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:

MULTIPLE SOLUTIONS

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.

PARTIALLY SKEWED

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.

LIMITING PALLIATION

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.

ONLY RHYTHM

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.

 Qs NEEDS

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.

WORD OF THE POST

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.

 Regards

Kiran

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