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Influence of Procedural Risk on Cardiac Catheterisation Complications
Abstracts CSANZ 2012 Abstracts
712 Influence of Procedural Risk on Cardiac Catheterisation Complications B. Anderson ∗ , C. Ward, J. Morwood, S. Fox, J. Johnson, R. Justo Queensland Paediatric Cardiac Service, Australia Introduction: The Congenital Heart Disease Adjustment for Risk Method (CHARM) was developed to adjust risk of cardiac catheterisation with case mix complexity. We have investigated this methodology in a pilot study to assess outcomes at Queensland Paediatric Cardiac Service (QPCS). Methods: From January 2001 to December 2011 demographic, procedural and complication data were prospectively collected on 2367 patients undergoing cardiac catheterisation. Procedural risk and associated complication severity was assigned a classification, consistent with CHARM, retrospectively from this dataset. Results: Patient median age was 2.9 years (range 1 day–20.6 years) and weight 13.6 kg (range 1.5–103 kg). The interventional catheterisation rate was 34.9% for the 10year study period, although this rate has been 41.4% for 2008–2011. Lower risk procedures predominated with 87.6% category 1–2 and 12.4% category 3–4 procedures. The overall complication rate was 6.5% and these patients had a median weight of 6.2 kg (range 1.9–71 kg). Higher complication rates were associated with high-risk procedures – complication rate of 5.1% for category 1–2 and 16.6% for category 3–4 procedures. 76.1% of complications were minor category 1–3 incidents (mainly minor peripheral vascular). Increased procedural risk was associated with a higher incidence of categories 3 and 4 complications. Category 5 complications occurred in 0.1% of patients all of whom were in a lower procedural risk group. Conclusions: Cardiac catheter complication rates at QPCS are consistent with published international literature. This study demonstrates that risk adjustment for case complexity may be a valuable tool for assessing catheter laboratory performance in the Australasian environment. http://dx.doi.org/10.1016/j.hlc.2012.05.723 713 Key Role of RV Hypertrophy for Maintaining Exercise Capacity in Adults with Repaired Tetralogy of Fallot M. Seneviratne 1,∗ , S. O’Meagher 1,2 , P. Celermajer 1,2 , R. Puranik 2
Munoz 2 , D.
1 University 2 Royal
of Sydney, Australia Prince Alfred Hospital, Sydney, Australia
Background and Aims: Adults with repaired Tetralogy of Fallot (ToF) usually have free pulmonary regurgitation (PR), progressive RV dilatation and subnormal exercise capacity. Adaptive mechanisms are poorly understood. RV hypertrophy and pulmonary artery (PA) distensibility may be important compensatory mechanisms in the presence of severe PR. We investigated the utility of RV
S295
volumes/mass/diastolic function and PA distensibility in predicting peak exercise performance. Methods: Cardiac MRI (1.5T) and detailed exercise testing were performed on 50 patients with repaired ToF (mean age at repair 2.4 ± 2.0 years; age at study 27.0 ± 8.9 years; 60% males). Results: In 25 patients with severely dilated RVs (RVEDVi 150-200 mL/m2 ) there was a significant correlation between RV mass and exercise capacity (p = 0.0015). Further, RV mass to volume ratio correlated positively with RV ejection fraction (p < 0.0001), and negatively with PR fraction (p = 0.01). RV diastolic function (E/A ratio) did not correlate with exercise capacity. Although PA cross-sectional area and PA forward flow-rate correlated positively with the severity of PR (p < 0.001), PA distensibility did not predict exercise capacity. Conclusions: RV hypertrophy is a key adaptive mechanism to preserve exercise capacity in adults with severe PR after ToF repair. Further study is warranted to determine whether RV mass has a role in the clinical treatment algorithm for adult ToF patients, specifically in the timing of pulmonary valve replacement. http://dx.doi.org/10.1016/j.hlc.2012.05.724 714 Long Term Problems from Surgical Patch Closure of Multiple Muscular Ventricular Septal Defects L. Hofmeyr ∗ , D. Radford The Prince Charles Hospital, Australia Background: Multiple muscular ventricular septal defects (VSD) in children can be difficult to treat and a range of techniques have been advocated. These include pulmonary artery banding, interventional catheter closure and a variety of surgical approaches. When there are apical muscular defects and associated coarse trabeculations in the right ventricle (RV) producing a “Swiss cheese” pattern, a large patch extending on to the RV free wall and excluding part of the apex has been used. Methods: We assessed four adult patients who had surgery 22–45 years ago to treat muscular VSD by patches which excluded the RV apex. Results: Ages ranged from 22 to 50 years. Representations were for polycythaemia, cyanosis, syncope and atrial flutter. Echocardiography showed bidirectional flow from LV to apex of RV, no pulmonary hypertension, small sized RV with diastolic dysfunction, enlarged right atria, reopening of foramen ovale (PFO) in three, and positive bubble studies with right to left shunting in two. Catheterisation confirmed elevated right atrial and RV end diastolic pressures. Two patients had evidence of hepatic cirrhosis. One woman had device closure of PFO, but has right heart failure. One man had re-do surgical closure of VSD and PFO. Another patient is being considered for a Glenn shunt to take some load off RV. Conclusions: Surgical closure of muscular VSD by large patch with RV apical exclusion gives good early results. However, long-term in adult life, the reduced size of RV
ABSTRACTS
Heart, Lung and Circulation 2012;21:S143–S316
712 Influence of Procedural Risk on Cardiac Catheterisation Complications B. Anderson ∗ , C. Ward, J. Morwood, S. Fox, J. Johnson, R. Justo Queensland Paediatric Cardiac Service, Australia Introduction: The Congenital Heart Disease Adjustment for Risk Method (CHARM) was developed to adjust risk of cardiac catheterisation with case mix complexity. We have investigated this methodology in a pilot study to assess outcomes at Queensland Paediatric Cardiac Service (QPCS). Methods: From January 2001 to December 2011 demographic, procedural and complication data were prospectively collected on 2367 patients undergoing cardiac catheterisation. Procedural risk and associated complication severity was assigned a classification, consistent with CHARM, retrospectively from this dataset. Results: Patient median age was 2.9 years (range 1 day–20.6 years) and weight 13.6 kg (range 1.5–103 kg). The interventional catheterisation rate was 34.9% for the 10year study period, although this rate has been 41.4% for 2008–2011. Lower risk procedures predominated with 87.6% category 1–2 and 12.4% category 3–4 procedures. The overall complication rate was 6.5% and these patients had a median weight of 6.2 kg (range 1.9–71 kg). Higher complication rates were associated with high-risk procedures – complication rate of 5.1% for category 1–2 and 16.6% for category 3–4 procedures. 76.1% of complications were minor category 1–3 incidents (mainly minor peripheral vascular). Increased procedural risk was associated with a higher incidence of categories 3 and 4 complications. Category 5 complications occurred in 0.1% of patients all of whom were in a lower procedural risk group. Conclusions: Cardiac catheter complication rates at QPCS are consistent with published international literature. This study demonstrates that risk adjustment for case complexity may be a valuable tool for assessing catheter laboratory performance in the Australasian environment. http://dx.doi.org/10.1016/j.hlc.2012.05.723 713 Key Role of RV Hypertrophy for Maintaining Exercise Capacity in Adults with Repaired Tetralogy of Fallot M. Seneviratne 1,∗ , S. O’Meagher 1,2 , P. Celermajer 1,2 , R. Puranik 2
Munoz 2 , D.
1 University 2 Royal
of Sydney, Australia Prince Alfred Hospital, Sydney, Australia
Background and Aims: Adults with repaired Tetralogy of Fallot (ToF) usually have free pulmonary regurgitation (PR), progressive RV dilatation and subnormal exercise capacity. Adaptive mechanisms are poorly understood. RV hypertrophy and pulmonary artery (PA) distensibility may be important compensatory mechanisms in the presence of severe PR. We investigated the utility of RV
S295
volumes/mass/diastolic function and PA distensibility in predicting peak exercise performance. Methods: Cardiac MRI (1.5T) and detailed exercise testing were performed on 50 patients with repaired ToF (mean age at repair 2.4 ± 2.0 years; age at study 27.0 ± 8.9 years; 60% males). Results: In 25 patients with severely dilated RVs (RVEDVi 150-200 mL/m2 ) there was a significant correlation between RV mass and exercise capacity (p = 0.0015). Further, RV mass to volume ratio correlated positively with RV ejection fraction (p < 0.0001), and negatively with PR fraction (p = 0.01). RV diastolic function (E/A ratio) did not correlate with exercise capacity. Although PA cross-sectional area and PA forward flow-rate correlated positively with the severity of PR (p < 0.001), PA distensibility did not predict exercise capacity. Conclusions: RV hypertrophy is a key adaptive mechanism to preserve exercise capacity in adults with severe PR after ToF repair. Further study is warranted to determine whether RV mass has a role in the clinical treatment algorithm for adult ToF patients, specifically in the timing of pulmonary valve replacement. http://dx.doi.org/10.1016/j.hlc.2012.05.724 714 Long Term Problems from Surgical Patch Closure of Multiple Muscular Ventricular Septal Defects L. Hofmeyr ∗ , D. Radford The Prince Charles Hospital, Australia Background: Multiple muscular ventricular septal defects (VSD) in children can be difficult to treat and a range of techniques have been advocated. These include pulmonary artery banding, interventional catheter closure and a variety of surgical approaches. When there are apical muscular defects and associated coarse trabeculations in the right ventricle (RV) producing a “Swiss cheese” pattern, a large patch extending on to the RV free wall and excluding part of the apex has been used. Methods: We assessed four adult patients who had surgery 22–45 years ago to treat muscular VSD by patches which excluded the RV apex. Results: Ages ranged from 22 to 50 years. Representations were for polycythaemia, cyanosis, syncope and atrial flutter. Echocardiography showed bidirectional flow from LV to apex of RV, no pulmonary hypertension, small sized RV with diastolic dysfunction, enlarged right atria, reopening of foramen ovale (PFO) in three, and positive bubble studies with right to left shunting in two. Catheterisation confirmed elevated right atrial and RV end diastolic pressures. Two patients had evidence of hepatic cirrhosis. One woman had device closure of PFO, but has right heart failure. One man had re-do surgical closure of VSD and PFO. Another patient is being considered for a Glenn shunt to take some load off RV. Conclusions: Surgical closure of muscular VSD by large patch with RV apical exclusion gives good early results. However, long-term in adult life, the reduced size of RV
ABSTRACTS
Heart, Lung and Circulation 2012;21:S143–S316