Pediatr Crit Care Med. 2007 May 29; [Epub ahead of print]

Prevalence of heparin-dependent platelet antibodies in children after
cardiopulmonary bypass*

Hanson SJ, Punzalan RC, Ghanayem N, Havens P.

From the Department of Pediatrics, Critical Care Medicine, Children’s Hospital of
Wisconsin and Medical College of Wisconsin, Milwaukee, WI (SJH); Department of
Pediatrics and Blood Center of Wisconsin, Medical College of Wisconsin,
Milwaukee, WI (RCP); Department of Pediatrics, Critical Care Medicine, Children’s
Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI (NG); and
Department of Pediatrics, Infectious Disease, Children’s Hospital of Wisconsin
and Medical College of Wisconsin, Milwaukee, WI (PH).

OBJECTIVE:: To determine the prevalence of heparin-dependent platelet antibodies
(HDPA) in children requiring heparin for >5 days after cardiopulmonary bypass
surgery. DESIGN:: Prospective, observational study. SETTING:: Tertiary care
pediatric intensive care unit. PATIENTS:: Thirty children were enrolled: 15
patients <30 days old and 15 patients between 30 days and 12 yrs of age.
INTERVENTIONS:: Detection of HDPA by heparin-platelet factor 4 enzyme-linked
immunosorbent assay after 5-10 days of postoperative heparin exposure. Positive
or equivocal results were confirmed with serotonin release assay. MEASUREMENTS
AND MAIN RESULTS:: There were no confirmed cases of HDPA in this study (95%
confidence interval 0-11.6%). Despite the lack of HDPA, the study population was
at high risk of thrombosis with symptomatic clot developing in six patients
(20%). Clinical models developed in adults to determine the pretest risk of
heparin-induced thrombocytopenia were not valid in this study population.
CONCLUSIONS:: The prevalence of HDPA in children after cardiopulmonary bypass
surgery is low. After bypass surgery, critically ill children are at risk of
developing thrombosis from multiple etiologies, and suspicion of heparin-induced
thrombocytopenia needs to be confirmed with laboratory testing including a
functional assay.

Intensive Care Med. 2007 May 25; [Epub ahead of print]

Agreement of central venous saturation and mixed venous saturation in cardiac
surgery patients.

Sander M, Spies CD, Foer A, Weymann L, Braun J, Volk T, Grubitzsch H, von Heymann
C.

Department of Anaesthesiology and Intensive Care Medicine, University Hospital
Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité
Universitätsmedizin, Charitéplatz 1, 10098, Berlin, Germany,
michael.sander@charite.de.

OBJECTIVE: Comparison of the bias and the limits of agreement (LOA; 2[Symbol: see
text]SD) of the central venous saturation (S(cv)O(2)) before, during and after
coronary artery bypass graft surgery with a simultaneous measurement of the mixed
venous saturation (S(v)O(2)). DESIGN AND SETTING: Prospective controlled study in
a university hospital department of anaesthesiology. PATIENTS: 60 patients with
coronary artery bypass surgery, 300 paired measurements of S(v)O(2) and
S(cv)O(2). MEASUREMENTS AND RESULTS: S(cv)O(2) and S(v)O(2) were analysed after
induction of anaesthesia 15[Symbol: see text]min after cardiopulmonary bypass and
1, 6 and 18[Symbol: see text]h after admission to the intensive care unit.
Regression analysis for the pooled measurements of S(cv)O(2) and S(v)O(2) showed
a correlation R (2)[Symbol: see text]=[Symbol: see text]0.52. After induction of
anaesthesia 15[Symbol: see text]min after weaning from cardiopulmonary bypass and
6[Symbol: see text]h after admission to the intensive care unit the correlation
coefficient was R (2)[Symbol: see text]=[Symbol: see text]0.46, on admission to
the intensive care unit it was R (2)[Symbol: see text]=[Symbol: see text]0.42,
and at 18[Symbol: see text]h it was R (2)[Symbol: see text]=[Symbol: see
text]0.38. Bland-Altman analysis for the measurements of S(cv)O(2) and S(v)O(2)
showed a mean bias and LOA of 0.3% and -11.9 to +12.4%. In patients with a low
S(cv)O(2) there was a trend to overestimate the S(v)O(2) by using the S(cv)O(2).
The only factor that influenced the DeltaS(v)O(2)[Symbol: see text]-[Symbol: see
text]S(cv)O(2) was the oxygen extraction rate (R (2)[Symbol: see text]=[Symbol:
see text]0.16). In patients with S(cv)O(2) below 70% this association was more
pronounced (R (2)[Symbol: see text]=[Symbol: see text]0.60). CONCLUSIONS: Our
findings demonstrate that oxygen extraction rate is the major factor in the
difference between S(v)O(2) and S(cv)O(2). Under certain circumstances S(cv)O(2)
differed substantially from S(v)O(2). Therefore in selected patients both
parameters should be monitored to exclude general or focal hypoperfusion.

Transplant Proc. 2007 May;39(4):1250-4.

Xenograft transplantation in congenital cardiac surgery at baskent university:
midterm results.

Ozkan S, Akay TH, Gultekin B, Sezgin A, Tokel K, Aslamaci S.

Baskent University, Faculty of Medicine, Department of Cardiovascular Surgery,
Ankara, Turkey.

OBJECTIVE: Xenograft valved conduits have been used in several cardiac
pathologies. In this study we have presented our midterm results of pediatric
patients pathologies who were operated with xenograft conduits. PATIENTS AND
METHODS: Between January 1999 and January 2005, 134 patients underwent open heart
surgery with xenograft conduits. The conduits were used to establish the
continuity of the right ventricle to the pulmonary artery or aorta, the left
ventricle to the pulmonary artery, or aorta due to various types of complex
cardiac anomalies. Patients were evaluated by transthoracic echocardiography
(ECHO) at 6-month follow-ups. Cardiac catheterization was performed when ECHO
demonstrated significant conduit failure. RESULTS: Hospital mortality was
observed in 28 patients (20.1%), and 13 patients died upon follow-up (9.7%). Mean
follow-up was 24.6 +/- 4 months (range, 13 to 85 months). Among 93 survivors 20
patients (21.5%) were reoperated due to conduit failure. The main reasons for
conduit failure were stenosis (n = 13), valvular regurgitation (n = 2), or both
conditions in 5 cases. Mean pulmonary gradient before conduit re-replacement was
47.7 +/- 30.1 mmHg. The 1-, 3-, and 6-year actuarial survival rates were 95 +/-
2%, 91 +/- 3%, and 86 +/- 5%. The 1-, 3-, and 6-year actuarial freedom rates from
reoperation were 95 +/- 1%, 90 +/- 3%, and 86 +/- 4%. An increased gradient
between the pulmonary artery and the right ventricle and prolonged
cardiopulmonary bypass times were observed to be significant risk factors for
reoperation. There was no mortality among reoperated patients. CONCLUSION:
Xenograft conduits should be closely followed for calcification and stenosis.
Conduit stenosis is the major risk factor for reoperation. In these patients,
reoperation for conduit replacement can be performed safely before deterioration
of cardiac performance.

Am J Ther. 2007 May-Jun;14(3):253-8.

A 5-year survey of nitric oxide use in a pediatric intensive care unit.

Ryan A, Tobias JD.

1University of Missouri School of Medicine, Columbia, MO; and 2Departments of
Anesthesiology and Pediatrics, University of Missouri, Columbia, MO, USA.

The authors retrospectively reviewed their experience with nitric oxide (NO) in a
pediatric ICU. Given its cost ($3000/d), ongoing evaluations are required to
ensure its effective use and avoid inappropriate applications. NO use included 4
categories: (1) hypoxemic respiratory failure, (2) pulmonary hypertension
following surgery for congenital heart disease (CHD), (3) intraoperatively for
surgical procedures such BT shunt placement or 1-lung ventilation, and (4) during
ECMO. In the 19 patients with respiratory failure, NO resulted in an increase in
oxygenation in 15 of 19 patients (Pao2/Fio2 ratio increased from 83 +/- 60 mm Hg
to 188 +/- 105 mm Hg, P = 0.0007). In 4 patients, NO did not improve oxygenation.
The 15 patients that responded to NO survived, whereas the 4 patients who did not
respond died (P = 0.0003). NO was used to treat pulmonary hypertension in 19
patients following cardiopulmonary bypass (CPB) and surgery for CHD. In 13 of 19
patients, a high pulmonary artery (PA) pressure was documented by direct
measurement with a needle inserted into the PA while the chest was open (n = 9)
or a postoperative transthoracic PA catheter (n = 4). NO resulted in a decrease
in the PA pressure in 9 of 13 patients (37 +/- 5 mm Hg to 21 +/- 3 mm Hg, P <
0.0001). In the one patient in whom NO did not lower intraoperative PA pressure,
it was not possible to wean from CPB. For the 10 patients in whom NO was started
in the PICU, 4 had PA catheters in place and documented elevated PA pressure. NO
resulted in a significant decrease in the PA pressure in only 1 of these 4
patients. The survival of responders was 9 of 9 versus 1 of 4 for nonresponders
(P = 0.014). No significant adverse effects requiring therapy other than
decreasing the inhaled NO concentration were noted. Potential interventions and
practices to limit the unwarranted use of this costly agent are discussed.

Resuscitation. 2007 May 10; [Epub ahead of print]

Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary
bypass: An analysis of variables based on the "Utstein Style for Drowning"

Eich C, Bräuer A, Timmermann A, Schwarz SK, Russo SG, Neubert K, Graf BM, Aleksic
I.

Department of Anaesthesiology, Emergency and Intensive Care Medicine,
Georg-August University, Göttingen, Germany.

BACKGROUND: In 2003, the International Liaison Committee on Resuscitation (ILCOR)
published the "Utstein Style for Drowning" (USFD) to advance knowledge on the
epidemiology, treatment, and outcome prediction after drowning. Applying the USFD
and evaluating its data template for outcome analysis, we report here on the
largest study published thus far of drowned children (age 0-14) who underwent
attempted resuscitation on cardiopulmonary bypass (CPB). METHODS: We conducted a
retrospective review of all drowned children admitted to Göttingen University
Hospital between 1/1987 and 12/2005 in sustained cardiopulmonary arrest and
resuscitation with CPB. We correlated eight outcome-affecting USFD variables and
four additional variables not included in the USFD with potential impact on
outcome to four outcome groups: survival, non-survival, survival with full
recovery, and failed resuscitation. RESULTS: Out of 12 children (aged 22 months
to 7.5 years), 5 survived to hospital discharge and 7 died in hospital. Two
survivors recovered fully and three remained in a vegetative state. In two
patients, resuscitation on CPB failed. Both children who fully recovered,
compared to the 10 others, had relatively low serum K(+) concentrations (2.6 and
3.7mmol/l versus 5.8+/-3.8mmol/l [mean+/-S.D.; n=10]), a relatively slow
rewarming speed (1.9 and 1.2 degrees C/h versus 3.4+/-1.8 degrees C/h), were
female (all three girls survived), received early basic life support (BLS) and
showed idioventricular bradycardia. Both children with failed resuscitation had
severe hyperkalaemia (11.7 and 13.3mmol/l versus 10 others, 4.0+/-1.5mmol/l),
were relatively rapidly rewarmed (6.9 and 4.0 degrees C/h versus 10 others,
2.61+/-1.32 degrees C/h), male, and in asystole. We identified no outcome trends
for age, pH, or water and core temperatures. CONCLUSIONS: Most variables relevant
for outcome in drowned children can be documented with the use of the USFD.
Additional variables not included in the USFD that have emerged from this study
and may predict outcome include serum K(+) concentration, rewarming speed, and
initial cardiac rhythm.

Am J Physiol Heart Circ Physiol. 2007 May 4; [Epub ahead of print]

Effects of cardio-pulmonary bypass surgery on coronary flow in children assessed
with transthoracic Doppler echocardiography.

Aburawi EH, Berg A, Liuba P, Pesonen E.

Pediatric Cardiology, Lund University Hospital, Lund, Skane, Sweden.

Perturbation of coronary blood flow (CF) is an important contributor to
myocardium-related complications. The study was primarily designed to assess the
impact of cardiopulmonary bypass (CPB) surgery on CF by aid of transthoracic
Doppler echocardiography (TTDE). Changes in CF after off-pump coarctation surgery
were also studied. All ultrasounds were performed before and 5+/-1 days after
surgery. Eighteen children underwent CPB surgery of ventricular left-to-right
shunts at the mean age of 6 months while off-pump surgery (aortic coarctectomy)
was undertaken at the mean age of 10 days in twelve children. After CPB surgery,
both LAD;s mean diameter and basal CF increased from 1.7+/-0.3 to 2.1+/-0.4 mm
(p=0.001) and 27+/-8 to 63+/-18 ml/minute (p=0.0001), respectively. These two
coronary variables decreased after off-pump coarctectomy: LAD's mean diameter
from 1.8 +/- 0.1 to 1.7 +/- 0.1 mm (p=0.06), and CF from 44 +/- 20 to 22 +/- 14
ml/minute (p=0.001). The findings are in keeping with the hypothesis that the
previously reported impairment of coronary flow reserve after CPB surgery could
be due to increase in basal coronary flow after CPB. Off-pump coarctectomy seems
to have little impact on CF as the post surgical decline in flow in these
patients seems to relate to the reduction in cardiac pressure afterload. Key
words: congenital heart disease, coronary blood flow, cardiopulmonary bypass
surgery.

Artif Organs. 2007 May;31(5):377-83.

Extracorporeal circulation, optimized: a pilot study.

Agati S, Ciccarello G, Trimarchi ES, Grasso D, Trimarchi G, Stefano SD, Carmelo
M.

Cardiac Surgery Unit, San Vincenzo Hospital, Messina, Italy.

We designed a pilot study to assess as primary end point the safety and efficacy
of a new phosphorylcholine-coated, closed cardiopulmonary bypass (CPB) system
(extracorporeal circulation, optimized [ECC.O], Dideco, Mirandola, Italy). The
secondary end point was to compare results with two retrospectively matched
cohorts of patients who underwent isolated coronary artery by-pass graft (CAGB)
with nonphosphorylcholine-bonded circuits and cardiotomy suction (Group II, n =
32) and off-pump coronary artery by-pass (OPCAB) (Group III, n = 26). In January
2005, 30 patients (Group I) undergoing first-time CABG were assigned to the ECC.O
group. Five minutes after CPB, initial hematocrit levels were significantly and
consistently highest in Group I relative to Group II (Group I, 29.7 +/- 4.4 vs.
Group II, 22.7 +/- 4.1; P < 0.001). Red blood cell transfusion rate was reduced
drastically in Group I versus Group II (P < 0.001). High differences were also
observed in C-reactive protein levels at 24 h after surgery (Group I vs. Group
II-P < 0.001 and vs. Group III-P < 0.001) and at 72-h peak value (Group I vs.
Group II-P < 0.001 and vs. Group III-P < 0.001). The routine clinical use of the
ECC.O system has been demonstrated to be both clinically safe and efficacious. An
intensive training program for surgeons, perfusionists, and anesthesiologists is
required.

J Thorac Cardiovasc Surg. 2007 May;133(5):1344-53, 1353.e1-3. Epub 2007 Mar
19.

Patient characteristics are important determinants of neurodevelopmental outcome
at one year of age after neonatal and infant cardiac surgery.

Gaynor JW, Wernovsky G, Jarvik GP, Bernbaum J, Gerdes M, Zackai E, Nord AS,
Clancy RR, Nicolson SC, Spray TL.

Division of Cardiothoracic Surgery, The Cardiac Center at The Children's Hospital
of Philadelphia, Philadelphia, PA 19104, USA. gaynor@email.chop.edu

OBJECTIVE: Many studies of neurodevelopmental outcomes after neonatal and infant
cardiac surgery have focused on potentially modifiable risk factors for adverse
outcomes, primarily intraoperative management strategies and the use of deep
hypothermic circulatory arrest. There is increasing evidence that
patient-specific factors are more important determinants of outcome. METHODS: We
investigated predictors of neurodevelopmental outcomes at 1 year of age after
neonatal and infant cardiac surgery in a subgroup of infants enrolled in a
prospective study of apolipoprotein E (APOE) genotype and neurodevelopmental
outcome. Children with a variety of 2-ventricle cardiac defects repaired with
only 1 operation with cardiopulmonary bypass and no more than 1 episode of deep
hypothermic circulatory arrest were included. Neurodevelopmental outcomes at 1
year of age included the Bayley Scales of Infant Development-II, which yield 2
indices, the Mental Developmental Index and the Psychomotor Developmental Index.
RESULTS: Two hundred forty-seven infants underwent surgical repair between
October 1998 and April 2003 with 1 hospital death and 3 deaths before 1 year of
age. Neurodevelopmental evaluation was performed in 188 (77%) of 243 survivors,
including 56 patients with tetralogy of Fallot, 39 with transposition of the
great arteries with intact ventricular septum, 34 with ventricular septal
defects, and 59 with other defects. The median age at operation was 56 days
(1-186 days), including 72 (38%) neonates. Confirmed or suspected genetic
syndromes were present in 59 (31%) of 188 infants. Deep hypothermic circulatory
arrest was used in 67 (35%) infants with a median duration of 34 minutes (1-80
minutes). For the entire cohort, the mean Mental Developmental Index was 90.6 +/-
14.9 and the mean Psychomotor Developmental Index was 81.6 +/- 17.2. For patients
without genetic syndromes, the mean Mental Developmental Index was 93.7 +/- 13.6
and the mean Psychomotor Developmental Index was 85.1 +/- 14.6. For the entire
cohort, predictors of lower scores for both the Mental Developmental Index and
Psychomotor Developmental Index were presence of a confirmed or suspected genetic
syndrome, lower birth weight, and presence of the APOE epsilon2 allele (all P <
.04). Black race was associated with higher scores on the Psychomotor
Developmental Index (P = .018). Lower nasopharyngeal temperature during
cardiopulmonary bypass was associated with a lower score on the Psychomotor
Developmental Index (P = .03) and was the only intraoperative factor that was a
significant predictor of either the Mental or Psychomotor Developmental Index.
CONCLUSIONS: The strongest predictors of a worse neurodevelopmental outcome at 1
year of age were patient-specific factors including presence of a genetic
syndrome, low birth weight, and presence of the APOE epsilon2 allele.
Patient-specific factors eclipsed the use and duration of deep hypothermic
circulatory arrest as predictors of worse neurodevelopmental outcomes.

Ann Thorac Surg. 2007 May;83(5):1731-6.

Novel techniques for tumor thrombectomy for renal cell carcinoma with intraatrial
tumor thrombus.

Chowdhury UK, Mishra AK, Seth A, Dogra PN, Honnakere JH, Subramaniam GK, Malhotra
A, Malhotra P, Makhija N, Venugopal P.

Departments of Cardiothoracic and Vascular Surgery, All India Institute of
Medical Sciences, New Delhi, India. ujjwalchow@rediffmail.com

BACKGROUND: Radical nephrectomy with tumor thrombectomy in patients with renal
cell carcinoma and level I to III thrombus extension is directly associated with
an improved prognosis. However, radical surgery in patients with level IV
thrombus extension is associated with high perioperative mortality, even if
long-term survival is possible. In this report, we describe an alternative
technique of vena caval and intraatrial tumor thrombectomy to decrease
perioperative mortality and morbidity. METHODS: A cohort of 6 patients aged 46,
50, 53, 56, 54, and 52 years underwent radical nephrectomy with tumor
thrombectomy from the vena cava and right atrium under mild hypothermic
cardiopulmonary bypass and intermittent cross-clamping of the supraceliac
abdominal aorta. Intraatrial tumor thrombectomy was performed on a beating,
perfused heart in 4 patients and a hypothermic, cardioplegia-perfused heart in 2
patients. RESULTS: There were no early or late deaths. The aortic cross-clamp
time was 12 and 15 minutes for patients 5 and 6, respectively. The cumulative
hepatic and renal ischemic time was 16 minutes (range, 14 to 22 minutes) at 32
degrees C. The mean cardiopulmonary bypass time was 53.3 +/- 8.9 minutes (range,
40 to 65 minutes). At a mean follow-up of 43 +/- 24.6 months (range, 10 to 70
months), all patients are active and remain disease-free. CONCLUSIONS: We
conclude that radical nephrectomy and tumor thrombectomy in patients with level
IV thrombi can be safely performed with cardiopulmonary bypass, mild hypothermia.
and intermittent supraceliac abdominal aortic occlusion, avoiding potential
hematologic, hepatic, renal, neurologic, and septic complications associated with
circulatory arrest.

J Anesth. 2007;21(2):148-52. Epub 2007 May 30.

Impact of Sonoclot hemostasis analysis after cardiopulmonary bypass on
postoperative hemorrhage in cardiac surgery.

Yamada T, Katori N, Tanaka KA, Takeda J.

Department of Anesthesiology, School of Medicine, Keio University, 35
Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

PURPOSE: The Sonoclot Analyzer provides a functional test of whole blood
coagulation by measuring the viscous property of the blood sample. In this study,
we used a modified Sonoclot assay, using cuvettes with a glass bead activator
containing heparinase, and compared the Sonoclot data before and after
cardiopulmonary bypass (CPB) to assess the usefulness in predicting postoperative
hemorrhage. METHODS: In 41 cardiac surgery patients, Sonoclot data were obtained
immediately after heparin administration (pre-bypass) and just before protamine
administration (post-bypass). Excessive bleeding was defined as chest tube
drainage greater than 2 ml.kg(-1).h(-1) in 1 h during the first 4 h after
surgery. RESULTS: There were no significant differences in Sonoclot values before
and after CPB in patients with acceptable bleeding (n = 29). In patients with
excessive bleeding (n = 12), Sonoclot variables reflecting fibrin formation
(activated clotting time [ACT], rate of fibrin formation [clot rate], and peak
clot signal) were preserved after CPB; however, the variables reflecting
platelet-fibrin interaction (time to peak, peak angle, and clot retraction rate)
were significantly different from their respective pre-bypass values. Sonoclot
analysis showed impairment of clot maturation after CPB in patients with
excessive postoperative bleeding. CONCLUSION: Our results suggest that abnormal
postoperative hemorrhage can be predicted by Sonoclot analysis with a new glass
bead-activated heparinase test performed after CPB.