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Papers by georgy frenkel

Journal of Cardiac Surgery

Cardiology in the Young, 2021

Background:Vascular rings cause respiratory symptoms in children. Treatment consists of surgical ... more Background:Vascular rings cause respiratory symptoms in children. Treatment consists of surgical division; however, data regarding mid-term results are scarce. The purpose of this study was to evaluate clinical results of vascular ring surgery.Methods:Retrospective chart review of consecutive patients who underwent vascular ring surgery. Mid-term follow-up consisted of clinic visits and telephone questionnaire over a 1-year period sampling at five points in time.Results:Follow-up of 85 patients who underwent vascular rings surgery revealed significant symptomatic improvement within 6 months. In total, 50% were symptomatic to some degree at their last documented clinic visit complaining of stridor (36.8%), cough (34.2%), wheezing (10.5%), dyspnoea on exertion (10.5%), or recurrent respiratory infections (23.7%). By telephone questionnaires, 83% described a significant improvement in respiratory symptoms, 63.4% had some residual symptoms, 36.6% stridor, 38.8% chronic cough, 32.4% bron...

Emerging Infectious Diseases, 2021

I nfective endocarditis (IE) is a rare but potentially life-threatening disease in children and h... more I nfective endocarditis (IE) is a rare but potentially life-threatening disease in children and has an incidence of 0.8-3.3 cases/1,000 pediatric hospital admissions (1). Although early reports described IE exclusively in children whose hearts were structurally abnormal because of congenital heart disease or acquired rheumatic heart disease, this infection has more recently been reported in diverse groups of patients. In addition to children with congenital heart disease, other groups of children have emerged as being at high risk for IE, including children born prematurely; those with noncardiac congenital malformations, genetic syndromes, and malignancies; and, in particular, children with central venous catheters and those who have been treated by invasive procedures or intravenous medications (1-3). The most common IE pathogens in children are gram-positive cocci, especially the α-hemolytic viridans group streptococci (e.g., Streptococcus sanguis, S. mitis group, and S. mutans), staphylococci, and enterococci. In patients with IE who are >1 year of age, the viridans group streptococci are the most commonly isolated organisms. Staphylococcus aureus is the second most common cause of IE in children but the most common cause of acute bacterial endocarditis (2). The HACEK group (Haemophilus parainfluenzae, H. aphrophilus, H. paraphrophilus, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae) is a rare cause of IE, accounting for ≈1.4% of all cases of endocarditis (2,4). Kingella spp. are carried asymptomatically in the oropharynx and disseminate through close interpersonal contact. These gram-negative bacteria (especially K. kingae) are commonly the etiology of pediatric bacteremia and the leading cause of osteomyelitis and septic arthritis in children 6-36 months of age (5). Invasive K. kingae disease usually affects previously healthy children <4 years of age, whereas older children and adults frequently have predisposing conditions (6). Kingella IE (KIE) is estimated to account for 0%-6% of all IE cases in the general population (7-10). Similar numbers have been described in the pediatric population in a few published reports. Kingella

International Journal of Cardiology Congenital Heart Disease, 2021

Abstract Background The effect of pulmonary vasodilator therapy in non-pulsatile pulmonary circul... more Abstract Background The effect of pulmonary vasodilator therapy in non-pulsatile pulmonary circulation in single ventricle palliation (Fontan operation) is controversial. We evaluated the effect of chronic pulmonary vasodilator therapy on the hemodynamic findings during balloon occlusion of fenestration in Fontan patients who were identified as high risk for fenestration closure on a previous catheterization. Methods and Results Of 44 consecutive patients who underwent a fenestrated Fontan operation and attempted fenestration closure at catheterization, 8 were found to be unsuitable due to a decrease in cardiac index by more than 35%, or a significant increase in central venous pressure. All 8 patients were treated with pulmonary vasodilator therapy for at least 6 months prior to an additional attempt at closure. All repeated catheterizations for fenestration closure were successful. Comparison of hemodynamic parameters during balloon occlusion, prior to and under therapy, demonstrated a significantly smaller decrease in cardiac index [36% (15%) vs. 10% (5%), p=0.008], a tendency to significant increase in pulmonary flow [3.2(1.2)vs. 2.5(1.2) Lit/min/m2, p=0.1) while the PVRi was significantly lower too [2.6(0.2)vs. 1.45(0.45) Wui, p=0.008]. Conclusion Chronic oral pulmonary vasodilator therapy in fenestrated Fontan patients with a Fontan unsuitable for fenestration closure demonstrated significant hemodynamic benefit during catheterization and afforded subsequent fenestration closure.

Pediatric Critical Care Medicine, 2020

Objectives: It is believed that management of neonates with dextro-transposition of the great art... more Objectives: It is believed that management of neonates with dextro-transposition of the great arteries is constantly improving. Renal function may play a role in the prognosis of patients after congenital heart surgery. The aim of this study was to describe the outcome of neonates who underwent arterial switch operation during the past 2 decades using renal function as a surrogate marker for morbidity and mortality. Design: Retrospective cohort study. Setting: Dedicated cardiac ICU of a university-affiliated pediatric medical center. Patients: Infants who underwent arterial switch surgery in 1993–2015. Interventions: None. Measurements and Main Results: The cohort included 336 infants who underwent arterial switch operation for dextro-transposition of the great arteries (n = 169, 50%), transposition of the great arteries/ventricular septal defect (n = 133, 40%), or Taussig-Bing anomaly (n = 34, 10%). Between 1993–1998 and 2012–2015, the mean minimal postoperative estimated glomerular filtration rate rose from 30 mL/min/1.73 m2 to 40 mL/min/1.73 m2 (p < 0.05), and the proportion of patients with estimated glomerular filtration rate less than 30 mL/min/1.73 m2 decreased from 56% to 23% (p < 0.05). The daily furosemide dosage decreased from 4 mg/kg/d to 0.5 mg/kg/d (p < 0.05). Urinary output on operative day 0 decreased over time, but urinary output on operative day 2 significantly increased. Maximal lactate levels and time to lactate normalization decreased steadily. Dialysis was performed in only a few patients in the early periods, and in none in the last 6 years. The mean mortality rate of patients with dextro-transposition of the great arteries and transposition of the great arteries/ventricular septal defect decreased to 2.7% in the last 6 years. The odds ratio of a prolonged hospital stay (≥ 28 d) in a patient with estimated glomerular filtration rate less than 30 mL/min/1.73 m2 was 18.79, and in a patient with transposition of the great arteries/ventricular septal defect, 3.39. The odds ratio of dying after Rashkind atrial septostomy was 4.42. Conclusions: During the past 2 decades, there has been significant improvement in outcome of patients undergoing transposition of the great arteries repair. Renal function was found to be a good prognostic marker of morbidity and mortality.

Pediatric Cardiology, 2020

We sought to examine the role of preoperative and 2nd postoperative day albumin levels as predict... more We sought to examine the role of preoperative and 2nd postoperative day albumin levels as predictors for postoperative course in infants undergoing repair of congenital heart disease. This retrospective, single-center, observational study comprised consecutive infants younger than 1 year who had undergone repair of tetralogy of Fallot, ventricular septal defect, complete atrioventricular canal or transposition of the great arteries over a 25 months period. We correlated preoperative and postoperative day (POD) #2 albumin level to vaso-inotropic score (VIS) and intensive care unit (ICU) length of stay (LOS) as markers for degree and duration of postoperative cardiac support. A composite outcome was defined as maximal vaso-inotropic score of > 10 and ICU LOS > 96 h. Preoperative albumin level negatively correlated with VIS and ICU LOS. Compared to preoperative albumin level of > 4 g/dL, the relative risk of meeting composite criteria was 1.5 for preoperative albumin of 3.1-4 g/dL and 2.6 for preoperative albumin ≤ 3 g/dL. Compared to POD#2 albumin level > 3 g/dL, the relative risk of meeting composite criteria was 1.8 for albumin of 2.6-3 g/dL, and 2.5 for albumin ≤ 2.5 g/dL. In summary, we found that preoperative and POD#2 albumin levels predicted prolonged and complicated postoperative course. These finding may help clinicians to inform the patient's parents, early in the ICU hospitalization, as to the predicted risks and difficulties of their infant's postoperative course.

Pediatric Critical Care Medicine, 2019

Objectives: Fontan surgery, the final surgical stage in single ventricle palliation, redirects sy... more Objectives: Fontan surgery, the final surgical stage in single ventricle palliation, redirects systemic venous blood into the pulmonary circulation for gas exchange. A decrease in pulmonary blood flow can lead to major complications and grave outcomes. Alveolar dead-space fraction represents the portion of inhaled air that does not participate in gas exchange and hence quantifies ventilation-perfusion abnormalities in the lung. Increased alveolar dead-space fraction has been associated with prolonged mechanical ventilation and worse outcome after congenital heart surgery. The association of alveolar dead-space fraction with clinical outcomes in patients undergoing Fontan operation has not been reported. Interventions: None. Design, Setting, and Patients: A retrospective charts review of all pediatric patients who underwent Fontan surgery during June 2010–November 2018 in a tertiary-care pediatric hospital. Associations between alveolar dead-space fraction and arterial oxyhemoglobin saturation to a composite outcome (surgical or catheter-based intervention, extracorporeal membrane oxygenation use, prolonged ventilation, prolonged hospital length of stay, or death) were explored. Secondary endpoints were parameters of severity of illness, chest drainage duration, and length of stay. Measurements and Main Results: Of 128 patients undergoing Fontan operation, 34 met criteria for composite outcome. Alveolar dead-space fraction was significantly higher in the composite (0.33 ± 0.14) versus control (0.25 ± 0.26; p = 0.016) group. Alveolar dead-space fraction greater than or equal to 0.29 indicated a 37% increase in risk to meet composite criteria. Admission arterial oxygen saturation was significantly lower in composite versus control group (93.4% vs 97.1%; p = 0.005). Alveolar dead-space fraction was significantly associated with increased durations of mechanical ventilation, ICU length of stay, duration of thoracic drainage, and parameters of severity of illness. Conclusions: Alveolar dead-space fraction and arterial saturation may predict complicated postoperative course in patients undergoing the Fontan operation.

Pediatric Cardiology, 2019

Infective endocarditis (IE) in the pediatric population can present as a life-threatening conditi... more Infective endocarditis (IE) in the pediatric population can present as a life-threatening condition. Optimal timing for surgical intervention should consider surgical risks versus the risk of neurologic complications. We herein report our experience with this group of critically ill children. Retrospective analysis of patient charts of all patients who underwent urgent surgical treatment of aortic IE from 1994 to 2014 was performed. Nine patients with acute storming IE of the aortic valve or the ascending aorta were urgently operated (eight normal heart, one congenital aortic stenosis), age ranged from 8 weeks to 4.2 years. Causative organisms were Staphylococcus aureus (2), Staphylococcus coagulase negative (1), Kingella kingae (2), Streptococcus pneumoniae (2), or culture negative (2). Presenting symptoms other than hemodynamic instability were neurologic decompensation (5) coronary embolization (1) and cardiogenic shock due to scalded skin syndrome (1). CT and MRI demonstrated significant brain infarcts in four patients. Operations performed were the Ross operation (7) and ascending aortic reconstruction (2). There were no operative deaths. At a median follow-up of 6 years (range 2-196 months), all patients are alive and well. Re-intervention included homograft replacement (2) and transcatheter Melody valve implantation (1). At their last follow-up, the neo-aortic valve was functional in all patients with minimal regurgitation and all had full resolution of the neurological deficits. Urgent surgical treatment for aortic valve IE in infants is challenging. Although surgery is complex and pre-disposing conditions such as sepsis, neurologic and cardiac decompensations are prevalent, operative results are excellent and gradual and significant neurologic improvement was noted over time.

The Israel Medical Association journal : IMAJ, 2016

neonatal cardiac surgery has evolved over the last 50 years with a large percentage of the patien... more neonatal cardiac surgery has evolved over the last 50 years with a large percentage of the patients achieving complete physiological repair in the neonatal period. The remaining patients achieve staged palliation with an increasing amount of success. To report our experience with 1000 neonatal cardiac surgical procedures performed in the last 10 years. We conducted a retrospective analysis of surgical outcome in all neonatal patients who underwent cardiac surgery between January 2007 and July 2016 at Schneider Children's Medical Center of Israel. A total of 1003 neonates aged < 30 days underwent surgery for congenital heart defects at our center. Neonatal surgery accounted for 22.5% of all cardiac surgeries. Neonatal operative mortality was 7.3%, Operative mortality for individual lesions were: simple aortic coarctation (CoA) (198 patients, 2.5%), CoA with hypoplastic arch (24, 4%), CoA with ventricular septal defect (VSD) (84, 2.3%), transposition of the great arteries (TGA,...

Pediatric Critical Care Medicine, 2014

Journal of Intensive Care Medicine, 2013

Ascitic fluid in the peritoneal cavity may severely impair respiratory and renal function followi... more Ascitic fluid in the peritoneal cavity may severely impair respiratory and renal function following neonatal heart surgery. It has been our practice to liberally insert percutaneous peritoneal catheters (PPCs) in order to manage fluid balance and thereby improve ventilatory function. We herein report our experience with PPC. Retrospective analysis of charts of all surviving neonates that underwent PPC insertion from January 2007 through March 2010. Charts were reviewed for demographic and clinical variables from the preoperative, operative, and postoperative periods. A total of 1268 patients underwent surgery, 292 (23%) were neonates. 17 (5.8%) patients required PPC. Mean age and weight were 16 days and 3.1 kg, respectively. Mean amount drained upon insertion was 55 ± 46 ml. Catheters were maintained for a mean of 5 days and drained an average of 201 ml on the first postinsertion day. Ventilatory settings did not change significantly prior to and postcatheter insertion (respiratory rate [29 ± 3.8 vs 28.7 ± 3.9; P = .93], inspiratory pressures [26.3 ± 3.6 vs 26.1 ± 3.3 cm H2O; P = .34], and fraction of inspired oxygen [0.66 ± 0.21 vs 0.63 ± 0.18; P = .53]). Carbon dioxide values decreased significantly (43.2 ± 9.7 vs 37 ± 4.9 mm Hg; P = .01), and PO2 values increased (78 ± 69 vs 104 ± 57 mm Hg; P = .05). The PPC insertion can be easily performed at the bedside with minimal complications. Fluid balance management is facilitated, and ventilation is improved. The PPC insertion is a valuable addition to the armamentarium of the physician treating neonates in the intensive care unit after complex congenital heart surgery.

Cardiology in the Young, 2010

Introduction: Anomalous origin of one pulmonary artery from the ascending aorta is a rare cardiac... more Introduction: Anomalous origin of one pulmonary artery from the ascending aorta is a rare cardiac anomaly in which the pulmonary artery abnormally arises from the ascending aorta. Physiologically, most patients develop signs of cardiac failure due to high flow to both lungs, with systemic or supra-systemic pressures in the normally connected lung. The purpose of this study is to present our experience with this rare anomaly, in which early anatomic repair lead to rapid physiologic correction. Materials and methods: Retrospective case review of all patients with anomalous origin of one pulmonary artery from the ascending aorta at Schneider Chidren's Medical center of Israel between 1986 and 2007. All clinical operative and echocardiographic charts were analysed. Results: Twelve patients were diagnosed as anomalous origin of one pulmonary artery from the ascending aorta. In 10 patients, the right pulmonary artery rose from the ascending aorta, while in two an anomalous origin of the left pulmonary artery was associated with a right aortic arch. Initial diagnoses was made with two-dimensional echocardiography in all patients. In six patients, diagnostic cardiac catheterisation was performed in order to confirm the diagnosis. Age at diagnosis ranged from 5 to 180 days with a median of 15 days, and patient weight ranged from 780 grams to 5 kilograms, with a median of 3 kilograms. Initial echocardiographic evaluation showed systemic (four patients) or supra-systemic (seven patients) pressures in the right ventricle and normally connected lung. All underwent surgical repair. There was no operatrive mortality. All reconstructed patients achieved normal right ventricular pressures within days after surgery. The flow pattern in both pulmonary arteries was normalised. Conclusions: Early surgical repair of anomalous origin of one pulmonary artery from the ascending aorta is feasible and safe even in newborn and premature babies with complete resolution of the pulmonary hypertension and normalisation of pulmonary vascular resistance.

The Annals of Thoracic Surgery, 2013

Background. Antegrade cerebral perfusion (ACP) is performed in neonates either by direct cannulat... more Background. Antegrade cerebral perfusion (ACP) is performed in neonates either by direct cannulation (DC) or indirect cannulation (IC) of the innominate artery. IC is achieved by a graft sutured to the innominate artery or advancement of a cannula through the ascending aorta into the innominate artery, whereas DC is performed by directly cannulating the innominate artery. These techniques may be limited by technical problems that can compromise perfusion. The purpose of the present study was to evaluate the flow measurements and safety of DC when compared with IC. Methods. This was a retrospective chart review of consecutive neonates who underwent ACP from January 2007 to December 2010. Patient characteristics, surgical and hemodynamic measurements, and postoperative neurologic findings were recorded. Results. Seventy neonates underwent ACP during the study period (46 using DC and 24 using IC). The groups were similar in age and weight. Operative variables were similar regarding cardiopulmonary bypass (CPB), crossclamp times, maximal flow at full CPB, minimal temperature, ACP time, flow and flow index, and upper extremity blood pressure and proximal cannula pressure during ACP. There was a significantly higher flow index at full CPB in the DC group (217 ؎ 40 mL/kg/min versus 190 ؎ 46 mL/kg/min; p ‫؍‬ 0.013), which correlated with higher proximal cannula pressures at full CPB (172 ؎ 27 mm Hg versus 158 ؎ 26 mm Hg; p ‫؍‬ 0.04). Sixty-two of the 65 survivors (95%) had normal neurologic evaluations on discharge. Conclusions. ACP using DC is comparable to that using IC, with appropriate pressures in the proximal aortic line at full CPB and adequate upper extremity pressures during ACP, reflecting suitable flows in the cerebral circulation.

The Journal of Thoracic and Cardiovascular Surgery, 2010