Vinod A. Sebastian

Ministernotomy for repair of congenital cardiac disease.

We report our experience with repair of a variety of congenital heart defects utilizing a ministernotomy incision. A ministernotomy was used in 79 patients with a variety of congenital heart diseases from November 2004 to August 2007. Patients included 36 males and 43 females with ages ranging from 1 month to 122 months (median age, 22 months). The weight ranged from 3.5 kg to 40 kg (median weight, 10.9 kg). There were no deaths, and one conversion to full median sternotomy (1/79, 1.3%). The median cardiopulmonary bypass time was 59 min, and median aortic cross-clamp time was 38 min. One patient underwent atrial septal defect (ASD) repair with fibrillatory arrest time of 35 min. The operating time ranged from 103 min to 312 min (median operating time, 168 min). The intensive care unit (ICU) stay ranged from 1 to 21 days (median ICU stay, 1 day) and the hospital stay ranged from 2 to 56 days (median hospital stay, 4 days). There were no reinterventions for residual cardiac defects. We demonstrate the safety and efficacy of ministernotomy for the correction of a range of congenital heart defects with improved cosmetic results.

CT and appendicitis: evaluation of correlation between CT diagnosis and pathological diagnosis.

Purpose: To evaluate the correlation between appendiceal size measured by contrast-enhanced CT of the abdomen and pelvis and the size of surgically removed appendixes on gross pathological examination. Materials and methods: The initial database consisted of the cases of 301 children, collected over 2 years, of which 56 met inclusion criteria. Both the radiology and surgical pathology reports of these patients were reviewed. Results: The mean size of appendixes meeting the CT size criteria of appendicitis was 10.3 mm, and that of the surgical pathology specimens was 10.4 mm. The pathological diagnosis of acute appendicitis was confirmed in 54 of 56 cases, yielding a positive predictive value of 96.4%. The Pearson product–moment correlation coefficient was calculated to be 0.5443 (95% CI 0.329 to 0.706). The slope of the linear correlation was 0.5788. The mean absolute difference in CT size versus pathological size was 2.2 mm. Conclusion: The data reveal a strong correlation in ability of CT to predict the presence of acute appendicitis, with moderate correlation in the size estimate of acutely inflamed appendixes, as imaged on CT, and the pathological specimen status after appendectomy.

Pyoderma gangrenosum associated with chronic idiopathic myelofibrosis after coronary artery bypass graft surgery

Pyoderma gangrenosum (PG) is an ulceronecrotizing dermatosis that can occur after minor trauma or surgery and is rare after cardiac surgery. We report a case of PG after coronary artery bypass grafting (CABG) in a patient with chronic idiopathic myelofibrosis (CIMF). Diagnosis was made with punch skin biopsy and he was treated with systemic steroids. His lesions showed remarkable improvement with this therapy. Cardiothoracic surgeons need to consider this diagnosis in all rapidly expanding postoperative lesions, especially those that do not improve with debridement or antibiotics or conservative wound care.

Management and Outcomes of Heterotaxy Syndrome Associated With Pulmonary Atresia or Pulmonary Stenosis

BACKGROUND Historic outcomes of patients with heterotaxy and pulmonary atresia or pulmonary stenosis (PA/PS) have been poor and in the current era are incompletely described. We reviewed our management of these patients and associated risk factors for death. METHODS We retrospectively reviewed the records of all patients with heterotaxy and PA/PS treated in our institution from January 1, 2002, to August 31, 2012. Death data were also confirmed with the Social Security Death Index. The log-rank test was done to assess six risk factors for death. RESULTS We identified 42 patients with heterotaxy and PA/PS. Median age at the first operation was 6.5 days, and median follow-up was 3.5 years. Death data were complete for all patients. Overall mortality was 19% (8 of 42). The 30-day, 1-year, and 5-year mortality estimation was 4.76%, 12.3%, and 19.1% respectively, as determined by the Kaplan-Meier method. The log-rank test showed total anomalous pulmonary venous return (TAPVR) (p<0.05) and obstructed TAPVR requiring an operation at less than 30 days (p=0.001) were significant risk factors for death. CONCLUSIONS In the current era, surgical treatment of heterotaxy and PA/PS can result in good outcomes. Associated TAPVR and obstructed TAPVR requiring neonatal correction were noted to be risk factors for death.

Thermally processed polymeric microparticles for year-long delivery of dexamethasone

Dexamethasone-releasing poly(lactic-co-glycolic acid) (PLGA) microparticles were formulated using a solvent displacement technique with the addition of distillation aiming to increase drug delivery lifetime. Two PLGA copolymer ratios (50:50 and 75:25) were used to determine the influence of lactic acid and glycolic acid ratio on microparticle characteristics. The addition of distillation significantly slows the release of dexamethasone compared to traditional solvent removal via evaporation while still maintaining a therapeutic dosage. Microparticles formulated with PLGA 50:50 controllably release dexamethasone up to one year and 75:25 release up to two years in-vitro. The ratio of lactic acid to glycolic acid plays a significant role in microparticle stability, drug loading efficiency, and thermal properties. In all, this formulation technique offers new prospects for inflammation suppression in pediatric vascular and airway diseases.

Single-Center Experience With the Senning Procedure in the Current Era

The Senning procedure is an operative technique for atrial inversion in congenital heart anomalies. We sought to evaluate our contemporary outcomes employing this technique. A retrospective analysis of all patients who underwent the Senning procedure at our institution was performed. Hospital records were reviewed, and follow-up data were obtained to evaluate outcomes. Overall, a total of 19 patients underwent a Senning procedure between August 2005 and July 2014. Median age at repair was 594 days (range: 5 days to 15 years). Of those, 7 patients underwent a combined Senning-Rastelli operation and 10 patients underwent a double switch operation (arterial switch or atrial switch). Primary diagnosis was congenitally corrected transposition of the great arteries (cc-TGA) in 17 patients. Associated lesions included ventricular septal defect (n = 10), pulmonary stenosis or atresia (n = 7), and Ebstein׳s anomaly of the tricuspid valve (n = 4). There was an operative death (5%). In all, 2 patients required superior vena cava baffle revision in the operating room. No new pulmonary venous or systemic venous baffle obstruction was observed during follow-up. A total of 5 (26%) patients developed heart block requiring pacemaker implantation. Actuarial survival was 81% at 5 years with a median follow-up of 38 months. The 2 patients in the cc-TGA group were subsequently transplanted. Surviving patients (n = 15) are all well at the last clinical follow-up, most with normal biventricular function. In conclusion, the Senning procedure offers excellent outcomes with regard to systemic and pulmonary venous baffle patency. Results in patients with cc-TGA, however, are affected by significant early mortality after Senning-Rastelli and incidence of left ventricular dysfunction after double switch; which should be considered during patient selection and surgical planning.