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Query: UMLS:C0018799 (heart disease)
 34,133 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A 8-year-old boy with a complex heart disease was underwent Fontan operation with Glenn operation, and had a good post-operative course by the management of hypothermia in coming off from cardiopulmonary bypass around 31 degrees C. The hypothermic therapy was thought to be effective in acute stage after Fontan operation, because it improved tachycardia, decreased the systemic metabolism, redistributed the systemic arterial blood flow and increased the urinary output.
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PMID:[A case of Fontan operation for complex heart disease with good post-operative course by the management of hypothermia in coming off from cardiopulmonary bypass]. 833 38

To evaluate cytokine balance related to cardiopulmonary bypass, we prospectively investigated 11 infants undergoing cardiac operations for congenital heart disease. Proinflammatory cytokines (tumor necrosis factor-alpha and interleukin-8) and the antiinflammatory cytokine interleukin-10 were measured at multiple time points before, during, and after bypass. Tumor necrosis factor-alpha and interleukin-8 values were within normal range before the operation. These values increased significantly during bypass, reaching their peaks after protamine administration (tumor necrosis factor-alpha, 133.6 +/- 124.9 pg/ml; mean +/- standard deviation; p<0.005) and 2 hours after termination of the procedure (interleukin-8, 92.1 +/- 44.1 pg/ml; p < 0.01). Tumor necrosis factor-alpha and interleukin-8 equaled normal prebypass values from the first postoperative day on. Interleukin-10 levels were within normal range before the operation and were already significantly increased 10 minutes after initiation of bypass (interleukin 10, 39.4 +/- 34.3 pg/ml; p<0.05). These levels remained elevated throughout the procedure but returned to normal after protamine administration. A second significant release of interleukin-10 occurred from the early postoperative period on, reaching its peak 24 hours after termination of cardiopulmonary bypass (interleukin-10, 351.6 +/- 304.0 pg/ml; p < 0.01). Interleukin-10 values were normal on the second postoperative day in all patients. Interleukin-10 kinetics showed an inverse pattern compared with tumor necrosis factor-alpha and interleukin-8. This difference suggests an interplay between proinflammatory and antiinflammatory cytokines released during and after cardiopulmonary bypass. Interleukin-10 levels measured 4 and 24 hours after bypass strongly correlated with the degree of hypothermia during bypass (Spearman's correlation coefficient, -0.77 [p < 0.01] and -0.89 [p < 0.0005], respectively); these levels did not correlate with duration of bypass and aortic crossclamping, however. This result suggests that besides immunologically mediated production of interleukin-10, hypothermia itself could modulate interleukin-10 production. In conclusion, this study demonstrates interleukin-10 production, in addition to interleukin-8 and tumor necrosis factor-alpha synthesis, in response to cardiopulmonary bypass in infants. Interleukin-10 could play a protective role by down-regulating proinflammatory cytokine release during and after cardiopulmonary bypass.
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PMID:Interleukin-10 release related to cardiopulmonary bypass in infants undergoing cardiac operations. 860 68

Primary repair of interrupted aortic arch and associated heart lesions was performed in 13 patients aged from 1 to 85 days. The surgery was performed through the midline sternotomy approach in extracorporeal circulation and deep hypothermia. Hypothermic circulatory arrest at 14 to 19 degrees C was used for reconstruction of the aortic arch. In all patients it was possible to perform a direct anastomosis between the ascendent and descendent aorta. At the same time closure of the ventricular septal defect was performed in 11 patients, closure of the atrial septal defect in 4, correction of persistent truncus arteriosus in 3, resection of subaortic stenosis in 2, arterial switch repair of transposition of the great arteries in 1, correction of double outlet right ventricle in 1 and patch closure of aortico-pulmonary window in 1 patient. Three (23.1%) newborns died in the early postoperative period: two from sepsis and one from multiple organ failure. Ten patients (76.9%) were followed up for 1 to 29 months postoperatively. All of them are in very good condition with a nonrestrictive aortic anastomosis. Primary one-stage repair of interrupted aortic arch and associated heart lesions is preferred to the two-stage repair in all newborns with this critical congenital heart disease.
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PMID:Primary repair of interrupted aortic arch and associated heart lesions in newborns. 920 Nov 19

When choosing cannulae for cardiac surgery the two most important factors to be considered are the proposed procedure and the patient anatomy. These factors are especially crucial in paediatric patients with congenital heart disease. A 3-year-old, 14-kg male presented to the University of Iowa Hospitals and Clinics with dextro-transposition of the great arteries, atrioventricular canal, left pulmonary stenosis, azygous continuation, bilateral superior vena cavae, partial anomalous pulmonary venous return, left aortic arch and status post-right Blalock-Taussing shunt. The complex anatomy presented a surgical dilemma. The course of surgical intervention was determined, a variation of the modified Fontan procedure, and the anatomy of the patient was directly viewed. The surgeon concluded that four venous cannulae were required to provide adequate venous return for the cardiopulmonary bypass (CPB) circuit and a bloodless surgical field. The operation was successfully performed under mild hypothermia with no complications. The patient fully recovered with only mild restrictions on his activity level. This case acutely illustrates the importance of anatomical and procedural awareness when choosing cannulae and cannulation sites for CPB in paediatric patients with congenital heart disease.
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PMID:Cardiopulmonary bypass venous cannulation challenges in a paediatric patient with complex congenital heart disease: a case report. 922 10

Pharmacologic manipulation of hemostasis is a prerequisite for cardiac surgery with cardiopulmonary bypass (CPB) to prevent clot formation in the extracorporeal circuit. Children who require surgical correction of congenital heart defects are at increased risk for prolonged and excessive bleeding after separation from CPB. Heparin remains the anticoagulant of choice for surgery requiring CPB. Traditional regimens of empiric heparin dosing and a fixed-dose ratio of protamine to heparin for reversal of anticoagulation do not account for individual differences in the half-life of heparin, clearance of heparin, and duration of CPB, particularly in children. In addition, the use of prolongation of the activated clotting time (ACT) as a measure of adequate anticoagulation does not account for alterations in ACT by factors unrelated to heparin activity, including hemodilution and hypothermia, that are frequently present during CPB. This manuscript reviews the pitfalls in the management of anticoagulation for children undergoing surgery that requires CPB. Pertinent literature related to the use of aprotinin, a serine protease inhibitor that has been shown to improve hemostasis during and after CPB, is discussed. It is hoped that this article will provide a practical guideline for the rational management of anticoagulation in children with congenital heart disease undergoing CPB surgery.
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PMID:Monitoring and management of anticoagulation in children requiring extracorporeal circulation. 946 31

The majority of pediatric cardiosurgery centers make use of cardiopulmonary bypass (CPB) with low hematocrit, and therefore we deemed it interesting to investigate the pathological effects of hemodilution on patients. Specifically, we studied the effect of hemodilution on aerobic and water metabolism in children with congenital heart disease subjected to CPB. Two groups of patients were examined. In the studied group (n = 12, mean age 7.1 +/- 1.1 years) the blood-fluid ratio in primary filling of the CPB device was 1:6.2 +/- 0.7 and minimal hematocrit during myocardial ischemia 18 +/- 0.7%. Control group consisted of 7 patients aged 8.3 +/- 0.6 years, with the above values 1:2.8 +/- 0.4 and 22 +/- 1.6%, respectively. The groups were similar as regards the initial status of patients, level of hypothermia, and duration of myocardial ischemia. Gas content in venous blood was the criterion of aerobic metabolism. Fluid accumulation in the extravasal space during and after surgery was assessed by bioelectroimpedance measurements of the total extracellular extravasal fluid (EEF). Monitoring showed a decrease of hematocrit during CPB to 18 +/- 0.7%, saturation of venous blood with oxygen within 70-75%, and oxygen content 37-43 mm Hg. In the main group a manifest increase of EEF was observed as early as during the early postperfusion period; this increase is probably one of the main components in the detrimental effect of hemodilution. Redistribution of fluid after CPB leads to expressed interstitial edemas and impairs the function of vital organs. That is why signs of cardiorespiratory failure were observed in the main group. Thus, one of the main problems in CPB with low hematocrit is fluid accumulation in the extravasal space.
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PMID:[The effect of hemodilution on the indices of aerobic metabolism and water metabolism in children with congenital heart defects operated on under artificial circulation]. 955 60

Several factors combine to facilitate the evolution towards heart and multi-organ failure following cardiac surgery. Some of these factors are related to pure cardiac aspects, for example, the existence of a preoperative heart disease, the use of aortic cross clamping or performance of cardiotomy. Cardiopulmonary bypass (CPB) also plays an important role in the occurrence of postoperative organ dysfunctions by two principal means. It induces a profound hemodilution, which impairs oxygen transport through tissues. This phenomenon becomes obvious in the postoperative period by the existence of increased transpulmonary O2 gradients, extravascular lung water volume and subsequent impairments of O2 transport. (2) Cardiopulmonary bypass is deleterious by triggering an important inflammatory reaction. This reaction is largely related to the ratio of the circuit area to the patient's body surface area and is therefore maximal in children. It has been widely demonstrated that the very early paths of this reaction imply several humoral factors including kinins, coagulation factor XII and complement fragments. The activation of these factors is self-amplified and triggers both expression and release of numerous mediators by endothelial cells and leukocytes. Finally, these mediators are responsible for the well described "post-bypass syndrome," which is, from a clinical viewpoint, very close to hyperkinetic septic shock. Several methods have been proposed to reduce the deleterious effects of both cardiac surgery and CPB. The older one is hypothermia that considerably reduces the triggering of the inflammatory mediator network. Heparin-coated circuits may also reduce this reaction to some extent. Hemofiltration has been introduced in the 1990s in CPB management. Because of its very high tolerance in patients with compromised circulatory status this technique was already used in the postoperative period to treat patients with acute renal failure. Initially hemofiltration was intended to correct the accumulation of extravascular water during or immediately following the surgical procedure. Nevertheless, several of its side-effects appeared to be useful, such as the reduction of postoperative blood loss and immediate improvement in hemodynamics. Several studies attempted to point out the mechanism of action of hemofiltration and although removal of inflammatory mediator occurs, there is currently no proof that this removal is the actual mechanism by which this technique acts.
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PMID:Hemofiltration during cardiopulmonary bypass. 957 98

Because of advances in surgical and cardiopulmonary bypass techniques it is now possible to definitively repair the vast majority of congenital heart disease in infancy or childhood. Although the majority of survivors do not have obvious cerebral sequelae, there is increasing disquiet about the high incidence of acute neurological events in the immediated postoperative period as well as evidence that at long-term follow-up there are subtle cognitive and motor deficits in many. Some children are more at risk of neurodevelopmental problems, either because of their cardiac (e.g. , extensive aortopulmonary collaterals) or cerebrovascular (e.g., the propensity to large vessel dissection) anatomy or because of genetic predisposition (e.g., to prothrombotic disorders). The incidence may vary with the surgery (e.g., the Fontan operation) and the cardiopulmonary bypass technique necessary to achieve an adequate technical repair (e.g., low or no flow at deep hypothermia). Recognition of the population at risk will lead to prevention of serious sequelae. Data collected in adults may be misleading, and many pediatric units have developed their own practice, but recent studies in animal models of child surgery and in children have produced some evidence to guide management to ensure the optimal cerebral as well as cardiac outcome. Pump flow should be maintained at least 30 ml/kg/min where possible, with inotropic support to maintain blood pressure if necessary. If pump flow must be lowered or circulatory arrest is essential, thorough cerebral cooling to deep hypothermic temperatures is mandatory; a pH-stat strategy may make this easier, but an alpha-stat strategy may be better in those operations that can be performed at moderate hypothermia. There is no evidence that the available pulsatile pumps offer an advantage. Tissue oxygenation may reach critical levels and a high hematocrit and oxygen tension may reduce the risk of significant hypoxia. There is a risk of embolization in children, which can be reduced with membrane oxygenators and careful monitoring; the role of arterial filtration remains controversial. The only protective agent that can currently be recommended is methylprednisolone to protect the spinal cord (e.g., in operations on the aortic arch). Further studies are needed in this important area.
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PMID:Recognition and prevention of neurological complications in pediatric cardiac surgery. 963 58

Cardiac disorders are observed when excessive plasma concentrations of local anaesthetics are reached, following for instance intravascular accidental injection for epidural anaesthesia or brachial plexus block. Bupivacaine particularly, which is one of the most used local anaesthetics, adversely affects intraventricular conduction and cardiac contractile strength from the 3.0-4.0 micrograms/ml blood levels. Depression of conduction is especially to be feared, for it can result in reentrant arrhythmias likely to degenerate into often fatal ventricular fibrillation. Such accidents may sometimes occur at far lower concentrations, subsequent to diffusion into systemic circulation from the injection site (0.4-1.2 micrograms/ml). These accidents were probably due to various factors which concomitantly intervene during the anaesthesia. We could identify a number of these factors by associating them to an intravenous infusion of bupivacaine (0.04 mg/kg/min after a loading dose of 1.00 mg/kg) in animals (dogs and pigs) under electrocardiographic monitoring, in which conduction time, monophasic action potential duration, effective refractory period and electrical fibrillation threshold were determined in the ventricular fibres. The electrophysiological changes due to bupivacaine may be enhanced by 1) dilution hyponatremia (115-110 mmol/l) induced by a short (5 min) intravenous 10 ml/kg/min infusion of hypotonic solution and/or hyperkalemia (7-8 mmol/l) induced by 0.05 mmol/kg/min infusion of potassium chloride; 2) the acceleration of cardiac contractions (180-210 beats/min) induced by ventricular pacing; 3) mild hypothermia (35-34 degrees C) induced by blood cooling in an extracorporeal circuit; 4) myocardial ischaemia induced by complete temporary occlusion of the left anterior descending coronary artery near its origin. The risk of cardiac accidents, possibly severe, is therefore enhanced by each of these factors capable of lowering the concentration required for their triggering and, of course, the combination of two or several of them. On the contrary, the knowledge of these factors should allow to prevent most of cardiac accidents of locoregional anaesthesia.
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PMID:[Cardiac accidents of locoregional anesthesia: experimental study of risk factors with bupivacaine]. 964 39

Several factors combine to facilitate the evolution towards heart and multi-organ failure following cardiac surgery. Some of these factors are related to pure cardiac aspects like the existence of a preoperative heart disease, the use of aortic cross clamping or performance of cardiotomy. Cardiopulmonary bypass (CPB) also plays an important role in the occurrence of postoperative organ dysfunctions by two principal means: firstly by inducing a profound hemodilution, which impairs oxygen transport through tissues. This phenomenon is pointed out in the postoperative period by the existence of increased transpulmonary O2 gradients, extravascular lung water volume and subsequent impairments of O2 transport. Secondly CPB is deleterious by triggering an important inflammatory reaction. This reaction is largely related to the ratio of the circuit area to the patient's body surface area and is therefore maximal in children. It has been widely demonstrated that the very early paths of this reaction imply several humoral factors including kinins, coagulation factor-XII and complement fragments. The activation of these factors is self-amplified and triggers both expression and release of numerous mediators by endothelial cells and leukocytes. Finally, these mediators are responsible for the well described "post-bypass syndrome" which is, from a clinical viewpoint, very close to hyperkinetic septic shocks. Several methods have been proposed to reduce the deleterious effects of both cardiac surgery and CPB. The older one is hypothermia that considerably reduces the triggering of the inflammatory mediators network. Heparin-coated circuits may also reduce this reaction to some extent. Hemofiltration has been introduced in the 90's in CPB management. Because of its very high tolerance in patients with compromised circulatory status this technique was already used in the postoperative period to treat patients with acute renal failure. Initially hemofiltration was intended to correct the accumulation of extravascular water during or immediately following the surgical procedure. Nevertheless several of its "side-effects" appeared to be useful like reduction of postoperative blood loss and immediate hemodynamics improvement. Several studies attempted to point out the mechanism of action of hemofiltration and although removal of inflammatory mediator occurs, there is currently no proofs that this removal is the actual mechanism by which this technique acts. At the early beginning of the use of its utilization hemofiltration during cardiac surgery aimed either to concentrate blood at the end of the procedure or to rapidly restore a normal fluid and electrolytes balance. Today some new implementations of this technique are proposed either to reduce the triggering of the inflammatory reaction to CPB or to reduce the immediate postoperative drug support.
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PMID:Hemofiltration during cardiopulmonary bypass. 1039 14


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