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BACKGROUND: We report our comprehensive approach to patients with hypoplastic left heart syndrome (HLHS) and describe our outcomes in 100 consecutive neonates. METHODS: One-hundred consecutive neonates (2015-2023) were stratified into 3 pathways: Pathway(1): 77/100=77% were standard-risk and underwent initial Norwood (Stage 1). Pathway(2): 10/100=10% were high-risk with noncardiac risk factors and underwent initial Hybrid Stage 1. Pathway(3): 13/100=13% were high-risk with cardiac risk factors: 10 underwent initial Hybrid Stage 1 + ventricular assist device insertion (HYBRID+VAD), while 3 underwent primary transplantation. RESULTS: One-year mortality=9/100=9%. Pathway(1): Operative Mortality for initial Norwood (Stage 1)=2/77=2.6%. Of 75 survivors of Norwood (Stage 1): 72 underwent successful Glenn, 2 underwent successful biventricular repair, and 1 underwent successful cardiac transplantation. Pathway(2): Operative Mortality for initial Hybrid Stage 1 without VAD=1/10=10%. Of 9 survivors of Hybrid (Stage 1): 4 underwent successful cardiac transplantation, 2 died while awaiting cardiac transplantation, 3 underwent Comprehensive Stage 2 (with 1 death), and 1 underwent successful biventricular repair. Pathway(3): Of 10 HYBRID+VAD: 7/10=70% underwent successful cardiac transplantation and are alive today and 3/10=30% died on VAD while awaiting transplantation. Median VAD support time=134 days (range=56-226). (Two of three patients who were bridged-to-transplant with prostaglandin underwent successful transplantation and one died while awaiting transplantation.) CONCLUSIONS: A comprehensive approach to the management of patients with HLHS is associated with Operative Mortality after Norwood of 2/77=2.6% and an overall one-year mortality of 9/100=9%. 10/100 patients=10% were stabilized with HYBRID+VAD while awaiting transplantation. VAD facilitates survival on the waiting list during prolonged wait times.
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OBJECTIVES: We reviewed outcomes in all 36 consecutive children <5 kg supported with the Berlin Heart pulsatile ventricular assist device at the University of Florida, comparing those with acquired heart disease (n = 8) to those with congenital heart disease (CHD) (n = 28). METHODS: The primary outcome was mortality. The Kaplan-Meier method and log-rank tests were used to assess group differences in long-term survival after ventricular assist device insertion. T-tests using estimated survival proportions were used to compare groups at specific time points. RESULTS: Of 82 patients supported with the Berlin Heart at our institution, 49 (49/82 = 59.76%) weighed <10 kg and 36 (36/82 = 43.90%) weighed <5 kg. Of 36 patients <5 kg, 26 (26/36 = 72.22%) were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 36 patients <5 kg was [days]: median = 109, range = 4-305.) Eight out of 36 patients <5 kg had acquired heart disease, and all eight [8/8 = 100%] were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 8 patients <5 kg with acquired heart disease was [days]: median = 50, range = 9-130.) Twenty-eight of 36 patients <5 kg had congenital heart disease. Eighteen of these 28 [64.3%] were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 28 patients <5 kg with congenital heart disease was [days]: median = 136, range = 4-305.) For all 36 patients who weighed <5 kg: 1-year survival estimate after ventricular assist device insertion = 62.7% (95% confidence interval = 48.5-81.2%) and 5-year survival estimate after ventricular assist device insertion = 58.5% (95% confidence interval = 43.8-78.3%). One-year survival after ventricular assist device insertion = 87.5% (95% confidence interval = 67.3-99.9%) in acquired heart disease and 55.6% (95% confidence interval = 39.5-78.2%) in CHD, P = 0.036. Five-year survival after ventricular assist device insertion = 87.5% (95% confidence interval = 67.3-99.9%) in acquired heart disease and 48.6% (95% confidence interval = 31.6-74.8%) in CHD, P = 0.014. CONCLUSION: Pulsatile ventricular assist device facilitates bridge to transplantation in neonates and infants weighing <5 kg; however, survival after ventricular assist device insertion in these small patients is less in those with CHD in comparison to those with acquired heart disease.
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BACKGROUND: We reviewed the outcomes of 82 consecutive pediatric patients (less than 18 years of age) supported with the Berlin Heart ventricular assist device (VAD), comparing those with congenital heart disease (CHD; n = 44) with those with acquired heart disease (AHD; n = 37). METHODS: The primary outcome was mortality after VAD insertion. Kaplan-Meier methods and log-rank tests were used to assess group differences in long-term survival. RESULTS: Forty-four CHD patients were supported (age: median = 65 days, range = 4 days-13.3 years; weight [kg]: median = 4, range = 2.4-42.3). Ten biventricular CHD patients were supported with eight biventricular assist devices (BiVADs), one left ventricular assist device (LVAD) only, and one LVAD converted to BiVAD, while 34 univentricular CHD patients were supported with single ventricle-ventricular assist devices (sVADs). In CHD patients, duration of VAD support was [days]: median = 134, range = 4-554. Of 44 CHD patients, 28 underwent heart transplantation, 15 died on VAD, and one was still on VAD. Thirty-seven AHD patients were supported (age: median = 1.9 years, range = 27 days-17.7 years; weight [kg]: median = 11, range = 3.1-112), including 34 BiVAD and 3 LVAD. In AHD patients, duration of VAD support was [days]: median = 97, range = 4-315. Of 37 AHD patients, 28 underwent transplantation, three died on VAD, five weaned off VAD (one of whom underwent heart transplantation 334 days after weaning), and one was still on VAD. One-year survival after VAD insertion was 59.9% (95% CI = 46.7%-76.7%) in CHD and 88.6% (95% CI = 78.8%-99.8%) in AHD, P = .0004. Five-year survival after VAD insertion was 55.4% (95% CI = 40.8%-75.2%) in CHD and 85.3% (95% CI = 74.0%-98.2%) in AHD, P = .002. CONCLUSIONS: Pulsatile VAD facilitates bridge-to-transplantation in neonates, infants, and children with CHD; however, survival after VAD insertion is worse in patients with CHD than in patients with AHD.
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Cardiopatías Congénitas , Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Lactante , Recién Nacido , Niño , Humanos , Resultado del Tratamiento , Ventrículos Cardíacos , Estudios RetrospectivosRESUMEN
OBJECTIVES: We reviewed outcomes in all 36 consecutive children <5 kg supported with the Berlin Heart pulsatile ventricular assist device (VAD) at the University of Florida, comparing those with univentricular circulation (n = 23) to those with biventricular circulation (n = 13). METHODS: The primary outcome was mortality. Kaplan-Meier methods and log-rank tests were used to assess group differences in long-term survival after VAD insertion. T-tests using estimated survival proportions and standard errors were used to compare groups at specific time points. RESULTS: Of all 82 patients ever supported with Berlin Heart at our institution, 49 (49/82 = 59.76%) weighed <10 kg and 36 (36/82 = 43.90%) weighed <5 kg. Of these 36 patients who weighed <5 kg, 26 (26/36 = 72.22%) were successfully bridged to transplantation. Of these 36 patients who weighed <5 kg, 13 (13/36 = 36.1%) had biventricular circulation and were supported with 12 biventricular assist devices (BiVADs) and 1 left ventricular assist device (LVAD) (Age [days]: median = 67, range = 17-212; Weight [kilograms]: median = 4.1, range = 3.1-4.9), while 23 (23/36 = 63.9%) had univentricular circulation and were supported with 23 single ventricle-ventricular assist devices (sVADs) (Age [days]: median = 25, range = 4-215; Weight [kilograms]: median = 3.4, range = 2.4-4.9). Of 13 biventricular patients who weighed <5 kg, 12 (12/23 = 92.3%) were successfully bridged to cardiac transplantation. Of 23 functionally univentricular patients who weighed <5 kg, 14 (14/23 = 60.87%) were successfully bridged to cardiac transplantation. For all 36 patients who weighed <5 kg: 1-year survival estimate after VAD insertion = 62.7% (95% confidence interval [CI] = 48.5%-81.2%) and 5-year survival estimate after VAD insertion = 58.5% (95% CI = 43.8%-78.3%). One-year survival after VAD insertion: 84.6% (95% CI = 67.1%-99.9%) in biventricular patients and 49.7% (95% CI = 32.3%-76.4%) in univentricular patients, P = 0.018. Three-year survival after VAD insertion: 84.6% (95% CI = 67.1%-99.9%) in biventricular patients and 41.4% (95% CI = 23.6%-72.5%) in univentricular patients, P = 0.005. CONCLUSION: Pulsatile VAD facilitates bridge to transplantation in neonates and infants weighing <5 kg; however, survival after VAD insertion in these small patients is less in those with univentricular circulation in comparison to those with biventricular circulation.
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Procedimiento de Fontan , Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Lactante , Recién Nacido , Humanos , Niño , Ventrículos Cardíacos/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Insuficiencia Cardíaca/cirugíaRESUMEN
Some patients with functionally univentricular circulation develop cardiac failure refractory to maximal management and are supported with a ventricular assist device (VAD). The purpose of this manuscript is to summarize our previous publications related to single ventricle-ventricular assist device (sVAD) support in patients with functionally univentricular circulation and to describe our current institutional approach at University of Florida to sVAD support in neonates, infants, and children prior to Fontan. Our programmatic philosophy at University of Florida is to strive to identify the minority of neonates with functionally univentricular circulation who are extremely high-risk prior to initiating staged palliation and to stabilize these neonates with primary preemptive sVAD in preparation for cardiac transplantation; our rationale for this approach is related to the challenges associated with failed staged palliation and subsequent bail-out sVAD support and transplantation. A subset of extremely high-risk neonates and infants with functionally univentricular ductal-dependent circulation undergo primary preemptive sVAD insertion and subsequent cardiac transplantation. Support with VAD clearly facilitates survival on the waiting list during prolonged wait times and optimizes outcomes after Norwood (Stage 1) by providing an alternative pathway for extremely high-risk patients. Therefore, the selective utilization of sVAD in extremely high-risk neonates facilitates improved outcomes for all patients with functionally univentricular ductal-dependent circulation. At University of Florida, our programmatic approach to utilizing sVAD support as a bridge to transplantation in the minority of neonates with functionally univentricular circulation who are extremely high-risk for staged palliation is associated with Operative Mortality after Norwood (Stage 1) Operation of 2.9% (2/68) and a one-year survival of 91.1% (82/90) for all neonates presenting with hypoplastic left heart syndrome (HLHS) or HLHS-related malformation with functionally univentricular ductal-dependent systemic circulation. Meanwhile, at University of Florida, for all 82 consecutive neonates, infants, and children supported with pulsatile paracorporeal VAD: Kaplan-Meier survival estimated one year after VAD insertion = 73.3% (95% confidence interval [CI] = 64.1-83.8%), and Kaplan-Meier survival estimated five years after VAD insertion = 68.3% (95% CI = 58.4-79.8%). For all 48 consecutive neonates, infants, and children at University of Florida with biventricular circulation supported with pulsatile paracorporeal VAD: Kaplan-Meier survival estimated one year after VAD insertion = 82.7% (95% CI = 72.4-94.4%), and Kaplan-Meier survival estimated five years after VAD insertion = 79.7% (95% CI = 68.6-92.6%). For all 34 consecutive neonates, infants, and children at University of Florida with functionally univentricular circulation supported with pulsatile paracorporeal sVAD: Kaplan-Meier survival estimated one year after VAD insertion = 59.7% (95% CI = 44.9-79.5%), and Kaplan-Meier survival estimated five years after VAD insertion = 50.5% (95% CI = 35.0-73.0%). These Kaplan-Meier survival estimates for patients supported with pulsatile paracorporeal VAD are better in patients with biventricular circulation in comparison to patients with functionally univentricular circulation both one year after VAD insertion (P=0.026) and five years after VAD insertion (P=0.010). Although outcomes after VAD support in functionally univentricular patients are worse than in patients with biventricular circulation, sVAD provides a reasonable chance for survival. Ongoing research is necessary to improve the outcomes of these challenging patients, with the goal of developing strategies where outcomes after sVAD support in functionally univentricular patients are equivalent to the outcomes achieved after VAD support in patients with biventricular circulation.
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Procedimiento de Fontan , Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Síndrome del Corazón Izquierdo Hipoplásico , Lactante , Niño , Recién Nacido , Humanos , Insuficiencia Cardíaca/cirugía , Síndrome del Corazón Izquierdo Hipoplásico/cirugía , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Comunicación , Seguridad del Paciente , Inteligencia Emocional , Humanos , Investigación CualitativaRESUMEN
This case describes an unusual intraoperative transesophageal echocardiogram (TEE) finding of an unknown sinus of Valsalva mass in a patient undergoing an off-pump coronary artery bypass procedure. The intraoperative TEE finding not only revealed a protruding right coronary ostial stent but also changed the surgical procedure to include an aortotomy that allowed successful removal of the stent. As interventional cardiologists begin exploring more techniques to manage difficult ostial lesions, this finding may be seen more commonly in the future. This case highlights how the use of routine TEE even in off-pump coronary artery bypass procedures may be very beneficial.
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Puente de Arteria Coronaria Off-Pump/métodos , Estenosis Coronaria/cirugía , Remoción de Dispositivos/métodos , Ecocardiografía Transesofágica/métodos , Complicaciones Posoperatorias/diagnóstico , Stents/efectos adversos , Anciano , Estenosis Coronaria/diagnóstico , Femenino , Humanos , Periodo Intraoperatorio , Complicaciones Posoperatorias/cirugía , Falla de PrótesisAsunto(s)
Transfusión Sanguínea/métodos , Plasma , Transfusión de Plaquetas/métodos , Resucitación/métodos , Centros Traumatológicos , Transfusión Sanguínea/normas , Humanos , Transfusión de Plaquetas/normas , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Resucitación/normas , Centros Traumatológicos/normasRESUMEN
Artifacts are frequently encountered during echocardiographic examinations. An understanding of the physics and underlying assumptions of ultrasound processing involved with image generation is important for accurate interpretation of 2D grayscale, spectral Doppler, color flow Doppler, and 3D artifacts and their clinical implications.
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Artefactos , Ecocardiografía/estadística & datos numéricos , Ecocardiografía/métodos , Ecocardiografía Tetradimensional , Humanos , Física , UltrasonidoRESUMEN
INTRODUCTION: We aimed to study the efficacy and safety of recombinant factor VIIa (rFVIIa) for management of perioperative bleeding in HeartMate II recipients. MATERIALS AND METHODS: Fifty-seven patients underwent HeartMate II implantation. Sixteen patients received rFVIIa (six intraop, eight early postop, and two both intra- and postop). The effect of rFVIIa on transfusion of blood products as well as the amount of chest tube drainage was used to assess efficacy and 30-day incidence of thromboembolic events was used to assess safety. RESULTS: Patients who received intraoperative rFVIIa had been transfused significantly more blood products prior to rFVIIa administration compared to total amount of intraoperatively transfused blood products in those who did not receive intra-op rFVIIa; however, there were no significant differences in the amount of transfused blood products and chest tube output in the 24-hour postoperative period between the two groups. Postoperative administration of rFVIIa did not have a significant impact on the amount of red blood cell transfusion but there was a trend towards decreased requirement for fresh frozen plasma (mean 2.7 vs. 1.1, p = 0.08), platelet (1.5 vs. 0.7, p = 0.14), and cryoprecipitate (5.3 vs. 1.2, p = 0.09). The hourly rate of chest tube output also decreased significantly from an average of 235 ± 57 mL/hour prior to rFVIIa administration to an average of 98 ± 36 mL/hour in the first four hours after rFVIIa administration (p value = 0.003). There were no 30-day thromboembolic events in those patients who received rFVIIa. CONCLUSIONS: This study supports selective use of rFVIIa in HeartMate II recipients for the management of severe perioperative bleeding.
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Factor VIIa/administración & dosificación , Corazón Auxiliar/efectos adversos , Hemorragia/etiología , Hemorragia/prevención & control , Adulto , Anciano , Transfusión Sanguínea/estadística & datos numéricos , Factor VIIa/efectos adversos , Femenino , Hemorragia/terapia , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Estudios Retrospectivos , Riesgo , Seguridad , Índice de Severidad de la Enfermedad , Tromboembolia/epidemiología , Tromboembolia/etiologíaRESUMEN
The role of transcatheter aortic valve replacement (TAVR) continues to evolve and expand at a rapid pace. The advanced age and frailty of many TAVR candidates often presents complex vascular access challenges when contemplating the exact route of valve delivery. As the indications and approved routes of delivery have evolved, so have the direct open vascular and percutaneous techniques paramount to success. We review the spectrum of access options that may be available for consideration during TAVR procedures and highlight the "pearls and pitfalls" of each technique. We additionally highlight reasons a technique may be preferred for a specific patient subset, as well as the concerns addressed by the anesthesiologist in approaching TAVR.
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Anestesiología/métodos , Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Válvula Aórtica/patología , Arteria Femoral , Ventrículos Cardíacos , HumanosRESUMEN
PURPOSE OF REVIEW: To review the perioperative use of noncardiac transesophageal echocardiography in anesthesiology and to explore the current mechanisms of teaching and certification. RECENT FINDINGS: Anesthesiologists frequently use echocardiography in many noncardiac situations with potential impact on outcomes. Certification has evolved to include those who use echocardiography in noncardiac situations. More advanced teaching tools have been developed for the learning of diagnostic and monitoring modality. SUMMARY: Transesophageal echocardiography can have many helpful uses in perioperative patient care. This study summarizes many noncardiac uses, certification, and echocardiography education for anesthesiologists.
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Anestesia General/métodos , Anestesiología/educación , Ecocardiografía Transesofágica/métodos , Atención Perioperativa/métodos , Competencia Clínica , Humanos , Internado y Residencia , Estados UnidosRESUMEN
Aortic arch surgery has become increasingly complex, and novel surgical approaches have been utilized. Efforts aimed at improving neurological outcomes in this patient population have been numerous, with varying degrees of success. This article summarizes the anesthetic considerations for procedures on the aortic arch, including evidence-based outcomes with respect to temperature management, perfusion strategies, hemodynamic goals, adjunct agents, and neuromonitoring.