Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual
-
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2006
ReviewMechanical cardiac support in the young. Short-term support: ECMO.
Although based on technology developed several decades ago, extracorporeal membrane oxygenation (ECMO) retains great clinical relevance in the management of advanced pediatric cardiorespiratory disease. Largely because of its widespread use in pediatric patients with respiratory failure, familiarity with this technology has established ECMO as the most commonly used form of mechanical circulatory support in children. Clinical applications and technical aspects of ECMO support continue to evolve, ensuring the ongoing importance of this modality for pediatric circulatory support.
-
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2006
ReviewSurgical repair of total anomalous pulmonary venous connection.
The diagnosis of total anomalous pulmonary venous connection (TAPVC) is made when all four pulmonary veins drain anomalously to the right atrium or to a tributary of the systemic veins. It constitutes between 1% and 1.5% of all children with congenital heart disease and can be categorized by the site of drainage into the systemic circulation (supracardiac, 45%; infracardiac, 25%; cardiac, 25%; mixed, 5%). The clinical presentation is different if the pulmonary venous drainage is unobstructed (heart failure, mild cyanosis) or obstructed (respiratory failure, severe heart failure). ⋯ Postoperative pulmonary artery hypertension can be problematic. Recent surgical results with isolated TAPVC have improved, with operative mortality consistently at less than 10%. A particularly challenging group of patients are those with single ventricle physiology and TAPVC with high operative mortality and poor long-term survival.
-
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2006
ReviewIndications and timing of pulmonary valve replacement after tetralogy of Fallot repair.
Surgical management of tetralogy of Fallot results in anatomic and functional abnormalities in the majority of patients. Although right ventricular volume load due to severe pulmonary regurgitation can be tolerated for years, there is now evidence that the compensatory mechanisms of the right ventricular myocardium ultimately fail and that if the volume load is not eliminated or reduced the dysfunction might be irreversible. ⋯ This article reviews the pathophysiology of chronic right ventricular volume load after tetralogy of Fallot repair and the risks and benefits of pulmonary valve replacement. Finally, recommendations for timing and indications for pulmonary valve replacement are given.
-
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2006
ReviewPhysiopathology of right ventricular failure.
The physiopathology of right ventricular failure after repair of tetralogy of Fallot is complex. While primarily reflecting chronic volume overload resulting from pulmonary regurgitation, its determinants reflect a varied contribution of different boundary conditions. ⋯ Indeed, there appears to be a close relationship between the mechanical properties of the right ventricle and its electrical stability. In this chapter the determinants of pulmonary incompetence and its secondary effects on right ventricular function and performance, and mechano-electric interactions will be discussed.
-
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu · Jan 2006
ReviewMechanical devices and US Food and Drug Administration (FDA) approval.
Long-term ventricular assist devices for adults have advanced far more than have suitable devices for neonates and infants. The difficulties of design and construction of miniaturized blood pumping systems and the high costs associated with developing, testing, and approval of such devices has been prohibitive. Still, there is an important clinical need for such devices as the availability of donor hearts for this age group has been especially limited. ⋯ This chapter reviews the current system for medical device classification and the approval processes in the United States and in Europe. This system is continually evolving, with dedicated and knowledgeable professionals charged with assuring the efficacy, safety, appropriate labeling, and continuing surveillance of approved devices. Pediatric cardiac surgeons involved in transplantation and assist devices need to be aware of the regulatory issues, and work with manufacturers and governmental agencies to make sure that successful devices are available as soon as possible for their patients.