CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
16
AFRICA
CBP. Extracorporeal membrane oxygenation (ECMO) was used for
35 children (median one month) and centrifugal left ventricular assist
device (LVAD) for 30 (median 2.8 months). Fourteen children (21%)
were post-palliation for single-ventricle physiology. Eleven patients
(17%) underwent surgical revision on ECLS, and 19 (29%) received
multiple ECLS runs. Thirty-eight patients (58%) survived to hospi-
tal discharge. Survival was not associated with diagnosis, single-
ventricle physiology, surgical revision, organ-specific complications
or ECMO versus LVAD. Survival occurred after up to nine days of
ECLS. From univariable analysis, older age (2.2 vs 0.2 months),
lower arterial lactate at four hours (2.6 mmol/l vs 4.9 mmol/l), shorter
ECLS (three vs six days), less patient or circuit complications, and
single ECLS run were associated with survival (all
p
<
0.05). From
multivariable regression models, prolonged ECLS (
p
<
0.001),
elevated lactate four hours post-support (
p
<
0.02) and repeat ECLS
(
p
<
0.03) were associated with hospital deaths.
Conclusion:
Almost 60% of children receiving ECLS for failure to
wean from CBP post cardiac surgery survived to hospital discharge.
Inadequate support as represented by higher arterial lactate and
multiple runs were associated with worse outcomes. Although prog-
nosis worsens with prolonged ECLS, individual patients survived
after up to nine days of support.
285: SYSTEMIC THROMBOLYSIS IN CHILDREN WITH
LIFE- OR ORGAN-THREATENING THROMBOSIS AFTER
CARDIAC SURGERY
Zuzana Hrubsova, Martin Zahorec, Peter Skrakq, Lubica Kovacikova
Paediatric Cardiac Centre, National Institute of Cardiovascular
Diseases, Bratislava, Slovakia
Background
: The use of thrombolysis in the postoperative period is
relatively contra-indicated because of risk for serious haemorrhagic
complications. The aim of the study was to assess the efficacy and
safety of thrombolysis and identify risk factors for major bleeding
complications in children with intracardiac or major vessel thrombo-
sis after cardiac surgery.
Methods
: This retrospective study included children with clinically
significant thrombi confirmed by sonography, angiography or CT
scan, who where treated with recombinant tissue plasminogen activa-
tor (rtPA) in the postoperative period after cardiac surgery between
2000 and 2011. Data are presented as median (range).
Results
: Fourteen patients at the age of 24 months (one month – 15
years) received 15 courses of systemic thrombolysis for intracardiac
(six) or major vessel (nine) thrombosis. Thrombolysis was initi-
ated on postoperative day nine (36 hours – 40 days after surgery).
Duration of therapy was six hours (two hours – three days) with
cumulative doses of rtPA of 2.7 mg/kg (0.3–18.2 mg/kg). Complete
clot resolution, a partial effect, and no effect were achieved in nine
(60%), four (26.7%), and two children (13.3%), respectively. Major
bleeding required blood transfusion in five patients (33.3%) and
surgical intervention in two (13.3%). One patient died of inferior
vena cava thrombosis after a Fontan procedure. All-cause hospital
mortality for the whole group was 35%. Higher international normal-
ised ratio immediately after thrombolysis discontinuation was associ-
ated with haemorrhagic complications (
p
=
0.01). Other factors were
not identified as predictors of outcome.
Conclusions
: Thrombolysis can be used as a treatment modality for
symptomatic thrombosis in children after cardiac surgery. The risk–
benefit ratio should be assessed for each individual patient.
292:
CONGENITAL CARDIAC SURGERY THROUGH THE
MINIMALLY INVASIVE MID-AXILLARY RIGHT LATER-
AL MUSCLE-SPARING THORACOTOMY APPROACH IN
INFANTS WEIGHTING 6 KG AND MORE
Anton Shmalts, Michail Plotnikov, Sergey Smirnov, Alfiya Drozdova,
Natalya Ganukova, Margarita Tungusova, Dmitry Tarasov
Federal Centre for Cardiovascular Surgery, Astrakhan, Russia
Background:
There is growing interest in minimally invasive
techniques in cardiac surgery and a legitimate desire to adopt these
approaches for minimal-weight and young patients. We used right
lateral thoracotomy (RLT) to repair congenital heart defects (CHD)
in infants weighting 6 kg and more.
Methods:
Between May 2009 and June 2012, 384 patients from six
months to 18 years underwent correction for CHD through RLT with
the use of direct cannulation of the aorta, caval veins and cardiople-
gia. Of these, 59 patients were infants younger than one year (group
1). This approach was compared to median sternotomy done on 78
infants under one year (group 2).
Results
: For 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), we operated through RLT in infants weighing at least 6 kg.
Mean patient age was 0.82
±
0.15 years (range 0.5–1.0) and 0.76
±
0.16 years (range 0.5–1.0) in groups 1 and 2, respectively (
p
>
0.05); the degree of CHD was the same. Exposure to the intracar-
diac anatomy in the RLT group was good and there was no need for
conversion to another approach. The mean duration of operation was
122.4
±
32.2 min in group 1 and 142.8
±
57.5 min in group 2 (
p
<
0.05). There was no operative or late mortality or major morbidity.
The follow up was 1.7
±
0.6 years. All patients in the RLT group had
gratifying cosmetic results. There was no scoliosis or deformity of
the chest or a breast.
Conclusions
: RLT can be used as an alternative to median sternot-
omy for a wide range of CHD that could be approached through the
right atrium in infants weighing at least 6 kg. RLT cosmetic results
were much better than with standard median sternotomy.
293: LATERAL ATRIAL TUNNEL AND EXTRACARDIAC
CONDUIT: COMPARISON OF EARLY RESULTS IN A
SINGLE-CENTRE EXPERIENCE
Katarzyna Januszewska, Anna Schuh, Robert Dalla-Pozza, Rainer
Kozlik-Feldmann, Sabine Greil, Anja Lehner, Martin Riester, Edward
Malec
Ludwig Maximilian University, Munich, Germany
Background:
After more than 40 years of history of Fontan opera-
tions (FO), two modifications are currently being used for cavopul-
monary anastomosis: lateral atrial tunnel (LT) or extracardiac conduit
(EC). The aim of the study was to compare the hospital outcomes of
LT and EC at a single institution over the same period of time.
Methods:
Between June 2007 and June 2012, a series of 149 consec-
utive children at a mean age of 3.6
±
2.1 years underwent FO: 56
(37.6%) patients after hemi-Fontan operation underwent fenestrated
LT and 91 (61.1%) patients after bidirectional Glenn anastomosis
underwent EC; two (1.3%) patients underwent other variants of FO
and were excluded from the study. The most common malformations
were: hypoplastic left heart syndrome (55.1%), hypoplastic right
heart syndrome (10.2%), double-inlet left ventricle (10.2%) and
double-outlet right ventricle with hypoplastic left ventricle (8.8%).
Haemodynamic, electrocardiographic and clinical peri-operative data
were retrospectively analysed.
Results:
The hospital mortality was 0%. There were no differences
between the groups regarding age, weight, morphology of the single
ventricle, pre-operative cardiac catheterisation values and postop-
erative intubation time (15.4
±
28.2 vs 11.5
±
17.6 h;
p
=
0.313).
Children after EC tended to stay longer in hospital (18.4
±
9.6 vs
15.5
±
8.2 days;
p
=
0.061) and had significantly longer right pleural
drainage for effusions (9.2
±
7.1 vs 5.9
±
5.0 days;
p
<
0.01). Patients
after LT had more frequent junctional or ectopic atrial rhythm on the
day of the operation (
p
<
0.01) and at discharge (
p
=
0.016).
Conclusions:
Fenestrated lateral atrial tunnel seems to facilitate
the early adaptation to Fontan physiology but in our experience this
operative technique caused higher incidence of atrial rhythm distur-
bances, which can influence the late functional status of the patients.
