Mohamed S. Kabbani

Bilateral scimitar syndrome.

Scimitar syndrome is a rare congenital anomaly that affects classically the right lung and the heart. We present a rare variant that involves both lungs in association with totally anomalous pulmonary venous connection, horseshoe lung, and right pulmonary cyst.

Five children with purulent pericarditis and review of the literature

Abstract Purulent pericarditis in children is a life-threatening disease that requires early diagnosis and immediate intervention. This cardiac emergency is rarely seen in the western world. However, cases of purulent pericarditis are still being reported in developing countries. We describe our experience with five cases of purulent pericarditis in children seen between 1998 and 2002. Haemophilus influenzae bacteria were isolated in all except one case. With active management, all five children survived.

Horner's syndrome after paediatric cardiac surgery: case report and review of the literature.

Iatrogenic Horners syndrome is a rare complication that can occur after trauma, cervical central line insertion, chest tube insertion, and rarely following adult thoracic and neck surgery, especially in high risk patients with hypertension and diabetes. The majority of cases reported in the literature describe non-iatrogenic Horners syndrome in adults as an unusual presentation for cervical tumours or apical lung carcinoma. In children, there are some reports describing acquired Horners syndrome following trauma or invasive intervention near the cervical-thoracic area. Less has been written about the incidence of Horners syndrome following paediatric cardiac surgery.

Early outcome of tetralogy of Fallot repair in the current era of management

BACKGROUND Traditional use of trans-annular patch (TAP) to release right ventricular outflow tract (RVOT) obstruction during tetralogy of Fallot (TOF) repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve (PV) function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function. METHODS A retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group (A) which include patients who had TAP without a valve. Group (B) includes those who had TAP with a monocuspid valve (Contegra). We compared post-operative care and outcome of all groups. RESULTS Eighty-three patients fulfilled the study criteria. There were 64 cases (77%) in group I, and 19 cases (23%) in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups. CONCLUSION Children undergoing TOF repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques.

Predictors of cardio pulmonary resuscitation outcome in postoperative cardiac children

Background Outcomes of cardiopulmonary resuscitation (CPR) in children with congenital heart disease have improved and many children have survived after an in-hospital cardiac arrest. Aim The purpose of this study is to determine predictors of poor outcome after CPR in critical children undergoing cardiac surgery. Methods We conducted a retrospective chart review and data analysis of all CPR records and charts of all postoperative cardiac children who had a cardiac arrest and required resuscitation from 2011 until 2015. Demographic, pre-operative, and postoperative data were reviewed and analyzed. Results During the study period, 18 postoperative pediatric cardiac patients had CPR. Nine of them had return of spontaneous circulation and survived (50%). On average CPR was required on the 3rd postoperative day. Univariate analysis demonstrated that poor outcome was associated with higher lactic acid measured 4–6 hours prior to arrest (p = 0.045; p = 0.02) coupled with higher heart rate (p = 0.031), lower O2 saturation (p = 0.01), and lower core body temperature (p = 0.019) recorded 6 hours before arrest. Nonsurvival required longer resuscitation duration and more epinephrine doses (p < 0.05). Conclusion Higher heart rate, lower core body temperature, lower O2 saturation, and higher lactic acid measured 6 hours before arrest are possible predictors of poorer outcome and mortality following CPR in postoperative cardiac children.

Effects of protocol-based management on the post-operative outcome after systemic to pulmonary shunt

Objectives Systemic to pulmonary shunt (commonly known as Modified Blalock-Taussig shunt) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lungs. Based on the most recent risk stratification score, the mortality and morbidity of this procedure is still high especially in neonates and over-shunting patients. We developed and implemented protocol-based management in March 2013 to better standardize the management of these patients. The aim of this study is to evaluate the effects of applying this protocol-based management in our center. Methods We conducted a retrospective cohort study through chart review analysis.We included all children who underwent MBTS from January 2000 till December 2015. We compared the early postoperative outcome of patients operated after the protocol-based management implementation (March 2013 till December 2015) (protocol group) with patients operated before implementing the MBTS protocoled management (control group). Results 197 patients underwent MBTS from January 2000 till December 2015. Of the 197 patients, 25 patients were in the protocol group and 172 patients were in the control group. There was a significant improvement in the postoperative course and less morbidity after protocoled management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, intensive care unit ICU stay and significantly lower postoperative complications in the protocol group. Mortality of the control group versus protocol group (19.3% VS 8%) with Standardized Mortality Ratio (SMR) dropped from 2.27 before protocoled management to 0.94 after protocoled management (protocol group). Conclusion The study suggests that protocoled management of patients with MBTS can improve the postoperative course and early outcome.

Fatal Hemorrhagic Bacteremic Escherichia Coli Pneumonia in Neonate Post Cardiac Surgery

Pneumonia is an important cause of neonatal infection with the potential of high morbidity and mortality, especially if complicated by blood-borne infection. We presented a fatal case with correlated radiological images of neonatal hemorrhagic bacteremic Escherichia coli pneumonia in cardiac patient post coarctation of aorta repair. The presentation was unusual with massive pulmonary hemorrhage and unilateral lung involvement leading to respiratory and hemodynamic failure that failed mechanical ventilator support and rescue extracorporeal membrane oxygenation (ECMO).

5. Effect of protocol-based management for systemic to pulmonary shunt operations

Abstract Type Clinical research. Presentation Type Oral presentation. Introduction Systemic to pulmonary shunt (commonly Modified Blalock-Tausing shunt – MBTS) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lung (1). Based on most recent risk stratification STAT score, the average mortality is still high (8.5%) in addition to significant post-operative morbidity especially in the neonatal and over-shunting patients. We developed and implemented protocoled management in March 2013 to better standardize the management of these patients. Aim of this study to evaluate the effect of applying this protocoled management in our center. Methodology We conducted a retrospective Cohort study through chart review analysis of all children who underwent MBTS since year January 2000 till December 2015, We compared the early postoperative outcome of patients operated after the protocol management implementation (March 2013 till December 2015) (group A) with patients operated before implementing the MBTS protocoled management (group B). Results 197 patients underwent MBTS since year 2000 till December 2015, 25 patients after the implementation the protocol management (group A), and 172 patients before the protocol implementation (group B). There was a significant improvement in the postoperative course and less morbidity after protocol management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, and postoperative complications were all significantly lower in (group A). Mortality group A versus group B (15.7% VS 8%). Based on STAT score, the standardized mortality ratio (SMR) dropped from 1.84 before protocol implementation to 0.94 after protocol implementation. Conclusion The study proves that protocol management of patients with MBTS can improve the postoperative course and early outcome.

58. Predictors for the outcome of aortic regurgitation after cardiac surgery in patients with ventricular septal defect and aortic cusp prolapse in Saudi patients

BACKGROUND AND AIM Aortic valve (AV) prolapse and subsequent aortic regurgitation (AR) are two complications of ventricular septal defects (VSD) that are located close to or in direct contact with the AV. This finding is one of the indications for surgical VSD closure even in the absence of symptoms to protect the AV integrity. The goal of our study was to assess the outcome and to identify the predictors for improvement or progression of AR after surgical repair. MATERIALS AND METHODS A retrospective study of all children with VSD and AV prolapse who underwent cardiac surgery at King Abdulaziz Cardiac Centre in Riyadh between July 1999 and August 2013. RESULTS A total of 41 consecutive patients, operated for VSD with prolapsed AV, with or without AR, were reviewed. The incidence of AV prolapse in the study population was 6.8% out of 655 patients with VSD. Thirty-six (88%) patients had a perimembranous VSD, and four had doubly committed VSD. Only one patient had an outlet muscular VSD. Right coronary cusp prolapse was found in 38 (92.7%) patients. Preoperative AR was absent in five patients, mild or less in 25 patients, moderate in seven, and severe in four patients. Twenty-six patients showed improvement in the degree of AR after surgery (Group A), 14 patients showed no change in the degree of AR (Group B) while only one patient showed the progression of his AR after surgery. Those with absent AR before surgery remained with no AR after surgery. Improvement was found more in those with mild degree of AR preoperatively compared to those with moderate and severe AR. Female gender also showed a tendency to improve more as compared to male. CONCLUSION Early surgical closure is advisable for patients with VSD and associated AV prolapse to achieve a better outcome after repair and to prevent progression of AR in future.

253: EFFECT OF NUTRITIONAL STATUS OF CHILDREN WITH CONGENITAL HEART DISEASE ON POST-OPERATIVE OUTCOME

Learning Objectives: Children with congenital heart disease (CHD) frequently get malnourished due to many factors including hypermetabolic state, inadequate caloric intake, malabsorption, genetic factors and fluid restriction as part of hemodynamic intervention. This nutritional status may affect the early postoperative outcome after pediatric cardiac surgery Methods: Prospective observational cohort study included all pediatric cardiac surgery patients over 2 yr. nutritional status assessed preoperatively according to Waterlow classification and calculated prognostic nutritional index (PNI). The following end points were recorded: patients NPO days, number of days to achieve Recommended Daily Allowance (RDA), weight gain /loss during ICU stay, ICU mortality, PCICU length of stay, hospital length of stay, ventilation hr and rate of infection. Results: 85 children were evaluated. At admission 36.4% (31/85) of the patients were severely malnourished. The usual intake was < 50 % of RDA at admission in 37.6% and was associated with severely malnutrition (P = 0.0001). Mean of the PNI was worse in the infected patients compared to the non-infected (P = 0.017). Comparing severely malnourished (n=31) to rest of our study population (n=54), the mean length of hospital stay was 22.84 ± 25.95vs20.67 ± 14.71 days; (95% CI -6.84–17.37P 0.038). Length of ICU stay was 13.27 ± 37.26 vs 7 ± 6.75 days, (95% CI -4.36–16.89P = 0.014). Patients with severe malnutrition were kept NPO longer postoperatively with mean 3.40 ± 5.56 vs 1.82 ± 1.45 days,(95% CI -0.05–3.21-P= 0.003). Delay in feeding postoperatively were associated with higher risk of infection (P =0.03). No statistically significant relation between mortality or ventilation hr in ICU and the malnutrition category of the patients Conclusions: Children with CHD were significantly malnourished preoperatively and had further loss in weight postoperatively. Delayed postop feeding was associated with higher rate of infection. Management by “specialized pediatric nutritionist” during outpatient visits and during hospital stay may optimize the nutritional status perioperatively.