First experience with sildenafil after Fontan operation: short-term outcomes.

BACKGROUND: We conducted a retrospective study to determine the effect of oral sildenafil administrated as monotherapy after Fontan operation in single ventricle physiology. METHODS: From January 2008 to March 2012, during two different periods, a total of 30 pediatric patients undergoing Fontan operation by extracardiac conduit were included in this study. Thirteen patients were in the sildenafil group and exclusively treated with sildenafil given at the dose of 0.35 mg/kg through a nasogastric tube and then orally every 4 h, at the start of cardiopulmonary bypass and for the first postoperative week; then we reduced and discontinued the therapy. The other 17 patients were in the control group. No other vasodilator was administered in both groups. We analyzed intraoperative and postoperative outcomes of sildenafil administration. RESULTS: There were no differences in mortality or operative time. The total and relative drainage loss was lower in the sildenafil group (P = 0.0003 and 0.0045). The hemodynamic parameters showed a better condition in the sildenafil group, with a lower mean pulmonary artery pressure (mPAP) (P = 0.0001) and better mPAP to mean systemic blood pressure (mSBP) ratio (P = 0.0043), whereas there was no difference in peripheral oxygen saturation (P = 0.31). The sidenafil group patients showed other additional positive differences as well as lower inotropic score (P = 0.0005) and intubation time (P = 0.0004). No complications related to the use of sildenafil were noted in any of the children studied. CONCLUSION: This initial experience provides evidence that sildenafil may be used in postoperative Fontan operation with positive effectiveness.

Tranexamic acid therapy in pediatric cardiac surgery: a single-center study.

BACKGROUND: We conducted a retrospective study of cyanotic and acyanotic patients undergoing cardiopulmonary bypass to determine the effect of tranexamic acid on blood loss and blood products administered during the operation in pediatric cardiac surgery. METHODS: From January 2008 to December 2011, during 2 different periods, a total of 231 pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (123 cyanotic, 108 acyanotic) were included in this study. A total of 104 patients were in the antifibrinolytic group and exclusively treated with tranexamic acid that was given as a bolus of 20 mg/kg(-1) after anesthetic induction and 20 mg/kg(-1) after protamine. The other 127 patients were in the control group. We analyzed intraoperative and postoperative outcomes of tranexamic acid administration. RESULTS: There were no differences in mortality or operative time, but blood loss in 48 hours was greater in the control group (p=0.0012). A significant difference was found in the amount of intraoperative erythrocyte concentrate transfused (140±55 vs 170±78 mL, p=0.0011) but not in number. The number and amount of erythrocyte concentrate transfused in the first 48 postoperative hours were also greater in the control group (45 vs 77 patients, p=0.012; 100±40 vs 120±55 mL, p=0.0022). There were not many differences in the effect of tranexamic acid between the cyanotic and acyanotic subgroup. CONCLUSIONS: This retrospective study provides evidence that tranexamic acid may be used in the field of congenital cardiac surgery effectively.

Sildenafil therapy for pulmonary hypertension before and after pediatric congenital heart surgery.

Pulmonary hypertension associated with pediatric congenital heart defects is a major cause of postoperative morbidity and death. Sildenafil has been combined with inhaled nitric oxide to treat pulmonary hypertension. We retrospectively studied the pre- and postoperative effects of oral sildenafil as monotherapy in children with pulmonary hypertension who underwent surgery to correct congenital cardiac defects. From September 2005 through November 2009, 38 children with moderate-to-severe pulmonary arterial hypertension (pulmonary arterial/aortic pressure ratio, >0.7) underwent cardiac surgery at our institution. Fifteen patients were given sildenafil (0.35 mg/kg, every 4 hr) orally or through nasogastric tubes 1 week before and 1 week after surgery. Twenty-three patients of comparable medical status were given sildenafil only upon the institution of cardiopulmonary bypass and for 1 week after surgery. Postoperatively, the 15 patients who were given preoperative sildenafil had significantly lower mean pulmonary arterial pressures (25.6 ± 3.1 vs. 30.4 ± 5.7 mmHg; P = 0.005) and pulmonary arterial/aortic pressure ratios (0.35 ± 0.05 vs. 0.42 ± 0.07; P = 0.002) than did the other 23 patients. The preoperative therapy also shortened cardiopulmonary bypass time, mechanical ventilation time, and lengths of intensive care unit and hospital stays. No sildenafil-related hypertensive crises or sequelae occurred. As monotherapy, oral sildenafil in low doses appears to control pulmonary hypertension safely and effectively in children undergoing operations to correct congenital heart defects, particularly when it is given both preoperatively and postoperatively. Further study is warranted.

Anterolateral minithoracotomies for the radical correction of congenital heart diseases.

During the past 10 years, minimally invasive surgical techniques have been applied more and more widely in both adult and pediatric populations, especially in female patients. Right anterolateral minithoracotomy is an alternative to median sternotomy that yields a better cosmetic outcome. From May 1997 through September 2008, 132 patients (107 females, 25 males) underwent open-heart surgery through right anterolateral minithoracotomy. Ages ranged from 1 to 49 years (mean, 10.12 yr). Mean body weight was 21.3 kg (range, 9.4-78 kg). Corrected defects included atrial septal defect, partial anomalous pulmonary venous connection, partial atrioventricular canal defect, ventricular septal defect alone or with pulmonary valve stenosis, tetralogy of Fallot, cor triatriatum, mitral valve defect, and pericardial cyst. The anterolateral skin incision was 5 to 7 cm. Our control group--which in the same period underwent the same interventional procedures through median sternotomy--consisted of 415 patients, 245 of whom were female (59%). There was no early or late death or major illness as a sequela. No patient required conversion to full sternotomy. All patients had gratifying cosmetic results at longer follow-up. Indeed the mortality and morbidity rates obtained through our approach were almost the same as those obtained through median sternotomy, and there were no significant differences in cardiopulmonary bypass time, aortic cross-clamp time, ventilation time, or postoperative hospital stay. We conclude that the right anterolateral minithoracotomy for correction of congenital heart defects offers superior cosmetic results without increasing morbidity or mortality rates and confers upon patients psychological and social satisfaction.