Impact of Blood Sampling Methods on Blood Loss and Transfusion After Pediatric Cardiac Surgery: An Observational Study.

OBJECTIVES: The aims of this study were to assess the impact of the closed-loop sampling method on blood loss and the need for blood transfusion in pediatric patients following cardiac surgery. DESIGN: Retrospective observational study. SETTING: A single tertiary center. PARTICIPANTS: All pediatric patients younger than 4 years old who were admitted to the pediatric intensive care unit (PICU) after cardiac surgery were enrolled. The study included 100 pediatric patients in the conservative (postimplementation) group and 43 pediatric patients in the nonconservative group (preimplementation). INTERVENTIONS: Observational. MEASUREMENTS: The primary outcome was the volume of blood loss during the PICU follow-up period. The secondary outcomes were the requirement for blood transfusion in each group, duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, and mortality. MAIN RESULTS: In the conservative (postimplementation) group, blood loss during the follow-up period was 0.67 (0.33-1.16) mL/kg/d, while it was 0.95 (0.50-2.30) mL/kg/d in the nonconservative (preimplementation) group, demonstrating a significant reduction in blood loss in the conservative group (p = 0.012). The groups showed no significant differences in terms of the required blood transfusion volume postoperatively during the first 24 hours, first 48 hours, or after 48 hours (p = 0.061, 0.536, 0.442, respectively). The frequency of blood transfusion was comparable between the groups during the first 24 hours, first 48 hours, or after 48 hours postoperatively (p = 0.277, 0.639, 0.075, respectively). In addition, the groups did not show significant differences in the duration of mechanical ventilation, length of ICU stay, length of hospital stay, or mortality. CONCLUSIONS: The closed-loop sampling method can be efficient in decreasing blood loss during postoperative PICU follow-up for pediatric patients after cardiac surgeries. However, its application did not reduce the frequency or the volume of blood transfusion in these patients.

Neonatal congenital heart surgery: contemporary outcomes and risk profile.

OBJECTIVE: Many studies still dispute the identification of independent risk factors that influence outcome after neonatal cardiac surgery. We present our study to announce the contemporary outcomes and risk profile of neonatal cardiac surgery at our institute. METHODS: We designed a retrospective study of neonatal patients who underwent surgery for congenital heart diseases between June 2011 and April 2020. Demographic, operative, and postoperative data were collected from medical records and surgical databases. The primary outcome was the operative mortality (in-hospital death) and secondary outcomes included hospital length of stay, intensive care unit stay, duration of mechanical ventilation. RESULTS: In total, 1155 cardiac surgeries in children were identified; of these, 136 (11.8%) were performed in neonates. Arterial switch operations (48 cases) were the most frequent procedures. Postoperatively, 11 (8.1%) patients required extracorporeal membrane oxygenation, and 4 (2.9%) patients had complete heart block. Postoperative in-hospital mortality was 11%. The median postoperative duration of mechanical ventilation, intensive care unit stay, and hospital length of stay were 6, 18, and 24 days, respectively. CONCLUSION: The early outcomes of neonatal cardiac surgery are encouraging. The requirement of postoperative extracorporeal membrane oxygenation support, postoperative intracranial hemorrhage, and acute kidney were identified as independent risk factors of mortality following surgery for congenital heart defects in neonates.

Equine pericardium: a versatile alternative reconstructive material in congenital cardiac surgery.

BACKGROUND: Pericardial patches are often used for repair of congenital cardiac defects. The aim of this study was to describe our initial experience with the use of equine pericardium and its safety and advantages and disadvantages compared to bovine pericardium. METHODS: We designed a retrospective cohort study of 111 patients who were surgically treated for congenital heart disease between 2017 and 2020. Equine pericardium was used in 58 patients and bovine pericardium was used in 53 patients. Recorded variables included demographic data, preoperative cardiac pathology, site of patch insertion, morbidity and mortality. RESULTS: The overall survival rate was 94.5% and no deaths were related to patch insertion. None of our patients were reoperated on for patch related complications. Postoperative transcatheter intervention was needed in 2 patients (1.8%): one for dilatation of aortic arch stenosis after repair of hypoplastic left heart syndrome with equine pericardium and one for dilatation of pulmonary artery branches after repair of tetralogy of Fallot using bovine pericardium. CONCLUSIONS: Equine pericardium is a safe patch material for reconstruction in congenital heart surgery. It may be preferable to bovine pericardium in cases requiring a complex shape or a pliable patch as in in arch reconstruction or for valve reconstruction.

Outcomes of Primary Bidirectional Glenn in Children with Single Ventricle Physiology and Increased Pulmonary Blood Flow.

BACKGROUND: We reported our experience in managing patients with single ventricle (SV) physiology and increased pulmonary blood flow (PBF), aiming to assess if it is feasible to proceed with primary Bidirectional Glenn (BDG) without a prior operation to limit PBF. MATERIALS AND METHODS: This is a retrospective study with 51 consecutive patients who underwent BDG operation as a primary operation or a second stage prior to the definitive Fontan operation at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia between 2010 and 2018. Patients were categorized into two groups based on their PBF prior to the operation: Patients who had SV physiology and increased PBF (seven patients) vs. patients with SV physiology and restricted PBF (44 patients). RESULTS: The median age for the increased PBF group was 9.9 months [interquartile range (IQR): 2-16.9 months], and the median age for the restricted PBF group was 15.3 months (IQR: 6.7-42.6 months). Although the length of hospital stay was longer in patients with increased PBF (P = 0.039), we couldn't find a statistically significant difference in early mortality, duration of mechanical ventilation, length of pleural drainage, and length of intensive care unit (ICU) stay between the groups. CONCLUSION: In our experience, we found that primary BDG could be done safely for patients having SV physiology and increased PBF with acceptable short-term outcomes. It might further reduce the morbidity and mortality for those patients by avoiding the risk of initial pulmonary artery banding or aortopulmonary shunts.

Myocardial Protection by Blood-Based Del Nido versus St. Thomas Cardioplegia in Cardiac Surgery for Adults and Children.

BACKGROUND: St. Thomas (ST) and Del Nido (DN) cardioplegic solutions are widely used for myocardial protection during cardiac surgery. In 2016, our university hospital shifted from modified St. Thomas to Del Nido solution for both adult and pediatric cardiac surgery. This retrospective study was conducted to compare ST and DN solutions regarding surgical workflow and clinical outcome in pediatric and adult patients undergoing cardiac surgery. METHODS: We reviewed 220 patients who underwent cardiac surgery requiring cardioplegic arrest. Patients were categorized in 2 groups: ST (n = 110) and DN (n = 110). Each group included 60 pediatric and 50 adult patients. Demographic, intraoperative, and postoperative variables were collected. RESULTS: In pediatric patients, no significant difference was found between the 2 groups regarding clamping time, bypass time, need for defibrillation, inotropic score, postoperative ejection fraction (EF), period of mechanical ventilation, intensive care unit stay, or postoperative arrhythmias. One patient in the ST group required mechanical support by extracorporeal membrane oxygenation. We had 5 cases of pediatric mortality (3 in DN and 2 in ST, P = .64). In adult patients, significantly fewer patients in the DN group needed defibrillation than in the ST group. No significant difference was found regarding clamping time, inotropic score, or intraaortic balloon pump use. Mortality in adult patients was 6 cases (4 in ST group and 2 in DN group). CONCLUSION: DN cardioplegia solution is as safe as ST solution in pediatric and adult cardiac surgery. It has comparable results of myocardial protection and clinical outcome, with superiority regarding uninterrupted surgery and lower rate of defibrillation.

Iatrogenic Coronary Artery Compromise Post Non-Coronary Cardiac Surgery in Patients With Normal Coronaries.

BACKGROUND: Unexpected events in cardiac surgery may increase morbidity and mortality. We present rare complications related to coronary arteries in non-coronary cardiac surgery in adults and pediatrics. PATIENTS AND METHODS: We retrospectively reviewed our surgical left-sided valve procedures and aortic root reconstruction for patients with documented coronary ostial injury or left circumflex artery (LCX) between January 2012 and December 2019. Preoperative echocardiography was the standard investigation for all cases and other specific work ups were ordered, according to each case. Management by surgical or non-surgical intervention was planned, according to each complication. Postoperative hemodynamics and mortality rate were the outcomes of interest. RESULTS: Seven patients were found to have coronary artery compromise post left-sided valve procedures and aortic root reconstruction in adults and children. The details are shown in Table 1. The complications were in 2 patients post-mitral valve (MV) repair, 3 patients post-aortic (AV) replacement, 2 pediatric patients, 1 post-aortic homograft, and the other post-repair of anomalous single coronary arising from the pulmonary artery (ASCAPA). Six patients were hemodynamically unstable. Five patients had intraoperative ischemic changes on electrocardiogram and echocardiography, while ventricular arrhythmias were documented in 3 patients. Two patients were treated with percutaneous coronary intervention to LCX and right coronary artery (RCA), while 4 patients required immediate surgery to graft the obtuse marginal branch of the LCX artery (1) and RCA (3). No revision to valvular procedure was done. With the exception of one, all patients survived. CONCLUSION: A high index of suspicion is required to diagnose and rescue coronary complications post-valvular surgery and aortic root reconstruction.

Delayed Sternal Closure in Congenital Heart Surgery: A Risk-Benefit Analysis.

BACKGROUND: Delayed sternal closure commonly is used after pediatric cardiac surgery. Its benefits include relieving cardiac compression and stabilizing postoperative critically ill patients. METHODS: We retrospectively reviewed the records of 72 patients, who had undergone delayed sternal closure, among 1,254 patients operated for congenital heart diseases. Indications of delayed sternal closure, perioperative hemodynamic and metabolic status, postoperative infection, and mortality were reported. RESULTS: Transposition of great arteries was the most common preoperative cardiac pathology (26.3%). Bleeding and hemodynamic instability were the most frequent indications for delayed sternal closure, representing 38.8% and 34.7%, respectively. The mean duration of open chest was 3.45 days ± 1.46 days. The mean duration of ICU stay was 20.95 days ± 20.06 days. Two patients had deep sternal wound infection. Sepsis was found in 39 patients (54.1%), and the most common causative organism was coagulase negative (30.5%). ICU stay was a significant risk factor for sepsis (P = .003); duration of open sternum, period of mechanical ventilation (MV), and total hospital stay were not statistically significant risk factors. Sternal closure time (SCT) was affected by period of hemodynamic instability (P = .036). Bypass time, clamping time, and nonsurgical bleeding did not significantly affect SCT. The mortality rate was 15.2% (N = 11). CONCLUSION: Delayed sternal closure is a simple and effective technique that could prevent postoperative cardiac compression in hemodynamic instability states after pediatric cardiac operations.