Congenital Cardiac Patients Research Articles

Fast-track paediatric and adult congenital cardiac surgery

Background: Aim of the study was to evaluate the benefits and predictors of success of fast-track and ultra-fast track paediatric and congenital cardiac surgery. Methods: Retrospective observational study of paediatric and adult congenital cardiac surgical patients presented for surgery in period between October 2023 and April 2024 at Queen Alia heart institute (QAHI). Patients’ demographic, clinical and perioperative date were collected and analysed. Patients were divided into groups according to their extubation time: UFTE (Ultra-fast track extubation group, FTE (Fast-track extubation) group, CE (Conventional extubation) group and DE (Delayed extubation) group. All groups were compared in reference to their age, weight, CPB time, AXC time, length of ICU stay and hospitalisation time. Statistical analysis was done to determine the benefits of early extubation after paediatric and congenital cardiac surgery. Predictors of early and DE were studied. Results: Data of 73 paediatric and adult congenital cardiac surgical patients was reviewed and analysed. Patients were 37 males and 36 females. Average age of patients was 11.1 years (ranged from 5 days to 57 years). Average weight of patients was 29.3 kg (ranged from 2.4 to 109 kg) and average height was 104.8 cm. Average time of tracheal extubation was 13.1 hours (ranged from 0 to 168 hours). UFTE was accomplished in 11 patients (15.1%). FTE was done in 19 patients (26%). CE (between was 6 and 24 hours) was carried out in 38 patients (52.1%) and DE (after more than 24 hours) was noted in 5 patients (6.8%). The average ICU stay was 3 days (ranged from 1 to 15 days). Patients from the UFTE group had the shortest average ICU stay of 1.2 days, while patients from the FTE group had an average ICU stay of 1.9 days. Patients from the CE and the DE groups had an average ICU stay of 4 days and 9.4 days, respectively. Length of hospitalisation was shortest in the UFTE group with an average of 6 days. The hospitalisation time doubled in the DE group to 12 days. The shorter the CPB and AXC times the more likely patients were to have UFTE and FTE. Neonates were less likely to have UFTE and FTE. Conclusions: UFTE and FTE were associated with shorter ICU stay and hospitalisation time. Predictors of UFTE and FTE were simple cardiac procedures, shorter CPB and AXC durations. Neonatal age and low body weight paediatric cardiac surgical patients were predictors for conventional or DE.

MODIFIED ULTRAFILTRATION IMPROVES LUNG MECHANICS IN CONGENITAL CARDIAC SURGERY - A FACT OR FUTILE: A PROSPECTIVE, OBSERVATIONAL, SINGLE-CENTER STUDY

Objective: Cardiac surgeries involving cardiopulmonary bypass (CPB) can have adverse effects on patients, potentially increasing morbidity. In infants who possess lower blood volume and are exposed to the more artificial surface and larger prime volumes of the CPB, the harmful effects can be significant. Several studies have indicated that modified ultrafiltration (MUF) may yield beneficial effects in cardiac surgery by reducing inflammatory markers, improving hemodynamics, and decreasing excess body water. Our study seeks to evaluate the impact of MUF on pulmonary mechanics in infants undergoing cardiac surgeries on CPB. Methods: This prospective, observational, single-center study was conducted on 56 infants with congenital heart disease, who underwent cardiac surgery, followed by CPB, were included in this study. The primary outcomes were oxygen saturation (SPO2), hemoglobin (Hb), peak inspiratory pressure (Ppeak), and plateau pressure (Pplat). The secondary outcomes were systolic and diastolic invasive blood pressures (IBPs), mean arterial pressure (MAP), mean airway pressure (Pmean), static lung compliance (C-stat), dynamic lung compliance (C-dyn), expiratory resistance (Re), and work of breathing (WOB). Results: A statistically significant increase in SPO2 (98.7 vs. 99.1), Hb (8.3 vs. 13.3), IBPsystolic (85 vs. 90), IBPdiastolic (56 vs. 61.4), and MAP (66.4 vs. 73.2) was observed in congenital cardiac surgery and CPB patients after MUF (all p<0.05). A statistically significant post-procedural decline in Ppeak (18.8 vs. 18.3), Pplat (18.4 vs. 18.1), Re (79.8 vs. 78), and WOB (1.4 vs. 1.3) was also observed (all p<0.05). However, no significant pre-procedural versus post-procedural differences were observed in Pmean, C-stat, and C-dyn (all p>0.05). Conclusion: MUF effectively improved lung mechanics, oxygen saturation, myocardial contractility, hematocrit, and hemodynamics, and minimized the blood transfusion requirement after CPB in infants with congenital heart disease. Future studies should reinvestigate these outcomes with a larger sample size for an extended follow-up duration.

Hospital Resources and Practice Patterns for Congenital Cardiac Surgery in Pakistan: A Nationwide Status Report.

Objective: Low- and middle-income countries such as Pakistan bear the brunt of the global burden of congenital heart disease (CHD), This nationwide study assessed hospital resources and surgical practice patterns pertaining to CHD surgery across Pakistan. Methods: A nationwide hospital facility survey was conducted, targeting all health centers performing CHD surgery in Pakistan. Descriptive data analysis was performed, with categorical variables being presented as frequencies and percentages and continuous variables being reported as means and standard deviations. Results: Seventeen surgeons across 17 different centers participated in the study. Eight of 17 (47%) surgeons were under 45 years of age, while the rest were older than 45 years. More respondents were employed at public/government-owned hospitals (11/17, 65%) and at specialized cardiac centers (13/17, 76%), with a majority of centers reported as having a special ICU designated for congenital cardiac patients (11/17, 65%). With regard to operative volume, 7 of 17 (41%) centers reported more than 350 cases per year, with 7 of 17 reported >10 neonatal cases per year (6/12, 50%). Only one center reported national and international collaborations for research, most centers carrying out less than five research projects in a year. Conclusion: This study has identified key areas that require the attention of local administrative bodies as well as international organizations and societies. The existing centers in Pakistan are unable to meet the demands of the population, leaving a large number of untreated patients, especially for neonatal lesions.

Retrospective Comparison of Recombinant Activated Factor VII Versus 4-Factor Prothrombin Complex Concentrate in Cardiac Surgical Patients

ObjectivesTo compare the incidence of postoperative thrombotic complications, transfusion of blood products, and chest tube output in congenital cardiac surgical patients who received either recombinant activated factor VII (rFVIIa) or four-factor prothrombin complex concentrate (4F-PCC) DesignRetrospective analysis SettingTertiary academic hospital ParticipantsPediatric patients who underwent cardiac surgery. InterventionsNone Measurements and Main ResultsData were obtained from the Society of Thoracic Surgeons and the Pediatric Cardiac Critical Care Consortium databases, as well as from manual chart review. Adjusted p-values were obtained from multivariable regression using age (days), surgeon (number), cardiopulmonary bypass time (minutes), and need for deep hypothermic circulatory arrest (yes/no). We included 55 patients in the 4F-PCC group and 89 in the rFVIIa group. The median dose of rFVIIa was 77 mcg/kg (46-88) and the median dose of 4F-PCC was 31 IU/kg (24-43). The incidence of thrombotic complications was 8% in the 4F-PCC group and 30% in the rFVIIa group (adjusted P= 0.023). No difference was reported between the group in terms of chest tube output on day 1 and 2, or transfusion of blood products. Using a sensitivity analysis with propensity matching, the incidence of thrombosis was 10% in the 4F-PCC group (n=38) and 31% in the rFVIIa group (n=39) (P=0.036). No difference was reported in term of bleeding or transfusion. ConclusionsThis retrospective study suggests that the administration of rFVIIa is associated with a higher risk of thrombotic complications when compared to 4F-PCC without benefits in term of bleeding and transfusions.

Risk stratification of non-cardiac surgeries in adult congenital heart disease

Abstract Background Adults with congenital heart disease (ACHD) face multiple surgeries throughout their lifetime. Data on the specific risk of undergoing non-cardiac surgery and impact of severity of ACHD on outcome are limited. We aimed to assess frequency and outcome of non-cardiac surgery and to identify ACHD patients specifically at risk. Methods Based on data including all hospital admissions in Germany from 2011 to 2018, we identified all ACHD cases that were admitted for non-cardiac surgery. Non-cardiac surgery was categorized in low-, medium and high-risk based on a clinically implemented risk score validated for non-congenital cardiac patients. The analyzed data contained information on patient demographics, diagnoses, in-hospital complications, and mortality. The primary endpoints of the study were major adverse cardiovascular events (MACE), major infection, major bleeding, thromboembolism and in-hospital death. Outcomes of ACHD were compared to a propensity score matched cohort of non-ACHD. Results Overall, 13,041 ACHD inpatient cases were included in the analysis (simple n=9,333 (72%), moderate n=2,741 (21%), and complex heart defects n=966 (7%)). 23.0% simple ACHD underwent low-risk surgery, whilst 31.1% were intermediate and 45.0% high-risk procedures. In the medium complexity ACHD cohort, 35.8% received low-risk, 42.3% intermediate risk and 21.8% high-risk surgery. In complex ACHD, 42.4% underwent low-risk, 41.2% intermediate risk and 16.4% high-risk surgery. Simple ACHD more frequently presented with typical cardiovascular risk factors such as dyslipidemia, arterial hypertension and diabetes mellitus compared to moderately and severely complex ACHD at time of non-cardiac surgery (p<0.001 for all). Compared to a propensity score matched cohort of non-ACHD, congenital cardiac patients more often met the endpoints with an increasing frequency depending on complexity of disease and pre-defined risk of surgery. After adjustment on multivariable logistic regression analysis, moderate and severe complexity of the congenital cardiac defect was associated with an adverse outcome. Risk for death was increased in moderately complex (OR 1.44, 95% CI 1.15 - 1.81, p=0.001) and severely complex ACHD (OR 2.28, 95% CI 1.63 - 3.20, p<0.001) compared to non-ACHD. Compared to low-risk surgeries, patients were at increased risk for death when undergoing mid- (OR 7.66, 95% CI 5.18 - 11.34, p<0.001) or high-risk surgeries (OR 8.03, 95% CI 5.42 - 11.90, p<0.001). Conclusions ACHD patients are at increased risk of adverse complications when undergoing non-cardiac surgery. Risk for adverse outcomes increased with complexity of disease and was generally higher than in non-ACHD individuals. The presented data show that surgical risk classifications implemented for non-congenital cardiac patients were also associated with a much higher adverse outcome in cases undergoing high- versus low-risk procedures.

Myocardial Protection With Remote Ischemic Preconditioning In Congenital Heart Surgery: Does It Deliver What Is Expected?

Objective: The discovery of the protective effects of antioxidant agents on organ functions enabled this system to be tested artificially. The impact of remote ischemic preconditioning (RIPC) on surgical clinical outcomes in patients with congenital heart defects is unclear. This study investigated the early consequences of ischemic preconditioning on cardiac protection. Methods: The study was designed prospectively. Cuffs were applied to one leg of patients in Group 1 (RIPC) after induction of anesthesia in three cycles (5 min inflation followed by 5 min reperfusion) to precondition ischemia-reperfusion. Antioxidant and cardiac marker levels were recorded in blood samples. Results: The patients' surgical median age was 19.1 months (IQR= 3.7- 57.7 months) in Group 1 (RIPC) and 16.7 months (IQR= 7.8- 35.9 months) in Group 2 (Control). The patients' median follow-up period was 58.3 months (IQR= 54.3- 62.1 months) in group 1 and 37.1 months (IQR= 34.8- 41.7 months) in group 2. Hospital mortality was in 7 (10.4%) patients. There was no late mortality. There was a significant difference between the groups in terms of Superoxide Dismutase (SOD) and Malondialdehyde (MDA) levels (p<005). Conclusion: The effects of ischemic preconditioning on cardiac protection have not been proven yet. Especially in congenital cardiac patients, chronic stimuli such as hypoxia and cyanosis or drugs used before surgery may affect the study’s results. Although there is no significant difference in mortality in these patients, a positive effect on the length of hospital stay is promising.

The effects of pulsatile versus nonpulsatile flow on cerebral pulsatility index, mean flow velocity at the middle cerebral artery, regional cerebral oxygen saturation, cerebral gaseous microemboli counts, and short-term clinical outcomes in patients undergoing congenital heart surgery

ObjectiveThe objective of this retrospective review was to evaluate whether or not pulsatile flow improves cerebral hemodynamics and clinical outcomes in pediatric congenital cardiac surgery patients. MethodsThis retrospective study included 284 pediatric patients undergoing congenital cardiac surgery with cardiopulmonary bypass support utilizing nonpulsatile (n = 152) or pulsatile (n = 132) flow. Intraoperative cerebral gaseous microemboli counts, pulsatility index, and mean blood flow velocity at the right middle cerebral artery were assessed using transcranial Doppler ultrasound. Clinical outcomes were compared between groups. ResultsPatient demographics and cardiopulmonary bypass characteristics between groups were similar. Although the pulsatility index during aortic crossclamping was consistently higher in the pulsatile group (P < .05), a significant degree of pulsatility was also observed in the nonpulsatile group. No significant differences in mean cerebral blood flow velocity, regional cerebral oxygen saturation, or gaseous microemboli counts were observed between the perfusion modality groups. Clinical outcomes, including intubation duration, intensive care unit and hospital length of stay, and mortality within 180 days were similar between groups. ConclusionsAlthough the pulsatility index was greater in the pulsatile group, other measures of intraoperative cerebral perfusion and short-term outcomes were similar to the nonpulsatile group. These findings suggest that while pulsatile perfusion represents a safe modality for cardiopulmonary bypass support, its use may not translate into detectably superior clinical outcomes.

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.

Diagnostic Electrophysiology Study: The Auckland Regional Experience

Auckland City Hospital provides electrophysiology (EP) procedures for people residing in the Northern Region and is a national service for paediatric and congenital cardiac patients. Electrophysiology procedures are primarily therapeutic and typically undertaken with a view to ablation. When ablation is not delivered, these procedures are considered diagnostic. This retrospective study was undertaken to explore the clinical characteristics and outcomes of patients who underwent diagnostic EP study. The Auckland City Hospital Electrophysiology Registry was reviewed and patients who underwent an EP procedure without ablation from 1 June 2020 to 31 December 2021 were included. Patient characteristics, indications, procedure prioritisation, study indication, reason for no ablation, antiarrhythmic medications, procedure outcomes, and complications were reviewed. There were 912 procedures, 79 (8.7%) were diagnostic EP studies alone. Patients were aged 3–83 years (median, 41). Ethnicities included NZ European (54%) and Māori (18%). The indication in 56 patients was for an assessment of palpations. The most common reason for no ablation undertaken was no inducible tachycardia (n=36). Other reasons included no accessory pathway identified, high-risk procedure due to proximity to the AV node, and no ablation was intended (i.e., for VT stimulation). There were three reported complications: one moderate pericardial effusion that did not require intervention, one VT/VF arrest, and one access site haematoma. Diagnostic EP studies remain common with acceptable complication rates.

Inhaled Nitric Oxide and Higher Necrotizing Enterocolitis Rates in Congenital Heart Disease Patients

IntroductionCertain congenital cardiac lesions are at increased risk for the development of necrotizing enterocolitis (NEC). These patients are often reliant on pulmonary and systemic vasomodulators to maintain adequate perfusion and oxygenation. This study sought to determine whether pulmonary or systemic vasodilator treatment is protective against the development of NEC in this population. MethodsWe utilized International Classification of Diseases (ICD) codes to identify high risk congenital cardiac disease patients ≤6 mo of age, cared for at a tertiary children's hospital between January 2011 and January 2021. Cardiac anomalies were stratified into ductal dependent (pulmonary DD-P or systemic DD-S) or independent lesions. The rate of NEC development in those who received vasodilators (inhaled nitric oxide [iNO], pulmonary vasodilators, systemic vasodilators) was compared to controls in a multivariate analysis. ResultsOf the 352 patients, who met inclusion criteria, 77.6% had ductal dependent lesions (DD-S 41.9%, DD-P 35.7%), 19.5% received iNO, and 37.5% received other vasodilatory drugs. The overall NEC rate was 15.1%. On univariate analysis, DD-S, iNO use, and systemic vasodilators was associated with a significantly higher risk of NEC, while DD-P was associated with lower NEC risk. On multivariate analysis, only iNO (odds ratio 2.725, confidence interval [1.36-5.44]) and DD-S (odds ratio 2.279, confidence interval [1.02-5.11]) were independent risk factors for NEC. ConclusionsIn patients with at-risk congenital cardiac disease lesions, a ductus dependent systemic circulation or iNO treatment is associated with an increased risk of developing NEC. The presence of iNO or DD-S should be utilized as markers of increased risk both in the prevention and workup of suspected NEC.

Cardiac Children Hospital Early Warning ScoreVersus the Inadequate Oxygen Delivery Index for the Detection of Early Warning Signs of Deterioration.

Single-center longitudinal pilot study. Pediatric cardiac ICU (PCICU), Aga Khan University. C-CHEWS and Inadequate Oxygen Delivery (IDO2) Index calculation every 2 hours. A total of 60 children (0 d to 18 yr old). A single-center longitudinal pilot study was conducted at PCICU. All postoperative extubated patients were assessed and scored between 0 and 11, and these scores were then correlated with the IDO2 index data available from the T3 platform. Adverse events were defined as a need for cardiopulmonary resuscitation, or reintubation, and death. A total of 920 C-CHEWS and IDO2 scores were analyzed on 60 patients during the study period. There were 36 males and 24 females, and the median age of the study population was 34 months (interquartile range, 9.0-72.0 mo). Fourteen patients (23.3%) developed adverse events; these included 9 reintubations and 5 cardiopulmonary arrests, resulting in 2 deaths. The area under the curve (AUC) for C-CHEWS scores fell in an acceptable range of 0.956 (95% CI, 0.869-0.992), suggesting an optimal accuracy for identifying early warning signs of cardiopulmonary arrest. Whereas, IDO2 showed no discriminatory power to detect the adverse events with an AUC of 0.522 (95% CI, 0.389-0.652). The C-CHEWS tool provides a standardized assessment and approach to deteriorating congenital cardiac surgery patients in recognizing early postoperative deterioration.

Effect of modified ultrafiltration in patients undergoing coronary surgery using cardiopulmonary bypass. A literature review

Aim: The purpose of this research is to describe the benefits of modified ultrafiltration (MUF) in cardiac surgery patients, especially in coronary revascularization patients. Introduction: The modified ultrafiltration is the new generation of ultrafiltration, which is used to filtrates the excess water and low molecular weight substances like IL-6, IL-8, TNF and endothelin out of the blood. These excess fluid and low molecular weight substances are the main factors of post-operative complications in coronary artery bypass graft patients. There is limited information about the use of MUF in adult surgery, but is mostly used in congenital cardiac surgery patients. It is found to be very beneficial in pediatric cardiac surgery, but we need more data for using it in adult cardiac surgery Material and Methods: This is a review article; in which we used the articles collected from world’s creditable journals and platforms. These articles have published since 2000. Results: From articles which we reviewed, 17 were about the benefits of MUF in congenital cardiac surgery and 8 articles were about the favorable effects of MUF in adult cardiac surgery. The rest of the articles were related indirectly to the MUF. About 5 of these researches proved the beneficial role of MUF on lungs functions after surgery, in 4 researches confirmed the significant decrease in post-operative bleeding and the need for blood transfusion, in 5 researches it has been measured that the level of inflammatory factors like interleukins, TNF and endothelin were decreased. In 6 articles the role of MUF in welfare of kidney functions were emphasized. And 1 article discussed about the benefits of MUF on cerebral metabolism correction. Nearly in all of the articles it was mentioned that MUF decreases the time of ventilation and vigorous urination after surgery. Conclusion: Modified ultrafiltration (MUF) is a technique which decreases the post-operation complications due to cardio-pulmonary bypass, and could be beneficial in CABG patients.

Inhaled Nitric Oxide Treatment Is Associated with Higher Rates of Necrotizing Enterocolitis in At-risk Congenital Cardiac Disease Patients

INTRODUCTION: Certain congenital cardiac lesions are at increased risk for the development of necrotizing enterocolitis (NEC). These patients with these lesions are often reliant on pulmonary and systemic vasomodulators to maintain adequate perfusion and oxygenation. This study sought to determine whether pulmonary or systemic vasodilator treatment is protective against the development of NEC in this population. METHODS: We used ICD codes to identify high-risk congenital cardiac disease patients ≤6 months of age, cared for at a tertiary children’s hospital between January 2011 and January 2021. Cardiac anomalies were stratified into ductal-dependent (pulmonary DD-P or systemic DD-S) or independent lesions. The rate of NEC development in those who received vasodilators (inhaled nitric oxide [iNO], pulmonary vasodilators, systemic vasodilators) was compared with controls in a multivariate analysis. RESULTS: Of the 353 patients who met inclusion criteria, 77.6% had ductal-dependent lesions (DD-S 41.9%, DD-P 35.7%), 19.5% received iNO, and 51.8% received other vasodilatory drugs. The overall NEC rate was 15.3%. On univariate analysis, DD-S, iNO use, and systemic vasodilators had a significantly higher risk of NEC, and DD-P was associated with lower NEC risk (Figure). On multivariate analysis, only iNO (odds ratio 2.725 [CI 1.36 to 5.44]) and DD-S (odds ratio 2.279 [CI 1.02 to 5.11]) were independent risk factors for NEC.FigureCONCLUSION: In patients with at-risk congenital cardiac disease lesions, a ductus-dependent systemic circulation and/or iNO treatment increases the risk of developing NEC. The presence of iNO or DD-S should be used as a marker of increased risk both in the prevention and workup of suspected NEC.

Management of pediatric sternal wounds following congenital heart surgery: The role of the plastic surgeon in debridement and closure.

Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single-institution experience with pediatric SWIs. Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival. Of the 14 patients, 8 (57%) were diagnosed with culture-positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities. The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.

Commentary: Small patients with big wounds.

Some would argue that kids aren't just little adults, but what about their sternums? We are reviewing a manuscript by Horriat, McCandless, and colleagues in the Journal of Cardiac Surgery describing their experience with managing sternal wound infections (SWI) after congenital heart surgery. They report encouraging results in 14 patients who required plastic surgery consultation to manage their sternal wounds. The nature of congenital cardiac abnormalities and the necessary steps to repair them leads to physiologic derangements predisposing patients to SWI. Rates of SWI vary and have been reported at 1.53% in this population. There is little guidance on how the management of the congenital cardiac surgery patient should differ from the adult patient.

Perioperative Management of an Adolescent Fontan Patient with Narrowing of the Aortopulmonary Space for Posterior Scoliosis Surgery

Congenital cardiac patients who received neonatal reconstructive aortic arch surgery are at risk of aortopulmonary space narrowing with compression of the left pulmonary artery and left main bronchus (LMB) later in life. We discuss a challenging adolescent single ventricle patient who presented for surgical treatment of a non-idiopathic thoracic scoliosis (posterior spinal fusion) with severe stenosis of the LMB and left pulmonary artery due to a narrow aortopulmonary space. Careful preoperative imaging, evaluation, and decision making resulted in successful surgical treatment and uneventful perioperative course.

Abstract P1040: The Protective Effects Of Sialidase Neu3 Against Cardiac Ischemia And Reperfusion Injury

The salvage of myocardium after acute myocardial infarction (AMI) can only be achieved by timely reperfusion. This is life-saving, however it may also lead to additional damage in the form of ischemia and reperfusion injury (IRI). Protecting cardiac tissue from IRI remains one of the greatest unmet clinical needs in cardiology. Therefore, a better understanding of IRI pathophysiology is necessary. There has been increasing recognition that the activation of specific molecular mechanisms, including the Reperfusion Injury Salvage Kinase (RISK) pathway and HIF-1&amp;#945; contributes to cardioprotection against IRI. Along this line, we previously reported that sialidase Neu3, which removes sialic acid from glycosphingolipids, controls HIF-1&amp;#945; activation via a prolyl hydroxylase-independent pathway. In fact, we found that Neu3 was up-regulated under chronic hypoxia in cyanotic congenital cardiac patients and its overexpression increased muscle cells’ resistance to hypoxic stress by activating the RISK pathway. In light of these premises, the goal of this study was to determine Neu3's involvement in the cardiac response to IRI and establish whether its inducible activation could promote cardioprotection. An IRI model in mice, obtained by temporarily blocking the LAD coronary artery, showed that Neu3 is modulated during this process. Notably, Neu3 showed progressive downregulation during the ischemic phase followed by its reactivation during reperfusion. These results were similar to the Neu3 modulation we observed in human cardiac cells (AC16) exposed to an IRI model in vitro . The overexpression of Neu3 during ischemia had beneficial effects both in terms of cell proliferation and reduction of oxidative stress after reperfusion. We found that Neu3 promotes the activation of glycolytic enzymes during the ischemic phase as well as the maintenance of the mitochondrial membrane potential, suggesting that the Neu3-overexpressing human cardiomyocyte undergoes more aerobic metabolism even in oxygen-deficient environments. In conclusion, these results support a role for Neu3 in cardioprotection against IRI, suggesting that it may be a useful therapeutic target for improving the recovery of patients who have undergone acute myocardial infarction.

A Randomized Clinical Trial of Perfusion Modalities in Pediatric Congenital Heart Surgery Patients

BackgroundThe objective of this randomized clinical trial was to investigate the effects of perfusion modalities on cerebral hemodynamics, vital organ injury, quantified by the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score, and clinical outcomes in risk-stratified congenital cardiac surgery patients. MethodsThis randomized clinical trial included 159 consecutive congenital cardiac surgery patients in whom pulsatile (n = 83) or nonpulsatile (n = 76) perfusion was used. Cerebral hemodynamics were assessed using transcranial Doppler ultrasound. Multiple organ injury was quantified using the PELOD-2 score at 24, 48, and 72 hours. Clinical outcomes, including intubation time, intensive care unit length of stay (LOS), hospital LOS, and mortality, were also evaluated. ResultsThe Pulsatility Index at the middle cerebral artery and in the arterial line during aortic cross-clamping was consistently better maintained in the pulsatile group. Demographics and cardiopulmonary bypass characteristics were similar between the 2 groups. While risk stratification with The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Categories was similar between the groups, Mortality Categories 1 to 3 demonstrated more patients than Mortality Categories 4 and 5. There were no differences in clinical outcomes between the groups. The PELOD-2 scores showed a progressive improvement from 24 hours to 72 hours, but the results were not statistically different between the groups. ConclusionsThe Pulsatillity Index for the pulsatile group demonstrated a more physiologic pattern compared with the nonpulsatile group. While pulsatile perfusion did not increase plasma-free hemoglobin levels or microemboli delivery, it also did not demonstrate any improvements in clinical outcomes or PELOD-2 scores, suggesting that while pulsatile perfusion is a safe method, it not a “magic bullet” for congenital cardiac operations.

Retrospective Evaluation of Platelet-Leukocyte Indices and Cardiac Surgical Outcomes in Acyanotic Heart Disease Patients with Pulmonary Hypertension (REPLICA-PH).

Acyanotic congenital heart disease (ACHD) patients with pulmonary hypertension (PH) are prone to postoperative complications, and characterization of the risk profile continues to fail in identifying inflammatory predilection. Our objective is to investigate the role of platelet-leukocyte indices (neutrophil-lymphocyte ratio [NLR], platelet-lymphocyte ratio [PLR], and systemic immune-inflammation index [SII] [neutrophil × platelet/lymphocyte]) in predicting poor outcomes following cardiac surgery in ACHD cohort with preoperative PH. This single-center, retrospective risk-predictive study included ACHD patients undergoing surgical correction at our tertiary cardiac center between January 2015 and December 2019. Standard institutional perioperative management protocol was followed, and poor postoperative outcome was defined as ≥ 1 of: low cardiac output syndrome, new-onset renal failure, prolonged mechanical ventilation (MV > 24 hours), stroke, sepsis, and/or death. One hundred eighty patients out of 1,040 (17.3%) presented poor outcome. On univariate analysis, preoperative factors including right ventricular systolic pressure (RVSP) (PH-severity marker), congestive heart failure, albumin, NLR, PLR, SII, and aortic cross-clamping (ACC) and cardiopulmonary bypass (CPB) times predicted poor outcome. However, on multivariate analysis, RVSP, NLR, SII, and ACC and CPB times emerged as independent predictors. An NLR, SII prognostic cutoff of 3.33 and 860.6×103/mm3 was derived (sensitivity: 77.8%, 78.9%; specificity: 91.7%, 82.2%; area under the curve: 0.871, 0.833). NLR and SII values significantly correlated with postoperative MV duration, mean vasoactive-inotropic scores, and length of intensive care unit and hospital stay (P<0.001). Novel parsimonious, reproducible plateletleukocyte indices present the potential of stratifying the risk in congenital cardiac surgical patients with pre-existing PH.

Lymphatic Endothelial Cell Defects in Congenital Cardiac Patients With Postoperative Chylothorax

Objectives:Chylothorax following cardiac surgery for congenital cardiac anomalies is a complication associated with severe morbidities and mortality. We hypothesize that there are intrinsic defects in the lymphatics of congenital cardiac patients.Methods:Postsurgical chylothorax lymphatic endothelial cells (pcLECs) (n = 10) were isolated from the chylous fluid from congenital cardiac defect patients, and characterized by fluorescent-activated cell sorting, immunofluorescent staining, and quantitative RT-PCR. Results were compared to normal human dermal lymphatic endothelial cells (HdLECs). pcLECs (n = 3) and HdLECs were xenografted into immunocompromised mice. Implants and postoperative chylothorax patient’s pulmonary tissues were characterized by immunostaining for lymphatic endothelial proteins.Results:pcLECs expressed endothelial markers VECADHERIN, CD31, VEGFR2, lymphatic endothelial markers PROX1, podoplanin, VEGFR3, and progenitor endothelial markers CD90 and CD146. However, pcLECs had key differences relative to HdLECs, including altered expression and mislocalization of junctional proteins (VECADHERIN and CD31), and essential endothelial proteins, VEGFR2, VEGFR3, and PROX1. When xenografted in mice, pcLECs formed dilated lymphatic channels with poor cell–cell association. Similar to congenital lymphatic anomalies, the pulmonary lymphatics were dilated in a patient who developed postoperative chylothorax after cardiac surgery.Conclusions:Recent studies have shown that some postoperative chylothoraces in congenital cardiac anomalies are associated with anatomical lymphatic defects. We found that pcLECs have defects in expression and localization of proteins necessary to maintain lymphatic specification and function. This pcLEC phenotype is similar to that observed in lymphatic endothelial cells from congenital lymphatic anomalies. Co-existence of lymphatic anomalies should be considered as a feature of congenital cardiac anomalies.