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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
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 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
Significant LV dysfunction was more in the late group but pre-discharge LV dysfunction was similar
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
LV status of the late group: :
Setting : 10 bedded PICU, ~ 600 cases/year
Design : Prospective pilot observational feasibility study
Tenure : Dec 2005 to Aug-2008
47 infants undergoing Arterial Switch operation for dTGA.IVS
25 <3 weeks of age - “early” group, 22 >3 weeks of age – “late” group
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
1st line drug : Dobutamine
2nd line drug : Milrinone
Vasoactive supports – nitroglycerine
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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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 ?
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