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OBJECTIVE(S): Modified ultrafiltration has gained wide acceptance as a powerful tool against cardiopulmonary bypass morbidity in pediatric cardiac surgery. The aim of our study was to assess the importance of modified ultrafiltration within conditions of contemporary cardiopulmonary bypass characteristics. METHODS: Ninetyâ»eight patients (overall cohort) weighing less than 12 kg undergoing surgical repair with cardiopulmonary bypass were prospectively enrolled in a randomized protocol to receive modified and conventional ultrafiltration (MUF group) or just conventional ultrafiltration (non-MUF group). A special attention was paid to forty-nine neonates and infants weighing less than 5 kg (lower weight (LW) cohort). RESULTS: Post-filtration hematocrit was significantly higher in the MUF group for both cohorts (overall cohort p = 0.001; LW cohort p = 0.04), but not at other time points. During the postoperative course, patients in the MUF group received fewer packed red blood cells, (overall cohort p = 0.01; LW cohort p = 0.07), but required more fresh frozen plasma (overall cohort p = 0.04; LW cohort p = 0.05). There was no difference between groups in hemodynamic state, chest tube output, duration of mechanical ventilation, respiratory parameters, duration of intensive care unit, and hospitalization stay. CONCLUSIONS: If conventional ultrafiltration provides adequate hemoconcentration modified ultrafiltration does not provide additional positive benefits except for reduction in blood cell transfusion, This, however, comes at the cost of needing more fresh frozen plasma. Of particular importance is that this also applies to infants with weight bellow 5 kg where modified ultrafiltration was supposed to have the greatest positive impact.
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22q11.2 microdeletion is the most common microdeletion in humans. The purpose of this study was to evaluate postoperative outcome in children with 22q11.2 microdeletion who had undergone complete surgical correction of a congenital heart defect. The study included 34 patients who underwent complete correction of conotruncal heart defects. Of these, 17 patients diagnosed with 22q11.2 microdeletion represent the investigated group. Another 17 patients without 22q11.2 microdeletion represent the control group. Investigated and control groups differ significantly for total length of stay in the hospital (average 37.35 and 14.12 days, respectively); length of postoperative stay in the intensive care unit (average 10.82 and 6.76 days, respectively); sepsis (eight and two patients, respectively); administration of antibiotics (15 and seven patients, respectively); duration of antibiotic therapy (average 17.65 and 14.59 days, respectively); occurrence of hypocalcemia (16 and 0 patients, respectively); and initiation of peroral nutrition during the postoperative course (average 10.29 and 3.88 days, respectively). No difference was found for duration of ventilatory support (average 6.12 and 4.24 days, respectively), administration of total parenteral nutrition, and postoperative mortality rate. The study results suggest that genotype of 22q11.2 microdeletion affects postoperative outcome after cardiac surgery. Possible targets for intervention in postoperative intensive care management are prevention and treatment of systemic infections, monitoring, and treatment of hypocalcemias, rational administration of antibiotics and careful planning of nutrition. Consequently, this could shorten patients' intensive care stay and overall duration of hospitalization.
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Procedimientos Quirúrgicos Cardíacos/métodos , Cromosomas Humanos Par 22/genética , Cardiopatías Congénitas/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Preescolar , Deleción Cromosómica , Cuidados Críticos/estadística & datos numéricos , Femenino , Genotipo , Cardiopatías Congénitas/genética , Humanos , Hibridación Fluorescente in Situ , Lactante , Recién Nacido , Cariotipo , Tiempo de Internación/estadística & datos numéricos , Masculino , Reacción en Cadena de la Polimerasa Multiplex , Complicaciones Posoperatorias/genética , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
OBJECTIVES: This study investigates the effects of high glucose content on patients undergoing cold crystalloid versus cold blood cardioplegia in terms of early clinical results, functional myocardial recovery and ischaemia-reperfusion injury in patients undergoing repair of acyanotic cardiac lesions. METHODS: Patients were randomly assigned to receive either crystalloid (n = 31) or blood cardioplegia (n = 31). Early clinical results were assessed. Changes in left ventricular fractional shortening, arterial blood lactate levels, central venous saturation, cardiac Troponin I release and blood glucose concentration were measured during the first 24 h after ischaemia. RESULTS: There was no significant difference in clinical outcomes and postoperative complication rates between groups. The postoperative changes in left ventricular function, lactate levels, central venous saturation and Troponin I were not significantly different between groups. The use of crystalloid cardioplegia was associated with significant increases in serum glucose compared with blood cardioplegia. CONCLUSIONS: A high glucose content blood cardioplegia does not show any advantage compared with crystalloid cardioplegia in terms of clinical outcomes, functional recovery and the degree of ischaemic injury in infants and children undergoing repair of acyanotic heart lesions. High glucose concentration of the cardioplegic solution might potentiate ischaemia-reperfusion injury and diminish the beneficial effects of blood cardioplegia.
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Glucemia/metabolismo , Procedimientos Quirúrgicos Cardíacos/métodos , Glucosa/administración & dosificación , Paro Cardíaco Inducido/métodos , Cardiopatías Congénitas/cirugía , Soluciones Isotónicas/farmacología , Función Ventricular Izquierda/efectos de los fármacos , Preescolar , Soluciones Cristaloides , Relación Dosis-Respuesta a Droga , Femenino , Cardiopatías Congénitas/sangre , Humanos , Incidencia , Lactante , Masculino , Daño por Reperfusión Miocárdica/epidemiología , Daño por Reperfusión Miocárdica/prevención & control , Serbia/epidemiologíaRESUMEN
INTRODUCTION: Acute kidney injury (AKI) is significant problem in children with congenital heart disease (CHD) who undergo cardiac surgery. The economic impact of a biomarker-based diagnostic strategy for AKI in pediatric populations undergoing CHD surgery is unknown. The aim of this study was to perform the cost effectiveness analysis of using serum cystatin C (sCysC), urine neutrophil gelatinase-associated lipocalin (uNGAL) and urine liver fatty acid-binding protein (uL-FABP) for the diagnosis of AKI in children after cardiac surgery compared with current diagnostic method (monitoring of serum creatinine (sCr) level). MATERIALS AND METHODS: We developed a decision analytical model to estimate incremental cost-effectiveness of different biomarker-based diagnostic strategies compared to current diagnostic strategy. The Markov model was created to compare the lifetime cost associated with using of sCysC, uNGAL, uL-FABP with monitoring of sCr level for the diagnosis of AKI. The utility measurement included in the analysis was quality-adjusted life years (QALY). The results of the analysis are presented as the incremental cost-effectiveness ratio (ICER). RESULTS: Analysed biomarker-based diagnostic strategies for AKI were cost-effective compared to current diagnostic method. However, uNGAL and sCys C strategies yielded higher costs and lower effectiveness compared to uL-FABP strategy. uL-FABP added 1.43 QALY compared to current diagnostic method at an additional cost of $8521.87 per patient. Therefore, ICER for uL-FABP compared to sCr was $5959.35/QALY. CONCLUSIONS: Our results suggest that the use of uL-FABP would represent cost effective strategy for early diagnosis of AKI in children after cardiac surgery.
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Lesión Renal Aguda/economía , Procedimientos Quirúrgicos Cardíacos/economía , Modelos Económicos , Complicaciones Posoperatorias/economía , Lesión Renal Aguda/sangre , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/etiología , Lesión Renal Aguda/orina , Proteínas de Fase Aguda/orina , Adolescente , Biomarcadores/sangre , Biomarcadores/orina , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Estudios de Casos y Controles , Niño , Preescolar , Costos y Análisis de Costo , Cistatinas/sangre , Femenino , Cardiopatías Congénitas/sangre , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/orina , Humanos , Lactante , Lipocalina 2 , Lipocalinas/orina , Masculino , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/orina , Proteínas Proto-Oncogénicas/orinaRESUMEN
INTRODUCTION: Diagnosis of neonatal coarctation of the aorta (CoA) still presents a challenge in routine practice because of absence of reliable morphologic and functional parameters for early detection of this congenital heart defect in newborns. OBJECTIVE: The aim of this study is to identify easy obtainable two-dimensional echocardiographic parameters for detection of the CoA in newborns. METHODS: Echocardiographic evaluation was performed in 30 newborns with CoA and 20 healthy neonates (control group). Measurements of the proximal transverse arch (PTA), distal transverse arch (DTA), isthmus, distance between the left common carotid artery (LCCA) at the origin of the left subclavian artery (LSA), were obtained by two-dimensional echocardiography. Aortic arch hypoplasia was defined using Mouleart, Karl and Mee criteria, and Z-value. Index 1 was calculated as a ratio of DTA and distance between origins LCCA-LSA, Index 2 was calculated as a ratio of the ascending aorta and the distance between LCCA-LSA origins, and Index 3 was calculated as a ratio of PTA and distance between LCCA-LSA origins. RESULTS: Index 1 was significantly lower in patients with CoA in comparison with control group (0.50 vs. 1.39; p≤0.01). A cut-off point at 0.39, for Index 1, showed a sensitivity of 92% and specificity of 99% for the diagnosis of neonatal CoA, while cut off points at 0.69 and 0.44, for Index 2 and Index 3, showed the highest sensitivity and specificity for the diagnosis of CoA in newborns. CONCLUSION: By using these echo indexes, two-dimensional echocardiographic aortic arch measurement becomes a simple, reliable noninvasive method for the evaluation of aortic coarctation in newborns and may lead to earlier diagnosis and subsequent surgical correction.
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Aorta Torácica/diagnóstico por imagen , Coartación Aórtica/diagnóstico por imagen , Arteria Subclavia/diagnóstico por imagen , Aorta Torácica/anomalías , Ecocardiografía/métodos , Femenino , Cardiopatías Congénitas/diagnóstico por imagen , Humanos , Recién Nacido , Masculino , Sensibilidad y EspecificidadRESUMEN
INTRODUCTION: Arterial switch operation (ASO) is a cardiosurgical method of choice for complete anatomical correction of transposition of great arteries. Improvement of this procedure has made considerably improved the outcome and long-term prognosis of children born with this complex congenital heart disease. OBJECTIVE: The aim of this study was to estimate the success rate of ASO through retrospective analysis of mortality and late complications. METHODS: This study included 57 children operated from 1st January 2005 until 31st December 2009. Parameters that could influence the outcome of surgery were investigated. The following late complications were investigated: neopulmonary artery stenosis, neoaortic stenosis and regurgitation, as well as clinical signs of heart failure. RESULTS: Early postoperative mortality was 15.8% (9/57 patients). During follow-up (8 to 72 months, average 36.5 months) there were no lethal outcomes. On the last echocardiography examination, 73.2% patients had neoaortic regurgitation and 67.4% patients had neopulmonary regurgitation, but all of them were mild in intensity. Neopulmonary stenosis had 32.6% of patients, but only two had moderate or severe stenosis. No one had ischemic ECG changes. Three reinterventions were performed due to serious residual problems: surgical correction of neoaortic stenosis, surgical correction of neopulmonary stenosis and transcatether balloon dilatation for aortic recoarctation. At the end of the follow-up period, only one of 46 consistently followed patients had signs of heart failure which required therapy (2.2%), while the majority of patients were without any symptoms and with good effort tolerance. CONCLUSION: Arterial switch operation has been successfully performed at our institution, with acceptable perioperative mortality and excellent late outcome.
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Transposición de los Grandes Vasos/cirugía , Aorta/diagnóstico por imagen , Aorta/cirugía , Niño , Preescolar , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Masculino , Proyectos Piloto , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Transposición de los Grandes Vasos/diagnóstico por imagen , Transposición de los Grandes Vasos/mortalidadRESUMEN
INTRODUCTION: Total anomalous pulmonary venous connection (TAPVC) is a rare congenital heart disease and in some variants represents the only true surgical emergency in congenital heart surgery. Basic anatomical characteristic of this anomaly is an abnormal connection of pulmonary veins with systemic venous circulation. Although the results of TAPVC repair in infancy have been markedly improved in recent years, the recurrent pulmonary venous obstruction (RPVO) remains relatively frequent complication of surgical treatment. OBJECTIVE: The aim of this study was a retrospective evaluation of TAPVC repair at a single institution, identifying the risk factors associated with the increased mortality and morbidity. METHODS: Between January 2001 and January 2010, 43 consecutive patients underwent repair of TAPVC at the University Children's Hospital, with median weight of 3.8 kg (1.8-13 kg). Median age at surgery varied from 5 days to 5 years. Distribution of TAPVC types was as follows: supracardiac 19 (44%), cardiac 12(28%), infracardiac 9 (21%), and mixed 3 (7%). Eleven patients (26%) were emergencies due to obstructed drainage. RESULTS: Early mortality was 9.30% (4/43). An average time of followup/survival for 95% interval of confidence was 101.6 +/- 6.7 months. Kaplan-Meier cumulative survival was 83.7 +/- 5.7%. Freedom from reintervention after 10 years was 87.2 +/- 0.5%. The principal reason for reintervention was RPVO. CONCLUSION: Preoperative obstruction is not a risk factor of early mortality and RPVO. Low body mass (below 2.5 kg) is the only identified risk factor of early mortality. Complex morphology of the confluens, particularly in a mixed type of TAPVR, is the main risk factor of RPVO development.
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Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas/cirugía , Venas Pulmonares/anomalías , Procedimientos Quirúrgicos Vasculares , Peso Corporal , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Preescolar , Femenino , Cardiopatías Congénitas/epidemiología , Humanos , Lactante , Recién Nacido , Masculino , Morbilidad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Venas Pulmonares/cirugía , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
INTRODUCTION: Balloon valvuloplasty (BVP) is one of the primary therapies for congenital aortic stenosis in children and adolescents. The aim of this interventional procedure is to gain time before possible surgical therapy (aortic valve replacement) until adulthood. OBJECTIVE: The aim of this study was to evaluate the efficacy, safety and mid-term results oftranscatheter BVP in children and adolescent in our Center. METHODS: From 2004 to 2011, 50 patients, aged 18 days to 18 years (mean 6.3 years) underwent BVP. Retrospective analysis of the echocardiographic and hemodynamic parameters were performed before and after procedure, especially peak pressure gradient (PG) across the aortic valve, semiquantification of the aortic regurgitation (AR) after the BVP as well as the left ventricle dimensions and functions. RESULTS: The mean peak PG in the whole group decreased from 74.80 +/- 27.72 mm Hg to 27.86 +/- 3.04 mm Hg (p < 0.001) after BVP. In 39 patients (78%), residual PG was lower than 30 mm Hg just after dilation. At the end of follow-up period, 25 patients (50%) had PG above 50 mm Hg, measured by Doppler technique, and four of them underwent re-dilation. Eight patients (16%) had severe AR. During the follow-up period (12-80 months, mean 51 months), six patients (12%) were referred to cardiac surgeons for aortic valve replacement or Ross procedure. CONCLUSIONS: This retrospective study analyzes our first experience of BVP as primary therapy of the congenital aortic stenosis. The results confirmed that BVP effectively postponed the need for surgery in children and adolescents toward the adulthood.
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Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Valvuloplastia con Balón/métodos , Complicaciones Posoperatorias/diagnóstico por imagen , Adolescente , Estenosis de la Válvula Aórtica/congénito , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Cateterismo , Niño , Preescolar , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Hemodinámica , Humanos , Lactante , Recién Nacido , Masculino , Reoperación , Estudios Retrospectivos , UltrasonografíaRESUMEN
Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) represents one of the most common causes of myocardial ischemia in infants and if left untreated results in a high mortality rate. When ALCAPA coexists with other congenital malformations, particularly those associated with pulmonary hypertension, the initial presentation can be quite confusing and is often misinterpreted. We report an infant with ALCAPA associated with scimitar syndrome and aortic coarctation whose clinical course illustrates the complexities and difficulties of management with a successful outcome.
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Coartación Aórtica/complicaciones , Anomalías de los Vasos Coronarios/complicaciones , Arteria Pulmonar/anomalías , Síndrome de Cimitarra/complicaciones , Anomalías Múltiples/diagnóstico , Anomalías Múltiples/cirugía , Coartación Aórtica/diagnóstico , Coartación Aórtica/cirugía , Anomalías de los Vasos Coronarios/diagnóstico , Anomalías de los Vasos Coronarios/cirugía , Humanos , Recién Nacido , Arteria Pulmonar/cirugía , Síndrome de Cimitarra/diagnóstico , Síndrome de Cimitarra/cirugíaRESUMEN
OBJECTIVES: Acute kidney injury (AKI) is a significant problem in children undergoing cardiopulmonary bypass (CPB). The aims of this study were to assess the diagnostic validity of serum CysC (sCysC), serum neutrophil gelatinase lipocalin (sNGAL), urine neutrophil gelatinase lipocalin (uNGAL), urine kidney injury molecule (uKIM)-1, and urine liver fatty acid-binding protein (uL-FABP) to predict AKI presence and severity in children undergoing CPB. DESIGN AND METHODS: We performed a prospective single-center evaluation of sCysC, sNGAL, uNGAL, uKIM-1 and uL-FABP at 0, 2, 6, 24 and 48 h postoperatively in children undergoing CPB during cardiac surgery. AKI was defined as ≥25% decrease in the estimated creatinine clearance (eCCl) from pre-operative baseline at 48h after surgery. RESULTS: Of the 112 patients, 18 patients (16.1%) developed AKI; four of them needed acute dialysis treatment and three AKI patients died. In the AKI compared to the non-AKI group, sCysC at 2h, and uNGAL and uL-FABP at 2-48 h were significantly increased, as well as CPB, aortic cross clamp time and length of hospital stay. Biomarkers increased with worsening AKI severity. At 2h after CPB the best accuracy for diagnosis of AKI had uL-FABP and sCysC with area under the receiver operator curve (AUC) of 0.89 and 0.73, respectively. At 6 and 24h after CPB the best AUC was found for uL-FABP (0.75 and 0.87 respectively) and for uNGAL (0.70 and 0.93, respectively). CONCLUSIONS: sCysC, uNGAL and uL-FABP are reliable early predictors for AKI after CPB. By allowing earlier timing of injury and earlier intervention, they could improve AKI outcome.
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Lesión Renal Aguda/genética , Lesión Renal Aguda/patología , Biomarcadores , Puente Cardiopulmonar/efectos adversos , Lesión Renal Aguda/sangre , Lesión Renal Aguda/orina , Proteínas de Fase Aguda/orina , Adolescente , Biomarcadores/sangre , Biomarcadores/orina , Niño , Preescolar , Cistatina C/sangre , Cistatina C/orina , Proteínas de Unión a Ácidos Grasos/orina , Femenino , Receptor Celular 1 del Virus de la Hepatitis A , Humanos , Lactante , Lipocalina 2 , Lipocalinas/sangre , Lipocalinas/orina , Masculino , Glicoproteínas de Membrana/orina , Proteínas Proto-Oncogénicas/sangre , Proteínas Proto-Oncogénicas/orina , Receptores Virales , Diálisis Renal/métodosRESUMEN
BACKGROUND: Acute kidney injury (AKI) is a common postoperative complication following cardiopulmonary bypass (CPB) surgery. New biomarkers to identify patients with early AKI (before increases in serum creatinine) are needed to facilitate appropriate treatment. This study aimed to test the role of urinary liver fatty-acid-binding protein (L-FABP) as an early biomarker for AKI in children undergoing CPB surgery. METHODS: This is a case-control study of children undergoing CPB. AKI was defined as 50 % increase in serum creatinine at 48 h after surgery. For each patient, five serum and urine samples were obtained corresponding to time 0 h (presurgery) and 2, 6, 24, and 48 h after surgery. RESULTS: Twenty-seven patients, median age 360 days, were enrolled. AKI developed in 11 patients (41 %); three needed renal replacement therapy (peritoneal dialysis); there were two deaths. There were significant differences between patients with and without AKI in L-FABP levels at 2, 6, and 48 h after surgery, length of hospital stay, and CPB time; there were no differences in gender, patient age, and body weight. L-FABP was normalized to urinary creatinine concentration at all time points, with area under the receiver operator curve (AUC ROC) 0.867 at 2 and 6 h postoperatively. Correlation coefficient between L-FABP and length of hospital stay after surgery was statistically significant (r = 0.722, p value = 0.000). CONCLUSIONS: Our results suggest that urinary L-FABP can be used to diagnose AKI earlier than rise in serum creatinine in children undergoing CPB.
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Lesión Renal Aguda/diagnóstico , Puente Cardiopulmonar/efectos adversos , Proteínas de Unión a Ácidos Grasos/orina , Lesión Renal Aguda/orina , Estudios de Casos y Controles , Preescolar , Femenino , Humanos , Lactante , MasculinoRESUMEN
INTRODUCTION: Critical congenital heart diseases (CHD) are mostly duct-dependent and require stable systemic-pulmonary communication. In order to maintain patency of the ductus arteriosus (DA), the first line treatment is Prostaglandin E1 and the second step is the surgical creation of aortic-pulmonary shunt. To reduce surgical risk in neonates with the critical CHD, transcatheter stenting of DA can be performed in selected cases. CASE OUTLINE: A four-month old infant was diagnosed with the pulmonary artery atresia with ventricular septal defect (PAA/VSD). The left pulmonary artery was perfused from DA, and the right lung through three major aortopulmonary collaterals (MAPCAs). A coronary stent was placed in the long and critically stenotic DA, with final arterial duct diameter of 3.5 mm, and significantly increased blood supply to the left lung. After the procedure, the infant's status was improved with regard to arterial oxygen saturation, feeding and weight gain. During the follow-up, one year later, aortography revealed in-stent stenosis. The left pulmonary artery, as well as the branches, was well-developed and the decision was made to proceed with further surgical correction. CONCLUSION: Stenting of DA can be an effective alternative to primary surgical correction in selected patients with duct-dependent CHD.