CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 124 AFRICA while two (2.8%) underwent modified mBT shunt, a form of conservative approach. The last 39 (54.2%) patients had palliative medical care. Of the 31 patients who had corrective surgery, 28 (90.3%) were successful while three patients (9.7%) died following the procedure. The two patients who underwent the mBT shunt died; the first died intra-operatively following a cardiac arrest and the second within 48 hours of surgery. The total mortality rate following surgical intervention was therefore five (15.2%). Among those who had palliative care, 30 (76.9%) were alive while nine had (23.1%) died at the time of this report. A higher mortality rate was therefore recorded among the children who had palliative care (23.1%) compared to those who had corrective surgery (9.7%). The overall mortality rate among the patients was 19.4%. Fig. 1 shows the frequency of immediate postoperative complications in the patients who underwent corrective surgery. The most common immediate post-operative complications were malaria (80.6%), arrhythmias (22.6%) and cardiac dysfunction (19.4%). Echocardiographic findings following corrective surgery are shown in Fig. 2. Fifteen (48.8%) patients had free pulmonary regurgitation, nine (29.9%) had residual pulmonary stenosis with a peak gradient greater than 30 mmHg, five (16.1) had mild aortic incompetence, two (6.5%) patients were found to have previously unseen VSD, 18 (58.1%) had pleural effusion, which was the most common complication, 15 (48.4%) patients had pericardial effusion and four (12.9) had right ventricular dysfunction. Table 2 shows the complications that were noted among the patients who had only palliative care. Thirty-eight (97.4%) of them had polycythaemia, for which they had partial exchange transfusion with normal saline whenever their haematocrit was 65% or above, 16 (41.0%) had right coronary cusp prolapse, 10 (25.6%) patients were found to have right ventricular dysfunction and eight (20.5) had aortic incompetence. The other complications observed are as shown in the table. Discussion TOF is a complex and treatable cyanotic CHD in the vast majority of patients. In this audit, less than half of the patients had corrective surgery and the average age at surgery was 5.13 years (range 1.1–17 years). This is unlike what occurs in developed nations of the world where corrective surgery is done in infancy. The ideal age for corrective surgery of TOF has been a subject of debate for some decades.2,20 Early intervention with corrective surgery within the first four to six months of life, and earlier in symptomatic neonates is now advocated.2,20 There are several reasons why experts advocate early corrective surgery of TOF.20,21 Early corrective surgery results in better preservation of the function of the left ventricle and eradicates cyanosis and hypoxaemia, which improves exercise capacity.15,17 Also, it achieves a reduction of the right ventricular pressure overload and significantly reduces secondary injury to the heart, lungs and central nervous system.20,22 Currently, most centres favour corrective surgery in infancy.20-22 Table 1. Treatment intervention and outcome Intervention Outcome, n (%) Alive Dead Total Corrective surgery 28 (90.3) 3 (9.7) 31 (43.0) Blalock–Taussig shunt 0 (0.00) 2 (100) 2 (2.8) Palliative care 30 (76.9) 9 (23.1) 39 (54.2) Total 58 (80.6) 14 (19.4) 72 (100) Table 2. Complications in patients who had palliative medical care Complications Number Percentage Death 9 23.1 Kyphoscoliosis 2 5.1 Polycythaemia 38 97.4 Pneumonia 8 20.5 Stroke 8 20.5 Cerebral abscess 4 10.3 Infective endocarditis 1 2.7 Pica 2 5.1 Right ventricular dysfunction 10 25.6 Right coronary cusp prolapse 16 41.0 Aortic incompetence 8 20.5 Cardiac dysfunction Seizure Arrhythmia UTI Hypomagnesaemia Sepsis Pneumonia Malaria 6 (19.4%) 1 (3.2%) 7 (22.6%) 2 (6.5%) 5 (16.1%) 3 (9.7%) 2 (6.5%) 25 (80.6%) 0 5 10 15 20 25 30 Fig. 1. Bar chart showing the frequency of immediate complications following corrective surgery for TOF. UTI, urinary tract infection. RV dysfunction Pericardial effusion Pleural effusion Previously unseen VSD AI (mild) Residual PS Free PR 4 (12.9%) 15 (48.4%) 18 (58.1%) 2 (6.5%) 5 (16.1%) 9 (29.0%) 15 (48.4%) 0 2 4 6 8 10 12 14 16 19 20 Fig. 2. Bar chart showing complications observed on echocardiogram following corrective surgery. Free PR, free pulmonary regurgitation; residual PS, residual pulmonary stenosis; AI, aortic incompetence; VSD, ventricular septal defect; RV dysfunction, right ventricular dysfunction.
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