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Table of Contents   
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 103-109
Selected abstracts presented at the Annual Conference of the Pediatric Cardiac Society of India, 2011

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Date of Web Publication12-Mar-2012

How to cite this article:
. Selected abstracts presented at the Annual Conference of the Pediatric Cardiac Society of India, 2011. Ann Pediatr Card 2012;5:103-9

How to cite this URL:
. Selected abstracts presented at the Annual Conference of the Pediatric Cardiac Society of India, 2011. Ann Pediatr Card [serial online] 2012 [cited 2019 Apr 25];5:103-9. Available from:

Selective cerebral perfusion using innominate artery cannulation for repair of aortic arch anomalies in neonates and infants

KVSS Saikiran, G Mannam, R Shastri, R Geetanjali, R Shetty, S Vyas, N Rao, AK Dharmapuram

Star Hospitals, Hyderabad, India

Aim: To use selective cerebral perfusion for avoiding deep hypothermic circulatory arrest in the repair of aortic arch anomalies in neonates and infants. Methods: From November 2009 to July 2011, seven neonates and ten infants (total n=17) underwent one stage repair of aortic arch anomalies with intracardiac defects using selective cerebral perfusion with innominate artery cannulation. The arch anomaly was an interruption in six and a coarctation with hypoplasia of the arch in the remaining. The associated defects were perimembranous ventricular septal defect (VSD) (5), apical muscular VSD (2), doubly committed VSD (1), multiple muscular VSD (1), aortopulmonary window (2), Taussig-Bing anomaly and sub-pulmonic VSD, requiring arterial switch operation and VSD closure (2), and ostium primum atrial septal defect (ASD) (1). One neonate had an associated supracardiac total anomalous pulmonary venous connection (TAPVC). One two-month-old infant had a univentricular heart, with a bulboventricular foramen, with the aorta coming from the outflow chamber and associated with coarctation and hypoplasia of the arch (pulmonary artery (PA) banding was done after the arch repair). Only one case (10-month-old infant) had isolated coarctation of the aorta, with diffuse arch hypoplasia, without intracardiac defect. Results: There was no operative mortality. There was one late death of the infant with multiple VSD, due to persistent pulmonary arterial hypertension (PAH), in view of moderate mitral stenosis. Postoperative echocardiography confirmed normal cardiac function and unobstructed arch repair in all the patients. There were no neurological complications. Conclusions: Selective cerebral perfusion with innominate artery cannulation for arch repair is an excellent method to avoid neurological and myocardial complications, without mortality. The major advantage of the technique is the feasibility to perform a wide end-to-side anastomosis of the descending aorta to the ascending aorta and the undersurface of the arch.

Nonspecific aortoarteritis presenting as acute decompensated heart failure in children: Immediate and short-term outcome of percutaneous transluminal renal angioplasty

MJ Varghese, S Ramakrishnan, S Salahuddin, K Sharath, S Gupta, SS Kothari, A Saxena, S Sharma, R Juneja, G Gulati, P Jagia, VK Bahl

All India Institute of Medical Sciences, New Delhi, India

Background: Nonspecific aortoarteritis (NSAA) results in stenotic lesions of the aorta and its major branches. We are reporting a series of children with NSAA, presenting with acute decompensated heart failure due to isolated renal artery narrowing. Methods: Twenty-three patients of NSAA, with hemodynamically significant renal artery stenosis, who presented with acute decompensated heart failure, over a period of three years (2007 to 2010), were included in this retrospective analysis. Patients presenting with acute decompensated heart failure due to abdominal aortic narrowing were excluded. Three patients were intubated and mechanically ventilated for acute decompensated heart failure. These patients underwent percutaneous transluminal renal angioplasty on an emergent/urgent basis for significant stenosis of renal arteries. The acute procedural results and improvements in clinical status and left ventricular function are reported herewith. Results: The mean age of the patients was 10.69 years (range 4-17 years). Hypertension was present in all these patients, and all had significant left ventricular dysfunction, with a mean left ventricular ejection fraction of 29.56%. Importantly, none of the patients had an established diagnosis of NSAA, and most of them had palpable and equal peripheral pulses. Procedural success with renal artery balloon angioplasty was 100% and no stents were used. The blood pressure fell immediately from 174/103.5 to 140/86 mmHg (P<0.01) and the left ventricular ejection fraction improved from 29.5% to 36.7% (P=0.07). An immediate improvement in left ventricular ejection fraction (LVEF) was seen in 11 patients and four of them had normalization of LVEF. Importantly, all the patients survived and all of them had an improvement in their clinical status. Twelve patients (52%) had evidence of disease activity, as judged by the established criteria. Conclusion: Isolated acute renal artery involvement occurs in NSAA and may lead to acute decompensated heart failure in children. A high index of suspicion is needed for its recognition. Angioplasty of the renal arteries is safe and successful, and aids in the recovery from acute decompensated heart failure.

Serum brain natriuretic peptide levels and myocardial performance indices after repair of tetralogy of fallot

Y Sathe, R Subramanyan, P Sekar, C Shanthi, R Agarwal, KM Cherian

Frontier Lifeline and Dr. KM Cherian Heart Foundation, Chennai, India

Background: The outcome after correction of Tetralogy of Fallot (TOF) can be influenced by myocardial dysfunction. We tried to correlate the serum Brain Natriuretic Peptide (BNP) levels and myocardial performance indices (MPI) by Tissue Doppler Imaging (TDI) and 2-D Doppler in the perioperative period, with an outcome. Methods: Thirty-three patients with TOF (age <18 years) underwent repair. The MPI were calculated by TDI and 2-D Doppler preoperatively, and on the first and seventh postoperative days. The serum BNP levels were simultaneously estimated. The TDI-MPI, 2D-MPI, BNP values, ventilation duration, Intensive Care Unit (ICU), and hospital stay were compared. Results: The preoperative BNP levels were abnormally elevated in 25 out of 33 patients. This showed a significant need for a transannular patch (two out of eight patients vs. 18 out of 25 patients, respectively). High preoperative BNP levels and abnormal 2D MPI also showed a significant association with postoperative morbidity, while preoperative TDI-MPI did not. Postoperatively, BNP increased in all patients on day one. This was accompanied by a marked increase in TDI-MPI, while the 2D MPI did not change much on day one. Conclusion: High preoperative BNP values and abnormal preoperative 2D MPI values significantly predicted an adverse clinical outcome. High preoperative BNP values also significantly suggested the need for a transannular patch.

Echocardiographic screening for congenital heart disease among 6270 asymptomatic school children in India - The rheumatic (rheumatic heart echo utilization and monitoring actuarial trends in Indian children) study

A Saxena, S Ramakrishnan, A Roy, S Seth, A Krishnan, P Misra, M Kalaivani, B Bhargava, M Flather, P Poole-Wilson

All India Institute of Medical Sciences, New Delhi, India and Royal Brompton Hospital and Imperial College, London

Purpose: The prevalence of echocardiographically detected congenital heart disease (CHD) among asymptomatic school children in India is not known. Conventionally, auscultation has been used for community screening for CHD, but echocardiography with Doppler may be more sensitive and specific. Methods: We carried out a cross-sectional survey to diagnose heart defects in asymptomatic school children of age between five and fifteen years, living in rural areas, using portable echocardiography. The demographic data was collected. After a history and physical examination, the echo-Doppler was performed, using a bedside portable echocardiography machine. Results: A total of 6270 asymptomatic children were screened, of whom 52% were male. The mean age was 10.79 ± 2.63 years. Echo-Doppler diagnosed CHD in 45 cases, giving a prevalence of 7.2/1000 school children (90% CI - 5.1 - 9.3/1000 children). The cardiac lesions identified by the echo-Doppler included: atrial septal defect (19 patients), bicuspid aortic valve with regurgitation (nine patients), ventricular septal defect (four patients), and patent ductus arteriosus (five patients). Two patients with operated Tetralogy of Fallot (TOF), one patient with unoperated TOF, one with Eisenmenger syndrome, and one with ventricular septal defect, with aortic regurgitation, were identified. All the lesions requiring surgical interventions were also identified clinically. Only two out of the 15 patients needing a surgical or interventional therapy had undergone the same. Conclusions: The study establishes the community prevalence of CHD in India. All the lesions requiring an intervention are also identifiable by careful clinical examination. A majority of patients needing a definite intervention have not undergone the same in rural India.

Levosimendan versus milrinone after corrective open-heart surgery in children

M Jadhav, P Bobhate, S Garekar, B Radhakrisshnan, Ranganathan, SR Mohanty, S Kulkarni, SG Rao

Children's Heart Center, Kokilaben Dhirubhai Ambani Hospital, Andheri (West), Mumbai, Maharashtra, India

Introduction: Levosimendan has been shown to improve cardiac function and hemodynamics in adults. After open-heart surgery in neonates and infants, the low cardiac output syndrome (LCOS) commonly complicates the postoperative course and is associated with poor outcome. The aim of our study is to evaluate whether levosimendan is superior to milrinone after open heart surgery in children. Methods: It is a retrospective study. All children (up to 18 years) operated at our center, from June 2011, and received levosimendan were selected. They were compared with patients receiving milrinone in the postoperative period. Results: A total of 14 patients were selected. The levosimendan group age range was two days to 17 years and in the milrinone group it was three days to 10 years. The weight in the milrinone group was between 2.8 and 30.8 kg and in the levosimendan group it was 2.2 to 44 kg. The mean duration of inotropic requirement was 3.14 days (75.3 hours) for the levosimendan group and it was 2.8 days (67.2 hours) for the milrinone group. The mean duration of Intensive Care Unit (ICU) stay was 4.4 days (105.6 hours) for the milrinone group versus 4.7 days (112.8 hours) for the levosimendan group. The ionotropic step up was not required for the milrinone group, while the levosimendan group required it in 21% of the cases. Conclusion: The mean duration of ionotropic support and ICU stay were marginally more in the levosimendan group. The step up of ionotropic support was required in the Levosimendan group. Levosimendan was not superior to milrinone in the children, after cardiac surgery. A large randomized controlled trial is required to evaluate the role of levosimendan in children, post cardiac surgery.

Palliative arterial switch operation in the context of multiple ventricular defects, potentially biventricular and univentricular hearts with malposed great arteries: A review of fifteen cases

A Katewa, S K Kaushal, R Sharma, AMarwah, V Singh

Pediatric Cardiac Surgery, Fortis-Escorts Heart Institute, New Delhi, India

Background: This study is an examination of our Unit's experience with performing palliative switch in univentricular and potentially biventricular hearts, with transposition of great arteries. Methods: Fifteen patients underwent a palliative arterial switch operation over the period of January 2008 to April 2011, at the Fortis-Escorts Heart Institute, New Delhi. The follow-up data was obtained from the medical records and via correspondence with the patients and/or their cardiologists. Results: These patients were divided into three groups based on their physiology. (a) Single ventricle physiology (8). All patients had univentricular hearts, transposition of great arteries, and systemic outflow tract obstruction (SOTO). The conventional approach is the Norwood procedure or its modification or a Damus-Kay-Stansel (DKS) operation. An arterial switch is being recognized as an alternative. An arterial switch in these patients effectively converts the SOTO to pulmonary stenosis and provides a restriction to pulmonary blood flow. The pulmonary blood flow was further regulated, if required, with pulmonary artery banding. Two patients (25%) died on POD126 and POD14, respectively. Five patients (62.5%) have undergone second stage palliation in the form of Bidirectional Glenn and the remaining one is awaiting surgery. (b) Borderline biventricular physiology (4). These patients had transposition of great arteries, ventricle septal defect/s and hypoplastic right ventricles, with a small tricuspid valve orifice. They underwent the arterial switch operation with pulmonary artery banding, without ventricular septation. One patient also underwent repair for associated coarctation of the aorta. One patient died secondary to small bowel gangrene and delay in diagnosis and surgery for the same. One patient required pulmonary artery band revision in view of failed extubation. One patient had subsequent one-and-a-half ventricle repair and the remaining two are awaiting evaluation and subsequent management. (c) Biventricular physiology (3). These patients had transposition of great arteries and multiple ventricular septal defects, which could not have been closed successfully without a mutilating ventriculotomy and consequent ventricular dysfunction. The second option was atrial septectomy and pulmonary artery banding, and deferring corrective surgery for later. The arterial switch with a pulmonary artery band was superior because it converted the transposition physiology to a ventricular septal defect (VSD) physiology, which allowed effective banding, without increasing the cyanosis.All patients made an uneventful recovery. One of them underwent subsequent VSD closure and pulmonary artery plasty. The remaining two are asymptomatic and awaiting corrective surgery at the appropriate time. Conclusions: The palliative arterial switch appears as a reasonable surgical option for patients with functional single ventricles, transposition of great arteries, and SOTO. The advantage over the conventional Norwood procedure and modifications thereof is that it provides a valved ventricular-pulmonary artery connection, and thereby prevents diastolic run off.

The arterial switch is definitely a safer option for patients with transposition of great vessels and multiple VSDs. Later, some defects may have closed spontaneously, or even if they have not, a right ventriculotomy is better tolerated in a grown up child. It also entails lesser potential damage to the tricuspid valve structure, conduction bundle, and the like. Patients with hypoplastic right ventricles can be safely palliated with the arterial switch and can be followed up for a potential biventricular repair. The option of a single ventricle repair or a one-and-a-half repair is also available in the event that the right ventricle and/or tricuspid valve sizes are deemed inadequate.

Stent implantation of arterial ductus for duct-dependent pulmonary circulation in infants with complex congenital heart disease: Short-term and long-term results

P Shunmugasundaram, S Bijulal, KM Krishnamoorthy, S Sivasankaran, T Titus, JM Tharakan, S Harikrishnan, N Namboodiri, T Anees, G Sanjay, Venkateshwaran

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

Background and Objective: Percutaneous ductal stenting for infants with duct-dependent pulmonary circulation avoids the complication of surgical aortopulmonary shunts. The aim of our study is to evaluate the safety, efficacy, and feasibility of ductal stenting in patients with ductal dependent pulmonary circulation and its short-term and long-term follow-up. Methods: Between September 2007 and July 2011, 19 patients underwent ductal stenting for complex congenital heart disease in our institute. The age group of the patients ranged from two days to 165 days (mean 33.6 ± 38.2 days; median 22 days) and the mean weight was 2.84 ± 0.54 kg. The patients included had complex congenital heart disease including pulmonary atresia (PA) with ventricular septal defect (VSD) (five), PA with intact ventricular septum (five), single ventricle physiology with PA (three), D-TGA with VSD with PA (three), Unbalanced atrioventricular (AV) canal defect with pulmonary atresia (two), and Tetralogy of Fallot (TOF) with severe subvalvular PS (one). Most of the patients had a tortuous or S shaped ductus arising from the undersurface of the arch. Forty-seven percent (nine patients) had pulmonary coarctation (pulmonary artery constriction at the insertion site of the patent ductus arteriosus (PDA)). Results: Eleven patients underwent the procedure via the axillary approach and eight via the femoral approach. The axillary approach was attempted ipsilateral to the side of the arch, but changed over to the contralateral side when the attempt failed. Saturation increased from a mean value of 54.6% to 78.6% after the procedure. The follow-up period varied between two months and 96 months. The number of stents used per patient varied from one to four (1.42 ± 0.76 per patient). A procedural success was achieved in 68.4% (13/19). The pulmonary end of the ductus could not be covered in three patients, of whom two patients died and the other underwent emergency Blalock-Taussig (BT) shunt. The aortic end could not be covered in two patients, as they required an emergency BT shunt in both. Stent migration (into RPA) occurred in one patient, wherein surgical retrieval was followed by a BT shunt. One patient developed stent thrombosis (5%) as the pulmonary end was not covered. In-stent restenosis occurred in two patients (10.5%). Stent patency was achieved for a mean period of 156.76 days (three hours to 482 days; median 113 days). Re-intervention in the form of an aortopulmonary shunt was necessary in four patients. Six patients underwent successful completion of the Bidirectional Glenn (BDG) procedure and one underwent corrective surgery. One patient is awaiting biventricular repair. Six patients died after the procedure (31% overall mortality) and one died after second-stage surgery (BDG). Early mortality occurred in three patients (15.7%), of which one was due to sepsis. All three mortalities occurred in patients with weight <2.6 kg. Late mortality on follow-up occurred in four patients, of whom one died after BDG, due to sepsis. Fifty-seven percent of the total mortality occurred in neonates of <2.6 kg, on admission. The overall survival rate in this cohort of complex cyanotic congenital heart disease was 65%. Conclusions: Ductal stenting in infants is an effective alternative to the invasive aortopulmonary surgical shunts. Growth of the pulmonary vascular bed allows corrective or palliative surgery at a later stage. Infants below the weight of 2.6 kg are at higher risk for this procedure. Covering both the aortic and pulmonary ends of the ductus arteriosus is crucial for its success.

What we learnt from 'quality of life assessment' in grownups with congenital heart defects and its probable reflection of the Indian perspective

S Chidambarathanu, V Basra, F Farzana, R Subramanyan, KM Cherian

Frontier Lifeline Hospital, Chennai, India

Aim: We are facing an increasing volume of grownups living with corrected and uncorrected congenital heart diseases (CHD) in recent years. 'Quality of life' (QOL) studies are being done in various centers with the intention of providing comprehensive care to this population. We present here what we observed with the use of a modified QOL study. Methods: One hundred patients who were resident Indians, above the age of 18 years, with CHD, who visited our Outpatient Department from January 2010 to January 2011, comprised the study population. The QOL study contained a questionnaire based on international studies, but modified to suit our population. The domains assessed were Marital, Social, Emotional, Medical, Educational, Employment, and Perception. Priorities in life were also noted. It was carried out by a clinical psychologist with prior oral consent. Appropriate psychological counseling was given by the end of the study. The clinical variables were age, gender, type of defect, age at diagnosis, initial diagnosis, disease severity, mode of treatment, type of surgery, age at surgery, current oxygen saturation, ability index, and functional index. Social variables were marital, educational, and employment status. Results: Cyanotic heart defects, current saturation below 85%, palliative surgery, severe initial diagnosis, high disease severity, a low ability index, and a low functional index showed a significant difference under the marital domain. Saturation below 85% and a low functional index showed significant difference in perception. No variable showed a significant influence in other domains. Family was considered to have the highest priority (54.5%), followed by health, job, friends, and spirituality. Conclusions: This study threw more light into the difficulties and perceptions of our grownup population with CHD. Premarital counseling and social support would play a greater role in rehabilitating this group. Incorporation of psychological counseling in the routine care and national level rehabilitative policies need to be considered.

Natural history of residual ventricular septal defect detected by transesophageal echo

B Chavan, A Mehta, D Changlani, PS Lal, TD Changlani, R Varghese, R Suresh Kumar

Madras Medical Mission, Chennai, India

Background: Routine Transesophageal Echo (TEE) is a standard practice to monitor congenital heart surgery in all leading institutions. A residual ventricular septal defect (VSD) is a common TEE finding in such a surgery. The subsequent outcomes of such defects have not been studied in detail. Methods: During the period January 2008 to December 2009, 197 patients underwent TEE for a surgery involving VSD closure as the only procedure or part of a complex procedure (e.g., Tetralogy of Fallot, AV canal repair). Intraoperative TEE and subsequent transthoracic echocardiographic examinations were performed using Phillips Sonos 5500 and IE 33 ultrasound systems, respectively [Phillips, Andover, MA]. A residual VSD was considered small if it had a flow jet ≤ 3 mm in width, as measured on the left ventricular septal side. A defect would be considered moderate if it measured 3 to 5 mm in diameter of the color flow jet width, whereas, a large defect was any defect measuring equal to or more than 5 mm of the color jet width. These patients were followed up by a repeat TEE, if they went back on bypass and repeat transthoracic echo before discharge and one year thereafter. Results: Out of the total of 197 patients (M: F - 2: 1; age range - 1 month to 47 years) who underwent surgery for VSD closure, 84 (42%) were simple VSD closures and 113 (58%) were complex VSD closures. Fifty-one (25%) patients had residual VSD`s on intraoperative TEE. Forty-five were small, five were moderate, and one defect was large. The surgeon went back on bypass for the patient with large defect and subsequent TEE showed no defect. Thirty-nine (76%) patients had residual VSD at one week, and 12 (21%) patients had a persistent defect of >3 mm at one year. There were two patients where a pre-discharge echocardiogram showed that a residual defect with TEE had failed to show any defect. No patient required surgery for residual VSD closure. Conclusions: Residual defects seen after VSD closure in TEE, in the operation theater, are generally small. Only rarely residual VSD`s need going back on bypass. In the majority, there is a decrease in the size of their defects and their eventual disappearance over the next one year.

Prevalence and outcome of subclinical rheumatic heart disease in india: the rheumatic (rheumatic heart echo utilization and monitoring actuarial trends in indian children) study

A Saxena, S Ramakrishnan, A Roy, S Seth, A Krishnan, P Misra, M Kalaivani, B Bhargava, M Flather, P Poole-Wilson

All India Institute of Medical Sciences, New Delhi, India and Royal Brompton Hospital and Imperial College, London

Background: Epidemiological studies using echocardiographic screening have reported a higher prevalence of rheumatic heart disease (RHD) in some African communities. The clinical impact of echocardiographically detected subclinical RHD is not known. The objective is to study the prevalence and the medium-term outcome of subclinical RHD in India. Methods: We carried out a cross-sectional echocardiographic screening study among 6270 randomly selected school children aged between five and fifteen years (10.8 ± 2.6 years; 52.7% male), living in the rural areas of north India. Of all the abnormal cases, 100 children (78%) were restudied at a mean follow-up of 15.4 ± 6.6 months. Results: A clinical examination detected mitral regurgitation (MR) in five patients and the estimated prevalence of clinical RHD was 0.8/1000 school children. Echocardiography-Doppler diagnosed RHD in 128 cases, gave a prevalence of 20.4/1000 school children (90% CI - 16.9 - 23.9/1000 children). On multivariate analysis, older age (OR 1.93, 95% CI -1.29 - 2.88; P=0.001), female sex (OR 1.84, 95% CI -1.25 - 2.72; P=0.002), and government funded school students, which is a surrogate measure of lower socioeconomic status, (OR 1.55, 95% CI -1.02 - 2.34; P=0.039) were found to be independent predictors of RHD. On follow-up, the severity of subclinical RHD was non-progressive in 68 children (68%), while it worsened in four (4%), and regressed in 28 children (28%). Conclusions: The prevalence of RHD is several folds higher using echocardiographic screening compared to clinical examination. The prevalence is higher among girls and children of lower socioeconomic status. In a majority of cases, subclinical RHD appears to be non-progressive on medium-term follow-up. Routine echocardiographic screening may be indicated in populations at high risk of RHD.

Immediate outcome of intracardiac repair with transannular patch, with right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocuspid pulmonary valve in tetralogy of fallot

DS Kumar, S Bijulal, BS Dharan, T Mathew, KM Krishnamoorthy, S Sivasankaran, T Titus, JM Tharakan

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

Background: The immediate postoperative outcome of intracardiac repair in Tetralogy of Fallot with no significant residual right ventricular outflow tract (RVOT) obstruction or ventricular septal defect (VSD) is governed by pulmonary regurgitation (PR) and RV function. Reconstruction of RVOT with a monocuspid pulmonary valve prevents pulmonary valve insufficiency, especially in the immediate postoperative period. We have used 0.1 mm Polytetrafluoroethylene (PTFE) for RVOT reconstruction. The aim of this study is to assess the immediate postoperative outcome of this surgery. Methods: Twenty-four patients who underwent intracardiac repair (ICR)with monocuspid valve repair from May 2011 to July 2011 were studied. 2-D echocardiography was performed before and after surgery. The levels of obstruction in the RVOT, pulmonary valve, pulmonary artery, and the branches were determined. The dimensions of pulmonary annulus, main pulmonary artery, and right and left pulmonary arteries just before the first branch were determined and the McGoon index calculated. Presence and severity of pulmonary and tricuspid regurgitation was assessed. Right ventricular (RV) dimensions in systole and diastole and the presence of major collaterals and abnormal coronary arteries were noted. Morphology of the pulmonary valve was determined at surgery and any unidentified substrate noted. Results: The median age at surgery was 36 months (range 3 - 312 months). The mean pulmonary annulus was 8.9 mm and the mean Mc Goon index was 1.8. Five patients had branch pulmonary artery (PA) stenosis (all had left pulmonary artery (LPA) origin stenosis) and five had supravalvar main pulmonary artery (MPA) narrowing and one patient had both. The mean cardiopulmonary bypass (CPB) time was 182 minutes and aortic cross clamp (ACC) time was 121 minutes. The mean pulmonary outflow gradient after surgery was 21.9 mm Hg. Three patients had a tiny residual VSD. Two patients had moderate PR and none had severe PR. One patient had postoperative right ventricle (RV) failure (not related to PR). Mean hospital stay was eight days. Out of the 24 historical controls of TOF with a transannular patch and without monocuspid valve repair, 12 had moderate PR and two had severe PR, in the immediate postoperative period. They were found to have a mean CPB time of 148 minutes, ACC time of 95 minutes, and mean hospital stay of 8.8 days. Conclusion: ICR with monocuspid pulmonary repair appears to reduce immediate postoperative PR, thereby reducing postoperative morbidity.

Two-ventricle repair for complex congenital heart defects that are palliated toward single ventricle repair

PK Brijesh, SH Mohanty, GS Sunil, K Mahesh, B Vaidyanathan, E Francis, R Balachandran, SG Nair, R Krishna Kumar

Departments of Pediatric Cardiovascular Surgery, Pediatric Cardiology, and Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Cochin, Kerala, India

Background: Complex congenital heart defects that present earlier in life are sometimes channeled toward a single ventricle repair, demanded by anatomical or logistic challenges required for two-ventricle correction. In view of the long-term functional and survival advantage, we have been consciously exploring the feasibility and outcome of a biventricular repair in these patients when they present later for Fontan completion. Methods: Since June 2009, 52 patients were referred for staged completion of the Fontan procedure. Following detailed evaluation, which included cardiac MRI (magnetic resonance imaging) and 3D echocardiography, seven patients (Group I - median age six years, median weight 16.8 kg) were identified and later underwent a complex biventricular repair with take down of the Glenn shunt, while completion extra cardiac-Fontan repair was performed on 45 patients (Group 2 - median age 6.5 years, median weight 18 kg). Results: Two-ventricle repair was accomplished in all seven group 1 patients. The surgical support and recovery times were longer in group 1 (mean cardiopulmonary bypass time of 361.4 vs. 154.7 minutes, mean ventilatory support of 2.1 vs. 1.6 days, and mean ICU stay of 7.4 vs. 5.7 days). One patient developed complete heart block requiring permanent pacemaker insertion. Late patch dehiscence occurred in another (awaiting repair). At a median follow-up of 11 months, there were no mortality among group 1 patients and all except for one patient were asymptomatic. There were two early deaths in group 2. Conclusion: Two-ventricular repair, although surgically challenging, should be considered in all patients with two functional ventricles, who come for Fontan completion. Comprehensive preoperative imaging and meticulous planning helps in identifying suitable candidates.

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