Left ventricular mass index and subendocardial myocardial function in children with chronic kidney disease, a transmural strain and three-dimensional echocardiographic study.

Introduction: Left ventricular hypertrophy (LVH) is the commonest myocardial response to chronic kidney disease (CKD); this response has been regarded detrimental as it impairs the blood flow to the deepest layers of the myocardium causing progressive myocardial dysfunction. The aim of these series is to assess the determinants of LVH in CKD patients and its impact on subendocardial function in such patients. Methods: This study has been conducted on 40 CKD patients (Group 1) and 40 age-matched controls, both groups were assessed by transmural echocardiography to determine the subepicardial and subendocardial global longitudinal strain (GLS) as an expression of the systolic function of each of those layers. LVH was assessed by calculation of left ventricle mass index (LVMI). Both groups underwent ambulatory blood pressure monitoring. Group 1 was assessed as regards lipid profile and insulin resistance by homeostasis model assessment of insulin resistance (HOMA-IR). Results: HOMA-IR proved to be a more important determinant of LV hypertrophy than SBP and DBP with a P of 0.01. Moreover subendocardial GLS was negatively correlated with LVMI with r = 0.69 and P < 0.01 denoting the negative effect. LVH plays on subendocardial function probably by impairing myocardial perfusion. Conclusion: This study points toward the importance of insulin resistance in aggravation of myocardial remodeling in CKD patients; more studies are warranted to examine the role of insulin Sensitizers in reversing such remodeling and restoring subendocardial function in such important systemic disorder.

Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2 years.

BACKGROUND: Junctional ectopic tachycardia is a serious arrhythmia that frequently occurs after tetralogy of Fallot repair. Arrhythmia prophylaxis is not feasible for all pediatric cardiac surgery patients and identification of high risk patients is required. The objectives of this study were to characterize patients with JET, identify its predictors and subsequent complications and the effect of various treatment strategies on the outcomes in selected TOF patients undergoing total repair before 2 years of age. METHODS: From 2003 to 2017, 609 patients had Tetralogy of Fallot repair, 322 were included in our study. We excluded patients above 2 years and patients with preoperative arrhythmia. 29.8% of the patients (n = 96) had postoperative JET. RESULTS: JET patients were younger and had higher preoperative heart rate. Independent predictors of JET were younger age, higher preoperative heart rate, cyanotic spells, non-use of B-blockers and low Mg and Ca (p = 0.011, 0.018, 0.024, 0.001, 0.004 and 0.001; respectively). JET didn't affect the duration of mechanical ventilation nor hospital stay (p = 0.12 and 0.2 respectively) but prolonged the ICU stay (p = 0.011). JET resolved in 39.5% (n = 38) of patients responding to conventional measures. Amiodarone was used in 31.25% (n = 30) of patients and its use was associated with longer ICU stay (p = 0.017). Ventricular pacing was required in 4 patients (5.2%). Median duration of JET was 30.5 h and 5 patients had recurrent JET episode. Timing of JET onset didn't affect ICU (p = 0.43) or hospital stay (p = 0.14) however, long duration of JET increased ICU and hospital stay (p = 0.02 and 0.009; respectively). CONCLUSION: JET increases ICU stay after TOF repair. Preoperative B-blockers significantly reduced JET. Patients with preoperative risk factors could benefit from preoperative arrhythmia prophylaxis and aggressive management of postoperative electrolyte disturbance is essential.

Diaphragmatic nerve palsy after cardiac surgery in children in Egypt: outcome and debate in management.

INTRODUCTION: Diaphragmatic paralysis (DP) due to phrenic nerve injury is a complication which occurs in association with congenital cardiac surgery and may be a life-threatening event in infants and young children. Information about this complication is still scarce from the developing countries. METHODS: Retrospective study evaluated the incidence of DP among 414 patients who underwent congenital cardiac surgery in Abo Elriesh Children's Specialized Hospital, Cairo University, Egypt, in the duration from April 2009 to December 2011. RESULTS: Incidence of DP was 3.6% (15 of 414 cases). Median age of affected patients was 10 months (ranged from 1 month to 13 years). Diagnosis of DP was observed after ventricular septal defect repair (3.9%), Glenn anastomosis (8.6%), Tetralogy of Fallot repair (4.3%), Senning operation (10%), arterial switch operation (3.2%), Fontan procedure (33%), coarctation of the aorta repair (7%), and pulmonary artery banding (6.4%). Diaphragmatic plication was performed in 4 of 15 cases. Patients with DP had significantly prolonged mechanical ventilation duration as compared to unaffected patients (median 120, range 48-600 vs 4, range 0-48 hours, P < .000). They also had a higher incidence of nosocomial pneumonia in 8 of 15 (53%) cases, longer duration of intensive care unit stay (median 15, range 4-62 days, P < .006), and significant mortality in 7 of 15 (46%; P < .004). Mortality among patients who underwent diaphragm plication was 1 of 4 (25%). CONCLUSION: Diaphragmatic paralysis is a relatively rare complication of congenital cardiac surgery in children. Its occurrence is associated with increased morbidity and mortality. A high index of clinical suspicion, utilization of bedside diagnostic tools, and a policy of early plication for certain patients may lead to improved outcomes.

Epidemiology of nosocomial infections and mortality following congenital cardiac surgery in Cairo University, Egypt.

BACKGROUND: Nosocomial infections (NI) have been associated with significant morbidity and attributed mortality, as well as increased healthcare costs. Relatively few data on congenital cardiac surgical ICU NI have been reported from developing countries. Little is known about the epidemiology of NI following congenital cardiac surgery in Egypt. The aims of the present study were: (a) to estimate the incidence rate and types of NI among children admitted to Pediatric Surgical Cardiac ICU in Cairo University Children's Hospital (Egypt) and (b) to estimate the mortality rate related to congenital cardiac surgery and identify its contributing risk factors. PARTICIPANTS AND METHODS: A follow-up study in the period between 1 January 2009 and 1 January 2010 included all patients admitted to the Pediatric Surgical Cardiac ICU in Cairo University, Abo El Reesh Children's Specialized Hospital (Egypt). Data were collected for each patient during the preoperative, intraoperative, and postoperative periods. Certain infection control procedures were carried out in certain months. RESULTS: Of 175 patients, NI were identified in 119 (68%). Poor hand hygiene was associated with increased NI in certain months of the study duration. NI were significantly higher at a younger age [median 9 (5-30) months, P<0.03]. Mortality was found in 54 patients, that is, 31% of the study population. Mortality was significantly observed with younger age, higher complexity score for congenital cardiac lesions, prolonged cardiopulmonary bypass and ischemic times, NI, prolonged mechanical ventilation, prolonged central line insertion, and the use of total parenteral nutrition. Mortality among the NI patients was found in 44 of 119 (37%). On carrying out a multivariate analysis, Acute Physiology and Chronic Health Evaluation II score [P<0.001, odds ratio (OR) 1.13, 95% confidence interval (CI) 1-1.2], age (P<0.001, OR 0.3, 95% CI 0.2-0.4), and prolonged duration of mechanical ventilation (P<0.03, OR 2.8, 95% CI 1.1-7.2) were identified as risk factors of mortality. CONCLUSION AND RECOMMENDATIONS: NI rate and subsequent mortality were high among cases followed up during the period from 1 January 2009 to 1 January 2010 in the University Children's Hospital (Cairo, Egypt). Early surgical interference, enforcement of proper infection control practices, especially hand hygiene, can reduce NI and trials for early extubation from mechanical ventilation might improve outcome following congenital cardiac surgery in pediatrics.