Transcript Document

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
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
Aim
Pilot , feasibilty study
70
Demographic data
Variables
Early switch group
N = 25
9 (3-18)
72/28
Mean Age (days)
Sex M/F ( %)
Late switch group
N = 22
55 (22-149)
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%)
1(4%)
Vasoactive supports – nitroglycerine
50
40
40
24
30
20
22.7
20
4
10
0
Steroid
Sepsis
Arrythmia
Early Group
Renal Injury *
Late Group
P.O. LV Dysfunction
Significant LV
dysfunction was more in
the late group but predischarge LV
dysfunction was similar
15(68%)
5(22.7%)
2(9.1%)
0(0%)
100
90.9
80
68
60
45.5
40
20
20
12
9.1
9.1
Early Group
Late Group
0
PO LV Dysfn Signf. LV
dysfn *
Early switch group
N = 25
132.6
(21.6)
61.5
(8.0)
1(4%)
Bypass time(min)
Mean(SD)
Cross clamp time(min)
Mean (SD)
Need for re-bypass(%)
Supportive bypass(%)
Deferred sternal closure(%)
1(4%)
13(52%)
Late switch group
N = 22
136.9
(20.8)
63.6
(11.4)
1(4.5%)
1(4.5%)
10(45.4%)
PreDischarge
LV dysfn
Captopril
Req
LV status of the late group: :
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
P > 0.05
140
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In-hospital mortality : comparable in both groups
131
120
100
80
60
40
20
95
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Right aligned if it refers to a figure
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The ventilatory requirement , ICU
stay and nasal CPAP requirement
was comparable
43
Early switch group: 2/25 (8.0%)
Late switch group : 1/22 (4.54%)
(p = 0.6)
38.5
0
Ventilatory req.
ICU stay
Early Group Late Group
Nasal CPAP Req
Pilot Study
Suggests that primary arterial switch is feasible in infants > 3
weeks of age using simple, inexpensive ICU strategies.
30
25
27.5
26
Preliminary observations - need to be validated in larger group of
older infants to decide “How old is safe” in our country ?
20
15
Adjuvant strategies
Calcium infusion
Cortcosteroid use
Thyroxine supplementation for hypothyroidism
Nasopharyngeal CPAP for LV dysfunction
The incidence of
arrhythmias, sepsis as well
as steroid requirement was
comparable but renal injury
was higher in early switch
group.
68.1
0
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
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
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60
Operative Data
Methods
Methods
76
% Patients
Surgical management of TGA.IVS in older infants remains contentious
Regressed LV mass with age
?? Less capable of sustaining systemic circulation after arterial switch
Results
% patients
Introduction
80
10
5
0
Inotrope Score
Early Group
LateGroup
The duration of hospital stay and the inotrope score were similar in both the groups
Acknowledgements
We are thankful to our nursing staff for their selfless patient care and to our
fellow doctors who helped us perform this study.