Continuous Amplitude-Integrated Electroencephalography During Neonatal and Pediatric Extracorporeal Membrane Oxygenation.

PURPOSE: Early prognostication of neurologic outcome in neonates and children supported with extra-corporeal membrane oxygenation (ECMO) is challenging. Amplitude-integrated EEG (aEEG) offers the advantages of continuous monitoring and 24-hours availability at the bedside for intensive care unit providers. The objective of this study was to describe the early electrophysiological background patterns of neonates and children undergoing ECMO and their association with neurologic outcomes. METHODS: This was a retrospective review of neonates and children undergoing ECMO and monitored with aEEG. Amplitude-integrated EEG was summarized as an aEEG background score determined within the first 24 hours of ECMO and divided in 3-hour periods. Screening for electrical seizures was performed throughout the full ECMO duration. Neurologic outcome was defined by the Pediatric Cerebral Performance Category score at hospital discharge. RESULTS: Seventy-three patients (median age 79 days [8-660], median weight 4.78 kg [3.24-10.02]) were included in the analysis. Thirty-two patients had a favorable neurologic outcome and 41 had an unfavorable neurologic outcome group at hospital discharge. A 24-hour aEEG background score >17 was associated with an unfavorable outcome with a sensitivity of 44%, a specificity of 97%, a positive predictive value of 95%, and a negative predictive value of 57%. In multivariate analysis, 24-hour aEEG background score was associated with unfavorable outcome (hazard ratio, 6.1; p = 0.001; 95% confidence interval, 2.31-16.24). The presence of seizures was not associated with neurologic outcome at hospital discharge. CONCLUSIONS: Continuous aEEG provides accurate neurologic prognostication in neonates and children supported with ECMO. Early aEEG monitoring may help intensive care unit providers to guide clinical care and family counseling.

Long-term results of the Warden procedure for right partial anomalous pulmonary venous connection.

INTRODUCTION: Surgery is considered as the first-line therapeutic strategy of partial anomalous pulmonary venous connection. The Warden technique has very good short-term results. The aim of this study is to evaluate the stability of these good results over a long period of follow-up. MATERIALS AND METHODS: We reviewed all patients who underwent a Warden procedure for partial anomalous pulmonary venous connection between 1997 and 2017 in our centre. A total of 73 patients were included. The median age was 14 years (5 months-72 years). Post-operative data were obtained through our hospital network. Late follow-up data were obtained through referrals, cardiologist letters and directly from the patient. RESULTS: The mean length of follow-up was 8 years and the longest time was 22 years (range, 1-22). Twenty-five percent of our cohort had more than 10 years of follow-up. There were no cardio-vascular deaths. Eight (11.6%) patients suffered from post-operative rhythm disturbances, 5 (7.2%) of which were permanent. Two (2.9%) patients required a pacemaker implantation. At the end of the follow-up period, only one patient remained pacemaker dependent. There were no pulmonary vein obstructions. Two (2.9%) caval vein stenosis were detected, one at 7 months and the other at 7 years. These patients were treated by angioplasty alone. Five (6.8%) patients were lost to follow-up. CONCLUSIONS: The good short-term results of the Warden procedure for right partial anomalous pulmonary venous connection appear to persist in the long term, with excellent freedom from pulmonary and caval stenosis in adolescence through to adulthood.

Medium-term follow-up of autologous pericardial patches for pediatric aortic arch reconstruction.

OBJECTIVES: Direct anastomosis, like end-to-end anastomosis or end-to-side anastomosis, is commonly employed to repair aortic coarctation or interrupted aortic arch. Direct anastomosis of the aorta, however, may result in restenosis or bronchial compression. To circumvent these complications, we have applied a technique consisting of aortic reconstruction using glutaraldehyde-fixed autologous pericardial patches. METHODS: Our database was queried for infants who underwent aortic arch reconstruction using autologous pericardial patches from 2007 to 2019. Medical records, including echography imaging, were reviewed, and Z-scores of aortic arch diameters were retrospectively assessed at baseline, immediately after surgery, and at follow-up end. RESULTS: Overall, 58 patients met the inclusion criteria, with a median age of 9.8 days at surgery and median postoperative follow-up of 46 months. Re-coarctation requiring re-intervention by either surgery or percutaneous angioplasty was documented in 14.7% of patients. Overall, 9% of patients died of all-cause mortality. The Z-scores evolved favorably from baseline, which clearly indicated hypoplastic aortic arch, to early postoperative status, which clearly showed values close to those obtained in normal infants, with likewise normal values obtained at median 46-month follow-up. CONCLUSIONS: Glutaraldehyde-fixed autologous pericardial patches were shown to provide correct medium-term results for aortic arch reconstruction. The incidence of restenosis requiring re-intervention was shown to be low. Autologous pericardial patches can be considered as an acceptable and easily available solution for aortic arch repair surgery.

Neurological Outcome According to the Site of Cannulation in Septic Children Supported by Venoarterial Extracorporeal Membrane Oxygenation.

The impact of cervical cannulation on neurologic outcome has not been yet studied among children receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the context of severe sepsis or septic shock. A retrospective cohort study was performed using the extracorporeal life support organization (ELSO) registry. A total of 559 children weighing less than 20 kg with a primary or secondary diagnosis of severe sepsis, septic shock or toxic shock syndrome were included between January 1, 2010, and December 31, 2019. Cervical cannulation was performed in 485 children (87%) and central cannulation in 74 children (13%). The prevalence of acute neurologic event (ANE) was 32%, including clinical and/or electroencephalographic seizures, cerebral infarction, cerebral hemorrhage, and/or brain death. In multivariable analysis, we did not find an association between cervical cannulation and greater/lesser odds of ANE during ECMO (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] 0.72-2.65; P = 0.326). Only pre-ECMO acidosis was independently associated with the development of ANE (pH < 6.99; aOR = 2.71, 95% CI 1.34-5.49; P = 0.006; pH 6.99 to <7.12; aOR = 2.57, 95% CI 1.37-4.82; P = 0.003). Thus, the site of cannulation appears not as a modifiable neurologic risk factor in this young septic population.

The Use of Intraoperative Peripheral Extracorporeal Membrane Oxygenation in High-Risk Airways Tumor Removal Procedures in Neonates and Children: A Single-Center Case Series.

Airway surgery involving trachea or main stem bronchi in neonates and children is challenging. The use of extracorporeal support for such unusual indications is poorly described. Here, we report on three patients receiving peripheral extracorporeal membrane oxygenation (ECMO) to maintain adequate ventilation while improving surgical site exposure. Case 1 is a 9-year-old boy diagnosed with proximal left stem bronchus endoluminal tumor; cases 2 and 3 are a neonate and a young infant diagnosed with a subcarinal bronchogenic cyst. Planned ECMO use consisted in peripheral venoarterial cannulation through jugular and carotid access. There was no bleeding complication during and after surgical care. Hemodynamic and respiratory supports were optimized in all cases. Children were successfully weaned off ECMO immediately after surgery. Planned peripheral ECMO cannulation offers optimal conditions for high-risk airway surgery in neonates and children.

Results of large pulmonary homograft implantation for right ventricular outflow tract reconstruction.

BACKGROUND: To evaluate the long-term results of implantation of homogeneous large size of pulmonary homograft (PH) for reconstruction of the right ventricular outflow tract (RVOT). METHODS: Between January 2000 and December 2017, 107 patients were implanted with PH for reconstruction of the RVOT. Data were collected retrospectively in this single-center study. PH failure was defined as a peak of gradient greater than 40 mmHg and/or as a pulmonary regurgitation greater than Grade 2. Primary endpoint was the reoperation of the RVOT during follow-up. Secondary endpoints were overall survival, occurrence of PH failure and the rate of reoperation for all cause. RESULTS: Mean age of the recipients was 26.1 ± 13.6 years. Median follow-up interval was 2.99 years (interquartile range [IQR]: 6.2). Mean size of PH was 24.9 ± 1.9 mm. Reoperation of the RVOT occurred in eight patients (7.8%). Time before reoperation was 2.74 years (IQR: 6.4). Freedom from reoperation for RVOT at 5 and 10 years was respectively 95.7% and 90.0%. Overall survival at 10 years was 95.2%. PH failure occurred in 13 patients (12.0%). Median time before PH failure was 6.7 years (IQR: 9.6). Freedom from PH failure at 10 years was 81.6%. Reoperation for PH failure occurred in four patients (3.9%). Concomitant tricuspid surgery (p = .01; 95% confidence interval [CI]: 1.9-319.6) and undersized PH (p = .01; 95% CI: 2.06-719.8) were independent risk factors of late reoperation. CONCLUSION: Implantation of large PH for RVOT reconstruction provides excellent midterm results in terms of reoperation.

Right watershed cerebral infarction following neck cannulation for veno-arterial extracorporeal membrane oxygenation in pediatric septic shock: a case series.

Children supported by extracorporeal membrane oxygenation present a high risk of neurological complications. Although carotid cannulation is known to be associated with neurologic injury, conflicting data exist with regard to the predominance of right- or left-sided lesions. We describe here two infants requiring veno-arterial extracorporeal membrane oxygenation for septic shock who encountered right watershed infarction ipsilateral to carotid artery cannulation. Hemodynamic failure seems to be the most probable underlying mechanism. The asymmetry of transcranial Doppler metrics in one case and the low right regional cerebral oxygen saturation value observed soon after right cannulation in both cases suggest an insufficient cerebral collateral flow compensation. The risk of ipsilateral watershed injury should be considered before cervical cannulation, notably in the context of sepsis and an evaluation of the cerebral collateral blood flow before and just after cannulation may be interesting in order to identify infants with higher risk of ipsilateral ischemic lesions.

Continuous cerebral and myocardial selective perfusion in neonatal aortic arch surgery.

BACKGROUND: To assess the feasibility and early outcome of continuous cerebral and myocardial selective perfusion (CCMSP) during aortic arch surgery in neonates. METHODS: We performed a single-center retrospective study between 2008 and 2019 on neonates who underwent aortic arch surgery with or without associated heart lesion repair. CCMSP with moderate hypothermia levels (28°C) was achieved using selective brachiocephalic artery and ascending aorta cannulation. Target rates of cerebral and myocardial perfusion were 25 to 35 mL/kg/min and 150 ml/m2/min. Cardiopulmonary bypass (CPB) variables and clinical outcomes were analyzed. RESULTS: Overall, 69 neonates underwent either isolated aortic arch repair (n = 31) or aortic arch repair with ventricular septal defect (VSD) closure (n = 38). Age and weight medians were 8 [6 to 15] days and 3.4 [2.9-3.5] kg, respectively. Mean CPB and aortic clamping times were 134 ± 47 and 26 ± 5 minutes for isolated aortic arch repair, and 159 ± 47 and 75 ± 30 minutes for aortoplasty accompanied by VSD closure. Mean CCMSP time was 52 ± 21 minutes with cerebral rate of 32.6 ± 10 mL·kg-1 ·min-1 . Overall in hospital survival was 98.5% (68/69). Major complications were: postoperative cardiac failure requiring mechanical support followed by stroke (n = 1; 1.44%) and transient renal failure requiring dialysis (n = 2; 2.89%). Neither myocardial nor digestive complication occurred. CONCLUSION: CCMSP is a safe and reproducible strategy for cerebral, myocardial and visceral protection in neonatal aortic arch repair, with or without VSD closure, resulting in low complication and mortality.

Right partial anomalous pulmonary venous connection to the superior vena cava following the Warden procedure.

BACKGROUND AND AIMS: Surgical repair of right partial pulmonary anomalous connection to the superior vena cava (SVC) with the Warden procedure can be complicated by SVC obstruction, pulmonary veins obstruction, and sinus node dysfunction. We review our 20 years of experience with Warden procedures for the repair of right partial pulmonary venous connection to the SVC. METHODS: This was a single-center retrospective study of all patients (pediatric and adult) with right partial pulmonary abnormal venous connections who underwent a complete repair with the Warden procedure between 1997 and 2016. A total of 59 patients were included. The median age was 14 years (5 months to 61 years) and the median weight was 44 kg (4.9-92 kg). RESULTS: The mean term follow-up was 7 (±5) years. No deaths were reported. One (1.7%) patient required a pacemaker implantation; two (3.4%) suffered from a SVC stenosis successfully treated with balloon dilatation and stent implantation; and eight (13.6%) patients had transient rhythm disturbances, one had junctional ectopic tachycardia, three had sick sinus syndrome, three had an atrial flutter, and one had an atrioventricular block. None suffered from pulmonary vein obstruction. CONCLUSION: The Warden procedure is safe and can be performed with very low morbidity, mortality, rhythm disturbances, and decreased pulmonary and SVC obstructions.