Pre-congress conference: neurodevelopment

The fetal cardiology and neurodevelopment conferences shared a morning session about the developing brain in the neonate with CHD. The neurodevelopment phenotype, the delivery of oxygen to the brain in the fetus with complex CHD, and when, where, and how these babies should be born were discussed. The impact of the hospital course on the developing brain in these neonates was discussed from anaesthesia, surgery, and intensive care perspectives. The effects of anaesthetic and sedative agents on the developing brain is not yet fully understood.Reference Andropoulos and Greene ¹ This is a hot topic, with the United States Food and Drug Administration issuing a safety communication in December, 2016 with an update in April, 2017. In this communication, the United States Food and Drug Administration warns that exposure to anaesthetic and sedative medications for lengthy periods of time or over multiple surgeries or procedures may negatively affect brain development in children younger than 3 years. This warning is based on animal studies in young and pregnant animals that demonstrated that exposure to general anaesthetic and sedation drugs for more than 3 hours can cause widespread loss of nerve cells in the developing brain; and studies in young animals suggested these changes resulted in long-term negative effects on the animals’ behaviour or learning. However, consistent with animal studies, recent human studies suggest that a single, relatively short exposure to general anaesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behaviour or learning. Further research is needed to fully characterise how early life anaesthetic exposure affects children’s brain development. Until this complex issue is fully solved, the United States Food and Drug Administration warns that health care professionals should balance the benefits of appropriate anaesthesia in young children and pregnant women against the potential risks, especially for procedures that may last longer than 3 hours or if multiple procedures are required in children under the age of 3 years. The challenges this presents for the paediatric cardiac community were discussed in the meeting.

Back–to-basics breakfast symposiums

There were two breakfast symposia with an anaesthesia component. The first was presented by Dr K. Brady (United States of America) on interpreting waveforms and haemodynamic data. This outstanding talk highlighted how technology and “big data” can be used in predictive analytics to help anticipate adverse events and alert health care providers before these occur. It was emphasised that the power of technology to detect and predict adverse events will only increase as more institutions become involved with data collection. These algorithms are the future of how large data can be harnessed to help individual patients and enable us to take the next steps in improving outcomes for patients with CHD. Dr K. Brady highlighted this topic with his own work utilising ST-segment analysis to predict cardiopulmonary arrest in patients with single ventricle physiology.Reference Vu, Rusin and Penny ² The second breakfast symposium was provided by Dr S. Walker (United States of America) and Dr W. Miller-Hance (United States of America). This session presented the haemodynamic effects of sedative and anaesthetic drugs and discussed pearls and pitfalls of using these drugs in patients with CHD. This session was popular with cardiologists who provide sedation during cardiac catheterisation or other procedures. The recent consensus statement for anaesthesia and sedation practice for patients undergoing diagnostic and therapeutic procedures in the cardiac catheterisation laboratory from the Society for Cardiovascular Angiography and Interventions, Society for Pediatric Anesthesia, and the CCAS was brought up during the discussion.Reference Odegard, Vincent and Baijal ³ The goal of this statement is to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations. The recommendations include patient monitoring in the cardiac catheterisation laboratory, regardless of whether minimal or no sedation is being used, or general anaesthesia is being provided by an anaesthesiologist.

Anaesthesia sessions

Three dedicated 2-hour sessions focussed on major anaesthesia topics. The first session discussed bleeding and coagulation. The first speakers provided an excellent debate on whether the monitoring of the coagulation system intraoperatively and the use of blood product protocols during congenital cardiac surgery should be a standard of care. Dr N. Guzetta (United States of America) provided a convincing “pro” argument backed by considerable data and experience.Reference Guzzetta, Allen, Wilson, Foster, Ehrlich and Miller ⁴ However, Dr D. Faraoni (Belgium) was equally well prepared with the “con” arguments and his own data!Reference Faraoni and O’Leary ^{5 ,} Reference Faraoni, Willems, Romlin, Belisle and Van der Linden ⁶ There was good participation from the audience and it became clear from the discussion there was a wide range of practices around the world. The current use of antifibrinolytics, especially aminocaproic acid and tranexamic acid, was well presented by Dr Eaton (United States of America).Reference Eaton, Alfieris and Sweeney ^{7 ,} Reference Yee, Wissler, Zanghi, Feng and Eaton ⁸ Although more centres are using tranexamic acid, there is a concern of an increase in the incidence of seizures.Reference Maeda, Sasabuchi, Matsui, Ohnishi, Miyata and Yasunaga ⁹ Next, Dr P. Arnold (United Kingdom) discussed novel agents and techniques to help stop bleeding in the cardiac operating room.Reference Guzzetta and Williams ¹⁰ The availability of blood component therapy varies around the world and makes it challenging for anaesthesiologists to interpret the data to facilitate their own practice. Although we spend much of our time stopping bleeding after surgery, anticoagulation is key for patients on extracorporeal support with assist devices. This balance of bleeding on mechanical support devices was well presented and discussed by Dr W. Ames (United States of America).

The second anaesthesia session focussed on neonatal congenital cardiac anaesthesia. The first talk on the limitations and vulnerabilities of the neonatal cardiovascular system presented by Dr K. Brady set an excellent backdrop for this session. This was followed by a fascinating talk on the impact of translational research on optimising neonatal cardiopulmonary bypass circuits and techniques. This was presented by Dr A. Undar (United States of America), a biomedical engineer by training who has helped establish research in this area.Reference Undar, Wang and Palanzo ¹¹ The problems anaesthesiologists commonly face after bypass were then presented by experts in their field. Dr P. Laussen (Canada) discussed low cardiac output state,Reference Schwartz, Floh and Laussen ¹² Dr M. Bojan (France) discussed renal dysfunction,Reference Bojan, Basto Duarte, Ermak, Lopez-Lopez, Mogenet and Froissart ¹³ and Dr K. Brady (United States of America) took the stage again to discuss monitoring and protecting the infant brain during cardiac surgery.

The third anaesthesia session focussed on anaesthetic considerations in specific situations or disease. Dr J. DiNardo (United States of America) presented excellent data on patients undergoing non-cardiac surgery and how to stratify risk and understand the factors that may contribute to this risk.Reference Nasr, DiNardo and Faraoni ¹⁴ Dr H. Nair (India) followed with anaesthetic considerations in the cardiac catheterisation laboratory and gave a wonderful overview of how patients with CHD are managed in her own institution. Three specific areas were then presented by experts in their field. Dr M. Twite (United States of America) discussed anaesthetic considerations in the patient with pulmonary hypertension,Reference Twite and Friesen ¹⁵ Dr J. Heggie (Canada) discussed anaesthetic considerations in the adult with CHD,Reference Heggie and Karski ¹⁶ and Dr H. Ravn (Denmark) presented the anaesthetic considerations for mechanical support devices.

All three anaesthesia sessions were outstanding and filled to capacity (Fig 1) The questions and discussions in every session were lively and enjoyable. The opportunity for the congenital cardiac anaesthesia community to come together and discuss common issues was tremendous, and by the end of the week, many new friendships had been established.

Figure 1 Full audience in the anaesthesia track sessions.

Bridging together

The strength of the world congress is that it puts everyone who cares for children and adults with CHD in the same location at the same time. This not only includes cardiac surgeons, cardiologists, anaesthesiologists, and nurses but also perfusionists, administrative leaders, and many other cardiac specialists. The problem at the conference is trying to decide what sessions to attend. Anaesthesiologists are unique because we interface with so many of these specialists every day and we have insight into many of the various cardiac areas. The opening plenary titled “Bridging Together: Teamwork in Caring for the Family touched by CHD” was presented by Dr R. Jonas (United States of America). This wonderful opening session grabbed the audience with its inclusiveness of every person in the room. Dr Jonas realises and values everyone’s contribution in caring for the whole family with a child with CHD and improving what we do. The first joint anaesthesia session was a focussed learning session with the intensivists. In this session, Dr P. Checchia presented an excellent overview of the Pediatric Cardiac Intensive Care Society as a global organisation for change. This talk resonated with many CCAS members, as our own society shares many of the same goals for improving the care of children with CHD around the world. Sharing the same stage was Dr I. James (United Kingdom) who provided a wonderful historical overview of lessons learned from caring for children with single ventricle physiology. Together these speakers highlighted the complexities of congenital cardiac care but they also gave hope that through collaborating with colleagues around the world, it is possible to positively impact the lives of children with CHD.

The second joint anaesthesia session was a bridging together session with the cardiac surgeons. The first half of this session was a compelling debate of whether it is safe to conduct normothermic cardiopulmonary bypass. Dr E. Belli (France), a cardiac surgeon, was well positioned with years of practice using normothermic cardiopulmonary bypass safely for patients. However, Dr J. DiNardo (United States of America) presented very strong scientific arguments of why such techniques are not safe, simply based on oxygen utilisation. The audience was polarised on this topic and it became clear that there is a large variation in practices of how cardiopulmonary bypass is conducted. The second half of this session had experts giving their perspectives on early extubation after congenital heart surgery. The anaesthesia perspective was very well presented by Dr A. Mittnacht (United States of America)Reference Mittnacht ¹⁷ and the surgery perspective equally well presented by Dr J. Hammel (United States of America).Reference Varghese, Kutty, Abdullah, Hall, Shostrom and Hammel ¹⁸ What was clear from this session was that the anaesthesiologist and the surgeon have a common goal for their patients – early, safe extubation. This can be achieved with clear agreed upon criteria and good communication between surgeons and anaesthesiologists for each patient.

Anaesthesia key note address and scientific abstracts

One of the highlights of the week was the key note address, which was an excellent presentation by Dr E. Mossad (United States of America), the immediate past president of the CCAS, who was standing in for his Texas Children’s Hospital chair and colleague, Dr D. Andropoulos (United States of America) (Fig 2). It is never an easy task to deliver someone else’s presentation, but Dr Mossad demonstrated his command of the topic and his excellence in public speaking by delivering the key note address on the impact of anaesthesia on neurodevelopmental outcomes in children with CHD. This topic provoked an excellent audience debate on how the issue should be presented to parents before their children undergo general anaesthesia. Thus, many of the children in our care do not have a choice regarding undergoing surgery or a procedure, and how anaesthesiologists should discuss the issue of anaesthesia drugs injuring the brain with families is not known. One avenue of research being pursued is the better understanding of drugs that may be protective to the developing brain, such as dexmedetomidine.

Figure 2 Key note address by Dr E. Mossad, immediate past president of the congenital cardiac anaesthesia society, on behalf of Dr D. Andropoulos.

There were 40 scientific anaesthesia abstracts accepted by the WCPCCS and these posters were displayed the same day as the key note address. The quality of research being done was high and the scope of topics was large, as was the number of countries represented. The posters brought people together to discuss areas of common interest. The oral abstracts were the top five submissions from cardiac anaesthesia trainees and junior faculty, selected jointly by the CCAS and WCPCCS (Fig 3). These top abstracts are shown in Table 1. Each of the presenters were very generously supported by a grant from the WCPCCS to attend the meeting. The five oral presentations were all excellent. It was wonderful to hear about the research being undertaken by very bright physicians in our field, but more importantly it confirms the future of our specialty is in good hands.

Figure 3 The top five scientific abstract presenters. From left to right: Dr Michelle DaCosta, Dr Theodora Wingert, Dr Faith Ross, Dr Nathaniel Greene, and Dr Rebecca Scholl.

Table 1 Top five scientific anaesthesia abstracts.

The CCAS hosted an informative luncheon after the key note address. The CCAS is a society organised within the Society for Pediatric Anesthesia. The CCAS concept originated with cardiac anaesthesia directors and other key leaders at major CHD programmes, who believed there was a need for a new society because of rapid advancement of highly specialised knowledge in the field, and a great increase in the numbers of patients, including adults, with CHD. The mission of CCAS is shown in Table 2. At the luncheon, the most recent data from the joint STS/CCAS Database were presented by Dr D. Vener (United States of America). A specific example of how the database can be used to look at current clinical practices was shown using dexmedetomidine.Reference Schwartz, Twite, Gulack, Hill, Kim and Vener ¹⁹ Past projects that CCAS has undertaken were presented, as well as future directions of the society. Finally, the numerous benefits of CCAS membership were presented, including the educational resources on the website (www.ccasociety.org), regular newsletters, question of the week, poll of the month, and the opportunity to network with colleagues interested in the care of patients with CHD.

Table 2 Mission of the congenital cardiac anaesthesia society.