Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2004
Risk adjustment for congenital heart surgery: the RACHS-1 method.
The new health care environment has increased the need for accurate information about outcomes after pediatric cardiac surgery to facilitate quality improvement efforts both locally and globally. The Risk Adjustment for Congenital Heart Surgery (RACHS-1) method was created to allow a refined understanding of differences in mortality among patients undergoing congenital heart surgery, as would typically be encountered within a pediatric population. ⋯ It can also be used to evaluate the performance of a single institution in comparison to other benchmark data, provided that complete model parameters are known. Underlying assumptions about RACHS-1 risk categories, inclusion and exclusion criteria, and appropriate and inappropriate uses are discussed.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2004
Routine use of mechanical ventricular assist following the Norwood procedure.
Conventional postoperative management after the Norwood procedure in patients with hypoplastic left heart syndrome suffers from three main shortfalls. First, the early postoperative care is often labor-intensive and ironically (despite sometimes heroic efforts), when babies die, health care providers often feel like failures, and in the worst scenarios, surgeons or other physicians create cultures of blame. Second, hospital survival is inconsistent in most centers, especially the ones with small surgical volume and limited experience. ⋯ Neurodevelopmental testing before the Glenn procedure was normal for all patients tested. Routine postoperative use of mechanical ventricular assist device can support the increased cardiac output demands of infants following Norwood procedure and results in a stable postoperative convalescence. This strategy can simplify postoperative management, lead to excellent hospital survival, and possibly augment cerebral oxygen delivery resulting in improved neurologic outcomes for these patients.
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Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2004
Home monitoring of infants after stage one palliation for hypoplastic left heart syndrome.
Despite improved early results with the Norwood procedure (stage one palliation), patients remain with at-risk anatomy and interstage mortality continues to be a limitation of staged single ventricle palliation. Retrospective analyses have implicated residual or recurrent anatomic lesions as well as intercurrent illness as causes of interstage mortality. ⋯ Frequent monitoring of these physiologic variables between stage one and two palliation identified life-threatening anatomic lesions and illness and permitted timely intervention that ultimately improved survival. All 36 survivors of the stage one palliation discharged from the hospital and entered into the home monitoring program survived the interstage period.
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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.