Fifteen-minute consultation: How to spot serious heart disease in the newborn

Congenital heart disease (CHD) is common and important as it remains a leading cause of neonatal morbidity and appreciable mortality. Prenatal diagnosis, the presence of a murmur, cyanosis, tachypnoea and/or poor or differential peripheral pulses raise the suspicion of CHD aided by differential pre/postductal saturations. Yet even serious CHD may not be considered when such clues are absent. Nevertheless, there are clinical cues which may alert the clinician to the possibility of a significant CHD which may lead to an early and accurate diagnosis and appropriate intervention to achieve best results. This paper addresses these issues which become especially difficult if caring for infants away from facilities provided by tertiary centres. Tachypnoea on the first postnatal day is generally non-cardiac in origin. Exceptions include large arteriovenous fistulae and/or ‘pump’ (ventricular) failure. In addition, attention is drawn to two important confounding factors in the newborn, namely the patency of the ductus arteriosus and the initially high pulmonary vascular resistance, both of which alter and may mask the clinical findings of a serious cardiac abnormality. An appreciation of the physiological changes that occur in early infancy will aid the clinician’s understanding of CHD as it affects the newborn.

A successful case of heart transplantation concurrent with pulmonary thromboendarterectomy

Introduction: Pre-transplant irreversible pulmonary hypertension and high pulmonary vascular resistance are generally considered as contraindications for orthotopic heart transplantation due to the high risk of right ventricular dysfunction after transplantation. However, there is no consensus on whether reversible pulmonary hypertension increases the incidence of post-transplant complications and mortality. Case report: A patient with acute heart failure and pulmonary artery occlusion successfully underwent heart transplantation concurrent with pulmonary thromboendarterectomy. Discussion and Conclusion: This case illustrates that heart transplantation concurrent with pulmonary thromboendarterectomy can be performed successfully with meticulous operability assessment, superb surgical technique and careful perioperative management.

PERIOPERATIVE MANAGEMENT OF PATENT DUCTUS ARTERIOSIS WITH EISENMENGERS SYNDROME WITH SEVERE PULMONARY HYPERTENSION POSTED FOR NON-CARDIAC SURGERY.

Victor Eisenmenger's initial definition of Eisenmengers syndrome was redefined by Wood as 'the presence of high pulmonary vascular resistance associated with pulmonary artery hypertension at or close to systemic pressure associated with a reversed or bi-directional shunt at the aortopulmonary, interatrial or interventricular level'. Survival beyond 50 years is unusual, but patients may lead a relatively active and productive life in early adulthood and will therefore present from time to time for noncardiac surgery. Though theoretical risks of anaesthesia are considerable patients are known to do well with a variety of techniques, if pathophysiology of the disease is well understood.We describe the anaesthetic management of the patient with Eisenmengers syndrome with abnormal uterine bleeding with multiple fibroids.She underwent a total abdominal hysterectomy after pre-operative stabilization.Anaesthetizing such a decompensated patient is an anaesthetic challenge.

4975Efficacy of pulmonary hypertension-targeted drugs for severe chronic thromboembolic pulmonary hypertension

Background High pulmonary vascular resistance (PVR) is a risk factor for reperfusion pulmonary edema by balloon pulmonary angioplasty (BPA). It has not been clarified whether improvement of hemodynamics by pulmonary hypertension (PH)-targeted drugs before BPA session is effective clinically. Severe chronic Thromboembolic pulmonary hypertension (CTEPH) patients have small vessel disease like pathological findings of idiopathic pulmonary arterial hypertension. Objectives The purpose of this study was to investigate the efficacy of PH-targeted drugs for patients with CTEPH before BPA. Methods This study included consecutive 147 CTEPH patients treated with PH-targeted drugs before BPA. All patients were divided into 2 groups such as severe group (PVR >12.5 wood units) and non-severe group (PVR <12.5 wood units). PVR were compared between baseline and after treated with PH-targeted drugs. All data were expressed by median [25thpercentile-75thpercentile]. Results The median age and male were 66 [53–74] years old and 42. Numbers of patients treated with phosphodiesterase V inhibitors, endothelin receptor antagonists and riociguat were 84 (57%), 92 (63%), and 43 (29%), respectively. PVR significantly decreased after treated with PH-targeted drugs in two groups (severe group: 16.3 [13.7–20.0] to 10.0 [7.2–13.3] wu, P<0.0001; non-severe group: 6.8 [4.9–8.9] to 5.7 [3.5] to 7.8, P<0.001). Changes of PVR in severe group were significantly larger than in non-severe group (−6.9 [−8.5 to −3.2] vs. −0.7 [−2.4 to 0.7], P<0.0001). There was no significant difference in efficacy of BPA and numbers of dilated vessel between two groups (severe vs. non-severe group after BPA; PVR: 2.7 [1.9–3.5] vs. 2.1 [1.7–3.1] wu, P>0.05; numbers of dilated vessel: 18 [14–21] vs. 16 [10–21], P>0.05) Conclusions PH-targeted drugs may improve hemodynamics for severe CTEPH more effectively.

Newborn Female with Hypoxic Respiratory Failure and Persistent Pulmonary Hypertension: A Case Report

Streptococcus pneumoniae (SP) is a rare but well recognized cause of sepsis in neonates.Persistent pulmonary hypertension of newborn (PPHN) is one of the serious complications of SP and afrequent cause for morbidity and mortality in neonatal SP sepsis. It is a state of oxygenation failurecharacterized by high pulmonary vascular resistance with right-to-left shunting of venous blood. Inhaled NO(iNO) and extracorporeal membrane oxygenation (ECMO) have proven beneficial to infants who failed torespond to ventilation. Here we report a case of SP sepsis. The patient was a term female, who presentedwith rapidly progressing respiratory failure that occurred hours after birth. She subsequently developedsevere PPHN, which did not respond adequately to ventilation and iNO. The patient was intermittentlymanually ventilated over a 3-hour period to keep SpO2 at 50-70%. She had leukopenia, bandemia,elevated inflammatory markers, and positive blood culture for SP. Ampicillin and meropenem wereadministered to treat fulminant sepsis. She was transferred to a Level IV NICU in urgent need of ECMO.After transport, she improved on conventional ventilator and iNO without ECMO, and was discharged homeon room air on day of life 39. The patient is currently a 12-month-old healthy female without anydevelopmental issues.