Surgical Management of Juxtaductal Coarctation of the Aorta in Adults: A Novel Technique.

Coarctation of the aorta (CoA) is a rare congenital malformation, the symptoms of which may remain subtle in childhood and appear at a later age. It can manifest only with symptoms of upper body hypertension. Various methods have been described for managing coarctation of the aorta in adults, including surgical or percutaneous balloon angioplasty with or without stent placement and medical therapy. Surgical approaches include an extra-anatomical bypass through a left lateral thoracotomy, a median sternotomy, or a combined median sternotomy and a laparotomy incision; all have their merit in overcoming the symptoms. We went ahead with an extra-anatomical tube graft between the ascending aorta and the descending thoracic aorta in a 24-year-old patient who presented to us with a diagnosis of coarctation of the aorta.

A Rare Case of Early-Onset Postpneumonectomy Syndrome After Right Pneumonectomy in Patient with Small Cell Carcinoma Right Lung.

ABSTRACT: Postpneumonectomy syndrome (PPS) is a rare, life-threatening complication characterized by dynamic airway obstruction due to mediastinal rotation at any time point following pneumonectomy. This can produce life-threatening respiratory and cardiovascular complications. We report a case who developed PPS following right pneumonectomy in a 55-year-old female patient with small cell carcinoma (SCC) right lung.

Post-ductal coarctation of aorta aneurysm repair in adult via left antero-axillary thoracotomy with antegrade cerebral perfusion-a case series.

Coarctation of the aorta is a common congenital abnormality that may be associated with serious and rare anomalies like aneurysms. Severe coarctation or interrupted aortic arch in adults is usually managed by percutaneous interventions or extra-anatomic bypass. However, the presence of an aneurysm beyond the coarcted segment implies the opening of a collateral-rich segment of the aorta with redressal of the arch if hypoplastic. We describe our experience in managing three such patients through antero-lateral thoracotomy with antegrade cerebral perfusion. We have found this technique helpful in treating aneurysms of the distal aortic arch or proximal descending thoracic aorta.

Correction to: Post­ductal coarctation of aorta aneurysm repair in adult via left antero­axillary thoracotomy with antegrade cerebral perfusion-a case series.

[This corrects the article DOI: 10.1007/s12055-024-01734-5.].

Comparative Effect of High-Frequency Nasal Cannula and Noninvasive Ventilation on the Work of Breathing and Postoperative Pulmonary Complication after Pediatric Congenital Cardiac Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: Various forms of commonly used noninvasive respiratory support strategies have considerable effect on diaphragmatic contractile function which can be evaluated using sonographic diaphragm activity parameters. OBJECTIVE: To compare the magnitude of respiratory workload decreased as assessed by thickening fraction of the diaphragm and longitudinal diaphragmatic strain while using high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) modes [nasal intermittent positive pressure ventilation (NIPPV) and bilevel positive airway pressure (BiPAP)] in pediatric patients after cardiothoracic surgery. METHODOLOGY: This prospective randomized controlled trial was performed at a tertiary care surgical intensive care unit in postcardiac surgery patients aged between 1 and 48 months, who were randomly allocated into three groups: 1) HFNC (with flows at 2 L/kg/min), 2) NIPPV via RAMS cannula in PSV mode (pressure support 8 cmH2O, PEEP 5 cmH2O), and 3) BiPAP in nCPAP mode (CPAP of 5 cmH2O). Measurements were recorded at baseline after extubation (R0) and subsequently every 12 hourly (R1, R2, R3, R4, R5) at 12, 24, 36, 48, and 60 hours respectively until therapy was discontinued. RESULTS: Sixty patients were included, with 20 patients each in the NIPPV group, HFNC group, and BiPAP group. Longitudinal strain at crura of diaphragm was lower in the BiPAP group as compared to HFNC group at R2-R4 [R2 (-4.27± -2.73 vs - 8.40± -6.40, P = 0.031), R3 (-5.32± -2.28 vs -8.44± -5.6, P = 0.015), and R4 (-3.8± -3.42 vs -12.4± -7.12, P = 0.040)]. PFR was higher in HFNC than NIPPV group at baseline and R1-R3[R0 (323 ± 114 vs 264 ± 80, P = 0.008), R1 (311 ± 114 vs 233 ± 66, P = 0.022), R2 (328 ± 116 vs 237 ± 4, P = 0.002), R3 (346 ± 112 vs 238 ± 54, P = 0.001)]. DTF and clinical parameters of increased work of breathing remain comparable between three groups. The rate of reintubation (within 48 hours of extubation or at ICU discharge) was 0.06% (1 in NIPPV, 1 in BiPAP, 2 in HFNC) and remain comparable between groups (P = 1.0). CONCLUSION: BiPAP may provide better decrease in work of breathing compared to HFNC as reflected by lower crural diaphragmatic strain pattern. HFNC may provide better oxygenation compared to NIPPV group, as reflected by higher PFR ratio. Failure rate and safety profile are similar among different methods used.

Congenital Absence of Sternum: A Surgical Technique for Successful Outcome.

Congenital absence of sternum is a rare malformation of the anterior chest wall that needs surgical correction to avoid life-threatening complications as a consequence of such defect. It results from either partial or complete failure of fusion of mesenchymal strip during in utero organogenesis. The absence of sternum entails the risk of trauma to the mediastinal structures and other life-threatening complications. This defect is evaluated by a thorough clinical examination and computed tomography imaging of the thoracic cage to plan the surgical procedure. Early repair of the defect when the thoracic cage is still compliant yields the best result.

Role of transesophageal echocardiography in early detection of myocardial ischemia before electrocardiography changes post arterial switch operation.

Myocardial ischemia after arterial switch operation is most commonly associated with imperfect translocation of coronary arteries to the neoaorta. Early post-operative myocardial ischemia is the main cause of morbidity and mortality in these patients. We present a rare case of intra-operative myocardial ischemia after ASO, detected with transesophageal echocardiography before electrocardiography changes.

Ultrasonic prediction of weaning failure in children undergoing cardiac surgery: A prospective observational study.

Background and Aim: To assess the utility of ultrasonic markers like B-line score (LUS), diaphragm thickness (DT), thickening fraction (DTF), and excursion (DE) as predictors of weaning outcomes in children on mechanical ventilation (MV) after cardiac surgery. Methods: This was a prospective observational study done in postcardiac surgical intensive care unit (ICU) of a tertiary care hospital. Children aged 1 month to 18 years, on MV after cardiac surgery from January to November 2017, were included. They were extubated after satisfying institutional weaning criteria. Ultrasound for LUS, DT, DTF, and DE was performed preoperatively, during pressure support ventilation (PSV) before extubation and 4 h after extubation. Results: Patients were divided into weaning failure and success groups based on reintubation within 48 h of extubation. Of the 50 evaluated patients, 43 (86%) were weaned successfully and 7 (14%) had weaning failure. The left DTF during PSV was lower in patients weaning failure (0.00%, interquartile range (IQR) 0.00-14.28 vs 16.67%, IQR 8.33-22.20, P = 0. 012). The left DTF≤ 14.64% during PSV (area under receiver's operating curve 0.795, P = 0.014), 85% sensitivity, and 57% specificity (positive likelihood ratio 1.97, negative likelihood ratio 0.25) could predict weaning failure. Conclusion: The left DTF during PSV is a good predictor of weaning failure in children on MV in postoperative ICU after congenital cardiac surgery. Take home message: In children on mechanical ventilation after cardiac surgery, left DTF during pressure support ventilation is a good predictor of weaning failure.

Intraoperative evaluation of renal resistive index with transesophageal echocardiography for the assessment of acute renal injury in patients undergoing coronary artery bypass grafting surgery: A prospective observational study.

Background: Acute kidney injury (AKI) is a common complication after on pump coronary artery bypass grafting (CABG) surgery and is associated with a poor prognosis. Postoperative AKI is associated with morbidity, mortality, and increase in length of intensive care unit (ICU) stay and increases the financial burden. Identifying individuals at risk for developing AKI in postoperative period is extremely important to optimize outcomes. The aim of the study is to evaluate the association between the intraoperative transesophageal echocardiography (TEE) derived renal resistive index (RRI) and AKI in patients undergoing on-pump CABG surgery. Methods: This prospective observational study was conducted in patients more than 18 years of age undergoing elective on pump CABG surgery between July 1, 2018, and December 31, 2019, at a tertiary care center. All preoperative, intraoperative, and postoperative parameters were recorded. TEE measurement was performed in hemodynamically stable patients before the sternum was opened. Postoperative AKI was diagnosed based on the serial measurement of serum creatinine and the monitoring of urine output. Results: A total of 115 patients were included in our study. Thirty-nine (33.91%) patients had RRI >0.7 while remaining seventy-six (66.08%) patients had RRI <0.7. AKI was diagnosed in 26% (30/115) patients. AKI rates were significantly higher in patients with RRI values exceeding 0.7 with 46.15% (18/39) compared to 15.75% (12/76) in RRI values of less than 0.7. Multivariate analysis revealed that AKI was associated with an increase in RRI and diabetes mellitus. The RRI assessed by receiver operating characteristic (ROC) curve and the area under the curve (AUC) to distinguish between non-AKI and AKI groups were 0.705 (95% CI: 0.588-0.826) for preoperative RRI. The most accurate cut-off value to distinguish non-AKI and AKI groups was a preoperative RRI of 0.68 with a sensitivity of 70% and specificity of 67%. Conclusions: An increased intraoperative RRI is an independent predictor of AKI in the postoperative period in patients undergoing CABG surgery. The cutoff value of TEE-derived RRI in the intraoperative period should be >0.68 to predict AKI in the postoperative period.

Aneurysmal Oscillation of the Capnogram: A Case Report.

Variations in the alveolar plateau phase of the capnogram are often confused with spontaneous breathing efforts in an intubated patient. The oscillations in the capnogram due to a large ascending thoracic aneurysm are a separate entity from cardiogenic oscillations, and can be an indicator of underlying bronchial or lung compression.

Utility of Transfontanelle Ultrasound in Predicting the Fluid Responsiveness in Children After Repair of Congenital Heart Diseases: A Prospective Observational Study.

OBJECTIVES: Postoperative fluid management in children undergoing cardiac surgery requires a balanced optimization. The blood flow velocity variation in the internal carotid artery (ΔICA) measured through transfontanelle ultrasound has been shown to predict fluid responsiveness during cardiac surgery. It may provide an excellent window to study fluid responsiveness in infants during the postoperative period when the intensivist is faced with the challenges of poor echocardiographic window. The authors aimed to observe the correlation between ΔICA measured on transfontanelle ultrasound with the respiratory variability of peak aortic blood flow velocity (ΔVpeak) on transthoracic echocardiography as a marker of fluid responsiveness in infants on mechanical ventilation during the postoperative period after cardiac surgery. DESIGN: A prospective observational study. SETTING: The postcardiac surgery intensive care unit (ICU) of a tertiary care hospital. PARTICIPANTS: Thirty infants undergoing congenital cardiac surgery. INTERVENTIONS: A fluid bolus of 10 mL/kg administered over 10 minutes at 1 and 6 hours after ICU admission. Patients were categorized into fluid responders and nonresponders based on >15% increase in the indexed stroke volume. MEASUREMENTS AND MAIN RESULTS: A total of 50 fluid boluses were administered in 30 patients. Among these, 22 (73.33%) were responders and 8 (26.67%) were nonresponders. There was moderate correlation between ΔICA and peak aortic blood flow velocity variation (ΔVpeak) (r = 0.59, p ≤ 0.001). The ΔVpeak >14.74% had 68% sensitivity and 75% specificity to predict fluid responsiveness (area under the receiver operating characteristic [AUROC], 0.749; p = 0.001; positive likelihood ratio, 2.71; negative likelihood ratio, 0.43). The ΔICA >9.85% could predict fluid responsiveness in infants (AUROC, 0.728; p = 0.003; 75% sensitivity; 60% specificity; positive likelihood ratio, 1.85; negative likelihood ratio, 0.42). Among children younger than 6 months, ΔICA >9.85% was a better predictor of fluid responsiveness (AUROC, 0.889; p = 0.009) than ΔVpeak >15% (AUROC, 0.778; p = 0.061). CONCLUSION: The ICA variability >9.85% measured via transfontanelle ultrasound is a good predictor of fluid responsiveness in infants, especially those younger than 6 months on mechanical ventilation after cardiac surgery.

Pulmonary Artery Pseudoaneurysm in COVID-19-Associated Pulmonary Mucormycosis: Case Series and Systematic Review of the Literature.

Literature on COVID-19-associated pulmonary mucormycosis (CAPM) is sparse. Pulmonary artery pseudoaneurysm (PAP) is an uncommon complication of pulmonary mucormycosis (PM), and rarely reported in CAPM. Herein, we report five cases of CAPM with PAP managed at our center and perform a systematic review of the literature. We diagnosed PM in those with clinico-radiological suspicion and confirmed it by microbiology or histopathology. We encountered five cases of CAPM with PAP (size ranged from 1 × 0.8 cm to ~ 4.9 × 4.8 cm). All subjects had diabetes and were aged 55-62 years (75% men). In two cases, COVID-19 and mucormycosis were diagnosed simultaneously, while in three others, COVID-19 preceded PM. One subject who underwent surgery survived, while all others died (80% mortality). From our systematic review, we identified one additional case of CAPM with PAP in a transplant recipient. CAPM with PAP is rare with high mortality. Early diagnosis and multimodality management are imperative to improve outcomes.

Surgical Challenges in a Case of a Recurrent Giant Pleomorphic Liposarcoma of Neck And Mediastinum in a Child: A Rare Occurrence.

Liposarcomas are rare in childhood, representing < 1% of all childhood soft tissue sarcomas. The most frequent site of involvement are the extremities with the involvement of head and neck being an absolute rarity. Pleomorphic subtype of liposarcoma is pretty aggressive and hence portends a poor prognosis. Here, we present the case of a child who presented with a recurrence of liposarcoma in the neck and mediastinum within 3 months of the index surgery. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-021-02837-w.

Assessment of factors affecting short-term pulmonary functions following cardiac surgery: A prospective observational study.

BACKGROUND: Pulmonary complications after cardiac surgery are very common and lead to an increased incidence of post-operative morbidity and mortality. Several factors, either modifiable or non-modifiable, may contribute to the associated unfavorable consequences related to pulmonary function. This study was aimed to investigate the degree of alteration and factors influencing pulmonary function (forced expiratory volume in one second (FEV1) and forced vital capacity), on third, fifth, and seventh post-operative days following cardiac surgery. METHODS: This study was executed in 71 patients who underwent on-pump cardiac surgery. Pulmonary function was assessed before surgery and on the third, fifth, and seventh post-operative days. Data including surgical details, information about risk factors, and assessment of pulmonary function were obtained. RESULTS: The FEV1 and forced vital capacity were significantly impaired on post-operative days 3, 5, and 7 compared to pre-operative values. The reduction in FEV1 was 41%, 29%, and 16% and in forced vital capacity was 42%, 29%, and 19% consecutively on post-operative days 3, 5, and 7. Multivariate analysis was done to detect the factors influencing post-operative FEV1 and forced vital capacity. DISCUSSION: This study observed a significant impairment in FEV1 and forced vital capacity, which did not completely recover by the seventh post-operative day. Different factors affecting post-operative FEV1 and forced vital capacity were pre-operative FEV1, age ≥60, less body surface area, lower pre-operative chest expansion at the axillary level, and having more duration of cardiopulmonary bypass during surgery. Presence of these factors enhances the chance of developing post-operative pulmonary complications.

Utility of Lung Ultrasound in the Estimation of Extravascular Lung Water in a Pediatric Population-A Prospective Observational Study.

OBJECTIVE: Lung ultrasound (LUS) is a promising bedside modality for the estimation of extravascular lung water index (EVLWI), but has not been validated against objective measures in children. This study aimed to investigate the correlation of LUS B-line scoring with EVLWI, thresholds indicating elevated EVLWI, and its outcome following pediatric cardiac surgery. DESIGN: Prospective observational study. SETTING: Cardiothoracic surgical intensive care unit in a tertiary care teaching hospital. PARTICIPANTS: Children younger than 12 years undergoing elective complete surgical correction of cyanotic or acyanotic congenital heart disease (Aristotle score ≤9), excluding neonates, those weighing <3.5 kg, and those with thoracic deformities, pulmonary pathology, and hemodynamic instability. INTERVENTIONS: Extravascular lung water index measurement by transpulmonary thermodilution, along with concurrent LUS B-line and Chest-X ray (CXR) scoring. MEASUREMENTS AND MAIN RESULTS: LUS B-line score had a moderate correlation with EVLWI (Pearson's correlation coefficient 0.57; 95% CI 0.44-0.69). LUS B-line scores showed acceptable discrimination only for higher thresholds of EVLWI (sensitivity 82% and 79%, respectively, for EVLWI >20 mL/kg v sensitivity and specificity 57% and 80% for EVLWI >10 mL/kg). Age, body surface area, vasoactive-inotropic score (VIS), chest X-ray score, and EVLWI but not LUS B-line score were significant predictors for duration of mechanical ventilation in this cohort. CONCLUSIONS: LUS B-line scoring has limited utility in semiquantitative estimation of EVLWI at lower thresholds of EVLWI in pediatric cardiac surgical patients. It may have better discrimination and acceptable sensitivity and specificity at higher thresholds of EVLWI. Contrasting with multiple reports of clinical utility, these results call for wider evaluation of LUS and its clinical modifiers like age, pathology, and pretest probability in estimation of EVLWI.

Honeycomb in the heart: A rare case of hydatid cyst of the interventricular septum.

The incidence of cardiac hydatid disease, caused by Echinococcus granulosus, is 0.5% to 2% in the sheep grazing areas of developing and under-developed countries. The cyst can be present in the interventricular septum in 5% to 9% of the patients, along with conduction block or arrythmia. Intraoperative transesophageal echocardiography (TEE) can guide the surgeon in cyst localization and excision. This image review highlights the TEE findings in a young patient with multiple hydatid cysts of the interventricular septum, and the cyst membrane adhering to the septal tricuspid leaflet.

Multimodality imaging of an interventricular septum hydatid cyst.

BACKGROUND: Cardiac hydatid over the interventricular septum is extremely rare. Echinococcus infests humans as an accidental host. Echocardiography usually clinches the diagnosis of cardiac hydatid. However, multimodality imaging including cardiac magnetic resonance (CMR) imaging, computed tomography (CT), and positron emission tomography (PET) helps in supporting the diagnosis and surgical planning. CASE PRESENTATION: We present a 29-year-old male who presented with dyspnea and was found to have cardiac hydatid on the interventricular septum on echocardiography. CT and CMR clinched the diagnosis. CT pulmonary angiography showed extensive pulmonary thromboembolization and cavitary consolidation in lungs. PET showed no active uptake in cardiac hydatid. Post-surgical enucleation of the cyst his hypotension worsened and succumbed. CONCLUSION: Cardiac hydatid has poor prognosis. Multimodality imaging helps in confirming the diagnosis and surgical planning.

Sub-pulmonic stenosis caused by a right ventricular outflow tract vegetation in a children with restricted ventricular septal defect.

Infective endocarditis involving the right heart is rarely observed in the pediatric population. Echocardiography plays an important role in its diagnosis, and surgery is indicated in patients with heart failure and persistent sepsis not responding to medical treatment. Here, we report a rare case of restricted ventricular septal defect complicated by a vegetation developed in the right ventricular outflow tract and causing sub-pulmonic stenosis in a 3-year-old male child.