CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
20
AFRICA
Conclusions:
The outcome after transplantation for patients with
or without previous cavopulmonary anastomosis is comparable.
Taking into account the higher median age at transplantation in the
group with cavopulmonary anastomosis regarding life expectancy, it
seems to be reasonable to do the palliative surgery instead of early
transplantation.
446: OPERATING ROOM SAFETY IN DEVELOPING COUN-
TRIES: THE IMPORTANCE OF LANGUAGE-INDEPEND-
ENT DIAGRAMS, CHECKLIST AND TIME-OUT
Erin Brenner
1
, Christian Gilbert
2
1
International Children’s Heart Foundation, Memphis, TN, USA
2
Cincinnati Children’s Hospital Medical Center, USA
Background:
In July 2009, the International Children’s Heart
Foundation piloted a quality-improvement initiative implementing
operation room time-out as a standard on all medical mission trips.
Through this process, safety initiatives, standardised teaching and
process improvement initiatives have been developed. We describe
a qualitative evaluation of a multi-faceted OR safety and education
initiative in a multi-national assistance programme.
Methods:
Intra-operative nursing checklists were introduced in addi-
tion to the time-out process. OR volunteers were asked to note OR
complications in a database sheet. Language-independent diagnostic
documentation (heart diagrams) followed patients from pre-operative
cardiology to the post-operative phase and were utilised in the OR as
part of pre-operative time-out and for teaching.
Results:
Time-out was performed on 86% of trips in 2012.
Complications found and dealt with during pre-surgical time-out
included: suboptimal antibiotic timing, blood availability, wrong
procedure prepared for by local staff, wrong patient brought to OR,
implant not on field, no definitive diagnosis/or understanding prior to
incision, change of plan based on an in-OR echo review, and equip-
ment issues/availability. Language-independent diagrams ensured the
entire team agreed with and understood the plan of care. Although
intended to ensure diagnostic echo accuracy and the right patent in
the OR, the diagrams were also used in staff and family education.
Conclusions
: Checklists are proven methods of improving patient
safety. Compliance of performing and tracking time-out is greater
where an ICHF OR staff member is present at the time of incision.
Issues that arose were recognised and fixed in a timely fashion,
usually due to the implementation of a ‘standard’ process prior to
incision. Heart diagrams are an indispensible language-independent
resource and aid in patient care when language barriers exist, for the
safety of diagnosis and understanding.
447: CHALLENGES IN DIAGNOSIS AND MANAGEMENT
OF PULMONARY ARTERIOVENOUS MALFORMATIONS
IN A RESOURCE-POOR SETTING: A CASE REPORT
Petronila Tabansi
1,2
, Barbara Otaigbe
1,2
, Chukuemeka Agi
1,2
1
University of Port Harcourt, Nigeria
2
University of Port Harcourt Teaching Hospital, Nigeria
Background:
Pulmonary arterio-venous malformations (PAVMs)
are rare vascular anomalies resulting in abnormal direct commu-
nication between pulmonary arteries and veins. Most PAVMs are
congenital but acquired cases also occur. PAVMs result in right-
to-left shunts and are an unusual cause of chronic cyanosis with
consequent polycythemia. The direct connection between arteries
and veins causes impairment of the normal filtering function of the
lungs, with potential paradoxical embolism and systemic infections.
Methods
: A young adult male with PAVMs and complications high-
lights the challenges in diagnosis and management in a resource-poor
setting. His report of congenital cardiovascular malformations is
presented.
Result:
PC, an 18-year-old male has been on evaluation and manage-
ment for polycythemia from chronic cyanosis since the age of eight
years. Cyanosis was variable and noticed by his mother from the age
of five years, for which she sought no treatment until he presented
at seven years with multiple chronic discharging fistulae of the left
thigh. He was treated for chronic bacterial osteomyelitis with some
relief, but defaulted on follow up. Five years later (now aged 12
years), he was rushed to the emergency unit with a day’s history of
recurrent convulsions culminating in coma. CT scans showed left
frontal lobe abscess suggestive of tuberculous abscess, CXR revealed
vague opacities in the right middle lobe. He was commenced on anti-
tuberculous therapy, regained consciousness and the fistulae healed.
However due to persisting cyanosis and polycythemia, a chest MRI
was done and revealed an abnormal connection between the right
pulmonary artery and pulmonary veins of the right middle lobe. An
interventional pulmonary angiogram could not be done due to lack of
skills and facilities. His need for further intervention where facilities
exist was hampered by financial constraints.
Conclusion:
PAVMs with complications are challenging to diagnose
and manage in resource-poor settings, resulting in chronic morbid-
ity. Provision of skilled manpower and facilities in these centres is
imperative to avert mortalities.
471: MENTORING PAEDIATRIC CARDIAC SURGERY
IN DEVELOPING COUNTRIES: FIVE-YEAR PROGRESS
REPORT AND EXIT STRATEGY
Kathleen Fenton
1,2
,Sergio Hernandez Castillo
2
, William Novick
1,3
1
International Children’s Heart Foundation, Memphis, TN, USA
Asociación Programa Corazón Abierto, Managua, Nicaragua
3
University of Tennessee, USA
Background:
Establishment of stable cardiac surgical centres in
developing countries includes training of personnel in the established
foreign centres, visits of mission teams to do multispeciality on-site
training, and donation of equipment and supplies. This usually
suffices to form a sustainable programme, but some countries require
further assistance. We report the results of a five-year mentoring
project in one such country.
Methods:
Following a ‘scouting’ trip with a small medical team, a
surgeon relocated to work full-time with the local surgeon, mentoring
him in surgical techniques, patient evaluation and care, programme
administration, and working closely with other team members and
with the local fund-raising organisation. After 4.5 years, a transition
period was initiated in which the visiting surgeon began to spend
progressively increasing amounts of time out of the country, leaving
the programme in the hands of the local surgeon. The local data-
base was examined for RACHS complexity, primary and assistant
surgeons, mortality and fundraising. Statistical significance was
defined as
p
<
0.05.
Results:
From January 2007 to June 2012, 282 operations were
performed with 21 deaths (mortality 7.4%). Case complexity
increased over time (RACHS 2/3 cases 44% in 2011 vs 22% in 2007,
p
<
0.001). Overall mortality decreased to
<
7.5% per year after the
first year (
p
<
0.01). The number of operations performed by the local
surgeon steadily increased (
p
<
0.001); all 2012 operations were done
by the local surgeon. Local fund raising increased progressively from
$10 909 in 2006 to $97 554 in 2010 (
p
<
0.01).
Conclusions:
Placement of a ‘mentoring’ surgeon full time in a
developing country can effectively promote the safe establishment
of a sustainable congenital heart surgery programme when other
methods of aid have failed. Good surgical results can be obtained and
maintained while simultaneously increasing the case complexity and
experience of the local surgeon.
475: INFLUENCE OF PULMONARY ARTERY SIZE ON
EARLY OUTCOME AFTER THE FONTAN OPERATION
Anja Lehner
1
, Anna Schuh
2
, Florian EM Herrmann
1
, Sabine
Pallivathukal
1
, Martin B Riester
1
, Robert Dalla-Pozza
1
, Rainer
Kozlik-Feldmann
1
, Edward Malec
2
, Katarzyna Januszewska
2
1
Department of Paediatric Cardiology, LudwigMaximilian University,
Munich, Germany
