Unsettled and Unanswered QuestionsChristopher CaldaroneAATS symposiumApril 26th, 2015

Case reportHLHS, 5d, 3.1 kgAS/MSAoV 3.5mmMiV 4mmMildly restrictive ASDSerpiginous isthmusGood candidateBilateral PAB, ductal stentNo reverse BT shunt

Judgment Error #1

Post-op5 hours postopRt radial arterial line not workingSuspect retrograde arch malperfusion

To cath lab for interventionPlanned stent across isthmusDelay in Diagnosis

Cath labHypotensive:Open chest, ECMO standby

Attempted retrograde isthmus cannulation!!! No flow >> Right radial pressure: 20 (CPR)>>>ECMO (RA - MPA)Rt radial pressure: mid 30sDiminished functionGood judgmentWhat now?

Restore arch perfusionTransfer arterial flow to right carotid

Return of function!Rescued!

StabilityNow what?ECMO as bridge to transplant?Norwood after recovery of function?

Tough problem

IdeaAdvance arterial cannula to aortic archReverse BT shunt as rescue treatment

Idea

Wean off ECMOD/C from ICU POD 9Success!

Success >> Late failure3 months postopBalloon atrial septostomy >> ischemiaPoor ventricular function with troponins (+)

>> reverse BT shunt is rendered inadequate after septostomyArch is malperfused

Failure (again)!

Idea #2Try ECMO (via left carotid) to perfuse archPrompt return of functionDx: Hibernating myocardium

Norwood (4.0 mm BT)

Success!

Subsequent courseSmall rt parietal stroke - seizuresBCPS at age 10mOsteoporosis leading to multiple fracturesDelayed milestonesPersistent ventricular dysfunctionBorderline high PVRResolved with medical therapy and timeFontan at 6 years

Technical ConclusionsAugmentation of arch perfusion with ECMO can reverse myocardial hibernationReverse BT shunt can be used as a rescue3.5 mm reverse BT shunt can keep you alive, but may not be adequate for long term

Big pictureBetter to avoid trouble

Successful rescue can have a big price

Success or Failure?

25th July 2008 to 24th January 2015 ICU 56 daysHospital LOS 105 daysInterventions 9Cost - $357,692ER visits 9Admissions 17Total LOS 222Total Interventions 15Total Clinic Visits 89

Bigger pictureRescues are important to preserve life

Success or Failure? is the wrong question

Quality of Rescue LifeMorbidityCost

First Admission

Length of Stay in Cardiac ICU 49.3 days Length of Stay in Cardiac Unit 55.7 daysResource Intensity Weight 68.778Total Length of Stay for the visit 105 daysNumber of Surgeons and Physician involved in the care - 10Total Cost for Visit - $357,652Number of Interventions - >9

Owen is Going Home!

Age - 6 years oldLength of Stay in Cardiac ICU 2 days Admission Date 12/01/2015Length of Stay in Cardiac Unit 10.2 daysDischarge Date 24/01/2015Number of Surgeons and Physician involved in the care - 5Total Length of Stay for the visit 12.2 daysNumber of Interventions - 3

Owens SickKids Journey

25th July 2008 to 24th January 2015

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