Serge Demontoux

Interleukin-10 release related to cardiopulmonary bypass in infants undergoing cardiac operations

To evaluate cytokine balance related to cardiopulmonary bypass, we prospectively investigated 11 infants undergoing cardiac operations for congenital heart disease. Proinflammatory cytokines (tumor necrosis factor-alpha and interleukin-8) and the antiinflammatory cytokine interleukin-10 were measured at multiple time points before, during, and after bypass. Tumor necrosis factor-alpha and interleukin-8 values were within normal range before the operation. These values increased significantly during bypass, reaching their peaks after protamine administration (tumor necrosis factor-alpha, 133.6 +/- 124.9 pg/ml; mean +/- standard deviation; p<0.005) and 2 hours after termination of the procedure (interleukin-8, 92.1 +/- 44.1 pg/ml; p < 0.01). Tumor necrosis factor-alpha and interleukin-8 equaled normal prebypass values from the first postoperative day on. Interleukin-10 levels were within normal range before the operation and were already significantly increased 10 minutes after initiation of bypass (interleukin 10, 39.4 +/- 34.3 pg/ml; p<0.05). These levels remained elevated throughout the procedure but returned to normal after protamine administration. A second significant release of interleukin-10 occurred from the early postoperative period on, reaching its peak 24 hours after termination of cardiopulmonary bypass (interleukin-10, 351.6 +/- 304.0 pg/ml; p < 0.01). Interleukin-10 values were normal on the second postoperative day in all patients. Interleukin-10 kinetics showed an inverse pattern compared with tumor necrosis factor-alpha and interleukin-8. This difference suggests an interplay between proinflammatory and antiinflammatory cytokines released during and after cardiopulmonary bypass. Interleukin-10 levels measured 4 and 24 hours after bypass strongly correlated with the degree of hypothermia during bypass (Spearmans correlation coefficient, -0.77 [p < 0.01] and -0.89 [p < 0.0005], respectively); these levels did not correlate with duration of bypass and aortic crossclamping, however. This result suggests that besides immunologically mediated production of interleukin-10, hypothermia itself could modulate interleukin-10 production. In conclusion, this study demonstrates interleukin-10 production, in addition to interleukin-8 and tumor necrosis factor-alpha synthesis, in response to cardiopulmonary bypass in infants. Interleukin-10 could play a protective role by down-regulating proinflammatory cytokine release during and after cardiopulmonary bypass.

Stroke volume and cardiac output evaluation by electrical cardiometry: accuracy and reference nomograms in hemodynamically stable preterm neonates

Objective:To investigate the accuracy of electrical cardiometry (EC) to measure stroke volume (SV) and cardiac output (CO) and to provide gestational age (GA) and birth weight (BW)-based reference data for SV and CO in hemodynamically stable preterm neonates.Study Design:Prospective observational blinded study. Paired measurements of SV and CO on stable preterm infants without any hemodynamic compromise were carried out using EC (SVEC) and echocardiography (SVECHO).Results:Seventy-nine preterm neonates (mean GA: 31±3.2 weeks) were enrolled. A good correlation was found for SV (r=0.743; P<0.0001) and CO (r=0.7; P<0.0001) measured by EC and echocardiography. These correlations remained significant after adjusting for GA, patent ductus arteriosus and type of respiratory support (SV: St.β=0.48, P<0.0001 and CO: St.β=0.69, P<0.0001). Mean biases (and variabilities) were −1.1 (from 0.7 to −2.9) ml and −0.21 (from 0.15 to −0.55) l min−1 for SV and CO, respectively. Local regression shows a tendency for EC to overestimate SV and CO especially at higher values (at about >2 ml and >0.4 l min−1, respectively). Coefficient of variation of SV was 48.9% and 52%, for EC and echocardiography. SV and CO rose with increasing GA and BW following an exponential equation (R2>0.8).Conclusion:Measuring SV and CO with EC in hemodynamically stable preterm infants shows good correlation and variability similar to that of echocardiography. A trend to overestimation exists at highest values, but it is unlikely to be clinically significant. Reference GA and BW-based nomograms for SV and CO are provided.

Transposition of the great arteries complicated by tricuspid valve incompetence

BACKGROUND Tricuspid valve insufficiency secondary to structural anomalies of the valve itself or to an iatrogenic complication of the Rashkind procedure is very rarely associated with transposition of the the great arteries. This condition represents an interesting perioperative challenge. Rapid restoration of the tricuspid valve to a low-pressure system by arterial switch operation associated with tricuspid repair should theoretically improve the outcome in terms of myocardial and valve function. METHODS Thirteen of 839 patients who underwent an arterial switch operation for various forms of transposition of the great arteries presented with moderate to severe tricuspid insufficiency. Three of them had a ventricular septum defect. Nine experienced severe cardiac failure with profound hypoxemia. Ventilatory support was necessary in 7, 6 had renal or hepatic dysfunction, and 5 had coagulation disorders. Inotropic support was started preoperatively in 8 patients. RESULTS Tricuspid lesions were as follows: primary annular dilatation and lack of coaptation at the commissural level (n = 1), straddling tricuspid valve (n = 1) redundant tricuspid valve tissue leading to left ventricular outflow tract obstruction (n = 1), small cleft of the septal leaflet (n = 1), and dysplastic valve tissue with juxtacommissural regurgitation (n = 1). In 8 patients, the cause of the tricuspid valve insufficiency was most probably an iatrogenic lesion, with rupture of the papillary muscle (n = 2), rupture of the chordae (n = 1), or tear of the anterior leaflet (n = 5), whereas no clear cause could be found in 1 patient. Repair consisted of the arterial switch operation associated with tricuspid valve repair in 10 patients. In 2 patients with only discrete anomaly and in 1 without a clear cause of tricuspid regurgitation, no valve repair was performed. Three patients had their ventricular septal defect closed. There were only one early and one late death, both not related to the tricuspid lesions. Late postoperative (mean, 6.5 years) evaluation revealed normal left ventricular function in 10, with no tricuspid incompetence in 7 and trivial tricuspid insufficiency in 3. CONCLUSIONS Restoration of an incompetent tricuspid valve in a low-pressure system by the arterial switch operation combined with valve repair provides good ventricular and valvar results. Preoperative management and appropriate timing of operation seem to be of utmost importance.

Basic Hemodynamic Monitoring Using Ultrasound or Electrical Cardiometry During Transportation of Neonates and Infants

Objectives: Electrical cardiometry and heart ultrasound might allow hemodynamic evaluation during transportation of critically ill patients. Our aims were 1) to test feasibility of stroke volume monitoring using electrical cardiometry or ultrasound during transportation and 2) to investigate if transportation impacts on electrical cardiometry and ultrasound reliability. Design: Prospective, pragmatic, feasibility cohort study. Setting: Mobile ICUs specialized for neonatal and pediatric transportation. Patients: Thirty hemodynamically stable neonates and infants. Interventions: Patients enrolled underwent paired stroke volume measurements (180 before/after and 180 during the transfer) by electrical cardiometry (SVEC) and ultrasound (SVUS). Measurements and Main Results: No problems or malfunctioning occurred neither with electrical cardiometry nor with ultrasound. Ultrasound lasted on average 90 (10) seconds, while 45 (15) seconds were needed to instigate electrical cardiometry monitoring. Coefficient of variation was higher for SVUS (before/after: 0.57; during: 0.66) than for SVEC (before/after: 0.38; during: 0.36). Correlations between SVEC and SVUS before/after and during the transfer were r equal to 0.57 and r equal to 0.8, respectively (p always < 0.001). Bland-Altman analysis showed that stroke volume tends to be higher if measured by electrical cardiometry. SVEC measured before (5.5 [2.4] mL), during (5.4 [2.4] mL), and after the transfer (5.4 [2.3] mL) are similar (p = 0.955); same applies for SVUS before (2.6 [1.5] mL), during (2.4 [2] mL), and after (2.9 [2] mL) the transfer (p = 0.268). Conclusions: Basic hemodynamic monitoring is feasible during pediatric and neonatal transportation both with electrical cardiometry and ultrasound. These two techniques show comparable reliability, although stroke volume was higher if measured by electrical cardiometry. The transportation itself does not affect the reliability of stroke volume measurements.

P6 Phrenic nerve palsy and Glenn anastomosis: One center 10 years experience

Introduction Diaphragmatic paralysis after cardiac surgery due to bilateral phrenic nerve palsy is an important complication especially in infants with Glenn procedure. The best pulmonary condition is a key factor for success in monoventricular palliative surgery. The response of the patient to phrenic nerve palsy may range from an asymptomatic radiographic abnormality to severe pulmonary dysfunction requiring prolonged mechanical ventilation and other associated morbidities and even mortality. Indeed, with a global incidence of 1.6% in most series, Glenn anastomosis appears to be one of the closed heart procedures of high risk of palsy.

PS-021 Electrical Cardiometry Stroke Volume Evaluation In Nicu: Comparison With Functional Echocardiography

Background Evaluation of cardiac output in neonates might be difficult because of the complexity and risks of invasive classical procedures. New systems like electrical cardiometry (EC: Osypka Medical, Berlin, Germany and La Jolla, California, USA) have been proposed but few data are available in neonates. We investigated stroke volume (SV) using EC in term and preterm infants. Methods Eligible patients were neonates admitted to the NICU and undergoing echocardiography for any clinical reasons, without congenital heart disease. We measured SV with EC and echocardiography, within 10 min. Measurements were repeated 6 times by the same operator to calculate repeatability before and after echocardiography. Data have been compared with correlation and Bland-Altman analysis. Results 59 neonates were enrolled, allowing 150 paired measurements. Mean gestational age and birth weight were 33.9 ± 3.4 wks and 1988 ± 823 g, respectively. Results of Pearson correlation and Bland-Altman analysis for the whole population were (r = 0.611; p < 0.001) and (mean error [echo-EC] -1.35 mL [95% CI: -6.55 mL ± 3.85 ml]), respectively. Correlation is maintained even with PDA (r = 0.627; p < 0.001). Gestational age seems to do not influence the correlation between EC and echo (Partial correlation coefficient r = 0.36; p < 0.0001). Repeatability (coefficient of variation) was 46% for EC and 52% for echocardiography. There was no difference in SV measured by EC after 10 min (3.76 ± SD vs 3.78 ± SD; p = 0.56, Wilcoxon test). Conclusions EC is feasible, reproducible and quick. It could be an useful tool for continuous monitoring and haemodynamic evaluation in neonates. EC is particularly interesting for the clinical management of preterm neonates.

PO-0488 Non-invasive Haemodynamic Monitoring Using Electrical Cardiometry In Neonates During Respiratory Procedures

Background Electrical cardiometry (EC: Osypka Medical, Berlin, Germany and La Jolla, California, USA) is a new non-invasive technique for haemodynamic monitoring of neonates. No data are available for preterm babies during respiratory procedures, such as elective extubation or chest physiotherapy. We designed this study to clarify if these procedures have any haemodynamic consequences. Abstract PO-0488 Figure 1 Methods We assessed stroke volume (SV), cardiac output (CO), contractility index (ICON) and heart rate (HR) with EC before and after 5, 10, 15, 30 and 60 min from elective extubation or physiotherapy sessions with accelerated expiratory flow [Demont B et al , Physiotherapy 2007;93:12–16]. Functional echocardiography has been performed by the same operator before and after 60 min from the above-described respiratory procedures. Infants with congenital heart disease were not eligible. Results Eleven (for physiotherapy) and thirteen (for extubation) preterm infants were enrolled. Gestational age and birth weight were 29.2 ± 0.5 wks and 1313 ± 915 g, respectively. Fig.1 shows trends of SV, CO, ICON and HR before and after the procedures: no differences were noticed (p = 0.318 for SV; p = 0.559 for CO; p = 0.23 for ICON;p = 0.78 for HR, Friedman test). No differences were found analysing separately extubation and physiotherapy groups. Conclusions No haemodynamic changes are visible during elective extubation or chest physiotherapy in preterm infants. These preliminary results deserve further evaluation studying cerebral oxygenation with NIRS.

SFN CO-06 - Evaluation non invasive du débit cardiaque chez le nouveau-né : comparaison de la vélocimétrie électrique et de l’échographie cardiaque

L’evaluation du debit cardiaque en neonatologie est complexe et les procedures classiques sont risquees. La velocimetrie electrique (VE) est un systeme non invasif mais peu de donnees existent chez le nouveau-ne. Ce travail compare les valeurs du volume d’ejection (SV) mesure par VE et echographie cardiaque chez les enfants hospitalisees en reanimation neonatale par des mesures repetees de VE avant et apres echographie par le meme operateur. 32 enfants sont inclus permettant 53 mesures avec un âge gestationnel (AG) et un poids moyens de 29 SA et 1265g. Les correlations de Pearson et analyses de Bland Altman sur la cohorte retrouvent r= 0,499 (p La VEest facile, rapide et reproductible. Elle peut etre une aide precieuse a l’evaluation hemodynamique neonatale notamment chez le premature, surtout en absence de canal arteriel.

SFNP-10 - Evaluation non invasive de l’hémodynamique chez le nouveau-né au cours de manœuvres respiratoires.

La velocimetrie electrique (VE) est une nouvelle technique non invasive de monitorage hemodynamique. Il n’existe pas de donnees pour le moment chez les nouveau-nes au decours de procedures respiratoires comme l’extubation ou la kinesitherapie respiratoire. Le but de ce travail est de savoir si elles entrainent des modifications hemodynamiques. Pour cela dans notre population des nouveau-nes prematures on recueille le volume d’ejection (SV), debit cardiaque (DC), l’index de contractilite (ICON) et la frequence cardiaque (FC) avec la VE avant, apres et a 5, 10, 15, 30 et 60 minutes de l’extubation ou de manœuvres d’acceleration du flux expiratoire (AFE). 11 (AFE) et 13 (extubation) enfants sont inclus avec un âge gestationnel et un poids moyen de 29 SA et 1313g. Aucune difference entre les valeurs mesurees n’a ete relevee au decours des procedures d’AFE et d’extubation quel que soit le parametre (p=0.318 pour SV; p=0.559 DC; p=0.23 ICON; p=0.78 FC, tests de Friedman). Aucune difference n’est relevee en analysant separement les 2 groupes. Aucune modification hemodynamique n’est relevee dans notre cohorte de prematures. Ces resultats preliminaires meritent d’etre approfondis notamment par mesure specifique du debit cerebral par NIRS.