Midterm safety and outcome of balloon angioplasty of native aortic coarctation in neonates and young infants and initial experience of prepartial dilatation using high-pressure noncompliant balloon.

Background: Balloon angioplasty (BA) for aortic coarctation in neonates and infants remains controversial due to high recurrence rate and vascular complications. Aim: This study aimed to determine the safety and outcome of percutaneous treatment of coarctation in neonates and infants and to share the initial experience of strategy of prepartial dilatation with high-pressure noncomplaint balloon before final targeted dilatation using low-pressure compliant balloon. Materials and Methods: Retrospective analysis of records of all neonates and infants aged <6 months who underwent BA either using only low-pressure balloon (Group A) or those with prepartial dilatation using high-pressure noncomplaint balloon followed by low-pressure compliant balloon (Group B) between July 2017 and February 2020 was performed. Demographic, clinical, echocardiographic, interventional, and follow-up data were collected for all. Results: A total of 51 patients (41.2% neonates) were included in the study. Median age was 1 month 14 days (60.8% girls) and mean weight was 3.6 ± 1.5 kg. The mean peak trans-coarctation gradient was 53 ± 12 (34-80) mmHg. The final pressure gradient dropped to <10 mmHg in all cases of Group B and only in 26.3% (5) patients of Group A (P < 0.001). Recoarctation rate was 25.5% (13) overall and was significantly higher in Group A patients (P < 0.001), in those with borderline/mildly hypoplastic arch (P = 0.04) and in those with postprocedure gradient between 10 and 20 mmHg (P = 0.02). Median time to re-coarctation was significantly delayed in Group B (P < 0.001). There were no major complications or mortality in either group. Conclusions: BA in neonates and young infants has an excellent short and mid-term safety and efficacy. The recoarctation rate is significantly reduced as well as delayed with prepartial dilatation using high-pressure noncompliant balloon.

Perioperative levels of tumor necrosis factor-α correlate with outcomes in children and adults with tetralogy of Fallot undergoing corrective surgery.

BACKGROUND: Previous studies reporting on tumor necrosis factor-α (TNF-α) as a marker of inflammatory response (IR) in patients with congenital heart disease were limited by small sample size and variability in diagnosis. We report perioperative changes in TNF-α levels and their correlation with preoperative factors and clinical outcomes in a large homogenous group of patients with tetralogy of Fallot (TOF) undergoing definitive repair at a tertiary care center. METHODS: A total of 167 patients were divided into four groups on the basis of age. Group 1 included infants less than 1 year, group 2 included children between 1 and 12 years, group 3 included adolescents between 12 and 18 years, and group 4 included adults more than 18 years of age. Serum TNF-α levels were measured at three time points and correlated with perioperative variables. RESULTS: The baseline TNF-α level correlated with patients' nutritional status and degree of cyanosis in all four groups. The magnitude of IR in the postcardiopulmonary bypass (post-CPB) period as measured by TNF-α level was much higher and correlated more consistently with adverse clinical outcomes in the younger age group (groups 1 and 2). On multivariable analysis; age at operation, preoperative degree of hypoxemia and TNF-α levels were found to be independent predictors of clinical outcomes. CONCLUSION: We demonstrated a rise in serum TNF-α levels in patients with TOF undergoing definitive repair on CPB, which correlated with preoperative severity of cyanosis, nutritional status, and adverse clinical outcomes. The TNF-α levels may be monitored to identify cyanotic patients at an increased risk of exhibiting augmented IR to CPB.

Comparison of a waxy maize and a potato starch-based balanced hydroxyethyl starch for priming in patients undergoing coronary artery bypass grafting.

OBJECTIVE: Concerns have been raised about differences in the safety profile of potato- versus waxy maize-derived hydroxyethyl starch (HES). The objective of this study was to compare 2 HES solutions derived from 2 different source materials (potato versus waxy maize) for their dose-related effects on hemostasis and organ function when used to prime the cardiopulmonary bypass circuit (CPB). DESIGN: A prospective, randomized, controlled study. SETTING: Tertiary care center. PARTICIPANTS: Eighty patients undergoing coronary artery bypass grafting (CABG) on CPB. INTERVENTIONS: For priming the CPB circuit, the HESPRL group received 1000 mL of potato-derived balanced 6% HES 130/0.42 along with 500 mL of Ringer's lactate; the HESP group received 1,500 mL of potato-derived balanced 6% HES 130/0.42; the HESMRL group received 1000 mL of waxy maize-derived balanced 6% HES 130/0.4 along with 500 mL of Ringer's lactate, and the HESM group received 1500 mL of waxy maize-derived balanced 6% HES 130/0.4. MEASUREMENTS AND MAIN RESULTS: There were no significant differences in 24-hour mediastinal drainage, rate of re-exploration, blood product usage, coagulation parameters, and measures of pulmonary, renal, and hepatic function with respect to plant source of HES, when equivalent doses were used. Sonoclot activated clotting time (SonACT) was significantly higher and clot rate (CR) significantly lower at end of surgery (T1) and 24 hours after surgery (T2) in the HESP and HESM groups compared with the HESPRL and HESMRL groups. Compared with baseline, CR and platelet function were significantly lower at T1, PaO2/FIO2 ratio decreased significantly at T1 and T2, and serum bilirubin and transaminases increased significantly at T2 in all 4 groups. CONCLUSIONS: There was no significant difference in cumulative 24-hour mediastinal drainage when potato-derived balanced 6% HES 130/0.42 or waxy maize-derived balanced 6% HES 130/0.4 was used to prime the CPB circuit in patients undergoing CABG. In equal doses, both starches exerted the same effect on blood coagulation and pulmonary, renal, and hepatic function.

Lung decortication and lobectomy in a child with unrepaired tetralogy of fallot.

Patients with uncorrected tetralogy of Fallot (TOF) have been reported as undergoing emergency noncardiac surgeries such as cesarean section, brain abscess drainage, and major abdominal surgery. The uncorrected TOF group presents a great challenge with issues related to long-term effects of chronic hypoxemia and decreased pulmonary blood flow modifying patient physiology. We report a rare case of a child with uncorrected TOF with necrotizing streptococcal pneumonia complicated by empyema and bronchopleural fistula. The child successfully underwent lung decortication and right middle lobectomy in the first stage followed by an intracardiac repair (ICR) 15 days later. This staged approach was directed at controlling the infective focus, improving the pulmonary status, and following it up with a definitive ICR electively.