Anil Bhan

Vasoactive Inotrope Score as a tool for clinical care in children post cardiac surgery

Background: Neonates and infants undergoing heart surgery on cardiopulmonary bypass (CPB) are at high risk for significant post-operative morbidity and mortality. Hence, there is a need to identify and quantify clinical factors during the early post-operative period that are indicative of short-term as well as long-term outcomes. Multiple inotrope scores have been used in practice to quantify the amount of cardiovascular support received by neonates. Aims: The goal of this study was to determine the association between inotropic/vasoactive support and clinical outcomes in children after open cardiac surgery. Materials and Methods: This is a retrospective analysis of the 208 patients who underwent cardiac surgery for congenital heart disease at a tertiary pediatric cardiac surgery Intensive Care Unit (ICU) from January 2012 to March 2013. Multiple demographic, intra-operative and post-operative variables were recorded, including the Vasoactive Inotrope Score (VIS). Results: A total of 208 patients underwent cardiac surgery for congenital heart disease in the study period. The mean age and weight in the study were 66.94 months and 16.31 kg, respectively. Statistically significant associations were found in the various variables and VIS, including infancy, weight < 10 kg, CPB time, pump failure and post-operative variables like sepsis, hematological complications, hepatic dysfunction, acute kidney injury during admission, mortality, prolonged ventilator requirement, CPB time (in min) and hospital stay. Conclusions: Inotrope score and its adaptations are an excellent tool to measure illness severity, deciding interventions and during parental counseling in the pediatric cardiac surgery ICUs.

Incidental left anterior descending coronary artery to pulmonary artery fistula in myxomatous mitral valve prolapse

Uniqueness of this case report is that though coronary cameral fistulas are itself rare, we closed fistula effectively in a different way. Since surgery was only good option available as patient had concomitant valvular disease, we closed distal end of fistula in PA and then took deep bites of suture in fistulous track itself. This approach closed fistula effectively and we had no need to dissect and ligate its origin from LAD which is more arduous and dangerous task.

Successful management of a giant unruptured mycotic coronary artery aneurysm after coronary angioplasty

Coronary artery stent infection has been reported with both bare metal stent and drug eluting stent and can present as mycotic coronary artery aneurysm, pseudoaneurysm, myocardial abscess, pericarditis or exudative effusion. Infection at the site of coronary stent implantation is rare and is believed to result typically from either direct stent contamination at the time of delivery or transient bacteraemia from access site. Introduction of drug-eluting stent (DES) has led to a marked reduction in the problem of in-stent restenosis across all patient subsets and lesions complexities. Recently, several case reports of pseudoaneurysm formation after DES implantation have been reported in the literature. We describe the successful surgical management of giant mycotic pseudoaneurysm of left anterior descending artery (LAD) presenting as fever of unknown origin. This report illustrates the importance of early detection and prompt management of these rare coronary pseudoaneurysms, which is a highly lethal condition.

Unusual cause of absent pulse in one arm: Isolated subclavian artery.

Isolated origin of the subclavian artery is a congenital anomaly of the aortic arch in which one subclavian artery originates from the homolateral pulmonary artery through the ductus arteriosus. Isolated right subclavian artery with left-sided aortic arch is extremely rare. We report a case of isolated right subclavian artery from the right pulmonary artery via a right-sided ductus arteriosus in a 4-year-old girl. The child presented with subclavian pulmonary steal with perfusion of the right arm and lung from the right vertebral and carotid arteries. She underwent successful surgical repair.

Which valve is which

A 25-year-old man presented with a history of breathlessness for the past 2 years. He had a history of operation for Tetralogy of Fallot at the age of 5 years and history suggestive of Rheumatic fever at the age of 7 years. On echocardiographic examination, all his heart valves were severely regurgitating. Morphologically, all the valves were irreparable. The ejection fraction was 35%. He underwent quadruple valve replacement. The aortic and mitral valves were replaced by metallic valve and the tricuspid and pulmonary by tissue valve.