CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
23
531: GOING DOWN, GOING SLOW: ESMOLOL AS POTENT
MYOCARDIAL PROTECTOR IN RESCUE CARDIAC
EXTRACORPORAL MEMBRANE OXYGENATION
Damian Hutter
1
, Alexander Kadner
1
, Florian Schanhoff
1
, Jean-Pierre
Pfammatter
1
, Mladen Pavlovic
1
, Bendicht Wagner
2
1
Centre of Congenital Heart Disease, University Hospital, Bern,
Switzerland
2
Paediatric Intensive Care Unit, University Children’s Hospital, Bern,
Switzerland
Introduction:
Cardiac failure or arrest post elective cardiac surgery
in neonates and children are rare events. However their occurrence
during a highly vulnerable period of myocardial recovery implies
immediate expert support. Timing, efficiency of resuscitation and
duration of cannulation for ECMO are crucial. Equally important is
the subsequent cardiovascular management to optimise myocardial
recovery. Besides volume unloading, optimal coronary perfusion
has to be maintained to protect cardiomyocytes from oxidative
stress. Beta-blockers combine cardioprotective mechanisms such as
improved myocardial relaxation, coronary perfusion and also anti-
oxidative activity.
Methods:
Six patients required rescue ECMO post elective cardiac
surgery. They were started on esmolol infusion as soon as they
stabilised (full-flow ECMO
≥
150 ml/kg/min). Serial transthoracic
echocardiography was performed to assess myocardial contractility.
Results:
Six patients (two male, four female), age 2.2
±
4.1 years
with single-ventricle physiology (
n
=
3), complex cyanotic heart
disease (
n
=
2) and coronary anomaly (
n
=
1) all had myocardial
stunning. ECMO was carried out at 8.8
±
1.9 days, maximum dose
esmolol was 106.7
±
50.1
μ
g/kg/min, maximum heart rate (HR)
prior to esmolol was 168.3
±
11.7 beats/min (bpm), maximum heart
rate during esmolol was 73.3
±
8.2 bpm, fractional shortening (FS)
prior to esmolol was 9.2
±
4.9%, FS post esmolol was 33.3
±
7.5%.
Weaning of ECMO was successful in four patients.
Conclusions:
In this small pilot study without case controls, all
patients showed significantly improved myocardial contractility.
Esmolol appears to provide cardioprotection for paediatric patients
post cardiac failure/arrest requiring ECMO. Its combined anti-oxida-
tive effect may support recovery of myocytes by increased gluthation
peroxidise and superoxide dismutase activity.
540: INCREMENTAL RISK FACTORS FOR MORTALITY
AND MORBIDITY AFTER INFANT HEART SURGERY IN
THE DEVELOPINGWORLD
Raman Krishna Kumar, Rakhi Balachandran, Mahesh Kappanayil,
Abish Sudhakar, Shaad Abquari, Srinath Reddy, Maitreyi Mohan,
Sunil Gopalraj, Benedict Raj, Suresh G Nair
Amrita Institute of Medical Sciences, Cochin, India
Background
: We examined our institutional paediatric heart surgery
database to determine the impact of low birth weight, malnutrition,
need for pre-operative intensive care support or mechanical ventila-
tion on the outcomes of 447 consecutive heart operations in children
under two years.
Methods:
Data on paediatric heart surgery (January 2010 to
December 2011) were collected prospectively as a part of the
International Quality Improvement Collaborative. Stepwise logistic
regression analysis was performed and all pre-operative variables
with
p
<
0.05 were allowed to enter into the model.
Results:
There were 90 newborns (20.1%) and 359 (80.3%) were
under one year old. Mean weight
Z
-score was −2.7
±
1.7 at surgery
and 112 (25%) had low birth weight. Prior to surgery, 59 (13.2%)
needed intensive care, 44 (9.8%) were ventilated and 13 (2.9%) had
positive blood cultures. Mortality (5.1%) was significantly associated
with RACHS-I risk category (1,
n
=
10: 0%; 2,
n
=
237: 1.3%; 3,
n
=
148: 8.8%; 4 and above,
n
=
52: 13.5%;
p
<
0.001). After adjust-
ment for RACHS-I category, pre-operative intensive care and pre-
operative mechanical ventilation emerged as significant determinants
of mortality, duration of mechanical ventilation and postoperative
sepsis. Pre-operative sepsis was strongly associated with postopera-
tive sepsis alone (odds ratio: 34.65; 95% CI, 7.35–163.4;
p
<
0.001).
Low birth weight and malnutrition were not associated with any of
the outcome measures. On stepwise logistic regression analysis pre-
operative ICU stay and pre-operative ventilation emerged as signifi-
cant predictors of outcome.
Conclusions:
The need for pre-operative intensive care and mechani-
cal ventilation were strongly associated with poor outcomes after
infant cardiac surgery in this large single-centre experience from a
developing country. It is worth exploring the utility of these addi-
tional variables in refining existing risk-adjusted scores for congeni-
tal heart surgery.
556: A PILOT PHASE I/II TRIAL OF ERYTHROPOIETIN
NEUROPROTECTION IN NEONATAL CARDIAC SURGERY
Dean Andropoulos, Ken Brady, Blaine Easley, Heather Dickerson,
Robert Voigt, Lara Shekerdemian, Marcie Meador, Dean McKenzie,
Jeffrey Heinle, Charles Fraser
Texas Children’s Hospital/Baylor College of Medicine, Houston,
Texas, USA
Background:
Acute neurological injury and longer-term neurode-
velopmental problems are common in neonates undergoing cardiac
surgery, with up to 50% of patients affected. Erythropoietin (EPO)
has anti-apoptotic, anti-inflammatory and anti-excitatory cell death
properties, protecting the brain against cerebral injury in animal
models and birth asphyxiated neonates. This phase I/II trial was
designed to assess safety and indicate efficacy of EPO treatment for
neonatal cardiac surgery.
Methods:
This was a prospective, randomised, blinded, placebo-
controlled trial of EPO vs normal saline control (US FDA IND
100011, NCT00513240). Neonates (
<
30 days) scheduled for cardiac
surgery with hypothermic CPB were enrolled. EPO doses were 1
000 units IV (or placebo equivalent) in three doses: (1) 12–24 hours
pre-operatively; (2) immediately after CPB; (3) 24 hours after dose
2. Brain MRI was performed pre-operatively and seven days postop-
eratively. Primary outcome was Bayley scales of infant and toddler
development III (BSID III) at 12 months of age.
Results:
The study drug was given to 59 patients. Five patients had
dural sino-venous thrombosis (two EPO, three placebo); six patients
died before the age of 12 months (three EPO, three placebo); 11
patients declined 12-month follow up (seven EPO, four placebo,
p
=
0.48), leaving 42 patients with 12-month BSID III (79% of survi-
vors). BSID scores were not different with EPO.
Conclusions:
EPO treatment was not associated with a difference
in 12-month BSID III. Complications, including major intracranial
thrombosis, MRI brain injury and death were not more common
with EPO treatment. An optimised study design, likely in a multicen-
tre setting, is required to define the utility of EPO neuroprotection
in neonatal cardiac surgery. We advocate such a study because of
the many desirable properties of EPO for neuroprotection, and its
demonstrated efficacy in other neonatal settings of cerebral injury.
558: THE ASSOCIATION OF VOLATILE ANAESTHETIC
EXPOSUREWITH NEURODEVELOPMENTAL OUTCOMES
AT AGE 12 MONTHS AFTER NEONATAL CARDIAC
SURGERY
DeanAndropoulos, Blaine Easley, Ken Brady, Stephen Stayer, Marcie
Meador, Taha Haq, Robert Voig
1
, Lara Shekerdemian, Charles Fraser
Texas Children’s Hospital/Baylor College of Medicine, Houston,
Texas, USA
Introduction:
Volatile anaesthetic agents (VAA) cause neuro-apop-
tosis in neonatal animals, and human data demonstrate an association
between early anaesthetic exposure and neurobehavioural problems.
This study quantitated VAA exposure in the first 12 months in
neonates undergoing cardiac surgery, to determine association with
neurodevelopmental outcomes.
