• Cardiology Clinical Trials
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Significant progress has been made in the area of congenital cardiac surgery in the Caribbean. In 1999, the Dominican Heart Program was established with the development of a congenital cardiac surgery unit within the Centro de Diagnóstico y de Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT) in Santo Domingo, Dominican Republic. Freddy Madera, MD, described recent successes and challenges that have been involved with the surgical treatment of tetralogy of Fallot (TOF) at CEDIMAT, based on the review of retrospective case series (n=44 patients). TOF accounts for ∼10% of cardiac congenital abnormalities and performance of corrective procedures for TOF are rapidly increasing in the Dominican Republic.

Dr. Madera and colleagues evaluated postoperative outcomes, risk factors, surgical techniques, and treatment approaches, based on TOF cases at CEDIMAT between January 2007 and April 2009. Most of the study population (70%) was quite ill with moderate to severe TOF. Forty-eight percent of patients were aged 6 to 10 years. Preoperatively, patients tended to have poor oxygen saturation levels (52% had <75% oxygen saturation) and a history of hypoxic crisis (59%). Preoperative hemoglobin levels were >18 g/dL in 52% of patients (n=23). Transesophageal echocardiogram (TEE) was performed on each patient pre- and postoperatively.

The surgical techniques that were utilized were total correction (84% of patients), conduit (11.5%), and Blalock-Taussig (BT) shunt (4.5%). Transannular patch was necessary in 45% of the cases, and cardiopulmonary bypass was utilized for >2 hours in 51% of the cases. Postoperative complications included right ventricular diastolic dysfunction in 30% (n=12), pleural effusion in 18% (n=7), severe bleeding in 8% (n=3), and dysrhythmia in 5% (n=2). Three patients (8%) required reintervention (1 due to patch dehiscence and 2 due to BT shunt obstruction). Postsurgical TEE revealed residual ventricular septal defect in 19% of patients, pulmonary insufficiency in 12% of patients, and right ventricular pressure of >50% in 7% of patients. Patients with these echocardiographic findings did not have clinical or hemodynamic repercussion and did not require additional interventions.

None of the patients who underwent total repair died perioperatively. Overall, perioperative and long-term mortality rates were quite low. One patient who received a BT shunt died within 30 days of treatment. However, this may be reflective of the patient's complex anatomy and the severity of disease. One death was reported >30 days postsurgical treatment. Total repair of TOF at CEDIMAT was associated with low morbidity and mortality rates, and it appears to be a reasonable therapeutic strategy for TOF. More follow-up is needed to establish long-term treatment outcomes and to determine the risk that is associated with complications, such as right ventricular dilatation and severe rhythm disturbances. Findings from this review are promising and demonstrate that TOF strategies that are currently being utilized in the Dominican Republic confer low mortality risk.

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