Correction Of Congenital Heart Disease Research Articles

Etiology and Management of Chylothorax Following Pediatric Heart Surgery

Chylothorax after congenital heart surgery (CHD) is a potentially challenging complication. The purpose of this study was to review our experience with the management of chylothorax following congenital heart surgery. Between September 1997 and August 2006, of 1341 pediatric patients undergoing correction of congenital heart disease in our institution, 18 (1.3%) developed chylothorax postoperatively. Surgical procedures included tetralogy of Fallot repair in 10 patients, ventricular septal defect closure (one), atrial septal defect with pulmonary stenosis repair (one), Fontan procedure (three), coarctation of the aorta repair (one), aortopulmonary shunt (one), and ligation of patent ductus arteriosus in one patient. All patients followed a therapeutic protocol including complete drainage of chyle collection and controlled nutrition. Somatostatin was used adjunctively in six (33.3%) patients. Surgical intervention was reserved for persistent lymph leak despite maximal therapy. Following resolution of chylothorax, a medium-chain triglyceride diet was implemented for six weeks. There were no deaths. Fifteen patients (83.3%) responded to conservative therapy. Lymph leak ranged from 2.5 to 14.7 mL/kg per day for 8 to 42 days. Three patients with persistent drainage required thoracotomy with pleurodesis to achieve resolution, in two of which previously attempted chemical pleurodesis with doxycycline proved ineffective. Duration of lymph leak in this subgroup ranged from 15 to 47 days with 5.1 to 7.4 mL/kg per day output. Postoperative chylothorax is an infrequent complication of surgery for congenital heart disease and can occur even after median sternotomy in the absence of pathologically elevated venous pressure or Fontan circulation. Although hospitalization can be prolonged, conservative therapy is effective in most cases, while surgical pleurodesis proved successful in the refractory cases.

Safety of Transesophageal Pacing for 24 Hours in a Canine Model

Temporary epicardial pacing is often necessary following surgical correction of congenital heart disease. Epicardial pacing wires, while generally effective, can, however, become nonfunctional. Transesophageal atrial pacing (TEAP) can be a useful adjunct in this setting. The potential for esophageal damage with sustained TEAP is unknown. We assessed the safety of continuous (24 hours) TEAP by evaluating gross and histological changes to the esophagus in a canine model. Thirteen juvenile beagle dogs were fitted with a 4-Fr multipolar catheter placed transnasally into the esophagus to a level to sustain atrial capture. Pacing was established in nine dogs for 24 hours while four control dogs had catheters but no pacing stimulus applied. Paced dogs were divided into two groups: group A (n = 5) that were euthanized immediately and group B (n = 4) that were euthanized 7 days after the pacing period. Nonpaced dogs (group C, n = 4) were treated similar to group A. Gross and histological examination of the esophageal tissue was completed. Gross and histological evidence of mild esophagitis was noted in dogs from groups A and C but not in dogs from group B. There was no evidence of esophageal stricture or fibrosis in any dog from any group. TEAP did not result in permanent esophageal changes after 24 hours of stimulation. Microscopic lesions of mild erosive esophagitis, seen after 24 hours of TEAP, were absent 7 days postpacing. Mechanical irritation from the catheter cannot be ruled out as a cause of these changes.

The changes in signal-averaged electrocardiogram after surgical correction of congenital heart disease

Purpose : To analyze abnormal ventricular activation in childhood congenital heart disease induced by postoperative changes in ventricular volume and pressure and ventricular scar formation using signal-averaged electrocardiography (SAECG). Methods : Fifty-two patients who had undergone open heart surgery (OHS) were enrolled. Patients were divided into the following 3 groups: right ventricular volume overload (atrial septal defect, group1), left ventricular volume overload (ventricular septal defect, group2), and right ventricular pressure overload (tetralogy of Fallot, group 3). The patients were monitored by standard 12-lead ECG and SAECG before and 2 months after the operation. QRS duration, QT and QTc intervals, filtered QRS (f-QRS), high frequency low amplitude potential (HFLA), and root mean square (RMS) voltage in the terminal 40 ms of SAECG were determined. Results : In the preoperative period, group1 showed significant increase in QRS (P=0.011) compared to those of the other 2 groups. In the postoperative period, group3 showed significant increase in the QTc interval (P=0.004) compared to those in the other 2 groups. SAECG parameters showed no significant differences among the groups in the pre- or postoperative period. Of the 52 patients, 12 (23%) in the preoperative period and 21 (40%) in the postoperative period had at least 1 SAECG abnormality. The prevalence of SAECG abnormalities was significantly higher in the postoperative group 2 and group 3 (preoperative: 20% versus postoperative: 28%, P

Intraabdominal Pressure in Children After Cardiothoracic Surgery

Intraabdominal Pressure in Children After Cardiothoracic Surgery Introduction. Intraabdominal pressure (IAP) now is widely recognized as an important variable and its monitoring is used in a variety of critically ill patients. Aim of the study. The aim of this study was to measure and to recognize the influence of various factors on IAP in children after surgical correction of congenital heart disease. Materials and methods. We conducted non-randomized, prospective observational study in Pediatric intensive care unitat a University Children's hospital. Study protocol was approved by Hospital Ethics commision. Measurements of IAP were performed in 15 children with mean body weight 8±5,83 kg, (Range 3,1-28 kg), mean age of 18,01 months (range 8 days-8 years) after cardiothoracic surgery. Cardiopulmonary bypass (CPB) was used in 12 patients. IAP was measured during first 24 hours postoperatively at 12 hour intervals via indwelling urinary catheter with bladder volumes of 1 ml/kg of normal saline. Of the 15 patients, 12 were mechanically ventilated at the time of the IAP measurements. Ventilation pressures: PIP (peak inspiratory pressure), MAP (mean airway pressure), PEEP (positive end expiratory pressure) and central venous pressure (CVP) via femoral vein were recorded. In some patients (6 from 15) amount of fluid evacuated via intraperitoneal drain from peritoneal cavity in first 24 hours was measured. Results. IAP was 12,24±3,54 mm Hg (Range 5,44-20,4 mm Hg), CVP 13±2,19, PIP 20±2,48 cm H2O, MAP 9±2,3 cm H2O, PEEP 5±1,35 cm H2O. Amount of fluid removed from peritoneal cavity during first 24 hours was 0,8±0,54 ml/kg/h (Range 0,04-1,7 ml/kg/h). Conclusions. We find elevated intraabdominal pressure (IAP> 12 mm Hg) in 10 from 15 (66,67%) pediatric patients in the first 24 hours after cardiothoracic surgery. There was a difference in IAP in patients with abdominal paracenthesis versus patients without the drain. The difference between groups was not statistically significant (P=0,4). We did not find a correlation between IAP, MAP and CVP. We, however, did not observe development of abdominal compartment syndrome (ACS).

Ablation of atrial tachycardias after correction of complex congenital heart diseases: utility of intracardiac echocardiography

Our goal was to analyse the utility of intracardiac echocardiography (ICE) for navigation and ablation of atrial tachycardias (ATs) after surgical correction of congenital heart disease (CHD). Catheter ablation of ATs was performed in seven patients (one woman, mean age 21 +/- 6 years) after correction of complex CHD: d-transposition of the great arteries (Mustard procedure in two patients, Senning procedure in two patients) and univentricular circulation (total cavopulmonary connection in two patients, atriopulmonary connection in one patient). The ablation was guided by a combination of electroanatomical mapping (CARTO, Biosense-Webster) and ICE (Acuson, Siemens). Intracardiac echocardiography was used during mapping to identify relevant anatomical structures and monitor tissue contact and for guidance of atrial baffle puncture. Biatrial mapping was necessary in six of seven patients and atrial baffle puncture in three. The clinical AT was abolished in all patients. No complications were noted. During follow-up of 23 +/- 13 months, two patients (28%) had arrhythmia recurrence. One patient developed atrial fibrillation, and recurrent AT in the other patient was controlled by re-ablation. Despite complicated cardiac anatomy, catheter ablation of AT after complex CHD can be performed safely and with a high success rate. Intracardiac echocardiography facilitates mapping, identification of relevant cardiac structures, and could be used for safe guidance of transbaffle puncture.

Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart disease in neonates and small infants: Relevance of near-infrared spectroscopy

Cardiac surgery with cardiopulmonary bypass for correction of congenital heart disease in neonates and small infants is associated with considerable neurologic sequelae. We assessed the extent to which mixed venous oxygen saturation as a measure for adequacy of perfusion, reflects the oxygenation status of upper and lower body compartments. Moreover, we evaluated potential benefits of near-infrared spectroscopic monitoring of regional tissue oxygenation. Twenty patients (body weight < 10 kg) undergoing open cardiac procedures with cardiopulmonary bypass were enrolled. Blood samples were obtained in parallel from inferior and superior caval vein cannulas and mixed venous line and assessed for venous oxygen saturation and lactate levels. Data were compared to simultaneously measured tissue oxygenation indices obtained by near-infrared spectroscopy from brain and lower limb. Venous oxygen saturation was lower and lactate concentration higher in blood from superior relative to inferior venous line. Mixed venous oxygen saturation correlated with venous oxygen saturation from inferior venous line and tissue oxygenation index of lower limb. No correlation was found between mixed venous oxygen saturation and venous oxygen saturation from superior venous line or cerebral tissue oxygenation index. In neonates and small infants undergoing cardiac surgery with cardiopulmonary bypass, considerable regional differences exist in venous oxygen saturation. Mixed venous oxygen saturation primarily represents lower-torso oxygen status but poorly reflects and systematically overestimates upper-body oxygenation. Near-infrared spectroscopy yields additional information on regional oxygenation and may be valuable in early and sensitive detection of regional malperfusion in critical organs such as the brain.

Cardiopulmonary bypass for surgical correction of congenital heart disease in children with sickle cell disease: a case series

We present a series of three children with sickle cell disease aged 3 months, 3 weeks and 18 months, all presenting for cardiac surgery requiring cardiopulmonary bypass. The cardiac lesions were atrioventricular septal defect, transposition of the great arteries and ventricular septal defect, with sickle cell loads of 35%, 11% and 39% respectively at presentation. We calculated that the bypass circuit would provide sufficient volume to decrease sickle cell levels to safe values, so we decided to proceed to bypass without pre-operative exchange transfusion, and modified the bypass technique so as to avoid the likely stimulants of a sickle cell crisis. Haemoglobin S levels after the start of bypass were significantly lower than before bypass, and remained low throughout the case and into the second postoperative day. By adopting this approach, we feel that we achieved a successful outcome with minimal distress to the children and their families.

Effects of Home-based Training at Dyspnea Threshold in Children Surgically Repaired for Congenital Heart Disease

The present investigation was aimed at assessing the effect of home-based training on cardiorespiratory responses in children surgically corrected for congenital heart impairment using dyspnea threshold (DT) as training intensity. A group of 23 children aged 15 +/- 1.4 years who had undergone surgical correction for congenital heart disease (CHD group) and 12 healthy children used as a control group performed an exercise protocol during which aerobic capacity, ventilatory threshold (VT), and DT were assessed. Afterwards, the CHD group was divided into two subgroups: trained and untrained subjects. Training sessions over a period of 2 months were performed at an intensity corresponding to DT by the CHD trained group. Dyspnea was scored according to a visual analog scale during the warm up, at each exercise stage, and during the recovery period. DT was located on the oxygen uptake/dyspnea curve when a sudden increase in the dyspnea score occured, while VT was defined according to the methodology previously employed by Beaver and colleagues. The results showed that children who had undergone surgery for CHD had reduced aerobic capacity. No significant difference was observed between VT and DT in children corrected for CHD. These two thresholds were highly related. Home-based training at DT did not strongly improve aerobic capacity nor did it influence the relationship between VT and DT. Further studies should be conducted to confirm these preliminary findings, particularly when aerobic capacity is improved by training.

Pharmacological Therapy in Children with Atrial Fibrillation and Atrial Flutter

Heart rhythm disorders in children are not different, on electrocardiographic trace, from heart rhythm disorders in adults with the exception of incidence which is different according to the age. Paticularly, atrial flutter (FlA) and fibrillation (FA) are very uncommon arrhythmias in the general pediatric population. Generally atrial fibrillation and atrial flutter, in our experience, is a temporary heart rhythm disturbance connected to specifical and resovable reasons with the exception of Fontain's surgical correction of congenital heart diseases or cardiopathies with dilatation of both atria. Presenting symptoms, symptom history (e.g., frequency, duration, and severity), risk assessment, previous response to alternative treatment options, convenience and patient preference for a specific treatment option, and costeffectiveness of a treatment option are among the many factors that should be considered. Treatment of atrial flutter and fibrillation in pediatric age involves several options: Pharmacological therapy, Transoesophageal atrial pacing (TEAP), Electrical cardioversion and Catheter ablation. In this review we evaluated the physiopathology, the clinical features and the current terapeutical strategies for these arrythmias in paediatric age.

Catheter Ablation for Ventricular Tachycardia

Sustained ventricular tachycardia (VT) is an important cause of morbidity and sudden death in patients with heart disease.1 Implantable cardioverter-defibrillators (ICDs) terminate VT episodes, reducing the risk of sudden death. Recurrent VT develops in 40% to 60% of patients who receive an ICD after an episode of spontaneous sustained VT. A first episode of VT occurs in ≈20% of patients within 3 to 5 years after ICD implantation for primary prevention of sudden death in high-risk groups.2–4 ICD shocks reduce quality of life and are associated with an increased risk of death.2–4 Antiarrhythmic drug therapy with amiodarone or sotalol reduces VT episodes but with disappointing incidence of side effects and efficacy.2 Catheter ablation is useful for reducing VT episodes and can be life-saving when VT is incessant.1,5,6 Idiopathic VTs occur in patients without structural heart disease and rarely cause sudden death. Electrophysiological study with catheter ablation is often warranted to confirm the diagnosis, to provide further evidence for the absence of ventricular scar or other disease, and often to cure the arrhythmia. Ablation is also an option for symptomatic nonsustained VT and frequent ventricular ectopy in these patients.1 The appearance of the VT on ECG often suggests its likely cause and associated heart disease (Figure 1). Monomorphic VT has the same QRS complex from beat to beat, indicating repetitive ventricular activation from a structural substrate or focus that can be targeted for ablation. Most are due to reentry through regions of ventricular scar.7 Figure 1. ECG types of VT and most common causes are shown with characteristic ECG features of selected VTs. LBBB indicates left bundle-branch block; LVOT, LV outflow tract; RBBB, right bundle-branch block; L, left; and R, right. Polymorphic VTs have a changing ventricular activation sequence that can be due to …

Aortic valve–sparing reimplantation for dilatation of the ascending aorta and aortic regurgitation late after repair of congenital heart disease

Aortic regurgitation resulting from progressive dilatation of the aortic root late after surgical correction of congenital heart disease is now widely recognized. We reviewed our experience with aortic valve-sparing operations to access the effectiveness of this approach. Three patients, aged 28, 31, and 32 years, had progressive dilatation of the ascending aorta and aortic regurgitation 25, 27, and 28 years, respectively, after surgical repair of complex congenital heart disease. At the time of reoperation, the maximum diameter of the aortic root ranged between 50 and 55 mm. All 3 patients survived the operation and were in New York Heart Association functional class II or less at a maximum of 9 years' follow-up. The most recent echocardiogram demonstrated mild or less aortic insufficiency with favorable systemic ventricular function. Aortic valve-sparing reimplantation is an effective treatment for aortic root dilatation and aortic regurgitation after corrective repair of complex congenital heart disease. This procedure leads to correction of aortic regurgitation, favorable durability of the native aortic valve, and excellent hemodynamics, avoiding a prosthetic valve and anticoagulation.

Therapeutic Hypothermia

Therapeutic hypothermia, introduced more than 5 decades ago, remains an important neuroprotective factor in the surgery for the correction of congenital heart disease, in particular when intraoperative circulatory arrest is required. Hypothermia decreases cerebral metabolism and energy consumption and reduces the extent of degenerative processes such as the excitotoxic cascade, apoptotic and necrotic cell death, microglial activation, oxidative stress, and inflammation. Neurological outcome has become the focus of several studies in the recent years, and deep hypothermic circulatory arrest durations of more than 40 minutes are associated with increased mid- and long-term disability. Physiologic cerebral flow-metabolism coupling seems to be preserved with moderate and mild hypothermia, but cerebral blood flow autoregulation is probably altered after deep hypothermic circulatory arrest, suggesting disordered cerebral metabolism and oxygen use. Although evidence from animal studies suggests potential benefit from very low temperatures, postoperative development of choreoathetosis has been found to correlate with the degree of intraoperative hypothermia, recommending the use of central temperatures greater than 15 degrees C in the clinical practice. Cooling times longer than 20 minutes are needed to obtain homogeneous brain cooling and effective neuroprotection. Finally, there is evidence that the sites of temperature monitoring used in the clinical practice may underestimate brain temperature after cardiopulmonary bypass, with the risk of postoperative hyperthermic brain damage.

Down Syndrome as an Independent Risk Factor for Thrombosis in Children.

Thromboembolic complications in children occur at an estimated rate of 5.3 per 10,000 hospitalized children per year. Over the last decade, investigators have determined that underlying medical conditions such as cancer and congenital heart disease (CHD) and the intensive therapies required to manage these conditions are strongly associated with the thromboembolic complications. Recently, we perceived an increase in the incidence of thrombosis in children with Down Syndrome (DS), a chromosomal abnormality which is associated with both CHD and cancer, but there is very little evidence in the medical literature to suggest that it is an independent risk factor for thrombosis. Although, there are case series describing an association of moyamoya disease and DS, only a few case reports describe venous and arterial thrombosis in children with DS, and there is no information about its rate and severity. Therefore, we conducted a retrospective analysis of patients treated at Children's Medical Center Dallas between January 1, 2000 and November 30, 2005, hypothesizing that thrombosis would be more prevalent in patients with DS (with or without associated co-morbidities) than in children without DS. ICD-9 codes for CHD, DS, cancer, and thromboembolic complications and the CPT codes for the surgical procedures used to correct CHD were used to identify patients of interest. During the study period, the emergency center, ambulatory outpatient areas, and inpatient units saw 729,324 children. Among these, we identified 511 patients with DS (0.07%), 2168 (0.29%) with CHD, and 1182 (0.16%) with cancer. Sixty-one percent (n=311) of the patients with DS also had CHD, and 2.9% (n=15) had cancer. Thrombosis was identified in 398 (5.4 per 10,000 children). The majority (n=220, 55%) developed deep venous thrombosis (DVT), with catheter-related thrombosis (n= 156) being most common. There were 165 (41%) arterial ischemic strokes (AIS), 19 associated with moyamoya disease. Fifteen children with DS developed thrombosis (rate of 293 per 10, 000 children with DS). Among these 15, DVT occurred in 11 (73%) patients and AIS in 5 (33%), 2 with moyamoya. Among the subgroup of patients diagnosed with AIS, DS was not found to be a risk factor for moyamoya disease (OR 5.6, 95% CI 1.05, 30.5, p=0.1). Two patients with DS (13%) had both DVT and AIS. Children diagnosed with DS (OR 57.5, 95% CI 34.2, 96.5, p<0.0001), CHD (OR 129.5, 95% CI 103, 163, p<0.0001), or cancer (OR 57.3, 95% CI 40, 82, p<0.0001) were more likely to develop thrombosis than children without these three diagnoses. Among the children with CHD, having DS did not increase the odds for thrombosis. However, for children with cancer, DS did increase the odds (OR 9.5, 95% CI 2.7, 33.1, p= 0.007). Four of 15 (27%) children with DS did not have cancer or CHD and still had a higher than expected rate of venous and/or arterial thrombosis (OR 60, 95% CI 23, 156, p< 0.0001). In conclusion, the results of this retrospective analysis indicate that DS may be an independent risk factor for thromboembolic disease during childhood. Prospective studies are needed to confirm these findings and explore potential mechanisms.

Urinary IL-18 is an early predictive biomarker of acute kidney injury after cardiac surgery

Acute kidney injury (AKI) is a frequent complication of cardiopulmonary bypass (CPB). The lack of early biomarkers for AKI has impaired our ability to intervene in a timely manner. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is recently demonstrated as an early biomarker of AKI after CPB, increasing 25-fold within 2 h and declining 6 h after surgery. In the present study, we tested whether interleukin-18 (IL-18) is a predictive biomarker for AKI in the same group of patients following CPB. Exclusion criteria included pre-existing renal insufficiency and nephrotoxin use. Serial urine samples were analyzed by enzyme-linked immunosorbent assay for IL-18 in 20 patients who developed AKI (defined as a 50% or greater increase in serum creatinine after CPB) and 35 controls (age, race, and gender-matched patients who did not develop AKI after CPB). Using serum creatinine, AKI was detected only 48-72 h after CPB. In contrast, urine IL-18 increased at 4-6 h after CPB, peaked at over 25-fold at 12 h, and remained markedly elevated up to 48 h after CPB. The performance of IL-18 as demonstrated by area under the receiver operating characteristics curve for diagnosis of AKI at 4, 12, and 24 h after CPB was 61, 75, and 73% respectively. Also, on multivariate analysis, both IL-18 and NGAL were independently associated with number of days in AKI among cases. Our results indicate that IL-18 is an early, predictive biomarker of AKI after CPB, and that NGAL and IL-18 are increased in tandem after CPB. The combination of these two biomarkers may allow for the reliable early diagnosis and prognosis of AKI at all times after CPB, much before the rise in serum creatinine.

Long term management of atrial arrhythmias in young patients with sick sinus syndrome undergoing early operation to correct congenital heart disease

The objective of our study was to evaluate the clinical outcome of patients with operated congenital heart disease (CHD), post-operative sinus node dysfunction and atrial tachyarrhythmias (AT) who had a new generation of DDDRP pacemakers (Model AT501, Medtronic Inc., MN, USA) able to deliver preventive atrial pacing and antitachycardia pacing (ATP) therapies. Fifteen CHD patients (mean age 17+/-9 years, eight after Mustard operation, five after extracardiac Fontan operation and two after atrial septum repair) received a dual-chamber pacemaker with transvenous (eight patients) or epicardial leads (seven patients). In the year before implantation, all patients had symptomatic AT (palpitations), eight patients required hospitalization and five required electrical cardioversion. Pacing prevention algorithms were enabled in all patients, and ATP therapies in six patients. During a mean follow-up of 30 months (range 24-44), three patients (two Fontan, one Mustard) died of CHF, whereas AT required hospitalization in three patients (two Fontan, one atrial septum repair). Only seven patients had symptomatic AT. One hundred and twenty-five AT episodes were treated by ATP in three patients, with an overall termination efficacy of 43.2%. In one patient, atrial lead noise induced inappropriate AT detection that resulted in ATP delivery. Several AT episodes were not treated owing to their very short duration, atrial undersensing, or 1:1 atrioventricular conduction. Our experience with antitachycardia pacemakers in CHD patients with post-operative sick sinus syndrome after biventricular correction or palliation shows that these devices are safe and that atrial pacing may play a role in AT prevention and treatment.

Análise das atividades dos oito anos iniciais do Banco de Valvas Cardíacas Humanas do Hospital de Caridade da Irmandade da Santa Casa de Misericórdia de Curitiba

OBJETIVO: O objetivo deste trabalho foi avaliar, retrospectivamente, os primeiros oito anos de funcionamento do Banco de Valvas Cardiacas Humanas do Hospital de Caridade da Irmandade da Santa Casa de Misericordia de Curitiba (BVCHSC), analisando aspectos relacionados as atividades de captacao, processamento, armazenamento e distribuicao de enxertos homologos cardiovasculares. METODO: A selecao inicial dos doadores seguiu as diretrizes nacionais para captacao de orgaos humanos, alem de criterios especificos do BVCHSC. Os coracoes foram obtidos de doadores de multiplos orgaos, doadores em parada cardiaca e receptores de transplante cardiaco, com somatoria dos tempos de isquemia inferior a 48 horas. A idade dos doadores variou desde recem-nascidos ate 60 anos para as valvas aorticas e 65 para as pulmonares. Os enxertos dissecados tiveram suas dimensoes mensuradas e sua morfologia avaliada, sendo classificados como categoria 0 (descartados), 1 (alteracoes morfologicas minimas) ou 2 (perfeitos). Foram determinados a incidencia e os germes responsaveis pela contaminacao nos enxertos recebidos, assim como a eficiencia da solucao de descontaminacao. Foram tambem avaliados aspectos relacionados a distribuicao dos enxertos. RESULTADOS: De setembro de 1996 a fevereiro de 2005, 1059 coracoes provenientes de 19 Estados foram recebidos no BVCHSC. Destes, 977 (92,3%) eram de doadores de morte encefalica. Foram processados 2105 enxertos, e dentre os aorticos e pulmonares analisados, 783 eram da categoria 2, 697 pertenciam a categoria 1 e 186 foram descartados por alteracoes morfologicas. No total, 433 enxertos recebidos estavam contaminados, sendo a solucao de antibioticos eficiente na esterilizacao de 330 destes casos. Quinhentos e setenta e um (27,1%) enxertos foram rejeitados em alguma fase do processo, sendo a contaminacao e as alteracoes morfologicas as causas mais frequentes. Foram distribuidos 1338 enxertos para 74 instituicoes de saude do pais, sendo mais comumente empregados na substituicao da valva aortica (529), na correcao de cardiopatias congenitas (478) e durante operacoes de Ross (272). CONCLUSOES: As atividades do BVCHSC durante estes oito anos de funcionamento foram satisfatorias, atingindo os objetivos propostos.

The Impact of Slow Rewarming on Inotropy, Tissue Metabolism, and “After Drop” of Body Temperature in Pediatric Patients

Pediatric patients undergoing surgical correction of congenital heart diseases using cardiopulmonary bypass (CPB) are subjected to hypothermia. Core temperature is cooled down to 26–28°C during CPB. Postoperative hypothermia in these patients remains a source of long-intensive care unit (ICU) stay. Therefore, this study was performed to build a rewarming strategy aiming to improve the cardiac performance, minimize the early after-drop in both core and foot temperatures, and to achieve early achievement of homeostasis. Thirty pediatric patients of acyanotic congenital heart diseases were randomly allocated into one of three equal groups of 10. Group I was kept at 3°C between nasopharyngeal and heater-cooler unit water temperatures during rewarming whereas group II and group III were kept at 5°C and 7°C, respectively. The following parameters were measured: 1) cardiac performance (cardiac index and peak velocity); 2) cumulative amrinone consumption, blood lactate levels, and total body oxygen consumption; 3) intraoperative and postoperative peak and trough core and foot temperatures; and 4) time to extubation and ICU stay. Group I patients showed statistically significant increase in cardiac index and peak velocity compared with groups II and III, at p &lt; 0.05 and p &lt; 0.025, respectively. Statistically, the consumption of amrinone was significantly decreased in group I compared with groups II and III, with p &lt; 0.005 and p &lt; 0.0005, respectively, at 6 hours postoperatively. Group I showed an insignificant increase in blood lactate level, where groups II and III showed significant increases compared with controls (p &lt; 0.001 at 6 hours postoperatively). Intraoperatively, both trough core and peak foot temperatures of group I patients statistically were significantly higher than in group III patients at p &lt; 0.0005 and p &lt; 0.05, respectively. The same applies in the ICU as regards to the time to core temperature (p &lt; 0.005) and the rate of foot warming (p &lt; 0.01). It was found that a difference of 3°C (group I) between nasopharyngeal and heater-cooler unit water temperatures during rewarming demonstrated the best outcome compared with 5°C and 7°C differences (groups II and III, respectively). This outcome was obvious in the following parameters: 1) the best cardiac performance (cardiac index and peak velocity); 2) the lowest values of cumulative amrinone consumption and blood lactate level; 3) the least after-drop in both core and foot temperatures; and 4) achievement of early homeostasis, shortest ICU stays, and conservation of the ICU resources.

Pregnancy and the Rastelli operation

The aim of surgical correction of congenital heart disease is for the patient to live a relatively normal life, including potential pregnancy and childbirth. The Rastelli repair operation using a valved conduit for certain complex congenital heart lesions has resulted in survival into adult life. We reviewed reproductive outcome of 22 women over 18 years of age who were survivors of the Rastelli operation performed between 1977 and 1999. Six women had a total of 12 pregnancies with six live births. Three women, with complex transposition of the great arteries, developed more severe subaortic obstruction during pregnancy. All required further heart surgery. Delivery was by Caesarean section in three patients and vaginally in the other three. All infants were healthy and free from defects. Two women had tubal ligations because of their cardiac problems. Women who have had Rastelli repair operation for complex congenital heart disease can have successful pregnancies. Subaortic stenosis can become a problem and should ideally be eliminated before pregnancy. Because of multiple operations, complications and genetic concerns, some women choose not to reproduce. Careful cardiac evaluation before, during and after pregnancy is essential.

O papel do ecocardiograma como método isolado na indicação cirúrgica de pacientes portadores de cardiopatia congênita

To determine the diagnostic accuracy of echocardiography for indicating surgery without catheterization in patients with congenital heart disease through a prospective analysis and comparison of the echocardiographic diagnosis with the intraoperative findings, or invasive study, or both. From February 2000 to January 2001, 493 patients with congenital heart diseases indicated for surgery were followed up. They underwent echocardiography with color-flow mapping for a therapeutic decision. The results were compared with the findings of surgery or catheterization, or both, when the latter were performed for diagnostic reasons. Of the patients studied, 94.3% (465 cases) underwent congenital heart disease correction based only on echocardiographic findings, without a diagnostic catheterization. The invasive study was performed for diagnostic reasons in 28 (5.6%) patients, the surgical treatment was performed in more than 95% of the patients, and therapeutic catheterization was performed in 3.6%. The echocardiographic findings were confirmed in 464 (94.1%) patients, which showed the high accuracy of the method. False-positive findings occurred in 8 (1.6%) patients, and false-negative findings in 39 (7.9%). According to surgeons, no diagnostic error led to complications or adversely affected the surgical results. Echocardiography proved to be a sensitive and safe method for indicating surgery, making catheterization, often, unnecessary. The invasive study was restricted to diagnostic or therapeutic uses.

Computational modeling of vascular anastomoses

Recent development of computational technology allows a level of knowledge of biomechanical factors in the healthy or pathological cardiovascular system that was unthinkable a few years ago. In particular, computational fluid dynamics (CFD) and computational structural (CS) analyses have been used to evaluate specific quantities, such as fluid and wall stresses and strains, which are very difficult to measure in vivo. Indeed, CFD and CS offer much more variability and resolution than in vitro and in vivo methods, yet computations must be validated by careful comparison with experimental and clinical data. The enormous parallel development of clinical imaging such as magnetic resonance or computed tomography opens a new way toward a detailed patient-specific description of the actual hemodynamics and structural behavior of living tissues. Coupling of CFD/CS and clinical images is becoming a standard evaluation that is expected to become part of the clinical practice in the diagnosis and in the surgical planning in advanced medical centers. This review focuses on computational studies of fluid and structural dynamics of a number of vascular anastomoses: the coronary bypass graft anastomoses, the arterial peripheral anastomoses, the arterio-venous graft anastomoses and the vascular anastomoses performed in the correction of congenital heart diseases.