Interventions on the heart and large vessels without prior heart catheterization

Between May 1983 and May 1987, 161 children of all age groups underwent surgery for congenital cardiac malformations without prior cardiac catheterization and angiocardiography. Their diagnoses were established by clinical investigation, electrocardiogram, chest X-ray and cross-sectional echocardiography only in all cases. The most common surgical procedures were ligation of a patent ductus arteriosus (n = 68), correction of aortic coarctation (n = 28), balloon atrial septostomy (n = 27), and closure of an atrial septal defect (n = 23). To prove the efficiency and accuracy of this method all patients with cardiac malformations surgically treated over the same time period, of the same age groups and with the same diagnoses, who had undergone routine preoperative cardiac catheterization and angiocardiography, were reviewed with regard to the attained results, which were compared with those of the non-invasive group. No patient in either group died postoperatively due to an incorrect or incomplete preoperative diagnosis. There were problems in the group diagnosed by echocardiography only in assessing the permeability of the tricuspid valve in cases of pulmonary atresia with a hypoplastic right ventricle and in assessing the operability of patients with a complete aterioventricular canal. A large group of congenital cardiac malformations can, however, be safely operated on the basis of non-invasive preoperative diagnoses only.     

Lack of irrefutable validation does not negate clinical utility of near-infrared spectroscopy monitoring: Learning to trust new technology

Reliance on new monitoring device technology is based upon an understanding of how the device operates and its reliability in a specific clinical setting. The introduction of new monitoring devices will therefore elicit either distrust of the new technology and the data presented or adoption of new devices. The use of near-infrared spectroscopy (NIRS) technology to monitor vital organs in postoperative pediatric cardiac surgery patients has been extensively described yet controversy remains as to the use of this monitoring device. The following retrospective case series demonstrates how learning from trends in data elicited from 2-site NIRS monitoring provided important bedside insights. These insights led to changes in clinician behavior and reliance on NIRS monitoring for early recognition of clinically silent deteriorations. Disregard for the NIRS data may have led to a fatal outcome in an unstable patient who might have received more timely intervention if the NIRS data had been acknowledged earlier. This case series demonstrates that 2-site NIRS monitoring accurately reflects situations in which poor clinical outcomes may occur when declining trends in somatic tissue oxygen saturations are not corrected. Physician management of the postoperative pediatric cardiac surgery patient can change based upon the insights gained through the application of NIRS monitoring.     

Robotically assisted cardiac surgery: minimally invasive techniques to totally endoscopic heart surgery

Over the past decade, advancements in cardiac surgery occurred secondary to improvements in technology and the desire for a less invasive approach to operations in general. Minimally invasive cardiac surgery has progressed from partial sternotomy incisions to totally endoscopic open-heart procedures with robotic-assistance. There are 2 major companies that produce robotic equipment for use in cardiac surgery. These companies must undergo Food and Drug Association (FDA) mandated clinical trials on each cardiac surgical procedure, before it can be approved for public use. The surgeon must demonstrate clinical proficiency to operate the robotic equipment per FDA approved company testing. The use of computer (robotic) enhancement is well documented for coronary artery bypass grafting and selected cardiac valve procedures. Recent advancements are now being directed at congenital heart disease. The use of robotic-assisted totally endoscopic atrial septal defect closure is a tremendous advancement in congenital cardiac surgery. The future of robotic cardiac surgery will hopefully expand to cover more advanced valve procedures, congenital heart defects, and other procedures once robots are further modified for pediatric use.     

Management of the pediatric postoperative cardiac surgery patient

Optimal management of the postoperative pediatric cardiac surgical patient requires a thorough understanding of patient anatomy, physiology, surgical repair or palliation, and clinical condition. This necessitates a dedicated team of clinicians including skilled nurses, physicians, and respiratory therapists specialized in the care of patients who have complex congenital heart disease. This article provides an overview of the multisystemic risk factors and consequences associated with cadiopulmonary bypass and cardiac surgery. An evaluation of cardiac hemodynamics and a review of major organ systems are included. Essential assessment information and interventional strategies for managing the pediatric postoperative cardiac surgery patient are detailed.     

Aortico-left ventricular tunnel: diagnosis based on two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging

Aortico-left ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. In previously reported cases, the diagnosis has often been missed initially despite use of cardiac catheterization and angiography. We describe a patient who underwent successful surgical correction of this malformation at 10 months of age after the diagnosis had been established by use of two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging. Aortico-left ventricular tunnel can be diagnosed by use of these noninvasive means without cardiac catheterization.     

Bloodless cardiac surgery and the pediatric patient: a case study

Peri-operative transfusion of blood or blood products is associated with increased morbidity and mortality after cardiac surgery. However, excessive hemodilution as a result of avoiding the use of homologous blood products can also lead to decreased oxygen delivery to vital end organs and dilutional coagulopathy. This is particularly challenging in pediatric cardiac surgery where there is a large discrepancy between the patient circulating blood volume and the priming volume of the cardiopulmonary bypass (CPB) circuit. Strategies to avoid the use of homologous blood products during pediatric cardiac surgery must also incorporate miniaturization of the CPB circuit and other bypass techniques in order to avoid problems with excessive hemodilution. We report a 5.9 kg male infant who underwent successful surgical correction of a ventricular septal defect without the use of homologous blood transfusion. Our strategies included the pre-operative administration of erythropoietin and iron to increase red blood cell mass, acute normovolemic hemodilution (ANH) before the institution of CPB, retrograde autologous priming (RAP), cell salvage, continuous ultrafiltration, vacuum-assisted venous drainage to minimize the circuit size and priming volume, and the use of near infrared spectroscopy (NIRS) to monitor the patient during the entire procedure. The utilization of these strategies is now standard for our entire pediatric cardiac surgical population.     

Streptokinase use in children undergoing cardiac catheterization

The development of cardiac catheterization procedures in the pediatric population has evolved from diagnostic in nature to present day advanced technology and interventions. A complication of vessel occlusion secondary to large catheters, length of procedures, and patient size requires immediate intervention. The advent of thrombolytic agents has provided a highly effective mode of treatment in restoring circulation. The use of streptokinase, its efficacy, side effects, and nursing management are discussed.     

Magnetic resonance imaging is the diagnostic tool of choice in the preoperative evaluation of patients with partial anomalous pulmonary venous return

Background Diagnosis of partial anomalous pulmonary venous return is usually suspected by echocardiography and often confirmed by cardiac catheterization. Magnetic resonance imaging is a powerful non-invasive diagnostic tool that can give accurate insight on systemic and pulmonary veins, cardiac anatomy and physiopathology.Aim To test the diagnostic accuracy of magnetic resonance in patient with suspected partial anomalous pulmonary venous return.Case presentation Twenty consecutive patients (10 male, mean age: 27±20 years) with suspected partial anomalous pulmonary venous return underwent a magnetic resonance study comprehensive of Gadolinium-enhanced three-dimensional magnetic resonance angiography and phase-velocity-contrast in order to evaluate pulmonary and systemic venous anatomy and QP/QS. In 14 of them a cardiac catheterization was also performed. Anatomy findings and QP/QS result of both exams were compared. Sixteen patients underwent surgical correction. In the other four patients with QP/QS<1.5, surgical correction was not indicated according to the literature (1).Among patient which performed both magnetic resonance and cardiac catheterization (14 patients) anatomy findings were concordant in 12 of them. In all operated patients, surgical findings were concordant with MRI report. There was a good correlation between magnetic resonance and cardiac catheterization QP/QS evaluation (mean value 2.23 and 2.4, respectively).Conclusion In patients with suspected anomalous pulmonary venous return, magnetic resonance provides a comprehensive evaluation of pulmonary venous return and the amount of shunt, overcoming most of the limitations of echocardiography. Therefore magnetic resonance is a powerful diagnostic tool for indicating therapeutic management and surgical strategies for this group of patients, and can be considered a non-invasive alternative to cardiac catheterization.     

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.     

Interventions in pediatric cardiac catheterization

Since its inception in 1929, cardiac catheterization has undergone many changes. In the last two decades we have seen an evolution in cardiac catheterization from a diagnostic (anatomic and physiologic) to a therapeutic modality. This article highlights some of the more common and newer interventional procedures now performed.     

Perioperative Schmerztherapie bei abdominellen und thorakalen Operationen

Abdominal and thoracic surgical procedures can result in significant acute postoperative pain. Present evidence shows that postoperative pain management remains inadequate especially after “minor” surgical procedures. Various therapeutic options including regional anesthesia techniques and systemic pharmacotherapy are available for effective treatment of postoperative pain. This work summarizes the pathophysiological background of postoperative pain after abdominal and thoracic surgery and discusses the indication, effectiveness, risks, and benefits of the different therapeutic options. Special focus is given to the controversial debate about the indication for epidural analgesia, as well as various alternative therapeutic options, including transversus abdominis plane (TAP) block, paravertebral block (PVB), wound infiltration with local anesthetics, and intravenous lidocaine. In additional, indications and contraindications of nonopioid analgesics after abdominal and thoracic surgery are discussed and recommendations based on scientific evidence and individual risk and benefit analysis are made. All therapeutic options discussed are eligible for clinical use and may contribute to improve postoperative pain outcome after abdominal and thoracic surgical procedures.     

Minimally invasive surgery

During the last 10 years, minimally invasive surgery has influenced the techniques used in every specialty of surgical medicine. This development has not only led to the replacement of conventional procedures with minimally invasive ones, but has also stimulated surgeons to reevaluate conventional approaches with regard to perioperative parameters such as pain medication. However, two major drawbacks have emerged with the introduction of this new technique: firstly, the prolonged learning curve for most surgeons, in comparison with the learning process in open surgery; and secondly, increased costs due to investment in the equipment required and the use of disposable instruments, as well as longer operating times. In the various health-care systems around the world, these increased costs are not always compensated for by shorter hospital stays. This review focuses on major areas of indication for minimally invasive surgery in the gastrointestinal tract. These include functional disorders of the upper and lower gastrointestinal tract, obesity surgery, minimally invasive techniques in gastric and hepatobiliary surgery and in other solid organs, and laparoscopic colorectal surgery. The shortening of the hospitalization period has led to increasing use of outpatient laparoscopic surgery, and many centers specializing in day-care surgery are using these techniques. The frontiers are being pushed even further, as the size of the instruments is reduced to achieve better cosmetic results. Clinical research has also focused on the topic of expanding the indications for minimally invasive approaches in the elderly and in high-risk patients, to take advantage of the shorter hospital stays and reduced surgical trauma that are possible. A considerable amount of basic research has been carried out on the stress response during and after minimally invasive procedures, and an improved immune response with the minimally invasive approach has been observed, leading to better results after extensive oncological procedures. Robotic surgery and telesurgery involve new computer-aided methods that allow greater precision in surgical technique, as well as offering an opportunity to supply surgical skill and expertise remotely, over long distances. Minimally invasive surgical techniques are thus now fully established in routine use, and the indications are continuing to expand.     

Contemporary management of pulmonary and systemic circulations after the Norwood procedure

Hypoplastic left heart syndrome remains one of the most challenging pathologies in pediatric cardiac surgery. The surgical techniques, and anesthetic and intensive care management, have evolved over the last decades, which has resulted in improved outcomes. A central component in the postoperative management of hypoplastic left heart syndrome patients is to achieve an optimal balance between the pulmonary and systemic circulations. This article discusses the contemporary postoperative management of pulmonary and systemic circulations in detail.     

Contemporary management of pulmonary and systemic circulations after the Norwood procedure

Hypoplastic left heart syndrome remains one of the most challenging pathologies in pediatric cardiac surgery. The surgical techniques, and anesthetic and intensive care management, have evolved over the last decades, which has resulted in improved outcomes. A central component in the postoperative management of hypoplastic left heart syndrome patients is to achieve an optimal balance between the pulmonary and systemic circulations. This article discusses the contemporary postoperative management of pulmonary and systemic circulations in detail.     

Autotransfusion systems (ATS)

Due to the large number of patients undergoing cardiac surgical procedures and the subsequent increase in demand for blood volume replacement, the use of autotransfusion is increasing in the postoperative setting. In a study conducted by Roche and Stengel it was estimated that the country's blood resources could be depleted by these surgical procedures. The use of autotransfusion offers a viable solution for this problem. Studies suggest that with autotransfusion, bank blood requirements may decrease as much as 50 percent. The ready availability and economic advantages associated with autotransfusion may also ensure continued use of systems of this type. It has been the authors' experience thus far that both systems presented have been safe and effective when used in postoperative management of the cardiac surgical patient.     

Trends in cardiac surgery: exploring the past and looking into the future

Today's successes would not be possible without the foundation of yesterday's practitioners and patients. This article assists in the exploration of cardiac surgery procedures, provides a brief historical review of the significant changes in cardiothoracic surgery, and provides an overview of current and future methods of treatment for coronary revascularization and heart failure. It is difficult for one article to encompass all aspects of cardiothoracic surgery. This article highlights many of the transforming moments that have led us to where we are today and explores the current trends of cardiac surgery and possibilities for tomorrow.     

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery [111]. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.     

Surgical reduction of fat surplus leading to pulmonary embolism

Surgical reduction of fat surplus is usually performed on healthy individuals and is reported as a safe procedure as it is not associated with a lethal outcome. Due to the anticipation of peri- and postoperative bleeding as a result of the large wound area, which may have a negative influence on the cosmetic result, patients often receive no or only inadequate anticoagulation. We report three cases in which surgical reduction of fat surplus led to sudden collapse and cardiac arrest. In all of our patients, fatal pulmonary embolism was the cause of cardiac arrest. These patients received only inadequate or no anticoagulation. Early postoperative mobilization, elastic stockings and compressive wound-dressing did not prevent pulmonary embolism. In addition to early postoperative mobilization of the patient and even though there is a risk of perioperative bleeding complications, the use of anticoagulation is highly recommended in surgical procedures like abdominoplasty or dermolipectomy. If sudden dyspnea, chest pain, collapse or cardiac arrest occurs after surgical interventions like these, pulmonary embolism should be considered and further diagnostic steps should be initiated.     

Care of children who have had surgery for congenital heart disease

Children who have had surgical correction for congenital heart disease can present to the ED with an acute illness that could be associated with their cardiac lesion. There is no data available to summarize complications that could be associated with surgically corrected congenital heart disease. This work was undertaken to describe the common procedures used, list known complications of these procedures, and review general management principles in caring for the acutely ill child who has had heart surgery.     

Therapeutic cardiac catheterization for congenital heart disease--a new era in pediatric care

In recent years, enormous technological advances have occurred that allow intervention for many congenital heart defects in the pediatric cardiac catheterization laboratory. Therapeutic catheterization procedures, including valvuloplasty, angioplasty, stent implantation, coil embolization, and device occlusion, are employed to treat heart defects in infants and children. This report describes these interventional procedures, outcomes, potential complications, and implications for nursing care.