Anomalous right pulmonary artery from aorta, surgical approach case report and literature review.

BACKGROUND: Anomalous origin of one pulmonary artery from the aorta is a rare congenital anomaly affecting the right pulmonary artery more than the left. These patients are at risk for the early development of significant pulmonary hypertension. Early surgical treatment has been proven safe with excellent results. The surgical approach and technique is challenging and should be decided ahead before the patient to surgery. Different techniques were described including direct reimplantation, conduit interposition, aortic ring flap. AIM: We present a neonate with anomalous origin of the right pulmonary artery from the aorta and discuss the surgical technique and complications in the literature.

Impact of stent of ductus arteriosus and modified Blalock-Taussig shunt on pulmonary arteries growth and second-stage surgery in infants with ductus-dependent pulmonary circulation.

INTRODUCTION: Ducts-dependent pulmonary circulation is spectrum of congenital heart diseases that need urgent intervention to augment pulmonary blood. Systemic to pulmonary shunt is the classical surgical management. Stenting of ductus arteriosus emerged in the last 2 decades as an alternative plausible intervention. OBJECTIVES: To evaluate and compare the short and midterm effects of PDA stenting in compared to surgically placed shunt for augmentation of pulmonary blood flow looking to pulmonary artery (PA) branches growth, oxygen saturation and suitability for second stage repair. METHODS: We conducted this prospective study in Cardiac Surgical Intensive Care Unit. Cases were divided into "stent group" and "surgical shunt" group. Results were compared between two groups regarding oxygen saturation, mechanical ventilation duration, intensive care stay, mortality and morbidity. Growth of PA branches was assessed during follow up by echocardiograph. Nakata index score was calculated by angiogram before second stage surgery and was compared between both groups. RESULTS: 43 patients were included. Forty-two cases were offered stent as initial management. 6/42 cases failed stenting (14%) and 3/42 (7%) required late BT shunt after PDA stenting. 10/43 cases ended up receiving BT shunt and were counted as "surgical shunt group". Stent group (33 cases) needed less mechanical ventilation (2.08 ± 0.65 vs.7.8 ± 4 days with p = 0.014), and less ICU stay compared with surgical shunt group (6.2 ± 1.02 vs. 14 ± 4.5 days, P = 0.009). Both groups achieved similar growth of pulmonary artery branches (p = 0.6 for Z score of left pulmonary artery and P = 0.8 for Z score for right pulmonary artery). Although "stent group" reached second stage surgery with lower O2 saturation 67.6 ± 4.6 vs. 80 ± 4.2 in "surgical shunt" group with P value = 0.0002). Majority of patients in both groups had some PA distortion and needed surgical reconstruction in main pulmonary artery or in its main branches during second stage repair. 3 cases (7.1%) died soon post stenting versus none in surgical shunt group (p = value 0.57). CONCLUSIONS: In neonates with ductus-dependent pulmonary circulation PDA stenting can be introduced as safe first possible option to augment pulmonary blood flow with good outcome and suitable preparation for second stage palliation.

Cardiac Catheterisation Interventions in Neonates and Infants Less Than Three Months.

INTRODUCTION: Pediatric cardiac catheterization interventions become an established way of care for selected patients with congenital heart diseases. Cardiac catheterization for neonates and small infants can be challenging. The indications for diagnostic cardiac catheterization have decreased with the advent of advanced non-invasive imaging modalities. PATIENTS AND METHOD: Between June 2012 and July 2017 patients less than three months who had cardiac catheterization in two centers were reviewed. RESULTS: During the study period, 174 patients underwent interventional cardiac catheterization,83.3% of them had CHD with two-ventricle circulation and 29 patients (16.7%) had single ventricle pathophysiology. Procedures include diagnostic cath, BAS, balloon pulmonary and aortic valvuloplasty, coarctation angioplasty, and stenting procedures. The vascular access depends upon the type of procedure. All except one had general anesthesia. ICU admission was required on 106 patients (62%). Patients were divided according to the type of cardiac lesion (single versus biventricular pathology) as well as according to the type of intervention (stenting and non-stenting procedures). Comparing these groups revealed that: stent procedures and procedures for patients with single ventricle pathologies were performed at an earlier age, with more contrast, fluoro and procedure time than for non-stent procedures and procedures for patients with biventricular pathologies. Complications include transient arrhythmias in most patients, perforation of the RVOT in one and lower limb hypoperfusion in 12 patients. ICU complications include low cardiac output symptoms (LCOS) in 10 (7%), and sepsis in 8. No intra-procedure mortality. The overall survival was 94%. Ten patients died, with one early and 9 late mortality. 60% of the dead patients had PDA stenting. Reintervention varies according to the patient's diagnosis. CONCLUSION: Cardiac catheterization intervention an important modality in the management of neonates and infants with critical CHD. Well planned procedures and team expertise are essential. Stenting procedures and procedures for patients with single ventricles carries higher morbidity and mortality.

Infective endocarditis in children with normal heart: Indication for surgical intervention.

Although infective endocarditis is an uncommon condition, it can be fatal if not treated. The new era of infective endocarditis in children with structurally normal heart has become apparent entity. Duke criteria has been established for a long time and gives clear guidelines for diagnosis; however, surgical indication in pediatric population needs to be tailored to individual patients.

Incidence and causes of prolonged mechanical ventilation in children with Down syndrome undergoing cardiac surgery.

INTRODUCTION: Trisomy 21 is the most common syndrome in children with a 30-50% association with congenital heart disease (CHD). Cardiac surgeries are required in the majority of Down syndrome (DS) with CHD cases. Because of the distinctive abnormalities in their respiratory system, children with DS may require longer positive pressure ventilation after cardiac surgery. The aim of this study is to investigate the incidence and possible risk factors for prolonged mechanical ventilation (PMV) need in DS patients undergoing cardiac surgery. METHODS: We conducted a prospective study on all DS children who underwent cardiac surgery from 2013 to 2016. Demographic and perioperative data were collected including the duration of mechanical ventilation, respiratory risk factors such as previous infection, evidence of pulmonary hypertension during the intensive care unit (ICU) stay, the presence of lung collapse, secretion and wheezy chest, inotropes score, sedation score, arrhythmias, and low cardiac output syndrome. Based on the duration of mechanical ventilation, cases were divided into two groups: the control group, comprising of children who required mechanical ventilation for less than 72 hours, and the PMV group, which consisted of children who required mechanical ventilation for 72 hours or more. Risk factors were compared and analyzed between both groups. RESULTS: A total of 102 participants fulfilled the inclusion criteria, 90 of whom were assigned to the control group and 12 to the PMV group (11.7%). Compared with the control group, the PMV group had a higher incidence of pulmonary hypertension at a younger age (83% vs. 23%, p = 0.012) and 50% of them required chronic treatment for pulmonary hypertension upon home discharge. Pneumonia during ICU stay was encountered more frequently in the PMV group (33.3% vs. 2.2%, p = 0.0042). In addition, the PMV group had more frequent signs of low cardiac output syndrome after surgery (25% vs. 2.2%, p = 0.019), longer ICU stays (7 ±â€¯0.3 days vs. 15.6 ±â€¯2.1 days, p = 0.0001), needed more days of inotropes infusion (7.5 ±â€¯0.4 days vs. 11.1 ±â€¯1.6 days, p = 0.0045), and required more sedative and paralytic agents postoperatively (6 ±â€¯0.6 days vs. 8.7 ±â€¯1 days, p = 0.022). CONCLUSION: Overall, 11.7% of DS patients required prolonged ventilation after cardiac surgery. Pulmonary hypertension was seen more frequently in cases requiring PMV, and half of PMV cases required antipulmonary hypertension medication upon discharge. Early recognition of pulmonary hypertension and proper perioperative management are recommended to avoid serious complication and comorbidity after cardiac surgery.

Can acute-phase response biomarkers differentiate infection from inflammation postpediatric cardiac surgery?

BACKGROUND: Infection is a common serious complication postpediatric cardiac surgery. Diagnosis of infection after cardiopulmonary bypass (CPB) is difficult in the presence of surgical stress, hemodynamic instability, and inflammatory reaction. AIM: The purpose of this study is to investigate the value of available inflammatory biomarkers and its validity to differentiate infection from inflammation postpediatric cardiac surgery and to find the trend and the change in the level of these biomarkers shortly after cardiac surgery. METHODS: We conducted a prospective study that included all children who underwent cardiac surgery in Prince Sultan Cardiac Centre-Qassim from November 2013 to October 2015. C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and neutrophil count were measured for all patients presurgery, 4 consecutive days postsurgery, and predischarge. Patients were divided into two groups (the infected and the noninfected group). We compared the level of biomarkers between both groups. Then, we further analyzed the effects of CPB and preoperative steroid on postoperative inflammatory biomarker levels. Collected data were then reviewed and analyzed. RESULTS: There were 134 pediatric cardiac patients included during the study period. Group 1 (bacterial negative culture group) had 125 cases and Group 2 (bacterial positive culture group) had nine cases. We found no statistically significant difference in inflammatory biomarker elevation between both groups. Only Group 2 had higher (RACHS) Risk adjustment for congenital heart surgery score, more ventilator days, and more drop in platelet count on the 2nd and 3rd postoperative days in comparison with the noninfected group 1. Both groups of patients who were in on and off CPB had the same level of inflammatory biomarkers with no significant differences. Giving corticosteroid preoperatively did not affect the trend of biomarker elevation and made no difference when it was compared to the group of patients who did not receive corticosteroid before surgery. CONCLUSION: Common inflammatory biomarkers cannot differentiate between infection and inflammation within the first 5 days postpediatric cardiac surgery as these reflect the inflammatory process rather than infection. Trend is more important than single reading.

Effects of blood transfusion on oxygen extraction ratio and central venous saturation in children after cardiac surgery.

BACKGROUND: Red blood cell transfusion is common in critically ill children after cardiac surgery. Since the threshold for hemoglobin (Hb) transfusion need is not well defined, the threshold Hb level at which dependent critical oxygen uptake-to-delivery (VO2-DO2) status compensation is uncertain. OBJECTIVES: To assess the effects of blood transfusion on the oxygen extraction ratio (O2ER) and central venous oxygen saturation (ScvO2) to identify a critical O2ER value that could help us determine the critical need for blood transfusion. DESIGN: Prospective, observational cohort study. SETTING: Cardiac Surgical Intensive Care Unit at Prince Sultan Cardiac Center in Qassim, Saudi Arabia. PATIENTS AND METHODS: Between January 2013 and December 2015, we included all children with cardiac disease who underwent surgery and needed a blood transfusion. Demographic and laboratory data with physiological parameters before and 1 and 6 hours after transfusion were recorded and O2ER before and 6 hours after transfusion was computed. Cases were divided into two groups based on O2ER: Patients with increased O2ER (O2ER > 40%) and normal patients without increased O2ER (O2ER < =40%) before transfusion. MAIN OUTCOME MEASURE(S): Changes in O2ER and ScvO2 following blood transfusion. RESULTS: Of 103 patients who had blood transfusion, 75 cases had normal O2ER before transfusion while 28 cases had increased O2ER before transfusion. Following blood transfusion, O2ER and ScvO2 improved in the group that had increased O2ER before transfusion, but not in the group that had normal O2ER before transfusion. CONCLUSIONS: The clinical and hemodynamic indicators O2ER and ScvO2 may be considered as markers that can indicate a need for blood transfusion. LIMITATIONS: The limitation of this study is the small number of patients that had increased O2ER before transfusion. There were few available variables to assess oxygen consumption.

Predictors of cardio pulmonary resuscitation outcome in postoperative cardiac children.

BACKGROUND: Outcomes of cardiopulmonary resuscitation (CPR) in children with congenital heart disease have improved and many children have survived after an in-hospital cardiac arrest. AIM: The purpose of this study is to determine predictors of poor outcome after CPR in critical children undergoing cardiac surgery. METHODS: We conducted a retrospective chart review and data analysis of all CPR records and charts of all postoperative cardiac children who had a cardiac arrest and required resuscitation from 2011 until 2015. Demographic, pre-operative, and postoperative data were reviewed and analyzed. RESULTS: During the study period, 18 postoperative pediatric cardiac patients had CPR. Nine of them had return of spontaneous circulation and survived (50%). On average CPR was required on the 3(rd) postoperative day. Univariate analysis demonstrated that poor outcome was associated with higher lactic acid measured 4-6 hours prior to arrest (p = 0.045; p = 0.02) coupled with higher heart rate (p = 0.031), lower O2 saturation (p = 0.01), and lower core body temperature (p = 0.019) recorded 6 hours before arrest. Nonsurvival required longer resuscitation duration and more epinephrine doses (p < 0.05). CONCLUSION: Higher heart rate, lower core body temperature, lower O2 saturation, and higher lactic acid measured 6 hours before arrest are possible predictors of poorer outcome and mortality following CPR in postoperative cardiac children.

Late-presenting complete heart block after pediatric cardiac surgery.

Late presenting complete heart block after pediatric cardiac surgery is a rare complication and its management is well defined once the initial diagnosis in made timely and appropriately. In this report we described a child who underwent atrioventricular septal defect repair with a normal sinus rhythm during the postoperative period, as well as during the first 2 years of follow up. She subsequently developed complete heart block with bradycardia that required insertion of a pacemaker. Here we discuss this unusual late-presenting complication, possible risk factors, and management.

Horner's syndrome after paediatric cardiac surgery: case report and review of the literature.

Iatrogenic Horner's syndrome is a rare complication that can occur after trauma, cervical central line insertion, chest tube insertion, and rarely following adult thoracic and neck surgery, especially in high risk patients with hypertension and diabetes. The majority of cases reported in the literature describe non-iatrogenic Horner's syndrome in adults as an unusual presentation for cervical tumours or apical lung carcinoma. In children, there are some reports describing acquired Horner's syndrome following trauma or invasive intervention near the cervical-thoracic area. Less has been written about the incidence of Horner's syndrome following paediatric cardiac surgery.