Snehal Kulkarni

Vascular ultrasound imaging to study immediate postcatheterization vascular complications in children

Vascular occlusion is the major complication of percutaneous cardiac catheterization in children. This is a prospective study to evaluate post catheterization vascular complications in 120 consecutive children with the help of vascular ultrasound and Doppler imaging. Ultrasound imaging of both iliac and femoral veins and arteries was done one hour prior and 24 hours after cardiac catheterization. Patients with prior thrombus or occlusion of femoral/iliac vein or artery due to previous cardiac catheterization were excluded from the study. Age of the patients ranged from 22 days to 12 years with a mean of 56 months and weight ranged from 3 to 57 kgs with a mean of 14.3 kgs. Procedure time was less than 60 minutes in 74 patients (61.66%) and more than 60 minutes in 46 patients (38.33%). 4F sized arterial sheath was used in 108 patients. 5F or bigger sized arterial sheath was used in remaining 12 patients. Incidence of arterial occlusion was higher in patients weighing less than 10 kgs (16%) as compared with patients weighing more than l0 kgs (5.5%) {P = 0.031}. Arterial thrombosis was more in infants (16%) as compared with older children (7%) {P = 0.203} Prolonged procedure time or use of larger sized sheath did not have higher incidence of arterial occlusion. Venous thrombosis was found in 2 patients (1.66%) who had 5F venous sheath. One patient had arterio venous fistula. Our study shows vascular ultrasound imaging can provide anatomical details of femoral and iliac vessels and is a easier and accurate method of assessing postcatheterization vascular complications in children.

Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after complete surgical repair of tetralogy of Fallot: A prospective randomized controlled study

Introduction: Incidence of junctional ectopic tachycardia (JET) after repair of tetralogy of Fallot (TOF) is 5.6–14%. Dexmeditomidine is a α-2 adrenoceptor agonist modulates the release of catecholamine, resulting in bradycardia and hypotension. These effects are being explored as a therapeutic option for the prevention of perioperative tachyarrhythmia. We undertook this study to examine possible preventive effects of dexmedetomidine on postoperative JET and its impact on the duration of ventilation time and length of Intensive Care Unit stay. Methods: After obtaining approval from the hospitals ethics committee and written informed consent from parents, this quasi-randomized trial was initiated. Of 94 patients, 47 patients received dexmedetomidine (dexmedetomidine group) and 47 patients did not receive the drug (control group). Results: Dexmedetomidine group had more number of complex variants like TOF with an absent pulmonary valve or pulmonary atresia (P = 0.041). Hematocrit on cardiopulmonary bypass (CPB), heart rate while coming off from CPB and inotrope score was significantly low in the dexmedetomidine group compared to control group. The incidence of JET was significantly low in dexmedetomidine group (P = 0.040) compared to control group. Conclusions: Dexmedetomidine may have a potential benefit of preventing perioperative JET.

Infective endocarditis following balloon dilatation of mitral valve

Three cases of infective endocarditis were encountered following balloon dilatation of the mitral valve. The diagnosis was difficult due to negative blood cultures and nondiagnostic transthoracic echocardiogram, the latter the consequence of the preexisting severe rheumatic valvar disease. Transoesophageal echocardiography proved superior in diagnosis. The possible causes and means of preventing this potentially lethal complication are discussed.

Neonates with critical congenital heart defects: Impact of fetal diagnosis on immediate and short-term outcomes

Background: Fetal echocardiography is being increasingly used for prenatal diagnosis of congenital cardiac malformations, but its impact on the neonatal outcomes in low- and middle-income countries is still unknown. Aims: The objective of this study is to determine the impact of fetal echocardiography on immediate postnatal and short.term outcome in a tertiary pediatric cardiac center. Study Design: This is a prospective study. Materials and Methods: One hundred consecutive patients with critical congenital heart defects (CHD) requiring active medical or surgical interventions in the 1st month of life were included in the study. The detailed history, postnatal examination findings, and fetal echocardiogram report were recorded. They were divided into two groups as antenatally diagnosed and postnatally diagnosed. Pre- and post-procedural variables were compared between the two groups. Results: Twenty-nine neonates were diagnosed antenatally while 71 were diagnosed postnatally. Totally, 10 babies (34.5%) among the antenatally diagnosed group were delivered in a tertiary health-care setup. The mean age at presentation was 0. day in the antenatally diagnosed group while 10 days. (0–30 days) in the postnatally diagnosed group. (P = 0.01). A total of 17 (58.6%) patients in the antenatal group had duct dependent CHD, and 15 (88.2%) of these patients were transported on prostaglandin E1. In comparison, 19/34 (55.9%) patients in the postnatal group were transported on prostaglandin. The pH on admission in the antenatal group was 7.32 ± 0.05 as compared to 7.28 ± 0.05 in the postnatal group. (P = 0.0004). There were 4 (5.6%) deaths in the postnatal group during transfer. There was no significant difference in the postoperative variables in both groups. Conclusions: Fetal echocardiography identifies patients with complex CHD resulting in better parental counseling, thus facilitating delivery at a tertiary care center and preoperative stabilization. This results in improved preoperative mortality and better stabilization.

Isolated Subclavian Artery: A Rare Entity Revisited.

Isolation of the subclavian artery is a rare aortic arch anomaly with fewer than 100 cases reported in the literature. Left subclavian artery isolation is seen in 0.8% of right aortic arches, and right subclavian artery isolation is seen four times less frequently. Other intracardiac or arch malformations are usually associated, among which tetralogy of Fallot is commonly described. We describe the presentation, preoperative imaging, surgical strategies, and outcomes of four patients with this rare condition and review the published literature. The embryological basis and interesting pathophysiology are also discussed. Surgical division and reimplantation of the isolated subclavian artery onto the aortic arch or common carotid artery is the treatment of choice, with good immediate and midterm outcomes.

Rare associations of tetralogy of Fallot with anomalous left coronary artery from pulmonary artery and totally anomalous pulmonary venous connection.

We describe the cases of two patients with tetralogy of Fallot, aged 4 years and 8 months, who were incidentally detected to have concomitant anomalous left coronary artery from pulmonary artery and total anomalous pulmonary venous connection, respectively, on preoperative imaging. They underwent surgical correction with good mid-term outcomes. In this study, we discuss the embryological basis, physiological effects, and review the literature of these two unusual associations. Awareness of these rare associations will avoid missed diagnoses and consequent surgical surprises.

Effect of preoperative propranolol on postoperative junctional ectopic tachycardia after complete surgical repair of Tetralogy of Fallot: A prospective observational study

Background: Postoperative junctional ectopic tachycardia (JET) is a common and transient phenomenon occurring after repair of Tetalogy of Fallot (TOF). Although propranolol is used in these patients to prevent and control hypercyanotic spells, its effects are not widely studied in postoperative scenario. Aims: The aim of this study was to examine the effect of preoperative use of propranolol on the incidence of postoperative JET after complete surgical correction of TOF. Materials and Methods: This is a prospective observational study of 51 patients undergoing complete repair of TOF between July 2010 and February 2012. Of these, 25 patients did not receive propranolol (control group) and 26 patients did receive it (propranolol group). Results: Lowest hematocrit on Cardiopulmonary Bypass (CPB) was significantly low in control group compared to propranolol group (P = 0.008). Though inotropic score was high (P = 0.015), incidence of postoperative JET was significantly low in propranolol group compared to control group (P = 0.040). Conclusions: Our findings suggest that the preoperative use of propranolol is associated with a lower incidence of JET after complete surgical repair of TOF. A randomized control trial should be considered to explore causality.

Definitive therapy for hypoplastic left heart syndrome – Indian scenario

When most of the centers in India do not entertain the patients with hypoplastic left heart syndrome, the original authors of the article in the present issue should be congratulated for the attempt of treating this patient with hybrid procedure. Its a spectacular beginning.

Neonatal Ross Konno procedure with aortic arch repair—a case report

A 14-day-old neonate presented with severe left ventricular outflow tract obstruction (LVOTO) and type B interrupted aortic arch. The child underwent a neonatal Ross Konno with interposition graft for arch reconstruction.

Delayed diagnosis of infective endocarditis in a child with a normal heart.

Sir, A 12 yold boy was admitted with high fever, and poor oral intake of 1 wk duration. Enteric fever was suspected and treatment with ceftriaxone initiated. Fever continued with rise in WBC count and CRP and fall in platelets. The blood culture was sterile and WIDAL was negative. Repeat malarial smears were negative and an abdominal ultrasound showed mild hepatosplenomegaly. Fever persisted and features of pneumonia appeared with tachypnea, hypoxemia and left sided consolidation on CXR. CT scan chest showed bilateral pneumonia with mild effusion. In view of non response to standard therapy, other unusual etiologies such as mycoplasma, scrub typhus, community acquired MRSA were considered and antibiotics upgraded to imipenem, linezolid, doxycycline and levofloxacin. The repeat blood culture grew methicillin sensitive S. aureus (MSSA). Owing to isolation of S. aureus and appearance of a soft systolic murmur on the precordium, a 2D ECHO was done which showed large pedunculated freely mobile vegetation attached to the septal leaflet of the tricuspid valve with mild dilatation of right atrium and moderate tricuspid regurgitation. This clinched the diagnosis of staphylococcal infective endocarditis with septic pulmonary embolism. Antibiotics cloxacillin and gentamycin were started as per standard recommendations. Over the next 1 wk, the fever completely resolved but the vegetation became more friable and mobile. Hence, vegetectomy and tricuspid valve repair was performed. Culture from tricuspid vegetation was sterile. IV cloxacillin was given for 4 wks. At 3 mo follow up the child is asymptomatic with a near normal ECHO. The absence of classical risk factors, the faint murmur of tricuspid regurgitation and failure to auscultate on a daily basis possibly led to delay in the diagnosis in the index case. The usual risk factors for TVE (Tricuspid Valve Endocarditis) include intravenous drug use, intracardiac catheterization, cardiac anomalies, immunodeficiency and indwelling central venous lines [1]. However TVE in children and adults with normal hearts and no risk factors have been reported with a high incidence of pulmonary embolism, sudden death, need for surgical intervention and poor surgical outcome [2-4]. The classical indications for surgical intervention in right sided endocarditis are persistent sepsis (intractable right heart failure or recurrent pulmonary embolism [5]. In the index case clinical and microbiologic cure had been achieved. However, in view of the largemobile and friable vegetation and in light of a previous case reports wherein children died suddenly due to pulmonary embolism, a decision to surgically intervene was taken. Infective endocarditis should be considered as a differential diagnosis in patients with prolonged pyrexia even if classical risk factors are absent. Meticulous and daily clinical cardiovascular evaluation is a must in all patients.