A Risk Management Strategy for Managing Critical Human Resource Changes in a Pediatric Heart Program.

Background: Relocation, recruitment, or retirement of critical team members may lead to changes in the expertise pool that could threaten patient outcomes in a pediatric heart program. We developed a quality initiative aimed at risk management that uses risk-stratified case complexity and outcomes to guide a program during critical fluxes in the expert staff. The Ramp Down/Up protocol is a systematic, voluntary reduction in the complexity of cases performed, followed by a transparent and intentional escalation of case complexity.

Effects of Wild-Type and Mutant Forms of Atrial Natriuretic Peptide on Atrial Electrophysiology and Arrhythmogenesis.

Background: Atrial natriuretic peptide (ANP) is a hormone with numerous beneficial cardiovascular effects. Recently, a mutation in the ANP gene, which results in the generation of a mutant form of ANP (mANP), was identified and shown to cause atrial fibrillation in people. The mechanism(s) through which mANP causes atrial fibrillation is unknown.

Protecting the aged heart during cardiac surgery: single-dose del Nido cardioplegia is superior to multi-dose del Nido cardioplegia in isolated rat hearts.

Background: Aged hearts are particularly vulnerable to reperfusion injury. We recently showed that single-dose del Nido cardioplegia was superior to 'standard' multi-dose 4:1 blood cardioplegia in aged rat hearts. This study seeks to determine if multi-dose del Nido cardioplegia offers additional benefits over single-dose del Nido cardioplegia.

The Na+/Ca2+ exchange inhibitor SEA0400 limits intracellular Ca2+ accumulation and improves recovery of ventricular function when added to cardioplegia.

Background: The Na+/Ca2+ exchange inhibitor SEA0400 prevents myocardial injury in models of global ischemia and reperfusion. We therefore evaluated its potential as a cardioplegia additive.

Methods: Isolated rat cardiomyocytes were exposed to hypoxia (45 min) followed by reperfusion.

Protecting the aged heart during cardiac surgery: use of del Nido cardioplegia provides superior functional recovery in isolated hearts.

Objectives: Aged hearts are particularly vulnerable to ischemia-reperfusion injury. Our objective was to determine if del Nido cardioplegia, which contains lidocaine, less blood, and less calcium than our standard cardioplegia, provides superior protection for aged hearts. We also sought to determine if the lidocaine in del Nido cardioplegia is adequate to prevent Na(+) influx via the window current.

Impact of hepatocyte growth factor on skeletal myoblast transplantation late after myocardial infarction.

In clinical studies, skeletal myoblast (SKMB) transplantation late after myocardial infarction (MI) has minimal impact on left ventricular (LV) function. This may be related to our previous observation that the extent of SKMB engraftment is minimal in chronic MI when compared to acute MI, which correlates with decreased hepatocyte growth factor (HGF) expression, an important regulator of SKMB function. Here, we investigated delivery of exogenous HGF as a strategy for augmenting SKMB engraftment late after MI.

Real-time complication monitoring in pediatric cardiac surgery.

Background: As overall mortality rates have fallen in pediatric cardiac surgical procedures, complication monitoring is becoming an increasingly important metric of patient outcome. Currently there is no standardized method available to monitor severity-adjusted complications in congenital cardiac surgical procedures.

Methods: Complications associated with pediatric cardiac surgical procedures were prospectively collected from consecutive cases in a single pediatric cardiac surgical unit from October 1, 2009 to September 31, 2011.

Improving and standardizing capture of pediatric cardiac surgical complications.

Objective: Our objective was to establish baseline data and develop a tool to allow for systematic evaluation of pediatric cardiac surgical complications. As a first step, we examined the incidence and distribution of complications, risk stratified by case complexity in a single institution. With improving mortality rates for congenital heart surgery, the next frontier for improving patient outcomes is characterizing and reducing complications.

Protecting the aged heart during cardiac surgery: the potential benefits of del Nido cardioplegia.

Objective: Aged hearts are more vulnerable than mature hearts to reperfusion injury during cardiac surgery because of altered cardiomyocyte Ca(2+) homeostasis. Inasmuch as immature cardiomyocytes have similar properties, a specialized cardioplegic solution (del Nido cardioplegia) designed to protect children's hearts may also be beneficial for elderly patients. Our objective was to evaluate the ability of del Nido cardioplegic solution, containing lidocaine and less Ca(2+) than our standard cardioplegic solution, to protect aged cardiomyocytes during cardioplegic arrest and reperfusion.

Engraftment is optimal when myoblasts are transplanted early: the role of hepatocyte growth factor.

Background: In a recent clinical trial, skeletal myoblast (SKMB) transplantation performed late after myocardial infarction (MI) did not improve left ventricular function. We hypothesized that (1) delaying SKMB transplantation until a chronic infarct scar has developed reduces engraftment, and (2) hepatocyte growth factor (HGF), a main regulator of SKMBs, is present in acute but not chronic MI, potentially influencing engraftment.

Methods: Rats underwent coronary artery ligation followed by SKMB transplantation immediately (n = 12) or delayed by 5 weeks (n = 11).

Low molecular weight heparin and unfractionated heparin are both effective at accelerating pulmonary vascular maturation in neonatal rabbits.

Background: Creation of a bi-directional cavopulmonary shunt after the Norwood procedure for hypoplastic left heart syndrome is delayed to allow pulmonary vascular resistance to fall with maturation of the pulmonary vascular bed. We hypothesized that unfractionated heparin (UFH) and low molecular weight heparin (LMWH), which promote angiogenesis and inhibit smooth muscle cell growth, could accelerate this process.

Methods And Results: Fifty-six newborn rabbits were randomly selected to receive UFH 225U/kg (n=12), LMWH 1 mg/kg (n=14), LMWH 10 mg/kg (n=16), or saline (n=14) by subcutaneous injection every 12 hours for 14 days.

Retroaortic innominate vein with coarctation of the aorta: surgical repair and embryology review.

A newborn girl with a retroaortic innominate vein, coarctation of the aorta, ventricular septal defect, and subaortic stenosis underwent a complete repair at 8 days of age. The ascending aorta was transected and the innominate vein was brought in front of it. We review the anatomy and embryology of this rare entity and describe the surgical technique to avoid recoarctation and innomante vein compression.

Aortic root replacement with anomalous origin of the coronary arteries.

Coronary arteries with anomalous origin from the aorta can be at risk during aortic valve procedures. We report a case of origin of the circumflex and left coronary artery from the proximal right coronary artery in a patient with a bicuspid aortic valve and aortic root aneurysm. Attention to the anatomic relationship of the anomalous arteries to the aorta allowed safe aortic root replacement.