Raman Krishna Kumar

Transcatheter closure of very large (≥ 25 mm) atrial septal defects using the Amplatzer septal occluder

Between June 1999 and September 2002, 45 patients (age, 34 ± 13 years; mean shunt ratio, 2.6 ± 0.6) underwent transcatheter atrial septal defect (ASD) closure at our institution with the Amplatzer septal occluder (mean device size, 31.4 ± 3 mm). Patients were selected by transesophageal echocardiography. The mean ASD dimension was 25.3 ± 3.7 mm and 33 (73%) patients had deficient anterior rim. Specific procedural details included the use of 13 or 14 Fr introducer sheaths and the right upper pulmonary vein approach if the conventional approach failed. There were two procedural failures, with device embolization in both (surgical retrieval in one, catheter retrieval in one). During follow‐up (3–30 months; median, 16 months), one patient (59 years) with previous atrial flutter had pulmonary embolism and was managed with anticoagulation. Two patients developed symptomatic atrial flutter. Fluoroscopy time was 31.6 ± 19.5 min for the first 22 cases and 19.6 ± 11.4 min for the rest (P = 0.04). Transcatheter closure of large ASDs is technically feasible but careful long‐term follow‐up is needed to document its safety. Cathet Cardiovasc Intervent 2003;59:522–527.

Echocardiographic Screening for Rheumatic Heart Disease in High and Low Risk Australian Children

Background— Echocardiographic screening for rheumatic heart disease (RHD) is becoming more widespread, but screening studies to date have used different echocardiographic definitions. The World Heart Federation has recently published new criteria for the echocardiographic diagnosis of RHD. We aimed to establish the prevalence of RHD in high-risk Indigenous Australian children using these criteria and to compare the findings with a group of Australian children at low risk for RHD. Methods and Results— Portable echocardiography was performed on high-risk Indigenous children aged 5 to15 years living in remote communities of northern Australia. A comparison group of low-risk, non-Indigenous children living in urban centers was also screened. Echocardiograms were reported in a standardized, blinded fashion. Of 3946 high-risk children, 34 met World Heart Federation criteria for definite RHD (prevalence, 8.6 per 1000 [95% confidence interval, 6.0–12.0]) and 66 for borderline RHD (prevalence, 16.7 per 1000 [95% confidence interval, 13.0–21.2]). Of 1053 low-risk children, none met the criteria for definite RHD, and 5 met the criteria for borderline RHD. High-risk children were more likely to have definite or borderline RHD than low-risk children (adjusted odds ratio, 5.7 [95% confidence interval, 2.3–14.1]; P<0.001). Conclusions— The prevalence of definite RHD in high-risk Indigenous Australian children approximates what we expected in our population, and no definite RHD was identified in the low-risk group. This study suggests that definite RHD, as defined by the World Heart Federation criteria, is likely to represent true disease. Borderline RHD was identified in children at both low and high risk, highlighting the need for longitudinal studies to evaluate the clinical significance of this finding.

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.

Bioptome-assisted coil occlusion of moderate-large patent ductus arteriosus in infants and small children.

Coil occlusion of patent ductus arteriosus (PDA), although inexpensive, is technically challenging for the moderate‐large ducts in small children. Bioptome assistance allows better control and precision. We describe case selection strategies, technique, immediate and short‐term results of bioptome‐assisted closure of moderate‐large (≥ 3 mm) PDA in 86 infants and children ≤ 10 kg (age, 18 days to 3 years; median, 8 months; weight, 6.6 ± 1.9 kg; duct size, 3.6 ± 0.8 mm; pulmonary artery mean pressures, 33 ± 12 mm Hg). Patients with PDA > 6 mm (> 4 mm for children under 5 kg) and/or shallow ampullae (by echocardiography) underwent operation (n = 41). Specific technical modifications included use of long sheaths (5.5–8 Fr) for duct delineation and coil delivery, cutting of coils turns (51 patients) to accommodate the coils in the ampulla, and simultaneous delivery of multiple coils (n = 43). As far as possible, coils were deployed entirely in the ampulla. Median fluoroscopy time was 7.3 min (1.2–42 min). Successful deployment was feasible in all (final pulmonary artery mean pressures, 20 ± 4.6 mm Hg). Coils embolized in 14 (16%) patients (all retrieved). Complete occlusion occurred immediately in 63 patients (73%) and in 77 patients (89%) at 24 hr. Three patients had new gradients in the left pulmonary artery. Follow‐up (62 patients; median duration, 13 months) revealed small residual Doppler flows in 11 patients (18%) at the most recent visit. Bioptome‐assisted coil occlusion of moderate‐large PDA in selected infants and small children is feasible with encouraging results. Catheter Cardiovasc Interv 2004;62:266–271.

What Determines Nutritional Recovery in Malnourished Children After Correction of Congenital Heart Defects

BACKGROUND: Malnutrition is common in children with congenital heart disease (CHD), especially in developing countries. OBJECTIVE: To examine the impact of corrective intervention on the nutritional status of children with CHD and identify factors associated with suboptimal recovery. METHODS: Consecutive patients with CHD in a tertiary center in South India were evaluated for nutritional status before and 2 years after corrective intervention. Anthropometry was performed at presentation and every 6 months for 2 years, and z scores were compared. Malnutrition was defined as a weight-for-age, height-for-age, and weight/height z score <−2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model. RESULTS: Of 476 patients undergoing corrective intervention (surgical: 344; catheter-based: 132) z scores of less than −2 for weight for age, height for age, and weight/height were recorded in 59%, 26.3%, and 55.9% of patients, respectively, at presentation. On follow-up (425 patients [92.5% of survivors; 20.63 ± 13.1 months of age]), z scores for weight for age and weight/height improved significantly from the baseline (weight: −1.42 ± 1.03 vs −2.19 ± 1.16; P < .001; weight/height: −1.15 ± 1.25 vs −2.09 ± 1.3; P < .001). Height-for-age z scores were not significantly different. Malnutrition persisted in 116 (27.3%) patients on follow-up and was associated with a birth weight of ≤2.5 kg, nutritional status at presentation, and height of parents and not with type of cardiac lesion, dietary intake, or socioeconomic factors. CONCLUSIONS: This study from South India demonstrates severe malnutrition in over half of the patients with CHD and is not always reversed by corrective surgery or intervention. Persistent malnutrition after corrective intervention is predicted by nutritional status at presentation, birth weight, and parental anthropometry.

Transesophageal echocardiography for device closure of atrial septal defects: case selection, planning, and procedural guidance.

transcatheter closure is an effective alternative to surgery in most patients with atrial septal defects (ASDs) of the secundum type ([1,2][1]). Factors that decide suitability for transcatheter closure include size of the defect and presence of adequate tissue rims around the defect ([3][2]).

Transcatheter closure of fistula between the right pulmonary artery and left atrium using the Amplatzer duct occluder

A congenital fistula between the right pulmonary artery and the left atrium is a rare condition that results in cyanosis. We report a successful catheter‐based closure of such a fistula in a 12‐year‐old using an Amplatzer duct occluder. The patient also had an atrial septal defect that was closed with an Amplatzer septal occluder. Catheter Cardiovasc Interv 2004;63:83–86.

Closure of muscular ventricular septal defects guided by en face reconstruction and pictorial representation.

BACKGROUND A surface reconstruction of the location and dimensions of muscular ventricular septal defects (VSDs) on right ventricular (RV) septal surface could serve as a better guide to surgical closure amid different classifications and confusing terminologies. METHODS We reconstructed muscular VSD requiring surgery on an en-face view of the RV septal surface from echocardiographic orthogonal views in 34 consecutive patients. The location, dimensions of the defects, and relation to various RV septal landmarks are illustrated as a diagram. Recommendations are presented regarding surgical approach to the defects, along with predictions on the possibility of residual defects and heart block. RESULTS Surgical findings were as predicted by the diagram in the 27 patients who underwent VSD closure. Seven infants (2.5 to 4.9 kg) underwent pulmonary artery (PA) banding based on predictions of heart block or major residual defects. Two patients with predicted risk of heart block underwent VSD closure with heart block ensuing in one of them. Based on the diagram limited ventriculotomy (n = 2) or detachment of tricuspid leaflets (n = 6) aided access to the VSD. Among patients undergoing VSD closure only 1 patient had a major residual defect that required PA banding. There were clinically insignificant residual defects in 8 patients. Four patients (12%) were anticipated preoperatively because of surgical inaccessibility and intentionally left alone. CONCLUSIONS En-face reconstruction of single or multiple muscular VSDs is feasible from orthogonal echocardiographic views. It helps plan the surgical approach and predict the likelihood of heart block and residual defects after surgery.

Catheter closure of atrial septal defects with deficient inferior vena cava rim under transesophageal echo guidance

Objectives: To describe the case selection, imaging considerations, technique, and results of catheter closure of atrial septal defects (ASD) with deficient inferior vena cava (IVC) rim. Background: Transcatheter closure with Amplatzer septal occluder (ASO) has become standard treatment for most secundum ASDs. Defects with deficient IVC rim continue to be challenging to image and close in the catheterization laboratory. Methods: Records of 12 patients with deficient IVC rim (<5 mm), who underwent catheter closure (April 2007 to June 2008) were reviewed. General anesthesia and transesophageal echo (TEE) guidance was used in all. The IVC rim was imaged at 70°–90° with retroflexion of the TEE probe, in addition to the conventional views. Devices 1–4 mm > maximal ASD size were selected. Deployment was accomplished either from the left atrium, left upper or from the right pulmonary veins. Results: The median age was 5.5 (2.5–27) years and median weight was 19.5 (9‐65) kg. The defects measured 16–32 mm and 18–36 mm septal occluders were used. The median fluoroscopic time was 13.1 (4.2–32.7) min. Initial device selection was revised in four patients. Two patients had residual flows at IVC margin. The device embolized to right ventricular outflow tract in one patient. This was retrieved, and a larger device was deployed. No other complications were observed immediately or on follow‐up (median 6; range 1–14 months). Conclusions: Transcatheter closure of ASDs with deficient IVC rim is feasible under TEE guidance. The modified retroflexed view allows adequate imaging of IVC rim through TEE.

Dynamics of growth and weight transitions in a pediatric cohort from India

BackgroundThere is paucity of information regarding time trends of weight status in children from rapidly developing economies like India. The aim of the study was to analyse the dynamics of growth and weight transitions in a cohort of school children from India.MethodsA population of 25 228 children was selected using stratified random sampling method from schools in a contiguous area in Ernakulam District, Kerala, India. Weight and height were measured at two time points, one in 2003-04 and another in 2005-06. The paired data of 12 129 children aged 5-16 years were analysed for the study.ResultsThe mean interval between the two surveys was 2.02 ± 0.32 years. The percentage of underweight, normal weight, overweight and obese children in the year 2003-04 were 38.4%, 56.6%, 3.7%, and 1.3% respectively. The corresponding figures in year 2005-06 were 29.9%, 63.6%, 4.8% and 1.7% respectively. Among the underweight children, 34.8% migrated to normal weight status and 0.1% migrated to overweight status. Conversion of underweight to normal weight predominated in urban area and girls. Among the normal weight children, 8.6% migrated to underweight, 4.1% migrated to overweight and 0.4% migrated to obesity. Conversion of normal weight to overweight status predominated in urban area, private schools and boys. Conversion of normal weight to underweight predominated in rural area, government schools and boys. Among the overweight children, 26.7% migrated to normal weight status, 16.4% became obese and 56.9% retained their overweight status. Of the obese children, 6.2% improved to normal weight status, 25.3% improved to overweight status and 68.5% remained as obese in 2005-06. There was significant difference in trends between socio demographic subgroups regarding conversion of underweight status to normal weight as well as normal weight status to overweight.ConclusionThe study population is experiencing rapid growth and nutritional transitions characterised by a decline in the underweight population coupled with an escalation of the overweight population. The heterogeneous nature of this transition appears to be due to differences in socio demographic factors.