Central Venous Pressure Estimation by Ultrasound Measurement of Inferior Vena Cava and Aorta Diameters in Pediatric Critical Patients: An Observational Study.

OBJECTIVES: To evaluate the ability to predict central venous pressure by ultrasound measured inferior vena cava and aortic diameters in a PICU population and to assess interoperator concordance. DESIGN: Noninterventional observational study. SETTING: PICU of a tertiary-care academic center. PATIENTS: Eighty-eight pediatric patients (0-16 yr old) with a central venous catheter in place were studied. Sixty-nine percent of the patients received positive-pressure ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: An experienced and a nonexperienced operator used ultrasound to measure the maximal diameter of inferior vena cava and minimal diameter of the inferior vena cava and the maximum diameter of the abdominal aorta from the subxiphoid window. The inferior vena cava collapsibility index and the ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta were then derived. The central venous pressure was measured using a central venous catheter and recorded. Twenty-three patients had low central venous pressure values (≤ 4 mm Hg), 35 patients a value in the range of 5-9 mm Hg, and 30 patients high values (≥ 10 mm Hg). Both inferior vena cava collapsibility index and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta were predictive of high (≥ 10 mm Hg) or low (≤ 4 mm Hg) central venous pressure. The test accuracy showed the best results in predicting low central venous pressure with an inferior vena cava collapsibility index greater than or equal to 35% and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta less than or equal to 0.8, and in predicting high central venous pressure with an inferior vena cava collapsibility index less than or equal to 20% and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta greater than or equal to 1.3. Inferior vena cava collapsibility index returned generally higher accuracy values than ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta. Lin's coefficient of concordance between the operators was 0.78 for inferior vena cava collapsibility index and 0.86 for ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta. CONCLUSIONS: Inferior vena cava collapsibility index and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta correlate well with central venous pressure measurements in this PICU population, and specific inferior vena cava collapsibility index or ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta thresholds appear to be able to differentiate children with high or low central venous pressure. However, the actual clinical application of these statistically significant results remains limited, especially by the intrinsic flaws of the procedure.

Surgical repair of aortic coarctation in pediatric age: A single center two decades experience.

BACKGROUND: To evaluate early and long-term results of surgical treatment of aortic coarctation (CoAo) in infants and children. METHODS: A retrospective clinical review of patients less than 18 years with CoAo, undergoing surgery between 1995 and 2015. Data were retrieved from our institutional database, to identify preoperative and postoperative characteristics. Statistical analysis was performed by bivariate, Cox's, and logistic regression analysis. RESULTS: Three hundred forty-one consecutive patients (male/female: 192/149; the median age at surgery of 25 days; interquartile range [IQR], 10-143 days) were included; 187 patients were less than 1 month (54.9%); 276 underwent extended end-to-end anastomosis (EEEA) (80.9%). Hypoplastic aortic arch (HAA) occurred in 34.6% and bicuspid aortic valve in 21.1%. The isolated type was present in 249 (73.0%). Significant postoperative complications occurred in 5.6%. Thirty-day mortality was 1.4%. At a median follow-up of 10.2 years (IQR, 6-15 years; FU completeness, 91.2%), there were eight late deaths (2.6%), most in the complex type. Among 298 survivors, 284 (95.3%) were in NYHA class I; 10 (3.0%) were on antihypertensive treatment. Reinterventions on aortic arch occurred only in 4.5%, being HAA a significant risk factor for reoperation ( P = 0.00173). Freedom from mortality and reintervention on aorta at 21 years were 93.5% and 93.6%, respectively. CONCLUSIONS: Surgical repair of CoAo by EEEA without CPBP is a safe and low-risk procedure, concerning either early or late outcomes, despite the presence of HAA and neonatal age can influence recoarctation. Most patients are clinically well in the long-term, and only a few require antihypertensive therapy.

Early modifications of cardiac function in preterm neonates using speckle tracking echocardiography.

BACKGROUND AND AIMS: Preterm newborns undergo hemodynamic challenges in the postnatal period. The aim of this study was to investigate myocardial mechanics changes in the postnatal period in preterm infants using speckle tracking echocardiography (STE). MATERIAL AND METHODS: Thirty-nine preterm infants ≤34 weeks' gestation underwent cardiac ultrasound evaluation during the first 96 hours of life. A repeated echocardiogram at 3 weeks of age was performed. Echocardiographic assessment involved left ventricular ejection fraction, mitral E/A ratio, S' and E' velocities, E/E' ratio, tricuspid annular plane systolic excursion (TAPSE), left atrium-to-aorta ratio, ductal diameter and ductal shunt pattern. Left ventricular longitudinal, circumferential and radial strain, apex-basal rotation and twist were measured from the apical 4-chamber and short-axis views using STE. RESULTS: The mean gestational age was 30 ± 2.7 weeks with a mean birth weight of 1318 ± 485 g. Apical segments demonstrated higher longitudinal strain than basal and mid-ones. In all gestational ages, endocardial longitudinal strain was higher than the epicardial. Epicardial longitudinal strain significantly increased during the first 3 weeks, resulting in the change in basal rotation from counterclockwise to clockwise and thus in the acquisition of twist. Deformation parameters were higher in infants with a hemodynamic significant patents ductus arteriosus. CONCLUSIONS: Echocardiographic assessment of myocardial deformation parameters is feasible in preterm infants. Our data suggest that the maturational process of the myocardium is due to the development of the epicardial layer after birth, which allows the acquisition of the twist.

Clinical Profile and Quality of Life of Adult Patients After the Fontan Procedure.

Increasingly, more patients with univentricular heart reach adulthood. Therefore, long-term psychological features are an important concern. The aim of this study was to evaluate the clinical and psychological profile of post-Fontan adult patients and to identify the most significant determinants of quality of life. In this retrospective cross-sectional study, we reviewed the surgical and medical history of post-Fontan adult patients. Patients underwent a 24-h electrocardiogram, echocardiography and exercise testing. Self-report questionnaires were used to assess the Work Ability Index, quality of life (Satisfaction with Life Scale), perceived health status (SF-36 questionnaire), coping strategies (Brief Cope questionnaire) and presence of mood disorders (Hospital Anxiety and Depression Scale). Thirty-nine patients aged between 18 and 48 years (mean 27.5 years) were enrolled. The mean follow-up was 21.5 years. Most patients were unmarried (82.9 %), had a high school diploma (62.9 %) and were employed (62.9 %). Twenty-nine patients (82.3 %) had at least one long-term complication. The median single ventricle ejection fraction was 57 %, and the median maximal oxygen consumption was 26.8 ml/min/kg. This population tended to be anxious and to use adaptive coping strategies. Quality of life was perceived as excellent or good in 57.2 % of cases and was not related to either cardiac function or exercise capacity. Both quality of life and SF-36 domains were related to the Work Ability Index. This cohort of post-Fontan adult patients enjoyed a good quality of life irrespective of disease severity.

Basic data from 176 studies on the immediate outcome after aortic valve replacement with or without coronary artery bypass surgery.

OBJECTIVE: The aim of this study was to summarize the immediate outcome after aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG). DESIGN: Systematic review and meta-analysis. SETTING: University hospitals. PARTICIPANTS: Participants were 683,286 patients who underwent AVR with or without CABG. Patients undergoing other major cardiac procedures were excluded from this analysis. INTERVENTIONS: AVR with or without CABG. MEASUREMENTS AND MAIN RESULTS: Operative mortality after AVR with or without concomitant CABG was 4.3%, stroke 2.1%, pacemaker implantation 5.9%, and dialysis 2.2%. After isolated AVR, operative mortality was 3.3%, stroke 1.7%, pacemaker implantation 3.3%, and dialysis 1.6%. Mortality was increased among very elderly (< 60 years: 3.3%, 60-69 years: 2.7%, 70-79 years: 3.8%,≥ 80 years: 6.1%, p < 0.001). Prevalence of minimally invasive AVR (mini-AVR) was associated with significantly lower operative mortality (p = 0.039, 46 studies). Mini-AVR only tended toward lower mortality when included in meta-regression analysis as a dichotomous variable (mini-AVR 4,367 patients: 2.3%, 95% CI 1.8-2.9% v full sternotomy 11,076 patients: 3.5%, 95% CI 28-4.1%, p = 0.088). Operative mortality after AVR plus CABG was 5.5% (versus isolated AVR: p < 0.001), stroke 3.0%, pacemaker implantation 3.9%, and dialysis 5.6%. Mortality was high in all age strata, particularly among very elderly (mean age < 70 years: 4.8%, mean age 70-79 years: 4.7%; mean age ≥ 80 years: 8.4%, p = 0.002). CONCLUSIONS: Isolated AVR is associated with low mortality and morbidity. Coronary artery disease requiring concomitant CABG increases the operative mortality. Patients requiring AVR and CABG should be the main target of less-invasive treatment strategies.

Pulmonary Artery Banding for Ventricular Rehabilitation in Infants With Dilated Cardiomyopathy: Early Results in a Single-Center Experience.

Background: Pulmonary artery banding (PAB) is reported as an innovative strategy for children with end-stage heart failure (ESHF) to bridge to transplantation or recovery. We report our early experience with PAB to evaluate outcomes, indications, and limitations. Materials and Methods: This is a single-center prospective clinical study, including infants and children admitted for ESHF owing to dilated cardiomyopathy (DCM) with preserved right ventricular function after failure of maximal conventional therapy. All patients underwent perioperative anticongestive medical therapy with ACE inhibitor, beta blocker, and spironolactone. Post-operatively, all patients underwent echocardiographic follow-up to assess myocardial recovery. Results: We selected five patients (four males) who underwent PAB at a median age of 8.6 months (range 3.9-42.2 months), with preoperative ejection fraction (EF) <30%. Sternal closure was delayed in all. One patient did not improve after PAB and underwent Berlin Heart implantation after 33 days, followed by heart transplant after 13 months. Four patients were discharged home on full anticongestive therapy. However, 2 months after discharge, one patient experienced severe acute heart failure secondary to pneumonia, which required mechanical circulatory support, and the patient underwent a successful heart transplant after 21 days. The remaining three patients are doing well at home, 22.4, 16.9, and 15.4 months after PAB. They all underwent elective percutaneous de-banding, 18.5, 4.8, and 10.7 months after PAB. EF increased from 17.7 ± 8.5% to 63.3 ± 7.6% (p = 0.03), and they have all been delisted. Conclusion: Use of PAB may be an effective alternative to mechanical support in selected infants for bridging to transplant or recovery. Better results seem to occur in patients aged <12 months. Further experience and research are required to identify responders and non-responders to this approach.

Hemodynamic impact of pulmonary vasodilators on single ventricle physiology.

INTRODUCTION: The Fontan procedure is the palliative procedure for single ventricle physiology. Pulmonary resistance plays a key role in the success of this operation. There are conflicting data concerning the impact of pulmonary vasodilators on survival and functional capacity among Fontan patients. AIM: The aim of this retrospective, single-center, nonrandomized study was to investigate the potential effect of pulmonary vasodilators on pulmonary vasculature in Fontan patients. METHOD: Twenty-seven patients with single ventricle physiology were enrolled. Eighteen patients were treated with pulmonary vasodilators: 9 patients after Glenn procedure or just after the Fontan completion (Group A) and 9 patients >5 years after Fontan completion (Group B). Nine patients after Glenn procedure were enrolled as a control group (Group C). The primary endpoint was to assess changes in hemodynamic profile and pulmonary branches' diameter after 2 right heart catheterizations. Adverse events were recorded. RESULTS: Mean age ± SD was 3.2 ± 1.5 years (Group A), 26.8 ± 12.7 years (Group B), and 3.1 ± 1.0 years (Group C). Patients included in Group A had reduced arterial compliance (34.3 ± 15.4 vs 52.2 ± 24.2 mm2 /[m2 *mm Hg]; P = .03) at baseline compared with Group C. After treatment, Nakata index and pulmonary compliance increased in patients treated with pulmonary vasodilators (Group A), while remaining stable in the control group (Nakata index: +26 ± 24% vs -8 ± 17%, P = .003; pulmonary compliance +80 ± 49% vs -5 ± 30%, P = .001). Similar results were found in Group B (Nakata index: pre-168.6 ± 70.7 mm2 /m2 ; post-204.9 ± 97.5 mm2 /m2 ; P = .026). CONCLUSIONS: Pulmonary vasodilators reduce pulmonary artery resistance and increase vascular compliance, pulmonary artery diameter, and cardiac output in Fontan patients. Therefore, pulmonary vasodilators may be used before the Fontan procedure in patients at high risk of Fontan procedure failure.

Ankyloblepharon Filiforme Adnatum in a Newborn.

Ankyloblepharon filiforme adnatum (AFA) is a rare congenital anomaly consisting of a partial or complete fusion of the eyelid margins. It is usually an isolated and benign malformation but its presence should alert the neonatologist because it can be rarely associated to other important multisystemic disorders. We report a case of a newborn presenting with isolated AFA at birth, treated in the first day of life.