RESUMEN
OBJECTIVES: We sought to identify factors associated with the timing and surgical outcomes of the superior cavopulmonary anastomosis. METHODS: The Pediatric Heart Network's Infant Single Ventricle trial database identified participants who underwent superior cavopulmonary anastomosis. Factors potentially associated with age at superior cavopulmonary anastomosis, length of stay and death by 14 months of age were evaluated. Factors included subject demographics, cardiac anatomy, measures from neonatal hospitalization and pre-superior cavopulmonary anastomosis visit, adverse events, echocardiographic variables, intraoperative variables, superior cavopulmonary anastomosis type, and number of concurrent cardiac surgical procedures. Age at superior cavopulmonary anastomosis was analyzed using Cox proportional hazards regression. Natural log length of stay was analyzed by multiple linear regression. RESULTS: Superior cavopulmonary anastomosis was performed in 193 subjects at 5.2 months of age (interquartile range, 4.2, 6.2) and weight of 5.9 kg (interquartile range, 5.3, 6.6). The median length of stay was 7 days (interquartile range, 6, 10). There were 3 deaths and 1 transplant during the superior cavopulmonary anastomosis hospitalization, and 3 deaths and 3 transplants between discharge and 14 months of age. Age at superior cavopulmonary anastomosis was associated with center and interstage adverse events. A longer length of stay was associated with younger age and greater case complexity. Superior cavopulmonary anastomosis type, valve regurgitation, ventricular ejection fraction, and ventricular end-diastolic pressure were not independently associated with age at superior cavopulmonary anastomosis or the length of stay. CONCLUSIONS: Greater case complexity and more frequent interstage adverse events are associated with an earlier age at superior cavopulmonary anastomosis. Significant variation in age at superior cavopulmonary anastomosis among centers, independent of subject factors, highlights a lack of consensus regarding the optimal timing. Factors associated with length of stay could offer insights for improving presuperior cavopulmonary anastomosis care and surgical outcome.
Asunto(s)
Puente Cardíaco Derecho , Cardiopatías Congénitas/cirugía , Ventrículos Cardíacos/cirugía , Factores de Edad , Extubación Traqueal , Método Doble Ciego , Puente Cardíaco Derecho/efectos adversos , Puente Cardíaco Derecho/mortalidad , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/mortalidad , Trasplante de Corazón , Ventrículos Cardíacos/anomalías , Mortalidad Hospitalaria , Humanos , Lactante , Recién Nacido , Tiempo de Internación , Modelos Lineales , Modelos Logísticos , Análisis Multivariante , América del Norte , Selección de Paciente , Modelos de Riesgos Proporcionales , Reoperación , Respiración Artificial , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
The validity and reproducibility of echocardiographic methods used to quantify mitral regurgitation (MR) in children with congenital heart disease are unknown. We evaluated the usefulness of methods used to quantify MR in children enrolled in a multicenter trial of enalapril 6 months after surgical repair of an atrioventricular septal defect (AVSD). MR severity in this trial was assessed using body surface area (BSA)-adjusted vena contracta lateral (i-VCW(lat)) and anterior-posterior (i-VCW(ap)) dimensions and cross-sectional area (i-VCA), regurgitant volume/BSA, regurgitant fraction, and qualitative MR grade. For each method, association with left ventricular end-diastolic volume (LVEDVz) and end-diastolic dimension (LVEDDz) z-scores and interobserver agreement were assessed. In 149 children (median age 1 year), i-VCW(lat), i-VCW(ap), and i-VCA were best associated with LVEDVz (r (2) = 0.54, r (2) = 0.24, and r (2) = 0.46, respectively; p < 0.001 for all) and showed the highest interobserver agreement (intraclass correlation coefficient = 0.62, 0.73, and 0.68, respectively). Qualitative MR grade was also associated with LVEDVz (r (2) = 0.31, p < 0.001) and showed modest interobserver agreement (kappa 0.56). Regurgitant volume/BSA and regurgitant fraction were associated with LVEDVz (r (2) = 0.45 and r (2) = 0.45, p < 0.001 for both) but showed poor interobserver agreement [ICC = 0.28 (n = 91) and ICC = 0.17 (n = 76), respectively], and their values were negative in 75% of subjects. In conclusion, echocardiographic assessment of MR severity after AVSD remains challenging. Among the quantitative methods used in this trial, i-VCW and i-VCA performed the best but offered little advantage compared with qualitative MR grade. The utility of regurgitant volume and fraction was severely limited by poor interobserver agreement and frequently negative values.
Asunto(s)
Defectos de los Tabiques Cardíacos/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Adolescente , Niño , Preescolar , Ecocardiografía , Defectos de los Tabiques Cardíacos/complicaciones , Humanos , Lactante , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/fisiopatologíaRESUMEN
OBJECTIVES: This study was undertaken to determine the effects of creating a systemic-to-pulmonary venous atrial-level communication (fenestration) at the time of the Fontan procedure on late outcomes. BACKGROUND: Fenestrations are frequently performed during Fontan procedures, but late consequences are not well described. METHODS: Patient characteristics were compared between those with and without surgical fenestration among 536 subjects (mean age 11.9 years) enrolled in the Pediatric Heart Network Fontan Cross-Sectional Study. The status of the fenestration and the association of a currently patent fenestration with health status and measures of ventricular performance were investigated. RESULTS: Fenestration was performed in 361 patients (67%), and frequency differed by year and center (p < 0.001 for each). After adjustment for center, age at Fontan, year of Fontan, and prior superior cavopulmonary surgery, the fenestrated group had shorter length of Fontan hospital stay. At the time of cross-sectional testing 8 ± 3 years after Fontan, the fenestration remained open in 19% of subjects. Among those with confirmed fenestration closure, 59% were by catheter intervention and 1% by surgical intervention, and 40% had apparent spontaneous closure. Compared with those without evidence of a fenestration, subjects with a current fenestration were taking more medications (p = 0.02) and had lower resting oxygen saturation (median 89% vs. 95%, p < 0.001). Functional health status, exercise performance, echocardiographic variables, prevalence of post-Fontan stroke or thrombosis, and growth did not differ by current fenestration status. CONCLUSIONS: Surgical fenestration is associated with well-demonstrated early post-operative benefits. This cross-sectional study found few associations between a persistent fenestration and deleterious later outcomes.
Asunto(s)
Procedimiento de Fontan/métodos , Cardiopatías Congénitas/cirugía , Hemodinámica/fisiología , Adolescente , Anastomosis Quirúrgica/métodos , Cateterismo Cardíaco/métodos , Niño , Estudios de Cohortes , Intervalos de Confianza , Estudios Transversales , Femenino , Estudios de Seguimiento , Procedimiento de Fontan/efectos adversos , Atrios Cardíacos/cirugía , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/mortalidad , Pruebas de Función Cardíaca , Humanos , Cuidados Intraoperatorios/métodos , Tiempo de Internación , Modelos Lineales , Modelos Logísticos , Masculino , Análisis Multivariante , Cuidados Posoperatorios/métodos , Venas Pulmonares/cirugía , Medición de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Kawasaki disease (KD) is an acute multisystem vasculitis of unknown etiology that typically affects young children. KD presenting as a retropharyngeal inflammatory process is very rare. OBJECTIVES: To report a case of KD initially presenting as a retropharyngeal edema mimicking a deep neck infection, and to review previously published reports in the literature. CASE REPORT: We report a case of KD in a previously healthy 3-year-old child who presented with acute onset of fever and cervical adenitis, along with computed tomography scan findings of retropharyngeal edema and inflammation. KD was suspected due to persistent fever and no improvement in the patient's condition despite appropriate antibiotic therapy; and other classic findings of KD eventually developed. An echocardiogram obtained on the 10th day of illness revealed pericardial effusion but no coronary ectasia or aneurysm. Treatment with high-dose intravenous immunoglobulin resulted in dramatic clinical improvement. Follow-up echocardiograms obtained 2 and 8 weeks after discharge revealed a small left coronary artery aneurysm (CAA). Nine months later, the CAA had resolved and the patient was well with no sequelae. CONCLUSIONS: Although unusual, physicians should be aware of retropharyngeal edema as an atypical presentation of KD.
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Edema/etiología , Síndrome Mucocutáneo Linfonodular/complicaciones , Síndrome Mucocutáneo Linfonodular/diagnóstico por imagen , Enfermedades Faríngeas/diagnóstico por imagen , Enfermedades Faríngeas/etiología , Antiinflamatorios/uso terapéutico , Aspirina/uso terapéutico , Preescolar , Edema/diagnóstico por imagen , Humanos , Inmunoglobulinas Intravenosas/uso terapéutico , Factores Inmunológicos/uso terapéutico , Linfadenitis/diagnóstico por imagen , Linfadenitis/etiología , Masculino , Síndrome Mucocutáneo Linfonodular/tratamiento farmacológico , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Video-assisted thoracic surgery has been shown to be a safe and effective method of closing the patent ductus arteriosus in infants and children. We have applied this technique in low birth weight premature infants and now report our experience. METHODS: Since 1996, we have used video-assisted thoracic surgery ligation as the treatment of choice for all patent ductus arteriosus, including 100 performed on premature infants (23 to 31 weeks' gestation, mean 25.6 weeks; 0.420 to 1.5 kg, mean 0.859 kg). A modification of our previously described technique was used with a three-port approach. All patients had some degree of symptoms of congestive failure with failure to wean from ventilatory support or oxygen dependency. Five infants had associated patent foramen, and 1 had a small ventricular septal defect. RESULTS: All 100 procedures were performed in the operating room. One infant was found to have a coarctation, and the procedure was aborted. The remaining 99 were successfully ligated, although three were converted to an open procedure (3%) because of coagulopathy, poor pulmonary compliance, or hemodynamic instability. There were no procedure-related deaths; however, 15 infants subsequently died of complications of prematurity, including enterocolitis, sepsis, and late respiratory failure. Six infants had chest tubes left in place for coagulopathy, effusions, suspected air leak, and existing empyema. There were six residual pneumothoraces, four requiring treatment. CONCLUSIONS: Video-assisted thoracic surgery is a safe and effective technique for patent ductus arteriosus ligation in premature infants, including those with very low and extremely low birth weight.
Asunto(s)
Conducto Arterioso Permeable/cirugía , Recien Nacido Prematuro , Cirugía Torácica Asistida por Video/métodos , Estudios de Cohortes , Conducto Arterioso Permeable/diagnóstico por imagen , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Ligadura/métodos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Cirugía Torácica Asistida por Video/mortalidad , Resultado del TratamientoRESUMEN
Echocardiography has become the method of choice in the diagnosis of a congenital heart defect (CHD) in neonates with Down syndrome. The most compelling argument for diagnosis of CHD in the neonatal period is the need for early surgical intervention (ideally prior to 6 months of age) in those with a complete atrioventricular (AV) canal. We evaluated the efficacy of a combined approach of physical examination (PE) and electrocardiography (ECG) in the detection of CHD in 49 neonates with Down syndrome. Our findings indicate that most hemodynamically significant defects (78%), especially a complete AV canal, can be detected by this approach. Hemodynamically insignificant minor defects, such as a small patent ductus arteriosus (PDA) and a small atrial septal defect (ASD), may be missed. Thus, echocardiography remains the most sensitive way to diagnose CHD. However, given that the combination of PE and ECG detects the majority of complete AV canal defects, it can be used as an alternative approach when echocardiography is not easily accessible, due to geographic or economic constraints. Follow-up after a few weeks of those with normal PE and ECG findings should enable detection of new symptoms and signs and evolving ECG findings that may have been missed in the immediate newborn period. Patients who are judged by PE and ECG to have CHD will need echocardiographic confirmation.