1. Primary Arterial Switch beyond 3 Weeks of age : What is feasible without ECLS? Surgical management of TGA.IVS in older infants remains contentious Regressed LV mass with age ?? Less capable of sustaining systemic circulation after arterial switch Primary arterial switch in infants > 3 weeks of age Western centres : Feasible option - ECLS for rescue In India : ECLS : Expensive, resource consuming modality Cannot be recommended for Routine rescue D TGA.IVS > 3 weeks of age : Sizeable Number Late primary arterial switch without ECLS : No data available Setting : 10 bedded PICU, ~ 600 cases/year Design : Prospective pilot observational feasibility study Tenure : Dec 2005 to Aug-2008 StudyPopulation : 47 infants undergoing Arterial Switch operation for dTGA.IVS 25 3 weeks of age – late group Surgery : Standard surgical techniques Efforts to minimize myocardial ischemia - Aortic cross clamp time minimized Sternum kept open Evident or anticipated hemodynamic instability: Sternum kept open LCOS management due to primary LV failure in the ICU :- Standard, inexpensive modalities ( evidence based) Aggressive afterload reduction - Phenoxybenzamine Inotropy : Algorithm based -Upgraded on the basis of Clinical Hemodynamic Biochemial Serial Echos 1st line drug : Dobutamine 2nd line drug : Milrinone Vasoactive supports – nitroglycerine Adjuvant strategies Calcium infusion Calcium infusion Cortcosteroid use Cortcosteroid use Thyroxine supplementation for hypothyroidism Thyroxine supplementation for hypothyroidism Nasopharyngeal CPAP for LV dysfunction Nasopharyngeal CPAP for LV dysfunction LV mass ( mean ) :34 gm/m 2 (30-43) LV post wall (mean ) :3.2mm (2-4.6) LV geometry – visual impression Favorable11/22 Borderline 9/22 Regressed 2/22 In-hospital mortality : comparable in both groups Early switch group: 2/25 (8.0%) Late switch group : 1/22 (4.54%) (p = 0.6) We are thankful to our nursing staff for their selfless patient care and to our fellow doctors who helped us perform this study. Pilot, feasibilty study To evaluate the outcome of primary arterial switch (A.S.O) in infants with dTGA.IVS beyond 3 wks of age without ECLS as a rescue strategy Captions to be set in Times or Times New Roman or equivalent, italic, between 18 and 24 points. Right aligned if it refers to a figure on its right. Caption starts right at the top edge of the picture (graph or photo). Introduction Aim Methods Results Conclusion Acknowledgements Krishna Iyer, Girish Kumar, Reetesh Gupta, Sunil Kaushal, Sameer Girotra, S. Radhakrishnan, Parvathi Iyer, Savitri Shrivastava Escorts Heart Institute & Research Centre, New Delhi, INDIA Early switch group N = 25 Late switch group N = 22 Bypass time(min) Mean(SD) 132.6 (21.6) 136.9 (20.8) Cross clamp time(min) Mean (SD) 61.5 (8.0) 63.6 (11.4) Need for re-bypass(%)1(4%)1(4.5%) Supportive bypass(%)1(4%)1(4.5%) Deferred sternal closure(%)13(52%)10(45.4%) P > 0.05 Operative Data Pilot Study Suggests that primary arterial switch is feasible in infants > 3 weeks of age using simple, inexpensive ICU strategies. Preliminary observations - need to be validated in larger group of older infants to decide How old is safe in our country ? The duration of hospital stay and the inotrope score were similar in both the groups The ventilatory requirement, ICU stay and nasal CPAP requirement was comparable Significant LV dysfunction was more in the late group but pre- discharge LV dysfunction was similar The incidence of arrhythmias, sepsis as well as steroid requirement was comparable but renal injury was higher in early switch group. Methods LV status of the late group: : Variables Early switch group N = 25 Late switch group N = 22 Mean Age (days)9 (3-18)55 (22-149) Sex M/F ( %)72/2890.9/9.1 Mean Weight (kg)2.843.05 Preop BAS(%)5231.8 Coronary anatomy 1 L Cx, 2 R 1 L, 2 R Cx Single coronary Other(no circumflex) 17(68%) 6(24%) 1(4%) 15(68%) 5(22.7%) 2(9.1%) 0(0%) Demographic data