Peritoneal Dialysis in Infants and Children After Open Heart Surgery

BackgroundInfants and children who undergo surgical repair of complex congenital heart diseases are prone to developing renal dysfunction. The purpose of this study was to investigate the risk factors associated with prolonged peritoneal dialysis (PD) and the mortality of pediatric patients with acute renal failure (ARF) after open heart surgery.MethodsFrom June 1999 to May 2007, a total of 542 children underwent open heart surgery for congenital heart disease. Fifteen (2.8%) experienced ARF and seven (1.3%) required PD. The clinical and laboratory variables were compared between the survivor and non-survivor groups of ARF patients that needed PD.ResultsThe non-survivors (n = 3, 43%) had a longer cardiopulmonary bypass time (154 ± 21 vs. 111 ± 8 minutes, p = 0.012) and longer aorta clamping time (92 ± 40 vs. 66 ± 15 minutes, p = 0.010) than the survivors (n = 4, 57%). Before the PD, the pH and base excess of the arterial blood gas analysis in the survivors was much higher than that non-survivors (7.30 ± 0.04 vs. 7.16 ± 0.10, p = 0.039; −5.15 ± 3.13 vs. −12.07 ± 2.9 mmol/L, p = 0.031). Furthermore, the survivors had a shorter interval between the onset of ARF and the day the PD was begun (1.2 ± 0.4 vs. 4.3 ± 1.2 days, p = 0.001), and shorter duration of PD (6.6 ± 2.7 vs. 13.0 ± 3.5 days, p= 0.036) than non-survivors.ConclusionEarly intervention with PD is a safe and effective method for managing patients with ARF after open heart surgery. The cardiopulmonary bypass and aortic clamping duration, time of initiating PD, duration of the PD, sepsis, and relative complications may predict the prognosis of these patients

A Right-sided Aortic Arch with Kommerell's Diverticulum of the Aberrant Left Subclavian Artery Presenting with Syncope

A right-sided aortic arch with an aneurysm of the aberrant subclavian artery is a rare disease. We report a case of Kommerell's diverticulum of an aberrant left subclavian artery in a patient with a right-sided aortic arch. Fewer than 50 cases have been reported in the literature. A number of operative strategies are described. Right thoracotomy provides good exposure and avoids the morbidity associated with bilateral thoracotomy or sternotomy and thoracotomy. In our patient with symptoms of dysphagia, syncope, and left subclavian steal syndrome, a left thoracotomy was used. The repair was accomplished by division of a left ligamentum arteriosum, obliteration of the Kommerell's aneurysm, and an aorto-subclavian bypass. Postoperative complications included left vocal cord palsy and Horner's syndrome. Hoarseness and left ptosis recovered spontaneously 3 months after surgery, and the patient remained symptom-free at the 1-year follow-up. We believe a left thoracotomy for direct repair of Kommerell's diverticulum is a simple and safe method without the increased morbidity found in other procedures

The role of adenosine in preconditioning by brief pressure overload in rats

Brief pressure overload of the left ventricle reduced myocardial infarct (MI) size in rabbits has been previously reported. Its effects in other species are not known. This study investigates effects of pressure overload and the role of adenosine in rats in this study. Methods: MI was induced by 40-minute occlusion of the left anterior descending coronary artery followed by 3-hour reperfusion. MI size was determined by triphenyl tetrazolium chloride staining. Brief pressure overload was induced by two 10-minute episodes of partial snaring of the ascending aorta. Systolic left ventricular pressure was raised 50% above the baseline value. Ischemic preconditioning was elicited by two 10-minute coronary artery occlusions. Results: The MI size (mean ± standard deviation), expressed as percentage of area at risk, was significantly reduced in the pressure overload group as well as in the ischemic preconditioning group (17.4 ± 3.0% and 18.2 ± 1.5% vs. 26.6 ± 2.4% in the control group, p < 0.001). Pretreatment with 8-(p-sulfophenyl)-theophylline (SPT), an inhibitor of adenosine receptors, did not significantly limit the protection by pressure overload and ischemic preconditioning (18.3 ± 1.5% and 18.2 ± 2.0%, respectively, p < 0.001). SPT itself did not affect the extent of infarct (25.4 ± 2.0%). The hemodynamics, area at risk and mortality were not significantly different among all groups of animals. Conclusion: Brief pressure overload of the left ventricle preconditioned rat myocardium against infarction. Because SPT did not significantly alter MI size reduction, our results did not support a role of adenosine in preconditioning by pressure overload in rats

Coronary Artery Bypass Grafting in Patients with Left Ventricular Dysfunction

Coronary artery bypass grafting surgery (CABG) remains a challenge for patients with coronary artery disease and left ventricular (LV) dysfunction. The aim of this study was to evaluate the result of CABG in patients with LV dysfunction. Methods: Medical records of 1,847 patients who underwent primary, isolated CABG at Taipei Veterans General Hospital from January 1, 1991 to December 31, 2002, were reviewed. The mortality rate associated with clinical and operative variables was compared between patients with LV ejection fraction (LVEF) = 35% and patients with LVEF < 35%. Results: Patients with LVEF < 35% had more episodes of myocardial infarction (57.5% vs 28.9%, p < 0.001) and history of congestive heart failure (18.1% vs 3.2%, p < 0.001), higher New York Heart Association (NYHA) class, and higher angina class. Longer cardiopulmonary bypass time (147 ± 44 minutes vs 137 ± 40 minutes, p < 0 .001) but fewer left internal mammary artery (LIMA) grafts (46.8% vs 65.7%, p < 0.001) were used in patients with LVEF < 35%. Patients with LVEF < 35% had significantly higher hospital mortality (6.6% vs 2.2%, p < 0.001), higher major morbidity (23.3% vs 16.1%, p < 0.01), and longer hospital stay (25 ± 23 days vs 21 ± 16 days, p < 0.01). Conclusion: Although patients with LV dysfunction had higher mortality and morbidity, CABG could be done in these high-risk patients with acceptable results

Prenatal Diagnosis of Tetralogy of Fallot with Pulmonary Atresia

Tetralogy of Fallot involves an abnormal embryological development in which an unequal conotruncal division results in a small pulmonary artery and a great aortic artery. In its most severe form, the infundibulum of the right ventricle and the pulmonary artery can be atretic with the anomaly commonly referred to as pulmonary atresia with ventricular septal defect. Reported here is a case of prenatal diagnosis of tetralogy of Fallot with pulmonary atresia. The characteristic ultrasonographic findings included a small pulmonary artery, a large aorta, and a ventricular septal defect. The search for an atretic pulmonary valve and a ductus arteriosus with reversed blood flow was emphasized in the presence of asymmetrically dilated fetal heart. After birth, the newborn received single-stage total correction for the tetralogy of Fallot and was discharged a month later in stable condition. In this case report, the neonatal angiogram is added for confirming the prenatal diagnosis, which is of value in teaching fetal echocardiography to novice practitioners. We believe a prenatal diagnosis of tetralogy of Fallot can improve neonatal outcome. [J Chin Med Assoc 2008;71(5):262–266

Prenatal Diagnosis of Dextrotransposition of the Great Arteries

Dextrotransposition of the great arteries (DTGA) is a common cardiac cause of cyanosis in newborn infants that can cause acidosis and death within a short period of time unless there is a large atrial-level shunt or a patent ductus arteriosus. Here, we report a case of prenatal diagnosis of DTGA at 24+1 gestational weeks. In a tilted 4-chamber view, the pulmonary trunk branched to the left and the right pulmonary, with its root connected to the left ventricle outflow tract. In the short-axis view, the pulmonary trunk was shown to be parallel with the ascending aortic root. Cesarean section was performed due to the nonreassuring fetal status at 38+5 gestational weeks. The male neonate appeared to have mild cyanotic symptoms and weighed 3,108 g. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Neonatal echocardiography was performed immediately after birth and the findings confirmed DTGA associated with atrial septal defect secundum. Postnatally, angiography confirmed the echocardiographic diagnosis of DTGA with a large atrial septal defect secundum and a large patent ductus arteriosus. Jatene arterial switch operation and atrial septal defect closure with Gore-Tex patch were performed. The neonate withstood the operation well and was discharged 27 days after birth weighing 2,950 g and in a stable condition. Prenatal diagnosis of DTGA can greatly aid to prepare the patient's family and the surgeon and significantly improve the outcome of complex heart disease in the neonatal period

Transplantation of insulin-producing cells from umbilical cord mesenchymal stem cells for the treatment of streptozotocin-induced diabetic rats

Abstract Background Although diabetes mellitus (DM) can be treated with islet transplantation, a scarcity of donors limits the utility of this technique. This study investigated whether human mesenchymal stem cells (MSCs) from umbilical cord could be induced efficiently to differentiate into insulin-producing cells. Secondly, we evaluated the effect of portal vein transplantation of these differentiated cells in the treatment of streptozotocin-induced diabetes in rats. Methods MSCs from human umbilical cord were induced in three stages to differentiate into insulin-producing cells and evaluated by immunocytochemistry, reverse transcriptase, and real-time PCR, and ELISA. Differentiated cells were transplanted into the liver of diabetic rats using a Port-A catheter via the portal vein. Blood glucose levels were monitored weekly. Results Human nuclei and C-peptide were detected in the rat liver by immunohistochemistry. Pancreatic β-cell development-related genes were expressed in the differentiated cells. C-peptide release was increased after glucose challenge in vitro. Furthermore, after transplantation of differentiated cells into the diabetic rats, blood sugar level decreased. Insulin-producing cells containing human C-peptide and human nuclei were located in the liver. Conclusion Thus, a Port-A catheter can be used to transplant differentiated insulin-producing cells from human MSCs into the portal vein to alleviate hyperglycemia among diabetic rats.</p

Preconditioning threshold of brief pressure overload of the left ventricle

Background: We previously reported that pressure overload of the left ventricle reduced myocardial infarct (MI) size in rabbits. The threshold of pressure overload was investigated in this study. Methods: Pressure overload of the left ventricle was induced by partial snare of the ascending aorta in anesthetized, open-chest rabbits. Systolic left ventricular pressure (SLVP) was elevated 50% or 30% above baseline value by varying the degree of partial snaring. Different duration of pressure overload, including 10 minutes, 5 minutes, 3 minutes, or 2 minutes, was applied to determine the threshold of protective effects. Ischemic preconditioning was elicited by two 10-minute coronary artery occlusions and reperfusions. Ten minutes after different pretreatment, 1 hour occlusion of the left anterior descending coronary artery followed by 3 hours reperfusion was done to induce MI. The size of area at risk and MI were determined by blue dye injection and triphenyl tetrazolium chloride staining after experiments. Results: Pressure overload increase of SLVP 50% above baseline value for 10 minutes, 5 minutes, and 3 minutes significantly reduced MI size (18.5 ± 3.6%, 21.4 ± 1.9% and 21.6 ± 1.7%, respectively, vs. 26.6 ± 1.0% in the control group, mean ± standard deviation, p < 0.01). A 30% increase of SLVP by pressure overload for 10 minutes, 5 minutes and 3 minutes also significantly decreased MI size (20.5 ± 2.5%, 21.6 ± 2.3%, and 21.5 ± 2.3%, p < 0.01). Ischemic preconditioning significantly decreased MI size (19.9 ± 2.8%, p < 0.001). Pressure overload to elevate SLVP 50% or 30% above baseline value for 2 minutes did not significantly alter MI size (25.0 ± 2.3% and 26.0 ± 1.7%, p = 0.122 and p = 0.457). Two episodes of 2 minutes pressure overload did not significantly decrease MI size (25.0 ± 2.2% and 25.5 ± 2.2%, p = 0.118 and p = 0.281). The hemodynamics, area at risk, and mortality were not significantly different among all groups of animals. Conclusion: Pressure overload to raise SLVP either 50% or 30% above baseline value reduced MI size. A minimum duration of 3 minutes was necessary to induce the protective effects

Comparisons of Differentiation Potential in Human Mesenchymal Stem Cells from Wharton’s Jelly, Bone Marrow, and Pancreatic Tissues

Background. Type 1 diabetes mellitus results from autoimmune destruction of β-cells. Insulin-producing cells (IPCs) differentiated from mesenchymal stem cells (MSCs) in human tissues decrease blood glucose levels and improve survival in diabetic rats. We compared the differential ability and the curative effect of IPCs from three types of human tissue to determine the ideal source of cell therapy for diabetes. Methods. We induced MSCs from Wharton’s jelly (WJ), bone marrow (BM), and surgically resected pancreatic tissue to differentiate into IPCs. The in vitro differential function of these IPCs was compared by insulin-to-DNA ratios and C-peptide levels after glucose challenge. In vivo curative effects of IPCs transplanted into diabetic rats were monitored by weekly blood glucose measurement. Results. WJ-MSCs showed better proliferation and differentiation potential than pancreatic MSCs and BM-MSCs. In vivo, WJ-IPCs significantly reduced blood glucose levels at first week after transplantation and maintained significant decrease till week 8. BM-IPCs reduced blood glucose levels at first week but gradually increased since week 3. In resected pancreas-IPCs group, blood glucose levels were significantly reduced till two weeks after transplantation and gradually increased since week 4. Conclusion. WJ-MSCs are the most promising stem cell source for β-cell regeneration in diabetes treatment

Malignancy After Heart Transplantation

The purpose of this study was to assess the incidence and type of malignancies after heart transplantation at a medical institute in Taiwan. Methods: From January 1987 to December 2008, a total of 66 patients who survived more than 30 days after transplantation were enrolled in this study. Results: Of the 66 heart transplant recipients, 8 (12.1%) post-transplant malignancies were diagnosed: 5 post- transplant lymphoproliferative diseases (PTLD), 1 prostate cancer, 1 lung cancer, and 1 squamous cell carcinoma of the cheek. The clinical presentations were diverse, and the diagnoses were confirmed by biopsy. Only 1 patient died of PTLD and subsequent multiple organ failure. Conclusion: Cancer is a limiting factor for long-term survival after heart transplantation. The most common type in this study was PTLD. Early detection and aggressive treatment results in good response and preserves the allograft