Artificial organs
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The objective of this study was to evaluate five small-bore arterial cannulae (6Fr and 8Fr) in terms of pressure drop and hemodynamic performance in simulated neonatal cardiopulmonary bypass (CPB) circuits. The experimental circuits consisted of a Jostra HL-20 roller pump, a Terumo Capiox Baby FX05 oxygenator with integrated arterial filter, an arterial and a venous tubing (1/4, 3/16, or 1/8 in × 150 cm), and an arterial cannula (Medtronic Bio-Medicus 6Fr and 8Fr, Maquet 6Fr and 8Fr, or RMI Edwards 8Fr). The circuit was primed using lactated Ringer's solution and heparinized packed human red blood cells (hematocrit 30%). ⋯ Appropriate arterial cannula and arterial tubing should be considered to match the expected flow rate. Larger cannula and tubing are recommended for neonatal CPB. Low-resistance neonatal arterial cannulae need to be developed.
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Randomized Controlled Trial
A Pilot Study of Antithrombin Replacement Prior to Cardiopulmonary Bypass in Neonates.
Neonates have low levels of antithrombin. Inadequate anticoagulation during cardiopulmonary bypass (CPB) due to low antithrombin activity may result in a poor preservation of the coagulation system during bypass. We hypothesize that antithrombin replacement to neonates prior to CPB will preserve the hemostatic system and result in less postoperative bleeding. ⋯ Total heparin administration was less in the antithrombin group; measurements of blood loss were similar in both groups. A single dose of recombinant antithrombin did not maintain 100% activity levels throughout the entire operation. Although no safety concerns were identified in this pilot study, a larger trial is necessary to determine clinical efficacy.
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Mixing of autologous blood with priming volume has relatively significant effects on blood composition, especially in low-bodyweight neonates. In an effort to reduce these effects, mini-volume priming (MP) has been applied in cardiopulmonary bypass (CPB). The present study was designed to examine the effect of MP on clinical outcomes of low-bodyweight neonates undergoing open heart surgery. ⋯ The results of the present study suggest that MP may be beneficial in avoiding transfusion without having a significant effect on the hematocrit. Clinical outcomes did not differ between the two groups. However, larger priming volume was a significant risk factor for postoperative ECMO support with RACHS-1 category.
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Right ventricular failure (RVF) is common after left ventricular assist device (LVAD) implantation and a major determinant of adverse outcomes. Optimal perioperative right ventricular (RV) management is not well defined. We evaluated the use of pulmonary vasodilator therapy during LVAD implantation. ⋯ Two-year survival was 77% (92% for HMII/HVAD): transplanted 54%, alive with LVAD 21%, recovery/explanted 2%. A low incidence of RVF and excellent outcomes were observed for patients treated early during LVAD implantation with combination, high-dose pulmonary vasodilators. The results warrant further investigation in a randomized controlled study.
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Cardiopulmonary bypass (CPB) in infants is associated with morbidity due to systemic inflammatory response syndrome (SIRS). Strategies to mitigate SIRS include management of perfusion temperature, hemodilution, circuit miniaturization, and biocompatibility. Traditionally, perfusion parameters have been based on body weight. ⋯ B, P = 0.07), reexploration for bleeding (1 vs. none, P = not significant [NS]), renal failure requiring dialysis (none vs. 1, P = NS), prolonged ventilation (9 vs. 4, P = NS), and sepsis (2 vs. 1, P = NS). The present study shows that normothermic CPB in neonates, infants, and young children can be safely managed exclusively by systemic and cerebral metabolic monitoring. This strategy allows reduction of at least 10% of predicted CPB flows under normothermia and may lay the ground for further tailoring of CPB parameters to individual patient needs.