Bilateral Paravertebral Block versus Thoracic Epidural Analgesia for Pain Control Post-Cardiac Surgery: A Randomized Controlled Trial.

BACKGROUND: Adequate pain control after cardiac surgery is essential. Paravertebral block is a simple technique and avoids the potential complications of epidural catheters. The objective of this study is to compare the effect of ultrasound-guided bilateral thoracic paravertebral block with thoracic epidural block on pain control after cardiac surgery. MATERIALS AND METHODS: Between March 2016 and 2017, 145 patients who had cardiac surgery through median sternotomy were randomized by stratified blocked randomization into two groups. Group I (n = 70 patients) had bilateral ultrasound-guided thoracic paravertebral block and Group II (n = 75 patients) had thoracic epidural analgesia. The primary end point was the postoperative visual analogue scale (VAS). The duration of mechanical ventilation, intensive care unit (ICU), and hospital stay were the secondary end points. The study design is a randomized parallel superiority clinical trial. RESULTS: Both groups had similar preoperative and operative characteristics. No significant difference in VAS measured immediately after endotracheal extubation then after 12, 24, and 48 hours between groups (p = 0.45). Pain score significantly declined with the repeated measures (p < 0.001) and the decline was not related to the treatment group. Postoperative pain was significantly related to diabetes mellitus (p = 0.039). Six patients in group I (8.5%) required an additional dose of morphine versus three patients (4%) in group II (p = 0.30). Patients in group I had significantly shorter ICU stay (p = 0.005) and lower incidence of urinary retention (p = 0.04) and vomiting (p = 0.018). No difference was found in operative complications between groups. CONCLUSION: This randomized parallel controlled trial demonstrates that ultrasound-guided paravertebral block is safe and effective method for relieving post-cardiac surgery sternotomy pain compared with thoracic epidural analgesia but not superior to it.

Arterial-level repair of transposition of great arteries without coronary artery transfer.

Hypoplastic ascending aorta and interrupted aortic arch (IAA) are rarely associated with dextro-transposition of the great arteries (D-TGA). Severe hypoplastic ascending aorta may preclude coronary artery transfer making arterial switch operation problematic. We report a case of D-TGA with a large subpulmonic ventricular septal defect, IAA, and hypoplastic ascending aorta that underwent successful biventricular surgical repair without coronary artery transfer.

Excess nonhemorrhagic pleural drainage after surgery for congenital heart diseases: Single center experience.

OBJECTIVE: Chylothorax after surgery for congenital heart disease is an uncommon but serious complication that adversely affects surgical outcomes. The aim of our study was presenting our experience for the management of postoperative chylothorax and excess nonhemorrhagic pleural drainage. METHODS: Medical records of patients with excess nonhemorrhagic pleural drainage were retrospectively reviewed and the collected data included demographics, surgical procedures, drainage characteristics, methods of postoperative management, and outcome. RESULTS: From March 2011 to May 2018, 52 patients with excess postoperative pleural drainage were identified from a total of 816 pediatric patients operated upon for congenital cardiac disease, giving an incidence of 63.7%. Tetralogy of Fallot and single ventricle morphology were the most common cardiac pathology. The serum triglyceride level was checked and found elevated in 30 patients (53.5%). The maximum daily drainage was 136.25 ± 109.7 mL/day and the mean duration of drainage was 32.23 ± 35.7 days. Medium-chain triglyceride formula was given for 27 patients (51.9%), octreotide for 22 (42.3%) for a mean duration of 8.07 ± 28.3 days. Total parenteral nutrition was needed for 11 patients (21.1%) for a mean duration of 3.13 ± 7.63 days. The success rate for conservative management was 94.2%. Thoracic duct ligation performed for three patients. The mean duration of mechanical ventilation was 7.4 ± 3.6 days, mean intensive care unit stay was 29.6 ± 35.1 days, and mean total hospital stay was 20.9 ± 17.5 days. We had six cases of hospital mortality (11.53%). CONCLUSION: Initiation of a stepwise approach for excess nonhemorrhagic pleural drainage based on the amount and rate of drainage achieve a favorable outcomes.

Autoimmune interstitial lung disease in Latin-America.

Information about the prognosis and natural history of autoimmune interstitial lung diseases (Ai-ILD) is limited. The aim of the study was to evaluate the characteristics of patients diagnosed with Ai-ILD in Latin-America. We conducted an ambispective multicenter cohort study in 25 centers of Argentina, Colombia, and Uruguay between January 2015 and April 2018. Participants were included in the study if they had diagnosis of Ai-ILD performed by a multidisciplinary team. Patients were classified into the following sub-groups: connective tissue disease-associated ILD (ILD-CTD), interstitial pneumonia with autoimmune features (IPAF), and positive antineutrophils cytoplasmatic antibodies associated ILD (ILD-ANCA). All images were reviewed by a blinded thoracic radiologist. Out of the 381 patients included during the study period, 282 (74%; 95% CI; 69.39-78.16) were women. Mean age was 58 years old (SD 16). Three-hundred and twenty-five (85.1%; 95% CI 81.39-88.5) patients were classified as ILD-CTD (rheumatoid arthritis 31%, systemic sclerosis 29%, dermatomyositis 15%). Thirty-six patients were classified as IPAF (9.5%; 95% CI 6.9-12.8), and 13 (3.5%; 95% CI 2-5.75) as ILD-ANCA. Fifty percent of patients (95% CI 45.12-55.43) had a mild decrease of the forced vital capacity at the time of diagnosis. The most common treatment strategy was the combination of steroids and cyclophosphamide (30.1%; 95% CI 25.32-35.34) followed by azathioprine (20,3%; 95% CI 16.32-25.14). In conclusion, to the best of our knowledge, this is the first study to evaluate the characteristics and treatment strategies used in patients affected by Ai-ILD in Latin-America. Future studies should to evaluate the prognosis and impact of current treatment strategies in patients with Ai-ILD.

Bidirectional glenn surgery without palliative pulmonary artery banding in univentricular heart with unrestricted pulmonary flow. Retrospective multicenter experience.

BACKGROUND: Although pulmonary artery banding (PAB) has been generally acknowledged as an initial palliative treatment for patients having single ventricle (SV) physiology and unrestrictive pulmonary blood flow (UPBF), it may result in unfavorable outcomes. Performing bidirectional Glenn (BDG) surgery without initial PAB in some selected cases may avoid the complications associated with PAB and reduce the number of operative procedures for these patients. This research aimed to assess the outcome of BDG surgery performed directly without doing initial PAB in patients with SV-UPBF. METHODS: This Multicenter retrospective cohort includes all patients with SV-UPBF who had BDG surgery. Patients were separated into two groups. Patients in Group 1 included patients who survived till they received BDG (20 Patients) after initial PAB (28 patients), whereas patients in Group 2 got direct BDG surgery without first performing PAB (16 patients). Cardiac catheterization was done for all patients before BDG surgery. Patients with indexed pulmonary vascular resistance (PVRi) ≥ 5 WU.m2 at baseline or > 3 WU.m2 after vasoreactivity testing were excluded. RESULTS: Compared with patients who had direct BDG surgery, PAB patients had a higher cumulative mortality rate (32% vs. 0%, P = 0.016), with eight deaths after PAB and one mortality after BDG. There were no statistically significant differences between the patient groups who underwent BDG surgery regarding pulmonary vascular resistance, pulmonary artery pressure, postoperative usage of sildenafil or nitric oxide, intensive care unit stay, or hospital stay after BDG surgery. However, the cumulative durations in the intensive care unit (ICU) and hospital were more prolonged in patients with BDG after PAB (P = 0.003, P = 0.001respectively). CONCLUSION: Direct BDG surgery without the first PAB is related to improved survival and shorter hospital stays in some selected SV-UPBF patients.

Reversible Cardiomyopathy, What Should the Clinicians Keep in Mind? A Case Report.

Primary carnitine deficiency (PCD) is an autosomal recessive disorder characterized by decreased carnitine levels essential for Beta oxidation in various organs, including the heart. Early diagnosis and treatment of PCD can revert cardiomyopathy. A 13-year-old girl presented with heart failure due to dilated cardiomyopathy and severe cardiac dysfunction; following L carnitine treatment, the patient's clinical conditions improved, and cardiac functions returned to normal within weeks. Investigations revealed PCD; regular L carnitine has been provided, all cardiac medications are discontinued, and the patient is doing well. We believe PCD should be ruled out in every patient with cardiomyopathy.

Percutaneous closure of postoperative residual ventricular septal defects, including dehiscence of surgical patches.

Background: Percutaneous closure of residual ventricular septal defects (VSDs) after congenital heart surgery may provide a safer and more efficient alternative to redo surgery. This study aimed to evaluate the outcome of transcatheter closure of residual postoperative VSD. Methods: This multicenter retrospective cohort study was conducted at the tertiary care institutions of King Faisal Specialist Hospital and King Abdulaziz University Hospital, Saudi Arabia, from March 2012 to March 2022. All patients who underwent transcatheter closure of postoperative residual VSD were included. As catheter closure of VSD related to surgical patches is challenging, patients were divided into two groups. Group 1 comprised patients with VSD related to the surgical patches, while Group 2 included residual muscular VSD. Various occluders and approaches were utilized based on the patient's weight and the VSD type, size, and proximity to the cardiac valves. Demographic, echocardiographic, catheterization, and outcome data were collected and analyzed using descriptive and comparative statistics. Results: Thirty-three patients underwent 37 VSD catheter closure procedures. Twenty-two procedures were done to close residual VSD related to the surgical patch, while fifteen were done for additional muscular VSD. The median age of the patients was 3.3 years, and the interquartile range (IQR) ranged between 9 months and 7 years. The median weight was 13.1 kilograms, with an IQR of 5.1 to 16.8 kilograms. The median pulmonary to systemic flow ratio (QP/QS) was 1.6 with an IQR of 1.5 to 2.44; the median systolic pulmonary pressure was 46 mmHg with an IQR of 32 to 54 mmHg. The median procedure duration was 120 minutes, with an IQR of 90 to 160 minutes. Patients in Group 1 were older and had a lower mean pulmonary pressure than Group 2 (P=0.02, P=0.007, respectively). Of the 37 procedures, 35 (94.6%) were done successfully, while two patients had redo surgery due to failed procedures (one had device embolization). Ten successful catheterizations were performed for infants weighing ≤5 kilograms. The functional heart failure class improved significantly after the closure of the residual VSD. There were three documented mortalities, none related to the procedure. No significant difference between patient groups regarding hospital stay or survival (P=0.660, P=0.791, respectively). Conclusions: After congenital heart surgery, transcatheter closure of residual VSD may be a safe and effective alternative to surgical closure. It can be applied to various residual VSD using a variety of occluders with satisfactory results. Moreover, using specific approaches can close residual VSD, even in small infants.

Percutaneous coronary stent implantation in children and young infants following surgical repair of congenital heart disease.

Background: Coronary artery stent implantation (CSI) in the pediatric population is rare. Only a few reports were published on managing postoperative coronary artery obstruction using coronary stents following surgical repair of congenital heart diseases (CHD). This study aimed to analyze the feasibility, indications, procedural technique, risk factors, and short-term outcomes of CSI after pediatric cardiac surgery. Methods: In this retrospective cohort study, we reviewed all pediatric patients who underwent surgical repair of CHD requiring postoperative CSI in two cardiac centers (King Abdulaziz University Hospital and King Faisal Specialist Hospital and Research Center) between 2012 and 2022. Survival to hospital discharge was the study's primary outcome. The secondary outcomes included procedural success, duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, need for coronary reintervention, and late mortality. A descriptive analysis was performed for the collected data from the patients' medical records. Results: Eleven patients who underwent postoperative CSI were identified. The most common anatomic diagnosis was congenital aortic valve stenosis. All patients underwent cardiac catheterization on extracorporeal membrane oxygenation support except one patient, who presented with chest pain after cardiac surgery. Procedural success was achieved in all patients with excellent revascularization documented by post-procedural angiograms. Both patients who had late coronary events after cardiac surgery survived hospital discharge. There was no in-hospital mortality among the two patients who required stenting of only the right coronary artery. The four patients who required more than 120 minutes to complete the procedure had early mortality. After CSI, the median duration of mechanical ventilation and ICU stay was 12 and 17 days, respectively. Six patients (54.5%) survived hospital discharge post-CSI; they did not require re-intervention during the follow-up period (38-1,695 days). Conclusions: CSI in pediatric patients can be performed with excellent procedural success for treating coronary artery stenosis after cardiac surgery. It could be considered a potential treatment strategy for this population.

Risk factors of early postoperative cardiac arrhythmia after pediatric cardiac surgery: A single-center experience.

OBJECTIVES: To evaluate the incidence of arrhythmia in the early postoperative period and to identify its risk factors among pediatric patients following cardiac surgery at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, between 2015-2020. METHODS: Out of 1242 patients, a total of 821 aged <18 years who underwent cardiac surgery were included in this retrospective cohort carried out in June 2021 at KAUH, Jeddah, Saudi Arabia. Information retrieved from the hospital medical records had patients' demographics, types of arrhythmias, hemodynamic stability, electrolyte disturbances, cardiopulmonary bypass (CPB), and aortic cross-clamp (AXC) durations. Univariate and multivariate logistic regression analyses were used to evaluate the possible risk factors associated with postoperative arrhythmia. RESULTS: Of the 821 patients, 140 (17.1%) developed arrhythmia postoperatively. The most common arrhythmias were junctional ectopic tachycardia (JET, 51.4%), atrioventricular block (27.1%), and supraventricular tachycardia (10%). The majority of cases occurred on the first day postoperatively (79.3%). Patients with postoperative arrhythmias had a more prolonged CPB (p=0.0001) and AXC (p=0.005) time, electrolytes disturbances (p=0.021), and hemodynamic instability (p=0.0001) than other patients. CONCLUSION: Postoperative arrhythmia, especially JET, is common after pediatric cardiac surgery. Prolonged cardiopulmonary bypass, prolonged aortic cross-clamping, electrolytes disturbances, and hemodynamic instability are possible risk factors for postoperative cardiac arrhythmias.

Clinical characteristics and outcomes of children with COVID-19 in Saudi Arabia.

OBJECTIVES: To determine the demographic and clinical characteristics, underlying comorbidities, and outcomes of children with coronavirus disease 2019 (COVID-19) infection. METHODS: In this retrospective study, we reported 62 pediatric patients (age <14 years) with confirmed COVID-19 between March 2 and July 1, 2020, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. RESULTS: Comorbid conditions, including cardiac, neurological, respiratory, and malignant disorders, were reported in 9 patients (14.5%). The most prominent presenting complaints were fever (80.6%) and cough (48.4%). Most of our patients (80.6%) had mild disease, 11.3% had moderate disease, and 8.1% exhibited severe and critical illness. Twenty-one patients (33.9%) were hospitalized, with 4 patients (6.5%) admitted to the pediatric intensive care unit, and 3 (4.8%) patients died. CONCLUSION: All pediatric age groups are susceptible to COVID-19, with no gender difference. COVID-19 infection may result in critical illness and even mortality in subsets of pediatric patients.

Impact of Thoracoscopic T2 Sympathectomy on Patients With Primary Palmar and Axillary Hyperhidrosis.

BACKGROUND: There are different techniques for thoracoscopic sympathectomy for management of primary hyperhidrosis. Each technique has the advantage of giving good surgical results, but may cause complications, which depend on the level of sympathectomy used in each technique. METHODS: From October 2012 to August 2016, a total number of 120 patients (of primary palmar and axillary hyperhidrosis) were enrolled in this prospective randomized study. Patients were randomized preoperatively and divided into 2 groups: group A (underwent T2, T3, and T4 sympathectomy) and group B (underwent T3 and T4 sympathectomy) with 1 year of follow-up. Improvement of palm sweating, development of complications, patient satisfaction, and quality of life were evaluated. RESULTS: Family history was positive in 33 patients (55%) in group A and in 31 patients (52%) in group B. All patients had improvement of hand sweating. Overdry hands were significant in group A (p = 0.032). Compensatory sweating was significant in group A after the first month (p = 0.016), after 6 months (p = 0.022), and after 12 months (p = 0.025). In group B, very satisfied patients were significant after 6 and 12 months (p = 0.002 and 0.000, respectively). CONCLUSIONS: Limited sympathectomy to the level of T3 and T4 has the same therapeutic effect obtained by T2, T3, and T4 sympathectomy with less complications, greater patient satisfaction, and better quality of life. It should be the technique of choice for treatment of primary palmar and axillary hyperhidrosis.