Infants with congenital heart defects have reduced brain volumes.

Children with congenital heart defects (CHDs) have increased risk of cognitive disabilities for reasons not fully understood. Previous studies have indicated signs of disrupted fetal brain growth from mid-gestation measured with ultrasound and magnetic resonance imaging (MRI) and infants with CHDs have decreased brain volumes at birth. We measured the total and regional brain volumes of infants with and without CHDs using MRI to investigate, if certain areas of the brain are at particular risk of disrupted growth. MRI brain volumetry analyses were performed on 20 infants; 10 with- (postmenstrual age 39-54 weeks, mean 44 weeks + 5 days) and 10 without CHDs (postmenstrual age 39-52 weeks, mean 43 weeks + 5 days). In six infants with- and eight infants without CHDs grey and white matter were also differentiated. Infants with CHDs had smaller brains (48 ml smaller; 95% CI, 6.1-90; p = 0.03), cerebrums (37.8 ml smaller; 95% CI, 0.8-74.8; p = 0.04), and cerebral grey matter (25.8 ml smaller; 95% CI, 3.5-48; p = 0.03) than infants without CHD. Brain volume differences observed within weeks after birth in children with CHDs confirm that the brain impact, which increase the risk of cognitive disabilities, may begin during pregnancy.

Relocation of patients after cardiac surgery: is it worth the effort?

BACKGROUND: Fast-track protocols may facilitate early patient discharge from the site of surgery through the implementation of more expedient pathways. However, costs may merely be shifted towards other parts of the health care system. We aimed to investigate the consequence of patient transfers on overall hospitalisation, follow-up and readmission rate after cardiac surgery. METHODS: A single-centre descriptive cohort study using prospectively entered registry data. The study included 4,515 patients who underwent cardiac surgery at Aarhus University Hospital during the period 1 April 2006 to 31 December 2012. Patients were grouped and analysed based on type of discharge: Directly from site of surgery or after transfer to a regional hospital. The cohort was obtained from the Western Denmark Heart Registry and matched to the Danish National Hospital Register. RESULTS: Median overall length of stay was 9 days (7.0;14.4). Transferred patients had longer length of stay, median difference of 2.0 days, p < 0.001. Time to first outpatient consultation was 41(30;58) days in transferred patients vs. 45(29;74) days, p < 0.001. 18.6% was readmitted within 30 days. Mean time to readmission was 18.4 ± 6.4 days. Median length of readmission was 3(1,6) days. There was no difference in readmissions between groups. Leading cause of readmission was cardiovascular disease with 48%. CONCLUSION: Transfer of patients does not overtly reduce health care costs, but overall LOS and time to first outpatient consultation are substantially longer in patients transferred to secondary hospitals than in patients discharged directly. Readmission rate is high during the month after surgery, but with no difference between groups.

Atrial fibrillation and stroke in adult patients with atrial septal defect and the long-term effect of closure.

OBJECTIVE: To estimate the risk of atrial fibrillation (AF) and stroke and the impact of closure in patients with atrial septal defect (ASD) compared with a general population cohort. METHODS: All adult Danish patients (>18 years) diagnosed with ASD from 1977 to 2009 (N=1168) were identified through population-based registries. Using Cox regression, we compared ASD patients' risk of AF and stroke with an age-matched and gender-matched comparison cohort. We computed prevalence proportions of anticoagulation and antiarrhythmic medicine use before and after closure and described stroke-related mortality. RESULTS: Median follow-up was 9.6 years (range 1-33 years). Patients with ASD had a higher risk of first-time AF (adjusted HR 8.2; 95% CI 6.6 to 10.2) after closure than the comparison cohort, but with no difference between transcatheter and surgical closure (HR 1.5, 95% CI 0.6 to 3.5). Patients without prevalent AF had a 10-year cumulative incidence of AF of 11% (95% CI 9% to 14%) after closure compared with 2% (95% CI 1.8% to 2.5%) in the comparison cohort. Patients with ASD with prevalent AF continued to use anticoagulation medicine after closure/diagnosis. Patients with ASD had increased risk of stroke without closure (adjusted HR 2.6; 95% CI 1.4 to 3.0) and with closure (adjusted HR 2.0; 95% CI 1.4 to 2.7). Risk of stroke after closure was related to AF (HR adjusted for AF 1.3; 95% CI 0.9 to 1.9). CONCLUSIONS: Patients with ASD had a higher risk of first-time AF after closure than the comparison cohort. There was no effect of closure on the use of AF-related medicine in patients with prevalent AF.

High pulse pressure is not associated with abnormal activation of the renin-angiotensin-aldosterone system in repaired aortic coarctation.

We investigated the relationship between pulse pressure (PP)--a surrogate marker of arterial stiffness-and activity of the renin-angiotensin-aldosterone system (RAAS) in adult patients with repaired coarctation and normal left ventricular (LV) function. A total of 114 patients (44 (26-74) years, 13 (0.1-40) years at repair) and 20 healthy controls were examined with 24-h ambulatory blood pressure monitoring, echocardiography, vasoactive hormone levels and magnetic resonance of the thoracic aorta. Forty-one patients (36%) were taking antihypertensives (28 RAAS inhibitors). Fifty-one had mean 24-h blood pressures >130/80 mm Hg. Hypertension was not associated with age at repair (P=0.257). Patients had higher PP and LV mass compared with controls (52±11 vs. 45±5 mm Hg and 221±71 vs. 154±55 g, respectively; both P<0.05). Differences were more pronounced in the presence of recoarctation, but independently of RAA levels. Even normotensive patients had higher LV mass than controls. LV mass and recoarctation were correlated with PP levels. In conclusion, adult patients with repaired coarctation have increased PP and LV mass compared with controls. PP increased with increasing recoarctation. Hypertension was present also in the absence of recoarctation. These changes could not be explained by abnormal activation of the RAAS.

The neonatal but not the mature heart adapts to acute tachycardia by beneficial modification of the force-frequency relationship.

The force-frequency relationship (FFR) reflects alterations in intracellular calcium cycling during changing heart rate (HR). Tachycardia-induced heart failure is associated with depletion of intracellular calcium. We hypothesized (1) that the relative resistance to tachycardia-induced heart failure seen in neonatal pigs is related to differences in calcium cycling, resulting in different FFR responses and (2) that pretreatment with digoxin to increase intracellular calcium would modifies these changes. LV +dP/dt was measured during incremental right atrial pacing in 16 neonatal and 14 adult pigs. FFR was measured as the change in +dP/dt as HR was increased. Animals were randomized to control or intravenous bolus digoxin (n = 8 neonate pigs in the 0.05 mg/kg group and n = 7 adult pigs in the 0.025 mg/kg group) and paced for 90 min at 25 bpm greater than the rate of peak +dP/dt. Repeat FFR was then obtained. The postpacing FFR in neonatal control pigs shifted rightward, with peak force occurring 30 bpm greater than baseline (P < 0.03). There was no vertical shift; thus, force at 150 bpm decreased (P < 0.03) and force at 300 beats/min increased (P < 0.08). In adult control pigs, FFR shifted downward (P < 0.01), with decreased force generation at all HRs. In both neonates and adult pigs, digoxin increased +dP/dt at all HRs; however, in neonate pigs digoxin decreased the contractile reserve by abrogation of the rightward shift of FFR. An adaptive response to tachycardia in the neonate pig leads to improved force generation at greater HRs. Conversely, the response of the mature pig heart is maladaptive with decreased force generation. Pretreatment with digoxin modifies these responses.

Chronic pain in adults after thoracotomy in childhood or youth.

BACKGROUND: Chronic pain is common after thoracotomy with reported prevalence rates of 20-60%. The pain may be caused by damage to the intercostal nerves during surgery. Some studies have suggested that young age at the time of surgery reduces the risk of developing chronic pain. So far, no studies have examined if children and adolescents develop chronic pain after thoracotomy. METHODS: Eighty-eight patients, mean (sd) age 39.3 (7.7) yr, who underwent thoracotomy between the age of 0 and 25 yr were asked to recall the duration of postoperative pain and-if pain was still present-to describe intensity and character of pain. In addition, all patients underwent quantitative sensory testing. RESULTS: Fourteen patients (16%) recalled that their postoperative pain had lasted for more than 3 months: one (3.2%) patient in the youngest group (0-6 yr), seven (19.4%) patients in the age group 7-12 yr, and six (28.5%) patients in the age group 13-25 yr (P=0.03). Three out of the 14 patients, who were 11, 11, and 18 yr of age at the time of surgery, still had pain at present. Quantitative sensory testing revealed hypo- and hyperphenomena in most patients, including those with persistent pain. Tactile detection thresholds and pressure detection thresholds were significantly higher on the operated side when compared with the contralateral side (n=88; P<0.001). CONCLUSIONS: The risk of developing chronic pain after thoracotomy seems to be lower if surgery is performed at a young age. Pain after thoracotomy is likely to be of neuropathic origin.

Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease.

The present single-center cohort study was based on a clinical intensive care unit database containing data on 1128 consecutive children undergoing their first operation for congenital heart disease between 1993 and 2002 at Aarhus University Hospital, Skejby, Denmark. A total of 130 (11.5%) children developed postoperative acute renal failure (ARF) managed with peritoneal dialysis (PD). Logistic regression analysis was used to examine risk factors for complications related to PD and to compare mortality between ARF and non-ARF patients controlling for potential confounding factors. A total of 43 complications related to PD were registered in 27 (20.8%) patients. Major complications were seen in eight (6.2%) patients, and only two (1.5%) patients were switched to hemodialysis after peritonitis and hemicolectomy due to bowel perforation. The main risk factors for complications to PD were duration of PD, high RACHS-1 score (Risk Adjusted Classification for Congenital Heart Surgery), and hyperkalemia at initiation of PD. Overall, in-hospital mortality was 6.8% (76/1128). Mortality of ARF patients was 20.0% compared to 5.0% among non-ARF patients (adjusted odds ratio=1.91, 95% confidence interval=1.10-3.36). After stratification, ARF was strongly associated with increased mortality in the subgroups of patients with the lowest overall risk of dying (age> or =1 year, body weight> or =5 kg, RACHS-1 score <3, and no preoperative cyanosis). For patients at high risk of dying (age <1 year, body weight <5 kg, RACHS-1 score> or =3, cardiopulmonary bypass time> or =60 min, and preoperative cyanosis), the association between ARF and mortality was substantially weaker. In conclusion, postoperative ARF was associated with increased mortality in children operated for congenital heart disease. Major complications to PD were few, and our data strongly support that PD is a simple, safe, feasible, and robust dialysis modality for the management of ARF in children.

Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.

BACKGROUND: Limited data exist on the risk factors for acute renal failure (ARF) following cardiac surgery in children with congenital heart disease. This cohort study was conducted to examine this subject, as well as changes in the incidence of ARF from 1993 to 2002, the in-hospital mortality and the time spent in the intensive care unit (ICU). METHODS: One thousand, one hundred and twenty-eight children, operated on for congenital heart disease between 1993 and 2002, were identified from our prospectively collected ICU database to obtain data on potential risk factors. RESULTS: A total of 130 children (11.5%) developed ARF after surgery. A young age [> or =1.0 vs. <0.1 year; odds ratio (OR), 0.23; 95% confidence interval (CI), 0.12-0.46], high Risk Adjusted Classification of Congenital Heart Surgery (RACHS-1) score (OR, 2.72; 95% CI, 1.66-4.45) and cardiopulmonary bypass (CPB) (<90 min vs. none; OR, 2.68; 95% CI, 1.03-6.96; > or =90 min vs. none; OR, 12.94; 95% CI, 5.46-30.67) were independent risk factors for ARF. The risk of ARF decreased during the study period. Children with ARF spent a significantly longer time in the ICU (2-7 days vs. <2 days, P = 0.002; > or =7 days vs. <2 days, P < 0.001) compared with non-ARF patients, and showed increased in-hospital mortality (20% vs. 5%, P < 0.001). CONCLUSION: A young age, high RACHS-1 score and CPB were independent risk factors for ARF after surgical procedures for congenital heart disease in children. The risk of ARF decreased during the study period. Children with severe ARF spent a longer time in the ICU, and the mortality in ARF patients was higher than that in non-ARF patients.

MRI-based multiscale models for the hemodynamic and structural evaluation of surgically reconstructed aortic arches.

The surgical reconstruction of the aortic arch is necessary in pediatric patients suffering from different types of congenital heart malformations, in particular, coarctation of the aorta. Among the reconstruction techniques used in surgical practice end-to-end anastomosis (E/E), Gore-tex graft interposition (GGI) and Gore-tex patch graft aortoplasty (GPGA) are compared in this study with a control model, employing a computational fluid-structure-interaction scheme. This study analyzes the impact of introducing synthetic materials on aortic hemodynamics and wall mechanics. Three-dimensional (3D) geometries of a porcine aortic arch were derived from magnetic resonance imaging (MRI) images. Inlet conditions were derived from MRI velocimetry. A multiscale approach was used for the imposition of outlet conditions, wherein a lumped parameter net provided an active afterload. Evidence was found that ring-like repairs increased blood velocity, whereas GPGA limited it. Vortex presence was greater and longer lasting in GGI. The highest power losses corresponded to GPGA. GGI had an intermediate effect, while E/E dissipated only slightly more than the control case. Wall stresses peak in a longitudinal strip on the subject's left side of the vessel, particularly in the frontal area. There was a concentration of stress at the suture lines. All surgical techniques performed equally well in restoring physiological pressures.

Maternal hyperglycemia improves fetal cardiac function during tachycardia-induced heart failure in pigs.

BACKGROUND: Fetal tachycardia often leads to cardiac failure, which in experimental settings can be prevented by direct fetal glucose-insulin administration. In this study, we hypothesize that similar effects can be obtained indirectly by inducing maternal hyperglycemia. METHODS AND RESULTS: Systolic and diastolic indices (dP/dt(max) and tau) of left ventricular function were measured by use of high-fidelity catheters during 180 minutes of aggressive atrial pacing ( approximately 300 bpm) in 12 preterm porcine fetuses. In 6 fetuses, maternal hyperglycemia (15 mmol/L) was induced for the last 120 minutes of pacing. The remaining fetuses served as controls. Glucose, insulin, and free fatty acid levels were determined, as was fetal myocardial glycogen content. Maternal glucose infusion led to significant fetal hyperglycemia and hyperinsulinemia but did not change the inherently low fetal levels of free fatty acids. There were no differences between groups with regard to dP/dt(max) (1025+/-226 and 1037+/-207 mm Hg, P=NS) and tau (20.6+/-2.0 and 21.4+/-1.6 ms, P=NS) at baseline (100%). During the 180 minutes of pacing, systolic function (dP/dt(max)) and diastolic function (tau) deteriorated more in the control group than in the hyperglycemic group (P<0.001 for both). At 180 minutes, dP/dt(max) was 62+/-18% of baseline in controls and 85+/-11% in hyperglycemic fetuses (P=0.03), and tau was 117+/-12% and 98+/-4%, respectively (P=0.004). CONCLUSIONS: Induced maternal hyperglycemia improves fetal cardiac function during fetal tachycardia and suggests a possible additional therapeutic option to improve the function of the failing fetal heart before or during antiarrhythmic therapy. The findings may be relevant in fetal heart failure in general.

Synchronous bilateral VATS decortication for paediatric bilateral empyema.

Bilateral empyema is a rare condition in children. In the current era of minimally invasive surgical treatment, our experience with two cases suggests that video thoracoscopic drainage and decortication for children with bilateral empyema is safe, effective, and potentially less expensive.

Neutrophil and platelet dynamics at organ level after cardiopulmonary bypass: an in vivo study in neonatal pigs.

The aim was to investigate if organ dysfunction is a consequence of cell accumulation in the tissue and whether this accumulation is caused by the cardiopulmonary bypass (CPB) procedure. Twenty-six piglets were used in the sham group (sternotomy, n=12) or in the CPB group (sternotomy, CPB, n=14). Isotope-labeled autologous (99m)Tc-neutrophils (PMNs) and (111)In-platelets were infused and dynamically followed at organ level with a gamma camera before, during, and 4 h after termination of CPB. The CPB group showed a 49% increase in (99m) Tc-PMNs in the kidneys in the postoperative period compared to a decrease of 2% in the sham group. A less marked decrease was observed in the lungs and peripheral blood between the two groups. The increased radioactivity at organ level post-CPB could be due to changes in flow, extraction in the organ or accumulation of cells, especially in the kidneys and lungs, and might contribute to temporary organ dysfunction postoperatively.

Effects of exercise and respiration on blood flow in total cavopulmonary connection: a real-time magnetic resonance flow study.

BACKGROUND: Little is known about blood flow and its relationship to respiration during exercise in patients with total cavopulmonary connection (TCPC). METHODS AND RESULTS: We studied 11 patients 12.4+/-4.6 years (mean+/-SD) of age 5.9+/-2.8 years (mean+/-SD) after TCPC operation. Real-time MRI was used to measure blood flow in the superior vena cava (SVC), inferior vena cava (IVC), and ascending aorta under inspiration and expiration during supine lower-limb exercise (rest, 0.5 and 1.0 W/kg) on an ergometer bicycle. IVC and aortic flow increased from 1.60+/-0.52 and 2.99+/-0.83 L/min per m2 at rest to 2.58+/-0.71 and 3.97+/-1.20 L/min per m2 at 0.5 W/kg and to 3.25+/-1.23 and 4.62+/-1.49 L/min per m2 at 1.0 W/kg (P< or =0.05). SVC flow remained unchanged. Resting flow in the IVC was greater during inspiration (2.99+/-1.25 L/min per m2) than during expiration (0.83+/-0.44 L/min per m2) (inspiratory/mean flow ratio, 1.9+/-0.5), and retrograde flow was present during expiration (11+/-12% of mean flow). The predominance of inspiratory flow in IVC diminished with exercise to an inspiratory/mean flow ratio of 1.5+/-0.2 (P< or =0.05) and 1.4+/-0.3 at 0.5 and 1.0 W/kg, respectively. CONCLUSIONS: In the TCPC, circulation IVC and aortic but not SVC flows increase with supine leg exercise. Inspiration facilitates IVC flow at rest but less so during exercise, when the peripheral pump seems to be more important.

Plasma cytokines do not reflect expression of pro- and anti-inflammatory cytokine mRNA at organ level after cardiopulmonary bypass in neonatal pigs.

BACKGROUND: Plasma concentrations of inflammatory markers are increased in response to the trauma of cardiac surgery and cardiopulmonary bypass (CPB). It is, however, unknown whether the plasma cytokine levels and cytokine mRNA expression at organ level reflect each other. METHODS: Twenty-six piglets (17-19 days) were allocated to the sham-group (sternotomy only, n = 13) or to the CPB-group (sternotomy, 120 min CPB procedure with 60-min aortic cross-clamp, n = 13). The pigs were observed for 0.5 h or 4 h post-CPB. Plasma levels of IL-1beta, IL-6, IL-8 and IL-10 and mRNA expression of TNF-alpha, IL-1beta, IL-6, IL-8, IL-10 and iNOS in organs were registered with concomitant changes in oxygenation index (OI) and expiratory nitric oxide (NO). RESULTS: In pigs killed 0.5 h post-CPB there was a significant increase in IL-10 mRNA in the lungs and kidneys compared with the sham-group. IL-1beta mRNA was detectable in the kidneys and lungs of the CPB-pigs, while IL-6 mRNA was up regulated only in lungs. In pigs killed 4 h post-CPB a significantly higher IL-6 mRNA was found in heart tissue and a lower IL-10 mRNA was found in lungs of CPB pigs compared with the sham-group. There was a concomitant significant increase in OI and increased plasma IL-8 and IL-10 concentrations in the CPB-pigs compared with the sham-pigs. CONCLUSION: The cytokine mRNA expression pattern was very different for the pigs killed already 0.5 h after the CPB procedure compared with the pigs killed 4 h post-CPB. The plasma cytokine levels poorly reflected mRNA expression of the pro- and anti-inflammatory cytokines.

Hybrid approaches to complex congenital cardiac surgery.

OBJECTIVES: A hybrid operation is a joint procedure involving the interventional cardiologist and the cardiac surgeon concomitantly to optimise surgical management. The aim of our study was to demonstrate the conceptual development and the feasibility of a hybrid approach to complex congenital cardiac surgery. METHODS: Descriptive study of two different indications for concomitant intervention by the cardiologist and the cardiac surgeon. Seven patients with complex congenital heart defects requiring high risk operative interventions were included in the study. The indications were: (1) intraoperative stenting of a pulmonary artery stenosis with concomitant additional surgical procedures (n=4). (2) Balloon occlusion of Blalock-Taussig shunts or major aorto-pulmonary collateral artery to control pulmonary blood flow during surgical repair (n=3). RESULTS: All patients had successful hybrid procedures. There were no important complications related to the temporal proximity of the interventional procedure and cardiac surgery, the latter being significantly facilitated by the former. CONCLUSIONS: Intraoperative stenting of pulmonary artery stenosis with additional surgical repair and balloon occlusion on cardiopulmonary bypass can be performed safely and may be complementary in patients with complex lesions by providing a better result in combination than either alone can offer.

Pulmonary endothelial dysfunction after cardiopulmonary bypass in neonatal pigs.

BACKGROUND: In neonatal pigs cardiopulmonary bypass (CPB) is associated with endothelial dysfunction in isolated large pulmonary arteries. It is, however, of great importance if this functional change extends to the small pulmonary resistance arteries, which are the key regulators of pulmonary flow and pressure. The aim of this study was to assess changes in pulmonary microvascular function after CPB using a clinically relevant pediatric procedure. METHODS: From three groups of neonatal pigs (CPB-, sham- and control group) pulmonary resistance arteries and systemic resistance arteries (from skeletal muscle) were isolated and mounted as ring preparations in wire myographs. Vessel diameters were less than 500 microm. Concentration-response curves were constructed for norepinephrine (NA), vasopressin (Vp), and the thromboxane A2-analog U46619, while the endothelium-dependent and -independent vasodilator functions were assessed as responses to acetylcholine and nitric oxide (NO). RESULTS: Maximum pulmonary vasodilator response to acetylcholine was attenuated after CPB compared with sham-operated and control animals (P=0.04). NO-induced relaxation, and contractile responses to NA, Vp, and U46619 were not influenced by CPB. In systemic arteries no changes in contractile or relaxant responses were seen after CPB. CONCLUSION: CPB seems to induce pulmonary endothelial dysfunction in pulmonary but not peripheral resistance arteries in neonatal piglets.

Flow during exercise in the total cavopulmonary connection measured by magnetic resonance velocity mapping.

OBJECTIVE: To measure caval and pulmonary flows at rest and immediately after exercise in patients with total cavopulmonary connection (TCPC). DESIGN: An observational study using the patients as their own controls. SETTING: Using a combination of magnetic resonance (MR) phase contrast techniques and an MR compatible bicycle ergometer, blood flow was measured in the superior vena cava, the tunnel from the inferior vena cava, and in the left and right pulmonary arteries during rest and on exercise (0.5 W/kg and 1.0 W/kg). PATIENTS: Eleven patients aged 11.4 (4.6) years (mean (SD)) were studied 6.3 (3.8) years after TCPC operation. MAIN OUTCOME MEASURES: Volume flow measured in all four branches of the TCPC connection during rest and exercise. RESULTS: Systemic venous return (inferior vena cava plus superior vena cava) increased from 2.5 (0.1) l/min/m2 (mean (SEM)) to 4.4 (0.4) l/min/m2 (p < 0.05) during exercise, with even distribution to the two pulmonary arteries. At rest, inferior vena caval flow was higher than superior vena caval flow, at 1.4 (0.1) v 1.1 (0.1) l/min/m2 (p < 0.05). During exercise, inferior vena caval flow doubled (to 3.0 (0.3) l/min/m2) while superior vena caval flow only increased slightly (to 1.4 (0.1) l/min/m2) (p < 0.05). The increased blood flow mainly reflected an increase in heart rate. The inferior vena caval to superior vena caval flow ratio was 1.4 (0.1) at rest and increased to 1.8 (0.1) (p < 0.05) at 0.5 W/kg, and to 2.2 (0.2) at 1.0 W/kg (p < 0.05). CONCLUSIONS: Quantitative flow measurements can be performed immediately after exercise using MR techniques. Supine leg exercise resulted in a more than twofold increase in inferior vena caval flow. This was equally distributed to the two lungs, indicating that pulmonary resistance rather than geometry decides flow distribution in the TCPC circulation.

Tissue injury and the inflammatory response to pediatric cardiac surgery with cardiopulmonary bypass: a descriptive study.

BACKGROUND: There are few detailed descriptions of the inflammatory response to cardiac surgery with cardiopulmonary bypass (CPB) in children beyond 24 h postoperatively. This is especially true for the antiinflammatory cytokines and the extent of tissue injury. The aim of the current study was to describe the inflammatory and injury responses in uncomplicated pediatric cardiac surgery with CPB, where methylprednisolone and modified ultrafiltration (MUF) were used. METHODS: Blood samples were collected up to 48 h postoperatively. Cytokines (tumor necrosis factor-alpha and interleukin-6, -1beta, -10, and -1ra), complement (C3d and C4d) and coagulation system (prothrombin activation fragments 1 and 2 and antithrombin III) activation, neutrophil elastase, and the resulting tissue injury (creatine kinase, lactate dehydrogenase, alanine transaminase, amylase, and gamma-glutamyl transferase) were measured. RESULTS: The proinflammatory cytokine release varied widely, in contrast to a clear-cut antiinflammatory response. Cytokine concentrations did not decrease immediately after MUF, and no rebound increases later in the postoperative period were observed. The coagulation system, but not complement, was activated. There was a late release of C-reactive protein. Tissue injury could be quantified biochemically without evidence of hepatic or pancreatic dysfunction. CONCLUSION: In this group of uncomplicated subjects, the antiinflammatory cytokine and tissue injury responses were well defined, in contrast to a variable proinflammatory cytokine release. This was accompanied by activation of the coagulation system but not of complement. Concentrations of inflammatory mediators did not decrease immediately after MUF, and there was no evidence for rebound release later in the postoperative period.

Self-management of oral anticoagulation in children with congenital heart disease.

OBJECTIVE: The concept of self-management of oral anticoagulation has been shown to entail better quality of treatment than conventional management when assessed in selected adults. We have extended the concept of self-management to include children with congenital cardiac disease, hypothesizing self-management of oral anticoagulation is also possible in this subset of patients. Our aim was to assess the quality of self-management. METHODS: We trained 14 children aged from 2.2 to 15.6 years, with a mean age of 9.7 years, and their parents, in domiciliary analysis of the International Normalized Ratio and necessary adjustment of dosage of coumarin. The curriculum for training lasted for 27 weeks, and the patients and their parents were followed for a period of up to 31 months by weekly measurement of the values obtained for the International Normalized Ratio. RESULTS: The patients were observed over a mean of 547 days, with a range from 214 to 953 days. The patients were within the therapeutic targetted range of the International Normalized Ratio for a median of 65.5% of the time, with a range from 17.6% to 90.4%. None of the patients experienced thromboembolic or bleeding complications requiring doctoral intervention. All the patients and their parents expressed full satisfaction with the treatment. CONCLUSION: Self-management of oral anticoagulation provides a good quality of treatment, which is feasible and safe in selected children with congenital cardiac disease.