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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.

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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

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)

Introduction

Results

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 rescueIn 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

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

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

Captions to be set in Times or Times New Roman or equivalent, italic, between 18 and 24 points. Right aligned if it refers to a figure on its right. Caption starts right at the top edge of the picture (graph or photo).

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