Neutrophil-Lymphocyte Ratio in Congenital Heart Surgery: What Is Known and What Is New?

Operative mortality after repair of congenital heart disease has improved dramatically over the past few decades. Nevertheless, there is always room for the additional mitigation of complications and mortality. Being able to anticipate adverse outcomes is clearly important, especially when using low-cost and easily accessible resources. The neutrophil-lymphocyte ratio (NLR) is defined as the ratio of the absolute neutrophil to lymphocyte count, which can be easily measured using a regular white blood cell count. Recently, preoperative NLR has been shown to be a predictor of outcomes in patients undergoing congenital heart surgery. Although it presented promising results, there are still many gaps to be filled like the normal value for children, the ideal cutoff value to predict adverse outcomes, the wide variation and its correlation with other biomarkers, and if it is a modifiable risk factor. The aim of this review is to understand the prognostic value of preoperative NLR as a biomarker predictor of outcomes in patients undergoing congenital heart surgery based on previous clinical studies and to propose future directions in order to solve the above-mentioned questions.

The role of the neutrophil-lymphocyte ratio for pre-operative risk stratification of acute kidney injury after tetralogy of Fallot repair.

INTRODUCTION: Acute kidney injury is a risk factor for chronic kidney disease and mortality after congenital heart surgery under cardiopulmonary bypass. The neutrophil-lymphocyte ratio is an inexpensive and easy to measure biomarker for predicting outcomes in children with congenital heart disease undergoing surgical correction. OBJECTIVE: To identify children at high risk of acute kidney injury after tetralogy of Fallot repair using the neutrophil-lymphocyte ratio. METHODS: This single-centre retrospective analysis included consecutive patients aged < 18 years who underwent tetralogy of Fallot repair between January 2014 and December 2018. The pre-operative neutrophil-lymphocyte ratio was measured using the last pre-operative complete blood count test. We used the Acute Kidney Injury Network definition. RESULTS: A total of 116 patients were included, of whom 39 (33.6%) presented with acute kidney injury: 20 (51.3%) had grade I acute kidney injury, nine had grade II acute kidney injury (23.1%), and 10 (25.6%) had grade III acute kidney injury. A high pre-operative neutrophil-lymphocyte ratio was associated with grade III acute kidney injury in the post-operative period (p = 0.04). Patients with acute kidney injury had longer mechanical ventilation time (p = 0.023), intensive care unit stay (p < 0.001), and hospital length of stay (p = 0.002). CONCLUSION: Our results suggest that the pre-operative neutrophil-lymphocyte ratio can be used to identify patients at risk of developing grade III acute kidney injury after tetralogy of Fallot repair.

Preoperative level of neutrophil-lymphocyte ratio: Comparison between cyanotic and acyanotic congenital heart disease.

INTRODUCTION: Elevated neutrophil-lymphocyte ratio (NLR) has been associated with poorer outcomes in children undergoing congenital heart surgery under cardiopulmonary bypass (CPB). OBJECTIVE: To compare preoperative NLR levels between cyanotic and acyanotic children undergoing surgical repair with CPB. METHODS: We performed a retrospective cohort study in 60-paired children (30 with tetralogy of Fallot [TOF] and 30 with ventricular septal defect [VSD]) between January 2018 and December 2019 matched by age, weight, and gender. Preoperative NLR was measured from the last complete blood count test before the surgery. All of them had negative viral screening. RESULTS: The median age in VSD children was 9.5 months (interquartile range [IQR]: 5-12), weight 7 kg (IQR: 5.5-8.7), 19 (63%) was female, and NLR was 0.45 (IQR: 0.3-0.65). The median age in TOF children was 8.5 months (IQR: 5-12), weight 7.6 kg (IQR: 5.8-8.7), 16 (53%) were female, and NLR was 0.67 (IQR: 0.41-1.1). Demographic parameters did not show any statistically significant difference between groups (p > .05). Children with TOF had higher preoperative NLR compared with VSD patients (p = .004). As lower O2 saturation as higher the NLR (p = .005). CONCLUSION: The preoperative level of NLR was higher in cyanotic congenital heart disease patients.

[Frecuencia de cardiopatías congénitas y adquiridas en 4,544 niños. Estudio basado en ecocardiografía]. / Frequency of 4,544 children with congenital and acquired heart disease. Echocardiographic study

Objective: To aim the incidence of congenital and acquired heart disease in our institution. Material and methods: A retrospective, transverse, descriptive and comparative study was conducted, from August 2001 to July 2011, in which we evaluated echocardiograms of patients between the ages of newborn to 18 years of age. They were grouped by heart disease. In the last statistical analysis, we obtained the frequency of occurrence and the proportional value of each cardiopathy. Results: In the last 10 years, we founded 4,544 patients with heart disease. The 14 most common cardiopathies represented 89% of the statistic. The congenital heart disease most frequent was persistent ductus arteriosus with 896 patients (19%), and the acquired heart disease most frequent was myocarditis with 116 patients (2.5%). The tetralogy of Fallot was most frequent congenital heart disease with cyanosis. Conclusions: The frequencies of congenital and acquired heart disease are different in difference geographic and ethnics areas.

Objetivo: Mostrar la frecuencia de las cardiopatías congénitas y adquiridas en nuestra institución. Material y métodos: Se realizó un estudio retrospectivo, transversal y descriptivo donde se revisaron las libretas de los estudios ecocardiográficos, realizados en pacientes cuyas edades fueron de recién nacidos a 18 años y se agruparon por tipos de cardiopatías. En el análisis estadístico obtuvimos la frecuencia de ocurrencia, el valor de la proporción de cada cardiopatía. Resultados: En los últimos 10 años ingresaron 4,544 pacientes con cardiopatía. Las 14 cardiopatías más frecuentes correspondieron al 89.21% de la estadística. La cardiopatía más frecuente fue la persistencia del conducto arterioso con 896 pacientes (19%) y la cardiopatía adquirida más frecuente fue la miocardiopatía, con 116 pacientes (2.5%). La tetralogía de Fallot fue la cardiopatía cianógena más frecuente, con 139 pacientes (3%), a diferencia de otros países. Conclusiones: La frecuencia de cardiopatías congénitas y adquiridas es variable en diferentes áreas étnicas y geográficas.

Clinically Asymptomatic Sleep-Disordered Breathing in Infants with Single-Ventricle Physiology.

OBJECTIVES: To assess clinically asymptomatic infants with single-ventricle physiology (SVP) for sleep-disordered breathing (SDB) in the supine and car seat positions using polysomnography. Polysomnography results also were compared with results of a standard Car Seat Challenge to measure the dependability of the standard Car Seat Challenge. STUDY DESIGN: This was an observational study of 15 infants with SVP. Polysomnography data included Obstructive Index, Central Index, Arousal Index, Apnea Hypopnea Index, and sleep efficiency. Polysomnography heart rate and oxygen saturation data were used to compare polysomnography with the standard Car Seat Challenge. RESULTS: Polysomnography demonstrated that all 15 infants had SDB and 14 had obstructive sleep apnea (Obstructive Index ≥1/hour) in both the supine and car seat positions. Infants with SVP had a statistically significant greater median Obstructive Index in the car seat compared with supine position (6.3 vs 4.2; P = .03), and median spontaneous Arousal Index was greater in the supine position compared with the car seat (20.4 vs 15.2; P = .01). Comparison of polysomnography to standard Car Seat Challenge results demonstrated 5 of 15 (33%) of infants with SVP with abnormal Obstructive Index by polysomnography would have passed a standard Car Seat Challenge. CONCLUSIONS: Infants with SVP without clinical symptoms of SDB may be at high risk for SDB that appears worse in the car seat position. The standard Car Seat Challenge is not dependable in the identification of infants with SVP and SDB. Further studies are warranted to further delineate its potential impact of SDB on the clinical outcomes of infants with SVP.

Electro-vectorcardiographic and electrophysiological aspects of Ebstein's anomaly.

Ebstein's anomaly is a congenital heart disease where the most important anatomic feature is the inferior displacement of the tricuspid valve leaflets. Vectorcardiographic features are mainly forgotten and electrocardiographic features may be unrecognized by cardiologists handling adult patients.

Dental considerations and recommendations in Eisenmenger syndrome: A report of an unusual paediatric case.

BACKGROUND: Eisenmenger syndrome (ES) is a heart cyanotic condition characterised by elevated pulmonary vascular resistance and an intra-cardiac right-to-left shunting of blood through a systemic-to-pulmonary circulation connection. Affected children usually exhibit severe hypoxia, clubbing of fingers/toes, haemoptysis, anaemia, and organ damage. CASE REPORT: During autumn 2015, the patient and her parents arrived at the paediatric dentistry clinic. The patient presented with the main complaint of generalised inflamed gingival tissues, severely protruded upper incisors, and evident abnormal mouth breathing. TREATMENT: This was performed under local analgesia, rubber-dam isolation, and antimicrobial prophylaxis with amoxicillin (50 mg/kg). The patient's parents agreed to the treatment plan through a signed informed consent. This treatment consisted of the placement of pit and fissure sealants on the four permanent first molars (which included enamel preparation with fissurotomy burs), in-depth gingiva/dental frequent cleanings, local fluoride varnish applications, and an exhaustive programme of at-home oral hygiene (brushing, flossing, and chlorhexidine mouth rinses), including adequate nutrition. Gingivoplasty surgery to remove residual enlarged tissues was indicated for the near future. FOLLOW-UP: The child did not return to the clinic. When contacted, the parents reported that their daughter's systemic condition worsened significantly. She was confined to a bed at home under palliative care, with a life-span expectation of only a few months. CONCLUSION: Comprehensive dental care of children with ES requires careful consideration of their medical condition, and dental care delivery should be coordinated with the paediatric cardiologist. General analgesia should be considered only in strictly selected cases, due to the high peri-operative mortality reported.

Implantación de stent en neonatos y lactantes menores con cardiopatía congénita cianosante ductus dependiente / Stent implantation in neonates and young infants with ductus-dependent cyanotic congenital heart disease

Introducción: Los pacientes con cardiopatía congénita cianosante ductus dependiente, requieren de su permeabilidad para garantizar el flujo al sistema pulmonar o al sistémico. En casos de permeabilidad del ductus arterioso, la implantación de un stent ductal mejora la sobrevida del paciente y acarrea complicaciones mínimas. Objetivos: General: caracterizar neonatos y lactantes menores con cardiopatía congénita cianosante ductus dependiente tratados con la implantación de stent ductal. Específicos: determinar la morbilidad y mortalidad en neonatos y lactantes menores con cardiopatía congénita cianosante ductus dependiente, tratados con implantación de stent ductal. Materiales y métodos: Se incluyeron 37 pacientes recién nacidos con cardiopatía congénita cianosante ductus dependiente tratados con implantación de stent ductal, entre el 1.º de enero de 2008 al 31 de diciembre de 2012 (5 años), en Cali, Colombia. Resultados: La implantación del stent ductal fue exitosa en 26 pacientes; uno falleció inmediatamente después del procedimiento. No hubo complicaciones mayores durante el procedimiento de implantación del stent. Diez pacientes fueron sometidos a cirugía de Blalock-Taussig modificada después de la implantación fallida del stent ductal. Conclusiones: La implantación del stent ductal se convierte en una herramienta importante en el paciente con cardiopatía congénita cianosante ductus dependiente ya que ofrece menor tasa de morbilidad y mortalidad.

Introduction: Patients with ductus-dependent cyanotic congenital heart disease require its permeability to ensure the flow to the pulmonary or systemic system. In cases of ductus arteriosus patency, the implantation of a ductal stent improves patient survival and carries minimal complications. Objectives: General: characterize neonates and young infants with ductus-dependent cyanotic congenital heart disease treated with ductal stent implantation. Specific: To determine the morbidity and mortality in neonates and young infants with ductus-dependent cyanotic congenital heart disease treated with ductal stent implantation. Materials and Methods: 37 newborn patients with ductus-dependent congenital cyanotic heart disease treated with ductal stent implantation, from January 1, 2008 to December 31, 2012 (5 years) in Cali, Colombia, were included. Results: Ductal stent implantation was successful in 26 patients; one died immediately after the procedure. There were no major complications during stenting procedure. Ten patients underwent modified Blalock -Taussig surgery after failed ductal stent implantation. Conclusions: Ductal stent implantation becomes an important tool in patients with ductus-dependent cyanotic congenital heart disease as it offers lower morbidity and mortality rate.

Síndrome de Eisenmenger en una paciente de la tercera edad / Eisenmenger syndrome in an elderly patient

Se describe el caso clínico de una paciente de 62 años de edad con cardiopatía congénita cianótica, quien fue ingresada en el Servicio de Cardiología del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba por presentar disnea. Al examen físico se constató cianosis, arritmia completa y soplo sistólico en mesocardio, con signos de insuficiencia cardíaca refractaria del lado derecho. Los exámenes complementarios efectuados confirmaron el diagnóstico de síndrome de Eisenmenger atribuible a comunicación interventricular. A pesar de la medicación que recibía evolucionó desfavorablemente hasta que falleció. Es poco frecuente que pacientes con esta complicación sobrevivan hasta la tercera edad.

A case report of a 62 year-old patient with cyanotic congenital heart disease, who was admitted to the Cardiology Department of "Saturnino Lora" Provincial Teaching Clinical Surgical Hospital of Santiago de Cuba to present with shortness of breath was described. On physical examination cyanosis, complete arrhythmia and systolic murmur in mesocardium with signs of refractory heart failure of the right side were found. Complementary tests confirmed the diagnosis of Eisenmenger syndrome attributable to ventricular septal defect. Despite receiving medication she made bad progress and died. It is rare for patients with this complication survive into old age.

Abscesso cerebral associado à cardiopatia congênita cianótica / Cerebral abscess in congenital heart disease

Abscesso cerebral associado a cardiopatia congênita cianótica não tem sido uma patologia comum na prática clínica. Foi feita extensa revisão bibliográfica sobre o tema e a casuística própria é apresentada. No período entre janeiro de 1992 e julho de 2000 foram internados 17 casos de abscesso cerebral associado à cardiopatia congênita cianótica no Serviço de Neurocirurgia do Hospital João Alves Filho e da Fundação Beneficente Hospital de Cirurgia (Aracaju, SE). Foram analisados quanto a sexo, idade, patologia cardíaca, microrganismos encontrados, localização do abscesso, quadro clínico, exames complementares, tratamento e prognóstico.Não houve predominância do sexo e a média etária foi de 6,5 anos. A cardiopatia congênita mais comum foi tetralogia de Fallot (76,5%), seguida da atresia tricúspide (11,7%), trilogia de Fallot (5,9%) e persistência do ducto arteriosus (5,9%). As sintomatologias predominantes foram febre(70,6%), cefaléia (53%), hemiparesia (47%), crise convulsiva (47%), náuseas e vômitos (35,3%) e papiledema (35,3%). A localização do abscesso predominou no lobo parietal (47,1%), seguido do lobo frontal (23,6%), frontoparietal (11,7%), temporoparietal (11,7%); abscessos múltiplos foram observados em um caso (5,9%). O tratamento cirúrgico foi realizado em 14 pacientes e o conservador, em três. Óbito ocorreu em quatro casos (23,5%.): em três devido a sepse e, em um, ao edema cerebral.

Brain abscess associated to congenital cyanotic heart disease has not been a common pathology in the clinical practice. During the period from January, 1992 to July, 2000, seventeen cases of brain abscess associated to congenital cyanotic heart disease were admitted in the Neurosurgery Service of the Hospital João Alves Filho and Fundação Beneficente Hospital de Cirurgia (Aracaju, Sergipe, Brazil). The following items were analyzed: sex, age, heart pathology, microbiological study, location of the abscess, clinical picture, suitable therapeuties and prognosis. No sex prevalence was observed and the mean age was 6.5 years. The most common congenital heart disease was tetralogy of Fallot (76.5%), followed by tricuspid atresia (11.7%), trilogy of Fallot (5.9%) and persistence ducto arteriosus (5.9%). Presenting symptons included: fever (70.6%), headache (53%), hemiparesis (47%), seizures (47%), nausea and vomiting (35.3%) and papilledema (35.3%). The predominant location of the abscess was the parietal lobe (47.1%) followed by the frontal lobe (23.6%), fronto-parietal (11.7%), temporo-parietal (11.7%); multiple abscesses were present in one case (5.9%). Surgical treatment was indicated in fourteen cases and conservative in three. The overall mortality rate was of 23.5%. There were four deaths: three due to sepsis andone due to intracranial hypertension. Two patients did not have the correction of the congenital heart disease due to the precariousness of their general condition.