Refractory Low Cardiac Output Research Articles

The Role of Shunt Occlusion During Extracorporeal Life Support.

The current recommendation for systemic to pulmonary artery shunt (SPS) patients requiring extracorporeal life support (ECLS) is to keep the shunt open, maintaining a higher pump flow. The practice in our center is to totally occlude the shunt while on ECLS, and we are presenting the outcome of this strategy. This is a retrospective analysis of patients who underwent SPS for cyanotic congenital heart disease with decreased pulmonary blood flow and required postoperative ECLS between January 2016 and December 2020. ECLS indication was excessive pulmonary blood flow, leading to either refractory low cardiac output syndrome (LCOS) or cardiac arrest. All patients had their shunts totally occluded soon after ECLS establishment. Of the 27 SPS patients who needed postoperative ECLS (13 refractory LCOS, 14 extracorporeal cardiopulmonary resuscitation), wherein the strategy of occluding the shunt on ECLS initiation was followed, 16 (59.3 %) survived ECLS weaning and eight (29.6%) survived to discharge. Increased flow to maintain systemic circulation for a SPS patient while on ECLS is an accepted strategy, but it should not be applied universally. A large subset of SPS patients, who require ECLS either due to cardiac arrest or refractory LCOS due to excessive pulmonary flow, might benefit from complete occlusion of the shunt soon after commencement of ECLS, especially in cases with frank pulmonary edema or haemorrhage in the pre-ECLS period. A prospective randomized trial could be ethically justified for the subset of patients receiving ECLS for the indication of excessive pulmonary blood flow.

The early and midterm results of coronary endarterectomy combined with coronary artery bypass grafting for diffuse coronary artery stenosis

Objective: To examine the early and mid-term results of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) in the treatment of diffuse coronary artery stenosis. Methods: The clinical data and follow-up results of 248 patients who underwent CE+CABG surgery from January 2010 to January 2019 at Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively. There were 201 males and 47 females, aged (65.6±8.5) years (range: 43 to 79 years). The on-pump group included 156 patients and the off-pump group included 92 patients. CABG was performed after CE. CE was performed on 248 patients who represented 269 target coronary lesions, of which 108 were located on the left anterior descending artery and sub-branches, 140 were located on the right coronary artery and sub-branches, and 21 were located on the left circumflex artery and obtuse marginal artery. A total of 872 bypass grafts were performed, including 248 left internal thoracic arteries, 48 radial arteries, and 576 great saphenous veins, with (3.5±0.8) grafts (range:2 to 6 grafts) per patient.The grafts had satisfactory bridge blood flow after CE, with the graft flow rates of (26±8) ml/min (range: 13 to 59 ml/min) and the pulsatility index value of 3.1±0.8 (range: 2.0 to 6.7). The t test and χ2 test was used to compare the surgical results and graft patency rate between patients in on-pump and off-pump group, respectively. Results: The number of graft vessels of on-pump group and off-pump group was 3.6±0.9 and 3.2±0.7, respectively(t=1.637, P=0.085). There were 3 deaths during the perioperative period, with a mortality rate of 1.2%. Two people died of renal failure, and one case was due to postoperative refractory low cardiac output. Perioperative myocardial infarction occurred in 9 cases. The follow-up time was (41.8±21.4) months (range:1 to 68 months). The all graft patency rate was 78.4%(812/232) in 1 year and 69.8%(162/232) in 3 years postoperatively. The left coronary graft patency rate was significantly higher than the right coronary graft patency rate(1-year: 87.4% vs.73.1%, χ²=6.533, P=0.011, 3-year: 78.2% vs. 64.8%, χ²=4.588, P=0.032). There was no significant difference in graft patency rates between the on-pump group and off-pump group (1-year: 80.0% vs. 76.9%, χ²=0.277, P=0.599, 3-year:71.5% vs. 67.9%, χ²=0.300, P=0.584). Conclusions: CE+CABG is a safe and feasible technique for patients with diffuse coronary artery disease to get more satisfied complete revascularization, with good early and medium-term results and graft patency rates. The outcomes of on-pump or off-pump CE+CABG are similar.

Extracorporeal Life Support in Postcardiotomy Cardiogenic Shock: A View on Scenario, Outcome, and Risk Factors in 261 Patients.

Weaning failure from cardiopulmonary bypass, postoperative low cardiac output (LCO), and cardiopulmonary resuscitation (CPR) are common scenarios preceding extracorporeal life support (ECLS) implantation after cardiac surgery. The impact of these scenarios on short- and long-term outcome are not well described. Between March 2006 and December 2018, 261 patients received ECLS support after cardiac surgery. Data of patients with weaning failure (NW), postoperative LCO, and CPR leading to ECLS implantation were retrospectively analyzed regarding outcome. Risk factors for outcome after postcardiotomy ECLS were assessed by uni- or multivariate regression analysis. Median duration of extracorporeal support was 5.5 ± 8.5 days. Overall mortality on ECLS was 39.1%. Scenario analysis revealed weaning failure from cardiopulmonary bypass in 40.6%, postoperative LCO in 24.5%, and postoperative CPR in 34.9% leading to initiation of ECLS. Most common cause of death was refractory LCO (25.3%). Overall follow-up survival was 23.7%. Survival after weaning and during follow-up in all subgroups was 9.2% (CPR), 5.0% (LCO), and 9.6% (NW), respectively. Uni- or multivariate regression analysis revealed age, aortic surgery, and vasopressor medication level on day 1 as risk for death on support, as well as postoperative renal failure, and body mass index (BMI) as risk factors for death during follow-up. Mortality after postcardiotomy ECLS is high. Overall, outcome after CPR, NW, weaning failure and LCO is comparable. Postoperative resuscitation does not negatively affect outcome after postcardiotomy ECLS. Neurological status of ECLS survivors is good.

Anesthesia management for orthotropic heart transplantation

Anesthesia was done for 36 patients undergoing orthotropic heart transplantation in Beijing Anzhen Hospital from April 2015 to November 2016.Anesthesia management for orthotropic heart transplantation and related problems were analyzed and investigated.Anesthesia management protocol for patients with end-stage heart disease was aimed at reducing fluctuation of hemodynamics and avoiding malignant arrhythmia.Anesthesia was induced by intravenously injecting diazepam 5-10 mg, etomidate 0.2-0.3 mg/kg or ketamine 1 mg/kg, sufentanil 1.0-1.5 μg/kg or fentanyl 10-15 μg/kg and rocuronium 0.6 mg/kg.Anesthesia was maintained by continuously infusing dexmedetomidine 0.3-0.5 μg·kg-1·h-1, cisatracurium 10 mg/h and sufentanil 0.5-1.0 μg·kg-1·h-1.Pulmonary arterial pressure and donor heart function were monitored using the flow-directed pulmonary artery catheter.Dopamine, epinephrine and isoprenaline were intravenously infused after cardiopulmonary bypass to maintain circulation stable.Nitroglycerin and prostacyclin were intravenously infused to decrease pulmonary arterial pressure.Immunosuppressive therapy was performed with methylprednisone, mycophenolate mofetil and cyclosporine/FK506.Thirty-two patients were discharged from hospital, and 4 cases died.Among the 4 patients died, 1 patient died of pulmonary hypertension (pulmonary arterial systolic pressure>67 mmHg) and right heart failure and, 1 patient showed difficulty in weaning from cardiopulmonary bypass and 2 patients died of refractory low cardiac output and multi-organ failure.Anesthetic management for heart transplantation required an appreciation of the pathophysiological mechanism of heart failure.Invasive monitoring, steady anesthesia induction and maintenance, stable hemodynamics in the perioperative period and good donor heart protection were the keys to ensuring anesthesia management for orthotropic heart transplantation. Key words: Heart transplantation; Anesthesia; Retrospective studies

Characterization of the Glucocorticoid Receptor in Children Undergoing Cardiac Surgery.

Postoperative administration of corticosteroids is common practice for managing catecholamine refractory low cardiac output syndrome. Since corticosteroid activity is dependent on the glucocorticoid receptor, we sought to characterize glucocorticoid receptor levels in children undergoing cardiac surgery and examined the association between glucocorticoid receptor levels and cardiovascular dysfunction. Prospective observational cohort study. Large, tertiary pediatric cardiac center. Children undergoing corrective or palliative cardiac surgery. None. A prospective observational cohort study was conducted in 83 children with congenital heart disease. Total glucocorticoid receptor levels were measured in the peripheral WBCs using flow cytometry. In addition, blood samples were collected for total cortisol levels. The primary outcome studied was the time to being inotrope free. An increase in glucocorticoid receptor level from postoperative day 1 to postoperative day 3 was associated with a longer time to being inotrope free (hazard ratio, 0.49 [0.29-0.81]; p = 0.01) in the univariate analysis. This association remained significant after adjusting for age, weight, cardiopulmonary bypass time, cross clamp time, Risk Adjustment for Congenital Heart Surgery-1 score, and postoperative steroid use (hazard ratio, 0.53 [0.29-0.99]; p = 0.05). Postoperative day 3 glucocorticoid receptor level showed a trend to have longer time to being inotrope free (hazard ratio, 0.66 [0.42-1.02]; p = 0.0.06). The cortisol levels minimally increased during the study duration and did not correlate with glucocorticoid receptor levels. Increasing glucocorticoid receptor levels in peripheral WBCs of children undergoing cardiac surgery are associated with a longer time to being inotrope free. Cortisol levels minimally increased during the study duration. These results suggest that exposure to high-dose perioperative corticosteroids may suppress the hypothalamic-pituitary-adrenal axis leading to increase in glucocorticoid receptor levels in response to a low cortisol environment. Further studies are required to better delineate the interplay between glucocorticoid receptor levels, cortisol levels, corticosteroid exposure, and postoperative inotropic requirements.

Short-Term Ventricular Assist Device as a Bridge to Decision in Cardiogenic Shock: Is It a Justified Strategy?

Low cardiac output syndrome is associated with significant mortality. In patients with refractory low cardiac output left ventricular assist devices (VAD) are used to re-establish cardiac output and to prevent death. However, long-term LVAD implantation in these is complicated by a high rate of right heart failure and mortality. Therefore, our strategy is to implant a short-term VAD (left or biventricular) as a bridge to decission. We retrospectively analysed data from 66 patients who received a short-term LVAD support prior to implantation of a long-term LVAD or HTx between 2003 and 2014. We performed short-term LVAD (CentriMag; Thoratec) implantation via median sternotomy with percutaneous cannulas. Patients were included regardless of perioperative status and severity of heart failure. Patients suffering postcardiotomy cardiogenic shock, receiving isolated RVAD as well as posttransplant patients were excluded from this study. Mean duration of support in the survivor group was 35 ± 25 days versus 25 ± 25 days in the nonsurvivor group (n.s.), range from 1 to 109 days. The overall survival on support was 40 (60%) patients. In the survivor group 12 patients could be successfully weaned from the system, 12 patients received a heart transplant and in 16 a long-term VAD was implanted. In the nonsurvivor group the rate of preoperative extracorporeal life support, the rate of postoperative renal failure and multiorgan failure was significantly higher. Thanks to its capacity for full ventricular support, short-term univentricular or biventricular LevotronixCentriMag VAD currently represents an ideal solution for bridge-to-decision.

0229: Intra-aortic balloon pump in children: single-centre experience and overview of practices

Intra-aortic balloon pump (IABP) is a commonly used method of temporary circulatory support in adults. Despite the availability of paediatric size balloons, the use of IABP in children is currently not widespread. To describe our practice of IABP in children and to review its indications. Single-centre retrospective study. We reviewed the medical records of all paediatric patients (<18 years) who were supported with IABP from April 2010 to April 2015. We compare our practice with those reported in Pubmed (37 articles). During this period 7 patients (6 boys) had a circulatory support with IABP. Mean age was 12.1 years (10-14) and mean weight was 46.1kg (30-61). All were mechanically ventilated and received inotropic support at the time of IABP deployment. 2 IABP were started before surgery to treat acute heart failure (1 myocarditis and 1 ischemic condition). The major indication for IABP was postoperative hemodynamic deterioration (n=5). 4 of them were related to suboptimal cardioplegia in a context of left ventricular hypertrophy. Mean duration of IABP support was 7.1 days (2-13). All IABP catheters were inserted through the common femoral artery. No local complication was reported. All IABP were inserted by an intensivist without surgical help. IABP is a feasible method in children with acute left ventricular failure. By improving diastolic perfusion of the coronary arteries, IABP is effective especially in case of myocardial ischemia. This life-saving technique has to be associated to conventional medical treatment of refractory low cardiac output. Sometimes, IABP may be an alternative for effective mechanical circulatory support.

Editorial Comment: Rescue mechanical circulatory support for failing transplanted hearts

It is indeed a rewarding experience for transplant surgeons when the donor heart, after being weaned from the cardiopulmonary bypass, beats in sinus rhythm, with satisfactory haemodynamics, and has excellent biventricular function as assessed by transoesophageal echocardiography, the chest is closed and the patient returns to the intensive care unit for postoperative monitoring and recovery. Conversely, it becomes a humbling and indeed terrifying experience when, while waiting expectantly, we find that the transplanted heart does not contract, but we observe an echocardiogram showing arrhythmias, which herald impending cardiac failure [1]. When this happens, we may have a recipient who cannot be weaned from cardiopulmonary bypass despite maximal medical management, or the donor heart may begin to fail on the intensive care unit, which may end in graft failure during his/her hospital stay. Why does the transplanted heart fail? It is believed to be largely due to the mechanism of ischaemia-reperfusion injury. Graft failure may result from long ischaemic times, inadequate myocardial preservation at the time of procurement, hyperacute rejection, which is extremely rare, or poor adaptation of the graft to the recipient’s haemodynamic environment. It may also be caused by donor heart hypertrophy, coronary artery disease, air embolism and the neural influence of the donor’s brain death. In children, it may be due to increased pulmonary vascular resistance either as a consequence of left ventricular (LV) failure or as a result of single ventricle physiology, resulting in the risk of right ventricular failure after transplantation [2]. Primary graft failure is a severe cardiac dysfunction of the cardiac allograft without obvious anatomical or immunological causes [2], characterized by hypotension, high filling pressures, and refractory low-cardiac output, and mostly right ventricular failure after coming off the cardiopulmonary bypass. Measures aimed at decreasing pulmonary vascular resistance after transplantation include the use of inhaled nitric oxide as well as medications with pulmonary vasodilator effects such as prostacyclin and milrinone. Graft ventricular function is also supported postoperatively with inotropes. However, despite these interventions, ventricular failure may persist, and mechanical circulatory support (MCS) then becomes necessary. Prior to the introduction of MCS, primary graft failure was fatal except in isolated cases where emergency salvage retransplantation, sometimes after prolonged periods of extracorporeal circulation, was attempted, but the outcomes of this strategy were poor [3], and it has, therefore, been seldom applied. With the advent of MCS devices, hopes of rescuing failing transplanted hearts have been resurging. Presently, we offer support either with extracorporeal membrane oxygenation (ECMO) or with ventricular assist devices (VADs), depending on whether recovery can be expected or retransplantation is anticipated.

Midterm Outcome After Surgical Correction of Anomalous Left Coronary Artery From Pulmonary Artery

Early establishment of a two-coronary artery system has become the standard surgical approach in patients with anomalous origin of the left coronary artery from the pulmonary artery. After surgical repair, presentation of severely impaired ventricular function and mitral regurgitation is a common finding. We reviewed midterm outcome of 18 consecutive patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) undergoing surgical repair for establishment of dual coronary system operated on between September 1999 and July 2009. Mortality, morbidity, echocardiography assessment of left ventricular function, mitral valve regurgitation, and indications for reoperation were studied retrospectively. The mean age at the time of surgery was 26 ± 44 months (range, 14 days-12.7 years), 14 patients were younger than 6 months. There was no in-hospital or late mortality. Recovery of left ventricular function was associated with improvement in the degree of mitral valve regurgitation. At the latest follow-up, mitral valve regurgitation was none or trace in 14 patients (78%), mild to moderate in 3 patients (16%), and remained severe in 1 patient (6%). Left ventricular function normalized in 16 patients and remained mildly impaired in 2 patients. Late postoperative echocardiograms demonstrated a patent left coronary artery in 17 patients. In 5 patients temporary left heart bypass (LHB) was needed. Early establishment of a 2-coronary artery system artery results in complete recovery of left ventricular function and without relevant mitral valve dysfunction. Reoperation rates are acceptable. Our results support the use of LHB in patients with refractory low cardiac output. The need of mechanical circulatory support was short and very effective in our patient cohort.

Rescue Extracorporeal Life Support for Acute Verapamil and Propranolol Toxicity in a Neonate

Extracorporeal life support (ECLS) to manage acute antiarrhythmic drugs toxicity in neonates has never been reported. Here presented is a case of venoarterial extracorporeal membrane oxygenation support in a newborn with refractory low cardiac output as a result of acute Ca-channel and β-receptor antagonist toxicity for treatment of paroxysmal supraventricular tachycardia (SVT). Shortly after onset of ECLS, the baby recovered sinus rhythm and subsequent bouts of SVT were controlled by amiodarone infusion and repeated DC shocks. Weaning was possible on the 5th day after implant, once recovery of the left ventricular function and optimization of the antiarrhythmic medication were achieved. In neonates with severe but potentially reversible cardiac dysfunction caused by drug toxicity, ECLS can maintain cardiac output and vital organ perfusion while allowing time for drug redistribution, metabolism, and clearance.

Long-term outcome after surgical correction of anomalous left coronary artery from pulmonary artery

Objectives: Early establishment of a two-coronary artery system has become the standard surgical approach in patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). After surgical repair, presentation of severely impaired ventricular function and mitral regurgitation is a common finding. Methods: We reviewed long-term outcome of 18 consecutive patients with ALCAPA undergoing surgical repair for establishment of dual coronary system operated on between 1999 and 2009. Mortality, morbidity, echocardiography assessment of left ventricular function, mitral valve regurgitation, and indications for reoperation were studied retrospectively. Results: The mean age at the time of surgery was 26±44 months, There was no in-hospital or late mortality. In 5 patients perioperative left ventricular assist device was needed. 1 patient required reoperation 6 years postoperatively because of relevant proximal stenosis of the left main coronary artery, Recovery of left ventricular function was associated with improvement in the degree of mitral valve regurgitation. At the latest follow up, mitral valve regurgitation was non or trace in 14 patients, mild to moderate in 3 patients and remained severe in 1 patient. Left ventricular function normalized in 16 patients, and remained mildly impaired in 2 patients. Conclusions: Early establishment of a two-coronary artery system artery results in complete recovery of left ventricular function and without relevant mitral valve dysfunction. Re-operation rates are acceptable. Our results support the use of LVAD in patients with refractory low cardiac output. The necessary of mechanical circulatory support was short and very effective in our patient cohort.

Intra-aortic balloon pumping in children undergoing cardiac surgery: An update of the Liverpool experience

Intra-aortic balloon pumping in children remains a rarity. We report our experience in supporting pediatric cardiac surgical patients with intra-aortic balloon pumping. We reviewed the cases of 24 children supported with intra-aortic balloon pumping after cardiac surgery in our institution from 1994 through 2003. Mean age at the time of the operation was 5.0 +/- 5.6 years (range, 7 days-17.5 years). Ten patients were infants less than 6 months old. Mean weight was 18.9 +/- 18.1 kg (range, 3.5-58.7 kg). Indications for intra-aortic balloon pump deployment were postoperative hemodynamic deterioration (n = 11, 8 survivors), failure to wean off cardiopu(n = 7, 5 survivors), and prophylaxis before weaning off cardiopulmonary bypass (n = 6, 5 survivors). The balloon was inserted through the ascending aorta in infants and through the femoral artery in children. Eighteen children (7 infants) were weaned off the intra-aortic balloon pump successfully (intra-aortic balloon pump survival, 75%). Mean duration of intra-aortic balloon pump support was 121.3 +/- 140.60 hours (range, 8-670 hours). There were 3 post-intra-aortic balloon pump in-hospital deaths (survival to hospital discharge, 62.5%). Severe intra-aortic balloon pump-related complications were mesenteric ischemia in 1 patient and lower limb ischemia requiring intra-aortic balloon pump removal in 1 patient. At a mean follow-up of 85 +/- 31 months (range, 18-124 months), all 15 long-term survivors were alive and well. Use of an intra-aortic balloon pump is an effective modality of cardiac support in properly selected pediatric cardiac surgical patients with refractory low cardiac output. It can be safely used in small infants and neonates. In selected cases with known left ventricular dysfunction, there is a place for prophylactic use of an intra-aortic balloon pump.

Mechanical support for postcardiotomy cardiogenic shock.

Postcardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality. Despite intraaortic balloon pump and inotropic support, some patients with PCCS continue to have a refractory low cardiac output. For these patients, more effective ventricular assistance is imperative to prevent death. Multiple systems are available for the short-term support of patients with PCCS. Regardless of the device employed, only 25% of these patients survive and are discharged home. Two strategies, however, may improve the outcome of PCCS. One is long-term support by an implantable assist device, which can allow optimal ventricular unloading. Unfortunately, not all cardiac surgery centers offer this type of support. Therefore, the other strategy is the creation of postcardiotomy referral centers that offer long-term support or heart transplantation. Such centers would conserve scarce donor organs, maximize the chance of myocardial recovery, and yield expertise applicable not only to device recipients but also to critically ill heart-failure patients who do not need an implantable pump.

Intraaortic balloon pumping in children

Background. Intraaortic balloon pump (IABP) usage in young children remains a rarity because, first, there is a widespread misconception that the greater elasticity of the aorta in children may prevent effective augmentation, and second, children in low cardiac output states are more likely to have associated right ventricular failure and pulmonary problems. We report our experience with the use of IABP in children undergoing cardiac surgery in whom mechanical support was necessary for the treatment of refractory cardiac failure. Methods. Over a 3-year period, 14 children were identified as requiring IABP support after cardiac surgery. Their median age was 3 years (range 7 days to 13 years) and their median weight was 13.3 kg (range 3.5–51 kg). Indications for IABP use were: failure to wean from cardiopulmonary bypass (5 patients), sudden deterioration in intensive therapy unit (ITU) (3 patients), progressive deterioration in ITU (4 patients), and prophylactic therapy for known poor preoperative ventricular function (2 patients). Results. Ten of 14 patients (71%) were successfully weaned from the IABP, of whom 8 became long-term survivors (57%). Among the survivors, the mean duration of IABP usage was 127 h (range 12–260 h), while for those who died while on IABP, the mean duration was 15 h (range 8–24 h). The most major IABP-related complication encountered was mesenteric ischemia, which had a fatal outcome. Conclusions. IABP therapy, used as an adjunct to conventional medical treatment, can give properly selected young children in refractory low cardiac output states after heart surgery a greater than 50% chance of long-term survival.

Centrifugal ventricular assist in children under 6 kg.

The clinical application of centrifugal ventricular assist devices (VAD) has generally been limited to adults and large paediatric patients. In our experience neonates and small paediatric patients requiring ventricular support post-cardiopulmonary bypass are well supported by VAD. In this study we analyse our experience. We have examined the records of our VAD patients who weighed less than 6 kg. Thirty-four patients, ranging in age from 2 to 258 days (median 60 days) and weight from 1.9 to 5.98 kg (median 3.7 kg), underwent 35 VAD procedures. One patient was supported on VAD twice. All patients had congenital heart lesions and were placed on VAD either because they could not be weaned from cardiopulmonary bypass after repair or palliation of the lesion (71.5%), or for support in the post-operative period due to refractory low cardiac output (28.5%). Twenty-two of the 35 VAD procedures (0.63, 95% CI: 0.45-0.78) resulted in successful weaning and decannulation, this was similar to the weaning probability for patients greater than 6 kg (P = 0.07). There were 10 late deaths in this group, with a 1-year KM survival of 0.31 (95% CI: 0.17-0.47). Most late deaths were related to irreversible cardiac disease processes as were the elective discontinuance of VAD outcomes. Neither weight, age, VAD duration, CPB duration, X clamp duration, univentricular anatomy or TGA anatomy predicted successful discharge from hospital (P > 0.05)--Weight P = 0.576; Age P = 0.532; VAD duration P = 0.181; CBP duration P = 0.549; X clamp duration P = 0.984; Univentricular anatomy P = 0.481; TGA anatomy P = 0.099. We believe centrifugal ventricular assist is a realistic option in very small patients who require post-cardiopulmonary bypass support. It is relatively easy to establish and manage, the results, although showing no factors predictive of successful discharge, are encouraging.

Ventricular assist devices in pediatric cardiac surgery

Early experience in other centers with pediatric assist devices has been favorable. Prospectively we examined our first 13 patients between January 1992 and September 1994. Thirteen children underwent ventricular assistance at Royal Alexandra Hospital for Children. Age ranged from 4 days to 30 months, weight from 2.9 kg to 17 kg. Ventricular assistance was employed from 1.5 hours to 190 hours. Of 12 surgical patients, 8 required left ventricular assistance to be weaned from cardiopulmonary bypass after correction of congenital defects, and 4 required support in the postoperative period for refractory low cardiac output. A child was supported after a kick to the chest by a horse caused cardiogenic shock. All 13 patients initially responded to ventricular assistance and 7 remain alive. Of the deaths, 2 were neurologic, 2 due to myocardial failure, and 2 to sepsis. The major complications in the first days were hemorrhage and tamponade. Later problems included thrombosis of the circuit despite systemic heparinization, and a cannula-related tear to the anterior mitral leaflet. The 7 survivors are well after 3 to 32 months. Despite the mortality and complications, we are encouraged by these results, in the light of almost certain death for all 13 patients without ventricular assistance.

Advantages of Delayed Sternal Closure in Cardiac-Compromised Adult Patients

Severe hemodynamic dysfunction may follow closure of the median sternotomy in patients with myocardial edema, cardiac dilatation, postcardiotomy shock, or raised end-expiratory alveolar pressure. Open sternotomy and delayed sternal closure (DSC) is a well described adjunct in complicated cardiac operations, which is more widely applied in neonates. In this article we report our results in using open sternotomy in eight adult patients from January 1994 to February 1995 (excluding patients who needed ventricular assistance devices [VADs]). Three patients died in hospital: 1 case of multiorgan failure; 1 cases of refractory low cardiac output syndrome; and 1 case of respiratory distress syndrome. Our experience confirms that DSC is an effective means of dealing with postoperative hemodynamic impairment. Furthermore, this technique may represent an intermediate step between intraaortic balloon counterpulsation and VADs and should be given a role in the prophylaxis of low postoperative cardiac output and multiorgan failure, particularly when contraindications to VAD exist.

Hydrochlorothiazide‐induced pulmonary edema with severe acute myocardial dysfunction

A 73-year-old woman presented with acute pulmonary edema and hypotension less than 1 h after taking hydrochlorothiazide 50 mg, a reaction which has been reported as a rare but classic adverse drug response. Though prior cases have supported a noncardiogenic pulmonary edema syndrome, hemodynamic monitoring in this patient demonstrated a refractory low cardiac output state for more than 24 h. In the absence of other etiologies, this represents a new finding.

Induced hypothermia in the management of refractory low cardiac output states following cardiac surgery in infants and children

Post-operative low cardiac output states remain a major cause of mortality following cardiac surgery in infants and children. Since 1979 we have used moderate induced whole-body hypothermia in the management of low-output states refractory to conventional modes of therapy. This is based not only upon the relationship between body temperature and oxygen consumption, but also on experimental work showing a beneficial effect of cooling upon myocardial contractility, particularly when there is pre-existing impairment of ventricular function. Between July 1986 and June 1990, 20 children with refractory low-output states were cooled by means of a thermostatically controlled water blanket to a rectal temperature of 32-33 degrees C. The median age was 12 months (1 week-11 years) with a median weight of 6 kg (3.5-33 kg). Ten children survived to leave hospital while a further two made a haemodynamic recovery. There was a marked reduction in heart rate (P < 0.001). The mean arterial pressure rose (P = 0.037) while there was a fall in mean atrial pressure (P < 0.001). There was a significant improvement in the urine output (P = 0.002). A fall in the platelet count (P < 0.001) was not accompanied by any change in the white cell count (P = 0.15). Although it is impossible to say whether cooling influenced the outcome in any of these children, it was usually effective in stabilising their clinical condition. The technique is simple and has a sound theoretical basis.(ABSTRACT TRUNCATED AT 250 WORDS)

Rescue of a patient with fulminant myocarditis by percutaneous extracorporeal bypass.

A previously well 53-year-old man with fulminant myocarditis is presented. Cardiogenic shock and medically refractory low cardiac output syndrome were unsuccessfully treated using an intraaortic balloon pump. A percutaneous extracorporeal bypass system improved hemodynamics, DIC and other multiorgan injuries following acute myocarditis.