CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
174
AFRICA
552: SICK CHILD OR SICK SINUS: REPEATED SYNCOPE
IN EARLY INFANCY
Damian Hutter, Mladen Pavlovic, Jean-Pierre Pfammatter
Centre of Congenital Heart Disease, University of Bern, Bern,
Switzerland
Introduction:
Syncope is often observed in paediatrics. The majority
of patients are teenagers. In contrast to adults, a cardiac origin is only
observed in 2–5% of cases. Regardless of the reported low incidence
of cardiac origin for sudden loss of consciousness (LOC) in child-
hood, detailed cardiac evaluation is mandatory as the rare organic
causes are all potentially dangerous (arrhythmia, cardiomyopathies,
structural heart disease, pulmonary hypertension).
Patient report:
A 19-month-old girl with repeated LOC since the
age of six months (two to three times per month) presented with
developmental delay. The mother had ablation at the age of 18 years
for WPW. Her other family history was unremarkable. Detailed
neurological evaluation (two EEGs, psychomotor skills) was unre-
markable. At the age of 18 months the frequency of LOC increased
after an event-free period of three months. Echocardiogram revealed
a large atrial septal defect. The standard ECG and 24-hour Holter
examination was unremarkable but a seven-day ECG recording
revealed two episodes with sinus pauses of up to 3.4 seconds, both
during the daytime when the toddler was awake. The diagnosis of a
sick sinus syndrome was made. AVVI pacemaker (back-up heart rate
80 beats/min) was put in place and ever since, no episodes of sudden
LOC have been reported. The closure of the atrial septal defect has
been postponed to the age of four to five years.
Conclusion
: This case illustrates the importance of detailed cardiac
assessment for sudden LOC in childhood, even for toddlers with
obvious neurological issues (i.e. developmental delay), as this might
be due to recurrent hypoxic encephalopathic events. The incidence of
sick sinus syndrome in paediatric patients is very low, which makes
it more difficult to diagnose. In our patient neither Holter recordings
nor standard ECG showed any sign of arrhythmia.
553: DOES THE 12-LEAD ELECTROCARDIOGRAM
IMPROVE DIAGNOSTIC DETECTION OF ATRIAL SEPTAL
DEFECTS DURING POPULATION-BASED SCREENING?
Minnette Son
1
, Cathy Woodward
1
, Kimberly Mcinney
3
, Kadeja
Harrell
3
, Kirk Milhoan
2
, Dave Bush
1
1
University of Texas Health Science Centre, San Antonio, USA
2
Hearts and Souls, San Antonio, USA
3
San Antonio Military Medical Centre, Fort Sam, Houston, Texas,
USA
Background:
Controversy continues regarding the diagnostic util-
ity of the electrocardiogram (ECG) for the diagnosis of congenital
heart disease (CHD) and cardiomyopathy. Unlike other forms of
clinically significant CHD, patients with atrial septal defects (ASDs)
often have few symptoms and may, under some circumstances, have
a nearly normal examination. We sought to evaluate the added diag-
nostic yield of ECGs in the diagnosis of ASDs.
Methods:
During a humanitarian screening in two rural provinces
in Mongolia (Bayan-Ulgi and Khovd), children from birth to 20
years underwent a cardiac physical examination by American and
Mongolian paediatricians and nurse practitioners. All children also
underwent a 12-lead ECG read by a paediatric electrophysiologist. A
potentially pathological murmur on examination or an ECG consist-
ent with ASD (QRS duration
>
100 ms with rSR’ in lead V
1
) prompt-
ed echocardiographic screening (ECHO) by a paediatric cardiologist.
Results:
CHD was identified in 47 of 1 615 patients (3.0%) screened
over five days, 14 (29.8%) of whom had an ASD by echo. All patients
with ASD had an abnormal examination, with 12 having ECG find-
ings consistent with the diagnosis (85%). No ASDs were identified
when the ECG was the only feature consistent with ASD. Overall, an
ECG was abnormal in 51 patients, of whom 31 had an abnormal echo.
Conclusions:
ECG was not found to improve the diagnostic yield
for ASDs over the physical examination alone, even when non-
cardiologists were employed. In addition, the ECG does not appear
to be more sensitive than the physical examination. Given the added
time and resources required to perform them, the use of an ECG for
population-based screening does not seem justified.
565: POST-FONTAN COMPLETION. USE OF WARFARIN
OR ASPIRIN: 12.5-YEAR EXPERIENCE FROM A SINGLE
PAEDIATRIC CARDIAC CENTRE
Joyce Su-Ling Lim
,
Michael Bowes, Gillian Mcburney, Gordon
Gladman
Alder Hey Children’s Hospital, Liverpool, UK
Introduction:
Thromboembolic events are known complications
after Fontan operations, with the published literature attempting to
distinguish the most effective preventative measure. Some articles
have shown no difference in efficacy between warfarin and aspirin.
We focused on the side effects of warfarin and aspirin in our experi-
ence.
Methods:
We retrospectively reviewed all patients undergoing
Fontan completion between January 2001 and June 2012.
Results:
Over the 12.5 year period, 134 patients underwent Fontan
completion. The median age at Fontan completion was 5.5 years
(range 2.9 to 16.5 years). Median follow up was 4.3 years (2 days to
11.9 years). Of these, 120 of 134 patients were started on warfarin,
while only 10 were started on aspirin. Four patients died in the early
postoperative period before establishment on warfarin or aspirin.
In the warfarin group, four patients converted to aspirin. One
patient had significant extradural haematoma following a bicycle
accident, which needed drainage. One patient developed postop-
erative haemorrhagic stroke, while two patients converted out of
choice. Of the remaining 116 patients on warfarin, seven had minor
complications with self-limiting epistaxis (four patients), superficial
bruising (one patient), bleeding into pleural cavity (one patient), and
clot in the left atrium (one patient due to low INR). One patient devel-
oped a clot on the fenestration plug device and was put on warfarin
and aspirin. Seven of these eight patients continued with warfarin.
In the aspirin group, there was no documented complication. The
limitations of this retrospective review are that the patients were non-
randomised into warfarin or aspirin therapy and we had not actively
looked for thrombus in asymptomatic patients.
Conclusions:
There is no increased risk of bleeding complications
from the use of warfarin post-Fontan surgery. Our future aim is to
prospectively randomise patients to warfarin or aspirin to assess
complications.
566: NOVEL APPLICATION OF REAL-TIME MAGNETIC
RESONANCE ANGIOGRAPHY: THE END OF DIAGNOSTIC
CATHETERISATION IN NEONATES?
James Wong
1
, Kuberan Pushparajah
1
, Tarique Hussain
1
, Reza Razavi
1
,
Aaron Bell
2
, Caner Salih
2
, David Anderson
2
, Conal Austin
2
, Gerald
Greil
1
, Sujeev Mathur
1
1
Division of Imaging Sciences, King’s College London, London, UK
2
Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation
Trust, London, UK
Background
: Magnetic resonance (MR) imaging for delineating
extracardiac vasculature in newborns with congenital heart disease
is not widely used. Fast circulation times mean current MR angio-
graphic techniques lack the temporal resolution to assess complex
cardiac anatomy within a single breath-hold. We report on the use
of four-dimensional time-resolved angiography with keyhole (4D
TRAK) to confirm diagnoses in newborns not fully resolved by
echocardiography. 4D TRAK has the advantage of rapid sequence
acquisition, providing high temporal resolution, three-dimensional
datasets, with dynamic multi-phase visualisation.
Methods
: A retrospective review of neonates (
<
28 days old) under-
going cardiac MR imaging with 4D TRAK from July 2011 to July
2012 was performed. All underwent an initial reference scan, with
