and adverse outcomes in single ventricle patients after Stage I palliation Richard U Garcia MD Cardiac Critical Care Childrens Hospital of Michigan Background Low cardiac output syndrome is not uncommon in infants after cardiac ID: 1041601
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1. Are renal and cerebral near infrared spectroscopy associated with low cardiac output and adverse outcomes in single ventricle patients after Stage I palliationRichard U. Garcia, MDCardiac Critical CareChildren’s Hospital of Michigan
2. BackgroundLow cardiac output syndrome is not uncommon in infants after cardiac surgeryNear-infrared spectroscopy (NIRS) is a non-invasive, continuous method of evaluating regional tissue oximetry based on the differential absorption of varying wavelengths of oxygenate and deoxygenate hemoglobinCerebral NIRS monitoring has been advocated as a surrogate measure of mixed venous oxygen saturationAfter Stage 1 Palliation, a true mixed venous saturation is difficult to obtain
3. AimsTo determine if postoperative cerebral and renal NIRS values are associated with low cardiac output (LCO) To determine the relationship between NIRS values and adverse outcomes:Cardiac arrest Need for ECMOMortality
4. MethodsRetrospective study approved by the Institutional Review Board, infants ≤ 6 months of age with single ventricle physiology who underwent stage 1 surgical palliation between January 2010 and December 2019 Cerebral and renal NIRS values at 1, 6, 12, 24 and 48 hours after surgery were recorded from the medical recordsDemographic data at the time of surgery and multiple perioperative variables were collected from the medical records
5. MethodsLCO within the first 48 after surgery was defined as per the pediatric cardiac critical care consortium database:Vasoactive inotropic score > 15 or tripling of the VIS at any point in the first 48 hours after surgery.Documentation of LCO in the medical records by attending physicianA-V Saturation difference > 40%Cerebral and renal NIRS values were compared in patients with low and normal cardiac output as well as with other adverse outcomes such as cardiac arrest, need for ECMO and mortality
6. Results91 patients with median (IQR) age of 10 days (6-26), weight of 3.3kg (3-3.5) and length of 51 cm (48.3-53) were included in the studyProcedures Performed:Norwood with Sano shunt: 16Norwood with right modified Blalock-Tausig shunt:18Isolated aortopulmonary shunt: 57LCO was seen in 42 (46%) patients in the first 48 post operative hours.Cardiac arrest: 20 (22%)VA ECMO: 16 (17%)Mortality: 15 (16.5%)
7. Results
8. ResultsCerebral NIRS at 6 hours (p=0.018), systolic blood pressure at 1 hour (p=0.04), and arterial lactate (p=0.024) at 1 hours remained independently associated with LCO after logistic regression analysis Cerebral NIRS of ≤57% at 6 hr had 91% sensitivity and 72% specificity in detecting LCOMean cerebral NIRS saturation of ≤ 55% during the first 24 hours had 81% sensitivity, and 60% specificity to determine LCOThere was no independent association between cerebral or renal NIRS with adverse outcomes such as cardiac arrest, need for ECMO and mortality.
9. Results
10. ResultsPatients who underwent the Norwood procedure had significant higher incidence of:LCO p< 0.001Need for ECMO p= 0.007Mortality p= 0.001Composite adverse outcome p= 0.005In the Norwood and aortopulmonary shunt group, cerebral NIRS values at 6 hours after admission to the cardiac intensive care unit were associated with LCO
11. ResultsVariables(mean (SD) or n %)*Norwood procedure(n = 34)AortopulmonaryShunt(n = 57)p valueAge, days6 (4)32.6 (42)0.002Weight, kg3.3 (0.7)3.45 (0.6)0.303Length, cm51 (3.1)51.2 (3.3)0.747Gestational age, weeks38.3 (1.3)37.8 (2.1)0.169CPB time, min265.9 (84)101.3 (75.7)<0.001Duration on MV, days23.9 (23.9)13.5 (12.8)0.034Length of Hospital stay, days71.8 (69.3)41.54 (51.8)0.018Low cardiac output26 (76.5%)16 (28.1%)<0.001Cardiac arrest11 (32.3%)9 (15.8%)0.091VA ECMO10 (29.4%)5 (8.8%)0.007Mortality11 (32.3%)4 (7%)0.001Composite adverse outcome15 (44.1%)10 (17.5%)0.005
12. Conclusions Cerebral NIRS ≤ 57% at 6 hours and mean cerebral NIRS ≤55% during the first postoperative day were indicative of LCONo association between NIRS values and adverse outcomesFuture prospective studies may be necessary to determine whether NIRS directed interventions can improve postoperative outcomes
13. Acknowledgments Sanjeev Aggarwal, MDPezad Doctor, MD