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Modified ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass
LITERATURE REVIEW Linda Shore-Lesserson, MD, Section Editor
Pediatrics
Rasanen J, Wood DC, Debbs RH, et ah Reactivity of the human fetal pulmonary circulation to maternal hyperoxygenation increases during the second half of pregnancy. Circulation 97:257-262, 1998 Forty women with an uncomplicated pregnancy were included in a randomized study in which they were administered either oxygen (FIO2, 0.6) or room air. Baseline and experimental measurements of fetal blood-velocity waveforms at the level of the aortic valve, pulmonic valve, right pulmonary artery (RPA), left pulmonary artery (LPA), and the ductus arteriosus (DA) were obtained using pulsed wave and color Doppler. Twenty fetuses were studied at 20 to 26 weeks of gestational age and 20 fetuses were studied at 31 to 36 weeks of gestational age. Baseline values did not differ among the groups. The administration of room air did not change any echocardiographic parameters in either gestational age group. During maternal hyperoxygenation in the fetuses aged 31 to 36 weeks, the pulsatility index (PI) of the RPA and LPA decreased and the PI of the DA increased significantly. These changes were not evident in the fetuses aged 20 to 26 weeks. Reactivity of the fetal circulation to oxygen increases with advanced gestational age.
Morris CD, Relier MD, Menashe VD: Thirty-year incidence of infective endocarditis after surgery for congenital heart defect. JAMA 279:599-603, 1998 The cohort of children in the state of Oregon who underwent surgical correction of a congenital heart defect was surveyed using a populationbased registry. Follow-up data for up to 25 years was available for 88% of the patients. All documented occurrences of endocarditis were confirmed by hospital echocardiography and blood culture results or by autopsy. The defect most frequently associated with infective endocarditis was aortic stenosis (13.3%) with a native or a prosthetic valve. Other defects associated with endocarditis were coarctation of the aorta (35%), ventricular septai defect (2.7%), and transposition of the great arteries (4%). Endocarditis in association with a ventricular septal defect repair was frequently accompanied by a residual septal defect. Secundum atrial septal defect, iigation of a ductus arteriosus, and repair of pulmonic stenosis were not associated with endocarditis in this population.
Zufelt K, Rosenberg HC, Li MD, et al: The electrocardiogram and the secundum atrial septal defect: A reexamination in the era of echocardiography. Can J Cardiol 14:227-232, 1998 Ostium secundum atrial septal defects (ASDs) account for a large portion of congenital heart disease, but they are usually asymptomatic and diagnosis is difficult. Characteristic electrocardiogram (ECG) criteria have already been established for adult patients with ASDs (rsR'-V1 with right ventricular hypertrophy [RVH], isolated rsR', and isolated RVH). The purpose of this study was to determine whether similar ECG abnormalities were consistently present in hemodynamically compromised pediatric patients with ASDs. Medical records were reviewed retrospectively for 67 children with ASDs and 77 children 604
with benign murmurs, and the ECGs and echocardiograms were compared. Eighty-seven percent of the patients with ASDs met predetermined ECG criteria, compared with 3.9% of the control patients. Use of the predetermined ECG criteria was 86.6% sensitive (95% confidence interval [CI], 0.784 to 0.947) and 96.1% specific (95% CI, 0.884 to 0.997) and may be useful in differentiating pediatric patients with ASDs from those with benign heart murmurs.
Davies M J, Nguyen K, Gaynor JW, Elliott M J: Modified ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass. J Thorac Cardiovasc Surg 115:361-370, 1998 Modified ultrafiltration after cardiopulmonary bypass in pediatric patients decreases total-body water and increases the hematocrit, cardiac index, and systolic blood pressure. The purpose of this prospective study was to show that the improvement of hemodynamic parameters after ultrafiltration was caused by an improvement of left ventricular function. Twenty-one pediatric cardiac surgical patients were randomized to receive nltrafiltration (n = 11) or as controls (n = 10). Multiple parameters of left ventricular function were evaluated using echocardiography and ultrasonic transducers placed in the mid-left ventricular cavity of all patients. Only those patients receiving ultrafiltration showed improvement in the parameters defining left ventricular systolic function and diastolic compliance. They also required less inotropic support than those patients in the control group.
Minimally Invasive Surgery~Myocardial Ischemia
Voutilainen S, Verkkala K, Jarvinen A, et al: Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery. Ann Thorac Surg 65:444-448, 1998 Anastomosis of the left internal thoracic artery (LITA) to the left anterior descending artery has become routine in patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCABG) surgery. Right gastroepiploic artery (RGEA) grafts have been successful in coronary bypass surgery during cardiopnlmonary bypass. The purpose of this study was to evaluate the anastomosis of the RGEA to the right coronary artery during MIDCABG surgery. Of the 100 patients undergoing MIDCABG with LITA grafts, 25 patients received an RGEA graft. Postoperative angiography showed that 82.6% of the RGEA grafts and all of the LITA grafts were patent. Three nonvisualized RGEA grafts showed noncritical proximal stenosis (40%, 50%, and 50%), thus allowing competitive flow. Indications for MIDCABG surgery may be expanded from one-vessel disease to two-vessel disease using LITA and RGEA grafts.
Gu Y J, Mariani MA, van Oeveren W, et al: Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 65:420-424, 1998 The systemic inflammatory response induced by cardiopulmonary bypass is a major contributor to postoperative morbidity in cardiac
Journal of Cardiothoracic and Vascular Anesthesia, Vo112, No 5 (October), 1998: pp 604-606
Pediatrics
Rasanen J, Wood DC, Debbs RH, et ah Reactivity of the human fetal pulmonary circulation to maternal hyperoxygenation increases during the second half of pregnancy. Circulation 97:257-262, 1998 Forty women with an uncomplicated pregnancy were included in a randomized study in which they were administered either oxygen (FIO2, 0.6) or room air. Baseline and experimental measurements of fetal blood-velocity waveforms at the level of the aortic valve, pulmonic valve, right pulmonary artery (RPA), left pulmonary artery (LPA), and the ductus arteriosus (DA) were obtained using pulsed wave and color Doppler. Twenty fetuses were studied at 20 to 26 weeks of gestational age and 20 fetuses were studied at 31 to 36 weeks of gestational age. Baseline values did not differ among the groups. The administration of room air did not change any echocardiographic parameters in either gestational age group. During maternal hyperoxygenation in the fetuses aged 31 to 36 weeks, the pulsatility index (PI) of the RPA and LPA decreased and the PI of the DA increased significantly. These changes were not evident in the fetuses aged 20 to 26 weeks. Reactivity of the fetal circulation to oxygen increases with advanced gestational age.
Morris CD, Relier MD, Menashe VD: Thirty-year incidence of infective endocarditis after surgery for congenital heart defect. JAMA 279:599-603, 1998 The cohort of children in the state of Oregon who underwent surgical correction of a congenital heart defect was surveyed using a populationbased registry. Follow-up data for up to 25 years was available for 88% of the patients. All documented occurrences of endocarditis were confirmed by hospital echocardiography and blood culture results or by autopsy. The defect most frequently associated with infective endocarditis was aortic stenosis (13.3%) with a native or a prosthetic valve. Other defects associated with endocarditis were coarctation of the aorta (35%), ventricular septai defect (2.7%), and transposition of the great arteries (4%). Endocarditis in association with a ventricular septal defect repair was frequently accompanied by a residual septal defect. Secundum atrial septal defect, iigation of a ductus arteriosus, and repair of pulmonic stenosis were not associated with endocarditis in this population.
Zufelt K, Rosenberg HC, Li MD, et al: The electrocardiogram and the secundum atrial septal defect: A reexamination in the era of echocardiography. Can J Cardiol 14:227-232, 1998 Ostium secundum atrial septal defects (ASDs) account for a large portion of congenital heart disease, but they are usually asymptomatic and diagnosis is difficult. Characteristic electrocardiogram (ECG) criteria have already been established for adult patients with ASDs (rsR'-V1 with right ventricular hypertrophy [RVH], isolated rsR', and isolated RVH). The purpose of this study was to determine whether similar ECG abnormalities were consistently present in hemodynamically compromised pediatric patients with ASDs. Medical records were reviewed retrospectively for 67 children with ASDs and 77 children 604
with benign murmurs, and the ECGs and echocardiograms were compared. Eighty-seven percent of the patients with ASDs met predetermined ECG criteria, compared with 3.9% of the control patients. Use of the predetermined ECG criteria was 86.6% sensitive (95% confidence interval [CI], 0.784 to 0.947) and 96.1% specific (95% CI, 0.884 to 0.997) and may be useful in differentiating pediatric patients with ASDs from those with benign heart murmurs.
Davies M J, Nguyen K, Gaynor JW, Elliott M J: Modified ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass. J Thorac Cardiovasc Surg 115:361-370, 1998 Modified ultrafiltration after cardiopulmonary bypass in pediatric patients decreases total-body water and increases the hematocrit, cardiac index, and systolic blood pressure. The purpose of this prospective study was to show that the improvement of hemodynamic parameters after ultrafiltration was caused by an improvement of left ventricular function. Twenty-one pediatric cardiac surgical patients were randomized to receive nltrafiltration (n = 11) or as controls (n = 10). Multiple parameters of left ventricular function were evaluated using echocardiography and ultrasonic transducers placed in the mid-left ventricular cavity of all patients. Only those patients receiving ultrafiltration showed improvement in the parameters defining left ventricular systolic function and diastolic compliance. They also required less inotropic support than those patients in the control group.
Minimally Invasive Surgery~Myocardial Ischemia
Voutilainen S, Verkkala K, Jarvinen A, et al: Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery. Ann Thorac Surg 65:444-448, 1998 Anastomosis of the left internal thoracic artery (LITA) to the left anterior descending artery has become routine in patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCABG) surgery. Right gastroepiploic artery (RGEA) grafts have been successful in coronary bypass surgery during cardiopnlmonary bypass. The purpose of this study was to evaluate the anastomosis of the RGEA to the right coronary artery during MIDCABG surgery. Of the 100 patients undergoing MIDCABG with LITA grafts, 25 patients received an RGEA graft. Postoperative angiography showed that 82.6% of the RGEA grafts and all of the LITA grafts were patent. Three nonvisualized RGEA grafts showed noncritical proximal stenosis (40%, 50%, and 50%), thus allowing competitive flow. Indications for MIDCABG surgery may be expanded from one-vessel disease to two-vessel disease using LITA and RGEA grafts.
Gu Y J, Mariani MA, van Oeveren W, et al: Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 65:420-424, 1998 The systemic inflammatory response induced by cardiopulmonary bypass is a major contributor to postoperative morbidity in cardiac
Journal of Cardiothoracic and Vascular Anesthesia, Vo112, No 5 (October), 1998: pp 604-606