Cristián Clavería

Mortalidad operatoria y estratificación de riesgo en pacientes pediátricos operados de cardiopatía congénita: experiencia de 10 años

Estudio de cohorte no concurrente (ene-ro 2000-julio 2010). Las cirugias fueron estratificadas segun puntuacion de riesgo. La tendencia de morta-lidad operatoria se evaluo dividiendo el periodo es-tudiado en tres subperiodos. Comparamos nuestros resultados con los publicados por las Sociedades de Cirujanos de Cardiopatias Congenitas y la de Ciruja-nos de Torax.

Infecciones asociadas a la atención en salud (IAAS) en pacientes pediátricos post-operados de cardiopatías congénitas

INTRODUCTION Nosocomial infections generate high morbidity and mortality in children undergoing cardiac surgery. OBJECTIVE To determine risk factors for nosocomial infections in children after congenital heart surgery. METHODS A retrospective case-control study, in patients younger than 15 years undergoing surgery for congenital heart disease from January 2007 to December 2011 admitted to the Pediatric Critical Patient Unit (UPC-P) in a university hospital. For cases, the information was analyzed from the first episode of infection. RESULTS 39 patients who develop infections and 39 controls who did not develop infection were enrolled. The median age of cases was 2 months. We identified a number of factors associated with the occurrence of infections, highlighting in univariate analysis: age, weight, univentricular heart physiology, complexity of the surgical procedure according to RACHS-1 and cardiopulmonary bypass (CPB) time ≥ 200 minutes. Multivariate analysis identified CPB time ≥ 200 minutes as the major risk factor, with an OR of 11.57 (CI: 1.04 to 128.5). CONCLUSION CPB time ≥ 200 minutes was the mayor risk factor associated with the development of nosocomial infections.

Nutritional recovery after cardiac surgery in children with congenital heart disease

Introduction: Malnutrition is common in children with congenital heart disease (CHD). Medical treatment and surgical interventions contribute improving the nutritional status of these children. Objective: To describe nutritional recovery in children with CHD and associated factors after surgery. Patients and Method: Longitudinal study. 46 Children under 18 years old admitted for CHD surgery between April 2015 and April 2016 were recruited. The following CHD were included: Ventricular septal defect (VSD), Atrial septal defect (ASD), Hypoplastic left heart syndrome (HLHS), Tetralogy of Fallot (TOF), and Transposition of great arteries (dTGA). Children with genetic syndromes and other diseases that could compromise nutritional status were excluded. We obtained demographic, CHD, nasogastric tube use (NGT), nutritional evaluation, and weight and height data at the time of admission and one, three and six months after surgery and. Z-score to assess anthropometric measures were calculated according to WHO standards. Results: Median age was 8 months (IQR: 3,26), 24 (52%) male, 6 (13%) preterm and 12 (26,1%) small for gestational age (SGA). CHD diagnosis were: 9 (19,6%) VSD, 8 (17,4%) ASD, 12 (26,1%) HLHS, 9 (19,6%) TOF and 8 (17,4%) dTGA. The mean weight-for-heigth-BMI-for-age-z-score (W/H-BMI/AZ) was 0,6 ± 1,5 SD, (28.3% of undernutrition). The mean heigth-for-age-z-score (H/AZ) was -0,86 ± 1.3sd (21.7% of short stature). We found differences between each CHD and age, use of NGT and been under nutritional follow-up. There was an improvement between H/AZ at admission and 3rd month (p = 0,02), and W/H-BMI/AZ at 3th (p = 0,046) and 6th month (p = 0,001). Use of NGT decreased from admission to 6th month (19 vs 3) (p = 0,0016). We found correlation between admission W/H-BMI/AZ and nutritional recovery (r= -0,7; p < 0,001). Conclusion: There is a high prevalence of prematurity, SGA, undernutrition and short stature use of with weight recovery but not in heigth after cardio-surgery.INTRODUCTION Malnutrition is common in children with congenital heart disease (CHD). Medical treatment and surgical interventions contribute improving the nutritional status of these children. OBJECTIVE To describe nutritional recovery in children with CHD and associated factors after surgery. PATIENTS AND METHOD Longitudinal study. 46 Children under 18 years old admitted for CHD surgery between April 2015 and April 2016 were recruited. The following CHD were included: Ventricular septal defect (VSD), Atrial septal defect (ASD), Hypoplastic left heart syndrome (HLHS), Tetralogy of Fallot (TOF), and Transposition of great arteries (dTGA). Children with genetic syndromes and other diseases that could compromise nutritional status were excluded. We obtained demographic, CHD, nasogastric tube use (NGT), nutritional evaluation, and weight and height data at the time of admission and one, three and six months after surgery and. Z-score to assess anthropometric measu res were calculated according to WHO standards. RESULTS Median age was 8 months (IQR: 3,26), 24 (52%) male, 6 (13%) preterm and 12 (26,1%) small for gestational age (SGA). CHD diagnosis were: 9 (19,6%) VSD, 8 (17,4%) ASD, 12 (26,1%) HLHS, 9 (19,6%) TOF and 8 (17,4%) dTGA. The mean weight-for-heigth-BMI-for-age-z-score (W/H-BMI/AZ) was 0,6 ± 1,5 SD, (28.3% of undernutri tion). The mean heigth-for-age-z-score (H/AZ) was -0,86 ± 1.3sd (21.7% of short stature). We found differences between each CHD and age, use of NGT and been under nutritional follow-up. There was an improvement between H/AZ at admission and 3rd month (p = 0,02), and W/H-BMI/AZ at 3th (p = 0,046) and 6th month (p = 0,001). Use of NGT decreased from admission to 6th month (19 vs 3) (p = 0,0016). We found correlation between admission W/H-BMI/AZ and nutritional recovery (r = -0,7; p < 0,001). CONCLUSION There is a high prevalence of prematurity, SGA, undernutrition and short stature use of with weight recovery but not in heigth after cardio-surgery.

Síndrome de hipoplasia de corazón izquierdo: experiencia de 10 años de un programa de etapificación quirúrgica

UNLABELLED Hypoplastic left heart syndrome (HLHS) is a lethal congenital heart disease in 95% of non-treated patients. Surgical staging is the main form of treatment, consisting of a 3-stage approach, beginning with the Norwood operation. Long term survival of treated patients is unknown in our country. OBJECTIVES 1) To review our experience in the management of all patients seen with HLHS between January 2000 and June 2012. 2) Identify risk factors for mortality. PATIENTS AND METHOD Retrospective analysis of a single institution experience with a cohort of patients with HLHS. Clinical, surgical, and follow-up records were reviewed. RESULTS Of the 76 patients with HLHS, 9 had a restrictive atrial septal defect (ASD), and 8 had an ascending aorta ≤2mm. Of the 65 out of 76 patients that were treated, 77% had a Norwood operation with pulmonary blood flow supplied by a right ventricle to pulmonary artery conduit, 17% had a Norwood with a Blalock-Taussig shunt, and 6% other surgical procedure. Surgical mortality at the first stage was 23%, and for Norwood operation 21.3%. For the period between 2000-2005, surgical mortality at the first stage was 36%, and between 2005-2010, 15% (P=.05). Actuarial survival was 64% at one year, and 57% at 5years. Using a multivariate analysis, a restrictive ASD and a diminutive aorta were high risk factors for mortality. CONCLUSIONS Our immediate and long term outcome for staged surgical management of HLHS is similar to that reported by large centres. There is an improvement in surgical mortality in the second half of our experience. Risk factors for mortality are also identified.

Infección del sitio quirúrgico en niños sometidos a cirugía cardíaca con cierre esternal diferido: Estudio de casos y controles

INTRODUCTION Surgical site infections (SSI) are an important cause of morbidity in pediatric cardiac surgery. Risk factors in patients requiring delayed sternal closure (DSC) are unknown. AIM To report the rate of SSI in children undergoing cardiac surgery with DSC and determine the risk factors. METHODOLOGY A retrospective case-control study, in patients younger than 15 years old undergoing cardiac surgery with DSC in our center between 2009 and 2010. SSI was diagnosed according to the criteria of the nosocomial infections committee of our institution, based on international recommendations. Univariate and multivariate analysis of variables was performed. A p < 0.05 was considered significant. RESULTS 58 patients were included; the average age was 9.5 days. The most frequent diagnosis were transposition of the great arteries (36%) and hypoplastic left heart syndrome (27%). 13 patients had SSI (22%); 11 incisional and 2 mediastinitis. It was independently associated to SSI by-pass (BP) time longer than 200 min (OR adjusted = 9,53; IC 95% 1,37-66,35) and mechanical ventilation (MV) more than 5 days (OR adjusted = 8,98; IC 95% 1,16-69,40). CONCLUSION The duration of BP and MV are risk factors of SSI in children undergoing cardiac surgery with DSC.

Evaluación física y rehabilitación cardiovascular en niños con patología cardíaca

Resumen: Debido a los avances en las tecnicas diagnosticas y resultados operatorios, los ninos con cardiopatias congenitas (CC) tienen hoy mayor ex-pectativa de vida. Nuestro hospital - un Centro de Referencia Nacional para la tratamiento de las CC en menores de 15 anos -, ha reportado una disminu-cion significativa de la mortalidad operatoria desde un 8,1% a un 4,7% entre 2000 y 2010, pero ello no se ha acompanado de mejoria importante de la calidad de vida. La falta de programas de actividad fisica y par-ticipacion social, puede ser un factor importante en la limitacion de la calidad de vida. La evidencia existen-te describe que la medida referida produce mejorias en el consumo de oxigeno peak (VO2peak), tolerancia al esfuerzo fisico y menores tasas de re hospitaliza-cion. En el presente articulo se revisan los metodos de evaluacion de la condicion fisica en la edad pediatrica, la evidencia actual de los programas de rehabilitacion cardiovascular pediatrica y recomendaciones de acti-vidad fisica en ninos portadores de CC.

Resultados inmediatos y alejados del switch arterial en pacientes con dextrotransposición de grandes arterias: experiencia de 20 años.

Estudio retrospectivo de pacientes sometidos a switch arterial entre mayo de 1992 y noviembre de 2012. Se comparo periodo 1 (1992 a 2002) con periodo 2 (2003 a 2012). Se de-finio D-TGA simple aquella sin lesiones asociadas y D-TGA compleja aquella con asociacion de comunica-cion interventricular o coartacion aortica.

Análisis de prevalencia de la mortalidad atribuible a causas conocidas de muerte súbita en Chile, población de 1 a 35 años, 2000-2010

Antecedentes: Pocas situaciones son mas devastadoras que los casos de pacientes, sin patologia previa diagnosticada, que presentan muerte subita (MS), especialmente durante la practica deportiva. La mayor parte de las MS son consecuencia de una patologia cardiaca subyacente no diagnosticada, definida como muerte subita cardiaca (MSC). En Chile no existen reportes que analicen la epidemiologia de la MSC. La literatura Internacional describe la relacion entre patologias cardiacas bien definidas y ejercicio competitivo como gatillante de la MSC. Objetivo: Caracterizar la prevalencia de patologias cardiacas y sus subtipos reconocidos como causas de MSC en el grupo etario de 1 ano a 35 anos. Metodos: Se analizaron los registros del Departamento de Estadisticas e Informacion del Ministerio de Salud y los certificados de defuncion de todos los fallecidos entre los anos 2000-2010 del grupo etario de 1 ano a 35 anos. Se seleccionaron datos de los fallecidos con diagnosticos relacionados con MSC de acuerdo al Codigo Internacional de Enfermedades (CIE-10). Resultados: de un total de 57.979 fallecidos, 1131 (1,95%) correspondieron a los codigos del CIE-10 que se estimaron como catalogables dentro de causas de MSC. Las patologias certificadas mas frecuentes fueron la enfermedad cardiaca isquemica 43% y las miocar-diopatias 27%. Conclusiones: Este estudio es un primer paso en la caracterizacion de la MSC en Chile. Los resultados obtenidos demuestran que la enfermedad cardiaca isquemica y las miocardiopatias son las patologias descritas con mayor frecuencia como causa de defuncion de MSC en ninos y adultos jovenes, lo que es consistente con la literatura internacional.