Right pulmonary artery to left atrium fistula.

In this report, we describe a 25-year-old patient in whom a fistula between the right pulmonary artery and the left atrium was accurately diagnosed. The successful surgical management of this patient is described. Current diagnostic methods, evaluation, and treatment options for this uncommon cause of cyanosis in an adult patient are discussed.

Totally anomalous pulmonary venous connection with intact atrial septum.

BACKGROUND: Total anomalous pulmonary venous connection with intact interatrial septum is extremely rare. AIMS: In these patients, a right to left shunt through a ventricular septal defect or a patent ductus arteriosus is mandatory to maintain the systemic circulation. Mechanical or physiological restriction of shunting through these pathways results in rapid clinical deterioration. DISCUSSION: We describe the anatomical findings with surgical repair in one such 10-day-old baby.

Modified ultrafiltration and postoperative course in patients undergoing repair of tetralogy of fallot.

BACKGROUND: Expected benefits of modified ultrafiltration (MUF) include increased hematocrit, reduction of total body water and inflammatory mediators, improved left ventricular systolic function, and improved systolic blood pressure and cardiac index (CI) following cardiopulmonary bypass (CPB). This prospective randomized trial tested this hypothesis. METHODS: Seventy-nine patients undergoing intracardiac repair of tetralogy of fallot were randomized to conventional ultrafiltration (CUF) + MUF (n = 39) or only CUF group (n = 40). The primary outcome was a change in hematocrit. Secondary outcomes were changes in peak airway pressures, ventilatory support, blood transfusions, time to peripheral rewarming, mean arterial pressure, central venous pressure, inotrope score (IS), and CI. Serum inflammatory markers were measured. RESULTS: Baseline hematocrit was 50.6 ± 10.02 in the only CUF group whereas it was 43.9 ± 5.55 in the CUF + MUF group (p = .36). Following MUF, the CUF + MUF group had higher hematocrit (44.7 ± 0.50 g/dl) compared to the only CUF group (37.2 ± 0.49 g/dl), p ≤ .001 after adjusting for baseline hematocrit. Central venous pressure (mmHg) immediately following sternal closure was 9.27 ± 3.12 mmHg in the CUF + MUF group and 10.52 ± 2.2 mmHg in the only CUF group (p = .04). In the intensive care unit (ICU), they were 11.52 ± 2.20 mmHg in the only CUF group and 10.84 ± 2.78 mmHg in the CUF + MUF group (p = .02). Time to peripheral rewarming was 6.30 ± 3.91 h in the CUF + MUF group and 13.67 ± 3.91 h in the only CUF group (p = .06). Peak airway pressures in ICU were 17 ± 2 mmHg versus 20.55 ± 2.97 mmHg in CUF + MUF group & only CUF group, respectively, p < .001). Duration of mechanical ventilation was 6.3 ± 2.7 h in CUF + MUF group compared to 14.7 ± 3.5 h in the only CUF group (p = .002). IS was 11.52 ± 2.20 in the only CUF group compared to 10.84 ± 2.78 in CUF + MUFs group. Eight of 39 (20.5%) patients in the CUF + MUF group had IS > 10 compared to 22 of 40 (55%) patients in the only CUF group (p = .02). Serum Troponin-T and interleukin-6 levels were lower in the CUF + MUF group; TNF-α and CPK-MB were similar. ICU and hospital stay were similar. CONCLUSION: Patients undergoing a combination of CUF and MUF had higher postoperative hematocrit, decreased duration of mechanical ventilation, lower need for inotropes and lower interleukin-6 and Troponin-T levels. This group had better postoperative outcomes. This study was registered with the Clinical trials registry of India (CTRI/2017/11/010512) before commencement.

Simultaneous cardiac and pulmonary central cyanosis in a young girl: the double trouble.

A 14-year-old girl admitted for corrective surgery for tetralogy of Fallot was found to have pulmonary arteriovenous malformations on pre-operative evaluation. In anticipation of a complicated postoperative course, percutaneous closure of the pulmonary arteriovenous malformations was undertaken first followed by a successful surgical outcome. Importance of this rare association and its clinical implication is hereby highlighted.

Effect of leukoreduction on transfusion-related immunomodulation in patients undergoing cardiac surgery.

OBJECTIVES: In this study, we aimed to determine the consequences of different amounts of leukocyte transfusion on the outcome of patients undergoing cardiac surgery. DESIGN: This was a prospective, single-blinded cohort study conducted for 1 year from July 2018 to June 2019. SETTING: The study setting was the Department of Transfusion Medicine, along with Cardiac Anaesthesia, Cardiac Surgery and Cardiac biochemistry departments in a tertiary care cardiac centre. PARTICIPANTS: A total of 150 patients undergoing cardiac surgery during the study period were divided into three groups (50 in each): Leukofiltered (LR), Buffy coat depleted (BCD) and Non-leukoreduced (NLR). INTERVENTION: The intervention was intra- and postoperative transfusion of packed red blood cells (PRBCs) having different amounts of leukocytes. MEASUREMENTS AND MAIN RESULTS: Patient details about length of intensive care unit (ICU) and hospital stay, blood usage, inotropic drug duration, mechanical ventilation, urine output and infection were recorded from the patient data sheet, whereas patients were followed up for 30 days post-operation, and any mortality was noted. Haematological parameters and biochemical parameters for renal function test were analysed on pre- and post-surgical days 1, 3, 5 and 7, whereas on postoperative days 1 and 7, cytokine-like FAS ligands, Interleukin-10 (IL-10) and Interferon-γ (INF-γ) were tested. Patients in all three groups received an average of four, two and two units of packed red blood cells, platelets and fresh frozen plasma, respectively. There was a statistically significant (P < .05) rise in total leukocyte, neutrophil and lymphocyte count in all three groups from day 0 to day 3, but it reduced to preoperative level on day 5. There was shorter ICU and hospital stay in the LR group of patients (46 ± 19.9 hours and 7.5 ± 2.4 days) compared to NLR (52.1 ± 24.2 hours and 7.9 ± 4.1 days) and BCD (53.3 ± 26.7 hours and 8.8 ± 3.1 days) group of patients, but it was statistically non-significant. The duration of mechanical ventilation was significantly lesser in LR group patients (10.2 ± 6.2 hours) as compared to NLR group (14.7 ± 12.7 hours). On risk ratio calculation of developing postoperative kidney injury, the NLR group had 1.3 and 2.6 times more risk compared to the BCD and LR groups, respectively. On postoperative days 1 and 7, FAS-L levels significantly increased in all three group of patients, whereas IL-10 increased in the NLR and BCD groups and decreased in the LR group non-significantly. The INF-γ levels decreased on day 1 in the NLR and BCD groups but increased in the LR group, but it was inversed on day 7. CONCLUSION: Depletion of leukocytes decreased Transfusion Related Immunomodulation (TRIM) effects in patients undergoing cardiac surgery, but this also depends on the degree of leukoreduction. As found in our study, leukofiltration is more effective compared to buffy-coat depletion only.

The use of an autologous right atrial free wall as a patch for closure of atrial septal defects.

BACKGROUND: Various patch materials to close large atrial septal defects (ASDs) are autologous pericardium or a large of prosthetic patches which may be associated with infrequent but definite problems. We describe our experience with the use of the right atrial free wall patch over the last two decades. METHODS AND RESULTS: Between July 1998 and December 2017, 157 patients (mean age 14.7 ± 13.9 years), underwent ASD closure using the right atrial free wall patch. Associated lesions were severe mitral regurgitation (n = 24), partial anomalous pulmonary venous drainage (n = 15), ASD closure occurring after myxoma excision (n = 12) total anomalous pulmonary venous drainage (n = 2) and tricuspid regurgitation (n = 2). Surgery was uneventful in all patients. All patients underwent serial electrocardiography and echocardiography. Follow-up in 140 of 155 survivors was 103.6 ± 0.6 months. One hundred forty of one hundred fifty-five survivors are in sinus rhythm and three have persistent atrial fibrillation. Twenty-four hours of Holter monitoring (n = 19) revealed normal sinus rhythm in all but three patients, with occasional atrial ectopics in one patient; four were lost to follow-op. Electrophysiological studies in seven consenting patients, 9 to 16 months following ASD closure showed normal atrial potentials from the site of the patch. CONCLUSIONS: The autologous right atrial free wall is a safe patch material for ASD closure. Its advantages are that it is autologous, endothelialized, probably viable, and carries a low risk of thromboembolism. Studies with a larger number of patients with longer follow are needed to further confirm these findings.

Ruptured sinus of valsalva presenting late following repair of tetralogy of fallot.

Rupture of sinus of valsalva following repair of tetralogy of fallot (TOF) is very rare. It should be suspected as a cause of recurrent or prolonged pleural effusion and congestive cardiac failure in patients who have undergone repair of TOF. We report one such patient.

Comparison of pleural effusion between fenestrated and nonfenestrated extracardiac Fontan: A prospective randomized study.

BACKGROUND: Fenestration of the baffle/conduit is believed to reduce pleural effusion following the Fontan operation. However, equivocal results have been observed with or without fenestration. This study aims to evaluate the efficacy of fenestration on the amount and duration of pleural effusion following the Fontan operation. METHODS: About 40 patients undergoing extracardiac Fontan (ECF) were randomized into two groups: one with fenestration (ECF-F; n = 20) or without fenestration (ECF-NF; n = 20). Primary outcome was the amount and duration of pleural effusions. Secondary outcomes were time to removal of the chest tubes, hospital stay, and readmission to the hospital because of recurrent pleural within 30 days of the operation. RESULTS: Mean age was 11.5 ± 5.07 (range, 8.7-13.5) years in the ECF-F group and 13.6 ± 0.4 years (range, 10.5-15.5) in the (ECF-NF) group. The total drain output was 7.89 mL/kg/d in ECF-NF compared with 6.9 mL/kg/d in the ECF-group (P = .14). Time for removal of pleural tubes was 14.6 ± 0.95 days in the ECF-NF group compared with 11.6 ± days in the ECF-F group. Total duration of hospital stay was higher but not significant in the ECF-NF group compared with the ECF-F group. Two patients in ECF-NF required readmission to the hospital within 30 days following discharge, while there were no readmissions in the ECF-F group. CONCLUSION: Contrary to the literature, the creation of a fenestration in the ECF circuit was not clearly associated with a reduction in the amount and duration of pleural effusion compared with a non-fenestrated Fontan. These findings may be debatable in high risks versus low risk candidates. However in the present study, in a low risk canditates undergoing the Fontan operation, the daily amount of pleural drainage was no different. Larger studies are needed to confirm these findings.

Unusual presentation and rupture of left sinus of Valsalva into mitral-aortic intervalvular fibrosa.

Ruptured sinus of Valsalva aneurysm from the left coronary sinus communicating through the mitral-aortic intervalvular fibrosa is rare. We report a 35-year-old patient who presented with only hemoptysis without any other cardiac complaint. The patient with this unusual diagnosis and presentation was managed successfully.

Surgical repair for aortopulmonary window with interrupted aortic arch in late childhood.

Aortopulmonary window with interrupted aortic arch is rarely reported beyond infancy. Pre-operative assessment and surgical repair are challenging. We report successful surgical repair of aortopulmonary window with interrupted aortic arch in a 6-year-old girl with near-normal pulmonary artery pressure immediately following surgery.

An alternative technique for completion of the total cavopulmonary connection.

BACKGROUND: Total Cavopulmonary connection (Fontan) is the final palliation for patients with a functionally univentricular heart. This is commonly accomplished after a prior bidirectional Glenn on cardiopulmonary bypass (CPB) with separate cannulation of the aorta, superior vena cava (SVC), and inferior vena cava. We describe an alternative technique of Fontan completion that eliminates the need for cannulation and dissection of the SVC, and pulmonary artery dissection. METHODS: Between January and October 2018, 17 patients underwent completion Fontan using an alternate technique at our institute. All operations were conducted on CPB at normothermia without cannulating the SVC RESULTS: Mean CPB time was 60 ± 16.8 minutes (range, 39-102 minutes). There were no early deaths. Mean postoperative Fontan pressures were 15.6 ± 1.2 mm Hg with no gradient between the SVC and IVC pressures. Mean duration of hospital stay was 15.6 ± 3.6 days (range, 10-22 days). No patient developed phrenic nerve paresis or palsy. CONCLUSIONS: Completion without cannulating the SVC is simple, reproducible, and easy to teach. It avoids the disadvantages associated with routine techniques.

An alternative technique for intracardiac exposure during transatrial repair of tetralogy of fallot.

The commonly used technique to facilitate intracardiac exposure during transatrial repair of tetralogy of fallot involves considerable retraction of the tricuspid valve using retractors. We describe an alternative surgical technique in which it is possible to dispense away with the retractors. The advantages of such a technique are discussed.

Unilateral unidirectional superior cavopulmonary anastomosis in a patient with bilateral superior caval veins and atretic left pulmonary artery.

A unidirectional superior cavopulmonary anastomosis was performed on the right side in a patient with a functionally univentricular heart, atresia of main and left pulmonary artery, bilateral superior caval veins, and a patent arterial duct in the right pulmonary artery. Anastomosis of the left superior caval vein to the right superior caval vein created a neo-innominate vein without using prosthetic material.

Elizabethkingia Meningoseptica: An Emerging Nosocomial Pathogen Causing Septicemia in Critically Ill Patients.

Elizabethkingia meningoseptica (E. meningoseptica), is an opportunistic Gram-negative bacteria, normally found in water and soil, notorious for causing nosocomial infections in extremes of ages and immunocompromised patients. It is now emerging as a serious nosocomial pathogen, intrinsically resistant to several commonly used antibiotics (e.g. beta-lactams, aminoglycosides, carbapenems and colistin etc. and a cause of high mortality in critically ill patients in intensive care units (ICUs). We report the first case of E. meningoseptica sepsis in a 5 month old child after open heart surgery for transposition of great arteries, initially on extracorporeal membrane oxygenation, then prolonged mechanical ventilation, with various invasive devices, inotropes and exposed to broad spectrum antibiotics in our ICU. The case highlights the potential risk factors responsible for E.meningoseptica sepsis. Its unusual pattern of resistance to many commonly used antibiotics makes this organism difficult to treat. HOW TO CITE THIS ARTICLE: Sahu MK, Balasubramaniam U et al. Elizabethkingia Meningoseptica: An Emerging Nosocomial Pathogen Causing Septicemia in Critically Ill Patients. Indian J of Crit Care Med 2019;23(2):104-105.

Randomized Controlled Trial of Heparin Versus Bivalirudin Anticoagulation in Acyanotic Children Undergoing Open Heart Surgery.

OBJECTIVE: To determine the safety and efficacy of bivalirudin as an anticoagulant for pediatric open heart surgery (OHS) and to determine its appropriate dosage for this purpose. DESIGN: Prospective, randomized controlled trial. SETTING: Tertiary care hospital. PARTICIPANTS: Fifty acyanotic children aged 1-12 years undergoing OHS. INTERVENTIONS: The children were randomized to receive either 4 mg/kg of heparin (n = 25, group H) or 1 mg/kg of bivalirudin bolus followed by 2.5 mg/kg/h infusion (n = 25, group B) as the anticoagulant. The doses were adjusted to maintain activated clotting time (ACT) above 480 seconds. At the conclusion of surgery, protamine (1.3 mg/100 U of heparin) was administered to children in group H. MEASUREMENTS AND MAIN RESULTS: The children were comparable in both groups with regard to demographic characteristics. The mean age and weight were 51.5 months and 13.4 kg in group H, and 59.3 months and 13.4 kg in group B. The dose of anticoagulant required was 4.0 ± 0.2 mg/kg in group H and 1.7 ± 0.2 mg/kg followed by 3.0 ± 0.7 mg/kg/h infusion in group B (p < 0.001). One child in group H required an additional dose compared to 13 (54.2%) children in group B. Intraoperatively, the ACT achieved was higher in group H compared to group B (p < 0.05). The ACT returned to baseline value after protamine administration in group H, but it remained elevated for 2 hours after termination of cardiopulmonary bypass (CPB) in group B (p < 0.01). The ACT was higher in group B compared to group H for 6 hours after termination of CPB (p < 0.05). Heparin prolonged the onset of clotting, decreased the rate and strength of thrombus formation, and inhibited platelet function to a greater extent than bivalirudin on viscoelastic coagulation testing. The total duration of surgery was prolonged in group B. The postoperative chest tube drainage was similar in group B (4.9 mL/kg) as in group H (5.9 mL/kg) in spite of higher ACT. The transfusion requirements were similar. No adverse event occurred in any patient. CONCLUSION: Bivalirudin is a safe and effective anticoagulant for pediatric OHS. Though it is not suitable as a routine anticoagulant for this purpose, it may be used as a heparin alternative in instances when heparin cannot be used. The dose required to maintain ACT for more than 480 seconds was 1.7 ± 0.2 mg/kg followed by 3.0 ± 0.7 mg/kg/h infusion. The ACT remained elevated for 2 hours after stopping the infusion. Bivalirudin did not increase postoperative bleeding and transfusion requirement.

Ruptured sinus of Valsalva aneurysm with tetralogy of Fallot in an adult.

A combination of ruptured sinus of Valsalva (RSOV) aneurysm with tetralogy of Fallot (TOF) is a very rare condition. We report a 32-year-old male who underwent repair of a RSOV aneurysm with TOF.

Multiple saccular aortic aneurysms following the arterial switch operation.

We report a 3-month-old male presenting with multiple aortic aneurysms arising de novo 2 months following the arterial switch operation. Successful repair of the aneurysms was performed under total circulatory arrest and at seven years follow-up, the patient has no recurrence.

An alternative technique of atrial septectomy during bidirectional superior cavopulmonary anastomosis.

An atrial septectomy is often required to create or enlarge a pre-existing restrictive atrial septal defect in patients with univentricular hearts undergoing the bidirectional superior cavopulmonary anastomosis. We describe an alternative surgical technique through the transected cardiac end of the superior vena cava without a right atriotomy successfully performed in 26 patients.

Bidirectional superior cavopulmonary anastomosis with or without cardiopulmonary bypass: A randomized study.

OBJECTIVES: This study aims to compare the bidirectional superior cavopulmonary anastomosis (BDG) with or without cardiopulmonary bypass (CPB). METHODS: 100 patients undergoing BDG were randomized into two groups: Off-CPB or on-CPB groups. All patients underwent near-infrared spectrophotometry (NIRS) and bispectral index (BIS) monitoring and pre- and postoperative serum 100 beta protein measurements (Sß100) and neuro-cognitive evaluation. Postoperative intensive care unit (ICU) parameters were also studied. RESULTS: The median age of patients in the on-CPB and off-CPB group were 42 and 48 months, respectively (p = 0.11). Median weights in the on-CPB group and off-CPB group were 13.5 (5-50) kg and 15 (7-36) kg, respectively (p = 0.927). There was a significant rise in superior vena cava (SVC) pressure on SVC clamping in the off-CPB group (23.12 ± 6.84 vs 2.98 ± 2.22 mmHg) on-CPB group (p < 0.001). There was a significant fall in NIRS and BIS values from baseline in the off-CPB group during the anastomosis but there was no statistically significant change in serum Sß100from pre-clamp to post-clamp in either group. Inotropic support, duration of ventilation, ICU stay, and hospital stay were significantly less in the off-CPB group (p < 0.001). Assessment of Social Adaptive Functioning revealed no adverse sequelae. There were significant cost savings if surgery was performed off-CPB (p < 0.001). CONCLUSION: Off CPB-BDG is an economical and safe procedure. Duration of inotropic and mechanical ventilatory support, ICU, and hospital stay is significantly less. We did not observe any early adverse neurologic sequelae in patients undergoing off-CPB BDG.

Bidirectional Glenn on cardiopulmonary bypass: A comparison of three techniques.

OBJECTIVE: To analyze the intraoperative and early results of the bidirectional Glenn (BDG) procedure performed on cardiopulmonary bypass (CPB) using three different techniques. METHODS: Between September 2013 and June 2015, 75 consecutive patients (mean age 42 ± 34.4 months) undergoing BDG were randomly assigned to either technique I: open anastomosis or technique II: superior vena cava (SVC) cannulation or technique III: intermittent SVC clamping. We monitored the cerebral near infrared spectrophotometry (NIRS), SVC pressure, CPB time, intensive care unit (ICU) stay, and neurocognitive function. RESULTS: Patients in technique III had abnormal lower NIRS values during the procedure (57 ± 7.4) compared to techniques I and II (64 ± 7.5 and 61 ± 8.0, P = 0.01). Postoperative SVC pressure in technique III was higher than other two groups (17.6 ± 3.7 mmHg vs. 14.2 ± 3.5 mmHg and 15.3 ± 2.0 mmHg in techniques I and II, respectively = 0.0008). CPB time was highest in technique II (44 ± 18 min) compared to techniques I and III (29 ± 14 min and 38 ± 16 min, P = 0.006), respectively. ICU stay was longer in technique III (30 ± 15 h) compared to the other two techniques (22 ± 8.5 h and 27 ± 8.3 h in techniques I and II, respectively = 0.04). No patient experienced significant neurocognitive dysfunction. CONCLUSION: All techniques of BDG provided acceptable results. The open technique was faster and its use in smaller children merits consideration. The technique of intermittent clamping should be used as a last resort.