Late Follow-up of Patients Submitted to Total Cavopulmonary Derivation: Clinical Aspects, Reinterventions, and Complications Interfering in Morbidity and Mortality.

OBJECTIVE: To identify main complications in outpatient follow-up, as well as factors before or during operation that may interfere in patient's evolution. METHODS: Retrospective study of patients submitted to total cavopulmonary shunt with extracardiac conduit from 2000 to 2014 at the Hospital do Coração (São Paulo, Brazil) and who underwent clinical follow-up at this institution. RESULTS: One hundred and fifty surgeries were performed and 59 patients maintained outpatient follow-up. The mean age of these patients at the time of surgery was 4.45 years (median of 45 months) and 70.2% of them were males. Among the patients undergoing outpatient follow-up, postoperative time at evaluation ranged from 10 days to 145 months; 30 (50.8%) patients had single left ventricle and 29 (49.2%) had single right ventricle (48.2% of these presented with hypoplastic left heart syndrome [HLHS]). Patients with single left ventricle had a higher percentage of reintervention-free survival, but without statistically significant difference. 40% of the patients had no complications and 35% of them presented with thrombosis at some point in the follow-up period, with ventricular dysfunction being the second most frequently found complication (15% of cases), mainly among patients with single right ventricle morphology (P=0.04). Between the patients currently under follow-up, 20 (35%) of them had been evaluated by ultrasonography and had some degree of hepatic congestion and/or hepatomegaly. 16.7% of the patients with such alteration had HLHS (P=0.057). CONCLUSION: Except for the right ventricular morphology, no other factor has been shown to interfere in late evolution after total cavopulmonary shunt.

Late follow-up of patients submitted to total cavopulmonary derivation: clinical aspects, reinterventions, and complications interfering in morbidity

Abstract Objective: To identify main complications in outpatient follow-up, as well as factors before or during operation that may interfere in patient's evolution. Methods: Retrospective study of patients submitted to total cavopulmonary shunt with extracardiac conduit from 2000 to 2014 at the Hospital do Coração (São Paulo, Brazil) and who underwent clinical follow-up at this institution. Results: One hundred and fifty surgeries were performed and 59 patients maintained outpatient follow-up. The mean age of these patients at the time of surgery was 4.45 years (median of 45 months) and 70.2% of them were males. Among the patients undergoing outpatient follow-up, postoperative time at evaluation ranged from 10 days to 145 months; 30 (50.8%) patients had single left ventricle and 29 (49.2%) had single right ventricle (48.2% of these presented with hypoplastic left heart syndrome [HLHS]). Patients with single left ventricle had a higher percentage of reintervention-free survival, but without statistically significant difference. 40% of the patients had no complications and 35% of them presented with thrombosis at some point in the follow-up period, with ventricular dysfunction being the second most frequently found complication (15% of cases), mainly among patients with single right ventricle morphology (P=0.04). Between the patients currently under follow-up, 20 (35%) of them had been evaluated by ultrasonography and had some degree of hepatic congestion and/or hepatomegaly. 16.7% of the patients with such alteration had HLHS (P=0.057). Conclusion: Except for the right ventricular morphology, no other factor has been shown to interfere in late evolution after total cavopulmonary shunt.

Incidence and Treatment of Chylothorax in Children Undergoing Corrective Surgery for Congenital Heart Diseases.

INTRODUCTION: Chylothorax is a lymphatic extravasation into pleural cavity and its incidence is 0.25%-5.3% in children undergoing cardiac surgery. OBJECTIVE: To evaluate the incidence of chylothorax in pediatrics patients operated, linking it in each surgical intervention. Evaluate treatment types and efficiency. METHODS: Retrospective study using medical records of children undergoing cardiac surgery in the Hospital do Coração between 2004 and 2014. For statistical analysis, qualitative variables by absolute frequency and relative frequency; quantitative variables, by median of 25 and 75 percentiles, as they did not present normal distribution (Shapiro-Wilk, P<0.05). The Chi-square test was used for the association between type of treatment and result. The adopted confidence level was 95%. RESULTS: Incidence of chylothorax was 2.1% (0.9% in intracardiac surgery, 1.7% correction of patent ductus arteriosus and aortic coarctation, 8.3% Glenn's surgery, 11.8% total cavopulmonary surgery and 3% in others). Among treatments, fasting associated with total parenteral nutrition (TPN) resolved 51% of the cases. Hypoglossal diet had failed treatment and surgical referral in 22% of the cases. Fasting with TPN associated with octreotide had success in the treatment of chylothorax in a period exceeding 15 days in 78% of cases, and 3.7% were referred for surgery. CONCLUSION: According to the results, incidence of chylothorax was 2.18%. Treatment with fasting and TPN leads to resolutions in 86.5%, and the association with octreotide was successful in 85.1% of cases, showing an efficient option, while the treatment with hypoglossal diet had therapeutic failure in 22% of the cases in which it was used.

Incidence and treatment of chylothorax in children undergoing corrective surgery for congenital heart diseases

Abstract Introduction: Chylothorax is a lymphatic extravasation into pleural cavity and its incidence is 0.25%-5.3% in children undergoing cardiac surgery. Objective: To evaluate the incidence of chylothorax in pediatrics patients operated, linking it in each surgical intervention. Evaluate treatment types and efficiency. Methods: Retrospective study using medical records of children undergoing cardiac surgery in the Hospital do Coração between 2004 and 2014. For statistical analysis, qualitative variables by absolute frequency and relative frequency; quantitative variables, by median of 25 and 75 percentiles, as they did not present normal distribution (Shapiro-Wilk, P<0.05). The Chi-square test was used for the association between type of treatment and result. The adopted confidence level was 95%. Results: Incidence of chylothorax was 2.1% (0.9% in intracardiac surgery, 1.7% correction of patent ductus arteriosus and aortic coarctation, 8.3% Glenn's surgery, 11.8% total cavopulmonary surgery and 3% in others). Among treatments, fasting associated with total parenteral nutrition (TPN) resolved 51% of the cases. Hypoglossal diet had failed treatment and surgical referral in 22% of the cases. Fasting with TPN associated with octreotide had success in the treatment of chylothorax in a period exceeding 15 days in 78% of cases, and 3.7% were referred for surgery. Conclusion: According to the results, incidence of chylothorax was 2.18%. Treatment with fasting and TPN leads to resolutions in 86.5%, and the association with octreotide was successful in 85.1% of cases, showing an efficient option, while the treatment with hypoglossal diet had therapeutic failure in 22% of the cases in which it was used.

Estudo comparativo entre o uso do antiagregante plaquetário e do anticoagulante oral na profilaxia de trombose em pacientes submetidos à operação cavopulmonar total com tubo extracardíaco: análise ecocardiográfica, angiotomográfica, cintilográfica, laboratorial e clínica / Comparative trial of the use of antiplatelet and oral anticoagulant in thrombosis prophylaxis in patients undergoing total cavopulmonary operation with extracardiac conduit: echocardiographic, tomographic, scintigraphic, clinical and laboratory analysis

Objetivo: Comparar a eficácia do AAS e da Varfarina na profilaxia da trombose em pacientes submetidos a operação cavopulmonar total. Avaliar se fatores de coagulação (VII, VIII e Proteína C), dados clínicos, fenestração ou fatores hemodinâmicos, interferem na trombose no pós-operatório. Métodos: Estudo prospectivo e randomizado de 30 pacientes, randomizados em Grupo I (Varfarina) e Grupo II (AAS), submetidos à derivação cavopulmonar total com tubo extracardíaco, entre 2008 e 2011, com seguimento de dois anos. Foram realizadas consultas clínicas que avaliavam efeitos colaterais e aderência. Realizado ecocardiograma transesofágico no pós-operatório imediato, 3, 6,12 e 24 meses; angiotomografia aos 6, 12 e 24 meses de pós-operatório para avaliação de alterações na parede interna do tubo ou trombos e cintilografia pulmonar, para avaliar possível TEP. Resultados: Dois óbitos no grupo I; 33,3% dos pacientes apresentaram trombo (46,7% no Grupo II). A ocorrência prévia de trombo e baixos níveis de proteína C da coagulação foram os únicos fatores que influenciaram no tempo livre de trombo (P=0,035 e 0,047). Avaliação angiotomográfica: 35,7% dos pacientes do grupo II tinham atapeteamento maior que 2 mm (P=0,082). Cintilografia: dois pacientes apresentaram TEP no grupo II. Cinco pacientes tiveram dificuldade de aderência, 4 no grupo I com INR variando de 1 a 6,4. Conclusão: A ocorrência prévia de trombo é um fator de risco para trombose no pós-operatório. Pacientes em uso de AAS tendem a depósito de material na parede do tubo. O número reduzido da amostra não permitiu concluir qual a droga mais eficaz na prevenção da trombose na população estudada. .

Objective: To compare the efficacy of aspirin and warfarin for prophylaxis of thrombosis in patients undergoing total cavopulmonary anastomosis. Evaluate whether coagulation factors (VII, VIII and protein C), clinical data, fenestration or hemodynamic factors, interfere with postoperative thrombosis. Methods: A prospective, randomized study of 30 patients, randomized into Group I (Warfarin) and Group II (AAS), underwent total cavopulmonary shunt with extracardiac conduit, between 2008 and 2011, with follow-up by clinical visits to evaluate side effects and adhesion. Performed transesophageal echocardiography in post operatory time, 3, 6,12 and 24 months; angiotomography at 6, 12 and 24 months to evaluate changes in the internal tube wall or thrombi and pulmonary scintigraphy to evaluate possible PTE. Results: Two deaths in group I; 33.3% of patients had thrombus (46.7% in Group II). The previous occurrence of thrombus and low levels of coagulation protein C were the only factors that influenced the time free of thrombus (P=0.035 and 0.047). Angiotomographic evaluation: 35.7% in group II presented material accumulation greater than 2 mm (P=0.082). Scintigraphy: two patients had PTE in group II. Five patients had difficulty to comply with the treatment, 4 in group I with INR ranging from 1 to 6.4. Conclusion: The previous occurrence of thrombus is a risk factor for thrombosis in the postoperative period. Patients using AAS tend to deposit material in the tube wall. The small sample size did not allow to conclude which is the most effective drug in the prevention of thrombosis in this population. .

Comparative trial of the use of antiplatelet and oral anticoagulant in thrombosis prophylaxis in patients undergoing total cavopulmonary operation with extracardiac conduit: echocardiographic, tomographic, scintigraphic, clinical and laboratory analysis.

OBJECTIVE: To compare the efficacy of aspirin and warfarin for prophylaxis of thrombosis in patients undergoing total cavopulmonary anastomosis. Evaluate whether coagulation factors (VII, VIII and protein C), clinical data, fenestration or hemodynamic factors, interfere with postoperative thrombosis. METHODS: A prospective, randomized study of 30 patients, randomized into Group I (Warfarin) and Group II (AAS), underwent total cavopulmonary shunt with extracardiac conduit, between 2008 and 2011, with follow-up by clinical visits to evaluate side effects and adhesion. Performed transesophageal echocardiography in post operatory time, 3, 6,12 and 24 months; angiotomography at 6, 12 and 24 months to evaluate changes in the internal tube wall or thrombi and pulmonary scintigraphy to evaluate possible PTE. RESULTS: Two deaths in group I; 33.3% of patients had thrombus (46.7% in Group II). The previous occurrence of thrombus and low levels of coagulation protein C were the only factors that influenced the time free of thrombus (P=0.035 and 0.047). Angiotomographic evaluation: 35.7% in group II presented material accumulation greater than 2 mm (P=0.082). Scintigraphy: two patients had PTE in group II. Five patients had difficulty to comply with the treatment, 4 in group I with INR ranging from 1 to 6.4. CONCLUSION: The previous occurrence of thrombus is a risk factor for thrombosis in the postoperative period. Patients using AAS tend to deposit material in the tube wall. The small sample size did not allow to conclude which is the most effective drug in the prevention of thrombosis in this population.

Use of octreotide in the treatment of chylothorax and chyloperitoneum.

Report of three cases of chylothorax and one case of chylous ascites in children who had undergone cardiac surgery with no response to routine clinical treatment, based on fasting and long-term parenteral nutrition. Treatment with octreotide at an initial dose of 1.0 mcg/kg/h was chosen, with a gradual increase of 1.0 mcg/kg/hr/day until a maximum dose of 4.0 mcg/kg/h. All cases had a favorable response, with gradual reduction of drainage output until prognosis improvement with no significant side effects.

Uso do octreotide no tratamento do quilotórax e quiloperitôneo / Use of octreotide in the treatment of chylothorax and chyloperitoneum / Uso del octreotide en el tratamiento del quilotórax y quiloperitoneo

Relato de três casos de quilotórax e um caso de ascite quilosa em crianças em pós-operatório de cirurgia cardíaca, que evoluíram sem resposta ao tratamento clínico habitual, baseado em jejum e nutrição parenteral prolongada. Tratamento com octreotide na dose inicial de 1,0 mcg/kg/h foi escolhido, com aumento progressivo de 1,0 mcg/kg/h/dia até a dose máxima de 4,0 mcg/kg/h. Todos os casos tiveram resposta favorável, com redução progressiva do débito do dreno, até resolução do quadro, sem efeito colateral significativo.

Report of three cases of chylothorax and one case of chylous ascites in children who had undergone cardiac surgery with no response to routine clinical treatment, based on fasting and long-term parenteral nutrition. Treatment with octreotide at an initial dose of 1.0 mcg/kg/h was chosen, with a gradual increase of 1.0 mcg/kg/hr/day until a maximum dose of 4.0 mcg/kg/h. All cases had a favorable response, with gradual reduction of drainage output until prognosis improvement with no significant side effects.

Relato de tres casos de quilotórax y un caso de ascitis quilosa en niños en postoperatorio de cirugía cardíaca, que evolucionaron sin respuesta al tratamiento clínico habitual, basado en ayuno y nutrición parenteral prolongada. Fue elegido tratamiento con octreotide en dosis inicial de 1,0 mcg/kg/h , con aumento progresivo de 1,0 mcg/kg/h/día hasta la dosis máxima de 4,0 mcg/kg/h. Todos los casos tuvieron respuesta favorable, con reducción progresiva del débito del drenaje, hasta resolución del cuadro, sin efecto colateral significativo.

[Relationship between waist circumference and nutritional status, lipid profile and blood pressure in low socioeconomic level pre-school children]. / Relação da cintura abdominal com a condição nutricional, perfil lipídico e pressão arterial em pré-escolares de baixo estrato socioeconômico.

OBJECTIVE: To evaluate anthropometric data, blood lipid levels, blood pressure (BP) and waist circumference (WC) in preschool children. To relate WC with blood lipid levels and BP in obese and non-obese children. METHODS: In a transversal study we investigated 65 preschool children of low socioeconomic level in Santo André, São Paulo. The evaluation consisted of BP measurement (Task Force, 1996), weight (W), height (H) expressed as z score (WHO, 1995) and body mass index (BMI), triglycerides, total and fractions of cholesterol blood levels (Kwiterovich and AHA). STATISTICAL ANALYSIS: Fisher test and correlations. RESULTS: We observed high BP and lipid levels unrelated to nutritional status. WC was significantly and positively correlated to BMI and ZWH (r = 0.87 and r = 0.83, respectively). Using as a cut-off 75 percentile of WC we found an accuracy of 89.1% with 87.2% specificity and 70.6% sensitivity and predictive value (+) 66.7% and (-) 66.7%. There was no relationship between WC and lipid and BP levels. CONCLUSIONS: WC showed direct correlation with anthropometric indexes commonly used and in preschool children wasn't predictor of cardiovascular risk.

Relação da cintura abdominal com a condição nutricional, perfil lipídico e pressão arterial em pré-escolares de baixo estrato socioeconômico / Relationship between waist circumference and nutritional status, lipid profile and blood pressure in low socioeconomic level pre-school children

OBJETIVO: Avaliar o diagnóstico nutricional, o perfil lipídico, os níveis pressóricos e a medida de cintura em pré-escolares. Pretende-se ainda verificar se a medida de cintura está associada com índices antropométricos usuais no diagnóstico nutricional, perfil lipídico e pressão arterial em crianças obesas e eutróficas. MÉTODOS: Estudo transversal realizado com 65 pré-escolares de baixo estrato socioeconômico, em escola municipal de Santo André. As avaliações clínico-laboratoriais consistiram em: medida de PA (Task Force, 1996), peso (P) e estatura (E) expressos como escore z (OMS, 1995) e IMC (índice de massa corpórea); níveis séricos de triglicérides, colesterol total e frações (VLDL-c, HDL-c, LDL-c) (Kwiterowich e AHA). Análise estatística: Teste exato de Fisher e correlação. RESULTADOS: Observamos alto porcentual de inadequação da PA e lipídios séricos, independentemente da condição nutricional. A medida de cintura mostrou correlação positiva e significante com IMC e ZPE (r = 0,87 e r = 0,83; p < 0,001, respectivamente). Visando ao estudo do poder diagnóstico da cintura, utilizando-se como ponto de corte o percentil 75 da amostra dessa medida, tendo como padrão o ZPE, observou-se acurácia de 89,1 por cento, especificidade de 87,2 por cento, sensibilidade de 70,6 por cento, e valores preditivos (+) 66,7 por cento e (-) 66,7 por cento. Não houve correlação significativa entre a cintura e o perfil lipídico e níveis pressóricos. CONCLUSÕES: A medida de cintura mostrou relação direta com os índices antropométricos habitualmente usados e não funcionou na faixa etária pré-escolar como preditor de risco cardiovascular.

Serum retinol and total carotene concentrations in obese pre-school children.

BACKGROUND: Obesity among pre-school children and its repercussions on adult life are growing problems, but there has been little research focusing on its relationship with the deficiency of serum retinol and carotenoids in our region. MATERIAL/METHODS: In a case-control study, a group of 46 preschool children, were matched by sex and age (23 obese and 23 non-obese subjects; average age 5.74 and 5.76 years, respectively). Serum retinol and carotenoid levels were evaluated according to Underwood and Sauberlich. Other aspects evaluated included nutritional status using the weight/height z-score (Obesity ZWH > or = 2), serum levels of triglicerides (TG), total cholesterol (TC) and the VLDL-c, HDL-c, and LDL-c fractions, classified according to Kwiterovich. RESULTS: Serum retinol insufficiency was 18.2% vs. 6.7% (p=0.38) for cases and controls, respectively. Low carotenoid levels were found in the obese in relation to the non-obese (82% vs. 26,6%, p=0,0054 and OR=12,4). No statistically significant difference between the case and control groups was found for TC and cholesterol fractions, TG and retinol. The findings for the tested parameters were as follows: high TC (cases 30.4%, controls 21.7%; p=0.50), LDL-c (cases and controls 34.8%; p=0.50), low HDL-c (cases 17.4%, controls 26%; p=0.47), high TG (cases 31.8%, controls 17.4%, p=0.65) and high VLDL-c (cases 21.7% and controls 8.7%; p=0.20). CONCLUSIONS: The association of obesity, hyperlipidemia and low serum level of carotenoids, which are essential to antioxidant protection, may be one of many factors predisposing obese children to a high risk of atherosclerosis later in life.

Impact of vitamin A megadose supplementation on the anthropometry of children and adolescents with non-hormonal statural deficit: a double-blind and randomized clinical study.

OBJECTIVE: To evaluate the intake of retinol and carotenoids, and their serum levels, as well as the impact of vitamin A supplementation on the anthropometry and body composition of children and adolescents with non-hormonal-related statural deficit. METHOD: Double-blind, randomized trial of 46 pre-pubertal patients, between 4 and 14 years of age, with normal growth rates. The subjects were divided into two groups, each with 23 individuals (Group I: Placebo; Group II: Vitamin A in a single megadose), and were evaluated at moments A and B with a six month interval. RESULTS: There were no statistically significant differences in serum retinol levels, anthropometry, growth velocity, or body composition, between moments A and B, in Group II. Carotenoids were significantly lower in Group I at moment B. The semi-quantitative food intake questionnaire showed that approximately 60.9% of the children and adolescents ingested less than half of the amounts of retinol and carotenoids recommended by the Food Guide Pyramid. Inadequate intake was more prevalent regarding vegetable and fruit carotenoid sources, with 75 and 70% of inadequacy, respectively. CONCLUSION: If one considers the inadequate food intake observed in the dietary evaluation in this study, it is possible that multiple micronutrient deficiencies could be involved in statural deficits. This could explain why vitamin A supplementation does not seem to influence growth in children and adolescents with statural deficit, as indicated by the present study. Thus in populations such as the one studied here, the supplementation with vitamin A should be integrated into comprehensive nutritional interventions, so as to possibly promote greater positive impact on linear growth.