World journal for pediatric & congenital heart surgery最新文献

IntroductionDelayed sternal closure is commonly used after complex congenital cardiac surgery in neonates and infants. The purpose of this study is to assess whether measurements on chest radiography can aid in determining optimal timing for delayed sternal closure.MethodsThis is a retrospective study evaluating 103 neonates and infants <3 months of age who underwent cardiac surgery with delayed sternal closure from January 2018 to June 2021. A Thoracic Radiographic Edema Ratio was calculated using chest radiography by dividing the thoracic cavity diameter by the total chest diameter, measured at the inferior aspect of T7. The ratios were measured on the day prior to surgery, the day of surgery, and each postoperative day until chest closure.ResultsPeak swelling was noted to take place on postoperative days 1 and 2. Chest closure timing ranged from postoperative day 1 to postoperative day 5 with approximately 60% (62/103) of chest closures occurring on postoperative days 2 and 3. Mean Thoracic Radiographic Edema Ratio prior to surgery, immediately after surgery, and on the day of chest closure was 0.82, 0.77, and 0.8, respectively, indicating that patients had less swelling at time of closure than on postoperative day 0 (P < .001).ConclusionThis study characterizes the natural history of postoperative chest wall edema. Timing of delayed sternal closure timing is a clinical decision based on multiple factors. The Thoracic Radiographic Edema Ratio can be a helpful tool in guiding delayed sternal closure timing in infants, as peak swelling is quantifiable, with evidence of peak chest wall edema appreciated on postoperative days 1 and 2.

BackgroundMost Tetralogy of Fallot (TOF) patients undergo reparative surgery at approximately 6 months of age. However, some patients experience severe cyanotic spells in the neonatal or infancy period requiring urgent procedures to increase pulmonary blood flow.MethodsRetrospective review of patients younger than 3 months with TOF who needed interventions between 2015 and 2021. In total, 42 babies required urgent procedures (19 surgical procedures in group 1 and 23 transcatheter interventions in group 2).ResultsMedian age and weight were 38 days (interquartile range [IQR] 19-70 days) and 3.7 Kg (IQR 3.4-4.2 Kg) in group 1 and 29 days (19-43 days) and 3.2 Kg (2.9-3.7 kg) in group 2, respectively. Group 1 had nine full surgical repairs (9/42, 21.4%), eight modified Blalock-Taussig-Thomas (BTT) shunts (8/42, 19%), one isolated transannular patch (1/42, 2.4%) and one right ventricle to pulmonary artery conduit (1/42, 2.4%). Six of the patients in Group 1 had their surgical intervention after an abandoned transcatheter procedure. Group 2 included nine patent ductus arteriosus (PDA) stents (9/42, 21.4%), nine right ventricular outflow tract (RVOT) stents (9/42, 21.4%), three pulmonary valve balloon dilatations (3/42, 7%) and two RVOT balloon dilatations (2/42, 4.8%). Median intensive care unit and hospital stays were 4 days (3-8) and 9 days (7.5-20) in group 1, compared with 1 day (1-1.5) and 5 days (3-15.5) in group 2, respectively. One patient (1/42, 2.4%) in group 1 needed reintervention before full repair, while five patients (5/42, 11.9%) in group 2 required further catheter reinterventions before full repair.ConclusionIn TOF patients requiring urgent early intervention, when catheter or surgical approach are tailored according to the anatomical substrate, excellent outcomes are expected. In patients with favorable anatomy, we believe that full repair can be performed as a primary procedure with good early and mid-term outcomes.

BackgroundWe reviewed our management strategy and outcome data for all 112 patients with congenital heart disease (CHD) who underwent cardiac transplantation at University of Florida from January 2011, to January 2022, and evaluated the impact of a pretransplant ventricular assist device (VAD).MethodsContinuous variables are presented as mean (SD); median [interquartile range] (range); categorical variables are presented as N (%). Univariable associations with long-term survival were assessed with Cox proportional hazards models. The impact of pretransplant VAD on survival was estimated with multivariable models.ResultsPretransplant VAD was present in 24 of 112 patients who underwent cardiac transplantation (21.4%). Patients with a VAD were younger (years): 3.0 (3.8); 1 [0.5,6] (0.1,14) versus 12.9 (14.9); 9 [0.6,19] (0.1,58), P = .008. More patients with a VAD had prior cardiac operations: 24 of 24 (100%) versus 71 of 88 (80.7%), P = .021 and were more likely to receive an ABO-incompatible transplant: 6 of 24 (25%) versus 7 of 88 (8%), P = .032.Univariable associations with long-term mortality include: Number of prior cardiac surgeries-hazard ratio (HR) multiplies by 1.2 for each additional surgery (1.02-1.44), P = .029.Pretransplant renal dysfunction - HR = 2.8 (1.21-6.68), P = .017.Cardiopulmonary bypass (CPB) time at transplant: HR multiplies by 1.1 for each 10 min increase above the minimum CPB time in this series (1.03-1.19), P = .008.In multivariable analysis, pretransplant VAD does not impact survival when controlling for each one of the factors shown in univariable analysis to be associated with long-term survival. Kaplan-Meier five-year survival (95% confidence interval) is 77.4% (68.4%-87.5%) for all patients; 76.5% (66.7%-87.9%) without pretransplant VAD and 84.3% (69.3%-99.9%) with pretransplant VAD (P = .436).ConclusionOur single-institution analysis of 112 patients with CHD undergoing cardiac transplantation over 11.25 years reveals similar survival in patients with (n = 24) and without (n = 88) pretransplant VAD. The presence of a pretransplant VAD is not a risk factor for survival after transplantation in patients with CHD.

Artificial neochordae crafted from expanded polytetrafluoroethylene are commonly utilized in mitral valve repair. Yet their application in tricuspid valve repair, particularly in the pediatric demographic, remains relatively unexplored. Upon reviewing the available literature, we have identified pediatric patients with tricuspid valve regurgitation, primarily of congenital origin and diagnosed at birth, who underwent repair procedures involving artificial neochordal implantation. Postoperatively, trivial-to-mild tricuspid regurgitation was predominantly observed in most cases. Operative mortality appears to be low, but a reliable estimate of operative mortality rates, early failure, and reoperation was not possible due to incomplete data reporting in the studies reviewed. Moreover, long-term data are not available since in most reports, postoperative evaluation was obtained early after repair. Our review suggests that artificial neochordal repair of the tricuspid valve may be a feasible surgical option to prosthetic valve replacement in pediatric patients. However, comprehensive data and further late follow-up are needed to analyze long-term effectiveness and clinical outcomes.

Introduction: Pericardial effusion (PCE) represents a significant postoperative complication following congenital heart surgery (CHS), contributing to more complex postoperative care and heightened morbidity. In this study, we aim to elucidate the risk factors contributing to PCE development post-CHS through analysis of data from a nationwide, multi-institutional database. Methods: Review of the Pediatric Health Information System Database from January 1, 2004, to December 30, 2023. All patients under the age of 18, who underwent a Society of Thoracic Surgeons benchmark procedure, were included. Results: A total of 66,695 surgeries were identified with 29,363 (44%) female, 35,084 (53%) non-Hispanic white, and median age at surgical admission of 5.1 [interquartile range: 2.0-14.1] months. Pericardial effusion occurred in 2,672 (4%) patients during the postoperative hospitalization, with the Norwood procedure having the highest incidence (245/2,726, 8.9%). Multivariable analysis revealed the Norwood procedure as having the highest adjusted odds of PCE (odds ratio [OR]: 2.34, 95%CI: 1.98-2.75, P < .001) when compared with isolated ventricular septal defect repair. Pericardial effusion was associated with a 16% (95%CI: 9.8-12.3, P < .001) increase in length of stay and increased mortality (OR: 1.84, 95%CI: 1.50-2.25, P < .001). Furthermore, 647 (1%) patients, out of 65,442 who survived to index hospital discharge, were readmitted due to PCE within 90 days of discharge. Fontan patients had the highest incidence of readmission (138/7,873, 1.7%) and increased adjusted odds for readmission (OR: 1.77, 95%CI: 1.37-2.28, P < .001). Conclusions: Incidence of PCE after CHS is low at 4%. However, certain procedures have an incidence as high as 8.9%. Pericardial effusion poses significant postoperative clinical challenges with increased mortality and resource utilization. Vigilant monitoring and targeted interventions in high-risk patients are essential for mitigating the impact of PCE on postoperative outcomes.

Background: To improve understanding of indications and outcomes for cardiac surgery for rheumatic aortic valvular disease in the young. Methods: Single institution retrospective cohort aged < 18 years with rheumatic heart disease who underwent surgery for isolated rheumatic aortic valve disease between 2000 and 2019. Baseline, intermediate follow-up, and late follow-up data were collected. Left ventricular (LV) dysfunction defined as LV ejection fraction < 55% or LV shortening fraction < 27%. Results: Thirty-nine patients who were 8 to 18 years of age were included (median age 14 years), weighing 27 to 157 kg (median 78 kg) with follow up of 2 to 15 years (median 7 years). Index operations were valve repair 6 of 39 (15%), valve replacement 33 of 39 (84%) with homograft (n = 20), and mechanical valve (13). The 30-day mortality was zero. Overall mortality was 8 of 39 (20%); 17 of 39 (43%) underwent reoperation. At intermediate and late follow up, 27% (7/26) and 53% (18/34) had persistent dysfunction, respectively. Baseline LV dysfunction increased the risk of death (hazard ratio 13.3 [1.52-115.5], P = .003), which increased adjusting for higher body surface area (BSA). All those with baseline weight > 105 kg either died or had LV dysfunction at late follow up (P = .001). Freedom from late valve-related complications at 5, 10, and 15 years was 72%, 31%, and 23%, respectively. Conclusions: Preoperative LV dysfunction is associated with an increased risk of death for pediatric patients undergoing isolated rheumatic aortic valve surgery. This risk increases further, adjusting for BSA. There was a high rate of reoperations and late complications.

Objectives: Extracorporeal membrane oxygenation (ECMO) plays a crucial role in the outcome of children following surgery for congenital heart disease. However, its availability and affordability are minimal across the globe. We present our experience with a modified ECMO circuit using a conventional cardiopulmonary bypass (CPB) oxygenator in postcardiotomy children following surgical repair of congenital heart disease. Material and Methods: The data were collected retrospectively by screening all pediatric cardiac surgery patients from June 2014 to December 2024. A total of 3,527 patients underwent surgery for congenital heart disease. The modified ECMO circuit was used in a total of 34/3,527 (0.9%) patients following congenital cardiac surgery during this period. Data on demographics, surgical details, indications, and duration of modified ECMO, complications, successful decannulation, and hospital discharge were collected from electronic health records. Kaplan-Meier was used to plot hospital stay and in-hospital mortality with respect to successful decannulation. Results: The median duration of support with the modified ECMO circuit was 39 hours (IQR 24-56). Successful decannulation was accomplished in 20/34 patients (58.8%), and 11/34 patients (32.3%) went home alive from the hospital. Complications encountered included renal dysfunction (39.4% [13/34]), bleeding (35.2% [12/34]), seizures (8.8% [3/34]), and stroke (5.8% [2/34]). Conclusion: The modified ECMO circuit, derived from the conventional CPB circuit, offers a cost-effective solution for short-term cardiac support in pediatric cardiac surgery. Survival rates and complications suggest its viability, particularly in resource-limited settings.

Background: Mitral valve replacement in infants is highly challenging due to size limitations and the lack of suitable prosthetic valves. The Melody™ valve, originally developed for transcatheter pulmonary valve replacement, offers an off-label alternative for surgical implantation in the mitral position, with the possibility of balloon expansion and valve-in-valve procedures during somatic growth. Aim: To evaluate the long-term outcomes and technical feasibility of the Melody™ valve in the mitral position in infants and very young children following failed surgical repair. Methods: This single-center, retrospective observational study included four pediatric patients who underwent Melody™ valve implantation in the mitral position between October 2015 and February 2020. Data on patient characteristics, surgical techniques, perioperative management, complications, and long-term outcomes were collected and analyzed through April 2024. All patients were followed clinically and with echocardiography. Additional interventions, including balloon dilations and valve-in-valve procedures, were documented. Results: All patients (mean age: 7 months; mean weight: 6.8 kg) had undergone prior mitral valve repair and presented with severe mitral dysfunction. Melody™ valves were successfully implanted with no perioperative mortality. Over a mean follow-up of 5.9 years (range: 4.2-8.5), six balloon dilations were performed (1-2 per patient), and one valve-in-valve procedure was conducted due to progressive stenosis. Two patients required valve excision: one for endocarditis, one for degeneration. The mean valve longevity before replacement was 44.6 months. Three patients developed complete atrioventricular block requiring pacemaker implantation. No thromboembolic events or LVOT obstructions were noted. Mean transmitral gradients at final follow-up were <5 mmHg in all patients. Conclusion: The Melody™ valve provides an adaptable solution for mitral valve replacement in infants, allowing for staged expansion and valve-in-valve strategies. Despite a notable risk of AV block, the long-term outcomes are promising, especially in patients too small for conventional prostheses. Close follow-up and further multicenter studies are needed to optimize patient selection and long-term management.

Background: After surgical repair of congenital heart disease with cardiopulmonary bypass, it is common for patients to present with a decrease in cardiac output with hemodynamic instability. Treatment goals should focus on achieving a balance between tissue oxygen availability and consumption. Central venous saturation (SvO2) provides valuable information about hemodynamics and global perfusion; however, it is not continuous and it is invasive. Near-infrared spectroscopy (NIRS) is a noninvasive technology that allows immediate and continuous monitoring of regional oxygen extraction and consumption in different organs. With multisite NIRS values (brain and kidney), global perfusion can be estimated through the Hoffman index. In this study we sought to determine the relationship between SvO2, Hoffman index, and cerebral NIRS (NIRSc) values in pediatric patients undergoing cardiovascular surgery with cardiopulmonary bypass. Methods: Prospective study in patients undergoing cardiovascular surgery with cardiopulmonary bypass who were admitted to the cardiovascular intensive care unit (CICU) at the Instituto Nacional de Pediatría, in Mexico City, from March 2021 to February 2022. Central venous oxygen saturation, cerebral, and renal NIRS values were recorded upon admission to the CICU, at 6 and 12 h. Results: A total of 41 patients were included with a median age of 19 months, 25/41 (61%) of the patients were male. The correlation between cerebral NIRS (NIRSc) and SvO2 was higher at 12 h (r = 0.55, P < .001), while a greater correlation was observed between Hoffman index and SvO2 at admission (r = 0.64, P < .001). When considering the 123 measurements, a better correlation was observed between Hoffman index and SvO2 (r = 0.72, P < .001), including patients with biventricular repair (r = 0.64, P < .001), univentricular physiology (r = 0.83, P < .001), and neonatal patients (r = 0.79, P < .001). Conclusion: The Hoffman index has a stronger correlation with SvO2 compared with NIRSc; both can be used as tools for hemodynamic monitoring of patients who underwent surgery for congenital heart disease.

Ventricular septal defect (VSD) is a common congenital heart defect that often requires surgical closure. We present the case of a seven-month-old infant with a large perimembranous VSD, moderate pulmonary valve stenosis, and hypertrophied right ventricular muscle bundles who failed to wean from cardiopulmonary bypass due to severe cyanosis after VSD closure and muscle bundle resection. An intraoperative transesophageal echocardiogram was performed with an agitated saline test, and a large atrial-level right-to-left shunt was seen. Return to cardiopulmonary bypass revealed an unroofed coronary sinus defect, which had not previously been identified. There was no evidence of a persistent left superior vena cava. Closure of the orifice of the coronary sinus eliminated the shunt, enabling successful weaning from cardiopulmonary bypass, and the patient was subsequently discharged home.