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Objective: B-type natriuretic peptide is used in the diagnosis, risk stratification, and management of adult patients with cardiac disease. However, its use in infants with congenital heart disease has been limited, particularly in the perioperative period. Our objective was to determine the alterations in perioperative B-type natriuretic peptide levels and their predictive value on postoperative outcomes, in infants undergoing congenital heart surgery., Methods: We prospectively enrolled 115 patients: 24 with univentricular heart disease undergoing a modified Norwood procedure, 11 with d-transposition of the great arteries, 55 with hemodynamically important left-to-right shunt, and 25 with tetralogy of Fallot undergoing primary repair. Clinical data and B-type natriuretic peptide samples were collected before and 2, 12, and 24 hours after cardiopulmonary bypass. Univariate analysis and multivariate linear regression analysis were performed., Results: The perioperative B-type natriuretic peptide levels were lesion specific. Patients with d-transposition of the great arteries and univentricular heart disease had high preoperative B-type natriuretic peptide levels that decreased postoperatively, and those with hemodynamically important left-to-right shunts and tetralogy of Fallot had lower preoperative levels that increased during the first 12 hours postoperatively. The patients with univentricular heart disease with an adverse outcome had a significantly greater 24-hour B-type natriuretic peptide level than those without (P < .05). Those with hemodynamically important left to right shunts and an adverse outcome had a greater 12-hour B-type natriuretic peptide level than those without (P < .05). A 12-hour postoperative/preoperative ratio greater than 45 was 100% sensitive and 82% specific for an adverse outcome in the patients with tetralogy of Fallot., Conclusions: The perioperative changes in B-type natriuretic peptide levels and their ability to predict outcomes are lesion-specific. Characterization of these changes might be useful in caring for infants after congenital heart surgery., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Tricuspid regurgitation is a significant risk factor for reoperation and mortality in patients with hypoplastic left heart syndrome. The effects of tricuspid valve repair on quantitative measures of right ventricle and tricuspid valve remodeling have not been well documented., Methods: We reviewed retrospectively the 2-dimensional echocardiograms of 17 tricuspid valve repairs (male, n = 12; female, n = 5; median age, 30 months; age range, 1.5-53 months) performed 1 month before and after tricuspid valve repair between 2005 and 2011. From the apical 4-chamber view, we measured right ventricle end-diastolic area, right ventricle fractional area change, and tricuspid valve leaflet coaptation length. The severity of tricuspid regurgitation was graded qualitatively. A 2-sided paired t test was used to compare changes in tricuspid valve and right ventricle outcomes, and the Wilcoxon signed-rank test was used to compare changes in tricuspid regurgitation grades., Results: Right ventricle end-diastolic area decreased significantly after tricuspid valve repair from 14.1 ± 5.2 to 11.8 ± 3.9 cm(2) (P = .001), whereas right ventricle fractional area change declined from 44.4% ± 6.4% to 39.7% ± 8.5% (P = .016). The coaptation length of the lateral and septal leaflet improved significantly after tricuspid valve repair (0.4 ± 2.4 mm vs 3.1 ± 2.7 mm, P = .002; 2.0 ± 2.7 vs 3.4 ± 2.0 mm, P = .036; respectively). Furthermore, the tricuspid regurgitation grade improved after tricuspid valve repair (3.1 ± 0.6 to 1.7 ± 0.9, P < .001)., Conclusions: Tricuspid valve repair improved significantly the tricuspid valve coaptation length and reduced right ventricle volume in children with hypoplastic left heart syndrome. Further follow-up of decreased right ventricle function is required to determine whether this is a temporary phenomenon related to reduced right ventricle preload, permanent right ventricle dysfunction from late repair of the tricuspid valve, or unavoidable sequelae of a right ventricle exposed to systemic vascular resistance., (Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.)

Objective: Extracorporeal life support is used in 3% to 8% of infants and children after cardiac surgery. B-type natriuretic peptide may have utility as a biomarker in these patients. The objective of this study was to investigate potential associations between changes in B-type natriuretic peptide during trials off extracorporeal life support and clinical outcome., Methods: Ten infants and children requiring extracorporeal life support after cardiac surgery were studied prospectively. Before separation from extracorporeal life support, a shunt was placed in the circuit, allowing for temporary trials off life support. Serum lactate, arterial-venous oxyhemoglobin saturation difference, and B-type natriuretic peptide levels were determined before each trial off life support and at the end of each trial off life support, and the ability to predict postoperative outcome from these data was evaluated., Results: During trials off extracorporeal life support, lactate, the arterial-venous oxyhemoglobin saturation difference, and B-type natriuretic peptide levels increased above pre-trial values (P < .05). Only the arterial-venous oxyhemoglobin saturation difference predicted successful separation from extracorporeal life support after a trial (P < .05). There were no associations between long-term outcome and alterations in lactate and the arterial-venous oxyhemoglobin saturation difference during the final trials off life support. However, an increase in B-type natruiretic peptide levels during the final trial off life support (trial/pre-trial ratio of >1) had a sensitivity of 80% and a specificity of 100% for predicting the need for an unplanned operation or death within 3 months (P < .05)., Conclusion: B-type natriuretic peptide determinations may be a useful tool for clinicians caring for infants and children requiring extracorporeal life support after cardiac surgery.

Objective: To compare changes in regional cerebral or flank oxygen saturation measured by near-infrared spectroscopy with changes in central venous oxygen saturation (ScvO2) and to determine clinical variables associated with these changes., Design: Prospective observational cohort study., Setting: University tertiary care center, pediatric cardiac intensive care unit., Patients: Seventy postoperative congenital cardiac surgical patients (median age 0.3 yrs; interquartile range 0.02-0.46 yrs)., Interventions: None., Measurements and Main Results: We measured temporally correlated regional oxygen saturation (rSO2) with hematologic (hematocrit), biochemical (arterial blood gas, ScvO2, and lactate) and physiologic (temperature, heart rate, mean blood pressure, and pulse oximetry) variables in the first postoperative day. Cerebral and flank rSO2 were strongly correlated with ScvO2, in both cyanotic or acyanotic patients and single- or two-ventricle physiology with and without aortic arch obstruction (all p < .001). However, individual values had wide limits of agreement on Bland-Altman analysis. The correlations of change in these measurements were weaker but still significant (all p < .0001), again with wide limits of agreement. Similar direction of change in cerebral rSO2 and ScvO2 was present 64% (95% confidence interval, 55-73%) of the time. Change in arterial pressure of carbon dioxide (delta PaCO2) was associated with cerebral delta rSO2 (delta PaCO2 beta = 0.35, p < .0001) but not flank delta rSO2 or delta ScvO2. A pattern of relative cerebral desaturation (flank rSO2 > cerebral rSO2) was noted in a majority of patients (81%) with two-site monitoring regardless of bypass method or age., Conclusions: Neither individual values nor changes in rSO2 are interchangeable measures of ScvO2 in postoperative pediatric cardiac patients. The unique relationship between changes in PaCO2 and cerebral rSO2 supports the hypothesis that cerebral near-infrared spectroscopy monitors regional cerebral oxygenation. Clinical application of this monitor must include recognition of the clinical variables that affect regional brain oxygenation.

Objective: We sought to review the outcome of infants with a functional single ventricle receiving postoperative extracorporeal life support., Methods: We reviewed all patients with a functional single ventricle receiving postoperative extracorporeal life support between January 1997 and May 2003., Results: We supported 25 infants (age range, 2-139 days; median age, 15 days; weight range, 1.9-5.9 kg; median weight, 3.4 kg) with extracorporeal life support. Operative procedures were Norwood stage 1 procedure in 18 patients, modified Blalock-Taussig shunt in 4 patients, bidirectional superior cavopulmonary shunt in 2 patients, and pulmonary vein repair in 1 patient. Indications for extracorporeal life support included cardiac arrest (14/25) and low cardiac output state (11/25). Extracorporeal membrane oxygenation was initiated in 19 patients, with conversion to a ventricular assist device in 7 patients. Ventricular assist device alone was initiated in 6 patients. Survival to decannulation was 76%, with 5 late deaths from multiorgan failure and 56% intensive care unit survival. Survival to hospital discharge was 44%. On univariate analysis, the presence of arrhythmia before extracorporeal life support (P = .005), renal failure (P = .0007), Candida species-induced sepsis (P = .026), and multiorgan failure (P = .0009) were significant risk factors in the nonsurvivors. Median hospital stay was 43.5 days (range, 6-181 days) for the whole group and 93 days (range, 36-181 days) for survivors. Eight patients completed next stage palliation., Conclusions: Twenty percent of patients were supported with a ventricular assist device alone, with 50% conversion to a ventricular assist device from extracorporeal membrane oxygenation. Survival to decannulation was encouraging. Multiorgan failure and risk of invasive infection in the post-extracorporeal membrane oxygenation period mitigate against survival to hospital discharge. Use of extracorporeal life support before cardiac arrest might reduce attrition between decannulation and hospital discharge.

Background: Large symptomatic mediastinal seroma following modified-BT shunts, traditionally required revisional thoracotomy., Objective: We describe percutaneous image-guided pigtail catheter drainage in the successful treatment of early mediastinal seroma secondary to PTFE Blalock-Taussig shunt, avoiding thoracotomy., Materials and Methods: A retrospective review of all relevant clinical and imaging records in five patients was performed., Results: All five presented with intermittent stridor, respiratory distress and/or episodic desaturation within 6 weeks of their surgery. In four of five infants, percutaneous drainage was effective and reoperation was avoided. In one of five, rather than urgent surgical evacuation and BT shunt revision, we were able to perform an elective stage-II bidirectional Glenn SVC-RA anastamosis in a stable infant. There were no complications., Conclusions: Percutaneous image-guided drainage of mediastinal seroma secondary to PTFE-BT shunt is a safe, minimally invasive, and effective treatment. This may avoid BT shunt revision.