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.

Electrical Cardiometry: A Reliable Solution to Cardiac Output Estimation in Children With Structural Heart Disease.

OBJECTIVE: Comparison of cardiac output (CO) obtained using electric cardiometry (EC) and pulmonary artery catheterization (PAC) in pediatric patients with congenital structural heart disease. DESIGN: Prospective, observational study. SETTING: A tertiary hospital. PARTICIPANTS: The study comprised 50 patients scheduled to undergo cardiac catheterization. INTERVENTIONS: CO data triplets were obtained simultaneously from the cardiometry device ICON (Osypka Medical, Berlin, Germany) and PAC at the following predefined time points-(1) T1: 5 minutes after arterial and venous cannulation and (2) T2: 5 minutes postprocedure; the average of the 3 readings was calculated. Reliability analysis and Bland-Altman analysis were performed to determine the limits of agreement, mean bias, and accuracy of the CO measured with EC. MEASUREMENTS AND MAIN RESULTS: The measured EC-cardiac index 4.22 (3.84-4.60) L/min/m2 and PAC-cardiac index 4.26 (3.67-4.67) L/min/m2 were statistically insignificant (p value>0.05) at T1. Bland-Altman analysis revealed a mean bias of 0.0051 L/min/m2 and precision limits of±0.4927 L/min/m2. The intraclass correlation coefficient was 0.789 and Cronbach's alpha was 0.652, indicating good reproducibility and internal consistency between the two techniques. Postcatheterization analysis also revealed strong agreement and reliability between the two techniques. CONCLUSIONS: This study demonstrated that cardiac indices measured in children with a variety of structural heart diseases using EC reliably represent absolute values obtained using PAC. EC technology is simple and easy to use and offers noninvasive beat-to-beat tracking of CO and other hemodynamic parameters in children with structurally abnormal hearts.

Assessment of Changes in Hemodynamics and Intrathoracic Fluid Using Electrical Cardiometry During Autologous Blood Harvest.

OBJECTIVE: To evaluate the effect of autologous blood harvest (ABH)-induced volume shifts using electrical cardiometry (EC) in patients with pulmonary artery hypertension secondary to left heart disease. DESIGN: Prospective, randomized, controlled trial. SETTING: A tertiary care hospital. PARTICIPANTS: The study comprised 50 patients scheduled to undergo heart valve replacement. INTERVENTIONS: Patients were divided randomly into 2 experimental groups that were distinguished by whether ABH was performed. Blood volume extracted in the test group was replaced simultaneously with 1:1 colloid (Tetraspan; B Braun Melsungen, Melsungen, Germany). Hemodynamic, respiratory, and EC-derived parameters were recorded at predefined set points (T1 [post-induction/pre-ABH] and T2 [20 minutes post-ABH]). MEASUREMENTS AND MAIN RESULTS: Withdrawal of 15% of blood volume in the ABH group caused significant reductions in thoracic fluid content (TFC) (-10.1% [-15.0% to -6.1%]); right atrial pressure (-23% [-26.6% to -17.6%]); mean arterial pressure (-12.6% [-22.2% to -3.8%]); airway pressures: (peak -6.2% [-11.7% to -2.8%] and mean -15.4% [-25.0% to -8.3%]); and oxygenation index (-10.34% [-16.4% to -4.8%]). Linear regression analysis showed good correlation between the percentage change in TFC after ABH and the percentage of change in right atrial pressure, stroke volume variation, autologous blood extracted, peak and mean airway pressures, and oxygen index. CONCLUSIONS: In addition to its proven role in blood conservation, therapeutic benefits derived from ABH include decongestion of volume-loaded patients, decrease in TFC, and improved gas exchange. EC tracks beat-to-beat fluid and hemodynamic fluctuations during ABH and helps in the execution of an early patient-specific, goal-directed therapy, allowing for its safe implementation in patients with pulmonary hypertension secondary to left heart disease.

Bombay blood group for pediatric cardiac surgery in the era of a pandemic: Newer challenges call for desperate measures!

Bombay blood group is one of the rarest blood types with a prevalence of 1 per 10,000 population in India. Children and adults of this blood group can receive autologous blood or blood from an individual with a Bombay phenotype only. Children with grown-up uncorrected cyanotic heart disease are associated with a high risk of perioperative hemorrhagic diathesis and may require multiple blood transfusions. Arrangement of adequate Bombay blood group units for pediatric cardiac surgery is a unique challenge. The COVID-19 pandemic brought about additional difficulties in the procurement of blood components due to donor hostility. Despite the associated risks, pre-operative multi-session autologous blood harvest under monitored anesthesia care was planned in a 16-year-old child and four units of autologous blood were harvested and preserved for performing total correction surgery.

Pericardiocentesis can be nasty. Accidents do occur while "Rail-roading" Sheaths and pigtails!

Pericardiocentesis is a challenging procedure and complications may vary depending on the patient-specific risk factors and procedural indications. Cardiac chamber perforation and the subsequent insertion of pigtail catheter into the main pulmonary artery are an unreported mishap during attempted pericardiocentesis. This potentially life-threatening complication is completely preventable by identification of high-risk patients and appropriate use of available technologies. Adjunctive imaging decreases procedural risk for difficult-to-access pericardial fluid collections and must be used to prevent inadvertent morbidities.

Valved patch closure of aortopulmonary window.

The case of an 8-year-old boy with an aortopulmonary window who underwent unidirectional valved patch closure of the window is described. The advantages of unidirectional valved patch closure in this setting are discussed.

Right-to-left shunting through the unidirectional valved patch after closure of ventricular septal defect.

Postoperative transesophageal echocardiography images of a patient undergoing unidirectional valved patch closure of ventricular septal defect in the setting of severe pulmonary hypertension are presented. The images and videos elegantly demonstrate a functioning valve without any obstruction to the left ventricular outflow.

Unidirectional ventricular septal valved patch for repair of late presenting ventricular septal defect with aortopulmonary window.

Management of long standing left to right shunt lesion resulting in elevated pulmonary vascular resistance (PVR) is challenging. Limited surgical options are further complicated by an unpredictable postoperative period. Unidirectional valve patch (UVP) closure has shown to be useful in cases of the large ventricular septal defect (VSD) who present late. We report a case of large aortopulmonary window coexisting with a large VSD with severe pulmonary artery hypertension and significantly elevated PVR that was managed surgically by closure of the window by sandwich technique and closure of the septal defect with a UVP. This report emphasizes the importance of UVP in the management of such patients.

Serum albumin perturbations in cyanotics after cardiac surgery: Patterns and predictions.

INTRODUCTION: Hypoalbuminemia is a well-recognized predictor of general surgical risk and frequently occurs in patients with cyanotic congenital heart disease (CCHD). Moreover, cardiopulmonary bypass (CPB)-induced an inflammatory response, and the overall surgical stress can effect albumin concentration greatly. The objective of his study was to track CPB-induced changes in albumin concentration in patients with CCHD and to determine the effect of hypoalbuminemia on postoperative outcomes. MATERIALS AND METHODS: Prospective observational study conducted in 150 patients, Group 1 ≤18 years (n = 75) and Group 2 >18 years (n = 75) of age. Albumin levels were measured preoperatively (T1), after termination of CPB (T2) and 48 h post-CPB (T3). Primary parameters (mortality, duration of postoperative ventilation, duration of inotropes and duration of Intensive Care Unit [ICU] stay) and secondary parameters (urine output, oliguria, arrhythmias, and hemodynamic parameters) were recorded. RESULTS: The albumin levels in Group 1 at T1, T2, and T3 were 3.8 ± 0.48, 3.2 ± 0.45 and 2.6 ± 0.71 mg/dL; and in Group 2 were 3.7 ± 0.50, 3.2 ± 0.49 and 2.7 ± 0.62 mg/dL respectively. All patients showed a significant decrease in albumin concentration 48 h after surgery (P < 0.01). Analysis between the groups, however, showed no statistical difference. Eleven patients expired during the study period, and nonsurvivors showed significantly lower serum albumin concentration 48 h after surgery 2.3 ± 0.62 mg/dL versus 3.7 ± 0.56 mg/dL in the survivors (P < 0.05). Receiver operating characteristic curve showed that a baseline albumin cut-off value of 3.3 g/dL predicts mortality with a positive predictive value 47.6% and a negative predictive value of 99.2% (P < 0.05). A strong correlation was seen between albumin levels at 48 h with duration of CPB (r2 = 0.6321), ICU stay (r2 = 0.7447) and incidence of oliguria (r2 = 0.8803). CONCLUSIONS: The study demonstrated similar fall in albumin concentration in cyanotic patients (both adult and pediatric) in response to CPB. Low preoperative serum albumin concentrations (<3.3 g/dL) can be used to identify and prognosticate subset of cyanotics predisposed to additional surgical risk.

Infective endocarditis of main pulmonary artery in tetralogy of Fallot: "Transesophageal echocardiography adds lease of life".

Infective endocarditis is a rare occurrence in the main pulmonary artery trunk and even rarer in tetralogy of Fallot.

Interventricular septal hydatid cyst: Transesophageal echocardiography as a therapeutic tool during bypass.

Cystic echinococcosis (hydatid disease) arising from infestation with a larval or adult form of the Echinococcus granulosus tapeworm is endemic in certain states of India, but affecting interventricular septum (IVS) solitarily is a scarce phenomenon. We present a rare case of transesophageal echocardiography guided management of IVS hydatid cyst even during cardiopulmonary bypass, which presented with a rather unusual complaint of repeated syncope.