Feasibility and Utility of Adenosine Stress Echocardiography in Children Following Post-Arterial Switch Operation: A Comparison with Technetium 99m-Sestamibi Myocardial Perfusion SPECT (MPS).

There is a need for a sensitive, safe, and cost-effective tool for coronary assessment among asymptomatic post-operative children who have undergone arterial switch operation (ASO) for transposition of great arteries (TGA). Adenosine stress echocardiography may be useful in assessing major structures as well for coronary functional assessment. Twenty-six children [median age 6.0 years; IQR 4.9-7.1 years, (22 boys)], who had undergone ASO at a median age of 40 days (IQR 30-75 days), were prospectively included. Left ventricular ejection fraction (LVEF) was calculated in both rest and stress studies (140 µg/kg/min of adenosine IV over 4 min), along with assessment of regional myocardial wall motion. Coronary flow reserve (CFR) was also measured in the left anterior descending artery (LAD). Technetium 99m-MIBI [0.2mCi/kg] was injected after 2 min of adenosine infusion. Adenosine infusion had to be stopped in two children, due to transient atrioventricular (AV) block. The LVEF increased from 55.87 ± 7.27 to 61.20 ± 7.70% (p < 0.001) with adenosine stress. No significant regional wall motion abnormality was seen in rest or stress. Distal LAD could not be visualized in four patients. Basal and peak coronary flow velocities were 41.51 ± 14.12 and 74.18 ± 6.01 cm/s. Mean CFR was 1.91 ± 0.51. Myocardial perfusion scintigraphy (MPS) was normal in all the patients. Four patients were lost to follow-up and remaining children did not develop any adverse events in the follow-up period of 64.5 ± 7.19 months. Adenosine stress echocardiography is feasible as the initial screening test in the assessment of asymptomatic post-operative children with ASO, at minimal to no inconvenience to the patient. The findings concurred with stress MPS.

Comparison of the Efficacy of Ultrasound-Guided Serratus Anterior Plane Block, Pectoral Nerves II Block, and Intercostal Nerve Block for the Management of Postoperative Thoracotomy Pain After Pediatric Cardiac Surgery.

OBJECTIVE: The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery. DESIGN: A prospective, randomized, single-blind, comparative study. SETTING: Single-institution tertiary referral cardiac center. PARTICIPANTS: The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy. INTERVENTIONS: Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS: A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups. CONCLUSION: SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB.

Bilateral Erector Spinae Plane Block for Acute Post-Surgical Pain in Adult Cardiac Surgical Patients: A Randomized Controlled Trial.

OBJECTIVES: To examine the analgesic efficacy of bilateral erector spinae plane (ESP) block compared with conventional treatment for pain after cardiac surgery in adult patients. DESIGN: A prospective, randomized, controlled, single-blinded study. SETTING: Single-center tertiary teaching hospital. PARTICIPANTS: One hundred and six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Patients were randomized into 2 groups. Patients in group 1 (ESP block group, n = 53) received ultrasound-guided bilateral ESP block with 3 mg/kg of 0.375% ropivacaine before anesthesia induction at the T6 transverse process level. Patients in group 2 (paracetamol and tramadol group, n = 53) received paracetamol (1 gm every 6 hours) and tramadol (50 mg every 8 hours) intravenously in the postoperative period. The primary study outcome was to evaluate pain at rest using an 11-point numeric rating scale (NRS). Mann-Whitney U test was used for comparing NRS scores. MEASUREMENTS AND MAIN RESULTS: The postoperative pain level after extubation and duration of analgesia during which NRS was < 4 of 10 was compared between the groups. The median pain score at rest after extubation in group 1 was 0 of 10 until hour 6, 3 of 10 at hour 8, and 4 of 10 at hours 10 and 12 postextubation. These were significantly less in comparison with group 2 (p = 0.0001). Patients in group 1 had a significantly higher mean duration of analgesia (8.98 ± 0.14 hours), during which NRS was < 4 of 10, compared with group 2 (4.60 ± 0.12 hours) (p = 0.0001). CONCLUSION: ESP block safely provided significantly better pain relief at rest for longer duration as compared to intravenous paracetamol and tramadol.

Trileaflet pulmonary valve reconstruction with the Ozaki technique in an adult patient of tetralogy of Fallot with absent pulmonary valve.

Pulmonary valve interventions are one of the most common cardiac interventions that are being performed in patients with a wide variety of congenital heart diseases, more so in adults with congenital heart disease. Despite the introduction of various different reconstructive techniques and conduits, the ideal option still remains elusive. Lack of growth and re-operation for conduit replacement remains an Achilles heel in such conduits. So, surgeons have constantly tried to evolve surgical techniques that would obviate their use and allow age-related growth. The Ozaki procedure has proven to be technically reproducible and have excellent mid-term results in the aortic position in adults. Extending the same principle for reconstruction of the pulmonary valve can prove to be a reasonable alternative. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01469-1.

Abernethy malformation type 2: varied presentation, management and outcome.

PURPOSE: To study the varied presentations and the outcomes in children with Type 2 Abernethy malformation following shunt ligation. MATERIAL AND METHODS: Children with Type 2 Abernethy who had had been operated between 2013 and 2017 were included in the study. The diagnosis had been confirmed on ultrasonography, CECT or angiography. All patients underwent laparotomy. The shunt was identified, clamped and the bowel congestion was noted. The shunt was ligated if the bowel congestion was not significant or had improved. Relevant follow-up investigations were done to document the resolution or amelioration of symptoms and the patency of the shunt. RESULTS: Five patients were included in the study with a median age of 6 years. Hepatopulmonary syndrome was the presentation in 4 patients while one patient presented with liver tumor. Ultrasonography and CECT were able to diagnose Type 2 malformation in 4 patients whereas in 1 patient the distal portal vein was not seen. The postoperative period was complicated in 3 patients. At the median follow up at 14 months, good intrahepatic portal flow in all patients. All patients demonstrated improvement/ resolution of symptoms. CONCLUSION: Abernethy is rare malformation which can have a varied presentation. Additional investigations may be needed to confirm the diagnosis of Type 2 variety. Most patients have gradual improvement of symptoms. LEVEL OF EVIDENCE: Level IV/ Treatment study.