Outcomes related to immediate extubation after stage 1 Norwood palliation for hypoplastic left heart syndrome.

OBJECTIVE: Immediate extubation may have outcome benefits when judiciously instituted after neonatal congenital cardiac surgery. We sought to evaluate the outcomes of immediate extubation specifically in neonates undergoing stage 1 Norwood palliation of hypoplastic left heart syndrome. METHODS: Consecutive neonates undergoing stage 1 Norwood (January 2010 to December 2016) for hypoplastic left heart syndrome were retrospectively studied. Immediate extubation was defined as successful extubation before termination of anesthetic care. Preoperative and intraoperative variables were compared between immediate extubation and nonimmediate extubation groups, and bivariate analyses and descriptive methods were used to express the association of outcome variables with immediate extubation. Data were expressed as number and percent for categoric variables, and median and interquartile range for continuous variables. RESULTS: Of 23 patients who underwent stage 1 palliation, 5 had immediate extubation (22%). There were no differences in preoperative or intraoperative factors between patients who did and did not undergo immediate extubation. There were no deaths in the immediate extubation group. In the nonimmediate extubation group, 3 patients died before hospital discharge. One patient who had immediate extubation and 4 patients among those who did not have immediate extubation had to be reintubated in the 96 hours that followed extubation (P = 1). Intensive care unit length of stay was 8 (3-17) and 8 (5-18) (days) for the immediate extubation group and nonimmediate extubation groups, respectively (P = .71). CONCLUSIONS: Immediate extubation strategy was safely accomplished in one-fifth of this cohort of hypoplastic left heart syndrome. A larger cohort may delineate the determinants of immediate extubation and its benefits in infants undergoing stage 1 single ventricle palliation.

Clinical Outcome of Patients With Inducible Capillary Blood Flow Abnormalities During Demand Stress in the Presence or Absence of Angiographic Coronary Disease.

BACKGROUND: Our aim was to determine the cardiovascular outcome of patients with capillary blood flow (CBF) abnormalities detected during demand stress in the absence of obstructive coronary artery disease. METHODS AND RESULTS: We identified 380 consecutive patients referred for coronary angiography (CA) after dobutamine or exercise stress echocardiography (SE) between 2008 and 2013 performed with real-time perfusion imaging to examine myocardial CBF with a continuous ultrasound contrast infusion. Patients with left ventricular ejection fraction <40% were excluded. There were 3 groups based on results: positive SE/negative CA, patients who had abnormal regional CBF but no significant angiographic disease; positive SE/positive CA, those with abnormal CBF and significant disease on subsequent CA; and negative SE/negative CA, patients with normal CBF and negative CA. Event-free survival examining death and nonfatal myocardial infarction was compared. Median follow-up was 4 years. There were 91 positive SE/negative CA, 189 positive SE/positive CA, and 100 negative SE/negative CA patients over the study period. The positive SE/negative CA patients were more frequently women and had a lower prevalence of hypertension and hyperlipidemia (all P<0.001). Analysis of event-free survival with Cox regression demonstrated that death/nonfatal myocardial infarction rates were higher in the positive SE/positive CA (hazard ratio, 2.10; CI, 1.02-4.29) and positive SE/negative CA (hazard ratio, 2.02; CI, 0.99-4.31) groups when compared with negative SE/negative CA groups. CONCLUSIONS: Patients with inducible CBF abnormalities in the absence of significant obstructive disease at CA still have similar death/nonfatal myocardial infarction rates as those with significant disease at CA.

Five-year experience with immediate extubation after arterial switch operations for transposition of great arteries.

Objectives: We sought to identify preoperative, intraoperative and anatomical factors associated with immediate extubation (IE) after arterial switch operation for d-transposition of great arteries (dTGA). Methods: This was a single-centre retrospective study performed from 1 January 2010 to 30 June 2015. IE was defined as successful extubation in the operating room (OR). Univariate/bivariate regression of preoperative, intraoperative and anatomical variables was used to determine associations with IE. Results: Of 32 patients in the dTGA spectrum (age at operation 6 days), 18 (56%) underwent IE. Twelve (71%) of the 17 patients with an intact ventricular septum and 6 (43%) of the 14 patients with ventricular septal defect (VSD) underwent IE, whereas none of the patients with double outlet right ventricle or aortic arch obstruction ( n = 4) did. Patients who had cardiopulmonary bypass time (CPB) >173 min ( P = 0.01), lowest temperature on CPB (T min) ≤ 30.4°C ( P = 0.04) and aortic cross-clamp time >86 min ( P = 0.04) were more likely to be left intubated at the end of the procedure. There was no significant difference in patient's chronological age, gestational age, post-conceptual age, weight, coronary anatomy or prevalence of VSD between those who did and did not undergo IE. There was a median increase in intensive care unit (ICU) length of stay (LOS) by 1 day (33%, P = 0.03) and ICU costs by $12 338 (15%, P = 0.06) in non-IE patients. The OR turnover time ( P = 0.09) and reintubation rate ( P = 1) at 24 h post-extubation did not differ between those who did and did not have IE. There was no myocardial dysfunction evident on predismissal echocardiography in either group. Conclusions: In this cohort of infants, post repair for TGA, 56% were extubated immediately in the OR. Greater CPB and cross-clamp times and T min ≤ 30.4°C were associated with a lesser likelihood of IE. IE was associated with shorter ICU length of stay.