Search

Background: The management of ventricular septal defect (VSD) alongside mitral regurgitation (MR) in pediatric patients remains a contentious issue due to the intricacies of cardiac surgery and the need to minimize ischemic time. Despite observations of MR regression following VSD closure, definitive guidelines for this patient subset are lacking, particularly concerning the management of the subgroup of patients with moderate MR. The objective of the study is to explore the factors influencing the choice between surgical intervention and conservative management for the mitral valve (MV) in VSD patients with moderate MR. Materials and Methods: A retrospective cohort study from January 2000 to December 2015, we analyzed management trends and focused on 53 patients with both VSD and moderate MR. This cohort was subdivided into four groups: first by their MV pathology, and then stratified by the receipt of intervention towards the diseased MV. Our primary goal was to identify correlations, especially concerning surgical outcomes such as mortality and need for re-operation. Statistical significance is determined when the P value is lower than 0.05. Results: There were no notable differences in preoperative variables across four cohort groups, apart from the cross-clamp duration which was longest in Group B intervention. Outcome analysis showed survival rates that were higher in cohort groups that underwent intervention toward the disease MV regardless of existing MV morphology, although results were not statistically significant. Cox model analysis found no correlation between the cohort groups and postoperative outcomes, but cross-clamp duration significantly correlated with mortality. Conclusions: In cases of VSD with moderate MR with associated pathologies of the valvular apparatus, opting for MV repair (MVr) appears to improve survival outcomes without significantly increasing postoperative morbidity. Similarly, for patients with moderate MR and isolated annular dilatation, surgical MVr is observed to have better survival trend compared to the control group. [ABSTRACT FROM AUTHOR]

Stress caused by cardioplegic ischemic arrest was shown to alter the expression levels of heat shock proteins (Hsp), but little is known about their effects, particularly on pediatric hearts. This study aimed to investigate whether myocardial cellular stress and apoptotic response changes due to different cardioplegia (CP) solutions during cardiopulmonary bypass (CPB) in infants and to determine their influence on surgical/clinical outcomes. Therefore, twenty-seven infants for surgical closure of ventricular septal defect were randomly assigned to a CP solution: normothermic blood (BCP), delNido (dNCP), and Custodiol (CCP). Hsp levels and apoptosis were determined by immunoblotting in cardiac tissue from the right atrium before and after CP, and their correlations with cardiac parameters were evaluated. No significant change was observed in Hsp27 levels. Hsp60, Hsp70, and Hsp90 levels decreased significantly in the BCP-group but increased markedly in the CCP-group. Decreased Hsp60 and increased Hsp70 expression were detected in dNCP-group. Importantly, apoptosis was not observed in dNCP- and CCP-groups, whereas marked increases in cleaved caspase-3 and -8 were determined after BCP. Serum cardiac troponin-I (cTn-I), myocardial injury marker, was markedly lower in the BCP- and dNCP-groups than CCP. Additionally, Hsp60, Hsp70, and Hsp90 levels were positively correlated with aortic cross-clamp time, total perfusion time, and cTn-I release. Our findings show that dNCP provides the most effective myocardial preservation in pediatric open-heart surgery and indicate that an increase in Hsp70 expression may be associated with a cardioprotective effect, while an increase in Hsp60 and Hsp90 levels may be an indicator of myocardial damage during CPB. [ABSTRACT FROM AUTHOR]

Although the median sternotomy has been the traditional approach for congenital heart surgery, young patients and their families often find the midline scar to be cosmetically unappealing. At our center, a right transverse axillary incision has become the standard approach for many congenital cardiac lesions because of its safety, versatility, and unsurpassed aesthetic result. We present our experience with the axillary approach for a diverse array of congenital defects. A retrospective review of patients receiving a right transverse axillary incision for congenital cardiac surgery between 2005 and 2016 was conducted. The right transverse axillary incision was performed in 358 patients for 24 unique procedures. Median age was 5 years (range 1 month-60 years) and 225 patients (63%) were female. Median weight was 17 kg (range 4-124 kg), with 19 patients (5%) weighing less than 6 kg. The most common lesions were atrial septal defects (n = 244, 68%) and ventricular septal defects (n = 72, 20%). As experience with this approach increased, other repairs included subvalvular aortic membrane resection (n = 10, 3%), tetralogy of Fallot repair (n = 7, 2%), ventricular assist device placement (n = 3, 1%), and mitral valve repair (n = 2, 1%). There were no intraoperative deaths or conversions to sternotomy. In-hospital complications included mortality (n = 1, 0.3%), reoperations for bleeding (n = 5, 1%), pneumothorax or pleural effusion (n = 6, 2%), and permanent pacemaker (n = 4, 1%). The right axillary incision allows a safe and effective repair for a broad range of congenital heart defects and is a potential new standard of care for many patients. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) is used in a variety of indications worldwide. One of the most important subsets is postoperative congenital cardiac surgery cases unresponsive to conventional therapies. In this study, we present our ECMO experience in a single congenital cardiac surgery center. Methods: ECMO was used in a total of 34 postoperative congenital cardiac surgery cases, whose operations had been performed by the same congenital cardiac surgery team. Patients’ ages were between 3 days to 15 years. ECMO was used in four different indications; in case of unsuccessful weaning from cardiopulmonary bypass (OR-ECMO), in low cardiac output syndrome (LCOS-ECMO), in refractory post cardiac arrest (CPR-ECMO) and in respiratory insufficiency after RSV infection (RSV-ECMO). Results: The follow-up period of patients ranged from 1 to 80 months, whereas ECMO duration ranged from 23 to 2218 hours. Six cases were OR-ECMO, 13 were LCOS-ECMO, 12 were CPR-ECMO and 3 were RSV-ECMO. Out of a total of 34 cases, 20 (58%) cases were weaned from ECMO. Two of the patients, who were able to be weaned from ECMO passed away in the hospital; however, the other 18 patients (52.9%) were discharged from the hospital without having any significant neurological deficits. The top survival rate (69%) and weaning from ECMO was in the LCOS-ECMO group and the worst weaning from ECMO support (33%) was in the RSV-ECMO. The worst survival rate (25%) was in the CPR-ECMO group. Sepsis and associated multiple organ dysfunction were observed as the major cause of mortality in these patients. The most common complications were bleeding and mechanical complications related to cannulation. Conclusions: ECMO may be required in postoperative congenital cardiac surgery cases in whom all other conventional therapies have failed. Indications, timing and maintenance of equipment are very important points in successful ECMO management. Increasing ECMO experience in the near future, will provide much decrease in mortality of congenital cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Postoperative mechanical ventilation is required in patients undergoing congenital heart surgery. However, the duration of mechanical ventilation may be extended as a result in some patients. Inflammation is a normal and expected process following surgery and the intensive care process. However, increased and prolonged inflammation increases the risk of mortality and morbidity. The neutrophil lymphocyte ratio (NLR) can be used as a new marker of inflammation in cardiovascular diseases. The aim of our study was to evaluate the association between NLR and successful extubation in pediatric patients undergoing cardiovascular surgery with prolonged intubation. Methods: Pre-extubation blood samples were used for the baseline data. Extubation failure was defined as reintubation within 24 hours of extubation for study purposes. Total white blood cell (WBC), neutrophil and lymphocyte count were recorded pre-extubation, and the NLR was calculated. Results: Ninety-nine patients who had undergone congenital heart surgery were classified. Statistically significant differences were observed with regard to the blood results for the two groups for WBC (P = 0.001), neutrophil count (P = 0.001), lymphocyte count (P = 0.003), and NLR (P = 0.001). Following multivariate logistic regression analysis, the NLR, WBC, neutrophil count, lymphocyte count remained significant predictors of successful extubation. Conclusions: The NLR was found to vary significantly in children in whom extubation failed compared to that in children in whom extubation was successful (following prolonged intubation) and was also predictive of successful extubation in our study. [ABSTRACT FROM AUTHOR]

Cardiopulmonary bypass ( CPB) elicits a systemic inflammatory response. The neutrophil elastase inhibitor sivelestat is known to suppress this systemic inflammatory response, which can eventually result in acute organ failure. The prophylactic effect of sivelestat on acute lung injury, especially in pediatric cardiac surgery, remains unclear. This prospective double-blind, randomized study evaluated the perioperative prophylactic effect of sivelestat in patients undergoing elective pediatric open heart surgery with CPB. Thirty consecutive patients, weighing 5-10 kg and undergoing open heart surgery with CPB, were assigned to sivelestat ( n = 15) or control ( n = 15) groups. From CPB initiation to 24 h after surgery, patients in the sivelestat group received a continuous intravenous infusion of 0.2 mg/kg/h sivelestat, whereas patients in the control group received the same volume of 0.9% saline. Blood samples were collected, and levels of interleukin ( IL)-6, IL-8, tumor necrosis factor alpha, polymorphonuclear elastase ( PMN- E), C-reactive protein ( CRP), as well as the white blood cell ( WBC) count, platelet count, and neutrophil count ( NC) were measured. PMN- E levels, IL-8 levels, WBC count, NC, and CRP levels were significantly lower, and platelet count was significantly higher in the sivelestat group, according to repeated two-way analysis of variance. The activated coagulation time was significantly shorter in the sivelestat group, similarly, blood loss was significantly less in the sivelestat group. In conclusion, Sivelestat attenuates perioperative inflammatory response and clinical outcomes in patients undergoing pediatric heart surgery with CPB. [ABSTRACT FROM AUTHOR]

Until recently, risk scoring systems for adult patients consisted of only clinical criteria. Currently, we are experiencing an abundant surge of literature integrating a wide range of biomarker arrays to clinical criteria in assessing the risk in an adult. In fact, novel risk scoring systems such as Reynolds criteria have emerged by combining the validated biomarkers to the traditional risk factors. Novel biomarkers potentially improve clinical management of cardiovascular disease, but there are gaps in understanding their role during childhood. The reason might be related to relatively lower prevalence of cardiovascular disease in children compared to the adult population. One exceptional group is the children with congenital heart disease. Recent studies indicate that novel biomarkers can alert the clinician in a timely manner about neurological and myocardial injury and their inflammatory consequences. Current technologies enable us to measure several biomarkers using only a few microliters of plasma. The preliminary studies show that novel biomarkers in addition to the traditionally studied biomarkers can help the clinician to identify children at high risk following pediatric heart surgery. Future studies are needed to confirm the role of biomarkers in monitoring children after cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

Objective: To evaluate procalcitonin and C-reactive protein as markers of inflammation severity and their value in predicting development of organ failure after pediatric open heart surgery.Design: Prospective, observational, clinical study.Setting: Single university hospital.Patients: Thirty-three pediatric patients with systemic inflammatory response syndrome (SIRS; n=19) and SIRS+organ failure (SIRS+OF; n=14) following open heart surgery were included.Measurements and Results: Plasma procalcitonin and C-reactive protein levels were measured before and after the operation, and 1, 2, 3, and 4 days after surgery. Patients were evaluated daily to assess organ failure. Postoperative procalcitonin levels in the SIRS+OF group were significantly higher than in the SIRS group. C-reactive protein levels were similar between the groups throughout the study period. Peak procalcitonin levels were found to be positively correlated with aortic cross-clamp and cardiopulmonary bypass times, duration of mechanical ventilation, intensive care unit and hospital stay, mortality and organ failure development. Peak procalcitonin was found to be a good predictor of postoperative organ failure development and mortality. However, the predictive value of peak C-reactive protein for organ failure and mortality was found to be weak. Double-peak procalcitonin curves were observed in SIRS+OF patients with infection during the intensive care unit stay.Conclusion: In the SIRS+OF group peak procalcitonin levels were found to be highly predictive for mortality and organ failure development, whereas C-reactive protein levels were not. Daily procalcitonin measurements in SIRS+OF patients may help identify the postoperative infection during the follow-up period. [ABSTRACT FROM AUTHOR]

Outcome variation in congenital heart surgery in the US is unacceptable. Mounting evidence shows higher volume programs have better outcomes than lower volume programs. According to the publicly available Society of Thoracic Surgeons (STS) data reflecting 2014–2017, centers with ≤2% adjusted mortality rate (AMR) perform an average of 300 cases per year while centers with >4% AMR perform an average of only 100 cases per year. Regionalization by collapsing low volume centers into fewer high volume centers would reduce mortality, but would also impact travel burden, hospital infrastructure, and medical education. A rational approach minimizes these impacts while achieving quality standards set collaboratively with professional societies. Ideally, regionalization of the over 150 congenital heart surgery programs operating today to 71 centers each performing 250–300 or more cases per year maintains a program for each state with a population of 2 million or more people and minimizes travel burden. These regional centers would work in concert with pediatric cardiology centers where patients could receive local diagnostic and long term follow up care. • There is significant concerning variation in congenital heart surgery outcomes. • The best outcomes occur at high volume centers performing 250–300 annual cases. • Regionalization of congenital heart surgery would improve outcomes. • Regionalization impacts travel burden, medical education, infrastructure, prestige. • Professional Societies should set standards for congenital heart surgery outcomes. [ABSTRACT FROM AUTHOR]

• Pediatric heart sugery remains challenging. • New tools are needed to tackle this enormous challenge. • Bioengineered heart muscle, ventricles, Fontan pumps and hearts can be used in pediatric heart surgery. • This technology can prove to be game-changer in the field of pediatric heart surgery. Pediatric heart surgery remains challenging due to the small size of the pediatric heart, the severity of congenital abnormalities and the unique characteristics of each case. New tools and technologies are needed to tackle this enormous challenge. Tissue engineering strategies are focused on fabricating contractile heart muscle, ventricles, Fontan pumps and whole hearts, and a transplantable tissue equivalent has tremendous implications in pediatric heart surgery to provide functional cardiac tissue. This technology will prove to be a game-changer in the field of pediatric heart surgery and provide a novel toolkit for pediatric heart surgeons. This review will provide insight into the potential applications of tissue engineering technologies to replace lost contractile function in pediatric patients with heart abnormalities. [ABSTRACT FROM AUTHOR]