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Stephens EH, Dearani JA, Qureshi MY, Segura LG, Arendt KW, Bendel-Stenzel EM, Ruano R. Toward Eliminating Perinatal Comfort Care for Prenatally Diagnosed Severe Congenital Heart Defects: A Vision. Mayo Clin Proc 2021; 96:1276-1287. [PMID: 33958058 DOI: 10.1016/j.mayocp.2020.08.029] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/25/2020] [Accepted: 08/26/2020] [Indexed: 12/16/2022]
Abstract
Over the past 40 years, the medical and surgical management of congenital heart disease has advanced considerably. However, substantial room for improvement remains for certain lesions that have high rates of morbidity and mortality. Although most congenital cardiac conditions are well tolerated during fetal development, certain abnormalities progress in severity over the course of gestation and impair the development of other organs, such as the lungs or airways. It follows that intervention during gestation could potentially slow or reverse elements of disease progression and improve prognosis for certain congenital heart defects. In this review, we detail specific congenital cardiac lesions that may benefit from fetal intervention, some of which already have documented improved outcomes with fetal interventions, and the state-of-the-science in each of these areas. This review includes the most relevant studies from a PubMed database search from 1970 to the present using key words such as fetal cardiac, fetal intervention, fetal surgery, and EXIT procedure. Fetal intervention in congenital cardiac surgery is an exciting frontier that promises further improvement in congenital heart disease outcomes. When fetuses who can benefit from fetal intervention are identified and appropriately referred to centers of excellence in this area, patient care will improve.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Leal G Segura
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ellen M Bendel-Stenzel
- Division of Maternal-Fetal Medicine, Mayo Clinic, Rochester, MN; Division of Neonatal Medicine, Mayo Clinic, Rochester, MN
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Mayo Clinic, Rochester, MN
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Narang K, Elrefaei A, Wyatt MA, Warner LL, Abrao Trad AT, Segura LG, Bendel-Stenzel E, Ahn ES, Arendt KW, Qureshi MY, Ruano R. Fetal Surgery in the Era of SARS-CoV-2 Pandemic: A Single-Institution Review. Mayo Clin Proc Innov Qual Outcomes 2020; 4:717-724. [PMID: 32839753 PMCID: PMC7437475 DOI: 10.1016/j.mayocpiqo.2020.08.001] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To cope with the changing health care services in the era of SARS-CoV-2 pandemic. We share the institutional framework for the management of anomalous fetuses requiring fetal intervention at Mayo Clinic, Rochester, Minnesota. To assess the success of our program during this time, we compare intraoperative outcomes of fetal interventions performed during the pandemic with the previous year. Patients We implemented our testing protocol on patients undergoing fetal intervention at our institution between March 1, and May 15, 2020, and we compared it with same period a year before. A total of 17 pregnant patients with anomalous fetuses who met criteria for fetal intervention were included: 8 from 2019 and 9 from 2020. Methods Our testing protocol was designed based on our institutional perinatal guidelines, surgical requirements from the infection prevention and control (IPAC) committee, and input from our fetal surgery team, with focus on urgency of procedure and maternal SARS-CoV-2 screening status. We compared the indications, types of procedures, maternal age, gestational age at procedure, type of anesthesia used, and duration of procedure for cases performed at our institution between March 1, 2020, and May 15, 2020, and for the same period in 2019. Results There were no statistically significant differences among the number of cases, indications, types of procedures, maternal age, gestational age, types of anesthesia, and duration of procedures (P values were all >.05) between the pre–SARS-CoV-2 pandemic in 2019 and the SARS-CoV-2 pandemic in 2020. Conclusions Adoption of new institutional protocols during SARS-CoV-2 pandemic, with appropriate screening and case selection, allows provision of necessary fetal intervention with maximal benefit to mother, fetus, and health care provider.
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Key Words
- ACOG, American College of Obstetrics and Gynecology
- AFPS, American Foundation for Patient Safety
- AGP, aerosol-generating procedures
- ASA, American Society of Anesthesiology
- CDH, congenital diaphragmatic hernia
- COVID-19, coronavirus-2019
- FETO, fetoscopic endoluminal tracheal occlusion
- GA, general anesthesia
- IFMSS, International Fetal Medicine and Surgery Society
- LUTO, lower urinary tract obstruction
- MAC, monitored anesthesia care
- NAFTNet, North American Fetal Therapy Network
- SMFM, Society for Maternal and Fetal Medicine
- TAPS, twin anemia polycythemia sequence
- TTTS, twin-to-twin transfusion syndrome
- WHO, World Health Organization
- qRT-PCR, quantitative real time polymerase chain reaction
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Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Amro Elrefaei
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Michelle A Wyatt
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Lindsay L Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ayssa Teles Abrao Trad
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leal G Segura
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ellen Bendel-Stenzel
- Division of Neonatology, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Edward S Ahn
- Division of Neurosurgery, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Katherine W Arendt
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - M Yasir Qureshi
- Pediatric Cardiology Division, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
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Affiliation(s)
- Lindsay L. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Katherine W. Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M. Yasir Qureshi
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Leal G. Segura
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Said SM, Qureshi MY, Taggart NW, Anderson HN, O'Leary PW, Cetta F, Alrahmani L, Cofer SA, Segura LG, Pike RB, Sharpe EE, Derleth DP, Nemergut ME, Van Dorn CS, Gleich SJ, Rose CH, Collura CA, Ruano R. Innovative 2-Step Management Strategy Utilizing EXIT Procedure for a Fetus With Hypoplastic Left Heart Syndrome and Intact Atrial Septum. Mayo Clin Proc 2019; 94:356-361. [PMID: 30711131 DOI: 10.1016/j.mayocp.2018.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/17/2018] [Accepted: 08/08/2018] [Indexed: 11/23/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) with intact atrial septum (HLHS-IAS) carries a high risk of mortality and affects about 6% of all patients with HLHS. Fetal interventions, postnatal transcatheter interventions, and postnatal surgical resection have all been used, but the mortality risk continues to be high in this subgroup of patients. We describe a novel, sequential approach to manage HLHS-IAS and progressive fetal hydrops. A 28-year-old, gravida 4 para 2 mother was referred to Mayo Clinic for fetal HLHS. Fetal echocardiography at 28 weeks of gestation demonstrated HLHS-IAS with progressive fetal hydrops. The atrial septum was thick and muscular with no interatrial communication. Ultrasound-guided fetal atrial septostomy was performed with successful creation of a small atrial communication. However, fetal echocardiogram at 33 weeks of gestation showed recurrence of a pleural effusion and restriction of the atrial septum. We proceeded with an Ex uteroIntrapartum Treatment (EXIT) delivery and open atrial septectomy. This was performed successfully, and the infant was stabilized in the intensive care unit. The infant required venoarterial extracorporeal membrane oxygenator support on day of life 1. The patient later developed hemorrhagic complications, leading to his demise on day of life 9. This is the first reported case of an EXIT procedure and open atrial septectomy performed without cardiopulmonary bypass for an open-heart operation and provides a promising alternative strategy for the management of HLHS-IAS in select cases.
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Affiliation(s)
- Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Nathaniel W Taggart
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Heather N Anderson
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Frank Cetta
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Layan Alrahmani
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Shelagh A Cofer
- Division of Pediatric Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leal G Segura
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Roxann B Pike
- Division of Cardiovascular Anesthesia, Mayo Clinic College of Medicine, Rochester, MN
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Douglas P Derleth
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael E Nemergut
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Stephen J Gleich
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Carl H Rose
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Rodrigo Ruano
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN.
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Clarke MJ, Price DL, Cloft HJ, Segura LG, Hill CA, Browning MB, Brandt JM, Lew SM, Foy AB. En bloc resection of a C-1 lateral mass osteosarcoma: technical note. J Neurosurg Pediatr 2016; 18:46-52. [PMID: 26966885 DOI: 10.3171/2015.12.peds15496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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] [Indexed: 11/06/2022]
Abstract
Osteosarcoma is an aggressive primary bone tumor. It is currently treated with multimodality therapy including en bloc resection, which has been demonstrated to confer a survival benefit over intralesional resection. The authors present the case of an 8-year-old girl with a C-1 lateral mass osteosarcoma, which was treated with a 4-stage en bloc resection and spinal reconstruction. While technically complex, the feasibility of en bloc resection for spinal osteosarcoma should be explored in the pediatric population.
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Affiliation(s)
| | | | | | | | | | - Meghen B Browning
- Department of Pediatric Oncology, Medical College of Wisconsin, Milwaukee
| | - Jon M Brandt
- Department of Pediatric Oncology, St. Vincent Hospital, Green Bay; and
| | - Sean M Lew
- Department of Pediatric Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew B Foy
- Department of Pediatric Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Segura LG, Lorenz JD, Weingarten TN, Scavonetto F, Bojanić K, Selcen D, Sprung J. Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth 2013; 23:855-64. [PMID: 23919455 DOI: 10.1111/pan.12248] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [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] [Accepted: 07/13/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are associated with life-threatening perioperative complications, including rhabdomyolysis, hyperkalemia, and hyperthermia. Current recommendations contraindicate use of succinylcholine and volatile anesthetics; however, the latter recommendation remains controversial. OBJECTIVE To review the perioperative outcomes of patients with DMD and BMD. METHODS We reviewed records of patients with DMD or BMD who underwent anesthetic management at our institution from January 1990 through December 2011. RESULTS We identified 47 patients (DMD, 37; BMD, 10) who underwent 117 anesthetic exposures (DMD, 101; BMD, 16). Volatile anesthetic agents were used 66 times (DMD, 59; BMD, 7). One patient with undiagnosed BMD received succinylcholine and developed acute rhabdomyolysis and hyperkalemic cardiac arrest. All other major complications were attributed to the procedure (i.e., large bleeding), to preexisting comorbidities (i.e., respiratory failure, cardiac disease), or to both. CONCLUSIONS Use of succinylcholine in children with dystrophinopathy is contraindicated. These patients have significant comorbidities and are frequently undergoing extensive operations; complications related to these factors can develop, as evidenced by our series. These complications may occur with use of volatile and nonvolatile anesthetics. However, because most of our patients were older than 8 years at the time of surgery, our observation cannot be generalized to younger dystrophin-deficient children.
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Affiliation(s)
- Leal G Segura
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
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Collard V, Segura LG, Daaboul DG, Yuki K. Retrograde intubation during laryngeal cleft repair on cardiopulmonary bypass. J Anesth 2012; 26:273-4. [PMID: 22302106 DOI: 10.1007/s00540-011-1310-5] [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] [Received: 11/02/2010] [Accepted: 12/09/2011] [Indexed: 11/24/2022]
Abstract
Retrograde intubation is part of the difficult airway algorithm in the American Society of Anesthesiologists, but its usage is rare in small pediatric patients with the advent of new intubation techniques. We present our experience of retrograde intubation for a 4-month-old patient who presented for laryngeal cleft repair on cardiopulmonary bypass. This case highlights the unique place for retrograde intubation in small patients in the current era.
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Affiliation(s)
- Vincent Collard
- Montreal Childrens Hospital, 2300 Tupper Street, Montreal, QC H3H 1P3, Canada.
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Smith HM, Jacob AK, Segura LG, Dilger JA, Torsher LC. Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent simulation training. Anesth Analg 2008; 106:1581-4, table of contents. [PMID: 18420882 DOI: 10.1213/ane.0b013e31816b9478] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [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
Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful resuscitation of bupivacaine-induced cardiac arrest treated with i.v. lipid emulsion by providers who had recently participated in simulation training involving a scenario nearly identical to this case. Upon debriefing, it was determined that the previous training influenced execution of the following steps: rapid problem recognition, prompt initiation of specific therapy in the setting of supportive advanced cardiac life support measures, and coordinated team efforts. Although the true cause of efficient resuscitation and ultimate recovery cannot be proven, the efficiency of the resuscitation process, including timely administration of lipid emulsion, is evidence that simulation may be useful for training providers to manage rare emergencies.
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Affiliation(s)
- Hugh M Smith
- Department of Anesthesiology, Mayo Clinic College of Medicine 200 First Street SW, Rochester, MN 55905, USA
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Segura LG, Harris J, Wang B, Rienzo A, Urken ML, Brandwein M. Plexiform fibrohistiocytic tumor: a rare low-grade malignancy of children and young adults. Arch Otolaryngol Head Neck Surg 2002; 128:966-70. [PMID: 12162780 DOI: 10.1001/archotol.128.8.966] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Plexiform fibrohistiocytic tumor (PFT) is a low-grade, superficial, soft tissue neoplasm with a limited but significant ability to metastasize. This type of tumor only rarely presents in the skin of the head and neck. Clinicians first encountering young patients with facial neoplasia, such as a PFT, might be unaware of its exact oncologic potential and instead be primarily concerned with the cosmetic outcome. We treated a 17-year-old boy with a PFT on his cheek who was initially treated only by shave biopsy. The tumor subsequently recurred and metastasized to the cervical lymph nodes 3 years after the initial biopsy. Therefore, appropriate initial therapy for PFT requires complete excision with negative resection margins.
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Affiliation(s)
- Leal G Segura
- Department of Otolaryngology, Mount Sinai School of Medicine, New York, NY 10029-3136, USA
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da Cruz Borges RC, Pereira CB, Segura LG, Costa França LDC. [A nursing problem - insulin-induced lipodystrophy]. Rev Bras Enferm 1978; 31:252-8. [PMID: 395577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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