Asunto(s)

RESUMEN

BACKGROUND: Patients with end-stage heart failure possess many attributes that place them at risk for prolonged mechanical ventilation (MV). However, there are only limited data on MV support among children after ventricular assist device (VAD) implantation. We report the duration of MV after VAD placement, indications for respiratory support in the postimplantation period, and associated patient factors. METHODS: This single-center retrospective study included 43 consecutive children (aged <18 years) with end-stage heart failure who were supported with a VAD as a bridge to transplantation from January 2005 to December 2011. Multivariable analysis was performed using the multiple Poisson regression model for the duration of MV. RESULTS: Overall, 33% (n = 14) remained on MV until heart transplant or death. Of those requiring pre-VAD extracorporeal membrane oxygenation (ECMO) support, 63% (n = 12 of 19) remained on MV until heart transplant or death compared with 8% (n = 2 of 24) among those not on ECMO before VAD (p < 0.001). Patients with moderate or severe mitral regurgitation while on VAD support had 1.7-times more MV days compared with those with none or trivial on-VAD mitral regurgitation. In addition, previous support on ECMO, those with moderate or severe tricuspid regurgitation, and those with only left VAD implants had an increased risk of prolonged MV. CONCLUSIONS: Our results suggest that VAD recipients previously supported on ECMO, those with moderate or severe mitral regurgitation, moderate or severe tricuspid regurgitation, and those with only left VAD implants had an increased risk of prolonged MV. Future studies in larger cohorts are necessary to confirm the findings from this single-institutional experience.

Asunto(s)

RESUMEN

OBJECTIVE: Because infants undergoing a Norwood operation have poor interstage weight gain, we hypothesized that preemptive gastrostomy tube (GT) placement would result in earlier discharge, improved growth, and higher survival to stage 2. STUDY DESIGN: Records of 74 neonates who underwent a Norwood operation were reviewed until stage 2 palliation. The patients were divided into conventional (n = 43) and preemptive GT groups (n = 31). Data included demographics, cardiac surgery, feeding strategy, length of hospitalization, and mortality. RESULTS: Transplant-free survival to stage 2 was significantly higher in the preemptive group, but there were no significant differences in survival to discharge after stage 1, length of hospitalization, and weight-for-age z-score at discharge and at stage 2 palliation. In the conventional group, 27 of 43 underwent GT placement, all via laparotomy, 23 with Nissen fundoplication. In the preemptive group, all underwent GT placement (21 laparoscopic, 10 laparotomy), 7 with Nissen fundoplication. A second gastric intervention was performed in 11 of 21 with laparoscopic GT (7 conversion to gastrojejunostomy tube, 4 Nissen fundoplication). CONCLUSION: Preemptive GT placement is associated with improved survival to stage 2 after a Norwood operation but not with shorter hospitalization or better growth. A thorough gastrointestinal evaluation must be performed before GT placement to avoid additional surgery.

Asunto(s)

RESUMEN

OBJECTIVE: To evaluate the impact of vocal cord dysfunction on feeding in children after cardiovascular surgery. STUDY DESIGN: Of the 2255 children who had cardiovascular surgery between January 2000 to January 2006, 38 (1.7%) had postoperative vocal cord dysfunction confirmed at laryngoscopy. The following data were obtained retrospectively: type of surgery, laryngoscopic examination results, swallowing studies, upper gastrointestinal (UGI) studies, and feeding route: oral, nasogastric tube (NG), and gastrostomy. RESULTS: Surgeries included aortic arch reconstruction (n = 20), patent ductus arteriosus ligation (n = 8), arterial switch (n = 3), cervical cannulation for extracorporeal membrane oxygenation (n = 2), and others (n = 5). A swallowing study confirmed dysfunction in 27 of 29 patients. Gastrostomy was placed in 18/38 patients. At discharge, 18 patients were fed by gastrostomy, 13 orally, 3 by NG, and 4 by combination oral/NG. At a median follow-up of 12 months, 20 were fed orally, 1 by NG, 7 by gastrostomy, 7 by combination gastrostomy/orally, 1 was lost to follow-up, 2 died. CONCLUSION: Vocal cord dysfunction after pediatric cardiovascular surgery is associated with significant feeding problems and may require prolonged gastrostomy feeding. These findings support aggressive surveillance for vocal cord dysfunction, especially in patients undergoing aortic arch surgery.

Asunto(s)