The Clinical Outcomes in Patients With Atrial Isomerism Undergoing Single Ventricular Palliation: Insights From A Single-Center Study in Thailand.

Background: The management of atrial isomerism across various countries may impact survival outcomes. Methods: This retrospective study involved patients diagnosed with atrial isomerism undergoing single ventricular palliation between 2000 and 2021. The objective was to evaluate survival outcomes within the right atrial isomerism (RAI) and left atrial isomerism (LAI) groups, as well as overall survival. Results: Of the 125 patients diagnosed with atrial isomerism, 105 (84%) had RAI, and 20 (16%) had LAI. The median age at presentation was 3 days (range: birth to 7.1 years), with median follow-up of 6.6 years (range: 0.59 months to 30.8 years). In the overall cohort, survival rates at one, five, and ten years were 85.6%, 72.3%, and 66.8%, respectively, with no statistically significant difference between RAI and LAI groups (log rank P value = .293). Specifically, survival rates in the RAI group at one, five, and ten years were 83.8%, 69.0%, and 62.6%, respectively, while in the LAI group, there were 95.0%, 89.7%, and 81.6%, respectively. Following the third-stage operation, overall survival rates at one and five years were 76.4% and 76.4%, respectively. Among patients in the RAI group, survival rates at one and five years post-third stage operation were 80.2% and 80.2%, respectively. Conclusions: Despite resource limitations, the survival outcomes of patients with atrial isomerism were found to be similar with those observed in high-income countries. Although an increased mortality rate was noted within the first year of life, focusing efforts on neonatal and infant care holds potential for improving overall outcomes.

Contemporary survival outcomes of congenital systemic-to-pulmonary shunt in children with borderline pulmonary vascular resistant index compared to Eisenmenger syndrome.

Pulmonary arterial hypertension (PAH) associated with congenital heart disease (PAH-CHD) is a complication that occurs after unrepaired significant systemic-to-pulmonary shunt. Treatment options for PAH-CHD-predominantly left-to-right (L-R) shunt in children with borderline-high pulmonary vascular resistant index (PVRi) have been debated. We aimed to assess the treatment and survival of children with PAH-CHD-predominantly L-R shunt with borderline to high PVRi, using Eisenmenger syndrome (ES) for comparison. In 1995-2021, a total of 142 patients with ES and 192 children with PAH-CHD-predominantly L-R shunt were eligible for our analysis. The PVRi in ES patients was 26.7 ± 16.8 WU m2. Most patients (91%) received PAH-targeted therapy. Of the 192 children with PAH-CHD-predominantly L-R shunt, the baseline PVRi was 9.2 ± 5.8 WU m2. A total of 64 patients (33.3%) had borderline PVRi (4-8 WU m2) and 98 patients (51%) had high PVRi (> 8 WU m2). Most patients (88.5%) responded to acute pulmonary vasodilatory testing and underwent repair, with 158 undergoing defect closure and 12 having fenestrated closure. A treat-and-repair strategy was used in 33 children (17.1%). The 10- and 15-year survival rates for patients with ES were 79.3% and 72.4%, respectively, which was significantly inferior to children with borderline PVRi [97.3% and 87.8% (p = 0.02)]; and high PVRi [91.6% and 89.5% (p = 0.06)], respectively. The survival rate of children receiving treat-and-repair was slightly higher than that of ES (p = 0.16). The independent mortality risk in children with PAH-CHD-predominantly L-R shunt was persistent PAH following the defect correction (adjusted hazard ratio 5.8, 95% CI 1.7-19.9, p = 0.005).Trial registration: TCTR20200420004.

Analgesic Effect and Sleep Quality of Low-Dose Dexmedetomidine in Cardiac Surgical Patients After Ultrafast-Track Extubation: A Randomized Clinical Trial.

OBJECTIVE: To compare the analgesic and sleep quality effects of dexmedetomidine infusion versus placebo in patients undergoing cardiac surgery with ultra-fast track extubation. DESIGN: The randomized, double-blind clinical trial study. SETTING: At a single academic center hospital. PARTICIPANTS: We included patients aged 25 to 65 scheduled for elective cardiac surgery under general anesthesia with cardiopulmonary bypass from October 2021 to December 2022. INTERVENTION: After immediate extubation in the operating room, the patients who were allocated at first after providing their consent to either the dexmedetomidine group (Dex) or the placebo group (Placebo) received continuous infusion of dexmedetomidine (0.2 µg/kg/h) or saline for 12 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: The groups' demographic and perioperative variables were not statistically significant. Total morphine consumption in milligrams at 12 and 24 hours after administered study drug, total sleep time in hours by BIS value ≤85, and sleep quality with the Richard-Campbell Sleep Questionnaire were compared. The analysis included 22 Dex and 23 Placebo patients. The consumption of morphine was not statistically different between the Dex and Placebo groups at 12 and 24 hours (p = 0.707 and p = 0.502, respectively). The Dex group had significantly longer sleep time (8.7 h [7.8, 9.5]) than the Placebo group (5.8 h [2.9, 8.5]; p = 0.007). The Dex group also exhibited better sleep quality (7.9 [6.7, 8.7] vs 6.6 [5.2, 8.0]; p = 0.038). CONCLUSIONS: Sedation with low-dose dexmedetomidine infusion for ultra-fast track extubation following cardiac surgery enhances sleep duration and quality.

Superior cavopulmonary shunt via right vertical axillary mini-thoracotomy.

We present 2 cases of patients with univentricular heart physiology of different anatomic variants who successfully underwent minimally invasive bidirectional cavopulmonary anastomosis via the right vertical axillary mini-thoracotomy.

Major infections following pediatric cardiac surgery pre- and post-CLABSI bundle implementation.

Background: Postoperative infection contributes to the worsening of congenital cardiac surgery (CCS) outcomes. Surgical site infection (SSI), bloodstream infection (BSI) and ventilator associated pneumonia (VAP) are common. An additional bundle of preventive measures against central-line associated bloodstream infection (CLABSI) bundle was implemented in April 2019. Objectives: To compare the incidence of major infections after pediatric CCS before and after the implementation of the CLABSI bundle and to identify risk factors for major infections. Methods: We conducted a single-center, retrospective study to assess the incidence of major infections including bloodstream infection (BSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP) after pediatric CCS one year before and after implementation of the CLABSI bundle during April 2018-March 2020. The demographics and outcomes of the patients were explored, and risk factors for major infections were identified using multivariate analysis. Results: A total of 548 children (53% male) underwent CCS with a median age of 1.9 years (range 0.01-17.5 years). The median Aristotle Basic Complexity score was 7.1 (range 3-14.5). The CLABSI bundle was applied in 262 patients. Overall mortality was 5.5%. 126 patients (23%) experienced major postoperative infections. During the year after the implementation of the CLABSI bundle, BSI was reduced from 8.4% to 3.1% (p = 0.01), with a smaller reduction in VAP (21% to 17.6%; p = 0.33). The incidence of SSI was unchanged (1.7% to 1.9%; p = 0.77). The independent risk factors for major infections were age at surgery <6 months (p = 0.04), postoperative ventilator usage >2 days (p < 0.01), central line usage >4 days (p = 0.04), and surgery during the pre-CLABSI bundle period (p = 0.01). Conclusion: Following the implementation of the CLABSI prevention package in our pediatric CCS unit, the incidence of BSI was significantly reduced. The incidence of VAP tended to decrease, while the SSI was unchanged. Sustainability of the prevention package through nurse empowerment and compliance audits is an ongoing challenge.

Early Outcome of Simplified Standardized Trileaflet Polytetrafluoroethylene Valved Conduit Placement.

BACKGROUND: Use of the expanded polytetrafluoroethylene (ePTFE) valved conduit in the pulmonary position during the correction of congenital heart defects has significantly increased in popularity over the last decade due to its promising conduit longevity. We describe the standardized process to create and implant a trileaflet ePTFE pulmonary conduit along with the early outcomes of such procedures at our institute. METHODS: Records of 100 consecutive patients who underwent ePTFE valved conduit placement using our technique from April 2018 through February 2022 were retrospectively analyzed. The function of the conduit was evaluated by transthoracic echocardiography. RESULTS: The mean age of the patients was 28 ± 13.2 years old at the time of the operation. The conduit diameters ranged from 16 to 24 mm (mean 23.0 ± 1.9 mm). Conduit placement was utilized for pulmonary valve replacement in 68 patients, conduit change in 25 patients, and as a part of total repair in 7 patients. There were 2 in-hospital conduit-unrelated deaths from multi-organ dysfunction and pulmonary hypertensive crisis. From the postoperative echocardiography, the average peak pressure gradient across the conduit was 18.6 ± 9.0 mm Hg, and the conduit regurgitation was graded as none or trace in 81 patients, mild in 17 patients, and moderate in 2 patients. At 589 days of median follow-up, there was no conduit reoperation. Follow-up imaging of 60 available patients at a median time of 511 days did not show a significant change in conduit function. CONCLUSIONS: Our standardized ePTFE valved conduit creation and placement demonstrated satisfactory clinical and echocardiographic outcomes.

A Risk Prediction Model and Risk Score of SARS-CoV-2 Infection Following Healthcare-Related Exposure.

Hospital workers are at high risk of contact with COVID-19 patients. Currently, there is no evidence-based, comprehensive risk assessment tool for healthcare-related exposure; so, we aimed to identify independent factors related to COVID-19 infection in hospital workers following workplace exposure(s) and construct a risk prediction model. We analyzed the COVID-19 contact tracing dataset from 15 July to 31 December 2021 using multiple logistic regression analysis, considering exposure details, demographics, and vaccination history. Of 7146 included exposures to confirmed COVID-19 patients, 229 (4.2%) had subsequently tested positive via RT-PCR. Independent risk factors for a positive test were having symptoms (adjusted odds ratio 4.94, 95%CI 3.83−6.39), participating in an unprotected aerosol-generating procedure (aOR 2.87, 1.66−4.96), duration of exposure >15 min (aOR 2.52, 1.82−3.49), personnel who did not wear a mask (aOR 2.49, 1.75−3.54), exposure to aerodigestive secretion (aOR 1.5, 1.03−2.17), index patient not wearing a mask (aOR 1.44, 1.01−2.07), and exposure distance <1 m without eye protection (aOR 1.39, 1.02−1.89). High-potency vaccines and high levels of education protected against infection. A risk model and scoring system with good discrimination power were built. Having symptoms, unprotected exposure, lower education level, and receiving low potency vaccines increased the risk of laboratory-confirmed COVID-19 following healthcare-related exposure events.

Modified del Nido versus blood cardioplegia in congenital cardiac surgery.

BACKGROUND: Lactated Ringer-based del Nido cardioplegia has been reported to be safe for acquired cardiac surgery. The original Plasma-Lyte-based solution has been proved for congenital cardiac surgery but its modification has not been adequately examined. We compared the clinical outcomes of congenital cardiac surgery using lactated Ringer-based del Nido cardioplegia versus cold blood cardioplegia. METHODS: Between September 2018 and November 2020, 116 consecutive patients with congenital heart disease undergoing operations with cardioplegic arrest performed by a single surgeon at Faculty of Medicine Siriraj hospital; 66 with modified del Nido solution and 50 with institutional's blood cardioplegia. The patient risk profiles, operative details, mortality rates, care durations, inotrope use, blood transfusion and complications were compared. RESULTS: Preoperative characteristics were similar between groups, including median age (2.5 vs. 3.1 years; p = 0.49), size, and gender. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score of 3 to 5 was more prevalent in the del Nido group (24.2% vs. 10%; p = 0.049). There were 4 deaths in the modified del Nido group (risk category score of 4) but none in the cold blood group (p = 0.13). There was no significant difference in median intubation duration, length of intensive care unit stay, and vasoactive medications immediately and 24 h after the operation. The del Nido group required 70 to 100 ml less blood transfusion (p = 0.04). All complications were similar between the two groups. CONCLUSIONS: Clinical outcomes of lactated Ringer-based del Nido cardioplegia were comparable to those of blood cardioplegia in congenital cardiac surgery.

Outcomes of Transcatheter Pulmonary Valve Replacement and Surgical Pulmonary Valve Replacement: A Cohort Analysis.

Background: Transcatheter pulmonary valve replacement (TPVR) has become an alternative to surgical pulmonary valve placement (SPVR) for patients after tetralogy of Fallot repair. This study compared the outcomes of TPVR with those of SPVR. Methods: We reviewed data from patients who underwent pulmonary valve replacement with a median of 2 years of follow-up. Results: Between 2010 and 2021, 215 patients underwent pulmonary valve replacement (72 TPVR and 143 SPVR). The median size of the right ventricular end-diastolic volume index in the TPVR group was 165 mL/m2 (IQR, 136-190) and 184 mL/m2 (IQR, 163-230) in the SPVR group (P = .001). The median value of the maximum landing zone at the right ventricular outflow tract (RVOT) in patients with native RVOT was 26 mm (IQR, 24-28) in the 43 patients in the TPVR group and 31 mm (IQR, 28-34) in the 101 patients in the SPVR group (P < .001). The median size of the pulmonary valve implant for the native RVOT in the TPVR group was 29.0 mm (IQR, 26.0-29.0) and 24.0 mm (IQR, 24.0-24.0) in the SPVR group (P < .001). There were no deaths in the TPVR group and 8 deaths in the SPVR group (P = .041). Major complications and the length of hospitalization were lower in the TPVR group (P = .001). After 2 years, the mean decrease in QRS duration was 5 milliseconds (IQR, 1-14) in the TPVR group and 1 millisecond (IQR, -4 to 10) in the SPVR group (P = .006). Conclusions: TPVR allows for larger implants, resulting in lower mortality, shorter hospital stays, and fewer major cardiac events. SPVR may be preferable in patients with larger (>30 mm) native RVOT and in those who require concomitant surgical procedures.

The effectiveness of split tablet dosing versus alternate-day dosing of warfarin: a randomized control trial.

Due to large dosage variation, a variety of warfarin prescription regimens are utilized for specific doses such as tablet splitting, or pill strength alternating. The clinical comparison between the two is lacking. We hypothesize that both approaches result in different times in therapeutic range. We randomized patients with specific warfarin dosage and stable INR for 6 months or longer to receive the whole tablet, alternate-day dosing or the split tablet, same daily-dosing regimen without initial dose change and followed them every 6 weeks for 6 months. The primary outcome was a time in therapeutic range of 2.0-3.0. The secondary outcomes included dosage, compliance, INR, anticoagulant-related events. A total of 66 patients were enrolled, 32 randomly assigned to the split tablet regimen (group S) and 34 to the alternate-day regimen (group A) with two withdrawers. The mean age was 58.6 ± 8.5 years. All baseline characteristics of both groups were similar. The average time in therapeutic range was 72.8 ± 25.4% in group S and 74.9 ± 22.0% in group A (p = 0.72). There were no significant differences in warfarin dosage, compliance, INR and, complications between the two groups. Both warfarin prescription methods, the split tablet and the alternate-day had comparable time in the therapeutic range.

Using bilateral radial arteries in coronary artery bypass grafting is safe.

BACKGROUND: Recent studies have revealed that radial artery grafts have excellent patency rates. However, harvesting of the radial artery is generally limited to the non-dominant forearm. We would like to demonstrate the effectiveness and safety of bilateral radial artery harvesting. METHODS: We enrolled 173 patients undergoing coronary artery bypass. Bilateral RA were used in 64 cases and unilateral in 109. The primary endpoint was post-harvest forearm and hand complications. RESULTS: Forearm and hand complications occurred immediately postoperatively in 28.1% of the bilateral radial artery group, significantly more than in the unilateral radial artery group (8.3%). During follow-up, no overall difference was found in post-harvest forearm and hand complications. However, the forearm and hand perception score in the bilateral radial artery group was higher: 8.78 ± 1.45 vs. 8.35 ± 0.84 in the unilateral radial artery group. Subgroup analysis in the bilateral radial artery group revealed no significant difference in forearm and hand perception score between the dominant and non-dominant donor forearms (8.78 ± 1.45 in non-dominant and 8.66 ± 1.00 in dominant forearms). The bilateral radial artery group had more arterial coronary anastomoses, longer operative times, and longer cardiopulmonary bypass times. However, a backward multiple linear regression model revealed that only two factors related to operative time, these were the number of arterial distal coronary anastomosis and cardiopulmonary bypass time. CONCLUSIONS: This study demonstrated that bilateral radial artery conduits can be used effectively and safely with no difference in persistent complications related to the hands and forearms.

Superior pulmonary arterial flap for the repair of the left coronary artery from the non-facing pulmonary sinus.

OBJECTIVES: The anomalous left coronary artery arising from the non-facing pulmonary sinus origin is uncommon but poses a great challenge as its distance precludes direct aortic implantation. We describe an innovative technique for aortic implantation of this anomaly in a 2-month-old infant. METHODS: Using a longitudinal pulmonary arterial flap, coronary tube extension was constructed without pulmonary commissure disturbance. RESULTS: Myocardial recovery after 2-coronary artery system restoration was excellent. CONCLUSIONS: With this approach, coronary transfer using autologous tissue with growth potential is possible.

Midterm results of anatomic repair in a subgroup of corrected transposition.

BACKGROUND: Anatomic repair has become the preferred option in the subgroup of patients with congenitally corrected transposition of the great arteries with ventricular septal defect and pulmonary obstruction. We report our 14-year experience with this approach. METHODS: From April 2001 to February 2014, 22 patients with congenitally corrected transposition with ventricular septal defect and pulmonary obstruction underwent anatomic repair. Nineteen patients had a modified Senning-Rastelli procedure, 2 had a Mustard-Rastelli procedure, and one had a hemi-Mustard-Glenn-Rastelli procedure. The mean age was 10.9 years, and 8 (36.4%) patients were male. RESULTS: There were 2 early deaths from sepsis and ventricular failure at 18 and 81 days postoperatively, and 3 late deaths from ventricular failure at 4, 33, and 113 months postoperatively. Left ventricular failure with mitral valve regurgitation was present in 3 of the 5 patients who died. Among the survivors, 3 underwent 4 transcatheter interventions for right ventricular outflow tract obstruction and 3 underwent 4 reoperations for atrial pathway obstruction, left and right ventricular outflow tract obstruction, or residual shunt. At a median follow-up of 64 months (range 14-167 months), 15 of 17 survivors were in functional class I. One patient had severe mitral valve regurgitation and was awaiting valve replacement. Another patient had right ventricular outflow conduit obstruction and was scheduled for reoperation. CONCLUSIONS: Results of atrial switch-Rastelli procedures in this subgroup of patients with corrected transposition are satisfactory but still imperfect. Mitral regurgitation might predict a poor outcome. Long-term follow-up is necessary.

Surgical Outcomes of Adult Congenital Heart Disease with Left to Right Shunt at Siriraj Hospital.

Background: Outcomes of surgical treatment of adult congenital heart disease (ACHD) in developing country are scant but are of critical importance for caring of these patients. Objective: We studied characteristic and surgical repair outcomes of simple ACHD at Siriraj Hospital. Material and Method: We studied 297 adults with atrial septal defect (ASD), ventricular septal defect (VSD), or patent ductus arteriosus (PDA) whom underwent surgical repair between January 2006 and September 2014. There were 211 ASD, 80 VSD, and 6 PDA. We focused on perioperative data, follow-up data, and factor(s) associated with adverse events. Results: Of 297 patients, 37.4% were males; mean age was 41.8 years (range, 20-78 years). Pulmonary hypertension and valvular regurgitation (mitral, tricuspid, or aortic) were presented in 74.7% and 35.0% of the patients, respectively. Majority of defects were closed with patching (85.4% for ASD and 82.7% for VSD), while the rest were closed directly. Of the 190 concomitant procedures, most of them were tricuspid repair (28.9%), and mitral repair (17.4%). There were eight hospital deaths (2.7%). At median follow-up of 25 months (range, 1-102 months), the mean functional classification was reduced from 1.9 to 1.1 (p<0.01). There were five re-interventions and four late deaths. Overall survival was 96.1% at five years and 76.1% at eight years. Concomitant procedure(s), tricuspid, and mitral regurgitation were associated with worse survival. Concomitant procedure(s), mitral, and aortic regurgitation were associated with re-intervention. Conclusion: Outcomes of surgical repair of simple ACHD were good. Valvular regurgitation and concomitant procedure(s) adversely affected the outcomes.