Indian Guidelines for Indications and Timing of Intervention for Common Congenital Heart Diseases: Revised and Updated Consensus Statement of the Working Group on Management of Congenital Heart Diseases. Abridged Secondary Publication

ustification: A number of guidelines are available for management of congenital heart diseases from infancy to adult life. However,these guidelines are for patients living in high income countries. Separate guidelines, applicable to Indian children, are required whenrecommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and mayhave co-existing morbidities and malnutrition. Process: Guidelines emerged following expert deliberations at the National ConsensusMeeting on Management of Congenital Heart Diseases in India, held on 10th and 11th of August 2018 at the All India Institute of MedicalSciences, New Delhi. The meeting was supported by Children’s HeartLink, a non-governmental organization based in Minnesota, USA.Objectives: To frame evidence based guidelines for (i) indications and optimal timing of intervention in common congenital heartdiseases; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for congenital heart diseases.Recommendations: Evidence based recommendations are provided for indications and timing of intervention in common congenitalheart diseases, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductusarteriosus and others), obstructive lesions (pulmonary stenosis, aortic stenosis and coarctation of aorta) and cyanotic congenital heartdiseases (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebsteinanomaly and others). In addition, protocols for follow-up of post surgical patients are also described, disease wise.

Early enteral nutrition therapy in congenital cardiac repair postoperatively: A randomized, controlled pilot study.

Background and Objectives: Adequate nutritional supplementation in infants with cardiac malformations after surgical repair is a challenge. Critically ill infants in the early postoperative period are in a catabolic stress. The mismatch between estimated energy requirement (EER) and the intake in the postoperative period is multifactorial, predisposing them to complications such as immune deficiency, more infection, and growth failure. This study aimed to assess the feasibility and efficacy of enriched breast milk feed on postoperative recovery and growth of infants after open heart surgery. Methodology: Fifty infants <6 months of age were prospectively randomized in the trial for enteral nutrition (EN) postoperatively from day 1 to 10, after obtaining the Institute Ethics Committee’s approval. They were equally divided into two groups on the basis of the feed they received: Control group was fed with expressed breast milk (EBM; 0.65 kcal/ml) and intervention group was fed with EBM + energy supplementation/fortification with human milk fortifier (7.5 kcal/2 g)/Simyl medium‑chain triglyceride oil (7.8 kcal/ml). Energy need for each infant was calculated as per EER at 90 kcal/kg/day, as the target requirement. The intra‑ and post‑operative variables such as cardiopulmonary bypass and aortic cross‑clamp times, ventilation duration, Intensive Care Unit (ICU), and hospital length of stay and mortality were recorded. Anthropometric and hematological parameters and infection control data were recorded in a predesigned pro forma. Data were analyzed using Stata 14.1 software. Results: The duration of mechanical ventilation, length of ICU stay (LOIS), length of hospital stay (LOHS), infection rate, and mortality rate were lower in the intervention group compared to the control group although none of the differences were statistically significant. Infants in control group needed mechanical ventilation for about a day more (i.e., 153.6 ± 149.0 h vs. 123.2 ± 107.0 h; P = 0.20) than those in the intervention group. Similarly, infants in control group stayed for longer duration in the ICU (13.2 ± 8.9 days) and hospital (16.5 ± 9.8 days) as compared to the intervention group (11.0 ± 6.1 days; 14.1 ± 7.0 days) (P = 0.14 and 0.17, respectively). The LOIS and LOHS were decreased by 2.2 and 2.4 days, respectively, in the intervention group compared to control group. The infection rate (3/25; 5/25) and mortality rate (1/25; 2/25) were lower in the intervention group than those in the control group. The energy intake in the intervention group was 40 kcal more (i.e., 127.2 ± 56.1 kcal vs. 87.1 ± 38.3 kcal) than the control group on the 10th postoperative day. Conclusions: Early enteral/oral feeding after cardiac surgery is feasible and recommended. In addition, enriching the EBM is helpful in achieving the maximum possible calorie intake in the postoperative period. EN therapy might help in providing adequate nutrition, and it decreases ventilation duration, infection rate, LOIS, LOHS, and mortality.

Incidence, microbiological profile of nosocomial infections, and their antibiotic resistance patterns in a high volume Cardiac Surgical Intensive Care Unit.

Background: Nosocomial infections (NIs) in the postoperative period not only increase morbidity and mortality, but also impose a significant economic burden on the health care infrastructure. This retrospective study was undertaken to (a) evaluate the incidence, characteristics, risk factors and outcomes of NIs and (b) identify common microorganisms responsible for infection and their antibiotic resistance profile in our Cardiac Surgical Intensive Care Unit (CSICU). Patients and Methods: After ethics committee approval, the CSICU records of all patients who underwent cardiovascular surgery between January 2013 and December 2014 were reviewed retrospectively. The incidence of NI, distribution of NI sites, types of microorganisms and their antibiotic resistance, length of CSICU stay, and patient‑outcome were determined. Results: Three hundred and nineteen of 6864 patients (4.6%) developed NI after cardiac surgery. Lower respiratory tract infections (LRTIs) accounted for most of the infections (44.2%) followed by surgical‑site infection (SSI, 11.6%), bloodstream infection (BSI, 7.5%), urinary tract infection (UTI, 6.9%) and infections from combined sources (29.8%). Acinetobacter, Klebsiella, Escherichia coli, and Staphylococcus were the most frequent pathogens isolated in patients with LRTI, BSI, UTI, and SSI, respectively. The Gram‑negative bacteria isolated from different sources were found to be highly resistant to commonly used antibiotics. Conclusion: The incidence of NI and sepsis‑related mortality, in our CSICU, was 4.6% and 1.9%, respectively. Lower respiratory tract was the most common site of infection and Gram‑negative bacilli, the most common pathogens after cardiac surgery. Antibiotic resistance was maximum with Acinetobacter spp.

Modified Blalock Taussig shunt: Comparison between neonates, infants and older children.

Objective: The aim was to compare various pre-and post-operative parameters and to identify the predictors of mortality in neonates, infants, and older children undergoing Modifi ed Blalock Taussig shunt (MBTS). Materials and Methods: Medical records of 134 children who underwent MBTS over a period of 2 years through thoracotomy were reviewed. Children were divided into three groups-neonates, infants, and older children. For analysis, various pre-and post-operative variables were recorded, including complications and mortality. Results: The increase in PaO2 and SaO2 levels after surgery was similar and statistically signifi cant in all the three groups. The requirement of adrenaline, duration of ventilation and mortality was signifi cantly higher in neonates. The overall mortality and infant mortality was 4.5% and 8%, respectively. Conclusion: Neonates are at increased risk of complications and mortality compared with older children. Age (<30 days), weight (<3 kg), packed red blood cells transfusion >6 ml/kg, mechanical ventilation >24 h and post shunt increase in PaO2 (PDiff) <25% of baseline PaO2 are independent predictors of mortality in children undergoing MBTS.

Comparison of straight sternotomy and interlocking sternotomy in open heart surgery.

BACKGROUND AND OBJECTIVES: Stable sternal approximation is an important factor to avoid respiratory complications after open heart surgery. The present study is designed to compare interlocking sternotomy and straight sternotomy in terms of sternal stability, pain and respiratory function. METHODS: Sixty patients scheduled for open heart surgery underwent a standard midline sternotomy (n=30) or an interlocking sternotomy (n=30). The features assessed were pain on visual analogue scale during rest and during cough, peak expiratory flow rate and sternal instability. Evaluation was performed on the first, fourth post-operative days, on discharge and one month and three month follow up. RESULTS: Analysis of the peak expiratory flow rates, visual analogue ratings of pain intensity at rest and on coughing were carried out for each group only for those patients who completed the study. Postoperatively, in all patients there was significant reduction in peak expiratory flow rates. In the straight sternotomy group resting pain intensity was higher on discharge (2.6+/- 2 vs 1.6 +/- 2.3, P= 0.005). In the interlocking sternotomy group pain on coughing was significantly less than straight sternotomy group (median 0.5 vs 2.8, P=0.005) at 1 month follow up and at 3 months (median 0 vs 1.6, P=0.003). INTERPRETATION AND CONCLUSION: Interlocking sternotomy can be performed with good functional results and offers a less painful alternative to straight sternotomy.

Anticoagulation protocol and early prosthetic valve thrombosis.

BACKGROUND: [corrected] Prosthetic valve thrombosis is a major cause of morbidity and mortality following heart valve replacement with a mechanical valve. METHODS AND RESULTS: 538 patients who underwent mechanical valve replacement between April 1999 and June 2003 were included in the study. They were divided into two groups. Group A (n=245) consisted of patients who underwent mechanical valve replacement between April 1999 and June 2001. Anticoagulation was started on the first post-operative day and consisted of only oral nicoumalone. Group B (n=293) consisted of patients who underwent mechanical valve replacement between July 2001 and June 2003; enoxaparin was started six hours following surgery in addition to oral nicoumalone which was started on first post-operative day. Fifteen (6.1%) patients in group A developed early prosthetic valve thrombosis at an interval of 4.33+/-0.97 months (range 3-6 months) following surgery. Ten had prosthetic valve thrombosis in the mitral position and five had prosthetic valve thrombosis in the aortic position. In group B, six (2.1%) patients developed early prosthetic valve thrombosis at a median interval of 4.58+/-0.9 months (range 3.5-6 months) in the mitral position (p=0.01). CONCLUSIONS: Addition of enoxaparin to the anticoagulation regime in the immediate post-operative period significantly reduces early prosthetic valve thrombosis.

Autologous right atrial patch for closure of atrial septal defect.

BACKGROUND: Prosthetic or pericardial patches used for the closure of atrial septal defects are associated with infrequent but definite problems. As an alternative, we used a right atrial free-wall patch in 12 patients, 7-54 years of age. METHODS AND RESULTS: The presence of a large secundum atrial septal defect (n=2). associated mitral valve regurgitation (n=7), primum atrial septal defect (n=2) and sinus venosus defect (n=1) necessitated the use of a patch. The mitral valve was repaired in 9 patients (including 2 with a primum defect). One patient with a primum defect who was in congestive heart failure preoperatively died after 3 weeks due to refractory ventricular fibrillation. The remaining patients were discharged 5 to 7 days post procedure. No flow was detected across the septal patch on predischarge echocardiography. One patient underwent reoperation for failed mitral valve repair one month postprocedure. At reoperation, the patch was found to be intact with normal texture and without any suture dehiscence. Histopathological examination of the explanted patch revealed viable endothellum and subendothelial muscle on both surfaces of the patch. Follow-up ranged from 6 to 36 months. Echocardiography performed after 6 to 32 months post procedure showed an intact patch with no residual defect. All the patients are in sinus rhythm. Holter monitoring performed in 6 patients was normal in all of them. Electrophysiological study was performed in 2 patients using a mapping catheter 4 and 6 months post-procedure, respectively, and recorded normal atrial potentials from the site of the patch. CONCLUSIONS: The use of an autologous free right atrial wall as a patch for atrial septal defect closure is a viable option.