Search

Three-dimensional (3-D) printed models are increasingly used to enhance understanding of complex anatomy in congenital heart disease. To assess feasibility and accuracy of 3-D printed models obtained from cardiac CT scans in young children with complex congenital heart diseases. We included children with conotruncal heart anomalies who were younger than 2 years and had a cardiac CT scan in the course of their follow-up. We used cardiac CT scan datasets to generate 3-D models. To assess the models’ accuracy, we compared four diameters for each child between the CT images and the printed models, including the largest diameters (Dmax) of ventricular septal defects and aortic annulus and their minimal diameters (Dmin). We obtained images from 14 children with a mean age of 5.5 months (range 1–24 months) and a mean weight of 6.7 kg (range 3.4–14.5 kg). We generated 3-D models for all children. Mean measurement difference between CT images and 3-D models was 0.13 mm for Dmin and 0.12 mm for Dmax for ventricular septal defect diameters, and it was 0.16 mm for Dmin and −0.13 mm for Dmax for aortic annulus diameter, indicating a non-clinically significant difference. Three-dimensional printed models could be feasibly generated from cardiac CT scans in a small pediatric population with complex congenital heart diseases. This technique is highly accurate and reliably reflects the same structural dimensions when compared to CT source images.

This new and easily reproducible pulmonary valve-sparing technique for the correction of Tetralogy of Fallot is based on a conservative management of the native pulmonary valve to preserve its growth potential. From July 2015 to December 2019, 67 children presenting with a Tetralogy of Fallot were operated consecutively in a single centre using this technique in all cases. A T-shaped infundibulotomy is used to release the anterior pulmonary annulus from any muscular attachment. After myocardial resection and ventricular septal defect closure, an extensive commissurotomy is achieved. Finally, the right ventricular outflow tract remodelling is completed by a shield-shaped bovine patch with an oversized square superior edge, attached directly on the pulmonary valve annulus, with an effect of systolic traction. Sixty patients (89.5%) had a Tetralogy of Fallot repair with preservation of the pulmonary valve. To date, with a median follow-up of 38.2 [14–64] months, no patient has needed a surgical or interventional procedure for pulmonary valve stenosis or regurgitation, with low residual gradients. This procedure could provide a significant increase in native pulmonary valve preservation. Long-term studies are needed to assess pulmonary valve growth and the consequent reduction in surgical or interventional reoperations.

Introduction 3D printed models are increasingly used to enhance understanding of complex anatomy in congenital heart disease. We aimed to assess feasibility and accuracy of 3D printed models obtained from cardiac CT scan in small pediatric population with complex congenital heart diseases. Method Patients with conotruncal heart anomalies aged less than 2 years old who had a cardiac CT scan in course of their follow-up were included. Cardiac CT scan datasets were used to generate 3D models. To assess model's accuracy, 4 diameters were compared for each patient between the CT images and the printed models, including the largest diameters (Dmax) of ventricular septal defects (VSD) and aortic annulus (AA) and their minimal diameters (Dmin). Results Images of 14 patients were obtained. Mean age was 5.5 months (1–24 months), mean weight was 6.7 kg (3.4–14.5 kg). 3D models were successfully obtained in all patients. Correlations between measurements obtained from printed models and CT images were excellent (r = 0.90 to 0.98). Mean measurement difference between CT image and 3D model was 0.13 mm for Dmin and 0.12 mm for Dmax for VSD diameters, and was 0.16 mm for Dmin and −0.13 mm for Dmax for AA diameter indicating a non-clinically significant difference ( Fig. 1 ). Conclusion 3D printed models are feasible from cardiac CT scan in small pediatric population with complex congenital heart diseases. This technic is highly accurate and reliably reflects the same structure dimensions when compared to CT source images.

Imaging fusion between echocardiography and fluoroscopy was recently developed. The aim of this study was to assess its feasibility and accuracy during pediatric cardiac catheterization.Thirty-one patients (median weight, 26 kg; interquartile range [IQR], 21-37 kg) who underwent percutaneous atrial septal defect closure were prospectively included. The feasibility and accuracy of various imaging fusion modalities (live two-dimensional, live color two-dimensional, live three-dimensional and markers) with EchoNavigator software were assessed. To assess the accuracy of spatial registration of the echocardiogram on the fluoroscopic image, the occluder screw, an object that appeared on each image, was used as a reference tool, and the distance between the two when fused was measured. A distance was measured on the fusion screen between a marker positioned on the screw from the echocardiography screen and from the fluoroscopy screen (distance 1). Another distance was measured on the fusion screen between the screw visualized by three-dimensional echocardiography and by fluoroscopy (distance 2). The two distances were measured on four C-arm orientations in end-systolic and end-diastolic frames.Fusion and marker positioning were feasible in real time in all cases. On the fusion screen, median systolic and diastolic distance 1 were 0.5 mm (IQR, 0.3-1 mm) and 2 mm (IQR, 1.5-2.5 mm; P .0001), respectively. The marker positioned from the echocardiography screen was fixed on the fusion screen and did not follow the movement of the screw. Median systolic and diastolic distance 2 were 0.5 mm (IQR, 0-0.5 mm) and 2 mm (IQR, 1.5-2.5 mm; P .0001), respectively.Echocardiographic fluoroscopic imaging fusion is feasible, safe, and accurate in children weighting20 kg. This technique offers a new method of imaging guidance in the catheterization laboratory for complex procedures and training.

As a result of innovations in informatics over the last decades, physiologic models elaborated in the second half of the 20th century could be transformed into specific virtual patients called computational models. These models, developed initially for teaching purposes, are of great potential interest in responding to current concerns about improving patient care and safety. However, even if there are obvious advantages to using computational models in cardiorespiratory management, major concerns persist as to their reliability and their ability to recreate real patient physiologic evolution over time. Once developed, these models require complex validation and configuration phases prior to implementation in daily practice. This article focuses on the development of computational models, and reviews the methodologies to clinically validate the models including specific patient databases (perpetual patients) and the use in clinical practice including very high fidelity simulation.

Summary Background Transoesophageal echocardiography (TOE) has become indispensable in the catheterization laboratory in the guidance of some percutaneous interventions, as a complementary imaging technique to fluoroscopy. However, the two imaging modalities are presented separately and differently, making interpretation of the anatomical spatial relationships complicated. EchoNavigator® (Philips Healthcare, Best, the Netherlands) is an innovative software package, enabling fusion of fluoroscopic and echocardiographic images on the same screen. Aims To assess the feasibility of EchoNavigator® in the guidance of interventional procedures, and to present our initial clinical experience with this software. Methods Children with congenital heart disease who underwent interventional catheterization needing guidance with TOE from December 2015 to December 2017 were included. TOE was realized using a X7-2t TOE probe (Philips Healthcare) connected to an echocardiographic system (EPIC™; Philips Healthcare, Andover, MA). Fluoroscopy was realized using the Allura Xper FD/10 system (Philips Healthcare). Image fusion was attempted in all patients using EchoNavigator®. Markers were positioned on the target zone on echocardiographic images, and projected onto the merged screen. Results Fifty-one children were included (mean age, 8 years; mean weight, 25 kg). Thirty-six patients underwent atrial septal defect closure, 10 ventricular septal defect closure, three aortic valve dilatation and two right ventricular outflow tract revalvulation. Image fusion was successfully obtained in all patients during all steps of the procedure. No complication related to the TOE probe was observed. Markers were successfully positioned in the all target zones, and were automatically projected onto the fusion screen. Conclusions The EchoNavigator® system is feasible and safe in the guidance of interventional catheterization in children with congenital heart disease; it enables better appreciation of anatomical relationships and improves the confidence of the interventionist.

Handovers during anaesthesia are common, and failures in communication may lead to morbidity and mortality. We hypothesised that intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room. Interventional cohort study. Single-centre tertiary care university hospital. A total of 204 random observations of handovers between anaesthesia providers (residents and nurse anaesthetists) over a 6-month period in 2016. Two geographically different hospital sites were studied simultaneously (same observations, but no training/checklist at the control site): first a 2-week 'baseline' observation period; then handover training and display of checklists in each operating room (at the intervention site only) followed by an 'immediate' second and finally a third (3 months later) observation period. A 22-item checklist was created by a modified DELPHI method and a checklist score calculated for each handover by adding the individual scores for each item as follows: -1, if error in communicating item; 0, unreported item; 0.5, if partly communicated item; 1, if correctly communicated item. Before training and display of the checklist, the scores in the interventional and the control groups were similar. There was no improvement in the control group's scores over the three observation periods. In the interventional group, the mean (95% confidence interval) score increased by 43% [baseline 7.6 (6.7 to 8.4) n = 42; 'immediate' 10.9 (9.4 to 12.4) n = 27, P

Summary Background There have been recent changes with regard to tools and concepts for respiratory management of children undergoing general anesthesia. Objectives To determine the practice of pediatric anesthetists concerning: preoxygenation, breathing systems, ventilation modes, anesthetic agent and airway device, strategies for a general anaesthetic of less than 30 min using spontaneous respiration, and opinion about technical aspects of ventilation. Methods Online questionnaire sent by e-mail to all the anesthetists registered on the mailing list of the French-speaking Pediatric Anesthetists and Intensivists Association (ADARPEF). Results 232 questionnaires (46%) were returned. More than 25% of anesthetists surveyed declared that they do not perform preoxygenation before induction for children

Introduction Imaging fusion between echocardiography and fluoroscopy is now available in the catheterization laboratory. We aim to test the feasibility and accuracy of imaging fusion in a pediatric population. Method Thirty-one patients (26 kgs [21–37]) underwent percutaneous atrial septal defect (ASD) closure were prospectively included. Occluder device's screw, visualized on both echocardiography and fluoroscopy images was used as a reference tool. Bias was measured between a marker positioned on the device screw visualized on echocardiography and the fluoroscopic screw image on the fusion screen (distance 1). Another bias was measured between the screw on 3D echocardiographic image and the screw on fluoroscopic image (distance 2). The 2 distances were measured on 4 orthogonal views in end-systolic and end-diastolic frames. Results Fusion and marker positioning were feasible in real-time in all cases. In 5 cases (16.1%), there was a transient loss of the automatic tracking of the probe during the procedure. Quality of imaging fusion was rated good in all cases. On the fusion screen, systolic and diastolic first distances were 0.5 [0.3–1] and 2 mm [1.5–2.5] (P Conclusion Echocardiographic-fluoroscopic imaging fusion is feasible, safe and accurate in children above 20 kgs. This innovate technic offers a new real-time imaging guiding modality in the catheterization laboratory with potential interest in complex procedures as well as for fellow training.

Right ventricular (RV) function is a prognostic marker of cardiac disease in children. Speckle tracking has been developed to assess RV longitudinal shortening, the dominant deformation during systole; little is known about its feasibility in children with congenital heart disease (CHD).To evaluate the feasibility and reproducibility of RV two-dimensional (2D) strain assessed by speckle tracking in infants undergoing CHD surgery compared with conventional markers.In this prospective single-centre study, RV peak systolic strain (RV-PSS) was measured using 2D speckle tracking in 37 consecutive children undergoing CHD surgery. Examinations were performed the day before surgery, a few hours after surgery and before discharge. Relationships with the z score of tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TA Sa) were assessed.Median (interquartile range) age was 19 months (5-63); median weight was 9.2 kg (5.3-18.0). RV-PSS analysis was feasible in 92.9% (95% confidence interval [CI]: 86.0-97.1) of examinations. The coefficient of variation was 9.7% (95% CI: 7.4-11.9) for intraobserver variability and 15.1% (95% CI: 12.7-17.6) for interobserver variability. Correlations between RV-PSS and z score of TAPSE and TA Sa were strong (r=0.71, P0.0001 and r=0.70, P0.0001, respectively). RV-PSS was significantly reduced after surgery compared with baseline (-10.5±2.9% vs. -19.5±4.8%; P0.0001) and at discharge (-13.5±4.0% vs. -19.5±4.8%; P0.0001). Similar evolutions were observed with TAPSE and TA Sa (both P0.0001).RV longitudinal strain by speckle tracking is a feasible and reproducible method of assessing perioperative evolution of RV function in children with CHD.

Background: Rupture of a splenic artery aneurysm during pregnancy is a rare and serious event, occurring mainly during the third trimester. The risk of rupture for an existing splenic artery aneurysm is very high during pregnancy (from 20% to 50%). When it does rupture, the maternal mortality rate is around 75% and the fetal mortality rate 95%. Of 110 cases reported in the literature, only one ruptured during the first trimester. Objectives: The aim of this case report is to make emergency physicians aware of this diagnosis, because only if it is considered can it be managed rapidly and appropriately. Case Report: We report the case of a 6-weeks pregnant patient referred to our institution in hemorrhagic shock who died of a ruptured splenic artery aneurysm shortly after surgery. The initial diagnosis considered was a ruptured ectopic pregnancy. Conclusion: We report this case to increase awareness of splenic artery rupture during pregnancy, even during the first trimester.

Longitudinal studies are essential tools in medical research. In these studies, variables are not restricted to single measurements but can be seen as variable-trajectories, either single or joint. Thus, an important question concerns the identification of homogeneous patient trajectories.kml and kml3d are R packages providing an implementation of k-means designed to work specifically on trajectories (kml) or on joint trajectories (kml3d). They provide various tools to work on longitudinal data: imputation methods for trajectories (nine classic and one original), methods to define starting conditions in k-means (four classic and three original) and quality criteria to choose the best number of clusters (four classic and one original). In addition, they offer graphic facilities to “visualize” the trajectories, either in 2D (single trajectory) or 3D (joint-trajectories). The 3D graph representing the mean joint-trajectories of each cluster can be exported through LATEX in a 3D dynamic rotating PDF graph (Figures 1 and 9).

Balloon atrial septostomy (BAS) increases peripheral oxygen saturation in neonates with transposition of the great vessels (TGV). Effect of BAS on cerebral oxygenation remains little known. We aimed to describe the modification of regional cerebral tissue oxygen saturation (rcSaO 2 ) during the catheterization. Methods we prospectively included 6 neonates with TGV and restrictive inter-atrial shunt who required BAS. BAS was performed in catheterization laboratory by an interventional pediatric cardiologist. rcSaO 2 was measured using near-infrared spectroscopy (NIRS) during the whole procedure. Results Median rcSa0 2 at the beginning of the procedure was 52.5% ranging from 21% to 78%. Median rcSaSaO 2 after the BAS was 69.5% ranging from 64% to 94%. The rcSa0 2 increased significantly immediately after the BAS (p=0.0273 by Wilcoxon signed rank test). Median rcSa0 2 delta between before and after BAS was 19% ranging from 11 to 43%. The rcSaO 2 delta was higher although not significantly when rcSa02 before the BAS was less than 50% (31% vs 16%, p=0.14). Linear regression analysis revealed that the delta of rcSaO 2 was significantly inversely related to the rcSa0 2 at the beginning of the procedure (Delta= –0.45 x rcSaO 2 av + 45.8, p=0.37, R 2 =0.70). Conclusion BAS improves cerebral oxygen saturation during the catheterization in neonates with TGV and restrictive inter-atrial shunt. The increase is proportional to the degree of alteration before the procedure.

BackgroundRV systolic strain evolution during peri-operative management of congenital heart diseases (CHD) is unknown.MethodsIn this prospective study, RV peak systolic strain (PSS) was measured using 2D speckle tracking echocardiography (Qlab10.0 software, Philips) in 39 children undergoing surgery of a CHD (Median age: 17 months, min 6 day-old, max 14.3 year-old). Three measures were performed the day before surgery, few hours after the surgery and before discharge and compared to conventional echocardiographic parameters of RV and left ventricular (LV) function. The relationships between the evolution of RV-PSS, peri-operative parameters and the type of CHD were assessed.ResultsMean RV-PSS at baseline was - 19.5±4.8. RV-PSS was moderately correlated with the heart rate (r=0.49), the LV Tmad (r=-0.48), the TAPSE (r=-0.54) and the tricuspid S’ wave (r=-0.44)(all p

Introduction The Echonavigator® software allows real-time imaging fusion between 2D or 3D echocardiography and fluoroscopy in the catheterization laboratory. We aim to test the accuracy of the imaging fusion in a pediatric population. Methods After percutaneous closure of atrial septal defect, occluder devices, visualized on echocardiography and fluoroscopy, were used as a reference tool. First, distance between the thread pitch on the 3D echo view and on fluoroscopy was measured on 4 orthogonal views (right anterior oblique, left anterior oblique, right posterior oblique, left posterior oblique), in systole and diastole (distance 1). Second, distance between a marker positionned on echo and the thread pitch on the fluoroscopy view was measured on the 4 orthogonal views in systole and diastole (distance 2). Results Thirty-one patients (7.9 years old [6.0–9.8]; 26 Kg [21–37]) were included. Fusion and marker positioning were feasible in all cases. No complication related to the echocardiography was reported. In 5 cases (16.1%), fusion was instable during the procedure with transient loss of the automatic tracking of the probe. Quality of the fusion imaging was rated good in 21 cases (67.7%) and excellent in 10 cases (32.3%). Fusion was available in real time in all patients. However there was a slight temporal delay between the fluoroscopic and the echo images. Minimal and maximal distances 1 were 0.5 [0–0.5] and 2 mm [1.5–2.5]. The marker positionned on echo was fixed and did not follow the movement of the thread pitch during the cardiac cycle. On the fusion view, minimal and maximal distances 2 during the cardiac cycle were 0.5 [0.3–1] and 2 mm [1.5–2.5]. Bias was not significantly different among the 4 axis ( Fig. 1 ). Conclusion Feasibility and accuracy of the echonavigator software is high in a pediatric population weighting more than 20 Kg. It could be improved by the development of a pediatric 3D trans-esophageal probe and by applying 3D speckle tracking technology.

Transoesophageal echocardiography is a useful tool for the intra-operative assessment of surgical repair in children with congenital cardiac malformations. We report the case of a subaortic membrane removal in a nine-year-old boy. Three-dimensional transoesophageal echocardiography revealed a mitral perforation created during the procedure.

OBJECTIVES Open arch surgery for aortic arch aneurysm was historically associated with a high risk of postoperative morbi-mortality. Improved operative techniques have now lowered the incidence of these complications but in parallel, hybrid arch procedures have emerged. Nowadays, very little data are available about their mid-term results compared with open surgery. METHODS From January 2002 to January 2014, 46 patients had treatment for an exclusive aortic arch aneurysm including 25 open arch surgeries and 21 type I hybrid arch procedures in our institution. All cases involved arch aneurysms involving at least one carotid artery (Zone 0 and Zone 1). Aneurysms of the distal arch and descending aorta were excluded (Zone 2 and beyond). Results from a retrospective database are reported. There were no patients lost to the follow-up. RESULTS There was no significant difference in preoperative comorbidities between the two groups. The incidence of in-hospital mortality was similar at 20% (5/25) for open surgery and 19% (4/21) for hybrid procedure (P = 0.830). The incidence of permanent cerebral neurological deficit was comparable at 17.4% (4/23) for open surgery and 21.1% (4/19) for hybrid procedure (P = 1). Median survival was 109.5 months for open surgery and 56.3 months for hybrid procedure. Freedom from all-cause mortality was 78, 63, 63 and 57% at 1, 3, 5 and 7 years, respectively in the open surgical group. Freedom from all-cause mortality was 74, 55, 46 and 28% at 1, 3, 5 and 7 years, respectively in the hybrid group. Survival rates and incidence of major adverse cardiac and cerebro-vascular event between open surgery and hybrid procedure were not statistically different (P = 0.530 and P = 0.325, respectively). However, incidence of reintervention was in favour of open surgery [14.5 vs 44.8% at 7 years, P = 0.045; 95% confidence interval: (0.06-0.97)]. CONCLUSIONS The type I hybrid arch procedure fails to demonstrate better results compared with open surgery, regarding morbi-mortality at the short- and mid-term follow-up. Moreover, it increases the risk of reintervention. Patients treated by this technique must undergo a closer follow-up because of this risk. Larger randomized studies are needed to better define the exact indications of this therapy.

BackgroundFrench humanitarian chains promote surgery for children with congenital heart diseases coming from developing countries. We assessed the results following complete repair of tetralogy of Fallot (TOF) in relation to the origin of patients.MethodsA 4-year retrospective review of 73 consecutive patients with TOF repair was performed. Children were divided into two groups: French children (group A, n=38) and children from developing countries (group B, n=35).ResultsPreoperative status differed between the two groups. Children from group B were older (0.82 vs 7.18 year-old, P

BackgroundIn pediatric cardiac surgery, anticoagulation protocols are derived from adult protocols. Age, Antithrombin III level, and capacity to generate thrombin are factors that affect unfractionated heparin (UFH) action in children. A starting UFH dose of 400 UI/kg is recommended to get an Activated Clotting Time (ACT) target over 400seconds. In our daily practice, we noticed a wide range of ACT increase (ΔACT) after this standardized weight based bolus of UFH.ObjectiveTo define factors affecting UFH effectiveness based on ΔACT before CPB initialization in pediatric cardiac surgery.MethodsA retrospective chart review of patient undergoing cardiac surgery requiring CPB in a single university hospital was performed. Patients receiving preoperative anticoagulation therapy or platelet aggregation inhibitors were excluded. We searched predictive factors for ΔACT. We defined 2 groups: hyperrespondents (HR; ΔACT>500) and normorespondents (NR; ΔACT5 months (r=0.59 P=0.00001) and>5kg (r=0.54 P=0.00001) for with a predictive ΔACT of 386 s [325–443]. There is no correlation between ΔACT and UFH dose for patients400 s in this specific population should be calculated using other method that still needs to be developed to avoid complications associated to excessive dose of UFH.

IntroductionNeuro-developmental impairment which follows management of complex congenital heart disease is a major issue. Balloon dilation is a frequent procedure, which can lead to brain injury. Whereas the pressure and diameter of balloon for inflation are quite normalized, there are no written guidelines for time of inflation. Our aim was to study the brain perfusion with the NIRS (Near Infra Red Spectroscopy) during catheter procedure.MethodsWe prospectively enrolled 20 consecutive children (mean±SD: age=2.8±3.4y.o.; weight=15.6±13.6kg) who underwent transcatheter balloon dilation of pulmonary valve, trunk or conduit stenosis. Procedure was done under general anesthesia with regular monitoring. SpO2 was used by physician for patient safety. Cerebral oxygen saturation (Rso2) was monitored by NIRS. Each brain desaturation events were collected. 40% of rSO2 was considered as the cut-off limit below which brain injury may occurs. Time to reach this limit (TTR40), time to recover (TTR95), area under curve and deepness of the events were extracted (Appendix 1).ResultsThe total number of inflation was 56, with a mean of 2,8 inflations per patient (min=2; max=10). The NIRS curve had two parts: it decreased during balloon inflation due to CO interruption and then increased during the reperfusion. Both were easily detected (Se=100%) whereas the SpO2 remained wrongfully high. Near 36% of desaturation were under the cut-off (NIRS

Background A trans-catheter closure of an atrial septal defect (ASD) is efficient. Balloon sizing (BS) during the catheterization leads to an overestimation of ASD size. Three-dimensional transoesophageal echocardiography (3D-TEE) allows the ASD morphology to be assessed comprehensively. The aim of this study was to assess the relationships between the shape and the measurements of ASDs by 2D-, 3D-TEE, and BS in children. Methods and results Thirty children who underwent percutaneous closures of a single ASD were enrolled. ASD diameters were measured by 2D-transthoracic echocardiography (TTE), 2D-TEE, 3D-TEE and compared with BS. The ASD area was measured on 3D-TEE images after multi-planar reconstruction. ASD was estimated as round or oval on 3D-TEE ‘en-face’ view. 2D-TTE, 2D-TEE, and 3D-TEEmax ASD diameters were well correlated with BS ( r = 0.75; 0.80, and 0.85, respectively). Mean diameters were all significantly smaller than the mean BS. The mean difference between the balloon area and 3D-TEE area was 1.6 ± 1.4 cm2 ( P < 0.0001). The mean difference between BS and 3D-TEEmax diameters was higher in round ASDs than in oval ASDs (4.0 ± 3.3 vs. 1.1 ± 3.3, P = 0.02). With multivariate linear regression analysis, two formulas were built to predict BS. The first model was BS = 1.07 × 3D-TEEmax− 3.1 × ASDshape + 3. The ASD shape was 0 for round and 1 for oval ASDs. A second model was BS = 4.5 × ASDarea + 11.5. Conclusion The ASD shape is accurately estimated by 3D-TEE and influences the relationship between echocardiographic measurements and BS. The ASD shape, its maximal diameter and the area assessed by 3D-TEE may be sufficient to determine the device size without BS in children.

BACKGROUND Preoperative flushing of an anesthesia workstation is an alternative for preparation of the anesthesia workstation before use in malignant hyperthermia-susceptible patients (MHS). We studied in vitro, using a test lung, the washout profile of sevoflurane in 7 recent workstations during adult and, for the first time, pediatric ventilation patterns. METHODS Anesthesia workstations were first primed with 3% sevoflurane for 2 hours and then prepared according to the recommendations of the Malignant Hyperthermia Association of the United States. The flush was done with maximal fresh gas flow (FGF) with a minute ventilation equal to 600 mL × 15, to reach a sevoflurane concentration of

We measured the time it takes to reach the desired inspired anesthetic concentration using the Primus (Dragerwerk, AG, Lubeck, Germany) and the Avance (GE Datex-Ohmeda, Munich, Germany) anesthesia machines with toddler and newborn ventilation settings. The time to reach 95% of inspired target sevoflurane concentration was measured during wash-in from 0 to 6 vol% sevoflurane and during wash-out from 6 to 0 vol% with fresh gas flows equal to 1 and 2 times the minute ventilation. The Avance was faster than the Primus (65 seconds [95% confidence interval (CI): 55 to 78] vs 310 seconds [95% CI: 261 to 359]) at 1.5 L/min fresh gas flow, tidal volume of 50 mL, and 30 breaths/min. Times were shorter by the same magnitude at higher fresh gas flows and higher minute ventilation rates. The effect of doubling fresh gas flow was variable and less than expected. The Primus is slower during newborn than toddler ventilation, whereas the Avance's response time was the same for newborn and toddler ventilation. Our data confirm that the time to reach the target-inspired anesthetic concentration depends on breathing circuit volume, fresh gas flow, and minute ventilation.

IntroductionThere is an association between congenital heart disease (CHD) and neurodevelopmental delay (42%). Brain injury can be minimized by adequate perfusion control based on NIRS (6% Vs 26%): a low NIRS index under 40% is a good predictor of brain lesion. Here, monitoring must be foolproof and easy to understand. Assessed parameters must imply the opportunity of an early intervention by the physician. Alas, NIRS is assessed peri-operatively. Our aim was to find an earlier predictor that could be used to assess brain vulnerability pre-operatively.MethodsWe prospectively enrolled 14 children (mean±SD: age=2.2±3.3 y.o.; weight=9.4±9 Kg) who underwent cardiopulmonary bypass for a CHD repair surgery. Cerebral oxygen saturation (rSo2) was monitored by NIRS. We calculated the ΔNIRS as de difference between NIRS level before the procedure and during the CPB. We compared the rSO2 data with the physiologic brain status assessed by a computed electroencephalogram (EEG spectral analysis). This later provided four spectral index (alpha, beta, delta, theta).ResultsThe NIRS decreased during CPB. ΔNIRS value was 24,21% (±16.28) .Two patients had a NIRS impairment below 40% (14.3%). There was no correlation between NIRS and either the spectral index alpha, delta or theta. Linear regression based on Beta index shows two significant relationships. The preoperative beta spectral index is correlated with the ΔNIRS (P=0,03*11* p value less than 0.05 - significant.) and with the minimum NIRS level during the CPB (P=0.01).ConclusionPreoperative Beta spectral index is therefore an early predictor of brain vulnerability. A high Beta index preoperatively could predict a low NIRS index during CPB and therefore a possibility of brain injury. That was a preliminary study and our findings need to be validated onto a wider panel of patients. Beta index is probably could be linked to the CHD type too. Nevertheless, beta index could help to design targeted procedure for brain protection adapted to each type of patient.

BackgroundFrench humanitarian chains promote surgery for children with congenital heart diseases coming from developing countries. We assessed the results following complete repair of tetralogy of Fallot (TOF) in relation to the origin of patients.MethodsA 4-years retrospective review of 73 consecutive patients with TOF repair was performed. Children were divided into two groups: French children (group A, n=38) and children from developing countries (group B, n=35).ResultsPreoperative status differed between the two groups. Children from group B were older (0.82 vs 7.18 year-old, p

Summary Background Transoesophageal echocardiography (TOE) is feasible in neonates using a miniaturized probe, but is not widely used because of low imaging quality. Aims To assess handling and imaging quality of a new release of a micro-TOE probe in children. Methods Thirty-eight consecutive children, enrolled during February and May 2013, underwent TOE with the Philips S8-3t probe. Insertion, handling and image quality were assessed. Results The 38 children (aged 7 days to 12 years; weight 3.1–27 kg) underwent 75 TOE (30 [40.0%] before cardiac surgery, 31 [41.3%] after cardiac surgery, 4 [5.3%] during a percutaneous procedure, 10 [13.3%] in the intensive care unit). Insertion of the micro-TOE probe was ‘very easy’ in 37/38 patients (97.4%). Handling was better in the lightest children (P = 0.001). Image quality was mainly ‘good’ or ‘very good’, with no significant changes between preoperative and postoperative examinations or over time. Total scores (insertion, handling, image quality) were significantly better in the lightest children (P = 0.02). Preoperative TOE did not provide additional information over transthoracic echocardiography. Postoperative TOE was useful to assess surgical results, but no residual lesions required extracorporeal circulation return. Micro-TOE was useful during the postoperative care of neonatal surgery with open breastbone to assess the surgical result and ventricular function. It was also useful to guide extracorporeal membrane oxygenation (ECMO) indication and withdrawal; and was a useful guide for percutaneous procedures. Conclusion Micro-multiplane TOE is safe and efficient for use in neonates and children. This minimally invasive tool increases the impact of TOE in paediatric cardiology.

BackgroundRV systolic strain evolution during peri-operative management of congenital heart diseases (CHD) is unknown.MethodsIn this prospective study, RV peak systolic strain (PSS) was measured using 2D speckle tracking echocardiography (Qlab10.0 software, Philips) in 39 children undergoing surgery of a CHD (Median age: 17 months, min 6 day-old, max 14.3 year-old). Three measures were performed the day before surgery, few hours after the surgery and before discharge and compared to conventional echocardiographic parameters of RV and left ventricular (LV) function. The relationships between the evolution of RV-PSS, peri-operative parameters and the type of CHD were assessed.ResultsMean RV-PSS at baseline was –19.5±4.8. RV-PSS was moderately correlated with the heart rate (r=0.49), the LV Tmad (r=–0.48), the TAPSE (r=–0.54) and the tricuspid S’ wave (r= –0.44)(all p