Abstract Background Increases in serum creatinine (ΔSCr) from baseline signify acute kidney injury (AKI) but offer little granular information regarding its characteristics. The 10th Consensus ...Conference of the Acute Dialysis Quality Initiative (ADQI) suggested that combining AKI biomarkers would provide better precision for AKI course prognostication. Objectives This study investigated the value of combining a functional damage biomarker (plasma cystatin C pCysC) with a tubular damage biomarker (urine neutrophil gelatinase-associated lipocalin uNGAL), forming a composite biomarker for prediction of discrete characteristics of AKI. Methods Data from 345 children after cardiopulmonary bypass (CPB) were analyzed. Severe AKI was defined as Kidney Disease Global Outcomes Initiative stages 2 to 3 (≥100% ΔSCr) within 7 days of CPB. Persistent AKI lasted >2 days. SCr in reversible AKI returned to baseline ≤48 h after CPB. The composite of uNGAL (>200 ng/mg urine Cr = positive +) and pCysC (>0.8 mg/l = positive +), uNGAL+/pCysC+, measured 2 h after CPB initiation, was compared to ΔSCr increases of ≥50% for correlation with AKI characteristics by using predictive probabilities, likelihood ratios (LR), and area under the curve receiver operating curve (AUC-ROC) values. Results Severe AKI occurred in 18% of patients. The composite uNGAL+/pCysC+ demonstrated a greater likelihood than ΔSCr for severe AKI (+LR: 34.2 13.0:94.0 vs. 3.8 1.9:7.2) and persistent AKI (+LR: 15.6 8.8:27.5 versus 4.5 2.3:8.8). In AKI patients, the uNGAL−/pCysC+ composite was superior to ΔSCr for prediction of transient AKI. Biomarker composites carried greater probability for specific outcomes than ΔSCr strata. Conclusions Composites of functional and tubular damage biomarkers are superior to ΔSCr for predicting discrete characteristics of AKI.
Background Perioperative advances have led to significant improvements in outcomes after many complex neonatal open heart procedures. Whether similar improvements have been realized for the modified ...Blalock-Taussig shunt, the most common palliative neonatal closed-heart procedure, is not known. Methods Data were abstracted from The Society of Thoracic Surgeons Congenital Heart Surgery Database (2002 to 2009). Inclusion criteria were all neonates who received a modified Blalock-Taussig shunt with or without cardiopulmonary bypass, and with or without concomitant ligation of a patent ductus arteriosus. Discharge mortality was the primary end point. A composite morbidity end point one or more of the following: postoperative extracorporeal membrane oxygenation, low cardiac output, or unplanned reoperation. Associations with patient and procedural variables were assessed with univariable and multivariable analyses. Results The inclusion criteria were met by 1273 patients. The discharge mortality rate was 7.2%, and composite morbidity, as defined, was 13.1%. Primary diagnoses were classified as (1) those potentially amenable to biventricular repair (62%), (2) functionally univentricular hearts (22%), and (3) pulmonary atresia with intact ventricular septum (PA/IVS; 14%), and miscellaneous (2%). Discharge mortality stratified by primary diagnoses was PA/IVS (15.6%), functionally univentricular hearts (7.2%), and diagnoses potentially amenable to biventricular repair (5.1%). Need for preoperative ventilatory support, diagnosis of PA/IVS or functionally univentricular hearts, and any weight less than 3 kg, were risk factors for death. Preoperative acidosis or shock (resolved or persistent) and diagnosis of PA/IVS or functionally univentricular hearts were predictors of composite morbidity. Nearly 33% of the deaths occurred within 24 hours postoperatively, and 75% within the first 30 days. Conclusions The mortality rate after the neonatal modified Blalock-Taussig shunt remains high, particularly for infants weighing less than 3 kg and those with the diagnosis of PA/IVS.
Background Acute kidney injury (AKI) is common in infants after cardiopulmonary bypass and is associated with poor outcomes. Peritoneal dialysis improves outcomes in adults with AKI after bypass, but ...pediatric data are limited. This retrospective case-matched study was conducted to determine if the practice of peritoneal dialysis catheter (PDC) placement during congenital heart surgery is associated with improved clinical outcomes in infants at high risk for AKI. Methods Forty-two infants undergoing congenital heart surgery with planned PDC placement (PDC+) were age-matched to infants undergoing similar surgery without PDC placement (PDC−). Demographic, baseline and outcome data were compared. Our primary outcome was negative fluid balance on postoperative days 1 to 3. Secondary outcomes included time to negative fluid balance, time to extubation, frequency of electrolyte corrective medications, inotrope scores, and other clinical outcomes. Results Baseline data did not differ between groups. The PDC+ group had a higher percentage of negative fluid balance on postoperative days 1 and 2 (57% vs 33%, P = .04; 85% vs 61%, P = .01). The PDC+ group had shorter time to negative fluid balance (16 vs 32 hours, P < .0001), earlier extubation (80 vs 104 hours, P = .02), improved inotrope scores ( P = .04), and fewer electrolyte imbalances requiring correction ( P = .03). PDC-related complications were rare. Conclusions PDC use is safe and associated with earlier negative fluid balance and improved clinical outcomes in infants at high risk for AKI. Routine PDC use should be considered for infants undergoing cardiopulmonary bypass. Further prospective studies are essential to prove causative effects of PDC placement in this population.
Objectives This study describes results of tracheal reconstruction in children with slide tracheoplasty with cardiopulmonary bypass and identifies predictors for adverse outcomes. Methods ...Preoperative characteristics, operative variables, and outcome measures were collected for children undergoing slide tracheoplasty with cardiopulmonary bypass between April 2001 and October 2009. Predictors of worse outcomes were identified by bivariate analysis. Multiple regression analysis was performed for predictors of prolonged hospital stay. Results Cohort included 80 patients (median age, 8.7 months; 7 days–21 years). Forty-eight patients had associated cardiac or great vessel anomalies; 24 had simultaneous repair of cardiovascular anomaly at tracheal reconstruction. Fifty (63%) were extubated within 48 hours after operation. Median stay was 18.5 days (range, 7–119 days). Twenty-three patients (29%) required significant airway reintervention during median follow-up of 12 months (range, 4 months–7.8 years). There were 4 deaths, 2 early and 2 late. In bivariate analysis, age ( P = .017), cardiopulmonary bypass duration ( P = .025), and duration of mechanical ventilation ( P < .05) were associated with mortality; duration of postoperative mechanical ventilation was associated with need for significant airway reintervention ( P = .009). Multiple regression analysis indicated preoperative ventilatory support ( P < .001), longer cardiopulmonary bypass ( P = .002), previous airway operation ( P = .01), and need for significant airway reintervention ( P < .001) as predictors of longer hospital stay. Conclusions Slide tracheoplasty with cardiopulmonary bypass can be performed with low mortality in a diverse pediatric population. This technique minimizes need for early significant airway reintervention in most cases.
Cardiovascular Magnetic Resonance Characterization of Mitral Valve Prolapse Yuchi Han, Dana C. Peters, Carol J. Salton, Dorota Bzymek, Reza Nezafat, Beth Goddu, Kraig V. Kissinger, Peter J. ...Zimetbaum, Warren J. Manning, Susan B. Yeon Cardiovascular magnetic resonance (CMR) has not been previously used to characterize mitral valve prolapse (MVP). Cardiovascular magnetic resonance was compared to transthoracic echocardiography in 25 MVP patients and 25 controls. A 2-mm leaflet excursion into the left atrium on the left ventricular outflow view was 100% sensitive and specific for MVP. Leaflet thickness, length, and mitral annular diameters correlated well between CMR and transthoracic echocardiography. Of 16 MVP patients, 10 (63%) demonstrated late gadolinium enhancement of the papillary muscles consistent with fibrosis whereas no controls did. This is the first study to demonstrate fibrosis in vivo in the subvalvular apparatus in MVP patients.
Background The purpose of this study was to evaluate the incidence of vocal cord (VC) and swallowing dysfunction in infants after the Norwood operation and to examine the relationship between ...laryngopharyngeal dysfunction and postoperative outcomes. Methods We conducted a retrospective review of 63 infants who underwent routine postoperative fiberoptic endoscopic evaluation of swallowing function and vocal cords after a Norwood operation at our institution during a recent 6-year period (2003–2009). Results The overall incidence of VC dysfunction after the Norwood operation was 58.7%. After a modification of the aortic arch dissection technique in 2007, the incidence of VC dysfunction decreased significantly from 79.5% in 2003 through 2006 to 25% in 2007 through 2009 ( p < 0.001). The incidence of swallowing dysfunction also decreased from 23.1% in 2003 through 2006 to 4.2% in 2007 through 2009 ( p = 0.07). Swallowing dysfunction was more common in patients with VC dysfunction (21.6%) as compared with patients without VC dysfunction (7.7%; p = 0.18). Patients with VC dysfunction were more often discharged home on tube-only feeding regimens compared with infants without VC dysfunction (46% versus 26.9%). In infants with both VC and swallowing dysfunction, 75% were discharged exclusively to have tube feeding. Median hospital length of stay tended to be longer in infants with swallowing dysfunction (31 days) than in infants without swallowing dysfunction (23 days; p = 0.16). Conclusions Vocal cord and swallowing dysfunction are common in infants after the Norwood operation and may increase the need for tube feeding regimens. Modification of surgical techniques for dissection and mobilization of the aorta can significantly reduce the incidence of these adverse outcomes.
When is palliation permanent? Manning, Peter B., MD
The Journal of thoracic and cardiovascular surgery,
06/2015, Letnik:
149, Številka:
6
Journal Article
Background A single-institution experience with slide tracheoplasty for management of tracheal stenosis in children with emphasis on identifying predictors of prolonged postoperative mechanical ...ventilation is reviewed. Methods Patient characteristics, hospital course, and outcomes for children undergoing slide tracheoplasty were recorded. Univariate and multivariate analysis was performed to identify factors leading to prolonged mechanical ventilation (>48 hours postoperatively). Results Since April 2001, 40 children underwent slide tracheoplasty utilizing cardiopulmonary bypass (CPB) support at a median age of 6.2 months (range, 7 days to 15 years), and median weight of 6.1 kg (range, 1.9 to 57 kg). Thirteen patients had undergone prior operations. Thirteen patients (32.5%) were mechanically ventilated before operation. Thirteen patients underwent additional procedures at the time of the slide tracheoplasty. Mean CBP support time was 123 minutes. Seven patients required aortic cross-clamping (mean, 69 minutes). There were 2 early and 2 late deaths, none related to the tracheoplasty. One patient required repair of a recurrent tracheal stenosis, 4 patients required tracheotomy, and 3 required temporary stent placement. Twenty-one patients (52.5%) were extubated within 48 hours after tracheoplasty. Univariate and multivariate analysis revealed only preoperative mechanical ventilatory support (odds ratio 28.4, p = 0.015) and duration of CPB support (odds ratio 1.06, p = 0.007) to be significant predictors of the need for prolonged intubation. Conclusions Slide tracheoplasty utilizing CPB support is a versatile and effective treatment for tracheal stenosis in children even when combined with repair of congenital cardiac anomalies. Most children can be successfully weaned from mechanical ventilatory support early after repair.
Background For neonates with atrioventricular septal defect and aortic arch obstruction including coarctation of the aorta, we sought to determine whether a difference in outcomes exists after a ...primary neonatal versus staged surgical repair (neonatal arch repair with delayed intracardiac repair). Methods This retrospective cohort study included consecutive neonates with atrioventricular septal defect and aortic arch obstruction who underwent cardiac surgery before 28 days of age at six centers from 1990 to 2009. Characteristics and outcomes between patients undergoing neonatal versus staged repair were compared. Results Of 66 study patients, 31 (47%) underwent primary neonatal repair and 35 (53%) underwent staged repair. At baseline echocardiogram, a greater percentage of neonatal repair patients had relative unbalanced ventricular size (56% versus 35%, p = 0.02). There were no other differences in demographic characteristics, cardiac anatomical or functional details, or surgical technique. Those undergoing neonatal repair tended to be more likely to have at least moderate left atrioventricular valve regurgitation early after repair (42% versus 19%, p = 0.05) and to have at least one major in-hospital complication (42% versus 20%, p = 0.06). After the initial cardiac operation, compared with the neonatal repair group, patients undergoing staged repair had greater survival (87% versus 57% at 6 years, log-rank p = 0.02) and freedom from the first unplanned cardiac reoperation (69% versus 45% at 6 years, log-rank p = 0.005). Conclusions For neonates with atrioventricular septal defect and aortic arch obstruction, when compared with neonatal repair, a staged approach was associated with improved survival and lower morbidity.
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