Pranava Sinha

Extracorporeal membrane oxygenation in postcardiotomy patients: factors influencing outcome.

OBJECTIVE Our objective was to assess the morbidity and mortality in children requiring extracorporeal membrane oxygenator support after cardiac surgery and to determine factors influencing outcome. METHODS Between January 2003 and June 2008, 58 patients required extracorporeal membrane oxygenator support after cardiac surgery. A retrospective study was performed and factors influencing outcome were determined by logistic regression modeling with the probability of outcome based on a combination of multivariate predictors. RESULTS Median age and weight were 12 days and 3.3 kg, respectively. Thirty-one patients had single ventricle repair and 27 had biventricular repair. Median duration of support with the oxygenator was 6 days. Thirty-nine (67%) patients were successfully weaned off the support, but only 24 (41%) survived to hospital discharge. Chief complications were renal failure (31%), neurologic complications (29%), and sepsis (16%). Multivariable logistic regression analysis identified 10 days or more of extracorporeal membrane oxygenation (odds ratio = 6.1), urine output less than 2 mL x kg(-1) x h(-1) in first 24 hours (odds ratio = 15), renal failure (odds ratio = 9.4), and pH less than 7.35 after 24 hours of extracorporeal membrane oxygenation (odds ratio = 82) as significant independent factors associated with failure to wean off extracorporeal membrane oxygenation. Factors associated with failure of hospital discharge despite successful decannulation were as follows: extracorporeal membrane oxygenator support time of 10 days or more, red blood cell transfusion of greater than 1000 mL/kg during the entire period of oxygenator support, and sepsis. Patients with single ventricle repair were at higher risk of hospital mortality. CONCLUSION Longer duration of extracorporeal membrane oxygenator support, low pH and urine output in the first 24 hours, and renal failure are significant factors associated with mortality during extracorporeal membrane oxygenator support. Exposure to high amounts of blood transfusion during extracorporeal oxygenation, extended extracorporeal membrane oxygenator support, and sepsis increase risk of death after successful decannulation.

Specialized Delivery Room Planning for Fetuses With Critical Congenital Heart Disease

Improvements in fetal echocardiography have increased recognition of fetuses with congenital heart disease (CHD) that require specialized delivery room (DR) care. In this study, care protocols for these low-volume and high-risk deliveries were created. Elements included (1) diagnosis-specific DR care plans and algorithms, (2) a multidisciplinary team with expertise, (3) simulation, (4) checklists, and (5) debriefing. The purpose of this study was to assess the accuracy of fetal echocardiography to predict the need for specialized DR care and determine the effectiveness of the care protocols for the treatment of patients with critical CHD. Fetal and postnatal medical records and echocardiograms of fetuses with CHD assigned to an advanced level of care were reviewed. Safety and outcome variables were analyzed to determine care plan and algorithm efficacy. Thirty-four fetuses were identified: 12 delivered at Childrens National Medical Center and 22 at the adult hospital. Diagnoses included hypoplastic left heart syndrome, aortic stenosis, d-transposition of the great arteries, tetralogy of Fallot with absent pulmonary valve, complex pulmonary atresia, arrhythmias, ectopia cordis, and conjoined twins. Delivery at Childrens National Medical Center was associated with a shorter time to specialty care or intervention. Measures of physiologic stability and survival were similar. Need for specialized care was predicted in 84% of deliveries. For hypoplastic left heart syndrome, intervention was predicted in 10 of 11 deliveries and for d-transposition of the great arteries in 10 of 12 deliveries. Care algorithms addressed most DR events. Of the unanticipated events, none were unrecoverable. DR survival was 100%, and survival to discharge was 83%. In conclusion, fetal echocardiography predicted the need for specialized DR care in fetuses with critical CHD. Algorithm-driven protocols enable planning such that maternal and infant risk is minimized and outcomes are good.

Implementation of an extracorporeal cardiopulmonary resuscitation simulation program reduces extracorporeal cardiopulmonary resuscitation times in real patients.

Objective: To determine if development of an extracorporeal cardiopulmonary resuscitation simulation program reduced extracorporeal cardiopulmonary resuscitation times in real patients Design: Before-after study. Setting: Twenty-six bed pediatric cardiac ICU in a tertiary urban hospital. Patients: Forty-three cardiac patients (aged 1 d to 16 yr) who received extracorporeal cardiopulmonary resuscitation. Interventions: An interdisciplinary team collaborated to define the roles and clarify responsibilities of each individual involved in extracorporeal cardiopulmonary resuscitation. An “ideal rapid deployment” was defined and tested using simulation sessions. This included a task analysis, role creation, and multidisciplinary simulations, including structured debriefings and video review and the creation of a master checklist. Measurements and Main Results: There were a total of 43 episodes of extracorporeal cardiopulmonary resuscitation during the study period, 16 (37%) of which occurred during the preintervention time period (from February 2009 to March 2010) and 27 (63%) during the postintervention time period (April 2010 to March 2013). The median deployment time in the preintervention time period was 51 minutes (interquartile range, 43–62 min), whereas the median deployment time in the postintervention time period was 40 minutes (interquartile range, 23–52 min) (p = 0.018). Conclusions: There are no standard guidelines of how a team should coordinate the efforts of nursing, physicians, extracorporeal membrane oxygenation specialists, surgeons, respiratory therapists, patient care technicians, and unit clerks to emergently execute this complex procedure. Because time is of the essence, it is essential to develop a highly functioning and well-coordinated team with a standardized method of the procedure, its documentation, and communication. Simulation accomplished this for our program. Following these simulation exercises, not only was there a subjectively observed improved coordination and smoother deployment of extracorporeal membrane oxygenation in real-life extracorporeal cardiopulmonary resuscitation, but we have also demonstrated a significantly faster deployment of extracorporeal membrane oxygenation as compared with the presimulation era.

Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation

OBJECTIVE The study objective was to compare the incidence of short- and intermediate-term arrhythmias among 3 different surgical modifications of the Fontan procedure. METHODS We performed a retrospective review of all patients who underwent the Fontan operation at a single institution between January 2004 and May 2010 for preoperative, perioperative, and follow-up variables. Three surgical modifications were studied: intra/extracardiac conduit with limited atriotomy, standard extracardiac conduit, and lateral tunnel. Rhythm was classified as normal or abnormal. A rhythm dysfunction grading was devised and used to identify worsening of rhythm for patients with abnormal rhythm preoperatively. Multivariable logistic regression was used to determine predictors of abnormal rhythm. To eliminate confounding effects of transient immediate postoperative arrhythmias, data were analyzed for abnormal rhythm within the first 2 weeks and for more than 2 weeks after surgery. RESULTS Of the 134 patients (n = 50 with intra/extracardiac conduit with limited atriotomy, n = 19 with standard extracardiac conduit, n = 65 with lateral tunnel) (median follow-up, 36 months; interquartile range, 22-50 months; 2 operative deaths and 6 late deaths), rhythm data for more than 2 weeks postoperatively were available in 88 (40 with lateral tunnel, 14 with standard extracardiac conduit, 34 with intra/extracardiac conduit with limited atriotomy). These patients constituted the study groups. Patients in the lateral tunnel group were relatively younger at the time of the Fontan operation (P < .001) and had a longer follow-up (P < .001). Multivariable logistic regression confirmed that greater than moderate atrioventricular valve regurgitation was the only independent predictor of abnormal rhythm during the first 2 postoperative weeks. Older age at Fontan (odds ratio, 1.20; 95% confidence interval, 1.05-1.38; P = .012) and higher preoperative mean pulmonary artery pressure (odds ratio, 1.2; 95% confidence interval, 1.03-1.44; P = .026) were predictors of abnormal rhythm more than 2 weeks postoperatively. Intra/extracardiac conduit with limited atriotomy Fontan modification was associated with a significantly lower incidence of abnormal rhythm after 2 weeks postoperatively compared with lateral tunnel modification (odds ratio, 0.28; 95% confidence interval, 0.10-0.84; P = .015). CONCLUSIONS Intra/extracardiac conduit with limited atriotomy Fontan modification has a significantly lower risk of abnormal rhythm postoperatively in the short and intermediate term when compared with the lateral tunnel.

Severe tricuspid valve stenosis secondary to pacemaker leads presenting as ascites and liver dysfunction: a complex problem requiring a multidisciplinary therapeutic approach

Tricuspid stenosis secondary to ventricular pacemaker leads is uncommon. We present a unique case of iatrogenic tricuspid stenosis secondary to fusion of the valve leaflets to transvenous implanted pacing leads. This occurred in an adult with childhood repaired Tetralogy of Fallot and high grade surgical heart block following multiple pacemaker procedures. The case was complicated by superior vena cava (SVC) and innominate vein stenosis secondary to implanted pacing leads, severe tricuspid valve (TV) stenosis, perforation of the heart by one of the implanted transvenous ventricular pacing leads, prolapse of the transvenous atrial pacing lead into the right ventricle, and unusual coronary sinus anatomy. We describe a multidisciplinary approach to management.

Femoral Vein Homograft for Neoaortic Reconstruction in Norwood Stage 1 Operation

Femoral vein homografts are increasingly being used for arterial reconstruction in peripheral vascular surgery. We explored the suitability of using cryopreserved femoral vein homograft for neoaortic reconstruction in Norwood stage I operation for hypoplastic left heart syndrome.

Detection of alpha-II-spectrin breakdown products in the serum of neonates with congenital heart disease

Objectives: To determine if alpha II-spectrin breakdown products can be detected in the serum of neonates with congenital heart disease in the perioperative period. Design: Prospective observational cohort study. Setting: Pediatric cardiac ICU in an urban tertiary care academic center. Patients: Neonates with congenital heart disease undergoing surgical repair or palliation. Interventions: Serial blood sampling for measurement of 120 and 150 kDa spectrin breakdown products. Measurements and Main Results: Fourteen neonates with congenital heart disease undergoing cardiac surgery were evaluated. Nine infants underwent open-heart surgery and five underwent closed-heart surgery. Serum spectrin breakdown products were measured with sandwich enzyme-linked immunosorbent assay preoperatively and then 6, 24, 48, 72, and 96 hours following surgery. Brain imaging was obtained as part of routine clinical care in 12 patients preoperatively and six patients postoperatively. Six patients had normal preoperative imaging (three closed-heart surgery and three open-heart surgery), whereas six had evidence of neurologic injury prior to surgery (one closed-heart surgery and five open-heart surgery). Only one patient had a postoperative imaging study that lacked injury. All others demonstrated infarction or hemorrhage. Spectrin breakdown product 120 kDa significantly increased 24 hours after open-heart surgery compared to preoperative values and time-matched closed-heart surgery levels. Spectrin breakdown product 150 kDa significantly increased 6 hours after open-heart surgery compared to preoperative values. There was no significant change in spectrin breakdown products following closed-heart surgery. Peak spectrin breakdown products significantly increased following open-heart surgery compared to closed-heart surgery. Conclusions: Spectrin breakdown products can be detected in the serum of neonates with congenital heart disease in the perioperative period and levels increased to a greater degree in infants following open-heart surgery. These findings suggest that, in future work, serum spectrin breakdown products may potentially be developed as biomarkers for brain necrosis and apoptosis in infants with congenital heart disease.

Right ventricular outflow tract reconstruction using a valved femoral vein homograft

Recently, Bhattacharyya and colleagues reported a case of decompression of an emphysematous bulla through a transbronchial aspiration needle. We considered this strategy to be unsuitable for our case because of the high risk of pneumothorax or bronchopleural fistula. Finally, we considered using EBVs, which were designed for the treatment of emphysema and have been applied successfully for occlusion of bronchopleural and bronchocutaneous fistulas. The EBVs work like a Heimlich valve, allowing escape of air and secretions from bulla at expiration (Figure 2, B) but preventing air inflow at inspiration (Figure 2, C), thus resulting in a redirection of airflow away from the blocked segments. The result is deflation of the GEB and the re-expansion of the more normal adjacent lung. Our experience confirms that this noninvasive bronchoscopic treatment may represent a valuable alternative for patients who are poor surgical candidates. Bronchoscopic

Bilateral branch pulmonary artery banding as a bridge to decision/preoperative optimization of high-risk neonates with hypoplastic left heart syndrome

We present our experience with bilateral branch pulmonary artery banding as a bridge to decision/optimization of hemodynamics, followed by standard Norwood stage I palliation in very high-risk infants with hypoplastic left heart syndrome.

Cor Triatriatum With Partial Anomalous Pulmonary Venous Return: A Rare Case of Parallel Obstruction and Successful Staged Treatment

Cor triatriatum sinister is an uncommon congenital cardiac defect that has rarely been described in association with left-sided partial anomalous pulmonary venous return. We present a case of such rare anatomy with multilevel obstruction that presented in infancy as cardiogenic shock. The patient underwent staged treatment with extracorporeal membrane oxygenation stabilization, catheter-based balloon dilatation of the cor triatriatum and atrial septostomy, followed by definitive surgical repair, with excellent result.