Kothandam Sivakumar

Atrial septostomy with a predefined diameter using a novel occlutech atrial flow regulator improves symptoms and cardiac index in patients with severe pulmonary arterial hypertension

A novel Occlutech atrial flow regulator (AFR) implantation gives an atrial septal predefined predictable fenestration.

A novel snare assistance safeguards against early embolization of devices and facilitates quick retrieval of malpositioned devices in atrial septal defects with deficient margins

Background : Embolization might complicate device closure of large atrial septal defects (ASDs) with deficient margins. When margins are deficient, a precariously placed device can appear to be held in good position by the rigid delivery cable. Once the cable is unscrewed, the device adopts the natural lie of the interatrial septum. This can occasionally expose the inadequately captured margins and lead to device embolization. Most embolizations occur immediately after release. Retrieval of the embolized device required prolonged fluoroscopy and sometimes open heart surgery. Objective : To evolve a new strategy of retrieval of a malpositioned device after unscrewing the cable before impending embolization. Materials and Methods : After deploying the device in place, a snare is passed through the delivery sheath around the cable to grip the screw on the right atrial disc of the device. With the snare holding the screw end, the device is released by unscrewing the cable. The device position is reconfirmed on echocardiography. The snare is subsequently removed if the device was stable. In case of device migration, the same snare is used to retrieve the device before it embolizes completely. Results : Snare assistance was used in 24 patients considered as high-risk for device embolization. Its usefulness was demonstrated in two patients with deficient posterior margin and small inferior margin where the device got malpositioned immediately after release. As the snare was still holding on to the screw end, the device could be retrieved into the sheath easily. Conclusion : This novel snare assisted device release strategy safeguards against device embolization in large ASDs with deficient rims and allows simplified retrieval.

Preliminary evaluation of a microtransesophageal probe in neonates and young infants undergoing surgery for congenital heart disease

Background: The larger size of the currently available transesophageal echocardiography (TEE) probes limits their use to relatively older infants undergoing cardiac surgery. In very young neonates and infants, epicardial echocardiogram is used to assess postoperative residual defects. Recently, a miniaturized microTEE probe compatible in neonates has been introduced for clinical use. We evaluated the use of this probe in small infants undergoing cardiac surgery. Materials and Methods: Thirty-three consecutive neonates and infants undergoing cardiac surgery at our institution were included in the study. Intraoperative echocardiography with Philips s8-3t microTEE probe done using IE33 platform was utilized to study the preoperative anatomy and assess postoperative results. Results: Thirty-three patients aged 3 days-2 years (mean 5.1 months) and weighing 2.5-11 kg (mean 4.4 kg) underwent perioperative evaluation using the microTEE probe. Good quality two-dimensional and color Doppler images were obtained in all patients. There were no complications related to the probe insertion or manipulation. The findings on microTEE led to revision of surgery in five patients. Certain echocardiographic parameters that could never be recorded with epicardial echocardiogram could be easily seen in microTEE. Conclusion: On preliminary evaluation, the microTEE probe provided good quality images in very small infants who were not amenable for transesophageal echocardiographic evaluation so far. The probe could be used safely in small infants without complications. It appears to be a promising imaging modality in the perioperative assessment of young infants undergoing cardiac surgery, in whom intraoperative epicardial echocardiography is currently the only tool.

Impact of Abernathy malformation on pulmonary circulatory hemodynamics in a univentricular heart

© 2017 Annals of Pediatric Cardiology | Published by Wolters Kluwer ‐ Medknow Sir, An 18-month-old male child weighing 9 kg with oxygen saturations of 78% was diagnosed to have heterotaxy, left isomerism, dextrocardia, right azygos continuation of the inferior vena cava, common atrioventricular valve, single ventricle, and pulmonary atresia. Cardiac catheterization demonstrated a communication from the renal portion of inferior vena cava to the final common splenic vein arising from multiple splenunculi [Figure 1 and Video 1]. The pulmonary artery pressures were recorded to be 15 mmHg through an end-hole catheter through the ductus arteriosus. There were no secondary effects attributable to this Abernathy malformation, and hence, it was not closed. He underwent total cavopulmonary (Kawashima) shunt uneventfully.

Tetralogy of Fallot with subarterial ventricular septal defect: Surgical outcome in the current era.

Background: Tetralogy of Fallot (TOF) with subarterial ventricular septal defect (VSD) is more common among Asians than Caucasians. Compared with the regular subaortic VSD postoperative right ventricular outflow obstruction is more common because of the sub-pulmonary extension of the defect. The objective of this study is to analyze the surgical implications and outcomes of patients with TOF - subarterial VSD in the current era. Patients and Methods: In all, 539 consecutive operated patients with TOF from May 2005 to September 2012 were retrospectively reviewed. Eighty-five patients had subarterial VSD. Seventy-nine of these underwent intracardiac repair. Preoperative clinical, echocardiographic features, operative and postoperative variables were assessed. Results: The median age at surgery was 6 years and the median weight was 14 kilograms. The male to female ratio was 1.7:1. TOF with subarterial VSD was associated with frequent use of transannular patch (74.6%). The early mortality was 2.5%. Follow up was 92% complete with a mean duration of 20 months with actuarial survival of 97.3% at 5 years. Two patients required reoperation for significant right ventricular outflow tract obstruction (RVOTO) at one year and three years, respectively. Conclusions: Intra cardiac repair for TOF with subarterial VSD has low perioperative mortality and morbidity. Transannular patch augmentation of the right ventricular outflow tract (RVOT) is required in a significant proportion of these patients. Precise suturing of the VSD patch, adequate infundibular resection and lower threshold for a transannular patch placement ensures a smooth early postoperative recovery.

Arterial Switch Operation for Double-Outlet Left Ventricle

Conventional repair of the double-outlet left ventricle involves a complex intraventricular tunnel, extracardiac conduit, or the pulmonary artery translocation operation. We report an arterial switch operation and closure of ventricular septal defect for anatomic correction of this anomaly.

Stent angioplasty of narrowed right ventricular outflow conduits and pulmonary arteries consistently reduces right ventricular systolic pressures and delays subsequent surgeries

OBJECTIVES Narrowed right ventricular (RV) outflow conduits and pulmonary arteries (PA) increase RV pressures and warrant interventions. Stent angioplasty is an alternative to more morbid redo-surgery in developing countries. We evaluate the efficacy and safety of stenting and assess need for redo-surgical reinterventions on midterm follow-up after stent angioplasty. METHODS Patients who underwent conduit, main PA and bilateral branch PA stenting for elevated RV pressures were analyzed retrospectively. Success was defined as 20% reduction in RV pressures or RV-aortic pressure ratio; 50% reduction in gradients or 50% increase of luminal diameter. Procedural results, complications and need for redo surgeries on follow-up were assessed. RESULTS Among 60 patients aged 1-46years, 57 were post-operative patients, who needed stenting at a median period of 48 months after surgery. Stenting succeeded in 98% and reduced RV pressures from 105.42±28.39mmHg to 54.46±16.89mmHg. Direct major procedural complications in five (8%) patients included procedural failure in one, stent migration in three and lung hemorrhage in one. None of the stented conduits needed a surgical change on a follow-up ranging 3-120 months. Following bilateral PA stenting in twenty-four patients, only two needed a repeat open-heart surgery during follow-up ranging 3-108 months. Catheter reinterventions on follow-up included elective percutaneous pulmonary valve implantation in nine patients and stent redilation in seven patients. CONCLUSIONS Stent angioplasty was safe and effective. Surgery was postponed in all stenosed conduits. Elective redilation of stents after bilateral PA stenting may be needed for somatic growth; but open-heart repeat surgeries can be avoided in a majority.

Case report: pericardial adhesions from a previous coronary artery bypass surgery contain a left ventricular free wall rupture after an acute myocardial infarction to form a pseudoaneurysm

Abstract Background Fatal mechanical complications of acute myocardial infarctions include free wall rupture and ventricular septal rupture. If pericardial adhesions wall off a free wall rupture, it may lead to formation of pseudoaneurysms that are characterized by a narrow mouth. Even though pseudoaneurysms are common after myocardial infarctions, they may also occur following surgery, trauma, and infections rarely. Case summary We present a case of a 62-year-old man who developed a left ventricular pseudoaneurysm 2 weeks after thrombolysis for an acute inferolateral myocardial infarction. Multiple non-invasive imaging modalities demonstrated the anatomy, regional and global ventricular function, distortion of mitral annulus by the eccentric large aneurysm. Pericardial scars after a previous coronary bypass surgery contained this left ventricular free wall rupture and helped in providing a safe window period for corrective surgery. Discussion While left ventricular pseudoaneurysms that develop following myocardial infarctions warrant emergency surgery due to the high impending chances of rupture and tamponade, previous surgical pericardial adhesions guarded against an imminent collapse. Multimodality imaging of the aneurysm helped in planning the surgical strategy.

Massive pericardial effusion, yet no signs of tamponade!

Our patient was incidentally detected to have 32 mm secundum ASD with deficient postero-inferior margin. Pericardial patch closure of the defect on cardiopulmonary bypass through the right posterolateral thoracotomy was uneventful; she was shifted to the ward on the 2nd day after chest tube removal. Although she remained asymptomatic, predischarge echocardiogram on the 6th day showed no residual ASD, good ventricular function, a massive pericardial effusion, and right pleural effusion, with the heart swinging in the pericardial fluid space [Figure 1 and Video 1]. A communication created between the right pleural and pericardial cavities during the postero-lateral thoracotomy served to reduce the pericardial pressures in spite of holding 1.2 L of fluid. When intrathoracic pressures fell during inspiration, color Doppler indicated the movement of pericardial fluid into the pleural cavity [Figure 2 and Video 2]. This inspiratory reduction in pericardial volume permitted unhindered systemic and pulmonary venous return. There was no right atrial or ventricular diastolic collapse, and mitral and tricuspid flows were normal [Figure 3 and Video 3]. After aspirating sanguinochylous fluid with high triglyceride levels using a percutaneous pigtail catheter and dietary modifications, she was discharged home the next day. There was no recurrence at 1-week and 1-month follow-up. The nature of fluid and relief after single aspiration indicates the etiology being small vessel and lymphatic injury during dissection.

Transhepatic permanent pacing in a child with complex cyanotic heart disease after total cavo pulmonary shunt (Kawashima repair).

Complex cyanotic congenital heart diseases with left isomerism are sometimes associated with atrioventricular nodal conduction disturbances that may need permanent pacing. Surgical palliation in such anatomy connecting the superior vena cava to the pulmonary artery precludes a transvenous access for an endocardial pacing lead to the ventricles. Epicardial leads in these patients fail if the pacing thresholds are very high. We report transhepatic permanent ventricular lead implantation for a young boy with heterotaxy complicated by complete heart block.