Irving Shen

Routine mechanical ventricular assist following the Norwood procedure—improved neurologic outcome and excellent hospital survival

BACKGROUND Although excellent survival following the Norwood procedure for palliation of hypoplastic left heart syndrome (HLHS) is being achieved by some, most centers, especially the ones with small surgical volume and limited experience, continue to struggle with initial results. Survivors often showed evidence of significant neurologic injury. The early postoperative care is labor-intensive as attempts are made to balance the systemic and pulmonary circulation for these infants. We report our experience with routine use of mechanical circulatory assist to support the increased cardiac output requirements present following Norwood procedure. METHODS Eighteen consecutive infants undergoing Norwood operation for HLHS (Oregon Health & Science University [OHSU] 13; University of Louisville [UL] 5) were placed on a ventricular assist device (VAD) immediately following modified ultrafiltration in the operating room using the cardiopulmonary bypass (CPB) cannulas that were in the right atrium and the neoaorta. VAD flows were maintained at approximately 200 mL x kg(-1) x min(-1) and the patients were transported to the intensive care unit (ICU). Patients operated at OHSU also received neurodevelopmental testing before their Glenn procedure, approximately 4 to 6 months following their Norwood operation. RESULTS All patients were stable on VAD support and no attempt was made to balance the systemic and pulmonary circulation. The ventilator was manipulated to achieve systemic Pa0(2) between 30 and 45 mm Hg and PaC0(2) between 35 and 45 mm Hg. Evidence of hypoperfusion (increasing lactates) was managed by increasing the VAD flow. Lactates normalized [< 2 mmol/L]) by 1.8 +/- 1.1 days following surgery. Average time of VAD support was 3.1 +/- 1.0 (range, 2 to 5 days) and average time until chest closure was 3.4 +/- 1.5 (range, 2 to 8 days). There were two cases of postoperative bleeding (11.1%) requiring reexploration and one case of mediastinitis (5.5%) in a patient who has now gone on to successful Glenn. Sixteen of the eighteen patients survived (hospital survival mean 89% with a 95% confidence interval of 63.9% to 98.1%; 12/13 OHSU [92.3%]; 4/5 UL [80%]). Neurodevelopmental testing using the Mullen Scales of Early Learning and the Vineland Adaptive Behavior Scale were normal for all infants tested. CONCLUSIONS Routine postoperative use of VAD can support the increased cardiac output demands of infants following Norwood operation and results in a stable postoperative convalescence that does not require aggressive ventilator or inotrope manipulation. Although not a panacea, this strategy can simplify postoperative management, lead to excellent hospital survival, and possibly augment cerebral oxygen delivery, resulting in improved neurologic outcomes for this challenging group of patients.

Current strategies for optimizing the use of cardiopulmonary bypass in neonates and infants

The use of cardiopulmonary bypass is still necessary for the repair of many congenital cardiac defects. However, exposure to cardiopulmonary bypass can still lead to major morbidity and sometimes mortality, especially in neonates and infants, despite a perfect surgical repair. Various research-based strategies have been used to minimize some of the complications related to cardiopulmonary bypass, including the systemic inflammatory response, hemodilution, and transfusion requirement. This overview provides some of the strategies that we use in our practice in applying cardiopulmonary bypass in the repair of congenital cardiac defects in neonates and infants.

Optimizing response of the neonate and infant to cardiopulmonary bypass.

Despite the ability to surgically correct complex defects in neonates and infants, limitations in outcome are sometimes encountered in relation to exposure to cardiopulmonary bypass (CPB). The deleterious effects of CPB in neonates are often pronounced because of their immature tissue/organ function and the disparity between the CPB circuit size and the patient. A variety of techniques that have been developed to prevent or lessen tissue edema, including miniaturization of the circuit and oxygenator, prime additives (eg, albumin, steroids), biocompatible circuitry, and variations in perfusion strategies, are discussed as are post-CPB strategies such as modified ultrafiltration, which removes inflammatory mediator-rich fluid from the patient and bypass circuit. With optimization of the response of the infant to our systems used during repair of their cardiac lesion, we will see significant improvement in surgical outcomes.

New technology and methodologies for intraoperative, perioperative, and intraprocedural monitoring of surgical and catheter interventions for congenital heart disease.

We review the new technology and methods available for support of intraoperative and intraprocedural imaging in the catheterization laboratory for surgical and interventional catheterization procedures in the treatment of congenital heart disease. The methods reviewed include miniaturized probes and new ways of using them perioperatively for cardiac imaging from transesophageal, substernal, and intracardiac imaging locations. The smaller and more versatile the probes, the better adapted they will be in providing methods to improve the outcomes in babies born with serious forms of congenital heart disease.

Recurrent Pulmonary Artery Sarcoma

Abstract  Pulmonary artery sarcomas are a diagnostic and therapeutic challenge. Most patients are initially thought to have pulmonary emboli, and during embolectomy, a sarcoma is found. Given the significant morbidity and mortality of cardiac sarcomas, an aggressive strategy for resection is indicated, as this leads to benefits in disease‐free and overall survival. Imaging tests and clinical signs and symptoms may assist in accurate preoperative determination of pulmonary artery sarcoma. We present an interesting case of a patient with pulmonary artery sarcoma who underwent successful re‐resection, along with a brief discussion regarding preoperative imaging and the surgical resection of these tumors.

Emergence of the arterial switch procedure for transposition of the great arteries and the potential cost of surgical innovation

From the Knight Cardiovascular Institute, and Divisions of Pediatric Cardiothoracic Surgery, Department of Surgery, and Pediatric Cardiology, Department of Pediatrics, Oregon Health & Science University, Portland, Ore. Received for publication July 25, 2016; revisions received Feb 5, 2017; accepted for publication March 10, 2017; available ahead of print April 12, 2017. Address for reprints: Craig S. Broberg, MD,MCR, UHN 62, Knight Cardiovascular Institute, 3181 SW Sam Jackson Pk Rd, Portland, OR 97239 (E-mail: brobergc@ohsu.edu). J Thorac Cardiovasc Surg 2017;154:1047-51 0022-5223/

Advances in congenital heart surgery.

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.03.035 Transition from atrial to arterial switch over time for transposition of the great arteries.

The Dicrotic Pulse: A Common, Non-Ominous Finding After the Ross Operation

Purpose of review We provide an overview of the past years literature on congenital heart surgery. Recent findings This review focuses on selected disease entities, operative techniques, perioperative management strategies, and quality of care. Summary Congenital heart surgery is an evolving field.

SCVIR annual meeting film panel session: Diagnosis and discussion of case 6

We noted a dicrotic pulse in several patients following a Ross operation. Although the etiology of this unique arterial waveform is not completely understood, it has been reported as a sign of low cardiac output and a poor prognosis. We reviewed preoperative echocardiograms and postoperative radial arterial pressure tracings in 33 patients who underwent a Ross procedure between 2000 and 2004. We found a dicrotic pulse to occur commonly (20/33; 61%) following a Ross operation. Moderate to severe preoperative aortic insufficiency was present in 19/20 patients (95%) in whom a dicrotic pulse was noted and in only 3/13 (23%) who did not exhibit a postoperative dicrotic pulse (p < 0.001). A dicrotic pulse was not associated with an increased use of vasoactive infusions or longer hospitalization following the Ross operation. The dicrotic pulse should be recognized as a common postoperative finding in Ross patients that does not herald a delayed postoperative convalescence. The mechanism for a dicrotic pulse in these patients is speculative but may result from changes in vascular compliance secondary to chronic aortic insufficiency.

Current Assessment of Mortality Rates in Congenital Cardiac Surgery

An 84-year-old man presented with the chief complaint of episodic hemoptysis, increasing in frequency and severity over the course of the previous three and a half weeks. He denied any associated chest pain. Comorbid conditions included chronic congestive heart failure (ejection fraction ,20%), coronary artery disease with stable angina, and a previous myocardial infarction and Kaposi sarcoma (HIV seronegative). He had undergone two coronary artery bypass grafting procedures (5 and 15 years earlier) and transurethral resection of a malignant bladder tumor. He was admitted to another facility where computed tomography (CT) of the chest was performed and a focal abnormality of the descending thoracic aorta was identified. Nitroprusside and esmolol infusions were administered to reduce blood pressure and shear stress. The patient was emergently transferred to the care of the cardiothoracic surgery team at our hospital with a diagnosis of aortobronchial fistula. On admission, he was hemodynamically stable with an unremarkable physical examination. Hemoptysis had ceased. Laboratory tests revealed a hematocrit level of 36%, a platelet count of 155,000/cm, an international normalized ratio of 1.2, a partial thromboplastin time of 31.2 seconds, and a creatinine level of 1.3 mg/dL. Unfortunately, the CT scan from the other hospital could not be located, so the study was repeated and further investigation with aortography was performed.