Assessment of PIM-2 performance among surgical patients with heart disease and correlation of results with RACHS-1

OBJECTIVE

To assess the performance of the Pediatric Index of Mortality (PIM) 2 and the Risk Adjustment for Congenital Heart Surgery (RACHS) in the postoperative period of congenital heart disease patients.

METHODS

Retrospective cross-sectional study. Data were collected from patient records to generate the scores and predictions using recommended techniques, demographic data and outcomes. The Mann-Whitney test, Hosmer-Lemeshow test, standardized mortality rate, area under the receiver operating characteristic (ROC) curve, chi square test, Poisson regression with robust variance and Spearman's test were used for statistical analysis.

RESULTS

A total of 263 patients were evaluated, and 72 died (27.4%). These patients presented significantly higher PIM-2 values than survivors (p < 0.001). In the RACHS-1 classification, mortality was progressively higher according to the complexity of the procedure, with a 3.24-fold increase in the comparison between groups 6 and 2. The area under the ROC curve for PIM-2 was 0.81 (95%CI 0.75 - 0.87), while for RACHS-1, it was 0.70 (95%CI 0.63 - 0.77). The RACHS presented better calibration power in the sample analyzed. A significantly positive correlation was found between the results of both scores (rs = 0.532; p < 0.001).

CONCLUSION

RACHS presented good calibration power, and RACHS-1 and PIM-2 demonstrated good performance with regard to their discriminating capacities between survivors and non-survivors. Moreover, a positive correlation was found between the results of the two risk scores.

Gestational and family risk factors for carriers of congenital heart defects in southern Brazil

BACKGROUND

Congenital heart disease (CHD) is a serious threat to public health. Despite this, its etiology is poorly understood and few cardiac teratogens have been defined. The aim of the present study was to identify gestational and family risk factors for CHD in a sample of patients from a pediatric hospital in southern Brazil.

METHODS

A prospective and consecutive sample from subjects with or without CHD, hospitalized at a pediatric intensive care unit, was enrolled. All patients with CHD underwent a GTG-banding karyotype. Chromosomal abnormalities were observed in 47 subjects (15.8%), and these were excluded from the study. The final sample consisted of 250 CHD subjects and 303 controls.

RESULTS

After statistical analysis, using logistic regression, the variables age, rural location, gestational loss, use of anti-hypertensive medication, antibiotics and alcohol in the first trimester of pregnancy were all independently associated with CHD. These results were similar to those of some studies and different from others. It should be noted, however, that, for several variables, the data in the literature as well as the present study were insufficient to determine risk.

CONCLUSIONS

Some differences found may be explained by genetic factors and sociocultural diversity. In contrast, because CHD consists of a heterogeneous group of lesions, the etiology may vary. The standardization of research data and classification of methods for future studies are essential.

Serum lactate as mortality and morbidity marker in infants after Jatene's operation

OBJECTIVE

To assess the morbidity and mortality after Jatene's operation using lactate as the main marker.

METHODS

We performed a historical cohort with infants admitted in a pediatric intensive care unit during 1995 to 2005 who underwent this surgery. We assessed the preoperative, immediate (IPD), third hour (3h), six hour (6h) and first day (POD1) serum lactate as well as other factors such as sepsis, increased bleeding, low cardiac output syndrome, renal insufficiency, pulmonary hypertension, cardiac arrythmias, chylothorax, myocardial ischemia, seizures, presence of other complication, and also information about length of PICU stay and death.

RESULTS

The mean age of 76 patients was 14.59± 19.09 days, birth weight 3.128± 0.48 kg Forty-four patients had the diagnosis of simple transposition of great arteries. The circulatory bypass time was 143.78± 28.77 minutes and aortic clamping time of 87.68± 22.3 minutes and LOS of 20.28 ± 15.62 days. Twenty four (31.58%) died during hospital stay. Lactate increased in IPD, returning to baseline at 24 hours. Patients who died raised and maintained IPD lactate higher. The 3h lactate best discriminated mortality with area under the curve of 0.68 (CI 0.54 to 0.83) P = 0.035. However, considering a cutoff point for lactate greater or equal to 5.8 mmol/dl in the 3-h PO, we obtained only 67% sensitivity and specificity of 64% for mortality. There is positive correlation between number of complications and lactate. The low cardiac output syndrome with an odds ratio (OR) of 7.67 (2.38-24), increased bleeding with OR 2.91 (1.07-7.94) and respiratory complication with OR 1.67 (1.35-2.05) are risk factors when combined.

CONCLUSION

After Jatene's operation, morbidity and mortality can be assessed with the serum lactate levels, suggesting increased values in the third hour is suggestive of a worse prognosis.

[22q11.2 deletion syndrome: importance of clinical evaluation and FISH analysis]

OBJECTIVE

The 22q11.2 deletion syndrome nowadays is considered one of the most often observed genetic diseases in humans. It is clinically characterized by a rather wide phenotypic spectrum, with more than 180 clinical features physical as well as behavioral, already described. However, none is pathognomonic or obligatory which makes diagnosis even more difficult. Thus, this study intended to determine the prevalence and clinical characteristics of patients with 22q11.2 microdeletion in a selected sample of subjects with clinical suspicion of 22q11.2 deletion syndrome and normal karyotype.

METHODS

A selected sample of 30 patients with clinical suspicion of 22q11.2 deletion syndrome and normal karyotype was evaluated by application of a standard clinical protocol and cytogenetic analysis with fluorescent in situ hybridization.

RESULTS

22q11.2 microdeletion was identified in 3 patients (10%), a prevalence similar to the majority of published studies, which ranged from 4 to 21%. The 22q11.2 deletion syndrome patients in this study were characterized by a variable phenotype and shared few clinical features, in agreement with the literature description.

CONCLUSIONS

These findings strengthen the idea that clinical diagnosis of 22q11.2 deletion syndrome is difficult due to the large phenotypic variability. Therefore a detailed clinical evaluation associated to a sensitive test such as fluorescent in situ hybridization analysis is crucial for the identification of these patients.

Health-related quality of life and right ventricular function in the midterm follow-up assessment after tetralogy of fallot repair

BACKGROUND

Few data are available on quality of life after surgical repair of tetralogy of Fallot (ToF), and on its relationship to right ventricle function.

METHODS

Patients with at least 1 year of follow-up evaluation after surgery were studied. Right ventricle function was evaluated by the Doppler-derived myocardial performance index (MPI), and health-related quality of life (HRQL) was assessed by the Child Health Questionnaire, Parent Form-50. Findings were compared with those for an age- and sex-matched group of healthy children.

RESULTS

The study enrolled 35 successfully repaired ToF patients with 4.9 years (range, 3-7 years) of follow-up evaluation after surgery and 36 healthy children. The MPI demonstrated right ventricle dysfunction in patients compared with controls (0.34; range, 0.26-0.49 vs 0.2; range, 0.13-0.27; p < 0.01), although HRQL for the psychosocial domain was similar between patients and healthy children (summary score, 47.9; range, 45-52 vs 47.5; range, 44.5-50; p = 0.17). A trend for poorer physical area results was observed in patients (summary score, 44; range, 31-52 vs 48.5; range, 45.7-51.7; p = 0.06). Neither physical nor psychosocial summary scores for HRQL had any correlation with right ventricle MPI.

CONCLUSIONS

Right ventricle dysfunction is present in postoperative ToF patients. The psychosocial domain of HRQL is preserved after surgery. A trend for worse results was observed in the physical domain. The right ventricle function is not related to quality of life after surgical repair of ToF.

Treatment of pulmonary arterial hypertension

OBJECTIVE

To perform a review of the diagnostic and therapeutic management of pulmonary hypertension in the pediatric population, with emphasis on pharmacological factors.

SOURCES

Electronic search of publications on the MEDLINE/PubMed, LILACS and Cochrane Collaboration databases. The search strategy adopted gave priority to the identification of clinical trials (controlled or uncontrolled), systematic reviews and directives published during the last 10 years.

SUMMARY OF THE FINDINGS

Many advances have been incorporated into our understanding of pulmonary hypertension during recent years. Issues related to differences in the pathophysiological mechanism of the disease between different age groups have altered both the treatment and prognosis of patients. The combined effect of more selective vasodilatory properties and antiproliferative action and the employment of new drugs are the basic principles of new treatment proposals. In order to be able to gauge the benefits associated with the use of these new therapies, it is of fundamental importance that all patients have their disease correctly diagnosed, the degree of functional compromise classified and their vascular reactivity capacity established, which is more difficult with pediatric patients.

CONCLUSIONS

To date there is no treatment that can be considered ideal for the management of pulmonary hypertension. With reference to the possibility of employing new drugs, the majority of studies that have been published were undertaken with adult populations. Few data are available on children, and the majority of studies are uncontrolled trials or case series. Taking into account differences that have already been established between different age groups in terms of disease mechanisms and prognostic aspects, it is difficult to claim that these drugs can be incorporated into the treatment of childhood pulmonary hypertension with the same indications and results.