Pediatric cardiac surgery without homologous blood transfusion, using a miniaturized bypass system in infants with lower body weight

ObjectiveWe have established a low–priming volume cardiopulmonary bypass system for pediatric heart surgery to avoid homologous blood transfusion. The priming volume of our system is down to 140 mL for patients weighing less than 7 kg. We can prime the bypass circuits without blood products for patients weighing more than 4 kg.MethodsSeventy consecutive patients weighing 4 to 7 kg underwent heart surgery with a bloodless prime from October 2003 to September 2006. The type of procedures (Risk Adjustment in Congenital Heart Surgery category) included the following: category 1: atrial septal defect (n = 3); category 2: ventricular septal defect, tetralogy of Fallot, bidirectional Glenn shunt, and others (n = 55); category 3: atrioventricular septal defect, double-outlet right ventricle, and others (n = 8); category 4: Rastelli procedure for transposition of the great arteries (n = 3); and category 6, Damus–Kaye–Stansel procedure (n = 1). Transfusion criteria were hematocrit less than 20%, mixed venous oxygen saturation less than 70%, regional cerebral oxygenation less than 50%, and plasma lactate level greater than 4.0 mmol/L during bypass.ResultsThe mean age and body weight were 7.3 ± 5.4 months and 5.4 ± 0.8 kg, respectively. Forty-five patients (64%) underwent transfusion-free procedures. Preoperative hematocrit, age, body weight, complexity of procedure and cardiopulmonary bypass time were compared between patients with and without transfusion. Bypass time and Risk Adjustment in Congenital Heart Surgery risk category in patients with transfusion were significantly greater than those in patients without (P < .0001, and P < .05, respectively). Body weight in patients without transfusion was significantly greater than that in patients with (P < .01). In multiple regression analysis, the determinants of blood transfusion were the bypass time and body weight (odds ratio 1.026, 95% confidence interval 1.011–.040, P < .0001, and odds ratio 0.366, 95% confidence interval 0.171–0.785, P < .01).ConclusionsIt is possible to do complex transfusion-free procedures safely for patients weighing more than 4 kg by using the low–priming volume circuit. The limiting factors of bloodless heart surgery are not preoperative hematocrit and complexity of procedure but the cardiopulmonary bypass time and the patient’s body weight

Use of the index of pulmonary vascular disease for predicting long-term outcome of pulmonary arterial hypertension associated with congenital heart disease

AimsLimited data exist on risk factors for the long-term outcome of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD-PAH). We focused on the index of pulmonary vascular disease (IPVD), an assessment system for pulmonary artery pathology specimens. The IPVD classifies pulmonary vascular lesions into four categories based on severity: (1) no intimal thickening, (2) cellular thickening of the intima, (3) fibrous thickening of the intima, and (4) destruction of the tunica media, with the overall grade expressed as an additive mean of these scores. This study aimed to investigate the relationship between IPVD and the long-term outcome of CHD-PAH.MethodsThis retrospective study examined lung pathology images of 764 patients with CHD-PAH aged &lt;20 years whose lung specimens were submitted to the Japanese Research Institute of Pulmonary Vasculature for pulmonary pathological review between 2001 and 2020. Clinical information was collected retrospectively by each attending physician. The primary endpoint was cardiovascular death.ResultsThe 5-year, 10-year, 15-year, and 20-year cardiovascular death-free survival rates for all patients were 92.0%, 90.4%, 87.3%, and 86.1%, respectively. The group with an IPVD of ≥2.0 had significantly poorer survival than the group with an IPVD &lt;2.0 (P = .037). The Cox proportional hazards model adjusted for the presence of congenital anomaly syndromes associated with pulmonary hypertension, and age at lung biopsy showed similar results (hazard ratio 4.46; 95% confidence interval: 1.45–13.73; P = .009).ConclusionsThe IPVD scoring system is useful for predicting the long-term outcome of CHD-PAH. For patients with an IPVD of ≥2.0, treatment strategies, including choosing palliative procedures such as pulmonary artery banding to restrict pulmonary blood flow and postponement of intracardiac repair, should be more carefully considered

Neutrophil-to-lymphocyte ratio is prognostic factor of prolonged pleural effusion after pediatric cardiac surgery

Objectives Postoperative pleural effusion (PE) is common after pediatric cardiac surgery, and if prolonged can lead to the deterioration of the general condition due to malnutrition and result in death. This study aims at identifying the prognostic factors of prolonged PE after pediatric cardiac surgery. Design and settings: Patients were divided into the effective (with chest tube removal within 10 days after medical therapy) and ineffective (with chest tube in place for more than 10 days) groups. The factors were compared between the two groups retrospectively. Participants Participants included patients who had prolonged PE after cardiac surgery in national center for child and health development between October 2014 and October 2017. Main outcome measures Baseline characteristics and procedure details were compared between the two groups to determine the predictor of prolonged PE. White blood cell count, platelet count, neutrophil-to-lymphocyte ratio, hemoglobin level, serum total protein level, serum albumin level, blood fibrinogen level, serum creatinine level, etc. were examined. Results Twenty patients were included. Between the two groups, no significant differences in baseline characteristics, such as age, weight, and sex were found, and significant differences were observed only in the NLR change ratio (effective group, 5.1 [4.1–8.0] versus ineffective group, 11.9 [9.9–14.1]; P = 0.01). Conclusions NLR change ratio is a potential prognostic factor of prolonged PE, including chylothorax, after pediatric cardiac surgery