Evaluation of the Performance of Vasoactive Ventilation Renal Score in Predicting the Duration of Mechanical Ventilation and Intensive Care Hospitalization After Pediatric Cardiac Surgery.

Various methods have been used to evaluate the predictivity of some markers during the recovery process after cardiac surgery in children. The aim herein was to evaluate the vasoactive ventilation renal (VVR) score in predicting the clinical outcomes of children who underwent congenital cardiac surgery within the early period in the pediatric intensive care unit (PICU). Patients who underwent congenital heart surgery (CHS) between November 2016 and March 2020 were enrolled and evaluated prospectively. The VVR score was calculated as follows: vasoactive inotrope score (VIS) + ventilation index + (change in serum creatinine level based on the baseline value × 10). The relationship between the duration of mechanical ventilation and the length of stay (LOS) in the PICU was evaluated via receiver operating characteristic (ROC) curve analysis and the cut-off values were calculated. At all of the time points identified in the study, the VVR score had a higher area under the ROC curve (AUC) when compared to the VIS and serum lactate levels, and the 48-h VVR score had the highest AUC (AUC 0.851, 95% confidence interval (CI) 0.761-0.942/LOS in the PICU; AUC 0.946, 95% CI 0.885-1.000/duration of mechanical ventilation). The 48-h VVR score for the LOS in the PICU was 6.7 (sensitivity 70%, specificity 92%) and that for the duration of mechanical ventilation was 9.1 (sensitivity 87%, specificity 97%). As a result, in our study, it was found that the VVR score is a new and effective predictor of the duration of mechanical ventilation and LOS in the PICU in postoperative CHS patients.

Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children.

BACKGROUND: We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO). METHODS: We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up. RESULTS: There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores. CONCLUSION: Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.

Long-term follow-up of subvalvular aortic stenosis in children: a single-centre experience.

OBJECTIVE: The aim of this study is to evaluate clinical and surgical outcomes of children with subaortic stenosis, to determine the risk factors for surgery and reoperation and to compare isolated subaortic stenosis and those concomitant with CHDs. METHODS: The study involved 80 children with subaortic stenosis. The patients were first classified as isolated and CHD group, and the isolated group was further classified as membranous/fibromuscular group. The initial, pre-operative, post-operative and the most recent echocardiographic data, demographic properties and follow-up results of the groups were analysed and compared. The correlation of echocardiographic parameters with surgery and reoperation was evaluated. RESULTS: There was a significant male predominance in all groups. The frequency of the membranous type was higher than the fibromuscular type in the whole and the CHD group. The median time to the first operation was 4.6 years. Thirty-five (43.7%) patients underwent surgery, 5 of 35 (14%) patients required reoperation. The rate of surgery was similar between groups, but reoperation was significantly higher in the isolated group. The gradient was the most important factor for surgery and reoperation in both groups. In the isolated group besides gradient, mitral-aortic separation was the only echocardiographic parameter correlated with surgery and reoperation. CONCLUSION: Reoperation is higher in isolated subaortic stenosis but similar in membranous and fibromuscular types. Early surgery may be beneficial in preventing aortic insufficiency but does not affect the rate of reoperation. Higher initial gradients are associated with adverse outcomes, recurrence and reoperation.

Surgical repair of non-obstructive supracardiac total anomalous pulmonary venous connection in an adult patient.

Total anomalous pulmonary venous connection is an uncommon congenital heart malformation with abnormal drainage of all pulmonary veins into the systemic venous system. Despite its very low incidence, it is usually a pediatric cardiac emergency and rarely allows survival into adulthood without surgical correction in infancy. Herein, we report one of the oldest cases from Turkey who was successfully operated for non-obstructive, supracardiac total anomalous pulmonary venous connection.

Perioperative factors associated with hyperglycemia after pediatric cardiac surgery and impact of hyperglycemia on morbidity and mortality.

Ödek Ç, Kendirli T, Yildirim-Yildiz N, Yaman A, Uçar T, Eyileten Z, Ates C, Uysalel A, Tutar E, Atalay S. Perioperative factors associated with hyperglycemia after pediatric cardiac surgery and impact of hyperglycemia on morbidity and mortality Turk J Pediatr 2018; 60 497-505. This retrospective, observational, single-center study aimed to determine the perioperative factors associated with postoperative hyperglycemia (blood glucose level ≥126 mg/dl) and the impact of hyperglycemia on morbidity and mortality in a cohort of children undergoing cardiac surgery. Non-diabetic children aged between 1 month to 18 years who were consecutively admitted to pediatric intensive care unit (PICU) after cardiac surgery for congenital heart disease between January 2008 and December 2013 were included. One hundred and twenty-six patients were qualified for inclusion during the study period. Seventy-four (57.8%) of the patients had at least one glucose measurement ≥ 126 mg/dl. Higher PRISM III-24 (OR 1.1, 95% CI 1.02-1.18, p= 0.004) and PELOD (p=0.006) scores, higher Wernovsky inotropic score (p=0.027) and vasoactive-inotropic score (p=0.029) were associated with hyperglycemia. Postoperative hyperglycemia was not associated with duration of mechanical ventilation), length of PICU stay, healthcare associated infections, or mortality. Our study establishes that hyperglycemia is common after pediatric cardiac surgery but not associated with short-term morbidity and mortality. Insulin therapy can be accomplished without hypoglycemia when a permissive glycemic target is used. A large prospective multiple institution trial is necessary to facilitate defined guidelines for postoperative hyperglycemia after pediatric cardiac surgery.

Effects of Preoperative Tricuspid Valve Diameters on Early Postoperative Surgical Outcomes in Patients Undergoing Tricuspid Valve Surgery.

BACKGROUND: Many of the previous studies on tricuspid valve surgery were on the materials that were used and the advantages and disadvantages of them. In this study, effects of preoperative tricuspid valve diameter on early postoperative outcomes were investigated. Methods: A total of 43 patients who underwent tricuspid valve repair surgery with the ring between the years 2012-2014 were included in this study. Tricuspid valve diameters and other cardiac functions of patients undergoing tricuspid intervention were evaluated with transthoracic echocardiography.Patients included in this study were divided into 2 groups: those with minimal, minimal-to-1st degree and 1st-degree tricuspid valve regurgitation found on thoracic echocardiography in the early postoperative period were considered as having a successful tricuspid repair (Group 1). Those with 1st-2nd degree and higher degrees of tricuspid regurgitation were considered as having an unsuccessful tricuspid repair (Group 2).The relationship between tricuspid valve dimensions and early tricuspid valve regurgitation was assessed with the help of preoperative, intraoperative, and postoperative data. RESULTS: Thirty patients (Group 1) were found to have a successful tricuspid valve repair in the postoperative period. The mean annulus diameter of the tricuspid valve at end-diastole in patients from Group 1 was similar to Group 2 (4.24 ± 0.44 cm versus 3.99 ± 0.40; P = .080). Also, tricuspid valve end-systolic diameter in Group 1 was similar to patients in Group 2 (3.59 ± 0.38 cm versus 3.42 ± 0.33 cm; P = .151). Conclusion: A direct relationship was not found between tricuspid valve diameter and post-operative development of moderate to severe regurgitation in tricuspid valve surgery in this study.

Acute kidney injury in congenital cardiac surgery: Pediatric risk-injury-failure-loss-end-stage renal disease and Acute Kidney Injury Network.

BACKGROUND: Acute kidney injury (AKI) is associated with an increased risk of mortality, especially in pediatric intensive care units. The aim of this study was to determine the risk factors of AKI in children undergoing cardiac surgery for congenital heart disease and to compare two different classification systems: pediatric risk-injury-failure-loss-end-stage renal disease (pRIFLE) and Acute Kidney Injury Network (AKIN). METHODS: We retrospectively analyzed 145 patients undergoing pediatric congenital heart surgery who were between 1 month and 18 years of years, and treated at a cardiovascular surgery department from January 2009 to October 2011. RESULTS: One hundred and thirty-seven patients (mean age, 36.6 ± 43.3 months) were enrolled: 84 (61.3%) developed AKI according to the pRIFLE criteria (25.5%, risk; 20.4%, injury; 15.3%, failure); and 65 patients (47.4%) developed AKI according to the AKIN criteria (15.3%, stage I; 18.2%, stage II; and 13.9%, stage III). Children younger than 11 months were more likely to develop AKI (P < 0.005). Longer cardiopulmonary bypass time was associated with an increased risk of AKI (P < 0.05). pRIFLE identified AKI more frequently than AKIN (P < 0.0005). pRIFLE may help in the early identification of patient at risk for AKI and seems to be more sensitive in pediatric patients (P < 0.05). Any degree of AKI in both classifications was associated with increased mortality (pRIFLE: OR, 15.1; AKIN: OR, 11.2; P = 0.007). CONCLUSION: pRIFLE identified AKI more frequently than the AKIN criteria. pRIFLE identified patients at risk for AKI earlier, and was more sensitive in pediatric patients. Any degree of AKI in both classifications was associated with increased mortality. Both sets of criteria had the same association with mortality.

Predictors of Early Extubation After Pediatric Cardiac Surgery: A Single-Center Prospective Observational Study.

This prospective, observational, single-center study aimed to determine the perioperative predictors of early extubation (<24 h after cardiac surgery) in a cohort of children undergoing cardiac surgery. Children aged between 1 month and 18 years who were consecutively admitted to pediatric intensive care unit after cardiac surgery for congenital heart disease between January 2012 and June 2014. Ninety-nine patients were qualified for inclusion during the study period. The median duration of mechanical ventilation was 20 h (range 1-480), and 64 patients were extubated within 24 h. Four of them failed the initial attempt at extubation, and the success rate of early extubation was 60.6 %. Older patient age (p = .009), greater body weight (p = .009), absence of preoperative pulmonary hypertension (p = .044), lower RACHS-1 category (OR, 3.8; 95 % CI 1.35-10.7; p < .05), shorter cardiopulmonary bypass (p = .008) and cross-clamp (p = .022) times, lower PRISM III-24 (p < .05) and PELOD (p < .05) scores, lower inotropic score (p < .05) and vasoactive-inotropic score (p < .05), and lower number of organ failures (OR, 2.26; 95 % CI 1.30-3.92; p < .05) were associated with early extubation. Our study establishes that early extubation can be accomplished within the first 24 h after surgery in low- to medium-risk pediatric cardiac surgery patients, especially in older ones undergoing low-complexity procedures. A large prospective multiple institution trial is necessary to identify the predictors and benefits of early extubation and to facilitate defined guidelines for early extubation.

Surgical Treatment of Isolated Interrupted Aortic Arch in a Young Female Diagnosed during Pregnancy.

Interrupted aortic arch (IAA) is a very rare pathology characterized by luminal discontinuity between ascending and descending aorta. IAA is commonly treated in pediatric ages, but the surgery is rarely used for adult patients. In this case report, we aimed to present a successful surgery in a young woman in whom IAA was diagnosed during pregnancy.

Does surgically induced right bundle branch block really effect ventricular function in children after ventricular septal defect closure?

In this prospective study, we aimed to assess left and right ventricular function in terms of the presence of right bundle branch block (RBBB) in the cases with repaired ventricular septal defect (VSD). Fifty-three patients who had VSD surgery at least 1-year preceding admission and 52 healthy controls were enrolled into the study. All the participants underwent electrocardiographic and echocardiographic examination. The cases with RBBB were determined. The conventional and tissue Doppler echocardiographic measurements of the patients with and without RBBB were compared with each other and healthy controls. Twenty-eight of VSD repair groups were male and 25 were female. Control group consisted of 30 males and 22 females. The mean age of the study and control groups was 7.5 ± 5.0 and 6.9 ± 4.3 years, respectively. RBBB was detected in 20 of 53 (37.7 %) operated patients. The only significant difference between the cases with and without RBBB was decreased right ventricular fractional area change (%) in the former group (33 ± 7 vs. 39 ± 5 p < 0.05). When compared to controls, operated group had statistically lower [corrected] tricuspid annular plane systolic excursion (p < 0.05), lower systolic, early diastolic, and late diastolic myocardial velocities, higher left and right ventricular myocardial performance indices, irrespective of the presence of RBBB. The ratios of mitral or tricuspid inflow to left or right ventricular myocardial in early diastolic velocities measured from lateral annular levels were increased in operated group (all p values <0.05). In conclusion, RBBB in the cases with surgical VSD repair might be associated with right ventricular dysfunction. Biventricular systolic and diastolic dysfunction may develop following VSD repair irrespective of the presence of RBBB. Tissue Doppler-derived myocardial performance indices are useful in detection of those subclinical dysfunctions.

Surgical repair of lower extremity vascular injuries in children: two cases.

The use of percutaneous devices is commonplace for the treatment of many congenital heart defects. However, there are some situations where procedure-related complications are encountered and surgical help is required to ameliorate this issue. Vascular injury due to transcatheter intervention is a significant and challenging complication and occasionally requires surgical approach. In this case report, we aimed to present successful surgical management of vascular injuries associated with percutaneous interventions in children.

Coronary artery bypass grafting in a Behçet's disease patient.

Behçet's syndrome is a chronic, multisystemic, inflammatory, vasculitic disorder characterised by oral aphta, ocular lesions, genital ulcers and the involvement of other systems. Although vascular involvement is seen frequently, coronary artery disease is extremely rare in Behçet's disease and it is generally treated with invasive or conservative procedures. In this case, we aimed to present a successful bypass grafting of three vessels using cardiopulmonary bypass in a patient with Behçet's disease.

Middle aortic syndrome in a teenager.

Middle aortic syndrome (MAS) is a rare pathology that involves diffuse/segmental narrowing of the distal thoracic or abdominal aorta. The most common clinical manifestation is severe hypertension, which requires multiple antihypertensive medications and/or surgical repair. We report the surgical repair of MAS in a 14-year-old male.

Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome.

Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome is a rare autosomal recessive congenital disorder that includes childhood-onset camptodactyly, synovial hyperplasia-related arthropathy, progressive coxa vara deformity and noninflammatory pericarditis. A seven-year-old male patient had a diagnosis of CACP. He had pericardial effusion and underwent surgical tube drainage. CACP syndrome is seen very rarely, and differential diagnosis is very important. CACP is usually treated medically, but surgery may sometimes be preferred, as in our patient.

Left ventricular myxoma producing cardiac failure.

INTRODUCTION: Seventy-five percent of primary cardiac tumors are benign, and most are myxomas. Seventy-five percent of myxomas originate from the left atrium, and 2.5% arise from the left ventricle. Heart failure is a rare complication of myxoma. CASE: A 54-year-old male patient with chronic obstructive pulmonary disease was admitted to the pulmonology department with a diagnosis of pneumonia and congestive heart failure during hospitalization. An echocardiography evaluation revealed a mobile mass (3.3 cm X 1.2 cm) in the left ventricle. The measured ejection fraction was 22%. Transthoracic and transesophageal echocardiography and magnetic resonance imaging examinations confirmed the presence of a myxoma in the left ventricle. The myxoma was a hanging mass with a stalk on the interventricular septum near the anterior mitral valve annulus. We visualized the gelatinous fragile mass on the septum; we then extracted the myxoma via a transaortic approach with the patient on cardiopulmonary bypass. The patient was discharged 10 days after surgery. DISCUSSION: Myxoma is treated by early surgical resection because of the potential for serious complications. Left ventricular myxomas have been reported to lead to a silent heart failure. This case is important because of its location and the patient's resultant heart failure.

An extremely rare complication of congenital heart surgery: interventricular septal hematoma.

We report a rare case of interventricular septal hematoma after patch closure of a perimembranous ventricular septal defect in a 10-month-old infant. Intraoperative transesophageal echocardiography was not performed. Routine transthoracic echocardiography at the 1st postoperative hour showed a huge intramural hematoma causing severe thickening of the ventricular septum. The patient's hemodynamics were stable and surgical revision was not required. The patient recovered well without complication.

The efficacies of modified mechanical post conditioning on myocardial protection for patients undergoing coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) with cardioplegic cardiac arrest and cardiopulmonary bypass (CPB) is associated with myocardial injury. The aim of this study was to investigate whether a modified mechanical post-conditioning (MMPOC) technique has a myocardial protective effect by enhancing early metabolic recovery of the heart following revascularization. METHODS: A prospective, randomized trial was conducted at a single-center university hospital performing adult cardiac surgery. Seventy-nine adult patients undergoing first-time elective isolated multivessel coronary artery bypass grafting were prospectively randomized to MMPOC or control group. Anesthetic, cardiopulmonary bypass, myocardial protection, and surgical techniques were standardized. The post reperfusion cardiac indices, inotrope use and biochemical-electrocardiographic evidence of myocardial injury were recorded. The incidence of postoperative complications was recorded prospectively. RESULTS: Operative characteristics, including CPB and aortic cross-clamp time, were similar between the two groups (p>0.05). The MMPOC group had lower troponin I and other cardiac biomarkers level post CPB and postoperatively, with greater improvement in cardiac indices (p<0.001). MMPOC shortened post surgery hospitalization from 9.1 ± 2.1 to 7.5 ± 1.6 days (p<0.001). CONCLUSIONS: MMPOC technique promotes early metabolic recovery of the heart during elective CABG, leading to better myocardial protection and functional recovery.

Native valve Brucella endocarditis.

OBJECTIVE: Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis. MATERIAL AND METHOD: Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography. RESULTS: On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months. DISCUSSION: In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery.

PURPOSE: To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis. METHODS: Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients. RESULTS: The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group. CONCLUSIONS: Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.