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Pulmonary hypertensive crises following surgery for congenital heart defects in young children
R A Hopkins1, C Bull, S G Haworth
1Thoracic Unit, Hospital for Sick Children, London, England, UK.
Insights
Pulmonary hypertensive crises in neonates after heart surgery are serious. Early treatment with vasodilators and individualized care improves survival rates for these high-risk infants.
Area of Science:
- Pediatric Cardiology
- Neonatal Intensive Care
- Cardiovascular Surgery
Background:
- Congenital cardiac defects necessitate surgery in high-risk infants and neonates.
- Postoperative pulmonary hypertensive crises pose a significant threat to survival.
- Effective management strategies for these crises are crucial.
Purpose of the Study:
- To identify and characterize pulmonary hypertensive crises in neonates undergoing surgery for congenital cardiac defects.
- To evaluate the effectiveness of vasodilator therapy in managing these crises.
- To determine factors influencing outcomes in affected infants.
Main Methods:
- Monitoring of 20 high-risk infants and neonates using pulmonary artery pressure catheters and transcutaneous oximetry.
- Continuous analog recording of hemodynamic data in 11 patients to analyze crisis antecedents and treatment responses.
- Postmortem examination of deceased patients to assess pulmonary vascular pathology.
Main Results:
- Eleven of 20 patients experienced one or more pulmonary hypertensive crises.
- Five patients survived crises with aggressive vasodilator therapy; six died.
- Pulmonary vasodilator therapy aided in ventilatory support weaning for four patients with episodic pulmonary hypertension.
- Crises were often linked to stress events and difficult to treat if not addressed promptly.
- Tolazoline and oxygen were the most effective vasodilators, with fentanyl analgesia important postoperatively.
Conclusions:
- Individualized postoperative management based on monitored pulmonary circulation responses is essential.
- Prompt recognition and treatment of pulmonary hypertensive crises improve survival.
- Aggressive vasodilator therapy can be life-saving in this vulnerable population.
Abstract:
In this clinical study, 20 high risk infants and neonates were monitored to identify and characterize pulmonary hypertensive crises following surgery for congenital cardiac defects. Monitoring included right ventricular or pulmonary artery pressure catheters and transcutaneous oximetry. Eleven patients also had continuous analog recording of hemodynamic data so that antecedents of crises and the sequence of events following treatment could be reconstructed. Eleven of the 20 patients had one or more crises. Six of these ultimately died whereas 5 patients survived with aggressive vasodilator therapy. Four patients without crises but with episodic pulmonary hypertension benefitted from pulmonary vasodilator therapy to ease weaning from ventilatory support. Typically, each crisis was associated with a stress event. Crises were difficult to ablate if not rapidly treated and multiple crises would often cluster following an initial event. High dose narcotic (fentanyl) analgesia was found to be important in the postoperative management. Tolazoline and oxygen were the most consistently useful vasodilators, but isoproterenol and nitrates also played a role. Five of the children who died were examined post mortem: histologically, there was increased pulmonary arterial muscularization in 2, in none were there changes of fixed pulmonary vascular disease. The postoperative management must be individualized on the basis of monitored responses of pulmonary circulation.