Implications of left atrial enlargement and patent foramen ovale creation on early surgical outcomes in patients with total anomalous pulmonary venous connection.

INTRODUCTION: In patients with total anomalous pulmonary venous connection (TAPVC), left atrium (LA) is small and suprasystemic pulmonary artery (PA) pressures may be present in some patients. In our study, we studied the relationship between surgical LA enlargement and patent foramen ovale (PFO) creation separately on the outcomes of patients with TAPVC. MATERIALS AND METHODS: Out of the 130 patients operated in our institute between January 2014 and December 2020, LA was enlarged in 60 patients. LA enlargement was done using a larger patch for atrial septal defect (ASD) closure. Thus, the LA volume was increased by shifting the patch towards the right atrium (RA). Suprasystemic or high PA pressures were present in 60 patients. In 33 patients, PFO was created. Early surgical outcomes were determined on the basis of vasoactive inotropic score (VIS), hours of ventilation, hours of inotropic support, intensive care unit (ICU) stay, and hospital stay. RESULT: Between the LA enlarged and nonenlarged group there was statistically significant less VIS score (18 [13-27.5] vs. 24 [18-30], p value .019), hours of ventilation (23 [16-46.5] vs. 26 [18-60], p value .039), hours of inotropic support (45.5 [30-72] vs. 55 [38-84], p value .038), and ICU stay (7 [5-9] vs. 8 [7-10] p value .0352) and statistically nonsignificant less hospital stay (11.5 [9-13] vs. 12 [9-14], p value .424). In patients with preoperative suprasystemic or high PA pressures, there was a statistically significant less VIS score (16 [11-23.5] vs. 18 [13-25], p value .044), hours of ventilation (20 [14-37] vs. 22 [18-39], p value .038), hours of inotropic support (34 [29.5-71] vs. 38 [30-78], p value .042), and hospital stay (9 [5-12] vs. 11 [9-14], p value .038) and statistically nonsignificant less ICU stay (7 [5.5-9] vs. 7 [6-9], p value .886) in the group with a PFO with respect to the other group in which no PFO was created. CONCLUSION: In patients with TAPVC, LA can be enlarged by using a large ASD patch and thus shifting the septum towards RA. Early surgical outcomes were improved with LA enlargement. In patients with suprasystemic or high PA pressures, leaving a PFO improved the postoperative outcomes.

Surgical outcome in aortopulmonary window beyond the neonatal period.

OBJECTIVE: Aortopulmonary window (APW) is a rare congenital cardiac defect accounting for 0.1% to 0.2% of all congenital cardiac defects. We here present the current midterm outcome of surgical repair of APW in patients more than 3 months of age. METHODS: The retrospective study was conducted to identify all the patients more than 3 months of age at presentation who underwent surgical repair of APW between June 2010 and August 2018 at our tertiary care institute and their outcome was analyzed. RESULTS: We found 14 patients of APW operated at the age of more than 3 months over a period of 8 years. Mean age of the cohort was 2.29 ± 2.96 years ranging from 3 months to 10 years with 57.14% being males. There were 11 (78.57%) patients with isolated APW and 3 (21.43%) had associated cardiac defects including tetralogy of Fallot (n = 1), ventricular septal defect (n = 1), subaortic membrane causing subaortic stenosis (n = 1), and one had extracardiac malformations. Two patients had type I, nine had type II, and three had type III APW as per Jacobs' classification. The mean size of the defect was 14.14 ± 4.33 mm. Mean duration of mechanical ventilation was 26.91 ± 16.65 hours (range, 12.25-67 hours). There was one in-hospital mortality and no late mortality over a mean follow-up of 3.06 ± 2.19 years. None of the patients required any kind of reintervention. CONCLUSION: Good results can be obtained even on late presentation with adequate perioperative care of the patients with the reversible pulmonary hypertensive disease.

Impact of hibernating and viable myocardium on improvement in perfusion and left ventricular ejection fraction after coronary artery bypass graft.

OBJECTIVES: The association between the extent and degree of perfusion-metabolism mismatch and improvement in perfusion and left ventricular ejection fraction (LVEF) after revascularization was assessed. The secondary aim was to identify the best precoronary artery bypass graft surgery (pre-CABG) PET parameter, if any, to predict the improvement in the perfusion and LVEF after CABG. METHODS AND RESULTS: Overal, 31 patients (mean age: 58+8.3 years) with ischemic left ventricle dysfunction underwent NH3 and F-FDG PET for the assessment of myocardial viability. CABG was performed in these patients and after a mean interval of 3 months, NH3 PET was repeated. The percentages of viable myocardium (VM), hibernating myocardium, degree of mismatch, and LVEF in pre-CABG PET were calculated. These were compared, the median [INCREMENT]LVEF and percent increase in perfusion being 5 (interquartile range: 3-9) and 78.7 (interquartile range: 51.3-100), respectively. No significant association was observed between the severity or extent of perfusion defect/mismatch and improvement in perfusion or LVEF after CABG. Patients with at least 65% VM predicted a 5-unit increase in LVEF at 88.9% sensitivity (P=0.1). CONCLUSION: There was no significant relation between the severity and extent of perfusion-metabolism mismatch with improvement in perfusion and LVEF after CABG. After CABG for ischemic left ventricle dysfunction, VM shows a tendency toward better improvement in LVEF.

Evaluation of closed-loop anesthesia delivery for propofol anesthesia in pediatric cardiac surgery.

OBJECTIVE: The objective of this study was to compare the feasibility of closed-loop anesthesia delivery with manual control of propofol in pediatric patients during cardiac surgery. METHODS: Forty ASA II-III children, undergoing elective cardiac surgery under cardiopulmonary bypass (CPB) in a tertiary care hospital, were randomized to receive propofol either through a closed-loop anesthesia delivery system (CL group) or through traditional manual control (manual group) to achieve a target BIS of 50. Patients were induced and subsequently maintained with a propofol infusion. The propofol usage and the efficacy of closed-loop system in controlling BIS within ±10 of the target were compared with that of manual control. RESULTS: The maintenance of BIS within ±10 of target and intraoperative hemodynamic stability were similar between the two groups. However, induction dose of propofol was less in the CL group (2.06 ± 0.79 mg·kg(-1) ) than the manual group (2.95 ± 1.03 mg·kg(-1) ) (P = 0.006) with less overshoot of BIS during induction in the closed-loop group (P = 0.007). Total propofol used in the off-CPB period was less in the CL group (6.29 ± 2.48 mg·kg(-1) h(-1) vs 7.82 ± 2.1 mg·kg(-1) h(-1) ) (P = 0.037). Phenylephrine use in the pre-CPB period was more in the manual group (16.92 ± 10.92 µg·kg(-1) vs 5.79 ± 5.98 µg·kg(-1) ) (P = 0.014). Manual group required a median of 18 (range 8-29) dose adjustments per hour, while the CL group required none. CONCLUSION: This study demonstrated the feasibility of closed-loop controlled propofol anesthesia in children, even in challenging procedures such as cardiac surgery. Closed-loop system needs further and larger evaluation to establish its safety and efficacy.

Major airway injury during esophagectomy: experience at a tertiary care center.

BACKGROUND: Tracheal laceration is a rare but life-threatening complication of esophagectomy. It is seen both with transhiatal and transthoracic esophagectomy. METHODS: Three hundred eighty-two esophagectomies were performed from 1998 to 2008. The medical records of five patients with laceration of trachea during esophagectomy managed at a tertiary care center were reviewed retrospectively. RESULTS: There were three males and two females with age range 18-62 years. The overall incidence of tracheal laceration was 1.31%. Four lacerations (1.30%) occurred during transhiatal and one (1.35%) during transthoracic resection of esophagus. Tracheal laceration was detected intraoperatively in all. Laceration was long (>3 cm) in three patients and short (<2 cm) in two. Patients with long laceration required direct suturing, while those with short laceration could be managed with gastric reinforcement. No patient required additional thoracotomy to access the lesion. Two patients had pneumonia, one had recurrent nerve palsy, while another developed anastomotic disruption. No patient died. CONCLUSION: Laceration of trachea is a potentially morbid complication of esophagectomy. Management should be individualized based on the extent and type of laceration. The surgical strategy depends upon the index procedure. The present series describes successful management of patients with tracheal injury associated with esophagectomy.

Thymectomy for myasthenia gravis: 12-year experience.

Thymectomy has been shown to be effective in the treatment of myasthenia gravis. The logical goal of operation is the complete removal of the thymus, but there is no consensus on the selection criteria of patients for surgery and the choice of surgical approach. We retrospectively reviewed 56 patients with myasthenia gravis who had been treated surgically by transsternal radical thymectomy between January 1990 and March 2002. The patients were symptomatically grouped according to the modified Osserman clinical classification. There was 1 hospital death, and 53 patients had been followed up for between 1 month and 12 years. Improvement after thymectomy was observed in 1 of 4 patients (25%) in Osserman group I, 25 of 34 patients (74%) in Osserman group IIA, and 16 of 18 patients (89%) in combined Osserman groups IIB and IIC. Transsternal radical thymectomy is an effective therapy for myasthenia gravis. Sustained improvement is achievable in female patients with moderate to severe symptoms and in patients with thymic hyperplasia.