Usefulness of the mitral valve Z score in predicting the need to close moderate- to large-sized atrial septal defects in infants with aortic coarctation.

Left ventricular anatomic substrates predisposing the development of congestive heart failure in infants with atrial left-to-right shunting after aortic coarctation repair were characterized. Mitral valve, but not aortic or left ventricular, hypoplasia correlated with the development of heart failure and the need for atrial defect closure shortly after coarctation repair.

Combined steroid treatment for congenital heart surgery improves oxygen delivery and reduces postbypass inflammatory mediator expression.

BACKGROUND: Steroid administration during cardiopulmonary bypass is thought to improve cardiopulmonary function by modulating bypass-related inflammation. This study was designed to compare preoperative and intraoperative methylprednisolone (MP) to intraoperative MP alone with respect to postbypass inflammation and clinical outcome. METHODS AND RESULTS: Twenty-nine pediatric patients undergoing bypass procedures were randomly assigned to receive preoperative and intraoperative MP (30 mg/kg 4 hours before bypass and in bypass prime, n=14) or intraoperative MP only (30 mg/kg, n=15). Myocardial inflammatory mediator mRNA expression was determined in paired atrial biopsies (before and after bypass) by ribonuclease protection. Before and after bypass, serum IL-6 and IL-10 were measured by ELISA. Postoperative outcome was assessed by intubation time, CICU length of stay, fluid balance, arterio-venous O2 difference (DeltaA-VO2), and inotrope requirements. Compared with intraoperative MP alone, combined preoperative and intraoperative MP was associated with reduced myocardial mRNA expression for IL-6, MCP-1, and ICAM-1 both before and after bypass (P<0.05). Patients who received combined steroids had lower serum IL-6 and increased IL-10 at end-bypass (P<0.05), although differences were negligible by 24 hours. Combined MP treatment was associated with reduced fluid requirements, lower body temperature, and lower DeltaA-VO2 for the first 24 hours after surgery (P<0.05), along with trends toward improvement in other clinical outcomes. CONCLUSIONS: Compared with intraoperative steroid treatment, combined preoperative and intraoperative steroid administration attenuates inflammatory mediator expression more effectively and is associated with improved indexes of O2 delivery in the first 24 hours after congenital heart surgery. These findings need to be confirmed in a larger multicenter trial.

Pancreatitis in Fontan patients is related to impaired ventricular relaxation.

BACKGROUND: Pancreatitis following cardiopulmonary bypass is a well-known complication in adults undergoing cardiac surgery. However, the occurrence of pancreatitis in pediatric patients undergoing repair of congenital heart disease is under-appreciated. Post-Fontan patients are particularly prone to postoperative pancreatitis. In an effort to identify specific perioperative factors predictive of postoperative pancreatitis, we retrospectively reviewed a group of Fontan patients. METHODS: From June 1996 to June 2001, 40 patients underwent a modified Fontan operation. Four patients developed acute pancreatitis postoperatively. The preoperative, intraoperative, and postoperative hemodynamics and ventricular function parameters were retrospectively analyzed and compared to 10 randomly selected Fontan patients who did not have pancreatitis. Preoperative echocardiographic and angiographic data, including digitized ventricular pressure tracings, were reviewed to obtain ventricular relaxation time constant (tau), pulmonary vascular resistance (PVR), ventricular end diastolic pressure (VEDP), positive dp/dt and negative dp/dt values. RESULTS: Patients developing acute pancreatitis had very high mortality (50%) compared to no mortality in the control group. The mean preoperative tau was significantly prolonged (41 ms vs 26 ms in control group, p < 0.001), and pre operative systemic output (Qs) lower in the pancreatitis group (mean 2.75 L/min/m2) compared with controls (Qs of 5.09 L/min/m2, p < 0.03). CONCLUSIONS: Impaired ventricular relaxation and decreased preoperative cardiac output are predictive of increased risk of postoperative pancreatitis in Fontan patients. Evaluation of preoperative diastolic function in these patients may provide additional insights in to clinical outcome following the Fontan procedure.

Surgical emergencies during pediatric interventional catheterization.

OBJECTIVE: To determine the incidence of catheter-related surgical emergencies during pediatric interventional catheterization procedures. STUDY DESIGN: We reviewed all interventional catheter procedures (n = 578) over a 4-year period (April 1996 to April 2000) to determine any complication during interventional catheterization that required surgery within 24 hours after catheterization. RESULTS: The overall incidence of surgical emergencies was 1.9% (70% confidence limits, 1.5% to 2.7%). Complications that required surgical intervention occurred with balloon dilation (valvuloplasty, angioplasty, n = 4), device deployment (coils, stents, atrial-septal defect devices, n = 5), transhepatic access (n = 1), and atrial transseptal puncture (n = 1). For the majority of interventions, the incidence of surgical emergencies was <4% except for two procedures (conduit and pulmonary artery angioplasty) with limited numbers of patients. There were no surgical emergencies during endomyocardial biopsy, coarctation angioplasty, or balloon atrial septostomy. CONCLUSIONS: Surgery was required in 1.9% of all interventional catheter procedures. Surgical emergencies occurred during a wide variety of catheter interventions and could not be predicted by the type of procedure performed.