Technical varieties of Ross procedure: a case series

Replacement of aortic valve with the pulmonary autograft is carried out through the Ross procedure due to its potential for growth, durability in pediatric population, and absence of anticoagulation. This case series reports the postoperative outcome of two technical variations of Ross procedure in eight patients who underwent surgery from January 2007 to December 2016. The dominant valvular hemodynamic indication was aortic regurgitation. The techniques employed for Ross procedure included free standing root replacement in six patients and modified root replacement with autograft stabilisation using Dacron interposition graft in two patients. Right ventricular outflow tract [RVOT] conduit reconstruction was achieved by utilisation of Contegra bio prosthesis in four patients; and use of manually constructed valved conduit comprising of PTFE [polytetrafluoroethelene] membrane and bovine pericardial tube in remaining four patients. There was no mortality and no re-intervention. The technical varieties of Ross procedure offer freedom from need of anti-coagulation, mortality, and RVOT conduit failure in younger adults

Comparison between intravenous boluses versus infusion of tranexamic acid [TXA] to reduce bleeding in paediatric cyanotic congenital heart disease [CHD] surgeries

Objective: To compare the intravenous boluses and intravenous continuous infusion of tranexamic acid [TXA] to reduce postoperative bleeding in cyanotic congenital heart disease surgeries

Study Design: Single-blinded randomised clinical trial

Place and Duration of Study: Anaesthesia Department, The Aga Khan University Hospital, Karachi, from July 2016 to April 2017

Methodology: Sixty patients of cyanotic congenital heart disease, undergoing either palliative or corrective surgery involving cardiopulmonary bypass [CPB], were recruited. These 60 patients were divided randomly into two groups. The infusion group received intravenous infusion of TXA at 5 mg/kg/hour while the bolus group received three intravenous boluses of 10 mg/kg after induction, after going to bypass and after protamine reversal. Data was collected through predesigned proforma. There were two primary outcomes: postoperative bleeding in the first 24 hours, and chest closure time

Results: Postoperative bleeding was 13.94 [10.27-20.18] ml/kg in the first 24 hours in infusion group and 15.05 [9.04-23.50] ml/kg in the bolus group. Chest closure time was 38.5 [25-45] in infusion group and 30 [20-46.25] minutes in the bolus group. There was no statistically significant and clinical difference between both groups regarding postoperative bleeding in the first 24 hours and chest closure time

Conclusion: These infusion and bolus groups had comparable postoperative bleeding and chest closure time

Accuracy of echocardiography in diagnosing total anomalous pulmonary venous return

Objective: Total anomalous pulmonary venous return is an uncommon cyanotic congenital heart defect. Echocardiography is the initial diagnostic tool. Complimentary non-invasive modalities like cardiac computerized tomographic angiography and cardiac magnetic resonance imaging have replaced the need for cardiac catheterization in difficult cases. This study aimed to determine the accuracy of echocardiography in diagnosing total anomalous pulmonary venous return, and to determine the factors that may decrease its sensitivity

Methods: This was a cross-sectional study conducted at the Aga Khan University Hospital Karachi, Pakistan from January 2010 to August 2016. All patients who were diagnosed with Total anomalous pulmonary venous return on echocardiography and had subsequent confirmation either on cardiac CT angiography or surgery were included. The diagnostic accuracy of echocardiography was expressed as sensitivity. Previously described taxonomy was used to define diagnostic error. Univariate and multivariate analysis were done by logistic regression OR [95 percent CI] were reported to identify factors causing the diagnostic error

Results: High diagnostic sensitivity [81 percent] was found in isolated total anomalous pulmonary venous return and low [27 percent] in heterotaxy and mixed [20 percent] varieties. Poor acoustic windows and right isomerism were found to be significant factors responsible for the diagnostic error on multivariate analysis

Conclusion: Echocardiography can diagnose isolated total anomalous pulmonary venous return with high accuracy. Use of additional modalities may be required for a complete diagnosis in cases with mixed variety, heterotaxy and poor acoustic windows

Single lung ventilation in a young child for repair of coarctation of aorta

Single lung ventilation in small children is extremely challenging. In this case, a paediatric bronchial blocker was successfully inserted in a 19-month-old child to provide single lung ventilation using a modified insertion technique. It provided excellent working conditions during thoracotomy and our method of insertion may help in reducing the cost