Tuesday, December 10, 2013

Dr Kiran welcomes all once more.This time, it is very brief!

One of the finest articles I came across recently in the field of pediatric cardiology was published in the October issue of International Journal of Cardiology by  Dr Rajiv Chaturvedi and colleagues from The Hospital for Sick Children and Fetal Medicine Unit of Mount Sinai Hospital, University of Toronto, Canada. The article is titled "Fetal stenting of the atrial septum: Technique and initial results in cardiac lesions with left atrial hypertension". The authors have reported their initial experience with percutaneous ultrasound-guided stenting of the fetal atrial septum to decompress the left atrium. It provides a fantastic view into what future holds for our specialty.

I had requested permission from the main author, Dr Rajiv Chaturvedi, to elaborate upon this article in our blog for our readership. However, our readers have hit upon much better deal!

Dr Chaturvedi was very kind in allowing our readership to access the article totally free of cost till 31st January 2014. (Please note that the article would cost $39.95 after that date)

Anyone interested can use the following link to access the article: http://elsarticle.com/18AAV6v

Please let me know your opinions on this article. Please write your comments. If you find any problem in posting comments, please feel free to mail it to my email id kiran.vs.dr@nhhospitals.org I shall post them on your behalf and will put it across to the author also.



Wednesday, December 4, 2013

Dr Kiran welcomes everyone back to the blog of Pediatric cardiology department of Narayana Hrudayalaya.

I am not clearly aware of copyright issues; hence this question. Can I review an article from a medical journal in the blog? Do I require permission from the authors? I emailed one author who, I felt, had written an interesting article in a journal, but I did not receive any reply. I felt that the temptation of discussing journal articles should be with-held until this question is sorted.

Let us see some interesting learning scenarios for the post:


What are the different ways of closing multiple VSDs, especially those at the apex? The conventional approach was ventriculotomy after clear understanding of the location of VSDs. Right Vs Left ventriculotomies found their pros and cons. Device closure cam e next. Hybrid device closures followed. Unconventional device closures with one surface buttressed against the ventricular wall was tried. Newer methodologies always appear from people who keep the spark alive to think outside the “ventricle”! One of the methods we recently understood was described by Brizard et al in which the defects were located with epicardial echocardiography, then transfixed with a guide wire inserted directly through the right ventricular free wall. They were closed with a custom-made multilayered double-patch device under cardioplegic arrest through a standard right atriotomy. This appears to be a wonderful technique and the double patch is likely to stick to IVS due to higher LV pressures! The original series of the authors had 14 patients. Has anybody tries this? Please share your experiences and any other novel technique that you have come across.


How useful is cath data in cases of ASD with partially anomalous pulmonary venous drainage (PAPVD)? Irrespective of PVRI, the pulmonary venous return would carry better oxygenated blood. So, in PAPVDs, the RA step up would be invariably high. The same blood goes into PA. The Qp calculation is skewed; thereby the PVRI calculation is skewed! Neither Qp/Qs nor absolute PVRI nor PVRI/SVRI ratio is going to determine the operability. The only advantage of cath study would be measurement of PA pressures by direct entry into PA. Many purists are against RV injection of PA entry in cases of severe PAH. Apart from clinical grounds, chest radiography and echocardiography, is the any objective method for determining operability in such scenarios? Please share your views.


How far one should go when a palliative surgical procedure is performed? Different surgeons have different views on this issue. There are surgeons who are aggressive towards palliation and there are few who are no aggressive even for high risk corrective procedure. There is no “right” or “wrong” here. The decision making is largely experience based and idiosyncratic. But, is there any policy by the institution for a collective opinion anywhere? How do the individual centres tackle these scenarios? Please let us know your take on this.


We had a 22-year old with CCTGA of single ventricle variant with hypoplastic MRV. On cath study, his mean PA pressure was 18mmHg, making him unfit for Fontan palliation. He also had complete heart block as an extension of his primary cardiac condition with baseline ventricular rate of 32bpm. Is there any advantage of isolated pacemaker insertion in such a scenario? How far and how much palliation can be achieved with this? What are the cost/benefit ratios of such palliations? Please jot in your views and how you would manage such scenarios.


With how much Qs can the body survive? When talking about Qp/Qs, we presume that the Qs remains same and body sucks in as much blood as needed for metabolic needs, making the Qs a variable entity. This logic enables us to formulate operability guidelines based on the ratio. But, can Qs suffer? We saw an 8-year-old girl with PAPVC with intact IAS. All the pulmonary right pulmonary veins were entering the RA directly. The left upper and middle pulmonary veins were entering innominate vein to reach RA. IAS was intact. Only the left lower pulmonary vein was reaching the LA! In other words, her entire Qs was contributed by one single pulmonary vein out of six she had! Yet, she has reached 8-years age with few symptoms. The anatomy was confirmed by CT scan. Our surgical team accepted the challenge of rerouting her pulmonary veins to LA. What is the least Qs you have come across in which a child has reached this sort of age with minimal symptoms. Let us know your experience.


From this post onwards, I have thought of posting a word of interesting etymological origin, relevant to field of medicine. The idea courtesy is Dr Muralimohan, my teacher and a renowned pulmonologist.

The word for this post is GENIUS.

In one of the interviews, Elizabeth Gilbert, author of the famous book “Eat, Pray, Love” had suggested that the origin of the word Genius is from Genie. Dictionary.com says that Starting in the 14th century, a genius denoted a guardian spirit, and someone with extraordinary talent was said to have a genius, because his or her gift was thought to be the result of some supernatural help.” In about 300 years, the meaning began to shift, and people began to call someone with natural ability a genius, someone with an exceptional natural capacity of intellect, not necessarily just a gift from a supernatural friend. How close is the original meaning to the ancient Indian thoughts – which claims that the root cause of all intellect is derived from Almighty and channelized through a chosen individual!

With that, we come to the end of this post. Please pen in your comments. If you find any problem in posting comments, please feel free to mail it to my emial id kiran.vs.dr@nhhospitals.org I shall post them on your behalf.



Wednesday, November 27, 2013

“Usually, there is nothing more pleasing than returning to a place where you have endured hardship.” (Tahir Shah, In Search of King Solomon's Mines)

Dr Kiran welcomes everyone back to the blog of Pediatric cardiology department of Narayana Hrudayalaya, after a very long hiatus.

It has been more than two years and I often wondered why am I not blogging anymore! As often teased, I had convinced myself that I am the sole writer and reader of my blog! Also, more approachable media like FB had come up with good forums for the discussions I had in my blog, with much better responses. May be, I felt the effort of blogging was not worth the sweat (and finger-pain) that went in making it.

But surprisingly, many had remembered the blog! I was asked about it in clinical meetings, emails, FB and rarely over phone also. I was given an understanding on how Google chooses it search priorities in vain attempt to convince me to continue blogging! All said and done, the inertia is lot difficult to break! Finally, here I am.

For a while, I will retain the old fashion! If this attempt to continue the blog survives, then I have plans to review one journal article on Pediatric cardiology every post, along with interesting learning scenarios with some snippets if possible.


Preparation of LV in cases of dTGA with intact IVS is the key for survival for those children who present late. Presence of VSD or large PDA, LVOT obstruction, PPHN are some of the causes for LV preparation we have observed. We had an interesting learning recently on this.
One-year-old baby presented to our OPD with cyanosis. During echo, we found ambiguous situs with TGA, intact IVS with moderate ASD. There was also obstructive cor-triatriatum for this child! The ASD was distal to the obstruction. Jet from cor-triatriatum was directed to RA across the ASD. The complex picture had eventually resulted in severe PAH which had kept the LV prepared! Added to this was L-posed great arteries, an uncommon association in isolated TGA. More surprisingly, the arch was right sided, making the entire combination truly unique. I would like to know the experience of the readers on different ways of LV preparation they have come across in TGA with intact IVS. Please let us know your experience.


As an unspoken rule, we see left arch in cases of L-malposed great arteries with any pathology underneath. How common is the right arch in any case of L-malposed great arteries? What problems can be anticipated in distal arch with this combination? We came across about three such cases in last two years. None of these cases posed any significant problems distal to arch. Please share you experience on this unusual combination. Any embryological explanations for the same?


By definition, the ventricle should have at least 50% of the corresponding AV valve committed to it. So, in cases of DILV, the other chamber is called by different names: Rudimentary chamber, trabecular pouch or outlet chamber depending on whether it is linked with only inflow, only bulboventricular foramen or only outflow. Sometimes, we see this unipartite chamber giving rise to both great arteries in DILV, which is called DILV with DORV!! The question is, if this is not a ventricle by definition, then how can we use the term DORV?! In that case, should we use a term or should we simply elaborate the description? Please share your point of view and what you do in your practice for such combinations.


Constrictive pericarditis is a gruesome condition. In the third-world, tuberculosis is still the dominating etiology for this, followed by septic infective etiology. Sometimes, we can see other causes too, like connective tissue disorders. Recently we came across a 9-year-old girl with a rare genodermatoses called H-syndrome with association of cutaneous hyperpigmented, hypertrichotic, and indurated patches associated with hearing loss, short stature, cardiac anomalies, hepatosplenomegaly and hypogonadism. Her heart was structurally normal but with effusive constriction. Her co-morbidities did not allow us to be aggressive on pericardiectomy, which we felt was definitely beneficial. Has anyone come across this syndrome earlier? What cardiac findings did you observe? How did you go about? In general, how many of us are really aggressive with cardiac intervention in presence of serious co-morbidities?


In cases of pulmonary atresia, AP collateral feeders to pulmonary artery are a common finding. How about a large collateral forming one of the pulmonary artery? We had a 4-year-old child with minimal cyanosis with no audible murmurs. Echo showed pulmonary atresia with a large VSD with impressive pulmonary venous return to LV, causing LA/LV dilatation! There was no MPA. PDA from right arch was continuing as RPA. LPA was not seen on echo, but the return from left pulmonary veins was good. In pursuit of collaterals, we felt that we found double arch! However, the right arch was giving rise to all 3 neck vessels along with PDA! On careful chasing, the large vessel which we thought was a double arch could be traced to bracheocephalic artery and tracing it distally, we lost it after it took a deviation towards left. CT scan revealed this large collateral to be continuing as LPA into the hilum of left lung. We still have difference of opinion on whether to call it LPA or collateral to left lung! Our surgeons are working on possibility of unifocalization. I shall keep the readers updated. It would be interesting if readers can share their experience.

With that, we come to the end of this post. Please pen in your comments. If you find any problem in posting comments, please feel free to mail it to my emial id I shall post them on your behalf.


Tuesday, November 26, 2013

Hi all Making a come back soon. Thank you for all the support and encouragement I received even when the blog was dormant. See you with new post soon - Kiran