Predictors of high maintenance prostaglandin E1 doses in neonates with critical congenital heart disease-ductal-dependent pulmonary circulation during preoperative care.

BACKGROUND: Neonates with critical congenital heart disease of the ductal-dependent pulmonary circulation type (CCHD-DDPC) require prostaglandin E1 (PGE1) to maintain oxygen saturation until surgery. However, the factors contributing to the maintenance doses of PGE1 remain unclear. This study aimed to determine the predictors of high maintenance PGE1 doses in these neonates. METHODS: This retrospective cohort study included neonates with CCHD-DDPC at Songklanagarind Hospital between January 1, 2006, and December 31, 2021. Factors associated with high maintenance PGE1 doses (> 0.01 mcg/kg/min) were analyzed to identify predictors. Odds ratios were calculated using tabulation and logistic regression analysis. A prediction score was developed for high maintenance PGE1 doses. RESULTS: Among 96 neonates with CCHD-DDPC, 55 % required high maintenance doses of PGE1. Three factors significantly associated with high maintenance PGE1 doses were patent ductus arteriosus (PDA) size-to-birthweight ratio ≤1.3 mm/kg, initial PGE1 dose >0.03 mcg/kg/min, and preoperative invasive mechanical ventilation. The area under the receiver operating characteristic curve for these three predictors was 0.7409. A predictive score of 0-3 was created based on these factors. The probabilities of receiving a high maintenance dose of PGE1 for patients with overall scores of 0, 1, 2, and 3 were 0.19 (95 % CI: 0.04-0.33), 0.42 (95 % CI: 0.30-0.54), 0.69 (95 % CI: 0.57-0.81), and 0.87 (95 % CI: 0.76-0.99), respectively. CONCLUSIONS: In neonates with CCHD-DDPC, a PDA size-to-birth weight ratio ≤1.3 mm/kg, an initial dose of PGE1 > 0.03 mcg/kg/min, and preoperative invasive mechanical ventilation were predictors of high maintenance PGE1 doses during the preoperative period.

A Single Center Study on the Risks of Peri-Intervention Stroke in Thoracic Endovascular Aortic Repair (TEVAR) and Endovascular Abdominal Aortic Repair (EVAR).

(1) Background: The risk factors of peri-intervention stroke (PIS) in thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic repair (EVAR) are different. This study aimed to compare the risks of PIS in both interventions. (2) Methods: Patients who had suffered a PIS related to TEVAR or EVAR from January 2008 to June 2015 in Songklanagarind Hospital were selected as the cases, while patients who had not suffered PIS were randomly selected to create a 1:4 case: control ratio for analysis. The associations between the factors from pre- to post-intervention and PISs in TEVAR or EVAR cases were analyzed by univariable analysis (p < 0.1). The independent risks of PIS were identified by multivariable analysis and presented in odds ratios (p < 0.05). (3) Results: A total of 17 (2.2%) out of 777 patients who had undergone TEVAR or EVAR experienced PIS, of which 9/518 (1.7%) and 8/259 (3.1%) cases were in TEVAR and EVAR groups, respectively. PIS developed within the first 24 h in nine (52.9%) cases. Large vessel ischemic stroke or watershed infarctions were the most common etiologies of PIS. The independent risks of PIS were the volume of intra-intervention blood loss (1.99 (1.88-21.12), p < 0.001) in the TEVAR-related PIS, and intervention time (2.16 (1.95-2.37), p = 0.010) and post-intervention hyperglycemia (18.60 (1.60-216.06), p = 0.001) in the EVAR-related PIS. There were no differences in the rate of PIS among the operators, intervention techniques, and status of the interventions performed. (4) Conclusion: The risks of PIS in TEVAR or EVAR in our center were different and possibly independent of the operator expertise and intervention techniques.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis.

OBJECTIVE: To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS). METHODS: Data from a retrospective cohort study were obtained from children aged 0-3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14-0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8-20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3-5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4-10.4), bleeding (HR 4.5, 95% CI:2.1-9.4) and renal failure (HR 4.1, 95% CI:1.5-10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2-7.7 and HR 3.1, 95% CI:1.3-7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4-32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001-1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8-61.4 and HR 7.8, 95% CI:1.7-34.8, respectively). CONCLUSIONS: Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Serum miR-339-3p as a potential diagnostic marker for non-small cell lung cancer.

Objective: MicroRNA (miRNA), a short noncoding RNA, is claimed to be a potential blood-based biomarker. We aimed to identify and evaluate miRNAs as diagnostic biomarkers for non-small cell lung cancer (NSCLC). Methods: Profiles of 745 miRNAs were screened in the serum of 8 patients with NSCLC and 8 age- and sex-matched controls using TaqMan low-density arrays (TLDAs) and validated in 25 patients with NSCLC and 30 with other lung diseases (OLs) as well as in 19 healthy persons (HPs). The diagnostic performance of the candidate miRNAs was assessed in 117 cases of NSCLC and 113 OLs using quantitative real-time polymerase chain reaction (qRT-PCR). Differences in miRNA expression between patients with NSCLC and controls were assessed using the Mann-Whitney U test. The area under receiver operating characteristic (ROC) curve (AUC) was obtained based on the logistic regression model. Results: Ten miRNAs were found to be differentially expressed between patients with NSCLC and controls, including miR-769, miR-339-3p, miR-339-5p, miR-519a, miR-1238, miR-99a#, miR-134, miR-604, miR-539, and miR-342. The expression of miR-339-3p was significantly higher in patients with NSCLC than in those with OLs (P < 0.001) and HPs (P = 0.020). ROC analysis revealed an miR-339-3p expression AUC of 0.616 [95% confidence interval (CI): 0.561-0.702]. The diagnostic prediction was increased (AUC = 0.706, 95% CI: 0.649-0.779) in the model combining miR-339-3p expression and other known risk factors (i.e., age, smoking status, and drinking status). Conclusions: MiR-339-3p was significantly upregulated in patients with NSCLC compared with participants without cancer, suggesting a diagnostic prediction value for high-risk individuals. Therefore, miR-339-3p expression could be a potential blood-based biomarker for NSCLC.

Risk factors for in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functionally univentricular heart undergoing a modified Blalock-Taussig shunt.

OBJECTIVES: To determine the association between several perioperative variables and in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functional univentricular heart (UVH) who underwent modified Blalock-Taussig shunt. METHODS: Between January 2006 and February 2016, 85 patients who weighed less than 3 kg with functional UVH and underwent modified Blalock-Taussig shunt were reviewed. In-hospital shunt thrombosis and mortality were the primary outcomes. The associations between perioperative variables and outcomes were assessed with univariate and multivariate analyses. RESULTS: In-hospital shunt thrombosis was 14% (12 of 85). Hospital mortality was 18% (15 of 85), which resulted in an 82% discharge survival rate. Shunt thrombosis was significantly associated with in-hospital mortality (odds ratio 18.9, 95% confidence interval 4.5-78.9). There were no statistically significant associations between weight, specific diagnosis of functional UVH and shunt thrombosis or mortality. Multivariate analysis identified delayed initiation of anticoagulant (P < 0.01) and postoperative cardiac arrest (P < 0.01) as risk factors of shunt thrombosis, while intraoperative bradycardia (P < 0.01), high postoperative haemoglobin (P = 0.03) and shunt thrombosis (P < 0.01) were risk factors for hospital mortality. CONCLUSIONS: In this high-risk group of patients who weighed less than 3 kg with functional UVH and who underwent modified Blalock-Taussig shunt, in-hospital mortality was strongly associated with the occurrence of shunt thrombosis. Our study highlighted the perioperative variables of delayed postoperative initiation of anticoagulant, cardiac arrest and the occurrence of intraoperative bradycardia that were significant risk factors for shunt thrombosis and mortality. Achieving better quality of perioperative care potentially improves outcomes.

Prediction score for effective bleeding control using recombinant activated factor VII in perioperative nonhemophilic patients.

BACKGROUND: Although there has been growing evidence from off-label use of recombinant activated factor VII (rFVIIa) in surgical bleeding, there is limited information on prediction scores. METHODS: A retrospective study was conducted from 2004 to 2009. The primary outcome was efficacy of bleeding control. Multivariate logistic regression was performed to develop a new prediction score for success of rFVIIa. RESULTS: A total of 320 bleeding episodes from 243 nonhemophilic patients who underwent surgery were analyzed. Effective bleeding control was demonstrated in 153 patients. The overall in-hospital mortality rate was 40%. Multivariate analysis identified 4 independent predictors for effective bleeding control: timing of rFVIIa administration, intraoperative blood loss, postoperative international normalization ratio values, and total units of platelets transfused. A rFVIIa success prediction score was developed. CONCLUSIONS: The use of this new prediction score may support decision making by identifying patients with a high probability of obtaining effective bleeding control from rFVIIa therapy.

Upper extremity deep vein thrombosis related to fatal massive pulmonary embolism after spinal surgery.

Upper extremity deep vein thrombosis (UEDVT) is an increasingly important clinical entity with potential for considerable morbidity, especially pulmonary embolism (PE). Here, the authors report a fatal case of the massive PE after spinal surgery, along with the UEDVT of superior vena cava (SVC).

Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection.

Deep sternal wound infection (DSWI) is an uncommon life-threatening complication of cardiac surgery performed through median sternotomy. Surgical treatment is considered complicated and challenging. We report our experience with a single-stage omental flap transposition in the treatment of the 14 consecutive patients who were diagnosed with DSWI within 3-16 days after the primary cardiac surgery, between August 2001 and January 2008. The single-stage omental flap transposition was achieved within 70-135 min, at four to eight hours after diagnosis of DSWI. The single-stage omental flap transposition was successfully applied and all 14 patients survived. They displayed a shortened intensive care unit stay (one to nine days) and hospital stay (19-36 days). Follow-up was 100% complete (26-92 months) and demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. However, the very few complications found were slight numbness of anterior chest and minor paradoxical chest movement. We obtained satisfactory outcomes when treating the patients with DSWI by a single-stage omental flap transposition. Based on our solid experience, we recommend this procedure as an option for patients with DSWI, especially those who are not in a state of severe low cardiac output or malnutrition.

Tracheo-innominate artery fistula in children with high-lying innominate artery.

Tracheo-innominate artery fistula (TIF) is an uncommon but frequently fatal complication of tracheostomy. Significant airway hemorrhage usually occurs after premonitory bleeding. When massive bleeding occurs, immediate control of arterial bleeding, control of the airway and subsequent definite treatment are the principles for saving lives. Without prompt surgical intervention, the outcome of this complication is grave. Physicians should maintain a high index of suspicion of TIF in any patient with a recent tracheostomy and subsequent tracheal hemorrhage.

Predicted outcome after repair of tetralogy of Fallot by postoperative pressure ratio between right and left ventricle.

BACKGROUND: The surgical management of tetralogy of Fallot (TOF) has continued to evolve and there are now generally excellent early and long-term results following complete repair. OBJECTIVE: To investigate the early results of the authors' current surgical management of TOF by assessing the perioperative and early to intermediate follow-up period. The authors paid particular attention to the post-operative ratio of right ventricular to left ventricular systolic pressure (RVSP/LVSP), focusing on the presence of low cardiac output, intensive care unit (ICU) stay, prolonged of inotropic support and ventilation support time. STUDY DESIGN: Retrospective study. MATERIAL AND METHOD: Between June 2002 and August 2004, 31 consecutive patients underwent complete repair of TOF. Their mean age was 7.7 +/- 5.1 years (range, 2.9 to 25.3). A previous palliative shunt had been performed in 14 (45.2%) patients. Twenty-three patients (74.2%) were in NYHA FC II. Mean hematocrit and oxygen saturation were 50.9 +/- 10.25% and 80.5 +/- 8.6%, respectively. Mean preoperative ratio of RVSP/LVSP was 1.1 +/- 0.15. The operative approach was transatrial/transpulmonary, and 17 (54.8%) patients required a transannular patch. An extracardiac valve conduit was necessary in 3 (9.7%) patients with pulmonary atresia. RESULTS: There were no operative or late deaths. Two cases were reoperated from cardiac tamponade. Mean postoperative ratio of RVSP/LVSP was 0.53 +/- 0.16. Median ICU and hospital stays were 2.2 and 11 days, respectively. Presence of low cardiac output and prolonged inotropic support were significantly (P < 0.05) related to a RVSP/LVSP ratio of more than 0.5. At median follow-up of 6 months, 29 (93.5%) patients were asymptomatic and all patients were free of significant residual lesion. CONCLUSION: The authors' early results in complete repair of TOF patients are acceptable with a low incidence of morbidity. A postoperative RVSP/LVSP ratio of more than 0.5 was significantly associated to adverse outcome. Late complications may, however, develop, and long term follow-up for early detection of any such complications is essential.

Terminal warm blood cardioplegia in mitral valve replacement: prospective study.

Terminal warm blood cardioplegia has had a profound impact on cardiac surgery, especially in coronary artery bypass surgery, but there have been few studies on its use in mitral valve replacement. The purpose of this study was to determine whether terminal warm blood cardioplegia offers any advantages in mitral valve replacement. Forty patients with mitral valve disease were prospectively randomized to one of two groups of 20 with different techniques of myocardial protection: group A had cold blood cardioplegia, and group B had cold blood cardioplegia with terminal warm blood cardioplegia. Intraoperative and postoperative variables were used to assess primary outcomes. Postoperative troponin T release was measured as a secondary outcome. Improved spontaneous recovery of sinus rhythm was observed in group B, but the difference was not significant. The maximum doses of inotropics, duration of inotropic support, intensive care unit stay, and postoperative left ventricular ejection fraction were similar in both groups. Troponin T release at 0 and 6 h postoperatively was not different between the two groups. This study did not find any benefit of terminal warm blood cardioplegia in either clinical outcome or troponin T release after mitral valve replacement.

Repair of extra-cranial internal carotid artery aneurysm with application of modified carotid shunt: a case report.

Aneurysms of the extracranial internal carotid artery (ICA) are uncommon. These lesions usually present with symptoms of transient ischemic attacks (TIA) from emboli and cranial nerve dysfunction from compression. The primary objective of treatment is to prevent a permanent neurologic deficit arising as a result of atheroembolism. The resection of an ICA aneurysm with restoration of flow is the preferred method of treatment. The authors present the case of a 32-year-old woman diagnosed with an ICA aneurysm. The patient underwent aneurysmectomy using an autologous saphenous vein graft with ICA blood flow being maintained using a carotid-to-carotid shunt, which was modifiedfrom an intravenous catheter set. This modified carotid shunt is easy to prepare for use and is of low cost. The authors do not expect this shunt to represent the standard commercially available shunt; but in some institutes, where commercial shunts are not available, this shunt may be suitably used.

Surgical outcome of traumatic aortic disruption of the thoracic aorta in Songklanagarind Hospital.

This retrospective study collected data from 11 patients who underwent TDTA' repair from February 1987 to June 2003, 10 patients were men (90.9%) and 1 was a woman (9.09%) with a mean age of 32 years. All patients had a blunt injury from a violent motor vehicle accident. None of them required thoracotomy at the emergency room. Standard chest x-ray was done in every patient and the widening of the upper mediastinum was mainly found in 10 patients (90.9%), hemothorax in 8 patients, blurred aortic knob in 7 patients, lower left main bronchus in 3 patients, pleural apical cap in 2 patients and pneumothorax in 1 patient, 8 patients were investigated by CT scan and presented a positive study. 3 patients (27.27%) were diagnosed by both aortogram and CT scan anda pseudo-false aneurysm was found Multi organ system injury was mainly found in 10 patients (90.91%). 7 patients (63.64%) had hypovolumic shock on admission, 3 patients died postoperation and 2 of them had experience of postoperative paraplegia. Clamp and sew technique was used in 6 patients (54.54%). The duration of aortic cross clamp time ranged from 19-67 minutes (mean time = 39.30 min.) Pneumonia was the significant postoperative complication found in 3 patients, including acute renal failure, ARDS (all died) and paraplegia in 2 patients. The duration of the aortic cross clamp time that was used in the patients who presented with paraplegia was more than 40 minutes. 1 patient had delayed the aortic repair for 3 weeks resulting from severe brain contusion. 5 patients (45.45%) died in hospital. 1 patient died in the operating theatre, 4 of them (36.36%) died during postoperatively within 24 hours. The mainly cause of death which occurred in every patient was intraoperative cardiac arrest, the others were postoperative bleeding, ARDS and arrhythmias. The mean of length of stay in the intensive care unit was 6.94 days. The period of hospitalization ranged from 11 to 180 days (mean = 62.83 days). The small sample size is the limitation for the present study. The authors plan to do prospective study about the factors which influence the mortality rate and factors related to postoperative paraplegia in TDTA patients at Songklanakarind Hospital.