Pulmonary Risk Factors Compromising Postoperative Recovery After Surgical Repair for Congenital Heart Disease

doi:10.1378/chest.116.3.740

Chest

Volume 116, Issue 3, September 1999, Pages 740-747

https://doi.org/10.1378/chest.116.3.740 Get rights and content

Study objectives

To identify pulmonary risk factors associated with prolonged ICU stay in young children (≤ 2 years) undergoing surgical repair for congenital heart disease (CHD).

Design

Retrospective case series analysis.

Setting

Tertiary-care facility.

Patients

Clinical records of 134 consecutive patients aged ≤ 2 years undergoing cardiac surgery for CHD were reviewed, and 37 were excluded according to inclusion criteria. Thus, 97 patients were allocated to two groups based on the duration of ICU stay: ≤ 7 days (group 1, n = 57), and > 7 days (group 2, n = 40).

Results

Mean ICU duration for groups 1 and 2 was 3.0 ± 0.4 days and 28.1 ± 4.4 days, respectively (p < 0.001). In group 1, there were three extubation failures, whereas 41 extubation failures occurred in group 2 (p < 0.0001). A total of 22 patients (4 in group 1 and 18 in group 2) developed noninfectious pulmonary complications, such as airway problems, including extrinsic airway compression and tracheobronchomalacia (n = 6); pulmonary hypertension (n = 5); phrenic nerve palsy (n = 7); and pleural effusion (n = 8). These 22 patients (23%) contributed to the majority of total ventilator days (67%) as well as ICU stay (61%).

Conclusions

Pulmonary complications in general, and central airway problems in particular, are a frequent cause for delayed recovery following cardiac surgery in young children.

Section snippets

Data Collection

Hospital records of 134 consecutive patients, aged ≤ 24 months, who underwent palliative or corrective surgery for CHD at Tulane University Medical Center during the 1-year period from August 1995 to July 1996 were retrospectively reviewed. Premature infants and infants with preexisting lung disease or with other major congenital anomalies were excluded (n = 13). Twenty-four patients died within 48 h after surgery (immediate mortality) and were also excluded. Therefore, the study population

Results

Demographics, intraoperative data, and ICU data are shown in Table 1. Group 1 consisted of 57 patients, representing 58.7% of the study population. The mean age was 8.8 ± 2.9 months, and there were 36 male infants in group 1. The mean weight percentile was 22.2 ± 3.3%. Group 2 included 40 infants (41.3%), 25 of whom were male, and their mean weight percentile was 29.3 ± 4.6% (p > 0.05, not significant [NS]). The patients in group 2 were significantly younger (mean age, 4.2 ± 0.7 months; p <

Discussion

In this study, we show that pulmonary complications in general, and central airway problems in particular, are not uncommon among young children undergoing surgical repair of congenital cardiac conditions, and account for a substantial proportion of the postoperative requirements for mechanical ventilatory support and the overall utilization of the ICU.

This is the first study to examine the role of pulmonary involvement in postoperative morbidity in this population. Several studies estimate

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Infants with congenital heart diseases often require mechanical ventilation and a prolonged intensive care unit (ICU) stay due to complex cardiopulmonary complications. The primary objective of the study was to determine the incidence and predictors of tracheal extubation failure in infants undergoing modified Blalock-Taussig shunt (MBTS). The secondary objective was to evaluate if extubation failure was associated with increased mortality and longer ICU and hospital stays.
Single-center, retrospective, cohort study.
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The demographic data and details related to the preoperative, intraoperative, and pretracheal extubation clinical conditions in the ICU were compared between the 2 study arms. Statistically significant predictors were analyzed using multivariate analysis. The p value was based on the Student's -t test for continuous variables and the chi-square test for categorical variables.
A total of 146 infants were recruited for the study. Extubation failure occurred in 27 infants (18.5%), resulting in longer ICU and hospital stays. Extubation failure was deemed to be positively associated with preoperative mechanical ventilation duration, the need for escalation of the inotropic score, diaphragmatic paralysis, and systolic blood pressure ≤50th percentile at the time of extubation.
The incidence rate of extubation failure after placement of MBTS was 18.5%. Preoperative mechanical ventilation, diaphragmatic paralysis, the need for escalation of the inotropic score, and systolic blood pressure ≤50th percentile could be considered predictors of extubation failure in these infants.
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All the surgeries in the present report adopted a left lateral intercostal approach. Analogous operations in children use a median sternotomy approach, and the incidence of UDP among children ranges from 0.3% to 12% [8–13]. Interestingly, minimally invasive cardiac surgeries in this population are associated with a higher incidence of UDP than median sternotomy [14].
Unilateral diaphragmatic paralysis (UDP) due to phrenic nerve injury is a potential complication of thoracic surgery. This study evaluated the prevalence of UDP associated with surgical mitral valve repair (MVR) and its effect on surgical outcomes in dogs.
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A total of 284 dogs survived until the day after surgery. The prevalence of UDP on the day after surgery, on the day of discharge, and after the first postoperative month was 30%, 24%, and 9%, respectively. One case of UDP was observed at 3 months after surgery. Unilateral diaphragmatic paralysis was exhibited by nine of the 21 patients that died in the hospital. The proportion of patients with UDP was higher in dogs that died of respiratory failure than in dogs that died of other causes (p = 0.002). Most dogs whose deaths were suspected to have been related to respiratory failure also had pre-existing respiratory diseases. The occurrence of UDP did not relate to the lengths of stay in the intensive care unit or the hospital.
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Outcomes of Infant Cardiac Surgery for Congenital Heart Disease Concomitant With Persistent Pneumonia: A Retrospective Cohort Study
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In this study, the authors analyzed the data of 94 infants admitted to our hospital from January 2014 to May 2016 who underwent surgical correction for left-to-right shunt congenital heart disease.
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There was no significant difference in sex composition between the 2 groups. Infants in the pneumonia group were younger and had a lower body weight (p < 0.001). There was a significant difference in types of congenital heart disease between the 2 groups (p < 0.001). Preoperative body temperature and heart rate of infants in the pneumonia group were higher than those in the control group (p < 0.001). The cardiopulmonary bypass time in the pneumonia group was significantly longer than that of the control group (p = 0.001). Perioperative major complications were not significantly different between the 2 groups. The postoperative ventilator-assisted time, duration of intensive care unit stay, and length of hospital stay were longer in the pneumonia group (p < 0.001). Only 1 patient in the control group died of severe low cardiac output syndrome.
The authors conclude that in the presented cases, no mortality or major morbidity was observed related to the practice of performing surgery in infants with signs of persistent pneumonia. The authors conclude that it is likely to be safe and effective for infants to receive cardiac surgery for left-to-right shunt congenital heart disease in the presence of persistent pneumonia.
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The incidence of TBM is probably increasing due to improved survival of premature infants and patients with congenital heart disease and OA/TOF [81]. TBM has been associated with increased morbidity [41] and longer stays on intensive care following surgery for congenital heart disease [82,83]. Although most children are eventually managed at home, some (for example those on a home ventilator scheme) incur significant costs to the health system for equipment and home nursing support [8,59].
Tracheobronchomalacia is a rare but clinically troublesome condition in paediatrics. The softening of the major airways – which can include some or all of the tracheobronchial tree can lead to symptoms ranging from the minor (harsh barking cough, recurrent chest infections) to severe respiratory difficulties including prolonged ventilator support and ‘near death attacks’. The causes are broadly divided into intrinsic softening of the airway wall which is considered a primary defect (e.g. syndromes; post tracheo-oesophageal fistula repair; extreme prematurity) or secondary malacia due to external compression from vascular structures or cardiac components. These secondary changes can persist even when the external compression is relieved, for example, following the repair of a pulmonary artery sling or double aortic arch. For children with severe clinical symptoms attributed to malacia, consideration is given to possible surgical remedies such as an aortopexy for short limited areas of malacia, or long term positive pressure support with CPAP either by non invasive or tracheostomy interface. More recently the role of stenting in children is receiving attention, especially with the development of newer techniques such as bioabsorbable stents which buy time for a natural history of improvement in the malacia to occur. This paper reviews the stents available and discusses the pros and cons of stenting in paediatric airway malacia.

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: This research was supported by National Institutes of Health grant HD-01072, Maternal and Child Health Bureau grant MCJ-229163, and an American Lung Association Career Development Award CI-002-N (Dr. Gozal).

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Chest

Clinical Investigations in Critical CarePulmonary Risk Factors Compromising Postoperative Recovery After Surgical Repair for Congenital Heart Disease

Study objectives

Design

Setting

Patients

Results

Conclusions

Section snippets

Data Collection

Results

Discussion

Ann Thorac Surg

Br J Anaesth

J Pediatr Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surgery

Pediatr Clin N Am

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Pediatr

Chest

Federal and nationwide intensive care units and health care costs

Crit Care Med

Early extubation after cardiac operations in neonates and young infants

J Thorac Cardiovasc Surg

Early extubation after surgical repair of congenital heart disease

Crit Care Med

Prolonged mechanical ventilation of infants after open heart surgery

Crit Care Med

Management of airway obstruction in patients with congenital heart defects

Ann Otol Rhinol Laryngol

Corrective cardiac surgery infants

Anesthesia

Clinical Investigations in Critical Care
Pulmonary Risk Factors Compromising Postoperative Recovery After Surgical Repair for Congenital Heart Disease