Impact of obesity on post-operative arrhythmias after congenital heart surgery in children and young adults

Background: Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery. Methods: Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2–20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5–85, overweight 85–95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis. Results: There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive–inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias. Conclusion: Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.

Vasoactive-Inotropic Score and Vasoactive-Ventilation-Renal Score as Outcome Predictors for Children on Extracorporeal Membrane Oxygenation

We aimed to determine the association of vasoactive-inotropic score (VIS) and vasoactive-ventilation-renal (VVR) score with in-hospital mortality and functional outcomes at discharge of children who receive ECMO. A sub-analysis of the multicenter, prospectively collected data by the Collaborative Pediatric Critical Care Research Network (CPCCRN) for Bleeding and Thrombosis on ECMO (BATE database) was conducted. Of the 514 patients who received ECMO across eight centers from December 2012 to February 2016, 421 were included in the analysis. Patients &gt; 18 years of age, patients placed on ECMO directly from cardiopulmonary bypass or as an exit procedure, or patients with an invalid or missing VIS score were excluded. Higher VIS (OR = 1.008, 95% CI: 1.002–1.014, p = 0.011) and VVR (OR: 1.006, 95% CI: 1.001–1.012, p = 0.023) were associated with increased mortality. VIS was associated with worse Pediatric Cerebral Performance Category (PCPC) (OR = 1.027, 95% CI: 1.010–1.044, p = 0.002) and Pediatric Overall Performance Category (POPC) score (OR = 1.023, 95% CI: 1.009–1.038, p = 0.002) at discharge. No association was found between VIS or VVR and Functional Status Score (FSS) at discharge. Using multivariable analyses, controlling for ECMO mode, ECMO location, ECMO indication, primary diagnosis, and chronic diagnosis, extremely high VIS and VVR were still associated with increased mortality.

Predictors of Perioperative Vasoactive Drug Requirement During Retroperitoneal Adrenalectomy for Pheochromocytoma: A Retrospective Exploratory Study

The aim of the present study was to test a hypothesis that baseline systemic vascular resistance index (SVRI) assessed by method of transpulmonary thermodilution predicts perioperative requirement for vasoactive drugs. The primary outcomes were: (1) peak vasoactive-inotropic score (VIS) and (2) peak dose of hypotensive drugs at any stage of surgery. The main exposure variable was baseline SVRI. Hemodynamics were retrospectively assessed by transpulmonary thermodilution in 50 adults who had undergone posterior retroperitoneal surgery for pheochromocytoma. Univariate linear regression analysis showed predictive value of SVRI on VIS [regression coefficient, 95% CI; 0.024 (0.005, 0.4), p=0.015]. Other significant factors were the history of peak diastolic pressure, baseline MAP, baseline betablocker therapy, and history of coronary artery disease (CAD). After adjustment of SVRI for the history of CAD, its prognostic value became non-significant [0.018 (0.008, 0.03), p=0.063 and 29.6 (19, 40.2), p=0.007 for SVRI and history of CAD, respectively]. Requirements of vasodilators were predicted by baseline adrenergic activity [0.37 (0.005, 0.74), p=0.047]. In conclusion, baseline SVRI is associated with perioperative requirement of vasopressor drugs, but history of CAD is a stronger prognostic factor for vasopressor support. Perioperative requirement in vasodilators is associated with baseline adrenergic activity.

Serum Copeptin Level as a Predictor Marker of Pediatric Heart Failure Outcomes

Background: This study aimed to assess the role of copeptin as a diagnostic marker of heart failure (HF) and outcomes. Method: We randomly recruited 76 cardiac patients aged 1 month to 15 years and 65 control healthy children matched in age and sex. Based on plasma copeptin level, the study population were sub-grouped into quartiles (Q). Results: The mean age of cases and control was 40.52 ±34.35 months and 42.43 ±30.42 months respectively. Median copeptin level was higher among patients 16.80 (16.4) compared to control 8.00 (3.0), P<0.01. Copeptin level was not statistically significantly different in-between patients with different etiologies of HF, P =0.515. Total leukocytic count, platelets, serum sodium, inotropic score, and troponin were significantly correlated with copeptin quartile. Three-fourth of dead children were within the Q4, and 12.5 % were within the first one, P=0.214. Around 76.5% of patients who had multiorgan dysfunction were within the Q4 while 5.9% belonged to Q1, P=0.022. Of those who developed sepsis, 82.6% and 4.3% were located within Q4 and Q1, P<0.01. All patients who required mechanical ventilation were within Q4, P= 0.005. Conclusion: Plasma level of copeptin is elevated in pediatric HF regardless its etiology and can be used as a predictor of poor outcomes.

Using Vasoactive-Ventilation-Renal Score in Pediatric Heart Failure Cases as a Predictor of an Extended Intensive Care Unit Stay

Background: The vasoactive-ventilation-renal (VVR) score is a disease severity index for predicting outcomes of pediatric patients receiving cardiac surgeries. We investigated whether the VVR score on admission can predict the length of stay (LOS) in the pediatric intensive care unit (PICU) in children diagnosed with heart failure (HF). Methods: Medical records were reviewed for pediatric HF cases between January 2010 and December 2016. We calculated the VVR score using the electronic data, including measurements obtained at the time of admission and analyzed the correlation between the VVR score and prolonged LOS (PLOS). A PLOS was defined by a longer stay than the median duration for the surviving cases. Results: A total of 113 pediatric HF cases were reviewed, of which 96 cases were finally included in the study. The median [IQR] LOS was 12 [6, 22] days. The use of a mechanical ventilator and extracorporeal membrane oxygenation (ECMO) were associated with PLOS. The area under the curve (AUC) of the vasoactive-inotropic score (VIS), VVR score, lactic acid level, and brain natriuretic peptide (BNP) for evaluating the association with mechanical ventilator or ECMO use was 0.682 (P = 0.006), 0.823 (P < 0.001), 0.683 (P = 0.006), and 0.783 (P < 0.001), respectively. In multivariable logistic regression analysis, the VVR score was the only significant parameter for predicting PLOS. Conclusions: The VVR score on admission to the PICU is predictive for mechanical ventilator or ECMO use, which correlates with a PLOS. Therefore, the VVR score at PICU admission in children with HF is a useful LOS marker.

A Vasoactive Inotropic Score Predicts the Severity of Hypotensive Shock and Mortality in Preterm Infants

Objective: To validate the prediction of the severity of hypotensive shock and mortality using the vasoactive inotropic score in preterm infants.Methods: In this retrospective study we calculated the vasoactive inotropic score (VIS) and cumulative exposure to cardiovascular medications over time (VISct) in a cohort of preterm infants with hypotensive shock who received a cardiovascular support. Receiver operator curve was constructed to predict the primary outcome which was death due to hypotensive shock. Results: VIS had an area under the curve of 0.73 (95% CI 0.85-0.98, p < 0.001). A VIS cut off of 25 has sensitivity and specificity of 66% and 92%, and positive and negative predictive values of 78.5% and 83%, respectively.Conclusion: High VIS predicts high mortality rate due to irreversible shock in preterm infants

Afterload-related cardiac performance identifies cardiac impairment and associates with outcome in patients with septic shock: a retrospective cohort study

Background Septic patients with cardiac impairment are with high mortality. Afterload-related cardiac performance (ACP), as a new tool for diagnosing septic cardiomyopathy (SCM), still needs to be evaluated for its impact on the prognosis for patients with septic shock. Methods In this retrospective study, 100 patients with septic shock undertaken PiCCO monitoring were included. The ability of ACP, cardiac index (CI), and cardiac power index (CPI) to discriminate between survivors and non-survivors was tested by comparing the area under the receiver operating characteristic curve (AUROC) analysis. Cox proportional hazards regression analyses were performed to assess the associations of ACP with day-28 mortality. Curve estimation was used to describe the relationship between the hazard ratio (HR) of death and ACP. Results ACP had a strong linear correlation with CI and CPI (P < 0.001). ACP demonstrated significantly greater discrimination for day-28 mortality than CI before adjusted [AUROC 0.723 (95% CI 0.625 to 0.822) vs. 0.580 (95% CI 0.468 to 0.692), P = 0.007] and CPI after adjusted [AUROC 0.693 (95% CI 0.590 to 0.797) vs. 0.448 (0.332 to 0.565), P < 0.001]. Compared with ACP > 68.78%, HR for ACP ≤ 68.78% was 3.55 (1.93 to 6.54) (P < 0.001). When adjusted with age, APACHE-II score, Vasoactive Inotropic Score, Lactate, CRRT, day-1 volume, fibrinogen and total bilirubin as possible confounders, and decrease ACP are still associated with increasing day-28 mortality (P < 0.05). An exponential relationship was observed between ACP12h and HR of day-28 death. Conclusions Our results suggested thatACP could improve mortality predictions when compared to CI and CPI. Decreased ACP was still an independent risk factor for increased day-28 mortality.