Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2003
ReviewRe-operative surgery in pediatric patients.
In spite of recent emphasis on primary repair for congenital heart defects, multiple operations are often required for staged repairs of complex lesions or replacement of outgrown or degenerated prosthetic material. The vast majority of re-do operations proceed without incident; however, re-operation entails greater risk of inadvertent injury to the phrenic nerve and other heart and vascular structures, postoperative bleeding, and may require alternative cannulation sites. Recommendations to address these hazards are reviewed, as are areas of research that may impact future approaches to the patient who requires re-operation. Pericardial closure and pericardial substitutes, bovine and synthetic, are briefly discussed, as is the use of aprotinin for its hemostatic and anti-inflammatory effects.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2003
ReviewThe effect of modified ultrafiltration on the postoperative course in patients with congenital heart disease.
Improvements in the technology of cardiopulmonary bypass have significantly reduced morbidity following repair of congenital cardiac defects. However, the use of cardiopulmonary bypass exposes infants to extremes of hemodilution and hyperthermia, often in association with tissue ischemia. Exposure of the blood to surfaces of the bypass circuit initiates a systemic inflammatory response that may result in organ dysfunction after cardiopulmonary bypass, especially the heart, lungs, and brain. ⋯ The mechanisms by which MUF results in these beneficial effects requires additional investigation. In addition, further studies are necessary to identify patients most likely to benefit from MUF and to define the optimal protocols for its use. In the future, prospective randomized studies incorporating recent advances in the technology of cardiopulmonary bypass will be necessary to define the optimal utilization of ultrafiltration during and after cardiopulmonary bypass.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2003
ReviewOptimizing response of the neonate and infant to cardiopulmonary bypass.
Despite the ability to surgically correct complex defects in neonates and infants, limitations in outcome are sometimes encountered in relation to exposure to cardiopulmonary bypass (CPB). The deleterious effects of CPB in neonates are often pronounced because of their immature tissue/organ function and the disparity between the CPB circuit size and the patient. A variety of techniques that have been developed to prevent or lessen tissue edema, including miniaturization of the circuit and oxygenator, prime additives (eg, albumin, steroids), biocompatible circuitry, and variations in perfusion strategies, are discussed as are post-CPB strategies such as modified ultrafiltration, which removes inflammatory mediator-rich fluid from the patient and bypass circuit. With optimization of the response of the infant to our systems used during repair of their cardiac lesion, we will see significant improvement in surgical outcomes.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2003
Review Comparative StudyEthical issues concerning cardiac surgery in patients with syndromic abnormalities.
Advances in surgical techniques, cardiac anesthesia, and pre- and postoperative care have made the surgical treatment of complex congenital cardiac disease available to an ever-increasing number of children, including those with a wide range of extracardiac anomalies. Over the past few decades cardiac surgery in infants and children with syndrome-associated physical and mental conditions has undergone a remarkable change, with previously held norms abandoned for new standards. The social, ethical, and clinical appropriateness of these changes has been the focus of much attention. In this article, we provide a brief history of cardiac surgery in children with congenital syndromes, discuss some groundbreaking cases such as that of "Baby Doe," and present some rules of thumb for the pediatric cardiac surgeon and cardiologist to use when caring for children with congenital syndromes.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2003
Arrhythmia surgery in association with complex congenital heart repairs excluding patients with fontan conversion.
Surgical arrhythmia therapy may be performed for patients failing the catheter ablation approach or incorporated into repair of complex congenital heart disease. Variations in atrial and ventricular anatomy that may limit the catheter approach can be directly addressed surgically assuring lesion depth and continuity of anatomic lines of block. Between July 1992 and August 2002, we performed arrhythmia surgery on 34 patients for refractory atrial (n = 29) or ventricular (n = 5) arrhythmias. ⋯ Ventricular tachycardia was inducible postoperatively in two of three patients with ventricular arrhythmias and congenital heart disease. Patient size or anatomic complexity should not be limiting factors in the combined surgical arrhythmia approach. Because older patients undergoing surgical revision of prior surgical repairs of congenital heart disease are at increased risk for the later development of atrial arrhythmias, incorporation of arrhythmia therapy into any planned surgical revision should be routinely considered.