Need For Mechanical Support Research Articles

Early rescue Neopuff for infants with transient tachypnea of newborn: a randomized controlled trial

Objective: To examine the efficacy of early continuous positive airway pressure (CPAP), delivered using a T-piece-based infant resuscitator (Neopuff) via a face mask, in reducing the severity and duration of transient tachypnea of the newborn (TTN) as well as testing a hypothesis suggesting that rapid clearance of fetal lung fluid to the circulation via CPAP would increase plasma B-type natriuretic peptide (BNP). Methods: A randomized controlled trial (NCT01859533) was conducted on 64 late preterm/term neonates, delivered by cesarean section and presented by respiratory distress shortly after birth. The Neopuff group included 34 neonates received 20 min of early CPAP and control group included 30 neonates received free flow O2. Plasma BNP was measured baseline and 2 h later. Results: The duration of tachypnea was shorter in Neopuff group with less need of neonatal intensive care unit admission and need of mechanical support (p < .05) with no effect on duration of hospitalization (p > .05). Plasma BNP showed no significant difference between pre- and post-Neopuff levels (p > .05). A positive correlation was found between BNP and duration of tachypnea as well as the length of hospitalization (p < .05) among Neopuff group. Conclusion: Early rescue CPAP reduces the duration and severity of respiratory distress among infants with TTN. Trial registration: ClinicalTrials.gov identifier: NCT01859533.

Invited Commentary

The report by Bavaria and coauthors [1Bavaria J.E. Prager R.L. Naunheim K.S. et al.Surgeon involvement in transcatheter aortic valve replacement in the United States: a 2016 Society of Thoracic Surgeons survey.Ann Thorac Surg. 2017; 104: 1088-1094Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] provides a broad overview of the involvement of surgeons in transcatheter aortic valve programs. The results confirm their frequent participation in all aspects of care, including the referral and evaluation process, the procedure itself, and postprocedure care. The spectrum of procedural involvement by surgeons is framed between the extremes of the surgeon as the primary transcatheter aortic valve replacement (TAVR) proceduralist and the surgeon who stands in the control room watching. The original pivotal TAVR trials established the team approach and the subsequent decision by the Centers for Medicare and Medicaid Services for coverage of TAVR solidified the team, but individual variation of involvement will continue as some surgeons pursue the full breadth of interventional skills and others confine their involvement to a subset of the steps performed during TAVR or to those cases requiring a hybrid approach. Traditional surgical skills are, and will, remain essential to transcatheter valve therapies. Currently approximately 93% of TAVRs being entered into The Society for Thoracic Surgeons-American College of Cardiology Transcatheter Valve Replacement Registry (ATS/ACC TVC Registry) are performed through transfemoral access and rarely by access through a cutdown procedure. This stands in contrast to the first few years of TAVR in the United States when alternative access was 40% to 50% and femoral cutdowns were often used. This shift has reduced, but certainly not eliminated, the need for surgical skills. Likewise the need for mechanical support and conversion to an open surgical procedure have diminished but not disappeared. Fundamental to the team approach to TAVR is the presence of team members with skills and experience who can plan and execute TAVR in those patients needing alternative access or transient mechanical support. In addition, effectively responding to sudden events such as annular rupture, coronary occlusion, and iliac dissection will require a team response even if the site restricts their activity to “simple femoral cases.” The Society of Thoracic Surgeons survey does not identify some of the nuances of evolution in the team approach and surgical career model. Young cardiac surgeons have a decision to make—“How deeply do I go into the interventional skill set and how do I develop these skills when few of my senior mentors have them?” With increasing volume at a TAVR center in which surgeons and interventional cardiologists are fully engaged, the playing field has leveled between the specialties in the critical aspect of intraprocedural troubleshooting and decision-making. Surgeons have the experience to recognize evolving complications, make technical suggestions, and become facile with performing catheter and wire tasks. Finally the emerging transcatheter mitral space will be facilitated by the established culture of the surgical-interventional partnership. Being at the table is the key for all operators to become competent and able to contribute and to become wise to lead the next decade of innovation and major care transformation in cardiac transcatheter therapies. Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons SurveyThe Annals of Thoracic SurgeryVol. 104Issue 3PreviewThe Society of Thoracic Surgeons (STS) surveyed cardiothoracic surgeon participants in its Adult Cardiac Surgery Database (ACSD) to learn the extent of surgeon involvement in transcatheter aortic valve replacement (TAVR) procedures. Full-Text PDF

Incidence and echocardiographic predictors of early postoperative right ventricular dysfunction following left ventricular assist implantation in paediatric patients.

Left ventricular assist device implantation is an established therapy for paediatric patients with end-stage heart failure. Early right ventricular dysfunction (RVD) after implantation still remains a challenge in the postoperative period. This study sought to determine the incidence of RVD and to identify echocardiographic predictors of RVD in paediatric patients, as well describing associated clinical outcome. Prospectively collected preoperative echocardiographic, haemodynamic, demographic and biochemical data from 48 patients scheduled for left ventricular assist device implantation were evaluated. Incidence of high central venous pressure, decreased central venous saturation, high inotropic support requirements or need for mechanical support of the right ventricle during the first 48 h after implantation were used to define RVD. Echocardiographic assessments of right ventricular geometry, function using linear dimensions, areas and tricuspid annular plane systolic excursion (TAPSE) were performed preoperatively and the relative relationships between these parameters were evaluated. We included 48 consecutive paediatric patients (median age 5 years, range 0-17; median weight 15.9 kg, range 3.6-91). According to our criteria, 24 (50%) patients developed RVD. TAPSE as the parameter for assessment of longitudinal systolic function was significantly lower in this group (P = 0.01). The difference became even more pronounced after normalization to the RV end-diastolic diameter in long axis with P = 0.003. The odds ratio for patients with TAPSE/RV end-diastolic diameter in long axis <17.1% to develop RVD was 7.7 (P = 0.002). RVD occurs frequently in paediatric patients after left ventricular assist device. TAPSE, normalized to the RV end-diastolic diameter, may help to identify patients at risk for RVD. The predictive value of this parameter supports decision making to plan for adequate pharmacological support or consider early upgrading to mechanical RV support.

Extubating Techniques for the Difficult Airway

PACU or ICU patients generally require reintubation for two main reasons - inadequate airway patency (extubation failure) and residual need for mechanical support (weaning failure). Such events are relatively common and can be associated with significant morbidity, mortality and costs. However, while the majority of reintubations are relatively straightforward, certain patients may be difficult to reintubate either from pre-existing conditions or from reasons related to their need for critical care.

Peripartum cardiomyopathy: a clinical review for nurses

Peripartum cardiomyopathy is a rare form of heart failure occurring within the last month of pregnancy and in the post-partum period. The pathophysiology is poorly understood and may be multi-factorial. Abnormal prolactin secretion, the presence of myocarditis, an autoimmune component, and nutritional causes are several potential aetiologies. Very little is known about its true prevalence as most data are derived from single-centre case series. The diagnosis is one of exclusion of other causes of symptoms, with echocardiography possessing an integral role in the diagnostic process ( Sliwa et al, 2010 ). Treatment is similar to that of other forms of heart failure, albeit with exclusion of renin–angiotensin–aldosterone inhibition in the pre-partum period. The clinical course is highly variable ranging from full recovery of left ventricular function to refractory heart failure resulting in the need for mechanical support and/or cardiac transplantation. Holistic nursing care involves early recognition of symptoms, haemodynamic instability and evaluation of the therapies administered. Care of the foetus needs to be addressed with foetal monitoring and an established birthing plan. Education regarding selfcare and counselling regarding future pregnancy and family planning is an integral component of nursing care. Follow-up with periodic echocardiography is essential in detecting improvement or persistent left ventricular dysfunction. There is a paucity of data and empirical evidence regarding this condition and the establishment of the EURObservational registry ( Sliwa et al, 2014 ) serves to increase knowledge and awareness of PPCM.

Cardiac Transplantation in the New Era.

The prevalence of heart failure continues to rise due to the aging population and longer survival of people with conditions that lead to heart failure, eg, hypertension, diabetes, and coronary artery disease. Although medical therapy has had an important impact on survival of patients and improving quality of life, heart transplantation remains the definitive therapy for patients that eventually deteriorate. Since the first successful heart transplantation in 1967, significant improvements have been made regarding donor and recipient selection, surgical techniques, and postoperative care. However, the number of potential organ donors has not changed and the growing number of patients in need for transplantation has resulted an increase in waiting list time, and the need for mechanical support. To overcome this issue, the United Network for Organ Sharing implemented an allocation system to prioritize the sickest patients on the list to receive organs. Despite the careful selection of patients, pretransplant immunological screening, and multidrug immunosuppressive regimens, acute and chronic rejections occur and potentially limit graft and patient survival. Treatment for rejection largely depends on the type of rejection, the presence of hemodynamic compromise, and time after transplantation. The limiting factor for long-term graft survival is allograft vasculopathy, an immune-mediated process causing diffuse narrowing of the coronary arteries. Percutaneous coronary intervention and coronary artery bypass surgery are often not an option for this vasculopathy due to the lack of focal lesions, and retransplantation is the only option in appropriate patients.

Abstract 18729: Comparative Analysis of the Use of Extracorporeal Membrane Oxygenation During Cardiopulmonary Resuscitation Within a Pediatric Cardiac Intensive Care Unit

Background: Mechanical support to aid in restoration of circulation during cardiopulmonary resuscitation (CPR) is increasingly common in the pediatric cardiac intensive care unit (CICU). We sought to both identify and quantify factors predicting the implementation of extracorporeal membrane oxygenation to support CPR (eCPR). Methods and Results: Events associated with CPR from July 2010 through December 2013 within our pediatric CICU were retrospectively reviewed. Of 135 arrests among 88 patients, 84% were among postsurgical patients and 98% (n=133) resulted in a return of circulation, either spontaneous (n=100, 74%) or with the assistance of mechanical support (n=33, 24%). Median age at arrest was 106 days (interquartile range [IQR] 26-207 days) and weight was 3.9 kg (IQR 3.0-6.0 kg). Median length of stay (LOS) at the time of arrest was 5 days (IQR 1-49 days). Common primary causes included low cardiac output (38%), respiratory failure (33%), and arrhythmia (15%). Univariate predictors of an eCPR arrest included smaller size (3.3 v. 4.3 kg, p=0.004), younger age (25 v. 130 days, p&lt;0.001), shorter length of stay at time of arrest (1 v. 8.5 days, p=0.001), single ventricle physiology (30% v. 14% among biventricular physiology arrests, p=0.04), and arrests not related to respiratory failure (34% v. 5% eCPR among respiratory failure arrests, p&lt;0.001). Unit factors not associated with an increased frequency of arrests resulting in eCPR included unit capacity, night shift, and the experience levels of both the bedside nurse and attending. Among patients with at least one arrest, median ICU LOS was 18 days (IQR 9-72 days) and overall survival to ICU discharge was 72%. Survival to ICU discharge was not significantly different with respect to use of eCPR as compared to conventional CPR (60% v. 77% respectively, p=0.11). Conclusions: We report predictors of the need for mechanical support during cardiopulmonary resuscitation within a pediatric CICU, and demonstrate comparable post-resuscitation survival to ICU discharge among those rescued with eCPR. Further longitudinal investigation is necessary to identify potential eCPR-associated differences in morbidity and neurocognitive outcomes following a CICU arrest.

Predictors of contemporary coronary artery bypass grafting outcomes

The study objective was to identify the predictors of outcomes in a contemporary cohort of patients from the Reduction in cardiovascular Events by acaDesine in patients undergoing CABG (RED-CABG) trial. Despite the increasing risk profile of patients who undergo coronary artery bypass grafting, morbidity and mortality have remained low, and identification of the current predictors of adverse outcomes may permit new treatments to further improve outcomes. The RED-CABG trial was a multicenter, randomized, double-blind, placebo-controlled study that determined that acadesine did not reduce adverse events in moderately high-risk patients undergoing nonemergency coronary artery bypass grafting. The primary efficacy end point was a composite of all-cause death, nonfatal stroke, or the need for mechanical support for severe left ventricular dysfunction through postoperative day 28. Logistic regression modeling with stepwise variable selection identified which prespecified baseline characteristics were associated with the primary outcome. A second logistic model included intraoperative variables as potential covariates. The 4 independent preoperative risk factors predictive of the composite end point were (1) a history of heart failure (odds ratio, 2.9); (2) increasing age (odds ratio, 1.033 per decade); (3) a history of peripheral vascular disease (odds ratio, 1.6); and (4) receiving aspirin before coronary artery bypass grafting (odds ratio, 0.5), which was protective. The duration of the cardiopulmonary bypass (odds ratio, 1.8) was the only intraoperative variable that contributed to adverse outcomes. Patients who had heart failure and preserved systolic function had a similar high risk of adverse outcomes as those with low ejection fractions, and new approaches may mitigate this risk. Recognition of patients with excessive atherosclerotic burden may permit perioperative interventions to improve their outcomes. The contemporary risks of coronary artery bypass grafting have changed, and their identification may permit new methods to improve outcomes.

Creation of a Quantitative Score to Predict the Need for Mechanical Support in Children Awaiting Heart Transplant

Due to the availability of new devices, the use of ventricular assist devices (VADs) in children has been increasing; however, patient selection and optimal timing of device implantation in this population remains uncertain. A retrospective review of the United Network for Organ Sharing dataset identified 5,200 listings without mechanical circulatory support (MCS) for isolated pediatric heart transplant, 1995 to 2012. Patients were randomly divided into a derivation and validation cohort. A multivariable logistic regression model predicting the likelihood of death or need for MCS within 60 days was built using the derivation cohort and tested in the validation cohort. A simplified score (PedsMCS score) was developed and evaluated for accuracy. The predictive model consisted of variables present at listing (age, albumin level, creatinine clearance, serum bilirubin, mechanical ventilation, and inotropic support). It had good predictive ability (C statistic 0.7304) within the validation cohort. The simplified PedsMCS score was also predictive (C statistic 0.7217) and there was a strong correlation between predicted and expected outcomes (r=0.91, p<0.0001). Patients with PedsMCS score 16 or greater had a significantly higher risk of death or MCS within 2 months (36.6%) than those with low scores (<6) (1.5%, p<0.0001). A single point increase in PedsMCS score was associated with a 16.7% increase in the risk of death or MCS with 2 months (p<0.0001). We have developed and validated a simplified score to predict the need for MCS based on risk factors present at listing. This will provide more accurate prognostication in children awaiting heart transplant, and may improve patient selection.

An update on bioresorbable vascular scaffolds: from lesion preparation, deployment and beyond

Abstract Recently, bioresorbable vascular scaffolds have emerged as an alternative to metallic stents since the need for mechanical support for the healing artery is temporary, and beyond the first few months there are potential disadvantages of a permanent metallic prosthesis. However, intrinsic properties related to its design and composition have resulted in some peculiarities about their deployment. In the present article, we briefly address a few aspects related to bioresorbable vascular scaffolds implantation.

Preoperative B-type natriuretic peptide levels are associated with outcome after total cavopulmonary connection (Fontan)

The study objective was to determine the association between preoperative B-type natriuretic peptide levels and outcome after total cavopulmonary connection. Surgical palliation of univentricular cardiac defects requires a series of staged operations, ending in a total cavopulmonary connection. Although outcomes have improved, there remains an unpredictable risk of early total cavopulmonary connection takedown. Theprediction of adverse postoperative outcomes is imprecise, despite an extensive preoperative evaluation. We prospectively enrolled 50 patients undergoing total cavopulmonary connection. We collected preoperative clinical data, preoperative plasma B-type natriuretic peptide levels, and postoperative outcomes, including the incidence of an adverse outcome within 1 year of surgery (defined as death, total cavopulmonary connection takedown, or the need for cardiac transplantation). The mean age of patients was 4.7 years (standard deviation, 2.1 years). The median (interquartile range) preoperative B-type natriuretic peptide levels were higher in patients who required total cavopulmonary connection takedown and early postoperative mechanical cardiac support (n=3; median, 55; interquartile range, 42-121) compared with those with a good outcome (n=47; median, 11; interquartile range, 5-17) (P<.05). A preoperative B-type natriuretic peptide level of 40 pg/mL or greater was highly associated with the need for total cavopulmonary connection takedown (sensitivity, 100%; specificity, 93%; P < .05), yielding a positive predictive value of 50% and a negative predictive value of 100%. Higher preoperative B-type natriuretic peptide levels also were associated with longer intensive care unit length of stay, longer hospital length of stay, and increased incidence of low cardiac output syndrome (P<.05). Preoperative B-type natriuretic peptide blood levels are uniquely associated with the need for mechanical support early after total cavopulmonary connection and total cavopulmonary connection takedown, and thus may provide important information in addition to the standard preoperative assessment.

Prebypass Hemodynamic Instability in Patients with Severe Pulmonary Hypertension Undergoing Double Lung Transplantation

Purpose Severe Pulmonary hypertension (PHTN) is defined as the mean pulmonary artery pressure (mPAP) greater than 40 mmHg at rest. Lung transplantation is often the common treatment pathway for end-stage pulmonary hypertension. Anesthetic management of lung transplantation in a patient with severe PHTN can be challenging. The intraoperative period during the induction, initial one lung ventilation, and clamping of the pulmonary artery is particular dangerous as vasodilation, myocardial depression, initiation of positive pressure ventilation, acute increase in RV afterload can lead to systemic hypotension and acute RV failure leading to cardiac arrest. Our aim is review patients with severe PHT undergoing their first double lung transplantation over the last 10 year period. Methods and Materials We investigated the role of the severity of PHT in predicting the need for mechanical support (VA-ECMO, or CPB) prior to first lung pneumonectomy. We retrospectively reviewed 88 cases of sequential double lung transplants, between 2007 and September 2009, who had a mean pulmonary pressure greater (mPA) 40 mmHg on their preoperative right heart catheterization. Results Our results show a clear dose response relationship between mPA and need for MCS: for patients with mPA between 40-49 (45/59 patient done under support, with 19/45 needing support unplanned), 50-60 (21/22 with support, 9/21 unplanned), 60-70 (8/9, and 1/8 unplanned), and >70 (1/1, 0/1 unplanned). Moreover, examining all 88 patients, patients needing support 75/88 vs 13/88 done without support, the average mean PA was 50 vs 45, PVR (7.7 vs 4.6), and 6 minute walk distance (161 vs 221 meters). In conclusion, we show that mean pulmonary artery pressure shows a dose response relationship with need for MCS. Conclusions The incidence of hemodynamic instability requiring resuscitation and emergency institution of cardiopulmonary bypass or extracorporeal life support is very high (26%) in severe PHT and future studies should focus on the prediction and management.

Primary Graft Dysfunction vs. Primary Graft Failure: Are All Graft Problems Created Equal?

Purpose Primary graft dysfunction (PGD) and failure (PGF) are severe complications after heart transplantation. Until now there are no common guidelines to differentiate between these complications. In this single center analysis, the impact of both PGD and PGF on outcome after transplantation was analyzed. Methods and Materials We investigated 1238 patients after heart transplantation between 1984-2011. PGD was defined as high inotropic support to wean a patient from bypass after transplantation. PGF was defined as need for mechanical support. Incidence, outcome and causes of death in both groups were compared during different time periods (A:1984-1999, B: 2000-2011). Survival was compared by Kaplan-Meier analysis. A p-value of Results Overall incidence of primary Graft problems was 15.4%. 116 patients developed PGD (9.3%) and 76 patients showed PGF (6.1%). Incidence of PGD and PGF changed significantly over time (PGD: A: 10%, B: 8.4%; p Conclusions Survival of patients with PGD and PGF is significantly reduced. In recent time eras survival haa increased. International guidelines for prevention and treatment of these complications are needed.

Effect of Adenosine-Regulating Agent Acadesine on Morbidity and Mortality Associated With Coronary Artery Bypass Grafting

Ischemia/reperfusion injury remains an important cause of morbidity and mortality after coronary artery bypass graft (CABG) surgery. In a meta-analysis of randomized controlled trials, perioperative and postoperative infusion of acadesine, a first-in-class adenosine-regulating agent, was associated with a reduction in early cardiac death, myocardial infarction, and combined adverse cardiac outcomes in participants undergoing on-pump CABG surgery. To assess the efficacy and safety of acadesine administered in the perioperative period in reducing all-cause mortality, nonfatal stroke, and severe left ventricular dysfunction (SLVD) through 28 days. The Reduction in Cardiovascular Events by Acadesine in Patients Undergoing CABG (RED-CABG) trial, a randomized, double-blind, placebo-controlled, parallel-group evaluation of intermediate- to high-risk patients (median age, 66 years) undergoing nonemergency, on-pump CABG surgery at 300 sites in 7 countries. Enrollment occurred from May 6, 2009, to July 30, 2010. Eligible participants were randomized 1:1 to receive acadesine (0.1 mg/kg per minute for 7 hours) or placebo (both also added to cardioplegic solutions) beginning just before anesthesia induction. Composite of all-cause mortality, nonfatal stroke, or need for mechanical support for SLVD during and following CABG surgery through postoperative day 28. Because results of a prespecified futility analysis indicated a very low likelihood of a statistically significant efficacious outcome, the trial was stopped after 3080 of the originally projected 7500 study participants were randomized. The primary outcome occurred in 75 of 1493 participants (5.0%) in the placebo group and 76 of 1493 (5.1%) in the acadesine group (odds ratio, 1.01 [95% CI, 0.73-1.41]). There were no differences in key secondary end points measured. In this population of intermediate- to high-risk patients undergoing CABG surgery, acadesine did not reduce the composite of all-cause mortality, nonfatal stroke, or SLVD. clinicaltrials.gov Identifier: NCT00872001.

Single-center experience with levosimendan in children undergoing cardiac surgery and in children with decompensated heart failure

BackgroundLevosimendan has pharmacologic and hemodynamic advantages over conventional intravenous inotropic agents. It has been used mainly as a rescue drug in the pediatric intensive care unit or in the operating room. We present the largest single-center experience of levosimendan in children.MethodsRetrospective analysis of all children who received levosimendan infusions between July 5, 2001 and July 4, 2010 in a pediatric intensive care unit. The results of a questionnaire for physicians (anesthesiologist/intensivists, cardiologists and cardiac surgeons) concerning their clinical perceptions of levosimendan are evaluatedResultsDuring the study period a total of 484 infusions were delivered to 293 patients 53% of whom were male. The median age of the patients was 0.4 years (4 hours-21.1 years) at the time of levosimendan administration. A majority of levosimendan infusions were administered to children who were undergoing cardiac surgery (72%), 14% to children with cardiomyopathy and 14% to children with cardiac failure. Eighty-nine out of the 293 patients (30.4%) received repeated doses of levosimendan (up to 11 infusions). The most common indication for the use of levosimendan (94%) was when the other inotropic agents were insufficient to maintain stable hemodynamics. Levosimendan was especially used in children with cardiomyopathy (100%) or with low cardiac output syndrome (94%). A majority (89%) of the respondents believed that levosimendan administration postponed the need for mechanical assist devices in some children with cardiomyopathy. Moreover, 44% of respondents thought that the mechanical support was totally avoided in some patients undergoing cardiac surgery after receiving levosimendan.ConclusionLevosimendan is widely used in our institution and many physicians believe that its use could decrease the need for mechanical support in children undergoing cardiac surgery or in children with decompensated heart failure. However, there is a lack of good empirical evidence in children to support this perception.

Impella assisted transradial coronary intervention in patients with acute coronary syndromes and cardiogenic shock

Operators may feel apprehension when considering the transradial approach in patients with cardiogenic shock due to concerns of the need for femoral access for mechanical support. There is however potential benefit of transradial approach in this setting by reducing bleeding complications in patients on potent anticoagulant and antiplatelet agents. We report three cases of patients with cardiogenic shock with successful transradial intervention (TRI) whilst using unilateral femoral access for Impella (ABIOMED, Danvers, MA) mechanical support. In two cases, the need for mechanical support was not clear at the beginning of the procedure, and in the third there was a clear need to combine femoral and radial access due to pre-existing anatomic issues. Two patients required transfusion of red blood cells but otherwise there were no vascular access complications.

Primary arterial switch operation in children presenting late with d-transposition of great arteries and intact ventricular septum. When is it too late for a primary arterial switch operation?

The surgical management of infants older than 2 weeks with d-transposition of great arteries and intact ventricular septum (IVS) is a matter of debate. Some studies have presented good results of primary arterial switch operation (ASO) in these children. The aim of this study was to assess the surgical outcome of the primary ASO in children with d-transposition of great arteries and IVS presenting beyond 6 weeks of age. The clinical records of the children (more than 6 weeks age) with d-transposition of great arteries and IVS, who underwent primary ASO at our institute between January 2003 and June 2009 were reviewed. Left ventricular geometry and interventricular septal motion on the transthoracic cross-sectional echocardiogram were taken to assess the left ventricle preparedness. Fifty-five children (age ranging from 42 days to 9 years) with d-transposition of great arteries and IVS underwent primary ASO. The mean cardiopulmonary bypass time was 94.7±21.3 min, while mean aortic cross-clamp time was 53.2±8.1 min. Seven (13%) of these children died during their hospital stay. The children who had severely regressed left ventricle (banana-shaped left ventricular geometry) were operated with integrated extra corporeal membrane oxygenation-cardiopulmonary bypass (ECMO-CPB) circuit for left ventricular re-training. The children with regressed left ventricle required longer ventilatory time and inotropic support. Recovery of left ventricular geometry has taken 1-6 months depending on age at surgery. The children older than 6 weeks with d-transposition of great arteries and IVS can benefit from primary ASO with acceptable results. However, the need for mechanical support in some of the older patients may limit the widespread adoption of such a strategy.

Prognostic factors in flail-chest patients☆

The records of 250 patients presenting with flail-chest injury in a level I trauma centre were reviewed and analysed in order to determine prognostic factors. There were 250 consecutive trauma patients with flail chest, 183 men (73.2%) and 67 women (26.8%) ranging in age from 18 to 91 years, admitted to our hospital. The leading cause of injury was road traffic accident. One hundred and six patients (42.4%) were conservatively treated, while 117 (46.8%) needed thoracic drainage. Ventilatory assistance was used in 28 cases (11.2%). Only 19 (7.6%) required thoracotomy and/or laparotomy. The mortality rate reached 8.8%. Patients were divided into three groups: group I consisted of 105 patients (70/35) with an isolated flail chest (Injury Severity Score (ISS): 16); group II included 58 cases (48/10) with extrathoracic fractures (ISS: 25-30); and group III comprised 87 patients (65/22) with injuries to the brain or to thoracic or abdominal organs requiring thoracotomy and/or laparotomy (ISS: >40). Parameters such as age, sex, ISS, presence of extrathoracic fractures, haemopneumothorax and head injury as well as the need for mechanical support in an intensive care unit (ICU) and mortality were evaluated. The mortality rate in group III was higher compared to those of groups I and II (16% vs 3.8% and 6.9%, respectively) and the difference was found to be statistically significant. Laparotomy and thoracotomy affected mortality, while age, pneumothorax and head injury did not. Finally, mechanical support was used only in a few cases. (1) ISS is the strongest predictor of outcome associated with increased mortality; and (2) mechanical support was not considered a necessity for the treatment of flail chest.

Critical care outcomes in pulmonary atresia and intact ventricular septum undergoing single-ventricle palliation

To examine early outcomes for pulmonary atresia with intact ventricular septum undergoing single-ventricle palliation and to determine risk factors for mortality. Retrospective observational study. Tertiary paediatric critical care unit. Risk factors for mortality were sought for infants after the primary intervention whether surgical shunt or ductal stent. We reviewed outcomes of 19 infants with pulmonary atresia with intact ventricular septum undergoing single-ventricle palliation between July, 2000 and July, 2008. Echocardiograms, cardiac catheterisation findings, anaesthesia, and critical care management, as well as autopsy reports were reviewed. We modelled survival after surgery and looked for predictors of early mortality. A total of 19 infants underwent single-ventricle palliation and seven of these died. The risk of death was increased by a lower arterial pH at induction of anaesthesia (p = 0.01), a lower systolic blood pressure (p = 0.01), and technical problems during surgery (p = 0.03). On admission to the critical care unit, a lower mixed venous saturation (p = 0.02) and presence of tachyarrhythmia (p = 0.02) were associated with the need for mechanical support within the first 48 hours. There is a high early mortality for those who undergo single-ventricle palliation. It is higher for those who are haemodynamically compromised before surgery; technical problems, and haemodynamic instability during surgery also increase mortality.

67: Comparing the Effects of Biventricular Support with Left Ventricular Support Alone on Heart Transplant Outcomes

The need for mechanical support of the right ventricle in patients with left ventricular failure requiring ventricular assist devices has been difficult to predict. While some programs place biventricular support almost exclusively, other will attempt all other options prior to placing right ventricular support. Our bias has been that biventricular support (BiVAD) has poorer long term outcomes compared to left ventricular support (LVAD) only, so we hypothesized that transplant patients with biventricular support would fair worse after transplant.