Enoxaparin Reduces Catheter-associated Venous Thrombosis After Infant Cardiac Surgery

Background Central venous catheter (CVC) related venous thrombosis (VT) after pediatric cardiac surgery increases morbidity and mortality. Although VT prevention using low-dose anticoagulation therapy has proven ineffective, anticoagulation therapy using high-dose enoxaparin to achieve a therapeutic anti-Xa level has not been studied. We hypothesized that high-dose enoxaparin would reduce VT after pediatric cardiac surgery. Methods Enoxaparin was administered to infants aged less than 150 days when postoperative CVC duration was anticipated to extend beyond 5 days. The primary outcome was the rate of VT, reexploration for bleeding, and postoperative red blood cell transfusions per 1000 CVC days. Results From 2012 to 2019, 157 infants were treated with enoxaparin. Infants were divided into two groups: (1) subtherapeutic (n = 51), in which therapeutic anti-Xa level (0.5 to 1.0 IU/mL) was not achieved; and (2) therapeutic (n = 106), in which therapeutic anti-Xa level was achieved. Baseline demographics demonstrated a lower age at operation in the therapeutic group. The subtherapeutic group had a higher VT rate per 1000 CVC days (8.2) compared with the therapeutic group (2.6; P = .005). Reexploration for bleeding was similar between groups. The number of postoperative red blood cell transfusions per 1000 CVC days was significantly greater in the subtherapeutic group (109.4 vs 81.6; P = .008). Multivariate analysis demonstrated that higher median anti-Xa levels reduced the risk of VT (odds ratio 0.02; 95% confidence interval, 0.001 to 0.63; P = .02). Conclusions These data suggest that enoxaparin treatment resulting in a therapeutic anti-Xa level reduces postoperative CVC-associated VT without increasing bleeding complications

In Vitro and In Vivo Comparison of Hemoglobin and Electrolytes Following the Collection of Cell Saver Blood Washed with Either Normal Saline or Plasma-Lyte A

Cell saver blood is typically washed with normal saline (NS); however, recent studies have reported decreased red blood cell hemolysis and increased platelet function when a more physiologic washing solution, such as Plasma-Lyte A (PL-A) is used. We evaluated the in vitro and in vivo effects of NS compared to PL-A as washing solutions for cell saver blood in pediatric cardiac surgery. Cell saver blood was re-infused for up to 24 hours post-collection. Laboratory and clinical data were collected from infants receiving cell saver washed with either NS (n = 20) or PL-A (n = 21). Compositions of the cell saver blood were compared between groups at 5 in vitro time points and in vivo patient blood at 24 hours post-bypass. Although there were differences in in vitro laboratory values between groups; 24 hours post-bypass, in vivo results were similar. Our data supports 24-hour reinfusion of cell saver washed with either NS versus PL-A in pediatric cardiac surgery patients, and provides data on the differences in cell saver composition to guide future studies

Five-year outcomes after regionalizing pediatric cardiac surgery centers

Infant mortality after cardiac surgery is multifactorial, but can be related to center and surgeon case volume. One method to increase case volume is to consolidate or regionalize pediatric cardiac surgical care. We evaluated in-hospital and 5-year outcomes in three separate pediatric cardiac surgical programs before and after they formed one regional consortium. Infants (<1 year of age) undergoing complete biventricular surgery were divided into two groups: pre-regionalization (when operations were performed at three separate hospitals between, 1991 and 1998) and post-regionalization (when all operations were performed at one regional program at two surgical centers between, 2001 and 2010). Cases during 1999 and 2000 were excluded as the consortium at that time included only two of the three programs. Primary outcomes were hospital mortality, 5-year survival, cardiac re-operation, and number of events (deaths plus re-operations) during the 5-year follow-up for each group. The 671 infants in the pre-regionalization group did not differ significantly from the 782 infants in the post-regionalization group in age at surgery, weight, or sex. Hospital mortality was significantly greater than the state average before regionalization (9.8% vs. 7.1%; 95% CI of difference: 0.008, 0.052, P < 0.001), but significantly lower than the state average after regionalization (1.9% vs. 4.5%; 95% CI of difference 0.013, 0.043, P < 0.001). Regionalization also significantly improved the 5-year survival (90.2% vs 95.2%; P < 0.001) and freedom from re-operation (83.4% vs. 91.1%; P < 0.001). Multivariate analysis showed that regionalization was independently associated with mortality lower event rate (hazard ratio, 0.35; 95% CI, 0.23 to 0.53; P < 0.001). In our experience, regionalizing and consolidating pediatric cardiac surgical care improved both in-hospital and 5-year survival outcomes. Application of this strategy in other regions of the US may be feasible and beneficial. •The regionalization of three pediatric surgical programs lowered hospital mortality.•Regionalization significantly lowered the rate of re-operation.•Regionalization significantly improved 5-year survival.•Multivariate analysis demonstrated regionalization lowered the event rate

Regional sharing optimizes arterial switch outcomes

Although the arterial switch operation has been performed with very low mortality and morbidity in large pediatric cardiac surgical centers, we sought to determine if similar arterial switch results could be achieved in two medium-sized pediatric cardiac surgical centers that share one full-time surgeon who implements a comprehensive management protocol for both centers. Patients with D-transposition of the great arteries undergoing arterial switch operations at two medium-sized pediatric cardiac surgery centers were evaluated for 30-day mortality and morbidity during three time periods: Period 1, before protocol was implemented at either center (Center 1: 11/1982–8/1995, Center 2: 3/1992–11/1999); Period 2, protocol implemented only at Center 1 (9/1995–11/1999); Period 3, protocol implemented at both centers with regional sharing of one surgeon (12/1999–1/2003). Ninety-six consecutive patients undergoing an arterial switch operation were reviewed. Mortality data were available for all cases. Mortality was 0% and significantly lower in Periods 2 and 3 versus Period 1 ( p<0.001). Mortality in both centers during Period 1 did not differ. New York State morbidity data were available for 59 patients born after state reporting was instituted (Period 1, 16/43; Period 2, 13/23; Period 3, 30/30). In Period 1, there were significantly more pre-operative risk factors ( p<0.001) and post-operative complications ( p<0.002) than in Periods 2 and 3. There were no significant differences in performance between Centers 1 and 2 in any time period. There were significant performance improvements between Period 1 versus Periods 2 and 3. There was no significant degradation in performance between Periods 2 and 3. Outstanding surgical results for the arterial switch operation, similar to those in the largest pediatric cardiac surgical centers, are obtainable in two medium-sized pediatric cardiac surgery centers that share one full-time congenital heart surgeon. This model may be applicable in many other regions of the United States, where several medium-sized pediatric cardiac centers are within acceptable driving distance