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ABSTRACT: OBJECTIVES: Single ventricle with apicocaval juxtaposition (ACJ) is a rare, complex anomaly, in which the optimal position of the conduit for completion of total cavopulmonary connection (TCPC) is still controversial. The purpose of this study was to identify a preoperative method for optimal conduit position using the IVC anatomy and computational fluid dynamics (CFD). METHODS: Twenty-four patients with ACJ (5.3 ± 5.7 years) who underwent TCPC were enrolled. A conduit was placed ipsilateral to the cardiac apex in each of 11 patients, of which 9 were intra-atrial and 2 extracardiac (group A) and, in a further 13 patients, extracardiac on the contralateral side (group B). As control, 10 patients with tricuspid atresia were also enrolled (group C). The location of the IVC in relation to the spine was evaluated from the frontal view of preoperative angiogram, using the following index: IVC-index = IVC width overlapping the vertebra/width of the vertebra × 100%. Energy loss was calculated by CFD simulation. RESULTS: IVC-index of group B was larger than groups A and C (45 ± 26 vs. 20 ± 21 and 28 ± 19%, P = 0.03). Postoperative catheterizations showed that, due to its curvature, conduit length in group B was significantly longer than the others (65 ± 12 vs. 36 ± 14 and 44 ± 10 mm, P < 0.001), although there was no statistical difference in central venous pressure or cardiac output. CFD studies revealed less energy loss in group A conduits compared with group B (1.6 ± 0.3 vs. 3.6 ± 0.6 mW, P = 0.05), although this did not appear to be clinically significant. Moreover, CFD simulation showed significant energy loss within the Fontan circulation when the conduit was either compressed or kinked: 4.9 and 18.2 mW respectively. CONCLUSIONS: In patients with ACJ, placement of a straighter and shorter conduit on the ventricular apical side provides better laminar blood flow with less energy loss. However, conduit compression and kinking are far more detrimental to the Fontan circulation. A preoperative IVC-index is pivotal for avoiding these factors and deciding the optimal conduit route.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2013; · 2.40 Impact Factor
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ABSTRACT: OBJECTIVES: In children with cardiac disease, common indications for extracorporeal membrane oxygenation (ECMO) include refractory cardiopulmonary resuscitation (E-CPR), failure to separate from cardiopulmonary bypass (OR-ECMO), and low cardiac output syndrome (LCOS-ECMO). Despite established acceptance, ECMO outcomes are suboptimal with a survival between 38% and 55%. We evaluated factors associated with significantly increased survival in cardiac patients requiring ECMO. METHODS: We conducted a retrospective investigation of consecutive patients undergoing ECMO between 2006 and 2010. Demographic, pre-ECMO, ECMO, and post-ECMO parameters were analyzed. Neurologic outcomes were assessed with the pediatric overall performance category scale at the latest follow-up. RESULTS: There were 3524 admissions, 95 (3%) of which necessitated ECMO; 40 (42%) E-CPR, 31 (33%) OR-ECMO, and 24 (25%) LCOS-ECMO. The overall hospital survival was 73%. The within-groups hospital survival was 75% in E-CPR, 77% OR-ECMO and 62% LCOS-ECMO. In the multivariable logistic regression analysis, chromosomal anomalies (odds ratio [OR], 8; 95% confidence interval [CI], 2-35), single ventricle (OR ,6; 95% CI, 3-33), multiple ECMO runs (OR, 15; 95% CI, 4-42), higher 24-hour ECMO flows (OR, 8; 95% CI, 4-22), decreased lung compliance (OR, 5; 95% CI, 2-16), and need for plasma exchange (OR, 5; 95% CI, 3-18) were all significant factors associated with mortality. From the univariate analysis, a common parameter associated with mortality within all groups was intracranial hemorrhage. At 1.9 years (0.9, 2.9) of follow-up, 66% were still alive, and 89% of survivors had normal function or only mild neurodevelopmental disability. CONCLUSIONS: ECMO was successfully used in children with cardiac disease with 73% and 66% short- and intermediate-term survival, respectively. The majority of the survivors had normal function or only a minimal neurodevelopmental deficit.
The Journal of thoracic and cardiovascular surgery 12/2012; · 3.41 Impact Factor
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ABSTRACT: Objectives. The current drug of choice for reentrant supraventricular tachycardia (SVT) is adenosine followed by verapamil or diltiazem. Although limitations and significant adverse events have been encountered over the years, an alternative effective and safe agent has not been available. Dexmedetomidine has recently been shown to have potential antiarrhythmic effects, and here we describe our experience in the acute termination of reentrant SVT. Design. Retrospective case series. Setting: Quaternary University Children's Hospital, Cardiac Intensive Care Unit. Patients: Patients who received dexmedetomidine for SVT in the past 5 years. Interventions: None. Outcome Measures: SVT episodes terminated with dexmedetomidine were compared with episodes terminated with adenosine. Results. Fifteen patients, median age of 10 days (6-16), were given 27 doses of dexmedetomidine, mean dose 0.7 ± 0.3 mcg/kg, for a total of 27 episodes of SVT. Successful termination occurred in 26 episodes (96%) at a median time of 30 seconds (20-35). Duration of sinus pause was 0.6 ± 0.2 seconds, there was one episode of hypotension and no bradycardia and sedation lasted for 34 ± 8 minutes. Five patients received 27 doses of adenosine, with an overall successful cardioversion in 17 patients (63%) (P= .0017). Transient bradycardia and hypotension was seen in three patients (11%), agitation in 16 patients (59%), and broncospasm in one patient. Median sinus pause was 2.5 seconds (2-9) (P < .001). Conclusions. Dexmedetomidine appears to have novel antiarrhythmic properties for the acute termination of reentrant SVT. Although adenosine is very effective, dexmedetomidine may prove to possess a more favorable therapeutic profile with increased effectiveness and fewer side effects.
Congenital Heart Disease 05/2012; · 0.90 Impact Factor
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ABSTRACT: Objective. Infants with critical congenital heart disease (CHD) can have genetic and other extracardiac malformations, which add to the short- and long-term risk of morbidity and perhaps mortality. We sought to examine our center's practice of screening for extracardiac anomalies and to determine the yield of these tests among specific cardiac diagnostic categories. Design. Retrospective review of infants admitted to the cardiac intensive care unit with a new diagnosis of CHD. Subjects were categorized into six groups: septal defects (SD), conotruncal defects (CTD), single-ventricle physiology (SV), left-sided obstructive lesions (LSO), right-sided obstructive lesions (RSO), and "other" (anomalous pulmonary venous return, Ebstein's anomaly). Screening modalities included genetic testing (karyotype and fluorescent in situ hybridization for 22q11.2 deletion), renal ultrasound (RUS), and head ultrasound (HUS). Results. One hundred forty-one patients were identified. The incidence of cardiac anomalies was: CTD (36%), SD (18%), SV (18%), LSO (14%), RSO (3%), and "other" (8%). Overall 14% had an abnormal karyotype, 5% had a deletion for 22q11.2, 28% had an abnormal RUS and 22% had abnormal HUS. Patients in SD and SV had the highest incidence of abnormal karyotype (36% and 17%); 22q11.2 deletion was present only in CTD and LSO groups (9% and 7%, respectively); abnormal RUS and HUS were seen relatively uniformly in all categories. Premature infants had significantly higher incidence of renal 43% vs. 24%, and intracranial abnormalities 46% vs. 16%. Conclusion. Infants with critical CHD and particularly premature infants have high incidence of genetic and other extracardiac anomalies. Universal screening for these abnormalities with ultrasonographic and genetic testing maybe warranted because early detection could impact short and long-term outcomes.
Congenital Heart Disease 11/2011; 7(2):145-50. · 0.90 Impact Factor
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ABSTRACT: Advancements in the preoperative management of patients with single-ventricle physiology continue to evolve. Previous reports have questioned the benefit of using inhaled nitrogen in single-ventricle patients, suggesting that this therapeutic modality may not provide adequate systemic cardiac output. The objective of this study was to review our institutional experience managing preoperative patients with single-ventricle physiology using a combination of afterload reduction and inhaled hypoxemic therapy.
This is a retrospective review of 49 consecutive single-ventricle patients admitted preoperatively between July 2004 and January 2009, to the cardiac intensive care unit at Children's Hospital of Pittsburgh who underwent single-ventricle palliation, and treated preoperatively with milrinone and inhaled nitrogen. Therapeutic interventions and indirect indicators of cardiac output were collected on day of admission (time 0) and compared with those collected on the morning of surgery (time 1); data included clinical assessment, hemodynamic measurements, and laboratory values.
When comparing time 0 to time 1, there was a statistically significant decrease in lactate (from 2.2 to 1.8 mEq/L [P < 0.001]) and an increase in pH (from 7.36 to 7.41 [P < 0.001]), serum bicarbonate (from 24.16 to 27.55 mmol/L [P < 0.001]) and arterial PaO2 (from 38.10 to 41.82 mm Hg [P = 0.027]). Preoperatively, there were no deaths, and only two patients had an evidence of multiorgan dysfunction on day of surgery (time 1).
Our results suggest that a combination of afterload reduction and hypoxemic therapy was able to maintain an appropriate distribution of the cardiac output in the majority of preoperative patients with single-ventricle physiology. An adequate balance of systemic and pulmonary blood flow was successfully achieved with an increase in arterial PaO2 values.
Congenital Heart Disease 11/2011; 7(2):96-102. · 0.90 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 10/2011; 25(5):836-7. · 1.06 Impact Factor
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Constantinos Chrysostomou,
Joan Sanchez-de-Toledo,
Peter Wearden,
Edmund H Jooste,
Steven E Lichtenstein,
Patrick M Callahan,
Tunga Suresh,
Elizabeth O'Malley,
Dana Shiderly,
Jamie Haney,
Masahiro Yoshida,
Richard Orr,
Ricardo Munoz,
Victor O Morell
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ABSTRACT: Postoperative tachyarrhythmias remain a common complication after congenital cardiac operations. Dexmedetomidine (DEX), an α-2 adrenoreceptor agonist, can have a therapeutic role in supraventricular tachyarrhythmias for cardioversion to sinus rhythm or heart rate control. Whether routine perioperative use of DEX decreases the incidence of supraventricular and ventricular tachyarrhythmias was studied.
In this prospective cohort study, 32 pediatric patients undergoing cardiothoracic operations received DEX and were compared with 20 control patients who did not receive DEX.
Dexmedetomidine was started after anesthesia induction and continued intraoperatively and postoperatively for 38±4 hours (mean dose, 0.76±0.04 μg/kg/h). Ten control patients and 2 DEX patients sustained 16 episodes of tachyarrhythmias (p=0.001), including a 25% vs 0% (p=0.01) incidence of ventricular tachycardia and 25% vs 6% (p=0.05) of supraventricular arrhythmias in the control and DEX group, respectively. Transient complete heart block occurred in 2 control patients and in 1 DEX patient. Control patients had a higher heart rate (141±5 vs 127±3 beats/min, p=0.03), more sinus tachycardia episodes (40% vs 6%; p=0.008), required more antihypertensive drugs with nitroprusside (20±7 vs 4±1 μg/kg; p=0.004) and nicardipine (13±5 vs 2±1 μg/kg; p=0.02), and required more fentanyl (39±8 vs 19±3 μg/kg; p=0.005).
Perioperative use of dexmedetomidine is associated with a significantly decreased incidence of ventricular and supraventricular tachyarrhythmias, without significant adverse effects.
The Annals of thoracic surgery 09/2011; 92(3):964-72; discussion 972. · 3.74 Impact Factor
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ABSTRACT: Kounis syndrome is coronary vasospasm because of mast cell degranulation in the context of an allergic reaction. The syndrome has known associations with several drugs used during anesthesia, including rocuronium and isoflurane. In this case report, we discuss a 2-year-old patient who developed signs and symptoms of an acute coronary syndrome soon after anesthesia for atrial septal defect repair. A diagnostic angiography after the episode revealed diffusely small coronary arteries. Subsequent angiography after clinical improvement showed essentially normal coronary anatomy. We report the clinical course of this patient and postulate that Kounis syndrome was the explanation for his transient coronary vasospasm. To date, this is the youngest known patient with reported Kounis syndrome.
Congenital Heart Disease 03/2011; 6(5):499-503. · 0.90 Impact Factor
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ABSTRACT: Abnormal diaphragmatic motion secondary to phrenic nerve injury is not uncommon after pediatric cardiothoracic surgery. Fluoroscopy is the most frequent method of diagnosis but it carries risks associated with transportation of critically ill children and exposure to ionizing radiation. Ultrasonography, a reliable diagnostic method in adults, eliminates both concerns. Since most cardiac intensivists are trained in echocardiography, we tested the hypothesis that chest ultrasound performed by a cardiac intensivist is faster than fluoroscopy, and is highly accurate in predicting fluoroscopy results, therefore serving as an equally useful diagnostic test.
Prospective study in consecutive pediatric patients with suspected abnormal diaphragmatic motion after cardiothoracic surgery. All patients underwent fluoroscopy and ultrasound study of the diaphragm. Ultrasound was performed by a pediatric cardiac intensivist and a trainee. Kappa statistic was calculated to assess concordance between both ultrasound readings. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated to assess accuracy of each ultrasound test in predicting fluoroscopy results.
Twenty-five patients with median age 3 months (12 days-11 years) and median weight of 3.8 kg (2.5-29 kg) were included. The ultrasound diagnosis of the cardiac intensivist was perfectly accurate (100% sensitivity, specificity, and PPV and NPV) in predicting fluoroscopy results. The ultrasound performed by the trainee achieved 85.7% sensitivity, 94.4% NPV, and 100% specificity relative to fluoroscopy. The interoperator reliability of chest ultrasound was 0.89 (95% confidence interval 0.69-1). Delay between clinical suspicion and the diagnostic tests was 15 minutes (5 minutes-2.5 hours) for ultrasound and 17 hours (60 minutes-82 hours) for fluoroscopy (P < 0.001).
Chest ultrasound performed by cardiac intensivists allows for an early and accurate diagnosis of abnormal diaphragmatic motion, as evidenced by their ability to predict fluoroscopy findings in pediatric cardiothoracic patients. Training in ultrasound-guided assessment of diaphragmatic motion should be reinforced during pediatric cardiac intensive care fellowship.
Congenital Heart Disease 11/2010; 5(6):565-72. · 0.90 Impact Factor
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Constantinos Chrysostomou
Pediatric Critical Care Medicine 09/2010; 11(5):646. · 3.13 Impact Factor
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Judith P Lazol,
Steven E Lichtenstein,
Edmund H Jooste,
Dana Shiderly,
Nivedit A Kudchadker,
Gregory H Tatum,
Richard A Orr,
Peter D Wearden,
Victor O Morell,
Ricardo A Munoz, Constantinos Chrysostomou
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ABSTRACT: To characterize the effects of dexmedetomidine on the pulmonary artery pressure in patients after congenital cardiac surgery.
Prospective observational pilot study.
Pediatric cardiac intensive care unit at a university hospital.
Twenty-two patients who received dexmedetomidine after cardiothoracic surgery.
None.
An echocardiogram was performed at three time points: 1) baseline (T0); 2) 6 mins after dexmedetomidine loading (T1); and 3) 1 hr after initiation of dexmedetomidine infusion (T2). Transthoracic echocardiography was used to estimate pulmonary artery pressure based on tricuspid regurgitant velocity (4 x Velocity2) plus central venous pressure. Twenty-two patients aged 0.9 yrs old (interquartile range, 7.9) were enrolled at a median of 1 hr (1.5) after surgery. Dexmedetomidine loading, 0.62 microg/kg (0.5), was given in all patients followed by 0.5 microg/kg/hr (0.6) at T1 and 0.65 microg/kg/hr (0.5) at T2. None of the patients had any increase in pulmonary artery pressure. Overall, the pulmonary artery pressure decreased from 30 mm Hg (13) at T0 to 24 mm Hg (10) at T1 and 26 mm Hg (8) at T2 (p < .001). The pulmonary artery pressure/systemic systolic blood pressure ratio decreased from 33% (12) at T0 to 23% (15) at T1 and 25% (13) at T2 (p = .002). There was no difference in the left ventricular function, Fio2, oxygen %, Po2, CO2, and vasoactive agents.
Administration of dexmedetomidine after congenital cardiac surgery was not associated with any increase in pulmonary artery pressure.
Pediatric Critical Care Medicine 09/2010; 11(5):589-92. · 3.13 Impact Factor
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Joan Sanchez de Toledo,
Sriya Gunawardena,
Ricardo Munoz,
Richard Orr,
Donald Berry,
Sara Sonderman,
Sara Krallman,
Dana Shiderly,
Li Wang,
Peter Wearden,
Victor O. Morell, Constantinos Chrysostomou
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ABSTRACT: Background Thromboembolic events are a serious complication occurring in critically ill children admitted to the cardiac intensive care unit. Although enoxaparin is one of the current anticoagulants of choice, dosages in children are extrapolated from adult guidelines. Recent data suggest that this population may need a higher dose than what is currently recommended to achieve target anti-factor Xa levels. The purpose of this study was to evaluate whether children less than 2 years old admitted to the cardiac intensive care unit require a higher enoxaparin dose than that currently recommended to achieve target anti-factor Xa levels.
Cardiology in the Young 03/2010; 20(02):138 - 143. · 0.76 Impact Factor
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Joan Sanchez de Toledo,
Sriya Gunawardena,
Ricardo Munoz,
Richard Orr,
Donald Berry,
Sara Sonderman,
Sara Krallman,
Dana Shiderly,
Li Wang,
Peter Wearden,
Victor O Morell, Constantinos Chrysostomou
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ABSTRACT: Thromboembolic events are a serious complication occurring in critically ill children admitted to the cardiac intensive care unit. Although enoxaparin is one of the current anticoagulants of choice, dosages in children are extrapolated from adult guidelines. Recent data suggest that this population may need a higher dose than what is currently recommended to achieve target anti-factor Xa levels. The purpose of this study was to evaluate whether children less than 2 years old admitted to the cardiac intensive care unit require a higher enoxaparin dose than that currently recommended to achieve target anti-factor Xa levels.
Retrospective chart review including patients who received enoxaparin for the treatment or prophylaxis of venous thrombosis between January, 2005 and October, 2007. Patients were classified as younger and older as well as prophylactic and therapeutic on the basis of age and enoxaparin dose, respectively. Younger patients were those 2 month old or less and older patients were those older than 2 months of age.
A total of 31 patients were identified; 13 (42%) were 2 months or younger and 25 (81%) were postoperative patients. Ten (32%) received prophylactic and 21 (68%) received therapeutic enoxaparin doses. To achieve optimal anti-factor Xa levels, enoxaparin dose was increased in all groups and reached statistical significance in all patients except those older than 2 months who received prophylactic enoxaparin. An average of 2.8 dosage adjustments was needed. No bleeding complications were reported.
Young children, infants, and neonates admitted to the cardiac intensive care unit required a significantly higher enoxaparin dose than that currently recommended to achieve target anti-factor Xa levels.
Cardiology in the Young 03/2010; 20(2):138-43. · 0.76 Impact Factor
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ABSTRACT: Assessment of electrocardiographic (ECG) effects of dexmedetomidine.
Prospective observational study including children 0-17 years of age with congenital heart disease (CHD) and children following cardiothoracic surgery. Patients who did not receive dexmedetomidine were used as a control group. All patients had two ECGs: one baseline, pre-dexmedetomidine (T1) and one during dexmedetomidine infusion (T2).
Fifty-one patients, median age of 0.5 years (IQR = 3.4), and 25 patients, age 0.25 (IQR = 2.9), were included in the dexmedetomidine and control groups, respectively. Forty received a dexmedetomidine-loading dose of 1 microg/kg (IQR = 0.5). At T2, the dexmedetomidine infusion was 1 microg/kg/h (IQR = 0.5). In the dexmedetomidine group, heart rate (HR) decreased from 140 +/- 22 to 115 +/- 23 (P < 0.001); PR, PRc and PR index changed from 115 +/- 28 to 122 +/- 29 ms (P = 0.01), 174 +/- 38 to 167 +/- 35 ms (P = 0.07) and 15,882 +/- 3,565 to 13,792 +/- 3,311 (P < 0.001), respectively. QRS decreased from 84 +/- 21 to 80 +/- 21 ms (P = 0.02), and QTc had no change (433 +/- 47 to 435 +/- 36 ms). When compared to the control group, none of the ECG intervals had any difference other than a trend towards lower HR (P = 0.08). Neonates and infants had a bigger drop in the HR compared to older children (P < 0.001), while other parameters were similar. At T2 none of the dexmedetomidine group patients had atrioventricular block or other arrhythmia. Four patients in the control group had accelerated junctional rhythm.
Use of dexmedetomidine in patients with CHD and patients following cardiothoracic surgery is not associated with any significant ECG interval abnormalities other than a trend towards lower HR.
European Journal of Intensive Care Medicine 03/2010; 36(5):836-42. · 5.17 Impact Factor
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ABSTRACT: Tetralogy of Fallot with absent pulmonary valve (TOFAPV) is a severe disease with an incidence of 0.2–0.4% among patients
with congenital heart defects and 3–6% among patients with TOF. Much less frequently, APV can also occur without the features
of TOF. In addition to the usual anatomic defects of TOF, i.e., anterior deviation of infundibular septum with right ventricular
outflow tract (RVOT) stenosis, malaligned ventricular septal defect (VSD), overriding aorta, and right ventricular hypertrophy,
patients with TOF-APV have rudimentary or absent pulmonary valve leaflets with free pulmonic insufficiency, minimally obstructed
RVOT and characteristic aneurysmal dilatation of the main and branch pulmonary arteries (Fig. 20.1). Associated anomalies include atrial septal defect and the absence of the ductus arteriosus.
12/2009: pages 207-211;
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ABSTRACT: Tetralogy of Fallot with Pulmonary Atresia (TOF-PA) accounts for 1.5–3.4% of all forms of congenital heart disease and for
20% of all forms of TOF [1]. The Baltimore Washington Infant study reported an incidence of 0.07 per 1,000 live births for
TOF-PA. TOF-PA is slightly more prevalent in males than in females. The intra-cardiac anatomy of TOF-PA has all the features
of classic Tetralogy of Fallot: ventricular septal defect, overriding of the aorta, right ventricular outflow obstruction,
and right ventricular hypertrophy. The difference is in the membranous or complete atresia of the pulmonary valve, and extreme
variability of the architecture of the main and distal pulmonary arteries [Fig. 21.1]. The central pulmonary arteries can be of good size, variably hypoplastic, discontinuous, or even absent. Blood flow to
the pulmonary vasculature may be provided by a persistent ductus arteriosus (PDA), major aorto-pulmonary collaterals (MAPCAs),
or both.
12/2009: pages 213-219;
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ABSTRACT: Tetralogy of Fallot (TOF) is a relatively common congenital heart defect occurring in approximately 15% of patients with congenital
heart disease. The four main anatomic features of TOF include right ventricular outflow tract (RVOT) obstruction [1, 2], ventricular
septal defect (VSD), aortic dextroposition overridding the VSD, and right ventricular hypertrophy (Fig. 19.1). Current teaching postulates that the basic pathology of TOF results from underdevelopment of the right ventricular infundibulum.
This underdevelopment causes an anterior malalignment of the infundibular septum which subsequently determines the degree
of RVOT obstruction. The VSD that results from this malalignment is almost always large, and thus unrestrictive, permitting
similar pressures between the right and left ventricles to occur. In addition to these features the pulmonary valve is frequently
hypoplastic and thickened and the level of obstruction may extend to the main pulmonary artery and right and left pulmonary
arteries.
12/2009: pages 199-206;
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ABSTRACT: Pulmonary atresia with intact ventricular septum (PAIVS) is a cyanotic congenital cardiac lesion with an incidence quoted
by various sources between 0.71 and 3.1% of all congenital heart disease. It is characterized by an imperforate pulmonary
valve with completely fused comissures, variable degrees of dysplasia and narrowing of the pulmonic valve, variable hypoplasia
of the right ventricle and tricuspid valve and a frequent association of coronary artery fistulae and sinusoids (Fig. 22.1).
The pulmonary arteries are usually normal in size and the pulmonary blood flow is supplied by a patent ductus arteriosus (PDA).
The right ventricular hypoplasia can be extensive and involve all three components, inlet, trabecular and infundibular parts
or be confined to one area. The left sided heart is usually normal, but in severe cases the ventricular septum is displaced
into the left ventricle and its cavity may be somewhat restricted. Occasionally, infants with PAIVS have shown signs of both
right and left ventricular ischemia, likely related to the coronary artery fistulae. Association with atretic, hypoplastic,
or obstructed central coronary arteries, called right ventricular-dependent coronary circulation (RVDCC) [1], carries a higher
risk of morbidity and mortality.
12/2009: pages 221-229;
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Ana M Manrique,
Margarita Arroyo,
Yan Lin,
Samar R El Khoudary,
Erin Colvin,
Steven Lichtenstein, Constantinos Chrysostomou,
Richard Orr,
Edmund Jooste,
Peter Davis,
Peter Wearden,
Victor Morell,
Ricardo Munoz
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ABSTRACT: We analyzed the role of magnesium sulfate (MgSO(4)) supplementation during cardiopulmonary bypass in pediatric patients undergoing cardiac surgery, assessing the incidence of hypomagnesemia and the incidence of junctional ectopic tachycardia.
We performed a randomized, double-blind, controlled trial in 99 children. MgSO(4) or placebo was administered during the rewarming phase of cardiopulmonary bypass: group 1, placebo group (29 patients); group 2, 25 mg/kg of MgSO(4) (30 patients); and group 3, 50 mg/kg of MgSO(4) (40 patients).
At the time of admission to the cardiac intensive care unit, groups receiving MgSO(4) had significantly greater levels of ionized magnesium (group 1, 0.51 + or - 0.07; group 2, 0.57 + or - 0.09; group 3, 0.59 + or - 0.09). Hypomagnesemia before bypass was common (75%-86.2%) and not significantly different among the groups. The proportion of hypomagnesemia decreased significantly at admission to the cardiac intensive care unit in groups receiving MgSO(4) (group 1, 77.8%; group 2, 63%; group 3, 47.4%). Patients receiving placebo (group 1) had a significantly greater occurrence of junctional ectopic tachycardia than groups receiving MgSO(4) (group 1, n = 5 [17.9%]; group 2, n = 2 [6.7%]; group 3, n = 0 [0%]). Age (<1 month), Aristotle score (>4), and history of cardiac failure were associated with junctional ectopic tachycardia. None of the patients with those characteristics in group 3 had junctional ectopic tachycardia. No association was found between study groups and the Pediatric Risk of Mortality score or length of stay in the cardiac intensive care unit.
Supplementation with MgSO(4) during cardiopulmonary bypass seems to reduce the incidence of hypomagnesemia and junctional ectopic tachycardia at admission to the cardiac intensive care unit. This effect seems to be dose related.
The Journal of thoracic and cardiovascular surgery 10/2009; 139(1):162-169.e2. · 3.41 Impact Factor
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ABSTRACT: To assess clinical response of dexmedetomidine alone or in combination with conventional sedatives/analgesics after cardiac surgery.
Retrospective study.
Pediatric cardiac intensive care unit.
Infants and neonates after cardiac surgery.
We identified 80 patients including 14 neonates, at mean age and weight of 4.1 +/- 3.1 months and 5.5 +/- 2 kg, respectively, who received dexmedetomidine for 25 +/- 13 hours at an average dose of 0.66 +/- 0.26 microgxkgxhr. Overall normal sleep to moderate sedation was documented 94% of the time and no pain to mild pain for 90%. Systolic blood pressure (SBP) decreased from 89 +/- 15 mm Hg to 85 +/- 11 mm Hg (p = .05), heart rate (HR) from 149 +/- 22 bpm to 129 +/- 16 bpm (p < .001), and respiratory rate (RR) remained unchanged. When baseline arterial blood gases were compared with the most abnormal values, pH decreased from 7.4 +/- 0.07 to 7.37 +/- 0.05 (p = .006), Po2 from 91 +/- 67 mm Hg to 66 +/- 29 mm Hg (p = .005), and CO2 increased from 45 +/- 8 mm Hg to 50 +/- 12 mm Hg (p = .001). At the beginning of the study, 37 patients (46%) were mechanically ventilated; and at 48 hours, 13 patients (16%) were still intubated and five patients failed extubation. Three groups of patients were identified: A, dexmedetomidine only (n = 20); B, dexmedetomidine with sedatives/analgesics (n = 38); and C, dexmedetomidine with both sedatives/analgesics and fentanyl infusion (n = 22). The doses of dexmedetomidine and rescue sedatives/analgesics were not significantly different among the three groups but duration of dexmedetomidine was longer in group C vs. A (p = .03) and C vs. B (p = .002). Pain, sedation, SBP, RR, and arterial blood gases were similar. HR was higher in group C vs. B (p = .01). Comparison between neonates and infants showed that infants required higher dexmedetomidine doses, 0.69 +/- 25 microgxkgxhr, and vs. 0.47 +/- 21 microgxkgxhr (p = .003) and had lower HR (p = .01), and RR (p = .009), and higher SBP (p < .001).
Dexmedetomidine use in infants and neonates after cardiac surgery was well tolerated in both intubated and nonintubated patients. It provides an adequate level of sedation/analgesia either alone or in combination with low-dose conventional agents.
Pediatric Critical Care Medicine 03/2009; 10(6):654-60. · 3.13 Impact Factor
