Left Ventricular Pseudoaneurysm: Unexpected Sequel of Tamponade-Complicated Infectious Pericarditis in Infancy.

Left ventricular pseudoaneurysm (LV-PsA) is a critical finding that could result in a fatal outcome. It may complicate myocardial infarction, cardiac surgery, trauma, or endocarditis but rarely follows pericarditis. We report a case of infectious pericarditis complicated by pericardial tamponade in an infant. After effusion drainage and medical therapy, a large LV-PsA was detected. Successful closure of the pseudoaneurysmá¾½s neck was accomplished using a Gore-tex patch.

Proximal Aortic Dilatation and Pulmonary Valve Replacement in Patients with Repaired Tetralogy of Fallot: Is There a Relationship? A Cardiac Magnetic Resonance Imaging Study.

Aortopathy is a known complication whose incidence is growing within the population of tetralogy of Fallot (TOF) patients. Its pathology and relationship with other comorbidities remain unclear. This study was designed to determine the prevalence and predictors of proximal aortic dilatation after TOF repair. We retrospectively investigated all patients who underwent follow-up cardiac magnetic resonance imaging (CMR; at least 4 years after TOF repair) between March 2004 and December 2019. The dimensions at the ascending aorta (AAo) and sinus of Valsalva (SoV) levels were measured. Aortic dilatation was defined as an internal aortic diameter that was >2 standard deviation of the previously published normal values. We included 77 patients (mean age 28.9 ± 10.5 years, 41.5% female, mean follow-up of 24.5 ± 8.1 years). AAo and SoV were dilated in 19 (24.6%) and 43 (55.8%) patients, respectively. Patients with dilated AAo and SoV were older during the corrective surgery (p < 0.001 and p = 0.004, respectively) and during CMR (p = 0.002 and 0.024, respectively) than patients without AAo and SoV dilatation. Patients of the dilated AAo group were more likely to have prior palliative shunt (p = 0.008), longer shunt duration (p = 0.005), and a higher degree of aortic valve regurgitation (AR) fraction (p < 0.001) and to undergo pulmonary (PVR) and/or aortic valve replacement (p < 0.001 and p = 0.013, respectively). PVR (p = 0.048, odds ratio = 6.413, and 95% CI = 1.013-40.619) and higher AR fraction (p = 0.031, odds ratio = 1.194, and 95% CI = 1.017-1.403) were independent predictors for AAo dilatation. Aortopathy is a common progressive complication that may require reintervention and lifelong follow-up. Our study shows that proximal aortic dilatation may be attributed to factors that increase the volume overload across the proximal aorta, including late corrective surgery and palliative shunt. We also found that PVR and higher AR fraction are independent predictors of AAo dilatation.

The direct comparison of inhaled versus intravenous levosimendan in children with pulmonary hypertension undergoing on-cardiopulmonary bypass cardiac surgery: A randomized, controlled, non-inferiority study.

STUDY OBJECTIVE: Pulmonary arterial hypertension is commonly seen in children with left to right intracardiac shunts and affects the outcomes of cardiac surgery. Our study aimed to compare the efficacy of inhaled levosimendan (LS) versus intravenous LS in reducing elevated pulmonary artery pressure (PAP) in children scheduled for cardiac surgery. DESIGN: Non-inferiority, prospective, randomized, blinded, controlled study. SETTING: Operative room and intensive care unit (ICU), institutional children's hospital of Mansoura Faculty of Medicine, Egypt. PATIENTS: 50 patients of either sex, aged 1 to 5 years undergoing surgical repair of intracardiac left to right shunt complicated by pulmonary hypertension were recruited for the study. INTERVENTIONS: In the intravenous LS group, patients received intravenous infusion of LS a rate of 0.1 µg/kg/min and in the inhaled LS group, LS (36 µg/kg/6 h) was delivered by nebulization. MEASUREMENTS: The primary endpoint was systolic PAP, while the secondary endpoints were the heart rate, mean arterial blood pressure, dose of norepinephrine, time to extubation and ICU length of stay. MAIN RESULTS: Both intravenous and inhaled routes of LS similarly reduced the high systolic PAP over all time points of measurement and intravenous LS was associated with higher heart rate, lower arterial pressure and the need for a higher dose of norepinephrine than the inhaled LS. CONCLUSION: Inhalation of LS is non-inferior to intravenous LS in reducing high PAP in children who underwent on-pump cardiac surgery and it is associated with less tachycardia and hypotension with reduced need for vasoactive drugs.

Challenges of Caring for Functionally Single Ventricle Patients in Africa.

Surgical palliation has remarkably improved survival of functionally single ventricle (FSV) patients born in developed nations but such outcomes have not occurred in Africa. The poor care coverage for FSV patients in Africa exists within the larger sphere of deficient health care for children born with congenital heart defects (CHDs) in Africa generally. This review takes the position that to improve health-care coverage for CHD patients on the continent, political priority is paramount. This can be attained with cohesive leadership for the CHD agenda, a guiding institution, and the mobilization of civil society to drive advocacy at national and international levels.

Status and Challenges of Care in Africa for Adults With Congenital Heart Defects.

The 54 countries in Africa have an estimated total annual congenital heart defect (CHD) birth prevalence of 300,486 cases. More than half (51.4%) of the continental birth prevalence occurs in only seven countries. Congenital heart disease remains primarily a pediatric health issue in Africa because of the deficient health-care systems: the adults with CHD made up just 10% of patients with CHD in Ghana, and 13.7% of patients with CHD presenting for surgery in Mozambique. With Africa's population projected to double in the next 35 years, the already deficient health systems for CHD care will suffer unbearable strain unless determined and courageous action is undertaken by the African leaders.

Isolated drainage of right superior vena cava into left atrium: A rare etiology of childhood central cyanosis.

Isolated right superior vena cava drainage into the left atrium (RSVC-LA) is an extremely rare anomaly in the absence of other cardiac or extracardiac abnormalities. The clinical and echocardiographic diagnosis is considered challenging. We report a female infant with cyanosis on crying who was diagnosed as isolated RSVC-LA using conventional and contrast echocardiography, but further confirmation was possible via multidetector CT. The surgical correction was performed with smooth postoperative recovery. In conclusion, isolated RSVC-LA must be in the differential diagnosis of cyanosis in the absence of intracardiac anomalies. Surgical correction is necessary management to guard against brain abscesses or paradoxical embolization.

The relation between hepatitis C virus and coronary heart disease.

It is well known that chronic hepatitis C is associated with insulin resistance and metabolic syndrome which are risk factors for atherosclerosis and coronary heart disease. As a result, chronic hepatitis C might be thought, through its association with metabolic syndrome, to increase the risk of myocardial infarction. However, unexpectedly it was found that HCV infection is not associated with an increased risk of myocardial infarction. We are providing here an hypothesis of the mechanism through which HCV infection does not increase the risk for myocardial infarction and also may be protecting against some cardiovascular risks that typically develop in many patients with metabolic syndrome who do not have chronic hepatitis C. The suggested mechanism includes factors that are normal consequences of chronic hepatitis, such as: significant decrease in cholesterol and LDL levels; defected blood clotting system; impaired myocardial function; decreased venous return and central venous pressure; increased nitric oxide and TNF alpha levels; and diminished cardiac beta receptors signal transduction. All these factors contribute to a protective effect against cardiac ischemia and coronary heart disease. We suggest further studies to investigate this hypothesis.

Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study.

To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.

Postoperative cardiac intensive care outcome for Down syndrome children.

OBJECTIVE: The purpose of this study is to review the postoperative intensive care unit (ICU) course, complications and outcome of Down's syndrome children undergoing surgical repair of congenital heart diseases (CHD). METHODS: A retrospective chart review analysis of intensive care course and outcome of Down syndrome children undergoing surgical repair of congenital heart diseases (CHD) from May 2000 to May 2004. The study was conducted in the Pediatric Cardiac ICU, King Abdul-Aziz Cardiac Center of National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. All Down's syndrome children who had surgical repair during the study period were included. RESULTS: During the study period, 80 patients (31 males and 49 females) with Down's syndrome had surgical repair of CHD. Their average weight was 5.8 +/- 0.3 kg and age was 11.7 +/- 1.5 months. Their primary surgical interventions were as follow: atrio-ventricular septal defect repair (44), ventricular septal defect closure (24), patent ductus arteriosus ligation (6), secundum atrial septal defect closure (3), and tetralogy of Fallot repair (3). Postoperative complications occurred in 19 patients (23%). Few patients had more than one complication. The compilations were as follow: 8 patients (10%) had sepsis, 3 (4%) required permanent pacemaker insertion, 4 (5%) had chylothorax, 2 (2.5%) had life threatening pulmonary hypertensive crisis with full recovery after proper managements, 5 (6%) needed prolong intubation, more than 7 days, and one patient (1.2%) required tracheostomy. All patients survived and were discharged home except one (1.2%) who expired 8 weeks after surgery from sepsis and multi-organ failure. CONCLUSION: Patients with Down's syndrome undergoing CHD repair had an acceptable postoperative morbidity and low mortality. Their results are comparable to non-Down's cardiac patients. From an ICU perspective, the majority of these patients do well postoperatively with good ICU outcome.

Acute effects of lobectomy on right ventricular ejection fraction and mixed venous oxygen saturation.

BACKGROUND: Traditional methods of assessing the operative risk for lung resection provide only a modest ability to predict postoperative morbidity and mortality. The aim of this study was to evaluate the effect of lobectomy on pulmonary hemodynamic and gas exchange variables using the RV thermodilution ejection fraction/oximetric catheter. METHODS: We evaluated the acute postoperative effects of lung resection on hemodynamic and gas exchange parameters in 30 patients. Anesthesia was induced with thiopentone sodium and maintained with midazolam, fentanyl and pipecuronium. Intubation was performed with a double-lumen, left-sided endobronchial tube for one lung ventilation. The hemodynamic and gas exchange parameters were recorded before and after induction of anesthesia, and two hours after lung resection. These parameters were also recorded after the classification of the patients according to the underlying lung pathology. RESULTS: Lobectomy was associated with significant hemodynamic changes and good maintenance of gas exchange variables. SVI, LVSWI and RVEF were significantly decreased in the early postoperative period after lung resection. MPAP, COP, CI, SVRI, PVRI, RVSWI, and RVEDVI showed no significant changes during the perioperative period. SVO2 showed a significant increase after lung resection when compared with preinduction values, while VO2 significantly decreased. SaO2, a-A PO2, QS-QT, DO2, and O2ER showed no significant changes during the perioperative period. CONCLUSIONS: We conclude that in the acute post-resection period (up to 2 hours postoperatively) there is right and left ventricular dysfunction with good maintenance of gas exchange.

Aortic arch advancement: the optimal one-stage approach for surgical management of neonatal coarctation with arch hypoplasia.

BACKGROUND: The optimal surgical treatment for neonatal coarctation with aortic arch hypoplasia (NCoAo/AAH) is controversial. Important long-term concerns include arch growth. We report our results obtained with a one-stage radical approach of coarctectomy and aortic arch advancement for NCoAo/AAH. METHODS: From June 1995 to December 2000, 65 newborns with NcoAo/AAH underwent coarctectomy and aortic arch advancement via a median sternotomy under deep hypothermic circulatory arrest. Patients were classified by diagnosis: group 1, isolated NCoAo/AAH (n = 13); group 2, NCoAo/AAH with ventricular septal defect (n = 20); and group 3, NCoAo/AAH with complex cardiac lesions (n = 32). RESULTS: The study population included 36 boys and 29 girls. Mean age was 13 +/- 1.7 days (range 1 to 43 days). Mild to moderate left ventricular outflow tract obstruction was present in 15 patients. Mean body weight was 3.4 +/- 0.1 kg (range 1.6 to 5 kg). Eight babies were premature. The mean Z value for the aortic arch was -4 +/- 0.3 (range -2 to -4.5) and for the isthmus -4.5 +/- 0.2 (range -3 to -7). Mean deep hypothermic circulatory arrest time was 28 +/- 2 minutes (range 14 to 60 minutes). Mean intensive care unit stay was 6 +/- 1 days (range 2 to 30 days). There were three early deaths (all in groups 2 and 3) and two late deaths (in group 3) (5-year actuarial survival, 91% +/- 7.9%). There was one recurrence (5-year actuarial freedom from recurrence, 98% +/- 4%). Peak Doppler velocity across the arch in the remaining patients was 1 +/- 0.1 m/s (range 0 to 2.2 m/s). CONCLUSIONS: Coarctectomy and aortic arch advancement is the optimal surgical method for management of NCoAo/AAH. It has low operative morbidity and mortality and a very low incidence of recoarctation or arch obstruction.