Perioperative factors affecting fast tracking in paediatrics cardiac surgical patients

Background: Preoperative and intraoperative factors that influence the postoperative period including weaning time from mechanical ventilation and extubation: in a paediatric cardiac patients have been widely studied with contradicting reports and variation from centre to centre. The aim of this study was to determine factors that influence the duration of weaning in paediatric cardiac surgical patients and their associated complications at our centre.Methods: This was a prospective study that recruited all eligible paediatric patients from infancy to childhood whom underwent cardiac surgical repair at Care Hospital Hyderabad, India between January and June 2007.Excluded were old age more than 18 years or patient with cardiac lesion undergoing palliative operation other than those involving cardiopulmonary bypass. Patients` demographic data including age, sex, height, weight and consequently body surface area were retrieved from patients` record file. The duration of symptoms was also determined and reported in months. Patients’ diagnoses details of the nature of the cardiac lesion as reported from echocardiography and or cardiac catheterization was recorded. Intraoperative parameters including the type of cardiac operation were taken care and recorded accordingly. Patient was followed up postoperatively both in the intensive care unit and in the general ward while closely monitored noting for any complications till the patient was discharged from either of these units. Patients’ data were entered into a master sheet data and later into a SPSS.11.5 window program for analyses using χ2-test for categorical data.Results: There were 103 patients of which 60.2% and 39.8% were male and female respectively. The mean age was 74.45 months: mean duration of symptoms was 54.52 months. Majority of patients had congenital heart disease that accounted for 93.6% of all cases while chronic rheumatic heart disease was found in 6.8% of cases. Tetrallogy of fallot and ventricular septal defect were the commonest among congenital heart disease representing 27.2% and 25.2% respectively. Young age was found to be a factor associated with prolonged mechanical ventilation and extubation. Further, the presence of pulmonary hypertension, lower cardiac grade and ventricular dysfunction were found to be factors significantly associated with prolonged weaning. While, cardiac disease occurring in combination, ischemia time, duration of cardiopulmonary bypass, total operation time, left ventricular ejection fraction, pH at the end of cardiopulmonary bypass and preoperative hemoglobin were factors found not to be associated with prolonged weaning.Conclusion: Our study has shown that presence of pulmonary hypertension, cardiac grade and ventricular dysfunction were factors associated with prolonged time to weaning. While aortic cross-clamp, total duration of cardiopulmonary bypass, , cardiac disease occurring in combination, total operation time and level of hemoglobin were not associated with prolonged time to weaning

Surgical Experience with Closure of an Isolated PDA at Muhimbili Cardiothoracic Unit in Dar es Salaam, Tanzania

Background: This study describes our experience in the management of isolated patent ductus arteriosus; complications and mortality rate. Further it describes the innovative technique for the closure of the duct.Methods: We retrospectively recruited all patients’ files that underwent PDA closure from May 2008 to July 2011 in all these patients clinical evaluation and confirmation of diagnosis was made by echocardiography. There were two-treatment group. The first group underwent a standard surgical closure and these were 26 patients this group was obtained from the usual and routinely done PDA ligation. The second group also comprised 26 patients who had undergone a modified closure technique as illustrated by Kirklin1. Patients’ age, sex duration of illness, stage of the disease as classified by New York Heart Association, ventricular function as depicted by left ventricular ejection fraction, any associated lesion were noted. During operation, confirmation of the PDA was done and the total operation time (TOT), total duration of ventilation (VT), and any complication were noted. The total duration of intensive care stay and the postoperative period stayin the ward were noted. Patients had been followed at six months interval for two years; in which during follow up evaluation for their cardiac status to exclude congestive heart failure, presence of residual PDA had been done. All data were entered in a structured data sheet and analyses using Spss window 17 statistical program.Results: A total of 52 patients with clinical diagnosis of PDA, 26 patients in each treatment group of either standard closure or new closure technique. Female patients had outnumbered male patients by 5.5 folds. A total of 46.1% of patients were under five years old. A relatively younger  population of patients was seen with the new closure technique as compared to patients in the standard closure technique (p=0.02). Similarly a correspondingly less heavier weight was noted in patients who underwent new closure technique as compared to those who had standard closuretechnique(p=0.03). Long- term follow up of patients with their treatment modalities it was found that 3 patients and 2 patients had residue lesion and congestive cardiac failure respectively who were exclusively in the standard closure technique, none of such complications were seen with thenew closure technique (p=0.04). With such evidence, the practice to date has been the new closure technique for definitive surgical treatment for PDA.Conclusion Open surgery for PDA closure remains the procedure of choice for facility and technically deprived countries. The approach and the technique of closure that minimize the postoperative complications is a challenge from centre to centre. However this study with a new closure in which a purse string on the ampulla of the PDA followed by a silk ligature has proved to be efficient and reliable technique that leaves no residual lesion with no long term complications.Key words: Closure, Isolated, Patent, ductus arteriosus, PD

Early outcome of Mitral Valve replacement: Results from Chordal Preservation at Muhimbiba National Hospital, Tanzania

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Modified blalock-taussig shunt in palliative cardiac surgery

Background: Cyanotic congenital heart diseases present early in life with poor general condition of the patient. Majority of deaths occurs within one year of life before surgical intervention due to severe cyanosis and metabolic acidosis. Modified Blalock-Taussig Shunt (MBTS) is one of the palliative cardiac surgeries done for cyanotic congenital heart diseases. It improves the general condition of the patient before definitive surgery is done. The aim of this study was to determine the commonest indications, post-operative anticoagulation and early complications following MBTS at CARE Hospital, India.Methods: This was a retrospective study from January 2004 to December 2006 including all patients who underwent Posterolateral Thoracotomy for MBTS. All patients had deep cyanosis, oxygen saturation of 65% or less and small pulmonary vasculature due to congenital heart defects. Acyanotic patients and those with oxygen saturation more than 65% were excluded from the study. All patients received a single dose of heparin intra-operatively and oral aspirin as anticoagulant regimen post-operatively. No heparin given postoperatively.Results: A total of 20 children with a mean age of 27.4 months were studied. Two patients had pre-operative ICU admission due to severe cyanosis (both had oxygen saturation of 35%), hypotension and severe body weakness. The commonest indications for MBTS included Tetralogy of Fallot (70%), pulmonary atresia (10%) with or without Ventricular Septal Defect (VSD), tricuspid atresia (10%) with pulmonary atresia or stenosis and Double Outlet Right Ventricle (DOVR) with pulmonary atresia or stenosis (10%). Mean duration of ICU stay was 2 days, mean duration of mechanical ventilation was four and half hours, mean duration of hospital stay was 7 days and mean systemic oxygen saturation improved significantly from 46% to 84% ( x2 = 7.03, p = 0.0080). No post-operative bleeding, seroma, shunt thrombosis or death occurred in this study.Conclusion: The commonest indication for MBTS is TOF. Intra-operative single dose of heparin followed by post-operative oral aspirin as anticoagulant regimen was not associated with a major complication in terms of bleeding, seroma, shunt thrombosis, or death

Cardiac Surgery: One year experience of cardiac surgery at Muhimbili National Hospital, Dar es Salaam- TANZANIA

Background: Establishing a cardiac unit in developing countries is usually difficult as it is associated with many obstacles of both expertise and financial constraints and more alarming is the mortality rate that may be high. Even after success in the initial stage sustainability of such program is a dilemma. The aim of this study was to determine pattern of disease profile, type of cardiac surgery done and the overall outcome.Methods: All patients who underwent cardiac operation at the centre were prospectively recruited. Patients’ demography and disease characteristics as demonstrated at echocardiography and its confirmation at operation were recorded. Peri-operative factors were the measurable statistics that determined the overall patients’ outcome. All data were entered and analyzed using a spss11.5 window program.Results: A total of 105 cases of cardiac surgery were done 21% were male and 79% were females. Mean age was 19.4±12.3. The majority of cases were due to Rheumatic heart diseases (47.6%), congenital heart disease (35.2%), myxomatous valvular degeneration (16.2%) and pericardial disease 1%. Mitral valve disease was the commonest cause of cardiac disease (58.1%). Prolonged duration of aortic cross-clamp and total operation time were associated with prolonged intensive care stay and poor patients’ outcome respectively (p<0.05). While, ventricular dysfunction and total cardiopulmonary bypass time were not. The overall mortality rate was 13.3%. Majority of all death (64.3%) followed mitral valve repair.Conclusion: The majority of patients (86.7%) who underwent cardiac surgery had full recovery. The mortality of (13.3%) is probably comparable to other settings. The diversity of spectrum of cardiac disease found elsewhere is also found in our community and therefore need to increase community awareness. Mitral valve repair deserve a special entity that requires skills and expertise. The mere presence of suboptimal ventricular dysfunction is probably not a contraindication to cardiac operation. The duration of aortic cross-clamp and total operation time were determinant of postoperative outcome

Neoadjuvant chemotherapy in patients with stages III/IV breast cancer disease surgical experience at Muhimbili National Hospital, Dar es Salaam, Tanzania

Background: Breast cancer disease is a health problem of public importance worldwide. In developing countries where majority of patients present late with locally advanced disease: further creates management difficulties to surgeons, oncologists and other medical personnel as to what management protocol suits a particular patient. The aim of this study was to determine disease response, recurrence and development of distant metastasis with the use of chemotherapy in the form of neoadjuvant chemotherapy.Patients and methods: This was a prospective study that had enrolled a total of 57 patients with locally advanced breast cancer disease between January 2003 and December 2005. After completion of treatment patients were followed at 6months interval for 2 years. Patients who fulfilled inclusion criteria at their initial presentation had baseline data including patient’s demography, size of the tumor, node status, presence of distant metastasis and finally stage of the tumor were established. 43 patients of the study group were given chemotherapy in the form of neoadjuvant chemotherapy at 3 weeks interval based on haematological stability until they had completed 4 cycles of dosages before they underwent surgical operation. They were given cyclophosphamide and adriamycin (CA-regime). During subsequent visits of chemotherapy; reassessment was done and recorded. After surgery patient were followed at 6 months interval to assess presence of local recurrence, distant metastasis or death. 14 patients of the study group had surgical treatment before they were given chemotherapy and these formed the adjuvant chemotherapy group. In this group chemotherapy was also given at 3 weeks intervals based on haematological stability and after completion were followed at 6 months interval to determine presence of local recurrence, distant metastasis or death. Radiotherapy was given to any patient in either group where suspicion of residual tumor was present. Patients’ data were entered in an SPSS window 11.5 program and data were analyzed.Results: Patient had mean age of 44.14±8.42 years, with age ranging from 29 to 65 years. 81.5% of patients were 50 years and below and were premenopausal. The mean duration of symptoms at presentation was 3.3±1.3 months with minimum and maximum of 1 and 7 months respectively. 19.3% of the study patients had family history of breast cancer disease to their first degree relatives. Ductal carcinoma was the commonest histopathological finding in 82.5% of all cases. Neoadjuvant chemotherapy was found to be effective in down staging locally advanced breast cancer disease and the response rate was 50-83.3%. During follow up period local recurrence occurred more on the 12 and 18 months in the adjuvant chemotherapy group as compared to the neoadjuvant chemotherapy group and this difference was statistically significant (ρ<0.05). A relatively higher incidence of distant metastasis was also noted on the 24 month of follow up in the adjuvant chemotherapy group as compared to the neoadjuvant chemotherapy group and the difference was statistically significant (ρ<0.05). No statistical difference was noted with regards to death in either of the treatment groups.Conclusion: This study has shown that neoadjuvant chemotherapy is associated with high response rate in down staging of locally advanced breast cancer and hence improving patient management from palliative to more definitive surgical management. It has further shown that use of neoadjuvant chemotherapy is associated with low recurrence and late emergence of distant metastasis when compared to patients who undergoes first surgery and then chemotherapy in a form of adjuvant chemotherapy. We therefore highly recommend the use of neoadjuvant chemotherapy in patients with locally advanced breast cancer disease before surgery is undertaken.Keywords: locally advanced breast cancer disease, neoadjuvant chemotherapy, adjuvant chemotherapy, and response rate

Closed Mitral Valvotomy-a Life Saving Procedure in Facility Deprived Countries: Experience at Muhimbili National Hospital, Tanzania.

Background: Rheumatic heart disease remains a major health cardiac problem in developing countries as the culprit of rheumatic fever. Mitral valve stenosis is the most common complication of valvular heart disease and its consequences of increase in pulmonary hypertension, heart failure, pulmonary vascular disease and if untreated death ensues. The management of this condition varies depending on availability of expertise and resource; however in a facility deprived country with low economic status closed mitral valvotomy remain the standard palliative treatment! The aim of this study was to evaluate the clinical status of patients with mitral stenosis following closed mitral valvotomy treated at Muhimbili National Hospital, Cardiothoracic Unit. Methods: All patients presenting with severe mitral stenosis in absence of calcification in its leaflets and regurgitation were enrolled for the study from May 2008 to November 2009. Excluded were those who failure consents. Results:A total of fourteen patients were included in the study of which 10 (71.4%) were females and 4 (28.6%) were males. They had a mean age of 21.5±8.8 and range from 11 to 41 years. The diagnosis was based on clinical evaluation using NYHA class and 2D-Echocardiography findings. All patients’ demographic data, preoperative and post operative findings were taken and data analysis was done using an SPSS 11.5 program. Categorical data were compared and analyzed using two Tailed- χ2 and values were taken 5% significance level. Conclusion: There was an overall highly significant improvement in clinical stage of the disease, reduction in mean pressure gradient across the mitral valve, reduction in pulmonary hypertension and mean left atrial size. Similarly there was improvement in ventricular function in terms of ejection fraction and increase in mean mitral valve area