In October 2022, we installed a 'Sound Ear' decibel (dB) monitor within the NICU, which continuou... more In October 2022, we installed a 'Sound Ear' decibel (dB) monitor within the NICU, which continuously records and stores sound levels. This device acts as a traffic light system, lightening up green for safe noise levels (up to 50dB), amber as a warning (51db to 70db), and red for unsafe levels (above 70dB). Since its implementation, we have consistently monitored noise, identifying specific triggers for noise levels within the amber and red zones. We identified ward rounds, closing and opening of bin containers, monitors and syringe alarms as the most common source of noise. Conclusion This project is ongoing, but it has already yielded valuable insights and promoted positive changes. Staff awareness of noise levels has increased, an educational video on the impact of noise on NICU has been shared with all hospital staff (available on the hospital intranet), and transitioning to quieter bin containers has been considered.
Chronic thromboembolic pulmonary hypertension (CTEPH) in pediatric population is rare. We present... more Chronic thromboembolic pulmonary hypertension (CTEPH) in pediatric population is rare. We present a case of five-year-old female child, diagnosed as CTEPH on warfarin and home oxygen for 6 months. Imaging showed extensive thrombus in distal right pulmonary artery (RPA) than left pulmonary artery (LPA). She clinically deterioration inspite of maximal medical management and was referred for surgical option. Considering lack of literature evidence on surgical outcomes in pediatric CTEPH, decision to perform surgery was made after multidisciplinary team discussion between adult and paediatric pulmonary hypertension and cardiothoracic surgical teams across two units in UK. We performed pulmonary thromboendarterectomy (PEA) using cardiopulmonary bypass under deep hypothermic circulatory arrest (DHCA). The surgical procedure was uneventful with good clinical recovery. Our report highlights the need for earlier and prompt diagnosis with a need for referral to a specialized surgical center at an earlier stage before intractable vascular resistance ensues. Surgery can be safely performed for CTEPH in pediatric populations.
Journal of Heart and Lung Transplantation, Apr 1, 2018
into the patients' thoracic cavity within the 3D software platform. The virtual transplant was th... more into the patients' thoracic cavity within the 3D software platform. The virtual transplant was then determined "appropriate" if the heart adequately fit without overlapping the chest wall anteriorly or compressing the left bronchus and segmental lobes posteriorly. The proportion of donor-recipient fits were compared with our current institutional weight based fitting standard of a donor to recipient weight ratio between 1:1 and 1:1.5. Results: Patients with DCM were found to have total cardiac volume greater than the donor group. Compared to a weight based fitting technique, virtual transplantation on average increased the yield of donor-recipient size match by 318%. Using paired t-test to compare the two methods, there was a significant difference in the number of size matches (n= 4, p= 0.039). Conclusion: This study demonstrates that size-matching pediatric donor and recipient hearts for patients with dilated cardiomyopathy, the use of virtual heart transplantation increases the donor pool availability beyond traditional weight-based fit criteria. In practice, knowledge of the cardiac volumes of healthy children should enable centers to better determine the maximum heart size that could be safely accepted.
World Journal for Pediatric and Congenital Heart Surgery
Background: Reimplantation of the left pulmonary artery (LPA) and slide tracheoplasty has been ou... more Background: Reimplantation of the left pulmonary artery (LPA) and slide tracheoplasty has been our standard approach of care for patients with pulmonary artery sling (PAS) and tracheal stenosis. We present our experience, with emphasis on tracheal arborization and hypoplastic lungs; and their impact on long-term outcome of children with PAS and tracheal stenosis. Methods: It is a retrospective comparative study. Data were classified and analyzed based on the type of tracheobronchial arborization and normal versus hypoplastic lungs. Results: Seventy-five children operated between January 1994 and December 2019 (67 with normal lungs and 8 with lung hypoplasia/agenesis) were included. Patients with hypoplastic lungs had higher rates of preoperative ventilation (87.5%), postoperative ventilation (10 vs 8 days, P = .621), and mortality (50% vs 9%, P = .009) compared with those with normal lungs. Nineteen patients had tracheal bronchus (TB) variety and 30 patients had congenital long-segm...
Paediatric airway surgery in the setting of complex tracheobronchial defects is challenging. This... more Paediatric airway surgery in the setting of complex tracheobronchial defects is challenging. This report describes the surgical management and outcomes of pericardial flap repair in three children. The first patient was a 4-month-old boy with a history of tracheoesophageal fistula repair who presented after out-of-hospital cardiac arrest. He was treated by re-do tracheobronchial reconstruction of the carina using a pedicled pericardial flap. The second patient was an 11-month-old boy who presented following aspiration of a button battery. Bronchoscopy showed erosion of the battery through both main bronchi and the oesophagus. The patient underwent emergency reconstruction of the extensive tracheobronchial defect with pedicled right and left pericardial patches. The third patient was a 5-year-old girl who fell from a swing, resulting in avulsion of the right main bronchus. Pedicled pericardium was used to reconstruct the damaged posterior tracheal wall and the right and left main bro...
Tracheal pathology in children are primarily congenital. They can be considered primary or de nov... more Tracheal pathology in children are primarily congenital. They can be considered primary or de novo, when this is seen as an inherent defect within the cartilages of the tracheal segment. While segmental cartilage defects are very rare, there are often occasions when one or more cartilages can be considered missing from the length of trachea, contributing to airway abnormality. Secondary tracheal pathologies can often be seen in relation to disorders affecting nearby vascular elements or thoracic cage in general. In general, the pathological entity of tracheal disorders can be classified into either tracheomalacia or tracheal stenosis.
BackgroundVascular rings are rare congenital abnormalities of the aortic arch. There are many emb... more BackgroundVascular rings are rare congenital abnormalities of the aortic arch. There are many embryological variants including a double aortic arch. In symptomatic children, division of ring and release of airway structures may be sufficient. Persistence of symptoms can be related to an anterior angle formed between the two arches. The aim of this study is to evaluate the clinical efficacy in improving symptoms and on changing this angle at the primary surgery.MethodsAll children who had surgery for double aortic arch between 2005 and 2020, were studied. Relevant factors were analyzed for persistent symptoms including anatomical substrates and surgical details.ResultsA total of 87 out of 224 children had surgery for a double aortic arch. At presentation, airway symptoms (n = 74/87) were more common than esophageal symptoms (n = 27/87). Early onset symptoms within 1 year were seen in 49 children. In addition to division of one arch, surgical steps also included realigning the anterio...
Airway surgery can be challenging in children. With increasing awareness of congenital lesions, e... more Airway surgery can be challenging in children. With increasing awareness of congenital lesions, expertise in diagnostic modalities and recent advances in surgical technique, complex airway malformations are increasingly better managed. Physiological and anatomical differences, combined with specific features of surgical problems seen in childhood, necessitate a different approach to perioperative care compared with adults. An often essential component for efficient and complete surgical correction is the appropriate utilisation of extracorporeal circulatory support. This article details the key differences between the paediatric and adult patient with respect to airway surgery, before discussing the role and applications of extracorporeal circulatory support in various airway reconstructions in children. We discuss the potential alternate options including use of extra-corporeal membrane oxygenation versus standard cardiopulmonary bypass (CPB) during surgery.
An acquired posterior tracheal wall defect, most commonly an acquired tracheoesophageal fistula, ... more An acquired posterior tracheal wall defect, most commonly an acquired tracheoesophageal fistula, is a challenging clinical scenario. Autologous pedicled pericardial patch repair is a versatile and sustainable technique for the repair of a large tracheal defect, from primary management to airway salvage. This video tutorial demonstrates the technical aspects of this technique using step-by-step video.
Heart failure is a global pandemic affecting 26 million people worldwide [1]. With advancement in... more Heart failure is a global pandemic affecting 26 million people worldwide [1]. With advancement in diagnostic modalities, the recognition of heart failure in the paediatric population has gradually increased since last 2 decades. The prevalence and associated cost burden of paediatric heart failure are largely unknown [2]. Unlike adults, the heart failure in paediatric population is caused by variable etiologies, having variable prognosis and outcome.
In October 2022, we installed a 'Sound Ear' decibel (dB) monitor within the NICU, which continuou... more In October 2022, we installed a 'Sound Ear' decibel (dB) monitor within the NICU, which continuously records and stores sound levels. This device acts as a traffic light system, lightening up green for safe noise levels (up to 50dB), amber as a warning (51db to 70db), and red for unsafe levels (above 70dB). Since its implementation, we have consistently monitored noise, identifying specific triggers for noise levels within the amber and red zones. We identified ward rounds, closing and opening of bin containers, monitors and syringe alarms as the most common source of noise. Conclusion This project is ongoing, but it has already yielded valuable insights and promoted positive changes. Staff awareness of noise levels has increased, an educational video on the impact of noise on NICU has been shared with all hospital staff (available on the hospital intranet), and transitioning to quieter bin containers has been considered.
Chronic thromboembolic pulmonary hypertension (CTEPH) in pediatric population is rare. We present... more Chronic thromboembolic pulmonary hypertension (CTEPH) in pediatric population is rare. We present a case of five-year-old female child, diagnosed as CTEPH on warfarin and home oxygen for 6 months. Imaging showed extensive thrombus in distal right pulmonary artery (RPA) than left pulmonary artery (LPA). She clinically deterioration inspite of maximal medical management and was referred for surgical option. Considering lack of literature evidence on surgical outcomes in pediatric CTEPH, decision to perform surgery was made after multidisciplinary team discussion between adult and paediatric pulmonary hypertension and cardiothoracic surgical teams across two units in UK. We performed pulmonary thromboendarterectomy (PEA) using cardiopulmonary bypass under deep hypothermic circulatory arrest (DHCA). The surgical procedure was uneventful with good clinical recovery. Our report highlights the need for earlier and prompt diagnosis with a need for referral to a specialized surgical center at an earlier stage before intractable vascular resistance ensues. Surgery can be safely performed for CTEPH in pediatric populations.
Journal of Heart and Lung Transplantation, Apr 1, 2018
into the patients' thoracic cavity within the 3D software platform. The virtual transplant was th... more into the patients' thoracic cavity within the 3D software platform. The virtual transplant was then determined "appropriate" if the heart adequately fit without overlapping the chest wall anteriorly or compressing the left bronchus and segmental lobes posteriorly. The proportion of donor-recipient fits were compared with our current institutional weight based fitting standard of a donor to recipient weight ratio between 1:1 and 1:1.5. Results: Patients with DCM were found to have total cardiac volume greater than the donor group. Compared to a weight based fitting technique, virtual transplantation on average increased the yield of donor-recipient size match by 318%. Using paired t-test to compare the two methods, there was a significant difference in the number of size matches (n= 4, p= 0.039). Conclusion: This study demonstrates that size-matching pediatric donor and recipient hearts for patients with dilated cardiomyopathy, the use of virtual heart transplantation increases the donor pool availability beyond traditional weight-based fit criteria. In practice, knowledge of the cardiac volumes of healthy children should enable centers to better determine the maximum heart size that could be safely accepted.
World Journal for Pediatric and Congenital Heart Surgery
Background: Reimplantation of the left pulmonary artery (LPA) and slide tracheoplasty has been ou... more Background: Reimplantation of the left pulmonary artery (LPA) and slide tracheoplasty has been our standard approach of care for patients with pulmonary artery sling (PAS) and tracheal stenosis. We present our experience, with emphasis on tracheal arborization and hypoplastic lungs; and their impact on long-term outcome of children with PAS and tracheal stenosis. Methods: It is a retrospective comparative study. Data were classified and analyzed based on the type of tracheobronchial arborization and normal versus hypoplastic lungs. Results: Seventy-five children operated between January 1994 and December 2019 (67 with normal lungs and 8 with lung hypoplasia/agenesis) were included. Patients with hypoplastic lungs had higher rates of preoperative ventilation (87.5%), postoperative ventilation (10 vs 8 days, P = .621), and mortality (50% vs 9%, P = .009) compared with those with normal lungs. Nineteen patients had tracheal bronchus (TB) variety and 30 patients had congenital long-segm...
Paediatric airway surgery in the setting of complex tracheobronchial defects is challenging. This... more Paediatric airway surgery in the setting of complex tracheobronchial defects is challenging. This report describes the surgical management and outcomes of pericardial flap repair in three children. The first patient was a 4-month-old boy with a history of tracheoesophageal fistula repair who presented after out-of-hospital cardiac arrest. He was treated by re-do tracheobronchial reconstruction of the carina using a pedicled pericardial flap. The second patient was an 11-month-old boy who presented following aspiration of a button battery. Bronchoscopy showed erosion of the battery through both main bronchi and the oesophagus. The patient underwent emergency reconstruction of the extensive tracheobronchial defect with pedicled right and left pericardial patches. The third patient was a 5-year-old girl who fell from a swing, resulting in avulsion of the right main bronchus. Pedicled pericardium was used to reconstruct the damaged posterior tracheal wall and the right and left main bro...
Tracheal pathology in children are primarily congenital. They can be considered primary or de nov... more Tracheal pathology in children are primarily congenital. They can be considered primary or de novo, when this is seen as an inherent defect within the cartilages of the tracheal segment. While segmental cartilage defects are very rare, there are often occasions when one or more cartilages can be considered missing from the length of trachea, contributing to airway abnormality. Secondary tracheal pathologies can often be seen in relation to disorders affecting nearby vascular elements or thoracic cage in general. In general, the pathological entity of tracheal disorders can be classified into either tracheomalacia or tracheal stenosis.
BackgroundVascular rings are rare congenital abnormalities of the aortic arch. There are many emb... more BackgroundVascular rings are rare congenital abnormalities of the aortic arch. There are many embryological variants including a double aortic arch. In symptomatic children, division of ring and release of airway structures may be sufficient. Persistence of symptoms can be related to an anterior angle formed between the two arches. The aim of this study is to evaluate the clinical efficacy in improving symptoms and on changing this angle at the primary surgery.MethodsAll children who had surgery for double aortic arch between 2005 and 2020, were studied. Relevant factors were analyzed for persistent symptoms including anatomical substrates and surgical details.ResultsA total of 87 out of 224 children had surgery for a double aortic arch. At presentation, airway symptoms (n = 74/87) were more common than esophageal symptoms (n = 27/87). Early onset symptoms within 1 year were seen in 49 children. In addition to division of one arch, surgical steps also included realigning the anterio...
Airway surgery can be challenging in children. With increasing awareness of congenital lesions, e... more Airway surgery can be challenging in children. With increasing awareness of congenital lesions, expertise in diagnostic modalities and recent advances in surgical technique, complex airway malformations are increasingly better managed. Physiological and anatomical differences, combined with specific features of surgical problems seen in childhood, necessitate a different approach to perioperative care compared with adults. An often essential component for efficient and complete surgical correction is the appropriate utilisation of extracorporeal circulatory support. This article details the key differences between the paediatric and adult patient with respect to airway surgery, before discussing the role and applications of extracorporeal circulatory support in various airway reconstructions in children. We discuss the potential alternate options including use of extra-corporeal membrane oxygenation versus standard cardiopulmonary bypass (CPB) during surgery.
An acquired posterior tracheal wall defect, most commonly an acquired tracheoesophageal fistula, ... more An acquired posterior tracheal wall defect, most commonly an acquired tracheoesophageal fistula, is a challenging clinical scenario. Autologous pedicled pericardial patch repair is a versatile and sustainable technique for the repair of a large tracheal defect, from primary management to airway salvage. This video tutorial demonstrates the technical aspects of this technique using step-by-step video.
Heart failure is a global pandemic affecting 26 million people worldwide [1]. With advancement in... more Heart failure is a global pandemic affecting 26 million people worldwide [1]. With advancement in diagnostic modalities, the recognition of heart failure in the paediatric population has gradually increased since last 2 decades. The prevalence and associated cost burden of paediatric heart failure are largely unknown [2]. Unlike adults, the heart failure in paediatric population is caused by variable etiologies, having variable prognosis and outcome.
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Papers by ARUN BEEMAN