Sameh R. Ismail

Early outcome of tetralogy of Fallot repair in the current era of management

BACKGROUND Traditional use of trans-annular patch (TAP) to release right ventricular outflow tract (RVOT) obstruction during tetralogy of Fallot (TOF) repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve (PV) function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function. METHODS A retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group (A) which include patients who had TAP without a valve. Group (B) includes those who had TAP with a monocuspid valve (Contegra). We compared post-operative care and outcome of all groups. RESULTS Eighty-three patients fulfilled the study criteria. There were 64 cases (77%) in group I, and 19 cases (23%) in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups. CONCLUSION Children undergoing TOF repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques.

Effects of protocol-based management on the post-operative outcome after systemic to pulmonary shunt

Objectives Systemic to pulmonary shunt (commonly known as Modified Blalock-Taussig shunt) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lungs. Based on the most recent risk stratification score, the mortality and morbidity of this procedure is still high especially in neonates and over-shunting patients. We developed and implemented protocol-based management in March 2013 to better standardize the management of these patients. The aim of this study is to evaluate the effects of applying this protocol-based management in our center. Methods We conducted a retrospective cohort study through chart review analysis.We included all children who underwent MBTS from January 2000 till December 2015. We compared the early postoperative outcome of patients operated after the protocol-based management implementation (March 2013 till December 2015) (protocol group) with patients operated before implementing the MBTS protocoled management (control group). Results 197 patients underwent MBTS from January 2000 till December 2015. Of the 197 patients, 25 patients were in the protocol group and 172 patients were in the control group. There was a significant improvement in the postoperative course and less morbidity after protocoled management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, intensive care unit ICU stay and significantly lower postoperative complications in the protocol group. Mortality of the control group versus protocol group (19.3% VS 8%) with Standardized Mortality Ratio (SMR) dropped from 2.27 before protocoled management to 0.94 after protocoled management (protocol group). Conclusion The study suggests that protocoled management of patients with MBTS can improve the postoperative course and early outcome.

5. Effect of protocol-based management for systemic to pulmonary shunt operations

Abstract Type Clinical research. Presentation Type Oral presentation. Introduction Systemic to pulmonary shunt (commonly Modified Blalock-Tausing shunt – MBTS) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lung (1). Based on most recent risk stratification STAT score, the average mortality is still high (8.5%) in addition to significant post-operative morbidity especially in the neonatal and over-shunting patients. We developed and implemented protocoled management in March 2013 to better standardize the management of these patients. Aim of this study to evaluate the effect of applying this protocoled management in our center. Methodology We conducted a retrospective Cohort study through chart review analysis of all children who underwent MBTS since year January 2000 till December 2015, We compared the early postoperative outcome of patients operated after the protocol management implementation (March 2013 till December 2015) (group A) with patients operated before implementing the MBTS protocoled management (group B). Results 197 patients underwent MBTS since year 2000 till December 2015, 25 patients after the implementation the protocol management (group A), and 172 patients before the protocol implementation (group B). There was a significant improvement in the postoperative course and less morbidity after protocol management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, and postoperative complications were all significantly lower in (group A). Mortality group A versus group B (15.7% VS 8%). Based on STAT score, the standardized mortality ratio (SMR) dropped from 1.84 before protocol implementation to 0.94 after protocol implementation. Conclusion The study proves that protocol management of patients with MBTS can improve the postoperative course and early outcome.

253: EFFECT OF NUTRITIONAL STATUS OF CHILDREN WITH CONGENITAL HEART DISEASE ON POST-OPERATIVE OUTCOME

Learning Objectives: Children with congenital heart disease (CHD) frequently get malnourished due to many factors including hypermetabolic state, inadequate caloric intake, malabsorption, genetic factors and fluid restriction as part of hemodynamic intervention. This nutritional status may affect the early postoperative outcome after pediatric cardiac surgery Methods: Prospective observational cohort study included all pediatric cardiac surgery patients over 2 yr. nutritional status assessed preoperatively according to Waterlow classification and calculated prognostic nutritional index (PNI). The following end points were recorded: patients NPO days, number of days to achieve Recommended Daily Allowance (RDA), weight gain /loss during ICU stay, ICU mortality, PCICU length of stay, hospital length of stay, ventilation hr and rate of infection. Results: 85 children were evaluated. At admission 36.4% (31/85) of the patients were severely malnourished. The usual intake was < 50 % of RDA at admission in 37.6% and was associated with severely malnutrition (P = 0.0001). Mean of the PNI was worse in the infected patients compared to the non-infected (P = 0.017). Comparing severely malnourished (n=31) to rest of our study population (n=54), the mean length of hospital stay was 22.84 ± 25.95vs20.67 ± 14.71 days; (95% CI -6.84–17.37P 0.038). Length of ICU stay was 13.27 ± 37.26 vs 7 ± 6.75 days, (95% CI -4.36–16.89P = 0.014). Patients with severe malnutrition were kept NPO longer postoperatively with mean 3.40 ± 5.56 vs 1.82 ± 1.45 days,(95% CI -0.05–3.21-P= 0.003). Delay in feeding postoperatively were associated with higher risk of infection (P =0.03). No statistically significant relation between mortality or ventilation hr in ICU and the malnutrition category of the patients Conclusions: Children with CHD were significantly malnourished preoperatively and had further loss in weight postoperatively. Delayed postop feeding was associated with higher rate of infection. Management by “specialized pediatric nutritionist” during outpatient visits and during hospital stay may optimize the nutritional status perioperatively.

PO-0032 Urinary Tract Infection In Children After Cardiac Surgery: Incidence, Risk Factors And Outcome

Introduction Urinary tract infection (UTI) can prolong hospitalisation, and increase morbidity. Catheter associated UTI (CAUTI) is a major cause of UTI. Objective To determine the incidence, risk factors, aetiology and outcome of UTI in postoperative cardiac children. Patients and methods This is retrospective cohort study. All post-operative patients admitted to PCICU during 2012 were included. Patients were divided into: group (1) Patients who developed and group (2) patients who did not develop UTI. The two groups were compared for demographic and other variable predictors for UTI. Results 413 post-cardiac surgical children were included. Group (1) had 29 patients (7%) all had CAUTI. Foley catheter utilisation ratio was 44%. CAUTI density rate was 18 per 1000 catheter days. Logistic regression analysis demonstrated that risk factors for developing UTI were: duration of Foley (p < 0.002), associated syndrome (p = 0.01) and prolonged PCICU and hospital stay (p < 0.05). Gram-negative were responsible for 63% and Candida for (24%) of the CAUTI. ESBL caused 30% and MDRO caused 10% of our patients CAUTI. Conclusion Foley catheter duration, presence of syndrome and prolonged PCICU and hospital stay were the main risk factors for CAUTI in postoperative paediatric cardiac patients. Resistant Gram-negative were the main cause for CAUTI with one third of CAUTI cases caused by MDRO or ESBL organisms. The cases with CAUTI were generally sicker and with more morbidity. The study will establish a baseline clinical indicator for monitoring quality improvement and the future measures to minimise CAUTI incidence, and its co-morbidity.

803 Effect of Body Weight on the Outcome of Ventricular Septal Defect Repair

Introduction Low body weight and failure to thrive (FTT) often are considered limiting factors for open heart surgery. The purpose of our study is to asses the impact of FTT on ICU outcome of children undergoing Ventricular septal defect repair. Methods A retrospective Study including all children less than 2 years who had VSD closure by open heart surgery during the period 2002–2010. Children were divided into 2 groups based on their weight for age using standard growth charts. Those with normal or mild failure to thrive (Z score > –3) are labeled as group A. group B included all children with severe failure to thrive (Z score ≤ –3). Both groups were compared in term of all operative and early post-operative outcome parameters. Results 145 patients were included. 58 cases in group A and 87 patients in group B. The age and weight in group A was (8±5.16 months) and (6.31±1.75 kg) respectively. The age and weight in group B was (7.6±3.9 months) and (4.84±1.12) kg respectively. There were no significant differences between the 2 groups in term of post operative mortality or morbidity. Conclusion Failure to thrive can complicate congenital heart diseases (CHD) associated with significant left to right shunt and heart failure. FTT was not associated with increase in ICU morbidity or mortality. Attempt to optimize the body weight for age in children with CHD may not add any beneficial advantages in term of surgical risk or postoperative ICU outcome.

1659 Post - Operative ICU Course of Infant Below 2.2 Kg Undergoing Cardiac Surgery

Introduction Infants with low body weight (LBW) are major challenges for post cardiac surgery care. We conducted this study to compare post-operative course and outcome of infant weighing 2.2 Kg or less with matching group of infants with normal body weight who underwent similar cardiac surgery. Methods We reviewed retrospectively all infants below 2.2 kg who underwent cardiac operation at our institution from January 2001 to March 2011. Cases with LBW (group A) were compared with matching group (Group B) of normal body weight infants who had similar cardiac surgery and matching surgical risk category. We compared demographic, ICU parameters, complications and short-term outcome of both groups. Results Thirty seven patients were included in group A and 39 in group B. Except for Weight (2.13±0.08 kg in Group A vs. 3.17±0.2 kg in group B); there was no statistical difference in demographic data between both groups. Cardiac procedures included coarctation repair, Arterial switch, VSD repair, tetralogy of Fallot repair, systemic to pulmonary shunt and Norwood procedures. Patients in group A had statistically significant difference from group B in term of bypass time (p =0.01), duration of inotrops (p=0.01), duration of mechanical ventilation (p=0.004), number of re-intubations (p = 0.015), PCICU length of stay (p =0.007) and mortality (13.5% in group A vs. 0% in group B, p value 0.02). Conclusion Patients with LBW below 2.2 Kg can go for cardiac surgery with overall satisfactory result but with increase risk of ICU morbidity and mortality.

1664 Impact of Chylothorax on the Post Operative Outcome after Pediatric Cardiovascular Surgery

Background Chylothorax is the accumulation of Chyle in the pleural cavity, usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases this rupture is secondary to trauma (including cardio thoracic surgeries). Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. Methods A retrospective study of all cases Complicated with Chylothorax after pediatric cardiac surgery in King Abdulaziz Cardiac Center between January 2007 and December 2009 was conducted. The study aim to determine the risk factors, and the impact on the post operative course. Results We have 1135 cases operated during the study period, 57 cases (5%) were complicated with chylothorax in the post operative period, The most common Surgeries complicated with chylothorax were the single ventricle repair surgeries (Glenn- Fontan) 15 cases (27%), followed by the arch repair cases 10 cases (18%), the ventricular septal defect cases 10 cases (18%), the Atrioventricular septal defect cases 7 cases (12%), the arterial switch cases 6 cases (11%), and others 8 cases (14%). The ICU stay, the length of hospital stay and the bypass time were significantly longer in the chylothorax group, also the ventilation time, the inotropes duration and number were higher in the chylothorax group. Conclusion Chylothorax after pediatric open heart surgery is not an uncommon complication, it Occurs more commonly with single ventricle repair and Aortic arch repair surgeries, it has a significant impact on the post operative course and post operative morbidity.