ABSTRACT
Objective: Injury to the recurrent laryngeal nerve can lead to significant morbidity during congenital cardiac surgery. The objective is to expand on the limited understanding of the severity and recovery of this iatrogenic condition
Design: A six-year retrospective review of all congenital heart operations at a single institution from January 1, 2008 to December 31, 2013 was performed. All patients with documented vocal cord paralysis on laryngoscopic examination comprised the study cohort. Evaluation of time to vocal cord recovery and need for further surgical intervention was the primary focus
Results: The incidence of post-operative vocal cord paralysis was 1.1% [32 out of 3036 patients; 95% confidence interval: 0.7-1.5%]. The majority were left-sided injuries [71%]. Overall rate of recovery was 61% with a median time of 10 months in those who recovered, and a total follow up of 46 months. Due to feeding complications, 45% of patients required gastrostomy tube after the injury, and these patients were found to have longer duration of post-operative days of intubation [median 10 vs. 5 days, p = 0.03], ICU length of stay [50 vs. 8 days, p = 0.002], and hospital length of stay [92 vs. 41 days, p = 0.01]. No pre-operative variables were identified as predictive of recovery or need for gastrostomy placement
Conclusion: Recurrent laryngeal nerve injury is a serious complication of congenital heart surgery that impacts post-operative morbidity, in some cases leading to a need for further intervention, in particular, gastrostomy tube placement. A prospective, multi-center study is needed to fully evaluate factors that influence severity and time to recovery
Subject(s)
Humans , Male , Female , Adult , Thoracic Surgery , Retrospective Studies , Vocal Cord Paralysis , Gastrostomy , Heart Defects, Congenital/surgery , Patient Outcome AssessmentABSTRACT
There are limited data on the relationship between the administered dose of recombinant factor seven [rFVIIa] and the development of adverse clinical outcomes after congenital heart surgery. This single institution case series reports on dosing, adverse events, and blood product usage after the administration of rFVIIa in the congenital heart surgery patient population. A retrospective review identified 16 consecutive pediatric patients at an academic, free-standing, children's hospital who received rFVIIa to curtail bleeding following congenital heart surgery between April 2004 and June 2012. Patients were assessed for survival to hospital discharge versus in-hospital mortality and the presence or absence of a major neurological event during inpatient hospitalization. The median age at surgery was 6.8 months [range: 3 days-42 years]. Seven patients [44%] survived to hospital discharge and nine patients [56%] died. The cause of mortality included major neurological events [44%], uncontrolled bleeding [33%], and sepsis [23%]. Eight patients [50%] required extracorporeal membrane oxygenation support following congenital heart surgery. The median cumulative rFVIIa dose administered was 97 mcg/kg, and the median cumulative amount of blood products administered was 452 ml/kg. In conclusion, this case series underscores the need to prospectively evaluate the effect that rFVIIa has on patient survival and the incidence of adverse events, including thrombotic and major neurological events, in congenital heart surgery patients. Ideally, a randomized, multicenter study would provide the sufficient numbers of patients and events to test these relationships
ABSTRACT
The hypoxemia caused by arteriovenous malformations after cavopulmonary shunt in patients with heterotaxy, an interrupted inferior vena cava and single ventricle physiology have been treated by incorporation of hepatic vein flow into the pulmonary circulation. However, some patients have persistent arteriovenous malformations because of offset hepatic venous flow to one pulmonary artery. Various approaches have been used to change offset flow to achieve balanced hepatic flow to the lungs in this patient population. This case report highlights the challenges that may be associated with anastomosis of the azygos vein to the inferior vena cava at the level of the diaphragm and illustrates an alternative technique to direct hepatic venous blood into an affected lung with arteriovenous malformations. The redirection of hepatic venous flow to the affected pulmonary artery resulted in resolution of symptoms within months of surgery
Subject(s)
Humans , Heart Bypass, Right , Hepatic Veins , Azygos Vein , Vena Cava, Inferior , Pulmonary Artery , Angiography , Magnetic Resonance ImagingABSTRACT
This paper reviews the evolution of surgical technique that has occurred with the Fontan procedure since it was first introduced more than 25 years ago. Although there has been recent enthusiasm at some centers for a return to Fontan's original concept of use of a conduit to achieve the Fontan pathway, we continue to believe that the lateral tunnel with double cavopulmonary anastomosis is the preferred approach. The late incidence of arrhythmias with the lateral tunnel at 10 years follow-up is remarkably low. On the other hand conduits present a risk of outgrowth and pseudointima accumulation. Even small gradients, e. g. less than 4mm, will be poorly tolerated over the longer term and may result in an increased incidence of cirrhosis and protein losing enteropathy.<br>Overall there has been a remarkable improvement in the early and late results of the Fontan procedure over the last decade. The role of the bi-directional Glenn shunt as either a staging procedure or definitive palliation when performed in conjunction with supplementary pulmonary blood flow needs to be defined by a prospective randomized study. Likewise the role of the fenestration also needs to be defined by a prospective randomized study including careful studies of late exercise capacity and maximal oxygen consumption. Another issue that needs to be defined by careful prospective randomized study is the importance of anti-coagulation with coumadin versus aspirin in reducing the incidence of thromboembolism.
ABSTRACT
The mortality for congenital heart surgery is now so low that the focus has shifted to improving the quality of life for children after heart surgery. Neurodevelopmental deficit is the most important surgical morbidity in congenital heart disease. This review article describes both clinical and laboratory studies in this area, most of which were performed at Children's Hospital Boston over the last 15 years. An epidemic of choreoathetoses at Children's Hospital in the late 1980[s] was the initial stimulus for studies of neurological injury after congenital heart surgery. A high index of suspicion associated the epidemic with a change in pH strategy from the more acidosis pH stat strategy to the alpha stat strategy during cardiopulmonary bypass. A more alkaline pH like alpha stat in a shift in the oxyhemoglobin dissociation curve to the left, i.e. tighter binding of oxygen with hemoglobin. Other potential factors that limit cerebral oxygen delivery during cardiopulmonary bypass include reduced perfusion flow rate of the cardiopulmonary bypass ump, a significant reduction in oxygen delivery secondary to hemodilution, a shift to the left of oxyhemoglobin dissociation secondary to hypothermic blood temperature, and run off the systemic circulation to the pulmonary circulation through collaterals and bronchial vessels. In addition venous cannulation in neonates and young infants can be tenuous. The fact that young children are free of arteriosclerosis potentially makes them an ideal population for studying the effects of cardiopulmonary bypass on neurodevelopmental outcome. On the other hand the heterogeneity of congenital heart defects as well as genetic associations such as microdeletion of chromosome 22 can complicate the interpretation of clinical studies in neurodevelopmental outcome after cardiac surgery. The results of several prospective and retrospective studies of neurological and developmental outcome after pediatric cardiac surgery as well as laboratory studies have led us to the following inferences: 1] the use of circulatory arrest should be minimized; 2] pH stat strategy is preferred for infant cardiopulmonary bypass over the alpha stat strategy; 3] a higher hematocrit, e.g. 30% may be preferable to 20%; 4] a hyperoxic perfusion strategy is preferred over a normoxic strategy; and 5] postoperative fever should be strenuously avoided