Systemic Shunt Research Articles

388 Persistent Left Superior Vena Cava With Unusual Drainage

Persistent left superior vena cava (PLSVC) can lead to thromboembolic phenomena including transient ischaemic attacks and stroke. This case report signifies the importance of its identification through simple investigations like echocardiography. The management of this condition described in literature is predominantly surgical. Treatment of this condition with anticoagulation, as described in our paper is a novel approach in managing this condition. A 64-year-old man with a background of dyslipidemia and hypertension presented with symptoms of aphasia and confusion. He was diagnosed with a bi-hemispheric stroke on MRI brain. A transoesophageal echocardiogram was performed as a part of the stroke work up. A bolus of agitated gelofusine administered via a left-sided cannula showed immediate contrast opacification of the left atrium before the right atrium, indicative of a venous to systemic shunt. When agitated gelofusine was injected via the right arm, normal contrast filling was demonstrated in the right atrium first. A cardiac CT confirmed the presence of a PLSVC draining into the left side of the heart. He was commenced on apixaban as secondary prevention for recurrent paradoxical embolisation and remains symptom free one year after initial presentation. In a setting of cryptogenic stroke, a venous-to-arterial shunt caused by a PLSVC should be considered as a potential source of embolus. Echocardiography with contrast injections from both arms should be carried out to assess possible anomalous thoracic venous drainage. Making the diagnosis of venous-to-systemic shunt would help formulate appropriate management to prevent recurrence of embolic phenomena.

Diffusion behavior of cerebral metabolites of congenital portal systemic shunt mice assessed noninvasively by diffusion-weighted 1 H magnetic resonance spectroscopy.

Diffusion-weighted 1 H-MRS (DW-MRS) allows for noninvasive investigation of the cellular compartmentalization of cerebral metabolites. DW-MRS applied to the congenital portal systemic shunt (PSS) mouse brain may provide specific insight into alterations of cellular restrictions associated with PSS in humans. At 14.1T, adult male PSS and their age-matched healthy (Ctrl) mice were studied using DW-MRS covering b-values ranging from 0 to 45ms/μm2 to determine the diffusion behavior of abundant metabolites. The remarkable sensitivity and spectral resolution, in combination with very high diffusion weighting, allowed for precise measurement of the diffusion properties of endogenous N-acetyl-aspartate, total creatine, myo-inositol, total choline with extension to glutamine and glutamate in mouse brains, in vivo. Most metabolites had comparable diffusion properties in PSS and Ctrl mice, suggesting that intracellular distribution space for these metabolites was not affected in the model. The slightly different diffusivity of the slow decaying component of taurine (0.015±0.003μm2 /ms in PSS vs 0.021±0.002μm2 /ms in Ctrl, P<0.05) might support a cellular redistribution of taurine in the PSS mouse brain.

633. Incidence, Microbial Etiology and Antibiotic Resistance Patterns with Special Reference to Shunt Infections in Neurosurgery at a Tertiary Center in North India

BackgroundVentriculoperitoneal (VP) shunt is one of the commonest procedures in neurosurgical practice. A significant problem encountered in shunt procedures is infection, with infection rate ranging from 2 to 27%, often with poor outcome. The objectives of the study were to retrospectively evaluate the infection rate associated with central nervous system (CNS) shunts, assess the frequency of the pathogens as well as their antibiotic sensitivity pattern to aim at suitable prophylaxis.MethodsMaterials and Methods. Retrospective study conducted in the Microbiology Department, SGPGI, Lucknow from December 2017 to August 2018. A total of 168 CSF samples were received with a suspected shunt infection. Samples were analyzed by wet mount, India ink, gram stain and inoculated on blood agar and MacConkey agar. Identification and AST were done by MALDI- TOF system (VITEK-MS) and Vitek 2.0 automated sensitivity system.ResultsDuring the study period, 37/168(22.02%) CSF were positive by culture. Most frequently isolated pathogen was Acinetobacter baumannii 20/37(54.05%), followed by Staphylococcus aureus 06/37 (16.20%), Enterococcus faecalis 04/37(10.81%) coagulase negative staphylococci- CONS 04/37(10.81%), Klebsiella pneumoniae 2/37 (5.40%)and Escherichia coli 1/37(2.70%). 100% of A. baumannii and E. coli strains were found to be XDR and carbapenem-resistant showing susceptibility to minocycline and colistin only. All strains of K.pneumoniae were MDR. 66.7% S.aureus were MRSA and showed 100% resistance to fluoroquinolone. A similar pattern was seen in CONS. 25% of Enterococci were found to be vancomycin resistant.ConclusionDiscussion and Conclusion. The antibiotic sensitivity pattern suggests aminoglycosides, colistin and vancomycin to be a better choice of antibiotics either prophylactically/therapeutically, which may result in effective sterilization of the CSF. Infections following VP shunt procedure are secondary to catheter blockage complicating the results of surgery and are associated with high morbidity and mortality rates.Disclosures All authors: No reported disclosures.

1199. Provider Perspectives on Nonsterile Glove Use in the NICU

BackgroundLate-onset infection is a serious cause of mortality and long-term morbidity in NICU patients. Healthcare worker hands are the most common vehicle for transmission of pathogenic organisms to neonates. Studies have suggested a reduction in infections in neonatal and pediatric patients cared for with universal nonsterile glove use.MethodsWe developed an online survey (https://fhspeds.mcmaster.ca/pedsCapOne/surveys/?s=9RDX7EHT79) for clinicians to understand the current glove use and hand hygiene practices in NICUs in North America. The survey was sent to neonatologists and Pediatric Infectious Disease Specialists via the AAP Neonatal-Perinatal Section listserv, SHEA and the Canadian Neonatal Network.ResultsOf 336 responses; the majority were from physicians at level 3 to 4 NICUs (97%), and from the United States (96.1%). Beyond sterile procedures, sterile gloves were used for central line dressing changes (88.4%), contact with central nervous system shunts (61.0%), and direct contact with central lines (57.4%). Nonsterile gloves were used most commonly for universal precautions and diaper changes (Table 1). Almost half of participants also used nonsterile gloves for all patients and 37.5% for extremely low birth weight (<1000 g) infants. While most sites (76.8%) stated that nonsterile gloves were not required for parents, 15.8% requested gloves also for parents. 58% of respondents felt there was not enough evidence for a practice change at this time and 53.3% felt further study was needed to assess the effect of nonsterile gloves and infection (Figures 2 and 3). Almost a third of respondents (n = 109) would be interested in participating in a randomized study to assess glove-based care. Major concerns with this approach included a possible reduction in hand hygiene compliance, environmental waste, and glove contamination (Figure 4).ConclusionThere is variability in gloving practices across NICUs in North America, with equipoise and interest in a potential randomized study to further explore the hypothesis that nonsterile gloves prevent late-onset infections in neonates. Disclosures All authors: No reported disclosures.

Novel design and analysis of RF MEMS shunt capacitive switch for radar and satellite communications

&lt;span&gt;In this paper, a new type of Radio Frequency Micro-Electro-Mechanical System (RF-MEMS) shunt capacitive switch is designed and studied. RF MEMS switch has a number of advantages in a modern telecommunication system such as low power consumption, easy to fabricate and power handling capacity at radio frequency. At high frequency applications, this switch shows very superior performance due to which it now became one of the key elements for RF application. In this proposed design, an innovative type of MEMS switch is designed. The MEMS switch structure consists of substrate, co-planar waveguide (CPW), dielectric material and a metallic bridge. The proposed MEMS switch has a dimension of 508 µm × 620 µm with a height of 500 µm. The substrate used is GaAs material. The relative permittivity of the substrate is 12.9. This proposed MEMS switch is designed and simulated in both UP (ON) state and DOWN (OFF) state. The proposed RF-MEMS switch is designed and simulated using Ansoft High frequency structure simulator (HFSS) electromagnetic simulator. The simulated result shows better performance parameters such as return loss ( &amp;lt;-10 dB) and insertion loss ( &amp;gt; -0.5 dB) in UP state, whereas return loss ( &amp;gt; -0.5 dB) and isolation (&amp;lt;-10 dB) in DOWN state. This switch has good isolation characteristics of – 43 dB at 27 GHz frequency.&lt;/span&gt;

Assessing hepatic impairment in Fontan-associated liver disease using the HepQuant SHUNT test.

Fontan surgery for single ventricle congenital heart disease leads to Fontan-associated liver disease (FALD). Typical laboratory tests, imaging, and histopathology cannot predict clinical severity in FALD. HepQuant SHUNT is a proprietary serum test of hepatic function and physiology that has not yet been evaluated in FALD. Fourteen adult FALD patients at a single urban tertiary care center who underwent a Fontan procedure in childhood received HepQuant SHUNT testing between September 2015 and April 2018. The HepQuant SHUNT disease severity index (DSI) assesses global liver function and physiology from systemic and portal hepatic filtration rates (HFRs, clearances adjusted for body mass) of orally and intravenously administered cholates labeled with deuterium or 13C. The SHUNT parameter of the test measures portal systemic shunting from the ratio of Systemic HFR to Portal HFR. Chart review included laboratory tests, imaging, and clinical findings. Data from FALD patients were compared with data from healthy controls. The average DSI and SHUNT values for the FALD patients were 17.5% and 36.1%, respectively, compared to 9.2% and 24.1%, respectively, for controls. Twelve (85.7%) FALD patients had a DSI >15 (upper limit of normal). Seven (50.0%) FALD patients had SHUNT values >30% (upper limit of normal), while three FALD patients (21.4%) had SHUNT values >49%. One FALD patient with preoperative SHUNT of 69%, who underwent a combined heart-liver transplant, had confirmed cirrhotic morphology within the liver explant. This pilot study demonstrated that most FALD patients had hepatic impairment detected by abnormal DSI, with a smaller number having markedly elevated SHUNT values >49% suggesting intrinsic liver disease. The HepQuant SHUNT test may be useful in detecting and quantifying liver disease severity in FALD patients.

Toward Transpulmonary Chemoembolization with Degradable Starch Microspheres: Systematic Analysis of Local and Systemic Effects in a Porcine Model.

To investigate local and systemic effects of transpulmonary chemoembolization (TPCE) with degradable starch microspheres (DSM) and doxorubicin. The long-term goal is to establish DSM-TPCE as a treatment option for pulmonary malignancies. Nine pigs underwent TPCE of either the right or left lower lobe pulmonary artery (LLPA) and bland embolization (TPE) of the contralateral LLPA. Before the procedures, macroaggregated albumin (MAA) particles were injected into both LLPAs, to exclude systemic shunting. Pulmonary arterial pressure, heart rate and oxygenation were recorded immediately before and at 1, 3, 5 and 10min after treatment. To investigate possible nontarget embolization, animals underwent cerebral MRI (cMRI). We killed the animals after a contrast-enhanced chest computed tomography (CT) and performed a pathologic examination at 12h (3), 24h (3) and 72h (3) after treatment. All experiments were technically successful. Mean injected DSM dose until stasis was similar in TPCE and TPE (4.3 ± 1.4 vs. 4.0 ± 1.4mL). Pulmonary arterial pressure increased significantly 3min after treatment (TPE: 17 ± 5 vs. 27 ± 7mmHg; TPCE: 22 ± 6 vs. 36 ± 8mmHg). No significant changes in heart rate or peripheral oxygenation levels occurred. We observed no evidence of structural lung damage or permanent perfusion disruption on CT. MAA test injection and cMRI revealed no shunting or nontarget embolization. The pathologic assessment revealed nonspecific local inflammation of the lung parenchyma. In this large-animal model, TPCE and TPE appear feasible and safe. We observed a mild increase in pulmonary arterial pressure. Nontarget embolization did not occur. TPCE, as well as TPE, did not cause structural damage to the normal lung parenchyma.

Beam and dielectric materials impact on improvement of the performance of a novel capacitive shunt RF MEMS switch

AbstractThis paper presents a novel radiofrequency micro‐electro‐mechanical systems (RF MEMS) shunt capacitive switch having high isolation and low insertion loss for microphone applications. The device optimization and various electromechanical analysis are performed using a finite element modeler (FEM) solver. The proposed switch results in a pull‐in voltage of 36.88 V to displace movable beam 2/3rd of its initial gap. By varying beam material, dielectric material, beam‐dielectric thickness, and air gap between movable beam and dielectric layer, various electromechanical and electromagnetic analyses are carried out. For better isolation, silicon nitride (Si3N4) is used for the dielectric layer than hafnium oxide (HfO2) and silicon carbide (SiC). To achieve maximum displacement of the beam, various materials such as aluminum, gold, nickel, and copper are chosen; among all, this gold shows high displacement because of its good conductivity. By implementing various meandering techniques along with perforations, pull‐in voltage and stiction problems are reduced. The switch exhibits good return loss of −28 dB and insertion loss of −0.017 dB during on‐state at 5 GHz and high isolation of −41.26 dB at 10.5 GHz during off‐state. The proposed switch is used at the subsystem/device level in the future microphone, aircraft navigation, and satellite applications.

Tetralogy of Fallot and abnormal coronary artery: use of a prosthetic conduit is outdated.

Repair of tetralogy of Fallot (ToF) can be challenging in the presence of an abnormal coronary artery (CA) in 5-12% of cases. The aim of this study was to report our experience with ToF repair without the systematic use of a right ventricle-to-pulmonary artery (RV-PA) conduit. We conducted a monocentric retrospective study from 2000 to 2016, including 943 patients with ToF who underwent biventricular repair, of whom 8% (n = 76) presented with an abnormal CA. Mean follow-up time was 50 months (1 month-18 years). The most frequent CA anomaly was the left descending artery arising from the right CA (n = 47, 61.8%). The median age at repair was 7.7 months (1.8 months-16 years). Thirteen patients (17%) required prior palliation, mostly systemic pulmonary shunts for anoxic spells in the neonatal period. Surgical repair allowed us to preserve the annulus in 40 patients (53%) by combining PA trunk plasty, commissurotomy and infundibulotomy under the abnormal CA. If the annulus had to be opened (n = 35, 46%), a transannular patch was inserted after a vertical incision of the PA trunk and extended obliquely on the RV over the anomalous crossing CA (with an infundibulotomy under the abnormal CA). Three patients (4%) required the insertion of an RV-PA conduit (1 valved tube and 2 RV-PA GORE-TEX tubes with annulus conservation). The early mortality rate was 4% (n = 3); none of the deaths was coronary related. Four patients (5%) required reoperation (2 early and 2 late reoperations) for residual pulmonary stenosis, 3 of whom had annulus preservation during the initial repair. The mean RV/left ventricle (LV) pressure ratio and an RV/LV pressure ratio >2/3 were identified as risk factors for right ventricular outflow tract (RVOT) reinterventions (P = 0.0026, P = 0.0085, respectively), RVOT reoperations (P = 0.0002 for both) and reoperation for RVOT residual stenosis (P = 0.0002, P = 0.0014, respectively). Two patients underwent pulmonary valve replacement. Freedom from late reoperation was 100% at 1 year, 97% at 5 years and 84% at 10 and 15 years. Repair of ToF and abnormal CA can be performed without an RV-PA conduit, with an acceptable low reintervention rate. The high early mortality rate in this series remains a concern. If any doubt remains about the surgical relief of the RVOT obstruction, the RV/LV pressure ratio should always be measured in the operating room.

Cardiorenal syndrome in renal transplant recipients - It's the fistula at fault: A case series.

Complications arising from a functional arteriovenous fistula (AVF) in successful kidney transplant recipients (KT) have been overlooked despite some reports of its deleterious effect on heart, lungs, and kidney allograft. As such, there is no consensus regarding management of AVF after renal transplantation. We report Cardio-Renal Syndrome Type 5 in kidney transplant recipients who presented with a clinical syndrome of shortness of breath, edematous state, kidney allograft dysfunction, and high pulmonary pressure 3-8months after successful transplantation. Investigations showed this to be due to high flow functioning AVF (>2L/min) behaving like a systemic shunt causing high output heart failure, along with pulmonary and venous hypertension. This led to allograft dysfunction of fluid homeostasis. Symptoms resolved with cessation or reduction of AVF flow. Right heart catheterization and echocardiographic features indicating the syndrome are discussed to help clinicians identify the entity and decide management strategy for these AVF.

Sonographic Evaluation of Umbilical Vein

To evaluate intraabdominal course of umbilical vein, its relation with portal vein and ductus venosus and its anomalies. All pregnant women were examined during midtrimester anomaly scan between January 2015 and December 2017. With evaluation of umbilical vein in its intraabdominal course, size of umbilical vein, its relation to the stomach and the gallbladder and origin of ductus venosus were studied in middle and upper abdominal axial and sagittal planes by two dimensional and colour doppler sonography. Anastomosis of umbilical vein with portal vein and its further course was examined and detailed anatomical survey was made to look for associated anomalies. Fetal and neonatal outcome was assessed after delivery. Twelve cases of umbilical vein abnormalities were evaluated. Of them, there were three cases of umbilical vein varix, four cases of persistent right umbilical vein and five cases of abnormal umbilical–portal–systemic venous shunt were noted. Examination of the intraabdominal course of umbilical vein and ductus venosus should be a part of second trimester anomaly scan. Proper knowledge of umbilical portal venous system is mandatory.

Design and Development of Shunt Active Filter Using MATLAB for Minimization of Harmonics

Nonlinear loads draw non sinusoidal current and voltage from the utility. These non-sinusoidal current and voltages created due to nonlinear loads are called harmonics. The harmonic voltage and current disturbs the system back and creates big power quality problem. Therefore in order to mitigate harmonic problems different mechanisms are used. In this work as introduction different power quality problems, harmonics and their mitigation techniques/filters are presented and discussed. Between the different ways to minimize/eliminate harmonics active power filters are most Prominent one. This research work presents three phase system shunt active power filter working based on PQ theory. MATLAB simulation used and results are discussed.

Enhancing Frequency of Grid-connected Wind Farm using Energy Capacitor System and Trap RC Shunt Damper Strategies

In this paper, a combination of the conventional energy capacitor system and a proposed two-trap Resistor Capacitor (RC) shunt damper circuitry is used to stabilize a grid network made up of fixed speed wind turbines, steam turbines and hydro turbines. The energy storage system is connected to the terminals of the wind farm and has the capability of stabilizing the grid network during periods of wind speed change. The two-trap damper has the ability to mitigate the mechanical vibration of the wind turbine and increase its output and rotor speed acceleration during disturbances, so the turbine speed is reduced. Simulations were run using Power System Computer Aided Design and Electromagnetic Transient Including DC (PSCAD/EMTDC) environment, for scenarios where grid frequency control was not implemented and when frequency control was employed using the energy storage device. A further investigation was carried out in enhancing the performance of the grid network considering the proposed two-trap shunt DC damper control topology. The results show the improved performance of the variables of the wind turbine and the entire grid network during dynamics, due to the coordinated control strategies of the two-trap RC circuit and the energy capacitor system employed.  Citation: Okedu, K. E. (2018). Enhancing Frequency of Grid-connected Wind Farm using Energy Capacitor System and Trap RC Shunt Damper Strategies. Trends in Renewable Energy, 4, 96-110. DOI: 10.17737/tre.2018.4.2.0070

Method for Calculating the Bending Angle of Puncture Needle in Preoperative Planning for Transjugular Intrahepatic Portal Systemic Shunt (TIPS).

Transjugular Intrahepatic Portal Systemic Shunt is a comprehensive interventional therapy for portal hypertension. During this intervention, puncturing from hepatic vein into portal vein is a difficult step. Selecting puncture needle with a proper bending angle is vital to accurate puncture. Thus, this prospective study provides a method to calculate the angle of the puncture needle using preinterventional contrast-enhanced CT imaging. According to the geometrical characteristics of puncture needle, Bezier curve equation was adopted to describe its bending part. By testing whether each point in a specific region satisfied the equation set of Bezier curves, the possible position of needle tip was obtained. Then, the bending angle of puncture needle was obtained by calculating curvature. The method was evaluated in 13 patients from 2 centers showing now a success rate of 100% and a duration of the procedure of 141 and 161 minutes. The method based on Bezier curve equation for calculating a proper bending angle of puncture needle was proven to be effective. And the clinical study is preliminary and additional work for clinical evaluation is necessary.

Impact of Serum Vancomycin Trough Levels in the Treatment of Central Nervous System Shunt Infections Caused by Coagulase-Negative Staphylococci

Coagulase-negative staphylococci (CoNS) are a common cause of pediatric ventricular shunt infections. The Infectious Diseases Society of America recommends vancomycin serum troughs of 15–20 µg/mL when treating CoNS shunt infections in adult patients. We report a series of pediatric cases of CoNS shunt infections in which clinical cure was obtained with troughs < 15 µg/mL. These findings question the relevance of this recommendation in pediatric patients.

Pulmonary Arterial Pressure Management Based on Oral Medicine for Pediatric Living Donor Liver Transplant With Portopulmonary Hypertension

Pediatric living donor liver transplantation (LDLT) in patients with advanced portopulmonary hypertension (PoPH) is associated with poor prognoses. Recently, novel oral medications, including endothelin receptor antagonists (ERAs), phosphodiesterase 5 (PDE5) inhibitors, and oral prostacyclin (PGI2) have been used to treat PoPH. Pediatric patients with PoPH who underwent LDLT from 2006 to 2016 were enrolled. Oral pulmonary hypertension (PH) medication was administered to control pulmonary arterial pressure (PAP). Four patients had PoPH. Their ages ranged from 6 to 16 years, and their original diseases were biliary atresia (n = 2), portal vein obstruction (n = 1), and intrahepatic portal systemic shunt (n = 1). For preoperative management, 2 patients received continuous intravenous PGI2 and 2 oral medications (an ERA alone or an ERA and a PDE5 inhibitor), and 2 received only oral drugs (an ERA and a PDE5 inhibitor). One patient managed only with intravenous PGI2 died. In the remaining 3 cases, intravenous PGI2 or NO was discontinued before the end of the first postoperative week. Postoperative medications were oral PGI2 alone (n = 1), an ERA alone (n = 1), or the combination of an ERA and a PDE5 inhibitor (n = 1). An ERA was the first-line therapy, and a PDE5 inhibitor was added if there was no effect. New oral PH medications were effective and safe for use in pediatric patients following LDLT. In particular, these new oral drugs prevent the need for central catheter access to infuse PGI2.

Metabolite profiling of Listeria innocua for unravelling the inactivation mechanism of electrolysed water by nuclear magnetic resonance spectroscopy

Bactericidal effects of low concentration electrolysed water (LcEW) on microorganisms are previously well reported; however, the inactivation mechanism of EW is not understood. The lethal and sublethal injuries of L. monocytogenes and L. innocua by EW treatments were determined and the metabolic profile changes for L. innocua were characterised using nuclear magnetic resonance (NMR). Microbial metabolomics approach combined with multivariate data analyses was used to interpret the cellular chemical fingerprints of L. innocua. The relative amount of intracellular reactive oxygen species (ROS) was assayed using 2′,7-dichlorodihydrofluorescein diacetate (H2DCFDA). The results showed that the proportion of the sublethally injured microbial cells L. monocytogenes and L. innocua increased from 40% to 70% and from 35% to 65%, respectively, when the free available chlorine (FAC) of LcEW increased from 2 to 8 mg/L. Overall, 36 low-molecular-weight metabolic compounds in L. innocua extracts were characterised by NMR spectroscopy. EW perturbation resulted in a drastic and multitude disruption across a wide range of biochemical process including peptidoglycan synthesis, nucleotides biosynthesis and amino acid metabolism. Elevated levels of α-ketoglutarate and succinate implicated the enhanced glutamate decarboxylase (GAD) system and γ-aminobutyric acid (GABA) shunt for the protection against oxidative stress. These findings provided the comprehensive insights into the metabolic response of Listeria to EW oxidative stress and can serve as a basis for better utilisation for sanitisation.

Results of portosystemic shunting in patients with hepatic cirrhosis and ascites syndrome

Purpose. Assess the results of portal systemic shunting (PSSh) in patients with liver cirrhosis (LC) with ascitic syndrome.&#x0D; Materials and methods. Analyse the results of PSSh in 556 patients operated a year from 2000 to 2015. The basis of the analysis taken all the features related to the development and progression of ascitic syndrome. Depending on the shunt type, research conducted with most frequently performed shunts groups.&#x0D; Results. Initial decompensated cirrhosis by edema-ascites syndrome significantly increases the risk of specific complications such as hepatic insufficiency from 6.9% to 13.5%, hepatic encephalopathy from 12.1% to 16.2% and increase in ascites from 7.2% to 16.2%, and the mortality rate from 2.1% to 3.8%. The main cause of early mortality after PSSh is a risk of thrombosis of the anastomosis with recurrent bleeding, whereas other specific complications, conservative measures allow neutralizing the difference in the index of satisfactory results of the operation (96.2% — in the group with ascites before PSSh against; 97.9% — in the group without ascites). Quantitative and qualitative analysis of ascites showed that in the coming period after the shunt (3-5 days) the development of this complication depends on the type of bypass surgery, so when the distal splenorenal shunts (DSRS) production of ascites significantly increased (P &lt;0,01), while total protein component fluid significantly (P &lt;0,02) higher than in patients in ascites with central bypass type. This fact is due to the formation of the selective type of bypass on the background of DSRS, and the growth of ascites does not depend on the presence of complications before surgery, indicating that the impact factor of the severity of portal hypertension and therefore the adequacy of decompression of the portal vein system, against which a decrease in blood albumin fraction and increase it in ascites (R2 = 0,57) may be indicative of a high residual portal pressure.&#x0D; Conclusion. In patients with cirrhosis after PSSh in 70.2% of cases of decompensation of ascites syndrome is caused directly with cirrhotic process and the growth of functional impairment of hepatocytes, the remaining 29.8% of cases, the formation of the complications associated with the progression of PH syndrome on the background of anastomotic thrombosis.

Patterns of Transition Experience for Parents Going Home from Hospital with their Infant after First Stage Surgery for Complex Congenital Heart Disease

PurposeThe purpose of this study was to explore parents' experiences of one specific timepoint in their infant's journey: the transition from hospital to home, following the first stage of their infant's cardiac surgery for complex congenital heart disease. Design and MethodsA prospective longitudinal mixed methods study, underpinned with Middle Range Transition Theory (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000). Face to face and telephone interviews were conducted and self-report forms completed by parents at four-time points: before discharge (T0), 2weeks after discharge (T1), 8weeks after discharge (T2) and after stage two surgery (T3). Interviews were transcribed verbatim before inductive thematic analysis. ResultsParents were recruited over a 15-month period from 2013 to 2015. Twelve mothers and 4 fathers took part. The infants had functionally univentricular heart (left n=10, right n=1) and a systemic shunt dependent lesion, tetralogy of Fallot (n=1). Dynamic constructivist and constructionist social processes occurred for all parents, involving physical, physiological, psychological and cognitive elements within four ‘patterns of experience’, two of which ‘safety and security’ and ‘love and support’ are presented in this paper. ImplicationsParental support is essential; parents need to be engaged in discharge planning process and given the opportunity to express their needs to ensure that discharge care is truly patient and family centered. ConclusionsTransition from hospital to home was complex and multi-faceted, with unanticipated physical and emotional transitions superimposed upon those that were expected.

Portal-to-right portal vein bypass for extrahepatic portal vein obstruction

ObjectiveRex shunt (mesenteric-to-left portal vein bypass) is considered a more physiologically rational treatment for EHPVO than other portosystemic systemic shunts in children. However, about 13.6% of children with EHPVO do not have usable left portal veins and up to 28.1%. Rex operations in children are not successful. Hence, a Rex shunt in these children was impossible. This study reports a novel approach by portal-to-right portal vein bypass for treatment of children with failed Rex shunts. Material and methodsEight children (age 6.1years, range 3.5–8.9years) who underwent Rex shunts developed recurrent gastrointestinal bleeding and hypersplenism 13months (11–30months) postoperatively. After ultrasound confirmation of blocked shunt, they underwent exploration. Three patients were found to have right portal vein agenesis. Five patients (62.5%) were found to have the patent right portal vein, with the diameter of 3–6mm. Four patients underwent bypass between the main portal vein in the hepatoduodenal ligament and the right portal vein by interposing an inferior mesenteric vein autograft, whereas the remaining patient underwent a bypass using ileal mesenteric vein autograft. ResultsThe operations took 2.3h (1.9–3.5h). The estimated blood loss was 50ml (30–80ml), with no complication. The portal venous pressure dropped from 34.6cmH2O (28–45 cmH2O) before the bypass to 19.6cmH2O (14–24cmH2O) after the bypass. The 5 patients were followed up for 10.2months (4–17months) and the post-operative ultrasound and CT angiography confirmed the patency of all the grafts and disappearance of the portal venous cavernova in all five patients. ConclusionThe portal-to-right portal vein bypass technique is feasible and safe for treatment of children with EHPVO who have had failed Rex shunts. Our preliminary result indicates that this technique extends the success of Rex shunt from left portal vein to right portal vein and open a new indication of physiological shunt for some of the children who not only have had failed Rex shunts or but also are not suitable for the Rex shunts. Type of studyTreatment study. Level of evidenceLevel IV.