Normalizing Anti-Thrombin III for heparin management during routine cardiopulmonary bypass for congenital cardiothoracic surgery: A single institution practice review.

INTRODUCTION: Over the past decade, there has been an increase in the use of recombinant Anti-Thrombin III (AT-III) administration during neonatal and pediatric short- and long-term mechanical support for the replacement of acquired deficiencies. Recombinant AT-III (Thrombate) administration is an FDA licensed drug indicated primarily for patients with hereditary deficiency to treat and prevent thromboembolism and secondarily to prevent peri-operative and peri-partum thromboembolism. Herein we propose further use of Thrombate for primary AT-III deficiency of the newborn as well as for acquired dilution and consumption secondary to cardiopulmonary bypass (CPB). METHODOLOGY: All patients undergoing CPB obtain a preoperative AT-III level. Patients with identified deficiencies are normalized in the OR using recombinant AT-III as a patient load, in the CPB prime, or both. Patient baseline Heparin Dose Response (HDR) is assessed using the Heparin Management System (HMS) before being exposed to AT-III. If a patient load of AT-III is given, a second HDR is obtained and this AT-III Corrected HDR is used as the primary goal during CPB. Once CPB is initiated, an AT-III level is obtained with the first patient blood analysis. A subtherapeutic level results in an additional dose of AT-III. During the rewarm period, a final AT-III level is obtained and AT-III treated once again if subtherapeutic. A retrospective, matched analysis review of practice analyzing two groups, a Study Group (Repeat HDR, May 2022 onward) and Matched Group (Without Repeat HDR, July 2019 to April 2022), for age (D), weight (Kg) and operation was conducted. The focus of the study was to determine any change in heparin sensitivity identified post AT-III patient bolus load in the HDR (U/mL), Slope (U/mL/s), ACT (s), and total amount of heparin on CPB (U) and protamine (mg) used in each group. RESULTS: No significance was seen in Baseline AT-III (%), post heparin load HDR (U/mL), first CPB ACT (s), first CPB HDR (U/mL), or total CPB heparin (u/Kg) between the two groups. Statistical significance was seen in Baseline ACT (s), Baseline HDR (U/mL), Baseline Slope (U/mL/s), Post Heparin Load ACT (s), first CPB AT-III (%), and Protamine (mg/Kg) (p < .05). No statistical significance was seen in the Study Intragroup between pre versus post AT-III patient load baseline sample in ACT (s), however significance was seen in HDR (U/mL) and Slope (U/mL/s) (p < .05). CONCLUSION: Implementation of AT-III monitoring and therapy before and during CPB in conjunction with the HMS allows patients to maintain a steady state of anticoagulation with overall less need for excessive heparin replacement and potentially thrombin activation. The result is obtaining a steady state of anticoagulation, a reduced fluctuation in the heparin and ACT levels and a potential for lower co-morbidities associated with prolonged CPB times.

A novel approach to retrograde autologous priming for infant, pediatric and adult populations undergoing congenital heart surgery.

INTRODUCTION: Retrograde Autologous Priming (RAP) of cardiopulmonary bypass (CPB) circuits is an effective way to reduce prime volume, commonly through the transfer of prime into separate reservoirs or circuit manipulation. We describe a simple and safe technique for RAP without the need for any circuit modifications or manipulations. METHODS: For this technique, a separate roller pump for ultrafiltration (UF) is used. After adequate heparinization and arterial cannulation, the UF pump is initiated slowly, removing prime through the effluent of the UF, replacing with the patient's blood from the aortic cannula. Once the arterial line and UF circuit are autologous primed, the arterial head displaces reservoir crystalloid toward the UF circuit at a flow rate equal to the UF pump, displacing the crystalloid prime with blood from the UF circuit, autologous priming the boot and oxygenator with blood, crystalloid again being removed by the effluent. After venous cannulation, the venous line prime is replaced with autologous blood, the crystalloid removed by the effluent of the UF circuit via the arterial head. During RAP, if the patient becomes hypovolemic, either autologous volume is transfused back to the patient, or CPB is initiated, without the need for circuitry modifications. RESULTS: The patient population in this sample consisted of 63 patients ranging between 6.1 kg and 115.6 kg. The smaller the patient, the less blood volume available for RAP and therefore the less prime volume able to be removed. Overall percent removal increases as our patients size increases compared to total circuit volume. CONCLUSION: This RAP technique is a safe and effective way to achieve a standardized asanguinous prime for many regardless of patient or circuit size in the absence of contraindications such as low starting hematocrit, emergency surgery or physiologic instability. Most importantly, this potentially reduces the amount of hemodilution patients see from CPB initiation and therefore the lowest nadir hematocrit and consequently the amount of required homologous blood products needed during surgery.

International Pediatric Perfusion Practice: 2016 Survey Results.

New cardiopulmonary bypass device techniques emerge and are reported in the scientific literature. The extent to which they are actually adopted into clinical practice is not well known. Since 1989, we have periodically surveyed pediatric cardiac centers to ascertain practice patterns. In December 2016, a 186-question perfusion survey was distributed to pediatric cardiac surgery centers all over the world using a Web-based survey tool. Responses were received from 93 North American (NA) centers (the United States and Canada) and 67 non-NA (NNA) centers, representing 19,645 cumulative annual procedures in NA and 27,776 in NNA centers on patients <18 years. Wide variation in practice was evident across geographic regions. However, the most common pediatric circuit consisted of a hard-shell (open) venous reservoir, an arterial roller pump, and a hollow-fiber membrane oxygenator with a separate or integrated arterial filter. Compared with our previous surveys, there was increased utilization of all types of safety devices. The use of an electronic perfusion record was reported by 50% of NA centers and 31% of NNA centers. There was wide regional variation in cardioplegia delivery systems and cardioplegia solutions. Seventy-nine percent of the centers reported the use of some form of modified ultrafiltration. The survey demonstrated that there remains variation in perfusion practice for pediatric patients. Future surveys will be useful to evaluate the adoption of emerging perfusion practice guidelines.

Comprehensive blood conservation program in a new congenital cardiac surgical program allows bloodless surgery for the Jehovah Witness and a reduction for all patients.

BACKGROUND: Cardiac surgery on Jehovah's Witnesses (JW) can be challenging, given the desire to avoid blood products. Establishment of a blood conservation program involving the pre-, intra- and post-operative stages for all patients may lead to a minimized need for blood transfusion in all patients. METHODS: Pre-operatively, all JW patients were treated with high dose erythropoietin 500 IU/kg twice a week. JW patients were compared to matching non-JW patients from the congenital cardiac database, two per JW to serve as control. Blood use, ventilation time, bypass time, pre-operative hematocrit, first in intensive care unit (ICU) and at discharge and 24 hour chest drainage were compared. Pre-operative huddle, operating room huddle and post-operative bedside handoff were done with the congenital cardiac surgeon, perfusionist, anesthesiologist and intensive care team in all patients for goal alignment. RESULTS: Five JW patients (mean weight 24.4 ± 25.0 Kg, range 6.3 - 60 Kg) were compared to 10 non-JW patients (weight 22.0 ± 22.8 Kg, range 6.2 - 67.8 Kg). There was no difference in bypass, cross-clamp, time to extubation (0.8 vs. 2.1 hours), peak inotrope score (2.0 vs. 2.3) or chest drainage. No JW patient received a blood product compared to 40% of non-JW. The pre-operative hematocrit (Hct) was statistically greater for the JW patients (46.1 ± 3.3% vs. 36.3 ± 4.7%, p<0.001) and both ICU and discharge Hct were higher for the JW (37 ± 1.8% vs 32.4 ± 8.0% and 41 ± 8.1% vs 34.8 ± 7.9%), but did not reach statistical significance. All patients had similar blood draws during the hospitalization (JW x 18 mL/admission vs non-JW 20 mL/admission). CONCLUSION: The continuous application and development of blood conservation techniques across the continuum of care allowed bloodless surgery for JW and non-JW patients alike. Blood conservation is a team sport and to make significant strides requires participation and input by all care providers.

Development of a novel hybrid strategy for transcatheter pulmonary valve placement in patients following transannular patch repair of tetralogy of fallot.

BACKGROUND: Transcatheter pulmonary valve replacement (tPVR) is an accepted therapy for treatment of dysfunctional right ventricular outflow tract (RVOT) conduits. At present, the majority of Fallot patients who undergo transannular patch (TAP) repair are not candidates for tPVR due to the large irregular nature of their RVOT. Herein, we describe a novel approach to assessing the RVOT in this group, which may then be used to design, test, and carry out hybrid RVOT modification and transcatheter valve implantation in this population. METHODS: A retrospective analysis of TAP patients who underwent 3D modeling of the RVOT which was then used to develop individualized hybrid procedures designed to modify the RVOT, thereby rendering patients suitable for transcatheter valve implantation. RESULTS: Eight consecutive patients underwent 3D RVOT modeling followed by hybrid implantation of a transcatheter valve via a perventricular approach. A landing zone stent was placed in all and four required additional intravascular geometric remodeling of the RVOT prior to valve implant. Transcatheter valves were successfully implanted in all. There were no instances of valve malposition, embolization, or death. There was one minor procedural complication. No patient had more than trivial pulmonary regurgitation at follow-up. CONCLUSIONS: Using a hybrid approach to remodel the RVOT in TAP patients supported by preprocedural 3D-model planning allows for successful tPVR implantation in this population. A larger cohort and longer follow-up will be needed to determine the ultimate utility of this approach.

Rapid placement of bicaval dual-lumen catheter in a swine model of venovenous ECMO.

BACKGROUND: Venovenous (VV) extracorporeal membrane oxygenation (ECMO) applied through a single site with a bicaval dual-lumen (BCDL) catheter is a growing method of treatment of acute respiratory failure, thus animal models for research purposes are needed. We describe a rapid technique for the placement of the BCDL catheter for single-site VV ECMO in swine. DESIGN: Prior to the application of single-site VV ECMO model with common crossbred piglets, BCDL catheters were placed using anatomical landmarks. Transthoracic echocardiography (TTE) with color Doppler was used to determine catheter placement. Final determination of catheter placement was confirmed by necropsy. Arterial blood gas and hemodynamic parameters were recorded at baseline and then hourly. The values are mean ± SD. RESULTS: Using anatomical landmarks by positioning the BCDL catheter tip approximately 6.5 cm distal to the tip of the manubrium, cannulation was easily accomplished in five piglets with no positional adjustments of the catheter required. Cannula placement was confirmed with both TTE color Doppler and necropsy. Respiratory support was achieved with baseline and hourly measurements of pH 7.45 ± 0.03, 7.44 ± 0.07, 7.46 ± 0.05, 7.47 ± 0.06 (p = NS); PO2 86 ± 30 mmHg, 98 ± 30 mmHg, 94 ± 40 mmHg, and 79 ± 30 mmHg (p = NS); and PCO2 43 ± 3 mmHg, 44 ± 8 mmHg, 38 ± 5 mmHg, and 40 ± 4 mmHg (p = NS). CONCLUSIONS: Using anatomical landmarks for the placement of the BCDL catheter was rapid and effective in a swine model of VV ECMO, resulting in improved time efficiency for research.

Bloodless extracorporeal membrane oxygenation in the Jehovah's Witness patient.

The successful use of prolonged extracorporeal life support with a heart-lung machine was first performed in 1972, as described by Hill et al., on a young man with post-traumatic respiratory failure. The first successful use of extracorporeal membrane oxygenation (ECMO) was 1976 by Bartlett et al. Since this time, the use of ECMO for neonatal and pediatric pulmonary support has become a standard of care in many children's hospitals. The use of ECMO, being a very invasive procedure, is not without risk. In our experience, most patients require multiple transfusions of the different blood components (packed red blood cells, plasma, platelets, and cryoprecipitate). Exposure to one or more blood products often occurs with connection to the ECMO circuit, as the circuit is generally primed with blood products or whole blood. Jehovah's Witnesses (JWs) are known best in the medical community for their refusal of blood products, even at the risk of death, which presents challenges for health care providers. This belief stems from the biblical passages that have been quoted as forbidding transfusion: Genesis 9:3-4, Leviticus 17:13-14, and Acts 15:19-21. This refusal of blood poses even greater challenges when treating the pediatric JW population. When a blood product is deemed medically necessary for the JW patient, the healthcare provider must either seek legal intervention, or support the patient's/family's wishes and associated outcome. This ethical dilemma may be further complicated in the setting of therapies, which may pose additional risks and potentially less clear benefit such as with ECMO. Bloodless cardiac surgery with cardiopulmonary bypass has been reported in the JW population in adults and pediatrics, including neonates. After a thorough search of the literature, no published report of a JW patient being supported on ECMO without blood or blood component utilization was identified. This case report will present our experience with multiple day, bloodless ECMO support of a 17-year-old male patient of the JW faith.

Changes in hemodynamic parameters and cerebral saturation during supraventricular tachycardia.

Induced supraventricular tachycardia (SVT) during electrophysiology studies (EPS) can be associated with hemodynamic changes. Traditionally, invasive arterial blood pressure has been used for continuous monitoring of these changes. This prospective study evaluated the efficacy of near-infrared spectroscopy (NIRS) monitoring during SVT. The use of NIRS has expanded with evidence of its accuracy and benefit in detecting cerebral hypoperfusion. This study aimed first to determine the hemodynamic changes associated with electrophysiology testing for SVT and second to determine whether the hemodynamic changes are associated with similar changes in the cerebral saturation as determined by NIRS. The study enrolled 30 patients 5-20 years of age with a history of SVT who underwent an EPS. The demographic data included age, gender, weight, height, and type of SVT. Hemodynamic data (invasive blood pressure and heart rate), NIRS, bispectral index (BIS), end-tidal carbon dioxide, and pulse oximetry were collected before and during three episodes of induced SVT. The linear correlation coefficient (r) was measured to calculate the relationship of the changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) to the changes in NIRS values during the SVT episodes. Data from 22 patients were collected. The induction of SVT was associated mainly with a change in SBP and a less prominent change in DBP and MAP from baseline. The changes in hemodynamic status were associated with minimal changes in cerebral saturations, as evidenced by an average absolute change in NIRS of <1 from baseline value. The changes in hemodynamics were correlated linearly with cerebral saturation. Changes in SBP, DBP, and MAP were correlated positively with changes in NIRS, as denoted by (r) values of 0.52, 0.57, and 0.67 respectively, and a P value less than 0.05 for all three association tests. Induction of SVT during electrophysiology testing is associated with hemodynamic changes, mainly in SBP. In this study, these hemodynamic changes resulted in a minimal decrease in cerebral perfusion, as evidenced by minimal changes in the cerebral saturation measured by NIRS (0.7% from baseline). Although the changes in the cerebral saturation were minimal, these changes were linearly correlated with the changes in the hemodynamics. This study is the first to demonstrate the possible application of NIRS monitoring during EPS and to document that despite changes in the hemodynamic status, the changes in cerebral oxygenation are minimal, thereby confirming the safety of EPS for SVT.

In-vitro quantification of gaseous microemboli in two extracorporeal life support circuits.

During the course of extracorporeal membrane oxygenation, patients are at constant risk of exposure to air emboli. Air emboli may enter the circuit during routine lab sampling, medication administration, air entrainment through the venous cannula, or via a circuit disruption. Circuit components have been designed and positioned to minimize the quantity of air that travels through the arterial line to the patient. The purpose of this study was to assess the air handling of a newer generation extracorporeal life support circuit. The extracorporeal life support circuit consisted of an open hard-shell venous reservoir, Better Bladder (BB14) or silicone bladder (R-14), and Quadrox D oxygenator or 0800 silicone oxygenator. Air emboli detection sensors were placed in the extracorporeal life support circuit: post bladder, post oxygenator, and post heat exchanger if applicable.Air was injected as a 1 mL/min for 5 minutes injection or as a single 5 mL bolus. Emboli detection was recorded continuously during and for 3 minutes post air injection at two blood flow rates (Qb) (.5 and 1.2 L/min). All tests were performed in triplicate with each condition. All tested components reduced the embolic volume transmitted through the circuit. The quantity of this reduction was dependent on both the Qb and the air injection condition. During this in-vitro testing, air emboli passing through any of the components tested was decreased. Furthermore, the emboli delivery was reduced post component with the slower Qb (.5 L/min).

Use of a dose-dependent follow-up protocol and mechanisms to reduce patients and staff radiation exposure in congenital and structural interventions.

BACKGROUND: Increasingly complex structural/congenital cardiac interventions require efforts at reducing patient/staff radiation exposure. Standard follow-up protocols are often inadequate in detecting all patients that may have sustained radiation burns. METHODS: Single-center retrospective chart review divided into four intervals. Phase 1 (07/07-06/08, 413 procedures (proc)): follow-up based on fluoroscopy time only; frame rate for digital acquisition (DA) 30 fps, and fluoroscopy (FL) 30 fps. Dose-based follow-up was used for phase 2-4. Phase 2 (07/08-08/09, 458 proc): DA: 30 fps, FL: 15 fps. Phase 3 (09/09-06/10, 350 proc): DA: 15-30 fps, FL: 15 fps, use of added radiation protection drape. Phase 4 (07/10-10/10, 89 proc): DA: 15-30 fps, FL: 15 fps, superior noise reduction filter (SNRF) with high-quality fluoro-record capabilities. RESULTS: There was a significant reduction in the median cumulative air kerma between the four study periods (710 mGy vs. 566 mGy vs. 498 mGy vs. 241 mGy, P < 0.001), even though the overall fluoroscopy times remained very similar (25 min vs. 26 min vs. 26 min vs. 23 min, P = 0.957). There was a trend towards lower physician radiation exposure over the four study periods (137 mrem vs. 126 mrem vs. 108 mrem vs. 59 mrem, P = 0.15). Fifteen patients with radiation burns were identified during the study period. When changing to a dose-based follow-up protocol (phase 1 vs. phase 2), there was a significant increase in the incidence of detected radiation burns (0.5% vs. 2%, P = 0.04). CONCLUSIONS: Dose-based follow-up protocols are superior in detecting radiation burns when compared to fluoroscopy time-based protocols. Frame rate reduction of fluoroscopy and cine acquisition and use of modified imaging equipment can achieve a significant reduction to patient/staff exposure.

The impact of obesity on early postoperative outcomes in adults with congenital heart disease.

BACKGROUND: As the prevalence of obesity continues to increase, it now includes the growing number of patients with congenital heart disease (CHD). This particular obese patient population may pose additional intraoperative as well as postoperative challenges that may contribute to poor outcomes. Our aims were to determine the influence of obesity on morbidity and mortality in adults with CHD undergoing surgical repair at a free standing children's hospital. METHODS: A retrospective analysis of adult (≥18 years) CHD surgery cases from 2002 to 2008 was performed. Congenital heart lesions were defined as mild, moderate, or complex. Patients were categorized by body mass index (BMI): underweight (BMI < 20 kg/m(2)), normal (BMI 20-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)). Demographics, incidence of mortality, or specific morbidities were statistically compared using Fisher's exact test and analyses of variance (anovas). RESULTS: In this population (n = 165), overweight (29%) and obese (22%) patients were prevalent. Hypertension (HTN) and pre-HTN were more prevalent in obese and overweight patients. Postoperative renal dysfunction was observed in obese patients with complex CHD (P = .04). Mortality was not different among groups. CONCLUSIONS: Obesity is becoming increasingly common among adults with CHD. Despite marginal evidence of postoperative renal complications in obese patients with CHD of severe complexity, the overall presence of obesity did not influence mortality or short term postoperative morbidities.

Perioperative care of an infant with an anomalous left innominate artery arising from the main pulmonary artery.

A 1.4-kilogram, male infant was born at 27 weeks gestation at an outside hospital. After birth, the patient's trachea was intubated and surfactant administered. Initial echocardiogram showed a patent ductus arteriosus (PDA) and a ventricular septal defect (VSD), with a possible aberrant vessel arising from the carotid artery. The patient was transferred to our hospital for further management. Repeat echocardiogram showed a right aortic arch with the left common carotid/innominate artery arising from the pulmonary artery. The infant was subsequently brought to the operating room where following sternotomy, the aberrant left innominate artery was reimplanted into the aorta. The origin of the left carotid artery or innominate artery from the pulmonary artery is an extremely rare form of congenital heart disease with a limited number of reports in the literature. The differential pressure gradient between the systemic and pulmonary beds may lead to a steal phenomenon, with shunting of blood from the carotid system into the pulmonary vascular bed, resulting in decreased cerebral blood flow. The left-to-right shunting from the systemic to pulmonary bed may also lead to volume overload of the left side of the heart. In the perioperative care of such patients, control of physiologic factors that control the balance between the pulmonary and systemic vascular resistance is mandatory to ensure that cerebral blood flow is maintained.

Changes in near-infrared spectroscopy and the bispectral index during tilt-table examination.

The head-upright tilt-table test is an important tool for the diagnosis of vasodepressor or neurocardiogenic syncope. The use of noninvasive near-infrared spectroscopy (NIRS) monitoring and bispectral index (BIS) monitoring during these cases can add another tool to the real-time monitoring and aid in their diagnosis. The authors report their experience using NIRS and BIS monitoring during tilt-table testing to investigate syncope in a 14-year-old adolescent. In this case, changes in the NIRS occurred earlier than changes in either blood pressure or the development of clinical symptoms. The change in the NIRS and BIS values correlated with the patient's level of consciousness. One major advantage of monitors such as the BIS, and more importantly, the NIRS is that they provide an instantaneous and continuous noninvasive measure of cerebral perfusion.

Modified surface coatings and their effect on drug adsorption within the extracorporeal life support circuit.

A recently completed study quantified the percent of fentanyl or morphine sulfate lost to uncoated polyvinylchloride (PVC) tubing or to one of two hollow fiber oxygenators within the extracorporeal life support (ECLS) circuit. The results demonstrated the majority of drug loss was due to adsorption by the PVC tubing. The purpose of this study was to determine if a tubing coating process affects fentanyl or morphine Sulfate adsorption. The goal was to quantify fentanyl or morphine sulfate lost due to adhesion within surface modified tubing. The following surface modifications were studied: 1) Maquet Safeline (synthetic immobilized albumin); 2) Maquet Softline (a heparin free biopassive polymer); 3) Maquet Bioline (recombinant human albumin + heparin) (Maquet Cardiopulmonary AG, Hirrlingen, Germany); 4) Terumo X Coating (poly2methoxylacrylate)) (Terumo Cardiovascular Systems Corporation, Ann Arbor, MI); 5) Medtronic Carmeda (covalently bonded heparin); and 6) Medtronic Trillium (covalently bonded heparin) (Medtronic, Minneapolis, MN). A total of 36 individual circuits were built from the above six available modified surface coatings, for a total of six individual circuits of each coating type. Blood samples were drawn at 5 minutes, 120 minutes, and 360 minutes followed by High-Performance Liquid Chromatography to determine available circulating levels of either fentanyl or morphine sulfate. Fentanyl concentrations decreased to an average final available concentration of 35% (+/- 5%) within the 18 circuits. Morphine sulfate however, decreased to a final available concentration of 57% (+ 1%) in all Maquet tubing and the Medtronic Trillium tubing, while it decreased to a final concentration of 35% (+ 1%) in the Medtronic Carmeda coated tubing and in the Terumo X Coating tubing. Biocompatible ECLS circuit surface coatings affected drug-adsorption and availability. Further evaluation is necessary to understand the adsorptive loss of other drugs administered to our patients while on modified surface coated ECLS circuits.

Perfusion techniques toward bloodless pediatric open heart surgery.

There continues to be evidence regarding the negative impact of blood transfusion on morbidity and mortality in the adult literature, including infection risk, increased hospital and intensive care length of stay, and costs. More effort has been put into reducing the use of blood components in adult surgical centers but blood transfusions continue to be used frequently in pediatric centers. From 2002 through 2005, we embarked on a mission of reduced prime volume in an effort toward bloodless cardiac surgery to meet the needs of the Jehovah's Witness patient. The same bloodless surgical and perfusion techniques were applied to all patients undergoing cardiopulmonary bypass beginning in 2006. Circuit size was minimized and acute normovolemic hemodilution (ANH) was considered and attempted more often, especially if a re-operation. Retrograde arterial prime (RAP) and venous antegrade prime (VAP), dilutional or balanced ultrafiltration during cardiopulmonary bypass, modified arteriovenous ultrafiltration post bypass, and cell salvage of remaining circuit contents after flushing with crystalloid were recorded. ANH, RAP, and VAP, separately or in combination, were used less than 1% of the time prior to 2006. From 2006-2008 ANH was performed on 42% of the patients and RAP/ VAP was performed on 70% of the patients. From 2006-2008, 43% (287 of 662) of the open heart surgeries were performed bloodless in the operating room versus 30% (193 of 633) from 2003-2005. Bloodless surgery more than doubled for the 0-6, 6-15, and 15-20 kg groups from 3.5%, 23%, and 23% respectively in 2003-2005 to 9%, 44%, and 58%, respectively in 2006-2008. With the cooperation of the entire cardiac surgical team, bloodless open heart surgery is achievable in a pediatric cardiac surgical center, including neonates.

Rationale and use of perfusion variables in the 2010 update of the society of thoracic surgeons congenital heart surgery database.

Patients undergoing congenital heart surgery are at risk of morbidity and mortality. The reasons underlying this risk are complex. To identify opportunities to reduce adverse sequelae, the cardiovascular perfusion community was invited to amend existing perfusion-related fields as well as add new ones to the current version of the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). The International Consortium for Evidence-Based Perfusion (ICEBP) was invited by the STS-CHSD Task Force to identify and resolve ambiguities related to definitions among the 3 current perfusion-related fields as well as to propose new variables (and definitions) for inclusion in the 2010 update of the STS-CHSD. The ICEBP used teleconferences, wiki-based communication software, and e-mail to discuss current definitions and create new fields with definitions. The ICEBP created modified definitions to existing fields related to cardiovascular perfusion and also developed and defined new fields that focus on (1) techniques of circulatory arrest and cerebral perfusion, (2) strategies of myocardial protection, and (3) techniques to minimize hemodilution and allogeneic blood transfusions. Three fields in the STS-CHSD related to perfusion were redefined, and 23 new variables and definitions were selected for inclusion. Identifying and defining fields specific to the practice of perfusion are requisite for assessing and subsequently improving the care provided to patients undergoing congenital heart surgery. The article describes the methods and justification for adjudicating extant and new perfusion-related fields added to the 2010 update of the STS-CHSD.

Radiation protection during hybrid procedures: innovation creates new challenges.

BACKGROUND: The cooperation between interventional cardiologists and cardiothoracic surgeons has expanded the spectrum of treatment modalities for patients with congenital heart disease. These hybrid techniques have created new challenges, one of which being the provision of adequate but practical radiation protection. This study evaluates the use of a lightweight radiation protection drape (RADPAD) that may be suitable for shielding during hybrid procedures. METHODS: To simulate a pediatric patient, an 8.7 liter water-filled tub was placed on an X-ray table and exposed to 10-second cine acquisition runs. Radiation exposure was measured at twelve specified locations around the table using a model with three different levels of radiation protection: no shielding, shielding using a traditional 0.35 mm lead-equivalent apron, and shielding using the 0.25 mm lead-equivalent RADPAD. RESULTS: The traditional lead apron and the RADPAD significantly reduced the amount of radiation dose when compared with no shielding. The standard lead apron provided slightly greater radiation protection than the RADPAD (0.000064 radiation absorbed dose [rad] vs. 0.000091 rad; p = 0.012). The measured rad was significantly higher on the right side of the table, and the measured radiation dose decreased significantly with increasing distance from the table. CONCLUSIONS: The RADPAD has been shown to function as an efficient shielding device, even though it does not quite match the protection that can be expected from a standard lead apron. It complies with regulatory radiation protection requirements and its lightweight and sterile use make it particularly useful during hybrid procedures in the operating room.

Completion angiography after cardiac surgery for congenital heart disease: complementing the intraoperative imaging modalities.

Residual structural pathology after cardiac surgery for congenital heart disease may complicate postoperative recovery. Completion angiograms obtained in the operating room may facilitate early detection and therapy of residual structural abnormalities. Our objective here is to report our institutional experience performing completion angiograms after cardiopulmonary bypass surgery. Between October 2007 and August 2008, 31 patients underwent completion angiograms after 32 cardiac surgical procedures. The median age was 7.5 months (range, 50 days to 31.2 years) and the median weight was 6.5 kg (range, 3.1-153 kg). Type of procedure, angiographic findings, and therapeutic decision were retrospectively reviewed. Procedures (proc) evaluated through completion angiography included comprehensive stage II or Glenn (n = 13), aortic arch reconstruction/conduit (n = 3), repair/palliation of tetralogy of Fallot or pulmonary atresia with ventricular septal defect (n = 4), PVR or conduit replacement (n = 5), and others (n = 7). Unexpected pathology was identified in 18 of 32 (56.3%) proc, which included left pulmonary artery (LPA) stenoses (n = 15), right pulmonary artery (RPA) stenoses (n = 11), and stenosis impairing coronary blood flow (after DKS; n = 1). In 9 of 32 (28.1%) proc, findings may have led to a change in therapeutic management. This included surgical revision (n = 1), 'Hybrid' therapy in the same setting (n = 2: LPA stent, 1; RPA balloon, 1), early catheterization within 3 months (n = 4), and change in medical management (n = 2: change in anticoagulation, 1; early CT, 1). Complications related to completion angiography were seen in only a single procedure (LPA staining). In conclusion, completion angiograms using a dedicated Hybrid cardiac operating suite may aid in early diagnosis and therapy of postsurgical abnormalities. They complement other methods of intraoperative imaging and may reduce the potential need for early surgical or transcatheter reintervention.

Predictors of successful early extubation following congenital cardiac surgery in neonates and infants.

BACKGROUND: There is a paucity of literature discussing the predictive likelihood of successfully extubating neonates and infants in the operating room immediately following congenital cardiac surgery. Given the unknown consequences of anaesthetics on neurodevelopmental outcomes, minimising the exposure of this population to such agents may have long-term benefits. METHODS: Retrospective chart review of 391 patients less than 1 year of age. RESULTS: The probability of successfully extubating these patients was based on quantifiable, objective criteria. The relevant variables include age, weight, bypass time, lactate level and specific congenital anomaly. CONCLUSIONS: The practice of immediate extubation of infants and neonates is achievable, safe and predicted based on specific patient variables. This practice will minimise the anaesthetic exposure of these especially young patients who may be at risk for long-term consequences related to anaesthetic exposure.