Vijay Kumar Gupta

Predictors of acute kidney injury post-cardiopulmonary bypass in children

ObjectiveTo investigate the incidence, implicating factors and outcome of acute kidney injury (AKI) after cardiopulmonary bypass (CPB) in patients admitted to a pediatric cardiothoracic intensive care unit (ICU).Materials and methodsDesign: A retrospective review study. Setting: A 10-bed cardiothoracic ICU. Patients: One hundred and twenty-four children (<18xa0years of age) admitted to the cardiothoracic ICU following CPB between January 2007 and December 2009. Methods: Age, sex, diagnosis, baseline and post-surgery hemoglobin, total leukocyte count, platelet count and biochemistry were recorded. Baseline and postoperative urea (mg/dl), creatinine (mg/dl), urine output (ml/kg/h) and inotrope dose were also recorded daily. The duration of CPB was noted. Postoperative cardiac, renal, hepatic, neurologic and respiratory dysfunctions were recorded.ResultsSeven (5%) children developed AKI stage I, five children (4%) developed AKI stage II and two children developed AKI stage III (2%). All patients with AKI had a longer stay in hospital and increased mortality. Two children required dialysis for AKI and none developed chronic renal impairment. All patients with AKI stage III died during the ICU stay. Using stepwise regression, younger age (<1xa0year), weight <10xa0kg, pump failure, sepsis and duration of CPB >90xa0min were significant risk factors identified for developing AKI.ConclusionsAKI is common and occurred in 11% of our patients following CPB; however, AKI requiring renal replacement therapy is uncommon.

When should you restart anticoagulation in patients who suffer an intracranial bleed who also have a prosthetic valve

A best evidence topic in cardiac surgery was written according to the structured protocol. The question addressed was about the best time to restart anticoagulation in patients with intracranial bleed with a prosthetic valve in situ. This difficult clinical decision has to balance the risk of thromboembolism during the period that the anticoagulation was reversed and later withheld vs the risk of haematoma expansion or rebleed if the anticoagulation was started early. Altogether, more than 80 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. There were two prospective studies and eight retrospective studies. There were no randomized controlled trials on this topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Seven studies reported the strategy of reversal of anticoagulation with vitamin K, fresh frozen plasma or prothrombin concentrate. The emphasis was on prompt initial reversal of anticoagulation; however, the best agent for reversal was not defined. Four studies dealt exclusively with intracranial bleed in patients with prosthetic valve in situ. The remaining six studies on intracranial bleed had only a subset of patients with a prosthetic valve in situ. The anticoagulation was restarted with heparin and later switched to oral anticoagulant. Thromboembolic events during the period of reversal and cessation of anticoagulants were low (5%) as was the incidence of rebleed or haematoma expansion (0.5%). We conclude that anticoagulation can safely be withheld for a short period, up to 7-14 days in a patient with intracranial bleed with a very low probability of thromboembolic phenomenon. In patients with prosthetic valves, in situ anticoagulation in the form of heparin can safely be restarted as early as 3 days and switched to oral anticoagulation in the form of warfarin at 7 days without major concerns of bleeding.

Pericardial Effusion in Children: Experience from Tertiary Care Center in Northern India.

ObjectiveTo describe profile and outcome in children with significant pericardial effusion.MethodsHospital records of 25 children admitted with significant pericardial effusion during January 2010 to March 2013 were analyzed.ResultsThirteen (52%) children had tubercular, 6 (24%) had bacterial, 3 viral, 2 recurrent idiopathic and one had malignant pericardial effusion. Only 3 children in our series required surgical drainage.ConclusionsEchocardiography guided percutaneous pericardiocentesis and pigtail catheter placement was found to be safe and effective.

Inferior vena cava thrombosis in a pediatric patient of amebic liver abscess

Amebic liver abscess (ALA) in pediatric age group is rare. We describe a successful thrombectomy and open drainage of a large left lobe ALA associated with thrombus in the hepatic veins and inferior vena cava extending into the right atrium in a 6-year-old boy.

Aortopulmonary Window: A Rare Congenital Heart Defect

A four-month-old female infant presented with complain of fast breathing and recurrent chest infection since birth. On clinical examination, there was bonding arterial pulse and wide pulse pressure along with systolic murmur present at 3rd intercostal space. A 2D echocardiography revealed situs solitus with dilated Left Ventricle (LV) and Left Atrium (LA) and presence of type 1 Aorto-Pulmonary (AP) window with left to right shunt. Consequently, patient was taken up for surgical correction. Intra-operative finding showed cardiomegaly with LA and LV enlargement with large AP window with having a separate pulmonary valve. There was no left superior vena cava, pulmonary stenosis, ventricular septal defect or patent ductus arteriosus. After standard surgical steps, patient was taken on cardiopulmonary bypass. Aorta, right pulmonary artery and left pulmonary artery were looped [Table/Fig-1]. Transverse aortotomy at the level of AP window and above the left coronary cusp was made [Table/Fig-2]. AP window was identified [Table/Fig-3]. Poly Tetra Flouro Ethylene (PTFE) patch closure of AP window was done [Table/Fig-4].

Spontaneous pneumomediastinum: A complication of swine flu.

The occurrence of spontaneous pneumomediastinum in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases have been reported in children. We describe a case of spontaneous pneumomediastinum in adult infected with swine flu.

Mitral Valve Replacement in a Young Pregnant Woman: A Case Report and Review of Literature

Introduction: Cardiac diseases occur in 2-4% of pregnancies and rheumatic mitral disease is the most common acquired heart disease in pregnancy. Cardiac surgery carries significant maternal and fetal complications. Cardiac operation during pregnancy is indicated only when medical management fails. Although emergency cardiac surgery during pregnancy increases fetal mortality, sometime urgent cardiac surgery is inevitable. Cardiac surgery can be performed with relative safety during pregnancy by adopting normothermic, high flow rate circulation and continuous fetal activity monitoring. Case Presentation: We reviewed English literature of a pregnant patient undergoing cardiac surgery during pregnancy. We presented a 25-year-old woman admitted with massive hemoptysis. Discussion: The patient underwent a successful mitral valve replacement during the third trimester. The aim of our study was to propose a practical guideline for similar situations.

A single-centre experience of coronary revascularisation in young patients

BackgroundCoronary bypass grafting is probably the most extensively studied surgical technique; however, the reported data on its outcome in the younger population are relatively scarce. We present our 10-year experience with young patients undergoing coronary revascularisation.Patients and methodFifty-one patients, 40xa0years or younger, underwent coronary bypass surgery in our institution, between January 2003 and December 2012. Relevant preoperative and intraoperative clinical data were retrieved from the patient’s medical records. Follow-up data was obtained by personal or telephonic interview of the patients or relatives.ResultsOut of 51 patients (4 females, 47 males), with a mean age of 37.35u2009±u20093.25xa0years (range 27–40xa0years), 47 patients underwent off-pump coronary artery bypass and the rest underwent on-pump beating heart coronary artery bypass. Indication for surgery was triple-vessel disease (TVD) in 24 patients (47xa0%), double-vessel disease (DVD) in 9 patients (17.7xa0%) and single-vessel disease (SVD) in 18 patients (35.3xa0%). A total of 104 grafts (51 with left internal thoracic artery, 10 with radial artery and 43 with saphenous vein) were constructed, with a mean of 2.04u2009±u20090.94 grafts per patient. There was no in-hospital or 30-day mortality. Mean ICU stay was 2.33u2009±u20090.76xa0days and mean hospital stay was 7.2u2009±u20091.6xa0days (range 5–13xa0days). Cumulative follow-up was 256.53xa0years (mean 5.03u2009±u20093.19xa0years); follow-up was 90.2xa0% complete. Actuarial probability of survival at 10xa0years was estimated to be 91.1xa0%.ConclusionEarly and midterm results of coronary artery bypass surgery in young patients are excellent.

A prospective randomized trial of endoscopic versus open saphenous vein harvesting technique for coronary artery bypass graft surgery

PurposeThe great saphenous vein harvested with a traditional open technique often results in leg wound complications. An endoscopic harvesting technique may decrease incidence of these complications.Methods and materialFifty consecutive patients having elective primary coronary artery bypass surgery were prospectively and randomly assigned to either endoscopic great saphenous vein harvesting (EVH—group A) or open great saphenous vein harvesting (OVH—group B). Both groups were demographically similar and received identical management. Leg wound healing was evaluated at discharge, 1xa0week, 1xa0month and 6xa0months for evidence of complications.ResultThe patient in endoscopic vein harvesting group had increased harvest time and an insignificant increase in vein injuries at the time of harvesting but decreased incision closure times when compared with traditional longitudinal open vein harvesting. Conversion from endoscopy to a traditional longitudinal open vein harvest occurred in 5xa0% of patients. Leg wound complications were significantly reduced postoperatively in the endoscopic vein harvesting group in comparison with the open vein harvesting group. Histological evaluation of structural integrity of vein samples shows that there is no significant difference between both the groups. No patient was readmitted to the hospital for leg wound complications in either group.ConclusionEVH is a safe, reliable method for saphenous vein harvesting. The best indication for EVH may be in patients who are in increased risk for wound infection and in whom cosmetics is a major concern.

Persistent left superior vena cava with absent right superior vena cava-an incidental intraoperative finding

Persistent Left Superior Vena Cava (PLSVC) is a rare venous abnormality. However, it is the most common congenital anomaly of thoracic venous system with a frequency of less than 0.5 % of the general population and up to 10 % of patients with congenital heart disease [1]. In most of such cases, associated right SVC is present. Very rarely right SVC may be absent and this condition is called as Isolated PLSVC. In these cases a persistent left SVC is the sole channel to drains the venous blood of both upper extremities and the head into the heart. Valvular heart disease with absent Right Superior Vena Cava (RSVC) and PLSVC is a very rare condition. We hereby describe this anomaly, which was incidently diagnosed intraoperatively.