CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
21
Objective:
Since Fontan stated his criteria for patient selection
undergoing the total cavopulmonary anastomosis, small pulmonary
arteries (PAs) are sometimes considered a contraindication to the
operation. The aim of this study was to evaluate whether the size of
the PAs is still one of the major impact factors on early outcome after
the Fontan operation (FO).
Methods:
Data of 146 patients (mean age of 3.6
±
2.4 years, mean
weight of 14.3
±
6.9 kg) who underwent a modified FO at our clinic
between 2007 and 2012 were retrospectively analysed with regard
to the traditional McGoon ratio, Nakata index and modified indices
(measuring the narrowest diameters) and with regard to the early
postoperative course.
Results:
Patients with a McGoon ratio
≤
1.6 (modified
≤
1.2) or
a Nakata index
<
150 mm²/m
2
(modified
<
100 mm²/m
2
) were not
at a higher risk of prolonged hospital stay [
p
=
0.078 (0.157) and
p
=
0.220 (0.178), respectively] or effusions [
p
=
0.323 (0.723)
and
p
=
0.289 (0.703), respectively]. Children with persistent (
>
14 days) effusions tended to have smaller PAs in comparison with
other patients, but McGoon ratio and Nakata index did not differ
significantly (
p
=
0.220 and
p
=
0.069, respectively). The need for
interventional dilatation before FO did not adversely influence the
time of mechanical ventilation (
p
=
0.652), ICU (
p
=
0.778) or hospi-
tal stay (
p
=
0.130) and pleural effusions (
p
=
0.166). Younger and
smaller children tended to have smaller PAs, but younger age (
<
24
months) and lower weight (
<
12 kg) were not predictive of poor early
postoperative outcome.
Conclusion:
Small pulmonary arteries did not significantly affect the
early postoperative period after FO. In our opinion there is no need
to postpone the Fontan operation due to ‘smaller’ pulmonary arteries.
The pre-Fontan palliative procedures to augment the size of PAs at
the expense of ventricular overload are not recommended.
476: OUTCOMES OF INFLOW-OCCLUSION OPEN PULMO-
NARYVALVULOTOMY PLUS CENTRAL SHUNT IN PULMO-
NARY ATRESIAWITH INTACT VENTRICULAR SEPTUM
Vichai Benjacholamas, Porntep Lertsapcharoen, Apichai
Khongphatthanayothin
Chulalongkorn University, Bangkok, Thailand
Background:
Patients with pulmonary atresia with intact ventricu-
lar septum (PA-IVS) and tripartite right ventricle (RV) have a great
opportunity to live with biventricular circulation. Direct-vision open
pulmonary valvulotomy under inflow occlusion is safe and provides
good pulmonary valve opening.
Methods:
Between August 1999 and September 2010, 18 patients
with PA-IVS underwent inflow-occlusion open pulmonary valvul-
otomy with a concomitant central shunt. All had tripartite RV with
a tricuspid valve
Z
-score of –1.17
±
0.99 (–0.08 to –3.5). The mean
inflow occlusion time was 2.5
±
0.4 minutes (1.6–3.0 minutes).
Results:
The primary operation was successful in all patients. There
was only one (5.6%) in-hospital death. At a median follow up of five
years (2–13 years), survival was 100%. Of the remaining 17 survi-
vors, 16 (94.12%) patients achieved biventricular circulation and one
(5.88%) patient survived with one-and-a-half circulation. There were
five (29.4%) survivors who needed percutaneous balloon pulmonary
valvulotomy and all had good results. Four (23.5%) of the survivors
needed surgical right ventricular outflow tract (RVOT) reconstruc-
tion. Bidirectional Glenn was performed concomitant with RVOT
reconstruction in one patient.
Conclusions:
Inflow-occlusion open pulmonary valvulotomy plus
central shunt is a safe and precise opening of the pulmonary valve
in PA-IVS patients with tripartite RV. Almost all patients achieved
biventricular circulation with this technique.
487: CARDIAC STROKE VOLUME AND SYMPATHETIC–
PARASYMPATHETIC MEASUREMENTS INCREASE THE
SENSITIVITY AND SPECIFICITY OF TILT-TABLE TESTS
(HUTT) IN CHILDREN AND ADOLESCENTS
Mohammed Numan
1
, Jeremy E Lankford
2
, Anand Gourishankar
3
,
Rawan Al Najjar
1
, Ian J Butler
2
1
University of Texas, Paediatric Cardiology, USA
2
University of Texas, Paediatric Neurology, USA
3
University of Texas, General Paediatrics, USA
The head-up tilt-table test (HUTT) is the gold standard in evaluat-
ing autonomic dysfunction and syncope in children and adolescents.
Limitations of the conventional HUTT, cycling blood pressure (BP)
every one to two minutes, with heart rate (HR) correlated with patient
symptoms results in low sensitivity and specificity. Investigators have
evaluated more reliable and sensitive physiological parameters to
increase the predictability of HUTT.
Methods:
From May 2009 to May 2012 we performed 422 HUTT
evaluations on children and adolescents. The first group of 152
patients had conventional HUTT, including HR, arm cuff BP and
oxygen saturation recorded every minute for 10 minutes while
supine, for 30 minutes while head up 70
o
and for 10 minutes with
supine reposition while recording patient symptoms. The second
group included 270 patients with HUTT using Task Force Monitor
®
with display and storage of continuous BP, HR and cardiac stroke
volume (SV) by trans-thoracic impedance and calculated sympathet-
ic and parasympathetic activity correlated with symptoms and signs.
Median ages were 12.5 years and 13.2 years in groups one and two,
respectively. Patients from both groups were referred by paediatric
neurologists, cardiologists, gastroenterologists and rheumatologists
with syncope (63%), dizziness (88%), light headedness and head-
aches (52%), chronic nausea and stomach pains (32%), chronic
fatigue (42%), convulsions (6%), fibromyalgia (2%), palpitations
and chest tightness (12%) and metabolic disorders (10%).
Results:
A positive test was defined in group one as severe symp-
toms of syncope, blackout, vomiting, severe headache, excessive
fatigue and tremors or convulsions accompanied by changes in HR
(tachycardia, bradycardia) and/or blood pressure. In group two,
similar symptoms were accompanied by significant changes in HR,
BP, cardiac SV and sympathetic/parasympathetic activity. There was
increased ability to correlate clinical manifestations with physiologi-
cal abnormalities on HUTT in the second cohort of subjects and also
an increased sensitivity of the test to determine whether there was
orthostatic intolerance.
493: ULTRA-FAST TRACK ANAESTHESIA WITH EARLY
EXTUBATION IN RESOURCE-LIMITED SETTINGS:
RESULTS OF A LARGE INTERNATIONAL COHORT
Frank Molloy
1
, Victor Baum
2
, Siarhai Liauchonak
1
, Pavel
Shauchenka
1,3
, Eugene Suslin
1,3
, William Novick
1,4
1
International Children’s Heart Foundation, Memphis TN, USA
2
Department of Anesthesiology and Pediatrics, University of Virginia,
VA, USA
3
National Children’s Cardiac Surgical Centre, Minsk, Belarus
4
University of Tennessee Health Science Center, Memphis TN, USA
Background:
Very early extubation [in the operating room (OR)
or on ICU admission] has been routinely practiced by our group in
countries with delayed access to cardiac care, older presentation, and
limited resources. We describe the ventilation data for a sequential
cohort of 2 300 children in a programme spanning 19 countries and
26 centres over 4.5 years.
Methods:
The database of the International Children’s Heart
Foundation was analysed for the period January 2008 to May 2012.
Outcomes of interest were ventilation times, re-intubation rates,
mortality, by RACHS-1 complexity category, and age.
Results:
Deaths in OR or ICU without extubation (64), incom-
plete data (190) and re-operation on same admission (217) were
all excluded; 1 829 extubations were analysed with a median age/
weight of 3.5 years/12 kg. Re-intubation rate and mortality decreased
with decreasing duration of postoperative tracheal intubation and
mechanical ventilation (
p
=
0.005,
R
²
=
0.89, and
p
=
0.002,
R
²
=
0.93, respectively)
.
Median ventilation time was 1.5 hours, with
