Effect of steroids on inflammatory markers and clinical parameters in congenital open heart surgery: a randomised controlled trial.

BACKGROUND: Cardiopulmonary bypass is associated with systemic inflammatory response. Steroids suppress this response, although the therapeutic evidence remains controversial. We hypothesised that intravenous steroids in children undergoing open-heart surgery would decrease inflammation leading to better early post-operative outcomes. We conducted a randomised controlled trial to evaluate the trends in the levels of immunomodulators and their effects on clinical parameters. OBJECTIVE: To assess the effects of intravenous steroids on early post-operative inflammatory markers and clinical parameters in children undergoing open-heart surgery. MATERIALS AND METHODS: A randomised controlled trial involving 152 patients, from one month up to 18 years of age, who underwent open-heart surgery for congenital heart disease from April 2010-2012 was carried out. Patients were randomised and administered either three scheduled intravenous pulse doses of dexamethasone (1 mg/kg) or placebo. Blood samples were drawn at four time intervals and serum levels of inflammatory cytokines - Interleukin-6, 8, 10, 18, and tumour necrosis factor-alpha - were measured. Clinical parameters were also assessed. RESULTS: Blood cytokine levels were compared between the dexamethasone (n=65) and placebo (n=64) groups. Interleukin-6 levels were lower at 6 and 24 hours post-operatively (p<0.001), and Interleukin-10 levels were higher 6 hours post-operatively (p<0.001) in the steroid group. Interleukin-8, 18, and tumour necrosis factor-alpha levels did not differ between the groups at any time intervals. The clinical parameters were similar in both the groups. CONCLUSION: Dexamethasone caused quantitative suppression of Interleukin-6 and increased Interleukin-10 activation, contributing to reduced immunopathology, but it did not translate into clinical benefit in the short term.

Successful surgical intervention of total anomalous pulmonary venous drainage in the third decade of life.

Total anomalous pulmonary venous drainage (TAPVD) accounts for approximately 1.5% of all congenital heart diseases. It is usually diagnosed in the neonatal period and is rarely seen in adults. We report an unusual case of a patient with TAPVD who was successfully treated at the age of 28 years. We believe that this is the oldest person in the South Asian literature to undergo surgical correction of TAPVD.

Successful Repair of Complete Atrio-ventricular Septal Defect at the Beginning of the Second Decade.

Complete atrio-ventricular septal defects (CAVSD) are present in about 3% of children born with congenital heart pathologies. They usually require early surgical correction, mostly in infancy, and surgery is considered to be the gold standard. It is unlikely that anyone would survive beyond the first years without severe morbidity. However, we report a case of a Pakistani girl who underwent successful surgical repair of CAVSD at the age of 11.

Earlier surgical intervention in congenital heart disease results in better outcome and resource utilization.

BACKGROUND: Congenital heart disease (CHD) accounts for a major proportion of disease in the pediatric age group. The objective of the study was to estimate the cost of illness associated with CHD pre, intra and postoperatively; among patients referred to a tertiary care hospital in Karachi, Pakistan. This is the first study conducted to estimate the cost of managing CHD in Pakistan. METHODS: A prevalence based cost of illness study design was used to estimate the cost of cardiac surgery (corrective & palliative) for congenital heart defects in children ≤ 5 years of age from June 2006 to June 2009. A total of 120 patients were enrolled after obtaining an informed consent and the data was collected using a pre-tested questionnaire. RESULTS: The mean age at the time of surgery in group A (1-12 mo age) was 6.08 ± 2.80 months and in group B (1-5 yrs) was 37.10 ± 19.94 months. The cost of surgical admission was found to be significantly higher in the older group, p = 0.001. The total number and cost of post-operative outpatient visits was also higher in group B, p = 0.003. Pre and post operative hospital admissions were not found to be significantly different among the two groups, p = 0.166 and 0.627, respectively. The number of complications were found to be different between the two groups (p = 0.019). Majority of these were contributed by hemorrhage and post-operative seizures. CONCLUSION: This study concluded that significant expenditure is incurred by people with CHD; with the implication that resources could be saved by earlier detection and awareness campaigns.

Conduit from hypoplastic right ventricle to pulmonary artery in tricuspid atresia.

Tricuspid atresia with transposition of the great arteries produces single ventricle physiology. Ultimate goals of neonatal palliative operations are to provide optimum anatomic and physiologic conditions for a Fontan procedure. A modification of the Norwood procedure is reported, with an aorto-pulmonary anastomosis, utilizing the hypoplastic right ventricle as the pulmonary outflow conduit, avoiding a left ventriculotomy and preserving its function with excellent recovery. We believe this technique has not been previously published in the English literature.