1
|
George J, Lotto A. Perception of congenital cardiac surgery as a career choice among cardiothoracic surgery trainees in the United Kingdom. Interdiscip Cardiovasc Thorac Surg 2024; 38:ivae008. [PMID: 38684184 PMCID: PMC11078891 DOI: 10.1093/icvts/ivae008] [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] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/20/2023] [Accepted: 04/27/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVES Our goal was to evaluate interest among trainees in pursuing congenital cardiac surgery (CCS) as a sub-specialty career and probe for reasons in decline in interest. METHODS An anonymized, voluntary survey of cardiothoracic surgical trainees across the United Kingdom and Ireland was conducted from October 2020 to December 2020. The questionnaire included demographics, congenital experience and career intentions. RESULTS A total of 43 respondents from all training regions responded with a response rate of 36%. A total of 28% reported having no access to a congenital cardiac unit in their training region, reflecting that 4 out of the 14 regions do not have a congenital unit. Although only 18% of trainees have undertaken a placement, a large proportion (74%) have considered a career in CCS, predominantly (50%) before entering training or in the first half of the training programme (38%). Reasons for not pursuing included discouragement by colleagues (42%) and concerns regarding the training pathway, citing, among other reasons, length of training, limited exposure to operations and uncertainty about career progression. Respondents suggested improvements to the training programme, including increasing exposure and early mentoring and steps to dispel unduly negative perceptions about the specialty. CONCLUSIONS A large proportion of cardiothoracic trainees have a negative perception of CCS in terms of career and training. Interest wanes substantially after entry into the United Kingdom cardiothoracic training programme for several reasons. As well as short-term measures to improve exposure to CCS and structure of training, there has to be long-term planning to improve perception about this sub-specialty at all levels.
Collapse
Affiliation(s)
- Joseph George
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Attilio Lotto
- Department of Cardiothoracic Surgery, Alder Hey Children’s Hospital, Liverpool, United Kingdom
- Liverpool John Moores University, Liverpool, United Kingdom
| |
Collapse
|
2
|
Zeilmaker-Roest G, de Vries-Rink C, van Rosmalen J, van Dijk M, de Wildt SN, Knibbe CAJ, Koomen E, Jansen NJG, Kneyber MCJ, Maebe S, Van den Berghe G, Haghedooren R, Vlasselaers D, Bogers AJJC, Tibboel D, Wildschut ED. Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial. Crit Care 2024; 28:143. [PMID: 38689310 PMCID: PMC11061924 DOI: 10.1186/s13054-024-04905-3] [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] [Received: 01/26/2024] [Accepted: 04/07/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0-3 years after cardiac surgery with cardiopulmonary bypass. METHODS Multi-center, randomized, double-blinded, controlled trial in four level-3 Pediatric Intensive Care Units (PICU) in the Netherlands and Belgium. Inclusion period; March 2016-July 2020. Children aged 0-3 years, undergoing cardiac surgery with cardiopulmonary bypass were eligible. Patients were randomized to continuous morphine or intermittent IV paracetamol as primary analgesic after a loading dose of 100 mcg/kg morphine was administered at the end of surgery. Rescue morphine was given if numeric rating scale (NRS) pain scores exceeded predetermined cutoff values. Primary outcome was median weight-adjusted cumulative morphine dose in mcg/kg in the first 48 h postoperative. For the comparison of the primary outcome between groups, the nonparametric Van Elteren test with stratification by center was used. For comparison of the proportion of patients with one or more NRS pain scores of 4 and higher between the two groups, a non-inferiority analysis was performed using a non-inferiority margin of 20%. RESULTS In total, 828 were screened and finally 208 patients were included; parents of 315 patients did not give consent and 305 were excluded for various reasons. Fourteen of the enrolled 208 children were withdrawn from the study before start of study medication leaving 194 patients for final analysis. One hundred and two patients received intermittent IV paracetamol, 106 received continuous morphine. The median weight-adjusted cumulative morphine consumption in the first 48 h postoperative in the IV paracetamol group was 5 times lower (79%) than that in the morphine group (median, 145.0 (IQR, 115.0-432.5) mcg/kg vs 692.6 (IQR, 532.7-856.1) mcg/kg; P < 0.001). The rescue morphine consumption was similar between the groups (p = 0.38). Non-inferiority of IV paracetamol administration in terms of NRS pain scores was proven; difference in proportion - 3.1% (95% CI - 16.6-10.3%). CONCLUSIONS In children aged 0-3 years undergoing cardiac surgery, use of intermittent IV paracetamol reduces the median weight-adjusted cumulative morphine consumption in the first 48 h after surgery by 79% with equal pain relief showing equipoise for IV paracetamol as primary analgesic. Trial Registration Clinicaltrials.gov, Identifier: NCT05853263; EudraCT Number: 2015-001835-20.
Collapse
MESH Headings
- Humans
- Morphine/therapeutic use
- Morphine/administration & dosage
- Acetaminophen/therapeutic use
- Acetaminophen/administration & dosage
- Male
- Female
- Infant
- Double-Blind Method
- Pain, Postoperative/drug therapy
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Belgium
- Netherlands
- Infant, Newborn
- Administration, Intravenous
- Cardiac Surgical Procedures/methods
- Child, Preschool
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Intensive Care Units, Pediatric/organization & administration
- Intensive Care Units, Pediatric/statistics & numerical data
- Pain Measurement/methods
Collapse
Affiliation(s)
- Gerdien Zeilmaker-Roest
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands.
| | - Christine de Vries-Rink
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Monique van Dijk
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein/Utrecht, Utrecht, The Netherlands
| | - Erik Koomen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Sofie Maebe
- Department of Pediatrics, Maastricht University Medical Center+, MosaKids Children's Hospital, Maastricht, The Netherlands
| | | | | | - Dirk Vlasselaers
- Department of Intensive Care Medicine, UZ Leuven, Louvain, Belgium
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Axelsson I, Gustafsson A, Isaksson H, Nilsson J, Malm T. Impact of storage time prior to cryopreservation on mechanical properties of aortic homografts. Cell Tissue Bank 2024; 25:27-37. [PMID: 36843158 PMCID: PMC10902001 DOI: 10.1007/s10561-023-10079-z] [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] [Received: 10/07/2022] [Accepted: 02/04/2023] [Indexed: 02/28/2023]
Abstract
Optimal time spans in homograft procurement are still debatable among tissue banks and needs to be further investigated. Cell viability decreases at longer preparation intervals, but the effect on collagen and elastic fibers has not been investigated to the same extent. These fibers are of importance to the homograft elasticity and strength. The objective of this study was to analyze the mechanical properties of homograft tissue at different time spans in the procurement process. Ten aortic homografts were collected at the Tissue Bank in Lund. Twelve samples were obtained from each homograft, cryopreserved in groups of three after 2-4 days, 7-9 days, 28-30 days, and 60-62 days in antibiotic decontamination. Mechanical testing was performed with uniaxial tensile tests, calculating elastic modulus, yield stress and energy at yield stress. Two randomly selected samples were assessed with light microscopy. Procurement generated a total of 120 samples, with 30 samples in each time group. Elastic modulus and yield stress was significantly higher in samples cryopreserved after 2-4 days (2.7 MPa (2.5-5.0) and 0.78 MPa (0.68-1.0)) compared to 7-9 days (2.2 MPa (2.0-2.6) and 0.53 MPa (0.46-0.69)), p = 0.008 and 0.011 respectively. Light microscopy did not show any difference in collagen and elastin at different time spans. There was a significant decrease in elastic modulus and yield stress after 7 days of decontamination at 4 °C compared to 2-4 days. This could indicate some deterioration of elastin and collagen at longer decontamination intervals. Clinical significance of these findings remains to be clarified.
Collapse
Affiliation(s)
- Ida Axelsson
- Tissue Bank Lund, Baravägen 37, 22242, Lund, Sweden.
- Department of Cardiothoracic Surgery, Skane University Hospital, Lund, Sweden.
- Department of Clinical Science, Cardiothoracic Surgery, Lund University, Lund, Sweden.
| | - Anna Gustafsson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Johan Nilsson
- Department of Cardiothoracic Surgery, Skane University Hospital, Lund, Sweden
- Department of Clinical Science, Cardiothoracic Surgery, Lund University, Lund, Sweden
- Department of Translational Medicine, Artificial Intelligence and Bioinformatics in Cardiothoracic Sciences, Lund University, Lund, Sweden
| | - Torsten Malm
- Tissue Bank Lund, Baravägen 37, 22242, Lund, Sweden
- Department of Clinical Science, Cardiothoracic Surgery, Lund University, Lund, Sweden
- Pediatric Cardiac Surgery Unit, Children's Hospital, Skane University Hospital, Lund, Sweden
| |
Collapse
|
4
|
Meccanici F, Notenboom ML, Meijssen J, Smit V, van de Woestijne PC, van den Bosch AE, Helbing WA, Bogers AJJC, Takkenberg JJM, Roos-Hesselink JW. Long-term surgical outcomes of congenital supravalvular aortic stenosis: a systematic review, meta-analysis and microsimulation study. Eur J Cardiothorac Surg 2024; 65:ezad360. [PMID: 37889257 PMCID: PMC10782899 DOI: 10.1093/ejcts/ezad360] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/10/2023] [Accepted: 10/26/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVES Congenital supravalvular aortic stenosis (SVAS) is a rare form of congenital outflow tract obstruction and long-term outcomes are scarcely reported. This study aims to provide an overview of outcomes after surgical repair for congenital SVAS. METHODS A systematic review of published literature was conducted, including observational studies reporting long-term clinical outcome (>2 years) after SVAS repair in children or adults considering >20 patients. Early risks, late event rates and time-to-event data were pooled and entered into a microsimulation model to estimate 30-year outcomes. Life expectancy was compared to the age-, sex- and origin-matched general population. RESULTS Twenty-three publications were included, encompassing a total of 1472 patients (13 125 patient-years; pooled mean follow-up: 9.0 (6.2) years; median follow-up: 6.3 years). Pooled mean age at surgical repair was 4.7 (5.8) years and the most commonly used surgical technique was the single-patch repair (43.6%). Pooled early mortality was 4.2% (95% confidence interval: 3.2-5.5%) and late mortality was 0.61% (95% CI: 0.45-0.83) per patient-year. Based on microsimulation, over a 30-year time horizon, it was estimated that an average patient with SVAS repair (mean age: 4.7 years) had an observed life expectancy that was 90.7% (95% credible interval: 90.0-91.6%) of expected life expectancy in the matched general population. The microsimulation-based 30-year risk of myocardial infarction was 8.1% (95% credible interval: 7.3-9.9%) and reintervention 31.3% (95% credible interval: 29.6-33.4%), of which 27.2% (95% credible interval: 25.8-29.1) due to repair dysfunction. CONCLUSIONS After surgical repair for SVAS, 30-year survival is lower than the matched-general-population survival and the lifetime risk of reintervention is considerable. Therefore, lifelong monitoring of the cardiovascular system and in particular residual stenosis and coronary obstruction is recommended.
Collapse
Affiliation(s)
- Frederike Meccanici
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre Rotterdam, Netherlands
| | - Jade Meijssen
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Vernon Smit
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | | | - Willem A Helbing
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre Rotterdam, Netherlands
| | | |
Collapse
|
5
|
Gil-Jaurena JM, Pardo C, Pita A, Perez-Caballero R. Left axillary approach for pulmonary valve replacement. Multimed Man Cardiothorac Surg 2023; 2023. [PMID: 38108603 DOI: 10.1510/mmcts.2023.096] [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: 12/19/2023]
Abstract
A 14-year-old girl was scheduled for pulmonary valve replacement. A computed tomography scan showed an enlarged cardiac silhouette with an aneurysmal pulmonary artery. A less-invasive approach through the left axilla with peripheral cannulation was selected. The patient was draped in the decubitus position, with a roll under the left shoulder and the left arm over the head. The anatomical landmarks were the left nipple and the tip of the scapula. A 5-cm vertical incision in the mid-axillary line was performed, and the thorax was entered through the fourth intercostal space. Peripheral cannulation for cardiopulmonary bypass was achieved by a right groin dissection. Partial bypass was instituted and, on an unloaded heart, the ascending aorta plus the right appendage and the pulmonary artery were further cannulated. With the heart beating, the pulmonary artery was opened, and a 25-mm biological Carpentier Perimount-Magna valve was chosen. A second stitch was used to close the arteriotomy with large bites in a double row to reduce the perimeter of the trunk. Cardiopulmonary bypass was discontinued (after 64 minutes), and the cannulas were removed sequentially. Echocardiography showed a good result, with proper valve function and a reduced pulmonary artery. The patient was discharged on postoperative day 12 on antiplatelet therapy.
Collapse
Affiliation(s)
- Juan-Miguel Gil-Jaurena
- Department of Congenital Cardiac Surgery, Gregorio Maranon University Hospital, Madrid, Spain
| | - Carlos Pardo
- Department of Congenital Cardiac Surgery, Gregorio Maranon University Hospital, Madrid, Spain
| | - Ana Pita
- Department of Congenital Cardiac Surgery, Gregorio Maranon University Hospital, Madrid, Spain
| | - Ramón Perez-Caballero
- Department of Congenital Cardiac Surgery, Gregorio Maranon University Hospital, Madrid, Spain
| |
Collapse
|
6
|
Shibbani K, Randall JT, Mohammad Nijres B, Aldoss O. Medium-Term Outcomes in Pediatric Patients Undergoing Cardiac Catheterization Early After Congenital Cardiac Surgery. Pediatr Cardiol 2023; 44:1808-1814. [PMID: 37129601 DOI: 10.1007/s00246-023-03171-4] [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: 01/02/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
Safety and acute outcomes for patients who need catheterization shortly after congenital cardiac surgery has been established; literature on mid-term outcomes is lacking. We sought to evaluate the mid-term outcomes of patients who undergo early postoperative cardiac catheterization. This is a retrospective cohort study of patients who underwent cardiac catheterization within 6 weeks of congenital cardiac surgery with longitudinal follow-up and assessment of mid-term outcomes. Multivariable analysis was utilized to relate variables of interest to outcomes. 99 patients underwent cardiac catheterizations within 6 weeks of cardiac surgery between January 2008 and September 2016. Forty-six (45.5%) interventional procedures were performed at a median age of 41 days (IQR 21-192) and a median weight of 3.9 kg (3.3-6.6). During a median follow-up duration of 4.24 years (1.6-5.6) in study survivors, 61% of patients remained free from the primary endpoint (death and/or transplant). Sixty-nine patients (69.7%) underwent an unplanned surgical or catheter procedure. Renal failure at catheterization (OR 280.5, p 0.0199), inotropic medication at catheterization (OR 14.8, p 0.002), and younger age were all significantly associated with meeting the primary endpoint. Patients requiring surgical intervention as an initial additional intervention underwent more unplanned re-interventions, while patients who survived to hospital discharge demonstrated favorable mortality, though with frequent need for re-intervention. In patients requiring early postoperative cardiac catheterization, renal failure, younger age, and need for inotropic support at catheterization are significantly associated with meeting the primary endpoint.
Collapse
Affiliation(s)
- Kamel Shibbani
- Division of Pediatric Cardiology, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
| | - Jess T Randall
- Department of Cardiology, Albany Medical Center, 22 New Scotland, Albany, NY, 12208, USA.
| | - Bassel Mohammad Nijres
- Division of Pediatric Cardiology, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
| | - Osamah Aldoss
- Division of Pediatric Cardiology, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
7
|
Heye T, Greiten L, Story-Hefta L, Reemtsen B, Moursi M. Aberrant right subclavian artery: a novel approach and an overview of operative techniques. J Vasc Surg Cases Innov Tech 2023; 9:101327. [PMID: 37928561 PMCID: PMC10624571 DOI: 10.1016/j.jvscit.2023.101327] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/28/2023] [Indexed: 11/07/2023] Open
Abstract
An aberrant right subclavian artery (ARSA) is a rare variation of normal anatomy occurring in 0.5% to 1.8% of the population. No current guidelines are available regarding ARSA management, and surgical intervention should be evaluated carefully. Moreover, symptomatic patients with a dominant left arch and aberrant ARSA require a surgical approach from the right side of the chest for ligation and division of the aberrant artery at its origin on the aorta. The ARSA can then be reimplanted onto the right common carotid artery via a supraclavicular incision. The extensive mobilization in the chest allows for easy reimplantation in the supraclavicular region and eliminates reliance on the collateral circulation. Postoperative monitoring is reliable and easy with radial pulse examinations.
Collapse
Affiliation(s)
- Thomas Heye
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lawrence Greiten
- Department of Pediatric Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lauren Story-Hefta
- Department of Vascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Brian Reemtsen
- Department of Pediatric Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mohammed Moursi
- Department of Vascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
8
|
Januszewska K. Milrinone, we all like you …. Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad150. [PMID: 37665733 PMCID: PMC10497447 DOI: 10.1093/icvts/ivad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/08/2023] [Accepted: 09/02/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Katarzyna Januszewska
- Department of Cardiac Surgery, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
| |
Collapse
|
9
|
Peek JJ, Bakhuis W, Sadeghi AH, Veen KM, Roest AAW, Bruining N, van Walsum T, Hazekamp MG, Bogers AJJC. Optimized preoperative planning of double outlet right ventricle patients by 3D printing and virtual reality: a pilot study. Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad072. [PMID: 37202357 PMCID: PMC10481772 DOI: 10.1093/icvts/ivad072] [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] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 03/23/2023] [Accepted: 05/17/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES In complex double outlet right ventricle (DORV) patients, the optimal surgical approach may be difficult to assess based on conventional 2-dimensional (2D) ultrasound (US) and computed tomography (CT) imaging. The aim of this study is to assess the added value of 3-dimensional (3D) printed and 3D virtual reality (3D-VR) models of the heart used for surgical planning in DORV patients, supplementary to the gold standard 2D imaging modalities. METHODS Five patients with different DORV subtypes and high-quality CT scans were selected retrospectively. 3D prints and 3D-VR models were created. Twelve congenital cardiac surgeons and paediatric cardiologists, from 3 different hospitals, were shown 2D-CT first, after which they assessed the 3D print and 3D-VR models in random order. After each imaging method, a questionnaire was filled in on the visibility of essential structures and the surgical plan. RESULTS Spatial relationships were generally better visualized using 3D methods (3D printing/3D-VR) than in 2D. The feasibility of ventricular septum defect patch closure could be determined best using 3D-VR reconstructions (3D-VR 92%, 3D print 66% and US/CT 46%, P < 0.01). The percentage of proposed surgical plans corresponding to the performed surgical approach was 66% for plans based on US/CT, 78% for plans based on 3D printing and 80% for plans based on 3D-VR visualization. CONCLUSIONS This study shows that both 3D printing and 3D-VR have additional value for cardiac surgeons and cardiologists over 2D imaging, because of better visualization of spatial relationships. As a result, the proposed surgical plans based on the 3D visualizations matched the actual performed surgery to a greater extent.
Collapse
Affiliation(s)
- Jette J Peek
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Thoraxcenter, Rotterdam, Netherlands
| | - Wouter Bakhuis
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Thoraxcenter, Rotterdam, Netherlands
| | - Amir H Sadeghi
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Thoraxcenter, Rotterdam, Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Thoraxcenter, Rotterdam, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Nico Bruining
- Department of Clinical Epidemiology and Innovation (KEI), Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Theo van Walsum
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Thoraxcenter, Rotterdam, Netherlands
| |
Collapse
|
10
|
Alshahrani D, Linnane N, McCrossan B, Oslizlok P, McMahon CJ, Walsh KP, Kenny DP. Transfemoral Perimembranous Ventricular Septal Defect Device Closure in Infants Weighing ≤ 10 kg. Pediatr Cardiol 2023; 44:1176-1182. [PMID: 36698044 PMCID: PMC10224829 DOI: 10.1007/s00246-023-03100-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023]
Abstract
Transcatheter closure of Perimembranous VSDs (PMVSD) remains challenging particularly in infants. The aim of this study is to evaluate the efficacy and safety of transfemoral PMVSD device closure in infants weighing ≤ 10 kg in a single centre. Retrospective review of departmental databases and medical charts to define patient cohort and collect demographic, procedural and follow-up data. Between July 2014 and March 2021, 16 patients underwent attempted transfemoral PMVSD device closure (12 retrograde) at a median age of 11 months (interquartile range [IQR] 9-15.5) and a median weight of 8.3 kg (IQR 7.2-9.5). All patients were either symptomatic, had progressive left heart dilation or had VSD associated valve regurgitation. Median defect size on pre-procedural transoesophageal echocardiography was 6.8 mm (IQR 6-8.5). Median device waist size was 6 mm (IQR 4.5-8). Successful device placement was achieved in 14 patients (88%). One patient developed moderate aortic and tricuspid valve regurgitation upon retrograde and antegrade device deployment, respectively, and subsequently underwent surgical closure. The second patient developed progressive aortic regurgitation (AR) 2 days post procedure, and also underwent surgical removal with no residual AR. There was no cases of device embolization and no femoral arterial compromise. On median follow-up of 40.5 months (IQR 25-64), none of the patients developed complete heart block. Three patients (18.75%) had small residual shunts at latest follow-up which have not required any further intervention. Device closure of PMVSD's in children weighing ≤ 10 kg is feasible and safe with good procedural success rates. Use of both the antegrade and retrograde approaches may be necessary depending on anatomical variances.
Collapse
Affiliation(s)
- Dhafer Alshahrani
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland
- Section of Pediatric Cardiology, Department of Cardiac Sciences, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Niall Linnane
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland
| | - Brian McCrossan
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland
- Department of Pediatric Cardiology, Royal Belfast Hospital of Sick Children, Belfast, UK
| | - Paul Oslizlok
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland
| | - Colin J McMahon
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland
| | - Kevin P Walsh
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland
| | - Damien P Kenny
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Republic of Ireland.
| |
Collapse
|
11
|
Jegatheeswaran A, DeCampli WM. Toward More Granular Guidelines in AAOCA: Associating Anatomical Details With Specific Surgical Strategies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2023; 26:63-74. [PMID: 36842800 DOI: 10.1053/j.pcsu.2022.12.007] [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] [Received: 10/28/2022] [Revised: 12/18/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
Patients with anomalous aortic origin of a coronary artery (AAOCA) require imaging to clarify the multiple potential anatomic sites of obstruction (fixed or dynamic). Once repaired, the pathway of blood to the myocardium must not encounter: (1) intrinsic ostial stenosis, (2) obstruction from compression or distortion near the commissure or the intercoronary pillar, (3) stenosis where the artery exits the aortic wall (due to an acutely angled "take-off"), (4) compression due to a pathway between the great vessels, (5) stenosis or compression along an intramural course, or (6) compression due to an intramuscular (intraseptal/intraconal) course. Detailed anatomic evaluation of each of these locations allows the surgeon to select an appropriate repair strategy, and each of these abnormal anatomic features should be "matched" with a particular surgical correction. We speculate that the most common surgical repair, unroofing with or without tacking, is often inadequate, as in isolation, it may not allow for correction with a large orifice from the appropriate sinus, without an interarterial course. While the evidence base is insufficient to call these recommendations formal guidelines, these recommendations should serve as a basis for further validity testing, and ultimate evolution to more granular guidelines on AAOCA management.
Collapse
Affiliation(s)
- Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London; Children's Cardiovascular Disease, Institute of Cardiovascular Sciences, University College London, London.
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida; Department of Clinical Sciences, University of Central Florida College of Medicine, Orlando, Florida
| |
Collapse
|
12
|
Greenberg JW, Raees MA, Dani A, Heydarian HC, Chin C, Zafar F, Lehenbauer DG, Morales DLS. Palliated Hypoplastic Left Heart Syndrome Patients Experience Superior Waitlist and Comparable Post-Heart Transplant Survival to Non-Single Ventricle Congenital Heart Disease Patients. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00271-4. [PMID: 36455711 PMCID: PMC10225473 DOI: 10.1053/j.semtcvs.2022.08.019] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
Congenital heart disease (CHD) is a well-established risk factor for inferior waitlist and post-heart transplant survival in children. Differences in outcomes between CHD subgroups are understudied. The present study compared outcomes for palliated hypoplastic left heart syndrome (HLHS) patients to other non-single ventricle CHD (non-SVCHD) and non-CHD patients. United Network for Organ Sharing was used to identify children (age < 18) listed for heart transplant in the United States between 2016 and 2021. CHD sub-diagnoses were only available for United Network for Organ Sharing status 1a after 2015, thereby defining the cohort. Waitlist outcomes were studied using competing-risk time-to-event analysis for transplantation, mortality/decompensation, and alive-on-waitlist. Multivariable Cox proportional hazards regression analyses were used to identify factors associated with inferior post-transplant survival. Patients included: palliated-HLHS (n = 477), non-SVCHD (n = 686), and non-CHD (n = 1261). At listing, Palliated-HLHS patients were older than non-SVCHD (median 2-year [IQR 0-8] vs median 0-year [0-3], respectively) and younger than non-CHD (median 7-year [0-14]) (P < 0.001 vs both), and were more likely to be white (P < 0.01 vs both). Upon time-to-event analysis, rates of waitlist mortality/decompensation rates were greater among non-SVCHD than palliated-HLHS. Post-transplant survival was comparable between palliated-HLHS and non-SVCHD (P = 0.920) but worse compared to non-CHD (P < 0.001). Both palliated-HLHS (HR 2.40 [95% CI 1.68-3.42]) and non-SVSCHD (2.04 [1.39-2.99]) were independently associated with post-transplant mortality. Palliated-HLHS patients with heart failure experience significantly worse post-transplant outcomes than non-CHD but, compared to other CHD patients, experience superior waitlist and comparable post-transplant survival. While a high-risk cohort, HLHS patients can achieve gratifying waitlist and post-transplant survival.
Collapse
Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Muhammad Aanish Raees
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alia Dani
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Haleh C Heydarian
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David G Lehenbauer
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
13
|
Liebrich M, Schweder M, Seeburger J, Voth V. Double intrathoracic arterial cannulation plus peripheral cannulation for whole-body perfusion in an infant. Multimed Man Cardiothorac Surg 2022; 2022. [PMID: 36218292 DOI: 10.1510/mmcts.2022.032] [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: 06/16/2023]
Abstract
We report a technique for distal body perfusion in an infant with hypoplastic aortic arch and isthmus stenosis by ultrasound- guided cannulation of the femoral artery using an intra-arterial vascular sheath establishing whole-body perfusion by triple cannulation.
Collapse
Affiliation(s)
| | - Marco Schweder
- Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart, Stuttgart, Germany
| | | | - Vladimir Voth
- Sana Cardiac Surgery Center Stuttgart, Stuttgart Germany
| |
Collapse
|
14
|
Tulsi A, Chellappan S, Manohar K. Timing of congenital cardiac surgery in children who turned COVID-19 positive. Cardiol Young 2022; 32:815-7. [PMID: 34505562 DOI: 10.1017/S1047951121003759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report a series of four patients with CHD who tested positive for COVID-19, got treated, and underwent cardiac surgery in the same sitting. All had an uneventful perioperative course similar to COVID-19-negative patients. We conclude that children with asymptomatic or mild COVID-19 disease may be subjected to surgery as early as within 1 week since COVID-19 negative.
Collapse
|
15
|
Buchanan R, Roy N, Parra MF, Staffa SJ, Brown ML, Nasr VG. Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program. J Cardiothorac Vasc Anesth 2022; 36:3603-3609. [PMID: 35577651 DOI: 10.1053/j.jvca.2022.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 02/25/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital. DESIGN A retrospective study. SETTING A single quaternary pediatric hospital. PARTICIPANTS Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients. CONCLUSIONS Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.
Collapse
Affiliation(s)
- Rica Buchanan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
| |
Collapse
|
16
|
Lotto RR, Seaton SE, Jones ID, Lotto AA. A qualitative study exploring risk perception in congenital cardiac surgery: the perspective of UK surgeons. Cardiol Young 2022; 32:208-14. [PMID: 33985618 DOI: 10.1017/S1047951121001724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Managing risk is central to clinical care, yet most research focuses on patient perception, as opposed to how risk is enacted within the clinical setting by healthcare professionals. AIM To explore how surgical risk is perceived, encountered, and managed by congenital cardiac surgeons. METHODS Semi-structured interviews were conducted with 20 congenital cardiac surgeons representing every unit across England and Wales. All interviews were transcribed verbatim, with analysis based on the constant comparative approach. FINDINGS Three themes were identified, reflecting the interactions between personal, institutional, and political context in which risk is encountered and managed. First, "communicating risk" highlights the complexity and variability in methods employed by surgeons to balance legal/moral obligations with parental need and expectations. Universally, surgeons described the need for flexibility in their approach in order to meet the needs of individual patients. Second, "scrutiny and accountability" captures the spectrum of opinion arising from the binary nature of the outcomes collated and the way in which they are perceived to be interpreted. Third, "nature of the job" highlights the personal and professional implications of conveying and managing risk and the impact of recent policy changes on the way this is enacted. CONCLUSION Variations in approaches to communicating risk demonstrate a lack of consensus, compounded by insufficient evidence to determine or monitor a "best-care" approach. With current surgical outcomes suggesting little room for increasing survival rates, future care needs should shift to the "soft skills" in order to continue to drive improvements in parental and patient experience.
Collapse
|
17
|
Cuomo M, Purbojo A, Blumauer R, Schöber M, Wällisch W, Dittrich S, Cesnjevar RA. Repair of common arterial trunk: palliation and delayed correction as a viable alternative strategy in selected patients. Eur J Cardiothorac Surg 2021; 62:6414287. [PMID: 34718491 PMCID: PMC9257668 DOI: 10.1093/ejcts/ezab455] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Primary repair of common arterial trunk (CAT) is burdened by high mortality rates, especially in the presence of multiple risk factors. Timing, possible palliative methods, optimal management of associated cardiac lesions and handling of a poor preoperative state are still under discussion. METHODS We retrospectively analysed all patients who underwent surgery for CAT in our institution between 2008 and November 2020. We included 22 patients, 11 of whom received primary correction (PC) and 11 of whom underwent initial palliation by partial repair, leaving the ventricular septal defect open and connecting the right ventricle to the pulmonary arteries with a small valveless right ventricle-to-pulmonary artery conduit. A delayed correction (DC) was performed after 11.5 ± 3.6 months. RESULTS The overall operative mortality was 4.5%; 1 patient (affected by severe truncal valve stenosis and presenting in a poor state preoperatively) in the DC group died after palliation. The incidence of postoperative pulmonary hypertensive crisis was significantly higher in the PC group (P = 0.027). No patient from either group required postoperative extracorporeal support. Survival rates after 6 years differed slightly (PC group, 90%; DC group, 70%; log-rank = 0.270). CONCLUSIONS PC of CAT remains an optimal surgical approach for patients with an expected low mortality. However, our data support palliation and DC as a suitable alternative strategy, especially in the presence of significant risk factors like interrupted aortic arch, poor preoperative condition or complex surgical anatomy.
Collapse
Affiliation(s)
- Michela Cuomo
- Department of Pediatric Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Ariawan Purbojo
- Department of Pediatric Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Robert Blumauer
- Department of Pediatric Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Martin Schöber
- Department of Pediatric Cardiology, University of Erlangen, Erlangen, Germany
| | - Wolfgang Wällisch
- Department of Pediatric Cardiology, University of Erlangen, Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, University of Erlangen, Erlangen, Germany
| | | |
Collapse
|
18
|
Liu S, Wang L, Zhang H, Zeng W, Hu F, Xiao H, Li G, Mei J, Zhu J. Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery. Interact Cardiovasc Thorac Surg 2021; 34:424-430. [PMID: 34661678 PMCID: PMC8860435 DOI: 10.1093/icvts/ivab284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/31/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Pectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar. METHODS A retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary. RESULTS There were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome. CONCLUSIONS The novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.
Collapse
Affiliation(s)
- Siming Liu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Wang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongkun Zhang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wenhui Zeng
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengqing Hu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haibo Xiao
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guoqing Li
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiaquan Zhu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
19
|
Arslanoglu E, Tuncer E, Cine N, Kara KA, Ozbek B, Yılmaz AA, Tomrukcu F, Savluk Faruk O, Ukil F, Ceyran H. Impact of platelet population behaviours in patients undergoing the Glenn procedure. Cardiol Young 2021; 31:1675-9. [PMID: 33843534 DOI: 10.1017/S104795112100086X] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary pressure is one of the most important parameters in the postoperative follow-up of patients who have undergone the Glenn procedure. Platelet activation markers, which are inexpensive and easily accessible blood count parameters, have been shown to be associated with the aetiology and pathogenesis of primary pulmonary artery hypertension. We examined the relationship between platelet activation markers and pulmonary pressures in the early postoperative period of patients who underwent the Glenn procedure.Eighty-five patients who underwent the Glenn procedure in our clinic between January 2011 and March 2020 were included in the study retrospectively. Fifty-one patients were male and 34 were female, and age varied from 4 to 416 months, with a mean of 28.64 ± 51 months.Patients with increased pulmonary blood flow on palliation before Glenn surgery had higher mean platelet volume values. However, no correlation was found between pulmonary pressures and platelet activation markers in the early postoperative period.There was not similar study evaluating platelet activation markers in the paediatric age group before and after postoperative Glenn surgery in the literature. Therefore, even if platelet activation markers provide information about the pulmonary bed, they may be misleading due to other reasons that trigger bleeding and inflammatory processes in the early postoperative period.
Collapse
|
20
|
Deshpande A, Tey CS, Chanani N, Landry A, Raymond M, Sebelik M, Shashidharan S, Wolf M, Raol N. The utility of handheld ultrasound as a point-of-care screening tool to assess vocal fold impairment following congenital heart surgery. Int J Pediatr Otorhinolaryngol 2021; 148:110825. [PMID: 34252699 DOI: 10.1016/j.ijporl.2021.110825] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/10/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vocal fold motion impairment (VFMI) is a known potential complication of congenital heart surgery (CHS). Flexible nasolaryngoscopy (FNL) is the gold standard for evaluation of vocal fold movement but has risks, including epistaxis, desaturation, and changes in heart rate. Laryngeal ultrasound (LUS) has begun to emerge as a diagnostic tool and has been shown to have high accuracy in the evaluation of VFMI. We sought to assess the utility of hand-held LUS as a point-of-care screening tool to assess VFMI in pediatric patients following congenital heart surgery. METHODS Using a prospective cohort design, children under 18 years who were undergoing congenital heart surgery at a tertiary care pediatric hospital were enrolled. All patients underwent postoperative LUS and FNL. All studies were reviewed by two otolaryngology reviewers blinded to the clinical diagnosis. Higher quality studies were reviewed by two cardiology reviewers also blinded to the clinical diagnosis. Accuracy and inter-rater reliability were calculated. RESULTS Sixty-two children were screened. Fourteen children with VFMI were identified via FNL. When comparing LUS and FNL, both individual accuracy (90.3% and 75.8%) and interrater agreement (79% overall, 96% for high quality videos) were high for the otolaryngology reviewers. The cardiology reviewers were able to obtain 100% accuracy for high quality videos. CONCLUSION Handheld LUS has utility as a point-of-care screening tool to assess VFMI. This may have benefit in low-resource settings, for universal screening in cardiac intensive care units, or in settings where otolaryngology consultation may be difficult to obtain.
Collapse
Affiliation(s)
- Anita Deshpande
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, USA
| | - Ching Siong Tey
- School of Medicine, Department of Pediatrics, Emory University, USA
| | - Nikhil Chanani
- School of Medicine, Department of Pediatrics, Emory University, USA; Children's Healthcare of Atlanta, USA
| | - April Landry
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, USA; Children's Healthcare of Atlanta, USA
| | - Mallory Raymond
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, USA
| | - Merry Sebelik
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, USA
| | - Subhadra Shashidharan
- School of Medicine, Department of Cardiothoracic Surgery, Emory University, USA; Children's Healthcare of Atlanta, USA
| | - Michael Wolf
- School of Medicine, Department of Pediatrics, Emory University, USA; Children's Healthcare of Atlanta, USA
| | - Nikhila Raol
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, USA; Children's Healthcare of Atlanta, USA.
| |
Collapse
|
21
|
Madhavan S, Nakao M. How efficacious are Octreotide and Somatostatin in the management of chylothorax in congenital cardiac surgical patients? Interact Cardiovasc Thorac Surg 2021; 33:773-778. [PMID: 34000045 DOI: 10.1093/icvts/ivab155] [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] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was how efficacious are Octreotide and Somatostatin in the management of chylothorax in congenital cardiac surgical patients. Altogether >55 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The comparative data on LOS and chylothorax duration are mixed though interpretation is difficult since Octreotide has been instituted belatedly from the onset of chylothorax in multiple instances. There is also preliminary evidence to suggest that responders to Somatostatin and Octreotide are affected by single-ventricle physiology and CVP levels. Meanwhile, non-responders tend to have higher mortality and may merit earlier surgical intervention. The included studies thus far have significant limitations such as low-level evidence study design, selection bias, variability in duration and dosage of therapy and heterogenous comparative arms. Notwithstanding these limitations, Octreotide has shown to be an useful adjunct treatment in reducing chylothorax volume especially in patients with higher output chylothorax (>40 ml/kg/h) after the failure of conservative management.
Collapse
Affiliation(s)
| | - Masakazu Nakao
- Department of Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
22
|
Nemoto S, Konishi H, Suzuki T, Shimada R, Katsumata T, Osawa S, Yamaguchi A. Long-term viability and extensibility of an in situ regenerated canine aortic wall using hybrid warp-knitted fabric. Interact Cardiovasc Thorac Surg 2021; 33:165-172. [PMID: 33880514 DOI: 10.1093/icvts/ivab064] [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] [Received: 12/04/2020] [Revised: 01/25/2021] [Accepted: 02/05/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Many surgical materials promoting tissue regeneration have been explored for use in paediatric cardiac surgery. The aim of this study is to evaluate the long-term viability and extensibility of the canine aortic wall regenerated using a novel synthetic hybrid fabric. METHODS The sheet is a warp-knitted fabric of biodegradable (poly-l-lactic acid) and non-biodegradable (polyethylene terephthalate) yarns coated with cross-linked gelatine. This material was implanted as a patch to fill an oval-shaped defect created in the canine descending aorta. The tissue samples were explanted after 12, 24 or 36 months (N = 3, 2, 2, respectively) for histological examination and biomechanical testing. RESULTS There was no shrinkage, rupture or aneurysmal change after 24 months. The regenerated wall showed prototypical vascular healing without material degeneration, chronic inflammation, calcification or abnormal intimal overgrowth. Bridging tissue across the patch was well-formed and had expanded over time. The biodegradable yarns had completely degraded at 24 months after implantation, as scheduled, but the regenerated aortic wall demonstrated satisfactory levels of mechanical strength and extensibility in tensile strength tests. CONCLUSIONS The sheet achieved good long-term viability and extensibility in the regenerated aortic wall. These findings suggest that it is a promising surgical material for repairing congenital heart defects. Further developments of the sheet are required, including clinical studies.
Collapse
Affiliation(s)
- Shintaro Nemoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Hayato Konishi
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Tatsuya Suzuki
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Ryo Shimada
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Satomi Osawa
- Toxicology Research Department, Teijin Institute for Bio-Medical Research, Teijin Pharma Limited, Tokyo, Japan
| | - Ayuko Yamaguchi
- Healthcare Business Development-Medical Device, Teijin Limited, Tokyo, Japan
| |
Collapse
|
23
|
Prasad Gourav KK, Mandal B, Mishra AK, Narayanan Nayanar VK. Successful medical management of fungal infective endocarditis post VSD closure. Ann Card Anaesth 2021; 24:95-98. [PMID: 33938843 PMCID: PMC8081123 DOI: 10.4103/aca.aca_33_19] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fungal infective endocarditis (IE) is uncommon in postoperative cardiac surgical patients. The fungal IE accounts for 1.3%–6.8% of all IE cases and is considered the most severe form with a mortality rate as high as 45%–50%. There are various predisposing factors for fungal IE which include congenital heart defects, cardiac interventions like pacemaker insertion, degenerative valvular heart diseases, long-term use of broad-spectrum antimicrobial therapy, and long-term use of central venous. Mortality can reach up to 100% without specific treatment. Definitive therapy necessitates surgical debridement of vegetations/mass/abscess followed by long-term treatment with antifungal agents in patients who have symptoms of heart failure despite optimum medical management. We, hereby, report a case of fungal IE which occurred after the closure of a ventricular septal defect and was treated successfully with liposomal amphotericin B.
Collapse
Affiliation(s)
| | - Banashree Mandal
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | | |
Collapse
|
24
|
Frankel WC, Maul TM, Chrysostomou C, Wearden PD, Lowry AW, Baker KN, Nelson JS. A Minimal Opioid Postoperative Management Protocol in Congenital Cardiac Surgery: Safe and Effective. Semin Thorac Cardiovasc Surg 2020; 34:262-272. [PMID: 33333164 DOI: 10.1053/j.semtcvs.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022]
Abstract
There is evidence that reducing opioid exposure in children undergoing cardiac surgery may enhance postoperative recovery. We aimed to describe a minimal opioid postoperative management protocol in children undergoing cardiac surgery and our early outcomes with this strategy. We reviewed the medical records of children (6 months-18 years) who underwent elective cardiac surgery through a median sternotomy with cardiopulmonary bypass at our institution between 2016 and 2018. All patients were managed postoperatively using a standardized protocol. 101 children (median age 5 years) were included and 85% were extubated in the operating room. Although most patients (96%) received opioids postoperatively, opioid requirements decreased steadily over time, with 88%, 58%, and 18% of children receiving opioids on postoperative day 1, 2, and 3, respectively; 41% received no opioids after postoperative day 1. The median cumulative opioid exposure was 0.25 morphine milligram equivalents per kg (interquartile range, 0.10-0.75). Greater than mild pain was rare (<10%) at each time point. The rates of operative mortality and major complication were 0% and 3%, respectively. The median postoperative length of stay was 3 days, and 13% required readmission within 30 days. Age, cardiopulmonary bypass time, and number of benzodiazepine doses were independently associated with cumulative opioid exposure. Any complication, chest tube time, and higher STAT Category were independently associated with prolonged postoperative length of stay. A minimal opioid postoperative management protocol can be safe and effective in children undergoing cardiac surgery. Future prospective studies are needed to determine optimal practice and patient selection.
Collapse
Affiliation(s)
| | - Timothy M Maul
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Constantinos Chrysostomou
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida; Memorial Care Miller Children's & Women's Hospital, Long Beach, California
| | - Peter D Wearden
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Adam W Lowry
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Kimberly N Baker
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Jennifer S Nelson
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida; Department of Surgery, University of Central Florida College of Medicine, Orlando, Florida.
| |
Collapse
|
25
|
Sharma D, Subramaniam G, Sharma N. Use of ivabradine for treatment of junctional ectopic tachycardia in post congenital heart surgery. Indian J Thorac Cardiovasc Surg 2020; 37:323-325. [PMID: 33967423 DOI: 10.1007/s12055-020-01056-2] [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] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 08/17/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022] Open
Abstract
Cardiac surgeries especially involving crux of the heart as performed in tetralogy of Fallot (TOF) and pulmonary stenosis are mainly responsible for junctional ectopic tachycardia (JET). Diversified antiarrhythmic agents have been used in an impressive way to treat JET but showed suboptimal efficacy and varied associated adverse effects. But, ivabradine has proved as final crusader for its treatment. We report our initial experience of 4 cases in last 6 months with ivabradine in the management of postoperative JET. Encouraged by various reports and our increasing experience with ivabradine in heart failure population, we have moved to ivabradine as the first drug of choice for postoperative JET. Bradycardia was the only significant adverse effect in our series. The availability of atrial and ventricular pacing wires or at least transvenous temporary pacing should be ensured before starting ivabradine.
Collapse
Affiliation(s)
- Dhruva Sharma
- Department of Cardiothoracic and Vascular Surgery, SMS Medical College & Attached Hospitals, J L N Marg, Jaipur, Rajasthan 302001 India
| | - Ganapathy Subramaniam
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, Tamil Nadu 600029 India
| | - Neha Sharma
- Department of Pharmacology, SMS Medical College & Attached Hospitals, J L N Marg, Jaipur, Rajasthan 302001 India
| |
Collapse
|
26
|
Todd Tzanetos DR, Montgomery V, Harrington W, Calhoun A. Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality improvement opportunities. Cardiol Young 2020; 30:860-5. [PMID: 32476642 DOI: 10.1017/S1047951120001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement. METHODS A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends. RESULTS Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed. CONCLUSIONS Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.
Collapse
|
27
|
Reed CR, McCoy CC, Nag U, Nixon AB, Otto J, Lawson JH, Lodge AJ, Turek JW, Tracy ET. Proteomic Analysis of Infants Undergoing Cardiopulmonary Bypass Using Contemporary Ontological Tools. J Surg Res 2019; 246:83-92. [PMID: 31562990 DOI: 10.1016/j.jss.2019.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/08/2019] [Accepted: 08/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is essential for the repair of many congenital cardiac defects in infants but is associated with significant derangements in hemostasis and systemic inflammation. As a result, hemorrhagic complications and thrombosis are major challenges in the management of children requiring CPB or extracorporeal membrane oxygenation. Conventional clinical laboratory tests capture individual hemostatic derangements (low platelets, elevated fibrinogen) but fail to describe the complex, overlapping interactions among the various components of coagulation, including cellular interactions, contact activation, fibrinolysis, and inflammation. Given recent advances in analytic tools for identifying protein-protein interactions in the plasma proteome, we hypothesized that an unbiased proteomic analysis would help identify networks of interacting proteins for further investigation in pediatric CPB. MATERIALS AND METHODS Infants up to 1 y of age were enrolled. Plasma samples were collected at 0, 1, 4, and 24 h after CPB. Mass spectrometry was used to identify proteins undergoing changes in concentration after CPB, and STRING and ToppGene tools were used to identify biological networks. Two-dimensional difference gel electrophoresis identified changes in protein concentrations. Inflammatory markers were assessed by enzyme-linked immunosorbent assay at the same time points. RESULTS Ten infants with cardiac anomalies requiring surgery and CPB were enrolled; no major complications were recorded (median age, 127.5 d; interquartile range, 181.25 d). Using two-dimensional difference gel electrophoresis, >1400 individual protein spots were observed, and 89 proteins demonstrated change in concentration >30% with P < 0.02 when comparing 1, 4, or 24 h to baseline. Among protein spots with significant changes in concentration after CPB, 29 were identified with mass spectrometry (33%). In our interrogation of functional associations among these differentially expressed proteins, our results were dominated by the acute phase response, coagulation, and cell signaling functional categories. Among cytokines analyzed by enzyme-linked immunosorbent assay, IL-2, IL-8, and IL-10 were elevated at 4 h but normalized by 24 h, whereas IL-6 was persistently elevated. CONCLUSIONS Infants manifest a robust response to CPB that includes overlapping, complex pathways. Further investigation of interactions among immune, coagulation, and cell signaling systems may lead to novel therapeutics or biomarkers useful in the management of infants requiring CPB.
Collapse
Affiliation(s)
| | | | - Uttara Nag
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew B Nixon
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - James Otto
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Andrew J Lodge
- Section of Pediatric Cardiac Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph W Turek
- Section of Pediatric Cardiac Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | |
Collapse
|
28
|
Uber AM, Montez-Rath ME, Kwiatkowski DM, Krawczeski CD, Sutherland SM. Nephrotoxin exposure and acute kidney injury in critically ill children undergoing congenital cardiac surgery. Pediatr Nephrol 2018; 33:2193-2199. [PMID: 29987455 DOI: 10.1007/s00467-018-4010-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 04/27/2018] [Revised: 06/16/2018] [Accepted: 06/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Though acute kidney injury (AKI) is often multifactorial, investigators are now emphasizing the specific contribution of nephrotoxins. This study examines the epidemiology of nephrotoxin exposure and nephrotoxin-associated AKI among children undergoing congenital heart surgery (CHS). METHODS This is a retrospective cohort study of children admitted following CHS between June 1, 2014, and September 30, 2014. Nephrotoxins were defined according to the Nephrotoxic Injury Negated by Just-in-time-Action (NINJA) collaborative; high nephrotoxin exposure was defined as receipt of ≥ 3 nephrotoxins concurrently. AKI was diagnosed according to KDIGO creatinine criteria. Severe AKI was defined as KDIGO stage ≥ 2. Poisson models were used to compute adjusted relative risk (aRR) of high nephrotoxin exposure for AKI. RESULTS One hundred fifty-four children (median age 20.4 months, IQR 2.3-59.5) were included. One hundred thirty-one (85.1%) received at least one nephrotoxin; 32 (20.8%) received ≥ 3 nephrotoxins. The most commonly administered medications were ketorolac (n = 74, 48.1%), aspirin (n = 62, 40.3%), ibuprofen (n = 51, 33.1%), vancomycin (n = 39, 25.3%), piperacillin/tazobactam (n = 35, 22.7%), and enalapril (n = 14, 9.1%). AKI occurred more commonly in those exposed to ≥ 3 nephrotoxins (62.5 vs. 50.8%); this was not statistically significant after adjusting for confounders (aRR = 1.2, 95% CI 0.9-1.7). Severe AKI was similar between those with and without high nephrotoxin exposure (21.9 vs. 19.7%, p = 0.78). CONCLUSIONS Nephrotoxin use is common following pediatric CHS. While we found no association between high nephrotoxin exposure and AKI, this may be related to the multifactorial nature of AKI in this population. For many common nephrotoxins, less injurious agents exist and nephrotoxin exposure may represent a modifiable risk factor for AKI.
Collapse
Affiliation(s)
- Amanda M Uber
- Department of Pediatrics (General Pediatrics), Stanford University School of Medicine, Stanford, CA, USA. .,Stanford Children's Health/Lucile Packard Children's Hospital, Stanford, 725 Welch Road, MC 5906, Palo Alto, CA, 94304, USA.
| | - Maria E Montez-Rath
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - David M Kwiatkowski
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Catherine D Krawczeski
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
29
|
Gandhi H, Mishra A, Thosani R, Acharya H, Shah R, Surti J, Sarvaia A. Elective nasal continuous positive airway pressure to support respiration after prolonged ventilation in infants after congenital cardiac surgery. Ann Pediatr Cardiol 2017; 10:26-30. [PMID: 28163425 PMCID: PMC5241841 DOI: 10.4103/0974-2069.197055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: We sought to compare the effectiveness of oxygen (O2) treatment administered by an O2 mask and nasal continuous positive airway pressure (NCPAP) in infants after congenital cardiac surgery. Methods: In this retrospective observational study, 54 infants undergoing corrective cardiac surgery were enrolled. According to the anesthesiologist's preference, the patients ventilated for more than 48 h were either put on NCPAP or O2 mask immediately after extubation. From pre-extubation to 24 h after treatment, arterial blood gas and hemodynamic data were measured. Results: After 24 h of NCPAP institution, the patients showed a significant improvement in oxygenation compared to O2 mask group. Respiratory rate (per minute) decreased from 31.67 ± 4.55 to 24.31 ± 3.69 (P < 0.0001), PO2 (mmHg) increased from 112.12 ± 22.83 to 185.74 ± 14.81 (P < 0.0001), and PCO2 (mmHg) decreased from 42.88 ± 5.01 to 37.00 ± 7.22 (P < 0.0076) in patients on NCPAP. In this group, mean pediatric cardiac surgical Intensive Care Unit (PCSICU) stay was 4.72 ± 1.60 days, with only 2 (11.11%) patients requiring re-intubation. Conclusion: NCPAP can be used safely and effectively in infants undergoing congenital cardiac surgery to improve oxygenation/ventilation. It also reduces the work of breathing, PCSICU stay, and may reduce the likelihood of re-intubation.
Collapse
Affiliation(s)
- Hemang Gandhi
- Department of Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| | - Amit Mishra
- Department of Cardiovascular Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| | - Rajesh Thosani
- Department of Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| | - Himanshu Acharya
- Department of Research, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| | - Ritesh Shah
- Department of Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| | - Jigar Surti
- Department of Pediatric Critical Care, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| | - Alpesh Sarvaia
- Department of Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Ahmedabad, Gujarat, India
| |
Collapse
|
30
|
Kogon B, Karamlou T, Baumgartner W, Merrill W, Backer C. Congenital cardiac surgery fellowship training: A status update. J Thorac Cardiovasc Surg 2016; 151:1488-95. [PMID: 27002229 DOI: 10.1016/j.jtcvs.2016.02.039] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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: 04/22/2015] [Revised: 09/09/2015] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND In 2007, congenital cardiac surgery became a recognized fellowship by the Accreditation Council of Graduate Medical Education (ACGME) and leads to board certification through the American Board of Thoracic Surgery (ABTS). We highlight the strengths and weaknesses in the current system of accredited training. METHODS Data were collected from program directors, the ACGME, and the ABTS. In addition, surveys were sent to training program graduates. Topics included program accreditation status, number of fellows trained per year and per program, match results, fellow operative experience, fellow satisfaction, and post-fellowship employment status. RESULTS There are twelve active accredited fellowship programs, and 44 trainees have completed accredited training. Each active program has trained a median of 3 fellows (range: 0-7). Operative logs were obtained from 38 of 44 (86%) graduates. The median number of total cases (minimum 75) was 136 (range: 75-236). For complex neonates (minimum 5), the median number of cases was 6 (range: 2-17). Some fellows failed to meet the minimum requirements. Thirty-six (82%) graduates responded to the survey; most were satisfied with their overall operative experience, but less with their neonatal operative experience. Of this total, 84% are currently practicing congenital cardiac surgery, and 74% secured jobs prior to completing their residency. CONCLUSIONS Since 2007, congenital cardiac surgery training has been accredited by the ACGME. In general, the training is uniform, the operative experience is robust, and the fellows are satisfied. Although shortcomings remain, this study highlights the many strengths of the current system.
Collapse
Affiliation(s)
- Brian Kogon
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Ga.
| | - Tara Karamlou
- Department of Cardiothoracic Surgery, University of California San Francisco, San Francisco, Calif
| | - William Baumgartner
- Department of Cardiothoracic Surgery, Johns Hopkins University, Baltimore, Md
| | - Walter Merrill
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Carl Backer
- Department of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| |
Collapse
|
31
|
Kiraly L, Tofeig M, Jha NK, Talo H. Three-dimensional printed prototypes refine the anatomy of post-modified Norwood-1 complex aortic arch obstruction and allow presurgical simulation of the repair. Interact Cardiovasc Thorac Surg 2015; 22:238-40. [PMID: 26590304 DOI: 10.1093/icvts/ivv320] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [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: 09/10/2015] [Accepted: 10/13/2015] [Indexed: 11/12/2022] Open
Abstract
Three-dimensional (3D) printed prototypes of malformed hearts have been used for education, communication, presurgical planning and simulation. We present a case of a 5-month old infant with complex obstruction at the neoaortic to transverse arch and descending aortic junction following the neonatal modified Norwood-1 procedure for hypoplastic left heart syndrome. Digital 3D models were created from a routine 64-slice CT dataset; then life-size solid and magnified hollow models were printed with a 3D printer. The solid model provided further insights into details of the anatomy, whereas the surgical approach and steps of the operation were simulated on the hollow model. Intraoperative assessment confirmed the anatomical accuracy of the 3D models. The operation was performed in accordance with preoperative simulation: sliding autologous flaps achieved relief of the obstruction without additional patching. Knowledge gained from the models fundamentally contributed to successful outcome and improved patient safety. This case study presents an effective use of 3D models in exploring complex spatial relationship at the aortic arch and in simulation-based planning of the operative procedure.
Collapse
Affiliation(s)
- Laszlo Kiraly
- Pediatric Cardiac Surgery, Sheikh Khalifa Medical City managed by Cleveland Clinic, Institute of Cardiac Sciences, Abu Dhabi, United Arab Emirates
| | - Magdi Tofeig
- Pediatric Cardiology, Sheikh Khalifa Medical City managed by Cleveland Clinic, Institute of Cardiac Sciences, Abu Dhabi, United Arab Emirates
| | - Neerod Kumar Jha
- Pediatric Cardiac Surgery, Sheikh Khalifa Medical City managed by Cleveland Clinic, Institute of Cardiac Sciences, Abu Dhabi, United Arab Emirates
| | - Haitham Talo
- Pediatric Cardiology, Sheikh Khalifa Medical City managed by Cleveland Clinic, Institute of Cardiac Sciences, Abu Dhabi, United Arab Emirates
| |
Collapse
|
32
|
Kogon B, Woodall K, Kanter K, Alsoufi B, Oster M. Reducing readmissions following paediatric cardiothoracic surgery: a quality improvement initiative. Cardiol Young 2015; 25:935-40. [PMID: 25115729 DOI: 10.1017/S1047951114001437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We have previously identified risk factors for readmission following congenital heart surgery - Hispanic ethnicity, failure to thrive, and original hospital stay more than 10 days. As part of a quality initiative, changes were made to the discharge process in hopes of reducing the impact. All discharges were carried out with an interpreter, medications were delivered to the hospital before discharge, and phone calls were made to families within 72 hours following discharge. We hypothesised that these changes would decrease readmissions. METHODS The current cohort of 635 patients underwent surgery in 2012. Demographic, preoperative, operative, and postoperative variables were evaluated. Univariate and multivariate risk factor analyses were performed. Comparisons were made between the initial (2009) and the current (2012) cohorts. RESULTS There were 86 readmissions of 77 patients during 2012. Multivariate risk factors for readmission were risk adjustment for congenital heart surgery score and initial hospital stay >10 days. In comparing 2009 with 2012, the overall readmission rate was similar (10 versus 12%, p=0.27). Although there were slight decreases in the 2012 readmissions for those patients with Hispanic ethnicity (18 versus 16%, p=0.79), failure to thrive (23 versus 17%, p=0.49), and initial hospital stay >10 days (22 versus 20%, p=0.63), they were not statistically significant. CONCLUSIONS Potential risk factors for readmission following paediatric cardiothoracic surgery have been identified. Although targeted modifications in discharge processes can be made, they may not reduce readmissions. Efforts should continue to identify modifiable factors that can reduce the negative impact of hospital readmissions.
Collapse
|
33
|
Abstract
The cor triatriatum sinister is an uncommon congenital cardiac anomaly and reports in the literature are limited. It is often associated with other cardiac malformations, such as atrial septal defect, transposition of the great arteries, tetralogy of Fallot or atrioventricular septal defect. We present here a 6-year old boy who was diagnosed with cor triatriatum sinister, initially showing symptoms similar to mitral valve stenosis and congestive heart failure, and who underwent subsequent surgical correction using a left atrial approach. The fibromuscular membrane, separating the pulmonary veins from the mitral valve, was completely resected and postoperative echocardiography showed unobstructed pulmonary venous flow.
Collapse
Affiliation(s)
- Alexander Kadner
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - Katharina Meszaros
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - Christoph Mueller
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - Florian Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - Damian Hutter
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| |
Collapse
|
34
|
Schweiger M, Dave H, Kelly J, Hübler M. Strategic and operational aspects of a transfusion-free neonatal arterial switch operation. Interact Cardiovasc Thorac Surg 2013; 16:890-1. [PMID: 23460601 DOI: 10.1093/icvts/ivt010] [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: 11/14/2022] Open
Abstract
Blood transfusion-free complex congenital cardiac surgery in a neonate remains a challenge for multidisciplinary cardiac teams. At our institution, a 3.5 kg neonate, born to a family of Jehovah's Witnesses and postnatally diagnosed with dextro-transposition of the great arteries (d-TGA) and a small muscular ventricular septal defect, underwent a successful arterial switch operation without blood or platelet transfusion. Key points that contributed to success were optimal preoperative haematopoetic conditioning using erythropoietin and iron, a miniaturized cardiopulmonary bypass circuit including a low prime volume oxygenator and crystalloid cardioplegia, and a well-coordinated multidisciplinary team. We report an overview of the literature regarding blood transfusion-free complex congenital cardiac surgery.
Collapse
Affiliation(s)
- Martin Schweiger
- Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | | | | | | |
Collapse
|