Original articleEvaluation of the vasoactive-inotropic score, mid-regional pro-adrenomedullin and cardiac troponin I as predictors of low cardiac output syndrome in children after congenital heart disease surgeryEvaluación de la escala vasoactiva-inotrópica, pro-adrenomedulina y troponina cardiaca-I como factores predictivos del síndrome de bajo gasto cardiaco en niños tras corrección quirúrgica de cardiopatías congénitas
Introduction
Current research focuses on preventing mortality and reducing the risk of morbidity in children who undergo congenital heart disease (CHD) surgery with cardiopulmonary bypass (CPB). In order to accomplish these objectives, it is essential to monitor the diverse variables influencing these potential outcomes, such as the levels of inotrope score (IS) and/or of vasoactive-inotropic score (VIS), and their prognostic value in the post-operative period.1, 2, 3 Nevertheless, the association between VIS and the post-operative course of the patient remains controversial.
Wermousky et al.1 have quantified the degree of inotrope support received by neonates after surgical repair of transposition of the great arteries, and have reported that the maximum IS within the first 48 h was an indicator of poor prognosis, of higher incidence of prolonged mechanical circulatory support, renal replacement therapy, neurological damage, of cardiac arrest and death. In addition to this, IS was also associated with longer duration of mechanical ventilation (MV), paediatric intensive care unit (PICU) and hospital stay.2 On the other hand, other authors have been unable to establish an association between VIS and the early post-operative outcomes in neonates who underwent heart surgery with CPB.4 Therefore, elevated VIS levels could not be associated with prolonged MV duration and PICU stay. Likewise, these authors have found that low cardiac output syndrome (LCOS) was not associated with MV duration or length of PICU stay.
Neonates undergoing CPB are more likely to present increased risk of morbimortality compared with other age groups. Thereby they might be considered a special group. Gaies et at.5 have studied 391 children (only one-third were neonates) who underwent CHD surgical repair, in which VIS > 15 within the first 24 h post-operatively was considered empirically high. A high VIS level was strongly associated with mortality at 30 days following surgery, with incidence of cardiac arrest, need for mechanical circulatory support, dialysis, neurological damage, MV duration and length of PICU stay. In another work on VIS as a short-term outcome biomarker, a maximal VIS on the second post-operative day predicted adverse outcomes in adolescents following cardiac surgery.6
There are other studies regarding the paediatric population that centre on cardiac biomarkers, such as the β-type natriuretic peptide (BNP),7 mid-regional pro-atrial natriuretic peptide (MR-proANP),8 pro-adrenomedulina (MR-proADM),9 cardiac troponin-I (cTn-I)10 and copeptin11 as early predictors of LCOS to monitor the post-operative period after CHD surgery with CPB. To date, there are no published studies that relate IS, VIS and cardiac biomarkers levels with the prediction of LCOS in children during the post-operative period after CHD surgery requiring CPB.
In order to address this knowledge gap, we have performed a study of CHD children to evaluate whether IS and VIS scores improve the predictive power for LCOS.IS and VIS have been estimated in the immediate post-operative period and during LCOS development and have been associated with the cardiac markers above mentioned predictors of LCOS in the paediatric population. These could be useful in aiding in therapeutic decision-making in clinical practice after CPB, and in improving the prognosis of the patient.
Section snippets
Study design and population
This prospective, observational study was conducted at a single referral hospital during a 2-year period. The current study enrolled 117 consecutively only patients (aged 10 days to 15 years) who had undergone CHD surgery requiring CPB, and who had been admitted to a PICU for monitorisation. The exclusion criteria included: (a) immediate death following PICU admission (with in the first 2 h), (b) infection, (c) renal failure requiring haemofiltration, (d) polymalformative syndromes, (e)
Results
The study enrolled 117 consecutive paediatric patients (aged 10 days to 15 years) who were admitted to a PICU after corrective surgery for congenital heart disease with CPB. Two patients were excluded from the study because they perished within the first 2 h following PICU admission. Six patients developed cardiogenic shock and required extracorporeal membrane oxygenation within the first 48 h post-CPB. Table 1 displays the type of congenital heart disease and the patient characteristics of the
Discussion
LCOS after CPB is frequently observed after corrective surgery for CHD in children. Normally, ventricular dysfunction following cardiac surgery with CPB peaks within 8–12 h post-CPB, and it gradually recovers within 24–48 h post-operatively.17 However, there are patients in whom LCOS is prolonged, as demonstrated in our study, in which LCOS occurrence at 48 h post-CPB was in 29% of the patients.
To diagnose LCOS is hard to achieve, especially in children, in whom the validation of estimation
Financial support received
BRAHMS GmbH Biotechnology Centre, Hennugsdorf, Berlin, Germany, in part supported this study. The partial sponsor of the study had no role in the study design or in analysis, and did not participate in writing the report.
Authors’ contributions
Juan L. Pérez-Navero, Ignacio Ibarra de la Rosa and Maria José de la Torre-Aguilar conceived, planned the project and drafted the manuscript experiments. Carlos Merino-Cejas, Susana Jaraba-Caballero and Manuel Frias-Perez carried out the experiments and contributed to sample preparation. Mercedes Gil-Campos and Elena Gómez-Guzmán contributed to the interpretation of the results. All authors provided critical feedback and helped shape the research, analysis and manuscript.
Conflict of interest
The authors report no conflicts of interest. The authors are responsible for the contents and writing of the paper.
Acknowledgements
The authors wish to thank the staff of the Maimónides Biomedical Research Institute of Córdoba (IMIBIC) at the University of Córdoba (Córdoba, Spain).
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