The effect of Del Nido versus custodiol cardioplegia on clinical outcomes and troponin-I changes among pediatrics with tetralogy of fallot undergoing cardiopulmonary bypass.

BACKGROUND: Myocardial protection during operations with cardiopulmonary bypass (CPB) and aortic cross clamping is vital. For this purpose, Del Nido (DN) and Custodiol cardioplegia (CC) solutions are used for single-dose cardioplegia in cardiac surgical procedures with CPB. Present study aimed to compare the effects of DN and CC on peri-operative clinical outcomes in pediatrics with Tetralogy of Fallot (TF) undergoing cardiopulmonary bypass. METHODS: Present randomized clinical trial was performed in two trial groups with parallel design. One group received DN and another group received CC. We assessed circulatory Troponin-I (cTnI) and coronary sinus lactate level as primary outcomes. Secondary outcomes were ventilation time, electrolytes levels, pump time, cross-clamp time and other clinical parameters. RESULTS: Duration of CPB and cross-clamp were the same in both groups. There were no significant differences in hemodynamic parameters, left ventricular ejection fraction after the surgery and discharge time between the two trial groups. Ventilation time (8.5 vs. 18; p = 0.001), ICU stay, Troponin-I in ICU admission and Coronary sinus lactate level (p = 0.001) were significantly higher among patients of Custodiol group compared to other trial group. Electrolytes Na, Cl and K levels, during CPB, were significantly less in Custodiol group. CONCLUSION: When used for inducing cardiac arrest during CPB, DN solution offers better maintenance of the electrolyte balance during CPB, and is associated with less circulatory cTnI and coronary sinus lactate level compared with the CC.

The fate of the fresh autologous pericardium after right ventricular outflow tract reconstruction.

Introduction: The autologous pericardium, treated or fresh, is used in reconstructive cardiovascular surgery. We aimed to describe the features of fresh pericardium utilized in right ventricular outflow tract (RVOT) reconstruction, years after the initial surgery. Methods: This cross-sectional study was performed on 72 patients (65.3% male, mean age =18.68 ± 9.63 y) with a history of RVOT reconstruction with the fresh autologous pericardium who underwent reoperation. During the surgery, a 1 × 1 cm sample was cut from the previous pericardial patch, and hematoxylin and eosin (H & E), Masson's trichrome, and immunohistochemistry (IHC) staining was conducted. All the stained slides were evaluated,and the descriptive results were explained. Results: The mean follow-up duration was 13.48 ± 7.38 years. In preoperative evaluations,53 (73.6%) patients exhibited no RVOT dilatation, 17 (23.6%) showed mild RVOT dilatation,and 2 (2.8%) had RVOT aneurysms. The H & E staining revealed no calcification in 80.55%(58/72), mild calcification in 9.72% (7/72), and moderate calcification in 9.72% (7/72) of the total samples. None of the specimens demonstrated a marked calcification. All the samples were positive for CD31, CD34, smooth muscle alpha-actin, and von Willebrand factor in IHC. In Masson's trichrome staining, on average, 64.74% (±18.61) of the tissue sections contained collagen fibers. Conclusion: The fresh autologous pericardium, utilized for RVOT reconstruction, showed viability, growth potential, positivity for endothelial cell markers, vascular differentiation,insignificant calcification, and no stenosis at long-term follow-up. We would, therefore, suggest it as a suitable choice for such reconstructive operations. Moreover, its usage during total correction of tetralogy of Fallot could be safe, feasible, and durable.

Iatrogenic partial diversion of inferior vena cava to left atrium after surgical closure of atrial septal defect.

BACKGROUND: Atrial septal defects (ASDs) are one of the most common congenital cardiac abnormalities. Repair of these defects is a quite secure and routine operation. The most common complications were postoperative atrial arrhythmias, sinus arrhythmia, and atrioventricular (AV) blocks requiring pacemaker implantation, mediastinal bleeding, and transient ischemic attacks (TIAs) or strokes. Iatrogenic diversion of the inferior vena cava (IVC) to the left atrium (LA) during surgical closure of an ASD is a very rare complication. CASE REPORT: We reported a patient who had a history of cardiac surgery in another center at the age of seven and was introduced to our clinic with complaints of dyspnea and cyanosis of extremities on exertion. She underwent surgery in our center with diagnosis of iatrogenic diversion of IVC to LA. CONCLUSION: The most common mechanism suggested is a large eustachian valve being mistaken for the inferior rim of the ASD.

Zero-balance ultrafiltration of the priming blood modifies the priming components and improves the clinical outcome in infants undergoing cardiopulmonary bypass: A randomized controlled trial.

Cardiopulmonary bypass (CPB) requirement in infants presents a unique challenge because of the large prime volume-to-blood volume ratio. Packed red blood cells (PRBCs) tend to deteriorate with long-term storage owing to their unphysiological composition and osmolality. Given that blood priming is inevitable in neonates, it is suggested that the metabolic load and osmolality are diminished before CPB initiation. We conducted the present study to test the hypothesis that the zero-balance ultrafiltration (Z-BUF) of the priming blood with 0.45% saline might be sufficient for modifying the metabolic load and osmolality and, thus, achieving a physiological state. Sixty infants with a weight below 10 kg undergoing CPB were randomly assigned either to a control group or to a Z-BUF group and the Z-BUF of the priming blood was performed in the latter group. Electrolytes and osmolality were measured in the priming blood. The bleeding volume, the blood transfusion rate, the length of mechanical ventilation, the length of stay in the intensive care unit (ICU), the body temperature, and renal biomarkers were compared between the 2 groups. The osmolality and the levels of potassium, sodium, glucose, chloride, and lactate in the priming blood were significantly decreased after Z-BUF (P < .01). The Z-BUF group showed significant reductions in postoperative blood loss; postoperative blood transfusion; time to extubation; the length of stay in the ICU; the levels of lactate, sodium, and blood urea nitrogen at 24 hours postoperatively and the body temperature at 18 hours postoperatively (P < .05). However, no statistically significant differences were found between the 2 groups regarding the body temperature and the levels of serum creatinine and blood urea nitrogen after admission to the ICU. The results of the present study demonstrated that the Z-BUF of the priming blood could be a useful strategy in infants undergoing CPB insofar as it significantly modified the composition of the priming blood and improved the clinical outcome among our patients.

Serum levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α, renal function biochemical parameters and clinical outcomes in pediatric cardiopulmonary bypass surgery.

BACKGROUND: Cardiopulmonary bypass causes detrimental effects on remote organs due to inflammatory response. One of these organs is kidney that is frequently affected by cardiac surgery. Acute kidney injury is a post-cardiopulmonary bypass complication, which may result in increased post-operative morbidity and mortality. Post-cardiopulmonary bypass inflammatory response may contribute to remote organ dysfunction. In the present study, we investigated the relation between cytokines including interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α, and renal function tests such as creatinine and blood urea nitrogen (BUN). METHODS: In total, 91 patients between the ages of 4 and 60 months were enrolled for elective cardiac surgery with cardiopulmonary bypass after informed consent. Data regarding renal function tests and clinical outcomes were carefully recorded until 24 hours after admission to intensive care unit and analyzed. RESULTS: Our findings support that there is a direct correlation between cytokines including interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α and cardiopulmonary bypass time, duration of operation, and intensive care unit stay. Longer cardiopulmonary bypass time was associated with higher interleukin-8 at cross-clamp removal and 24 hours post- intensive care unit as well as higher interleukin-10 at declamp time. Higher interleukin-6 at declamp time was directly correlated with higher post-operative BUN. Interleukin-8 level after anesthesia induction was directly correlated with intensive care unit stay duration. Higher blood interleukin-6 and tumor necrosis factor-α levels following 24 hours of admission to intensive care unit were associated with longer mechanical ventilation time. CONCLUSION: Higher circulatory pro-inflammatory cytokine level is associated with adverse outcomes such as increased intensive care unit stay and longer mechanical ventilation time in pediatric patients. It is also correlated with unfavorable biochemical parameter of renal function, BUN. Findings hint that proper control of the inflammatory response is vital for the control of unfavorable clinical and pathological outcomes.

Undiagnosed Double Aortic Arch in an Adult With Repaired Tetralogy of Fallot.

Double aortic arch, the most common vascular ring, causes a complete ring surrounding the esophagus and trachea that leads to compressive symptoms. This report describes a young woman with a history of totally corrected tetralogy of Fallot who was a candidate for pulmonic valve replacement. A double aortic arch was detected incidentally by echocardiography and cardiac computed tomography. (Level of Difficulty: Intermediate.).

Zero-Balance Ultrafiltration of Priming Blood Attenuates Procalcitonin and Improves the Respiratory Function in Infants After Cardiopulmonary Bypass: A Randomized Controlled Trial.

Blood priming is needed for cardiopulmonary bypass (CPB) in neonates and infants to avoid exceeding hemodilution; however, transfusion-related inflammation affects post-CPB outcomes in infant open-heart surgery. Procalcitonin, a newly detected inflammatory moderator and a sensitive parameter for predicting pulmonary dysfunction secondary to CPB, rises after CPB. We hypothesized that the hemofiltration of priming blood before CPB might decrease inflammatory mediators in the blood and post-CPB inflammatory replications, thereby improving the respiratory function after CPB in infants. Sixty infants with a weight below 10 kg were divided randomly into two equal groups of CPB with the zero-balance ultrafiltration (Z-BUF) of priming blood and CPB without it. The procalcitonin level was measured before anesthesia, after admission to the intensive care unit (ICU), and 24 h afterward. The respiratory index and pulmonary compliance were measured after anesthesia, at the end of CPB, and 2 h after admission to the ICU. Additionally, time to extubation was recorded. The Z-BUF of priming blood maintained electrolytes within a physiologic level, and procalcitonin had a slighter rise in the Z-BUF Group at 24 h after admission to the ICU (P = 0.05). The respiratory index was decreased in the Z-BUF Group, but the difference with the control group did not reach statistical significance (P > 0.05). The change in pulmonary compliance was significantly increased in the cyanotic patients in the intervention group, but there was no significant difference between the two groups. The time to extubation and the ICU stay were shorter in the Z-BUF Group (P < 0.05). A positive correlation was found between the peak procalcitonin concentration and the time to extubation directly and pulmonary compliance reversely. These results suggest that the Z-BUF of priming blood may have some beneficial clinical effects such as improved respiratory function and attenuated procalcitonin.

Surgical Repair for Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery.

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a very rare congenital heart defect. Herein, we describe three cases of ARCAPA in an 8 months old, 18 months old, and 4 year old child. Two cases were incidentally diagnosed using a computed tomographic angiograph, and the other was incidentally diagnosed using a coronary angiograph. These cases underwent a reimplantation technique on diagnosis and resulting in positive clinical outcomes during the follow-up period which was a mean of 1.5 years.

Conduction Disorders in Continuous Versus Interrupted Suturing Technique in Ventricular Septal Defect Surgical Repair.

BACKGROUND: Ventricular septal defects (VSD) is one of the most frequent congenital cardiac malformations and cardiac conduction disorders are still one of the serious postoperative complications in this surgery. OBJECTIVES: This study aimed to compare the incidence of conduction disorders with the use of continuous compared to interrupted suturing techniques in VSD surgical repair. PATIENTS AND METHODS: Previously recorded data of 231 patients who underwent surgical closure of VSD between January 2009 and January 2012 at the Rajaie cardiovascular medical and research center were retrospectively reviewed. VSD surgical repair was performed using continues suturing technique in group A patients (n = 163, 70.6%) and interrupted suturing technique in group B patients (n = 68, 29.4%). RESULTS: The most common concomitant congenital anomaly was Tetralogy of Fallot (27.3%). Twenty-four (10.4%) patients had intraoperative cardiac arrhythmia, including 19 (8.2%) transient and 5 (2.2 %) permanent arrhythmia. During their ICU stay, ventricular arrhythmia and complete heart block were observed in 34 (14.7%) and 5 patients (2.2%), respectively. At the time of the last follow-up, incomplete right bundle branch block (RBBB), complete RBBB, RBBB with left anterior hemi-block, and complete heart block were identified in 84 (36.4%), 42 (18.2%), 29 (12.6%), and 5 patients (2.2%), respectively. The results revealed that group A patients were most likely to have had cardiac arrhythmias during their ICU stay and at the time of last follow-up (P < 0.001), while the intraoperative incidence of cardiac arrhythmia during surgery was not statistically significant between the two groups (P = 0.06). CONCLUSIONS: In the absence of any statistical differences in the other risk factors between the two groups, the difference in the incidence of conduction disorders can be attributed to the type of suturing used during the procedure.

Repair of Post-Infarction Ventricular Free Wall Rupture With TachoSil(®).

INTRODUCTION: Left ventricular free wall rupture (LVFWR) is a frequent cause of death after acute myocardial infarction, and its repair remains a surgical challenge. CASE PRESENTATION: TachoSil(®) is a ready-to-use equine collagen patch which has been successfully used for hemostasis in cardiovascular surgery. However, a limited number of studies have reported its application for LVFWR repair. In this study, we describe our initial experience using TachoSil(®) for LVFWR repair. CONCLUSIONS: A hemodynamic study was acceptable at a 12-month follow-up, and no complication was seen.

Safety and efficacy of caproamin fides and tranexamic Acid versus placebo in patients undergoing coronary artery revascularization.

INTRODUCTION: Excessive fibrinolysis contributes to post-cardiopulmonary bypass bleeding. Tranexamic Acid (TXA) and Caproamin Fides are synthetic lysine analogues that inhibit plasminogen-fibrin binding. The present study aimed to compare TXA and Caproamin Fides versus placebo in patients undergoing elective coronary artery revascularization. METHODS: We analyzed perioperative data of 300 adult patients undergoing coronary artery revascularization. Patients were randomly allocated to receive TXA (n=100), Caproamin Fides (n=100) or placebo (n=100) during perioperative time. Mediastinal bleeding during the first 24 hours post-operation, transfusion requirement and post-surgical complications were assessed. RESULTS: Most descriptive and intra-operative parameters were well comparable between the 3 study groups. Except for mean number of packed red blood cell (PRBC) units transfused during ICU stay (P=0.01), patients in the Caproamin Fides and TXA groups did not show any statistically significant differences regarding transfusion of blood products during peri-operative period. There was no evidence of a significant difference in mediastinal blood loss during the first 24 hours post-operation between the patients receiving TXA or placebo, while patients in the Caproamin Fides group had significantly lower mediastinal bleeding than the other 2 groups (Caproamin Fides vs. placebo, P=0.002, <0.001 and <0.001 at 6, 12 and 24 hours post-operation; Caproamin Fides vs. TXA, P=0.009, 0.003, <0.001 at 6, 12 and 24 hours post-operation). The incidence of postoperative complications were comparable between Caproamin Fides and TXA groups (P>0.05). CONCLUSION: In conclusion, Caproamin Fides seems to be superior to TXA regarding the blood saving effects in patients undergoing coronary artery revascularization.

Haemostatic Role of TachoSil Surgical Patch in Cardiac Surgery.

INTRODUCTION: Excessive bleeding presents a risk for the patient in cardiovascular surgery. Local haemostatic agents are of great value to reduce bleeding and related complications. TachoSil (Nycomed, Linz, Austria) is a sterile, haemostatic agent that consists of an equine collagen patchcoated with human fibrinogen and thrombin. This study evaluated the safety and efficacy of TachoSil compared to conventional technique. METHODS: Forty-two patients scheduled for open heart surgeries, were entered to this study from August 2010 to May 2011. After primary haemostatic measures, patients divided in two groups based on surgeon's judgment. Group A: 20 patients for whom TachoSil was applied and group B: 22 patients that conventional method using Surgicel (13 patients) or wait and see method (9 cases), were performed in order to control the bleeding. In group A, 10 patients were male with mean age of 56.95±15.67 years and in group B, 9 cases were male with mean age of 49.95±14.41 years. In case group 70% (14/20) of the surgeries were redo surgeries versus 100% (22/22) in control group. RESULTS: Baseline characteristics were similar in both groups. In TachoSil group 75% of patients required transfusion versus 90.90% in group B (P=0.03).Most transfusions consisted of packed red blood cell; 2±1.13 units in group A versus 3.11±1.44 in group B (P=0.01), however there were no significant differences between two groups regarding the mean total volume of intra and post-operative bleeding. Re-exploration was required in 10% in group A versus 13.63% in group B (P=0.67). CONCLUSION: TachoSil may act as a superior alternative in different types of cardiac surgery in order to control the bleeding and therefore reducing transfusion requirement.