Combined perioperative ultrafiltration in pediatric cardiac surgery. The preliminary results

INTRODUCTION AND OBJECTIVES: Recently, ultrafiltration techniques are used more and more as a treatment for the inflammatory response of cardiopulmonary bypass. It also provides fine control of fluids. The purpose of this study is to present a technique which combines conventional and modified ultrafiltration and to analyze the obtained results. PATIENTS AND METHODS: 22 patients (mean weight 13.1 +/- 8.4 kg) operated on cardiopulmonary bypass. Combined ultrafiltration was performed during cardiopulmonary bypass (conventional) and after pump (modified ultrafiltration). We analyzed cardiopulmonary bypass variables, the first 24-hour hemodynamics, biological variables (arterial blood gases, cell counts, IL-6, adhesion molecules ICAM-1 and VCAM-1, and coagulation profiles). RESULTS: A total amount of 1,399 +/- 680 ml/m2 of mean combined ultrafiltrate volume was obtained (657 +/- 386 ml/m2 during cardiopulmonary bypass and 845 +/- 358 ml/m2 post-cardiopulmonary bypass). After modified ultrafiltration, hematocrit rose from 23 +/- 2.3 to 32 +/- 4.1, arterial systolic blood pressure rose from 74 +/- 13 to 98 +/- 20 mmHg, heart rate decreased from 133 +/- 22 to 126 +/- 23 bpm, and central versus pressure did not change. A statistically significant relationship (multivariable), was shown between modified ultrafiltration time and VCAM-1 post-ultrafiltration levels. Platelet count was lower and diuresis rose related to cardiopulmonary bypass ultrafiltration volume and diuresis increased. CONCLUSIONS: Perioperative combined ultrafiltration is feasible without undue morbidity and provides adequate hemoconcentration and excellent postoperative hemodynamic results. More studies with control groups are necessary to better define the therapeutic influence in antiinflammatory properties of this technique.     

Aorta-pulmonary artery shunts with expanded polytetrafluoroethylene (PTFE) tube.

Ten patients underwent an aortapulmonary artery shunt with a polytetrafluoroethylene (PTFE) tube between December, 1976, and October, 1977. Five of them were less than 1 month old. The diameter of the PTFE tube was 5 mm in 9 patients and 4 mm in 1 patient. Seven patients survived the operation. One of them had a clotted shunt, which was reoperated on successfully. Three patients died in the postoperative period, and all had a patent shunt. Overall patency was 90% (9/10). Congestive heart failure refractory to medical treatment developed in 1 patient with a patent Blalock-Taussig and PTFE shunt. In our institution, the Blalock-Taussig shunt is the procedure of choice. The PTFE shunt is used when the anatomy of a patient is unsuitable for a Blalock-Taussig shunt. A tube diameter of 5 mm is optimal for infants when further growth is considered, even if digitalization is necessary to control congestive heart failure.     

Sinus Venosus Atrial Septal Defect Associated with Partial Anomalous Pulmonary Venous Drainage: Surgical Repair

This report describes a new technique for the repair of sinus venosus atrial septal defect associated with partial anomalous pulmonary venous drainage. A right atrial wall flap is used both to deflect the anomalous venous blood into the left atrium and to close the atrial septal defect. Then an atrioplasty is performed. This method does not employ any foreign materials, avoids injury to the sinoatrial node and internodal tracts, and minimizes the risk of obstruction of the ostia of the anomalous pulmonary veins and superior vena cava.     

Left ventricular approach to multiple ventricular septal defects

Multiple muscular ventricular septal defects were closed through an apical left ventriculotomy in 11 patients. The patients were divided into two groups: Group 1, 8 patients who had transposition of the great arteries, and group 2, 3 patients without transposition. There were 4 deaths in Group 1 and non in Group 2. Two of the deaths were caused by a hypoplastic right ventricle, 1 by airway obstruction, and 1 by heart failure and pulmonary edema in a patient who had additional unrecognized muscular defects. An apical left ventriculotomy provides excellent exposure of the septum. The field is not obscured by trabecular bands or papillary muscles. Although 1 patient died because of residual VSDs, this approach, compared with previously described methods, minimizes the risk of unrecognized defects.     

Successful correction of a complete form of atrioventricular canal associated with tetralogy of Fallot: case report.

This is the third reported case of successful correction of a complete form of atrioventricular (AV) canal associated with tetralogy of Fallot. The surgical mortality rate from this combination is high, in part due to failure to recognize the associated anomaly and to completely close the ventricular septal defect. This successful correction was accomplished by giving the ventricular portion of the patch more width and by suturing it from both the atrium and ventricle. This patient reported herein is doing well 6 months after the operation.     

Perventricular pulmonary valvuloplasty under echocardiographic guidance

We report the case of a small neonate with a complex congenital heart disease who successfully underwent a perventricular pulmonary valvuloplasty during the early postoperative period, using echocardiographic guidance alone without fluoroscopy. We describe the technique and the advantages of this novel procedure.     

Toxicity of 2-methyl-4-chlorophenoxyacetic acid to the adult crested newt

The toxicity of the herbicide Agroxone 3, a commercial formulation of the sodium salt of 2-methyl-4-chlorophenoxyacetic acid (MCPA), in the adult newt (Triturus cristatus carnifex) was tested after percutaneous exposure. At the concentration of 3200 ppm, the LT50 values were 17 and 21 hr for male and female newts. At 1600 ppm, the LT50 values were 35 and 45.5 hr. At 800 ppm, most of the animals were still alive after the 3 months of experimentation. There were no deaths at 400 and 200 ppm. Severe neuromuscular disorders were observed in animals exposed to lethal concentrations.     

Reconstruction of the right ventricular outflow tract using a Medtronic Freestyle aortic root bioprosthesis

Uncorrected, long-term pulmonary regurgitation leads to right ventricular dilatation and dysfunction in a significant percentage of patients. We used magnetic resonance imaging (MRI) before and after surgery to assess the effect of pulmonary valve replacement with the Medtronic Freestyle bioprosthesis on right ventricular function and volume in nine patients with pulmonary regurgitation or stenosis. Mean follow-up time was 26 (10) months. We observed a decrease in mean end-diastolic volume from 143.6 (85.1) mL/m2 to 74.1 (12.6) mL/m2 (P=.018) and, in end-systolic volume from 88.0 (50.3) mL/m2 to 35.8 (19.3) mL/m2 (P=.016). In pulmonary valve disease, extensive follow-up by MRI is essential for timely evaluation of the degree of right ventricular dilation or dysfunction and for selecting a suitable time for valve replacement. The Medtronic Freestyle bioprosthesis is a good surgical choice for pulmonary valve replacement as its use is associated with low morbidity and mortality and the successful normalization of ventricular volumes.