Peeter Jögi

SERUM S-100 PROTEIN LEVELS AFTER PEDIATRIC CARDIAC OPERATIONS: A POSSIBLE NEW MARKER FOR POSTPERFUSION CEREBRAL INJURY☆☆☆★

BACKGROUND The release of neuron-specific astroglial S-100 protein to the cerebrospinal fluid is a marker of cerebral damage. The aim of this study was to determine the pattern of release of S-100 protein to serum after pediatric cardiac operations and extracorporeal circulation. METHODS Sequential blood samples from 97 children (up to 16 years) were taken after induction of anesthesia, immediately after the discontinuation of extracorporeal circulation, and 5 and 15 hours after extracorporeal circulation. The children were divided into five groups including three age groups, children with Mb Down syndrome, and children undergoing circulatory arrest. RESULTS The serum concentrations of S-100 protein before the cardiac operation were found to be highest in neonates. Children with Down syndrome, regardless of age, had basal levels comparable to those in neonates. There was an increase in S-100 protein concentration immediately after extracorporeal circulation and a multivariate regression analysis showed this difference in S-100 protein concentration to be significant with respect to age (p = 0.002), perfusion time (p < 0.001), and circulatory arrest (p < 0.001), but the difference was not significant with respect to weight, Down syndrome, and core temperature (p > 0.8). In children younger than 1 month old and after circulatory arrest, levels of S-100 protein remained high at 5 hours after extracorporeal circulation. CONCLUSION These findings emphasize the necessity of using age-matched reference values and taking perfusion time into consideration when S-100 protein levels are evaluated with respect to cerebral postperfusion injuries in pediatric patients undergoing cardiac operations.

Normal Coronary Flow Reserve After Arterial Switch Operation for Transposition of the Great Arteries An Intracoronary Doppler Guidewire Study

Background—Recent studies performed with positron emission tomography have suggested that coronary flow reserve (CFR) is moderately to severely reduced after the arterial switch operation (ASO). These findings are of great concern but have not been confirmed by other methods. Methods and Results—Eleven symptom-free children were studied between 4 and 11 (median 6.0) years after the ASO. Flow velocity in the left anterior descending (LAD) and right coronary arteries (RCA) was measured with a 0.014-inch Doppler FloWire (Cardiometrics) before and after intracoronary injection of adenosine (0.5 &mgr;g/kg) and nitroglycerin (5 &mgr;g/kg). CFR was defined as the ratio of hyperemic to basal average peak velocity (APV). The median (range) CFR in the LAD was 3.7 (3.0 to 4.8) and 3.4 (2.9 to 4.8) in the RCA. The increase in APV after intracoronary injection of nitroglycerin was 300% (240% to 420%) in the LAD and 260% (190% to 460%) in the RCA. APV at rest was 15.0 (14.0 to 21.0) cm/s in the LAD and 16.0 (9.6 to 30.0) cm/s in the RCA. A linear relation was found between right ventricular systolic pressure and resting APV in the RCA (r =0.77, P =0.0056), and between resting APV and CFR (r =-0.61, P <0.05) in the RCA. Conclusions—The CFR and coronary vasoreactivity to nitroglycerin in children treated for transposition of the great arteries with the ASO was within normal limits. Increased right ventricular pressure and myocardial hypertrophy can cause increased resting coronary flow velocity in the RCA and affect CFR negatively.

Heart transplantation across the antibodies against HLA and ABO.

We have intentionally performed heart transplantation in a 5‐year‐old child, despite the most unfavourable risk factors for patient survival; the presence of high level of antibodies against donors human leucocyte antigen (HLA) class I/II and blood group antigens. Pretransplant treatment by mycophenolate mofetil, prednisolone, tacrolimus, intravenous immunoglobulin, rituximab, protein‐A immunoadsorption (IA) and plasma exchange reduced antibody titres against the donors lymphocytes from 128 to 16 and against the donors blood group antigen from 256 to 0. The patient was urgently transplanted with a heart from an ABO incompatible donor (A1 to O). A standard triple‐drug immunosuppressive protocol was used. No hyperacute rejection was seen. Antibodies against the donors HLA antigens remained at a low level despite three acute rejections. Rising anti‐A1 blood group antibodies preceded the second rejection and were reduced by two blood group‐specific IAs and remained at a low level. The patient is doing well despite the persistence of donor‐reactive antibodies.

Successful Thrombolysis of an Occluded Modified Blalock Shunt Three Days After Operation

A 10-day-old boy with pulmonary atresia received a right-sided aortopulmonary polytetrafluoroethylene shunt. Three days after the operation he became cyanotic and was reintubated. Shunt occlusion was confirmed with angiography. Recombinant tissue plasminogen activator was given locally into the proximal end of the shunt. The thrombus was completely resolved after 2 days. When administration of recombinant tissue plasminogen activator was stopped, heparin infusion was started for 5 days. Shunt patency was demonstrated by angiography at 3 months postoperatively.

Use of pediatric Berlin Heart EXCOR biventricular device as a bridge to retransplantation in a 10-month-old infant with acute graft failure after cardiac transplantation.

We report the implantation of the Berlin Heart EXCOR (Berlin Heart, Berlin, Germany) as a pediatric biventricular assist device in a 10-month-old boy with primary graft failure after cardiac transplantation. The EXCOR was successfully used as a bridge to cardiac retransplantation. The pneumatically driven paracorporeal device supported the patient for 165 days until another suitable heart was obtained.

Improved Disinfection and Maintenance of Human Heart Valve Allografts

A novel formula based on broad spectrum antimicrobial drugs for the disinfection and maintenance of human heart valve allografts is presented. The antimicrobial efficiency was evaluated on sixteen aerobic, facultative aerobic and anaerobic bacterial species and 5 species of fungi, all from clinical material. Since 1986 the formula has been used for 66 human aortic and pulmonary valves. The composition and mode of preparation of the antibiotic mixtures, the procedures of disinfection, the outcome of aerobic and anaerobic blood cultures as well as the results of microbiological analysis valves are presented. The principles of valve selection and the criteria for the selection of drugs is described.