Nancy Poirier

Antireflux Operations in Patients With Scleroderma

Fourteen patients with scleroderma underwent antireflux operations (10 short Nissen, 2 Collis-Nissen, 1 Collis-Belsey, and 1 vagotomy and antrectomy with Roux-en-Y). Esophageal function was assessed preoperatively and postoperatively with a follow-up range of 8 to 181 months (mean, 65 months). Reflux symptoms were relieved in 10 of the 14 patients (p < 0.01), as shown by a decrease in their 24-hour acid exposure of from 15% to 7.5% (p < 0.05). However, the lower esophageal sphincter pressure gradient created by the operations did not increase significantly (3.7 +/- 3.4 mm Hg to 5.5 +/- 3.5 mm Hg). The esophageal acid exposure decreased sufficiently to promote some alleviation of the esophagitis. Radiologic signs of stenosis regressed in 6 of 7 patients. Postoperative endoscopic assessment revealed complete or partial healing of erosions seen preoperatively in 6 of the 7 patients so studied, and healing of all ulcers in 3 patients. Twelve patients continued to have columnar metaplasia. Manometric studies disclosed no significant changes in propulsion and contractility. Distal esophageal resting pressures rose significantly from 6.2 to 9.4 mm Hg (p < 0.05 mm Hg), suggestive of stasis. Radionuclide transit studies, however, showed no significant decrease in the esophageal emptying capacity after operation. It is concluded that conventional antireflux operations in patients with scleroderma can palliate reflux damage without jeopardizing esophageal function.

Cardiac transplantation for hypertrophic cardiomyopathy: a valid therapeutic option

BACKGROUNDnHypertrophic cardiomyopathy is a rare indication for cardiac transplantation, with only anecdotal reports in the literature. Transplantation has been proposed to patients with hypertrophic cardiomyopathy who remained symptomatic despite optimal medical treatment or who progressed to congestive heart failure, and when conventional surgical correction was not or was no longer possible. In this report, we analyze the clinical results of cardiac transplantation in these patients.nnnMETHODSnWe retrospectively reviewed complete clinical data and prospectively gathered complete follow-up data for 14 patients who underwent orthotopic cardiac transplantation for hypertrophic cardiomyopathy at the Montreal Heart Institute and Ste-Justine Hospital between 1984 and 2001.nnnRESULTSnTen male (71.4%, 5 adults and 5 children) and 4 female (28.6%, 2 adults and 2 children) patients underwent heart transplantation for hypertrophic cardiomyopathy. The median age of the recipients in the pediatric group was 13 years (range, 6-16) and was 40 years (range, 22-46) in the adult group. Median duration of follow-up was 9.5 years (mean, 8.8 +/- 4.8 years; range, 1-18) and was 100% complete. We found no operative mortality and found 2 late deaths related to coronary graft atherosclerosis. Long-term survival at 5, 10, and 15 years was 100%, 85%, and 64%, respectively. Freedom from acute rejection at 1, 5, and 10 years was 73%, 32%, and 9%, respectively. The remaining 11 survivors exhibit few symptoms and are currently in New York Heart Association Class I or II.nnnCONCLUSIONSnCardiac transplantation is a valid therapeutic option for patients with symptomatic hypertrophic cardiomyopathy who do not respond to optimal medical management and who are not candidates for conventional surgical treatment. The long-term outcome is excellent in these patients.

What Is the Role of the Ross Procedure in Today's Armamentarium?

The Ross procedure, which consists of replacing the aortic root with a pulmonary autograft, is the only surgery that ensures long-term viability of the aortic valve substitute. The presence of a living valve in the aortic position was theorized to translate into improved clinically relevant outcomes. This has now been confirmed by a number of recently published studies, which highlight the benefits associated with this surgery in terms of survival, quality of life, hemodynamic characteristics, and freedom from valve-related complications. Nevertheless, despite the evidence, the Ross procedure remains largely underused and has even been abandoned by a large number of groups based on some real and sometimes justifiable concerns, and a number of unfounded biases. The aim of this article is to provide a comprehensive, evidence-based review of the current literature pertaining to the Ross procedure, with an emphasis on the rationale, results, technical key points, alternatives, and future directions.

Rejection of transplanted hearts in patients evaluated by the component analysis of multi-wavelength NAD(P)H fluorescence lifetime spectroscopy

Rejection of transplanted hearts remains one of the principal reasons for death of paediatric patients, but an appropriate diagnostic tool for the mild rejection in early stages is still missing. Tissue autofluorescence (AF) is one of the most versatile non-invasive tools for mapping the metabolic state in living tissues. Increasing interest in the imaging and diagnosis of living cells and tissues based on their intrinsic fluorescence rather than fluorescence labelling is closely connected to the latest developments in high-performance spectroscopy and microscopy techniques. In this contribution, we investigate individual components in spectrally- and time-resolved NAD(P)H fluorescence, revealed by linear unmixing, responsible for increased fluorescence in patients presenting mild rejection of transplanted hearts. Application of such approach has the potential to improve the diagnostics of the cardiac transplant rejection by helping currently used histological analysis.

Blood Transfusions After Pediatric Cardiac Operations: A North American Multicenter Prospective Study

BACKGROUNDnRed blood cell transfusion is an important supportive measure after pediatric cardiac operations. However, no clear hemoglobin threshold has been established. This study characterized anemia development and red blood cell transfusions in the pediatric intensive care unit (PICU) after cardiac operations.nnnMETHODSnA prospective, multicenter, 6-month cohort study on the management of anemia in critically ill pediatric patients was conducted in 30 North American PICUs. This observational study enrolled 977 consecutive children (aged <18 years) who stayed in the PICU for 48 hours or more. We analyzed a subgroup of postcardiac surgical patients from this study.nnnRESULTSnIncluded were 175 cardiac patients, 56% of whom had cyanotic heart disease. The mean Pediatric Risk of Mortality (PRISM III) score was 6.4 ± 5.4. Fifty-four percent of children were anemic in the PICU (20% on admission, 34% during PICU stay). Most patients (79%) received at least one red blood cell transfusion in the PICU. Patients who received a transfusion had a significantly longer PICU stay (9.3 ± 6.3 vs 6.1 ± 5.4 days, pxa0= 0.01). Pretransfusion hemoglobin was different in acyanotic and cyanotic patients (mean ± standard deviation: 11.1 ± 2.2 g/dL and 11.8 ± 2.1 g/dL, respectively). According to the attending physician, a low hemoglobin level was the primary indication for transfusion in only 17% of cases.nnnCONCLUSIONSnPediatric cardiac surgical patients are at high risk of receiving red blood cell transfusions. This study, which showed great variability in transfusion practices across North American PICUs, highlights the need for clearer transfusion guidelines in this specific population.

Analysis of NAD(P)H Fluorescence Components in Cardiac Myocytes from Human Biopsies, a New Tool to Improve Diagnostics of Rejection of Transplanted Patients

Tissue autofluorescence is one of the most versatile non-invasive tools for mapping the metabolic state in living tissues. Increasing interest in the imaging and diagnosis of living cells and tissues, based on their intrinsic fluorescence rather than fluorescence labeling, is closely connected to the latest developments in high-performance spectroscopic and microscopic techniques. We investigate metabolic state of cardiac cells isolated from one additional human biopsy from transplanted pediatric patients presenting either no rejection (R0) or mild rejection (R1). Two different approaches for isolation of human cardiac myocytes are also compared. Spectrally-resolved fluorescence lifetime detection of NAD(P)H fluorescence (excitation by pulsed 375 nm picosecond laser) is tested as a promising new tool for quantitative analysis of intrinsic cellular autofluorescence signals in living cardiomyocytes. This work opens new horizons in the evaluation of cardiac transplant rejection using latest fluorescence imaging approaches.

Percutaneous Angioplasty Used to Manage Native and Recurrent Coarctation of the Aorta in Infants Younger than 1 Year: Immediate and Midterm Results

Balloon angioplasty (BAP) used to manage native coarctation of the aorta (CoAo) in infants remains controversial. This study aimed to compare short- and midterm results of BAP between native CoAo (NaCo) and postsurgical recoarctations (ReCo) in infants younger than 1xa0year. This retrospective study compared the clinical, echocardiographic, hemodynamic, and angiographic data for infants who underwent BAP between July 2003 and September 2012. The 12 NaCo and 13 ReCo patients in this study underwent BAP at 4.61xa0±xa03.69 and 4.88xa0±xa03.07xa0months (pxa0=xa00.84) and weighed 5.49xa0±xa02.57 and 6.10xa0±xa02.11xa0kg (pxa0=xa00.52), respectively. Their respective heights were 60.58xa0±xa010.58 and 61.15xa0±xa06.74xa0cm (pxa0=xa00.87). All the ReCo patients had their initial surgery before the age of 3xa0months. The minimal CoAo diameter was 2.81xa0±xa00.96xa0mm in the NaCo group and 2.86xa0±xa01.0xa0mm in the ReCo group (pxa0=xa00.90). The relative gradient reduction was 62.79xa0±xa032.43xa0% in the NaCo group and 73.37xa0±xa020.78xa0% in the ReCo group (pxa0=xa00.33). The in situ complication rate (pseudoaneurysm) was 8.33xa0% in the NaCo group and 7.69xa0% in the ReCo group (pxa0=xa00.74). During the early follow-up evaluation, five NaCo patients (41.66xa0%) presented with recoarctation requiring BAP reintervention within 1.75xa0±xa01.41xa0months (all had their initial BAP before 3 months of age) compared with 1 ReCo patient (7.69xa0%) (pxa0=xa00.165). The mean follow-up period was 3.09xa0±xa02.69xa0years for the NaCo patients and 3.6xa0±xa03.18xa0years for the ReCo patients (pxa0=xa00.69), during which the blood pressure gradient was 12.33xa0±xa09.67 for the NaCo patients and 7.80xa0±xa08.78 for the ReCo patients (pxa0=xa00.17), with corresponding Doppler peak instantaneous gradients of 21.29xa0±xa011.19 and 16.20xa0±xa010.23 (pxa0=xa00.24). The resultant diameter ratio between the minimal isthmus diameter and the aortic diameter at the diaphragmatic level was 0.81xa0±xa00.15 in the NaCo group and 0.85xa0±xa00.12 in the ReCo group (pxa0=xa00.53). The immediate and midterm results of BAP for the NaCo and ReCo infants were comparable. Accordingly, BAP seems to be an acceptable alternative to surgery for infants older than 3xa0months.

Spectrally and time-resolved study of NAD(P)H autofluorescence in cardiac myocytes from human biopsies

Rejection of transplanted hearts remains an important reason for death of transplanted children. Finding diagnostic tools for its detection can therefore improve the prognosis in this population of patients. Endomyocardial biopsy (EMB) by cardiac catheterization is currently accepted as the gold standard for the diagnosis of rejection. Here, we investigate new approach to monitor mitochondrial metabolic state of cardiac cells using spectrally-resolved autofluorescence lifetime detection of nicotinamide adenine dinucleotide (phosphate), or NAD(P)H, the principal electron donor in mitochondrial oxidative energy metabolism responsible for vital ATP supply of cardiomyocytes. NAD(P)H autofluorescence is long used for non-invasive fluorescent probing the metabolic state of the heart. In this contribution we report dynamic characteristics of NAD(P)H fluorescence decays in living human cardiomyocytes from EMB, following excitation by UV-pulsed laser diode and detection by spectrally-resolved time-correlated single photon counting. At least a 3-exponential decay model, with 0.5-0.7 ns, 1.9-2.4 ns and 9.0-15.0 ns lifetimes, is necessary to describe cardiomyocyte autofluorescence in human cells. When gathered data were compared to those recorded under same conditions in rats, autofluorescence in human hearts was found significantly lower in comparison to rat ones. Rotenone, the inhibitor of the Complex I of the respiratory chain, increased the fluorescence in human cardiac cells, making them more comparable to experimental rat model. These results suggest that human cardiac cells are more metabolically active than the rat ones in the same conditions. Presented work proposes a new tool for evaluation of oxidative metabolism changes in transplanted hearts.

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

The optimal red blood cell transfusion threshold for postoperative pediatric cardiac surgery patients is unknown. This study describes the stated red blood cell transfusion practice of physicians who treat postoperative pediatric cardiac surgery patients in intensive care units. A scenario-based survey was sent to physicians involved in postoperative intensive care of pediatric cardiac surgery patients in all Canadian centers that perform such surgery. Respondents reported their red blood cell transfusion practice in four postoperative scenarios: acyanotic or cyanotic cardiac lesion, in a neonate or an infant. In part A of each scenario, the patient was critically ill, but stabilized; in part B, the patient became unstable. Response rate was 58xa0% (71 of 123), with 45 respondents indicating direct involvement in postoperative intensive care. There was a wide variability in stated transfusion threshold, ranging from <7.0–14.0xa0g/dL for stabilized cases. There was no significant difference between neonates and infants in stated transfusion threshold. The mean hemoglobin level below which respondents would transfuse a stabilized patient was 9xa0g/dL for acyanotic and 11.2xa0g/dL for cyanotic patients, a statistically significant difference (2.2xa0±xa00.9xa0g/dL, pxa0<xa00.001). All clinical determinants of instability significantly increased transfusion threshold. Hemodynamic instability increased transfusion threshold by 2.3xa0±xa01.3xa0g/dL in acyanotic patients and by 1.3xa0±xa01.1xa0g/dL in cyanotic patients. Cyanotic lesion and clinical instability, but not patient age, increased stated red blood cell transfusion threshold. Significant variation in reported red blood cell transfusion practice exists among physicians treating pediatric patients in intensive care following cardiac surgery.

Superior Performance in Prone in Infants With Congenital Heart Disease Predicts an Earlier Onset of Walking

Infants with congenital heart disease are at risk of impaired neurodevelopment, which frequently manifests as motor delay during their first years of life. This delay is multifactorial in origin and environmental factors, such as a limited experience in prone, may play a role. In this study, we evaluated the motor development of a prospective cohort of 71 infants (37 males) with congenital heart disease at 4 months of age using the Alberta Infant Motor Scales (AIMS). We used regression analyses to determine whether the 4-month AIMS scores predict the ability to walk by 18 months. The influence of demographic and clinical variables was also assessed. Fifty-one infants (71.8%) were able to maintain the prone prop position (AIMS score of ≥3 in prone) at 4 months. Of those, 47 (92.2%) were able to walk by 18 months compared to only 12/20 (60%) of those who did not maintain the position. Higher AIMS scores were predictive of a greater likelihood of walking by 18 months (P < .001), with the scores in prone having a higher predictive ability compared to those in other positions (Exp(B) 15.2 vs 4.0). Shorter hospital stays and female gender were also associated with an earlier onset of walking. In conclusion, our study demonstrates that early ventral performance in infants with congenital heart disease impacts the age of acquisition of walking and could be used to guide referral to rehabilitation.