Pleuropulmonary blastoma masquerading as pneumothorax in a patient with a ventricular septal defect.

Pleuropulmonary blastoma is a rare pediatric primary lung tumor. We report a case of a child with Down syndrome and a large ventricular septal defect presenting with pleuropulmonary blastoma initially misdiagnosed as spontaneous pneumothorax. Following tube thoracostomy drainage of the pneumothorax, the child underwent surgical closure of the ventricular septal defect. However, the postoperative period was complicated by recurrent left pleural collection requiring prolonged intercostal tube drainage and two thoracotomies to evacuate the necrotic pleural material. The biopsy of the necrotic material was suggestive of type III pleuropulmonary blastoma. In view of the high propensity of metastasis associated with this variant of a tumor, the patient was started on chemotherapy. This case report highlights the possibility of pleuropulmonary blastoma presenting as pneumothorax and emphasizes the need to consider the etiology, before intervening in a child presenting with spontaneous pneumothorax.

Total Anomalous Pulmonary Venous Connection With an Intact Interatrial Septum.

An interatrial communication is essential for adequate mixing and survival in cases of total anomalous pulmonary venous connection. We report a 5-month-old infant with total anomalous pulmonary venous connection (cardiac type) without an interatrial communication and a large ventricular septal defect.

Surgical repair for common arterial trunk with pulmonary dominance, hypoplasia of ascending aorta, and interrupted aortic arch.

The arrangement of aortic and pulmonary pathways is extremely variable in the hearts with a common arterial trunk. Almost always, interruption of the aortic arch is seen in the setting of hypoplasia of the ascending aorta and dominance of the pulmonary circulation. This subset poses substantial challenges in surgical repair and portends poor outcomes. In this report, we briefly describe the technique of ascending aorta reconstruction and other aspects of the surgical repair of this rare malformation.

Functionally univentricular heart with systemic venous anomalies: surgical palliation and pulmonary arterial reconstruction with a roll of left atrial appendage.

In this report, we describe a 3-year-old patient with a functionally univentricular heart (UVH), who had a combination of double outlet right ventricle (DORV) along with an unrouteable interventricular communication (VSD), severe infundibular and pulmonary valvar stenosis, and severe left pulmonary artery (LPA) ostial stenosis. This patient also had an interrupted inferior caval vein (IVC) with bilateral superior caval veins (SVC). We were able to undertake a successful Kawashima procedure with interruption of the antegrade pulmonary blood flow, reconstructing the LPA using a pedicled roll of the left atrial appendage (LAA).

One and half ventricle repair: rationale, indications, and results.

Surgical strategies in patients with functionally or anatomically borderline right ventricles include a high-risk biventricular repair, a Fontan procedure, or a one and half ventricle repair (also referred to as the partial biventricular repair). One and half ventricle repair (1.5VR) circumvents the high early mortality of a biventricular repair and also the late morbidity of the Fontan. The two most common indications for a 1.5VR are a small pulmonary ventricle and a dilated poorly functioning pulmonary ventricle. Extension of 1.5VR to patients undergoing anatomical repair for congenitally corrected transposition of great arteries, straddling tricuspid valves, and severe Ebstein's anomaly has facilitated biventricular repair with decreased mortality. We reviewed the relevant literature on this subject in detail and describe its rationale, indications and its early and late results.

Arrhythmias in Children in Early Postoperative Period After Cardiac Surgery.

BACKGROUND: Postoperative arrhythmias are a known complication after cardiac surgical repairs for congenital heart disease. METHODS: Data were reviewed pertaining to incidence, diagnosis, potential risk factors, and management of postoperative arrhythmias in 369 consecutive patients under 18 years of age, undergoing elective open heart surgery. All children were admitted to the intensive care unit and continuous electrocardiographic monitoring was performed. Patient factors such as Aristotle Basic Complexity Score, total surgical duration, hypotension, tachycardia, serum lactate level, and inotropic score were analyzed. Univariate analysis was done to assess associations between these factors and the occurrence of postoperative arrhythmias. RESULTS: Twenty-five (6.7%) patients developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia occurring in 15 (60%) patients, followed by supraventricular tachycardia in 3 (12%), ventricular premature contractions in 3 (12%), hemodynamically unstable ventricular tachycardia and fibrillation in 3 (12%), and atrial fibrillation in 1 (4%) patient. Different grades of heart block were noted in 13 patients. Aristotle score (P = .014), total surgical duration (P < .01), hypotension (P = .02), heart rate (beats per minute) (P = .001), serum lactate level (P = .04), and inotropic score (P = .02) in the early postoperative period were associated with arrhythmia occurrence. Surgeries for ventricular septal defect alone or in association with other diseases including tetralogy of Fallot (TOF) and transposition of the great arteries (TGA) were found to be associated with higher risk of arrhythmias. CONCLUSION: This study showed a low incidence of arrhythmias, JET being the commonest, seen more in TOF repair and these could be treated efficiently. Higher Aristotle score, longer surgical time, hypotension, tachycardia, high inotropic score, and high serum lactate levels were associated with the occurrence of arrhythmias postoperatively.

Aortopulmonary window: results of repair beyond infancy.

OBJECTIVES: To study the anatomic and haemodynamic data and results of surgery in patients undergoing surgical repair of aortopulmonary window beyond infancy. METHODS: Between July 2005 and December 2015, 23 patients, older than 1 year undergoing surgery for aortopulmonary window were analysed retrospectively. Postoperative clinical and echocardiography follow-up were performed. RESULTS: Median age and weight at repair was 4 years (range 14 months-12 years) and 12 kg (range 3.5-22 kg), respectively. Fifteen patients had Richardson's Type I, 6 patients had Type II and 2 patients had Type III aortopulmonary window. Six patients had associated defects. Baseline mean systolic pulmonary artery pressure was 101 ± 14.9 mmHg (range 80-130, median 100 mmHg) and pulmonary vascular resistance index was 9.6 ± 5.9 (median 7.7 Wood units/m2, range 3.7-23.5 Wood units/m2). Patch repair of aortopulmonary window was performed using the sandwich method (transwindow) (n = 15), transaortic (n = 3) and transpulmonary artery (n = 2) approaches; 2 patients underwent double ligation and 1 underwent division and suturing. Two patients underwent valved patch closure of aortopulmonary window and 1 patient underwent valved patch closure of associated ventricular septal defect. There were 2 in-hospital deaths: one due to intractable pulmonary hypertension and the other due to low cardiac output. Mean follow-up was 36 months (range 2-119 months). Eighteen patients were in NYHA Class I at last follow-up. There were no late deaths or reoperation. CONCLUSIONS: Surgery can be safely undertaken beyond infancy in carefully selected patients of aortopulmonary window with acceptable early and mid-term outcomes.

Incidence, microbiological profile of nosocomial infections, and their antibiotic resistance patterns in a high volume Cardiac Surgical Intensive Care Unit.

BACKGROUND: Nosocomial infections (NIs) in the postoperative period not only increase morbidity and mortality, but also impose a significant economic burden on the health care infrastructure. This retrospective study was undertaken to (a) evaluate the incidence, characteristics, risk factors and outcomes of NIs and (b) identify common microorganisms responsible for infection and their antibiotic resistance profile in our Cardiac Surgical Intensive Care Unit (CSICU). PATIENTS AND METHODS: After ethics committee approval, the CSICU records of all patients who underwent cardiovascular surgery between January 2013 and December 2014 were reviewed retrospectively. The incidence of NI, distribution of NI sites, types of microorganisms and their antibiotic resistance, length of CSICU stay, and patient-outcome were determined. RESULTS: Three hundred and nineteen of 6864 patients (4.6%) developed NI after cardiac surgery. Lower respiratory tract infections (LRTIs) accounted for most of the infections (44.2%) followed by surgical-site infection (SSI, 11.6%), bloodstream infection (BSI, 7.5%), urinary tract infection (UTI, 6.9%) and infections from combined sources (29.8%). Acinetobacter, Klebsiella, Escherichia coli, and Staphylococcus were the most frequent pathogens isolated in patients with LRTI, BSI, UTI, and SSI, respectively. The Gram-negative bacteria isolated from different sources were found to be highly resistant to commonly used antibiotics. CONCLUSION: The incidence of NI and sepsis-related mortality, in our CSICU, was 4.6% and 1.9%, respectively. Lower respiratory tract was the most common site of infection and Gram-negative bacilli, the most common pathogens after cardiac surgery. Antibiotic resistance was maximum with Acinetobacter spp.