Axillary arterial access for balloon dilatation of coarctation of aorta in newborns: a case series.

Balloon dilatation of coarctation of aorta is a standard of care for the patients presenting with severe left ventricular dysfunction. It can be performed through femoral, carotid, and axillary arterial access. Very few case series were available in the literature through axillary arterial access, despite being its advantage as non-end artery and easily palpable in coarctation of aorta. We present our experience with five cases of neonatal coarctation of aorta with severe left ventricular dysfunction where successful balloon dilatation of coarctation of aorta was performed via axillary approach without adverse events.

Techniques to repair parachute tricuspid valve.

Parachute deformity of atrioventricular valve occurs when chordae tendineae arise either from one papillary muscle or a closely placed muscle group. Preoperative detection is easier with mitral involvement than with tricuspid valve. We present two cases of parachute tricuspid valve (PTV) which were successfully repaired.

Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases.

OBJECTIVE: In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Flexible fiber-optic bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in pediatric cardiac intensive care units (PCICU). The objective of this study was to evaluate the utility of FFB in children with congenital heart disease (CHD). MATERIALS AND METHODS: A retrospective, descriptive study was conducted at a tertiary care center in pediatric patients who underwent FFB in PCICU over a period of 6 years (2012-2017). RESULTS: Total 71 bronchoscopies were done in 58 patients with CHD with median age and weight of 2.5 months and 3.4 kg, respectively. Total of 20 different cardiac lesions were present among patients who underwent FFB. While 38 (53.5%) and 30 (42.3%) procedures were performed in pre-op and postoperative patients, respectively, 3 intraoperative bronchoscopies were also performed. The main indications for FFB were persistent atelectasis (42/71), prolonged oxygen requirement (13/71), stridor (8/71), and suspected airway anomaly (6/71). Tracheobronchitis was the commonest bronchoscopy finding (51/71, 71.8%) followed by tracheobronchomalacia (27/71, 38.3%). Cause of stridor detected in 7/8 cases. Associated preoperative and postoperative respiratory complications were detected and necessary interventions were done. These included slide tracheoplasty (5/58), tracheostomy (5/58), antibiotic change based on bronchoalveolar lavage (BAL) cultures (11/71), and continued positive pressure ventilation (4/71). Nonconsequential complications were transient hypoxemia (10/71), bleeding (2/71), and transient bradycardia (1/71). CONCLUSION: Bedside FFB is a safe and a valuable diagnostic tool that also helps in guiding interventions in children with cardiac diseases. HOW TO CITE THIS ARTICLE: Sachdev A, Chhawchharia R, Gupta D, Gupta N, Joshi R, Agarwal N. Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases. Indian J Crit Care Med 2020;24(5):340-343.

Assessment of Risk Factors for a Sustainable "On-Table Extubation" Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience.

OBJECTIVE: To delineate risk factors for failure of extubation in the operating room among pediatric cardiac surgery patients. DESIGN: Prospective, observational study. SETTING: Single center, tertiary care, teaching hospital. PARTICIPANTS: The study comprised 448 congenital cardiac surgery patients who were enrolled for intended extubation in the pediatric cardiac operating room over 5 years. INTERVENTIONS: The airways of enrolled patients were extubated in the operating room if predetermined suitability criteria were met. If the criteria were not met, patients were transferred to the intensive care unit with an endotracheal tube in situ. Patients whose airways were extubated successfully were followed up to determine specifically whether reintubation or use of noninvasive ventilation was necessary post-procedure. MEASUREMENTS AND MAIN RESULTS: The airways of 92% (412) patients were extubated in the operating room. Incidence of reintubation in the intensive care unit was 2.4%. There were 4 mortalities in the whole group. A 100% success rate for operating room extubation was achieved for patients in Risk Adjusted Congenital Heart Surgery category 1, and patients undergoing adult congenital cardiac disease surgery and redo sternotomy. The airways of 85% of patients with preoperative pulmonary hypertension were extubated in the operating room. Statistical analysis was applied to identify risk factors present in the group that made extubation in the operating room unachievable. CONCLUSIONS: Extubation in the operating room was successful in a majority of patients undergoing cardiac surgery. Multivariate analysis identified weight<5 kg, age<1 year, cardiopulmonary bypass time>120 minutes, and presence of significant noncardiac structural anomalies as significant factors affecting extubation in the operating room, with an adjusted odds ratio (95% confidence interval) of 10 (2.7-37), 7.2 (2-22), 5.5 (1.7-17.7), and 3.3 (1.2-9.3), respectively. Pulmonary hypertension, redo sternotomy, higher Risk Adjusted Congenital Heart Surgery category, and aortic clamp time>60 minutes did not achieve significance in the multivariate analysis as risk factors for extubation in the operating room.

Mitral annular disjunction with atrial septal defect in children: An intriguing association.

Mitral annular disjunction (MAD) is defined as a separation between the mitral annulus and the left ventricular myocardium and is most often seen in association with mitral valve prolapse (MVP). MAD has been linked to ventricular arrhythmias in adults, independent of MVP. However, it has rarely been reported in children. We, hereby, report two cases of MAD associated with a large atrial septal defect (ASD). Thus far, there are no consensus guidelines for the management of MAD. The additional association of large ASD further complicates the decision-making in these patients. To the best of our knowledge, this is the first report of the association of MAD with ASD. We further discuss the challenges in the management of this condition.

Chylothorax in Infants and Children After Congenital Heart Surgery: Approach and Review.

Chylothorax in infants after surgery for congenital heart disease is associated with significant morbidity and mortality. Numerous management modalities applied alone or in various combinations have been utilized but definitive guidelines have not yet been established. We present two infants who developed refractory chylothorax after congenital heart surgery. We also reviewed evidence for the use of available treatment modalities. In our experience, the use of lymphangiography followed by pleurodesis by povidone-iodine was safe and our impression was that it may have played a decisive role in controlling the lymph leak.

Comparison of Levosimendan Versus Milrinone After the Arterial Switch Operation for Infants ≤3†kg.

Background: Various inotropes and inodilators have been utilized to treat low cardiac output syndrome after the arterial switch operation. The use of levosimendan, a calcium sensitizer has been limited in this setting. This study compares the effects of levosimendan with milrinone in managing low cardiac output after the arterial switch operation. Methods: A retrospective, comparative study was conducted in a tertiary care hospital on patients weighing up to 3 kg undergoing the arterial switch operation between January 2017 and January 2022. Patients received a loading dose followed by continuous infusion of either levosimendan or milrinone. Echocardiographic, hemodynamic and biochemical parameters were compared. Results: Forty-three patients received levosimendan and 42 patients received milrinone as the primary test drug. Cardiac index of less than 2.2 L/min/m2 on postoperative day 1 and 2 was found in 9.3% and 2.3% of patients receiving levosimendan versus 26.2% and 11.9% in those receiving milrinone, respectively (P = .04 and .08, respectively). Early lactate-clearance and better central venous oxygen saturations were noted in the levosimendan group. Prevalence of acute kidney injury was higher in the milrinone group (50% vs 28%; P = .03). Use of peritoneal dialysis in the milrinone group versus levosimendan was 31% and 16.3%, respectively (P = .11). There was no difference in hospital mortality between the groups (milrinone, 3; levosimendan, 2, P = .62). Conclusions: Levosimendan is safe and as effective as milrinone to treat low cardiac output syndrome occurring in neonates after the arterial switch operation. In addition we found that levosimendan was renal protective when compared with milrinone.

"Prolonged" venoarterial extracorporeal membrane oxygenation support for respiratory failure: Outcome in an infant.

Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support which provides cardiorespiratory support to patients with potentially reversible pathophysiological processes. ECMO has evolved over the past few decades as a standard technology for neonatal severe respiratory support. However, its use in the pediatric population has increased only since 2009. We report a case of a 9-month infant who required a prolonged (789 h) venoarterial ECMO for severe acute respiratory distress consequent to pneumonia probably secondary to aspiration. He was discharged after this prolonged ECMO run without any obvious unfavorable outcome and is neurodevelopmentally sound at a 26-month follow-up.

Perfusion Strategy to Prevent Right Ventricular Decompression on Cardiopulmonary Bypass During Extracardiac Fontan for Right Ventricle-Dependent Coronary Circulation.

Early and long-term outcomes in patients with pulmonary atresia-intact ventricular septum undergoing staged univentricular palliations have been known to be adversely affected by the presence of right ventricle-dependent coronary circulation. We describe a surgical technique to circumvent the coronary insufficiency caused by acute decompression of the right heart.

Outcomes of primary repair of sternal cleft defects: Providing a "bony cover".

Background: Sternal clefts are rare congenital anterior chest wall defects created by a lack of midline thoracic fusion. Various surgical repairs have been proposed to provide protection to underlying viscera in these defects. Aim: This study aims to perform primary sternal cleft repair using techniques, leading to the provision of a complete bony cover and to assess their outcomes on follow-ups. Materials and Methods: During 2009-2020, seven patients were referred to our unit with sternal defects. Out of them, four infants with sternal clefts underwent primary repair using bilateral perichondrial flap creation of the sternal bars and sliding costal chondrotomy at our institute. In one of them with a wider defect, bilateral "intraperiosteal" sliding clavicular osteotomy was additionally performed to achieve tension-free closure. Results: Satisfactory surgical outcomes were achieved with an uneventful postoperative period. On follow-up, all four patients are thriving well and have a stable anterior chest wall. Those with follow-ups longer than 5 years showed evidence of bone formation. Conclusion: Bony cover to the heart can be provided in all varieties of sternal cleft defects using primary surgical repair early in infancy. The delay in surgical correction increases the complexity of the procedure and may require the use of prosthetic material which has its own disadvantages.

Strategies to mitigate inflammation in management of complex congenital heart disease complicated by "multisystem inflammatory syndrome in children".

A 6-month-old boy, a case of Shone's complex, presented in decompensated state was found to have severe mitral stenosis along with multisystem inflammatory syndrome in children (MISC) warranting urgent surgical intervention. Various modalities including cytokine-adsorbing hemofilter were used to target inflammation. Postoperatively, the child recovered from low cardiac output accompanied by decrease in the levels of inflammatory markers, inopressors, and ventilatory requirements. Open heart surgery in itself is a proinflammatory process and is best avoided during the active inflammatory phase of MISC. In the rare and unavoidable circumstance exemplified by this index case, multipronged strategy targeting inflammation as described can be successfully implemented.

Aneurysm of Pulmonary Sinus of Valsalva: Successful Management of a Case.

Pulmonary sinus of Valsalva aneurysm is an extremely rare entity, reported only twice in the literature. It can remain asymptomatic or can present with symptoms when associated with pulmonary artery aneurysms. We present a case of pulmonary sinus of Valsalva aneurysm causing severe right ventricular outflow tract obstruction. This report aims to alert the physicians of such an entity when evaluating the causes of subvalvar right ventricular outflow tract obstruction.

Endovascular stent implantation as a primary method of treatment for blocked modified Blalock‒Taussig shunt.

Modified Blalock‒Taussig shunt is a commonly performed palliative cardiac surgery. Complications like early or late occlusion have been reported in approximately 10% of patients. Thrombosis, stenosis, or kinking are possible mechanisms that lead to shunt obstruction which may be life-threatening and need urgent intervention in form of medical, surgical, or interventional catheterization. Traditionally, these patients are managed in the operating room with shunt revision but with advancing techniques, percutaneous interventions are being increasingly deployed to salvage these patients effectively. We describe our experience of two cases of blocked modified Blalock‒Taussig shunt, which was successfully managed by stenting the shunt.

Impact of irradiation on physico-chemical and nutritional properties of fruits and vegetables: A mini review.

Background: Fruits and vegetables are healthy because they contain good nutrients and secondary metabolites that keep the body healthy and disease-free. Post-harvest losses of fresh fruits and vegetables limit access and availability as a result of foodborne infections and poor storage technologies. The selection of fruits and vegetables depend on the starting microbial load, the size of fruits and vegetables, and the type of infrastructure. Scope and approach: Despite the positive impacts of conventional thermal (roasting, boiling, blanching) and some non-thermal processing techniques such as High Pressure Processing (HPP), Pulse Electric Field (PEF), Cold Plasma Technology (CPT) on shelf-life extension, their use is commonly associated with a number of negative consequences on product quality such as cold plasma treatment increases the acidity and rate of lipid oxidation and further decrease the colour intensity and firmness of products. Similarly, in high pressure processing and pulse electric field there is no spore inactivation and they further limit their application to semi-moist and liquid foods. On that account, food irradiation, a non-thermal technique, is currently being used for post-harvest preservation, which could be very useful in retaining the keeping quality of various fresh and dehydrated products without negatively affecting their versatility and physico-chemical, nutritional and sensory properties. Conclusion: Existing studies have communicated the effective influence of irradiation technology on nutritional, sensory, and physico-chemical properties of multiple fruits and vegetables accompanying consequential deduction in microbial load throughout the storage period. Food irradiation can be recognized as a prevalent, safe and promising technology however, still is not fully exploited on a magnified scale. The consumer acceptance of processed products has always been a significant challenge for innovative food processing technologies such as food irradiation. Therefore, owing to current review, additional scientific evidences and efforts are still demanded for increasing its technological request.

Techniques to avoid hypothermic circulatory arrest in the management of renal tumor with right atrium extension in children.

Clear cell sarcoma of the kidney is a rare variety of renal tumor accounting for less than 5% of all pediatric renal tumors. Cardiopulmonary bypass along with hypothermic circulatory arrest is frequently used for management of tumor thrombus extending into supra-hepatic inferior vena cava and right atrium. In this paper, we present a strategy of avoiding circulatory arrest and hypothermia and thereby fast-tracking the recovery in managing a case of clear cell sarcoma of the kidney in a 3.5-year-old child with tumor thrombus extending into the right atrium.

Structural Features of Coronavirus and the COVID-19 Pandemic's Impact in India.

The rapid transmission of COVID-19 infection around the world in a brief timeframe has caused an exponential decline in street traffic and other industrial activities in various parts of the world. The confined human collaboration with the nature at the time of this emergency has shown up as an advantage for Mother Nature after COVID-19 flare because the air present in the atmosphere and water flowing in river streams is upgrading and untamed life is blossoming. India, being consistently seen as the center of contamination due to a tremendous population, overwhelming road traffic and industries which contribute to heavy pollution prompting rise in air quality index for almost all the big cities of the country. However, after the announcement of lockdown because of COVID-19, the air quality begun to upgrade and other environmental variables, for example, water quality in streams and waterways have begun offering a positive hint towards restoration. This review gives a brief knowledge on the structure and genomic organization of novel coronavirus as well as it focuses on alterations in air and water quality along with its environmental consequences at specific locations of the country during lockdown due to this pandemic circumstance.

Anesthesia protocols for "bedside" preterm patent ductus arteriosus ligation: A single-institutional experience.

BACKGROUND: Hemodynamically significant patent ductus arteriosus (PDA) is frequently encountered in preterm infants sometimes requiring surgical attention. Although PDA ligation is regularly performed in the operating room, conducting it at the bedside in a neonatal intensive care unit (NICU) and its anesthetic management remains challenging. AIM: We aim to discuss the anesthetic considerations in patients undergoing bedside PDA ligation and describe our experience highlighting the feasibility and safety of this procedure. SETTING AND DESIGN: The study was conducted in the NICU in a tertiary care hospital; This was a retrospective, observational study. METHODS: Preterm infants scheduled for bedside PDA ligation using a predefined anesthesia protocol between August 2005 and October 2020 were included. STATISTICAL ANALYSIS USED: Quantitative data were presented as median with interquartile range and categorical data were presented as numbers and percentage thereof. RESULTS: Sixty-six premature infants underwent bedside PDA ligation. Thirty-day mortality was 4.5% (3 infants), but there were no procedural deaths. One (1.5%) patient had intraoperative endotracheal tube dislodgement. Three (4.5%) infants had postoperative pneumothorax requiring an additional chest tube insertion. Twenty-one (32%) patients required initiation of postoperative inotrope/vasodilator therapy within 6 h. Three postligation cardiac syndromes (≥ Grade-III mitral regurgitation with left ventricular dysfunction and hypotension) occurred. CONCLUSIONS: Although anesthesia for preterm neonates undergoing bedside PDA ligation poses unique challenges, it can be safely conducted by following a predetermined standardized anesthesia protocol. Its successful conduct requires utmost vigilance and pristine understanding of the principles of neonatal and cardiac care.

Anomalous Left Subclavian Artery from the Left Pulmonary Artery in Transposition of the Great Arteries with Right Aortic Arch.

Anomalous origin of the subclavian artery from the pulmonary artery is a rare but well-described entity. We report a case of anomalous origin of the left subclavian artery from the left pulmonary artery in a patient with transposition of the great arteries. We discuss the safe intraoperative management of this anomaly in a patient in whom the diagnosis was made intraoperatively.

A review of the Yasui operation with long-term follow-up of a case.

Yasui operation combines Norwood arch reconstruction with Rastelli operation for interrupted or hypoplastic aorta with aortic valvar atresia or hypoplasia with ventricular septal and two adequately sized ventricles, establishing biventricular repair. We present a case of aortic atresia, mitral hypoplasia, and ventricular septal defect (VSD) treated by Yasui procedure, and its long-term (108 months) follow-up and brief review of literature. Review of literature was done using keywords to search on "PubMed" and "Google Scholar." SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01174-5.