Raja Joshi

Successful use of levosimendan as a primary inotrope in pediatric cardiac surgery: An observational study in 110 patients.

Context: Levosimendan is a new generation inotrope with calcium sensitizing properties and proven benefits in adults. Aims: This study investigates the use of levosimendan as a first line inotrope in congenital heart surgery. Settings and Design: Prospective, observational study in a tertiary care center. Materials and Methods: One hundred and ten patients undergoing congenital cardiac surgery received levosimendan at a loading dose of 12 mcg/kg during rewarming on cardiopulmonary bypass followed by continuous infusion of 0.1 mcg/kg/min for 48 h. Hemodynamic parameters were recorded at the time of admission to Intensive Care Unit, and at 3 h, 6 h, 12 h, 24 h, and 48 h thereafter. Statistical Analysis: Categorical variables were compared using Chi-square test. Non-normally distributed quantitative variables were compared between groups using Kruskal-Wallis test. Results: At discharge from operating room (OR), 36 (32.7%) patients required levosimendan alone to maintain optimum cardiac output, 59 (53.6%) patients required the addition of low-dose adrenaline (<0.1 mcg/kg/min) and 15 (13.6%) patients required either increment in adrenaline to high-dose (≥0.1 mcg/kg/min) or starting another inotrope/vasoactive agent. Overall, there were five mortalities. Hypotension leading to discontinuation of levosimendan was not found in any patient. Arrhythmias were observed in three patients. Fifty-four patients were extubated in the OR. Conclusions: Levosimendan-based inotropic regime offers optimized cardiac output with a well-controlled heart rate and a low incidence of arrhythmias in patients undergoing all categories of congenital heart surgeries.

Contained Rupture of Mycotic Aneurysm of the Left Circumflex Coronary Artery in a Child

Coronary artery aneurysm (CAA) is defined as dilatation of a coronary artery segment to a diameter of more than 1.5-fold normal size. Rupture of CAA is a catastrophic event and may result in sudden death or myocardial infarction. We report this unusual case of contained rupture of the left circumflex CAA.

Assessment of Risk Factors for a Sustainable "On-Table Extubation" Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience.

OBJECTIVE To delineate risk factors for failure of extubation in the operating room among pediatric cardiac surgery patients. DESIGN Prospective, observational study. SETTING Single center, tertiary care, teaching hospital. PARTICIPANTS The study comprised 448 congenital cardiac surgery patients who were enrolled for intended extubation in the pediatric cardiac operating room over 5 years. INTERVENTIONS The airways of enrolled patients were extubated in the operating room if predetermined suitability criteria were met. If the criteria were not met, patients were transferred to the intensive care unit with an endotracheal tube in situ. Patients whose airways were extubated successfully were followed up to determine specifically whether reintubation or use of noninvasive ventilation was necessary post-procedure. MEASUREMENTS AND MAIN RESULTS The airways of 92% (412) patients were extubated in the operating room. Incidence of reintubation in the intensive care unit was 2.4%. There were 4 mortalities in the whole group. A 100% success rate for operating room extubation was achieved for patients in Risk Adjusted Congenital Heart Surgery category 1, and patients undergoing adult congenital cardiac disease surgery and redo sternotomy. The airways of 85% of patients with preoperative pulmonary hypertension were extubated in the operating room. Statistical analysis was applied to identify risk factors present in the group that made extubation in the operating room unachievable. CONCLUSIONS Extubation in the operating room was successful in a majority of patients undergoing cardiac surgery. Multivariate analysis identified weight<5 kg, age<1 year, cardiopulmonary bypass time>120 minutes, and presence of significant noncardiac structural anomalies as significant factors affecting extubation in the operating room, with an adjusted odds ratio (95% confidence interval) of 10 (2.7-37), 7.2 (2-22), 5.5 (1.7-17.7), and 3.3 (1.2-9.3), respectively. Pulmonary hypertension, redo sternotomy, higher Risk Adjusted Congenital Heart Surgery category, and aortic clamp time>60 minutes did not achieve significance in the multivariate analysis as risk factors for extubation in the operating room.

Critical decision of operability in congenital heart disease patient with severe pulmonary hypertension

Repair of congenital heart disease in the presence of high pulmonary pressure has always been a contentious issue. Pulmonary vascular resistance (PVR) is considered important for establishing operability in these patients. However, PVR estimation is not always accurate and cannot solely be relied upon to make critical decision of operability. Clinical examination, chest X-ray, and echocardiography are also important indicators of pulmonary vascular disease. Knowledge of pits and falls of each investigation is important for appropriate management in these patients. We present a case report of successfully operated, 6-year-old child with anomalous origin of the right pulmonary artery from aorta, deemed inoperable on the basis of PVR estimation.

An Unusual Cause of Persisting Hyperlactatemia in a Neonate Undergoing Open Heart Surgery

Being a reflection of the degree of global tissue anoxia, serum lactate levels therefore can be used as a marker of organ damage and eventual outcome. A statistically significant association was observed between serum lactate levels and subsequent mortality and morbidity in critically ill adults, children, and neonates. In cardiac critical care, hyperlactatemia is usually multifactorial in origin, resulting from a combination of etiologies. Many centers are using serial lactate levels in conjugation with other parameters of cellular oxygen delivery, consumption, or extraction to monitor prognosis after pediatric cardiac surgery. A single initial lactate level has a lesser predictive value for morbidity and mortality after pediatric cardiac surgery than its failure to fall within 48 hours of surgery. In case of persistently high lactate levels with no other evidence of cellular hypoperfusion, other possibilities must be considered. There has been an established association of lactic acidosis with thiamine deficiency, but this has not yet been reported in newborns undergoing congenital cardiac surgery. We present one such rare case.

Compression of undiagnosed aberrant right subclavian artery during transesophageal echocardiography probe insertion

Transesophageal echocardiography (TEE) has become an important monitoring tool for the anesthesiologist during repair of intracardiac defects. Although the incidence of reported complications associated with its use is low, one should be careful during the insertion and use of TEE probe, as it may result in potential devastating problems. We present a case of undiagnosed aberrant right subclavian artery (ARSA) that got compressed by the TEE probe during its insertion. It was noticed because of the presence of the right radial artery catheter, else it would have passed unnoticed.

Device closure of patent ductus arteriosus in interrupted inferior vena cava

Introduction A 3-year-old child, weighing 8 kg, presented with patent ductus arteriosus (PDA) and interrupted inferior vena cava (IVC). The patient underwent successful PDA device closure via transjugular route after failing attempt at femoral venous route. Case summary PDA device closure was attempted via femoral venous route but could not be accomplished due to difficult curves to negotiate. Following this, PDA could be closed by device from jugular venous route with ease. Discussion Interrupted IVC poses challenges for PDA device closure and various alternative routes are described like internal jugular, transhepatic, or femoral venous – azygous route. Our case describes difficulties associated with femoral venous route and advantages of jugular venous route in such cases. Conclusion Internal jugular access is a safe and feasible method of PDA device closure in cases of interrupted IVC even in smaller children.

A multivariate analysis of factors affecting blood component requirement in pediatric open heart surgeries

BackgroundBleeding in children after Cardiopulmonary Bypass (CPB) can be an important cause of morbidity and mortality. Multiple perioperative factors have been evaluated to predict bleeding and hence blood and blood component requirements in such children.Materials and methodsPerioperative blood and blood product transfusion data were recorded for 264 children who underwent open heart procedures. Preoperative factors like patient age, sex, body surface area, hemoglobin, hematocrit, platelet count and cyanosis were compared with the Packed Red Cell (PRC), Fresh Frozen Plasma (FFP) and Random Donor Platelet (RDP) units transfused. Intraoperative factors like cardiopulmonary bypass time (CPB Time), prime type (heme prime done or not) and core body temperature attained during the surgery were also evaluated for the same. The results were statistically analyzed.ResultsVariables found to have a positive correlation with PRC use (i.e., those with p-value < 0.05) are CPB time, heme prime and Partial Thromboplastin Time (PTT). However, age, hematocrit and cyanosis were negatively associated with PRC use. CPB time also had a positive correlation with Fresh Frozen Plasma and Random donor platelet usage. FFP use was positively correlated with heme prime performed. Cryoprecipitate consumption was positively correlated with preoperative cyanosis and hematocrit of the patient.ConclusionWe identified patient’s age, preoperative hematocrit and coagulation profile, presence of cyanosis along with intraoperative parameters like prime type and CPB time as significant determinants of blood consumption especially packed red cells.

Gastrointentinal bleed with clopidogrel and aspirin

Anti-platelet drugs have been used to prevent thrombosis of systemic to pulmonary artery shunts. Aspirin has traditionally been used. Clopidogrel is being studied as an alternative and in combination with aspirin for shunt patients. We report a near fatal gastro-intestinal bleed in a patient with shunt and on aspirin and clopidogrel. This combination has been known to produce similar bleeds. The authors recommend caution in combining them. Prospective studies currently underway should evaluate this aspect of the antiplatelet drugs.

CONGENITAL CARDIAC DEFECTS: WHEN TO INTERVENE

Delayed diagnosis and referral of Pediatric Cardiac patients in addition to inability of parents to financially undertake pediatric cardiac surgery have resulted in several patients becoming inoperable. Improved survival after early repair has also resulted in earlier age of surgery. Several procedures are now feasible in the neonatal period and in addition reparative procedures which required an addition palliative surgery are now performed in a single step. The objective of this article is to review contemporary recommendations for timing for surgery and interventions.