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Cardiac catheterization in children with pulmonary hypertensive vascular disease: consensus statement from the Pulmonary Vascular Research Institute, Pediatric and Congenital Heart Disease Task Forces. - Pulmonary circulation
Cardiac catheterization is important in the diagnosis and risk stratification of pulmonary hypertensive vascular disease (PHVD) in children. Acute vasoreactivity testing provides key information about management, prognosis, therapeutic strategies, and efficacy. Data obtained at cardiac catheterization continue to play an important role in determining the surgical options for children with congenital heart disease and clinical evidence of increased pulmonary vascular resistance. The Pediatric and Congenital Heart Disease Task Forces of the Pulmonary Vascular Research Institute met to develop a consensus statement regarding indications for, conduct of, acute vasoreactivity testing with, and pitfalls and risks of cardiac catheterization in children with PHVD. This document contains the essentials of those discussions to provide a rationale for the hemodynamic assessment by cardiac catheterization of children with PHVD.
Graft function and nutritional parameters in stable postrenal transplant patients. - Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia
Bioelectrical impedance analysis (BIA) is a method for the assessment of nutritional status. We studied the effect of graft function on nutritional status in postrenal 45 transplant patients with borderline to good allograft function using BIA. The patients had a mean serum creatinine of 1.42 Â± 0.42 mg% and mean glomerular filtration rate (GFR) of 45.1 Â± 14.1 mL/min. Based on BIA-derived GFR, the patients were divided into two groups; group 1: borderline graft function GFR <40 mL/min and a mean of 27.34 Â± 9.1 mL/min and group 2: good graft function GFR â‰¥40 mL/min and a mean of 51.60 Â± 9.16 mL/min. The patient data were compared with 30 healthy individuals. There was a significant difference between healthy controls and the posttransplant patients. There were significant differences between the study groups in body weight (P <0.01), serum creatinine (P <0.005), body mass index (BMI) (P <0.000), fat free mass (FFM) (P <0.003), fat mass (FM) (P <0.003), body cell mass (P <0.000), and dry weight (P <0.001). Group 1 had significantly lower body weight, BMI, FFM, FM, and dry weight, indicating poorer nutritional status compared with those in group 2. Based on phase angle, there were significant differences between group A (phase angle <4.0) and group B (phase angle >4.0) in extracellular water (P <0.015), intracellular water (P <0.002), plasma fluid (P <0.016), interstitial fluid (P <0.016), and body cell mass (P <0.024). Subjective global assessment (SGA) scores showed that transplant patients had normal nutritional status, but when compared with healthy individuals as assessed by BIA, there were significant differences in FM, FFM, and body cell mass. In conclusion, BIA was more sensitive to evaluate nutritional depletion than SGA in transplant patients with borderline.
Mid-term outcomes of patients undergoing adjustable pulmonary artery banding. - Indian heart journal
The adjustable pulmonary artery band (APAB) has been demonstrated by us earlier to be superior to the conventional pulmonary artery banding (CPAB), in terms of reduced early morbidity and mortality. In this study, we assessed the adequacy of the band and its complications over the mid-term.Between 2002 and 2012, 73 patients underwent adjustable PAB, and their operative and follow-up data were collected and analyzed.There was one early death following the APAB. Follow-up data were available for 57 patients of which 44 patients (61.7%) underwent definitive repair, 10 were awaiting definitive repair, and 3 patients were kept on medical follow-up because of inadequate fall in pulmonary artery (PA) pressures. 14 patients (19%) were lost to follow-up. Major PA distortion or stenosis was absent in the majority. 1 patient had pseudoaneurysm of the main pulmonary artery (MPA) with sternal sinus infection and required surgical reconstruction. 1 patient had infective endocarditis of the pulmonary valve managed medically. Band migration was not encountered. There were two deaths after definitive repair and one after APAB.Patients undergoing APAB fulfilled the desired objectives of the pulmonary artery banding (PAB) with minimum PA complications in the mid-term. This added to the early postoperative benefits, makes the APAB an attractive alternative to the CPAB.Copyright Â© 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Rheumatic heart disease screening by "point-of-care" echocardiography: an acceptable alternative in resource limited settings? - Translational pediatrics
Rheumatic heart disease (RHD) is estimated to affect over 20 million people worldwide, the vast majority being in developing countries. Screening for RHD has been recommended by World Health Organization (WHO) since 2004. Conventionally, auscultation has been used for diagnosing RHD. Auscultation has its limitations and may not detect mild cases. With the evolution of portable echocardiographic systems, mass screening for subclinical RHD has become possible. Portable echo has the advantage of rapid access and hence screening in schools or communities is possible. Its cost is lower than that of standard echo equipment. A large number of studies have reported echocardiographic screening for RHD over the last decade or so. A 3-10 fold increase in prevalence of RHD has been detected by using portable echo when compared with conventional method of auscultation. More recently, a small, compact, easy to carry in a pocket, hand held system has been introduced which is much cheaper than the conventional portable system. A few previous reports have shown the feasibility of using hand held echo system for diagnosis of various cardiac diseases. A recently published article has shown that the hand held system can be used to screen for RHD. It is more sensitive than the conventional auscultation for RHD. Authors of this report have concluded that screening with the hand held device may be a more cost effective strategy for screening for RHD in resource limited settings, since it is much cheaper than the portable echocardiography equipment.
Oscillometric Blood Pressure in Indian School Children: Simplified Percentile Tables and Charts. - Indian pediatrics
Data on blood pressure recorded by oscillometric method is limited.To develop simplified tables and charts of blood pressure recorded by oscillometric method in children.Cross-sectional.Ballabhgarh, Haryana.Healthy school-children.Blood pressure measured by oscillometric method.The study group included 7,761 children (58.4% males) with mean (SD) age of 10.5 (2.8) years. Age and gender were used to create simplified percentile tables and charts, as height was seen to explain very little variability of either systolic or diastolic blood pressure. Formulae for SBP and DBP thresholds for hypertension were derived as [110 + 1.6 x age] and [79 + 0.7 x age], respectively, with 1 mm Hg to be added for females. 95th percentile values suggest simple levels indicating hypertension to be 120/80, 125/85 and 135/90 at ages of 5, 10 and 15 years, respectively.Simplified reference tables and charts, formulae for SBP and DBP, and simple convenient thresholds may be useful for rapid screening of hypertension using oscillometric method.
Results of Fontan operation in patients with congenitally corrected transposition of great arteriesâ€ . - Interactive cardiovascular and thoracic surgery
The purpose of this study was to examine the outcome after the Fontan operation in patients with congenitally corrected transposition of great arteries with ventricular septal defect and pulmonary stenosis (ccTGA-VSD-PS).Patient- and procedure-related variables were analysed in 23 patients with ccTGA-VSD-PS operated between April 2003 and April 2015.The mean age was 14.07 Â± 6.38 years (range 4-23, median 11 years), with 82% patients being male (19/23). Dextrocardia was present in 52% (12/23) of patients and left superior vena cava was present in 26% (6/23) of patients. Most patients underwent extracardiac Fontan (n = 18), whereas in 5 patients lateral tunnel Fontan was performed. All patients received polytetrafluoroethylene grafts of size 18-22 mm for extracardiac Fontan. In 8 patients, conduits were fenestrated to reduce the intraconduit pressure. The mean hospital stay was 15.7 Â± 11.24 days (5-60, median 14 days). The most common cause for prolonged hospital stay was pleural effusion in 5 patients (21.7%). One 7-year old patient developed conduit thrombosis, intracranial bleed, seizures and died. The mean follow-up was 46.4.4 Â± 32.2 months (range 8-142, median 42 months) and was available for 21 patients (91.3%). There was 1 mid-term non-cardiac death after 3 years of operation. Of the total, 85.7% (18/21) patients in follow-up are in NYHA class I, whereas 3 patients are in class II. The actuarial event-free survival rate was 81.8 Â± 13.2% at 10 years.In ccTGA-VSD-PS patients with non-routable VSD and in those with difficult options for biventricular repair, the Fontan approach provides satisfactory mid-term palliation.Â© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Changes in Myocardial Contractility and Electromechanical Interval During the First Month of Life in Healthy Neonates. - Pediatric cardiology
This study aims at documenting the changes in ventricular tissue velocities, longitudinal strain and electromechanical coupling during the first month of life. During the neonatal period, when the ventricular myocardium is not yet fully maturated, the heart is subjected to significant hemodynamic changes. We studied the ventricular performance of 16 healthy neonates at three time points over the first month of life: on days 2 (IQR [2;2]), 13 [12;14] and 27 [25;29]. We found that systolic and diastolic tissue velocities increased significantly in both left and right ventricle (by 1.2-1.7 times, pÂ <Â 0.001). Congruently, we found that peak systolic longitudinal strain of the right and left ventricles increased significantly. However, no significant changes in longitudinal strain rate were observed. Finally, QS-intervals shortened during the neonatal period: being measured at 12 points throughout the left ventricle, time to peak systolic velocity decreased on average to 89Â % in the second and to 80Â % in the fourth week of life (22.3Â Â±Â 0.2 vs. 19.8Â Â±Â 0.3 vs. 17.8Â Â±Â 0.5Â ms, rÂ =Â -0.564, pÂ <Â 0.001). When comparing opposing walls of the left ventricle, no dyssynchrony in left ventricular contraction was found. In addition to increasing systolic and diastolic tissue velocities during the first month of life, the time to peak systolic contraction shortens in the neonatal heart, which may reflect an increasing efficiency of the excitation-contraction coupling in the maturing myocardium. While there appears to be no dyssynchrony in ventricular contraction, these findings may extend our appreciation of the immature neonatal heart and certain disease states.
Adult With Congenital Heart Disease in Developing Country: Scope, Challenges and Possible Solutions. - Current treatment options in cardiovascular medicine
Adults with congenital heart disease (CHD) are rapidly increasing in numbers in developed countries where facilities for interventions for CHD are available to infants and children. Over 90Â % of children survive to adulthood in these countries. However, less than 50Â % of children born in developing countries undergo any form of intervention due to nonavailability of paediatric cardiac centres. Prevalence of CHD in adults is estimated at 3000 per million population in developed countries. Such data is not available from developing countries, but prevalence is likely to be much lower due to early attrition. In these countries, adult population with CHD mostly consists of relatively milder forms of CHD with a very small proportion of post-operated patients. Specialized centres for care of adults with CHD are sparse or nonexistent in most developing countries, although the situation is changing for the better in some of these countries. Major challenges to care of adults with CHD include lack of trained persons, low levels of awareness about the disease and lack of government interest. Sustainable strategies which are practical in the local environment are required to deal with these challenges. An urgent need is to initiate training of cardiologists and other team members, required for optimal care of these patients. Special clinics for adults with CHD, run by the trained staff, can be incorporated into already operational cardiac centres. Formation of expert groups and patient support groups will help to formulate local guidelines and to pursue advocacy with the government. Maintenance of registries for adults with CHD is necessary to generate data on disease burden and to set research priorities. It is likely that care for adult CHD will be delivered in less than ideal settings considering the limited resources available.
Non-invasive method for preventing intradialytic hypotension: A pilot study. - Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia
Intradialytic hypotension (IDH) is a life-threatening condition. We evaluated the feasibility of blood volume monitoring (BVM) and blood temperature monitoring (BTM) in preventing IDH in patients prone to the same. Fourteen hemodynamically unstable end-stage renal disease patients who were prone to IDH and unable to achieve dry weight were given BVM treatment twice weekly for two weeks. Forty patients who were not on BVM treatment served as controls. Patients were anemic, had low serum albumin (3.4 Â± 0.43 g/dL) and fluid overload and were edematous. Of the 40 patients in the control group, 18 patients experienced IDH and dialysis had to be terminated. The incidence of IDH was 5% in the control group. In the BVM group, the total volume of fluid removed during hemodialysis was between 2.0 and 4.5 L (mean 3.2 L). By the end of dialysis, the hemo-concentration increased by 34.8%. With use of BVM and BTM, the blood pressure did not drop below 120/80 mm Hg, the dialysis sessions were uneventful and none of the patients suffered symptoms of hypotension. There was a difference of 3 kg between weight achieved and dry weight of the patient, although there was a 14.2% reduction in extracellular water (ECW), 14.5% in plasma fluid and 14.5% decrease in interstitial fluid. Blood volume significantly correlated with post-dialysis intracellular water (ICW) (r = 0.722, P = 0.008) and ECW/ICW ratio (r = 0.698, P = 0.012). There was a significant correlation between systolic blood pressure and ECW (r = 0.615, P = 0.033). Diastolic blood pressure significantly correlated with post-dialysis ECW (r = 0.690, P = 0.008), plasma fluid post-dialysis (r = 0.632, P = 0.027) and interstitial fluid (r = 0.604, P = 0.038). The ECW/ICW ratio was high (1.13 Â± 0.48; control 0.74), implying overhydration and expanded extracellular fluid. BVM should be included in the dialysis protocol where patient compliance to maintenance hemodialysis is poor and patients are constantly in volume overload.
Evaluation of Acquired Valvular Heart Disease by the Pediatrician: When to Follow, When to Refer for Intervention? Part I. - Indian journal of pediatrics
Lesions of the heart valves are the commonest acquired cardiac abnormalities seen in pediatric age group. In India, the underlying cause for most valvular diseases is chronic rheumatic heart disease (RHD). The aim of evaluation of patients with valvular heart disease is not only to make a diagnosis, but also to decide the management plan. The pediatrician or physician is usually the first health care provider to whom such patients (or their parents) report. It is therefore imperative that the general physician and pediatricians are well versed with valvular heart diseases. Valvular abnormalities produce characteristic murmurs and a bedside diagnosis is possible in majority. However, further investigations such as X ray of the chest and an ECG are useful tools to refine the diagnosis. Echocardiography is now widely available to most of the patients in India and is very useful for assessing the severity of valve lesion and to identify the underlying etiology. Serial echocardiography is instrumental in deciding the timing of intervention. Mitral valve is most commonly affected followed by aortic; in some patients both valves may be affected. The valve may not close properly, resulting in regurgitation of blood flow in reverse direction or does not open fully (stenosis). In mitral regurgitation (MR), the blood flows in the reverse direction. MR can occur secondary to several causes, but in India, the commonest cause is RHD. Patient may remain asymptpmatic for a long period of time. Symptoms include fatigue, palpitations and later exertional breathlessness. MR typically produces a pansystolic murmur at apex, which may radiate to left axilla. Surgical intervention is reserved for all symptomatic patients with severe MR. Valve repair is preferred over prosthetic valve replacement. Mitral stenosis (MS) is almost always due to RHD. Severe MS results in pulmonary hypertension, right ventricular failure and tricuspid regurgitation. Patients are often symptomatic with dyspnea. Hemoptysis may occur. A typical rumbling mid diastolic murmur is the hallmark of MS. Balloon mitral valvotomy, performed in the catheterization lab, is recommended for severe MS.
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