Original Article--Surgical site infections following pediatric cardiac surgery in a tertiary care hospital: Rate and risk factors.

BACKGROUND: Surgical site infections [SSIs] are the second most common type of healthcare-associated infections and leading cause of postoperative morbidity and mortality in pediatric cardiac surgery. This study aims to determine the rate of, risk factors for, and most common pathogen associated with the development of SSIs after pediatric cardiac surgery. METHODS: Patients aged ≤14 years who underwent cardiac surgery at our tertiary care hospital between January 2010 and December 2015 were retrospectively reviewed. RESULTS: The SSI rate was 7.8% among the 1510 pediatric patients reviewed. Catheter-associated urinary tract infection [CAUTI] [odds ratio [OR] 5.7; 95% confidence interval [CI] 2.3-13.8; P < 0.001], ventilator-associated pneumonia [VAP] [OR 3.2; 95% CI 1.4-7.2; P = 0.005], longer postoperative stay [≥25 days] [OR 4.1; 95% CI 2.1-8.1; P < 0.001], and a risk adjustment in congenital heart surgery [RACHS-1] score of ≥2 [OR 2.4; 95% CI 1.2-5.6; P = 0.034] were identified as risk factors for SSIs. Staphylococcus aureus was the most common pathogen [32.2%]. CONCLUSIONS: SSI risk factors were longer postoperative stay, CAUTI, VAP, and RACHS-1 score of ≥2. Identification and confirmation of risk factors in this study is important in order to reduce the rate of SSIs following cardiac surgery.

Predictors for the Outcome of Aortic Regurgitation After Cardiac Surgery in Patients with Ventricular Septal Defect and Aortic Cusp Prolapse in Saudi Patients.

BACKGROUND AND AIM: Aortic valve (AV) prolapse and subsequent aortic regurgitation (AR) are two complications of ventricular septal defects (VSD) that are located close to or in direct contact with the AV. This finding is one of the indications for surgical VSD closure even in the absence of symptoms to protect the AV integrity. The goal of our study was to assess the outcome and to identify the predictors for improvement or progression of AR after surgical repair. MATERIALS AND METHODS: A retrospective study of all children with VSD and AV prolapse who underwent cardiac surgery at King Abdulaziz Cardiac Centre in Riyadh between July 1999 and August 2013. RESULTS: A total of 41 consecutive patients, operated for VSD with prolapsed AV, with or without AR, were reviewed. The incidence of AV prolapse in the study population was 6.8% out of 655 patients with VSD. Thirty-six (88%) patients had a perimembranous VSD, and four had doubly committed VSD. Only one patient had an outlet muscular VSD. Right coronary cusp prolapse was found in 38 (92.7%) patients. Preoperative AR was absent in five patients, mild or less in 25 patients, moderate in seven, and severe in four patients. Twenty-six patients showed improvement in the degree of AR after surgery (Group A), 14 patients showed no change in the degree of AR (Group B) while only one patient showed the progression of his AR after surgery. Those with absent AR before surgery remained with no AR after surgery. Improvement was found more in those with mild degree of AR preoperatively compared to those with moderate and severe AR. Female gender also showed a tendency to improve more as compared to male. CONCLUSION: Early surgical closure is advisable for patients with VSD and associated AV prolapse to achieve a better outcome after repair and to prevent progression of AR in future.

Role of intraoperative transesophageal echocardiography in pediatric cardiac surgery.

BACKGROUND: Intraoperative transesophageal echocardiography (TEE) has a major role in detecting residual lesions during and/or after pediatric cardiac surgery. METHODS: All pediatric patients who underwent cardiac surgery between July 2001 and December 2008 were reviewed. The records of surgical procedure, intraoperative TEE, and predischarge transthoracic echocardiograms were reviewed to determine minor and major residual cardiac lesions after surgical repair. RESULTS: During the study period, a total of 2268 pediatric cardiac patients were operated in our center. Mean age was 21 months (from 1 day to 14 years). Of these patients, 1016 (48%) had preoperative TEE and 1036 (46%) were evaluated by intraoperative echocardiography (TEE or epicardial study). We identified variations between TEE and preoperative transthoracic echocardiography in 14 patients (1.3%). Only one surgical procedure was cancelled after atrial septal defect exclusion. The other 13 patients had minor variation from their surgical plan. Major residual lesions requiring surgical revision were detected in 41 patients (3.9%), with the following primary diagnoses: tetralogy of Fallot in 12 patients (29%), atrioventricular septal defect in seven patients (17%), ventricular septal defect in seven patients (17%), double outlet right ventricle in two patients (5%), Shone complex in two patients (5%), subaortic stenosis in two patients (5%), mitral regurgitation in two patients (5%), pulmonary atresia in two patients (5%), and five patients (12%) with other diagnoses. CONCLUSION: Intraoperative TEE has a major impact in pediatric cardiac surgery to detect significant residual lesions. Preoperative TEE has a limited role in case of a high quality preoperative transthoracic echocardiography. We recommend routine use of intraoperative TEE during and/or after intracardiac repair in children.

Outcome of low body weight (<2.2 kg) infants undergoing cardiac surgery.

INTRODUCTION: Infants with low body weight (LBW) following cardiac surgery are a major challenge for the post cardiac surgery care unit. It has been observed that post surgery outcome for LBW infants is worse compared to the outcome of normal body weight infants. A study was conducted to compare post operative course and outcome of infants with body weight of 2.2 kg or less against infants with normal body weight who underwent similar cardiac surgeries. METHODS: A retrospective review was performed for all infants below 2.2 kg who underwent cardiac operations at King Abdulaziz Cardiac Center from January 2001 to October 2011. Cases with LBW (Group A) were compared with matching group (Group B) of normal body weight infants who had similar cardiac surgeries and matching surgical risk category. The demographic, ICU parameters, complications, and short-term outcome of both groups were analyzed. RESULTS: Two groups were formed, with 37 patients in Group A, and 39 patients in Group B. Except for weight (2.13 ± 0.08 kg in Group A vs 3.17 ± 0.2 kg in Group B), there was no statistical difference in demographic data between both groups. Cardiac procedures included coarctation repair, arterial switch, ventricular septal defect (VSD) repair, tetralogy of Fallot repair, systemic to pulmonary shunt and Norwood procedures. Patients in Group A had statistically significant difference from Group B in terms of bypass time (p = 0.01), duration of inotropes (p = 0.01), duration of mechanical ventilation (p = 0.004), number of re-intubations (p = 0.015), PCICU length of stay (p = 0.007), and hospital mortality: 13.5% in Group A vs 0% in Group B (p value 0.02). CONCLUSION: Patients with LBW (<2.2 kg) underwent cardiac surgery with overall satisfactory results, but with increased risk of ICU morbidity and mortality.

Short- and mid-term outcomes of total correction of Taussig-Bing anomaly.

Double-outlet right ventricle (DORV)/Taussig-Bing (TB) anomaly is the second most common type of DORV. This study evaluates our experience and outcomes of total correction of DORV-TB anomaly at King Abdulaziz Cardiac Center. We conducted a retrospective study for all cases of TB anomaly repaired between June 2001 and April 2009. Patients were divided into two groups: Group A included patients repaired with arterial switch operation, and group (B) included patients repaired with Rastelli procedure. Thirteen patients with TB anomaly underwent total correction. There were 5 male (38%) and 8 female (62%) patients. Mean age and weight at surgery were 6.8 ± 6 weeks and 3.6 ± 0.7 kg, respectively. Of the 13 patients, 9 (69%) were in group A, and 4 (31%) were in group B. Aortic arch abnormalities were present in 9 patients (69%); abnormal coronary artery patterns were present in 7 patients (54%); side-by-side great arteries were present in 5 patients (38%); dextrotransposition of the great arteries was present in 7 patients (54%); and levo-malposition of the great arteries was present in 1 patient (8%). At postoperative follow-up, 4 patients (31%) had developed either left- or right-ventricular outflow tract (VOT) obstruction requiring surgical and/or catheter intervention. There was no early mortality, but there was 1 late mortality caused by left-ventricle dysfunction. DORV-TB is often associated with other congenital cardiac anomalies. In general, total repair is feasible in the majority of patients with satisfactory results and improved outcome. Residual lesion and development of VOT obstruction can occur, requiring close follow-up and intervention for residual lesion.

Outcome of Norwood and Damus-Kaye-Stansel procedures for univentricular congenital heart anomalies.

OBJECTIVES: To review the experience with Norwood and Damus-Kaye-Stansel (DKS) staged repair in the management of hypoplastic left heart syndrome (HLHS), or functional single ventricle (FSV) with systemic outflow tract obstruction (SOTO). METHODS: A retrospective study was conducted from a single center from January 2001 to September 2007 at the Cardiac Sciences Department, King Abdulaziz Cardiac Center, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia. The cardiac departmental database was reviewed, together with the echocardiographic findings. Demographic data representing age and weight at operation, gender, cardiac anatomy, non-cardiac abnormalities, and operative details were collected. RESULTS: Twenty-eight patients with a diagnosis of HLHS were included in the study. The mean +/- SD for weight was 3.4 +/- 0.85kg and 32 +/- 37 days for age. All infants at our institution who underwent a Norwood or DKS surgery for HLHS, or other forms of FSV with SOTO were included. All included patients underwent first stage palliation consisting of either a classical Norwood procedure in 6/23 (21%) patients, or a modified Norwood with right ventricle to pulmonary artery (RV-PA) conduit in 22/28 (79%) patients. After first stage palliation, 23 patients (82%) survived, and all but one underwent second stage palliation with bidirectional cavopulmonary anastomosis (BCPA). The survival rate after second stage repair was 91%. Subsequently, 4 patients completed a third stage Fontan with 100% survival. All deceased patients had HLHS. CONCLUSION: The Norwood procedure is applied to a heterogeneous group of patients with variable outcomes in certain subgroups. Patients with HLHS palliated with the Norwood procedure are at a greater risk for morbidity and mortality compared to those with other forms of FSV with SOTO.

Early outcome of children with complex atrial isomerism undergoing uni-ventricular cardiac palliation.

OBJECTIVE: To review the postoperative intensive care unit (ICU) course and early outcome of children with complex atrial isomeric hearts undergoing cardiac surgery for uni-ventricular heart repair. METHODS: A retrospective review and analysis of ICU course of pediatric patients with atrial isomerism admitted from January 2000 to December 2004 in King Abdul-Aziz Medical City, Riyadh, Kingdom of Saudi Arabia, who underwent uni-ventricular repair. RESULTS: During the study period, 18 (n=18) patients were identified to have complex congenital heart disease (CHD) associated with atrial isomerism. They were in the form of right atrial isomerism (n=12), and left atrial isomerism (n=6). Eight patients did not meet the inclusion criteria of the study and were excluded. Ten of the 18 patients fulfilled the study criteria and underwent first stage uni-ventricular heart repair with 8 survivals (80%). Three of the 8 operated survival cases underwent second stage repair with 2 survivals (66%) and one patient completed Fontan surgery with a good outcome. An uneventful ICU course was noted in 3 of 10 operated patients (30%). Complications were noted in (40%) of cases including sepsis (n=4), tracheostomy (n=1), prolonged mechanical ventilation >7days (n=2). Over 50% of the operated patients required prolonged ICU stay (>2 weeks). CONCLUSION: Atrial isomerism is frequently associated with complex cardiac defects that often present in the neonatal stage and requires multiple staged cardiac surgeries. The surgical repair and peri-operative management of this group of patients can be difficult, challenging, and with potential risk of significant morbidity or mortality. In our setting, we found the outcome of children with atrial isomerism undergoing uni-ventricular palliation comparable to the literature.

A familial variant of the Scimitar syndrome with a meandering pulmonary vein.

We report a rare variant of the Scimitar syndrome, in which the right lower pulmonary vein takes a meandering course before finally connecting in normal fashion to the left atrium. The pulmonary parenchymal segment drained by the tortuous vein is supplied by a systemic collateral artery, which was coiled via a catheter. We also closed the intracardiac defects by surgery. The elder brother of the patient had classical Scimitar syndrome.