Postoperative kinetics of common inflammatory biomarkers after congenital heart defect procedures with extracorporeal circulation in children.

BACKGROUND: Extracorporeal circulation is associated with systemic inflammatory response syndrome. Therefore, the diagnosis of infection should be differentiated from a typical postoperative course. AIM: The aim of the study was to evaluate the kinetics of inflammatory biomarkers in children in the first days after cardiac surgery with extracorporeal circulation. METHODS: Prospective data were collected from 51 consecutive children referred for surgical treatment in Department of Paediatric Cardiac Surgery, St. Adalbertus Hospital in Gdansk, between February and August 2015. Blood samples were collected on the first, second, and third postoperative days and sent to the institutional laboratory for routine investigations: white blood cell count, serum C-reactive protein (CRP) and procalcitonin concentrations. RESULTS: The highest levels of procalcitonin were on the first postoperative day (median 3.53 ng/mL), although the peak values of CRP concentration and white blood cell count were on the second postoperative day (96 mg/L and 17.3 G/L). In the group of patients with foreign material implantation (Contegra® or Gore-Tex®), the higher values of procalcitonin concentration and white blood cell count were measured in the subsequent postoperative days. CONCLUSIONS: The kinetics of analysed inflammatory biomarkers on the first days after cardiac surgery for congenital heart disease in children have different characteristics. The knowledge about the kinetics of inflammatory biomarkers could be useful in determining the possibility of evolving infections in the early postoperative period.

Monitoring both procalcitonin and C-reactive protein in the early period after tetralogy of Fallot correction in children promotes rational antibiotic use.

PURPOSE: This retrospective cohort study aimed to identify the early postoperative kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in children undergoing tetralogy of Fallot (ToF) correction. The ability of these inflammatory markers to guide rational antibiotic usage was also determined. MATERIALS AND METHODS: All consecutive children who underwent ToF correction in 2009-2016 in our referral pediatric cardiac surgery clinic in Gdansk, Poland and did not exhibit infection signs on early postoperative days (POD) were identified. All patients received 48h antibiotic prophylaxis. Antibiotic treatment was extended or empirical antibiotic therapy was introduced if the clinician considered it necessary. CRP and PCT levels were measured on POD1-4 and 1-3, respectively. RESULTS: Of the 60 eligible children, 44 underwent CRP testing only. The remaining 16 patients underwent both CRP and PCT testing. All patients had abnormally high CRP values after surgery. All patients who also underwent PCT testing also displayed elevated PCT levels. The CRP and PCT levels peaked on POD2 (median=99.8mg/L) and POD1 (median=4.08ng/mL), respectively. In the CRP-alone patients, antibiotic prophylaxis was prolonged or empirical antibiotic therapy was started in 59%; in the CRP and PCT group, this was 25% (p<0.05). CONCLUSIONS: The children had elevated CRP and PCT levels after ToF correction, with peaks observed on POD2 and POD1, respectively. Monitoring both CRP and PCT in the early postoperative period may guide antibiotic therapy, thus reducing unnecessary treatment, additional toxicity, and adverse drug interactions without increasing treatment failure. Rational antibiotic treatment may also reduce antibiotic resistance.

Symptomatic cardiac hemangioma resected on the first day of life.

Cardiac tumors are extremely rare in neonates. We describe the case of a right atrial hemangioma in a neonate diagnosed prenatally and successfully operated on the first day of life.

Mycobacterium chimaera - a new threat for cardiac surgical patients?

An outbreak of invasive Mycobacterium chimaera infections associated with "heater-cooler" devices in patients treated with cardiac surgery has been described worldwide. The authors summarize the current state of knowledge regarding the epidemiology, diagnostics, treatment, and prevention of Mycobacterium chimaera infections in patients after cardiothoracic surgery.

Department of Pediatric Cardiac Surgery in Gdansk in its new location - previous activity and perspectives for development.

The Department of Pediatric Cardiac Surgery in Gdansk is the only pediatric cardiac surgery center in northern Poland providing comprehensive treatment to children with congenital heart defects. The Department of Pediatric Cardiac Surgery in Gdansk currently offers a full spectrum of advanced procedures of modern cardiac surgery and interventional cardiology dedicated to patients from infancy to adolescence. January 19, 2016 marked the official opening of its new location.

Paediatric Melody® mitral valve replacement in acute endocarditis - alternative surgical-hybrid technique.

BACKGROUND AND AIM: Acute endocarditis (AE) is still rare disease in the paediatric population; nevertheless, the children suffering from AE usually need heart valve repair or replacement in emergency settings. METHODS: We present a case of emergency mitral valve replacement with the use of Melody balloon expandable stented bioprosthesis in a two-year-old patient with AE and subsequent mitral (bicuspid) valve incompetence after aggressive infective destruction with the symptoms of critical multi-organ failure. RESULTS: The patient, with a history of rapid deterioration after two-week-long septicaemia in the course of AE, was operated urgently after initial antibiotic treatment because of huge vegetations into the mitral valve orifice. A Melody TVP 22 valve was expanded over a 16-mm TyShak balloon and implanted into a mitral position (Melody-MVR) with good result. CONCLUSIONS: Based on current knowledge concerning heart valve reconstructions and institutional experience, we conclude that infected mitral valve in children should be primarily repaired; nevertheless, the Melody valve could be reasonably con-sidered as a mitral prosthesis in such conditions.

Hybrid Interventional Treatment of Iatrogenic Innominate Artery Aneurysm in a Child.

An iatrogenic aneurysm of an innominate artery is an extremely rare complication, especially in children. Nevertheless, this pathology was diagnosed in a child given palliative care with chronic respiratory insufficiency and a history of encephalitis requiring permanent ventilation at home via a tracheal tube.A nine-year-old girl with colitis ulcerosa and a history of hemorrhagic encephalitis, with chronic home ventilation therapy, was admitted in an emergency setting because of massive bleeding from the upper respiratory tract and the area surrounding the tracheotomy. Repeated tamponade with topically applied thrombin, and administration of tranexamid acid and cyclonamine appeared ineffective Because of a life-threatening condition and unknown origin of massive bleeding, the child was referred for cardiac catheterization with aortography before qualifying for surgery, with the option of alternative interventional treatment. An alternative option with PTFE-coated stent direct implantation into the brachiocephalic trunk from a peripheral vascular approach was performed. The girl was discharged home after a short recovery. Her chronic home ventilation was continued without additional problems.Stenting of a brachiocephalic trunk aneurysm with a PTFE-coated stent appeared to be a safe and effective treatment of massive bleeding from the respiratory tract, with its main advantage of avoiding the risk of a classic surgical approach in a palliatively treated patient.

Damus-Kaye-Stansel Procedure with Extracardiac Fontan: Successful Recruitment of Previously Ligated Pulmonary Valve.

We present a case of a 2.5-year-old-girl with complex congenital heart disease: tricuspid atresia (TA), bulboventricular septal defect (VSD), hypoplastic right ventricle, d-transposition of the great arteries (d-TGA) with aortic outflow from redundant RV. Due to II/III degree atrioventricular block induced after diagnostic cardiac catheterization, an epicardial pacemaker was implanted during the Glenn procedure. Because of severe left ventricle outflow tract obstruction, she was finally referred for extracardiac TCPC (extracardiac Fontan type) with recruitment of PV and Damus-Kaye-Stansel anastomosis. Intraoperatively, the pulmonary trunk stump was opened and a competent pulmonary valve with flaccid leaflets was found. Simple ligation of the pulmonary trunk with a preserved pulmonary valve enabled an effective aorto-pulmonary bridging of systemic outflow tract with the use of natural fully competent ventricle-arterial valves. The relief of single ventricle outflow tract obstruction led to final stabilization of spontaneous sinus rhythm recovery after 2 years of pacemaker stimulation.

Right Ventricle Mass Removal from Tricuspid Valve Apparatus: An Unusual Thromboembolic Complication of Severe Ketoacidosis.

The presence of a pathologic mass in the right ventricle (RV) may lead to hemodynamic consequences and to a life-threatening incident of pulmonary embolism. The diagnosis of an unstable thrombus in the right heart chamber usually necessitates intensive treatment to dissolve or remove the pathology. We present a report of an unusual complication of severe ketoacidosis: thrombus in the right ventricle, removed from the tricuspid valve (TV) apparatus. A four-year-old boy was diagnosed with diabetes mellitus (DM) type I de novo. During hospitalization, a 13.9 × 8.4 mm tumor in the RV was found in a routine cardiac ultrasound. The patient was referred for surgical removal of the floating lesion from the RV. The procedure was performed via midline sternotomy with extracorporeal circulation (ECC) and mild hypothermia. Control echocardiography showed complete tumor excision with normal atrioventricular valves and heart function. Surgical removal of the thrombus from the tricuspid valve apparatus was effective, safe, and a definitive therapy for thromboembolic complication of pediatric severe ketoacidosis.

Fungal infections in children in the early postoperative period after cardiac surgery for congenital heart disease: a single-centre experience.

OBJECTIVES: Postoperative infections are still an important problem in cardiac surgery, especially in the paediatric population, and may influence the final outcome of congenital heart disease treatment. Postoperative infections with fungi are uncommon. The aetiology is poorly understood, and the proper diagnosis and treatment is unclear. In this single-centre study, the frequency of invasive fungal disease in children who underwent surgical management of congenital heart diseases was determined along with the risk factors for infection, treatment options and outcomes. METHODS: All consecutive paediatric patients (<18 years of age) who underwent cardiac surgery for congenital heart disease between September 2008 and December 2015 in a paediatric cardiac centre in Poland were identified. Those who developed invasive fungal disease in the early postoperative period (30 days) were identified. RESULTS: Of the 1540 cardiosurgical procedures for congenital heart disease, 6 were complicated by fungal infection (0.39%). One patient had a high probability of fungal infection, but the diagnosis was unproved. Nevertheless, the patient was successfully treated with antifungal treatment. Five had proven invasive fungal disease. Of these, 3 were diagnosed with candidaemia. All had undergone cardiopulmonary bypass. Of the remaining 2 patients, 1 was a preterm newborn with complete atrioventricular septal defect who developed rib fungal invasion. The remaining patient had pulmonary atresia with ventricular septal defect and developed Fournier's gangrene after surgery. None of the patients died due to infection in the early postoperative period. However, the child with rib fungal invasion died 39 days after surgery as a result of multiorgan failure. CONCLUSIONS: Fungal infections in paediatric patients after cardiac surgery may markedly influence morbidity and mortality. Fungal infection prophylaxis in this specific group of children may reduce morbidity, whereas early empirical treatment followed by a targeted approach may improve outcomes. The 'hit fast, hit hard' treatment strategy may be the best rescue option for children who develop invasive fungal disease after cardiac surgery.

Iatrogenic obstruction of the aorta - a sequence of delayed, fatal complications after 'off-label' interventional persistent ductus arteriosus closure.

A 10-month-old girl was admitted to the Intensive Care Unit with the symptoms of critical cardiac decompensation. In the 3rd month of life, 3 kg bw, she underwent an interventional persistent ductus arteriosus (PDA) closure in a high-reference pediatric cardiology center. Echocardiography performed on admission showed myocardial injury, with poor contractility, mild pulmonary hypertension and severe stenosis of the isthmus of aorta. The girl was urgently referred for surgical removal with the use of extracorporeal circulation (ECC) and deep hypothermia circulatory arrest (DHCA) technique. In the 4th postoperative day (POD), she developed cardiovascular decompensation and died in the 7th POD due to circulatory arrest in the mechanism of refractory ventricular fibrillation. In autopsy there were found microscopic signs of apoptosis in parenchymal organs below iatrogenic 'coarctation', typical for chronic ischemia. In the segments proximal to iatrogenic aortic stenosis there were evident vascular changes characteristic for chronic severe arterial hypertension.