Pediatric Cardiac Surgery Unit Research Articles

I vantaggi della correzione mininvasiva delle cardiopatie congenite riletti dopo 25 anni di esperienza

Background - For many years the treatment of congenital heart disease has been performed through median sternotomy. Recently, the dimensions of the cutaneous incision have been reduced to optimize functional recovery and improve the aesthetic result. However, there are still few experiences in this field. Objectives - The objective of the study is to describe the results of minimally invasive cardiac surgery at the Paediatric Cardiac Surgery Unit of the Hospital-University of Padua in over 25 years of experience. Materials and Methods - The study included all paediatric patients who underwent minimally invasive cardiac surgery (ministernotomy, right anterior minithoracotomy, or right lateral minithoracotomy) between January 1998 and December 2022. Intraoperative and early postoperative (during hospitalization) outcomes were investigated. Results - All patients (1,111) underwent a successful correction, without any need for conversion to median sternotomy. The median length of stay in the intensive care unit was 1 day (1-2 days), and in the hospital was 5 days (4-6 days). There were no in-hospital deaths and the rate of major complication was 3% (33/1,111 patients). Conclusions - The treatment of congenital heart disease with minimally invasive cardiac surgery when performed in experienced centres shows excellent clinical results without any additional risk compared to the traditional median sternotomy. For this reason, minimally invasive cardiac surgery has been the gold standard for the treatment of many congenital heart diseases for over 25 years.

Establishing Pediatric Cardiac Surgery Unit in Underprivileged Area. An Audit of First 100 Cases & Challenges Faced

Nevertheless, congenital anomalies predominantly cardiac are still leading cause of under five-year-old mortality. There is significant global improvement has been observed in declining of under 5-year mortality from 93 deaths per 1,000 births in 1990 to 39 in 2017 (58%).Objective: The aim of this audit was to present our experiences of first hundred cases of congenital heart defects surgeries along with the challenges faced during the establishment of new pediatric cardiac surgery center in underprivileged area. Methods: This was an audit of the first 100 cardiac surgeries performed for congenital heart defects at Gambat Institute of Medical Science from 15- 3- 2021 to1-10-2022. During the period challenges other then related with surgical interventions; more than an investment of money but political, cultural, and social faced. Results: The mean age was 9+/-6.5 years, with female predominance of 57. Sever pulmonary hypertension was present in 6 patients. The majority of our patients were from RACHS1 score category 1. Out of 100 patient open heart surgeries were 89(89%) and close heart were 11(11%). We have single mortality of patient underwent Tetralogy of Fallot correction developed massive stroke and expired at 5th postoperative day. Three patients were re explored for bleeding while one required emergency reopening in PICU for cardiac arrest. Post clamp removal arrhythmias were observed in 7(7%) patients. We received three patients in emergency from Pediatric cardiology post intervention including device embolization, device malposition and acute Mitral regurgitation post intervention. Conclusions: Providing Pediatric cardiac surgery services to the children of remote and socioeconomically deprived area is a greatly rewarding. It has many challenges other than providing direct patient care.

Down’s Syndrome with Congenital Heart Disease: Our Surgical Experience

Background: Our objective was to analyze the outcome of patients of Down’s syndrome with congenital heart diseases undergoing cardiac surgery.
 Methods: This was a retrospective study conducted between January 2013 and June 2019. 49 consecutive patients with Down’s syndrome with congenital heart disease admitted in pediatric cardiac surgery unit at National Institute of Cardiovascular Diseases (NICVD). Patients were followed up postoperatively for in-hospital outcome.
 Results: Among 49 patients the heart lesion ranked in incidence as follows- VSD 24(48.97%), AV canal defect 12(24.48%), TOF 6(12.24%), PDA 6(12.24%) and ASD 1(2.04%). Pulmonary hypertension was found in 63.25% patients. Moderate pulmonary hypertension was most common, found in 18(38.66%) patients. Severe and mild pulmonary hypertension was found in 10(32.38%) and 3(9.67%) patients respectively. All the patients had undergone surgical correction. The postoperative period was complicated in 44.89% of patients. The most frequent complication was pulmonary infection 20.40%, Wound infection 6.12% and low output syndrome 6.12% were the next. One patient had postoperative heart block, needed permanent pace maker implantation. In-hospital mortality was 12.24%.
 Conclusion: Patients with Down’s syndrome with congenital heart disease undergoing surgical correction had an acceptable postoperative morbidities and mortality.
 Cardiovasc. j. 2020; 13(1): 35-39

Relation between right ventricular function and the time of extubation after total repair of tetralogy of fallot in the pediatirc population

To study the relation between the systolic and diastolic right ventricular (RV) function in relation to the time of extubation after total repair of tetralogy of Fallot (TOF) in a pediatric population. Prospective, descriptive, non-randomized study. Pediatric cardiac surgery unit at Ain Shams University Hospitals, Cairo, Egypt. The study was conducted from January 2016 to February 2018. A total of 60 patients having elective primary total repairs of TOF made up the study sample. The patients were divided into two groups based on the time of extubation: Group I included patients who were extubated 6 hours or more after the procedure, while Group II included patients who were extubated within the first 6 hours. Total corrective surgery involving open-heart surgery with cardiopulmonary bypass. Measurements and Main Results: Early outcomes of mortality and morbidity were evaluated. RV systolic and diastolic functions were evaluated in the routine echocardiography performed on the first and fifth postoperative days. Additionally, patients’ inotropic drug requirements during their intensive care unit (ICU) stays were calculated to produce the inotropic index for evaluation of postoperative low cardiac output. Group I contained 32 patients, while Group II contained 28. The mean ages in Group I and II, respectively, were 1.2 ± 0.8 years and 1.5 ± 0.9 years (p = 0.180). The mean weight in Group I and II, respectively, was 10.5 ± 2.5 kg and 9.86 ± 3.2 kg (p = 0.396). There were 20 (62.5%) males in Group I and 18 (64.29%) males in Group II (p = 0.886). Mortality was 2 cases (6.3%) in Group I and 1 case (3.6%) in Group II, with no statistical difference. Postoperative echocardiographic examination revealed significantly better RV functional parameters in Group II than in Group I.

Vascular Ring; Spectrum of Pathologies and Scenarios for Diagnosis and Management

<i>Background</i>: Vascular rings represent approximately 1% of all congenital cardiac anomalies, with Edward’s classification being the first to outline them into a complete or partial vascular ring. A Complete ring is a combination of patent vessels, atretic vascular segments or ligamentous structures. <i>Methods</i>: We reviewed patients` records from our Pediatric Cardiac Surgery Unit, over 10 years. We encountered 63 patients from January 2009 to January 2019. Our patients were 57 (90.5%) complete vascular rings, 5 (7.9%) pulmonary artery slings, and 1 (1.6%) patient with innominate artery compression. <i>Results</i>: The age of our Patients ranged from 2 to 57 months (mean 16.25±1.3 m), weight ranges from 3k to 26k (mean 9.87±0.8kg). Males were 38 (60.3%) and male: female ratio was 1.5:1. In our series various types of vascular rings were encountered; Double Aortic Arch was the right dominant arch variant in 25 (53.2%) and left arch dominant in 7 (14.9%) whilethe co-dominant variant was 15 (31.9%). Fifty-seven cases of vascular rings operated through left posterolateral thoracotomy. Fivecases of pulmonary artery sling (7.9%) operated by median sternotomy and one case (1.6%) of innominate artery compression. No reported intraoperative mortality in our study. <i>Conclusion</i>: Vascular ring is a rare anomaly that needs suspicion for diagnosis. The operative strategy relies on extensive dissection and division of the non-dominant arch and division of the ligamentum, freeing all fibrous bands between the arch and esophagus and trachea. For augmented results; we need collaboration from pediatricians and pulmonologists who must be aware of such anomalies.

Single-Shot Cold Histidine-Tryptophan-Ketoglutarate Cardioplegia for Long Aortic Cross-Clamping Durations in Neonates

More than 30% of European pediatric cardiac surgery centers use single-dose cold histidine-tryptophan-ketoglutarate cardioplegia (Custodiol; Dr Franz Köhler Chemie GmbH, Bensheim, Germany). In neonates with transposition of the great arteries, arterial switch surgery (ASO) implies aortic division, and it is unknown whether repeated ostial cannulation causes intimal insult and affects long-term results, and therefore, single-dose Custodiol is appealing. The present study investigated the association among myocardial no-flow duration, postoperative troponins, and postoperative outcomes in neonates undergoing ASO with Custodiol cardioplegia. Retrospective analysis of the association among myocardial no-flow duration, postoperative troponin release (concentration magnitude × measurement duration within 48 h), and outcomes using stratification according to coronary anatomy and attending surgeon. Single-institutional, tertiary pediatric cardiac surgery unit of a university hospital. The study comprised 101 neonates undergoing ASO. None. The mean age of patients was 6.1 ± 5.4 days, the cardiopulmonary bypass duration was 108.7 ± 54.1 minutes, the temperature during cross-clamping was 31.1°C ± 1.7°C, the duration of mechanical ventilation was 4 (3-6) days, the length of intensive care unit stay was 7 (5-8) days, delayed sternal closure occurred in 32 (31.7%) patients, and no patients died. The myocardial no-flow duration averaged 62.3 ± 14.6 minutes and was linked with both troponin release (p = 0.04) and low cardiac output syndrome, as assessed by the requirement for delayed sternal closure (p = 0.03), regardless of cardiopulmonary bypass duration and temperature. Eighty-two percent of the patients with myocardial no-flow duration >74 minutes necessitated delayed sternal closure. Single-dose Custodiol may be inadequate for prolonged cross-clamping durations without myocardial perfusion in neonates.

Paediatric cardiac surgery in a peripheral European region: is a joint programme a safe alternative to regionalisation?

In 2007, a partnership was initiated between a small-volume paediatric cardiac surgery unit located in Las Palmas de Gran Canaria, Spain, and a large-volume cardiac surgery unit located in Milan, Italy. The main goal of this partnership was to provide surgical treatment to children with CHD in the Canary Islands. An operative algorithm for performing surgery in elective, urgent, and emergency cases was adopted by the this joint programme. Demographic and in-hospital variables were collected from the medical records of all the patients who had undergone surgical intervention for CHD from January, 2009 to March, 2013. Data were introduced into the congenital database of the European Congenital Heart Surgeons Association Congenital Database and the database was interrogated. In total, 65 surgical mission trips were performed during the period of this study. The European Congenital Heart Surgeons Association Congenital Database documented 214 total patients with a mean age at operation of 36.45 months, 316 procedures in total with 198 cardiopulmonary bypass cases, 46 non-cardiopulmonary bypass cases, 26 cardiovascular cases without cardiopulmonary bypass, 22 miscellaneous other types of cases, 16 interventional cardiology cases, six thoracic cases, one non-cardiac, non-thoracic procedure on a cardiac patient with cardiac anaesthesia, and one extracorporeal membrane oxygenation case. The 30-day mortality was 6.07% (13 patients). A joint programme between a small-volume centre and a large-volume centre may represent a valid and reproducible model for safe paediatric cardiac surgery in the context of a peripheral region.

Template of patient-specific summaries facilitates education and outcomes in paediatric cardiac surgery units.

Few educational opportunities exist in paediatric cardiac critical care units (PCCUs). We introduced a new educational activity in the PCCU in the form of of patient-specific summaries (TPSS). Our objective was to study the role of TPSS in the provision of a positive learning experience to the multidisciplinary clinical team of PCCUs and in improving patient-related clinical outcomes in the PCCU. Prospective educational intervention with simultaneous clinical assessment was undertaken in PCCU in an academic children's hospital. TPSS was developed utilizing the case presentation format for upcoming week's surgical cases and delivered once every week to each PCCU clinical team member. Role of TPSS to provide clinical education was assessed using five-point Likert-style scale responses in an anonymous survey 1 year after TPSS provision. Paediatric cardiac surgery patients admitted to the PCCU were evaluated for postoperative outcomes for TPSS provision period of 1 year and compared with a preintervention period of 1 year. TPSS was delivered to 259 clinical team members including faculty, fellows, residents, nurse practitioners, nurses, respiratory therapists and others from the Divisions of Anesthesia, Cardiology, Cardio-Thoracic Surgery, Critical Care, and Pediatrics working in the PCCU. Two hundred and twenty-four (86%) members responded to the survey and assessed the role of TPSS in providing clinical education to be excellent based on mean Likert-style scores of 4.32 ± 0.71 in survey responses. Seven hundred patients were studied for the two time periods and there were no differences in patient demographics, complexity of cardiac defect and surgical details. The length of mechanical ventilation for the TPSS period (57.08 ± 141.44 h) was significantly less when compared with preintervention period (117.39 ± 433.81 h) (P < 0.001) with no differences in length of PCICU stay, hospital stay and mortality for the two time periods. Provision of TPSS in a paediatric cardiac surgery unit is perceived to be beneficial in providing clinical education to multidisciplinary clinical teams and may be associated with improved clinical outcome.

A reflection on the performance of pediatric cardiac surgery in the State of São Paulo

1. Department of Pediatric Cardiovascular Surgery of the BrazilianSociety of Cardiovascular Surgery, Physician Assistant, Divisionof Cardiovascular Surgery, Heart Institute of the Medical SchoolClinical Hospital, University of Sao Paulo (INCOR-HCFMUSP),Sao Paulo , SP, Brazil.2. Department of Pediatric Cardiovascular Surgery of the BrazilianSociety of Cardiovascular Surgery, Director of Pediatric CardiacSurgery Unit INCOR-HCFMUSP, Sao Paulo, SP, Brazil.3. Master’s Student of the Professional Master Course in CollectiveHealth, Graduate School of Medical Sciences of Santa Casa de SaoPaulo, Sao Paulo, SP, Brazil.

Perirenal hematoma in a 7 months old child four days after a cardiac operation

Dear Editor, Dr. Peters et al. [1] presented in your journal an interesting case regarding a subcapsular hematoma of the kidney after a cardiac catheterization in an adult patients and its clinical management. This complication, albeit rare in adults [2], is of great interest in children with congenital heart disease undertaking diagnostic or interventional catheterizations [3–5] and it should be considered in the differential diagnosis when managing ‘‘apparently’’ spontaneous perirenal hematomas in this selected population. We describe a case of a ‘‘late onset’’ retroperitoneal hematoma in a 7 months old child discovered in the fourth postoperative day (POD) after a cardiac operation, discussing the possible differential diagnosis and treatment options. A 7 months old child, weighting 7 kg, affected by a pulmonary atresia with intact ventricular septum treated with a systemic-pulmonary shunt early after birth, was admitted in the pediatric cardiac surgery unit for the intervention of bidirectional cavo-pulmonary anstomosis (Glenn operation). An angiographic evaluation, scheduled the day before surgery, was performed with a percutaneous catheterization from the left femoral vein. The access to the vessel was easily obtained under ultrasound guidance and a 5 French sheath with a 0.35 guidewire (Terumo, Tokyo, Japan) was used. The child was heparinized for the diagnostic procedure (100 UI/Kg) to reach an Activated Clotting Time of 180–200 s. Catheterization was performed under fluoroscopic guidance and resulted apparently uneventful. The following day the patient successfully underwent to the scheduled cardiac operation and was discharged from the PICU in the second POD. Anticoagulant therapy with warfarin was suddenly started according to the institutional protocol. In the fourth POD, the child presented vomiting and diaphoresis. Clinical examination revealed an important left flank pain and a tense abdomen. Blood tests showed: increased levels of the C reactive protein (C-RP) (15 mg/l), white blood cells (WBC) count (18 9 10/ mm), a marked reduction of the haemoglobin concentration with an international normalized ratio (INR) F. De Sanctis Department of Anesthesia and Intensive Care Medicine, ‘‘La Sapienza’’ University, II Faculty of Medicine, Sant’ Andrea Hospital, Rome, Italy

Clinical and environmental distribution of Legionella pneumophila in a university hospital in Italy: efficacy of ultraviolet disinfection

The molecular epidemiology of Legionella pneumophila in the 'V. Monaldi' University Hospital was studied. Seven cases of nosocomial Legionnaires' disease were diagnosed between 1999 and 2003. Two clinical legionella strains obtained from two patients in the adult cardiac surgery unit (CSU) and 30 environmental legionella strains from the paediatric and adult CSUs, neonatal intensive care unit (NICU) and the cardiorespiratory intensive care unit (CR-ICU) were serotyped and genotyped. L. pneumophila serogroup 1/Philadelphia with an identical pulsed-field gel electrophoresis (PFGE) profile A was isolated from two patients in the adult CSU, and from three and one water samples taken in the adult CSU and the paediatric CSU, respectively, from 2001 to 2002. Furthermore, L. pneumophila serogroup 3 with an identical PFGE profile B was identified in 20 environmental strains from all wards, L. pneumophila serogroup 3 with PFGE profile C was identified in a single environmental strain from the CR-ICU, and non-pneumophila Legionella with identical PFGE profile D was identified in five environmental strains from the adult CSU, paediatric CSU and NICU. Ultraviolet irradiation was effective in disinfection of the hospital water supplies in the adult and paediatric CSUs contaminated by L. pneumophila clone associated with nosocomial Legionnaires' disease. In conclusion, these data demonstrate that two cases of nosocomial legionellosis were caused by the persistence of a single clone of L. pneumophila serogroup 1/Philadelphia in the hospital environment, and that disinfection by ultraviolet irradiation may represent an effective measure to prevent nosocomial Legionnaires' disease.

The challenge of objective assessment of surgical skill

Technical performance in surgery has come under increased scrutiny in recent years, not least due to several highly publicized cases where it has been suggested that poor outcomes were the result of inadequate technical skill [ 1 Hamdorf J.M. Hall J.C. Acquiring surgical skills. Br J Surg. 2000; 87: 28-37 Crossref PubMed Scopus (177) Google Scholar , 2 Parsa C.J. Organ C.H. Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg. 2000; 135: 570-575 Crossref PubMed Scopus (41) Google Scholar , 3 Smith R. All changed, changed utterly. British medicine will be transformed by the Bristol case. BMJ. 1998; 316 ([editorial] [see comments]): 1917-1918 Crossref PubMed Scopus (256) Google Scholar ]. In the Bristol case, which involved a pediatric cardiac surgery unit, the concerns voiced by a member of medical staff have now resulted in disciplinary action against two surgeons by the General Medical Council, and a judicial inquiry, which is yet to hand down its report (www.bristol-inquiry.org.uk). The resulting debate, both public and within the profession, has focused on the need for objective and independent assessment of surgical skill, and a significant research interest has developed in this area.