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					Original Article                                       FACTORS INFLUENCING SUCCESSFUL FAST TRACKING AFTER TOTAL
                                                              INTRACARDIAC REPAIR OF TETRALOGY OF FALLOT




                                                ABSTRACT



Sujatha D I                                     Background
Keerthi
Kanagarajan N
                                                Fast tracking in children after cardiac surgery has been reported to be a safe alternative to prolonged
Roy Varghese
Suresh Kumar R                                  postoperative ventilation. This was a prospective study to assess the safety and efficacy of fast
Robert Coelho                                   tracking (extubation within 8 hours) in patients undergoing Total Intra Cardiac Repair (ICR) for
Benjamin Ninan                                  Tetralogy of Fallot (TOF).

                                                Methods

                                                60 consecutive patients who underwent corrective surgery for TOF from September 2005 to
Key words :                                     October 2006 in our institution formed our material for this study and were divided into four
congenital heart defects
                                                groups according to the type of repair. Factors affecting the Intensive Care Unit stay and duration
early extubation
paediatric anaesthesia                          of ventilation were analyzed.
tetralogy of fallot
                                                Results

                                       Fast tracking was successful in 39 out of 60 patients. Success rate was highest in Group I (92%).
                                       Success rate was 56% (n=17) for Group 2, 50% (n=3) for Group 3, and 54.5% (n=6) for
                                       Group 4. Dopamine, adrenaline, noradrenaline, and milrinone were the inotropes used. 12 patients
                                       (85.7%) in Group 1 required one inotrope (dopamine) and 20 patients (69% ) in Group 2, 3
                                       patients (50%) in group 3 and 6 patients(54.5%) in group 4 required two inotropes (dopamine +
                                       adrenaline). Mean duration of ICU stay in the early extubation group was 1.94 ± 0.45 days
                                       while in the other group it was 7.2 ± 7.56 days (p<0.001). Mean duration of hospital stay in the
                                       early extubation group was 8.2 ± 1.88 days versus 16.5 ± 11 days (p<0.001) in late extubation
                                       group. The most common cause for delay in extubation and increase in the ICU and hospital stay
                                       was haemodynamic instability. None of the patients extubated early were reintubated. 2 patients
Department of Cardiac Anaesthesia, were reintubated in the late extubation group. One patient in Group 3 expired.
Paediatric Cardiology and Paediatric
Cardiac Surgery                        Conclusion
Institute of Cardio Vascular Diseases,
Madras Medical Mission, Chennai Fast tracking the patients after TOF repair is safe and effective. Most of the patients who underwent
                                       simple ICR were extubated early. While approximately 50% of patients who underwent right
                                       ventricular outflow tract reconstruction were fast tracked. In the others haemodynamic instability
                                       was the commonest cause preventing fast tracking. This tended to be related to pulmonary regurgitation,
                                       main pulmonary artery / branch pulmonary artery plasty and restrictive right ventricular physiology.




Journal of the Institute of Cardio Vascular Diseases                               Factors influencing succesful fast tracking after total intracardiac repair of tetralogy of fallot   21
INTRODUCTION                                                  risk patients. Of late, fast tracking has been increasingly
                                                              employed in more complex paediatric cardiac surgeries.
Total correction of Tetralogy Of Fallot (TOF) has been        Fast tracking in patients undergoing TOF repair has
in practice for the past four decades. Development of         been reported to be safe 12,14,15,16.
Right Ventricular (RV) dysfunction 1, pulmonary
insufficiency and ventricular arrhythmias 2 after             The aim of this study is to assess the safety and efficacy
transventricular repair has lead to the adoption of           of early extubation and factors influencing ventilation
transatrial or transpulmonary approach3,4,5 and excellent     and ICU stay in patients undergoing definitive repair
results have been demonstrated. Controversy still exists      for TOF.
regarding the timing of the primary correction6. Some
centers prefer early primary correction to avoid late         METHODS
complications like right ventricular dysfunction and
arrhythmias2. However the optimal management is still         This was a prospective analysis of factors influencing
debated7.                                                     fast tracking in TOF patients undergoing definitive
                                                              cardiac repair. 60 consecutive patients who underwent
 Our surgical management of TOF is individualized 8.          corrective surgery for TOF from September 2005 to
If the patient is less than 3 months old, we prefer to        October 2006 at the Institute of Cardio Vascular
do a pallitative Blalock Taussig shunt (BT shunt). Patients   Diseases, Madras Medical Mission, Chennai were
between 3 and 9 months of age undergo BT shunt if             assessed for fast tracking. All patients who were less
they have unfavourable outflow and pulmonary                  than 15 kgs were premedicated with trichloryl 70 mg/
anatomy. If the patient has spells and good outflow           kg and patients more than 15 kgs with Meperidine 1
anatomy, we prefer to do a definitive procedure (total        mg/kg and Phenergan 0.5 mg/kg were used. The
correction of TOF). Beyond 1 year of age, most of             children generally received similar anaesthetic
the patients undergo definitive repair.                       management. Sevofluorane was used for induction in
                                                              patients without intravenous access.
Currently, health care delivery is aimed at rational
management, cost containment, resource utilization and        The patients were divided into 4 groups.
minimization of post-operative ICU stay and total
length of hospital stay. To achieve this goal good            Group 1: ICR (VSD closure, infundibular resection ±
coordination is required between the surgeons,                Pulmonary Valvotomy)
anaesthesiologists, intensivists and paramedical staff .      Group 2: ICR + Transannular pericardial patch
All paediatric patients without significant pulmonary or      Group 3: ICR + Transannular monocusp pericardial
residual cardiac pathology can be managed by expedited        patch
post-operative protocols 10, 16 . Fast track clinical         Group 4: Homograft repair of Right Ventricular
guidelines include careful choice and titration of short      Outflow Tract (RVOT)+ VSD closure
acting anaesthetic drugs, minimally invasive surgical
approaches, meticulous haemostasis, use of                    Patients were induced with midazolam 0.05-0.1 mg/
ultrafiltration, effective rewarming and sustained post       kg and fentanyl 5-7 microgram/kg and fentanyl 3-5
operative normothermia, early extubation, effective post      microgram/kg was given before skin incision, on
operative pain control without excessive narcotic doses,      Cardio Pulmonary Bypass (CPB), immediate post CPB
avoidance of prolonged intensive therapy unit stay, early     and as indicated by vital signs variation. Pancuronium
ambulation, alimentation and discharge.                       was the primary relaxant and vecuronium was given
                                                              post CPB. Monitoring included 5 lead ECG, radial
Fast tracking (extubation within 8 hours) was initially       arterial pressure, central venous pressure, pulse oximetry
employed only for simple cardiac procedures such as           and temperature.
atrial septal defect(ASD), ventricular septal defect(VSD)
or patent ductus arteriosus(PDA) ligation and for low

Journal of the Institute of Cardio Vascular Diseases          Number 1, 2007                                         22
A paediatric biplane Trans Esophageal                          annulus, pulmonary atresia, absent pulmonary valve
Echocardiography probe (TEE) (Philips –CE 0086                 syndrome or a coronary crossing RVOT. At the end
USA Sonos 5500) was inserted after the induction of            of the surgical procedure, depending on the venous
anaesthesia. All patients received methylprednisolone 30       temperature of 36.5°C, patients were weaned off CPB.
mg/kg IV before the skin incision to decrease the              After completion of modified ultrafiltration and
inflammatory response. Aprotinin at a dose of 4.2 mg/          removal of venous cannula, 5 mg/kg of protamine
kg / min bolus followed by 1.4 mg / kg/ hour as                sulfate was administered to reverse the anticoagulant
infusion was continued till the patient was shifted to         effect of heparin. All patients were weaned off CPB
intensive care unit.                                           with infusions of nitroglycerine (0.5 µg/kg/min) and
                                                               dopamine (5 µg/kg/min), if additional support was
Standard paediatric perfusion protocol was used in             required adrenaline and milrinone were used. TEE was
all the patients with aortic and bicaval cannulation. Before   done immediately after weaning off bypass to assess
CPB, all patients received systemic anticoagulation            the surgical repair. HCT on pump, volume of
                                                               ultrafiltrate, CPB time, Aortic Cross Clamp (ACC) time,
with unfractionated heparin (400 IU/kg) to achieve an
                                                               inotropic support required during weaning, time to
activated clotting time of more than 480 seconds. The
                                                               extubate, complications in ICU, length of ICU and
pump was primed with ringer lactate and 20% albumin,
                                                               hospital stay were also recorded. After shifting to ICU,
which constituted 5% of the priming volume. In
                                                               weaning from the ventilator was started depending on
addition NaHCO3 1.5 cc/kg and heparin were added.
                                                               chest X-ray, Arterial Blood Gas (ABG), and
The haematocrit was maintained around 28% during               hemodynamic stability with no compromise in
CPB.                                                           ventilation during transition from controlled to assist
                                                               mode of ventilation. Patients were extubated when
Non-pulsatile flow of 125 – 150 ml/kg/min was                  they were fully rewarmed, haemodynamically stable
achieved during CPB using a twin roller pump                   with low or no inotropes, without significant
(Stockhert SIII, Sarns 9000). A hollow fibre membrane          arrhythmias, not having significant mediastinal bleeding
oxygenator (Capiox, Minimax, Baby Rx, Polystan) with           and maintaining arterial oxygen saturation with adequate
an arterial line filter, bubble trap and level sensor in the   respiratory efforts.
reservoir were used. Myocardial preservation protocol
included maintaining a moderate systemic hypothermia           STATISTICAL ANALYSIS
(Nasopharyngeal temperature 28 - 32°C),
administration of cold (10°C) antegrade hyperkalemic           To test association between 2 categorical variables chi
cardioplegic solution (David bull) with blood in 1:1           square test was used. Students t-test was applied to find
proportion and topical cooling of the myocardium with          any significant difference between the early (<8 hrs) and
ice slush. The first dose of cardioplegia was 20 ml/kg,        late extubation (>8 hrs) group with respect to all
                                                               continuous variables. One-way analysis of variables
followed by 10 ml/kg every 15-20 minutes. Arterial
                                                               (ANOVA) was used to find if any significant difference
blood gas measurements were performed every 15 –
                                                               in the mean values of the continuous variables between
20 minutes. A stat management was followed to
                                                               the group.
maintain arterial CO2 of 35 – 40 mmHg unadjusted
for temperature and an O 2 partial pressure of
                                                               RESULTS
approximately 150 mmHg.
                                                               The four groups did not differ with respect to weight
Transatrial approach was used in all the cases and             and BSA (Table 1). However homograft patients
transpulmonary in a few cases. Our surgeons prefer to          (Group 4) were older than other surgical patients. CPB
do a transannular patch only if the annulus is small.          and ACC time were statistically significant when
Pericardial monocusp is prepared along the transannular        compared within the surgical groups. ICR + Monocusp
patch only when the native valve is dysplastic, tethered       transannular patch(Group 3) had longer CPB and ACC
and functionless. Since homograft is readily available
at our institution, it is used when there is a hypoplastic

Journal of the Institute of Cardio Vascular Diseases           Factors influencing succesful fast tracking after total intracardiac repair of tetralogy of fallot   23
time compared to ICR + transannular patch
patients(Group 2).                                                                                        Table.4. Causes for hypotension

     Table .1 . Demographic data and on pump details
   VARIABLES       GROUP I             GROUP II         GROUP III         GROUP IV
                      n=14                 n=29             n=6             n=11
                   MEAN± SD            MEAN± SD          MEAN± SD         MEAN± SD
   AGE (yrs)         7.27± 7.18         4.65± 5.36         9.75± 9.37      13.69 ± 9.16

   WEIGHT (kg)       18.2 ±15.65       16.92 ± 23.73     21.84 ± 28.75    23.22 ±14.29
            2                                                                                (PR – Pulmonary Regurgitation, MPA – Main Pulmonary Artery, RV – Right
   BSA (m )          0.72 ±0.41         0.57 ± 0.25        0.67 ± 0.63     0.90 ± 0.35
                                                                                                                            Ventricle)
   CPB (mins)      117.21 ± 45.99      173.24± 43.60     216.5 ± 44.18    252.54 ±79.88

   ACC (mins)        80.5 ±30.74       107.8 ± 22.46     136.83 ± 41.01   144.27 ± 55.24
                                                                                           The duration of ventilation (Fig. 1) in the 4 groups
      (BSA – Body Surface Area , CPB- Cardiopulmonary Bypass duration,
                                                                                           showed that none of the patients in Group 1 was on a
                   ACC – Aortic Cross Clamp Duration)                                      ventilator for > 24 hours.
                                                                                           Patients in Group 1 were extubated early [highest
Group 4 (Homograft repair of RVOT + VSD closure)                                           percentage of 92% (n=13)] while the success rate in
had the longest CPB & ACC time compared with other                                         Group 2, 3 and 4 were 56% (n=17), 50% (n=3) and
groups. Fast tracking was successful in 39 / 60 patients.                                  54.5% (n=6) respectively (Fig.2).

 Table .2.      Comparison between successful fast tracking
                                                                                                            Fig. 1 - Duration of ventilation
                    and failed fast tracking
                 Succesful Fast Tracking          Failed Fast Tracking
VARIABLES          MEAN ± SD (N=39)               MEAN ± SD (N = 21)          P value
AGE (yrs)               7.99 ± 7.49                     6.39 ± 7.98                0.445

WEIGHT (kg)            22.36 ± 23.69                    12.42 ± 11.9               0.077
       2
BSA (m )                0.74 ± 0.38                     0.55 ± 0.32                0.063

CPB (mins)            162.25 ± 65.34                   210.19 ± 64.44              0.009

ACC (mins)            101.05 ± 36.20                   129.57 ± 41.2               0.007

CMV (hrs)                2.50 ± 1.8                    101.8 ± 389.2                 -

ASV (hrs)               3.36 ± 1.37                     8.35 ± 3.86                  -

DICU (days)             1.94 ± 0.45                      7.2 ±7.56                   -

DHOSP (days)             8.2 ± 1.88                    16.57 ± 11.02                 -



    (CMV- Controlled Mode of Ventilation, ASV – Assist Mode of Ventilation
       DICU – Duration of ICU stay, DHOSP – Duration of hospital stay
                                                                                                                 DOV – Duration of ventilation
                      Other abbreviations as in table 1)



Duration of CPB and ACC time, duration of controlled                                                Fig. 2 - Successful vs failed fast tracking
and assist mode of ventilation, duration of ICU and
hospital stay were statistically significant when compared
between successful and failed fast tracking.

 Table.3 . Complications that prevented fast tracking in
                                  all the 4 groups




                                                                                                                 DOV – Duration of ventilation




Journal of the Institute of Cardio Vascular Diseases                                       Number 1, 2007                                                         24
               Fig. 3 - Requirement of inotropes                                  Fig. 5 - Duration of hospital stay




                                                            DISCUSSION
The requirement of inotropes varied among the groups
(Fig. 3). 85.7% (n=12) of patients in Group 1 required     Fast tracking in TOF patients is a team effort.
one inotrope (dopamine), while 69% (n=20) of patients
in Group 2 required 2 inotropes (dopamine +                Surgeon’s role: Surgeons play an important role in
adrenaline). 50% (n=3) and 54.5% (n=6) of patients in      early extubation. Over the past few decades changes in
Group 3 and 4 respectively also recieved intravenous       surgical techniques have facilitated fast tracking. Earlier
inotrops.                                                  surgeons used to repair TOF by transventricular
                                                           approach (or ventriculotomy), which resulted in
The duration of ICU stay is detailed in Fig. 4. In group   increased incidence of ventricular arrhythmias and post
1, 93% (n=13) patients were shifted out of ICU within      operative RV dysfunction20.
48 hours.
                   Fig. 4 - Duration of ICU stay           VSD closure, infundibular resection and pulmonary
                                                           valvotomy can be performed through the right atrium
                                                           without right ventriculotomy and is found to give good
                                                           results6. The concept of aggressively resecting the right
                                                           ventricular outflow tract (infundibulum) is being
                                                           deferred by surgeons. Resection of pulmonary
                                                           infundibular parietoseptal and parietoparietal muscular
                                                           bands destabilizes the muscular cylinder supporting the
                                                           pulmonary valve19. The pulmonary infundibulum is
                                                           required for ejection of blood from RV to pulmonary
                                                           artery and for maintaining the pulmonary valve
                                                           competence. Aggressive resection of infundibulum to
                                                           relieve RVOT obstruction ends up in severe pulmonary
                                                           regurgitation and impaired forward flow of blood
                                                           from RV to PA. Present day surgeons prefer limited
                                                           resection of pulmonary infundibulum and accept the
                                                           minimal obstruction to pulmonary outflow rather than
The duration of hospital stay (Fig.5) was less than 8      causing severe pulmonary regurgitation (PR) in the
days in Group 1 which constituted 85%                      postoperative period causing RV dysfunction, delayed
(n=12)compared to 66% (n=19), 33 %( n=2) and 27%           weaning of the patient from the ventilator and causing
(n=2) in Groups 2, 3 and 4 respectively.

Journal of the Institute of Cardio Vascular Diseases       Factors influencing succesful fast tracking after total intracardiac repair of tetralogy of fallot   25
poor functional class necessitating pulmonary valve            Anaesthetist’s Role: Anaesthetist role is to plan the
replacement later 17, 18. Our surgeons also follow             anaesthetic management from induction to extubation
pulmonary valve preserving techniques like double              for fast tracking. Usage of short acting anaesthetic agents,
patch technique (patch above and below the pulmonary           aprotinin to reduce post operative bleed, time taken
annulus) in patients who have normal annulus or valves         for hemostasis and providing excellent post operative
with long narrow infundibulum and main pulmonary               pain relief are the key factors in fast tracking .
artery (MPA) narrowing21. These techniques help in
preventing PR since the surgeon does not cut across            Perfusionist’s Role: Perfusionists should follow
the annulus and disturb the anatomy of pulmonary valve         proper techniques to reduce fluid retention post CPB.
apparatus. When a transannular patch is required a             20% Albumin, constituting 5% of the priming volume,
smaller patch is used. Anterior incision across the annulus    is added to increase the oncotic pressure and prevent
is preferred since it does not affect the valve anatomy        interstitial fluid sequestration into the lungs. In cyanotics
if the pulmonary valve is vertically bicuspid. If it is        clear prime is preferred to reduce the circulating
transversely bicuspid anterior incision may injure the         haematocrit approximately to 28%. Haematocrit is
anterior leaflet.                                              maintained on pump by diluting the blood with
                                                               crystalloids. In cyanotics hyperoxygenation is avoided.
The institutional preference is to preserve the posterior      Since the cyanotic myocardium has reduced antioxidant
leaflet, which is sufficient to prevent PR. Use of             levels to tackle O 2 free radicles released due to
transannular monocuspid patch is limited since there is        hyperoxygenation, PaO2 on pump is maintained in the
a difference of opinion regarding its beneficial effects22,    normal physiological range27,29. Filter is used to perform
23,24
     . It is said that monocusp helps to tide over the         Conventional Ultra Filtration (CUF) and Modified Ultra
immediate post operative period by moderating the              Filtration (MUF), to remove excess fluid and
PR and later even if the patient develops PR, right            inflammatory mediators.
ventricle will be able to tolerate it better. Monocusp is
used only when leaflets are dysplastic, tethered and           Cold blood cardioplegia is given at 15- 20 min intervals
functionless so that monocusp can help in fast tracking        and care is taken to maintain hypothermia. Before
the patient by moderating the PR.                              releasing the cross clamp warm blood cardioplegia (32°
                                                               C) containing mannitol is perfused through the
Since in our institution there is ready availability of        coronaries. Mannitol is an O2 free radical scavenger and
homograft valves, it is preferred when the patient has a       reduces myocardial edema. Care is taken to rewarm
hypoplastic annulus, pulmonary atresia, absent                 the patient uniformly.
pulmonary valve syndrome and coronary crossing the
RVOT. Myocardial preserving techniques are followed            Intensivist’s Role: All patients after TOF repair are
by giving cardioplegia at 15 - 20 min intervals.               assessed for early extubation. Peritoneal Dialysis (PD)
Anteriorly placed RV is exposed to theatre light and           is done for prophylactic or therapeutic purpose. When
theatre temperature, which results in warming up.              patients have prolonged CPB time, oliguria, positive
Myocardial preservation can be done by covering the            fluid balance or hyperkalemia, PD is done. Cold cycles
RV with ice slush which maintaines the RV hypothermia.         of PD are performed when patient has Junctional
                                                               Ectopic Tacycadia (JET). Care is taken to maintain
Immediately after coming off CPB, TEE is done to               normothermia and provide good postoperative pain
assess the cardiac repair, since any residual cardiac defect   relief facilitating early extubation.
will delay extubation. Weaning the patient will be delayed
if the patient drains postoperatively. Meticulous              All patients were assessed for fast tracking after shifting
haemostasis by the surgeon plays and important role in         to Pediatric Intensive Care Unit (PICU). Fast tracking
fast tracking.                                                 could not be done in 2 patients because of JET,
                                                               necessitating elective ventilation for induction of
                                                               hypothermia by performing cold cycles of peritoneal

Journal of the Institute of Cardio Vascular Diseases           Number 1, 2007                                           26
dialysis. Hypotension was the most common cause for            phosphate and increased lactate accumulation, when
delayed extubation in all the groups. Hypotension in           compared to adults with coronary artery disease making
the postoperative period after TOF repair could be             the TOF myocardium more vulnerable to injury27, 29.
due to many reasons. Moderate to severe pulmonary              They also have decreased and defective antioxidant levels
regurgitation due to extensive resection of pulmonary          predisposing the myocardium to reperfusion injury.
infundibulum can destabilize the pulmonary valve
apparatus and cause free PR and RV dysfunction.                Two syndromes of RV restrictive physiology in patients
Increase in the gradient across the RVOT due to                with Tetralogy of Fallot have been described 27. An
inadequate resection of pulmonary infundibulum can             acute syndrome in the immediate post operative period
also cause low forward flow across the RVOT and                and a late syndrome whose clinical manifestations are
causes hypotension. Extensive MPA, bifurcation and             delayed by years. Although acute RV restriction initially
or patch plasty of pulmonary arteries can also cause           resolves within 14 days, the late RV restriction presumed
hypotension or low output state due to increased               to reflect a stiffer RV that allows less pulmonary
gradient across the pulmonary artery reconstruction site.      regurgitation resulting in a smaller heart improved
Other causes for hypotension are rhythm disturbances           exercise tolerance, and decreased risk of ventricular
(JET), increased postoperative bleeding, and most              arrhythmia. In our study 3 patients developed restrictive
frequently RV dysfunction due to free PR or restrictive        RV dysfunction demonstrated by late antegrade flow
RV physiology. Restrictive RV physiology is a condition        in the pulmonary artery during diastole. All of them
in which the right ventricle is unfillable and is truly        belonged to transannular patch group. Studies have
“restrictive” in diastole. So RV acts as a passive conduit     shown that transannular patch is an independent risk
between the right atrium and pulmonary artery                  factor of restrictive RV physiology following repair of
characterized by antegrade late diastolic flow in              TOF33. Our findings are similar to that observed by
pulmonary artery during atrial systole. It is diagnosed        Gunnar Norgard et al 33 and M. S. Sachdev et al 34.
by pulsed doppler echocardiography by demonstrating            Patients with restrictive physiology in our study had
forward late diastolic flow in the right ventricular           increased and longer requirement of inotropes,
outflow tract coinciding with premature opening of             increased ventilation time and longer ICU stay which
the pulmonary valve during atrial systole 32, 34. It is        were similar to the findings reported by M. S. Sachdev
associated with episodes of low cardiac output, raised         et al34.
central filling pressure, prolonged ventilation and
inotropic support25.                                           One patient in Group 1 had hypotension due to
                                                               moderate pulmonary regurgitation and the other child
The origin of RV restriction is unknown. The right             had junctional ectopic tachycardia (JET) necessitating
ventricle in Tetralogy of Fallot may be inadequately           cold cycles of peritoneal dialysis(PD) to induce
protected due to endomyocardial fibrosis in older              hypothermia. 6 patients belonging to Group 2 had
patients and due to right ventricular hypertrophy which        hypotension due to pulmonary regurgitation in the
is always present in patients with TOF 27 . CPB,               immediate postoperative period preventing fast tracking.
ventriculotomy, myocardial oedema, and the placement           MPA augmentation and branch plasty were the other
of nonfunctional patches on ventricular septum and             causes for hypotension in 4 patients belonging to Group
RVOT influence the diastolic performance. RV                   2. Two patients belonging to Group 2 developed sepsis
myocardial protection is inadequate, since it is exposed       due to gram negative bacteria and both the patients
to room temperature and radiant heat from overhead             had long bypass time due to extensive RVOT
lights28. Maintaining satisfactory hypothermia is difficult,   reconstruction and branch plasty of pulmonary arteries.
and RV hypertrophy as such complicates the                     One patient in this group desaturated due to
homogenous delivery of cardioplegia26, 27, 28. Studies         pneumothorax necessitating reintubation in the PICU.
have shown that children with TOF are predisposed to           Three patients belonging to Group 4 were re-explored
severe myocardial ischaemic injury during cardiac              for increased drainage and was found to have
operations with more rapid decline in high-energy              generalized oozing from the homograft site. One patient

Journal of the Institute of Cardio Vascular Diseases           Factors influencing succesful fast tracking after total intracardiac repair of tetralogy of fallot   27
in Group 3 expired. This patient had supravalvular MPA                4. CA Dietl, AR Torres, ME Cazzaniga and RG Favaloro. Right
                                                                      atrial approach for surgical correction of tetralogy of Fallot. Ann
stenosis and distal RPA stenosis for which extensive
                                                                      Thorac Surg 1989, 47, 546-551.
reconstructive of MPA and RPA was done.
Postoperatively patient was in low cardiac output state               5. Balram Airan, Shiv Kumar Choudhary, Honnakere Venkataiya
and echo revealed turbulence across RPA with a                        Jayanth Kumar, Sachin Talwar, Jayesh Dhareshwar, Rajnish Juneja,
                                                                      Shyam Sunder Kothari, Anita Saxena, Panangipalli Venugopal. Total
significant gradient of 50 mmHg with global depression
                                                                      Transatrial Correction of Tetralogy of Fallot: No Outflow Patch
of ventricular function, RV was dilated and
                                                                      Technique Ann Thorac Surg 2006; 82:1316-1321
noncontractile.
                                                                      6. Frank A. Pigula, Philipe N. Khalil, John E. Mayer, Pedro J. del
We are not aware of any published paper exclusively                   Nido, Richard A. Jonas. Repair of Tetralogy of Fallot in Neonates
addressing the issue of fast tracking in TOF patients. In             and Young Infants. Circulation 1999; 100:II-157
other studies, series of fast tracking was done where
                                                                      7. Marco Pozzi, Dipesh B. Trivedi, Denise Kitchiner, Robert A.
TOF has been considered along with other complicated                  Arnold. Tetralogy of Fallot:what operation, at which age. Eur J
congenital cardiac surgeries and it has been found to be              Cardiothorac Surg 2000; 17:631-636
safe. In conclusion our study shows that fast-tracking
                                                                      8. Charles D. Fraser, E. Dean McKenzie, Denton A. Cooley . Tetralogy
patients after TOF repair is safe and effective. Most of
                                                                      of Fallot: surgical management individualized to the patient .Ann
the patients who underwent simple ICR were extubated                  Thorac Surg 2001; 71:1556-1563
early, while approximately 50% of patients who
underwent right ventricular outflow tract reconstruction              9. Turley K, Tyndall M, Roge C etal. Critical Pathway methodology:
                                                                      effectiveness in congenital cardiac surgery. Ann Thorac Surg 1994;
were fast tracked. In the others haemodynamic
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tracking. This tended to be related to pulmonary                      10. Cheng DCH . Pro: early extubation after cardiac surgery decreases
regurgitation, MPA/branch pulmonary artery plasty and                 intensive care unit stay and cost. J Cardiothorac Vasc Anaesth 1995;
                                                                      9:465-4
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management (careful titration of short acting anaesthetic             11. Carol L. Lake. Fast Tracking in Paediatric Cardiac Anaesthesia:
agents), changes in the surgical techniques (smaller                  An Update. Annals Of Cardiac Anaesthesia 2002; 5:203-208
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                                                                      12. Luca A. Vricella, Joseph A. Dearani, Steven R. Gundry, Anees
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                                                                      J. Razzouk, Stanley D. Brauer, Leonard L. Bailey. Ultra fast track
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ICU and hospital stay.                                                871

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Journal of the Institute of Cardio Vascular Diseases                       Factors influencing succesful fast tracking after total intracardiac repair of tetralogy of fallot   29

				
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