Consensus reporting guidelines to address gaps in descriptions of ultra-rare genetic conditions

Genome-wide sequencing and genetic matchmaker services are propelling a new era of genotype-driven ascertainment of novel genetic conditions. The degree to which reported phenotype data in discovery-focused studies address informational priorities for clinicians and families is unclear. We identified reports published from 2017 to 2021 in 10 genetics journals of novel Mendelian disorders. We adjudicated the quality and detail of the phenotype data via 46 questions pertaining to six priority domains: (I) Development, cognition, and mental health; (II) Feeding and growth; (III) Medication use and treatment history; (IV) Pain, sleep, and quality of life; (V) Adulthood; and (VI) Epilepsy. For a subset of articles, all subsequent published follow-up case descriptions were identified and assessed in a similar manner. A modified Delphi approach was used to develop consensus reporting guidelines, with input from content experts across four countries. In total, 200 of 3243 screened publications met inclusion criteria. Relevant phenotypic details across each of the 6 domains were rated superficial or deficient in >87% of papers. For example, less than 10% of publications provided details regarding neuropsychiatric diagnoses and "behavioural issues", or about the type/nature of feeding problems. Follow-up reports (n = 95) rarely contributed this additional phenotype data. In summary, phenotype information relevant to clinical management, genetic counselling, and the stated priorities of patients and families is lacking for many newly described genetic diseases. The PHELIX (PHEnotype LIsting fiX) reporting guideline checklists were developed to improve phenotype reporting in the genomic era.

Single Versus Dual Antiplatelet Therapy After Coronary Artery Bypass Grafting for Unprotected Left-Main Coronary Disease

BACKGROUND

The use of dual antiplatelet therapy (DAPT) after coronary revascularization for left-main disease is still debated. The study aimed to characterize patients who received dual versus single antiplatelet therapy (SAPT) after coronary artery bypass grafting (CABG) for unprotected left-main disease and compare the outcomes of those patients.

RESULTS

This multicenter retrospective cohort study included 551 patients who were grouped into 2 groups: patients who received SAPT (n = 150) and those who received DAPT (n = 401). There were no differences in age ( P = 0.451), gender ( P = 0.063), smoking ( P = 0.941), diabetes mellitus ( P = 0.773), history of myocardial infarction ( P = 0.709), chronic kidney disease ( P = 0.615), atrial fibrillation ( P = 0.306), or cerebrovascular accident ( P = 0.550) between patients who received SAPT versus DAPT. DAPTs were more commonly used in patients with acute coronary syndrome [87 (58%) vs. 273 (68.08%); P = 0.027], after off-pump CABG [12 (8%) vs. 73 (18.2%); P = 0.003] and in patients with radial artery grafts [1 (0.67%) vs. 32 (7.98%); P < 0.001]. While SAPTs were more commonly used in patients with low ejection fraction [55 (36.67%) vs. 61 (15.21%); P < 0.001] and in patients with postoperative acute kidney injury [27 (18%) vs. 37 (9.23%); P = 0.004]. The attributed treatment effect of DAPT for follow-up major adverse cerebrovascular and cardiac events was not significantly different from that of SAPT [β, -2.08 (95% confidence interval (CI), -20.8-16.7); P = 0.828]. The attributed treatment effect of DAPT on follow-up all-cause mortality was not significantly different from that of SAPT [β, 4.12 (CI, -11.1-19.32); P = 0.595]. There was no difference in bleeding between groups ( P = 0.666).

CONCLUSIONS

DAPTs were more commonly used in patients with acute coronary syndrome, after off-pump CABG, and with radial artery grafts. SAPTs were more commonly used in patients with low ejection fraction and acute kidney injury. Patients on DAPT after CABG for left-main disease had comparable major adverse cerebrovascular and cardiac events and survival to patients on SAPT, with no difference in bleeding events.

Does Gender Affect the Outcomes of Myocardial Revascularization for Left-Main Coronary Artery Disease?

Currently, gender is not considered in the choice of the revascularization strategy for patients with unprotected left main coronary artery (ULMCA) disease. This study analyzed the effect of gender on the outcomes of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with ULMCA disease. Females who had PCI (n = 328) were compared with females who had CABG (n = 132) and PCI in males (n = 894) was compared with CABG (n = 784). Females with CABG had higher overall hospital mortality and major adverse cardiovascular events (MACE) than females with PCI. Male patients with CABG had higher MACE; however, mortality did not differ between males with CABG vs PCI. In female patients, follow-up mortality was significantly higher in CABG patients, and target lesion revascularization was higher in patients with PCI. Male patients had no difference in mortality and MACE between groups; however, MI was higher with CABG, and congestive heart failure was higher with PCI. In conclusion, women with ULMCA disease treated with PCI could have better survival with lower MACE compared with CABG. These differences were not evident in males treated with either CABG or PCI. PCI could be the preferred revascularization strategy in women with ULMCA disease.

Left Main Coronary Artery Revascularization in Patients with Impaired Renal Function: Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting

INTRODUCTION

The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function.

METHODS

This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19-15.76], p < 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79-3.73]; p < 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71-1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90-1.39], p = 0.312).

CONCLUSIONS

PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function.

Percutaneous coronary intervention vs. coronary artery bypass grafting in emergency and non-emergency unprotected left-main revascularization

BACKGROUND

The optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease.

METHODS

This retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Emergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P < 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P = 0.002) and intermediate (P = 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P = 0.001) and high (P = 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P = 0.031) and intermediate (P = 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10-37), emergency PCI had lower MACCE compared to CABG [HR: 0.30 (95% CI 0.14-0.66), P < 0.003], with no significant difference in all-cause mortality between emergency PCI and CABG [HR: 1.18 (95% CI 0.23-6.08), P = 0.845].

CONCLUSIONS

PCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores.

Outcomes of Left Main Revascularization in Patients with Anemia: Gulf Left Main Registry

INTRODUCTION

The aim of this study was to evaluate the effects of baseline anemia and anemia following revascularization on outcomes in patients with unprotected left main coronary artery (ULMCA) disease.

METHODS

This was a retrospective, multicenter, observational study conducted between January 2015 and December 2019. The data on patients with ULMCA who underwent revascularization through percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were stratified by the hemoglobin level at baseline into anemic and non-anemic groups to compare in-hospital events. The pre-discharge hemoglobin following revascularization was categorized into very low (<80 g/L for men and women), low (≥80 and ≤119 g/L for women and ≤129 g/L for men), and normal (≥130 g/L for men and ≥120 g/L for women) to assess impact on follow-up outcomes.

RESULTS

A total of 2,138 patients were included, 796 (37.2%) of whom had anemia at baseline. A total of 319 developed anemia after revascularization and moved from being non-anemic at baseline to anemic at discharge. There was no difference in hospital major adverse cardiac and cerebrovascular event (MACCE) and mortality between CABG and PCI in anemic patients. At a median follow-up time of 20 months (interquartile range [IQR]: 27), patients with pre-discharge anemia who underwent PCI had a higher incidence of congestive heart failure (CHF) (p < 0.0001), and those who underwent CABG had significantly higher follow-up mortality (HR: 9.85 (95% CI: 2.53-38.43), p = 0.001).

CONCLUSION

In this Gulf LM study, baseline anemia had no impact upon in-hospital MACCE and total mortality following revascularization (PCI or CABG). However, pre-discharge anemia is associated with worse outcomes after ULMCA disease revascularization, with significantly higher all-cause mortality in patients who had CABG, and a higher incidence of CHF in PCI patients, at a median follow-up time of 20 months (IQR: 27).

Outcomes of Myocardial Revascularization in Diabetic Patients With Left Main Coronary Artery Disease: A Multicenter Observational Study From Three Gulf Countries

BACKGROUND

Real-world data for managing patients with diabetes and left main coronary artery (LMCA) disease are scarce. We compared percutaneous coronary intervention (PCI) outcomes versus coronary artery bypass grafting (CABG) in diabetes and LMCA disease patients.

METHODS

We retrospectively studied patients with LMCA presented to 14 centers from 2015 to 2019. The study included 2138 patients with unprotected LMCA disease; 1468 (68.7 %) had diabetes. Patients were grouped into; diabetes with PCI (n = 804) or CABG (n = 664) and non-diabetes with PCI (n = 418) or CABG (n = 252).

RESULTS

In diabetes, cardiac (34 (5.1 %) vs. 22 (2.7 %); P = 0.016), non-cardiac (13 (2 %) vs. 6 (0.7 %); P = 0.027) and total hospital mortality (47 (7.1 %) vs. 28 (3.5 %); P = 0.0019), myocardial infarction (45 (6.8 %) vs. 11 (1.4 %); P = 0.001), cerebrovascular events (25 (3.8 %) vs. 12 (1.5 %); P = 0.005) and minor bleeding (65 (9.8 %) vs. 50 (6.2 %); P = 0.006) were significantly higher in CABG patients compared to PCI; respectively. The median follow-up time was 20 (10-37) months. In diabetes, total mortality was higher in CABG (P = 0.001) while congestive heart failure was higher in PCI (P = 0.001). There were no differences in major adverse cerebrovascular events and target lesion revascularization between PCI and CABG. Predictors of mortality in diabetes were high anatomical SYNTAX, peripheral arterial disease, chronic kidney disease, and cardiogenic shock.

CONCLUSIONS

In this multicenter retrospective study, we found no significant difference in clinical outcomes during the short-term follow-up between PCI with second-generation DES and CABG except for lower total mortality and a higher rate of congestive heart failure in PCI group of patients. Randomized trials to characterize patients who could benefit from each treatment option are needed.

Impact of left ventricular ejection fraction on outcomes after left main revascularization: g-LM Registry

AIMS

The impact of left ventricular dysfunction on clinical outcomes following revascularization is not well established in patients with unprotected left main coronary artery disease (ULMCA). In this study, we evaluated the impact of left ventricular ejection fraction (LVEF) on clinical outcomes of patients with ULMCA requiring revascularization with percutaneous coronary intervention (PCI) compared with coronary artery bypass graft (CABG).

METHODS

The details of the design, methods, end points, and relevant definitions are outlined in the Gulf Left Main Registry: a retrospective, observational study conducted between January 2015 and December 2019 across 14 centres in 3 Gulf countries. In this study, the data on patients with ULMCA who underwent revascularization through PCI or CABG were stratified by LVEF into three main subgroups; low (l-LVEF <40%), mid-range (m-LVEF 40-49%), and preserved (p-LVEF ≥50%). Primary outcomes were hospital major adverse cardiovascular and cerebrovascular events (MACCE) and mortality and follow-up MACCE and mortality.

RESULTS

A total of 2137 patients were included; 1221 underwent PCI and 916 had CABG. During hospitalization, MACCE was significantly higher in patients with l-LVEF [(10.10%), P = 0.005] and m-LVEF [(10.80%), P = 0.009], whereas total mortality was higher in patients with m-LVEF [(7.40%), P = 0.009] and p-LVEF [(7.10%), P = 0.045] who underwent CABG. There was no mortality difference between groups in patients with l-LVEF. At a median follow-up of 15 months, there was no difference in MACCE and total mortality between patients who underwent CABG or PCI with p-LVEF and m-LVEF.

CONCLUSION

CABG was associated with higher in-hospital events. Hospital mortality in patients with l-LVEF was comparable between CABG and PCI. At 15 months' follow-up, PCI could have an advantage in decreasing MACCE in patients with l-LVEF.

Unprotected Left Main Revascularization in the Setting of Non-Coronary Atherosclerosis: Gulf Left Main Registry

BACKGROUND

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in revascularization of left main coronary artery (LMCA) disease has been evaluated in previous studies. However, there has been minimal study of the relationship between co-existing non-coronary atherosclerosis (NCA) and LMCA disease revascularization. We aim to examine this relationship.

METHODS

The Gulf-LM study is a retrospective analysis of unprotected LMCA revascularization cases undergoing PCI with second generation drug-eluting stent versus CABG across 14 centers within 3 Gulf countries between January 2015 and December 2019. A total of 2138 patients were included, 381 with coexisting NCA and 1757 without. Outcomes examined included major adverse cardiovascular and cerebrovascular events (MACCE), cardiac and non-cardiac death, and all bleeding.

RESULTS

In patients with NCA, preexisting myocardial infarction and congestive heart failure were more common, with PCI being the most common revascularization strategy. A statistically significant reduction in in-hospital MACCE and all bleeding was noted in patients with NCA undergoing PCI as compared to CABG. At a median follow-up of 15 months, MACCE and major bleeding outcomes continued to favor the PCI group, though no such difference was identified between revascularization strategies in patients without NCA.

CONCLUSIONS

In this multicenter retrospective study of patients with and without NCA who require revascularization (PCI and CABG) for unprotected LMCA disease, PCI demonstrated a better clinical outcome in MACCE both in-hospital and during the short-term follow-up in patients with NCA. However, no such difference was observed in patients without NCA.

547 Postoperative Outcomes Are Significantly Worse Among Patients Undergoing Repair of Ruptured Versus Unruptured Iliac Artery Aneurysms – a 10-Year Longitudinal Cohort Study

Aim

The European Society for Vascular Surgery defines iliac artery aneurysms (IAA) as beyond 1.5 times its normal diameter. Common iliac arteries (CIA) beyond 1.8cm in men and 1.5cm in women are considered aneurysmal. This study aimed to assess outcomes following IAA rupture as their natural history is poorly understood and treatment recommendations based on low-level evidence.

Method

Patients with IAAs at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included aneurysm rupture, rupture diameter, post-operative complications, 30-day, 1-year and 5-year mortality rates. Statistical analysis with SPSS® was performed using chi-squared tests.

Results

Of 203 patients included, 90.6% were men and median(IQR) age at detection was 77 (71–83). Co-morbidities included hypertension (54.2%), hyperlipidaemia (42.9%) and ischaemic heart disease (35.5%). IAA were in the CIA (85.2%), IIA (21.7%) and EIA (2.0%), mostly asymptomatic (78.8%). Overall IAA rupture rate was 7.9% with CIA (81.2%) and EIA (18.8%). Mean (SD) diameters at rupture were 4.6 (2.4)cm for CIA and 4.6 (3.0)cm for IIA. Post-operative major adverse cardiovascular events (MACE) more frequently occurred following repair of ruptured compared to unruptured IAA (33.3% vs 3.5%, p=.011). Mortality at 30-days, 1-year and 5-years postoperatively were higher following repair of ruptured vs unruptured aneurysms (88.9%, 88.9%, 100% vs 1.2%, 10.6%, 36.1% respectively).

Conclusions

Early detection and elective treatment of IAA aneurysms before they approach 4.6cm may reduce rupture risk, morbidity and mortality associated with emergency repair following rupture.

548 A 10-Year Longitudinal Cohort Study Assessing Growth Rates and Surveillance Intervals for Common Iliac Artery Aneurysms

Aim

The European Society for Vascular Surgery defines common iliac artery (CIA) aneurysms as greater than 1.8cm in men and 1.5cm in women. Their reported growth rate is 1–4mm/year depending on their diameter. This study aimed to assess the natural history and surveillance intervals for CIA aneurysms as intervention threshold is based on low-quality evidence.

Method

Patients diagnosed with an IAA at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included diameter-based mean aneurysm growth rates and median surveillance intervals. Statistical analysis with SPSS® was performed using chi-squared tests.

Results

Of the 203 patients included, 90.6% were men and median (IQR) age at detection was 77 (71–83). IAA were located in the CIA (85.2%), IIA (21.7%) and EIA (2.0%) with the majority being asymptomatic (78.8%). CT was most frequently used as the imaging modality for IAA surveillance (66.3%), followed by ultrasound scan (29.8%) and MRA (3.9%). Growth rate for CIA aneurysms measuring 1.0–1.9cm were -2.1mm/year, 2.0–2.9cm were 0.8mm/year, 3.0–3.9cm were 3.5mm/year, 4.0–4.9cm were 9.4mm/year, 5.0–5.9cm were 2.9mm/year and &gt;6.0cm were 13.8mm/year. Median surveillance intervals for CIA aneurysms at 1.0–1.9cm were 12-monthly, 2.0–2.9cm were 11-monthly, 3.0–3.9cm were 5-monthly, 4.0–4.9cm were 5-monthly, 5.0–5.9cm were 5.5-monthly and &gt;6.0cm were 14.5-monthly. Mean(SD) CIA diameter at rupture was 4.6 (2.4)cm.

Conclusions

CIA aneurysms demonstrate faster growth rates as they enlarge and may require more frequent clinical assessments, surveillance, and consideration for repair prior to rupture.

One Versus Two Stents Strategies for Unprotected Left Main Intervention: Gulf Left Main Registry

The optimal stenting strategy for unprotected left main coronary artery (ULMCA) disease remains debated. This retrospective observational study (Gulf Left Main Registry) analyzed the outcomes of 1 vs 2 stents in patients with unprotected left main percutaneous coronary intervention (PCI). Overall, 1222 patients were evaluated; 173 had 1 stent and 1049 had 2 stents. The 2-stent group was older with more comorbidities, higher mean SYNTAX scores, and more distal bifurcation lesions. In the 1-stent group, in-hospital events were significant for major bleeding, and better mean creatinine clearance. At median follow-up of 20 months, the 1-stent group was more likely to have target lesion revascularization (TLR). Total mortality was numerically lower in the 1-stent group (.00% vs 2.10%); however, this was not statistically significant (P=.068). Our analysis demonstrates the benefits of a 2-stent approach for ULMCA patients with high SYNTAX scores and lesions in both major side branches, while the potential benefit of a 1-stent approach for less complex ULMCA was also observed. Further studies with longer follow-up are needed to definitively demonstrate the optimal approach.

Cardiac Catheterization During Extracorporeal Membrane Oxygenation After Congenital Cardiac Surgery: A Multi-Center Retrospective Study

Cardiac catheterization can affect clinical outcomes in patients on extracorporeal membrane oxygenation (ECMO) after congenital heart surgery; however, its effect in this group of patients remains unclear. This study aimed to evaluate the safety and outcome of cardiac catheterization in patients undergoing ECMO after congenital cardiac surgery and determine predictors that influence successful weaning. This retrospective cohort study included pediatric patients who underwent cardiac catheterization while on ECMO after congenital heart surgery in two cardiac centers between November 2012 and February 2020. Predictors of successful weaning from ECMO were studied using univariate and multivariate logistic regression analyses. Of 123 patients on ECMO support after congenital cardiac surgery, 60 patients underwent 60 cardiac catheterizations (31 diagnostic and 29 interventional). Thirty-four (56.7%) and 22 patients (36.7%) underwent successful decannulation from ECMO support and survived after hospital discharge, respectively. Patients who underwent earlier catheterization (within 24 h of ECMO initiation) had more successful weaning from ECMO and survival compared to others. Patients who underwent an interventional procedure (interventional catheterization or redo cardiac surgery after cardiac catheterization) had better survival than those who underwent only diagnostic catheterization (P = 0.038). Shorter durations of ECMO was the most important predictor of successful weaning from ECMO. Early cardiac catheterization greatly impacts successful weaning from ECMO and survival. Patients with correctable lesions amenable either by catheterization or redo surgery are more likely to survive. Shorter durations of ECMO could have a significant influence on successful weaning from ECMO and survival.

The Role of Cardiovascular Surgery in the Management of a Patient Diagnosed With Congenital Cutis Laxa Syndrome Complicated by Multivalvular Heart Disease

Cutis laxa syndrome is an uncommon connective tissue disorder affecting the major ultrastructure of the skin by progressive loss of elasticity. The results of this syndrome lead to the appearance of premature aging, which might also affect the internal organs. The disorder can be either congenital or acquired. The congenital form consists of autosomal dominant, autosomal recessive, and X-linked recessive patterns. The autosomal recessive pattern is the most common and severe one. Different systemic complications have been described in congenital cutis laxa syndrome, but the most serious and lethal one is cardiopulmonary abnormalities. In this report, we discuss the presentation of congenital cutis laxa syndrome with successful cardiovascular surgical management of multiple valvular heart diseases.

Percutaneous Coronary Intervention Vs Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Disease: G-LM Registry

Coronary artery bypass surgery (CABG) has been the standard of care for revascularization for patients with obstructive unprotected left main coronary disease (ULMCA). There have been multiple randomized and registry data demonstrating the technical and clinical efficacy of PCI in certain patients with ULMCA. The purpose of this study is to evaluate clinical outcomes of ULMCA PCI as compared to CABG in patients requiring revascularization in three Gulf countries. All ULMCA cases treated by PCI with DES versus CABG were retrospectively identified from 14 centers in 3 Arab Gulf countries (KSA, UAE, and Bahrain) from January 2015 to December 2019. In total, 2138 patients were included: 1222 were treated with PCI versus 916 with CABG. Patients undergoing PCI were older, and had higher comorbidities and mean European System for Cardiac Operative Risk Evaluation (EuroSCORE). Aborted cardiac arrest and cardiogenic shock were reported more in the PCI group at hospital presentation. In addition, lower ejection fractions were reported in the PCI group. In hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) occurred more in patients undergoing CABG than PCI. At median follow-up of 15 months (interquartile range, 30), no difference was observed in freedom from revascularization, MACCE, or total mortality between those treated with PCI and CABG. While findings are similar to Western data registries, continued follow-up will be needed to ascertain whether this pattern continues into latter years.

Rosai-Dorfman disease with pulmonary involvement mimicking bronchogenic carcinoma

Background

Rosai-Dorfman disease is a histiocytic lesion that affects lung rarely.

Case presentation

We present a 52-year-old female diagnosed with right intrabronchial mass invading the bronchial wall and the extrabronchial tissues with lymphadenopathy. Multiple bronchoscopic biopsies were not diagnostic. Pneumonectomy was performed and postoperative histology revealed marked mucin impaction and bronchial dilatation. The pulmonary tissue showed areas of hemorrhage and chronic inflammation. The mass exhibited an excessive number of lymphocytes, plasma cells, and numerous histiocytes engulfing them (lymphocytophagocytosis). These histiocytes were S100 protein and CD68 positive. These features are consistent with Rosai-Dorfman disease.

Conclusion

Rosai-Dorfman Disease with pulmonary affection can be misdiagnosed as malignancy. Careful histological examination of the specimen for emperipolesis or lymphocytophagocytosis together with S100 protein and CD68 positivity are the clue for proper diagnosis.

Implementation of an evidence-based practice to decrease surgical site infection after coronary artery bypass grafting

Objective

Surgical site infection (SSI) is a serious complication after coronary artery bypass grafting (CABG). This study was performed to evaluate evidence-based practice and structured problem-solving to reduce SSI after CABG.

Methods

An infection control strategy including supervised chlorhexidine gluconate (CHG) showers was implemented from January 2017 to March 2018 for 119 patients undergoing CABG. The controls comprised 244 patients who underwent CABG from 2014 to 2016. Risk factors for SSI were identified, and a problem-focused strategy was used to control SSI. Propensity score matching was used to study the effect of CHG showers on SSI.

Results

SSI occurred in 25 patients (10.25%) in the control group, and the significant risk factors were the postoperative blood glucose level, transfer from an outside hospital, emergency operation, redo sternotomy, a higher American Society of Anesthesiologists score, and the duration of surgery. After implementation of the program, the SSI rate significantly decreased to 3.36%. Patients who had undergone preoperative CHG showers had a significantly lower SSI rate (1.69%) than the matched controls (13.56%).

Conclusion

SSI after CABG can be reduced using evidence-based practice and structured problem-solving to identify risk factors. A preoperative CHG shower is associated with a lower SSI rate after CABG.

Transposition of Great Arteries with Left Main Coronary Artery Atresia-Case Report

Background  The coronary artery anatomy in patients with transposition of the great artery (TGA) is a contributing factor for outcome in arterial switch procedure. Case Presentation  A full-term, 7-day-old baby boy diagnosed as dextro-TGA (dTGA) with intact ventricular septum. Intraoperatively, the left coronary sinus had a blind indentation from which a firm cord-like left main coronary artery originates. Procedure completed as usual for a routine arterial switch operation. Conclusion  About 5% of patients with D-TGA have a single coronary artery. Assessment of blood flow to all branches intraoperatively is mandatory to choose between either transfer of single ostium or bypass grafting to the other coronary system.

Staged Surgical Palliation for HLHS in a Girl with Severe Factor X Deficiency

Background  Factor X deficiency (also known as Stuart-Prower factor deficiency) is an autosomal recessive extremely rare hereditary hematologic disorder, affecting around 1:1,000,000 of the general population. Case Presentation  This case report describes a patient with hypoplastic left heart syndrome and severe factor X deficiency, who underwent staged surgical palliation. From stage 1 Norwood palliation, through superior cavopulmonary anastomosis and ending with total cavopulmonary connection with satisfactory hemostasis and no significant perioperative bleeding complication. Conclusion  The need to maintain hemostasis while aiming to prevent intracardiac thrombosis requires multidisciplinary team approach including hematologist, cardiac surgeon, pediatric cardiac intensivist, and anesthesiologist along with meticulous hemostasis during surgery and careful monitoring of coagulation profile in the postoperative period.

Extracorporeal Membrane Oxygenation in Postcardiotomy Pediatric Patients—15 Years of Experience Outside Europe and North America

Background The increasing complexity of congenital cardiac surgery has resulted in the increased use of extracorporeal membrane oxygenation (ECMO) support for children who cannot be weaned from cardiopulmonary bypass. The purpose of this research was to assess the mortality and morbidity in children requiring ECMO support after the repair of congenital heart defects (CHDs).

Methods The hospital records of all patients with CHD who required ECMO after a cardiac surgical procedure between January 2001 and December 2016 were retrospectively reviewed. Various outcomes were reported and tested for any association with hospital death.

Results A total of 113 children required ECMO for cardiopulmonary support after congenital cardiac surgery; 88 (77.9%) were placed on ECMO in the operating room. Median age of the patients was 3 months (range, 4 days–15 years) and median weight was 3.5 kg (range, 2.2–42.5). Forty-two (37.2%) survived to hospital discharge. In children with single-ventricle physiology, survival to discharge was 37.3% (19/51 patients) and for biventricular physiology, it was 37.1% (23/62 patients). Univariate analysis revealed number of days on ECMO support, renal failure, and stroke as risk factors for hospital mortality, while age and cross-clamp time were found to be statistically nonsignificant.

Conclusion Satisfactory results can be achieved in pediatric patients by using ECMO support for postoperative cardiac and pulmonary failure refractory to medical management. Prolonged ECMO support, renal failure, and stroke are risk of mortality.

Left Ventricular Dysfunction after Closure of Large Patent Ductus Arteriosus

Changes in left ventricular dimensions and performance were studied in 43 patients after transcatheter occlusion or surgical ligation of patent ductus arteriosus. The patients were assigned to 2 groups based on their ductal diameter: ≥ 3.1 mm to group A ( n = 27) and ≤ 3 mm to group B ( n = 16). The mean age and weight of the groups were comparable. Before intervention, group A had a significantly larger mean left ventricular end-diastolic diameter than group B, while all patients had normal shortening fraction and ejection fraction. Within 1 month after intervention, left ventricular end-diastolic diameter showed a trend towards regression while shortening fraction and ejection fraction decreased significantly in group A. There were no significant changes in these parameters in group B. Between 1 and 6 months after intervention, left ventricular performance improved in most of the group A patients who were followed up. We conclude that closure of large ductus arteriosus in children leads to significant immediate deterioration of left ventricular performance, which appears to recover within a few months. Echocardiographic study before hospital discharge is recommended in these patients. Serious deterioration of ventricular performance after closure may warrant the use of angiotensin converting enzyme inhibitors.

Nitroglycerin cardioplegia effect on coronary artery targets in bypass grafting

BACKGROUND

Coronary artery targets are essential for referral acceptance to achieve complete coronary revascularization.

PATIENTS AND METHODS

A prospective double-blind study was carried out to determine whether the addition of nitroglycerin to cold blood hyperkalemic cardioplegia would optimize the size and number of coronary artery targets during conventional coronary bypass grafting.

RESULTS

A total of 60 adult elective coronary artery bypass grafting cases were enrolled; 30 in group N (nitroglycerin added to cardioplegia) and 30 in group C (controls). The number of bypassed vessels ranged from 2 to 5 with a mean of 3.63. In a comparison between groups N and C, the average number of grafts per patient (3.67 ± 0.77 vs. 3.67 ± 0.92); the average performed/predicted ratio for coronary artery bypass grafting targets (0.96 ± 0.18 vs. 1.02 ± 0.31); and the average intraoperatively measured luminal diameter of the bypassed coronary artery targets (1.55 ± 0.23 vs. 1.51 ± 0.23) showed no significant difference between the two groups, except that the luminal diameter of the obtuse marginal II artery was larger in group C compared to group N ( P = 0.037).

CONCLUSIONS

The addition of nitroglycerin to cardioplegia did not show any benefit, either quantitatively or qualitatively, for optimizing coronary artery bypass grafting targets.

High resolution spiral CT scan in the diagnosis of pseudoaneurysm of ascending aorta

Pseudoaneurysms of the ascending aorta are rare (<1%), and extremely rare from aortic vent site, but can be a lifethreatening complication. The basic methods of diagnosis are computed tomography scan and aortography. We report high resolution spiral CT may provide the best less invasive means in the diagnosis of the pseudoaneurysm of the ascending aorta originated from the aortic vent site.

Can the outcome of pediatric extracorporeal membrane oxygenation after cardiac surgery be predicted?

PURPOSE

The purpose of this study is to assess whether clinical and biochemical variables may be used to predict outcome in children treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery and to determine when to discontinue ECMO support.

METHODS

We retrospectively reviewed the medical records of 26 children treated with ECMO after cardiac surgery at our institution from October 2000 to May 2004.

RESULTS

Patients mean age was 16.4 months (range, two weeks to 144 months) and mean weight was 6.3 kg (range, 2.2-26 kg). Of the 26 children requiring ECMO support, 23 underwent biventricular repair, and 3 had single ventricle procedure. None of the single ventricle repair or the truncus arteriosus repair group survived the ECMO support. Twelve patients (46%) survived the ECMO support and were discharged from hospital. Four patients needed ECMO support after 45 min (mean) of cardiopulmonary resuscitation (CPR) time (range = 30-55 min) with 2/4 survived to discharge. All patients who survived to discharge showed no evidence of neurological deficit or disseminated intravascular coagulopathy (DIC) whereas 5 patients died following stroke, and 8 following DIC, respectively (p = 0.021 and 0.002). Renal failure developed in 8 cases (1 survivor and 7 nonsurvivors, p = 0.022). Seventeen patients (65%) required re-exploration of the mediastinum for bleeding. Length of time on ECMO, although it was longer among the nonsurvivors, was not significantly different between the survivor (74.5 hours) and nonsurvivor (118.2 hours) groups (p = 0.41). Inotrope score at ECMO initiation and serum lactate within 72 hours of ECMO were calculated and the difference between the two groups was not significantly related to survival (p = 0.29 and 0.22 respectively).

CONCLUSION

Our findings suggest patients who develop renal failure, stroke and DIC during ECMO support have a high mortality. Patients with single ventricle physiology, and repaired truncus arteriosus may benefit less from ECMO support and have an increased risk of death. Elevated levels of lactate during the first 72 hours, high inotrope score at the initiation of ECMO and long ECMO support duration (more than 3 days) are all potential variables that can be used in determining when to discontinue ECMO support.

Spinal aspergillosis in nonimmunocompromised host mimicking Pott's paraplegia

The aim of this report is to highlight the less-known aspergillus spondylitis (AS) that may completely mimic Pott's paraplegia, leading to occasional but expensive diagnostic error, as the chemotherapeutic management of the two is different. A case of a patient with the diagnosis of Pott's paraplegia who turned out to have aspergillus spondylitis is described. Issues and difficulties regarding the differentiation between these two forms of spine infection and their therapeutic implications are discussed. We conclude that differential diagnosis of spinal tuberculosis (TB) should include aspergillus spondylitis, as cure of spinal aspergillosis, especially in early stages, is possible with surgery and/or antifungal agents, and morbidity and mortality are high in neglected cases.

Atypical forms of spinal tuberculosis: case report and review of the literature

OBJECTIVE

The object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis. Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer.

CLINICAL PRESENTATION

An unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented. Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis. The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis. The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion. Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits.

CONCLUSION

Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases.

Intramedullary ossified cavernous angioma of the spinal cord: case report

A case of a heavily ossified cavernous angioma of the spinal cord along with its histological features and surgical implications is reported. The unusually dense calcification and even bone formation along with the unique eggshell-like cyst formation posed problems in diagnosis and surgical excision. This calcified vascular lesion was treated by subtotal excision.

Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases

Two cases of orbito-cranial injury caused by foreign bodies (FBs) penetrating the lateral wall and roof of the orbit are described. In the first patient, a long rusted nail acted as a missile and was only detected by X-rays and CT scan. The nail penetrated the orbit, the eyeball, the lateral orbital wall, and the temporal lobe of the brain. Lodged partly in the orbit and partly in the brain, this nail caused leakage of cerebrospinal fluid (CSF) through eye and led to orbital cellulitis and localized meningitis. The foreign body (FB) was removed through an extradural pterional approach with rapid resolution of orbital cellulitis and meningitis. In the second patient, large metallic FB, having penetrated the orbital roof was lodged intracranially above the chiasma. This was removed via frontal craniotomy. Mechanism of such injuries and appropriate surgical approaches are described as well.

Childhood brain abscess in Saudi Arabia

The characteristics of childhood brain abscess in Saudi Arabia are outlined in this review of 17 consecutive cases treated at King Khalid University Hospital (KKUH) between 1985 and 1994. The data on 20 consecutive adults with brain abscess treated at KKUH during the same period were also analysed. Compared with series from the West, the children were unusual because of the relatively low incidence of cardiogenic and anaerobic abscesses and the relatively high incidence of post-traumatic, infratentorial and staphylococcal abscesses and sterile cultures. Compared with cases of brain abscess in adults, the children showed a much lower incidence of idiopathic abscess, a higher incidence of infratentorial abscess and a much better outcome. Factors accounting for the zero mortality rate in these children are discussed.

Neural arch tuberculosis: radiological features and their correlation with surgical findings

Radiological features of 17 cases of neural arch tuberculosis (NAT), treated surgically by the authors, are reviewed and correlated with the operative and histopathological findings. The diagnostic accuracy of different imaging modalities in the evaluation of this rare, atypical form of spinal tuberculosis was found to be very low. Thus, the initial diagnosis was in error in 15 out of 17 of our cases. Recognition of the radiological diagnostic features of NAT is important, not only because they may mimic primary or metastatic spinal neoplasms, but also because of the surgical implications. Computed tomography (CT) and magnetic resonance imaging (MRI) features correlated most closely with the surgical findings, whereas plain spinal radiographs and myelograms were found to be non-specific and non-diagnostic.

Intestinal obstruction caused by extraperitoneal cerebrospinal fluid collection

External compression caused by a massive extraperitoneal cerebrospinal fluid collection lead to intestinal obstruction in a 3-year-old child who had previously had a ventriculoperitoneal shunt for treatment of hydrocephalus. Radiological findings and ways of preventing this situation are discussed. A useful diagnostic radiological sign, the "coiling sign', indicating shunt misplacement at the peritoneal level, is also described.

Cranial and intracranial aspergillosis of sino-nasal origin. Report of nine cases

This paper is an attempt at defining the most efficacious surgical and antifungal therapy for invasive cranial and intracranial aspergillosis, and is based on experience with nine non-immunocompromised patients treated and followed-up by the authors between 1983 and 1994; as well as on the summary of previously reported cases and advances in therapy of this condition. Depending on the degree of aspergillar involvement of the cranial base and intracranial structures, a classification, with implications for treatment and prognosis, is also proposed. Two patients had extracranial skull base erosion; whereas relentlessly progressive granulomas, mimicking malignancy, invaded the skull base and intracranial contents in seven cases. Of these seven patients with cranial and intracranial invasion, two died of acute intracranial haemorrhage due to fungal invasion of cerebral blood vessels. In two patients, complete surgical eradication of the disease proved impossible due to cavernous sinus involvement, while residual aspergillomas are still present in orbit and paranasal sinuses (PNS) in a further two patients in spite of multiple surgical procedures and prolonged antifungal chemotherapy (AFC). What appears to be a cure has been effected in one patient only. Multiple therapeutic strategies were used. Biopsy plus systemic AFC was ineffective, surgical drainage and debridement plus systemic AFC resulted in long-term survivals but no cure. Radical surgery in conjunction with systemic and local (intracavitary) AFC should be considered to improve an otherwise poor prognosis.

Modified coronal computerized tomographic cuts for transsphenoidal surgery. Technical note

Computerized tomographic (CT) cuts passing through the anterior nasal spine and the most prominent part of the sellar floor (spino-sellar or SS cuts) were found to be useful in minimizing the chances of anatomical disorientation during the transsphenoidal microsurgical approach as well as in preoperative planning and selection of the length and choice of the instruments to be used. Routine preoperative SS cuts of CT scan are advised.

Isolated posterior fossa hypertension and brainstem compression caused by entrapped Dandy-Walker cyst: a case report

Lateral ventricular shunting alone is often considered to be adequate treatment for hydrocephalus caused by Dandy-Walker syndrome. A patient is presented in whom progressive spastic tetraparesis and signs of severe brainstem compression developed due to an entrapped posterior fossa cysts, in spite of an adequately functioning lateral ventricular shunt. Addition of a cystoperitoneal shunt resulted in rapid resolution of symptoms and deficits. This case illustrates that potentially fatal brainstem compression and dangerous posterior fossa hypertension may develop if the posterior fossa cyst does not communicate with the lateral ventricles, where the shunt is placed.

Survival in malignant astrocytoma at King Khalid University Hospital

Malignant astrocytoma (Kernohan grade III and IV) still has one of the worst outcomes of all malignant tumors. To determine factors affecting the survival of patients with malignant astrocytoma in Saudi Arabia, a retrospective study of 76 cases that were treated at King Khalid University Hospital over one decade was carried out. Kaplan-Meier survival diagrams were constructed for each prognostic factor. Twenty-eight percent of cases survived two years. A significantly better survival rate was found in females, patients </=50 years and patients who had re-operation for a recurrence. A better survival rate which did not reach significance was found in patients with grade III tumors, patients with a Karnofsky score of >/=70 at presentation, patients who had craniotomy and excision and patients who had radiotherapy. It is suggested that to improve the outcome of patients with malignant astrocytoma, aggressive surgical excision with radiotherapy (and possibly chemotherapy) is required.

Spinal intradural extramedullary enterogenous cysts. Report of two cases and review of literature

Two patients with intradural extramedullary cysts of the spinal canal are described. Both presented with slowly progressive myelo-radiculopathy caused by mucin-producing epithelial-lined cysts in cervical and upper thoracic region. Histologically, both lesions were considered to be neurenteric cysts with an endodermal origin. Radiographic diagnosis was made by a combination of myelography, computed tomographic scan with myelography (CTM), and magnetic resonance imaging (MRI). Complete surgical resection was curative in both cases. Clinical presentation, histological characteristics, imaging findings and surgical management of this rare lesion are highlighted.

Bronchoalveolar lavage: results of sequential, selective techniques in viable murines

The purpose of this study was to develop an optimal technique for performing sequential bronchoalveolar lavage (BAL) in a murine animal model. Two general anesthetic regimens and four operative techniques of BAL were tested. Anesthesia by intraperitoneal injection of ketamine hydrochloride (100 mg/kg body wt) resulted in death for four of ten subjects, whereas inhalation of diethyl ether led to death for one of ten subjects. BAL using a balloon catheter under bronchoscopic guidance was comparable with postmortal lavage, tolerated better, and resulted in superior cell retrieval with respect to cell differential (macrophages: 95 +/- 2.3; lymphocytes: 3 +/- 1.2; polymorphonuclear lymphocytes [PNL]: 1.2 +/- 1.4) compared with two other techniques using a bent metal tube/polyethylene tubing combination (macrophages: 19.3 +/- 27.4; lymphocytes: 3.8 +/- 4.3; PNL: 35.5 +/- 35.5) and a bronchoscope/polyethylene tubing combination (macrophages: 11.1 +/- 25.5; lymphocytes: 0.7 +/- 1.0; PNL: 55.8 +/- 41.0). The BAL fluid contained significantly more alveolar macrophages and fewer PNL and epithelial cells (p = 0.0001, p = 0.0025, p = 0.02, respectively). We conclude that the technique using a balloon catheter under bronchoscopic guidance during inhalation of diethyl ether is the procedure of choice and results in a representative sample of BAL.

Growing skull fractures: classification and management

Seven patients with growing skull fractures treated between 1983 and 1993 are described. These growing fractures constituted 1.6% of all the cases of skull fractures seen during the period (a total of 449 cases). Based on aetiopathogenesis, computed tomography (CT) appearances, operative findings and management strategies required, three main types of growing skull fractures were recognized. In type I (n = 3) a leptomeningeal cyst, in type II (n = 3) damaged and gliotic brain, and in type III (n = 2) a porencephalic cyst extended through the skull defect into the subgaleal space. A combination of type I and type III co-existed in one patient. Initial head injury and neurological deficit were judged to be mild to moderate in all the seven cases. Continued growth of skull fractures correlated closely to the increasing neurological deficit in five cases. In two patients natural arrest of fracture growth at 5 and 7 months after trauma was accompanied by arrest in progress of neurological deficit. Available surgical options are discussed and general guidelines for the management are given.