Congenital Heart Surgery In Children Research Articles

Indications and outcomes of cardiac catheterization following congenital heart surgery in children

Indications and outcomes of cardiac catheterization following congenital heart surgery in children

Short-term outcomes following congenital heart surgery in children with Down syndrome

Background Children with Down syndrome (DS) differ from typical children because of many genetic-related aspects that may affect outcomes after congenital heart surgery. To date, there have been no studies on outcomes after congenital heart surgery on pediatric DS patients in Indonesia.
 Objective To determine outcomes and mortality in DS patients who underwent heart surgery at Dr. Cipto Mangunkusumo Hospital, Jakarta.
 Methods A prospective and retrospective cohort study was conducted in DS patients aged <15 years who underwent heart surgery from July 2007 to April 2015. The control group were patients in the same age range without DS who underwent heart surgery for various types of heart defects.
 Results There were 57 DS and 43 non-DS patients during study period. The types of heart defects found in DS patients were atrioventricular septal defect (AVSD) and ventricular septal defect (VSD) in 18/57 (31.6%) patients each, tetralogy of Fallot (12/57; 21%), atrial septal defect (ASD) (4/57; 7%), patent ductus arteriosus (PDA) (4/57; 7%) and transposition of the great arteries with VSD (TGA-VSD) (1/57; 1.8%). DS patients showed an increased incidence of preoperative PH (63.1%) compared to non-DS patients (25.6%). Median duration of surgery was longer in DS [2.9 (range 0.5-5.8) hours] than in non-DS [2.2 (range 0.7-4.7) hours]. DS patients have a longer mean cardiopulmonary bypass duration [79.5 (SD 33.9) minutes] compared to non-DS [59.9 (SD 23.6) minutes], longer mean aortic cross-clamp duration [45.3 (SD 23.7) minutes] compared to non-DS [34.8 (SD 15.7)]. There were significant differences in the incidence of preoperative pulmonary hypertension, surgical time, duration of cardiopulmonary bypass (CPB), and length of the aortic cross-clamp in DS patients compared to non-DS (P<0.05). Median length of ICU stay was 1.9 (range 0.6 to 34) days in DS and 1 (range 0.3 to 43) day in non-DS patients (P=0.373). Median duration of mechanical ventilation [19.9 (range 3-540) vs. 8 (range 3-600) hours (P=0.308)], rate of pulmonary complications [14/57 (24.6%) vs. 6/43 (14%) patients (P=0.216)], and incidence of sepsis [16/57 (28.1%) vs. 6/43 (14%) patients (P=0.143)] were not significantly different between DS and non-DS patients. However, complete atrioventricular (AV) block only occurred in DS patients [6/57 (10.5%)]. In the DS group, 5/57 (8.8%) patients died. There was no mortality in the non-DS group.
 Conclusion Morbidity and mortality after cardiac surgery in were higher in DS than in non-DS patients. DS patients may have problems related to preoperative PH, AV block, longer surgical time, duration of CPB, and aortic cross-clamp compared to non-DS.

Early Cardiac Catheterizations within 30 Days Post Congenital Heart Surgery in Children

Background: This study set out to assess the indications, feasibility, safety, and outcome of early cardiac catheterizations (CC) within 30 days after congenital heart surgery (CHS) in children. Methods and Results: This is a retrospective, single-center case review study of all CC within 30 days after CHS between 1/2010-12/2020. A total of 317 (138 diagnostic, 179 interventional) CC were performed in 245 patients at a median of 4 days (IQR 13) after CHS. The median age was 3 months (IQR 6), and body weight was 5 kg (IQR 4). A total of 194 (61.2%) CC were performed in patients with univentricular hearts. CC revealed significant pathologies leading to early redo-surgery in 37 patients (12%). The transcatheter interventions primarily were needed in patients after cavo-pulmonary connection (n = 69%, 21.8%), right ventricle to pulmonary artery conduit (n = 39%, 12.3%), and Norwood-I surgery (n = 34%, 10.7%) presenting with hypoxemia, prolonged postoperative course, and suspected arterial stenosis on echocardiography. The clinical impact of an early postoperative transcatheter intervention for the following clinical course was high in most cases. There were nine (2.8%) major and 20 (6.3%) minor intra-procedural complications. Risk factor analysis revealed no difference for the occurrence of complications for patients’ age, weight, and time from initial CHS, underlying uni- vs. biventricular heart disease, or ECMO. Conclusion: Early CC within 30 days after CHS in children can be performed safely with a high diagnostic and therapeutic value. The rate of complications is low, while the therapeutic consequence is relevant.

Indications and outcomes of cardiac catheterization following congenital heart surgery in children.

Our goal was to evaluate the indications for postoperative cardiac catheterizations after paediatric cardiac surgeries and their impact on outcomes. Non-planned cardiac catheterizations performed after congenital heart surgeries and before discharge between January 2013 and July 2019 were reviewed. Hybrid procedures were excluded. Heart defects, illness course, surgeries and catheter procedures were classified. Indications and findings were comprehensively regrouped. Outcomes were analysed. Cardiac catheterizations were performed on 192 patients (median age 2.3 months, weight 4.2 kg) on median postoperative day 7 (interquartile range, 2-17 days). Patients had defects of great complexity (79.9%), high disease severity index (46.4%), high Aristotle level of surgical complexity (75%) and a high Catheterization RISk Score for Pediatrics category of catheterizations (61%). Catheterizations confirmed 66% of suspected diagnoses. Confirmed diagnoses were more likely to be haemodynamic anomalies than anatomical lesions (81.3% > 53.7%, P < 0.001). Confirmed anatomical lesions were more likely to be residual than new lesions created by surgery (88.5% > 40.4%, P < 0.001). New diagnoses were identified in 36.5% of patients. Catheterization findings led to catheter-based or surgical interventions in 120 (62.5%) patients. Transcatheter interventions were successful (97.7%), immediate (89.5%) and performed across fresh suture lines (27.8%). Repeat catheterizations (76% interventional) were necessary in 25 (13%) patients. A high index of disease severity [odds ratio (OR): 16.26, 95% confidence interval (CI): 3.72-71.17], extracorporeal membrane oxygenation support (OR: 10.35, 95% CI: 2.78-38.56), delayed sternal closure (OR: 4.66, 95% CI: 1.25-17.32) and surgically acquired lesions (OR: 3.70, 95% CI: 1.22-11.16) were significant risk factors of 12-month mortality. Postoperative cardiac catheterizations answer both anatomical and haemodynamic questions in high-risk patients with complicated courses and guide subsequent treatment with satisfactory outcomes.

Impact of obesity on post-operative arrhythmias after congenital heart surgery in children and young adults.

Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery. Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2-20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5-85, overweight 85-95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis. There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive-inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias. Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.

Indications and outcomes of cardiac catheterization following congenital heart surgery in children

To evaluate indications of post-operative cardiac catheterization procedures (POCCPs) after pediatric cardiac surgery and their impact on outcomes. POCCP is proposed in a variety of situations. Clinical impact of diagnostic POCCPs and transcatheter interventions (TCIs) remain scarcely described. Non-planned POCCPs performed after congenital heart surgeries and before hospital discharge between January 2013 and July 2019 were reviewed. Hybrid procedures were excluded. Heart defects, illness course, surgeries, and POCCPs were classified. Indications and findings were comprehensively regrouped. Outcomes were analyzed. Two hundred and seventeen POCCPs were performed on 192 patients (median age 2.3months, weight 4.2 kg) on median postoperative-day 8 (IQR 2-20days). Patients had defects of great complexity (79.9%) and a high disease severity index (46.4%). Aristotle's complexity level of surgeries was III (27.6%) and IV (47.4%). POCCPs CRISP category was 4 (39.6%) and 5 (22.6%). POCCPs identified 70 (32.3%) new diagnostic information. POCCPs confirmed 67.1% of suspected diagnoses: anatomical lesions were less likely to be confirmed when compared to physiological anomalies (55.6% < 81.7%, P < 0.01). Surgically-acquired lesions were less likely confirmed when compared to residual lesions ( P < 0.01). In confirmed diagnoses, POCCP indicated interventions (74.1%), and changes in medical management (25.9%). Interventions (133 TCIs, 16 redo-surgeries) were successful (97%) and immediate (92.6%). TCIs were unplanned (38.3%) and performed across fresh suture lines (30.1%). Eight significant adverse events were recorded and survival to discharge was 87.5%. POCCP provides adequate answers for both anatomical and physiological questions in high-risk patients with complicated courses. POCCP guides appropriately subsequent treatment with high efficiency and satisfactory outcomes.

Early postoperative arrhythmias in patients undergoing congenital heart surgery.

Background This study aims to evaluate early postoperative arrhythmias in children undergoing congenital cardiac surgery. Methods A total of 670 pediatric patients (355 males, 315 females; median age: 4 months; range, 1 day to 18 years) who underwent cardiac surgery due to congenital heart defects between December 2018 and November 2019 were included. The rate of postoperative arrhythmias, diagnosis, potential risk factors, and management strategies were evaluated. Multivariate regression analysis was used to identify significant factors of development of postoperative arrhythmias. Results Tachyarrhythmia was detected in 54 patients (8.1%), and the most common tachyarrhythmia was junctional ectopic tachycardia. Medical treatment was required in 25/38 (66%) of junctional ectopic tachycardia patients. Amiodarone was initiated in 18, dexmedetomidine in five, and flecainide + amiodarone in two of the patients. Different degrees of atrioventricular block were observed in 30 patients (4.5%). In 12 patients, permanent pacemakers were implanted during hospitalization. Age at the time of surgery under one-year-old, high inotropic scores, prolonged operation time, and high Aristotele"s scores were independent risk factors associated with early postoperative arrhythmia (p<0.05). The most common operations associated with early postoperative arrhythmia were left ventricular outflow tract, (6/20, 30%), complete atrioventricular septal defect (13/53, 24%), and tetralogy of Fallot (20/134, 14%) surgeries. Conclusion Cardiac arrhythmias are common in the early period after congenital heart surgery in children. The diagnosis and frequency of arrhythmias may vary according to different surgical procedures.

Single-center experience of extracorporeal membrane oxygenation in children with biventricular physiology in the postoperative period

Aim . To assess the efficacy and safety of venoarterial ECMO in the early postoperative period after congenital heart surgery in children with biventricular physiology, to evaluate the recovery of ventricular contractile function, and to determine predictors able to predict the outcome of treatment and the prognosis of the disease. Methods . 15 medical records of pediatric patients treated in the period from 2016 to 2018 were retrospectively reviewed in a single-center study. The short-term outcomes of venoarterial ECMO in the early postoperative period were examined. Patients aged 1 month to 18 years were selected for the study. The median age of patients undergoing congenital heart surgery was 5 months (from 1 month to 4 years). 60% of them were male. Results . ECMO was started in the postoperative period due to inability to go off-pump in 5 OR patients (33.3%), postoperative circulatory arrest in 4 patients (26.7%), and low cardiac output syndrome in 6 patients (40%). The median body weight was 5.7 kg (from 3.7 to 15.6 kg). 14 patients underwent biventricular surgery. One patient underwent palliative repair, and then was referred to the total repair. The mean cardiopulmonary bypass time was 103.6 (±62.3) minutes with the aortic cross-clamp time of 51.9 (±27.3) minutes. 12 patients (80%) were disconnected from ECMO. The overall hospital survival was 66.7% (10 patients). The mean duration of ECMO support in survivors was 118.4 (±37.5) hours. Conclusion . The survival of patients improves with the steeper learning curve. ECMO contributes to the improved ventricular contractile function. Prolonged ECMO increases the number of specific complications associated with the procedure and affects survival. Our single-center experience in pediatric ECMO is generally consistent with the national and global trends in the use of mechanical support for intensive care.

Con: Extubation in the Operating Room After Pediatric Cardiac Surgery

ENHANCED RECOVERY AFTER surgery (ERAS) protocols have been implemented in adult and pediatric cardiac surgery patients and are designed to facilitate recovery, minimize cost, and decrease intensive care unit (ICU) and hospital length of stay (LOS). 1 Mittnacht Aj Thanjan M Srivastava S et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg. 2008; 136: 88-93 Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar ,2 Neirotti RA Jones D Hackbarth R et al. Early extubation in congenital heart surgery. Heart Lung Circ. 2002; 11: 157-161 Abstract Full Text PDF PubMed Scopus (51) Google Scholar These protocols target multiple components of perioperative care, including hemostasis, hemodynamic stability, timing of extubation, sedation and analgesia, postoperative nausea, vomiting prophylaxis, and treatment.

Causes of Death after Congenital Heart Surgery in Children

<b>Background:</b> This retrospective cohort study aimed to explore the causes of death in children with congenital heart disease (CHD) after cardiac surgery in one of the biggest cardiac centers for children with CHD in China. <b>Methods:</b> A total of 26,856 children undergoing cardiac surgery from January 1, 2012 to December 31, 2019 were included. Based on the clinical data, the causes of death were divided into ten categories and further compared among different periods, types of CHD and surgical procedures. <b>Results:</b> Of all patients, 513 (1.9%) died (median age 162 d, median weight 5.6 kg). The mortality in 2016–2019 was lower than that in 2012–2015 (1.4 ± 0.3% <i>vs</i>. 2.5 ± 0.3%, <i>p</i> = 0.005). A total of 42.5% of children died of heart failure, and 32.9% died of residual anatomic defects. Patients with transposition of the great arteries tended to die from residual anatomic defects (21.9%), while those with double-outlet right ventricle (20%) and single ventricle (20%) tended to die from pulmonary hypertension (PH) (<i>p</i> = 0.006). After biventricular repair, children tended to die from heart failure (90.4%), while after single-ventricle repair, children tended to die from PH (50%) (<i>p</i> < 0.0001). There is a negative correlation between mortality and the ECMO implantation rate (<i>r</i> = −0.898, <i>p</i> = 0.002). <b>Conclusions:</b> Heart failure and residual anatomic defects were the main causes of death after cardiac surgery. The cause of death patterns differed among CHD types and surgical strategies. ECMO may be a life-saving tool when other conventional therapies do not work.

Catheterization Performed in the Early Postoperative Period After Congenital Heart Surgery in Children.

The aim of this study was to describe pediatric patients who underwent early postoperative cardiac catheterization after congenital heart surgery, their clinical indications, findings, interventions, and complications in a cardiovascular center. A descriptive retrospective study was performed. All catheterizations performed within 6weeks after congenital heart surgery between January 2004 and December 2014 were reviewed. We analyzed 101 early postoperative catheterizations. They were performed on median postoperative day five (IQR: 0-39); the median age was 64days (IQR: 22-240). The most common diagnoses were single ventricle (53%), left heart obstruction (12%), and tetralogy of fallot or pulmonary atresia with ventricular septal defect (11%). Most common indications were persistent cyanosis (53%), low cardiac output (24%), and residual defect on echocardiogram (20%). Most frequent findings during the catheterization were pulmonary artery stenosis (29%), surgical conduit obstruction (12%), and coarctation or hypoplasia of the aorta (11%). Forty-six (45%) procedures involved intervention. Most frequent interventions were pulmonary artery, aorta, and Blalock-Taussig fistula angioplasty with or without stent implantation. There were adverse effects in 11 cases (11%), and 30-day mortality was 28% (28 patients) with the majority unrelated to the catheterization directly. Although early postoperative catheterizations are high-risk procedures, they are currently a very good option to solve acute problems in critically ill patients. This study provides relevant information for a better understanding and approach to this complex group of patients.

Does young age really put the heart at risk?

Despite significant advances in the management and treatment of heart disease in children, there continue to be patients who have worse outcomes than might be expected. A number of risk factors that could be responsible have been identified. Evidence-based findings will be reviewed, including whether young age and (or) reduced body weight exacerbate these responses. For example, newborn children undergoing congenital cardiac surgery are known to have worse outcomes than older children. Evidence exists that newborn hearts do not tolerate ischemia as well as adult hearts, developing irreversible injury sooner and exhibiting at-risk metabolic profiles. As well, in response to the administration of heparin, elevations in free fatty acids occur during congenital heart surgery in children, which can have detrimental effects on the heart. Furthermore, myocardial energetic state has also been suggested to impact outcomes. Unfavourable energetic profiles were correlated to lower body weights in the same age healthy newborn piglet model. Newborn children suffering from congenital heart disease, with lower body weights, also had lower myocardial energetic state and this correlated with longer postoperative ventilatory support as well as a trend to longer intensive care unit stay. These findings imply that unfavourable myocardial metabolic profiles could contribute to postoperative complications.

Practice Patterns in Postoperative Echocardiographic Surveillance after Congenital Heart Surgery in Children: A Single Center Experience

To review current institutional practice and describe factors contributing to variation in inpatient postoperative imaging surveillance after congenital heart surgery. We reviewed records of all children who underwent congenital heart surgery from June to December 2014. Number and primary indications for postoperative transthoracic echocardiograms (TTEs), providers involved, cardiovascular intensive care unit (CVICU) and total hospital length of stay, and Risk-Adjustment for Congenital Heart Surgery-1 scores were recorded. A total of 253 children (age at surgery: 8 months [2 days-19 years]) received 556 postoperative TTEs (median 1 TTE/patient [1-14]), and 23% had ≥3 TTEs. Fifteen of 556 TTEs (2.7%) revealed a new abnormal finding. The majority of TTEs (59%) were performed in the CVICU (1.5 ± 1.1 TTEs/week/patient), with evaluation of function as the most common indication (44%). Attending physician practice >10 years was not associated with fewer TTEs (P = .12). Patients with ≥3 TTEs had higher Risk-Adjustment for Congenital Heart Surgery-1 scores (P = .001), longer CVICU lengths of stay (22 vs 3 days; P < .0001), longer overall hospitalizations (28 vs 7 days; P < .0001), and a higher incidence of mechanical circulatory support (10% vs 0%; P < .0001) than those with <3 TTEs. Eight patients with ≥3 TTEs did not survive, compared with 3 with <3 TTEs (P = .0004). There was wide intra-institutional variation in echocardiographic use among similar complexity surgeries. Frequency of postoperative echocardiographic surveillance was associated with degree of surgical complexity and severity of postoperative clinical condition. Few studies revealed new abnormal findings. These results may help establish evidence-based guidelines for inpatient echocardiographic surveillance after congenital heart surgery.

Implementation of a Quality Improvement Bundle Improves Echocardiographic Imaging after Congenital Heart Surgery in Children

Postoperative echocardiography after congenital heart disease surgery is of prognostic importance, but variable image quality is problematic. We implemented a quality improvement bundle comprising of focused imaging protocols, procedural sedation, and sonographer education to improve the rate of optimal imaging (OI). Predischarge echocardiograms were evaluated in 116 children (median age, 0.51years; range, 0.01-5.6years) from two centers after tetralogy of Fallot repair, arterial switch operation, and bidirectional Glenn and Fontan procedures. OI rates were compared between the centers before and after the implementation of a quality improvement bundle at center 1, with center 2 serving as the comparator. Echocardiographic images were independently scored by a single reader from each center, blinded to center and time period. For each echocardiographic variable, quality score was assigned as 0 (not imaged or suboptimally imaged) or 1 (optimally imaged); structures were classified as intra- or extracardiac. The rate of OI was calculated for each variable as the percentage of patients assigned a score of1. Intracardiac structures had higher OI than extracardiac structures (81% vs 57%; adjusted odds ratio [OR], 3.47; P<.01). Center 1 improved overall OI from 48% to 73% (OR, 4.44; P<.01), intracardiac OI from 69% to 85% (OR, 3.53; P=.01), and extracardiac OI from 35% to 67% (OR, 5.16; P<.01). There was no temporal difference for center2. After congenital heart disease surgery in children, intracardiac structures are imaged more optimally than extracardiac structures. Focused imaging protocols, patient sedation, and sonographer education can improve OI rates.

The role of dexmedetomidine in fast-track extubation for closed congenital heart surgery in children: a randomized double-blinded placebo-controlled trial

Background The definition of early extubation is not well-established; some authors extended its time to 24 h postoperatively. In our study, we tried to extubate the patients by the end of the surgery. We investigated the role of dexmedetomidine use during induction of anesthesia in the improvement of outcomes with fast-track extubation in children undergoing cardiac surgery. We assumed that the use of dexmedetomidine will help in extubating the patients at the end of operation with decreased use of inhalational anesthetic and fentanyl, thus improving oxygenation and decreasing the need for analgesia postoperatively. Patients and methods A study was conducted in a population of 84 pediatric patients scheduled for closed congenital heart surgery. Patients were randomly allocated to two groups: group D (42 patients), which received a single dose of dexmedetomidine 0.4 mg/kg over 10 min in the induction of anesthesia, and group C (42 patients), which received normal saline. Both groups were compared in relation to percentage of extubated patients by the end of the surgery as primary outcome. Hemodynamics (mean arterial blood pressure and heart rate), sevoflurane consumption, fentanyl consumption, incidence of postoperative infection, and length of ICU stay were recorded. Arterial blood gases were analyzed before extubation and in the ICU 1 and 3 h after transfer to the ICU. Results Compared with the control group, group D showed lower intraoperative sevoflurane and fentanyl consumption (14.2±2.9 vs. 37.8±24.1, P Conclusion Adding dexmedetomidine as an adjuvant to induction of anesthesia in children undergoing congenital heart surgery improved the success of extubation, the oxygenation, and decreased the length of hospital stay.

The Impact of Rhinovirus Infections in Paediatric Cardiac Surgery (Risk): Study Protocol for a Prospective Cohort Study

Background: Respiratory infections are considered a potential risk of adverse events in children undergoing surgery. Rhinovirus is a common cause of respiratory infections and congenital heart disease is a risk factor for severe rhinovirus infection. However, we do not know what the impact of, clinical or subclinical, rhinovirus infections is on postoperative course following congenital heart surgery in children. Based on our clinical experience, one case-controlled study, and a case reported in the literature, we hypothesize that paediatric patients with per-operative rhinovirus positive Polymerase Chain Reaction testing have a longer paediatric intensive care unit admission, compared to children who test negative. Methods/Design: This is a prospective single-center observational study in the Leiden University Medical Center with approximately 250 children (<12 years) undergoing elective cardiac surgery, for congenital heart disease. The parents/guardians of the children will be asked to fill out a questionnaire, to asses respiratory symptoms in the last weeks, before the operation of their child. In the operating theatre, a nasopharyngeal swab will be collected. Clinical data will be collected daily during paediatric intensive care admission and paediatric intensive care unit and hospital length of stay will be recorded. If children are still intubated at day 4, a second nasopharyngeal swab and residual blood will be collected. The samples will be tested for rhinovirus with polymerase chain reaction. Primary outcome is the paediatric intensive care unit length of stay in per-operative rhinovirus-positive compared to rhinovirus-negative patients. Discussion: This is the first study to screen children for rhinovirus before undergoing cardiac surgery and to study the effects on paediatric intensive care unit length of stay. Furthermore, we aim to identify children at risk for prolonged paediatric intensive care admission after cardiac surgery.

Totally endoscopic congenital heart surgery compared with the traditional heart operation in children

SummaryObjectiveTotally endoscopic surgery compared with the conventional heart operation in children is described in this article to find a preferable treatment for congenital heart diseases.MethodsBetween May 2000 and December 2007, 708 children with congenital heart disease were divided into two groups: endoscopic group and conventional group. For the endoscopic group, all children underwent total endoscopic procedures with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia, whereas for the conventional group, all children were operated in traditional way. Three 1–2-cm intercostal ports in the right chest were used for access in the endoscopic group. The intrathoracic part of the operation was performed completely under two-dimensional video, using conventional instruments. Directly closureed of the atrial septal defect was performed in 74 cases, patch closureed of the atrial septal defect in 48 cases, directly closureed of the ventricular septal defect in 158 cases, patch closureing of the ventricular septal defect in 116 cases. For the conventional group, all operations were done with traditional median sternotomy. Directed closureing of the atrial septal defect was performed in 38 cases, patch closed of the atrial septal defect in 56 cases, directly closureed of the ventricular septal defect in 76 cases, patch closureed of the ventricular septal defect in 142 cases.ResultsThere was no hospital mortality in both groups. For the endoscopic group, operations were performed successfully in 390 (98.5 %) patients, enlarging a port to a 5-cm incision in 4 children. Reoperation was necessary in two children, and no conversion to median sternotomy incision was necessary. The mean duration of operation was 132 ± 48 min, and cardiopulmonary bypass and aortic cross-clamp times were 54 ± 16 min and 25 ± 8 min, respectively. Major postoperative complications occurred in nine (2.3 %, p < 0.05) cases. For the conventional group, all children were operated by median sternotomy, and the mean duration of operation was 118 ± 41 min (p < 0.05); cardiopulmonary bypass and aortic cross-clamp times were 51 ± 13 min and 21 ± 6 min (p < 0.05), respectively. Major postoperative complications occurred in 16 (5.1 %) cases. Also, the intensive care unit stay time (8.3 ± 2.8 h versus 8.9 ± 2.9 h, p < 0.01), postoperative drainage (120 ± 21 ml versus 433 ± 140 ml, p < 0.05), and hospital time (8.6 ± 1.8 days versus 11.5 ± 1.9 days, p < 0.05) were statistically different.ConclusionsTotally endoscopic closed chest congenital heart surgery in children was feasible and safe. The results were similar or even superior to the traditional operations due to the decreased use of blood products and shortened hospital time. Degree of satisfaction with cosmetic result and postoperative comfort were very high. Therefore, endoscopic surgery will become a new popular choice for some congenital heart disease patients in the future.

Pro: Early Extubation Following Surgery for Congenital Heart Disease

EARLY EXTUBATION in adult patients undergoing cardiac surgery has been shown to be safe and to decrease resource use. 1 Myles P.S. Daly D.J. Djaiani G. et al. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. Anesthesiology. 2003; 99: 982-987 Crossref PubMed Scopus (45) Google Scholar , 2 Cheng D.C. Fast track cardiac surgery pathways: Early extubation, process of care, and cost containment. Anesthesiology. 1998; 88: 1429-1433 Crossref PubMed Scopus (135) Google Scholar , 3 Cheng D.C. Karski J. Peniston C. et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: A prospective randomized controlled trial. J Thorac Cardiovasc Surg. 1996; 112: 755 Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar , 4 Cheng D.C. Fast-track cardiac surgery: Economic implications in postoperative care. J Cardiothorac Vasc Anesth. 1998; 12: 72-79 Abstract Full Text PDF PubMed Scopus (89) Google Scholar Despite several large studies showing that this practice can be extended to pediatric patients undergoing surgery for congenital heart disease (CHD), there is still a significant amount of controversy. Some centers attempt extubation as soon as possible, whereas others routinely sedate patients after surgery. A quick literature search shows that early extubation in children undergoing surgery for CHD had been introduced in the late 1970s. 5 Barash P.G. Lescovich F. Katz J.D. et al. Early extubation following pediatric cardiothoracic operation: A viable alternative. Ann Thorac Surg. 1980; 29: 228-233 Abstract Full Text PDF PubMed Scopus (86) Google Scholar , 6 Schuller J.L. Bovill J.G. Nijveld A. et al. Early extubation of the trachea after open heart surgery for congenital heart disease A review of 3 years' experience. Br J Anaesth. 1984; 56: 1101-1108 Crossref PubMed Scopus (64) Google Scholar , 7 Heard G.G. Lamberti J.J. Park S.M. et al. Early extubation after surgical repair of congenital heart disease. Crit Care Med. 1984; 13: 830-832 Crossref Scopus (48) Google Scholar Several large studies and case series have since proved that early extubation can be performed safely in simple and complex surgical cases for all age groups, including neonates. 8 Mittnacht A.J. Thanjan M. Srivastava S. et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg. 2008; 136: 88-93 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar , 9 Kloth R.L. Baum V.C. Very early extubation in children after cardiac surgery. Crit Care Med. 2002; 30: 787-791 Crossref PubMed Scopus (69) Google Scholar , 10 Heinle J.S. Diaz L.K. Fox L.S. Early extubation after cardiac operations in neonates and young infants. J Thorac Cardiovasc Surg. 1997; 114: 413-418 Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar , 11 Vricella L.A. Dearani J.A. Gundry S.R. et al. Ultra fast track in elective congenital cardiac surgery. Ann Thorac Surg. 2000; 69: 865-871 Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar , 12 Neirotti R.A. Jones D. Hackbarth R. et al. Early extubation in congenital heart surgery. Heart Lung Circ. 2002; 11: 157-161 Abstract Full Text PDF PubMed Scopus (60) Google Scholar The term “early extubation” typically is applied when patients are extubated within 6 to 8 hours after surgery but also includes extubation in the operating room (OR) at the end of the surgical procedure. Early extubation typically is part of a fast-tracking regimen with the goal of early patient mobilization and intensive care unit (ICU) and hospital discharge, with benefits that are well documented and that will be discussed in detail below.

Optimization of myocardial strain imaging and speckle tracking for resynchronization after congenital heart surgery in children

Cardiac resynchronization therapy can improve cardiac function in children with heart failure. The optimal method of assessing dyssynchrony has not been established. Newer tissue Doppler techniques such as strain assessment and speckle tracking appear to be promising for optimization of resynchronization. Two children aged 7 weeks and 4 months, with transposition of the great arteries and ventricular septal defect, and double outlet right ventricle with pulmonary stenosis, developed heart block after surgery. Conventional epicardial pacing resulted in heart failure in both. Upgrade to cardiac resynchronization therapy was not associated with normalization of function by echo, necessitating optimization. Baseline ventriculo-ventricular delay was 4 ms. Speckle tracking strain assessment was performed while adjusting ventriculo-ventricular delay. In Patient 1, synchrony was best with left ventricular (LV) activation preceding right ventricular (RV) by 30 ms. In Patient 2, it was best with RV preceding LV by 20 ms. At follow-up, both patients had normalization of function. In each case, optimization and reprogramming could be done live with no need for offline analysis. Speckle tracking strain analysis appears to be successful in the live, on-site optimization of cardiac resynchronization therapy in children. Further studies may help refine this process further.

Oral sildenafil for persistent pulmonary hypertension early after congenital cardiac surgery in children☆

Sildenafil is a strong pulmonary vasodilator that increases the intracellular cyclic guanosine monophosphate concentration through inhibition of phosphodiesterase-5. We assessed the benefit of oral sildenafil for persistent pulmonary hypertension early after congenital cardiac surgery in paediatric patients. Sildenafil was administered at a starting dose of 0.5 mg kg(-1) following admission to the intensive care unit. With careful monitoring of haemodynamics, the dose was increased stepwise by 0.5 mg kg(-1) every 4-6 h up to a maximum of 2 mg kg(-1). After successful weaning from a ventilator and from other vasodilators, sildenafil was gradually discontinued over the next 5-7 days. A retrospective review of medical records showed an age distribution of <1 month (n=26), > or = 1-<6 months (n=36), > or = 6-<12 months (n=19), 1-3 years (n=8), 4-9 years (n=9) and >10 years (n=2) at the time of surgery. The surgeries were performed for ventricular septal defect closure (n=17), arterial switch (n=30), truncus arteriosus repair (n=10), complete atrioventricular septal defect repair (n=12), total anomalous venous drainage repair (n=9), and other open-heart surgery (n=22). The aforementioned concomitant inhaled nitrous oxide treatment was performed in 66 patients. Pulmonary arterial pressure decreased in 28, was unchanged in five and elevated in one patient out of the total of 34 cases for which data from continuous pressure monitoring were available. Bosentan was added in three cases with persistent symptoms due to pulmonary hypertension despite sildenafil treatment. After sildenafil administration, modest oxygen desaturation occurred in seven cases, but no 'rebound' pulmonary hypertension occurred. There were no significant adverse events during sildenafil treatment. Our results suggest that oral sildenafil is a safe and effective alternate for persistent pulmonary hypertension following congenital heart surgery in children.