Vincent Parnell

Acute Kidney Injury After Surgery for Congenital Heart Disease

BACKGROUND The RIFLE criteria (risk, injury, failure, loss, and end-stage kidney disease) have been used to assess acute kidney injury (AKI) in various populations of critically ill children. There are limited reports of AKI using RIFLE criteria in large pediatric populations undergoing congenital heart disease surgery. METHODS Records of patients 18 years and younger who underwent surgery for congenital heart disease between January 2006 and November 2009 were reviewed. The RIFLE score was determined for each patient postoperatively. Multivariate logistic regression analyses were performed to determine risk factors for AKI and the association with clinical outcomes, with subanalyses of patients 1 month of age or younger. RESULTS Data for 458 patients (median age, 7.6 months) were collected and analyzed. Evidence of AKI was demonstrated in 234 patients (51%), the vast majority of whom recovered within 48 hours. Younger age, higher RACHS-1 (risk-adjusted classification for congenital heart surgery) category, and longer cardiopulmonary bypass time were associated with development of AKI. Acute kidney injury was associated with longer duration of ventilation and lengths of intensive care unit and hospital stay. Incidence of AKI in patients 1 month of age or younger was 60.9%, of which more than half required greater than 72 hours to recover. In patients 1 month of age or younger, use of cardiopulmonary bypass, lower preoperative serum creatinine, and higher preoperative blood urea nitrogen were associated with AKI, and AKI was the only factor associated with longer intensive care unit and hospital lengths of stay. CONCLUSIONS Incidence of AKI based on RIFLE criteria in patients undergoing congenital heart disease surgery is higher than previously reported. Risk factors include age 1 month or younger and use of cardiopulmonary bypass. Acute kidney injury is associated with longer lengths of stay.

Effects of morbid obesity and diabetes mellitus on risk of coronary artery bypass grafting

Abstract Obesity has been identified as an independent risk factor for cardiovascular disease 1–4 and the occurrence of complications of coronary artery bypass grafting (CABG). 5,6 A study was designed to determine if the risks associated with morbid obesity should alter the indications for CABG, the operative strategy or the postoperative care.

Noninvasive Pulse Oximetry In Children With Cyanotic Congenital Heart Disease

Arterial oxygen saturation, determined noninvasively by pulse oximetry in 32 pediatric patients with cyanotic congenital heart disease (CHD), was compared with oxygen saturation measured by a cooximeter in simultaneously obtained arterial blood samples. The patients were studied in the cardiac catheterization laboratory, operating room, and ICU. Excellent correlation by linear regression (n = 108, r = .95) was observed between the two methods at oxygen saturations ranging from 35% to 95%. These observations show that in infants and children with cyanotic CHD, arterial oxygen saturations can be determined accurately and reliably by pulse oximetry at rest and during changing circulatory states.

Usefulness of triiodothyronine (T3) treatment after surgery for complex congenital heart disease in infants and children

This is a study of the use of T3 infusion in the postoperative period in 6 pediatric patients who underwent complex cardiac surgical procedures under cardiopulmonary bypass. Normalization of serum T3 levels was reflected in a marked decrease in requirement of inotropic support, conversion to normal sinus rhythm, and progressively improving clinical course.

Aortic dissection: Rupture into right ventricle and right pulmonary artery

Rupture of an acute ascending aortic dissection into a surrounding cardiac chamber or pulmonary artery is an uncommon occurrence, and is often only diagnoses post mortem. Although fistulization (aortopulmonary and aorta-right atrial) after acute aortic dissection has been well documented in the literature, acute aortic dissection fistulizing into both the right ventricle and pulmonary artery has not. We report on a 75-year-old woman who presented with an acute ascending aortic dissection with both aortopulmonary and aorta-right ventricular fistulas who underwent repair and had long-term survival.

Diagnosis and postoperative evaluation of supravalvular aortic stenosis by magnetic resonance imaging

Abstract Electrocardiogram-gated magnetic resonance imaging (MRI) is a new noninvasive technique that has been used to evaluate many forms of congenital heart disease.1 In this report, the pre- and postoperative cardiac MRI findings in a patient with severe supravalvular ortic stenosis are presented and correlated with angiographic studies.

Transvenous Pacemaker Insertion Ipsilateral to Chronic Subclavian Vein Obstruction: An Operative Technique for Children and Adults

OVADIA, M., et al.: Transvenous Pacemaker Insertion Ipsilateral to Chronic Subclavian Vein Obstruction: An Operative Technique for Children and Adults. Subclavian vein occlusion limits insertion of pacing electrodes in children and adults. The concern is greatest in children with a long‐term need for pacing systems necessitating use of the contralateral vein and potential bilateral loss of access in the future. We describe an operative technique to provide ipsilateral access in chronic subclavian vein occlusion in five consecutive pediatric (n = 4, mean age 6.5 years) and adult (n = 1, age 70 with bilateral subclavian vein occlusion) patients in whom this condition was noted at the time of pacemaker or ICD implant. Occlusion was documented by venography. Pediatric cardiac diagnoses included complete heart block in all patients, tetralogy of Fallot in three, and L‐transposition of the great vessels in one. Percutaneous brachiocephalic (innominate) or deep subclavian venous access was achieved by a supraclavicular approach using an 18‐gauge Deseret angiocath, a Terumo Glidewire, and dilation to permit one or two 9–11 Fr sheaths. Electrode(s) were positioned in the heart and tunneled (pre– or retroclavicularly) to a pre– or retropectoral pocket. Pacemaker and ICD implants were successful in all without any complication of pneumothorax, arterial or nerve injury, or need for transfusion. Inadvertent arterial access did not occur as compared with prior infraclavicular attempts. One preclavicularly tunneled electrode dislodged with extreme exertion and was revised. Ipsilateral transvenous access for pacemaker or ICD is possible via a deep supraclavicular percutaneous approach when the subclavian venous obstruction is discovered at the time of implant. In children, it avoids the use of the contralateral vein that may be needed for future pacing systems in adulthood. This venous approach provides access large enough to allow even dual chamber pacing in children and can be accomplished safely.

Brain injury with systemic inflammation in newborns with congenital heart disease undergoing heart surgery

The potential role of systemic inflammation on brain injury in newborns with congenital heart disease (CHD) was assessed by measuring levels of central nervous system (CNS)-derived proteins in serum prior to and following cardiac surgery. A total of 23 newborns (gestational age, 39±1 weeks) with a diagnosis of CHD that required cardiac surgery with cardiopulmonary bypass (CPB) were enrolled in the current study. Serum samples were collected immediately prior to surgery and 2, 24 and 48 h following CPB, and serum levels of phosphorylated neurofilament-heavy subunit (pNF-H), neuron-specific enolase (NSE) and S100B were analyzed. Systemic inflammation was assessed by measuring serum concentrations of complement C5a and complement sC5b9, and the following cytokines: Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL12p70, interferon γ and tumor necrosis factor (TNF)-α. Analysis of cord blood from normal term deliveries (n=26) provided surrogate normative values for newborns. pNF-H and S100B were 2.4- to 2.8-fold higher (P<0.0001) in patient sera than in cord blood prior to surgery and remained elevated following CPB. Pre-surgical serum pNF-H and S100B levels directly correlated with interleukin (IL)-12p70 (ρ=0.442, P<0.05). pNF-H was inversely correlated with arterial pO2 prior to surgery (ρ=−0.493, P=0.01) and directly correlated with arterial pCO2 post-CPB (ρ=0.426, P<0.05), suggesting that tissue hypoxia and inflammation contribute to blood brain barrier (BBB) dysfunction and neuronal injury. Serum IL12p70, IL-6, IL-8, IL-10 and TNF-α levels were significantly higher in patients than in normal cord blood and levels of these cytokines increased following CPB (P<0.001). Activation of complement was observed in all patients prior to surgery, and serum C5a and sC5b9 remained elevated up to 48 h post-surgery. Furthermore, they were correlated (P<0.05) with low arterial pO2, high pCO2 and elevated arterial pressure in the postoperative period. Length of mechanical ventilation was associated directly with post-surgery serum IL-12p70 and IL-8 concentrations (P<0.05). Elevated serum concentrations of pNF-H and S100B in neonates with CHD suggest BBB dysfunction and CNS injury, with concurrent hypoxemia and an activated inflammatory response potentiating this effect.

231: INTRAOPERATIVE REGIONAL SATURATION TO PREDICT LOW CARDIAC OUTPUT SYNDROME AFTER CARDIAC SURGERY

Learning Objectives: Low cardiac output syndrome (LCOS) is a well-known sequelae of cardiopulmonary bypass (CPB) surgery. Near infrared spectroscopy (NIRS) is used to monitor regional saturation in CPB surgeries. Low NIRS and a derived desaturation score ≥3000% per second during CPB surgery have been shown to predict neurologic dysfunction and acute kidney injury. We aim to assess the predictive ability of intraoperative NIRS (desaturation score) and post-operative LCOS. Methods: Prospective observational study evaluating intra-operative cerebral and somatic NIRS in all children undergoing CPB and correlating with post-operative lactate and vasoactive inotropic score (VIS) as surrogates for LCOS in the first 24 hours. Secondary outcomes measured were ICU-free days, ventilator-free days (VFD), and number of fluid boluses required in first 24 hours. Results: 52 patients underwent CPB, of whom 28 had cerebral NIRS desaturation score ≥3000% per second and 8 had somatic NIRS desaturation score ≥3000% per second. A linear mixed-model regression showed that there is significant association between cerebral desaturation score <3000% per second and lactate (P<0.028) but no significant association between somatic NIRS and lactate. There is no significant association neither between cerebral nor somatic NIRS and VIS. There is no significant association between cerebral or somatic NIRS and VFD or ICU-free days. Conclusions: Lower derived cerebral desaturation score (<3000%/sec) is associated with increased post-operative lactate, a surrogate for LCOS. While this finding does not reflect previously published studies, this may be due to a small sample size; data collection is ongoing. Differences in cerebral and somatic NIRS might reflect the difference in auto regulation across these vascular beds. NIRS is a valuable tool in monitoring intraoperative regional desaturation and might have applicability in predicting post-operative low cardiac output syndrome. Studies with larger sample size are required to prove this conclusively.

Experience with Congenital Heart Disease in Children from Developing Countries

The natural history of cyanotic congenital heart disease was described in the 1940s and 1950s from experiences in the United States and other developed nations. [1–3]. Since the advent of palliative procedures (including balloon septostomy), palliative surgery, and corrective surgery, the natural history of cyanotic congenital heart disease has been greatly altered. However, in developing countries around the world, individuals with congenital heart disease still do not receive the benefits of modern therapeutic modalities. In 1980, a program called Lifeline was instituted at North Shore University Hospital, Manhasset, New York. This program was designed to provide care for children with heart disease living in developing countries.