Pediatric Cardiac Surgery Research Articles

Serum soluble triggering receptor levels expressed on myeloid cells2 identify early acute kidney injury in infants and young children after pediatric cardiopulmonary bypass.

Acute kidney injury (AKI) is a potential complication after cardiopulmonary bypass (CPB) of pediatric cardiac surgery and contributes to a certain amount of perioperative mortality. Serum soluble triggering receptor expressed on myeloid cells2 (sTREM2) is an inflammation-associated cytokine in circulation. Alterations of sTREM2 level have been reported in Alzheimer's disease, sepsis, and some other pathologic conditions. This study aimed to investigate the role of sTREM2 as a forecasting factor for AKI in infants and young children and other factors associated with early renal injury after pediatric CPB. A prospective cohort study with consecutive infants and young children ≤ 3 years old undergoing CPB from September 2021 to August 2022 was conducted in an affiliated university children's hospital. These patients were divided into an AKI group (n = 10) and a non-AKI group (n = 60). Children's characteristics and clinical data were measured. Perioperative sTREM2 levels were analyzed with enzyme-linked immunosorbent assay (ELISA). In children developing AKI, the sTREM2 levels significantly decreased at the beginning of CPB compared to the non-AKI group. Based on binary logistic regression analysis and multivariable regression analysis, risk-adjusted classification for congenital heart surgery (RACHS-1), operation time, and the s-TREM2 level at the beginning of CPB (AUC = 0.839, p = 0.001, optimal cut-off value: 716.0 pg/ml) had predictive value for post-CPB AKI. When combining the sTREM2 level at the beginning of CPB and other indicators together, the area under the ROC curve enlarged. Operation time, RACHS-1 score, and sTREM2 level at the beginning of CPB were independent prognosis factors of post-CPB AKI in infants and young children ≤ 3 years old. Decreased sTREM2 identified post-CPB AKI, and ultimately hampered the outcomes. Our findings indicated that sTREM2 may be a protective factor for AKI after CPB in infants and young children ≤ 3 years old.

Comparison of Short-Term Outcomes of Transcatheter versus Surgical Closure of Atrial Septum Defect at a Tertiary Cardiac Care Facility

Objective: To compare the short-term outcomes of transcatheter versus surgical closure of atrial septal defect (ASD) at a tertiary cardiac care facility in South Punjab, Pakistan.
 Study Design: Prospective comparative study.
 Place and Duration of the Study: Department of Paediatric Cardiology and Paediatric Cardiac Surgery, Chaudhary Pervez Elahi Institute of Cardiology, Multan Pakistan, from Jul 2019 to Jun 2021.
 Methodology: A total of 110 patients with moderate to large isolated secundum ASDs without severe pulmonary hypertension and planned to undergo closure of secundum ASD by either surgical approach or device closure were included. All surgical and transcatheter procedures were performed adopting standard techniques. Intra-procedural or post-procedural outcomes were noted.
 Results: In a total of 110 patients, 59(53.6%) underwent transcatheter closure of ASD, while surgical closure was done in the remaining 51(46.4%) patients. Post-procedural complications were significantly more in the Surgical Closure Group in comparison to the Transcatheter Closure Group, [14(27.5%) vs 5(8.5%) (p=0.026)]. None of the cases in the Transcatheter Closure Group required inotropes in the post-procedure period in comparison to 24(47.1%) cases (p<0.001). The total cost of treatment was significantly higher in transcatheter closure patients compared to surgical closure patients (1504±60.4 US$ versus 1448±75.4 US$, p<0.001). Overall, successful closure was noted in 108(98.2%) cases. No mortality was recorded.
 Conclusion: Overall, short-term outcomes of transcatheter ASD closure were comparable to the surgical approach, but patients with transcatheter ASD closure had significantly less duration of hospitalization and low rates of post-procedural complications.Keywords: Atrial septum defect, Mortality, Surgical closure, Transcatheter closure.

Acute Kidney Injury Following Paediatric Cardiac Surgery: Experience of A Paediatric Cardiac Center of Bangladesh

Background: Acute kidney injury following cardiac surgery in children is a relatively common phenomenon. The risk ranges from 15% to 64% with a mortality rate of 10% to 89% for those who need dialysis.
 Objective: To identify the occurrence of acute kidney injury following cardiac surgery in children, as well as its consequences and treatment options.
 Methods: This study was conducted in the pediatric cardiac recovery center at Bangladesh Shishu Hospital & Institute from January 2019 to December 2020. Using the KDIGO (kidney disease improving global outcome) criteria, 50 children having cardiac surgery were assessed for the occurrence of AKI. Children were divided into two groups. The AKI group consists of 20 patients, whereas the non-AKI group consists of 30 patients. Age, sex, cardiac illness, past operations, RACHS-1 (Risk adjustment for congenital Heart surgery) and pre and post-operative creatinine levels were noted. Fisher’s exact test was used to determine whether or not AKI was associated with categorical factors, while the Mann- Whitney U-test was used to see whether or not AKI was associated with continuous variables.
 Results: Mean age of study population was 4.50±4.03 years for those who did not develop AKI and 7.55±5.79 years for those who did. Male constituted a majority in both groups. Despite the fact that patients with AKI were more acidotic at baseline, lower bicarbonate levels were not linked to an increased risk of AKI (p=0.89). Neither group had higher or lower pressure than the other. Time spent in bypass and crossclamping was comparable across AKI and non-AKI patients. Patients with AKI did not have a higher risk of developing extracellular fluid excess than non-AKI patients. There was no significant difference between the groups in terms of the average time spent on mechanical ventilation or total hospital stay in days (p=0.17 and p=0.62, respectively). Duration of stay in the cardiac recovery increased for patients who had AKI (p=0.02). The mortality rate among the AKI patients was 20% (4/14). In the control group without AKI, there was one death (3.33%) (p 0.0001).
 Conclusion: AKI is common complication of paediatric cardiac surgery. Prolong times spent on mechanical ventilation in the ICU and in the hospital have all been linked to AKI.
 DS (Child) H J 2021; 38(1): 44-48

#3169 EXPERIENCE IN INTRAOPERATIVE AUTOLOGOUS BLOOD SALVAGE IN PEDIATRIC CARDIAC SURGERY

Abstract Background and Aims Due to the drastic reduction in the number of voluntary blood donors has led to the need for the development of alternative strategies for allogeneic blood transfusion, which include the use of different strategies for autologous transfusion. Display: a) the use of "Cell-Saver" pediatric cardiac surgery at the Department of Cardiothoracic Surgery, Institute for Health Protection of Mother and Child of Serbia" Dr Vukan Cupic"; b) to analyze the reduced use of allogeneic blood and /or chemo products using "Cell-Saver" pediatric cardiac surgery; c) to evaluate the "cost benefit" of this strategy (e.g. the ratio of prices "set", "Cell-Saver") and pretransfusion rates processing one unit of allogeneic blood; d) to identify increased intraoperative security in complex. reconstructive and redocardiac surgery using the "Cell-Saver" combined with ultrafiltration (conventional or modified), particularly in cyanogenic congenital heart defects, and e) to establish and improve the hemodynamic status of hemoreologic operated child. Method A retrospective study was conducted. Experimental group included 63 patients (aged 12 days - 16 years and 4 months, body weight of patients that ranged between 2.9 kg and 80 kg - the mean body weight was 28.3 kg). In the experimental group patients were performed following cardiac surgery: 46 patients underwent reconstructive surgery (most often reoperations for cyanogenic congenital heart defects); 3 patients who underwent cardiovascular belief, and 3 patients who underwent cardio-surgical procedures had hematological disorders. The control group included 60 patients of similar age and body mass who underwent the cardio-surgical procedure without the use of "Cell-Saver" with application of allogeneic blood and/or chemo products during transfusion care. The following laboratory parameters were accompanied: hematocrit, platelet count, fibrinogen, prothrombin time (PT) and activated partial thromboplastin time (aPTT), after 3, 6, and 12 hours postoperatively compared to the control group. We compared the volume of postoperative bleeding by patients of the experimental group with the control group (1h, 4h, 7h, 11h, 15h, 21h and 24h) and analyzed the amount of used allogeneic and autologous blood and/or hemoglobin products used in the transfusion care during hospitalization the experimental group compared with the control group. Results Postoperative administration of allogeneic blood and/or hemoproducts was statistically significantly lower in the experimental group using "CellSaver" than in the control group. The amount of salvaged blood after surgery ranged from 210 ml - 620 ml. Intraoperative hematocrit "rescued" autologous blood ranged between 0.32 l / l and 0.38 l / l. e range of values preoperative and postoperative hematocrit were lower in the experimental group than in the control group that used "Cell-Saver". The total volume of postoperative drainage content was significantly lower in the experimental group, which used "Cell-Saver" compared to the control group. The postoperative hematocrit was higher in the experimental group patients who used "Cell-Saver", compared with the same operating using allogeneic blood and/or hemoproducts patients in the control group. The mean platelet count, fibrinogen, PT and aPTT results showed no statistically significant difference between the experimental group of patients in whom we used "Cell-Saver" in comparison to the control group. Conclusion The results obtained by the retrospective analysis of above mentioned data indicate a positive therapeutic effect of the application of the "Cell Saver" that is most common in reoperations. With the introduction of the "bell" of small volume, the use of the Cell Saver has become an integral part of the pediatric cardiac surgery - perfusion, regardless of body weight, age and body surface area of the child. The performance of intraoperative "rescue" of autologous blood using the "Cell Saver", while the follow-up of pediatric patients in the perioperative and postoperative period has immeasurable significance of teamwork perfuser, expert specialist nursing, pediatrician, cardiac surgeon and transfusion.

#4339 CARDIORENAL SYNDROME TYPE 1 IN CHILDREN AFTER SURGICAL TREATMENT OF CONGENITAL HEART DISEASE USING CARDIOPULMONARY BYPASS

Abstract Background and Aims According to recent data, acute kidney injury (AKI) after pediatric cardiac surgery is a significant postoperative complication that occurs in 35-64% of children (1,2) and is associated with increased hospital mortality and unfavorable short-term outcomes. The problem of acute kidney injury in children after cardiac surgery remains relevant, despite the development of modern technologies and methods. Complications after pediatric cardiac surgery have serious negative consequences, prolonging the days of stay in the pediatric intensive care unit (PICU) and increasing mortality (3). The aim of the study is to analyze the frequency of AKI in children after open-heart surgery for congenital heart defects (CHD) using cardiopulmonary bypass (CBP). Method We conducted a retrospective analysis of 402 medical records of patients hospitalized in the ICU of JSC NRCSC Astana, Kazakhstan, from January 2018 to December 2022. Inclusion criteria: Children under 18 with CHD who underwent open-heart surgery with the following diagnosis - transposition of the great vessels, total anomalous pulmonary venous connection, interrupted aortic arch, coarctation of the aorta, ventricular septal defect. Exclusion criteria: The presence of AKI and terminal chronic kidney failure. Results The analysis included the total number of patients - 402 patients. The frequency of AKI was 15.6% (63 out of 402). Among the patients who developed AKI: boys - 45 (71.4%), girls - 18 (28.5%). The age distribution is as follows: children under 1 month among AKI - 50 (79.3%), under 6 months among AKI – 13 (20.6%), under 1 year among AKI – 5 (7.9%). According to the statistical analysis results, the complication depends on the type of operation, as there is a statistical significance of the differences in the groups (p = 0.046). However, the type of operation (p = 0.35) does not matter for the outcome. Also, the children's weight (p = 0.082) has no statistical significance on the number of complications and the outcome. The sex of children has a statistical significance for complications; in boys, it is significantly higher (p = 0.05). In addition, the lethal outcome in male children is higher than in girls (p = 0.000). The total number of patients with peritoneal dialysis is 63 (15.6%). The total mortality was 80 patients (19.9%). Mortality in the intensive care unit in patients with AKI after open-heart surgery for CHD was 43 (68.2%). Conclusion According to our data, the frequency of AKI developed in 15.6% of patients after surgical treatment of CHD using CBP. The overall mortality rate is 19.9%, with boys having a higher risk. Thus, the frequency of AKI is influenced by many factors before, during and after surgery. Therefore, developing preventive measures is a priority for improving the cardiac surgery results in children.

On-table Extubation Facilitated by Regional Analgesic Techniques Combined with General Anesthesia for PDA Ligation: A Case-series and Literature Review

Background: An increasing embracement of safer regional techniques as pivotal components of multimodal analgesia regimen has made fast-tracking possible following pediatric cardiac surgery. Speaking of fast-tracking in pediatrics, the feasibility of on-table extubation (OTE), and its’ potential benefits are also being ardently researched with simultaneous emphasis on appropriate patient selection and adequate perioperative safety. Case Series: We report eight consecutive pediatric cases featuring a combination of serratus anterior plane block (SAPB) or erector spinae plane block (ESPB) to general anesthesia (GA) for patent ductus arteriosus (PDA) ligation through a left thoracotomy incision. Following induction of GA, the left-sided SAPB was performed in five patients and the other three patients received left-sided ESPB, each with 0.5 mL/kg of 0.2% ropivacaine. Demonstrating a mean intraoperative fentanyl requirement of 3.25 ± 0.71 µg/kg, OTE could be successfully contemplated in all the 8 patients. Subsequently, the post-operative face, leg, activity, cry, and consolability (FLACC) score was recorded at 1, 2, 4, 6, 8, and 12 h. Meanwhile, all the patients depicted acceptable pain scores till 4 h, administration of 0.5 µg/Kg rescue fentanyl was necessitated in three patients each at 6-h and 8-h postoperatively (given FLACC scores ≥4), amounting to a mean 0.375 ± 0.23 µg/kg post-operative fentanyl requirement. All patients received intravenous paracetamol at 8-h postoperatively. No block-related complication or need for reintubation was discovered. Conclusion: Incorporation of fascial plane blocks (SAPB or ESPB) to the conduct of GA for PDA ligation, allowed for safe OTE in our experience, due to an opioid-sparing potential.

Calciferol Status and Clinical Outcomes in Children with Congenital Heart Disease after Heart Surgery

Highlights: Calciferol has cardioprotective properties, and a severe deficiency of calciferol is associated with septic shock, a longer duration of mechanical ventilation and treatment in the intensive care unit, and mortality. The role of calciferol in critical conditions has been described in several research reports, but relatively little is known about its function in pediatric cardiac surgery. Abstract Calciferol is a micronutrient and a secosteroid hormone that plays a role in maintaining the health of bones and soft tissues in the body, such as the myocardium, as well as the immune system. Hypovitaminosis D has been reported to be associated with poor clinical outcomes and child mortality in pediatric intensive care units. Children with congenital heart disease (CHD) are vulnerable to critical conditions and require early intervention due to heart failure. This study aimed to investigate the influence of calciferol status on the clinical outcomes of pediatric CHD patients who underwent heart surgery. A systematic literature review was conducted using the electronic databases from PubMed, Elsevier, and Cochrane. This study included observational and randomized control studies that assessed the calciferol status of pediatric CHD patients undergoing cardiac surgery. From a total of 168 studies, 8 studies were selected for review. The preoperative and postoperative calciferol status as well as clinical outcomes following pediatric cardiac surgery were reviewed. According to the findings, most pediatric CHD patients suffered from calciferol deficiency prior to corrective heart surgery, which further decreased postoperatively and was associated with clinical outcomes in the intensive care unit (ICU). Preoperative calciferol supplementation has been reported to enhance serum calciferol levels and is associated with good clinical outcomes in pediatric patients undergoing cardiac surgery.

Results of Cardiac Surgeries in Pediatric Requiring Cardiac Surgery Hospitalized in the Intensive Care Unit

Results of Cardiac Surgeries in Pediatric Requiring Cardiac Surgery Hospitalized in the Intensive Care Unit

Invasive Pulmonary Aspergillosis After Sars-CoV-2 Infection as Limitation of Contemporary Transplantology: A Case Report

Invasive fungal infections are uncommon in pediatric heart transplant recipients. Risk and mortality are highest in the first 6 months post-transplant, especially in patients with previous surgery and those requiring mechanical support. There is a possibility that prior SARS-CoV-2 infection may cause a more severe course of pulmonary aspergillosis, especially in immunosuppressed individuals. This report describes a female patient, eight years of age, who was admitted to the pediatric cardiac surgery department with symptoms of end-stage heart failure in urgent need of mechanical circulatory support (MCS). A left ventricular assist device (LVAD) was implanted as a bridge to transplantation. During over a year on the waiting list, LVAD was replaced twice due to the presence of fibrin on the inlet valve. While staying in the ward, the patient underwent SARS-CoV-2 infection. An orthotopic heart transplant was successfully performed after 372 days of MCS with LVAD. One month after transplantation, the girl developed severe pulmonary aspergillosis complicated by sudden cardiac arrest and implantation of venovenous extracorporeal membrane oxygenation (VV ECMO) used for 25 days. Unfortunately, a few days after weaning from VV ECMO, the patient died due to intracerebral bleeding.

Association of underweight and obesity with adverse postoperative renal outcomes in infants and young children undergoing congenital heart surgery.

Postoperative acute kidney injury (AKI) is a prevalent condition and associated with increased morbidity and mortality following cardiac surgery. This study aimed to investigate the association of underweight and obesity with adverse postoperative renal outcomes in infants and young children undergoing congenital heart surgery. This retrospective cohort study included patients aged from 1month to 5years who underwent congenital heart surgery with cardiopulmonary bypass at the Second Xiangya Hospital of Central South University from January 2016 to March 2022. On the basis of the percentile of body mass index (BMI) for age and sex, eligible participants were divided into three nutritional groups: normal bodyweight, underweight (BMI P5), and obesity (BMI P95). Primary outcomes included postoperative AKI and major adverse kidney events within 30days (MAKE30). Multivariable logistic regression was performed to determine the association of underweight and obesity with postoperative outcomes. The same analyses were reproduced for classifying patients using weight-for-height instead of BMI. A total of 2,079 eligible patients were included in the analysis, including 1,341 (65%) patients in the normal bodyweight group, 683 (33%) patients in the underweight group, and 55 (2.6%) patients in the obesity group. Postoperative AKI (16% vs. 26% vs. 38%; P < 0.001) and MAKE30 (2.5% vs. 6.4% vs. 9.1%; P < 0.001) were more likely to occur in the underweight and obesity groups. After adjusting for potential confounders, underweight (OR1.39; 95% CI 1.08-1.79; P = 0.008) and obesity (OR 3.85; 95% CI 1.97-7.50; P < 0.001) were found to be associated with an increased risk of postoperative AKI. In addition, both underweight (OR 1.89; 95% CI 1.14-3.14; P = 0.014) and obesity (OR 3.14; 95% CI 1.08-9.09; P = 0.035) were independently associated with MAKE30. Similar results were also found when weight-for-height was used instead of BMI. Conclusion: In infants and young children undergoing congenital heart surgery, underweight and obesity are independently associated with postoperative AKI and MAKE30. These results may help assess prognosis in underweight and obese patients, and will guide future quality improvement efforts. What is Known: • Postoperative acute kidney injury (AKI) is prevalent and associated with increased morbidity and mortality following pediatric cardiac surgery. • Major adverse kidney events within 30days (MAKE30) have been recommended as a patient-centered endpoint for evaluating AKI clinical trajectories. A growing concern arises for underweight and obesity in children with congenital heart disease. What is New: • Prevalence of underweight and obesity among infants and young children undergoing congenital heart surgery was 33% and 2.6%, respectively. • Both underweight and obesity were independently associated with postoperative AKI and MAKE30 following congenital heart surgery.

Effectiveness of Pre-Admission Videos to Improve Patient and Family Engagement in Paediatric Congenital Cardiac Surgery

Paediatric cardiac surgery is an emotional and challenging journey for patients and families, often leading to high stress and anxiety. They start their journey not knowing what lies ahead, with limited understanding of what to expect, and a feeling of being overwhelmed.

Contemporary Hospital Outcomes Following Paediatric Cardiac Surgery in Patients With Trisomy 21 in Australia and New Zealand

To investigate whether trisomy 21 (T21) patients have worse early outcomes following paediatric cardiac surgery compared with non-T21 patients.

Clinical Stakeholder Preferences for Paediatric Cardiac Surgery Outcome Reporting in Australia and New Zealand

This study aimed to examine stakeholder preferences for the content, format, and dissemination of outcomes and benchmarking of paediatric cardiac surgery in Australia and New Zealand.

Del Nido Cardioplegia in Adult Cardiac Surgery: The Auckland Experience

del Nido solution is a crystalloid-based cardioplegia that was first used in paediatric cardiac surgery. Its use in adult cardiac surgery in New Zealand is limited, with most centres using traditional blood cardioplegia. We report our early experience of using del Nido cardioplegia across the full breadth of adult cardiac surgery.

Is Early Recovery Possible After Congenital Cardiothoracic Surgery?

The primary aim of this study was to implement the fast-track (FT) model of care in eligible children following paediatric cardiac surgery.

Efficacy and safety of inhaled nitric oxide administered during cardiopulmonary bypass for pediatric cardiac surgery: a systematic review and meta-analysis.

A systematic literature search was conducted on 26 July 2022, using the electronic databases of PubMed, Cochrane, Scopus, and Web of Science to include randomized controlled trials, with no restriction regarding the date of study conduction. The quality of studies was assessed using the Cochrane tool. RevMan 5.3 software was used to analyze data in the inverse variance method, with pooling data as mean difference (MD), risk ratio, and 95% CI. Six trials were included comprising 1666 children who had undergone the interventions of interest. All studies amenable to assessment were of good quality. NO was significantly superior to the control treatments regarding ventilation time (MD=-8.34; 95% CI [-14.50 to -2.17], P=0.008), postoperative interleukin-6 (IL-6) levels (MD=-0.50; 95% CI [-0.54 to -0.46], P<0.001), 24-h IL-6 levels (MD=-0.30; 95% CI [-0.32 to -0.20], P<0.001), and 24-h tumor necrosis factor-alpha (TNF-α) levels (MD=-1.72; 95% CI [-3.44 to -1.00], P=0.05). The side effects of NO and the control treatments were comparable (P=0.9). NO administered as part of the CPB circuit during cardiac surgeries is efficacious in terms of reducing ventilation time, postoperative IL-6, and TNF-α levels compared to control, with a comparable safety profile.

Proof of concept of an accelerometer as a trigger for unilateral diaphragmatic pacing: a porcine model

BackgroundUnilateral diaphragmatic paralysis in patients with univentricular heart is a known complication after pediatric cardiac surgery. Because diaphragmatic excursion has a significant influence on perfusion of the pulmonary arteries and hemodynamics in these patients, unilateral loss of function leads to multiple complications. The current treatment of choice, diaphragmatic plication, does not lead to a full return of function. A unilateral diaphragmatic pacemaker has shown potential as a new treatment option. In this study, we investigated an accelerometer as a trigger for a unilateral diaphragm pacemaker (closed-loop system).MethodsSeven pigs (mean weight 20.7 ± 2.25 kg) each were implanted with a customized accelerometer on the right diaphragmatic dome. Accelerometer recordings (mV) of the diaphragmatic excursion of the right diaphragm were compared with findings using established methods (fluoroscopy [mm]; ultrasound, M-mode [cm]). For detection of the amplitude of diaphragmatic excursions, the diaphragm was stimulated with increasing amperage by a cuff electrode implanted around the right phrenic nerve.ResultsResults with the different techniques for measuring diaphragmatic excursions showed correlations between accelerometer and fluoroscopy values (correlation coefficient 0.800, P < 0.001), accelerometer and ultrasound values (0.883, P < 0.001), and fluoroscopy and ultrasound values (0.816, P < 0.001).ConclusionThe accelerometer is a valid method for detecting diaphragmatic excursion and can be used as a trigger for a unilateral diaphragmatic pacemaker.

Evaluation of YouTube Videos Quality of Pediatric Cardiac Surgery Anesthesia

Evaluation of YouTube Videos Quality of Pediatric Cardiac Surgery Anesthesia

Effect of red blood cell storage time in pediatric cardiac surgery patients: A subgroup analysis of a randomized controlled trial

ObjectiveThis study aimed to determine whether or not transfusion of fresh red blood cells (RBCs) reduced the incidence of new or progressive multiple organ dysfunction syndrome compared with standard-issue RBCs in pediatric patients undergoing cardiac surgery. MethodsPreplanned secondary analysis of the Age of Blood in Children in Pediatric Intensive Care Unit study, an international randomized controlled trial. This study included children enrolled in the Age of Blood in Children in Pediatric Intensive Care Unit trial and admitted to a pediatric intensive care unit after cardiac surgery with cardiopulmonary bypass. Patients were randomized to receive either fresh (stored ≤7 days) or standard-issue RBCs. The primary outcome measure was new or progressive multiple organ dysfunction syndrome, measured up to 28 days postrandomization or at pediatric intensive care unit discharge, or death. ResultsOne hundred seventy-eight patients (median age, 0.6 years; interquartile range, 0.3-2.6 years) were included with 89 patients randomized to the fresh RBCs group (median length of storage, 5 days; interquartile range, 4-6 days) and 89 to the standard-issue RBCs group (median length of storage, 18 days; interquartile range, 13-22 days). There were no statistically significant differences in new or progressive multiple organ dysfunction syndrome between fresh (43 out of 89 [48.3%]) and standard-issue RBCs groups (38 out of 88 [43.2%]), with a relative risk of 1.12 (95% CI, 0.81 to 1.54; P = .49) and an unadjusted absolute risk difference of 5.1% (95% CI, −9.5% to 19.8%; P = .49). ConclusionsIn neonates and children undergoing cardiac surgery with cardiopulmonary bypass, the use of fresh RBCs did not reduce the incidence of new or progressive multiple organ dysfunction syndrome compared with the standard-issue RBCs. A larger trial is needed to confirm these results.

Myocardial protection in paediatric cardiac surgery: building an evidence-based strategy.

Cardioplegia is fundamental to the surgical repair of congenital heart defects by protecting the heart against ischaemia/reperfusion injury, characterised by low cardiac output and troponin release in the early postoperative period. The immature myocardium exhibits structural, physiological and metabolic differences from the adult heart, with a greater sensitivity to calcium overload-mediated injury during reperfusion. Del Nido cardioplegia was designed specifically to protect the immature heart, is widely used in North America and may provide better myocardial protection in children; however, it has not been commercially available in the UK, where most centres use St Thomas' blood cardioplegia. There are no phase 3 clinical trials in children to support one solution over another and this lack of evidence, combined with variations in practice, suggests the presence of clinical equipoise. The best cardioplegia solution for use in children, and the impact of age and other clinical factors remain unknown. In this Hunterian lecture, I propose an evidence-based strategy to improve myocardial protection during cardiac surgery in children through: (1) conducting multicentre clinical trials of established techniques; (2) improving our knowledge of ischaemia/reperfusion injury in the setting of cardioplegic arrest; (3) applying this to drive innovation, moving beyond current cardioplegia solutions; (4) empowering personalised medicine, through combining clinical and genomic data, including ethnic diversity; and (5) understanding the impact of cardioplegic arrest on the late outcomes that matter to patients and their families.