Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients.

BACKGROUND: We determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients. MATERIALS AND METHODS: The hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups. RESULTS: Six hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003). CONCLUSION: PD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival. HOW TO CITE THIS ARTICLE: Sahu MK, Bipin C, Arora Y, Singh SP, Devagouru V, Rajshekar P, et al. Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients. Indian J Crit Care Med 2019;23(8):371-375.

Hospital-acquired Infection: Prevalence and Outcome in Infants Undergoing Open Heart Surgery in the Present Era.

BACKGROUND: The aim of this study is to evaluate the causal relation between hospital-acquired infection (HAI) and clinical outcomes following cardiac surgery in neonates and infants and to identify the risk factors for the development of HAI in this subset of patients. MATERIALS AND METHODS: After Ethics committee approval, one hundred consecutive infants undergoing open heart surgery (OHS) between June 2015 and June 2016 were included in this prospective observational study. Data were prospectively collected. The incidence and distribution of HAI, the microorganisms, their antibiotic resistance and patients' outcome were determined. The Centers for Disease Control and Prevention criteria were used for defining HAIs. Univariate and multivariate risk factor analysis was done using Stata 14. RESULTS: Sixteen infants developed microbiologically documented HAI after cardiac surgery. Neonatal age group was found to be most susceptible. Lower respiratory tract infections accounted for majority of the infections (47.4%) followed by bloodstream infection (31.6%), urinary tract infection (10.5%), and surgical site infection (10.5%). Klebsiella (36.8%) and Acinetobacter (26.3%) were the most frequently isolated pathogens. HAI was associated with prolonged ventilation duration (P = 0.005), Intensive Care Unit stay (P = 0.0004), and hospital stay (P = 0.002). Multivariate risk factor analysis revealed that preoperative hospital stay (odds ratio [OR] 1.22, 95% confidence interval (CI) 1.6-1.39, P = 0.004), and prolonged cardiopulmonary bypass (CPB) (OR 1.03, 95% CI 1.01-1.05, P = 0.001) were associated with the development of HAI. CONCLUSION: HAI still remains a dreaded complication in infants after OHS and contributing to morbidity and mortality. Strategies such as decreasing preoperative hospital stay, CPB time, and early extubation should be encouraged to prevent HAI.

Three-year outcomes of surgical valve replacement with Dafodil™ pericardial bioprosthesis: Dafodil™-1 trial.

Background: The Dafodil™-1 trial was designed to evaluate the clinical safety and performance of Dafodil™ pericardial bioprosthesis for replacing diseased native or prosthetic aortic or mitral valves in patients with advanced valvular heart disease (VHD). Methods: The Dafodil™-1 trial was a prospective, multicenter, first-in-human clinical trial. Patients were enrolled if they had advanced VHD requiring aortic valve replacement (AVR) or mitral valve replacement (MVR) with or without concomitant valve surgery and having surgical risk scores <4%. Major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI), and stroke; and hemodynamics were analyzed. Results: A total of 136 patients (aortic: 67 and mitral: 69) were enrolled in the trial (with mean age-AVR group: 60.2 ± 8.3 years and MVR group: 49.7 ± 14.4 years). A total of 134 patients (aortic: 66 and mitral: 68) completed the 3-year follow-up (total 300 per 100 patient-years of follow-up). The AVR group demonstrated a significant reduction in the mean pressure gradients from 51.2 ± 24.1 mmHg at baseline to 11.1 ± 6.0 mmHg at the 3-year follow-up (p < 0.0001). The mean effective orifice area (EOA) improved from baseline (0.9 ± 0.6 cm2) to 3-year follow-up (1.8 ± 0.4 cm2) (p < 0.0001). In the MVR group, the mean indexed EOA (iEOA) increased significantly from baseline (0.7 ± 0.4 cm2/m2) to 3-year follow-up (1.1 ± 0.4 cm2/m2) (p < 0.001). There was significant improvement in New York Heart Association functional class and mean SF-12 scores in both groups. At 3-year follow-up, the MACE incidence was 2.3% per 100 patient-years (1.3% strokes per 100 patient-years and 1.3% deaths per 100 patient-years) for AVR group and 4.7% per 100 patient-years (0.6% strokes per 100 patient-years and 4.0% deaths per 100 patient-years) for MVR group. No cases of MI, structural valve deterioration and prosthetic valve endocarditis were reported. The AVR and MVR groups achieved 89.6% and 79.7% MACE-free survival, respectively at 3-year follow-up. Conclusions: The Dafodil™-1 trial demonstrated satisfactory outcomes of clinical safety, hemodynamic performance, and quality-of-life metrics. Additionally, no incidence of structural valve deterioration and very low rates of valve thrombosis during the 3-year follow-up period of Dafodil™-1 first-in-human trial indicated acceptable valve durability up to three years and similar outcomes are warranted for longer follow-ups as a primary goal. Clinical Trial Registration Number: https://www.ctri.nic.in/Clinicaltrials/showallp.php?mid1=18377&EncHid=&userName=CTRI/2017/07/009008, CTRI/2017/07/009008.

Role of Cardiac MRI Including LGE, T1 and T2 Mapping in the Assessment of Cardiac Involvement in Patients of Nonspecific Aorto-arteritis: A Prospective Study.

Objective Nonspecific aorto-arteritis (NSAA) may involve the myocardium in the form of edema and fibrosis. We conducted this study to investigate role of cardiac MRI including late gadolinium enhancement (LGE), T1 and T2 mapping in the assessment of cardiac involvement in NSAA. Methods and Materials Over the period between 2016 and 2019, 36 patients with NSAA presenting with uncontrolled hypertension, left ventricular dysfunction, congestive cardiac failure, or tachyarrhythmia were included in the study. We also had 16 voluntary control patients for providing normal T1 and T2 mapping values. Results The average age of patients was 27.1 years and the majority were females. MRI is more sensitive than echocardiography in the detection of LV dysfunction and RWMA. Out of 36 patients, 10 (27.8%) had LGE. The most common pattern of midmyocardial enhancement was present in 5 out of 10 patients. Five (13.8%) patients show mid-myocardial enhancement, followed by epicardial enhancement, which was seen in four (11.11%) patients. The values of post-gad T1 mapping values were significantly lower than pre-gad T1 mapping values. At a cut-off global native T1 mapping value of 1019 milliseconds had the sensitivity of 83.3% and specificity of 81.2% in detecting an abnormal T1 map. No significant association of MRI contrast enhancement with elevated ESR and CRP levels. There was no significant relation of myocardial T2 mapping values between NSAA and control groups. Conclusion Quantitative tissue characterization in the myocardium with native T1 mapping values help in the detection of cardiac involvement in patients with NSAA. T1 mapping may provide incremental value in the assessment of myocardial involvement in NSAA in addition to LGE imaging.

Outcome of COVID-19-positive children with heart disease and grown-ups with congenital heart disease: A multicentric study from India.

BACKGROUND: Outcome data of children with heart disease who acquired COVID-19 infection are limited. AIMS: We sought to analyze outcome data and identify risk factors associated with mortality in children with heart disease and grown-ups with congenital heart disease (GUCH) who had a laboratory-confirmed COVID-19 infection. SETTINGS AND DESIGN: This is a retrospective, multicentric, observational study. MATERIALS AND METHODS: The study included children with heart disease and GUCH population, who presented with either symptomatic or asymptomatic COVID-19 infection to any of the participating centers. COVID-19-negative patients admitted to these centers constituted the control group. RESULTS: From 24 pediatric cardiac centers across India, we included 94 patients with a median age of 12.5 (interquartile range 3-96) months and 49 (52.1%) patients were males. Majority (83 patients, 88.3%) were children. One-third of the patients (n = 31, 33.0%) had acyanotic congenital heart disease, and 41.5% (n = 39) were cyanotic, with > 80% of the patients being unoperated. Only 30 (31.9%) patients were symptomatic for COVID-19 infection, while the rest were incidentally detected positive on screening. A total of 13 patients died (case fatality rate: 13.8%). The in-hospital mortality rate among hospitalized patients was significantly higher among COVID-19-positive cases (13 of 48; 27.1%) as compared to COVID-negative admissions (9.2%) during the study period (P < 0.001). On multivariate analysis, the independent predictors of mortality among COVID-19-positive cases were severity of illness at admission (odds ratio [OR]: 535.7, 95% confidence interval [CI]: 6.9-41,605, P = 0.005) and lower socioeconomic class (OR: 29.5, 95% CI: 1.1-814.7, P = 0.046). CONCLUSIONS: Children with heart disease are at a higher risk of death when they acquire COVID-19 infection. Systematic preventive measures and management strategies are needed for improving the outcomes.

Impact of COVID-19 pandemic on pediatric cardiac services in India.

BACKGROUND: COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India. AIMS: The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries. SETTINGS AND DESIGN: This is a retrospective, multicentric, observational study. METHODS: We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019. RESULTS: The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%). CONCLUSIONS: The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

Immunohistochemical characterization of glandular elements in glandular cardiac myxoma: Study of six cases.

Back ground: Glandular cardiac myxoma has varying clinical presentation with uncertain histogenesis and debatable immunohistochemical profile. Glandular epithelial differentiations are rare phenomenon known to be present as an intrinsic component of the tumor. The origin of the glands has been attributed to epithelial differentiation of a totipotent cardiomyogenic precursor cells or the entrapped foregut rests in the tumor. MATERIALS AND METHODS: Retrospective study includes six cases of glandular cardiac myxoma collected over a perior of 4 years. Sections were examined to define the histogenesis, histological and immunohistochemical profile of the glandular elements. RESULTS: Incidence of glandular cardiac myxoma was 6.6% with a male to female ratio of 1:2.Mean age was 49.9 years. Left atrium was the commonest site. Five were sporadic and one was familial. Chest pain and dyspnea were the commonest clinical symptoms. Histologically all myxoma showed well formed glandular structures with typical myxomatous area. No atypia, mitosis or necrosis was identified in the glandular elements. Markers in six cases of glandular cardiac myxoma were immunopositive for CK7, CK 19, EMA, CEA, focally for E-cadherin while immunonegative for CK20, Chromogranin, Synaptophysin, calretenin, vimentin, B-catenin, TTF-1 and GCDFP-15 favoring enteric differentiation. CONCLUSION: Glandular cardiac myxoma is a rare entity which shows characteristics similar to those of classical cardiac myxoma with benign glandular elements showing enteric differentiation. Complete surgical excision is the treatment of choice with good prognosis. It is important to recognize this entity to avoid an erroneous diagnosis of metastatic adenocarcinoma.

Familial biatrial cardiac myxoma with glandular elements: A Rare entity with review of literature.

Cardiac myxomas are benign neoplasm of the heart with an incidence of 0.3%. Glandular cardiac myxomas are very rare and accounts for less than 3% of all cardiac myxomas. Here, we report a case of familial glandular cardiac myxoma in a 35 year old male who complained of exertional dyspneoa and weakness of right side of body on clinical presentation. Associated features of Carney's complex were not present. Family history revealed presence of cardiac myxoma in younger brother and sister. Transthoracic echocardiography detected biatrial myxoma. Excision of both lesions was done under cardiopulmonary bypass. Histopathology confirmed myxoma with glandular elements. Postoperative course was uneventful.

Modified circuit for retrograde cerebral perfusion.

A modified circuit for delivery of retrograde cerebral perfusion during ascending aortic or aortic arch surgery is described. The technique was applied in 15 patients who showed good postoperative recovery.

Leiomyosarcoma of inferior vena cava involving bilateral renal veins: Surgical challenges and reconstruction with upfront saphenous vein interposition graft for left renal vein outflow.

Leiomyosarcoma of inferior vena cava (IVC) involving bilateral renal veins presents a surgical challenge. Herein, we report the successful management of two such cases using restoration of left renal venous outflow by saphenous vein interposition graft as first step of surgery. Then radical resection of tumor and right kidney was done. IVC was lastly reconstructed using Gore-Tex graft. This report highlights the surgical challenges to ensure radical resection. Furthermore, the importance of restoring left renal outflow in presence of concomitant right nephrectomy is discussed. Both the patients were disease free at six months with no loss of left renal glomerular filtration rate.