Thilo Fleck

Comparison of different near‐infrared spectroscopic cerebral oxygenation indices with central venous and jugular venous oxygenation saturation in children

Background:  We compared two different near‐infrared spectrophotometers: cerebral tissue oxygenation index (TOI) measured by NIRO 200 and regional cerebral oxygenation index (rSO2) measured by INVOS 5100 with venous oxygen saturation in the jugular bulb (SjO2) and central SvO2 from the superior caval vein (SVC) during elective cardiac catheterization in children.

Relation of cerebral tissue oxygenation index to central venous oxygen saturation in children

ObjectiveTo evaluate the relationship between the cerebral tissue oxygenation index measured by near-infrared spectroscopy and central venous oxygen saturation (SvO2) after corrective surgery of congenital heart defects in children.DesignProspective observational clinical study.SettingA tertiary neonatal and paediatric intensive care unit for paediatric cardiology.PatientsNeonates and children consecutively admitted to the paediatric cardiology intensive care unit after corrective surgery of non-cyanotic congenital heart defects.Measurements and resultsForty-three children were studied. Cerebral tissue oxygenation index, measured non-invasively by near-infrared spectroscopy, was compared to SvO2, measured by a catheter placed in the right atrium, and to haemodynamic and respiratory parameters. Pearson’s correlation coefficients and p values were calculated. Simultaneously measured values for SvO2 (62.2±9.8%, 39.8–80.4%) and cerebral tissue oxygenation index (56.7±8.8%, 35.8–71.2%) showed a significant correlation (r=0.52, p<0.001).ConclusionCerebral tissue oxygenation index and SvO2 are not interchangeable parameters, but cerebral tissue oxygenation index reflects the haemodynamic influence on cerebral oxygenation after cardiovascular surgery. Further work is necessary to confirm the clinical role of continuous non-invasive measurement of cerebral tissue oxygenation index with regard to the variations of global systemic oxygen consumption after cardiac surgery in children.

Influence of intravenous sildenafil on cerebral oxygenation measured by near-infrared spectroscopy in infants after cardiac surgery.

Sildenafil (Viagra) has been shown to be an effective pulmonary vasodilator and is increasingly used in patients with pulmonary hypertension. Its effects on the cerebral circulation are unclear and have not yet been described. We investigated the effect of i.v. sildenafil treatment on cerebral oxygenation in 13 children with elevated pulmonary vascular resistance due to congenital heart defects after cardiac surgery using near-infrared spectroscopy (NIRS). Median age was 4.5 mo, and median weight was 5.5 ± 1.8 kg. Sildenafil was administered in three steps of 15 min each with cumulative doses of 0.025, 0.1, and 0.25 mg/kg. We examined the changes of oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (HHb), total hemoglobin (tHb) concentration, cytochrome oxidase (CytOx) oxygenation, and cerebral tissue oxygenation index (TOI) in 13 children. A significant increase in cerebral HbO2 and tHb at the beginning of i.v. sildenafil administration with a decrease in HHb was observed. These changes led to a significant elevation in cerebral TOI from 63.4 ± 2.5% to 65.7 ± 2.8%, whereas mean systemic arterial pressure and arterial oxygen partial pressure tended to decrease. In conclusion, we observed a reversible increase of HbO2, tHb, and hemoglobin oxygen saturation in the scanned tissue section after i.v. sildenafil administration. These findings may be clinically relevant because they indicate that after cardiac surgery, sildenafil may increase cerebral blood flow (CBF), probably due to general endothelial dysfunction after cardiopulmonary bypass (CPB).

European perspective on less invasive surfactant administration—a survey

AbstractLess invasive surfactant administration or minimally invasive surfactant therapy (LISA/MIST) has been proposed for the administration of surfactant in preterm infants without intubation. The aim of our survey was to assess the rate of utilization, premedication as well as technique and equipment used for LISA/MIST. Furthermore, attitudes and experiences in regard to indications, side effects, and efficacy should be assessed. An online-based survey was sent to 324 neonatologists from different centers within 37 European countries between December 2015 and March 2016. Of those 165 who responded (response rate 51%), 86 (52%) were using LISA/MIST. It is regarded the standard procedure for surfactant administration by 41%, with a wide variation in personal views on patient selection in terms of indication, appropriate gestational and postnatal age. Policies concerning premedication, devices, and technique of LISA/MIST differed widely. Side effects like surfactant reflux, bradycardia, and hypoxia were observed by 77% of neonatologists. Of neonatologists inexperienced in LISA/MIST, 89% would consider utilizing it in the future. Perceived efficacy of LISA/MIST was high (52%) to medium (33%). Conclusion: The use of LISA/MIST within Europe is widespread. There is a wide variation concerning all aspects of LISA in daily clinical routine and different views on when and how LISA should be performed.What is Known:• Noninvasive surfactant administration has been the subject of randomized controlled trials and has found its way into clinical routine.What is New:• Noninvasive surfactant administration techniques are widely applied in European neonatal units.• There is a wide variety of equipment used and techniques applied for less invasive surfactant delivery as well as different views on the indications and perceived efficacy of this intervention.

Transcatheter closure of atrial septal defects in children and adolescents: single-center experience with the GORE® septal occluder.

Device closure of atrial septal defects (ASD II) is an alternative to surgery. ASD morphology and intracardiac relationships may influence device selection. Biocompatibility, techniques for closing large or multiple defects, and the risk of erosion are main issues in children

Influence of external cardiac pacing on cerebral oxygenation measured by near infrared spectroscopy in children after cardiac surgery

Background:  The brain of children in the early period after repair of congenital heart defects with cardiopulmonary bypass (CPB) may be more vulnerable to hemodynamic changes because of impaired cerebral autoregulation. During postoperative testing of the external temporary safety pacer, we performed desynchronizing ventricular pacing (VVI) while monitoring cerebral oxygenation using near‐infrared spectroscopy (NIRS).

Long-Term Follow-Up on Health-Related Quality of Life After Mechanical Circulatory Support in Children.

Objective: The objective of this study was to evaluate health-related quality of life in long-term survivors of mechanical circulatory support after acute cardiopulmonary failure. Design: Prospective follow-up study. Setting: Single-institutional in a center for congenital heart disease and pediatric cardiology. Patients: Fifty patients who underwent 58 mechanical circulatory support therapies in our institution from 2001 to 2012. Median age was 2 (0–213) months, and median supporting time was 5 (1–234) days. Indication groups: 1) extracorporeal life support in low cardiac output: 30 cases (52%); 2) extracorporeal cardiopulmonary resuscitation: 13 cases (22%); 3) extracorporeal membrane oxygenation in acute respiratory distress syndrome: four cases (7%); and 4) ventricular assist devices: 11 cases (19%). Interventions: Health-related quality of life was measured using standardized questionnaires according to the age group and completed by either parent proxies in children under 7 years old or the survivors themselves. Measurements and Main Results: Fifty percentage of the patients were discharged home, and 22 long-term survivors (44%) were studied prospectively for health-related quality of life. Median follow-up period was 4.5 (0.3–11.3) years. Median age at follow-up was 5 (0.6–29) years old. Nineteen long-term survivors filled in the health-related quality of life questionnaires and were classified into three age groups: 0–4 years (n = 7): median health-related quality of life score, 69 (59–86) points; 4–12 years (n = 7): median health-related quality of life score, 50 (48–85) points; older than 12 years (n = 5): median health-related quality of life score, 90 (80–100) points. Conclusion: Long-term survivors’ health-related quality of life as reported by their parents is lower than that of healthy children. However, the self-assessed health-related quality of life of the patients older than 12 years in our group is comparable to a healthy control population.

No-React® Injectable BioPulmonic™ valves re-evaluated: discouraging follow-up results

OBJECTIVES The No-React® Injectable BioPulmonic™ valve (BioIntegral) was introduced for minimally invasive off-pump replacement of the pulmonary valve almost 10 years ago. We present our mid- to long-term follow-up results. METHODS We conducted a retrospective analysis of all 7 patients treated at our institution at the median age of 9 (range 1-24) years. The children underwent cardiac catheterization when worsening strain on the right heart was suspected after examining their medical history and/or observing significant changes on echocardiography. RESULTS After a median follow-up period lasting 5.2 (range 0.7-6.7) years, all patients presented the indication for recatheterization, particularly because the maximum instantaneous velocity measured by Doppler had revealed systolic gradients of a median 63 (dP 18-74) mmHg across the right ventricular outflow. Catheterization confirmed severe stenosis in 2, and moderate stenosis together with moderate insufficiency in 4 patients. We observed two principal failure mechanisms: technical problems resulting from poor alignment to the right ventricular outflow tract and structural problems leading to neointimal proliferation even in cases with appropriate prosthesis positioning. At median of 5.7 (0.7-7) years after implantation, 6 of the 7 patients underwent valve rereplacement. Redo surgery was necessary in 3, and percutaneous valve-in-valve implantation in the remaining 3 patients. Histological analysis of two explanted valves confirmed significant neointima proliferation and thickened valve cusps leading to stenosis of the graft. CONCLUSIONS These mid-term results after implantation of the No-React® Injectable BioPulmonic™ valve are disappointing. Graft failure was mainly due to neointimal formation and valve malposition.

Antithrombotic therapy in pediatric ventricular assist devices: Multicenter survey of the European EXCOR Pediatric Investigator Group

Objectives: Mechanical circulatory support for pediatric heart failure patients with the Berlin Heart EXCOR ventricular assist system is the only approved and established bridging strategy for recovery or heart transplantation. In recent years, the burden of thromboembolic events has led to modifications of the recommended antithrombotic therapy. Therefore, we aimed to assess modifications of antithrombotic practice among the European EXCOR Pediatric Investigator Group members. Methods: We sent a questionnaire assessing seven aspects of antithrombotic therapy to 18 European hospitals using the EXCOR device for children. Returned questionnaires were analyzed and identified antithrombotic strategies were descriptively compared to “Edmonton protocol” recommendations developed for the US EXCOR pediatric approval study. Results: Analysis of 18 received surveys revealed substantial deviations from the Edmonton protocol, including earlier start of heparin therapy at 6–12 h postoperatively and in 50% of surveyed centers, monitoring of heparin effectiveness with aPTT assay, administering vitamin K antagonists before 12 months of age. About 39% of centers use higher international normalized ratio targets, and platelet inhibition is changed in 56% including the use of clopidogrel instead of dipyridamole. Significant inter-center variability with multiple deviations from the Edmonton protocol was discovered with only one center following the Edmonton protocol completely. Conclusion: Current antithrombotic practice among European EXCOR users representing the treatment of more than 600 pediatric patients has changed over time with a trend toward a more aggressive therapy. There is a need for systematic evidence-based evaluation and harmonization of developmentally adjusted antithrombotic management practices in prospective studies toward revised recommendations.

Echocardiographic characteristics in Fontan patients before the onset of protein‐losing enteropathy or plastic bronchitis

It was this studys objective to evaluate the echocardiographic characteristics and flow patterns in abdominal arteries of Fontan patients before the onset of protein‐losing enteropathy (PLE) or plastic bronchitis (PB).