Sunday, June 20, 2010

Dr Kiran welcomes everyone to the new post. The objective of the blog is to develop a meaning dissemination of Pediatric cardiology for everyone with a taste for this phenomenal subject. We learn few interesting facts and discuss few scenarios on practical issues. Before that, let me start with an anecdote. As a part of my interest in medical history, I came across this extraordinary piece of courage and conviction which I felt like sharing. Please go through this and discuss.

Tylenol is the brand name for paracetamol, which is a household name in USA. It is one of the most popular over-the-counter medications and a household name. It was manufactured and marketed by Johnson and Johnson. In contrast to the tablets from of present day, it was available in capsule form 3 decades back.

In 1982, something terrible happened. Eight people who used the Tylenol capsules died. A psychopath claimed that he had put cyanide in some of the capsules. No further information was available as which batches were affected and how many such capsules were likely contaminated.

If you are the boss of a company who has something like 31 million bottles of the drug in the market at that moment with few possible contaminated capsules (claimed and not proven), how would you react?

Random sample testing? Financial assistance to the deceased? Legal battle on proving the non-involvement of the company? Animal testing? Methods to educate the public on ways to find out the non-contamination? Denial? Prove that the deaths are not related to Tylenol? Bribe the officials to get a clean chit? Bury the issue? Some more skeletons in the cabinet? What else?

Mr James Burke, the CEO of J&J at that time was a smart man and a smarter businessman. He could have done anything mentioned above or even more. But what he “did” was amazing.

He opted for full cooperation with the media immediately. He personally appeared on one TV program after another to take responsibility and keep people up to date on the situation. He ordered withdrawal of all the 31 million bottles of Tylenol from the market! He offered to replace the possibly contaminated capsules by Tablets, whose packing was fool-proof. On behalf of the company he accepted responsibility and made it sure to everyone that J&J had not actually done anything wrong, but still is taking the measures for damage control.

It cost J&J a whooping $100 million! More for the replacement in the form of tablets. For the mistake not committed by them.

What J&J gained out of this could not be measured by money. Its way of handling the situation and the decisions taken won applauds from media. "What Johnson & Johnson executives have done is communicate the message that the company is candid, contrite and compassionate, committed to solving the murders and protecting the public," noted the Washington Post.

But what J&J had lost was not just money. It had to recreate the trust. It is not easy when a big thing falls. And Tylenol was the biggest J&J had. It invested heavily in the restoration job. Its share was estimated to be around 37% in the market."It will take time, it will take money, and it will be very difficult; but we consider it a moral imperative, as well as good business, to restore Tylenol to its preeminent position," said James Burke.

It was the responsible handling of the situation that probably saved the day for J&J. It was too big a catastrophe for easy recovery. J&J made it only because its CEO stuck to the ethics, forgetting the money. The Tylenol crisis brought values of J&J into sharp relief. Instead of bringing in a contingency plan, the company carried on by expressing the principles and values. The public could see the transparency of effort, magnitude of the exercise and more importantly, a principled leadership.

Very shortly, public had placed Tylenol on its top position. Its market value enhanced. People could see why they need to trust the brand. Moreover, they were not ready to disown a company which had social responsibility of the magnitude they displayed.

Today, the market share of Tylenol is much larger than what it used to be. Just to end the anecdote, it did not take J&J more than 2 years to recover their financial losses. What they gained out of the display of honesty was priceless.

It takes good principles and strong base of ethics to be a leader. There are bosses so thimble that they cannot even reprimand an undisciplined subordinate! If a problem is brought to their notice, the first thing they do is to demoralize the whistle-blower! They find the whistle-blowers to be a big nuisance. Good or bad, the show must go on with minimal tension for them. Internal nexus with people of cheap morals for ulterior motives by others in the company does not bother them. Honesty need not be honoured; indiscipline need not be punished; cheating someone of their rights need not be corrected – all for own peace of mind. The definition of success in the present day corporate culture depends on how many controversies the leader avoids. After all, avoiding resolving a problem or denying the existence of a problem is much simpler than solving it. Why put your hand into a troublesome beehive when the the affected person is not you?!

Contrasting such scenarios of the present day is what makes James Burke a magnanimous character. He accepted the problem instead of brushing it aside despite his company did not really have anything to do with the actions of a psychopath; the entire thing had happened outside the production and despatch. He instilled a discipline amongst his staff by setting up a crisis management team. He identified the key people who needed to be involved, and limited the number of spokespersons. Most important of all, he took the lead and worked hard in executing the morals. The whistle blowers were honoured. No lazy bum was spared. Profits and losses did not matter in front of ethics. He did not let any internal nexus or outsider encash the situation to their profit. The cash flow would have suffered as the brand was the biggest they had. He accepted it. He sought a lion’s share of trouble by being in the air and media, taking questions, justifying the stand of his company to public and so on. If we can name any one person with maximum loss of sleep and peace in this fiasco, it was the leader, James Burke.

It is just to see what prevails in the end. The loose characters in corporate history who “ruled” with a single objective have perished shortly. It is the people with courage and ethics whose names are remembered today. It is for anyone to choose what they want to be.

Type Tylenol and James Burke in Google. Read the amazing story with many other details when you are free.

With this, let us get back to our regular feature: Interesting leaning scenarios:


We happened to see a child with a double orifice tricuspid valve. I do not remember to have seen this before. This particular child had one orifice communicating with RV and the other with LV! A large VSD was associated. An ASD had decompressed the RA, so the flow gradient was not found across the TV orifices. Overall, the hemodynamic effects of the lesion were effaced due to coexisting lesions. If such a lesion is seen by you earlier, please let us know how it was and how it behaved.


We often come across such situations. We had a 7-month-old first timer who presented with a large PDA. The operability was unclear in the clinical evaluation and echo. On cath, the pulmonary and systemic pressures were identical and Qp/Qs was 0.9:1. Calculated PVRI was 7.3. Is the condition due to failure of primary pressures to fall or rapid development of PVRI? Both possibilities will have opposite ends of management. Should we do something or leave? Would a trial of sildenafil help? Someone suggested a partial ligation of PDA. It will control the Qp in former case if the primary pressures drop. Otherwise, it will act as a pop-off and help the overall survival. It sounded practical, but is it accepted? Please let me know your experiences of handling such situations.


Few children come with diastolic challenges. The picture remains unclear even with the last investigation we can think of. One such had come to us one year back with left ventricular failure. She had a subaortic membrane with moderate gradient across LVOT. Medical management did not get along. She was operated on and the membrane was resected. With a ferocious post-operative battle by team of our intensivists, she could be discharged. She did not come back for follow up for one year and recently, returned with biventricular failure. There was no subaortic membrane this time, but the LVOT gradient was severe. Being refractive to medical therapy, we catheterized her to get a better delineation of anatomy. The EDPs were very high (30-45 mmHg). Her LVOT gradient was 70 mmHg. We projected a high risk and asked surgical team to take a call. They wanted to go in and take the risk of “act of commission”. However, she could not take make it to OT; died a day prior to proposed surgery. The scenario was depressing. We wanted to get a pathological and histochemical diagnosis, but the family was not for it. If such scenarios are seen earlier, please enlighten us on the possible lines of management.


It is difficult to take a stand in some of the situations. We had a 22-year-old with TOF and diminutive RPA. About 9 years back, he had undergone a BTT shunt. He came back now with history of exercise intolerance and increasing cyanosis. We could not see the BTT shunt on echo. We expected the shunt to have got blocked. On cath, we found a different scene. The RPA had grown a little to about 6 mm. The LPA was big. The left lung had received a good quantity of blood from BTT shunt for the past 9 years and had become hypertensive. The PVRI of left lung was very high. This had lead to the tardiness of BTT shunt. Management was the issue now. Doing nothing Vs doing another palliation. Since the patient was symptomatic, some felt that another shunt should be created to RPA. However, the risk of another procedure, high risk palliation, proposed benefit and other factors took precedence and the patient was decided on medical management. What is the opinion of readership? How would you go about in such cases?


An interesting discussion happened between two of the senior consultants of our team recently. The cardiologist quoted a “big man from the west” of having avoided transannular patching in Tetralogies. The statistics and the outcome presented in the data were impressive. However, our surgeon was not impressed. He quoted the anatomical variations of the Hispanic populations versus oriental populations. He said that the Asian anatomy demands transannular patching where as the western may not. These statements open up the possibility for epidemiological research. If anyone knows any further data on this, please let us know.


31. In CCTGA, Complete heart block may be as high as 10% at initial presentation and the incidence is cumulative as the age progresses (Bharati S, McCue CM, Tingelstad JB, et al. American Journal of Cardiology 1978 page147)

32. Although the incidence of congenital bicuspid aortic valve is as high as 1.3 to 2% of general population, only 2% of patients with congenitally abnormal aortic valve will experience significant stenosis or regurgitation by adolescence (Bonowro, Carabello B, de Leon AC Jr, et al Journal of American College of Cardiology 1998 page148)

33. Although anterior leaflet of the mitral valve appears to be bigger, it is not so. The posterior mitral leaflet is longer at its base and shorter in its basal-to-apical length than the anterior leaflet. Hence, both the leaflets have approximately the same area (Ranganathan M, Lam JHC, Wigle ED, et al. Circulation journal 1970 page 459)

34. In the mitral valve, congenital cleft is directed anteriorly toward the outflow septum or aortic root in contrast to the cleft in atrioventricular septal defect, which is directed towards the interventricular septum (Smallhorn J, de Leval M, Stark J, et al. British Heart Journal 1982 page 109)

35. A correlation has been found between the anatomy of mitral valve and the central nervous system, more in the behavioural aspects. The subendocardial surface on the atrial aspect of the middle portion of the mitral valve is rich in nerve endings, including afferent nerves; mechanical stimuli from this area caused by abnormal mitral valve coaptation may cause abnormal autonomic nerve feedback between the central nervous system and mitral valve nervous system. Floppy Mitral Valve innervation patterns with distinct nerve terminals provide a neural basis for brain - heart interactions, augmented by mechanical stimuli from the prolapsing Floppy Mitral Valve (Boudoulas H, Schaal SF, Wooley CF. Floppy mitral valve/mitral valve prolapse: Cardiac arrhythmias. In: Vardas PE, ed. Cardiac Arrhythmias, Pacing, and Electrophysiology. London: Kluwer Academic Publishers, 1998: page 95)

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