Efficacy of paravertebral block in "Fast-tracking" pediatric cardiac surgery - Experiences from a tertiary care center.

Introduction: Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery. Methods: We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB. Results: The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*). Conclusion: PVB provides an effective and safe anaesthetic approach which can form an important component of "fast-track" care in paediatric cardiac surgery.

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta.

Purpose: To report a technique of global cerebral embolic protection (CEP) designed for use during thoracic endovascular aortic repair (TEVAR). Technique: Arterial cannulas are inserted percutaneously in the right axillary artery (12-F) and left common carotid artery (LCCA; 10-F) to provide normothermic antegrade cerebral perfusion during TEVAR with neuromonitoring. Inferior vena cava blood is drawn using a 19-F femoral cannula, filtered, oxygenated, and delivered through independent roller pumps to the arterial cannulas. Static CEP is obtained by balloon occlusion of the 3 aortic arch branches proximally, resulting in complete separation of aortic and cerebral blood flow; static CEP is used during aortic endograft delivery and deployment. Dynamic CEP, obtained by creating flow reversal in the innominate artery and proximal LCCA, is used at all other times. Successful use of this CEP technique is illustrated in a patient with shaggy aorta undergoing fenestrated total arch TEVAR. Conclusion: Percutaneous normothermic bilateral antegrade cerebral perfusion provides effective CEP during TEVAR.

Combined mitral and aortic valve replacement for rheumatic heart disease: fifteen-year follow up and long-term results.

BACKGROUND AND AIM OF THE STUDY: Rheumatic heart disease is the most common cause of multivalvular disease in developing countries. Unless aggressive and timely intervention in the form of valve replacement is pursued, the condition progresses rapidly to disability and death. Combined mitral-aortic valve replacement represents a major technical challenge, and carries high early and late mortality rates. METHODS: The course of 382 consecutive hospital survivors of combined mitral-aortic valve replacement, operated on between January 1992 and December 2006, was reviewed. The valve of choice for the mitral position was the Starr-Edwards (98%), while Medtronic-Hall and St. Jude Medical valves were favored for the aortic position (81%). RESULTS: The mean postoperative follow up was 64.8 +/- 53.9 months, with a total cumulative follow up of 1,792 patient-years (pt-yr); the follow up was 87% complete (n=332). Late death occurred in 29 patients (8.7%). Long-term survival at five, 10 and 15 years was 92%, 78% and 45%, respectively, with a mean survival of 153 months. The linearized rates of thromboembolism, anticoagulation-related hemorrhage and prosthetic valve endocarditis were 1.06, 2.41 and 0.334% per pt-yr, respectively. CONCLUSION: Among the rheumatic population, double valve replacement offers excellent symptomatic improvement and favorable late survival. Hemodynamic superiority and thromboresistance are the normal selection criteria for these prostheses, although the surgeon's experience, and the ease of insertion, availability and cost of the valve also play important roles. A strict adherence to optimal anticoagulation levels optimizes protection against thromboembolism and anticoagulation-related hemorrhage, and helps to provide the patient with a good quality life.

Aortic and mitral valve replacement in a patient with hemophilia B.

A 25-year-old man with factor IX deficiency had an aortic and mitral valve replacement using a 2M Starr Edwards valve in the mitral position and a 22 Medtronic valve in the aortic position under cover of factor IX concentrate. The surgical procedure and the immediate postoperative period were uneventful except for a pericardial effusion which required a pericardiostomy. He was anticoagulated with heparin in the immediate postoperative period while the factor IX concentrate was being administered. Oral anticoagulation with acenocoumarol (Acitrom) was started, maintaining the international normalized ratio between 1.5 and 2. He was doing well at follow-up 9 months later.

Surgical results in bronchiectasis: analysis of 149 patients.

Bronchiectasis remains a serious problem in developing countries. We reviewed the morbidity, mortality, and functional outcome of surgical treatment for bronchiectasis in our institution. Between 1992 and 2003, 149 patients (105 males, 44 females) underwent pulmonary resection for bronchiectasis. Their mean age was 33.7 years (range, 5-66 years). The indications for surgery were failure of conservative treatment in 59 (40%) patients, recurrent hemoptysis in 53 (36%), bronchial obstruction by a tumor in 9 (6%), and destroyed lung in 28 (19%). Bilateral disease was seen in 24 (16%) patients. Surgical treatment included pneumonectomy in 55 (37%) patients, lobectomy in 55 (37%), bilobectomy in 37 (25%), and lobectomy and/or segmentectomy in 2 (1%). There was one operative death (mortality, 0.67%) and morbidity occurred in 22 (14.8%) patients. Follow-up was complete in 94 patients, for a mean of 4.8 years (range, 3 months to 12 years). After surgery, 51 (34%) patients were asymptomatic. Surgical treatment for bronchiectasis can achieve good results with acceptable morbidity and mortality, not only in localized disease but also in extensive disease, if complete resection can be achieved.

Anomalous left anterior descending coronary artery from pulmonary artery with ventricular septal defect.

Anomalous origin of the left anterior descending coronary artery with associated congenital defects is very rare. An angiogram of a 47-year-old woman admitted for a ventricular septal defect closure revealed an anomalous left anterior descending coronary artery arising from the left posterior sinus of the pulmonary artery. During the surgical procedure, the origin of the left anterior descending coronary artery was closed with pledgetted polypropylene sutures through the pulmonary artery. The ventricular septal defect was closed with a patch through the right atrium, and the left anterior descending coronary artery was bypassed with the left internal mammary artery.

Pseudoaneurysm of ascending aorta after aortic valve replacement.

A pseudoaneurysm of the ascending aorta is an unusual and potentially fatal complication after aortic surgical procedures. A contrast computed tomographic scan is the investigation of choice. Surgical treatment is mandatory. We describe the successful management of a pseudoaneurysm of the ascending aorta by instituting femorofemoral bypass and achieving hypothermic circulatory arrest, which provided safe reentry and prevented an impending rupture.

Bronchovenous fistula - leading to fatal massive systemic air embolism during cardiopulmonary bypass.

OBJECTIVES: We report a case of a bronchovenous fistula in an adult who could not be resuscitated following a mitral valve replacement. METHODS: A 39-year-old man underwent a mitral valve replacement for severe mitral stenosis and regurgitation. Following uneventful valve replacement surgery, and while attempting to wean the patient off bypass, we encounted a bronchovenous fistula following mechanical ventilation. RESULTS: This patient could not be resuscitated following surgery because of persistent air embolism in the patient. CONCLUSION: Systemic air embolism has been reported to occur following penetrating chest injury. Especially, when the entry and the exit sites have been over sewn and either a marked Valsalva maneuver by the patient (such as coughing or straining) or forced positive pressure ventilation in excess of 60 torr occurs, systemic air embolism can be created from bronchiolar-alveolar to pulmonary venous fistula. It has also been described in blunt thoracic trauma. Bronchovenous fistula is occasionally encountered in neonates due to ventilation injuries with high ventilatory pressures, especially with underlying lung pathology like respiratory distress syndrome, necessitating such high ventilatory pressures. To our knowledge, this is the first such case reported in the literature.

Inflammatory pseudotumour of the lung.

Inflammatory pseudotumours of the lungs have rarely been reported. These have been described as a benign entity of unknown origin and are often locally invasive requiring extensive pulmonary resection. We present a 12-year-old boy with fever and massive haemoptysis who was found to have a well defined left-sided paracardiac mass lesion on chest X-ray and CT scan thorax. A CT-guided fine needle aspiration cytology was reported as inflammatory pseudotumour. As a result of recurrent episodes of massive haemoptysis during admission the child underwent an emergency left posterolateral thoracotomy and excision of the mass along with a left pneumonectomy. The biopsy of the mass was conclusive. Postoperatively the child was ventilated over night and was extubated the next day. He has been doing well on follow-up. Based on our case report and on other similar reports it would appear that the primary treatment of inflammatory pseudotumors of the lung is surgical. Complete resection is the key to prevent recurrence and the prognosis is excellent following surgery.

Emergency valve replacement in rheumatic heart disease.

BACKGROUND AND AIM OF THE STUDY: Emergency valve replacement is defined as surgery undertaken to correct valvular heart disease which otherwise would have proved fatal within 24 h. METHODS: Among 1,742 patients who underwent valve replacement during the past 15 years at the authors' institution, 61 who had emergency surgery formed two groups. Group 1 (n = 24) had a previous good circulatory status but suffered a sudden change in valvular function, in the initial period after closed mitral valvotomy (CMV), and in later years after balloon aortic valvotomy (BAV) or balloon mitral valvotomy (BMV) for aortic or mitral valvular stenosis. Group 2 (n = 37) had chronic decompensated rheumatic valvular disease and acute low cardiac output. RESULTS: Four deaths occurred in group 1 (17%) during the early stage of the study, but no deaths have occurred during the past five years. Mean follow up was 13.5 months (range: 5-30 months). Among 20 survivors, 14 were in NYHA class I, and six in class II. Ten deaths occurred in group 2 (27%), including two during the past eight years among patients who had surgery. Mean follow up was 37.7 months (range: 8-96 months). Among 27 survivors, 11 were in NYHA class I, 12 in class II, two in class III and two in class IV. CONCLUSION: In this potential terminally ill group of patients, surgery offers the only option for survival.

Unruptured aneurysm of the sinus of Valsalva presenting with right ventricular outflow obstruction.

Sinus of Valsalva aneurysms rarely present until rupture occurs. We describe the case of a patient who presented with acute right heart failure and upon investigation was found to have an unruptured sinus of Valsalva aneurysm causing right ventricular outflow obstruction; there was an associated subaortic ventricular septal defect. To the best of our knowledge, only 1 other case with these features has been reported in the medical literature. The diagnosis was made by transthoracic echocardiography and cardiac catheterization. Through an aortic and right ventricular approach, we successfully excised the aneurysmal right coronary sinus, closed the ventricular septal defect, and replaced the aortic valve.