Regional Anesthesia for Neonates.

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Long-term results of mitral valve repair using autologous pericardium annuloplasty.

BACKGROUND AND AIM OF THE STUDY: The use of autologous pericardium for annuloplasty during mitral valve repair is a subject of controversy; hence, the study aim was to evaluate the authors' long-term results using this technique. METHODS: A retrospective review was conducted of 173 consecutive patients (mean age 59.6 +/- 16.3 years; range: 19-92 years) who underwent mitral valve repair complemented by annuloplasty between January 1998 and December 2003. The major causes of mitral regurgitation (MR) were annular dilatation and prolapse of the posterior leaflet. Annuloplasty was performed in all patients using a strip of pericardium treated with 0.6% glutaraldehyde for 10 min. Two rows of continuous horizontal mattress Gore-Tex sutures were used to secure the pericardium to the mitral annulus. Follow up continued for a mean period of 5.25 +/- 1.62 years (range: 1.97 to 9.43 years), and was complete. RESULTS: Three patients (1.7%) died within 30 days of surgery. Subsequently, five patients (2.9%) with MR (with or without mitral stenosis) underwent reoperation at a mean of 3.0 +/- 2.7 years after the initial surgery. At seven years after surgery the actuarial survival rate was 92.5%, and freedom from reoperation 97.1%. Follow up echocardiography was performed in 160 patients. Among these patients, no MR was detected in 34 (21.2%), while 88 (55%) had grade 1 MR, 35 (21.8%) grade 2, and three (1.8%) had grade 3. None of the patients had grade 4 MR. CONCLUSION: The study results indicated that autologous pericardium mitral annuloplasty of the mitral valve provides effective, durable and reproducible repair, and avoids the use of foreign materials.

Tricuspid valve repair using autologous pericardium annuloplasty in adults.

Uncorrected functional tricuspid regurgitation can lead to long-term morbidity and mortality. To evaluate our results using autologous pericardium annuloplasty to treat tricuspid regurgitation, we retrospectively reviewed 59 consecutive adult patients aged 19 years to 83 years (58.7 +/- 15.5 years) who underwent tricuspid valve annuloplasty between 2000 and 2003. Concomitant procedures consisted of mitral valve surgery in 83% of patients, aortic valve surgery in 28%, coronary bypass in 31%, and atrial-septal defect correction in 28%. Annuloplasty was performed using a strip of pericardium treated in glutaraldehyde 0.6% for 10 min. Two rows of continuous horizontal mattress Gore-Tex sutures were used to secure the pericardium to the tricuspid annulus. Follow-up was performed in 100% of the patients, and the mean follow-up was 4.4 +/- 1.2 years (range, 2.4 to 7 years). Postoperative death within 30 days occurred in 1 of 59 patients (1.6%). None of the patients required reoperation related to tricuspid regurgitation or stenosis. The actuarial survival rate was 98.4% at 7 years after operation. Echocardiography was performed in 58 of 58 surviving patients (100%). Up to 7 years postoperatively, tricuspid regurgitation was trace in 67.2% of patients, mild in 31%, and moderate in 1.8%; there was no occurrence of severe regurgitation on follow-up. Our results indicate that autologous pericardium tricuspid annuloplasty is a useful procedure in patients with moderate or severe tricuspid regurgitation. This procedure provides a durable, reproducible annuloplasty of the tricuspid valve.

Alcohol use in donors is a protective factor on recipients' outcome after heart transplantation.

OBJECTIVE: The outcome of heart transplantation is highly influenced by good donor selection. Because a history of alcoholism is prevalent among potential heart donors, we sought to explore the effect of alcohol use in donors on the outcome of heart transplantation in the recipient. METHOD: A total of 437 consecutive patients underwent heart transplantation from January 2002 through September 2005. Patients' files were retrospectively studied. Mean follow-up period was 3.14+/-1.9 years (range, 3 days to 6.5 yrs). The cohort was divided into two subgroups. The alcoholic donor group (ADG) included 98 of 421 patients and the nonalcoholic donor group (NADG) included 323 of 421 patients. Mean age was 35.3+/-11.4 yrs (range, 18-66) for the ADG and 33+/-12.2 yrs (range, 18-62) for the NADG. RESULTS: Mortality among the ADG was 7 of 98 (7.1%) and for NADG was 55 of 323 (17.1%) (P=0.015). The mean interval time between transplant and mortality was, for ADG, 27.7+/-20.6 months (range, 0.07-51) and for NADG, 16.4+/-19.6 months (range, 0.14-73) (P=0.031). Survival rate was significantly higher among the ADG at 72.8+/-1.9 months compared with NADG at 66.2+/-1.5 months (P=0.019). Overall rejection rate was 22 of 421 (5.2%); rejection rate was 17 of 323 (5.2%) in NADG and 5 of 98 (5.1%) in ADG. Rejection free survival was 74.6+/-0.85 with no significant difference between the two groups (P=0.85). CONCLUSION: The chronic alcoholism of donors was found to be a protective factor regarding the outcome after heart transplantation. Significant differences were found in mortality rate and survival after heart transplantation between the ADG and NADG. These data support the fact that it is safe to use donors' hearts regardless of a history of alcoholism.

Aortic valve-sparing repair with autologous pericardial leaflet extension has a greater early re-operation rate in congenital versus acquired valve disease.

OBJECTIVE: We sought to establish whether there was a difference in outcome after aortic valve repair with autologous pericardial leaflet extension in acquired versus congenital valvular disease. METHODS: One hundred and twenty-eight patients underwent reparative aortic valve surgery at our institution from 1997 through 2005 for acquired or congenital aortic valve disease. The acquired group (43/128) (34%) had a mean age of 56.4+/-20.3 years (range, 7.8-84.6 years) and the congenital group (85/128) (66%) had a mean age of 16.9+/-19.2 years (range, 0.3-82 years). The endpoints of the study were mortality and reoperation rates. RESULTS: Thirty-day mortality was 0/43 (0%) in the congenital group and 1/85 (1.1%) in the acquired group. Late mortality in the acquired group was 3/43 (7%) and 3/84 (3.5%) in the congenital group (neither early nor late proportion of mortality is significantly different between the two groups, according to the nonparametric Binomial test for proportions). There were 13 total reoperations among 11 patients: 1/43 (2.3%) in the acquired group and 10/85 (11.7%) in the congenital group (p=0.07). Two patients from the congenital group were reoperated on twice. The mean interval between original repair and reoperation was 3.6+/-5 years (range, 0-7 years) for acquired and 3.5+/-2.5 years (range, 0-7 years) for the congenital group (Wilcoxon 2-sample test, p=0.7). Total early reoperation rate (<30 days after first surgery) was 11/128 (8.5%); for the congenital group 9/85 (10.5%) and for the acquired group 2/43 (4.6%). Early reoperation rate was significantly higher among the congenital group (p=0.013). The remaining patients are well at mean follow-up of 2.8+/-2.4 years (range 0-7.9). In the acquired group, the mean postoperative aortic regurgitation and stenosis grade by echocardiography was 0.5+/-0.3 (scale, 0-4) and 0.3+/-0.1, respectively. In the congenital group, the follow-up, mean aortic regurgitation and stenosis were 0.9+/-0.8 and 0.5+/-0.3, respectively. CONCLUSIONS: There was no significant difference in early or late mortality and late reoperation rate between the two groups. Early reoperation rate was higher in the congenital versus the acquired aortic valvular disease group. This study supports the fact that the valve-sparing technique is safe and reproducible and repeatable in patients with acquired valve disease.