Complex Congenital Cardiac Surgery Research Articles

Enhanced congenital cardiac surgery knowledge with multidisciplinary collaborative education series for paediatric cardiology fellows and nurse practitioners.

Paediatric cardiologists and nurse practitioners lack structured education tools focused on basic cardiac surgery principles. However, non-surgical specialties caring for surgical patients require this knowledge for comprehensive clinical care. We created a cardiac surgical educational curriculum focused on improving knowledge and attitudes towards communication for non-surgical trainees and advanced practice providers. Over one academic year, six paediatric cardiology fellows and seven paediatric cardiac surgery nurse practitioners at Seattle Children's Hospital participated in this study. With surgical supervision, six lectures were prepared by each fellow and delivered monthly. Sessions were hybrid and recorded for later viewing. Pre- and post-intervention survey of attitudes regarding surgical topics and pre- and post- test-based knowledge assessments were administered. Participants positively rated the usefulness of the lecture series (4.2/5) and would recommend it to a colleague (4.5/5). Self-reported confidence discussing surgical concepts with patients increased from 2.3 to 3.4 among paediatric cardiology fellows (p < 0.001) and from 2.8 to 3.9 among nurse practitioners (p < 0.001), out of 5. In both groups, knowledge assessment scores improved from 54 to 79% post-intervention (p < 0.001). After a six-part educational series taught by paediatric cardiology fellows, both paediatric cardiology fellows and paediatric cardiac surgery nurse practitioners demonstrated improved knowledge and reported increased comfort counselling families on basic cardiac surgery topics. Structured, active-learning lessons taught by fellows for non-surgical audiences can improve attitudes and build clinically relevant knowledge. Creating an effective level-appropriate multidisciplinary curriculum accessible to various types of medical providers could enhance comprehensive care of complex congenital cardiac surgery patients.

Editorial introductions.

Editorial introductions.

Editorial introductions.

Current Opinion in Anesthesiology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of anesthesiology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors of the journal and the Section Editors for this issue. SECTION EDITORS Jill MhyreJill MhyreJill Mhyre is The Dola S Thompsom Professor and Chair of Anesthesiology at the University of Arkansas for Medical Sciences, Arkansas, USA. She is Executive Section Editor of Obstetric Anesthesiology for Anesthesia & Analgesia, and Associate Editor for the textbook, Chestnut's Obstetric Anesthesia: Principles & Practice. Her academic interests include maternal safety systems such as early warning systems, cardiopulmonary resuscitation, and morbidity and mortality. Christiane BeckChristiane BeckDr Christiane Beck is the leading senior consultant at the Clinic of Anesthesiology and Intensive Care Medicine at Hannover Medical School, Germany. She has studied medicine at the Universities of Göttingen, Germany, Johannesburg, South Africa, and Madison, USA. She received her degree in 1997 from the University of Göttingen, Germany. She completed her anesthesiology residency training in 2003 and is a certified anesthesiologist, intensivist and emergency physician. She achieved her doctoral degree at the Center for Radiologic Diagnostics, University of Göttingen, Germany in 2000. Dr Christiane Beck habilitated in 2021 at the Hannover Medical School, Germany. Besides clinical duties, she implemented and coordinates to date preoperative fasting guidelines for children. She is co-author of the actual ESAIC Fasting Guideline and coordinator of the German fasting guidelines on this subject. She specializes in pediatric anesthesia, anesthesia for complex congenital cardiac surgery and transplant surgery in children. She is a member of the German Society of Anesthesiology and Intensive Care Medicine (DGAI), the Professional Association of German Anesthesiologists (BDA), the European Society of Anesthesiology and Intensive Care Medicine (ESAIC), the Scientific Working Group for Pediatric Anesthesia and since 2021, Speaker of the Scientific Working Group for Pediatric Cardiac Anesthesia of the German Society of Anesthesiology. Her focus is on the research of pediatric anesthesia. She coordinated a national study on preoperative fasting in children for the Scientific Working Group for Pediatric Anesthesia and is part of the research group of Prof. Robert Sümpelmann. She has published several journal articles and book chapters, mainly on the field of pediatric anesthesia. She is a passionate mentor for trainees and early career junior residence in building a clinical or scientific career. Dr Christiane Beck has been involved on a voluntary basis as the leading anesthetist to pediatric cardiac missions to Moldova, Bosnia Herzegovina, Cyprus and Romania. She is in close contact and provides support to an innovative project MOHKI – the mobile kinderherzen clinic of kinderherzen - Fördergemeinschaft deutscher Kinderherzzentren e.V. to provide excellent medical infrastructure for cardiac missions in low-income countries. Wolfgang BuhreWolfgang BuhreWolfgang Buhre is Anaesthesiologist and Medical Director of the Division of Anesthesiology, Perioperative Medicine, Emergency Medicine and Critical Care Medicine at Maastricht University Medical Centre (MumC), The Netherlands. He is also Professor of Anesthesiology at Maastricht University, The Netherlands. At Maastricht, he is a member of the School Council and a research fellow in the School of Mental Health and Neurosciences (MhenS). He is also an associated research fellow in the Care and Public health Research Institute (CAPHRI), Maastricht University. He earned his medical degree at the University of Göttingen, Germany, where he also completed his residency training. He is trained in intensive care medicine and pain medicine. His areas of research are outcome research, artificial intelligence, and modern technology to support decision making in clinical practice. Wolfgang Buhre is leading the Research Mentorship Program of the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC). Moreover, he is coordinating investigator in the Academic Research Organization of ESAIC and serves within the society also as industrial liaison member for the Academic Research Organization (A-CRO).

Repeated extracorporeal membrane oxygenation for support of an Adult with Congenital Heart Disease and reperfusion pulmonary oedema.

We present the case of 28-year-old woman with a history of complex congenital cardiac surgery who developed cardiovascular collapse with reperfusion pulmonary oedema and right ventricular failure after surgical replacement of a severely stenosed right ventricle to pulmonary artery conduit. She required two separate episodes of support with extracorporeal membrane oxygenation and is alive and well 6 months after her initial cardiorespiratory crisis. We believe that consideration of a second period of support with extracorporeal membrane oxygenation is appropriate for select adults with CHD, provided they have a potentially reversible cause of postoperative cardiorespiratory collapse.Our case provides several important lessons: (1) adults with CHD with severe postcardiotomy cardiorespiratory failure may potentially be salvaged even if they require multiple runs of extracorporeal membrane oxygenation; (2) adults with CHD with severe postcardiotomy respiratory failure with adequate cardiac function may potentially be salvaged with veno-venous extracorporeal membrane oxygenation; and (3) patients supported with extracorporeal membrane oxygenation will benefit from care from a skilled multidisciplinary team who are able to focus on the support of the function of the organs of the patient whilst providing nutrition and mobilisation.

Editorial introductions.

Editorial introductions.

Three-Dimensional Virtual and Printed Prototypes in Complex Congenital and Pediatric Cardiac Surgery-A Multidisciplinary Team-Learning Experience.

Three-dimensional (3D) virtual modeling and printing advances individualized medicine and surgery. In congenital cardiac surgery, 3D virtual models and printed prototypes offer advantages of better understanding of complex anatomy, hands-on preoperative surgical planning and emulation, and improved communication within the multidisciplinary team and to patients. We report our single center team-learning experience about the realization and validation of possible clinical benefits of 3D-printed models in surgical planning of complex congenital cardiac surgery. CT-angiography raw data were segmented into 3D-virtual models of the heart-great vessels. Prototypes were 3D-printed as rigid “blood-volume” and flexible “hollow”. The accuracy of the models was evaluated intraoperatively. Production steps were realized in the framework of a clinical/research partnership. We produced 3D prototypes of the heart-great vessels for 15 case scenarios (nine males, median age: 11 months) undergoing complex intracardiac repairs. Parity between 3D models and intraoperative structures was within 1 mm range. Models refined diagnostics in 13/15, provided new anatomic information in 9/15. As a team-learning experience, all complex staged redo-operations (13/15; Aristotle-score mean: 10.64 ± 1.95) were rehearsed on the 3D models preoperatively. 3D-printed prototypes significantly contributed to an improved/alternative operative plan on the surgical approach, modification of intracardiac repair in 13/15. No operative morbidity/mortality occurred. Our clinical/research partnership provided coverage for the extra time/labor and material/machinery not financed by insurance. 3D-printed models provided a team-learning experience and contributed to the safety of complex congenital cardiac surgeries. A clinical/research partnership may open avenues for bioprinting of patient-specific implants.

Enhancing Recovery in Congenital Cardiac Surgery

BackgroundThe benefits of a comprehensive enhanced recovery after surgery (ERAS) program for patients with congenital heart disease are largely unknown. This study evaluated adherence and to outcomes of a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery. MethodsPatients undergoing elective procedures for simple and moderately complex congenital cardiac surgery have followed institutional ERP guidelines since October 2018. Adherence to guidelines over a 12-month period (P2) was compared with implementation data (P1, 5 months). The association of outcomes with continuous time was estimated using linear regression. ResultsAmong 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except a higher incidence of previous operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. The following improvements were notable: operating room extubation, 27% in P2 vs16% in P1 (P = .006); and a decrease in median ventilation time, 6.0 hours (interquartile range [IQR], 0-9.2 hours) in P2 vs 7.6 hours (IQR, 3.8-12.3 hours) in P1 (P = .002). In addition, there was a reduction in opioids, reported as oral morphine equivalents, that was most significant for intraoperative oral morphine equivalents: 5.00 mg/kg (IQR, 3.11-7.60 mg/kg) in P2 vs 6.05 mg/kg (IQR, 3.77-9.78 mg/kg) in P1 (P = .001). There was no difference in overall intensive care unit and postoperative lengths of stay, except in lower-risk surgical procedures. Surgical outcomes were similar in the 2 periods. ConclusionsAn enhanced recovery program reduced the use of opioids, led to more extubation in the operating room, and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.

Vasoplegic syndrome after cardiovascular surgery: A review of pathophysiology and outcome-oriented therapeutic management.

Vasoplegic syndrome (VPS) is defined as systemic hypotension due to profound vasodilatation and loss of systemic vascular resistance (SVR), despite normal or increased cardiac index, and characterized by inadequate response to standard doses of vasopressors, and increased morbidity and mortality. It occurs in 9%-44% of cardiac surgery patients after cardiopulmonary bypass (CPB). The underlying pathophysiology following CPB consists of resistance to vasopressors (inactivation of Ca2+ voltage gated channels) on the one hand and excessive activation of vasodilators (SIRS, iNOS, and low AVP) on the other. Use of angiotensin-converting enzyme inhibitor (ACE-I), calcium channel blockers, amiodarone, heparin, low cardiac reserve (EF < 35%), symptomatic congestive heart failure, and diabetes mellitus are the perioperative risk factors for VPS after cardiac surgery in adults. Till date, there is no consensus about the outcome-oriented therapeutic management of VPS. Vasopressors such as norepinephrine (NE; 0.025-0.2 µg/kg/min) and vasopressin (0.06 U/min or 6 U/h median dose) are the first choice for the treatment. The adjuvant therapy (hydrocortisone, calcium, vitamin C, and thiamine) and rescue therapy (methylene blue [MB] and hydroxocobalamin) are also considered when perfusion goals (meanarterial pressure [MAP] > 60-70 mmHg) are not achieved with nor-epinephrine and/or vasopressin. The aims of this systematic review are to collect all the clinically relevant data to describe the VPS, its potential risk factors, pathophysiology after CPB, and to assess the efficacy, safety, and outcome of the therapeutic management with catecholamine and non-catecholamine vasopressors employed for refractory vasoplegia after cardiac surgery. Also, to elucidate the current and practical approach for management of VPS after cardiac surgery. "PubMed," "Google," and "Medline" weresearched, and over 150 recent relevant articles including RCTs, clinical studies, meta-analysis, reviews, case reports, case series and Cochrane data were analyzed for this systematic review. The filter was applied specificallyusing key words like VPS after cardiac surgery, perioperative VPS following CPB, morbidity, and mortality in VPS after cardiac surgery, vasopressors for VPS that improve outcomes, VPS after valve surgery, VPS after CABG surgery, VPS following complex congenital cardiac anomalies corrective surgery, rescue therapy for VPS, adjuvant therapy for VPS, definition of VPS, outcome in VPS after cardiac surgery, etiopathology of VPS following CPB. This review did not require any ethical approval or consent from the patients. Despite the recent advances in therapy, the mortality remains as high as 30%-50%. NE has been recommended the most frequent used vasopressor for VPS. It restores and maintain the MAP and provides the outcome benefits. Vasopressin rescue therapy is an alternative approach, if catecholamines and fluid infusions fail to improve hemodynamics. It effectively increases vascular tone and lowers CO, and significantly decreases the 30 days mortality. Hence, suggested a first-line vasopressor agent in postcardiac surgery VPS. Terlipressin (1.3μg/kg/h), a longer acting and more specific vasoconstrictor prevents the development of VPS after CPB in patients treated with ACE-I. MB significantly reduces morbidity and mortality of VPS. The Preoperative MB (1%, 2mg/kg/30min, 1h before surgery) administration in high risk (on ACE-I) patients for VPS undergoing CABG surgery, provides 100% protection against VPS, and early of MB significantly reduces operative mortality, and recommended as a rescue therapy for VPS. Hydroxocobalamin (5 g) has been recommended as a rescue agent in VPS refractory to multiple vasopressors. A combination of ascorbic acid (6 g), hydrocortisone (200 mg/day), and thiamine (400 mg/day) as an adjuvant therapy significantly reduces the vasopressors requirement, and provides mortality and morbidity benefits. Currently, the VPS is frequently encountered (9%-40%) in cardiac surgical patients with predisposing patient-specific risk factors and combined with inflammatory response to CPB. Multidrug therapy (NE, MB, AVP, ATII, terlipressin, hydroxocobalamin) targeting multiple receptor systems is recommended in refractory VPS. A combination of high dosage of ascorbic acid, hydrocortisone and thiamine has been used successfully as adjunctive therapyto restore the MAP. We also advocate for the early use of multiagent vasopressors therapy and catecholamine sparing adjunctive agents to restore the systemic perfusion pressure with a goal of preventing the progressive refractory VPS.

Higher total ultrafiltration volume during cardiopulmonary bypass-assisted infant cardiac surgery is associated with acute kidney injury and fluid overload.

Ultrafiltration (UF) is used for fluid removal during and after infant cardiopulmonary bypass (CPB) surgery to reduce fluid overload. Excessive UF may have the opposite of its intended effect, resulting in acute kidney injury (AKI), oliganuria, and fluid retention. This is a single-center, retrospective review of infants treated with conventional and/or modified UF during CPB surgery. UF volume was indexed to weight. AKI was defined using serum creatinine "Kidney Disease Improving Global Outcome (KDIGO)" criteria. Fluid balance was defined according to: [Formula: see text]. Peak fluid overload was determined on postoperative day 3. Multivariable logistic regression adjusted for multiple covariates was used to explore associations with UF, AKI, and fluid overload. Five hundred thirty subjects < 1 year of age underwent CPB-assisted congenital heart surgery with UF. Sixty-four (12%) developed postoperative AKI. On multivariable regression, higher indexed total UF volume was associated with increased AKI risk (OR 1.11, 95% CI=1.04-1.19, p = 0.003). UF volume > 119.9 mL/kg did not reduce peak fluid overload. Subjects with AKI took longer to reach a negative fluid balance (2 vs. 3 days, p = 0.04). Those with more complex surgery were at highest AKI risk (STAT 3 [25-75 percentile: 3-4] in AKI group versus STAT 3 [25-75 percentile: 2-4] in non-AKI group, p = 0.05). AKI was reduced in subjects undergoing more complex surgery and treated with UF volume < 119.9 mL/kg. Judicious use of UF in more complex congenital cardiac surgery reduces the risk of AKI.

Thrombosis incidence after recombinant active factor VII administration in paediatric cardiac surgery.

Bleeding following complex congenital cardiac surgery under cardiopulmonary bypass (CPB) is a serious problem. It results from long durations of CPB, hypothermia and the complex anastomoses involved in these procedures.[1,2] The outcomes of intraoperative administration of recombinant activated factor VII (rFVIIa) during paediatric cardiac surgery have not been extensively studied. We aimed to review paediatric cardiac operations involving rFVIIa administration performed at our hospital and compare the incidence of postoperative thrombosis with or without rFVIIa.

MS11.3 Three-Dimensional Virtual and Printed Models Improve Preoperative Planning and Promote Patient-Safety In Complex Congenital and Pediatric Cardiac Surgery

MS11.3 Three-Dimensional Virtual and Printed Models Improve Preoperative Planning and Promote Patient-Safety In Complex Congenital and Pediatric Cardiac Surgery

Role of terminal warm blood cardioplegia in complex congenital heart surgery.

Introduction Myocardial protection is vital to ensure successful open heart surgery. Cardioplegic solution is one method to achieve good myocardial protection. Inevitably, ischemia-reperfusion injury occurs with aortic crossclamping. Histidine-tryptophan-ketoglutarate solution is a frequently used cardioplegia for complex congenital heart surgery. We postulated that addition of terminal warm blood cardioplegia before removal of the aortic crossclamp might improve myocardial protection. Method A randomized controlled trial was conducted on 109 cyanotic patients aged, 1 to 5 years who underwent complex biventricular repair. They were divided into a control group of 55 patients who had histidine-tryptophan-ketoglutarate only and a treatment group of 54 who had histidine-tryptophan-ketoglutarate with terminal warm blood cardioplegia. Endpoints were clinical parameters, troponin I levels, and caspase-3 as an apoptosis marker. Results The incidence of low cardiac output syndrome was 34%, with no significant difference between groups (35.2% vs. 33.3%, p = 0.84). The incidence of arrhythmias in our treatment group was lower compared to the control group (36% vs. 12%, p = 0.005). Troponin I and caspase-3 results did not show any significant differences between groups. For cases with Aristotle score ≥ 10, weak expression of caspase-3 in the treatment group post-cardiopulmonary bypass was lower compared to the control group. Conclusion For complex congenital cardiac surgery, the addition of terminal warm blood cardioplegia does not significantly improve postoperative clinical or metabolic markers.

Thyroid hormone supplementation following open-heart surgery in children

In patients undergoing open-heart surgery, abnormalities in thyroid hormone levels have been observed even in the absence of primary thyroid disease. These abnormal changes in thyroid hormone level and function have been found to be sufficient to affect myocardial performance and postoperative recovery. In the intensive care unit, postoperatively, it has been found that features such as low cardiac output, left ventricular dysfunction and prolonged ventilator support were associated with hypothyroidism. We reviewed the available literature on the effect of thyroid hormone supplementation in paediatric patients undergoing open-heart surgery under cardiopulmonary bypass and concluded that children after complex congenital cardiac surgery are at risk of developing a clinically significant hypothyroid state in the early postoperative period. In the literature where the effects of supplementation of thyroxine were studied, beneficial effects were observed in terms of reduced mechanical ventilation time, reduced inotropic support and intensive care unit stay, rapid achievement of negative fluid balance and early recovery. Supplementation with thyroid hormones enables a smoother postoperative recovery and is beneficial. The total duration of this therapy is, however, unclear.

Trends in Pharmacotherapy for Neonatal Hypotension

To determine trends in pharmacotherapy for neonatal hypotension in all infants and in extremely low birth weight (ELBW, birth weight 300-1000g) infants. We queried the Pediatric Health Information System database for all infants ≤28days with a diagnosis code for hypotension that were discharged between January 2001 and December 2012. Patients were excluded if they had complex congenital heart disease or cardiac surgery, sepsis or meningitis, or had extracorporeal membrane oxygenation. We determined trends in pharmacotherapy for hypotension in all infants and ELBW infants, an especially vulnerable group. A total of 8019 hypotensive infants met study criteria. The 2 most prescribed medications were dopamine (65.3%) and dobutamine (19.9%). For 1487 hypotensive ELBW infants, the 2 most prescribed medications were dopamine (83.4%) and hydrocortisone (33%). During the study period, the use of dobutamine decreased, and hydrocortisone and vasopressin use increased for all infants and for ELBW infants. Treatment of neonatal hypotension varies widely between institutions and individual practitioners, and pharmacotherapy for neonatal hypotension has changed over the past decade. Although dopamine and dobutamine were the most frequently used agents, their use has declined and the uses of hydrocortisone and vasopressin have increased.

Prophylactic fibrinogen administration during complex congenital cardiac surgery leading to thrombosis of a patient’s brachial artery and the cardiopulmonary bypass circuit: a case report

Cardiac surgery represents one of the largest consumers of blood products due to the level of blood loss in these patients. As such, there is considerable interest in hemostatic therapies for this patient population. A hemostatic agent that has recently garnered interest is fibrinogen. The conversion of fibrinogen to fibrin by activated thrombin results in clot formation, leading to hemostasis. Currently, a number of studies are underway to evaluate the efficacy of fibrinogen concentrate in cardiac surgery patients. While potentially beneficial in hemostasis for cardiac patients, the current case report provides evidence of the importance of timing in the administration of this product.

Sickle cell disease and complex congenital cardiac surgery: a case report and review of the pathophysiology and perioperative management

Sickle cell anemia and thalassemia are hemoglobinopathies rarely encountered in the United States. Compounded with congenital heart disease, patients with sickle cell disease (SCD) requiring cardiopulmonary bypass and open-heart surgery represent the proverbial "needle in the haystack". As such, there is some trepidation on the part of clinicians when these patients present for complex cardiac surgery. SCD is an autosomal, recessive condition that results from a single nucleotide polymorphism in the β-globin gene. Hemoglobin SS molecules (HgbSS) with this point mutation can polymerize under the right conditions, stiffening the erythrocyte membrane and distorting the cellular structure to the characteristic sickle shape. This shape change alters cellular transit through the microvasculature. As a result, circumstances such as hypoxia, hypothermia, acidosis or diminished blood flow can lead to aggregation, vascular occlusion and thrombosis. Chronically, SCD can give rise to multiorgan damage secondary to hemolysis and vascular obstruction. This review and case study details an 11-year-old African-American male with known SCD who presented to the cardiothoracic surgical service with congenital heart disease consisting of an anomalous, intramural right coronary artery arising from the left coronary sinus for surgical consultation and subsequent surgical correction. This case report will include a review of the pathophysiology and current literature regarding preoperative, intraoperative and postoperative management of SCD patients.

Strategic and operational aspects of a transfusion-free neonatal arterial switch operation

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.

Postoperative extra-corporeal mechanical support in neonates and infants. Impact of residual lesions on outcome

Objectives: In complex congenital cardiac surgery a better survival can be achived by the postoperative use of mechanical support (ECMO). We examined a single institution experience with postoperative ECMOs in neonates and infants aiming to identify outcome predictors.

Use of recombinant factor VIIa for uncontrolled bleeding in neonates after cardiopulmonary bypass

Increasingly, recombinant activated factor VII (rFVIIa) is used adjunctively in nonhemophiliacs to control hemorrhage unresponsive to conventional therapy in a variety of settings including postcardiopulmonary bypass (CPB). Studies examining rFVIIa administration to neonates after CPB are limited. The goal of this study was to evaluate retrospectively the clinical outcomes of neonates treated at our institution with rFVIIa for uncontrolled post-CPB bleeding. We retrospectively identified eight neonates undergoing complex congenital cardiac surgery who received rFVIIa, either intraoperatively or postoperatively, for uncontrolled post-CPB bleeding. Transfusion trends and prothrombin times (PT) were assessed both pre- and post-rFVIIa administration. Chest tube drainage volumes were recorded pre- and post-rFVIIa administration in those neonates receiving rFVIIa postoperatively in the intensive care unit. We documented such adverse events as thrombosis, dialysis (hemodialysis and peritoneal dialysis), extracorporeal membrane oxygenation (ECMO) and in-hospital mortality. The mean amount of transfused packed red blood cells, platelets and fresh frozen plasma decreased significantly after the administration of rFVIIa. Transfusion of cryoprecipitate trended towards a decrease but did not reach statistical significance. PT values also decreased significantly after the administration of rFVIIa. A high mortality was found in neonates exposed to both rFVIIa and ECMO; however, this was not significantly different from the mortality of neonates exposed to ECMO alone. Administration of rFVIIa to neonates for the treatment of uncontrolled post-CPB bleeding significantly reduced transfusion requirements and normalized PT values. Future randomized, controlled trials are needed to evaluate the potential hemostatic benefit and adverse effects of rFVIIa administration to neonates following CPB.

Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery

Peritoneal dialysis after complex congenital cardiac surgery was introduced to a group of neonates and infants (n = 756; age, 0 to 1 year) between May 1993 and December 2005. Indications of peritoneal dialysis were determined as well as methods, prolonged dialysis, and its outcomes. Demographic characteristics, preoperative risk factors, intraoperative variables, and postoperative complications were compared in 756 cases with ages below 1 year. All cases underwent ultrafiltration during the perioperative stage. One hundred eighty-six cases (24.6% of total) required peritoneal dialysis. The cardiac pathology was transposition of great arteries in 133 cases, tetralogy of Fallot in 37, aorticopulmonary window associated with interrupted aortic arch in 4 and total anomalous pulmonary venous return in 5, and other complex pathology in 7 cases. Prolonged peritoneal dialysis was usually required in infants with low weight, with episodes of pulmonary hypertensive crisis (p < 0.05), and with preoperative renal dysfunction. No major complication was observed related to the peritoneal dialysis catheter. Of 186 patients, 23 (12.3%) had acute renal failure, and 4 of them died (2.15% of all patients underwent operation, 17.3% of those with acute renal failure). It has been demonstrated that the combination of peritoneal dialysis with perioperative ultrafiltration application was effective in providing the required postoperative negative fluid balance in especially complex congenital heart cases and affected survival positively.