Biomarkers in low cardiac output syndrome after open cardiac surgery in children

Main Article Content

Reby Kusumajaya
Najib Advani
Piprim B. Yanuarso
Zulham Effendy


Background Corrective cardiac surgery is the standard management for complex congenital heart disease. Cardiopulmonary bypass surgery and post-surgical intensive care may lead to low cardiac output syndrome (LCOS), as a major complication after open heart surgery.  To diagnose early LCOS, lactate level, pCO2 gap, and mixed venous oxygen saturation (SvO2) are parameters reported to have correlations with decreased cardiac output, morbidity, and post-cardiac surgery mortality.

Objective To determine the usefulness of lactate level, pCO2 gap (arterial-vein), and SvO2 for early detection of LCOS in children post-open heart surgery.

Methods This prospective cohort study was done from August to October 2017 in the ICU of the Integrated Cardiac Center, Dr. Cipto Mangunkusumo Hospital, Jakarta. Subjects were pediatric patients who underwent cardiac surgery. After surgery, patients underwent monitoring in the ICU for clinical signs of LCOS and examinations for lactate levels, pCO2 gap, and SvO2 at 15 minutes, 4 hours and 8 hours.

Results Thirty-three open heart surgery patients were the subjects. Lactate level at 4 hours and 8 hours post-operative were significantly higher in the LCOS group compared to non-LCOS group. For the pCO2 gap, only the 4-hour post-operative results were significantly higher in LCOS group compared to non-LCOS groups. In addition, only SvO2 at 4 hours after surgery was significantly lower in LCOS group compared to non-LCOS group.

Conclusion Elevated lactate, high pCO2 gap, as well as decreased SvO2 at 4 hours post-operatively are the most reliable markers of LCOS after pediatric open heart surgery.

Article Details

How to Cite
Kusumajaya R, Advani N, B. Yanuarso P, Effendy Z. Biomarkers in low cardiac output syndrome after open cardiac surgery in children. PI [Internet]. 23Aug.2021 [cited 23Sep.2021];61(4):223-. Available from:
Pediatric Cardiology
Received 2020-11-06
Accepted 2021-08-23
Published 2021-08-23


1. Kantor PF, Lougheed J, Dancea A, McGillion M, Barbosa N, Chan C, et al. Presentation, diagnosis, and medical management of heart failure in children: Canadian Cardiovascular Society guidelines. Canadian Journal of Cardiology. 2013;29:1535-52. DOI: 10.1016/j.cjca.2013.08.008.
2. Murni IK, Djer MM, Yanuarso PB, Putra ST, Advani N, Rachmat J, et al. Outcome of pediatric cardiac surgery and predictors of major complication in a developing country. Ann Pediatr Cardiol. 2019;12:38-44. DOI: 10.4103/apc.APC_146_17.
3. Brown DW, Fulton DR. Congenital heart disease in children and adolescents. In: Fuster V, Walsh RA, Harrington RA, editors. Hurst's The Heart. 13th ed. New York, NY: The McGraw-Hill Companies; 2011. p. 1-18.
4. Chandler HK, Kirsch R. Management of the low cardiac output syndrome following surgery for congenital heart disease. Curr Cardiol Rev. 2016;12:107-11. DOI: 10.2174/1573403x12666151119164647.
5. Karamlou TB, Welke KF, Ungerleider RM. Congenital heart disease. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al., editors. Schwartz's Principles of Surgery. 9th ed. New York, NY: The McGraw-Hill Companies; 2010. p. 1-71.
6. Vogt W, Läer S. Treatment for paediatric low cardiac output syndrome: results from the European EuLoCOS-Paed survey. Arch Dis Child. 2011;96:1180-6. 10.1136/archdischild-2011-300370.
7. Rotta AT, Laussen PC, Wessel DL. Critical care after surgery for congenital cardiac disease. In: Fuhrman BP, Zimmerman JJ, editors. Pediatric Critical Care. 4th ed. Saint Louis: Mosby; 2011. p. 401-40.
8. Tibby SM. Hemodynamic monitoring. In: Wheeler DS, Wong HR, Shanley TP, editors. Pediatric critical care medicine: care of the critically ill or injured Child. London: Springer London; 2014. p. 543-67.
9. Levin R, Marcela D, Carlos DM, Eduardo T, Rafael P. Preoperative levosimendan decreases mortality and the development of low cardiac output in high-risk patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting with cardiopulmonary bypass. Exp Clin Cardiol. 2012:125-30. PMID: 23620700.
10. Vela JP, Benitez JM, Gonzalez MC, de la Cal López M, Pérez RH, Meneses VS, et al. Summary of the consensus document:“Clinical practice guide for the management of low cardiac output syndrome in the postoperative period of heart surgery”. Med Intensiva. 2012;36:277-87. DOI: 10.1016/j.medin.2012.01.016.
11. Chakravarti SB, Mittnacht AJ, Katz JC, Nguyen K, Joashi U, Srivastava S. Multisite near-infrared spectroscopy predicts elevated blood lactate level in children after cardiac surgery. J Cardiothorac Vasc Anesth. 2009;23:663-7. DOI: 10.1053/j.jvca.2009.03.014.
12. Wati DK, Sastroasmoro S, Madjid A, Boedina S, Djer MM, Santoso H. Superior cava vein saturation and cardiac lactate as cardiac output predictor after cardio-pulmonary bypass on children. Crit Care Shock. 2016;19:14-20.
13. Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88:1127-40. DOI: 10.1016/j.mayocp.2013.06.012.
14. Rao V, Ivanov J, Weisel RD, Cohen G, Borger MA, Mickle DA. Lactate release during reperfusion predicts low cardiac output syndrome after coronary bypass surgery. J Thorac Cardiovasc Surg. 2001;71:1925-30. DOI: 10.1016/s0003-4975(01)02634-0.
15. Basaran M, Sever K, Kafali E, Ugurlucan M, Sayin OA, Tansel T, et al. Serum lactate level has prognostic significance after pediatric cardiac surgery. J Cardiothorac Vasc Anesth. 2006;20:43-7. DOI: 10.1053/j.jvca.2004.10.010.
16. Maillet J-M, Le Besnerais P, Cantoni M, Nataf P, Ruffenach A, Lessana A, et al. Frequency, risk factors, and outcome of hyperlactatemia after cardiac surgery. Chest. 2003;123:1361-6. DOI: 10.1378/chest.123.5.1361.
17. Charpie JR, Dekeon MK, Goldberg CS, Mosca RS, Bove EL, Kulik TJ. Serial blood lactate measurements predict early outcome after neonatal repair or palliation for complex congenital heart disease. Journal of thoracic and cardiovascular surgery. 2000;120:73-80. DOI: 10.1067/mtc.2000.106838.
18. Cheifetz IM, Kern FH, Schulman SR, Greeley WJ, Ungerleider RM, Meliones JN. Serum lactates correlate with mortality after operations for complex congenital heart disease. Annals of Thoracic Surgery. 1997;64:735-8. DOI: 10.1016/s0003-4975(97)00527-4.
19. Dres M, Monnet X, Teboul J-L. Hemodynamic management of cardiovascular failure by using PCO2 venous-arterial difference. J Clin Monit Comput. 2012;26:367-74. DOI: 10.1007/s10877-012-9381-x.
20. Mallat J, Lemyze M, Tronchon L, Vallet B, Thevenin D. Use of venous-to-arterial carbon dioxide tension difference to guide resuscitation therapy in septic shock. World J Crit Care Med. 2016;5:47. DOI: 10.5492/wjccm.v5.i1.47.
21. Furqan M, Hashmat F, Amanullah M, Khan M, Durani HK, Haque A. Venoarterial PCO2 difference: a marker of postoperative cardiac output in children with congenital heart disease. J Coll Physicians Surg Pak. 2009;19:640. DOI: 10.2009/JCPSP.640643.
22. Buheitel G, Scharf J, Hofbeck M, Singer H. Estimation of cardiac index by means of the arterial and the mixed venous oxygen content and pulmonary oxygen uptake determination in the early post-operative period following surgery of congenital heart disease. Intensive Care Med. 1994;20:500-3. DOI: 10.1007/BF01711904.
23. Tweddell JS, Ghanayem NS, Mussatto KA, Mitchell ME, Lamers LJ, Musa NL, et al. Mixed venous oxygen saturation monitoring after stage 1 palliation for hypoplastic left heart syndrome. Ann Thorac Surg. 2007;84:1301-13101. DOI: 10.1016/j.athoracsur.2007.05.047.