A. Saxena

Congenital severe aortic stenosis with congestive heart failure in late childhood and adolescence : Effect on left ventricular function after balloon valvuloplasty

Left ventricular (LV) dysfunction with congestive heart failure (CHF) resulting from severe congenital aortic stenosis (AS) is a well‐described condition in infancy, but it is rarely found in older children and adolescents. Aortic valve surgery in such cases may be associated with higher rates of morbidity and mortality. Aortic valve balloon dilatation (AVBD) is a viable alternative, but its effect on LV function has not been evaluated. We describe follow‐up results of AVBD in 10 cases of severe congenital AS in older children and adolescents with CHF and LV dysfunction. The ages of these patients ranged from 5 to 18 yr (mean ± SD: 10.8 ± 4 yr), and nine were males. The follow‐up period after AVBD ranged from 3 mo to 7 yr (mean ± SD: 2.93 ± 2.1 yr). Success was achieved in all cases, with no immediate complications. After valvuloplasty, the peak‐to‐peak systolic gradient declined from 74.7 ± 30.8 to 33.9 ± 18.2 mm Hg (P < 0.0001). The cardiac index increased slightly but significantly, from 1.9 ± 0.27 to 2.2 ± 0.5 L/min/m2 (P < 0.015). Hemodynamic improvement was also confirmed by a significant decrease in mean pulmonary artery and pulmonary artery wedge pressures from 41.9 ± 9 to 32.6 ± 6.6 and from 25.5 ± 2.9 to 19.3 ± 3.4 mm Hg, respectively. The echocardiographically derived left ventricular ejection fraction (LVEF) improved from 21.6 ± 5.37% to 31 ± 6.5% within 24 hr after AVBD, and it further improved in all cases on follow‐up. Mean LVEF at last follow‐up was 59.4 ± 11.4%. The Doppler instantaneous peak systolic gradient (IPSG) increased from 37.3 ± 18.8 to 64.8 ± 30.7 mm Hg at late follow‐up. Significant aortic regurgitation (AR) developed in 20% of patients. The Doppler IPSG across the aortic valve was > 60 mm Hg in five cases on follow‐up. Two of these patients underwent another AVBD successfully 4 and 16 mo later, respectively. Aortic valve replacement was done in two patients, one for severe restenosis with mild AR 12 mo after AVBD and another for severe re‐restenosis with moderate AR 21 mo after a second AVBD. Severe congenital AS can be associated with LV dysfunction and CHF in late childhood and adolescence. AVBD results in good palliation with improvement in LV function on follow‐up. Cathet. Cardiovasc. Intervent. 51:168–172, 2000.

Prostaglandin E1: First stage palliation in neonates with congenital cardiac defects

E-type prostaglandins (PGE1) can effectively maintain the patency of the ductus arteriosus in neonates. Its use, therefore can be life saving in infants born with ductus dependent congenital heart disease. Although PGE1 is available for over two decades in western world, it has been introduced in India only since April, 1995. Various cardiac defects where PGE1 is useful include (a) lesions with ductus dependent pulmonary blood flow eg. pulmonary atresia with or without ventricular septal defect, critical valvular pulmonic stenosis etc, (b) lesions with ductus dependent systemic blood flow eg. critical aortic stenosis, coarctation of aorta, interruption of aortic arch etc, and (c) admixture lesions like transposition of great arteries.The drug is given as a continuous intravenous infusion. The initial dose is 0.05 to 0.4 ug/kg/min, infusion rate must be decreased to 0.01 ug/kg/min as soon as the desired effect is achieved as incidence of side effects is more at higher doses. Serious side effects include apnoea, hypotension, hyperthermia, seizures etc. We have used this drug in 43 infants ranging in age from one to forty five days. Beneficial response was seen in 41 of 43 infants and the major side effect was apnoea (seen in 5 of 32 spontaneously breathing infants). Unfortunately the high cost of the drug prohibits its wide spread and long term use.PGE1 is a life saving drug for infants born with ductus dependent congenital cardiac malformations. It helps in stabilizing these patients prior to further surgical palliation or correction.

Lone atrial fibrillation with complete heart block in a child

An asymptomatic 9-year-old boy presented with a slow heart rate and a structurally normal heart. He was detected to have complete atrioventricular block and fine atrial fibrillation that was not evident on the surface electrocardiogram. This case appears to be an unusual example of a disease of the cardiac conduction system presenting in childhood.

Guide wire outer coat shearing and embolisation: an unusual complication of pericardiocentesis

We report a case of shearing of the outer coat of the guide wire and its embolization into the pulmonary artery during pericardiocentesis. This unusual foreign body was successfully removed by pervenous method.

Urolithic property of Varuna (Crataeva nurvala): An experimental study

Despite modern techniques, the recurrence rate of Urolithiasis is approximately 50% within 5 years. Thus, there must be some drug that corrects the metabolic errors and prevents the formation of stone. In Ayurveda, a detailed description of urolithiasis is mentioned under the heading of Ashmari. A group of Ayurvedic drugs are described for the management of Urolithiasis, like Pashanbheda (Bergenia ligulata), Varuna (Crataeva nurvala), Kullattha (Dolichos biflorus), Gokshur (Tribulus terrestris), etc. in our ancient texts. The present work was designed to study the effect of Varuna (Crataeva nurvala) on the experimental model of urolithiasis (albino rats). The study was categorized into two groups: Group I, treated and Group II, control. In all albino rats, stone was surgically implanted into the urinary bladder. Estimation of the urinary and serum electrolyte done periodically and x-rays were exposed at a regular interval. This study suggests the decoction of Varuna (Crataeva nurvala) is effective in the management of urolithiasis.