Changes in tissue oxygen tension, venous saturation, and Fick-based assessments of cardiac output during hyperoxia.

BACKGROUND: Hyperoxemia (arterial oxygen tension >100 mm Hg) may occur in critically ill patients and have effects on mixed venous saturation (SvO2 ) and on Fick-based estimates of cardiac output (CO). We investigated the effect of hyperoxemia on SvO2 and on assessments of CO using the Fick equation. METHODS: Yorkshire swine (n = 14) were anesthetized, intubated, and paralyzed for instrumentation. SvO2 (co-oximetry) and tissue oxygen tension (tPO2 , implantable electrodes) in brain and myocardium were measured during systematic manipulation of arterial oxygen tension (PaO2 ) using graded hyperoxia (fraction of inspired oxygen 0.21 → 0.8). Secondarily, oxygen- and carbon dioxide-based estimates of CO (FickO2 and FickCO2 , respectively) were compared with measurements from a flow probe placed on the aortic root. RESULTS: Independent of changes in measured oxygen delivery, cerebral and myocardial tPO2 increased in proportion to PaO2 , as did SvO2 (P < 0.001 for all). Based on mixed model analysis, each 100 mm Hg increase in PaO2 resulted in a 4.8 ± 0.9% increase in SvO2 under the conditions tested. Because neither measured oxygen consumption, arterial oxyhemoglobin saturation or cardiac output varied significantly during hyperoxia, changes in SvO2 resulted in successively increasing errors in FickO2 during hyperoxia (34% during normoxia, 72% during FiO2 0.8). FickCO2 lacked the progressively worsening errors present in FickO2 , but correlated poorly with CO. CONCLUSION: SvO2 acutely changes following changes in PaO2 even absent changes in measured DO2 . This may lead to errors in FickO2 estimates of CI. Further work is necessary to understand the impact of this phenomenon in disease states.

Are Bioprosthetic Valves Appropriate for Aortic Valve Replacement in Young Patients?

Selection of a prosthetic aortic valve for use in the young patient is complicated by a variety of important considerations. Age, growth potential, activity and life style expectations, child bearing, and social factors, in addition to anatomic considerations, are all important to the recommendation of a prosthetic valve choice. We review the clinical experience and expectations of currently available prosthetic aortic valves available for the young patient, and describe the advantages and disadvantages for each.

Tight glycemic control versus standard care after pediatric cardiac surgery.

BACKGROUND: In some studies, tight glycemic control with insulin improved outcomes in adults undergoing cardiac surgery, but these benefits are unproven in critically ill children at risk for hyperinsulinemic hypoglycemia. We tested the hypothesis that tight glycemic control reduces morbidity after pediatric cardiac surgery. METHODS: In this two-center, prospective, randomized trial, we enrolled 980 children, 0 to 36 months of age, undergoing surgery with cardiopulmonary bypass. Patients were randomly assigned to either tight glycemic control (with the use of an insulin-dosing algorithm targeting a blood glucose level of 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) or standard care in the cardiac intensive care unit (ICU). Continuous glucose monitoring was used to guide the frequency of blood glucose measurement and to detect impending hypoglycemia. The primary outcome was the rate of health care-associated infections in the cardiac ICU. Secondary outcomes included mortality, length of stay, organ failure, and hypoglycemia. RESULTS: A total of 444 of the 490 children assigned to tight glycemic control (91%) received insulin versus 9 of 490 children assigned to standard care (2%). Although normoglycemia was achieved earlier with tight glycemic control than with standard care (6 hours vs. 16 hours, P<0.001) and was maintained for a greater proportion of the critical illness period (50% vs. 33%, P<0.001), tight glycemic control was not associated with a significantly decreased rate of health care-associated infections (8.6 vs. 9.9 per 1000 patient-days, P=0.67). Secondary outcomes did not differ significantly between groups, and tight glycemic control did not benefit high-risk subgroups. Only 3% of the patients assigned to tight glycemic control had severe hypoglycemia (blood glucose <40 mg per deciliter [2.2 mmol per liter]). CONCLUSIONS: Tight glycemic control can be achieved with a low hypoglycemia rate after cardiac surgery in children, but it does not significantly change the infection rate, mortality, length of stay, or measures of organ failure, as compared with standard care. (Funded by the National Heart, Lung, and Blood Institute and others; SPECS ClinicalTrials.gov number, NCT00443599.).

Evaluation of cerebral oxygenation and perfusion with conversion from an arterial-to-systemic shunt circulation to the bidirectional Glenn circulation in patients with univentricular cardiac abnormalities.

OBJECTIVE: Superior vena cava pressure after the bidirectional Glenn operation usually is higher than that associated with the preceding shunt-dependent circulation. The aim of the present study was to determine whether the acute elevation in central venous pressure was associated with changes in cerebral oxygenation and perfusion. DESIGN: Single-center prospective, observational cohort study. SETTING: Academic children's hospital. PARTICIPANTS: Infants with single-ventricle lesions and surgically placed systemic-to-pulmonary artery shunts undergoing the bidirectional Glenn operation. INTERVENTIONS: Near-infrared spectroscopy and transcranial Doppler sonography were used to measure regional cerebral oxygen saturation and cerebral blood flow velocity. MEASUREMENTS AND MAIN RESULTS: Mean differences in regional cerebral oxygen saturation and cerebral blood flow velocity before anesthetic induction and shortly before hospital discharge were compared using the F-test in repeated measures analysis of variance. In the 24 infants studied, mean cerebral oxygen saturation increased from 49%±2% to 57%±2% (p = 0.007), mean cerebral blood flow velocity decreased from 57±4 cm/s to 47±4 cm/s (p = 0.026), and peak systolic cerebral blood flow velocity decreased from 111±6 cm/s to 99±6 cm/s (p = 0.046) after the bidirectional Glenn operation. Mean central venous pressure was 8±2 mmHg postinduction of anesthesia and 14±4 mmHg on the first postoperative day and was not associated with a change in cerebral perfusion pressure (p = 0.35). CONCLUSIONS: The bidirectional Glenn operation in infants with a shunt-dependent circulation is associated with an improvement in cerebral oxygenation, and the lower cerebral blood flow velocity is likely a response of intact cerebral autoregulation.

Hypercoagulability panel testing predicts thrombosis in neonates undergoing cardiac surgery.

Thrombosis contributes to morbidity and mortality in neonates following cardiac surgery. Alterations in hemostatic factors following cardiac surgery have been described, but there is no data correlating these changes with risk of thrombosis in neonates. The aim of this study is to predict thrombosis in neonates undergoing cardiac surgery by assessment of a panel of hypercoagulability markers. Neonates undergoing cardiac surgery were enrolled preoperatively and prospectively followed. Preoperative hypercoagulability panel testing included thrombin generation assay (TGA), immunoassays for antithrombin III, protein C, protein S, factor VIII, thrombin-activatable fibrinolytic inhibitor (TAFI), plasminogen activator inhibitor-1 (PAI-1), and cardiolipin antibody. Postoperative thrombosis was defined by clinical events (shunt thrombosis, limb ischemia, and stroke) or imaging (intravascular or intracardiac thrombus). Risk factors for thrombosis were assessed. One hundred neonates were enrolled in the study over a two-year period. The incidence of postoperative in-hospital thrombosis was 20%. The only significant clinical risk factor associated with thrombosis was the single ventricle physiology. Hypercoagulability factors associated with increased risk of thrombosis by univariate analysis were elevated PAI-1, TAFI, and TGA, and presence of anticardiolipin antibodies. Multivariable logistic regression analysis demonstrated that elevated PAI-1 (P = 0.015), TAFI (P = 0.028), and TGA (P = 0.007) were independent predictors of thrombosis. Hypercoagulability panel testing may help identify neonates at high risk for thrombosis following cardiac surgery. Future studies are warranted to determine if high risk patients benefit from targeted anticoagulation therapies.

Outcomes of transcatheter approach for initial treatment of pulmonary atresia with intact ventricular septum.

OBJECTIVE: To review the short and medium term outcome of transcatheter pulmonary valve perforation (PVP) in patients with pulmonary atresia-intact ventricular septum and non-right ventricular dependant coronary circulation (PA/IVS non-RVDCC). BACKGROUND: PVP in patients with PA/IVS non-RVDCC has become more common in the past two decades. However, data on outcomes with this strategy are mixed. METHODS: Data were reviewed retrospectively for all patients with PA/IVS non-RVDCC treated from 1996- 2010 at our institution. Patients who had severe neonatal Ebstein malformation, or initial interventional management at another institution were excluded. RESULTS: PVP was attempted in 30 of 50 patients (60%); 26 (87%) of these had a successful procedure. Twenty-four patients (48%) had surgery without PVP. There were no deaths in the cohort. Complications of PVP included 5 (17%) myocardial perforations. Of those with successful PVP, 10 (38%) did not have surgery (PVP-NS) and 16 (62%) had surgery (PVP-S) prior to discharge. Tricuspid valve (TV) Z-score was larger in the PVP-NS than in PVP-S patients, with median TV diameter Z-scores of +0.7 (-0.9, 1.7) and -1.1 (-2.8, 2), respectively (P = 0.01). Time from PVP to either hospital discharge (PVP-NS group) or surgery (PVP-S group) was significantly different between groups: 15 (7, 22) and 8 days (0, 46), respectively (P = 0.01). There were no differences in the number of trials or lowest arterial PaO2 off prostaglandins between groups. All patients in the PVP-NS group had a biventricular circulation at a median follow-up of 4.3 years. CONCLUSIONS: The results of a collaborative approach to treating neonates with PA/IVS non-RVDCC are excellent. Smaller TV size is associated with greater likelihood of surgery prior to discharge, and may serve as a surrogate for early RV inadequacy.

Design and rationale of safe pediatric euglycemia after cardiac surgery: a randomized controlled trial of tight glycemic control after pediatric cardiac surgery.

OBJECTIVES: To describe the design of a clinical trial testing the hypothesis that children randomized to tight glycemic control with intensive insulin therapy after cardiac surgery will have improved clinical outcomes compared to children randomized to conventional blood glucose management. DESIGN: Two-center, randomized controlled trial. SETTING: Cardiac ICUs at two large academic pediatric centers. PATIENTS: Children from birth to those aged 36 months recovering in the cardiac ICU after surgery with cardiopulmonary bypass. INTERVENTIONS: Subjects in the tight glycemic control (intervention) group receive an intravenous insulin infusion titrated to achieve normoglycemia (target blood glucose range of 80-110 mg/dL; 4.4-6.1 mmol/L). The intervention begins at admission to the cardiac ICU from the operating room and terminates when the patient is ready for discharge from the ICU. Continuous glucose monitoring is performed during insulin infusion to minimize the risks of hypoglycemia. The standard care group has no target blood glucose range. MEASUREMENTS AND MAIN RESULTS: The primary outcome is the development of any nosocomial infection (bloodstream, urinary tract, and surgical site infection or nosocomial pneumonia). Secondary outcomes include mortality, measures of cardiorespiratory function and recovery, laboratory indices of nutritional balance, immunologic, endocrinologic, and neurologic function, cardiac ICU and hospital length of stay, and neurodevelopmental outcome at 1 and 3 yrs of age. A total of 980 subjects will be enrolled (490 in each treatment arm) for sufficient power to show a 50% reduction in the prevalence of the primary outcome. CONCLUSIONS: Pediatric cardiac surgery patients may recognize great benefit from tight glycemic control in the postoperative period, particularly with regard to reduction of nosocomial infections. The Safe Pediatric Euglycemia after Cardiac Surgery trial is designed to provide an unbiased answer to the question of whether this therapy is indeed beneficial and to define the associated risks of therapy.

Left ventricle after palliation of hypoplastic left heart syndrome: friend, fiend, or innocent bystander?

Hypoplasia of the left side of the heart is the most common cause of death from congenital heart disease in the first weeks of life. Once considered a surgically fatal disease, hypoplasia has been successfully palliated for more than 30 years. Although the palliative route is staged by an early differential bypass of the systemic outflow and the venous inflow to the right ventricle, the left ventricle remains anatomically and biologically influential throughout. Given the variation of the left ventricle, contemporary outcomes for different hypoplastic left heart subsets can vary both early after palliation and long term. This review critically examines the contemporary understanding of the structure and function of the hypoplastic ventricle in this syndrome. It also provides insight into future research directions relevant to clinicians and surgeons.

Nutritional markers accompanying acquired chylothorax in infants: a systematic review.

CONTEXT: Chylothorax is a well-established acquired complication of thoracic surgery in infants. Current data suggest acquired chylothorax may affect infant growth and nutrition because of a loss of essential nutrients via chylous effusion. OBJECTIVE: The 3 objectives for this study were: (1) identify nutritional markers affected by the development of acquired chylothorax in infants; (2) highlight the variability in methods used to assess nutritional status and growth in this patient population; and (3) highlight nutritional deficits that can serve as treatment targets during postoperative feeding protocols. DATA SOURCES: A systematic literature search was conducted between May 31, 2021, and June 21, 2022, using the PubMed, Embase, CINAHL, and Web of Science databases. Search terms included, but were not limited to, "chylothorax," "infants," and "nutrition." DATA EXTRACTION: Inclusion criteria required studies that measured quantitative markers of nutrition in ≥10 participants aged <1 year with acquired chylothorax. A total of 575 studies were screened and all but 4 were eliminated. Nutritional markers were categorized into 4 different groups: total serum protein level, triglyceride levels, growth velocity, and weight for length. DATA ANALYSIS: The variation in methods, time points, interventional groups, and nutritional markers did not facilitate a meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias in Nonrandomized Studies assessment tool. CONCLUSION: This review highlights the need for reliable quantitative markers of nutrition that will enable providers to assess the nutritional needs of infants with chylothorax. Future studies must focus on measuring markers of nutrition at regular intervals in larger study populations.

Relationship of intraoperative cerebral oxygen saturation to neurodevelopmental outcome and brain magnetic resonance imaging at 1 year of age in infants undergoing biventricular repair.

BACKGROUND: Near-infrared spectroscopy monitoring of cerebral oxygen saturation (rSo(2)) has become routine in many centers, but no studies have reported the relationship of intraoperative near-infrared spectroscopy to long-term neurodevelopmental outcomes after cardiac surgery. METHODS AND RESULTS: Of 104 infants undergoing biventricular repair without aortic arch reconstruction, 89 (86%) returned for neurodevelopmental testing at 1 year of age. The primary near-infrared spectroscopy variable was the integrated rSo(2) (area under the curve) for rSo(2)

Outcomes and risk factors for mortality in premature neonates with critical congenital heart disease.

We sought to describe contemporary outcomes and identify risk factors for hospital mortality in premature neonates with critical congenital heart disease who were referred for early intervention. Neonates who were born before 37 weeks' gestation with critical congenital heart disease and admitted to our institution from 2002 to 2008 were included in this retrospective cohort study. Critical congenital heart disease was defined as a defect requiring surgical or transcatheter cardiac intervention or a defect resulting in death within the first 28 days of life. Logistic regression analyses were performed to identify risk factors for mortality before hospital discharge. The study included 180 premature neonates, of whom 37 (21%) died during their initial hospitalization, including 6 (4%) before cardiac intervention and 31 (17%) after cardiac intervention. For the 174 patients undergoing cardiac intervention, independent risk factors for mortality were a 5 min Apgar score ≤ 7, need for preintervention mechanical ventilation, and Risk Adjustment in Congenital Heart Surgery category ≥ 4 or not assignable. Mortality for premature infants with critical congenital heart disease who are referred for early intervention remains high. Patients with lower Apgar scores who receive preintervention mechanical ventilation and undergo more complex procedures are at greatest risk.

Right ventricle and tricuspid valve function at midterm after the Fontan operation for hypoplastic left heart syndrome: impact of shunt type.

This study aimed to evaluate clinical outcomes including hemodynamics, right ventricle (RV) function, and tricuspid valve (TV) function in patients with hypoplastic left heart syndrome (HLHS) at midterm after completion of staged palliation based on the source of pulmonary blood flow provided at stage 1. The records of all patients with HLHS who completed Fontan palliation between 2001 and 2007 were retrospectively reviewed. The outcome variables were RV dysfunction, TV, and neo-atrioventricular (neo-AV) regurgitation (from latest echocardiogram), cardiac index (CI), pulmonary vascular resistance (PVR), pulmonary artery pressure (PAp), and right ventricular end-diastolic pressure (RVEDp) (from latest catheterization). Clinical status was obtained from medical records and by contact with the referring cardiologist if necessary. Of 118 patients undergoing a Fontan for HLHS, 116 had a fenestrated lateral tunnel and 2 had an extracardiac conduit. At the time of stage 1 palliation, 36 patients had a right ventricle-to-pulmonary artery (RV-PA) conduit, and 82 patients had a modified Blalock-Taussig shunt (mBTS). All the patients except one who died of sepsis on extracorporeal membrane oxygenation (ECMO) survived the Fontan operation and were discharged home. At a mean follow-up post-Fontan period of 28.4 months (range, 0.16-95.3 months), three patients had died (2 on the transplantation list and 1 from pulmonary vein stenosis), and one patient had the Fontan circulation taken down. No patient had a heart transplantation. A follow-up echocardiogram was performed for 115 patients (after a mean of 15.6 months for RV-PA and 32.1 months for BTS), and 66 patients underwent a post-Fontan catheterization (after a mean of 15.8 months for RV-PA and 29.3 months for BTS). The hemodynamic results for RV-PA conduit versus BTS were a CI of 3.4 ± 0.8 versus 3.4 ± 1.2, a PVR of 1.8 ± 0.7 versus 1.7 ± 0.8, a PAp of 14.3 ± 3.1 versus 14.2 ± 4.5, and an RVEDp of 7.1 ± 3.3 versus 8.9 ± 5.3. No statistically significant differences were found between shunt types regarding survival or degree of RV dysfunction or in terms of neo-AV regurgitation, CI, PVR, PAp, RVEDp, or rhythm problems. Patients in the BTS group required more tricuspid valvuloplasties and had more tricuspid regurgitation at follow-up evaluation. The patients in the RV-PA group had more PA interventions. In conclusion, the contemporary results after Fontan palliation for HLHS were excellent. At the midterm follow-up evaluation, outcomes and hemodynamic data were similar between shunt types. However, the patients in the BTS group exhibited more tricuspid regurgitation, and the patients in the RV-PA group had increased pulmonary artery interventions.

Massive air embolism in a Fontan patient.

Most institutions performing cardiopulmonary bypass for congenital heart disease patients use an integrated hard shell cardiotomy and venous reservoir attached to an oxygenator. It is of paramount importance that the integrated reservoir be vented so as not to cause pressurization. A pressurized sealed cardiotomy has been reported to occur secondary to issues with vacuum assisted venous drainage systems as well as improper venting in general. We report a case of air embolus caused by retrograde propulsion of air through the venous line secondary to a pressurized cardiotomy reservoir in a patient with Fontan circulation. The mechanism of cardiotomy pressurization is described, and the scenario simulated in a mock circuit.

Successful Surgical Management of Aortic Arch Thrombosis in the Neonate.

Spontaneous thrombosis in the aortic arch is a rare finding in the neonate. Often the thrombosis is initially interpreted as arch obstruction secondary to coarctation or interrupted aortic arch. Thus the obstruction is mechanical with no structural abnormality. We describe 2 newborns with coarctation and extensive thrombosis within the aortic arch. We report their successful surgical management, with a brief review of the literature and pertinent management principles.

Outcomes after anatomic repair for d-transposition of the great arteries with left ventricular outflow tract obstruction.

BACKGROUND: D-transposition of the great arteries (TGA) with left ventricular outflow tract obstruction (LVOTO) may be treated with arterial switch operation (ASO) with or without LVOT intervention, as well as non-ASO anatomic repairs, such as aortic translocation or Rastelli procedure. We evaluated midterm results of repair for TGA/LVOTO at our institution. METHODS AND RESULTS: Eighty-eight patients with TGA/LVOTO who underwent anatomic repair were retrospectively reviewed. LVOTO was defined as pulmonary valve (PV) z-score < or =-2.0 or LVOT gradient > or =20 mm Hg in the presence of anatomic subvalvar stenosis. Risk factors for LVOT reintervention were determined by logistic regression. There was no hospital mortality and 1 late mortality. Patients undergoing Rastelli procedure were more likely to require surgical reintervention for LVOTO compared to the other groups (P=0.015). Patients undergoing ASO alone had a higher rate of late LVOT reintervention compared to those who had concomitant ASO/LVOT intervention (P=NS). In those undergoing Rastelli, a larger PV z-score was a predictor of LVOT reintervention (P=0.012). PV z-scores significantly decreased before repair in patients undergoing delayed repair (P=0.005); however, they increased significantly after neonatal ASO (P<0.001). CONCLUSIONS: Patients with TGA/LVOTO who undergo Rastelli repair have a high rate of LVOT reintervention. Higher preoperative PV z-score is a risk factor for reintervention in this group. Patients with mild/moderate LVOTO undergoing ASO alone without LVOT intervention may have an increased risk of LVOT reintervention. In neonates who are candidates for ASO, delay of repair is associated with diminution in size of PV, which may subsequently reduce their suitability for ASO.

Neonatal closure of a large coronary-cameral fistula in a case of single coronary artery: the utility of intraoperative angiography.

Isolated coronary artery fistula in the newborn is a very rare congenital anomaly. When symptomatic, treatment options include surgical management with ligation and/or patch closure or transcatheter coil embolization. We describe the case of a newborn with symptomatic left coronary-right ventricular fistula, which was managed operatively with off-pump ligation and on-table angiogram for confirmation of fistula obliteration and normal distribution of flow in the coronary artery. We point out the advantages of on-table angiography to evaluate and potentially treat residual structural pathology after cardiac surgery.

Association between intraoperative and early postoperative glucose levels and adverse outcomes after complex congenital heart surgery.

BACKGROUND: This study sought to determine whether associations exist between perioperative glucose exposure, prolonged hospitalization, and morbid events after complex congenital heart surgery. METHODS AND RESULTS: Metrics of glucose control, including average, peak, minimum, and SD of glucose levels, and duration of hyperglycemia were determined intraoperatively and for 72 hours after surgery for 378 consecutive high-risk cardiac surgical patients. Multivariable regression analyses were used to determine relationships between these metrics of glucose control, hospital length of stay, and a composite morbidity-mortality outcome after controlling for multiple variables known to influence early outcomes after congenital heart surgery. Intraoperatively, a minimum glucose 126 mg/dL) during the 72 postoperative hours was associated with longer duration of hospitalization (P<0.001). In the 72 hours after surgery, average glucose <110 mg/dL (OR, 7.30; 95% CI, 1.95 to 27.25) or >143 mg/dL (OR, 5.21; 95% CI, 1.37 to 19.89), minimum glucose or=250 mg/dL (OR, 2.55; 95% CI, 1.20 to 5.43) were all associated with greater adjusted odds of reaching the composite morbidity-mortality end point. CONCLUSIONS: In children undergoing complex congenital heart surgery, the optimal postoperative glucose range may be 110 to 126 mg/dL. Randomized trials of strict glycemic control achieved with insulin infusions in this patient population are warranted.

Factors associated with prolonged recovery after the fontan operation.

BACKGROUND: Mortality and major morbidity after the Fontan operation is low in the current era. However, factors contributing to prolonged postoperative recovery are not clearly understood. METHODS AND RESULTS: Data on all patients admitted to the cardiac intensive care unit (CICU) after a Fontan operation between June 2001 and December 2005 were retrospectively analyzed. We excluded all patients who died, required Fontan takedown, or required ECMO. The study cohort was further divided into a prolonged recovery group that included patients with >75%ile for duration of mechanical ventilation or pleural drainage, and a standard recovery group which included all other patients. A multivariable logistic regression model was used to compare demographic, anatomic, and physiological variables between the prolonged and standard recovery groups. There were 226 Fontan operations performed. Of the study population (n=218), the median age was 2.61 years (1.0 to 31.9 years) and weight was 12.45 kg (8.4 to 77.5 kg). The most common diagnosis was hypoplastic left heart syndrome (n=80, 36.7%). A systemic right atrioventricular valve was present in 139 (63.7%). The lateral tunnel fenestrated Fontan was the most common surgery (n=195, 89.4%). Within the study population, 81 (38%) patients meet criteria for prolonged recovery. Univariate risk factors for prolonged recovery included higher preoperative PVR (P=0.033), longer bypass times (P=0.009), higher postbypass lactate level (P=0.017), higher postoperative central venous (P<0.001) common atrial pressure (P=0.042), inotropic score (P<0.001), and need for greater volume resuscitation during the 24 postoperative hours (>75% for the entire group; P<0.001). In a multivariable model, need for greater volume resuscitation (OR 2.81, 95% CI 1.30, 6.05) was the only independent risk factor for prolonged outcome after the Fontan operation. CONCLUSIONS: High volume expansion in the early postoperative period is an independent risk factor for prolonged recovery. The need for high volume expansion may represent the compound effects of multiple risk factors including preoperative hemodynamics and a marked systemic inflammatory response to surgery and cardiopulmonary bypass, which in turn may mediate prolonged recovery.

Towards Alternative Approaches for Coupling of a Soft Robotic Sleeve to the Heart.

Efficient coupling of soft robotic cardiac assist devices to the external surface of the heart is crucial to augment cardiac function and represents a hurdle to translation of this technology. In this work, we compare various fixation strategies for local and global coupling of a direct cardiac compression sleeve to the heart. For basal fixation, we find that a sutured Velcro band adheres the strongest to the epicardium. Next, we demonstrate that a mesh-based sleeve coupled to the myocardium improves function in an acute porcine heart failure model. Then, we analyze the biological integration of global interface material candidates (medical mesh and silicone) in a healthy and infarcted murine model and show that a mesh interface yields superior mechanical coupling via pull-off force, histology, and microcomputed tomography. These results can inform the design of a therapeutic approach where a mesh-based soft robotic DCC is implanted, allowed to biologically integrate with the epicardium, and actuated for active assistance at a later timepoint. This strategy may result in more efficient coupling of extracardiac sleeves to heart tissue, and lead to increased augmentation of heart function in end-stage heart failure patients.

Contemporary results and current strategies in the management of hypoplastic left heart syndrome.

The treatment of hypoplastic left heart syndrome (HLHS) is clearly evolving. Over the last few years, the standard surgical approach has been modified by the application of the right ventricle to pulmonary artery conduit and regional perfusion techniques. Even more radical conceptual changes are now occurring. New treatment paradigms, such as the "hybrid" procedure, are dramatically altering the approach to treatment, whereas fetal intervention aims to impact the developmental biology responsible for hypoplastic left heart syndrome. This institutional review presents contemporary surgical results from Children's Hospital Boston between 2001 and 2006. An overview for stage 1 palliation will be presented, as well as the outcomes obtained from the initial experience with these new treatment schemes.