Kartik Patel

Early postoperative arrhythmias after pediatric cardiac surgery

Background This prospective study proposed to determine the incidence, risk factors, and management protocols for early postoperative arrhythmias after pediatric cardiac surgery, with focus on outcomes, using a uniform protocol, and also to see if children operated on at a later age have different issues from those operated on earlier. Methods Of 224 consecutive pediatric patients undergoing cardiac surgery from September 2013 to July 2014, 24 were excluded because their procedures were performed without cardiopulmonary bypass. Results The median age was 24 months (mean 50.1 ± 62.4 months, range 0.5–216 months). Fifteen (7.5%) patients developed arrhythmia, the most common was junctional ectopic tachycardia (n = 7, 46.6%) followed by supraventricular tachycardia (n = 5, 33.3%). All junctional ectopic tachycardias occurred within 24 h of intensive care unit admission. Of the 7 patients with junctional ectopic tachycardia, 5 responded to conventional measures and 2 required amiodarone infusion. There was a significant longer cardiopulmonary bypass time in patients with arrhythmias compared to those without arrhythmias. Conclusion We observed a very low incidence of arrhythmias, particularly junctional ectopic tachycardia, after open heart surgery in children. Other than a longer cardiopulmonary bypass time, no specific predictors were identified. It appears that the cause of arrhythmias following pediatric cardiac surgery is multifactorial and needs further study with a greater number of patients.

Procalcitonin level for prediction of postoperative infection in cardiac surgery

Background Diagnosing infection after cardiac surgery remains difficult due to the systemic inflammatory response induced by cardiopulmonary bypass. We compared procalcitonin levels with white blood cell counts as predictors of infection after cardiac surgery. Methods We prospectively enrolled 100 consecutive adult cardiac patients. Postoperative white blood cell counts, serum procalcitonin levels, and blood cultures were examined. Result The sensitivity and specificity of white blood cell count and procalcitonin > 2 ng mL−1 were 60% and 100%, 58.8% and 42.5%, respectively. Procalcitonin > 7 ng mL−1 had 95% sensitivity and 80% specificity. Receiver-operating characteristic analysis showed a greater area under the curve for procalcitonin level (p < 0.0001) compared to white blood cell count (p = 0.31). Patients with positive blood cultures had significantly higher procalcitonin levels (51.97 ± 39.62 vs. 6.67 ± 10.73 ng mL−1), Acute Physiology and Chronic Health Evaluation-II scores (16.95 ± 3.24 vs. 13.60 ± 2.98), and intensive care unit stay (6.35 ± 3.42 vs. 4.6 ± 2.2 days). Non-survivors had significantly higher Acute Physiology and Chronic Health Evaluation-II scores (19.09 ± 1.30 vs. 13.67 ± 2.97) and procalcitonin levels (43.83 ± 52.15 vs. 12.26 ± 19.89 ng mL−1) but on logistic regression analysis, only Acute Physiology and Chronic Health Evaluation-II score was an independent risk factor for mortality. Conclusion The diagnostic accuracy of procalcitonin for bacterial infection is fairly high. Acute Physiology and Chronic Health Evaluation-II score is a better predictor of mortality and morbidity than absolute procalcitonin level. Procalcitonin > 7 ng mL−1 can prognosticate and identify the high-risk group.

Hemodiafiltration-A Technique for Physiological Correction of Priming Solution in Pediatric Cardiac Surgery: An In Vitro Study: Thoughts and Progress

Pediatric cardiopulmonary bypass (CPB) circuit invariably requires priming with packed red blood cells (PRBCs). Metabolic composition of stored PRBCs is unphysiological and becomes worse with increasing duration of storage. It is recommended to correct these abnormalities before initiation of CPB. We tested the hypothesis that hemodiafiltration of the prime with 0.45% saline is sufficient for reducing the metabolic load and reaching a physiologic state. In an in vitro study, 100 mL of blood each from 45 units of PRBCs stored for 3-20 days were used for priming the 45 neonatal CPB circuits. Based upon the method used for removal of excess crystalloid from the prime, circuits were divided into three groups. Group 1: Direct removal through manifold line. Group 2: Ultrafiltration of prime. Group 3: Hemodiafiltration of the prime. Blood gas analyses were obtained from the PRBCs and from the prime before and after removal of crystalloid. Both direct removal of crystalloid and ultrafiltration resulted in significant reduction in biochemical and metabolic load of blood (P < 0.001). However, the final composition of the prime was far from being physiological. Hemodiafiltration resulted in improvement of metabolic parameters to near physiological range (lactate: 33.8 ± 4.44 vs. 14 ± 2.53 mg/dL, pH: 7.05 ± 0.15 vs. 7.34 ± 0.06, bicarbonates: 4.83 ± 0.59 vs. 27.6 ± 2.94 meq/L; P < 0.001). Similarly, sodium (147.76 ± 12.73 vs. 144.6 ± 5.96 meq/L) and potassium (9.6 ± 2.83 vs. 4.23 ± 0.37 meq/L) also changed significantly (P < 0.001) to near physiologic range. Hemodiafiltraion of final prime is a simple, efficients and rapid method of correcting the biochemical parameters and reducing the metabolic load of stored PRBCs towards the physiological range before initiating the CPB.

Right Coronary Artery to Pulmonary Arterial Fistula Associated With Tetralogy of Fallot A Case Report and Review of Literature

A 16-year-old boy with tetralogy of Fallot (TOF), pulmonary stenosis, and coronary artery to pulmonary arterial fistulous communication arising from the proximal right coronary artery is reported for its rarity. The surgical importance of this anomaly is highlighted. The diagnosis should be borne in cases of TOF, with echocardiographic demonstration of severe right ventricular outflow tract obstruction without a corresponding degree of systemic arterial desaturation.

Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study

BACKGROUND Retrospective reviews have found the use of stored packed red blood cells (PRBCs) in priming to be associated with increased risk of postoperative complications. The purpose of study was to prospectively investigate the influence of duration of storage of PRBCs used in priming the cardiopulmonary bypass (CPB) circuit on the metabolic profile of the patients, and postoperative outcome after paediatric cardiac surgery. METHODS Between January 2015 and December 2015, 198 consecutive children operated for cardiac surgery using CPB and received blood for priming the circuit were included. Patients were divided into two groups based on the duration of storage of the blood, newer PRBCs group who received blood stored for ≤14days and the older PRBCs group who received blood stored for >14 days. RESULTS Mean duration of blood storage used for priming in newer PRBCs blood group (n=103) was 8.4±3.7days while it was 21.9±4.5days in older PRBCs group (n=95). Metabolic parameters of the PRBCs improved to physiological limits in both the groups after initiation of CPB. Postoperative hepatic, pulmonary, haematological complications, sepsis and multi-organ failure were more in the old PRBCs group. However, the difference was not significant. Similarly, there was no significant difference in incidence of prolonged mechanical ventilation, intensive care unit stay and hospital stay and mortality between the two groups. CONCLUSIONS Metabolic parameters of the stored blood become normal after initiation of CPB irrespective of duration of storage. In paediatric patients without significant co-morbidity, undergoing cardiac surgery, transfusion of washed stored blood up to 28days in CPB priming is safe especially if lesser amount of transfusion is required.

OPCABG for Moderate CIMR in Elderly Patients: a Superior Option?

Objective To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. Methods One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. Results Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). Conclusion Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Effect of Prime Blood Storage Duration on Clinical Outcome After Pediatric Cardiac Surgery

Background: In this study, we tested the hypothesis that in pediatric patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) with blood prime, the storage duration of the packed red blood cells (PRBCs) used in prime led to differences in postoperative complications and metabolic profiles of the patients. Methods: For this prospective observational study we included 400 pediatric patients undergoing cardiac operations using CPB and requiring PRBCs prime. To study the effect of storage duration of PRBCs on postoperative morbidity, mortality, and metabolic profile, patients were divided into four groups (based on storage duration of PRBCs used in prime). Group 1: ≤7 days, group 2: 8 to 14 days, group 3: 15 to 21 days, and group 4: >21 days. Results: On univariate analysis, patients transfused with PRBCs stored >14 days had significantly higher incidence of postoperative complications, for example, liver dysfunction, hematological complications, sepsis, and multiorgan failure. However, after regression analysis and adjusting for the other confounder’s effects, no significant association was found between storage duration of PRBCs and postoperative complications and mortality. Metabolic profile of PRBCs was observed to become deranged with increasing duration of storage. This, however, improved to near physiological range early after the initiation of CPB and remained normal one hour after weaning from CPB, irrespective of the storage duration. Conclusion: Storage duration of PRBCs used for priming the pediatric CPB circuit neither affects the metabolic profile of the patients on CPB or early after surgery, nor it has any association with postoperative complications and mortality.

Transverse Split Sternotomy: A Mini-invasive Approach for Repair of Congenital Cardiac Defects

Objective In this article, we aim to review our mini-invasive technique of transverse sternal split (TSS) with or without cervical cannulation for cardiopulmonary bypass (CPB), its usefulness, and efficiency for repair of congenital cardiac defects. Methods Between January 2013 and June 2015, 34 infants and small children were operated through TSS in third or fourth intercostal space [Tetralogy of Fallot 11, perventricular ventricular septal defect (VSD) device closure 23]. Cardiopulmonary bypass was established through cervical (common carotid artery [CCA] and internal juglar vein [IJV]) and inferior vena cava cannulation. In patients operated on CPB, near-infrared spectroscopy was monitored during surgery for cerebral oxygenation and Doppler ultrasonography was performed postoperatively for patency of CCA and IJV. Patients were followed up after discharge with physical examination and transthoracic echocardiography (TTE). Results Surgical site exposure through TSS was adequate in all patients. There was no significant morbidity, postoperatively or during follow-up except three patients with VSD device closure who required prolonged mechanical ventilation. Cervical cannulation was sufficient for arterial inflow in all patients operated on CPB. There was one mortality and three procedure failures in VSD device closure group. There was no incidence of neurological complication. Both CCA and IJV were patent in all patients operated on CPB. No significant residual defect was found in either group on postoperative transthoracic echocardiography. Conclusions Transverse sternal split with or without cervical cannulation is a feasible technique for repair of tetralogy of Fallot and perventricular device closure in selected group of infants and small children without compromising the exposure or quality of repair.

Left Atrial Myxoma Following Coronary Artery Bypass Grafting withPatient Coronary Arterial Grafts: a Rarity

The development of left atrial myxoma after coronary artery bypass graft surgery is a rare entity. A 60-year-old man with previous off-pump coronary artery bypass grafting four years ago with patent coronary grafts was diagnosed with left atrial mass. The patient underwent successful resection of the same through minimally invasive right anterolateral thoracotomy. Histopathology of the atrial mass confirmed the diagnosis of atrial myxoma.

Anterior Minithoracotomy: a Safe Approach for Surgical ASD Closure& ASD Device Retrieval

Objective Midline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect. Methods Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy. Results Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication. Conclusion Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.