Anand K. Mishra

Histopathologic changes in ascending aorta and risk factors related to histopathologic conditions and aortic dilatation in patients with tetralogy of Fallot.

OBJECTIVE The purposes of this study were to evaluate the histologic characteristics of the aortic wall and the risk factors related to histopathology and aortic dilatation in patients undergoing intracardiac repair of tetralogy of Fallot. METHODS Operatively excised full-thickness aortic wall tissue from 98 consecutive patients undergoing intracardiac repair of tetralogy of Fallot aged 6 months to 47 years (mean 104.5 +/- 102.8 months; median 72 months) were studied by light microscopy. The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of loss of lamellar counts and multiple logistic regression models. RESULTS Twenty-five (25.5%) aortic tissue specimens were indicated as histologically normal and were used as normal controls. The incidence of elastic fragmentation, increased ground substance, medionecrosis, smooth muscle disarray, and fibrosis was 74.5%, 54%, 39.8%, 26.5%, and 57.1%, respectively. A lamellar count of less than 60 was associated with a sensitivity of 80% and a specificity of 87.67%. Area under the receiver operating characteristic curve indicated that 93.37% (standard error +/- 0.039) of the time the value of lamellar count was lower for the abnormal histopathology group than for the normal group (P < .001). The risk of aortic dilatation was 15.97 times higher in patients with histopathologically abnormal aorta. CONCLUSIONS The majority of aortic media of the ascending aorta in cyanotic tetralogy of Fallot indicates significant loss of lamellar units and pre-existing intrinsic aortopathy. The changes are present since infancy and are more pronounced in older patients subjected to long-standing cyanosis and volume overload and may account for or may coexist with the higher incidence of aortic dilatation encountered in these patients.

A suggested new surgical classification for mixed totally anomalous pulmonary venous connection.

The morphologic variations of mixed totally anomalous pulmonary venous connection are many and varied. In this review, we give an account of all cases previously described as mixed totally anomalous pulmonary venous connection, analyzing in detail those cases where an accurate anatomical description was provided. We identified 182 suitable cases, from 54 investigations, and reviewed the clinical presentation, anatomic variations, diagnostic features, and management of the patients described.Cross-sectional echocardiography, and cardiac catheterization, provided the necessary diagnostic information, and defined the anatomy before surgery in 139 patients. Magnetic resonance imaging and computerized tomographic angiography had been used for further clarification of the pulmonary venous anatomy. An obstructive pattern of drainage, involving one or more pulmonary veins, had been described in over half of the patients. We then grouped the lesions into categories that have a bearing on the appropriate surgical approach, discussing the appropriate repair for each group. For the overall group, the operative mortality remains high, at 22.9%. We submit that an increased appreciation of various types of mixed totally anomalous pulmonary venous connection may well contribute to improved future surgical management.

Effect of continuous paravertebral dexmedetomidine administration on intraoperative anesthetic drug requirement and post thoracotomy pain syndrome after thoracotomy: A randomized controlled trial

OBJECTIVES To assess the effect of paravertebral administration of dexmedetomidine as an adjuvant to local anesthetic on the intraoperative anesthetic drug requirement and incidence of post-thoracotomy pain syndrome. DESIGN Prospective, randomized, controlled, double-blind trial. SETTING Single university hospital. PARTICIPANTS The study comprised 30 patients who underwent elective thoracotomy and were assigned randomly to either the Ropin or Dexem group (n = 15 each). INTERVENTIONS All patients received the study medications through paravertebral catheter. Patients in the Ropin group received a bolus of 15 mL of 0.75% ropivacaine over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine at 0.1 mL/kg/hour. Patients in the Dexem group received 15 mL of 0.75% ropivacaine plus dexmedetomidine, 1 µg/kg bolus over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine plus 0.2 µg/kg/hour of dexmedetomidine at 0.1 mL/kg/hour. MEASUREMENTS AND MAIN RESULTS The primary outcome of the study was intraoperative anesthetic drug requirement. The secondary outcome was the incidence of post-thoracotomy pain syndrome 2 months after surgery. The amount of propofol required for induction of anesthesia was significantly less in the Dexem group (Dexem 49.33±20.51 v 74.33±18.40 in the Ropin group, p = 0.002). End-tidal isoflurane needed to maintain target entropy was significantly less in the Dexem group at all time points. Intraoperative fentanyl requirement was lower in the Dexem group (Dexem 115.33±33.77 v 178.67±32.48 in the Ropin group, p = 0.002). Postoperative pain scores and morphine consumption were significantly less in the Dexem group (p<0.001). The incidence of post-thoracotomy pain syndrome was comparable between the 2 groups (69.23% v 50%, p = 0.496). CONCLUSIONS Paravertebral dexmedetomidine administration resulted in decreased intraoperative anesthetic drug requirement, less pain, and lower requirements of supplemental opioid in the postoperative period. However, it had no effect on the incidence of post-thoracotomy pain syndrome.

Aberrant right vertebral artery from descending thoracic aorta.

We present a case of an abnormal origin of right subclavian artery and right vertebral artery distal to the origin of left subclavian artery in a 2-year-old patient who presented with cyanotic congenital heart disease with single ventricle physiology. The anomalous origin of a right vertebral artery from the proximal descending thoracic aorta is very rare. We have described the cine-angiographic identification of its origin and course, its embryologic development, and its clinical relevance.

Homograft saphenous vein for facilitating arterial cannulation in a neonate.

A simplified technique of arterial cannulation in neonates with diminutive aorta is presented. The technique is simple, inexpensive, and reproducible.

Central Pulmonary Artery Histopathology in Patients With Cyanotic Congenital Heart Diseases

BACKGROUND This study evaluated the pulmonary arterial (PA) wall histopathology and the risk factors related to histopathology and inadequate pulmonary artery growth in patients with cyanotic congenital heart diseases (CHDs) undergoing primary or second-stage operations after different types of systemic-to-PA shunts with or without pulmonary arterioplasty. METHODS Operatively excised full-thickness PA tissue from 150 consecutive patients (mean age, 90.8 +/- 62.8 months; range, 6 months to 47 years) undergoing primary or second-stage procedures for different cyanotic CHDs were studied by light microscopy. The controls were 43 patients (23.8%) with normally developed central PAs and normal wall histology. RESULTS The incidence of elastic fragmentation, increased ground substance, smooth muscle disarray, intimal thickening, and fibrosis was 61.3%, 36.6%, 34.6%, 39.3%, and 42% respectively. The risk of inadequate PA growth was 174.8, 64.7, and 45.5 times higher in patients with muscle disarray of the PA, abnormal lamellar count, and absence of palliative shunting procedures. CONCLUSIONS Almost all PA walls in shunted patients undergoing primary/second-stage procedures for cyanotic CHD indicate significant lamellar loss and intrinsic pulmonary arteriopathy. These changes are present in infancy, are more pronounced in patients with deep cyanosis, and may account for or may coexist with a higher incidence of PA hypoplasia and inadequate PA growth encountered in these patients.

An alternative technique for transfer of anomalous left coronary artery from the pulmonary trunk in children and adults using autogenous aortic and pulmonary arterial flaps.

BACKGROUND Direct re-implantation of an anomalous left coronary artery into the aorta is the preferred surgical option for creating a dual coronary arterial system in patients in whom the anomalous artery originated from the pulmonary trunk. This technique, however, is applicable only when the anomalous artery arises from the right posterior pulmonary sinus. We report a new technique for re-implantation using combined autogenous aortic and pulmonary arterial flaps in situations when a direct connection was not possible. PATIENTS AND METHODS We have treated 4 patients, aged 3 months, 6 months, 18 months, and 27 years respectively, who presented with anomalous origin of the left coronary artery from the left posterior pulmonary sinus. We used our proposed technique for transfer because lack of coronary arterial length, diminished vessel elasticity, and extensive collaterals around the pulmonary sinuses prevented direct attachment. RESULTS There was no early or late death. Postoperatively, all patients are in functional class I, with good biventricular function at a median follow-up of 74 months, with a range from 9 to 96 months. Postoperative coronary angiography in our 4th patient showed good arterial flow, without any distortion. CONCLUSIONS The potential benefits of this modification of the trapdoor technique are excellent operative exposure, use of autogenous and viable tissue capable of further growth, avoidance of injury to the aortic and pulmonary valvar apparatus and production of obstruction within the right ventricular outflow tract, complete elimination of use of pericardium for augmentation of the neo-aortic tube, achievement of the anastomosis with correct angling and length, and the possibility of implantation in all patients, including adults, regardless of the distance from the aorta or the coronary arterial configuration.

Utility of Sonoclot in Prediction of Postoperative Bleeding in Pediatric Patients Undergoing Cardiac Surgery for Congenital Cyanotic Heart Disease: A Prospective Observational Study

OBJECTIVES To assess the utility of Sonoclot in prediction of postoperative bleeding in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass for congenital cyanotic heart disease. DESIGN Prospective, observational study. SETTING Single university hospital. PARTICIPANTS Eighty-seven pediatric patients undergoing cardiac surgery for congenital cyanotic heart disease. INTERVENTIONS Laboratory coagulation parameters (prothrombin time, international normalization ratio, activated partial thromboplastin time, fibrinogen, D-dimer) as well as point-of-care Sonoclot glass bead activation time, clot rate, and platelet function (gbPF) were done before induction of anesthesia and following heparin reversal after termination of cardiopulmonary bypass (CPB) in all patients. MEASUREMENTS AND MAIN RESULTS Postoperative blood loss was monitored by the amount of chest tube drainage. The primary outcome was to define Sonoclot parameters for prediction of postoperative bleeding. Secondary outcomes studied were amount of postoperative blood loss, transfusion requirement of various blood products, incidence of surgical re-exploration, duration of postoperative mechanical ventilation, intensive care unit and hospital stay. Among studied subjects, 37.9% (33 of 87 patients) were designated as bleeders while 62.1% (54 of 87 patients) were non-bleeders. Lower age, D-dimer, and gbPF test after termination of CPB following heparin neutralization were predictive for postoperative bleeders. Among these, post-protamine gbPF had the highest area under the curve (0.725), 95% confidence interval (0.619-0.831) for prediction of postoperative bleeders. Duration of mechanical ventilation (26.41±36.44 v 8.25±6.36 h, respectively, p = 0.001), intensive care unit stay (7.36 ± 4.05 v 4.96 ± 2.49, p = 0.001), and hospital stay (11.69±4.82 v 8.63±3.48 p = 0.001) were higher in bleeders; however, incidence of re-exploration was comparable between both groups. CONCLUSION Postoperative bleeders may be predicted independently by post-CPB gbPF, postoperative D-dimer, and lower age of patients. Among these, post-CPB gbPF has maximum predictive value.

Simple and Inexpensive Technique for Internal Mammary Artery Harvest

A simple, inexpensive, and easy-to-use method for exposure of the left internal mammary artery is described. Two blades of the conventional four-blade sternal spreader hooking the Adson forceps, which passes through the loops of sternal wires, provides excellent exposure of the IMA. The same retractor is used for the rest of the procedure.

A novel percutaneously adjustable device for ligature of the vertical vein in the setting of obstructive totally anomalous pulmonary venous connection.

BACKGROUND A patent vertical vein might be desirable in patients with obstructive totally anomalous pulmonary venous connection with pulmonary hypertension, in order to decrease perioperative pulmonary arterial pressure and avoid pulmonary hypertensive crises. A subset of patients with an unligated vertical vein requires interruption of the vein due to the development of significant left-to-right shunt and right heart failure. We describe here a new device, permitting adjustable ligation of the vertical vein, which permits us to avoid multiple reoperations. PATIENTS AND METHODS In five patients, aged 2, 4, 3, 4, and 3 months respectively, and undergoing rechannelling of totally anomalous pulmonary venous connection with an unligated vertical vein, were treated with a device permitting adjusted ligation of the vertical vein over the course of postoperative congestive cardiac failure. RESULTS There was no early or late death. Postoperatively, all ligatures were tightened gradually over a period of 24 to 96 hours, maintaining stable haemodynamics. At a mean follow-up of 55.40 months, there was no evidence of congestive heart failure in any patient, the clinical risk score varying from zero to 2, and no requirement of anti-failure medications. Computed tomographic angiograms during follow-up revealed absence of flow through the vertical vein, and ruled out distortion of the left upper pulmonary and left brachiocephalic veins. CONCLUSION Use of a percutaneously adjustable device to ligate the vertical vein allows gradual tightening or loosening of the ligature under optimal physiologic conditions, without re-opening the sternum, or having to resort to another thoracotomy once the reactive components of pulmonary hypertension disappear.