Coronary artery spasm in a neonate with transposition of great arteries: a rare complication and reason for heart transplant.

Arterial switch operation has become the standard of care for d-transposition of great arteries and has excellent short- and long-term outcomes. We report the case of a newborn with a diagnosis of d-transposition of great arteries with intact ventricular septum and a low-risk coronary artery anatomy who developed coronary artery vasospasm while coming off bypass following arterial switch operation in the operating room. The coronary artery spasm led to severe biventricular dysfunction and need for extracorporeal membranous oxygenation support. Despite extracorporeal membranous oxygenation and inotropic support, there was no improvement in the left ventricular function, and cardiac transplantation was performed after 8 days. The explanted heart showed extensive infarction of both ventricles. Both the coronary ostei were patent with no evidence of thrombus, suggesting coronary artery vasospasm rather than embolus or thrombus formation. This is the first case of coronary artery vasospasm in a neonate with d-transposition of great arteries leading to cardiac transplantation. We speculate that early identification of patients who are at a high risk for coronary vasospasm and prophylactic or timely infusion of papaverine directly into the coronary arteries may be beneficial in this condition.

Acute kidney injury following first-stage palliation in hypoplastic left heart syndrome: hybrid versus Norwood palliation.

OBJECTIVE: The aim of this study was to evaluate the prevalence of acute kidney injury after first-stage surgical palliation in patients with a single ventricle and to explore associated risk factors and outcomes. Design and patients This single-centre retrospective study included neonates who underwent either Norwood or Hybrid procedure from 2008 to 2015 for a single ventricle. Postoperative acute kidney injury was defined using the paediatric risk, injury, failure, loss, end-stage renal disease (pRIFLE), criteria within 72 hours of the procedure. Main results Our cohort (n=48) underwent surgical palliation at a mean (SD) age of 12 (11) days. Postoperative acute kidney injury was diagnosed in 14 (29%) patients. The prevalence of acute kidney injury in the Hybrid group was 16% and 53% in the Norwood group. Infants who developed acute kidney injury underwent surgery at younger ages [6 (5-10) versus 10 (8-16) days, p=0.016], and had a higher peak lactate level in the initial 24 hours [5.9 (4.2-9.1) versus 3.4 (2.4-6.7), p=0.007]. Norwood procedure was significantly associated with acute kidney injury [odds ratio 11.7 (95% confidence interval 1.3-101.9), p=0.03]. ICU stay [38 (21-84) versus 16 (6-45) days, p=0.038] and time to extubation [204 (120-606) versus 72 (26-234) hours, p=0.014] were longer in those with acute kidney injury. The two patients who developed early postoperative renal failure as per pRIFLE died before discharge from associated comorbidities. CONCLUSIONS: Acute kidney injury occurs in a third of the patients with single ventricle after surgical palliation but is mostly transient. Norwood, compared with Hybrid procedure, is a risk factor for postoperative acute kidney injury, which, in turn, is associated with longer ICU stay and time to extubation.

Vasoactive Inotropic Score (VIS) as Biomarker of Short-Term Outcomes in Adolescents after Cardiothoracic Surgery.

Our aim was to evaluate the Vasoactive Inotropic Score (VIS) as a prognostic marker in adolescents following surgery for congenital heart disease. This single-center retrospective chart review included patients 10-18 years of age, who underwent cardiac surgery from 2009 to 2014. Hourly VIS was calculated for the initial 48 postoperative hours using standard formulae and incorporating doses of six pressors. The composite adverse outcome was defined as any one of death, resuscitation or mechanical support, arrhythmia, infection requiring antibacterial therapy, acute kidney injury or neurologic injury. Surgeries were risk-stratified by the type of surgical repair using the validated STAT score. Statistical analysis (SPSS 19.0) included Mann-Whitney U test, Chi-square test, ROC curves, and binary regression analysis. Our cohort (n = 149) had a mean (SD) age of 13.9 (2.4) years and included 97 (65.1 %) males. Maximal VIS at 24 and 48 h following surgery was significantly higher in subjects (n = 27) who suffered an adverse outcome. Subjects with adverse outcome had longer bypass and cross-clamp times, durations of stay in the hospital, and a higher rate of acute kidney injury, compared to those (n = 122) without postoperative adverse outcomes. The area under the ROC for maximum VIS at 24-48 h after surgery was 0.76, with sensitivity, specificity, and positive and negative predictive values with 95 % CI of 67 (48-82) %, 74 (70-77) %, and 36 (26-44) % and 91 (86-95) %, respectively, at a cutoff >4.75. On binary logistic regression, maximum VIS on second postoperative day remained significantly associated with adverse outcome (OR 1.35; 95 % CI> 1.12-1.64, p = 0.002). Maximal VIS at 24 and 48 h correlated significantly with length of stay and time to extubation. Maximal VIS on the second postoperative day predicts adverse outcome in adolescents following cardiac surgery. This simple yet robust prognostic indicator may aid in risk stratification and targeted interventions in this population.

Effect of Hybrid stage 1 procedure on ventricular function in infants with hypoplastic left heart syndrome.

OBJECTIVE: The effect of Hybrid stage 1 palliation for hypoplastic left heart syndrome on right ventricular function is unknown. We sought to compare right ventricular function in normal neonates and those with hypoplastic left heart syndrome before Hybrid palliation and to assess the effect of Hybrid palliation on right ventricular function, using the right ventricular myocardial performance index and the ratio of systolic and diastolic durations. METHODS: We carried out a retrospective review of echocardiographic data on 23 infants with hypoplastic left heart syndrome who underwent Hybrid palliation and 35 normal controls. Data were acquired before Hybrid and after Hybrid palliation - post 1, 0-4 days; post 2, 1 week; post 3, 2-3 weeks; post 4, 1-1.5 months following Hybrid palliation. RESULTS: Myocardial performance index and ratio of systolic and diastolic durations were higher in the pre-Hybrid hypoplastic left heart syndrome group (n=23) - 0.47±0.16 versus 0.25±0.07, p<0.001; 1.59±0.44 versus 1.09±0.14, p<0.0001 - compared with controls (n=35). There was no significant change in the myocardial performance index at any of the post-Hybrid time points. Ratio of systolic and diastolic durations increased significantly 2 weeks after Hybrid - post 3: 2.08±0.62 and post 4: 2.21±0.45 versus pre: 1.59±0.44, p=0.043 and 0.003. There were no significant differences in parameters between sub-groups of infants who died (n=10) and survivors (n=13). CONCLUSIONS: Right ventricular myocardial performance index and ratio of systolic and diastolic durations were significantly higher in infants with hypoplastic left heart syndrome before intervention compared with controls. The ratio of systolic and diastolic durations increased significantly 2 weeks after Hybrid palliation. Our data suggest that infants with hypoplastic left heart syndrome have right ventricular dysfunction before intervention, which worsens over 2 weeks after Hybrid palliation.

Prevalence and risk factors for upper airway obstruction after pediatric cardiac surgery.

OBJECTIVE: To determine the prevalence of and risk factors for extrathoracic upper-airway obstruction after pediatric cardiac surgery. STUDY DESIGN: A retrospective chart review was performed on 213 patients younger than 18 years of age who recovered from cardiac surgery in our multidisciplinary intensive care unit in 2012. Clinically significant upper-airway obstruction was defined as postextubation stridor with at least one of the following: receiving more than 2 corticosteroid doses, receiving helium-oxygen therapy, or reintubation. Multivariate logistic regression analysis was performed to determine independent risk factors for this complication. RESULTS: Thirty-five patients (16%) with extrathoracic upper-airway obstruction were identified. On bivariate analysis, patients with upper-airway obstruction had greater surgical complexity, greater vasoactive medication requirements, and longer postoperative durations of endotracheal intubation. They also were more difficult to calm while on mechanical ventilation, as indicated by greater infusion doses of narcotics and greater likelihood to receive dexmedetomidine or vecuronium. On multivariable analysis, adjunctive use of dexmedetomedine or vecuronium (OR 3.4, 95% CI 1.4-8) remained independently associated with upper-airway obstruction. CONCLUSION: Extrathoracic upper-airway obstruction is relatively common after pediatric cardiac surgery, especially in children who are difficult to calm during endotracheal intubation. Postoperative upper-airway obstruction could be an important outcome measure in future studies of sedation practices in this patient population.

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery.

OBJECTIVE: Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, although data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. DESIGN: Retrospective chart review. SETTING: Urban tertiary care free-standing children's hospital. PATIENTS: Neonates (0-30 d) who underwent cardiac surgery at our institution between January 2009 and December 2012 was performed. INTERVENTIONS: Extubation failure was defined as reintubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. MEASUREMENTS AND MAIN RESULTS: We included 120 neonates, of whom 21 (17.5%) experienced extubation failure. On univariate analysis, patients who failed extubation were more likely to have genetic abnormalities (24% vs 6%; p = 0.023), hypoplastic left heart (43% vs 17%; p = 0.009), delayed sternal closure (38% vs 12%; p = 0.004), postoperative infection prior to extubation (38% vs 11%; p = 0.002), and longer duration of mechanical ventilation (median, 142 vs 58 hr; p = 0.009]. On multivariate analysis, genetic abnormalities, hypoplastic left heart, and postoperative infection remained independently associated with extubation failure. Furthermore, patients with infection who failed extubation tended to receive fewer days of antibiotics prior to their first extubation attempt when compared with patients with infection who did not fail extubation (4.9 ± 2.6 vs 7.3 ± 3; p = 0.073). CONCLUSIONS: Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.

Hybrid procedure of bilateral pulmonary artery banding and bilateral ductal stenting in an infant with aortic atresia and interrupted aortic arch.

We report an infant with aortic valve atresia, interrupted aortic arch, ventricular septal defect, confluent pulmonary arteries, bilateral arterial ducts, absent common carotid arteries, and anomalous coronary arteries arising from main pulmonary artery. Hybrid procedure consisting of bilateral pulmonary artery banding and bilateral arterial duct stenting was performed at 4 weeks of age. Hybrid procedure can be an alternative palliative approach in an infant with this complex cardiac anatomy.

Safety and utility of passive peritoneal drainage following Fontan palliation.

OBJECTIVE: Placement of peritoneal drainage catheters intra-operatively has been shown to help prevent fluid overload in children recovering from surgery for two-ventricle heart disease. We aimed to determine whether this practice is also helpful in children recovering from Fontan palliation. MATERIAL AND METHODS: A retrospective review was performed on children with single-ventricle anatomy undergoing Fontan palliation at our institution from 2007 to 2011. Variables in those with peritoneal drainage were compared with those without using t-tests, Mann-Whitney U-tests, chi-square tests, or analysis of variance for repeated measures as appropriate. Data were represented as mean with standard deviation unless otherwise noted. RESULTS: A total of 43 children were reviewed, 21 (49%) with peritoneal drainage catheters. No complications from catheter placement occurred. The groups did not differ with regard to cardiopulmonary bypass duration, dominant ventricle, pre-operative haemodynamic data, fenestration use, and initial intensive care unit ventilation index. Central venous pressures, vasoactive medication use, and diuretic use during the first 48 hours were also not statistically different. At 48 hours, the median fluid balance was -9 (interquartile range : -50, +20) in those with peritoneal drainage and +77 cc/kg (interquartile range : +22, +96) in those without (p < 0.001), yet median duration of mechanical ventilation was 40 hours (range: 19-326) in those with peritoneal drainage and 23 hours (range: 9-92) in those without, p = 0.01. CONCLUSION: Patients with peritoneal drainage recovering from Fontan palliation achieved negative fluid balance as compared with those without peritoneal drainage, although this difference was associated with a longer duration of mechanical ventilation.

Hyponatremia during arginine vasopressin therapy in children following cardiac surgery.

OBJECTIVE: To describe the incidence and severity of hyponatremia after initiation of arginine vasopressin therapy in children recovering from cardiothoracic surgery, and to compare these patients with a control group with similar disease complexity and severity who did not receive arginine vasopressin. DESIGN: Retrospective chart review. SETTING: PICU at a tertiary care university hospital. PATIENTS: Twenty-nine patients who received arginine vasopressin for at least 6 hours during the first 48 postoperative hours following cardiothoracic surgery were compared with 47 patients who did not receive arginine vasopressin. After surgery, all patients received intravenous fluids consisting of dextrose and 0.22% saline for daily fluid requirements as well as isotonic colloid and blood products as needed for additional resuscitation. RESULTS: Mean initial postoperative serum sodium did not differ between groups, 144.6 ± 3.4 in those patients who received arginine vasopressin and 144.5 ± 3.7 in those who did not, p = 0.969. Mean lowest sodium in the first 72 hours, however, was 134.7 ± 3.8 in those who received arginine vasopressin as compared with 137.1 ± 4.3 in the control group, p = 0.019. Hyponatremia occurred in 14 of the patients (48%) who received arginine vasopressin but only in 8 of the patients (17%) in the control group, p = 0.004. Mean age, weight, sex, Aristotle score, and duration of cardiopulmonary bypass were not statistically different between groups. Mean volumes of hypotonic fluids administered and cumulative diuretic dosing during the first 72 hours post-surgery were also not statistically different between groups. CONCLUSIONS: Hyponatremia occurred in nearly half of the infants and children receiving arginine vasopressin therapy in this study. Clinicians should be aware of this association, monitor serum sodium values closely, and consider providing less free water to these patients before hyponatremia occurs.

Clinical response to arginine vasopressin therapy after paediatric cardiac surgery.

OBJECTIVE: To describe the haemodynamic response of children who receive arginine vasopressin for haemodynamic instability after cardiac surgery and to identify clinical variables associated with a favourable response. Materials and Methods We reviewed patients less than or equal to 6 years undergoing open heart surgery in our institution between January, 2009 and July, 2010 who received arginine vasopressin during the first 7 days post operation. Favourable responders were defined as those in whom blood pressure was increased or maintained and catecholamine score was decreased, or blood pressure was increased by greater than or equal to 10% of baseline and catecholamine score was unchanged at 6 hours following arginine vasopressin initiation. RESULTS: Of the 34 patients identified, 17 (50%) patients responded favourably to arginine vasopressin. At 6 hours, the mean blood pressure was increased by 32.2% in responders as compared with 4.6% in non-responders, with a p-value less than 0.001. The mean catecholamine score decreased by 30.1% in responders and increased by 7.6% in non-responders, with a p-value less than 0.001. Anthropometric, demographic, and intra-operative variables were similar in both groups, as was maximum dose of arginine vasopressin. The median time after arrival to the intensive care unit at which arginine vasopressin was initiated, however, was later in those who responded, 20 hours as compared with those who did not, 6 hours, with a p-value equal to 0.032. CONCLUSIONS: Arginine vasopressin therapy led to haemodynamic improvement in only half of the children in this study, and improvement was more likely to occur if arginine vasopressin was initiated after the post-operative night.

Amplatzer vascular plug for transcatheter closure of persistent unligated vertical vein after repair of infracardiac total anomalous pulmonary venous connection.

Repair of total anomalous pulmonary venous connection (TAPVC) involves anastomosing the pulmonary venous confluence with the left atrium and ligating the vertical vein. Sometimes, the vertical vein needs to be left open as a pop off with the idea that it will close over time. Infrequently an unligated vertical vein may remain patent after repair of infaracardiac TAPVC leading to hemodynamic instability. We report an infant in whom an unligated vertical vein remained patent after the repair of infracardiac TAPVC and caused hemodynamically significant left-to-right shunting. A successful transcatheter closure of persistent patent unligated vertical vein was performed using the Amplatzer Vascular Plug-I device.

Hypoplastic left heart syndrome, restrictive patent foramen ovale, and pulmonary valve stenosis: an unusual combination.

An infant presented with a rare combination of hypoplastic left heart syndrome, restricted patent foramen ovale, and moderately dysplastic pulmonary valve. In preparation for heart transplantation, bilateral pulmonary artery banding was performed to protect the pulmonary vasculature.

Low donor-to-recipient weight ratio does not negatively impact survival of pediatric heart transplant patients.

A major limitation to success in pediatric heart transplantation is donor organ shortage. While the use of allografts from donors larger than the recipient is accepted, the use of undersized donor grafts is generally discouraged. Using the UNOS database, we wanted to evaluate whether using smaller donor hearts affects the short- and long-term survival of pediatric heart transplant patients. A retrospective analysis of data entered into the UNOS database from April 1994 to May 2008 was performed. Pediatric heart transplant recipients (ages 0-18 yr) with DRWR <2.0 were identified and divided into two groups: Low-DRWR (<0.8) and Ideal-DRWR (0.8-2.0). Patients' demographics, pretransplant diagnoses, age at transplantation, severity of pretransplant condition, and rate of complications prior to hospital discharge after transplantation were noted. Fisher's exact, chi-square, and Wilcoxon rank sum tests were used to compare patients' baseline characteristics. Kaplan-Meier curves and Cox proportional hazard regression were used to compare patients' survival and to identify independent risk factors for outcomes. There were 3048 patients (204 with Low- and 2844 with Ideal-DRWR). The Low-ratio group patients were older (8.3 vs. 6.9 yr; p = 0.001), there was a slight male predominance in the Low-DRWR group (p = 0.055). The Low-DRWR group had longer transplant wait time than the Ideal-DRWR group (97 vs. 85 days; p = 0.04). The groups did not differ in race, primary diagnoses, severity of pretransplant condition (medical urgency status, need for ventilation, inotropic support, ECMO, nitric oxide, or dialysis, the PVR for those with bi-ventricular anatomy), or post-transplant complications (length of stay, need for inotropic support, dialysis, and rate of infections). The Low-DRWR patients had less episodes of acute rejection during the first-post-transplant month. Infants with DRWR 0.5-0.59 had lower 30-day survival rate (p = 0.045). There was no difference in short- and long-term survival between the patients with DRWR 0.6-0.79 and DRWR 0.8-2.0. Use of smaller allografts (DRWR 0.6-0.8) has no negative impact on the short- and long-term survival of pediatric heart transplant patients.

Arginine vasopressin to manage hypoxemic infants after stage I palliation of single ventricle lesions.

OBJECTIVE: Management of patients with single ventricle physiology following stage I palliation procedures is often challenging, with optimization of the ratio of pulmonary-to-systemic blood flow as an important goal. Persistent hypoxemia may be a manifestation of elevated pulmonary vascular resistance and therefore decreased blood flow to the lungs. In such situations, the use of arginine vasopressin to increase systemic vascular resistance may be an effective strategy to improve pulmonary blood flow and maintain adequate pulmonary-to-systemic blood flow ratio. We describe three infants in whom persistent hypoxemia improved after institution of arginine vasopressin. DESIGN: Retrospective chart review. SETTING: Twenty-four bed medical-surgical pediatric intensive care unit at a large tertiary care academic hospital. PATIENTS: Three neonates with single ventricle physiology who received arginine vasopressin in the setting of hypoxemia following stage I palliation. RESULTS: Arginine vasopressin was initiated in all three patients for hypoxemia with a goal to increase systemic vascular resistance and generate a higher driving pressure for pulmonary blood flow. Twelve hours after arginine vasopressin initiation, systemic arterial saturation as determined by pulse oximetry and blood pressure increased, whereas heart rate, inotrope score, and Fio2 decreased in all three patients. Urine output was maintained and arterial lactate decreased during this time. Pulmonary-to-systemic flow ratio increased in one patient in whom it could be determined. CONCLUSION: In patients with single ventricle physiology and persistent hypoxemia following stage I palliation, administration of arginine vasopressin could improve oxygenation possibly by increasing systemic vascular resistance and therefore the pulmonary blood flow.

Technique of single-stage repair of coarctation of the aorta with ventricular septal defect.

The results of single-stage and two-stage repair of coarctation of the aorta (CoA) with ventricular septal defect (VSD) have improved, but the optimal treatment strategy remains controversial. This article emphasizes the technical details for performing the single-stage repair of CoA with VSD and compares the results of this technique with the two-stage approach. A retrospective analysis of 46 patients who underwent completed surgical repair of CoA with VSD at Children's Hospital of Michigan, either using the single-stage (N=23) or the two-stage (N=23) techniques, was performed. The postoperative complications, hospital mortality, freedom from cardiac re-interventions, and actuarial survival were the same in both groups. The advantages of single-stage over two-stage repair include an earlier age at completion of repair, fewer operations, and fewer incisions. The one disadvantage of a single-stage repair was the increased need for delayed sternal closure compared with the two-stage approach, but this disadvantage has been neutralized in the recent era.

Large pseudoaneurysm following right ventricle to pulmonary artery homograft placement in an infant.

Pseudoaneurysm (PSA) is a known but rare complication of the right ventricle to pulmonary artery (RV-PA) conduits. The patient's clinical presentation can be variable ranging from asymptomatic to potential rupture. We describe an unusual case of a massive PSA in an infant who underwent RV-PA pulmonary homograft placement after relief of right ventricular outflow tract obstruction.

Effect of inhaled corticosteroid on pulmonary injury and inflammatory mediator production after cardiopulmonary bypass in children.

OBJECTIVE: To determine whether inhaled steroid administration after cardiopulmonary bypass will attenuate pulmonary inflammation and improve lung compliance and oxygenation. DESIGN: Randomized, prospective, double-blind, placebo-controlled clinical trial. SETTING: Children's Hospital of Michigan, intensive care unit. PATIENTS: Thirty-two children <2 yrs of age with congenital heart disease requiring cardiopulmonary bypass. INTERVENTIONS: Participants were randomly assigned to one of two groups. Group 1 (n = 16) received an inhaled steroid, Budesonide (0.25 mg/2 mL), and group 2 (n = 16) received an inhaled placebo (2 mL of inhaled 0.9% saline). The nebulizations were given at the end of cardiopulmonary bypass, 6 hrs after cardiopulmonary bypass, and 12 hrs after cardiopulmonary bypass. Two hours after each nebulization, bronchoalveolar lavage for interleukin-6 and interleukin-8 was collected. MEASUREMENTS AND MAIN RESULTS: The concentrations of interleukin-6 and interleukin-8 in the bronchoalveolar lavage increased in both groups after cardiopulmonary bypass. Interleukin-6 peaked 2 hrs after cardiopulmonary bypass and was decreasing by 14 hrs after cardiopulmonary bypass. However, administration of corticosteroid did not affect the production of interleukin-6 when compared with the placebo group (378 +/- 728 vs. 287 +/- 583 pg/mL pre-cardiopulmonary bypass, 1662 +/- 1410 vs. 1584 +/- 1645 pg/mL at the end of cardiopulmonary bypass, 2601 +/- 3132 vs. 3677 +/- 4935 pg/mL 2 hrs after cardiopulmonary bypass, and 1792 +/- 3100 vs. 1283 +/- 1344 pg/mL 14 hrs after cardiopulmonary bypass; p > .05). Likewise, interleukin-8 in the lavage fluid was similar in both the placebo and steroid groups at all time points (570 +/- 764 vs. 990 +/- 1147 pg/mL pre-cardiopulmonary bypass, 1647 +/- 1232 vs. 1394 +/- 1079 pg/mL at the end of cardiopulmonary bypass, 1581 +/- 802 vs. 1523 +/- 852 pg/mL 2 hrs after cardiopulmonary bypass, and 1652 +/- 1069 pg/mL vs. 1808 +/- 281 pg/mL 14 hrs after cardiopulmonary bypass; p > .05). Lung compliance and oxygenation were similar in both groups. CONCLUSIONS: Cardiopulmonary bypass is associated with a pulmonary inflammatory response. Inhaled corticosteroid did not affect the pulmonary inflammatory response as measured by interleukin-6 and interleukin-8 concentrations in the lung lavage after cardiopulmonary bypass. Pulmonary mechanics and oxygenation were not improved by the use of inhaled corticosteroid.

Prospective Validation of a Novel Vasoactive-Ventilation-Renal Score as a Predictor of Outcomes After Pediatric Cardiac Surgery.

BACKGROUND: We sought to further validate the novel vasoactive-ventilation-renal (VVR) score in a prospective study of a heterogeneous cohort of children undergoing cardiac surgery that includes patients with single-ventricle anatomy and residual mixing lesions. METHODS: We prospectively performed an observational study of all children less than 18 years of age who underwent surgery for congenital heart disease at our center from November 2013 to June 2014. We calculated VVR score as follows: vasoactive-inotrope score + ventilation index + (change in serum creatinine from baseline × 10). Admission, peak, and 48-hour measurements were recorded. Outcomes of interest were prolonged duration of mechanical ventilation and intensive care unit and hospital stays, represented by the upper 25% for all patients. Areas under the receiver-operating characteristic curves (AUC) were determined for all study timepoints and outcome variables. RESULTS: Ninety-two patients were analyzed; their median age was 0.65 (range, 3 days to 17.9 years), and 17 (18%) had single-ventricle anatomy. The VVR measurements outperformed vasoactive-inotrope scores in isolation at all timepoints, with higher AUC values for all outcomes. Of the three timepoints assessed, the 48-hour VVR score most consistently predicted poor outcome, especially with regard to prolonged duration of mechanical ventilation (AUC 0.980) and prolonged intensive care unit stay (AUC 0.919). CONCLUSIONS: In a heterogeneous population of children undergoing cardiac surgery, the 48-hour VVR score was a very strong predictor of outcomes, and outperformed the more traditional vasoactive-inotrope score. The VVR score, therefore, represents a novel and potentially powerful means of predicting clinical outcomes relatively early in the hospital course of these patients.

Efficacy of intraluminal pulmonary artery banding.

OBJECTIVE: The extraluminal technique of pulmonary artery banding can be difficult to perform precisely in conjunction with cardiopulmonary bypass and is associated with a significant risk of band-related complications. We analyzed our results with an intraluminal technique of pulmonary artery banding in patients who required cardiopulmonary bypass for the performance of associated cardiac repairs. METHODS: The medical records of 18 neonates and infants who underwent intraluminal pulmonary artery banding were retrospectively reviewed. A circular patch with a 3.0-mm, 3.6-mm, or 4.0-mm diameter fenestration was sutured to the inner circumference of the main pulmonary artery. Preoperative, intraoperative, and postoperative variables were reviewed to assess the efficacy and safety of the intraluminal technique. RESULTS: Intraluminal pulmonary artery banding produced a consistent and significant reduction in the systolic pulmonary artery pressure (64.00 +/- 12.24 to 16.53 +/- 6.33 mm Hg, P < .001), the systolic pulmonary artery pressure/systolic systemic pressure ratio (0.91 +/- 0.10 to 0.19 +/- 0.07, P < .001), and the pulmonary flow/systemic flow ratio (4.32 +/- 3.04 to 0.91 +/- 0.49, P = .015). There were no band-related anatomic complications. Two patients did require percutaneous dilation of the intraluminal pulmonary artery band before debanding to palliate systemic arterial desaturation. CONCLUSIONS: Intraluminal pulmonary artery banding is an effective palliative procedure that can be used in patients who require cardiopulmonary bypass for the performance of cardiac repairs in addition to placement of the pulmonary artery band.

Use of a novel vasoactive-ventilation-renal score to predict outcomes after paediatric cardiac surgery.

OBJECTIVES: Prior studies have established peak postoperative lactate and the vasoactive-inotrope score (VIS) as modest predictors of outcome following paediatric cardiac surgery. We developed a novel vasoactive-ventilation-renal (VVR) score and aimed to determine if this index, which incorporates postoperative respiratory, cardiovascular and renal function, would more consistently predict outcome in this patient population. METHODS: We performed an Institutional Review Board-approved retrospective analysis of 222 infants at our institution less than 365 days old who underwent surgery for congenital heart disease at our centre from January 2009 to April 2013. The VVR score was calculated as follows: vasoactive-inotrope score + ventilation index + (change in serum creatinine from baseline × 10). For all patients, peak lactate and admission, peak, and 48 h VIS and VVR were recorded. RESULTS: For all outcome measures, areas under the curve for 48-h VVR were greater than its corresponding admission and peak values, VIS alone at all three time points and peak lactate. On multivariate regression, 48-h VVR was strongly associated with prolonged intubation [odds ratio (OR): 39.13, P <0.0001], significantly more so than 48-h VIS (odds ratio: 6.18, P <0.0001) and peak lactate (odds ratio: 2.52, P = 0.017). The 48-h VVR was also more significantly associated with prolonged use of vasoactive infusions, chest tube drainage and ICU and hospital stay when compared with VIS alone and peak lactate. CONCLUSIONS: The novel 48-h VVR was a robust predictor of outcome following paediatric cardiac surgery and outperformed the VIS and peak postoperative lactate.