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A 14-year-old girl admitted for corrective surgery for tetralogy of Fallot was found to have pulmonary arteriovenous malformations on pre-operative evaluation. In anticipation of a complicated postoperative course, percutaneous closure of the pulmonary arteriovenous malformations was undertaken first followed by a successful surgical outcome. Importance of this rare association and its clinical implication is hereby highlighted.
Advance statements are expressions of wishes made by an individual anticipating future mental incapacity to express treatment choices, spiritual or cultural needs and to nominate someone to be consulted in the event of future incapacity.Advance statements about medical treatment are usually positively-framed treatment choices or requests. An advance statement could also inform the process of determining a person's best interests under the Mental Capacity Act 2005 procedure. Advance Directives project was initiated at Langdon Hospital(Regional Secure Unit with medium and low secure as well as open Forensic wards) in early 2011 and rolled out across site by late 2011.
Aims and objectives:
To audit the opportunity for patients at Langdon Hospital to have Advance Statements in place and its recording on Rio electronic system.To find out areas within the procedure that need improvement and changes.
Data was collected from Rio electronic records of all patients of all wards at Langdon Hospital during a 3 week period.
Results and conclusions:
Most wards had offered above 80% of patients a chance to make Advance Statements. 2 wards achieved 100%. The uptake by patients who were offered an opportunity was high at 70%. Most patients prefer to have a named advocate.In some cases patients specifically asked for a relative not to be involved.Improvement needed in using recommended format and uploading it to Rio. Some staff were concentrating mainly on physical health/end of life decisions. Improvement needed in including questions related to management of future aggression and violence.
Aortopulmonary window with interrupted aortic arch is rarely reported beyond infancy. Pre-operative assessment and surgical repair are challenging. We report successful surgical repair of aortopulmonary window with interrupted aortic arch in a 6-year-old girl with near-normal pulmonary artery pressure immediately following surgery.
A unidirectional superior cavopulmonary anastomosis was performed on the right side in a patient with a functionally univentricular heart, atresia of main and left pulmonary artery, bilateral superior caval veins, and a patent arterial duct in the right pulmonary artery. Anastomosis of the left superior caval vein to the right superior caval vein created a neo-innominate vein without using prosthetic material.
Arterial switch operation is the treatment of choice in infants with transposed arterial trunks. It is technically challenging to perform in patients having usual atrial arrangement and concordant atrioventricular connections but having a left-sided aorta. Correction in this setting requires surgical expertise and precision. Here we review our experience with such patients.
Between January, 2002 and October, 2013, the arterial switch operation was performed in 20 patients in the combination emphasised above. Patient records were analysed in detail for coronary arterial patterns, and for the techniques used for transfer of the coronary arteries and reconstruction of the great arteries. Outcomes were recorded in terms of in-hospital survival and left ventricular function at the most recent follow-up.
All patients survived the procedure. Ages ranged from 3 days to 18 months, with a median of 75 days; the weight of the patients ranged from 3 to 8.8 kg, with a median of 3.85 kg. The LeCompte manoeuvre was performed in only nine patients. The mean cardiopulmonary bypass time was 157.5±24.9, with a median of 161 minutes, and the mean aortic cross-clamp time was 101.2±23.8, with a median of 102 minutes. Subsequently, two patients died: the first due to a sudden onset of ventricular fibrillation and the second during a crisis of severe pulmonary hypertension. At the last follow-up, which ranged from 23 to 41 months, with a mean of 38.04±2.32 and a median of 38.4 months, all 18 survivors were in NYHA class I, with none requiring cardiac medications and all having normal bi-ventricular function without residual defects.
With appropriate technical modifications, patients with concordant atrioventricular and discordant ventriculo-arterial connections with a left-sided aorta can undergo successful anatomical repair.
Between January, 2002 and December, 2011, 27 patients (19 boys) underwent pericardiectomy. The mean age was 9.3 ± 4.96 years (range 0.4 to 15 years) and the mean duration of symptoms was 16.9 ± 22.15 months. In all, 25 patients had dyspnoea; eight were in New York Heart Association (NYHA) class IV; six had bacterial pericarditis; and 18 were on anti-tuberculosis treatment, although only nine had records suggesting tuberculosis. There were nine patients who underwent pre-operative pigtail catheter drainage of pericardial fluid. Surgical procedures were complete pericardiectomy (n = 20), partial pericardiectomy (n = 6), and pleuropericardial window (n = 1).The mean pre-operative right atrial pressure was 20.4 ± 4.93 mmHg. There were six hospital deaths due to low cardiac output (n = 5) and arrhythmia (n = 1). The mean intensive care unit stay was 2.7 ± 1.2 days and mean post-operative stay was 9.9 days. The mean right atrial pressure dropped to 8.7 ± 1.15 mmHg. Adverse outcomes defined as death/prolonged intensive care unit stay, prolonged post-operative stay were not associated with sex, diagnosis of tuberculosis or pyopericardium, or the duration of symptoms or pre-operative right atrial pressure. Younger patients had prolonged intensive care unit stay (p = 0.03) but not increased mortality. Advanced NYHA class predicted death (p = 0.02). The mean follow-up was 23.1 ± 23.8 months. All except one survivor are in NYHA class I and off all cardiac medications. Despite adequate surgery, pericardiectomy in children is associated with a high mortality, which is related to delayed surgery and poor pre-operative general condition. No specific pre-operative variable other than worse pre-operative NYHA class is a predictor of survival. Therefore, early pericardiectomy should be undertaken in such patients.
A large number of patients in developing countries require surgical correction of congenitally malformed hearts. Unfortunately, only a limited number of centres offer these patients surgery at an affordable cost. In this review, we discuss the problems in managing these patients, with an emphasis on reduction of costs, so that the maximum number of patients can benefit. It is apparent that containing costs requires a multipronged approach, which begins with timely referral, and continues with early surgical correction and adequate postoperative care carried out in a scientific manner. Indigenization, innovation, training of manpower, and building a team, are essential to cut the costs, and to improve the quality of care.
Background: We describe alternative surgical techniques for construction of systemic-to-pulmonary arterial shunts, and propose criterions for their application in selected patients. Patients and methods: We constructed a variety of modified systemic-to-pulmonary arterial shunts, using polytetrafluroethylene grafts, in 92 selected patients with cyanotic congenital heart disease and anomalies of the aortic arch and systemic veins. Their age ranged from 7 days to 3.6 years, with a mean of 7.08 months. We performed 88 operations through a thoracotomy. Of this cohort, 60 patients underwent a second-stage operation, with 15 receiving a superior cavopulmonary connection, 16 a total cavopulmonary connection, and 29 proceeding to biventricular repair after a mean interval of 15.6 months. We have 21 patients awaiting their second or final stage of palliation. Results: There were five early (5.4%) and six late deaths (6.8%), two of which were related to construction of the shunts. At a mean follow-up of 45.29 months, the increase in diameter of pulmonary trunk and its right and left branches was uniform and significant (p value less than 0.001). Pulmonary arterial distortion requiring correction at the time of second-stage operation was observed in 5 patients (6.1%). Adequate overall palliation was achieved in 98% of the cohort at 8 months, 91% at 12 months, and 58% at 18 months. Conclusions: Patients with a right- or left-sided aortic arch and right-sided descending thoracic aorta, those with anomalies of systemic venous drainage masking the origin of great arterial branches, and those withdisproportionately small subclavian arteries, constitute the ideal candidates for our suggested modification of the construction of a modified Blalock-Taussig shunt. The palliation provided by these shunts was satisfactory, with predictable growth of pulmonary arteries, insignificant distortion in the great majority, and easy take-down.
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