Pediatric cardiac transplantation in children with high panel reactive antibody.

BACKGROUND: Elevated panel reactive antibody (PRA) may be considered a risk factor precluding pediatric orthotopic heart transplantation. We retrospectively reviewed our management strategy and outcome data for children undergoing heart transplantation with high PRA (> 10%). METHODS: Sixty consecutive children (median age = 130.5 days) underwent heart transplantation. Diagnoses included hypoplastic left heart syndrome (HLHS) (30 patients), cardiomyopathy (18 patients), and postoperative complex congenital heart disease (CCHD) (12 patients). Standard induction immunosuppressive therapy included pulse steroids, gamma globulin, and polyclonal rabbit antithymocyte globulin. Initial immunosuppression is a calcinurin inhibitor and an antiproliferative agent. Eight children exhibited elevated PRA (group P). Fifty-two exhibited nonelevated PRA (group N). Immunosuppression was modified in group P as follows: preoperative intravenous immunoglobulin G (IVIG) and/or cyclophosphamide or mycophenolate mofetil and preoperative and postoperative exchange transfusions or plasmapheresis. In group P, cyclophosphamide was the initial antiproliferative agent. RESULTS: Group P = 4 HLHS patients (all status post [s/p] prior cardiac surgery) and 4 postoperative CCHD patients. Group N = 26 HLHS patients (4 patients s/p prior cardiac surgery), 18 cardiomyopathy patients, and 8 postoperative CCHD patients. Group P patients were older and weighed more than group N patients. Waiting time for donor heart, cardiac ischemic time, and length of hospital stay were similar in both groups. Thirty-day mortality for group P was 25% and for group N it was 7.9% (p = 0.178). Overall mortality for group P was 50% and for group N it was 15.4% (p = 0.043). CONCLUSIONS: Although heart transplantation can offer children with end-stage heart failure and elevated PRA their only chance of survival, these patients remain high risk despite aggressive immunosuppression.

The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery and interventional cardiology coil occlusion.

BACKGROUND: In an effort to analyze our experience and develop treatment guidelines, we reviewed all our patients with patent ductus arteriosus (PDA) treated with video-assisted thoracoscopic surgery (VATS) or interventional cardiology coil occlusion. METHODS: One hundred patients underwent 102 cardiac catheterizations. Forty-five children underwent VATS. The entire cohort of patients is 141 because 4 patients underwent both catheterization and VATS. RESULTS: Successful PDA coil occlusion occurred in 91 patients (91 of 100; 91%); 8 had unsuccessful attempts at coil occlusion and 1 was referred for surgical ligation after catheterization without any attempt at coil placement. Thirty-nine children had successful VATS PDA closure. Six children required conversion to thoracotomy because of inadequate exposure during VATS. Hospital stay for children more than 45 days of age was as follows: VATS median stay, 1 day, mean, 1.4 days; thoracotomy median stay, 4 days, mean, 4.6 days. One patient treated with PDA coil occlusion developed a recurrent PDA and required reembolization. Three children underwent initial catheterization without successful coil placement with subsequent successful VATS. All VATS patients left the operating theater with echocardiography documenting no residual PDA. Two children who underwent successful VATS with no residual PDA at hospital discharge were found on outpatient follow-up to have developed tiny recurrent PDAs and both were successfully coil occluded; 1 of these 2 children is 1 of the 3 children initially evaluated by catheterization and then referred for VATS. CONCLUSIONS: Video-assisted thoracoscopic surgery and coil occlusion represent complementary techniques for PDA treatment. A rationale for selection of the appropriate treatment modality can be based upon the size and age of the patient and the size and morphology of the PDA.

Minimally invasive endoscopic repair of pectus excavatum.

OBJECTIVE: We report our initial 3 years 4 months' single institution experience in 31 consecutive patients with pectus excavatum treated with minimally invasive endoscopic pectus excavatum repair utilizing a modification of the 'Nuss' technique. METHODS: Under general anesthesia, a curved steel bar is individually shaped for each patient to match the ideal chest wall shape and is placed through an endoscopically created retrosternal tunnel between two bilateral midaxillary line 2-cm incisions. The tunnels initially go along the outside of the rib cage, under the pectoral muscles. At the level of the sternum, these tunnels go retrosternal and communicate with each other. The steel bar is passed with the convexity facing posteriorly, within a protective flat silastic drain. Under endoscopic guidance, the curved steel bar is passed through one tunnel, under the sternum, and out the other tunnel. Once positioned, the bar is turned over, thereby correcting the deformity. An epidural catheter provides perioperative pain relief. RESULTS: Minimally invasive endoscopic pectus excavatum repair has been performed on 31 patients (age: range 4.4-31.0 years, median 15.0 years, mean 14.5 years). Median hospital length of stay is 4 days (range 3-10 days, mean 4.6 days). Pneumothorax occurred in five patients requiring tube thoracostomy in three. One patient developed delayed bilateral pleural effusions requiring drainage. Two patients developed evidence of sterile seroma formation at the skin incision several months after minimally invasive repair of pectus excavatum. These seromas resolved with non-interventional conservative medical treatment. No other complications occurred. CONCLUSION: The minimally invasive endoscopic pectus repair is safe and effective and currently our procedure of choice for primary pectus excavatum in all ages. Endoscopic visualization facilitates the safe creation of the retrosternal tunnel. Short-term results have been excellent. Further follow-up will be necessary to determine long-term results.