CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
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AFRICA
ity with functional class IV. Investigation revealed a diagnosis of
tetralogy of Fallot with pulmonary atresia with right aortic arch.
There were confluent branch pulmonary arteries with severe bifurca-
tion stenosis, which was supplied by a posteriorly located stenotic
duct. There were no MAPCAs. During surgery it was noted that there
was severe peri-adventitial fibrosis of the branch pulmonary arteries,
which was supplied by a stenotic duct. The size of the pulmonary
arteries looked satisfactory at the hilum. Aorta and SVC transaction
provided unhindered exposure to the branch PAs at the hilum, which
was reconstructed with 15-mm Goretex tube. The VSD was closed
with a PTFE patch and a bovine jugular vein was used to establish
RV–PA continuity.
Results:
The postoperative course of the child was complicated by
bleeding (which was controlled using factor VIIa), reperfusion lung
injury and renal failure (which was managed with appropriate venti-
lator settings and continuous veno-venous haemodialysis). The child
made a gradual recovery and was discharged home at the end of the
third week. Postoperative echo showed satisfactory surgical repair.
Conclusion
: Management of severely cyanotic adolescents can
prove both a surgical and postoperative challenge. Early institution
of supportive therapy with appropriate multidisciplinary input may
provide gratifying results. Whether an interim palliation with shunt
would reduce the severity of postoperative complications remains
debatable.
122: CROSS-BORDER TRAINING IN PAEDIATRIC ANAES-
THESIA: CHALLENGES AND SOLUTIONS
Jagdish Shahani
KK Hospital for Women and Children, Singapore
A number of countries have the basic infrastructure to perform
paediatric cardiac surgery. However, they lack the expertise in vari-
ous fields to perform complicated surgeries. KK Hospital for Women
and Children in Singapore, in conjunction with the Singapore
International Foundation has undertaken a three-year project to
improve the outcomes of paediatric cardiac surgery at Children’s
Hospital No. 2 at Ho Chi Minh, Vietnam. The paediatric anaesthetic
team involved in the project was faced with numerous challenges to
fulfill the aims and outcomes of this project. The challenges faced
by the team included the language barrier, non-availability of certain
equipment, lack of trained manpower, non-availability of certain
medications, and certain aspects of managing smaller children (
<
5
kg) on pump. A total of three trips lasting five days each have been
undertaken. Solutions have been found to all the challenges listed
above and the project objectives and outcomes are being evaluated.
The WHO’s aim of ‘Health for all by 2020’ can only be met if such
trainings are carried out on-site and by overcoming the challenges
faced by the trainers.
124: MORPHOLOGY AND SURGERY IN ATRIO-VENTRIC-
ULAR SEPTAL DEFECT WITH LEFT VENTRICULAR
OUTFLOW TRACT OBSTRUCTION
Tomas Tlaskal, Roman Gebauer, Tomas Matejka, Jiri Gilik, Viktor
Tomek, Jan Janousek
Children´s Heart Center, University Hospital Motol, Prague, Czech
Republic
Background:
Outcome after repair of AVSD may be unfavour-
ably altered by co-existing left ventricular outflow tract obstruction
(LVOTO).
Methods:
The morphology of 73 heart specimens was examined and
compared with the morphology and clinical data of operated patients
with atrio-ventricular septal defect (AVSD). The aim of the study was
to determine the prevalence of LVOTO and analyse the results of the
surgical treatment of AVSD with LVOTO.
Results:
LVOTO was found in nine (12.3%) of 73 specimens. It was
caused by hypertrophy and anterior displacement of the antero-lateral
papillary muscle (five hearts), septal hypertrophy (three), or fibro-
muscular membrane (one). In our clinical series, LVOTO was found
in 19 (2.8%) of 675 patients with AVSD. It was caused by a fibromus-
cular membrane, septal hypertrophy, abnormal valvar attachments
and fibromuscular strands, which occured in combination. LVOTO
was present at the time of AVSD repair in eight patients and devel-
oped after repair in 11. Membrane excision (nine patients), myectomy
(six), excision of abnormal valvar tissue (three) and valvotomy (one)
were required. Correction of AVSD consisted of two- or one-patch
repair and individually modified plasty of the AV valves. Survivors
were examined by echo. There was one (5.3%) early and one (5.3%)
late death. The causes of death were heart failure and mitral stenosis,
respectively, and resulted in part from the presence of LVOTO in both
of them. Two survivors required re-operation for LVOTO. Operated
patients remain in a good condition without LVOTO at a mean of 6.5
±
3.8 years after surgery.
Conclusions:
The prevalence of LVOTO was 2.8%. Fibromuscular
membrane, septal hypertrophy and abnormal valvar tissue repre-
sented the most common causes of LVOTO in the operated patients.
Septal hypertrophy, oblique ‘cleft’, displastic valve and abnormal
attachments in LVOT may contribute to LVOTO formation after
surgery. LVOTO did not increase mortality but the long-term
outcome and the re-operation rate may be influenced by progression
of the LVOTO.
135: EXPERIENCE WITH RESECTION OF LARGE LEFT
VENTRICULAR FIBROMAS
Tomas Tlaskal, Roman Gebauer, Jan Skovranek, Petr Tax
Children’s Heart Centre, University Hospital Motol, Prague, Czech
Republic
Background:
Large left ventricular (LV) fibromas are rare tumours
with an unfavourable prognosis and high risk of ventricular fibrilla-
tion. There is not enough experience with their surgical treatment.
Methods:
Since 2004 large LV fibromas have been seen in four
children at the ages of 3.2, 1.7, 0.9 and 1.2 years, respectively.
One child who was not operated on suffered from an attack of
ventricular fibrillation, which resulted in severe neurological deficit.
Three patients underwent surgical resection of the tumour. The pre-
operative diagnosis was set by echocardiography. All fibromas were
similarily located at the lateral LV free wall from the base to the apex.
The surgery was performed with CPB and blood cardioplegia. It
consisted of total excision of the tumour and plication of the LV wall.
All tumours were large (70 × 40 × 25 mm) with a similar appearance.
They were ovoid, white and stiff. The thin external layer of the LV
wall was longitudinally incised and the tumour was excised, leaving
both layers intact. Meticulous inspection for bleeding and injury to
the inner layer was necessary. The LV wall was plicated.
Results:
Total excision without injury to the coronary arteries,
atrio-ventricular (AV) valves or connective tissue was possible in all
patients. The diagnosis was confirmed histologically. In two oper-
ated patients the postoperative course was uneventful. In one patient
re-operation for bleeding of the LV wall was required on the first
postoperative day. All operated patients survived and are now 8.2,
2.4 and 2.2 years, respectively after surgery, without arrhythmias and
with good LV and MV function. The unoperated patient remains in
an unfavourable neurological status, though the deficit is improving.
In this child a cardioverter/defibrillator was implanted and resection
of the tumour is being considered.
Conclusion:
LV fibromas can be completely excised. The risk of
postoperative complications and arrhythmias is low in surgically
treated patients.
141: EXPERIENCE ON THE PRACTICAL USE OF LEVOSI-
MENDAN IN CHILDREN IN KUWAIT: EXPANDED REVIEW
Ayman Almasri, Hesham Menshawy, Nasreldeen Almeeri, Osama
Abolfottoh, Olga Ristovic, Adel Mustafa, Ahmed Abdelfattah, Sami
Shukrulla, Khaled Tabl, Abdullah Elsanae
Chest Disease Hospital, Kuwait
