Intravenous versus topical tranexamic acid for pediatric open cardiac surgery in cyanotic heart disease

Objective This study was designed to investigate and compare the possibility of reducing postoperative blood requirements by using Tranexamic acid TX either intravenously or topically in pediatric patients with cyanotic heart disease. Study Design Double-blind, r and omized fashion Setting Children's Hospital - Assiut University- Egypt Participants 120 children undergoing repair of cyanotic congenital heart disease. Measurements and Main Results: Patients were r and omized into three equal groups 40 patients in each one; Control C group did not receive either study drug, Intravenous Tranexamic acid ITX group received Intravenous TX 50 mg / kg at the induction of anesthesia followed by infusion of 1 mg/kg/hr. till 6 hours postoperatively while the topical Tranexamic acid group TTX received topical TX 50 mg / kg poured into the precordial cavity before sternal closure. Total blood loss and transfusion requirement within the first 24 hours postoperatively were recorded together with hematocrit percentage, platelet counts and coagulation studies. In addition; chest closure time, duration of mechanical ventilation, length of Intensive Care Unit ICU stay and length of hospital stay were recorded and the occurrence of re-exploration for excess bleeding, or any other thrombotic or adverse events were recorded. Postoperative blood loss during the first 24 h was significantly higher in the C group 29.13 +/- 8.69 ml/kg compared to the other two groups who were treated with Tranexamic acid either intravenously or topically. ITX group patientrecorded less blood loss 13.05 +/- 7.88 ml/kg in comparison to TTX group 17.40 +/- 8.117 ml/kg. The amount of packed red blood cells and Fresh Frozen Plasma FFP transfusion in the first 24 hours administrated were significantly less in the ITX group patients 10.75 +/- 6.53, 12.00 +/- 5.86 ml/kg followed by TTX group patients 12.60 +/- 6.90, 10.50 +/- 6.77 ml/kg compared to control group of patients 25.00 +/- 6.53, 25.95 +/- 8.05 ml/kg. The control group had the largest re-exploration rate. ITX group had the shortest ventilation time, ICU and hospital stay. No significant difference between the three groups as regard the coagulation parameters except for significant lowest level of fibrin degradation product in ITX group. No side effects were recorded among the three groups. Conclusion: Tranexamic acid effectively reduces postoperative blood loss and the need for transfusion of allogeneic blood products in patients with cyanotic congenital heart disease. However, the intravenous regimen seems to be more effective than the topical one. Key words: Pediatric cyanotic heart disease; Tranexamic acid; Postoperative; Blood transfusion

Temporary tricuspid valve detachment for perimembranous VSD closure in children [early and long-term results]

VSDs can be successfully closed using a transatrial approach working across the tricuspid valve. Previous reports suggested tricuspid valve detachment technique [TVD] to improve exposure for closure of VSDs. However there has been concern that TVD might impair valve function, increase operative time and the incidence of postoperative heart block. Our Objective is to review the use of TVD technique for transatrial closure of perimembranous VSD in children and any resulting complications over 5 years postoperative follow up. This retrospective study reviewed the database from 2002 to 2007 and identified 158 children [91 males and 67 females] with mean age 3.16 +/- 2.6ys and weight 12.5 +/- 8.5 kg that underwent transatrial closure of pVSD in the Cardiotlioracic Surgery department, Assiut University Hospitals. Patients with types other than pVSDs and who underwent VSD closure via pulmonary artery or ventriculotomy were excluded from the study. Out of 158 children, 22 [13.9%] were operated with TVD technique while 136 [86.1%] were non TVD. The diagnosis of VSD and the postoperative follow up [Immediately and over 5ys] were done clinically and by echocardiography in the Pediatric Cardiology unit, Children University Hospital. VSD patch closure was done in 79% and primary closure in 21%. Mean cardiopulmonary bypass time was 58 +/- 14 min, cross clamp time was 41 +/- 13 min and postoperative hospital duration was 6.4 +/- 2.8 days with no significant difference between TVD and non TVD group No postoperative heart block or needs for pacemaker implantation were recorded in both groups on postoperative follow up there was a significant improvement in the cardiac size, chest infections and infective endocarditis and this become more pronounced over years and significantly better in TVD than non TVD group. Immediately postoperative and on follow up echocardiography determined grade I-IIITR significantly lower [16.5% and 12.2% respectively] than preoperative [39%] with no significant difference between TVD and non TVD group. Insignificant residual VSD shunting was detected in 8% of non TVD patients that spontaneously closed on follow up with only residual VSD in 2-4%. No residual VSD shunting was detected in TVD group. Improvement in almost all echocardiographic parameters with no significant difference in between groups was detected on follow up. The study concludes that pVSD can be closed with low complication rate using TVD technique TVD is a safe method to enhance the exposure of VSD with no residual VSD shunting, less postoperative TR and it does not result in tricuspid valve dysfunction on follow up. It could be freely used for difficult VSD exposure

Evaluation of an accommodating intraocular lens

Introduction: Conventional intraocular lenses [IOLs] that focus light at a fixed distance provide excellent visual outcomes in most patients who have cataract extraction. However, most patients require reading glasses or bifocals for near vision, Steinert et al, [1999]. Replacing the natural lens with a multifocal intraocular lens that provides multiple focal distances for both near and distance vision offers an alternative to patients who need near vision correction after cataract surgery, Wolffsohn, et al. [2006]. The optical quality of the retinal image is worse than the retinal image produced with a monofocal IOL. The loss of image quality can affect visual performance and has led to an interest in alternative modalities for correcting near vision in pseudophakic patients, Steinert et al, [1999]. By using the new accommodating IOLs, ophthalmic surgeons will be able to provide a full range of visual focus in each eye of a patient to maintain binocular function while also avoiding visual disturbances that are experienced with monovision and multifocal IOLs, Doane [2004] . The Crystalens AT-45 [Eyeonics], is an accommodating, foldable, multi-piece plate shaped IOL. [Eyeonics Crystalens fact sheet]

Aim of the work: This research was designed to study the efficiency of the foldable accommodating IOL; Crystalens [AT-45] in the restoration of both distant and near visual acuity after phacoemulsification. Also, assessment of the IOL's possible displacement during accommodation and the accompanying modifications of the ciliary body and anterior chamber depth by using ultrasound biomicroscopy [UBM]

Patients and methods: This study comprised twenty five eyes of 25 patients [12 females and 13 males]. Patients had no preexisting ocular conditions other than cataract. All patients were subjected to phacoemulsification and Crystalens AT-45 [Eyeonics Inc.] implantation. All patients were above 45 years old and expressed a preference for spectacle independence. Postoperatively, measuring the monocular distant visual acuity [uncorrected and best corrected] and visual acuity for near [uncorrected, through a distance correction and best corrected with near add] were done. UBM was used to examine the anterior chamber depth and the shift of the IOL along the visual axis in response to ciliary muscle pharmacological stimulation

Results: The mean age was 52.23 +/- 5.3 years [Ranged from 45 to 65 years]. All surgeries were uneventful with no complications or adverse events. The mean preoperative decimal uncorrected visual acuity [UCVA] was 0.08 + 0.05. The mean preoperative best corrected visual acuity [BCVA] was 0.1 +/- 0.06. After 6 months follow up, the mean postoperative UCVA was 0.52 +/- 0.17; BCVA was 0.94 +/- 0.18. The mean uncorrected near visual acuity [UCNVA] was J5; distance corrected near visual acuity [DCNVA] was J5. The mean Add near correction was +/- 1.58 +/- 0.21 D. The mean postoperative anterior chamber depth was 4 mm +/- 0.55 and after pharmacological stimulation with 2% Pilocarpine, the mean depth was 3.5 +/- 0.35mm. The amplitude of accommodation was calculated by both an objective and subjective methods. The mean postoperative amplitude of accommodation was 0.91 +/- 0.27 D. Faint opacification was observed in 3 eyes at the first month postoperatively, and in 8 eyes at six months postoperatively

Conclusions: Accommodating IOL provides patients with excellent visual acuities both for distance and near. It should be considered to allow cataract patients to be spectacle independent. We have the clinical impression that the degree of pseudophakic accommodation provided with Crystalens is useful for patients' daily life. The accommodation range depends on the displacement of optic which is controlled by the range of ciliary body effect [contraction and anterior rotation]

Effectiveness and response predicition of pre-emptive modified CMV chemotherapy in invasive transitional cell carcinoma of the urinary bladder

The effectiveness of pre-emptive [neoadjuvant] chemotherapy and prediction of tumor response were explored in 79 patients who had inasive transitional cell carcinoma [T. C. C.] of the urinary bladder in a prospective study. Patients were blindly randomized into 2 groups. Arm I included 35 patients who received 2 cycles of paraplatin, methotrexate and vinblastine [P. M. V] prior to radical cystectomy. While in arm II, 44 patients had radical cystectomy alone. The effectiveness of P.M.V. in relation to tumour cell type, stage, regional lymph nodal involvement, and D. N. A. ploidy were studied. Following P. M. V. complete response [CR] was achieved in 48% of patients who had pure T. C. C. while mixed tumors had no CR. pathologic down staging [PDS] was documented in 29% of arm I and 5% of arm II patients [p < 0.05]; Locoregional lymph nodal spread was evident among arm I and II patients in 3 and 14% respectively. [P > 0.05] D. N. A. ploidy in relation to tumour response was studied using rapid flow cytometry technique in bladder wash outs before initiation of treatment and before cystectomy in arm I patients. Aneuploid tumors responded better than diploid ones. Moreover, favourable response was associated with a shift to diploid pattern. In conclusion, P. M. V is highly effective against pure T. C. C. it had PDS in almost one third of patients who received neoadjuvant chemotherapy. Moreover, in this particular group of patients, the leco-regional lymph node involvement dropped to only 3%. We beleive that D. N. A. ploidy may become a clinically usefull predictor for positive chemotherapeutic response and consequently, it identifies certain sub-population of patients who must be suitable for neoadjuvant chemotherapy in insasive T.C.C. of the urinary bladder