Hani K. Najm

Impact of Bloodstream Infection on the Outcome of Children Undergoing Cardiac Surgery

Bloodstream infections (BSIs) are a main cause of nosocomial infection in the critical care area. The development of BSI affects the surgical outcome and increases intensive care unit (ICU) morbidity and mortality. This prospective cohort study was undertaken to determine the incidence, etiology, risk factors, and outcome of BSI for postoperative pediatric cardiac patients in the pediatric cardiac ICU setup. All postoperative pediatric patients admitted to the pediatric cardiac ICU from January 2007 to December 2007 were included in the study. Data were prospectively collected using a standardized data collection form. Patients with BSI (group 1) were compared with non-BSI patients (group 2) in terms of age, weight, surgical complexity score, duration of central line, need to keep the chest open postoperatively, and the length of the pediatric cardiac ICU and hospital stay. Of the 311 patients who underwent cardiac surgery during the study period, 27 (8.6%) were identified as having BSI (group 1). The 311 patients included in the study had a total of 1,043 central line days and a catheter-related BSI incidence density rate of 25.8 per 1,000 central line days. According to univariate analysis, the main risk factors for the development of BSI after pediatric cardiac surgery were lower patient weight (pxa0=xa00.005), high surgical complexity score (pxa0<xa00.05), open sternum postoperatively (pxa0<xa00.05), longer duration of central lines (pxa0<xa00.0001), and prolonged pediatric cardiac ICU and hospital stay (pxa0<xa00.0001). Gram-negative organisms were responsible for 67% of the BSI in the pediatric cardiac ICU, with pseudomonas (28%) and enterobacter (22%) as the main causative organisms. The mortality rate in the BSI group was 11% compared with 2% in the non-BSI group. In our pediatric cardiac ICU, BSI developed in 8.6% of the children undergoing cardiac surgery, mainly caused by a Gram-negative organism. The main risk factors for BSI in the postoperative pediatric cardiac patient were high surgical complexity, open sternum, low body weight, longer duration of central line, and prolonged pediatric cardiac ICU stay.

Early outcome for the primary arterial switch operation beyond the age of 3 weeks.

The arterial switch operation (ASO) for neonates is the standard management for transposition of the great arteries (TGA) with an intact ventricular septum (IVS). Patients presenting for late ASO are at risk due to the possibility of left ventricle (LV) involution. This study aimed to assess the early postoperative course and outcome for children with TGA/IVS and still conditioned LV presenting for late primary ASO. A retrospective study of all TGA/IVS patients who underwent a primary ASO between March 2002 and March 2008 was conducted. The cases were divided into two groups. Group A included all the cases of early ASO repaired before the age of 3xa0weeks, whereas group B included all the preslected cases of late ASO repaired after the age of 3xa0weeks. The demographics, intensive care unit (ICU) parameters, complications, and short-term outcomes of the two groups were compared. The study enrolled of 91 patients: 64 patients (70%) in group A and 27 patients (30%) in group B. The mean age was 11xa0±xa04xa0days in group A and 37xa0±xa017xa0days in group B (Pxa0<xa00.001). The two groups showed no significant statistical differences in ICU parameters, complications, or mortality. For patients with TGA/IVS, ASO still can be tolerated beyond the first month of life in selected cases. Provided the LV still is conditioned, age should not be a limitation for ASO.

Acute Renal Failure and Outcome of Children with Solitary Kidney Undergoing Cardiac Surgery

The aim of this study was to investigate the risk of acute renal failure (ARF), the need for renal replacement therapy, and the outcome of children with a solitary functioning kidney undergoing open heart surgery. The study was performed retrospectively on all children diagnosed with solitary functioning kidney and who required open heart surgery between January 2003 and January 2007. Demographic, perioperative renal function and intensive care course data were documented. Eight patients (six females) fulfilled the study criteria and were included in the study. Their median age and weight were 4.5xa0months and 3.6xa0kg, respectively. Their meanxa0±xa0standard deviation (SD) preoperative blood urea nitrogen (BUN) and creatinine levels were 3.7xa0±xa01.6xa0mmol/L and 55xa0±xa010xa0μmol/L, respectively. Postoperatively, the mean BUN and creatinine levels peaked on the first postoperative day to reach 7.8xa0±xa02.6xa0mmol/L and 76xa0±xa022xa0μmol/L, respectively, before starting to return to their preoperative values. Two out of eight patients (25%) developed ARF after surgery, but only one of them (12.5%) required renal replacement therapy. Open heart surgery on bypass can be performed safely for children with solitary functioning kidney with a good outcome. ARF requiring renal replacement therapy might occur temporarily after bypass surgery in a minority of cases.

Five children with purulent pericarditis and review of the literature

Abstract Purulent pericarditis in children is a life-threatening disease that requires early diagnosis and immediate intervention. This cardiac emergency is rarely seen in the western world. However, cases of purulent pericarditis are still being reported in developing countries. We describe our experience with five cases of purulent pericarditis in children seen between 1998 and 2002. Haemophilus influenzae bacteria were isolated in all except one case. With active management, all five children survived.

Pulmonary Atresia, VSD in Association with Coronary-Pulmonary Artery Fistula

Congenital coronary-pulmonary artery fistula is rare in patients with pulmonary atresia and ventricular septal defect. The nomenclature, physiological, clinical, and surgical implications of these fistulas are yet to be defined. We report a one-year-old child with pulmonary atresia, ventricular septal defect, and a right coronary-pulmonary artery fistula who also had a diminutive, disconnected left pulmonary artery in addition to aortopulmonary collaterals. The patient underwent corrective surgery. However, the fate of diminutive pulmonary arteries is unknown. The literature was reviewed to explore the clinical or surgical implications of such fistulas for improved understanding and management in the future.

Outcome of low body weight (<2.2 kg) infants undergoing cardiac surgery.

INTRODUCTIONnInfants with low body weight (LBW) following cardiac surgery are a major challenge for the post cardiac surgery care unit. It has been observed that post surgery outcome for LBW infants is worse compared to the outcome of normal body weight infants. A study was conducted to compare post operative course and outcome of infants with body weight of 2.2xa0kg or less against infants with normal body weight who underwent similar cardiac surgeries.nnnMETHODSnA retrospective review was performed for all infants below 2.2xa0kg who underwent cardiac operations at King Abdulaziz Cardiac Center from January 2001 to October 2011. Cases with LBW (Group A) were compared with matching group (Group B) of normal body weight infants who had similar cardiac surgeries and matching surgical risk category. The demographic, ICU parameters, complications, and short-term outcome of both groups were analyzed.nnnRESULTSnTwo groups were formed, with 37 patients in Group A, and 39 patients in Group B. Except for weight (2.13xa0±xa00.08xa0kg in Group A vs 3.17xa0±xa00.2xa0kg in Group B), there was no statistical difference in demographic data between both groups. Cardiac procedures included coarctation repair, arterial switch, ventricular septal defect (VSD) repair, tetralogy of Fallot repair, systemic to pulmonary shunt and Norwood procedures. Patients in Group A had statistically significant difference from Group B in terms of bypass time (pxa0=xa00.01), duration of inotropes (pxa0=xa00.01), duration of mechanical ventilation (pxa0=xa00.004), number of re-intubations (pxa0=xa00.015), PCICU length of stay (pxa0=xa00.007), and hospital mortality: 13.5% in Group A vs 0% in Group B (p value 0.02).nnnCONCLUSIONnPatients with LBW (<2.2xa0kg) underwent cardiac surgery with overall satisfactory results, but with increased risk of ICU morbidity and mortality.

Short- and Mid-Term Outcomes of Total Correction of Taussig-Bing Anomaly

Double-outlet right ventricle (DORV)/Taussig–Bing (TB) anomaly is the second most common type of DORV. This study evaluates our experience and outcomes of total correction of DORV-TB anomaly at King Abdulaziz Cardiac Center. We conducted a retrospective study for all cases of TB anomaly repaired between June 2001 and April 2009. Patients were divided into two groups: Group A included patients repaired with arterial switch operation, and group (B) included patients repaired with Rastelli procedure. Thirteen patients with TB anomaly underwent total correction. There were 5 male (38%) and 8 female (62%) patients. Mean age and weight at surgery were 6.8xa0±xa06xa0weeks and 3.6xa0±xa00.7xa0kg, respectively. Of the 13 patients, 9 (69%) were in group A, and 4 (31%) were in group B. Aortic arch abnormalities were present in 9 patients (69%); abnormal coronary artery patterns were present in 7 patients (54%); side-by-side great arteries were present in 5 patients (38%); dextrotransposition of the great arteries was present in 7 patients (54%); and levo-malposition of the great arteries was present in 1 patient (8%). At postoperative follow-up, 4 patients (31%) had developed either left- or right-ventricular outflow tract (VOT) obstruction requiring surgical and/or catheter intervention. There was no early mortality, but there was 1 late mortality caused by left-ventricle dysfunction. DORV-TB is often associated with other congenital cardiac anomalies. In general, total repair is feasible in the majority of patients with satisfactory results and improved outcome. Residual lesion and development of VOT obstruction can occur, requiring close follow-up and intervention for residual lesion.

Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery

BACKGROUND AND AIMnChylothorax is the accumulation of chyle in the pleural cavity, which usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases, this rupture is secondary to trauma (including cardio thoracic surgeries). Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. This study aims to determine the risk factors and the impact of chylothorax on the early postoperative course after pediatric cardiac surgery.nnnMETHODSnA retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery was conducted at King Abdulaziz Cardiac Center between January 2007 and December 2009.nnnRESULTSnThere were 1135 cases operated on during the study period. Of these, 57 cases (5%) were complicated by chylothorax in the postoperative period. Thirty patients (54%) were males, while 27 (47%) were females. Ages ranged from 4 to 2759xa0days. The most common surgeries complicated by chylothorax were the single ventricle repair surgeries (15 cases, 27%); arch repairs (10 cases, 18%); ventricular septal defect repairs (10 cases, 18%); atrioventricular septal defect repairs (7 cases, 12%); arterial switch repair (6 cases, 11%), and others (8 cases, 14%). The intensive care unit (ICU) and the length of hospital stays were significantly longer in the chylothorax group. Additionally, some early postoperative parameters such as incidence of sepsis, ventilation time, and inotropes duration and number were higher in the chylothorax group.nnnCONCLUSIONnChylothorax after pediatric cardiac surgery is not a rare complication. It occurs more commonly with single ventricle repair and aortic arch repair surgeries, and has a significant impact on the postoperative course and post operative morbidity.

Early outcome of tetralogy of Fallot repair in the current era of management

BACKGROUNDnTraditional use of trans-annular patch (TAP) to release right ventricular outflow tract (RVOT) obstruction during tetralogy of Fallot (TOF) repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve (PV) function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function.nnnMETHODSnA retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group (A) which include patients who had TAP without a valve. Group (B) includes those who had TAP with a monocuspid valve (Contegra). We compared post-operative care and outcome of all groups.nnnRESULTSnEighty-three patients fulfilled the study criteria. There were 64 cases (77%) in group I, and 19 cases (23%) in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups.nnnCONCLUSIONnChildren undergoing TOF repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques.

803 Effect of Body Weight on the Outcome of Ventricular Septal Defect Repair

Introduction Low body weight and failure to thrive (FTT) often are considered limiting factors for open heart surgery. The purpose of our study is to asses the impact of FTT on ICU outcome of children undergoing Ventricular septal defect repair. Methods A retrospective Study including all children less than 2 years who had VSD closure by open heart surgery during the period 2002–2010. Children were divided into 2 groups based on their weight for age using standard growth charts. Those with normal or mild failure to thrive (Z score > –3) are labeled as group A. group B included all children with severe failure to thrive (Z score ≤ –3). Both groups were compared in term of all operative and early post-operative outcome parameters. Results 145 patients were included. 58 cases in group A and 87 patients in group B. The age and weight in group A was (8±5.16 months) and (6.31±1.75 kg) respectively. The age and weight in group B was (7.6±3.9 months) and (4.84±1.12) kg respectively. There were no significant differences between the 2 groups in term of post operative mortality or morbidity. Conclusion Failure to thrive can complicate congenital heart diseases (CHD) associated with significant left to right shunt and heart failure. FTT was not associated with increase in ICU morbidity or mortality. Attempt to optimize the body weight for age in children with CHD may not add any beneficial advantages in term of surgical risk or postoperative ICU outcome.