Influence of the type of congenital heart defects on epithelial lining fluid composition in infants undergoing cardiac surgery with cardiopulmonary bypass.

BackgroundIn children with congenital heart disease (CHD), altered pulmonary circulation compromises gas exchange. Moreover, pulmonary dysfunction is a complication of cardiac surgery with cardiopulmonary bypass (CPB). No data are available on the effect of different CHDs on lung injury. The aim of this study was to analyze epithelial lining fluid (ELF) surfactant composition in children with CHD.MethodsTracheal aspirates (TAs) from 72 CHD children (age 2.9 (0.4-5.7) months) were obtained before and after CPB. We measured ELF phospholipids, surfactant proteins A and B (SP-A, SP-B), albumin, and myeloperoxidase activity. TAs from 12 infants (age 1.0 (0.9-2.9) months) with normal heart/lung served as controls.ResultsHeart defects were transposition of great arteries (19), tetralogy of Fallot (TOF, 20), atrial/ventricular septal defect (ASD/VSD, 22), and hypoplastic left heart syndrome (11). Increased levels of ELF SP-B were found in all defects, increased myeloperoxidase activity in all except the TOF, and increased levels of ELF albumin and SP-A only in ASD/VSD patients. Postoperatively, ELF findings remained unchanged except for a further increase in myeloperoxidase activity.ConclusionELF composition has distinctive patterns in different CHD. We speculate that a better knowledge of the ELF biochemical changes may help to prevent respiratory complications.

Less-invasive off-pump ventricular assist device implantation in regional paravertebral analgesia.

We describe the clinical course and treatment of a 58-year-old male with a primary cardiogenic shock, who underwent a minimally invasive off-pump ventricular-assist-device (VAD) implantation with the aid of paravertebral regional analgesia. He was extubated soon after the procedure, in the operating room, with the aim to reduce the right ventricle impairment. We illustrate how a minimally invasive implant may improve the clinical outcomes of VAD patients shortening their return time to active life.

Cardiopulmonary-Bypass Glial Fibrillary Acidic Protein Correlates With Neurocognitive Skills.

BACKGROUND: Neurocognitive deficits at school starting age may affect as many as 50% of children who underwent cardiac surgery for complex congenital heart disease (CHD). The aim of this study was to identify which phases of cardiopulmonary bypass (CPB) are associated with an increased risk of impaired neurodevelopmental skills in children with complex CHD. This was assessed by means of glial fibrillary acidic protein (GFAP) plasma levels during CPB for CHD surgery, as a marker of neurologic insult. We correlated GFAP levels with clinical parameters and neurodevelopmental outcome. METHODS: We studied 45 children undergoing surgery for complex CHD. We measured plasma GFAP levels by enzyme-linked immunosorbent assay at the following steps: anesthesia induction, CPB start, end of hypothermia, end of rewarming, and end of CPB. Neurologic assessment and Vineland Adaptive Behavior Scales (VABS-I) were administered to patients at least 18 months after surgery. RESULTS: GFAP was undetectable before surgery and it peaked at the end of hypothermia or rewarming. Multiple regression analyses showed that GFAP peak level and preoperative neurologic comorbidity were significant independent predictors of neurologic impairment, as showed by VABS-I communication domain intelligence quotient (IQ). Receiver operating characteristic curve showed that the model was highly significant. CONCLUSIONS: Impaired neurodevelopment was associated with increase of GFAP plasma levels during cardiac surgery in infants. The identification of the neurologic high-risk phases of CPB run could support the application of new neuroprotective strategies for CHD repair.

A pilot study on the efficacy and safety of a minimally invasive surgical and anesthetic approach for ventricular assist device implantation.

BACKGROUND: The aim of our study was to compare 2 surgical and anesthetic approaches during ventricular assist device implantation. METHODS: 68 patients (50.4 ± 17.1 years old) were supported with the HeartWare® HVAD (32 patients) and the Jarvik 2000 VAD (36 patients) between January 2010 and August 2016. Two surgical techniques were applied: a minimally invasive approach with the aid of paravertebral-block (mini-invasive group, 41 patients) and a standard-surgical-approach with the aid of general anesthesia (27 patients). RESULTS: The minimally invasive approach allowed faster postoperative recovery by significantly reducing the duration of surgery (p<0.05), anesthesia (p<0.05), mechanical ventilation (p<0.05), inotropic support (p<0.05), ICU and in-hospital stay (p<0.05), and time to first mobilization (p<0.05). No case of epidural hematoma was observed. Eleven patients died (16%) at 30 days, 3 in the mini-invasive group (7.3%) and 8 in the invasive group (29.6%). CONCLUSIONS: Minimally invasive approaches play a substantial role in VAD surgery by facilitating faster recovery, which is important for patients at very high risk.

Simultaneous coronary artery bypass grafting and carotid endarterectomy in an awake Jehova's witness patient without endotracheal intubation.

Complex surgical procedures are associated with a major risk of peri-operative bleeding. Jehova's witnesses (JW) necessitate a tailored strategy warranting the optimal surgical management, in observance to their religion principles. In this report, we present a JW female patient, who underwent combined coronary artery bypass grafting and carotid endarterectomy, with neither endotracheal intubation nor general anaesthesia. Patient had previously undergone bilateral endarterectomy and required a reoperation on the left side. She was also scheduled for revascularization of left anterior descending coronary artery. After an extensive evaluation of all the possible operative strategies, we planned to perform CABG via a mid-line sternotomy, followed by CEA, in the awake patient. There were no intra-operative complications. Hb level, monitored by blood gases controls, maintained above 10 g/dl. The post-operative course was uneventful. In this patient, for the first time, a high-risk CABG procedure and a high-risk CEA were carried out simultaneously, in the awake setting. This approach represented a meeting point between surgical requirements and specific patient's needs. We believe it could be a safe alternative management applicable to high risk candidates to combined carotid and coronary artery surgery, presenting with bleeding-related issues.

Anesthetic considerations for nontransplant procedures in lung transplant patients.

Lung transplantation has become an accepted option for many patients with end-stage pulmonary diseases. Anesthesia and surgery following lung transplantation may be required for various diseases that may affect both systemic organs and the transplanted graft. When a patient with a lung transplant undergoes surgery, there is the potential for interference with lung function, depending on the type of intervention and its anatomical site. Accurate preoperative evaluation, an understanding of the physiology of the transplanted lung, proper airway instrumentation, individualized management of intraoperative ventilation, and fluid balance are essential for a positive perioperative outcome.

Minimally invasive operation for congenital heart disease: a sex-differentiated approach.

OBJECTIVES: Since 1996, we have routinely used a minimally invasive sex-differentiated surgical approach for surgical repair of various simple congenital heart diseases, mostly including a right anterior minithoracotomy in female subjects and a midline ministernotomy in male subjects. METHODS: Between August 1996 and December 2004, all patients who underwent a sex-differentiated surgical approach were included. Hospital results were compared with those of a group undergoing full sternotomy (control subjects). Patients' clinical conditions and satisfaction at follow-up were evaluated. RESULTS: Three hundred eight patients underwent the sex-differentiated surgical approach: (1) minithoracotomy in 147 (47.7%) and (2) ministernotomy in 161 (52.3%). Thirty patients had a full sternotomy for atrial septal defect closure. The most common diagnosis was an atrial septal defect (231 [75%] patients). None of the patients required an extension of the surgical access. There were neither major complications nor hospital deaths. All patients were discharged home without residual defects. Median follow-up time was 71.5 months (range, 48.2-85.7 months). There were no late deaths. No scoliosis, asymmetric breast development, or lactation problems were reported in the minithoracotomy group. Twenty-five (17%) of 147 patients with minithoracotomies complained of a trivial, persistent (<6 months), sensitive skin deficit in the mammary area, most often localized at the inferomedial quadrant. The vast majority of patients (296 [96%] 308 patients) were in New York Heart Association class I, and 282 (91.5%) of 308 patients were satisfied with the cosmetic result of the operation. CONCLUSIONS: The sex-differentiated surgical approach for simple congenital heart disease is a safe procedure, providing both excellent functional and cosmetic results. Anterolateral minithoracotomy is a valid and highly appreciated procedure in female patients.