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Biomedical subjects

Gil Wernovsky

Publications and source records attributed to Gil Wernovsky.

At least 37 records · Page 2Linked to original sources
PubMed2005

Effect of congenital heart disease on neurodevelopmental outcomes within multiple-gestation births.

OBJECTIVES: We sought to assess the effect of congenital heart disease requiring surgical intervention with cardiopulmonary bypass at 6 months of age or less on developmental outcomes and growth at 1 year of age while controlling for socioeconomic status, prematurity, home environment, and parental intelligence. METHODS: We performed within-family comparison of 11 multiple-gestation births in which one child had congenital heart disease. At 1 year of age, the Bayley Scales of Infant Development II were administered, and growth parameters were assessed. Paired comparisons were made by using fixed effects regression conditioned on family. RESULTS: The multiple-gestation subjects were mildly premature on average (mean gestational age, 35.4 +/- 3.0 weeks). At 1 year of age, children with congenital heart disease scored lower on the Mental Development Index (85.0 +/- 19.3 vs 93.9 +/- 16.0, P = .037) and the Psychomotor Development Index (76.6 +/- 16.9 vs 91.3 +/- 14.9, P = .015) on the Bayley Scales of Infant Development II than did their siblings without congenital heart disease. There were no differences between siblings in weight, height, or head circumference. CONCLUSIONS: The presence of congenital heart disease requiring surgical intervention with cardiopulmonary bypass at 6 months of age or less is associated with a deficit in developmental achievement at 1 year of age, as measured by using the Bayley Scales of Infant Development II.

Female↗
PubMed2005

Haemodynamic changes during modified ultrafiltration immediately following the first stage of the Norwood reconstruction.

BACKGROUND: Modified ultrafiltration has been shown to reverse haemodilution and improve ventricular function following cardiopulmonary bypass. There has been concern, however, about the safety and efficacy of modified ultrafiltration after the first stage of Norwood reconstruction for palliation of neonates with hypoplasia of the left heart and its variants. METHODS: We reviewed the intraoperative course of all patients undergoing the first stage of Norwood reconstruction between September 1, 2000, and August 31, 2002. RESULTS: The first stage of reconstruction was performed in 99 neonates, 78 with classical hypoplasia of the left heart, and 21 with variants. Mean weight at surgery was 3.1 plus or minus 0.7 kilograms. Genetic syndromes, weight less than or equal to 2.5 kilograms, and/or major additional cardiac or non-cardiac anomalies, were present in 44 patients. We deemed these patients to constitute the group at high risk. A modified Blalock-Taussig shunt was utilized in 95 patients, and a conduit from the right ventricle to the pulmonary arteries in 4. Deep hypothermic circulatory arrest was used in all patients for a mean period of 45 minutes, plus or minus 15 minutes. Total support time on cardiopulmonary bypass plus deep hypothermic circulatory arrest was 100 minutes plus or minus 26 minutes. Modified ultrafiltration was performed in all patients. The mean duration of modified ultrafiltration was 10 plus or minus 2 minutes, and the total volume of filtrate removed was 104 plus or minus 29 millilitres per kilogram. There were no complications from modified ultrafiltration, and no patient required discontinuation of modified ultrafiltration for haemodynamic instability. During modified ultrafiltration, the haematocrit increased from 31 percent plus or minus 4 to 46 percent plus or minus 6. Heart rate decreased from 170 plus or minus 17 beats per minute to 158 plus or minus 16 beats per minute. Systolic blood pressure increased from 57 plus or minus 12 to 63 plus or minus 13 millimetres of mercury, and diastolic blood pressure from 30 plus or minus 8 to 35 plus or minus 7 millimetres of mercury. All these values are significant at a p value of less than 0.0001. Hospital morality in the patients at low risk was 3 of 55 (5.5 percent), but was 12 of 44 (27.3 percent) in the patients deemed to be at high-risk. CONCLUSIONS: Modified ultrafiltration is safe procedure following the first stage of Norwood reconstruction, with improvement in all haemodynamic parameters measured. Modified ultrafiltration is an additional incremental strategy, which may contribute to the overall improvement in outcome following surgical palliation of patients with hypoplasia of the left heart or its variants.

Cardiac Surgical Procedures↗
PubMed2005

Late outcomes in patients with surgically treated congenital heart disease.

Optimizing late outcomes should be the end result of improvements in medical and surgical care for congenital heart disease (CHD). In addition to mortality, significant morbidities after surgery for CHD need to be considered. These include the need for reintervention, cardiovascular complications, exercise limitations, neurocognitive morbidities, effects on pregnancy, difficulty obtaining insurance, need for chronic medications, and impaired functional status and quality of life. Long-term outcome studies are difficult to perform, and their interpretation is complicated by intervening changes in management. Specific discussion of long-term follow-up of tetralogy of Fallot, D-transposition of the great arteries, and hypoplastic left heart syndrome illustrates the myriad management changes over the last three decades, the challenges in predicting outcomes for recent patients, and the need for ongoing initiation of long-term follow-up studies.

Female↗
PubMed2005

Central nervous system outcomes in children with complex congenital heart disease.

PURPOSE OF REVIEW: To provide a brief overview of our current understanding of the types of neurodevelopmental sequelae in congenital heart disease survivors and to review the most recent studies from the past year, which have focused on 4 interrelated issues: (1) outcome studies, (2) the mechanism and etiology of central nervous system injury in children with CHD, (3) perioperative monitoring for brain injury, and (4) strategies for neuroprotection during cardiac surgery. RECENT FINDINGS: As the number of survivors of surgery for complex congenital heart disease continues to rise, it is recognized that there is an increased incidence of adverse neurological outcomes in the survivors. In particular, a pattern similar to that seen in premature infants is emerging, including learning disabilities, behavioral abnormalities, inattention and hyperactivity. Imaging studies have revealed a high prevalence of structural brain abnormalities and periventricular leukomalacia, fetal and postnatal cerebral blood flow is abnormal, postnatal oxygen delivery is decreased, and intraoperative support techniques and postoperative low cardiac output are associated with cerebral hypoperfusion. SUMMARY: The causes of these late developmental abnormalities are most likely sequential, cumulative and multifactorial.

Central Nervous System Diseases↗
PubMed2005

Electrographic neonatal seizures after infant heart surgery.

PURPOSE: Neonatal seizures are relatively common and an important early sign of acute encephalopathy in those who survive infant heart surgery. The contemporary occurrence of seizures in this setting is not fully known, and their electrographic characteristics are incompletely described. This study describes the characteristics of electrographic neonatal seizures (ENSs) in contemporary infants with congenital heart disease (CHD) surgically repaired by using cardiopulmonary bypass, with or without deep hypothermic circulatory arrest. METHODS: Consecutive infants undergoing heart surgery were monitored by video-EEG for 48 h postoperatively to establish the time of first seizure, total number of ENSs, site(s) of ENS(s) origin and other characteristics. RESULTS: ENSs occurred in 21 (11.5%) of 183 infants. None had clinically visible seizures. The mean time to the first ENS was 21 h (range, 10-36 h). The total number of ENSs among the entire cohort was 1,429. Mean total number of ENSs per patient over a 48-h period was 72 (range, 1-217). Phenobarbital administration was associated with a > or =50% reduction in seizure counts in five (41.7%) of 12 subjects. CONCLUSIONS: ENSs were relatively common in a large, contemporary cohort of infants after infant heart surgery. A wide variation was noted in seizure burden, but many experienced numerous seizures. Electrographic neonatal seizures are a candidate outcome end point in future neuroprotection trials in this patient population.

Cardiac Surgical Procedures↗
PubMed2004

Brain versus lung: hierarchy of feedback loops in single-ventricle patients with superior cavopulmonary connection.

BACKGROUND: CO2 vasodilates and O2 vasoconstricts the cerebral vascular bed; the opposite is true in the lungs. When the brain and lungs are connected exclusively in series, which feedback loop predominates is unknown. The circulation of the superior cavopulmonary connection (SCPC) provides a unique physiology to answer this question. METHODS AND RESULTS: To determine cerebral and pulmonary blood flow and to establish the hierarchy of cerebral and pulmonary feedback mechanisms, 12 intubated, ventilated, single-ventricle patients in SCPC physiology (age 2.2+/-0.5 years) underwent magnetic resonance imaging velocity mapping of their jugular veins and aorta in room air, hypercarbia, and 100% O2. Flows in these vessels and arterial blood gases were measured. With 22+/-6 torr CO2 (Pco2) increased from 40 to 63 mm Hg, P<0.01), flow to the brain and lungs increased (1.5 to 2.7 L/min per m2, P=0.0003), Po2 improved (48 to 60 mm Hg, P=0.0004), and cardiac index increased (4.3 to 5.4 L/min per m2, P=0.0003). The increased cardiac index accounted for the increased cerebral and pulmonary blood flow (R=0.73, P=0.02) and cerebral O2 transport increased by 80% (P=0.0005) while preserving body O2 delivery. Hyperoxia did not change cerebral and pulmonary blood flow; Po2 increased 94% (P=0.01). CONCLUSIONS: The cerebral CO2 feedback loop predominates over the pulmonary one when they directly compete with each other. CO2 has a major impact on flow distribution whereas O2 has little impact. Increased CO2 improves cerebral oxygenation in SCPC patients. This may provide a clue in determining neurological sequelae in SC physiology and may influence timing of Fontan completion.

Aorta↗
PubMed2004

Periventricular leukomalacia is common after neonatal cardiac surgery.

OBJECTIVES: Periventricular leukomalacia is necrosis of the cerebral white matter adjacent to the lateral ventricles and results from injury to immature oligodendroglia. In infants without congenital heart disease, periventricular leukomalacia is associated with an increased incidence of developmental delay and attention deficit/hyperactivity disorder. The incidence of periventricular leukomalacia and the risk factors for development of periventricular leukomalacia after infant cardiac surgery are not known. METHODS: Magnetic resonance imaging of the brain was performed 6 to 14 days after cardiac surgery utilizing cardiopulmonary bypass with or without deep hypothermic circulatory arrest in 105 neonates and infants < or = 6 months of age. RESULTS: Median age at surgery was 6 days (range 1-178), with 82 neonates (age < or = 30 days). Periventricular leukomalacia was found in 44 of the neonates (54%) compared with 1 of 23 infants (4%). Forward logistic regression using age at surgery as a continuous variable identified a model containing longer total support time (cardiopulmonary bypass plus deep hypothermic circulatory arrest), lower systolic blood pressure at cardiac intensive care unit admission postoperatively, lower minimum diastolic blood pressure, and Po(2) in the first 48 hours after surgery. When age at surgery was considered as a dichotomous variable (neonate versus infant), younger age at surgery replaced systolic blood pressure, Po(2), and total support time in the model. Lower minimum diastolic blood pressure was a significant risk factor in both models. CONCLUSIONS: Periventricular leukomalacia was found in >50% of neonates after cardiac surgery but rarely in older infants. Hypoxemia and hypotension in the early postoperative period, particularly diastolic hypotension, may be important risk factors for periventricular leukomalacia.

Apolipoproteins E↗
PubMed2004

Preoperative cerebral blood flow is diminished in neonates with severe congenital heart defects.

OBJECTIVE: Impaired neurodevelopmental outcome represents a major morbidity for survivors of infant heart surgery for congenital heart defects. Previous studies in these neonates have reported preoperative microcephaly, periventricular leukomalacia, and other findings. The hypothesis of this study is that preoperative cerebral blood flow is substantially diminished and might relate to preoperative neurologic conditions. METHODS: Preoperative brain magnetic resonance imaging was performed. Cerebral blood flow measurements in infants with congenital heart defects were obtained by using a novel noninvasive magnetic resonance imaging technique, pulsed arterial spin-label perfusion magnetic resonance imaging. Cerebral blood flow was measured before the operation under standard ventilation and repeated after increased carbon dioxide. RESULTS: A total of 25 term infants were studied. The average age at the time of the operation was 4.4 +/- 4.6 days. Congenital heart defects varied widely. Microcephaly occurred in 24% (6/25). Baseline cerebral blood flow was 19.7 +/- 9.2 mL . 100 g -1 . min -1 (8.0-42.2 mL . 100 g -1 . min -1 ). Five patients had cerebral blood flow measurements of less than 10 mL . 100 g -1 . min -1 . Mean hypercarbic cerebral blood flow increased to 40.1 +/- 20.3 mL . 100 g -1 . min -1 (11.4-94.0 mL . 100 g -1 . min -1 , P < .001). Pairwise analyses found that low hemoglobin levels were associated with higher baseline cerebral blood flow values ( P = .04). Periventricular leukomalacia occurred in 28% (7/25) and was associated with decreased baseline cerebral blood flow values ( P = .05) and a smaller change in cerebral blood flow with hypercarbia ( P = .003). CONCLUSIONS: Structural brain abnormalities are common in these neonates before surgical intervention. Preoperative cerebral blood flow for this cohort was low and drastically reduced in some patients. Low cerebral blood flow values were associated with periventricular leukomalacia. Carbon dioxide reactivity was preserved but might be compromised by some aspects of the cardiac anatomy. The full spectrum of cerebral blood flow measurements with this technique in congenital heart defects and their long-term significance require continued investigation.

Brain↗
PubMed2004

Academic performance and behavioral difficulties after neonatal and infant heart surgery.

Although advances in medical and surgical arenas have allowed the ability to "mend" children born with congenital heart disease, the increasing number of survivors has created a growing cohort of children with potential academic difficulties. This article reviews the current understanding of the midterm neurologic outcomes of children who underwent neonatal and infant cardiac surgery. Lesions including transposition of great arteries, tetralogy of Fallot, hypoplastic left heart syndrome, total anomalous pulmonary venous connection, and single ventricle lesions requiring Fontan palliation or cardiac transplantation are discussed.

Child Behavior Disorders↗
PubMed2004

Parental decision-making in congenital heart disease.

OBJECTIVE: To explore whether prenatal diagnosis of congenital heart disease is associated with lower levels of parental distress and greater satisfaction with decisions about cardiothoracic surgery when compared to postnatal diagnosis. METHODOLOGY: A combined quantitative-qualitative design was used. Participants included the parents of 31 neonates (30 mothers and 22 fathers) admitted to the cardiac intensive care unit between 1 November 2001 and 1 May 2002 for repair of congenital cardiac malformations. Participants completed self-report measures of anxiety, optimism, and life events pre-operatively, and semi-structured qualitative interviews assessing satisfaction with decision-making within 1 week of the operation. RESULTS: At the time of surgery, mothers of neonates receiving the diagnosis prenatally did not differ from mothers of neonates receiving the diagnosis postnatally on measures of anxiety, optimism, and life events. Fathers of neonates receiving the diagnosis prenatally, however, reported more optimism, lower state and trait anxiety, and fewer negative life events than fathers of neonates receiving the diagnosis postnatally. When we analyzed the interviews, we found that, regardless of the timing of the diagnosis, parents felt as though they made a genuine choice for their baby to have surgery. CONCLUSIONS: In this pilot study, fathers who learned prenatally that their child had a congenital cardiac malformation were less distressed than those who discovered this fact only postnatally. From the parental perspective, nonetheless, distress and urgency do not impair their ability to make decisions about neonatal cardiac surgery.

Adult↗
PubMed2004

A population pharmacokinetic analysis of milrinone in pediatric patients after cardiac surgery.

The purpose of this study was to ascertain the optimal pharmacokinetic model for milrinone in pediatric patients after cardiac surgery when milrinone was administered as a slow loading dose followed by a constant-rate infusion. The data used for pharmacokinetic analysis were collected in a prospective, randomized, placebo-controlled multi-center trial of milrinone as prophylaxis for the development of low cardiac output syndrome after surgery for repair of complex congenital cardiac defects. Two blood samples were randomly collected from each patient for determination of plasma milrinone concentrations with subsequent population pharmacokinetic modeling. The pharmacokinetics of milrinone in pediatric patients under 6 year's age were best described by a weight-normalized one compartment model after a slow loading dose followed by a constant-rate infusion. The volume of distribution was 482 ml kg(-1) and was independent of age. Clearance was a linear function of age given by Cl = 2.42 ml kg(-1) min(-1) [1 + 0.396*age].

Age Factors↗
PubMed2004

Neurodevelopmental outcomes in hypoplastic left heart syndrome.

Infants with hypoplastic left heart syndrome (HLHS) are now surviving to school age and early adulthood because of surgical palliation with either staged reconstruction or transplantation. Although in some respects these patients are doing remarkably well, recent investigations have shown that they are at risk for cognitive, neuromotor, and psychosocial problems. This article examines the neurodevelopmental outcome for children and adolescents with HLHS. In addition, hemodynamic and genetic factors unique to this patient population that may impact longer-term outcome are explored. The continued evolution of the pre-, intra- and post-operative care of the patient with HLHS has significantly improved early survival. Concomitant changes in care, such as selective cerebral perfusion and neurologic monitoring, aimed at reducing neurologic insult may also favorably impact later neurodevelopmental status.

Adolescent↗
PubMed2004

Risk factors for mortality in 137 pediatric cardiac intensive care unit patients managed with extracorporeal membrane oxygenation.

OBJECTIVE: To identify factors associated with mortality in children with heart disease managed with extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective chart review. SETTING: Tertiary care university-affiliated children's hospital. PATIENTS: All pediatric cardiac intensive care unit patients managed with ECMO between January 1, 1995, and June 30, 2001. INTERVENTIONS: None. RESULTS: During the study period, 137 patients were managed with ECMO in the pediatric cardiac intensive care unit. Of the 137 patients, 80 (58%) survived > or =24 hrs after decannulation, and 53 (39%) survived to hospital discharge. Patients managed with ECMO following cardiac surgery were analyzed separately from patients not in the postoperative period. Factors associated with an increased probability of mortality in the postoperative patients were age <1 month, male gender, longer duration of mechanical ventilation before ECMO, and development of renal or hepatic dysfunction while on ECMO. Single ventricle physiology and failure to separate from cardiopulmonary bypass were not associated with an increased risk of mortality. Cardiac physiology and indication for ECMO were not associated with mortality rate. Although longer duration of ECMO was not associated with increased mortality risk, patients with longer duration of ECMO were less likely to survive without heart transplantation. CONCLUSIONS: In a series of 137 patients managed with ECMO in a pediatric cardiac intensive care unit, survival to hospital discharge was 39%. In postoperative patients only, mortality risk was increased in males, patients <1 month old, patients with a longer duration of mechanical ventilation before initiation of ECMO, and patients who developed renal or hepatic failure while on ECMO.

Adolescent↗
PubMed2004

Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest.

OBJECTIVE: To report survival outcomes and to identify factors associated with survival following extracorporeal cardiopulmonary resuscitation for in-hospital pediatric cardiac arrest. DESIGN: Retrospective chart review, consecutive case series. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: During a 7-yr study period, there were 66 cardiac arrest events in 64 patients in which a child was cannulated for extracorporeal membrane oxygenation during active cardiopulmonary resuscitation with chest compressions. A total of 33 of 66 events (50%) resulted in the child being decannulated and surviving at least 24 hrs; 21 of 64 (33%) children undergoing extracorporeal cardiopulmonary resuscitation survived to hospital discharge. A total of 19 of 43 children with isolated heart disease compared with two of 21 children with other medical conditions survived to hospital discharge (p <.01). Pediatric Cerebral Performance Category and Pediatric Overall Performance Category were determined for survivors >2 months old. Five of ten extracorporeal cardiopulmonary resuscitation survivors >2 months old had no change in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category compared with admission. Three of six extracorporeal cardiopulmonary resuscitation patients who survived after receiving >60 mins of chest compressions before extracorporeal cardiopulmonary resuscitation had grossly intact neurologic function. During a 2-yr period in the same hospital, no patient who received >30 mins of cardiopulmonary resuscitation without extracorporeal cardiopulmonary resuscitation survived. In this case series, age, weight, or duration of chest compressions before extracorporeal cardiopulmonary resuscitation did not correlate with survival. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation can be used to successfully resuscitate selected children following refractory in-hospital cardiac arrest, and can be implemented during active cardiopulmonary resuscitation. Intact neurologic survival can sometimes be achieved, even when the duration of in-hospital cardiopulmonary resuscitation is prolonged. In this series, children with isolated heart disease were more likely to survive following extracorporeal cardiopulmonary resuscitation than were children with other medical conditions.

Adolescent↗