Predictors of Reopening the Sternum in Children After Cardiac Surgery.

OBJECTIVES: Capillary leak syndrome can be severe in children after open-heart surgery which may hinder sternum closure and described as mediastinal tamponade. Reopening the sternum postoperatively may help maintaining hemodynamics and respiratory function. We looked for predictors that indicate the need for reopening the sternum. DESIGN: A retrospective cohort study. SETTING: A single cardiac center experience from 2009 to end of 2015. PATIENTS: All children who required emergent reopening the sternum in the pediatric cardiac ICU after cardiac surgery were grouped as index cases and matched to a control group for age, body weight, cardiac diagnosis, and type of repair (single vs biventricular). INTERVENTIONS: Emergent reopening the sternum. MEASUREMENTS AND MAIN RESULTS: With a ratio of two control cases for each index case, variables related to cardiac output (predictors) were collected in a time line of 12, 6 hours, and just before reopening the sternum. Morbidities and mortality were also reviewed. Thirty-three index cases were compared with 63 control cases. Hospital stay and hospital-acquired infections were the same between the groups. Ventilation hours were longer in the index cases. Temperature gap more than 3°C, inotropic score more than 14, and acute kidney injury indicated by doubled blood urea nitrogen and creatinine were higher in the index group 6 hours before reopening the sternum. Mortality was more in the reopening sternum group with higher risk when extracorporeal membrane oxygenation was needed. CONCLUSIONS: Low cardiac output after cardiac surgery in children in form of temperature gap more than 3°C, inotropic score more than 14, and acute kidney injury may predict the need of reopening the sternum. Rate of mortality was higher in the reopening sternum group when extracorporeal membrane oxygenation was needed.

Short- and mid-term outcomes of total correction of Taussig-Bing anomaly.

Double-outlet right ventricle (DORV)/Taussig-Bing (TB) anomaly is the second most common type of DORV. This study evaluates our experience and outcomes of total correction of DORV-TB anomaly at King Abdulaziz Cardiac Center. We conducted a retrospective study for all cases of TB anomaly repaired between June 2001 and April 2009. Patients were divided into two groups: Group A included patients repaired with arterial switch operation, and group (B) included patients repaired with Rastelli procedure. Thirteen patients with TB anomaly underwent total correction. There were 5 male (38%) and 8 female (62%) patients. Mean age and weight at surgery were 6.8 ± 6 weeks and 3.6 ± 0.7 kg, respectively. Of the 13 patients, 9 (69%) were in group A, and 4 (31%) were in group B. Aortic arch abnormalities were present in 9 patients (69%); abnormal coronary artery patterns were present in 7 patients (54%); side-by-side great arteries were present in 5 patients (38%); dextrotransposition of the great arteries was present in 7 patients (54%); and levo-malposition of the great arteries was present in 1 patient (8%). At postoperative follow-up, 4 patients (31%) had developed either left- or right-ventricular outflow tract (VOT) obstruction requiring surgical and/or catheter intervention. There was no early mortality, but there was 1 late mortality caused by left-ventricle dysfunction. DORV-TB is often associated with other congenital cardiac anomalies. In general, total repair is feasible in the majority of patients with satisfactory results and improved outcome. Residual lesion and development of VOT obstruction can occur, requiring close follow-up and intervention for residual lesion.

Early outcome for the primary arterial switch operation beyond the age of 3 weeks.

The arterial switch operation (ASO) for neonates is the standard management for transposition of the great arteries (TGA) with an intact ventricular septum (IVS). Patients presenting for late ASO are at risk due to the possibility of left ventricle (LV) involution. This study aimed to assess the early postoperative course and outcome for children with TGA/IVS and still conditioned LV presenting for late primary ASO. A retrospective study of all TGA/IVS patients who underwent a primary ASO between March 2002 and March 2008 was conducted. The cases were divided into two groups. Group A included all the cases of early ASO repaired before the age of 3 weeks, whereas group B included all the preslected cases of late ASO repaired after the age of 3 weeks. The demographics, intensive care unit (ICU) parameters, complications, and short-term outcomes of the two groups were compared. The study enrolled of 91 patients: 64 patients (70%) in group A and 27 patients (30%) in group B. The mean age was 11 +/- 4 days in group A and 37 +/- 17 days in group B (P < 0.001). The two groups showed no significant statistical differences in ICU parameters, complications, or mortality. For patients with TGA/IVS, ASO still can be tolerated beyond the first month of life in selected cases. Provided the LV still is conditioned, age should not be a limitation for ASO.

Impact of Cardiopulmonary Bypass and Aorta Cross Clamp Time on the Length of Mechanical Ventilation after Cardiac Surgery among Children: A Saudi Arabian Experience.

Aim Several factors determine the perioperative outcome besides the nature of the congenital heart defect. Prolonged mechanical ventilation (PMV) is a major factor that determines mortality, length of stay (LOS), residual disability, and other functional outcomes. We aim to determine the clinical variables predicting PMV and LOS in hospital, and specifically the impact from the duration of cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC). Method We conducted a retrospective review of the medical records of 413 children consecutively admitted to the Pediatric Cardiac Intensive Care Unit (PCICU) in one year at a single center. We collected demographic information (e.g., age, gender, and weight), perioperative variables, clinical outcomes, length of mechanical ventilation, high-frequency ventilator use, and mortality. We used logistic regression to analyze the data. PMV was defined as mechanical ventilation for longer than seven days. Results A total of 410 records were included in our study. We found no statistically significant association between CPB time and mechanical ventilation days. Forty-seven children had PMV, 362 did not have PMV. We found no statistically significant association between CPB time and mechanical ventilation days after adjusting for covariates. Reanalyzing the data with PMV defined as longer than four days produced the same results. Using a regression model to assess the variables via the least absolute shrinkage and selection operator for feature selection, we found no statistically significant association between ACC time and mechanical ventilation days after adjusting for covariates. Conclusion According to our results, CPB and ACC time are not associated with PMV or prolonged hospital LOS.

Cardiac recovery and outcome of neonates and infants presenting with severe aortic coarctation and depressed cardiac function.

OBJECTIVES: Coarctation of the aorta represents 5-8% of all congenital heart diseases. Children with severe coarctation of the aorta may present with significant depression of myocardial function. The aim of this study is to identify short and midterm outcomes of neonates and infants with isolated coarctation of the aorta and depressed left ventricular systolic function with regard to recovery of their cardiac function. METHODS: All patients with isolated coarctation of the aorta who underwent surgical repair between December 2002 and December 2015 were retrospectively reviewed in a cohort study. The patients were divided into 2 groups: (1) Patients with depressed left ventricle systolic function who were found to have an ejection fraction and fractional shortening less than 55% and 25%, respectively, (2) Patients with coarctation of the aorta and normal left ventricle systolic function (Control Group). We reviewed both groups after surgery and compared them in terms of their cardiac function recovery. RESULTS: 58 patients were included. 25 patients (43%) depressed left ventricle systolic function group, 33 patients (57%) Control Group. There were statistically significant differences in ejection fraction and fractional shortening (p < 0.0001) between the two groups before surgery. Follow-up demonstrated improvement and recovery of ventricular function in most of the patients, six months after surgery there was no more statistical difference between the groups in terms of cardiac function. CONCLUSION: Majority of the patients with isolated coarctation of the aorta and depressed left ventricle systolic function showed improvement of ventricular function within 4 weeks after surgery, except for patients with residual coarctation of the aorta.

Effects of protocol-based management on the post-operative outcome after systemic to pulmonary shunt.

OBJECTIVES: Systemic to pulmonary shunt (commonly known as Modified Blalock-Taussig shunt) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lungs. Based on the most recent risk stratification score, the mortality and morbidity of this procedure is still high especially in neonates and over-shunting patients. We developed and implemented protocol-based management in March 2013 to better standardize the management of these patients. The aim of this study is to evaluate the effects of applying this protocol-based management in our center. METHODS: We conducted a retrospective cohort study through chart review analysis.We included all children who underwent MBTS from January 2000 till December 2015. We compared the early postoperative outcome of patients operated after the protocol-based management implementation (March 2013 till December 2015) (protocol group) with patients operated before implementing the MBTS protocoled management (control group). RESULTS: 197 patients underwent MBTS from January 2000 till December 2015. Of the 197 patients, 25 patients were in the protocol group and 172 patients were in the control group. There was a significant improvement in the postoperative course and less morbidity after protocoled management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, intensive care unit ICU stay and significantly lower postoperative complications in the protocol group. Mortality of the control group versus protocol group (19.3% VS 8%) with Standardized Mortality Ratio (SMR) dropped from 2.27 before protocoled management to 0.94 after protocoled management (protocol group). CONCLUSION: The study suggests that protocoled management of patients with MBTS can improve the postoperative course and early outcome.

Predictors for the Outcome of Aortic Regurgitation After Cardiac Surgery in Patients with Ventricular Septal Defect and Aortic Cusp Prolapse in Saudi Patients.

BACKGROUND AND AIM: Aortic valve (AV) prolapse and subsequent aortic regurgitation (AR) are two complications of ventricular septal defects (VSD) that are located close to or in direct contact with the AV. This finding is one of the indications for surgical VSD closure even in the absence of symptoms to protect the AV integrity. The goal of our study was to assess the outcome and to identify the predictors for improvement or progression of AR after surgical repair. MATERIALS AND METHODS: A retrospective study of all children with VSD and AV prolapse who underwent cardiac surgery at King Abdulaziz Cardiac Centre in Riyadh between July 1999 and August 2013. RESULTS: A total of 41 consecutive patients, operated for VSD with prolapsed AV, with or without AR, were reviewed. The incidence of AV prolapse in the study population was 6.8% out of 655 patients with VSD. Thirty-six (88%) patients had a perimembranous VSD, and four had doubly committed VSD. Only one patient had an outlet muscular VSD. Right coronary cusp prolapse was found in 38 (92.7%) patients. Preoperative AR was absent in five patients, mild or less in 25 patients, moderate in seven, and severe in four patients. Twenty-six patients showed improvement in the degree of AR after surgery (Group A), 14 patients showed no change in the degree of AR (Group B) while only one patient showed the progression of his AR after surgery. Those with absent AR before surgery remained with no AR after surgery. Improvement was found more in those with mild degree of AR preoperatively compared to those with moderate and severe AR. Female gender also showed a tendency to improve more as compared to male. CONCLUSION: Early surgical closure is advisable for patients with VSD and associated AV prolapse to achieve a better outcome after repair and to prevent progression of AR in future.

Urinary tract infection in children after cardiac surgery: Incidence, causes, risk factors and outcomes in a single-center study.

Nosocomial urinary tract infection (UTI) increases hospitalization, cost and morbidity. In this cohort study, we aimed to determine the incidence, risk factors, etiology and outcomes of UTIs in post-operative cardiac children. To this end, we studied all post-operative patients admitted to the Pediatric Cardiac Intensive Care Unit (PCICU) in 2012, and we divided the patients into two groups: the UTI (UTI group) and the non-UTI (control group). We compared both groups for multiple peri-operative risk factors. We included 413 children in this study. Of these, 29 (7%) had UTIs after cardiac surgery (UTI group), and 384 (93%) were free from UTIs (control group). All UTI cases were catheter-associated UTIs (CAUTIs). A total of 1578 urinary catheter days were assessed in this study, with a CAUTI density rate of 18 per 1000 catheter days. Multivariate logistic regression analysis demonstrated the following risk factors for CAUTI development: duration of urinary catheter placement (p<0.001), presence of congenital abnormalities of kidney and urinary tract (CAKUT) (p<0.0041) and the presence of certain syndromes (Down, William, and Noonan) (p<0.02). Gram-negative bacteria accounted for 63% of the CAUTI. The main causes of CAUTI were Klebsiella (27%), Candida (24%) and Escherichia coli (21%). Resistant organisms caused 34% of CAUTI. Two patients (7%) died in the UTI group compared with the one patient (0.3%) who died in the control group (p<0.05). Based on these findings, we concluded that an increased duration of the urinary catheter, the presence of CAKUT, and the presence of syndromes comprised the main risk factors for CAUTI. Gram-negative organisms were the main causes for CAUTI, and one-third of them found to be resistant in this single-center study.

Outcome of low body weight (<2.2 kg) infants undergoing cardiac surgery.

INTRODUCTION: Infants with low body weight (LBW) following cardiac surgery are a major challenge for the post cardiac surgery care unit. It has been observed that post surgery outcome for LBW infants is worse compared to the outcome of normal body weight infants. A study was conducted to compare post operative course and outcome of infants with body weight of 2.2 kg or less against infants with normal body weight who underwent similar cardiac surgeries. METHODS: A retrospective review was performed for all infants below 2.2 kg who underwent cardiac operations at King Abdulaziz Cardiac Center from January 2001 to October 2011. Cases with LBW (Group A) were compared with matching group (Group B) of normal body weight infants who had similar cardiac surgeries and matching surgical risk category. The demographic, ICU parameters, complications, and short-term outcome of both groups were analyzed. RESULTS: Two groups were formed, with 37 patients in Group A, and 39 patients in Group B. Except for weight (2.13 ± 0.08 kg in Group A vs 3.17 ± 0.2 kg in Group B), there was no statistical difference in demographic data between both groups. Cardiac procedures included coarctation repair, arterial switch, ventricular septal defect (VSD) repair, tetralogy of Fallot repair, systemic to pulmonary shunt and Norwood procedures. Patients in Group A had statistically significant difference from Group B in terms of bypass time (p = 0.01), duration of inotropes (p = 0.01), duration of mechanical ventilation (p = 0.004), number of re-intubations (p = 0.015), PCICU length of stay (p = 0.007), and hospital mortality: 13.5% in Group A vs 0% in Group B (p value 0.02). CONCLUSION: Patients with LBW (<2.2 kg) underwent cardiac surgery with overall satisfactory results, but with increased risk of ICU morbidity and mortality.

Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery.

BACKGROUND AND AIM: Chylothorax is the accumulation of chyle in the pleural cavity, which usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases, this rupture is secondary to trauma (including cardio thoracic surgeries). Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. This study aims to determine the risk factors and the impact of chylothorax on the early postoperative course after pediatric cardiac surgery. METHODS: A retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery was conducted at King Abdulaziz Cardiac Center between January 2007 and December 2009. RESULTS: There were 1135 cases operated on during the study period. Of these, 57 cases (5%) were complicated by chylothorax in the postoperative period. Thirty patients (54%) were males, while 27 (47%) were females. Ages ranged from 4 to 2759 days. The most common surgeries complicated by chylothorax were the single ventricle repair surgeries (15 cases, 27%); arch repairs (10 cases, 18%); ventricular septal defect repairs (10 cases, 18%); atrioventricular septal defect repairs (7 cases, 12%); arterial switch repair (6 cases, 11%), and others (8 cases, 14%). The intensive care unit (ICU) and the length of hospital stays were significantly longer in the chylothorax group. Additionally, some early postoperative parameters such as incidence of sepsis, ventilation time, and inotropes duration and number were higher in the chylothorax group. CONCLUSION: Chylothorax after pediatric cardiac surgery is not a rare complication. It occurs more commonly with single ventricle repair and aortic arch repair surgeries, and has a significant impact on the postoperative course and post operative morbidity.

Early outcome of tetralogy of Fallot repair in the current era of management.

BACKGROUND: Traditional use of trans-annular patch (TAP) to release right ventricular outflow tract (RVOT) obstruction during tetralogy of Fallot (TOF) repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve (PV) function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function. METHODS: A retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group (A) which include patients who had TAP without a valve. Group (B) includes those who had TAP with a monocuspid valve (Contegra). We compared post-operative care and outcome of all groups. RESULTS: Eighty-three patients fulfilled the study criteria. There were 64 cases (77%) in group I, and 19 cases (23%) in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups. CONCLUSION: Children undergoing TOF repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques.