Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2010
Congenital heart surgery databases around the world: do we need a global database?
The question posed in the title of this article is: "Congenital Heart Surgery Databases Around the World: Do We Need a Global Database?" The answer to this question is "Yes and No". Yes--we need to create a global database to track the outcomes of patients with pediatric and congenital heart disease. No--we do not need to create a new "global database." Instead, we need to create a platform that allows for the linkage of currently existing continental subspecialty databases (and continental subspecialty databases that might be created in the future) that will allow for the seamless sharing of multi-institutional longitudinal data across temporal, geographical, and subspecialty boundaries. ⋯ Outcomes should determine primary therapy, and as such must be monitored life-long. The relatively small numbers of patients with congenitally malformed hearts requires multi-institutional cooperation to accomplish these goals. The creation of a Global Federated Multispecialty Congenital Heart Disease Database that links extant databases from pediatric cardiology, pediatric cardiac surgery, pediatric cardiac anesthesia, and pediatric critical care will create a platform for improving patient care, research, and teaching related to patients with congenital and pediatric cardiac disease.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2010
CommentNear infrared spectroscopy (NIRS) should not be standard of care for postoperative management.
Neurologic dysfunction is a problem in patients with congenital heart disease. Near infrared spectroscopy (NIRS) may provide a real-time window into cerebral oxygenation. Enthusiasm for NIRS has increased in hopes of reducing neurologic dysfunction. ⋯ However, the current literature on the use of NIRS alone does not demonstrate improvement in neurologic outcome. Data correlating NIRS findings with indirect measures of neurologic outcome or mortality are limited. Although NIRS has promise for measuring regional tissue oxygen saturation, the lack of data demonstrating improved outcomes limits the support for wide-spread implementation.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2010
Pro: NIRS is "standard of care" for postoperative management.
Successful postoperative management depends on early detection and correction of circulatory insufficiency. Global cardiac output and oxygen delivery must be adequate and distributed appropriately to meet metabolic demands to prevent the development of multi-organ dysfunction, morbidity, and death. Decreased cardiac output during the postoperative period is common, but circulatory assessment using standard monitoring provides inadequate information to reliably detect low cardiac output syndrome or effectively guide therapy. ⋯ Multiple prospective observational studies have shown that NIRS-derived measures of systemic oxygen balance correlate with global circulatory measures, including SvO2 and biochemical indicators of shock. Additionally, NIRS has been shown in multiple prospective observational studies to identify circulatory inadequacy in specific organ systems, such as the brain, kidney, and gut. NIRS provides continuous, non-invasive measures that are suitable targets for goal-directed therapy to treat deficiencies in global and regional perfusion and should be standard of care.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2010
Improving pediatric cardiac surgical care in developing countries: matching resources to needs.
This article reviews a systematic approach to the design and support of pediatric cardiac surgery programs in the developing world with the guidance and strategies of Children's HeartLink, an experienced non-government organization for more than 40 years. An algorithm with criteria for the selection of a partner site is outlined. ⋯ In addition to these factors, it is essential that the development effort includes considerations of environment (eg, governmental support, regulatory environment, and social structure) and health system (elements related to affordability, access, and awareness of care) that impact success. Partner programs should be willing to initiate a clinical database with the intent to analyze and critique their results to optimize quality assurance and improve outcomes.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2010
Evolution of the Fontan-Kreutzer procedure.
The surgical techniques used to construct the Fontan-Kreutzer circulation have evolved considerably since the initial reports. In the early years, it was thought that a power source other than the main ventricular chamber was useful or even necessary to serve the pulmonary circulation. Better understanding of the physiology of the Fontan-Kreutzer circulation has led to an understanding that avoidance of flow disturbances and energy losses in the surgically constructed pathways is critically important. ⋯ These innovations have resulted in extension of the Fontan-Kreutzer procedure to the management of complex univentricular hearts and, in particular, the management of hypoplastic left heart syndrome. There have been significant improvements of early mortality and morbidity following the Fontan-Kreutzer procedure. Yet it is important to recognize that there is continuing late attrition and morbidity for patients with the Fontan-Kreutzer circulation.