Cardiomegaly secondary to patent ductus arteriosus causing extrinsic compression of left pulmonary vein.

Primary pulmonary vein (PV) stenosis is a challenging condition to manage. Recently, extrinsic compression of the PV is being detected has cause of narrowing and subsequent turbulence. This can be managed without direct intervention on the PV, reducing the risk of recurrence. We report a case of extrinsic compression of the PV due to cardiomegaly, relieved after patent ductus arteriosus ligation.

Aortic root enlargement: Short-term outcomes from a decade's worth of experience.

BACKGROUND: Patient prosthesis mismatch is a real problem observed in patients receiving aortic valves too small for their body surface area. This situation is entirely preventable with the apt use of root augmentation procedures. This study aims to evaluate and analyze short-term outcomes in patients who have undergone root enlargement procedures. METHODS: Fifty-five patients with ages ranging from 11 to 65 years (36.74 ± 13.27), who have undergone root enlargement procedures between January 2009 and January 2019 are recruited for this study. The group comprises 23 males (41.8%) and 32 females (58.2%). Admission and follow-up parameters recorded over a period of 1 year were used for analyzing outcomes. The mean iAVA (aortic valve area indexed to body surface area) of the group was 0.49 ± 0.06 cm2 /m2 . RESULTS: There was a significant increase in the indexed aortic valve area after root enlargement surgery from 0.49 ± 0.06 to 1.09 ± 0.19 cm2 /m2 . The difference was statistically significant (p < .05). St Jude Masters bileaflet prosthesis resulted in the highest iEOA (1.29 ± 0.18 cm2 /m2 ). TTK Chitra monoleaflet valve was the most commonly used valve in 61.81% of the cohort. At 1 year follow-up, there was a progressive decrease in left ventricle (LV) mass Index and mean gradients resulting in progressive improvement in the New York Heart Association functional class among patients. CONCLUSION: In experienced hands, root enlargement procedures result in good curative outcomes for patients through effective LV regression and symptom resolution on a short-term basis.

Successful surgical management of a congenital giant right atrial appendage aneurysm: a case report on a rare cardiac anomaly.

Aneurysms of the right atrial appendage are usually congenital in origin, with rare citations. We report a case of a large atrial aneurysm in an adult male presenting with atrial flutter and right ventricular dysfunction, who underwent a successful aneurysmectomy, repaired with a novel technique with uneventful recovery.

Primary intrathymic lymphangioma in an infant.

Lymphangiomas are relatively uncommon lesions of the lymphatic channels which can arise in virtually any part of the body. Although the most common site is the head/neck region, they could be found in the mediastinum. If mediastinal lymphangiomas are said to be rare, the thymic subentity is even scanty. We describe one case of mediastinal lymphangioma with a true intrathymic localization, which to our knowledge has been reported just once in the literature. This case report elucidates the surgical management of the first lymphangioma reported in an infant.

Preoperative Sildenafil administration in children undergoing cardiac surgery: a randomized controlled preconditioning study.

OBJECTIVES: Sildenafil has strong cardiac preconditioning properties in animal studies and has a safe side-effect profile in children. Therefore, we evaluated the application of Sildenafil preconditioning to reduce myocardial ischaemia/reperfusion injury in children undergoing surgical ventricular septal defect (VSD) closure. METHODS: This is a randomized, double-blind study. Children (1-17 years) undergoing VSD closure were randomized into three groups: placebo (Control group), preconditioning with 0.06 mg/kg (Sild-L group) and 0.6 mg/kg Sildenafil (Sild-H group). PRIMARY ENDPOINT: troponin release. CK-MB, Troponin I, inflammatory response (IL-6 and TNF-α), bypass and ventilation weaning times, inotropy score and echocardiographic function were assessed. Data expressed as median (range), and a value of P < 0.05 was considered significant. RESULTS: Thirty-nine patients were studied (13/group). Aortic cross-clamp time was similar [27 (18-85) and 27 (12-39) min] in the Control and Sild-L groups, respectively, but significantly longer [39 (20-96) min] in the Sild-H group when compared with the Control group. Area under the curve of CK-MB release was 1105 (620-1855) h ng/ml in the Control group, 1672 (564-2767) h ng/ml in the Sild-L group and was significantly higher in the Sild-H group [1695 (1252-3377) h ng/ml] when compared with the Control group. There were no significant differences in inflammatory response markers, cardiopulmonary bypass and ventilation weaning times, inotropy scores and echocardiographic function between the groups. CONCLUSIONS: In this small study, Sildenafil failed to reduce myocardial injury in children undergoing cardiac surgery, nor does it alter cardiac function, inotropic needs or postoperative course. A subclinical increase in cardiac enzyme release after Sildenafil preconditioning cannot be excluded. CLINICAL TRIALS REGISTRY: CTRI/2014/03/004468.

Extubation in the operating room after cardiac surgery in children: a prospective observational study with multidisciplinary coordinated approach.

OBJECTIVE: This prospective observational study was undertaken to determine the feasibility of extubation of children in the operating room after cardiac surgery. DESIGN: A prospective observational study compared with historic controls. SETTING: A single tertiary care referral hospital. PARTICIPANTS: One thousand consecutive pediatric patients requiring cardiac surgery aged 1 day to 18 years. Patients with spinal deformity, neurologic problems, coagulopathy as diagnosed by high international normalized ratio (INR) more than 1.5, and patients preoperatively on mechanical ventilation were excluded from the study. Data were also reviewed for another 1,000 patients operated before the beginning of this study, which constituted historic controls. INTERVENTIONS: All 1,000 patients were considered as potential candidates for extubation in the operating room after cardiac surgery and managed by a combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine, and extubation in the operating room was attempted after completion of the surgical procedure. These comprised the study group (SG). Data also were reviewed for another 1,000 patients before the beginning of this study when extubation in the operating room was not attempted and compared with this group to study the impact of extubation in the operating room on intensive care unit (ICU) stay and resource utilization. This data comprised the before-study group (BSG). MEASUREMENTS AND MAIN RESULTS: Eight hundred seventy-one (87.1%) patients were extubated in the operating room. This included 40% of neonates and 70%, 85%, and 91% of patients aged between 1 and 3 months, 3 months to 1 year, and more than 1 year, respectively. Forty-five patients (4.5%) required re-intubation within 24 hours, and 9 patients died among those extubated in the OR, but for reasons thought not to be related to extubation. The ICU stay was significantly less in the study group (2.56±1.84 v 5.4±2.32 days, p<0.0001) as compared to before-study group (BSG). The number of patients in the ICU (34.76±3.19 v 59.98±4.92, p<0.0001) and the number of patients on a ventilator (5.1±1.24 v 24.5±2.88, p<0.0001) on a daily basis were significantly less in the study group, reflecting positive impact on resource utilization. CONCLUSION: Extubation in the operating room was successful in 87.1% of the patients without any increase in mortality and morbidity, but with a decrease in ICU length of stay and less use of hospital resources.

Unusual differential diagnosis of common arterial trunk.

Common arterial trunk is relatively a straightforward diagnosis on echocardiography. We describe a neonate who was referred to our centre as a case of common arterial trunk but on evaluation was found to have pulmonary atresia with ventricular septal defect and aortopulmonary window, for which he underwent repair with Barbero-Marcial technique. These two conditions differ anatomically and embryologically, and careful echocardiographic evaluation will help in diagnosis and appropriate management.

Assessment of operability in d-transposition of great arteries with ventricular septal defect: A practical method.

INTRODUCTION: Pulmonary vascular disease is a risk factor in the surgical management of patients with d-transposition of great arteries (d-TGA) and a ventricular septal defect (VSD). In older infants or children with this physiology, the question of operability often arises. Cardiac catheterization in this condition can be fallacious. It is well known that oxygen reduces pulmonary arterial pressure and pulmonary vascular resistance especially where irreversible pulmonary vascular obstructive disease has still not set in. We tried to implement this effect of oxygen in correlation with echocardiography in patients with TGA-VSD physiology where operability was in question. METHODS: Patients with d-TGA and a large post tricuspid shunt in whom operability was considered doubtful were selected for the study. We administered humidified oxygen at the rate of 10 litres/minute by mask for 48 hours in the ward or intensive care unit. After administration of oxygen we reassessed the child echocardiographically looking for signs of lowering of pulmonary vascular resistance which included increased pulmonary venous blood flow to the left atrium (LA) and right to left shunting across the VSD. OBSERVATION: We studied 1 patient with d-TGA and aortopulmonary window (APW), 4 patients with TGA / large VSD and 1 patient with Taussig-Bing anomaly. The age of the studied children ranged from 4 months to 3 years with a mean age of 1.1 years. After administering oxygen as described, echocardiogram showed an increase in pulmonary venous blood flow to the LA and right to left shunting across the VSD in 5 patients and increased flow reversal in aorta in presence of the APW. CONCLUSION: Patients with TGA/VSD physiology with doubtful operability can be subjected to this method of determining operability using echocardiography after administering oxygen. Although not 100% accurate in predicting long term postoperative pulmonary hypertension, this is a simple, noninvasive method that can aid in decision making in such a situation.

Utility of intra-operative capnogram to detect branch pulmonary artery obstruction following total correction of tetralogy of Fallot.

Branch pulmonary artery obstruction is one of the prime reasons for re-operation in patients who have undergone repair for tetralogy of Fallot. Branch pulmonary artery obstruction may develop over a period of time due to dilation of right ventricular outflow tract or it may be caused by residual stenosis after inadequate repair. This may lead to differential lung perfusion causing morbidity. Intra-operative capnogram monitoring reveals ventilation-perfusion relationship. We report two cases where the capnogram helped the diagnosis and management of branch pulmonary artery obstruction. We found a redundant patch in the first and an extra length of the homograft in second case which led to the obstruction. However, but for the changes in the intraoperative capnogram, this condition may by far remain undiagnosed considering the fact that it does not produce hemodynamic changes but can lead to postoperative morbidity.

Intra-operative trans-esophageal echocardiography in congenital heart disease.

Intra-operative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for repair of congenital heart disease. In several studies,TEE has been shown to provide additional intra-cardiac anatomic information. Its ability to be used intra- operatively before and after cardiac repair makes it a unique tool. Before TEE was available for intra-operative use, significant residual abnormalities were frequently not detected. The result was often substantial post-operative morbidity and mortality and sometimes the need for re-operation. According to practice guidelines established by the Society of Cardiovascular Anesthesiologists and the American Society of Anesthesiologists, there is strong evidence for the usefulness of TEE in surgery for congenital heart disease because it significantly improves the clinical outcome of these patients. Before surgical correction, TEE helps confirm diagnosis and spot any additional lesion, while after the surgical correction, it provides baseline parameters for comparison after the surgical correction.