Garg, Pankaj

Abstract Lung transplant recipients are at higher risk of developing COVID-19 infection compared to other solid organ transplants. The risk further increases in the unvaccinated patients. We present a case of a 43-year-old male who underwent bilateral sequential lung transplantation for pulmonary alveolar microlithiasis (PAM) and had an uneventful recovery. However, two years post-transplantation, the patient developed chronic lung allograft dysfunction (CLAD) with bronchiolitis obliterans syndrome and two episodes of COVID-19 infection. During the second episode of COVID-19 infection, the patient developed sepsis and multi-organ dysfunction ultimately resulting in death. Our case report highlights the increased susceptibility of PAM patients’ post-lung transplant to COVID-19 infection. Continuous follow-up of PAM patients’ post-lung transplantation is necessary to prevent unfavorable outcomes.

Abstract Backgound Infections of the left ventricular assist device (LVAD) driveline are a dreaded complication that results in high mortality and morbidity. Method We retrospectively reviewed five consecutive patients with severe continuous‐flow LVAD (HVAD, Heartmate 2, and Heartmate 3) driveline infection. These infections, which developed on an average of 960.4 ± 843.9 days after LVAD placement, were refractory to systemic antibiotics and local wound care. All were treated with extensive surgical debridement, local installation of absorbable antibiotic‐loaded calcium sulfate beads (vancomycin and tobramycin), primary wound closure, and 6 weeks of systemic antibiotics after surgery. Results Four patients had resolution of DLI, and one had a recurrent infection at another part of the driveline 7 months after the complete resolution of the previous site. This patient was successfully treated with debridement and bead placements. Three patients still have their LVADs, while two received orthotopic heart transplants. At the time of the transplant, there was no evidence of gross infection of the LVAD drivelines or pumps. At the average follow‐up time of 425.8 ± 151 days, no patients have an active infection. Conclusion Treatment of LVAD driveline infection with absorbable antibiotic beads with primary wound closure is a viable option and merits further investigation.

Introduction: The incidence and pattern of neurological complications after congenital cardiac surgery have been changing over the years due to improvement in surgical technique and perioperative management. The aim of this study was to evaluate the incidence and pattern of neurological injury in our institute. Materials and Methods: We retrospectively reviewed all pediatric patients who underwent noncontrast computed tomography of the brain for suspected postoperative neurological injury occurring during the 1 st week after pediatric cardiac surgery between April 2016 and February 2020. We identified neurological injury as patients having ischemic infarct and intracranial hemorrhage. Results: A total of 2971 pediatric cardiac surgeries were performed at our institute. Sixty-seven patients (2.25%) developed neurological injury. Fifty-five patients (82%) developed ischemic infarct while 12 patients (18%) had intracranial hemorrhagic. Pattern of ischemic infarct included global hypoxic injury in 30 patients (54.5%), posterior cerebral artery territory in 9 patients (16.3%), middle cerebral artery territory in 8 patients (14.5%), multiterritory involvement in 5 patients (9.0%), and anterior cerebral artery territory in 3 patients (5.4%). In patients with intracranial hemorrhage, 5 patients (7.4%) developed subarachnoid hemorrhage (SAH), 4 patients (5.9%) developed subdural hemorrhage, and 3 patients (4.4%) developed intraparenchymal hemorrhage. Conclusions: Neurological complication accounts for significant morbidity and mortality after congenital cardiac surgery. In our study, ischemic infarct accounted for 82% cases. In ischemic infarct, global ischemia was the most common type and carried high risk of mortality. In hemorrhage group, SAH was the most common finding. Nevertheless, the aim of this study was to characterize the current incidence of acute clinically evident neurologic complications in children undergoing congenital cardiac surgery in a tertiary hospital, although acute neurologic morbidity appears to be appreciably lower than in the past at our institution.

Abstract A 64-year-old man with interstitial pulmonary fibrosis and a small patent foramen ovale with right-to-left shunting underwent bilateral lung transplant without closure of the patent foramen ovale. Postoperatively, the patient remained persistently hypoxemic with partial response to high-flow oxygen. Investigations revealed the presence of a large patent foramen ovale with right-to-left shunting on echocardiography and a shunt fraction of 21% on cardiac catheterization. Two months after the lung transplantation, primary surgical repair of the patent foramen ovale was performed with immediate improvement in oxygenation. Three years postoperatively, the patient remained oxygen independent.

Background: Neurological complications (NCs) (stroke) remain a devastating complication after cardiovascular surgical procedures despite advances in perioperative monitoring and management. The incidence of NC related to cardiovascular surgeries (CS) is comparatively very high and associated with high morbidity and mortality. The aim of this study is to evaluate the overall incidence of neurological complications in adult as well as pediatric patients and various pattern of neurological injury on noncontrast computed tomography head (NCCT) associated with various types of CS. Materials and Methods: We retrospectively analyzed all the NCCT heads of the postoperative cardiovascular surgery patients done in the immediate and early postoperative period (<7 days) who developed postoperative neurological deficits between April 2016 and February 2020. The medical records of all these cardiac surgery patients were analyzed for various variants such as the total number of patients who underwent CS, various types of cardiac surgery done during the study period, demographic information, associated comorbidities, various types of NC, postoperative data and various spectrum of computed tomography (CT) findings in the brain. Results: A total of 12,896 adult and pediatric cardiac surgeries were performed at our institute. Out of these, 1115 patients (8.6%) underwent CT brain for suspected neurological injury. A total of 215 patients (1.6%) had a positive finding on their NCCT head. Out of 215 patients, 148 (68.9%) were adult patients, whereas 67 (31.1%) were pediatric patients. A total of 156 (72.5%) patients had ischemic infarction (stroke), whereas hemorrhagic lesions were present in 59 patients (27.4%). The various types of positive CT scan findings were-156 ischemic infarcts (72.5%), 20 intraparenchymal hemorrhages (9.3%), 16 subdural hemorrhage (7.4%), 15 subarachnoid hemorrhage (6.9%), 01 cerebrovascular thrombosis (0.4%), and 07 intraventricular hemorrhage (3.2%). In an adult patient, pattern of ischemic infarct comprised middle cerebral artery (MCA) territory in 42 patients (41.5%), posterior territory in 34 patients (33.6%), anterior cerebral territory in seven patients (7.0%), multi-territory infracts in 11 patients (11.0%) and global ischemia in six patients (6.0%). Intraparenchymal hemorrhage was present in 17 patients (11.4%). In a pediatric subset of patient, the pattern of ischemic infarct included global hypoxic injury (GHI) in 30 patients (54.5%), posterior cerebral artery territory in nine patients (16.3%), MCA territory in eight patients (14.5%), multi-territory involvement in five patients (9.0%), and anterior cerebral artery territory in three patients (5.4%). In the hemorrhage group, five patients (7.4%) developed subarachnoid hemorrhage (SAH). Conclusion: In an adult patient, subset MCA territory infarcts were common in the infract group, whereas intra parenchymal haemorrhage (IPH) in the hemorrhage group. In the pediatric patient subset, GHI was common in infract group and SAH in hemorrhage group. Moreover, NCCT of the head is very useful in diagnosing early postoperative neurological complications in cardiovascular surgeries and managing the complications accordingly.

Abstract Bronchopleural fistulas (BPFs) are a dreaded complication following pulmonary surgery. Endobronchial valves (EVs), with endobronchial sealant (ES), instilled with robotic bronchoscopy (RB), allow occlusion of BPF, avoiding surgery. The patient was a 71-year-old woman with a history of chronic obstructive pulmonary disease and bronchiectasis who underwent bilateral lung transplantation and wedge resection of the right middle lobe and left lingula. A BPF was discovered on postoperative day (POD) 21. Conservative measures with chest tubes failed, and robotic-assisted bronchoscopy aided in reaching the bronchial segment and instilling ES, and EV was deployed with the conventional bronchoscope. The pneumothorax was cleared 12 days later, and on POD 56, she was discharged. The RB procedure was successful, with no pneumothorax or BPF symptoms after a median follow-up of POD 284. Robotic endobronchial closure of BPF with EV and ES is an effective treatment option avoiding invasive surgeries.

Abstract Pulmonary embolization in donor lungs is a common finding and found in up to 38% of cases. To expand the pool of organs, transplant centers now utilize lungs, from increased risk donors, that may have pulmonary embolic disease. Modalities of clearing pulmonary artery embolisms are critical to reduce the prevalence of primary graft dysfunction post transplantation. There have been anecdotal cases of pulmonary embolectomy pre and post organ procurement or in vivo and ex vivo thrombolytic therapy performed in donors with massive pulmonary emboli. We report for the first time therapeutic ex vivo thrombolysis on the back table without Ex Vivo Lung Perfusion (EVLP), followed by successful transplantation.