Postoperative management of heart failure in pediatric patients

ABSTRACT

Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25–65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.

KEYWORDS:

• Congenital heart disease
• low cardiac output syndrome
• acute heart failure
• cardiac arrest
• extracorporeal membrane oxygenation
• ventricular assist device
• pediatric heart transplantation

Key issues

• Low cardiac output syndrome is common and occurs in 25–65% of pediatric patients with congenital heart disease undergoing open-heart surgery requiring cardiopulmonary bypass.

• Milrinone decreases the occurrence of postoperative low cardiac output syndrome.

• Pharmacological management for low cardiac output syndrome include milrinone, catecholamines, afterload reducing agents, hydrocortisone and triiodothyronine.

• Evaluation for residual lesions by echo and/or cardiac catheterization is crucial to identify disease-specific residual anatomical lesions.

• Extracorporeal membrane oxygenation is preferred biventricular short-term mechanical support for severe low cardiac output syndrome.

• Berlin Heart EXCOR is currently the only available pulsatile ventricular assist device for small children.

• Experience with continuous-flow ventricular assist devices for long-term mechanical circulatory support in older children and adolescents is increasing.

• Pediatric heart transplantation is possible in the immediate postoperative phase but challenged by anatomical, immunological and psychological factors as well as by limited time.