Outcomes of Extracorporeal Membrane Oxygenation in Patients After Repair of Congenital Heart Defects.

Extracorporeal membrane oxygenation (ECMO) is widely used after congenital heart surgery. The purpose of this study is to analyze the factors influencing mortality and morbidity in patients who require ECMO support after congenital cardiac surgery. All 109 patients (5.8% of total cases) who underwent ECMO support after congenital heart surgery between January 2014 and 2021 were included in this single-center study. The mean age was 10.13 ± 20.55 months, and the mean weight was 6.41 ± 6.79 kg. 87 (79.8%) of the patients were under 1 year of age. A total of 54 patients (49.5%) were weaned successfully from ECMO support, and 27 of them (24.8%) were discharged. The childhood age group had the best outcomes. Seventy-seven percent of the children were weaned successfully, and 50% were discharged. 69 patients (63.3%) had biventricular physiology; weaning and survival outcomes were better than single ventricle patients (P-value 0.002 and < 0.001, respectively). Low cardiac output (n = 49; 44.9%) as an ECMO indication had better outcomes than extracorporeal cardiopulmonary resuscitation (n = 31; 28.4%) (P = 0.05). Most of the patients had ≥ 4 Modified Aristotle Comprehensive Complexity (MACC) levels, and higher MACC levels were associated with a higher mortality rate. The most common procedure was the Norwood operation (16.5%), with the worst outcome (5.5% survival). Bleeding and renal complications were the most common complications affecting outcomes. Results were more satisfactory in patients with biventricular repair, childhood, and lower MACC levels. Early initiation of ECMO in borderline patients without experiencing cardiac arrest or multiorgan failure may improve outcomes.

The Predictive Effects of Clinical Hematological Changes on Saphenous Graft Patency after Coronary Artery Surgery.

OBJECTIVES: To investigate the association between clinical hematologic parameters and saphenous vein graft failure after on-pump coronary artery bypass surgery. METHODS: A total of 1950 consecutive patients underwent isolated on-pump coronary artery surgery between November 2010 and February 2013. Of these, 284 patients met our inclusion criteria; their preoperative clinical hematological parameters were retrospectively obtained for this cohort study. And of them, 109 patients underwent conventional coronary angiography after graft failure was revealed by coronary computed tomography angiography. The primary endpoint was to catch at least one saphenous vein graft stenosis or occlusion following the coronary angiogram. We then analyzed risk factors for graft failure. In sequential or T grafts, each segment was analyzed as a separate graft. RESULTS: In logistic regression analysis, older age, platelet distribution width, and diabetes mellitus were identified as independent predictors of saphenous vein graft failure (P<0.). In contrast, preserved ejection fraction value favored graft patency (P<0.001). CONCLUSION: Increased platelet distribution width is easily measurable and can be used as a simple and valuable marker in the prediction of saphenous vein graft failure.

The predictive effects of clinical hematological changes on saphenous graft patency after coronary artery surgery

Abstract Objectives: To investigate the association between clinical hematologic parameters and saphenous vein graft failure after on-pump coronary artery bypass surgery. Methods: A total of 1950 consecutive patients underwent isolated on-pump coronary artery surgery between November 2010 and February 2013. Of these, 284 patients met our inclusion criteria; their preoperative clinical hematological parameters were retrospectively obtained for this cohort study. And of them, 109 patients underwent conventional coronary angiography after graft failure was revealed by coronary computed tomography angiography. The primary endpoint was to catch at least one saphenous vein graft stenosis or occlusion following the coronary angiogram. We then analyzed risk factors for graft failure. In sequential or T grafts, each segment was analyzed as a separate graft. Results: In logistic regression analysis, older age, platelet distribution width, and diabetes mellitus were identified as independent predictors of saphenous vein graft failure (P<0.). In contrast, preserved ejection fraction value favored graft patency (P<0.001). Conclusion: Increased platelet distribution width is easily measurable and can be used as a simple and valuable marker in the prediction of saphenous vein graft failure.

Perioperative risk factors of acute kidney injury after non-cardiac surgery: A multicenter, prospective, observational study in patients with low grade American Society of Anesthesiologists physical status.

BACKGROUND: The aim of this study was to determine the incidence and the perioperative risk factors of acute kidney injury (AKI) using "Kidney Disease: Improving Global Outcomes" (KDIGO) guidelines, in patients with low grade American Society of Anesthesiologists physical status (ASA-PS) undergoing non-cardiac surgery. METHODS: In this multicenter, prospective, observational study, 870 surgical patients older than 40 years with ASA-PS I-II who underwent noncardiac surgery, were included. The primary outcome of this study was perioperative AKI defined by the KDIGO criteria. RESULTS: AKI was detected in 49 (5.63%) of the patients. Multivariate analysis detected the presence of preoperative hypertension (aOR = 0.130; CI = 0.030-0.566; p = 0.007) and intraoperative transfusion of erythrocytes (aOR = 0.076; CI = 0.008-0.752; p = 0.028) as independent predictors of postoperative AKI development. CONCLUSION: Approximately, 6% of patients with ASA I-II presenting for noncardiac surgery developed postoperative AKI. Preoperative hypertension and intraoperative erythrocyte transfusion are independent predictors of AKI after non-cardiac surgery in this patient population.

Outcomes of hybrid and Norwood Stage I procedures for the treatment of hypoplastic left heart syndrome and its variants.

BACKGROUND: In this study, we present the outcomes of hybrid and Norwood Stage I procedures for the treatment of hypoplastic left heart syndrome and its variants. METHODS: In this study, a total of 97 pediatric patients who were operated due to hypoplastic left heart syndrome and its variants between March 2011 and October 2018 were retrospectively analyzed. Thirty-two of the patients (28 males, 4 females; median age 5 days; range, 1 to 25 days) underwent Norwood Stage I operation (Group N), while the remaining 65 patients (44 males, 21 females; median age 6 days; range, 1 to 55 days) underwent a hybrid procedure (Group H). Both treatment strategies were compared. RESULTS: The median body weight in Group H was significantly lower and the number of patients with a low birth weight (<2,500 g) was significantly higher than Group N (p=0.002 and 0.004, respectively). The postoperative early mortality rate was similar between the groups. Univariate and multivariate analyses revealed that the need for preoperative mechanical ventilation was a significant factor for mortality (p=0.004 and 0.003, respectively). Syndromic appearance was also a significant factor the multivariate analysis (p=0.03). There was a statistically significant difference between the groups in terms of the inter-stage mortality rates (p=0.0045). Second-stage procedure was performed in 32 patients. The early mortality rate after the Glenn operation was 7.6%. Six patients died after comprehensive Stage II operation. Five patients underwent biventricular repair and 8 patients had third-stage fenestrated extracardiac Fontan operation (Group N, n=7 and Group H, n=1). The Kaplan-Meier survival curve demonstrated that Group N had a higher survival rate at both one and five years than Group H, although the difference was not statistically significant (p=0.15). Subgroup analysis showed that the Norwood procedure with Sano modification had the highest survival rate with 40% at five years. CONCLUSION: Our study results show that patients undergoing the Norwood procedure have a more uneventful course of inter-stage period and Stage II and III, despite drawbacks early after Stage I procedure. Based on our experiences, we recommend performing the hybrid intervention in patients with a poor clinical condition and a body weight of <2,500 g.

The impact of pulmonary valve-sparing techniques on postoperative early and midterm results in tetralogy of Fallot repair.

BACKGROUND: In this study, we analyzed the impact of pulmonary valve-sparing techniques on early and midterm postoperative results of tetralogy of Fallot repair. METHODS: A total of 64 patients diagnosed with tetralogy of Fallot, who underwent total correction operation by the same surgeon between November 2010 and September 2015 were included in this retrospective study. Mean age of the patients was 20.0±14.2 months (5.5-96 months). Forty patients (62.5%) were male. Thirty two of the patients (50%) were under one year of age. Pulmonary valve-sparing techniques were performed in 29 patients (Group 2), while transannular patch was applied in the remaining 35 patients (Group 1). Pericardial monocusp valve was constructed in 15 patients in Group 1. In Group 2, pulmonary valve-sparing techniques were transatrial repair in nine patients; transatrial-transpulmonary in eight, infundibular patch in eight, and infundibular-pulmonary patch in four patients. RESULTS: There was no early postoperative mortality in Group 2. Five patients (14.2%) in Group 1 died in the early postoperative period (p=0.058). Pulmonary monocusp insertion was performed in 2 (13.3%) of these patients (p=1). The causes of mortality were sudden cardiac arrest (n=2), multiorgan failure (n=1), low cardiac output (n=1), and neurological complications (n=1). Five patients in Group 1 required extracorporeal membrane oxygenation support (ECMO). Three of them were separated from ECMO and two of the patients that were separated were discharged uneventfully. Total postoperative morbidity rate was significantly higher in Group 1 (51.4% vs. 6.8%) (p=0.0001). Morbidity rate was significantly lower in patients with pulmonary monocusp insertion than patients in the same group without a monocusp (p=0.0176). Forty nine (83%) of the patients were followed up for a median of 6.5 (1-24) months. While free pulmonary regurgitation was detected in all non-monocusp patients in Group 1, pulmonary regurgitation was absent or mild in Group 2. Twelve (80%) of the patients in Group 1 who had monocusp insertion were followed up. Only two of these patients had free pulmonary regurgitation (16.6%). The rest of them had mild (n=6) or mildmoderate pulmonary regurgitation (n=4). CONCLUSION: Mortality and morbidity rates are lower when pulmonary valvesparing techniques are used in repair of tetralogy of Fallot. Monocusp pulmonary valve insertion may improve results in patients who require transannular patch repair. It is suggested that every effort should be made to achieve a competently working pulmonary valve during repair.

Myocardial bridging in a child with hypertrophic obstructive cardiomyopathy.

Myocardial bridging (MB) is a rare coronary anomaly in children which is typically associated with hypertrophic obstructive cardiomyopathy (HCM) or left ventricular hypertrophy. Hypertrophic obstructive cardiomyopathy is the leading cause of sudden cardiac death in young patients, and the association of myocardial ischemia with sudden death has been recognized in patients with HCM. In this report, we describe an 11-year-old boy presented with a history of exertional, nonspecific chest pain and palpitations. Cardiac catheterization revealed MB of the left anterior descending coronary artery with evidence of intramyocardial obstruction during systole. Surgical unroofing of the affected coronary artery segment resulted in complete recovery. Myocardial bridging should be included in the differential diagnosis of children presenting with signs of ischemia.

Cerebral perfusion during cardiopulmonary bypass in children: correlations between near-infrared spectroscopy, temperature, lactate, pump flow, and blood pressure.

Near-infrared spectroscopy (NIRS) is a noninvasive modality to monitor regional brain oxygenation (rSO(2) ). In this study, we aimed to investigate the correlation between cerebral rSO(2) and lactate, pump flow, hematocrit, pCO(2) , and mean blood pressure (MBP) during cardiopulmonary bypass (CPB). Between March and September 2011, 50 pediatric patients who underwent congenital heart surgery were enrolled into the study. Ages ranged from 6 days to 168 months (median 14 months). A NIRS sensor (Somanetics 5100B, Troy, MI, USA) was placed on the right forehead of patients. CPB period was divided into five stages: 1-at the beginning of CBP, 2-cooling at 32°C, 3-at final hypothermic temperature, 4-rewarming at 32°C, 5-before weaning from CPB. Data collection included measurements of each parameter at five stages of CPB. Data were analyzed using multivariate analysis within groups and Spearman's correlation to test association between parameters. Lactate levels increased significantly from stage 1 to stage 5 during CPB (P < 0.05). There was no significant correlation between cerebral rSO(2) and MBPs, pump flows, hematocrit, or pCO(2) during CPB. Cerebral rSO(2) levels showed changes between the stages; there was a significant increase during cooling period, compared to stage 1 (P < 0.05). Significant changes during cooling stage did not happen for other parameters. At stage 3, there was a negative correlation between lactate level and MBP. At stage 4, there was no significant change in cerebral rSO(2) levels despite decreased MBP. At the warming stage, low MBPs, but normal rSO(2) values, are observed despite increased pump flows. Increased rSO(2) levels despite insignificant changes at other parameters during the cooling stage of CPB may show that optimal pump flow with adequate intravascular volume may provide effective cerebral perfusion even without changes in MBP. Considering normal rSO(2) values during CPB in this study, it may be speculated that brain protection can be assessed by using NIRS and applying a standard bypass protocol.

Does the level of soluble intercellular adhesion molecule 1 predict myocardial injury before cardiac markers increase?

BACKGROUND: The measurement of cardiac markers is still the gold standard for diagnosing myocardial infarction (MI), but there is always a transition period between the time of infarction and when a marker can be measured in the blood. Therefore, clinicians are shifting their focus to the identification of potential new analytes capable of predicting MIs before the standard cardiac markers increase. In this study, we tested whether measurement of the concentration of soluble intercellular adhesion molecule 1 (sICAM-1) in plasma can be used for this purpose. MATERIALS AND METHODS: In this prospective study, we included 60 male patients who had a left main coronary artery lesion or a left main equivalent and who underwent elective (group I, n = 20), urgent (group II, n = 20), or emergent (group III, n = 20) coronary artery bypass grafting (CABG). We excluded patients who had increased cardiac markers at admission, and drew blood samples for sICAM-1 measurements from other patients immediately after coronary angiography evaluations. We divided the patients into 3 groups according to their clinical characteristics and cardiac marker levels. Only patients with increased cardiac markers underwent emergent CABG (group III). We measured sICAM-1 concentrations immediately after coronary angiography and measured creatine kinase MB (CK-MB) and cardiac troponin I (cTnI) just before CABG. We then evaluated the results for correlations. RESULTS: CK-MB, cTnI, and sICAM-1 levels were significantly higher in group III than in groups I and II (P < .05 for all). Our analysis for correlations between the sICAM-1 level and cardiac marker levels revealed no significant correlations in group I (CK-MB, r = 0.241 [P = .15]; cTnI, r = -0.107 [P = .32]) and group II (CK-MB, r = -0.202 [P = .19]; cTnI, r = 0.606 [P = .002]), but our analysis did reveal highly significant correlations in group III (CK-MB, r = 0.584 [P = .003]; cTnI, r = 0.605 [P = .002]). CONCLUSION: Measuring the plasma concentration of sICAM-1 before the concentrations of cardiac markers increase in patients with MI may provide clinicians with faster and reliable data for deciding on and administering the most appropriate procedures and/or therapies.