Experiences With Aggressive Cardiac Rehabilitation in Pediatric Patients Receiving Mechanical Circulatory Supports.

Although some patients with fulminant myocarditis can be rescued owing to the improvements in mechanical circulatory support therapy, there are few reports providing evidence of cardiac rehabilitation during mechanical circulatory supports, particularly among pediatric patients. We treated two pediatric patients who underwent aggressive cardiac rehabilitation during mechanical support. Five days after the initiation of extracorporeal membrane oxygenation therapy aggressive cardiac rehabilitation was started in a 10-year-old girl with fulminant myocarditis. After explantation of the device, she was discharged on postoperative day 23. A 6-year-old girl with fulminant myocarditis started receiving cardiac rehabilitation two days after the initiation of an extracorporeal left ventricular assist device, despite having hemiplegia due to a recent broad stroke. She achieved an exercise capacity of supported walking for 280 meters after 127 days of cardiac rehabilitation and then went abroad to undergo heart transplantation when she was in the best physical condition possible. Early initiation of cardiac rehabilitation may be safe and effective for successful pediatric mechanical circulatory support therapy; this acts as a bridge to explantation or heart transplantation.

Predictors of 90-day mortality after congenital heart surgery: the first report of risk models from a Japanese database.

OBJECTIVE: The purpose of this study was to develop risk models for congenital heart surgery short-term and midterm outcomes from a nationwide integrated database drawn from hospitals in Japan. METHODS: The Japan Congenital Cardiovascular Surgery Database collects clinical information from institutions throughout Japan specializing in congenital heart surgery. Variables and definitions used in the Japan Congenital Cardiovascular Surgery Database are almost identical to those of the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery database for congenital heart surgery. We used logistic regression to develop risk models, which were then validated through spilt-sample validation. In addition to procedural complexity categories by Risk Adjustment in Congenital Heart Surgery (RACHS-1) score, we incorporated patient characteristics to predict surgical outcome. RESULTS: Among 8923 congenital heart operations performed at 69 sites with cardiac surgical programs, 30-day mortalities by RACHS-1 category were as follows: I, 0.1% (n=1319); II, 0.5% (n=3211); III, 2.2% (n=3285); IV, 4.3% (n=818); and V and VI, 8.6% (n=290). From the test data set (n=7223), we developed 3 risk models (30-day mortality, 90-day mortality, and 90-day and in-hospital mortality) with 11 variables, including age category, RACHS-1 category, preoperative risk factors, number of surgical procedures, unplanned reoperations, status of surgery, surgery type, asplenia, and prematurity (<35 weeks). For the performance metrics of the risk models, C statistic values of 30-day, 90-day, and 90-day and in-hospital mortalities for the test data set were 0.85, 0.85, and 0.84, respectively. When only the RACHS-1 score was used for discrimination, the C statistic values of 30-day, 90-day, and 90-day and in-hospital mortalities for the validation data set were 0.73, 0.73, and 0.77, respectively. CONCLUSIONS: The proposed risk scores and categories have high discrimination power for predicting mortality, demonstrating improvement relative to existing consensus-based methods. Risk models incorporating these measures may be useful for comparing mortality outcomes cross institutions or countries with mixed cases.

Left ventricular assist device support with a centrifugal pump for 2 months in a 5-kg child.

The mid-term and long-term results of left ventricular assist device (LVAD) implantation for small children are still unsatisfactory. There have been few reports of LVAD implantation for more than a month in children weighing under 5 kg. We report the case of a 4-month-old female infant who survived for 2 months after being diagnosed with dilated cardiomyopathy (DCM) with extracorporeal centrifugal pump support. In recent years, although pumps designed for small children have been introduced and are used as a bridge to transplantation or recovery, mid-term or long-term mechanical support for small children with heart failure is still difficult. We managed to successfully provide support for a low-body-weight child with a centrifugal pump over a mid-term period. We achieved acceptable control of thrombosis, but eventually the infant died of sepsis. Autopsy revealed no prominent thrombosis in the perfusion cannula, drainage cannula, the pump, or the left ventricle. This is the first case report of LVAD support with the centrifugal pump, ROTAFLOW(®) (Maquet, Rastatt, Germany), for 2 months in a child weighing under 5 kg. Our method may potentially save severe heart failure children who need mid-term LVAD support.

Precise evaluation of bilateral pulmonary artery banding for initial palliation in high-risk hypoplastic left heart syndrome.

OBJECTIVES: In patients with high-risk hypoplastic left heart syndrome (HLHS), the Norwood operation (NW) in the neonatal period still results in high mortality compared with other cardiac surgery. Bilateral pulmonary artery banding (bPAB), a very effective initial procedure for HLHS, for which the specific evaluation is as yet unsatisfactory, was performed, and we report our findings in the present study. METHODS: We have performed bPAB since 2006. A total of 17 patients with HLHS or a variant underwent bPAB before the NW. Echocardiography was performed between bPAB and the NW, and the flow acceleration just after bPAB and before NW was evaluated. Before the NW, a catheter examination was also performed. RESULTS: bPAB was performed at 6.6 ± 0.6 days of age, and the NW at 130 ± 88 days. The patients' mean body weight (BW) was 2.5 ± 0.4 kg at bPAB and 4.0 ± 1.1 kg at the NW. The length of the tape for bPAB was 9.9 ± 0.6 mm in the right pulmonary artery (RPA) and 9.4 ± 0.6 mm in the left (LPA) because the RPA was usually wider than the LPA. The tape width was 2 mm in all cases. The catheter examination was performed at 95 ± 85 days after bPAB. The arterial oxygen saturation (SaO2) was 71% ± 8.6%. Multivariate regression analysis revealed that SaO2 was estimated well using 4 factors: the banding size of the RPA, BW at bPAB, BW at NW, and BW in the period between bPAB and catheter examination (R² = 0.79). Echocardiography just after bPAB showed that the blood flow at the bPAB had accelerated to 3.0 ± 0.8 m/s in the RPA and 3.3 ± 0.8 m/s in the LPA (P = .004). The estimated pressure gradient was 39.2 ± 17.6 mm Hg in the RPA and 46.1 ± 23.0 mm Hg in the LPA (P = .006). The blood flow at bPAB was accelerated to 3.7 ± 0.7 m/s in the RPA and 4.0 ± 0.6 m/s in the LPA before NW (P = .013). The estimated pressure gradient was 62.6 ± 27.6 mm Hg in the RPA and 56.1 ± 19.6 mm Hg in the LPA before NW (P = .014). The catheter examination revealed mean wedge pressures of 18.0 ± 7.2 mm Hg for the RPA and 16.2 ± 4.3 mm Hg for the LPA. The operative mortality rate was 0%. One patient required a repeat operation to adjust the bPAB, and prolonged pleural effusion was observed in 1 case. CONCLUSIONS: The postoperative SaO2 after bPAB correlated closely with the banding size and BW at bPAB, NW and during the period after bPAB. Because the mean PA pressure before NW was low enough for single ventricular circulation, the bPAB in this study was an effective option for high-risk patients undergoing HLHS or a variant. We believe the bPAB sizes used were suitable and were determined as follows: BW plus 7 mm for the LPA and BW plus 7.5 mm for the RPA.

Evaluation of valved saphenous vein homograft as right ventricle-pulmonary artery conduit in modified stage I Norwood operation.

Potential drawbacks from right ventricle-pulmonary artery (RV-PA) conduit in modified Norwood procedure may be regurgitation through the conduit and incision at the systemic ventricle. In order to address the question if valved RV-PA conduit can provide hemodynamic advantages, we retrospectively reviewed the data of patients who underwent modified stage I Norwood operation with either a non-valved ePTFE RV-PA conduit (ePTFE) or a valved saphenous vein homograft (SVG). Four patients in each group, both the ePTFE and SVG, were involved in the study and 2 patients in each group eventually died. Conduit regurgitation was seen mild to moderate-to-severe in all patients with ePTFE and mild in one patient with SVG. This regurgitation progressed over the next several months in the ePTFE group. Tricuspid regurgitation became worse in the ePTFE group, whereas it was improved in 2 patients within the SVG group. RV ejection fraction was reduced from 70+/-4% to 55+/-12% in the ePTFE group, whereas it was improved from 62+/-10% to 70+/-2% in the SVG group postoperatively (P<0.05). We conclude that conduit regurgitation may cause RV systolic dysfunction and prolong a functional recovery after modified stage I Norwood procedure. Saphenous vein homograft may be a choice as RV-PA conduit in this procedure.

Thoracic surgery residency program and health care system in the United States.

The Japanese Board of General Surgery as well as the Japanese Board of Thoracic Surgery voted to change the educational and training requirements for certification eligibility. The health care system has been modified due to a reduction of the budget for national health care, such as introduction of Diagnosis Related Groups (DRG)/Prospective Payment System (PPS). Several problems regarding the system have already been discussed in the United States, ranging from 30-year experience of residency program to 20-year experience of health care system. In a residency requirement, training period became longer in Japan than in the United States, although number of cases required is ten times less in Japan. The General Surgery Board now became mandatory in Japan, whereas optional in the United States. Interprogram transfer is possible in the United States, but not in Japan. Quality control has been organized for Thoracic Surgery in the United States, but the Japanese counterpart needs more work. In health care system, health insurance is mandatory and operated publicly in Japan while the United States counterpart is mostly optional and managed privately. Malpractice suits are 7-8 times more frequent in the United States. DRG/PPS health care system was temporarily useful in reducing the national budget for health care in the United States. However, an incentive to treat patients with uncomplicated diseases and short hospital stay increased the expenditure. In order to control this, Peer Review Organization has been established and restricted the physician's activities. Because health insurance is optional in the United States, people opt for cheaper health insurance with greater benefits. So the health insurance companies with huge number of customers have had strong opinions over physicians and hospitals. This also has created restrictions on practice. These potential problems may occur shortly in the Japanese residency program and health care system as well. Thus, preventive strategies may be needed.