Ventricular cardiac-assist devices in infants and children: anesthetic considerations.
OBJECTIVE
The application of a mechanical cardiac-assist device is now a common procedure in modern cardiac surgery in patients with end-stage failure, whereas in pediatric patients it is still a great challenge. In the recent literature, a broad range of survival and weaning rates have been reported, depending on the variety of mechanical devices and the choice of patients with different conditions before implantation or if the device is used in emergency surgery. In this article, the authors report their experience with pediatric cardiac-assist devices and the perioperative anesthesia management in this group of patients.


METHODS
From 1997 to 2001, 11 infants and children were supported with a left and/or right ventricular-assist device. Diagnosis included myocarditis and complex cardiac malformations (hypoplastic left heart syndrome, tetralogy of Fallot with cardiomyopathy, and combined heart defects). The data sets of all patients were recorded using the online anesthesia record-keeping system NarkoData (IMESO GmbH, Hüttenberg, Germany). The program collects all perioperative data during surgery and during a stay in the PACU, including vital signs, administered drugs, as well as the data set of the German Society of Anesthesiology and Intensive Care Medicine.


RESULTS
All patients were divided into 2 groups: group 1 = survivors and group 2 = nonsurvivors. A total of 5 patients were in group 1, and group 2 consisted of 6 patients. The duration of anesthesia in group 1 patients (173.2 +/- 95.1 minutes) was significantly (p < 0.05) shorter than in group 2 (631.1 +/- 258.8 minutes) as well as the amount of packed red cells (group 1= 540.5 +/- 150.3 mL, group 2 = 880.6 +/- 400.3 mL). Cardiopulmonary bypass before implantation of a VAD was necessary only in 2 patients from group 1, whereas 5 patients in group 2 were on pump during the procedure. The rate of aortic cross-clamping was also significantly lower in group 1 than in group 2 (p < 0.05).


CONCLUSIONS
The surgical outcome depends on the patient's condition at the time of surgery. Emergency surgery, preoperative multiorgan failure, and the need for an extracorporeal circulation with aortic cross-clamping seem to predict a negative outcome in this group of patients.
Department of Anesthesiology and Intensive Care Medicine, German Pediatric Heart Center, Asklepios Klinik Sangt Augustin, Germany. es@anesthesiology.de
Ehrenfried
E
Schindler
Matthias
M
Müller
Myron
M
Kwapisz
Hakan
H
Akintürk
Klaus
K
Valeske
Josef
J
Thul
Gunter
G
Hempelmann
D015105:3',5'-Cyclic-AMP Phosphodiesterases / Q000037:antagonists & inhibitors / Q000627:therapeutic use; D000527:Alprostadil / Q000627:therapeutic use; D000758:Anesthesia; D001803:Blood Transfusion; D009202:Cardiomyopathies / Q000401:mortality / Q000628:therapy*; D002315:Cardiopulmonary Bypass / Q000295:instrumentation; D016887:Cardiopulmonary Resuscitation; D002395:Catecholamines / Q000627:therapeutic use; D002648:Child; D002669:Child Welfare; D002675:Child, Preschool; D054684:Cyclic Nucleotide Phosphodiesterases, Type 3; D004359:Drug Therapy, Combination; D017558:Elective Surgical Procedures; D004632:Emergency Medical Services; D004867:Equipment Design; D006330:Heart Defects, Congenital / Q000401:mortality / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D007223:Infant; D007229:Infant Welfare; D007231:Infant, Newborn / Q000502:physiology*; D009205:Myocarditis / Q000401:mortality / Q000628:therapy*; D005996:Nitroglycerin / Q000627:therapeutic use; D009599:Nitroprusside / Q000627:therapeutic use; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D016019:Survival Analysis; D016896:Treatment Outcome; D014655:Vascular Resistance / Q000187:drug effects; D014665:Vasodilator Agents / Q000627:therapeutic use
D002395:Catecholamines; D014665:Vasodilator Agents; D009599:Nitroprusside; D015105:3',5'-Cyclic-AMP Phosphodiesterases; D054684:Cyclic Nucleotide Phosphodiesterases, Type 3; D000527:Alprostadil; D005996:Nitroglycerin