Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis

BackgroundElevated pulmonary vascular resistance (PVR) is common following repair of truncus arteriosus. Inhaled nitric oxide (iNO) is an effective yet costly therapy that is frequently implemented postoperatively to manage elevated PVR.ObjectivesWe aimed to describe practice patterns of iNO use in a multicenter cohort of patients who underwent repair of truncus arteriosus, a lesion in which recovery is often complicated by elevated PVR. We also sought to identify patient and center factors that were more commonly associated with the use of iNO in the postoperative period.DesignRetrospective cohort study.Setting15 tertiary care pediatric referral centers.PatientsAll infants who underwent definitive repair of truncus arteriosus without aortic arch obstruction between 2009 and 2016.InterventionsDescriptive statistics were used to demonstrate practice patterns of iNO use. Bivariate comparisons of characteristics of patients who did and did not receive iNO were performed, followed by multivariable mixed logistic regression analysis using backward elimination to identify independent predictors of iNO use.Main ResultsWe reviewed 216 patients who met inclusion criteria, of which 102 (46%) received iNO in the postoperative period: 69 (68%) had iNO started in the operating room and 33 (32%) had iNO initiated in the ICU. Median duration of iNO use was 4 days (range: 1‐21 days). In multivariable mixed logistic regression analysis, use of deep hypothermic circulatory arrest (odds ratio: 3.2; 95% confidence interval: 1.2, 8.4) and center (analyzed as a random effect, p = .02) were independently associated with iNO use.ConclusionsIn this contemporary multicenter study, nearly half of patients who underwent repair of truncus arteriosus received iNO postoperatively. Use of iNO was more dependent on individual center practice rather than patient characteristics. The study suggests a need for collaborative quality initiatives to determine optimal criteria for utilization of this important but expensive therapy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/152533/1/chd12849_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/152533/2/chd12849.pd

Multicenter Analysis of Early Childhood Outcomes Following Repair of Truncus Arteriosus

Background Literature describing morbidity and mortality following truncus arteriosus repair is predominated by single-center reports. We created and analyzed a multicenter dataset to identify risk factors for late mortality and right ventricle-to-pulmonary artery (RV-PA) conduit reintervention for this patient population. Methods We retrospectively collected data on children who underwent repair of truncus arteriosus without concomitant arch obstruction at 15 centers between 2009 and 2016. Cox regression survival analysis was conducted to determine risk factors for late mortality, defined as death occurring after hospital discharge and greater than 30 days after surgery. Probability of any RV-PA conduit reintervention was analyzed over time using Fine-Gray modelling. Results We reviewed 216 patients, with median follow-up of 2.9 years (range:0.1-8.8). Operative mortaility occurred in 15 patients (7%). Of the 201 survivors, there were 14 (7%) late deaths. DiGeorge syndrome (HR:5.4; 95%CI:1.6-17.8) and need for postoperative tracheostomy (HR:5.9; 95%CI:1.8-19.4) were identified as independent risk factors for late mortality. At least one RV-PA conduit catheterization or surgical reintervention was performed in 109 patients (median time to reintervention:23 months, range:0.3-93). Risk factors for reintervention included use of pulmonary or aortic homografts versus Contegra® bovine jugular vein conduits (HR:1.9; 95%CI:1.2,3.1) and smaller conduit size (HR per mm/m2:1.05; 95%CI:1.03,1.08). Conclusions In a multicenter dataset, DiGeorge syndrome and need for tracheostomy postoperatively were found to be independent risk factors for late mortality after repair of truncus arteriosus, while risk of conduit reintervention was independently influenced by both initial conduit type and size

Use of venovenous extracorporeal membrane oxygenation and an atrial septostomy for pulmonary and right ventricular failure.

BACKGROUND: Right ventricular failure is a major contributor to morbidity and mortality on the lung transplant waiting list. This study was designed to evaluate the effectiveness of an atrial septostomy with venovenous extracorporeal membrane oxygenation (VV-ECMO) as a novel potential bridge to transplantation. METHODS: Adult sheep (58±3 kg; n=12) underwent a clamshell thoracotomy and instrumentation to measure all relevant pressures and cardiac output (CO). Sheep with tricuspid insufficiency (TI [n=5]) and without tricuspid insufficiency (ØTI [n=7]) were examined. After creation of a 1-cm atrial septal defect and initiating VV-ECMO, the pulmonary artery (PA) was banded to allow progressive reduction of pulmonary blood flow, and data were collected. RESULTS: The CO in both groups remained unchanged from baseline at all pulmonary blood flow conditions. With TI, the CO was 5.1±1.2 L/min at baseline versus 5.1±1.2 L/min with a fully occluded PA (p=0.99). For ØTI, the CO was 4.5±1.4 L/min at baseline versus 4.5±1.2 L/min with no pulmonary blood flow (p=0.99). Furthermore, CO was not affected by the presence of TI (p=0.76). Mean right ventricular pressures were significantly lower in the TI group (TI=20.2±11 mm Hg versus ØTI=29.9±8.9 mm Hg; p0.5). Lastly, VV-ECMO maintained normal blood gases, with mean O2 saturations of 99% ± 4.1% in both groups. CONCLUSIONS: Right to left atrial shunting of oxygenated blood with VV-ECMO is capable of maintaining normal systemic hemodynamics and normal arterial blood gases during high right ventricular afterload dysfunction.</p

Long-term animal model of venovenous extracorporeal membrane oxygenation with atrial septal defect as a bridge to lung transplantation.

<p>This study evaluated the effectiveness of an atrial septal defect (ASD) with venovenous extracorporeal membrane oxygenation (vv-ECMO) as a bridge to transplantation. Sheep (56 ± 3 kg; n = 7) underwent a right-sided thoracotomy to create the ASD (diameter = 1 cm) and place instrumentation and a pulmonary artery (PA) occluder. After recovery, animals were placed on ECMO, and the PA was constricted to generate a twofold rise in right ventricular (RV) systolic pressure. Sheep were then maintained for 60 hours on ECMO, and data were collected hourly. Five sheep survived 60 hours. One sheep died because of a circuit clot extending into the RV, and another died presumably because of an arrhythmia. Mean right ventricular pressure (mRVP) was 19 ± 3 mm Hg at baseline, averaged 27 ± 7 mm Hg over the experiment, but was not statistically significant (p = 0.27) due to one sheep without an increase. Cardiac output was 6.8 ± 1.2 L/min at baseline, averaged 6.0 ± 1.0 L/min during the experiment, and was statistically unchanged (p = 0.34). Average arterial oxygen saturation and PCO2 over the experiment were 96.8 ± 1.4% and 31.8 ± 3.4 mm Hg, respectively. In conclusion, an ASD combined with vv-ECMO maintains normal systemic hemodynamics and arterial blood gases during a long-term increase in RV afterload.</p

Characteristics and Operative Outcomes for Children Undergoing Repair of Truncus Arteriosus: A Contemporary Multicenter Analysis

Objective We sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort. Methods We conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation (ECMO), cardiopulmonary resuscitation (CPR), or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (OR) with 95% confidence intervals (CI). Results We reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative ECMO, 26 (12%) received CPR, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus prior to discharge from the nursery (OR:3.1; 95%CI:1.3,7.4), cardiopulmonary bypass duration greater than 150 minutes (OR:3.5; 95%CI:1.5,8.5), and right ventricle-to-pulmonary artery conduit diameter greater than 50mm/m2 (OR:4.7; 95%CI:2.0,11.1). Conclusions In a contemporary multicenter analysis, 20% of children undergoing repair of truncus arteriosus experienced MACE. Early diagnosis, shorter duration of cardiopulmonary bypass, and use of smaller diameter right ventricle-to-pulmonary artery conduits represent potentially modifiable factors that could decrease morbidity and mortality in this fragile patient population

Characteristics and Operative Outcomes for Children Undergoing Repair of Truncus Arteriosus: A Contemporary Multicenter Analysis

Objective We sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort. Methods We conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation (ECMO), cardiopulmonary resuscitation (CPR), or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (OR) with 95% confidence intervals (CI). Results We reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative ECMO, 26 (12%) received CPR, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus prior to discharge from the nursery (OR:3.1; 95%CI:1.3,7.4), cardiopulmonary bypass duration greater than 150 minutes (OR:3.5; 95%CI:1.5,8.5), and right ventricle-to-pulmonary artery conduit diameter greater than 50mm/m2 (OR:4.7; 95%CI:2.0,11.1). Conclusions In a contemporary multicenter analysis, 20% of children undergoing repair of truncus arteriosus experienced MACE. Early diagnosis, shorter duration of cardiopulmonary bypass, and use of smaller diameter right ventricle-to-pulmonary artery conduits represent potentially modifiable factors that could decrease morbidity and mortality in this fragile patient population