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Download Program and Abstracts - Asia-Pacific Pediatric Cardiac Society
Transcript
The First Asia-Pacific Congress
of Pediatric Cardiology and
Cardiac Surgery
November 1-4, 2006
Bangkok Convention Center (BCC)
Sofitel Central Plaza
Bangkok, Thailand
Program and Abstracts
Welcome Message
Message from Chairman Organizing Committee
It gives me great pleasure to welcome you to The First Asia-Pacific
Congress of Pediatric Cardiology and Cardiac Surgery which is held
during November 1-4, 2006 at Bangkok Convention Center, Sofitel
Central Plaza, Bangkok, Thailand. This year is a very important year
for Thai people to cerebrate the Sixtieth Anniversary Cerebration of
His Majesty’s Accession to the throne.
Asian Pacific Pediatric Cardiology Society was founded in 1979.
Scientific meeting was a one day program during Asia-Pacific Congress of Cardiology.
With a rapid progress in the area of pediatric cardiology, cardiac surgery and related fields,
president of national societies agreed to hold a separate meeting every two years.
We are proud to host this first meeting which was originally planned to be in Shanghai.
Our Scientific Committee has been working very hard with time frame of less than one
year trying to make this meeting beneficial to all of us.
We have invited world renowned experts as well as experts in Asia-Pacific in all area
related to the care of children with heart diseases with emphasis on problems in developing
countries in Asia-Pacific and recent advance knowledge and technology.
In addition, this congress will provide a wonderful opportunity for discussion and sharing
experiences for future co-operation.
On behalf of the Organizing Committee, I wish your staying in Thailand is an enjoyable one.
Boonchob Pongpanich, M.D., F.A.C.C.
Chairman Organizing Committee
Welcome Message
Dear all,
On behalf of the Asia-Pacific Pediatric Cardiac Society ( APPCS ) it
gives me immense pleasure to welcome you to the First Biannual
Conference of the Society to be hosted by Thailand in Bangkok.
As you are aware the Asia-Pacific society of Pediatric cardiology
was renamed the APPCS at the World Congress in Beunos Aires
with a view to encourage equal participation from cardiologists,
surgeons, intensivists, anesthesiologists, pediatricians, radiologists
and others involved in the care of children with heart disease. It was
also recognized that the current practice of having a pediatric sub-section at the biannual
meeting of the Asia-Pacific Society of Cardiology was proving inadequate and that ample
advances have occurred in the field of pediatric cardiac care in this region to merit a
separate conference. Additionally, problems and practices in pediatric cardiac care in the
Asia Pacific region differ significantly from those in the Americas and Europe. It is time
that we have a forum where we can deliberate upon and find solutions to our regional
problems.
I would like to thank our colleagues from Thailand who have readily volunteered to take
on the challenge and host the first conference at short notice. As members of the society
we should provide them with all the help and support that they need to make the conference a grand success and I urge all of you to make every effort to attend the meeting. I also
request you to pass on this information to all your colleagues involved in pediatric cardiac
care, as we are still in the early days of the new society and our database is still being
compiled.
Please feel free to respond with suggestions and comments. I look forward to seeing you
all in Bangkok.
Krishna Iyer, M. Ch.
President, Asia-Pacific Pediatric Cardiac Society
Director, Pediatric & Congenital Heart Surgery,
Escorts Heart Institute & Research Centre,
Okhla Road, New Delhi, INDIA 110025
Welcome Message
Dear friends,
On behalf of The Society of Pediatric Cardiology of Thailand, I would
like to extend all of you a very warm welcome to Thailand, the land
of smile, to participate in the First Asia-Pacific Congress of Pediatric
Cardiology and Cardiac Surgery to be held in Bangkok during
November 1-4, 2006. Besides seeing old friends and making new
friends, gaining new knowledge in the field of Pediatric Cardiology,
Cardiac Surgery and related fields from all the specialists invited to
this Congress, I hope you would find opportunities to see our
beautiful country and taste our famous food.
Table
Last but not least, I hope some of you would be able to extend your stay in Bangkok after
the Congress to enjoy our Loy Krathong festival.
I wish this Congress a very successful one and hope that it would be one of the most
memorable ones for all of us.
Have a very good time in Thailand, and … Sawasdee
Professor Emeritus Chule Thisyakorn, M.D.
President, The Society of Pediatric Cardiology of Thailand
Welcome Message
Dear Friends and Colleagues,
It is our honor to host the First Asia-Pacific Congress of
Pediatric Cardiology and Cardiac Surgery in Bangkok,
Thailand. This is the first scientific meeting of the Asia-Pacific
Pediatric Cardiac Society which was previously known as the
Asian-Pacific Society of Pediatric Cardiology. Our previous
scientific meetings were done in conjunction with the AsiaPacific Society of Cardiology. Through these years, we have
seen the progress and healthy growth and maturation of the
pediatric cardiology and cardiac surgery in Asia-Pacific to
warrant its own scientific meeting.
The First Congress in Thailand cannot be success without the
tremendous help from our friends and colleagues. In addition to many invited outstanding world renowned cardilogists, surgeons and investigators,
our Asia-Pacific speakers will also present their unique knowledge and experience. The AsiaPacific Congress of Pediatric Cardiology and Cardiac Surgery will aim to provide a forum for
discussion of a broad spectrum of topics ranging from issues concerning countries in this region
with emerging economies to the state-of-the-art knowledge and break-through technologies. Participants will have the opportunity to acquaint themselves with some of the latest technical innovations in each field. Most importantly, this will help to build up the capacity of the participants for
an improvement of care and treatment for children with heart diseases.
Furthermore, the congress has served the occasion for renewal and further strengthening of our
friendship, which already exists within Asia-Pacific and with international colleagues. On behalf
of the scientific committee, I would like to extend my warm welcome to all our friends and delegates from Asia-Pacific and other countries and wish you a very pleasant and memorable stay in
Thailand. Please take advantage of your time to explore the beautiful country of Thailand as well
as to enjoy the exciting city of Bangkok.
Warmest regards,
Apichai Khongphatthanayothin, M.D.
Kritvikrom Durongpisitkul, M.D.
Co-Chairman
Scientific Chairman,
Chaisit Sangtaweesin, M.D.
Co-Chairman
Pirapat Mokarapong, M.D.
Secretary General
Table of Contents
Welcome Message
Chairman Organizing Committee
President, Asia-Pacific Pediatric Cardiac Society
President, The Society of Pediatric Cardiology of Thailand
Scientific Chairman
Organizing Committee
Advisory Committee
Scientific Committee
Asia-Pacific Pediatric Cardiac Society (APPCS)
Invited International Speakers
Invited Asia-Pacific Speakers
General Information
Registration Information
Guidelines for Speaker’s Presentation
Instruction for Poster Presentation
Program at a Glance
Scientific Program
Tuesday, October 31, 2006
Wednesday, November 1, 2006
Lunch Symposium
Thursday, November 2, 2006
Lunch Symposium
Friday, November 3, 2006
Lunch Symposium
Saturday, November 4, 2006
Speaker’s Abstracts (November 1, 2006)
Speaker’s Abstracts (November 2, 2006)
Speaker’s Abstracts (November 3, 2006)
Speaker’s Abstracts (November 4, 2006)
Abstract for Free Paper
Free Paper 1-2
Free Paper 3-4
Free Paper 5-6
Free Paper 7-8
Free Paper 9, Young Investigator Award
Table of Contents
Abstract for Poster
Instruction for Poster Presentation
Poster Group 1: PS1-PS 24
Poster Group 1: PS25-PS 48
Poster Group 1: PS49-PS 70
Poster Group 1: PS71-PS 94
Poster Group 1: PS95-PS 119
Map Of BTS & MRTA in Bangkok
Floor Plan, Bangkok Convention Center
4th Floor
5th Floor
Trade Exhibitors
Social Program
Index of Abstracts
Index of Authors
Acknowledgements
Organizing Committee
Honorary Advisors:
-
Chairman:
Vice Chairman:
Secretary General:
Scientific Coordinator:
Treasurer:
Social:
Audio Visual:
Publication:
Congress Facility & Exhibition:
Executive Committee:
Chadsri Prachuabmoh, M.D.
Charlie Phornphatkul, M.D.
Choompol Vongprateep, M.D.
Chotima Pathamanand, M.D.
Pantpis Sakornpant, M.D.
Santa Ha-Upala, M.D.
Suphachai Chaithiraphan, M.D.
Usa Thisyakorn, M.D.
Virojna Sueblinvong, M.D.
Boonchob Pongpanich, M.D.
Chule Thisyakorn, M.D.
Pirapat Mokarapong, M.D.
Suthep Wanitkun, M.D.
Worakan Promphan, M.D.
Apichai Khongphatthanayothin, M.D.
Kritvikrom Durongpisitkul, M.D.
Chaisit Sangtaweesin, M.D.
Jarunun Ungbhakorn
Sureeporn Kunathai, M.D.
Chantana Daorai
Pimjai Bodhipakti
Teerachat Silarat, M.D.
Chalermkiet Tuntrakool, M.D.
Vichai Benjacholamas, M.D.
Pornthep Lertsapcharoen, M.D.
Jurapim Soongswang, M.D.
Boonchu Sririchongkolthong, M.D.
Pirapat Mokarapong, M.D.
Tawatchai Kirawittaya, M.D.
Worakan Promphan, M.D.
Apichart Nana, M.D.
Chareonkiat Roekkliang, M.D.
Cherdchai Tontisirin, M.D.
Manat Panamonta, M.D.
Oranuch Kyokong, M.D.
Pongsak Khowsathit, M.D.
Somchai Sriyoschati, M.D.
Somkiat Sopontammarak, M.D.
Sukasom Attanawanich, M.D.
Supachai Chuerattanaphong, M.D.
Supreecha Tanamai, M.D.
Ungkab Prakanrattana, M.D.
Yupada Pongprot, M.D.
Advisory Committee
Anna U Rahayoe, M.D.
Antony C Chang, M.D.
Edgardo E. Ortiz, M.D.
Gary Sholler, M.D.
Heung Jae Lee, M.D.
Hung Chi Lue, M.D.
In Sook Park, M.D.
Jim Wilkinson, M.D.
Jinfen Liu, M.D.
Kalim Uddin Aziz, M.D.
Koichiro Niwa, M.D.
Krishna Iyer, M.D.
Krishna Kumar, M.D.
Lee Chuen Neng, M.D.
Lee Sang Bum, M.D.
Makoto Nakazawa, M.D.
Masood Sadiq, M.D.
Maurice Leung, M.D.
Mazeni Alwi, M.D.
Mei Hwan Wu, M.D.
Shunji Sano, M.D.
Sukman Putra, M.D.
Teiji Akagi, M.D.
William C Yip, M.D.
(Indonesia)
(USA)
(Philippines)
(Australia)
(Korea)
(Taiwan)
(Korea)
(Australia)
(China)
(Pakistan)
(Japan)
(India)
(India)
(Singapore)
(Korea)
(Japan)
(Pakistan)
(Hong Kong)
(Malaysia)
(Taiwan)
(Japan)
(Indonesia)
(Japan)
(Singapore)
Scientific Committee
General Cardiology:
Duangmanee Laohaprasittiporn, M.D.
Thanarat Layangool, M.D.
Rattanaporn Pornkul, M.D.
Suthep Wanitkun, M.D.
Kritvikrom Durongpisitkul, M.D.
Pornthep Lertsapcharoen, M.D.
Apichai Khongphatthanayothin, M.D.
Preecha Laohakunakorn, M.D.
Vichai Benjacholamas, M.D.
Vorasin Ketanon, M.D.
Vichao Kojuranjit, M.D.
Samphant Pornvilawan, M.D.
Thivakorn Kasemsri, M.D.
Dusit Staworn, M.D.
Satid Thammasitboon, M.D.
Yuttapong Wongswadiwat, M.D.
Worakan Promphan, M.D.
Vachara Jamjureeruk, M.D.
Jarupim Soongswang, M.D.
Aungkana Gengsakul, M.D.
Anant Khositseth, M.D.
Alisa Limsuwan, M.D.
Rutja Phuphaibul, R.N., Ph.D.
Echo & Non – Invasive Imaging:
Intervention Cardiology:
Arrhythmia & Electrophysiology:
Surgery:
Intensive Care:
Genetic & Fetal Cardiology:
Adult Congenital Heart Disease:
Nursing:
Asia-Pacific Pediatric Cardiac Society
Asia-Pacific Pediatric Cardiac Society
Interim Officer 2005-2006
President: Krishna Iyer, M.D. (India)
Secretary: Apichai Khongphatthanayothin, M.D. (Thailand)
Steering Committee*
Country
Australia
Steering Committee
Gary Sholler, M.D.
Dan Penny, M.D.
China
Hong Kong
Leung Ping, Maurice, M.D.
India
Krishna Iyer, M.D.
R. Juneja, M.D.
Indonesia
Anna U. Rahayoe, M.D.
Sukman Putra, M.D.
Japan
Makoto Nakazawa, M.D.
Koichiro Niwa, M.D
Korea
Heung Jae Lee, M.D.
Lee Sang Bum, M.D.
Malaysia
Geetha Kandavello, M.D.
Mazeni Alwi, M.D.
Pakistan
Kalimudin Aziz, M.D.
Masood Sadiq, M.D.
Philippines
Rhodora de Leon, M.D.
Della Pelaez, M.D.
Singapore
William Yip, M.D.
Quek Swee Chye, M.D.
Sri Lanka
Sepalika Mendis, M.D.
Taiwan
Mei-Hwan Wu, M.D.
Jou-Kou Wang, M.D.
Thailand
Boonchob Pongpanich, M.D.
Apichai Khongphatthanayothin, M.D.
Vietnam
Nguyen Lan Hieu, M.D.
*From countries that were represented at the Business Meeting of the APSPC in Buenos Aires, Argentina,
Septermber 2005.
Invited International Speakers
Afksendiyos Kalangos, M.D.
Clinique de Chirurgie Cardio Vasculaire, HCUG, Geneva, Switzerland
Andrew N. Redington, M.D.
Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
Andrew Cook, M.D.
Cardiac Unit, Institute of Child Health, University College London, UK
Anthony C. Chang, M.D., MBA
CHOC Heart Institute, Children’s Hospital of Orange County, Orange, CA, USA
Bernadette McCormick, R.N., C.C.R.N.
University of California, San Diego, San Diego, California, USA
Christof Stamm, M.D.
Deutsches Herzzentrum Berlin
Augustenburger Platz 1, Berlin, Germany
David J. Sahn, M.D.
Professor of Pediatrics, Diagnostic Radiology, Obstetrics & Gynecology and Biomedical
Engineering Director, OHSU Interdisciplinary Program in Cardiac Imaging, Pediatric
Cardiology, Oregon Health & Science University, Portland, OR, USA
Laurance L. Lequier M.D., FRCP(C)
Director, ECLS Program, Stollery Children’s Hospital, Canada
Michael J. Silka, M.D.
Division of Cardiology, Childrens Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
Michael A. Gatzoulis, M.D., Ph.D., FACC, FESC
Professor of Cardiology, Congenital Heart Disease and Consultant Cardiologist, Adult
Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart & Lung Institute, Imperial College, London, UK
Roger B. B. Mee, M.D.
Chairman Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, USA
(Retired)
Thomas L. Spray, M.D.
Children’s Hospital of Philadelphia, PA, USA
Ziyad M. Hijazi, M.D., MPH, FACC, FAAP, FSCAI
George M. Eisenberg, Professor of Pediatrics and Medicine, Chief, Section of Pediatric
Cardiology, Medical Director, The University of Chicago Heart Center, University of
Chicago, IL USA
Invited Asia-Pacific Speakers
Australia
Dan Penny, M.D., Ph.D., FRACP
Director of Cardiology, The Royal Children’s Hospital, Professorial Fellow, Dept. of Paediatrics, University of Melbourne, Australia
Geoffrey K Lane, B Pharm, MB.BS, FRACP
Interventional Cardiologist, Royal Children’s Hospital, Honorary Cardiologist, Royal
Melbourne Hospital, Melbourne, Australia
James L Wilkinson, M.D.
Honorary Cardiologist, Royal Melbourne Hospital, Melbourne, Australia
Samuel Menahem, M.D.
Department of Paediatric Cardiology, Monash Medical Centre, Victoria Australia.
China
Guo-Ying Huang, M.D.
Professor of Pediatrics, Director of Echo-Cardiology Lab, Pediatric Heart Center, Executive Vice President, Children’s Hospital of Fudan University, Shanghai, PR China
Jinfen Liu, M.D.
Chief Physician, Shanghai Children Medical Center, Shanghai, China
Lily Lihwa Hsu, RN., MSN
Program Director Nursing Education-Shanghai, Deputy Dean Shanghai Jiao Tong University School of Nursing, Preject HOPE Shanghai Office, Shanghai Jiao Tong University
School of Medicine, Shanghai, China
Yonghao Gui, M.D., MSc
President , Children’s Hospital of Fudan University, Vice Chairman, Chinese Pediatric
Society, Shanghai, China
Zhuoming XU, M.D.
Shanghai Children Medical Center, Shanghai China
Zhiwei Xu, M.D.
Shanghai Children Medical Center, Shanghai China
Li Juan Fu
Vice Dean School of Nursing Shianghai, Jiao Tong University, Shanghai China
Germany
Trong-Phi Le, M.D.
Department of Pediatric Cardiology, University of Hamburg, Germany
Invited Asia-Pacific Speakers
India
Amit Varma, M.D.
Director, Medical Services & Business Planning, Director Critical Care, New Delhi, India
Krishna Iyer, M.D.
Director, Pediatric & Congenital Heart Surgery, Escorts Heart Institute and Research
Center, New Delhi, India
Neeti Chandra, M.D.
Fortis Healthcare Ltd., New Delhi, India
Pavathi Iyer, M.D.
Pediatric & Congenital Heart Surgery, Escorts Heart Institute and Research Center, New
Delhi, India
Sunita Maheshwari, M.D.
Consultant Pediatric Cardiologist, Narayana Hrudayalaya, Bangalore, India
Indonesia
Anna U. Rahayoe, M.D.
President, National Cardiovascular Center, Jakarta, Indonesia
Najib Advani, M.D. MMed
Consultant Pediatric Cardiologist, University of Indonesia, Jakarta, Indonesia
Sukman T Putra, M.D. FACC, FESC
Consultant Pediatric Cardiologist, Division Chief, Pediatric Cardiology, Department of
Pediatric, University of Indonesia, Cipto Mangunkusumo General Hospital, Jakarta,
Indonesia
Japan
Hiromi Kurosawa, M.D.
Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Tokyo, Japan
Katuhino Tatsuno, M.D.
President, Chiba Cardiovascular Center, Chiba, Japan
Koichiro Niwa M.D. Ph.D. FACC
Chief, Department of Pediatrics, Director, Adult Congenital Heart Disease Program, Chiba
Cardiovascular Center, Japan
Invited Asia-Pacific Speakers
Makoto Nakazawa, M.D.
Director, Pediatric and Lifelong Congenital Cardiology Institute, Southern TOHOKU
General Hospital, Southern TOHOKU Research Institute, Fukushima, Japan
Masao Yoshinaga, M.D.
Head, Dept of Pediatrics, National Hospital Organization, Kagoshima Cardiovascular &
Cancer Center Kagoshima, Japan
Shunji Sano M.D., Ph.D.
Professor and Chairman, Department of Cardiovascular Surgery, Okayama University
Graduate School of Medicine and Dentistry, Okayama, Japan
Teiji Akagi, M.D.
Cardiac Care Unit, Okayama University Hospital, Okayama, Japan
Yasuki Maeno, M.D.
Maternal and Perinatal Medical Center, Department of Pediatrics and Child Health,
Kurume University School of Medicine, Kurume, Japan
Yoshihide Mitani, M.D., Ph.D.
Department of Pediatrics, Mie University School of Medicine, Japan
Korea
Dong Man Seo, M.D.
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Eun Jung Bae, M.D., Ph.D.
Associate Professor, Department of Pediatrics, Seoul National University College of
Medicine, Seoul, South Korea
Heung Jae Lee, M.D.
Professor of Pediatrics, Sungkyunkwan University School of Medicine, Cardiac &
Vascular Center, Samsung Medical Center, Seoul, Korea
Hyun Woo Goo, M.D.
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
In-Sook Park, M.D.
Dean, Professor in Pediatric Cardiology, Asan Medical Center, University of Ulsan
College of Medicine, Seoul, Korea
Sang Bum Lee, M.D.
Kyungpook National University, School of Medicine, Department of Pediatrics, Taegu,
Korea
Invited Asia-Pacific Speakers
Seong-Ho Kim, M.D., Ph.D.
Director, Cardiovascular Center, Chairman, Department of Pediatrics, Staff Pediatric
Cardiologist Halla General Hospital, South Korea
Malaysia
Geetha Kandavello, M.D.
Consultant Pediatric Cardiologist, Dept of Pediatric Cardiology, Institut Jantung Negara,
National Heart Institute, Kuala Lumpur, Malaysia
Mazeni Alwi, M.D.
Consultant & Head, Department of Paediatric Cardiology, Institut Jantung Negara (National Heart Institute), Kuala Lumpur, Malaysia
Mohamed Azhari Yakub, M.D.
National Heart Institute, Dept of Cardiothoracic Surgery, Kuala Lumpur, Malaysia
New Zealand
Nigel Wilson, M.D.
Pediatric Cardiologist, Green Lane Hospital Clinical Services, Starship Hospital, Auckland,
New Zealand
Pakistan
Kalim Uddin Aziz, M.D.
Professor (Emiritus) of Paediatric Cardiology, National Institute of Cardiovascular
Diseases, Pakistan
Masood Sadiq, M.D.
Professor of Pediatric Cardiology, The Children’s Hospital/The Institute of
Child Health and The Punjab Institute of Cardiology, Lahore, Pakistan
Philippines
Edgardo E. Ortiz, M.D.
Chairperson and Professor of the Department of Pediatrics, UP-PGH, College
of Medicine-Philippine General Hospital, University of the Philippine,
Manila, Philippines.
Luis Mabilangan, M.D.
Professor Emeritus, University of Philippines College of Medicine, Manila,
Philippines
Invited Asia-Pacific Speakers
Saudi Arabia
Mohammed Omar Galal, M.D.
Cardiovascular Department, King Faisal Specialist Hospital and RC, Jeddah,
Saudi Arabia.
Singapore
James Yip, M.D., MRCP
Director, Adult Congenital Heart Programme, The Heart Institute, National University
Hospital, Singapore.
William C.L. Yip, M.D.
National University Hospital, Singapore Baby & Child Clinic, Gleneagles Medical Centre, Singapore
Taiwan
Hung Chi Lue, M.D.
President and Physician-in-Chief, MS General Hospital, Professor Emeritus of Pediatrics,
National Taiwan University, Taiwan
Chun-Wei Lu, M.D.
Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Jou-Kou Wang, M.D.
National Taiwan University, Division of Pediatric Cardiology, National Taiwan University Hospital, Taipei, Taiwan
Mei-Hwan Wu, M.D., Ph.D., FACC, FESC
Professor of Pediatrics, National Taiwan University Hospital, President, Taiwan Society
of Pediatric Cardiology, Taipei, Taiwan
Yih-Sharng Chen, M.D.
Associate Professor, Department of Cardiovascular Surgery, National Taiwan University
Hospital, Taipei, Taiwan
USA
Satid Thammasitboon, M.D., M.H.P.E.
Assistant Professor of Pediatrics, Associate Director, Pediatric residency program, West
Virginia University School of Medicine, Department of Pediatrics, Pediatric Critical Care
Section, Morgantown, WV, USA
Invited Asia-Pacific Speakers
Thivakorn Kasemsri, M.D., F.A.A.P
Director, PICU, Covenant Children’s Hospital, Lubbock, Texas, USA
Vietnam
Nguyen Lan Hieu, M.D.
Vietnam Heart Institute, Bach Mai Hospital, Hanoi, Vietnam.
Nguyen Thanh Cong, M.D.
Badinh, Hanoi, Vietnam.
Thailand
Boonchob Pongpanich, M.D.
Professor Emeritus of Pediatrics, Department of Pediatrics, Faculty of Medicine
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Apichai Khongphatthanayothin, M.D.
Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok,
Thailand
Kritvikrom Durongpisitkul, M.D.
Department of Pediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Manat Panamonta, M.D.
Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen,
Thailand
Pornthep Lertsapcharoen, M.D.
Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok,
Thailand
Suvipaporn Siripornpitak, M.D.
Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Thanarat Layangool, M.D.
Queen Sirikit National Institute of Child Health, Bangkok, Thailand
Vachara Jamjureeruk, M.D.
Bangkok Heart Hospital, Bangkok, Thailand
Yuttapong Wongswadiwat, M.D.
Pediatric cardiologist/intensivist, Queen Sirikit Heart Center of the Northeast, Khon Kaen
University, Khon Kaen, Thailand
General Information
Congress Dates
November 1-4, 2006
Congress Venue
Bangkok Convention Center (BCC), Sofitel Central Plaza Hotel, Bangkok, Thailand
Opening Ceremony & Welcome Cocktail Reception
October 31, 2006, 18.00-22.00 hrs
Official Language
The official language of the congress is English. There will be no simultaneous
translation.
Exhibition
An exhibition will be organized at the congress venue. There will be a display of pharmaceutical products to bring participants up to date with the most recent advancements in the
field of Pediatric Cardiology and Cardiac Surgery. Non pharmaceutical products are also
will be displayed.
Accompanying Persons
Accompanying person(s) must be registered (before August 15, 2006 US$ 100 and after
August 15, 2006 US$ 120 per person) for admission to the Exhibits, Opening Ceremony,
Complimentary Tour.
Payment
All prices quoted in this book are in US$. Payment in other currencies will not be
accepted. By register online at www.pccs2006.com or download registration form to
complete it as mail order and return to Congress Secretariat, the fees can be paid by Credit
cards (VISA, Master and JCB Card). Please note that personal or company cheques are
not accepted. Payment of fees must accompany all Registration form. The registration
will be authorized only after receipt of the registration fee. There are credit card facilities
for on site registration.
Cancellation Policy
Cancellation of your registration, Hotel reservation and Tour Arrangement should be made
in writing to the conference organizer by September 1, 2006, in order to make the
necessary amendments, stating the name and address of the bank and account name and
number which you wish your refund to be send. Administration cost for each cancellation
will be charged 30% of the total amount. Please note that the refund will be send after the
congress.
General Information
Hotel Cancellation by Participants
Participants may cancel their reservation by notifying the hotel 15 days before the
scheduled arrival date. In the event that cancellation is not notified to the hotel as set forth
herein, the hotel will charge the equivalent of charges for one night’s accommodation
from their credit card or prepaid deposit.
Certificate of Attendance
A certificate of attendance will be available upon request during registration.
Accreditation
The scientific sessions have been accredited for continuing medical education (CME)
26.5 credits.
Climate
The climate is influenced by seasonal monsoon. There are three main seasons; rainy
(May-October), winter (November-January) and summer (February-April). The average
low temperature is approximately in low to mid 20 c and high temperature in mid 30 c.
Transportations
1. BTS Sky Train stations can mostly be found in commercial areas of Sukhumvit, Silom,
it is fast and safe. The sky train is divided into 2 lines: Sukhumvit line (On Nut StationMo Chit Station), and Silom lines (Saphan Taksin Station-National Stadium Station).
The sky train has a minimum and maximum fare of 10-40 baht. Tourists may buy 30 day
tourist tickets to save money, only 250 baht/10 trips, or day tickets, 100 baht
(unlimited trips). The BTS Tourist Information Centers is open daily from 8.00 a.m. 8.00 p.m. at the following stations: Siam, Nana and Saphan Taksin. For more
information,call: 0-2617-7340.
2. MRTA Subway is another comfortable and fast transportation choice. The beginning of
“Chalerm Ratcha Mongkhon” line is Hua Lum Phong station (also the main train station
in Bangkok), total of 18 stations, major stations at: The Queen Sirikit’s International
Convention and Exhibition Center, Silom, Suan Lumpini, Asoke, Ratchada, Ladprao and
Pahonyotin road. The Asoke and Silom stations are connected to the the BTS. There are
also “Park & Ride” at Ladprao and Phra Ram 9 Stations. MRTA Subway has a minimum
and maximum fare of 14-36 baht. The MRTA subway is open daily from 06.00 a.m. 12.00 midnight. For more information, call: 0-2624-5200.
3. Taxis in Bangkok are metered. They charge a minimum of 35 baht, for the
first 3 kilometers, and approximately 5 baht per kilometer thereafter. When in Traffic
the meter is timed and calculated in the fare.
General Information
4. Tuk-Tuk, these three-wheeled ‘open-air’ motorised taxis are popular for short journeys.
Fares must be bargained in advance. Minimum fares, for journeys of up to 3 kilometers,
are approximately 30 baht.
5. Motorcycles Taxi, in rush hours, there is a lot of traffic jam, if your late and want to be
on time you can try the motorcycle taxi. Fares must be bargained in advance. Minimum
fares are 5 baht. You need to bargain the fare before taking the ride.
Travels Cheques and Credit Cards
Major credit cards, such as VISA and Master Card are widely accepted in hotels and
shops. Traveller’s cheques can be conveniently cashed at all commercial banks and
authorized money exchanges.
Currency
The Thai currency is baht which is divided into 100 satang. Coins are in 25 and 50 satangs,
1, 5, and 10 baht. Foreign currency may be exchanged at authorized exchanged banks,
hotels and shops.
Liability
The Congress will not assume any responsibility for accidents, losses damages, delays or
any modifications in the program caused by unforeseen circumstances.
Non-Smoking Policy
The Congress follows a non-smoking policy. No smoking every where during the
congress, such as in the lecture or meeting rooms, exhibition area, poster presentation
area etc.
Emergency Clinic
Located infront of elevator 4th Floor convention center.
Registration Information
Pre-registered delegates are required to produce their confirmation of registration at the
registration counters to obtain their registration badges and congress kits. On-site
registration will also be accepted at the registration counters and can be made in cash
(baht or USD)
Registration Hours
Registration will be from 10.00 - 17.00 Tuesday, October 31, 2006, at the registration
area, 4th Floor, Bangkok Convention Center (BCC), Sofitel Central Plaza Hotel, Bangkok,
Thailand.
Onsite Registration Fee
Status
Delegate
Main-Congress
Oneday
US$450
US$150
Accompanying Person
US$120
* Person registering as a student, postdoctoral and fellow must enclose a copy of their
cards or a document from institutions.
- Please use the registration form for registration.
- Delegate, student, postdoctoral, fellow: Registration fee includes conference admission,
proceeding and other materials, opening/closing ceremony/coffee or tea break.
- Accompanying person: Registration fee includes opening/closing ceremony,
reception and Royal Grand Palace Tour.
Badges
All delegates and accompanying persons are kindly requested to wear the name
badges when attending any meeting or social gathering. Only delegates who are wearing
the name badges will be admitted to the lecture halls.
Please note: accompanying persons will not be admitted to the scientific session
and exhibition.
Name badges have been color-coded as follow:
Pink
Main congress
Navy Blue
One-day registration on November 1, 2006
Purple
One-day registration on November 2, 2006
Orange
One-day registration on November 3, 2006
Green
Speaker, Moderator and Chairperson
Yellow
Committee
Grey
Accompanying persons
Guidelines for Speaker’s Presentations
General Information
1. Please proceed to the registration counter to collect your meeting materials.
2. The Slide Preview Room is provided for speakers to view your slides, disks and CDs
before presentation. It is located on the 4th Floor adjacent fo the secretariat office.
3. You are requested to hand in your slides, disks and CDs at least one day before your
scheduled presentation. Your co-operation in handling in your slides, disks and CDs early
will ensure that the technicians will have sufficient time to load your presentations.
4. All speakers are requested to collect their slides, disks and CDs from the Slide Preview
Room, preferable on the same day after presentation and not later than 5.00 pm the same
day. The Organizing Committee will not be responsible for your slides, disks and CDs not
collected within this period.
Audiovisual Aids
The rooms used for the presentations are equipped with
- Dedicated Presentation PC Computer with floppy disk and CD-ROM equipped
with Microsoft Office
- Screen for single projection
- A LCD projector
- A laser pointer
- 33 mm slide projector (as requested)
Please note that
- Universal fonts, such as Arial and Times New Roman, are preferable for the
PowerPoint presentation.
- Presentation on an Apple computer (Macintosh system) is not possible.
Note: Presentation by slide 35 mm or any presentations, which do not use computer
projection, will cause an inconvenient viewing for participants. PowerPoint presentation
is the most recommended presentation tool.
Instruction for Poster Presentation
- The poster board is 120 cm in width x 240 cm in height. The suitable poster size is
within 100 cm in width x 150 cm in height.
- The abstract title, author names and institutions in large letters should be placed at
the top of the poster followed by the headings: Background, Objectives, Materials
& Methods, Results, and Conclusion to identify your poster layout.
- The posters should be displayed in the poster areas throughout the period of the
conference. Each poster board is marked with the number assigned to each abstract.
Authors are requested to affix their posters at the number assigned to them during the
official conference hours from 8.00 am on November 1, 2006 and 12.00 noon on
November 4, 2006.
- Pins, staplers, nails or any other sharp materials which might destroy the poster
board are not allowed to use for affixing the poster. Two-side tape is the most
recommended material for presentation. Please be noted that the posting material
should be provided by the presenter.
- Authors are requested to present at their posters during the poster sessions during
coffee break.
- Posters can be removed following the designated poster session if necessary. All
posters not collected by November 4, 2006 12.00 noon will be disposed off.
The conference assumes no responsibilities for the condition of posters not removed
by the presenter.
Saturday
Nov4, 2006
Friday
Nov3, 2006
Thursday
Nov2, 2006
Wednesday
Nov 1, 2006
Tuesday
Oct31, 2006
C
B
Plenary 3:
Cardiology from
bench to bedside
Plenary 2: Novel
issues in cardiac
surgery and noninvasive imaging
Plenary 4: Towards
the optimum care
for pediatric and
S36: Subpulmonary VSD congenital heart
disease in AsiaPacific
S37: Heterotaxy
syndrome
Abstract 8: FP15-FP21:
Cardiac Surgery
D
Debate: Transcatheter
valve therapy
Abstract 7: FP43-FP49:
Intervention
C
A
S27: Hot topics in
Cardiac CICU 2
B
Abstract 4: FP29-FP35:
General
D
S26: Sudden cardiac
death in children
Abstract 3: FP8-FP14:
Cardiac Surgery
C
A
S15: Rheumatic carditis
revisited
S4: Kawasaki disease
D
B
S3: Nursing 1: care of
child wiht CHD
C
S14: Pulmonary
regurgitation in TOF
S2: Surgical tips and
techniques
B
Plenary 1:
Children with
heart disease in
developing
countries: How
much can one do?
9:30-10:30
Young Investigator
Award Presentation
and Closing
Ceremony
Symposium S29: Nursing
2: Basic CHD
S32: Nursing 3: Role of
nursing in CHD 1
S31: SVT and Catheter
ablation in CHD
S30:Interventional
club: “How to”
S28: Cardiac service in
developing countries
Abstract 9: YIA1-YIA6
YIA Contest
S21: Fetal Cardiology
Revisited 1
Abstract 6: FP36-FP42:
General & Arrhythmia
Lunch
Symposium3:
Intervention
symposium:
VSD device
closure
S20: Grown Up CHD
(GUCH)
S19: Cardiac cath in
Asia-Pacific 1
Abstract 5: FP50-FP56:
General Cardiology
S17: Surgery for TGA
S18:Cardiac ICU in
developing world
S16: Heart Failure
Lunch
Symposium2:
Eisenmenger
Syndrome
S10:Genetics in
pediatric heart disease
Abstract 2: FP22-FP28
Intensive Care
S8: Cardiac Life
Support (ECLS)
S7:Advanced noninvasive imaging
14:00-15:30
S9: The Fontan
Operation
Lunch
Symposium1:
Valve repair in
Children
Registration
12:15-14:00
Abstract 1: FP1-FP7
Cardiac Surgery
S6: Acquired heart
disease in Asia-Pacific
S5: Interventional tips
and techniques
10:45-12:15
S35: Nursing 4: Role
of nursing in CHD 2
S34: Device therapy in
children
S33: Intervention:
Difficult cases
S25: Fetal Cardiology Revisited 2
S24: Congenitally
Corrected TGA
S23: Cardiac cath in
Asia-Pacific 2
S22: Hot topics for
CICU I
S13:Cardiomyopathy:
What’s new?
Hands-on: Workshop
on Biodegradable Ring
S12: CICU interactive
case presentation
S11: Advanced ECHO
imaging
15:45-17:15
Scientific Program: “Towards the Optimal Care for Children with Heart Diseases in Asia-Pacific”
A
S1: Pulmonary
Hypertension
08:00-9:30
A
Room
PS 1-22, PS115, PS121
PS 47-67, PS114, PS119,
PS122
PS 92-120
Break
PS 23-46
PS 68-91, PS116
Break
Date
Siam
Niramit
(Advance
Booking)
Committee
dinner/Joe
Louis
Theater
(Advance
Booking)
Opening
ceremony &
Reception
18:00-21:00
Program at a Glance
Scientific Program
Tuesday, October 31, 2006
10:30-17:00
18:00-19:00
19:00-21:00
Registration
Opening ceremony
Reception
Wednesday, November 1, 2006
08:00-9:30 Symposium 1: PulmonaryHypertension
Chairman:
Dr. Edgardo E. Ortiz
Co-Chairman: Dr. Alisa Limsuwan
1. Treatment of PH in CICU
Dr. Dan Penny (Australia)
2. Treatment of Chronic PH
Dr. James Yip (Singapore)
3. Testing of vasoreactivity in patient with PAH
Dr. Geetha Kandavello (Malaysia)
Room A
Symposium 2: Meet the experts: Surgical tips and techniques Room B
Chairman:
Dr. Krishna Iyer
Co-Chairman: Dr. Vichai Benjachalamas
1. Sano operation
Dr. Shunji Sano (Japan)
2. Modified Norwood procedure
Dr. Thomas L. Spray (USA)
3. RVOT reconstruction for first stage palliation of PA/VSD
Dr. Jinfen Liu (China)
Symposium 3: Nursing 1: The care of children with CHD
Chairman:
Rutja Phuphaibu, R.N., Ph.D.
Co-Chairman: Ms. Bernadette McCormick (USA)
1. Postoperative care for children with heart disease
Dr. Anthony Chang (USA)
2. Medications for pediatric patients after surgery for CHD
Ms. Xiao-Rong, Gu (China)
Ms. Lily Lihwa Hsu (China)
3. Sedation in children: What a nurse should know
Dr. Neeti Chandra (India)
Room C
Scientific Program
Symposium 4: Kawasaki disease
Chairman:
Dr. Hung Chi Lue
Co-Chairman: Dr. Chule Thisyakorn
1. Epidemiology in non-Oriental: KD in Indonesia
Dr. Najib Advani (Indonesia)
2. Vascular biology in Kawasaki disease
Dr. Yoshihide Mitani(Japan)
3. Catheter and surgical treatment
Dr. Teiji Akagi (Japan)
Room D
09:30-10:30 Plenary1: Children with heart disease in developing countries:
How much can one do?
Room A
Chairman:
Dr. Shuji Sano
Co-Chairman: Dr. Sukman Putra
1. Medical perspective
Dr. Boonchob Pongpanich (Thailand)
2. Surgical Perspective
Dr. Krishna Iyer (India)
10:30-10:45 Coffee break and Poster presentation 1: PS 1-22, PS115, PS121
(Adult CHD, Arrhythmia, ECHO, Pediatric CHD)
10:45-12:15 Symposium 5: Meet the expert:
Interventional tips and technique
Chairman:
Dr. Yonghao Gui
Co-Chairman: Dr. Khalilullah
1. Coil occlusion of AV fistula and collateral
Dr. Teiji Akagi (Japan)
2. Stenting of coarctation of aorta
Dr. Masood Sadiq (Pakistan)
3. Intervention for PDA closure
Dr. Mohammad Omar Galal (Saudi Arabia)
Room A
Symposium 6: Acquired heart disease in Asia-Pacific 2006
Room B
Chairman:
Dr. Anita Khalil
Co-Chairman: Dr. Chotima Pathamanand
1. Infective endocarditis in Pediatric Patients: Thailand Experience
Dr. Vachara Jamjureeruk (Thailand)
2. Risk factor for coronary heart disease: management in childhood in
developing countries
Dr. Kalim Uddin Aziz (Pakistan)
Scientific Program
3. Metabolic syndrome in children
Dr. Masao Yoshinaga (Japan)
Abstract 1: FP1-FP7 Cardiac Surgery
Chairman:
Dr. Katuhino Tatsuno
Co-Chairman: Dr. Somboon Boonkasem
Room C
Abstract 2: FP22-FP28 IntensiveCare
Chairman:
Dr. Dan Penny
Co-Chairman: Dr. Amit Varma
Room D
12:15-14:00 Lunch Symposium1: Valve repair in Children
Room A
Chairman:
Dr. Thomas L. Spray
Co-Chairman: Dr. Pirapat Mokarapong
1. Value repair in congenital MS/MR
Dr. Dong Man Seo (Korea)
2. Mitral and tricuspid valve repair using a Biodegradable Ring in pediatric
population
Dr. Afksendiyos Kalangos (Switzerland)
3. The Kalangos Ring in pediatric valve repair
Dr. Mohamad Azhari Yakub (Malaysia)
14:00-15:30 Symposium 7: Advanced non-invasive imaging
Chairman:
Dr. Guo-ying Huang
Co-Chairman: Dr. Rattanaporn Pornkul
1. The role of multistice CT in the diagnosis of CHD
Dr. William C. L. Yip (Singapore)
2. Advance of cardiac MRI in the evaluation of CHD
Dr. Suvipaporn Siripornpitak (Thailand)
3. 3D and 4D echo: Does it matter?
Dr. David Sahn (USA)
Room A
Symposium 8: Cardiac Extracorporeal Life Support (ECLS)
Chairman:
Dr. Nguyen Thanh Cong
Co-Chairman: Dr. Yuttapong Wongswadiwat
1. Ventricular Assist Devices (VAD)
Dr. Anthony C. Chang (USA)
2. Post – operative ECLS
Dr. Laurance L. Lequier (Canada)
Room B
Scientific Program
3. Organization of ECLS in Medical Center and its multi-application
Dr. Yih-Sharng Chen (Taiwan)
Symposium9: The Fontan Operation
Chairman:
Dr. Zhi-Wei Zu
Co-Chairman: Dr. Samphant Ponvilawan
1. Lateral tunnel vs. extracardiac Fontan: Which is the best?
Dr. Thomas L. Spray (USA)
2. Fontan in heterotaxy syndrome
Dr. Hiromi Kurosawa (Japan)
3. Alternative treatments for unsuitable Fontan
Dr. Roger B. Mee (Australia)
Room C
Symposium10: Genetics in pediatric heart disease
Chairman:
Dr. Yoshihide Mitani
Co-Chairman: Dr. Pongsak Khowsathit
1. Marfan syndrome
Dr. Heung Jae Lee (Korea)
2. Genetic basis of cardiac arrhythmias
Dr. Chun-Wei Lu (Taiwan)
3. 22q11 deletion
Dr. In-Sook Park (Korea)
Room D
15:30-15:45 Coffee break and Poster presentation 2:
PS 23-46 (Basic Science, Kawasaki disease)
15:45-17:15 Symposium 11: Advanced ECHO imaging
Chairman:
Dr. Sang Bum Lee
Co-Chairman: Dr. Suthep Wanichkul
1. Novel ECHO parameter for cardiac functional evaluation
Dr. David Sahn (USA)
2. Tele-Echo and its utility in Asia-Pacific: Experience in India
Dr. Sunita Maheshwari (India)
3. Real-time 3D Echo for CHD
Dr. Guo-ying Huang (China)
Symposium 12: CICU interactive case presentation
Chairman:
Dr. Anthony C. Chang
Co-Chairman: Dr. Pavathi Iyer
1. Case presentation from SCMC
Dr. Zhuoming XU (China)
Room A
Room B
Scientific Program
2. Case presentation from SCH
Dr. Laurance L. Lequier (Canada)
Hand-on session 1 (Surgery): Workshop on Biodegradable Ring Room C
Chairman:
Dr. Afksendiyos Kalangos
Co-Chairman: Dr. Supreecha Tanamai
Symposium13: Cardiomyopathy:What’s new?
Chairman:
Dr. Yonghao Gui
Co-Chairman: Dr. Yupada Pongprot
1. Childhood cardiomyopathy: Experience in Australia
Dr. James L. Wilkinson (Australia)
2. Cell therapy
Dr. Christoff Stamm (Germany)
3. Heart transplantation
Dr. Yih-Sharng Chen (Taiwan)
Room D
18:00-21:00 Committee dinner/Joe Louis Theater (Advance Booking)
Scientific Program
Thursday, November 2, 2006
08:00-09:30 Symposium 14: Pulmonary regurgitation in TOF:
Old Problems, New Answers
Chairman:
Dr. Pantpis Sakornpant
Co-Chairman: Dr. William C. L. Yip
1. Surgical repair: How to avoid late complication
Dr. Shunji Sano (Japan)
2. Physiologic determinant of PR
Dr. Andrew N. Redington (Canada)
3. The role of the evaluation of PR/RV function post TOF repair
Dr. Hyun Woo Goo (Korea)
Room A
Symposium 15: Rheumatic carditis revisited
Room B
Chairman:
Dr. Luis Mabilangan
Co-Chairman: Dr. Cherdchai Tontisirin
1. Evolution of ARF presentation: Does Jone’s criteria work well in
high-prevalence countries ?
Dr. Nigel Wilson (New Zealand)
2. The use of echocardiography in acute rheumatic fever.
Dr. Manat Panamonta (Thailand)
3. RHD after 30 years of benzathine penicillin
Dr. Hung Chi Lue (Taiwan)
Abstract 3: FP8-FP14: Cardiac Surgery
Chairman:
Dr. Roger B.B. Mee
Co-Chairman: Dr. Vichao Kojuranjit
Room C
Abstract 4: FP29-FP35: General Cardiology
Chairman:
Dr. Anna U. Rahayoe
Co-Chairman: Dr. Masood Sadiq
Room D
09:30-10:30 Plenary 2: Novel issues in cardiac surgery
and non-invasive imaging
Chairman:
Dr. Chadsri Prachuabmoh
Co-Chairman: Dr. Jinfen Liu
1. Tissue Engineering in CHD
Dr. Hiromi Kurosawa (Japan)
2. Advanced ultrasound methods for procedural guidance in
non-invasive cardiovascular imaging
Dr. David Sahn (USA)
Room A
Scientific Program
10:30-10:45 Coffee break and Poster presentation 3: PS 47-67, PS114, PS119, PS122
(Rheumatic, Endocarditis, Cardiomyopathy, Genetics, Intensive Care)
10:45-12:15 Symposium 16: Heart Failure
Chairman:
Dr. Virojna Sueblinvong
Co-Chairman: Dr. Anthony C. Chang
1. Basic mechanism and treatments of heart failure in children
Dr. Makoto Nakazawa (Japan)
2. LCOS in CICU without mechanical support: What is possible?
Dr. Pavathi Iyer (India)
3. Heart failure in GUCH
Dr. Andrew N. Redington (Canada)
Room A
Symposium 17: Surgery for TGA
Room B
Chairman:
Dr. Dong Man Seo
Co-Chairman: Dr. Kriengchai Prasongsukarn
1. Aortic translocation in TGA/VSD/PS
Dr. Zhi-Wei Xu (China)
2. TGA with abnormal coronary pattern: Technique and precaution
Dr. Thomas L. Spray (USA)
3. Long-term FU post arterial switch: What to be concern
Dr. James L. Wilkinson (Australia)
Abstract 5: FP50-FP56: General Cardiology
Chairman:
Dr. Nigel Wilson
Co-Chairman: Dr. Chalermkiet Tantrakool
Room C
Abstract 6: FP36-FP42: General Cardiology and Arrhythmia
Chairman:
Dr. Michael J. Silka
Co-Chairman: Dr. Mei-Hwan Wu
Room D
12:15-14:00 Lunch Symposium 2: Eisenmenger Syndrome
Chairman:
Dr. Kritvikrom Durongpisitkul
Co-Chairman: Dr. Koichiro Niwa
1. Management of Eisenmenger Syndrome: Current practice
Dr. Geetha Kandevello (Malaysia)
2. BREATH 5
Dr. Michael A Gatzoulis (UK)
Room A
14:00-15:30 Symposium 18: Cardiac intensive care in developing world
Chairman:
Dr. Thivakorn Kasemsri
Room A
Scientific Program
Co-Chairman: Dr. Lourance L. Leguier
1. Experience in India
Dr. Pavathi Iyer (India)
2. Experience in China
Dr. Zhuoming XU (China)
3. Experience in Thailand
Dr. Yuttapong Wongswadiwat (Thailand)
Symposium 19: Cardiac catheterization in Asia:
Different point of view 1
Room B
Chairman:
Dr. Sukman Putra
Co-Chairman: Dr. Seong-Ho Kim
1. A staged catheter-surgery approach in TOF/PA
Dr. Seong-Ho Kim (Korea)
2. From bench to clinical practice: Lesson learned from platinum coated Notinol
device
Dr. Pornthep Lertsapcharoen (Thailand)
3. PDA stenting: what is the indication and outcome?
Dr. Mazeni Alwi (Malaysia)
Symposium 20: Grown Up Congenital Heart disease (GUCH) Room C
Chairman:
Dr. Heung Jae Lee
Co-Chairman: Dr. Aungkana Gengsakul
1. Life-long concern in CHD: Experience of the GUCH clinic in Asia-Pacific
Dr. James Yip (Singapore)
2. Exercise toterance in GUCH after the surgery
Dr. Michael A. Gatzoulis (UK)
3. Pregnancy related issues in women with congenital heart disease
Dr. Koichiro Niwa (Japan)
Symposium 21: Fetal Cardiology Revisited 1
Room D
Chairman:
Dr. Samuel Menahem
Co-Chairman: Dr. Jarupim Soongswang
1. Fetal cardiac pathology
Dr. Andrew Cook (UK)
2. Impact of fetal echocardiography: Changing pattern of congenital heart
disease
Dr. In-Sook Park (Korea)
3. Progression of CHD during fetal life
Dr. Yasuki Maeno (Japan)
Scientific Program
APPCS Business Meeting
Chairman:
Dr. Krishna Iyer
Secretary:
Dr. Apichai Khongphatthanayothin
Kamphengphet
15:30-15:45 Coffee break and Poster presentation 4: PS 68-91, PS116
(Intervention, Nursing, Surgery)
15:45-17:15 Symposium 22: Hot topics for CICU I
Room A
Chairman:
Dr. Ungkab Prakanrattana
Co-Chairman: Dr. Sunita Maheshwari
1. Renal replacement therapy
Dr. Laurance L. Lequier (Canada)
2. LCOS in CICU
Dr. Zhuoming XU (China)
3. Expectation and outcome for Congenital Heart Surgery Programs
Dr. Thivakorn Kasemsri (USA)
Symposium 23: Cardiac catheterization in Asia:
Different point view 2
Room B
Chairman:
Dr. Teiji Akagi
Co-Chairman: Dr. Kritvikrom Durongpisitkul
1. PFM coil for VSD occlusion: A real alternative treatment modality
Dr. Trong-Phi Le (German)
2. Difficult case for PDA closure
Dr. Jou-Kou Wang (Taiwan)
Symposium 24: Congenitally Corrected TGA
Room C
Chairman:
Dr. James L. Wilkinson
Co-Chairman: Dr. Anant Khositseth
1. Systemic RV: Natural History
Dr. Michael A. Gatzoulis (UK)
2. The management of Congenitally Corrected Transposition of Great Arteries
Dr. Roger B. B. Mee (Australia)
Symposium 25: Fetal Cardiology Revisited 2
Room D
Chairman:
Dr. Samuel Menahem
Co-Chairman: Dr. Vachara Jamjureeruk
1. Pre- and perinatal management of fetal arrhythmia
Dr. Yasuki Maeno (Japan)
2. The management implication following the diagnosis of fetal heart anomalies
Dr. Samuel Menahem (Australia)
Scientific Program
APPCS Business Meeting
Chairman:
Dr. Krishna Iyer
Secretary:
Dr. Apichai Khongphatthanayothin
18:00-22:00 Siam Niramit (Advance Booking)
Kamphengphet
Scientific Program
Friday, November 3, 2006
08:00-09:30 Symposium 26: Sudden cardiac death in children
Room A
Chairman:
Dr. Eun-Jung Bae
Co-Chairman: Dr. Somkiat Sopontammarak
1. Risks and mechanisms of sudden death following surgical treatment of
congenital heart disease
Dr. Michael J. Silka (USA)
2. The long QT syndrome
Dr. Masao Yoshinaga(Japan)
3. Sudden death in patients with right atrial isomerism
Dr. Mei Hwan Wu (Taiwan)
Symposium 27: Hot topics in Cardiac CICU 2
Room B
Chairman:
Dr. Oranuch Kyokong
Co-Chairman: Dr. Neeti Chandra
1. Haemodynamic monitoring: tool or toy?
Dr. Dan Penny (Australia)
2. Cardiopulmonary interaction: How principles become practices?
Dr. Satid Thammasitboon (USA)
3. Nutritional support and immunocompetence
Dr. Amit Varma (India)
Abstract 7: FP43-FP49: Interventional Cardiology
Chairman:
Dr. Geoffrey Lane
Co-Chairman: Dr. Jou-Kou Wang
Room C
Abstract 8: FP15-FP21: Cardiac Surgery
Chairman:
Dr. Shunji Sano
Co-Chairman: Dr. Chareonkiat Roekkliang
Room D
09:30-10:30 Plenary3: Cardiology from bench to bedside
Room A
Chairman:
Dr. Makoto Nakazawa
Co-Chairman: Dr. In-Sook Park
1. Pathologist’s bench: A New Look at Cardiac Development
Dr. Andrew Cook (UK)
2. Cardiologist’s aspect of genetics of congenital CV disease: From molecular
bench to bedside
Dr. Makoto Nakazawa (Japan)
Scientific Program
10:30-10:45 Coffee break and Poster presentation 5: PS 92-120 (Surgery)
10:45-12:15 Symposium 28: Children cardiac service in developing countries:
Asia-Pacific experience
Room A
Chairman:
Dr. Boonchob Pongpanich
Co-Chairman: Dr. Sukman Putra
1. Pakistan
Dr. Kalim Uddin Aziz (Pakistan)
2. Indonesia
Anna U. Rahayoe (Indonesia)
3. The “Heart to Heart” project
Dr. Heung Jae Lee (Korea)
Dr. Thanh Cong Nguyen (Vietnam)
Abstract 9: YIA1-YIA6: Young Investigator Award Contest
Chairman:
Dr. Edgardo E. Ortiz
Co-Chairman: Dr. Chaisit Sangtawesin
Room B
Symposium 29: Nursing 2: Basic CHD
Chairman:
Rutja Phuphaibu, R.N., Ph.D.
Co-Chairman: Ms. Lily Lihwa Hsu
1. Acyanotic CHD
Ms. Li-Juan Fu (China)
Ms. Lily Lihwa Hsu (China)
2. Cyanotic CHD
Ms. Bernadette McCormick (USA)
Room C
12:15-14:00 Lunch Symposium 3: Intervention symposium:
VSD device closure
Room A
Chairman:
Dr. Mazeni Alwi
Co-Chairman: Dr. Mohammad Omar Galal
1. Introduction
Dr. Kritvikrom Durongpisitkul (Thailand)
2. What does the Interventionist need to know about the anatomy of VSD?
Dr. James L. Wilkinson (Australia)
3. Transcatheter closure of VSD: Results and Complications
Dr. Ziyad M. Hijazi (USA)
14:00-15:30 Symposium 30: Interventional club: “How to”
Chairman:
Dr. Mosood Sadiq
Room A
Scientific Program
Co-Chairman: Dr. Trong-Phi Le
1. Transcatheter closure of ASD “tips and techniques for large ASD”
Dr. Geoffrey Lane (Australia)
2. Transcatheter closure of VSD: Asian perspective
Dr. Mazeni Alwi (Malaysia)
3. Technique of balloon dilation of aortic coarctation
Dr. Mohammed Omar Galal (Saudi Arabia)
Symposium 31: SVT and Catheter ablation in CHD
Room B
Chairman:
Dr. Mei Hwan Wu
Co-Chairman: Dr. Preecha Laohakunakorn
1. Conduction system in CHD
Dr. Andrew Cook (UK)
2. SVT in complex 2-ventricle CHD: Ebstein, L-TGA, D-TGA post Mustard
Dr. Michael J. Silka (USA)
3. SVT in complex single ventricle and post Fontan operation
Dr. Eun-Jung Bae (Korea)
Symposium 32: Nursing 3: Role of nursing in the care of CHD 1 Room C
Chairman:
Ms. Bernadette McCormick (USA)
Co-Chairman: Rutja Phuphaibul, R.N., Ph.D.
1. Patient and family education
Ms. Bernadette McCormick (USA)
2. Support for family with in a child with CHD
Ms. Lily Lihwa Hsu (China)
15:30-15:45 Coffee break
15:45-17:15 Symposium 33: Interventional symposium:
Difficult cases presentation
Chairman:
Dr. Ziyad M. Hijazi
Co-Chairman: Dr. Geoffrey Lane
1. Transcatheter Closure of PDA: Some problems & difficulties
Dr. Sukman Putra (Indonesia)
2. Migrated stent and repositioning
Dr. Seong-Ho Kim (Korea)
3. VSD and AV block
Dr. Kritvikrom Durongpisitkul (Thailand)
4. Coil occlusion of VSD
Dr. Nyuyen Lan Hieu (Vietnam)
Room A
Scientific Program
Symposium 34: Device therapy in children
Room B
Chairman:
Dr. Apichai Khongphatthanayothin
Co-Chairman: Dr. Eun Jung Bae
1. Controversial indications for pacemaker implantation in children
Dr. Michael J. Silka (USA)
2. CRT in children
Dr. Mei Hwan Wu (Taiwan)
3. Pediatric AICD: A review
Dr. Apichai Khongphatthanayothin (Thailand)
Symposium 35: Nursing 4: Role of nursing in the care of CHD 2 Room C
Chairman:
Ms. Lily Lihwa Hsu
Co-Chairman: Rutja Phuphaibul, R.N., Ph.D.
1. Long-term outcomes in patients with congenital heart defects
Ms. Bernadette McCormick (USA)
Scientific Program
Saturday, November 4, 2006
08:00-9:00 Debate 1: Transcatheter valve therapy (weird or wonderful?)
Chairman:
Dr. Mohammad Omar Galal
Co-Chairman: Dr. Geoffrey Lane
1. Pro
Dr. Ziyad M. Hijazi (USA)
2. Con
Dr. Andrew N. Redington (Canada)
3. Rebuttal
Room A
Symposium 36: Subpulmonary VSD, when to repair?
Chairman:
Dr. Apichart Nana
Co-Chairman: Dr. Nguyen Lan Hieu
1. Natural history and echocardiographic evaluation
Dr. Thanarat Layangool (Thailand)
2. Subpulmonary VSD: When and how to repair the AR
Dr. Katuhino Tatsuno (Japan)
Room B
Symposium 37: Heterotaxy syndrome
Chairman:
Dr. Pongpira Suwannakul
Co-Chairman: Dr. Najib Adani
1. The essence of isomerism of the atrial appendages, and its
relationship to visceral heterotaxy
Dr. Andrew Cook (UK)
2. Arrhythmia in heterotaxy syndrome
Dr. Eun Jung Bae (Korea)
Room C
09:00-10:30 Plenary 4: Towards the optimum care for pediatric and
congenital heart disease in Asia-Pacific
Room A
Chairman:
Dr. Krishna Iyer
Co-Chairman: Dr. Boonchob Pongpanich
1. Towards the optimum care of pediatric and congenital heart disease
in the next decade
Dr. Roger B. B. Mee (Australia)
2. The future of cardiac catheterization
Dr. Ziyad M. Hijazi (USA)
3. Delivery of care in congenital heart programs: past, present and future
Dr. Andrew N. Redington (Canada)
Scientific Program
10:30-11:00 Young Investigator Award Presentation
and Closing Ceremony
Room A
Chairman:
Dr. Boonchob Pongpanich
Co-Chairman: Dr. Chaisit Sangtawesin
YIA Finalist Presentation and President’s closing remarks
Dr. Krishna Iyer, President
Host country closing remark and presentation of the next host country
Dr. Boonchob Pongpanich, host country
Dr. Lee Sang Bum, next host country (Korea)
11:00-11:15 Coffee break
Remark: Topics & Speakers are subjected to change according to availability.
The First Asia-Pacific Congress
of Pediatric Cardiology and
Cardiac Surgery
November 1-4, 2006
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S1(1/3)
PULMONARY HYPERTENSION ON THE CARDIAC INTENSIVE
CARE UNIT.
Dan Penny, M.D., Ph.D, FRACP
Director of Cardiology, The Royal Children’s Hospital, Melbourne, Australia
A number of congenital heart lesions, particularly those resulting in a left-to-right shunt or
pulmonary venous hypertension are associated with pulmonary arterial hypertension.
Pulmonary vascular resistance is commonly increased during cardiopulmonary bypass
and in susceptible patients, the post-bypass period may be complicated by pulmonary
hypertension and in some, pulmonary hypertensive crises.
It is now well-recognised that pulmonary hypertension after cardiac surgery is an important
risk factor for morbidity and mortality and is an important determinant of ICU requirement.
However, severe post-operative pulmonary hypertension is now much less common than
before, because of timely surgery for lesions with left-to-right shunt and recent
improvements in cardiopulmonary bypass, including the use of modified ultrafiltration.
Severe episodic pulmonary hypertension after cardiac surgery is characterised by increases
in central venous and pulmonary arterial pressures, reductions in left atrial pressure and
oxygen saturation and ultimately reductions in systemic arterial pressure … the so-called
‘pulmonary hypertensive crisis’. These haemodynamic changes are commonly associated
with changes in lung mechanics with acute increases in lung stiffness, a sign commonly
mistaken for the development of obstruction of the endotracheal tube.
Good basic intensive care, involving adequate analgesia, and in particular optimised
ventilator strategies are the mainstay of prevention and treatment. However, the use of
newer agents, based on increased understanding of the role of the endothelium in regulating
the function of vascular smooth muscle has transformed our care.
Nitric oxide (NO) inhalation has been one of the most important advances in cardiac
intensive care over the last decade or so. NO is a selective and potent pulmonary vasodilator
which when used appropriately can be life-saving. It is now recognized that even low
inhalation rates (of around 2-5 ppm) can have a profound pulmonary vasodilator effects.
However a number of problems with its use remain. First, it is unclear as to when exactly
NO should be commenced and units differ considerably in their threshold indications.
Second, some patients do not respond well to its application and third, rebound pulmonary
hypertension after its withdrawal remains an important problem.
The threshold indications for the initiation of NO inhalation remain ill-defined and different
units have markedly different protocols for its commencement. While some papers in the
literature point towards a clinical benefit for using NO to prevent pulmonary hypertension
in at-risk patients, some protocols recommend its use only where pulmonary hypertension
is associated with significant alterations in systemic haemodynamics.
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
In patients who do not respond to inhaled NO an important consideration is whether there
is an anatomic reason for the elevated pulmonary arterial pressure. Having excluded a
large vessel mechanical problem, for the lack of response, other agents may be considered,
including the phosphodiesterase inhibitor sildenafil or possibly an endothelin agonist
(although both approaches remain experimental).
Rebound pulmonary hypertension can by an important problem. It may occur, even in
patients where NO inhalation did not result in therapeutic benefit, in the first place. Rebound
appears to be related to downregulation of NO synthase activity, possibly related to
superoxide formation. In most patients, rebound may be prevented by cautious withdrawal
of NO to concentrations of less than 1ppm before stopping. Recently, we have performed
a randomized trial which demonstrated that a single dose of oral sildenafil before stopping
inhaled NO may prevent rebound. Other approaches which are of more experimental use
are antioxidants and endothelin antagonists.
In conclusion, the problem of pulmonary hypertension is now less common than before in
patients on the cardiac intensive care unit. However, when it occurs, it carries with it,
significant morbidity and mortality. Timely surgery, meticulous attention during
cardiopulmonary bypass and good, basic intensive care, are the mainstay of prevention
and treatment. Where these measures are insufficient, inhalation of NO may be indicated.
Patients with elevated right ventricular or pulmonary arterial pressure who do not respond
to NO treatment should be carefully assessed for residual haemodynamic lesions.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S1(2/3)
Treatment of Chronic PH
James Yip, M.D.
The Heart Institute, National University Hospital, Singapore
PCCS 2006
Testing of vasoreactivity in patient with PAH
Geetha Kandavello, M.D.
Consultant Pediatric Cardiologist, Dept of Pediatric Cardiology Institute Jantung Negara,
National Heart Institute, Kuala Lumpur, Malaysia
SPEAKER’S ABSTRACTS November 1, 2006
S1(3/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S2(1/3)
Sano operation
Shunji Sano, M.D., Ph.D.
Professor and Chairman Department of Cardiovascular Surgery, Okayama University
Graduate School of Medicine and Dentistry, Okayama, Japan
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
S2(2/3)
Modified Norwood procedure
Thomas L. Spray, M.D.
Children’s Hospital of Philadelphia, Philadelphia, PA, USA.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S2(3/3)
RVOT reconstruction for first stage palliation of PA/VSD
Jinfeng Liu, M.D.
Chief Physician, Shanghai Children Medical Center, Shanghai, China
Background:To evaluate restoration of anterior pulmonary circulation with Gore-tex
conduit in first-stage palliation of pulmonary atresia with ventricular septal defect.
Methods: Between January 2003 and July 2005,14 patients underwent operation?male 8
cases?female 6 cases.Mean age was 32 30m(4-53m),weight 14 6kg(3-14.5kg),
SpO269 16%(58-88%) preoperatively.
PA/VSD is classified into four types according to the development of main pulmonary
artery(MPA) and the presence of major aortopulmonary collateral vessels(MAPCVs).Type
I,duct dependent and MPA present.Type II, duct dependent and MPA not present. Type
III,dual supply by true pulmonary artery and MAPCVs. Type IV?no true pulmonary
artery,only MAPCAs.
Left and right pulmonary artery should be dissected freely. Ductus arterious was ligated
immediately after commencing bypass. Left or right pulmonary arery less than 2 to 3mm
was enlarged to 4 to 5mm in 6 cases. There was no confluence between left and right
pulmonary artery whose posterior wall was end-end anastomosed and anterior wall was
enlarged by pericardial in 4 cases .Right pulmonary anterior wall was incised and reversed
as posterior wall cause there was a long distance between left and right pulmonary artery
in 1 case. Then new anterior wall was enlarged by pericardial. The distal Gore-Tex conduit
was fashioned to the true pulmonary artery. A small incision less than 1 to 2mm of conduit
diameter is made in the infundibulum of right ventricle. The proximal Gore-Tex conduit
was sutured to it.For 2 cases of less than or equal 7kg 6mm conduit is used, 4 cases of less
than 9kg 8mm used,6 cases less than 14kg 10mm used,2 cases of large than or equal 14kg
13mm used. Modified ultralfiltration was performed after CPB.
Results:Type I 5 patients,type II 4 patients ,type III 5patients.9 patients performed with
parallel cardiopulmonary bypass,mean time was 61 20min(34-96min) 5 patients performed
with heart arrest, mean aortic clamp time was 46 24min(18-80min),mean cardiopulmonary
bypass time 95 33min(47-123min) Mean ventilator time was 31 17h(19-74h),ICU stay
time 4 2d(2-8d) HR and AoSP were lower 24h and 48h than 6h postoperatively(P<0.05).
After 6h,24h and 48h of postoperation, HR was 148 20/min,139 18/min and 143 8/min
relatively. Aortic systolic pressure 97 13mmHg, 94 22mmHg and 91 12mmHg.Aortic
diastolic pressure 57 8mmHg,53 10mmHg and56 8mmHg.The HR and aortic systolic
pressure after 24h and 48h of postoperation were significantly less than 6h(P<0.05). After
6h,24h and 48h of postoperation,PaO2 was 57 13mmHg,59 12 mmHg and 58 7 mmHg
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
relatively.PaCO2 38 4 mmHg,35 4 mmHg and 34 7 mmHg .,SaO2 0.88 0.07,0.9 0.05
and 0.86 0.04.There were no significant difference in PaO2 and SaO2 6h,24h and 48h
postoperatively.
1 type I case complicated with right pleural effusion after removal of ventilator and was
drained, recovered 3 days later.1 type I case complicated with pericardial effusion after
removal of ventilator and decreased obviously 4 days later. 1 type III case was reoperated
because of bleeding after returning ICU.
Fellow ECHO showed VSD double shunt ,mean gradient of right venticle-pulmonary
artert was 42 17mmHg(10-68mmHg). EKG showed sinus rhythm.Heart function I 3 cases,
II 8 cases, III cases 3 cases.
Conclusion: Restoration of anterior pulmonary circulation with Gore-tex conduit can
maintain pulmonary blood flowin rightly, stabilize hemodynamics, remove ventilator
favorably providing good condition for two-stage procedure.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S3(1/3)
Postoperative care for children with heart disease
Anthony C. Chang, M.D., MBA
CHOC Heart Institute Children’s Hospital of Orange County, CA, USA
PCCS 2006
Medications for Pediatric Patients after Cardiovascular Surgery for
Congenital Heart Diseases
Xiao Rong Gu1, RN., BSN
Lily Hsu2, RN., MSN
Ping Ping He1, RN., BSN
Shanghai Children’s Medical Center Affiliated with Shanghai Jiao Tong University School
of Medicine1
Shanghai Jiao Tong University School of Nursing, Project HOPE2
Pediatric patients with Congenital Heart Disease (CHD) post surgery require various
medications to maintain their cardiac function and to promote the stability of their
physiological parameters. Children who received cardiovascular surgery frequently suffered
from pain, anxiety, cardiac arrhythmias, low cardiac output, high pulmonary arterial
hypertension, low systematic pressure, low urine output, heart block, or heart failure, etc..
These condition required several medications in order to maintain the cardiac output, to
lower the pulmonary hypertension, and to promote their comfort post surgery in Cardiac
Intensive Care Unit.
While patients receive several important medications, it is essential for nurses to
realize the drug action, side effects, rational to use, and pharmacokinetics property of
these medications in order to provide prompt care and to avoid complication associated
with these medications. Nursing assessment becomes essential and the effect of medication
needs to be timely documented.
It is essential for nurses to recognize patients’ clinical status in critical care setting.
The nurse's ability to understand children’s clinical condition and medications is enhanced
by an understanding of the principles of cardiac anatomy and physiology, as well as
developmental changes in cardiac function (Miller-Hoover, 2003). Beta-blockers,
angiotensin-converting enzyme inhibitors, calcium channel blockers are commonly used
during postoperative period. Frequently used medications in CICU are Lidocaine,
Amiodarone, Amrinone, Adenosine, Capropril, Digoxin, Dopamine, Dobutamine,
Furosemide (Lasix), Nipride, Prostaglandin, and Nitroglycerin. Each medication’s side
effects and nursing intervention need to be monitored and addressed carefully.
Corticosteroids are often used in CICU during postoperative period with aim to
reduce the postoperative inflammatory response. Inotropic support is provided to ensure
the stability of homodynamic status. Phosphodiesterase inhibitors, such as milrinone, are
used after the Norwood procedure because of their combined inotropic and vasodilator
properties (Soetenga & Mussatto, 2004). Dobutamine is used to support myocardial
contractility and Dopamine is commonly used in CICU for blood pressure support, and
promoting the cerebral and renal perfusion. Sodium nitroprusside is for decreasing afterload;
SPEAKER’S ABSTRACTS November 1, 2006
S3(2/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
nitroglycerin is to improve left ventricular function by lowering preload from vasodilatation.
ACE inhibitor is used for afterload reduction. Also, digoxin is frequently used to support
the function of the single ventricle, a diuretic to prevent fluid retention is also used for
children at home, an Captopril will be ordered as an after-load-reducing agent to decrease
the workload of the single ventricle, and aspirin or enoxaparin sodium (Lovenox) to decrease
the risk of thrombotic complications (Soetenga & Mussatto, 2004). For patients’ agitation
and post-operative pain, Fentany l5-10 micro/g/kg per hour with neuromuscular blocker
benzodiazepines (lorazepam) are used frequently in CICU. Children in the post-operative
stages need to receive a comprehensive discharge teaching. Medication is one of key topic
to be covered by nurse at bedside.
Prompt nursing intervention is important for taking care of children who receive
various cardiac medicines during post-operative stage. These interventions include assess
the level of consciousness, monitor serum electrolytes, BUN, serum creatinine, live enzyme,
monitor intake & output, and assess any significant bodyweight changes. In addition,
nurses need to assess parameters of cardiovascular functioning on a regular basis, any
change of cardiac rhythm on EKG need to report immediately. The fluctuation of Blood
pressure and weak pulse rate may indicate patient’s condition in instable, heart murmur
my indicate regurgitation post surgery, course lung sounds will direct to more efficient
respiratory management, weak peripheral pulses need to monitor homodynamic status,
presence of edema (especially in dependent areas) and level of jugular venous distention
all need to be carefully assessed for the possibility of heart failure.
Patients’ medication adjustment should be based on patient clinical status, postoperative cardiac function, and should use a micro drip intravenous set-up to delivery the
medication. Nurses need to label all intravenous infusions carefully, and keep accurate
records of drug additives to prevent inadvertent medication errors. All medication
calculation needs to be double checked, especially medications that may affect systematic
pressure and cardiac output. Nurses also need to teach patients and families about the
desired effects and common side effects of prescribed drugs.
For discharge teaching, nurses need to teach parents to keep all medications out of
reach of children, keep all health care providers informed of all medications being used,
emphasize to patients the importance of taking drugs as ordered, not discontinuing drugs
without consulting with the physician, not sharing drugs with friends of relatives, and not
self-medicating with over-the-counter drugs unless first approved by the physician. Teach
patients about the signs of drug allergies. If patients take corticosteroids or anticoagulants,
instruct children to wear medical identifications. Instruct parents to let children take drugs
with the food to lessen the gastric irritation and this may improve the compliance of the
home medications. In addition, using mealtimes as a reminder is often a way to help
patients remember prescribed drugs.
Children post cardiac surgery will experience various cardiac medications. It is
nurse’s responsibility to get familiar with the medication. Continue education and reading
key article are ways to enhance the knowledge on medications that are used in CICU.
Carefully assess patients’ status during pre-operative and post-operative and document
adequate medications record are essential for understanding the status of the patients.
PCCS 2006
Sedation in children: What a nurse should know
Neeti Chandra, M.D.
New Delhi, India
SPEAKER’S ABSTRACTS November 1, 2006
S3(3/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S4(1/3)
Epidemiology in non-Oriental: KD in Indonesia
Najib Advani, M.D., MMed
Consultant Pediatric Cardiologist University of Indonesia, Jakarta, Indonesia
Kawasaki disease is still not very well known in Indonesia, a country with 220 million
populations. The estimated annual incidence is approximately 5000 cases, but the number
of diagnosed cases is less than 100 per year. The first case series consisted of 27 Kawasaki
patients in Indonesia was reported at the Eighth International Kawasaki Disease Symposium
in SanDiego, 2005. In order to introduce the disease to the community and medical
personnel, we give lectures to undergraduate medical students, case presentations to the
residents, talks in radio stations and TV channels, publish book and flyers, also write
articles in public magazines and newspapers on Kawasaki disease. As a result, the number
of diagnosed cases is increasing gradually. However it is still far from expected. We are
worried of the undiagnosed cases. A lot of effort is needed in order to make all the medical
practitioners aware of the disease.
PCCS 2006
Vascular biology in Kawasaki disease: Lessons learned
from long-term issues.
Yoshihide Mitani, M.D.
Mie University School of Medicine, Japan
Background: Coronary sequelae which persist after Kawasaki disease (KD) have been
associated with obstructive changes of the lesions and coronary vascular events in
adolescents and young adults. However, little is known about the association between
sequelae late after KD and inflammatory markers, which are potential mediators and
markers for atherogenesis.
Methods and Results: Cross-sectional study was performed to test the hypothesis that
coronary sequelae are associated with elevated levels of inflammatory markers in patients
late after KD?(mean time interval after the onset:10y10m). Levels of high sensitivity Creactive protein (CRP), serum amyloid-A (SAA), interleukin-6, and soluble intercellular
adhesion molecule-1 were measured in 4 groups (n=80): referent (n=15) and KD subgroups
with normal coronary arteries from the onset (n=27), with regressed aneurysms (n=18),
and with coronary artery lesions, such as persistent aneurysms, stenosis, and occulusion
(n=20). CRP levels were significantly elevated in a KD subgroup with coronary artery
lesions, compared with the referent or other KD subgroups, as analyzed by analysis of
variance, and analysis of covariance after adjustment for a confounding factor body mass
index. Levels of CRP, SAA and interleukin-6 were positively correlated. Stepwise
regression and logistic regression analyses support the association between the persistence
of coronary artery lesions and the levels of CRP and SAA.
Conclusions: Results demonstrate that the persistence of coronary lesions late after KD
was independently associated with levels of CRP and SAA, suggesting inflammation may
be a novel functional aspect of coronary artery diseases late after KD.
SPEAKER’S ABSTRACTS November 1, 2006
S4(2/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S4(3/3)
Catheter and surgical treatment of KD
Teiji Akagi, M.D.
Associate Professor Cardiac Care Unit, Okayama University Hospital Okayama, Japan
Even if the perfect IVIG treatment was undertaken in the acute stage of illness, we could
not reach the complete avoidance of coronary artery complications. The most striking
feature of coronary artery abnormality is the change of size or shape of aneurysm. About
50% of coronary aneurysms regress within 2 years. On the other hand, coronary artery
stenosis occurred in 4% of all patients, or in 20% with coronary aneurysms in the followup period. Myocardial infarction occurred in about 1% of patients, one-third of those
patients died due to cardiac shock. It is important to know that half of the fatal cases did
not demonstrate any ischemic findings before the onset of myocardial infarction.
In this regard, the result of coronary bypass grafting in children with Kawasaki disease is
not reached sufficient level. More than 90% of 15 years graft patency rate was expecting
if intrathoracic arterial bypass surgery underwent older than 12 years old, however, 15
years graft patency rate decreased 65% in children under 12 years old even if the arterial
graft was selected. In fact, the most of candidates of coronary bypass surgery are children
younger than 12 years old. Especially in these young children, 15 years graft patency is
not enough for their long future life.
During past 10 years, the clinical experience of catheter interventional treatment in
Kawasaki disease has been gradually increasing. These are including balloon angioplasty,
stent implantation, rotational ablation, and transluminal coronary revascularization. Because
the coronary artery stenosis in Kawasaki disease commonly involves severe calcification
in contrast with adult atherosclerotic coronary artery lesions, the indication or technique
of catheter intervention for adult patients cannot be directly employed in Kawasaki disease
patients. Satisfactory acute results for coronary balloon angioplasty were obtained in patients
with a relatively short interval from the onset of disease, especially within 6 years, however
the incidence of restenosis after angioplasty was still high. Rotational ablation may be the
most appropriate catheter intervention for Kawasaki disease. The advantage of rotational
ablation is the high success rate, even in patients with calcified coronary artery stenosis.
Stent implantation requires larger arterial access and is not possible in younger children.
Care should be paid to the detection of new aneurysm formation, as the formation of new
aneurysms was associated with the use of additional balloon angioplasty using high pressure
balloon inflations. Anticoagulation or anti-platelet regimens are essential for the longterm management.
Above procedures should be performed at selected institutions with experience in coronary
interventional procedures by highly experienced interventional cardiologists. Cooperation
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
between pediatric and adult cardiologists is essential for the optimal decision making in
this setting. Patients should be referred by a cardiologist, who has fully knowledge of not
only the catheter intervention but also the clinical feature and the natural course of this
disease. The indications for catheter intervention and appropriate anti-thrombus regimen
after the interventional catheterization require further clarification in the setting of Kawasaki
disease, based on the natural history of coronary artery lesion especially vascular endothelial
function.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
P1(1/2)
Problems of Children with Heart Disease in Developing Countries,
How Much Can One Do?
Boonchob Pongpanich M.D.,FACC.
President of the Cardiac Children Foundation of Thailand
The problems in developing countries (GNP per capita less than 10,000 US dollars) are
inadequate medical personels, both specialists and general practitioners, causing a long
waiting list and delay diagnosis and treatment. In addition the government health care
budget are limited. Heart disease in infant and children are considered to be a low priority,
because there are too many urgent health problems. With these limitation, pediatric
cardiologist and cardiac surgeon has to work hard, usually with low income because most
children with heart disease come from poor family, many has social problems.
The most common type of heart disease in children is congenital heart disease
(CHD) account for over 80 percents of cases and occur in almost one percent of live born
infants, followed by rheumatic heart disease and Kawasaki disease. We also for seen future
cardiovascular problems related to childhood obesity which are predispose to early type
two diabetes mellitus and hypertension at a later age.
This paper will focus mainly on CHD. It is estimated that each year there will be
over 675,000 infants born with CHD in Asia-Pacific and most of them, over 600,000 are
in the developing countries. Since CHD mostly unpreventable, approximately 20 % of
CHD may die in infants if there is no treatment, many die before the diagnosis was made.
To cope with these problems, training non-MD such as community nurses and public
health personals of how to diagnose and early referral is very helpful. Mobile or extended
pediatric cardiac clinic to the rural and remote area where there are no pediatric cardiologist
is also very important. This could be done through a co-operation between public and
private organization. In addition we should be cost conscious, both direct medical cost
such as cost of investigation and treatment and social cost such as traveling, lodging and
loss of work for parents. We should avoid too many appointments by co-operation with
local MD.
Thailand population is 63 millions, in 2003 there were 742,183 live born infants
with over 7400 infants with CHD. Half of this number need intervention or surgery. There
are 60 pediatric cardiologists and 20 cardiac surgeons who can perform pediatric cardiac
surgery, very few can do surgery in the newborn and complex CHD. Each year less than
2500 infants and children could be able get surgical treatment. In the past few years with
the support of the Cardiac Children Foundation and The Foundation for Pediatric Cardiac
Surgery, several thousands children (over 5000) were operated during weekend or evening.
These procedures could be done with the support of government budget through the
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
universal health care coverage which was started in 2002 and public donation. The Cardiac
Children Foundation of Thailand has been organizing extended cardiac clinic for 13
consecutive years, with 38 trips, in 34 provinces. We have examined 3327 children,2262
with heart diseases and 1276 patients were sent for surgery or intervention.
Conclusion. In developing countries with limit health man power and budget, we
should try our best to improve coverage and quality care at a reasonable cost through a cooperation between public and private sectors. A co-operation among Asia-Pacific in training,
service and research is necessary for future development.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
P1(2/2)
Children with heart disease in developing countries - How much can one do?
‘Surgical Perspective’
Krishna Iyer, M.Ch.
Director, Pediatric & Congenital Heart Surgery, Escorts Heart Institute & Research Center,
New Delhi, INDIA
Congenital Heart Disease (CHD) continues to be a major pediatric health issue in developing
countries. Surgical intervention remains the mainstay of treatment in CHD despite rapid
advances in catheter-based interventions. Over the years appropriate and timely surgical
intervention has dramatically altered the natural history of CHD, however surgery still
comes at a significant cost. Socio-Economic considerations remain the major factor
hampering the growth of this specialty in developing countries.
There is a significant and sadly increasing disparity between health care facilities in the
developed and the developing world. Since the prevalence of CHD is dependant on birth
rates, developed countries with lower birthrates face a lower prevalence. At the same time
they also have more resources to expend on their care. Health care expenditure by
governments as a proportion of GDP is abysmal in developing countries and very little if
any of this is available for high end health care like pediatric cardiac surgery. Increasingly,
therefore in many developing countries pediatric cardiac care is shifting to the nongovernmental sector. Pediatric cardiac surgery in developing countries is particularly
challenging because non-cardiac issues play a major role in determining surgical outcomes.
High quality intensive care is difficult to establish and sustain leading to closure of many
start-up surgical programs.
Nevertheless, despite all these hurdles a lot can still be done. We need to take advantage of
the large intellectual pool and relatively inexpensive labor force available in developing
countries. Over 70% of congenital heart disease is treatable with relatively straightforward
one time surgery.. The focus should therefore be on developing high volume centers
managed by a few well-trained and skilled professionals making appropriate use of an
easily available semi-skilled workforce. Cost cutting measures need to be aggressively
pursued and these include use of locally made consumables and equipment, bulk purchase
of imported items, careful recycling of selected items, rigorous screening of patients preoperatively and careful planning of surgical procedures to reduce post operative
complications. Funding is a constant problem and every available source of funding needs
to be tapped – government, charity organizations, world health bodies, philanthropists,
religious bodies, corporate bodies, rich individuals and other revenue-generating programs
within the same hospital.
Dedicated and goal-directed team-work is the key to success in any pediatric cardiac
program and if cardiac health care professionals in developing countries join hands and
work towards a common goal a lot can be achieved despite the daunting drawbacks.
PCCS 2006
Teiji Akagi, M.D.
Cardiac Care Unit Okayama University Hospital, Japan
Coronary arteriovenous fistula (CAVF) is rare congenital anomaly, usually found out by
continuous precordial heart murmur. Occasionally this disease is found by routine evaluation
of cardiac echocardiography or coronary angiography
Usually, patients have non specific ECG changes, also less symptom even if significant
L-R shunt.
In the point of surgical management of CAVF, direct ligation of fistula is usually
difficult by the anatomy of fistula vessels. Thus, closure of drainage site was performed
under the cardiopulmonary bypass. Thus, the most surgical management is performed
under the non beating heart, that cause of difficulties of simultaneous evaluation of coronary
artery perfusion. Complications are not rare, such as myocardial infarction, cardiac
tamponade, residual shunt, atrial or ventricular arrhythmias after the surgery were reported.
The most benefit of interventional procedure of CAVF is the possibility of
simultaneous evaluation of coronary perfusion. Additionally, repeat or staged procedure
can be possible, CP bypass is not required in the interventional procedure. These can be
contributed to reduce the complications.
Currently, catheter intervention of CAVF is performed by coil, detachable balloon,
Amplatzer duct occluder or vascular plug. The benefit of coil occlusion of CAVF is 1)
small arterial access, 2) excellent flexibility of coil itself and delivery system, 3) easy
repositioning, 4) easy retrieve and 5) availability of various device size.
Procedure is performed under the fully hepalinazation (ACT >200 sec.). Selective
coronary angiography should be performed by several different projections. After that,
test occlusion of distal fistula using small occlusion balloon or regular Berman catheter is
performed to confirm whether ischemic changes are produced by occlusion of fistula or
not. After the confirmation of no producing ischemic change by test occlusion, coil or
other device implantation is performed. After the deployment, repeated coronary
angiography is performed to check the device position and presence of residual leakage.
Indication of catheter intervention for CAVF has been considered as same as surgical
indication. However, under the recent development of interventional procedure, more
preventive indication can be considered. Anticoagulation after the interventional procedure
is not standardized. Aspirin or sometimes warfarin were used after the procedure, contrary,
some investigators follow the patients without anticoagulation. Management of residual
shunt is unclear. Long-term outcome after the interventional procedure including natural
course of aneurysmal dilatation of coronary artery are not known completely.
In conclusion, coil occlusion of coronary AV fistula should be considered as the
initial therapeutic option. Optimal timing, anticoagulation, long-term outcome should be
re-evaluated under the current interventional results.
SPEAKER’S ABSTRACTS November 1, 2006
S5(1/3)
Coil occlusion of AV fistula and collateral
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S5(2/3)
Stenting of coarctation of aorta
Masood Sadiq, M.D.
The Children’s Hospital Punjab Institute of Cardiology, Lahore. Pakistan.
In our part of the world, coarctation of the aorta (CoA) is not uncommonly missed
in early life & patients are diagnosed in adolescence & adult age group usually in the
context of investigation for hypertension. It can be managed in different ways depending
upon the age of presentation, coarctation morphology, whether the coarctation is native or
a recurrence following surgery/angioplasty and the local institutional expertise/results of
each type of treatment. Stent implantation is becoming a popular method of treatment in
older children and adults but is avoided if at all possible in infants and young children
where surgery and balloon angioplasty is preferred treatment.
The rationale for stent implantation is that over dilation of the coarctation segment
are unnecessary, thus avoiding major transmural tears, while at the same time the stent
struts will splint any smaller tears against the aortic wall preventing progressive dissection
and aneurysm formation. The acute elastic recoil of the coarctation segment that contributes
to a suboptimal initial result and later recoarctation is prevented by stent implantation.
In the last decade, stenting has been performed in this age group as an alternative
to balloon angioplasty and surgery with good intermediate term results. A particular role
for stent implantation is in the situation where aortic valve or root replacement or coronary
bypass grafting is needed. Pre-surgical stenting of the coarctation segment removes the
need to dissect the coarctation area or try to recover from bypass in the face of an aortic
obstruction. The risk of aneurysm formation, dissection, aortic rupture and death, however,
has not been eliminated. Excessive stretching of a tight coarctation, however, could still
lead to aneurysm formation and rupture so graded dilation, allowing for healing before
further dilation.
Availability of covered stents may decrease all these complications and has a special
place in developing countries where cost is an important issue. Covered stents will be
especially of value in our part of the world where staged dilatation of bare stent adds
significant cost to the treatment, patient may be lost to the follow up and one off treatment
may have to be offered. Co-existent lesions like PDA can be treated in the same setting
with no extra cost. This is an additional consideration along with other indications like
complex anatomy with tortuous arch, near atretic lesion, long segment coarctation, and
transverse arch coarctation, associated aneurysms whether native, after surgery or catheter
intervention, Turner syndrome and advanced age with higher risk of dissection or rupture.
The most commonly used stent is the balloon dilatable type which allows for further
expansion of the stent as child grows or if further dilatation is needed in a critical lesion.
Palmaz stainless steel stents (J&J) were the first ones to be used. They have a closed cell
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
design which gives them high radial strength but less flexibility. They can foreshorten
significantly (33-50%) if over dilated. Palmaz genesis stent was introduced to overcome
some of shortfalls of Palmaz stent and is designed to have low profile. It can be expanded
to 18mm while maintaining flexibility and radial force. The intrastent (IT) LD stent
(Intratherapeutics, now ev3) was introduced to improve on Palmaz stent. It has an open
cell design for better maneuverability. Elastic recoil and distortion were noticed although
better suited for curve of the arch. The CP stent (NuMed) is made from heat tempered 90%
platinum and 10% Iridium. It can be dilated up to 24mm and is better choice for treating
coarctation.
To evaluate the use of covered Cheatham-Platinum (CP) stents in the management
of native coarctation of the aorta (Co A) in a developing country, 15 covered CP stents
were implanted in 13 procedures on 12 patients with native Co A at our institute in the last
3 years. This represents 36% of 33 patients, who underwent stenting of aortic coarctation
for native coarctation of the aorta at our center during the same period. These were at risk
patients with near atretic lesion, long segment coarctation, transverse arch coarctation,
and Turner syndrome, associated PDA and as rescue treatment in a patient with previous
stent related dissection. In addition patients with severe lesions who would have needed
serial dilatations were offered one off treatment with desired dilatation in one go. One
patient had previous bare stent implantation leading to dissection needing 4 covered stents
in 2 procedures.
Mean patient age and weight were 21( 16) years, range 11-46 yrs and 49( 13) kg, range
35-84kg, respectively. The systolic gradient across the CoA decreased from a mean ( SD)
of 45 23mmHg before, to a mean of 3 4mmHg after the procedure (p<0.0001), and the
diameter of the CoA increased from 5.7 4mm to 18.1 3.8 mm (p<0.0001).
Follow up period was up to 50 months (mean months). All stents were patent and in good
position on CT or MRI performed 3-6 months later. In 33% of the patients antihypertensive
medication was decreased and in one patient it could be stopped.
Our results add to the current limited knowledge about covered stents and these
may be used as the therapy of choice in patients with native coarctation of the aorta with
severe and complex coarctation of aorta and provide a safe cost effective alternative to
conventional stenting in patients likely to need serial dilatations and where they may be
lost to follow up.
The disadvantages of stenting an aortic wall is that it may alter wall compliance,
pressure wave propagation and blood pressure. In young patients additional dilatations
will be required to keep pace with growth. Neointimal growth causing mild restenosis
may also need additional dilatations.
In conclusion, in selected patients with coarctation of the aorta stent implantation is feasible
and short and mid term follow up is encouraging. A small incidence of aneurysm formation
is inevitable in all forms of treatment. Most procedure related complications can be treated
with covered stents. Covered stents may become treatment of choice in adolescents and
adults. Long term follow up is needed to address the complications and disadvantages.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S5(3/3)
Interventional Tips and Techniques of PDA Transcatheter Closure
Mohammad Omar Galal (Saudi Arabia), M.D., Ph.D., MBA
King Faisal Specialist Hospital&RC, Jeddah, Saudi Arabia
PDA closure has been introduced over 30 years ago as an alternative to surgical ligation.
Today, transcatheter closure is regarded as the first choice of treatment for this disease.
There are different types of plugs, occluders and coils devices in clinical use.
This intervention is generally regarded as a relatively straightforward procedure, where
almost all problems have been resolved. This statement goes for most of the ducts.
The different types and sizes of the PDA in relation to the body weight of the patients does
need special techniques in order to offer the patient the best and safest outcome.
Like for all other procedures, decision-making is the most important part of the intervention.
Occasionally few PDA has to be regarded as being not yet amenable for the available
devices. Premature babies with large PDA are still problematic. But also older babies with
very large ducts can be a challenge. A closure of the window type duct is still a technical
brick wall, as it could lead to protrusion of the device into the aorta. Also in the tubular
type PDA, the secure anchoring of the available devices can be very difficult if not
impossible. In case of the combination of a coarctation and a PDA, possibly the implantation
of a covered stent could be the answer. PDA with pulmonary hypertension is another
confront for the clinician.
In this session the different techniques and tips for PDA closure will be discussed in an
interactive way with the attendees.
PCCS 2006
Infective Endocarditis in Pediatric Patients: Thailand Experience
Vachara Jamjureeruk, M.D.
Bangkok Heart Hospital, Bangkok, Thailand
Infective endocarditis in pediatric patient is not a common disease. But, this disease is a
serious one resulting in significant morbidity and mortality. From our retrospective,
collaborative study (Queen Sirikit's National Institute of Child Health, Pediatric Department,
Chulalongkorn University and Pediatric Department, Chiangmai University) from 19892002 had the total of IE in pediatric patients 125 cases. There were 64 boys and 61 girls.
The age ranged from 7 days to 16 years old. The most common organisms were
Streptococcus (33-50%) and Staphylococcus (16.6-41.5 %). The common presenting
symptoms were fever (63-92%), congestive heart failure 19-60 %, splenomegaly 16-39
% and petechiae 8-13 %. The common underlying congenital heart diseases were VSD
(20-30%) and Tetralogy of Fallot (7.7-12%). The Echocardiogram was very useful for
determining the diagnosis of IE by the detection of vegetation and valvular destruction.
The numbers of vegetations ranged from 1 to 4 lesions. One vegetation lesion was the
most common finding. The most common vegetation site was at MV 31.2 % and then at
the TV 11.2 %.The systemic embolism was correlated with the vegetation size of >/ 1 cm.
in diameter especially at the left side of the heart. The complication rate was 63 %. The
most common complications were congestive heart failure (22%) and brain complication
(18%). The overall mortality rate was 19 %. Antibiotics were the mainstay of the treatment.
Appropriate choice, adequate dosage with sufficient length of treatment were needed to
eradicate the organism. Penicillin or ampicillin with gentamycin were the common
antibiotics used at that period and the duration of treatment was 4-6 weeks. In some
severe cases, Cloxacillin, Vancomycin and third generation cephalosporin had to be added.
Due to IE in pediatric patient is one of the serious disease resulting in significant
morbidity and mortality, the early diagnosis and the appropriate treatment especially
antibiotics are very important with cautiousness to look for the complications especially
systemic embolism, brain complication and mycotic aneurysm. Both TTE and TEE may
produce false –negative results if vegetations are small or have already embolized. The
persistent vegetation after systemic embolization, big vegetation (>1 cm.) at the anterior
MV or AV, valve perforation or rupture, prosthetic valve dehiscence, new heart block or
arrhythmias, large myocardial abscess or heart failure unresponsive to medical therapy
are the bad signs of disease which usually need surgical intervention. The CT scan and
MRI for detecting vegetation are limited in children due to insufficient breath holding and
poor cooperation which some of them needed to be under general anesthesia. But this
modality is very important for suspicion of intracranial hemorrhage from rupture of mycotic
SPEAKER’S ABSTRACTS November 1, 2006
S6(1/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
aneurysm or embolism . The new Duke's criteria is very useful and applicable to the care
of pediatric patients. But, clinical presentations of IE in newborn infants have some
differences from children. It is mostly associated with using the invasive techniques to
manage neonate with multiple complex medical problems. The morbidity and mortality
rate are also high in this age group. The IE also should be aware in unexplained high and
prolonged fever pediatric patient despite no definite heart murmur.
PCCS 2006
Risk factor for coronary heart disease: management in childhood in
developing countries
Kalim Uddin Aziz, M.D.
Professor (Emiratus) of Paediatric Cardiology National Institute of Cardiovascular
Diseases, Pakistan
There is evidence to suggest that risk factors (RF) for coronary heart disease (CHD) are
present during early childhood and can be detected. These RF track to adulthood so that
hypertensive, hypercholesterolemic and obese child to ill became hypertensive,
hypercholestrolemic and obese adult .. RF data in Pakistani children population showed
5.3 % prevalence of hypertension, 0.5-2.2% obesity and 9-14% hypercholesterolemia.
These RF can be modified and this has formed the basis of early prevention of CHD in the
early childhood RF modifiers are physically active life style, molding of daily consumption
of calories to the physical activities, modification of diet which involves reduction of fat
consumption, substitution of saturated fats with oils, increase consumption of white meat,
fish, fruits and vegetables.
Various strategies are available for implementing these RF modification recommendations
Universal, community based and targeted, which is physician based.
Pros and Cons of implementation of these recommendations in the developing countries
shall be discussed.
SPEAKER’S ABSTRACTS November 1, 2006
S6(2/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S6(3/3)
Metabolic syndrome in children
Masao Yoshinaga, M.D, Ph.D.
National Hospital Organization Kagoshima Cardiovascular & Cancer Center
Obesity is a serious problem among young people as well as among adults. The number
of preschool children and adolescents who are obese is increasing in both developed and
developing countries, and the current evidence suggests that this problem is rapidly
worsening.
1) Rapid increase in the prevalence of obesity in Japanese elementary school children.1)
As regards the development of obesity in childhood, there appears to be at least three
critical periods: fetal; a period of adiposity rebound between ages 4 and 6; and adolescence.
Our study showed that a significant risk for development of obesity during the elementary
school years (age 6-11 years) applied only to boys from around 1993 onward in our City
and applied throughout the study period (1989-2002) in nationwide Japan.
2) Metabolic syndrome in overweight (at risk for obesity) and obese children.2)
Japanese obese children were found to have a significantly lower prevalence (17.7%) of
metabolic syndrome than US obese adolescents (28.7%, p=0.0014). However, Japanese
overweight children have a similar incidence (8.7%) of metabolic syndrome when compared
with US overweight adolescents (6.8%). Hyperinsulinemia in females and abdominal
obesity in males are characteristic features of individual metabolic syndrome in Japanese
children.
3) Emergence of cardiovascular risk factors from mild obesity in children.3)
In Asian countries, especially Japan, obesity-associated disorders arise in mildly to
moderately obese adults. A tendency toward early development of cardiovascular risk
factors from mild obesity was found not only in adults but also in elementary school
children. An important feature in boys is that an abrupt worsening of insulin resistance
can emerge from both mild and severe obesity.
4) Prevention of mildly obese children from development of more obese condition.4)
Two programs began in 1992 in Kagoshima City; first, a program to screen overweight
children with obesity-related complications, and second, a program to treat obese children.
The treatment program was found to be important because it prevents mildly obese children,
who may worsen their obesity indices without the program, from developing more obese
condition. 4,5)
References
1) Yoshinaga M, et al. Int J Obes, 2004 ;28:494-9.
2) Yoshinaga M, et al. Obes Res, 2005;13:1135-40.
3) Yoshinaga M, et al. Diabetes Care, 2006; 29:1408-10.
4) Yoshinaga M, et al. Prev Med, 2004; 38:172-4.
5) Tanaka S, Yoshinaga M, et al. Circ J, 2005; 69:232-6.
PCCS 2006
Dong Man Seo, M.D.
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
SPEAKER’S ABSTRACTS November 1, 2006
LS1(1/3)
Value repair in congenital MS/MR
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
LS1(2/3)
Mitral and tricuspid valve repair using a Biodegradable Ring in
pediatric population
Afksendiyos Kalangos, M.D.
Clinique de Chirurgic Cardio Vasculaire, HCUG, Geneva, Switzerland
PCCS 2006
The Kalangos Ring in pediatric valve repair
Mohamad Azhari Yakub, M.D.
National Heart Institute, Kuala Lumpur, Malaysia
SPEAKER’S ABSTRACTS November 1, 2006
LS1(3/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S7(1/3)
The Role of Multislice Computed Tomography in the Diagnosis of
Congenital Heart Disease
William C.L. Yip, M.D.
National University Hospital Singapore Baby & Child Clinic
Currently the most important tool for diagnostic evaluation of congenital heart
disease (CHD) is echocardiography. In experienced hands most of the congenital heart
defects in infants and young children can be delineated with confidence. Indeed many of
them can be surgically corrected without the need of cardiac catheterization. However,
crucial information of certain cardiac anatomy, like extracardiac structures, systemic and
pulmonary veins and surgical shunts, may not be adequately imaged when there is poor or
no echo-window, especially in older children and adults.
Although computed tomography has been occasionally utilized to study the anatomy of
the heart, principally by cross sectional imaging for some time, the role of the recently
available multislice computed tomography (MSCT) in the evaluation of CHD has not
been well defined. This paper is not a report of comparative evaluation of MSCT and
other modalities of imaging. Rather, it aims to demonstrate the ability of MSCT to display
specific cardiac anatomy, deemed difficult to or suboptimally imaged by echocardiography.
MSCT enables not only examination of the heart in two-dimension in multiple
number of sub-millimeter thin slices in any selected plane, but also display of astonishingly
accurate reconstructed three-dimensional structures, reminiscent of the gross specimen of
the heart. Advancement in computer technology also allows differential colour-coding,
isolation of structures of interest and rotational viewing, enabling the study of the heart
without actually cutting and touching it, in a manner never possible before. Moreover,
complex CHD is not infrequently associated with tracheobronchial / pulmonary anomalies,
which can be displayed in exquisite clarity by MSCT. Finally the currently available 64slice computed tomography allows rapid acquisition of the data set in less than 5 seconds,
thus minimizing patient’s discomfort and saving time, compared to cardiac catheterization.
Hence MSCT definitely has an useful role in the diagnostic evaluation of CHD.
The unique role of MSCT in the diagnosis of CHD can be summarized below:
1. Demonstration of extracardiac structures, like aortic arch anomalies,
peripheral pulmonary artery anomalies, systemic and pulmonary vein
anomalies, and coronary artery anomalies
2. Display of surgical shunts
3. Delineation of connectional and spatial anomalies, and
4. Demonstration of airway structures and tracheobronchial/pulmonary
anomalies associated with CHD
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
For diagnosis of complex CHD by MSCT, one has to identify first the three cardiac
segments, viz. the morphologic right and left atria and ventricles, and the great arteries,
namely, aorta and pulmonary artery. This is achieved by identification of the respective
typical morphological atrial appendages to establish the atrial situs. The definition of the
atrial situs can be further collaborated by the display of morphology of the bronchial trees
and lungs. The characteristic trabecular morphology of the respective ventricles can also
be accurately demonstrated by MSCT, thus confidently differentiating the morphologic
left from the right ventricle. The branches of aorta and the peripheral pulmonary arteries
can be identified with ease from their respective origin. With experience, the systemic and
pulmonary venous structures can also be demonstrated without much difficulty.
The next step is to display the connection of the three segments of the heart and the
venous drainage to the respective atrial chamber. The connectional and spatial relationship
of the various components of the heart is best demonstrated by multiple two-dimensional
slices of the heart in different planes. Finally the associated structural lesions (like septal
defects and valvar stenosis or atresia) and variation of the size of the components of the
heart (like hypoplasia of ventricular chamber and aortic arch hypoplasia) can be clearly
demonstrated by MSCT.
In summary, because of the unique features of MSCT, it enables cardiologists to
image accurately extra-cardiac structural defects and complex CHD which is frequently
associated with complicated connectional and spatial abnormality. This is especially
important in older children and adults, where echocardiography is frequently handicapped
by poor or no echo-window and by its inability to image clearly the tracheobronchial tree
and the extracardiac structures. However, in view of the radiation exposure, MSCT should
only be carried out when the anatomy cannot be adequately displayed by echocardiography
and simultaneous cardiac catheterization is not deemed necessary in the same occasion, in
order to minimize the radiation risk to patients.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S7(2/3)
Advance of cardiac MRI in the evaluation of CHD
Suvipaporn Siripornpitak, M.D.
Department of Radiology, Ramathibody Hospital, Mahidol University, Bangkok, Thailand
PCCS 2006
3D and 4D echo: Does it matter?
David J. Sahn, M.D.
Professor of Pediatrics, Diagnostic Radiology, Obstetrics & Gynecology and Biomedical
Engineering Director, OHSU Interdisciplinary Program in
Cardiac Imaging L608, Pediatric Cardiology Oregon Health & Science University
SPEAKER’S ABSTRACTS November 1, 2006
S7(3/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S8(1/3)
Ventricular Assist Devices (VAD)
Anthony C. Chang, M.D., MBA
CHOC Heart Institute Children’s Hospital of Orange County
“See Chang, A. C. and E. D. McKenzie (2005). “Mechanical cardiopulmonary support in
children and young adults: extracorporeal membrane oxygenation, ventricular assist devices,
and long-term support devices. “ Pediatr Cardiol 26(1): 2-28.”
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
S8(2/3)
Post – operative ECLS
Laurance L. Lequier, M.D., FRCP (C)
Director of ELCS Program, Strolley’s Children Hospital, Canada
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S8(3/3)
Organization of ECLS Team in Medical Center and the Multi-application
Yih Sharng Chen (Taiwan), M.D., Ph.D.
National Taiwan University Hospital, Taipei, Taiwan
Extracorporeal life support (ECLS), also called extracorporeal membrane
oxygenation (ECMO), had been widely applied in the neonatal pulmonary disease with
excellent and stable outcome. However, ECLS for neonatal pulmonary disease is gradually
decreased because of the recent advancement of pulmonary physiology and ventilator.
ECLS for Cardiac support is gradually accepted internationally and the result is improving.
The patient group is also extended from neonate to pediatric group, and even to adult
patients.
Organization of ECLS team is essential for a medical center to start a steady ECLS
program. Physicians, including pediatric ICUist, pulmonologist, cardiologist and surgeons
(cardiovascular surgeons is more suitable), special technicians and nurses should recruited.
Centralization of instrumentation, simplification of the equipment and regular member
training and education are important issue to maintain improvement of the ECLS program.
However, adequate case for ECLS (the economic scale) is important to keep the team
economic balance.
With the improvement in ECLS, it has been applied not only in postcardiotomy
shock, but also applied in patients under resuscitation and cardiac massage, non-heartbeating donation. Our data of ECLS application in CPR had 33% survival in adult and
40% survival in pediatric group. In pediatric group, the patients with isolated cardiac
disease had survival rate of 47% and better outcome in those with other medical conditions
had survival of 25%. The non-survivors had a higher serum lactate levels, longer duration
of cardiopulmonary resuscitation and presence of renal failure after ECPR. 80% of the
survivors had normal neurological function.
We also applied ECLS as screening tool to select suitable candidate for VAD
implant. It is controversial in VAD or ECLS selection in the early stage of collapse. But
the selection of the proper mechanical support is location/nation specific. It depends on
the different local sources in different nations or areas.
ECLS is improving its selection criteria and it outcome.
PCCS 2006
Lateral tunnel vs extracardiac Fontan: Which is the best?
Thomas L. Spray, M.D.
Children’s Hospital of Philadelphia, PA, USA
SPEAKER’S ABSTRACTS November 1, 2006
S9(1/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S9(2/3)
Fontan in heterotaxy syndrome
Hiromi Kurosawa, M.D.
Tokyo Women’s Medical University, Tokyo, Japan
PCCS 2006
Alternatives for unsuitable Fontan
Roger B. B. Mee, M.D.
Chairman Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic.
(Retired)
For an unseptatable heart the Fontan type procedure offers the most efficient circuit,
in theory, but when performed on less than suitable patients, the result is unpleasant.
Therefore, considerable thought, based on good data, needs to be exercised before tracking
a patient towards a Fontan, and if so tracked, before the final decision to complete the
Fontan. The Bidirectional Cavo Pulmonary Shunt has been a useful intermediate step but,
again, should not be used automatically. In less than suitable cases, there are alternatives
which will be associated with a better quality of life. There are factors which may suggest
unsuitability for a Fontan, but if they are correctable, an at least average Fontan may
ensue. Static Fontan criteria have been established (Fontan & Baudet) and variously
challenged. It may be more useful to work with a list of prospective criteria. Whatever the
management strategy, the basic principles of Fontan tracking are based on early diagnosis.
Preliminary palliations should be designed to preserve the entire pulmonary circuit and
avoid prolonged volume and pressure overload on the ventricular mass.
The most common errors in management decision making are based on erroneous
calculation of total resistance to forward blood flow through the pulmonary circuit, and on
the shallowness of “wishful thinking”. Sometimes, interim repair of fixable defects, may
result in a patient who proves more suitable for a Fontan when reassessed a year or two
later. If it is determined that a given patient will have a less than average Fontan result, a
better quality of life may be offered by procedures providing controlled pulmonary blood
flow in the presence of venous admixing. The 1 ? ventricle repair offers an alternative but
is usually only usable in patients who could have had a Fontan procedure.
For non-septatable hearts, all available procedures, including heart transplantation,
offer a palliation to patients who won’t have a long life expectancy.
SPEAKER’S ABSTRACTS November 1, 2006
S9(3/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S10(1/3)
Marfan syndrome
Heung Jae Lee, M.D.
Professor of Pediatrics, Sungkyunkwan University School of Medicine
Samsung Medical Center, Seoul, Korea
The Marfan syndrome (MFS) is an autosomal dominant disorder of connective
tissue characterized by involvement of three major systems (skeletal, ocular, and
cardiovascular) due to alteration in microfibrils, but with highly variable clinical
manifestations. Mutations in the gene for fibrillin-1 (FBN1) at 15q21.1 was found to cause
Marfan syndrome in 1991, and in 2004 TGFBR2 at 3p24.1 was newly identified as the
Marfan syndrome type II gene. More than 500 FBN1 mutations have been found to date,
and tentative genotype - phenotype correlations have emerged. FBN1 mutations have been
found not only in MFS, but also in a range of connective tissue disorders collectively
termed ‘fibrillinopathies’ ranging from mild form of isolated ectopia lentis, to severe
disorders including neonatal MFS, which generally leads to death in infancy.
TGFBR2 mutations are still limited, however, in 2005 were also reported to cause a new
aneurysm syndrome.
This review intends to provide an overview of clinical overview of MFS and the
mutations found in MFS. The review will includes the clinical characteristics of ca 230
MFS patients listed in database of the Marfan clinic in Samsung Medical Center(SMC),
and will include the results of our mutation analysis of FBN-1 gene in 54 Koreans with
MFS(Yoo, Lee & Ki)
From May 2003 to July 2006, a total of 54 Korean patients were referred to SMC
for FBN1 gene analysis. Among them, 23 patients fulfilled or possibly meet the diagnostic
criteria of MFS by Ghent criteria (Group I) but 9 patients did not (Group II). Remaining
22 patients could not be evaluated due to lack of information (Group III). All patient’s
genomic DNA was extracted, amplified and sequenced for whole exons and their flanking
intronic regions of the FBN1 gene. In Group I, 18 out of 23 patients (78.3%) had the FBN1
gene mutations but none in Group II had the mutation. In Group III, FBN1 gene mutations
were found in 10 patients (35.5%). Among 29 FBN1 mutations identified in the present
study, 22 were novel and 7 were previously reported mutations. Sixty-two percent of the
all mutations (18/29) occurred in cbEGF-like modules and 44.8% (13/29) were either
nonsense or frameshift mutations that led to a premature termination codon. In line with
previous reports, classical or suspected MFS patients showed higher probability of carrying
FBN1 gene mutation but none had the mutation who did not fulfill the Ghent criteria.
Therefore, careful evaluation of any patient with suspected MFS according to the Ghent
criteria is important for predicting positive result on FBN1 gene testing and the mutation
analysis of FBN1 gene is very useful for confirmatory diagnosis and genetic counseling
for MFS.
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
S10(2/3)
Genetic basis of cardiac arrhythmias
Chun-Wei Lu, M.D.
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S10(3/3)
22q11 deletion
In-Sook Park, M.D.
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
PCCS 2006
Novel ECHO parameter for cardiac functional evaluation
David Sahn, M.D.
Oregon Health Sciences University, Portland, OR, USA
SPEAKER’S ABSTRACTS November 1, 2006
S11(1/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S11(2/3)
Tele-echo for congenital heart disease: Our experience in India
Sunita Maheshwari, M.D.
Consultant Pediatric Cardiologist Narayana Hrudayalaya, Bangalore India
Diagnosis is key! Without an adequate diagnosis, a child with heart disease may
never reach a center that can treat the child, either medically or surgically. Although there
are several internists and adult cardiologists in remote India there is a severe dearth of
Pediatric Cardiologists or any trained personnel who can do or interpret a Pediatric echo.
Even if semi-trained personnel can be deployed in remote areas the high cost of establishing
a tele medicine facility may be a deterrent.
Over the past 2 years we have, through trial and error, established low cost tele
echo solutions for remote India. Technicians or internists/pediatricians spent 2-4 weeks at
our tertiary care center learning the basics of Pediatric echo. On return we linked them to
our center either via a basic setup which included a video camera or more recently via a
locally created software that costs 1500$ as a one time setup charge.
Tele-echo with remote sites with the interpreting cardiologist being at our tertiary
center in Bangalore was performed on more than 1200 children. Of these children over
350 came to the tertiary center and got operated. The diagnosis via tele-echo was accurate
enough to refer straight to the operating room in most patients; however, in a minority of
the patients, some changes in the echo diagnosis on site changed the eventual surgical
management.
The advantage of tele-echo for use in remote areas of Asia are 1) an accurate
diagnosis can be made on a child with suspected heart disease and 2) the management
strategy can be discussed with the treating doctor and patient before the patient travels
long distances to a tertiary center. Thus, high quality pediatric cardiac care can begin to be
delivered to children who otherwise would not have access to a diagnosis, let alone
treatment.
PCCS 2006
Real Time Three-dimensional Transthoracic Echocardiography in
Congenital Heart Disease
Guo-Ying Huang, M.D.
Pediatric Heart Center, Children’s Hospital of Fudan University, Shanghai 200032, China
Abstract: A series of studies have shown that transthoracic real-time three-dimensional
echocardiography (RT3DE) is able to provide better information on spatial recognition of
the VSD and ASD and their relationship to the surrounding anatomic structures as compared
with color Doppler echocardiography, and it may become an optimal tool for clinical
diagnosis in congenital cardiac septal defects. More recently, the reliability and advantage
of RT3DE has been used to evaluate complex congenital heart disease in our center. Fifty
patients with complex CHD were examined by RT-3DE with modes of Live 3DE and Full
Volume. Ten sectional volumetric views and Van Praagh sequential segmental approach
were introduced to reveal the pathological morphology of the hearts, which were compared
with the findings of two-dimensional echocardiography, angiography and cardiac surgery.
The results showed that 190 image acquisitions of Full Volume were performed at several
acoustic windows including subcostal, apical and parasternal regions. Among them, 94.2%
(179/190) of image acquisitions were successful. Most sectional volumetric views could
be clearly displayed in 92.6% of the successful image acquisitions. However, sectional
volumetric views could not be clearly displayed in 7.4%, which was mainly due to poor
perspective conditions of examination location, improper instrument multi-parameter setting
and insufficient information of whole heart captured in Full Volume acquisitions. As
compared with surgical findings and angiography, RT-3DE made correction to the diagnoses
in 2 cases including one with corrected transposition of the great arteries and the other
with single atrium and mitral cleft. The diagnoses initially made by 2DE for these 2 patients
were complete transposition of the great arteries and complete atrio-ventricular septal
defect. We concluded that RT-3DE can clearly display the pathological morphology of
complex CHD by using sectional volumetric views combined with sequential segmental
approach through providing more spatial informative cardiovascular structures.
Key Words: echocardiography; real time; three dimensional imaging; congenital heart
disease
SPEAKER’S ABSTRACTS November 1, 2006
S11(3/3)
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S12(1/2)
Case presentation from SCMC
Zhuoming XU, M.D., Ph.D.
Cardiac Intensive Care Unit, Shanghai Children’s Medical Center, Shanghai, China
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
S12(2/2)
Case presentation from SCH
Laurance L. Lequier, M.D.
Strolley’s Children Hospital, Canada
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S13(1/3)
Childhood cardiomyopathy: Experience in Australia
James L. Wilkinson, M.D.
Royal Melbourne Hospital, Melbourne, Australia
PCCS 2006
SPEAKER’S ABSTRACTS November 1, 2006
S13(2/3)
Cell therapy
Christoff STamm, M.D.
Deutsches Herzzentrum Berlin, Berlin, Germany
SPEAKER’S ABSTRACTS November 1, 2006
PCCS 2006
S13(3/3)
Heart transplantation
Yih-Sharng Chen, M.D., Ph.D.
National Taiwan University Hospital, Taipei, Taiwan
Cardiomyopathy continues to be a unsolved and unclear topic in heart failure. Several
advancements had been approached with improvement. Early detection of the failing heart
with more accurate tool, BNP, MRI and tissue Doppler, help physicians to intervene the
early stage of heart failure before the failure loses control. The improvement in
pharmacology and exercise physiology also extended the survival of chronic failure and
the quality of the life.
Pediatric heart transplantation has undergone major changes over the past two
decades, marked by a substantial improvement in survival, ultimate the ABO-incompatible
infant donors, and enhancement in quality of life for transplant recipients. Actuarial survival
has improved substantially in the last decade. Due to the shortage of pediatric donor hearts
in Asia, various biological and mechanical bridge methods had been used to prolong waiting
patients’ survival. There are now new left and right ventricular assist devices that are
suitable for use in infants as a bridge to transplantation. New immunosuppressive agents
have reduced the risk of rejection while minimizing side effects and strategies to reduce
the risk of graft coronary disease are beginning to show promise. Finally, long-term survival
for children after heart transplant is improving to better quality of life.
PCCS 2006
S14(1/3)
Surgical repair: How to avoid late complication
SPEAKER’S ABSTRACTS November 2, 2006
Shunji Sano, M.D.
Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
PCCS 2006
S14(2/3)
SPEAKER’S ABSTRACTS November 2, 2006
Physiologic determinant of PR
Andrew N. Redington, M.D.
Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
PCCS 2006
S14(3/3)
The role of the evaluation of PR/RV function post TOF repair
In patients with TOF repair, long-term postsurgical outcome depends on chronic PR, RV
dilatation, and ventricular dysfunction. Cardiac MRI is a well-established diagnostic method
(the standard of reference) for quantification of PR fraction and evaluation of RV function,
and thereby it may be helpful to determine optimal timing of intervention for preventing
deterioration of cardiac function and improving long-term outcome during serial
postoperative follow-up of this cohort.
ECG-gated phase-contrast imaging is used for calculation of PR fraction and ECG-gated
balanced steady state free precession (SSFP) imaging provides end-diastolic and endsystolic volumes, ejection fraction, and mass of RV. Although both MR techniques are
quite accurate and reproducible, several limitations and pitfalls are worth considering. For
PR fraction, data obtained from the main pulmonary artery may not be accurate because
of its short length and motion. In such case, we can rely on data calculated from both
branch pulmonary arteries. To overcome this limitation, a vessel-tracking technique should
be employed to phase-contrast imaging in the future. The same PR fraction may have
different clinical impacts and, therefore, it should be interpreted with other hemodynamic
parameters. It is not easy in defining paravalvuar (the pulmonary and tricuspid valves)
areas of RV, which is a main source of error in RV volume measurement. Cross-reference
between short- and long-axis cine imaging is quite helpful to reduce this error. Better
segmentation between myocardium and blood may eventually increase the accuracy of
MR evaluation of RV function. Exclusion of RVOT aneurysm and correction of pulmonary
regurgitation are other unsolved problems in the evaluation of RV function.
Comprehensive analysis of hemodynamic events occurred in RV and MR tissue Doppler
evaluation will enhance our understanding of substrates in MR evaluation of post TOF.
Further studies are necessary to establish more clear guidelines of PR and RV function
provided by MRI as to when patients with TOF repair should be treated.
SPEAKER’S ABSTRACTS November 2, 2006
Hyun Woo Goo, M.D.
Department of Radiology
University of Ulsan College of Medicine, Asan Medical Center
PCCS 2006
S15(1/3)
SPEAKER’S ABSTRACTS November 2, 2006
Evolution of Acute Rheumatic Fever (ARF) presentation: Does the
Jones Criteria work well in high prevalence countries?
Nigel Wilson, M.D.
Pediatric Cardiologist Green Lane Hospital Clinical Services Starship Hospital
Auckland, New Zealand
The risk of ARF after the first attack of group A streptoccoci is approximately 0.33%, but with subsequent infection this risk rises to 25-75%. In addition, those who suffer
carditis during their initial attack are significantly more likely to develop further carditis
with subsequent streptococcal throat infections. Secondary penicillin prophylaxis reduces
the incidence of recurrent rheumatic fever, the need for hospitalisation and cardiac surgery.
Hence it is important not to under-diagnose ARF especially in developing countries.
There is no single symptom, sign, or laboratory test that is diagnostic for ARF. The
Jones criteria for the diagnosis of ARF were introduced in 1944. The criteria divide the
clinical features of ARF into major and minor manifestations, based on their prevalence
and specificity. The Jones criteria have been periodically modified and updated by the
American Heart Association. The 1992 update is currently the most widely used and
quoted version. Each change to the Jones criteria was made to improve specificity at the
expense of sensitivity, largely in response to the falling incidence of ARF in the USA. As
a result, the criteria may not be sensitive enough to pick up disease in high incidence
populations in whom the consequences of under-diagnosis are likely to be greater than
those of over-diagnosis. Moreover, the pre-test probability for the diagnosis of ARF varies
according to location and ethnicity e.g. a child with fever and arthritis is more likely to
have ARF in a region with high ARF incidence compared to a region with low ARF
incidence, similarly indigenous patients in regions with high ARF are more likely to have
ARF than non-indigenous patients in the same region.
Recent data from New Zealand shows the incidence of subclinical or
echocardiographic only carditis is seen in 30-35% of patients but influences the diagnosis
in only 10% of cases with ARF. In addition 2nd and 3rd degree heart block in ARF is not
uncommon, has benign prognosis, but is of diagnostic significance.
Studies from India, Australia and New Zealand reveal that mono-arthritis can be a
frequent presentation in ARF as well as classical migratory polyarthritis or polyarthralgia.
The main modifications made to the Jones 1992 criteria for the recent New Zealand
guidelines (http://www.heartfoundation.org.nz) and Australian guidelines (http://
www.heartfoundation.com.au) are
1) echocardiographic evidence of subclinical carditis as a major criterion
2) monoarthritis can be a major criterion especially when there is a history of
PCCS 2006
SPEAKER’S ABSTRACTS November 2, 2006
non-steroidal anti-inflammatory use that is likely to have aborted migratory
polyarthritis
Conclusion. The Jones criteria still forms the basis for diagnosis of ARF but in countries
with high prevalence of ARF experienced clinicians are expanding the criteria to avoid
under diagnosis.
PCCS 2006
S15(2/3)
SPEAKER’S ABSTRACTS November 2, 2006
The use of Echocardiography in Acute Rheumatic Fever.
Manat Panamonta, M.D.
Khon-Kaen University, Khon-Kaen, Thailand
Acute rheumatic fever (ARF) is an inflammatory syndrome which follows group A
beta-hemolytic streptococcal infection of the throat. ARF consists of clinical manifestations
including carditis, arthritis, Sydenham’s chorea, subcutaneous nodule and erythema
marginatum. However, carditis is the most important manifestation of ARF because it can
lead to permanent rheumatic heart disease and death.
Diagnosis of carditis in ARF is generally based on auscultatory findings of either
mitral regurgitation or aortic regurgitation or both. The reported prevalences of carditis in
ARF range from 41-93%. Currently, color Doppler echocardiography (CD Echo) can
detect all audible valvular regurgitation and probably can differrentiate the unheard
pathological valvular regurgitation so called subclinical carditis (SCC) from functional or
physiological flow disturbance. WHO criteria are widely accepted for echocardiographic
diagnosis of SCC including: the jet should be > 1 cm in length, seen in at least 2 planes,
have a peak velocity > 2.5 m/sec, and persist throughout systole(mitral valve) or
diastole(aortic valve). To date, the reported prevalences of SCC in ARF ranged from 0%
(in one study) to 53% in 23 reports. In addition, the data of these reports also suggested
that approximately half of the patients diagnosed with SCC at the time of ARF had
persistence or deterioration of the carditis over the two-year follow-up. Therefore, it became
apparent that CD echo has been proven to be a useful tool in the early diagnosis of rheumatic
carditis and for the follow-up of rheumatic heart disease.
The great concern is how long of the prophylactic duration for a patient with SCC.
Since the duration of secondary prophylaxis depends on the risk of ARF recurrence
including the presence of clinical (auscultatory) evidence of carditis. According to the
WHO recommendation, the duration of secondary prophylaxis should be continued beyond
5 years after the last attack of ARF or until 18 years of age (whichever is longer) in a
patient without proven carditis. However, the evolution of valve damage during a
recurrence, in a patient who did not have apparent carditis in the initial attack of ARF, has
been a subject of debate. It has long been known that a patient who has no apparent
carditis in the initial attack of ARF is likely to remain free of carditis during a recurrence.
However, the study from Thailand revealed that rheumatic recurrence can develop new
valve damage evident by echocardiography for the patients with initially SCC. Longer
duration of secondary prophylaxis is recommended to prevent a recurrence of rheumatic
fever in the patient with SCC.
PCCS 2006
S15(3/3)
RHD after 30 years of benzathine penicillin
SPEAKER’S ABSTRACTS November 2, 2006
Hung Chi Lue, M.D.
National Taiwan University, Taiwan
PCCS 2006
P2(1/2)
SPEAKER’S ABSTRACTS November 2, 2006
Tissue Engineering in CHD
Hiromi Kurosawa, M.D.
Tokyo Women’s Medical Cernter, Tokyo, Japan
PCCS 2006
P2(2/2)
Advanced ultrasound methods for procedural guidance in
non-invasive cardiovascular imaging
SPEAKER’S ABSTRACTS November 2, 2006
David Sahn M.D.
Oregon Health Sciences University, Portland, OR, USA
PCCS 2006
S16(1/3)
SPEAKER’S ABSTRACTS November 2, 2006
Basic mechanism and treatments of heart failure in children
Makoto Nakazawa, M.D.
Sounthern TOHOKU General Hospital, Sounthern TOHOKU Research Institute,
Fukushima, Japan
PCCS 2006
S16(2/3)
LCOS in CICU without mechanical support : What is possible ?
Mechanical support is often considered a routine tool in the PCICU and is available
for rapid deployment whenever needed in most developed countries. In India, despite
rapid industrialization over the last decade pediatric cardiac care is largely provided by
non governmental institutions. Our public health care policy does not cover expense for
pediatric cardiac care and health insurance excludes “all birth defects”. Thus, the prohibitive
costs of mechanical support has to be largely borne by the family. Most instances of severe
refractory low cardiac output state (LCOS) where mechanical support may be useful often
occur in infants and children whose families are least able to incur such expenses. Thus, in
our country alternative, less expensive modalities assume increasing importance and often
need to be speedily employed.
The author’s experience largely constitutes postoperative management of severe
LCOS without mechanical support. Even though progressive low cardiac output states
occur after cardiac surgery, appropriate anticipation, early identification and aggressive
management has been shown to minimize the need for mechanical support. Most pediatric
cardiac centers report a < 2% need for ECMO or other mechanical support in infants and
children after cardiac surgery with this approach. Thus, our current multipronged approach
is highly proactive and focuses greatly on simple, easily affordable measures to diminish
requirement of mechanical support in high risk surgeries.
Intraoperative measures : This commences with various modalities to minimize
cardiopulmonary bypass mediated injury by prophylactic intraoperative corticosteroid
therapy combined with modified ultrafiltration to remove inflammatory mediators.
Intraoperative ECHOs are done to finetune and perfect surgical repairs. Surgical strategies
in selected high risk instances are currently routine practice. Deferred sternal closure in
situations of late presentation with very poor left ventricular function or prolonged
cardiopulmonary bypass times in complex repairs is “no longer dreaded”. Complications
related to deferred sternal closure like wound infection is unusual and we have thus far
had no instance of mediastinitis. Similarly creation of right to left shunts to decompress
the right ventricle in situations of severe pulmonary hypertension ( hypertensive VSDs,
hypertensive multiple shunts) , selected cases of tetralogy of Fallot, truncus arteriosus) is
a carefully planned and frequently implemented surgical practice.
LCOS protocol : Postoperatively we follow a meticulous approach for early diagnosis of
LCOS and deteriorating cardiac output. Clinical, biochemical and hemodynamic parameters
are vigilantly followed and monitored so that vasoactive therapy can be titrated and
SPEAKER’S ABSTRACTS November 2, 2006
Pavathi Iyer, M.D.
Pediatric & Congenital Heart Surgery, Escorts Heart Institute and Research Center,
Okhla Road, New Delhi, India
SPEAKER’S ABSTRACTS November 2, 2006
PCCS 2006
finetuned. The approach to ventilator dependence and persistent LCOS is aggressive.
Residual structural and physiological issues are looked for assiduously by serial ECHOs
with a low threshold for cardiac catheterization. Residual defects are addressed by resurgery and collaterals or anomalous vessels appropriately coiled.
Milrinone : In our unit, phosphodiesterase III inhibitors like milrinone is usually a second
line drug due to cost constraints. However, in situations where there is high risk of LCOS
“prophylactic high dose milrinone” is instituted early. We also have a low threshold to use
milrinone if the child is not adequately responding to catecholamines. Significant
hypotension is not considered a contraindication to milrinone usage, milrinone being
administered along with gentle volume augmentation - titrated carefully to LA pressures.
We have occasionally used higher than recommended doses up to 2 mcg/Kg/min in severe
left ventricular dysfunction.
Hormones : In catecholamine and milrinone resistant LCOS or hypotension, we have a
low threshold to use corticosteroids. Cortisosteroids are commenced in physiologic doses
and usually an improvement in blood pressures have been observed 12-18 hours later. Our
practice is based on the published paper which showed a reduction in epinephrine
requirement in critically ill cardiac infants after initiation of steroids (1). Similarly, we
routinely monitor thyroid functions in all our patients and thyroid hormones are replenished
in the presence of documented deficiency (2). Occasionally, we have administered thyroxine
even in those infants with borderline or normal thyroid functions with severe LCOS. The
benefit of such thyroxine administration is not yet established.
PEEP, IPPV : Harnessing cardiopulmonary interactions appropriately has been very useful
in managing very severe LCOS. We have used high PEEP of up to 15-20 mm in severe
LCOS with left ventricular failure and pulmonary edema even in the presence of severe
hypotension. There has been a fairly dramatic improvement in blood pressures followed
by improvement in LA p, peripheral perfusion and biochemical parameters. Infants with
severe LV dysfunction are electively supported for a week to 10 days with noninvasive
respiratory support following extubation. Similarly recommended strategies of early
extubation and shorter inspiratory times are used to improve LCOS in infants with
“restrictive physiology” like tetralogy of Fallot (3).
Metabolic control : Most malnourished infants have persistently low ionic calcium levels
in the range of 0.5-0.8mmol/L following CPB. In infants with LCOS, we run a calcium
infusion to restore the ionic calcium homeostasis. In significantly hypocalcemic patients
with LCOS, calcium repletion appears to improve mean arterial pressures. More recently
glycemic control with insulin administration has been shown to improve morbidity due to
LCOS in adults undergoing cardiac surgery (4). Pediatric data is limited but preliminary
published data indicates that hyperglycemia is associated with increased mortality and
morbidity.
In severe LCOS and significant hypotension with no residual structural defects
the most useful measures have been a combination of modalities -early initiation of high
dose milrinone, calcium infusion, early institution of corticosteroids and continued
PCCS 2006
SPEAKER’S ABSTRACTS November 2, 2006
ventilatory support with moderately high PEEP.
Management of PAH : Management of severe postoperative pulmonary hypertension
and pulmonary hypertensive crises has also been considerably improved largely by
refinements of intraoperative and postoperative care with emphasis on avoidance of triggers
of pulmonary artery hyeprtension (PAH), improvements in ventilatory strategies, and the
use of sildenafil as first line pulmonary vasodilator.
We have no experience with arginine vasopressin or newer drugs like nesiritide,
levosimendan since they are unavailable in India.
With a judicious combination of pharmacological methods, appropriate use of
respiratory support and PEEP and attention to calcium homeostasis, it has been possible to
achieve acceptable overall survival rates even in instances of severe PAH and LCOS.
With a mean basic Aristotle score around 6.8 to 6.9 our current overall 30 day survival has
improved to between 98 to 98.5 % over the last 4-5 years. Our current neonatal 30day
survival ranges between 89 to 91 % and 31day to 1 year survival ( the sickest group which
includes infants of late presentation, severe PAH and severe LV dysfunction) is 97 to
98.5%.
In summary, we believe that with attention to detail and refinements of easily
available and affordable modalities most instances of severe LCOS can be salvaged without
access to mechanical support – a modality that my country can ill afford.
References :
1. Shore S, Nelson DP, Pearl JM, Manning PB, Wong H, Shanley TP et al,
Usefulness of corticosteroid therapy in decreasing epinephrine requirements
in critically ill infants with congenital heart disease. Am J Cardiol 2001,
88;591-594.
2. Bettendorf M, Schmidt KG, Grulich-Henn J, Ulmer HE, Heinrich UE. Triiodothyronine treatment in children after cardiac surgery : a double blind,
randomized , placebo controlled study. Lancet 2000, 12; 356(9229):529-534.
3. Cullen S, Shore D, Redington A. Characterization of right ventricular diastolic
performance after complete repair of tetralogy of Fallot. Circulation 1995,
91(6);1782-1789.
4. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckk F et al,
Intensive insulin therapy in critically ill patients. N Eng J Med 2001,
345 (19);1359-1366.
PCCS 2006
S16(3/3)
SPEAKER’S ABSTRACTS November 2, 2006
Heart failure in GUCH
Andrew N. Redington, M.D.
The Hospital for Sick Children, Toronto, Canada
PCCS 2006
S17(1/3)
Aortic translocation in TGA/VSD/PS
SPEAKER’S ABSTRACTS November 2, 2006
Zhi-Wei Xu, M.D.
Shanghai Children Medical Center, Shanghai, China
PCCS 2006
S17(2/3)
SPEAKER’S ABSTRACTS November 2, 2006
TGA with abnormal coronary pattern: tachnique and precaution
Thomas L. Spray, M.D.
Children’s Hospital of Philadelphia, PA, USA
PCCS 2006
S17(3/3)
Long-term follow up after Arterial Switch
The justification for making the change from the Mustard or Senning procedures to the
“Arterial Switch” (Jatene procedure) was the belief that long term follow up would be
likely to show much better survival after the latter operation, even if the early mortality,
associated with the “learning curve” was substantially higher? This change occurred at a
stage when long term follow up after atrial switch operations was limited to about twenty
years and follow up after the arterial switch was limited to little more than five years. Thus
the pressure to change strategies was based on limited solid evidence and may be viewed
as having been a “leap of faith”?
Fortunately the early mortality after arterial switch has dropped to levels comparable with,
or better than, the best results after atrial switch procedures so that the tragic problem of
very high initial mortality, which lead to the “Bristol enquiry” and all its consequences,
has largely disappeared.
Long term follow up after arterial switch now extends to more than twenty years and after
atrial switch to forty years.
Late problems after the earlier (atrial switch) procedures included venous pathway
obstruction, arrhythmias, right ventricular failure and tricuspid regurgitation. Deterioration
and premature death or need for transplant has become a regular phenomenon by middle
adult life (e.g. 40 – 50 years old), or sooner. This has largely confirmed the gloomy prognosis
that was predicted after the first twenty years of follow up, at the time that the change to
arterial switch was being proposed, although a substantial number of patients have had
good quality survival, without major problems, through early adult life, with many females
going through successful pregnancies without problems.
Long term studies of patients after the arterial switch show a different set of problems
which include late coronary stenosis or occlusion – fortunately rare, aortic regurgitation
which becomes more frequent with longer term survival / follow up but rarely requires
intervention within the first twenty years of follow up, pulmonary stenosis (which has
become less common with improved surgical technique) and rare arrhythmias. Recent
evidence raises the prospect of a predisposition to coronary atheroma and later ischaemic
heart disease, but this remains unproven at the present time.
Overall the actuarial survival after arterial switch is excellent, with little late mortality
during the follow up thus far.
SPEAKER’S ABSTRACTS November 2, 2006
James L Wilkinson, Prof., M.D.
Honorary Cardiologist, Royal Melbourne Hospital, Melbourne, Australia
PCCS 2006
LS2(1/3)
SPEAKER’S ABSTRACTS November 2, 2006
Management of Eisenmenger Syndrome (from conventionalto novel approach)
Kritvikrom Durongpisitkul, M.D. FACC
Pulmonary arterial hypertension (PAH) is a recognized complication of congenital heart
disease (CHD) with systemic to pulmonary arterial cardiac shunts. Patients will develop
degree of oxygen desaturation. In Thailand, around 15% of patient who routinely underwent
cardiac catheterization had pulmonary hypertension and required acute pulmonary
vasodilator testing. Eisenmenger physiology (EP) is the most extreme case of the above
phenomenon since it is associated with high pulmonary resistances, right to left shunting
with suboptimal oxygen saturation, and usually large areas of defects allowing the blood
to easily circulate from right to left. The conventional management of this group of patients
will be discussed. We also shared the experience of empirical management with various
pulmonary vasodilator drugs. Also including is a recent double-blind, randomized, placebocontrolled study (BREATHE-5), patients with Eisenmenger physiology treated with new
dual endothelin receptor antagonist (bosentan) which showed a significant decrease in
pulmonary vascular resistance (PVRi) (treatment effect -472dyn.sec.cm-5;p=0.04) and a
significant improvement in exercise capacity, measured by 6-minute walk distance (6MWD)
(treatment effect +34m; p=0.02).
PCCS 2006
LS2(2/3)
Management of Eisenmenger Syndrome: Current practice
SPEAKER’S ABSTRACTS November 2, 2006
Geetha Kandevello, M.D.
National Heart Institute, Kuala Lumpur, Malaysia
PCCS 2006
LS2(3/3)
SPEAKER’S ABSTRACTS November 2, 2006
BREATH 5
Michael A Gatzoulis, M.D.
Royal Brompton Hospital and the National Heart & Lung Institute, London, UK
PCCS 2006
S18(1/3)
Cardiac intensive care in the developing world: Experience in India
Cardiac intensive care in developing countries like India is often perceived as
daunting largely due to concomitant problems of late presentation, malnutrition and
associated infections including various forms of hepatitis. This talk is about our experience
of a decade of pediatric cardiac care in an evolving unit, about the problems we faced and
the simple and affordable strategies that were developed to deliver “meaningful” pediatric
cardiac intensive care.
Our unit was started in 1995 in a private hospital and in the initial years we
performed 300-350 cases annually with an unacceptable 30 day mortality of 7.73% despite
“apparently good surgery”. More than 80% of all deaths occurred in bi-ventricular repairs
and nearly 60 % of all deaths were due to “sepsis syndromes”. In 1995, this appeared to be
the situation in many other units across the country. A compelling need to improve the
situation led to a stringent morbidity and mortality audit coupled with an in-depth study of
risk factors. We interacted closely with large units across the world and some staff members
went overseas for brief periods of re-training. Simple, innovative and affordable strategies
were evolved and implemented – all of which led to a dramatic improvement in outcomes
with reduced morbidity and hospital stays.
Currently we do over 550 cases annually with a mean Basic Aristotle score of 6.8
to 6.9 and our overall 30 day mortality has improved to between 1.5 to 2.5 % over the last
4-5 years. About 40 % of surgical procedures occur in infants < 1 year with two thirds of
all surgeries being in males. Our current neonatal 30day mortality ranges between 9 to 11
% and 31day to 1 year mortality - ( the sickest group which includes infants of late
presentation, severe PAH and severe LV dysfunction) is 1.1 to 2%. “Preventable deaths
due to sepsis” in biventricular repairs is unusual today.
Problems identified and strategies Severe malnutrition : All deaths in large left to right shunts occurred in severely cachectic
infants, problems encountered being pan atelectasis following extubation related to very
poor chest wall compliance. This invariably led to a cascade of events leading to repeated
reintubations, airleaks, sepsis and sepsis syndromes. Simple strategies evolved include
“fast tracking and earlier extubation” (rather than elective prolonged ventilation which
was our earlier practice), “elective prone nursing” after extubation for better alveolar
recruitment and earlier elective recourse to noninvasive ventilatory support.
Likewise our nutritional policy has become more aggressive, enteral feeds being
initiated on the very 1st po day in the absence of suspected bowel ischemia.
SPEAKER’S ABSTRACTS November 2, 2006
Pavathi Iyer, M.D.
Pediatric & Congenital Heart Surgery, Escorts Heart Institute and Research Center,
Okhla Road, New Delhi, India
SPEAKER’S ABSTRACTS November 2, 2006
PCCS 2006
Sepsis (preexisting and iatrogenic): Sepsis was identified as largely due to highly virulent
ESBL producers ie third generation cephalosporin resistant gram negative organisms.
Stringent surveillance of CICU nursing procedures as well as surveillance cultures of
“sick at risk” infants helped early detection of indolent sepsis. Many infants at presentation
(~ 40%) were found to have preexisting gram negative sepsis or asymptomatic urinary
infection which were then treated. Antibiotic usage was rationalized . Severe sepsis was
managed as per the ‘Surviving sepsis campaign’ guidelines (1). Implementation of these
measures alone significantly reduced sepsis related morbidity and mortality.
Other important practices : After basics were addressed, further practices implemented
have been a highly systematic approach to the early diagnosis of low cardiac output state
( LCOS) followed by a more meticulous and aggressive management (2).
Management of the post op infant tetralogy is based on a better understanding of “restrictive
physiology” and on published recommendations (3). Perioperative care of the late
presenting hypercyanotic tetralogy with extensive collaterals has also been considerably
refined and our current 30 day mortality in tetralogy has improved to ~1 %.
Management of severe postoperative pulmonary hypertension and pulmonary
hypertensive crises has been considerably improved by refinements in intraoperative and
postoperative care with emphasis on avoidance of triggers of pulmonary artery hypertension
(PAH), improved ventilatory strategies and the use of sildenafil as first line pulmonary
vasodilator. Persistent postoperative LCOS as well as ventilatory dependence is
aggressively investigated by early and serial ECHOs and re-catheterization. Airway
abnormalities and diaphragmatic paresis are assiduously looked for and addressed
appropriately.
We have also learnt the benefits of “shared knowledge and shared expertise” and practise
a highly integrated team approach and continue to audit ourselves carefully.
Finance and manpower issues : India has witnessed a radical change in pediatric cardiac
care over the last decade. Pediatric cardiac surgery is today largely done in non governmental
institutions with costs being largely borne by the families. Our public health care policy
does not cover expense for pediatric cardiac care and health insurance excludes “all birth
defects”. Total cost ranges from 1,800$ to 5,500$ depending on complexity and duration
of hospital stay. ICU cost is roughly $ 130 per day ( iNO and milrinone are additional
costs). With increased awareness and economic prosperity not only are more families
able to afford this but there is increasing parental and familial expectation with focus
being not only on intact immediate survival but also a good quality future life with good
mainstream integration.
There is a huge manpower crunch with nurses and residents forming the backbone
of the unit. Our unit has one senior and two junior surgeons, 2 cardiologists, 2 anesthetists
and 1 intensivist. There are no nutritionists or respiratory therapists and only a part-time
physiotherapist. There is tremendous migration among nurses and residents to the USA
and Europe, thus our backbone is a “highly floating one”! Our CICU care is thus shared,
with increasing maternal, aunt or grandmother’s involvement in the ICU care.
PCCS 2006
SPEAKER’S ABSTRACTS November 2, 2006
Nurse and resident standards are improved by a focus on in-service education–
both being encouraged to continuously update themselves by electronic reading apart from
regular discussions on ward rounds. Junior medical staff participate in regional and national
meetings while seniors go periodically for retraining to overseas units. Due to this approach,
despite a largely floating and migrant population “the basal standard of care and awareness”
has gradually improved over the last 11 years especially in intensive care – which was the
weakest link !.
In summary, even though we continue to battle late presentation, malnutrition and
overwhelming infections the developing world should not despair, because we believe it
is still possible to salvage 97-98% of all surgical procedures despite huge manpower and
resource constraints.
References :
1. Dellinger PR, Carlet JM, Masur H, Gertach H, Calandra T, Cohen J, et al .
Surviving sepsis campaign guidelines for management of severe sepsis and
septic shock. Crit Care Med 2004, 32 (3); 858-873.
2. Wessel DL. Managing low cardiac output syndrome after congenital heart
surgery. Crit Care Med ( Suppl) 2001, 29 (10); S220-S230.
3. Cullen S, Shore D, Redington A. Characterization of right ventricular diastolic
performance after complete repair of tetralogy of Fallot. Circulation 1995,
91 (6);1782-1789.
PCCS 2006
S18(2/3)
SPEAKER’S ABSTRACTS November 2, 2006
Cardiac intensive care in developing world: Experience in China
Zhuoming XU, M.D.
Shanghai Children Medical Center, Shanghai, China
PCCS 2006
S18(3/3)
Pediatric cardiac intensive care: Experience in Thailand
The pediatric cardiac intensive care is a new subspecialty in Thailand. Most critically ill
children that have been admitted in the pediatric intensive care unit are being taken care
by pediatrician, anesthesiologist, or cardiac surgeon while the pediatric cardiologists are
acting as consultants. This is due to the limited number of certificated pediatric critical
care specialist.
While private hospitals are rapidly growing in numbers, most rural residents still have
very limited access to the health care services. Due to this, the Thai government has initiated
the universal coverage scheme and the referral system and regionalized policies have
been providing chances for the rural area residents to gain access to the appropriate
treatments. However, the misdistribution of facilities and manpower including well trained
specialist, advance technology, equipments and patient education are still the problems.
Most of the sophisticated equipments and treatments are located in the university hospital
and private hospital.
In the past five years, there is a significant increase in the number of congenital heart
operations and they are the major population in cardiac intensive care unit. Most of them
need postoperative care. The strategy to decrease mortality rate and cardiac intensive care
unit cost may be answered by early extubation strategy, step down unit, well organized
intensive care unit and excellent hospital management.
We still need to improve our system to make early diagnosis of congenital heart disease,
early management of cardiac critical condition, and a good transfer system which may
need the transfer teams that consist of specialists to take care of critically ill children.
In developing countries with limited budget, the budgets should be regionalized and the
discrepancies must be controlled. Everyone needs to pay attention to the balance between
technology and limited resources.
There are 62 certified pediatric cardiologists and less number for pediatric cardiac surgeons
in Thailand. The recruitment of new staffs and keeping them are difficult because of the
salary. In the meantime, the holistic approach and patient center care need to be emphasized
and extended to all junior doctors who will be practicing in this high work load field.
The result of the survey on pediatric cardiac intensive care practice in Thailand will be
presented in this symposium session.
SPEAKER’S ABSTRACTS November 2, 2006
Yuttapong Wongswadiwat M.D.
Queen Sirikit Heart Center of the Northeast Khon Kaen University
Khon Kaen, Thailand
PCCS 2006
SPEAKER’S ABSTRACTS November 2, 2006
S19(1/3)
A STAGED CATHETER-SURGERY APPROACH IN TETRALOGY
OF FALLOT WITH PULMONARY ATRESIA AND DIMINUTIVE
PULMONARY ARTERIES
Seong-Ho Kim, M.D.
Halla General Hospital, Jeju, Korea
Pulmonary arteries are defined as diminutive when the Nakata index is smaller than 90, or
in cases if the continuous pulmonary arteries are supplied by major aortopulmonary
collaterals, it is upto 150. Tetralogy of Fallot with pulmonary atresia and diminutive
pulmonary arteries is difficult to manage, even though several methods of treatment have
been tried. Last year, a study about a multi staged surgical approach was reported from
Melbourne(JTCS 2005). Its subtitle was “unifocalization brings no long-term benefits.”
Among 60 unifocalized MAPCAs, 26 were thrombosed, and 12 showed stenosis more
than 50%. A new collaborative approach-a staged catheter-surgery approach- has been
introduced since stenotic pulmonary arteries could be enlarged by balloon dilation. This
approach is composed of 4 steps. First, catheterization is performed to define PA anatomy
and collateral circulation, and to embolize MAPCAs with coils. Second, surgery of
establishing RV to PA continuity with a conduit or outflow patch is performed, and it
increases pulmonary flow and allows catheter access to PA. In step 3, catheterization is
performed again to redefine PA and collaterals, to dilate peripheral PA stenosis, to embolize
collaterals, and to reassess hemodynamics. Finally, surgery is performed to close VSD
and to reconstruct RV outflow tract.
Rome et al reported in 1993 the preliminary result of this approach was superior to other
approaches such as conservative treatment, primary unifocalization or BT shunt. They
could achieve complete repair in 10 of 20 patients. I would like to briefly introduce our
results of this staged catheter-surgery approach. Eighteen patients (PAI=55 18) who was
diagnosed as Tetralogy of Fallot with pulmonary atresia and diminutive pulmonary arteries
followed this staged approach. Fifteen of 18 patients(83%) could achieve complete
biventricular repair, and 3 patients died - 2 after first surgery, and one after total correction.
The final mean pressure ratio of right ventricle to aorta after total correction was 0.63.
Establishment of early right ventricle to pulmonary arterial continuity with subsequent
pulmonary balloon angioplasty and coil embolization of collaterals allow eventual
successful complete repair in 83% of patients. This may be a superior outcome compared
with those of previous reports. Nevertheless, long-term follow-up is warranted.
PCCS 2006
S19(2/3)
From Bench to Clinical Practice: Lesson Learned From PlatinumCoated Nitinol Device
During the past 50 years, several devices for transcatheter closure of atrial septal defect
(ASD) and patent ductus arteriosus (PDA) have been developed. With the wonderful superelastic
and shape memory property of Nitinol, new devices composed of Nitinol, have been designed
in the last decade. These new devices have been extremely tolerated and widely used. Although
Nitinol alloy has a good biocompatibility, nickel release after Nitinol device implantation has
been demonstrated (Ries et al. 2003, Burian et al 2006). In addition, systemic allergic reaction
after Nitinol device implantation has also been reported (Fukahara et al. 2003, Vincent et al.
2003). Because of the nickel’s adverse biological effects, including potent allergen, extreme
toxicity and possible suspected carcinogen; nickel release phenomenon after Nitinol device
implantation in the body should be concerned. Platinum is a biocompatible metal, resist to
corrosion and has no allergic reaction. With nanotechnology, namely Nanofusion, layers of
platinum atoms can be placed on top of the Nitinol wire for the purpose of preventing nickel
release.
The ASD and PDA devices were braided from the platinum-coated Nitinol wires and
filled with polyester sheaths for enhancement of thrombogenicity. In the swine model, ASD
device was successfully implanted to close ASD that was created by transcatheter balloon
dilation of patent foramen ovale. The PDA study, designed by occlusion of the subclavian
artery with PDA device, also had a successful outcome. The echocardiographic study showed
complete closure of the created ASD within an hour after implantation. The PDA device totally
occluded the subclavian artery within a few minutes after implantation. The post-mortem
study confirmed complete closure of the ASD and the subclavian artery. It also demonstrated
complete neoendothelialization over the surface of the ASD device, occurred within 6 weeks
after implantation.
In the clinical trial, 33 ASD cases was attempted to perform transcatheter closure.
Twenty nine patients had successful deployment and all had complete closure within 1 month
after implantation. The procedure-related complications included transient brachial plexus
injury in 1, transient complete heart block in 1, and transient junctional rhythm in 3 patients.
There was no device-related complication during 4-12 months follow-up. The PDA device
was successfully deployed in 30 patients. There was no serious procedural complication. Twenty
nine of 30 patients had complete closure within 24 hours after the procedure. One patient still
had tiny leak at 8 months follow-up. Serum nickel level was studied in 25 ASD cases and 25
PDA cases, before and within 90 days after implantation. There was no significant difference
in serum nickel level in both groups before and after implantation.
The platinum-coated Nitinol ASD and PDA devices had good results in both animal
experiment and clinical trial. The platinum coating can prevent nickel release from Nitinol alloy
after device implantation.
SPEAKER’S ABSTRACTS November 2, 2006
Pornthep Lertsapcharoen, M.D.
Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok,
Thailand
PCCS 2006
S19(3/3)
SPEAKER’S ABSTRACTS November 2, 2006
PDA stenting: what is the indication and outcome
Mazeni Alwi, M.D.
Consultant & Head Department of Paediatric Cardiology Institut Jantung Negara
(National Heart Institute), Kuala Lumpur, Malaysia
PDA stenting is an attractive alternative to conventional shunt surgery in duct dependent
congenital heart disease as it avoids thoracotomy and its related problems. With today’s
generation of coronary stents which have better profile, flexibility and trackability, PDA
stenting may be achieved safely and with considerably less difficulty than previously
described.
The indications for PDA stenting is exactly the same at Blalock Taussig shunt. In the
modern era of cardiac surgery where corrective/definitive surgery for various complex
congenital heart diseases is done in late infancy or early childhood, PDA stenting is indicated
mainly in duct-dependent lesions chiefly in the neonatal period. PDA stenting is also
indicated as adjunct to pulmonary valvotomy in PAIVS or critical PS when the RV is
deemed too hypoplastic to support the pulmonary circulation. Apart from indication, it is
also pertinent to discuss about the contraindications of PDA stenting. This is chiefly because
stenting the PDA tends to accelerate pre-existing branch PA stenosis. Unlike the PDA as
an isolated lesion, the ductus in cyanotic heart disease have a remarkable morphologic
variability. The ductus tends to arise more proximally under the aortic arch, giving rise to
a vertical PDA or occasionally it may arise from the subclavian artery. It also tends to be
long and sometimes very tortuous, rendering stent implantation technically impossible.
The ductus in these patients may also insert onto one of the branch pulmonary arteries
with some stenosis at the site of insertion (pulmonary coarctation). The ductus in TOF
with PA tend to exhibit these morphologic features and to a lesser degree TGA-VSD-PS
and the more complex forms of univentricular hearts.
The presence of pre-existing branch PA stenosis at the site of PDA insertion should be
considered a contra-indication for PDA stenting, especially in those destined for the Fontan
track. PDAs that are long and very tortuous is also a contraindication for technical reasons.
PDAs that are larger than 3.5 mm should also be considered contraindication if small
coronary stents are to be used because of the likelihood of stent migration.
PDA stenting is effective maintaining ductal patency and provides sufficient palliation
until the definitive surgery in the majority of cases. However the durability of stent patency
is considerably less than Blalock Taussig shunt due to rapid neo-intimal proliferation.
This may require a palliative Blalock Taussig shunt in a small number of cases.
The major complication of PDA stenting is acute thrombosis but this is uncommon.
Haemodynamic instability is often transient. ICU and hospital stay tends to be more
PCCS 2006
SPEAKER’S ABSTRACTS November 2, 2006
favourable compared to Blalock Taussig shunt.
In summary, PDA stenting in neonatal duct-dependent cyanotic congenital heart disease is
a preferred choice of first palliation. This is however contraindicated in those with branch
pulmonary artery stenosis. PDA stenting may also be indicated in certain cases of pulmonary
atresia with intact septum at the time of transcatheter valvotomy. PDA stenting is safe
and effective in providing short-term palliation. The post procedural morbidity, ICU and
hospital stay compare favourably to conventional surgical shunt.
PCCS 2006
S20(1/3)
SPEAKER’S ABSTRACTS November 2, 2006
Life-long concern in CHD: Experience of the GUCH clinic in Asia-Pacific
James Yip, M.D.
National University Hospital, Singapore
An estimated 11,000 adults with congenital heart defects (ACHD) live in Singapore. At
least half, face the prospect of complications, reoperation and premature/sudden death.
Their numbers are growing. Experts in the field know that health risks can be reduced and
outcomes improved if co-ordinated care by qualified and informed health care professionals
were available in the country.
Pediatric care for patients with CHD, over the past 25 years, has been so outstanding that
as many as 85% of these children now survive into adulthood. Given these successes, it
has long been apparent that a “new group of adult patients” was going to appear in
Singapore. Remarkably and inexplicably, no provision was made to care for them after
they “graduated” from the pediatric units. Many were simply lost to follow-up as adolescents
or young adults. Most had not been educated about their expected future health issues, or
their responsibilities for their own care. This has led to a marked lack of access to qualified
and informed cardiology and primary care specialists. Most adult cardiologists are not
qualified to care for many of these patients according to leaders in CHD. Many paediatric
cardiologist are similarly not trained to care for adult problems like ischemic heart disease,
arrhythmias and issues of pregnancy. It is known that the outcome of CHD patients cared
for in specialized ACHD centers are better than those presenting in non-specialized units.
Diseases like rheumatic heart disease are on the decline, but congenital heart disease will
increase as more survivors reach adulthood.
In the National University Hospital alone, there are estimated to be 800-1000 ACHD
cases above the age of 16 (about half of them on follow-up by paediatric cardiologists).
These patients are unlike other cardiac patients in many ways. Their estimated age is 32.
They are still studying or training; have careers; are sorting out their lifestyles and having
relationships; are getting married and having children; want to live and live to see their
children grow and prosper; and contribute to their communities. They need information
on career planning, on the wisdom of pregnancy and their contraceptive options, and many
other matters. They are often stigmatized at work, and concerned about what they can
safely do.They are trying to learn about their conditions and trying to promote their own
health. Some patients with good outlooks don’t know they can expect a normal life. Other
patients with major health risks don’t know what to watch for, or how and where to access
informed care. They are presenting to obstetricians who have no knowledge of how to
manage them. They are in emergency rooms with cardiac arrhythmias, heart failure,
endocarditis, and chest pain as well as with appendicitis, gallstones, and strokes.
PCCS 2006
SPEAKER’S ABSTRACTS November 2, 2006
Prior to 2003 there has not been any setup to care for patients with ACHD in Singapore.
In 2002, funding was obtained from the Health Service Development Programme (HSDP),
to fund a national programme to care for these patients. This funding was used to train
nursing staff, start a cardiopulmonary laboratory and subsidize patient care for device
intervention. In 2006, we now have 2 ACHD units in Singapore to care for the needs of
these patient.
PCCS 2006
S20(2/3)
SPEAKER’S ABSTRACTS November 2, 2006
Exercise toterance in GUCH after the surgery
Michael A. Gatzoulis, M.D.
Royal Brompton Hospital and the National Heart & Lung Institute, London, UK
PCCS 2006
S20(3/3)
Pregnancy related issues in women with Congenital Heart Disease
Most women with mild acyanotic CHD tolerate pregnancy, labor, and delivery
well, and their management can be almost same as general population. Patients with
moderate to severe CHD require frequent assessment and follow-up by not only
obstetricians but also the other specialists such as cardiologists, anesthesiologists,
neonatologists and special nurses, who should work as a team. Management consists of
limitation of physical activity when appropriate, avoidance of excessive weight gain, use
of diuretics to prevent fluid retention, close observation for signs or symptoms of early
congestive heart failure with prompt treatment, and control of arrhythmias with
antiarrhythmic medications known to be safe for the fetus. Cardiac failure and/or arrhythmia
in patients with CHD during pregnancy may be attributable not only to dramatic changes
of hemodynamics, hormone, catecholamine and autonomic nervous systems during
pregnancy but also underlying anatomy and specific hemodynamics of CHD and scars
from prior surgery. Patients with severe cyanotic CHD and reduced functional capacity,
Eisenmenger syndrome, or severe cardiac failure constitute a high risk group and should
be advised against pregnancy or counseled for therapeutic abortion if pregnancy has
occurred. Patients with large aorta, severe left ventricular outflow or inflow stenosis are
also high risk for pregnancy and the lesion should be repaired before pregnant if feasible.
If surgical correction has been performed without a significant residua or sequelae, the
tolerance of pregnancy is nearly normal excluding issue of inheritance.
It is essential that the patient should understand the maternal and fetal risks
associated with pregnancy. Cardiovasucular surgery or catheter intervention during
pregnancy should be considered only in patients who are severely disabled and are not
responding to optimal medical therapy. Delivery by cesarean section is indicated only for
obstetrical reasons and when there is cardiac instability in spite of medical therapy. Second
stage of labor should be as short as possible. The use of prophylactic antibiotics at the time
of delivery is indicated in patients with CHD and >moderate risk for infective endocarditis.
Hemodynamic and electrocardiographic monitoring should be used in all high-risk patients
to identify and correct hemodynamics and electrical instability as soon as possible.
Although pregnancy can pose substantial risks for women with CHD, it remains
feasible for most with suitable medical support. Pre-pregnancy counseling and
multidisciplinary care are essential to help them have their own children at the minimal
possible risk and, thus allow them to lead their life potential.
SPEAKER’S ABSTRACTS November 2, 2006
Dr. Koichiro Niwa, M.D., FACC
Chiba Cardiovascular Center, Chiba, Japan
PCCS 2006
S21(1/3)
SPEAKER’S ABSTRACTS November 2, 2006
Fetal cardiac pathology
Andrew Cook, M.D.
Institute of Child Health, University College London, UK
PCCS 2006
S21(2/3)
Impact of fetal echocardiography: Changing pattern of congenital
heart disease
SPEAKER’S ABSTRACTS November 2, 2006
In-Sook Park, M.D.
Asan Medical Center, Seoul, Korea
PCCS 2006
S21(3/3)
SPEAKER’S ABSTRACTS November 2, 2006
Progression of CHD During Fetal Life.
Yasuki Maeno, M.D.
Kurume University School of Medicine, Kurume, Japan
Fetal echocardiography provides new viewpoint for congenital heart defects (CHD).
Cardiac structures and function of CHD at birth, which we usually observe in neonatal
period, are final result of whole process of the heart development during long prenatal
period. Fetal echocardiography gives us interesting opportunity to reveal these
developmental changes during prenatal period, and several studies have reported this
progression of fetal cardiac structure. Although some of these progressions were already
speculated from the examination of cardiac structure after birth, some findings were
unexpected before prenatal echocardiography.
Left and right ventricular outflow tract obstruction makes progressively hypoplastic
left and right heart structure, respectively. Prediction for severity of these progressions
was reported in several previous studies. However, optimal pre- and perinatal management
was still not clear. We still need information to decide the indication of prenatal treatment,
and an adequate timing of delivery for these fetuses.
Prenatal diagnosis of Transposition of the great arteries (TGA) was proved to
improve outcome. Some of the fetuses with TGA were reported to have restrictive foramen
ovale, restrictive ductus arteriosus, and developed pulmonary vascular disease. These
findings were not even speculated until the prenatal echocardiography found them.
Mechanisms of development of theses anatomical changes are still not investigated.
Furthermore, appropriate perinatal management for these cases are still unknown.
Univenricular heart including heterotaxy syndrome is usually easily detected by
prenatal screening. Although several risk factors for the successful Fontan repair had been
well investigated for the postnatal cases with these univentricular heart, prediction of
progression of these risk factors during fetal period have not been well discussed. For
example, atrioventricular valve regurgitation is one important risks for the Fontan type
repair, however an amount of this regurgitation at the time of surgery is very difficult to
predict during prenatal period. Furthermore, although presence of obstructive pulmonary
vein represents poor prognosis, progression of this abnormality after birth is often difficult
predict before birth.
It is very important to know these pre- and perinatal progressions of the cardiac
disease, when we manage these affected fetuses, when we decide the treatment, and
especially when we counsel family.
PCCS 2006
S22(1/3)
Renal replacement therapy
SPEAKER’S ABSTRACTS November 2, 2006
Laurance L. Lequier, M.D.
Strolley’s Children hospital, Canada
PCCS 2006
S22(2/3)
SPEAKER’S ABSTRACTS November 2, 2006
LCOS in CICU
Zhuoming XU, M.D.
Shanghai Children Medical Center, China
PCCS 2006
S22(3/3)
Expectations and Outcomes for Congenital Heart Surgery Programs
Congenital heart disease has moved from a “fatal” disease to a “chronic” disease due to
advances in surgical technique and pre- and post- operative care. The treatment approach
has progressed from surgeon-centered to multidisciplinary team concept, from Congenital
Heart Surgery to Congenital Heart Surgery Programs. As programs mature, the expectations
and outcomes of treatments should also progress from focus on mortality to focus on
quality/safety and quality of life. Currently, two mortality indices are being tested in
many settings, Aristotle and RACHS-1. In the U.S., the Agency for Healthcare Research
and Quality is leading the way for quality improvement in healthcare including congenital
heart surgery. Recently, Pediatric Quality Indicators have been delineated and efforts are
on going to validate them. Finally, quality of life is a more difficult concept to identify
and measure especially in the pediatric population. However, treating a “chronic” disease
should involve some efforts to monitor quality of life. Examples of such efforts can be
seen in the treatment of extremely low birth weight premature newborns, patients with
cystic fibrosis, and patients with cancer.
SPEAKER’S ABSTRACTS November 2, 2006
Thivakorn Kasemsri, M.D.
Medical Director, Pediatric Intensive Care Unit, Covenant Children’s Hospital, Lubbock,
Texas, USA
PCCS 2006
S23(1/2)
SPEAKER’S ABSTRACTS November 2, 2006
PFM coil for VSD occlusion: A real alternative treatment modality
Trong-Phi Le, M.D.
University of Hamburg, Germany
PCCS 2006
S23(2/2)
Difficult cases for PDA closure
Transcatheter closure of patent ductus arteriosus (PDA) was first performed in 1967 by
Dr. Porstman and his associates using Ivalon foam plug. Since then, a variety of devices
have been developed to close PDA with variable success. Currently, the most popular
device used is Gianturco coil because of easy in delivery, low profile in sheath requirement,
high occlusion rate and a low cost. However, high incidence of distal migration of coil
was encountered in patients with a large ductus. Coil closure in patients with type B or C
ductus also carries a higher percentage of distal embolization. In recent few years, Amplatzer
duct occluder has been used to close moderate-to-large sized ductus with a high success
rate and complete closure rate. However, deployment of Amplatzer septal occluder is
sometimes difficult in young infants with a large ductus. In adult patients with very large
ductus where Amplatzer duct occluder may not be sufficient to close the ductus, Amplatzer
muscular VSD occluder could be used. Severe pulmonary hypertension is commonly present
in adults with a large ductus. Amplatzer duct or muscular VSD occluder could be used for
trial occlusion. In contrast to large ductus, small ductus can be closed without difficulty.
However, catheter closure of very small ductus is difficult since advancement of catheter
across the ductus is difficult. Snare-assisting technique can be useful. In very few cases,
guide wire manipulation within the ductus could result in complete occlusion. Therefore,
with the advent of devices, transcatheter closure of difficult PDA is feasible and safe in
most patients.
SPEAKER’S ABSTRACTS November 2, 2006
Jou-Kou Wang, M.D.
National University of Taiwan, Taiwan
PCCS 2006
S24(1/2)
SPEAKER’S ABSTRACTS November 2, 2006
Systemic RV: Natural History
Michael A. Gatzoulis, M.D.
Royal Brompton Hospital and the National Heart & Lung Institute, London, UK
PCCS 2006
S24(2/2)
THE MANAGEMENT OF CONGENITALLY CORRECTED
TRANSPOSITION OF GREAT ARTERIES
This is a complex form of congenital heat disease with many variables needing to be taken
into account before arriving at the best management decision for each patient. Repairs that
leave the morphological right ventricle (mRV) in the systemic circuit, and a low pressure
in the morphological left ventricle (mLV) – physiological repair – have the disadvantage
of a significant incidence of mRV failure coupled with progressive tricuspid valve (TV)
incompetence. This is similar to the result of Mustard or Senning operation in TGA
particularly if a large VSD has been patched. In ccTGA the result is even worse because of
the high incidence of large VSD’s, the higher incidence of arrhythmias (particularly
complete Heart Block before and after surgery) and the much higher incidence of congenital
deformity of the TV. The established results of physiological repair of ccTGA lead to a
drive to return the mRV to the low pressure pulmonary circuit (anatomical repair). This
was achieved by the double switch procedure consisting of a Mustard or Senning combined
with an arterial switch operation, or combined with a Rastelli operation if the pulmonary
valve was absent or unsuitable to become an aortic valve. In some patients with failing
mRV and TV the mLV has been at low pressure, and mLV retraining with a pulmonary
artery band can be considered before anatomical repair. mLV retraining is only reliable at
young age while the heart is still growing rapidly.
“Anatomical repair”, even in the most favorable patient, cannot be considered a cure, for
obvious reasons. It is a long and complex operation. Patients must be carefully selected
for suitability, most particularly in the older age group where it may be more prudent to
simply replace a TV in the presence of good mRV function, partially relieve LVOTO,
apply only a moderately tight PAB, correct a rhythm problem, or transplant, as forms of
palliation which are less risky. Certainly, a policy of “Double Switch or bust” is
inappropriate.
SPEAKER’S ABSTRACTS November 2, 2006
Roger B. B. Mee, M.D.
Chairman Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic.
(Retired)
PCCS 2006
S25(1/2)
SPEAKER’S ABSTRACTS November 2, 2006
Pre- and Perinatal Management of Fetal Arrhythmias
Yasuki Maeno, M.D.
Kurume University School of Medicine, Kurume, Japan
Prenatal diagnosis and treatment of fetal arrhythmia is well documented since early
1980’s. Fetal arrhythmia is divided into tachycarrhythmias, bradyarrhythmia, and ectopic
beats. Although many prenatal management strategies of fetal arrhythmias have been
reported, there are still many issues to be addressed to find the optimal management for
each fetus.
Fetal tachyarrhythmia consists of supraventricular tachyarrhythmia (SVT) with
1:1 atrioventricular conduction, atrial flutter (AF) with 2:1 atrioventricular conduction,
ventricular tachycardia with dissociated atrioventricular conduction, and others. Intrauterine
treatment using digoxin is known as a first line treatment in the fetuses with SVT and AF.
However, fetuses associated with hydrops or long VA interval SVT are rarely treated by
digoxin. Other antiarrhythmic drug such as sotalol, flecainide, or amiodaron, is indicated
from the beginning for these fetuses. After birth, some develop to refractory tachyarrhythmia
during early neonatal period. Hence close observation after birth is required even after
successful prenatal treatment.
Fetal bradyarrhythmia consists of atrioventricular block (AVB) with or without
structural heart anomaly, and sinus bradycardia. The main cause of AVB without heart
anomaly is maternal anti SS-A antibody. Maternal administration of beta-stimulant is
effective for increasing fetal heart rate in some of the fetuses. The management of fetuses
with maternal SSA antibody is not well established. Since prediction of developing fetal
AVB for maternal positive SSA antibody is not established, early detection and early
treatment is the currently available perinatal management. Trans-placental steroid
administration has been reported to improve the degree of AVB in some of the affected
fetuses. Slower fetal ventricular heart rate or presence of mitral valve regurgitation may
be early signs to develop fetal hydrops. Dilated cardiomyopathy or endocardial fibroelastosis
may be developed during pre- and postnatal period.
Further study using large number of patient by multi-center study is required to
find optimal pre- and perinatal management for the fetuses with arrhythmias.
PCCS 2006
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The Management Implications Following The Diagnosis of Fetal Heart
Anomalies
The prenatal diagnosis, usually by 20 weeks, of a fetal cardiac abnormality tends to
precipitate a crisis for the affected parents. In a setting of grief and emotional distress,
there is a challenge to provide meaningful information of the abnormality, the need and
risks of any likely interventions and the probable outcomes. That hopefully will enable the
parents if allowed the option, to come to an informed decision as to whether to continue
with the pregnancy. For any counselling to be credible there must be an accurate and as
complete a diagnosis of the cardiac abnormality wherever possible. In addition there is a
need for the exclusion of other malformations and/or chromosomal abnormalities.
Repeated scans often done to clarify the diagnosis, allows for improved understanding
and assimilation of the complex knowledge imparted. Repeated scans are also indicated
for a significant arrhythmia where the development of worsening cardiac failure despite
medication, may lead to an early delivery once the fetus is viable. Pulmonary compression
from increasing cardiac size as for example from severe incompetence of an Ebstein or
dysplastic tricuspid valve, may also warrant early delivery. An evolving cardiac lesion
such as a hypoplastic left or right heart also necessitates further cardiac scans to help plan
management. Throughout the pregnancy there is a need to monitor the well being and
growth of the fetus, which if compromised may lead to an early delivery.
Any fetus with a major cardiac abnormality or where there is a duct dependent pulmonary
or systemic circulation as for example in a severe Fallot’s or critical aortic valve stenosis,
warrants delivery at a tertiary centre with appropriate obstetric and neonatal intensive
care. A prostaglandin E1 infusion may be required with additional ventilation and/or
inotropic support.
The early confirmation of the prenatal diagnosis helps plan the immediate neonatal
management, and may facilitate mother/infant handling and bonding. Once the diagnosis
is confirmed, the anticipated interventions may be proceeded with. The parents previously
counselled seem better prepared for the stresses of the surgery that their infant need endure.
A prenatal diagnosis also allows for the anticipatory care of the newborn which permits
such affected infants to be in as good a state as possible prior to surgical and/or catheter
interventions.
The fetus with a minor cardiac lesion or one that results in an increasing left to right shunt
even if substantial, may be delivered at the parents’/obstetrician’s hospital of choice.
Usually the neonate remains asymptomatic until the pulmonary vascular resistance drops
SPEAKER’S ABSTRACTS November 2, 2006
Samuel Menahem, M.D.
Fetal Cardiac Unit, Monash Medical Centre, Melbourne, Australia
SPEAKER’S ABSTRACTS November 2, 2006
PCCS 2006
and the left to right shunt increases. Once again early confirmation of the diagnosis helps
reinforce the trust that the parents have in the attending cardiologist who usually has been
involved in the prenatal counselling.
The diagnosis of a cardiac abnormality in the fetus allows for appropriate counselling of
the affected parents. It enables one to plan the management of the pregnancy and perinatal
period to ensure an optimal and hopefully improved outcome both for the infant and mother.
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S26(1/3)
Risks and mechanisms of sudden death following surgical treatment of
congenital heart disease.
Michael J. Silka, M.D.
Division of Cardiology, Childrens Hospital Los Angeles, University of Southern California,
USA
SPEAKER’S ABSTRACTS November 3, 2006
Identification of patients at risk for sudden cardiac death (SCD) following surgical
treatment of congenital heart disease (CHD) remains a major challenge. In part, this is
attributable to the relatively low incidence of unexpected SCD, which has precluded
prospective evaluation of the problem. However, this challenge is further complicated by
the evolving profile of patients at risk for late SCD, due to the survival of patients with
complex defects, along with evolving medical, catheter and surgical treatments for
congenital heart defects.
In spite of these challenges, population-based studies have provided some insight
in to the risks and mechanisms of late SCD in patients with CHD. For patients <20 years
of age, the risk of sudden death following CHD surgery is estimated at 1 per 1,000 patient
years, compared to 1 per 25,000 patients years in the general population. Three basic
mechanisms of late SCD have been identified: arrhythmia, heart failure and thromboembolic events, with approximately 75% of late SCD due to arrhythmias.
The types of CHD with long-term survival at highest risk for late SCD are
postoperative transposition of the great arteries (atrial switch), tetralogy of Fallot, aortic
stenosis and coarctation of the aorta. For some of these defects, the risk of SCD appears to
be time-dependent, i.e., increasing incrementally with longer follow-up.
Risk stratification for late SCD in adult CHD patients is further complicated by
progressive ventricular and AV valve dysfunction, atrial and ventricular arrhythmias related
to progressive fibrosis and hypertrophy and possibly late-onset of complete heart block.
In addition to the aforementioned defects, SCD has been reported in adults with Ebstein’s
anomaly and “corrected transposition” of the great arteries (L-TGA).
To date, there have been few reports of late SCD following surgical palliation for
univentricular physiology. Given the compromised circulatory physiology and extensive
surgical intervention(s), it is anticipated that SCD will become an increasingly prevalent
problem in these patients with extended follow-up.
In spite of the limited data available, it remains the role of the clinician to assess
the risk of late SCD in these patients and make reasonable decisions regarding testing and
therapies. This session will conclude with the author’s experience in this field and a
proposal for a graded scoring system to assess the risk for late SCD in an individual or
group of patients with various forms of CHD.
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Long QT syndrome
SPEAKER’S ABSTRACTS November 3, 2006
Masao Yoshinaga, M.D., Ph.D.
National Hospital Organization Kagoshima Cardiovascular & Cancer Center, Japan
Long QT syndrome (LQTS) is a rare disease characterized by prolonged ventricular
repolarization and a high risk for cardiac events including sudden cardiac death. Most
cases of LQTS that come to the attention of physicians are either symptomatic or familial.
However, a screening program by ECG conducted for Japanese children (all 1st, 7th and
10th graders) has uncovered large numbers of children with LQTS with no family history
and those with no history of LQTS-related cardiac events at the time of diagnosis.
1) Prevalence of LQTS in Japanese children.
We measured three consecutive QT and RR intervals of 4,655 children. Their ECGs were
recorded when they were 6 years in 1994 and 12 years in 2000. All four children diagnosed
as definite LQTS at 12 years did not show characteristic ECG findings of LQTS at 6
years. They are all non-familial cases. The prevalence of LQTS at 12 years old is 1/1,164
(4/4,655).
2) Face immersion test to induce prolongation of QT interval and notched T waves.
Recent study has shown that provocation of transient bradycardia followed by sinus
tachycardia with adenosine induces abnormal QT prolongation and notched T waves in
patients with LQTS. We also showed that face immersion test is a useful bedside test to
induce prolongation of the QT interval and T-wave changes in children with LQTS.
3) Correction of the QT interval to minimize the effect of a high heart rate in children.
It is well known that Bazett’s formula {(QT)/(RR)k, k=0.5} overcorrects the QT interval
in children with a high heart rate. We evaluated the usefulness of 11 formulas in 23,861
1st, 7th, and 10th graders. Exponential or Fridericia’s formulas minimized the effect of
the heart rate. The best fit for exponential parameter k for each sex and the graders ranged
from 0.30 to 0.35.
4) Risk factors for cardiac events in young patients.
A total of 197 Japanese children with LQTS were analyzed. Seven of the 129 (5%) cases
without past history and 32 of the 68 (47%) cases with past history of LQTS-related cardiac
events experienced new events after diagnosis. Incompliance with medicine and a lower
age at diagnosis (p<0.005 for both) were significant predictors for the group with past
history.
References
1) Fukushige T, Yoshinaga M, et al. Am J Cardiol, 2002 ;89 :395-8.
2) Yoshinaga M, et al. Am J Cardiol, 1999;83:1494-7.
3) Aihoshi S, Yoshinaga M, et al. Jpn Circ J, 1995;59:190-7.
4) Yoshinaga M, et al. Circ J, 2003 ;67 :1007-12.
PCCS 2006
S26(3/3)
Patients with Right Atrial Isomerism
Mei-Hwan Wu, M.D., Ph.D.
Departments of Pediatrics, National Taiwan University, Taipei, Taiwan
SPEAKER’S ABSTRACTS November 3, 2006
Right atrial isomerism is nearly always associated with complex congenital heart disease,
typically a combination of anomalous pulmonary venous return, common atrium, common
atrioventricular valve, dominant right ventricle, double outlet right ventricle and pulmonary
stenosis (atresia). Most of the patients need a palliative shunt with or without rerouting of
the obstructed pulmonary veins, and later staged total cavopulmonary connection. The
prognosis has been poor with an estimated 5-year survival ranged from 29 to 51 %.
Moreover, probably due to the residual hemodynamics abnormalities, abnormal cardiac
conduction system, asplenism and gastrointestinal anomaly, these patients are also at risk
of sudden death even palliation. The sudden death rate may range from 5% to 14 %. From
1980 to 2005, 257 patients (1,171 patient-years) were diagnosed as RAI in this institution.
The one-year, 5-year and 10 year survival was 66%, 49% and 41%, respectively. There
were a total of 29 sudden deaths (acute cardiovascular collapse from which biological
death occurred within 24 hours) (24 events/1,000 patient-years). Sudden death tended to
occur in infancy or early childhood. The freedom of sudden death was 85 % at the age of
3 years and remains relatively stationary thereafter. The mechanisms were classified as
sudden tachyarrhythmic in 2 (6.9%), sudden cardiac but nontachyarrrhythmic (sudden
onset severe cyanosis) in 17 (58.6%), and sudden noncardiac in 10 (34.5 %) (fulminant
sepsis with positive blood culture: streptococcus pneumonia 6, E. coli 1 and yeast-like
organism 1). The age of the life threatening infection ranged from 5 months to 4.5 years
(median 17 months, 18 15 months). Among the 257 patients, we found that the presence
of obstructed non-cardiac drainage of pulmonary venous return (42%), pulmonary atresia/
stenosis (31/59%), major aortopulmonary collateral arteries (5%), aortic arch coarctation
or interruption (2.3%) and hital hernia (16%), or the occurrence of narrow QRS tachycardia
(24 %) was not associated with a higher risk of sudden death. It is concluded that the
sudden death in patients with right isomerism may be related to the complex cardiac
anomalies per se, a susceptibility to fulminant peumococcal infection, and only rarely
arrhythmia. Early vaccination against the pneumococcus may reduce the risk of fulminant
infection.
PCCS 2006
S27(1/3)
HAEMODYNAMIC MONITORING: TOOL OR TOY?
SPEAKER’S ABSTRACTS November 3, 2006
Dan Penny, M.D., Ph.D., FRACP
Director of Cardiology, The Royal Children’s Hospital
Professorial Fellow Dept. of Paediatrics, University of Melbourne, Australia
In 1929, a German surgeon, Werner Forsmann, introduced a catheter into his right atrium
from an arm vein. This was the first time that a mixed venous saturation was measured in
a human, but the technique was considered unsafe for routine application in humans.
In 1941, Andre Cournand, who is considered to be the pioneer of cardiac catheterisation,
published his paper on “catheterisation of the right auricle in man”. He had perfected the
technique for safe catheterisation of the right heart, in health and disease. This report
represented a landmark for cardiologists and cardiovascular physiologists, for two important
reasons. First, this opened a ‘Pandora’s box’ in the field of cardiovascular monitoring and
investigation. Second, it enabled the practical application of the Direct Fick measurement
of cardiac output for the first time, since it was described by Adolph Fick in nearly 70
years previously.
The thermal indicator technique (thermodilution) of measuring cardiac output was
introduced by Fegler in 1954, and this was further refined, with the advent of the Swan
Ganz catheter in 1971. Over the past 3 decades, there has been huge literature on the pros
and cons of cardiac output measurement in intensive care. The technique enjoyed periods
of near-routine use in adult intensive care practice, but more recently has been used less
frequently. This is because the evidence base in favour of so-called ‘goal-directed’ therapy
is limited, and there are some safety concerns associated with pulmonary artery
catheterisation.
Invasive monitoring in children in intensive care, has – as for many techniques in paediatrics
– lagged behind adult practice. It is really only in post-operative cardiac intensive care,
that the use of haemodynamic monitoring has extended beyond the arterial, or central
venous line.
Nowadays, a major paradox exists in post-operative cardiac intensive care. As our patients
become increasingly complex, we are moving away from multiple, invasive monitoring.
For example, pulmonary artery pressure monitoring catheters were previously ‘routine’ in
many neonates undergoing surgery, and in infants with large septal defects. These catheters
are now rarely used, due to concerns regarding catheter-associated thrombus, infection,
embolus, or tamponade upon their removal which must be balanced against the benefits
associated with their use. The same risk can be applied to cardiac output monitoring, whether
using the traditional pulmonary artery thermodilution technique, or the more recent
transpulmonary thermodilution (PICCO) technique. PICCO has recently been introduced
into paediatric practice, and requires the placement of a small femoral artery catheter.
PCCS 2006
SPEAKER’S ABSTRACTS November 3, 2006
Cannulation of the femoral artery is generally avoided in paediatrics outside of the catheter
laboratory, due to significant risks of thrombosis, and theoretical risks associated with
limb growth, and so it is unlikely that the use of PICCO will be widespread in cardiac
intensive care.
Cardiac output monitoring in paediatric cardiac intensive care has rarely been used outside
of the research setting, and there is little, if any, evidence to support its routine application.
Indeed, we still do not know what is a ‘normal’ cardiac output for an infant after an arterial
switch operation, or a larger child after a Fontan operation. Furthermore, in infants with a
functionally univentricular heart, the measurement of total cardiac output is relatively
meaningless, given that we are largely focussed on systemic oxygen delivery. In the
absence of compelling supporting evidence, it is unlikely that the invasive measurement
of cardiac output will become more routine in cardiac intensive care.
In the modern era, morbidity and mortality early after cardiac surgery is almost exclusively
confined to the neonate and young infant with complex heart disease. In particular, with
the functionally univentricular circulation, after Norwood-type operations. In these infants,
systemic oxygen delivery is the parameter which is of greatest relevance, and paradoxically
the most difficult to measure accurately. As clinicians caring for these patients, most of us
would welcome additional haemodynamic monitoring tools to ‘guide’ us, or reassure us
that our patients are doing well. Conversely, additional information which will herald
haemodynamic deterioration at an early stage, would be very desirable in this fragile
population. There is some limited literature that continuous monitoring of central venous
oxygen saturation, can be used as a guide to the adequacy of systemic oxygen delivery.
This technique requires the placement of a catheter directly into the superior caval vein,
which can be used for sampling of mixed venous blood. As we have already discussed,
this technique is not without its own inherent risks, and the search for a ‘surrogate
surrogate(!)’ has resulted in the increasing use of non-invasive cerebral oxygen saturation
monitoring in the Norwood population. This technique is appealing in that it is non-invasive
and has no known direct risks, but requires further validation in the neonatal cardiac
population.
A number of other haemodynamic monitoring tools are coming into vogue in clinical
intensive care. These include transthoracic or oesophageal Doppler to monitor stroke
volume, which has recently been introduced into paediatric (non-cardiac) practice. Tools
which target the assessment of regional oxygen delivery are also becoming available in
adults: these include spectral monitoring of the tissue microcirculation (in sepsis), regional
perfusion, and tissue oxygen monitoring. The usefulness of these in paediatric cardiac
intensive care is currently unknown, and their will likely be a typical time-lag between
their application in adults and children.
Ultimately, many of these techniques can be regarded as ‘toys’, or perhaps less harshly
could be considered as research tools in paediatric cardiac intensive care. Right now, we
do not yet have an accurate, reliable, and risk-free measure of systemic oxygen delivery.
Until we do, we will continue to rely on ‘surrogate’ markers of perfusion such as acid-base
balance, lactate, mixed venous oxygen saturation, and end-organ function.
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Cardiopulmonary interaction: How principles become practices?
SPEAKER’S ABSTRACTS November 3, 2006
Satid Thammasitboon, M.D.
West Verginia University School of Medicine, USA
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Nutritional support and immunocompetence
Amit Varma, M.D.
Fortis Health Care, New Delhi, India
SPEAKER’S ABSTRACTS November 3, 2006
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P3(1/2)
Pathologist’s bench: A New Look at Cardiac Development
SPEAKER’S ABSTRACTS November 3, 2006
Andrew Cook, M.D.
Institute of Child Health, University College London, UK
PCCS 2006
P3(2/2)
Cardiologist’s aspect of genetics of congenital CV disease: From
molecular bench to bedside
Makoto Nakazawa, M.D.
Sounthern TOHOKU General Hospital, Sounthern TOHOKU Research Institute,
Fukushima, Japan
SPEAKER’S ABSTRACTS November 3, 2006
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S28(1/3)
Paediatric Cardiac Services in Pakistan
SPEAKER’S ABSTRACTS November 3, 2006
Kalim Uddin Aziz, M.D.
Professor (Emiratus) of paediatric Cardiology National Institute of Cardiovascular
Diseases, Pakistan
The first exclusive Paediatric Cardiology Services was started at National Institute of
Cardiovascular Disease at Karachi in 1981. Invasive or noninvasive services were instituted
which involved out patient service for children under 12 years age, echocardiography. Mmode in the early days and then 2-D Color Doppler in 1983.
Cardiac Catheterization for all age groups was started in 1981. The cadiac catheterization
service was mostly diagnostic except for balloon atrial septosmy . Balloon dilatation were
started in 1987 and later device deployment for congenital lesions was started beginning
with Coil Closure of PDA at Armed Forces Institute Rawalpindi and in Punjab Institute of
cardiology at Lahore. At present catheter intervention services are available in two institutes
in Karachi, two at Lahore and one in Rawalpindi.
Integrated training program of training of Catheter Therapeutics, by involving consultants
form England, America, was started in1994 and the end result is that catheter intervention
is now a major component of paediatric catheterization work around the country.
Fellowship training program for Paediatric Cardiology culminating in FCPS by the College
of Physicians and surgeons Pakistan, was initiated at NICVD in 1991, culminating in
FCPS in paed cardiology, by the college of Physician and Surgeons of Pakistan (similar to
board certificate).The fellowship program is available in two institutions, AKU and NICVD
at Karachi, two Punjab Institute of Cardiology and Children Hospital, in Lahore and one
Armed Forces Institute, at Rawalpindi.
While surgery in older children is being performed in five hospitals started since 1981.
The man power and infrastructures for surgical services for infants are being developed.
Three centers, one in Karachi (2006), one in Lahore (2000) and one in Rawalpindi (2001)
have dedicated Paediatric Cardiology surgeon and who are performing corrective surgery
in the infants..
In conclusion development of Paediatric Cardiology services are progressing at a rapid
rate in Pakistan and the goal is to correct congenital cardiac malformation at an early age
PCCS 2006
S28(2/3)
CONGENITAL HEART DISEASEMANAGEMENT IN
DEVELOPING COUNTRY: THE INDONESIAN EXPERIENCE
Anna Ulfah Rahajoe, M.D.
President, National Cardiovascular Center, Jakarta – Indonesia
SPEAKER’S ABSTRACTS November 3, 2006
At a crude birth rate of 20.34/1000 in Indonesia, the total annual live-births would be
approximately 5 million. Considering the estimate of 9/1000 live-births, approximately
45.000 infants with CHD are added every year to the total pool. About 45% of CHD cases
require some form of intervention or surgery during childhood. Thus, every year,
approximately 20.000 children require surgery or care at an advanced infant cardiac center.
The number of surgery and intervention for CHD in the whole country is less than 1000
cases per-year. Majority CHD cases are undetected, leading to high infant mortality rate
of 34.39 deaths/1,000 live births. The development of non surgical intervention has led to
a significant increase in the number of conditions which are now amenable to treatment in
the cardiac catheter laboratory. Balloon Pulmonal Valvuloplasty is the treatment of choice
for pulmonal stenosis, as well as Balloon Atrial Septostomy in some types of cyanotic
CHD. Closure of the patent arterial duct, atrial and ventricular septal defect using Amplatzer
devices tend to increase every year. While this approach has considerable benefits over
surgery, in Indonesia the cost is higher than surgery. In two years periode (2003-2005),
1336 patients had open and closed heart surgery at the National Cardiovascular Center,
the mortality rate was 5.56%. Almost 70% were ductus ligation, atrial or ventricular septal
defect (ASD/VSD) closure, and tetralogy of Fallot repair. Surgery in infancy tend to
increase, during this periode there were approximately 30% of the total case. Arterial
switch operation, repair of atrioventricular septal defect and coarctation of the aorta
associated with other lesions usually performed in neonates or infancy, the mortality rate
in this particular cases is still high (15-20%). Evaluation on VSD cases underwent surgery
in 2000 – 2004, confirmed the high incidence of subarterial doubly committed VSD, 26.6%
and 43.6% in childhood and adult respectively; while muscular VSD were less than 2%.
The resources are not only limited but also are at times improperly utilized. The existing
number of trained personnel for pediatric cardiology and pediatric cardiac surgery is
inadequate. Above all there is no national policy for pediatric heart care. In conclusion,
pediatric cardiac care in Indonesia is still in its infancy. The barriers are: lack of awareness
on CHD, limited resources and facilities, high cost of treatment and limited financial support.
Training programs exclusively dedicated to pediatric cardiology and pediatric cardiac
surgery need to be established in centers with good standards of pediatric cardiac care.
Keywords : Congenital heart diseases; Pediatric cardiology; Pediatric cardiac surgery;
Pediatric cardiac care
PCCS 2006
S28(3/3)
‘Heart to Heart’ Project for Vietnamese Children - Joint Heart Project
between SMC & NHP -
SPEAKER’S ABSTRACTS November 3, 2006
Heung Jae Lee, M.D.
Professor of Pediatrics, Sungkyunkwan University School of Medicine
Samsung Medical Center, Seoul, Korea
Korean Experience during the Past 5 Decades:
Korea’s infrastructure including economic, social, medical and educational systems
collapsed after the Korean war, and rebuilding efforts started from mid- 50s.
Open-heart surgery was first introduced in Korea in 1959, thanks to the Minnesota Plan,
a program sponsored by the United Nations to rebuild higher education in Korea.
But we had to wait for another 20 years to see congenital heart surgery become popular.
During these years, the majority of pediatric heart diseases seen in Korean hospitals were
kids suffering from rheumatic heart disease, diphtheric myocarditis, pyogenic and
tuberculous pericarditis. Only some children suffering from congenital heart disease could
be saved after heart surgery in the US, thanks to the help of the International Human
Assistance Program, a US charity program. Unfortunately more young lives, however,
perished without proper treatment.
The national social security system was established in 1977, which provided momentum
for promoting heart surgery for children. This year, Korea’s gross national product (GNP)
reached 944 US dollars. And it was this year that one cardiac center started to performed
over 100 open-heart surgeries per year, for the first time in Korea.
In the early 1980s, Korea’s GNP surpassed 1,000 US dollars and various circles from the
society participated in the campaign to help children with heart disease. And this campaign
played a decisive role in the rapid development of heart surgery in Korea —the number of
heart surgical operations increased and the medical technology improved.
Also, the Korean Heart Foundation was set up and offered monetary assistance every year
to 1,000 children suffering from congenital heart disease for their operations. In addition,
religious organizations and charities led the campaign for charity operation. As a result,
every single young patient from a poor family was able to receive heart surgery without
concerns about medical fees since the mid-1980s.
Technological improvement was also remarkable. Surgical technology for newborn infants
with complex CHD developed fast. With these achievements, Korea became almost equal
to advanced countries such as the US and European countries in surgical technology after
the mid-1990s. For instance, in Samsung Medical Center, one of the 5 major cardiac centers
in Seoul, there has been no single mortality with the arterial switch operation, even for the
complex transposition patients, during the past 10 years.
PCCS 2006
SPEAKER’S ABSTRACTS November 3, 2006
With the society maturing, Korea has offered charity operations for young patients with
congenital heart disease in neighboring developing countries in Asia, since the early 1990s,
when the Korean GNPs surpassed 5,000 US$. Also, surgical training for doctors in these
countries and medical technology transfer has been provided.
As mentioned, Korea overcame post-war hardship very successfully. The two major factors
for this success were: 1) Rapid economic development; 2) Overseas training for medical
experts and their commitment.
‘Heart to Heart’ Project for Vietnamese Children:
‘Heart to Heart’ is a 5-year joint heart project between National Hospital of Pediatrics
(NHP) in Hanoi and Samsung Medical Center (SMC) in Seoul, for the Vietnamese children
with congenital heart disease, with the financial support from Samsung VINA Electronic
Company.
The project started in September, 2003, when the ‘NHP-SMC joint heart surgical team
performed, for the first time in NHP, open heart surgeries on Vietnamese kids with congenital
heart disease.
From that time on, the ‘NHP-SMC Joint Heart Project’ has been carried out in two directions
as follows:
First, technical support from SMC has been provided in order for the pediatric heart surgical
team to be established at NHP. To this end, medical staffs from both hospitals have visited
each other from time to time. During the past 3 years, the SMC congenital heart team from
Seoul has visited Hanoi 6 times to cooperate with NHP, and the 7 groups of 26 medical
staffs from NHP has visited SMC to attend short term (1~3 months) training course. Long
term training programs will be offered to young and competent medical staffs during the
later segment of the project.
Second, charity medical treatment and free surgery for the Vietnamese children with
congenital heart disease is one of the major on-going programs during the period of five
year project. The surgery has been jointly conducted by medical staff from both hospitals
at either NHP or SMC, depending on the situation.
During the last 3 years, 25 joint open heart surgery between both hospitals and 2 joint
interventions has been performed at NHP, and 8 other complicated patients has been
transferred to SMC for surgery, together with the NHP staffs. Since 2005, when the surgical
team at NHP become reasonably well-established, the team has take the lead in providing
this treatment service for the kids with relatively simple congenital heart disease. So far,
pediatric hear surgical team in NHP has performed over 250 open heart surgery by
themselves, and the catheter interventions are regularly carried out by the NHP staffs.
‘Heart to Heart’ Project is a comprehensive and integrated joint project between two
hospitals, one in developed and one in developing countries, in the field of congenital
heart disease, which includes collaborations in high tech treatment services and education
programs, and also in charity activities. The project will evolve into collaboration in
academic and research activities as long as it is possible.
PCCS 2006
S28(3/3)
Heart to heart project: Between National Hospital of Pediatrics
(Vietnam) and Samsung Medical Center (South Korea)
SPEAKER’S ABSTRACTS November 3, 2006
Nguyen Thanh Cong, M.D.
9 Cao Ba Quat, Badinh, Hanoi, Vietnam
National Hospital of Pediatrics is located in Hanoi, Vietnam, with 500 beds. It is a highest
level of pediatrics in the North of Vietnam.
Situation of cardiology in National Hospital of Pediatrics before project (2002): Department
of Cardiology has 30 beds, 6 cardiac pediatricians, Diagnoses are based on only
echocardiography. In Surgical Department, with 4 cardiothoracic surgeons the possible
surgical treatments are: PDA and palliative procedure for Tetralogy of Fallot.
The aims of Project: Helping N.H.P. to develop pediatric cardiology and pediatric cardiac
surgery. The project has got the financial support from Samsung Electronics Company.
Every year, there are the teaching programs in Samsung Medical Center and practical
training courses in N.H.P.
Three years after the Heart to heart project, a big step has been done. One open heart
surgery team and one cardiac intervention team have been organized and are capable for
independent every day activity. In Department of Cardiology, doctors could give more
precise diagnoses, 400 cardiac interventions have been done.
For open heart surgery, one operating theatre with one cardiopulmonary bypass pump
from Terumo Company and 2-beds CICU was also established, 2 doctor of CICU have got
training course in S.M.C.
Five first cases of open heart surgery (4 ASD, 1 VSD) were operated on successfully
during second week of Sep. 2003 with the help of cardiac surgery team from Samsung
Medical Center.
Up to now, 300 cases of open heart surgery has been done, there are ASD, VSD, AVSD,
TAPVC, and Tetralogy of Fallot. The lowest body weight was 4.5 kg.
With the success of first step, N.H.P and S.M.C. would like to share their experiences with
other children cardiac service in developing countries and hope that N.H.P. could become
the highest-level center of pediatric cardiology for the North of Vietnam in 5 – 10 years
period.
PCCS 2006
S29(1/2)
Acyanotic CHD
Ms. Lily Lihwa Hsu, R.N., MSN.
Ms. Li-Juan Fu, R.N.
Shanghai Children Medical Center, China
SPEAKER’S ABSTRACTS November 3, 2006
PCCS 2006
S29(2/2)
Cyanotic CHD
SPEAKER’S ABSTRACTS November 3, 2006
Bernadette McCormick, BSN, RN
Rady Children’s Hospital, San Diego, CA USA
Designed for Nurses working with Children with Congenital Heart Defects (CHD), this
presentation will include a review of common cyanotic CHD’s anatomy and physiology,
and common treatment strategies.
PCCS 2006
LS3(1/3)
Introduction
Transcatheter closure of perimembranous and subpulmonary VSD :
immediate term follow-up for late AV block
Background: Ventricular septal defect (VSD) is the most common congenital heart disease.
Traditional surgical correction is the procedure of choice for closure of VSD. Transcatheter
device closure using AmplatzerTM Perimembranous VSD device has emerged as an
alternative treatment.
Objectives: To report an immediate results with follow-up for patient underwent
transcatheter closure of VSD. All cardiac rhythm pre and post procedure were recorded up
to 6 months. Materials and methods: We collected data from patients who had transcatheter
closure of VSD from February 2004 to June 2006. A peri-procedure ECG were reviewed
in each patients for abnormalities such as right bundle branch block (RBBB) or complete
3rd degree atrioventricular block (3AVB) and follow-up ECG was done within 1 year post
procedure.
Results: 39 patients were included in this study. Their age varied from 1 to 34 years old
(median age = 13.3 10.7 yrs). The average body weight was 38 25 kg. There were 34
pre-procedure ECG available for reviewed. 27 of them had normal ECG with 6 of them
with RBBB and 1 of 1AVB with RBBB. There was successful transcatheter closure of
VSD in 38 out of 39 patients. The diameter of VSD varied from 4.5 to 14mm (mean VSD
diameter = 7.6mm.). The average device Size: VSD size (DV ratio) was 1.2 0.19. One
patient did not have VSD device closure due to transient AVB. Type of VSD closed were
Perimembranous VSD (n=28), subpulmonary infundibular type(n= 8), midmuscular (n
=2) and right ventricular systolic pressure (RVSP) was 38?12 mmHg.
Immediate post deploys 6 more patients developed RBBB post-procedure. Two of them
had 3AVB out of hospital during the 1st week post-closure. One patient recovered after
steroid treatment within one week (DV=1.33). The other had persistent 3AVB with symptom
and had permanent pacemaker placed two months later (DV=1.4). Late 3AVB was noted
in one asymptomatic girl (2 years old, DV=1.6). All three patients had perimembranous
VSD.
Conclusion : Transcatheter closure of VSD appears effective and relatively safe procedure.
AVB was noted in 7.8% of patients. One permanent pacemaker was placed. Although
there was no clear risk factors identifies. It appeared that the appearing of RBBB postprocedure may have some relationship with post-procedure early or late 3AVB.
SPEAKER’S ABSTRACTS November 3, 2006
Kritvikrom Durongpisitkul, M.D.
Division of Cardiology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital,
Mahidol University, Bangkok 10700, Thailand
PCCS 2006
LS3(2/3)
What does the Interventionist need to know about the
anatomy of VSD?
SPEAKER’S ABSTRACTS November 3, 2006
James L Wilkinson, M.D.
Honorary Cardiologist, Royal Melbourne Hospital, Melbourne, Australia
The anatomy of the ventricular septum is complex. A clear understanding of the normal
anatomy, as well as a knowledge of the sites of septal defects and their relationships to
adjacent structures, is important. The anatomy of the membranous septum, the conducting
system and the semi-lunar valves and awareness of the implications of septal defects in
this area is vital. The suitability of different types of VSD for device closure depends on
their location and proximity to these and other structures within the heart, as well as to the
size of the septal defect.
This presentation will cover important features of normal anatomy as well as the issues
presented by septal defects at various locations within the ventricular septum.
PCCS 2006
LS3(3/3)
Transcatheter Closure of Ventricular Septal Defects: Results &
Complications
Ziyad M. Hijazi, M.D., MPH, FSCAI
The University of Chicago Hospitals and The Pritzker School of Medicine, USA
SPEAKER’S ABSTRACTS November 3, 2006
Ventricular septal defects (VSD) are the most common congenital cardiac anomalies,
accounting in isolation for almost 20% of congenital cardiac lesions. Ventricular septal
defects have also been reported after myocardial infarction, trauma as well as residual
defects after prior attempts at surgical closure.
Depending on size, VSD’s can cause variable degrees of left-to-right shunting with or
without pulmonary hypertension. Small muscular defects diagnosed in infancy have a
high likelihood of spontaneous closure, whereas larger defects tend to persist through
adulthood. The likelihood of spontaneous closure decreases with advancing age and is
less common for defects located within the perimembranous region of the ventricular
septum. Irrespective of the hemodynamic effects of VSDs there is an additional risk of
developing subacute bacterial endocarditis.
Surgical closure has been advocated as the gold standard for treatment of large VSD’s.
Surgical closure of perimembranous VSD’s yields excellent results with low morbidity
and mortality. However, the outcome is less favorable in patients with increased surgical
risk factors, multiple previous cardiac surgical interventions, poorly accessible muscular
VSDs or “Swiss-cheese” type VSDs.
In 1988 Lock and colleagues reported the first experience of transcatheter closure of
muscular VSD’s in 7 patients using the Rashkind double umbrella device. Since then
different devices have been used to close muscular as well as perimembranous VSD’s
with variable success, such as the Clamshell / CardioSeal device, the buttoned device as
well as detachable coils . Since 1998 different types of Amplatzer devices have been used
to close VSD’s .
Devices for closure of VSD’s have not only been used in the cardiac Catheterization
laboratory. In 1993 Fishberger and colleagues first reported intraoperative
VSD device closure using the Rashkind double umbrella device in 10 patients. More
recently Bacha and colleagues reported perventricular device closure of muscular VSDs
without cardiopulmonary bypass, using the Amplatzer mVSD device in 6 patients. In this
presentation, I will discuss device closure of muscular and PmVSD using the Amplatzer
devices and outline their results including the complications encountered during and after
the closure.
PCCS 2006
S30(1/3)
Transcatheter Closure of ASD: Tips and Technique
SPEAKER’S ABSTRACTS November 3, 2006
Dr. Geoffrey K Lane, B. Pharm, MB.BS, FRACP
Director Cardiac Catheterisation and Interventional Cardiology
Royal Children’s Hospital Melbourne, Australia
Success in percutaneously closing atrial septal defects with any device is dependent upon
proper case selection. In general, patients with “deficiency” of more than 2 margins of the
fossa ovalis should be considered unsuitable for percutaneous closure. Assessment of
atrial septal defect suitability is often performed with transthoracic echocardiography and
refined with either trans-oesophageal or intracardiac echocardiography at the time of
catheterisation. The use of balloon sizing remains the “gold standard” for device selection.
The most frequently used method is static balloon sizing utilising the “stop flow” end
point.
The choice of device depends largely on the size of the defect to be closed. For small to
medium sized atrial septal defects, either the Amplatzer Septal Occluder or the Helex
Septal Occluder are equally effective. Device sizing varies depending on which device is
chosen for implantation. For Amplatzer Septal Occluder implantation, a device size equal
to the stretched balloon size or no greater than 1mm larger should be considered. For
Helex Septal Occluder implantation, the device should be at least 1.7 times larger than the
stretched balloon size. Defects with a stretched size of greater than 18mm should be
considered unsuitable for use with a Helex Septal Occluder.
For closure of large atrial septal defects, the use of additional techniques or speciality
delivery sheaths may need to be utilised.
PCCS 2006
S30(2/3)
Transcatheter closure of VSD: Asian perspective
Mazeni Alwi, M.D.
National Heart Institute, Kuala Lumpur, Malaysia
SPEAKER’S ABSTRACTS November 3, 2006
PCCS 2006
S30(3/3)
Technique of balloon dilation of aortic coarctation
SPEAKER’S ABSTRACTS November 3, 2006
Mohammed Omar Galal, M.D., Ph.D., MBA
King Faisal Specialist Hospital & RC, Jeddah, Saudi Arabia
An interventional catheterization procedure is like every other process; a series of clearly
defined steps that achieves a projected end result. As a matter of fact procedures are done
in the same way each time. They almost follow a structured format. Balloon dilation of
aortic coarctation is no exception.
As goes for many other interventions, the process of balloon dilation will first follow a
linear type of procedure, where primarily basic tasks that contain sequential steps are
needed. The conditions and basic tools of the first linear part is a functional cardiac
catheterization laboratory, excellent technical staff, availability of the materials and tools
needed for access, establishing diagnosis- in our example an excellent aortic angiography
to visualize the coarcted segment. In other words, this part includes the preparation for the
actual balloon dilation.
This is then followed by a decision or branched type procedure. The decision has to be
made: is this specific case for balloon dilation or not, if yes, which balloon to aortic diameter
ratio to use, which balloon manufacturer is best for this case etc. When the decision is
taken, a linear type procedure is followed to proceed with the actual intervention and than
conclude the examination.
While the beginning and the last part are more or less the technical and hence easy learnable,
the main part is the clinical part and needs besides knowledge, also experience and intuition
to make the right decision for the specific patient and lesion.
In the context of our presentation, the different steps of this procedure will be addressed
and highlighted, the potential risks and complications will be also mentioned.
PCCS 2006
S31(1/3)
Conduction system in CHD
Andrew Cook, M.D.
Institute of Child Health, University College London, UK
SPEAKER’S ABSTRACTS November 3, 2006
PCCS 2006
S31(2/3)
Supraventricular tachycardia and catheter ablation in complex
biventricular forms of congenital heart disease.
SPEAKER’S ABSTRACTS November 3, 2006
Michael J. Silka, M.D.
Division of Cardiology, Childrens Hospital Los Angeles, University of Southern California,
USA
Catheter ablation has emerged as a highly effective and low risk definitive therapy
for patients with supraventricular tachycardia (SVT). However, the success rates for catheter
ablation have remained significantly lower for patients with congenital heart disease, along
with a greater risk of procedural complication, most notably advanced AV block.
In this session, the mechanisms of SVT, abnormalities of conduction system
anatomy and approaches to catheter ablation for patients with complex bi-ventricular
congenital heart defects will be discussed. This include patients with AV septal defects,
Ebstein’s anomaly, discordant AV connections (L-TGA) and patients with d-transposition
of the great arteries (d-TGA) following an atrial “switch” procedure. In any of these defects,
the presence of intrinsic conduction system abnormalities such as bundle branch block or
conduction system displacement may render ECG prediction of accessory AV connection
location inaccurate. Furthermore, AV node re-entrant tachycardia may often occur as a
second mechanism of SVT in these patients.
For patients with an AV septal defect, awareness of the posterior (inferior)
displacement of the conduction system is paramount. Compared to the normal location of
the AV node-His bundle, the conduction system is displaced in an AVSD to the posterior
aspect of the triscuspid valve annulus. Ablation of accessory AV connections in the posterior
or posterior-septal region may result in simultaneous injury to the normal conduction system.
The anatomic substrate of Ebstein’s anomaly presents several unique challenges
in the performance of catheter ablation. These include accurate definition of the anatomic
AV groove (site of accessory pathway insertion), the presence of multiple accessory AV
connections along with the fractionation of electrograms which complicates the
interpretation of intracardiac signals. For patients with marked right heart dilation, catheter
positioning and stability also remain formidable technical challenges.
Although accessory AV connections are commonly reported in association with
discordant AV connections (L-TGA), minimal data exists regarding the ablation of these
pathways. It is important to appreciate the anterior displacement of the AV conduction
system in this defect compared to normal, and to limit catheter manipulation in this region.
The majority of accessory AV connections in L-TGA occur in the posterior septal region.
However, due to anatomic distortion and displacement, cannulation of the coronary sinus
may be difficult in these patients.
PCCS 2006
Following an atrial switch procedure (Mustard or Senning), intra-atrial re-entrant
tachycardia is the most common mechanism of SVT. For some patients, RF ablation along
the cavo-tricuspid isthmus provides cure for this arrhythmia. However, in others, the
arrhythmia is incision related and may require more complex mapping techniques. Caution
with attempted ablation in the posterior-septal space is required, as AV block has been
reported during attempted ablation in this region.
SPEAKER’S ABSTRACTS November 3, 2006
PCCS 2006
S31(3/3)
SVT and complex single ventricle and post Fontan operation
SPEAKER’S ABSTRACTS November 3, 2006
Eun Jung Bae, M.D., Ph.D.
Associate professor Department of Pediatrics, Seoul National University College of
Medicine, Korea
Because of recent advance of surgical results, many children with complex congenital
heart disease have survived after corrective or palliative repair. However, tachyarrhythmia
is recognized to be an important source of early and late morbidity and mortality especially
in post-Fontan patients. Intraatrial reentrant tachycardia (IART) and atrial fibrillation have
been known to be major tachycardias following Fontan type palliation. Various treatment
modalities such as antiarrhythmic medications, pacemaker implantation, transcatheter
ablation, and Fontan conversion with arrhythmia surgery have been tried successfully.
Recently we reported the coexistence of two distinct AV nodes in complex congenital
heart disease and its incidence and relation to arrhythmias. From 2001 to 2003, we
performed an electrophysiologic study upon 52 consecutive patients who had undergone
cardiac catheterization after Fontan completion. Atrial pacing was performed at 3 or more
different atrial sites. In 10/52 patients, two different QRS complexes were recorded at
different pacing sites, suggesting twin AV node (9/20 in right atrial isomerism, 1/8 AV
discordance, 0/24 other complex anomalies). AV reciprocating tachycardia (AVRT),
presumably involving two AV nodes and a connecting sling, was induced in 6 of 10 patients
who had twin AV node (4/6 used posterior AV node as an antegrade limb, 2/6 used an
anterior AV node as an antegrade limb). Heterotaxy syndrome (p<0.001) and complete
atrioventricular septal defect (p=0.002) were found to be risk factors for twin AV node.
Junctional tachycardia (JT; HR>150/min) with either VA dissociation (7/9) or second degree
VA block (2/9) were induced by pacing or isoproterenol infusion in 9/52 patients. Junctional
tachycardia induction was associated with a twin AV node (p=0.04), or a history of early
postoperative junctional ectopic tachycardia (p=0.02). A complicated AV node conduction
system such as twin AV node was frequent in heterotaxy syndrome. Both AVRT, and JT
with VA block may be important causes of tachyarrhythmia in this patient group.
PCCS 2006
S32(1/2)
Patient and Family Education.
Bernadette McCormick, BSN, R.N.
Rady Children’s Hospital, San Diego, CA. USA
SPEAKER’S ABSTRACTS November 3, 2006
This presentation will review the current data on long-term physical and
developmental outcomes of children with Congenital Heart Defects. The focus will be on
patients with complex lesions.
PCCS 2006
S32(2/2)
Supporting Family with Congenital Heart Disease Child
SPEAKER’S ABSTRACTS November 3, 2006
Lily Lihwa Hsu, RN., MSN
Program Director Nursing Education-Shanghai Deputy Dean Shanghai Jiao Tong
University School of Nursing, Shanghai, China
Family with Congenital Heart Disease (CHD) child frequently suffers from stress,
uncertainty, and guilt. Stress may come from disease treatment and complication that occur
during surgery and recovery period. Feeling of uncertainty is frequently associated with
long-term unpredictable outcome or cardiac function after corrective or palliative surgery.
Many families with critically ill child staying in critical care setting also have unmet
needs that are important to be recogni
Family with critical ill child has many needs, that including to be with and be able
to participate in child care, to receive accurate consistent information on the case, to discuss
in depth with physicians, to feel that everything possible is done for their child, to have an
appropriate place to stay overnight near ICU, to feel respected by health professionals
while taking care of their child, to feel hopeful about the child’s survival outcome, and to
know the child is free from pain.
In addition, it is essential to assess family condition during critical time. The
assessment should include family’s level of anxiety from ICU setting, family’s coping
style, their concerns on worry and pain, loss of parents normal caregiver’s role, loss of
control while being hospitalized, feeling of inadequacy, restricted visiting rules, and the
appearance of the ill child. Also, the condition of other patients nearby may worsen the
stressful condition. All of the above conditions require health care professionals to provide
extra support to these families to help them to overcome their uncertainty or fear while
their child is in critical care situation.
In order to serve parents of child with Congenital Heart Disease, the family-centered
approach was initiated in Shanghai Children’s Medical Center (SCMC) cardiovascular
surgery units. A descriptive study was conducted in 6 units to identify the gap between
what parents perceive care should be, and how they view nurses’ actual practice in the
family-centered care. A total of 180 parents were selected by purposive sampling. The
study result indicated that nurses were able to meet the physical needs of hospitalized
children and their parents, able to assist parents for them to be closer to their child, and
willing to help children to feel “well cared for”. However, data also indicated that nurses
have gap to respond to children’s behavioral manifestation, psychological needs, and
emotional reaction related to illness or hospitalization.
The above study suggests that the nurses are more attentive to disease treatment.
However, psychological needs are as important as the physical manifestation. Study also
PCCS 2006
SPEAKER’S ABSTRACTS November 3, 2006
identified that children undergoing cardiac surgery are at risk for developing Post Traumatic
Syndrome Disorder (PTSD), especially if the ICU stay is prolonged. (Connolly, McClowry,
Hayman, Mahony, Artman, 2004). Therefore, it is important to recognize children’s behavior
and psychological stress, and teach parents ways to recognize children’s fear, emotion,
and unusual behavior and inform health professional.
The ongoing technological advances in cardiovascular critical care have improved
the survival rates among children born with life-threatening congenital heart diseases. As
technology progresses, nursing care needs to move beyond the technical surgical
intervention, and try to respond to the physical and psychological challenges that parents
face with their ill children.
PCCS 2006
S33(1/4)
TRANSCATHETER CLOSURE OF PDA :
Some problems and difficulties
SPEAKER’S ABSTRACTS November 3, 2006
Sukman T Putra, M.D., FACC, FESC
Division Pediatric Cardiology, Department of Pediatrics & Child Health University of
Indonesia, Dr Cipto Mangunkusumo, National Hospital Jakarta, Indonesia
Transcatheter closure of persistent ductus arteriosus (PDA) with various occluders and
coils has been well accepted as an alternative to surgical ligation . It decreases the morbidity,
hospital stay and cost. Amplatzer duct occluder (ADO) is one of the devices available
using for transcatheter closure of PDA which has been used worldwide with high success
rate and safe. However, it is not recommended using ADO for infants less than 5 kg due to
the risk of narrowing of the aortic arch by the devices. The use of ADO is well established
and reported in many cardiac center all over the world.
There has been various devices and coils were used since the first percutaneous
closure of PDA performed by Portsmann. Some weakness of the previous devices are high
incidence of residual shunts, sometimes complex delivery system, large delivery sheath
and unsuitability for large PDA or small children. The incidence of residual shunting was
reported between 3-38%. Several significant complication that may occur are embolization
of the device and required surgery, acquired aortic narrowing, and blood loss. The procedural
complications consist of two groups: mayor adverse events and minor adverse events. The
mayor adverse events are device embolization requiring surgery or retrieved percutaneously,
partial obstruction of pulmonary artery, loss of femoral pulses and bleeding that requiring
transfusion. Whereas, the minor adverse events are hematoma of the groin, arrhythmia
requiring medication, loss of peripheral pulses.
In our multicenters clinical experiences over the last 3 years, 115 patients with
PDA was occluded using Amplatzer occluder (92.2%) and coils (7.8%). The age ranging
from 6 month to 13 yrs (median: 4.2 yrs) and the size of devices 4-12 mm (median 8mm).
We had some problems in our case series. One patient a 6 yrs girl with large
PDA(12mm) , implanted ASO (10mm) as the duct occluder was not available. The device
embolized to RPA in 24 hrs follow up. Lung perfusion scan in 6 months revealed minimal
uptake disturbances. Now clinically she was well, except mild tahypnoea. The other case
a boy of 5,5yrs old with large PDA (12 mm), type C PDA (tubular) . ADO (14-16) implanted
successfully, but embolized to RPA which was detected in 24 hrs follow up. Surgical duct
ligation was performed with good results. We failed to implant duct occluder to a 5 yrs old
girl with large PDA (11.2mm) . The surgical ligation was performed. But a significant
residual shunt was detected in the follow up. The residual shunt was closed subsequently
using Gianturco coil with good result.
PCCS 2006
In conclusion, transcatheter closure of PDA is safe and effective as an alternative
procedure to surgery . However, there were still some problems, difficulties and
complications mostly related to the anatomy of the defects, size, weight and some procedures
and techniques.
Acknowledgements to : Dr Mulyadi M.Djer (Jakarta), Dr. Didik Haryanto (Jakarta), Dr
Mahrus A.Rahman (Surabaya), Ria Nova (Palembang) on their great help in contributing
the data.
SPEAKER’S ABSTRACTS November 3, 2006
PCCS 2006
S33(2/4)
Migrated stent and repositioning
SPEAKER’S ABSTRACTS November 3, 2006
Seong-Ho Kim, M.D.
Halla General Hospital, Jeju, Korea
PCCS 2006
S33(3/4)
VSD and AV block
Transcatheter closure of perimembranous and subpulmonary VSD :
immediate term follow-up for late AV block
Background: Ventricular septal defect (VSD) is the most common congenital heart disease.
Traditional surgical correction is the procedure of choice for closure of VSD. Transcatheter
device closure using AmplatzerTM Perimembranous VSD device has emerged as an
alternative treatment.
Objectives: To report an immediate results with follow-up for patient underwent
transcatheter closure of VSD. All cardiac rhythm pre and post procedure were recorded up
to 6 months.
Materials and methods: We collected data from patients who had transcatheter closure
of VSD from February 2004 to June 2006. A peri-procedure ECG were reviewed in each
patients for abnormalities such as right bundle branch block (RBBB) or complete 3rd
degree atrioventricular block (3AVB) and follow-up ECG was done within 1 year post
procedure.
Results: 39 patients were included in this study. Their age varied from 1 to 34 years old
(median age = 13.3 10.7 yrs). The average body weight was 38 25 kg. There were 34
pre-procedure ECG available for reviewed. 27 of them had normal ECG with 6 of them
with RBBB and 1 of 1AVB with RBBB. There was successful transcatheter closure of
VSD in 38 out of 39 patients. The diameter of VSD varied from 4.5 to 14mm (mean VSD
diameter = 7.6mm.). The average device Size: VSD size (DV ratio) was 1.2 0.19. One
patient did not have VSD device closure due to transient AVB. Type of VSD closed were
Perimembranous VSD (n=28), subpulmonary infundibular type(n= 8), midmuscular (n
=2) and right ventricular systolic pressure (RVSP) was 38 12 mmHg.
Immediate post deploys 6 more patients developed RBBB post-procedure. Two of them
had 3AVB out of hospital during the 1st week post-closure. One patient recovered after
steroid treatment within one week (DV=1.33). The other had persistent 3AVB with symptom
and had permanent pacemaker placed two months later (DV=1.4). Late 3AVB was noted
in one asymptomatic girl (2 years old, DV=1.6). All three patients had perimembranous
VSD.
Conclusion : Transcatheter closure of VSD appears effective and relatively safe procedure.
AVB was noted in 7.8% of patients. One permanent pacemaker was placed. Although
there was no clear risk factors identifies. It appeared that the appearing of RBBB postprocedure may have some relationship with post-procedure early or late 3AVB.
SPEAKER’S ABSTRACTS November 3, 2006
Kritvikrom Durongpisitkul, M.D.
Division of Cardiology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital,
Mahidol University, Bangkok 10700, Thailand
PCCS 2006
Predeploy
Pre ECG
SPEAKER’S ABSTRACTS November 3, 2006
34
Post deploy
F/U
Normal
Normal
Normal
27
24
33
RBBB
RBBB
7
12
RBBB
3
3° AVB
Unknown ECG
3°AVB
4
2
2
PCCS 2006
S33(4/4)
Coil occlusion of VSD
Nyuyen Lan Hieu, M.D.
Vietnam Heart Institute, Hanoi, Vietnam
SPEAKER’S ABSTRACTS November 3, 2006
PCCS 2006
S34(1/3)
Controversial indications for pacemaker implantation in children
SPEAKER’S ABSTRACTS November 3, 2006
Michael J. Silka, M.D.
Division of Cardiology, Childrens Hospital Los Angeles, University of Southern California,
USA
In an effort to provide guidance for the clinician, the American College of Cardiology
and the American Heart Association have developed guidelines (indications) for the
implantation of pacemakers and implantable cardioverter-defibrillators. These guidelines
are based on clinical data, which is often limited, and remain a topic of considerable
debate. Three classes of recommendations exist: class I, where there is evidence and/or
consensus that a pacemaker is generally indicated: class II, where there is controversy or
debate regarding benefit of pacemaker implantation and class III, where there is evidence
and/or consensus that cardiac pacing is not beneficial.
In recognition of the controversy regarding some class II indications, these
conditions have been further sub-divided into class IIA, where the majority of evidence is
in support of pacing and class IIB, conditions where the usefulness of pacing is debatable.
This session will examine the class IIA and class IIB indications, the current evidence
regarding pacing in each of these conditions and possible future modifications to the existing
recommendations.
The specific class IIA indications to be discussed include:
1. The brady-tachy syndrome in post-operative congenital heart disease patients,
particularly when chronic antiarrhythmic medications are required
2. Congenital complete heart block, beyond the first year of life, when the average
ventricular rate is < 50/minute, there are abrupt pauses in the intrinsic rhythm
or there are symptoms due to chronotorphic incompetence
3. The long QT syndrome with 2:1 AV block or complete heart block
4. Asymptomatic sinus bradycardia (<40/minute) in the child with complex
congenital heart disease or when there are sinus pauses > 3 seconds
5. Patients with congenital heart disease and impaired hemodynamics due to sinus
bradycardia or loss of AV synchrony
The specific class IIB indications to be discussed include:
1. Transient postoperative third degree heart block that reverts to sinus rhythm
with residual bifascicular block
2. Congenital third degree heart block in the asymptomatic child or adolescent
with an acceptable rate and normal QRS complex
3. Asymptomatic sinus bradycardia (< 40/minute) in the child with prior
biventricular repair of congenital heart disease or when there are sinus
pauses > 3 seconds
4. Neuromuscular disease with any degree of AV block, with or without symptoms,
due to the unpredictable progression of AV conduction disease
PCCS 2006
S34(2/3)
Cardiac Resynchronization Therapy in Children
Mei-Hwan Wu, M.D., Ph.D.
Departments of Pediatrics, National Taiwan University, Taipei, Taiwan
SPEAKER’S ABSTRACTS November 3, 2006
Cardiac resynchronization therapy (CRT) using biventricular pacing may improve the
myocardial performance in patients with electrico-mechanical dysynchrony. Typical patients
are those with myocardial dysfunction and left bundle branch block. The effectiveness of
CRT had been well documented in earlier eight landmark trials in adults with moderate to
severe heart failure on optimal medical therapy. In children, potential benefits of CRT had
been described in those with ventricular dysfunction and electrical delay (inter- or intraventricular dyysynchrony) both in the acute and chronic settings.
In previous studies in children after surgery for congenital heart defects, short-term CRT
by multi-site pacing may improve the postoperative cardiac output and systolic blood
pressure and facilitate the weaning from cardiopulmonary bypass. As to chronic
biventricular CRT in this age group, although the case number is still low, the benefit of
CRT is well recognized. In contrast to adult patients, more than half of the children with
CRT have associated congenital heart disease. Some have congenital complete
atrioventricular block or dilated cardiomyopathy. The acute or chronic effects of CRT are
shown not only in patients with two-ventricle circulation but also in those with single
ventricle physiology or systemic right ventricle. Adverse effects are relatively common,
as compared to adults, and mainly the coronary sinus lead issues. Case selection for CRT
in children is usually based on the clinical criteria, including low ventricular ejection
fraction and widen QRS duration (either left bundle branch block or right bundle branch
block). In adults with dilated cardiomyopathy, it was estimated that 7-14 % of the patients
had widen QRS duration and potentially benefit from CRT. In our series of children with
dilated cardiomyopathy, 17 % of them had wide QRS duration (10 with complete left
bundle branch block and 3 intraventricular conduction delay).
Predictors for chronic CRT responders in children with ventricular dysfunction are still
unclear. A relatively lower baseline ventricular ejection fraction had been found in
responders as compared to non-responders. In adults, echocardiographic studies have
demonstrated that the presence of LV dyssynchrony is an important factor determining
response to CRT, whereas interventricular dyssynchrony appears of less importance. These
criteria may also be adopted for children to predict the response after CRT but still need to
be validated.
PCCS 2006
S34(3/3)
Pediatric AICD : A review
SPEAKER’S ABSTRACTS November 3, 2006
Apichai Khongphatthanayothin, M.D.
Chulalongkorn Hospital & University, Bangkok, Thailand
PCCS 2006
S35(1/1)
Long Term Outcomes in Patients with Congenital Heart Defects
Bernadette McCormick, BSN, R.N.
Rady Children’s Hospital, San Diego, CA. USA
SPEAKER’S ABSTRACTS November 3, 2006
This presentation will review the current data on long-term physical and developmental
outcomes of children with Congenital Heart Defects. The focus will be on patients with
complex lesions.
PCCS 2006
Debate1(1/2)
Percutaneous Pulmonary Valve Implantation: Animal Studies and
Human Experience
SPEAKER’S ABSTRACTS November 4, 2006
Ziyad M. Hijazi, MD, MPH, FSCAI
The University of Chicago Hospitals and The Pritzker School of Medicine.
5841 South Maryland Ave., MC4051
Chicago, IL 60637, USA
Tel: (773) 702 6172; Fax: (773) 834-4100; E-mail: [email protected]
Significant pulmonary valve regurgitation results in progressive right ventricle
dilation that may lead to the risk of development of ventricular arrhythmias, right ventricle
dysfunction and sudden death. The occurrence of pulmonary regurgitation and or obstruction
is not uncommon after surgery for congenital heart defects, including tetralogy of Fallot,
pulmonary atresia and any other surgical procedure requiring reconstruction of the right
ventricle outflow tract. Even if a valved conduit or a bioprosthetic valve has been used for
this purpose, progressive pulmonary regurgitation and or stenosis of such conduits or
valves (homografts, Contegra, porcine valves) can occur. Surgical pulmonary valve
implantation at an appropriate age may restore right ventricular function and improve the
symptoms, however cardiopulmonary bypass and ventriculotomy needed for such
operations may further impair the right ventricular function. Therefore timing and
indications for resurrection of a competent pulmonary valve are controversial issues.
In October 2000, Bonhoeffer and his colleagues reported the first animal experience
of a percutaneously implanted pulmonary valve using a bovine jugular vein valve sutured
inside an intravascular stent and since then the procedure has been reported in 59 patients.
In December 2002, Cribier and his colleagues reported on the first human application
of another percutaneous heart valve (PHV) in the aortic position. This valve was designed
initially for application only in the aortic position and the early clinical experience with
this PHV in the aortic position is ongoing.
In this debate, I’ll discuss the animal experience implanting this valve in the
pulmonary position and discuss our early human experience. Furthermore, I will discuss
the experience with the Bonhoeffer valve that has been accumulated so far. He has done
over 135 cases with very good results.
PCCS 2006
Debate1(2/2)
Transcatheter valve therapy (weird or wonderful?): Con
Andrew N. Redington (Canada)
The Hospital for Sick Children, Toronto, Canada
SPEAKER’S ABSTRACTS November 4, 2006
PCCS 2006
S36(1/2)
Natural History of Subpulmonic VSD and
Echocardiographic Evaluation
SPEAKER’S ABSTRACTS November 4, 2006
Layangool T., Kirawitthaya T, Sangtawesin C
Queen Sirikit Institute of Child Health, Bangkok, Thailand
Objective: To study the natural history of the ventricular septal defect, types of VSD, the
incidence and onset of aortic valve prolapse (AVP) and aortic regurgitation (AR).
Study design: A prospective cohort study.
Population: The children diagnosis of isolated VSD who under one year of age at Queen
Sirikit national institute of child health. The studying period was started from October
2000 to September 2006. By using Toshiba (Provision) or Aloka echo machine,
echocardiographic studies were schedule performed every 2-3 month in the first year of
age and then every 6 month to evaluate the size, location, flow across VSD, aortic valve
morphology and evidence of aortic regurgitation.
Results: Three hundred twenty one cases of VSD have been followed up. One was excluded
due to associated hypoplastic RV. The overall 2,644 echocardiograms had been performed.
The percentage of perimembranous, subpulmonic, muscular, inlet and multiple types were
70.3%, 19.4%, 5.6%, 3.1% and 1.6%, respectively. Five cases (1.6%) had loss to follow
up. The incidence of AVP in subpulmonic VSD was 87.1% compared to 16.4% in
perimembranous VSD, with a risk ratio of 5.3. From the survival analysis, AVP in
subpulmonic VSD developed within 60 months of age; with nearly 80% had AVP in about
24 months of age. The incidence of AR in subpulmonic VSD was 37.1% compared to
5.3% in perimembranous VSD, with a risk ratio of 7.0. From the survival analysis, about
47% of subpulmonic VSD had AR occurred within 60 months of age, 25% of subpulmonic
VSD had AR in about 30 months of age. The percentage of small, moderate, and large
VSD was 62.5%, 15.9% and 21.6%, respectively. One hundred and three cases (32.2%)
underwent cardiac operation. All, except one had VSD closure. The indications for VSD
closure were congestive heart failure unresponsive to medical treatment or occurrence of
AR. Fifty percent of subpulmonic VSD required surgical closure compared to 27.5% of
the perimembranous type during the follow-up period. Sixty one cases (19.1%), including
two cases of subpulmonic type had spontaneous closure of VSD. Progressive subpulmonic
stenosis was found in ten cases (3.1%). Forty four cases (13.7%) of all VSD had associated
minor cardiac anomalies. Five cases died during the follow-up period.
Conclusion: The prevalence of subpulmonic type is relatively high in Thai children with
VSD. This type of VSD has much higher incidence of AVP and AR compared to other
types. The results of our study suggest that the aortic valve complications in subpulmonic
VSD can develop in early childhood period.
PCCS 2006
S36(2/2)
Subpulmonary VSD – When and How to repair the AR?
Katsuhiko Tatsuno, M.D.
Department of Cardiovascular Surgery Chiba Cardiovascular Center, Ichihara Chiba,
Japan
SPEAKER’S ABSTRACTS November 4, 2006
Wide-ranging studies on the ventricular septal defect with aortic regurgitation (VSD with
AR) started in 1950’s and 1960’s by Scott, Keck, Nadas, Halloran, Van Praagh and other
many investigators elucidated the entire clinical and morphological features of this entity.
Van Praagh (1968) explained that the normal aortic valve was supported by three parts,
from above, at the leaflet level, and from below. In subcristal (perimembranous) VSD, the
most relevant cause of AR was underdevelopment of one aortic commissure (lack of support
from above). On the other hand, in subpulmonary VSD, AR was caused by lack of supportfrom-below with conal (infundibular) septum.
We observed precise movement of the prolapsed aortic valve into VSD with thoracic
aortography (Tatsuno 1973). This study confirmed that the anatomically unsupported aortic
sinus and annulus were protruded by a left-to-right shunt blood stream through the VSD in
the systolic phase. And intraaortic pressure in the diastolic phase forced to hang down the
free margin of the aortic cusp resulting in AR.
The first successful operation was made independently by Garamella and Starr in
1960. In the early periods, selection criteria of operative procedure were considerably
confused. Robinson mentioned that VSD closure should be selected in the first step of
surgical treatment. Spencer and Blumenthal reported superiority of the aortic valvuloplasty.
On the other hand, Ellis, Dubost and Gonzalez-Lavin emphasized the necessity of a
monocusp or total aortic valve replacement. After the initial confusion, Plauth(1965),
Frater(1967) and Trusler(1971) introduced new techniques of aortic valvuloplasty. They
placed a stitch in the three Arantius bodies of the cusps, and plicated the redundant free
margin in order to keep apposition with the adjacent normal cusps. Following the
improvement of surgical technique, aortic valvuloplasty became the acceptable choice for
treatment of the prolpasing AR.
While these surgical techniques were developing, Plauth, Hallidie-Smith (1969),
Treasure (1971), and Trusler (1973) proposed the following criteria for selection of surgical
treatment. 1) In the young patient with mild AR, VSD closure alone is indicated. 2) In the
young patient with moderate or severe AR, aortic valvuloplasty is the first choice. However,
if it was failure, a secondary operation should be prepared. 3) In the adult patient with
severe AR, aortic valve replacement is selected. We proposed new criteria in 1973 for
selection of surgical procedures based on the three determinant factors, 1) elapsed time
after the onset of AR, 2) mechanical mobility of the bulging aortic valve during cardiac
cycle, 3) severity of AR.
PCCS 2006
SPEAKER’S ABSTRACTS November 4, 2006
Early detection of the prolapsed aortic valve and closure of the VSD, if possible
before occurrence of AR, is another ultimate approach to eliminate this combined disease.
If echocardiography and/or thoracic aortography are applied in all patients with
subpulmonary VSD, and if a suitable surgical correction in the patient with prolapsed
aortic valve, a good half of the cases of VSD with AR may be prevented.
PCCS 2006
S37(1/2)
The essence of isomerism of the atrial appendages, and its relationship
to visceral heterotaxy
Andrew Cook, M.D.
Institute of Child Health, University College London, UK
SPEAKER’S ABSTRACTS November 4, 2006
PCCS 2006
S37(2/2)
Arrhythmia in Heterotaxy Syndrome
SPEAKER’S ABSTRACTS November 4, 2006
Eun Jung Bae, M.D., Ph.D.
Associate professor Department of Pediatrics, Seoul National University College of
Medicine, Korea
Heterotaxy syndrome is uncommon congenital disorder characterized by abnormal
visceroatrial situs with either right isomerism of atrial appendages or left isomerism of
atrial appendages. In heterotaxy syndrome, the structure of the cavo-atrial junction and
atrio-ventricular junction is usually anomalous. In right isomerism, bilateral superior vena
cava, bilateral sinoatrial nodes, and paired (twin) AV node may be found. In left isomerism,
there may not be specific structure of sinoatrial node. Supraventricular tachycardia is
common in patients with right isomerism in both preoperative and postoperative period.
Abnormal electrophysiologic characteristics of AV junction and twin AV node may be the
basis for this tachycardia. Recently we reported the high correlation of right isomerism
and internodal tachycardia circling twin AV node. Among complex univentricular heart
requiring Fontan type palliation, both heterotaxy syndrome and complete AV canaseptal
defect were found to increase the risk of having a twin AV node. The presence of a rapid
conducting bundle between the two AV nodes (M?nkeberg’s sling) was also documented
by electrophysiologic recordings. Junctional tachycardia with AV dissociation is another
supraventricular tachycardia occurring in heretotaxy syndrome. We also reported the
electrophysiologic characteristics of this atypical focal junctional tachycardia. The patients
with heterotaxy syndrome, especially in left isomerism, have high probability of developing
bradyarrhythmia such as sinus bradycardia and AV block as well as tachyarrhythmia. In
the case of heterotaxy syndrome, surgical method of neither lateral tunnel Fontan operation
nor extracardiac conduit Fontan operation had significant influence on postoperative sinus
node dysfunction .
PCCS 2006
P4(1/3)
Towards the Optimum Care of Pediatric and Congenital Heart Disease
in the next decade.
Roger B. B. Mee, M.D.
Chairman Department of Pediatrics and Congenital Heart Surgery, Cleveland Clinic,
USA (Retired)
SPEAKER’S ABSTRACTS November 4, 2006
For the most part, the next 10 years of Pediatric and Congenital Heart disease management
will see incremental improvements in outcome, institution by institution. There remains a
wide range of results in terms of morbidity and mortality and this will persist, but one
expects an increasing number of centres with near optimal results - a consistent 30 day or
Hospital mortality of less than 2% and an incidence of pre-operative seizures in neonatal
surgery of less than 5%
The pathway to improving results will be focused on improved training through establishing
standards of education, particularly for the surgeons; through increased commitment in
terms of increasing numbers of dedicated full time congenital heart surgeons and
interventional cardiologists working in groups in centres with high volume loads; through
planning and organization in terms of geographical clustering of facilities within an
institution; through administrative set up and centre governance; and through leadership
fostering of a sense of mission.
Many congenital heart programs will remain disadvantaged in terms of late referral of
patients and limited resources. However, a most difficult field of medicine will yield to
improved organization, commitment and a sense of mission – changes which can be made
really quite rapidly. This expensive form of medicine becomes less so with increased
patient load, increased efficiency and above all when morbidity is reduced.
A most useful guiding principle is to Place the Patient First under ALL circumstances, as
a matter of “Top Down” policy.
PCCS 2006
P4(2/3)
The Future of Cardiac Catheterization
SPEAKER’S ABSTRACTS November 4, 2006
Ziyad M. Hijazi, M.D., MPH, FSCAI
The University of Chicago Hospitals and The Pritzker School of Medicine, USA
Interventional therapy for congenital cardiac defects is becoming more acceptable. There
are four major areas that will advance further over the next decade: Hybrid therapy,
transcatheter valve replacement, VSD closure and Completion of Fontan operation in the
cath lab.
The hybrid therapy will focus mainly on doing the first stage repair in the cath lab. This
stage consists of bilateral PA banding, stenting the PDA and possibly enlarging the atrial
septum. I will discuss the technical aspects and share some results.
The transcatheter valve replacement already has started in the pulmonary valve position.
The Bonhoeffer valve made of bovine jugular vein and sewn inside a CP stent has been
implanted in over 150 patients with very good results. I will discuss this valve and the
Cribier Edwards valve made of a stainless steel stent with equine pericardium leaflets.
VSD device closure can be done percutaneously in the cath lab or perventricularly in the
operating suite. I will discuss these techniques and outline our results.
Finally, I will discuss the Fontan completion in the cath lab.
PCCS 2006
P4(3/3)
Delivery of Care in Congenital Heart Programs: Past, Present
and Future
Andrew N. Redington, M.D.
The Hospital for Sick Children, Toronto, Canada
SPEAKER’S ABSTRACTS November 4, 2006
The First Asia-Pacific Congress
of Pediatric Cardiology and
Cardiac Surgery
November 1-4, 2006
FP1
FREE
PAPER
LONG-TERM RESULT OF PATIENTS WITH ATRIAL
ISOMERISM AFTER MODIFIED FONTAN OPERATION
Hoashi T, Ichikawa H, Fukushima N, Ueno T, and Sawa Y
Division of Cardiovascular Surgery, Department of Surgery, Osaka University
Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
Background. Due to the improvement of operative strategy and techniques, patients with atrial
isomerism tolerate Fontan operation. However, the long-term outcome is still unknown. We
investigated the long-term clinical feature of the patients with atrial isomerism after modified
Fontan operation.
Methods. Since 1954, preparatory palliative procedure for Fontan operation was performed in
58, and Fontan operation was performed in 25(43%). Among these patients, 11 patients were
identified to be followed up for more than 5 years after the definitive operation. The patients’
records were reviewed and the long-term result were analyzed.
Results. Mean follow-up period was 14 years (6-21). Ventricular morphology was right in 10
and left in 1. Nine patients had common atrioventricular valve (CAVV). Moderate to severe
CAVV regurgitation was recorded in 3 patients. No patient had total anomalous pulmonary
venous connection with pulmonary venous obstruction. Surgical procedure of definitive repair
was intra atrial routing in 1, atriopulmonary connection in 2, total cavo-pulmonary connection
with extracardiac conduit (EC-TCPC) in 5 and Kawashima in 3. Fenestration was placed in 3,
and one of them has not been closed. Concomitant operations were a CAVV repair and a
replacement. Seven patients (63.6%) survived, and all but one patient showed NYHA class1
without complication. The latest catheterization of all survivors showed mean pulmonary artery
pressure was 11± 2.6 mmHg (mean± S.D.) and systemic ventricular end-diastolic volume index
was 104± 37. The current echocardiogram showed systemic ventricle ejection fraction was
51.4± 6.5%. The oldest survivor is 34 years old. Univariate analysis identified absence of CAVVR
(p=0.04), staged strategy (intermediate BCPS or bidirectional Glenn shunt) (p=0.02), and ECTCPC (p=0.02) as significant predictors of long-term survival.
Conclusions. Seven out of 11 atrial isomerism patients after modified Fontan operation were
long-term survivors, and all but one showed excellent long-term clinical course.
FP2
The results of pediatric arch repair under normothermia without
circulatory arrest
There was no operative death. Postoperative peak pressure gradient across the aortic arch was
6 mmHg. Postoperative urination were 4.7, 2.7, 3.3, and 3.4 ml/kg/day at POD 0, 1, 2, and 3,
respectively. Max serum creatinine was 0.7 mg/dl. Duration of peritoneal dialysis was 2.9 days.
Output of pericard-mediastinal drainage tube were 21.4, 12.8, 6.7, and 4.2 ml/kg/day at POD
0,1,2,and 3,respectively. Duration of drainage tube insertion was 4.0 days. Duration of respirator
was 5.0 days. There were no cereblo-spinal dysfunction and no re-exploration for bleeding.
Pediatric arch repair under normothermia without circulatory arrest preserves renal and coagulative
function with few neurological complications. We believe that this technique is beneficial especially
in a patient with ductal shock and in a more complicated case such as HLHS.
PAPER
To minimize the risk of hypothermic circulatory arrest, we have performed pediatric arch repair
under normothermia without circulatory arrest.
Since July, 2004, 12 children (10 neonates and 2 infants) underwent an arch repair. Ages ranged
from 3 to 183 days. Body weight ranged from 2.5 to 4.4 kg. Diagnosis were Coarctation (CoA)/
VSD in 9, CoA/double outlet right ventricle (DORV) in 1, CoA/aortic stenosis in 1, and CoA/
tricuspid atresia (TA,type 2c) in 1. Preoperative status of patients were ductal shock in 2, respirator
in 7, and PGE1 infusion in 7. Emergent operation was required in all 10 neonates.
Bicaval cardiopulmonary bypass (CPB) was established through 2 cannulae at innominate artery
(3.0 or 3.5 mm ePTFE graft interposed) and descending aorta (DesAo) just above the diaphragm.
Arch repair was performed with end to end anastomosis in all but 1 case, in which Norwood
type arch repair was required (CoA/TA). Concomitant procedures were VSD closure in 9,
inter-ventricular rerouting in 1 (CoA/DORV), PA-debanding in 1, and modified BT shunt in 1
(CoA/TA).
FREE
Junichi Koizumi, Ishihara K, Mitsunaga Y, Takahashi K, Kazui T, Kin H, Ohsawa A, Oyama
K, Kadosaki M, Kawazoe K
Department of Cardiovascular Surgery, Memorial Heart Center, Iwate Medical University
FP3
FREE
PAPER
OFF-PUMP MIDLINE STERNOTOMY APPROACH IN AORTIC
ARCH REPAIR IN NEONATES WITH SINGLE VENTRICLE
Yoshimichi Kosaka, Asou T, Takeda Y, Kajihara N, Norimatsu T
Kanagawa Children’s Medical Center
An off-pump midline sternotomy approach was employed in the first stage palliation for coarctation
of the aorta associated with single ventricle in neonates. With this technique, both pulmonary
arteries were come in sight and thus could avoid migration of the pulmonary artery band (PAB
. Furthermore, the anomalous arch vessel could be repaired concomitantly. The purpose of this
study was to review outcomes of the present technique.
Patients: Five neonates had a functionally single ventricle associated with coarctation of the
aorta. The distal aortic arch was hypoplastic in 4 and the coarctation was localized in the aortic
isthmus in 1. One patient had the aberrant right subclavian artery. The median age at surgery was
10 days and the median body weight was 2.6 kg. All underwent the first stage palliation including
aortic arch repair and PAB through a midline sternotomy without use of a heart-lung machine.
Technique: The hypoplastic distal aortic arch was augmented with the left carotid arterial flap
through a midline sternotomy. Thereafter, the aortic arch was reconstructed with an end-to-end
anastomosis and the pulmonary artery was banded. In a patient with the aberrant right subclavian
artery, it was divided at its origin of the aorta and pulled behind the esophagus and re-anastomosed
to the right carotid artery in an end-to-side fashion.
Results: There was no operative morbidity and mortality. All were extubated within 48 hours.
Postoperative catheterization revealed no residuals in the aortic arch. All patients completed the
second stage palliation, bidirectional Glenn shunt (BCPS). In two patients, subaortic stenosis
developed and, hence, Damus-Kaye-Stansel anastomosis was performed concomitantly with
BCPS. Total cavopulmonary connection was completed in two and awaiting in the remainder.
Conclusions: An off-pump midline sternotomy approach was safe and useful in aortic arch
repair in neonates with single ventricle.
FP4
Mid-term results of bilateral pulmonary artery banding strategy for
hypoplastic left heart syndrome
PAPER
Background: We report our experience of performing bilateral pulmonary artery banding (BPAB)
for stage I palliation and maintaining systemic flow by prostaglandin E1 infusion or a main pulmonary
artery to the descending aorta shunt until stage II palliation.
Methods: Since 2002, BPAB for stage I was performed for eight hypoplastic left heart syndrome
patients; 5 diagnosed with aortic atresia/mitral atresia, and 3 with aortic stenosis/mitral stenosis.
Two patients had an associated chromosome anomaly. One had an intact atrial septum and left
atrium-innominate vein communication and another had anal atresia and left external ear atresia.
Results: Balloon atrial septostomy was performed in four patients before stage I. BPAB (right
or left circumference: 9 to 14) was performed at 2 to 19 days of age and 2.3 to 3.5 kg weight. In
all patients, delayed sternal closure was not required at stage I. Systemic flow was maintained in
6 patients by prostaglandin E1 infusion, and by a main pulmonary artery to the descending aorta
shunt in 2; two required an additional main pulmonary artery to the descending aorta shunt
before stage II. Before stage II, balloon atrial septostomy was performed in 4 patients, and an
atrial septal defect enlargement or creation was in one patient each. One patient was lost by
sudden death. For 7 patients, bidirectional Glenn shunt with aortic arch and coronary flow
reconstruction was performed in stage II (3 to 9 months of age, 2.9 to 4.7 kg weight). Two early
death occurred due to postoperative pulmonary hypertension crisis. The other 5 patients are
alive (5/8: 63%), 3 with a status of Fontan completion, and 2 waiting for Fontan completion.
Conclusions: The outcomes of BPAB strategy for hypoplastic left heart syndrome were
satisfactory. BPAB strategy may offer a staged surgical option for hypoplastic left heart syndrome.
FREE
Shin Takabayashi, Hideto Shimpo 1, Kazuto Yokoyama 1, Hiroyuki Ohashi 2,
Yoshihide Mitani 2
1
Departments of Thoracic and Cardiovascular Surgery and 2Pediatrics, Mie University
Graduate School of Medicine
FP5
FREE
PAPER
Biventricle Repair of Double outlet Right ventricle with NonCommitted VSD
Chung-I Chang, Jou-Kau Wang, Mei-Hwan Wu
Department of Surgery and Pediatrics*, National Taiwan University Hospital
Purpose: Surgical treatment of double outlet right ventricle (DORV) with non-committed ventricular
septal defect (VSD) is still controversial in either biventricular or univertricular repair and challenging
to the pediatric cardiac surgeon.
Materials and Methods: From Oct 1996 to June 2005, fifteen patients of DORV with noncommitted VSD underwent biventricular repair. The age distribution is from 13 days to 23 year
old (Mean 2.8 years old). The sex ratio of male to female is eight to seven. The associate
anomalies included pulmonary stenosis and atresia 4, ECD 2, straddling of atrioventricular valve
3, juxtaposed atrial appendage 2, CoA 2, LV diventriculum 1, anatomical corrected malposition
(ACM) 1, TAPVR 1. Nine patient had palliative procedure (shunt 4, PA banding 3, CoA repair
2). The definite surgical procedures divided into two groups. Group 1, five patients underwent
arterial switch operation. Two of them had VSD enlargement. Group 2. Ten patients underwent
intraventricular rerouting procedure. Six of them had VSD enlargement. Only one had extracardiac
conduit.
Results: There are three early mortality and no late mortality. Two of the mortality were neonates.
The follow up period was 3 months to 7 years. The postoperative complications are AV block 1,
residual LVOTO 3, (pressure gradient < 20 mmHg), residual PS 3 and mitral regurgitation 1.
Conclusion: Biventricular repair is feasible in DORV and non-committed VSD with certain
anatomical features. Precise preoperative evaluations will determined the type of the definite
repair.
FP6
Mitral valve repair in pediatric patients for mitral regurgitation
PAPER
Background: Mitral regurgitation is uncommon and features wide spectrum of morphologic
abnormalities in pediatric patients. We retrospectively evaluated the midterm results of mitral
valve repair for mitral regurgitation in pediatric patients.
Material and Methods: Between December 1993 and February 2005, mitral valve repair was
performed for mitral regurgitation in 33 patients aged less than 18 years. Mean age was 5.4 5.4
years (range 4 months to 17 years) and 6 patients (18.2%) were less than one year old. Mean
body weight was 20.4 16.7kg (range 5.9 to 69.5kg). 17 patients had associated cardiac
anomalies; ventricular septal defect was the most common(n=8). In regards to pathologic findings,
there were annular dilatation(n=12), cleft leaflet(n=8), leaflet prolapse(n=6), short chordae(n=6)
and so on. The most common method of repair was double orifice technique(Table 1). Mean
follow up duration was 47.5 39.0 months(range 4.3-138months).
Results: There was no early mortality. In terms of mitral regurgitation, 32 patients showed
improvement in the degree of regurgitation after the first operation. Eight patients(24.2%) underwent
reoperation, and five of them required mitral valve replacement. The causes of reoperation were
regurgitation in five and stenosis in three. Among three ring annuloplasty cases, two have developed
mitral stenosis. Four out of 14 double orifice cases required reoperation. The median interval
from the first operation to reoperation was 5.5months (range 0-89.2months). One early and one
late mortality occurred in the reoperation cases, and both of them were subject to mitral valve
replacement. The 5-year survival rate and the freedom from reoperation were 93.3 4.6% and
76.1 8.2%, respectively. The 5-year freedom from mitral valve replacement was 83.6 6.7%.
There was no significant risk factor for reoperation.
Conclusions: Mitral valve repair for mitral regurgitation in pediatric patients resulted in acceptable
early and midterm mortality and reoperation rates. Long term follow-up and further studies will
be needed.
FREE
Hyung-Tae Sim, Dong-man Seo, M.D. 1, Tae-Jin Yun, M.D.1, Jung-Jun Park, , M.D.1,
Sung-Ho Jung, M.D. 1 ,Ju-Yeon Uhm, R.N. 1 , Young-Hwue Kim, M.D.2, Jae-Kon Ko,
M.D.2, In-Sook Park, M.D.2
1: Asan Medical Center, University of Ulsan, Department of Thoracic and
cardiovascular Surgery
2: Asan Medical Center, University of Ulsan, Department of Pediatrics
FREE
PAPER
Table 1. Operation methods
Operation method
Double orifice technique
Cleft repair
Focal Annuloplasty
Papillary muscle splitting
Ring annuloplasty
Leaflet resection
Wooler’s procedure
New chordae formation
Kay annuloplasty
No.
14
7
7
4
3
3
2
2
1
FP7
Sinus Node Dysfunction Following the Repair of Partial Anomalous
Pulmonary Venous Connection
PAPER
Objective:An atrial pedicle flap in the intra-atrial rerouting for the repair of partial anomalous
pulmonary venous connection(PAPVC)0is expected to grow, resist infection,and last for the life
span of the patient. However, this procedure may lead to postoperative sinus node
dysfunction(SND). This retrospective study is to identify the cause of the incidence of SND after
repair of PAPVC.
Methods:The records of 22 patients undergoing repair for PAPVC between September 1991
and January 2006 were examined.Mean age at repair was 5.8 years(range,5 months to 17
years). Fifteen patients with PAPVC to superior vena cava were repaired using the caval division
technique. Seven patients had PAPVC to the right atrium. Intra-atrial rerouting was performed
with a right atrial wall flap in 14 patients(Group A) ,and with a patch(6) or direct suture(2) in 8
patients(Group B).
Results: Follow-up averages 4.7 years(range, 2 months to 12 years).There were no hospital or
late deaths.Postoperative echocardiograms showed that all patients had no evidence of superior
vena caval or pulmonary venous obstruction.The thirteen patients(93%) in Group A and two
patients(25%) in Group B had SND early postoperatively. Eight patients with SND at the discharge
were all in Group A. Six cases of them have still SND late postoperatively. One of them required
implantation of a pacemaker.
Conclusions:In the atrial pedicle flap repair, the incision or suture crossing the crista terminalis
have the potential to cause SND. However, intra-atrial rerouting with patch or direct suture
maintains normal sinus node function.
FREE
Hiroaki Hiroaki, Yoshihiro Oshima, Masahiro Yoshida, Chikashi Shimazu, Hironori
Matsuhisa, Tomonori Higuma, Yutaka Okita
Kobe Children’s Hospital, The Department of Cardiovascular Surgery
FP8
FREE
PAPER
EXCLUSION OF THE NON-FUNCTIONING RIGHT VENTRICLE
Ji-Hyuk Yang, Jun TG1, Park PW1, Huh J2, Kang IS2, Lee HJ2
Samsung Seoul Hospital, Sungkyunkwan University School of Medicine
135-710 Seoul, Korea
Department of Thoracic and Cardiovascular Surgery, Samsung Seoul Hospital
Objectives: Non-functioning right ventricle (RV) not merely cause collapse of pulmonary
circulation but may affect function of the left ventricle (LV). To prevent the deleterious effects, the
right ventricle was excluded surgically.
Materials and methods: Fourteen patients underwent right ventricular exclusion between Dec
2000 and Feb 2006 at our institution. The patients were divided into two groups; Group I
(n=10) had hypertrophied RV associated with pulmonary atresia/intact ventricular septum (n=9)
or tricuspid atresia (n=1), and group II (n=4) had dilated RV with Ebstein malformation. In
group I, the median age at surgery was 5 (0.2 ~ 13.8) months and RV exclusion was performed
during a cavo-pulmonary anastomosis (n=6) or systemic-to-pulmonary artery shunt (n=4). In
group II, the median age at surgery was 29 (0.2 ~ 377) months, and the exclusion was performed
during a Fontan procedure (n=2), cavo-pulmonary anastomosis (n=1), and Starnes operation
(n=1). The tricuspid valve was closed either with patch or directly in all patients except one
having tricuspid atresia. Additional procedures for RV exclusion were Gelfoam insertion into the
cavity (n=8) in group I, suture plication of ventricular wall externally or internally (n=3), or free
wall resection(n=1) in group II.
Results: In group I, there was no mortality. Seven patients showed totally obliterated RV, 2
patients still had small communications between RV and coronary artery, and 1 had remaining
RV cavity, which impairs LV diastolic function. In this patient, tricuspid valve had been closed
directly without the use of Gelfoam because of rather sizable RV cavity. Fontan procedure was
completed in 5 of the 10 patients. In group II, two patients died of ventricular arrhythmia and low
cardiac output. Another patient still had large RV cavity. All these patients had had their RV wall
been plicated. The other whose RV wall had been resected showed shrinkage of RV and an
improvement in the motion of ventricular septum and LV function. Follow-up was completed in
all survivors for a period of 3.6 to 66.7 (median 24.6) months.
Conclusion : Exclusion of non-functioning RV can provides effective decompression of right
ventricle, and subsequently left ventricle in a certain type of functional single ventricle. Although
our experiences are small, it is advisable that hypertrophied RV should be obliterated with
thrombotic material and patch, and dilated RV with free wall resection. Also, it would be
easier for RV to be collapsed, if RV exclusion is performed earlier stage of palliation when the
patient is expected to follow single ventricle correction
F9
AORTIC VALVE REPLACEMENT IN CHILDREN – LATE REOPERATION DUE TO PATIENT PROSTHESIS MISMATCH IS
UNLIKELY IN RHEUMATIC PATIENTS
PAPER
Background : Rheumatic heart disease (RHD) and congenital heart disease(CHD) remains the
two most common cause of aortic valve replacement (AVR) in children. Implanting adequate
size prosthesis is important to avoid patient prosthesis mismatch and re-operation. Annular
enlargement may be required for implanting adequate size prosthesis.
Methods and Patient profile: From Jan 2001 till July 2006. 41 patients underwent AVR with
St. Jude medical regent mechanical heart valve prosthesis using standard cardiopulmonary bypass
technique. 22 patients had associated mitral valve replacement. 36 patients were operated for
RHD and 5 for CHD. In group A, 33 patients had predominantly regurgitant lesion (AR) and
only 3 patients had pure stenosis along with severe mitral regurgitation (MR). All patients ingroup B had bicuspid aortic stenosis. Two of them had previous balloon Aortic valvotomy.
Results: Patients with CHD needed early intervention than RHD group(10 ± 4.12 yrs Vs 15.53±
2.59). The mean size of valve implanted in RHD group was significantly larger (21.33± 2.59mm
Vs 17± 0 mm , p < 0.005) than CHD group. As a result, the mean indexed effective orifice area
was significantly larger (1.87± 0.29mm/m2 Vs 1.47±0.54 mm/m2 , p < 0.05) in RHD group.
Only one patient with RHD (2.7%) needed aortic annular enlargement. Where as in CHD group,
3 patients (60%) had annular enlargement.
Conclusion: In our study aortic valve replacement in children with RHD is predominantly due to
AR. Implantation of relatively bigger size prosthesis with significantly larger orifice area was
possible with very low incidence of annular enlargement compared to patients with CHD. Therefore
late re –operation due to patient prosthesis mismatch is unlikely in rheumatic patients.
FREE
Biswajit Bandyopadhyay, Das Mrinalendu., Ashutosh Raghuvanshi.
Rabindranath Tagore International Institute of Cardiac Sciences
FP10
FREE
PAPER
Modified simple sliding aortoplasty for supravalvar aortic stenosis
Dong-Man Seo, Hong-Ju Shin, M.D. 1, Jeong-Jun Park, M.D.1, Tae-Jin Yun, M.D.1,
Young-Hwue Kim, M.D.2, Jae-Kon Ko, M.D.2, In-Sook Park, M.D.2
1: Asan Medical Center, University of Ulsan, Department of Thoracic and
cardiovascular Surgery
2: Asan Medical Center, University of Ulsan, Department of Radiology
3: Asan Medical Center, University of Ulsan, Department of Pediatrics
Background: The surgical approach for treating supravalvar aortic stenosis has evolved from
plain patch technique to 3-dimensional patch repair. However, this 3-dimensional patch is complex,
time-consuming procedure. We propose a modified simple sliding aortoplasty for supravalvar
aortic stenosis without using foreign material.
Material and Methods: Between June 2001 and December 2005, 7 children (mean age 7
years; range 3 to 12) with supravalvar aortic stenosis were surgically treated. Four patients had
clinical features of Williams syndrome. Three patients had undergone right pulmonary artery
angioplasty due to right pulmonary artery stenosis. One patient had undergone aortic valve
commissurotomy due to bicuspid aortic valve.
Results: There were no in-hospital deaths. No patient required repeat surgery. Cardiopulmonary
bypass mean time was 66.3±15.8 minutes (range, 51 to 94). The mean cross-clamp time was
28.9±11.7 minutes (range, 19 to 52). All patients were discharged from the hospital with no
problems. Patients were followed-up for a mean duration of 29.7±21.8 months (range 2 to 55).
All patients were underwent postoperative echocardiography or computed tomographic scan,
which showed good results of the surgical correction.
Conclusions: For the patients presented in this study, the mid-term results of modified simple
sliding aortoplasty have proved promising. Long-term follow-up is required to determine if this
technique ultimately improves aortic anatomy significantly enough to decrease the incidence of
postoperative aortic stenosis and insufficiency, and results in fewer operations.
FP11
A new concept of infundibular rehabilitation in the correction of
TOF: a more functional and anatomic approach
PAPER
Objective: Recent evidences of the importance of the infundibulum in TOF repair made us
develop a new concept of infundibular rehabilitation. The early results of our experience are
presented.
Methods: From Sep.2001 to Sep.2004, 85 consecutive patients underwent total correction of
TOF. VSD was closed through the RA in every case. Transannular patching(TAP) was performed
in 60 patients(group I,70.6%) and in 25 patients no patching was done(group II,29.4%). TAP
was performed by a new technique consisting of minimal damage to the transverse basal loop
while producing effective mobilization of the pulmonic annulus and the infundibulum. In order to
evaluate the right ventricular(RV) function, the degree of PR and RV dilatation by echocardiogram
and the QRS duration by EKG were assessed. The results were compared with those of patients
who did not undergo TAP.
Results: There were no significant differences between the two groups in terms of age and body
weight, but CPB time(group I,95.1±18.3min vs group II, 82.3±14.0min,p<0.01) and ACC
time(group I,63.6±10.4min vs group II, 53.1±9.7 min,p<0.01) were both longer in group I.
There was also no mortality, in either group. A total of 5 re-operations(5.9%) were performed;
3 in group I(5%) and 2 in group II(8%), all of which were for residual RVOT stenosis. As for the
RV function, there were no differences between the two groups with regards to RV dilatation(group
I,19/60 vs group II,7/25,p>0.7), QRS duration(group I, 101.5 ±20.6ms vs group II,
97.9±18.3ms,p>0.4) or the incidence of mild and moderate PR(less than mild;group I,56/
60,93.3% vs group II,24/25,96%, moderate;group I,4/60,6.7% vs group II,1/25,4%).
Furthermore, there was no case of severe PR in either group. Median follow up was 30.9months.
Conclusions: The new concept of the infundibular rehabilitation was safe and promising, especially
in excellent RV performance. For assessment of long-term RV function, further quantitative studies
should be followed.
FREE
Dong-Man Seo, Jeong-Jun Park, M.D.1, Tae-Jin Yun, M.D.1, Hyun Woo Goo, M.D.2,
Young-Hwue Kim, M.D.3, Jae-Kon Ko, M.D.3, In-Sook Park, M.D.3
1: Asan Medical Center, University of Ulsan, Department of Thoracic and
Cardiovascular Surgery
2: Asan Medical Center, University of Ulsan, Department of Radiology
3: Asan Medical Center, University of Ulsan, Department of Pediatrics
FP12
FREE
PAPER
Redo surgery after corrective surgery for Tetralogy of Fallot in the
long term period
Kozo Matsuo, Sugimoto K, Kabasawa M, Asano S, Murayma H, Tastsuno K.
Department of Cardiovascular Surgery, Chiba Cardiovascular Center.
Objectives: Long-term results after corrective surgery (CS) of Tetralogy of Fallot (TOF) are
reported almost satisfactory. We reviewed TOF patients who required redo surgery over 10
years after CS to examine the timing of re-operation regarding preservation of cardiac function.
Patients and Methods: In 12 TOF-CS patients, the age at re-operation was 31 ± 11 years and
the interval from the CS was 23 ± 8 years. The lesions to be repaired were pulmonary stenosis
or regurgitation (PS, PR) in 10 pts, peripheral PS in 5, RV outflow stenosis in 3, atrial fibrillation
or flutter (Af, AF) in 3, ventricular tachycardia (VT) in 3, residual shunt in 2 and so on. RVEF
and RVEDV were 39 ± 4.3 %, 170 ± 45 %N in PR group against 43 ± 6.7% , 105 ± 15 %N
in PS group respectively. Serious arrhythmia was seen in 6 pts out of 8 (75%) associated with
residual shunt or PR. For repair of RV-PA lesions, transannular patch was used in 4 pts, tissue
valve in 3 and hand-made valved conduit in 2. Maze procedure was added in 2 pts and cryoablation
in 3. In 7 patients (PS 3, PR 4) RV muscles were sampled during re-operation to analyze histological
changes.
Results: There was no operative deaths and all patients are in I - II class of NYHA in the mean
follow-up period of 48 months. CONCLUSION: RV dysfunction and arrhythmia were prevalent
among the patients with PR or residual shunt. Histological examination of RV muscles indicated
tendency of lighter degeneration in PS and earlier redo group. We conclude that early repair of
residual shunt or PR should be considered to prevent secondary lesions in follow-up of TOFCS.
FP13
Analysis arterial switch operation results of 113 patients with
complete transposition of the great arteries
PAPER
Objective Aim to review and analysis the surgical results of 113 arteries switch operations.
Methods 113 patients had been repaired by arterial switch operation from Jan. 2001 to Des.
2005. There were 60 patients with transposition of the great arteries and intact ventricular septum
(TGA/IVS), 53 patients with transposition of great arteries and ventricular septal defect (TGA/
VSD) .The lowest body weight was 2.3kg, and the youngest operative age was 6 hours. The
arteries Switch operation was performed underwent deep hypothermic circulation arrest and
low-flow perfusion. Results The total mortality was 9.73%. There were 5 deaths among TGA/
IVS (8.3%), 6 deaths among TGA/VSD (11.3%) . Following improvement of surgical technique,
post-operative management and cardiopulmonary bypass , the operative mortality was decreased
from 16.65% to 5.5%. Conclusions The main reason for operative mortality was abnormal
coronary arteries. The incidence of abnormal coronary arteries was high at TGA/VSD. The
surgical results was not infected by the position of great arteries. The low cardiac output was
appeared if the ratio of left ventricular pressure and right ventricular pressure less than 0.6.
FREE
Xu Zhiwei, Liu Jinfeng, Zhang Haibo, yanqing, Zhen Jinghao, Qiu Lisheng, Wang Shunming,
Su Zhaokang , Ding Wenxiang.
Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical
Center, Shanghai Jiaotong University, Shanghai 200127, China
FP14
FREE
PAPER
Aortic translocation in the treatment of transposition of the great
arteries with ventricular septal defect and pulmonary stenosis
Xu Zhiwei, Wang Shun-ming, Zheng Jin-hao,Su Zhao-kang, Ding Weng-xiang
Department of pediatric thoracic and cardiovascular surgery, Shanghai Children’s
Medical Center
Objective: Aim to review the clinical treatment of the aortic translocation operation for complete
transposition of the great arteries with ventricular septal defect and pulmonary stenosis ( TGA/
VSD/PS ) Methods Between Augest 2004 and July 2005, Six patients with TGA/VSD/PS
were surgical repaired by the aortic translocation operation. There were 5 male and 1 female.
The operative age was from 4 month to 2 years (median age 11.33±6.86 month ) and the weight
was from 5.6~11 kg (median weight 8.43±2.19Kg ). Results The median total bypass time was
153.83±33.70min (range from 112~204min ), and the median cross-clamp time was
89.16±18.61min (range from 73~139min ). There was no hospital death. All of patients were
followed up from 2 month to 1 year and all patients are alive. The chest X- ray showed that the
heart was a little enlargement than that of pre-operation and the pulmonary vascular marking was
increased. ECG showed sinus rhythem There were trivial aortic insufficiency in two patients and
mild aortic insufficiency in one patient. The ventricular function was normal, EF 74~86, FS
34~52. Conclusions Now the Rastelli repair has become the standard surgical repair for the
treatment of TGA/VSD/PS, but the long-term results have been less than optimal. The aortic
translocation and biventricular outflow tract reconstruction is a valuable procedure to prevent of
left ventricular outflow tract obstruction and extra-cardiac conduit obstruction after Rastelii
operation. It is need to accumulate experience of this new operation because of no many patients
and a short period of followed up at this report.
FP15
Arterial Switch Operation for TGA with Unusual Coronary patterns
PAPER
Introduction: Complex coronary anatomy is a risk factor for arterial switch operation (ASO).
Its presence doesn’t preclude the feasibility of an ASO. Successful coronary translocation can
be achieved in almost all cases of TGA with unusual coronary patterns by individualizing and
using modifications of the standard techniques albeit at a slightly higher risk considering the
unfavorable alternatives.
Materials and Methods: The data of 157 consecutive patients who underwent ASO from
June 2001 to July 2006, were analysed retrospectively. Of these 52 (33.1 %) had coronary
pattern other than 1 LCx, 2R. The pattern of coronary arteries were circumflex coronary artery
(Cx) from right coronary artery (RCA) in 29 patients, single coronary artery from sinus 2 (11),
inverted coronary arteries (4), left anterior descending artery (LAD) from RCA arising from
sinus 2 (3), RCA from LAD arising from sinus 1 (3), and dual circumflex coronary artery
(2).Various techniques used to transfer theabnormal coronaries, were the standard button
technique (15), medially based trap door incision (29), pericardial hood augmentation of the
trap door technique(8), pericardial tubes of short length(3), and a Westaby like flap with pericardial
patch augmentation (1). Nine patients required intra operative revision of the coronary anastomosis,
as coronary flow was thought to be suboptimal during rewarming or weaning from
Cardiopulmonary Bypass.
Results: There was one operative death and three early postoperative deaths attributable to
coronary perfusion related issues. All other patients had an uneventful recovery and had no
regional wall motion abnormality on echocardiogram. On follow up (1 – 50 months Median 37
months), there were two late mortalities, one due to an unrelated cause, the other due to a
possible coronary cause. All other patients (except two lost for follow up) have clinical and
echocardiographic evidence of good coronary perfusion.
Conclusions: 1. ASO should be performed in all patients of TGA with unusual coronary patterns,
even though at a slightly higher risk, as the alternatives are dismal in the long term, especially
when VSD is an associated lesion.
2. The technique of transfer should be individualized depending on the coronary anatomy and
great artery relationship as assessed intraoperatively.
3. Aggressive revision of coronary transfer if myocardial ischaemia is suspected, has always paid
rich dividends. This assumes significance particularly in developing countries where ECMO /
VAD facilities are hard to come by if needed to be instituted in an emergency.
4. Though intermediate term follow up appears promising, long term patency of these transferred
coronary arteries needs to be evaluated in the light of current literature.
FREE
Rao Suresh G, Shivaprakasha K, Sunil G.S, Bafna Mahendra, and. Krishna Kumar R*
Division of Pediatric & Congenital Heart Surgery & Pediatric Cardiology*
Amrita Institute of Medical Sciences, School of Medicine, Kochi, Kerala, India
FP16
FREE
PAPER
Surgical Treatment for Transposition of the Great Arteries with
Posterior Aorta
CHUNG-I CHANG M.D., Shu-Chien Huang, Ing-Sh Chiu, Yih-Sharng Chen, Jou-Kou
Wang*, Mei-Hwan Wu*
Department of Surgery and Pediatrics*, National Taiwan University Hospital, Taipei,
Taiwan
We reported six infants of TGA with posterior aorta during 1993 and 2001 five of which underwent
arterial switch operation. The other died before operation. The age at operation ranged 8days to
5 months old. All of them received cardiac catheterization and balloon atrial septostomy before
operation. Typical picture of ventricularterial discordance with aorta located posterior to the
main pulmonary artery was delineated. All hearts had a blind pouch at right ventricular outflow
tract (RVOT) just in front of the aortic root, which was thought the characteristic feature of the
anomaly. We performed arterial switch operation without Lecompte maneuver in the five operated
patients. The ventricular septal defects (VSD) were closed through the native aortic root after
aortic transection. Four of them were doing well during follow-up except mild to moderate
pulmonary stenosis. One had second degree atrioventricular block and obstruction of superior
vena cava. He died 65 days later postoperatively. There is no late mortality. We concluded TGA
with Posterior aorta could be successfully corrected by arterial switch operation during early
infancy. VSD closure through native aortic root and no Lecompte maneuver were recommended.
FP17
Results of One stage repair of Transposition complexes and arch
obstruction
Ji-Hyuk, Tae-Gook Jun, Pyo Won Park, June Huh, I-Seok Kang, Heung Jae Lee
Department of Thoracic and Cardiovascular Surgery,
2
Department of Pediatric Cardiology
Samsung Seoul Hospital, Sungkyunkwan University School of Medicine
135-710 Seoul, Korea
1
PAPER
FREE
Objectives: While the results of an arterial switch operation (ASO) have improved remarkably
in recent years, the presence of arch obstruction continues to make this a surgical challenge. This
study evaluates the surgical outcome of the patients with transposition complex and arch obstruction.
Materials and methods: Between 1996 and 2005, 10 patients underwent surgery for
transposition complex and arch obstruction at Samsung Seoul Hospital. The indication for ASO
was Taussig-Bing heart(TBH) in 6 patients, transposition of great arteries(TGA) with ventricular
septal defect in 3, and situs inversus, TGA with intact ventricular septum in 1. Combined arch
obstruction was coarctation in 8 patients and interruption in 2. All patients underwent ASO and
arch repair simultaneously. Arch obstruction was relieved during a period of selective cerebral
perfusion in 8 patients or circulatory arrest in 2. The mean body weight at surgery was 3.5 0.4
days. Preoperative aortic valve size was 7.7±1.0 mm, and the ratio of aortic to pulmonic valve
size was 0.64±0.07 on echocardiography
Results: There was no mortality. Sternal closure was delayed in all patients, who were discharged
at 21.1±9.2 postoperatively. During 20.7±20.3 months of follow up, no patient developed
recoarctation or airway obstruction. One patient underwent intervention due to branch pulmonary
artery stenosis. In 2 patients, right ventricular outflow tract (RVOT) had to be reconstructed
because of the small neo-pulmonic valve. However, no statistical difference could be found
between the preoperative valve size of these 2 patients and that of other patients.
Conclusion: Simultaneous correction of transposition complex and arch obstruction had no
detrimental influence on survival. However this condition continues to be associated with longer
hospital stays and an incremental risk of developing RVOT obstruction associated with nogrowth of the valve, which could not be explained solely by the preoperative small valve size in
our small experiences.
FP18
FREE
PAPER
Quality of life in adolescents after the Fontan operation in
comparison to ordinary adolescents
Yu Mi Im, Kim H.S, Yun T.J, Park J.J, Seo D.M, Jung S.H, Jhang W.K, Kim Y.W, Park I.S,
Ko J.K
Congenital Heart Disease Center, Asan Medical Center, seoul, Republic of Korea
Purposes : To assess the overall quality of life(QOL) in adolescents after the Fontan operation,
and to seek for relative risk factors affecting the QOL in these patients.
Methods : Twenty-three adolescents who had received the Fontan operation were enrolled in
this study (Group I). Twenty-three age/sex-matched ordinary adolescents selected by randomized
sampling were also included for case-control comparison (Group II). Data were collected and
collated from May 1st to June 21st, 2006. Quality of Life Profile (Adolescent Version) was used
for the quantification of overall QOL. Student t-test and Analysis of Variance were employed for
the case–control comparison, and multiple linear regression was utilized for the determination of
risk factors affecting the QOL in group I.
Results : The mean overall QOL scores of group I and II were 0.13 ± 0.73 and 0.38 ± 0.61,
respectively. The difference, however, did not reach statistical significance. Group I had lower
mean QOL scores compared to group II in ‘Being’ and ‘Belonging’ domains. Mean QOL score
in ‘Becoming’ domain was comparable between the two groups. General characteristics, such
as school attendance, religion, sex, and the number of siblings, had no impact on ‘Satisfaction’ in
group I. Number of operations that post-Fontan adolescents had undergone (t=2.411, p=.025)
and number of medications they were taking at the time of investigation (t=2.602, p=.017) had a
negative impact on ‘Satisfaction’ in group I.
Conclusion : Overall quality of life in post-Fontan adolescents was comparable to that of ordinary
adolescents. Number of operations that post-Fontan adolescents had undergone, and number of
medications they were currently taking had a negative impact on ‘Satisfaction’ score in postFontan adolescents. Given the fact that post-Fontan adolescents are unique in terms of mental
and physical states, it is mandatory to establish a special supporting system for these patients.
FP19
OUTCOMES OF PATIENTS WITH RIGHT ATRIAL ISOMERISM
PAPER
Background: Hearts with right atrial isomerism (RAI) are usually combined with complex cardiac
anomaly and their surgical managements are varied and challenging. We reviewed our experience
of these patients.
Methods: Between April 1991 and April 2006, 84 patients were diagnosed with right atrial
isomerism. Of these, 75 patients underwent surgical treatment. Median age and body weight at
initial operation were 5.7months (0-141months) and 6.2kg (2.1-29.5kg), respectively. Thirtyfive (46.7%) patients had total anomalous pulmonary venous return (TAPVR). Pulmonary outflow
tract obstruction was identified in 63 (84%) and included pulmonary atresia in 23 (30.7%).
Follow-up was possible in all patients with median follow up duration of 36.8months (0 day182months).
Results: In-hospital mortality was 13.3% (10/75) and late mortality was 20% (13/65). The
most common cause of in-hospital mortality was low cardiac output (n=5). Causes of late death
were infection (n=5), pulmonary vein stenosis (n=3), shunt occlusion (n=3), and cerebral infarction
(n=1). Biventricular repair was done in two patients with one death. The others were in the single
ventricle physiology. Until now 40 patients (53.3%) received Fontan procedures. Overall survival
estimates were 71% at 5 years and 53.7% at 10 years. Survival rates in patients without TAPVR
were 88% at 5 and 10 years and in patients with TAPVR were 52.7% at 5 years and 20.1% at
10years. Risk factors for in-hospital mortality in univariate analysis were age less than 1 month
(p=0.019), TAPVR (p=0.038), and no PS (p=0.048). Risk factor for late death was only TAPVR
(p=0.001).
Conclusions: This study showed that the early results of patients with RAI were not so bad,
especially, in patients without TAPVR. During the follow up we should keep in mind the problems
related to the asplenia, pulmonary vein stenosis, and shunt occlusion.
FREE
Sung-Ho Jung, Dong-Man Seo, M.D.1, Jeong-Jun Park, M.D.1, Tae-Jin Yun, M.D.1, WonKyoung Jhang, M.D.2, Young-Hwue Kim, M.D.2, Jae-Kon Ko, M.D.2, In-Sook Park, M.D.2
1 Asan Medical Center, University of Ulsan, Department of Thoracic and
Cardiovascular surgery, Seoul, Korea
2 Asan Medical Center, University of Ulsan, Department of Pediatrics, Seoul, Korea
FP20
FREE
PAPER
The role of intraoperative transesophageal echocardiography in
predicting neo-pulmonary artery stenosis after arterial switch
operation
Yih-Sharng Chen, MD*; Ming-Jiuh Wang, MD, Shen-Ko Tsai, MD, Ph.D; Chung-I
Chang*, MD, Ing-Sh Chiu*, MD, Jou-Ko Wang , MD, Mei-Hwan Wu , MD,
Department of Surgery*, Pediatrics and Anesthesiology, National Taiwan University
Hospital and National Taiwan University Hospital YunLin Branch, National Taiwan
University College of Medicine
Background : The arterial switch operation (ASO) is the preferred surgical procedure for
transposition of the great arteries (TGA). Supravalvular stenosis of the neo-pulmonary artery
(neoPS) remains the major complication for long-term follow-up. We prospectively investigated
the role of intraoperative transesophageal echocardiography (TEE) in predicting development of
neoPS after ASO.
Methods and Results: Between August 1997 and August 2002, 49 infants less than 2 months
old with TGA undergoing ASO were prospectively studied. The neoPS found by intraoperative
TEE (TEEPS) was defined when the peak flow velocity was over 3 m/sec at the neo main
pulmonary artery (neo-MPA) after ASO. Regular follow-up of the status of neo-MPA was
performed with transthoracic echocardiography afterward. Reintervention including balloon
angioplasty or reoperation was done if indicated. According to the set criteria, 21 patients (42.8%)
were found to have TEEPS. In patients with TEEPS the probability of freedom from reintervention
was 28% at one year and was 23% at 2 years of follow-up (p<0.0001). On the other hand, the
probability of freedom from reintervention for PS was 92% at one-year follow-up and 78% at 2
years of follow-up and thereafter in patients without TEEPS. The hazard ratio of reintervention
(angioplasty or reoperation) for patients with TEEPS to patients without TEEPS was 7.29
(p<0.0001). In addition, the time interval from ASO to reintervention was significantly shorter in
patients with TEEPS than in patients without TEEPS.
Conclusion: Findings of the intraoperative TEE in neonates and small infants undergoing ASO
are very helpful in predicting the development of severe postoperative supravalvular stenosis of
the neo-MPA, and intraoperative TEE could provide real-time monitoring for this issue.
FP21
Centrifugal Pump in Cardiopulmonary Bypass and Temporary
Ventricular Assistance
PAPER
Background: The centrifugal pump can be utilized for cardiopulmonary bypass, ECMO, or
ventricular assistance. This non-pulsatile ventricular assist device (VAD) concept has been in
existence since late 1970s, but is only recently more utilized in children. Compared to roller
pumps, there is less trauma to red blood cells and less pronounced inflammatory response; in
addition, centrifugal pumps are also advantageous in the event of air entrainment since the acrylic
cones create an air trap (as bubbles accumulate in the middle of the vortex). There is also purported
evidence that myocardial recovery may be superior to ECMO. Herein we report our experience
with centrifugal pump for cardiopulmonary bypass (CPB) and left VAD in pediatric (weight<15kg).
Materials and Methods: Since January 2004, 17 cases (weight< 15 kg) underwent CPB with
centrifugal pump. Ten of these patients underwent second procedure. Also, five patients, 4 months
to 4 years (1.78±1.65years) and 6 to 14.5kg (8.98±3.57kg), were affected with postcardiotomy
hemodynamic failure and left VAD was used in all cases. The circuit included a centrifugal pump
and pretreated tubing and cannulas. All patients were drained from left atrium and four of arterial
cannula was placed in ascending aorta whereas one was put in left femoral artery. The flow rate
were maintained 70-100ml/kg.min. Anticoagulation was obtained by continuous heparin infusion
(5-30u/kg.min) adapted to activated clotting time between 160 and 200 seconds. Coagulation
factors were maintained above 50%, hemoglobin above 120g/L, and platelets above 80,000/ml.
Artificial ventilation was kept at the same level as before VAD support. All patients were treated
with peritoneal dialysis (PD) because of oliguresis or anuresis before or during VAD support.
Results: In CPB cases, all patients were weaned form the bypass successfully. Eight cases
(80%) with second procedure showed hemoglobin urine, whereas clear urine was observed in
each first operation case. Regarding to the VAD cases, after 40 and 74 hours support, two
patients were recovered and weaned from the VAD, and discharged successfully. The other
three cases were expired from bleeding, right ventricular dysfunction and neurological complication,
respectively.
Comments: Although the centrifugal pump is benefit to the blood trauma, 80% of the second
procedures still showed the hemoglobin urine. It seems the sucker instead of the blood pump is
the major cause of blood trauma. And the temporary centrifugal VAD appears to be one of the
choices as a bridge to postcardiotomy recovery. Left VAD is an effective method for bridging to
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Wei Wang, De-ming Zhu, Hong Chen, Zhi-wei Xu, Wen-xiang DING
Department of pediatric thoracic and cardiovascular surgery,
Shanghai Children’s Medical Center,
Shanghai Jiao Tong University, School of Medicine,
Shanghai (200127), P.R. China
recovery of the heart function even in the infant and small children. The choice of the device
should be decided according to the right ventricular function, lung function. Complications such
as bleeding, infection and thrombolitics are not uncommon and should be treated conservatively.
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PAPER
Intensive care
FP22
Association of intensity and duration of hyperglycemia with morbidity
and mortality in a pediatric cardiac ICU
Objective: To study the association of intensity and duration of postoperative hyperglycemia
with mortality and morbidity in children undergoing cardiac surgery.
Design: A retrospective cohort study.
Setting: Patients and Methods : We reviewed 157 children ( median age 24 months) who
underwent surgery for congenital heart disease. Association of peak blood glucose and duration
of hyperglycemia with mortality, inotropy requirement and organ dysfunction was analyzed using
chi square, Fisher’s exact test and logistic regression analysis. Association with ventilatory
requirement, ICU and hospital stay were analyzed using Mann Whitney-U test.
Results: Peak blood glucose >126mg/dl and >150 mg/dl occurred in 89.8% and 86% of
children respectively but was poorly associated with mortality and morbidity. However, peak
blood glucose >200mg/dl occurred in 90/157 ( 57% ) and was associated with longer ventilatory
requirement (mean 56.17±12.62 vs 12.46±0.92 hrs, p< 0.001), ICU stay (mean 112.63±17.52
vs 59.06±11.73 hrs, p< 0.01), and hospital stay (12.12±2.19 vs. 7.430.79 days, p< 0.01);
increased incidence of acute renal failure (11/90 vs. 0/67, p= 0.003 ), acute lung injury ( 9/90 vs
0/67, p=0.008) and higher inotrope requirement (p<0.05) compared to children with blood
glucose <200mg/dl. Overall mortality being low ( 3/157 deaths) - no association with mortality
was found. Increased duration of hyperglycemia was strongly associated with MODS ( p<
0.05) and significantly increased epinephrine(p<0.01), norepinephrine (p<0.01) and milrinone
requirement (p< 0.0001).
Conclusion: Hyperglycemia > 126mg/dl was common in children who underwent cardiac surgery.
Peak blood glucose >200mg/dl and prolonged duration of hyperglycemia is associated with
increased morbidity. A prospective randomised trial of strict glycemic control is warranted.
PAPER
Hyperglycemia in sick adults is a known risk factor for adverse outcome. Data in pediatric
patients is scarce.
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Parvathi IYER, Sheth K, Kaushal SK, Dagar KS, Iyer KS
Escorts Heart Institute & Research Centre
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FP23
FP24
Use of inhaled Prostacyclin analog (Iloprost) on the Pulmonary
vascular reactivity in patients with Pulmonary arterial hypertension
secondary to Congenital Heart defects: Randomized Controlled Trial
PAPER
Objective: To determine the efficacy and safety of inhalational or aerosolized prostacyclin analog
(iloprost) on patients with pulmonary arterial hypertension secondary to congenital heart disease.
Methods and Results: A prospective, randomized placebo-controlled interventional study was
done on 27 pediatric patients ages 1-19 years old with congenital heart disease who underwent
cardiac catheterization for hemodynamics studies. Patients were randomly assigned to receive
either placebo or aerosolized iloprost 25 ng/k/min for 10 minutes(N=12). Baseline and postinhalational hemodynamic parameters were determined for both groups. Aerosolized iloprost
caused a decline in the mean pulmonary artery pressure by 7.8 ± 1.4 mmHg ( p<0.001 vs.
baseline) and in the diastolic PA pressure by 5.33 ± 2.19 mmHg (p<0.001) Patients who
received iloprost had a decreased in the pulmonary vascular resistance by 4.21 ± 7.84 woods
unit (25% from the baseline) and Rp:Rs ratio declined by 0.19 ± 0.21 (p=0.01 vs. baseline)
There was a significant effect in the mean and diastolic PA pressure (p<0.001) as compared to
placebo. With inhalational iloprost, there was no systemic arterial hypotension noted and there
was no significant change in the cardiac output (-0.12 ± 0.67 L/min; p =0.54 when tested against
baseline)
Conclusion: Inhaled iloprost exerted a selective pulmonary hemodynamic response, reducing
the mean and diastolic pulmonary artery pressure 30 minutes after inhalation. Moreover, it
decreased the pulmonary vascular resistance without significant systemic vasodilation. There
were no adverse reaction to iloprost observed.
Keywords: iloprost, pulmonary artery hypertension, congenital heart
disease ,prostacyclin, pulmonary vascular resistance
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MARITES FLORES, Mappala,V. Baldera J Casa ML Lopez, WL
Philippine Heart Center, Quezon City, Philippines
FP25
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PAPER
Cardiorespiratory effect of pressure-regulated volume control
ventilation in infants after surgical repair of complex congenital
heart disease
Limin Zhu, Xu Zhuoming, Chen Lin, Shi Zhenying, Xu Zhiwei, Liu Jinfen, Su Zhaokang
Department of cardiothoracic surgery, Shanghai Children’s Medical Center, Medical
College of Shanghai Jiao Tong University
Introduction : Mechanical ventilation is essential in the perioperative period for the successful
treatment of infants undergoing congenital cardiac surgery. Mechanical ventilation supports the
patient’s respiratory function during much of the operative period, recovery from anesthesia,
hemodynamic stabilization in the cardiac intensive care unit (CICU), and weaning to successful
extubation. Positive pressure ventilation has both positive and negative hemodynamic
consequences. High intrathoracic pressure decreases venous return to the heart while at the
same time decreasing afterload to the left ventricle. These combined cardiopulmonary interactions
have complex effects on cardiac output.
Pressure-limited ventilation was mainstay in pediatric critical care in the past due to the
inability of ventilators to deliver small tidal volumes consistently. Pressure-limited ventilation is
particularly problematic in critically ill children with congenital heart disease (CHD) due to the
inability to deliver a constant minute ventilation in patients undergoing rapid changes in lung
compliance.
Pressure-regulated volume control (PRVC) ventilation is a mode of ventilation now available
in newer ventilators. This method delivers a controlled tidal and minute volume in a pressurelimited manner, using the lowest possible pressure, which is constant during the inspiratory phase.
The decelerated gas flow is pressure and flow constantly vary, breath by breath, to achieve the
preset tidal volume at a minimum peak inspiratory pressure (PIP). It is particularly useful in
patients ventilated when there are rapid changes in lung compliance and airway resistance.
Objective : The aim of this study was to compare how three modes of ventilation, specifically
PRVC, volume control (VC) and pressure control (PC), affect cardiac output, airway pressure
and oxygenation in infants after surgical repair of complex CHD.
Methods : Fifty nonconsecutive infants with mean age (7.0±4.9) months and mean weight
(6.3±2.0) kg underwent cardiac surgery in our institution were enrolled in this study. The diagnosis
and operation of these patients were listed in table 1. Patients were admitted to CICU after
complete surgical repair their cardiac defect and stabilized on a Siemens Servo 300 or Maquet
Srevo i ventilator in VC mode. Two hours after operation, hemodynamic parameters, airway
pressure and ventilator settings, and an arterial blood gas were obtained. Patients were then
changed to PRVC and PC mode, who were changed back to VC ventilation finally. The tidal
Diagnosis
With increased pulmonary flow
CAVSD, PH
CoA, VSD, PH
CoA, MR, PH
D-TGA/VSD, ASD, PH
DORV, VSD, PH (Taussing-Bing)
IAA, VSD, PH
IAA, AP W, PH
L-TGA, VSD, PH
PTA, IAA, PH
TAPVC (Obstructive), PH
With decreased pulmonary flow
DORV, VSD, PS
D-TGA/IVS, ASD, PDA
D-TGA, VSD, PS
PA/VSD
PA/VSD (S/P RVOT patch)
TOF
cases
Surgical procedure
cases
CPB
5
3
1
6
1
1
1
1
1
5
Repair
CoA,VSD repair
CoA repair, MV plasty
ASO+VSD repair
B-Ts+PAB’!staged ASO
ASO+VSD repair
IAA,VSD repair
IAA, A-P window repair
VSD repair
Corrective repair
Corrective repair
5
3
1
5
1
1
1
1
1
1
5
ON
ON
ON
DHCA+DHLF
DHCA+DHLF
DHCA+DHLF
DHCA+DHLF
DHCA+DHLF
ON
DHCA+DHLF
ON
1
4
1
3
1
15
Corrective repair
ASO
Lecompt repair
Repair
Repair
Corrective repair
1
4
1
3
1
15
ON
DHCA+DHLF
ON
ON
ON
0N
CAVC: Complete atrial ventricular septal defect, PH: pulmonary hypertension, CoA: Coarctation of aortic arch,
VSD: Ventricular septal defect, MR: Mitral valve regurgitation D-TGA/VSD: D-transposition of great arteries with
ventricular septal defect, ASD: Atrial septal defect, DORV: Double outlet right ventricle, IAA: Interrupted aortic
arch, APW: Aortopulmonary window, L-TGA: L-transposition of great arteries, PTA: Persistent truncus arteriosus,
TAPVC: Total anomalous pulmonary venous connection, PS: pulmonary stenosis, D-TGA/IVS: D-transposition of
great arteries with intact ventricular septum, PDA: Patent ductus arteriosus, PA/VSD: Pulmonary atresia with
ventricular septal defect, TOF: Tetralogy of Fallot, ASO: Arterial switch operation, B-Ts Blalock-taussing shunt,
PAB: Pulmonary arterial banding, DHCA: Deep hypothermia circulatory arrest, DHLF: Deep hypothermia low flow
PAPER
Table 1 Diagnosis and operation of these 50 patients
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volume, positive end expiratory pressure (PEEP), inspiratory time, and respiratory rate were
preserved as the initial setting. All of the measurements were repeated 30 minutes after each
mode. Nineteen patients who needed mechanical ventilation more than 24 hours were repeated
this protocol 24 hours after operation.
Results : The hemodynamic data, airway and ventilator parameters, and oxygenation data on
operative day and day 1 after operation were summarized in table 2 and table 3. The tendency of
these parameters in different ventilation modes was shown in figure 1 and figure 2. On operative
day, there was a significant decrease in PIP and an increase in dynamic compliance, respiratory
index (RI) and A-a DO2 in either PRVC or PC mode when compared to VC ventilation. But the
increase of cardiac index (CI), stroke index (SI) and PaO2/FiO2 were only obtained in PRVC
mode, while no significant increase of mean airway pressure (MAP) was found at the same time.
The results of 24 hours after operation were similar to the operative day.
Conclusion : Using PRVC or PC mode has the similar result of oxygenation parameters and
airway and ventilator parameters, while the improvement of hemodynamic and PaO2/FiO2 was
only obtained when using PRVC mode. Compared to VC mode, patient’s CI increased 6.05%
and 6% at postoperative 2 and 24 hours with PRVC ventilation. So PRVC mode is safety and
beneficial during the period after surgical repair of complex CHD in infants.
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PAPER
Table 2 Hemodynamic data, airway and ventilator parameters, and oxygenation data 2 hours after
operation
Hemodynamic
LAP (mmHg)
CVP (mmHg)
CI (L/min.m2)
SI (ml/m2)
SRVI
(dyne.s.cm-5)
PVRI
(dyne.s.cm-5)
Airway and
ventilator
PIP(cmH2O)
MAP(cmH 2O)
C dyn
(ml/cmH2O)
Oxygenation
PaO2/FiO2
RI
A-a DO2
VC
PRVC
PC
VC2
9.94 3.00
9.45 2.57
2.83 0.88
19.40 6.54
10.16 2.97
9.59 2.71
2.98 0.99*
20.50 7.25*
10.39 2.89*
9.73 2.74
2.87 0.95
19.89 6.84
9.87 2.93
9.94 2.47
2.83 0.97
19.92 7.19
1795.70 626.97
1805.35 691.17
1882.24 644.76
1862.10 734.19
373.93 352.76
352.71 321.97
372.65 392.87
371.94 410.26
18.73 5.45
6.12 1.58
15.98 4.68**
6.29 1.46
16.25 4.52**
6.44 1.58*
19.04 5.90
6.15 1.64
5.57 2.39
6.91 3.11**
6.80 2.95**
5.83 3.46
333.64 103.38
1.09 0.85
130.39 65.35
361.79 106.16**
0.94 0.73*
120.44 58.71*
344.24 100.76
0.93 0.66*
119.66 57.07*
339.17 98.38
0.97 0.85
124.12 57.52
*: P<0.05, **: P<0.01
Table 3 Hemodynamic data, airway and ventilator parameters, and oxygenation data 24 hours after
operation
Hemodynamic
LAP (mmHg)
CVP (mmHg)
CI (L/min.m2)
SI (ml/ m2)
SRVI
(dyne.s.cm-5)
PVRI
(dyne.s.cm-5)
Airway andv
entilator
PIP(cmH2O)
MAP(cmH 2O)
C dyn
(ml/cmH2O)
Oxygenation
PaO2/FiO2
RI
A-a DO2
VC
PRVC
PC
VC2
9.95 3.37
9.45 2.57
3.24 1.17
24.18 9.15
9.89 2.73
9.59 2.71
3.63 1.41*
26.10 9.61*
10.42 3.04
9.73 2.74
3.39 1.12
24.85 8.90
10.26 2.68
9.94 2.47
3.43 1.47
25.11 10.60
1508.46 407.71
1523.11 501.10
1481.96 473.84
1516.14 602.09
271.84 81.64
238.48 85.55
237.00 81.10
227.83 67.83
17.58 4.60
5.89 0.94
14.84 4.81**
5.89 1.79
15.21 3.74**
6.58 1.77*
17.53 4.31
6.26 1.79
5.70 2.42
7.38 3.67**
6.81 2.76**
5.80 2.55
343.50 104.38
1.05 1.00
117.92 61.84
367.78 102.57**
0.88 0.75
107.18 61.75*
343.45 97.49
0.97 0.63
118.36 56.02*
334.55 101.12
1.07 0.78
121.48 60.09
*: P<0.05, **: P<0.01
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PAPER
Figure 1 Tendency of airway and ventilator parameters (A), oxygenation data (B) and
hemodynamic data (C) in different ventilation mode 2 hours after operation
Figure 2 Tendency of airway and ventilator parameters (A), oxygenation data (B) and
hemodynamic data (C) in different ventilation mode 24 hours after operation
FP26
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PAPER
Rescue patients of severe enterovirus71 infection with flexible
cardiovascular medication
Jeng-Sheng Chang, Shiou-Jien Lin, Hung-Chih Lin, Bai-Hong Su, Ching-Tien Peng
Division of cardiology+, China Medical University Hospital, Taichung, 404, Taiwan
Ever since the spring 1998, the severe enterovirus71 (EV71) infection in Taiwan has resulted in
fatality of 224 children, mostly under 3-years-old. Although mild EV71 infection causes only
hand-foot-mouth syndrome or herpangina, a full-blown severe EV71 infection usually presents
itself by 3 devastating stages as encephalomyelitis, hypercatecholamine and shock. Because of
its rapid flip-flop changes between hypertension/tachycardia and shock during the later 2 stages,
patients may be expired precipitously on fulminant cardiopulmonary failure. Between May 1998
and Jan. 2001, we experienced 8 mortality cases in this hospital, which accounts for 19.5% and
80% case fatality rates of the 41 severe EV71 patients and the 10 patients complicating with
pulmonary hemorrhage/edema (PH/PE), respectively. Starting from Feb. 2001, we implemented
a flexible cardiovascular medication protocol on these patients, stressing on uses of - blockers
and multiple vasodilators during the hypercatecholamine stage to suppress the severe tachycardia
and hypertension to < 170 beat-per-minute and < 90percentile arterial blood pressure for age,
respectively. Also, multiple inotropic agents were used to combat shock. Thereafter, until Apr.
2004 a total of 45 patients were treated by this protocol. The EV71 infection was confirmed in
every patient by RT-PCR study on specimens collected from the throat, anus, blood or
cerebrospinal fluid. The case fatality rate declined remarkably to 2.2% in the 45 severe EV71
patients, as well as reduced to 8.3% in those complicated with PH/PE.
Conclusion: the flexible cardiovascular medication protocol is effective in reducing the mortality
rate of severe EV71 infection.
FP27
Low Cardiac Output in Pediatrics After Cardiac Surgery: Predictor
and Clinical Outcome
PAPER
The purpose of this study was to identify patients at risk for the development of low cardiac
output syndrome (LCOS) in pediatric after cardiac surgery. Low cardiac output syndrome was
defined as poor perfusion due to transient myocardial dysfunction.
Methods: The patient characteristics that were independent predictors of low cardiac output
syndrome were identified among 472 consecutive pediatric patients who underwent cardiac surgery
at Harapan Kita Hospital between January 1, 2005, and December 31, 2005.
Results: The overall prevalence of low cardiac output syndrome was 15.43 % (n = 73). Logistic
regression analyses identified eight independent predictors of low output syndrome and calculated
the factor-adjusted odds ratios associated with each predictor: (1) residual lesion (odds ratio
141.98); (2) complexity score (odds ratio 1.74); (3) CPB time (odds ratio 1.01); (4) preoperative
ICU (odds ratio 8.51); (5) preoperative CHF (odds ratio 3.14); (6) bleeding(odds ratio 24.88);
(7) arrhythmia (odds ratio 4.78); and (8) pulmonary hypertension (odds ratio 3.75). The operative
mortality rate was higher in patients in whom low cardiac output syndrome developed than in
those in whom it did not develop (39.72% versus 0.75%, p < 0.001). Mean basic complexity
score was 6.25 with mortality rate 6.76, and the overall performance was 5.83.
Conculsion: Compared to STS and EACTS, the performance of Harapan Kita was still lower.
LCOS caused longer time of intubation time, ICU and hospital stay. There were eight independents
predictor that can be used to predicts of LCOS in patient of Harapan Kita Hospital . Patients at
high risk for the development of low cardiac output syndrome should be the focus of more
intensive management to prevent the development of LCOS.
Key words : Low Cardiac Output Syndrome, pediatric, cardiac surgery
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Eva Miranda Marwali, Busro PW, Budiwardhana N, Koto CG, Indriwanto,Roebiono PS,
Rahajoe AU, Harimurti GM, Fachri D, Rahmat J
National Cardiovascular Center Harapan Kita Jakarta - Indonesia
FP28
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PAPER
MILRINONE IMPROVE HAEMODYNAMICS DURING AND
AFTER CORRECTIVE SURGERY FOR CONGENITAL HEART
DISEASES.
Mohammed Sallam, department of cardiac anaesthesia
Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
Maintenance of adequate oxygen balance is one of the primary objectives when dealing with
paediatric patients undergoing cardiac surgery.
Cardiac output is one of the major components of oxygen delivery so that its maintenance is an
important consideration. Due to preoperative cardiac lesion and myocardial dysfunction secondary
to the events related to cardiac surgery and cardiopulmonary bypass, circulatory supports by
pharmacological means is frequently required. Therefore inotropes and vasodilators are used to
improve cardiac performance after cardiac surgery.
Epinephrine, dopamine and dobutamine are commonly used inotropes; phosphodiasterase III
inhibitors as milrinone have been introduced in clinical practice recently.
Milrinone produces a positive inotropic effect with concurrent vasodilatation and little chronotropic
effect and lacking the undesirable effects of catecholamine which includes an increase in heart
rate and myocardial oxygen consumption, down- regulation of beta-adrenergic receptors and
increase in systemic vascular resistance. As a result of these differences, milrinone has become a
valuable tool in the treatment of infants and children following cardiac surgery.
Several investigators have studied the effect of milrinone in reversing the low cardiac output
frequently observed in infant and children after cardiac surgery (25% of cases develop low
cardiac output syndrome after cardiac surgery).
Chag and colleagues administered milrinone 50 mic.gm over 15 minutes in 10 neonates suffering
from low output syndrome following cardiac surgery and observed an averages increase in CI of
42% and averages decrease in systemic and pulmonary vascular resistance of 37% and 27%
respectively.
Baily et al characterized the pharmacodynamics of milrinone along its correlation with the
pharmacokinetics in 20 children between 3-22 months of age after they underwent repair of
congenital heart defect. A loading dose of 50 mic.gm/kg given over a period of 5 minutes resulted
in a mean decrease in mean arterial pressure of 12% and mean increase in cardiac index of 18%
at a mean peak plasma concentration of 235 ngm/ml.
Chu et al studied the effect of a loading dose of 20 mic.gm/kg followed by continuous infusion of
0.2 mic.gm/kg/min in 10 children with post bypass pulmonary hypertension after TOF repair
within 6 months, they found a significant reduction in PAP/SBP within 15 minutes and the effect
persist for 24 h. during infusion without remarkable adverse effect.
PAPER
About 750 cases/year of different types of congenital heart diseases are corrected surgically in
our center (PSCC.), and we are using milrinone during surgery and in ICU in almost of them with
good haemodynamics and less postoperative complications.
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An important multicenter study done in USA (31 center participated in this study) evaluated the
efficacy and safety of prophylactic milrinone in paediatric patients (about 238 patients) at high
risk for developing low cardiac output syndrome, they used different doses of milrinone and they
concluded that high dose milrinone after pediatric congenital heart surgery reduce the risk of low
cardiac output syndrome.
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PAPER
Infliximab treatment for refractory Kawasaki disease in Korean
children
Song Min Seob, Yoon KL, Sohn SJ, Oh JH, Lee SB, KimCH
Department of Pediatrics1, Paik hospital, Inje University, Pusan, Department of Pediatrics2
Eastwest Neo Medical Center, Kyunghee University, Seoul, Department of Pediatris3,
Mokdong Hospital, Ewha Womans University, Seoul, Department of Pediatrics4, St.Vincent’s
Hospital, Catholic University, Suwon, Department of Pediatrics5, Kyungpook National
University, Daegu, Republic of Korea
Introduction: This study is a multicenter study to evaluate the use of tumor necrosis
factor (TNF) -alpha blokade for treatment of patients with refractory Kawasaki disease (KD)
in Korean children. Refractory KD was defined as the persistence or recrudescence of fever or
persistent arthritis after multipe dose of intravenous immunoglobulin or
methylprednisolone pulse therapy with high dose aspirin.
Methods: Six cases (5 M, 1 F; median age 2.4 years(0.3 to 5.4 yrs)) were retrospectively
collected from clinicians throughout Korea between July 2004 and January 2006 who had used
infliximab, a monoclonal antibody against TNF-alpha for patients with refractory KD.
Results: Response to therapy with cessation of fever occurred in 5 of 6 patients including one
patient with resolution of fever and accompanying persistent arthritis. C-reactive protein level
was elevated in all patient before infliximab infusion, and the level was lower following infusion in
all 5 patients in whom it was remeasured . There were no infusion reactions to infliximab but
there was one case in which acute hepatitis occurred during acute treatment and calculous
cholecystitis occurred after 4 months and subsided later. All patients had coronary artery
abnormalities (from mild dilatation of coronary artery to aneurysms) documented by
echocardiography before infliximab therapy. Two had transient mild dilatation of coronary artery
and four had coronary aneurysms with subsequent normalization in two patients and persistent
mild dilatation in one, aneurysm in one patient on follow-up echocardiography. It seems that no
further significant progression of coronary artery lesions develop after infliximab treatment.
Conclusion: These preliminary data in this small series of patients suggests that infliximab can be
useful in the treatment of refractory KD. Multicenter trials with larger numbers of patients are
necessary to assess it’s clinical efficacy and safety in refractory KD.
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Glycemic control in the pediatric cardiac ICU : is it useful ?
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PAPER
Parvathi IYER, K, Kaushal SK, Dagar KS, Iyer KS
Escorts Heart Institute and Research Centre, ND, 110025, INDIA
Hyperglycemia in the pediatric cardiac patient has been reported to be associated with increased
morbidity and mortality. Data on glycemic control is not available due to concerns of insulin
related hypoglycemia.
Objective : To compare the effect of moderate glycemic control ( target blood sugars < 150mg/
dl and less tight glycemic control ( blood sugars 150 – 200mg/dl) on outcome in children undergoing
cardiac surgery.
Design : A prospective randomized controlled study.
Setting, Patients and Methods : 302 children under 21 years of age undergoing cardiac
surgery were randomized to receive insulin therapy to maintain blood sugars 1) < 150mg/dl or 2)
150-200mg/dl. The two groups were comparable wth regard to age, weight, type of surgery (
open/closed), PIM and Aristotle score, admitting and peak blood sugar levels. Insulin was
administered along with potassium as an infusion to prevent hypokalemia. Differences in primary
( mortality) and secondary ( measures of morbidity) outcome were analyzed using Fisher’s exact
test, chi square, Mann-Whitney U and student t test as appropriate.
Results : Peak blood glucose >126mg/dl occurred in 98.34% admitted to the PCICU. Mortality
was similar in both groups ( 2% and 0.7%). Organ failure ( p<0.05), multiple vasoactive and
inotrope requirement ( p< 0.05), hydrocortisone requirement for vasopressor unresponsive
hypotension ( p<0.01) were significantly greater in group 2. Group 2 also had longer ICU stay
(108.94 hours vs 73.39 , p<0.05) and overall hospital stays (9.74 vs 7.78 days. There were no
differences in the incidence of renal failure, acute lung injury, sepsis or severe sepsis in the two
groups. Insulin related asymptomatic hypoglycemia ( blood sugar < 40)and hypokalemia
(potassium < 3.0 mmol/L was infrequent – 3 and 4 occasions respectively.
Conclusion: Level of glycemic control did not influence mortality -overall mortality being low.
Preliminary observations indicate that relatively tighter glycemic control ( target blood sugars <
150mg/dl) was associated with reduced morbidity in children undergoing cardiac surgery. These
observations need to be validated in larger studies or in multicentric trials.
FP32
CORONARY ARTERIAL ABNORMALITIES AFFECT SURVIVAL
IN PATIENTS WITH PULMONARY ATRESIA AND INTACT
VENTRICULAR SEPTUM
PAPER
Background : Pulmonary atresia with intact ventricular septum remains a frequently lethal condition
because of associated anomalies, though survival is improving. We suspect that the arterial fistulous
connections (fistulae) between the right ventricular (RV) cavity and coronary arteries are a
significant factor.
Methods : Eighty-eight patients had surgical treatment between 1967 and 2002. The first
procedure was a shunt alone in 45 patients, a shunt plus RV outflow enlargement in 34 and RV
outflow enlargement only in 9. Among hospital survivors 19 have had a Fontan procedure, 7 had
a 1.5 ventricular repair and 12 had a 2 ventricle repair.
Cineangiocardiograms (angios) in 83 patients were available for review. The size of the tricuspid
valve (TV) and RV, the presence of fistulae, their severity (graded as none, small, significant with
opacification of the aorta from a RV angio, associated with one interruption of a major coronary
or associated with two interruptions) were noted. A myocardial score quantifying the amount of
left ventricular myocardium affected by coronary arterial occlusions was applied to evaluate the
degree of RV dependent coronary arterial circulation.
Results : Factors not affecting survival were the presence fistulae found in 58/83 (70 %, P =
0.25), and interruptions in 26 (31 %, P = 0.08). Significant factors included hypoplasia of RV (P
= 0.04), severity of fistulae (P = 0.02), increased myocardial score (P = 0.005), and absent
connections of coronary arteries to aorta in 11 (13%, P = 0.002).
Conclusions : Awareness of the severity of the coronary arterial abnormalities should assist in
planning patient treatment.
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LOUISE CALDER and Occleshaw, CJ
Green Lane Paediatric Cardiac and Congenital Services, Auckland, New Zealand
FP33
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PAPER
MAGNETIC RESONANCE CORONARY ANGIOGRAPHY AND
MYOCARDIAL IMAGING TO EVALUATE CORONARY
ARTERIAL LESIONS AND MYOCARDIAL ISCHEMIA IN
PATIENTS WITH KAWASAKI DISEASE
Atsuko Suzuki, Takemura A, Kitatsume T, Inaba R, Sonobe T,Tsuchiya K, Korenaga T
(1) Department of Pediatrics, Tokyo Teishin Hospital, Tokyo 102-8798, Japan.
(2) Department of Radiology, Tokyo Teishin Hospital, Tokyo 102-8798, Japan.
(3) Department of Pediatrics, Japan Red Cross Medical Center, 150-8935,Tokyo, Japan
We have performed non-contrast enhanced, free-breathing magnetic resonance coronary
angiography (MRCA) in 470 patients with Kawasaki disease from the acute to the late phase
(aged 4 months to 37 years; median 9.1 years ) by 1.5T Gyroscan Intera Master R.9 (Philips)
since July 2000. The steady-state free precession technique (SSFP), and navigator-echo proton
density-weighted black-blood imaging (BB), were both performed in 106 patients from May
2003 to July 2005. We evaluated the efficiency of MRCA in detecting obstructive lesions in the
106 patients based on X-ray coronary angiography. With SSFP, sensitivity of occlusion and
localized stenosis was 94.2% and 97.2%, specificity was 99.5% and 97.2%, and the negativepredictive value was 99.5% and 97.2%, respectively. BB visualized a remarkably thick intima of
aneurysms and/or thrombi in 38 lesions.
Magnetic resonance myocardial imaging (MRMI) was performed in 22 patients with obstructive
lesions from August 2005 using contrast agents (gadolinium), and it showed ischemic regions (n=
15) by perfusion defect and myocardial infarction (n=23) by late hyper enhancement. If the
transmural extent of the hyper enhancement is less than 50% (n= 8) the myocardium is considered
to remain viable.
MRCA and MRMI are useful to follow up patients with coronary artery lesions and to determine
the indication for bypass surgery.
FP34
THE UTILITY OF CORONARYMAGNETIC RESONANCE
ANGIOGRAPHY IN CHILDREN UNDER SIX YEARS OF AGE
WITH KAWASAKI DISEASE.
PAPER
To follow up coronary arterial lesions due to Kawasaki disease (KD) using noninvasive magnetic
resonance coronary angiography (MRCA), we studied a method to improve the quality of images
in young children.
Non-contrast enhanced, free-breathing MRCA with the vector ECG gating real-time navigatorecho 3D steady-state free precession technique (SSFP) was performed using a 1.5-T wholebody MR imaging system (Phillips) in 68 children with KD aged 4 months to less than 6 years.0
A flex medium coil was used. Data were acquired by the whole heart imaging technique. Slices,
1.8 mm thick (interpolated to 0.6 mm), were acquired with a 180 to 200 mm FOV and were
reconstructed with a 512 360 matrix. Patients were sedated during the examination. Many
parameters were optimized for each patient; i.e., field of view, acquisition delay, turbo-field
echo-factor, navigator-window and resolution, which resulted in the acquisition of high-resolution
and high-signal images of the coronary arteries. These conditions remarkably improved not only
the quality of the images, but also the detection rate of coronary arterial segments (American
Heart Association) in the children. The rates were as follows; Segments 1(97%), 2 (97%),
3(87%), 4 (66%), 5 (97%), 6 (96%), 7 (83%), 8 (56%), 9 (53%), 10 (21%), 11 (96%), 12
(29%), 13 (93%), 14 (54%), and 15(65%).
MRCA is a useful method for evaluating coronary aneurysms from the early stages of KD, even
in infants and small children.
FREE
Atsushi Takemura, Suzuki A, Kitazume T , Sonobe T , Tsuchiya K ,and Korenaga T
1) Department of Radiology, Tokyo Teishin Hospital, 102-8798 Tokyo, Japan.0
2) Department of Pediatrics, Tokyo Teishin Hospital, 102-8798 Tokyo, Japan.
3) Department of Pediatrics, Japan Red-Cross Medical Center, 150-8935 Tokyo,0Japan
FP35
FREE
PAPER
The effects of ventilation level on cerebral blood flow after bidirectional superior
cavopulmonary connection
LU Ya-nan, LIU Jin-fen, SHI zhen-yin, Xu Zhi-wei, SU Zhao-kang, DING Wen-xiang.
Department of Pediatric Cardiothoracic Surgery, Shanghai Children’s Medical Center,
Xinhua Hospital, School of Medicine Shanghai Jiaotong Universitsy, Shanghai 200127,
China
Objective: In most instances, after congenital heart diseases surgery, hyperventilation can decrease
the pulmonary vascular resistance, thus it can increase the pulmonary blood flow and may elevate
the oxygen content in blood. But there is a clinical phenomenon that hyperventilation actually
impairs, rather than improves, systemic oxygenation in patients after Bidirectional superior
cavopulmonary connection. Because the connection places the cerebral and pulmonary vascular
beds in series, the probable explanation for this effect is that hyperventilation produces hypocarbia,
which increases cerebral vascular resistance and decreases cerebral blood flow. The aim of our
study was to determine the effects of different ventilation level on cerebral blood flow after
bidirectional superior cavopulmonary connection.
Methods: Eight pediatric patients who underwent bidirectional superior cavopulmonary
connection were enrolled in this study. There were six males, 2 females. Ages ranged from 8
months to 13 years, the median age was 14 months. All patients were diagnosed as functional
single ventricle. The transcutaneous oxygen saturation was 60%-78%, mean 72%. Patients were
studied in the intensive care unit, within 5 hours after the operation, while sedated, paralyzed, and
mechanically ventilated. Initial ventilation parameters were set as synchronized intermittent
mandatory ventilation, volume control mode. The tidal volume was 10-15ml/kg, ventilation
frequency 20 per minute, inspiratory time 0.75S, positive end expiratory pressure 0mmHg, FiO2
40%-50%. Different ventilation level was achieved by adjusting mechanical ventilation frequency.
Each patient was studied at 3 consecutive time points: (1) baseline, during normal ventilation; (2)
during hyperventilation; (3) during hypoventilation. Blood gas analysis, hemodynamic parameters
and Doppler determinations of internal carotid artery were obtained after at least a 20-minute
stabilization period at each time point of the protocol. During the study the oxyhemoglobin in the
cerebral tissue was continually monitored using near-infrared spectroscopy.
Results: During hyperventilation, there were significant decreases in arterial pressure and superior
vena cava pressure, the mean arterial partial pressure of oxygen and carbon dioxide both decreased
significantly while the peak velocity of the internal carotid artery blood flow and the oxyhemoglobin
in the cerebral tissue which represent the perfusion of the cerebral tissue was also decreased
significantly. During the hypoventilation the opposite phenomenon were observed.
Conclusion: The hemodynamic status, systemic oxygenation, cerebral blood flow and thus the
pulmonary blood flow can be affected by ventilation level after bidirectional superior
cavapulmonary connection. Compared with hyperventilation, hypoventilation improves systemic
oxygenation and arterial blood pressure, the mechanism of these effects is supposed that
hypoventilation decreases cerebral vascular resistance, thus increasing blood flow through cerebralpulmonary series after superior bidirectional cavapulmonary connection.
FREE
PAPER
FP36
FREE
PAPER
Cardiac Conduction Disturbance Detected from a Large-Scale
Pediatric Population Screening: Prevalence and the Implications
Chiu Shuenn-Nan, Mei-Hwan Wu, Jou-Kou Wang, Chun-An Chen, Ming-Tai Lin, En-Ting
Wu, Yu Chuan Hua, Hung-Chi Lue, Taipei Pediatric Cardiology Working Group
National Taiwan University Hospital, and Medical College, National Taiwan University
Objective: Data regarding the cardiac conduction disturbance (CCD) detected from school
children survey are limited. We sought to obtain an estimate for the prevalence and the clinical
implication of CCD.
Patients and Methods: A citywide survey on elementary, junior and senior high school, by
using questionnaire, 4-lead EKG, phonograph and physical examination, had been performed in
Taipei from 1999 to 2001. Patients with abnormalities in each item were referred for final diagnosis.
Results: From 432,166 EKG, the prevalence of CCD was 0.856% and was higher in male
than in female (0.902% vs. 0.807%, p=0.001). Incomplete right bundle branch block (RBBB)
(0.360%), complete RBBB (0.152%), ventricular premature beat (0.114%) and Wolff-ParkinsonWhite syndrome (WPW) (0.068 %) were the most common CCDs. Second-degree
atrioventricular block (AVB), IRBBB, CRBBB and intraventricular conduction delay (IVCD)
were more often found in male, but vise versa for atrial premature beat and long QT. The prevalence
of CCD increased with age, as 0.589% in elementary and 1.079% in high school students.
Detection of CCD identified patients with previously undiagnosed atrial septal defect (ASD, 63
patients). The positive predictive value of having ASD when EKG showed IRBBB, IVCD, and
1st degree AVB was 2.70%, 4.30%, and 2.37%, respectively. In addition, 15 high-risk cardiac
patients were sort out in those with CCD (0.405%).
Conclusions: The prevalence of CCD in children, commonly including IRBBB, CRBBB, VPC
and WPW, was 0.856 and was lower than that in adults. The presence of CCD helps to detect
unrecognized ASD and possible high-risk cardiac patients.
FP37
REVERSIBILITY OF SEVERE PULMONARY HYPERTENSION
AMONG PEDIATRIC PATIENTS WITH LEFT-TO-RIGHT
SHUNTS USING MILRINONE – A DOUBLE-BLIND, PLACEBOCONTROLLED INTERVENTIONAL TRIAL
PAPER
Background : Preoperative assessment of pulmonary vascular reactivity among children with
CHD specifically L-to-R shunts with pulmonary hypertension (PHT) is routinely performed to
identify patients with fixed PHT who are at risk for heart failure and death after surgical correction.
Several maneuvers aside from giving of 100% oxygen & nitric oxide, employs the use
pharmacological agents to lower PVR have its own limitations and complications. Several studies
already demonstrated the safety of Milrinone in the treatment of heart failure thus; it is the objective
of this study to examine the feasibility of using Milrinone to test pulmonary vascular reactivity in
pediatric patients with L-to-R shunt and severe PHT before the contemplated surgical correction.
The hypothesis of this study is that Milrinone would lower PVR in pediatric patients with L-to-R
shunts with severe PHT.
Methodology : This preliminary, prospective, double-blinded, randomized, placebo-controlled,
interventional study includes 24 pediatric patients age 1-15 years old with cardiac L-to-R shunts
and severe PHT admitted for cardiac catheterization at a tertiary cardiac referral center. Patients
were randomly divided to receive either a single dose of 50 ug/kg IV Milrinone bolus or an equal
volume bolus of placebo in a double-blinded fashion to test reversibility of PHT. Outcome variable
were measured at the baseline and then 20 minutes after giving the Milrinone or the placebo
bolus. For the differences in the values of the outcome variable in the 2 independent groups,
Independent t-test & Chi-square test were used. Analysis of Covariance (ANCOVA) was used
to control for the influence of a confounding variable, in which the baseline parameters (preintervention – whether placebo or test drug), acted as co-variates. Statistical analyses were done
using the SPSS for Windows with level of significance set at p = <0.05.
Results : 19 out of 24 patients were included in the study. By paired sample t-test, 3 out of 15
variable in the Milrinone group tested had significant results: SVR (0.023), decrease in mean
PAP (0.001), and decrease in PASP (0.006). Using ANCOVA, 8 out of 15 variables tested in
the Milrinone group had significant results: Increase in CO by 38.7% (0.046), 333% increase in
the PBF (0.046), 10% decrease in PASP (0.002), decrease in diastolic PAP (0.019), decrease
in mean PAP (0.010), decrease in Rp (0.013), decrease in Rp:Rs ratio
FREE
Sheldon Principe Paragas, Teofilo Cantre, Ma. Lourdes SR Casas
Department of Pediatric Cardiovascular Medicine, Philippine Heart Center
East Avenue, Quezon City
PHILIPPINES
PAPER
FREE
(0.044), and decrease in PVR (0.026). There was no significant change noted from the baseline
in the placebo group.
Conclusion : Milrinone bolus consistently decreases PAP and PVR in pediatric patients with
severe PHT secondary to CHD specifically L-to-R shunts. The effect is rapid in onset and well
tolerated, with no significant hemodynamic alteration. An intravenous bolus of Milrinone can be
used to test for the reversibility of PHT in pediatric patients cardiac L-to-R shunt defects undergoing
evaluation for surgical/anatomic correction. No adverse reaction to Milrinone was observed.
Keywords : Milrinone, Congenital Heart Disease, Pulmonary Hypertension, Secondary Pulmonary
Hypertension, Phosphodiesterase Inhibitors, Pediatrics, Pulmonary Vascular Resistance,
FP38
Clinical Course of Children with Congenital Long QT Syndrome at
King Chulalongkorn Memorial Hospital
PAPER
Background: The clinical course of the congenital long QT syndrome (LQTS) appears to depend
on the underlying genotype. The prognosis and outcome of these children in Thailand is not
known.
Objectives: To define clinical presentation, triggering events, response to treatment and prognosis
of the congenital long QT syndrome in our institution.
Patients and Methods: From August 1998 to July 2006, 10 patients were diagnosed as
congenital long QT syndrome by the previously published criteria. Data were collected
retrospectively. Baseline clinical information, 12-lead EKG, 24 hours Holter monitoring, exercise
stress test, and treatments including response to therapy were determined.
Results: Age at presentation varied from in utero (gestational age 32 weeks) to 13.9 (7.5 ± 4.9)
years. Five patients (50%) were male. Clinical presentation varied from seizure (30%), syncope
(40%), aborted sudden cardiac death (30%), multiform tachyarrhythmia (40%), Torsade de
Pointes (10%), palpitation (10%), fetal bradycardia (10%), heart murmur (10%) and asymptomatic
family screening (10%). Triggering events were exercise (10%), rest/sleep (30%), both exercise
and rest (20%), and unknown triggering events (40%). Other associated diseases were found in
4 patients, including sensorineural hearing loss, LV aneurysm and mental retardation. Twelve
leads EKG demonstrated QTc interval varied from 460 to 620 (530 ± 52) milliseconds. Treatments
included medication alone (beta-blocker, mexiletine, amiodarone) in 70%, electrophysiologic
study and radiofrequency ablation of triggering atrial tachycardia or PVC in 20% and automatic
implantable cardioverter defibrillator (AICD) implanted in 2 patients (20%). One patient died
from sudden cardiac arrest resulting in brain death. Family history of LQTS was found in 2
patients of the same family.
Conclusions: The congenital LQTS at our institution were mostly sporadic cases. Arrhythmic
event mostly occurred at rest or during sleep. Except for cases that presented with cardiac
arrest, the short term prognosis was good.
FREE
Monnipa Suesaowalak, Vidhavas La-orkhun, Pornthep Lertsapcharoen, Apichai
Khongphatthanayothin
*Department of Pediatrics, Faculty of Medicine, King Chulalongkorn Memorial Hospital,
Bangkok, Thailand
FP39
FREE
PAPER
INDUCIBILITY OF ATRIAL FLUTTER AFTER FONTAN
MODIFICATIONS
Bo-Sang Kwon, Eun-Jung Baea, Chung-Il Noha, Jung-Yun Choia, Yong-Soo Yuna,
Woong-Han Kimb, Jeong-Ryul Leeb, Yong-Jin Kimb
Department of pediatricsa and Department of Thoracic and Cardiovascular Surgeryb, Seoul
National University Children’s Hospital, Seoul, South Korea
Background: Atrial flutter (AFL) is a common postoperative problem after Fontan repair. The
purpose of this study was to evaluate the preventive effect of the elective isthmus cryoablation
(EIC) against AFL and identify risk factors for the induciblity of the sustained AFL.
Methods: From 2001 to 2006, we performed an electrophysiologic (EP) study upon 59
consecutive patients who had undergone cardiac catheterization after Fontan completion.
Results: Mean age was 13.25±5.29 (range: 6-30) years. Follow-up duration was 6.82±3.88
years. In 16/59 (27%) patients, EIC was performed concomitantly with Fontan operations.
Sustained AFL was induced in 23 cases and non-sustained AFL in 17. Mean cycle length of AFL
was 199.4 ± 47.5 (range: 132-296) msec. Sustained AFL was more likely to occur in patients
who were older (16.7±5.2 vs. 11.0±4.1 years, P < 0.001), had a longer follow-up interval
(9.2±4.0 vs. 5.3±3.0 years, P <0.001), were older at the time of EP study (13.4±5.0 vs. 8.7±4.0
years, P <0.001) and underwent atriopulmonary connection procedure than extracardiac conduit
Fontan procedure (4/5 vs. 2/12, P=0.047). Anatomic diagnoses, perioperative hemodynamics,
NYHA functional class, sinus node dysfunction and other previous palliative operations were not
associated with an increased incidence of sustained AFL during EP study. There was a high
prevalence of the clinical AFL in those patients with an inducible sustained AFL (P=0.063) at
intermediate term follow-up. Sustained AFL was less frequently developed in patients who were
performed to EIC (1/16 vs. 22/43, P=0.002) (P=0.011, OR 15.7). Multivariate analysis identified
chronological age (P=0.022, OR 2.1) and duration of follow-up (P=0.026, OR 1.43) as factors
associated with the induction of sustained AFL after Fontan operation.
Conclusions: Sustained AFL continues to develop with time after Fontan operation. EIC during
Fontan procedure reduced the induction rate of sustained AFL during intermediate term follow
up EP study.
FP40
LEFT VENTRICULAR MASS IN OBESE CHILDREN
PAPER
Introduction: Obesity can cause alterations in cardiovascular system even in the absence of
systemic hypertension and underlying organic heart disease.
Objective: This study was to evaluate the left ventricular mass (LVM) by echocardiography in
obese children.
Patients & Methods: A cross-sectional study on 49 obese children (age 9.6 ± 2.6 years)
underwent 12-lead ECG and echocardiography to assess left ventricular hypertrophy (LVH)
and left ventricular mass (LVM), respectively.
Results: Mean weight of this cohort study was 61.8 ± 22.0 kg., BMI 29.9 ± 5.8, and percentage
of actual weight to ideal body weight for height (%IBW) 172.4 ± 28.3%. There were 3, 18,
and 28 children with mild (<140%IBW), moderate (141-160%IBW), and severe obesity
(>160%IBW), respectively. Overall, the left ventricular mass index (LVMI) was 38.2 ± 8.9 gm/
m2.7. LVMI in severe obesity (n = 28) was significantly greater than in mild to moderate obesity
(n = 2) (40.7 ± 8.8 vs 35.1 ± 8.1 gm/m2.7, p =0.02). Thirty-seven children (75.5%) had
normotensive while 12 (24.5%) had systemic hypertension. The LVMI was not significant different
in normotensive and hypertensive groups (37.6 ± 9.7vs 40.4 ± 5.7 gm/m2.7). Importantly, there
were 13/37(35.1%) in normotensive group and 8/12 (66.7%) in hypertensive group had LVMI
>38.6 gm/m2.7 which met the criteria for the LVH. The 12-lead ECG was not the good screening
test for LVH. ECG had sensitivity, specificity, positive, and negative predict values in detection of
LVH only 28.6%, 78.6%, 50%, and 59.5%, respectively.
Conclusions: The left ventricular mass was increased in most of the hypertensive obese children.
However, the left ventricular mass in obese children can be increased without associated systemic
hypertension. The severity of obese had effect on the increase in left ventricular mass. Weight
control to decrease the severity of obesity should be recommended to decrease the left ventricular
hypertrophy.
FREE
Anant Khositseth, Suthutvoravut Umaporn, Chongviriyaphan Nalinee,
Ruangkanchanasetr Suwanna
Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahdiol
University
FP41
TRANS-ATRIAL ENDOCARDIAL PACING IN PATIENTS WITH
COMPLETE HEART BLOCK
FREE
PAPER
Snehal Kulkarni
Aims and Objective: Epicardial lead placement is the standard approach for patients requiring
permanent pacemaker following Fontan completion due to restricted venous access. We report
two patients with corrected transposition of great vessels, large ventricular septal defect with
severe pulmonary stenosis who underwent Fontan completion. They had associated Complete
Heart block. They underwent transatrial endocardial lead placement during surgery.
Methods : Permanent pacing lead was placed through the atrial appendage and anchored into
the endocardium. The other end of the lead was brought out through the pleural space into a
subcutaneous pocket in the infraclavicular region, where it was later connected to the pacemaker
generator. The sensing threshold obtained were 0.8 and 0.6 volts respectively at the time of
implantation. The sensing and pacing characteristics were analyzed 3 monthly up to 1 year.
Results : Both the patients had uneventful postoperative course. The pacing and sensing
thresholds have remained stable through a follow-up period of 12 and 9 months respectively.
Both the patients are on antiplatelet drugs and anticoagulatants. There were no thromboembolic
complications.
Conclusion: Transatrial endocardial lead through a purse string in the atrial appendage avoids
the problem of increasing chronic stimulation thresholds typically observed with epicardial leads.
Such an approach would be useful in patients, who have undergone Fontan type procedure
resulting in less frequent lead and generator replacements,
FP42
Brain natriuretic peptide and cardiac function in doxorubicin
administrative cancer children
PAPER
Background: Doxorubicin-induced cardiomyopathy was the serious complication of cancer
therapy in children. Conventional methods to screen early ventricular dysfunction were limited.
This study was conducted to use serum NT-pro BNP level to early diagnose ventricular dysfunction
in children.
Patients and methods: There were 55 cancer patients with accumulative dose of doxorubicin
< 300 mg/m 2 (group 1), 49 cases with dose > 300 mg/m2 (group 2) and 52 cases as a control
group (group 3). Electrocardiogram, chest roentgenogram, echocardiogram and serum
NT- proBNP level were studied.
Results: There were significantly higher serum NT-pro BNP level in group 2 than group1
(384±291 VS 92±89; p = 0.001) and than group 3 (79±92; p = 0.001) in patients age 1-10
years. At serum NT-pro BNP level >1SD of control group, there was 3.8 times (95%CI, p=
0.02) to have abnormal >2 parameters of diastolic function. There were 2.8 times (95%CI, p =
0.03) of patients in group 2 to have abnormal 2 parameters of diastolic function and 8 times
( 95%CI, p = 0.001) of chance to have serum NT-pro BNP level >1SD when compare to
patients in group 1.
Conclusion : There was an association between serum NT-proBNP level >1SD, accumulative
doses of doxorubicin > 300 mg/mand early left ventricular diastolic dysfunction (especially E/A
<-1 SD and PVA > 1SD). Serum NT-proBNP level >1SD have high propability of early
doxorubicin-induced cardiomyopathy in children age 1-10 years.
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W. Hongkan,1 J. Soongswang,1 G.Veerakul,1 K. Sanpakit,1 K.Punlee,2W. Rochanasiri,2
S.Udompunturak3
1
Department of Pediatrics, Siriraj Hospital, Faculty of Medicine, Mahidol University, 2
Prannok Road, Bangkok, 10700, Thailand
2
Her Majesty Cardiac Center, Siriraj Hospital, Faculty of Medicine, Mahidol University
3
Research Promotion Center, Siriraj Hospital, Faculty of Medicine, Mahidol University
FP43
FREE
PAPER
Comparison of transcatheter closure of atrial septal defect using
alternative imaging techniques
Kritvikrom Durongpisitkul, M.D., Jarupim Soongswang, M.D., Duangmanee
Laohaprasitiporn, M.D., Prakul Chanthong, M.D, Apichart Nana, M.D.,
Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok 10700, Thailand
Objectives: Transcatheter closure has become a standard procedure for patients with atrial
septal defect (ASD). Imaging techniques for sizing the ASD have evolved over past few years.
We compare the results of transcatheter closure of ASD using three different imaging methods:
1).Transesophageal echocardiography guide with balloon sizing (TEE & Balloon) under general
anesthesia. 2). Transesophageal echocardiography without balloon sizing (TEE) under general
anesthesia, and 3). Intracardiac echocardiography (ICE) under local sedation.
Patients & Methods: Patients having an ASD and had transcatheter closure between January
1999 to July 2006 were selected. Comparison was made regarding age, ASD size: device size,
procedure (proc) and fluoroscopy (flu) time.
Results: There were 402 patients who had ASD. The results were shown in table.
Parameter
Age (yr)
Weight (kg)
ASD size
(mm)
Device size
(mm)
Qp:Qs
Device/ASD
ratio
Proc time
(min)
Flu time
(min)
TEE&balloon
N = 299
23.4 9.4
46.9 17.4
TEE
N = 56
22.9 7.4
50.1 16.7
ICE
N = 47
21.6 6.4
55.2 16.3
P=value
0.68
0.007*
23.4 9.4
22.9 7.3
21.6 6.4
0.453
26.7 7.2
4.0 3.1
28.4 7.9
3.2 1.8
27.2 6.3
4.1 3.2
0.304
0.177
1.25 1.23
1.27 0.21
1.31 0.27
0.949
51.7 23.7
44.7 15.5
49.8 21.2
0.085
16.5 9.2
11.6 4.7
9.1 2.6
< 0.01*
The patients in the ICE group were older than the other two groups. However, there was no
significant difference between ASD size, Qp:Qs, device size, or device:ASD ratio among three
groups. Although the average procedure time was not different three groups, however, there was
a significant shorter fluoroscopy time in the ICE group.
Conclusions: We have demonstrated that Transcatheter closure of ASD using alternative imaging
tools such as TEE without balloon sizing or ICE can achieve the same results as conventional
methods by using general anesthesia and TEE with balloon sizing. The advantage of alternative
imaging methods such as ICE is the shorter fluoroscopy time. .
FREE
PAPER
FP44
FREE
PAPER
A STAGED CATHETER-SURGERY APPROACH IN TETRALOGY
OF FALLOT WITH PULMONARY ATRESIA AND DIMINUTIVE
PULMONARY ARTERIES
Seong Ho Kim, Kim SJ, Han MY, Kang IS, Bae EJ , Lee HJ, Lee YT
Department of Pediatrics , Halla General Hospital
Objective: Tetralogy of Fallot with pulmonary atresia and diminutive pulmonary arteries(PAI<90)
is difficult to manage, even though several methods of treatment have been tried. A new collaborative
approach has been introduced since stenotic pulmonary arteries could be enlarged by balloon
dilation. Methods: We catheterize to get detailed pulmonary anatomy and collateral circulation,
and establish right ventricle to pulmonary arterial continuity by surgery, and re-catheterize to
dilate stenotic pulmonary arteries and to embolize collaterals. Finally, we close ventricular septal
defect by surgery.
Results: Eighteen patients(PAI=55±18) followed this staged approach. Fourteen of 18
patients(78%) could achieve complete biventricular repair, and 3 patients died - 2 after first
surgery, and one after total correction. The final mean pressure ratio of right ventricle to aorta
after total correction was 0.63. Conclusions: Establishment of early right ventricle to pulmonary
arterial continuity with subsequent pulmonary ballon angioplasty and coil embolization of collaterals
allow eventual successful complete repair in 78% of patients. This may be a superior outcome
compared with those of previous reports. Nevertheless, long-term follow-up is warranted.
FP45
NITINOL VASCULAR PLUG FOR PERCUTANEOUS
OCCLUSION OF CORONARY CAMERAL FISTULA - A CASE
REPORT
FREE
Prem Sekar, Pramod Jaiswal
Frontier Lifeline, Chennai, India
PAPER
Catheter based occlusion of coronary fistula is an accepted alternative to standard surgical closure.
Commonly used occlusion material are stainless steel coils, Amplatzer PDA occluder and
detachable balloons. We report the case of a 6 year old child with a large coronary cameral
fistula successfully occluded using a 10mm Amplatzer Nitinol vascular plug. The symptomatic
child (NYHA class I) had presented with a continous murmur, a cardiothoracic ratio of 60% on
chest X-ray and echocardiographic finding of a large coronary fistula from the left coronary
system draining in to the RA. Cardiac catheterization immediately prior to occlusion of the fistula
revealed a 2:1 left to right shunt. Post procedure, at three months follow-up, the child reported
symptomatic improvement and echocardiography continued to show complete abolition of the
left to right shunt. This confirms that the Nitinol vascular plug is an effective device for satisfactory
and safe occlusion of moderate to large coronary fistulae.
FP46
FREE
PAPER
ELIMINATING PEDIATRIC CORONARY STENOSIS IS
POSSIBLE USING SIROLIMUS-ELUTING STENTS
James Yashu Coe, W.J. TYMCHAK1, J. RUTLEDGE1, AND J.R. BURTON1
1
University of Alberta, Edmonton, Alberta
Objective: Transluminal coronary angioplasty and stenting are uncommon events in infants and
children. Maintaining patency in a growing child may be a concern. Sirolimus-eluting stents have
been shown in adult coronary artery disease to have significantly lower incidence of restenosis.
Methods: Since May 2002, Sirolimus-eluting stents (n=4) have been used in 3 children, 9
months to 13 years of age, with coronary artery stenosis. Two of the children were moribund at
the time of the procedure. The stenoses occurred after surgical repair of anomalous left coronary
artery, pulmonary valve implantation and heart transplantation. All procedures were performed
under general anesthesia. All patients were treated with heparin and abciximab during the procedure,
aspirin and clopidogrel for six months.
Results : All procedures were performed under general anesthesia. All patients were treated
with heparin and abciximab during the procedure, aspirin and clopidogrel for six months. Sirolimuseluting stents were successfully deployed in all patients without undesirable embolization or vascular
injury. Cardiac function was restored in the critically ill patients and discharged from hospital.
Recatheterization, up to two years in one, showed patency of the stented vessel and appropriate
growth of the adjacent coronary artery.
Conclusions : This study showed that it is feasible to treat coronary artery stenosis in the young
by balloon angioplasty and maintain their patency using Sirolimus-eluting stents.
FP47
TRANSCATHETER PLATINUM-COATED NITINOL
OCCLUDING DEVICES: PREVENTION OF NICKEL RELEASE
PAPER
Background: Recently, Nitinol-based alloys are widely used in medical products, including
transcatheter occluding devices in cardiac intervention. However, possibility of systemic nickel
release leading to a rise in serum concentrations of nickel after device implantation should be
concerned. In this study, the atrial septal defect (ASD) and patent ductus arteriosus (PDA)
occluding devices were braided from Nitinol wires and coated with Nanoplatinum. With
Nanotechnology, layers of platinum were coated on the surface of meshed Nitinol wires in order
to prevent the exposure of Nitinol alloy to the blood after implantation.
Objective: Our purpose was to evaluate the change in serum nickel concentrations in the patients
before and after transcatheter ASD and PDA closure with platinum-coated Nitinol occluding
devices.
Method: In 50 patients (25 ASD cases and 25 PDA cases), blood samples were taken during
the cardiac catheterization before and at 1, 3, 7, 30, 90 and 180 days after device implantation.
Blood samples in 104 normal adult populations were also included. Serum nickel concentrations
were measured by atomic absorption spectrophotometry.
Results: The mean serum nickel levels were 0.65, 0.63, 0.67, 0.55, 0.53 and 0.42 ng/ml,
before and at 1, 7, 30, 90 and 180 days after device implantation in the ASD group; and 0.59,
0.57, 0.56, 0.55, 0.61 and 0.46 ng/ml, before and at 1, 3, 7, 30, 90 and 180 days after device
implantation in the PDA group; respectively. The mean level in 104 normal populations was 0.67
ng/ml. There was no statistical difference in serum nickel concentrations before and after device
implantation in both the ASD and PDA groups. The serum nickel levels in the 50 patients were
not significant different from those in the normal populations.
Conclusion: Layers of platinum coated on the surface of meshed Nitinol-wires are able to cover
the exposed surface of the Nitinol alloy. Prevention of serum nickel release by using platinumcoated Nitinol occluding devices is possible.
FREE
Pornthep Lertsapcharoen, Khongphatthanayothin A, La-orkhun V, Supachokchaiwattana P
Division of Pediatric Cardiology, Department of Pediatrics
Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
FP48
FREE
PAPER
COMPARISON OF BALLOON ANGIOPLASTY AND PRIMARY
STENTING IN CONGENITAL HEART DISEASE
Roymanee S, Durongpisitkul K, Soongswang J, Laohaprasitiporn D, Chanthong P, Nana A.
Division of Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital,
Mahidol University, Bangkok, 10700. Thailand
Objective: To compare the results and complications of balloon angioplasty (BA) with stent
implantation (SI) for vascular stenosis in congenital heart disease.
Background: Traditionally BA was used primarily for angioplasty. However, due to poor results
in some patients, primary stenting was increasingly acceptable for management of resistant lesions.
We compared the results of using BA and SI.
Methods: A retrospective study of 80 patients who underwent BA or SI between January 1998
and December 2005 at our institution. Procedural success is determined by either increasing of
the stenotic diameter > 50% (anatomic success) or decreasing of the pressure gradient > 50%
(hemodynamic success).
Result: The majority of cases were pulmonary artery stenosis (66.3%) and coarctation of aorta
(25.0%). Of these 80 patients, 27 patients underwent SI. The immediate results have shown in
Table 1. There was a significant difference in diameter increment percentage and post-dilatation
pressure gradient between two groups. Neither mortality nor significant morbidity was observed
in each procedure.
Table 1. Comparison between the two groups
Age (yr)
Body weight (kg)
Stenosis diameter (mm)
Pre-dilatation
Post-dilatation
% Diameter increment
Anatomic success
Pressure Gradient (mmHg)
Pre-dilatation
Post-dilatation1
% Gradient reduction
Hemodynamic success
BA
(Mean + SD)
13.5 16.7
29.8 17.3
SI
(Mean + SD)
15.6 11.6
36.1 23.1
P value
6.9 4.2
9.2 5.0
50.0 56.4
15/48 (31.3%)
5.6 2.8
10.0 2.8
114.9 71.2
21/24 (87.5%)
0.205
0.518
< 0.001
25.9 18.1
4.5 16.1
51.2 37.3%
19/35 (54.3%)
25.1 17.9
4.2 5.5
69.4 48.4%
17/19 (89.5%)
0.866
< 0.001
0.131
0.579
0.172
Conclusion: Primary stenting showed a better immediate outcome for achieving larger final
diameter and reliving of post-dilation gradient when compared to balloon angioplasty alone.
FREE
PAPER
FP49
FREE
PAPER
Transcatheter closure of Secundum Atrial Septal Defect in Children
Wei Gao, ZHOU Ai-qing , YU Zhi-qing , LI Fen, ZHANG Yu-qi, SUN Kun,
ZHONG Yu-min
Shanghai Children’s Medical Center
Objective : To discuss the indication 0methodology and complication preventing in transcatheter
closure of secundum Atrial septal defect(ASD).
Background : ASD transcatheter occlusion techniques have become an alternative to surgical
procedures. A number of different devices are available for transcatheter ASD closure. The type
and rate of complications are different for different devices.
Methods : Retrospective analysis was performed on the patients treated from October 1998
to January 2006. Transcatheter closure of secundum ASD with Amplatzer septal occluder
(ASO) was performed in 226 cases, of whom 3 mutiple ASD, 3 associated with pulmonary
stenosis (PS), 3 patent ductus arteriosus (PDA). Age 0.8~17.0 years (mean 7.5±2.8 years),
weight 6.7~88Kg (mean 23.7±7.8 Kg). They are all met with criteria for transcatheter closure
received this operation. The balloon-stretched diameter of ASD was determined by
fluoroscopy,ultrasound and measuring plate. A choice of device size was identical to or within
2mm larger than the stretched diameter(SD). 6 cases associated with PDA or PS were performed
simultaneously PDA closure with device or balloon dilation. Follow up with echocardiography
and clinical examination.
Results: In 226 cases with transesophageal echocardiography (TEE) or trans-thoracic
echocardiography (TTE), ASD mean diameter 12.9±5.6 mm (6.5~34.5 mm), pulmonary mean
pressure 29.0 5.0mmHg (25.0~62.0 mmHg), SD 15.7±4.8mm (8.0~38.0 mm). The diameter
of these devices were 15.0±5.0mm (8mm-38mm). The devices were successfully implanted in
220 cases. Of whom 3 were multiple ASD with one device occlusion. 6 cases associated with
PDA or PS were performed successfully PDA occlusion or balloon dilatation. The immediate,
one month and one year complete occlusion rate were 97.7% (215/220), 99.1% (218/220),
99.1% (218/220) respectively. A trivial hemodynamic insignificant residual shunt remained in 2
cases. No complication occurred except transient atrial premature beats and II0I A-V block
happened in 5 cases (4.5%)and 1 cases (0.9%). Procedure time ranged from 25~68 minutes
and fluoroscopy time from 12~36 minutes .The total follow up was one month to 7.4 years. No
unsatisfactory device position or embolization .No clinical evidence of bacterial arteritis.
Conclusion Transcatheter closure of secundum ASD using the ASO is a safe and effective
alternative to surgical repair. Transcatheter closure of secundum ASD associated with small
anterior, inferior or posterior rim is feasible using ASO. Infant and young children can be performed
ASO only if the diameter of disk is smaller than the diameter of atrial septum. Multiple ASD is not
contraindicaton for intervention. If the diameter of ASD >36mm the device choice was depent
on measureing maximum diameter of ASD with Echo. TTE is suitable for small ASD and TEE
for bigger ASD. The routine or other advanced methods were performed in using ASO. It is
very important to prevent air embolism and atrial perforation.
General Cardiology
FREE
PAPER
FP50
FREE
PAPER
PULSE OXIMETRY SCREENING FOR CRITICAL CONGENITAL
HEART DISEASE IN ASYMPTOMATIC NEWBORNS
RUANGRITNAMCHAI CHATREE*, PONGPANICH BOONCHOB **
*
Department of Pediatrics, Synphaet Hospital, Bangkok, Thailand
** The Cardiac Children Foundation of Thailand
Aim: To determine the prevalence of Critical congenital heart disease (CCHD), pulse-oximetric
screening combined with clinical examination is superior in the diagnosis of congenital heart disease
to clinical examination alone and the effectiveness of a pulse-oximetric screening performed on
the first day of life for the detection of CCHD in otherwise healthy newborns
Methods: Pulse oximetry was performed on asymptomatic newborns at >24 hours of age. If
pulse-oximetric screening for O2saturation was < 95%, echocardiography was performed. Data
regarding true and false positives as well as negatives were collected and analyzed.
Results: Pulse-oximetric screening was performed on 1609 asymptomatic newborns, and 3
cases of CCHD were detected (1 transposition of the great vessels, 1 complete atrioventricular
canal with moderate tricuspid regurgitation and 1 ventricular septal defect with patent foramen
ovale with moderate tricuspid regurgitation (TR) with pulmonary regurgitation). The prevalence
of CCHD among all live births was 1 in 543 and among the screened population was 1 in 536
(sensitivity: 100%; specificity: 99.8%; positive predictive value: 100%; negative predictive value:
100%; accuracy: 99.8%).
Conclusion: Routine newborn auscultation for murmurs is an insensitive method for early detection
of critical congenital heart disease, Routine pulse oximetry may improve the early diagnosis. If
postductal oxygen saturation is persistently below 95% or if clinical signs occur, referral to a
cardiology unit is suggested.
Key words: pulse • oximetry • screening • newborn • heart
Abbreviations: CHD, Congenital heart disease • CCHD, Critical congenital heart disease
FP51
PRENATAL DIAGNOSIS AND OUTCOME OF FETUSES WITH
TETRALOGY OF FALLOT
PAPER
Objective: To review the correlation of the prenatal echocardiographic(echo) features and
postnatal outcome in fetuses with tetralogy of Fallot(TOF).
Materials and Methods: Between January 2000 and July 2006, a total of 78 fetuses were
diagnosed with TOF in our institution. Among these, 43 fetuses had complete prenatal and postnatal
echo data and were subject of this study. During fetal echo we measured diameter of all valves,
great arteries and chambers and also flow velocity across great arteries as well as complete
cardiac and non-cardiac structures.
Results: Among 43 fetuses, 40 had a pulmonary valvar diameter below normal range(±2SD)
at some point during gestation. The ratio of the diameter of the aortic to the pulmonary valve was
upper than normal in all fetuses. The pulmonary arterial (PA) Doppler velocity was higher than
normal in all fetuses. There was a significant increase in PA Doppler velocity from fetal to postnatal
life. Mean PA Doppler velocity was 1.17±0.27 m/s at 2nd trimester, 1.36±0.42 m/s at 3rd trimester,
2.34±0.55 m/s at birth, and 4.29±0.44 m/s at 3month after birth. Location of VSD was
perimembranous in 34, subarterial in 6, muscular outlet in 2 and total conal defect in 1. Among
43 newborns, 21 underwent one stage total correction at 10.4±4.0 months, 6 underwent systemicpulmonary shunt operation at 2.6±2.9 months and 16 are awaiting operation. There was no
significant difference in echo measurements between fetuses who subsequently underwent onestage total correction and fetuses who underwent shunt operation.
Conclusions: In TOF, pulmonary valve hypoplasia and increased pulmonary arterial Doppler
velocity are detected from fetal life. Progression of obstruction in right ventricular outflow tract
was observed during fetal life and after birth. There was no prenatal echo feature that can predict
the need for early intervention.
FREE
Jhang W.K, 1 Won H.S, 2 Kim Y.H,1 Ko J.K,1 Jung S.H,3
Park J.J,3 Yoon T.J,3 Seo D.M,3 Park I.S1
Department of Pediatrics, 1 Department of Obstetrics, 2 Department of Cardiac
Surgery3 University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
FP52
FREE
PAPER
ADOLESCENCE AND ASSIST DEVICES, ARE THEY
A GOOD MATCH?
Lisa Underwood
c- Ward 23b, Starship Children’s Hospital, Private Bag 92-024, Auckland 1023,
New Zealand
This presentation will delve into the experience of a teenage boy who was one of the first recipients
of the newly developed left ventricular assist device.
The PCCS in Auckland, New Zealand, although a small isolated country provides world class
treatment using the latest technological developments available on the world stage.
This young person had a long history of dilated cardiomyopathy, but in his early teens his function
had decreased to the point of making him dependent upon hospital treatments. When his function
decreased to a critical point a decision was made to utilize the Melbourne team, in Australia, to
implant the LVAD.
He was transplanted 10 months later.
This case study will delve into the heart and soul of life as a chronically ill teenager and his family,
the challenges faced and overcome, with the support of a variety of networks within the hospital.
By Lisa Underwood, c- Ward 23b, Starship Children’s Hospital, Private Bag 92-024, Auckland
1023, New Zealand.
FP53
QUANTIFICATION OF AORTOPULMONARY COLLATERAL
BLOOD FLOW AFTER BIDIRECTIONAL GLENN PROCEDURE
PAPER
Background: Hemodynamics of bidirectional Glenn (BDG) circulation with aortopulmonary
collateral arteries are not well understood because of difficulty in quantifying the collateral blood
flow. This study attempted to provide a new method to quantify the aortopulmonary collateral
blood flow after BDG procedure.
Methods: Five patients after BDG procedure underwent cardiac catheterization and nuclear
scintigraphy using 99m-Tc labeled macroaggregated albumin (MAA) administrated from lower
extremity vein. Albumin aggregates were distributed to lung and body through collateral arteries
and systemic arteries, respectively. The collateral/systemic flow ratio (=M) was measured from
total body image: M = total lung count/ (total body count - total lung count). Combining Fick
principle and the MAA-based collateral/systemic flow ratio, collateral/pulmonary flow ratio (Qc/
Qp) was obtained, where pulmonary flow = collateral flow + superior vena cava flow: Qc/Qp =
(pulmonary venous saturation - inferior vena cava saturation)/(1+1/M)(systemic saturation - Inferior
vena cava saturation). Using this formula, we calculated the collateral blood flow.
Results: The median age at operation was 1.52 years (range, 1.0 to 2.0), and the median age at
catheterization was 2.61 years (range, 1.83 to 9.47). The collateral/systemic flow ratio was 0.48
± 0.12 (mean ± SD), and the collateral/pulmonary flow ratio was 0.60 ± 0.17. The collateral
blood flow was 1.67 ± 0.30 L/min/m2 (range, 1.34 to 2.01). Pulmonary vascular resistance
(PVR) was 1.97 ± 0.79 Woods units m2. If we ignore the collateral blood flow (assuming M =
0), calculated PVR would be 3.08 ± 1.30 Woods units m2, overestimated by 31 to 64%.
Conclusions: The aortopulmonary collateral blood flow after BDG procedure can be calculated
with new MAA-catheterization-combined approach. The collateral blood flow plays an important
role in BDG circulation. This approach enables us to avoid overestimation of PVR in considering
the indication of Fontan procedure.
FREE
Ryo Inuzuka, Hiromichi Nakajima, Kouta Agematsu, Yuji Naitou, Kenji Sugamoto, Shunsuke
Tatebe, Mitsuru Aoki, Tadashi Fujiwara, Hiroyuki Aotsuka
The Divisions of Pediatric Cardiology and Pediatric Cardiothorascic Surgery, Chiba
children’s hospital
FP54
FREE
PAPER
Acute Cardiac Remodelling After Transcatheter Closure of Atrial
Septal Defect in Adult Patients
En-Ting Wu, Teiji Akagi, MD, PhD, Tsutomu Taniguchi, MD, PhD , Tsumoru Maruo, MD,
PhD , Shinichi Otsuki, MD, PhD, Shunji Sano, MD, PhD
Cardiac Care Center, Okayama University Hospital
Objectives: To evaluate the acute cardiac remodeling after transcatheter closure of ASD in
adult patients.
Background: Transcatheter closure of atrial septal defect (ASD) has showed good short-term,
mid-term and even long-term results, especially in pediatric patients. But in adults, due to longstanding RV volume overload and subsequent change in pulmonary vasculature, longer period of
cardiac adaptation may be expected after the procedure. There are limited reports about this
remodeling in adult patients.
Methods: We enrolled 17 adults (mean age 58.4 ±17.3 years old) who underwent successful
catheter closure of ASD since August 2005 to July 2006. We arranged routine transthoracic
echocardiographic study including LV and RV Tei indexes and serum BNP sampling before
ASD closure, one day, 1 month and 3 months after closure. Thereafter, a statistically analysis
was performed.
Results: We found 1) LVEDD increased, and RVEDD decreased markedly early after the
closure of ASD (p <0.05); 2) Tei index of LV declined soon after the procedure, but which of
RV showed a trend of increasing level until 1 month, then decreasing at 3 month visit; and 3)
BNP elevated one day after closing ASD and declined at the one-month visit. This trend is
possibly related to the change of LVEDD.
Conclusion: We confirmed that the acute “shrinkage” of the right ventricle and “expansion “of
the left ventricle occurred soon after the procedure, even in elder patients. Besides, the LV Tei
index decreased after the procedure which indicated the recovery of LV from the compression.
The RV Tei index increased initially after the procedure but declined one month after. The elevation
of plasma BNP was related to the acute extension of LV chamber but it relationship with the LV
function remained unclear.
FP55
DOES THORACIC SITUS ACCURATELY PREDICT ATRIAL
SITUS IN HETEROTAXY SYNDROMES?
Symmetrical R lungs
Symmetrical lengths
L/R ratio < 1.5
Cartilage rings (L)
Bilat eparterial Br
P value
<0.0001
<0.0001
<0.0001
0.4
<0.0001
AUC
0.59
0.69
0.83
0.56
0.81
Sensitivity
0.25
0.41
0.79
0.84
0.66
Specificity
0.94
0.97
0.86
0.29
0.97
Conclusion: In a patient with congenital cardiac disease, the first step in the diagnosis of the
segmental combinations is to establish atrial situs. If bronchial situs or symmetry can be identified,
this may provide a clue to the heterotaxy syndrome usually associated with severe complex
cardiac lesions. In the splenic syndromes, the relationship of bronchi to pulmonary arteries was
the best predictor but exceptions do occur.
PAPER
Background: Symmetry of thoracic viscera and atrial appendages is well known in heterotaxy
syndromes. This study was undertaken to assess the reliability of thoracic situs to indicate atrial
situs.
Method: Thoracic situs was assessed in 247 post mortem case with situs solitus of the atria and
58 cases with heterotaxy (32 with asplenia, 11 polysplenia and 15 others).
Five features to assess thoracic situs are lung lobation, the lengths of the right(R) and left (L) main
bronchi (Br), the ratio of L/R lengths, the number of cartilage rings, and the relationship of bronchi
to the pulmonary arteries.
Results: In cases with heterotaxy, symmetry (or isomerism) was found of lung lobation in 42/58
(72%), of bronchial lengths in 78 %, in relationship of bronchi to pulmonary arteries in 91%,
and in cartilage rings in 30 %. The L/R ratio was < 1.5 in 83 %. All patients with asplenia had
bilateral right atrial appendages. In polysplenia the atrial appendages were morphologically left in
82 %.
Predictors for Heterotaxy:
FREE
LOUISE CALDER
Green Lane Paediatric Cardiac and Congenital Services, Auckland, 1030, New Zealand
FP56
FREE
PAPER
Contrast-Enhanced Magnetic Resonance Angiography of Persistent
Fifth Aortic Arch In Children
Yumin Zhong, Richard B. Jaffe, Ming Zhu, Aimin Sun, Yuhua Li,
Wei Gao
Shanghai Children’s Medical Center
Background: Cineangiography and echocardiography have been utilized to
diagnose congenital aortic arch anomalies. However, the visualization of
great vessels by echocardiography is limited, while cineangiography requires cardiac catheterization
with ionizing radiation. Contrast-enhanced magnetic resonance angiography (MRA) is a
noninvasive modality for visualization of congenital aortic arch anomalies.
Objective: To evaluate the utility of contrast-enhanced MRA in the diagnosis of persistent fifth
aortic arch, a rare congenital aortic arch anomaly, and to compare its diagnostic accuracy with
that of cineangiography and echocardiography.
Materials and Methods: In four pediatric patients, contrast-enhanced MRA studies were
performed for diagnosing persistent fifth aortic arch. The findings of MRA were compared with
echocardiographic findings and confirmed by cineangiography and operation.
Results: Transthoracic surface echocardiography noted an aberrant vessel arising from the
ascending aorta in two of four patients and the etiology of this vessel was uncertain. In the other
two patients a diagnosis of coarctation was made. In four patients, only one patient was diagnosed
with interruption of the aortic arch. Contrast-enhanced MRA clarified uncertain echocardiographic
findings correctly diagnosing persistent fifth aortic arch with fourth aortic arch interruption in all
four patients.
Conclusion: Contrast-enhanced MRA is a safe, accurate fast-imaging technique for the evaluation
of persistent fifth aortic arch, and may obviate the need for conventional cineangiography. Cardiac
catheterization may be reserved for some complicated congenital heart disease and for obtaining
hemodynamic information.
Keywords: contrast-enhanced MR angiography, echocardiography, persistent fifth aortic arch,
congenital anomaly, aortic arch anomaly, interruption of the aortic arch
YIA1
Transxiphoid approach for children with atrial septal defects
Shin Takabayashi 1, Shimpo 1, Kazuto Yokoyama 1, Hiroyuki Ohashi 2, Yoshihide Mitani 2
1
Departments of Thoracic and Cardiovascular Surgery and 2Pediatrics, Mie University
Graduate School of Medicine
PAPER
FREE
Objective: Minimal invasive procedures have recently been sought in cardiovascular surgery.
We sought to confirm the efficacy of a transxiphoid approach that negates a full sternotomy.
Methods: Between January 1999 and June 2005, 29 children underwent surgical direct closure
of the atrial septal defect through a transxiphoid approach. Before August 2003, 19 patients
underwent the operation, group E, with the remainder, 10, in group L. Mean age and body
weight were; group E, 64±30 months and 18±6.2 kg; group L, 71±12 months and 17±1.7 kg.
Results: Operation time (127±24 minutes versus 249±35 minutes), cardiopulmonary bypass
time (41 8.4 minutes versus 74±13 minutes), and aorta clamp time (11±3.3 minutes versus
23±9.8 minutes) were all shorter in group L than in group E, respectively (p<0.05). Sedative
frequency after operation in group L was less than in group E (1.3±1.3 times versus 4.0±3.4
times, p=0.004) and chest drainage duration was shorter in group L than in group E (1.0±0 day
versus 1.6±0.7 days, p<0.001). Although water balance of operative day in group L was less
than in group E (-284±156 ml versus -138±187 ml, p=0.04), oral intake of operative day in
group L was more than in group E (182±92 ml versus 103±61 ml, p=0.04). Group L started
walking earlier than group E (post operative day 1.7±0.9 versus 2.7±1.1, p=0.03).
Conclusion: It is possible to perform the operation in a short time through a transxiphoid approach.
Shortening operation and CPB times leads to the earlier recovery of patients after their operation.
YIA2
FREE
PAPER
Pre-operative Evaluation with Magnetic Resonance Imaging in
Tetralogy of Fallot and Pulmonary Atresia with Ventricular Septal
Defect
Monnipa Suesaowalak, Kritvikrom Durongpisitkul, Prakul Chanthong, Jarupim Soongswang,
Duangmanee Laohaprasitiporn, Apichart Nana
*Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
Background: Pre-operative evaluation of patients undergone repair of Tetralogy of Fallot and
Pulmonary Atresia / Ventricular Septal Defect were generally done by echocardiogram and cardiac
catheterization. Our objectives of this study were to compare the findings of Gadolinium (Gd)
enhanced cardiac MRI with cardiac catheterization and surgical findings for patients undergone
surgical repair of Tetralogy of Fallot and Pulmonary Atresia / Ventricular Septal Defect.
Patients and Methods: Patients who underwent repair of Tetralogy of Fallot and Pulmonary
Atresia / VSD were prospectively evaluated using cardiac catheterization and cardiac MRI within
3 months. Branch of pulmonary arteries were divided into: main pulmonary artery (MPA), right
and left branch pulmonary artery (RPA & LPA), major aortopulmonary collateral arteries
(MAPCAs) and minor APCAs. The study results were interpreted blindly. The agreement of
findings were compared using Kappa statistics. Surgical findings were compared with cardiac
catheterization and cardiac MRI using percentage of patients.
Results: There were 43 patients who received both cardiac catheterization and cardiac MRI
within 3 months period. The average age was 13.8±8.4 (2-30) years old. There were an agreement
among measurement of both main and branches (right and left) pulmonary artery with Kappa
statistics more than 0.8. MRI was able to identify more branches of MAPCAs compared to
cardiac catheterization. There were 15 patients who underwent surgical repair. There were an
agreement of main and branches (right and left) pulmonary artery 78% - 85%. MRI can identified
more branches of MAPCAs compare to surgical findings.
Conclusions: The results of this study indicate that Gd-enhanced 3D MRA is a feasible, fast and
accurate technique for identification of all sources of pulmonary blood supply in patients with
Tetralogy of Fallot and complex Pulmonary Atresia. The study was a noninvasive alternative to
cardiac catheterization. MRI can better delineated small (minor) branches of collateral arteries
that were used as a guide for planning of transcatheter coil embolization in addition to routine
cardiac catheterization.
YIA3
MANAGEMENT AND OUTCOME OF FETAL ATRIAL FLUTTER
IN THE KOREAN POPULATION
PAPER
Introduction: The aim of this study was to evaluate fetal atrial flutter(AF) and the efficacy
of maternally administered antiarrhythmic agents, postpartum management and outcome.
Methods: Fetal AF cases seen in three institutions between June 1997 and June 2006 were
reviewed retrospectively.
Results: AF was diagnosed prenatally in 12 fetuses. Mean age at detection was 35.3+/4 weeks’ gestation. Most fetuses with AF had structurally normal hearts except one with
critical PS. AF was incessant in 9 and intermittent in 3, with a mean atrial rate of 422+/-103
beats/min and a mean ventricular rate of 216+/-37 beats/min. A predominance of 2:1
atrioventricular (AV) conduction was observed except one 1:1 AV conduction. In 2 of 12
cases supraventricular tachycardia coexisted with AF. Fetal hydrops was seen in 3 patients and
were treated in utero with maternal therapy, 1 received digoxin and 2 mutidrug therapy (digoxin
and flecainide). In the nonhydropic group of 9 patients, one case of fetal AF resolved
spontaneously in utero and one case treated in utero with digoxin and another case received
multiple drugs, digoxin and flecainide with atrial ectopic tachycardia after birth. And the
remaining 6 were delivered immediately. Three fetuses received no medication and were
delivered and AF subsided. Three neonates were in AF at birth. Rhythm control could be
achieved in 2 patients with propafenone (n = 1), or electrical cardioversion (n = 1) without any
relapse. But one patient with 2:1 AV conduction died after birth due to complication
from renal and heart failure in spite of multiple therapy without conversion to sinus
rhythm. Recurrence of AF after initial conversion to sinus rhythm did not occur in any of the
patients.
Conclusion: Even though fetal AF can be a serious and life-threatening rhythm disorder,
therapy can be useful for most of them. And once fetuses with AF survive, their longterm prognosis seems to be excellent. And it appears that recurrence of AF is unlikely beyond the
neonatal period.
FREE
Song Min Seob 1,Won HS2, Jeong DH3, Hong YM4, Park IS5
Department of Pediatrics1 and Obstetrics and Gynecology3, Paik Hospital,
Inje University,Pusan,Department of Obstetrics and Gynecology2 and Division of
Pediatric Cardiology5, Asan Medical Center, Ulsan University, Seoul, Department
of Pediatrics4, DongDaeMun Hospital, Ewha Woman’s University, Seoul,
Republic of Korea
YIA4
FREE
PAPER
Regression of Dilated Cardiomyopathy after Switching Iron Chelator
from Deferoxamine (DFX) to Deferiprone (L1)
Tzu-Yao Chuang, Jeng-Sheng Chang, Yu-Chih Huang, Kang-Hsi Wu, Ching-Tien
Peng Dep of Pediatrics, Devision of Cardiology, China Medical University Hospital ,
Taichung, 404, Taiwan
Background: Cardiac dysfunction from iron deposition is the most common cause of mortality
in patients of thalassemia major after long-term blood transfusions. Deferoxamine (DFX)
subcutaneous or intravenous iron chelator, though effective, has long been complained of user
inconvenience and poor compliance. With introducing of a new oral iron chelator, Deferiprone
(L1), in latest years, the medication compliance improves substantially. This study tries to compare
the cardiac protection effects between DFX and L1.
Method: From Nov. 1989 through Jan. 2005, nine thalassemia major patients receiving
deferoxamine (DFX) injection therapy for more than 10 years but complicated with some degree
of myocardial dysfunction were enrolled into the study to switch from DFX to L1, at a dose of
75 mg/kg/day. Echocardiographical studies focusing on systolic, diastolic and global functions of
the left heart were performed regularly every 6 months. Mean values of each parameter are
compared between the DFX and L1 periods by paired t-test and Wilcoxon signed-rank test.
Result: Significant improvements of global cardiac function are shown in reducing of E-point to
Septal separation (EPSS) (8.11+ 3.67 vs. 2.9+ 0.89 mm, P<0.01), EPSS/LVDd (left ventricle
diastolic dimension) ratio (0.19 + 0.08 vs. 0.06 + 0.02, P< 0.01) and left atrium/aorta (LA/AO)
ratio (1.27+ 0.15 vs. 1.10+ 0.13, P= 0.02).
Conclusion: The myocardial dysfunction of -Thalassemia can be reversed by regular oral iron
chelator L1.
YIA5
THE USE OF AEROSOLIZED PROSTACYCLIN ANALOGUE (ILOPROST)
IN THE PREVENTION OF POSTOPERATIVE PULMONARY
HYPERTENSIVE CRISIS AMONG CHILDREN WITH LEFT-TO-RIGHT
SHUNTS AND MODERATE TO SEVERE PULMONARY HYPERTENSION
PAPER
Background: The natural history of an uncorrected congenital heart disease is the development
of pulmonary hypertension. This study was conceptualized to determine the effect of aerosolized
Iloprost in the prevention of pulmonary hypertensive crisis when given at least 48 hours in the
postoperative period.
Method: This is a randomized placebo controlled study. The study included pediatric patients
(0-19 years old) with congenital heart disease: left to right shunts with moderate to severe
pulmonary arterial hypertension admitted at the Philippine Heart Center from March 2005January 2006. PA pressure was determined by echocardiography using pulmonary acceleration
time. Patients with PA pressure of >60 mmHg were included in the study.
Patients were divided into two groups: Group I received every 6 hours aerosolized
Iloprost for 48 hours, and group II was the control group, given nebulized saline solution.
Randomization was done by using a table of random samples. Evaluation of parameters, including
Doppler echocardiogram for PAT was done at 0-hour, 24-hour, and 48-hour postoperatively.
There were 19 patients enrolled in the study: ten in Group I and nine in Group II. Aerosolized
Iloprost was given at a dose of 25 ng. kg-1 min-1, given every 6-hour interval for 48 hours.
Results: Of the nineteen patients, 58% were males with a 1.4:1 male to female ratio. Mean age
was 7.25 + 5.93 in the Iloprost group and 3.63 + 5.19 in the placebo group. Both were
comparable in their preoperative baseline characteristics, with a mean PAP of 60.37 + 12.66
and 68.55 + 10.70 respectively (p <0.05). Ventricular Septal Defect was the most common
lesion (59%).
Iloprost nebulization in Group I showed statistically significant increase in oxygen saturation
every 6-hour nebulization till the 48th hr (p=0.05). No significant change in systolic and diastolic
BP was seen at 0-hr, 6 and 24th hr. Pulmonary to systemic flow ratio increased significantly
compared with the placebo at 0-hour, 24-hour and 48-hour (p<0.05). Pulmonary resistance
significantly dropped by 9 secs/min (p0.012) but this was not significantly different from group I.
Drop in PAP until the 48th hour was not significant. Increasing the sample size is recommended.
There was no mortality in both groups with no episode of desaturation despite an increased PAP.
Conclusion: Aerosolized Iloprost given every 6-hour is an important pharmacologic agent to
be used in the immediate post-operative period to prevent pulmonary hypertensive crisis.
FREE
RUZENETTE FELICITAS HERNANDEZ,
J., FERRERA BT., LAZARO E.,
LAGAMAYO M., CASAS M.
Philippine Heart Center, East Avenue, Quezon City, Philippines
YIA6
FREE
PAPER
LEFT PULMONARY ARTERIOPLASTY -SLIDING TECHNIQUE
AND MAIN PULMONARY ARTERIAL TRANSLOCATION
TECHNIQUE
Masahiro Yoshida, Yoshihiro Oshima, Chikashi Shimazu, Hironori Matsuhisa, Tomonori
Higuma, Hiroaki Takahashi
The Department of Cardiovascular Surgery, Kobe Children’s Hospital
Surgical arterioplasty for left pulmonary branch stenosis has often produced unsatisfactory results.
We report new operative techniques involving sliding technique, a modification of end-to-end
anastomosis, and main pulmonary arterial translocation technique. These techniques provided
widely patent and non-redundant anastomosis. (Techniques) The operation is performed through
a median sternotomy. In cases that require an additional aortopulmonary shunt, a standard left
posterolateral thoracotomy is performed. The left pulmonary artery and main pulmonary artery
are completely dissected to allow anastomosis without tension, and the stenotic portion is
transected. For sliding technique, the distal incision is made on the superior aspect of the left
pulmonary artery and the proximal incision is made on the inferior aspect of the main pulmonary
artery. The anastomosis is completed with running suture of 7-0 polypropylene. If neccesssary,
autologous pericardium patch is used at the distal left pulmonary artery. For the other technique,
the main pulmonary artery is transected and the stump is translocated to the distal left pulmonary
artery and anastomsis is completed. (Patients and results) From 2002 to May 2006, 11 patients,
median age was 1.5 years, underwent the left pulomnary arterioplasty using sliding techniques or
translocation technique. The sliding technique was performed in eight of them at the time of
biventricular repair in six, bidirectional Glenn anastomosis in one and modified BT shunt in one.
In five of them, autologous pericardial patch was used to avoid tension. The other two patients
underwent translocation technique at the time of bidirectional Glenn anastomosis in one and
modified BT shunt in one. Postoperative angiograms or three-dimensional computed tomography
showed patency of left pulmonary artery with enough size of diameter in all patients. (Conclusion)
These two techniques are useful for patients with severe left pulomonary stenosis by means of
providing enough continuity of autologous pulmonary tissue.
