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ABSTRACT: The ideal management strategy for patients presenting late with transposition of great arteries (TGA), intact ventricular septum (IVS), and regressed left ventricle (LV) is not clear. Primary switch, two-stage switch, and Senning operation are the options. Left ventricular retraining prior to arterial switch by ductal stenting may be effective, but the experience is very limited.
Five of six children aged 3-6 months with TGA-IVS and regressed LV underwent recanalization and transcatheter stenting of ductus arteriosus. The ductal stent was removed during arterial switch surgery.
The procedure was successful in 5/6 patients. All the patients had totally occluded ductus and needed recanalization with coronary total occlusion hardware. The ductus was dilated and stented with coronary stents. In all the patients, there was significant luminal narrowing despite adequate stent placement and deployment. Two patients needed reintervention for abrupt closure of the stent. Ductal stenting resulted in left ventricular preparedness within 7-14 days. One patient died of progressive sepsis after 14 days of stenting, even though the LV was prepared. Four patients underwent successful uneventful arterial switch surgery. During surgery, it was observed that the mucosal folds of duct were protruding through the struts of the stent in one patient.
Ductal stenting is a good alternative strategy for left ventricular retraining in TGA with regressed LV even in patients with occluded ducts.
Annals of Pediatric Cardiology 07/2011; 4(2):135-8.
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ABSTRACT: Cyanotic spell is an important complication of tetralogy of Fallot. We report a simple, innovative method that bailed out a patient with life-threatening, refractory cyanotic spell in the catheterization laboratory. Manual autotransfusion of blood from aorta into the pulmonary arteries resulted in significant clinical improvement.
Catheterization and Cardiovascular Interventions 06/2011; 78(2):280-1. · 2.29 Impact Factor
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ABSTRACT: Adequate analgesic medication is mandatory after coronary artery bypass grafting (CABG) surgery. The aim of this study was to assess the analgesic efficacy, side effects, and need for rescue analgesia after CABG surgery comparing diclofenac and placebo rectal suppository.
Thirty-seven consenting adults undergoing elective CABG surgery were randomly assigned in a double-blind fashion to receive either rectal diclofenac 100 mg (Group 1, n = 19) or placebo suppository (Group 2, n = 18) postoperatively, just after extubation. Both groups were given intravenous tramadol as a rescue analgesic. Pain scores in the two groups were assessed on a 10-cm visual analog scale at 0, 0.5, 1, 1.5, 2, 6, 12, 18, and 24 hours after suppository administration. Rescue analgesic consumption, sedation, nausea, and vomiting in both the groups were also recorded.
Twenty-four-hour tramadol consumption in Group 1 was 92.5 +/- 33.5 mg compared to 157.5 +/- 63.4 mg in Group 2 (P = 0.002). Patients in the placebo group had significantly greater pain scores 1.5 to 12 hours after extubation. Group 1 patients were significantly more awake compared to Group 2 (P < 0.05). The incidence of postoperative nausea was less in Group 1 than in Group 2 (P = 0.001). Though not statistically significant, three patients in Group 2 each had a single episode of vomiting, whereas no patient had vomiting in Group 1.
Rectal diclofenac suppository with tramadol provides adequate pain relief after cardiac surgery, and also reduces tramadol consumption and side effects commonly associated with tramadol.
Pain Practice 08/2009; 9(5):385-93. · 2.21 Impact Factor
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ABSTRACT: Our aim was to define the prevalence of specific sequelae after repair of partial atrioventricular septal defect.
A total of 132 consecutive patients undergoing repair of partial atrioventricular septal defect were studied for mortality, left atrioventricular valve function, reoperations, left ventricular outflow tract obstruction, and supraventricular arrhythmias. Age was 2.5 months to 43 years (median, 54 months); 13 (9.8%) were more than 20 years old. Preoperatively, 26.5% patients were in New York Heart Association class III/IV, 15.9% had supraventricular arrhythmias, 25.7% had pulmonary artery hypertension, 16.6% had moderate-to-severe left valvular regurgitation, and 29.5% had additional left atrioventricular valvular malformations. Autologous pericardium (n = 127) and right atrial patch (n = 5) were used to patch the defect. Left atrioventricular valvuloplasty was performed in 91% of patients despite older age and additional malformations of the left atrioventricular valve.
Operative and late mortalities were 4.5% and 3.2%, respectively. Postoperative supraventricular arrhythmias were observed in 11.3% of patients. Reoperations were required in 5.8% patients because of a residual atrial septal defect (n = 1) and severe left atrioventricular valvular regurgitation (n = 6). At a mean follow-up of 106.82 +/-55.04 months, actuarial survival was 83.70% +/- 0.07%. The risk of death was 38.92 (95% confidence intervals: 7.8-195.1) and 6.88 (95% confidence intervals: 1.79-38.18) times higher in patients with grossly malformed left atrioventricular valve and preoperative pulmonary artery hypertension, respectively, by logistic regression analysis.
Detailed assessment of the valve morphology and individualized valvuloplasty techniques improves the long-term survival after repair of partial atrioventricular septal defects. The presence of grossly malformed left valvular apparatus, pulmonary artery hypertension, and moderate-to-severe left atrioventricular valve regurgitation are independent predictors of death and defect-related morbidity after surgical repair.
The Journal of thoracic and cardiovascular surgery 04/2009; 137(3):548-555.e2. · 3.41 Impact Factor
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ABSTRACT: The purpose of this study was to identify the morphologic characteristics and other risk factors that may predispose patients with mixed totally anomalous pulmonary venous connection to continuing high mortality after surgery.
Fifty-seven consecutive patients aged 15 days to 18 years (median, 6 months) underwent rechanneling of mixed totally anomalous pulmonary venous connection. Twenty-three patients had "2+2" pattern (I category), 29 had "3+1" pattern (II category), and 5 patients had pulmonary venous connections of different combinations (III category). Obstructive patterns involving one or more pulmonary veins were present in 19 (33.3%) patients.
Operative and late mortality rates were 19.3% and 4.3%, respectively. At a mean follow-up of 63.26 +/- 58.47 months, actuarial survival was 86.9% +/- 0.07% in category I, 86.2% +/- 0.06% in category II, and 20.0% +/- 0.18% in category III (log-rank, P = .001), respectively. At their last follow-up, all survivors (n = 43) had a Ross clinical heart failure score of 0 to 2.
Patients with a "2+2" pattern of mixed totally anomalous pulmonary venous connection constitute the safe anatomic category for rechanneling, followed by the "3+1" variety. Cross-sectional echocardiography and/or computed tomographic angiography are mandatory to provide necessary diagnostic information and define the anatomy. Patients aged 2 months or younger, obstructive totally anomalous pulmonary venous connection, and perioperative pulmonary hypertensive crises were significant risk factors for death by logistic regression analysis. The risk of death was 5.85 times higher (95% confidence interval: 1.46-35.68; P = .02) in patients with category III of mixed TAPVC. The precise technique adopted in an individual patient depends on the pattern of anatomic drainage, and an individualized surgical approach is recommended.
The Journal of thoracic and cardiovascular surgery 02/2008; 135(1):106-16, 116.e1-5. · 3.41 Impact Factor
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Circulation 10/2006; 114(11):e487-8. · 14.74 Impact Factor
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Journal of Cardiothoracic and Vascular Anesthesia 03/2006; 20(1):80-1. · 1.64 Impact Factor
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Annals of Cardiac Anaesthesia 02/2003; 6(1):27-30.
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ABSTRACT: To determine the most effective dose regimen of aprotinin for infants undergoing arterial switch operation for transposition of the great arteries in reducing blood loss and postoperative packed red blood cell (PRBC) requirements. A total of 24 infants scheduled for arterial switch operation for transposition of the great arteries were included in the study. The infants were randomly assigned to one of the three groups. Group I (n = 8) patients received aprotinin in a dose of 20,000 kallikrein inhibiting units (KIU)/kg after induction of anesthesia, 20,000 KIU/kg was added to the pump prime, and 20,000 KIU/kg/hour infusion for three hours after weaning from bypass; group II (n = 8) patients received aprotinin 30,000 KIU/kg after induction of anesthesia, 30,000 KIU/kg was added to the pump prime and 30,000 KIU/Kg/hour infusion for three hours after weaning from bypass; group III patients (n = 8) received aprotinin 40,000 KIU/kg after induction of anesthesia, 40,000 KIU/kg was added to the pump prime and 40,000 KIU/kg/hour infusion for three hours after weaning from bypass. Postoperatively, the cumulative hourly blood loss and PRBC requirements were noted up to 24 hours from the time of admission in the intensive care unit (ICU). Use of blood and blood products were noted. Coagulation parameters such as hematocrit, activated clotting time (ACT), fibrinogen, prothrombin time (PT), international normalized ratio (INR), platelet count, and fibrin degradation products (FDP) were investigated before cardiopulmonary bypass (CPB), after protamine administration, and at four hours postoperatively in the ICU. The number of infants reexplored for increased mediastinal drainage was recorded. Renal functions were monitored by measuring urine output (hourly) and serum urea (mg%) and serum creatinine (mg%) at 24 hours. The sternal closure time was comparable in all the three groups. Cumulative blood loss (ml/kg/24 hours) was greatest in group I (17.30 +/- 7.7), least in group III (8.14 +/- 3.17), whereas in group II, it was 16.45 +/- 6.33 (P = 0.019 group I versus group III; (P = 0.036 group II versus group III). Postoperative PRBC requirements were significantly less in high dose group III (P = 0.008, group I versus III; p = 0.116, group II versus group III) . Tests for coagulation performed at four hours postoperatively, viz. ACT, PT, INR, FDP, and platelets were comparable in the three groups. Urine output on CPB was comparable in all the groups. Serum urea and creatinine showed no significant difference between the three groups twenty four hours postoperatively. Aprotinin dosage regimen of 40,000 KIU/kg at induction, in CPB prime and postoperatively for three hours was most effective in reducing postoperative blood loss and PRBC transfusion requirements. Aprotinin does not have any adverse effect on renal function.
Annals of Cardiac Anaesthesia 13(2):110-5.
