CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
40
AFRICA
this late presentation is often elevated pulmonary vascular resistance.
Consequently, in those countries where paediatric cardiac surgery is
performed, these children are considered too high a risk to undergo
an operation because of postoperative pulmonary hypertension. We
have pioneered the use of a fenestrated uni-directional double-patch
closure technique in such children since 1996.
Methods:
We reviewed our database and contacted all sites where the
procedure has been performed to our knowledge. The database was
searched for catheterisation data, pre- and postoperative echo data,
extubation time, survival on discharge and use of sildenafil pre- or
postoperatively. All values are expressed as mean
±
standard devia-
tion. A
p-
value of 0.05 was considered significant.
Results:
A total of 219 patients underwent the double-patch opera-
tion. There were 139 who underwent isolated ventricular septal defect
(VSD) closure and 80 who received the double patch as part of a
more complex repair. Pre-operative pulmonary vascular resistance
was 11.4
±
2.7 wood units in the VSD group and 9.2
±
3.1 in the
complex group (
p
<
0.02). The ratio of pulmonary to aortic systolic
pressures was 0.97
±
0.08 in the isolated VSD and 0.91
±
0.1 in the
complex group (
p
<
0.01). The Qp/Qs in the VSD group was 1.4
±
0.5, and 1.7
±
0.9 (NS) in the complex group. Pre-operative satura-
tion was 90
±
4% in the VSD group and 85
±
9% in the complex
group (
p
<
0.05) and sildenafil use was not significantly different.
Survival in the isolated VSD was 95.9 and 83.7% in the complex
group (
p
<
0.01). Recent sildenafil use improved survival in both
groups (
p
<
0.05).
Conclusion:
Double-patch VSD closure provides operative inter-
vention in developing countries, with reasonable mortality rates.
Complex defects remain difficult to deal with.
1048: ARE EXTREMELY HIGH BNP (BRAIN NATRIURETIC
PEPTIDE) LEVELS AN INDICATOR OF CATASTROPHIC
OUTCOMES IN PAEDIATRIC PATIENTS?
David Horne, Reeni Soni, Dion Pepelassis, Ilan Buffo
University of Manitoba, Canada
Objectives
: BNP is known to be increased in patients with clinical
heart failure and correlates with the severity. It is unknown if BNP
has predictive value regarding prognosticating outcomes or mechani-
cal circulatory support (MCS) requirements. Current literature hints
towards this possibility. We attempted to quantify at which critical
BNP level patients are likely to need MCS in a non-homogeneous
paediatric population.
Methods
: We carried out a single-centre retrospective review of all
patients who had a BNP level drawn between 2009 and September
2011. Chart reviews of all patients with a value
>
600 pg/ml were
undertaken. Primary outcomes included: urgent/emergency surgical
intervention, MCS and transfer for MCS, and sudden cardiac death.
Fisher’s exact test was used to predict likelihood of primary outcome
at BNP levels
>
1 500 pg/ml. Sensitivity, specificity, and positive and
negative predictive values were calculated for BNP
>
1 500 pg/ml.
Results
: Eleven (surgical intervention
=
four, MCS
=
three, emer-
gency transfer for MCS
=
two, sudden cardiac death
=
two) patients
had the primary outcome, nine with a BNP level
>
1 500 pg/ml
compared to two patients who didn’t have the primary outcome [one
with neonatal hypertension and congestive heart failure (CHF) and
one with diabetic keto-acidosis with CHF] (odds ratio
=
209.25, 95%
CI
=
26.25–1 668.18,
p
<
0.001). BNP
>
1 500 pg/ml had sensitivity
and a positive predictive value of 82%, while specificity and a nega-
tive predictive value was 98%.
Conclusions
: BNP levels
>
1 500 pg/ml are predictive of poor
outcomes and alert the clinician to the seriousness of the patient
and potential need for MCS, even when other parameters of perfu-
sion seem normal. We recommend following BNP values serially to
assist in determining changes in cardiac function/reserve in selected
patients, i.e. stable dilated cardiomyopathy versus viral myocarditis.
As low levels of BNP showed good negative predictive value, low
results should be reassuring.
1089: ASSESSMENT OF LEFT VENTRICULAR FUNCTION
AND MITRAL VALVE REGURGITATION AFTER CREA-
TION OFA DUAL CORONARY SYSTEM FORANOMALOUS
LEFT CORONARY ARTERY ORIGINATING FROM THE
PULMONARY ARTERY IN INFANTS
Piotr Kazmierczak, Katarzyna Ostrowska, Jadwiga Moll, Jacek Moll
Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
Background
: Anatomical correction seems to be an ideal method
of surgical treatment of the anomalous left coronary artery arising
from the pulmonary artery (ALCAPA) in infancy. The medium-term
outcome was investigated for infants with the ALCAPA following
creation of a dual coronary arterial circulation.
Methods
: Between April 1995 and July 2012, 23 infants with a
median age of four months underwent aortic re-implantation of the
ALCAPA at our Department. Direct implantation of the anomalous
coronary artery into the ascending aorta was feasible in 16 patients.
A trapdoor flap method was used in five infants and a tubular exten-
sion technique in two patients. No infant underwent mitral valve
repair at the time of the ALCAPA surgery. Left ventricular function
and degree of mitral regurgitation were assessed during a 10-year
follow up.
Results
: Four patients died in early postoperative period. There were
no independent predictors associated with postoperative mortality.
During follow up, both early and late improvement of myocardial
function was observed in all patients. There was only one improve-
ment of severe mitral regurgitation in the postoperative period. Later,
two children needed mitral valve replacement. There were no early or
late re-operations of the re-implanted coronary arteries.
Conclusions
: Anatomical correction is an effective method of surgi-
cal treatment of the ALCAPA in infants burdened with a low risk
of re-operation due to coronary artery stenosis. There is a favorable
potential for myocardial recovery within the first year of surgery.
Primary mitral valve repair should be associated with coronary revas-
cularisation in infants with severe mitral regurgitation.
1098: INITIAL PALLIATION OF COMPLEX INTERRUPTED
AORTIC ARCHWITH A ‘HYBRID’APPROACH
Frank Scholl, Richard Perryman, Lilliam Valdes-Cruz, Kak-Chen
Chan
Joe DiMaggio Children’s Hospital, Hollywood, Florida
Background:
Successful neonatal surgical treatment of complex
interrupted aortic arch (CIAA) remains challenging. This report
constitutes our experience with the ‘hybrid’ approach for palliation of
these patients prior to elective definitive repair to facilitate concomi-
tant treatment of the associated lesions and to decrease morbidity.
Methods:
This report is a single-institution, retrospective review of
consecutive patients with CIAA treated by the ‘hybrid’ approach.
Complex IAA is defined as weight
≤
2.5 kg, multiple VSDs, multi-
organ system failure and diminutive left ventricular outflow tract. All
patients were palliated via median sternotomy with bilateral branch
pulmonary arterial bands and ductal stenting. Left heart structural
dimensions were measured pre-palliation and prior to surgical repair
and are reported.
Results:
From July 2007 to December 2010, eight patients under-
went ‘hybrid’ palliation. Weights were 1.7 to 3.4 kg (mean of 2.6).
Mean aortic valve annulus was 4.63 mm. Associated complexity was
weight
≤
2.5 kg (
n
=
5), multiple VSD (
n
=
2), shock with multi-
organ failure (
n
=
1), and aorto-pulmonary window (
n
=
1). All
patients were discharged home after ‘hybrid’ palliation. One patient
died two weeks post palliation from necrotising enterocolitis. All
other patients underwent successful biventricular definitive repair
at a mean age of 4.4 months. One patient underwent trans-catheter
device closure of a muscular VSD and another peri-ventricular device
closure at the time of definitive biventricular repair.
Conclusions:
‘Hybrid’ palliation of CIAA with bilateral branch PA
banding and ductal stenting is feasible and provides adequate pallia-
tion with excellent somatic growth. Although LV structures did not
