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Bonello B, Issitt R, Hughes M, Carr M, Iriart X, Khambadkone S, Giardini A, Kostolny M, Marek J. Long-term outcome after neonatal intervention for congenital critical aortic stenosis. Int J Cardiol 2024; 405:131932. [PMID: 38437954 DOI: 10.1016/j.ijcard.2024.131932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/08/2024] [Accepted: 03/01/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND This study explored long-term outcome and functional status of patients born with critical aortic stenosis (CAS) following neonatal surgical or catheter interventions. METHODS A 40-year retrospective review of all consecutive patients within a large, single-center referral unit who required neonatal (<30 days) intervention for CAS. Additional detailed evaluation of surviving patients >7 years age was performed, with clinical assessment, objective cardiopulmonary exercise testing and state-of-the-art characterization of myocardial function (advanced echocardiography and cardiac MRI). RESULTS Between 1970 and 2010, ninety-six neonates underwent CAS intervention (mean age 9 ± 7.5 days). Early death occurred in 19 (19.8%) and late death in 10 patients. Overall survival at 10 and 30 years was 70.1% and 68.5%, freedom from reintervention was 41.8% and 32.9% respectively. Among the 25 long-term survivors available for detailed assessment (median age 15.7 ± 6.4 years), 55% exhibited impaired peak oxygen uptake. Mean left ventricle (LV) ejection fraction was 65 ± 11.2%, with a mean LV end-diastolic volume z-score of 0.02 ± 1.4. Mean LV outflow tract Vmax was 2.3 ± 1.02 m/s. CAS patients had reduced LV longitudinal and increased radial strain (p = 0.003, p < 0.001 respectively). Five patients had severe LV diastolic dysfunction associated with endocardial fibroelastosis (EFE) (p = 0.0014). CONCLUSION Despite high early mortality rate, long-term survival of patients with CAS is reasonable at the expense of high reintervention rate. With successful intervention, there remained long-term clinical and subclinical LV myocardial impairment, of which EFE was one marker. Long-term follow-up of all CAS patients is crucial, involving detailed myocardial functional assessment to help elucidate physiology and optimise management.
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Affiliation(s)
- Beatrice Bonello
- Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; University College of London, Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | - Richard Issitt
- Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; University College of London, Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | - Marina Hughes
- Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich NR4 7UY, UK.
| | - Michelle Carr
- Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
| | - Xavier Iriart
- CHU Bordeaux, Av. du Haut Lévêque, Pessac 33604, France.
| | - Sachin Khambadkone
- Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; University College of London, Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | | | - Martin Kostolny
- Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; University College of London, Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | - Jan Marek
- Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; University College of London, Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Majithia-Beet G, Naemi R, Issitt R. Efficacy of outcome prediction of the respiratory ECMO survival prediction score and the predicting death for severe ARDS on VV-ECMO score for patients with acute respiratory distress syndrome on extracorporeal membrane oxygenation. Perfusion 2023; 38:1340-1348. [PMID: 35830605 DOI: 10.1177/02676591221115267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal Membrane Oxygenation (ECMO) therapy for respiratory failure is an increasingly popular modality of support. Patient selection is an important aspect of outcome success. This review assesses the efficacy of the popular prognostic tools Respiratory ECMO Survival Prediction Score (RESP) and Predicting Death for Severe ARDS on VV-ECMO score (PRESERVE) for ECMO patient selection. METHODS A literature search was performed. Six publications were found to match the specified selection criteria. These publications were assessed and compared using the area under the receiver operating characteristic (AUROC) curve statistical method to ascertain the discriminatory ability of the models to predict treatment outcome. RESULTS Six articles were included in this review from 306 screened, of which all were retrospective cohort studies. Data was generated over a period of 3-9 years from 13 referring hospitals. Studies consisted of 467 male and 221 female (30 unknown) participants in total with a high heterogeneity. The PRESERVE prognostic model was found to have a higher AUROC score than the RESP model, however both models were found to be sub-optimal in their discriminatory ability. A high chance of bias was seen across all included studies. CONCLUSION It was the findings of this review, indicated by analysis using the AUROC measures, that the prognostic model PRESERVE performed better than RESP for predicting post ECMO therapy outcomes, for patients presenting with Acute Respiratory Distress Syndrome within their respective validated time frames, i.e., RESP at Intensive care unit (ICU) discharge and PRESERVE at 6 months post ICU discharge. However, It was recognized that comparator groups were small thereby introducing bias into the study. Further prospective, randomized studies would be necessary to effectively assess the utility of these predictive survival scores.
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Affiliation(s)
- Gavin Majithia-Beet
- Department of Perfusion, Glenfield Hospital, Leicester, UK
- School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Roozbeh Naemi
- School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Richard Issitt
- Department of Perfusion, Great Ormond Street Hospital, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
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3
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Issitt R, Shetty P, Crook R, Cross N, Henwood S, Broadhead M, Spencer H, Aurora P, Gupta A, Kallon D, Fenton M, Muthialu N. Lung transplantation in an 18-month-old with donor specific antibodies - The use of intraoperative, targeted plasma exchange. Perfusion 2023; 38:1530-1533. [PMID: 35840547 DOI: 10.1177/02676591221114958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sensitised patients undergoing Human Leukocyte Antigen-incompatible transplantation are at increased risk of hyperacute rejection and may be predisposed to antibody-mediated rejection, chronic lung allograft dysfunction and higher mortality. CASE We present a case of primary lung transplantation in the setting of late identification of donor specific antibodies treated with intraoperative target plasma exchange. The patient was treated with fresh human plasma to a final volume of 1.5 times the patient's systemic circulation. From a pre-transplant mean fluorescence intensity of 5002, donor-specific antibodies were undetectable following plasma exchange on single antigen bead assay. CONCLUSIONS This method represents a potential desensitisation technique for use in the intraoperative period.
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Affiliation(s)
- Richard Issitt
- Department of Perfusion, Great Ormond Street Hospital, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Pooja Shetty
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Richard Crook
- Department of Perfusion, Great Ormond Street Hospital, London, UK
| | - Nigel Cross
- Department of Perfusion, Great Ormond Street Hospital, London, UK
| | - Sophie Henwood
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
| | - Michael Broadhead
- Department of Anaesthetics, Great Ormond Street Hospital, London, UK
| | - Helen Spencer
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Paul Aurora
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Arun Gupta
- Clinical Transplantation Laboratory, Barts Health NHS Trust, London, UK
| | - Delordson Kallon
- Clinical Transplantation Laboratory, Barts Health NHS Trust, London, UK
| | - Matthew Fenton
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Nagarajan Muthialu
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
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Singh D, Jerrom T, Issitt R, Saxena R. Early thromboembolic complications after total cavopulmonary connection/Fontan operation in children: A five year single centre review. Progress in Pediatric Cardiology 2021. [DOI: 10.1016/j.ppedcard.2021.101344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Booth J, Margetts B, Bryant W, Issitt R, Hutchinson C, Martin N, Sebire NJ. Machine Learning Approaches to Determine Feature Importance for Predicting Infant Autopsy Outcome. Pediatr Dev Pathol 2021; 24:351-360. [PMID: 33781121 DOI: 10.1177/10935266211001644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Sudden unexpected death in infancy (SUDI) represents the commonest presentation of postneonatal death. We explored whether machine learning could be used to derive data driven insights for prediction of infant autopsy outcome. METHODS A paediatric autopsy database containing >7,000 cases, with >300 variables, was analysed by examination stage and autopsy outcome classified as 'explained (medical cause of death identified)' or 'unexplained'. Decision tree, random forest, and gradient boosting models were iteratively trained and evaluated. RESULTS Data from 3,100 infant and young child (<2 years) autopsies were included. Naïve decision tree using external examination data had performance of 68% for predicting an explained death. Core data items were identified using model feature importance. The most effective model was XG Boost, with overall predictive performance of 80%, demonstrating age at death, and cardiovascular and respiratory histological findings as the most important variables associated with determining medical cause of death. CONCLUSION This study demonstrates feasibility of using machine-learning to evaluate component importance of complex medical procedures (paediatric autopsy) and highlights value of collecting routine clinical data according to defined standards. This approach can be applied to a range of clinical and operational healthcare scenarios.
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Affiliation(s)
- John Booth
- Great Ormond Street Hospital, Great Ormond Street Hospital Institute of Child Health and NIHR GOSH BRC, London, UK
| | - Ben Margetts
- Great Ormond Street Hospital, Great Ormond Street Hospital Institute of Child Health and NIHR GOSH BRC, London, UK
| | - Will Bryant
- Great Ormond Street Hospital, Great Ormond Street Hospital Institute of Child Health and NIHR GOSH BRC, London, UK
| | - Richard Issitt
- Great Ormond Street Hospital, Great Ormond Street Hospital Institute of Child Health and NIHR GOSH BRC, London, UK
| | - Ciaran Hutchinson
- Great Ormond Street Hospital, Great Ormond Street Hospital Institute of Child Health and NIHR GOSH BRC, London, UK
| | - Nigel Martin
- Department of Computer Science and Information Systems, Birkbeck University of London, London, UK
| | - Neil J Sebire
- Great Ormond Street Hospital, Great Ormond Street Hospital Institute of Child Health and NIHR GOSH BRC, London, UK
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Issitt R, Booth J, Crook R, Robertson A, Molyneux V, Richardson R, Cross N, Shaw M, Tsang V, Muthurangu V, Sebire NJ, Burch M, Fenton M. Intraoperative anti-A/B immunoadsorption is associated with significantly reduced blood product utilization with similar outcomes in pediatric ABO-incompatible heart transplantation. J Heart Lung Transplant 2021; 40:1433-1442. [PMID: 34187714 PMCID: PMC8579753 DOI: 10.1016/j.healun.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative anti-A/B immunoadsorption (ABO-IA) was recently introduced for ABO-incompatible heart transplantation. Here we report the first case series of patients transplanted with ABO-IA, and compare outcomes with those undergoing plasma exchange facilitated ABO-incompatible heart transplantation (ABO-PE). Methods Data were retrospectively analysed on all ABO-incompatible heart transplants undertaken at a single centre between January 1, 2000 and June 1, 2020. Data included all routine laboratory tests, demographics and pre-operative characteristics, intraoperative details and post-operative outcomes. Primary outcome measures were volume of blood product transfusions, maximum post-transplant isohaemagglutinin titres, occurrence of rejection and graft survival. Secondary outcome measures were length of intensive care and hospital stay. Demographic and survival data were also obtained for ABO-compatible transplants during the same time period for comparison. Results Thirty-seven patients underwent ABO-incompatible heart transplantation, with 27 (73%) using ABO-PE and 10 (27%) using ABO-IA. ABO-IA patients were significantly older than ABO-PE patients (p < 0.001) and the total volume of blood products transfused during the hospital admission was significantly lower (164 [126-212] ml/kg vs 323 [268-379] ml/kg, p < 0.001). No significant differences were noted between methods in either pre or post-transplant maximum isohaemagglutinin titres, incidence of rejection, length of intensive care or total hospital stay. Survival comparison showed no significant difference between antibody reduction methods, or indeed ABO-compatible transplants (p = 0.6). Conclusions This novel technique appears to allow a significantly older population than typical to undergo ABO-incompatible heart transplantation, as well as significantly reducing blood product utilization. Furthermore, intraoperative anti-A/B immunoadsorption does not demonstrate increased early post-transplant isohaemagglutinin accumulation or rates of rejection compared to ABO-PE. Early survival is equivalent between ABO-IA, ABO-PE and ABO-compatible heart transplantation.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK; Institute of Cardiovascular Science, University College London, London, UK; Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK.
| | - John Booth
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | | | | | - Nigel Cross
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Victor Tsang
- Institute of Cardiovascular Science, University College London, London, UK; Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, UK
| | - Neil J Sebire
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Michael Burch
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Matthew Fenton
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
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Neijenhuis RML, Tsang VT, Marek J, Issitt R, Bonello B, Von Klemperer K, Hughes ML. Cone reconstruction for Ebstein anomaly: Late biventricular function and possible remodeling. J Thorac Cardiovasc Surg 2020; 161:1097-1108. [PMID: 33293067 DOI: 10.1016/j.jtcvs.2020.10.124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 09/16/2020] [Accepted: 10/09/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate late-term tricuspid valve competence and biventricular function following cone reconstruction for Ebstein anomaly, and to explore biventricular remodeling. METHODS Consecutive adult and pediatric patients who underwent cone reconstruction from 2009 to 2019 were reviewed for inclusion in this retrospective cardiac magnetic resonance imaging study. Tricuspid valve competence was assessed with tricuspid regurgitation fraction. Biventricular systolic function was assessed by ejection fraction, cardiac index, indexed stroke volume, and indexed aortic and pulmonary artery beat volume. Biventricular remodeling was assessed by planimetered areas (right atrium, functional right ventricle, left heart), and indexed end-diastolic and end-systolic ventricular volumes. Paired t tests or Wilcoxon signed-rank tests were used for analyses. RESULTS Of 58 included patients, 50 underwent cardiac magnetic resonance imaging. Twelve patients had both preoperative and late postoperative cardiac magnetic resonance imaging with a median follow-up of 5.11 years (interquartile range, 3.12-6.07 years). Focusing on these, tricuspid regurgitation fraction decreased (from 69% to 10%; P = .014), right ventricle ejection fraction remained stable, and antegrade pulmonary artery beat volume increased (from 26.7 to 41.6 mL/beat/m2; P = .037). The left ventricle stroke volume (from 30.4 to 44.1 mL/m2; P = .015) and antegrade aortic beat volume (from 28.5 to 41.1 mL/beat/m2; P = .014) also increased, and the left ventricle stroke volume improved progressively with time since surgery (P = .048). Whereas the right atrium area decreased (P = .004), the functional right ventricle and left heart area increased (cm2, P = .021 and P = .004). Right ventricle volumes showed a tendency to normalize and left ventricle indexed end-diastolic volume increased (from 50 to 69 mL/m2; P = .03) over time. CONCLUSIONS Cone valve integrity was sustained. Biventricular function improved progressively during follow-up, and there are positive signs of biventricular remodeling late after cone reconstruction.
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Affiliation(s)
- Ralph M L Neijenhuis
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Victor T Tsang
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom; Grown-up Congenital Heart Unit, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
| | - Jan Marek
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Richard Issitt
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Digital Research Environment, Great Ormond Street Hospital for Children, London, United Kingdom; Department of Perfusion, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Beatrice Bonello
- Department of Cardiology, Great Ormond Street Hospital for Children, London, United Kingdom; Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Marina L Hughes
- Department of Cardiology, Great Ormond Street Hospital for Children, London, United Kingdom; Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children, London, United Kingdom
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Toescu SM, Samarth G, Layard Horsfall H, Issitt R, Margetts B, Phipps KP, Jeelani NUO, Thompson DNP, Aquilina K. Fourth ventricle tumors in children: complications and influence of surgical approach. J Neurosurg Pediatr 2020; 27:52-61. [PMID: 33096529 DOI: 10.3171/2020.6.peds2089] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The goal of this study was to characterize the complications and morbidity related to the surgical management of pediatric fourth ventricle tumors. METHODS All patients referred to the authors' institution with posterior fossa tumors from 2002 to 2018 inclusive were screened to include only true fourth ventricle tumors. Preoperative imaging and clinical notes were reviewed to extract data on presenting symptoms; surgical episodes, techniques, and adjuncts; tumor histology; and postoperative complications. RESULTS Three hundred fifty-four children with posterior fossa tumors were treated during the study period; of these, 185 tumors were in the fourth ventricle, and 167 fourth ventricle tumors with full data sets were included in this analysis. One hundred patients were male (mean age ± SD, 5.98 ± 4.12 years). The most common presenting symptom was vomiting (63.5%). The most common tumor types, in order, were medulloblastoma (94 cases) > pilocytic astrocytoma (30 cases) > ependymoma (30 cases) > choroid plexus neoplasms (5 cases) > atypical teratoid/rhabdoid tumor (4 cases), with 4 miscellaneous lesions. Of the 67.1% of patients who presented with hydrocephalus, 45.5% had an external ventricular drain inserted (66.7% of these prior to tumor surgery, 56.9% frontal); these patients were more likely to undergo ventriculoperitoneal shunt (VPS) placement at a later date (p = 0.00673). Twenty-two had an endoscopic third ventriculostomy, of whom 8 later underwent VPS placement. Overall, 19.7% of patients had a VPS sited during treatment.Across the whole series, the transvermian approach was more frequent than the telovelar approach (64.1% vs 33.0%); however, the telovelar approach was significantly more common in the latter half of the series (p < 0.001). Gross-total resection was achieved in 70.7%. The most common postoperative deficit was cerebellar mutism syndrome (CMS; 28.7%), followed by new weakness (24.0%), cranial neuropathy (18.0%), and new gait abnormality/ataxia (12.6%). Use of intraoperative ultrasonography significantly reduced the incidence of CMS (p = 0.0365). There was no significant difference in the rate of CMS between telovelar or transvermian approaches (p = 0.745), and multivariate logistic regression modeling did not reveal any statistically significant relationships between CMS and surgical approach. CONCLUSIONS Surgical management of pediatric fourth ventricle tumors continues to evolve, and resection is increasingly performed through the telovelar route. CMS is enduringly the major postoperative complication in this patient population.
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Affiliation(s)
- Sebastian M Toescu
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children, London.,2Developmental Imaging and Biophysics Section, UCL GOS Institute of Child Health, London
| | - Gargi Samarth
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children, London
| | - Hugo Layard Horsfall
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children, London.,3Department of Neurosurgery, Addenbrooke's Hospital, Cambridge; and
| | - Richard Issitt
- 4Digital Research Environment, Great Ormond Street Hospital for Children, DRIVE Office, London, United Kingdom
| | - Ben Margetts
- 4Digital Research Environment, Great Ormond Street Hospital for Children, DRIVE Office, London, United Kingdom
| | - Kim P Phipps
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children, London
| | | | | | - Kristian Aquilina
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children, London
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Issitt R, Crook R, Shaw M, Robertson A. The Great Ormond Street Hospital immunoadsorption method for ABO-incompatible heart transplantation: a practical technique. Perfusion 2020; 36:34-37. [PMID: 32493108 PMCID: PMC7770210 DOI: 10.1177/0267659120926895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Traditionally, ABO-incompatible heart transplantation was accomplished using a plasma exchange technique to remove recipient plasma containing donor-incompatible anti-A/B isohaemagglutinins. However, this technique exposed patients to large volumes of allogeneic blood and blood products (up to three times the patient’s circulating volume). In 2018, we published the first reported case of an ABO-incompatible heart transplant using an intraoperative immunoadsorption technique which minimises the exposure to blood products by specifically targeting anti-A/B isohaemagglutinins. We have subsequently used this technique in all children undergoing ABO-incompatible heart transplantation and become convinced of its efficacy in this population while observing no adverse effects. This article outlines the practical details required to perform the technique in order to avoid hyperacute rejection.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
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10
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Crook R, Issitt R. Cardiopulmonary Bypass for a Patient With Congenital Hyperinsulinemia. World J Pediatr Congenit Heart Surg 2018; 11:NP117-NP119. [PMID: 29334830 DOI: 10.1177/2150135117742649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Congenital hyperinsulinism is a clinical syndrome of pancreatic β-cell dysfunction characterized by failure to suppress insulin secretion in the presence of hypoglycemia. Here, we describe the concerns, the techniques used to ameliorate these potential problems, and the outcomes for a child with this condition undergoing cardiopulmonary bypass for correction of an atrial septal defect.
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Affiliation(s)
- Richard Crook
- Department of Perfusion, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Richard Issitt
- Department of Perfusion, Great Ormond Street Hospital for Children, London, United Kingdom
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Abstract
Beta (β)-thalassemia is a blood disorder with an incidence of 1 in 100,000.1 This case report outlines a patient with β-thalassemia requiring cardiopulmonary bypass (CPB) and the measures taken to ensure an uneventful procedure.
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Affiliation(s)
- Rebecca Richardson
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Richard Issitt
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
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12
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Issitt R, Ball J, Bilkhoo I, Mani A, Walsh B, Voegeli D. Leukocyte filtration of the cardiotomy suction. Does it affect systemic leukocyte activation or pulmonary function? Perfusion 2017; 32:574-582. [DOI: 10.1177/0267659117709922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Cardiopulmonary bypass is thought to propagate a global systemic response through contact with the non-physiological surfaces of the extracorporeal circuit, leading to the stimulation of leukocytes, their adherence to endothelial cells and the release of cytotoxic molecules. This, in turn, has been shown to accelerate pulmonary injury. This study tested a new leukocyte-filtration system (RemoweLL) against a conventional system with no leukocyte-depleting capacity to determine the efficacy of the filtration system and its effects on pulmonary function. Methods: Thirty patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Data were collected on the total number of leukocytes, their differentiation and activation, using the leukocyte adhesion integrin CD11b as a surrogate marker. Pulmonary function was assessed using the Alveolar-arterial Oxygenation Index (AaOI) and patients were categorized using the Berlin definition of acute respiratory distress syndrome (ARDS). Results: Both groups showed significant increases in leukocyte numbers during CPB (p<0.001), with no differences noted between the groups. CD11b showed a significant increase in both groups, with peak activation occurring at the end of CPB, but no difference between the groups (p=0.8). There was a trend towards lower AaOI increases in the filtration group, but this did not reach significance (p=0.075) and there was no difference in ARDS definitions (p=0.33). Conclusions: Leukocyte filtration of cardiotomy suction did not influence total leukocyte counts or activation as measured by CD11b upregulation. Furthermore, no evidence could be found to suggest improved pulmonary function.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jon Ball
- Perfusion Department, University Hospital Southampton, Southampton, UK
| | - Indie Bilkhoo
- Perfusion Department, University Hospital Southampton, Southampton, UK
| | - Adnan Mani
- Flow Cytometry Department, University Hospital Southampton, Southampton, UK
| | - Bronagh Walsh
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - David Voegeli
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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13
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Robertson A, Issitt R, Crook R, Gustafsson K, Eddaoudi A, Tsang V, Burch M. A novel method for ABO-incompatible heart transplantation. J Heart Lung Transplant 2017; 37:451-457. [PMID: 28554587 DOI: 10.1016/j.healun.2017.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 04/21/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Since 1996, ABO-incompatible heart transplantation has been undertaken by performing whole-body plasma exchange to remove isohemagglutinins using the cardiopulmonary bypass (CPB) circuit at the time of transplantation. This requires large volumes of donated blood and blood products, causes hemodynamic instability during the exchange transfusion, and limits practical use to small children. We sought to determine the efficacy of anti-A/B immunoadsorption within the CPB circuit on removal of isohemagglutinins in an ex vivo setting before its use clinically. METHODS An anti-A/B immunoadsorption column was placed into a CPB circuit mimicking a typical ABO-incompatible transplant patient, which had been primed with type O whole human blood. Samples were taken for determination of isohemagglutinin titers following each plasma volume pass through the anti-A/B immunoadsorption column. RESULTS There was a linear decrease of at least 1 dilution seen in both anti-A and anti-B IgG and IgM antibodies with each plasma volume pass through the column. This predictable removal allowed the formulation of selection criteria for ABO-incompatible heart transplantation given the reciprocal of titer and patient weight. This degree of predictability allowed us to use it successfully in the clinical setting, reducing antibodies to an undetectable level during ABO-incompatible heart transplantation. CONCLUSIONS The incorporation of an anti-A/B immunoadsorption column into the extracorporeal circuit reduces allogeneic blood product requirement for ABO-incompatible heart transplantation, while providing efficacious removal of anti-A and anti-B isohemagglutinins. This can be undertaken within the time period of CPB before graft reperfusion and expands the potential recipient pool to larger patients with higher isohemagglutinin titers.
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Affiliation(s)
- Alex Robertson
- Department of Perfusion, Great Ormond Street Hospital, London
| | - Richard Issitt
- Department of Perfusion, Great Ormond Street Hospital, London.
| | - Richard Crook
- Department of Perfusion, Great Ormond Street Hospital, London
| | - Kenth Gustafsson
- Department of Molecular Immunology, Institute of Cardiovascular Science, University College London, London
| | - Ayad Eddaoudi
- Department of Flow Cytometry, Institute of Cardiovascular Science, University College London, London
| | - Victor Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Michael Burch
- Department of Transplantation, Great Ormond Street Hospital, London; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, United Kingdom
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14
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Abstract
BACKGROUND Acute kidney injury (AKI) following cardiopulmonary bypass affects 5% of patients, representing significant postoperative morbidity and mortality. Animal models have shown an increased uptake of lipid microemboli (LME) into the renal vasculature, potentially indicating ischaemic causation. This study tested a new lipid filtration system (RemoweLL) against a conventional system with no lipid-depleting capacity to determine the efficacy of the filtration system and its effects on renal function. METHODS Thirty consecutive patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Renal function was assessed using cystatin C concentrations as a surrogate marker of glomerular injury, as well as perioperative glomerular filtration rate (GFR) and serum creatinine concentrations. Patients were defined as having acute renal injury if there was an increase in absolute serum creatinine ⩾3 mg/dL (26.4 µmol/L) or 1.5-fold increase from baseline as categorised using the AKIN criteria. RESULTS Postoperative differences in LME count between the two groups were highly significant [p<0.001]. Analysis of peak cystatin C concentrations showed significantly lower levels in the LME filtration group on the 2nd postoperative morning [p=0.04]. Two-factor ANOVA revealed a trend towards interaction, but this failed to reach significance [p=0.06]. There were no differences throughout the study period in serum creatinine or GFR [p>0.05]. There were no differences in any of the serum or urinary electrolytes. CONCLUSIONS This study has shown a trend towards improved cystatin C removal with LME filtration; with significantly lower peak concentrations, although no further evidence of renoprotection could be demonstrated. Further research is warranted to establish possible renal benefits of LME filtration in patients undergoing cardiac surgery.
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Affiliation(s)
- Richard Issitt
- 1 Perfusion Department, Great Ormond Street Hospital for Children, London, UK.,2 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Tim James
- 3 Biochemistry Department, John Radcliffe Hospital, Oxford, UK
| | - Bronagh Walsh
- 2 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - David Voegeli
- 2 Faculty of Health Sciences, University of Southampton, Southampton, UK
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15
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Crook R, Issitt R. Oncotic pressure and paediatric cardiopulmonary bypass: establishing baseline data for complex congenital cardiac surgery and its relation to risk stratification. Perfusion 2017; 32:378-382. [DOI: 10.1177/0267659117690251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Colloid osmotic pressure (COP) is a major determinant of fluid shift in paediatric patients undergoing corrective surgery for congenital heart disease (CHD) using cardiopulmonary bypass (CPB). However, very few baseline data are available for those patients requiring surgery within the first few weeks and months of life. Our aim was to determine if our CHD population exhibited COP similar to that of other extremely ill subsets of patients and, if so, whether this related to risk stratification model scores. Methods: Thirty consecutive patients under 10 kg underwent cardiac surgery with CPB. Data were collected on COP, albumin concentration, prime composition, post-operative length of ventilation and intensive care unit (ICU) stay as well as risk stratification utilising Risk Adjustment for Congenital Heart Surgery (RACHS-1) and Partial Risk Adjustment in Surgery (PRAiS) scoring systems. Results: The patients had a mean pre-bypass COP of 13.9±2.5 mmHg. A significant negative correlation was observed between pre-operative baseline COP and length of ventilation (r=0.7; p<0.001) and a significant negative correlation between PRAiS (r=0.64; p<0.001) and RACHS-1 (r=0.5; p=0.004) scores and baseline COP was seen. Conclusions: Neonatal and paediatric patients requiring surgical correction of complex congenital cardiac malformations exhibit extremely low baseline COP, comparable to other sick neonatal populations, and are lower than those previously reported. Baseline COP correlates significantly with predicted survival rates and time spent on a ventilator.
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Affiliation(s)
- Richard Crook
- Department of Perfusion, Great Ormond Street Hospital for Children, London, UK
| | - Richard Issitt
- Department of Perfusion, Great Ormond Street Hospital for Children, London, UK
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16
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Issitt R, Crook R, Robertson A, Shaw M, Tsang V. Conclusions from in vitro vs in vivo data. Perfusion 2014; 30:174-5. [PMID: 25336139 DOI: 10.1177/0267659114557721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- R Issitt
- Department of Clinical Perfusion, Great Ormond Street Children's Hospital, London, UK
| | - R Crook
- Department of Clinical Perfusion, Great Ormond Street Children's Hospital, London, UK
| | - A Robertson
- Department of Clinical Perfusion, Great Ormond Street Children's Hospital, London, UK
| | - M Shaw
- Department of Clinical Perfusion, Great Ormond Street Children's Hospital, London, UK
| | - V Tsang
- Department of Paediatric Cardiothoracic Surgery, Great Ormond Street Children's Hospital, London, UK
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Issitt R, Robertson A, Cross N, Crook R, Molyneux V, Shaw M, Walton N, Tsang V. Clinical experience with Affinity Pixie oxygenation system in paediatric and infant patients. Perfusion 2014; 29:194-8. [PMID: 24447948 DOI: 10.1177/0267659114521101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Great Ormond Street Children's Hospital undertakes over 500 open heart cardiothoracic procedures requiring cardiopulmonary bypass per year. Data from our centre show that many of our neonatal/paediatric patients require higher cardiac indexes than previously thought. We evaluated the new Pixie oxygenation system, rated from 0.1 L/min to 2 L/min, to determine if it could be used for these patients. METHODS Between 2010 and 2012, 250 Pixie oxygenators were used on consecutive patients requiring correction of congenital cardiac defects. Data were collected on FiO2 requirements, oxygenator pressure drop and gaseous microemboli handling. Retrospective analysis was also undertaken on the procedures and demographics of all patients during 2011-2012 to determine the percentage of patients on whom the Pixie could be used. RESULTS Analysis of the procedures undertaken at Great Ormond Street Hospital (GOSH) showed that 89% were in patients under 20 kg, requiring a flow rate of <2 L/min (at a base cardiac index of 2.8 L/min/m2). The maximum FiO2 required at 2.5 L/min was 85%. Gaseous microemboli were reduced by 82.5±9.9% and bubble volume was decreased by 94.3±8.4% from the 'venous' pre-oxygenator to the 'arterial' post-oxygenator. DISCUSSION The Pixie oxygenator proved effective at flows up to 2.5 L/min, with air-handling capabilities comparable with other oxygenators. This represents a single oxygenator that could potentially be used to cover 89% of our surgical procedures. However, we believe that, for the smallest patients (i.e., < 2 kg), a smaller priming oxygenator should be used in order to limit unnecessary haemodilution in this vulnerable group.
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Affiliation(s)
- R Issitt
- Department of Clinical Perfusion Great Ormond Street Children's Hospital, London, UK
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18
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Issitt R. Invited commentary. Ann Thorac Surg 2011; 91:1595. [PMID: 21524468 DOI: 10.1016/j.athoracsur.2011.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 01/18/2011] [Accepted: 01/20/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Richard Issitt
- Perfusion Department, Level 3 Cardiac Theatres, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom.
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Abstract
The pathological effects of pericardial suction blood (PSB) have been well described in numerous studies for many years; yet, despite this, there is no definitive answer to the question of how best to attenuate this pathology. More recently, large studies have shown that, whilst PSB contains many factors indicating its pathological potential, the direct re-infusion of PSB and residual pump volume (RPV) after cardiopulmonary bypass (CPB) potentially reduces the risk of transfusion and is no more harmful to the patient than the re-infusion of cell salvage-processed PSB after CPB.We conducted a telephone audit of UK perfusion units to determine if current protocols and practices reflected this.We found that there is a definite majority processing RPV with cell-saving devices, with many units defining their protocols as "surgeon dependent" whilst half immediately returned PSB to the systemic circulation whilst on CPB. The results of this national audit suggest that the issue of dealing with PSB and RPV is confused, heavily influenced by surgical and anaesthetic preference and lacking clear guidance and high quality evidence.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, John Radcliffe Hospital, Oxford, UK.
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20
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Abstract
This prospective study was designed to evaluate the fundamental clinical performance of a new, small surface area oxygenator. Data were collected from twenty patients undergoing first-time coronary artery bypass grafting using this device. This study focuses on how the reduction of surface area and prime volume affects the essential function of the oxygenator in terms of oxygenation efficiency, heat transference, membrane pressure drops, haemolysis and safety. Oxygenation efficiency was deemed to be well within acceptable margins, even at high flows, over a temperature range of 32-36 degrees C. Heat-exchanger performance was assessed by recording the heater/chiller water temperature compared to retrospective data from a current standard oxygenator. Heater/ chiller water temperatures were on average 0.3 degrees C higher with the small surface oxygenator than the standard data. The air handling of the device was excellent and extremely safe. Haemolysis, measured as plasma free haemoglobin, did not increase during bypass (p > 0.05). This new oxygenator offers a reduced surface area and priming volume while still ensuring an acceptable safety reserve and performance.
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Affiliation(s)
- R Issitt
- London Perfusion Science, London, United Kingdom
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