CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
73
who presented at 4 years of age underwent banding of PA, later
surgical repair of VSD. Because of long postoperative ICU stay,
he needed percutaneous closure of his residual VSD and was then
discharged. The patient with large muscular VSD and impaired LV
function underwent percutaneous VSD closure with good result
despite low weight (4.2 kg). One patient needed balloon dilation of
residual coarctation; the other because of severe obstruction to his
bilateral Glenn anastomosis, underwent stenting of these stenoses.
Both had good results.
Conclusions:
In severely sick children and late presenters with multi-
ple shunts, a tailored management including therapeutic catheterisa-
tion and supportive measures are essential before cardiac surgery.
Catheterisation and possible intervention should be considered early
during the postoperative phase in severely sick patients.
433: PERCUTANEOUS CLOSURE OF CORONARY ARTERY
FISTULAS: VARIOUS EMBOLISATION TECHNIQUES AND
DEVICES
Ghee Tiong Koh, Sharifah Ainon Ismail Mokthar, Ahmad Rustam
Zainudin
Department of Pediatric Cardiology, Penang General Hospital,
Malaysia
Background/hypothesis:
Percutaneous closure of coronary artery
fistulas (CAF) has emerged as an alternative to surgery. Closure of
CAF with coils has been well described. We aimed to review our
experience of the closure of CAF with various techniques and devices.
Materials and methods:
We retrospectively reviewed 6 patients (4
male, 2 female) with a median age of 10.6 years (range: 4.1–24.1
years) who had undergone percutaneous closure of CAF from March
2010 to March 2012. The closure results and clinical follow-up were
analysed.
Results:
The origin sites of the fistulas were left (3) and right (3)
coronary arteries. The fistulas drained to the right atrium (3) and
right ventricle (3). One patient had multiple drainage sites to the right
ventricle. A single device was used in 4 patients: vascular plug (2),
vascular plug II (1) and duct occluder II (1). Two patients required
the use of more than one device (duct occluder and duct occluder
II, 2 duct occluders with multiple coils). All devices were deployed
retrogradely except in one patient. One patient had significant resid-
ual shunt at 6-month follow-up and was occluded by percutaneous
technique. Follow-up studies 1.6–22.0 months (mean 13.9 months)
showed complete occlusion in all patients.
Conclusions:
Percutaneous closure of CAF is effective and safe with
good results. With the availability of newer devices, most CAF can
be closed percutaneously. Transcatheter closure should be considered
as the treatment of choice.
442: RECOGNITION OF SURGICAL OUTCOME BIAS
IN MULTI-CENTRE STUDIES: A METHODOLOGICAL
APPROACH USING 109 CASES OF FOETAL AORTIC
STENOSIS
Helena Gardiner
1, 2
, Alexander Kovacevic
2, 3
, Gerald Tulzer
4
, Joanna
Dangel
5
, Annika Ohman
6
, Mats Mellander
7
, Alan Magee
2
, Olivier
Ghez
2
, Rudi Meyer
4
, Klaus Schmidt
3
1
Imperial College London, UK
2
Royal Brompton NHS Foundation Trust, London, UK
3
Heinrich Heine University Dusseldorf, Germany
Children’s Heart Center, Linz, Austria
5
Medical University of Warsaw, Poland
6
Uppsala University Hospital, Uppsala, Sweden
7
The Queen Silvia Children’s Hospital, Gothenburg, Sweden
Background/hypothesis:
Foetal Working Group of Association for
European Paediatric and Congenital Cardiology studied influence
of foetal valvuloplasty on natural course of aortic stenosis (AoS)
from foetal diagnosis to determination of surgical pathway. To
recognise bias, we tested a committee approach for the following
hypothesis: institutional preference for neonatal AoS treatment over-
rides a committee’s decisions based on morphological and clinical
characteristics.
Material and methods:
The committee re-assessed postnatal, pre-
procedure imaging studies (including measurements and z-scores)
of 109 liveborn infants with prenatally diagnosed AoS (2005-2011),
treated in 24 institutions, blinded to foetal intervention, location and
outcome.
Outcome measures for decision concordance:
Individual
and consensus decision on univentricular (UV) or biventricular (BV)
pathway; concordance for first (BV) and second (UV) decision for
those converting BV-UV; image quality; specialism (foetal/paediatric
cardiologist, interventionalist or surgeon) and institutional ethos.
Results:
Of 109 infants 64 had initial BV outcome, with later
conversion to UV circulation in 6. Consensus concordance for first
pathway was 85/109 (78%) and for second: 81/109 (74%). There was
concordance with initial BV surgical pathway in 4 of 6 requiring later
conversion to UV. Poor imaging led to consensus ‘undecided’ in 3 of
4. Committee decision was BV in 16/45 (36%) final UV decisions
and undecided in 1 (poor imaging). The interventionalist disagreed
with first (
p
=
0.015) and final outcome (
p
=
0.009), grading more
UV than other specialists. Those with greatest foetal intervention
experience (GT, RM) agreed more with first and final outcomes:
odds ratio (OR) 1.86 (1.03, 3.33;
p
=
0.039) and OR 1.87 (1.04,
3.38;
p
=
0.037). Committee’s discordance was less for cases treated
in surgical centres performing neonatal Ross-Konno (11% vs 27%).
Conclusions:
The committee’s consensus was more optimistic than
eventual outcome, perhaps reflecting study members’ experience in
foetal intervention and neonatal Ross-Konno. This approach recog-
nised greater discordance with institutions not performing Ross-
Konno, leading to the potential to underestimate the influence of
foetal valvuloplasty in achieving BV outcomes.
444: DOPPLER ECHOCARDIOGRAPIC DIAGNOSIS OF
FOETAL LONG QT SYNDROME WITH FUNCTIONAL
SECOND-DEGREE HEART BLOCK
Sven-Erik Sonesson
1
, Håkan Eliasson
Karolinska Institute, Stockholm, Sweden
Background:
A rare presentation of foetal long QT syndrome (LQTS)
is a functional second-degree atrioventricular block (2°AVB), some-
times in association with ventricular tachycardia leading to congestive
heart failure. Junctional and/or ventricular tachycardia has also been
suggested as being characteristic of an acute stage of antibody-medi-
ated heart block, requiring a completely different strategy of treatment.
Recently observing a foetus with 2°AVB and abnormal diastolic
relaxation, later confirmed to have LQT1, we speculated that this
probably was an effect of a long refractory period in the ventricles, and
a possible marker to differentiate LQTS from other causes of 2°AVB.
Material and methods:
Isovolumetric relaxation (IRT) and contrac-
tion (ICT) time intervals were retrospectively determined from left
ventricular inflow/outflow Doppler records obtained from 21 cases
of foetal bradycardia. Five had 2°AVB (one LQTS), 7 3°AVB, and 9
blocked atrial bigeminy.
Results:
A markedly prolonged IRT (105 ms) and a short ICT (7 ms)
clearly distinguished our LQTS case from all other cases, where IRT
values ranged between 29 and 67 ms and short ICT values only were
seen in those with blocked atrial bigeminy. Long ICT values were
seen in 75% of cases with antibody-mediated 2°AVB.
Conclusions:
Even if our observation of IRT prolongation in LQTS
with 2°AVB is based on only one case, it is not unexpected and
could well be explained by a QT-interval exceeding the duration of
mechanical systole. Moreover, IRT prolongation was not seen in any
other case with other mechanisms causing the foetal bradycardia,
suggesting that measurements of IRT and ICT could be a valuable
complement to get a correct diagnosis.
449: STENT IMPLANTATION IN THE AORTIC ISTHMUS:
AN ANIMAL MODEL OF HAEMODYNAMIC, HORMONAL,
PRESSURE AND GENE EXPRESSION EFFECTS
