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ABSTRACT: This report describes three neonates who were supported with extracorporeal membrane oxygenation before surgical correction of total anomalous pulmonary venous connection. Extracorporeal membrane oxygenation was initially used to treat preoperative end-organ failure and suspected persistent pulmonary hypertension. All patients underwent surgical correction of total anomalous pulmonary venous connection after 8, 4 and 4 days of preoperative support, respectively. Two of these patients required extracorporeal membrane oxygenation after surgery; one died from bleeding while the other was weaned from extracorporeal membrane oxygenation on day 8 and discharged from the hospital. These results show that veno-arterial extracorporeal membrane oxygenation represents a life-saving perioperative means for supporting moribund neonates with total anomalous pulmonary venous connection and is effective in improving preoperative patient's condition.
Cardiovascular Surgery 07/1999; 7(4):473-5.
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ABSTRACT: Acute decompensation leading to progressive pump failure is a main cause of death in patients with congestive heart failure. To find possible metabolic defects associated with the onset of this fatal occurrence, we measured myocardial adenine nucleotides, glycogen, and Na,K-ATPase in patients with end-stage idiopathic dilated cardiomyopathy. The biopsy specimens were obtained from the right ventricle of beating hearts during implantation of a biventricular assistance device in 23 patients (group I) suffering from irreversible cardiogenic shock and during heart transplantation in 20 patients (group II) in compensated heart failure. Left ventricular ejection fraction (LVEF) was determined preoperatively by echocardiography. Left ventricular function in group I was more severely impaired than in group II (LVEF 16.8%+/-4.6% vs 22.1%+/-5.1 %; p <0.01). Myocardial adenosine triphosphate (ATP) in group I was significantly reduced in comparison with group II (119.4+/-10.2 vs 27.7+/-7.4 nmol/mg noncollagen protein; p <0.01). There was no difference in glycogen levels. Na,K-ATPase concentration in group I (n = 8) was lower than that of group II (n = 20) (425+/-80 vs 498+/-75 pmol/g wet weight; p <0.05). Linear regression analyses showed a significant correlation between adenosine triphosphate (ATP) and LVEF (r = 0.41, p <0.01) and between Na,K-ATPase and LVEF (r = 0.55, p <0.01). These results indicate that loss of myocardial ATP and Na,K-ATPase could partially contribute to the development of spontaneous deterioration of the chronically overloaded heart.
The American Journal of Cardiology 03/1999; 83(3):396-9. · 3.37 Impact Factor
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ABSTRACT: The feasibility and efficacy of the pneumatic 'Berlin Heart' ventricular assist device (VAD) were evaluated in 14 pediatric patients with profound cardiogenic shock refractory to conventional therapy.
There were two patient groups. Eleven patients, aged 2 weeks 15 years and weighing 3.2-52 kg received a left ventricular assist device or a biventricular assist device as a bridge to cardiac transplantation (bridge group). Nine of them had liver, kidney, or lung dysfunction before device implantation. Three patients were supported with a biventricular assist device for myocardial recovery (recovery group): a 6-month-old girl for postcardiotomy shock, a 10-month-old girl for allograft failure after cardiac transplantation, and a 4-year-old boy with acute myocarditis.
In the bridge group, eight patients were transplanted after a bridge duration of 6-98 days (mean, 32 days) with five long-term survivors. Organ functions were normalized during bridging in all of the transplant recipients. In the recovery group, the first patient was removed from support after 2 days because of irreversible brain damage. The second patient was weaned from biventricular support after 8 days, but suffered from recurrent allograft failure. The third patient received biventricular support for 21 days followed by extracorporeal membrane oxygenation and was subsequently discharged from the hospital.
The 'Berlin Heart' VAD can keep selected infants and children with life-threatening heart failure for weeks or months.
European Journal of Cardio-Thoracic Surgery 06/1997; 11(5):965-72. · 2.55 Impact Factor
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ABSTRACT: A 7-day-old boy who had been placed on extracorporeal membrane oxygenation on his second day of life developed biventricular failure after undergoing surgical repair of a supracardiac variant of total anomalous pulmonary venous connection. Extracorporeal membrane oxygenation was again necessary for postoperative cardiopulmonary support. However, severe left ventricular failure made it imperative to leave the vertical vein open during support in order to decrease pressure on the left ventricle. The patient was successfully weaned from extracorporeal membrane oxygenation on day 8 after surgery and discharged from the hospital on day 23.
European Journal of Cardio-Thoracic Surgery 04/1997; 11(3):585-7. · 2.55 Impact Factor
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ABSTRACT: Controversy continues to surround determining which is the most beneficial method of complete atrioventricular septal defect repair, eg, one- versus two-patch repair, closure of mitral cleft, and the necessity of annuloplasty.
Between January 1988 and November 1995, 120 patients with complete atrioventricular septal defect underwent total correction at the German Heart Institute Berlin. Sixty-nine of the patients were infants and 51 were children or adolescents. Eleven patients had previously undergone pulmonary artery banding. One hundred three patients had Down's syndrome. In all 120 patients complete atrioventricular septal defect repair was performed using the two-patch technique. The mitral cleft was closed with interrupted sutures in 119 cases.
Thirty-four patients required aggressive treatment of postoperative pulmonary hypertensive crises (including nitric oxide inhalation). There were 12 hospital deaths (10%). Mortality was highest in patients with persistently high postoperative pulmonary arterial pressure (pulmonary artery pressure/systemic artery pressure > 0.6) (7 of 17 patients died; 41%). Associated atrioventricular valve anomalies, especially dysplastic valve tissue and severe preoperative cardiopulmonary instability necessitating catecholamine support and artificial ventilation, represented other risk factors. There were six late deaths (5%); cumulative mortality was 15%. Four patients suffered a complete heart block and sick sinus node syndrome necessitating pacemaker implantation 1 to 6 months after operation. During the follow-up period (3 to 80 months after operation), 7 patients (6.8% of survivors) were successfully reoperated on after significant mitral valve incompetence due to an open "cleft" (suture failure) developed.
Correcting complete atrioventricular septal defect using the two-patch technique, routine cleft closure, and atrial septal incision led to a low incidence of residual mitral valve incompetence. Mortality was primarily influenced by severe cardiopulmonary instability and additional atrioventricular valve anomalies preoperatively and the persistence of high pulmonary arterial hypertension postoperatively.
The Annals of Thoracic Surgery 09/1996; 62(2):519-24; discussion 524-5. · 3.74 Impact Factor
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ABSTRACT: The feasibility and efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation was examined in 6 pediatric patients who suffered irreversible myocardial failure after undergoing surgery for congenital heart defects. The mean time of ECMO support was 260.5 h, range 101-402 h. Three patients underwent transplantation, 2 of whom are long-term survivors. Progressive hypotension as a result of capillary leak syndrome precluded further ECMO support in the other 3 patients. Overall, 2 of the 6 patients survived. Major complications were encountered in 4 patients including bleeding in 2, a seizure in 1, and renal failure in 3, 2 of whom recovered renal function after transplantation. Infection did not occur in any of the 6 patients. Exchanging ECMO components was performed with no difficulties; these exchanges included a centrifugal pump once for 3 patients and a membrane oxygenator once for 2 patients. Our results indicate that ECMO can safely keep critically ill pediatric transplant candidates alive for more than 1 week with a low incidence of multiple organ failure.
Artificial Organs 07/1996; 20(6):728-32. · 2.00 Impact Factor
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ABSTRACT: Since recent results have suggested that the relative neuroendocrine response to physical activity is exaggerated following cardiac transplantation, we studied the haemodynamic-neuroendocrine responses to mental stress, and to physical exercise, in heart transplant recipients free of antihypertensive medication. Ten patients were studied 1.7 years (mean) after transplantation and compared with 10 age-matched controls. Plasma levels of catecholamines, renin activity, aldosterone, atrial natriuretic factor, calcitonin gene-related peptide (CGRP), and endothelin were measured, together with blood pressure and heart rate, during mental stress and graded, submaximal ergometry. Mental stress increased blood pressure in both groups (P < 0.02), but heart rate in controls only (P < 0.05). Noradrenaline did not change. Adrenaline rose in controls only (P < 0.05). Plasma renin activity increased in both groups (P < 0.02), while aldosterone increased in controls only P < 0.02). Atrial natriuretic factor, and endothelin were higher in patients (P < 0.01). Mental stress, however, did not induce any changes. No significant differences were found in relative changes (delta %), except for plasma renin activity which was greater in controls (P < 0.05). During ergometry, only delta % noradrenaline was greater in patients (P < 0.05). delta % for all other parameters were either of the same order as in controls, or blunted. Thus, apart from noradrenaline, cardiac transplant recipients, not receiving antihypertensive medication, do not show an exaggeration in the relative neuroendocrine response to mental or physical stress.
European Heart Journal 07/1995; 16(6):852-8. · 10.48 Impact Factor
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ABSTRACT: Studies indicate that centrally mediated rhythms in sympathetic tone play a prominent role in diurnal cardiovascular variability. Recent evidence from heart transplant recipients, in whom blood pressure does not decline during sleep despite normal variability in plasma norepinephrine, however, suggests that afferent cardiac nervous traffic is necessary for the generation of diurnal variability. This implies that in the presence of an innervated heart excluded from the systemic circulation, blood pressure would still decrease during sleep. To assess this hypothesis, we studied 24-hour blood pressure, heart rate, and neuroendocrine variability in patients with biventricular assist devices in whom the retained native hearts had ceased to pump.
Eight patients were free of medication and were studied every 3 hours. Pump rates and output were kept constant throughout the study. Blood pressure showed a significant decline during sleep, as did norepinephrine and epinephrine (all P < .05). Atrial natriuretic factor showed a significant increase around midnight (P < .01). Significantly elevated levels were found for all hormones studied except for aldosterone and endothelin.
Our results suggest that diurnal variations in cardiac function or in catecholamine levels (indicative of sympathetic activity) as found in cardiac transplant recipients alone are not responsible or sufficient for producing a nocturnal drop in blood pressure. The presence of an innervated heart appears crucial in this respect. This could be of importance for the understanding of circadian cardiovascular pathophysiology.
Circulation 07/1994; 89(6):2601-4. · 14.74 Impact Factor
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ABSTRACT: The development of severe heart failure is the main cause of postoperative mortality after the surgical treatment of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Two patients with ALCAPA who developed low cardiac output and could not be weaned from cardiopulmonary bypass (CPB) after aortic reimplantation of the anomalous left coronary artery were successfully treated with a centrifugal left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO). The circulation of a 10-month-old infant with severe left ventricular dysfunction was supported 192 h postoperatively with a LVAD and a 9-year-old boy with severe right ventricular failure received ECMO support for 99 h following surgery. Both patients survived and, 4 and 9 months after surgery, are asymptomatic and have normal ventricular function. If CPB (up to 3 h) is not effective in improving ventricular function after surgery for ALCAPA, ECMO or LVAD must be used since myocardial recovery in these patients can occur only after prolonged extracorporeal circulatory support.
European Journal of Cardio-Thoracic Surgery 02/1994; 8(10):533-6. · 2.55 Impact Factor
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ABSTRACT: The development of severe heart failure is the main cause of postoperative mortality after the surgical treatment of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Two patients with ALCAPA who developed low cardiac output and could not be weaned from cardiopulmonary bypass (CPB) after aortic reimplantation of the the anomalous left coronary artery were successfully treated with a centrifugal left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO). The circulation of a 10-month-old infant with severe left ventricular dysfunction was supported 192 h postoperatively with a LVAD and a 9-year-old boy with severe right ventricular failure received ECMO support for 99 h following surgery. Both patients survived and, 4 and 9 months after surgery, are asymptomatic and have normal ventricular function. If CPB (up to 3 h) is not effective in improving ventricular function after surgery for ALCAPA, ECMO or LVAD must be used since myocardial recovery in these patients can occur only after prolonged extracorporeal circulatory support.
European Journal of Cardio-Thoracic Surgery.
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ABSTRACT: Eleven infants weighing 2.3 to 7.8 kg underwent mechanical circulatory support for post cardiotomy cardiogenic shock. Initiated pre-operatively in two patients, extracorporeal membrane oxygenation was used in a total of eight patients aged 6 days to 3 months in association with repair of cyanotic congenital heart disease with increased pulmonary blood flow or with a right sided obstructive lesion. Ventricular assist devices were used in three other patients: a centrifugal left ventricular assist device in Patient 1 (10 months, 5.7 kg) after repair of the anomalous left coronary artery, and a pneumatic biventricular assist device (stroke volume 12 ml) in Patient 2 (6 months, 7.0 kg) for cardiac arrest after closure of ventricular septal defect and in Patient 3 (10 months, 7.8 kg) for post transplant graft failure. Duration of extracorporeal membrane oxygenation duration ranged from 26 to 192 hr (mean, 88 hr). Three patients were weaned from extracorporeal membrane oxygenation and two survived. Two others were separated from extracorporeal membrane oxygenation because of bleeding, but both subsequently died. Patient 1 was weaned from the left ventricular assist device after 192 hr and discharged from the hospital. Support was discontinued after 45 hr in Patient 2 who exhibited irreversible brain damage. Patient 3 was weaned from a biventricular assist device after 174 hr, but suffered recurrent graft failure. Our results show that an appropriate circulatory support system should be selected according to the cardiac anatomy in infants.
ASAIO Journal 42(5):M735-8. · 1.39 Impact Factor
