An unusual case of coronary artery compression that did not preclude successful transcatheter pulmonary valve placement.

During transcatheter pulmonary valve placement, coronary compression observed during simultaneous right ventricular outflow tract angioplasty and coronary angiography typically contraindicates valve implantation. We present a unique patient with tetralogy of Fallot who underwent successful transcatheter Melody valve placement despite coronary compression observed during right ventricular outflow tract balloon angioplasty.

Fontan Fenestration Closure Prior to Posterior Spinal Fusion in Patients With Single-Ventricle Heart Disease.

STUDY DESIGN: Case series. OBJECTIVE: To describe transcatheter closure of the Fontan fenestration prior to posterior spinal fusion in two children to prevent paradoxical venous air embolism during the operation. SUMMARY OF BACKGROUND DATA: Scoliosis is common among patients with single-ventricle congenital heart disease who have undergone Fontan operation and spinal surgery can offer physiologic benefits. Venous air embolism is a rare, but important reported complication during spinal surgery performed in the prone position. Patients with Fontan circulation can have significant right to left shunting via a patent Fontan fenestration that can increase the risk of paradoxical systemic embolization of any entrained venous air. METHODS: We retrospectively reviewed the charts of two patients with single-ventricle congenital heart disease who had undergone fenestrated Fontan operation and underwent transcatheter fenestration closure prior to spinal fusion. RESULTS: Two patients with Fontan circulation underwent successful transcatheter fenestration closure with Amplatzer Ductal Occluder II devices. Five to 6 months after closure, both underwent uncomplicated posterior spinal fusion. CONCLUSION: Transcatheter closure of the Fontan fenestration prior to spinal fusion in two with Fontan circulation and scoliosis is a rare, but important indication for fenestration closure that warrants emphasis. LEVEL OF EVIDENCE: N/A.

Alternative anticoagulation during cardiovascular procedures in pediatric patients with heparin-induced thrombocytopenia.

Patients with heparin-induced thrombocytopenia (HIT) that require anticoagulation for cardiovascular procedures represent a challenging and high-risk group. Bivalirudin and argatroban have been successfully used as alternative anticoagulants in adult patients with HIT. There have been few experiences published involving the pediatric population and controversy exists regarding the properties and optimal dosing of these drugs. This report describes the experience of managing two pediatric patients with HIT that underwent cardiovascular procedures requiring anticoagulation. Bivalirudin was used in both cases for anticoagulation during cardiopulmonary bypass, while argatroban was used without complications during cardiac catheterization. A description of perfusion and anticoagulation protocols is included.

Perioperative hyperglycemia: effect on outcome after infant congenital heart surgery.

BACKGROUND: Studies demonstrate that cardiopulmonary bypass (CPB) causes intraoperative and postoperative hyperglycemia. Hyperglycemia has been associated with morbidity and mortality after infant cardiac surgery. We studied the effects on early postoperative outcomes of glucose (GLU) changes during and after pediatric cardiac surgery. METHODS: The records of 144 infants less than 10 kg who underwent CPB for a variety of congenital cardiac procedures were reviewed. The GLU values (at multiple intervals during and after surgery), age, weight, CPB time, ultrafiltration volume, and risk adjustment for congenital heart surgery (RACHS-1) score were recorded. Univariate and multivariate linear and binary logistic regression were used to examine the dependence of the composite outcome mortality or postoperative infection, the mechanical ventilation time (VENT time), and the length of stay (LOS), on these variables. RESULTS: The RACHS-1 score was the only significant predictor of the composite variable "mortality or infection" (p = 0.008). Glucose at any time was not a significant factor predicting this outcome. Lower pre-CPB GLU, younger age, and higher RACHS-1 score were significant predictors of greater LOS and VENT time. CONCLUSIONS: In this study, post-CPB and postoperative hyperglycemia were not risk factors for postoperative morbidity and mortality after infant cardiac surgery.

Dexmedetomidine/ketamine for diagnostic cardiac catheterization in a child with idiopathic pulmonary hypertension.

The use of a combination of dexmedetomidine and ketamine to provide procedural sedation in a 12-year old boy with a diagnosis of idopathic pulmonary hypertension and a behavioral disorder, undergoing diagnostic cardiac catheterization, is presented. Following a loading dose of ketamine one mg/kg and dexmedetomidine one mcg/kg, an infusion of dexmedetomidine at one mcg/kg/hr was used with the patient breathing spontaneously. Stable hemodynamics were observed throughout the procedure and pulmonary vascular resistance was measured under three conditions. The dexmedetomidine infusion was continued for two hours post-catheterization, facilitating a smooth emergence.

Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery.

AIM: To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery. BACKGROUND: The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population. METHODS/MATERIALS: Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation. RESULTS: Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg x kg(-1) vs 0.2 mg x kg(-1), P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes. CONCLUSIONS: A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg x kg(-1) x h(-1), a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold.

Initial experience with dexmedetomidine for diagnostic and interventional cardiac catheterization in children.

BACKGROUND: Children undergoing diagnostic and interventional cardiac catheterization require deep sedation or general anesthesia (GA). Dexmedetomidine, a selective alpha-2 adrenergic agonist, has sedative, analgesic and anxiolytic properties without respiratory depression. These characteristics make it potentially suitable as a sedative agent during diagnostic procedures in children. We report our experience using dexmedetomidine in 20 children aged 3 months to 10 years undergoing cardiac catheterization. METHODS: Following a midazolam premedication, intravenous access was secured facilitated by the inhalation of sevoflurane in oxygen. A loading dose of 1 microg x kg(-1) dexmedetomidine was administered over 10 min followed by an initial infusion rate of 1 microg x kg(-1) x h(-1). Nasal cannulae were applied, allowing endtidal CO2 monitoring with the patients breathing spontaneously. Hemodynamic parameters, Bispectral Index Score (BIS) and sedation score were measured every 5 min. Patient movement or evidence of inadequate sedation were treated with propofol (1 mg x kg(-1)). The dexmedetomidine infusion rate was titrated to the level of sedation to a maximum of 2 microg x kg(-1) x h(-1) to maintain a sedation score of 4-5 and a BIS value <80. RESULTS: Five patients (25%) had some movement on local infiltration or groin vessel access. This did not necessitate restraint or result in difficulty securing vascular access. No patients failed sedation that required the addition of another sedative agent or conversion to GA; eight patients were sedated with dexmedetomidine alone; however, 12 (60%) patients did receive a propofol bolus at some time during the procedure due to movement, increasing BIS value or in anticipation of stimulation. There were no incidences of airway obstruction or respiratory depression. In all cases the heart rate and blood pressure remained within 20% of baseline. No patient required treatment for profound bradycardia or hypotension. The average infusion rate for dexmedetomidine following the loading dose was 1.15 (+/-0.29)microg x kg(-1) x h(-1) (range 0.6-2.0 microg x kg(-1) x h(-1)). CONCLUSIONS: This initial experience showed dexmedetomidine, with or without the addition of propofol, may be a suitable alternative for sedation in spontaneously breathing patients undergoing cardiac catheterization.

Evaluation of biocompatible cardiopulmonary bypass circuit use during pediatric open heart surgery.

The contact of blood with nonbiological surfaces during cardiopulmonary bypass (CPB) induces a whole body inflammatory response and increases postoperative morbidity directly related to bleeding complications and end organ dysfunction. Methods to reduce these effects have included modification of extracorporeal circuits through biocompatible coating of disposables and the application of various pharmacological agents. Biocompatible coated surfaces are designed to mimic physiologic surfaces. This study was designed to ascertain the effects of using coated circuits during pediatric CPB. After Institutional Review Board approval and parent/guardian consent, patients undergoing CPB, weighing less than 15 kg, with target CPB temperatures more than 28 degrees C, were enrolled into the Coated Circuit Group using an entirely biocompatible CPB circuit with poly(2-methoxyethylacrylate) (PMEA) and a biocompatible coated oxygenator (n = 16). Those patients were retrospectively matched to control patients having the same congenital repair with respect to patient size, surgeon, anesthesiologist, bypass time, cross-clamp time, bypass temperature, and noncoated bypass disposables; (n = 16). CPB data collected included on-bypass platelet count, hematocrit (HCT), and CPB blood product use. Postprotamine data collected in the operating room included blood product use, time from initial protamine administration to chest closure, platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR). Postoperative intensive care unit (ICU) data included blood product use, HCT, chest tube output, platelet count, PT, aPTT, INR, blood gases, lactate, and ventilator settings at 1, 2, 4, 6, 12, and 24 hours. Other data collected included intubation time, length of time to chest tube removal, and length of ICU stay. Statistical significance (p < .05) was seen in units of platelets transfused postprotamine, ventilator peak inflation pressure (PIP) on admission to the ICU, postoperative day 0 packed red blood cells (PRBC) and fresh frozen plasma (FFP) transfused, and lactate at 1, 2, 4, 6, and 12 hours postoperative. Several parameters approached statistical significance, including PRBC transfused postprotamine, time from protamine administration to chest closure, postoperative day 0 platelets transfused, and ICU stay. The data suggest that PMEA biocompatible CPB circuits can be used safely during pediatric heart surgery, resulting in a decrease in postoperative blood product use, improved postoperative lung function, and a reduction in the time spent in the ICU.