Review of the 2010 CCAS Meeting
Held April 15, 2010 in San Antonio, Texas
By Faye Evans, MD; Mark Twite, MD, BCh; and Courtney Hardy, MD
The 5th Annual Meeting of the Congenital Cardiac Society was held on April 15, 2010 in San Antonio, Texas. There were 245 attendees from the USA, United Kingdom, Canada and Australia reflecting the continued growth and international appeal of the society. Program chairs Dr. Emad Mossad and Dr. Anshuman Sharma put together a stimulating program focusing on various topics within the realm of pediatric cardiac anesthesiology.
Dr. Duncan De Souza moderated the first session entitled “Brainstorm! Recent Advances in Neurologic Monitoring and Protection.” Dr. Dean Andropoulos began the session by discussing the role of brain MRI in pediatric cardiac surgery. He gave a very poignant lecture showing how brain MRI can be very useful in helping to evaluate short and long term neurological injury in children with congenital heart disease. He also discussed how these findings might in the future impact our decision-making process especially in regards to the timing of pediatric cardiac surgery in neonates.
The session continued with Dr. Kenneth Brady giving a talk entitled “Beyond an Oximeter: NIRS Monitoring and Protection.” Dr. Brady began his talk by giving a brief history of the development of the NIRS monitor. He went on to discuss the role of autoregulation in traumatic brain injury and described in great detail how the NIRS monitor may help us examine cerebral autoregulation more carefully. Dr. Brady postulated that NIRS monitoring might be a tool we can use to provide individual hemodynamic optimization in our patients, which may help us to make cardiopulmonary bypass safer for the brain.
The final speaker in this session was Dr. Jeffrey Heinle who spoke about “Antegrade Cerebral Perfusion: Recent Advances.” Dr. Heinle began the lecture by reviewing the history of antegrade cerebral perfusion use in pediatric cardiac surgery. He emphasized that we are getting away from just “survival’ in our patients, as we have become much better at that, and are becoming much more interested in neurological outcomes. Techniques, such as regional perfusion, are being developed to try and improve long-term neurological outcomes. He suggested using both NIRS and transcranial doppler as tools to guide regional perfusion flow rates; therefore, customizing appropriate flow rates to each individual patient. He concluded his lecture by presenting Texas Children’s protocol for regional perfusion.
The second morning session was entitled “Safe Sweets: Glucose Management in Pediatric Cardiac Surgery” and was moderated by Dr. Nina Guzzetta. The first speaker, Dr. Ian James, gave a comprehensive review of glucose homeostasis in the pediatric cardiac patient. He began by giving an overview of reasons for our increased interest in glucose management. Despite there being studies showing an increase in perioperative morbidity and mortality associated with hyperglycemia, there are also studies showing that perioperative hypoglycemia is associated with poor outcomes. Currently there is a lack of consensus in pediatric patients regarding perioperative blood glucose control. Dr. James laid the foundation for this session by reviewing the physiology of glucose management and discussing the variables impacting glucose homeostasis in the setting of pediatric cardiac surgery.
The second part of this session was devoted to debating the issue of perioperative blood glucose control in the pediatric cardiac patient. Dr. Barry David Kussman presented: “Pro: Strict Glycemic Control is Essential in pediatriac cardiac surgery.” Dr. Kussman reviewed the literature supporting strict glycemic control in cardiac surgery and discussed the risks of hyperglycemia. He summarized the pro stance by stating that the ideal target and ideal duration of strict glycemic control is unknown. However, it is generally agreed that we should avoid hypoglycemia and blood glucose variability.
Dr. James Steven presented: “Con: Hyperglycemia Should be Accepted and Safe in pediatric cardiac surgery.” His argument was based on the belief that there is a causal association between hyperglycemia and poor outcomes. He argued that intraoperative increases in blood glucose might actually be potentially beneficial to some organ systems; however, hypoglycemia is generally accepted as detrimental. He concluded his discussion by stating that hyperglycemia is not a proven cause of adverse outcomes. Large trials have actually shown that there is an increased risk of hypoglycemia with tight perioperative blood glucose control. We know this can be detrimental to the brain and that avoiding dextrose actually leads to hypoglycemia. Dr. Steven also pointed out that we do not currently have good bedside glucose monitoring. Without this ability, tight blood glucose control becomes more difficult and perhaps detrimental.
The third session of the morning was an update on pulmonary hypertension and was moderated by Dr. Anshuman Sharma. Dr. Jeffrey Fineman began this session by giving a lecture entitled: “Pathophysiology of Cardiac PHTN.” He provided a thorough review of the history, the etiologies, and the pathophysiology of pulmonary hypertension in children with congenital heart disease. He also reviewed recent advances in the management of this disease. His therapeutic discussion focused on the endothelial aspect of pulmonary hypertension, as this has been the target of the “newer therapies” developed.
The second half of the session was given by Dr. Robert Friesen who presented “Perioperative Management of Pulmonary Hypertension Patients.” He began his discussion by reviewing the known principles involved in the pre-operative assessment, anesthetic management, and post-operative care of patients with pulmonary hypertension. He emphasized that these patients have an increased risk of complications and cardiac arrest in the perioperative period and a balanced anesthetic technique is the safest approach in these patients. He briefly reviewed 3 classes of drugs to consider in the acute perioperative period for the management of an acute pulmonary hypertensive crisis including; inhaled nitric oxide, prostacyclin analogs and phosphodiesterase inhibitors.
The afternoon session began with “Study of a Lesion: CAVC”. This session was moderated by Dr. Wanda Miller Hance. Dr. Deborah Kearney, a pathologist, began the session by providing us with an excellent and informative review of the anatomic characteristics of atrioventricular canal defects as well as the variant lesions present in this defect. She reviewed the embryology, nomenclature, major anatomic features, Rastelli classification, associated features, associated anomalies, and the issues related to the conduction system. Descriptive pictures as well as anatomic specimens were used to help the audience better understand this complicated lesion.
The next speaker, Dr. Isobel Russell, presented a review of the “Echocardiographic Evaluation” of a patient with CAVC. She had an outstanding collection of ECHO images that she used to demonstrate the different types of CAVC, the Rastelli classification as well as associated pathology. Dr. Russell emphasized that ECHO is an important tool in the pre and post bypass periods and that intra-operative ECHO findings should be clearly communicated with the surgeon.
The final speaker in this session was Dr. Jeffrey Heinle, a surgeon, who discussed “Surgical Approaches and Decisions” in children with CAVC. Dr. Heinle provided a comprehensive review of surgical considerations in children with CAVC as well as outcomes of the various strategies. He described the surgical objectives which include: complete closure of the VSD and the primum ASD, a competent left and right AV valve, avoid heart block, and maintain good left and right ventricular function. He described three different techniques, and their advantages and limitations, used to treat this lesion: single patch, two patch and modified single patch.
The next session of the afternoon was “Pacemakers and Defibrillators – An Interactive Workshop" which was moderated by Dr. Steve Auden. Dr. Naomi Kertesz began this session by reviewing defibrillators and pacemakers. She gave an excellent review of the indications, applications, and complications associated with defibrillators and pacemakers in children. She provided a simplified approach for the cardiac anesthesiologist evaluating an EKG tracing trying to figure out what rhythm the patient was in. She proposed that anesthesiologists answer three questions: 1. Are there pacing spikes? 2. Is the pacemaker capturing? 3. If there is no capture, is the pacemaker sensing? If you can answer these three questions, it will help you to understand what is going on with the patient.
Dr. Kertesz also led the second half of this session. She provided an energetic and interactive workshop where the audience had the opportunity to test their knowledge. Clinical scenarios with EKG rhythm strips were displayed and the audience had the opportunity to try and guess the rhythm.
The final session of the day was “Cardiac Jeopardy.” In response to the overwhelming popularity of Dr. Myron Yaster’s “Jeopardy” during the SPA, Dr. Anthony Clapcich developed a pediatric cardiac jeopardy for the CCAS meeting. The final session of the day provided a fun and entertaining collection of categories in which the audience had the opportunity to test their knowledge. The categories included: Syndromes, ECHO, Cath, Imaging, and EKG This session will definitely become an anticipated highlight of the annual CCAS meeting.
Although the CCAS is a young society it has enjoyed strong, rapid growth largely due to the support of its members. The final judgments of any meeting come from the participants. Below are real comments from this year’s meeting - we are all looking forward to another successful meeting next year!
