Prolonged Mechanical Ventilatory Support Research Articles

Congenital Heart Surgery Machine Learning-Derived In-Depth Benchmarking Tool

BackgroundWe previously showed that machine learning-based methodologies of optimal classification trees (OCTs) can accurately predict risk after congenital heart surgery and assess case-mix–adjusted performance after benchmark procedures. We extend this methodology to provide interpretable, easily accessible, and actionable hospital performance analysis across all procedures. MethodsThe European Congenital Heart Surgeons Association Congenital Cardiac Database data subset of 172,888 congenital cardiac surgical procedures performed in European centers between 1989 and 2022 was analyzed. OCT models (decision trees) were built predicting hospital mortality (area under the curve [AUC], 0.866), prolonged postoperative mechanical ventilatory support time (AUC, 0.851), or hospital length of stay (AUC, 0.818), thereby establishing case-adjusted benchmarking standards reflecting the overall performance of all participating hospitals, designated as the “virtual hospital.” OCT analysis of virtual hospital aggregate data yielded predicted expected outcomes (both aggregate and for risk-matched patient cohorts) for the individual hospital’s own specific case-mix, readily available on-line. ResultsRaw average rates were hospital mortality, 4.9%; mechanical ventilatory support time, 14.5%; and length of stay, 15.0%. Of 146 participating centers, compared with each hospital’s overall case-adjusted predicted hospital mortality benchmark, 20.5% statistically (<90% CI) overperformed and 20.5% underperformed. An interactive tool based on the OCT analysis automatically reveals 14 hospital-specific patient cohorts, simultaneously assessing overperformance or underperformance, and enabling further analysis of cohort strata in any chosen time frame. ConclusionsMachine learning-based OCT benchmarking analysis provides automatic assessment of hospital-specific case-adjusted performance after congenital heart surgery, not only overall but importantly, also by similar risk patient cohorts. This is a tool for hospital self-assessment, particularly facilitated by the user-accessible online-platform.

Mechanical ventilation in acute myocardial infarction: Outcomes from a prospective audit at a cardiovascular hospital in Pakistan.

This clinical audit aims to evaluate the clinical data regarding the management and outcomes of acute myocardial infarction (AMI) patients requiring mechanical ventilator (MV) support, along with identifying factors associated with prolonged MV support and 180-day mortality. In this study, we audited clinical data regarding management, in-hospital and short-term outcomes of adult patients with AMI required MV support. Patients with prolonged MV duration (>24h) and/or 180-day mortality were compared with their counterparts, and associated factors were identified. The binary logistic and Cox regression analyses were performed to determine the predictors of prolonged MV duration and 180-day mortality. In a sample of 312 patients, 72.8% were male, and the mean age was 60.3±11.5 years. The median MV duration was 24 [24-48] hours, with 48.7% prolonged MV duration. The admission albumin level was found to be the independent predictor of prolonged MV duration with an adjusted OR of 0.42 [0.22-0.82]. Overall 7.4% were re-intubated, 6.7% needed renal replacement therapy, 17.6% required intra-aortic balloon pump (IABP) placement, and 16.7% required temporary pacemaker placement. The survival rate was 80.4% at the time of hospital discharge, 74.7% at 30-day, 71.2% at 90-day, and 68.6% at 180-day follow-up. Age, prolonged MV duration, and ejection fraction were found to be the independent predictors of cumulative 180-day mortality with adjusted HR of 1.04 [1.02-1.07], 1.02 [1.01-1.03], and 0.95 [0.92-0.98], respectively. Prolonged ventilator duration has significant prognostic implications; hence, tailored early recognition of high-risk patients needing more aggressive care can improve the outcomes.

TRACHEOSTOMY: REVIEW OF LITERATURE

Tracheotomy is a surgical procedure in which a tracheocutaneous airway is created in the anterior neck. It is routinely done in critically ill patients requiring prolonged mechanical ventilatory support or in emergency cases of upper airways obstruction. Both open surgical tracheostomy and percutaneous dilatational tracheostomy are methods used to perform tracheostomy in select individuals. The best technique for performing tracheostomy remains a matter of debate. Each method has his advantages and disadvantages. The determining factors in deciding whether to use an open surgical or percutaneous dilatational tracheostomy in a particular situation depends on patient anatomical and physiological factors and as well on surgeon experiences and prefers. The basic technique and variations are described.

315: PROPOFOL-RELATED HYPERTRIGLYCERIDEMIA AS A RISK FACTOR FOR PANCREATITIS IN PATIENTS WITH COVID-19

Introduction: Hypertriglyceridemia is a known complication of propofol infusion, and higher levels of triglycerides are known to be associated with pancreatitis. Patients with severe COVID-19 pneumonia often require prolonged mechanical ventilatory support and often undergo prolonged sedation with medications such as propofol. In our study we looked to identify safe cut offs for triglyceride levels as well as cumulative dosing of propofol in order to minimize the risk of developing pancreatitis. Methods: Utilizing our COVID-19 database from hospitals in the Steward Health Care Network we conducted a retrospective multi-center review to evaluate the instances of pancreatitis in critically ill patients with COVID-19 pneumonia who received propofol for sedation while intubated. We chart reviewed each patient and collected data regarding the number of days over which propofol was administered, cumulative doses of propofol, peak triglyceride levels, lipase levels, symptoms of pancreatitis and abdominal CT imaging consistent with pancreatitis. For the data analysis we used ROC analysis in conjunction with Youden’s index to identify the optimal thresholds for propofol administration parameters and triglyceride levels that would offer maximal sensitivity and specificity for predicting pancreatitis. Results: We reviewed 499 cases of COVID-19 pneumonia and found 154 patients that were on propofol for sedation for a sufficient period of time. Among these we identified 6 cases of suspected pancreatitis. Using the ROC analysis and Youden’s index we identified optimal cut-offs for peak triglyceride levels (688 mg/dl), number of days on propofol (4.5 days), Average daily propofol dose (3007 mg/day), cumulative propofol dose (24,113 mg) to indicate low risk of pancreatitis. The NPVs for suspected pancreatitis for these cut-offs were found to be from 0.98 to 1. Conclusions: Our study suggests that patients who have triglyceride levels less than 688 mg/dl, have been on propofol for less than 4.5 days, received less than 3007 mg of propofol per day or have received less than 24113 mg in total of propofol may have a lower risk of developing pancreatitis. While these results are encouraging, larger prospective studies with more confirmed cases of pancreatitis are still necessary.

P442 Bacterial and fungal infection in COVID-19 diagnosed cases in a tertiary care ICU setting in the wake of second wave in Kolkata, India

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMFungal and bacterial infections increase the mortality rate of COVID-19-positive patients. In addition to the risk factors that we cannot change, invasive procedures should be avoided, constant blood sugar regulation should be applied, and unnecessary antibiotics use should be avoided. To investigate the incidence of bacterial and fungal infection of hospitalized patients intensive care units with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this retrospective observational study in a tertiary care hospital in Kolkata in the wake of second-wave in India. A retrospective study of hospitalized patients with confirmed SARS-CoV-2 by PCR was analyzed study in a tertiary care hospital in Kolkata in the wake of second-wave from February 2021 to October 2021. The records of 327 patients hospitalized in ICU with the diagnosis of COVID-19 were investigated from electronic health records and hospitalization files. The demographic characteristics (age, gender), the number of ICU hospitalization days and mortality rates, APACHE II scores, accompanying diseases, antibiotic-steroid treatments taken during hospitalization, and microbiological results (blood, urine, tracheal aspirate samples) of the patients were recorded. Blood cultures, respiratory samples, pneumococcal or Legionella urinary antigens, and respiratory viral PCR panels were obtained from COVID-19 patients, respectively. The average APACHE II score of the patients was 28 ± 6. A positive blood culture was identified in 60 patients (7.1%), of which 39 were classified as contaminants. Bacteremia resulting from respiratory infection was confirmed in two cases (one each community-acquired Klebsiella pneumoniae and ventilator-associated Enterobacter cloacae). Line-related bacteremia was identified in six patients (three Candida, two Enterococcus spp., and one Pseudomonas aeruginosa). All other community-acquired bacteremias (n = 16) were attributed to non-respiratory infections. Zero concomitant pneumococcal, Legionella or influenza infection was detected. A low yield of positive respiratory cultures was identified; Staphylococcus aureus was the most common respiratory pathogen isolated in community-acquired coinfection (4/24; 16.7%), with pseudomonas and yeast identified in late-onset infection. Invasive fungal infections (n = 3) were attributed to line-related infections. Opportunistic fungal infection was detected in 58 patients (17.37%) of 327 patients monitored in ICU with a COVID-19-positive diagnosis. Candida albicans was the opportunistic fungal agent isolated from most blood samples taken from COVID-19-positive patients. The mortality rate of COVID-19-positive patients with candidemia was 80%. While 2/3 patients (66.6%) for whom fungi were grown from their tracheal aspirate died, one patient (33.3%) was transferred to the ward. Prolonged mechanical ventilation support was associated with the development of nosocomial candidemia and bacteremia. Parallel to the developments in the field of diagnosis and treatment, an increase in the incidence of fungal infections and the number of patients who are in the risk group for the development of opportunistic fungal infections have been observed in recent years. Among the hospitalized patients, those most at risk in terms of fungal infections are intensive care unit (ICU) patients. The rate of Candida infections amongst critical care patients is very and may pose severe mortality if not diagnosed, treated, and handled effectively, and promptly.

The impact of prolonged mechanical ventilation after acute type A aortic dissection repair

ObjectivePatients with type A aortic dissection have increased resource use. The objective of this study was to describe the relationship between prolonged mechanical ventilation and longitudinal survival in patients undergoing type A aortic dissection repair. MethodsWe conducted a retrospective analysis of patients with type A aortic dissection undergoing repair from 2010 to 2018; Kaplan–Meier function and adjusted Cox regression analysis were used to compare in-hospital mortality and longitudinal survival accounting for time on mechanical ventilatory support. ResultsA total of 552 patients were included. The study population was divided into 12 hours or less (n = 291), more than 12 to 24 or less hours (n = 101), more than 24 to 48 hours or less (n = 60), and more than 48 hours (n = 100) groups. Patients within the 12 or less hours group were the youngest (60.0 vs 63.5 years vs 63.6 vs 62.8 years; P = .03) and less likely to be female (31.6% vs 43.6% vs 46.7% vs 56.0%; P < .001). On the other hand, the more than 48 hours group presented with malperfusion syndrome at admission more often (24.4% vs 29.7% vs 28.3% vs 53.0%; P < .001) and had longer cardiopulmonary and ischemic times (P < .05). In-hospital mortality was significantly higher in the more than 48 hours group (5.2% vs 6.9% vs 3.3% vs 30.0%; P < .001). Multivariable analysis demonstrated worse longitudinal survival for the 24 to 48 hours group (hazard ratio, 1.94, confidence interval, 1.10-3.43) and more than 48 hours ventilation group (hazard ratio, 2.25, confidence interval, 1.30-3.92). ConclusionsThe need for prolonged mechanical ventilatory support is prevalent and associated with other perioperative complications. More important, after adjusting for other covariates, prolonged mechanical ventilation is an independent factor associated with increased longitudinal mortality.

Defining High-Risk Tracheostomy in the Intensive Care Unit

Percutaneous dilational tracheostomy (PDT) is becoming a ubiquitous bedside procedure in the intensive care unit (ICU) in patients requiring prolonged invasive mechanical ventilatory support. Complications of PDT include bleeding, airway compromise, hypoxemia, and procedural failure. There is no clear definition for which patients are considered high-risk for these complications, therefore, we set out to review existing data and define the clinical parameters of a high-risk tracheostomy in the ICU.

Benchmarking in Congenital Heart Surgery Using Machine Learning-Derived Optimal Classification Trees.

Background: We have previously shown that the machine learning methodology of optimal classification trees (OCTs) can accurately predict risk after congenital heart surgery (CHS). We have now applied this methodology to define benchmarking standards after CHS, permitting case-adjusted hospital-specific performance evaluation. Methods: The European Congenital Heart Surgeons Association Congenital Database data subset (31 792 patients) who had undergone any of the 10 "benchmark procedure group" primary procedures were analyzed. OCT models were built predicting hospital mortality (HM), and prolonged postoperative mechanical ventilatory support time (MVST) or length of hospital stay (LOS), thereby establishing case-adjusted benchmarking standards reflecting the overall performance of all participating hospitals, designated as the "virtual hospital." These models were then used to predict individual hospitals' expected outcomes (both aggregate and, importantly, for risk-matched patient cohorts) for their own specific cases and case-mix, based on OCT analysis of aggregate data from the "virtual hospital." Results: The raw average rates were HM = 4.4%, MVST = 15.3%, and LOS = 15.5%. Of 64 participating centers, in comparison with each hospital's specific case-adjusted benchmark, 17.0% statistically (under 90% confidence intervals) overperformed and 26.4% underperformed with respect to the predicted outcomes for their own specific cases and case-mix. For MVST and LOS, overperformers were 34.0% and 26.4%, and underperformers were 28.3% and 43.4%, respectively. OCT analyses reveal hospital-specific patient cohorts of either overperformance or underperformance. Conclusions: OCT benchmarking analysis can assess hospital-specific case-adjusted performance after CHS, both overall and patient cohort-specific, serving as a tool for hospital self-assessment and quality improvement.

ELEVATED GLYCOSYLATED HEMOGLOBIN IS HARBINGER OF ADVERSE SHORT-TERM OUTCOMES FOLLOWING CORONARY ARTERY BYPASS GRAFTING

Objective: To determine the association of elevated HbA1c levels with length of ICU stay, prolonged mechanical ventilator and ionotropic support, and infections in diabetic patients undergoing CABG.&#x0D; Methodology: This Prospective cohort study was conducted at National Institute of Cardiovascular Diseases, Karachi. One hundred fifty eight (158) diabetic patients were enrolled fulfilling inclusion criteria. Data was classified into two groups, Exposed group: elevated HbA1c (≥7%) and Un-exposed group: HbA1c (&lt;7%) and study outcomes in both groups were compared for any statistically significant difference.&#x0D; Results: Total 86.1% patients had prolonged ICU duration, 79.7% (p&lt;0.001) had prolonged mechanical ventilator and 87.3% (p&lt;0.001) patients with prolonged ionotropic support in Exposed group (elevated HbA1c). In Un-exposed group (controlled HbA1c), 44.3% patients had prolonged ICU duration, 12.7% patients had prolonged mechanical ventilator and 64.6% had prolonged ionotropic support. In group-A, 35.4% were observed with sepsis, 16.5% with pneumonia and 31.6% (p=0.026) were with urinary tract infection while in group-B, 49.4% were with sepsis, 16.5% pneumonia and 16.5% urinary tract infection.&#x0D; Conclusion: Elevated HbA1c level is risk marker for higher rate of infections and hospital length of stay after CABG. An HbA1c of 7% or greater was found to be a strong predictor of a length of ICU stay, ventilator support and adverse short-term outcomes including urinary tract infections.

ELEVATED GLYCOSYLATED HEMOGLOBIN IS HARBINGER OF ADVERSE SHORT-TERM OUTCOMES FOLLOWING CORONARY ARTERY BYPASS GRAFTING

Objective: To determine the association of elevated HbA1c levels with length of ICU stay, prolonged mechanical ventilator and ionotropic support, and infections in diabetic patients undergoing CABG. Methodology: This Prospective cohort study was conducted at National Institute of Cardiovascular Diseases, Karachi. One hundred fifty eight (158) diabetic patients were enrolled fulfilling inclusion criteria. Data was classified into two groups, Exposed group: elevated HbA1c (≥7%) and Un-exposed group: HbA1c (<7%) and study outcomes in both groups were compared for any statistically significant difference. Results: Total 86.1% patients had prolonged ICU duration, 79.7% (p<0.001) had prolonged mechanical ventilator and 87.3% (p<0.001) patients with prolonged ionotropic support in Exposed group (elevated HbA1c). In Un-exposed group (controlled HbA1c), 44.3% patients had prolonged ICU duration, 12.7% patients had prolonged mechanical ventilator and 64.6% had prolonged ionotropic support. In group-A, 35.4% were observed with sepsis, 16.5% with pneumonia and 31.6% (p=0.026) were with urinary tract infection while in group-B, 49.4% were with sepsis, 16.5% pneumonia and 16.5% urinary tract infection. Conclusion: Elevated HbA1c level is risk marker for higher rate of infections and hospital length of stay after CABG. An HbA1c of 7% or greater was found to be a strong predictor of a length of ICU stay, ventilator support and adverse short-term outcomes including urinary tract infections.

The Characterization of Postoperative Mechanical Respiratory Requirement in Neonates and Infants Undergoing Cardiac Surgery on Cardiopulmonary Bypass in a Single Tertiary Institution

Although neonates and infants undergoing cardiac surgery on cardiopulmonary bypass (CPB) are at high risk of developing perioperative morbidity and mortality, including lung injury, the intraoperative profile of lung injury in this cohort is not well-described. Given that the postoperative course of patients in the pediatric cardiac surgical arena has become increasingly expedited, the objective of this study was to characterize the profiles of postoperative mechanical ventilatory support in neonates and infants undergoing cardiac surgery on CPB and to examine the characteristics of lung mechanics and lung injury in this patient population who are potentially amendable to early postoperative recovery in a single tertiary pediatric institution. A retrospective data analysis of neonates and infants who underwent cardiac surgery on cardiopulmonary bypass. A single-center, university teaching hospital. The study included 328 neonates and infants who underwent cardiac surgery on cardiopulmonary bypass. A subset of 128 patients were studied: 58 patients undergoing ventricular septal defect (VSD) repair, 36 patients undergoing complete atrioventricular canal (CAVC) repair, and 34 patients undergoing bidirectional Glenn (BDG) shunt surgery. Of the entire cohort, 3.7% experienced in-hospital mortality. Among all surgical procedures, VSD repair (17.7%) was the most common, followed by CAVC repair (11.0%) and BDG shunt surgery (10.4%). Of patients who underwent VSD repair, CAVC repair, and BDG shunt surgery, 65.5%, 41.7%, and 67.6% were off mechanical ventilatory support within 24 hours postoperatively, respectively. In all three of the surgical repairs, lung compliance decreased after CPB compared to pre-CPB phase. Sixty point three percent of patients with VSD repair and 77.8% of patients with CAVC repair showed a PaO2/FIO2 (P/F) ratio of <300 after CPB. Post- CPB P/F ratios of 120 for VSD patients and 100 for CAVC patients were considered as optimal cutoff values to highly predict prolonged (>24 hours) postoperative mechanical ventilatory support. A higher volume of transfused platelets also was associated with postoperative ventilatory support ≥24 hours in patients undergoing VSD repair, CAVC repair, and BDG shunt surgery. There was a high incidence of lung injury after CPB in neonates and infants, even in surgeries amendable for early recovery. Given that CPB-related factors (CPB duration, crossclamp time) and volume of transfused platelet were significantly associated with prolonged postoperative ventilatory support, the underlying cause of cardiac surgery-related lung injury can be multi-factorial.

Fungemia in COVID-19 ICU patients, a single medical center experience.

A known proportion of patients who are admitted for the novel coronavirus disease 2019 (COVID-19) requires intensive care unit (ICU) level of care. Prolonged ICU stay is a risk factor for the development of nosocomial candidemia. The current study aimed to investigate the incidence and risk factors associated with the development of nosocomial candidemia among patients admitted to the ICU for COVID-19. Patients who developed nosocomial candidemia were identified, and their clinical course was reported. A 1:3 case control matching was used to identify non-candidemia patients who served as controls. 89 patients were admitted to the ICU for COVID-19 during the study period. The incidence of nosocomial candidemia was 8.9% (n = 8). Case-control matching identified 24 patients with similar disease severity at the time of ICU admission. Median time to first isolation of yeast was 26 days. Candidemia patients reported longer median ICU stay than controls. (40 vs. 10 days, p = .004). In hospital death rates were comparable in both groups (38% vs. 54%, p = .548). Prolonged mechanical ventilation support was associated with the development of nosocomial candidemia.

Implications of Obesity for the Management of Severe Coronavirus Disease 2019 Pneumonia.

Objectives:To investigate patients’ characteristics, management, and outcomes in the critically ill population admitted to the ICU for severe acute respiratory syndrome coronavirus disease 2019 pneumonia causing an acute respiratory distress syndrome.Design:Retrospective case-control study.Setting:A 34-bed ICU of a tertiary hospital.Patients:The first 44 coronavirus disease 2019 acute respiratory distress syndrome patients were compared with a historical control group of 39 consecutive acute respiratory distress syndrome patients admitted to the ICU just before the coronavirus disease 2019 crisis.Interventions:None.Measurements and Main Results:Obesity was the most frequent comorbidity exhibited by coronavirus disease 2019 patients (n = 32, 73% vs n = 11, 28% in controls; p < 0.001). Despite the same severity of illness and level of hypoxemia at admission, coronavirus disease 2019 patients failed more high flow oxygen via nasal cannula challenges (n = 16, 100% vs n = 5, 45% in controls; p = 0.002), were more often intubated (n = 44, 100% vs n = 22, 56% in controls; p < 0.001) and paralyzed (n = 34, 77% vs n = 3, 14% in controls; p < 0.001), required higher level of positive end-expiratory pressure (15 vs 8 cm H2O in controls; p < 0.001), more prone positioning (n = 33, 75% vs n = 6, 27% in controls; p < 0.001), more dialysis (n = 16, 36% vs n = 3, 8% in controls; p = 0.003), more hemodynamic support by vasopressors (n = 36, 82% vs n = 22, 56% in controls; p = 0.001), and had more often a prolonged weaning from mechanical ventilation (n = 28, 64% vs n = 10, 26% in controls; p < 0.01) resulting in a more frequent resort to tracheostomy (n = 18, 40.9% vs n = 2, 9% in controls; p = 0.01). However, an intensive management requiring more staff per patient for positioning coronavirus disease 2019 subjects (6 [5–7] vs 5 [4–5] in controls; p < 0.001) yielded the same ICU survival rate in the two groups (n = 34, 77% vs n = 29, 74% in controls; p = 0.23).Conclusions:In its most severe form, coronavirus disease 2019 pneumonia striked preferentially the vulnerable obese population, evolved toward a multiple organ failure, required prolonged mechanical ventilatory support, and resulted in a high workload for the caregivers.

Design and Impact of a COVID-19 Multidisciplinary Bundled Procedure Team.

Design and Impact of a COVID-19 Multidisciplinary Bundled Procedure Team.

Early Amplified Respiratory Bioactive Lipid Response Is Associated With Worse Outcomes in Pediatric Influenza-Related Respiratory Failure.

BackgroundBiomarkers are needed for early identification of patients at risk of severe complications from influenza infection, including prolonged respiratory failure and death. Eicosanoids are bioactive lipid mediators with pro- and anti-inflammatory properties produced in response to infection. This study assessed the relationships between the host bioactive lipid response, influenza viral load, and clinical outcomes.MethodsInfluenza-positive, intubated children ≤18 years old were enrolled across 26 US pediatric intensive care units (PICUs). Mass spectrometry was used to measure >100 lipid metabolites in endotracheal and nasopharyngeal samples. Influenza viral load was measured by quantitative polymerase chain reaction.ResultsAge and bacterial co-infection were associated with multiple bioactive lipids (P < .05). Influenza viral load was lower in patients with bacterial co-infection compared with those without, and pro-inflammatory bioactive lipids positively correlated with viral load in bacterially co-infected children (P < .05). Lipids associated with disease resolution correlated with viral load in patients without bacterial co-infection (P < .01). After adjusting for age and bacterial co-infection status, elevated pro- and anti-inflammatory lipids measured early in the intensive care unit course were associated with higher mortality, whereas influenza viral load and endotracheal cytokine levels were not associated with clinical outcomes. Prostaglandin E2, arachidonic acid, docosahexaenoic acid, and 12-hydroxyeicosatetraenoic acid measured within 72 hours of PICU admission predicted death or prolonged (≥28 days) mechanical ventilator support (area under the curve, 0.72–0.79; P < .02) not explained by admission illness severity.ConclusionsChildren with influenza-related complications have early bioactive lipid responses that may reflect lung disease severity. Respiratory bioactive lipids are candidate prognostic biomarkers to identify children with the most severe clinical outcomes.

P854 The role of multimodality imaging in revealing a rare cause of persistent ascites

Abstract Primary cardiac tumors are very rare causes of intracavitary masses, about 5% of all cardiac tumors. Most of them are benign tumors, and 50% are represented by atrial myxomas. They are usually developed in the left atrium, with a pedicle attached to the interatrial septum. Cardiac myxomas are one of the "greatest mimes" of pathology, with a polymorphic clinical presentation, from obstructive, to embolic and constitutional clinical manifestation. We present the case of a 58-year-old female patient with 4 years history of chronic obstructive pulmonary disease (COPD), on bronchodilator treatment and long-term oxygen therapy. She accused two months duration of abdominal distension due to ascites, for which she was evaluated in the gastroenterology department and received diuretics association. The symptoms were refractory to the treatment, so the patient was referred for cardiovascular examination. At presentation, the patient was afebrile, with a heart rate of 100/minute, blood pressure was 125/90 mmHg. Cardiovascular examination did not reveal any murmurs, jugular venous distension was present. 12-lead electrocardiogram (ECG): sinus rhythm, with right atrial enlargement. The transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) revealed a lobulated giant mass in RA, which occupied almost the entire cavity, with prolapse towards the right ventricle during diastole. Due to the large intracavitary mass, the point of attachment could not be ascertained. Computed tomography (CT) of the thorax was performed and it confirmed the presence of the giant right cardiac mass. The patient underwent surgical excision of the tumor under cardiopulmonary bypass. Intraoperative findings were represented by a yellowish-brown lobulated friable mass in the right atrium cavity, measuring 70/30/35 mm. The pedicle of the tumor was inserted on the free wall of the right atrium. The histopathological examination revealed round to stellate cells in a myxoid stroma, specific for cardiac myxoma. Postoperative evolution was influenced by the severe pulmonary disease, with prolonged mechanical ventilation and positive inotropic support, but it was slowly favorable, and the patient was discharged in good condition. Right atrial myxoma is a very rare intracardiac tumor with nonspecific forms of clinical presentations, that create difficulties in diagnosis. Ascites represents an unusual form of manifestation in a patient with a cardiac tumor. The insertion of the pedicle of the myxoma was atypical and induced difficulties in early evaluation of the tumor type. Even though myxomas are mainly benign tumors, the complication rate is very high, especially of embolic events due to the friable tumoral mass, so they can become life threatening conditions. Early diagnosis of cardiac myxoma based on multimodality imaging is essential, leading to optimal surgical management, with good long-term survival. Abstract P854 Figure. TEE view of giant RA tumor

DOZ047.105: Minimally invasive surgical approach for posterior tracheobronchopexy to treat severe tracheobronchomalacia

Abstract Purpose Posterior tracheobronchopexy directly addresses membranous airway intrusion in severe tracheobronchomalacia (TBM). Our experience of posterior tracheobronchopexy through an open approach in a large series of patients has been previously reported by us. This study aimed to review lessons learned from our initial series of posterior tracheobronchopexy through a minimally invasive surgical approach. Methods A retrospective review of all patients with symptomatic TBM who underwent video-assisted or robot video-assisted thoracoscopic posterior tracheobronchopexy between October 2016 and January 2019 was carried out. Results Fourteen patients underwent video-assisted (n = 4) or robotic video-assisted (n = 10) thoracoscopic posterior tracheobronchopexy (age range: 8 months–19 years). Two patients had a history of esophageal atresia (type C) repair; none of the other patients had undergone prior operations. Two patients required open conversion to achieve the desired precision of suture placement. Operative times ranged from 4.5 to 15 hours, depending on the additional procedures performed. The intraoperative bronchoscopic evaluation demonstrated marked improvement in airway patency of all patients at the conclusion of each case. Patients were hospitalized 2 to 7 days, with 0 to 4 days for ICU observation. One patient with bronchopulmonary dysplasia and diffuse TBM, including segmental bronchi, required longer hospitalization and prolonged mechanical ventilation support. Follow-up after surgery ranged from 1 to 27 months. Three patients required subsequent anterior aortopexy and tracheopexy. In these three cases, dynamic tracheobronchoscopy showed that posterior tracheopexy remained intact; nonetheless, anterior airway support was still required to prevent dynamic anterior airway collapse. Conclusions The thoracoscopic approach for posterior tracheobronchopexy, while challenging, can be applied in children with severe TBM. As experience is gained, more complicated procedures and reoperative cases are possible. The simultaneous use of flexible bronchoscopy is mandatory to confirm precision by providing luminal visualization during suture placement. Thoracoscopic surgery with robotic assistance can eliminate some technical limitations of the video-assisted approach by providing an easier platform for very complicated suturing angles.

Role of air way stenting (Duman- silica stent) in benign stricture trachea management

Background: Tracheal strictures are known to recur after dilatation, so they need stenting to prevent recurrence. The objective was to study role of air way stenting (Duman- silica stent) in benign stricture trachea management.Methods: A hospital based prospective study was carried out among 15 cases (as these cases are very rare, author could study only 15 cases) presented with various clinical features suggestive of tracheal strictures. They were examined and managed by putting tracheal stent for up to eight months period. All cases were followed at regular intervals till 14months after the stent was placed. The outcome was studied.Results: The tracheal strictures have been found to be more in the age group of 25-30 years. The male to female ratio was 4:1 i.e. for everyone female case there were four male cases. Thus, the tracheal strictures have been more common among the males compared to the females. All of the patients presented with severe stridor, breathing difficulty, and poor exercise tolerance. Most common cause of tracheal stricture was prolonged mechanical ventilatory support &gt;8 days due to organo phosphorus poisoning in past 3months and all of them were males. All cases had good outcome at the end of 14months of follow up. All cases had normal findings. No one developed foreign body reaction, nor did no one develop granuloma formation at the stent site. After stent removal flexible bronchoscopy repeated after 3rd month and 6th month.Conclusions: Tracheal stenting is very useful procedure in the management of air way strictures.

Tracheostomy among pediatric patients: A review

Tracheostomy is a surgical procedure which has been performed since ancient time. Tracheostomy is a life-saving surgical procedure done among critically sick patients. Children with airway compromise often require tracheostomy. The indication of the tracheostomy among children ranges from airway obstruction to prolonged mechanical ventilator support. There are numerous research papers published for adult tracheostomy with its indications, operative technique, and complications, but the literature on pediatric tracheostomy is scarce. Advanced technique of pediatric anesthesia and increased awareness for vaccination for serious diseases such as polio, measles, diphtheria, tetanus, and Haemophilus influenzae type b (Hib) among children increased the changing indication for tracheostomy from emergency to more elective procedure. Standardization of the procedure, timing, and exact indications is helping to reduce the mortality related to the tracheostomy among the pediatric patients. Here, we attempt to discuss the indications, techniques, selection of the tracheostomy tube complications, and outcome of the tracheostomy among pediatric patients.

Pediatric Tracheotomies: A 5-Year Experience In 152 Children

Objective: To analyze the indications, complications, and outcomes of pediatric tracheotomies. Material and methods: All tracheotomies performed in a tertiary referral center between January 2011 and December 2015 were reviewed retrospectively. Demographic characteristics of patients, types of referral to hospital, tracheotomy indications, preoperative evaluation findings, surgical technique, postoperative care and complications, discharge and follow-up results were analyzed. Results: A total of 152 pediatric patients underwent tracheotomy at our hospital during this five year period. The median age of patients at the time of tracheotomy was 15.8 months, ranging from 24 days to 17 years. Of the 152 patients, 91 had neurological diseases, 38 had cardiopulmonary diseases, 14 had craniofacial abnormalities, seven had upper airway obstruction, and two underwent tracheostomy for trauma. Eleven (7.2%) patients experienced early complications, and 15 (9.8%) experienced late complications. Twenty (13.1%) patients were decannulated during the follow-up period. Unfortunately, 9 patients (5.9 %) died of primary disease and 3 patients (1.9 %) died of tracheostomy-related complications Conclusions: The majority of procedures were performed for diseases leading to prolonged mechanical ventilator support such as neurological and cardiopulmonary diseases. This study demostrates the importance of tracheotomy indications, which are the main predictors of decannulation rates. The other significant predictor is pulmonary complications that may cause permanent dependence of mechanical ventilator support as a result of pulmonary failure