Abstract
There is scarce information about the relationships between postoperative pulmonary hemodynamics, inflammation, and outcomes in pediatric patients with congenital cardiac communications undergoing surgery. We prospectively studied 40 patients aged 11 (8–17) months (median with interquartile range) with a preoperative mean pulmonary arterial pressure of 48 (34–54) mmHg who were considered to be at risk for postoperative pulmonary hypertension. The immediate postoperative pulmonary/systemic mean arterial pressure ratio (PAP/SAPIPO, mean of first 4 values obtained in the intensive care unit, readings at 2-hour intervals) was correlated directly with PAP/SAP registered in the surgical room just after cardiopulmonary bypass (r = 0.68, p < 0.001). For the entire cohort, circulating levels of 15 inflammatory markers changed after surgery. Compared with patients with PAP/SAPIPO ≤ 0.40 (n = 22), those above this level (n = 18) had increased pre- and postoperative serum levels of granulocyte colony-stimulating factor (p = 0.040), interleukin-1 receptor antagonist (p = 0.020), interleukin-6 (p = 0.003), and interleukin-21 (p = 0.047) (panel for 36 human cytokines) and increased mean platelet volume (p = 0.018). Using logistic regression analysis, a PAP/SAPIPO > 0.40 and a heightened immediate postoperative serum level of macrophage migration inhibitory factor (quartile analysis) were shown to be predictive of significant postoperative cardiopulmonary events (respective hazard ratios with 95% CIs, 5.07 (1.10–23.45), and 3.29 (1.38–7.88)). Thus, the early postoperative behavior of the pulmonary circulation and systemic inflammatory response are closely related and can be used to predict outcomes in this population.
Highlights
Pulmonary hypertension is an important factor influencing the outcomes following pediatric cardiac surgery
Elevation of pulmonary vascular resistance was suggested by increased pulmonary arterial pressure in the presence of relatively restricted pulmonary blood flow considering the size of the cardiac communications
We analyzed the behavior of pulmonary and systemic arterial pressure curves and the occurrence of significant cardiopulmonary events (SCAPEs) and investigated how they might be related to systemic inflammation, which we assessed by measuring circulating levels of inflammatory markers pre- and postoperatively
Summary
Pulmonary hypertension is an important factor influencing the outcomes following pediatric cardiac surgery. Young patients with unrestrictive congenital cardiac communications have altered pulmonary hemodynamics associated with functional and structural changes in the pulmonary vascular bed. These abnormalities pose a risk for immediate postoperative clinical instability and residual pulmonary hypertension long after the repair of cardiac lesions, in individuals not treated in a timely fashion (early in life). A number of perioperative factors contribute to postoperative systemic and pulmonary vascular tone instability, leading to hemodynamic disturbances. Superimposed on preexisting endothelial cell dysfunction, the inflammatory reaction elicits an increased propensity to spasm in the pulmonary circulation [2]. Alveolar edema, ventilation-perfusion mismatch, and bronchoconstriction contribute to hypoxia, which may either trigger or exacerbate pulmonary vasoconstriction [2, 7]
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