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Ismail, M. F., A. F. Elmahrouk, A. A. Arafat, T. E. Hamouda, A. Edrees, A. Bogis, A. M. Arfi, A. M. Dohain, A. Alkhattabi, A. W. Alharbi, et al., "Bovine jugular vein valved xenograft for extracardiac total cavo-pulmonary connection: The risk of thrombosis and the potential liver protection effect.", Journal of cardiac surgery, vol. 35, issue 4, pp. 845-853, 2020. Abstract

BACKGROUND: Currently, non-valved conduits are preferred for extracardiac total cavo-pulmonary connection (TCPC). However, previous work has failed to provide objective data comparing the postoperative outcome between non-valved TCPCs and bovine jugular vein valved xenograft (BJV) TCPCs. Hence, the objective of this study is to compare the postoperative outcomes in extracardiac TCPC patients who received BJV vs synthetic non-valved conduits and evaluate the effect of BJV on liver fibrosis.

METHODS: Of 206 patients who had extracardiac TCPC from 2002 to 2017 were divided into three groups. Group A (n = 66) received BJV, group B (n = 37) received PET conduits and group C (n = 103) received polytetrafluoroethylene (PTFE) tube. Study endpoints were hospital outcomes, conduits thrombosis, reinterventions, and survival. Liver stiffness and fibrosis were assessed in eight patients with BJV.

RESULTS: Preoperative parameters were comparable among groups. Thrombosis was significantly lower in group C (P < .0003) but no difference between groups A and B (P = .951). Reinterventions did not differ significantly among groups (Log-rank P = .598). Hospital deaths occurred in seven patients (3.4%). There was no difference in survival between groups (Log-rank P = .221). The median liver stiffness score was 18.65 kPa and the eight patients had advanced liver fibrosis (grade F3-4) in group A.

CONCLUSION: PTFE is the recommended conduit for TCPC with a lower risk of thrombosis compared to BJV and PET. BJV conduits in TCPC circuits may not protect against liver fibrosis. BJV should not be considered as an option for TCPC.

El-Shabrawi, M., W. Lotfy, R. Hegazy, O. AbdElAziz, R. Sobhy, GaserAbdelmohsen, H. Ibrahim, and A. M. Dohain, "Evolution of ventricular function in children with permanent right ventricular pacing after tetralogy of Fallot repair: A midterm follow-up.", Journal of cardiac surgery, vol. 35, issue 4, pp. 831-839, 2020. Abstract

OBJECTIVE: We aim to evaluate the midterm effect of chronic apical right ventricular (RV) pacing on right and left ventricular (LV) function using different modalities of echocardiography including conventional echocardiography, tissue Doppler imaging and two-dimension speckle tracking echocardiography.

METHODS: This case-control study enrolled 49 patients divided into two groups: a paced group and a nonpaced group. The paced group included 23 patients that underwent tetralogy of Fallot (TOF) repair and required permanent pacemaker insertion for postoperative complete heart block. The nonpaced group included 26 patients that had TOF repair at the same period.

RESULTS: The median age for the paced and nonpaced groups was 6 and 8 years, respectively (P = .169). The follow-up duration after TOF surgical repair was 4 years for the paced patients and 5 years for nonpaced patients (P = .411). In the nonpaced group, the QRS duration increased and LV global longitudinal strain (GLS) decreased significantly with increasing duration after TOF repair, P value was .006 and .042, respectively. In the paced group, tricuspid annular systolic plane excursion (TAPSE) was significantly correlated with age (r = .578; P = .004) and duration following TOF correction (r = .724; P < .001).

CONCLUSION: Chronic RV apical pacing in children after TOF repair was associated with better clinical status, preservation of RV systolic function, and prevention of progressive QRS prolongation. RV pacing was not associated with progressive deterioration of LV systolic function with increasing the time interval following TOF repair. Therefore, RV pacing can be beneficial in corrected TOF patients presenting with RV failure.

Elassal, A. A., O. O. Al-Radi, A. M. Dohain, G. A. Abdelmohsen, K. E. Al-Ebrahim, and O. S. Eldib, "Excess nonhemorrhagic pleural drainage after surgery for congenital heart diseases: Single center experience.", Journal of cardiac surgery, vol. 35, issue 1, pp. 108-112, 2020. Abstract

OBJECTIVE: Chylothorax after surgery for congenital heart disease is an uncommon but serious complication that adversely affects surgical outcomes. The aim of our study was presenting our experience for the management of postoperative chylothorax and excess nonhemorrhagic pleural drainage.

METHODS: Medical records of patients with excess nonhemorrhagic pleural drainage were retrospectively reviewed and the collected data included demographics, surgical procedures, drainage characteristics, methods of postoperative management, and outcome.

RESULTS: From March 2011 to May 2018, 52 patients with excess postoperative pleural drainage were identified from a total of 816 pediatric patients operated upon for congenital cardiac disease, giving an incidence of 63.7%. Tetralogy of Fallot and single ventricle morphology were the most common cardiac pathology. The serum triglyceride level was checked and found elevated in 30 patients (53.5%). The maximum daily drainage was 136.25 ± 109.7 mL/day and the mean duration of drainage was 32.23 ± 35.7 days. Medium-chain triglyceride formula was given for 27 patients (51.9%), octreotide for 22 (42.3%) for a mean duration of 8.07 ± 28.3 days. Total parenteral nutrition was needed for 11 patients (21.1%) for a mean duration of 3.13 ± 7.63 days. The success rate for conservative management was 94.2%. Thoracic duct ligation performed for three patients. The mean duration of mechanical ventilation was 7.4 ± 3.6 days, mean intensive care unit stay was 29.6 ± 35.1 days, and mean total hospital stay was 20.9 ± 17.5 days. We had six cases of hospital mortality (11.53%).

CONCLUSION: Initiation of a stepwise approach for excess nonhemorrhagic pleural drainage based on the amount and rate of drainage achieve a favorable outcomes.

Al-Ebrahim, K., O. O. Al-Radi, Z. F. Zaher, M. H. Ibrahim, A. M. Dohain, and A. A. Elassal, "Iatrogenic Coronary Artery Compromise Post Non-Coronary Cardiac Surgery in Patients With Normal Coronaries.", The heart surgery forum, vol. 23, issue 2, pp. E221-E224, 2020. Abstractiatrogenic_coronary_artery_compromise.pdf

BACKGROUND: Unexpected events in cardiac surgery may increase morbidity and mortality. We present rare complications related to coronary arteries in non-coronary cardiac surgery in adults and pediatrics.

PATIENTS AND METHODS: We retrospectively reviewed our surgical left-sided valve procedures and aortic root reconstruction for patients with documented coronary ostial injury or left circumflex artery (LCX) between January 2012 and December 2019. Preoperative echocardiography was the standard investigation for all cases and other specific work ups were ordered, according to each case. Management by surgical or non-surgical intervention was planned, according to each complication. Postoperative hemodynamics and mortality rate were the outcomes of interest.

RESULTS: Seven patients were found to have coronary artery compromise post left-sided valve procedures and aortic root reconstruction in adults and children. The details are shown in Table 1. The complications were in 2 patients post-mitral valve (MV) repair, 3 patients post-aortic (AV) replacement, 2 pediatric patients, 1 post-aortic homograft, and the other post-repair of anomalous single coronary arising from the pulmonary artery (ASCAPA). Six patients were hemodynamically unstable. Five patients had intraoperative ischemic changes on electrocardiogram and echocardiography, while ventricular arrhythmias were documented in 3 patients. Two patients were treated with percutaneous coronary intervention to LCX and right coronary artery (RCA), while 4 patients required immediate surgery to graft the obtuse marginal branch of the LCX artery (1) and RCA (3). No revision to valvular procedure was done. With the exception of one, all patients survived.

CONCLUSION: A high index of suspicion is required to diagnose and rescue coronary complications post-valvular surgery and aortic root reconstruction.

Dohain, A. M., J. Almogati, O. O. Al-Radi, A. A. Elassal, Z. F. Zaher, T. H. Fatani, A. Abdulgawad, and GaserAbdelmohsen, "Serum vitamin D status following pediatric cardiac surgery and association with clinical outcome.", European journal of pediatrics, vol. 179, issue 4, pp. 635-643, 2020. Abstract

Our aim is to determine the prevalence of vitamin D deficiency in children with congenital heart disease (CHD). In addition, we demonstrated the effect of cardiopulmonary bypass (CPB) on vitamin D, parathyroid hormone (PTH), and calcium levels. The association between perioperative vitamin D levels and postoperative clinical outcomes has been explored. A prospective observational study was conducted from February 2018 to June 2019 on 69 children undergoing elective surgery for CHD under CPB. Blood samples were collected preoperatively, immediate postoperatively, and 24 h postoperatively. Vitamin D deficiency was present in 34 (49.3%) patients preoperatively and 63 (91.3%) patients immediately postoperative. We identified 42.03% decline of 25(OH)D immediately postoperative. Changes in ionized calcium (iCa) concentrations were accompanied by reciprocal alterations in PTH concentrations. Lower postoperative 25(OH)D was associated with higher maximum vasoactive inotropic score (VIS) in the first 24 h postoperative (r = - 0.259, p = 0.03).Conclusion: Vitamin D deficiency is common in children with CHD and the majority are vitamin D deficient following cardiac surgery with acute decline of serum 25(OH)D after CPB. Lower postoperative vitamin D levels in children undergoing cardiac surgery are associated with the need for increasing the inotropic support.What is Known:• Vitamin D is a pleiotropic hormone, important for calcium homeostasis.• Vitamin D deficiency might affect the outcome in critically ill patients.What is New:• Cardiopulmonary bypass causes acute decline of vitamin D in children.• Lower postoperative vitamin D is associated with higher inotropic support.

Alamri, R. M., A. M. Dohain, A. A. Arafat, A. F. Elmahrouk, A. H. Ghunaim, A. A. Elassal, A. A. Jamjoom, and O. O. Al-Radi, "Surgical repair for persistent truncus arteriosus in neonates and older children.", Journal of cardiothoracic surgery, vol. 15, issue 1, pp. 83, 2020. Abstracttruncus_artriosus.pdf

OBJECTIVES: Persistent truncus arteriosus represents less than 3% of all congenital heart defects. We aim to analyze mid-term outcomes after primary Truncus arteriosus repair at different ages and to identify the risk factors contributing to mortality and the need for intervention after surgical repair.

METHODS: This retrospective cohort study included 36 children, underwent repair of Truncus arteriosus in the period from January 2011 to December 2018 in two institutions. We recorded the clinical and echocardiographic data for the patients preoperatively, early postoperative, 6 months postoperative, then every year until their last documented follow-up appointment.

RESULTS: Thirty-six patients had truncus arteriosus repair during the study period. Thirty-one patients had open sternum post-repair, and two patients required extracorporeal membrane oxygenation. Bleeding occurred in 15 patients (41.67%), and operative mortality occurred in 5 patients (14.7%). Patients with truncus arteriosus type 2 (p = 0.008) and 3 (p = 0.001) and who were ventilated preoperatively (p < 0.001) had a longer hospital stay. Surgical re-intervention was required in 8 patients (22.86%), and 11 patients (30.56%) had catheter-based reintervention. Freedom from reintervention was 86% at 1 year, 75% at 2 years and 65% at 3 years. Survival at 1 year was 81% and at 3 years was 76%. High postoperative inotropic score predicted mortality (p = 0.013).

CONCLUSION: Repair of the truncus arteriosus can be performed safely with low morbidity and mortality, both in neonates, infants, and older children. Re-intervention is common, preferably through a transcatheter approach.

Elassal, A. A., O. S. Eldib, A. M. Dohain, G. A. Abdelmohsen, A. H. Abdalla, and O. O. Al-Radi, "Delayed Sternal Closure in Congenital Heart Surgery: A Risk-Benefit Analysis.", The heart surgery forum, vol. 22, issue 5, pp. E325-E330, 2019. Abstract

BACKGROUND: Delayed sternal closure commonly is used after pediatric cardiac surgery. Its benefits include relieving cardiac compression and stabilizing postoperative critically ill patients.

METHODS: We retrospectively reviewed the records of 72 patients, who had undergone delayed sternal closure, among 1,254 patients operated for congenital heart diseases. Indications of delayed sternal closure, perioperative hemodynamic and metabolic status, postoperative infection, and mortality were reported.

RESULTS: Transposition of great arteries was the most common preoperative cardiac pathology (26.3%). Bleeding and hemodynamic instability were the most frequent indications for delayed sternal closure, representing 38.8% and 34.7%, respectively. The mean duration of open chest was 3.45 days ± 1.46 days. The mean duration of ICU stay was 20.95 days ± 20.06 days. Two patients had deep sternal wound infection. Sepsis was found in 39 patients (54.1%), and the most common causative organism was coagulase negative (30.5%). ICU stay was a significant risk factor for sepsis (P = .003); duration of open sternum, period of mechanical ventilation (MV), and total hospital stay were not statistically significant risk factors. Sternal closure time (SCT) was affected by period of hemodynamic instability (P = .036). Bypass time, clamping time, and nonsurgical bleeding did not significantly affect SCT. The mortality rate was 15.2% (N = 11).

CONCLUSION: Delayed sternal closure is a simple and effective technique that could prevent postoperative cardiac compression in hemodynamic instability states after pediatric cardiac operations.

Al-Ebrahim, K. E., A. A. Elassal, O. S. Eldib, A. H. A. Abdalla, A. R. A. Allam, E. K. Al-Ebrahim, G. A. Abdelmohsen, A. M. Dohain, and O. O. Al-Radi, "Diaphragmatic palsy after cardiac surgery in adult and pediatric patients.", Asian cardiovascular & thoracic annals, vol. 27, issue 6, pp. 481-485, 2019.
GaserAbdelmohsen, hossam mohamed, M. Mohsen, O. AbdElAziz, D. Ahmed, M. Abdelsalam, and A. Dohain, "Evaluation of cardiac function in pediatric patients with mild to moderate bronchial asthma in the era of cardiac strain imaging.", Pediatric pulmonology, vol. 54, issue 12, pp. 1905-1913, 2019. Abstract

OBJECTIVE: Bronchial asthma is a common chronic inflammatory airway disease, which may be associated with pulmonary hypertension and cardiac dysfunction. The aim of this study was to evaluate the ability of 2D-speckle tracking echocardiography (2D-STE) and tissue doppler imaging (TDI) to detect subtle cardiac dysfunction in pediatric patients with mild to moderate bronchial asthma.

METHODOLOGY: The study included 30 children with mild to moderate bronchial asthma and 27 age-matched healthy controls. Both groups underwent pulmonary function tests, TDI and 2D-STE. Myocardial performance index (MPI), S', E', A' velocities, global strain of left ventricle (LV), right ventricle (RV), and right atrium (RA) were measured.

RESULTS: RV diastolic function was impaired in the patient group, as the tricuspid E' velocity was significantly lower in the patients when compared with the controls (16 [14-17] vs 16 [17-19] cm/s, P = .044), while the RV-MPI was significantly higher in patients when compared to controls (0.30 [0.27-0.36] vs 0.30 [0.30-0.30], P = .001). The global RV longitudinal strain, RA strain, and LV strain did not show significant differences between the test and the control groups. RV systolic parameters and LV systolic and diastolic parameters did not differ significantly between the two groups.

CONCLUSION: Pediatric patients with mild to moderate bronchial asthma may have early RV diastolic dysfunction with preserved other cardiac functions.

Dohain, A. M., GaserAbdelmohsen, A. A. Elassal, A. F. Elmahrouk, and O. O. Al-Radi, "Factors affecting the outcome of extracorporeal membrane oxygenation following paediatric cardiac surgery.", Cardiology in the young, vol. 29, issue 12, pp. 1501-1509, 2019. Abstract

BACKGROUND: Extracorporeal membrane oxygenation has been widely used after paediatric cardiac surgery due to increasing complex surgical repairs in neonates and infants having complex CHDs.

MATERIALS AND METHODS: We reviewed retrospectively the medical records of all patients with CHD requiring corrective or palliative cardiac surgery at King Abdulaziz University Hospital that needed extracorporeal membrane oxygenation support between November 2015 and November 2018.

RESULTS: The extracorporeal membrane oxygenation population was 30 patients, which represented 4% of 746 children who had cardiac surgery during this period. The patients' age range was from 1 day to 20.33 years, with a median age of 6.5 months. Median weight was 5 kg (range from 2 to 53 kg). Twenty patients were successfully decannulated (66.67%), and 12 patients (40%) were survived to hospital discharge. Patients with biventricular repair tended to have better survival rate compared with those with single ventricle palliation (55.55 versus 16.66%, p-value 0.058). During the first 24 hours of extracorporeal membrane oxygenation support, the flow rate was significantly reduced after 4 hours of extracorporeal membrane oxygenation connection in successfully decannulated patients.

CONCLUSION: Survival to hospital discharge in patients requiring extracorporeal membrane oxygenation support after paediatric cardiac surgery was better in those who underwent biventricular repair than in those who had univentricular palliation. Capillary leak on extracorporeal membrane oxygenation could be a risk of mortality in patients after paediatric cardiac surgery.

, "Heart Failure in Congenital Cyanotic Heart Diseases", Advances & Innovations in Heart Failure (AIHF): Jaypee Brothers Medical Publishers, 2019.
GaserAbdelmohsen, M. Y. A. E. Rahman, A. Dohain, S. A. Latif, and W. Attia, "Left circumflex coronary artery to coronary sinus fistula diagnosed in infancy.", Journal of cardiology cases, vol. 15, issue 3, pp. 97-99, 2017. Abstract

Coronary artery fistulas are rare anomalies, their incidence range from 0.1 to 0.2% of congenital heart defects. The left circumflex coronary artery (LCX) fistula draining into the coronary sinus (CS) is a less common form, and most cases described in the literature were adult cases. We are describing this type of fistula in an 8-month-old asymptomatic female presenting with a continuous murmur over the pericordium. Electrocardiogram was normal. Echocardiography revealed a dilated LCX and CS with turbulent flow in CS; 2-D speckle tracking echocardiography revealed normal left ventricular strain with no regional wall abnormalities. Multidetector computed tomography demonstrated the fistula. As the patient was asymptomatic, with no ventricular dilatation or dysfunction, we decided conservatively. < Coronary artery fistulas are rare anomalies that require complementary diagnostic modalities. 2D echocardiography, color flow Doppler, 2D speckle tracking, and multidetector computed tomography are needed to delineate the anomaly and to conclude the prognosis and long-term follow-up plans.>.