RESUMO
Lung transplantation is a crucial component in the treatment of end-stage lung disease in infants. Traditionally, most lung transplants have been performed in older children and adults, resulting in a scarcity of data for infant patients. To address the challenges unique to this age group, novel strategies to provide the best preoperative, intraoperative, and postoperative care for these youngest patients are paramount. We review recent advances in bridge-to-transplantation therapy, including the use of a paracorporeal lung assist device, and differences in surgical technique, including bronchial artery revascularization, for incorporation into the overarching treatment strategy for infants undergoing lung transplantation.
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Oxigenação por Membrana Extracorpórea , Transplante de Coração , Coração Auxiliar , Transplante de Pulmão , Criança , Humanos , Lactente , PulmãoRESUMO
The objective of this study was to examine a large institutional experience of patients with trisomy 13 and trisomy 18 in the setting of comorbid congenital heart disease and present the outcomes of surgical versus expectant management. It is a retrospective single-institution cohort study. Institutional review board approved this study. Thirteen consecutive trisomy 18 patients and three consecutive trisomy 13 patients (sixteen patients in total) with comorbid congenital heart disease who were evaluated by our institution's Division of Cardiovascular Surgery between January 2008 and December 2013 were included in the study. The primary outcome measures evaluated were operative mortality (for patients who received surgical management), overall mortality (for patients who received expectant management), and total length of survival during follow-up. Of the thirteen trisomy 18 patients, seven underwent surgical management and six received expectant management. With surgical management, operative mortality was 29 %, and 80 % of patients were alive after a median follow-up of 116 days. With expectant management, 50 % of patients died before hospital discharge. Of the three patients with trisomy 13, one patient underwent surgical management and two received expectant management. The patient who received surgical management with complete repair was alive at last follow-up over 2 years after surgery; both patients managed expectantly died before hospital discharge. Trisomy 13 and trisomy 18 patients with comorbid congenital heart disease can undergo successful cardiac surgical intervention. In this population, we advocate that nearly all patients with cardiovascular indications for operative congenital heart disease intervention should be offered complete surgical repair over palliative approaches for moderately complex congenital cardiac anomalies.
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Procedimentos Cirúrgicos Cardíacos/métodos , Cromossomos Humanos Par 13 , Cromossomos Humanos Par 18 , Cardiopatias Congênitas/cirurgia , Trissomia/patologia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Estudos de Coortes , Comorbidade , Feminino , Seguimentos , Cardiopatias Congênitas/epidemiologia , Cardiopatias Congênitas/genética , Cardiopatias Congênitas/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
UNLABELLED: Idiopathic pulmonary hemosiderosis is a rare disease defined by the triad of iron deficiency anemia, hemoptysis, and diffuse pulmonary infiltrates on chest radiograph. Idiopathic pulmonary hemosiderosis is known to cause dyspnea and, in some cases, acute onset of massive pulmonary hemorrhage which is traditionally treated with conventional mechanical ventilation or high-frequency oscillation in conjunction with immunosuppressive therapy. In this case report, we describe a 5-week-old infant presenting with hemoptysis, massive pulmonary hemorrhage, and significant hypercapnic respiratory failure. The patient failed conventional ventilation but responded well to extracorporeal life support that was initiated early in his course. Idiopathic pulmonary hemosiderosis was suspected in light of his response to high-dose steroids and was confirmed by subsequent lung biopsies. CONCLUSION: Patients with severe pulmonary hemorrhage secondary to idiopathic pulmonary hemosiderosis can be safely supported with extracorporeal life support when conventional therapies have been exhausted.
Assuntos
Oxigenação por Membrana Extracorpórea , Hemossiderose/terapia , Pneumopatias/terapia , Hemossiderose/diagnóstico , Humanos , Lactente , Pneumopatias/diagnóstico , Masculino , Hemossiderose PulmonarRESUMO
A 3-year-old boy with familial long QT syndrome type 2 presented with recurrent syncope despite adequate beta-blocker therapy. Two family members had experienced sudden cardiac arrest, and one other relative had experienced sudden cardiac death. Given the high risk for ventricular arrhythmia/syncope, the decision was made to perform primary cardiac denervation therapy through a minimally invasive approach without concomitant automatic cardioverter-defibrillator implantation. Using video-assisted thoracoscopic surgery, the left-sided sympathetic ganglia from T2-T5 were identified, and dissection along the sympathetic chain with transection of the corresponding rami along T2-T5 in addition to the lower half of the stellate ganglion was performed. The chest tube was removed on day 1 after surgery, and the patient was discharged on postoperative day 4. During 14 months of follow-up evaluation, no intervening episodes of ventricular arrhythmia or syncope and no symptoms of Horner's syndrome were noted.
Assuntos
Síndrome do QT Longo/cirurgia , Gânglio Estrelado/cirurgia , Simpatectomia/métodos , Pré-Escolar , Frequência Cardíaca , Humanos , Síndrome do QT Longo/fisiopatologia , Masculino , Cirurgia Torácica VídeoassistidaRESUMO
We have previously described our novel surgical technique in addressing the anomalous aortic origin of the left coronary artery with a transseptal course behind the right ventricular outflow tract. By means of the Najm procedure, we performed complete unroofing of the transseptal anomalous aortic origin of the left coronary artery and elongated the right ventricular outflow tract posteriorly using an autologous pericardial patch. This report documents modifications to address challenging anatomic variants and highlights the importance of managing septal arteries and myocardial bridges. We also describe the excellent midterm outcomes of 14 patients who have undergone the Najm procedure.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Anomalias dos Vasos Coronários , Humanos , Procedimentos Cirúrgicos Cardíacos/métodos , Aorta/cirurgia , Vasos Coronários , Miocárdio , Anomalias dos Vasos Coronários/cirurgiaRESUMO
Heart-lung transplantation has historically been used as a definitive treatment for children with end-stage cardiopulmonary failure, although the number performed has steadily decreased over time. In this review, we discuss current indications, preoperative risk factors, outcomes, and heart-lung transplantation in unique patient subsets, including infants, children with single-ventricle physiology, tetralogy of Fallot/major aortopulmonary collateral arteries, and prior Potts shunt palliation. We also describe the different surgical techniques utilized in pediatric heart-lung transplantation.
Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração-Pulmão/métodos , Pneumopatias/cirurgia , Adolescente , Criança , Pré-Escolar , Insuficiência Cardíaca/complicações , Humanos , Lactente , Pneumopatias/complicações , Resultado do TratamentoAssuntos
Cardiopatias Congênitas , Atresia Pulmonar , Septo Interventricular , Humanos , Atresia Pulmonar/complicações , Atresia Pulmonar/diagnóstico por imagem , Atresia Pulmonar/cirurgia , Septo Interventricular/diagnóstico por imagem , Septo Interventricular/cirurgia , Circulação Coronária , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/cirurgia , Ventrículos do Coração/anormalidadesAssuntos
COVID-19 , Cardiopatias Congênitas , Síndrome do Coração Esquerdo Hipoplásico , Criança , Família , Humanos , SARS-CoV-2RESUMO
The following report describes the case of newborn girl with an asymptomatic systolic murmur, which on imaging revealed a nearly obstructive mass in the left-ventricular outflow tract. The mass was resected and found to be consistent with a rhabdomyoma. Here, we describe the pathologic and clinical characteristics of this tumor.
RESUMO
OBJECTIVE: Gastrostomy tube (G-tube) placement during three-stage surgical palliation of single-ventricle cardiac physiology has been shown to improve weight gain in this population of infants who often suffer from inadequate feeding. The optimal timing of this intervention is unclear and requires further investigation. DESIGN: A retrospective review of all patients who underwent G-tube placement at any stage of surgical palliation of single-ventricle physiology from January 2005 to December 2012 was performed at a single congenital cardiac surgery center. Analysis of weight gain and survival was undertaken by comparing patients who received the G-tube either less than or greater than 90 days after the first surgical stage. RESULTS: Fifty-four patients were identified that met the criteria, 26 (48%) of which received the G-tube within 90 days of stage 1, while 28 (52%) patients received the tube at greater than 90 days. Percentage of weight gain at time of discharge from stage 1 was significantly higher for group B (A: median 9.9%, interquartile range [IQR] 4.9-29.8; B: median 29.0%, IQR 16.0-44.3; P = .05). However, total hospital length of stay was decreased for the patients who received G-tubes earlier (A: median 60 days, IQR 35-100; B: median 83, IQR 48-184) as was intensive care unit length of stay (A: median 27 days, IQR 13-69; B: median 48, IQR 16-119) by nearly half, although not statistically significant (P = .47). Survival to time of discharge from stage 1 surgery was not significantly different between earlier tube placements vs. later (92% vs. 100%, respectively; P = .14). Multivariable analysis found inclusion of fundoplication to predict weight gain (P = .006) at time of first discharge. CONCLUSION: Earlier placement of G-tube may increase the rate of recovery from stage 1 of multistage palliative cardiac surgery for single-ventricle physiology. Fundoplication may improve perioperative weight gain when indicated.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Nutrição Enteral/instrumentação , Gastrostomia/instrumentação , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Cuidados Paliativos , Tempo para o Tratamento , Fatores Etários , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Nutrição Enteral/efeitos adversos , Nutrição Enteral/mortalidade , Feminino , Fundoplicatura , Gastrostomia/efeitos adversos , Gastrostomia/mortalidade , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/mortalidade , Ventrículos do Coração/anormalidades , Mortalidade Hospitalar , Humanos , Lactente , Mortalidade Infantil , Fenômenos Fisiológicos da Nutrição do Lactente , Tempo de Internação , Modelos Lineares , Masculino , Análise Multivariada , Estado Nutricional , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Aumento de PesoRESUMO
There are limited data on the relationship between the administered dose of recombinant factor seven (rFVIIa) and the development of adverse clinical outcomes after congenital heart surgery. This single institution case series reports on dosing, adverse events, and blood product usage after the administration of rFVIIa in the congenital heart surgery patient population. A retrospective review identified 16 consecutive pediatric patients at an academic, free-standing, children's hospital who received rFVIIa to curtail bleeding following congenital heart surgery between April 2004 and June 2012. Patients were assessed for survival to hospital discharge versus in-hospital mortality and the presence or absence of a major neurological event during inpatient hospitalization. The median age at surgery was 6.8 months (range: 3 days-42 years). Seven patients (44%) survived to hospital discharge and nine patients (56%) died. The cause of mortality included major neurological events (44%), uncontrolled bleeding (33%), and sepsis (23%). Eight patients (50%) required extracorporeal membrane oxygenation support following congenital heart surgery. The median cumulative rFVIIa dose administered was 97 mcg/kg, and the median cumulative amount of blood products administered was 452 ml/kg. In conclusion, this case series underscores the need to prospectively evaluate the effect that rFVIIa has on patient survival and the incidence of adverse events, including thrombotic and major neurological events, in congenital heart surgery patients. Ideally, a randomized, multicenter study would provide the sufficient numbers of patients and events to test these relationships.
RESUMO
INTRODUCTION: Following congenital heart surgery, pediatric patients may experience persistent respiratory failure that requires tracheostomy placement. Currently, definitive knowledge of the optimal timing for tracheostomy placement in this patient population is lacking. METHODS: An 8-year retrospective review of 17 pediatric patients who underwent congenital heart surgery and subsequently required tracheostomy placement was performed. Patients were evaluated with regard to the timing of tracheostomy and mortality. RESULTS: The overall study mortality was 24%. The median duration of intubation prior to tracheostomy was 60 days (interquartile range: 19-90 days); there was no difference in the average time between intubation and tracheostomy for survivors compared with nonsurvivors (51 vs. 73 days, P = .37). No difference was observed in the overall duration of positive pressure ventilation when tracheostomy was performed within 30 days of intubation compared with greater than 30 days following intubation (481 vs. 451 days, P = .88). Overall, 18% of patients were successfully weaned from the ventilator after a median duration of positive pressure ventilation of 212 days. CONCLUSION: The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiopatias Congênitas/cirurgia , Insuficiência Respiratória/terapia , Tempo para o Tratamento , Traqueostomia , Fatores Etários , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/mortalidade , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal , Masculino , Respiração com Pressão Positiva , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Traqueostomia/efeitos adversos , Traqueostomia/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND: Congenital ion channel disorders, including congenital long QT syndrome (LQTS), cause significant morbidity in pediatric patients. When medication therapy does not control symptoms or arrhythmias, more invasive treatment strategies may be necessary. This study examines our institution's clinical experience with surgical cardiac denervation therapy for management of these arrhythmogenic disorders in children. METHODS: An institutional review board-approved retrospective review identified ten pediatric patients with congenital ion channelopathies who underwent surgical cardiac denervation therapy at a single institution between May 2011 and April 2014. Eight patients had a diagnosis of congenital LQTS, two patients were diagnosed with catecholaminergic polymorphic ventricular tachycardia (CPVT). All patients underwent sympathectomy and partial stellate ganglionectomy via video-assisted thoracoscopic surgery (VATS). RESULTS: Six of the ten patients had documented ventricular arrhythmias preoperatively, and 70% of the patients had preoperative syncope. The corrected QT interval decreased in 75% of patients with LQTS following sympathectomy. Postoperative arrhythmogenic symptoms were absent in 88% of congenital LQTS patients, but both patients with CPVT continued to have symptoms throughout the duration of follow-up. All patients were alive after a median follow-up period of 10 months. CONCLUSIONS: Surgical cardiac denervation therapy via VATS is a useful treatment strategy for congenital LQTS patients who fail medical management, and its potential benefit in the management of CPVT is unclear. A prospective comparison of the efficacy of surgical cardiac denervation therapy and implantable cardioverter-defibrillator use in congenital ion channelopathies is timely and crucial.
Assuntos
Canalopatias/cirurgia , Síndrome do QT Longo/cirurgia , Gânglio Estrelado/cirurgia , Simpatectomia , Taquicardia Ventricular/cirurgia , Cirurgia Torácica Vídeoassistida , Adolescente , Canalopatias/congênito , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Taquicardia Ventricular/congênito , Resultado do TratamentoRESUMO
OBJECTIVE: Although simulation-based education is now commonly utilized in medicine, its use in the instruction of congenital heart disease remains limited. The objective of this study is to evaluate whether heart models created with three-dimensional printing technology can be effectively incorporated into a simulation-based congenital heart disease and critical care training curriculum for pediatric resident physicians. DESIGN: Utilizing heart models created with a three-dimensional printer, pediatric residents participated in a 60-minute simulation seminar with three consecutive components: (1) didactic instruction on ventricular septal defect anatomy; (2) didactic/simulation-based instruction on echocardiographic imaging of ventricular septal defects and anatomical teaching/operative simulation of ventricular septal defect repair; (3) simulation-based instruction on postoperative critical care management of ventricular septal defects. SETTING: Academic, free-standing, children's hospital with quaternary care referrals. PARTICIPANTS: Twenty-three pediatric resident physicians. OUTCOME MEASURES: Subjective, Likert-type questionnaires assessing knowledge acquisition, knowledge reporting, and structural conceptualization of ventricular septal defects. RESULTS: Three-dimensional printing technology was successfully utilized to create heart models of five common ventricular septal defect subtypes. After using these models in a simulation-based curriculum, pediatric residents were found to have improvement in the areas of knowledge acquisition (P = .0082), knowledge reporting (P = .01), and structural conceptualization (P < .0001) of ventricular septal defects, as well as improvement in the ability to describe and manage postoperative complications in ventricular septal defect patients in the critical care setting. CONCLUSIONS: The utilization of three-dimensional printing in a simulation-based congenital heart disease and critical care training curriculum is feasible and improves pediatric resident physicians' understanding of a common congenital heart abnormality.
Assuntos
Cuidados Críticos , Currículo , Educação Médica/métodos , Cardiopatias Congênitas , Cardiopatias/congênito , Internato e Residência , Modelos Anatômicos , Pediatria/educação , Impressão Tridimensional , Treinamento por Simulação , HumanosRESUMO
The use of extracorporeal membrane oxygenation (ECMO) in terminally ill pediatric patients who are not candidates for long-term mechanical circulatory support or heart transplantation requires careful deliberation. We present the case of a 16-year-old female with a relapse of acute lymphoid leukemia and acute-on-chronic cardiomyopathy who received short-term ECMO therapy. In addition, we highlight several ethical considerations that were crucial to this patient's family-centered care and demonstrate that this therapy can be accomplished in a manner that respects patient autonomy and family wishes.
Assuntos
Cardiomiopatias/terapia , Oxigenação por Membrana Extracorpórea/ética , Insuficiência Cardíaca/terapia , Futilidade Médica/ética , Assistência Terminal/ética , Adolescente , Antraciclinas/efeitos adversos , Circulação Assistida , Cardiomiopatias/induzido quimicamente , Progressão da Doença , Feminino , Transplante de Coração , Humanos , Transferência de Pacientes , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , RecidivaRESUMO
Surgical repair of congenital heart disease during cardiopulmonary bypass is common, and performing these complicated procedures in the absence of blood transfusions is especially challenging. A case of a Jehovah's Witness child who underwent surgical repair of a ventricular septal defect utilizing a new tetrastarch for autologous normovolemic hemodilution is reported. A successful operative repair was achieved without the need for non-autologous blood transfusion.
Assuntos
Ponte Cardiopulmonar/métodos , Comunicação Interventricular/cirurgia , Derivados de Hidroxietil Amido/administração & dosagem , Testemunhas de Jeová , Pré-Escolar , Feminino , Cardiopatias Congênitas/cirurgia , Hemodiluição/métodos , Humanos , Substitutos do Plasma/administração & dosagemRESUMO
The development of acquired von Willebrand syndrome (AVWS) after placement of a pulsatile-flow left ventricular assist device (LVAD) is rare and only recently recognized. We report the case of a young infant who was diagnosed with ventricular assist device (VAD)-related AVWS following implantation of a Berlin Heart EXCOR Pediatric Ventricular Assist Device (Berlin Heart Inc., The Woodlands, Texas, USA) for treatment of severe heart failure. Despite significant bleeding, the patient was successfully managed with von Willebrand factor-containing concentrate until VAD explantation led to definitive resolution of the AVWS. This case demonstrates that the possibility of this diagnosis should be considered in pediatric patients when extensive, nonsurgical bleeding is encountered after pulsatile-flow VAD implantation.
Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Doenças de von Willebrand/etiologia , Remoção de Dispositivo , Feminino , Humanos , Lactente , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Doenças de von Willebrand/terapia , Fator de von Willebrand/administração & dosagemRESUMO
A full-term male neonate presented with cyanosis upon delivery and was subsequently diagnosed with d-transposition of the great arteries, ventricular septal defect, and restrictive atrial septal defect. Following initiation of intravenous prostaglandins and balloon atrial septostomy, an arterial switch operation was performed on day 3 of life. The postoperative course was complicated by intractable ventricular tachycardia that was refractory to lidocaine, amiodarone, esmolol, fosphenytoin, and mexiletine drug therapy. Ventricular tachycardia was suppressed with overdrive atrial pacing but recurred upon discontinuation. Seven weeks postoperatively, radiofrequency catheter ablation was performed due to hemodynamically compromising persistent ventricular tachycardia refractory to medical therapy. The ventricular tachycardia was localized to the inferior-lateral right ventricular outlet septum. The procedure was successful without complications or recurrence. Antiarrhythmics were discontinued after the ablation procedure. Seven days after the ablation, a different, slower fascicular rhythm was noted to compete with the infant's sinus rhythm. This was consistent with the preablation amiodarone having reached subtherapeutic levels given its very long half-life. The patient was restarted on oral beta blockers and amiodarone. The patient was subsequently discharged home in predominantly sinus rhythm with intermittent fascicular rhythm.