Longer Bypass Research Articles

Higher extracellular volume is associated with longer bypass times at corrective surgery and reduced exercise tolerance in children late after repair of tetralogy of Fallot

Higher extracellular volume is associated with longer bypass times at corrective surgery and reduced exercise tolerance in children late after repair of tetralogy of Fallot

Vasoactive Inotropic Score (VIS) as Biomarker of Short-Term Outcomes in Adolescents after Cardiothoracic Surgery.

Our aim was to evaluate the Vasoactive Inotropic Score (VIS) as a prognostic marker in adolescents following surgery for congenital heart disease. This single-center retrospective chart review included patients 10-18 years of age, who underwent cardiac surgery from 2009 to 2014. Hourly VIS was calculated for the initial 48 postoperative hours using standard formulae and incorporating doses of six pressors. The composite adverse outcome was defined as any one of death, resuscitation or mechanical support, arrhythmia, infection requiring antibacterial therapy, acute kidney injury or neurologic injury. Surgeries were risk-stratified by the type of surgical repair using the validated STAT score. Statistical analysis (SPSS 19.0) included Mann-Whitney U test, Chi-square test, ROC curves, and binary regression analysis. Our cohort (n = 149) had a mean (SD) age of 13.9 (2.4) years and included 97 (65.1 %) males. Maximal VIS at 24 and 48 h following surgery was significantly higher in subjects (n = 27) who suffered an adverse outcome. Subjects with adverse outcome had longer bypass and cross-clamp times, durations of stay in the hospital, and a higher rate of acute kidney injury, compared to those (n = 122) without postoperative adverse outcomes. The area under the ROC for maximum VIS at 24-48 h after surgery was 0.76, with sensitivity, specificity, and positive and negative predictive values with 95 % CI of 67 (48-82) %, 74 (70-77) %, and 36 (26-44) % and 91 (86-95) %, respectively, at a cutoff >4.75. On binary logistic regression, maximum VIS on second postoperative day remained significantly associated with adverse outcome (OR 1.35; 95 % CI> 1.12-1.64, p = 0.002). Maximal VIS at 24 and 48 h correlated significantly with length of stay and time to extubation. Maximal VIS on the second postoperative day predicts adverse outcome in adolescents following cardiac surgery. This simple yet robust prognostic indicator may aid in risk stratification and targeted interventions in this population.

Trends in coronary artery bypass surgery: impact on early outcomes

improvements in nonsurgical revascularization have left a group of higher-risk patients presenting for operation in a later stage of coronary artery disease. We undertook this study to analyze temporal changes in demographic and clinical profiles and outcomes of cardiac surgical patients. we identified and retrieved preoperative, intraoperative, and postoperative variables for 3064 consecutive patients who underwent myocardial revascularization at the Aga Khan University Hospital between 2006 and 2011. Mortality and morbidity outcomes were compared using univariate and multivariate analyses. mean age, prevalence of left ventricular systolic dysfunction, unstable angina, mean number of occluded vessels, and arrhythmias at presentation increased steadily over time. The prevalence of diabetes, chronic lung disease, peripheral vascular disease, prior stroke, prior myocardial infarction, and left main disease declined. Operative mortality did not change significantly (3.5% vs. 3.8%, p = 0.512). Determinants of operative mortality included older age, female sex, renal insufficiency, left ventricular systolic dysfunction, and longer bypass and crossclamp times. coronary operations are increasingly performed in higher-risk patients with greater comorbidities. Despite this, operative mortality has not increased.

The RIME trial: Are we closer to the answer of when to repair ischemic mitral regurgitation?

BACKGROUND The development of mitral valve regurgitation as a result of left ventricular remodelling following myocardial infarction carries adverse implications on survival and quality of life (QOL). There is uncertainty whether mitral valve repair at the time of surgical revascularization improves survival and quality of life and enhances left ventricular reverse remodelling in patients with moderate ischemic mitral regurgitation (IMR). The Randomized Ischemic Mitral Evaluation (RIME) trial investigators tried to address this issue by studying whether repairing moderate IMR at the time of surgical revascularization can lead to more favourable outcomes compared with surgical revascularization only. Results of this multicentre, randomized, controlled trial were recently published in Circulation. 1 RIME was conducted in 6 centres in the UK and one in Poland. Out of 172 patients referred for CABG with moderate IMR, the RIME investigators randomized 73 eligible patients to receive either CABG alone (CABG group; n ¼ 39 patients) or CABG with mitral valve repair (Repair group; n ¼ 34 patients) The primary end-point was oxygen consumption at maximal exercise (VO2Max) measured by cardiopulmonary exercise testing, as an objective measure of functional capacity, at one year. The secondary end-points were left ventricular end-systolic volume indexed to body surface area (LVESVI) and mitral regurgitation volume as well as plasma B-type natriuretic peptide (BNP). All measurement were performed before enrollment and at one year postoperatively. Moderate IMR was defined by echocardiographically derived quantitative measures – namely regurgitant orifice area, regurgitant volume and vena contracta width – as per the ACC/AHA/ASE Valvular Heart Disease Guidelines. Patients were considered eligible if they met any of the above criteria whether at rest or during exercise. 2 Patients were excluded if they had ejection fraction ,30%, structural mitral valve disease (including papillary muscle rupture), significant aortic valve disease, previous or active endocarditis, previous cardiac surgery, unstable angina, symptoms of advanced heart failure or cardiogenic shock or significant comorbidities like liver or renal impairment and chronic obstructive airway disease. All CABG procedures utilized the left internal mammary artery to graft the left anterior descending coronary artery All technically graftable, significantly narrowed coronary arteries were addressed. Mitral repair was performed using a complete annuloplasty ring with the aim of achieving a leaflet coaptation length of at least 8mm and no or trace mitral regurgitation at the end of the operation. Both groups received similar number of grafts but the repair group expectedly had longer bypass and cross clamp times compared to the CABG group. The trial met all its end points with high statistical significance at the proposed follow up period of one year. The primary end point of change in peak oxygen consumption (Peak VO2) showed significant improvement at 1 year. The Peak VO2 in the repair group increased by 22% (from 14.8 ^ 3.2 to 18.1 ^ 2.9mL/kg/min) while the CABG group only increased by 5% (from 15.1 ^ 3.3 to

Pulmonary cusp augmentation in repair of tetralogy of Fallot

pulmonary insufficiency after transannular patch repair of tetralogy of Fallot is associated with a poorer outcome. to compare the results of 2 techniques of transannular patch repair. 93 patients with tetralogy of Fallot and hypoplasia of the right ventricular outflow tract underwent repair between 1990 and 2004 by 2 different techniques. Their ages ranged from 6 months to 12 years. The conventional transannular patch repair was used in 38 patients and 55 had transannular patch repair with pulmonary cusp augmentation. mortality rates were 13.16% after conventional transannular patch repair and 0% after transannular patch repair with pulmonary cusp augmentation. Follow-up periods were 13-18 years (mean, 15.7±1.64 years) and 5-14 years (mean, 10.8±2.07 years), respectively. The early and midterm results demonstrated significantly more pulmonary insufficiency in the conventional repair group. Transannular patch repair with pulmonary cusp augmentation had longer bypass and operative times, but it was associated with a lower operative mortality than conventional repair. The long-term results showed differences in pulmonary insufficiency, cardiothoracic ratio, and rate of reoperation for pulmonary valve replacement. reconstruction of the native pulmonary valve accompanied by pulmonary cusp augmentation can reduce postoperative pulmonary insufficiency and has a more favorable long-term outcome.

Red blood cell transfusion is an independent risk factor for cardiovascular complications in adult patients undergoing cardiac surgery: a propensity score-matched analysis

Red blood cell (RBC) transfusion is associated with a higher occurrence of clinical complications after cardiac surgery. However, the cause-effect relationship is confounded by other risk factors for worse outcomes as advanced age, valve or combined procedure, high EuroSCORE, redo surgery, longer bypass time and previous anemia. The objective of this study was to evaluate the effect of RBC transfusion in a propensity score-matched case-control analysis.

Hybrid Management Strategy for Percutaneous Fontan Completion Without Surgery: Early Results

We report early results of surgical preparation and subsequent percutaneous Fontan completion strategy for the treatment of single-ventricle defects. Two hundred twenty-seven patients underwent bidirectional cavopulmonary connection (BDCPC) between 2002 and 2007. Thirty-four patients had lateral tunnel created at time of BDCPC, fenestrated with 10 to 14 mm openings with the cardiac superior vena cava end patched to maintain BDCPC physiology. At second stage, Fontan circulation was established by superior vena cava patch perforation, tunnel dilatation, and stenting plus fenestration device closure. Thirty-four patients underwent Fontan preparation with BDCPC. Median age was 7.7 months (5 to 51) and 29 patients (85%) had previous palliation. Mean bypass and ischemic times were 141 and 72 minutes, respectively. Median ventilation, intensive care, and hospital stay durations were 1, 5, and 10 days, respectively. There was one early death and two take-downs. Twenty-eight patients underwent Fontan procedure: surgical (n = 3), percutaneous (n = 25). None of the patients who underwent percutaneous Fontan completion required inotropes, chest tube insertion, or mechanical ventilation. Median intensive care and hospital stay durations were 1 and 6 days, respectively. There were no early mortalities after percutaneous Fontan but one late death and one surgical revision. Overall survival after BDCPC with Fontan preparation was 77%. Despite longer bypass and ischemic times, Fontan preparation at time of BDCPC is feasible and associated with encouraging early outcomes. Percutaneous Fontan completion is associated with short recovery, low morbidity and excellent early dynamics, and echocardiographic and clinical outcomes. Further follow-up is needed to confirm those favorable results.

Ventilación mecánica invasiva en fibrosis quística: influencia en el trasplante pulmonar

Introduction Invasive mechanical ventilation (IMV) in patients with advanced cystic fibrosis (CF) is a relative contraindication for lung transplant (LT) in adults, although there is currently no data on children. Patients and methods An 8-year retrospective study on 21 children with CF who underwent LT was performed, analysing their results as they were receiving (n=8) or not (n=13) IMV pretransplant. Demographic and surgical data, postoperative course, lung function and survival (immediate and 1-year) were compared between both groups. The role of the IMV pretransplant as a postoperative risk factor was estimated (odds ratio) and Kaplan Meier survival study was performed in both groups. Results No differences in patient age, sex and nutritional parameters were observed between both groups. Those on IMV who received LT required more frequent and longer bypass, more need for tracheotomy, a higher number of rejection episodes per patient and multiorgan failure, longer PICU stay and longer time on IMV than those who were not on IMV when LT was received. Nevertheless, no differences could be found regarding graft function and immediate and 1-year survivals (62.5% vs. 92.3% with and without IMV respectively). On the other hand, long-term survival was significantly lower than in patients on IMV. Conclusions In our experience, children with CF on IMV who receive LT have more complicated surgery and immediate postoperative course. Though immediate and 1-year results and survivals may be encouraging, medium and long-term ones are significantly lower.

Surgical repair of multiple muscular ventricular septal defects: The role of re-endocardialization strategy

Surgical repair of multiple muscular ventricular septal defects (Swiss cheese septum) is associated with important morbidity and mortality. We sought to examine factors associated with permanent heart block, early mortality, and time-related survival. Additionally, we evaluated a new approach, transatrial re-endocardialization of interventricular septum, to mitigate risk. One hundred sixteen patients underwent surgery for multiple muscular ventricular septal defects (1982-2005), of whom 64 (55%) had associated cardiac anomalies. Twenty-seven consecutive patients (median age 0.54 years, range 15 days-7.2 years) underwent transatrial re-endocardialization (2002-2005). Forty-four percent had Swiss cheese septum (>4 defects). Multivariable regression analysis determined risk factors for pacemaker and survival. Operative mortality for the entire cohort was 9%. Risk factors for death were double-outlet right ventricle (odds ratio 44.7, P = .003), ventriculotomy (odds ratio 6.4, P = .03), and fewer multiple muscular ventricular septal defects repaired (odds ratio 4.7/defect, P = .04). Era mortalities differed: 16% for 1982 through 1990, 13% for 1990 through 1998, and 0% for 1999 through 2005, P = .006). Fourteen patients (12%) required a pacemaker. Time-related survivals at 1 and 10 years were 90% +/- 3% and 82% +/- 5%. Risk factors for death were double-outlet right ventricle (hazard ratio 8.3, P = .02) and longer bypass (hazard ratio 1.02/min, P = .02). In 27 re-endocardialization patients, a combined closure strategy to close 184 defects were applied: transatrial re-endocardialization (median 5, range 2-21), patch (median 1, range 0-4), and device (range 0-1). Post-repair ventricular function was good in 25 of 27 patients. The median number of residual defects was 1.5 (range 0-3), and median residual jet width on color Doppler was 2.3 mm (range 0-4.2 mm). One child required a pacemaker. There were no early or late deaths. Outcome of surgical repair of multiple muscular ventricular septal defects (Swiss cheese septum) has improved. Transatrial re-endocardialization strategy enables early complete or nearly complete obliteration of multiple muscular ventricular septal defects with minimal residual lesions (shunt, ventricular dysfunction). Long cardiopulmonary bypass duration is well tolerated. The incidence of permanent heart block has improved. Early echocardiographic and clinical outcomes are promising.

Early postoperative arrhythmias after pediatric cardiac surgery

Early postoperative arrhythmias are a known complication of cardiac surgery; however, little data exists specific to pediatrics. The purpose of this study was to determine the incidence and risk factors associated with the development of arrhythmias immediately after surgery in a pediatric population. Data were collected in a prospective observational format from pediatric patients undergoing cardiac surgery between September 2000 and May 2003. This format included age, anatomy, surgical repair, and serum magnesium and calcium levels, as well as cardiopulmonary bypass and aortic crossclamp times. Patients were continuously monitored, and hemodynamically significant arrhythmias were recorded. Arrhythmias occurred in 28 of the 189 patients enrolled (15%) including 16 with junctional ectopic tachycardia, 7 with complete atrioventricular block, 4 with ventricular tachycardia, and 1 with re-entrant supraventricular tachycardia. Significant differences were found between the arrhythmia and nonarrhythmia groups with regard to age (22 vs 45 months), cardiopulmonary bypass time (189 vs 109 minutes), and aortic crossclamp time (105 vs 44 minutes); P < .05. Magnesium and calcium levels were not significantly different between the groups. Two repairs carried an increased risk: complete atrioventricular septal defect repair, 8 of 11 patients (72%), and the arterial switch 5 of 8 patients (62.5%); P < .05. Atrioventricular septal defects had an even higher incidence when controlled for age, bypass time, and crossclamp time (odds ratio = 7.65). Hemodynamically significant postoperative arrhythmias are a frequent complication of pediatric cardiac surgery. Younger age and longer bypass and crossclamp times are risk factors for arrhythmia. In addition, the repair of atrioventricular septal defects carries an independent risk of arrhythmias.

Comparison of the immediate post-operative outcome of two different myocardial protection strategies: antegrade–retrograde cold St Thomas blood cardioplegia versus intermittent cross-clamp fibrillation

The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.

Langzeitresultate der chirurgischen Behandlung der akuten Aortenklappenendokarditis

Late results after surgery for acute infectious aortic endocarditis using allografts are compared with those achieved with bioprostheses or mechanical heart valves. Cryopreserved allografts were used in 74 (22 %) and prosthetic heart valve in 262 out of 336 (78 %) patients presenting acute aortic endocarditis. Prosthetic (p = 0.001) and destructive endocarditis (p = 0.001) were more frequent in patients receiving allografts. Mean follow-up time was 6.6 ± 4 years (range, 3 to 28 years). The 30-daymortality was 19 % for allograft patients and 6 % for those receiving prosthetic heart valves (p = 0.002). Early reoperation, postoperative renal failure and sepsis did not differ between groups. After 20 years, actuarial survival was 60 % for mechanical heart valves, 44 % for bioprosthesis and 38 % for allografts (p = 0.003), reoperation was unnecessary in 52 % of mechanical heart valves and 10 % of bioprostheses and allografts (p = 0.0007). Acute infection at the time of operation (p = 0.0001), redo surgery (p = 0.0006), staphylococci (p = 0.0003), older age (p = 0.004) and mitral valve involvement (p = 0.004) were risk factors for late death, irrespective of preoperative antibiotic treatment and type of prosthesis used. A longer bypass and aortic cross-clamp time predicted early (p = 0.0001) and late survival (p = 0.0001), independently. Destructive aortic endocarditis has a poor long-term outcome irrespective of the use of allografts. Acute infection at the time of surgery predicted early and late death; however, surgery is indicated prior to secondary involvement of the mitral valve. The duration of preoperative antibiotic treatment did not affect outcome. A thorough surgical technique directly influences early and late survival.

Nucleated red blood cells after cardiopulmonary bypass in infants and children: is there a relationship to the systemic inflammatory response syndrome?

In a retrospective case control study we aimed to evaluate whether infants and children with nucleated red blood cells (NRBCs) in their peripheral blood smears after cardiopulmonary bypass (CPB) had longer bypass times than controls without NRBCs. On review of a 3-year period, 58 children with NRBCs after CPB (and without NRBCs prior to CPB) were identified (cases). A random sample of 100 children without NRBCs after CPB over the same period served as controls. The median age (range) of the children with NRBCs and without NRBCs was 0.6 years (2 days to 20 years) and 1.4 years (2 days to 16 years), respectively (p = 0.03). The children with NRBCs had a significantly longer bypass time than the controls (mean, standard deviation (SD): 114 min, 50 vs 79 min, 46 min; p < 0.0001). For the patients with postoperative polychromasia alone, the mean CPB time (111 min, SD 46 min) was also significantly longer than the respective time in the controls (p < 0.001). Markers of organ dysfunction (renal failure, use of inotropic support, time of endotracheal intubation, stay in intensive care unit and stay in hospital) were significantly more frequent/longer in the NRBC group. Post-CPB release of NRBCs is associated with longer CPB time. This alteration may be part of the CPB-related systemic inflammatory response syndrome.

An institutional experience with the bidirectional cavopulmonary shunt: do we know enough about it?

AbstractBackgroundThe bidirectional cavopulmonary shunt has become a mainstay in the palliation of patients with a functionally single ventricle. Despite its usefulness, there are a number of concerns following its construction, including issues of timing, the development of pulmonary arteriovenous fistulas, and growth of the pulmonary arteries.MethodsBetween January 1990 and April 1996, we constructed a bidirectional cavopulmonary shunt in 123 patients. Median age at surgery was 9.4 months, and ranged from 24 days to 43 years. In 25 patients (20%), it was the first operative procedure. An auxiliary source of pulmonary blood flow was included in 72 patients (58%).ResultsSix patients (4.9%) died in the early postoperative period, and the overall early rate of failure (death or take-down) was 8.1%(n=10). By multivariate analysis, longer bypass time (p=0.012), age less than 1 month (p=0.03), and higher pulmonary vascular resistance (p = 0.043) were significant. Early reoperation was performed in 11 other patients to decrease (n=8) or increase (n=3) the amount of pulmonary blood flow. Early survivors were followed for a median of 15 months (range: 1 to 48 months), during which time 5 patients died and a Fontan circulation was completed in 30. Including early and late mortality, actuarial survival rates at 1 and 2 years were 91% and 88%, respectively. Among hospital survivors, the only significant predictor of poorer survival by Cox regression was age less than 2 months at the time of the initial cavopulmonary shunt (p=0.02). Atrioventricular valvar regurgitation was decreased after construction of the cavopulmonary shunt in 17 of the 28 patients (61%) in whom echocardiographic data were available to compare preoperative and postoperative status.ConclusionsThe bidirectional cavopulmonary shunt is a useful procedure in the early or intermediate term management of patients with a functionally univentricular heart. Much remains to be learned, nonetheless, about this unique physiologic system. The role of accessory pulmonary blood flow remains unclear, as does the use of the shunt as long-term palliation. Pulmonary arteriovenous fistulas are a serious concern, especially in young patients with heterotaxy syndrome (isomeric atrial appendages).

Myocardial infarction complicating aortic valve replacement

One hundred consecutive aortic valve replacements were studied. Fifteen patients had a myocardial infarction as a result of the operation, and four of the five deaths in the series stemmed from this group. In the four deaths from infarction, autopsy revealed occlusion of a main coronary artery. This was attributable to coronary perfusion in three instances. All of the 11 survivors who sustained an infarct were free of angina and left ventricular failure 6 weeks after the operation. Patients with infarcts had longer bypass times and larger aortic systolic gradients than the patients who did not have an infarct. It is suggested that an infarct can occur as the result of occlusion of a main coronary artery; this is a fatal event commonly related to trauma from the coronary perfusion cannula. Alternatively, infarction may result from regional ischemia, perhaps without vessel occlusion, and is associated with long bypass times and with large aortic valve gradients. In such cases the prognosis is good. However, myocardial infarction was the major cause of death in this series.