Indispensable Role of Transesophageal Echocardiography in Double-Chamber Right Ventricle Repair Surgery.

Double-chamber right ventricle repair surgery requires the excision of anomalous obstructive muscular or fibromuscular bundles in the right ventricular outflow tract. Because of the close proximity of key structures in the right ventricular outflow tract, the surgery is extremely challenging and requires precise resection. Underresection of the muscle bands can lead to significant residual gradients in the postoperative period, whereas overenthusiastic resection can cause iatrogenic injury to surrounding structures. Various techniques like Hegar sizing by the surgeons, direct chamber pressure measurement, transesophageal echocardiography, and epicardial echocardiography can guide the surgeons about the adequacy of repair. Transesophageal echocardiography is crucial at each step, as it can precisely determine the exact site of obstruction in the preoperative period. Postoperatively, it helps determine the adequacy of surgical repair and identification of inadvertent iatrogenic complications.

MICS CABG: a single-center experience of the first 100 cases.

PURPOSE: To study the learning curve and outcomes of the first 100 cases of minimally invasive cardiac surgery (MICS) coronary artery bypass grafting (CABG) performed at our center. METHODS: From January 2017 to November 2019, a total of 100 patients underwent CABG via left anterior thoracotomy approach. We have studied the operative times within the MICS CABG patients to analyze our learning curve. We also studied the postoperative outcomes and compared these with those of patients who underwent sternotomy during the same period. RESULTS: The mean age was 59.33 ± 9.95 (range 37-82) years. The numbers of males and females were 72 and 28 respectively. The preoperative average ejection fraction (EF) was 51.08 ± 9.75%. All these patients underwent CABG via left thoracotomy approach, after satisfying the exclusion criteria. All patients received left internal mammary artery (LIMA) to left anterior descending (LAD) as a standard graft, with the radial artery and saphenous vein being the next alternative conduits. The average length of the incision was 6.06 ± 0.45 cm. Only 2 cases were done on pump. The average number of grafts per patient was 2.33 ± 0.92. The mean operative time was 132.40 ± 11.56 min. The mean duration of ventilation was 4.79 ± 1.90 h and average intensive care unit (ICU) stay was 2.62 ± 0.84 days. There was one conversion and no mortalities in our study. We had analyzed our operative times and noticed a significant reduction after the first 20 cases, which was our learning curve. CONCLUSION: MICS CABG can be performed for multivessel disease with the same comfort as for a single or a double vessel disease, once the learning curve has been achieved. Only significant difference from the sternotomy approach was noted in the longer operative times for MICS CABG during the learning curve, and not thereafter. Significant benefits of MICS over sternotomy were noticed in the immediate postoperative parameters like duration of ventilation, mean drainage, postoperative pain, ICU stay, and hospital stay, with no difference in postoperative adverse events.

Community-based screening to detect school readiness problems in very preterm children.

AIM: Very preterm (VPT) children (≤32 weeks) have school readiness difficulties across multiple domains, but routine follow-up is often limited. We assessed the performance of VPT children on the Before School Check (B4SC), a community-based screening programme of school readiness at 4 years of age. METHODS: VPT children discharged from Wellington and Auckland Neonatal Intensive Care Units (2005-2009) were compared to a national control cohort born during the same period. Outcome measures included Parental Evaluation of Developmental Status (PEDS), parent and teacher versions of the Strengths and Difficulties Questionnaire (SDQ-P and SDQ-T) and vision and hearing screening, and were related to perinatal and demographic characteristics obtained from the Australia and New Zealand Neonatal Network database. RESULTS: Of 1105 VPT children, 920 were matched to the B4SC database, of whom 814 (88%) had one or more B4SC screening outcomes recorded. Compared with controls, VPT children were more likely to have abnormal PEDS (odds ratio (OR) = 1.79, 1.53-2.10), SDQ-P (OR = 1.82, 1.49-2.23), SDQ-T (OR = 1.51, 1.10-2.06), vision (OR = 2.00, 1.54-2.60) and hearing (OR = 1.95, 1.65-2.31) screen outcomes. While VPT children with an abnormal screen were more likely to be referred for further assessment, only 34%, 22%, 94% and 51% with abnormal PEDS, SDQ or vision and hearing screen, respectively, had evidence of appropriate referral. School readiness difficulties were significantly associated with birthweight z-score ≤ -1, vaginal delivery, significant cranial ultrasound abnormalities, younger maternal age, higher deprivation neighbourhood and ventilation ≥72 h. CONCLUSION: Community-based screening may be useful for identifying VPT children with school readiness difficulties, but low referral rates may limit the effectiveness of such programmes.

Surgical treatment for coronary artery aneurysm: a single-centre experience.

OBJECTIVES: Coronary artery aneurysm is a rare condition with a reported incidence of 0.14-4.9% in patients undergoing coronary angiography and 0.3-5.3% in patients after percutaneous transluminal coronary angioplasty (PTCA). Optimum surgical therapy for this entity is difficult to standardize. We present here a series of 4 cases with the aim of establishing an optimal surgical therapy for this rare entity. METHODS: Four cases of coronary artery aneurysm were admitted in the Department of Cardiology and Department of Cardiothoracic and Vascular Surgery, King George's Medical University, Lucknow, from April 2010 to April 2012. All patients underwent a surgical procedure that involved ligation and plication of the aneurysm with coronary artery bypass grafting. RESULTS: Out of the four coronary artery aneurysm patients, 1 was atherosclerotic and the remaining 3 patients developed coronary artery aneurysm after PTCA with a drug eluting stent to the left anterior descending artery. After surgery, all patients recovered uneventfully without any recurrence of symptoms in the follow-up. CONCLUSIONS: Coronary artery aneurysm is a rare entity and is being seen more frequently with the increasing use of stents during PTCA. Proximal ligation and plication of the aneurysm with coronary artery bypass grafting in the present series provided good results. With this case series, we seek to establish an optimal surgical therapy for this rare entity.

A novel cardiac positioning device for left main coronary artery stenosis.

Significant hemodynamic alterations often occur during off-pump coronary artery bypass operations. Historically, left main coronary artery stenosis has been excluded from off-pump coronary artery bypass operations because of this concern. Many articles in recent times support off-pump operations in left main coronary artery (LMCA) stenosis. We describe here a safe and effective method to reduce the incidence of hemodynamic changes during beating heart surgery in patients with LMCA stenosis.

Aneurysmal aorto-right ventricular tunnel.

A successful closure of an aneurysmal aorto-right ventricular tunnel (ARVT) in a 16-year-old male patient is reported here. An attempt at device closure had failed in this patient. Diagnosis was confirmed by Doppler echocardiography, 3-dimensional computed tomography, and cardiac catheterization. Surgical closure with a Dacron patch (W.L. Gore & Associates, Flagstaff, AZ) at the aortic end and direct closure at the ventricular end was done successfully with the patient under mild hypothermia. The postoperative echocardiogram showed a competent aortic valve with a closed ARVT.

Intraventricular polymyxin B for the treatment of neonatal meningo-ventriculitis caused by multi-resistant Acinetobacter baumannii--case report and review of literature.

Central nervous system infections due to multi- and pan-drug resistant Acinetobacter baumannii are an emerging problem in intensive care patients. A high mortality rate is seen in neonatal and central nervous system infections. Treatment can be prolonged and challenging. Polypeptide antibiotics remain one of the options but have poor cerebrospinal fluid (CSF) penetration. We present our experience of successfully treating pan-drug resistant A. baumannii neonatal meningitis and ventriculitis with intraventricular polymyxin B. This was administered by repeated ventricular punctures due to lack of consent for insertion of a ventricular reservoir.