Short-term exposure to ambient fine particulate pollution aggravates ventilator-associated pneumonia in pediatric intensive care patients undergoing cardiovascular surgeries.

BACKGROUND: Ambient air pollutants can be hazardous to human health, especially for vulnerable children. The impact of ambient air pollutant exposure before and during intensive care unit (ICU) stays on the development of ventilator-associated pneumonia (VAP) in critically ill children has not been established. We aimed to determine the correlations between short-term exposures to ambient fine particulate matter (PM2.5) and VAP in pediatric cardiac surgery patients in the ICU, and explore the effect of delayed exposure. METHODS: The medical record of 1755 child patients requiring artificial ventilation in the ICU between December 2013 to December 2020, were analyzed. The daily average concentrations of particulate matters (PM2.5 and PM10), sulfur dioxide (SO2), and ozone (O3) were calculated from public data. Interactions between these pollutants and VAP were simulated with the distributed lag non-linear model. RESULTS: Three hundred forty-eight cases (19.829%) of VAP were identified in this study, while the average concentrations of PM2.5, PM10, O3 and SO2 were 58, 118, 98 and 26 µg/m3, respectively. Exposure to increased levels of PM2.5 two days prior (lag 2-day) to VAP diagnosis is significantly correlated with an enhanced risk for VAP development. Even a slight increase of 10 µg/m3 in PM2.5 can translate to a 5.4% increase in VAP incidence (95% CI: 1.4%-9.5%) while the VAP incidence increased to 11.1% (95%CI: 4.5-19.5%) when PM2.5 concentration is well below the National Ambient Air Quality standard (NAAQS) of 50 µg/m3. The association was more pronounced in those aged below 3-months, with low body mass index or suffered from pulmonary arterial hypertension. CONCLUSION: Short-term PM2.5 exposure is a significant risk for development of VAP in pediatric patients. This risk is present even with PM2.5 levels below the NAAQS. Ambient PM2.5 may represent a previously unrecognized risk factor for pneumonia and the current environmental pollution standards need to be reevaluated to consider susceptible populations. TRIAL REGISTRATION: The trial was registered with the National Clinical Trial Center: The correlation between ambient air pollution and the complications in ICU underwent cardiac surgery. TRIAL REGISTRATION NUMBER: ChiCTR2000030507. Date of registration: March 5, 2020. URL of trial registry record: http://www.chictr.org.cn/index.aspx .

Highly selective NH3 gas sensor based on Co(OH)2/Ti3C2T x nanocomposites operating at room temperature.

Ammonia (NH3) is a common air pollutant and is a biomarker for kidney disease. Therefore, the preparation of ammonia gas sensors with high sensitivity, good selectivity and low operating temperature is of great importance for health protection. Using the in situ electrostatic self-assembly approach, a chemoresistive gas sensor based on Co(OH)2/Ti3C2T x hybrid material was created in this study. The prepared samples were characterized by XRD, XPS, TEM, BET and other testing methods for structure, surface topography and elements. These samples were fabricated into sensors, and the gas sensing properties of the materials were investigated under different test conditions. The results show that the gas response value of the C/M-2 sensor is up to about 14.7%/100 ppm, which is three times the response value of the sensor made of pure MXene to NH3. In addition, the Co(OH)2/Ti3C2T x hybrid sensors exhibit excellent repeatability, high sensitivity under low concentration (less than 5 ppm), fast response/recovery time (29 s/49 s) and long-time stability, which indicates their promising utility in the IoT field.

The Clinical Characteristics of 88 Patients with Total Anomalous Pulmonary Venous Connection and Risk Factors Associated with Early Postoperative Death.

Objective: This study aimed to analyze the outcomes and risk factors of early postoperative death (within 30 days after surgery) in a single-center after repair of total anomalous pulmonary venous connection (TAPVC). Methods: The clinical data of 88 children who had been diagnosed with TAPVC and underwent radical operation in the Shandong Provincial Hospital Affiliated with Shandong First Medical University (China) from January 2015 to July 2021 were retrospectively analyzed. All the patients were divided into the survival group (n = 81) and the death group (n = 7) for the analysis of preoperative and postoperative clinical data. The variables associated with early postoperative death were statistically analyzed to obtain the risk factors for early postoperative death of TAPVC. Results: Of the 88 patients included in this study, 7 (7.95%) patients died early, including 4 supracardiac and 3 infracardiac cases. Recurrent pulmonary vein obstruction occurred in 2 patients after discharged from hospital, and both were intracardiac TAPVC. Delayed death occurred in 2 children, both of which were intracardiac TAPVC cases. According to univariate analysis, the risk factors statistically significantly associated with the early postoperative death included infracardiac type (P = 0.08), preoperative maximum pulmonary vein flow velocity (P = 0.031), preoperative mechanical ventilation (P = 0.043), preoperative maximum pulmonary artery pressure (P = 0.000), intraoperative cardiopulmonary bypass time (P = 0.003) and intraoperative aortic cross-clamp time (P = 0.000). Conclusion: Infracardiac type of TAPVC, preoperative maximum pulmonary vein flow velocity, preoperative mechanical ventilation, preoperative maximum pulmonary artery pressure, intraoperative cardiopulmonary bypass time and aortic cross-clamp time are the risk factors for early postoperative death.

A clinical prediction model to estimate the risk for coarctation of the aorta: From fetal to newborn life.

AIM: A prenatal diagnosis of coarctation of the aorta (CoA) is challenging. This study aimed to develop a coarctation probability model incorporating prenatal cardiac sonographic markers to estimate the probability of an antenatal diagnosis of CoA. METHODS: We reviewed 89 fetuses as an investigation cohort with prenatal suspicion for CoA and categorized them into three subgroups: severe CoA: symptomatic CoA and surgery within the first 3 months; mild CoA: surgery within 4 months to 1 year (29); and false-positive CoA: not requiring surgery (45). Logistic regression was used to create a multiparametric model, and a validation cohort of 86 fetuses with suspected CoA was used to validate the model. RESULTS: The prediction model had an optimal criterion >0.25 (sensitivity of 97.7%; specificity of 59.1%), and the area under the receiver operator curve was 0.85. The parameters and their cut-off values were as follows: left common carotid artery to left subclavian artery distance/distal transverse arch (LCCA-LSCA)/DT Index >1.77 (sensitivity 62%, specificity 88%, 95% confidence interval [CI]: 0.6-0.8), and z-score of AAo peak Doppler > -1.7 (sensitivity 77%, specificity 56%, 95% CI: 0.6-0.8). The risk assessment demonstrated that fetuses with a model probability >60% should have inpatient observation for a high risk of CoA, whereas fetuses with a model probability <15% should not undergo clinical follow-up. CONCLUSION: The probability model performs well in predicting CoA outcomes postnatally and can also improve the accuracy of risk assessment. The objectivity of its parameters may allow its implementation in multicenter studies of fetal cardiology.

Epicardial mesothelial cyst originating from the roof of the left atrium: a case report.

Background: Epicardial mesothelial cysts are cysts that are attached to the epicardium within the pericardial cavity. Reports on epicardial mesothelial cysts are rare, and limited studies have investigated their surgical management. Here, we report the rare case of an epicardial cyst originating from the roof of the left atrium. Case summary: A 73-year-old man with dyspnoea on exertion and lower limb oedema was diagnosed with a giant cyst (diameter, 7 cm × 4.5 cm) in the pericardial cavity using computed tomography. Off-pump surgery was performed with successful resection of the cyst with a pedicle connected to the roof of the left atrium. Histological examination confirmed the mesothelial origin of the tumour cells. Conclusion: Cysts rarely develop within the pericardial cavity, especially an epicardial cyst. The few studies exploring this disease have suggested that patients with this condition may be asymptomatic or have mild breathlessness or cardiac tamponade, which might be occasionally or incidentally diagnosed. Sufficient preoperative evaluation, particularly involving the coronary artery, is essential, and a rational way of surgery should be planned considering all factors.

Surgical repair of an aortico-left ventricular tunnel with Takayasu's arteritis.

Aortico-left ventricular tunnel is a very rare congenital cardiac anomaly, always arises from the right coronary sinus and enters the left ventricle. However, aortico-left ventricular tunnel associated with Takayasu's arteritis has not been described so far in the literature. Here, we present an unusual case of aortico-left ventricular tunnel associated with Takayasu's arteritis in a 44-year-old man.

Early and Intermediate-Term Results for the Combined Superior Approach Correction of Supracardiac Total Anomalous Pulmonary Venous Connection in Neonatal Patients.

BACKGROUND: There are different surgical approaches used for repairing a supracardiac total anomalous pulmonary venous connection (TAPVC), with different results. This retrospective study evaluated the outcomes of surgical repair for supracardiac TAPVC through the combined superior approach in neonatal patients. METHODS: Medical records were retrospectively reviewed and 21 neonates who underwent supracardiac TAPVC repair with the combined superior approach between July 2014 and January 2020 were identified. There were 13 males and eight females. RESULTS: The patients' median age was 20.6±8.9 days (range, 3-27). The median weight was 3.1±0.39 kg (range, 2.5-3.7) The median aortic cross-clamp and cardiopulmonary bypass times were 49.3±19.5 minutes (range, 27-86) and 91.1±23.7 minutes (range, 57-146). They were two deaths during the intensive care unit stay. One (1) patient died 2 months after discharge, the other remaining patients had no pulmonary venous obstruction (PVO) at the 6-month and intermediate-term follow-ups. CONCLUSIONS: The combined superior approach is a useful method for repair of neonatal critical supracardiac TAPVC. This technique may be more helpful in preventing early postoperative anastomotic stenosis and contribute to an improved patient outcome.

Infected Anastomotic Pseudoaneurysm after Aortic Valve Replacement with Annular Enlargement.

Anastomotic pseudoaneurysm remains one of the main life-threatening complications of cardiac and thoracic aorta surgery. We report a rare case of infected pseudoaneurysm at the anastomotic line found during follow-up. Blood culture results suggested Enterococcus faecium infection. Transthoracic echocardiography and computed tomography scans revealed the presence of a pseudoaneurysm of the ascending aorta. The pseudoaneurysm was resected and the ascending aorta was reconstructed with an artificial vascular patch without complications. Reducing the anastomotic tension, with complete hemostasis at the anastomotic incision, is the most important means of preventing the formation of pseudoaneurysm.

Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial.

BACKGROUND: The administration of levosimendan prophylactically to patients undergoing cardiac surgery remains a controversial practice, and few studies have specifically assessed the value of this approach in pediatric patients. This study therefore sought to explore the safety and efficacy of prophylactic levosimendan administration to pediatric patients as a means of preventing low cardiac output syndrome (LCOS) based upon hemodynamic, biomarker, and pharmacokinetic readouts. METHODS: This was a single-center, double-blind, randomized, placebo-controlled trial. Patients ≤ 48 months old were enrolled between July 2018 and April 2019 and were randomly assigned to groups that received either placebo or levosimendan infusions for 48 h post-surgery, along with all other standard methods of care. LCOS incidence was the primary outcome of this study. RESULTS: A total of 187 patients were enrolled, of whom 94 and 93 received levosimendan and placebo, respectively. LCOS incidence did not differ significantly between the levosimendan and placebo groups (10 [10.6%] versus 18 [19.4%] patients, respectively; 95% confidence interval [CI] 0.19-1.13; p = 0.090) nor did 90-day mortality (3 [3.2%] versus 4 [4.3%] patients, CI 0.14-3.69, p = 0.693), duration of mechanical ventilation (median, 47.5 h and 39.5 h, respectively; p = 0.532), ICU stay (median, 114.5 h and 118 h, respectively; p = 0.442), and hospital stay (median, 20 days and 20 days, respectively; p = 0.806). The incidence of hypotension and cardiac arrhythmia did not differ significantly between the groups. Levels of levosimendan fell rapidly without any plateau in plasma concentrations during infusion. A multiple logistic regression indicated that randomization to the levosimendan group was a predictor of LCOS. CONCLUSIONS: Prophylactic levosimendan administration was safe in pediatric patients and had some benefit to postoperative hemodynamic parameters, but failed to provide significant benefit with respect to LCOS or 90-day mortality relative to placebo. TRIAL REGISTRATION: Name of the registry: Safety evaluation and therapeutic effect of levosimendan on the low cardiac output syndrome in patients after cardiopulmonary bypass. TRIAL REGISTRATION NUMBER: ChiCTR1800016594. Date of registration: 11 June 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx.

Protective effect of HTK solution on postoperative pulmonary function in infants with CHD and PAH.

OBJECTIVE: In the present study, we aimed to investigate the effect of pulmonary arterial perfusion (PAP) with Histidine-tryptophan-ketoglutarate (HTK) on lung protection in infants with congenital heart disease (CHD) and pulmonary arterial hypertension (PAH) after cardiopulmonary bypass (CPB). METHODS: Fifty infant patients with CHD and PAH at our hospital from January, 2016 to February, 2017 were randomly divided into control group and HTK group. The levels of interleukin-6 (IL-6), malondialdehyde (MDA), and endothelin-1 (ET-1) in serum were detected using ELISA Kit. Oxygen index (OI) and respiratory index (RI) were calculated at each time point. The time of postoperative mechanical ventilation and ICU stay was counted, and the right lower lung tissues in patients were taken for pathological examination. RESULTS: Compared with preanesthesia, the levels of IL-6, MDA, and ET-1 in the two groups were significantly increased after CPB, and their levels in HTK group were significantly lower than that in control group. Moreover, OI in control group decreased markedly and RI in control group increased significantly after CPB. Compared with control group, the postoperative mechanical ventilation time, postoperative ICU stay, and total hospital stay in HTK group were markedly short. In addition, inflammatory cells infiltration decreased and pulmonary interstitial showed mild edema in HTK group. CONCLUSION: PAP with HTK could effectively reduce CPB-induced lung injury and improve lung function.

Isolated Right Ventricular Apical Trabecular Hypoplasia: A Case Report.

Right ventricular (RV) hypoplasia with isolated myocardial disease and complete absence of RV trabeculae is a rare congenital heart disease, the current treatment of which is ineffective. Here, a rare case is presented of a middle-aged female patient with RV hypoplasia complicated by tricuspid regurgitation, right atrial thrombus, and atrial fibrillation. The patient was treated with a one-and-a-half ventricular repair, and showed significant improvements in cardiac function and physical activity tolerance. The study results suggest that this surgical approach can significantly improve the prognosis of an adult patient with isolated RV hypoplasia.

Application of prospective ECG-gated high-pitch 128-slice dual-source CT angiography in the diagnosis of congenital extracardiac vascular anomalies in infants and children.

PURPOSE: To investigate the value of prospective ECG-gated high-pitch 128-slice dual-source CT (DSCT) angiography in the diagnosis of congenital extracardiac vascular anomalies in infants and children in comparison with transthoracic echocardiography (TTE). METHODS: Eighty consecutive infants or children clinically diagnosed of congenital heart disease and suspected with extracardiac vascular anomaly were enrolled, and 75 patients were finally included in this prospective study. All patients underwent prospective ECG-gated high-pitch DSCT angiography after TTE with an interval of 1-7 days. The diagnostic accuracy and sensitivity of high-pitch DSCT angiography and TTE were compared according to the surgical/CCA findings. The image quality of DSCT was assessed using a five-point scale. The effective radiation dose (ED) was calculated. RESULTS: A total of 17 congenital heart diseases and 162 separate extracardiac vascular anomalies were confirmed by surgical/CCA findings in 75 patients. The diagnostic accuracy of high-pitch DSCT angiography and TTE was 99.67% and 97.89%, respectively. The sensitivity of high-pitch DSCT angiography and TTE was 97.53% and 79.62%, respectively. There was significant difference regarding to the diagnostic accuracy and the sensitivity between high-pitch DSCT angiography and TTE (χ2 = 23.561 and 28.013, P<0.05). The agreement on the image quality scoring of DSCT between the two observers was excellent (κ = 0.81), and the mean score of image quality was 4.1±0.7. The mean ED of DSCT was 0.29±0.08 mSv. CONCLUSIONS: Prospective ECG-gated high-pitch 128-slice DSCT angiography with low radiation dose and high diagnostic accuracy has higher sensitivity compared to TTE in the detection of congenital extracardiac vascular anomalies in infants and children.

Impact of sinogram affirmed iterative reconstruction (SAFIRE) algorithm on image quality with 70 kVp-tube-voltage dual-source CT angiography in children with congenital heart disease.

PURPOSE: To compare the image quality and diagnostic accuracy between sinogram affirmed iterative reconstruction (SAFIRE) algorithm and filtered back projection (FBP) reconstruction algorithm at 70 kVp-tube-voltage DSCT angiography in children with congenital heart disease (CHD). MATERIALS AND METHODS: Twenty-eight patients (mean age: 13 months; range: 2-48 months; male: 16; female: 12; mean weight: 8 kg) with CHD underwent 70 kVp DSCT angiography. Imaging data were reconstructed with both FBP and SAFIRE algorithms. Subjective image quality was evaluated on a five-point scale. The parameters of image noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) on the objective image quality were compared for the two reconstruction algorithms. Surgery was performed in 20 patients, whereas conventional cardiac angiography (CCA) was performed in 8 patients. The diagnostic accuracy was evaluated on the surgical and/or CCA findings. The effective radiation doses were calculated. RESULTS: Compared to FBP algorithm, SAFIRE algorithm had significantly higher scores for subjective image quality (P<0.05), and lower image noise (P<0.05) as well as higher SNR & CNR values (P<0.05). There was no significant difference in the diagnostic accuracy between the FBP and SAFIRE algorithm (χ2 = 1.793, P>0.05). The mean effective dose for 70 kVp DSCT angiography was 0.30±0.13 mSv. CONCLUSIONS: The SAFIRE algorithm can significantly reduce image noise and improve the image quality at 70 kVp DSCT angiography for the assessment of CHD in children.

[Medical treatment following successful separation of thoracopagus conjoined twins].

OBJECTIVE: To analyze and summarize the medical treatment experience following separation of thoracopagus conjoined twins. METHOD: The clinical manifestations and the medical therapy of a pair of thoracopagus conjoined twins were analyzed. The conjunction of the female twins was from 5 cm above the nipple to the umbilicus. They also suffered from complex congenital heart diseases. At the 17th day of their lives, they were surgically separated. One girl died after the operation, the other survived but experienced heart failure, sepsis and multiple organ dysfunction (including liver, blood and kidney et al). In order to protect or maintain the main organ function, the vital signs and the objective indexes were monitored continually, such as blood routine test, C reactive protein, hepatorenal function, bacterial culture, and galactomannan test, blood gas analysis and chest radiogram. CONCLUSION: It is important to protect the main organ function and prevent or control infection. The early surgical correction of congenital heart disease may contribute to recovery of the children.

Transplantation of microencapsulated Schwann cells and mesenchymal stem cells augment angiogenesis and improve heart function.

Because of their plasticity and availability, bone-marrow-derived mesenchymal stem cells (MSC) are a potential cell source for treating ischemic heart disease. Schwann cells (SC) play a critical role in neural remodeling and angiogenesis because of their secretion of cytokines such as vascular endothelial growth factor (VEGF). Cell microencapsulation, surrounding cells with a semipermeable polymeric membrane, is a promising tool to shelter cells from the recipient's immune system. We investigated whether transplantation of microencapsulated SC (MC-SC) and MSC together could improve heart function by augmenting angiogenesis in acute myocardial infarction (AMI). Sprague-Dawley rats with ligation of the left anterior descending artery to induce AMI were randomly divided for cell transplantation into four groups-MC-SC+MSC, MC+MSC, MSC, MC-SC, and controls. Echocardiography was performed at 3 days and 2 and 4 weeks after AMI. Rat hearts were harvested on day 28 after transplantation and examined by immunohistochemistry and western blot analysis. Echocardiography revealed differences among the groups in fractional shortening and end-systolic and end-diastolic dimensions (P < 0.05). The number of BrdU-positive cells was greater with MC-SC+MSC transplantation than the other groups (P < 0.01). The vessel density and VEGF level in the infarcted zone was significantly increased with MC-SC+MSC transplantation (P < 0.05). These results show that transplanting a combination of MC-SC and MSC could augment angiogenesis and improve heart function in AMI.

Modified edge-to-edge technique for correction of congenital mitral regurgitation in infants and children.

Since 2008, 28 patients with congenital mitral regurgitation have undergone mitral valve repair with a modified edge-to-edge technique at our institution. The regurgitant mitral leaflet was sutured with a pledget-reinforced, horizontal mattress suture with No. 4-0 polypropylene on the ventricle side and a pledget-reinforced mattress suture with Gore-Tex sutures (W.L. Gore & Associates, Flagstaff, AZ) and Dacron pledgets (Chest, Shanghai) placed on the anterior and posterior annulus corresponding to the edge-to-edge suturing site. Early results are encouraging, but a longer follow-up is needed.