Tuesday, May 31, 2011

Dr Kiran welcomes you to the present post of blog.

As usual, I did not receive any comments for the last post. But I have heard that many people do read and follow the blog. Just that they are as lazy as I am when it comes to writing!

Without much ado, let us carry on with the interesting learning scenarios:

SMOOTH FLOW PALLIATION?

We had a 6-year-old with congenitally corrected transposition of great arteries, with small VSD (non-routable) and severe subvalvar and valvar PS. The LV was suprasystemic and TR was moderate. Neither double switch nor Senning-Rastelli were possible. The surgeons were not happy with the tricuspid valve and ruled that the conventional repair (RA to LV to PA and LA to RV to Ao) by pulmonary valve repair was inadequate unless the TV was also intervened. However, their scepticism was, “what if the TV is not repairable?” The child was too young for TV replacement. We argued that the pulmonic valve repair alone should bring down the LV pressures and improve the LV geometry. This would take away the Bernheim-reverse Bernheim effect and would improve the RV geometry in return, thereby reducing the TR. I felt this intervention would be better than leaving a suprasystemic chamber for follow up. But, this logic did not please the surgical team and they ruled out any such improvement. Although it sounds theoretical, I could see practical point in it. How would the readers like to decide? Please let me know the folly in this logic!

INSIDE THE HEART OF FONTAN

Once a single ventricle goes into the Fontan correction, we usually feel that the woes for patients lie outside the heart. We had a 12-year-old with Fontan completion done 5 years back. This child came with a new cardiac murmur, not documented in the previous records. On echo, we found a significant subaortic obstruction! I had not come across this earlier. This actually poses a new issue for the patient. Since the obstruction was moderate, the surgical team suggested close follow up. If this becomes severe, what would be the plan? Is going inside the Fontanised heart simple? How frequent are such complaints? Our experience with Fontan is not huge. Can anyone with more experience help us in this?

MONOCUSP

We had some heated debates and discussions on the utility of monocusp valve in intracardiac repairs of tetralogy? Few argued for long-term benefits and few for short-term. Surgeons discussed the risk-benefit ratio of monocusp valve. However, at the end of all these, no one was ready to change their views and opinions. That left most of the simple audience with more confusion and no conclusion. Can the readers put up their opinions in this issue and get us better understanding?

FONTAN WITH HEART BLOCK

Sinus rhythm is one of the Choussat’s criteria for Fontan completion. We had a 9-year-old boy with BD Glenn shunt done outside 5 years back. He had NYHA class III symptoms. During OPD evaluation, he had an ECG which documented sinus rhythm. He was catheterised and the pressures were OK for Fontan completion. However, in the ward, we documented slow heart rate and Holter monitoring showed intermittent A-V dissociation. Surgeons opined that the Fontan completion is still possible with DDD pacemaker insertion simultaneously. This was news to us. Is it done? Is it acceptable? Please let us know about your opinion and experience.

STUBBORN PA

We had a 6-year-old who had undergone a PA banding for multiple VSDs at an outside hospital few years back. The same hospital did a PA de-banding and closed a large upper muscular VSD at the same setting about one year back. When this child came to us, we were surprised to find few sizeable VSDs and a significant gradient across the MPA segment. The operative notes at outside hospital had clearly stated PA de-banding. But, our echo could still pick up a constricted segment in the MPA prior to bifurcation. On cath, we found this narrow segment, which had cicatrised and did not re-open following de-banding. As for the residual VSDs, our expert surgical team was confident that all of them can be dealt with. Hence, we decided for a resection of cicatrised MPA segment and closure of VSDs. How common is this cicatrisation at PA band level? Although we perform good number of PA bands, we at NH had never witnessed this complication. Are such lesions innate to few patients or is it widely seen? Please let us know your experiences on this.

It is time to congratulate Dr Shwetha Nathani, our fellow for the last two years for having successfully completing the Fellowship FNB exam in Pediatric Cardiology. All the good luck for her bright future.
It is time to mourn another departure. Our beloved echo technician, Mrs. Harini is moving to Chennai city for good. We all miss her expertise and keen acumen. Good luck wherever you go.

Pen in your criticisms at comments box or to drkiranvs@gmail.com Shall get back shortly.

Regards

Kiran

3 comments:

  1. With regards to Fontan and heart block. Yes Fontan with DDD is carried out. As you know the original criteria are being continually challenged around the world with smaller PAs being accepted and AV valves being repaired. It will have to be an epicardial system due to lack of endocardial lead access to the heart with Fontanisation.I have seen patients in junctional rhythm post Fontan with exercise intolerance in whom insertion of epicardial DDD pacemaker has been carried out with symptom improvement.

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  2. That was Dr Sangeeta, our new consultant of Pediatric Cardiology, NH group of hospitals.

    Thanks for that info, Dr Sangeeta.
    Theoretically, I agree with that concept. Sounds logical too. But, we in India are still at the learning curve when it comes to DDD with Fontan, largely due to enormous cost involved in this combo.

    It would be good experience to follow up this kid for future challenges!

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