Meeting Reviews

Session VIII: Professor Poster Rounds Review

By Pablo Motta, MD, FAAP
Baylor College of Medicine and Texas Children’s Hospital

Thursday, February 27, 2020 | 5:15 pm-6:00 pm

The Professor Poster Round was a well-attended session in which 33 posters were presented. This session was divided into six different interest groups - anesthesia/regional; bleeding and transfusion; novel techniques; outcomes; risk, prevention, and protection; and sedation/anesthesia.

Full text posters and abstracts can be viewed here. Below is a review of the leading findings:

ANESTHESIA/REGIONAL POSTERS
Moderators: Rania K. Abbasi, MD and Richard J. Ing, MD, MB, BCh

Poster #: CCAS-1
Title: Too Weak for a Fix? May be not? Anesthetic Management of a Muscular Dystrophy Patient Undergoing VAD Placement as a Bridge to Transplant
Authors: Tan A, Scholl R
Description: The authors reported the anesthetic management of a patient with limb-girdle muscular dystrophy (LGMD) and severe cardiomyopathy undergoing left ventricular assist device (LVAD) placement.
Learning points: Careful titration of anesthetics that have less cardio depressant effects can be used safely in patients with poor cardiac reserve undergoing LVAD placement. LGDM patients can be candidates for LVAD as destination therapy.

Poster #: CCAS-2
Title: Safety of Same Day Discharge Following Cardiac Catheterization in Children with Pulmonary Arterial Hypertension
Authors: Kleiman Z, Adamson G, Dasgupta M, Peng L, Ogawa M, Feinstein J, Ramamoorthy C
Description: Kleiman et al queried the pulmonary hypertension (PH) database for all cardiac catheterization (CC) between January 2009 and July 2018 (0 to 18 years).  Included were patients without a hospital admission linked within 30 days prior to their CC encounter.
Discussion: In the majority of the patients it was a same day procedure. The younger, smaller, those requiring intubation, and longer procedural times were more likely to be admitted.
Key Findings: Same day discharge is safe and feasible for select outpatients, even those with moderate and severe PH.

Poster #: CCAS-3
Title: Review of Anaesthetic Management of Surgical Atrial Septal Defect Closure Via Thoracotomy
Authors: Karuppiah N, Haller C, Taylor K
Description: The authors reviewed the records of 15 patients undergoing surgical atrial septal defect (ASD) repair via thoracotomy.
Discussion: Even though thoracotomies offer the advantage of a smaller incision, improved recovery, and shorter duration of stay, they have several challenges like difficult cannulation, respiratory complications, pulmonary vein injury, and suspected right diaphragm paresis
Key Findings: This study supports the design of a randomized clinical trial to further study this patient population.

Poster #: CCAS-4
Title: Peripheral Regional Techniques Can Decrease Opioid Consumption: Comparison of Postoperative Pain Management Strategies for Aortic Coarctation Repair
Authors: Otu C, Vo V, Staffa S, Yuki K, Quinonez L, Brown M
Description: Otu et al performed a retrospective chart review of pediatric patients who underwent aortic coarctation (CoA) repair via thoracotomy between September 2013 and July 2018 to assess the role of peripheral regional anesthesia.
Discussion: The study suggested lower opioid usage at 24-hours among pediatric patients who received a regional catheter. There were no complications related to the use of regional anesthesia.
Key Findings: Peripheral regional techniques may be used to reduce opioid requirements in patients after CoA repair.

Poster #: CCAS-5
Title: Anesthetic Considerations in a two y/o Patient with Severe Tracheal Stenosis and Bronchus Suis Undergoing Slide Tracheoplasty
Authors: Easwar J, Haydar B, Malviya S
Description: The authors present a case involving a patient with bronchus suis, severe tracheal stenosis, and congenital heart disease undergoing tracheoplasty on cardiopulmonary bypass.
Key Findings: Thorough understanding of the anatomy and pathophysiology in tracheal stenosis is of paramount importance to manage the airway successfully.

Poster #: CCAS-6
Title: Use of Erector Spinae Plane Block in Patients for Repair of Congenital Heart Disease via Thoracotomy
Authors: Smith B, Clopton R, Albertz M, Schwartz L
Description: Smith et al reported a cohort of 19 patients during 2018-2019 undergoing left-sided thoracotomy for repair of 14 vascular rings (VR) and five coarctations of the aorta (CoA) using ultrasound guided erector spinae plane (ESP) blocks as a part of the anesthetic plan.
Discussion: ESP block was effective for pain control supported by low pain scores (1, 8 and 24 hours) and facilitated extubation (16 of 19 patients).  No block complications were reported.
Key Findings: ESP blocks are efficacious for the treatment of post-operative pain.

BLEEDING AND TRANSFUSION
Moderators: David Faraoni, MD and Nina A. Guzzetta, MD

Poster #: CCAS-7
Title: Solvent/Detergent-Treated Plasma vs. Fresh Frozen Plasma for Cardiopulmonary Bypass Surgery in Children: Single Center, Case Control Comparison
Authors: Crawford J, Alten J, Hock K, Borasino S, Crawford J
Description: The authors compare coagulation parameters post cardiopulmonary bypass surgery in children treated with solvent/detergent-treated plasma (SDP) vs. fresh frozen plasma (FFP). Perioperative coagulation studies, blood product utilization, lab data, and outcomes were compared.
Discussion: The coagulation studies, heparin doses and product requirements were all similar except for fibrinogen.
Key Findings: SDP was associated with lower intra- and post-bypass fibrinogen levels and longer pro-thrombin time.

Poster #: CCAS-8
Title: Postoperative Hematocrit and Adverse Outcomes in Pediatric Cardiac Surgery Patients
Authors: Long J, Engorn B, Hill K, Chiswell K, Feng L, Goswami D
Description: Long et al hypothesized that risk of adverse outcomes increases at lower and higher hematocrit (HCT) values compared to the midrange values on pediatric cardiac surgery patients admitted to the intensive care unit.
Discussion: In the multivariate analysis for each 5% incremental increase in HCT in both acyanotic and cyanotic patients, the mortality and major complications increased.
Key Findings: High HCT is associated with increased perioperative risks in pediatric cardiac surgery and optimal postop HCT ranges require additional study.

Poster #: CCAS-10
Title: A Survey of Current Anesthesia Practice for Pediatric Cardiac Surgery with Cardiopulmonary Bypass
Authors: Andrews J, Benkwitz C, Abbasi R, Adams P, Brown M, Chilson K, Colon J, Downey L, Wise-Faberowski L, Gautam N, Goswami D, Guzzetta N, Jooste E, Latham G, Nasr V, Navaratnam M, Ross F, Spurrier E, Twite M, Vener D, Williams G, Zabala L, Machovec K
Description: The authors conducted a survey of its members to define the current practices of member institutions for two index neonatal operations: single ventricle first stage palliation and arterial switch operation.
Discussion: Sixteen different institutions completed the survey which included practices regarding anticoagulation, anti-fibrinolytic administration, blood product management, and cardiopulmonary bypass management.
Key Findings: Significant variability in practice exists between different institutions as well as between different anesthesiologists within the same institution.

Poster #: CCAS-12
Title: A Comparison of Cryoprecipitate Versus Fibrinogen Concentrate on Fibrinogen Measurements Using TEG® Functional Fibrinogen and Clauss Fibrinogen Levels in Infants Undergoing Cardiac Surgery
Authors: Fiedorek M, Downey L, Miller K
Description: Fiedorek et al examine in a randomized trial the correlations between thromboelastogram functional fibrinogen assay (TEG-FF) parameters and plasma fibrinogen (PFib) before and after cardiopulmonary bypass (CPB) in infants undergoing cardiac surgery who received fibrinogen replacement with either cryoprecipitate or fibrinogen concentrate (FC).
Discussion: Thirty-three patients were included in the study (15 cryoprecipitate; 18 FC). There were no significant differences between groups.
Key Findings: TEG-FF assay may provide a point-of-care test to assess the quantitative and qualitative fibrinogen deficiencies for infants undergoing cardiac surgery to enable goal-directed transfusion.

Poster #: CCAS-13
Title: The Effect of Pre-operative Anemia on Pediatric Cardiac Surgical Patients Undergoing Cardiopulmonary Bypass
Authors: Chu R, Wadia R, Nadkarni A, Digiusto M, Goswami D
Description: The authors’ single-center retrospective study characterized the prevalence and risk factors associated with preoperative anemia in children undergoing cardiac surgery.
Discussion: Three hundred patients who underwent cardiac surgery had preoperative hemoglobin levels recorded.
Key Findings: Preoperative anemia increased the risk for postoperative complication and length of stay in children undergoing cardiac surgery.

NOVEL TECHNIQUES
Moderators: Kelly A. Machovec, MD and David F. Vener, MD

Poster #: CCAS-14
Title: Perioperative Protocol for Amplatzer Piccolo Occluder Placement in Premature Infants
Authors: Wasson C, Berens R, Stucke A
Description: Wasson et al performed a retrospective review of the protocol of infants undergoing percutaneous closure of patent ductus arteriosus (PDA) with Amplatzer Piccoloâ„ Occluder between May and October 2019.
Discussion: Transport to and from the NICU and device placement in the cardiac catheterization lab were feasible and did not result in any major adverse events. Hypothermia and desaturation occurred frequently during the procedure.
Key Findings: Transcatheter PDA closure is now feasible in premature infants. Multidisciplinary planning is required to minimize adverse events in these high-risk patients.

Poster #: CCAS-15
Title: Coil Occlusion of Left Ventricular Pseudoaneurysm in a Neonate after Arterial Switch Operation
Authors: Spilka J, Ibla J, Callahan R
Description: The authors report the successful interventional management of a left ventricular pseudoaneurysm in a neonate after arterial switch operation.
Key Findings: Catheter-based interventions can be successfully utilized to avoid the risk imposed by redo sternotomy.

Poster #: CCAS-17
Title: Transcatheter PDA (TC-PDA) Closure in Low Birth Weight Premature Infants Less Than 1500 Grams: An Institutional Anesthetic Experience
Authors: Gorbea M, Zabala L, Reddy S, Yallapragada S, Pirolli T, Ullah S
Description: Gorbea et al reviewed the preoperative status, intraoperative anesthetic management and postoperative outcome of all preterm infants who underwent TC-PDA closure between August 30, 2018 and October 4, 2019.
Discussion: A total of 35 premature TC-PDA closure (10 < 1500 grams) with a mean gestational age of 25.65+/-2.13 weeks were reviewed. The intraoperative course was mostly uneventful without code events, hemodynamically significant arrhythmias, vascular trauma, and device embolization. The post-procedure complications included pulmonary hypertensive crisis (n=1), infections (n=2), and chylous effusion (n=1).
Key Findings: Preliminary findings show promising outcomes in decreased mortality and survival to hospital discharge following TC-PDA closure.

Poster #: CCAS-18
Title: The Feasibility of Measurement of Tricuspid Annular Plane Systolic Excursion (TAPSE) by Intraoperative Transesophageal Echocardiography (TEE) and its Interchangeability with Transthoracic Echocardiography in Pediatric Patients Undergoing Cardiac Surgery
Authors: Puri G, Biswas I, Negi S, Munirathinam G
Description: Puri et al studied the feasibility of measurement of TAPSE by intraoperative TEE and its interchangeability with TTE in pediatric patients undergoing cardiac surgery. 
Discussion: In a prospective observational study 34 children (1-12 years) undergoing corrective/palliative surgery for congenital heart disease were included. TAPSE was measured by TTE in apical 4-chamber right ventricle (RV) focused view, using M-Mode and then by TEE using traceable lines in M-Mode (MM) and Angled M-Mode (AMM) in several views (mid- esophagic and trans-gastric).
Key Findings: Measurement of TAPSE utilizing Angled M Mode in different views of TEE is highly feasible in children undergoing cardiac surgery and can be used interchangeably with standard MM TAPSE measured by TTE.

Poster #: CCAS-19
Title: Use of Melody Valve in the Mitral Position in Small Babies: An Institutional Experience
Authors: Widing A, Deer J, Monahan A
Description: The authors describe their experience with the anesthetic management of two babies receiving a Melody valve for mitral valve replacement (MVR) in left atrioventricular valve insufficiency. One patient had repaired atrioventricular septal defect (AVSD) and the other repaired right dominant AVSD and double outlet right ventricle.
Key Findings: Melody valve use in babies is an evolving practice but potential issues include leaflet perforation, paravalvular leak, and left ventricular outflow tract obstruction.

Poster #: CCAS-20
Title: Targeting Lymphatics: A Promising Treatment for Protein-Losing Enteropath
Authors: Kim A, Ryan K
Description: Kim et al reported the management of a 15-year-old male, with single ventricle and Fontan physiology, who was burdened with severe protein losing enteropathy (PLE) including leg edema and hypoalbuminemia. The patient was managed by a successful embolization of liver lymphatics with spread into the duodenal lymphatics with decrease of peripheral edema and albumin increase.
Key Findings:  Interventional occlusion of aberrant lymphatics can lead to complete remission of PLE even though repeat procedures may be necessary.

OUTCOMES
Moderators: Barry D. Kussman, MB, BCh and Lisa Wise-Faberowski, MD

Poster #: CCAS-21
Title: Competing Interests! Cardiac Tamponade in a Pediatric Patient with Hypertrophic Cardiomyopathy
Authors: Bunnell A, Pearce B
Description: The authors present the physiologic and anesthetic challenges when caring for a pediatric patient with tamponade and hypertrophic cardiomyopathy (HCM) undergoing mediastinal exploration
Key Findings: Patients with cardiac tamponade are critically dependent on activation of the sympathetic nervous system in tamponade; while in HCM the management is different requiring inhibition of the sympathetic nervous system to prevent left ventricular outflow tract obstruction.

Poster #: CCAS-23
Title: Incidental Intraoperative Diagnosis of Left Coronary Ostial Atresia in a Pediatric Patient
Authors: Keese Harvey M, Trieu C
Description: Keese Harvey et al presented the unusual case of a 7-year-old that underwent a mitral valve repair becoming unstable post cardiopulmonary bypass during epicardial imaging of left coronary artery requiring ECMO.  In the catherization lab, left coronary ostial atresia was diagnosed and subsequently repaired in the operating room.
Key Findings: Left coronary ostial atresia is an extremely rare diagnosis with potentially fatal consequences if not identified and treated to provide antegrade blood flow to the left coronary system.

Poster #: CCAS-24
Title:  Giant Hepatic Hemangioma (GHH) Embolization in a 28 Weeks Neonate
Authors: Luis T, Bertolizio G
Description: The authors present the anesthetic management of a preterm neonate with biventricular hypertrophy, heart failure, and pulmonary hypertension (pHTN) undergoing embolization GHH.
Key Findings: GHH is associated with high-output heart failure, pHTN, renal failure, consumptive coagulopathy, and hypertrophic cardiomyopathy. Anesthesia can be successfully conducted with judicious use of inotropes and vasopressors during embolization. 

Poster #: CCAS-25
Title: Urgent Non-obstetric Surgery in a Noncompliant Parturient with Fontan Circulation Physiology
Authors: Adams J, Vizzini S, Romeo D
Description: Adams et al describe the anesthetic care of a parturient (27 weeks) with Fontan circulation for urgent replacement of pacemaker generator.
Key Findings: Patients with single ventricle physiology requiring urgent non-obstetric surgery can pose a variety of complications to both mother and baby due to fixed cardiac output, anti-coagulation status, heart failure, and arrhythmias.

Poster #: CCAS-26
Title: Cognitive Aid for Recorder Improves Trainee Performance in ACLS Simulation
Authors: Chai C, Shaffner D, Koka R
Description: The authors designed a cognitive aid to be used by the recorder to not only record but also suggest upcoming interventions in trainee performance in ACLS simulation.
Discussion: In a randomized, controlled simulation study the authors compared the control group (the recorder simply recorded time and interventions) and the intervention group (the recorder used the cognitive aid to remind the code leader of interventions).
Key Findings: Cognitive aid for recorders to remind code leaders of upcoming interventions is effective in achieving tasks in a timely manner in an ACLS simulation.

Poster #: CCAS-27
Title: Tetralogy of Fallot: A Case Report of a Patient with a Potts Shunt and Decompensated Heart Failure
Authors: Coppola C, Balabanoff Acosta C, Silverman R
Description: Coppola et al describe the critical care management of a 47-year-old female with history of Tetralogy of Fallot and pulmonary atresia s/p Potts shunt (18 months of age) but never fully repaired, who was admitted with decompensated heart failure.
Key Findings: There is an increasing adult population with repaired or unrepaired CHD, knowledge of the current morpho-functional status by clinicians is imperative.

RISK, PREVENTION AND PROTECTION 
Moderators: Gregory J. Latham, MD and Mona Momeni, MD

Poster #: CCAS-28
Title: Ventricular Assist Device (VAD) as Bridge to Transplant (BTT) in a Single Ventricle Child for Myocardial Infarction after Second Stage Palliation
Authors: Houska N, Albertz M
Description: The authors reported the management of a 4-month male with hypoplastic left heart syndrome post Norwood procedure that in the postoperative period of a Hemi-Fontan developed an aortic root and left coronary thrombus requiring initially ECMO and eventually VAD as a BTT.
Key Findings: Single ventricle heart palliations if failed may require the use of VAD as BTT.

Poster #: CCAS-29
Title: Management of a Bleeding Tongue Mass after Head and Neck Irradiation in a Child with Hypertrophic Obstructive Cardiomyopathy
Authors: Newton M, Shaw R, Wang J
Description: Newton et al present the anesthetic care of an 8-year-old female with hypertrophic obstructive cardiomyopathy (HOCM) with recurrent Ewing’s sarcoma of the tongue for direct laryngoscopy and biopsy.
Key Findings: Include the post-radiation changes in head and neck anatomy that affects intubation conditions and concurrent management of HOCM in the setting of both sudden blood loss and strong surgical stimulation.

Poster #: CCAS-30
Title: Relationship of Perioperative Somatic Oxygen Saturation to Acute Kidney Injury in Children After Fontan Surgery
Authors: Ferguson L, Dunbar-Masterson C, Allan C, Costello J, Thiagarajan R, DiNardo J, Kussman B
Description: The authors hypothesized that perioperative somatic regional NIRS saturations (rSO2) can predict acute kidney injury (AKI) after Fontan surgery. 
Discussion: In secondary sub-analysis of a randomized clinical trial of Nesiritide versus Milrinone versus placebo infusion in patients undergoing Fontan surgery, rSO2 was measured continuously on the right flank and forehead and measurements correlated with the incidence of AKI. Area under the ROC curve for the NIRS variables to predict AKI was highest for duration of somatic rSO2 <60%.
Key Findings: Postoperative periods of diminished regional oxygen delivery, as indicated by somatic rSO2, are associated with AKI among patients undergoing Fontan surgery.

Poster #: CCAS-31
Title: Hypothyroid Induced Cardiomyopathy- Lost in Transfer
Authors: Lee C, Ryan K
Description: Lee et al present a case of a 14-year-old with severely depressed left ventricular function due to hypothyroid (TSH 1309) that was missed upon hospital transfer. The patient was managed with left ventricular assist device and function never improved despite correcting thyroid levels.
Key Findings:  Common cardiovascular effects of hypothyroidism include decreased cardiac output, elevated diastolic pressure, and increased systemic vascular resistance. Long term, severe hypothyroidism can also initially present with psychosis and heart failure.

Poster #: CCAS-33
Title: Scoliosis Repair in a Failing Fontan with Coagulopathy
Authors: Kainth H, Dobija N
Description: The authors report the anesthetic management in a patient with a failing Fontan (listed transplant) undergoing a posterior spinal fusion to improve functional status.
Key Findings: The challenge is to balance several challenging conflicts 1) the effects of anesthetic on single ventricle with the need for adequate anesthesia, 2) preload to maintain blood flow against surgical blood loss, and 3) hemostasis of surgical bleeding and thromboembolic events in Fontan pathway.

SEDATION/ANESTHESIA
Moderators: Jamie M. Schwartz, MD and Luis M. Zabala, MD

Poster #: CCAS-35
Title: Pheochromocytoma in a Patient with Decompensated Fontan Physiology
Authors: Fiedorek M, Lessans G, Tosone S
Description: Fiedorek et al present the anesthetic management of a Fontan patient undergoing laparoscopic pheochromocytoma resection.
Key Findings: The main intraoperative management goals are to minimize PVR and SVR fluctuations secondary to insufflation and the acute catecholamine surges during pheochromocytoma resection in order to maintain an adequate transpulmonary gradient.

Poster #: CCAS-36
Title: Perioperative Anesthetic Management of Patients with Failing Single Ventricle Physiology Undergoing Ventricular Assist Device (SVAD) Placement: A Single Institutional Experience
Authors: Gorbea M, Hernandez J
Description: The article presents the authors’ anesthetic experience and considerations during failing single ventricle physiology undergoing ventricular assist device (SVAD).
Key Findings: The management for SVAD placement presents multifaceted perioperative considerations including diastolic dysfunction impeding systemic perfusion and hepatic venous congestion altering anesthetic dosing. SVAD support decreasing CVP (Goal < 20mmHg) while providing enough flows that compensate for existing collaterals.

Poster #: CCAS-37
Title: Biventricular Conversion in Unseptatable Complex Congenital Heart Diseases: Anesthesia Perspective and Considerations. Case Series Study
Authors: Huarte M, Martin A, Chhabada S
Description: Huarte et al reported novel paradigm for utilizing both ventricles with the morphologic LV as the sub-pulmonary ventricle in prior unseptatable diverse group of patients.  The series was characterized by prolonged dissection and CPB times along with high bleeding and transfusion requirements despite anti-fibrinolytic therapy. In the postoperative period prolonged inotropic and ventilatory support were common.
Key Findings: Anesthesia management for these patients should focus on optimizing blood volume, inotropic support pre- and post- CPB and managing coagulopathy.

Poster #: CCAS-38
Title: Anaphylaxis during Cardiopulmonary Bypass
Authors: Lee A, Harvey R, Mitchell M, Ing R, Grayck M, Twite M
Description: The authors report a case of anaphylaxis during an RV outflow tract replacement on cardiopulmonary bypass (CPB). It manifested by persistent low MAP and systemic vascular resistance (SVR) was refractory to multiple boluses of 40 mcg of phenylephrine during implantation of pulmonary homograft.
Key Findings: The differential diagnosis of decreased SVR during CPB includes low pump flows, anaphylaxis, vasoplegia from hemodilution, and decreased blood viscosity.

Poster #: CCAS-39
Title: Hypermetabolic Condition Presumed to be Malignant Hyperthermia (MH) after a Non-Triggering Anesthetic for a Bidirectional Glenn Shunt
Authors: Coppola C, Kuntz M, Saab A, Gencorelli F
Description: Coppola et al report the unusual case of presumed postoperative MH that responded to dantrolene on a patient undergoing a Glenn shunt with non-triggering agents (Propofol, ketamine).
Key Findings: Even in the absence of typical triggers, MH susceptible patients may still develop signs of MH that necessitate dantrolene therapy.  Prophylactic administration of dantrolene for particularly high-risk patients warrants discussion. 

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