Jacek Moll

The use of recombinant coagulation factor VIIa in uncontrolled postoperative bleeding in children undergoing cardiac surgery with cardiopulmonary bypass.

Objective: To assess the hemostatic efficacy of recombinant coagulation factor VIIa (rFVIIa) in the management of uncontrolled bleeding in postcardiac surgery with cardiopulmonary bypass in children. Design: An open-label study. Setting: A postoperative intensive care unit. Patients: Eight consecutive pediatric patients with excessive bleeding after cardiac surgery with cardiopulmonary bypass that met the criteria for reexploration and did not respond to optimal transfusions of platelets and fresh frozen plasma. Interventions: rFVIIa 30 &mgr;g/kg was given as a bolus injection. A higher dose of 60 &mgr;g/kg was used if a patient had preoperative coagulopathy, preoperative multiple-organ failure, or indications that required an emergency operation. The same dose was repeated 15 mins after the previous injection if the bleeding had not decreased. If the bleeding had decreased but still exceeded 10 mL/hr for body weight ≤5 kg or exceeded 2 mL·kg−1·hr−1 for body weight >5 kg, the same dose was repeated 2 hrs after the previous injection. A maximum of four doses could be given before rFVIIa was considered ineffective and a reexploration was needed. Measurements and Main Results: Postoperative blood loss was estimated from the volume of chest tube drainage. rFVIIa successfully controlled bleeding and prevented reexploration in all seven patients who received treatment according to the protocol. One patient who received only one dose of rFVIIa required reexploration because a second dose was not available. No adverse events related to rFVIIa were seen. Conclusions: rFVIIa may be useful in preventing reexploration in uncontrolled postoperative bleeding in children undergoing cardiac surgery with cardiopulmonary bypass. Randomized, placebo-controlled studies are needed to confirm the safety and efficacy of rFVIIa in this clinical setting.

Predictors of long intensive care unit stay following cardiac surgery in children

OBJECTIVE Prolonged length of stay in intensive care units after congenital heart disease surgery is associated with poor outcome, places a considerable burden on the financial resources of hospitals, and is an organizational challenge as well. This research discusses the impact of perioperative factors on prolonged stay in intensive care units. METHODS This is a retrospective study examining the determinants of prolonged intensive care length of stay in 693 children after cardiac surgery. Univariate and multivariate analyses were performed for an intensive care unit stay over 3 and over 14 days. RESULTS Neonatal age, preoperative mechanical ventilation and preoperative myocardial dysfunction, complexity and duration of procedures, as well as postoperative complications (low cardiac output syndrome, bleeding, re-operation, acute kidney injury, sepsis, respiratory insufficiency, pulmonary hypertension, pneumothorax, postoperative cardiac arrest, pneumonia, and delayed sternum closure) prolong intensive care unit hospitalization over 3 days. Patients with acute kidney injury requiring renal replacement therapy, pneumothorax, pulmonary hypertension, need for re-operation during the same admission, and myocardial dysfunction prior to surgery are at high risk of intensive care unit stay over 14 days. CONCLUSIONS Some patients with a risk of prolonged hospitalization may be identified preoperatively, the others just after the operation. Optimizing preoperative status and aggressive treatment of complications may have significant influence on the duration of hospitalization in intensive care units. The knowledge of risk factors may facilitate organizational procedures and rational bed management.

Use of Recombinant Activated Factor VII for Controlling Refractory Postoperative Bleeding in Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass

OBJECTIVE To review the efficacy, safety, and dose of recombinant activated factor VII in off-label management of refractory bleeding in pediatric patients with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass. DESIGN A retrospective database analysis with medical records review. SETTING A single research hospital. PARTICIPANTS Ninety pediatric patients with uncontrolled postoperative hemorrhage after cardiac surgery with cardiopulmonary bypass for congenital heart disease. INTERVENTIONS Intravenous recombinant activated factor VII treatment according to institutional treatment protocol. MEASUREMENTS AND MAIN RESULTS The recombinant activated factor VII treatment was effective in reducing bleeding in 78 pediatric patients. The 12 patients who failed to respond had surgical sources of bleeding. The mean blood loss decreased from 51.04 mL/kg/2 h to 7.8 mL/kg/2 h (p < 0.001) in neonates, from 40.2 mL/kg/2 h to 7.7 mL/kg/2 h (p < 0.001) in infants, and from 29.1 mL/kg/2 h to 4.0 mL/kg/2 h in children (p < 0.001). The mean (standard deviation) total recombinant activated factor VII doses required to achieve hemostasis were 131.7 (69.8) μg/kg in neonates, 104.6 (36.0) μg/kg in infants, and 44.6 (15.3) μg/kg in children aged 1 to ≤18 years. There was no evidence of thrombosis in the first 24 hours after the administration of recombinant activated factor VII. CONCLUSIONS Recombinant activated factor VII treatment reduced blood loss and transfusion requirements and prevented re-exploration in the majority (83.8%) of pediatric cardiac surgery patients. High doses were required to discontinue bleeding promptly in neonates, the majority of whom had hypoplastic left-heart syndrome. No treatment-related thrombotic events were observed.

The properties of carbon layers deposited onto titanium substrates

Abstract Thin, hard, amorphous carbon layers, deposited using a dense r.f. methane plasma onto titanium substrates, were investigated. This includes an examination of the interface between the carbon layer and the substrate and the optimization of the process and its application. The substrates coated with carbon layers were analysed by Auger electron spectroscopy (AES) and scanning electron microscopy (SEM). Results of AES studies show that the surface layer, several thousand angstroms thick, consists of carbon. The carbon film passes smoothly into a thick layer (about 1 μm) consisting of titanium carbide. The composition varies across the transitional layer between carbon and carbide regions. This coating structure ensures a high mechanical strength and very good adhesion to Ti substrates. These coatings also protect metal implants against corrosion, and protect man from a serious illness, metallosis. Preliminary investigations in vivo and in vitro confirm the biocompatibility of the C/TiC/Ti system and its biointegration. In addition, investigations of the mechanical, anticorrosive and structural properties of the coatings, deposited using a dense methane plasma excited in an r.f. electric field, show that this can be a very good material to apply in cardiovascular surgery. The r.f. decomposition of methane seems to be a very convenient method for the production of superhard carbon coatings on Ti substrates for medical applications.

Interventions Complementing Surgery as Part of Multistage Treatment for Hypoplastic Left Heart Syndrome: One Center's Experience

Background Interventional procedures often are used as part of multistage treatment for hypoplastic left heart syndrome (HLHS). This study aimed to evaluate the efficacy of interventions in multistage treatment of HLHS. Methods and Results Between 1999 and 2007, 78 interventions were performed for 58 children with HLHS at different stages of surgical treatment. Group 1, involving 30 interventions for 22 patients with postoperative pulmonary arterial stenosis, showed reduced pulmonary artery pressure and increased vessel diameter. Group 2, involving 15 interventions after the Norwood operation for 12 patients with aortic arch obstruction, showed success for 11 patients. Group 3, involving eight balloon angioplasties of narrowed Glenn anastomosis for seven patients, showed abolition of the pressure gradient between the superior vena cava and the right pulmonary artery. Group 4, involving eight interventional closures of a fenestration for eight patients after a Fontan operation, showed increased oxygen saturation for all eight patients. Group 5, involving seven interventions for six patients in whom venovenous collaterals were closed percutaneously, showed improved oxygen saturation. For Group 6, uncommon miscellaneous interventions were used to stabilize the patients’ condition before the next surgical treatment. Conclusions Interventional procedures play an important role during multistage treatment of HLHS. They allow for a reduction in the number of operations or stabilization of the patients’ condition before the next surgical treatment.

The neoaortic root in children with transposition of the great arteries after an arterial switch operation

OBJECTIVES Neoaortic root changes in children with transposition of the great arteries (TGA) are reportedly risk factors for the development of neoaortic regurgitation (NeoAR). The aims of this study were to assess the neoaortic root diameter and relative proportion in children with TGA after surgical correction and to identify possible correlations with the development of neoaortic insufficiency. METHODS Of the 611 children who had the arterial switch operation performed in the Cardiology Department of the Polish Mothers Memorial Hospital, 172 consecutive patients were qualified for this study. The inclusion criteria were: anatomical correction performed during the neonatal period, more than 10 years of postoperative observation and at least two full echocardiographic examinations. RESULTS NeoAR increased during postoperative follow-up and at the end of the observation period, 76% of the patients had NeoAR (27%-trace, 42%-mild, 7%-moderate and 0.6%-severe). Among the analysed risk factors for NeoAR development, the significant ones were arterial valve discrepancy (OR = 2.05; 95% CI: 1.04-4.02; P = 0.031) and the non-facing commissures (OR = 4.05; 95% CI: 1.34-11.9; P = 0.01). The neoaortic root diameter was not statistically significantly correlated with the presence of NeoAR or with the heart defects associated with transposition. The neoaortic root was initially, on average, 37% (z-score = 1.58) bigger than the aortic root in healthy children. This disproportion increased during the follow-up evaluations to 57% (z-score = 2.09). CONCLUSIONS The neoaortic root in children after the arterial switch procedure develops differently from that in healthy children, but this is not evidently related to NeoAR development or associated heart defects.

Long-Term Outcome of Direct Neopulmonary Artery Reconstruction During the Arterial Switch Procedure

BACKGROUND Neopulmonary stenosis at anastomosis site is one of the most frequent complications after the arterial switch procedure for transposition of the great arteries. The surgical technique is a crucial factor associated with the frequency of stenotic complications. We present the outcomes of direct neopulmonary anastomosis during the arterial switch procedure in patients with simple transposition. This research was to assess the efficacy of this surgical technique based on the incidence of postprocedural supravalvular neopulmonary stenosis (SVPS). METHODS Among 545 patients operated on in our department between 1992 and 2009, the 346 consecutive survivors who had undergone simple transposition in the first month of life were included in this analysis. Switch procedures were performed with direct neopulmonary artery anastomosis in 318 patients (92%); in the remaining 28 (8%), the risk of coronary artery compression required the use of a pericardial patch for pulmonary reconstruction. RESULTS Neopulmonary stenosis occurred in 9 patients (2.6%): 5 had undergone direct neopulmonary reconstruction, and 4 had been treated with a patch. Balloon angioplasty of SVPS was performed twice in 1 patient. No patients required reoperation to treat neopulmonary stenosis. In multivariate analysis (logistic regression), patch reconstruction (odds ratio, 27.5; p=0.001) and nonfacing commissures (odds ratio, 11.1; p=0.004) were correlated significantly with the incidence of SVPS. CONCLUSIONS Direct neopulmonary artery anastomosis during arterial switch is an interesting alternative to patch reconstructions and ensures a good postoperative result with low rates of complications and SVPS.

Repair of anomalous origin of the left coronary artery from the pulmonary artery in infants.

OBJECTIVES Anatomical repair seems an ideal method for the surgical treatment of the anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in infancy. The medium-term outcome has been investigated for infants with ALCAPA following the restoration of a dual-coronary arterial circulation. METHODS Between April 1995 and July 2012, 23 infants with a median age of 4 months underwent surgical repair of ALCAPA in our department. Direct implantation of the anomalous coronary artery into the ascending aorta was feasible in 16 patients. A trap door flap method was used in 5 cases and a tubular extension technique in 2. No infant underwent mitral valve repair at the time of ALCAPA surgery. Left ventricular function and the degree of mitral valve regurgitation were assessed during a 10-year follow-up. RESULTS Four patients died in the early postoperative period, without independent predictors associated with this mortality. During follow-up, improvement in myocardial function occurred in all patients both early and late. There was only one improvement in severe mitral valve regurgitation. Subsequently, 2 children needed mitral valve replacement. There were no early or late reoperations of the reimplanted coronary arteries. CONCLUSIONS Aortic reimplantation is an effective surgical treatment for ALCAPA in infants burdened with a low risk of reoperation due to coronary artery stenosis. There was good potential for myocardial recovery within the first year after surgery. Restoration of the anatomical coronary circulation did not improve mitral valve function in infants with severe preoperative mitral incompetence.

Prenatal diagnosis and follow-up of 23 cases of cardiac tumors

To evaluate the prenatal characteristics and postnatal outcome of cardiac tumors diagnosed at two prenatal Polish cardiology centers.

Prenatally evolving ectopia cordis with successful surgical treatment.

Ectopia cordis (EC) is a rare malformation due to failure of maturation of the midline mesodermal components of the chest and abdomen. It can be defined as a complete or partial displacement of the heart outside the thoracic cavity. It comprises 0.1% of congenital heart diseases. Common cardiac anomalies associated with EC are ventricular septal defect, atrial septal defect, and tetralogy of Fallot. EC and additional anomalies usually lead to intrauterine death. The possibility and efficacy of surgery in a surviving neonate depends on the degree of EC, coexisting congenital heart defects and extracardiac malformations. We present a case of prenatally diagnosed isolated EC diagnosed in the first half of pregnancy. After counseling, the patient decided to continue her pregnancy which ended with a newborn baby discharged from the hospital after cardiac surgery performed just after elective cesarean section.