Survival was 100%. Complications occurred in 4 (7.5%) of 53 patients (mean follow-up 29 months). Patency was confirmed in 97.7% with TTE, and 23 (95.8%) of 24 patients had a negative postoperative functional study. Conclusions: Transthoracic echocardiography was found to be very accurate at defining the presence or absence of an intramural course in AAOCA. Both MRI and CTA can provide additional information but may not be as accurate as TTE.
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Affiliation(s)
- Immanuel I. Turner
- Pediatric Cardiac Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W. Turek
- Cardiothoracic Surgery, Childrens Hospital of Philadelphia, Philidelphia, PA, USA
| | - James Jaggers
- Pediatric Cardiac Surgery, The Childrens Hospital, University of Colorado, Aurora CO, USA
| | - J. Rene Herlong
- Pediatric Cardiology, Carolinas Medical Center, The Sanger Clinic Pediatric Cardiology, Charlotte, NC, USA
| | - Dale S. Lawson
- Pediatric Cardiac Surgery, The Childrens Hospital, University of Colorado, Aurora CO, USA
| | - Andrew J. Lodge
- Pediatric Cardiac Surgery, Duke University Medical Center, Durham, NC, USA
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Pasquali SK, Sun JL, d'Almada P, Jaquiss RDB, Lodge AJ, Miller N, Kemper AR, Lannon CM, Li JS. Center variation in hospital costs for patients undergoing congenital heart surgery. Circ Cardiovasc Qual Outcomes 2011; 4:306-12. [PMID: 21505154 DOI: 10.1161/circoutcomes.110.958959] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Congenital heart disease consumes significant health care resources; however, there are limited data regarding factors affecting resource utilization. The purpose of this study was to evaluate variation between centers in total hospital costs for 4 congenital heart operations of varying complexity and associated factors. METHODS AND RESULTS The Premier Database was used to evaluate total cost in children undergoing isolated atrial septal defect (ASD) repair, ventricular septal defect (VSD) repair, tetralogy of Fallot (TOF) repair, or arterial switch operation (ASO) from 2001 to 2007. Mixed models were used to evaluate the impact of center on total hospital costs adjusting for patient and center characteristics and length of stay. A total of 2124 patients were included: 719 ASD (19 centers), 792 VSD (20 centers), 420 TOF (17 centers), and 193 ASO (13 centers). Total cost increased with complexity of operation from median $12 761 (ASD repair) to $55 430 (ASO). In multivariable analysis, models that accounted for center effects versus those that did not performed significantly better for all 4 surgeries (all P≤0.01). The proportion of total cost variation explained by center was 19% (ASD repair), 11% (VSD repair), 6% (TOF repair), and 3% (ASO). Higher-volume centers had significantly lower hospital costs for ASD and VSD repair but not for TOF repair and ASO. CONCLUSIONS Total hospital costs varied significantly by center for all congenital heart surgeries evaluated, even after adjustment for patient and center characteristics and length of stay. Differences among centers were most prominent for lower complexity procedures.
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Affiliation(s)
- Sara K Pasquali
- Divisions of Pediatric Cardiology and Cardiothoracic Surgery and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
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Piacentino V, Williams ML, Depp T, Garcia-Huerta K, Blue L, Lodge AJ, Mackensen GB, Swaminathan M, Rogers JG, Milano CA. Impact of tricuspid valve regurgitation in patients treated with implantable left ventricular assist devices. Ann Thorac Surg 2011; 91:1342-6; discussion 1346-7. [PMID: 21457940 DOI: 10.1016/j.athoracsur.2011.01.053] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 01/14/2011] [Accepted: 01/20/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND The progression of tricuspid valve regurgitation (TR) and the impact of preoperative TR on postoperative outcomes in patients having left ventricular assist device (LVAD) implantation has not been studied. METHODS One hundred seventy-six consecutive implantable LVAD procedures were retrospectively reviewed. A total of 137 patients comprised the final study group with complete preimplant characteristics, before and after echocardiogram assessment of TR, and outcomes data. Patients were divided into two groups: insignificant TR (iTR) consisting of those with preimplant TR grades of none, trace, and mild; and significant TR (sTR) consisting of those with moderate and severe TR grades. RESULTS Relative to patients with iTR, patients with sTR were younger (53.6±12.8 versus 58.4±10.0 years, p=0.02) and more commonly had nonischemic cardiomyopathies (69% versus 38%, p<0.001). The preimplant incidence of iTR and sTR was 51% and 49%. Immediately after the LVAD implant procedure, TR did not significantly change. At late follow-up (156±272 days), 32% had moderate or severe TR. Also, 41% of the original sTR group persisted with moderate or severe TR. Relative to patients with iTR, patients with sTR required longer postimplant intravenous inotropic support (8.5 versus 5.0 days, p=0.02), more commonly required a temporary right ventricular assist device, and had a longer postimplant length of hospital stay (27.0 versus 20.0 days, p=0.03). There was also a trend toward decreased survival for sTR versus iTR (log rank=0.05). CONCLUSIONS Tricuspid regurgitation is not reduced immediately after LVAD implantation. Significant TR is associated with longer postimplant inotropic support and length of hospital stay.
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Affiliation(s)
- Valentino Piacentino
- Division of Cardiac and Thoracic Surgery, Department of Cardiac and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Hornik CP, Hartman ME, Markert ML, Lodge AJ, Cheifetz IM, Turner DA. Successful extracorporeal membrane oxygenation for respiratory failure in an infant with DiGeorge anomaly, following thymus transplantation. Respir Care 2011; 56:866-70. [PMID: 21333090 DOI: 10.4187/respcare.01051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the first successful use of venovenous extracorporeal membrane oxygenation (ECMO) for refractory respiratory failure in an infant with DiGeorge anomaly, following thymus transplantation. A 23-month-old female with complete immune-incompetent DiGeorge anomaly 65 days after allogenic thymus transplantation was treated in our pediatric intensive care unit for acute respiratory failure secondary to bacterial sepsis. She subsequently developed acute hypercarbic respiratory failure unresponsive to conventional medical therapy. She was successfully managed with venovenous ECMO for 4 days, with complete resolution of her respiratory symptoms. This case demonstrates the complex decision making process regarding initiation of ECMO in patients with severe immunodeficiency.
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Affiliation(s)
- Christoph P Hornik
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Trivedi B, Smith PB, Barker PC, Jaggers J, Lodge AJ, Kanter RJ. Arrhythmias in patients with hypoplastic left heart syndrome. Am Heart J 2011; 161:138-44. [PMID: 21167346 DOI: 10.1016/j.ahj.2010.09.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 09/29/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mortality between stage I and II palliation for hypoplastic left heart syndrome (HLHS) has been associated with arrhythmias. The stage-related proportion, associations, and clinical impact of arrhythmias in patients with HLHS have not been evaluated. In addition, arrhythmia subtypes have not been described in this patient group. METHODS We performed a retrospective analysis of all patients at Duke University Medical Center who received one or more palliative stages for HLHS from September 2000 to October 2008. RESULTS Overall, 49 (57%) of 86 patients had 63 arrhythmias. The majority of arrhythmias occurred between stage I and II, with 44 (51%) of 86 patients manifesting a new arrhythmia. Arrhythmias occurring in this interval tended to be associated with a higher mortality compared with arrhythmias occurring after stage II (odds ratio = 3.2 [95% CI 0.84-12.0], P = .09). Overall mortality was similar in patients with and without arrhythmias (P = .99). Supraventricular tachycardia was the most common arrhythmia (16/63; 25%), but persistent bradycardias (sinus node dysfunction or high-grade atrioventricular block) had the worst clinical outcome with 73% mortality (8/11). There was no association between arrhythmia occurrence and degree of tricuspid regurgitation, left ventricular hypertension, genetic syndrome, type of stage I operation, or need for extracorporeal membrane oxygenation. CONCLUSIONS A large proportion of patients with HLHS experience serious arrhythmias requiring therapy, especially between stage I and II. Persistent bradycardia following stage I is associated with a high mortality rate. Considering all arrhythmia patients, overall mortality was not different compared with the arrhythmia-free group.
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Pasquali SK, Hall M, Li JS, Peterson ED, Jaggers J, Lodge AJ, Marino BS, Goodman DM, Shah SS. Corticosteroids and outcome in children undergoing congenital heart surgery: analysis of the Pediatric Health Information Systems database. Circulation 2010; 122:2123-30. [PMID: 21060075 PMCID: PMC3013053 DOI: 10.1161/circulationaha.110.948737] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children undergoing congenital heart surgery often receive corticosteroids with the aim of reducing the inflammatory response after cardiopulmonary bypass; however, the value of this approach is unclear. METHODS AND RESULTS The Pediatric Health Information Systems Database was used to evaluate outcomes associated with corticosteroids in children (0 to 18 years of age) undergoing congenital heart surgery at 38 US centers from 2003 to 2008. Propensity scores were constructed to account for potential confounders: age, sex, race, prematurity, genetic syndrome, type of surgery (Risk Adjustment in Congenital Heart Surgery [RACHS-1] category), center, and center volume. Multivariable analysis, adjusting for propensity score and individual covariates, was performed to evaluate in-hospital mortality, postoperative length of stay, duration of ventilation, infection, and use of insulin. A total of 46 730 children were included; 54% received corticosteroids. In multivariable analysis, there was no difference in mortality among corticosteroid recipients and nonrecipients (odds ratio, 1.13; 95% confidence interval, 0.98 to 1.30). Corticosteroids were associated with longer length of stay (least square mean difference, 2.18 days; 95% confidence interval, 1.62 to 2.74 days), greater infection (odds ratio, 1.27; 95% confidence interval, 1.10 to 1.46), and greater use of insulin (odds ratio, 2.45; 95% confidence interval, 2.24 to 2.67). There was no difference in duration of ventilation. In analysis stratified by RACHS-1 category, no significant benefit was seen in any group, and the association of corticosteroids with increased morbidity was most prominent in RACHS-1 categories 1 through 3. CONCLUSION In this observational analysis of children undergoing congenital heart surgery, we were unable to demonstrate a significant benefit associated with corticosteroids and found that corticosteroids may be associated with increased morbidity, particularly in lower-risk patients.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27715, USA.
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Lee MS, Kozitza R, Mudrick D, Williams M, Lodge AJ, Harrison JK, Glower DD. Intraoperative device closure of postinfarction ventricular septal defects. Ann Thorac Surg 2010; 89:e48-50. [PMID: 20494012 DOI: 10.1016/j.athoracsur.2010.03.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Revised: 02/16/2010] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
Abstract
Postinfarction ventricular septal defects (VSDs) are associated with high mortality and typically these are treated urgently with surgery for exclusion patch repair. Percutaneous closure of postinfarction VSDs using occlusion devices is feasible in some patients, but in some cases device deployment may not be possible due to VSD anatomy or valvular apparatus interference. We report the novel technique of deploying Amplatzer VSD devices in the operating room under direct vision through a right atriotomy with and without aortotomy in 2 patients with large inferobasal VSDs after myocardial infarction.
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Affiliation(s)
- Michael S Lee
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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Daneshmand MA, Rajagopal K, Lima B, Khorram N, Blue LJ, Lodge AJ, Hernandez AF, Rogers JG, Milano CA. Left Ventricular Assist Device Destination Therapy Versus Extended Criteria Cardiac Transplant. Ann Thorac Surg 2010; 89:1205-9; discussion 1210. [DOI: 10.1016/j.athoracsur.2009.12.058] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 12/17/2009] [Accepted: 12/18/2009] [Indexed: 10/19/2022]
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Rajagopal K, Rogers JG, Lodge AJ, Gaca JG, McCann RL, Milano CA, Hughes GC. Two-stage total cardioaortic replacement for end-stage heart and aortic disease in Marfan syndrome: case report and review of the literature. J Heart Lung Transplant 2010; 28:958-63. [PMID: 19716050 DOI: 10.1016/j.healun.2009.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2008] [Revised: 04/15/2009] [Accepted: 05/06/2009] [Indexed: 11/18/2022] Open
Abstract
A 24-year-old man with Marfan syndrome underwent mitral valve repair for prolapse at age 13. He sustained an acute type A aortic dissection at age 20 and underwent aortic root/ascending aortic replacement with a mechanical valved conduit. He initially did well after the latter procedure, but end-stage heart disease developed 4 years later, apparently secondary to primary cardiomyopathy. Pre-transplant evaluation revealed residual chronic dissection with aneurysmal dilatation of the distal ascending aorta, transverse arch, and descending thoracic aorta. He underwent combined orthotopic heart transplantation (OHT) and total arch replacement (stage I elephant trunk procedure). Subsequently, he underwent extent II thoracoabdominal aneurysm repair, leaving no residual aortic disease. The 2 procedures resulted in total cardioaortic replacement, thus definitively managing his cardiomyopathy and aortic disease resulting from Marfan syndrome. The operative strategies employed represent a novel approach in this clinical setting. This report emphasizes that patients with this disease should not be denied potentially life-saving OHT on the basis of concomitant aortic disease, but rather should be treated in centers offering expertise in both areas of surgical therapy.
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Affiliation(s)
- Keshava Rajagopal
- Department of Surgery (Division of Thoracic and Cardiovascular Surgery), Duke University Medical Center, Durham, North Carolina 27710, USA
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Pal JD, Piacentino V, Cuevas AD, Depp T, Daneshmand MA, Hernandez AF, Felker GM, Lodge AJ, Rogers JG, Milano CA. Impact of Left Ventricular Assist Device Bridging on Posttransplant Outcomes. Ann Thorac Surg 2009; 88:1457-61; discussion 1461. [DOI: 10.1016/j.athoracsur.2009.07.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 07/07/2009] [Accepted: 07/10/2009] [Indexed: 11/16/2022]
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Rajagopal K, Lima B, Petersen RP, Mesis RG, Daneshmand MA, Lemaire A, Felker GM, Hernandez AF, Rogers JG, Lodge AJ, Milano CA. Infectious Complications in Extended Criteria Heart Transplantation. J Heart Lung Transplant 2008; 27:1217-21. [DOI: 10.1016/j.healun.2008.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Revised: 06/30/2008] [Accepted: 08/06/2008] [Indexed: 10/21/2022] Open
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Drinker LR, Camitta MGW, Herlong JR, Miller S, Lodge AJ, Jaggers J, Barker PCA. Use of the monoplane intracardiac imaging probe in high-risk infants during congenital heart surgery. Echocardiography 2008; 25:999-1003. [PMID: 18771552 DOI: 10.1111/j.1540-8175.2008.00719.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED Imaging options are limited in high-risk infants with small or abnormal oropharyngeal anatomy during congenital heart surgery. METHODS All cases in which the monoplane intracardiac echo probe was used for transesophageal intraoperative imaging over a 15-month period at a single institution were reviewed. RESULTS Eleven patients underwent intraoperative imaging using the intracardiac probe. Patient weight ranged from 1.96 kg to 4 kg. Adequate images of the anatomy relevant to the surgical repair were obtained in all cases. No adverse events related to probe use occurred. CONCLUSION Transesophageal echocardiography using the monoplane intracardiac echo probe provides safe and effective imaging in patients who are not candidates for standard transesophageal echocardiography.
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Affiliation(s)
- Lisa R Drinker
- The Duke Children's Heart Program, Duke University Medical Center, Durham, North Carolina 27710, USA
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Lodge AJ, Wells WJ, Backer CL, O'Brien JE, Austin EH, Bacha EA, Yeh T, DeCampli WM, Lavin PT, Weinstein S. A Novel Bioresorbable Film Reduces Postoperative Adhesions After Infant Cardiac Surgery. Ann Thorac Surg 2008; 86:614-21. [DOI: 10.1016/j.athoracsur.2008.04.103] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 04/23/2008] [Accepted: 04/24/2008] [Indexed: 10/21/2022]
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Curzon CL, Milford-Beland S, Li JS, O'Brien SM, Jacobs JP, Jacobs ML, Welke KF, Lodge AJ, Peterson ED, Jaggers J. Cardiac surgery in infants with low birth weight is associated with increased mortality: Analysis of the Society of Thoracic Surgeons Congenital Heart Database. J Thorac Cardiovasc Surg 2008; 135:546-51. [DOI: 10.1016/j.jtcvs.2007.09.068] [Citation(s) in RCA: 231] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 08/30/2007] [Accepted: 09/14/2007] [Indexed: 11/28/2022]
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