Efficacy of extracorporeal membrane oxygenation in pediatric COVID-19 and MIS-C cases: A single-center experience.

Background: This study aimed to evaluate the need and the indication of extracorporeal membrane oxygenation (ECMO) in patients diagnosed with coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C) followed up in the pediatric intensive care unit by the demographic, clinical, and laboratory data and treatment response. Methods: A total of 79 patients (43 males, 36 females; median age: 138 months; range, 6 to 210 months) with COVID-19 and MIS-C followed up between September 2020 - September 2021 were included in this retrospective study. Demographic and clinical data were retrospectively collected from patient files, and clinical data, laboratory findings, chest X-rays, and echocardiography results of six patients (1 male and 5 female, median age: 159 months, range, 13 to 210 months) who needed ECMO due to poor response to medical treatment were recorded before and after the ECMO therapy. Results: Extracorporeal membrane oxygenation therapy was performed on one patient with a positive COVID-19 polymerase chain reaction test and five patients with MIS-C in our unit. Five patients were supported with venoarterial (v-a) ECMO, and one patient was supported with venovenous ECMO. Median hospitalization time was 29 (range, 24 to 50) days, median Pediatric Risk of Mortality score was 19.5 (range, 11 to 36), and median length of mechanical ventilation was 23.5 (range, 10 to 45) days. The median vasoactive inotropic score was 55.5 (range, 18 to 110) before ECMO, while the median vasoactive inotropic score was 11 (range, 0 to 34) after ECMO. Four patients were successfully weaned off ECMO, and one of these patients was lost due to brain death 15 days after the weaning. One patient infected with the delta variant of COVID-19, which remained positive during the clinical course, and one patient diagnosed with MIS-C was lost despite the v-a ECMO support. Three of the patients were discharged. Thrombosis developed in the superficial femoral artery of one patient on the cannulated side during v-a ECMO. No death due to complications of ECMO was recorded. Conclusion: In our study, although the majority of our patients followed up with the diagnosis of COVID-19 and MIS-C showed a mild or moderate clinical course, it was observed that a severe clinical course could develop in a small number of patients and that ECMO treatment may be needed in these patients. In agreement with the ECMO studies with different indications in the literature, we conclude that ECMO therapy may markedly contribute to the prognosis in COVID-19 and MIS-C patients when the initiation and termination timing of therapy is correct.

Evaluation of chronic inflammation in the aetiology of venous insufficiency by investigating cytomegalovirus DNA.

INTRODUCTION: Lower extremity venous insufficiency is a significant health problem with economic and sociological consequences, lowering the quality of life, and sometimes leading to serious complications. The aim of this study is to evaluate the cytomegalovirus (CMV) effect on chronic inflammation in the aetiology of chronic venous insufficiency. MATERIAL AND METHODS: Between November 2017 and August 2018, 468 patients who underwent radio-frequency ablation therapy and phlebectomy were included in the study. PCR analyses for CMV DNA were performed on the venous tissue samples. Patients with post-thrombotic syndrome were excluded from the study. After ethical approval, the relationship between the presence of CMV DNA, gender, body mass index, and bilaterality of chronic venous insufficiency were investigated. RESULTS: When the relationship between CMV DNA and gender or body mass index was examined, a significant relationship was not detected. But when the patients with bilateral chronic venous insufficiency and patients with unilateral chronic venous insufficiency were compared regarding CMV DNA positivity, the patients with bilateral chronic venous insufficiency had significantly higher CMV DNA positivity (p = 0.002). Also, the incidence of venous ulcers in the CMV DNA exposed group was significantly higher. CONCLUSIONS: In the literature there are many studies showing that CMV triggers atherosclerosis, but there is no study in which CMV directly produces chronic venous insufficiency. The high rates of positivity suggest that CMV, which is the basis of chronic inflammation, may be a significant factor in the aetiology of chronic venous insufficiency.

Analysis of outcomes in patients with abnormal laterality undergoing congenital heart surgery.

OBJECTIVE: Laterality anomalies are almost always associated with severe cardiac anomalies. Demographic properties, type of the procedures, associated anomalies, and early and mid-term prognosis of four types of laterality anomalies were analysed. METHODS: A total of 64 consecutive patients with laterality anomalies were enrolled between July 2014 and July 2020. We grouped the patients as situs solitus dextrocardia (SSD) (n = 12; 18.7%); situs inversus (SI) (n = 16; 25%); right atrial isomerism (RAI) (n = 29; 45.3%); and left atrial isomerism (LAI) (n = 7; 10.9%). TAPVC was only present in the RAI group (31%). Incidence of mitral or tricuspid atresia was higher in the SSD group (25%). All the patients were followed up with a mean of 19.06 ± 17.6 (0.1-72) months. RESULTS: Early postoperative mortality was 17 patients, among 107 procedures (15.8%). Twelve patients were in the neonatal period. All ten patients survived after isolated ductal stenting. Fourteen of the deaths were in the RAI group (48.3%). The 3-year survival rates were 85% in LAI, 78.7% in SI, 55.8% in SSD, and 38% in RAI groups. According to the multivariable Cox regression model, mechanical ventilation, kidney injury, RAI, and complex surgery in the neonatal period were independent risk factors for early mortality. CONCLUSION: Laterality anomalies are one of the most challenging patients who commonly had univentricular physiology. The most prevalent anomaly was RAI, and RAI had the worst outcome and survival. Ductal stent is an acceptable first intervention during the neonatal period in suitable patients. Complex procedures may carry a high risk of death in the neonatal period.

Management of Interrupted Aortic Arch With Associated Anomalies: A Single-Center Experience.

OBJECTIVES: Interrupted aortic arch (IAA) includes a broad spectrum of associated anomalies. In this study, we present our surgical management and patient-specific decisions regarding IAA anomalies with early- and mid-term outcomes. METHODS: The medical records of 25 patients undergoing IAA repair between 2014 and 2019 were retrospectively reviewed. Sixteen patients had type B (64%) interruptions, 7 had type A (28%) interruptions, and 2 had type C (8%) interruptions. Fourteen patients had an isolated ventricular septal defect, and 3 of them had associated left ventricular outflow tract obstruction. Other associated anomalies were functional single ventricle (n = 5), Taussig-Bing anomaly (n = 3), aortopulmonary window (n = 1), multiple ventricular septal defects (n = 1), and truncus arteriosus with dextrocardia (n = 1). The initial operation age was 17.2 ± 14 (range: 1 - 60) days. RESULTS: Single-stage total repair was performed for 15 patients. Six patients underwent aortic arch repair and pulmonary artery banding. Four patients with left ventricular outflow tract obstruction or who were premature underwent the hybrid procedure. The aortic arch repair was performed in 16 cases (64%) by the anterior patch augmentation technique, in 3 cases (12%) by the reverse left subclavian artery flap technique, and in 3 cases (12%) by direct end-to-end anastomosis. Postoperative early mortality occurred in 4 (16%) patients, and sternal closure was delayed in 13 (52%) patients. Three patients who underwent a hybrid procedure due to left ventricular outflow tract obstruction underwent biventricular repair 8 to 13 months later. Eight patients (38%) required reintervention due to arch restenosis during the follow-up period. The mean follow-up was 37.1 ± 21.7 months. CONCLUSION: Planning surgical treatment according to the characteristics of the patients and accompanying anomalies may improve the results.

Outcomes of home mechanical ventilation with tracheostomy after congenital heart surgery.

OBJECTIVE: After congenital heart surgery, some patients may need long-term mechanical ventilation because of chronic respiratory failure. In this study, we analysed outcomes of the patients who need tracheostomy and home mechanical ventilation. METHODS: Amongst 1343 patients who underwent congenital heart surgery between January, 2014 and June, 2018, 45 needed tracheostomy and HMV. The median age of these patients was 6.4 months (12 days-6.5 years). Nineteen patients underwent palliation while 26 patients underwent total repair. Post-operative diaphragm plication was performed in five patients (11%). Median duration of mechanical ventilation before tracheostomy was 32 days (8-154 days). The patients were followed up with their home ventilators in ward and at home. Mean follow-up time was 36.24 ± 11.61 months. RESULTS: The median duration of ICU stay after tracheostomy was 27 days (range 2-93 days). Follow-up time in ward was median 30 days (2-156 days). A total of 12 patients (26.6%) were separated from the ventilator and underwent decannulation during hospital stay. Thirty-two patients (71.1%) were discharged home with home ventilator support. Of them, 15 patients (46.9%) were separated from the respiratory support in median of 6 weeks (1 week-11 months) and decannulations were performed. Total mortality was 31.1%. in which four patients are still HMV dependent. There was no significant difference for decannulation between total repair and palliation patients. CONCLUSION: HMV via tracheostomy is a useful option for the treatment of children who are dependent on long-term ventilation after congenital heart surgery although there are potential risks.

Management of aortic arch hypoplasia in neonates and infants.

OBJECTIVES: Surgical management of aortic arch hypoplasia (AAH) with associated intracardiac anomalies is a challenge in newborns. We reviewed the characteristics and outcomes of neonates and infants who underwent pulmonary artery banding concomitant to arch repair and single-stage total repair at our institution. METHODS: Medical records of 60 patients undergoing aortic arch reconstruction for AAH from 2014 to 2019 were retrospectively reviewed. Twenty-five patients were female (41.6%), and the age of the patients ranged from 4 to 120 days (median, 19.5 days). The patients were divided into two groups: Group 1 (23 patients) underwent pulmonary artery banding concomitant to arch repair, and Group 2 (37 patients) underwent single-stage total repair in addition to arch repair. All arch repair procedures consisted of an extended (to the midportion of the ascending aorta) patch aortoplasty. RESULTS: Postoperative early mortality occurred in 12 patients, eight in Group 1 (34.8%) and four in Group 2 (10.8%). There was an early survival advantage in Group 2 (p = .019). Recoarctation occurred in 13 cases (21.6%), and 11 (18.3%) of them required reintervention (balloon angioplasty: 7, reoperation: 4). On univariate analysis, risk factors associated with death were pulmonary artery banding (hazard ratio [HR], 0.44; confidence interval [CI], 0.09-2; p = .019), prematurity (HR, 4.67; CI, 1.34-16.18; p = <.001), preoperative mechanical ventilation support requirement (HR, 0.048; CI, 0.52-6.39; p = .048), and functional single ventricle (HR, 0.43; CI, 0.1-1.86; p = .006). The mean duration of follow-up was 21.9 ± 15.1 months, and there was no late death in either group. CONCLUSION: Single-stage repair of AAH with intracardiac pathologies has better results than palliation, according to survival rates and postoperative results. The use of the patch augmentation technique in AAH is valid and associated with an acceptable incidence of recurrent arch obstruction.