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

Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery

Chylothorax is the accumulation of chyle in the pleural cavity, which usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases, this rupture is secondary to trauma [including cardio thoracic surgeries]. Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. This study aims to determine the risk factors and the impact of chylothorax on the early postoperative course after pediatric cardiac surgery. A retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery was conducted at King Abdulaziz Cardiac Center between January 2007 and December 2009. There were 1135 cases operated on during the study period. Of these, 57 cases [5%] were complicated by chylothorax in the postoperative period. Thirty patients [54%] were males, while 27 [47%] were females. Ages ranged from 4 to 2759 days. The most common surgeries complicated by chylothorax were the single ventricle repair surgeries [15 cases, 27%]; arch repairs [10 cases, 18%]; ventricular septal defect repairs [10 cases, 18%]; atrioventricular septal defect repairs [7 cases, 12%]; arterial switch repair [6 cases, 11%], and others [8 cases, 14%]. The intensive care unit [ICU] and the length of hospital stays were significantly longer in the chylothorax group. Additionally, some early postoperative parameters such as incidence of sepsis, ventilation time, and inotropes duration and number were higher in the chylothorax group. Chylothorax after pediatric cardiac surgery is not a rare complication. It occurs more commonly with single ventricle repair and aortic arch repair surgeries, and has a significant impact on the postoperative course and post operative morbidity

Resting heart rate in patients with ischemic heart disease in Saudi Arabia and Egypt

To assess the level of resting heart rate [RHR] in an outpatient population presenting with stable coronary artery disease [CAD] as well as to measure its association with current therapeutic management strategies for cardiovascular events. A multi-center cross-sectional survey was carried out in Saudi Arabia and Egypt over a three month period [between January 2007 and April 2007]. 2049 patients with CAD without clinical heart failure [HF] were included in this study through "cluster sampling". RHR was measured by manual palpitation. Mean age of CAD patients was 56.7 +/- 10.4 and the mean RHR was 78.9 +/- 13.9 b/m. 1686 patients [83.1%] were on beta -blockers for whom the RHR was 78.5 +/- 14.0 b/m [95.5% had RHR >/= 60 b/m, which is higher than recommended by the guidelines]. 1094 [73.5%] of patients on beta -blockers were on a lower dose, probably to avoid the complications associated with such a class. Among those not on beta-blockers [16.9%], RHR was 80.9 +/- 13.0 b/m. Moreover, 98 patients [4.8%] were on calcium channel blocker [diltiazem or verapamil] but not on beta-blockers, for whom the RHR was 80.9 +/- 12.0 b/m. Finally, 163 patients [8.0%] were on both beta-blockers and the calcium channel blocker, and their RHR was 79.0 +/- 14.4 b/m. Optimal target RHR has not been achieved in a significant number of screened patients. Achievements of such targets are known to decrease mortality and to improve survival

Coronary insufficiency in children: Review of literature and report of a rare case with unknown aetiology

Myocardial ischemia due to coronary artery disease is a rare condition in children. The reported causes of this condition include vasculitis; commonest being Kawasaki' disease, premature atherosclerosis due to familial dyslipidemias, congenital coronary artery anomalies and post-operative complications of procedures requiring coronary artery re-implantation in children, e.g. arterial switch procedure and Ross procedure. Allograft arteriopathy after heart transplantation is a more recent addition to this list [Mavroudis et al., 1996]. Surgical procedures required for the treatment of coronary artery disease in children include, but are not limited to coronary artery re-implantation, re-routing, augmentation of the osteum, and coronary artery bypass grafting [CABG]. We present our experience of a rare case of triple vessel coronary artery disease of unknown aetiology in a child, treated with coronary artery bypass grafting procedure

Gender differences in the surgical management and early clinical outcome of coronary artery disease: Single centre experience

To investigate the gender disparity in the distribution of patient-related risk factors and their effect on the surgical management and clinical outcome of coronary artery disease in Saudi population. We carried out a retrospective analysis of prospectively collected data of 971 patients undergoing isolated coronary artery bypass grafting [CABG] at our institution between January 2005 and December 2008. Seven hundred and eighty seven patients [81%] were males and 184 patients [19%] were females. We analyzed gender-based difference in clinical presentation and patient-related pre-operative risk factors and studied their impact on surgical management and clinical outcome. The mean age was 59.5 years in males and 63.4 years in females [p = < 0.0001]. Associated co-morbidities were higher in females. Prevalence of diabetes mellitus was 61.2% in males and 78.8% in females [p-value < 0.0001]; hypertension 61.9% in males and 79.9% in females [p-value < 0.0001]; hyperlipidemia 66.7% in males and 77.7% in females [p-value 0.0035]; morbid obesity 24.7% in males and 45.1% in females [p-value < 0.0001]; and Hypothyroidism 2.5% in males and 13.6% in females [p-value < 0.0001]. Smoking was the only risk factor with higher prevalence in males compared to females [44.2% v/s 2.2%; p-value < 0.0001]. The mean logistic euro-SCORE was 3.94 in males and 5.51 in females [p < 0.0003]. On-pump and off-pump CABG was carried out in equal numbers in two groups. Females required urgent surgery and less than 3 grafts more frequently while males underwent elective surgery and more than 3 grafts in greater numbers. No significant difference was present between the two gender groups in aortic occlusion times and bypass times. Univariant analysis revealed females gender as an independent risk factor for higher in-hospital mortality [1.1% versus 4.9% p = 0.0026] and higher incidence of post-operative complications like surgical wound infection, need for prolonged ventilation, low cardiac output state and multi-organ failure [p-values 0.01 or less]. Female gender is an independent predictor of adverse outcome after isolated CABG due to significantly higher co-morbidities and acute presentation and independent of their peri-operative management. Therefore, major socioeconomic education and preventive measures are needed to reduce the burden of major co-morbidities in females and to seek early cardiac advice and care

Early outcome of tetralogy of fallot repair in the current era of management

Traditional use of trans-annular patch [TAP] to release right ventricular outflow tract [RVOT] obstruction during tetralogy of Fallot [TOF] repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve [PV] function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function. A retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group [A] which include patients who had TAP without a valve. Group [B] includes those who had TAP with a monocuspid valve [Contegra]. We compared postoperative care and outcome of all groups. Eighty-three patients fulfilled the study criteria. There were 64 cases [77%] in group I, and 19 cases [23%] in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups. Children undergoing TOP repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques

Dextrocardia, aortopulmonary window with transposition of the great arteries, case report

Transposition of the great arteries [D-TGA] in combination with aortopulmonary window [APW] is a very rare entity and carries high morbidity and mortality. Only few cases have been reported with this association. We report the first case of D-TGA and APW with mirror image dex-trocardia which was repaired successfully

Moderate ischemic mitral regurgitation: is there a case for early intervention?

Ischemic mitral regurgitation [IMR] results from left ventricular remodelling after myocardial infarction and severely affects cardiovascular mortality and morbidity. Ischemic mitral valve regurgitation also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a moderate degree of regurgitation. In this review, we wish to highlight the negative impact of IMR on long-term survival and discuss the available evidence for surgical correction of IMR at the time of coronary revascularization

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

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]. 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. 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. 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

Routine intraoperative transesophageal echocardiography for pediatric open heart surgery: is it justifiable?

The routine use of intraoperative transesophageal echocardiography [IO TEE] in children is still debatable. The aim of this study was to determine the safety, benefit, and the possible risk of the routine use of IO TEE. IO TEE was performed in all children under the age of 14 years with complex congenital heart defects undergoing open heart surgery, from July 2001 to December 2002. Simple lesions such as secundum atrial septal defects or simple perimembranous ventricular septal defects [VSD], and neonates less than 2.7 kg were excluded. All children underwent a pre-repair and post-repair complete IO TEE study. There were 112 children, 65 males and 47 females. Ages ranged from 4 days to 156 month, a median of 9 months. A full study was not done in three neonates [3%] because the probe could not be inserted in one, and because of airway compression resulting in desaturation in another two. A pre-repair study confirmed the preoperative transthoracic echocardiographic findings in 105 children [95%]. Diagnostic discrepancy or unexpected lesions not reported preoperatively were found in 6 children [5%]. Of the 109 children who had full post-repair studies, 67 [60%] showed optimum repair with no residual lesions, and 26 [23%] showed trivial or mild residual lesions accepted by the team. Going back on pump to fix moderate or severe residual lesions occurred in 16 [14%] children. In all of these children, the decision for going back on pump was prompted by the IO TEE examination alone. Mild complications occurred in two children [2%]. Based on our results, we recommend the routine use of IO TEE. It is safe, has a low complication rate, adds additional information and has a high impact on the diagnosis of residual lesions required in the operating room. However, careful monitoring of the ventilation and airway pressure, particularly during probe insertion and manipulation in small children, is very essential

Mild to moderate renal dysfunction. creatinine clearance versus serum creatinine as a risk factor for perioperative mortality and morbidity after isolated coronary artery bypass surgery

Risk stratification algorithms for coronary artery bypass grafting [CABG] do not include a weighting for preoperative mild and moderate renal impairment defined as a serum Creatinine 130 to 179 micromol/L [1.47 to 2.1 mg/dL], which may impact mortality and morbidity after CABG. Renal dysfunction [RD] is one of the predictors of mortality and morbidity in cardiac surgery. Creatinine clearance can be easily estimated by the Cockcroft and Gault equation from serum creatinine, gender, age and body weight. In this work we examine whether this estimation of the glomerular filtration rate can advantageously replace the serum creatinine in the preoperative risk assessment, and whether this calculated creatinine clearance could be used as a predictor of early mortality and postoperative complications in patients undergoing coronary artery bypass grafting. Three hundred ninety six consecutive patients without dialysis- dependent renal insufficiency undergoing a first isolated coronary artery bypass grafting were included. Preoperative serum creatinine concentrations and creatinine clearance calculated by using the Cockroft-Gault formula were related to early perioperative mortality and morbidity. The in-hospital mortality was 2.5% [10 of 396], the need for new dialysis/hemofiltration was 1.5% [6 of 396]. Using serum Creatinine, only 9.5% of our patient population was stratified as having preoperative mild to moderate RD versus 48.3% using calculated Creatinine clearance [CrCl]. Operative mortality was higher in the mild renal dysfunction group and increased with increasing preoperative serum Creatinine level. While we were able to find strong correlation using CrCl estimates, peri-operative mortality was higher in the mild [0.5% versus 3.7%; P = 0.03] and moderate RD group [0.5% versus 6.7%; P < 0.001], with S.Cr estimates, this correlation was only found in those who had preoperative mild RD. Similar finding has been found regarding the incidence of dialysis/hemoflitration [according to CrCl, 0.5% versus 1.4%; P = 0.387 in mild RD, and 0.5%, versus 5%; P = 0.003, in moderate RD]. Creatinine Clearance estimates were stronger predictor of mortality and dialysis/hemnofiltration than serum Creatinine. Mortality rate among patients who had dialysis/hemnofiltration was 66.6% versus an overall mortality of 2.5%. Mild and moderate renal insufficiency could increases the risk of early death and dialysis/hemoflitration with its associated morbidity after coronary artery bypass grafting. Our results indicate that calculated creatinine clearance is a stronger predictor of early mortality and morbidity postoperatively than serum creatinine level. We also could suggest that creatinine clearance should be applied to estimate the preoperative renal function instead of serum creatinine

Staged versus combined approaches for concomitant carotid and coronary artery disease. perioperative morbidity and mortality

There is a continuing controversy about the management of patients with concomitant occlusive disease of the coronary and carotid arteries. The options vary from combined to staged approach. The efficacy and safety of each method can be measured, essentially, by the global mortality, and morbidity. 33 of 1490 [2.21%] consecutive patients who were referred for isolated CABG were found to have significant carotid disease and underwent isolated coronary artery bypass graft [CABG] and carotid endarterectomy [CEA]. 23 patients had the staged approach [CEA, and subsequently CABG], while 10 patients had the combined approach [simultaneous CEA and CABG]. For these high-risk patients, there were 3 in-hospital mortalities, 1 patient in staged group [4.3%], and 2 patients [20%] in the combined group. While no patients in the staged group had stroke, 2 cases of disabling stroke were encountered in the combined group. One of these 2 cases was disabling stroke and death [Stroke related mortality]. Both patients who experienced postoperative stroke had a previous history of CVA. No patients in either group had Perioperative myocardial infarction. Staged approach is a good and safe alternative surgical option for patients with concomitant carotid and coronary artery disease. Our current approach is to favor staged carotid and coronary surgery, based on our operative experience and our Risk analyses [lower perioperative mortality and morbidity rates]. A rapid staged procedure may be a safe option to decrease the hospital stay