Successful Surgery and Long-Term Outcome of a Critical Isthmic Coarctation in an Extremely Preterm Infant with a Birth Weight of 545 g

The incidence of critical isthmic coarctation among preterm infants with a birth weight less than 750 g is expected to be fewer than 1:2,000,000 live births. A male twin was born after 26 weeks of gestation with a birth weight of 545 g. On day 9 of his life, he experienced anuria due to a critical neonatal isthmic coarctation. Resection of the coarctation and end-to-end anastomosis were performed. A magnetic resonance imaging (MRI) scan when the boy was 2 years old demonstrated no significant postoperative re-stenosis. At this writing, up to the age of 6 years, the boy has not needed retreatment. Critical neonatal isthmic coarctation in extremely low-birth-weight preterm infants can be corrected successfully.     

Early Surgical Intervention for Diaphragmatic Paralysis in a Neonate; Report of a Case and Literature Review

Background

Diaphragmatic paralysis in newborns is related to brachial plexus palsy. It can cause respiratory failure necessitating prolonged mechanical ventilation and subsequent extubation failure.

Case Presentation

We present a two-hour-old male newborn with a birth weight of 4500 grams who had a right-sided brachial plexus palsy and right diaphragmatic paralysis due to shoulder dystocia. He developed respiratory distress due to isolated paralysis of the right hemi diaphragm. The clinical course was progressive, his condition worsening despite oxygen application. Physical examination, chest X-rays and M-mode ultrasonography of the diaphragm confirmed the diagnosis diaphragmatic paralysis. Surgical plication of diaphragm was done earlier than the usual time because of recurrent extubation failure. Diaphragmatic plication led to rapid improvement of pulmonary function and allowed discontinuation of mechanical ventilation in less than 3 days.

Conclusion

Early diaphragmatic plication enhances weaning process and may prevent or minimize the morbidity associated with long-term mechanical ventilation in a neonate with diaphragmatic paralysis.     

Tissue Doppler Echocardiography Before and After the Surgical Reconstruction of an Insufficient Mitral Valve in a Patient with Fontan Circulation

We report a patient with tricuspid atresia after total cavopulmonary connection who developed significant mitral valve regurgitation. Doppler myocardial echocardiography tracings showed "pseudonormalization" of diastolic velocities. After successful surgical reconstruction of the mitral valve, the diastolic myocardial velocities changed to the typical Fontan physiology with predominant late diastolic ventricular filling.     

Analysis of Atrioventricular Plane Movements by Doppler Tissue Imaging and M-Mode in Children with Atrial Septal Defects Before and After Surgical and Device Closure

Our objective was to compare the effects of surgical and device closure of atrial septal defects (ASDs) on atrioventricular plane function. In healthy individuals, both short- and long-axis motion contribute to ventricular pump function. Short-axis function (i.e., the amplitude and velocity of atrioventricular plane movements) may be evaluated by M-mode and Doppler tissue imaging. The study group consisted of 19 children with ASD of the secundum type before and after surgical (n = 12) or device (n = 7) closure and 10 healthy controls. Surgical and device closures were uncomplicated and all defects were completely closed. Registrations of atrioventricular plane systolic and diastolic amplitude and velocity were made from the tricuspid and the mitral annulus and from the septum in the apical four-chamber view. Comparisons were made between examinations before and after closure, between the two subgroups of patients treated by surgical and device closure, respectively, and between the patient group and the control groups. Before ASD closure, all measurements were normal or near normal. After surgery, systolic amplitudes and velocities of the tricuspid annulus and in the septum decreased significantly, whereas no changes were seen in the device group. Less marked changes were seen in diastolic measurements. However, in the surgical group significant decrease to subnormal values were found in the tricuspid annulus and in the septum, which may indicate a decreased diastolic function postoperatively. Mitral valve annulus amplitude and velocity were not affected by the treatment. Atrioventricular function is normal in children with right ventricular volume overload. The decrease to subnormal values after open-heart surgery is not seen after device closure of the ASD, indicating that surgery affects right ventricular function.     

Surgical Treatment of Varicocele in Children by the open and Laparoscopic Palomo Technique. a Metanalysis

PurposeTo evaluate the surgical RESULTS of the varicocele treatment in children by open and laparoscopic and open varicocele technique by means of a systematic review of the literature.Material and MethodsA systematic review was performed based on an English literature search using the MEDLINE^® database between 1970 and 2006. The key words used were varicocele and children. All articles that were related to treatment of varicocele in children and adolescents with Palomo technique were selected. The exclusion criteria were age higher than 18 years old and articles which the type of treatment and the outcome were not clear. Of 264 papers evaluated 27 were selected.Results1090 patients who underwent Palomo surgery were included in the analisis. 744 and 1346 patients were treated by the open and the laparocopic Palomo technique, respectively. The rate of postoperative hydrocele, recurrence of the varicocele, testicular catch up and testicular atrophy in the open and laparoscopic Palomo surgery was 10,6 % and 11 % (p > 0,05), 7,08 % and 4,8 % (p > 0,05), 65,6 % and 80 % (p < 0,05), 6 % and 11,2 % (p < 0,05), respectively.ConclusionsThis metanalysis of the literature demonstrates that because of the high rate complication, open and laparoscopic Palomo technique should not be recomended.     

Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)

Purpose

Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.

Methods

Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).

Results

Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5–15 CDH repairs were reported annually per institution; 26–50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III–IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4–5 weeks.

Conclusions

Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.

Level of evidence

V (expert opinion).

     

Acute Coronary Syndrome as a First Presentation of Systemic Lupus Erythematosus in a Teenager: Revascularization by Hybrid Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Intervention: Case Report

Patients with systemic lupus erythematosus (SLE) may present with acute coronary syndrome (ACS) due to coronary vasculitis or premature atherosclerosis. There is a paucity of data on invasive management strategies for young adults who present with an ACS secondary to active vasculitis. This article describes the case of a teenager who presented with an ACS secondary to lupus vasculitis as his first presentation of active SLE. Coronary angiography showed a left main equivalent lesion involving a proximal very large left anterior descending artery (LAD) and diagonal stenosis (with a diminutive left circumflex artery). The boy underwent a successful endoscopic coronary bypass surgery to his LAD followed by percutaneous coronary intervention to his diagonal artery. This case demonstrates the feasibility and safety of a hybrid coronary revascularization in a teenager with acute coronary syndrome due to coronary vasculitis.