Anil Kumar Singhi

Transcatheter occlusion of patent ductus arteriosus in pre-term infants.

OBJECTIVES The aim of this study was to describe our institutional experience with transcatheter coil occlusion of patent ductus arteriosus (PDA) in symptomatic low birth weight pre-term infants. BACKGROUND Transcatheter treatment of PDA in very small infants (<2 kg) is technically challenging and therefore often not considered as an alternative to traditionally accepted modalities (surgical or medical treatment). METHODS Coil occlusion was offered as an option to selected infants with symptomatic PDA. Case selection for the transcatheter procedure was determined by the patients weight, PDA size, size of ampulla, and the anticipated coil mass required for complete closure (determined through echocardiography). The PDA occlusion was achieved with coils delivered with assistance of a 3-F bioptome. Arterial access and catheter manipulation within the cardiac chambers were avoided whenever feasible. RESULTS Eight pre-term infants underwent coil occlusion. Gestational age ranged from 27 to 32 weeks (28.7 +/- 1.9 weeks). The median birth weight was 1,040 g (range 700 to 1,700 g), and the median weight at the time of procedure was 1,100 g (range 930 to 1,800 g). Three patients were receiving mechanical ventilation before intervention. Duct sizes ranged between 2 and 3.5 mm. Complete occlusion of the duct was instantly achieved in 7 patients, and 1 patient had a small residual flow for 24 h. There were no major procedure or access-related complications; 4 patients were discharged within 72 h; 1 patient was discharged on Day 10. Three patients required prolonged ventilation (34 and 150 days) due to pulmonary pathology. CONCLUSIONS It is technically feasible to undertake transcatheter coil closure of PDA in carefully selected symptomatic pre-term infants, and it is a safe alternative to surgical ligation.

Isolated absence of right pulmonary artery

Background: Absence of right pulmonary artery (RPA) is a rare congenital abnormality with variable presentation. The diagnosis is often missed in infants Objective: The aim of this study was to describe infantile presentation of isolated absence of RPA along with a brief review of the literature. Methods: The details of five patients diagnosed with isolated absence of RPA from April 2007 to October 2009 were reviewed retrospectively Results: Five patients were identified with this anomaly. The median age of presentation was 86 days (range, 40–120 days) and the median weight was 3.65 kg (range, 3.1–5.5 kg). All patients presented with breathing difficulty and had severe pulmonary hypertension (PHT) along with absent RPA on echocardiography. A multidetector computed tomographic scan was performed to confirm the diagnosis in four cases. Three patients had major aortopulmonary collateral and the hilar RPA was not well developed in all. A correct diagnosis was made before referral in one patient only. Differential vascularity in chest X-ray, a useful clue, was seen in four of five cases. Surgical correction was not considered in view of the small hilar pulmonary artery. The patients were all managed medically with diuretics and Sildenafil. Conclusion: Isolated absence of RPA is a rare congenital abnormality with varied presentation. Infantile presentation is marked with congestive cardiac failure and PHT. Specific diagnostic clue includes differential vascularity on the chest X-ray.

Pulmonary edema following transcatheter closure of atrial septal defect

Pulmonary edema after device closure of atrial septal defect (ASD) is a rare complication. We present illustrative images of a case of pulmonary edema after device closure of ASD in a 53 year old adult. Older patients undergoing ASD closure can benefit from their left atrial and left ventricular end diastolic pressures measurement before and after temporary balloon occlusion of ASD.

Acute rheumatic fever: Subcutaneous nodules and carditis

We present images of an 8-year-old child with a fever for the preceding 45 days, migratory polyarthralgia involving large joints, and progressively worsening dyspnea on exertion. Examination revealed subcutaneous nodules over the bony prominences of the spine, scapulae, forehead, extensor surfaces of bilateral elbow joints and knee joints, ankles, and the rib cage (Figure 1). The nodules were 0.5 to 1.5 cm in size, rounded, firm, nontender, and mobile. A …

Decline in arterial partial pressure of oxygen after exercise: a surrogate marker of pulmonary vascular obstructive disease in patients with atrial septal defect and severe pulmonary hypertension

OBJECTIVES To examine the utility of decline in arterial partial pressure of oxygen after exercise as a marker of pulmonary vascular obstructive disease in patients with atrial septal defect and pulmonary hypertension. METHODS Treadmill exercise was performed in 18 patients with atrial septal defect and pulmonary hypertension. Arterial blood gas samples were obtained before and after peak exercise. A decline in the arterial pressure of oxygen of more than 10 millimetres of mercury after exercise was considered significant based on preliminary tests conducted on the controls. Cardiac catheterisation was performed in all patients and haemodynamic data sets were obtained on room air, oxygen, and a mixture of oxygen and nitric oxide (30-40 parts per million). RESULTS There were 10 patients who had more than a 10 millimetres of mercury drop in arterial partial pressure of oxygen after exercise and who had a basal pulmonary vascular resistance index of more than 7 Wood units per square metre. Out of eight patients who had less than a 10 millimetres of mercury drop in arterial partial pressure of oxygen after exercise, seven had a basal pulmonary vascular resistance index of less than 7 Wood units per square metre, p equals 0.0001. A decline in arterial partial pressure of oxygen of more than 10 millimetres of mercury predicted a basal pulmonary vascular resistance index of more than 7 Wood units per square metre with a specificity of 100% and a sensitivity of 90%. CONCLUSIONS A decline in arterial partial pressure of oxygen following exercise appears to predict a high pulmonary vascular resistance index in patients with atrial septal defect and pulmonary hypertension. This test is a useful non-invasive marker of pulmonary vascular obstructive disease in this subset.

Ruptured submitral aneurysm in an eight-year-old girl.

We present illustrative images of submitral aneurysm in a young girl. The diagnosis was established on echocardiography and the extent of the problem was defined through multi-detector computerized tomography.

Juxtaposed atrial appendages: A curiosity with some clinical relevance

If the atrial appendages lie adjacent to each other on same side of the great arteries, instead of encircling their roots, they are referred as juxtaposed. Right juxtaposition of atrial appendages is less common than left juxtaposition. The images demonstrate the classical radiological, echocardiographic, and surgical images of juxtaposed atrial appendages. Their clinical incidence, associations, and relevance during interventional and surgical procedures are discussed.

Unusual method of creation of a transcatheter fenestration in an extracardiac conduit fontan circulation

Failing Fontan physiology in univentricular hearts manifest with protein-losing enteropathy, plastic bronchitis, low cardiac output, and recurrent effusions. Transcatheter creation of fenestration in a failing Fontan may be useful in alleviating the symptoms by improving the cardiac output. It is traditionally achieved by puncturing through the conduit from femoral or jugular venous access. In the absence of good venous path, transhepatic access provides a direct route for needle puncture of the conduit. If marked intimal ingrowth into the conduit results in increasing rigidity and makes the conduit nonyielding, alternative approaches may be needed. A successful creation of pulmonary artery to atrial roof communication through the potential space of transverse sinus using a covered stent is presented.

A rare case of cardiac tumor in a child

Pediatric cardiac tumors are rare and usually benign. An infectious etiology like tuberculosis invading myocardium and presenting as infiltrative mass is extremely rare. We present a case of a 15 month old girl with clinical feature of cardiac failure who had infiltrative multiple myocardial masses in echocardiogram. Advanced cardiac imaging by Cardiac Magnetic resonance imaging (MRI ) helped in tissue delineation. Therapeutic trial of anti-tubercular drugs in view clinical suspicion of Tuberculosis resulted in complete remission of symptom and disappearance of the cardiac mass.

Anomalous origin of right coronary artery causing myocardial ischemia in a young patient

Anomalous right coronary artery from left coronary sinus can have dynamic narrowing and kinking causing symptoms of myocardial ischemia and sudden cardiac death. Surgical repair of the anomaly is required in the symptomatic patient because of risk of ischemia or ventricular arrhythmia. Asymptomatic incidentally diagnosed low-risk patients can be closely followed up with exercise restriction as per present guideline.