Hybrid approach for closure of muscular ventricular septal defects.

BACKGROUND: The complexity of ventricular septal defects in early infancy led to development of new mini-invasive techniques based on collaboration of cardiac surgeons with interventional cardiologists, called hybrid procedures. Hybrid therapies aim to combine the advantages of surgical and interventional techniques in an effort to reduce the invasiveness. The aim of this study was to present our approach with mVSD patients and initial results in the development of a mini-invasive hybrid procedure in the Gdansk Hybrid Heartlink Programme (GHHP) at the Department of Pediatric Cardiac Surgery, Pomeranian Centre of Traumatology in Gdansk, Poland. MATERIAL AND METHODS: The group of 11 children with mVSDs was enrolled in GHHP and 6 were finally qualified to hybrid trans-ventricular mVSD device closure. Mean age at time of hybrid procedure was 8.22 months (range: from 2.7 to 17.8 months, SD=5.1) and mean body weight was 6.3 kg (range: from 3.4 to 7.5 kg, SD=1.5). RESULTS: The implants of choice were Amplatzer VSD Occluder and Amplatzer Duct Occluder II (AGA Med. Corp, USA). The position of the implants was checked carefully before releasing the device with both transesophageal echocardiography and epicardial echocardiography. All patients survived and their general condition improved. No complications occurred. The closure of mVSD was complete in all children. CONCLUSIONS: Hybrid procedures of periventricular muscular VSD closure appear feasible and effective for patients with septal defects with morphology unsuitable for classic surgical or interventional procedures. The modern strategy of joint cardiac surgical and interventional techniques provides the benefits of close cooperation between cardiac surgeon and interventional cardiologist for selected patients in difficult clinical settings.

Candidemia in children after complex congenital heart defects surgery treated with caspofungin--our own experience and a review of literature.

BACKGROUND: Invasive fungal infections due to Candida species constitute an increasing clinical problem. There are no guidelines for the management of candidemia in children undergoing surgical procedures for congenital heart defects (CHD). The aim of the study was to draw attention to the problem of candidemia in children who are operated on due to congenital heart defects. MATERIAL/METHODS: We retrospectively analyzed medical documentation of 307 children with congenital heart defects treated in 1 clinical centre in Poland, from whom we selected those diagnosed with candidemia during the postoperative period. Next, we analyzed in detail the clinical course of invasive candidiasis in each individual and we performed an analysis of risk factors that lead to candidemia. RESULTS: In the analyzed period, among 307 children who underwent surgical procedures, we observed 2 cases of candidemia (0.65%) which were effectively cured with caspofungin. No adverse effects were observed after treatment with the drug. CONCLUSIONS: Candidemia in children who undergo surgical treatment of congenital heart defects is an important factor that can influence final clinical results. Caspofungin may be an effective therapeutic option when treating candidemia in children after extensive cardiosurgical procedures.

Delayed closure of multiple muscular ventricular septal defects in an infant after coarctation repair and a hybrid procedure--a case report.

There are several strategies of surgical approach for the repair of multiple muscular ventricular septal defects (mVSDs), but none leads to a fully predictable, satisfactory therapeutic outcome in infants. We followed a concept of treating multiple mVSDs consisting of a hybrid approach based on intraoperative perventricular implantation of occluding devices. In this report, we describe a 2-step procedure consisting of a final hybrid approach for multiple mVSDs in the infant following initial coarctation repair with pulmonary artery banding in the newborn. At 7 months, sternotomy and debanding were performed, the right ventricle was punctured under transesophageal echocardiographic guidance, and the 8-mm device was implanted into the septal defect. Color Doppler echocardiography results showed complete closure of all VSDs by 11 months after surgery, probably via a mechanism of a localized inflammatory response reaction, ventricular septum growth, and implant endothelization.

Effects of thoracic epidural anaesthesia on cardiac repolarization.

1. Prolongation of the QT interval is associated with a risk of life-threatening cardiac arrhythmias. In the present study, we examined whether reversible blockade of preganglionic sympathetic fibres of the heart, achieved by thoracic epidural anaesthesia, affects cardiac repolarization and thus confers an anti-arrhythmic effect. 2. Fifty-two men, aged between 28 and 65 years, were included in the study: 28 were patients scheduled for thoracic epidural anaesthesia (Group T) and 24 were patients scheduled for lumbar epidural anaesthesia (Group L). Epidural blockade was achieved with 0.5% isobaric bupivacaine solution. Measurements were taken from electrocardiogram fragments obtained before epidural anaesthesia and after detection of blockade (T1 or T8 segment sensory block in Groups T and L, respectively). Correction of the QT interval was calculated using Bazett's formula (QTcb), Fridericia's correction (QTcf) and the Framingham formula (QTcF). Transmural dispersion of repolarization (TDR) was determined using the Tpeak--Tend time, where Tpeak is the peak of the T wave and Tend is the end of the T wave. 3. Significant shortening of the QTcb interval and TDR was detected after blockade in Group T. However, there were no changes in the ECG parameters in Group L. 4. In conclusion, reversible blockade of preganglionic sympathetic fibres to the heart, achieved by thoracic epidural anaesthesia, results in a reduction in QTcb, as well as the TDR. These changes may explain the anti-arrhythmic action seen with central blockade.

[Effectiveness of total parenteral nutrition in critically ill patients]. / Ocena skutecznosci calkowitego zywienia pozajelitowego krytycznie chorych.

BACKGROUND: Stress metabolism that develops in critically ill patients leads to acute malnutrition in approximately 40% of intensive care patients. Many of them cannot be fed enterally, and total parenteral nutrition (TPN) is necessary. On the other hand, TPN is often not fully effective, and may be associated with various side effects and complications. We have assessed our practice by seeking the answers to three questions: (1) Was the TPN sufficient and adequate? (2) Did the TPN improve the nutritional status of patients? and (3) Were there any disease-dependent differences? METHODS: Seventy-one adult patients receiving TPN for at least 2 weeks, were allocated to five groups according to their underlying disease: A--patients after cardiovascular surgery, B--patients with acute pancreatitis, C--multiple trauma victims, D--patients after abdominal surgery; and E--septic or leukemic patients.The following parameters were assessed twice a week, in all cases: serum total protein, albumin, glucose, triglycerides, total cholesterol, and C-reactive protein, as well as nitrogen daily excretion and nitrogen balance. All patients were receiving "all-in-one" nutritional mixtures, consisting of amino acids, glucose, electrolytes, fat emulsion, vitamins and microelements. RESULTS: TPN increased serum total protein and serum albumin concentrations and improved nitrogen balance in all patients. Nutritional status also improved, regardless of underlying disease. Hyperglycemia was common, but glucose concentrations did not differ among the groups. There were no TPN-related complications. CONCLUSION: We conclude that, in the categories of patients studied, standard TPN is sufficient for improvement of nutritional status during life-threatening illness.

[Perioperative assessment of body temperature in elderly patients during thoracic surgery]. / Sródoperacyjna ocena cieploty ciala u chorych w podeszlym wieku poddanych operacjom torakochirurgicznym.

Within the last years there is observed the increase in number of elder patients operated in planned terms. Perioperative disorders of thermoregulation are strongly expressed in the group of patients, and the number of complications rises significantly during inadvertent perioperative hypothermia. The aim of this study was estimation of body temperature in patients subjected to thoracosurgical operations. The study was performed in 23 patients older than 65 years, which were divided into 2 groups. In the group I (12 persons) we used usual methods of heat loss prevention. In group II there were used: passive methods of protection against heat loss as well as Hotline blood and fluids warmer with the possibility of intravenous fluids warming. The body temperature was estimated every 30 minutes. The temperature detectors were located on plantar surface of hallux and in nasopharynx. We observed statistically significant decrease in body temperature values in group I. We conclude that there is the necessarity of the using of accessory methods of heat loss prevention in elder patients subjected to thoracosurgery.

Miniinvasive hybrid procedure for device migration after percutaneous closure of persistent arterial duct: a case report.

We report a case of an 8-month-old girl admitted to the Department of Paediatric Cardiac Surgery, Pomeranian Centre of Traumatology in Gdansk with migration of an Amplatzer Duct Occluder II device (AGA Med. Corp., USA) to the left pulmonary artery after interventional patent arterial duct (PDA) closure. Using a hybrid strategy, we performed a classical surgical closure of the PDA with simultaneous intraoperative miniinvasive catheter removal of the displaced implant from the left pulmonary artery using a muscle bioptome (Cook, EU). The procedure was successful, without any further complications. Percutaneous procedures of PDA closure in small children, although safe and effective, are associated with a risk of accompanying complications, especially in patients with inconvenient anatomy. Our strategy demonstrates that a miniinvasive hybrid strategy could be beneficial for the patient with implant PDA migration after a failed interventional procedure. We strictly maintain the practice of qualifying these borderline patients with great care to avoid predictable complications, and to provide immediate surgical support in any emergency, following modern models of cooperation between cardiologists and cardiac surgeons in hybrid heart teams. A modern strategy that combines miniinvasive cardiac surgery with interventional techniques provides new, effective algorithms for selective difficult clinical settings.

[Intraoperative imaging of hybrid procedure for muscular ventricular septal defects closure with Amplatzer Duct Occluder II]. / Sródoperacyjne obrazowanie hybrydowego zabiegu zamkniecia ubytku w przegrodzie miedzykomorowej za pomoca Amplatzer Duct Occluder II.

Hybrid approach becomes a promising conception of an alternative treatment for muscular ventricular septal defects (VSD) closure in infants. In this paper we report epicardial echocardiography imaging that enabled successful hybrid procedure performed in premature infant referred for surgical correction of a large perimembraneous VSD with simultaneous perventricular approach for concomitant muscular VSD.