CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
61
nosis and management of chylothorax. The cardiac database and
dietetic records were used to identify the paediatric population with
CHD that underwent cardiac surgery at the Yorkshire Heart Centre.
Results:
Between July 2005 and June 2012, 2 290 operations were
performed in paediatric patients with CHD. Chylothorax was diag-
nosed in 117 of them, an incidence of 5.1% (95% CI: 4.2–6%), of
which 69 (59%) were under one year of age. The average time to
diagnosis was six days postoperatively. All patients were commenced
on medium-chain triglyceride diets (MCT) and 33 (28.2%) were
treated with octreotide, when drainage was refractory. Surgical inter-
vention was performed in seven patients. Chest drains remained for
an average of 11 days, nine (range 3–22) for those on only MCT and
15 days (range 6–32) for those on octreotide. Fourteen patients died.
Among the survivors, 33 (32%) were on a six-week MCT diet (our
policy until the beginning of 2008), one was treated for five weeks,
59 (57.3%) had a four-week diet, and the rest (9.7%) had less than
four weeks (range 2 days to 3 weeks) mainly for nutritional reasons.
There were two recurrences (1.9%, six-week regime).
Conclusions:
Chylothorax is a rare complication following paediat-
ric cardiac surgery. The MCT diet remains the gold standard in the
management of chylothorax. A maximum of four weeks has proven
to be sufficient for our patients. A shorter duration of the MCT diet
could be considered. Octreotide can be reserved for the more persis-
tent cases. Surgical intervention is required in a limited number of
patients.
1710: TRANSITION OF SURGICAL REPAIR FROM
‘CONVENTIONAL’ TO ‘PRIMARY SUTURELESS’ TECH-
NIQUE FOR TOTAL ANOMALOUS PULMONARY VENOUS
CONNECTION
Suresh Rao, HariBipin Radhakrishnan, Smrutiranjan Mohanty
Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
Background:
The ‘sutureless’ repair has been described for post-
repair pulmonary vein stenosis. It has since been reported as a modi-
fied technique for the primary repair of infracardiac total anomalous
pulmonary venous connection and recently for the primary repair of
other types as well.
Methods:
One hundred and two consecutive patients (median age 60
days; median weight 3.5 kg) underwent conventional or sutureless
total anomalous connection repair between July 2009 and July 2012.
Results:
Types of total anomalous pulmonary venous connection
included supracardiac in 54 patients (53%), cardiac in 24 (23%),
infracardiac in 17 (16%), and mixed type in seven patients (6%).
Median follow-up time was six months. Vertical vein obstruction
was found pre-operatively in 43 patients (40%). A primary suture-
less repair was carried out in 19 patients (18.6%; supracardiac,
n
=
4; cardiac,
n
=
1; and infracardiac,
n
=
14). A proportionately greater
number of patients with high-risk infracardiac total anomalous pulm-
nary venous connection underwent the sutureless technique (73 vs
3.6%). There were seven early operative deaths, of which four were
from non-cardiac causes. Early outcomes for death and re-operation
for pulmonary venous stenosis were not significantly different
between these two disparate groups.
Conclusion:
The sutureless group had more infracardiac total
anomalous pulmonary venous connection and a higher rate of decline
in the postoperative right ventricular systolic pressure with a shorter
ICU stay and earlier hospital discharge. Early results of suture-
less repair has led to a change in our practice from conventional to
primary sutureless repair for all cases of infracardiac total anomalous
pulmonary venous connection and for selected cases of supracardiac,
cardiac and mixed types with pre-operative pulmonary vein stenosis
or confluence obstruction.
1712: DOBUTAMINE DOES NOT OFFER SUSTAINED
CONTRACTILITY IN A PIGLET MODEL OF RIGHT
VENTRICULAR FAILURE
Janus Hyldebrandt, Christian Frederiksen, Johan Heiberg, Michael
Schmidt, Hanne Ravn
Aarhus University Hospital, Denmark
Background:
The immature myocardium has significantly different
receptor kinetics, metabolism and enzyme activity. Previous haemo-
dynamic studies have primarily focused on the inotropic effect on
left ventricular function. A piglet study was planned to investigate
the effect of three different inotropic strategies on right ventricular
failure.
Methods:
Twenty-one piglets aged four days old were prepared to
measure right ventricular pressures. Stunning of the right ventricle
(RV) was induced by 10 cycles of ischaemia–reperfusion injury. We
randomised the animals to placebo or one of three inotropic protocols:
AM (adrenaline): 0.09
μ
g.kg
-1
.min
-1
and milrinone: 50
μ
g.kg
-1
bolus
and 0.4
μ
g.kg
-1
.min
-1
; DM (dopamine): 6
μ
g.kg
-1
.min
-1
, milrinone: 50
μ
g.kg
-1
bolus and 0.4
μ
g.kg
-1
.min
-1
; and Dob (dobutamine): (8
μ
g.kg
-1
.
min
-1
) for 240 minutes. We used maximum pressure development
over time (dP/dt
max
) as a marker of contractility, and minimum pres-
sure development over time (dP/dt
min
) to evaluate diastolic function.
Arterial elastance and end-systolic pressure–volume relationship
were calculated to evaluate arterio-ventricular coupling (Ea/ESPVR).
One-way ANOVA was used to analyse differences between area
under the curve (AUC) and mean values from specified time points.
Results:
Maximum response was fastest in the Dob group: 30 min,
followed by DM: 40 min, and AM: 80 min. After 180 min, dP/dT
max
decreased to a level indistinguishable from baseline in the Dob group
(non significant), whereas dP/dt
max
in the AM and DM groups contin-
ued to increase throughout the study period (
p
<
0.01 and
p
=
0.03,
respectively). AUC did not differ between groups (
p
=
0.48). dP/dt
mi
n
improved in all groups, and remained stable in all groups. Only DM
improved Ea/ESPVR compared to controls (
p
<
0.05).
Conclusions:
In the stunned RV, Dob effectively increased contrac-
tility, however the effect was not sustained over the infusion period
in comparison with the AM and DM groups. Only DM improved
the arterio-ventricular coupling after right ventricular failure. The
three inotropic interventions improved diastolic function to a similar
degree.
1715: TRANSITIONING PAEDIATRIC HEART SURGERY
IN MONGOLIA, FROM HYPOTHERMIC SURGERY TO
CARDIOPULMONARY BYPASS: LESSONS LEARNED
Ariuntsatsral Erdenebileg
1
, Tsegenjav D
1
, Kirk Milhoan
2
1
Shastin IIIrd Surgical Hospital, Ulaan Baatar, Mongolia,
2
University of Texas Health Science Center, San Antonio, USA
Introduction:
Mongolian paediatric cardiac and cardiac surgery
care faced a growing need to develop a new cardiac programme
after its 1990 independence from the USSR. This was due in part to
budgeting constraints and a lack of advanced cardiac surgery care
and infrastructure. Therefore, hypothermic cardiac surgery without
cardiopulmonary bypass was instituted as the standard approach to
congenital defect repair.
Methods:
In 2005 a visiting paediatric team composed of a cardio-
thoracic surgeon, cardiologists, cardiac anaesthesiologists, a perfu-
sionist, cardiac intensivists, and cardiac intensive care nurses started
systematically training the Mongolian cardiac team in all aspects of
paediatric cardiac surgery using cardiopulmonary bypass.
Results:
From 2005 to 2011 the visiting cardiac team visited eight
times and performed 30 closed- and 50 open-heart surgeries with
the Mongolian team. During that time period the Mongolian team
successfully transitioned from hypothermic surgery to cardiopulmo-
nary bypass surgery. In 2011 the total number of bypass cases was
176, with a 30-day operative mortality rate of less than 5%.
Conclusions:
Our institution has safely and cost-effectively tran-
sitioned to the surgical repair of congenital cardiac defects using
cardiopulmonary bypass. We will discuss the procedures and lessons
learned from this transition to more advanced cardiac surgery tech-
niques which can be used as a model for other developing countries
such as Mongolia.
