Prolonged warm ischemia for transfusion-free arterial switch and ventricular septal defect surgery in a 4.5-Kg baby.

Blood-free pediatric surgery is increasingly used for surgical correction of simple cardiopathies. Herein, we describe a complex cardiopathy, arterial switch operation and ventricular septal defect, with pre-operative thrombocytopenia in a 4.5 Kg baby treated with warm surgery and intermittent warm blood microplegia without any blood product. Bypass time was 89 min and aortic cross-clamp time 61 min. The maximal length of warm ischemia (time between microplegia injections) was 42 minutes. The postoperative course was uneventful. The patient was weaned off the ventilator after 7 hours, was discharged from the ICU on day 2 and was discharged from the hospital on day 7. The two main factors involved in this result were high pre-operative hemoglobin level and bypass technique with small prime volume, microplegia and warm perfusion. However, the success of this challenging case is also the result of teamwork and of rigorous patient care.

Near Infrared Spectroscopy during pediatric cardiac surgery: errors and pitfalls.

As a result of improvements in early outcomes, long-term neurologicalal outcomes are becoming a major issue in pediatric cardiac surgery. The mechanisms of brain injury are numerous, but a vast majority of injuries are impervious to therapy and only a few are modifiable. The quality of perfusion during cardiac surgery is a modifiable factor and cerebral monitoring during bypass is the way to assess the quality of intra-operative cerebral perfusion. Near infrared spectroscopy (NIRS), as a diagnostic tool, has gained in popularity within the perfusion community. However, NIRS is becoming the standard of care before its scientific validation. This manuscript relates four clinical cases, demonstrating the limitations of NIRS monitoring during pediatric cardiac surgery as well as uncertainties about the interpretation of the recorded values. The clinical relevance of cerebral oxymetry is needed before the use of NIRS as a decision making tool. Multimodal brain monitoring with NIRS, trans-cranial Doppler and electroencephalogram are currently under way in several pediatric centers. The benefit of this time-consuming and expensive monitoring system has yet to be demonstrated.

[Discontinuous warm cardioplegia in pediatric cardiac surgery: preliminary results]. / Cardioplégie chaude discontinue en chirurgie cardiaque pédiatrique: expérience initiale.

This article describes the use of warm cardioplegia in paediatric surgery. Warm blood enriched with potassium was injected every 15 minutes during aortic clamping in 770 operations. The efficacy and quality of this technique were assessed by the return of cardiac electrical activity, troponin I levels 12 hours after aortic clamping and the duration of postoperative ventilation in 3 groups of patients: ventricular septal defect under 6 months (N = 82), tetralogy of Fallot under one year (N = 55), simple transposition of the great arteries (N = 42). These results were compared retrospectively with those obtained using cold cardioplegia. The return of sinus rhythm was spontaneous in 99% of cases versus 77% with cold cardioplegia; the troponin I levels were under 10 ng/ml in 46% of cases versus 37% (NS). Patients operated for ventricular septal defect were ventilated 10 +/- 8 hours versus 13 +/- 10 hours with cold cardioplegia (p = 0.02). The children operated for tetralogy of Fallot were ventilated 8 +/- 4 hours versus 14 +/- 7 hours (p = 0.01) and those with simple transposition 56 +/- 71 hours versus 83 +/- 105 hours (NS). Warm cardioplegia, in the authors' experience, was associated with an improved postoperative course. In this group of 770 operations, 646 operated patients had a stay of less than two days in the intensive care unit.

[Post-haemodilution anaemia in paediatric cardiac surgery: benefit of intravenous iron therapy]. / Intérêt du fer intraveineux dans les anémies induites par l'hémodilution en chirurgie cardiaque pédiatrique.

OBJECTIVE: Anaemia is the main complication following haemodilution in paediatric cardiac surgery. Iron oral therapy is ineffective to improve anaemia. The aim of this study is to assess the effect of a single dose of intravenous iron saccharate Venofer. STUDY DESIGN: Open, randomized. PATIENTS AND METHODS: 93 patients were randomized in two groups. The first one is the control group without iron supplementation and the second one received a 5 mg/kg injection of Venofer administered at day 1. Three biological factors were studied on day 1 and day 5 following surgery: haemoglobin, ferrritin and reticulocyte rate. Student test was used for statistical analysis of results. RESULTS: Age, weight, haemoglobin, ferritine and reticulocyte on day 1 were similar in both group (no significant difference). On day 5 ferritin was higher in the treated group 215+/-87 vs 101+/-55 mug/l in the non treated group (P<0.001). Reticulocyte rate was also higher in the treated group 3.25+/-1.16 vs 2.65+/-0.97% (P<0.005) in the untreated group. CONCLUSION: Postoperative systemic inflammation is probably the factor which impaired the effect of oral iron therapy. Parenteral iron may act by treating a functional iron deficiency and/or by increasing endogenous erythropoietin synthesis. Faster reversibility of anaemia following iron injection improves quality of the postoperative recovery.

[Acute Corynebacterium diphtheriae aortic endocarditis with negative blood cultures]. / Endocardite aortique aiguë à Corynebacterium diphteriae à hémoculture négative.

UNLABELLED: Acute endocarditis with negative blood culture is a challenge requiring close cooperation between several specialists. CASE REPORT: A 15-year-old boy presented with an acute aortic endocarditis due to Corynebacterium diphtheriae. Blood cultures were negative due to an empiric anti-infective therapy. Valvular replacement with a mechanical prosthesis failed to cure the sepsis, which resolved after a cryopreserved allograft implantation. CONCLUSION: This case underlines the efficiency of the highly specialized bacteriological centers and the advantages of using a cryopreserved allograft during the septic state.

[Postoperative mediastinitis due to methicillin resistant Staphylococcus epidermidis with low sensitivity to vancomycin]. / Médiastinite postopératoire à Staphylococcus epidermidis méthicilline-résistant, à sensibilité réduite à la vancomycine.

BACKGROUND: Vancomycin is the drug of choice for methicillin-resistant Staphylococcus. Antibiotherapy failure is rarely clinically related to Staphylococcus with vancomycin low susceptibility. CASE REPORT: A surgical cure of an aortic stenosis in a neonate was complicated by a Staphylococcus mediastinitis. After initiation of antibiotherapy with vancomycin and rifampin and surgical debridement, there was a rapid improvement. Few days later, failure of therapy was obvious. Despite continuous infusion of vancomycin, with a serum level of 29 mg/L, blood cultures were positive again to Staphylococcus. There was no endocarditis or inadequate surgical drainage. Susceptibility of the Staphylococcus was tested, looking for a tolerant strain. The vancomycin minimum bactericidal concentration was 30 mg/L (above usual value 2 to 8 mg/L), while the minimum inhibitory concentration was 3.75 mg/L. A higher dosage of vancomycin associated with fusidic acid was rapidly efficient, and total recovery was achieved. CONCLUSION: In case of failure of vancomycin therapy, despite correct serum levels, the susceptibility of the Staphylococcus strain has to be determined. A low susceptibility strain prescribes more prolonged combination of two antibiotics.

[A global evaluation of the quality of care in cardiac surgery]. / Valutazione globale della qualità delle cure in cardiochirurgia.

Until now, all reflections about cardiac surgery have been quantitative. Currently, quantitative saturation of cardiac surgery needs in France has been reached or even exceeded in some areas. Consequently, a qualitative approach becomes fundamental: to provide each patient, prior to the operation, with an assessment of his/her vital risk at a specific site; to allow cardiologists to objectively and statistically know the complete results obtained by various surgical teams; to incite improvements among surgical teams; and lastly, to allow the administration to assess services provided to patients. This study concerns 1271 patients consecutively operated on between January 1990 and December 1993 by the very same surgeon and represents the outline of a logical method of controlling clinical results.

Venovenous single lumen cannula extracorporeal lung support in neonates. A five year experience.

The authors have developed a venovenous extracorporeal lung support technique with an original single lumen cannula to avoid the carotid ligation of venoarterial extracorporeal membrane oxygenation (ECMO). During a 5 year period, the authors have used the technique in 107 neonates (weight: 3.045 +/- 0.6 1 kg; gestational age: 38.1 +/- 2.2 weeks). All of the neonates had severe respiratory failure despite maximal conventional treatment and the same indications as those for ECMO. The venovenous technique associates extracorporeal CO2 removal and apneic oxygenation. The system includes a single lumen cannula, an alternating clamp that generates a tidal flow, and an original non-occlusive roller pump that avoids the use of a venous bladder. The PaCO2 was normal (34.6 +/- 3.9 mmHg) with a blood flow of 40-50% of the total cardiac output. Under apneic oxygenation, PaO2 improved rapidly, allowing a decrease in FiO2 and mean airway pressure, minimizing barotrauma. The mean duration of bypass was 117.8 +/- 83.9 hr, and 91 of the 107 (85%) neonates were weaned from AREC. The technical complications were less important than those associated with venoarterial ECMO. The authors conclude that AREC is as effective as venoarterial ECMO and is easier to use.

[Ventriculo-arterial malpositions with ventricular septal defect. Surgical indications]. / Les malpositions ventriculo-artérielles avec communication interventriculaire. Indications chirurgicales.

Cardiac anomalies with ventriculo-arterial malposition are defined as malformations in which the aortic and/or pulmonary rings are in abnormal relation with the atrioventricular rings. When a high ventricular septal defect is also present, resection of the conal septum enables the reconstitution of normal or close to normal anatomy, without tubal interposition. Experience based upon 188 operations leads us to suggest surgical indications based upon the positions of the aortic and pulmonary rings in relation to the atrioventricular valves. Creation of the left ventricle-aorta channel may require widening of a tight ventricular septal defect, or result in resection or tilting of the conal septum onto which the tricuspid is inserted. Otherwise, left ventricle-aorta passage will be made impossible by the interposition of a straddling mitral or of tricuspid insertions which come to be inserted around the aortic ring. If the pulmonary ring is in a high, normal, position, it will not interfere with fashioning of the left channel. If situated too low, it must be shifted and reimplanted on the right ventricle. Creation of the right ventricle-pulmonary artery channel depends upon the presence or absence of concomitant pulmonary artery hypertension. In the presence of pulmonary artery hypertension, devalvulation and hence pulmonary reimplantation is poorly tolerated and is therefore contraindicated. If the pulmonary ring is in a high position (tricuspid-pulmonary distance of one normal aortic diameter for the child or more), partitioning without pulmonary displacement is the best solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Preliminary report: extracorporeal lung support for neonatal acute respiratory failure.

A technique for ventilatory support of life-threatening neonatal acute respiratory failure by use of apnoeic oxygenation and low-frequency positive-pressure ventilation, with extracorporeal membrane CO2 removal through a single-cannula perfusion circuit, is described. 20 severely ill babies with respiratory failure were treated with this technique, 17 of whom survived with no clinical evidence of pulmonary handicap or neurological deficit at discharge from hospital. All 10 patients followed up at 6 months showed normal growth and development.

Single-cannula venovenous bypass for respiratory membrane lung support.

Clinical use of a single cannula would make extracorporeal membrane oxygenation simpler and less aggressive. It would probably limit the occurrence of the complications of currently used techniques (double-cannula, venoarterial, or venovenous bypass). In this experimental study an original system is described that is composed of a single cannula, an alternating clamp, and a nonocclusive roller pump, the characteristics of which permit its use as a venous reservoir. To overcome the limitations of the oxygenation in any venovenous bypass, we used the method of "apneic oxygenation" through the natural lungs, which we previously proved efficient in infants and children. The optimal setting of the alternative clamp was first tested in vitro to obtain the maximal flow in the circuit and the minimal amount of recirculation. The single-cannula bypass then was compared with a two-cannula circuit regarding the efficiency of carbon dioxide removal and the hemodynamic consequences. At less than 50% of the maximal speed of the pump, flows were equivalent in both types of circuits. The efficiency of carbon dioxide removal was only slightly decreased by the use of a single cannula (30 +/- 2 ml/min versus 36 +/- 2 ml/min with two cannulas). This could easily be offset by increasing the gas flow/blood flow ratio in the oxygenator. Arterial carbon dioxide tension was maintained at normal levels in both types of circuits. Hemodynamic condition was only slightly affected by the alternative flow of the bypass. This system of single-cannula membrane lung support thus seems to be adequate for clinical use.

Mediastinal infection after cardiac operation. A simple closed technique.

From March 1984 to March 1987, a simple closed method, previously described for the treatment of osteomyelitis after orthopedic operations, was used to treat deep sternal infection in 11 patients. The basis of this technique is, after meticulous débridement of the wound, to drain all the infected areas with small catheters connected to a bottle inside of which a strong (700 mm Hg) negative pressure is created (Redon drainage device). The method does not require irrigation. The maximum duration of the drainage was 24 days and complete recovery was obtained in all patients without further surgical treatments. The comfort of the patients was optimal.

Anatomic repair of anomalies of ventriculo-arterial connection (REV). Results of a new technique in cases associated with pulmonary outflow tract obstruction.

From November 1980 to November 1986, 63 patients aged 4 months to 13 years (mean 3.4 years) underwent repair of anomalies of ventriculo-arterial connection with ventricular septal defect and pulmonary outflow tract obstruction, using a technique (REV) first described by us in 1982. The selection of patients was based on preoperative criteria, namely the measurement of the distance between the tricuspid and the semilunar valves. These measurements enabled us to select from patients with an abnormal ventriculo-arterial connection, those in whom the anomaly could be repaired by intra-ventricular partition alone. In the remaining cases, REV was indicated in the presence of pulmonary stenosis. The principles of the technique are: (1) resection of the infundibular septum creating a large, direct and subarterial communication between the left ventricle and the aorta; (2) construction of a straight left ventricle to aorta tunnel by intraventricular partition; (3) direct anastomosis of the pulmonary trunk to the right ventricle. There were 12 hospital deaths (19%). The mean follow-up was 32 months. One patient died suddenly 1 year after repair. Six patients required reoperation. All survivors are in NYHA class I, except for 3 patients who are in class II. No stenosis of the left ventricular outflow tract was found but 5 patients had a significant pressure gradient at the pulmonary outflow tract level. Our present experience suggests that in properly selected patients, REV allows anatomic repair in a wide variety of anomalies of the ventriculo-arterial connection associated with VSD and pulmonary outflow tract obstruction with an acceptable rate of mortality and morbidity.

Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. I. Criteria of surgical decision.

The feasibility of anatomic repair (defined as the reconstruction of normal ventriculoarterial connection) was investigated in 104 patients who underwent an operation for anomalies of ventriculoarterial connection associated with ventricular septal defect. Three types of anatomic repair were used: intraventricular rerouting, REV (association of intraventricular rerouting with translocation of the pulmonary arterial trunk on the right ventricle), and arterial switch associated with closure of the ventricular septal defect. Intraventricular repair was considered to be the best and simplest method when possible. In the other cases, REV was indicated if pulmonary outflow tract obstruction was present, and arterial switch was performed when the tract was patent. The feasibility of intraventricular repair was related to the distances between the tricuspid valve and the semilunar valves. Preoperative measurement of these distances is an essential criterion to choose the appropriate repair of anomalies of ventriculoarterial connection associated with ventricular septal defect.

[Postoperative inotropic treatment in cardiac surgery of the newborn infant and infant]. / Traitement inotrope postopératoire dans la chirurgie cardiaque du nouveau-né et du nourrisson.

Corrective cardiac surgery in infants and neonates induces acute circulatory and anatomical changes which, together with the myocardial ischaemia of cardiopulmonary bypass, impair cardiac function. Although this cardiac dysfunction usually disappears without any after-effects, inotropic treatment is mandatory for a short time. There, however, is no easy way to monitor cardiac output in these small patients. Neither is there much universally recognized objective data available to help choose between these drugs available or between different protocols. Physiologically, infants are not small adults. In the neonatal period, the heart works virtually at its maximum, with little reserve : the stroke volume has a limited capacity to increase because of poor compliance, and the heart rate is high. Cardiac output is therefore rate dependent. To improve therapeutic adjustment, an attempt is made to rationalize the use of inotropic drugs in the postoperative period. Cardiac dysfunction can frequently be recognized already in theatre. It is of paramount importance to exclude faulty surgical repair by measuring the pressures and oxygen saturation in all the cardiac chambers and vessels. The severity of haemodynamic impairment will then have to be defined. As well as the usual clinical criteria (blood pressure, diuresis), the trend in the capnographic curve during a reduction of extracorporeal blood flow rate and acid-base measurements are most helpful. If no further immediate surgery is found to be necessary, the most serious cases are treated by cardiopulmonary support (right to left, or cardiac left to left, or exceptionally biventricular), usually for 1 to 3 h.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immediate hypertensive flare-up after coronary bypass. A predictable complication]. / Poussée hypertensive immédiate après pontage coronaire. Une complication prévisible.

An immediate post-operative rise in blood-pressure occurred in 44% of 191 patients undergoing coronary bypass. In a retrospective study of the patients' records, the authors have endeavoured to determine which of the 23 parameters characteristic of each patient was predictive of post-bypass hypertension. Using a Bayesian discriminant analysis method, they found that the only variables predictive of hypertension in 86% of the cases were an history of myocardial infarction and the urinary sodium/ potassium ratio. When combined, an urinary Na/K ratio below 1 and the absence of previous infarction constitute a good index of possible post-operative rise in blood pressure.

[Atrioventricular valve replacement in congenital cardiopathies. A series of 25 surgically-treated patients under 10 years of age]. / Remplacement des valves auriculo-ventriculaires dans les cardiopathies congénitales. Une série de 25 opérés âgés de moins de 10 ans.

A series of 25 congenital malformations of the atrioventricular valves underwent valve replacement (10 mechanical and 15 bioprostheses). Seven children died during surgery. The operative mortality was higher before 2 years of age (4/7) than in older children (3/18). It was also higher when valve replacement was performed at second intention (5/14) than when decided on from the outset (2/11). With an average follow-up over 3 years, 9 of the 18 survivors are considered to be good surgical results. Of the other 9, 3 are considered to be moderate results (2 associated subaortic stenoses), 3 present indications of reoperation for calcification of the bioprosthesis, and 3 died in the late follow-up period. This series suggests that plastic surgery of congenital malformations of the atrioventricular valves should continue to be developed.