Spontaneous expectoration of a Blalock-Taussig shunt a decade after operation

An eleven-year-old boy expectorated a foreign body in cough that was identified as the prosthetic graft used for a Blalock-Taussig shunt. The shunt procedure was done 10 years earlier, and a definitive repair for tetralogy of Fallot was done a year later. He had no other symptoms, and a computed tomography (CT) angiogram did not reveal any other significant anomaly. The reason for this extremely rare event is unclear

Basic arterial blood gas biomarkers as a predictor of mortality in tetralogy of Fallot patients

Background: Serum lactate and base deficit have been shown to be a predictor of morbidity and mortality in critically ill patients. Poor preoperative oxygenation appears to be one of the significant factors that affects early mortality in tetralogy of Fallot (TOF). There is little published literature evaluating the utility of serum lactate, base excess (BE), and oxygen partial pressure (PO 2 ) as simple, widely available, prognostic markers in patients undergoing surgical repair of TOF. Materials and Methods: This prospective, observational study was conducted in 150 TOF patients, undergoing elective intracardiac repair. PO 2 , BE, and lactate levels at three different time intervals were recorded. Arterial blood samples were collected after induction (T1), after cardiopulmonary bypass (T2), and 48 h (T3) after surgery in the Intensive Care Unit (ICU). To observe the changes in PO 2 , BE, and lactate levels over a period of time, repeated measures analysis was performed with Bonferroni method. The receiver operating characteristics (ROC) analysis was used to find area under curve (AUC) and cutoff values of various biomarkers for predicting mortality in ICU. Results: The patients who could not survive showed significant elevated lactate levels at baseline (T1) and postoperatively (T2) as compared to patients who survived after surgery (P < 0.001). However, in nonsurvivors, the BE value decreased significantly in the postoperative period in comparison to survivors (−2.8 ± 4.27 vs. 5.04 ± 2.06) (P < 0.001). In nonsurvivors, there was a significant fall of PO 2 to a mean value of 59.86 ± 15.09 in ICU (T3), whereas those who survived had a PO 2 of 125.86 ± 95.09 (P < 0.001). The ROC curve analysis showed that lactate levels (T3) have highest mortality predictive value (AUC: 96.9%) as compared to BE (AUC: 94.5%) and PO 2 (AUC: 81.1%). Conclusion: Serum lactate and BE may be used as prognostic markers to predict mortality in patients undergoing TOF repair. The routine analysis of these simple, fast, widely available, and cost-effective biomarkers should be encouraged to predict prognosis of TOF patients

Serum albumin perturbations in cyanotics after cardiac surgery: Patterns and predictions

Introduction: Hypoalbuminemia is a well-recognized predictor of general surgical risk and frequently occurs in patients with cyanotic congenital heart disease (CCHD). Moreover, cardiopulmonary bypass (CPB)-induced an inflammatory response, and the overall surgical stress can effect albumin concentration greatly. The objective of his study was to track CPB-induced changes in albumin concentration in patients with CCHD and to determine the effect of hypoalbuminemia on postoperative outcomes. Materials and Methods: Prospective observational study conducted in 150 patients, Group 1 ≤18 years (n = 75) and Group 2 >18 years (n = 75) of age. Albumin levels were measured preoperatively (T1), after termination of CPB (T2) and 48 h post-CPB (T3). Primary parameters (mortality, duration of postoperative ventilation, duration of inotropes and duration of Intensive Care Unit [ICU] stay) and secondary parameters (urine output, oliguria, arrhythmias, and hemodynamic parameters) were recorded. Results: The albumin levels in Group 1 at T1, T2, and T3 were 3.8 ± 0.48, 3.2 ± 0.45 and 2.6 ± 0.71 mg/dL; and in Group 2 were 3.7 ± 0.50, 3.2 ± 0.49 and 2.7 ± 0.62 mg/dL respectively. All patients showed a significant decrease in albumin concentration 48 h after surgery (P < 0.01). Analysis between the groups, however, showed no statistical difference. Eleven patients expired during the study period, and nonsurvivors showed significantly lower serum albumin concentration 48 h after surgery 2.3 ± 0.62 mg/dL versus 3.7 ± 0.56 mg/dL in the survivors (P < 0.05). Receiver operating characteristic curve showed that a baseline albumin cut-off value of 3.3 g/dL predicts mortality with a positive predictive value 47.6% and a negative predictive value of 99.2% (P < 0.05). A strong correlation was seen between albumin levels at 48 h with duration of CPB ( r2 = 0.6321), ICU stay ( r2 = 0.7447) and incidence of oliguria ( r2 = 0.8803). Conclusions: The study demonstrated similar fall in albumin concentration in cyanotic patients (both adult and pediatric) in response to CPB. Low preoperative serum albumin concentrations (<3.3 g/dL) can be used to identify and prognosticate subset of cyanotics predisposed to additional surgical risk

The role of blood lactate clearance as a predictor of mortality in children undergoing surgery for tetralogy of Fallot

Background: The identification of biomarkers for predicting morbidity and mortality, particularly in pediatric population undergoing cardiac surgery will contribute toward improving the patient outcome. There is an increasing body of literature establishing the clinical utility of hyperlactatemia and lactate clearance as prognostic indicator in adult cardiac surgical patients. However, the relationship between lactate clearance and mortality risk in the pediatric population remains to be established. Objective: To assess the role of lactate clearance in determining the outcome in children undergoing corrective surgery for tetralogy of Fallot (TOF). Methods and Study Design: A prospective, observational study. Setting: A tertiary care center. Study Population: Two hundred children undergoing elective surgery for TOF. Study Method: Blood lactate levels were obtained as baseline before operation (T0), postoperatively at admission to the cardiac intensive care unit after surgery (T1), and then at every 6 h for the first 24 h of Intensive Care Unit (ICU) stay (T6, T12, T18, and T24, respectively). The lactate clearance in the study is defined by the equation ([lactate initial - lactate delayed]/lactate initial) ×100%. Lactate clearance was determined at T1-T6, T1-T12, T1-T18, and T1-T24 time interval, respectively. The primary outcome measured was mortality. Secondary outcomes measured were the duration of mechanical ventilation, duration of inotropic requirement, and duration of ICU stay. Results: Eleven out of the two hundred patients enrolled in the study died. Nonsurvivors had higher postoperative lactate concentration (P 10%, relative to patients with a lactate clearance 10%) after 6 h have improved outcome compared with those with lower lactate clearance

Indications, timing and techniques of radical pericardiectomy via modified left anterolateral thoracotomy (ukc's modification) and total pericardiectomy via median sternotomy (holman and willett) without cardiopulmonary bypass

Background: Patients with constrictive pericarditis can be treated by pericardiectomy by either left anterolateral thoracotomy or median sternotomy. The terms “radical,” “total,” “extensive,” “complete,” “subtotal,” “adequate,” “near-total,” and partial pericardiectomy have been used often without much clarity. We describe our experience with a radical pericardiectomy technique via modified left anterolateral thoracotomy and compare the same to total pericardiectomy via median sternotomy. Methods: In this study, 67 (54.9%) patients underwent radical pericardiectomy via modified left anterolateral thoracotomy (Group I), and 55 (45.1%) patients underwent total pericardiectomy via median sternotomy (Group II). Results: The operative mortalities were 2.9% and 7.2% for the radical and total pericardiectomy groups, respectively. The time taken for normalization to Class I/II in Groups I and II was 30 ± 11 and 36 ± 14 days, respectively (P = 0.009). Surgical techniques did not affect the outcome of atrial fibrillation (P = 0. 77). Reoperation was not required for any patient. The radical pericardiectomy was also associated with less postoperative low cardiac output state as compared to patients undergoing total pericardiectomy (P < 0.001). There was no difference in mean duration of hospitalization; however, the radical pericardiectomy group achieved the New York Heart Association I and II Status quicker than the total pericardiectomy group (P = 0. 009). Conclusions: We conclude that using several technical modifications of pericardial excision, it is possible to achieve radical pericardiectomy via modified left anterolateral thoracotomy, particularly removing the constricting pericardium over the anterolateral, diaphragmatic surfaces of left ventricle and the anterior and diaphragmatic surfaces of the right ventricle until the right atrioventricular groove without using cardiopulmonary bypass in the great majority of patients undergoing pericardiectomy for chronic constrictive pericarditis. Although the surgical approach for pericardiectomy is based on surgeon's preference, left anterolateral thoracotomy is the preferred and noncontroversial approach in the setting of purulent pericarditis and effusive constrictive pericarditis to prevent sternal infection. We recommend median sternotomy approach with or without cardiopulmonary bypass, in the setting of calcific pericardial patches, pericardial masses, reoperations, and calcific pericardial “cocoon” and for those with predominant right-sided and annular involvement

Bidirectional Glenn with interruption of antegrade pulmonary blood flow: Which is the preferred option: Ligation or division of the pulmonary artery?

We report a rare complication of massive aneurysm of the proximal ligated end of the main pulmonary artery which occurred in the setting of a patient with a functionally univentricular heart and increased pulmonary blood flow undergoing superior cavopulmonary connection. Awareness of this possibility may guide others to electively transect the pulmonary artery in such a clinical setting

Successful surgical osteoplasty of the left main coronary artery with concomitant mitral valve replacement and tricuspid annuloplasty

A 50-year-old woman with rheumatic heart disease, mitral stenosis, and critical isolated left main ostial stenosis was successfully treated by mitral valve replacement, tricuspid annuloplasty, and surgery of left main osteoplasty and is reported for its rarity. Notable clinical findings included an intermittently irregular pulse, blood pressure of 100/70 mmHg, cardiomegaly, a diastolic precordial thrill, a mid-diastolic murmur without presystolic accentuation that was loudest at the mitral area. Chest radiograph revealed cardiomegaly with a cardiothoracic ratio of 0.7 due to enlarged right atrium, right ventricle with a straightened left heart border and evidence of pulmonary hypertension. The investigation shows that surgical reconstruction of the left main coronary artery is safe and effective for the treatment

Short-term prognostic value of perioperative coronary sinus-derived-serum cardiac troponin-I, creatine kinase-MB, lactate, pyruvate, and lactate-pyruvate ratio in adult patients undergoing open heart surgery

Objectives: To investigate the release pattern of different cardiac metabolites and biomarkers directly from the coronary sinus (CS) and to establish the diagnostic discrimination limits of each marker protein and metabolites to evaluate perioperative myocardial injury in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Patients and Methods: Sixty-eight patients undergoing first mitral and/or aortic valve replacements with/without coronary artery bypass grafting and Bentall procedure under CPB and blood cardioplegic arrest were studied. All cardiac metabolites and biomarkers were measured in serial CS-derived blood samples at pre-CPB, immediate post aortic declamping, 10 minutes post-CPB and 12 hrs post-CPB. Results: Receiver operating characteristic curve analysis of cardiac biomarkers indicated lactate-pyruvate ratio as the superior diagnostic discriminator of myocardial injury with an optimal "cut-off" value >10.8 immediately after aortic declamping (AUC, 0.92; 95% CI: 0.85-0.98). Lactate was the second best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2mmol/l at immediately after aortic declamping (AUC, 0.89; 95% CI: 0.80-0.96). Cardiac troponin-I was the third best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2.1ng/ml at immediately after aortic declamping (AUC, 0.88; 95% CI: 0.80-0.95). Creatine kinase-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >58 log units/ml prior to decanulation (AUC, 0.85; 95% CI: 0.78-0.94). Conclusions: Measurable cardiac damage exists in all patients undergoing cardiac surgery under cardioplegic arrest. The degree of myocardial injury is more in patients with poor ventricular function and those requiring longer aortic clamp time. CS-derived lactate-pyruvate ratio, lactate, cTn-I served as superior diagnostic discriminators of peri-operative myocardial damage