Extracorporeal membrane oxygenation after stage 1 palliation for hypoplastic left heart syndrome Sherwin, Elizabeth D., MD; Gauvreau, Kimberlee, ScD; Scheurer, Mark A., MD, MSc ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
12/2012, Letnik:
144, Številka:
6
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Objective To report the outcomes from a large multicenter cohort of neonates requiring extracorporeal membrane oxygenation (ECMO) after stage 1 palliation for hypoplastic left heart syndrome. Methods ...Using data from the Extracorporeal Life Support Organization (2000–2009), we computed the survival to hospital discharge for neonates (age ≤30 days) supported with ECMO after stage 1 palliation for hypoplastic left heart syndrome. The factors associated with mortality were evaluated using multivariate logistic regression analysis. Results Among 738 neonates, the survival rate was 31%. The median age at cannulation was 7 days (interquartile range, 4–11). Black race (odds ratio OR, 2.0; 95% confidence interval CI, 1.2–3.6), mechanical ventilation before ECMO (>15–131 hours: OR, 1.6; 95% CI, 1.1–2.4; >131 hours: OR, 1.9; 95% CI, 1.3–2.9), use of positive end expiratory pressure (>6–8 cm H2 O: OR, 1.7; 95% CI, 1.1–2.7; >8 cm H2 O: OR, 1.9; 95% CI, 1.2–3.1), and longer ECMO duration (per day, OR, 1.2; 95% CI, 1.1–1.3) increased mortality. ECMO support for failure to wean from cardiopulmonary bypass (OR, 1.6; 95% CI, 1.02–2.4) also decreased survival. ECMO complications, including renal failure (OR, 1.9; 95% CI, 1.2–3.1), inotrope requirement (OR, 1.5; 95% CI, 1.1–2.1), myocardial stun (OR, 3.2; 95% CI, 1.3–7.7), metabolic acidosis (OR, 2.9; 95% CI, 1.3–6.7), and neurologic injury (OR, 1.7; 95% CI, 1.1–2.6), during support also increased mortality. Conclusions Mortality for neonates with hypoplastic left heart syndrome supported with ECMO after stage 1 palliation is high. Longer ventilation before cannulation, longer support duration, and ECMO complications increased mortality.
Background Extracorporeal membrane oxygenation (ECMO) to support cardiopulmonary resuscitation (CPR) has been shown to improve survival in children and adults. We describe outcomes after the use of ...ECMO to support CPR (E-CPR) in adults using multiinstitutional data from the Extracorporeal Life Support Organization (ELSO) registry. Methods Patients greater than 18 years of age using ECMO to support CPR (E-CPR) during 1992 to 2007 were extracted from the ELSO registry and analyzed. Results Two hundred and ninety-seven (11% of 2,633 adult ECMO uses) reports of E-CPR use in 295 patients were analyzed. Median age was 52 years (interquartile range IQR, 35, 64) and most patients had cardiac disease (n = 221; 75%). Survival to hospital discharge was 27%. Brain death occurred in 61 (28%) of nonsurvivors. In a multivariate logistic regression model, pre-ECMO factors including a diagnosis of acute myocarditis (odds ratio OR: 0.18; 95% confidence interval CI: 0.05 to 0.69) compared with noncardiac diagnoses and use of percutaneous cannulation technique (OR: 0.42; 95% CI: 0.21 to 0.87) lowered odds of mortality, whereas a lower pre-ECMO arterial blood partial pressure of oxygen (Pa o 2 ) less than 70 mm Hg (OR: 2.7; 95% CI: 1.21 to 6.07) compared with a Pa o 2 of 149 mm Hg or greater increased odds of mortality. The need for renal replacement therapy during ECMO increased odds of mortality (OR: 2.41; 95% CI: 1.34 to 4.34). Conclusions The use of E-CPR was associated with survival in 27% of adults with cardiac arrest facing imminent mortality. Further studies are warranted to evaluate and better define patients who may benefit from E-CPR.
Variation in perioperative care across centers for infants undergoing the Norwood procedure Pasquali, Sara K., MD, MHS; Ohye, Richard G., MD; Lu, Minmin, MS ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
10/2012, Letnik:
144, Številka:
4
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Objectives In the Single Ventricle Reconstruction trial, infants undergoing the Norwood procedure were randomly allocated to undergo a right ventricle-to-pulmonary artery shunt or a modified ...Blalock-Taussig shunt. Apart from shunt type, subjects received the local standard of care. We evaluated variation in perioperative care during the Norwood hospitalization across 14 trial sites. Methods Data on preoperative, operative, and postoperative variables for 546 enrolled subjects who underwent the Norwood procedure were collected prospectively on standardized case report forms, and variation across the centers was described. Results Gestational age, birth weight, and proportion with hypoplastic left heart syndrome were similar across sites. In contrast, all recorded variables related to preoperative care varied across centers, including fetal diagnosis (range, 55%-85%), preoperative intubation (range, 29%-91%), and enteral feeding. Perioperative and operative factors were also variable across sites, including median total support time (range, 74-189 minutes) and other perfusion variables, arch reconstruction technique, intraoperative medication use, and use of modified ultrafiltration (range, 48%-100%). Additional variation across centers was seen in variables related to postoperative care, including proportion with an open sternum (range, 35%-100%), median intensive care unit stay (range, 9-44 days), type of feeding at discharge, and enrollment in a home monitoring program (range, 1%-100%; 5 sites did not have a program). Overall, in-hospital death or transplant occurred in 18% (range across sites, 7%-39%). Conclusions Perioperative care during the Norwood hospitalization varies across centers. Further analysis evaluating the underlying causes and relationship of this variation to outcome is needed to inform future studies and quality improvement efforts.
Survival after bidirectional cavopulmonary anastomosis: Analysis of preoperative risk factors Scheurer, Mark A., MD; Hill, Elizabeth G., PhD; Vasuki, Nagavardhan, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
07/2007, Letnik:
134, Številka:
1
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Objective Prognostic factors for survival after bidirectional cavopulmonary anastomosis for functionally single ventricle are not well defined. We analyzed preoperative hemodynamic and ...echocardiographic data to determine risk factors for death or transplantation at least 1 year after bidirectional cavopulmonary anastomosis. Methods Data for all patients who underwent bidirectional cavopulmonary anastomosis before 5 years of age at our institution from September 1995 through June 2005 were analyzed. Available preoperative echocardiograms and catheterizations were reviewed. Survivors were compared with those who died or underwent transplantation. Bivariable associations between demographic and clinical risk factors and survival status (alive without transplantation vs dead or transplanted) were assessed with Wilcoxon rank sum test and χ2 or Fisher exact tests. Survival functions were constructed with Kaplan–Meier estimates, and event times compared between subgroups with log–rank tests. Cox proportional hazard modeling was used for multivariable modeling of risk of death or transplantation. Results One hundred sixty-seven patients underwent bidirectional cavopulmonary anastomosis with hemi-Fontan (n = 62) or bidirectional Glenn (n = 105) operations. Three patients died before discharge, 11 died later, and 1 has undergone transplantation. Freedom from death or transplantation after bidirectional cavopulmonary anastomosis was 96% at 1 year and 89% at 5 years. Multivariable analysis of preoperative variables showed atrioventricular valve regurgitation to be an independent risk factor for death or transplantation (hazard ratio 2.8, 95% confidence interval 1.1–7.1, P = .02). Conclusion Although survival after bidirectional cavopulmonary anastomosis is high, preoperative atrioventricular valve regurgitation is an important risk factor for death or transplantation.
A composite outcome for neonatal cardiac surgery research Butts, Ryan J., MD; Scheurer, Mark A., MD; Zyblewski, Sinai C., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
01/2014, Letnik:
147, Številka:
1
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Objective The objective of this study was to determine whether a composite outcome, derived of objective signs of inadequate cardiac output, would be associated with other important measures of ...outcomes and therefore be an appropriate end point for clinical trials in neonatal cardiac surgery. Methods Neonates (n = 76) undergoing cardiac operations requiring cardiopulmonary bypass were prospectively enrolled. Patients were defined to have met the composite outcome if they had any of the following events before hospital discharge: death, the use of mechanical circulatory support, cardiac arrest requiring chest compressions, hepatic injury (2 times the upper limit of normal for aspartate aminotransferase or alanine aminotransferase), renal injury (creatinine >1.5 mg/dL), or lactic acidosis (an increasing lactate >5 mmol/L in the postoperative period). Associations between the composite outcome and the duration of mechanical ventilation, intensive care unit stay, hospital stay, and total hospital charges were determined. Results The median age at the time of surgery was 7 days, and the median weight was 3.2 kg. The composite outcome was met in 39% of patients (30/76). Patients who met the composite outcome compared with those who did not had a longer duration of mechanical ventilation (4.9 vs 2.9 days, P < .01), intensive care unit stay (8.8 vs 5.7 days, P < .01), hospital stay (23 vs 12 days, P < .01), and increased hospital charges ($258,000 vs $170,000, P < .01). In linear regression analysis, controlling for surgical complexity, these differences remained significant ( R 2 = 0.29-0.42, P < .01). Conclusions The composite outcome is highly associated with important early operative outcomes and may serve as a useful end point for future clinical research in neonates undergoing cardiac operations.
Survival and Clinical Course at Fontan After Stage One Palliation With Either a Modified Blalock-Taussig Shunt or a Right Ventricle to Pulmonary Artery Conduit Mark A. Scheurer, Joshua W. Salvin, ...Vladimiro L. Vida, Francis Fynn-Thompson, Emile A. Bacha, Frank A. Pigula, John E. Mayer, Jr, Pedro J. del Nido, David L. Wessel, Peter C. Laussen, Ravi R. Thiagarajan Despite improved surgical and interstage survival in some series with the use of a right ventricle to pulmonary artery (RV-PA) conduit during stage one palliation for single ventricle defects, long-term outcomes are unknown. Concerns about pulmonary artery (PA) growth and the effects of the required ventriculotomy linger. In the review of 2 groups of patients who underwent stage one palliation contemporaneously, one receiving a modified Blalock-Taussig shunt and the other an RV-PA conduit, we found the clinical courses at Fontan were nearly identical. Nonstatistically significant trends toward increased PA interventions and improved cumulative survival were demonstrated in the RV-PA conduit group.
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