Perioperative management of low birth weight infants for open-heart surgery

Open-heart surgery in preterm infants: A single-center experience

Background

Open-heart surgery is challenging in preterm neonates and infants, and its feasibility in low-resource settings has not been defined. We describe our institutional experience with open-heart surgeries performed on consecutive preterm infants.

Materials Methods and Results

This was a single-center retrospective cohort from a tertiary hospital in Southern India and included consecutive preterm neonates (<37 weeks) admitted for open-heart surgery. This report is limited to babies who were <3 months at the surgery. The salient features of the 15 preterm included twin gestation: 7 (46.7%); median gestational age at birth: 35 weeks (28-36 weeks); median corrected gestational age at surgery: 37 weeks (33-40 weeks); birth weight: 1.75 kg (1.0-2.6 kg); weight at surgery: 1.8 kg (1.2-2.9 kg); and small for gestational age: 12 (80%). The heart defects included transposition of the great arteries (7), total anomalous pulmonary venous return (3), large ventricular septal defect (VSD) (1), and VSD with coarctation of the aorta (4). Eleven (73%) were mechanically ventilated preoperatively and five had preoperative sepsis. The mean cardiopulmonary bypass time was 169.7 ± 61.5 min, and cross-clamp time was 99.7 ± 43.8 min. There was no inhospital mortality; one baby expired during follow-up at 1 month. Postoperative mechanical ventilation duration was 126.50 h (84.25-231.50 h), and intensive care unit stay was 13.5 days (9-20.8). The total hospital stay was 39 days (11-95 days). Two children (13.3%) had postoperative sepsis.

Conclusion

Through collaborative multidisciplinary management, excellent outcomes are feasible in low-resource environments for selected preterm neonates undergoing corrective open-heart operations.

Etiology and Risk Factors for Extubation Failure in Low Birth Weight Infants Undergoing Congenital Heart Surgery

OBJECTIVE

The aim of the present study was to explore the etiology and risk factors of extubation failure (ExF) in low birth weight (LBW) infants undergoing congenital heart surgery.

DESIGN

Retrospective, comparative study.

SETTING

A Cantonese cardiac center in China.

PARTICIPANTS

The cases of all LBW infants undergoing congenital heart surgery admitted to the authors' neonatal intensive care unit from January 2010 to September 2018 were reviewed retrospectively. ExF was defined as reintubation within 72 hours after extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, preoperative, perioperative, and postoperative data were collected. The exclusion criteria were surgical ligation of patent ductus arteriosus and no extubation attempt. Risk factors for ExF were analyzed with univariate and multivariate logistic regression analysis. Ninety-nine infants met the inclusion criteria; the study comprised 66 males and 33 females, including 60 premature infants. ExF occurred in 16 of 99 infants for various kinds of reasons. Infants with ExF had longer postoperative intensive care unit length of stay (LOS) (p < 0.001) and total hospital LOS (p = 0.022). The multivariate logistic regression analysis identified preoperative mechanical ventilation (odds ratio 9.3; 95% confidence interval 1.11-79.52; p = 0.040) and prolonged mechanical ventilation before the first attempted extubation (odds ratio 6.48; 95% confidence interval 1.20-35.17; p = 0.030) as risk factors for ExF.

CONCLUSIONS

The prevalence of ExF is very high in LBW infants undergoing congenital cardiac surgery. ExF in LBW infants is associated with an increase in hospital LOS. Presumed reasons for failed extubation are diverse. Preoperative mechanical ventilation and prolonged mechanical ventilation before the first attempted extubation were independent risk factors for ExF.

Predictors of postoperative outcomes in infants with low birth weight undergoing congenital heart surgery: a retrospective observational study

Background

Despite improvements in neonatal cardiac surgery and postoperative care, hospitalized death for infants with low birth weight remains high.

Objective

This study sought to identify predictors of postoperative outcomes in low-birth-weight infants undergoing congenital heart surgery and establish nomograms to predict postoperative intensive-care unit (ICU) stay.

Methods

From June 2009 to June 2018, a retrospective review of 114 infants with low birth weight (≤2.5 kg) undergoing congenital heart surgery was conducted at Guangdong Provincial People’s Hospital. Purely surgical ligation of patent ductus arteriosus was excluded from this study. A total of 26 clinical variables were chosen for univariate, multivariate, and Cox regression analysis, and 14 variables were analyzed as predictors of postoperative outcomes. Nomograms were established to predict risk of postoperative cardiac ICU (CICU) stay, postoperative neonatal ICU (NICU) stay, and total ICU length of stay in infants with cardiac diseases.

Results

Two variables were independent predictors in multiple logistic regression analysis of hospitalized death: operation weight and Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery (STAT) risk categories. Six variables were independent predictors in the Cox model of postoperative ICU length of stay, including sex, prematurity, birth weight, preoperative stay time in NICU, diagnostic classification, and STAT risk categories. We calculated concordance-index values to estimate the discriminative ability of models of risk of postoperative CICU stay, postoperative NICU stay, and total ICU length of stay, with values of 0.758 (95% CI 0.696–0.820), 0.604 (95% CI 0.525–0.682), and 0.716 (95% CI 0.657–0.776), which indicated the possibility of true-positive results.

Conclusion

Our findings might help clinicians predict postoperative outcomes and optimize therapeutic strategies.

Management of the Preterm Infant with Congenital Heart Disease

The premature neonate with congenital heart disease (CHD) represents a challenging population for clinicians and researchers. The interaction between prematurity and CHD is poorly understood; epidemiologic study suggests that premature newborns are more likely to have CHD and that fetuses with CHD are more likely to be born premature. Understanding the key physiologic features of this special patient population is paramount. Clinicians have debated optimal timing for referral for cardiac surgery, and management in the postoperative period has rapidly advanced. This article summarizes the key concepts and literature in the care of the premature neonate with CHD.

Outcomes of cardiac surgery in patients weighing <2.5 kg: affect of patient-dependent and -independent variables

OBJECTIVE

A recent Society of Thoracic Surgeons database study showed that low weight (<2.5 kg) at surgery was associated with high operative mortality (16%). We sought to assess the outcomes after cardiac repair in patients weighing <2.5 kg versus 2.5 to 4.5 kg in an institution with a dedicated neonatal cardiac program and to determine the potential role played by prematurity, the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) risk categories, uni/biventricular pathway, and surgical timing.

METHODS

We analyzed the outcomes (hospital mortality, early reintervention, postoperative length of stay, mortality [at the last follow-up point]) in patients weighing <2.5 kg at surgery (n = 146; group 1) and 2.5 to 4.5 kg (n = 622; group 2), who had undergone open or closed cardiac repairs from January 2006 to December 2012 at our institution. The statistical analysis was stratified by prematurity, STAT risk category, uni/biventricular pathway, and usual versus delayed surgical timing. Univariate versus multivariate risk analysis was performed. The mean follow-up was 21.6 ± 25.6 months.

RESULTS

Hospital mortality in group 1 was 10.9% (n = 16) versus 4.8% (n = 30) in group 2 (P = .007). The postoperative length of stay and early unplanned reintervention rate were similar between the 2 groups. Late mortality in group 1 was 0.7% (n = 1). In group 1, early outcomes were independent of the STAT risk category, uni/biventricular pathway, or surgical timing compared with group 2. A lower gestational age at birth was an independent risk factor for early mortality in group 1.

CONCLUSIONS

A dedicated multidisciplinary neonatal cardiac program can yield good outcomes for neonates and infants weighing <2.5 kg independently of the STAT risk category and uni/biventricular pathway. A lower gestational age at birth was an independent risk factor for hospital mortality.

Low birth weight and very low birth weight neonates with congenital heart disease: timing of surgery, reasons for delaying or not delaying surgery

Conventional management of low birth weight and very low birth weight neonates was composed of deferring corrective surgery by aggressive medical management or palliative surgery which does not require cardiopulmonary bypass. However, while waiting for weight gain, these neonates are at risk for various comorbidities. In the current era, this "wait and let the baby grow" approach has not been shown to result in better clinical outcomes. Early primary repair hence has become the standard strategy for congenital heart disease requiring surgery in these neonates. However, there still exist some circumstances, which are considered to be unfavorable for corrective surgery due to medical, physiologic, surgeon's technical and institutional-systemic factors. We reviewed the recent literature and examined the reasons for delaying or not delaying surgery.