ADHD symptomatology of children with congenital heart disease 10 years after cardiac surgery: the role of age at operation.

BACKGROUND: The aim of the present study was to investigate the differences in ADHD symptomatology between healthy controls and children who underwent cardiac surgery at different ages. METHODS: Altogether, 133 children (54 patients with congenital heart disease undergoing first cardiac surgery under 3 years of age, 26 operated at the age of 3 or later, and 53 healthy controls) were examined. Patients completed the Youth Self Report (YSR), while their parents completed the Child Behaviour Checklist (CBCL) and the ADHD Rating Scale-IV. RESULTS: Children receiving surgery for the first time under the age of 3 years were more likely diagnosed with cyanotic type malformation and have undergone to a greater number of operations. However, ADHD symptoms of those treated surgically at or above 3 years of age were more severe than that of the control group or those who were treated surgically at a younger age. The control group and those treated surgically below the age of three did not differ across any of the ADHD symptom severity indicators. CONCLUSIONS: The age at the time of cardiac surgery might be associated with later ADHD symptom severity - with lower age at operation associated with better outcomes. Further, adequately powered studies are needed to confirm these exploratory findings and investigate the moderators of this relationship.

Fluid Overload Is Associated With Higher Mortality and Morbidity in Pediatric Patients Undergoing Cardiac Surgery.

OBJECTIVES: Fluid overload after pediatric cardiac surgery is common and has been shown to increase both mortality and morbidity. This study explores the risk factors of early postoperative fluid overload and its relationship with adverse outcomes. DESIGN: Secondary analysis of the prospectively collected data of children undergoing open-heart surgery between 2004 and 2008. SETTING: Tertiary national cardiac center. PATIENTS: One thousand five hundred twenty consecutive pediatric patients (<18 years old) were included in the analyses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In the first 72 hours of the postoperative period, the daily fluid balance was calculated as milliliter per kilogram and the daily fluid overload was calculated as fluid balance (L)/weight (kg) × 100. The primary endpoint was in-hospital mortality; the secondary outcomes were low cardiac output syndrome and prolonged mechanical ventilation. One thousand three hundred and sixty-seven patients (89.9%) had a cumulative fluid overload below 5%; 120 patients (7.8%), between 5% and 10%; and 33 patients (2.1%), above 10%. After multivariable analysis, higher fluid overload on the day of the surgery was independently associated with mortality (adjusted odds ratio, 1.14; 95% CI, 1.008-1.303; p = 0.041) and low cardiac output syndrome (adjusted odds ratio, 1.21; 95% CI, 1.12-1.30; p = 0.001). Higher maximum serum creatinine levels (adjusted odds ratio, 1.01; 95% CI, 1.003-1.021; p = 0.009), maximum vasoactive-inotropic scores (adjusted odds ratio, 1.01; 95% CI, 1.005-1.029; p = 0.042), and higher blood loss on the day of the surgery (adjusted odds ratio, 1.01; 95% CI, 1.004-1.025; p = 0.015) were associated with a higher risk of fluid overload that was greater than 5%. CONCLUSIONS: Fluid overload in the early postoperative period was associated with higher mortality and morbidity. Risk factors for fluid overload include underlying kidney dysfunction, hemodynamic instability, and higher blood loss on the day of the surgery.

Transpulmonary thermodilution in neonates undergoing arterial switch surgery.

Measurement of the global end-diastolic volume index (GEDI) by transpulmonary thermodilution (TPTD) has become a useful technique for measuring preload in adults. This study aimed to investigate the hemodynamic changes in neonates during the postoperative period after arterial switch surgery. Over a 13-month period, the postoperative data of 12 neonates with transposition of the great arteries were retrospectively investigated. Arterial and central venous blood pressures were monitored, Cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI), GEDI, and extravascular lung water index (ELWI) were measured by thermodilution. The CI was significantly correlated with the SVRI only in the closed chest condition (r = -0.92; P < 0.001). The CI and SVI values were significantly lower and the ELWI and SVRI values significantly higher in both the open and closed chest conditions than the postextubation values. The relationship between change in GEDI and change in CI was stronger in the open chest condition (r = 0.93; P < 0.006) than in the closed chest condition (r = 0.75; P = 0.055). However, the latter just missed statistical significance. According to the findings, TPTD seems to be a useful tool for assessing cardiac function after neonatal arterial switch surgery. Establishment of normal values will be essential for proper guidance of therapy for this population using volumetric parameters.

[Redo procedures for correction of aortic valve diseases in infants and children. The Bentall-Konno procedure]. / Csecsemô- és gyermekkori REDO mûtéteket igénylô aortabillentyû-betegség. Az elsô magyarországi Bentall-Konno-mûtét gyermekkorban.

On an infant with critical valvular aortic stenosis balloon-valvoplasty, and 3 years later because of the aortic valve regurgitation Ross operation was performed. In the early postoperative period an aortic-root abscess occurred due to an infective endocarditis; the aortic root was corrected by homograft implantation. Due to a relatively small, calcified aortic valve, with aortic valve regurgitation grade III at the age of 12 years, a Bentall-Konno procedure was performed successfully. This is the first case when this complex surgical procedure was performed successfully on a child in Hungary.

Development of bronchus-associated lymphoid tissue hyperplasia following lipopolysaccharide-induced lung inflammation in rats.

Gram-negative bacterial endotoxin lipopolysaccharide (LPS) administration has been used as an animal model of sepsis-related acute lung injury and adult respiratory distress syndrome (ALI/ARDS). This paper describes the lung histology following lung injury induced by the intraperitoneal (i.p.) administration of endotoxin to rats, in comparison with earlier findings. ALI was induced by the i.p. administration of Esherichia coli LPS 2 (n = 8) or 3 (n = 5) mg/kg, whereas physiological saline was administered to the control animals (n = 5). Eighteen hours after the LPS injections, the animals were euthanized. The lungs and heart were removed in one block for histological study (hematoxylin and eosin [H&E], periodic acid-Schiff [PAS], Mason's trichrome; light microscopy). The lung tissue injury (bronchial wall, vessels, alveoli, interstitium) was graded via a scoring system (0 to 3+). The control animals showed intact lung tissue. Ten of the 13 LPS group had bronchus-associated lymphoid tissue (BALT) hyperplasia. Pathological signs of ALI/ARDS, diffuse alveolar damage (DAD) and emphysema, were observed in 5 and 8 cases, respectively. LPS injection induces primarily BALT hyperplasia and also the less characteristic DAD. This rat model is suitable for the investigation not only of ALI/ARDS but also of BALT hyperplasia occurring as a consequence of chronic pulmonary inflammatory processes.

[Surgical management of anomalous origin of the left coronary artery from the main pulmonary artery with Takeuchi procedure]. / Takeuchi mutét, egy ritka szívmutét elso sikeres hazai alkalmazása.

Anomalous origin of the left coronary artery from the main pulmonary artery is a rare form of congenital heart disease. It carries a very poor prognosis with a mortality rate of more than 85% in the first year of life due to severe left ventricular failure. Surgical repair results in progressive improvement of left ventricular function even in patients with a severely damaged myocardium. The current surgical management is to reimplant the anomalous origin of the left coronary artery from the pulmonary artery to the aorta. Historically, ligation of the anomalous origin and a subclavian artery-left coronary artery bypass were carried out. A 20-month-old boy underwent a Takeuchi procedure (a fenestration between the aorta and the main pulmonary artery, an intrapulmonary tunnel between the orifice of anomalous left coronary artery and fenestration, and a pulmonary artery reconstruction), because the reimplantation of the anomalous coronary artery was technically impossible. The success of this procedure was proven by good early result.

Chylothorax after pediatric cardiac surgery complicates short-term but not long-term outcomes-a propensity matched analysis.

BACKGROUND: The occurrence of postoperative chylothorax in children with congenital heart disease is a rare and serious complication in cardiac intensive care units (ICUs). The aim of our study was to identify the perioperative characteristics, treatment options, resource utilization and long term complications of patients having chylothorax after a pediatric cardiac surgery. METHODS: Patients were retrospectively assessed for the presence of chylothorax between January 2002 and December 2012 in a tertiary national cardiac center. Occurrence, treatment options and long term outcomes were analyzed. Chylothorax patients less than 2 years of age were analyzed using propensity-matched statistical analysis in regard to postoperative complications after discharge. RESULTS: During the 10-year period, 48 patients had chylothorax after pediatric cardiac surgery. The highest incidence was observed on the second postoperative day (7 patients, 14.6%). Seven patients (14.6% of the chylothorax population) died. During the follow up period, 5 patients had additional thromboembolic complications (2 had confirmed thrombophilia). Eleven patients had a genetic abnormality (3 had Down's syndrome, 3 had Di-Giorge's syndrome, 1 had an IgA deficiency and 4 had other disorders). During the reoperations (49 cases), no chylothorax occurred. After propensity matching, the occurrence of pulmonary failure (P=0.001) was significantly higher in the chylothorax group, and they required prolonged mechanical ventilation (P=0.002) and longer hospitalization times (P=0.01). After discharge, mortality and neurologic and thromboembolic events did not differ in the matched groups. CONCLUSIONS: Chylothorax is an uncommon complication after pediatric cardiac surgery and is associated with higher resource utilization. Chylothorax did not reoccur during reoperations and was not associated with higher mortality or long-term complications in a propensity matched analysis.

An improved technique for repeated bronchoalveolar lavage and lung mechanics measurements in individual rats.

Lung function and bronchoalveolar lavage (BAL) fluid are commonly analyzed to assess the severity of lung disease in sacrificed animals. The input impedance of the respiratory system (Z(rs)) was measured and BAL fluid was collected in intubated, anesthetized, mechanically ventilated rats on three occasions 1 week apart. Measurements were performed in control animals (group C), while lung injury was induced in the other group (group LPS) by i.p. injection of lipopolysaccharide (LPS) before the second measurement. The airway resistance (R(aw)), tissue damping (G) and elastance (H) were determined from the Z(rs) spectra. The total cell counts (TC) from 0.3- to 0.4-ml BAL fluid were also determined. R(aw) exhibited no significant change in either group C (-6.7+/-3.6[S.E.]%) or LPS (-0.9+/-3.7%). Reproducible G and H values were obtained in group C (2.5+/-5.3%, -7.0+/-4.4%), while G and H increased in group LPS (18.4+/-6.5%, 14.9+/-13.8%, p<0.05). The changes in TC followed a similar pattern to those observed in G, with no change in group C (-7.9+/-30%), but with a marked increase in group LPS (580+/-456%, p<0.05). The method devised for repeated BAL measurements in another group of rats without intubation and muscle relaxant resulted in similar results in BAL profile. We conclude that longitudinal follow-up of the airway and tissue mechanics and inflammatory cells in the BAL fluid are feasible in rats. The current method allows an early detection of lung injury, even in a relatively mild form.

[Aortic root replacement with pulmonary allograft (Ross procedure) in children. Early results]. / Veleszületett aortabillentyú-betegség kezelése aortagyökpótlással pulmonalis allografttal (Ross-mútét) gyermekkorban. Korai eredmények.

INTRODUCTION: For infants and children with congenital aortic valve disease root replacement with pulmonary allograft (Ross procedure) is the preferred method of choice. PATIENTS/RESULTS: The authors have successfully applied this operation in 12 children (age range from 2.5 to 17 years--mean 9 years, body weight from 12 to 58 kg--mean 46 kg), one of whom has also required a Konno extension for long segment left ventricular outflow tract obstruction. The operation was complicated by early postoperative endocarditis in one case, and the child required redo homograft root replacement on the ninth postoperative day. All patients, including this one survived, and are doing well at present. CONCLUSIONS: In the Hungarian literature this is the first report on the Ross and Konno procedure in children. On the basis of our excellent early results, Ross procedure is the method of choice in aortic valve disease in children.

Assessment of global tissue perfusion and oxygenation in neonates and infants after open-heart surgery.

OBJECTIVES: Monitoring and preserving adequate perfusion and oxygen balance is a primary objective of critical care. This prospective observational study aimed to assess the relationship between global haemodynamic parameters and variables reflecting tissue oxygenation during the early period following corrective cardiac surgery in neonates and infants. The postoperative time course of oxygen delivery and consumption was evaluated. As surrogate markers of oxygen balance, the central venous oxygen saturation (ScvO2) and venoarterial PCO2 difference (PvaCO2) were thoroughly investigated. METHODS: Thirteen children <1 year of age who underwent open-heart surgery were prospectively enrolled. In addition to conventional postoperative monitoring, transpulmonary thermodilution (TPTD) was used to monitor cardiac output and calculate oxygen delivery and consumption. In parallel with each TPTD measurement, arterial and central venous blood gas values were recorded. Global haemodynamic parameters and oxygenation measurements were compared with weighted linear regression statistics and Pearson's correlation coefficient. RESULTS: Data from 145 TPTD measurements and 304 blood gas samples were recorded. The early postoperative period was characterized by a supply-dependent oxygen consumption, as demonstrated by the direct correlation between the change in oxygen delivery and consumption (r = 0.62, P < 0.001). Regarding haemodynamic parameters, none of the heart rate, mean arterial pressure or cardiac index correlated with the measured ScvO2. However, the ScvO2 and PvaCO2 were found to correlate significantly (r = -0.49, P < 0.001), and both strongly related to oxygen extraction. CONCLUSIONS: Both the ScvO2 and PvaCO2 are reliable and comparable parameters in following tissue oxygen balance during the early postoperative course after open-heart surgery in neonates and infants. As part of multiparameter monitoring, our data highlight the importance of regular ScvO2 measurements and PvaCO2 calculations in paediatric intensive care.

A comparison of the systems for the identification of postoperative acute kidney injury in pediatric cardiac patients.

BACKGROUND: The pediatric-modified Risk, Injury, Failure and Loss, and End-Stage (pRIFLE) criteria and a different but conceptually similar system termed Acute Kidney Injury Network (AKIN) were created to standardize the definition of acute kidney injury (AKI) in children. Kidney Disease: Improving Global Outcomes (KDIGO) currently recommends a combination of AKIN and pRIFLE in AKI. This study aimed to compare the three classifications for predicting AKI in pediatric patients undergoing cardiac operations. METHODS: We analyzed the prospectively collected data of 1,489 consecutive pediatric patients undergoing cardiac operations between January 2004 and December 2008. AKI presence and severity was assessed for each classification using the change in serum creatinine and estimated creatinine clearance levels calculated by the Schwartz equation. RESULTS: AKI was present in 285 (20%), 481 (34%), and 409 (29%) patients according to the AKIN, pRIFLE, and KDIGO systems, respectively. The KDIGO classification categorized 121 patients (8%) who were placed in the AKIN 0 category, whereas the pRIFLE system categorized 74 (5%) in KDIGO 0 and 200 (14%) in AKIN 0 stages as having an AKI. The overall mortality rate was 3.9%. The KDIGO stage III (odds ratio [OR], 18.8; 95% confidence interval [CI], 9.6 to 36.6, p < 0.001), the AKIN stage III (OR, 38.3; 95% CI, 20.6 to 70.9, p < 0.001), and pRIFLE failure group (OR, 13.6, 95% CI, 7 to 26.3; p < 0.001) were associated with increased mortality. CONCLUSIONS: The pRIFLE system was the most sensitive test in detecting AKI, and this was especially so in the infant age group and also in the early identification of AKI in low-risk patients. The AKIN system was more specific and detected mostly high-risk patients across all age groups. The KDIGO classification system fell between pRIFLE and AKIN in performance. All three had increasing severity of AKI associated with mortality.

Airway responsiveness and bronchoalveolar lavage fluid profiling in individual rats: effects of different ovalbumin exposures.

We studied repeatedly the development of bronchial hyperreactivity (BHR) and bronchoalveolar lavage fluid (BALF) in rats undergoing different modes of ovalbumin exposures. Treatment was two intraperitoneal injections of ovalbumin in Groups 1-3, followed by one ovalbumin aerosolization in Groups 2 and 3, while rats in Group 4 received repeated ovalbumin aerosols after one single intraperitoneal injection. BHR was assessed longitudinally on day 0 (before treatment) and on day 14 (Groups 1 and 2) or 20 (Groups 3 and 4) and cellular influx was estimated from BALF. No BHR or change in BALF cellular profile was detected in Groups 1-3. However, the infiltration of inflammatory cells, associated with BHR (PC(100) 8.9+/-1.3 microg/kg vs. 4.2+/-1.1 microg/kg), was observed in Group 4. The BHR was always associated with increased number of eosinophils in the BALF. The substantial interindividual variability confirmed the need for a technique that permits follow-up of lung responsiveness and BALF profile. This approach evidenced strong associations between the severity of BHR and the eosinophilia.