Open heart surgery in neonates

Recent progress in pre-operative care and cardiopulmonary bypass methods in neonates are described and 13 years' experience of neonatal open heart surgery at Fukuoka Children's Hospital are reviewed. Between October 1980 and May 1993, 145 neonates underwent open heart surgery at Fukuoka Children's Hospital. The overall surgical mortality was 15.2%, but decreased to 9% between 1989 and 1993. Deaths occurred as follows: transposition of the great arteries (TGA), two deaths out of 69 cases; total anomalous pulmonary venous drainage (TAPVD), four deaths of 34 cases; interruption of the aortic arch complex (LAA), three deaths of 17 cases; hypoplastic left heart syndrome (HLHS), eight deaths of 13 cases; and one death each for asplenia, cor triatriatum and endocardial cushion defect, Ebstein's malformation and endocardial fibroelastosis. Crucial determinants for surgical outcome were the date of operation (December 1987 or before, mortality 29% vs January 1988 or after, 9%, p < 0.01), the character of the operation (curative, 9% us palliative, 63%, p < 0.001) and the pre-operative condition (shock and acidosis, 44% vs others, 10%, p < 0.01). Intensive pre-operative medical management has become routine. Prostaglandin E₁ was used pre-operatively in the majority of patients with TGA, IAA and HLHS. Pre-operative mechanical ventilatory support was utilised in 51% of patients with TGA, 83% with TAPVD, 77% with IAA and 58% with HLHS. To minimise the damaging effects of cardiopulmonary bypass due to activation of major cascades in the blood, whole blood and fresh frozen plasma have not been used in the pump priming. Pulsatile, high-flow (2.5-3.0 l/m²/min) cardiopulmonary bypass with moderate hypothermia was routinely used and no postoperative brain damage was seen. Water accumulation during cardiopulmonary bypass was 0.22 ml/kg/minute. Mean duration of postoperative mechanical ventilatory support was four days. Recent advances in cardiac surgery have improved the results of curative open heart repair in neonates; however, results of palliative open heart repair are still poor.