Background-Prenatal surgery for congenital anomalies can prevent fetal demise or alter the course of organ development, resulting in a more favorable condition at birth. The indications for fetal surgery continue to e...Background-Prenatal surgery for congenital anomalies can prevent fetal demise or alter the course of organ development, resulting in a more favorable condition at birth. The indications for fetal surgery continue to expand, yet little is known about the acute sequelae of fetal surgery on the human cardiovascular system. Methods and Results-Echocar-diography was used to evaluate the heart before, during, and early after fetal surgery for congenital anomalies, including repair of myelomeningocele(MMC, n=51), resection of intrathoracic masses (ITM, n=15), tracheal occlusion for congenital diaphragmatic hernia (CDH, n=13), and resection of sacrococcygeal teratoma (SCT, n=4). Fetuses with MMC all had normal cardiovascular systems entering into fetal surgery,whereas those with ITM, CDH, and SCT all exhibited secondary cardiovascular sequelae of the anomaly present. At fetal surgery, heart rate increased acutely, and combined cardiac output diminished at the time of fetal incision for all groups including thzose with MMC, which suggests diminished stroke volume. Ventricular dysfunction and valvular dysfunction were identified in all groups, as was acute constriction of the ductus arteriosus. Fetuses with ITM and SCT had the most significant changes at surgery. Conclusions-Acute cardiovascular changes take place during fetal surgery that are likely a consequence of the physiology of the anomaly and the general effects of surgical stress, tocolytic agents, and anesthesia. Echocardiographicmonitoring during fetal surgery is an important adjunct in the management of these patients.展开更多
Objectives This study was designed to determine if a subset of patients who ha ve undergone bidirectional cavopulmonary anastomosis could be identified in whic h catheterization was of little benefit before completion...Objectives This study was designed to determine if a subset of patients who ha ve undergone bidirectional cavopulmonary anastomosis could be identified in whic h catheterization was of little benefit before completion of the Fontan procedur e. Background Diagnostic evaluation before Fontan procedure has typically includ ed cardiac catheterization. However, the overall management strategy for patient s with functional single ventricle has evolved to include staging bidirectional cavopulmonary anastomosis in most, and it has become uncommon to exclude patient s from Fontan based on catheterization data. Methods Patients who underwent bidi rectional cavopulmonary anastomosis and had complete echocardiograms and cathete rizations within three months of each other between January 1992 and October 199 7 were evaluated with a series of clinical and echocardiographic characteristics to identify a subset in whom catheterization was predicted to be of little adde d value (“no-cath”group). The predictive value and sensitivity of these crite ria in excluding patients who required additional intervention, were excluded fr om Fontan, or died within 30 days of Fontan was determined. Results A total of 9 9 patients who underwent bidirectional cavopulmonary anastomosis at 6.7 months ( range 2.9 months to 14 years) were studied; 46 met criteria for the “no-cath” group. Noninvasive criteria stratified all patients who died (n=5) or did not pr oceed to Fontan (n =1) and 9 of 11 who required additional interventions to the “cath”group. Thus, the negative predictive value of these criteria was 93%. C onclusions Our data suggest that catheterization before Fontan could be avoided in a large percentage of patients without adversely affecting outcome; prospecti ve evaluation of this strategy is warranted.展开更多
Background: Although parents of neonates with congenital heart disease are oft en asked permission for their neonates to participate in research studies, littl e is known about the factors parents consider when making...Background: Although parents of neonates with congenital heart disease are oft en asked permission for their neonates to participate in research studies, littl e is known about the factors parents consider when making these decisions. Objec tive: To determine the reasons for parents’decisions about participation in res earch studies. Methods: Qualitative analysis of the unsolicited comments of 34 p arents regarding reasons for agreeing or declining to participate in research st udies. Parents’comments were offered spontaneously during interviews about clin ical care decisions for neonates with congenital heart disease. Results: Parents cited five types of reason for or against permitting their newborn to participa te in research studies: societal benefit (n = 18), individual benefit for their infant (n = 16), risk of study participation (n = 10), perception that participa tion posed no harm (n = 9), and anti-experimentation views (n = 4). Conclusion: Addressing parental decision making in the light of these reasons could enhance the parental permission process for parents of critically ill neonates.展开更多
文摘Background-Prenatal surgery for congenital anomalies can prevent fetal demise or alter the course of organ development, resulting in a more favorable condition at birth. The indications for fetal surgery continue to expand, yet little is known about the acute sequelae of fetal surgery on the human cardiovascular system. Methods and Results-Echocar-diography was used to evaluate the heart before, during, and early after fetal surgery for congenital anomalies, including repair of myelomeningocele(MMC, n=51), resection of intrathoracic masses (ITM, n=15), tracheal occlusion for congenital diaphragmatic hernia (CDH, n=13), and resection of sacrococcygeal teratoma (SCT, n=4). Fetuses with MMC all had normal cardiovascular systems entering into fetal surgery,whereas those with ITM, CDH, and SCT all exhibited secondary cardiovascular sequelae of the anomaly present. At fetal surgery, heart rate increased acutely, and combined cardiac output diminished at the time of fetal incision for all groups including thzose with MMC, which suggests diminished stroke volume. Ventricular dysfunction and valvular dysfunction were identified in all groups, as was acute constriction of the ductus arteriosus. Fetuses with ITM and SCT had the most significant changes at surgery. Conclusions-Acute cardiovascular changes take place during fetal surgery that are likely a consequence of the physiology of the anomaly and the general effects of surgical stress, tocolytic agents, and anesthesia. Echocardiographicmonitoring during fetal surgery is an important adjunct in the management of these patients.
文摘Objectives This study was designed to determine if a subset of patients who ha ve undergone bidirectional cavopulmonary anastomosis could be identified in whic h catheterization was of little benefit before completion of the Fontan procedur e. Background Diagnostic evaluation before Fontan procedure has typically includ ed cardiac catheterization. However, the overall management strategy for patient s with functional single ventricle has evolved to include staging bidirectional cavopulmonary anastomosis in most, and it has become uncommon to exclude patient s from Fontan based on catheterization data. Methods Patients who underwent bidi rectional cavopulmonary anastomosis and had complete echocardiograms and cathete rizations within three months of each other between January 1992 and October 199 7 were evaluated with a series of clinical and echocardiographic characteristics to identify a subset in whom catheterization was predicted to be of little adde d value (“no-cath”group). The predictive value and sensitivity of these crite ria in excluding patients who required additional intervention, were excluded fr om Fontan, or died within 30 days of Fontan was determined. Results A total of 9 9 patients who underwent bidirectional cavopulmonary anastomosis at 6.7 months ( range 2.9 months to 14 years) were studied; 46 met criteria for the “no-cath” group. Noninvasive criteria stratified all patients who died (n=5) or did not pr oceed to Fontan (n =1) and 9 of 11 who required additional interventions to the “cath”group. Thus, the negative predictive value of these criteria was 93%. C onclusions Our data suggest that catheterization before Fontan could be avoided in a large percentage of patients without adversely affecting outcome; prospecti ve evaluation of this strategy is warranted.
文摘Background: Although parents of neonates with congenital heart disease are oft en asked permission for their neonates to participate in research studies, littl e is known about the factors parents consider when making these decisions. Objec tive: To determine the reasons for parents’decisions about participation in res earch studies. Methods: Qualitative analysis of the unsolicited comments of 34 p arents regarding reasons for agreeing or declining to participate in research st udies. Parents’comments were offered spontaneously during interviews about clin ical care decisions for neonates with congenital heart disease. Results: Parents cited five types of reason for or against permitting their newborn to participa te in research studies: societal benefit (n = 18), individual benefit for their infant (n = 16), risk of study participation (n = 10), perception that participa tion posed no harm (n = 9), and anti-experimentation views (n = 4). Conclusion: Addressing parental decision making in the light of these reasons could enhance the parental permission process for parents of critically ill neonates.
