Right aortic arch with isolated left subclavian artery: a rare association with coarctation of the left pulmonary artery.

We present a case report of rare association of right aortic arch with isolated left subclavian artery with coarctation of the left pulmonary artery.

The use of high-frequency jet ventilation for removal of obstructing casts in patients with plastic bronchitis.

OBJECTIVE: To describe improved cast removal with short periods of high-frequency jet ventilation (HFJV) in patients with single ventricle physiology. DESIGN: Case report. SETTING: Pediatric cardiac intensive care unit. PATIENTS: Two patients with plastic bronchitis during prolonged stay in a intensive care unit after a Fontan-type operation. INTERVENTIONS: Short periods of HFJV. MAIN RESULTS: Plastic bronchitis with lower airway obstruction developed in two intubated patients during intensive care stay after the Fontan operation. Mucolytics and suctioning were not effective in controlling symptoms. Urgent bronchoscopy was considered a high-risk procedure for the first patient and was not available for the second. Cast removal was achieved with short periods of HFJV and subsequent suctioning. CONCLUSIONS: The use of short-term HFJV resulted in resolution of the airway obstruction in intubated patients with plastic bronchitis.

Renovascular hypertension in infant presenting with cardiogenic shock.

A 35-day-old infant admitted with cardiogenic shock was hypertensive shortly after initial resuscitation therapy. The hypertension did not respond to increasing doses of sodium nitroprusside. An abnormal blood flow in the right renal artery was detected by pulsed Doppler ultrasonography, and a prompt blood pressure response to oral captopril suggested a diagnosis of renovascular disease. Renal angiography showed right main renal artery stenosis, abnormal intrarenal arteries, and nonfunctional right kidney; the patient subsequently underwent right nephrectomy with good effect. Myocardial dysfunction resolved 2 months after control of the blood pressure.

Thyroid function and ioduria in infants after cardiac surgery: comparison of patients with primary and delayed sternal closure.

OBJECTIVES: Thyroid hormone alterations after cardiac surgery may be aggravated by the use of iodine antiseptics. We evaluated thyroid function and ioduria in infants with delayed sternal closure (DSC) who are exposed to povidone-iodine for sternal wound protection and compared them with findings in infants after primary sternal closure. DESIGN: Prospective clinical study. SETTING: Pediatric cardiac intensive care unit. PATIENTS: Ninety-three infants after cardiac surgery using cardiopulmonary bypass, 60 of them with primary sternal closure and 33 of them with delayed sternal closure. MEASUREMENTS AND MAIN RESULTS: Thyroid hormones were studied in patients with primary sternal closure immediately after surgery, 5 days and 19 days after surgery, in patients with DSC immediately after surgery, immediately after sternal closure, and 2 wks after sternal closure. Ioduria was evaluated on the first, third, and fifth postoperative days after cardiac surgery with primary sternal closure and immediately after DSC. In both groups of patients, low total triiodothyronine, total thyroxine, thyroxine-binding globulin levels, high reverse triiodothyronine levels, and normal free triiodothyronine, free thyroxine, and thyroid-stimulating hormone levels were recorded immediately after surgery. Concentrations of total triiodothyronine and thyroid-stimulating hormone were lower in the patients with DSC. Five days after primary sternal closure and 2 wks after DSC, all thyroid hormone levels were normal for age. Ioduria after DSC was higher than ioduria after primary sternal closure. CONCLUSIONS: Patients with DSC compared with patients with primary sternal closure display more profound thyroid suppression in the immediate postoperative period. The use of povidone-iodine adhesive drapes with single povidone-iodine mediastinal irrigation in patients with DSC is associated with significant iodine absorption but no significant thyroid dysfunction.

Thyroid hormone status after cardiac surgery in infants with delayed sternal closure and continued use of cutaneous povidone-iodine.

OBJECTIVE: The aim of this prospective study was to examine whether providone-iodine used for sternal wound protection in infants with delayed sternal closure (DSC) influences the thyroid function. PATIENTS AND METHODS: Thyroid hormones (see bellow) and thyroxine binding globulin (TBG) were estimated by radioimmunoassay and ioduria by mass spectrometry in 20 infants in whom cutaneous povidone-iodine was continuously applied on the skin for 1-7 days before DSC after open heart surgery. RESULTS: In the early postoperative period the median levels of total triiodothyronine (TT3), total thyroxine (TT4) and thyroxine-binding globulin (TBG) were below the lower limit of normal, while these of reverse triiodothyronine (rT3) were above normal. The median levels of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) were normal. Two weeks after the sternal closure, the levels of TT3, TT4 and TBG increased significantly (P < 0.001), while these of rT3 decreased, but not significantly. The levels of TSH increased (P < 0.001), being above normal in 7 patients. Four weeks after the sternal closure, TSH levels remained markedly increased in 4 infants. These patients were considered to be hypothyroid and were started on thyroxine replacement therapy. Such replacement treatment was withdrawn at a median age of 6.5 months (range 5-8 months). Urinary iodine concentration on the last day of povidone-iodine exposure was several times higher (P < 0.001) than that in the control group of healthy infants. CONCLUSIONS: Transient hypothyroidism was found in four of 20 infants with DSC who were exposed to povidone-iodine. It is suggested to monitor TSH level in these patients, optimally at 4 weeks after closure of the sternum, when findings may show true hypothyroidism.