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Groody KR, Nicolson SC, Jobes DR. Anesthetic challenges in patients with multicompartmental lymphatic failure after Fontan palliation undergoing transcatheter thoracic duct decompression. Paediatr Anaesth 2024. [PMID: 38651655 DOI: 10.1111/pan.14891] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/25/2024]
Abstract
Lymphatic flow abnormalities are central to the development of protein losing enteropathy, plastic bronchitis, ascites and pleural effusions in patients palliated to the Fontan circulation. These complications can occur in isolation or multicompartmental (two or more). The treatment of multicompartmental lymphatic failure aims at improving thoracic duct drainage. Re-routing the innominate vein to the pulmonary venous atrium decompresses the thoracic duct, as atrial pressure is lower than systemic venous pressure in Fontan circulation. Transcatheter thoracic duct decompression is a new minimally invasive procedure that involves placing covered stents from the innominate vein to the atrium. Patients undergoing this procedure require multiple general anesthetics, presenting challenges in managing the sequelae of disordered lymphatic flow superimposed on Fontan physiology. We reviewed the first 20 patients at the Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for transcatheter thoracic duct decompression between March 2018 and February 2023. The patients ranged in age from 3 to 26 years. The majority had failed prior catheter-based lymphatic intervention, including selective embolization of abnormal lympho-intestinal and lympho-bronchial connections to treat lymphatic failure in a single compartment. Fourteen had failure in three lymphatic compartments. Patients were functionally impaired (ASA 3-5) with significant comorbidities. Concurrent with thoracic duct decompression, three patients required fenestration closure for the resultant decrease in oxygen saturation. Ten patients had improvement in symptoms, seven had no changes and three have limited follow up. Five (25%) of these patients were deceased as of January 2024 due to non-lymphatic complications from Fontan failure.
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Affiliation(s)
- Kirsten R Groody
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology, Division of Pediatric Anesthesiology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David R Jobes
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Jolley MA, Sulentic A, Amin S, Gupta M, Ching S, Cianciulli A, Wang Y, Sabin P, Zelonis C, Daemer M, Silvestro E, Coleman K, Ford LK, Edelson JB, Ruckdeschel ES, Cohen MS, Nicolson SC, Gillespie MJ. Introduction of transcatheter edge-to-edge repair in patients with congenital heart disease at a children's hospital. Catheter Cardiovasc Interv 2024; 103:326-334. [PMID: 38149722 PMCID: PMC10911413 DOI: 10.1002/ccd.30935] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/19/2023] [Accepted: 12/03/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Atrioventricular valve regurgitation (AVVR) is a devastating complication in children and young adults with congenital heart disease (CHD), particularly in patients with single ventricle physiology. Transcatheter edge-to-edge repair (TEER) is a rapidly expanding, minimally invasive option for the treatment of AVVR in adults that avoids the morbidity and mortality associated with open heart surgery. However, application of TEER in in CHD and in children is quite novel. We describe the development of a peri-procedural protocol including image-derived pre-intervention simulation, with successful application to four patients. AIMS To describe the initial experience using the MitraClip system for TEER of dysfunctional systemic atrioventricular valves in patients with congential heart disease within a pediatric hospital. METHODS A standardized screening and planning process was developed using cardiac magnetic resonance imaging, three dimensional echocardiography and both virtual and physical simulation. Procedures were performed using the MitraClip G4 system and patients were clinically followed post-intervention. RESULTS A series of four CHD patients with at least severe AVVR were screened for suitability for TEER with the MitraClip system: three patients had single ventricle physiology and Fontan palliation, and one had repair of a common atrioventricular canal defect. Each patient had at least severe systemic AVVR and was considered at prohibitively high risk for surgical repair. Each patient underwent a standardized preprocedural screening protocol and image-derived modeling followed by the TEER procedure with successful clip placement at the intended location in all cases. CONCLUSIONS The early results of our protocolized efforts to introduce TEER repair of severe AV valve regurgitation with MitraClip into the CHD population within our institution are encouraging. Further investigations of the use of TEER in this challenging population are warranted.
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Affiliation(s)
- Matthew A. Jolley
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Analise Sulentic
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Silvani Amin
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Mudit Gupta
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Stephen Ching
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alana Cianciulli
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Yan Wang
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Patricia Sabin
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher Zelonis
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew Daemer
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Silvestro
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Keith Coleman
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lauren K. Ford
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jonathan B. Edelson
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Meryl S. Cohen
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Susan C. Nicolson
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
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Laurent GH, Ko TS, Mensah-Brown KG, Mavroudis CD, Jacobwitz M, Ranieri N, Nicolson SC, Gaynor JW, Baker WB, Licht DJ, Massey SL, Lynch JM. Electroencephalography as a tool to predict cerebral oxygen metabolism during deep-hypothermic circulatory arrest in neonates with critical congenital heart disease. JTCVS Open 2023; 16:801-809. [PMID: 38204663 PMCID: PMC10774939 DOI: 10.1016/j.xjon.2023.08.004] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 01/12/2024]
Abstract
Objectives Recent research suggests that increased cerebral oxygen use during surgical intervention for neonates with congenital heart disease may play a role in the development of postoperative white matter injury. The objective of this study is to determine whether increased cerebral electrical activity correlates with greater decrease of cerebral oxygen saturation during deep hypothermic circulatory arrest. Methods Neonates with critical congenital heart disease requiring surgical intervention during the first week of life were studied. All subjects had continuous neuromonitoring with electroencephalography and an optical probe (to quantify cerebral oxygen saturation) during cardiac surgical repair that involved the use of cardiopulmonary bypass and deep hypothermic circulatory arrest. A simple linear regression was used to investigate the association between electroencephalography metrics before the deep hypothermic circulatory arrest period and the change in cerebral oxygen saturation during the deep hypothermic circulatory arrest period. Results Sixteen neonates had both neuromonitoring modalities attached during surgical repair. Cerebral oxygen saturation data from 5 subjects were excluded due to poor data quality, yielding a total sample of 11 neonates. A simple linear regression model found that the presence of electroencephalography activity at the end of cooling is positively associated with the decrease in cerebral oxygen saturation that occurs during deep hypothermic circulatory arrest (P < .05). Conclusions Electroencephalography characteristics within 5 minutes before the initiation of deep hypothermic circulatory arrest may be useful in predicting the decrease in cerebral oxygen saturation that occurs during deep hypothermic circulatory arrest. Electroencephalography may be an important tool for guiding cooling and the initiation of circulatory arrest to potentially decrease the prevalence of new white matter injury in neonates with critical congenital heart disease.
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Affiliation(s)
- Gerard H. Laurent
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Tiffany S. Ko
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | | | - Marin Jacobwitz
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Nicolina Ranieri
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Wesley B. Baker
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J. Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Shavonne L. Massey
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jennifer M. Lynch
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
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Shaw K, Mavroudis CD, Ko TS, Jahnavi J, Jacobwitz M, Ranieri N, Forti RM, Melchior RW, Baker WB, Yodh AG, Licht DJ, Nicolson SC, Lynch JM. The use of novel diffuse optical spectroscopies for improved neuromonitoring during neonatal cardiac surgery requiring antegrade cerebral perfusion. Front Pediatr 2023; 11:1125985. [PMID: 37425272 PMCID: PMC10327557 DOI: 10.3389/fped.2023.1125985] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/01/2023] [Indexed: 07/11/2023] Open
Abstract
Background Surgical procedures involving the aortic arch present unique challenges to maintaining cerebral perfusion, and optimal neuroprotective strategies to prevent neurological injury during such high-risk procedures are not completely understood. The use of antegrade cerebral perfusion (ACP) has gained favor as a neuroprotective strategy over deep hypothermic circulatory arrest (DHCA) due to the ability to selectively perfuse the brain. Despite this theoretical advantage over DHCA, there has not been conclusive evidence that ACP is superior to DHCA. One potential reason for this is the incomplete understanding of ideal ACP flow rates to prevent both ischemia from underflowing and hyperemia and cerebral edema from overflowing. Critically, there are no continuous, noninvasive measurements of cerebral blood flow (CBF) and cerebral oxygenation (StO2) to guide ACP flow rates and help develop standard clinical practices. The purpose of this study is to demonstrate the feasibility of using noninvasive, diffuse optical spectroscopy measurements of CBF and cerebral oxygenation during the conduct of ACP in human neonates undergoing the Norwood procedure. Methods Four neonates prenatally diagnosed with hypoplastic left heart syndrome (HLHS) or a similar variant underwent the Norwood procedure with continuous intraoperative monitoring of CBF and cerebral oxygen saturation (StO2) using two non-invasive optical techniques, namely diffuse correlation spectroscopy (DCS) and frequency-domain diffuse optical spectroscopy (FD-DOS). Changes in CBF and StO2 due to ACP were calculated by comparing these parameters during a stable 5 min period of ACP to the last 5 min of full-body CPB immediately prior to ACP initiation. Flow rates for ACP were left to the discretion of the surgeon and ranged from 30 to 50 ml/kg/min, and all subjects were cooled to 18°C prior to initiation of ACP. Results During ACP, the continuous optical monitoring demonstrated a median (IQR) percent change in CBF of -43.4% (38.6) and a median (IQR) absolute change in StO2 of -3.6% (12.3) compared to a baseline period during full-body cardiopulmonary bypass (CPB). The four subjects demonstrated varying responses in StO2 due to ACP. ACP flow rates of 30 and 40 ml/kg/min (n = 3) were associated with decreased CBF during ACP compared to full-body CPB. Conversely, one subject with a higher flow6Di rate of 50 ml/kg/min demonstrated increased CBF and StO2 during ACP. Conclusions This feasibility study demonstrates that novel diffuse optical technologies can be utilized for improved neuromonitoring in neonates undergoing cardiac surgery where ACP is utilized. Future studies are needed to correlate these findings with neurological outcomes to inform best practices during ACP in these high-risk neonates.
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Affiliation(s)
- Kalil Shaw
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Tiffany S. Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jharna Jahnavi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Marin Jacobwitz
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicolina Ranieri
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Rodrigo M. Forti
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Richard W. Melchior
- Department of Perfusion Services, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Wesley B. Baker
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Arjun G. Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel J. Licht
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jennifer M. Lynch
- Division of Cardiothoracic Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Licht DJ, Jacobwitz M, Lynch JM, Ko T, Boorady T, Devarajan M, Heye KN, Mensah‐Brown K, Newland JJ, Schmidt A, Schwab P, Winters M, Nicolson SC, Montenegro LM, Fuller S, Mascio C, Gaynor JW, Yodh AG, Gebb J, Vossough A, Choi GH, Putt ME. Impaired Maternal-Fetal Environment and Risk for Preoperative Focal White Matter Injury in Neonates With Complex Congenital Heart Disease. J Am Heart Assoc 2023; 12:e025516. [PMID: 36974759 PMCID: PMC10122900 DOI: 10.1161/jaha.122.025516] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 01/24/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
Background Infants with congenital heart disease (CHD) are at risk for white matter injury (WMI) before neonatal heart surgery. Better knowledge of the causes of preoperative WMI may provide insights into interventions that improve neurodevelopmental outcomes in these patients. Methods and Results A prospective single-center study of preoperative WMI in neonates with CHD recorded data on primary cardiac diagnosis, maternal-fetal environment (MFE), delivery type, subject anthropometrics, and preoperative care. Total maturation score and WMI were assessed, and stepwise logistic regression modeling selected risk factors for WMI. Among subjects with severe CHD (n=183) who received a preoperative brain magnetic resonance imaging, WMI occurred in 40 (21.9%) patients. WMI prevalence (21.4%-22.1%) and mean volumes (119.7-160.4 mm3) were similar across CHD diagnoses. Stepwise logistic regression selected impaired MFE (odds ratio [OR], 2.85 [95% CI, 1.29-6.30]), male sex (OR, 2.27 [95% CI, 1.03-5.36]), and older age at surgery/magnetic resonance imaging (OR, 1.20 per day [95% CI, 1.03-1.41]) as risk factors for preoperative WMI and higher total maturation score values (OR, 0.65 per unit increase [95% CI, 0.43-0.95]) as protective. A quarter (24.6%; n=45) of subjects had ≥1 components of impaired MFE (gestational diabetes [n=12; 6.6%], gestational hypertension [n=11; 6.0%], preeclampsia [n=2; 1.1%], tobacco use [n=9; 4.9%], hypothyroidism [n=6; 3.3%], and other [n=16; 8.7%]). In a subset of 138 subjects, an exploratory analysis of additional MFE-related factors disclosed other potential risk factors for WMI. Conclusions This study is the first to identify impaired MFE as an important risk factor for preoperative WMI. Vulnerability to preoperative WMI was shared across CHD diagnoses.
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Affiliation(s)
- Daniel J. Licht
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Marin Jacobwitz
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Jennifer M. Lynch
- Department of Anesthesia and Critical Care, Division of Cardiac AnesthesiaThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Tiffany Ko
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Timothy Boorady
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Mahima Devarajan
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Kristina N. Heye
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Kobina Mensah‐Brown
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - John J. Newland
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Alexander Schmidt
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Peter Schwab
- Department of NeurologyThe University of PennsylvaniaPennsylvaniaPA
| | - Madeline Winters
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Susan C. Nicolson
- Department of Anesthesia and Critical Care, Division of Cardiac AnesthesiaThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Lisa M. Montenegro
- Department of Anesthesia and Critical Care, Division of Cardiac AnesthesiaThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Stephanie Fuller
- Department of Surgery, Division of Cardiothoracic SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Christopher Mascio
- Department of Surgery, Division of Cardiothoracic SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - J. William Gaynor
- Department of Surgery, Division of Cardiothoracic SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Arjun G. Yodh
- Department of Physics and AstronomyUniversity of PennsylvaniaPhiladelphiaPA
| | - Juliana Gebb
- Department of Surgery, Richard D. Wood Jr Center for Fetal Diagnosis & Treatment in the Division of Pediatric General, Thoracic and Fetal SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Arastoo Vossough
- Department of RadiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Grace H. Choi
- Department of Biostatistics, Epidemiology and InformaticsUniversity of PennsylvaniaPhiladelphiaPA
- CHOP/Penn Intellectual and Developmental Disabilities Research CenterPhiladelphiaPA
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology and InformaticsUniversity of PennsylvaniaPhiladelphiaPA
- CHOP/Penn Intellectual and Developmental Disabilities Research CenterPhiladelphiaPA
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Grogan K, Thibault C, Moorthy G, Prodell J, Nicolson SC, Zuppa A. Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease. Anesth Analg 2023; 136:152-162. [PMID: 35446797 DOI: 10.1213/ane.0000000000005988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children. METHODS Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 μg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg. RESULTS A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 μg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 μg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 μg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg. CONCLUSIONS Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.
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Affiliation(s)
- Kelly Grogan
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Céline Thibault
- Department of Pediatrics, Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Ganesh Moorthy
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Janice Prodell
- Sidney Kimmel Cancer Center-Jefferson Health, Washington Township, New Jersey
| | - Susan C Nicolson
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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7
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Kurth CD, Nicolson SC, Cohen DE, Steven JM, Costarino AT. In memory of Dr. John J. "Jack" Downes. Paediatr Anaesth 2022. [PMID: 35170163 DOI: 10.1111/pan.14397] [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] [Indexed: 11/26/2022]
Affiliation(s)
- C Dean Kurth
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David E Cohen
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James M Steven
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew T Costarino
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Lynch JM, Mavroudis CD, Ko TS, Jacobwitz M, Busch DR, Xiao R, Nicolson SC, Montenegro LM, Gaynor JW, Yodh AG, Licht DJ. Association of Ongoing Cerebral Oxygen Extraction During Deep Hypothermic Circulatory Arrest With Postoperative Brain Injury. Semin Thorac Cardiovasc Surg 2022; 34:1275-1284. [PMID: 34508811 PMCID: PMC8901799 DOI: 10.1053/j.semtcvs.2021.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 01/03/2023]
Abstract
Cardiac surgery utilizing circulatory arrest is most commonly performed under deep hypothermia (∼18°C) to suppress tissue oxygen demand and provide neuroprotection during operative circulatory arrest. Studies investigating the effects of deep hypothermic circulatory arrest (DHCA) on neurodevelopmental outcomes of patients with congenital heart disease give conflicting results. Here, we address these issues by quantifying changes in cerebral oxygen saturation, blood flow, and oxygen metabolism in neonates during DHCA and investigating the association of these changes with postoperative brain injury. Neonates with critical congenital heart disease undergoing DHCA were recruited for continuous intraoperative monitoring of cerebral oxygen saturation (ScO2) and an index of cerebral blood flow (CBFi) using 2 noninvasive optical techniques, diffuse optical spectroscopy (DOS) and diffuse correlation spectroscopy (DCS). Pre- and postoperative brain magnetic resonance imaging (MRI) was performed to detect white matter injury (WMI). Fifteen neonates were studied, and 11/15 underwent brain MRI. During DHCA, ScO2 decreased exponentially in time with a median decay rate of -0.04 min-1. This decay rate was highly variable between subjects. Subjects who had larger decreases in ScO2 during DHCA were more likely to have postoperative WMI (P = 0.02). Cerebral oxygen extraction persists during DHCA and varies widely from patient-to-patient. Patients with a higher degree of oxygen extraction during DHCA were more likely to show new WMI in postoperative MRI. These findings suggest cerebral oxygen extraction should be monitored during DHCA to identify patients at risk for hypoxic-ischemic injury, and that current commercial cerebral oximeters may underestimate cerebral oxygen extraction.
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Affiliation(s)
- Jennifer M. Lynch
- The Children’s Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania 19104
| | - Constantine D. Mavroudis
- The Children’s Hospital of Philadelphia, Division of Cardiothoracic Surgery, Philadelphia, Pennsylvania 19104
| | - Tiffany S. Ko
- The Children’s Hospital of Philadelphia, Division of Neurology, Philadelphia, Pennsylvania 19104
| | - Marin Jacobwitz
- The Children’s Hospital of Philadelphia, Division of Neurology, Philadelphia, Pennsylvania 19104
| | - David R. Busch
- Departments of Anesthesiology and Pain Management and Neurology, University of Texas Southwestern Medical Center, Dallas, Texas 75390
| | - Rui Xiao
- University of Pennsylvania, Department of Biostatistics and Epidemiology, Philadelphia, Pennsylvania 19104
| | - Susan C. Nicolson
- The Children’s Hospital of Philadelphia, Division of Cardiothoracic Anesthesia, Philadelphia, Pennsylvania 19104
| | - Lisa M. Montenegro
- The Children’s Hospital of Philadelphia, Division of Cardiothoracic Anesthesia, Philadelphia, Pennsylvania 19104
| | - J. William Gaynor
- The Children’s Hospital of Philadelphia, Division of Cardiothoracic Surgery, Philadelphia, Pennsylvania 19104
| | - Arjun G. Yodh
- University of Pennsylvania, Department of Physics and Astronomy, Philadelphia, Pennsylvania 19104
| | - Daniel J. Licht
- The Children’s Hospital of Philadelphia, Division of Neurology, Philadelphia, Pennsylvania 19104
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Hunt ML, Ittenbach RF, Kaplinski M, Ravishankar C, Rychik J, Steven JM, Fuller SM, Nicolson SC, Spray TL, Gaynor JW, Mascio CE. Outcomes for the superior cavopulmonary connection in children with hypoplastic left heart syndrome: a 30-year experience. Eur J Cardiothorac Surg 2021; 58:809-816. [PMID: 32572451 DOI: 10.1093/ejcts/ezaa117] [Citation(s) in RCA: 4] [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] [Received: 10/04/2019] [Revised: 02/17/2020] [Accepted: 03/10/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective of this study was to estimate hospital mortality and length of stay (LOS) for children with hypoplastic left heart syndrome undergoing superior cavopulmonary connection (SCPC). METHODS All hypoplastic left heart syndrome interstage survivors who underwent SCPC between 1 January 1988 and 31 December 2017 were included. The study period was divided into 4 eras based on changes in operative or medical management. Mortality rates were estimated using standard binomial proportions. Adjusted and unadjusted logistic regression models were used to identify risk factors for mortality and LOS. RESULTS The most common procedures for the cohort (n = 958) were Hemi-Fontan (57.3%) or Bidrectional Glenn shunt (35.7%). The mortality was 4.1% overall and decreased in all 3 later eras compared to era 1. Factors associated with mortality in a multiple covariate model included longer total support time, earlier gestational age, longer LOS at the Norwood Procedure and need for additional procedures. Overall, the median LOS was 7.0 days with a decrease from eras 1 to 2 and plateaued in eras 3 and 4. Predictors of longer LOS included genetic anomaly, longer Norwood LOS, additional procedures, lower weight at surgery and longer total support time. The type of SCPC was not associated with mortality or LOS. CONCLUSIONS In this large cohort of patients with hypoplastic left heart syndrome undergoing SCPC, hospital mortality has decreased significantly. LOS initially declined but plateaued in recent eras. The risk factors for mortality and longer LOS are related to patient and procedural complexity, especially the need for additional procedures at the time of SCPC.
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Affiliation(s)
- Mallory L Hunt
- Department of Surgery, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard F Ittenbach
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Michelle Kaplinski
- Department of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Chitra Ravishankar
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James M Steven
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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10
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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11
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Witte MK, Mahle WT, Pasquali SK, Nicolson SC, Shekerdemian LS, Wolf MJ, Zhang W, Donohue JE, Gaies M. Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study. Pediatr Crit Care Med 2021; 22:204-212. [PMID: 33273409 PMCID: PMC7855235 DOI: 10.1097/pcc.0000000000002620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/25/2022]
Abstract
OBJECTIVES The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants. DESIGN Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry. SETTING Four Pediatric Heart Network Collaborative Learning Study active-site hospitals. PATIENTS Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras. CONCLUSIONS We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices.
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Affiliation(s)
- Madolin K Witte
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Wenying Zhang
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Janet E Donohue
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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12
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Lawrence KM, Ittenbach RF, Hunt ML, Kaplinski M, Ravishankar C, Rychik J, Steven JM, Fuller SM, Nicolson SC, Gaynor JW, Spray TL, Mascio CE. Attrition between the superior cavopulmonary connection and the Fontan procedure in hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2020; 162:385-393. [PMID: 33581902 DOI: 10.1016/j.jtcvs.2020.10.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 05/25/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We investigated the incidence and predictors of failure to undergo the Fontan in children with hypoplastic left heart syndrome who survived superior cavopulmonary connection. METHODS The cohort consists of all patients with hypoplastic left heart syndrome who survived to hospital discharge after superior cavopulmonary connection between 1988 and 2017. The primary outcome was attrition, which was defined as death, nonsuitability for the Fontan, or cardiac transplantation before the Fontan. Subjects were excluded if they were awaiting the Fontan, were lost to follow-up, or underwent biventricular repair. The study period was divided into 4 eras based on changes in operative or medical management. Attrition was estimated with 95% confidence intervals, and predictors were identified using adjusted, logistic regression models. RESULTS Of the 856 hospital survivors after superior cavopulmonary connection, 52 died, 7 were deemed unsuitable for Fontan, and 12 underwent or were awaiting heart transplant. Overall attrition was 8.3% (71/856). Attrition rate did not change significantly across eras. A best-fitting multiple logistic regression model was used, adjusting for superior cavopulmonary connection year and other influential covariates: right ventricle to pulmonary artery shunt at Norwood (P < .01), total support time at superior cavopulmonary connection (P < .01), atrioventricular valve reconstruction at superior cavopulmonary connection (P = .02), performance of other procedures at superior cavopulmonary connection (P = .01), and length of stay after superior cavopulmonary connection (P < .01). CONCLUSIONS In this study spanning more than 3 decades, 8.3% of children with hypoplastic left heart syndrome failed to undergo the Fontan after superior cavopulmonary connection. This attrition rate has not decreased over 30 years. Use of a right ventricle to pulmonary artery shunt at the Norwood procedure was associated with increased attrition.
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Affiliation(s)
- Kendall M Lawrence
- Department of Surgery, Weill Cornell New York Presbyterian, New York, NY
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mallory L Hunt
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Michelle Kaplinski
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, Calif
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - James M Steven
- Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa.
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13
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Fuller S, Ramachandran A, Awh K, Faerber JA, Patel PA, Nicolson SC, O'Byrne ML, Mascio CE, Kim YY. Comparison of outcomes of pulmonary valve replacement in adult versus paediatric hospitals: institutional influence†. Eur J Cardiothorac Surg 2020; 56:891-897. [PMID: 30957859 DOI: 10.1093/ejcts/ezz102] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Controversy exists in ascertaining the ideal location for adults with congenital heart disease requiring surgical intervention. In this study, we sought to compare the perioperative management between our paediatric and adult hospitals and to determine how clinical factors and the location affect the length of stay after pulmonary valve replacement. METHODS A retrospective analysis of patients, ≥18 years of age, undergoing pulmonary valve replacement was conducted at our paediatric and adult hospitals between 1 January 2000 and 30 October 2014. Patients with previous Ross or concomitant left heart procedures were excluded. Descriptive statistics were used to assess demographics and clinical characteristics. Inverse probability weight-adjusted models were used to determine differences in the number of surgical complications, duration of mechanical ventilation and postoperative length of stay between paediatric and adult hospitals. Additional models were calculated to identify factors associated with prolonged length of stay. RESULTS There were altogether 98 patients in the adult (48 patients) and paediatric (50 patients) hospitals. Patients in the adult hospital were older with more comorbidities (arrhythmia, hypertension, depression and a history of cardiac arrest, all P < 0.05). Those at the paediatric hospital had better preoperative right ventricular function and less tricuspid regurgitation. The cardiopulmonary bypass time, the length of intubation and the length of stay were higher at the adult hospital, despite no difference in the number of complications between locations. Factors contributing to the increased length of stay include patient characteristics and postoperative management strategies. There were no deaths. CONCLUSIONS Pulmonary valve replacement may be performed safely with no deaths and with a comparable complication rate at both hospitals. Patients undergoing surgery at the adult hospital have longer intubation times and length of stay. Opportunities exist to streamline management strategies.
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Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abhinay Ramachandran
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine Awh
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer A Faerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yuli Y Kim
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Divison of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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14
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Kaplinski M, Ittenbach RF, Hunt ML, Stephan D, Natarajan SS, Ravishankar C, Giglia TM, Rychik J, Rome JJ, Mahle M, Kennedy AT, Steven JM, Fuller SM, Nicolson SC, Spray TL, Gaynor JW, Mascio CE. Decreasing Interstage Mortality After the Norwood Procedure: A 30-Year Experience. J Am Heart Assoc 2020; 9:e016889. [PMID: 32964778 PMCID: PMC7792374 DOI: 10.1161/jaha.120.016889] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The superior cavo‐pulmonary connection was introduced at our institution in 1988 for infants undergoing surgery for hypoplastic left heart syndrome. Patients with hypoplastic left heart syndrome remain at high risk for mortality in the time period between the Norwood procedure and the superior cavo‐pulmonary connection. The primary objectives of this study were to compare interstage mortality across 4 eras and analyze factors that may impact interstage mortality. Methods and Results Patients with hypoplastic left heart syndrome who underwent the Norwood procedure, were discharged from the hospital, and were eligible for superior cavo‐pulmonary connection between January 1, 1988, and December 31, 2017, were included. The study period was divided into 4 eras based on changes in operative or medical management. Mortality rates were estimated with 95% CIs. Adjusted and unadjusted logistic regression models were used to identify risk factors for mortality. There were 1111 patients who met the inclusion criteria. Overall, interstage mortality was 120/1111 (10.8%). Interstage mortality was significantly lower in era 4 relative to era 1 (4.6% versus 13.4%; P=0.02) during the time that age at the superior cavo‐pulmonary connection was the lowest (135 days; P<0.01) and the interstage monitoring program was introduced. In addition, use of the right ventricle to pulmonary artery shunt was associated with decreased interstage mortality (P=0.02) and was more routinely practiced in era 4. Conclusions During this 30‐year experience, the risk of interstage mortality decreased significantly in the most recent era. Factors that coincide with this finding include younger age at superior cavo‐pulmonary connection, introduction of an interstage monitoring program, and increased use of the right ventricle to pulmonary artery shunt.
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Affiliation(s)
- Michelle Kaplinski
- Division of Pediatric Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford University Palo Alto CA
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology Department of Pediatrics Cincinnati Children's Hospital University of Cincinnati College of Medicine Cincinnati OH
| | - Mallory L Hunt
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Donna Stephan
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Shobha S Natarajan
- Division of Cardiology Department of Pediatrics The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Chitra Ravishankar
- Division of Cardiology Department of Pediatrics The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Therese M Giglia
- Division of Cardiology Department of Pediatrics The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Jack Rychik
- Division of Cardiology Department of Pediatrics The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- Division of Cardiology Department of Pediatrics The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Marlene Mahle
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Andrea T Kennedy
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - James M Steven
- Division of Cardiac Anesthesia Department of Anesthesiology and Critical Care Medicine The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Susan C Nicolson
- Division of Cardiac Anesthesia Department of Anesthesiology and Critical Care Medicine The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery Department of Surgery The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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15
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Faraoni D, Caplan LA, DiNardo JA, Guzzetta NA, Miller-Hance WC, Latham G, Momeni M, Nicolson SC, Spaeth JP, Taylor K, Twite M, Vener DF, Zabala L, Nasr VG. Considerations for Pediatric Heart Programs During COVID-19: Recommendations From the Congenital Cardiac Anesthesia Society. Anesth Analg 2020; 131:403-409. [PMID: 32459667 PMCID: PMC7273948 DOI: 10.1213/ane.0000000000005015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 12/15/2022]
MESH Headings
- Betacoronavirus/pathogenicity
- COVID-19
- COVID-19 Testing
- Cardiology/standards
- Clinical Laboratory Techniques/standards
- Consensus
- Coronavirus Infections/diagnosis
- Coronavirus Infections/therapy
- Coronavirus Infections/transmission
- Coronavirus Infections/virology
- Delivery of Health Care, Integrated/standards
- Health Services Accessibility/standards
- Health Services Needs and Demand/standards
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/therapy
- Host-Pathogen Interactions
- Humans
- Infant, Newborn
- Infection Control/standards
- Infectious Disease Transmission, Patient-to-Professional/prevention & control
- Infectious Disease Transmission, Vertical/prevention & control
- Needs Assessment/standards
- Pandemics
- Pediatrics/standards
- Personal Protective Equipment/standards
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/therapy
- Pneumonia, Viral/transmission
- Pneumonia, Viral/virology
- Risk Assessment
- Risk Factors
- SARS-CoV-2
- Time-to-Treatment/standards
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Affiliation(s)
- David Faraoni
- From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Lisa A. Caplan
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - James A. DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nina A. Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Wanda C. Miller-Hance
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Gregory Latham
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Mona Momeni
- Division of Cardiac Anesthesia, Department of Acute Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Brussels, Belgium
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesia, The Cardiac Center at The Children’s Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - James P. Spaeth
- Division of Cardiac Anesthesia, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Katherine Taylor
- From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mark Twite
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children’s Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - David F. Vener
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Luis Zabala
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children’s Health, Dallas, Texas
| | - Viviane G. Nasr
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Geoffrion TR, Ravishankar C, Dorfman AT, Montenegro LM, Nicolson SC, Mascio CE. Repair of arch hypoplasia and ventricular septal defect in unseparated, pyopagus conjoined twins. JTCVS Tech 2020; 3:300-302. [PMID: 34317908 PMCID: PMC8302882 DOI: 10.1016/j.xjtc.2020.04.005] [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: 03/13/2020] [Revised: 03/13/2020] [Accepted: 04/02/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Tracy R. Geoffrion
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
- Address for reprints: Tracy Geoffrion, MD, MPH, The Cardiac Center, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 8574, Philadelphia, PA 19104.
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aaron T. Dorfman
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Lisa M. Montenegro
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher E. Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
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17
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Vener DF, Abbasi RK, Brown M, Greene N, Guzzetta NA, Jacobs JP, Latham G, Mossad E, Nicolson SC, Twite M, Zhang S, Wise-Faberowski L. The Congenital Cardiac Anesthesia Society—Society of Thoracic Surgeons Cardiac Anesthesia Database Collaboration. World J Pediatr Congenit Heart Surg 2019; 11:14-21. [DOI: 10.1177/2150135119884911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multi-institutional databases and registries have proliferated over the last decade in all specialties of medicine. They may be especially helpful in low-frequency/high-acuity fields such as pediatric and congenital heart diseases. The Society of Thoracic Surgeon’s Congenital Heart Surgery Database (STSCHSD) is the largest single data set for the congenital heart disease population and includes contemporaneous data from over 120 programs in the United States (and several outside of the United States), capturing greater than 98% of the congenital cardiac surgical procedures in the United States. In 2010, the Congenital Cardiac Anesthesia Society partnered with the STSCHSD to incorporate anesthesia-related elements into the data set. Voluntary site participation in the anesthesia data has grown steadily. Currently, over 60 sites performing more than 60% of cardiac bypass procedures in the STSCHSD are submitting anesthesia data annually into the STSCHSD. Anesthesia data include perioperative medication usage, modalities for hemodynamic and neurologic monitoring, blood product, antifibrinolytic and procoagulant use, and anesthesia-related adverse events. This special article provides a descriptive summary of relevant findings to date, reflecting the wide variety in anesthesia practice patterns present among institutions and illustrates the functionality of a multisite registry in pediatric cardiac anesthesia which can be utilized both locally and nationally.
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Affiliation(s)
- David F. Vener
- Pediatric Cardiac Anesthesia, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Rania K. Abbasi
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Morgan Brown
- Division of Pediatric Cardiac Anesthesia, Boston Children's Hospital, Harvard University, Cambridge, MA, USA
| | - Nathaniel Greene
- Department of Pediatric Anesthesia, Duke University Medical Center, Durham, NC, USA
| | - Nina A. Guzzetta
- Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Jeffrey P. Jacobs
- Pediatric Cardiac Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Gregory Latham
- Division of Pediatric Anesthesiology, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Emad Mossad
- Pediatric Cardiac Anesthesia, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Susan C. Nicolson
- Pediatric Cardiac Anesthesia, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark Twite
- Pediatric Cardiac Anesthesia, University of Colorado, Children’s Hospital Colorado, Aurora, CO, USA
| | - Shuaqi Zhang
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Lisa Wise-Faberowski
- Pediatric Cardiac Anesthesia, Lucille Packard Children’s Hospital, Stanford University, Palo Alto, CA, USA
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Zuppa AF, Nicolson SC, Wilder NS, Ibla JC, Gottlieb EA, Burns KM, Stylianou M, Trachtenberg F, Ni H, Skeen TH, Andropoulos DB. Results of a phase 1 multicentre investigation of dexmedetomidine bolus and infusion in corrective infant cardiac surgery. Br J Anaesth 2019; 123:839-852. [PMID: 31623840 PMCID: PMC6993105 DOI: 10.1016/j.bja.2019.06.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 06/01/2019] [Accepted: 06/19/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing. METHODS We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations. RESULTS Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1. CONCLUSIONS When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection. CLINICAL TRIALS REGISTRATION NCT01915277.
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Affiliation(s)
- Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole S Wilder
- Department of Anesthesiology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Juan C Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Gottlieb
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Kristin M Burns
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, Bethesda, MD, USA
| | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Hua Ni
- New England Research Institutes, Watertown, MA, USA
| | - Tera H Skeen
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Dean B Andropoulos
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
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Weiss SL, Nicolson SC, Naim MY. Clinical Update in Pediatric Sepsis: Focus on Children With Pre-Existing Heart Disease. J Cardiothorac Vasc Anesth 2019; 34:1324-1332. [PMID: 31734080 DOI: 10.1053/j.jvca.2019.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/07/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 11/11/2022]
Abstract
SEPSIS REMAINS one of the most common causes of childhood morbidity, mortality, and higher healthcare costs, with over 75,000 hospital admissions in the United States and an estimated 4 million cases worldwide per year. While standardized criteria to define sepsis are in flux, the general concept of sepsis is a severe infection that results in organ dysfunction. Although sepsis can affect previously healthy children, those with certain pre-existing comorbid conditions, including congenital and acquired heart disease, are at higher risk for both developing sepsis and having a poor outcome after sepsis. Multiple specialists including intensivists, cardiologists, surgeons, and anesthesiologists commonly contribute to the management and outcome of sepsis in children. In this article, the authors examine the evolving epidemiology of pediatric sepsis, including the subset of patients with underlying heart disease; contrast pediatric and adult sepsis; review the latest hemodynamic guidelines for management of pediatric septic shock and their application to children with heart disease; discuss the role of mechanical circulatory support; and review key aspects of anesthetic management for children with sepsis.
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Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Mitochondrial and Epigenomic Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA
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20
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Russell MW, Moldenhauer JS, Rychik J, Burnham NB, Zullo E, Parry SI, Simmons RA, Elovitz MA, Nicolson SC, Linn RL, Johnson MP, Yu S, Sampson MG, Hakonarson H, Gaynor JW. Damaging Variants in Proangiogenic Genes Impair Growth in Fetuses with Cardiac Defects. J Pediatr 2019; 213:103-109. [PMID: 31227283 PMCID: PMC6765419 DOI: 10.1016/j.jpeds.2019.05.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Received: 01/15/2019] [Revised: 04/30/2019] [Accepted: 05/09/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the impact of damaging genetic variation in proangiogenic pathways on placental function, complications of pregnancy, fetal growth, and clinical outcomes in pregnancies with fetal congenital heart defect. STUDY DESIGN Families delivering a baby with a congenital heart defect requiring surgical repair in infancy were recruited. The placenta and neonate were weighed and measured. Hemodynamic variables were recorded from a third trimester (36.4 ± 1.7 weeks) fetal echocardiogram. Exome sequencing was performed on the probands (N = 133) and consented parents (114 parent-child trios, and 15 parent-child duos) and the GeneVetter analysis tool used to identify damaging coding sequence variants in 163 genes associated with the positive regulation of angiogenesis (PRA) (GO:0045766). RESULTS In total, 117 damaging variants were identified in PRA genes in 133 congenital heart defect probands with 73 subjects having at least 1 variant. Presence of a damaging PRA variant was associated with increased umbilical artery pulsatility index (mean 1.11 with variant vs 1.00 without; P = .01). The presence of a damaging PRA variant was also associated with lower neonatal length and head circumference for age z score at birth (mean -0.44 and -0.47 with variant vs 0.23 and -0.05 without; P = .01 and .04, respectively). During median 3.1 years (IQR 2.0-4.1 years) of follow-up, deaths occurred in 2 of 60 (3.3%) subjects with no PRA variant and in 9 of 73 (12.3%) subjects with 1 or more PRA variants (P = .06). CONCLUSIONS Damaging variants in proangiogenic genes may impact placental function and are associated with impaired fetal growth in pregnancies involving a fetus with congenital heart defect.
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Affiliation(s)
- Mark W Russell
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jack Rychik
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Nancy B Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Erin Zullo
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Samuel I Parry
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Rebecca A Simmons
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michal A Elovitz
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca L Linn
- Division of Anatomic Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Matthew G Sampson
- Division of Pediatric Nephrology, Department of Pediatrics, and Center for Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI
| | - Hakon Hakonarson
- The Center for Applied Genomics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
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Russell MW, Moldenhauer JS, Rychik J, Burnham NB, Zullo E, Parry SI, Simmons RA, Elovitz MA, Nicolson SC, Linn RL, Johnson MP, Yu S, Sampson MG, Hakonarson H, Gaynor JW. Effect of parental origin of damaging variants in pro-angiogenic genes on fetal growth in patients with congenital heart defects: Data and analyses. Data Brief 2019; 25:104311. [PMID: 31453292 PMCID: PMC6700409 DOI: 10.1016/j.dib.2019.104311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 11/03/2022] Open
Abstract
The placenta is a highly vascular structure composed of both maternal and fetal elements. We have determined that damaging variants in genes responsible for the positive regulation of angiogenesis (PRA) (GO:0045766) that are inherited by the fetus impair fetal growth and placental function in pregnancies involving critical congenital cardiac defects (Russell et al., 2019). In this dataset, we present the specific genetic variants identified, describe the parental origin of each variant where possible and present the analyses regarding the potential effects of parental origin of the variant on placental function and fetal growth. The data presented are related to the research article "Damaging variants in pro-angiogenic genes impair growth in fetuses with cardiac defects" (Russell et al., 2019).
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Affiliation(s)
- Mark W. Russell
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Zullo
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samuel I. Parry
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca A. Simmons
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michal A. Elovitz
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca L. Linn
- Division of Anatomic Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark P. Johnson
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthew G. Sampson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Hakon Hakonarson
- The Center for Applied Genomics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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22
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Gaynor JW, Parry S, Moldenhauer JS, Simmons RA, Rychik J, Ittenbach RF, Russell WW, Zullo E, Ward JL, Nicolson SC, Spray TL, Johnson MP. The impact of the maternal-foetal environment on outcomes of surgery for congenital heart disease in neonates. Eur J Cardiothorac Surg 2019; 54:348-353. [PMID: 29447332 DOI: 10.1093/ejcts/ezy015] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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: 09/13/2017] [Accepted: 01/04/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Pregnancies with congenital heart disease in the foetus have an increased prevalence of pre-eclampsia, small for gestational age and preterm birth, which are evidence of an impaired maternal-foetal environment (MFE). METHODS The impact of an impaired MFE, defined as pre-eclampsia, small for gestational age or preterm birth, on outcomes after cardiac surgery was evaluated in neonates (n = 135) enrolled in a study evaluating exposure to environmental toxicants and neuro-developmental outcomes. RESULTS The most common diagnoses were transposition of the great arteries (n = 47) and hypoplastic left heart syndrome (n = 43). Impaired MFE was present in 28 of 135 (21%) subjects, with small for gestational age present in 17 (61%) patients. The presence of an impaired MFE was similar for all diagnoses, except transposition of the great arteries (P < 0.006). Postoperative length of stay was shorter for subjects without an impaired MFE (14 vs 38 days, P < 0.001). Hospital mortality was not significantly different with or without impaired MFE (11.7% vs 2.8%, P = 0.104). However, for the entire cohort, survival at 36 months was greater for those without an impaired MFE (96% vs 68%, P = 0.001). For patients with hypoplastic left heart syndrome, survival was also greater for those without an impaired MFE (90% vs 43%, P = 0.007). CONCLUSIONS An impaired MFE is common in pregnancies in which the foetus has congenital heart disease. After cardiac surgery in neonates, the presence of an impaired MFE was associated with lower survival at 36 months of age for the entire cohort and for the subgroup with hypoplastic left heart syndrome.
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Affiliation(s)
- James William Gaynor
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samuel Parry
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca A Simmons
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William W Russell
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Zullo
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John Laurenson Ward
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan C Nicolson
- Division of Pediatric Cardiac Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas L Spray
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Mascio CE, Irons ML, Ittenbach RF, Gaynor JW, Fuller SM, Kaplinski M, Kennedy AT, Steven JM, Nicolson SC, Spray TL. Thirty years and 1663 consecutive Norwood procedures: Has survival plateaued? J Thorac Cardiovasc Surg 2019; 158:220-229. [PMID: 31248509 DOI: 10.1016/j.jtcvs.2018.12.117] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [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: 04/28/2018] [Revised: 11/26/2018] [Accepted: 12/27/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypoplastic left heart syndrome is one of the most common and challenging lesions requiring surgical intervention in the neonatal period. The Norwood procedure for hypoplastic left heart syndrome was first reported in 1983. The objective of this study was to describe early outcomes after the Norwood procedure at a single institution over 30 years. METHODS This retrospective cohort study included all patients with hypoplastic left heart syndrome (and variants) who underwent the Norwood procedure between January 1984 and May 2014 at a single institution. The study period was divided into 6 eras: era 1, 1984 to 1988; era 2, 1989 to 1993; era 3, 1994 to 1998; era 4, 1999 to 2003; era 5, 2004 to 2008; and era 6, 2009 to 2014. The primary outcome was in-hospital mortality after the Norwood procedure. Binomial point estimates complete with 95% confidence intervals (CL0.95) were computed for the entire cohort and by era. RESULTS During the study period, 1663 infants underwent the Norwood procedure. Overall in-hospital mortality was 25.9% (CL0.95, 23.8-28.0). Mortality by chronologic era was 40.4% (CL0.95, 34.9-45.9), 33.6% (CL0.95, 29.2-37.9), 28.7% (CL0.95, 22.8-34.6), 14.9% (CL0.95, 10.4-19.3), 11.2% (CL0.95, 7.4-15.0), and 15.7% (CL0.95, 10.3-21.1). Survival was improved in eras 4 to 6 compared with eras 1 to 3 (P all < .03). Anomalous pulmonary drainage, moderate to severe atrioventricular valve regurgitation, lower birth weight, earlier era, younger gestational age, genetic anomaly, preterm birth, race other than white or African-American, and lower weight at the Norwood procedure were associated with increased mortality. Mortality was greatest in patients with 3 or more risk factors. In the best-fitting multiple covariate model, anomalous pulmonary venous drainage, gestational age in weeks, genetic anomaly, and race other than white and African American were statistically significant contributors, after adjusting for era. CONCLUSIONS Survival after the Norwood procedure has plateaued despite improvements in diagnosis, perioperative care, and surgical techniques. Nonmodifiable patient characteristics are important determinants of the risk of mortality.
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Affiliation(s)
- Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Mallory L Irons
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Michelle Kaplinski
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Andrea T Kennedy
- Clinical Data Analytics, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - James M Steven
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
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Bates KE, Mahle WT, Bush L, Donohue J, Gaies MG, Nicolson SC, Shekerdemian L, Witte M, Wolf M, Shea JA, Likosky DS, Pasquali SK. Variation in Implementation and Outcomes of Early Extubation Practices After Infant Cardiac Surgery. Ann Thorac Surg 2018; 107:1434-1440. [PMID: 30557537 DOI: 10.1016/j.athoracsur.2018.11.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 07/11/2018] [Revised: 10/23/2018] [Accepted: 11/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes. METHODS Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites. RESULTS A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p < 0.001); however, there was variation in the post-CPG median time to extubation (0.3 to 5.3 hours, p = 0.01) and magnitude of change (-73.3% to -99.2%). Site A achieved the shortest post-CPG time to extubation and had the greatest percentage change. Two sites had significant decreases in medical ICU LOS in TOF patients; no hospital LOS changes were seen. All sites valued the collaborative learning strategy, site visits, CPG flexibility, and had similar core team composition. Site A used several unique strategies: inclusion of other staff and fellows, regular in-person data reviews, additional data collection, and creation of complementary protocols. CONCLUSIONS All PHN CLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.
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Affiliation(s)
- Katherine E Bates
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - William T Mahle
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Lauren Bush
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Janet Donohue
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Michael G Gaies
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lara Shekerdemian
- Department of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Madolin Witte
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michael Wolf
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Judy A Shea
- Department of Internal Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Sara K Pasquali
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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Gaies M, Pasquali SK, Nicolson SC, Shekerdemian L, Witte M, Wolf M, Zhang W, Donohue JE, Mahle WT. Sustainability of Infant Cardiac Surgery Early Extubation Practices After Implementation and Study. Ann Thorac Surg 2018; 107:1427-1433. [PMID: 30391249 DOI: 10.1016/j.athoracsur.2018.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 07/12/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Pediatric Heart Network Collaborative Learning Study (PHN CLS) successfully changed practice at four hospitals to increase the rate of early extubation within 6 hours after infant heart surgery. It is unknown whether this practice continued after study completion. METHODS We linked the PHN CLS dataset to the Pediatric Cardiac Critical Care Consortium registry to compare outcomes at four active hospitals between the study period (post-clinical practice guideline [CPG]) and the first year after study completion (follow-up) after a 3-month washout. Inclusion and exclusion criteria were the same across eras. Primary outcome was early extubation rate after tetralogy of Fallot or aortic coarctation repair. Secondary outcomes included time to first extubation and intensive care and hospital lengths of stay. RESULTS There were 121 patients in the post-CPG era and 139 patients in the follow-up era with no difference in patient characteristics or operation subtypes. Post-CPG early extubation rate declined from 67% to 30% in follow-up (p < 0.0001); time to first extubation increased (4.5 versus 13.5 hours, p < 0.0001). One hospital maintained the rate of early extubation (72% versus 67%), whereas the other three hospitals had significantly lower rates in follow-up (p < 0.02 for each). Intensive care (2.8 versus 2.9 days) and postoperative hospital (6 versus 5 days) stays did not differ between eras (p > 0.05 for both). Findings were consistent across operation subtypes. CONCLUSIONS Extubation practice in the first year of follow-up after the PHN CLS reverted toward prestudy levels. One of four hospitals maintained its early extubation strategy, suggesting that specific implementation and maintenance approaches may effectively sustain impact from quality initiatives.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lara Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Madolin Witte
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael Wolf
- Department of Pediatrics, Emory University, Atlanta, Georgia; Sibley Heart Center, Emory University, Atlanta, Georgia
| | - Wenying Zhang
- Michigan Congenital Heart Outcomes Research and Discovery Unit, Pediatric Cardiac Critical Care Consortium Data Coordinating Center, University of Michigan, Ann Arbor, Michigan
| | - Janet E Donohue
- Michigan Congenital Heart Outcomes Research and Discovery Unit, Pediatric Cardiac Critical Care Consortium Data Coordinating Center, University of Michigan, Ann Arbor, Michigan
| | - William T Mahle
- Department of Pediatrics, Emory University, Atlanta, Georgia; Sibley Heart Center, Emory University, Atlanta, Georgia
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Mavroudis CD, Karlsson M, Ko T, Hefti M, Gentile JI, Morgan RW, Plyler R, Mensah-Brown KG, Boorady TW, Melchior RW, Rosenthal TM, Shade BC, Schiavo KL, Nicolson SC, Spray TL, Sutton RM, Berg RA, Licht DJ, Gaynor JW, Kilbaugh TJ. Cerebral mitochondrial dysfunction associated with deep hypothermic circulatory arrest in neonatal swine. Eur J Cardiothorac Surg 2018; 54:162-168. [PMID: 29346537 PMCID: PMC7448940 DOI: 10.1093/ejcts/ezx467] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/15/2017] [Accepted: 12/02/2017] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Controversy remains regarding the use of deep hypothermic circulatory arrest (DHCA) in neonatal cardiac surgery. Alterations in cerebral mitochondrial bioenergetics are thought to contribute to ischaemia-reperfusion injury in DHCA. The purpose of this study was to compare cerebral mitochondrial bioenergetics for DHCA with deep hypothermic continuous perfusion using a neonatal swine model. METHODS Twenty-four piglets (mean weight 3.8 kg) were placed on cardiopulmonary bypass (CPB): 10 underwent 40-min DHCA, following cooling to 18°C, 10 underwent 40 min DHCA and 10 remained at deep hypothermia for 40 min; animals were subsequently rewarmed to normothermia. 4 remained on normothermic CPB throughout. Fresh brain tissue was harvested while on CPB and assessed for mitochondrial respiration and reactive oxygen species generation. Cerebral microdialysis samples were collected throughout the analysis. RESULTS DHCA animals had significantly decreased mitochondrial complex I respiration, maximal oxidative phosphorylation, respiratory control ratio and significantly increased mitochondrial reactive oxygen species (P < 0.05 for all). DHCA animals also had significantly increased cerebral microdialysis indicators of cerebral ischaemia (lactate/pyruvate ratio) and neuronal death (glycerol) during and after rewarming. CONCLUSIONS DHCA is associated with disruption of mitochondrial bioenergetics compared with deep hypothermic continuous perfusion. Preserving mitochondrial health may mitigate brain injury in cardiac surgical patients. Further studies are needed to better understand the mechanisms of neurological injury in neonatal cardiac surgery and correlate mitochondrial dysfunction with neurological outcomes.
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Affiliation(s)
- Constantine D Mavroudis
- Department of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael Karlsson
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tiffany Ko
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Javier I Gentile
- Department of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ross Plyler
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kobina G Mensah-Brown
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy W Boorady
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard W Melchior
- Department of Perfusion Services, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tami M Rosenthal
- Department of Perfusion Services, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brandon C Shade
- Department of Perfusion Services, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kellie L Schiavo
- Department of Perfusion Services, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas L Spray
- Department of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Department of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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27
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Jobes DR, Brown LA, Dori Y, Itkin M, Nicolson SC. Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations. Paediatr Anaesth 2018; 28:507-512. [PMID: 29687529 DOI: 10.1111/pan.13385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 03/23/2018] [Indexed: 11/29/2022]
Abstract
The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures. We reviewed a one-year cohort of all pediatric patients in a newly created Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for lymphatic procedures. The patients ranged in age from 4 days to 17 years and weighed from 2.5 to 92 kg. There were 106 anesthetics for 68 patients. Patients were functionally impaired (98% ASA 3 or 4) and included significant comorbidities (79.4%). Concurrent with lymphatic imaging and intervention additional procedures were frequently performed (76%). They included cardiac catheterization, bronchoscopy, endoscopy, and drain placement (thoracic or abdominal). Paralysis and controlled ventilation was used for all interventions. Reversal of paralysis and tracheal extubation occurred in all patients not previously managed by invasive respiratory support. All patients having an intervention were admitted to intensive care for observation where escalation of care or complications (fever, hypotension, bleeding, or stroke) occurred in 25% in the first 24 hours.
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Affiliation(s)
- David R Jobes
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren A Brown
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maxim Itkin
- Department of Radiology, Division of Interventional Radiology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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28
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Downing TE, Allen KY, Goldberg DJ, Rogers LS, Ravishankar C, Rychik J, Fuller S, Montenegro LM, Steven JM, Gillespie MJ, Rome JJ, Spray TL, Nicolson SC, Gaynor JW, Glatz AC. Surgical and Catheter-Based Reinterventions Are Common in Long-Term Survivors of the Fontan Operation. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.116.004924. [PMID: 28851719 DOI: 10.1161/circinterventions.116.004924] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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] [Received: 12/27/2016] [Accepted: 07/24/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited follow-up studies examining surgical and catheter-based reinterventions in long-term survivors of the Fontan operation. METHODS AND RESULTS All 773 patients who underwent Fontan at our institution between 1992 and 2009 were retrospectively reviewed. Current information regarding post-Fontan intervention was available for 70%. By 20 years after Fontan, 65% of patients had experienced either surgical or transcatheter intervention. The median time to first reintervention was 9.8 years. Freedom from reoperation was 69% at 15 years and 63% at 20 years. The most common operations were pacemaker placement and Fontan revision. Risk factors for pacemaker placement included systemic left ventricle (hazard ratio [HR], 2.2; P=0.006) and lateral tunnel Fontan (HR, 4.3; P=0.001). Freedom from interventional catheterization was 53% at 15 years and 50% at 20 years. The most common procedures performed were fenestration closure and pulmonary artery intervention. Catheter intervention for anatomic indications was associated with Fontan after 2002 (HR, 2.1; P=0.007), Norwood operation (HR, 2.3; P=0.001), and longer cardiopulmonary bypass time (HR, 1.1 per 10 minutes; P=0.001). Catheter intervention for physiological indications was associated with prolonged post-Fontan pleural drainage (HR, 4.0; P<0.001) and hypoplastic left heart syndrome (HR, 2.0; P=0.01). CONCLUSIONS In this study of Fontan survivors, two thirds of patients required surgical or catheter-based reintervention by 20 years. Families should be counseled that the Fontan is typically not the final stage of single-ventricle palliation.
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Affiliation(s)
- Tacy E Downing
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.).
| | - Kiona Y Allen
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - David J Goldberg
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Lindsay S Rogers
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Chitra Ravishankar
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Jack Rychik
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Stephanie Fuller
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Lisa M Montenegro
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - James M Steven
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Matthew J Gillespie
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Jonathan J Rome
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Thomas L Spray
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Susan C Nicolson
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - J William Gaynor
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.)
| | - Andrew C Glatz
- From the Division of Pediatric Cardiology (T.E.D., D.J.G., C.R., J.R., M.J.G., J.J.R., A.C.G.), Department of Surgery (S.F., T.L.S., J.W.G.), and Department of Anesthesiology and Critical Care (L.M.M., J.M.S., S.C.N.), The Perelman School of Medicine at the University of Pennsylvania, and Cardiac Center at The Children's Hospital of Philadelphia; Division of Cardiology, University of Texas, Houston (L.S.R.); and Division of Critical Care, Lurie Children's Hospital, Chicago, IL (K.Y.A.).
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Lynch JM, Ko T, Busch DR, Newland JJ, Winters ME, Mensah-Brown K, Boorady TW, Xiao R, Nicolson SC, Montenegro LM, Gaynor JW, Spray TL, Yodh AG, Naim MY, Licht DJ. Preoperative cerebral hemodynamics from birth to surgery in neonates with critical congenital heart disease. J Thorac Cardiovasc Surg 2018; 156:1657-1664. [PMID: 29859676 DOI: 10.1016/j.jtcvs.2018.04.098] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [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: 05/22/2017] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hypoxic-ischemic white matter brain injury commonly occurs in neonates with critical congenital heart disease. Recent work has shown that longer time to surgery is associated with increased risk for this injury. In this study we investigated changes in perinatal cerebral hemodynamics during the transition from fetal to neonatal circulation to ascertain mechanisms that might underlie this risk. METHODS Neonates with either transposition of the great arteries (TGA) or hypoplastic left heart syndrome (HLHS) were recruited for preoperative noninvasive optical monitoring of cerebral oxygen saturation, cerebral oxygen extraction fraction, and cerebral blood flow using diffuse optical spectroscopy and diffuse correlation spectroscopy, 2 noninvasive optical techniques. Measurements were acquired daily from day of consent until the morning of surgery. Temporal trends in these measured parameters during the preoperative period were assessed with a mixed effects model. RESULTS Forty-eight neonates with TGA or HLHS were studied. Cerebral oxygen saturation was significantly and negatively correlated with time, and oxygen extraction fraction was significantly and positively correlated with time. Cerebral blood flow did not significantly change with time during the preoperative period. CONCLUSIONS In neonates with TGA or HLHS, increasing cerebral oxygen extraction combined with an abnormal cerebral blood flow response during the time between birth and heart surgery leads to a progressive decrease in cerebral tissue oxygenation The results support and help explain the physiological basis for recent studies that show longer time to surgery increases the risk of acquiring white matter injury.
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Affiliation(s)
- Jennifer M Lynch
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Penn.
| | - Tiffany Ko
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pa; Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa
| | - David R Busch
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa; Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - John J Newland
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Madeline E Winters
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kobina Mensah-Brown
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Timothy W Boorady
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Lisa M Montenegro
- Division of Cardiothoracic Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa
| | - Maryam Y Naim
- Division of Cardiac Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
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Gaynor JW, Nicolson SC, Spray DM, Burnham NB, Chittams JL, Sammarco T, Walsh KW, Spray TL, Licht DJ. Remote Ischemic Preconditioning Does Not Prevent White Matter Injury in Neonates. Ann Thorac Surg 2018; 106:151-155. [PMID: 29601806 DOI: 10.1016/j.athoracsur.2018.02.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 01/09/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) is a mechanism to protect tissues from injury during ischemia and reperfusion. We investigated the neuroprotective effects of RIPC in neonates undergoing cardiac surgery. METHODS The outcome was white matter injury (WMI), assessed by the change in volume of WMI from preoperative to postoperative brain magnetic resonance imaging (MRI). Patients were randomized to RIPC or SHAM. RIPC was induced prior to cardiopulmonary bypass by four 5-minute cycles of blood pressure cuff inflation to produce ischemia of the lower extremity. For patients randomized to SHAM, the cuff was positioned, but not inflated. RESULTS The study included 67 patients, with 33 randomized to RIPC and 34 randomized to SHAM. Preoperative and postoperative MRIs were available in 50 patients, including 26 of the 33 RIPC patients and 24 of the 34 SHAM patients. There were no differences in baseline and operative characteristics for either the overall study group or the group with evaluable MRIs. WMI was identified in 28% of the patients preoperatively and in 62% postoperatively. There was no difference in the prevalence of WMI by treatment group (p > 0.5). RIPC patients had an average change in WMI of 600 mL3, and SHAM subjects had an average WMI change of 107 mL3. There was no significant difference in the mean value of WMI change between patients who received RIPC and those who received SHAM treatments (p = 0.178). CONCLUSIONS In this randomized, blinded clinical trial, there was no evidence that use of RIPC provides neuroprotection in neonates undergoing repair of congenital heart defects with cardiopulmonary bypass.
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Affiliation(s)
- J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Susan C Nicolson
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diane M Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy B Burnham
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jesse L Chittams
- Biostatistics Consulting Unit, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Therese Sammarco
- Biostatistics Consulting Unit, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Kevin W Walsh
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Department of Pediatrics, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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31
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Manrique Espinel AM, Feldman JM, Nelson S, Smaliak T, Flynn JM, Nicolson SC. Anaphylaxis to Surgiflo During Posterior Spinal Fusion in an Adolescent Status Post Truncus Arteriosus Repair: A Case Report. A A Pract 2018; 10:129-132. [PMID: 29068803 DOI: 10.1213/xaa.0000000000000646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anaphylactic reaction to gelatin-containing hemostatic agents has been reported in the orthopedic literature, most commonly during scoliosis repair in adolescents. However, the risk, differential diagnosis, and management of anaphylaxis in patients with complex congenital heart disease undergoing noncardiac procedures have not been previously reported. We describe the case of an adolescent with a history of repaired truncus arteriosus undergoing posterior spinal fusion who developed sudden and profound hypotension that was ultimately confirmed to be an anaphylactic reaction to Surgiflo. Echocardiography was used to aid in diagnosis and management of the cardiovascular effects of anaphylaxis in this patient with residual cardiac pathophysiology.
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Affiliation(s)
- Ana Maria Manrique Espinel
- From the Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Critical Care Medicine, General Anesthesiology, Division of Orthopaedic Surgery, and Cardiac Center Operations, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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32
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Nasr VG, Guzzetta NA, Miller-Hance WC, Twite M, Latham GJ, Zabala L, Nicolson SC, Mossad EB, DiNardo JA. Consensus Statement by the Congenital Cardiac Anesthesia Society: Milestones for the Pediatric Cardiac Anesthesia Fellowship. Anesth Analg 2018; 126:198-207. [PMID: 28922234 DOI: 10.1213/ane.0000000000002482] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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
Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship.
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Affiliation(s)
- Viviane G Nasr
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Wanda C Miller-Hance
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Texas Children's Hospital, Houston, Texas
| | - Mark Twite
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Children's Hospital Colorado, Aurora, Colorado
| | - Gregory J Latham
- Department of Anesthesiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Luis Zabala
- Division of Cardiac Anesthesia, Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, Texas
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emad B Mossad
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Texas Children's Hospital, Houston, Texas
| | - James A DiNardo
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Grasty MA, Ittenbach RF, Knightly C, Solot CB, Gerdes M, Bernbaum JC, Wernovsky G, Spray TL, Nicolson SC, Clancy RR, Licht DJ, Zackai E, Gaynor JW, Burnham NB. Hearing Loss after Cardiac Surgery in Infancy: An Unintended Consequence of Life-Saving Care. J Pediatr 2018; 192:144-151.e1. [PMID: 29246336 PMCID: PMC6447030 DOI: 10.1016/j.jpeds.2017.09.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 04/14/2017] [Revised: 08/30/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To investigate the prevalence of hearing loss after cardiac surgery in infancy, patient and operative factors associated with hearing loss, and the relationship of hearing loss to neurodevelopmental outcomes. STUDY DESIGN Audiologic and neurodevelopmental evaluations were conducted on 348 children who underwent repair of congenital heart disease at the Children's Hospital of Philadelphia as part of a prospective study evaluating neurodevelopmental outcomes at 4 years of age. A prevalence estimate was calculated based on presence and type of hearing loss. Potential risk factors and the impact of hearing loss on neurodevelopmental outcomes were evaluated. RESULTS The prevalence of hearing loss was 21.6% (95% CI, 17.2-25.9). The prevalence of conductive hearing loss, sensorineural hearing loss, and indeterminate hearing loss were 12.4% (95% CI, 8.8-16.0), 6.9% (95% CI, 4.1-9.7), and 2.3% (95% CI, 0.6-4.0), respectively. Only 18 of 348 subjects (5.2%) had screened positive for hearing loss before this study and 10 used a hearing aid. After adjusting for patient and operative covariates, younger gestational age, longer postoperative duration of stay, and a confirmed genetic anomaly were associated with hearing loss (all P < .01). The presence of hearing loss was associated with worse language, cognition and attention (P <.01). CONCLUSIONS These findings suggest that the prevalence of hearing loss in preschool children after heart surgery in infancy may be 20-fold higher than in the 1% prevalence seen in the general population. Younger gestational age, presence of a genetic anomaly, and longer postoperative duration of stay were associated with hearing loss. Hearing loss was associated with worse neurodevelopmental outcomes.
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Affiliation(s)
- Madison A. Grasty
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Richard F. Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Carol Knightly
- Center for Childhood Communication, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia B. Solot
- Center for Childhood Communication, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Marsha Gerdes
- Center for Psychology, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Judy C. Bernbaum
- Center for Pediatrics, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Gil Wernovsky
- Center for Cardiology, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania,Department of Anesthesia and Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L. Spray
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Susan C. Nicolson
- Department of Anesthesia and Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert R. Clancy
- Department of Pediatrics Division of Neurology, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J. Licht
- Department of Pediatrics Division of Neurology, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine Zackai
- Center for Pediatrics, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania,Department of Genetics, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
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Kim DS, Li YK, Kim JH, Bergquist CS, Gerdes M, Bernbaum JC, Burnham N, McDonald-McGinn DM, Zackai EH, Nicolson SC, Spray TL, Nickerson DA, Hakonarson H, Jarvik GP, Gaynor JW. Autosomal dominant mannose-binding lectin deficiency is associated with worse neurodevelopmental outcomes after cardiac surgery in infants. J Thorac Cardiovasc Surg 2017; 155:1139-1147.e2. [PMID: 29452463 DOI: 10.1016/j.jtcvs.2017.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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] [Received: 02/24/2017] [Revised: 07/01/2017] [Accepted: 08/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The MBL2 gene is the major genetic determinant of mannose-binding lectin (MBL)-an acute phase reactant. Low MBL levels have been associated with adverse outcomes in preterm infants. The MBL2Gly54Asp missense variant causes autosomal dominant MBL deficiency. We tested the hypothesis that MBL2Gly54Asp is associated with worse neurodevelopmental outcomes after cardiac surgery in neonates. METHODS This is an analysis of a previously described cohort of patients with nonsyndromic congenital heart disease who underwent cardiac surgery with cardiopulmonary bypass before age 6 months (n = 295). Four-year neurodevelopment was assessed in 3 domains: Full-Scale Intellectual Quotient, the Visual Motor Integration development test, and the Child Behavior Checklist to assess behavior problems. The Child Behavior Checklist measured total behavior problems, pervasive developmental problems, and internalizing/externalizing problems. A multivariable linear regression model, adjusting for confounders, was fit. RESULTS MBL2Gly54Asp was associated with a significantly increased covariate-adjusted pervasive developmental problem score (β = 3.98; P = .0025). Sensitivity analyses of the interaction between age at first surgery and MBL genotype suggested effect modification for the patients with MBL2Gly54Asp (Pinteraction = .039), with the poorest neurodevelopment outcomes occurring in children who had surgery earlier in life. CONCLUSIONS We report the novel finding that carriers of MBL2Gly54Asp causing autosomal dominant MBL deficiency have increased childhood pervasive developmental problems after cardiac surgery, independent of other covariates. Sensitivity analyses suggest that this effect may be larger in children who underwent surgery at earlier ages. These data support the role of nonsyndromic genetic variation in determining postsurgical neurodevelopment-related outcomes in children with congenital heart disease.
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MESH Headings
- Age Factors
- Cardiac Surgical Procedures/adverse effects
- Checklist
- Child Behavior
- Child Development
- Child Development Disorders, Pervasive/diagnosis
- Child Development Disorders, Pervasive/etiology
- Child Development Disorders, Pervasive/physiopathology
- Child Development Disorders, Pervasive/psychology
- Child, Preschool
- Female
- Gene-Environment Interaction
- Genetic Predisposition to Disease
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/surgery
- Humans
- Infant
- Infant, Newborn
- Male
- Mannose-Binding Lectin/deficiency
- Mannose-Binding Lectin/genetics
- Metabolism, Inborn Errors/complications
- Metabolism, Inborn Errors/diagnosis
- Metabolism, Inborn Errors/genetics
- Metabolism, Inborn Errors/physiopathology
- Motor Skills
- Mutation, Missense
- Nervous System/growth & development
- Neurologic Examination
- Phenotype
- Risk Assessment
- Risk Factors
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Daniel Seung Kim
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash; Department of Biostatistics, University of Michigan, Ann Arbor, Mich
| | - Yatong K Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Mich
| | - Jerry H Kim
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Curtis S Bergquist
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Marsha Gerdes
- Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Judy C Bernbaum
- Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Nancy Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Donna M McDonald-McGinn
- Division of Genetics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Elaine H Zackai
- Division of Genetics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
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Fogel MA, Li C, Elci OU, Pawlowski T, Schwab PJ, Wilson F, Nicolson SC, Montenegro LM, Diaz L, Spray TL, Gaynor JW, Fuller S, Mascio C, Keller MS, Harris MA, Whitehead KK, Bethel J, Vossough A, Licht DJ. Neurological Injury and Cerebral Blood Flow in Single Ventricles Throughout Staged Surgical Reconstruction. Circulation 2016; 135:671-682. [PMID: 28031423 DOI: 10.1161/circulationaha.116.021724] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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: 01/25/2016] [Accepted: 12/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with a single ventricle experience a high rate of brain injury and adverse neurodevelopmental outcome; however, the incidence of brain abnormalities throughout surgical reconstruction and their relationship with cerebral blood flow, oxygen delivery, and carbon dioxide reactivity remain unknown. METHODS Patients with a single ventricle were studied with magnetic resonance imaging scans immediately prior to bidirectional Glenn (pre-BDG), before Fontan (BDG), and then 3 to 9 months after Fontan reconstruction. RESULTS One hundred sixty-eight consecutive subjects recruited into the project underwent 235 scans: 63 pre-BDG (mean age, 4.8±1.7 months), 118 BDG (2.9±1.4 years), and 54 after Fontan (2.4±1.0 years). Nonacute ischemic white matter changes on T2-weighted imaging, focal tissue loss, and ventriculomegaly were all more commonly detected in BDG and Fontan compared with pre-BDG patients (P<0.05). BDG patients had significantly higher cerebral blood flow than did Fontan patients. The odds of discovering brain injury with adjustment for surgical stage as well as ≥2 coexisting lesions within a patient decreased (63%-75% and 44%, respectively) with increasing amount of cerebral blood flow (P<0.05). In general, there was no association of oxygen delivery (except for ventriculomegaly in the BDG group) or carbon dioxide reactivity with neurological injury. CONCLUSIONS Significant brain abnormalities are commonly present in patients with a single ventricle, and detection of these lesions increases as children progress through staged surgical reconstruction, with multiple coexisting lesions more common earlier than later. In addition, this study demonstrated that BDG patients had greater cerebral blood flow than did Fontan patients and that an inverse association exists of various indexes of cerebral blood flow with these brain lesions. However, CO2 reactivity and oxygen delivery (with 1 exception) were not associated with brain lesion development. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135081.
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Affiliation(s)
- Mark A Fogel
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.).
| | - Christine Li
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Okan U Elci
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Tom Pawlowski
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Peter J Schwab
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Felice Wilson
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Susan C Nicolson
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Lisa M Montenegro
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Laura Diaz
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Thomas L Spray
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - J William Gaynor
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Stephanie Fuller
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Christopher Mascio
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Marc S Keller
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Matthew A Harris
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Kevin K Whitehead
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Jim Bethel
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Arastoo Vossough
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Daniel J Licht
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
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36
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Mahle WT, Nicolson SC, Hollenbeck-Pringle D, Gaies MG, Witte MK, Lee EK, Goldsworthy M, Stark PC, Burns KM, Scheurer MA, Cooper DS, Thiagarajan R, Ben Sivarajan V, Colan SD, Schamberger MS, Shekerdemian LS. Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med 2016; 17:939-947. [PMID: 27513600 PMCID: PMC5053873 DOI: 10.1097/pcc.0000000000000918] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [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: 11/25/2022]
Abstract
OBJECTIVE To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING Ten children's hospitals. PATIENTS Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). CONCLUSIONS A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.
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Affiliation(s)
| | | | | | | | | | - Eva K Lee
- Georgia Institute of Technology, Atlanta, GA
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Mahle WT, Jacobs JP, Jacobs ML, Kim S, Kirshbom PM, Pasquali SK, Austin EH, Kanter KR, Nicolson SC, Hill KD. Early Extubation After Repair of Tetralogy of Fallot and the Fontan Procedure: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2016; 102:850-858. [DOI: 10.1016/j.athoracsur.2016.03.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/02/2016] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
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Su F, Gastonguay MR, Nicolson SC, DiLiberto M, Ocampo-Pelland A, Zuppa AF. Dexmedetomidine Pharmacology in Neonates and Infants After Open Heart Surgery. Anesth Analg 2016. [DOI: 10.1213/ane.0000000000000869] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Diaz LK, Gaynor JW, Koh SJ, Ittenbach RF, Gerdes M, Bernbaum JC, Zackai EH, Clancy RR, Rehman MA, Pennington JW, Burnham N, Spray TL, Nicolson SC. Increasing cumulative exposure to volatile anesthetic agents is associated with poorer neurodevelopmental outcomes in children with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2016; 152:482-9. [PMID: 27183886 DOI: 10.1016/j.jtcvs.2016.03.095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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] [Received: 10/01/2015] [Revised: 03/03/2016] [Accepted: 03/17/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Despite improved survival in children with hypoplastic left heart syndrome (HLHS), significant concern persists regarding their neurodevelopmental (ND) outcomes. Previous studies have identified patient factors, such as prematurity and genetic syndromes, to be associated with worse ND outcomes. However, no consistent relationships have been identified among modifiable management factors, including cardiopulmonary bypass strategies, and ND outcomes after cardiac surgery in infancy. Studies in immature animals, including primates, have demonstrated neurodegeneration and apoptosis in the brain after certain levels and extended durations of anesthetic exposure. Retrospective human studies have also suggested relationships between adverse ND effects and anesthetic exposure. METHODS Cumulative minimum alveolar concentration hours (MAC-hrs) of exposure to volatile anesthetic agents (VAA) (desflurane, halothane, isoflurane, and sevoflurane) were collected from an anesthetic database and medical record review for 96 patients with HLHS or variants. ND testing was performed between ages 4 and 5 years, including full-scale IQ, verbal IQ, performance IQ, and processing speed. Four generalized linear modes were hypothesized a priori and tested using a Gaussian (normal) distribution with an identity link. RESULTS Cumulative VAA exposure ranged from 0 to 35.3 MAC-hrs (median 7.5 hours). Using specified covariates identified previously as significant predictors of ND outcomes, statistically significant relationships were identified between total MAC-hrs exposure and worse full-scale IQ and verbal IQ scores (P's < .05) alone and after adjusting for relevant covariates. CONCLUSIONS Increased cumulative MAC-hrs exposure to VAA is associated with worse ND outcomes in certain domains in children with HLHS and variants.
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Affiliation(s)
- Laura K Diaz
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - J William Gaynor
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa.
| | - Shannon J Koh
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Marsha Gerdes
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Judy C Bernbaum
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Elaine H Zackai
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Robert R Clancy
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Mohamed A Rehman
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Jeffrey W Pennington
- Center for Biomedical Informatics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Nancy Burnham
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Thomas L Spray
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Susan C Nicolson
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
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Achuff BJ, Elias MD, O’Connor MJ, Ittenbach RF, Ravishankar C, Nicolson SC, Spray TL, Fuller S, Gaynor JW. RISK FACTORS FOR MORTALITY IN PEDIATRIC CARDIAC INTENSIVE CARE UNIT PATIENTS MANAGED WITH EXTRACORPOREAL MEMBRANE OXYGENATION IN A CONTEMPORARY COHORT. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30976-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kim DS, Kim JH, Burt AA, Crosslin DR, Burnham N, Kim CE, McDonald-McGinn DM, Zackai EH, Nicolson SC, Spray TL, Stanaway IB, Nickerson DA, Heagerty PJ, Hakonarson H, Gaynor JW, Jarvik GP. Burden of potentially pathologic copy number variants is higher in children with isolated congenital heart disease and significantly impairs covariate-adjusted transplant-free survival. J Thorac Cardiovasc Surg 2015; 151:1147-51.e4. [PMID: 26704054 DOI: 10.1016/j.jtcvs.2015.09.136] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [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: 04/20/2015] [Revised: 08/14/2015] [Accepted: 09/14/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Copy number variants (CNVs) are duplications or deletions of genomic regions. Large CNVs are potentially pathogenic and are overrepresented in children with congenital heart disease (CHD). We sought to determine the frequency of large CNVs in children with isolated CHD, and to evaluate the relationship of these potentially pathogenic CNVs with transplant-free survival. METHODS These cases are derived from a prospective cohort of patients with nonsyndromic CHD (n = 422) identified before first surgery. Healthy pediatric controls (n = 500) were obtained from the electronic Medical Records and Genetic Epidemiology Network, and CNV frequency was contrasted for CHD cases and controls. CNVs were determined algorithmically; subsequently screened for >95% overlap between 2 methods, size (>300 kb), quality score, overlap with a gene, and novelty (absent from databases of known, benign CNVs); and separately validated by quantitative polymerase chain reaction. Survival likelihoods for cases were calculated using Cox proportional hazards modeling to evaluate the joint effect of CNV burden and known confounders on transplant-free survival. RESULTS Children with nonsyndromic CHD had a higher burden of potentially pathogenic CNVs compared with pediatric controls (12.1% vs 5.0%; P = .00016). Presence of a CNV was associated with significantly decreased transplant-free survival after surgery (hazard ratio, 3.42; 95% confidence interval, 1.66-7.09; P = .00090) with confounder adjustment. CONCLUSIONS We confirm that children with isolated CHD have a greater burden of rare/large CNVs. We report a novel finding that these CNVs are associated with an adjusted 2.55-fold increased risk of death or transplant. These data suggest that CNV burden is an important modifier of survival after surgery for CHD.
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Affiliation(s)
- Daniel Seung Kim
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash; Department of Biostatistics, University of Washington, Seattle, Wash
| | - Jerry H Kim
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Amber A Burt
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash
| | - David R Crosslin
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash
| | - Nancy Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Cecilia E Kim
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - Elaine H Zackai
- Division of Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ian B Stanaway
- Department of Genome Sciences, University of Washington, Seattle, Wash
| | | | | | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash.
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Kilbaugh TJ, Himebauch AS, Zaoutis T, Jobes D, Greeley WJ, Nicolson SC, Zuppa AF. A pilot and feasibility study of the plasma and tissue pharmacokinetics of cefazolin in an immature porcine model of pediatric cardiac surgery. Paediatr Anaesth 2015; 25:1111-9. [PMID: 26372607 DOI: 10.1111/pan.12756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 07/31/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical site infection (SSI) prevention for children with congenital heart disease is imperative and methods to assess and evaluate the tissue concentrations of prophylactic antibiotics are important to help maximize these efforts. AIM The purposes of this study were to determine the plasma and tissue concentrations with standard of care, perioperative cefazolin dosing in an immature porcine model of pediatric cardiac surgery, and to determine the feasibility of this model. METHODS Piglets (3-5 days old) underwent either median sternotomy (MS) or cardiopulmonary bypass with deep hypothermic circulatory arrest (CPB + DHCA) and received standard of care prophylactic cefazolin for the procedures. Serial plasma and microdialysis sampling of the skeletal muscle and subcutaneous tissue adjacent to the surgical site was performed. Cefazolin concentrations were measured, noncompartmental pharmacokinetic analyses were performed, and tissue penetration of cefazolin was assessed. RESULTS Following the first intravenous dose, maximal cefazolin concentrations in the subcutaneous tissue and skeletal muscle were similar between groups with peak tissue concentrations 15-30 min after administration. After the second cefazolin dose given with the initiation of CPB, total plasma cefazolin concentrations remained relatively constant until the end of DHCA and then decreased while muscle- and subcutaneous-unbound cefazolin concentrations showed a second peak during or after rewarming. For the MS group, 60-67% of the intraoperative time showed subcutaneous and skeletal muscle concentrations of cefazolin >16 μg·ml(-1) while this percentage was 78-79% for the CPB + DHCA group. There was less tissue penetration of cefazolin in the group that underwent CBP + DHCA (P = 0.03). CONCLUSIONS The cefazolin dosing used in this study achieves plasma and tissue concentrations that should be effective against methicillin-sensitive Staphylococcus aureus but may not be effective against some gram-negative pathogens. The timing of the cefazolin administration prior to incision and a second dose given during cardiopulmonary bypass may be important factors for achieving goal tissue concentrations.
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Affiliation(s)
- Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Theoklis Zaoutis
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Infectious Diseases, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - David Jobes
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - William J Greeley
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Fogel MA, Li C, Wilson F, Pawlowski T, Nicolson SC, Montenegro LM, Diaz Berenstein L, Spray TL, Gaynor JW, Fuller S, Keller MS, Harris MA, Whitehead KK, Clancy R, Elci O, Bethel J, Vossough A, Licht DJ. Relationship of cerebral blood flow to aortic-to-pulmonary collateral/shunt flow in single ventricles. Heart 2015; 101:1325-31. [PMID: 26048877 DOI: 10.1136/heartjnl-2014-307311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 12/09/2014] [Accepted: 05/11/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Patients with single ventricle can develop aortic-to-pulmonary collaterals (APCs). Along with systemic-to-pulmonary artery shunts, these structures represent a direct pathway from systemic to pulmonary circulations, and may limit cerebral blood flow (CBF). This study investigated the relationship between CBF and APC flow on room air and in hypercarbia, which increases CBF in patients with single ventricle. METHODS 106 consecutive patients with single ventricle underwent 118 cardiac magnetic resonance (CMR) scans in this cross-sectional study; 34 prior to bidirectional Glenn (BDG) (0.50±0.30 years old), 50 prior to Fontan (3.19±1.03 years old) and 34 3-9 months after Fontan (3.98±1.39 years old). Velocity mapping measured flows in the aorta, cavae and jugular veins. Analysis of variance (ANOVA) and multiple linear regression were used. Significance was p<0.05. RESULTS A strong inverse correlation was noted between CBF and APC/shunt both on room air and with hypercarbia whether CBF was indexed to aortic flow or body surface area, independent of age, cardiopulmonary bypass time, Po2 and Pco2 (R=-0.67--0.70 for all patients on room air, p<0.01 and R=-0.49--0.90 in hypercarbia, p<0.01). Correlations were not different between surgical stages. CBF was lower, and APCs/shunt flow was higher prior to BDG than in other stages. CONCLUSIONS There is a strong inverse relationship between CBF and APC/shunt flow in patients with single ventricle throughout surgical reconstruction on room air and in hypercarbia independent of other factors. We speculate that APC/shunt flow may have a negative impact on cerebral development and neurodevelopmental outcome. Interventions on APC may modify CBF, holding out the prospect for improving neurodevelopmental trajectory. TRIAL REGISTRATION NUMBER NCT02135081.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christine Li
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Felice Wilson
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tom Pawlowski
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa M Montenegro
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Diaz Berenstein
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marc S Keller
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew A Harris
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Clancy
- Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Day TE, Sarawgi S, Perri A, Nicolson SC. Reducing postponements of elective pediatric cardiac procedures: analysis and implementation of a discrete event simulation model. Ann Thorac Surg 2015; 99:1386-91. [PMID: 25661577 DOI: 10.1016/j.athoracsur.2014.12.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/01/2014] [Accepted: 12/05/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study describes the use of discrete event simulation (DES) to model and analyze a large academic pediatric and test cardiac center. The objective was to identify a strategy, and to predict and test the effectiveness of that strategy, to minimize the number of elective cardiac procedures that are postponed because of a lack of available cardiac intensive care unit (CICU) capacity. METHODS A DES of the cardiac center at The Children's Hospital of Philadelphia was developed and was validated by use of 1 year of deidentified administrative patient data. The model was then used to analyze strategies for reducing postponements of cases requiring CICU care through improved scheduling of multipurpose space. Each of five alternative scenarios was simulated for ten independent 1-year runs. RESULTS Reductions in simulated elective procedure postponements were found when a multipurpose procedure room (the hybrid room) was used for operations on Wednesday and Thursday, compared with Friday (as was the real-world use). The reduction Wednesday was statistically significant, with postponements dropping from 27.8 to 23.3 annually (95% confidence interval 18.8-27.8). Thus, we anticipate a relative reduction in postponements of 16.2%. Since the implementation, there have been two postponements from July 1 to November 21, 2014, compared with ten for the same time period in 2013. CONCLUSIONS Simulation allows us to test planned changes in complex environments, including pediatric cardiac care. Reduction in postponements of cardiac procedures requiring CICU care is predicted through reshuffling schedules of existing multipurpose capacity, and these reductions appear to be achievable in the real world after implementation.
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Affiliation(s)
- Theodore Eugene Day
- Office of Safety and Medical Operations, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Sandeep Sarawgi
- Office of Safety and Medical Operations, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexis Perri
- The Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan C Nicolson
- The Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Fogel MA, Li C, Nicolson SC, Spray TL, Gaynor JW, Fuller S, Keller MS, Harris MA, Yoganathan AP, Whitehead KK. Comparison by magnetic resonance phase contrast imaging of pulse-wave velocity in patients with single ventricle who have reconstructed aortas versus those without. Am J Cardiol 2014; 114:1902-7. [PMID: 25432153 DOI: 10.1016/j.amjcard.2014.09.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 05/29/2014] [Revised: 09/20/2014] [Accepted: 09/20/2014] [Indexed: 11/29/2022]
Abstract
Pulse-wave velocity (PWV), a measure of arterial stiffness, is a known independent risk factor for cardiovascular events. Patients with single ventricle who undergo aortic to pulmonary anastomosis (recon) have noncompliant patch material inserted into the neoaorta, possibly increasing vessel stiffness and afterload. The purpose of this study is to determine if PWV in patients with single ventricle differed between those who did and those who did not undergo aortic reconstruction (nonrecon). We retrospectively reviewed cardiac magnetic resonance anatomic, cine, and phase contrast evaluations in the ascending aorta and descending aorta (DAo) at the level of the diaphragm data from 126 patients with single ventricle (8.6 ± 8.0 years) from January 2012 to May 2013. Significance = p <0.05. Seventy-five patients underwent recon and 51 did not. PWV in recon was significantly higher than in nonrecon (3.9 ± 0.9 m/s vs 3.2 ± 1.0 m/s, p = 0.008); in recon, patients >13 years old had a higher PWV than those <7 years (4.5 ± 0.6 vs 3.5 ± 0.7 m/s, p = 0.004). Whether <7 or >13 years old, PWV of those with recon was higher than nonrecon DAo distensibility was similar between both groups. There was no difference in age, body surface area, or cardiac index between recon and nonrecon. No correlations between various hemodynamic and ventricular function parameters with PWV were noted. In conclusion, PWV in recon is higher than in nonrecon with similar DAo distensibility implicating the aortic reconstruction as a possible cause of increased afterload; older recon patients have stiffer aortas than younger ones, possibly imposing an additional cardiovascular risk in the future. Other biomaterials may potentially moderate PWV if clinical outcome is adversely affected.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Christine Li
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc S Keller
- Department of Radiology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew A Harris
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
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Fogel MA, Pawlowski T, Schwab PJ, Nicolson SC, Montenegro LM, Berenstein LD, Spray TL, Gaynor JW, Fuller S, Keller MS, Harris MA, Whitehead KK, Vossough A, Licht DJ. Brain magnetic resonance immediately before surgery in single ventricles and surgical postponement. Ann Thorac Surg 2014; 98:1693-8. [PMID: 25149046 DOI: 10.1016/j.athoracsur.2014.05.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 03/04/2014] [Revised: 05/14/2014] [Accepted: 05/27/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Single-ventricle patients undergoing surgical reconstruction experience a high rate of brain injury. Incidental findings on preoperative brain scans may result in safety considerations involving hemorrhage extension during cardiopulmonary bypass that result in surgical postponement. METHODS Single-ventricle patients were studied with brain scans immediately preoperatively, as part of a National Institutes of Health study, and were reviewed by neuroradiology immediately before cardiopulmonary bypass. RESULTS Of 144 consecutive patients recruited into the project, 33 were studied before stage I (3.7±1.8 days), 34 before bidirectional Glenn (5.8±0.5 months), and 67 before Fontan (3.3±1.1 years) operations. Six operations (4.5%), 2 before stage I, 3 before bidirectional Glenn, and 1 before Fontan, were postponed because of concerning findings on brain magnetic resonance imaging. Five were due to unexpected incidental findings of acute intracranial hemorrhage, and 1 was due to diffuse cerebellar cytotoxic edema; none who proceeded to operation had these lesions. Prematurity and genetic syndromes were not present in any patients with a postponed operation. Four of 4 before bidirectional Glenn/Fontan with surgical delays had hypoplastic left heart syndrome compared with 44 of 97 who did not (p=0.048). After observation and follow-up, all eventually had successful operations with bypass. CONCLUSIONS Preoperative brain magnetic resonance imaging performed in children with single ventricles disclosed injuries in 4.5% leading to surgical delay; hemorrhagic lesions were most common and raised concerns for extension during the operation. The true risk of progression and need for delay of the operation due to heparinization associated with these lesions remains uncertain.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Tom Pawlowski
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Peter J Schwab
- Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Lisa M Montenegro
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Laura Diaz Berenstein
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Marc S Keller
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Matthew A Harris
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Affiliation(s)
- Aruna T Nathan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lynch JM, Buckley EM, Schwab PJ, McCarthy AL, Winters ME, Busch DR, Xiao R, Goff DA, Nicolson SC, Montenegro LM, Fuller S, Gaynor JW, Spray TL, Yodh AG, Naim MY, Licht DJ. Time to surgery and preoperative cerebral hemodynamics predict postoperative white matter injury in neonates with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2014; 148:2181-8. [PMID: 25109755 DOI: 10.1016/j.jtcvs.2014.05.081] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [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] [Received: 02/27/2014] [Revised: 05/12/2014] [Accepted: 05/29/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Hypoxic-ischemic white mater brain injury commonly occurs in neonates with hypoplastic left heart syndrome (HLHS). Approximately one half of HLHS survivors will exhibit neurobehavioral symptoms believed to be associated with this injury, although the exact timing of the injury is unknown. METHODS Neonates with HLHS were recruited for pre- and postoperative monitoring of cerebral oxygen saturation, cerebral oxygen extraction fraction, and cerebral blood flow using 2 noninvasive optical-based techniques: diffuse optical spectroscopy and diffuse correlation spectroscopy. Anatomic magnetic resonance imaging was performed before and approximately 1 week after surgery to quantify the extent and timing of the acquired white matter injury. The risk factors for developing new or worsened white matter injury were assessed using uni- and multivariate logistic regression. RESULTS A total of 37 neonates with HLHS were studied. On univariate analysis, neonates who developed a large volume of new, or worsened, postoperative white matter injury had a significantly longer time to surgery (P=.0003). In a multivariate model, a longer time between birth and surgery, delayed sternal closure, and greater preoperative cerebral blood flow were predictors of postoperative white matter injury. Additionally, a longer time to surgery and greater preoperative cerebral blood flow on the morning of surgery correlated with lower cerebral oxygen saturation (P=.03 and P=.05, respectively) and greater oxygen extraction fraction (P=.05 for both). CONCLUSIONS A longer time to surgery was associated with new postoperative white matter injury in otherwise healthy neonates with HLHS. The results suggest that earlier Norwood palliation might decrease the likelihood of acquiring postoperative white matter injury.
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Affiliation(s)
- Jennifer M Lynch
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa.
| | - Erin M Buckley
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa; Athinoula A. Martinos Center for Biomedical Imaging, Optics Division, Massachusetts General Hospital, Charlestown, Mass; Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Peter J Schwab
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ann L McCarthy
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Madeline E Winters
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - David R Busch
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pa
| | - Donna A Goff
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda, Calif
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Lisa M Montenegro
- Division of Cardiothoracic Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa
| | - Maryam Y Naim
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
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Kim DS, Kim JH, Burt AA, Crosslin DR, Burnham N, McDonald-McGinn DM, Zackai EH, Nicolson SC, Spray TL, Stanaway IB, Nickerson DA, Russell MW, Hakonarson H, Gaynor JW, Jarvik GP. Patient genotypes impact survival after surgery for isolated congenital heart disease. Ann Thorac Surg 2014; 98:104-10; discussion 110-1. [PMID: 24811984 DOI: 10.1016/j.athoracsur.2014.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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: 12/10/2013] [Revised: 02/21/2014] [Accepted: 03/05/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival after cardiac surgery in infancy requires adaptive responses from oxidative stress management and vascular regulation pathways. We tested the hypothesis that genetic variation in these pathways influences postoperative survival in nonsyndromic congenital heart disease children. METHODS This is an analysis of a cohort of nonsyndromic congenital heart disease patients who underwent cardiac surgery with cardiopulmonary bypass before 6 months of age (n=422). Six single nucleotide polymorphisms (SNPs) in six genes involved in oxidative stress and vascular response pathways, identified through a priori literature search, were tested for effects on transplant-free survival. Survival curves, adjusting for confounding covariates, were calculated using the Cox proportional hazard models. RESULTS Long-term survival was strongly associated with vascular endothelial growth factor A gene SNP rs833069 (p=7.03×10(-4)) and superoxide dismutase 2 gene SNP rs2758331 (p=0.019). To test for joint effects of the two SNPs on transplant-free survival, the genotypes were grouped to form a risk score reflecting the cumulative number of risk alleles (0 to 4 alleles per patient). A higher risk score based on the VEGFA and SOD2 SNP genotypes was associated with worse transplant-free survival (p=3.02×10(-4)) after confounder adjustment. The total burden of risk alleles was additive; subjects with the highest risk score of 4 (n=59 subjects, 14.2% of the cohort) had a total covariate-adjusted hazard ratio of 15.64 for worse transplant-free survival. CONCLUSIONS After cardiac surgery, infants who are homozygous for the high-risk alleles for both the VEGFA and SOD2 SNPs have an approximately 16-fold increased risk of death or heart transplant, suggesting that genetic variants are important modifiers of survival after surgery for congenital heart disease.
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Affiliation(s)
- Daniel Seung Kim
- Department of Medicine, Division of Medical Genetics, University of Washington School of Medicine, Seattle, Washington; Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Jerry H Kim
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Amber A Burt
- Department of Medicine, Division of Medical Genetics, University of Washington School of Medicine, Seattle, Washington
| | - David R Crosslin
- Department of Medicine, Division of Medical Genetics, University of Washington School of Medicine, Seattle, Washington; Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Nancy Burnham
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Elaine H Zackai
- Division of Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ian B Stanaway
- Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Deborah A Nickerson
- Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Mark W Russell
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gail P Jarvik
- Department of Medicine, Division of Medical Genetics, University of Washington School of Medicine, Seattle, Washington; Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington.
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50
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Jain V, Buckley EM, Licht DJ, Lynch JM, Schwab PJ, Naim MY, Lavin NA, Nicolson SC, Montenegro LM, Yodh AG, Wehrli FW. Cerebral oxygen metabolism in neonates with congenital heart disease quantified by MRI and optics. J Cereb Blood Flow Metab 2014; 34:380-8. [PMID: 24326385 PMCID: PMC3948119 DOI: 10.1038/jcbfm.2013.214] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [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: 07/31/2013] [Revised: 10/30/2013] [Accepted: 11/04/2013] [Indexed: 11/09/2022]
Abstract
Neonatal congenital heart disease (CHD) is associated with altered cerebral hemodynamics and increased risk of brain injury. Two novel noninvasive techniques, magnetic resonance imaging (MRI) and diffuse optical and correlation spectroscopies (diffuse optical spectroscopy (DOS), diffuse correlation spectroscopy (DCS)), were employed to quantify cerebral blood flow (CBF) and oxygen metabolism (CMRO(2)) of 32 anesthetized CHD neonates at rest and during hypercapnia. Cerebral venous oxygen saturation (S(v)O(2)) and CBF were measured simultaneously with MRI in the superior sagittal sinus, yielding global oxygen extraction fraction (OEF) and global CMRO(2) in physiologic units. In addition, microvascular tissue oxygenation (StO(2)) and indices of microvascular CBF (BFI) and CMRO(2) (CMRO(2)(i)) in the frontal cortex were determined by DOS/DCS. Median resting-state MRI-measured OEF, CBF, and CMRO(2) were 0.38, 9.7 mL/minute per 100 g and 0.52 mL O(2)/minute per 100 g, respectively. These CBF and CMRO(2) values are lower than literature reports for healthy term neonates (which are sparse and quantified using different methods) and resemble values reported for premature infants. Comparison of MRI measurements of global S(v)O(2), CBF, and CMRO(2) with corresponding local DOS/DCS measurements demonstrated strong linear correlations (R(2)=0.69, 0.67, 0.67; P<0.001), permitting calibration of DOS/DCS indices. The results suggest that MRI and optics offer new tools to evaluate cerebral hemodynamics and metabolism in CHD neonates.
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Affiliation(s)
- Varsha Jain
- Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - Erin M Buckley
- 1] Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA [2] Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer M Lynch
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter J Schwab
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maryam Y Naim
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natasha A Lavin
- Division of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesia, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa M Montenegro
- Division of Cardiothoracic Anesthesia, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
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