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1.
J Am Coll Cardiol ; 77(8): 1093-1106, 2021 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-33632484

RESUMO

BACKGROUND: Neonates with tetralogy of Fallot and symptomatic cyanosis (sTOF) require early intervention. OBJECTIVES: This study sought to perform a balanced multicenter comparison of staged repair (SR) (initial palliation [IP] and subsequent complete repair [CR]) versus primary repair (PR) treatment strategies. METHODS: Consecutive neonates with sTOF who underwent IP or PR at ≤30 days of age from 2005 to 2017 were retrospectively reviewed from the Congenital Cardiac Research Collaborative. The primary outcome was death. Secondary outcomes included component (IP, CR, PR) and cumulative (SR): hospital and intensive care unit lengths of stay; durations of cardiopulmonary bypass, anesthesia, ventilation, and inotrope use; and complication and reintervention rates. Outcomes were compared using propensity score adjustment. RESULTS: The cohort consisted of 342 patients who underwent SR (IP: surgical, n = 256; transcatheter, n = 86) and 230 patients who underwent PR. Pre-procedural ventilation, prematurity, DiGeorge syndrome, and pulmonary atresia were more common in the SR group (p ≤0.01). The observed risk of death was not different between the groups (10.2% vs 7.4%; p = 0.25) at median 4.3 years. After adjustment, the hazard of death remained similar between groups (hazard ratio: 0.82; 95% confidence interval: 0.49 to 1.38; p = 0.456), but it favored SR during early follow-up (<4 months; p = 0.041). Secondary outcomes favored the SR group in component analysis, whereas they largely favored PR in cumulative analysis. Reintervention risk was higher in the SR group (p = 0.002). CONCLUSIONS: In this multicenter comparison of SR or PR for management of neonates with sTOF, adjusted for patient-related factors, early mortality and neonatal morbidity were lower in the SR group, but cumulative morbidity and reinterventions favored the PR group, findings suggesting potential benefits to each strategy.


Assuntos
Tetralogia de Fallot/cirurgia , Estudos de Coortes , Cianose/etiologia , Cianose/cirurgia , Transplante de Coração/estatística & dados numéricos , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Tempo de Internação/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Tetralogia de Fallot/mortalidade , Fatores de Tempo
3.
World J Pediatr Congenit Heart Surg ; 11(4): 504-506, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32645777

RESUMO

We describe a case of a low birth weight neonate who presented on second day of life with progressive cyanosis and oxygen saturation of 60% by pulse oximetry. The echocardiography examination revealed a large tumor-like mass connected to the tricuspid valve, with severe obstruction of the right ventricular inflow and massive right-to-left shunt through the distended foramen ovale. A large vegetation-like lesion with calcifications was discovered intraoperatively and was debrided by shave excision technique under deep hypothermic circulatory arrest. Follow-up showed normal function of the tricuspid valve and preserved biventricular function.


Assuntos
Cianose/etiologia , Doenças das Valvas Cardíacas/congênito , Valva Tricúspide/anormalidades , Procedimentos Cirúrgicos Cardíacos/métodos , Cianose/diagnóstico , Cianose/cirurgia , Ecocardiografia , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/diagnóstico , Humanos , Recém-Nascido , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/cirurgia
4.
World J Pediatr Congenit Heart Surg ; 11(3): 377-379, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32294011

RESUMO

Vascular ring malformations usually occur as an isolated lesion. d-Transposition of the great arteries (d-TGA) associated with vascular ring malformations has seldom been reported in the literature. In this report, we describe two unusual cases of d-TGA associated with non-Kommerell diverticulum resulting in vascular ring. Our approach for the diagnosis and surgical management of this unusual combination of congenital heart lesions is described.


Assuntos
Aorta Torácica/cirurgia , Cardiopatias Congênitas/cirurgia , Transposição dos Grandes Vasos/cirurgia , Aorta/cirurgia , Broncomalácia/cirurgia , Cianose/cirurgia , Feminino , Coração/diagnóstico por imagem , Humanos , Imageamento Tridimensional , Recém-Nascido , Masculino , Situs Inversus , Artéria Subclávia/anormalidades , Toracotomia , Tomografia Computadorizada por Raios X , Traqueia/patologia , Traqueostomia , Malformações Vasculares , Anel Vascular
5.
Biomed Res Int ; 2020: 1349432, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33415140

RESUMO

Methods: This prospective single-blinded clinical trial included 72 ASA I-II stage children aged 1-36 months with cCHD who were scheduled to undergo TTE under sedation. Children were assigned to group A (n = 37) with a previous history of cardiac surgery and group B (n = 35) with no history of cardiac surgery. Doses of intranasal DEX were analyzed by up-down sequential allocation at an initial dose of 2.3 µg/kg and an increase in steps of 0.2 µg/kg. Intranasal DEXED50 values were analyzed by the up-and-down method of Dixon-Massey and probit regression to determine ED50 and 95% confidence interval (CI) for sedation. The time to effective sedation, time to regaining consciousness, vital signs, oxygen saturation, time of performing TTE, clinical adverse effects, and characteristics of regaining consciousness were compared between the two groups. Results: ED50 of intranasal DEX sedation was 2.530 µg/kg (95% CI, 1.657-4.156) in group A and 2.500 µg/kg (95% CI, 1.987-3.013) in group B. There was no significant difference in sedation onset time and time to regaining consciousness between the two groups. Additionally, no significant adverse hemodynamic or hypoxemic effect was observed. There was no significant difference in sedation-onset time and wake-up time between the two groups (15 ± 4 min vs.16 ± 5 min; 50 ± 11 min vs.48 ± 10 min). This trial is registered with the China Clinical Trials Registry (ChiCTR-IOR-1800015038). Conclusions: ED50 of intranasal DEX sedation for TTE is similar in children with and without a history of cardiac surgery for cCHD.


Assuntos
Anestesia , Procedimentos Cirúrgicos Cardíacos , Cianose/complicações , Cianose/cirurgia , Dexmedetomidina/administração & dosagem , Dexmedetomidina/farmacologia , Ecocardiografia , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/cirurgia , Administração Intranasal , Período de Recuperação da Anestesia , Criança , Humanos , Lactente , Fatores de Tempo
6.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(3): 363-366, 2019 Mar.
Artigo em Chinês | MEDLINE | ID: mdl-30914102

RESUMO

OBJECTIVE: To evaluate the efficacy of volume therapy with sodium acetate Ringer solution during the perioperative period in children with cyanotic congenital heart disease (CHD). METHODS: The children who underwent elective surgery for cyanotic CHD admitted to Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University from September to December 2018 were divided into three groups according to random number table with the informed consent of their legal representatives. All of the children received volume therapy with infusion of sodium acetate Ringer solution intravenously upon anesthesia induction. The volume of infusion was calculated according to the "4-2-1" formula (group A, the rehydration volume was 4 mL×kg-1×h-1 for the first 10 kg body weight, 2 mL×kg-1×h-1 for the second 10 kg, and 1 mL×kg-1×h-1 for the third 10 kg and above), and the volume was increased by 50% or 100% in groups B and C, respectively. The intravenous infusion lasted for 30 minutes in all the three groups. Arterial blood gas analysis was performed before and 30 minutes after infusion to observe the acid-base status and electrolyte level. Pulse oxygen saturation (SpO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) before and 10, 20, 30 minutes after infusion, central venous pressure (CVP) at 30 minutes after infusion were recorded, as well as adverse events occurred after infusion. RESULTS: Twenty-six children with cyanotic CHD, 17 male and 9 female, aged from 1 to 36 months, body weight 3.6 to 16.0 kg, and America Society of Anesthesiologists (ASA) level of III or IV, were enrolled in the study. The pH value in group B at 30 minutes after infusion was significantly higher than that before infusion (7.35±0.05 vs. 7.32±0.06, P < 0.05), while no significant changes were found before and after infusion in the other two groups. The hematocrits (Hct) after infusion in three groups were significantly lower than those before infusion (0.433±0.141 vs. 0.473±0.146 in group A, 0.324±0.054 vs. 0.372±0.063 in group B, 0.363±0.097 vs. 0.418±0.111 in group C, all P < 0.01), indicating that all the children in the three groups achieved effective hemodilution. However, there was no significant difference in blood gas analysis before and after infusion among the three groups. The level of blood lactic acid (Lac) in all CHD children was decreased from (1.33±0.63) mmol/L to (0.98±0.36) mmol/L after infusion of sodium acetate Ringer solution, the serum Ca2+ concentration was decreased from (1.22±0.06) mmol/L to (1.19±0.06) mmol/L, and the serum Cl- concentration was increased from (108.74±2.70) mmol/L to (109.77±2.54) mmol/L with the statistically significant differences (all P < 0.01). However, no significant difference was found in Lac or electrolyte levels before and after infusion among the three groups. There was no significant difference in vital signs before and after infusion among the three groups, but the period of infusion had an effect on SpO2 (F = 5.998, P < 0.01), HR (F = 34.279, P < 0.01) and SBP (F = 4.345, P < 0.05). HR in groups A and C were significantly lower than those before infusion, and SBP in group A was decreased gradually with the prolongation of infusion time. The CVP value at 30 minutes after infusion in group B was higher than that in group A. No adverse reactions such as rash or anaphylactic shock occurred after infusion of sodium acetate Ringer solution in all children. CONCLUSIONS: The perioperative volume therapy with sodium acetate Ringer solution in children with cyanotic CHD can effectively prevent the increase in Lac level and does not aggravate metabolic acidosis. The volume of infusion was well tolerated by all the children without disturbing the hemodynamic parameters.


Assuntos
Cianose/terapia , Hidratação , Cardiopatias Congênitas/terapia , Assistência Perioperatória , Acetato de Sódio/administração & dosagem , Pré-Escolar , China , Cianose/cirurgia , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Recém-Nascido , Infusões Intravenosas , Masculino , Resultado do Tratamento
7.
Cardiol Young ; 28(4): 605-607, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29362005

RESUMO

The formation of a fistula between the right pulmonary artery and the left atrium via a sac is a very rare cyanotic congenital cardiopulmonary defect. A fistula between the pulmonary artery and left atrium may cause cardiac failure in utero. It can safely be treated surgically and in selected cases closure can be performed with transcatheter insertion of a device. In this article, we present a case with a fistula between the right pulmonary artery and the left atrium that was considered unsuitable for transcatheter closure and was safely treated surgically.


Assuntos
Fístula Arteriovenosa/complicações , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Cianose/etiologia , Átrios do Coração/anormalidades , Adulto , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/cirurgia , Cianose/diagnóstico , Cianose/cirurgia , Feminino , Átrios do Coração/diagnóstico por imagem , Humanos , Recém-Nascido , Masculino , Gravidez , Diagnóstico Pré-Natal , Radiografia Torácica , Doenças Raras
8.
Neonatology ; 113(3): 231-234, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29316539

RESUMO

Small remnants of the right valve of the sinus venosus are commonly found in adults, but the incidence and risk associated with these embryonic remnants in neonates are not well studied. The following report describes a cyanotic neonate with a large Eustachian valve remnant creating a functional cor triatriatum dexter who was initially diagnosed with persistent pulmonary hypertension of the newborn. The cyanosis in this infant improved over the first postnatal week with conservative management, but she suffered multifocal subcortical stroke, likely related to her intracardiac shunt. The clinical presentation and questions regarding long-term management of this rare diagnosis are explored.


Assuntos
Coração Triatriado/complicações , Cianose/etiologia , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Cardíacos , Coração Triatriado/diagnóstico por imagem , Coração Triatriado/cirurgia , Cianose/cirurgia , Diagnóstico Diferencial , Ecocardiografia , Feminino , Humanos , Recém-Nascido , Imageamento por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico por imagem
9.
Artigo em Inglês | MEDLINE | ID: mdl-29310560

RESUMO

BACKGROUND: Traditional palliation for biventricular cyanotic congenital heart lesions often involves staging with systemic-to-pulmonary arterial shunts to secure pulmonary blood flow (PBF) in the newborn period prior to complete repair. However, shunts may lead to life-threatening events secondary to shunt occlusion or acute coronary steal. They may be associated with morbidity secondary to diastolic runoff, systemic steal and volume loading, and do not provide pulsatile flow which has the potential to promote pulmonary artery (PA) growth. We have alternatively performed modified right ventricular outflow (mRVO) procedures by establishing antegrade right ventricle-to-PA flow. METHODS: Retrospective review of data on all patients who underwent the mRVO procedure from 2013 to 2016, including anatomy, number of interstage catheterizations, reoperations, intensive care unit admissions, hypercyanotic episodes, interval to complete repair, and mortality. RESULTS: Seventeen nonconsecutive patients included tetralogy of Fallot (n = 14), pulmonary valve stenosis (n = 2), and 1 with pulmonary atresia-intact septum; 14 had significant branch PA stenosis. Median age of first mRVO procedure was 14 days (range 5-193), and median duration of follow-up was 15.3 months (range 4-47 months). No patients had post-palliation acute hypercyanotic episodes. Nine were admitted to the ICU for persistent interstage hypoxemia, 7 of whom required reintervention prior to complete repair, which was achieved in 11 patients. Two late deaths unrelated to mRVO occurred. CONCLUSIONS: The mRVO procedure is a potential option with satisfactory results. It avoids potential shunt-related sudden death. The physiology of the mRVO palliation may provide unique benefits by providing antegrade pulsatile PBF, facilitates catheter interventions, and avoids branch PA distortion and stenosis.


Assuntos
Tetralogia de Fallot/cirurgia , Cianose/cirurgia , Feminino , Seguimentos , Ventrículos do Coração/cirurgia , Humanos , Recém-Nascido , Masculino , Cuidados Paliativos , Artéria Pulmonar/cirurgia , Atresia Pulmonar/cirurgia , Estenose da Valva Pulmonar/cirurgia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
10.
Ann Card Anaesth ; 20(3): 323-330, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28701598

RESUMO

The systemic to pulmonary artery shunts are done as palliative procedures for cyanotic congenital heart diseases ranging from simple tetralogy of Fallots (TOFs)/pulmonary atresia (PA) to complex univentricular hearts. They allow growth of pulmonary arteries and maintain regulated blood flow to the lungs till a proper age and body weight suitable for definitive corrective repair is reached. We have reviewed the BT shunt with its anaesthtic considerations and management of associated complications.


Assuntos
Procedimento de Blalock-Taussig/métodos , Artéria Pulmonar/cirurgia , Cianose/cirurgia , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Recém-Nascido , Cuidados Paliativos , Tetralogia de Fallot/cirurgia
11.
Cardiol Young ; 27(2): 325-332, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27194079

RESUMO

OBJECTIVE: Oxidative stress refers to an imbalance between reactive oxidative species and antioxidants. In this case-controlled, prospective, observational study, we investigated the total oxidant status, total antioxidant status, oxidative stress index, and albumin and C-reactive protein levels of children with cyanotic and acyanotic congenital heart diseases who had undergone on-pump cardiac surgery. METHOD: The study groups consisted of 60 patients with congenital heart disease, who were operated under cardiopulmonary bypass, and a control group of 30 healthy individuals. The patients were classified into two groups. Among them, one was a patient group that consisted of 30 patients with acyanotic congenital heart disease and the other group consisted of 30 patients with cyanotic congenital heart disease. In the patient groups, blood samples were collected before surgery and at one and 24 hours following surgery. In control groups, blood samples were collected once during hospital admission. RESULTS: No statistically significant differences were found between the groups in terms of baseline total oxidant status, total antioxidant status, and oxidative stress index values. Regarding the postoperative first-hour and 24-hour total oxidant status and total antioxidant status levels as well as oxidative stress index values, there were no significant differences between the groups, except for an increase in total antioxidant status levels (p=0.002) 24 hours after surgery in cyanotic patients. CONCLUSION: There was no difference between oxidative stress status of cyanotic and acyanotic congenital heart disease patients and healthy individuals. Oxidative stress status of cyanotic and acyanotic patients does not change after cardiac surgery under cardiopulmonary bypass.


Assuntos
Antioxidantes/metabolismo , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Cianose/metabolismo , Cardiopatias Congênitas/sangue , Oxidantes/sangue , Estresse Oxidativo , Estudos de Casos e Controles , Pré-Escolar , Cianose/etiologia , Cianose/cirurgia , Feminino , Seguimentos , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/cirurgia , Humanos , Masculino , Período Pós-Operatório , Prognóstico , Estudos Prospectivos , Fatores de Tempo
12.
Hippocampus ; 27(4): 417-424, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28032672

RESUMO

Neonatal hypoxia can lead to hippocampal atrophy, which can lead, in turn, to memory impairment. To test the generalizability of this causal sequence, we examined a cohort of 41 children aged 8-16, who, having received the arterial switch operation to correct for transposition of the great arteries, had sustained significant neonatal cyanosis but were otherwise neurodevelopmentally normal. As predicted, the cohort had significant bilateral reduction of hippocampal volumes relative to the volumes of 64 normal controls. They also had significant, yet selective, impairment of episodic memory as measured by standard tests of memory, despite relatively normal levels of intelligence, academic attainment, and verbal fluency. Across the cohort, degree of memory impairment was correlated with degree of hippocampal atrophy suggesting that even as early as neonatal life no other structure can fully compensate for hippocampal injury and its special role in serving episodic long term memory. © 2017 Wiley Periodicals, Inc.


Assuntos
Hipocampo/patologia , Hipóxia-Isquemia Encefálica/complicações , Transtornos da Memória/diagnóstico por imagem , Transtornos da Memória/etiologia , Transposição dos Grandes Vasos/complicações , Sucesso Acadêmico , Adolescente , Atrofia/diagnóstico por imagem , Atrofia/etiologia , Criança , Estudos de Coortes , Cianose/diagnóstico por imagem , Cianose/etiologia , Cianose/psicologia , Cianose/cirurgia , Feminino , Hipocampo/diagnóstico por imagem , Hipocampo/crescimento & desenvolvimento , Humanos , Hipóxia-Isquemia Encefálica/patologia , Inteligência , Idioma , Imageamento por Ressonância Magnética , Masculino , Memória Episódica , Testes Neuropsicológicos , Tamanho do Órgão , Transposição dos Grandes Vasos/diagnóstico por imagem , Transposição dos Grandes Vasos/psicologia , Transposição dos Grandes Vasos/cirurgia
13.
Interact Cardiovasc Thorac Surg ; 23(5): 839-840, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27357466

RESUMO

A fistula between the right pulmonary artery and the left atrium is a very rare cause of central cyanosis. A clinical diagnosis is often made by first excluding other common causes and then performing diagnostic catheterization. Surgical closure offers a definitive cure for this rare congenital anomaly.


Assuntos
Cianose/etiologia , Fístula/complicações , Átrios do Coração/anormalidades , Cardiopatias/complicações , Artéria Pulmonar/anormalidades , Procedimentos Cirúrgicos Cardíacos/métodos , Pré-Escolar , Cianose/diagnóstico , Cianose/cirurgia , Feminino , Fístula/diagnóstico , Fístula/cirurgia , Cardiopatias/diagnóstico , Cardiopatias/cirurgia , Humanos , Imagem Cinética por Ressonância Magnética , Doenças Raras
14.
World J Pediatr Congenit Heart Surg ; 6(2): 220-5, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25870341

RESUMO

BACKGROUND: Axillary or brachial arteriovenous fistulae are occasionally created to improve systemic oxygen saturation in patients with functionally univentricular circulation after superior cavopulmonary anastomosis. Different techniques of fistula construction may account for the conflicting results. We sought to determine the impact of axillary arteriovenous fistula on systemic oxygen saturation and survival before subsequent palliation or heart transplantation. METHODS: Medical records of patients who underwent a side-to-side anastomosis between an adjacent axillary artery and vein for cyanosis after superior cavopulmonary anastomosis between 1991 and 2010 were reviewed. RESULTS: The median age (n = 23) at the time of fistula creation was 54 months (4-278 months). There was no operative mortality. The median duration of fistula patency was 48 months (1-174 months). Oxygen saturation improved from 71% ± 10% preoperatively to 84% ± 4% early (P < .05) and 81% ± 4% long term after the arteriovenous fistula (P < .05). Twelve patients underwent additional surgery (total cavopulmonary anastomosis 6, partial biventricular repair 2, and heart transplantation 4) after an interval of 10 to 141 months. Six patients are alive with a patent fistula without subsequent interventions after an interval of 48 to 174 months. Two patients with spontaneous closure or device closure of the fistula are alive after an interval of 76 to 80 months without subsequent interventions. Three deaths occurred with a patent fistula without subsequent interventions after an interval of 1 to 84 months. CONCLUSIONS: Systemic oxygen saturation improved with creation of an axillary arteriovenous fistula after superior cavopulmonary anastomosis. The fistula extended the duration of this stage of palliation without precluding the option for additional palliation or heart transplantation.


Assuntos
Derivação Arteriovenosa Cirúrgica/métodos , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/anormalidades , Adolescente , Artéria Axilar/cirurgia , Veia Axilar/cirurgia , Criança , Pré-Escolar , Cianose/sangue , Cianose/cirurgia , Feminino , Derivação Cardíaca Direita/métodos , Cardiopatias Congênitas/sangue , Transplante de Coração/métodos , Humanos , Masculino , Oximetria , Oxigênio/sangue , Cuidados Paliativos/métodos , Circulação Pulmonar/fisiologia , Reoperação/métodos , Resultado do Tratamento , Grau de Desobstrução Vascular/fisiologia
15.
Catheter Cardiovasc Interv ; 85(5): 842-6, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25511470

RESUMO

Transcatheter atrial septal defect occlusion is described in three pregnant patients with Ebstein's anomaly and exercise-induced cyanosis. Procedures took place in the second and third trimester. Careful hemodynamic testing was performed prior to permanent atrial septal occlusion to confirm the capacity of the right ventricle to accept the entirety of systemic venous return in the volume-expanded state of pregnancy. Outcomes for mother and fetus were favorable in all patients with significant reduction in maternal symptoms and resolution of cyanosis.


Assuntos
Anormalidades Múltiplas , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Cianose/cirurgia , Anomalia de Ebstein/cirurgia , Comunicação Interatrial/cirurgia , Complicações Cardiovasculares na Gravidez/cirurgia , Adulto , Septo Interatrial/cirurgia , Cianose/etiologia , Feminino , Seguimentos , Humanos , Recém-Nascido , Gravidez , Resultado da Gravidez , Valva Tricúspide/anormalidades , Adulto Jovem
16.
Pediatr Cardiol ; 36(3): 600-15, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25404555

RESUMO

The central aortic shunt, consisting of a Gore-Tex (polytetrafluoroethylene) tube (graft) connecting the ascending aorta to the pulmonary artery, is a palliative operation for neonates with cyanotic congenital heart disease. These tubes often have an extended length, and therefore must be angulated to complete the connection to the posterior pulmonary arteries. Thrombosis of the graft is not uncommon and can be life-threatening. We have shown that a viscous fluid (such as blood) traversing a curve or bend in a small-caliber vessel or conduit can give rise to marked increases in wall shear stress, which is the major mechanical factor responsible for vascular thrombosis. Thus, the objective of this study was to use computational fluid dynamics to investigate whether wall shear stress (and shear rate) generated in angulated central aorta-to-pulmonary artery connections, in vivo, can be of magnitude and distribution to initiate platelet activation/aggregation, ultimately leading to thrombus formation. Anatomical features required to construct the computer-simulated blood flow pathways were verified from angiograms of central aortic shunts in patients. For the modeled central aortic shunts, we found wall shear stresses of (80-200 N/m(2)), with shear rates of (16,000-40,000/s), at sites of even modest curvature, to be high enough to cause platelet-mediated shunt thrombosis. The corresponding energy losses for the fluid transitions through the aorta-to-pulmonary connections constituted (70 %) of the incoming flow's mechanical energy. The associated velocity fields within these shunts exhibited vortices, eddies, and flow stagnation/recirculation, which are thrombogenic in nature and conducive to energy dissipation. Angulation-induced, shear stress-mediated shunt thrombosis is insensitive to aspirin therapy alone. Thus, for patients with central aortic shunts of longer length and with angulation, aspirin alone will provide insufficient protection against clotting. These patients are at risk for shunt thrombosis and significant morbidity and mortality, unless their anticoagulation regimen includes additional antiplatelet medications.


Assuntos
Aorta/cirurgia , Prótese Vascular/efeitos adversos , Simulação por Computador , Hemodinâmica , Artéria Pulmonar/cirurgia , Trombose/fisiopatologia , Anastomose Cirúrgica/métodos , Velocidade do Fluxo Sanguíneo , Cianose/fisiopatologia , Cianose/cirurgia , Feminino , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Trombose/etiologia
18.
Pediatr Cardiol ; 35(7): 1108-15, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24714980

RESUMO

Cardiopulmonary bypass (CPB) reduces coagulation factor levels through hemodilution and consumption. Differences in CPB-induced alterations of factor XIII (FXIII) levels in children with cyanotic and acyanotic congenital heart defects (CHDs) are not well characterized. FXIII activity (determined by Berichrom assay), prothrombin index, activated partial thromboplastin time, and fibrinogen were measured before open heart surgery with CPB and 5 days postoperatively for children older than 3 years with acyanotic (n = 30) and cyanotic (n = 30) CHDs. The preoperative FXIII levels did not differ significantly among the children of the compared groups. The cyanotic patients showed a significantly longer duration of CPB (111.4 ± 45.8 vs 71.5 ± 33.6 min; p = 0.026) and aortic cross-clamp (68.0 ± 27.1 vs 45.4 ± 31.4 min; p = 0.034). The drop in FXIII levels after termination of CPB was more profound for the children with cyanotic CHDs (87.1 ± 13.4 to 49.1 ± 13.2 vs 81.5 ± 12.6 to 58.6 ± 11.1 %, respectively; p = 0.018). The cyanotc patients also were restored to their baseline FXIII levels later than the children with acyanotic CHDs (at 48 vs 24 h). The post-CPB dynamics of the majority of the other coagulation parameters in the compared groups of patients were similar. The cyanotic patients experienced significantly greater postoperative blood loss than the acyanotic patients (12.6 ± 4.9 vs 5.0 ± 2.1 mL/kg; p < 0.001) and were transfused with larger volumes of red blood cells (10.4 ± 6.5 vs 4.2 ± 2.5 mL/kg; p = 0.007). The decrease in FXIII levels after CPB is more profound and lasts longer in children with cyanotic CHDs than in acyanotic patients. The rational strategy of postoperative FXIII replacement therapy for these categories of patients needs to be determined.


Assuntos
Coagulação Sanguínea/fisiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Cianose/sangue , Fator XIII/metabolismo , Cardiopatias Congênitas/cirurgia , Adolescente , Biomarcadores/sangue , Criança , Pré-Escolar , Cianose/etiologia , Cianose/cirurgia , Feminino , Seguimentos , Cardiopatias Congênitas/sangue , Cardiopatias Congênitas/complicações , Humanos , Masculino , Período Pós-Operatório , Prognóstico , Estudos Prospectivos
19.
Indian J Pediatr ; 80(8): 663-74, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23640699

RESUMO

The purpose of this review/editorial is to discuss how and when to treat the most common cyanotic congenital heart defects (CHDs); the discussion of acyanotic heart defects was presented in a previous editorial. By and large, the indications and timing of intervention are decided by the severity of the lesion. While some patients with acyanotic CHD may not require surgical or transcatheter intervention because of spontaneous resolution of the defect or mildness of the defect, the majority of cyanotic CHD will require intervention, mostly surgical. Total surgical correction is the treatment of choice for tetralogy of Fallot patients although some patients may need to be palliated initially by performing a modified Blalock-Taussig shunt. For transposition of the great arteries, arterial switch (Jatene) procedure is the treatment of choice, although Rastelli procedure is required for patients who have associated ventricular septal defect (VSD) and pulmonary stenosis (PS). Some of these babies may require Prostaglandin E1 infusion and/or balloon atrial septostomy prior to corrective surgery. In tricuspid atresia patients, most babies require palliation at presentation either with a modified Blalock-Taussig shunt or pulmonary artery banding followed later by staged Fontan (bidirectional Glenn followed later by extracardiac conduit Fontan conversion usually with fenestration). Truncus arteriosus babies are treated by closure of VSD along with right ventricle to pulmonary artery conduit; palliative banding of the pulmonary artery is no longer recommended. Total anomalous pulmonary venous connection babies require anastomosis of the common pulmonary vein with the left atrium at presentation. Other defects should also be addressed by staged correction or complete repair depending upon the anatomy/physiology. Feasibility, safety and effectiveness of treatment of cyanotic CHD with currently available medical, transcatheter and surgical methods are well established and should be performed at an appropriate age in order to prevent damage to cardiovascular structures.


Assuntos
Cardiopatias Congênitas/cirurgia , Procedimentos Cirúrgicos Cardíacos , Circulação Colateral , Cianose/cirurgia , Dupla Via de Saída do Ventrículo Direito/cirurgia , Anomalia de Ebstein/cirurgia , Cardiopatias Congênitas/fisiopatologia , Comunicação Interventricular/epidemiologia , Comunicação Interventricular/cirurgia , Humanos , Atresia Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Transposição dos Grandes Vasos/epidemiologia , Transposição dos Grandes Vasos/cirurgia , Atresia Tricúspide/epidemiologia , Atresia Tricúspide/cirurgia , Tronco Arterial/cirurgia
20.
J Extra Corpor Technol ; 45(1): 40-5, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23691783

RESUMO

Using a novel noninvasive, visible-light optical diffusion oximeter (T-Stat VLS Tissue Oximeter; Spectros Corporation, Portola Valley, CA) to measure the tissue oxygen saturation (StO2) of the buccal mucosa, the correlation between StOz and central venous oxygen saturation (ScvO2) was examined in children with congenital cyanotic heart disease undergoing a cardiac surgical procedure. Paired StO2 and serum ScvO2 measurements were obtained postoperatively and statistically analyzed for agreement and association. Thirteen children (nine male) participated in the study (age range, 4 days to 18 months). Surgeries included Glenn shunt procedures, Norwood procedures, unifocalization procedures with Blalock-Taussig shunt placement, a Kawashima/ Glenn shunt procedure, a Blalock-Taussig shunt placement, and a modified Norwood procedure. A total of 45 paired StO2-ScvO2 measurements was obtained. Linear regression demonstrated a Pearson's correlation of .58 (95% confidence interval [CI], .35-.75; p < .0001). The regression slope coefficient estimate was .95 (95% CI, .54-1.36) with an interclass correlation coefficient of .48 (95% CI, .22-.68). Below a clinically relevant average ScvO2 value, a receiver operator characteristic analysis yielded an area under the curve of .78. Statistical methods to control for repeatedly measuring the same subjects produced similar results. This study shows a moderate relationship and agreement between StO2 and ScvO2 measurements in pediatric patients with a history of congenital cyanotic heart disease undergoing a cardiac surgical procedure. This real-time monitoring device can act as a valuable adjunct to standard noninvasive monitoring in which serum SyvO2 sampling currently assists in the diagnosis of low cardiac output after pediatric cardiac surgery.


Assuntos
Cianose/metabolismo , Cardiopatias Congênitas/metabolismo , Cardiopatias Congênitas/cirurgia , Oximetria/métodos , Oxigênio/metabolismo , Procedimentos Cirúrgicos Cardíacos/métodos , Estudos de Coortes , Cianose/sangue , Cianose/diagnóstico , Cianose/cirurgia , Feminino , Cardiopatias Congênitas/sangue , Humanos , Lactente , Recém-Nascido , Masculino , Monitorização Fisiológica/instrumentação , Monitorização Fisiológica/métodos , Oximetria/instrumentação , Oxigênio/sangue
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