Pedro José Curi-Curi

Ten-year experience in cardiac surgery for congenital

Modified ultrafiltration is used in cardiac surgery with cardiopulmonary bypass in order to diminish systemic inflammatory response syndrome. We aimed to show its utility for removing pro-inflammatory agents in operated pediatric patients with congenital heart disease and its impact at operative care. A clinical case-control trial was designed, including patients with simple congenital heart disease operated on with cardiopulmonary bypass in a 1-year period. We randomized them to a problem group (with modified ultrafiltration, n = 15) and a control group (without it, n = 16), and blood samples to measure interleukins (6 and 10); 3d and 4d complement fraction concentrations were taken at the following times: baseline, before cardiopulmonary bypass, after it, after modified ultrafiltration, and from the ultrafiltration concentrate. Operative clinical end points of success were defined as hemodynamic stability, absence of morbidity, and lack of mortality. We observed a higher significant interleukin 6 concentration in the problem group patients at baseline, as well as a higher removal of this pro-inflammatory agent at the ultrafiltration concentrate. Modified ultrafiltration has a positive impact over simple congenital heart disease surgery with cardiopulmonary bypass because of removing interleukin 6. We recommend its routine use when hemodynamic conditions are favorable.

The modified Fontan procedure represents the final stage of reconstructive surgery for most patients with functionally univentricular hearts. Although outcomes following Fontan procedures performed at sea level are widely reported, less has been documented and reported concerning outcomes in regions at high altitude. To clarify the main features involved, we present our institutional experience with Fontan operations performed in Mexico city (2,240 m above the sea level), with an emphasis on historical evolution of treatment. A retrospective and observational study was undertaken, which included 98 patients over a period of 18 years, and clinical outcomes in terms of morbidity and mortality were analyzed. A change in operative technique from intra-cardiac nonfenestrated Fontan procedure to extra-cardiac fenestrated technique occurred in 2001. Early mortality rates before and after this change in surgical approach were 26% and 4.7%, respectively. The most common morbidity was the occurrence of pleural effusions (98% of patients), which also appears to be a risk factor for operative mortality. Much remains unknown about the pathophysiology of the Fontan circulation at high altitude, and we need to develop morphological study protocols that include pulmonary biopsy to increase our knowledge and inform our therapeutic actions.