E Schindler

Pulmonary artery sling with tracheal stenosis

Pulmonary artery sling (PAS) is a rare congenital heart disease in which the left pulmonary artery (LPA) originates from the right pulmonary artery (RPA) and encircles the distal trachea and right mainstem bronchus as it courses between the trachea and esophagus. Typically, patients with PAS have some respiratory symptoms, either due to external tracheal compression that can be corrected by relief of the sling mechanism, or due to severe diffuse tracheal stenosis with complete rings (ring-sling complex). The diagnosis of PAS is optimally made by echocardiography, while bronchoscopy is the key to the assessment of tracheal stenosis. Diagnosis is indication for surgery. Repair using a strategy of median sternotomy, cardiopulmonary bypass, division of the LPA and reimplantation into the main pulmonary artery (MPA), and simultaneous tracheal repair takes preference. Tracheal repair should be considered only in clinically symptomatic patients. The techniques of free tracheal autograft plasty or slide tracheoplasty offer promising results, and the choice of tracheal reconstruction should be guided by the clinical experience of the surgeon. Coexisting intracardiac pathologies are repaired at the same time. Postoperative care requires close multidisciplinary effort to achieve the best long-term result.

Surgical Management of Congenital Heart Disease: Correlation between Hospital Costs and the Aristotle Complexity Score

BACKGROUNDnHospital costs are expected to correlate with clinical complexity. Do costs for congenital heart surgery correlate with Aristotle complexity scores?nnnMETHODSn442 inpatient stays in 2008 were evaluated. Aristotle scores and levels were determined. Costs were estimated according to the German Institute for Hospital Reimbursement system. Pearson and Spearman R correlation coefficients and corresponding goodness-of-fit regression coefficients R2 were calculated.nnnRESULTSnMean basic and comprehensive Aristotle scores were 7.60 +/- 2.74 and 9.23 +/- 2.94 points, respectively. Mean expenses per hospital stay amounted to 29,369 +/- 30,823 Euros. Aristotle basic and comprehensive scores and levels were positively correlated with hospital costs. With a Spearman R of 1 and related R2 of 0.9436, scores of the 6 Aristotle comprehensive levels correlated best. Mean hospital reimbursement was 26,412 +/- 17,962 Euros. Compensation was higher than expenses for patients in comprehensive levels 1 to 3, but much lower for those in levels 4 to 6.nnnCONCLUSIONSnAristotle comprehensive complexity scores were highly correlated with hospital costs. The Aristotle score could be used as a scale to establish the correct reimbursement after congenital heart surgery.

Congenital Heart Surgery: Expected Versus Observed Surgical Performance According to the Aristotle Complexity Score

BACKGROUNDnThe Aristotle score quantifies the complexity involved in congenital heart surgery. It defines surgical performance as complexity score times hospital survival. We studied how expected and observed surgical performance evolved over time.nnnMETHODSn2312 main procedures carried out between 2006 and 2010 were analyzed. The Aristotle basic score, corresponding hospital survival and related observed surgical performance were estimated. Expected survival was based on the mortality risks published by OBrien and coauthors. Observed performance divided by expected performance was called the standardized ratio of performance. This should trend towards a figure above 100%. Survival rates and performance are given with 95% confidence intervals.nnnRESULTSnThe mean Aristotle basic score was 7.88 ± 2.68. 51 patients died: observed hospital survival was 97.8 % (97.1 %-98.3%). 115 deaths were anticipated: expected survival was 95.2% (93.5%-96.3%). Observed and expected surgical performance reached 7.71 (7.65-7.75) and 7.49 (7.37-7.59), respectively. Therefore the overall standardized ratio of performance was 102.94%. The ratio increased from 2006 (ratio = 101.60%) to 2009 (103.92%) and was 103.42% in 2010. Performance was high for the repair of congenital corrected transposition of the great arteries and ventricular septal defect (VSD) by atrial switch and Rastelli procedure, the Norwood procedure, repair of truncus arteriosus, aortic arch repair and VSD closure, and the Ross-Konno procedure, with corresponding standardized ratios of 123.30%, 116.83%, 112.99%, 110.86% and 110.38%, respectively. With a ratio of 82.87%, performance was low for repair of Ebsteins anomaly.nnnCONCLUSIONnThe standardized ratio of surgical performance integrates three factors into a single value: procedure complexity, postoperative observed survival, and comparison with expected survival. It constitutes an excellent instrument for quality monitoring of congenital heart surgery programs over time. It allows an accurate comparison of surgical performance across institutions with different case mixes.

Prolonged Activated Clotting Time after Protamine Administration Does Not Indicate Residual Heparinization after Cardiopulmonary Bypass in Pediatric Open Heart Surgery.

BACKGROUNDnIn open heart surgery, heparinization is commonly neutralized using an empirical heparin:protamine ratio ranging between 1:1 and 1:1.5. However, these ratios may result in protamine overdose that should be avoided for its negative side effects on the coagulation system. This study aimed to indicate the appropriate treatment for prolonged activated clotting time (ACT) after protamine administration following cardiopulmonary bypass (CPB) in pediatric open heart surgery by investigating the underlying reasons for it.nnnMETHODSnTwenty-seven children (<10 kg) undergoing open heart surgery were included. Heparin was administered only before CPB (400 IU/kg) and in the pump priming volume for CPB (2,000 IU) and was neutralized by 1:1 protamine after CPB. The blood heparin concentration was measured using anti-Xa assay. ACT and blood concentrations of heparin, coagulation factors, thrombin-antithrombin complex, and prothrombin fragment 1u2009+u20092 were assessed. A rotational thromboelastometry (ROTEM; Tem International GmbH, München, Bayern, Germany) was used to confirm the coagulation status and residual heparin after protamine administration.nnnRESULTSnAnti-Xa assay showed that there is no residual heparin in the blood after 1:1 protamine administration. Nevertheless, ACT (128.89u2009±u20093.09u2009seconds before heparin administration) remained prolonged (177.14u2009±u20095.43u2009seconds at 10 minutes after protamine, 182.00u2009±u20095.90u2009seconds at 30 minutes after protamine). The blood concentrations of coagulation factors were significantly lower than those before heparin administration (pu2009<u20090.01). The low FIBTEM MCF of ROTEM (4.43u2009±u20090.32 mm) at 10 minutes after protamine indicated low fibrinogen concentration.nnnCONCLUSIONnProlonged ACT after heparin neutralization by 1:1 protamine administration does not necessarily indicate residual heparin, but low blood concentrations of coagulation factors should be considered as a reason as well. Accordingly, supply of coagulation factors instead of additional protamine should be considered.

Contemporary results of aortic valve repair for congenital disease: lessons for management and staged strategy†

OBJECTIVES Any aortic valve (AoV) operation in children (repair, Ross or mechanical replacement) is a palliation and reinterventions are frequent. AoV repair is a temporary solution primarily aimed at allowing the patient to grow to an age when more definitive solutions are available. We retrospectively analysed AoV repair effectiveness across the whole age spectrum of children, excluding neonates and AoV disease secondary to congenital heart disease. METHODS From 2003 to 2015, 193 consecutive patients were included. The mean age was 9.2 ± 6.9 years (22% <1 year); 86 (45%) had a preceding balloon valvuloplasty. The indications for the procedure were stenotic (n = 123; 64%), regurgitant (n = 63; 33%) or combined (n = 7; 4%) disease. The procedures performed were commissurotomy shaving (n = 74; 38%), leaflet replacement (n = 78; 40%), leaflet extension (n = 21; 11%) and neocommissure creation (n = 21; 11%). Post‐repair geometry was tricuspid in 137 (71%) patients. RESULTS The 10‐year survival rate was 97.1%. Freedom from reoperation and replacement at 7 years was, respectively, 57% (95% confidence interval, 47‐66) and 68% (95% confidence interval, 59‐76). In multivariate analysis, balloon dilatation before 6 months, the absence of a developed commissure, a non‐tricuspid post‐repair geometry and cross‐clamp duration were predictors for reoperation and replacement. After a mean follow‐up period of 5.1 ± 3.0 years, 145 (75%) patients had a preserved native valve, with undisturbed valve function (peak gradient <40 mmHg, regurgitation ≤mild) in 113 (58%). CONCLUSIONS Aortic valve repair in children is safe and effective in delaying the timing for more definitive solution. Surgical strategy should be individualized according to the age of the patient. Avoidance of early balloon dilatation and aiming for a tricuspid post‐repair arrangement may improve outcomes.

Surgical Management of Congenital Heart Disease: Contribution of the Aristotle Complexity Score to Planning and Budgeting in the German Diagnosis-Related Groups System

Planning and budgeting for congenital heart surgery depend primarily on how closely reimbursement matches costs and on the number and complexity of the surgical procedures. Aristotle complexity scores for the year 2010 were correlated with hospital costs and with reimbursement according to the German diagnosis-related groups (DRG) system. Unit surgical performance was estimated as surgical performance (complexity scorexa0×xa0hospital survival) times the number of primary procedures. This study investigated how this performance evolved during years 2006 to 2010. Hospital costs and reimbursements correlated highly with Aristotle comprehensive complexity levels (Spearman rxa0=xa01). Mean costs and reimbursement reached 35,050€xa0±xa032,665€ and 31,283€xa0±xa034,732€, respectively, for an underfunding of 10.7%. Basic and comprehensive unit surgical performances were respectively 3036xa0±xa01009 and 3891xa0±xa01591 points in 2006. Both performances increased in sigmoid fashion to reach 3883xa0±xa01344 and 5335xa0±xa01314 points, respectively, in 2010. Top performances would be achieved in year 2011, and extrapolated costs would comprise about 19,434,094.92€ (95% confidence interval, 11,961,491.22–22,495,764.42€). The current underfunding of congenital heart surgery needs correction. The Aristotle score can help to adjust reimbursement according to complexity of procedures. Unit surgical performance allows accurate budgeting in the current German DRG system.

Function of Contegra valved grafts after unifocalization.

BACKGROUNDnCan Contegra grafts withstand high pressure?nnnMETHODSnThe function of Contegra grafts implanted after unifocalization of major aortopulmonary collateral arteries (MAPCAs) in 10 patients was evaluated. Median age at repair was 194 days and two conduit sizes were used: 12 mm (n = 8) and 14 mm (n = 2). Echocardiography and heart catheterization findings were reviewed.nnnRESULTSnTwo patients died: one early after repair, one late. Death was not graft related. The median duration of observation for survivors was 31 (range 4 - 42) months. The postoperative right ventricular/left ventricular pressure ratio was greater than 75 % in 9 patients. High pressures persisted in 6 survivors. Seven patients underwent interventional dilatation/stenting of pulmonary arteries on 19 occasions. No obstruction was detected in the conduit. Graft valve regurgitation increased in 5 patients, but never exceeded grade 2 (n = 4). Freedom from reoperation for conduit dysfunction/failure was 100 % at month 42.nnnCONCLUSIONnAt mid-term follow-up, the Contegra grafts withstood high pressure without significant dysfunction or aneurysmal dilatation requiring surgery. Contegra appears to be an acceptable alternative to the aortic homograft for use after unifocalization of MAPCAs in infancy.

Short title: Anaesthetic mechanisms in the CNS Where and how do anaesthetics act? Mec

General anaesthesia is a balance of hypnosis, amnesia, analgesia, and immobility, including the inhibition of noxious autonomic reflexes. Local anaesthesia implements the latter two elements in a conscious patient. This review article discusses several important aspects of anaesthesia, beginning with basic concepts such as the minimum alveolar concentration and afterwards developing into a discussion about the mechanisms of action of anaesthetics on a cellular level, introducing electrophysiological investigations in the brain to study hypnosis and amnesia, in the dorsal horn of the spinal cord to study analgesia and the inhibition of noxious reflexes, and in the ventral horn of the spinal cord to study immobility, separately. In accordance with the results of electrophysiological patch clamp studies, researchers have confirmed that the modulation of neurotransmission input from dorsal afferent neurons into the dorsal horn of the spinal cord and effects on the spinal reflex arc from the dorsal horn to ventral horn motor neurons are important anaesthetic action mechanisms. Accordingly, intraoperative body movement of patients is not a sign of insufficient muscle relaxation, but rather insufficient analgesia. In conclusion, sufficient analgesia is a correct strategy (rather than muscle relaxant administration) for performing intraoperative patient immobility and for providing patients with good and safe intraoperative anaesthesia management by protecting them from noxious reflexes and stress including autonomic reactions such as hypertension and tachycardia.