Name : Ahmad Naqib Naqiuddin Bin Ahmad Kamil
MRN : 167747
IC : 040922140269
Date of Birth : 22/09/2004
Admission Date : 28/11/2004
Discharge Date: 07/01/2005
Consultant : Dr. Haifa Abdul Latif / Mr. Hamdan Leman
Principal Diagnosis : Simple transposition of great arteries with involuted right ventricle. Status post balloon atrial septostomy (23/9/2004).
Secondary Diagnosis: Pre-existing conditions or complications that arose which required treatment during this hospitalisation:
Principal Operation(s) and or Procedure(s) :
1). Right Blalock-Taussig Shunt and pulmonary artery banding for left ventricular retraining were done on 3rd December 2004 by Mr. Hamdan’s team. Findings: Left ventricle involuted.
- Left ventricle pressure 20/16. Left ventricle / aorta < 0.7.
- Right ventricle 80/40..
- D-transposition of great arteries..
- Aorta anterior to the right of pulmonary artery.
- Pulmonary artery : aorta =2:1.
- Single coronary artery.
- Post pulmonary artery banding and right Blalock-Taussig Shunt:
- Oxygen saturation 67% on Fi02 100%.
- Left ventricle 60/20. Aorta 80/38.
2). Arterial switch operation and pulmonary artery debanding were done on 17th December 2004 by Mr. Hamdan’s team.
- D-transposition of great arteries. Aorta anterior to pulmonary artery (30% anterior to the right).
- Pericardial adhesion.
- Right Blalock-Taussig Shunt functioning. Pulmonary artery banding in-situ. Patent ductus arteriosus small and patent.
- Coronaries 1 – LR 2Cx.
3). Delayed sternal closure was done on 18th December 2004 by Mr. Hamdan’s team.
Brief Hospital Course:
A). Post pulmonary artery banding and Blalock-Taussig Shunt.
1). Blocked shunt.
– About 2 hours postop, he was noted to desaturated to 40%.
– Urgent echocardiography revealed :
- No pericardial effusion.
- Tachycardic heart.
- Poor left ventricular function LVEF = 32%.
- Pulmonary artery band pressure gradient 39mm Hg.
- Right Blalock-Taussig Shunt not seen.
– So heparin infusion lOunits/kg/hour was commenced immediately.
– Following that oxygen saturation gradually improved.
– About 7 hours later shunt murmur could be heard and his oxygen saturation maintain > 75%.
– Repeat echocardiography reveal Blalock-Taussig Shunt flow seen but minimal.
– Serial CXR done since post operative day 4 showed pneumonic changes.
– Initially he was treated with IV Rocephine and IV Amikacin.
– However as he still having low grade fever after 6 days of these antibiotics, he was started on IV Imipenam.
– All cultures were negative.
3). Ventilator dependent.
– On post operative day 5, he persistently had lowish oxygen saturation despite on high ventilatortings.
– So nitric oxide ventilation was commenced immediately.
– Following that his oxygen saturation improved.
– So his nitric oxide ventilation was gradually wean down and managed to off after 6 days.
– However he required quite high ventilatortings and had difficulty in weaning down histing.
– Discussion was done in the cardiothoracic – paediatric cardiology meeting and decided
to proceed with arterial switch and pulmonary artery debanding.
B). Post arterial switch operation:
1). Pulmonary hypertension.
– Immediately postop, he was noted to have high pulmonary artery pressure that is about 1/2 systemic.
– So nitric oxide ventilation and primacor infusion were commenced immediately.
– Following that his pulmonary artery pressure gradually decreased to 1/3 systemic.
– So his nitric oxide ventilation and primacor infusion were gradually wean down and was off by post operative day 3 and post operative day 6 respectively.
2). Renal impairment.
– Few hours postop, he was noted to have decreased urine output and his body became oedematous.
– So peritoneal dialysis was inserted and lasix infusion were commenced immediately.
– Following that he had good urine output.
– His peritoneal dialysis and lasix infusion were discontinued by post operative day 3.
3). Wound infection.
– On post operative day 6, his wound was noted to be infected.
– Wound swab C&S : no growth.
– Treated with IV Vancomycin and IV Amikacin for 10 days.
4). Presumed sepsis.
– On post operative day 12 he was noted to have thrombocytosis and leucocytosis.
– Treated with IV Imipenam for 1 week.
– Blood C&S : no growth.
5). Chronic lung disease.
– His serial CXR since post operative day 6 shows chronic lung changes.
– Had failed trial of extubation twice.
– Finally managed to extubate him by post operative day 10.
– He was given IV Dexamethasone according to BPD regime and was put on Budesonide MDI and combivent MDI.
Condition of Patient upon Discharge :
Pink with oxygen saturation > 95% on air.
Lungs : clear.
Cardiovascular system: Ejection systolic murmur at left sternal edge 3/6.
– No pericardial effusion / pleural effusion.
– Both diaphragm moving well.
– Normal chambers size.
– Good left ventricular function ejection fraction 70%.
– No mitral regurgitation / tricuspid regurgitation.
– Mild pulmonary regurgitation pressure gradient 11mm Hg ( normal pulmonary artery pressure ).
– Proximal right pulmonary artery / left pulmonary artery well seen and no obstruction.
– Small patent foramen ovale with left to right shunt.
* Pleural and pericardia! effusion are common complications following cardiac surgery. They should be suspected if the patient presents with cardio-respiratory symptoms.
Syr. Lasix – 5mg tds
Syr. Captopril – 3mg bd
Syr. Aldactone – 6.25mg bd
Syr. Viagra – 2mg 6 hourly
Budesonide MDI – 400mcg bd
Combivent MDI – 200mcg 6 hourly
Follow up care (Clinic Visit) :
To come again 6 weeks for review ( 22/2/2005 @ 11.00am) – Cardiothoracic doctor .
To come again 3 months for review (13/4/2005 @ 10.00am) – Paediatric cardiology doctor.
Referring Doctor :
Prof. Madya Dr. Bilkis Abd. Aziz
Pakar Perunding Kardiologi Kanak-Kanak Address :
Hospital Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
Senior Registrar / Medical Officer : Dr. Rozaina Hj Md Said, Senior Medical Officer
Department of Pedriatic Cardiology,
Institut Jantung Negara Sdn Bhd,
Date : 7th January 2005