Duraisamy Balaguru

Occlusion of a large coronary-cameral fistula using the Amplatzer vascular plug in a 2-year old.

A 2‐year‐old girl underwent transcatheter occlusion of a fistula. The fistula originated from the right coronary artery and drained into the right atrium. Three interlocking Gianturco coils were initially placed in the distal portion of the fistula resulting in near‐total occlusion of blood flow. Placing a 12‐mm Amplatzer vascular plug obliterated the proximal, dilated portion of the fistula. Complete occlusion with accurate placement was achieved. Advantages and technical implications of the Amplatzer vascular plug in this clinical setting are discussed.

Use of Multiplane Transesophageal Echocardiography to Guide Closure of Atrial Septal Defects Using the Amplatzer Device

AbstractBy providing unlimited imaging planes, multiplane transesophageal echocardiography (MTEE) should improve real-time guidance of interventional procedures. The potential advantages of MTEE in this scenario have not been systematically evaluated. We retrospectively reviewed our experience with MTEE-guided Amplatzer device closure of atrial septal defects (ASDs) MTEE angles used to obtain images for guiding all measurements and maneuvers were recorded. These angles were compared to the range of MTEE angles that are postulated to be available from biplane TEE. Images obtained using MTEE angles from 21° to 70° and from 111° to l59° were defined as only obtainable by MTEE. The MTEE probe was successfully introduced in all (89) patients. Thirteen patients (15%) had multiple defects. Ninety-five devices (5–32 mm in diameter) were deployed. In 66% of patients, balloon sizing and device deployment necessitated imaging planes that are only obtainable by MTEE. All devices were well positioned, with no impingement on inflows or outflows. At follow-up, 79 of 89 (88.7%) patients had no residual ASDs. Each of the remaining 10 patients (11.3%) had a small (<3 mm) residual defect. MTEE played an important role in guiding device closure of ASD, particularly during the phases of balloon sizing and device deployment.n

Management of heart failure in children

B dvances in our understanding of the pathophysiology and molecular basis of diseases offer new, challenging, controversial, and sometimes, counterintuitive forms of therapy. This is especially true with regard to the syndrome of heart failure. Therapeutic approaches to heart failure in adults have evolved rapidly during the past decade. Unfortunately, as with many other aspects of medicine, our concepts of heart failure in the pediatric population have been reduced to a simple extrapolation of the adult model. Pediatricians know that a child is not a small adult. Consequently, heart failure is perhaps a far more complex entity in the pediatric population with regard to pathophysiology and the possible courses of action. In this review we summarize recent advances in heart failure research in adults and attempt to integrate these findings in a pediatric context. The basic paradigm of hemodynamic derangement and the consequent symptoms have dominated our approach to congestive heart failure for most of this century (Fig 1). Despite constraint by this narrow viewpoint, the normalization of hemodynamics has an immediate positive effect on symptomatic improvement. Multiple clinical trials were conducted in the adult population with a variety of pharmacologic strategies aimed at enhancing systolic performance only. The clinical outcome of these trials was disappointing because of adverse effects on the heart in the long term, since the initial improvement in the standard measures of heart failure severity (such as exercise tolerance, symptoms, and hemodynamics) was not sustained. 1,2 Application of information available from recent heart failure research enables us to go beyond the concept of the heart as a simple pump and formulate a more comprehensive understanding of the syndrome of heart failure (Fig 2). We are now beginning to recognize the

Enteroviral sepsis and ischemic cardiomyopathy in a neonate: case report and review of literature.

Neonatal entero-viral sepsis is a rare but fulminant infection with multisystem involvement, often presenting with hepatitis, meningo-encephalitis, disseminated intravascular coagulation (DIC), and myocarditis. Neonatal myocarditis often proves fatal. We report here a case of neonatal enteroviral myocarditis with multisystem organ failure and ischemic cardiomyopathy that was managed medically.

Investigational Lymphatic Imaging at the Bedside in a Pediatric Postoperative Chylothorax Patient

Chylothorax is a rare but serious complication in children who undergo heart surgery. Its pathogenesis is poorly understood, and invasive surgical treatments are considered only after conservative management fails. Current diagnostic imaging techniques, which could aid decision making for earlier surgical intervention, are difficult to apply. Herein, we deployed near-infrared fluorescence (NIRF) lymphatic imaging to allow the visualization of abnormal lymphatic drainage in an infant with postoperative chylothorax to guide the choice of surgical management. A 5-week-old male infant, who developed chylothoraces after undergoing Norwood surgery for hypoplastic left heart syndrome, was intradermallyxa0administered trace doses of indocyanine green in both feet and the left hand. NIRF imaging was then performed at the bedside to visualize lymphatic drainage patterns. Imaging results indicated impeded lymphatic drainage from the feet toward the trunk with no fluorescence in the chest indicating no leakage of peripheral lymph at the thoracic duct. Instead, lymph drainage occurred from the axilla directly into the pleural cavity. As a result of imaging, left pleurodesis was performed to stop the pleural effusion with the result of temporary decrease of left chest tube drainage. Although additional studies are required to understand normal and abnormal lymphatic drainage patterns in infants, we showed the potential of using NIRF lymphatic imaging at the bedside to visualize the lymphatic drainage pathway to guide therapy. Timely management of chylothorax may be improved by using NIRF imaging to understand lymphatic drainage pathways.

Computed tomography scan measurement of abdominal wall thickness for application of near-infrared spectroscopy probes to monitor regional oxygen saturation index of gastrointestinal and renal circulations in children.

Objectives: To measure abdominal wall thickness to determine the depth at which the renal vascular bed and mesenteric vascular bed are located, and to determine the appropriate site for placement of near-infrared spectroscopy probes for accurate monitoring regional oxygen saturation index in children. Design: Abdominal computerized tomography scans in children were used to measure the abdominal wall thickness and to ascertain the location of kidneys. Setting: Tertiary care childrens hospital. Subjects: Children 0–18 yrs of age; n = 38. Interventions: None. Measurements and Main Results: The main mass of the kidneys is located between vertebral levels T12 and L2 on both sides. The left kidney is located about a half-vertebral length higher than the right kidney. Posterior abdominal wall thickness ranged from 6.6 to 115.8 mm (median, 22.1 mm). Posterolateral abdominal wall thickness ranged from 6.7 to 114.5 mm (median, 19.6 mm). Anterior abdominal wall thickness in the supraumbilical level ranged from 3.5 to 62.9 mm (median, 16.0 mm). All abdominal wall thicknesses correlated better with weight of the subjects than their age. Conclusion: Abdominal wall thickness potentially exceeds the sampling depth of currently used near-infrared spectroscopy probes above a certain body size. Application of current near-infrared spectroscopy probes and design of future probes should consider patient size variations in the pediatric population.

Vasodilators in the treatment of pediatric heart failure

The goals of heart failure therapy have shifted from purely hemodynamic manipulation to a combination of hemodynamic and neurohumoral modulation. Vasodilators with neurohumoral modulatory properties [such as ACE inhibitors (ACEi) and third generation beta-blockers] have become the cornerstone of chronic heart failure therapy. These newer agents have proven to improve morbidity and mortality in adults with chronic heart failure. Pure vasodilators still have a place in the treatment of acute decompensated heart failure and in patients who are intolerant to ACEi or beta-blocker therapy. In decompensated heart failure management, improvement of cardiac output is of paramount importance and restoration of normal hemodynamics takes priority over modulation of cardiac maladaptation. Under these circumstances agents that improve contractility and modify cardiac preload and afterload are used. In the intensive care unit setting inodilators offer the advantage of an added positive inotropic effect. NO donors play an important role when close titration of blood pressure is also needed. It is the purpose of this manuscript to address principles and current practice regarding the use of vasodilators in pediatric heart failure. ACE inhibitors and third generation beta-blockers due to their importance in todays therapeutic approach to heart failure are the focus of more detailed articles in this issue of Progress in Pediatric Cardiology.

Abnormal Left Ventricular Longitudinal Wall Motion in Rheumatic Mitral Stenosis Before and After Balloon Valvuloplasty: A Strain Rate Imaging Study

Rheumatic mitral stenosis may be associated with left ventricular dysfunction. We report improvements of abnormal longitudinal wall motion and strain rate post-balloon valvuloplasty of severe mitral stenosis in a girl with normal ejection fraction.

Anomalous origin of left coronary artery from pulmonary artery - Duped by 2D; saved by color Doppler: Echocardiographic lesson from two cases.

Echocardiography is an important first-line investigation for detection of anomalous origin of a coronary artery from the pulmonary artery (ALCAPA). We report two cases of ALCAPA that illustrate the importance of systematic performance of the echocardiogram, mindful of technical artifacts that may mislead the echocardiographer color Doppler imaging in diagnosis of this condition.

Predictors of residual defects following closure of defects in the oval fossa using the Amplatzer device: echocardiography recapitulates morphometry

OBJECTIVESnThis study was designed to identify predictors of residual defects following deployment of the Amplatzer device to close septal defects within the oval fossa.nnnMETHODSnBetween February 1997 and February 2000, we used the Amplatzer device to close defects in the oval fossa in 89 patients. Of these patients, 18 (20%) had residual defects. At 6 or 12 months following placement of the device, 13 defects (14.6%) had persisted. We evaluated several variables derived from clinical features, transesophageal echocardiography and catheterization to establish predictors for residual shunting.nnnRESULTSnMultivariate analysis identified a shorter superior rim of less than 8 mm (Odds ratio = 10.1; 95% confidence intervals = 2.64-38.72; p = 0.001), and a smaller interatrial septum in the 30-degree transesophageal echocardiographic plane of less than 30 mm (Odds ratio = 5.5; 95% confidence intervals = 1.17-26.14; p = 0.03) as independent predictors of residual defects. When the analysis was repeated defining only those 13 patients with persisting residual defects at 6 or 12 months as failures, a short superior rim (p = 0.004) remained a predictor for residual shunting.nnnCONCLUSIONSnDefects with a short superior rim and smaller interatrial septum in the 30-degree transesophageal echocardiographic plane independently and additively predict an increased probability of residual shunting following closure of defects in the oval fossa using the Amplatzer device.