Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation

INTRODUCTION

Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion.

METHODS

Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018.

RESULTS

A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5-15), a weight of 32 kg (IQR, 16-55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6-14.9), and preoperative hematocrit of 40.4% (IQR, 37.2-44.3). Median CPB time was 81.5 min (IQR, 58-125), and median hematocrit coming off CPB was 26% (IQR, 23-29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001).

CONCLUSIONS

Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays.

Three-year experience with immediate extubation in pediatric patients after congenital cardiac surgery

Background

In pediatric cardiac anesthesiology, there is increased focus on minimizing morbidity, ensuring optimal functional status, and using health care resources sparingly. One aspect of care that has potential to affect all of the above is postoperative mechanical ventilation. Historically, postoperative ventilation was considered a must for maintaining patient stability. Ironically, it is recognized that mechanical ventilation may increase risk of adverse outcomes in the postoperative period. Hence, many institutions have advocated for immediate extubation or early extubation after many congenital heart surgeries which was first reported decades ago.

Methods

637 consecutive patient charts were reviewed for pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Patients were placed into three groups. Those that were extubated in the operating room (OR) at the conclusion of surgery (Immediate Extubation or IE), those that were extubated within six hours of admission to the ICU (Early Extubation or EE) and those that were extubated sometime after six hours (Delayed Extubation or DE). Multiple variables were then recorded to see which factors correlated with successful Immediate or Early Extubation.

Results

Overall, 338 patients (53.1%) had IE), 273 (42.8%) had DE while only 26 patients (4.1%) had EE. The median age was 1174 days for the IE patients, 39 days for the DE patients, whereas 194 days for EE patients (p < 0.001). Weight and length were also significantly different in at least one extubation group from the other two (p < 0.001). The median ICU LOS was 3 and 4 days for IE and EE patients respectively, whereas it was 9.5 days for DE patients (p < 0.001). DE group had a significant longer median anesthesia time and cardiopulmonary bypass time than the other two extubation groups (p > 63,826.88 < 0.001). Regional low flow perfusion, deep hypothermia, deep hypothermic circulatory arrest, redo sternotomy, use of other sedatives, furosemide, epinephrine, vasopressin, open chest, cardiopulmonary support, pulmonary edema, syndrome, as well as difficult intubation were significantly associated with delayed extubation (IE, EE or DE).

Conclusions

Immediate and early extubation was significantly associated with several factors, including patient age and size, duration of CPB, use of certain anesthetic drugs, and the amount of blood loss and blood replacement. IE can be successfully accomplished in a majority of pediatric patients undergoing surgery for congenital heart disease, including in a minority of infants.

Smart Graft Monitoring After the Fontan Operation

The Fontan operation for children with congenital heart disease places them in a physiological state of mildly elevated systemic venous pressure and low-normal cardiac output. Consequently, close follow-up is imperative, yet currently no method is available to obtain Fontan pressures without direct measurements in the cardiac catheterization laboratory while supine and sedated. We hypothesize that by suturing the CardioMEMS sensor device into the Fontan conduit during the standard Fontan operation for a child with single ventricular physiology, clinicians can accurately retrieve Fontan pathway pressure measurements noninvasively during normal physiological states.

Echocardiographic and Surgical Correlation of Coronary Artery Patterns in Transposition of the Great Arteries

OBJECTIVE

Determine the accuracy of echocardiography to diagnose coronary anatomy in transposition of the great arteries and to evaluate the effect of accuracy on surgical outcomes and changes in accuracy over time.

DESIGN

Retrospective chart review of neonates admitted February 1999 to March 2013 with transposition. Coronary pattern from the preoperative echocardiogram and operative reports were collected and compared with determine diagnostic accuracy. Coronary patterns were further confirmed by intraoperative images taken during surgery.

SETTING

Tertiary care children's hospital.

PATIENTS

Neonates with transposition of the great arteries and planned arterial switch operation with an echo and operative report or image describing the coronaries.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Accuracy of echocardiography to diagnose coronary anatomy in transposition, and to identify factors related to correct diagnosis.

RESULTS

One hundred forty-two patients met inclusion criteria with 122 correctly diagnosed, 16 incorrect, and 4 inconclusive. Accuracy was 86%, with 95% accuracy in patients with typical coronary patterns, 85% with the most common variant (left coronary from the leftward sinus and right and circumflex from the rightward sinus), and 61% with less common patterns. Typical and common variants were more likely to be correct than atypical patterns (P < .001). Cases with ventricular septal defect were more likely to have correctly diagnosed coronaries than with an intact ventricular septum (94% vs. 79%, P = .01). There was no change in accuracy over time (P > .05). There was no difference in duration of cardiopulmonary bypass, cross-clamp times, length of stay, or postoperative stay between the correct and incorrectly diagnosed groups (P > .05).

CONCLUSIONS

In our center, accuracy of echocardiographic imaging of the coronary arteries in transposition was 86% without improvement over time, and perioperative outcomes were not affected by diagnostic accuracy. Further invasive imaging may not be necessary to determine the coronary pattern in this lesion.

Web-based survey of current trends in hemodynamic monitoring after congenital heart surgery

Strategies for monitoring patients recovering after congenital heart surgery have evolved considerably as technology continues to progress. Monitoring techniques traditionally centered around the comprehensive physical examination have been replaced by a number of revolutionary technologies developed to objectively evaluate various components of the cardiovascular system. Despite scant evidence that these methodologies actually improve outcomes, some have been embraced by clinicians. We developed an Internet survey designed to describe current practices of clinicians who care for patients after congenital heart surgery. There were 162 respondents to our survey with the majority from the United States. The views of cardiologists, intensivists, those dual trained in both cardiology and critical care medicine, and surgeons are all robustly represented in the results. Serial lactate monitoring was the strategy that was utilized most often by respondents (94%), followed by multisite near-infrared spectrometry (NIRS, 67%). There were 78% who utilized the combination of serial lactate and NIRS monitoring. Serial lactate monitoring was the technique that was thought to best represent cardiovascular well-being after heart surgery (40%). The results of this survey suggest that despite the paucity of evidence that clinical outcomes of patients recovering after congenital heart surgery are improved by any of these monitoring techniques, there is almost universal acceptance to monitor patients with serial lactate monitoring, NIRS monitoring, or a combination of these techniques.

Comparison of point-of-care activated clotting time systems utilized in a single pediatric institution

This study compares four different activated clotting time (ACT) point-of-care (POC) testing systems used at our institution for the management of patients undergoing heparin therapy. We evaluated these systems under identical conditions to determine their accuracy, reproducibility, ease of use, and cost. Two separate testing stations containing four ACT systems were used. The testing order was randomized for every sample and performed by two trained individuals. Samples of fresh heparinized whole blood were taken at regular intervals and distributed to each station. Each operator tested 50 samples, totaling 400 ACT tests. The ACT value was significantly affected by the type of machine used at both stations 1 and 2 (p < .001). Compared with all systems, the Medtronic ACT Plus Automated Coagulation Timer System (ACT Plus) resulted in the most consistent ACT values (median = 171, Interquartile Range (IQR): 169-175) and least variability (172.17 +/- 5.24). The Hemochron Signature Elite Whole Blood Microcoagulation System had the most variability (221.10 +/- 14.78) and yielded consistently higher ACT values (median = 220, IQR: 210-229.5) compared with other systems. The ACT values reported by the i-STAT Handheld and Test Cartridge Blood Analysis System (153.30 +/- 7.87) were consistently lower (median = 154, IQR: 147-161) in comparison to the ACT Plus and Medtronic HMS Plus Hemostasis Management System (180.60 +/- 7.60, median = 181, IQR: 175-186). There was no statistical difference in results between the two testing sites (p > .05) or the operators (p > .05). The significant finding of this study was the affect each system has on the ACT value. This investigation demonstrates the variability that exists among different ACT monitoring systems at our institution. The discrepant variation in ACT values that exists with the Hemochron system questions the reliability of its use in the management of patients undergoing heparin therapy.

Urgent permanent pacemaker implantation in critically ill preterm infants

The management of complete heart block in premature low birth-weight infants, particularly those with hydrops fetalis, is challenging. We report emergent implantation of permanent epicardial pacemakers in the first 48 hours of life in two premature infants (one with hydrops fetalis) with birth weights of 1,400 grams and 1,000 grams.

Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery

AIM

To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery.

BACKGROUND

The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population.

METHODS/MATERIALS

Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation.

RESULTS

Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg x kg(-1) vs 0.2 mg x kg(-1), P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes.

CONCLUSIONS

A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg x kg(-1) x h(-1), a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold.

Frequency and indications for tracheostomy and gastrostomy after congenital heart surgery

Patients undergoing congenital heart surgery may occasionally require additional surgical procedures in the form of tracheostomy and gastrostomy. These procedures are often performed in an attempt to diminish hospital morbidity and length of stay. We reviewed the Web-based medical records of all patients undergoing congenital heart surgery at Miami Children's Hospital from February 2002 through August 2007. Patients who were deemed preterm and had undergone closure of a patent ductus arteriosis were eliminated. The records of all other patients were queried for the terms gastrostomy, g-tube, Nissan, fundal plication, tracheostomy, or tracheotomy. Patients' medical records in which these terms appeared in any portion were completely reviewed. There were 1660 congenital heart operations performed in the study period. There were 592 operations performed on patients whose age ranged from 1 month to 1 year and 441 neonatal operations. Mortality was 2%. Median postoperative stay was 8 days (range, 1-191 days), 12 days for neonates (range, 3-142 days), and 19 days for neonates undergoing RACHS-1 category 6 operations (range, 4-142 days). Tracheostomies were performed in four patients (0.2%). Gastrostomies were performed on eight patients (0.4%), representing 0.8% of patients <1 year of age, 1.4% of neonates, and 2.4% of patients undergoing RACHS-1 category 6 operations. The rate of patients undergoing either tracheostomy or gastrostomy after congenital heart surgery at our institution was quite low. Avoidance of either of these two procedures was achieved without increased morbidity or length of stay. The rate at which these procedures need to be performed may reflect the magnitude of the patients' lifetime trauma related to their underlying condition and acute and total surgical experiences.

Primary cardiac alveolar soft part sarcoma. A report of the first observed case with molecular diagnostics corroboration

A case of primary alveolar soft part sarcoma (ASPS) of the heart is reported in an 11-year-old female as 1 of 16 cases of ASPS presenting in the first 2 decades of life in our institutional 17-year review period. The classic alveolar or organoid pattern was inconspicuous as compared to a more diffuse or formless pattern consisting of a population of uniform round cells with abundant eosinophilic cytoplasm, but in addition there was a second, minor population of gigantiform tumor cells with a variety of unusual shapes. Scattered tumor cells contained dense eosinophilic condensations in the cytoplasm. Other unusual features for ASPS in our case included a lymphohistocytic reaction and zonal necrosis. Immunohistochemistry revealed nuclear reactivity for TFE3, and the ASPL-TFE3 fusion transcript was identified by reverse-transcriptase polymerase chain reaction. The only other examples of ASPS involving the heart were 3 cases in the literature of metastatic disease from tumors arising in the soft tissues. This initial case of primary cardiac ASPS joins the list of other types of sarcomas in children that have been reported as primary neoplasms of the heart.

Rapid Cardiopulmonary Support in Children With Heart Disease: A Nine-Year Experience

BACKGROUND

We developed a novel mechanical rapid cardiopulmonary support system (CPS) in 1996 to eliminate what we believed were shortcomings of conventional extracorporeal membrane oxygenation (ECMO) circuits when used in patients with congenital heart disease. We reviewed the use of this system over a nine year period to determine if we had been successful in improving results compared with ECMO and if outcomes have changed over this time.

METHODS

All children supported with CPS (110 procedures) were reviewed. Noncardiac CPS cases (7) were excluded. The study population was divided into two time periods (1995 to 2000 and 2001 to 2004), which correlate with significant differences in intraoperative, postoperative, and CPS management. Patients were further analyzed by age (< or = 30 days or > 30 days), repair complexity (risk adjusted classification for congenital heart surgery [RACHS]-1 category 6 or categories 1 to 5), and length of support.

RESULTS

Overall thirty day survival of cardiac CPS patients was 55% (57 of 103). Overall survival increased from 45% (23 of 51) during the first period to 65% (34 of 52) during the second period [p < or = 0.005]. Survival rates in neonates improved from 41% (11 of 27) to 56% (15 of 27) and RACHS-1 category 6 survival improved from 38% (5 of 13) to 69% (9 of 13), but neither change reached statistical significance. Intracranial hemorrhage occurred in 6.4% of all CPS patients.

CONCLUSIONS

Cardiopulmonary support is an effective alternative to ECMO for pediatric cardiac support. Further, our experience suggests that patient survival may be improved by CPS compared with reported results for ECMO in cardiac patients.

Complex Neonatal Single Ventricle Palliation Using Antegrade Cerebral Perfusion

BACKGROUND

The efficacy of antegrade cerebral perfusion (ACP) during complex neonatal single ventricle palliation requiring arch reconstruction is uncertain. We adapted the use of ACP in early 2001 in a programmatic effort to minimize the use of deep hypothermic circulatory arrest (DHCA).

METHODS

We retrospectively analyzed data of 126 consecutive patients operated on between 1995 and 2004, including stage-one palliation of hypoplastic left heart syndrome, stage-one palliation for nonhypoplastic left heart syndrome, and Damus-Kaye-Stansel procedures. Patients were divided into two groups: those repaired with prolonged DHCA only (n = 67) and those with ACP (n = 59) and usually a shorter period of DHCA. Risk was further stratified into high risk (weight < or = 2.5 kg or other cardiac lesion) and usual risk for each group.

RESULTS

Survival at 30 days in the usual-risk groups was 72.0% DHCA and 93.2% ACP (p < or = 0.025), and in the high-risk groups it was 61.5% DHCA and 80% ACP (not significant). One-year survival in the usual-risk groups was 57.4% DHCA and 84.1% ACP (p < or = 0.01), and in the high-risk groups it was 38.5% DHCA and 46.7% ACP (not significant). Overall survival to date is 52.2% DHCA and 71.2% ACP (p < or = 0.5).

CONCLUSIONS

There is a statistically significant survival advantage for usual-risk patients with the use of ACP. Although there is a trend to improved survival in the high-risk groups, it does not reach statistical significance and long-term outcomes in these patients remains disappointing. We continue to use ACP and believe it contributes to an overall survival advantage in our institution.

The "hinge-twist" technique for anomalous origin of the left coronary artery

A murmur was heard in an asymptomatic boy (age 4), and transthoracic echocardiography revealed anomalous origin of the left main coronary artery (LMCA) from the right sinus of Valsalva (age 6). Confirmed by catheterization and computed tomographic angiography (age 10), the LMCA followed a short interarterial course between the aorta and main pulmonary artery before supplying the anterior descending and circumflex coronary arteries. An intramural segment was not clearly seen. Results of stress testing were normal. Because sudden death was a concern, the patient underwent surgery at age 11. The "hinge-twist" technique was utilized in the absence of an intramural component or ostial stenosis in an effort to avoid the long-term complications of coronary reimplantation, ostial patching, or bypass grafting.

Patterns of Lactate Values after Congenital Heart Surgery and Timing of Cardiopulmonary Support

BACKGROUND

We sought to determine if postoperative serial lactate determinations follow predictable patterns that could be useful in directing management, especially the initiation of postoperative mechanical cardiopulmonary support (CPS).

METHODS

Eight patients undergoing CPS in a 2-year period and 147 patients not requiring postoperative CPS in 6 months of that period were stratified into 6 categories based on short-term risk for mortality (1 being the lowest risk). Lactate values for the first 48 hours postoperatively were retrospectively analyzed.

RESULTS

Survivors not requiring CPS in category 6 (n = 16) followed a distinct pattern different from those of categories 1 through 4 (n = 128). Review of postoperative CPS survivors (n = 4) indicated that CPS was initiated electively without cardiac arrest in all 4, and lactate values showed a downward trend within 12 hours of initiation in all cases (mean lactate, 10.12 +/- 1.88 mmol/L; range, 1.4 to 16 mmol/L; mean initiation time, 16.5 hours postoperatively). Three fourths of the CPS nonsurvivors suffered cardiac arrest before CPS and showed rising lactate values despite support (mean lactate, 11.95 +/- 1.37 mmol/L; range, 1.6 to 18.6 mmol/L; mean initiation time, 21.25 hours postoperatively). Indications for initiation of CPS in patients with elevated lactate values were reviewed. Two thirds of patients who died without CPS had preterminal cardiac arrest.

CONCLUSIONS

We have defined the normal pattern of postoperative lactate values in our institution. These data suggest that an abnormal lactate pattern may be useful in determining the timing of CPS initiation in hemodynamically stable patients with high or rising lactate values, before cardiac arrest or end organ damage.

Anesthetic Management of Conjoined Twins Presenting for Palliative Open-Heart Surgery

A set of dicephalous parapagus twins was born at 36 wk gestational age. Twin A had complex congenital heart disease in the form of a single ventricle that would be fatal without surgical intervention. Twin B had normal intracardiac anatomy. The twins were deemed surgically inseparable and the parents requested palliative open-heart surgery on Twin A. The twins shared a common circulatory system to the lower half of the body so that physiological manipulations in one twin adversely affected the other's hemodynamic condition. Twin A underwent successful single ventricle palliation; however, after a prolonged hospitalization, the infants died secondary to severe respiratory disease in Twin B.

Creating a database with cardioscopy and intra-operative imaging

The abilities for both computer technology, and intra-operative video-imaging, are evolving rapidly. The merger of these two sciences can be very beneficial, both to congenital cardiac surgeons in general, and in facilitating the creation of a cardioscopic database in particular.

Interventional catheterization performed in the early postoperative period after congenital heart surgery in children

OBJECTIVES

The purpose of this study was to examine the safety and efficacy of interventional catheterization performed early after congenital heart surgery.

BACKGROUND

Transcatheter interventions performed in the early postoperative period are viewed as high risk. To date, there have been limited published data regarding these procedures.

METHODS

All catheterizations performed within six weeks after congenital heart surgery between August 1995 and January 2001 were retrospectively reviewed. A cardiac anesthesiologist, cardiac intensivist, cardiac surgeon, and operating room team were available for all cases. Interventional procedures were performed based on clinical indications, regardless of the time elapsed from surgery.

RESULTS

Sixty-two patients, median age four months (2 days to 11 years), weight 4.7 kg (2.3 to 45 kg), underwent 66 catheterizations on median postoperative day 9 (0 to 42 days). Thirty-five cases involved 50 interventional procedures. Nine patients required extracorporeal cardiopulmonary support. Success rates by procedure were: angioplasty, 100%; stent implantation, 87%; vascular/septal occlusion, 100%; and palliative pulmonary valvotomy, 75%. Complications included stent migration (one patient), cerebral vascular injury (one patient), and left pulmonary artery stenosis (one patient). Thirty procedures involved angioplasty or stent implantation, including 26 involving a recently created suture line. Suture disruption or trans-mural vascular tears were not observed. There was no procedural mortality. Thirty-day survival for patients undergoing intervention was 83%.

CONCLUSIONS

Transcatheter interventions can be successfully performed in the early postoperative period. These procedures can have a positive impact on patient outcome; however, they should be performed only by a pediatric interventional cardiologist supported by a multi-disciplinary team.

Achieving resonance in a programme for congenital cardiac surgery

In 1995, Miami Children's Hospital recognized an institutional problem with its programme providing surgical treatment for congenital cardiac malformations. There was a high rate of mortality for neonatal surgery, and no patients had survived attempted first stage palliation for hypoplastic left heart syndrome. The hospital enlisted nationally recognized consultants in congenital cardiac surgery and cardiology to review the existing programme, and to make recommendations for improvement. Based on these recommendations, a new team was recruited. The recruits were a young attending surgeon, an interventional cardiologist, and a cardiac intensivist, attracted from recognized centers of excellence in Boston and Toronto.

The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery and interventional cardiology coil occlusion

BACKGROUND

In an effort to analyze our experience and develop treatment guidelines, we reviewed all our patients with patent ductus arteriosus (PDA) treated with video-assisted thoracoscopic surgery (VATS) or interventional cardiology coil occlusion.

METHODS

One hundred patients underwent 102 cardiac catheterizations. Forty-five children underwent VATS. The entire cohort of patients is 141 because 4 patients underwent both catheterization and VATS.

RESULTS

Successful PDA coil occlusion occurred in 91 patients (91 of 100; 91%); 8 had unsuccessful attempts at coil occlusion and 1 was referred for surgical ligation after catheterization without any attempt at coil placement. Thirty-nine children had successful VATS PDA closure. Six children required conversion to thoracotomy because of inadequate exposure during VATS. Hospital stay for children more than 45 days of age was as follows: VATS median stay, 1 day, mean, 1.4 days; thoracotomy median stay, 4 days, mean, 4.6 days. One patient treated with PDA coil occlusion developed a recurrent PDA and required reembolization. Three children underwent initial catheterization without successful coil placement with subsequent successful VATS. All VATS patients left the operating theater with echocardiography documenting no residual PDA. Two children who underwent successful VATS with no residual PDA at hospital discharge were found on outpatient follow-up to have developed tiny recurrent PDAs and both were successfully coil occluded; 1 of these 2 children is 1 of the 3 children initially evaluated by catheterization and then referred for VATS.

CONCLUSIONS

Video-assisted thoracoscopic surgery and coil occlusion represent complementary techniques for PDA treatment. A rationale for selection of the appropriate treatment modality can be based upon the size and age of the patient and the size and morphology of the PDA.

The fenestrated Kawashima operation for single ventricle with interrupted inferior vena cava

An 8-month-old boy with double outlet right ventricle with hypoplastic left ventricle, heterotaxy, left atrial isomerism, bilateral superior vena cavae without bridging vein, and interruption of the inferior vena cava with azygous continuation to the left superior cava underwent a bilateral bidirectional cavopulmonary anastomosis. A calibrated 3-mm connection between the right pulmonary artery and the common atrium was constructed with the proximal right superior vena cava to allow right to left shunting, analogous to a fenestration in a Fontan operation. We hypothesize that in small young patients undergoing the Kawashima operation a fenestration may improve postoperative hemodynamics.

Reducing the trauma of congenital heart surgery

Techniques to reduce surgical trauma for congenital heart repairs continue to evolve in tandem with advances in the more conventional protection strategies. The concept of chest wall protection has been increasingly accepted as an important standard for congenital heart surgeons, as long as neuroprotection, myocardial protection, and operative precision are not adversely affected. Unfortunately, it is difficult to measure chest wall trauma, making it difficult to evaluate the efficacy of minimally invasive techniques. Efforts to reduce surgical trauma are advancing on multiple fronts. Many extracardiac repairs are being performed thoracoscopically, with excellent results. Intracardiac procedures can be performed through smaller incisions. Full sternotomy is giving way to a variety of sternal-sparing incisions for open-heart repairs, usually using direct visualization. Operative strategies to avoid or minimize the effects of cardiopulmonary bypass have emerged. And recently, hybrid procedures, utilizing a combination of transcatheter and minimally invasive techniques, are creating new therapeutic options for the congenital heart team.

Video-assisted endoscopy for congenital heart repair

Endoscopic imaging techniques can be used to enhance visualization of and access to remote intracardiac structures to improve congenital heart repairs. Database storage of these images builds a foundation for retrospective analysis of surgical failures and clinical correlations with other imaging techniques. The images also function as an educational tool for patients, families, and the cardiac team. Combining cardiac endoscopic imaging with interventional catheterization techniques has created a group of hybrid procedures, extending the capabilities of both the surgeon and the interventional cardiologist. This synergy has the potential to decrease therapeutic trauma.

Anomalous origin of innominate artery from right pulmonary artery in DiGeorge Syndrome

We experienced a case of anomalous origin of innominate artery from right pulmonary artery (isolated innominate artery). This patient was a 2-month-old baby girl weighing 3.2 kg with DiGeorge syndrome, who was diagnosed with perimembranous ventricular septal defect, atrial septal defect, and patent ductus arteriosus. This type of anomaly is exceedingly rare.

Assisted venous drainage cardiopulmonary bypass in congenital heart surgery

BACKGROUND

A novel active venous drainage perfusion circuit was designed to achieve effective venous return through small venous cannulas. The efficacy and safety of this new system was investigated and compared with a conventional gravity drainage system.

METHODS

Four hundred consecutive patients undergoing open heart repair of congenital heart lesions by one surgeon were studied. The first 200 patients were supported by gravity drainage and the next 200 patients were supported by assisted venous drainage. No patient in the time period was excluded from the study.

RESULTS

The two groups did not differ significantly in weight, bypass time, or cross-clamp time. Priming volumes were less in the assisted group than in the gravity group (576+/-232 mL versus 693+/-221 mL, p < 0.001). Venous cannula size was smaller in the assisted group when compared with the gravity group (33.2F+/-7.4F versus 38.5F+/-7.1F, p < 0.001). There was a trend to lower operative mortality in the assisted drainage group (5 of 200, 2.5% versus 11 of 200, 5.5%; p = 0.10). Hospital stay and pulmonary, infectious, and neurologic complications were comparable in both groups. Cardiac complications were less common in the assisted group than in gravity group (22 of 200, 11% versus 38 of 200, 19%; p = 0.017). Hematologic complications were less common in the assisted group than the gravity group (6 of 200, 3% versus 19 of 200, 9.5%; p < 0.01).

CONCLUSIONS

These findings suggest that assisted venous drainage is safe in congenital heart operations and facilitates the use of smaller venous cannulas.

Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm

A 5-year-old girl with pulmonary atresia, ventricular septal defect, hypoplastic pulmonary arteries, and multiple pulmonary artery reconstructive procedures presented with an enlarging pulmonary artery pseudoaneurysm. A previous attempt to occlude the aneurysm was unsuccessful and the aneurysm continued to enlarge. We describe the percutaneous placement of an endovascular stent graft to occlude the aneurysm. This novel use of a covered graft effectively treated a potentially lethal problem without reoperative thoracotomy or sternotomy.

Reducing the trauma of congenital heart surgery

While describing the circulatory system in De Moto Cordis, in 1628, William Harvey developed precepts for investigation, which could be modified slightly to guide the adoption of new technology and technique in the twenty-first century. Harvey might suggest (1) careful and accurate observation and description of a new technique, (2) a tentative explanation of how the technique improves on existing techniques, (3) a controlled testing of the hypothesis, and (4) conclusions based on the results of the experiments. Also, he might admonish surgery today, with its massively enhanced capabilities for information management, to rigorously test the validity of these conclusions with quantitative reasoning. In the future, precise measurement of the "trauma" of surgery, or even an individual surgeon, may be possible, and the long-term impact of a chest wall incision on a patient's self-esteem may be predictable. Absent such objective measures, justifications for "minimally invasive" deviations from conventional technique in surgery for CHD lack substance. Morbidity, mortality, and physiological endpoints will continue to form the foundation for therapeutic plans; however, the potential for emerging technology to reduce the trauma of these plans remains tantalizing.

Outcome of cardiopulmonary resuscitation in a pediatric cardiac intensive care unit

OBJECTIVE

To determine the eventual outcome of children with heart disease who had cardiopulmonary resuscitation (CPR) in a specialized pediatric cardiac intensive care unit (CICU), and to define the influence of any prearrest variables on the outcome.

DESIGN

A retrospective review of patients' medical records.

SETTING

A pediatric CICU of a tertiary pediatric teaching hospital.

PATIENTS AND METHODS

Patients were all children who presented with cardiopulmonary arrest and who were administered CPR in the pediatric CICU between June 1995 and June 1997. Prearrest variables such as age, diagnosis, prior cardiac surgery, and inotropic support with epinephrine, as well as cause of arrest, were evaluated.

MEASUREMENTS AND MAIN RESULTS

Thirty-two patients, ranging in age from 1 day to 21 yrs (median, 1 month), satisfied criteria for inclusion in the study group. These 32 patients had a total of 38 episodes of cardiopulmonary arrest. Twenty-five of these patients (78%) had cardiac surgery before arrest. Inotropic support with continuous infusion of epinephrine was being administered at the time of arrest in 18 of 38 (47%) arrests. These prearrest variables did not influence outcome of CPR. Of the 38 episodes of CPR, 24 episodes (63%) were successful, with 20 episodes resulting in return of spontaneous circulation and four patients being successfully placed on mechanical cardiopulmonary support. Fourteen children, including all four patients who were rescued with mechanical cardiopulmonary support, survived to discharge. At 6-month follow-up, 11 patients were still alive, with three having neurologic impairment.

CONCLUSIONS

After cardiopulmonary resuscitation in this pediatric CICU, the rate of success was 63% and the rate of survival was 42%. Prior cardiac surgery and use of epinephrine before arrest did not influence the outcome of CPR. The availability of effective mechanical cardiopulmonary support can improve the outcome of CPR.

Rapid cardiopulmonary support for children with complex congenital heart disease

BACKGROUND

Extracorporeal membrane oxygenation has limitations in children with congenital heart disease (prolonged setup times, increased postoperative blood loss, and difficulty during transport). We developed a miniaturized cardiopulmonary support circuit to address these limitations.

PATIENTS AND METHODS

The cardiopulmonary support system includes a preassembled, completely heparin-coated circuit, a BP-50 Bio-Medicus centrifugal pump, a Minimax plus membrane oxygenator, a Bio-Medicus flow probe, and a Bio-trend hematocrit/oxygen saturation monitor. Short tubing length permits a 250-mL bloodless prime in less than 5 minutes. From 1995 to 1997, 23 children with congenital heart disease were supported with this technique.

RESULTS

Overall survival to discharge was 48% (11 of 23 patients). Survival to discharge was 80% (4 of 5) in the preoperative support group, 20% (1 of 5) in the postoperative failure to wean from cardiopulmonary bypass group, 44% (4 of 9) in the group placed on support postoperatively after transfer to the intensive care unit, and 50% (2 of 4 patients) in the nonoperative group. Neonatal cardiopulmonary support survival to discharge was 46% (6 of 13 patients).

CONCLUSIONS

This pediatric cardiopulmonary support system is safe and effective. Advantages over conventional extracorporeal membrane oxygenation include rapid setup time, decreased postoperative blood loss, and simplified transport.

Video-assisted cardioscopy for intraventricular repair in congenital heart disease

BACKGROUND

Video-assisted thoracoscopic surgical techniques have been widely adopted as a means to reduce surgical trauma. By adapting pediatric thoracoscopic instrumentation, we have developed a technique for video-assisted cardioscopy (VAC). We report our experience and describe the technical feasibility of VAC.

METHODS

Since June 1995, 409 consecutive patients underwent 431 intracardiac procedures (ventricular septal defect, 150; tetralogy of Fallot or double outlet right ventricle, 101; atrioventricular canal, 52; subaortic stenosis, 43; valve repair, 50; Rastelli procedure, 12; Konno or Ross Konno operation, 11; and miscellaneous, 12) using VAC at Miami Children's Hospital. Using a prospective database, we tracked outcomes and operative events to delineate the usefulness and efficacy of this technique.

RESULTS

VAC provided clear and precise imaging of small or remote intracardiac structures during repair of congenital heart defects without technical complications. Procedure times and aortic cross-clamp times using VAC were not prolonged. Intraoperative images were collected for every operation, documenting each patient's cardiac anatomy before and after repair. Surgery through small incisions was facilitated. Operative mortality was 1.2% (5 of 409), and no patient required reoperation before discharge. At a mean follow-up interval of 22 months, the incidence of reoperation for residual or recurrent lesions was 1.2% (5 of 404).

CONCLUSIONS

Our experience demonstrates the technical feasibility and clinical utility of routine endoscopic imaging during open heart surgery for congenital heart repair.

Heparin-coated cardiopulmonary bypass circuit: clinical effects in pediatric cardiac surgery

OBJECTIVES

Heparin-coated cardiopulmonary bypass (CPB) circuits have been reported to reduce complement activation and the inflammatory response associated with CPB. We retrospectively compared patients utilizing heparin-coated perfusion circuits with those using noncoated circuits to determine the clinical effects of the different circuits in pediatric cardiac surgery.

METHODS

Between July 1995 and July 1997, 203 patients weighing < 10 kg underwent cardiac surgery, 153 patients using heparin-coated bypass circuits and 50 patients using noncoated circuits. The 50 patients operated on with the noncoated circuit (Group N) were matched to 100 patients operated on with coated circuits (Group H) in age, weight, and type of procedure. Urine output during bypass, blood products used after bypass, postoperative ventilation days, hospital stay, morbidity, and mortality were compared between these groups.

RESULTS

Body weight, perfusion time, and procedure time were not different between the two groups. Urine output during bypass was notably greater in Group H than in Group N (11.3 +/- 10.5 mL/kg per hour vs 4.8 +/- 3.1 mL/kg per hour, respectively, p < 0.0001). Postoperative mechanical ventilation markedly decreased in Group H (Group H vs N = 2.8 +/- 2.7 days vs 5.1 +/- 7.5 days, respectively, p < 0.05). Red blood cell usage, hospital stay, morbidity, and mortality were not statistically different, although there was a tendency toward decreased transfusion of red cell and platelets in Group H (Group H vs N = 61.2 +/- 121.1 mL/kg vs 102.0 +/- 176.7 mL/kg, respectively, in red cell, p = 0.15; and Group H vs N = 7.9 +/- 13.7 mL/kg vs 13.2 +/- 24.5 mL/kg, respectively, in platelets, p = 0.16).

CONCLUSIONS

Patients operated on with the use of heparin-coated circuits had increased urine output during bypass and required less time postoperatively on the ventilator. These results suggest a reduction in the acute inflammatory response, capillary leakage, and overall systemic edema. We now routinely use coated circuits on all pediatric pump cases.

Minimally invasive resection of congenital subaortic stenosis

Fifteen consecutive patients with membranous subaortic stenosis underwent resection by a minimal-access approach through a partial upper sternotomy using a cardioscope. There were no operative deaths and no postoperative complications. Twelve patients (80%) were extubated in the operating room. The mean hospital stay was 3.1 days, and 3 patients (20%) needed blood products. Our experience demonstrates that this modified approach is a safe and effective surgical option for resection of subaortic stenosis.

Congenital Heart Surgery Nomenclature and Database Project: atrial septal defect

The extant nomenclature for atrial septal defect (ASD) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: aortopulmonary window

The extant nomenclature for aortopulmonary window (AP window) and pulmonary artery origin from ascending aorta (hemitruncus) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: ventricular septal defect

The extant nomenclature for ventricular septal defect (VSD) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Four basic VSD types are described: Subarterial, Perimembranous, Inlet, and Muscular. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analysis. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: atrioventricular canal defect

The extant nomenclature for atrioventricular (AV) canal/atrioventricular septal defect is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. The three general categories are: partial AV canal (ostium primum defect), transitional (intermediate) AV canal, and complete AV canal. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

The Ross operation in a Jehovah's Witness: a paradigm for heart surgery in children without transfusion

A 3-year-old 18 kg male child of the Jehovah's Witness faith presented with severe aortic regurgitation. A successful Ross procedure was performed using a pulmonary autograft, without the use of blood or blood product transfusion. Blood conservation strategy included: (1) preoperative treatment with recombinant human erythropoietin; (2) intraoperative strategies, including technical modifications to the Ross procedure, and the prophylactic use of fibrin glue; (3) utilization of a heparin-bonded cardiopulmonary bypass circuit and assisted venous drainage; and 4) the use of prebypass phlebotomy, cell-saving device and autotransfusion. The patient was discharged home on postoperative day 7 with a hemoglobin level of 11.9.

Tracheal allograft reconstruction: the total North American and worldwide pediatric experiences

BACKGROUND

We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis.

METHODS

The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction.

RESULTS

In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy.

CONCLUSIONS

Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.

Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has been assuming an expanded role in the management of cardiothoracic disease. As instrumentation and experience increase, VATS is being applied to treat smaller patients. We report our experience with 34 low birth weight infants undergoing VATS interruption of patent ductus arteriosus (PDA).

METHODS

VATS allows PDA interruption without the muscle cutting or rib spreading of a standard thoracotomy. Four small, 3-mm incisions are made along the line of a potential thoracotomy incision. Ports placed through these incisions admit endoscopic instruments, a camera, and a vascular clip applier.

RESULTS

Median age at surgery was 15.5 days (range: 1-44 days). Median weight at surgery was 930 g (range: 575-2500 g). Twenty patients weighed <1 kg, and 13 weighed <750 g. All patients had congestive heart failure and had either failed indomethacin therapy or had contraindications to indomethacin. Median surgical time was 60 minutes (range: 31-171 minutes). Echocardiography documented elimination of ductal flow in all patients. Operative mortality was zero. Four patients (4/34 = 12%) required conversion to open thoracotomy: 1 because of difficult exposure, 1 because of pulmonary dysfunction and anasarca, 1 because of a large 1-cm duct, and 1 because of coagulopathy and poor pulmonary compliance. Two patients died before discharge: 1 patient (surgical weight: 605 g) died on postoperative day 2 because of intracranial hemorrhage, and 1 patient (surgical weight: 1725 g) died on postoperative day 88 because of multiple system organ failure. Follow-up has demonstrated no PDA murmur in any patient, but echocardiography revealed trace ductal flow in 2 patients.

CONCLUSIONS

VATS offers a minimally traumatic, safe, and effective technique for PDA interruption in low birth weight neonates and infants.

Adverse hemodynamic effects observed with inhaled nitric oxide after surgical repair of total anomalous pulmonary venous return

The following is a case report of a 1-month-old patient who developed adverse hemodynamic sequelae during the use of nitric oxide (NO) in the postoperative period for pulmonary hypertension after correction of total anomalous pulmonary venous return. At the time of diagnosis, the patient had evidence of systemic right ventricular pressures estimated by continuous-wave Doppler. He was sedated and paralyzed for hyperventilation in preparation for surgery and underwent pulmonary vein confluence to left atrial anastomosis. Postoperative pulmonary hypertension was managed by hyperventilation, sedation, and paralysis until a sudden onset of systemic-level pulmonary pressure required NO therapy. Satisfactory results were obtained in minutes, but a rebound pulmonary hypertension occurred with concomitant systemic hypertension and no radiographic changes. We suspected left atrial hypertension secondary to a sudden increase in pulmonary blood flow to an noncompliant left ventricle. Discontinuation of NO resulted in stabilization of the hemodynamic profile of the patient and he continued to be managed with paralysis, hyperventilation, and sedation. Based on this experience we suggest that NO should be used with caution in patients with obstructive lesions at the atrial level prior to surgery (mitral valve stenosis and cor triatriatum) or in patients with a poorly compliant left ventricle (cardiomyopathy and left ventricular dysfunction). These entities are unable to tolerate a sudden increase in pulmonary blood return thus creating paradoxical pulmonary hypertension.

Minimally invasive pediatric cardiac surgery

Minimally invasive cardiac surgery has evolved in response to the intrinsic irony facing cardiac surgeons: that we must injure our patients to treat them. In recent years, advances in fiberoptic imaging technology, applied to other surgical specialties, suggested the possibility that cardiac surgery might also be performed endoscopically. The anatomic and spatial constraints of pediatric cardiac surgery, and its dependence on extreme levels of speed, precision, and three-dimensional perception, made the application of remote, two-dimensional operating systems seem impossible, or at least imprudent in this special group of patients. Despite these limitations, however, applications of video-assisted endoscopic surgical techniques have been demonstrated to allow the safe and effective performance of an expanding range of operative procedures in congenital heart surgery. The guided development of new technology will accelerate this process in the coming years.

Minimally invasive pediatric cardiac surgery

Minimally invasive cardiac surgery has evolved in response to the intrinsic irony facing cardiac surgeons: that we must injure our patients to treat them. In recent years, advances in fiberoptic imaging technology, applied to other surgical specialties, suggested the possibility that cardiac surgery might also be performed endoscopically. The anatomic and spatial constraints of pediatric cardiac surgery, and its dependence on extreme levels of speed, precision, and three-dimensional perception, made the application of remote, two-dimensional operating systems seem impossible, or at least imprudent in this special group of patients. Despite these limitations, however, applications of video-assisted endoscopic surgical techniques have been demonstrated to allow the safe and effective performance of an expanding range of operative procedures in congenital heart surgery. The guided development of new technology will accelerate this process in the coming years.

Video-assisted cardioscopy for left ventricular thrombectomy in a child

Left ventricular thrombus is a complication of myocardial infarction, ventricular aneurysm, cardiomyopathy, and myocarditis. Left ventriculotomy has been the standard approach for removal of left ventricular thrombus. This approach has produced an unacceptable incidence of ventricular dysfunction, arrhythmias, and aneurysm formation. We describe a case of left ventricular thrombus with systemic embolization in a patient with myocarditis. Video-assisted cardioscopy allowed visualization and removal of the thrombus via an aortotomy, thereby avoiding a left ventriculotomy.