Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications

Purpose

We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone.

Methods

We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT.

Results

We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43–2.87, p ≤ 0.0001, I ² = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28–4.05, p = 0.005, I ² = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43–2.78, p < 0.0001, I ² = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62–3.11, p = 0.42, I ² = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35–1.68, p = 0.46, I ² = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean).

Conclusions

Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.

     

Long-Term Serial Follow-Up of Pulmonary Artery Size and Wall Shear Stress in Fontan Patients

Pulmonary arterial (PA) flow is abnormal after the Fontan operation and is marked by a lack of pulsatility. We assessed the effects of this abnormal flow on the size and function of the PA’s in Fontan patients in long-term serial follow-up. Twenty-three Fontan patients with serial follow-up were included. Median age was 11.1 (9.5–16.0) years at baseline and 15.5 (12.5–22.7) years at follow-up. Median follow-up duration was 4.4 (4.0–5.8) years. Flow and size of the left pulmonary artery were determined using phase-contrast MRI. From this wall shear stress (WSS), distensibility and pulsatility were determined. A group of healthy peers was included for reference. Flow and pulsatility were significantly lower in patients than in controls (p < 0.001). Mean area was comparable in patients and controls, but distensibility was significantly higher in controls (p < 0.001). Mean and peak WSS were significantly lower in Fontan patients (p < 0.001). Between baseline and follow-up, there was a significant increase in normalized flow (15.1 (14.3–19.1) to 18.7 (14.0–22.6) ml/s/m², p = 0.023). Area, pulsatility, distensibility and WSS did not change, but there was a trend toward a lower mean WSS (p = 0.068). Multivariable regression analysis showed that flow, area and age were important predictors for WSS. WSS in Fontan patients is decreased compared to healthy controls and tends to decrease further with age. Pulsatility and distensibility are significantly lower compared to healthy controls. Pulmonary artery size, however, is not significantly different from healthy controls and long-term growth after Fontan operation is proportionate to body size.     

Effect of Inhaled Nitric Oxide on Blood Flow Dynamics in Patients After the Fontan Procedure Using Cardiovascular Magnetic Resonance Flow Measurements

Invasive hemodynamic studies have shown that nitric oxide (NO), a selective pulmonary vasodilator, can lower pulmonary vascular resistance in Fontan patients. Because oximetry-derived flow quantification may be unreliable, we sought to detect changes in blood flow within the Fontan circulation after inhalation of NO using cardiovascular magnetic resonance (CMR). Thirty-three patients (mean age 12.8 ± 7.0 years) after the Fontan procedure underwent CMR as part of their routine clinical assessment. Standard two-dimensional blood flow measurements were performed in the Fontan tunnel, superior vena cava (SVC) and ascending aorta (AAO) before and after inhalation of 40 ppm NO for 8–10 min. Systemic-to-pulmonary collateral (SPC) flow was calculated as AAO ? (SVC + tunnel). Heart rate (82 ± 18 to 81 ± 18 bpm; p = 0.31) and transcutaneous oxygen saturations (93 ± 4 to 94 ± 3 %; p = 0.13) did not change under NO inhalation. AAO flow (3.23 ± 0.72 to 3.12 ± 0.79 l/min/m²; p = 0.08) decreased, tunnel flow (1.58 ± 0.40 to 1.65 ± 0.46 l/min/m²; p = 0.032) increased, and SVC flow (1.01 ± 0.39 to 1.02 ± 0.40 l/min/m²; p = 0.50) remained unchanged resulting in higher total caval flow (Qs) (2.59 ± 0.58 to 2.67 ± 0.68 l/min/m²; p = 0.038). SPC flow decreased significantly from 0.64 ± 0.52 to 0.45 ± 0.51 l/min/m² (p = 0.002) and resulted in a significant decrement of the Qp/Qs ratio (1.23 ± 0.23 to 1.15 ± 0.23; p = 0.001). Inhalation of NO in Fontan patients results in significant changes in pulmonary and systemic blood flow. The reduction in SPC flow is accompanied by a net increase in effective systemic blood flow suggesting beneficial effects of pulmonary vasodilators on cardiac output, tissue perfusion and exercise capacity.     

The Impact of a Designated Cardiology Team Involving Telemedicine Home Monitoring on the Care of Children with Single-Ventricle Physiology After Norwood Palliation

We evaluated the effect of an interdisciplinary single-ventricle task force (SVTF) that utilizes a family-driven, telemedicine home monitoring program on clinical outcomes of stage II admissions and its acceptance by parents and cardiologists. Study population was divided into two cohorts, one with Norwood surgery dates before the SVTF (pre-SVTF) and one interventional (post-SVTF). Post-SVTF data also included surveys of parents and cardiologists on the efficacy of the SVTF. Comparative and multivariate statistical testing was performed. Compared to the pre-SVTF group, the post-SVTF group had lower complications after stage II (18.4 vs. 34.1 %, p = 0.02), higher weight-for-age z scores at stage II (?1.5 ± 0.97 vs. ?1.58 ± 1.34, p = 0.02) and were less likely to have a stage II weight-for-age z score below ?2 (26.5 vs. 31.7 %, p = 0.03). A multivariate regression analysis showed providing a written red-flag action plan to parents at discharge was independently associated with higher weight at stage II (β = 0.42, p = 0.04) and higher weight-for-age z score (β = 0.48, p = 0.02). Parents’ satisfaction with SVTF (α = 0.97) was 4.34 ± 0.62; (95 % CI 4.01–4.67) and cardiologists’ acceptance (α = 0.93) was 4.1 ± 0.7 (95 % CI 3.79–4.42). Development of SVTF was associated with a reduction in complications post-stage II and improved weight status at stage II. A written red-flag action plan provided to parents at the time of Norwood discharge was associated with higher weight status at stage II. Parents and cardiologists expressed satisfaction with the utility of SVTF and encouraged expansion to cover all children with congenital heart disease.     

Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: a systematic review and meta-analysis

Objective

A meta-analysis was performed for a comparison of outcomes between open repair (OR) and thoracoscopic repair (TR) for esophageal atresia with tracheoesophageal fistula (EA with TEF).

Methods

Electronic databases, including PubMed, Cochrane Library, and Medline, were searched systematically for the literatures aimed mainly at comparing the therapeutic effects for EA with TEF administrated by OR and TR. Corresponding data sets were extracted and two reviewers independently assessed the methodological quality. Meta-analysis was performed with Stata 12.0.

Results

Ten studies meeting the inclusion criteria were included, involving 447 subjects in total. It was observed that OR entailed a shorter operative time with significant statistical differences (SMD 0.604; 95% CI 0.344–0.864, P = 0). While TR was superior in two aspects: shorter length of hospital stay (SMD 0.584; 95% CI 0.214–0.953; P = 0.002) and shorter first oral feeding time (SMD 0.652; 95% CI 0.27–1.035; P = 0.001). However, meta-analyses of occurrence rate of leaks (OR, 1.747; 95% CI 0.817–3.737; P = 0.15), strictures (OR, 0.937; 95% CI 0.5–1.757; P = 0.839), pulmonary complications (OR, 1.08; 95% CI 0.21–5.44; P = 0.897), fundoplication rate of Gastroesophageal Reflux Disease (GERD) (OR, 1.642; 95% CI 0.855–3.153; P = 0.601), and blood loss (SMD 0.048; 95% CI ?1.292 to 1.388; P = 0.944) showed no significant differences between OR and TR. Meta-analysis of ventilation time showed similar outcome between OR and TR (SMD 0.474; 95% CI 0.02–0.968; P = 0.06), but the result remained controversial due to estimated result changing after sensitivity analysis (SMD 0.61; 95% CI 0.16–1.07; P = 0).

Conclusions

Compared with OR, a longer operative time was associated within TR group, although the TR procedure could possibly reduce the length of hospital stay and first oral feeding time. Meanwhile, the occurrence rate for leaks, strictures, pulmonary complications, and the fundoplication rate of GERD, and blood loss were similar between the OR and TR groups. Estimated result of ventilation time between the two groups remained ambiguous.

     

Predictors of Early Extubation After Pediatric Cardiac Surgery: A Single-Center Prospective Observational Study

This prospective, observational, single-center study aimed to determine the perioperative predictors of early extubation (<24 h after cardiac surgery) in a cohort of children undergoing cardiac surgery. Children aged between 1 month and 18 years who were consecutively admitted to pediatric intensive care unit after cardiac surgery for congenital heart disease between January 2012 and June 2014. Ninety-nine patients were qualified for inclusion during the study period. The median duration of mechanical ventilation was 20 h (range 1–480), and 64 patients were extubated within 24 h. Four of them failed the initial attempt at extubation, and the success rate of early extubation was 60.6 %. Older patient age (p = .009), greater body weight (p = .009), absence of preoperative pulmonary hypertension (p = .044), lower RACHS-1 category (OR, 3.8; 95 % CI 1.35–10.7; p < .05), shorter cardiopulmonary bypass (p = .008) and cross-clamp (p = .022) times, lower PRISM III-24 (p < .05) and PELOD (p < .05) scores, lower inotropic score (p < .05) and vasoactive-inotropic score (p < .05), and lower number of organ failures (OR, 2.26; 95 % CI 1.30–3.92; p < .05) were associated with early extubation. Our study establishes that early extubation can be accomplished within the first 24 h after surgery in low- to medium-risk pediatric cardiac surgery patients, especially in older ones undergoing low-complexity procedures. A large prospective multiple institution trial is necessary to identify the predictors and benefits of early extubation and to facilitate defined guidelines for early extubation.     

Unplanned Repeat Echocardiography with Sedation in Children: Patient Risk Factors

Patient selection criteria for echocardiography with sedation in children are not well defined. We attempted to identify predictors of unplanned repeat echocardiography with sedation. This was a single-center, case–control study of echocardiograms performed in children aged 1–36 months. Cases underwent unplanned repeat examinations with sedation, while controls did not. Patient variables and study indications were compared. Logistic regression identified the most significant predictors. Cases (n = 104, median time to repeat echocardiogram 17 days, median age 12.9 months) were older than controls (n = 212, median age 5.0 months, P < 0.001). Significantly more cases than controls had structural cardiac disease (64 vs. 23 %) and anatomic complexity ≥moderate (38 vs. 5 %, P < 0.001 for both). Cases more often had Kawasaki disease (11 vs. 2 %), and controls more often had murmur (56 vs. 11 %, P < 0.001 for both). Logistic regression identified age 6 months to <2 years (OR 3.26, 95 % CI 1.70–6.28, P < 0.001), Kawasaki disease (OR 5.20, 95 % CI 1.46–18.50, P = 0.01), and known pre-echocardiogram anatomic complexity ≥moderate (OR 3.99, 95 % CI 1.64–9.66, P = 0.002) as significant risk factors. An indication for murmur was protective (OR 0.32, 95 % CI 0.13–0.76, P = 0.01). We identified several risk factors for unplanned repeat echocardiography with sedation in children, including age 6 months to <2 years, higher anatomic complexity, and Kawasaki disease. Murmur was a protective factor. These results may help pediatric echocardiography laboratories establish criteria for sedation.     

<Emphasis Type="Italic">IL10</Emphasis> Promoter Polymorphisms are Associated with Rheumatic Heart Disease in Saudi Arabian Patients

Rheumatic heart disease (RHD) is an inflammatory disease that develops following streptococcal infections. IL10 helps to balance immune responses to pathogens. IL10 polymorphisms have been associated with RHD, although results remain inconclusive. Our aim was to investigate the association between IL10 polymorphisms and RHD in Saudi Arabian patients. IL10 promoter polymorphisms (-1082A/G, -829C/T, and -592C/A) were genotyped in 118 RHD patients and 200 matched controls using the TaqMan allelic discrimination assay. There was a significant difference in IL10-1082 genotype frequency between patients and controls (p = 0.01). -1082G allele carriage (GG+GA vs AA) and the (-1082, -819, -592) GCC haplotype carriage were associated with an increased risk of RHD (p = 0.004, OR 2.1, 95 % CIs 1.7–3.4 and p = 0.004, OR 2, 95 % CIs 1.3–3.4, respectively). The ACC haplotype was associated with a decrease in RHD risk (p = 0.015, OR 0.6, 95 % CIs 0.4–0.9). IL10 promoter polymorphisms may play an important role in the development of RHD and provide an opportunity for therapeutic stratification.     

Fontan Outcomes and Pulmonary Blood Flow at Birth

We previously noted, in a small group of post-Fontan patients, a possible association between hepatic fibrosis scores and the status of pulmonary blood flow at birth. To further explore this observation, we examined data from all Fontan patients seen in our center from July 2010 to March 2015. We identified 200 patients for analysis. Of the 200 patients, 56 underwent transvenous-hepatic biopsy. Of the 200 patients, 13 (6.5 %) had protein-losing enteropathy. We divided both the 56 biopsy patients and the entire cohort of 200 patients into 4 groups: (1) unobstructed pulmonary blood flow at birth with functional left ventricles, (2) unobstructed pulmonary blood flow at birth with functional right ventricles, (3) obstructed pulmonary blood flow at birth with functional left ventricles, and (4) obstructed pulmonary blood flow at birth with functional right ventricles. Analysis of the 56 liver-biopsy patient groups showed median hepatic total-fibrosis scores for the 4 groups of 2 (0–6), 2 (0–8), 3 (2–6), and 4 (1–8), respectively, with statistical significance between groups 4 and 1 (p = 0.031). For the entire cohort of 200 patients, we analyzed the incidence of protein-losing enteropathy for each of the four groups and found protein-losing enteropathy percent occurrences of 0, 2.9, 8.8, and 16.1, respectively, with statistical significance between groups 4 and 2 (p = 0.031) and between groups 4 and 1 (p = 0.025). A history of obstructed pulmonary blood flow at birth, coupled with a functional right ventricle, may predict a poorer long-term Fontan outcome.     

Body Mass Index (BMI) is Associated with the Therapeutic Response to Oral Rehydration Solution in Children with Postural Tachycardia Syndrome

We aimed to explore whether the body mass index (BMI) was associated with the therapeutic response to oral rehydration solution (ORS) in children with postural tachycardia syndrome (POTS). Fifty-four children diagnosed as having POTS were included in this study. Fifty-six healthy children served as the controls. Children with POTS were treated with ORS, and their treatment response was evaluated. The baseline BMI was obtained by measuring the height and weight. The Pearson correlation was made between the baseline BMI and change in heart rate from supine to upright (ΔHR) and between baseline BMI and symptom score change (post-treatment vs. pre-treatment) in the POTS group. The value of BMI in predicting the therapeutic response to ORS was assessed by analyses of the receiver operating characteristic (ROC) curve. The BMI in the POTS group was significantly lower than that in the control group (18.22 ± 3.23 vs. 20.62 ± 3.05 kg/m², p < 0.01). There were no statistical differences between responders and non-responders in symptom scores before treatment (p > 0.05), but symptom score was lower in responders than that in non-responders (1.52 ± 0.95 vs. 2.32 ± 1.22, p < 0.01) after treatment. The BMI in responders to ORS was significantly lower than that of non-responders (16.32 ± 2.28 vs. 20.43 ± 2.74 kg/m², p < 0.01). The BMI was correlated negatively with ΔHR in the POTS group (n = 54, r = ?0.766, p < 0.01) and with the decrease in symptom scores after treatment in POTS patients (n = 54, r = ?0.28, p < 0.05). ROC curve revealed the area under the curve to be 92.3 % (95 % confidence interval 0.829–0.996). A cutoff value of the BMI of 18.02 kg/m² had high sensitivity (92 %) and high specificity (82.8 %) for predicting the effect of ORS treatment for POTS. BMI is associated with the therapeutic response to ORS in children with POTS.     

Laparoscopic versus open pyloromyotomy in infants: a systematic review and meta-analysis

Purpose

To determine whether open or laparoscopic pyloromyotomy is superior for the treatment of hypertrophic pyloric stenosis in infants.

Methods

We searched MEDLINE, EMBASE, and CENTRAL for articles comparing laparoscopic and open procedures. We conducted meta-analyses when possible and described other results narratively.

Results

Our meta-analyses revealed no significant difference in our primary outcome of major complications [risk difference (RD) 0.03, 95% confidence interval (CI) ?0.03 to 0.08, P = 0.35, I ² = 55%], or in our secondary outcomes of all perioperative complications (RD ?0.01, 95% CI ?0.06 to 0.04, P = 0.74, I ² = 0%), operative time [mean difference (MD) 0.68, 95% CI ?3.60 to 4.79, P = 0.76, I ² = 86%], and length of stay (MD ?2.60, 95% CI ?6.05 to 0.86, P = 0.14, I ² = 0%). Laparoscopy was associated with a shorter time to full feeds (standardized mean difference ?0.25, 95% CI ?0.43 to ?0.06, P = 0.009, I ² = 8%) and a slightly higher rate of inadequate pyloromyotomy (RD 0.04, 95% CI 0.00–0.08, P = 0.03, I ² = 0%). Results from one randomized controlled trial indicate a better cosmetic outcome after laparoscopy compared to open procedure.

Conclusion

There is no strong evidence to support a recommendation of one procedure over the other; therefore, the choice of laparoscopic or open procedure should be left to the discretion of the surgeon.

     

Change in Pediatric Functional Classification During Treatment and Morbidity and Mortality in Children with Pulmonary Hypertension

Despite advances in therapy, outcomes for children with pulmonary hypertension remain poor. We sought to assess the validity of a pediatric-specific functional classification system for pulmonary hypertension (PH) in a heterogeneous population of children with PH diagnosed by echocardiogram or cardiac catheterization. A single-center, retrospective study of 65 infants and children with PH was performed. Pediatric Functional Class (FC) at diagnosis, at last visit, and change in FC over time were evaluated for their association with mortality and PH-associated morbidity in univariate, time-to-event, and multivariate regression analyses. Median age at PH diagnosis was 5.3 months (0 days–12.7 years). Twenty-five children (38 %) had idiopathic PH or PH secondary to congenital heart disease, one (2 %) had left heart disease, and 39 (60 %) had PH secondary to respiratory disease. Mortality was 25 % (16/63), primarily in the first year of follow-up. FC at diagnosis was not significantly associated with survival (p = 0.22), but higher FC (more impaired) at last visit (p < 0.001) and change in FC over time (HR 2.3, 95 % confidence interval 1.3–4, p = 0.0003) were associated with mortality. Higher FC at last visit was associated with greater days of hospitalization in the intensive care unit per year (p = 0.006) and history of cardiac arrest (p = 0.012) and syncope (p = 0.02). Although pediatric FC at diagnosis was not predictive of mortality, response to therapy (as assessed by change in FC over time and FC at last visit) was associated with morbidity and mortality in this heterogeneous cohort. Multicenter prospective studies are necessary to further validate these findings.     

Laparoscopic-assisted pull-through operation for Hirschsprung’s disease: a systematic review and meta-analysis

Purpose

In the last two decades, laparoscopic-assisted pull-through (LAPT) has gained much popularity in the treatment of Hirschsprung’s disease. The aim of this meta-analysis was to determine the long-term outcome of patients treated laparoscopically.

Methods

A systematic literature-based search for relevant cohorts was performed using the terms “Hirschsprung’s disease and Laparoscopy”, “Laparoscopic-assisted pull-through outcome”, “Laparoscopic-assisted Soave pull-through” “Laparoscopic-assisted Swenson pull-through” and Laparoscopic-assisted Duhamel pull-through. The relevant cohorts of laparoscopic operated HD were systematically searched for outcome regarding continence, constipation, secondary surgery related to the laparoscopic approach and enterocolitis. Pooled incidence rates and odds ratios (ORs) with 95 % confidence intervals (CI) were calculated using standardized statistical methodology.

Results

Sixteen studies met defined inclusion criteria, reporting a total of 820 patients. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. The median cohort size consisted of 28 patients (range 15–218). In the long-term follow-up, 97 patients (11.14 %) experienced constipation (OR 0.06, 95 % CI 0.05–0.08, p < 0.00001), 53 (6.46 %) incontinence/soiling (OR 0.01 95 % CI 0.01–0.01, p < 0.00001), 75 (9.14 %) recurrent enterocolitis (OR 0.02 95 % CI 0.01–0.02, p < 0.00001) and 69 (8.4 %) developed complications requiring secondary surgery (OR 0.01 95 % CI 0.01–0.02, p < 0.00001). Overall events in long-term follow-up occurred in 225 (27.5 %) patients (OR 0.24 95 % CI 0.20–0.30, p < 0.00001).

Conclusions

This meta-analysis shows that nearly one-third of the patients continue to have long-term bowel problems, such as constipation, soiling and recurrent enterocolitis following LAPT. Many patients treated by LAPT require secondary surgery. Large randomized studies with long-term follow-up are necessary to determine the difference in outcome between LAPT and completely transanal pull-through operation.

     

Clinical Factors Associated with Dose of Loop Diuretics After Pediatric Cardiac Surgery: Post Hoc Analysis

A post hoc analysis of a randomized controlled trial comparing the clinical effects of furosemide and ethacrynic acid was conducted. Infants undergoing cardiac surgery with cardiopulmonary bypass were included in order to explore which clinical factors are associated with diuretic dose in infants with congenital heart disease. Overall, 67 patients with median (interquartile range) age of 48 (13–139) days were enrolled. Median diuretic dose was 0.34 (0.25–0.4) mg/kg/h at the end of postoperative day (POD) 0 and it significantly decreased (p = 0.04) over the following PODs; during this period, the ratio between urine output and diuretic dose increased significantly (p = 0.04). Age (r ?0.26, p = 0.02), weight (r ?0.28, p = 0.01), cross-clamp time (r 0.27, p = 0.03), administration of ethacrynic acid (OR 0.01, p = 0.03), and, at the end of POD0, creatinine levels (r 0.3, p = 0.009), renal near-infrared spectroscopy saturation (?0.44, p = 0.008), whole-blood neutrophil gelatinase-associated lipocalin levels (r 0.30, p = 0.01), pH (r ?0.26, p = 0.02), urinary volume (r ?0.2755, p = 0.03), and fluid balance (r 0.2577, p = 0.0266) showed a significant association with diuretic dose. At multivariable logistic regression cross-clamp time (OR 1.007, p = 0.04), use of ethacrynic acid (OR 0.2, p = 0.01) and blood pH at the end of POD0 (OR 0.0001, p = 0.03) was independently associated with diuretic dose. Early resistance to loop diuretics continuous infusion is evident in post-cardiac surgery infants: Higher doses are administered to patients with lower urinary output. Independently associated variables with diuretic dose in our population appeared to be cross-clamping time, the administration of ethacrynic acid, and blood pH.     

Predictors of Long-Term Outcome in Children with Hypertrophic Cardiomyopathy

To date limited data are available to predict the progression to end-stage heart failure (HF) with subsequent death (non-SCD), need for heart transplantation, or sudden cardiac death (SCD) in children with hypertrophic cardiomyopathy (HCM). We aimed to determine predictors of long-term outcome in children with HCM. A total of 112 children (median 14.1, IQR 7.8–16.6 years) were followed up for the median of 6.5 years for the development of morbidity and mortality, including arrhythmic and HF-related secondary end points. HF end point included HF-related death or heart transplant, and arrhythmic end point included resuscitated cardiac arrest, appropriate ICD discharge, or SCD. Overall, 23 (21 %) patients reached the pre-defined composite primary end point. At 10-year follow-up, the event-free survival rate was 76 %. Thirteen patients (12 %) reached the secondary arrhythmic end point, and 10 patients (9 %) reached the secondary HF end point. In multivariate model, prior cardiac arrest (r = 0.658), QTc dispersion (r = 0.262), and NSVT (r = 0.217) were independent predictors of the arrhythmic secondary end point, while HF (r = 0.440), LV posterior wall thickness (r = 0.258), LA size (r = 0.389), and decreased early transmitral flow velocity (r = 0.202) were all independent predictors of the secondary HF end point. There are differences in the risk factors for SCD and for HF-related death in childhood HCM. Only prior cardiac arrest, QTc dispersion, and NSVT predicted arrhythmic outcome in patients aged <18 years. LA size, LV posterior wall thickness, and decreased early transmitral flow velocity were strong independent predictors of HF-related events.     

Plasma adrenomedullin level in children with obesity: relationship to left ventricular function

Background

Obese children are at increased risk for abnormal cardiac structure and function. Little is known about adrenomedullin (AM), a cytokine produced in various organs and tissues, as a biomarker of cardiac hypertrophy in obese children. This study aimed to assess the plasma AM levels in a cohort of obese children and its relationship to left ventricular (LV) functions.

Methods

The study included 60 obese children and 60 non-obese children matched for age and gender as control group. Blood pressure, serum lipid profile, fasting glucose, insulin and plasma AM and the homeostatic model assessment of insulin resistance (HOMA-IR) were measured. Cardiac dimensions and LV functions were assessed using conventional echocardiography.

Results

Compared to control subjects, obese children had higher blood pressure (P = 0.01), insulin (P = 0.001), HOMA-IR (P = 0.001), and AM (P = 0.001). Moreover, obese children had higher LV mass index (LVMI) (P = 0.001), indicating LV hypertrophy; prolonged isovolumic relaxation times (P = 0.01), prolonged mitral deceleration time (DcT) (P = 0.01) and reduced ratio of mitral E-to-mitral A-wave peak velocity (P = 0.01), indicating LV diastolic dysfunction. Laboratory abnormalities were only present in children with LV hypertrophy. In multivariate analysis in obese children with LV hypertrophy, AM levels were positively correlated with LVMI [odds ratio (OR) 1.14, 95% confidence interval (Cl) 1.08–1.13, P = 0.0001] and mitral DcT (OR 2.25, 95% CI 1.15–2.05, P = 0.01) in the presence of higher blood pressure and HOMA-IR. A cut-off value of AM at 52 pg/mL could differentiate obese children with and without left ventricular hypertrophy at a sensitivity of 94.32% and specificity of 92.45%.

Conclusions

Plasma AM levels may be elevated in obese children particularly those with LV hypertrophy and is correlated with higher blood pressure and insulin resistance. Measurement of plasma AM levels in obese children may help to identify those at high risk of developing LV hypertrophy and dysfunction.

     

Measurement of Cardiac Output in Children by Pressure-Recording Analytical Method

We evaluated two pressure-recording analytical method (PRAM) software versions (v.1 and v.2) to measure cardiac index (CI) in hemodynamically stable critically ill children and investigate factors that influence PRAM values. The working hypothesis was that PRAM CI measurements would stay within normal limits in hemodynamically stable patients. Ninety-five CI PRAM measurements were analyzed in 47 patients aged 1–168 months. Mean CI was 4.1 ± 1.4 L/min/m² (range 2.0–7.0). CI was outside limits defined as normal (3–5 L/min/m²) in 53.7 % of measurements (47.8 % with software v.1 and 69.2 % with software v.2, p = 0.062). Moreover, 14.7 % of measurements were below 2.5 L/min/m², and 13.6 % were above 6 L/min/m². CI was significantly lower in patients with a clearly visible dicrotic notch than in those without (3.7 vs. 4.6 L/min/m², p = 0.004) and in children with a radial arterial catheter (3.5 L/min/m²) than in those with a brachial (4.4 L/min/m², p = 0.021) or femoral catheter (4.7 L/min/m², p = 0.005). By contrast, CI was significantly higher in children under 12 months (4.2 vs. 3.6 L/min/m², p = 0.034) and weighing under 10 kg (4.2 vs. 3.6 L/min/m², p = 0.026). No significant differences were observed between cardiac surgery patients and the rest of children. A high percentage of CI measurements registered by PRAM were outside normal limits in hemodynamically stable, critically ill children. CI measured by PRAM may be influenced by the age, weight, location of catheter, and presence of a dicrotic notch.     

Comparison of abdominal radiographs and sonography in prognostic prediction of infants with necrotizing enterocolitis

Purpose

The purpose of this study was to investigate the comparison of AR and AUS in predicting prognosis in infants with necrotizing enterocolitis.

Methods

All patients were diagnosed as NEC at the department of general surgery and neonatal surgery, Qilu children’s hospital between 1st, Jun, 2010 and 30th, Dec, 2016. The logistic regression analysis and the area under ROC curve (AUC)s were also used to compare the prognostic values of radiograph and sonograph for NEC.

Results

Throughout the study period, 86 preterm neonates were hospitalized with diagnosis of definite NEC. Among these patients, 39 infants (45.3%) required surgical treatment. After adjusting for competing sonographic factors, we identified that thick bowel wall (more than 2.5 mm) (p?=?0.001, HR: 1.849), intramural gas (pneumatosis intestinalis) (p?=?0.017, HR: 1.265), portal venous gas (p?=?0.002, HR: 1.824), and reduced peristalsis (p?=?0.021, HR: 1.544) were independent prognostic factors associated with NEC. After adjusting for competing radiographic factors, we identified that free peritoneal gas (p?=?0.007, HR: 1.472), portal venous gas (p?=?0.012, HR: 1.649), and dilatation and elongation (p?=?0.025, HR: 1.327). Moreover, we found that the AUROC for AR logistic model was 0.745 (95% CI 0.629–0.812), which was significant lower than the AUS logistic model (AUROC: 0.857, 95% CI 0.802–0.946) for predicting prognosis of NEC.

Conclusions

In conclusion, we found that several radiographic and sonographic parameters were associated with the prognosis of patients with NEC. The AUS model based on the logistic regression analysis was significant superior to the AR model in the prognostic prediction of NEC.

     

Assessment of cardiac function in infants with transposition of the great arteries after surgery: comparison of two methods

Background

Assessment of cardiac function is crucial in pediatric patients undergoing cardiovascular surgery, monitoring cardiac output and changing hemodynamic conditions during surgery accordingly is important to improve post-surgical outcome. We aimed to measure cardiac index (CI) and maximal rate of the increase of left ventricular pressure dp/dt(max) with the pressure recording analytic method (PRAM, MostCare^®) and compared it with transthoracic echocardiographic cardiac index estimation in infants with transposition of the great arteries (TGA) undergoing surgical correction.

Methods

We enrolled 74 infants with TGA consecutively into this study. CI and dp/dt(max) were measured with PRAM and echocardiography at 0, 4, 8, 12, 24 and 48 h postoperatively. Blood brain natriuretic peptide (BNP) and blood lactate (Lac) were measured at baseline and after operation.

Results

The median age at surgery was 13 days (range 1–25 days) with an average weight of 3.24 kg (range 2.31–4.17 kg). CI estimated by PRAM was 1.11 ± 0.12 L/min/m² (range 0.69–1.36) and by Doppler echocardiography was 1.13 ± 0.13 L/min/m² (range 0.76–1.40). dp/dt(max) estimated by PRAM was 1.31 ± 0.03 mmHg/s (range 1.23–1.43) and by Doppler echocardiography was 1.31 ± 0.04 L/min/m² (range 1.25–1.47). CI (r = 0.817, P < 0.001) and dp/dt(max) (r?=?0.794, P?<?0.001) measured by two methods were highly correlated with a linear relation. Blood BNP and lactate increased to the highest level at 8–12 h post-operatively.

Conclusions

In the early post-operative period, PRAM provides reliable estimates of cardiac index and dp/dt(max) value compared with echocardiographic measurements. PRAM through mostcare^® is a reliable continuous monitoring method for peri-operative management in children with congenital heart disease.