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A secondary analysis of the MiLe-1 trial was published in Acta Anaesthesiologica Scandinavica, focusing on biomarker profiles in children with congenital heart defects (CHD). The study found that elevated levels of inflammatory markers were associated with an increased risk of acute kidney injury, longer ventilatory support time, and the need for vasoactive drugs. However, it is unclear whether the inflammatory response is primarily due to surgical trauma or the use of cardiopulmonary bypass. The study also highlighted the potential impact of enhanced recovery after anesthesia and surgery (ERAAS) protocols in improving outcomes for children with CHD. Overall, the study suggests the need for further research to understand the causes and outcomes of acute kidney injury in this population. [Extracted from the article]

Aims: Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound‐guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery. Methods: Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two‐year period receiving central venous catheters for cardiac surgery. Primary endpoint: Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height‐based formula without adjustment for side used. Results: Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively. Conclusions: Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth. [ABSTRACT FROM AUTHOR]

Perioperative mortality and morbidity in childhood essentially depend on the quality of the anesthesia. The Safe Anesthesia for every Tot (SafeTots) initiative takes this into account and has defined normotension, normovolemia and normal heart rate as quality criteria in pediatric anesthesia. Appropriate monitoring of pediatric hemodynamics is necessary to fulfil these criteria. This article provides an overview of currently used methods and techniques for instrumental and non-instrumental cardiovascular monitoring in children. The current study situation, recommendations and guidelines on the application as well as practical aspects of the measurement methods are explained as far as possible. For a better understanding, procedures not routinely used in clinical practice are described in more detail. [ABSTRACT FROM AUTHOR]

Background: Several formulae or methods are reported to predict the ideal central venous catheter insertion depth. However, they are complicated and often unsuitable in cases requiring rapid management. Aims: This study aimed to determine a simple and practical method to predict the ideal central venous catheter insertion depth after the real‐time ultrasound‐guided right internal jugular vein, or left or right supraclavicular approach in pediatric patients. Method: Pediatric patients with congenital heart diseases who underwent cardiovascular surgery between July 2015 and February 2018 in the German Pediatric Heart Center Sankt Augustin were enrolled. Body height, body weight, patient age (months), and central venous catheter insertion depth were retrieved from the anesthesia records. Ideal central venous catheter insertion depth was calculated by measuring the distance between the level of the carina tracheae and the  central venous catheter tip on the first postoperative chest radiograph. The relationships of body height, body weight, and patient age (months) to ideal central venous catheter insertion depth for the right internal jugular, left supraclavicular, and right supraclavicular approaches were investigated. Results: Body height was the best parameter, providing the best coefficients of determination as well as the simplest relationship. Based on analysis for ideal central venous catheter insertion depth for every 10‐cm increase in body height, there was an ideal central venous catheter insertion depth for each body height, independent of the anesthesiologist's experience with the approach used. Whereas ideal central venous catheter insertion depths for the right internal jugular vein approach and the left supraclavicular approach showed no significant difference, ideal central venous catheter insertion depth for the right supraclavicular approach was significantly shorter than that of the other two approaches. Conclusion: This study successfully determined a visually simple and practical bar graph to predict the ideal central venous catheter depth inserted using only the real‐time ultrasound‐guided insertion technique for the right internal jugular vein, left supraclavicular, and right supraclavicular approaches. [ABSTRACT FROM AUTHOR]

Numerous formulas that can predict endotracheal intubation depth at the corner of the mouth or the nasal wing of patients have been reported, even though the oral and nasal cavity anatomies differ among patients. Therefore, the purpose of this study was to derive a simple and reliable formula to predict the ideal endotracheal tube insertion depth at the vocal cord level in pediatric patients. The current study was conducted as a retrospective observational study, involving 425 and 335 cardiac pediatric patients in Germany and Japan, respectively, and aimed to determine a formula for predicting tracheal length and ideal depth of endotracheal intubation at the vocal cord level in pediatric patients. The distance between the vocal cords and the carina tracheae was defined as the tracheal length, and was measured on preoperative chest radiographs obtained in the supine position. The tracheal length in cardiac pediatric patients ranged from 6 to 10% of the body height in Germany and from 7 to 11% in Japan. This study revealed racial differences in the tracheal length, that is, in the ideal depth of endotracheal intubation at the vocal cord level. This study suggests that an adequate endotracheal intubation depth can be achieved by inserting endotracheal tubes at the vocal cord level with the minimum tracheal length of each racial group in pediatric patients, for example, 6% and 7% of the body height in Europeans and Asians, respectively. If the endotracheal tube inserted with this method appears to be shallow on chest radiographs, this does not represent an increased risk of accidental extubation, due to an excessively short intubation depth, because the minimum tracheal length for each racial group is considered. That is, it is not due to the endotracheal tube insertion length, but is likely due to the tracheal length of the patient, who has a relatively long tracheal length in the racial group. [ABSTRACT FROM AUTHOR]

Objectives In pediatric patients vascular access is often more difficult than in adults because of the smaller size of the vessels and the inability of the patient to cooperate without deep sedation or general anesthesia. Therefore Ultrasound has already become an invaluable tool for vascular access, but the full potential of ultrasound has yet to be fully realized. Improvements in image quality and a better understanding of optimal insertion techniques continue to help clinicians safely and efficiently place catheters with fewer complications. Methods and Technique The probes used for the vascular access are mainly linear and convex type. Higher- frequency ultrasound provides a vivid image; however, the signals are remarkably attenuated. Therefore, the choice of the probe with appropriate frequency is essential. As blood vessels are relatively easily identified with ultrasound, ultrasound-guided vascular access does not require as sharp images as ultrasound-guided nerve block. For pediatric vascular access, the linear probe with 5-15 MHz, 2-5 cm depth is ideal and adequate for almost all cases. Ultrasound-guided vascular access has two main approaches: 'long-axis' or 'in-plane approach' and 'short-axis' or 'transverse approach'. The long-axis approach visualizes the vessel along the insertion pathway and is commonly used to monitor the entire approach of the needle into the vessel. The short-axis approach is easier to show the positional relationship and depth of target vessels, but it is much harder to follow the needle tip within the tissues. Conclusion The use of 'real-time' ultrasound has been shown to increase first insertion success, reduce access time, have a higher overall success, and reduce arterial puncture. As the technology continues to improve the use of ultrasound will become as ubiquitous as the lines themselves. [ABSTRACT FROM AUTHOR]

Abstract: Objective: There has been concern about the usage of aprotinin, an antifibrinolytic drug that was often used in pediatric cardiac surgery until 2006. At our center, these concerns led to the replacement of aprotinin with tranexamic acid for antifibrinolytic treatment. Methods: In this retrospective observational study, two groups of pediatric patients were studied during two different periods, receiving either aprotinin (n =70) or tranexamic acid (n =70) upon cardiac surgery. Data were collected from children with cyanotic heart defects, children who weighed less than 10kg, and children who underwent re-operation. Results: There was no difference in terms of blood loss or amount of erythrocyte concentrates and fresh frozen plasma transfused. Only the intraoperative amount of platelet concentrate received by children in the tranexamic acid group was 29ml (p =0.013) higher. There was no significant difference in the length of stay at the intensive care unit, in renal function values, or in the rate of rethoracotomy. Conclusions: The results of this study suggest that tranexamic acid represents an adequate alternative to aprotinin in congenital cardiac surgery. [Copyright &y& Elsevier]

Abstract: Objective: Paediatric cardiac surgery is often performed under hypothermic conditions, that is, with a reduced core body temperature. Certain interventions even require the circulation to be stopped. This can only be done at a body temperature of 18°C, with no risk of neurological damage and harm to the brain and other organs. Vasoconstriction is a natural reaction of the body to cold, causing the blood vessels to contract. Such a reaction would lead to a clear rise in blood pressure on cardiopulmonary bypass (CPB). Since the blood pressure is regulated in the arteriolar loop of the capillary system, there is a marked increase in blood pressure and a suppression of free water into the surrounding tissue, which, in turn, may lead to the intra-operative development of oedemas. This study aimed to investigate whether the high-flow, low-resistance (HFLR) technique offers any benefits over conventional methods. Method: This open, prospective, randomised study was to recruit 48 children scheduled to undergo surgery for congenital heart disease. To investigate the two different perfusion strategies, we have measured intestinal perfusion as well as skin perfusion with laser Doppler spectroscopy. To identify the effects on the immune system, selected immunologic parameters of systemic inflammation were additionally measured. Laser Doppler spectroscopy is a method that uses a glass fibre probe to determine the parameters of oxygen saturation of haemoglobin and relative haemoglobin quantity in an illuminated tissue volume, as well as the perfusion parameters of relative blood flow and blood flow velocity in the sample volume of the probe. Results: During the study period, the change in oxygen saturation over time was comparable in both groups. At the end of surgery, the patients of the high-flow group had significantly higher saturation levels in the intestinal mucosa (p <0.05). Over the course of intensive care, the groups did not differ in terms of fluid supply, administration of packed red blood cells, platelet concentrates or fresh frozen plasma. Analysis of urinary output revealed significant group differences. It was higher in the patients of the high-flow group than the normal-flow group (p< 0.03), without differences in diuretic administration. Conclusion: Laser Doppler spectroscopy is highly suited to the detection even of the slightest changes in flow characteristics and oxygenation of the skin, musculature and intestinal mucosa during surgery with extracorporeal circulation using CPB. At the same time, the technique of HFLR perfusion was found to have benefits over conventional bypass methods. [Copyright &y& Elsevier]

The authors discuss the real-time ultrasound-guided supraclavicular approach technique to the central vein in pediatric patients. Topics covered include targeting the innominate vein, positioning the ultrasound probe for the skin puncture, and fixing the central vein catheter inserted by the left supraclavicular approach on the left shoulder. Avoiding placement of the tip of the central vein catheter at the anastomatic region during congenital heart disease operations is also mentioned.

Sir - We have written a review article regarding ultrasound-guided technique for vascular access in pediatric patients.[1] In subsequent papers, we described the technique of real-time ultrasound-guided blood access to the central vein via supraclavicular approach in greater detail.[[2]] In the current Letter to the Editor, we introduce a femoral artery cannulation for blood delivery on cardiopulmonary bypass (CPB) during aortic repair procedure in small pediatric patients with congenital heart disease as another application of real-time ultrasound-guided vascular access technique. An extremely low body temperature is not necessary anymore when using this blood delivery method via femoral artery cannulation. [Extracted from the article]

: In neonates and small children, percutaneous insertion of arterial catheters may be very difficult because of the small diameter of the arteries. Multiple attempts at cannulation are common and may be a predictor of serious adverse events following arterial cannulation. As an endartery, the brachial artery is usually not recommended for cannulation. However, limited data exist about brachial artery catheterization in neonates and young children. In this retrospective study, we report our experience with arterial indwelling catheters placed in neonates and small children prior to surgery for congenital heart defects. : We reviewed 1473 patient medical files containing information about 1574 arterial lines for perioperative and intensive care monitoring. Patient data (age and weight), cannulation characteristics (site, type, percutaneous or cut down insertion), duration of catheterization and complications were documented using the anesthesia and/or intensive care unit files. Patients were divided into three groups according to body weight. Group I: patients with a bodyweight up to 5 kg ( n = 561), group II: bodyweight 5–10 kg ( n = 615), and group III: bodyweight 10–20 kg ( n = 297). : The vast majority of our patients had radial or brachial artery catheterization. In group 1, we placed 200 brachial artery lines. Radial artery insertion was more successful with increasing body weight. Two ‘cut downs’ were necessary to place the arterial cannula (0.3%). The mean duration of the arterial cannula in place was 5.8 + 4.3 days in group I, which was significantly longer than in group III (2.9 + 2.2 days). Multiple attempts at catheter insertion were required for 200 patients in group I ( P < 0.05 compared with groups II and III). The number of guide wires used was similar in all study groups. Generally, we preferred 24 and 22 G catheters for cannulation. Serious complications such as permanent ischemic damage were not observed. Temporary occlusion of an artery occurred in five of 1473 patients. The rate of local infection was 0.5% in group I, 0.7% in group II and 2.3% in group III. Local hematoma were observed more frequently, but with no relevant consequences. Most of our patients were cannulated on the right side. In group I, 112 brachial artery catheters were placed. The greater the weight, the more radial catheters were used compared with a brachial approach. The mean functional time of the catheters (5.8 ± 4.3 days in group I) was significant shorter compared with patients from group III (2.9 ± 2.2 days). In 33.3% ( n = 200) multiple punctures were needed to place a catheter in group I ( P < 0.05 compared with the other groups) whereas the use of a guide wire was evenly distributed throughout the study groups. Small catheters (24 and 22 G) were preferred for most patients. In total only eight 20 G sized catheters were used in the children of group III. : Even considering the nature of a retrospective study design, we conclude that the brachial artery could be considered for cannulation in neonates and small children. [ABSTRACT FROM AUTHOR]

Schindler E, Müller M, Akintürk H, Valeske K, Bauer J, Zickmann B, Hempelmann G. Perioperative management in pediatric heart transplantation from 1988 to 2001: Anesthetic experience in a single center. Pediatr Transplantation 2004: 8: 237–242. © 2004 Blackwell Munksgaard Pediatric cardiac transplantation is currently an accepted option for end-stage heart disease and congenital cardiac malformations. This report focuses on the anesthetic perioperative management in 12 yr. From 1988 to 2001 we performed 90 heart transplantations in 88 children, infants and neonates. The pediatric heart transplant program of the children's heart center at our university hospital started in June 1988 with the transplantation of a 2-yr-old boy who was suffering from congenital heart disease. Since then, 88 transplants have been performed. We divided our patients into two groups. Group 1 ranged from 1988 to 1996 and Group 2 from 1997 to 2001. The patient characteristics have not significantly changed over the years in our institution. At the time of transplantation, mean age of the patients was 2.6 ± 4.3 yr from the period of 1988–1996 and 2.5 ± 4.1 yr from 1997 to 2001. Since 1988, 90 transplants (Tx) in 88 patients have been performed. Two patients needed re-Tx within 2 days after the initial operation because of primary graft failure. Indications for Tx were congenital heart disease (n = 67) and cardiomyopathy (n = 21). In the subgroup of the patients suffering from congenital heart disease there were 46 with the diagnosis of HLHS, followed by endocardial fibroelastosis (n = 7); the remaining 14 patients had other complex cardiac malformations and some underwent corrective palliative cardiac surgery before Tx. Sixty-three patients were younger than 1 yr of age and only five children were older than 10 yr. Twenty-three percent of the patients on the waiting list died before Tx was possible. The overall survival rate was 79% at 1 yr and 73% at 5 and 10 yr. Infants with HLHS had a lower probability of survival after 5 yr compared with other diagnosis (69% vs. 84%). Until now 21 patients have died after Tx. The duration of anesthesia, time of CPB and the age at the time of surgery decreased over the years. It is always a challenge for the anesthesiologist to treat these patients with pulmonary hypertension as one of the most critical risks in this group of patients. The preventive therapy with vasodilators as well as the availability of mechanical assist devices before and after heart transplantation reduces the effects of transitional pulmonary hypertension and prevents the development of post-operative right heart failure. [ABSTRACT FROM AUTHOR]

Background: In children, central venous catheter (CVC) placement is usually performed under ultrasound guidance for optimal visualization of vessels and reduction of puncture‐related complications. Nevertheless, in many cases, additional radiographic examinations are performed to check the position of the catheter tip. Aim: The primary objective of this observational feasibility study was to determine the number of ultrasound‐guided central venous catheter tips that can be identified in a subsequent position check using ultrasonography. Furthermore, we investigated the optimal ultrasound window, time expenditure, and success rate concerning puncture attempts and side effects. In addition, we compared the calculated and real insertion depths and analyzed the position of the catheter tip on postoperative radiographs with the tracheal bifurcation as a traditional landmark. Methods: Ninety children with congenital heart defects who required a central venous line for cardiac surgery were included in this single‐center study. After the insertion of the catheter, the optimal position of its tip was controlled using one of four predefined ultrasound windows. A chest radiograph was obtained postoperatively in accordance with hospital standards to check the catheter tip position determined by ultrasonography. Results: The children had a median (IQR) age of 11.5 (4.0, 58.8) months and a mean (SD) BMI of 15.3 (2.91) kg/m2 Ultrasound visualization of the catheter tip was successful in 86/90 (95.6%) children (95% confidence interval [CI]: 91.3%, 99.8%). Postoperative radiographic examination showed that the catheter tip was in the desired position in 94.4% (95% CI: 89.7%, 99.2%) of the cases. None of the children needed the catheter tip position being corrected based on chest radiography. Conclusion: Additional radiation exposure after the placement of central venous catheters can be avoided with the correct interpretation of standardized ultrasound windows, especially in vulnerable children with cardiac disease. [ABSTRACT FROM AUTHOR]

A review of an article by Naveen Raj on alternative methods of regional anesthesia for heart surgery in children beyond spinal or epidural anaesthesia in this issue is presented.

Organization of healthcare strongly differs between European countries and results in country‐specific requirements in postgraduate medical training. Within the European Union (EU), the European Board of Anaesthesiology has set recommendations of training for the Specialty of Anaesthesiology including standards for Postgraduate Medical Specialist training including a description for providing service in pediatric anesthesia. However, these standards are advisory and not mandatory. Here we aimed to review the current state and associated challenges of pediatric anesthesia training in Europe. We report an important country‐specific variability both in training and regulations of practice of pediatric anesthesia in the EU and in the United Kingdom. The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3–6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country‐specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest and support for the establishment of a European pediatric anesthesia curriculum. [ABSTRACT FROM AUTHOR]

Background: In the course of the corona pandemic, digital media has increasingly been used in many areas of medical practice to reduce personal contact. As it is of interest whether this can be practiced in the context of anesthesia consultations without loss of quality, we interviewed parents whose children received a cardiac or neuro magnetic resonance imaging (MRI) under sedation. Parents either received an on‐site or a remote consultation conducted by an anesthesiologist. Both parents and anesthesiologist were asked to indicate their satisfaction with the respective consultation procedure in a questionnaire. Aim: The aim of this study was to investigate if remote pre‐anesthesia consultation, supported by an online video, for parents whose children are receiving MRI examinations under sedation can replace the commonly performed on‐site consultation, without decreasing its quality. Methods: In this randomized trial, a total of 200 patients were included, one half received pre‐anesthesia consultation on‐site and the other half was given a link to a video and pre‐anesthesia consultation was conducted by phone. As a primary analysis, we compared the level of satisfaction for the general procedure, the quality of the pre‐anesthesia consultation and the contact to the anesthesiologists (or parents). We further investigated the frequency of complications and the preference for a possible next informed consent. Results: Both groups showed high levels of satisfaction. Some anesthesiologists and parents were less satisfied with the quality of on‐site pre‐anesthesia consultation than with the remote. In our patient cohort, there was no evidence for higher risk of complications when information was provided by telephone. Further, parents as well as anesthesiologists clearly favored the combined form of telephone information and online video. Overall, 61.2% of parents and 64% of anesthesiologists would choose this form of pre‐anesthesia consultation for repeat anesthesia. Conclusions: We did not observe that combined telephone and video decreased the quality of pre‐anesthesia consultation. A remote version seems feasible for simple procedures such as sedation for MRI. Further research on this topic in other areas of anesthesia would be beneficial. [ABSTRACT FROM AUTHOR]

A response by Ehrenfried Schindler and Nicodème Sinzobahamvyab to a letter to the editor about their article " Tranexamic acid: an alternative to aprotinin as antifibrinolytic therapy in pediatric congenital heart surgery," in the 2012 issue is presented.

Background: Enhanced recovery after surgery (ERAS) protocols are utilizing a multidisciplinary approach, reassessing physiology to improve clinical outcomes, reducing length of hospital stay (LOS) stay, resulting in cost reduction. Since its introduction in colorectal surgery. the concept has been utilized in various fields and benefits have been recognized also in adult cardiac surgery. However, ERAS concepts in pediatric cardiac surgery are not yet widely established. Therefore, the aim of the present study was to assess the effects of on-table extubation (OTE) after pediatric cardiac surgery compared to the standard approach of delayed extubation (DET) during intensive care treatment. Study Design and Methods: We performed a retrospective analysis of all pediatric cardiac surgery cases performed in children below the age of two years using cardiopulmonary bypass at our institution in 2021. Exclusion criteria were emergency and off pump surgeries as well as children already ventilated preoperatively. Results: OTE children were older (267.3 days vs. 126.7 days, p < 0.001), had a higher body weight (7.0 ± 1.6 kg vs. 4.9 ± 1.9 kg, p < 0.001), showed significantly reduced duration of ICU treatment (75.9 ± 56.8 h vs. 217.2 ± 211.4 h, p < 0.001) and LOS (11.1 ± 10.2 days vs. 20.1 ± 23.4 days; p = 0.001) compared to DET group. Furthermore, OTE children had significantly fewer catecholamine dependencies at 12-, 24-, 48-, and 72-h post-surgery, while DET children showed a significantly increased intrafluid shift relative to body weight (109.1 ± 82.0 mL/kg body weight vs. 63.0 ± 63.0 mL/kg body weight, p < 0.001). After propensity score matching considering age, weight, bypass duration, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality (STATS)-Score, and the outcome variables, including duration of ICU treatment, catecholamine dependencies, and hospital LOS, findings significantly favored the OTE group. Conclusion: Our results suggest that on-table extubation after pediatric cardiac surgery is feasible and in our cohort was associated with a favorable postoperative course. [ABSTRACT FROM AUTHOR]

Background: The validity of current tools for intraoperative objective assessment of nociception/antinociception balance during anesthesia in young and very young surgery children is unknown. Aim: Primary aim of the study was to test the hypothesis that the Newborn Infant Parasympathetic Evaluation (NIPE) index performs better in indicating nociception in anesthetized children below 2 years than changes in heart rate. Secondary aims were to evaluate associations between intraoperative changes in NIPE index values and postoperative pain and emergence delirium. Methods: Fifty‐one children aged <2 years who underwent surgery were included in this prospective observational study. Patients were assigned to either group 1 (healthy children, n = 31) or group 2 (critically ill, ventilated premature infants and neonates, n = 20). The NIPE index and heart rate in response to three defined nociceptive stimuli were continuously recorded. Two different scales, Kindliche Unbehagens‐ und Schmerzskala (KUS) and Pediatric Anesthesia Emergence Delirium (PAED) as well as a Pain Questionnaire were used to assess postoperative pain levels and emergence delirium. Results: In total, 110 nociceptive events were evaluated. The analysis revealed a statistically significant association between a decrease in the NIPE index and all nociceptive stimuli, with a sensitivity of 92% and a specificity of 96%. The mean percentage decrease ranged from approx. 15%–30% and was highly statistically significant in both groups and for each of the nociceptive events except for venous puncture (p =.004). In contrast, no consistent change in heart rate was demonstrated. The KUS and PAED scale scores were significantly associated with the duration of anesthesia (p =.04), but not with intraoperative NIPE depression. Conclusion: The NIPE index was reliable for assessing intraoperative nociception in children aged <2 years and was more reproducible for detecting specific nociceptive stimuli during general anesthesia than heart rate. An effect on postoperative outcome is still elusive. [ABSTRACT FROM AUTHOR]

Background: Children with congenital heart disease require repeated catheterization. Anesthetic management influences the procedure and may influence outcome; however, data and recommendations are lacking for infants. We studied the influence of sedation versus general anesthesia (GA) on adverse events during catheterization for children <2 years old. Methods: We conducted a monocentric, retrospective study of all catheterization procedures (2008–2013). High-severity adverse event (HSAE) rates were compared using propensity-score-adjusted models, including pre- and intra-procedural variables. Results: 803 cases (619 patients) (368 (46%) GA, 435 (54%) sedation) with a mean age of 6.9 ± 6.1 months were studied. The conversion rate (GA after sedation) was 18 (4%). Hospital stay was 4.9 ± 4.0 and 4.1 ± 2.5 (p = 0.01) after GA or sedation, respectively. HSAE occurred in 75 (20%) versus 40 (9%) (p < 0.01) in GA versus sedation procedures, respectively. Risk factors (multivariable analysis) were older patients (p = 0.05), smaller weights (p < 0.01), palliated status (OR 3.2 [1.2–8.9], p = 0.02), two-ventricle physiology (OR 7.3 [2.7–20.2], p < 0.01), cyanosis (OR 4.6 [2.2–9.8], p < 0.01), pulmonary hypertension (OR 5.6 [2.0–15.5], p < 0.01), interventional catheterization (OR 1.8 [1.1–3.2], p = 0.02) and procedure-type risk category 4 (OR 28.9 [1.8–455.1], p = 0.02). Sedation did not increase the events rate and decreased the requirement for hemodynamic support (OR 5.2 [2.2–12.0], p < 0.01). Conclusion: Sedation versus GA for cardiac catheterization in children <2 years old is safe and effective with regard to HSAE. Sedation also decreases the requirement for hemodynamic support. Paradoxical effects (older age and two-ventricle physiology) on risk have been found for this specific age cluster. [ABSTRACT FROM AUTHOR]

Near-infrared spectroscopy (NIRS) does not provide information about changes in oxygenation in whole-brain areas. Although the branching vessels of the aortic arch are not always easy to identify using transesophageal echocardiography (TEE), the blood flow status of cervical arteries can always be assessed by applying an ultrasound probe via the "ultrasound window" on the patient's neck, which can be ensured by devising alternative insertion approaches of the central venous catheter. This method is very simple but compensates for the limitations of the combination of NIRS and TEE, especially during cardiac surgery with cardiopulmonary bypass management using selective cerebral perfusion. [ABSTRACT FROM AUTHOR]

We previously presented a cardiopulmonary bypass (CPB) method with blood delivery via femoral artery cannulation for pediatric aortic arch repair operations using the Radifocus Introducer sheath. However, the flow rate with the Radifocus Introducer sheath is limited by accessory parts with the same structure having a smaller inner diameter among different sizes, rather than the sheath body. Therefore, we further devised a combination of the JELCO IV catheter, an extension tube, and a three-way stopcock with a larger opening to obtain more flow rate keeping the CPB circuit pressure significantly lower than when using the Radifocus Introducer sheath successfully. [ABSTRACT FROM AUTHOR]

Summary Therapy of hypoplastic left heart syndrome (HLHS) consists of the staged Norwood procedure or cardiac transplantation. Stenting the ductus arteriosus and subsequent banding of the pulmonary arteries allows the combination of neoaortic reconstruction with the establishment of a bidirectional cavopulmonary connection (combined stage 1 and 2 procedure) in a later session. We report the anaesthetic management in eight infants ranging from 107 to 195 days undergoing a combined stage 1 and 2 procedure. Nonselective pulmonary vasodilators and nitric oxide were needed in all cases to improve oxygen saturation in the postbypass period. Phosphodiesterase inhibitors and epinephrine were required in all patients for inotropic support during and after weaning off cardiopulmonary bypass. The procedure was successful in seven patients. One patient died intraoperatively because of right heart failure. The physiological changes of this new surgical strategy for palliation of HLHS offers a challenge for the anaesthetist primarily in the early postbypass period. [ABSTRACT FROM AUTHOR]

Background: A preliminary national audit of real fasting times including 3324 children showed that the fasting times for clear fluids and light meals were frequently shorter than recommended in current guidelines, but the sample size was too small for subgroup analyses. Aims: Therefore, the primary aim of this extended study with more participating centers and a larger sample size was to determine whether shortened fasting times for clear fluids or light meals have an impact on the incidence of regurgitation or pulmonary aspiration during general anesthesia in children. The secondary aim was to evaluate the impact of age, emergent status, ASA classification, induction method, airway management or surgical procedure. Methods: After the Ethics Committee's approval, at least more than 10 000 children in total were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures, and occurrence of target adverse events defined as regurgitation or pulmonary aspiration were documented using a standardized case report form. Results: At fifteen pediatric centers, 12 093 children scheduled for surgery or interventional procedures were included between October 2018 and December 2019. Fasting times were shorter than recommended in current guidelines for large meals in 2.5%, for light meals in 22.4%, for formula milk in 5.3%, for breastmilk in 10.9%, and for clear fluids in 39.2%. Thirty‐one cases (0.26%) of regurgitation, ten cases (0.08%) of suspected pulmonary aspiration, and four cases (0.03%) of confirmed pulmonary aspiration were reported, and all of them recovered quickly without any consequences. Fasting times for clear fluids shortened from 2 hours to 1 hour did not affect the incidence of adverse events (upper limit 95% CI 0.08%). The sample size of the cohort with fasting times for light meals shorter than 6 hours was too small for a subgroup analysis. An age between one and 3 years (odds ratio 2.7,95% CI 1.3 to 5.8%; P <.01) and emergent procedures (odds ratio 2.8,95% CI 1.4 to 5.7;P <.01) increased the incidence of adverse events, whereas ASA classification, induction method, or surgical procedure had no influence. The clear fluid fasting times were shortest under 6/4/0 as compared to 6/4/1 and 6/4/2 fasting regimens, all with an incidence of 0.3% for adverse events. Conclusion: This study shows that a clear fluid fasting time shortened from 2 hours to 1 hour does not affect the incidence of regurgitation or pulmonary aspiration, that an age between one and 3 years and emergent status increase the incidence of regurgitation or pulmonary aspiration, and that pulmonary aspiration followed by postoperative respiratory distress is rare and usually shows a quick recovery. [ABSTRACT FROM AUTHOR]

Background: Prolonged fasting before anesthesia is still common in children. Shortened fasting times may improve the metabolic and hemodynamic condition during induction of anesthesia and the perioperative experience for parents and children and simplify perioperative management. As a consequence, some centers in Germany have reduced fasting requirements, but the national guidelines are still unchanged. Aims: This prospective multicenter observational study was initiated by the Scientific Working Group for Pediatric Anesthesia of the German Society of Anesthesiology and Intensive Care Medicine to evaluate real fasting times and the incidence of pulmonary aspiration before a possible revision of national fasting guidelines. Methods: After the Ethics Committee's approval, at least 3000 children were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures and occurrence of regurgitation or pulmonary aspiration were documented using a standardized case report form. Results were presented as median [interquartile range] (range) or incidence (percentage). Results: At ten pediatric centers, 3324 children were included between October 2018 and May 2019. The real fasting times for large meals were 14 [12.2‐15.6] (0.5‐24) hours, for light meals 9 [5.6‐13.3] (0.25‐28.3) hours, for formula milk 5.8 [4.5‐7.4] (0.9‐24) hours, for breast milk 4.8 [4.2‐6.3] (1.3‐25.3) hours and for clear fluids 2.7 [1.5‐6] (0.03‐22.8) hours. Prolonged fasting (deviation from guideline >2 hours) was reported for large meals in 88.3%, for light meals in 54.7%, for formula milk in 44.4%, for breast milk in 25.8% and for clear fluids in 34.2%. Eleven cases (0.33%) of regurgitation, four cases (0.12%) of suspected pulmonary aspiration and two cases (0.06%) of confirmed pulmonary aspiration were reported; all of them could be extubated after the end of the procedure and recovered without any incidents. Conclusion: This study shows that prolonged fasting is still common in pediatric anesthesia in Germany that pulmonary aspiration with postoperative respiratory distress is rare and that improvements to current local fasting regimens and national fasting guidelines are urgently needed. [ABSTRACT FROM AUTHOR]

Summary: Pediatric anesthetic guidelines for the management of preoperative fasting of clear fluids are currently 2 hours. The traditional 2 hours clear fluid fasting time was recommended to decrease the risk of pulmonary aspiration and is not in keeping with current literature. It appears that a liberalized clear fluid fasting regime does not affect the incidence of pulmonary aspiration and in those who do aspirate, the sequelae are not usually severe or long‐lasting. With a 2‐hour clear fasting policy, the literature suggests that this translates into 6‐7 hours actual duration of fasting with several studies up to 15 hours. Fasting for prolonged periods increases thirst and irritability and results in detrimental physiological and metabolic effects. With a 1‐hour clear fluid policy, there is no increased risk of pulmonary aspiration and studies demonstrate the stomach is empty. There is less nausea and vomiting, thirst, hunger, and anxiety, if allowed a drink closer to surgery. Children appear more comfortable, better behaved and possibly more compliant. In children less than 36 months this has positive physiological and metabolic effects. It is practical to allow children to drink until 1 hour prior to anesthesia on the day of surgery. In this joint consensus statement, the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology, and L'Association Des Anesthésistes‐Réanimateurs Pédiatriques d'Expression Française agree that, based on the current convincing evidence base, unless there is a clear contraindication, it is safe and recommended for all children able to take clear fluids, to be allowed and encouraged to have them up to 1 hour before elective general anesthesia. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Any aortic valve (AoV) operation in children (repair, Ross or mechanical replacement) is a palliation and reinterventions are frequent. AoV repair is a temporary solution primarily aimed at allowing the patient to grow to an age when more definitive solutions are available. We retrospectively analysed AoV repair effectiveness across the whole age spectrum of children, excluding neonates and AoV disease secondary to congenital heart disease. METHODS: From 2003 to 2015, 193 consecutive patients were included. The mean age was 9.2 ± 6.9 years (22% <1 year); 86 (45%) had a preceding balloon valvuloplasty. The indications for the procedure were stenotic (n = 123; 64%), regurgitant (n = 63; 33%) or combined (n = 7; 4%) disease. The procedures performed were commissurotomy shaving (n = 74; 38%), leaflet replacement (n = 78; 40%), leaflet extension (n = 21; 11%) and neocommissure creation (n = 21; 11%). Post-repair geometry was tricuspid in 137 (71%) patients. RESULTS: The 10-year survival rate was 97.1%. Freedom from reoperation and replacement at 7 years was, respectively, 57% (95% confidence interval, 47-66) and 68% (95% confidence interval, 59-76). In multivariate analysis, balloon dilatation before 6 months, the absence of a developed commissure, a non-tricuspid post-repair geometry and cross-clamp duration were predictors for reoperation and replacement. After a mean follow-up period of 5.1 ± 3.0 years, 145 (75%) patients had a preserved native valve, with undisturbed valve function (peak gradient <40 mmHg, regurgitation ≤mild) in 113 (58%). CONCLUSIONS: Aortic valve repair in children is safe and effective in delaying the timing for more definitive solution. Surgical strategy should be individualized according to the age of the patient. Avoidance of early balloon dilatation and aiming for a tricuspid post-repair arrangement may improve outcomes. [ABSTRACT FROM AUTHOR]

Background Anesthesia for pediatric cardiac surgery requires a high level of expert knowledge. There are currently no recommendations and standards for anesthetic management for congenital cardiac surgery in Germany. Aim The aim of the present study was to assess the current status of structural and personnel anesthetic standards at pediatric cardiac surgery centers in Germany. Methods All cardiac surgical centers in Germany were reviewed for an active program for congenital heart surgery. Centers with an active program were invited to respond to an online survey. The questionnaire containing 55 items in 16 categories assessed current practice in pediatric cardiac anesthesia. Results An active program for pediatric cardiac surgery was identified at 27 centers. The response rate to the survey was 96.3%. A specialized group of anesthesiologists for pediatric cardiac anesthesia was reported from 26 centers (92.3%). The mean size of this group was 4.8 anesthesiologists per center. However, the annual case load of centers and relative annual case load per specialized anesthesiologist varied considerably between 12.5 and 250. Nonanesthesiologists performed sedation and general anesthesia for diagnostic and therapeutic interventions outside the operating theater in children with congenital heart diseases in 24 centers (77%). Although special equipment, for example, pediatric TEE, near-infrared spectroscopy, and devices for mechanical auto transfusion were available in most centers, their routine use was not always part of standard operating procedures. The proposal for mean adequate training in pediatric cardiac anesthesia as estimated by the participating centers was 10.8 months. Conclusion The present study represents the current structural situation for anesthesia at German pediatric cardiac surgery centers. [ABSTRACT FROM AUTHOR]

Background In open heart surgery, heparinization is commonly neutralized using an empirical heparin:protamine ratio ranging between 1:1 and 1:1.5. However, these ratios may result in protamine overdose that should be avoided for its negative side effects on the coagulation system. This study aimed to indicate the appropriate treatment for prolonged activated clotting time (ACT) after protamine administration following cardiopulmonary bypass (CPB) in pediatric open heart surgery by investigating the underlying reasons for it. Methods Twenty-seven children (<10 kg) undergoing open heart surgery were included. Heparin was administered only before CPB (400 IU/kg) and in the pump priming volume for CPB (2,000 IU) and was neutralized by 1:1 protamine after CPB. The blood heparin concentration was measured using anti-Xa assay. ACT and blood concentrations of heparin, coagulation factors, thrombin-antithrombin complex, and prothrombin fragment 1 + 2 were assessed. A rotational thromboelastometry (ROTEM; Tem International GmbH, München, Bayern, Germany) was used to confirm the coagulation status and residual heparin after protamine administration. Results Anti-Xa assay showed that there is no residual heparin in the blood after 1:1 protamine administration. Nevertheless, ACT (128.89 ± 3.09 seconds before heparin administration) remained prolonged (177.14 ± 5.43 seconds at 10 minutes after protamine, 182.00 ± 5.90 seconds at 30 minutes after protamine). The blood concentrations of coagulation factors were significantly lower than those before heparin administration (p < 0.01). The low FIBTEM MCF of ROTEM (4.43 ± 0.32 mm) at 10 minutes after protamine indicated low fibrinogen concentration. Conclusion Prolonged ACT after heparin neutralization by 1:1 protamine administration does not necessarily indicate residual heparin, but low blood concentrations of coagulation factors should be considered as a reason as well. Accordingly, supply of coagulation factors instead of additional protamine should be considered. [ABSTRACT FROM AUTHOR]

Background: One undisputed benefit of digital support is the possibility of contact reduction, which has become particularly important in the context of the COVID-19 pandemic. However, to the best of our knowledge, there is currently no study assessing the Europe-wide use of digital online pre-operative patient information or evaluation in the health sector. The aim of this study was to give an overview of the current status in Europe. Methods: A web-based questionnaire covering the informed consent process was sent to members of the European Society of Anaesthesia and Intensive Care Medicine (ESAIC) in 47 European countries (42,433 recipients/930 responses). Six questions related specifically to the practice in paediatrics. Results: A total of 70.2% of the respondents indicated that it was not possible to obtain informed consent via the Internet in a routine setting, and 67.3% expressed that they did not know whether it is in line with the legal regulations. In paediatric anaesthesia, the informed consent of only one parent was reported to be sufficient by 77.6% of the respondents for simple interventions and by 63.8% for complex interventions. Just over 50% of the respondents judged that proof of identity of the parents was necessary, but only 29.9% stated that they ask for it in clinical routine. In the current situation, 77.9% would favour informed consent in person, whereas 60.2% could imagine using online or telephone interviews as an alternative to a face-to-face meeting if regulations were changed. Only 18.7% participants reported a change in the regulations due to the current pandemic situation. Conclusion: Whether informed consent is obtained either online or on the telephone in the paediatric population varies widely across Europe and is not currently implemented as standard practice. For high-risk patients, such as the specific cohort of children with congenital heart defects, wider use of telemedicine might provide a benefit in the future in terms of reduced contact and reduced exposure to health risks through additional hospital stays. [ABSTRACT FROM AUTHOR]

Background: Central venous catheters (CVC) are commonly required for pediatric congenital cardiac surgeries. The current standard for verification of CVC positioning following perioperative insertion is postsurgical radiography. However, incorrect positioning may induce serious complications, including pleural and pericardial effusion, arrhythmias, valvular damage, or incorrect drug release, and point of care diagnostic may prevent these serious consequences. Furthermore, pediatric patients with congenital heart disease receive various radiological procedures. Although relatively low, radiation exposure accumulates over the lifetime, potentially reaching high carcinogenic values in pediatric patients with chronic disease, and therefore needs to be limited. We hypothesized that correct CVC positioning in pediatric patients can be performed quickly and safely by point-of-care ultrasound diagnostic. Methods: We evaluated a point-of-care ultrasound protocol, consistent with the combination of parasternal craniocaudal, parasternal transversal, suprasternal notch, and subcostal probe positions, to verify tip positioning in any of the evaluated views at initial CVC placement in pediatric patients undergoing cardiothoracic surgery for congenital heart disease. Results: Using the combination of the four views, the CVC tip could be identified and positioned in 25 of 27 examinations (92.6%). Correct positioning was confirmed via chest X-ray after the surgery in all cases. Conclusions: In pediatric cardiac patients, point-of-care ultrasound diagnostic may be effective to confirm CVC positioning following initial placement and to reduce radiation exposure. [ABSTRACT FROM AUTHOR]

(1) Background: we compare a new SBAR based electronic handover tool versus a paper-based checklist for handover in a pediatric intensive care unit (PICU). (2) Methods: this is a randomized, observational study of 40 electronic vs. 40 paper checklist handovers after pediatric cardiac surgery, with a 48 items checklist for comparison of reporting frequencies and notification of disturbances and noise. PICU staff satisfaction was evaluated by a 12-item questionnaire. (3) Results: in 14 out of 40 cases, there were problems with data processing (incomplete or no data processing). Some item groups (e.g., hemodynamics) were consistently reported at higher frequencies than other groups. Items not specifically asked for did not get reported. Some items, automatically processed in the SBAR handover page, did not get reported. Many handovers suffered a noisy and distracting atmosphere. There was no difference in staff satisfaction between the two handover approaches. Nurses were highly unsatisfied with the general approach by which the handover was performed. (4) Conclusions: human error appears to be a main factor for unreliable data processing. Software is still too complicated, and multitasking is a stressful and error prone event. Handover is a complex task with many factors required for a successful completion. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to estimate the morbidity according to observed complications after congenital heart surgery over 1-year period. Methods The previously established list of conditions prone to affect patients' wellbeing or increase cost of in-hospital stays was used systematically to score the severity of postoperative complications from 1 to 4 points. The morbidity score was calculated by adding the scores of observed complications. When the sum amounted to more than 5 points, a morbidity score of only 5 points was attributed. If no complication was detected, a score of 0.5 points was assigned. The resulting morbidity scores were correlated with the length of stay in the intensive care unit (ICU) and in the hospital, the duration of mechanical ventilation, and Aristotle complexity scores. Results A total of 542 primary procedures performed in the year 2011 were studied. Aristotle basic and comprehensive scores amounted to 7.78 ± 2.65 and 10.15 ± 3.83, respectively. Mortality was 1.85% (10/542). The standardized ratio of surgical performance reached 103.10%. Total cavopulmonary connection with extracardiac fenestrated conduit constituted the most frequent operation (n = 34). No complication was observed following 183 (33.8%) procedures. More than two complications were observed in 114 cases (21%). The three most frequent unfavorable conditions were "mechanical ventilation 25 to 95 hours" (n = 150), low cardiac output syndrome (n = 56), and cardiac arrhythmia requiring medication (n = 50). The estimated mean morbidity score amounted to 2.26 ±1.80 points. Scores ranged from 0.68 ± 0.50 for primary closure of atrial septal defect to 4.50 ± 0.79 for the Norwood procedure. They were perfectly related to the length of ICU stay and to the duration of mechanical ventilation (Spearman coefficient r = 1). Correlation was high with the length of hospital stay (r = 0.83), Aristotle basic score (r = 0.89) (C-index = 0.96), and comprehensive score (r = 0.94) (C-index = 0.97). The observed mean morbidity score was statistically not different from the expected mean morbidity score according to the basic Aristotle complexity: p = 0.73.Conclusion Quantification of morbidity indicates the length of ICU stay and the duration of mechanical ventilation as the best surrogates for morbidity. Such benchmarking and scoring of observed postoperative complications paves the way for an accurate assessment and improvement of quality care in congenital heart surgery. [ABSTRACT FROM AUTHOR]

Improved results have evolved from the modified Norwood procedure (NP). This study compares the incidence of interventions after NP with the Sano ( n = 37) and modified Blalock-Taussig (BT n = 70) shunt. Incidence, location, interval of interventions, and weight were retrospectively analysed for 107 neonates undergoing NP during the period from October 2002 to December 2009. Forty-six (43.0 %) patients underwent interventions, mostly for dilatation of the aortic arch ([DAA] n = 26 [24.3 %]; Sano n = 10, BT n = 16, p = 0.6), dilatation of the shunt ([DS] n = 15 [14.0 %]; Sano n = 11, BT n = 4; p = 0.002), or closure of aortopulmonary collaterals ([APC] n = 15 [14.0 %]; Sano n = 3, BT n = 12; p = 0.08). Mean interval after NP and body weight at DAA, DS, and APC were 72.4 ± 18.9, 108.5 ± 15.8, and 110.7 ± 17.8 days and 4.5 ± 1.3, 4.9 ± 1.9, 5.3 ± 1.2 kg, respectively. The interventions were not associated with mortality but with a greater rate of complications (9 of 46 [21.4 %]) compared with the rate after diagnostic catheterization (0 of 45, p = 0.03). Complications included closure of the femoral or subclavian artery ( n = 5), cerebral embolic or bleeding events ( n = 4), cardiopulmonary resuscitation ( n = 3), and temporary heart block ( n = 2). Actuarial survival was similar from the postoperative month 8 onward at 78.6 ± 4.9 % (95 % confidence interval [CI] 67.0-86.5 %) for Sano and 78.4 ± 6.8 % (95 % CI 61.4-88.6 %) for BT ( p = 0.95). Interventions after NP were common irrespective of shunt type. However, a significantly greater rate of shunt interventions was noted in the Sano group. In particular, interventions addressing the aortic arch and the shunt were related with a significant rate of complications. [ABSTRACT FROM AUTHOR]

OBJECTIVES With improved short-term outcomes the right ventricular to pulmonary artery shunt (Sano) has become the preferred pulmonary blood source in the Norwood procedure in many centres. However, most studies analysed consecutive cohorts, with a first modified Blalock–Taussig shunt (BT) followed by the Sano cohort. Besides, neither comprehensive preoperative risk analysis nor outcome beyond 1 year of age was investigated. METHODS This study reviews 109 neonates undergoing the Norwood procedure in the same interval between October 2002 and December 2009. The Sano (38) or BT shunt (71) was assigned according to the surgeon's preference. Two neonates subsequently underwent successful biventricular repair and were excluded. The Aristotle comprehensive score (ACS) was used to evaluate preoperative risk, with high-risk patients (n = 39) classified as having an ACS ≥20, and low-risk patients (n = 68) given an ACS <20. RESULTS Mean Aristotle score at the Norwood operation was 18.8 ± 0.4 and 18.9 ± 0.3 (P = 0.9) in Sano and BT, respectively. Mean follow-up interval was 4.1 ± 2.1 years (range: 1.7–8.9 years). Actuarial survival was similar, stabilizing from the 8th postoperative month onwards at 78.6 ± 4.9% (95% CI: 67.0–86.5%) for Sano and 78.4 ± 6.8% (95% CI: 61.4–88.6%) for BT; P = 0.95. Midterm actuarial survival was higher in low-risk patients, 88.2 ± 3.9% (95% CI: 77.8–93.9%) than in high-risk patients: 61.5 ± 7.8% (95% CI: 44.5–74.7%, P = 0.0003). No survival benefit was detected in low- or high-risk cases for either shunt type. Risk factors for midterm mortality were cardiorespiratory failure requiring ventilation (13/34, P = 0.004), and ACS ≥20 (15/39, P = 0.001), but not shunt type (8/37, P = 0.95). Increased number of shunt-related interventions before the Glenn procedure were noted with Sano (32.4 versus 6.5%, P = 0.002). CONCLUSIONS Preoperative risk factors, regardless of shunt type, influence midterm survival after the Norwood procedure with an excellent outcome in low-risk patients, while high-risk cases still incur a significant mortality. Sano shunt interventions occurred with increased numbers. Although, Sano shunt may be the only feasible option in some instances, given the possible negative effects of ventriculotomy on right ventricle function, the widespread use of Sano shunt should be reconsidered. [ABSTRACT FROM AUTHOR]

Planning and budgeting for congenital heart surgery depend primarily on how closely reimbursement matches costs and on the number and complexity of the surgical procedures. Aristotle complexity scores for the year 2010 were correlated with hospital costs and with reimbursement according to the German diagnosis-related groups (DRG) system. Unit surgical performance was estimated as surgical performance (complexity score × hospital survival) times the number of primary procedures. This study investigated how this performance evolved during years 2006 to 2010. Hospital costs and reimbursements correlated highly with Aristotle comprehensive complexity levels (Spearman r = 1). Mean costs and reimbursement reached 35,050€ ± 32,665€ and 31,283€ ± 34,732€, respectively, for an underfunding of 10.7%. Basic and comprehensive unit surgical performances were respectively 3036 ± 1009 and 3891 ± 1591 points in 2006. Both performances increased in sigmoid fashion to reach 3883 ± 1344 and 5335 ± 1314 points, respectively, in 2010. Top performances would be achieved in year 2011, and extrapolated costs would comprise about 19,434,094.92€ (95% confidence interval, 11,961,491.22-22,495,764.42€). The current underfunding of congenital heart surgery needs correction. The Aristotle score can help to adjust reimbursement according to complexity of procedures. Unit surgical performance allows accurate budgeting in the current German DRG system. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The Aristotle basic complexity (ABC) score (1.5–15 points) is the sum of potentials for early mortality, morbidity and anticipated surgical technique difficulty. The Aristotle comprehensive complexity (ACC) score (1.5–25 points) is the sum of ABC score and patient-adjusted complexity score; it comprises six complexity levels. We used the ACC score to evaluate quality in surgical management of congenital heart disease. Methods: Procedures performed in year 2002 and 2007 were analysed. Proportion of procedures requiring at least 1 week of stay in the intensive care unit was chosen as the marker of morbidity. We adopted threshold duration of 120min for cardio-pulmonary bypass (CPB) cases and the same duration for operations without CPB as surrogate of surgical technical difficulty. The ACC scores were correlated to mortality, morbidity and technical difficulty. Results: This study included 758 patients who underwent 787 primary procedures. The mean ABC and ACC scores amounted to 7.61±2.46 and 9.51±3.84. Early mortality was 3.05% (24/787), 95% confidence interval (CI): 1.97–4.51%. Zero at ACC levels 1 and 2, it increased from 1.2% (2/161) for level 3 up to 22.2% (2/9) for level 6. Morbidity index was evaluated at 25.9% (204/787), 95% CI: 22.9–29.1%. 1.9% at level 1, it escalated up to 77.8% at level 6. Index of technique difficulty was estimated at 35.2% (277/787), 95% CI: 31.8–38.6%, ranging from 4.8% for level 1 to 66.7% for level 6. A high correlation was found between the ACC scores and mortality, indices of morbidity and technique difficulty, Spearman''s correlation coefficient r being 0.9856, 1 and 0.9429, respectively. Mortality (p =0.037) and morbidity (p =0.041) were lower in year 2007 than in 2002 with ABC (p =0.18) and ACC (p =0.37) surgical performance being not significantly different. Conclusions: The Aristotle score is still under development. Morbidity evaluation should be ideally based on observed postoperative complications; estimation of surgical technical difficulty chosen in this study may not be generalised. Nevertheless, the actual Aristotle comprehensive complexity score, as evaluated in its three components, accurately determined the outcome of surgical management of congenital heart disease. It appears to be an adequate tool to evaluate quality in paediatric cardiac surgery, over time. [Copyright &y& Elsevier]

Abstract: Objective: This study analyzes whether small-diameter Contegras behave in the same way as small-diameter homografts, when implanted for the first time in pulmonary position. Methods: Small-diameter conduits include 12 and 14mm Contegras and 8–14mm homografts. Graft dysfunction is defined as right ventricular outflow tract obstruction with peak echo-Doppler gradient>40mmHg, or grade III/IV graft regurgitation. Graft failure is defined as need for conduit replacement or need for catheter or surgical reintervention. Thirty-eight patients who received small Contegras (n =25) and small homografts (n =13) from October 2002 to end December 2006 were studied. The most frequent indication was pulmonary atresia and ventricular septal defect (n =20; 10 associated with major aorto-pulmonary collateral arteries), followed by truncus arteriosus (n =12). Most patients’ characteristics were comparable except that recipients of homografts were smaller (p for body area=0.014). Survival, freedom from graft dysfunction, failure and explantation were estimated by the Kaplan–Meier method. The log-rank test was used to compare outcomes. Results: There were three early and four late deaths. No death was graft related. Survival was 80±8.2% for patients with Contegras and 77±11.7% for those with allografts: p =0.82. Mean follow-up duration is 22±16 months. Freedom from dysfunction for Contegra conduits decreased in the first 6 months and stabilized at 58±11% from month 14. For homografts it decreased only 1 year after implantation, down to 35±19.7% from month 31: p =0.61. Freedom from Contegra failure diminished the first 16 months to level out at 57±13%. No homograft failed the first 2 years. With a p-value of 0.14, homografts tended to fail less frequently. Five grafts were explanted. Freedom from explantation was similar (p =0.98): 90±6.7% for Contegras and 75±21.6% for homografts at year 3. Conclusion: In the first 4 years after pulmonary implantation of small-diameter Contegras and homografts, the fate of both conduits was statistically similar, in spite of different behavior. As Contegra is ‘off-the-shelf’ available, it constitutes a sound alternative to homograft for right ventricular outflow tract reconstruction in neonates and infants. [Copyright &y& Elsevier]

Abstract: Objective: Incidence of right ventricular outflow tract obstruction (RVOTO) may be suspected to be higher after arterial switch operation (ASO) for Taussig–Bing heart than after ASO for transposition of the great arteries (TGA), as Taussig–Bing anomaly is frequently associated with aortic arch obstruction and subvalvular aortic stenosis. We evaluated the risk to develop RVOTO after ASO for Taussig–Bing heart. Methods: The 34 Taussig–Bing cases who underwent ASO from 1984 to 2005 were reviewed. RVOTO was defined as peak echo-gradient ≥30mmHg across right ventricular outflow tract. Kaplan–Meier method was used to estimate time-related events. Results: Subaortic stenosis was resected in 25 patients, 20 of whom (80%: 20/25) were discharged from hospital free from RVOTO. There was one early death: 2.9% mortality. Three patients died late. Actuarial survival was 85.1%±7.0% from 54 month onwards. Eleven survivors (36.7%: 11/30) experienced postoperative RVOTO. Obstruction was seen in 82% (9/11) of cases at subvalvular and/or valvular level. Surgery (n =4) or percutaneous intervention (n =2) was required in six patients. Patients discharged from hospital with RVOTO (n =8) were more likely to undergo reintervention for RVOTO (p =0.026). Freedom from reintervention for RVOTO decreased rapidly in the first two years to 86.5±6.3%, slowly thereafter (80.4±8.4% at year 7) and stabilized at 70.3±11.9% from year 11 on. Risk for RVOTO occurrence was 23.5±7.3% early after repair and progressively increased to level out at 53.6±11% at year 11. Patients who underwent subaortic resection were more likely (p =0.023) to be free from RVOTO occurrence or development. In the period under review, for patients who underwent ASO for simple (n =355) and complex (n =92) TGA, reoperation rate for neopulmonary stenosis was 0.3% (1/355) and 5.4% (5/92), respectively, to be compared to 11.8% (4/34) RVOTO rate of reoperation for Taussig–Bing heart in this study. Conclusions: Postoperative right-sided obstruction occurs more frequently after ASO repair of Taussig–Bing heart than after TGA arterial switching, leading to higher reintervention rate. Resection of the commonly associated subaortic stenosis often prevents RVOTO development. [Copyright &y& Elsevier]

Abstract: Objective: Imbalances of pulmonary to systemic blood flow ratio (Q p/Q s) compounded with inadequate systemic oxygen delivery correlate with mortality after first-stage Norwood palliation of hypoplastic left heart syndrome. Mathematical models suggest that maximal systemic oxygen delivery occurs with Q p/Q s of less than 1. Whether this applies to clinical practice is unclear. This study evaluates the level of Q p/Q s that correlates with best hemodynamic status in the first 48 postoperative hours. Methods: Hemodynamic data of 25 consecutive patients who underwent Norwood procedure from October 2002 to January 2005 were retrospectively analyzed. Data included, in particular, systemic venous and arterial oxygen saturation (SvO2 and SaO2, respectively), Q p/Q s, lactate levels, and doses of required inotropes. Parameters were recorded 3 hourly. Data were assigned to three groups according to their corresponding Q p/Q s: Groups 1, 2, and 3 for Q p/Q s ≤1, Q p/Q s between 1 and 2, and Q p/Q s ≥2, respectively. Thereafter, independent t-test or Fisher''s exact test was used to reveal significant differences. Q p/Q s ratios and lactate levels were compared in hospital survivors and non-survivors. Results: Out of 343 samples, 110, 184, and 49 were assigned to groups 1, 2, and 3, respectively. Group 1 (Q p/Q s ≤1) was characterized by lower SaO2 (p <0.001) with similar SvO2 (p =0.3 and p =0.5) and, therefore, higher systemic oxygen delivery (arteriovenous oxygen saturation difference, p <0.001; oxygen excess factor, p <0.001) compared to groups 2 and 3. However, lower mean arterial pressure (p =0.07 and p <0.001), higher lactate levels (p =0.009 and p =0.01), and norepinephrine doses (p =0.006 and p <0.001) highlighted worse hemodynamics. The best hemodynamic status corresponded to group 2. Q p/Q s remained above 1 in 21 survivors and was, most of the times, below 1 in four patients who died. Lactate levels were almost always above 4mmol/l or increasing in non-survivors. Conclusions: Maximum oxygen delivery after Norwood operation occurs at Q p/Q s of less than 1. However, optimal hemodynamic status and end-organ function and higher survival correlates with Q p/Q s between 1 and 2. Thus, Q p/Q s should be targeted at 1.5 for improved course early after first-stage Norwood palliation. [Copyright &y& Elsevier]

Abstract: Objective: Moderate restrictive foramen ovale in neonates with hypoplastic left heart syndrome (HLHS) is considered to be favourable, reducing pulmonary overcirculation, before modified Norwood operation. However, some newborns with severe restriction of interatrial communication will have pulmonary vascular disease at birth, which correlates with increased perioperative mortality. This article studies the post-Norwood hemodynamic patterns and outcome for the particular group of HLHS newborns with restrictive left atrial outflow compared to other patients. Methods: Restrictive left atrial outflow is defined as mitral and/or aortic atresia with intact ventricular septum, and restrictive foramen ovale, with 3mm diameter or less with mean interatrial pressure gradient more than 5mmHg at preoperative echo-Doppler. Four neonates fulfilled these criteriae among 18 consecutive patients, who underwent Norwood procedure from October 2002 to December 2003. Mean arterial pressure, heart rate, mean common atrial pressure, urinary output, central venous and arterial oximetry data, serum lactate levels, and dosages of milrinone, phentolamine and norepinephrine were collected at 0, 6, 12, 18 and 24h after operation. Data were summarized as mean±SEM. For univariate comparison of different variables, Student''s t-test was used. Results: The postoperative hemodynamic pattern of patients with restrictive left atrial outflow was characterized by hypoxemia and low cardiac output. Arterial (66±3.0% vs 76±1.0%, P=0.01) and central venous (37±1.2 vs 52±1.1%, P=0.001) oxygen saturations were much lower than in patients without restriction. Arterio-venous oxygen saturation difference was wider (29±2.4% vs 23±0.9%, P=0.02) and serum lactate levels were higher (10.8±3.0 vs 2.8±0.2mmol/l, P=0.03). Common atrial pressures were more elevated (12±0.8 vs 8±0.3mmHg, P&#60;0.001) and higher norepinephrine doses were needed (0.44±0.15 vs 0.06±0.01μg/kg/min, P=0.03). The difference for the mean arterial pressures did not reach the significance level (48±2.0 vs 51±2.0mmHg, P=0.2). Operative mortality was higher 75% (3/4) compared to 14.3% (2/14, P=0.04) for the other patients. Conclusions: Restrictive left atrial outflow adversely affects outcome after modified Norwood procedure. Abnormal pulmonary vasculature leading to insufficient pulmonary perfusion is incriminated. To improve outcome, implantation of larger size modified Blalock-Taussig or right ventricle-to-pulmonary artery shunts and routine use of postoperative mechanical assist device should be considered. [Copyright &y& Elsevier]

A correction to the article "Contemporary Results of Aortic Valve Repair for Congenital Disease: Lessons for Management and Staged Strategy" which appeared in the previous issue is presented.

Abstract: Objectives: Aristotle score methodology defines surgical performance as ‘complexity score times hospital survival’. We analysed how this performance evolved over time and in correlation with case volume. Methods: Aristotle basic and comprehensive complexity scores and corresponding basic and comprehensive surgical performances were determined for primary (main) procedures carried out from 2006 to 2009. Surgical case volume performance described as unit performance was estimated as ‘surgical performance times the number of primary procedures’. Results: Basic and comprehensive complexity scores for the whole cohort of procedures (n =1828) were 7.74±2.66 and 9.89±3.91, respectively. With an early survival of 97.5% (1783/1828), mean basic and comprehensive surgical performances reached 7.54±2.54 and 9.64±3.81, respectively. Basic surgical performance varied little over the years: 7.46±2.48 in 2006, 7.43±2.58 in 2007, 7.50±2.76 in 2008 and 7.79±2.54 in 2009. Comprehensive surgical performance decreased from 9.56±3.91 (2006) to 9.22±3.94 (2007), and then to 9.13±3.77 (2008), thereafter increasing up to 10.62±3.67 (2009). No significant change of performance was observed for low comprehensive complexity levels 1–3. Variation concerned level 4 (p =0.048) which involved the majority of procedures (746, or 41% of cases) and level 6 (p <0.0001) which included a few cases (20, or 1%), whereas for level 5, statistical significance was almost attained: p =0.079. With a mean annual number of procedures of 457, mean basic and comprehensive unit performance was estimated at 3447±362 and 4405±577, respectively. Basic unit performance increased year to year from 3036 (2006, 100%) to 3254 (2007, 107.2%), then 3720 (2008, 122.5%), up to 3793 (2009, 124.9%). Comprehensive unit performance also increased: from 3891 (2006, 100%) to 4038 (2007, 103.8%), 4528 (2008, 116.4%) and 5172 (2009, 132.9%). Conclusions: Aristotle scoring of surgical performance allows quality assessment of surgical management of congenital heart disease over time. The newly defined unit performance appears to well reflect the trend of activity and efficiency of a congenital heart surgery department. [Copyright &y& Elsevier]