Preoperative Management of Neonates With Congenital Heart Disease.

Clinicians caring for neonates with congenital heart disease encounter challenges in clinical care as these infants await surgery or are evaluated for further potential interventions. The newborn with heart disease can present with significant pathophysiologic heterogeneity and therefore requires a personalized therapeutic management plan. However, this complex field of neonatal-cardiac hemodynamics can be simplified. We explore some of these clinical quandaries and include specific sections reviewing the anatomic challenges in these patients. We propose this to serve as a primer focusing on the hemodynamics and therapeutic strategies for the preoperative neonate with systolic dysfunction, diastolic dysfunction, excessive pulmonary blood flow, obstructed pulmonary blood flow, obstructed systemic blood flow, transposition physiology, and single ventricle physiology.

Extracorporeal Membrane Oxygenation (ECMO) Support in Special Patient Populations-The Bidirectional Glenn and Fontan Circulations.

Extracorporeal membrane oxygenation (ECMO) is a support modality used within the pediatric cardiac ICU population as a bridge to recovery or decision in the setting of acute myocardial decompensation, support for combined cardiopulmonary failure or in the setting of refractory cardiopulmonary arrest. Patients with univentricular physiology are at particular risk for decompensation requiring ECMO support. This review will focus upon current evidence and techniques for ECMO support of single ventricle patients who have undergone a stage II bidirectional Glenn procedure or the stage III Fontan procedure.

Cardiac morphology for the millennial cardiology fellow: Nomenclature and advances in morphologic imaging.

Cardiology fellows-in-training, both in adult and pediatric hospitals, need structured education in regards to congenital heart disease (CHD) nomenclature. With improved survival of patients with CHD, it is not uncommon for these patients to seek care in multiple adult and pediatric hospitals. A deep understanding of CHD nomenclature would aid in providing accurate medical and surgical care for these patients. In this forum, we share our experience with such structured education and also comment on recent advances in morphologic imaging that would aid in understanding the nomenclature.

Hemodynamic effects of ketamine in children with congenital heart disease and/or pulmonary hypertension.

INTRODUCTION: Ketamine is a drug often used for procedural sedation or as adjunct agent for general sedation in children with congenital heart disease. In the clinical realm, there is often confusion regarding the effects of ketamine on hemodynamics, particularly pulmonary vascular resistance and systemic vascular resistance. We performed a meta-analysis of studies investigating the effects of ketamine on hemodynamics. METHODS: A systematic review was conducted to identify studies characterizing the hemodynamic effects of ketamine in children with congenital heart disease. Studies were assessed for quality and those of satisfactory quality with pre- and postketamine hemodynamics for each patient were included in the final analyses. Those not limited to pediatric patients and those not limited to patients with congenital heart disease were excluded from the final analyses. RESULTS: A total of 7 studies with 139 patients were included in the final analyses. Pulmonary vascular resistance, systemic vascular resistance, mean pulmonary artery pressure, mean systemic pressure, heart rate, pH, and arterial oxygen concentration did not significantly change with administration of ketamine. Carbon dioxide concentration did increase significantly by a mean of 1.38 mm Hg with the administration of ketamine. CONCLUSION: Ketamine has minimal impact on hemodynamics in children with congenital heart disease when used at usual clinical doses. Systemic vascular resistance and pulmonary vascular resistance are not significantly altered. Blood gas values are also only minimally affected by ketamine.