Manikala Vinod Kumar

Is sternotomy superior to thoracotomy for modified Blalock–Taussig shunt?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is sternotomy approach superior to a thoracotomy approach for a modified Blalock-Taussig shunt procedure? More than 58 papers were found using the search as described below, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three of seven papers compared the sternotomy and thoracotomy approaches. The operative approach was a significant predictor of shunt failure. The criterion used to define early shunt failure was either the complete occlusion during hospitalization or the need to return to the operating room for a second shunt. The studies that compared the thoracotomy and sternotomy approaches observed increased shunt failure rates in the thoracotomy group. The sternotomy approach was associated with advantages like less pulmonary artery distortion, ease of technical performance, cosmetic advantage of a single sternotomy incision, ease of ligation of patent ductus, less phrenic nerve injury, less collateral formation in chest wall adhesions and less thoracotomy induced scoliosis. However, other papers studied either the sternotomy approach only or the thoracotomy approach and drew conclusions regarding risk factors for operative morbidity and mortality. We conclude that the sternotomy approach is beneficial to neonates and infants undergoing modified Blalock-Taussig shunt when compared with the conventional thoracotomy approach.

Extraanatomic Bypass to Supraceliac Abdominal Aorta for Complex Thoracic Aortic Obstruction.

BACKGROUND The standard surgical treatment of coarctation of the aorta is through a left posterolateral thoracotomy. However, when a concomitant cardiac procedure is required or the conventional approach is not possible or is hazardous, extraanatomic bypass to the supraceliac abdominal aorta may be advantageous. We discuss our technique and report the long-term results. METHODS Between January 1986 and January 2015, 25 patients (16 males, 9 females) underwent extraanatomic bypass to the supraceliac abdominal aorta for various lesions of the arch and the descending thoracic aorta. Extraanatomic bypass to the supraceliac abdominal aorta was performed for patients in whom balloon dilatation was not feasible due to associated arch hypoplasia (n = 9), long-segment thoracic aorta narrowing due to nonspecific aortoarteritis (n = 3), or isolated long-segment coarctation of the aorta (n = 3). Patients who needed concomitant cardiac procedures, such as aortic valve replacement (n = 4), ascending aortic aneurysm repair (n = 2), or coronary artery bypass grafting (n = 1), and in whom balloon dilatation had failed, also underwent extraanatomic bypass to the supraceliac abdominal aorta. Extraanatomic bypass was also performed in 3 patients with recurrent coarctation after surgical repair and in whom balloon dilation was not feasible or unsuccessful. RESULTS There were no early or late deaths. The peak-to-peak gradients between the upper limb and the lower limb decreased from 59.3 ± 16.3 mm Hg to 2.0 ± 2.8 mm Hg (p < 0.0001). The mean follow-up was 96.6 ± 92.6 months (range, 1 to 240 months; median, 54 months). Doppler interrogation of the lower limb arterial system after a mean follow-up of 86.4 ± 85.2 months showed an unobstructed flow pattern. The ankle-brachial pressure index improved from a preoperative value of 0.60 ± 0.07 to 1.04 ± 0.11 (p < 0.0001). Systolic blood pressure decreased significantly compared with preoperative values (153.9 ± 18.9 vs 122.8 ± 10.2, p < 0.0001). Three patients continued to receive antihypertensive medication due to persistent mild hypertension. CONCLUSIONS Extraanatomic bypass to the supraceliac abdominal aorta provides effective palliation for complex aortic obstructions. It is easy and quick to perform, avoids fatal complications, and is well tolerated in all age groups.

Factors determining outcomes in grown up patients operated for congenital heart diseases

Background: The number of grown ups with congenital heart diseases (GUCHs) is steadily increasing. Aims: To analyze factors predicting early cardiac morbidity following cardiac surgery in GUCH at a tertiary care center. Setting and Design: Retrospective study at a multispeciality tertiary referral center. Methods: Between January 2004 and December 2014, 1432 patients ≥13 years of age (acyanotic defects: 843, cyanotic defects: 589) underwent surgery for congenital heart defects. Factors associated with early cardiac morbidity were analyzed. Statistical Analysis: Univariable and multivariable analysis of all factors affecting outcomes. Results: On multivariate analysis, previous sternotomy, aortic cross-clamp time. >45 min, cyanosis, and emergency procedure were independent predictors of early morbidity with respective odds ratios. (ORs) of 12.4, 3.6, 2.6, and 8.1. For more precise estimation, a risk score was generated. Taking the log odds with each of these four as respective weights, a score was generated. The variables were. previous sternotomy. (2.5), aortic cross.clamp. >45 min. (1.3), emergency procedure. (2.1), and cyanosis. (0.9), if the respective condition is present, zero otherwise. The score ranged from 0 to 4.5. The average value of the score based on the four variables was significantly higher in cases with morbidity. (1.85. ± 1.17) vs. (0.75. ± 0.88), P < 0.001. Distribution of scores was significantly different between patients with and without morbidity. Sixty-seven percent patients without any morbidity had score. <1 compared to 24.6% with morbidity. Only 0.9% patients without morbidity had score of ≥3 compared to 16.4% patients with morbidity. Compared with patients having score. <1, patients with scores 1-2 had OR of 3.4, 2.3 had OR of 6.0, and. >3 had OR of 48.7. Conclusion: GUCH can be safely operated when adequate caution is taken in the presence of independent predictors such as previous sternotomy, aortic clamp time >45 min, cyanosis, and emergency procedure.

Bidirectional Glenn on cardiopulmonary bypass: A comparison of three techniques

To analyze the intraoperative and early results of the bidirectional Glenn (BDG) procedure performed on cardiopulmonary bypass (CPB) using three different techniques.

Thrombus in the Proximal Aorta: Cardiopulmonary Bypass Strategy and Surgical Management.

De novo noninfective thrombus formation in the ascending aorta is rare. We report two cases of ascending aortic thrombus, their surgical management, and cardiopulmonary bypass strategy.

Repair of Concomitant Double Orifice Mitral and Tricuspid Valves

The coexistence of double orifice mitral and tricuspid valves is rare. We report a five-year-old boy with double orifice mitral and tricuspid valves requiring surgical correction of hemodynamically significant mitral and tricuspid stenosis.

Atrial Switch Operation in a Late Presenter With d-Transposed Great Arteries, Juxtaposed Atrial Appendages, and Bilateral Superior Caval Veins.

A 26-year-old patient with d-transposition of great arteries (d-TGA), bilateral superior vena cava, and juxtaposed atrial appendages underwent a successful atrial switch operation. It is extremely uncommon to encounter a previously unpalliated patient with d-TGA at this age. Unusual morphologic features in this patient necessitated technical modifications to successfully accomplish an atrial switch procedure.

Thyroid hormone supplementation following open-heart surgery in children

In patients undergoing open-heart surgery, abnormalities in thyroid hormone levels have been observed even in the absence of primary thyroid disease. These abnormal changes in thyroid hormone level and function have been found to be sufficient to affect myocardial performance and postoperative recovery. In the intensive care unit, postoperatively, it has been found that features such as low cardiac output, left ventricular dysfunction and prolonged ventilator support were associated with hypothyroidism. We reviewed the available literature on the effect of thyroid hormone supplementation in paediatric patients undergoing open-heart surgery under cardiopulmonary bypass and concluded that children after complex congenital cardiac surgery are at risk of developing a clinically significant hypothyroid state in the early postoperative period. In the literature where the effects of supplementation of thyroxine were studied, beneficial effects were observed in terms of reduced mechanical ventilation time, reduced inotropic support and intensive care unit stay, rapid achievement of negative fluid balance and early recovery. Supplementation with thyroid hormones enables a smoother postoperative recovery and is beneficial. The total duration of this therapy is, however, unclear.

Factors determining outcomes in adult patients operated for congenital heart diseases

Results On multivariate analysis, previous sternotomy, aortic cross clamp time more than 45 min, cyanosis, emergency procedure were identified as independent predictors of early cardiac morbidity with respective odds ratios of 10.5, 3.7, 2.3 and 8.0. These four variables together could discriminate 77% of all procedures correctly as to their immediate post-operative morbidity. Taking the log odds with each of these 4 as the respective weights, a score was generated. The weights were previous sternotomy (2.4), aortic cross clamp > 45 min (1.3), emergency (2.1), cyanosis (0.8), if the respective condition is present, zero otherwise. The score ranged from 0 to 4.5.The average value of the score based on the 4 variables was significantly higher in cases with cardiac morbidity (0.75 ± 0.88) v/s (1.85 ± 1.17), p < 0.001. Distribution of the scores was significantly different between patients with and without morbidity. 67% patients without any morbidity had score < 1 compared to 24.6% with morbidity. Only 1.2% patients without morbidity had score of ≤ 3 compared to 15% patients with morbidity. Compared to patients having score < 1, patients with score between 1 and 2 had an odds ratio of 3.5; patients with score between 2 and 3 had an odds ratio of 6.3; > 3 had an odds ratio of 32.1 for cardiac morbidity.