(Circulation. 1995;92:2226-2235.)
© 1995 American Heart Association, Inc.
Articles |
Postoperative Course and Hemodynamic Profile After the Arterial Switch Operation in Neonates and Infants
A Comparison of Low-Flow Cardiopulmonary Bypass and Circulatory Arrest
Presented in part at the 65th Scientific Sessions of the American Heart Association, November 16-19, 1992, New Orleans, La.
From the Departments of Cardiology (G.W., A.Z.W., A.C.C., J.W.N., D.L.W.), Cardiac Surgery (R.A.J., J.E.M., F.L.H., A.R.C.), and Anesthesia (P.R.H.), Children's Hospital; the Departments of Pediatrics (G.W., A.C.C., J.W.N., D.L.W.), Surgery (R.A.J., J.E.M., F.L.H., A.R.C.), and Anesthesia (P.R.H.), Harvard Medical School; and the Department of Biostatistics (D.W.), Harvard School of Public Health, Boston, Mass.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Background The neurological morbidity associated with prolonged periods of circulatory arrest has led some cardiac surgical teams to promote continuous low-flow cardiopulmonary bypass as an alternative strategy. The nonneurological postoperative effects of both techniques have been previously studied only in a limited fashion.
Methods and Results We compared the hemodynamic profile (cardiac index and systemic and pulmonary vascular resistances), intraoperative and postoperative fluid balance, and perioperative course after deep hypothermia and support consisting predominantly of total circulatory arrest or low-flow cardiopulmonary bypass in a randomized, single-center trial. Eligibility criteria included a diagnosis of transposition of the great arteries and a planned arterial switch operation before the age of 3 months. Of the 171 patients, 129 (66 assigned to circulatory arrest and 63 to low-flow bypass) had an intact ventricular septum and 42 (21 assigned to circulatory arrest and 21 to low-flow bypass) had an associated ventricular septal defect. There were 3 (1.8%) hospital deaths. Patients assigned to low-flow bypass had significantly greater weight gain and positive fluid balance compared with patients assigned to circulatory arrest. Despite the increased weight gain in the infants assigned to low-flow bypass, the duration of mechanical ventilation, stay in the intensive care unit, and hospital stay were similar in both groups. Hemodynamic measurements were made in 122 patients. During the first postoperative night, the cardiac index decreased (32.1±15.4%, mean±SD), while pulmonary and systemic vascular resistance increased. The measured cardiac index was <2.0 L · min-1 · m-2 in 23.8% of the patients, with the lowest measurement typically occurring 9 to 12 hours after surgery. Perfusion strategy assignment was not associated with postoperative hemodynamics or other nonneurological postoperative events.
Conclusions After heart surgery in neonates and infants, both low-flow bypass and circulatory arrest perfusion strategies have comparable effects on the nonneurological postoperative course and hemodynamic profile.
Key Words: cardiopulmonary bypass • circulatory arrest • transposition of great vessels • cardiac output • edema
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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The dramatic reduction in surgical mortality associated with repair of congenital heart disease in recent decades has been accompanied by a growing recognition of adverse neurological sequelae in some survivors. In 1989, we undertook a prospective clinical trial to assess the short- and long-term neurological sequelae of infant heart surgery, comparing deep hypothermic circulatory arrest to continuous low-flow cardiopulmonary bypass.1 2
A related aim was to examine the short-term hemodynamic effects of the different perfusion strategies during the perioperative period. Patients undergoing the arterial switch operation for TGA were chosen as study subjects because of the relative homogeneity of patients with TGA (eg, clinical presentation, anatomy, and age at repair), low operative mortality,3 favorable long-term hemodynamic results,4 and the ability to perform surgery with equal facility using either perfusion technique.
This purposes of this report are to examine the postoperative course and short-term hemodynamic profile after the arterial switch operation in a large patient population and to compare the nonneurological perioperative effects of deep hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in neonates and infants.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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Patient Enrollment
Eligibility criteria for entry were diagnosis of TGA with either an IVS or VSD, planned arterial switch at <3 months of age, no prior cardiac surgery (eg, coarctation repair), and informed consent from the infant's parents. Exclusion criteria included birth weight <2.5 kg, recognizable syndrome of congenital anomalies, and associated extracardiac anomalies of more than minor severity (eg, arch hypoplasia or coarctation). The study was approved by the Institutional Human Investigation Committee.
Study Design
We randomly assigned participating patients to
receive either
predominantly circulatory arrest or predominantly low-flow (50
cm3 · kg-1 · min-1)
bypass, with stratification according to diagnosis (IVS versus VSD) and
each individual surgeon. The Coordinating Center developed
randomization schemes for each diagnosis-surgeon stratum using a
permuted blocks design. Low-flow (rather than full-flow)
cardiopulmonary bypass was chosen as the alternative to
circulatory arrest to minimize blood return during surgery and to
facilitate the repair.
Surgical Technique
The surgical techniques used in our
institution for various
aspects of the arterial switch were reported
previously.5 The four study surgeons used previously
reported2 standardized techniques with respect to the time
sequence of the operation, including cannulation, cardioplegia (see
below), transection of the great arteries, coronary
mobilization, completion of the coronary and aortic
anastomoses, closure of atrial and (if present) VSDs, patch closure
of the coronary donor sites and completion of the
pulmonary anastomosis, and decannulation. Either one or two
glutaraldehyde-treated autologous pericardial
patches were used for the coronary donor sites at the
discretion of the individual surgeon.
Anesthesia and Extracorporeal Perfusion
Protocol
Anesthetic management was standardized for all patients and
was
reported previously.2 Pump prime consisted of various
amounts of Normosol-R and whole blood, depending on estimated blood
volume, hematocrit, and total priming volume used (Cobe Variable
Prime Membrane Oxygenator). No calcium was added to the priming
solution. Hypothermic myocardial protection was provided by core
cooling at flow rates of 150 to 200
mL · kg-1 · min-1 (2.0 to 3.0
kg) or
100 to 150
mL · kg-1 · min-1(3.0 to
5.0 kg) to rectal and esophageal temperatures of 
18°C, followed by
aortic cross clamping and infusion of oxygenated St
Thomas cardioplegia in a single dose of 20
cm3/kg.
Once profound hypothermic temperatures were reached, either deep hypothermic circulatory arrest or continuous low-flow cardiopulmonary bypass was instituted during completion of the aortic and coronary anastomoses. Circulatory arrest was used in all cases for closure of the atrial septal defect and/or VSD. Core rewarming was instituted during completion of the pulmonary anastomosis. Mean perfusion pressures were maintained between 30 and 70 mm Hg during rewarming by use of phentolamine 100 µg/kg or phenylephrine 5 µg/kg, as needed. An additional 25 µg/kg of fentanyl and 100 µg/kg of pancuronium were given to maintain anesthesia. All patients were weaned from cardiopulmonary bypass with at least 5 µg · kg-1 · min-1 dopamine support after the rectal temperature reached 35°C. Lactated ringers, fresh whole blood, blood products, and increased inotropic support were given as necessary to maintain normal filling pressures and a systolic perfusion pressure of at least 60 mm Hg.
Intraoperative Fluid Balance
Intraoperative fluid intake was
assessed by totaling the
intravenous fluids, cardioplegia volume, and pump volume
(total volume added during cardiopulmonary bypass plus
reservoir volume at the start of cardiopulmonary bypass
minus reservoir volume at the termination of
cardiopulmonary bypass). Intraoperative fluid output was
the total of urine produced on cardiopulmonary bypass,
chest tube drainage before the patient left the operating room, and
estimated blood loss (obtained by weighing intraoperative sponges).
Intraoperative net fluid balance was the difference between fluid
intake and output. In addition, patients were weighed before the
induction of anesthesia and again (if
hemodynamically stable) just before leaving the
operating room.
Postoperative Management
The anesthetic period was extended
through the first
postoperative night in all patients by use of a continuous fentanyl
infusion, typically 10
µg · kg-1 · h-1, and
neuromuscular blockade. Routine continuous postoperative monitoring
included the surface ECG, transcutaneous pulse oximetry,
pulmonary arterial and right and left atrial
pressures (through transthoracic catheters), and systemic
arterial pressure. Inotropic, chronotropic, and afterload
reducing agents were used as clinically indicated. Volume infusions
(usually packed red blood cells or 5% albumin) were given to
maintain adequate filling pressures with systolic perfusion pressures
of at least 50 mm Hg. Diuretics (usually furosemide 1 to 2
mg/kg per dose, two to four times daily) were begun on the first
postoperative morning or earlier if the patient was oliguric (<1
cm3 · kg-1 · h-1).
Maintenance doses (5 µg/kg per dose, once or twice
daily) of Digoxin (without digitalizing doses) were also instituted on
the first postoperative morning.
Continuous fentanyl infusions and neuromuscular blockade were discontinued on the first postoperative morning in the hemodynamically stable patient or continued for longer periods as dictated by the clinical status of the patient. The rate of weaning of mechanical ventilation was determined by the patient's fluid balance and gas exchange as indicated by arterial blood sampling, pattern of breathing, and daily radiographic findings.
Data Collection
Postoperative data were collected
prospectively by the study
team from the day of surgery until hospital discharge. Laboratory data
included daily measurements of arterial blood gases, serum
glucose, calcium, electrolytes, hematologic parameters,
BUN, and creatinine. In cases of repeated measurements in
the same 24-hour period, the values obtained between 5 and 7
AM each postoperative day were used for this
analysis. Each day, we recorded significant medical events,
the total volume and type of fluid intake, urine output, and chest tube
drainage. The total hours of mechanical ventilation and the days in the
CICU and the hospital were recorded.
Hemodynamic Profile
Cardiac output was obtained by
thermodilution technique. The
pulmonary artery catheter was a 3.5F double lumen
(American-Edwards) equipped with a radiopaque thermistor. Triplicate
determinations of cardiac output were made over 1 to 2 minutes using
1-cm3 injections into the right atrial line of iced 5%
dextrose in water. Measurements were made at 3, 6, 9, 12, 18, and 24
hours after removal of the aortic cross clamp. Mean systemic
arterial, pulmonary arterial, and right
and left atrial pressures were recorded. Cardiac index was
calculated by dividing the average cardiac output at each time period
by the body surface area (using the preoperative weight and height and
standard nomogram). Systemic and pulmonary vascular resistances
were determined (Wood units corrected for body surface area,
U · m2) with standard formulas. The doses of inotropic,
chronotropic, and afterload reducing agents at the time of the cardiac
output measurements were recorded. For between-group
comparisons, a total inotrope dose was calculated by adding the doses
of dopamine and dobutamine in micrograms per kilogram per
minute and assigning an arbitrary equivalent value of 10
µg · kg-1 · min-1 inotrope
for each
0.1 µg · kg-1 · min-1
epinephrine.
Hemodynamic data were excluded from later analysis if there was evidence of residual left-to right shunt from physical examination or visual inspection of the thermodilution curve for a recirculation phase or evidence of a residual atrial septal defect or VSD on early postoperative echocardiography (performed at discharge in all patients).6 7 Data were considered for analysis if at least four of the six measurements were obtained during the first 24 postoperative hours.
Statistical Methods
Treatment groups were compared in
intention-to-treat
analyses in which the strategy consisting predominantly of
circulatory arrest was compared with the strategy consisting of
predominantly low-flow bypass. Diagnostic groups were
also compared, with the diagnosis of TGA/IVS compared with that of
TGA/VSD.
Perioperative outcomes included continuous and categorical variables. Pearson correlation coefficients, t tests, linear regression, and graphical methods were used to analyze continuous outcome variables. When normality assumptions about the data were suspect, Wilcoxon's rank-sum test was used to compare groups. Fisher's exact tests and stratified exact tests were used to analyze categorical outcome variables. All probability values are two-tailed.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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We enrolled patients from January 1989 through February 1992. Of the 246 patients who had an arterial switch in this time period, 174 infants met study criteria, and 166 (95.4%) were enrolled. The arterial switch was performed in 157 of 166 infants (94.6% of those enrolled); the remaining 9 patients were found at operation to have unsuitable coronary artery anatomy for the arterial switch (these 9 patients had an alternative operation performed and thus were ineligible for continued study). Fourteen additional infants met eligibility criteria, were enrolled and randomized according to the study protocol, and underwent the arterial switch between April 1988 and August 1988 (before the onset of the funded enrollment phase of the trial). Inclusion of these infants was approved by the Safety and Data Monitoring Board of the NIH, yielding a total of 171 study subjects.
Of the 129 infants with TGA/IVS, 66 were randomized to receive
predominantly circulatory arrest and 63 to receive predominantly
low-flow bypass. Of the 42 infants with TGA/VSD, 21 were randomized
to receive predominantly circulatory arrest and 21 to receive
predominantly low-flow bypass. Intraoperative data, including
perfusion and circulatory arrest times, were reported
previously2 and are summarized in Table 1
.
Total support times (sum of circulatory arrest and total bypass times)
and myocardial ischemic times were similar for both circulatory
arrest and low-flow bypass groups within each
diagnostic category (IVS or VSD), supporting the notion
that either perfusion strategy can be used with equal facility during
the arterial switch. Patients with an associated VSD had
longer periods of both total support and myocardial ischemia
compared with patients with TGA/IVS. With adjustment for diagnosis (IVS
or VSD), there were no significant differences in other perfusion
variables (eg, pH, base deficit, perfusion pressures, and ionized
calcium) between treatment groups.
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Hospital Mortality
There were 3 early deaths (1.8%), 2 in the
early postoperative
period and 1 shortly after discharge from the hospital. A 5-day-old
child with TGA/VSD had a single coronary artery arising from
the right, posterior-facing sinus8 that supplied the
entire myocardium. Transfer of this vessel produced kinking
and inadequate filling of the left coronary artery. The patient
could not be weaned from cardiopulmonary bypass.
Another 5-day-old child with a large, anterior malalignment type of VSD had moderate tricuspid stenosis and right ventricular hypoplasia that was not recognized preoperatively. The postoperative course was marked by a low output state with progressive oliguria, hepatic failure, and anasarca. Cardiac catheterization was undertaken on the seventh postoperative day with the child in grave condition; death occurred during attempted tricuspid valve dilation.
A 4-day-old child with TGA/IVS had an uncomplicated arterial switch and was discharged 8 days after surgery. Frequent emesis with mild tachypnea was noted, and a presumed diagnosis of gastroesophageal reflux was made. An echocardiogram 7 days postoperatively suggested near-systemic right ventricular pressure without pulmonary anastomosis obstruction, possibly caused by pulmonary hypertension. Four days after discharge, the patient died suddenly after feeding, presumably of aspiration. At autopsy, aspiration was confirmed, and narrowing of the right main stem bronchus was noted. The pulmonary arteries were mildly thickened. The great vessel and coronary anastomoses were widely patent. Early postoperative measurements of cardiac output (see below) were not made in these patients.
Hospital Morbidity
For the 169 hospital survivors, the median
duration of mechanical
ventilation was 2.9 days (4.2±5.5 days [mean±SD];
range, 22 hours
to 61 days), and the median stays in the intensive care unit and the
hospital were 5 and 9 days (mean, 6.7±6.4 and 11±8 days; ranges,
3 to
65 and 5 to 71 days, respectively). Eight patients (4.7%) were
mechanically ventilated for >2 weeks.
In 19 patients (11.2%) with severe myocardial edema or poor hemodynamics, the sternotomy was not closed primarily at the time of the arterial switch; in one additional patient, the sternum was reopened in the CICU. The wound was covered with a Silastic sheet, and the sternum was subsequently closed in the intensive care unit (n=19) or operating room (n=1) at a median of 3 days (range, 1 to 5 days) after surgery.
Table 2
summarizes the significant postoperative events.
Early postoperative cardiac catheterization was
performed in 5 patients (2.9%) for hemodynamic and/or
electrophysiological studies (n=3),
pulmonary artery dilation (n=1), and neoaortic valve dilation
(n=1). Other significant postoperative problems included clinical
seizures (n=11, 6.5%), hemidiaphragm paresis (n=5, 2.9%),
chylothorax
(n=3, 1.8%), suspected necrotizing enterocolitis (n=2, 1.2%),
and
mediastinitis (n=1, 0.6%).
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Other than the incidence of seizures (which was related to the duration of circulatory arrest, older age at surgery, and an associated VSD),2 the only other postoperative complication or event associated with perfusion strategy was acidosis; infants randomized to low-flow bypass were more likely to have had a pH <7.25 than those randomized to circulatory arrest (P=.05). In particular, perfusion strategy did not influence the frequency of delayed sternal closure, duration of mechanical ventilation, or duration of CICU or hospital stay.
Hemodynamic Profile
Cardiac index was determined in 122 of
170 patients (71.8%) who
returned to the CICU from the operating room. In these 122 patients,
six measurements were made in 99, five were made in 19, and four were
made in 4 patients. Complete data were not obtained in 48 patients
because of no pulmonary artery catheter (n=27), dysfunctional
pulmonary arterial (n=9) or right atrial (n=3)
catheter, residual atrial (n=1) or ventricular (n=5)
left-to-right shunt, or "other" (n=3).
The 48 patients without complete (ie, fewer than four measurements) hemodynamic data differed slightly from the 122 operation survivors with complete hemodynamic measurements. These 48 patients had a higher lowest-documented pH preoperatively (7.30 versus 7.26 pH, P=.04), were more likely to have TGA/IVS (P=.001) and to have been randomized to circulatory arrest (P=.04), and had a longer mean duration of circulatory arrest (46±20 versus 32±21 minutes, P<.001). They were also more likely to have a longer myocardial ischemic time (87±18 versus 79±13 minutes, P=.006) and longer total support time (154±37 versus 140±28 minutes, P=.02). Finally, these 48 patients tended to receive slightly more pressor support in the immediate postoperative period (although this did not reach statistical significance). Thus, compared with the 48 patients without complete hemodynamic data, the 122 patients with complete data were slightly "less sick." However, intraoperative fluid balance, weight gain, and most preoperative (eg, birth weight, Apgar scores, and lowest PO2) and postoperative (eg, duration of mechanical ventilation, inotropic support received, and total CICU and hospital stays) variables were similar between the groups with and without complete hemodynamic measurements.
Fig 1A
shows the mean values for the groups at each time
period. When analyzed as a group, cardiac index reached a nadir
at 9 to 12 hours postoperatively (P<.001 versus baseline
measurement at 3 hours), returning to baseline by 24 hours after
surgery. During this period, the mean dose of inotropic support did not
change (Fig 1A). When individual patients were reviewed, the
measured
cardiac index was <2.0
L · min-1 · m-2 at least once
in 29
of 122 patients (23.8%). The lowest measured cardiac index was first
recorded at 3 hours in 12 patients (9.8%), at 6 hours in 22
patients (18.0%), at 9 hours in 30 patients (24.6%), at 12 hours in
40 patients (32.8%), at 18 hours in 13 patients (10.7%), and at 24
hours in 5 patients (4.1%). For the 113 patients whose lowest measured
cardiac index occurred after the baseline measurement at 3 hours, the
average fall in cardiac index was 32.1±15.4% during the first
postoperative night.
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Perfusion strategy (circulatory arrest or low-flow
bypass) did not
have an impact on postoperative hemodynamics. Patients
with TGA/VSD had slightly better cardiac indexes and received slightly
less inotropic support during the first postoperative night (Fig
1B
)
than TGA/IVS patients. Longer total bypass and myocardial
ischemic times were associated with higher doses of inotropic
support and slightly higher cardiac index measurements in the first
postoperative night. Fig 2 shows other
hemodynamic parameters.
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In addition to dopamine (n=168), some patients received pressors and/or vasodilators during the study period at the discretion of the treating physicians; these included epinephrine (n=14), dobutamine hydrochloride (n=4), isoproterenol (n=11), sodium nitroprusside (n=26), and amrinone lactate (n=20). The use of additional inotropic agents or vasodilators was not related to perfusion strategy.
Weight Gain, Fluid Balance, and Mechanical
Ventilation
During surgery, patients randomized to receive
predominantly
low-flow bypass gained significantly more weight (P=.01)
and had more positive fluid balance (P<.001) than those
randomized to receive circulatory arrest. When analyzed as a
continuous variable, longer bypass time was positively associated
with greater weight gain (r=.23, P=.01) and
positive fluid balance (r=.46, P<.001; Fig
3).
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All patients received diuretics beginning on the
first
postoperative day. Urine output rose from 3.2±1.5
cm3 · kg-1 · h-1
during
the first postoperative night to 7.1±1.8
cm3 · kg-1 · h-1 on
the
third postoperative day (Fig 4), with no significant
difference between randomized groups. However, fluid balance (input
minus output) tended to be more negative on the second
(P=.17) and third (P=.18) postoperative days
in
patients assigned to low-flow bypass (Fig 4). As patients lost
their total body fluid load, serum levels of BUN rose, while serum
creatinine remained stable (Fig 4).
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Patients randomized to low-flow bypass were mechanically ventilated for a median of 71 hours (range, 22 hours to 19 days), whereas those randomized to circulatory arrest were ventilated for a median of 68.5 hours (range, 32 hours to 65 days; P=.47). Thus, although patients assigned to low-flow bypass had increased total body water immediately after surgery, the increased net fluid output the first 2 days after surgery resulted in similar net fluid balance, so the duration of mechanical ventilation was similar in both groups.
Arrhythmia
Sinus node dysfunction, treated with mechanical
pacing (through
either the esophagus or transthoracic temporary atrial
wires), was seen in 23 patients (13.5%).
Supraventricular tachycardia was seen in 23
patients (13.5%), was frequently brief and self-limited, but was
treated with burst atrial pacing in 3 patients and cardioversion in 1
patient. Three patients (1.8%) had transient complete heart block.
Sustained ventricular tachycardia was seen in 3
patients (1.8%; all underwent early postoperative
catheterization [see above], which documented normal
coronary perfusion). Perfusion strategy was not related to the
incidence of postoperative arrhythmia. A more detailed
analysis of arrhythmia after the arterial
switch operation in a larger cohort of patients is reported
elsewhere.9
Hematologic Data
After surgery, there was an initial
elevation in the white blood
cell count, percent neutrophils, and percent band forms in both
treatment groups, which fell into the normal range by the second
postoperative day (Fig 5). The platelet count
reached a nadir on the second postoperative morning; although there was
a comparable fall in both treatment groups, patients with TGA/VSD had
significantly lower platelet counts than those with TGA/IVS (Fig
6). The number of patients with platelet counts
<50 000 (Table 2) and the number of patients receiving
platelet
transfusions (n=36 [21.2%]: low-flow, n=19;
circulatory arrest,
n=17) were similar in both treatment groups. The duration of
cardiopulmonary bypass was not associated with lowest
platelet count or the need for platelet transfusion.
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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Data from this study suggest that both low-flow bypass and circulatory arrest perfusion strategies have comparable effects on the nonneurological postoperative course in neonates and small infants after corrective surgery for TGA. As previously reported in this study population, prolonged periods of circulatory arrest were associated with a higher incidence of clinical and EEG seizures,2 longer recovery time to the first reappearance of EEG activity,2 a greater release of the brain isoenzyme of creatine kinase,2 and a higher prevalence of neurological and cognitive abnormalities at 1 year of age.1
We found that a longer duration of cardiopulmonary bypass (ie, shorter periods of circulatory arrest) was associated with increased weight gain and positive fluid balance immediately after surgery. Despite the increased total body edema, however, a strategy consisting predominantly of circulatory arrest, compared with one consisting predominantly of low-flow cardiopulmonary bypass, had no significant effect on postoperative hemodynamics, laboratory studies, the duration of mechanical ventilation, or the length of stay in the intensive care unit or hospital in this patient population.
The postoperative course in most patients was uneventful and rather
predictable. The first postoperative night was typically characterized
by a significant fall in cardiac index (similar to findings reported by
Fontan et al10 in adults), coupled with a rise in the
calculated systemic and pulmonary vascular resistance (Figs 1
and 2). This finding was consistent in both treatment and
diagnostic groups. The overall cardiac index was in the
low-normal range in our patients (despite receiving inotropic
support); values were similar to those in previously reported studies
in neonates and infants after other forms of cardiac
surgery.11 12 13 14 Most
patients received moderate (5 to 10
µg · kg-1 · min-1)
inotropic
support with dopamine; afterload reduction, when indicated, was
typically given as amrinone (if cardiac index was low) or sodium
nitroprusside. The amount and duration of inotropic support, ordered by
the bedside physicians as determined by clinical examination and
postoperative monitoring, remained fairly constant during the first 24
hours after surgery and was not related to treatment assignment. Thus,
the fall in cardiac index seen during the first postoperative night was
not related to withdrawal or reduction of inotropic medications.
This finding of a significant fall in the measured cardiac index during
the first postoperative night, despite otherwise acceptable
hemodynamics, is consistent with the
observation that blood pressure may be maintained in neonates and young
infants despite a falling cardiac output. The
physiological mechanism most likely responsible for
the maintained blood pressure is an elevation of systemic vascular
resistance, which rose an average of 20% in our patients (Fig
2). This
is also consistent with the conventional teaching that
hypotension is a late finding in neonates with low cardiac output.
The mechanism of the fall in cardiac index with a rise in systemic and pulmonary vascular resistances remains undefined but may be related to ischemia-reperfusion injury.15 16 17 18 19 20 21 22 23 24 Studies with monoclonal antibodies to leukocyte adhesion molecules have suggested a prominent role for inflammation in the response of the heart to ischemia and reperfusion.25 The actual time course of expression of the adhesion molecules in an intact organism is unknown, but in vitro studies showed that expression occurs hours after the inciting stimulus; we recently described how the mRNA of two endothelial adhesion molecules (e-selectin and intercellular adhesion molecule–1) is induced within hours of the institution of cardiopulmonary bypass.26 It is therefore tempting to speculate that this type of inflammation-mediated event is associated with the fall in cardiac index observed in this group of patients, but additional experimental work is clearly necessary to confirm this hypothesis.
We found a significant relation between the duration of cardiopulmonary bypass and edema (weight gain and positive fluid balance) in our patients. Although the observed weight gain and positive fluid balance seen in these patients are also potentially related to inflammation, this clinical finding is most likely multifactorial. It is a common clinical observation that young infants, particularly neonates, are prone to significant edema formation during cardiopulmonary bypass. The permeability of capillaries is known to be greater in immature than in mature individuals,27 28 and this microvascular permeability is enhanced by cardiopulmonary bypass.29 In addition, cardiopulmonary bypass is known to activate multiple potent vasoactive substances, including the serum anaphylatoxins C3a and C5a,30 tumor necrosis factor,16 31 and oxygen-derived free radicals,32 33 and stimulate the release of lysosomal hydrolases.33 34 All these factors combine to cause the nearly 30% increase in body weight in these neonates and infants. The weight gain was sufficient in 20 of our patients to warrant delayed sternal closure35 in the CICU after diuresis and loss of myocardial and chest wall edema.
The next 2 to 4 days after surgery were typically characterized by significant diuresis (augmented by diuretics in all cases), negative fluid balance, weaning from mechanical ventilation, and extubation. Patients randomized to low-flow bypass were typically more edematous after surgery but reduced the fluid load sufficiently through diuresis to achieve extubation at a time similar to that of the patients randomized to circulatory arrest. In our study conditions (hypothermia to 12°C to 18°C and relatively short periods of renal ischemia),36 37 there did not appear to be any significantly different effect on renal function caused by the different perfusion strategies.
The effects of cardiopulmonary bypass and hypothermia on platelet number38 39 and function40 41 42 43 were described previously in adult patients and laboratory studies. In our patients, the significant fall in the platelet count seen on the second postoperative morning is consistent with the hypothesis that platelets may be partially degranulated, misshapen, and aggregated after exposure to the prosthetic material of cardiopulmonary bypass. Radionuclide studies44 suggested that these dysfunctional platelets are sequestered primarily in the liver during the first 48 hours after cardiopulmonary bypass and that the mean survival time of these damaged, but still circulating, platelets was 58±8 hours.
Study Limitations
Despite the prospective nature of this
randomized trial, the
hemodynamic profile measured in these infants does not
necessarily reflect the natural history of myocardial function after
cardiopulmonary bypass, aortic cross clamping, and deep
hypothermic circulatory arrest. Although the mean values for the entire
group fell consistently during the first postoperative night,
there was considerable patient-to-patient variation, so the
nadir of cardiac index for an individual patient may have been at any
point during the measurement sequence. In addition, the clinicians
caring for the patients were aware of the clinical status and the
measured hemodynamic profile and were likely to respond
to a falling cardiac output by adjusting support. This increased
support in an individual patient might then be reflected in higher
measurements of cardiac output later in the study period, which might
confound the analysis of the effects of prolonged myocardial
ischemic time or cardiopulmonary bypass time on
hemodynamic measurements. Although we did not find a
significant relation between the duration of aortic cross clamping or
cardiopulmonary bypass time with postoperative
hemodynamics, the intervening medical management may
have masked a true relation. There also may have been other similar
effects of prolonged cardiopulmonary bypass or myocardial
ischemia on other postoperative issues, such as
thrombocytopenia, that were not identified with this study design.
Although the data presented here represent a typical cross section of patients undergoing the arterial switch operation in our institution, the results may not be broadly generalizable to neonatal and early infant repair of other forms of congenital heart disease or to the effects of deep hypothermic circulatory arrest and low-flow cardiopulmonary bypass in older infants, children, and adults. The arterial switch is predominantly an extracardiac operation, so either circulatory arrest or low-flow bypass strategies can be used with equal facility. However, the use of low-flow bypass in other types of neonatal and infant surgeries may be associated with a longer total support time than that achievable with circulatory arrest, which may result in an increase in total body fluid overload and expose the patient to pump-related sources of brain injury.
Cardiovascular surgical teams will thus need to balance on an individual basis the technical advantages of circulatory arrest in facilitating a complete repair against the potential neurological risks of prolonged circulatory arrest. Postoperative nonneurological results are likely to be similar with either perfusion strategy but must be studied prospectively.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This work was supported by grant HL-41786 from the NHLBI, NIH, Bethesda, Md. We would like to thank the medical and nursing staffs of the Cardiac Intensive Care Unit at Children's Hospital for their help in the care of these patients and compliance with the data collection and study protocol; the members of the Safety and Data Monitoring Committee (Julien I.E. Hoffman, MD, chairman) appointed by the NIH; the perfusionists, Willis G. Gieser, CCP, Robert A. LaPierre, BS, CCP, Robert J. Howe, BS, CCP, David M. Farrell, MA, CCP, and Bettina Archilla, BS, CCP; Kristin C. Lucius, RN, for help with data acquisition; Ludmila Kyn for database and statistical programming; Donna M. Donati, Donna M. Duva, and Lisa-Jean Buckley for data management; Kathleen M. O'Brien for project coordination; and Matthew Martin and Tannis Bolton for help with manuscript preparation.
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Footnotes |
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Reprint requests to David L. Wessel, MD, Director, Cardiac Intensive Care Unit, Farley 653, Children's Hospital, 300 Longwood Ave, Boston, MA 02115.
Received December 27, 1994; revision received March 29, 1995; accepted May 10, 1995.
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H. G. Piper, J. L. Alexander, A. Shukla, F. Pigula, J. M. Costello, P. C. Laussen, T. Jaksic, and M. S.D. Agus Real-Time Continuous Glucose Monitoring in Pediatric Patients During and After Cardiac Surgery Pediatrics, September 1, 2006; 118(3): 1176 - 1184. [Abstract] [Full Text] [PDF]
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 T. Jones and M. Elliott Paediatric CPB: Bypass in a High Risk Group Perfusion, July 1, 2006; 21(4): 229 - 233. [Abstract] [PDF]
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M. M.H. Cheung, R. K. Kharbanda, I. E. Konstantinov, M. Shimizu, H. Frndova, J. Li, H. M. Holtby, P. N. Cox, J. F. Smallhorn, G. S. Van Arsdell, et al. Randomized Controlled Trial of the Effects of Remote Ischemic Preconditioning on Children Undergoing Cardiac Surgery: First Clinical Application in Humans J. Am. Coll. Cardiol., June 6, 2006; 47(11): 2277 - 2282. [Abstract] [Full Text] [PDF]
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J. Li, G. Zhang, H. M. Holtby, B. W. McCrindle, S. Cai, T. Humpl, C. A. Caldarone, W. G. Williams, A. N. Redington, and G. S. Van Arsdell Inclusion of oxygen consumption improves the accuracy of arterial and venous oxygen saturation interpretation after the Norwood procedure J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1099 - 1107. [Abstract] [Full Text] [PDF]
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H. E. Jeffries, W. J. Wells, V. A. Starnes, R. C. Wetzel, and D. Y. Moromisato Gastrointestinal Morbidity After Norwood Palliation for Hypoplastic Left Heart Syndrome Ann. Thorac. Surg., March 1, 2006; 81(3): 982 - 987. [Abstract] [Full Text] [PDF]
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Disruption of the ventricular myocardial force-frequency relationship after cardiac surgery in children: noninvasive assessment by means of tissue Doppler imaging. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 625 - 631.
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Alterations in plasma B-type natriuretic peptide levels after repair of congenital heart defects: a potential perioperative marker. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 632 - 638.
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S. J. Roth, I. Adatia, G. D. Pearson, and and Members of the Cardiology Group Summary proceedings from the cardiology group on postoperative cardiac dysfunction. Pediatrics, March 1, 2006; 117(3 Pt 2): S40 - S46. [Abstract] [Full Text] [PDF]
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J. M. Schultz, T. Karamlou, J. Swanson, I. Shen, and R. M. Ungerleider Hypothermic Low-Flow Cardiopulmonary Bypass Impairs Pulmonary and Right Ventricular Function More Than Circulatory Arrest Ann. Thorac. Surg., February 1, 2006; 81(2): 474 - 480. [Abstract] [Full Text] [PDF]
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A. S. Mackie, S. J. Roth, and J. W. Newburger Reply to the Editor J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 506 - 506. [Full Text] [PDF]
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 J. M. Simsic, M. Scheurer, J. D. Tobias, J. Berkenbosch, W. Schechter, F. Madera, S. Weinstein, and R. E. Michler Perioperative Effects and Safety of Nesiritide Following Cardiac Surgery in Children J Intensive Care Med, January 1, 2006; 21(1): 22 - 26. [Abstract] [PDF]
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C. D. Myers, K. Mattix, R. G. Presson Jr, P. Vijay, D. Maynes, K. N. Litwak, J. W. Brown, and M. D. Rodefeld Twenty-Four Hour Cardiopulmonary Stability in a Model of Assisted Newborn Fontan Circulation Ann. Thorac. Surg., January 1, 2006; 81(1): 264 - 271. [Abstract] [Full Text] [PDF]
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C. L. Dent, J. P. Spaeth, B. V. Jones, S. M. Schwartz, T. A. Glauser, B. Hallinan, J. M. Pearl, P. R. Khoury, and C. D. Kurth Brain magnetic resonance imaging abnormalities after the Norwood procedure using regional cerebral perfusion J. Thorac. Cardiovasc. Surg., January 1, 2006; 131(1): 190 - 197. [Abstract] [Full Text] [PDF]
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C. L. Dent, J. P. Spaeth, B. V. Jones, S. M. Schwartz, T. A. Glauser, B. Hallinan, J. M. Pearl, P. R. Khoury, and C. D. Kurth Brain magnetic resonance imaging abnormalities after the Norwood procedure using regional cerebral perfusion J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1523 - 1530. [Abstract] [Full Text] [PDF]
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M. Ando, I.-S. Park, N. Wada, and Y. Takahashi Steroid Supplementation: A Legitimate Pharmacotherapy After Neonatal Open Heart Surgery Ann. Thorac. Surg., November 1, 2005; 80(5): 1672 - 1678. [Abstract] [Full Text] [PDF]
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A. S. Mackie, K. L. Booth, J. W. Newburger, K. Gauvreau, S. A. Huang, P. C. Laussen, J. A. DiNardo, P. J. del Nido, J. E. Mayer Jr, R. A. Jonas, et al. A randomized, double-blind, placebo-controlled pilot trial of triiodothyronine in neonatal heart surgery J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 810 - 816. [Abstract] [Full Text] [PDF]
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S. Riphagen, M. McDougall, S. M. Tibby, N. Alphonso, D. Anderson, C. Austin, A. Durward, and I. A. Murdoch "Early" Delayed Sternal Closure Following Pediatric Cardiac Surgery Ann. Thorac. Surg., August 1, 2005; 80(2): 678 - 684. [Abstract] [Full Text] [PDF]
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 I. Malagon, K. Hogenbirk, J. van Pelt, M. G. Hazekamp, and J. G. Bovill Effect of three different anaesthetic agents on the postoperative production of cardiac troponin T in paediatric cardiac surgery Br. J. Anaesth., June 1, 2005; 94(6): 805 - 809. [Abstract] [Full Text] [PDF]
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I. Malagon, W. Onkenhout, G. Klok, P. F. H. van der Poel, J. G. Bovill, and M. G. Hazekamp Gut permeability in paediatric cardiac surgery Br. J. Anaesth., February 1, 2005; 94(2): 181 - 185. [Abstract] [Full Text] [PDF]
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M. Ruel, T. A. Khan, P. Voisine, C. Bianchi, and F. W. Sellke Vasomotor dysfunction after cardiac surgery Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 1002 - 1014. [Abstract] [Full Text] [PDF]
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J. Li, A. Hoschtitzky, M. L. Allen, M. J. Elliott, and A. N. Redington An Analysis of Oxygen Consumption and Oxygen Delivery in Euthermic Infants After Cardiopulmonary Bypass With Modified Ultrafiltration Ann. Thorac. Surg., October 1, 2004; 78(4): 1389 - 1396. [Abstract] [Full Text] [PDF]
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S. M. Bradley, J. M. Simsic, T. C. McQuinn, D. M. Habib, G. S. Shirali, and A. M. Atz Hemodynamic status after the Norwood procedure: A comparison of right ventricle-to-pulmonary artery connection versus modified blalock-taussig shunt Ann. Thorac. Surg., September 1, 2004; 78(3): 933 - 941. [Abstract] [Full Text] [PDF]
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C. A. Caldarone, E. W. Barner, L. Wang, M. Karimi, C. E. Mascio, J. M. Hammel, J. L. Segar, C. Du, and T. D. Scholz Apoptosis-related mitochondrial dysfunction in the early postoperative neonatal lamb heart Ann. Thorac. Surg., September 1, 2004; 78(3): 948 - 955. [Abstract] [Full Text] [PDF]
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C. L Cua, T. M Hoffman, R. Taeed, S. Weinstein, D. Gomez, V. F Olshove, and J. M Craenen Cerebral saturations trend with mixed venous saturations in patients undergoing extracorporeal life support Perfusion, May 1, 2004; 19(3): 171 - 176. [Abstract] [PDF]
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J. Li, E. Stenbog, A. Bush, T. Grofte, A. N. Redington, and D. J. Penny Insulin-like growth factor 1 improves the relationship between systemic oxygen consumption and delivery in piglets after cardiopulmonary bypass J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1436 - 1441. [Abstract] [Full Text] [PDF]
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R R Chaturvedi, D Macrae, K L Brown, M Schindler, E C Smith, K B Davis, G Cohen, V Tsang, M Elliott, M de Leval, et al. Cardiac ECMO for biventricular hearts after paediatric open heart surgery Heart, May 1, 2004; 90(5): 545 - 551. [Abstract] [Full Text] [PDF]
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J. M. Bartlett, D. Wypij, D. C. Bellinger, L. A. Rappaport, L. J. Heffner, R. A. Jonas, and J. W. Newburger Effect of Prenatal Diagnosis on Outcomes in D-Transposition of the Great Arteries Pediatrics, April 1, 2004; 113(4): e335 - e340. [Abstract] [Full Text] [PDF]
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M. Karimi, L. X. Wang, J. M. Hammel, C. E. Mascio, M. Abdulhamid, E. W. Barner, T. D. Scholz, J. L. Segar, W. G. Li, S. D. Niles, et al. Neonatal vulnerability to ischemia and reperfusion: Cardioplegic arrest causes greater myocardial apoptosis in neonatal lambs than in mature lambs J. Thorac. Cardiovasc. Surg., February 1, 2004; 127(2): 490 - 497. [Abstract] [Full Text] [PDF]
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S. M. Cottrell, K. P. Morris, P. Davies, D. C. Bellinger, R. A. Jonas, and J. W. Newburger Early postoperative body temperature and developmental outcome after open heart surgery in infants Ann. Thorac. Surg., January 1, 2004; 77(1): 66 - 71. [Abstract] [Full Text] [PDF]
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C.-H. Yeh, J.-H. S. Pang, Y.-C. Wu, Y.-C. Wang, J.-J. Chu, and P. J. Lin Differential-Display Polymerase Chain Reaction Identifies Nicotinamide Adenine Dinucleotide-Ubiquinone Oxidoreductase as an Ischemia/Reperfusion-Regulated Gene in Cardiomyocytes Chest, January 1, 2004; 125(1): 228 - 235. [Abstract] [Full Text] [PDF]
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D. C. Bellinger, D. Wypij, A. J. duPlessis, L. A. Rappaport, R. A. Jonas, G. Wernovsky, and J. W. Newburger Neurodevelopmental status at eight years in children with dextro-transposition of the great arteries: The Boston Circulatory Arrest Trial J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1385 - 1396. [Abstract] [Full Text] [PDF]
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V. A. Schroeder, J. M. Pearl, S. M. Schwartz, T. P. Shanley, P. B. Manning, and D. P. Nelson Combined Steroid Treatment for Congenital Heart Surgery Improves Oxygen Delivery and Reduces Postbypass Inflammatory Mediator Expression Circulation, June 10, 2003; 107(22): 2823 - 2828. [Abstract] [Full Text] [PDF]
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 M. Wojtalik, G. Sharma, W. Mrowczynski, A. Siwinska, J. Henschke, R. Bartkowski, M. Pawelec-Wojtalik, and M. Piaszczynski Arterial Switch Operation in Neonates With Complex Congenital Heart Defects Asian Cardiovasc Thorac Ann, March 1, 2003; 11(1): 14 - 17. [Abstract] [Full Text] [PDF]
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T. M. Hoffman, G. Wernovsky, A. M. Atz, T. J. Kulik, D. P. Nelson, A. C. Chang, J. M. Bailey, A. Akbary, J. F. Kocsis, R. Kaczmarek, et al. Efficacy and Safety of Milrinone in Preventing Low Cardiac Output Syndrome in Infants and Children After Corrective Surgery for Congenital Heart Disease Circulation, February 25, 2003; 107(7): 996 - 1002. [Abstract] [Full Text] [PDF]
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I. Shen, C. Giacomuzzi, and R. M. Ungerleider Current strategies for optimizing the use of cardiopulmonary bypass in neonates and infants Ann. Thorac. Surg., February 1, 2003; 75(2): S729 - 734. [Abstract] [Full Text] [PDF]
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S M Tibby and I A Murdoch Monitoring cardiac function in intensive care Arch. Dis. Child., January 1, 2003; 88(1): 46 - 52. [Abstract] [Full Text] [PDF]
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H. H. Hovels-Gurich, J. F. Vazquez-Jimenez, A. Silvestri, K. Schumacher, R. Minkenberg, J. Duchateau, B. J. Messmer, G. von Bernuth, and M.-C. Seghaye Production of proinflammatory cytokines and myocardial dysfunction after arterial switch operation in neonates with transposition of the great arteries J. Thorac. Cardiovasc. Surg., October 1, 2002; 124(4): 811 - 820. [Abstract] [Full Text] [PDF]
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P. Tassani, A. Barankay, F. Haas, S. U. Paek, M. Heilmaier, J. Hess, R. Lange, and J. A. Richter Cardiac surgery with deep hypothermic circulatory arrest produces less systemic inflammatory response than low-flow cardiopulmonary bypass in newborns J. Thorac. Cardiovasc. Surg., April 1, 2002; 123(4): 648 - 654. [Abstract] [Full Text] [PDF]
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D. P. Nelson, S. Burns Wechsler, T. Miura, A. Stagg, J. W. Newburger, J. E. Mayer Jr, and E. J. Neufeld Myocardial immediate early gene activation after cardiopulmonary bypass with cardiac ischemia-reperfusion Ann. Thorac. Surg., January 1, 2002; 73(1): 156 - 162. [Abstract] [Full Text] [PDF]
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D. Chowdhury, K. Ojamaa, V. A. Parnell, C. McMahon, C. P. Sison, and I. Klein A prospective randomized clinical study of thyroid hormone treatment after operations for complex congenital heart disease J. Thorac. Cardiovasc. Surg., November 1, 2001; 122(5): 1023 - 1025. [Full Text] [PDF]
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U. Kiziltepe, A. Uysalel, T. Corapcioglu, K. Dalva, H. Akan, and H. Akalin Effects of combined conventional and modified ultrafiltration in adult patients Ann. Thorac. Surg., February 1, 2001; 71(2): 684 - 693. [Abstract] [Full Text] [PDF]
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M. Nagashima, Y. Imai, K. Seo, M. Terada, M. Aoki, T. Shin'oka, and M. Koide Effect of hemofiltrated whole blood pump priming on hemodynamics and respiratory function after the arterial switch operation in neonates Ann. Thorac. Surg., December 1, 2000; 70(6): 1901 - 1906. [Abstract] [Full Text] [PDF]
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R. M. Ungerleider Role for deep hypothermic circulatory arrest during repair of heart defects in infants J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 425 - 426. [Full Text] [PDF]
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L. L. Lequier, H. Nikaidoh, S. R. Leonard, J. L. Bokovoy, M. L. White, P. J. Scannon, and B. P. Giroir Preoperative and Postoperative Endotoxemia in Children With Congenital Heart Disease Chest, June 1, 2000; 117(6): 1706 - 1712. [Abstract] [Full Text] [PDF]
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U. Dyamenahalli, B. W. McCrindle, G. A. Barker, W. G. Williams, R. M. Freedom, and D. J. Bohn Influence of perioperative factors on outcomes in children younger than 18 months after repair of tetralogy of Fallot Ann. Thorac. Surg., April 1, 2000; 69(4): 1236 - 1242. [Abstract] [Full Text] [PDF]
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R R Chaturvedi, V E Hjortdal, E V Stenbog, H B Ravn, P White, T D Christensen, A B Thomsen, J Pedersen, K E Sorensen, and A N Redington Inhibition of nitric oxide synthesis improves left ventricular contractility in neonatal pigs late after cardiopulmonary bypass Heart, December 1, 1999; 82(6): 740 - 744. [Abstract] [Full Text]
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E. B. Rosenzweig, T. J. Starc, J. M. Chen, S. Cullinane, D. M. Timchak, W. M. Gersony, D. W. Landry, and M. E. Galantowicz Intravenous Arginine-Vasopressin in Children With Vasodilatory Shock After Cardiac Surgery Circulation, November 9, 1999; 100 (2009): II-182 - II-186. [Abstract] [Full Text] [PDF]
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J. F. Rhodes, A. D. Blaufox, H. S. Seiden, J. D. Asnes, R. P. Gross, J. P. Rhodes, R. B. Griepp, and A. F. Rossi Cardiac Arrest in Infants After Congenital Heart Surgery Circulation, November 9, 1999; 100 (2009): II-194 - II-199. [Abstract] [Full Text] [PDF]
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C. Metais, J. Li, J. Li, M. Simons, and F. W. Sellke Serotonin-Induced Coronary Contraction Increases After Blood Cardioplegia-Reperfusion : Role of COX-2 Expression Circulation, November 9, 1999; 100 (2009): II-328 - II-334. [Abstract] [Full Text] [PDF]
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D. C. Bellinger, D. Wypij, K. C. K. Kuban, L. A. Rappaport, P. R. Hickey, G. Wernovsky, R. A. Jonas, and J. W. Newburger Developmental and Neurological Status of Children at 4 Years of Age After Heart Surgery With Hypothermic Circulatory Arrest or Low-Flow Cardiopulmonary Bypass Circulation, August 3, 1999; 100(5): 526 - 532. [Abstract] [Full Text] [PDF]
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C. Mavroudis, M. Gevitz, W. S. Ring, C. L. McIntosh, and M. Schwartz The Society of Thoracic Surgeons national congenital heart surgery database report: : Analysis of the first harvest (1994-1997) Ann. Thorac. Surg., August 1, 1999; 68(2): 601 - 624. [Abstract] [Full Text] [PDF]
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R. Hirsch, C. L. Dent, M. K. Wood, C. B. Huddleston, E. N. Mendeloff, D. T. Balzer, Y. Landt, C. A. Parvin, M. Landt, J. H. Ladenson, et al. Patterns and Potential Value of Cardiac Troponin I Elevations After Pediatric Cardiac Operations Ann. Thorac. Surg., May 1, 1998; 65(5): 1394 - 1399. [Abstract] [Full Text] [PDF]
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M. J. Davies, K. Nguyen, J. W. Gaynor, M. J. Elliott, and M. R. de Leval Modified Ultrafiltration Improves Left Ventricular Systolic Function In Infants After Cardiopulmonary Bypass J. Thorac. Cardiovasc. Surg., February 1, 1998; 115(2): 361 - 370. [Abstract] [Full Text] [PDF]
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R. R. Chaturvedi, C. Lincoln, J. W. W. Gothard, M. H. Scallan, P. A. White, A. N. Redington, and D. F. Shore Left ventricular dysfunction after open repair of simple congenital heart defects in infants and children: Quantitation with the use of a conductance catheter immediately after bypass J. Thorac. Cardiovasc. Surg., January 1, 1998; 115(1): 77 - 83. [Abstract] [Full Text] [PDF]
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T. Shin'oka, D. Shum-Tim, P. C. Laussen, S. M. Zinkovsky, H. G. W. Lidov, A. d. Plessis, and R. A. Jonas Effects of Oncotic Pressure and Hematocrit on Outcome After Hypothermic Circulatory Arrest Ann. Thorac. Surg., January 1, 1998; 65(1): 155 - 164. [Abstract] [Full Text] [PDF]
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J. L. Myers Transposition of the Great Arteries Ann. Thorac. Surg., March 1, 1997; 63(3): 895 - 898. [Full Text]
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L. A. Skaryak, A. J. Lodge, P. M. Kirshbom, L. R. DiBernardo, B. G. Wilson, J. N. Meliones, R. M. Ungerleider, and J. W. Gaynor Low-Flow Cardiopulmonary Bypass Produces Greater Pulmonary Dysfunction Than Circulatory Arrest Ann. Thorac. Surg., November 1, 1996; 62(5): 1284 - 1288. [Abstract] [Full Text]
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