This is Dr.Kiran welcoming the readers to NH blog. The blog aims to put something "old and fresh" of Pediatric Cardiology everytime and invites the readership to actively participate in the dialogue process.

Let me render my apologies to begin with. It has been more than one month that I have posted anything. I was a bit busy with an article for publication, under a strict ultimatum! Howsoever small the readership might be, I owe this explanation to them. Hence this.

So far, we have seen something about the historical developments, Nobel prize winners and historical developments of drugs: all in relation to Pediatric Cardiology.

I had run out of the ideas and asked the readers on some suggestions on the topics of possible interest. As usual, I have got none! So, I have tried to do something which was suggested sometime back by one of the very good friends and a fabulous team-member, Dr Vishal Changela. He strongly felt that some personal medical anecdotes about our professional relationship with patients should be put up for others to read. In the absence of any other better things to write, I am trying this from now on.

Long back, I had heard a short story written by one of the greatest short-story writers of Kannada, the legendary Dr Masti Venkatesha Iyengar. It is a simple village story. One evening in one of the villages neighbouring a forest, a cowherd realises that a buffalo and its calf are missing. Since it is already dark, they fear entering the forest in search of the missing duo. He keeps his fingers crossed and waits till the dawn. A search party with the armamentarium enters the forest carefully. After a couple of hours of search in the deep forest, they hear the hunger cries of a calf. They start towards the sound and find the same calf of the buffalo safe and secure. In a short distance from this, they find the wounded buffalo in a pool of blood, breathing heavily. To their shock, they find the paw marks of tiger moving away from the spot with blood splattered all along its course, disappearing into the heart of the forest. They immediately realised the entire sequence of events. The calf must have wandered into the forest unknowingly in the late evening and its mother must have followed it to safeguard the kid. A tiger must have attacked the calf and the docile buffalo had fought the mighty tiger tooth and nail throughout the night to save its baby. It finally succeeded at the cost of its own life, driving the deadly beast wounded and away. Just imagining a tame buffalo fighting a ferocious tiger in the night to protect its calf keeping its own life on stake was nerve wrecking and emotions filled the souls of those poor peasants. The villagers carried the wounded buffalo and the calf back to the village. The buffalo eventually died and the villagers buried it with full honours that befitted a brave person and had a small monument built in the memory of its love and courage. This true story stands as a phenomenal symbol of selfless sacrifice of a mother for its child.

The story brings about various kinds of emotions in the reader. Few imagine the scenario and feel for the motherhood. Few imagine themselves in the scenario and try emoting. Few extrapolate the real life situations and think of cross references. What comes out an anecdote is your experience and empathy inside. We all feel for the sacrifice of the buffalo largely because of the courage this helpless, docile and mute animal showed at the time of danger and crisis to its calf. It is probably the basic nature of this animal that stands contrast to the courage it displayed, which fills the mind.

We do see situations in the hospital similar to the one the anecdotal buffalo underwent. We see parents who would sacrifice what all they can to get their children treated. We see them selling the last piece of jewellery, spreading their hand in front of the last available donor, saving money by choosing the least expensive accommodation for themselves or taking just one lunch and so on when the child is admitted in the hospital. All the gruesome effort happens despite accepting the risk and keeping the outcome sceptical. The sacrifice appears to be hanging only to a 4-letter word: HOPE. I am often reminded of the anecdotal buffalo whenever I come across such situations. The scenario of the otherwise helpless buffalo is no different from helpless parents here. The buffalo fought with mighty, cruel tiger and the parents here fight with mightier, more cruel and more than that - an unseen destiny. I feel the sacrifices on both occasions are no less than each other. The first scenario got noticed. But the latter goes unnoticed all the time.

These are the kind of anecdotes that we would like to present. It need not always be tragical. Some triumphs can also be interspersed. At finale, what re-shines is the humanity. The Mahabharata says, “there needs to be only one religion and one principle in the world: compassion to the fellow life”. It is said that the humanity re-lives every time it triumphs. If you have any such anecdotes, please send them to me via email to drkiranvs@gmail.com I shall acknowledge your contribution and give full credit to you for your story!!

I shall get back to our regular feature: Interesting and perplexing case scenarios

TO OR NOT TO TIGHTEN

When the pre-Glenn shunt cath procedure is done, we often see PA pressures being borderline high, but all other parameters would favour Glenn shunt. In such scenarios, few suggest tightening of MPA and going ahead with Glenn. It may get the circuit OK for Glenn, but may reduce the SO2. Is this acceptable? Isn’t good SO2 one of the objectives of Glenn? By tightening the MPA, do we always achieve the Glenn suitability? If anyone found answers for these, please let me know.

BALLOONING IN REGURGITATION

In cases of severe Aortic stenosis with moderate aortic regurgitation, can we consider ballooning? We had a 13-year-old with this scenario. His aortic annulus was very small and looked mildly dysplastic. Surgical team felt that placing a good sized aortic prosthesis was not possible. Doing a Konno was considered very risky. Annuli were not suitable for Ross. In such cases, can we contemplate controlled balloon dilatation, accepting the eventual AR? Our senior consultant was of the opinion that free AR would be very dangerous in such children and balloon should not be attempted. Is the natural history in this subset any different from any kind of intervention? What would you do in such cases? Please put your comments on it.

Qp OR Qep?..

Numbers are funny. We have seen hair-splitting episodes on the basis of numbers generated after gruelling procedures! Whether operability or fitness for univentricular procedures, numbers do play a vital role in this field. During the combined cath meeting, the house is split many a times on this factor alone. We often find children cathed for operability. When the shunt is bidirectional, as per the standard references, we use the effective shunt – Qep. The Qep, many times, is significantly different from the Qp. In all such cases, should we use Qep or Qp as the denominator for calculating the PVRI? This alone can make the difference for the patient. We had a 7-year-old with VSD, PDA and PAH, whose operability was doubtful on the clinical grounds. Basic investigations could not be deciding. Cath showed reasonable Qp/Qs, but the PVRI was marginally high. Our team felt that the child should be operated, as this might be his last chance. Surgical team quoted the higher number PVRI and mooted inoperability. We were no sure how much to believe the numbers when the denominator was not fully certain. Is there a correction factor to the formulae when Qep is involved? Let me know your experience and literature back up if any.

PLACING THE BAND

An interesting analogy was discussed by the surgical team in one of the meetings. It is probably not textbook written and might be more experience oriented. While witnessing the angio images of a child who had undergone a PA banding as an infant in a hospital abroad, one of the senior surgeons commented that the said PA band was meant for a future single pump physiology. We were surprised how he could be so certain, as he was seeing the details of the patient for the first time! Then the surgeon pointed out that the PA band was placed close to the pulmonary valve, which is done to prevent distortion to the branch PAs. Similarly, he said, the PA bands are placed close to the bifurcation if a future 2-pump repair is contemplated. We were not certain if that was the rule, as we were considering both options in the present patient. Other members of the surgical team agreed with this. However, I could not recall reading about this anywhere, nor my cardiology colleagues. If anyone has read something about this, please enlighten us.

SINGLE VENTRICLE: WOULD LV/RV BE A FACTOR?

This was an interesting one. We had a 5-year-old with tricuspid atresia IIIC, who had undergone a PA band as an infant and saturating 88% at present. We had suggested single pump repair for the child. She fulfilled the criteria for single pump repair. However, the surgical team felt that the child can be followed up, as the saturations are OK. We argued that the long-term ventricular load should be the main consideration for present surgery. At this point, one of the senior surgeons commented that he would have taken it if it were to be a mitral atresia instead of tricuspid! He was of the opinion that the volume load on the ventricle would be a factor only when the pumping single chamber is RV. As this patient would have LV as the pumping single chamber, volume load should not be a consideration for present intervention. In any of the criteria of single ventricle, this factor does not find a place. We were using this logic for long term prognosis of single ventricle repair, but what our surgeon told appeared new. It may sound logical, but is there any consensus among the surgeons on this? How would you tackle this situation and argument? Please let me know your take on this.

TWO IN ONE?!

We had an infant with dTGA, ASD, small VSD and severe peripheral PS. The branch PAs appeared to have a tortuous course. The echo study alone was not enough to understand the branch PA anatomy. It was not very clear if they had multiple constrictions. From our side, we were not in consensus on the plan. We decided to place the scenario in the meeting. We showed the echo images and asked the surgeons to comment on it. Although it was decided for a close follow up at present, one of the surgeons felt that the LeCompte manoeuvre done during arterial switch can straighten the branch PAs and they may not require any additional intervention! This was hitherto unheard of! Again, sounded logical, but is it the fact? One can understand that the logic would work if the branch PAs have just folded upon themselves. Would the same logic apply if there are anatomical constrictions in the branch PAs? If anyone had any similar experiences earlier, please let us know the outcome and the way you went ahead with the plan.

That brings us to the end of the present post. I have tried something different; totally different from my areas of strength! If there are any differences of opinion, please let me know. If you think any better formats for presentation, please suggest. Put them in the comments box or mail them to drkiranvs@gmail.com I shall consider them seriously and get back to the readership

Regards

Kiran