The role of posterior aortopexy in the treatment of left mainstem bronchus compression

OBJECTIVES: We reviewed the role of posterior aortopexy for left mainstem bronchus compression in infants and children. METHODS: Eighteen children with respiratory symptoms were enrolled between 2005 and 2015 for surgical decompression of the left mainstem bronchus. The children were managed from diagnosis to follow-up by a dedicated tracheal team. Primary outcomes were the complete relief of symptoms or improvement with respect to preoperative clinical status. RESULTS: The median age was 4 years (0.3-15.4) and the median weight was 13.2 kg (3, 1-40). Symptoms or indications for bronchoscopy included difficult weaning from mechanical ventilation (n = 3, 17%), difficult weaning from tracheotomy (n = 4, 22%), recurrent pneumonia (n = 4, 22%), wheezing (n = 3, 17%), atelectasis (n = 1, 5.5%), bitonal cough (n = 1, 5.5%) and stridor (n = 2, 11%). Associated malformations were present in 88.7%. The diagnosis was made by bronchoscopy and computed tomography. Indication for surgery was the presence of pulsations and reduction in the diameter of the left mainstem bronchus compression of more than 70%. Surgery was performed by left posterolateral thoracotomy. Aortopexy was done under bronchoscopic control. No early or late deaths were observed, nor were reoperations necessary. Residual malacia was observed in 8 children (44%). Median follow-up was 4.1 years (0.1-7.1). At last follow-up, 17/18 (94.4%) children showed adequate airway patency. CONCLUSIONS: The intrathoracic location of the left mainstem bronchus predisposes it to compression. Vascular anomalies represent the most frequent causes. Aortopexy has been advocated as a safe and useful method to relieve the compression, and our results confirmed these findings. Management of these patients is challenging and requires a multidisciplinary team

The role of cardiovascular magnetic resonance in candidates for Fontan operation: Proposal of a new Algorithm

<p>Abstract</p> <p>Background</p> <p>To propose a new diagnostic algorithm for candidates for Fontan and identify those who can skip cardiac catheterization (CC).</p> <p>Methods</p> <p>Forty-four candidates for Fontan (median age 4.8 years, range: 2-29 years) were prospectively evaluated by trans-thoracic echocardiography (TTE), Cardiovascular magnetic resonance (CMR) and CC. Before CC, according to clinical, echo and CMR findings, patients were divided in two groups: Group I comprised 18 patients deemed suitable for Fontan without requiring CC; group II comprised 26 patients indicated for CC either in order to detect more details, or for interventional procedures.</p> <p>Results</p> <p>In Group I ("CC not required") no unexpected new information affecting surgical planning was provided by CC. Conversely, in Group II new information was provided by CC in three patients (0 vs 11.5%, p = 0.35) and in six an interventional procedure was performed. During CC, minor complications occurred in one patient from Group I and in three from Group II (6 vs 14%, p = 0.7). Radiation Dose-Area product was similar in the two groups (Median 20 Gycm², range: 5-40 vs 26.5 Gycm², range: 9-270 p = 0.37). All 18 Group I patients and 19 Group II patients underwent a total cavo-pulmonary anastomosis; in the remaining seven group II patients, four were excluded from Fontan; two are awaiting Fontan; one refused the intervention.</p> <p>Conclusion</p> <p>In this paper we propose a new diagnostic algorithm in a pre-Fontan setting. An accurate non-invasive evaluation comprising TTE and CMR could select patients who can skip CC.</p

Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis

Endoscopic therapy; Appendicitis; AppendectomyTerapia endoscópica; Apendicitis; ApendicectomíaTeràpia endoscòpica; Apendicitis; ApendicectomiaIntroduction Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment. Methods This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials). Results Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference –14.38, 95% confidence interval [–20.17, –8.59]) and length of hospital stay (mean difference –1.19, 95% confidence interval [–2.37, –0.01]), with lower post-intervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14.87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference –1.91, 95% confidence interval [–3.18, –0.64]). Conclusion This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year

Role of semisupine exercise stress echocardiography in operated Fallot

Background: Right Ventricle (RV) outflow tract anomalies in operated Tetralogy of Fallot (TOF) leads to RV dysfunction. Due to the difficulties to its assessment, timing of RV outflow reconstruction is still a matter of debate. Semi-supine exercise echo (SEE) has potential for simultaneous evaluation of RV function, pressure, and area changes during stress. Aim to assess the feasibility and value of SEE in operated TOF. Methods: we evaluated 62 consecutive operated Fallot by SEE (mean age 24 ? 11 years, 16 pts were less than 18 y. o.). The following parameters were measured at rest and peak exercise: RV area (from apical 4 chamber view), Tricuspid annular plane systolic excursion (TAPSE), Right ventricular pressure (RVP, from tricuspid regurgitant jet velocity); RV fractional area change (RV-FAC). Within 3 days, all patients also underwent cardiac Magnetic Resonance, Cardio-pulmonary Exercise Test and Amino-Terminal pro-Brain Natriuretic Peptide (NT-proBNP) essay. Results: Exercise was stopped at 105 ? 35 Watt; heart rate increased from 83 ?16 bpm to 149 ?17 bpm. During exercise, interpretable images for RV FAC analysis were obtained in 56/62 patients (RV FAC feasibility = 90 %). Due to continent tricuspid valve in 7 patients RVP we couldn\u27t been measured (RVP feasibility = 89%). There was on average an increase in RVP (rest = 45 ? 18 vs. stress= 78 ? 37 mmHg, p<0.01 vs. rest), TAPSE (rest=15?4 vs. stress= 18? 3 mm , p<0.01 vs. rest), and RV-FAC (rest= 48? 9 vs. stress= 52 ? 8 % , p<0.05 vs. rest), with substantial individual variability. In particular, RV FAC increased in 40 ("responders") and remained stable or decreased in the remaining 9 pts, all of them > 18 y.o. ("non responders") (see figure). Compared to responders, non-responders had higher NT-proBNP (366 ? 264 vs 127 ? 92 ng/l,p<0.001), lower peak VO2/Kg (15 ? 4.4 vs 22 ? 5.4 ml/Kg/min, p<0.001), larger MRI-assessed RV End diastolic volume (166 ?61 vs 130 ? 42 ml/m2, p<0.05) and end systolic volume (86 ml/m2 ? 29 vs 58 ? 25, p<0.001) and lower RV EF (47 ? 8 vs 56 ? 8.5 %, p<0.01). Conclusion: SEE is feasible in patient with repaired TOF and allows the integrated assessment of variation of RV pressures, area, and function during exercise, which usefully complement more conventional indices of hemodynamic burden in these patients. Longitudinal follow-up is needed to better delineate the prognostic value of such SEE results

What Is Hidden Behind Inferior Negative T Waves: Multiple Cardiac Glomangiomas

Abstract Negative T waves in the inferior leads in an asymptomatic 17-year-old female patient prompted a diagnostic evaluation disclosing the presence of multiple cardiac glomangiomas. The combination of different imaging modalities (echocardiography, magnetic resonance, and positron emission tomography/computed tomography) and myocardial biopsy was crucial to establishing the correct diagnosis. (Level of Difficulty: Advanced.

Tele-echocardiography between Italy and Balkan area

A project (PIS-SRCE) has been started for promoting international medical cooperation in the Balkan area according to the Stabilization and Association Process, the European Union\u27s policy framework for the Western Balkan countries. Information and communication technology is presently mature to set up a telemedicine network breaking down geographical barriers and providing specialized medical care virtually anywhere in the world. Videoconferencing equipment is commercially available to transmit securely over Internet echocardiography or other modality images in addition to standard audio/video signals. Real-time transmission capability is crucial for allowing specialists to drive remotely proper echo scanning of cardiac structures in patient or foetus with suspected congenital heart disease

Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis

Introduction: Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment. Methods: This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials).Results: Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference -14.38, 95% confidence interval [-20.17, -8.59]) and length of hospital stay (mean difference -1.19, 95% confidence interval [-2.37, -0.01]), with lower postintervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14 .87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference -1.91, 95% confidence interval [-3.18, -0.64]).Conclusion: This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year

Data Integration in Cardiac Surgery and Resource Management

At "G. Pasquinucci" Hospital in Massa, a section of CNR Institute of Clinical Physiology, an information system for cardiac surgery has been in use during the last years. This system was integrated with the Hospital Information System, already set up at the head of our institute in Pisa. Anesthesia data are recorded in the Operating Room (OR) as well as materials used during cardiac surgery operations. From the OR, data are transferred into the central clinical database, creating surgery reports in the medical record and filling in standardized clinical registers. Since 2000 a total of 2185 adult and 956 pediatric cardiac surgery operations were recorded

Echocardiographic nomograms for chamber diameters and areas in Caucasian children

BACKGROUND: Although a quantitative evaluation of cardiac chamber dimensions in pediatric echocardiography is often important, nomograms for these structures are limited. The aim of this study was to establish reliable echocardiographic nomograms of cardiac chamber diameters and areas in a wide population of children. METHODS: A total of 1,091 Caucasian Italian healthy children (age range, 0 days to 17 years; 44.8% female) with body surface areas (BSAs) ranging from 0.12 to 1.8 m(2) were prospectively enrolled. Twenty-two two-dimensional and M-mode measurements of atrial and ventricular chamber diameters and areas were performed. Models using linear, logarithmic, exponential, and square-root relationships were tested. Heteroscedasticity was tested by the White test and the Breusch-Pagan test. Age, weight, height, and BSA, calculated by the Haycock formula, were used as the independent variables in different analyses to predict the mean value of each echocardiographic measurement. The influence of various confounders, including gender, type of delivery, prematurity, and interobserver variability, was also evaluated. Structured Z scores were then computed. RESULTS: The Haycock formula provided the best fit and was used when presenting data as predicted values (mean ? 2 SDs) for a given BSA and within equations relating echocardiographic measurements to BSA. Confounders were not included in the final models, because they did not show significant effects for most of the measurements. CONCLUSIONS: Echocardiographic reference values are presented for chamber area and diameters, derived from a large population of healthy children. These data partly cover a gap in actual pediatric echocardiographic nomograms. Further studies are required to reinforce these data, as well as to evaluate other parameters and ethnicities