Background: St. Thomas (ST) and Del Nido (DN) cardioplegic solutions are widely used for myocardial protection during cardiac surgery. In 2016, our university hospital shifted from modified St. Thomas to Del Nido solution for both adult and pediatric cardiac surgery. This retrospective study was conducted to compare ST and DN solutions regarding surgical workflow and clinical outcome in pediatric and adult patients undergoing cardiac surgery. Methods: We reviewed 220 patients who underwent cardiac surgery requiring cardioplegic arrest. Patients were categorized in 2 groups: ST (n = 110) and DN (n = 110). Each group included 60 pediatric and 50 adult patients. Demographic, intraoperative, and postoperative variables were collected. Results: In pediatric patients, no significant difference was found between the 2 groups regarding clamping time, bypass time, need for defibrillation, inotropic score, postoperative ejection fraction (EF), period of mechanical ventilation, intensive care unit stay, or postoperative arrhythmias. One patient in the ST group required mechanical support by extracorporeal membrane oxygenation. We had 5 cases of pediatric mortality (3 in DN and 2 in ST, P = .64). In adult patients, significantly fewer patients in the DN group needed defibrillation than in the ST group. No significant difference was found regarding clamping time, inotropic score, or intraaortic balloon pump use. Mortality in adult patients was 6 cases (4 in ST group and 2 in DN group). Conclusion: DN cardioplegia solution is as safe as ST solution in pediatric and adult cardiac surgery. It has comparable results of myocardial protection and clinical outcome, with superiority regarding uninterrupted surgery and lower rate of defibrillation.
Background Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. Objective To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. Methods Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. Results Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. Conclusion Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
Background Pericardial patches are often used for repair of congenital cardiac defects. The aim of this study was to describe our initial experience with the use of equine pericardium and its safety and advantages and disadvantages compared to bovine pericardium. Methods We designed a retrospective cohort study of 111 patients who were surgically treated for congenital heart disease between 2017 and 2020. Equine pericardium was used in 58 patients and bovine pericardium was used in 53 patients. Recorded variables included demographic data, preoperative cardiac pathology, site of patch insertion, morbidity and mortality. Results The overall survival rate was 94.5% and no deaths were related to patch insertion. None of our patients were reoperated on for patch related complications. Postoperative transcatheter intervention was needed in 2 patients (1.8%): one for dilatation of aortic arch stenosis after repair of hypoplastic left heart syndrome with equine pericardium and one for dilatation of pulmonary artery branches after repair of tetralogy of Fallot using bovine pericardium. Conclusions Equine pericardium is a safe patch material for reconstruction in congenital heart surgery. It may be preferable to bovine pericardium in cases requiring a complex shape or a pliable patch as in in arch reconstruction or for valve reconstruction.
Objective: Chylothorax after surgery for congenital heart disease is an uncommon but serious complication that adversely affects surgical outcomes. The aim of our study was presenting our experience for the management of postoperative chylothorax and excess nonhemorrhagic pleural drainage.Methods: Medical records of patients with excess nonhemorrhagic pleural drainage were retrospectively reviewed and the collected data included demographics, surgical procedures, drainage characteristics, methods of postoperative management, and outcome.Results: From March 2011 to May 2018, 52 patients with excess postoperative pleural drainage were identified from a total of 816 pediatric patients operated upon for congenital cardiac disease, giving an incidence of 63.7%. Tetralogy of Fallot and single ventricle morphology were the most common cardiac pathology. The serum triglyceride level was checked and found elevated in 30 patients (53.5%). The maximum daily drainage was 136.25 ± 109.7 mL/day and the mean duration of drainage was 32.23 ± 35.7 days. Medium-chain triglyceride formula was given for 27 patients (51.9%), octreotide for 22 (42.3%) for a mean duration of 8.07 ± 28.3 days.Total parenteral nutrition was needed for 11 patients (21.1%) for a mean duration of 3.13 ± 7.63 days. The success rate for conservative management was 94.2%. Thoracic duct ligation performed for three patients. The mean duration of mechanical ventilation was 7.4 ± 3.6 days, mean intensive care unit stay was 29.6 ± 35.1 days, and mean total hospital stay was 20.9 ± 17.5 days. We had six cases of hospital mortality (11.53%). Conclusion:Initiation of a stepwise approach for excess nonhemorrhagic pleural drainage based on the amount and rate of drainage achieve a favorable outcomes.
Background Important differences in the mechanism of respiration between adults and children warrant distinction in the management of diaphragmatic paralysis as a complication of cardiac surgery. We describe the management and outcomes of this complication in both groups. Methods We retrospectively analyzed 16 patients (5 adults and 11 children) with diaphragmatic paralysis after cardiac surgery performed between 2008 and 2018. Clinical examination, chest radiography, and confirmation with fluoroscopy in selected cases were our modalities of diagnosis. All adults were managed conservatively, whereas plication was performed in all children. Results The incidence of diaphragmatic paralysis was 0.98% in pediatric patients and 0.43% in adults. The mean age was 2.33 ± 2.59 years in children and 53.2 ± 17.99 years in adults. All adults were symptomatic. All children showed difficulty in weaning from mechanical ventilation after cardiac surgery. The period of mechanical ventilation before plication was 2–6 days (median 4 days). Death occurred as a result of low cardiac output in a 10-year-old boy, and due to respiratory failure in a 30-year-old woman. Children were successfully weaned from mechanical ventilation after diaphragmatic plication. The median time to extubation after plication was 2.5 days (range 1–13 days). The median period of recovery in adults was 52 days (range 32–85 days). All survivors had acceptable outcomes at 6 months to one year. Conclusion Conservative management in adults and early plication in children are viable treatment options for diaphragmatic palsy after cardiac surgery, with acceptable outcomes.
Background: Functional tricuspid regurgitation is a challenge regarding indications for repair and proper surgical technique. Aim of the study: We reviewed our midterm results of tricuspid valve repair for functional regurgitation comparing pericardial strip versus ring annuloplasties. Patients and methods: From January 2008 to December 2013, we operated 59 patients (male:female, 41:18, with a mean age of 34 ± 14 years) for functional tricuspid regurgitation. Tricuspid annuloplasty was done using pericardial strip in 39 patients and ring in 20 patients. Concomitant procedures were mitral valve replacement in 66% of patients, aortic valve replacement in 5% and double valve replacement in 29%. Clinical and echocardiographic data were collected. Results: Preoperative characteristics of the two groups were similar regarding age, percentage of female patients, New York Heart Association functional class and pulmonary artery pressure. More patients with preoperative right ventricular dysfunction were found in pericardial annuloplasty group although this was not statistically significant (13 versus 5; P = 0.52). Operative times were similar in both groups. We had one mortality case (1.69%) due to low cardiac output in the pericardial group. Postoperative complications included reexploration for bleeding in one patient and chronic heart failure in another patient. The average follow up period was 3 years and it was complete in 100% of patients. Postoperative freedom from recurrent moderate tricuspid regurgitation was 90% in both groups. Conclusion: Pericardial strip annuloplasty is a simple, inexpensive, reproducible and efficient technique that has comparable results to ring annuloplasty.
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