Open Heart Surgery In Infants Research Articles

Developmental and Functional Outcomes at School Entry in Children with Congenital Heart Defects

To describe developmental and functional outcomes of children with congenital heart defects (CHDs) at school entry after open heart surgery. Infants with CHDs who underwent surgical repair in infancy were recruited and assessed prospectively for developmental progress. At 5 years of age (64.2 +/- 11.3 months), 94 subjects were evaluated in a blind fashion by using a variety of standardized measures. Mean IQ scores were in the low average range (90-94). Receptive language was in the average range (103.6 +/- 14.4). Behavioral difficulties were common (27.1%), with internalizing problems being more frequent. Functional limitations in socialization (93.0 +/- 17.1), daily living skills (94.6 +/- 16.4), communication (90.0 +/- 14.1), and adaptive behavior (92.1 +/- 15.8) were noted in 11% to 17% of children. With the Functional Independence Measure for Children, 20% to 22% of subjects were more dependent than their peers in self-care and social cognition, although few (4.5%) had mobility restrictions. Predictors of developmental and functional limitations included: abnormal postoperative neurologic examination, microcephaly, deep hypothermic circulatory arrest time, palliation, acyanotic heart lesion, age at surgery, and maternal education. After infant open-heart surgery, children with CHDs may exhibit a range of developmental difficulties at school entry that enhances risk for learning challenges and decreased social participation.

Comparison of hospital episode statistics and central cardiac audit database in public reporting of congenital heart surgery mortality

Objective To verify or refute the value of hospital episode statistics (HES) in determining 30 day mortality after open congenital cardiac surgery in infants nationally in comparison with central cardiac...

Acute Renal Failure and Mortality After Open-Heart Surgery in Infants

Acute renal failure (ARF) is a major complication in infants who undergo cardiac surgery. The aim of this investigation was to identify possible risk factors for ARF and mortality in this patients group. Out of 64 patients, 21 (32.8%) cases developed acute renal failure and overall mortality rate was 25%. The mortality rate was higher in the infants who developed ARF than those who did not (66.7% and 4.7%, respectively, p < 0.05). Also, ARF was positively correlated with mortality (r:0.70, p < 0.0001). The nonsurvivors had lower mean serum albumin than did the survivors (p < 0.05), and serum albumin level was negatively correlated with mortality (r = − 0.34, p < 0.05). For the patients with serum albumin level < 3.5 g/dL, the unadjusted odds ratio for mortality was 4.3 (CI 95%:1.05 − 17.86). Total bypass time and aorta clamping time were significantly longer in the nonsurvivor group than in the survivor group (p < 0.05 for both). In conclusion, the significant risk factors for mortality in these patients were development of ARF, low serum albumin level, and long total bypass and aorta clamping times, which may be predictive of poor prognosis.

The influence of partial or total thymectomy during open heart surgery in infants on the immune function later in life.

Infants undergoing open heart surgery often have all or part of their thymus removed. The activity of the immune system has not been investigated thoroughly in these children, and only shortly after the operation. Therefore, it was decided to investigate the activity of the immune system in more detail in children several years after their operation. Peripheral blood samples from 19 children who had undergone open heart surgery during their first months of life was collected (study group) and from 19 age- and gender-matched children (control group). The activity of the immune system was evaluated by measuring the number of different cell types in peripheral blood, the phenotype of lymphocytes and the response of T cells following in vitro stimulation by mitogen, tetanus toxoid and measles antigen. The study group had significantly lower counts of total lymphocytes, which was reflected in a lower number of T cells but not B cells. Furthermore, the study group had significantly lower proportion of T cells (CD3(+)) and helper T cells (CD4(+)), but not cytotoxic T cells (CD8(+)). The level of neutrophils in peripheral blood was significantly higher in the study group. This may indicate enhanced innate immunity when the acquired immunity is defective. The results indicate a shift to extrathymic T cell maturation, which is less efficient for CD4(+) helper cells than for CD8(+) cytotoxic cells.

Early postoperative body temperature and developmental outcome after open heart surgery in infants

Background Experimental data have suggested that early postoperative temperature management after cerebral ischemia may alter neurologic outcome. We explored whether minor deviations in early postoperative body temperature after infant heart surgery affects developmental outcome. Methods In a study of infants undergoing repair of congenital heart disease, 95% of whom had a period of deep hypothermic circulatory arrest, postoperative temperature data were collected following cardiac surgery. Subjects were infants who had been enrolled in one of two prospective randomized single-center trials. Development was tested at age one year (the Bayley Scales of Infant Development) and at four years (Wechsler Preschool and Primary Scale of Intelligence, including Full Scale IQ, a Verbal IQ, and a Performance IQ). Results Perioperative temperature data were reviewed in 329 patients, of whom 244 (74%) were evaluated at age one year and 156 (48%) were evaluated at four years. The temperature profile was recorded during the rewarming phase and for 36 hours postoperatively on the Intensive Care Unit. There were no significant associations between postoperative temperature and any of the neurodevelopmental tests at age one or four years. A further analysis assessing the percentage of time over specific temperature cutoff points of 37.5°C, 38°C, 38.5°C, and 39°C, revealed no significant effect. Conclusions Neurodevelopmental outcome at one and four years after repair of complex congenital heart disease was not significantly affected by the early postoperative body temperature profile of the infant when a management strategy aiming for normothermia is employed.

Reducing Stress Responses in the Pre-Bypass Phase of Open-Heart Surgery in Infants and Young Children: A Comparison of Different Fentanyl Doses

Reducing Stress Responses in the Pre-Bypass Phase of Open-Heart Surgery in Infants and Young Children: A Comparison of Different Fentanyl Doses

Clinical Variables and Pro-inflammatory Activation in Paediatric Heart Surgery

Objectives - The first aim was to analyse the role of preoperative characteristics and perioperative variables in predicting the inflammatory response during and early after operations for congenital heart malformations of moderate to severe complexity. The second aim was to correlate complement and cytokine activation during the same period with clinical variables reflecting the postoperative course. Methods - Prospective descriptive clinical study that involved 22 consecutive children (1-28 months). Five children had Down's syndrome. Concentrations of C3a, C5b-9 and IL-6 were measured. Results - C3a, C5b-9 and IL-6 increased significantly during the study period (ANOVA: C3a, p = 0.001; C5b-9, p = 0; IL-6, p = 0). C3a correlated with preoperative haemoglobin (r = 0.71, p = 0.0002) and CPB time (r = 0.72, p = 0.0005). C5b-9 correlated with CPB time (r = 0.58, p = 0.004). IL-6 related to presence of Down's syndrome (p = 0.0001) and correlated with preoperative haemoglobin (r = 0.55, p = 0.02), preoperative weight deviation (r = -0.52, p = 0.03) and time in the ventilator (r = 0.68, p = 0.002) Conclusions - Preoperative and perioperative characteristics predict the inflammatory response during open heart surgery in infants and small children. IL-6 response is related to the postoperative course.

The role of insulin-like growth factor I, growth hormone, and plasma proteins in surgical outcome of children with congenital heart disease.

OBJECTIVE: To evaluate postoperative serum concentrations of growth hormone (GH), insulin-like growth factor I (IGF-I), C-reactive protein (CRP), and prealbumin as predictors of clinical outcome as defined by the incidence of 30-day postoperative mortality, the postoperative length of pediatric intensive care unit (PICU) stay, and the risk of postoperative infection in infants of high surgical risk undergoing operative correction of congenital cardiac defects. DESIGN: Prospective, observational study. SETTING: PICU of a university hospital. PATIENTS: A high surgical risk group of 36 children admitted for elective cardiac surgery. INTERVENTION: Measures of serum levels of IGF-I, basal GH, prealbumin, and CRP. These parameters were followed from the hospital admission until the discharge from the PICU at specific time points: preoperative and on the second, fifth, and tenth postoperative days. MEASUREMENTS AND MAIN RESULTS: Surgical stress response was marked by an increase of GH and CRP levels and a fall in prealbumin levels on the second postoperative day. Prealbumin, CRP, and GH returned to preoperative levels on average 10 days following surgery; the values of IGF-I, which had decreased on the fifth day, remained below those values observed before the surgery. Patients whose PICU stay was </= 10 days showed significant decreases in GH and CRP serum levels and an increase in IGF-I and prealbumin levels on postoperative day 5 compared with the patients who stayed > 10 days. The sustained high CRP (>/= 8.4 mg/dL, p <.05) and GH (>/= 66 mIU/L, p <.03) values on the fifth day were associated with increased mortality in contrast with patients in whom the values were returning to preoperative levels. CONCLUSIONS: Serial monitoring of serum GH, IGF-I, CRP, and prealbumin levels may be useful as a means to a) stratify the acute metabolic response to surgically induced injury insult and b) predict clinical outcome as defined by the length of stay in the PICU and the likelihood of 30-day survival following open-heart surgery in infants.

Reducing stress responses in the pre-bypass phase of open heart surgery in infants and young children: a comparison of different fentanyl doses

High-dose opioids are advocated for paediatric cardiac surgery to suppress stress responses but they can produce unwanted side effects. There are no data on the dose-dependent effects of opioids on the stress response on which to base rational opioid administration. We conducted a dose ranging study on 40 children less than 4 yr undergoing elective open heart surgery using one of five fentanyl doses: 2, 25, 50, 100 or 150 micrograms kg-1 before surgery. The standardized anaesthetic also included pancuronium and isoflurane. Blood samples were taken at induction, before incision, after sternotomy, immediately before, and at the end of cardiopulmonary bypass. Patients in the 2 micrograms kg-1 group had significant rises in prebypass glucose (P < 0.01), pre- and post-bypass cortisol (P < 0.01), and pre- and post-bypass norepinephrine (P < 0.01). No significant rise occurred in glucose, cortisol and catecholamines in any of the higher dosage groups. Patients in the 2 micrograms kg-1 group had significantly higher mean systolic blood pressure (P < 0.02) and heart rate (P < 0.04). A balanced anaesthetic containing fentanyl 25-50 micrograms kg-1 is sufficient to obtund haemodynamic and stress responses to the pre-bypass phase of surgery. Higher doses of fentanyl (100 and 150 micrograms kg-1) offer little advantage over 50 micrograms kg-1, and can necessitate intervention to prevent hypotension.

Modified ultrafiltration improves global left ventricular systolic function after open-heart surgery in infants and children.

Modified ultrafiltration increases blood pressure and cardiac index following open-heart surgery in children, but it is unclear if this is secondary to an improvement in global left ventricular function. A previous report has suggested that left ventricular systolic function as assessed in a single chord is improved by ultrafiltration (Davies MJ, Nguyen K, Gaynor JW, Elliott MJ. Modified ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998;115:361--370). The prominent vascular actions of modified ultrafiltration necessitate left ventricular assessment using load-independent indices of systolic and diastolic function. In 22 consecutive infants and children undergoing open-heart surgery, left ventricular function was assessed following bypass and then 10 min later. Sixteen children (median weight 8.1 kg) underwent modified ultrafiltration during this period, the remainder (median weight 7.3 kg) were controls for spontaneous recovery without ultrafiltration. Real-time pressure-volume loops, with transient inferior caval vein snaring were generated from conductance and microtip pressure catheters inserted through the LV apex. From these, load-independent (slope of the end-systolic pressure-volume [Ees] and end-diastolic pressure-volume [Eed] relationships) and load-dependent (Pmax, maximum LV pressure; Ped, end-diastolic LV pressure; maximum [dP/dtmax] and minimum [dP/dtmax] time derivatives of LV pressure; tau, time constant of isovolumic relaxation) indices of left ventricular function were measured. Haemoconcentration was achieved in all modified ultrafiltration patients, median increase in haematocrit 34% (interquartile range 21%, 42%), final haematocrit 0.40 (0.35, 0.41). Ees increased 58% (9, 159, P = 0.005). The changes in Eed, Pmax, Ped, dP/dtmax, dP/dtmin, and tau were not significantly different from the control group. Modified ultrafiltration improves global left ventricular systolic function in infants and children following open-heart surgery.

クリアランスからみた小児開心術後におけるドーパミン投与量の検討

クリアランスからみた小児開心術後におけるドーパミン投与量の検討

Cerebral physiology in paediatric cardiopulmonary bypass.

To analyze studies of neurological injury after open-heart surgery in infants and children and to discuss the effects of cardiopulmonary bypass, hypothermia and deep hypothermic circulatory arrest on cerebral blood flow, cerebral metabolism and brain temperature. Articles were obtained from the databases, Current Science and Medline, from 1966 to present. Search terms include cardiopulmonary bypass (CPB), hypothermia, cerebral blood flow (CBF), cerebral metabolism and brain temperature. Information and abstracts obtained from meetings on the topic of brain and cardiac surgery helped complete the collection of information. In adults the incidence of neurological morbidity is between 7 to 87% with stroke in about 2-5%, whereas the incidence of neurological morbidity increases to 30% in infants and children undergoing cardiopulmonary bypass. Besides the medical condition of the patient, postoperative cerebral dysfunction and neuronal ischaemia associated with cardiac surgery in infants and small children are a combination of intraoperative factors. Deep hypothermic circulatory arrest impairs CBF and cerebral metabolism even after termination of CPB. Inadequate and/or non-homogenous cooling of the brain before circulatory arrest, as well as excessive rewarming of the brain during reperfusion are also major contributory factors. Newer strategies, including the use of low-flow CPB, pulsatile CPB, pH-stat acid-base management and a cold reperfusion, are being explored to ensure better cerebral protection. Advances in monitoring technology and better understanding of the relationship of cerebral blood flow and metabolism during the different modalities of cardiopulmonary bypass management will help in the medical and anaesthetic development of strategies to improve neurological and developmental outcomes.

Changes in cerebral hemodynamics and oxygenation during hypothermic cardiopulmonary bypass in neonates and infants.

Delay in development after open-heart surgery in infants has frequently been reported. Inadequate brain perfusion and oxygenation during deep hypothermic cardiopulmonary bypass (CPB) may play an important role. We investigated the effect of CPB on cerebral perfusion and oxygenation in 12 neonates and infants (age 0-11 months) undergoing open-heart surgery. Changes in cerebral blood volume (delta CBV; in ml/100 g brain tissue) and oxidation level of the intracerebral mitochondrial enzyme cytochrome aa3 (delta Cytaa3; in mumol/l) were measured with near infrared spectroscopy. Nasopharyngeal temperature (Tnas) for assessment of changes in brain temperature, and mean arterial blood pressure (MAP) were monitored continuously. CBV lowered during cooling and increased during rewarming. These changes were only related with changes in Tnas (p < 0.001; 0.07 ml.100 g-1/ degrees C). No relation was found with changes in MAP or pump flow rate of the heart-lung machine. During steady-state hypothermic CPB, changes in CBV were only related to changes in MAP (p < 0.001). The individual regression lines between delta CBV and MAP became steeper at lower absolute Tnas. Cytaa3 showed an increase shortly after the initiation of CPB in 9 patients, with a sustained decrease to baseline values in 8 patients towards the end of the CPB period. Two patients who had a circulatory arrest during CPB had a sharp decrease in delta cytaa3 after cessation of the heart-lung pump and showed no complete recovery of delta Cytaa3 to baseline at the end of the CPB period. We conclude that changes in CBV during CPB are related to changes in Tnas. During deep hypothermic steady-state CPB, changes in CBV and MAP were related to each other, suggesting lack of cerebral autoregulation. The large decrease in Cytaa3 in 2 patients with circulatory arrest suggests that this procedure compromises energy metabolism of the brain cell.

Bloodless open-heart surgery in infants and children.

Between October 1984 and January 1993, seven children of Jehovah's Witnesses underwent corrective open-heart surgery for congenital defects, on cardiopulmonary bypass (CPB). Age at surgery ranged from three months to 6.5 years, and weight ranged from 4.2 kg to 23.2 kg, with two children weighing less than 10 kg. The principal cardiac anomalies were tetralogy of Fallot (two), double outlet right ventricle (one), subaortic stenosis (one), transposition of the great arteries and ventricular septal defect (one), atrial septal defect and congenital heart block (one), and congenital mitral regurgitation (one). Hypothermic CPB was used in all seven operations with crystalloid priming of the extracorporeal circuit. CPB was based on our standard perfusion protocols. All surgical procedures were done without the use of blood or blood products. The mean preoperative haematocrit (Hct) was 40.9% (range 31.0-47.8%). The mean lowest intraoperative Hct was 17.3% (range 15.0-24.3%), whereas the immediate post-CPB Hct was 19.6% (range 15.3-24.0%). The Hct progressively increased to 29.2% (range 21.0-34.2%) on the first postoperative day, and 32.3% (range 24.2-38.3%) at the time of discharge. There was no hospital mortality, and the mean hospital stay was 10 days (8-13 days). We report the safe repair of complex open-heart surgery in children, without blood transfusion, even in small infants. The successful management of these patients requires meticulous attention to surgical and perfusion technique, and sound postoperative management.

Multiple System Organ Failure after Open Heart Surgery in Infants and Children

Between January 1985 and March 1989 we retrospectively observed multiple system organ failure (MSOF) in 16 of 460 children (3.5%) who underwent cardiac surgery with cardiopulmonary bypass for congenital heart disease. MSOF was arbitrarily defined as a clinical entity with failure of two or more vital organ systems associated with high fever, thrombocytopenia, and cardiocirculatory insufficiency and occurring within the first postoperative week. In 13 children the first clinical manifestations of MSOF were evident on the first post-operative day and in the other 3 on the second or third post-operative day. All children showed acute renal failure, acute hepatic failure, high fever, and thrombocytopenia. Most of them showed respiratory insufficiency and neurological involvement. Seven of the 16 children died. Four of the 9 surviving patients had neurological sequelae still present 6 months after the operation, and the others recovered completely.

乳児期体外循環施行症例の検討 : 術中水分バランス・尿量に及ぼす因子について

乳児期体外循環施行症例の検討 : 術中水分バランス・尿量に及ぼす因子について

Cerebral blood flow pattern and autoregulation during open-heart surgery in infants and young children: a transcranial, Doppler ultrasound study.

To elucidate the effect of cardiopulmonary bypass on cerebral perfusion and on the autoregulatory ability of the cerebral vascular bed of infants and young children. Operating room. Prospective study. Thirteen newborn infants and young children undergoing open-heart surgery. Cerebral blood flow velocity was monitored in the patients undergoing open-heart surgery from just before the induction of anesthesia until the discontinuation of anesthesia after completion of the surgery. Cerebral blood flow velocity was assessed by semicontinuous measurement of temporal mean blood flow velocity in the middle cerebral artery using a range-gated, pulsed Doppler flowmeter with a transducer that was firmly attached to the left temporal region of the head. Mean arterial pressure (MAP) and nasopharyngeal temperature were continuously monitored. During hypothermic (18.4 degrees C to 31.9 degrees C) cardiopulmonary bypass, cerebral blood flow velocity decreased and showed a close relationship with nasopharyngeal temperature (p less than .0001). During steady-state cardiopulmonary bypass, cerebral blood flow velocity showed a correlation with MAP (p less than .01). The nasopharyngeal temperature influenced this relationship: at lower (absolute) nasopharyngeal temperatures, lack of cerebral autoregulation was more common. The finding suggests that cerebral blood flow decreases with decreasing nasopharyngeal temperature. During hypothermic cardiopulmonary bypass, cerebral autoregulation seems to be easily disturbed, especially at low nasopharyngeal temperatures.

Lipid peroxidation during open heart surgery in infants: S. Tatebe, H. Miyamura, H. Watanabe, Y. Takahashi and S. Eguchi. Department of Thoracic and Cadiovascular Surgery, Niigata University School of Medicine, Niigata, 951, Japan

Lipid peroxidation during open heart surgery in infants: S. Tatebe, H. Miyamura, H. Watanabe, Y. Takahashi and S. Eguchi. Department of Thoracic and Cadiovascular Surgery, Niigata University School of Medicine, Niigata, 951, Japan

乳幼児開心術後の低カリウム血症の成因に関する研究 : 第2編 カリウム動態およびアルドステロンの影響の経時的変化についての Prospective な検討

乳幼児開心術後の低カリウム血症の成因に関する研究 : 第2編 カリウム動態およびアルドステロンの影響の経時的変化についての Prospective な検討

小児麻酔最近の話題 新生児開心術管理の進歩 福岡市立こども病院の１０年間を省みて

小児麻酔最近の話題 新生児開心術管理の進歩 福岡市立こども病院の１０年間を省みて