Massive bilateral pulmonary embolism in a child.

We describe a rare case of acute pulmonary artery thromboembolism in a 17-year-old male patient who presented to our emergency department following a syncopal episode. A chest radiograph showed a convex pulmonic cone and an increased cardiothoracic index, and two-dimensional echocardiogram suggested near-occlusion of both pulmonary arterial branches. Multi-slice pulmonary angio-tomography revealed massive thrombosis of the pulmonary artery. He was treated with systemic anticoagulation and subsequently required surgical thrombectomy, with favourable early outcome. Although the cause of the thromboembolism remains unproven, we discuss possible etiologies.

Contemporary trends in surgical rheumatic valve disease in a Caribbean nation.

BACKGROUND: Clinical practice suggests that rheumatic heart disease (RHD) represents a significant public health challenge in the Caribbean region where advanced disease appears early often leading to surgical intervention. We aimed to determine the burden of RHD and type of procedure among patients undergoing valve surgery in the Dominican Republic (DR). METHODS: Demographic, clinical and procedural data of all subjects intervened between January 2014 and December 2018 were obtained including valve disorder, anatomic location and type of surgery. Correlation coefficients were used to assess yearly trends of RHD among the 7 cardiovascular surgical centers in the country. RESULTS: Of 1626 valvular surgeries performed, 733 (45%) corresponded to RHD; 55% female patients, age 50 ± 11 (6-72) years; involving mitral 458 (63%); mitral + aortic 139 (19%); aortic 105 (14%); mitral + tricuspid 31 (4%); 95% prosthetic replacement and 5% mitral/tricuspid repairs. Mean proportion of RHD valve procedures per center for the study period was 53 ± 34%. Age-adjusted analysis showed an overall upwards trend in RHD valvular surgery (mean annual increment of 50 ± 40%, P = 0.01). CONCLUSIONS: Despite inter-center variability, rates of surgical RHD in the DR increased during the last 5 years affecting a relatively young population. Mitral involvement was the predominant lesion and prosthetic replacement the leading procedure. These data may guide local and regional institutions and policy makers towards the implementation of cost-effective initiatives against RHD.

Extrapleural Closure of Patent Ductus Arteriosus: How We Do It.

Patent ductus arteriosus (PDA) is a clinical condition mostly found in premature newborns. Among several medical, surgical and interventional treatment options, extrapleural ligation through a left minithoracotomy is recognized as a safe, efficient and less expensive technique. In fact, it requires short surgical times, grants good exposure of the duct and nearby structures (e.g., thoracic duct, left recurrent laryngeal nerve), and avoids pleural space opening and subsequent pulmonary complications in preterm patients. This approach seems ideal due to its lower costs, especially in developing countries with a high birth rate and limited resources.

Giant Right Atrial Abscess in a Premature Infant With Fungal Endocarditis in a Developing Country.

Although infective endocarditis rarely appears during infancy, fungal infections remain a concern in the preterm neonatal population as the result of compromised immunity, prolonged hospitalization, and invasive procedures. The increased awareness of fungal colonization and improvements in medical therapy have not reduced the high mortality rate of mycotic infections in premature newborns, especially in developing countries, and there is no consensus on the surgical timing to treat neonatal fungal endocarditis. We present the case of a two-month-old boy with a history of three weeks of hospitalization for prematurity. After being discharged, the patient developed symptomatic candidemia resulting from a large right atrial abscess obstructing the tricuspid valve; despite antifungal therapy, urgent surgical resection was required.

Pediatric cardiac surgery: a challenge and outcome analysis of the Guatemala effort.

A large underserved population of children with congenital cardiac malformation (CCM) exists in many developing countries. In recent years, several strategies have been implemented to supplement this need. These strategies include transferring children to first-world countries for surgical care or the creation of local pediatric cardiovascular surgical programs. In 1997, an effort was made to create a comprehensive pediatric cardiac care program in Guatemala. The objective of this study is to examine the outcome analysis of the Guatemala effort. The goals of our new and first pediatric cardiac care program were to: 1) provide diagnosis and treatment to all children with a CCM in Guatemala; 2) train of local staff surgeons, 3) established a foundation locally and in the United States in 1997 to serve as a fundraising instrument to acquire equipment and remodeling of the pediatric cardiac unit and also to raise funds to pay the hospital for the almost exclusively poor pediatric cardiac patients. The staff now includes 3 surgeons from Guatemala, trained by the senior surgeon (A.R.C.), seven pediatric cardiologists, 3 intensivists, and 2 anesthesiologists, as well as intensive care and ward nurses, respiratory therapists, echocardiography technicians, and support personnel. The cardiovascular program expanded in 2005 to 2 cardiac operating rooms, 1 cardiac catheterization laboratory, 1 cardiac echo lab, 4 outpatients clinics a 6-bed intensive care unit and a 4-bed stepdown unit, a 20 bed general ward (2 beds/room) and a genetics laboratory. Our center has become a referral center for children from Central America. A total of 2,630 surgical procedures were performed between February 1997 and December 2007, increasing the number of operations each year. Postoperative complication occurred in 523 of 2,630 procedures (20%). A late follow-up study was conducted of all the patients operated from 1997 to 2005. Late mortality was 2.7%. Development of a sustainable pediatric cardiac program in emerging countries presents many difficult challenges. Hard work, perseverance, adaptability, and tolerance are useful aptitudes to develop a viable PCP in an "emerging" country. We are not in favor of Medical-Surgical Safari efforts, unless these efforts include training of a local team and eventual unit independence. It helps if an experienced (+/- senior/retired!) surgeon leads this effort on a full-time, pro bono basis. Local and international fund raising is essential to complement vastly insufficient government subsidies.

The improvement of care for paediatric and congenital cardiac disease across the World: a challenge for the World Society for Pediatric and Congenital Heart Surgery.

The diagnosis and treatment for paediatric and congenital cardiac disease has undergone remarkable progress over the last 60 years. Unfortunately, this progress has been largely limited to the developed world. Yet every year approximately 90% of the more than 1,000,000 children who are born with congenital cardiac disease across the world receive either suboptimal care or are totally denied care.While in the developed world the focus has changed from an effort to decrease post-operative mortality to now improving quality of life and decreasing morbidity, which is the focus of this Supplement, the rest of the world still needs to develop basic access to congenital cardiac care. The World Society for Pediatric and Congenital Heart Surgery [http://www.wspchs.org/] was established in 2006. The Vision of the World Society is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The Mission of the World Society is to promote the highest quality comprehensive care to all patients with pediatric and/or congenital heart disease, from the fetus to the adult, regardless of the patient's economic means, with emphasis on excellence in education, research and community service.We present in this article an overview of the epidemiology of congenital cardiac disease, the current and future challenges to improve care in the developed and developing world, the impact of the globalization of cardiac surgery, and the role that the World Society should play. The World Society for Pediatric and Congenital Heart Surgery is in a unique position to influence and truly improve the global care of children and adults with congenital cardiac disease throughout the world [http://www.wspchs.org/].

Clinical Progress in the Management of Tetralogy of Fallot in the Dominican Republic: A Case Series.

BACKGROUND: Definitive surgical interventions for Dominican children with congenital heart disease, like those of other low- and middle-income countries, have been historically limited. METHODS: We undertook review of a case series focusing on the surgical correction of complex forms of tetralogy of Fallot at a single center, CEDIMAT Centro Cardiovascular, in the Dominican Republic, over a 30-month period. RESULTS: According to our criteria, 43 cases were determined to be complex tetralogy of Fallot repairs from the two-year period. Besides tetralogy of Fallot, the cohort had an additional 55 anatomic anomalies that had to be addressed at the time of surgery. Median age at the time of surgery was notably 30 months, and an average of 42 months elapsed from the time of diagnosis to the time of surgery for this group. Only 33% of the cases reviewed had no hypercyanotic crises before repair. Median time to extubation for this group of patients was one day, with a three-day median length of stay in the intensive care setting. CONCLUSIONS: Our study importantly captures the present experience of a surgical congenital heart program that has recently transitioned from a traditional "mission model" to a now self-sustaining local practice. Both the number and the complexity of the lesions corrected in this caseload represent an advance from the level of care previously provided to children in the Dominican Republic.

A Gore-Tex 'new-innominate' vein: a surgical option for complicated bilateral cavopulmonary shunts.

A bilateral bidirectional cavopulmonary shunt was performed in a cyanotic 14-month-old girl who had tricuspid and pulmonary valve atresia, with right pulmonary artery (RPA) hypoplasia (3 mm), bilateral superior vena cavae and a ductus arteriosus-dependent pulmonary blood flow. Because of 62% postoperative arterial oxygen saturation and a right superior vena cava (RSVC) pressure of 30 mmHg, a 5 mm Gore-Tex tube was interposed to connect the two superior venae cavae. The creation of a 'new-innominate' vein allowed decompression of the right superior vena cava and an increase in arterial oxygen saturation to 86%.

Paediatric cardiac surgery in low-income and middle-income countries: a continuing challenge.

Despite advances in surgical and catheter-based treatment for congenital heart disease (CHD), there remain wide disparities across the globe. Ongoing international humanitarian and in-country programmes are working to address these issues with the ultimate goal to increase the quality and quantity of paediatric cardiac care, particularly in under-served regions of the world. This review aims to illustrate the reasons for these inequalities and suggests novel ways of improving access and sustainability of CHD programmes in low-income and middle-income countries.

Extrapleural closure of patent Ductus Arteriosus: how we do it

Abstract Patent ductus arteriosus (PDA) is a clinical condition mostly found in premature newborns. Among several medical, surgical and interventional treatment options, extrapleural ligation through a left minithoracotomy is recognized as a safe, efficient and less expensive technique. In fact, it requires short surgical times, grants good exposure of the duct and nearby structures (e.g., thoracic duct, left recurrent laryngeal nerve), and avoids pleural space opening and subsequent pulmonary complications in preterm patients. This approach seems ideal due to its lower costs, especially in developing countries with a high birth rate and limited resources.

Subaortic membrane and aorto-septal angle: an echocardiographic assessment and surgical outcome.

BACKGROUND: Development of a subaortic membrane is not fully understood. Recurrence after surgical removal continues to be high. We sought to assess the differences in aorto-septal angles (AoSA) to possibly explain alterations within the left ventricular outflow tract, hence in subaortic membrane formation. METHODS: A total of 113 patients who underwent subaortic membrane resection were matched by age and sex with 113 controls. The subaortic membrane resection group included isolated subaortic membranes (n = 34, group I), associated with ventricular septal defect (n = 29, group II), or patent ductus arteriosus (n = 50, group III). RESULTS: Mean (± standard deviation) AoSA (in degrees) were not different between subaortic membrane groups I, II, and III but were steeper than their control groups (126.2 ± 9.2 vs 138.6 ± 7.0, 129.2 ± 9.9 vs 137.7 ± 10.0, and 126.2 ± 8.1 vs 135 ± 8.5, respectively; all Ps < .05). Additionally, group II had lower preoperative gradients (28.8 ± 20.7 mm Hg) compared to groups I and III (67.0 ± 32.9 and 66.2 ± 33.1 mm Hg, respectively, P < .001). Follow-up ranged from 3 to 132 months. In 22 (32%) patients, a subaortic membrane recurred. Early postoperative residual gradients and development of aortic regurgutation were associated with the need for reoperation (P < .05). CONCLUSIONS: These findings suggest a contributing role of the AoSA in the development of subaortic membrane. Further rheological experiments are warranted. Whether the steeper the angle the higher the risk of recurrence may be revealed by longer follow-up periods.

Persistent institutional difficulties in surgery for transposition of the great arteries in guatemala: analysis with the aristotle basic and comprehensive scores.

Background. Neonates with complex congenital cardiac lesions are largely inadequately managed in Guatemala. Methods. Between 1997 and 2009, 79 patients who underwent operations for transposition of the great arteries were identified; 51 (63.3%) had an arterial switch operation (ASO) and 28 (36%) an atrial switch operation (ATSO). The Aristotle Basic Complexity score (ABC score) and the Aristotle Comprehensive Complexity score (ACC score) have been used to aid in the evaluation of quality of care associated with pediatric cardiac surgery by adjusting for operative complexity. Results. In-hospital mortality was 47% for the ASO and 25% for the ATSO group; 36.7% were beyond 1 month of age and many exhibited increased preoperative risk factors. The mean ABC score was 9.75 ± 0.89 and the ACC score was 12.12 ± 2.7, with a mean 2.36-point increase (P < .05). Comparing survivors and nonsurvivors with both scores, significant differences were identified (ABC: P < .04 and ACC: P < .02). Conclusion. During this 13-year period, a low volume of surgery for transposition of the great arteries (TGA) was performed at our institution with a relatively high surgical mortality. Many patients with TGA in Guatemala are either never referred for surgery or referred late. Strategies to improve outcomes for neonates with TGA in Guatemala must include increases in early diagnosis countrywide and prompt referral to our unit. Based on the larger number of neonates with TGA that would be referred to our center, we anticipate that this strategy should substantially improve surgical outcomes and favor overall team-related skills.

Antibiotic sandwich patch for ventricular septal defect complicated by endocarditis.

Infective endocarditis in patients with ventricular septal defects can prove life threatening due to acute heart failure or septic embolization. Persistent postoperative risk is bacterial colonization of prosthetic material. We designed the Antibiotic Sandwich Patch to reduce this risk, using a double layer of autologous pericardium containing antibiotic powder. Five patients were managed with this technique for closure of ventricular septal defects complicated by acute infective endocarditis. No colonization of the patches occurred after a median follow up of 1.5 years. This technique reduced the risk of bacterial colonization of the antibiotic sandwich patch, offering an additional surgical option.

The right-sided window ductus: a rare anatomical entity.

A rare type of patent ductus arteriosus called window ductus was identified in association with a right aortic arch in a 1-year-old child who was referred for closure of a membranous ventricular septal defect.

Pulmonary artery hypertension: is it really a contraindicating factor for early extubation in children after cardiac surgery?

BACKGROUND: One of the perceived major contraindications to early extubation after pediatric cardiac surgery is preoperative pulmonary arterial hypertension (PAH). The objective of this study is to present the results of early extubation (within 6 hours after open heart surgery) in children who had varying degrees of preoperative pulmonary arterial hypertension. METHODS: We reviewed the charts of 100 consecutive children who underwent subaortic ventricular septal defect closure and also had preoperative PAH. Outcomes measured included early extubation rate, clinical status of patients, and hospital costs. RESULTS: The median age at surgery was 2.5 years (range, 0.4 to 30). Sixty-five patients were extubated successfully in the operating room; 25 additional patients were extubated in the intensive care unit within 6 hours from surgery, increasing the early extubation rate from 65% to 90%. Postoperative complications were present in 12 patients; 10 of these patients required mechanical ventilation for more than 6 hours, and 1 of them died postoperatively in septic shock. Two patients required reintubation 25 and 26 hours, respectively, after initial extubation in the operating room, for causes unrelated to pulmonary hypertensive crises or ventilatory failure. The mean cost of procedures in patients who had successful early extubation was USD 3,786.50 +/- 302.45. Every additional day in the intensive care unit, in case of delayed extubation, increased the overall cost of the procedure by 10%. CONCLUSIONS: Pulmonary artery hypertension does not seems to be a contraindicating factor to early extubation in patients who underwent ventricular septal defect closure, and may be considered a feasible way to decrease postoperative intensive care unit stay and hospital costs.

Surgical versus percutaneous occlusion of ostium secundum atrial septal defects: results and cost-effective considerations in a low-income country.

OBJECTIVES: We compared the effectiveness and cost of percutaneous occlusion using an Amplatzer septal occluder (ASO) (AGA Medical Corp., Golden Valley, Minnesota) device compared with surgical closure of an ostium secundum atrial septal defect (ASD II) in Guatemala. BACKGROUND: The percutaneous occlusion of ASD II in first-world nations seems to offer better clinical results and lower cost compared with surgical closure. METHODS: We reviewed the clinical course of 111 patients referred to our institution for closure of isolated ASD II. Successful closure was assessed immediately after the procedures and at 12 months. Actual hospital costs were calculated for every patient who underwent either of the two procedures. RESULTS: Eighty-three patients with ASD II (75%) were selected for percutaneous occlusion with the ASO device, and the remaining 28 patients (25%) underwent surgical closure. In the device group, in 72 patients (86.7%) devices were successfully deployed. At immediate and 12-month follow-up, the complete closure rate was 87.5% (63 of 72 patients) and 97.2% (70 of 71 patients), respectively. In the surgical group, all patients had successful closure immediately after the procedure and at 12 months. Surgical closure offered a 27% cost savings in comparison with percutaneous occlusion (U.S. 3,329.50 dollars +/- 411.30 dollars and U.S. 4,521.03 dollars +/- 429.71 dollars; p < 0.001, respectively). Cost of the device (U.S. 2,930.00 dollars) proved to be the main cause for this difference. CONCLUSIONS: We confirmed the clinical advantages of percutaneous occlusion over surgical closure of ASD II. However, percutaneous occlusion costs were higher compared with surgical closure. In Guatemala, where health care resources are limited, ASD II closure with the ASO device did not prove to be cost-effective.

Modified extrapleural ligation of patent ductus arteriosus: a convenient surgical approach in a developing country.

BACKGROUND: Minimally invasive surgery for the closure of a large patent ductus arteriosus (PDA) using an extrapleural technique offers an alternative to other minimally invasive approaches such as video-assisted thoracoscopic surgery or interventional cardiologic procedures. METHODS: Between August 1999 and December 2003, 513 patients with PDA were admitted to Unidad de Cirugia Cardiovascular de Guatemala, of whom 327 (64%) were considered surgical candidates. Of these, 218 (67%) were selected for surgical extrapleural (SEP) closure initially by weight (< 10 kg) and a ductal diameter at the pulmonary end of greater than 4 mm. Subsequently, we included also patients who weighed more than 10 kg. Median age at operation was 51 months (range 5 days to 38 years). RESULTS: Median operating time was 32 minutes (range 23 to 52 minutes). All 218 patients had SEP closure and were extubated in the operating room. There were no hospital deaths. Two patients required a blood transfusion. Two additional patients bled postoperatively, requiring reoperation. A pneumothorax occurred in 3 patients that required a chest tube. The 6-month follow-up revealed residual ductal shunts in 2 patients that were closed percutaneously with a coil. The treatment of the remaining 295 patients included a surgical transpleural (STP) approach in 109 (37%) and transcatheter closure in 186 (63%), with a coil in 110 (37%) and an Amplatzer device in 76 (26%). CONCLUSIONS: Minimally invasive closure of a PDA through a short, 3-cm to 5-cm skin and muscle-sparing posterior thoracotomy and an SEP approach provides a convenient and safe technique with a low incidence of complications and also a cost-saving option compared with other invasive techniques.