Endale Tefera

Outcome in Children Operated for Membranous Subaortic Stenosis: Membrane Resection Plus Aggressive Septal Myectomy Versus Membrane Resection Alone.

Background: The optimal surgical procedure for treatment of fibromembranous subaortic stenosis has been a subject of debate. We report our experience with patients treated for membranous subaortic stenosis using membrane resection alone and membrane resection plus aggressive septal myectomy. Methods: Patients followed in the pediatric cardiology clinic of a university hospital, who had undergone surgery for subaortic stenosis between 2002 and 2013 were reviewed. Recurrence of subaortic membrane, residual left ventricular outflow gradient, and aortic valve function were analyzed. Results: Forty-six patients underwent surgery for subaortic membrane. Of these, 19 had membrane resection plus aggressive septal myectomy, while 27 had membrane resection alone. Mean age at surgery for the membrane resection group was 7.7 ± 3.9 years and 10.9 ± 3.6 years for the membrane resection plus aggressive myectomy group. Preoperative subaortic gradient for the membrane resection group was 75.5 ± 26.7 mm Hg and 103.2 ± 39.7 mm Hg for the membrane resection plus aggressive myectomy group. The mean follow-up left ventricular outflow tract gradient was 42.3 ± 31.3 mm Hg in the membrane resection group, while it was 11.6 ± 6.3 mm Hg in the aggressive septal myectomy group. Nine patients from the membrane resection group had significant regrowth of the subaortic membrane during the follow-up period, while none of the aggressive septal myectomy group had detectable membrane on echocardiography. Seven of the nine patients with recurrence of the subaortic membrane underwent subsequent membrane resection plus aggressive septal myectomy. Intraoperative finding in all these redo cases was recurrence (growth) of a subaortic membrane. Conclusion: Aggressive septal myectomy offers less chance of recurrence, freedom from reoperation, and an improved aortic valve function. This is especially important in sub-Saharan settings where a chance of getting a second surgery is unpredictable.

Rebuttal: Percutaneous balloon dilation of severe pulmonary valve stenosis in patients with cyanosis and congestive heart failure

Objectives This article reports outcomes of percutaneous balloon dilation in patients with severe pulmonary valve stenosis, in particular in those treated late with cyanosis, congestive heart failure, and pericardial effusion. Background Percutaneous balloon dilation is the treatment of choice for pulmonary valve stenosis. Although earlier intervention may produce better results, patients may present late with congestive heart failure and cyanosis. Methods Fifty-five patients who underwent pulmonary valve balloon dilation, were grouped into two groups, based on the presence or absence of congestive right heart failure and/or central cyanosis. Group I included 33 patients with severe pulmonary valve stenosis, but without clinical evidence of congestive right heart failure in the form of liver enlargement, raised jugular venous pressure, and peripheral edema and/or central cyanosis and group II included 22 patients with severe pulmonary valve stenosis and congestive right heart failure and/or central cyanosis. Their outcomes were compared. Results Doppler measured transvalvar pressure gradient decreased from 110.2 ± 34.0 mm Hg before to 52.5 ± 28.7 mm Hg in group I after dilation (P < 0.001), and from 138.4 ± 32.3 mm Hg to 53.9 ± 19.3 mm Hg in group II, (P < 0.001). Complications included ventricular tachycardia/fibrillation in three patients and severe bradycardia in one patient in group II. Twelve patients in group II developed clinical and radiologic evidence of reperfusion injury/pulmonary edema within the first 24 hr of intervention and needed ventilation for 2–9 days. Three of these patients died from intractable pulmonary edema. On follow up, clinical and echocardiographic improvement parameters were similar in the two groups. Conclusion Those patients with severe pulmonary valve stenosis with congestive right heart failure, especially those with pericardial effusion, ascites and cyanosis, represent an important technical and clinical challenge. They are a high-risk group with or without treatment. If they survive the procedure, they may still remain at a high risk in the first few days afterward. Maintaining their ventilator and inotropic support after balloon dilation may increase survival. However, excellent results can be obtained.

Humanitarian Cardiology and Cardiac Surgery in Sub-Saharan Africa: Can We Reshape the Model?

Background: In recent decades, humanitarian cardiology and cardiac surgery have shifted toward sending short-term surgical and catheter missions to treat patients. Although this model has been shown to be effective in bringing cardiovascular care to the patients’ environment, its effectiveness in creating sustainable service is questioned. This study reports the barriers to contribution of missions to effective skill transfer and possible improvements needed in the future, from the perspective of both the local and overseas teams. Methods: We reviewed the mission-based activities in the Children’s Heart Fund Cardiac Center in the past six years. We distributed questionnaires to the local surgeons and the lead surgeons of the overseas teams. Results: Twenty-six missions visited the center 57 times. There were 371 operating days and 605 surgical procedures. Of the procedures performed, 498 were open-heart surgeries. Of the operations, 360 were congenital cases and 204 were rheumatic. Six local surgeons and 18 overseas surgeons responded. Both groups agree the current model of collaboration is not optimal for effective skill transfer. The local surgeons suggested deeper involvement of the universities, governmental institutions, defined training goals and time frame, and communication among the overseas teams themselves as remedies in the future. Majority of the overseas surgeons agree that networking and regular communication among the missions themselves are needed. Some reflected that it would be convenient if the local surgeons are trained by one or two frequently visiting surgeons in their early years and later exposed to multiple teams if needed. Conclusion: The current model of collaboration has brought cardiac care to patients having cardiac diseases. However, the model appears to be suboptimal for skill transfer. The model needs to be reshaped to achieve this complex goal.

Successful training of self-sufficient interventional paediatric cardiology team in a sub-Saharan setting: a multicentre collaborative model.

BACKGROUND Most children in the Third World do not have access to treatment for heart diseases, as the priorities of health care are different from the developed countries. MATERIALS AND METHODS Since 2009, teams supported by the Chain of Hope and Spanish medical volunteers have travelled twice a year to help develop paediatric cardiac services in the Cardiac Center in Ethiopia, undertaking four missions each year. As of December 2012, 296 procedures were performed on 287 patients. The procedures included 128 duct occlusions, 55 pulmonary valve dilations, 25 atrial septal defect closures, 14 mitral valve dilations, and others. The local staff were trained to perform a majority of these cases. RESULTS Procedural success was achieved in 264 (89.2%). There were three deaths, five device embolisations, and three complications in mitral valve dilation. During the visits, the local staff were trained including one cardiologist, six nurses, and two technicians. The local team performed percutaneous interventions on its own after a couple of years. The goal is also to enable the local team to perform interventions independently. CONCLUSION Training of an interventional cardiology team in a sub-Saharan setting is challenging but achievable. It may be difficult for a single centre to commit to sending frequent missions to a developing country to make a meaningful contribution to the training of local teams. In our case, coordination between the teams from the two countries helped to achieve our goals.

Percutaneous balloon dilation of severe pulmonary valve stenosis in patients with cyanosis and congestive heart failure: Pulmonary Valvotomy in Congestive Heart Failure

This article reports outcomes of percutaneous balloon dilation in patients with severe pulmonary valve stenosis, in particular in those treated late with cyanosis, congestive heart failure, and pericardial effusion.

Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach

Percutaneous closure of the patent arterial duct in patients with interrupted inferior caval vein poses a technical challenge. A 12-year-old girl with a patent ductus arteriosus (PDA) and interrupted inferior caval vein is described in this report. The diagnosis of interrupted inferior caval vein and azygos continuation was made in the catheterization laboratory. A catheter was advanced and snared in the descending aorta. An exchange wire was advanced through the catheter and snared in the descending aorta. Then, an Amplatzer TorqVue 2 delivery sheath was advanced over the wire from the venous side and again snared in the descending aorta. An Amplatzer duct occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare. The device was opened. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted. The device was then released and it attained a stable position. An aortic angiogram was performed which showed complete occlusion.

Pulmonary Artery Aneurysm With Patent Arterial Duct Resection of Aneurysm and Ductal Division

Congenital or acquired aneurysm of the pulmonary artery (PA) is rare. Although aneurysms are described following surgical treatment of patent ductus arteriosus (PDA), occurrence of this lesion in association with PDA without previous surgery is extremely uncommon. An eight-year-old patient with PDA and aneurysm of the main PA is described in this report. Clinical diagnosis of PDA was made upon presentation. Diagnosis of PA aneurysm was suspected on chest x-ray and was confirmed on transthoracic echocardiography. Successful surgical resection of the aneurysm and division of the duct were performed under cardiopulmonary bypass. The patient did well on follow-up both from clinical and echocardiographic point of view.

Discrete subpulmonic membrane in association with isolated severe pulmonary valvar stenosis.

BackgroundSubpulmonic membrane as a cause of right ventricular outflow tract obstruction in patients with concordant ventriculoarterial connection and intact ventricular septum is considered to be rare.Case presentationA 7 – year – old boy was referred to a tertiary care hospital with complaints of dyspnea on moderate exertion and palpitations of about 2 years duration. Physical examination revealed parasternal lift, systolic thrill and a 4/6 ejection systolic murmur, best heard over the left 2nd intercostal space. His oxygen saturation was 88% on room air. Two-dimensional echocardiography showed a thickened pulmonary valve with fused leaflets that show severe systolic doming. There was a discrete subpulmonic membrane about 1.3 cm below the pulmonary valve annulus. Continuous wave Doppler interrogation showed peak systolic pressure gradient of 185 mmHg across the pulmonary valve. Balloon dilation of the pulmonary valve was performed and the pressure gradient came down to 50 mmHg. Follow-up transthoracic echocardiography showed residual pressure gradient of about 50 – 60 mmHg across the pulmonary valve. The residual pressure gradient appeared to be mainly subvalvar, as seen on the continuous wave Doppler tracing. The patient reported marked improvement in terms of exercise tolerance and subjective symptoms.ConclusionsAssociation of subpulmonic membrane with severe pulmonary valvar stenosis, concordant ventriculoarterial connection and intact ventricular septum is rare. When it occurs, the result of percutaneous valve dilation may be suboptimal.

Spectrum of cardiovascular diseases in six main referral hospitals of Ethiopia

Background The spectrum of cardiovascular diseases varies between and within countries, depending on the stage of epidemiological transition and risk factor profiles. Understanding this spectrum requires regional and national data for each region or country. This study was designed to determine the spectrum of cardiovascular diseases in six university hospitals in Ethiopia. Methods This is a cross-sectional study of the spectrum of cardiovascular diseases in six main referral/teaching hospitals located in different parts of the country. Consecutive patients visiting the follow-up cardiac clinics of these hospitals from 1 January to 30 June 2015 were included in the study. Data were collected on a pretested questionnaire. Results A total of 6275 patients (58.5% females) were included in the study. Nearly 61% of the patients were from urban areas. The median age was 33 years (IQR 14–55 years). Valvular heart disease was the most common diagnosis, accounting for 40.5% of the cases. Of 2541 patents with valvular heart disease, 2184 (86%) were cases of chronic rheumatic heart disease. Conclusion Our study shows that chronic rheumatic valvular heart disease is the most common cardiovascular diagnosis among patients seen at cardiology clinics of six referral/teaching hospitals in the country, followed by congenital heart diseases. Hypertensive and ischaemic heart diseases also accounted for a significant proportion of the cases. Therefore, strategies directed towards primary and secondary prevention of acute rheumatic fever as well as prevention of risk factors for hypertension and ischaemic heart disease may need to be strengthened.

Hydatid cyst of the interventricular septum

While cardiac involvement is not a common presentation in human echinococcosis, it may lead to life-threatening complications including cyst rupture; anaphylactic shock; tamponade; pulmonary, cerebral or peripheral arterial embolism; acute coronary syndrome; dysrhythmias; infection; ventricular or valvular dysfunction, as well as sudden death. Here we report a 9-year old girl who was diagnosed to have hydatid cyst of the interventricular septum four years after diagnosis and medical treatment of pulmonary hydatidosis. Presentation, management and follow-up of the patient is discussed.