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Background: The management of ventricular septal defect (VSD) alongside mitral regurgitation (MR) in pediatric patients remains a contentious issue due to the intricacies of cardiac surgery and the need to minimize ischemic time. Despite observations of MR regression following VSD closure, definitive guidelines for this patient subset are lacking, particularly concerning the management of the subgroup of patients with moderate MR. The objective of the study is to explore the factors influencing the choice between surgical intervention and conservative management for the mitral valve (MV) in VSD patients with moderate MR. Materials and Methods: A retrospective cohort study from January 2000 to December 2015, we analyzed management trends and focused on 53 patients with both VSD and moderate MR. This cohort was subdivided into four groups: first by their MV pathology, and then stratified by the receipt of intervention towards the diseased MV. Our primary goal was to identify correlations, especially concerning surgical outcomes such as mortality and need for re-operation. Statistical significance is determined when the P value is lower than 0.05. Results: There were no notable differences in preoperative variables across four cohort groups, apart from the cross-clamp duration which was longest in Group B intervention. Outcome analysis showed survival rates that were higher in cohort groups that underwent intervention toward the disease MV regardless of existing MV morphology, although results were not statistically significant. Cox model analysis found no correlation between the cohort groups and postoperative outcomes, but cross-clamp duration significantly correlated with mortality. Conclusions: In cases of VSD with moderate MR with associated pathologies of the valvular apparatus, opting for MV repair (MVr) appears to improve survival outcomes without significantly increasing postoperative morbidity. Similarly, for patients with moderate MR and isolated annular dilatation, surgical MVr is observed to have better survival trend compared to the control group.

In this study, we aimed to evaluate the effects of thyroid hormone levels on the prognosis of patients who underwent congenital heart surgery under cardiopulmonary bypass. A total of 40 children who underwent congenital heart surgery were enrolled to this prospective study. The patients were divided into two groups according to the presence or absence of postoperative low cardiac output state. Plasma free thyroxine, free triiodothyronine and thyroid stimulating hormone levels were measured preoperatively and at 24 and 48 hours postoperatively. Postoperative low cardiac output state was observed in five patients (12.5 %). Preoperative free thyroxine levels were significantly higher in the low cardiac output state group (p=0.021). Postoperative free triiodothyronine and free thyroxine levels were significantly lower, and lactate levels, inotropic index were significantly higher in the low cardiac output state group. Duration of mechanical ventilation, intensive care unit stay, operation and cardiopulmonary bypass were significantly higher in the low cardiac output state group. Four patients (10 %) died in the early postoperative period, and all of them were in the low cardiac output state group. Our findings showed that the occurrence of low cardiac output state after congenital heart surgery was associated with the high levels of preoperative free thyroxine and the reduction in percentage of free triiodothyronine and free thyroxine levels at the 24th and 48th hours postoperatively. [Med-Science 2019; 8(2.000): 395-400]

Cinematic rendering (CR) is based on a new algorithm that creates a photo-realistic three-dimensional (3D) picture from cross-sectional images. Previous studies have shown its positive impact on preoperative planning. To date, CR presentation has only been possible on 2D screens which limited natural 3D perception. To depict CR-hearts spatially, we used mixed-reality technology and mapped corresponding hearts as holograms in 3D space. Our aim was to assess the benefits of CR-holograms in the preoperative planning of cardiac surgery. Including 3D prints allowed a direct comparison of two spatially resolved display methods. Twenty-six patients were recruited between February and September 2019. CT or MRI was used to visualize the patient's heart preoperatively. The surgeon was shown the anatomy in cross-sections on a 2D screen, followed by spatial representations as a 3D print and as a high-resolution hologram. The holographic representation was carried out using mixed-reality glasses (HoloLens®). To create the 3D prints, corresponding structures were segmented to create STL files which were printed out of resin. In 22 questions, divided in 5 categories (3D-imaging effect, representation of pathology, structure resolution, cost/benefit ratio, influence on surgery), the surgeons compared each spatial representation with the 2D method, using a five-level Likert scale. The surgical preparation time was assessed by comparing retrospectively matched patient pairs, using a paired t-test. CR-holograms surpassed 2D-monitor imaging in all categories. CR-holograms were superior to 3D prints in all categories (mean Likert scale 4.4 ± 1.0 vs. 3.7 ± 1.3, P < 0.05). Compared to 3D prints it especially improved the depth perception (4.7 ± 0.7 vs. 3.7 ± 1.2) and the representation of the pathology (4.4 ± 0.9 vs. 3.6 ± 1.2). 3D imaging reduced the intraoperative preparation time (n = 24, 59 ± 23 min vs. 73 ± 43 min, P < 0.05). In conclusion, the combination of an extremely photo-realistic presentation via cinematic rendering and the spatial presentation in 3D space via mixed-reality technology allows a previously unattained level of comprehension of anatomy and pathology in preoperative planning.

Objectives: In the previous study we demonstrated that normothermic cardiopulmonary bypass (N-CPB, ≥35°C) provided better early clinical outcomes compared to mild/moderate hypothermic cardiopulmonary bypass (H-CPB, 28–34°C) for congenital heart surgery. In this follow-up study we compare early neurodevelopmental outcomes 2–3 years post-surgery.Methods: In this retrospective, non-randomized observational study, the medical notes of children from our previous cohort were reviewed after 2–3 years. Demographic and neurodevelopmental outcomes were tabulated to enable blinded statistical analysis comparing outcomes between N-CPB and H-CPB surgery for congenital heart defects. Multivariate logistic regression models were developed to identify any differences in outcomes after adjustment for confounders.Results: Ninety-five children who underwent H-CPB (n = 50) or N-CPB (n = 45) were included. The proportions of patients with one or more adverse neurodevelopmental outcomes 2–3 years later were 14/50 (28.0%) in the H-CPB group and 11/45 (24.4%) in N-CPB, which was not significantly different between groups (p = 0.47). The two CPB groups were balanced for demographic and surgical risk factors, with the exception of genetic conditions. A higher incidence of H-CPB patients acquired learning difficulties [23.1% compared to 2.56% for N-CPB (p = 0.014)] and neurological deficits [30.8% compared to 7.69% for N-CPB (p = 0.019)], but these differences were not robust to adjustment for genetic syndromes.Conclusions: Our study did not reveal any significant differences in early neurodevelopmental outcomes between H-CPB or N-CPB surgery for congenital heart defects. The most important factor in predicting outcomes was, as expected, the presence of a genetic syndrome. We found no evidence that CPB temperature affects early neurodevelopmental outcomes.

مقدمه: یکی از مشکلات مهم جراحی قلب اطفال، خونریزی پس از بای‌پاس قلبی- ریوی است و تزریق پلاسمای تازه منجمد شده (FFP یا Fresh frozen plasma) جهت جبران خون از دست رفته و پیش‌گیری از اختلالات انعقادی، به طور معمول اولین اقدامی است که برای بیمار انجام می‌گیرد، اما برخی مطالعات نشان داده است تزریق فیبرینوژن و آلبومین می‌تواند در جبران خون از دست رفته و پیش‌گیری از اختلالات انعقادی مؤثر باشد. از این رو، مطالعه‌ی حاضر با هدف تعیین تأثیر ترکیب فیبرینوژن سنتتیک و آلبومین با پلاسمای تازه منجمد شده، در پیش‌گیری از اختلالات انعقادی در جراحی قلب اطفال بستری در بیمارستان چمران اصفهان طی سال 1393 انجام شد. روش‌ها: طی یک مطالعه‌ی کارآزمایی بالینی، 90 بیمار دارای معیارهای ورود به مطالعه به روش تصادفی‌سازی بلوکی در دو گروه تقسیم شدند. گروه اول، تحت تزریق پلاسمای تازه منجمد شده و گروه دوم تحت تزریق فیبرینوژن سنتتیک و آلبومین قرار گرفتند. قبل و بعد از عمل در تمام بیماران، مقدار پلاکت (Plt یا Platelet)، زمان پروترومبین (PT یا Prothrombin time)، زمان ترومبوپلاستین نسبی (PTT یا Partial thromboplastin time)، زمان انعقاد فعال (ACT یا Activated clotting time)، گازهای خون شریانی (ABG یا Arterial blood gas)، هموگلوبین (Hb یا Hemoglobin) و سطح فیبرینوژن خون بررسی و مقایسه شد. یافته‌ها: بررسی سطح هموگلوبین بیماران در قبل از عمل در دو گروه دریافت کننده‌ی پلاسمای تازه منجمد شده و فیبرینوژن و آلبومین، به ترتیب 9/1 ± 6/10 و 3/3 ± 9/11 (290/0 = P)، در یک ساعت بعد از عمل 2/2 ± 9/12 و 3/2 ± 3/12 و در 24 ساعت بعد از عمل 7/1 ± 9/12 و 6/2 ± 1/13 بود (750/0 = P) و تفاوت معنی‌داری بین دو گروه مشاهده نشد. همچنین، روند تغییرات سطح هموگلوبین بین دو گروه اختلاف معنی‌دار نداشت (690/0 = P). سطح فیبرینوژن در قبل از عمل در دو گروه متفاوت بود، اما در بعد از عمل اختلاف معنی‌داری بین دو گروه مشاهده نشد. نتیجه‌گیری: استفاده از ترکیب فیبرینوژن و آلبومین در بیماران تحت اعمال جراحی قلب حداقل به اندازه‌ی پلاسمای تازه منجمد شده از اختلالات انعقادی و میزان نیاز به تزریق پلاسمای تازه منجمد شده می‌کاهد. از این رو، استفاده از این ترکیب در کودکانی که تحت عمل جراحی قلبی قرار می‌گیرند، طبق نظر پزشک جراح و در صورت عدم وجود کنترا اندیکاسیون، توصیه می‌گردد.

Background: Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas.Materials and Methods: We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing.Results: The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial.Conclusions: The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.

Se realizó un estudio de casos y controles de 121 niños intervenidos por cirugía cardíaca con circulación extracorpórea en el Cardiocentro de Santiago de Cuba (de 336 en total), en el período 1987- 2004, a fin de identificar los factores asociados que influyeron en la aparición de complicaciones neurológicas graves (en 11 de los catalogados como casos), entre los cuales figuraron: tipo de cardiopatía (adquirida) y tiempo total de perfusión (prolongado); los escogidos como controles, no complicados, sumaron 110. Desde el punto de vista significativo se consideraron importantes las variables: complejidad de la operación, tiempo de paro anóxico y temperatura utilizada en la circulación extracorpórea, cuya presencia, tanto aisladas como asociadas, debe alertar al equipo médico sobre la posible ocurrencia de dichas complicaciones. Este estudio es el primero de su tipo efectuado en Cuba.A case-control study was carried out in 121 children who underwent heart surgery with cardiopulmonary bypass at the Cardiology Center of Santiago de Cuba (of 336 total), in the period 1987 - 2004, in order to identify associated factors that influenced the occurrence of serious neurological complications (in 11 of those identified as cases), among which were: type of heart disease (acquired) and total time of perfusion (prolonged). Those chosen as controls without complications added up to 110. The following variables were considered statistically significant: complexity of the operation, time of anoxic arrest and temperature used in cardiopulmonary bypass. The presence of both isolated and associated variables should alert the medical team to the possible occurrence of such complications. This study is the first of its kind made in Cuba.