Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2002
Review Historical ArticleSoftware development, nomenclature schemes, and mapping strategies for an international pediatric cardiac surgery database system.
The field of congenital heart surgery has the opportunity to create the first comprehensive international database for a medical subspecialty. An understanding of the demographics of congenital heart disease and the rapid growth of computer technology leads to the realization that creating a comprehensive international database for pediatric cardiac surgery represents an important and achievable goal. The evolution of computer-based data analysis creates an opportunity to develop software to manage an international congenital heart surgery database and eventually become an electronic medical record. ⋯ An international committee will map the two systems. The ideal coding system will permit a diagnosis or procedure to be coded only one time with mapping allowing this code to be used for patient care, billing, practice management, teaching, research, and reporting to governmental agencies. The benefits of international data gathering and sharing are global, with the long-term goal of the continued upgrade in the quality of congenital heart surgery worldwide.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2002
ReviewPostoperative management in patients with complex congenital heart disease.
Life-threatening problems occur in the neonate and infant after cardiac surgery because of the interplay of diminished cardiac output (CO), increased metabolic demand, inflammatory responses to cardiopulmonary bypass, and maladaptive responses to stress. Therefore, the postoperative management of patients with complex congenital heart defects is directed at optimization of oxygen delivery to maintain end-organ function and promote wound healing. Traditionally, assessment of circulation in the postoperative congenital heart patient has depended on indirect assessment of CO using parameters such as blood pressure, pulses, capillary refill, and urine output. ⋯ A uniform approach to airway maintenance, vascular access, and drug infusions, all universal concerns during the perioperative period, minimizes the potential for these predictable and necessary interventions to result in morbidity or mortality. Management of the postoperative single ventricle patient targets stabilization of the systemic vascular resistance through the use of vasodilators to improve systemic perfusion and simplify ventilator management. Management of any individual patient should be driven by objective analysis of available data and must include efforts to re-evaluate the treatment plan as well as to identify unanticipated problems.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2002
ReviewRepair of congenital tracheal stenosis.
We have used six different techniques in 61 operations performed at Children's Memorial Hospital (Chicago, IL) between 1982 and 2001 on 54 infants with complete tracheal rings and primary or recurrent tracheal stenosis. Short-term and long-term outcomes are reviewed for all techniques including pericardial tracheoplasty, tracheal autograft, tracheal resection, cartilage tracheoplasty, slide tracheoplasty, and aortic homograft patch tracheoplasty. Patients' ages ranged from 7 days to 72 months; mean age at operation was 6 months. ⋯ Follow-up is complete in all patients. Tracheal autograft is currently our procedure of choice for patients with long-segment tracheal stenosis because of its use of all-autologous material, technical ease of performance, already-present epithelial lining of the autograft, intrinsic maintenance of the cartilage contour, potential for growth, and ready availability. We limit the use of tracheal resections to patients with eight or less rings of tracheal stenosis.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2002
ReviewFontan operation for patients with severe distal pulmonary artery stenosis, atresia, or a single lung.
In the absence of a ventricular pump, the status of the pulmonary circulation is crucial to the success of the Fontan operation. In an updated version (1999) of the optimal criteria for the Fontan operation, several of these criteria address the pulmonary circulation: pulmonary artery pressure, pulmonary vascular resistance, pulmonary artery size, and absence of significant pulmonary artery branch stenosis. This chapter reviews the role of the pulmonary circulation in a successful Fontan operation, with a particular emphasis on surgical techniques to repair severe distal or hilar pulmonary artery stenosis or atresia. ⋯ Severe hilar pulmonary artery stenosis or atresia can be repaired by the technique of intrapulmonary pulmonary artery reconstruction with pericardial patch or tube and allow the successful completion of the Fontan operation. In the selected patient with a single pulmonary artery and optimal hemodynamics, the Fontan operation is possible with good outcome. However, further experience is needed in a larger number of patients to assess the long-term outcome of these treatment strategies.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2002
Management of aortopulmonary collateral arteries in Fontan patients: occlusion improves clinical outcome.
Children with chronic cyanotic heart disease often develop systemic-to-pulmonary artery collateral vessels that can be deleterious at the time of a Fontan procedure because of excessive pulmonary blood flow with resultant ventricular volume overload. We therefore occlude all significant collateral arteries during preoperative cardiac catheterization. From June 1993 to September 2001, 137 children ranging from 1.5 to 18.3 years old (median, 2.4 years), underwent a fenestrated lateral tunnel Fontan procedure. ⋯ Hemodynamically significant collateral arteries are common in Fontan candidates. Aggressive control can result in good early and medium-term survival. After the Fontan operation, the presence of significant collateral vessels may be a marker for eventual cardiac failure; 11 of the 29 patients who required postoperative coil placement went on to transplantation or died of heart failure.