1. Primary Arterial Switch beyond 3 Weeks of age : What is feasible without ECLS?
Krishna Iyer, Girish Kumar, Reetesh Gupta, Sunil Kaushal, Sameer Girotra, S. Radhakrishnan, Parvathi Iyer, Savitri Shrivastava
Escorts Heart Institute & Research Centre, New Delhi, INDIA
Introduction
Results
LV mass ( mean ) : 34 gm/m 2 (30-43)
LV post wall (mean ) : 3.2mm (2-4.6)
LV geometry – visual impression
Favorable 11/22
Borderline 9/22
Regressed 2/22
In-hospital mortality : comparable in both groups
Early switch group: 2/25 (8.0%)
Late switch group : 1/22 (4.54%)
(p = 0.6)
The incidence of arrhythmias, sepsis as well as steroid requirement was comparable but renal injury was higher in early switch group.
Surgical management of TGA.IVS in older infants remains contentious
Regressed LV mass with age
?? Less capable of sustaining systemic circulation after arterial switch
Primary arterial switch in infants > 3 weeks of age
Western centres : Feasible option - ECLS for rescue In India : ECLS : Expensive , resource consuming modality
Cannot be recommended for “Routine rescue”
D TGA.IVS > 3 weeks of age : Sizeable Number
Late primary arterial switch without ECLS : No data available
Demographic data
Variables
Early switch group
N = 25
Late switch group
N = 22
Mean Age (days)
9 (3-18)
55 (22-149)
Sex M/F ( %)
72/28
90.9/9.1
Mean Weight (kg)
2.84
3.05
Preop BAS(%) 52
31.8
Coronary anatomy
1 L Cx, 2 R
1 L, 2 R Cx
Single coronary
Other(no circumflex)
17(68%)
6(24%)
1(4%)
15(68%)
5(22.7%)
2(9.1%)
0(0%)
Significant LV dysfunction was more in the late group but pre-discharge LV dysfunction was similar
Aim
Pilot , feasibilty study
To evaluate the outcome of primary arterial switch (A.S.O) in infants with dTGA.IVS beyond 3 wks of age without ECLS as a rescue strategy
Operative Data
Early switch group
N = 25
Late switch group
N = 22
Bypass time(min)
Mean(SD)
132.6
(21.6)
136.9
(20.8)
Cross clamp time(min)
Mean (SD)
61.5
(8.0)
63.6
(11.4)
Need for re-bypass(%)
1(4%)
1(4.5%)
Supportive bypass(%)
Deferred sternal closure(%)
13(52%)
10(45.4%)
LV status of the late group: :
Methods
Methods
Setting : 10 bedded PICU, ~ 600 cases/year
Design : Prospective pilot observational feasibility study
Tenure : Dec 2005 to Aug-2008
StudyPopulation :
47 infants undergoing Arterial Switch operation for dTGA.IVS
25 <3 weeks of age - “early” group, 22 >3 weeks of age – “late” group
Surgery :
Standard surgical techniques
Efforts to minimize myocardial ischemia - Aortic cross clamp time minimized
Evident or anticipated hemodynamic instability: Sternum kept open
LCOS management due to primary LV failure in the ICU :-
Standard, inexpensive modalities ( evidence based)
Aggressive afterload reduction - Phenoxybenzamine
Inotropy : Algorithm based -Upgraded on the basis of
Clinical
Hemodynamic
Biochemial
Serial Echos
1st line drug : Dobutamine
2nd line drug : Milrinone
Vasoactive supports – nitroglycerine
Adjuvant strategies
Calcium infusion
Cortcosteroid use
Thyroxine supplementation for hypothyroidism
Nasopharyngeal CPAP for LV dysfunction
P > 0.05
The ventilatory requirement , ICU stay and nasal CPAP requirement was comparable
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Conclusion
Pilot Study
Suggests that primary arterial switch is feasible in infants > 3 weeks of age using simple, inexpensive ICU strategies.
Preliminary observations - need to be validated in larger group of older infants to decide “How old is safe” in our country ?
Acknowledgements
We are thankful to our nursing staff for their selfless patient care and to our fellow doctors who helped us perform this study.
The duration of hospital stay and the inotrope score were similar in both the groups