Caudal epidural sufentanil and bupivacaine decreases stress response in paediatric cardiac surgery.

Surgery and anaesthesia are known to cause stress response. Attenuation of stress response can decrease morbidity, postoperative hospital length of stay and, thus, cost. Intrathecal and epidural techniques produce reliable analgesia in patients undergoing surgery along with stress response attenuation. The present study was undertaken to evaluate the efficacy of caudal sufentanil and bupivacaine combination on perioperative stress response in paediatric patients undergoing open heart surgery. Thirty patients (ASA grade II-III) undergoing elective corrective cardiac surgery for acyanotic congenital heart disease, were randomly allocated to two groups. In group GA (n = 15), patients received balanced general anaesthesia. In group GC (n = 15), in addition to general anaesthesia, caudal block with bupivacaine and sufentanil combination was given after endotracheal intubation. Monitoring included electrocardiography, invasive arterial pressure, end-tidal carbon dioxide, pulse oximetry, arterial blood gases including serum electrolytes, blood glucose, serum cortisol, urine output, central venous pressure and temperature. Haemodynamic responses in both groups were statistically similar. Serum cortisol levels were significantly lower in GC group than GA group (P < 0.05) after sternotomy (9.8+/-7.5 vs. 34.74+/-27.35), on cardiopulmonary bypass (CPB) (12.17 +/- 6.2 vs. 35.36 +/- 24.15), after sternal closure (14.03 +/- 5.1 vs. 37.62 +/- 20.69), 4 hours (26.64 +/- 14.61 vs. 37.62 +/- 9.13) and 24 hours (14.30 +/- 8.11 vs. 28.12 +/- 16.31) after intubation. Blood glucose levels were significantly higher in GA group as compared to GC group at sternal closure (277.46 +/- 77.25 vs.197.73 +/- 42.17) and 4 hours (255.26 +/- 73.73 vs. 185.26 +/- 57.41) after intubation (P < 0.05). To conclude, supplementation of caudal epidural bupivacaine and sufentanil could effectively attenuate the stress response in paediatric patients undergoing cardiac surgery under CPB in acyanotic congenital heart anomaly.

Medium-term outcome of anatomically repaired congenitally corrected transposition: the double switch operation.

BACKGROUND: The double switch operation is emerging as the procedure of choice for congenitally corrected transposition of the great arteries. However, rhythm disturbances in the postoperative period are rarely discussed. METHODS AND RESULTS: Eighteen survivors who underwent corrective surgery for congenitally corrected transposition of the great arteries were followed up. Patients in group I (n=8), who also had a ventricular septal defect and pulmonary stenosis, had undergone the Senning plus Rastelli operation. Patients in group II (n=10), who did not have pulmonary stenosis, had undergone the Senning and arterial switch operation. The patients were followed up by periodical clinical examination, echocardiography and 24-hour Holter monitoring. In group I, follow-up ranged from 24 to 66 months (mean 44 months). There was no late death and all the patients are symptom free. There was no significant atrioventricular valve regurgitation and left ventricular function was normal. There were no rhythm disturbances. In group II, follow-up ranged from 2 to 72 months (mean 48 months). There were 2 late deaths due to atrial tachyarrhythmia and residual pulmonary hypertension 36 and 8 months after the procedure, respectively. One patient had significant mitral regurgitation and required mitral valve replacement. Three patients had recurrent atrial/junctional tachyarrhythmia: one of them was lost to follow-up after 1 year while another died of resistant atrial tachyarrhythmia. The third patient underwent mitral valve replacement for severe mitral regurgitation and developed complete heart block necessitating a permanent pacemaker implantation. CONCLUSIONS: Though good long-term results are obtained following the double switch operation, the problem of atrial arrhythmias still needs to be addressed suitably.

Ventricular septal defect with congenital mitral valve disease: long-term results of corrective surgery.

BACKGROUND: A retrospective analysis of the mortality, morbidity and long-term follow-up of patients undergoing corrective surgery for ventricular septal defect and congenital mitral valve disease is presented. METHODS AND RESULTS: Between January 1991 and December 2000, 69 consecutive patients aged 2 months to 45 years (median 18 months) underwent repair of ventricular septal defect and associated mitral valve disease. In 52 patients (75%), the ventricular septal defects were located in the perimembranous and subarterial area. Forty-six patients had congenital mitral incompetence and 23 had congenital mitral stenosis. The ventricular septal defect was repaired through the right atrium in all. Sixty-five patients underwent reconstruction of the mitral valve and 4 underwent primary mitral valve replacement. Another 4 patients underwent mitral valve replacement after a failed repair. Associated procedures included: patent ductus arteriosus ligation (n=12), aortic valve replacement (n=6), coarctation repair (n=13), interrupted aortic arch repair (n=1), atrial septal defect closure (n=17) and Takeuchi repair (n=1). There were 6 early deaths (8.6%). Three deaths were due to pulmonary arterial hypertensive crisis and one due to residual mitral stenosis. One death was due to intractable congestive heart failure. Another patient died due to persistent low cardiac output. Follow-up ranged from 6 months to 120 months (mean 64.4+/-33.6 months). Reoperation was required in 22 patients, mainly for recurrent/residual mitral valve dysfunction or hemodynamically significant left ventricular outflow tract obstruction. There were 4 late deaths, 2 due to residual mitral stenosis and the other 2 as a result of a thrombosed prosthetic valve. At 10 years, the actuarial survival rate was 850+/-5.0%, and freedom from reoperation was 45%+/-10.0%. CONCLUSIONS: Reconstruction of the mitral valve along with closure of VSD is possible in most cases. However, careful follow-up is recommended to detect changes in the mitral valve status over a course of time.