Coronary Artery Anomalies in D-Transposition of the Great Artery Following Arterial Switch Operation

Background: The survival rate of patients following arterial switch operation (ASO) exceeds 95%, but coronary artery anomalies (CAA) contribute to a 2% incidence of sudden cardiac arrest later in life. Therefore, we aimed to assess abnormal findings of coronary arteries in post-ASO patients. Methods: Coronary computed tomography angiography (CCTA) is performed on post-ASO patients who meet institutional criteria. Intraoperative findings of coronary artery patterns were retrospectively reviewed and categorized using the Leiden classification system. Coronary artery anomalies were detected by CCTA and associations with coronary artery compromise were explored. Results: Forty-three patients who had CCTA with a median age of 15.6 years (12–21.3 years) were included in the study. Unusual coronary patterns were identified in 20 (46%) patients before ASO. CCTA identified 25 CAA in 22 patients (eleven with prepulmonic course, nine with interarterial course, three with acute take-off angle, and two with significant stenosis). Postoperative CAA was more common in patients with unusual coronary patterns (90% vs. 17.4%; p < 0.001). Nine patients experienced chest pain and two patients required coronary artery bypass graft. A common ostium of RCA and LAD or LMCA were associated with significant chest pain (OR 14.3%, 95% CI 2.5 to 82.3). Conclusions: Coronary artery anomalies in post-ASO are common. All post-ASO patients should have coronary artery imaging before participating in competitive sport and when they reach adolescence. Patients with unusual preoperative coronary artery patterns should undergo coronary artery imaging when feasible. Follow-up imaging studies are indicated in patients with post-operative coronary artery abnormalities.     

Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients

Background

Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale-Thai version (MDAS-T) in PC patients.

Materials and Methods

The MDAS was translated into Thai. Content validity, inter-rater reliability, and internal consistency were explored. The construct validity of the MDAS-T was analyzed using exploratory factor analysis. Instrument testing of the MDAS-T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU-T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded.

Results

The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one-factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93–0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS-T were 0.92 (0.85–0.96) and 0.90 (0.82–0.94), respectively, with a cutoff score of 9, whereas the CAM-ICU-T yielded 0.58 (0.48–0.67) and 0.98 (0.93–0.99), respectively. The median MDAS-T assessment time was 5 minutes.

Conclusion

This study established and validated the MDAS-T as a good and feasible tool for delirium screening and severity rating in PC settings.

Implications for Practice

Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS-T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population.

     

Patient satisfaction in ambulatory anesthesia: A systematic review

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Congenital Coronary Artery Fistula in Children: A Review of 28 Cases with Clinical and Imaging Outcomes

Background: Congenital coronary artery fistula (CCAF) is a rare anomaly. Treatment strategies tend to close the defect with a symptomatic and significant shunt, primarily based on expert consensus and case series. Results for long-term follow-up in children are limited Methods: We conducted a retrospective study to assess clinical and imaging outcomes of children with CCAF at Siriraj Hospital, Thailand during 2000–2020. Patients with single ventricle were excluded. Treatment strategies [surgical closure (SC), and percutaneous closure (PC)] were classified and the clinical outcomes at the follow-up in 2021, including coronary thrombosis, myocardial ischemia, and the results of cardiovascular imaging were reviewed. Results: Twenty-eight children with CCAF were included in the study. The median age at diagnosis was 2.5 years (2 days–18 years). Presenting symptoms were audible murmur (82%) and heart failure (35%). Most of fistulae arose from the right coronary artery (12/28) and exited at the right atrium (11/28). In recent visits (0.5–14 years follow-up), six patients with asymptomatic small CCAF were managed by watchful follow-up without complications. PC was primarily treated in 11 children: 7 underwent successful procedures; 1 had a residual shunt and required re-intervention; 1 had ischemic symptoms immediately after the procedure with left coronary occlusion that required device removal plus SC and 2 were technically unable to place the device, requiring SC. Four patients were waiting for interventions (1 PC and 3 SC). Cardiovascular imaging surveillance that followed closure demonstrated asymptomatic thrombus formation in three patients (1 PC and 2 SC). No mortality presented. Conclusion: CCAF with significant shunt is indicated to close either SC or PC. Ischemic events are rare but have been reported after closure. In addition, thrombus formation should be watched for post-intervention. Surveillance with cardiovascular imaging is recommended after defect closure (ideally 1–5 years post closure), or at interval follow-ups in patients with symptoms to evaluate possible recanalization, thrombus, or ischemia. Life-long clinical and echocardiographic follow-up is warranted. Watchful follow-up is acceptable for hemodynamically insignificant fistula without complication in the series.     

Contemporary outcomes and mortality risks of Ebstein anomaly: A single‐center experience in Thailand

Background: The increasing number of patients with Ebstein anomaly (EA) surviving into adulthood implies improvements in the treatments for the complex lesion. We revisited the clinical outcomes of patients with EA to demonstrate their “real world” survival.
Objectives: To identify the survival and predictors of mortality in patients with EA who underwent medical or surgical management in the present era.
Methods: All patients who had EA with atrioventricular concordance between 1994 and 2016 were retrospectively reviewed. Baseline characteristics, initial echocardio‐ graphic findings, treatments, and outcomes were explored. The survival analysis was performed at the end of 2017. A multivariate analysis was used to assess mortality risks.
Results: A total of 153 patients (25.4 ± 20.4 years, 60% female) were analyzed. Of these, 89 patients had been diagnosed with EA in childhood. During the follow‐up [median time of 5.2 years (3 days‐23.5 years)], 32 patients (20.9%) died due to major cardiac adverse events. The overall survival at 1, 5, and 10 years were 89%, 82.2%, and 79%, respectively. Of the total 153 patients, 64 patients underwent at least one surgical intervention [median age of 17 years (1 day‐64.4 years)]. The survival at 1, 5, and 10 years were 87.5%, 82.4%, and 77.7%, respectively, in patients with EA sur‐ gery. This survival is comparable to the survival of 89 nonoperated patients with EA: 89.9%, 87.5%, and 81.8%, at 1, 5, and 10 years, respectively. The significant predic‐ tors of mortality were: age at diagnosis ≤2 years, tricuspid valve (TV) z‐score >3.80, TV displacement >19.5 mm/m2, presence of severe tricuspid regurgitation, and ab‐ sence of forward flow across the pulmonic valve at the initial diagnosis.
Conclusion: Patients with EA had a moderately good survival in this era. In this paper, we report five simple predictors of death in this patient population.     

Validation of Traditional Prognosis Scoring Systems and Skeletal Oncology Research Group Nomogram for Predicting Survival of Spinal Metastasis Patients Undergoing Surgery

BackgroundMany scoring systems that predict overall patient survival are based on clinical parameters and primary tumor type. To date, no consensus exists regarding which scoring system has the greatest predictive survival accuracy, especially when applied to specific primary tumors. Additionally, such scores usually fail to include modern treatment modalities, which influence patient survival. This study aimed to evaluate both the overall predictive accuracy of such scoring systems and the predictive accuracy based on the primary tumor.MethodsA retrospective review on spinal metastasis patients who were aged more than 18 years and underwent surgical treatment was conducted between October 2008 and August 2018. Patients were scored based on data before the time of surgery. A survival probability was calculated for each patient using the given scoring systems. The predictive ability of each scoring system was assessed using receiver operating characteristic analysis at postoperative time points; area under the curve was then calculated to quantify predictive accuracy.ResultsA total of 186 patients were included in this analysis: 101 (54.3%) were men and the mean age was 57.1 years. Primary tumors were lung in 37 (20%), breast in 26 (14%), prostate in 20 (10.8%), hematologic malignancy in 18 (9.7%), thyroid in 10 (5.4%), gastrointestinal tumor in 25 (13.4%), and others in 40 (21.5%). The primary tumor was unidentified in 10 patients (5.3%). The overall survival was 201 days. For survival prediction, the Skeletal Oncology Research Group (SORG) nomogram showed the highest performance when compared to other prognosis scores in all tumor metastasis but a lower performance to predict survival with lung cancer. The revised Katagiri score demonstrated acceptable performance to predict death for breast cancer metastasis. The Tomita and revised Tokuhashi scores revealed acceptable performance in lung cancer metastasis. The New England Spinal Metastasis Score showed acceptable performance for predicting death in prostate cancer metastasis. SORG nomogram demonstrated acceptable performance for predicting death in hematologic malignancy metastasis at all time points.ConclusionsThe results of this study demonstrated inconsistent predictive performance among the prediction models for the specific primary tumor types. The SORG nomogram revealed the highest predictive performance when compared to previous survival prediction models.     

Beneficial effects of transcatheter closure of atrial septal defects not only in young adults

Objectives: To compare cardiac events and remodeling effects after transcatheter closure of atrial septal defects (ASD) in pediatric, adult, and older adult patients. Methods: A retrospective review was conducted of 353 patients who underwent transcatheter ASD closure between February 1999 and December 2007 at Siriraj Hospital. The patients were divided into 3 groups according to age: children (<18 years; n = 99); adults (18–50 years; n = 169); and older adults (>50 years; n = 85). Cardiac events at 1 year, and changes in left and right ventricular dimensions between preprocedure and 6 months and 1 year postprocedure were compared between groups. Results: Of the 353 patients, the average size of ASD was 22.1 ± 6.6 mm. Device: ASD diameter was 1.25 ± 0.28 mm. At 1 year postprocedure, the prevalence of chest discomfort and atrial fibrillation (AF) was higher in older adult patients, compared to the other age groups. Device embolization, cardiac erosion, pericardial effusion, syncope, migraine, thrombus formation, and residual shunt did not differ between groups. Within the first 6 months, the right ventricular (RV) dimension tended to dramatically decrease, while the left ventricular (LV) dimension increased in all age groups. These changes leveled off in children and in older adults, but in the adult group (18–50 years), RV shrinkage and LV expansion continued for 1 year. A low rate of early and late complications was noted. Conclusion: Transcather closure of ASD can cause cardiac remodeling, regardless of the patient's age at the time of the procedure. For older adult patients, the long‐term risk of AF continuation and chest discomfort is likely. (J Interven Cardiol 2012;25:382–390)     

The patterns of proximal attachments of the popliteus muscle: form and function

The proximal attachments of the popliteus muscle exhibit some variability in the literature, leading to questions regarding function. The anatomic variability of the proximal attachments of popliteus muscles in Thais was studied in order to compare with the previous reported literature by carefully tracking its fibers caudo-cephalically. The sites of the proximal attachments of popliteus muscles found in this study were at the lateral femoral condyle (100%), the posterior horn of the lateral meniscus (63%) and the fibular head (52.1%). Our result also reveals the difference of the strength of the attachment at the lateral meniscus, having some relationship with the attachment at the fibular head, which corresponds with the concept of form and function.