Transcatheter Resolution of a Failed Neoconfluence in Pulmonary Atresia With Discontinuous Pulmonary Arteries

We present a case of a full-term newborn with complex congenital heart defects, including single-ventricle physiology and discontinuous pulmonary arteries. Prompt surgical intervention was performed, which involved pulmonary neoconfluence with autologous pericardium graft and systemic-to-pulmonary shunt placement. However, postoperative complications required stenting to address pulmonary artery stenosis.

Bombay blood group for pediatric cardiac surgery in the era of a pandemic: Newer challenges call for desperate measures!

Bombay blood group is one of the rarest blood types with a prevalence of 1 per 10,000 population in India. Children and adults of this blood group can receive autologous blood or blood from an individual with a Bombay phenotype only. Children with grown-up uncorrected cyanotic heart disease are associated with a high risk of perioperative hemorrhagic diathesis and may require multiple blood transfusions. Arrangement of adequate Bombay blood group units for pediatric cardiac surgery is a unique challenge. The COVID-19 pandemic brought about additional difficulties in the procurement of blood components due to donor hostility. Despite the associated risks, pre-operative multi-session autologous blood harvest under monitored anesthesia care was planned in a 16-year-old child and four units of autologous blood were harvested and preserved for performing total correction surgery.

Association Between Plasma Fibrinogen Concentration After Cardiopulmonary Bypass and Postoperative Blood Loss in Children Undergoing Cardiac Surgery: A Retrospective Cohort Study

Background Intraoperative hypofibrinogenemia is a major factor associated with increased postoperative blood loss in adult cardiac surgery. However, previous pediatric studies on this topic did not sufficiently adjust for potential confounders and variations in surgeons' techniques. Therefore, evidence for the association between hypofibrinogenemia and postoperative blood loss after cardiac surgery in children remains insufficient. In this study, we aimed to evaluate the association between postoperative blood loss and hypofibrinogenemia by adjusting for potential confounders and the effects of differences in surgeons' techniques. Methodology This single-center, retrospective, cohort study included children who underwent cardiac surgery with cardiopulmonary bypass from April 2019 to March 2022. Multilevel logistic regression models with mixed effects were used to evaluate the association of major blood loss in the first six hours postoperatively with fibrinogen concentration at the end of cardiopulmonary bypass. The difference in the surgeon's techniques was adjusted as a random effect for the model. The model included potential confounders identified as risk factors in previous studies. Results A total of 401 patients were included. A fibrinogen concentration ≤150 mg/dL (adjusted odds ratio (aOR) = 2.08; 95% confidence interval (CI) = 1.18-3.67; p = 0.011) and the presence of cyanotic disease (aOR = 2.34; 95% CI = 1.10-4.97; p = 0.027) were associated with major blood loss in the first six postoperative hours. Conclusions A fibrinogen concentration ≤150 mg/dL and the presence of cyanotic disease were associated with postoperative blood loss in pediatric cardiac surgery. Maintaining a fibrinogen concentration >150 mg/dL is recommended, especially for patients with cyanotic diseases.

Recurrent Brain Abscess in a Child With Cyanotic Congenital Heart Disease

Brain abscesses are rare but life-threatening conditions associated with morbidity and mortality. They are encountered in unoperated and partially treated cyanotic congenital heart diseases. Our patient is a diagnosed case of transposition of great arteries with a ventricular septal defect. She had recurrent abscesses for which a combination of antimicrobial therapy and surgical excision was performed. Surgical excision carries a great risk of rupture of abscess into the ventricular system and is associated with poorer outcomes. The outcome of brain abscess primarily depends on Glasgow Coma Score (GCS) at the time of admission and ventricular extension of the abscess. Fortunately, our patient showed good results without any apparent neurological sequelae. Early diagnosis of the brain abscess and timely administration of antibiotics help in a good outcome.

Transcatheter Mitral Valve Repair in a Tricuspid Atresia Patient With Potts and Glenn Shunts

Our patient was a 50-year-old woman with tricuspid atresia who had undergone palliation with a Potts shunt to the left pulmonary artery as an infant and a classic Glenn shunt to the right pulmonary artery as a young child. Under general anesthesia, she underwent transcatheter edge-to-edge repair of the mitral valve for severe symptomatic mitral regurgitation. (Level of Difficulty: Advanced.)

Heart Block in Unpalliated Complex Adult Congenital Heart Disease: Massive Collateral Burden Precludes Epicardial Pacemaker

Complete heart block is a common complication for adults with congenital heart disease (CHD). Epicardial pacing is preferred in patients with septal shunting due to risk of thromboembolism. Anatomic changes in complex CHD may preclude surgical epicardial lead placement. Thromboembolism risk reduction in such patients requiring endocardial pacing remains questionable. (Level of Difficulty: Advanced.)

Early outcomes after the on pump bidirectional Glenn procedure: A single center experience

OBJECTIVE

Bidirectional Glenn procedure is a staged palliative procedure for patients with the univentricular hearts or complex congenital heart disease. We in our study, attempted to evaluate the preoperative characteristics, operative data and the early postoperative outcomes in the patients who underwent Bidirectional Glenn procedure at our center.

METHODS

In our single center retrospective experience, 115 patients underwent Bidirectional Glenn procedure from January 2015 to December 2019.

RESULTS

The mean age of the patients was 6.55 ± 6.5 years (range from 9 months to 48 years) and a median of 5 years. The most common anatomic diagnosis was double outlet right ventricle (n = 49, 42.6%). The primary diagnosis and the additional cardiac anamolies were not associated with the adverse outcomes. The increased cardiopulmonary bypass and operative time affect the postoperative outcomes. The median oxygen saturation in the patients postoperatively was 82%. The median postoperative stay was 8 days. The early postoperative complications were seen in 29 patients (25.2%). There were 12 early deaths (10.4%) in our study. The late age of presentation and poor preoperative nutrition, increased the risk of the postoperative morbidity and mortality.

CONCLUSION

Bidirectional Glenn procedure is an effective procedure to improve efficacy of the gas exchange and reduce volume overload on the single ventricle at early as well as late stages. However, the late age of presentation increases the risk of the postoperative outcomes.

Incidental Diagnosis After a Car Accident: A Rare Case of Asymptomatic Uncorrected Tetralogy of Fallot

Tetralogy of Fallot (TOF) is a heterogeneous congenital heart disease that is occasionally diagnosed during adulthood. However, although they are often asymptomatic, adult patients with uncorrected TOF often have a poor prognosis. Poor outcomes indicate the importance of the identification and management of these patients, especially in the context of intercurrent disease or noncardiac surgery. We describe a case of clinically silent TOF in a 51-year-old woman. TOF was unmasked during a major noncardiac surgery for a polytrauma and successfully treated with the cooperation of a multidisciplinary team. (Level of Difficulty: Advanced.).

Combined Use of Rotational Thromboelastometry (Rotem) and Platelet Impedance Aggregometry (Multiplate Analyzer) in Cyanotic and Acyanotic Infants and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass: Subgroup Analysis of a Randomized Clinical Trial

OBJECTIVES

Few studies have investigated the Multiplate platelet function analyzer in pediatrics. The authors evaluated Multiplate combined with Rotem in terms of guiding platelet transfusion after pediatric cardiac surgery with cardiopulmonary bypass (CPB). The authors further compared coagulation parameters between cyanotic and acyanotic patients.

DESIGN

Subgroup analysis of a randomized clinical trial.

SETTING

Tertiary hospital.

PARTICIPANTS

Patients weighing between seven and 15 kg.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Rotem and Multiplate tests were performed (1) after anesthesia induction, (2) upon CPB separation, and (3) upon intensive care unit arrival. Among a total of 59 subjects, 9 patients required platelet transfusion. In multivariate linear regression, analysis EXTEM maximum clot firmness upon CPB separation was associated with the volume of transfused platelets (regression coefficient = -0.348 [95% confidence interval -1.006 to -0.028]; p = 0.039). No such association was found for the Multiplate test. Acyanotic and cyanotic heart disease were present in 32 and 27 children, respectively. There were no significant differences between these two groups in terms of platelet count and function. Postoperative blood loss was significantly higher in the cyanotic group compared with the acyanotic arm (p = 0.015; difference [95% confidence interval -2.40 {-4.20 to -0.60}]). There were no differences between groups regarding transfusion of allogeneic blood products.

CONCLUSIONS

This study showed that Rotem, but not Multiplate results, were associated with platelet transfusion in pediatric cardiac surgery with no intake of platelet inhibitors. The usefulness of combining these tests in platelet transfusion decision-making needs to be evaluated in larger populations.

Maternal and perinatal outcomes of pregnant women with tetralogy of Fallot: a tertiary center experience from south-India

BACKGROUND

Women with tetralogy of Fallot especially uncorrected are at increased risk of adverse maternal and perinatal outcomes.

METHOD

We reviewed the maternal complications and pregnancy outcomes of women with tetralogy of Fallot (ToF), having corrected or uncorrected lesion during the period from 2011 to 2019 attending a south-Indian tertiary care center. Data regarding demographics, clinical course, and medications received and echocardiographic diagnosis regarding ToF, labor and delivery details, and postpartum follow-up was collected from the records. For each case, four women matched for age (±2 years), without a diagnosis of heart disease, were included as controls. We compared the outcomes in pregnant women with ToF and controls as well between those who have undergone repair with those without repair and also with the controls.

RESULTS

There were 27 pregnancies in 19 patients with ToF, including eight pregnancies in seven women with uncorrected lesions. There was no maternal death or occurrence of infective endocarditis. Women with uncorrected lesion had significantly higher rates of fetal growth restriction (37.5% vs 6.7%), preterm birth (50% vs. 13.3%) resulting in lower birth weight (1907.5 g vs. 2607.3 g)) compared to those with a corrected lesion. Women with corrected lesion had similar outcomes to the controls (p > .5).

CONCLUSION

Women with uncorrected ToF are at increased risk of perinatal complications compared to those with corrected lesion and require care under a multidisciplinary team, with an individualized plan for delivery to optimize the outcomes.

COVID-19 in an Adult With Tricuspid Atresia S/P Fontan Palliation

In December 2019, a pathogenic novel human coronavirus (HCoV), termed SARS-CoV-2, was recognized in Wuhan, China, causing significant morbidity and mortality. The illness caused by SARS-CoV-2 is labelled coronavirus disease-2019 (COVID-19) by the World Health Organization. We report the first case of COVID-19 in an adult congenital heart disease patient with single ventricle physiology S/P Fontan palliation. (Level of Difficulty: Advanced.).

Evaluation of noninvasive hemoglobin monitoring in children with congenital heart diseases

BACKGROUND

Noninvasive measurement of blood hemoglobin could save time and decrease the risk of anemia and infection. The accuracy of CO-oximetry-derived noninvasive hemoglobin (Sp-Hb) had been evaluated in pediatric population; however, its accuracy in children with congenital heart disease has not been studied till date. We evaluated the accuracy of Sp-Hb in relation to laboratory-measured hemoglobin (Lab-Hb) in children with congenital heart disease.

METHODS

This prospective observational study included children with congenital heart disease undergoing procedural intervention. Sp-Hb measurements were obtained using Radical-7 Masimo pulse CO-oximeter and were compared against simultaneous Lab-Hb measurements obtained from the arterial line. Children were divided in cyanotic and acyanotic, and separate analysis was performed for each group. The values of both measurements were analyzed using Spearman's correlation coefficient and Bland-Altman analysis. Correlation was performed between Sp-Hb and Lab-Hb bias and each of arterial oxygen saturation and perfusion index.

RESULTS

One-hundred and eleven pairs of readings were obtained from 65 children. The median (quartiles) age and weight of the children were 1 (1.2-4) years and 11 (8-17) kg, respectively. There was moderate correlation between Lab-Hb and Sp-Hb with a correlation coefficient (95% confidence interval [CI]) of 0.75 (0.63-0.83) in acyanotic children and 0.62 (0.37-0.79) in cyanotic children. The mean bias (95% limits of agreements) was -0.4 g/dL (-2.4 to 1.6 g/dL) and 1 g/dL (-2.7 to 4.6 g/dL) in acyanotic and cyanotic children, respectively. The mean bias between Sp-Hb and Lab-Hb showed a weak negative correlation with oxygen saturation (r [95% CI]): (-0.36 [-0.51--0.18]), and a weak positive correlation with the perfusion index (r [95% CI]): (0.19 [0.01-0.37]).

CONCLUSION

The large bias and the wide limits of agreement between Sp-Hb and Lab-Hb denote that Masimo-derived Sp-Hb is not accurate in children with congenital heart disease especially in the cyanotic group; the error in Sp-Hb increases when oxygen saturation decreases.

Congenitally "Inverted" Pulmonary Valve in Tetralogy of Fallot: When Nature Falters

A cyanotic neonate with tetralogy of Fallot was found to have a congenitally inverted pulmonary valve. Diagnosis was made via echocardiography and cardiac catheterization. The valve opened retrograde into the right ventricle, which allowed severe regurgitation and prevented anterograde flow. This report is the first description of this anomaly in medical literature. (Level of Difficulty: Intermediate.).

Mystery still unresolved: Untouched "Blue heart" presenting at 40yrs of age

The modern-day surgical techniques and strategies have changed the outlook of patients with dextro-transposition of great arteries (d-TGA). The survival of an unrepaired d-TGA into late adulthood is difficult to explain. Even when large intracardiac shunts are present, it still remains a lethal cyanotic congenital heart disease if it is not surgically corrected soon after birth. Here, we report an extremely rare case of d-TGA presenting at 40 years of age, with moderately elevated pulmonary artery pressures and relatively stable symptoms.

Fontan Liver Lesions: Not Always HCC

A 24-year-old Fontan procedure patient underwent surveillance liver cardiac magnetic resonance imaging. Findings were suggestive of hepatocellular carcinoma (HCC). Currently, HCC is diagnosed based on imaging alone. Given her otherwise reassuring clinical profile, she underwent liver biopsy. Pathology demonstrated focal nodular hyperplasia. This raises concern for overdiagnosis of HCC in Fontan patients without tissue confirmation. (Level of Difficulty: Advanced.)

Accuracy of pulse oximeters at low oxygen saturations in children with congenital cyanotic heart disease: An observational study

BACKGROUND

Pulse oximetry overestimates arterial oxygen saturation (SaO₂ ) at less than 90% saturation in cyanotic children. The Masimo Blue sensor (Masimo Corp., Irvine, CA) is a pulse oximetry sensor developed for use in children with cyanosis. However, there remains a lack of research in actual clinical practice.

AIMS

We evaluated the intraoperative performance of three different pulse oximeters to measure oxyhemoglobin saturation (SpO₂ ) at low saturations in pediatric patients with cyanotic heart disease and the influence of clinical variables (SaO₂ , hemoglobin concentration, perfusion index, and weight) on the accuracy of the sensors.

METHODS

This prospective observational study compared SpO₂ measured using three pulse oximeters (Masimo Blue [Masimo Corp., Irvine, CA]; Masimo LNCS, and Nellcor [Medtronic, Dublin, Ireland]) at selected SaO₂ ranges (≥85%, 75%-84%, 60%-74%, and < 60%). Accuracy was evaluated according to bias and Bland-Altman analysis with appropriate correction for multiple measurements. Relationships between bias and clinical variables were assessed using a generalized estimating equation.

RESULTS

Two hundred and fifty-eight samples were analyzed. The mean overall bias (limits of agreement) of Masimo Blue, Masimo LNCS, and Nellcor sensor was -5.3 (-20.9 to 10.3%), -7.4 (-21.9 to 7.1%), and -7.4 (-22.5 to 15.1%), respectively. However, there was no difference in bias among the three sensors at SaO₂ <60%. Generalized estimating equation showed that SaO₂ value was associated with bias of all sensors. Perfusion index affected the bias of Blue sensor and LNCS sensor, and patients' weight was associated with bias of Nellcor sensor.

CONCLUSION

Masimo blue sensor demonstrated overall lower bias compared to the other two sensors. However, the accuracy of all sensors was similarly poor at SaO₂ less than 60%. Bias was influenced by SaO₂ , perfusion index, and body weight.

Thrombolytics for late superior caval vein thrombus in a patient with tricuspid atresia and single-lung Glenn anastomosis

BACKGROUND

Those with cyanotic heart disease have an elevated bleeding risk but also are hypercoaguable. Treating haemodynamically significant thrombi in this unique cohort poses a monumental challenge. Case A 29-year-old women with tricuspid atresia and left pulmonary artery atresia presented with superior caval vein syndrome. She had a right modified Blalock-Taussig shunt as a neonate. A left modified Blalock-Taussig shunt performed later failed to establish flow to her left lung. At age 5, she had a Fontan procedure to the right lung but could not tolerate the physiology and had a low cardiac output syndrome. The Fontan was taken down and she was left with a Glenn anastamosis to the right pulmonary artery. She did well for years until she had dyspnea, upper extremity oedema and "facial fullness". On examination she was tachycardic, hypotensive, and more desaturated than baseline. She also had facial plethora. Decision-making Echocardiogram showed a large 9 × 3 mm nearly occlusive thrombus in the superior caval vein at the bifurcation of the left and right innominate veins. An emergent venogram confirmed the location and size of the thrombus. Given the thrombus burden and potential for distal embolisation through the Glenn to the single functional lung, we chose to treat the patient with thrombolytics. She had uncomplicated ICU course and was sent home on warfarin. Follow-up echocardiogram showed complete resolution of clot.

CONCLUSION

This case shows the importance of history and physical exam in caring for this complex cohort of adult patients with CHD.

Management of tetralogy of Fallot with unilateral absence of pulmonary artery: an overview

Tetralogy of Fallot with unilateral absence of pulmonary artery (PA) is a rare congenital anomaly that has been reported in isolated case reports and small case series. There is no well-defined treatment algorithm for these patients, and repair has been associated with high mortality, although survival is improving in the more recent era. Recent reports suggest strict case selection criteria based on PA dimensions and size of the left ventricle.

Surgery for brain abscess in children with cyanotic heart disease: An anesthetic challenge

Context:

Patients with cyanotic congenital heart disease (cCHD) are prone to develop frequent brain abscesses. Surgery for these abscesses is often limited to aspiration under local anesthesia because excision under general anesthesia (GA) is considered a riskier option. Perioperative hemodynamic instability, cyanotic spells, coagulation defects, electrolyte and acid base imbalance, and sudden cardiac arrest are among the major anesthetic concerns. Most of our current knowledge in this area has been gained from a neurosurgical standpoint while there is a paucity of corresponding anesthesia literature.

Aims:

To highlight the anesthesia issues involved in cCHD children undergoing brain abscess excision under GA.

Settings and Design:

Retrospective study of our institutional experience over a 5 year period.

Materials and Methods:

Of all the children with cCHD who underwent brain abscess surgery from January 2005 to December 2009, only 4 were operated under GA. Surgery was done after correcting fever, dehydration, electrolyte imbalance, coagulopathy and acid-base abnormalities, and taking appropriate intraoperative steps to maintain hemodynamic stability and prevent cyanotic spells and arrhythmias. Results: All 4 patients had a successful abscess excision though with varying degrees of intraoperative problems. There was one death, on postoperative day 34, due to septicemia. Conclusions: Brain abscess excision under GA in children of cCHD can be safely carried out with proper planning and attention to detail.

Pulmonary endarteritis, cerebral abscesses, and a single ventricle: An uncommon combination

Endocarditis of the right side of the heart is otherwise uncommon in children. Pulmonary endarteritis as a complication of congenital heart disease is even rarer. Herein, we report the case of pulmonary endarteritis with a 7 mm ×5 mm vegetation, involving the main pulmonary artery in a 4-year-old male child, with cyanosis and a 1-week history of fever and rapidly-progressive hemiparesis. A full segmental echocardiography demonstrated a double inlet left ventricle with left-sided subaortic hypoplastic right ventricle (Van Praagh's A-III type – Single Ventricle). Additionally, CT scan of the brain revealed bilateral cerebral abscesses. To the best of our knowledge, the occurrence of pulmonary endarteritis and cerebral abscesses in a case of single ventricle is hitherto unreported. This article underlines the importance of heightened clinical awareness and meticulous echocardiography in cases of congenital heart disease so that relatively rare complications may not be missed.

Comparison of the effects of propofol and midazolam on inflammation and oxidase stress in children with congenital heart disease undergoing cardiac surgery

PURPOSE

To investigate and compare the effects of propofol and midazolam on inflammation and oxidase stress in children with congenital heart disease undergoing cardiac surgery.

MATERIALS AND METHODS

Thirty-two ASA class I-II children with congenital heart disease undergoing cardiac surgery were randomly divided into two groups: propofol combined with low dose fentanyl (PF group, n = 16) and midazolam combined with low dose fentanyl (MF group, n = 16). Tracheal extubation time and length of Intensive Care Unit (ICU) stay were recorded. Blood samples were taken before operation (T₀), at 2 h after release of the aorta cross-clamp (T₃) and at 24 h after operation (T₄) to measure interleukin 6 (IL-6), IL-8, superoxide dismutase (SOD) and malondialdehyde (MDA) levels. Myocardium samples were collected at 10-20 min after aorta cross-clamp (T₁) and at 10-20 min after the release of the aorta cross-clamp (T₂) to detect heme oxygenase-1 (HO-1) expression.

RESULTS

Tracheal extubation time and length of ICU stay in PF group were significantly shorter than those of the MF group (p < 0.05, respectively). After cardiopulmonary bypass, IL-6, IL-8 and MDA levels were significantly increased, and the SOD level was significantly reduced in both two groups, but PF group exhibited lower IL-6, IL-8 and MDA levels and higher SOD levels than the MF group (p < 0.05, respectively). The HO-1 expression in the PF group was significantly higher than that in MF group at the corresponding time points (p < 0.05, respectively).

CONCLUSION

Propofol is superior to midazolam in reducing inflammation and oxidase stress and in improving post-operation recovery in children with congenital heart disease undergoing cardiac surgery.

An innovative simple technique of blood conservation in adult patients with tetralogy of Fallot and severely raised hemoglobin

The adult patients of tetralogy of Fallot often present with high hemoglobin levels. High hemoglobin and hematocrit on cardiopulmonary bypass (CPB) are associated with increased hemolysis, plasma free hemoglobin, renal dysfunction or failure, postoperative bleeding, exploration for bleeding, and increased requirement of allogeneic blood and blood products. Despite the presence of high hemoglobin and its association with adverse outcome, blood conservation is rarely practiced in these patients because of the fear of possible hemodynamic instability, and hypoxemic spell. We describe an innovative, simple technique of blood conservation for adult patients of tetralogy of Fallot with severely raised hemoglobin. With this technique, hemoglobin can be normalized on CPB; moreover, there is no fear of hypoxemic spell or hemodynamic instability. Furthermore, the blood conserved is readily available for transfusion in the perioperative period, if needed.

Cor triatriatum and anomalous pulmonary venous return: an unusual case

In December 1954, a 29-year-old man with cor triatriatum underwent partial surgical repair consisting of left atrial implantation of a single anomalous pulmonary vein that had been draining into the innominate vein. In April 1989, at age 64, he returned for definitive cardiac repair. The contrast between these 2 procedures illustrates the tremendous progress that has been made in cardiac diagnosis and surgery during the past 35 years.