CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
22
AFRICA
1 363 (73%) extubations in under four hours. Extubation in under one
hour was possible in 42% overall, and by RACHS (R) category: R1
(70%), R2 (42%), R3 (29%) and R4 (19%). Median ventilation time
increased with increasing RACHS category (
p
<
0.05): R1 (
n
=
327)
0.1 hour, R2 (
n
=
827) 1.5 hours, R3 (n
=
466) 3 hours, R4 (n
=
114)
5.9 hours. Ventilation times (re-intubation rates) were increased in
the smallest children:
<
three months, 12 hours (12%); three months
to one year, four hours (14%).
Conclusions:
This is the largest such series analysed in children.
Age and weight were typical of many developing world populations
awaiting surgery. Mechanical ventilation need not be a standard part
of postoperative cardiac surgical management; significant numbers
in all age and RACHS groups can be safely extubated in OR or under
one hour postoperatively in ICU.
506: IMPACT OF VSD ENLARGEMENT WITH D-TGA OR
DORV FOR POSTOPERATIVE CARDIAC FUNCTION AND
ARRHYTHMIA IN RASTELLI PROCEDURE
Yasuyuki Toyoda, Takeshi Hiramatsu Hiramatsu, Gogi Matsumura,
Takeshi Konuma, Minori Tateishi, Yuuki Nakayama, Yuuji Kaku,
Minako Hayakawa, Mitsugi Nagashima, Kenji Yamazaki
Tokyo Women’s Medical University, Japan
Introduction:
Restrictive VSD with TGA or DORV may cause
LVOTO in the late period, and simultaneous VSD enlargement is
mandatory in that case. However it may cause cardiac dysfunction
and arrhythmia. We separated our patients who underwent Rastelli
procedure into two groups; group A with VSD enlargement (46
cases) and group B without enlargement (28 cases). We evaluated
the long-term outcomes.
Methods:
Since 1983, Rastelli procedures have been performed in
74 patients: d-TGA (56 cases) or DORV (18 cases) in our institute;
mean age at operation 7.0 years, mean body weight at operation 18.5
kg, mean follow-up period 13.7 years. Indication of VSD enlarge-
ment in our institute: existence of pressure gradient between the two
ventricles, the VSD diameter below the diameter of aortic valve.
Rhythms were assessed with ECG and Holter. Pacemaker implan-
taion or medication for anti-arrhythmia was searched. Postoperative
LVEF, CVP and pressure gradient at intraventricular conduit were
assessed in catheterisation.
Results:
There were no early deaths and five late deaths in group A
and two in B. Replacement of intraventricular conduit was performed
in two cases in group A and two in B. With ECG, 42 cases in group A
and 26 in B kept sinus rhythm. No significant PVC was recognised in
either group. Pacemaker implantation was performed in three cases
in group A and one in B. Need for anti-arrhythmic agency were two
cases in group A and two in B. Mean LVEDV was 150.6% of
n
in
group A and 144.8% of
n
in B. Mean LVEF were 57.0% in group
A and 57.9% in B. There were statistically significant differences
between the two groups.
Conclusion:
VSD enlargement with the Rastelli procedure was
performed safely without cardiac dysfunction and arrhythmia. VSD
enlargement should be performed if necessary to prevent LVOTO in
the late period.
513: CONGENITAL CARDIAC SURGERY THROUGH A
MINIMALLY INVASIVE MID-AXILLARY RIGHT LATER-
AL MUSCLE-SPARING THORACOTOMY APPROACH: A
THREE-YEAR EXPERIENCE IN 384 PATIENTS
Anton Shmalts, Michail Plotnikov, Sergey Smirnov, Alfiya Drozdova,
Natalya Ganukova, Margarita Tungusova, Dmitry Tarasov
Federal Centre for Cardiovascular Surgery, Astrakhan, Russia
Background:
Median sternotomy has been the conventional
approach for correction of congenital heart defects (CHD) despite
poor cosmetic results. Minimally invasive mid-axillary muscle-spar-
ing right lateral thoracotomy (RLT) was assessed as an alternative
procedure with better a cosmetic outcome.
Methods:
Between May 2009 and June 2012, 384 patients aged from
six month to 18 years underwent correction of CHD through RLT
with the use of direct cannulation aorta, caval veins and cardioplegia
(group 1). This approach was compared to median sternotomy on 135
patients (group 2) from the position of exposure to the intra-cardiac
anatomy, postoperative period and cosmetic results.
Results:
CHD that could be approached through the right atrium
(atrial septal defect, partial anomalous pulmonary venous drainage,
atrial component of atrioventricular septal defect, ventricular septal
defect, mitral or tricuspid valve regurgitation) were operated on
through RLT. Mean patient age was 6.0
±
5.1 years (range 0.5–18)
and 3.1
±
6.3 years (range 0.2–18) in groups 1 and 2 (
p
<
0.05) and
the degree of CHD was the same. Exposure to the intracardiac anat-
omy in the RLT group was good. There was no need for conversion
to another approach. The mean operative time was 132.3
±
36.2 min
in group 1 and 151.4
±
52.7 min in group 2 (
p
<
0.05), mean cardio-
pulmonary bypass time was 49.7
±
27.3 and 58.5
±
28.7 minutes
(
p
<
0.05), respectively, and mean aortic cross-clamping time was
32.4
±
19.1 and 36.7
±
21.4 minutes, respectively (
p
>
0.05). The
advantage of RLT included absence of any pericardial effusion. The
follow up was 1.8
±
0.8 years. Cosmetic results of RLT were good in
all patients. There was no scoliosis, deformity of the chest or breast.
Conclusions:
RLT is a safe and effective alternative to median ster-
notomy for correction of CHD that could be approached through the
right atrium. Its cosmetic results were highly satisfactory.
524: ASSESSMENT OF RECOVERY IN CHILDREN ON
BERLIN HEART EXCOR VENTRICULAR-ASSIST DEVICE
SUPPORT
Claire Irving, Richard Kirk, Jane Cassidy, Asif Hasan, Massimo
Griselli, David Crossland
Department of Paediatric Cardiology and Cardiac Surgery, Freeman
Hospital, Newcastle, UK
Background
: Ventricular assist device (VAD) support is increasingly
used in paediatrics, mainly as a bridge to transplant, although use as
a bridge to recovery is increasingly described. In 2007 we developed
a protocol to assess recovery of ventricular function in children on
Berlin Heart Excor
®
VAD support. We aimed to review the effective-
ness of this protocol in assessing which patients could have the VAD
safely removed.
Methods
: Patients with myocarditis were initially assessed after two
weeks of support, and with cardiomyopathy after four weeks. Testing
involved echocardiographic and haemodynamic assessment over
90 minutes with the VAD paused, and measurements were taken at
predetermined intervals. If haemodynamic stablility was maintained
with fractional shortening
>
25% and normal response to dobu-
tamine, explantation was subsequently performed. A retrospective
review was performed of patients assessed using this protocol.
Results
: Ten of 55 (18%) supported patients from 2007 to 2011
showed recovery of ventricular function on this protocol and under-
went explantation. Primary diagnoses were dilated cardiomyopathy
(
n
=
4), hypertrophic cardiomyopathy (
n
=
1), post-transplant acute
graft failure (
n
=
1), myocarditis (
n
=
3) and congenital heart disease
(
n
=
1). Median age was 1.1 years (range 0.5–17 years) with median
time on support 31 days (range 7–120 days). Three patients under-
went early testing or ‘forced’ testing not in keeping with the protocol
outlined, due to complications on support and the need to explant
early if possible. There was one non-cardiac death post-explantation
and two patients needed to go back on support (one after eight days
and one had three VAD runs with two successful explantations each
over a year apart). Both were subsequently transplanted.
Conclusions
: Long-term support to recovery is achievable even in
small children. A protocol that demonstrates normal cardiac output
and ventricular function on echocardiography with a positive inotrop-
ic response may be used to predict which patients can successfully
undergo VAD explantation.
