Junctional ectopic tachycardia following repair of congenital heart defects - experience in multimodal management from a West African Centre

Background: Postoperative junctional ectopic tachycardia (JET) is a rare and transient phenomenon occurring after repair of congenital heart defects. Report on this arrhythmia in the subregion is rare. We set out to determine the incidence of this arrhythmia and review the treatment and outcomes of treatment in our centre. Methods: Retrospective search of the records of all patients aged 18 years and below admitted into the intensive care unit (ICU) following repair or palliation of a congenital heart defect over 5 years, from January 1, 2006 to December 31, 2010. A review of clinical notes, operative records, anaesthetic charts, cardiopulmonary bypass (CPB) records, nursing observation charts, electrocardiograms (ECGs) and out-patient follow-up records was undertaken. Results: 510 children under 18 years were enlisted. 7 cases of postoperative JET were recorded, (1.37%). 184 (36.1%) of these were performed under CPB. All JET cases were from cases done under CPB, 3.8%. Median age was 3 years and median weight 11.3kg. No patient was febrile at diagnosis. 4 patients had amiodarone administration, 5 had magnesium sulphate infusion, 2 patients had direct current shock (DCS) whilst 3 patients had all three therapeutic modalities. All patients had control of the arrhythmia with conversion to sinus rhythm and no recurrence. Conclusion: We report a JET incidence of 1.37% among children undergoing CPB for repair of congenital heart defects. We demonstrate the therapeutic effectiveness of amiodarone, magnesium sulphate infusions and DCS alone or in combination in the management of JET on various substrates with good outcome. Pan African Medical Journal 2012; 12:1

Bilateral tension pneumothorax resulting from a bicycle-to-bicycle collision

Bilateral tension pneumothorax occurring as a result of recreational activity is exceedingly rare. A 10-year-old boy with no previous respiratory symptoms was involved in a bicycle-to-bicycle collision during play. He was the only one hurt. A few hours later, he was rushed to the general casualty unit of the emergency department of our institution with respiratory distress, diminished bilateral chest excursions and diminished breath sounds. The correct diagnosis was made after a chest radiograph was obtained in the course of resuscitation at the casualty unit. Pleural space needle decompression was suggestive of tension only on the right. Bilateral tube thoracostomies provided effective relief. He was discharged from hospital after a week in excellent health. This case illustrates the need for children to have safety instruction to reduce the risks of recreational bicycling. Chest radiography may be needed to establish the diagnosis of bilateral tension pneumothorax. Needle thoracostomy decompression is not always effective

Freedom from thromboembolism despite prolonged inadequate anticoagulation

Life-long and meticulous control of anticoagulation is mandatory following mechanical valve replacement to prevent thromboembolism. Two patients who underwent mechanical mitral valve replacement with third generation bi-leaflet valves and in whom therapeutic anticoagulation could not be achieved for many months postoperatively form the basis for this report. In the first patient, the target international normalised ratio (INR) of 2.5–3.5 could not be achieved until 53.5 months postoperatively despite good compliance with oral anticoagulation and INR monitoring. In the second patient, the target INR was achieved after 16.9 months of oral anticoagulation treatment and regular INR monitoring. No thromboembolism occurred in either patient; nor did any valve-related event occur. The two patients are in excellent physical health 8 and 5 years, respectively, after the procedure. This unusual phenomenon is reviewed in light of the few reported cases of patients with mechanical heart valves surviving for prolonged periods without anticoagulation