Results of consecutive training procedures in pediatric cardiac surgery

This report from a single institution describes the results of consecutive pediatric heart operations done by trainees under the supervision of a senior surgeon. The 3.1% mortality seen in 1067 index operations is comparable across procedures and risk bands to risk-stratified results reported by the Society of Thoracic Surgeons. With appropriate mentorship, surgeons-in-training are able to achieve good results as first operators

Perioperative use of steroids in neonatal heart surgery:Evidence based practice or tradition?

A best evidence topic was written according to a structured protocol. The question addressed was: Is the use of prophylactic, perioperative steroids associated with better clinical outcomes following heart surgery in neonates? Altogether, 194 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. One study found improved hospital survival in the group without steroids. Steroids increased infection in one large retrospective study. Incidence of hyperglycaemia was increased in the steroid group in 2 out of 5 studies. Use of steroids was associated with a shorter duration of ventilation and better oxygenation in one study. Postoperative steroid infusion was associated with reduced low cardiac output syndrome, inotrope requirement and less fluid retention in two controlled trials in which all patients received preoperative steroid. High dose steroid was associated with renal dysfunction in one study, comparing single versus double dose steroid prophylaxis. Steroid non-recipients had a shorter intensive care length of stay in 2 out of 7 studies. We conclude that use of steroids perioperatively does not unequivocally improve clinical outcome in neonatal heart surgery. A large, multicentre prospective randomized controlled trial is needed to clarify the role of steroids in paediatric heart surgery

Outcomes following aortic valve procedures in 201 complex congenital heart disease cases:results from the UK National Audit

OBJECTIVES: Some patients with complex congenital heart disease (cCHD) also require aortic valve (AoV) procedures. These cases are considered high risk but their outcome has not been well characterized. We aim to describe these scenarios in the current practice, and provide outcome data for counselling and decision-making. METHODS: This was a retrospective study using the UK National Congenital Heart Disease Audit data on cCHD patients undergoing aortic valve replacement, balloon dilation (balloon aortic valvuloplasty) or surgical repair (surgical aortic valve repair) between 2000 and 2012. Coarsened exact matching was used to pair cCHD with patients undergoing AoV procedures for isolated valve disease. RESULTS: A total of 201 patients with a varied spectrum of cCHD undergoing 242 procedures were included, median age 9.4 years (1 day–65 years). Procedure types were: balloon aortic valvuloplasty (n = 31, 13%), surgical aortic valve repair (n = 57, 24%) and aortic valve replacement (n = 154, 63%). Mortality at 30 days was higher in neonates (21.8% vs 5.3%, P = 0.02). Survival at 10 years was 83.1%, freedom from aortic valve replacement 83.8% and freedom from balloon aortic valvuloplasty/surgical aortic valve repair 86.3%. Neonatal age (P < 0.001), single ventricle (P = 0.08), concomitant Fontan/Glenn (P = 0.002) or aortic arch procedures (0.02) were associated with higher mortality. cCHD patients had lower survival at 30 days (93% vs 100%, P = 0.003) and at 10 years (86.4% vs 96.1%, P = 0.005) compared to matched isolated AoV disease patients. CONCLUSIONS: AoV procedures in cCHD can be performed with good results outside infancy, but with higher mortality than in isolated AoV disease. Neonates and patients with single ventricle defects, especially those undergoing concomitant Fontan/Glenn, have worse outcomes

Normothermic versus hypothermic cardiopulmonary bypass in children undergoing open heart surgery (thermic-2):study protocol for a randomized controlled trial

BACKGROUND: During open heart surgery, patients are connected to a heart-lung bypass machine that pumps blood around the body (“perfusion”) while the heart is stopped. Typically the blood is cooled during this procedure (“hypothermia”) and warmed to normal body temperature once the operation has been completed. The main rationale for “whole body cooling” is to protect organs such as the brain, kidneys, lungs, and heart from injury during bypass by reducing the body’s metabolic rate and decreasing oxygen consumption. However, hypothermic perfusion also has disadvantages that can contribute toward an extended postoperative hospital stay. Research in adults and small randomized controlled trials in children suggest some benefits to keeping the blood at normal body temperature throughout surgery (“normothermia”). However, the two techniques have not been extensively compared in children. OBJECTIVE: The Thermic-2 study will test the hypothesis that the whole body inflammatory response to the nonphysiological bypass and its detrimental effects on different organ functions may be attenuated by maintaining the body at 35°C-37°C (normothermic) rather than 28°C (hypothermic) during pediatric complex open heart surgery. METHODS: This is a single-center, randomized controlled trial comparing the effectiveness and acceptability of normothermic versus hypothermic bypass in 141 children with congenital heart disease undergoing open heart surgery. Children having scheduled surgery to repair a heart defect not requiring deep hypothermic circulatory arrest represent the target study population. The co-primary clinical outcomes are duration of inotropic support, intubation time, and postoperative hospital stay. Secondary outcomes are in-hospital mortality and morbidity, blood loss and transfusion requirements, pre- and post-operative echocardiographic findings, routine blood gas and blood test results, renal function, cerebral function, regional oxygen saturation of blood in the cerebral cortex, assessment of genomic expression changes in cardiac tissue biopsies, and neuropsychological development. RESULTS: A total of 141 patients have been successfully randomized over 2 years and 10 months and are now being followed-up for 1 year. Results will be published in 2015. CONCLUSIONS: We believe this to be the first large pragmatic study comparing clinical outcomes during normothermic versus hypothermic bypass in complex open heart surgery in children. It is expected that this work will provide important information to improve strategies of cardiopulmonary bypass perfusion and therefore decrease the inevitable organ damage that occurs during nonphysiological body perfusion. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN93129502, http://www.isrctn.com/ISRCTN93129502 (Archived by WebCitation at http://www.webcitation.org/6Yf5VSyyG)

Arterial Switch for Transposition of the Great Arteries

Background Reports of long-term mortality and reintervention after transposition of the great arteries with intact ventricular septum treatment, although favorable, are mostly limited to single-center studies. Even less is known about hospital resource utilization (days at hospital) and the impact of treatment choices and timing on outcomes. Objectives The purpose of this study was to describe survival, reintervention and hospital resource utilization after arterial switch operation (ASO) in a national dataset. Methods Follow-up and life status data for all patients undergoing ASO between 2000 and 2017 in England and Wales were collected and explored using multivariable regressions and matching. Results A total of 1,772 patients were identified, with median ASO age of 9.5 days (IQR: 6.5-14.5 days). Mortality and cardiac reintervention at 10 years after ASO were 3.2% (95% CI: 2.5%-4.2%) and 10.7% (95% CI: 9.1%-12.2%), respectively. The median time spent in hospital during the ASO spell was 19 days (IQR: 14, 24). Over the first year after the ASO patients spent 7 days (IQR: 4-10 days) in hospital in total, decreasing to 1 outpatient day/year beyond the fifth year. In a subgroup with complete risk factor data (n = 652), ASO age, and balloon atrial septostomy (BAS) use were not associated with late mortality and reintervention, but cardiac or congenital comorbidities, low weight, and circulatory/renal support at ASO were. After matching for patient characteristics, BAS followed by ASO and ASO as first procedure, performed within the first 3 weeks of life, had comparable early and late outcomes, including hospital resource utilization. Conclusions Mortality and hospital resource utilization are low, while reintervention remains relatively frequent. Early ASO and individualized use of BAS allows for flexibility in treatment choices and a focus on at-risk patients

Costs of postoperative morbidity following paediatric cardiac surgery: observational study.

OBJECTIVE: Early mortality rates for paediatric cardiac surgery have fallen due to advancements in care. Alternative indicators of care quality are needed. Postoperative morbidities are of particular interest. However, while health impacts have been reported, associated costs are unknown. Our objective was to calculate the costs of postoperative morbidities following paediatric cardiac surgery. DESIGN: Two methods of data collection were integrated into the main study: (1) case-matched cohort study of children with and without predetermined morbidities; (2) incidence rates of morbidity, measured prospectively. SETTING: Five specialist paediatric cardiac surgery centres, accounting for half of UK patients. PATIENTS: Cohort study included 666 children (340 with morbidities). Incidence rates were measured in 3090 consecutive procedures. METHODS: Risk-adjusted regression modelling to determine marginal effects of morbidities on per-patient costs. Calculation of costs for hospital providers according to incidence rates. Extrapolation using mandatory audit data to report annual financial burden for the health service. OUTCOME MEASURES: Impact of postoperative morbidities on per-patient costs, hospital costs and UK health service costs. RESULTS: Seven of the 10 morbidity categories resulted in significant costs, with mean (95% CI) additional costs ranging from £7483 (£3-£17 289) to £66 784 (£40 609-£103 539) per patient. On average all morbidities combined increased hospital costs by 22.3%. Total burden to the UK health service exceeded £21 million each year. CONCLUSION: Postoperative morbidities are associated with a significant financial burden. Our findings could aid clinical teams and hospital providers to account for costs and contextualise quality improvement initiatives

The influence of toxic metals As, Cd, Ni, and Pb on nutrients accumulation in Mentha piperita

Medicinal plants are, for a considerable part of the population, an important source of treatment for certain diseases. They contain essential nutrients for the human body such as magnesium, iron and zinc. The present study shows the influence of the addition of As, Cd, Ni, Pb on mineral nutrients in different organs of Mentha piperita. The experiments were carried out in the laboratory for a period of three months (May-July). Mentha piperita plants were AsCd and AsCdNiPb exposed up to final concentrations corresponding to the soil intervention threshold according to Romanian Order no.756/1997 (25 mg/kg As, 5 mg/kg Cd, 150 mg/kg Ni and 100 mg/ kg Pb). Simultaneously with these experiments, a control experiment (M) was performed. To evaluate the effect of the addition of AsCd and AsCdNiPb on the accumulation and transfer of Ca, Cr, Cu, Mn, Mo, Fe and Zn, the transfer coefficient (TC), the translocation factor (TF), and the enrichment factor (EF) were calculated. A higher concentration of Ca, Cr, Cu, Fe, Mn, Mo, and Zn was observed especially in the mint root in the experiments in which AsCdNiPb was added compared to those in which only AsCd was added. The AsCdNiPb addition did not influence the translocation of micro and macronutrients from the root to the aerial (edible) parts of the plant. In the case of the AsCd, addition, the translocation of zinc from the root to the aerial parts (leaves and stem) of the plant was increased

Hospital resource utilization in a national cohort of functionally single ventricle patients undergoing surgical treatment

Objective: To provide a detailed overview of health resource utilization from birth to 18 years old for functionally single ventricle (f-SV) patients and identify associated risk factors./ Methods: All f-SV patients treated between 2000-2017 in England and Wales were linked to hospital and outpatient records using data from the Linking AUdit and National datasets in Congenital HEart Services (LAUNCHES) project. Hospital stay was described in yearly age intervals and associated risk factors were explored using quantile regression./ Results: A total of 3,037 f-SV patients were included, 1409 (46.3%) undergoing a Fontan procedure. During the first year of life the median days spent in-hospital was 60 (IQR 37-102), mostly inpatient days, mirroring a mortality of 22.8%. This decreases to between 2-9 in-hospital days/year afterwards. Between 2-18 years most hospital days were outpatient, with a median of 1-5 days/year./ Lower age at the first procedure, hypoplastic left heart syndrome/mitral atresia, unbalanced atrioventricular septal defect, preterm birth, congenital/acquired comorbidities, additional cardiac risk factors and severity of illness markers were associated with fewer days-at-home and more ICU days in the first year of life. Only markers of early severe illness were associated with fewer days-at-home in the first 6 months post Fontan procedure./ Conclusions: Hospital resource utilization in f-SV is not uniform, decreasing tenfold during adolescence compared to the first year of life. There are subsets of patients with worse outcomes during their first year of life, or with persistently high hospital usage throughout their childhood, which could be the target of future research