Transvenous pacing in infants and children with congenital heart disease

A technique for transvenous pacemaker implantation in children with complex heart disease is described. The use of small positive-fixation leads, introducers, retained guidewires, and atrial lead loops to allow for growth all have an important role in management of this often challenging problem.     

Renal function and injury in infants and young children with congenital heart disease

Background

The aim of this study was to investigate renal function and injury in infants and young children with congenital heart disease (CHD).

Methods

We prospectively enrolled 58 CHD children aged ??3?years and 20 age-matched controls and divided these into four groups: Group I, acyanotic CHD (n?=?24); Group II, cyanotic CHD with arterial oxygen saturation of >75?% (n?=?20); Group III, cyanotic CHD with arterial oxygen saturation of ??75?% (n?=?14); Group IV, normal controls (n?=?20). Urinary levels of microalbumin (MA), N-acetyl-?-D-glucosaminidase (NAG), and ??1-microglobulin (??1-MG) corrected by creatinine (UCr) were compared.

Results

Children with CHD had elevated urinary ??1-MG/UCr levels, with Group III children having the highest level. Groups I and III children had higher urinary NAG/UCr levels than those of Groups II and IV. Urinary MA/UCr levels in the three patient groups were comparable and significantly higher than that in the control group. A ??1-MG?×?100/ (??1-MG?+?MA) of <15?%, indicative of glomerular damage, was present in two patients in Group I and one in Group III, but none in Group II.

Conclusions

Tubular injury can occur in CHD patients during infancy and early childhood. Among our patient cohort, it was most prominent in children with severe cyanosis. Glomerular injury was detected in some individuals with advanced heart failure or severe cyanosis.     

The safety and efficacy of sevoflurane anesthesia in infants and children with congenital heart disease

We tested the hypothesis that sevoflurane is a safer and more effective anesthetic than halothane during the induction and maintenance of anesthesia for infants and children with congenital heart disease undergoing cardiac surgery. With a background of fentanyl (5 microg/kg bolus, then 5 microg. kg(-1). h(-1)), the two inhaled anesthetics were directly compared in a randomized, double-blinded, open-label study involving 180 infants and children. Primary outcome variables included severe hypotension, bradycardia, and oxygen desaturation, defined as a 30% decrease in the resting mean arterial blood pressure or heart rate, or a 20% decrease in the resting arterial oxygen saturation, for at least 30 s. There were no differences in the incidence of these variables; however, patients receiving halothane experienced twice as many episodes of severe hypotension as those who received sevoflurane (P = 0.03). These recurrences of hypotension occurred despite an increased incidence of vasopressor use in the halothane-treated patients than in the sevoflurane-treated patients. Multivariate stepwise logistic regression demonstrated that patients less than 1 yr old were at increased risk for hypotension compared with older children (P = 0.0004), and patients with preoperative cyanosis were at increased risk for developing severe desaturation (P = 0.049). Sevoflurane may have hemodynamic advantages over halothane in infants and children with congenital heart disease. IMPLICATIONS: In infants and children with congenital heart disease, anesthesia with sevoflurane may result in fewer episodes of severe hypotension and less emergent drug use than anesthesia with halothane.     

Surgical treatment of airway obstruction associated with congenital heart disease in infants and small children

In the last 12 years, 21 patients age 1 month to 5 years (median, 7 months) underwent surgical treatment for severe airway obstruction associated with congenital heart disease. Plico-suspension of the pulmonary artery was carried out in 14 patients with documented severe left bronchial compression by a distended pulmonary artery together with repair of ventricular septal defects (11 patients), repair of large coronary artery fistula (1), division of ductus (1) and pulmonary artery banding (1), with subsequent significant relief of compression. Aortopexy was used in 2 patients with documented severe tracheal compression by a right aortic arch. Five patients had congenital tracheal stenoses (3 extensive, 2 localized). Two of 3 patients with associated complex intracardiac anomalies underwent concomitant repair of both lesions with the use of cardiopulmonary bypass and 1 had a tracheoplasty and pulmonary artery banding. Tracheal reconstruction with a cartilaginous graft together with repair of pulmonary artery sling was carried out in 2 infants. Nineteen patients are alive and well, at a mean follow-up of 87 months. In conclusion, we advocate early aggressive surgical intervention to both lesions to obtain a better result in the management of infants and small children with this difficult and often fatal combination.     

Anesthesia in children with congenital heart disease

Anesthesiologists involved in the care of children with congenital heart disease (CHD) have to understand the pathophysiology of each cardiac lesion and anticipate the impact of the planned procedure. Often the dimished margin of hemodynamic stability determines the guidelines of care. In children with CHD maintainance of the homeostasis during anesthesia for a wide variety of procedures is the anesthesiologist's challenge. Left-to-right shunting means a volume load to the left ventricle frequently combined with pulmonary hypertension. Right-to-left shunting leads to a central cyanosis.     

Activated thrombelastogram in neonates and infants with complex congenital heart disease in comparison with healthy children

Background. The goal of the study was to determine activatedthrombelastographic (TEG®) parameters with the rotationalTEG® (ROTEG or ROTEM) device (Pentapharm GmbH, Munich, Germany)in neonates and infants <1 yr with complex congenital heartdisease (CCHD) and to compare them with those of healthy children. Methods. A total of 59 children were included: Group I (Gr I)24 children, ASA I, scheduled for minor surgery; and Group II(Gr II) 35 children with CCHD, ASA III–IV, scheduled forcardiac surgery. Each group was subdivided into four age groups.Blood samples were obtained before the surgical procedure. Results. Statistically significant differences (two-way ANOVAanalysis) between Gr I and Gr II [mean (SD); P-value] were foundin INTEG-CT [Gr I 175(19), Gr II 271(162); P=0.049], EXTEG-MCF[Gr I 63(8), Gr II 56(8); P=0.013], EXTEG-MCE [Gr I 186(65),Gr II 137(41); P=0.003], FIBTEG-MCF [Gr I 24(7), Gr II 19(5);P=0.012], FIBTEG-MCE [Gr I 32(13), Gr II 24(8); P=0.012] andEXTEG-MCE–FIBTEG-MCE [Gr I 155(55), Gr II 113(37); P=0.003].Clotting time via contact activation was prolonged in Gr IIand varied widely, mainly in the age group 0–1 month andto a lesser extent in 1–3 months, and maximum clot firmnesswas reduced in the same age groups. In comparison with Gr II,the healthy children showed relatively homogenous TEG valueswith a tendency to hypercoagulability; the maximum was foundin age group 1–3 months, decreasing towards adult valuesin the course of the first year of life. Conclusions. These preliminary TEG results indicate that thecoagulation-fibrinolytic system in CCHD patients <1 yr isfunctionally intact and balanced but at a lower level than inhealthy children. This could be interpreted as a reduction inthe haemostatic potential with less reserve.     

Bronchial compression by posteriorly displaced ascending aorta in patients with congenital heart disease

BACKGROUND: We encountered several patients with posteriorly displaced ascending aorta and bronchial compression associated with congenital heart disease. We describe the helical computed tomography (CT) findings and explore the mechanism of airway compression. METHODS: We retrospectively reviewed the clinical data and CT findings of 8 patients with posterior displacement of the ascending aorta. The bronchial stenosis was quantified on reformatted images perpendicular to the main-stem bronchi. On an axial image at the level of main bronchi, we measured depth of retrosternal space, interaortic distance, and aorto-spinal distance. To compare with control, we measured the same variables in 10 control patients. RESULTS: In 7 patients, the main bronchus on the side of the aortic arch was squeezed between the ascending and descending aorta and showed slit-like stenosis. The right pulmonary artery was elongated around the ascending aorta in 5 patients and showed slit-like stenosis in 3. Patients with posterior displacement had significantly larger retrosternal space, smaller interaortic distance, and smaller aorto-spinal distance than did the control group. Aortopexy was undertaken in 3 patients. Follow-up computed tomograms of 2 patients showed improvement. CONCLUSIONS: The posteriorly displaced ascending aorta may compress the main bronchus on the side of the aortic arch and right pulmonary artery against the descending aorta or spine. Even if the bronchial compression is mild with tolerable airway symptoms, these patients must be closely observed. When airway symptoms are severe, aortopexy should be considered.     

Correction of simple congenital heart defects in infants and children through a minithoracotomy.

BACKGROUND: Minimally invasive surgical techniques in pediatric cardiac surgery have evolved throughout the last 10 years. Advantages of minimally invasive procedures include excellent cosmetic results and superior postoperative outcome. However, safety of minimally invasive techniques has to be proven. METHODS: In 21 female infants and children, a right anterolateral thoracotomy was performed. Mean age was 7.1 years (0.5 to 16.6 years) and mean body weight was 20.8 kg (8.3 to 56 kg). The following defects were repaired: atrial septum defect type II (n = 14); partial atrioventricular septum defect (n = 3); partial anomalous pulmonary venous connection (n = 2); ventricular septum defect (n = 2); mitral valve insufficiency (n = 1); and resection of an embolized atrial septum defect occluder (n = 1). In two cases, aortic cross-clamping was performed by using a transthoracic clamp. In 5 patients, femoral cannulation was performed. Skin incisions were limited to 4 to 7 cm. RESULTS: There was no operative or late mortality. Mean operation time, bypass time, and aortic cross-clamp time were 138 (95 to 275), 72 (32 to 179), and 35 (12 to 120) minutes, respectively. Mean postoperative mechanical ventilation time, mean intensive care unit stay, and mean hospital stay were 3.9 hours (1 to 12 hours), 1.4 days (1 to 3 days), and 12 days (8 to 18 days), respectively. Postoperative complications included hemorrhage in 1 patient requiring surgical intervention. Mean follow-up period was 13.3 months (1 to 36 months). All patients were in New York Heart Association class I postoperatively. Trivial mitral insufficiency was evident in 1 patient operated for partial atrioventricular septum defect. CONCLUSIONS: A small right anterolateral thoracotomy as a minimally invasive technique in pediatric cardiac surgery is a safe and suitable alternative in the operative management of simple congenital heart defects. Cosmetic results are superior, however, improved postoperative outcome has to be proven.     

Brain injury in children with congenital heart disease

The incidence of neurodevelopmental impairment in children with congenital heart disease is high. Its aetiology is multiple and complex. Prevention and treatment must start during the preoperative period and continue through the intra- and postoperative periods. Research has resulted in a clearer understanding of the relationship between congenital heart disease and the brain, and of the effects of cardiopulmonary bypass, hypothermia and circulatory arrest. This has led to modifications in management which may improve neurological outcome in the future.     

Laparoscopic gastrostomy in children with congenital heart disease

AIM: The aim of this study was to study the type and frequency of complications and change in weight after a laparoscopic gastrostomy procedure in 31 children with congenital heart disease, comparing patient groups of children with univentricular and biventricular circulation, and with completed and uncompleted cardiac surgery. METHODS: The method used was that of a retrospective study of all 31 children with congenital heart disease who underwent a laparoscopic gastrostomy at our center from 1995 to 2004. MAIN OUTCOME MEASURES: Postoperative complications and body weight changes during follow-up were the main outcome measures used in this study. RESULTS: Minor stoma-related problems were common in both groups. Two severe complications requiring an operative intervention occurred in the univentricular circulation group. Weight was normal at birth, low at the time of the gastrostomy procedure, and did not catch up completely during the follow-up period of a mean of 20 months. There were no significant differences regarding mean weight gain between the groups. CONCLUSIONS: The complication rate after the laparoscopic gastrostomy procedure was higher in our patient group, compared to previously studied children with various diseases. Comparisons regarding mean weight gain between the groups showed no significant differences. The mean weight gain was low, suggesting that the energy expenditure in this patient group of children with severe congenital heart disease may be even higher than previously assumed.     

Laparoscopic surgery in children with congenital heart disease

PurposeThe study aim was to determine outcomes of children with congenital heart disease who underwent laparoscopic procedures.MethodsA single-institution, institutional review board–approved, retrospective review was conducted including children younger than 5 years with congenital heart disease who underwent laparoscopic or open abdominal procedures. Patient demographics, operative details, complications, and 30-day mortality were examined.ResultsOver 10 years, 111 children with congenital heart disease underwent 121 laparoscopic procedures. Median age was 2.5 months, with 87% being infants. Laparoscopic gastrostomy was the most common procedure (101). There was no intraoperative hemodynamic instability, median operative time was 70 minutes, postoperative complications were low (5%), and all children were alive at 30 days. Only 8 patients required conversion from laparoscopic to open, all secondary to technical issues, not hemodynamic instability. There were 42 children with cardiac disease who underwent 45 open procedures during the study period. There were no significant differences between patient demographics, type of procedure, operative time, complications, or 30-day mortality comparing the open and laparoscopic groups.ConclusionIn this review, there were no major contraindications to performing laparoscopic procedures in children with congenital heart disease, and we conclude that it is reasonably safe to perform laparoscopic surgery on these children.