Total Anomalous Pulmonary Venous Connection in Adults: Should We Offer Surgery?

Background: We aim to determine the surgical outcomes of adult patients with total anomalous pulmonary venous connection (TAPVC) and examine the regression of pulmonary artery (PA) pressures after the procedure. Methods: We reviewed the hospital records from 2003 to 2022 and identified 49 adult patients with TAPVC. We assessed their surgical outcomes and the trend of PA pressures after the procedure. Continuous data are presented as mean ± SD or median (interquartile range) and categorical variables are presented as percentages. Results: The median age of the patients was 23 years (range 18-42) and 31 (63.3%) were male. Thirty-six patients (73.5%) had supracardiac TAPVC. The mean systolic PA pressure was 65.8 ± 16.4 mm Hg and it decreased by 47.9% (34%, 61.8%) after surgery. Moderate or more tricuspid regurgitation was seen in 27 (55.1%) patients before surgery; however, it was present in only 3 (6.1%) patients during early follow-up. There was no intraoperative or 30-day mortality, and the median hospital length of stay was six days. Long-term follow-up data were available for 29 patients with the average duration of follow-up being 5.6 years (range 6 months to 15 years) and the mean systolic PA pressures of this cohort was 29.8±7.9 mm Hg. Forty-six (93.1%) patients were asymptomatic; four women had uneventful pregnancies and delivered healthy children. Conclusion: Surgical repair of the naturally selected group of adult TAPVC patients can be performed safely with good results. Regression in flow-related pulmonary hypertension and an improvement in functional quality of life are seen in nearly all patients.

Effect of blood conservation protocol on the utilisation of blood and outcome of patients undergoing open heart surgery

INTRODUCTION

Cardiac surgery is fraught with increased consumption of blood and blood products. Various strategies for blood conservation have been described. Our aim was to study the impact of a structured blood conservation protocol (BCP) on the utilization of blood and patient outcome.

METHODS

Retrospective analysis of prospectively collected data comparing adult patients undergoing open heart surgery with BCP with those undergoing surgery without BCP. The primary objective was to compare the amount of blood utilized and the hematocrit at discharge. The secondary objective was to compare the parameters of patient outcomes. The level of significance was set at 0.05.

RESULTS

The proportion of patients requiring transfusion (19.1% [9/47] vs 58.9% [33/56]; p < 0.001) and the quantity of blood transfused (12 units vs 45 units; p 0.003) in the BCP group was significantly lower. Interestingly, the hematocrit level at discharge was comparable between the groups (30.9 (4.8) versus 31.8 (2.4), p-0.671). The average cost incurred for transfusing blood in the BCP group was ₹ 370.2 as compared to ₹1165.1 in the other (p < 0.001). BCP reduced the odds of overall blood transfusion by 79.8% (OR 0.202 (0.084-0.485); p < 0.001) and intraoperative blood transfusion by 95.3% (OR 0.047 (0.010-0.213); p < 0.001). The morbidity and mortality were comparable between the groups.

CONCLUSION

Implementing a structured blood conservation protocol in patients undergoing open heart surgery significantly reduces the need for blood transfusion. It also has a promising impact on patient recovery after surgery and significant positive cost implications.

Cardiomegaly secondary to patent ductus arteriosus causing extrinsic compression of left pulmonary vein

Primary pulmonary vein stenosis is a challenging condition to manage. Recently, extrinsic compression of the pulmonary veins is being detected has cause of narrowing and subsequent turbulence. This can be managed without direct intervention on the pulmonary veins, reducing the risk of recurrence. We report a case of extrinsic compression of the pulmonary veins due to cardiomegaly, relieved after patent ductus arteriosus ligation.

Pulsatile flow in descending aorta: Can coarctation of aorta be ruled out by transesophageal echocardiography?

A 5-year-old child with L posed great arteries, large subpulmonic ventricular septal defect (VSD), atrial septal defect (ASD), and a large patent ductus arteriosus (PDA) with mild isthmic narrowing was scheduled for surgical correction. Intraoperatively, it was a case of anatomically corrected malposition of great arteries. Due to abnormal positioning of great vessels, the isthmus was ligated instead of the large PDA. The postoperative transesophageal echocardiography showed pulsatile flow in descending aorta as it was being filled by large PDA, and thus iatrogenic coarctation (CoA) was missed. It was detected in the intensive care unit due to the onset of acidosis on blood gas analysis and the presence of gradient between radial and femoral arterial line pressures. The patient was taken for redo surgery, the PDA was then ligated, resection of the isthmic narrowing and repair by end-to-end anastomosis was done.

Clinical outcomes and hemodynamic performance of Dafodil™ aortic and mitral pericardial bioprosthesis: 1-year results from Dafodil-1 first-in-human trial

BACKGROUND

Bioprosthesis has been increasingly implanted for the treatment of transvalvular disease across the world. A new Dafodil™ pericardial bioprosthesis (Meril Life Sciences Pvt. Ltd., India) recently approved by Conformité Européenne (CE) is a tri-leaflet, stented, bovine valve. The purpose of Dafodil-1 first-in-human trial was to evaluate clinical safety and performance (including hemodynamic parameters) of the Dafodil pericardial bioprosthesis in patients who underwent aortic or mitral valve replacement.

METHODS

This prospective, multicenter clinical trial enrolled 60 patients (Aortic: 30 patients; Mitral: 30 patients) from seven sites across India. Safety endpoints were early (≤30 days) and late (> 30 days) mortality and valve-related morbidity. The performance endpoints were hemodynamic performance, improvement in NYHA functional class, and change in the quality of life using SF-12v1 health survey.

RESULTS

From July 2017 to July 2018, 60 patients underwent implantation of the Dafodil pericardial bioprosthesis. Post-operatively, NYHA functional class significantly improved in all the patients (Aortic: 90% NYHA class-I and 10% NYHA class-II; Mitral: 96.55% NYHA class-I and 3.45% NYHA class-II; P < 0.001). There was no death in aortic valve replacement patients till 12-month. In mitral valve replacement patients, early mortalities occurred in three patients, and late mortality occurred in one patient; none of these were valve-related. Freedom from all-cause mortality reported was 93.33% at 12-month. Mean aortic pressure gradient decreased from 52.71 ± 24.47 mmHg [with 0.89 ± 0.70 cm² effective orifice area (EOA)] pre-operatively to 14.49 ± 6.58 mmHg (EOA: 1.85 ± 0.27 cm²) at 12-month. Overall, the mitral mean pressure gradient and EOA were 4.41 ± 1.69 mmHg and 2.67 ± 0.48 cm², respectively, at 12-month. Significant improvement (P < 0.05) in the patients' quality of life was reported at all follow-ups.

CONCLUSIONS

The clinical safety and performance of the Dafodil pericardial bioprosthesis were favourable at 12-month. Moreover, a study with a larger patient population and longer follow-up is warranted to further assess the device.

TRIAL REGISTRATION

Dafodil-1 trial has been prospectively registered on 10/07/2017 under Clinical Trial Registry-India (http://www.ctri.nic.in). (Registration number: CTRI/2017/07/009008).

Airway anomalies in cases of anomalous pulmonary venous connection - A single-center experience

Background:

Patients with congenital heart defects may present with concomitant defects involving other organ systems. Roughly 4 percent of this nature are airway anomalies. Presence of anomalous airways summon major challenge before the anesthesiologist, surgeon, and intensivist in the perioperative management of such patients. There is paucity of literature in the study of airway anomalies in the subset of congenital anomalous pulmonary venous connections. We present the analysis of three cases of airway anomalies in patients operated for anomalous venous drainage at our center. We hope to explicate the clinical implications and management of such rare presentations.

Methods:

The records of all patients who underwent surgical correction for anomalous venous return between January 2016 and January 2018 were reviewed retrospectively. The records were examined for presence of any airway issues, abnormal radiological findings, perioperative intubation or extubation issues and perioperative surgical findings.

Results:

Amidst the 410 cases operated for congenital heart defects in this period, 92 were operated cases for anomalous pulmonary venous return, of which 3 patients presented with airway issues. One patient had an aberrant right tracheal bronchus with normal carina and bilateral main bronchial stenosis, the second patient had a hypoplastic left lung and the third patient had congenital lobar emphysema of the left lung.

Conclusion:

Prudent perioperative management necessitates prior evaluation and preemptive planning for airway anomalies in patients with anomalous venous return, since they can belong to the “Malinosculation Syndrome” group, which involves anomalous communication by means of small openings between the different components of lung tissue, namely, the lung parenchyma, tracheobronchial tree, arteries, and veins.

Refining the Journal Club Presentations of Postgraduate Students in Seven Clinical Departments for Better Evidence-based Practice

BACKGROUND

A gap between best practice and actual clinical care exists and this can be overcome by evidence-based practice (EBP), which is essential to improve the clinical decision making. A strategy to reduce deficits in care provision is to train the postgraduate students in the practice of EBP in the journal clubs as evidence from medical colleges in India reveals that current format of journal club presentations is unsatisfactory.

AIM

The aim of the present study was to refine the journal club presentations of postgraduate students of clinical departments and to study the effectiveness of EBP training in them for better EBP.

SUBJECTS AND METHODS

This study was conducted in S. Nijalingappa Medical College, Bagalkot, Karnataka, India, and it was a pre- and post-trial. This study was a pre- and post-trial done during the journal club presentations of postgraduate students from clinical departments. Postgraduate students' understanding of concepts about EBP was assessed using Fresno test questionnaire in traditional journal club presentation. A hands-on session incorporating steps of EBP was imparted to them. Soon after the session, each student was assessed. In the next journal club presentation, 1 week later, the students were assessed again with the same questionnaire by the same faculty. Scores of the postgraduate students, before and after intervention (immediate and 1 week later), were compared. Data were analyzed by paired t-test using SPSS.

RESULTS

An increase in mean posttest scores was seen immediately and also 1 week later as compared to the pretest scores. The scores also increased significantly, when each step of EBP was considered.

CONCLUSIONS

Incorporating teaching of EBP in journal club presentations improved the competencies of postgraduate students in clinical decision making.

Ab initio/DFT electronic structure calculations, spectroscopic studies and normal coordinate analysis of 2-chloro-5-bromopyridine

FT-IR (4000-400 cm(-1)) and FT-Raman (3500-50 cm(-1)) spectral measurements of solid sample of 2-chloro-5-bromopyridine have been done. Ab initio and DFT calculations have been performed giving energies, optimized structures, harmonic vibrational frequencies, depolarization ratios, IR intensities, Raman activities and atomic displacements. Furthermore, force field calculations have been performed by normal coordinate analysis. A complete assignment of the observed spectra, based on spectral correlations, electronic structure calculations and normal coordinate analysis, has been proposed. The results of the calculations have been used to simulate IR and Raman spectra for the molecule that showed good agreement with the observed spectra. The SQM method, which implies multiple scaling of the DFT force fields, has been shown superior to the uniform scaling approach. The energy and oscillator strength calculated by Time-dependent DFT results are in good agreement with the experimental results.

Vibrational spectra, ab initio/DFT electronic structure calculations, and normal coordinate analysis of 2-bromo-5-fluorobenzaldehyde

FT-IR (4000-400 cm(-1)) and FT-Raman (3500-50 cm(-1)) spectral measurements of solid samples of 2-bromo-5-fluorobenzaldehyde (BFB) have been done. Ab initio (RHF/6-311G*) and DFT (B3LY/6-311G* and B3PW91/6-311G*) calculations have been performed giving energies, optimized structures, harmonic vibrational frequencies, depolarization ratios, infrared intensities, Raman activities and atomic displacements. Furthermore force field calculations have been performed by normal coordinate analysis. Force field calculations showed that several normal modes are mixed in terms of the internal coordinates. A complete assignment of the observed spectra, based on spectral correlations, electronic structure and normal coordinate analysis, has been proposed. Optimization leads to C(S) symmetry with O-trans and O-cis isomers, with respect to aldehydic oxygen and bromine, with O-trans-isomer as the low energy stable form. The energy difference between the two isomers is 2.95084 kcal/mol. The results of the calculations have been used to simulate IR and Raman spectra for BFB that showed excellent agreement with the observed spectra. The SQM method, which implies multiple scaling of the ab initio and DFT force fields has been shown superior to the uniform scaling approach.

Revised vibrational band assignments for the experimental IR and Raman spectra of 2,3,4-trifluorobenzonitrile based on ab initio, DFT and normal coordinate calculations

In the present study, a systematic vibrational spectroscopic investigation for the experimental IR and Raman spectra of 2,3,4-trifluorobenzonitrile (TFB), aided by electronic structure calculations has been carried out. The electronic structure calculations -ab initio (RHF) and hybrid density functional methods (B3LYP) - have been performed with 6-31G* basis set. Molecular equilibrium geometries, electronic energies, IR intensities, harmonic vibrational frequencies, depolarization ratios and Raman activities have been computed. The results of the calculations have been used to simulate IR and Raman spectra for TFB that showed excellent agreement with the observed spectra. Potential energy distribution (PED) and normal mode analysis have also been performed. The assignments proposed based on the experimental IR and Raman spectra have been reviewed. A complete assignment of the observed spectra has been proposed.

Vibrational assignments and effect of aldehyde rotation on substituents in some trisubstituted benzaldehydes

Fourier-transform, laser Raman (3500-50 cm(-1)) and infrared (IR) (4000-400 cm(-1)) spectral measurements have been made for solid samples of 2-chloro-3,6-difluoro-, 3-chloro-2,6-difluoro- and 2-chloro-6-fluoro-3-methyl-benzaldehydes. The electronic structure calculations at RHF/6-311G* and B3LYP/6-311G* levels have been performed. Molecular electronic energies, equilibrium geometries, IR and Raman spectra have been computed. Potential energy distributions (PEDs) and normal modes, for the spectral data computed at B3LYP/6-311G* have also been obtained from a force-field calculations. A complete assignment of the observed spectra has been proposed. Investigation of the internal rotation of the aldehyde has shown two rotamers, O-cis and O-trans, with respect to aldehydic oxygen and chlorine. The energy difference between rotamers for three compounds is 226 cal/mol, 8 cal/mol and 167 cal/mol respectively.

FT-Raman and infrared spectra and vibrational assignments for 3-chloro-4-methoxybenzaldehyde, as supported by ab initio, hybrid density functional theory and normal coordinate calculations

Fourier-transform laser Raman (3500-50 cm(-1)) and infrared (4000-400 cm(-1)) spectral measurements have been made for the solid 3-chloro-4-methoxybenzaldehyde. The electronic structure calculations -ab initio (RHF) and hybrid density functional methods (B3LYP and B3PW91) -- have been performed with 6-31G* and 6-311G* basis sets. Molecular electronic energies, equilibrium geometries, IR and Raman spectra have been computed. Potential energy distribution (PEDs) and normal mode analysis have also been performed. A complete assignment of the observed spectra has been proposed. Investigation of the relative orientation of the aldehydic oxygen and chlorine atom with respect to the methoxy group has shown that two forms, O-cis and O-trans exist, with O-trans form being more stable. The energy difference between O-cis and O-trans forms is 0.057 kcal/mol (21 cm(-1)) with B3LYP/6-31G*, which is less than the calculated torsional vibrational frequencies of the aldehyde and methoxy group. In the CH (O) aldehydic stretching region five observed bands are probably due to multiplet Fermi resonance. An infrared doublet near 1700 cm(-1) with nearly equal intensities has been ascribed to the Fermi resonance: the two bands at 1696 and 1679 cm(-1) arise due to the interaction between the CO stretching fundamental and a combination of O-CH(3) and CC stretching vibrations.