Sunday, May 9, 2010

Hello all. This is Dr Kiran, welcoming you to the present session of blog. We were in the process of learning greater meaning of few anecdotes. The present anecdote was picked up from a newspaper article. Please go through.

Mr Iyer was a busy man. He worked for a MNC. Clock and calendars did not have any role in his life. He would often work for days together without coming home. He was known for his rigid stands, no-nonsense approach and upright decisions. When some lesser mortals made the mistake of asking about his salary, he would reply, “Rs.1000 per hour” to prevent them from talking any further.

Mr Iyer had a relatively big test the next day. He was supposed to give a business presentation to one of the global biggies. True to his meticulous self, he had done everything to perfection. He wanted to make sure that the things are alright. He took the previous day off and stayed home to fine-tune his presentation.

Mr Iyer’s son was a bubbly 5-year-old. People described him of having inherited his father’s intelligence. The son was elated to see his dad home that day and refused to go to school.

Mr Iyer did not heed much importance to this issue. He wanted peace of mind. He thought that losing his temper on anything may affect his performance the next day. He just let his son stay back.

The scene was not as simple as Mr Iyer thought. His son came down to the dad every two minutes and kept talking to him. Mr Iyer tried his best to calm himself, but his son was too insisting.

“Don’t you see that I am working on a presentation? This is important. Tell me what you want and let go of me” he tried to negotiate from his son.

The son was shocked for a while. He left the room, but returned 5 minutes later. “Dad”, he cried. “Can I have Rs 100/- from you please?”

On other times, Mr Iyer would have asked for reason, but this day was unlike that. He brought out his wallet and threw a Rs 100/- bill on his son. “Take this and leave” he demanded.

The boy picked up the cash from the floor and left. He returned in next five minutes. “Dad”, he said softly this time.

Mr Iyer’s temper was rising. He was getting annoyed. He grinded his teeth and asked in a stern voice, “What now?” “Please see” the son demanded.

Mr Iyer decided that unless some force is applied, this disturbance would persist. He got up from his chair and was about to thrash his son, when he noticed the clutched fist of his son held towards him.

“What is in your hand?” Mr Iyer asked angrily.

His son slowly unclenched his fist. There were few notes of various designations in the hand.

Mr Iyer was perplexed. “What are you doing? What do you want?” he asked in the same tone of annoyance.

“I opened my piggy bank. It had Rs 400/- I have taken Rs 100/- from you.”

“So?” the tone of Mr Iyer was mellowing down.

“I have heard you telling many uncles that you earn Rs 1000/- per hour.”

Mr Iyer was silent this time. His son continued.

“I have Rs 500/- with me. Can you please take this and play with me for half an hour?”

Mr Iyer went back to his laptop and shut it down. He played and spent time with his son the rest of the day. Mr Iyer was so much pleased with himself that his presentation the next day was applauded by everyone as the best he had done till then.

Very often, we do not understand the value small things. What we perceive as a small issue may really be a big one for the others. Our few minutes may be what the opposite person desperately needs. It is true with our family members and patients too. Often, big-wigs of the hospitals find it futile to find any time for their subordinates and patient attendants. I have seen busy practitioners starting their day around 5 pm and going home back by midnight. They are proud of their time management skills and claim that they stretch a couple of hours sleep in their cars during the travel. Few also say that their kids would not have woken up when they leave the house and would have slept well by the time they reach home. One of our consultants was very angry that he had to apply leave for a day to attend his son’s school day, as the boy was insisting on it a lot. It is very common in medical profession to have such scenarios. What majority does usually become a rule and makes an easy way others to follow. Doctors who try to defy the rule are termed “lazy”, “useless”, “waste body” and so on. It may be prudent to understand what the time management actually stands for before deciding on to invest on it. This small anecdote can open up lot of these issues pertinent to each of us in its own way.

With this, let us go back to the interesting learning scenarios of this post.

PROBLEM WITH WINDOWS

We had a situation which took lot of cerebral exercise. This 11-year-old boy had undergone closure of AP Window and PDA few years back. He came back to us with exertional dyspneoa. On echo, we reported him as possible residual PDA as suggested by the location of jet. However, on cath study, the outcome was a residual AP window. The data showed operability on oxygen study. During the cath meeting, our senior surgeon had a different opinion. He felt that the cause of this residual APW after these many years might be due to high PVRI per se and the residual opening is actually a pop-off. In his opinion, such lesions should be left alone if the symptoms are not much pressing. But the data we had did not suggest the same. Hence, we tried to attempt device closure of the lesion. We initially tried a VSD device, but it slipped. After few days, we tried a PDA device unsuccessfully. Now, we may not attempt the non-surgical ways anymore. What is the opinion of the readership on this? We shall keep you informed on the progress of this boy. Let me know your ideas on this issue.

PULMONARY CONTRIBUTION

We often see Qp/Qs in cath studies that are too high to believe. Yet, the pressure from dilated pulmonary arteries on the bronchi is not too high to compress the respiratory tract. We had a 8-month-old blue boy with large ASD shunting bidirectional and multiple muscular VSDs shunting right to left. The CHD lesions could not explain the clinical scenario. We found reduced air entry on the left lung. The chest radiograph showed collapsed left lung. The cardiac CT showed a completely collapsed left bronchus with collapsed left lung and a dilated left pulmonary artery adjacent to the bronchus. How to chronalize the cause-effect relationship? The surgical team felt that the dilated PA must have compressed the Left bronchus and the resultant lung collapse must have contributed to the PVRI causing right to left shunt. But, haven’t we seen ample number of large ASDs? How many times do we recall such a picture happening? Our logic was different. There might be an inherent defect in the left bronchus, which might have collapsed early due to added pressure by the LPA. Who is correct? We asked for pediatric surgical opinion for which a bronchoscopy for learning about the status of left bronchus. But the bronchoscopy was not much helpful. We were not clear on how to proceed. I hope the readership can also participate in this cerebral exercise for a while and come out with their suggestion.

BALLOON DECISIONS

How far is the balloon occlusion helpful in decision making of PDA operability? The technique or the interpretation does not seem to be standardized. We had an adult lady with a decent PDA shunting left to right. The balloon occlusion data was not helpful either way. We still went ahead with the device closure based on clinical and echo data. It turned out to be successful. The patient went home well. If we had gone by the cath data alone, we probably would have not touched the patient. Taking the entire picture, the cath data on balloon occlusion was invalid. Can the readership inform any published data on the proper balloon occlusion technique and interpretation? Please let me know.

TRACING THE PROBLEM

It was a nice question which we never had thought prior. The LV and RV tracings in the cath are very characteristic and reproducible. What causes the difference in the morphology of the tracing pattern? The question came up when one of the students put up this question in an e-class. “What does the LV tracing look like in a TGA?” Logical answer may be “like an RV tracing”. But, what is the correct answer? Please let me know the answer with references.

DISGUISING AS TAPVC

We had a 2-month-old who came to us with an echo report from outside as TAPVC. On the echo, we were surprised with the left to right shunting across the ASD. The left atrium looked very small with a normal mitral valve. The pulmonary veins were seen draining into the left atrium. Why was the LA small? On a close look, we found a bleak line within the presumed LA outside which no colour percolated. We decided that the echo free space is likely to be a cyst. Cardiac CT defined the mass to be cystic. On the surgical table, the cystic lesion was confirmed. There was no TAPVC. The smallish LA was secondary to an external compression by a cystic mass. It was only because of a machine with good resolution that we could pick up the diagnosis. I wonder what I could have done with a suboptimal machine that I am usually handed with at peripheral centres! If the readership has come across any similar events, please let us know.

PEDIATRIC CARDIOLOGY PEARLS:

11. The embrtological sequence of atrial septation is one of the most interesting understandings for both students and examiners. This hypothesis has been successful in explaining the abnormalities of atrial sepatations. This sequence of events was explained for the first time by van Mierop in 1976. Even today, we follow the same with few minor modifications. (Van Mierop LHS. In: Feldt RH, McGoon DC, Ongley PA, et al., eds. Atrioventricular Canal Defects. WB Saunders publications, 1976: page 12)

12. Children with Down syndrome are more likely to have complete AVSD than children without Down syndrome. They are also more likely to have associated tetralogy of Fallot (Vet TW, Ottenkamp. J in American Journal of Diseases in Children 1989, page 1362)

13. VSD happens to have most variants of classification. The most accepted version was published by Soto et al in 1980. In this classification, the ventricular septum is considered to have four components: An inlet septum separating the mitral and tricuspid valves; a trabecular septum, which extends from the attachments of the tricuspid leaflets outward to the apex and upward to the crista supraventricularis; the smooth-walled outlet or infundibular septum, which extends from the crista to the pulmonary valve; and the membranous septum, which is relatively small and is usually divided into two parts by the septal leaflet of the tricuspid valve. Each zone has defects going by their generic name. (Soto B, Becker AE, Moulaert AJ, et al, British Heart Journal 1980, page 33)

14. The incidence of PDA is about 30 times greater at high altitude (4,500 to 5,000 m) than at sea level (Alzamora-Castro V, Battilana G, Abugattas R, et al. American Journal of Cardiology 1960, page 761)

15. In Tetralogy of Fallot, about 40% of patients have an abnormally long, large conus artery from the right coronary artery that supplies a significant mass of myocardium. In 4% to 5%, the left anterior descending coronary artery arises from the right coronary artery and passes across the right ventricular outflow tract (RVOT). The resultant abnormal anatomy leads to compromises for surgical repair in the region of RVOT and pulmonary annulus. Hence, if the echo does not pick up the anomaly, one needs cath for proper surgical planning. (Fellows KE, Freed MD, Keane JF, et al. Circulation journal 1975, page 561)

With this, the present post ends. Please mail your suggestions and feedback to drkiranvs@gmail.com or use the comments section. I am planning to add few more things to the new segment. Please ask your general pediatric friends about the blog and get their feedback on what would their need be.

Regards

Kiran

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