Myocardial protection by pressure- and volume-controlled continuous hypothermic coronary perfusion in combination with Esmolol and nitroglycerine for correction of congenital heart defects in pediatric risk patients.

OBJECTIVE

This study assesses the technical applicability and the clinical value of the continuous coronary perfusion with oxygenated blood as a method for myocardial protection used for congenital heart surgery in pediatric risk patients.

METHODS

Thirty non-consecutive pediatric risk patients aged from 1 month to 16 years (mean 3.9 years; 11/30 patients aged <6 months) underwent open heart procedures on the beating heart for simple and complex cardiac malformations using a self designed perfusion system with pressure- and volume-controlled continuous hypothermic coronary perfusion (PVC-CONTHY-CAP) in combination with ultra-short beta1-receptor blockade (Esmolol) and nitroglycerine for myocardial protection. The following procedures were done: VSD patch closure (n = 6), repair of total a-v canal with 'double patch' (n = 4), total repair of tetralogy of Fallot (n = 7), correction of truncus arteriosus communis type IV (n = 1), mitral valve reconstruction (n = 4), total cavo-pulmonary connection (n = 4), and Rastelli procedure (n = 4).

RESULTS

The mean cardio-pulmonary bypass time was 131.5 min (range: 44-245 min), the mean coronary perfusion time: 90.1 min (range: 13-202 min). The weaning off extracorporeal circulation was uneventful in all patients, in 21 patients with low-dose and in nine patients with moderate catecholamine support: the mean weaning time was 25 min (range: 7 58 min). The post-operative mean peak creatine kinase (CK-MB) value was 58 U/l, (range: 14-202 U/l). The mean ICU stay in the cardiac surgery unit was 2.9 days, (range: 1-10 days). The mean post-operative mechanical ventilatory support was 2 days (range: 6 h-9 days). Six patients developed thrombocytopenia with values <40 tsd/microl, four patients renal dysfunction, two patients ascites, five patients heart rhythm disturbances, one patient neurological deficits. In three patients (VSD closure: n = 2; age: 1 and 2 months; total a-v-canal: n = 1; age: 3 months) re-do procedures for significant intraventricular shunt had to be done, in one patient implantation of a permanent pacemaker system was necessary. One patient died due to multiple organ failure after uneventful surgery (total cavo-pulmonary connection for single ventricle).

CONCLUSIONS

PVC-CONTHY-CAP can be successfully used for repair of simple and complex congenital cardiac malformations. However, in children less than 3 months of age, the transatrial repair of intraventricular defects is technically much more demanding and challenging than under conventional cardioplegic arrest and is possibly accompanied by an increased incidence of residual or recurring intraventricular shunts.