Outcome of obstructed total anamalous pulmonary venous connection (TAPVC) repair patients with milrinone versus milrinone and inhaled nitric oxide (INO): A prospective randomized observational study.

Background: Obstructed total anomalous pulmonary venous connection (TAPVC) typically present with severe cardiovascular decompensation and requires urgent surgical management. Pulmonary arterial hypertension (PAH) is a major risk factor affecting mortality. Perioperative management focuses on providing inotropic support and managing potential pulmonary hypertensive episodes. Milrinone and inhaled nitric oxide (iNO) efficiently reduce pulmonary artery pressure (PAP) and help to improve the outcome. The aim was to determine the outcome of patients with high PAP with milrinone alone and a combination of iNO and milrinone. Material and Method: After ethical committee approval, the study was conducted over a period of 3 years in 80 patients with obstructed TAPVC repair. A total of 80 patients having severe PAH (supra systemic arterial pressure) randomly divided into two groups with 40 patients in each (M & MN). Group M (milrinone) patients received milrinone and Group MN (milrinone & iNO) patients received both milrinone (after opening aortic cross clamp) and iNO (post operative ICU). Ventilation time, hospital stay, ICU stay, complications, in hospital mortality were compared between both groups. Result: Ventilation time, Intensive Care Unit (ICU) stay, hospital stay for group M was 8.02 ± 5.74 days, 11.25 ± 7.33 day, 14.92 ± 8.55 days, respectively, and for group MN was 5.02 ± 1.78 days, 8.27 ± 3.24 days, 10.3 ± 3.18 days, respectively. In hospital mortality for group M and MN was 10% and 2.5%, respectively. P value for each variable was significant < 0.05 (except mortality). Conclusion: Most of the patients with obstructed TAPVC had severe PAH. Management of severe PAH with a combination of milrinone with iNO had a better outcome than milrinone alone.

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery.

OBJECTIVE: The aim of this study was to compare efficacy and safety of paravertebral block (PVB) and interpleural analgesia (IPA) after minimally invasive cardiac surgery through thoracotomy in terms of quality of analgesia, post-operative mechanical ventilation time, intensive care unit (ICU) and hospital length of stay (LOS) and complications. DESIGN: A randomized, prospective study. PARTICIPANTS: A total of 50 adult patients (18-50 years old) undergoing minimally invasive cardiac surgery via thoracotomy. INTERVENTION: Patients were randomized for group A: paravertebral epidural catheter (n = 25), group B: interpleural catheter (n = 25). All patients were given Inj. Bupivacaine 0.125%, 8 ml and Inj. Tramadol 100 mg as an adjuvant, total volume 10 ml. RESULTS: After obtaining institutional review board approval, data collected and analysed - visual analogue score (VAS) at rest and on coughing, haemodynamic and respiratory parameters, time to extubation, supplementary analgesia requirement, LOS and complications. VAS was recorded at 0, 2, 3, 4, 8, 12 and 24 h post-extubation, while blood gases at-after shifting, 4, 8, 12 and 24 h. There were no significant differences in haemodynamic or respiratory parameters, VAS at rest and on coughing, ventilation duration, ICU and hospital LOS between two groups. The requirement of rescue analgesia was in one patient of mini coronary artery bypass in group B, while one patient in group A required reintubation due to respiratory acidosis and got successfully extubated on next day morning. CONCLUSION: PVB and IPA both are safe and effective techniques for minimally invasive cardiac surgery with thoracotomy. It allows optimal pain control and safe ICU fast-track post-operative course.

Assessment of the effect of two regimens of milrinone infusion in paediatric patients with pulmonary artery hypertension undergoing corrective cardiac procedure: A prospective observational study.

Background: The aim of the study was to compare the effect of two different regimens of milrinone in pediatric patients with pulmonary artery hypertension (PAH) undergoing corrective procedure. Materials and Methods: This randomized prospective study included 100 pediatric patients undergoing corrective cardiac surgeries. Group E: Milrinone was started as infusion 0.5 µg/kg/min without a loading dose after induction of anesthesia and continued as infusion 0.5-0.75 µg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 µg/kg over 10 min before weaning from cardiopulmonary bypass (CPB) followed by infusion 0.5-0.75 µg/kg/min in the PSICU. We compared heart rate, mean arterial blood pressure, central venous pressure, cardiac index (CI), mean pulmonary arterial pressure (MPAP), serum lactate level, urine output, vasoactive inotropic score, mechanical ventilation duration, and intensive care unit (ICU)- and hospital length of stay between the groups. Results: There was an increase in mean arterial blood pressure, CI, and urine output in Group E compared to Group L (P < 0.05). MPAP, serum lactate level, and requirement of inotropes and vasopressors were lower in Group E compared to Group L (P < 0.05). Mechanical ventilation duration, ICU, and hospital length of stay were shorter in Group E than Group L (P < 0.05). Conclusions: Early use of milrinone in patients with PAH undergoing corrective cardiac surgeries improved CI and mean arterial pressure, decreased MPAP, improved urine output, decreased serum lactate level, and decreased requirement of inotropes and vasopressors after weaning from CPB compared to the milrinone bolus group.

Topical and low-dose intravenous tranexamic acid in cyanotic cardiac surgery.

Background Coagulopathy is a major problem in surgery for cyanotic congenital heart disease. Tranexamic acid has been used both topically and systemically and plays a vital role in pediatric cardiac surgery by reducing blood loss and blood product requirement. We aimed to determine the anti-fibrinolytic effectiveness of low-dose systemic or topical tranexamic acid or a combination of both. Methods Seventy-five patients were divided in 3 groups of 25. Group A patients were given tranexamic acid 20 mg kg-1 intravenously after sternotomy and 20 mg kg-1 after heparin reversal. Group B patients were given tranexamic acid 50 mg kg-1 in 20 mL of saline intrapericardially before sternal closure, with the drain clamped for 20 min. Group C patients were given tranexamic acid 20 mg kg-1 intravenously after sternotomy and 50 mg kg-1 intrapericardially before sternal closure. A number of clinical variables were recorded in the first 3 postoperative days. Ventilator time, intensive care unit stay, and outcome were also recorded. Results Chest tube drainage and blood product requirements were lowest in group C. Blood urea and serum creatinine levels were higher in groups A and C ( p < 0.05). Intensive care unit stay and ventilator time were similar in all 3 groups. No patient died and none had a seizure or other neurological event or thromboembolic complication postoperatively. Conclusion The combination of low-dose intravenous and topical tranexamic acid reduces postoperative blood loss and blood product requirement without incurring neurological, renal or thromboembolic complications. We recommend the routine use of topical and low-dose systemic tranexamic acid in cyanotic pediatric cardiac surgery.

Comparison of Albumin, Hydroxyethyl Starch and Ringer Lactate Solution as Priming Fluid for Cardiopulmonary Bypass in Paediatric Cardiac Surgery.

INTRODUCTION: In paediatric cardiac surgery, there is still not any information with regard to the best choice of priming fluids for Cardiopulmonary Bypass (CPB). Albumin, Hydroxyethyl Starch (HES) & ringer lactate are equally used, but each has its advantages & disadvantages. Albumin & HES had better fluid balance which affect outcome in paediatric cardiac surgery significantly. AIM: To compare priming solution containing albumin, hydroxyethyl starch and ringer lactate during elective open-heart surgery in paediatrics aged up to 3 years. MATERIALS AND METHODS: All patients were managed by standardized institution protocol and were randomly distributed into three groups based on the priming solution which is used in the CPB Circuit and having 35 patients in each group. Group A: Receive albumin 10 ml/kg in priming solution, Group B: Receive Hydroxyethyl starch (HES130/0.4) 6% 20ml/kg in priming solution, Group C: Receive ringer lactate priming solution. Primary outcome variable included perioperative haemoglobin, total protein, colloid osmotic pressure, platelets, fluid balance, urine output, post-operative blood loss, blood products usage, renal & liver function, extubation time, ICU stay & outcome. RESULTS: Patients receiving albumin had higher perioperative platelet count, total protein level & colloid osmotic pressure, lesser post-operative blood loss & blood products requirement. Patients receiving HES had lower level of platelets postoperatively than ringer lactate group but not associated with increase blood loss. HES did not affect renal function & haemostasis in this dose. Patients receiving ringer lactate had positive fluid balance intraoperatively. All three groups have similar effect on renal & liver function, urine output, time to extubation, ICU stay & outcome. CONCLUSION: We conclude that albumin is expensive but better prime as maintain haemostasis, colloid oncotic pressure & reduced blood product requirement. HES will not hamper haemostasis & renal function in lower dose & better than crystalloid as maintain negative fluid balance. Patient outcome & ICU stay was similarly affected by priming solutions.

Fluorescein dye-guided intraoperative identification and closure of muscular ventricular septal defect.

OBJECTIVE: Various techniques for intraoperative identification of muscular ventricular septal defects (VSDs) are cumbersome, difficult to use in infants, and inefficient in confirming the completeness of closure. We used simple technique of intraoperative fluorescein saline injection into the left ventricle to locate the muscular VSDs and to confirm their closure. METHODS: This is a prospective observational study conducted between April 2013 to December 2013, involving 22 patients with multiple VSDs either in isolated form or in association with other congenital cardiac anomalies. Following the closure of all visible VSDs, an 8F infant feeding tube was introduced into the left ventricle through the fossa ovalis and fluorescein saline was injected. Right ventricle was observed for saline leakage and VSD site tracking. Saline injection was repeated till appearance of no significant leak. RESULTS: A total of 63 defects were closed in 22 patients. Only two patients required re-endocardialization or septal exclusion technique for Swiss cheese septum. None of them required division of moderator band or major trabeculae. Eleven patients had insignificant residual shunting found on postoperative echocardiography. There were two deaths. In the remaining 20 patients, the mean of intensive care unit (ICU) and hospital stay was 5.4 ± 3.72 and 10.2 ± 4.64 days, respectively. Comparative study between patients with and without residual VSD showed no significant difference in mean inotropic score, ICU, and hospital stay, confirming the absence of significant residual shunting. CONCLUSIONS: Intraoperative fluorescein saline injection into the left ventricle is safe, effective in precisely localizing muscular VSDs and confirming the completeness of their closure.