Incremental value of fetal spatiotemporal image correlation echocardiography in the diagnosis of tetralogy of Fallot with disconnected pulmonary arteries with ductus arteriosus supplying the left pulmonary artery

Disconnected branch pulmonary arteries are sparsely reported cases in prenatal diagnosis literature. We report a case of tetralogy of Fallot with disconnected branch pulmonary arteries, the left pulmonary artery (LPA) arising from an indirect ductus arteriosus (DA) from the base of the innominate artery in a right aortic arch, diagnosed by fetal echocardiography with 3D/4D spatiotemporal image correlation (STIC) imaging. Prenatal diagnosis led to early neonatal intervention to maintain blood flow to the LPA by stenting of the DA. Fetal echocardiographic evaluation (Voluson E10 systems, GE Healthcare, Zipf) with acquisition of images and volumes in the right ventricular outflow tract and three-vessel trachea view with rendering of 3D/4D STIC volume datasets to display images in high-definition color format. Prenatal evaluation was initially done at 17-week gestation in a 28-year-old pregnant female which showed tetralogy of Fallot (TOF). Subsequent evaluation at 34 weeks with 3D/4D STIC datasets showed a small main pulmonary artery (MPA) continuing into an adequately sized right pulmonary artery. The LPA was very small (Z-score -2.63), with no visible connection to MPA. Rendering of the 3D/4D STIC datasets revealed disconnected pulmonary arteries with the vertical DA from the base of the innominate artery in a right aortic arch, continuing as the LPA. Findings were confirmed on postnatal high-resolution CT pulmonary angiography and cardiac catheterization with subsequent stenting of the ductus. This report highlights the incremental benefit of advanced 3D/4D STIC rendering in accurate prenatal diagnosis of a rare anomaly of TOF with disconnected pulmonary arteries, leading to early neonatal intervention to preserve the blood supply to the left lung.

Transcatheter closure of congenital portosystemic shunts – A multicenter experience

Background:

Congenital portosystemic shunts (CPSS) are rare and present variably with hepatic encephalopathy, pulmonary arteriovenous malformations (PAVMs), and pulmonary hypertension (PH).

Objective:

The objective of the study was to see the feasibility of transcatheter closure of CPSS and their outcome.

Materials and Methods:

We analyzed the data of 24 patients of CPSS who underwent transcatheter closure from five institutions (March 2013 to April 2019). Baseline evaluation included echocardiography with bubble contrast study, ultrasound examination of the abdomen, computed tomography angiogram, and cardiac catheterization with test balloon occlusion of the CPSS. The evaluation showed cyanosis due to PAVM in 12, PH in 8, and respiratory distress in 2. Two had both cyanosis and PH. Criteria for eligibility for complete catheter closure of CPSS included demonstration of intrahepatic portal vein (PV) radicals together with a PV pressure of ≤18 mmHg on occlusion.

Results:

The median age and weight were 8 years (0.5–21) and 19.5 kg (4.2–73), respectively. Transcatheter closure was performed in 21 patients (22 procedures) using a variety of occlusive devices and stent-graft exclusion was done in one patient. Closure was not done in 3 in view of high portal venous pressures and hypoplastic PVs. During the follow-up (median: 42 months and range: 61 days–4.8 years), saturation normalized in 14 patients with PAVM. PH declined in all eight patients who underwent the procedure. Respiratory distress improved in two patients.

Conclusions:

Early and short-term follow-up results of catheter closure of CPSS appear promising. However, further, follow-up is needed to demonstrate long-term effectiveness.

Outcomes of Venus P-valve for dysfunctional right ventricular outflow tracts from Indian Venus P-valve database

Background :

Balloon-expandable pulmonary valves are usually not suitable for dilated native outflow tracts.

Methods :

Indian Venus P-valve registry was retrospectively analyzed for efficacy, complications, and midterm outcomes. Straight valve was used in prestented conduits in patients with right ventricular pressure above two-thirds systemic pressure and/or right ventricular dysfunction. Flared valve 1–4 mm larger than balloon waist was used in native outflow in symptomatic patients, large ventricular volumes, and ventricular dysfunction.

Objectives :

A self-expanding porcine pericardial Venus P-valve is available in straight and flared designs..

Results :

Twenty-nine patients were included. Straight valve was successful in all seven conduits, reducing gradients significantly, including one patient with left pulmonary artery (LPA) stent. Flared valve was successfully implanted in 20 out of 22 native outflow tracts. Sharp edges of the older design contributed to two failures. Complications included two migrations with one needing surgery, endocarditis in one, insignificant wire-frame fractures in three, and groin vascular complication in one patient. There were no deaths or valve-related reinterventions at a mean follow-up of 47.8 ± 24.5 months (1–85 months). Modifications of technique succeeded in three patients with narrow LPA. There was significant improvement in symptoms, right ventricular volume, and pulmonary regurgitant fraction.

Conclusion :

Straight and flared Venus P-valves are safe and effective in appropriate outflow tracts. Straight valve is an alternative to balloon-expandable valves in stenosed conduits. Flared valve is suitable for large outflows up to 34 mm, including patients with LPA stenosis. Recent design modifications may correct previous technical failures. Studies should focus on durability and late complications.

Impact of COVID-19 pandemic on pediatric cardiac services in India

BACKGROUND

COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India.

AIMS

The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries.

SETTINGS AND DESIGN

This is a retrospective, multicentric, observational study.

METHODS

We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019.

RESULTS

The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%).

CONCLUSIONS

The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

POS1262 A COHORT STUDY OF COVID-19 RELATED MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN AND ADOLESCENTS FROM MULTIPLE TERTIARY CARE CENTRES IN SOUTH INDIA

Background:

After the peak of COVID 19 pandemic, a surge of cases with multi-system involvement and hyperinflammatory state was reported in children, at multiple tertiary care centers across the world. (1) This COVID-19 associated multisystem inflammatory syndrome in children and adolescents is also known as multisystem inflammatory syndrome in children (MIS-C). There is a paucity of literature of clinical profile of MIS-C patients from India.

Objectives:

To study the clinical manifestations and treatment outcomes of COVID-19 related multisystem inflammatory syndrome in children (MIS-C) and adolescents.

Methods:

It was a cohort study including cases defnied as per the case definitions of MIS-C by World Health Organisation (WHO) or Centre for Disease Control and Prevention(CDC).(2)The clinical parameters, laboratory parameters (including inflammatory markers, D dimer and NT ProBNP), electrocardiogram, 2D echocardiogram, course in hospital, and immediate outcomes were noted.

Results:

Twenty five patients (male-14) with a mean age of 6.22 ±4.25 years and a mean body mass index of 16.21 ±3.36 kg/m2 were enrolled on the study. Average length of hospital stay was 8.12±5.76 days. Associated comorbidities were present in 4 of our patients (16%). Figure 1 shows the frequency of clinical features in our study patients. Table 1 shows the clinical, laboratory, imaging findings, disease course and outcomes.

Figure 1.

Frequency of clinical features in our MIS-C cohort patients

Table 1.

Clinical characteristics of MIS-C patients (n)=25

Clinical Phenotypes:Incomplete/ Atypical Kawasaki Disease (KD)18 (72%)Macrophage activation syndrome (MAS)11 (44%)Unexplained Shock13 (52%)Fever with gastrointestinal symptoms17 (68%)Fever with neurological symptoms9 (36%)Fever with respiratory symptoms5 (20%)COVID chronology:MISC with acute COVID 19 with MAS1 (4%)MISC with acute COVID 19 with incomplete/atypical KD1 (4%)COVID 19 tests:COVID 19 RTPCR positive2 (8%)COVID 19 RTPCR negative23 (92%)COVID 19 IgG positive20 (80%)COVID 19 IgM positive6 (24%)COVID 19 IgG and IgM both positive2 (8%)COVID 19 IgG and IgM not done4 (16%)Other laboratory investigations(Peak/ trough values):Anaemia20 (80%)Leukopenia2 (8%)Thrombocytopenia6 (24%)Pancytopenia2 (8%)Positive CRP23 (92%)High Procalcitonin9 (36%)High ferritin10 (40%)High D- dimer17 (68%)High NT ProBNP23 (92%)Hypoalbuminemia14 (56%)Sterile pyuria7 (28%)Proteinuria4 (16%)Cardiac assessment:Abnormal Electrocardiogram (ECG)5 (20%)Abnormal Echocardiography15 (60%)Coronary dilation/prominence/non-tapering9 (36%)Coronary aneurysm1 (4%)LAD Z score (Mean±SD)2.12 ± 1.11Decreased Ejection fraction (EF)5 (20%)Systolic Dysfunction5 (20%)Pericardial effusion9 (36%)Global/septal hypokinesia4 (16%)Mitral Valve regurgitation3 (12%)Complete heart block1 (4%)

Twenty patients (80%) had severe illness requiring intensive care. Fourteen patients (56%) required inotropic support, 8 patients (32%) required supplemental oxygen, 5 patients (20%) required mechanical ventilation and 2 patients (8%) expired. A total of 23 patients (92%) received pulse steroids followed by oral/iv steroids, 22 patients (88%) received IVIG (2g/kg) and 3 patients (12%) required anticoagulation.

Conclusion:

Our MIS-C cohort had varied clinical manifestations ranging from the mild cutaneous and gastrointestinal symptoms to fatal multiorgan dysfunctions. In contrast to western cohorts, our study cohort had higher number of patients from younger age group and lower BMI.

References:

[1]Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K et al. Multisystem inflammatory syndrome in children: A systematic review. EClinicalMedicine. 2020;26:100527.

[2]Jiang L, Tang K, Levin M, Irfan O, Morris S, Wilson K et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet Infectious Diseases. 2020;20(11):e276-e288.

Disclosure of Interests:

None declared

COVID-19 related multisystem inflammatory syndrome in children (MIS-C): a hospital-based prospective cohort study from Kerala, India

OBJECTIVES

To study (1) epidemiological factors, clinical profile and outcomes of COVID-19 related multisystem inflammatory syndrome in children (MIS-C), (2) clinical profile across age groups, (3) medium-term outcomes and (4) parameters associated with disease severity.

DESIGN

Hospital-based prospective cohort study.

SETTING

Two tertiary care centres in Kerala, India.

PARTICIPANTS

Diagnosed patients of MIS-C using the case definition of Centres for Disease Control and Prevention.

STATISTICAL ANALYSIS

Pearson χ² test or Fisher's exact test was used to compare the categorical variables and independent sample t-test or Mann-Whitney test was used to compare the continuous variables between the subgroups categorised by the requirement of mechanical ventilation. Bonferroni's correction was used for multiple comparisons.

RESULTS

We report 41 patients with MIS-C, mean age was 6.2 (4.0) years, and 33 (80%) were previously healthy. Echocardiogram was abnormal in 23 (56%), and coronary abnormalities were noted in 15 (37%) patients. Immunomodulatory therapy was administered to 39 (95%), steroids and IVIg both were used in 35 (85%) and only steroids in 3 (7%) patients. Intensive care was required in 36 (88%), mechanical ventilation in 8 (20%), inotropic support in 21 (51%), and 2 (5%) patients died. Mechanical ventilation requirement in MIS-C was associated with hyperferritinaemia (p=0.001). Thirty-seven patients completed 3 months follow-up by April 2021, of whom 6 (16%) patients had some residual echocardiographic changes.

CONCLUSIONS

Patients with MIS-C in our cohort had varied clinical manifestations ranging from fever with mild gastrointestinal and mucocutaneous involvement to fatal multiorgan dysfunction. Immediate and medium-term outcomes remain largely excellent except for the echocardiographic sequelae in a few patients which are also showing a resolving trend. Hyperferritinaemia was associated with the requirement of mechanical ventilation.

Complete Sternal Cleft Repair

Sternal cleft (SC) is a rare congenital malformation which can be partial or complete. We report a case of complete SC in a 9-month-old child. Our technique involves a combination of reinforcement with the deep cervical fascial extension, followed by the anterior perichondrial flaps, bridged with the rib graft, incorporating surplus resected cartilaginous xiphoid process, and covered with the bilateral pectoralis major muscle flap for the chest wall reconstruction with 3D printing assisting preoperative planning. The size of the defect in relation to the age of presentation was a deciding factor in the adoption of this alternative surgical technique.

Comparison of Fontan Surgical Options for Patients with Apicocaval Juxtaposition

Apicocaval juxtaposition (ACJ) is a rare form of viscerocardiac malpositions in association with single-ventricle congenital heart defects. The Fontan surgery is the common palliation, and possible surgical options include ipsilateral, contralateral, and intra-atrial conduits. Concerns include lower hemodynamic performances or risks of conduit compression by the cardiac mass. This study investigates the hemodynamics and clinical outcomes of ACJ patients and potential surgical improvements. Ten consecutive ACJ patients were included, along with a reference cohort of ten non-ACJ patients. Magnetic resonance images were acquired at 6 ± 0.6 year follow-up for anatomical analysis and hemodynamic assessments using computational fluid dynamics. Metrics of interest are deformation index (DI), indexed power loss (iPL), and hepatic flow distribution (HFDoff). A "virtual" surgery was performed to explore potential hemodynamic improvements using a straightened conduit. DI for ACJ patients fell within the DI range of non-ACJ patients. Contralateral conduits had insignificantly higher iPL (0.070 [0.032,0.137]) than ipsilateral conduits (0.041 [0.013,0.095]) and non-ACJ conduits (0.034 [0.011,0.061]). HFDoff was similar for the ipsilateral (21 [12,35]), contralateral (26 [7,41]), and non-ACJ Fontan conduits (17 [0,48]). Virtual surgery demonstrated that a straightened conduit reduced HFDoff and iPL for the contralateral and ipsilateral conduits, potentially leading to improved clinical outcomes. In this limited sample, the hemodynamic performance of ACJ patients was not significantly different from their non-ACJ counterparts. The use of a straightened conduit option could potentially improve patient outcomes. Additionally, the fear of significant compression of conduits for ACJ patients was unsupported.

Common inflammatory markers after cardiac surgery in infants and their relation to blood stream sepsis

Background

Limited information exists on trends of common inflammatory markers after infant heart surgery and their role in identifying post-operative sepsis.

Methods

275 consecutive infants undergoing cardiac surgery (231 with and 44 without Cardiopulmonary Bypass) were studied prospectively. Daily trends (0-4 day post-operative) of leucocyte counts, platelet counts and C-reactive protein were recorded. Association of these trends with early post-operative bloodstream sepsis, Cardiopulmonary Bypass and surgical outcomes were studied.

Observations

Trends of these inflammatory markers were noted. While off-Cardiopulmonary Bypass Surgery, and sepsis were associated with a statisticaly insignificant rise in total leucocyte count peaking on first post-operative day, Cardiopulmonary Bypass exposure was associated with significant decline (p = 0.002), more pronounced with Cardiopulmonary Bypass-exposure exceeding 150 min. Percentage of neutrophils showed a rise (maximum on first post-operative day) but no significant association with sepsis or Cardiopulmonary Bypass.Platelet counts significantly declined after surgery, with nadir on 2^nd POD (p < 0.001), the drop being more marked in patients operated on Cardiopulmonary Bypass (p < 0.005). Counts were significantly lower in patients exposed to >150 min Cardiopulmonary Bypass compared to those with shorter Cardiopulmonary Bypass. Septic patients had significantly lower platelet counts than uninfected patients, decline >2 SD from mean pre-operative level strongly associated with sepsis (p < 0.001).C-Reactive Protein levels rose markedly after surgery, peaking on 2^nd POD; levels were significantly higher if operated on Cardiopulmonary Bypass. Cardiopulmonary Bypass >150 min was associated with lower mean C-Reactive Protein on first post-operative day, but significantly higher values on third and fourth post-operative days, as compared to Cardiopulmonary Bypass <150 min. Comparison of infected versus non-infected patients showed significantly higher mean C-Reactive Protein in the former group.

Conclusion

While leucocyte count, platelet count and C-Reactive Protein emerged as useful markers of post-operative inflammatory response and reaction to Cardiopulmonary Bypass, they proved unsatisfactory predictors of early post-operative sepsis.

Medium-term results of percutaneous pulmonary valve implantation using the Venus P-valve: international experience

AIMS

The aim of this study was to assess the international procedural and short-term to midterm experience with the new percutaneous Venus P-valve.

METHODS AND RESULTS

Retrospective data of patient characteristics, clinical and imaging follow-up of Venus P-valve implantation outside China were collected. Thirty-eight patients underwent attempted Venus P-valve implantation between October 2013 and April 2017. Thirty-seven valves were successfully implanted during 38 procedures. There was one unsuccessful attempt and there were two valve migrations, one of which required surgical repositioning. The mean follow-up was 25 months with no short-term or midterm valve failure or deterioration in performance. Frame fractures occurred in 27% of patients. The cohort demonstrated a statistically significant reduction in pulmonary regurgitation fraction and indexed right ventricular diastolic volumes at six and 12 months.

CONCLUSIONS

Implantation of the Venus P-valve has provided satisfactory short-term to midterm results with high success and low complication rates in an inherently challenging patient substrate.

Percutaneous ultrasound guided thrombin injection for axillary artery pseudoaneurysm following stenting of the arterial duct in two infants: Case report with review of literature

We report pseudoaneurysm of the axillary artery following stenting of the arterial duct in two infants. They were both successfully managed by ultrasound guided thrombin injection with preservation of native arterial flow. We also review the relevant literature.

Platelet parameters in children with chromosome 22q11 deletion and conotruncal heart defects

BACKGROUND AND OBJECTIVES

The 22q11 deletion syndrome is associated with a wide spectrum of phenotypic features, hence clinical diagnosis is difficult. Individuals with this syndrome are found to have a risk of developing transfusion associated graft-versus-host reaction, if they are given nonirradiated blood. Our aim was to elucidate whether chromosome 22q11 deletion in children with syndromic conotruncal heart defects is associated with platelet abnormality.

MATERIALS AND METHODS

The genetic analysis was performed by standard cytogenetic and Fluorescence in situ hybridization technique. The platelet parameters in 39 patients with chromosome 22q11 deletion were compared with 154 cases without deletion.

RESULTS

In deletion versus no deletion group, the mean of mean platelet volume (MPV) was 10.5 ± 2.5 vs 7.6 ± 1.5 fL, platelet count was 225 ± 80.7 and 339 ± 127.3 × 10 ⁹ /L and frequency of high MPV was 49% vs 7% (P < .0001). The MPV was associated with a sensitivity of 90.9% and a specificity of 79.6% at a cutoff value of 8.32 fL, (area under the ROC curve 91%). A nonsignificant negative correlation was found between MPV and platelet count (r = -0.152; P = .361) in children with deletion.

CONCLUSION

A cutoff value of 8.32 fL for MPV can be an indicator of high risk of chromosome 22q11 deletion in individuals with syndromic conotruncal defects. Individuals with chromosome 22q11 deletion should be given irradiated blood especially during cardiac surgery. Further investigation should clarify the etiology behind variation in frequency of high MPV in different conotruncal lesions.

Pulmonary Hemorrhage Due to Unrecognized Bronchial Collateral After Arterial Switch Operation

We report a neonate with transposition of great arteries and intact ventricular septum who had a massive pulmonary hemorrhage soon after an arterial switch operation. An emergency cardiac catheterization revealed a large bronchial collateral artery from the descending aorta feeding the right lung. The hemorrhage was controlled by coil embolization of the collateral, and the patient recovered after prolonged intensive care.

Three-dimensional-printed cardiac prototypes aid surgical decision-making and preoperative planning in selected cases of complex congenital heart diseases: Early experience and proof of concept in a resource-limited environment

Introduction:

Three-dimensional. (3D) printing is an innovative manufacturing process that allows computer-assisted conversion of 3D imaging data into physical “printouts” Healthcare applications are currently in evolution.

Objective:

The objective of this study was to explore the feasibility and impact of using patient-specific 3D-printed cardiac prototypes derived from high-resolution medical imaging data (cardiac magnetic resonance imaging/computed tomography [MRI/CT]) on surgical decision-making and preoperative planning in selected cases of complex congenital heart diseases (CHDs).

Materials and Methods:

Five patients with complex CHD with previously unresolved management decisions were chosen. These included two patients with complex double-outlet right ventricle, two patients with criss-cross atrioventricular connections, and one patient with congenitally corrected transposition of great arteries with pulmonary atresia. Cardiac MRI was done for all patients, cardiac CT for one; specific surgical challenges were identified. Volumetric data were used to generate patient-specific 3D models. All cases were reviewed along with their 3D models, and the impact on surgical decision-making and preoperative planning was assessed.

Results:

Accurate life-sized 3D cardiac prototypes were successfully created for all patients. The models enabled radically improved 3D understanding of anatomy, identification of specific technical challenges, and precise surgical planning. Augmentation of existing clinical and imaging data by 3D prototypes allowed successful execution of complex surgeries for all five patients, in accordance with the preoperative planning.

Conclusions:

3D-printed cardiac prototypes can radically assist decision-making, planning, and safe execution of complex congenital heart surgery by improving understanding of 3D anatomy and allowing anticipation of technical challenges.

Preoperative Determinants of Outcomes of Infant Heart Surgery in a Limited-Resource Setting

We studied the effect of preoperative determinants on early outcomes of 1028 consecutive infant heart operations in a limited-resource setting. Comprehensive data on pediatric heart surgery (January 2010-December 2012) were collected prospectively. Outcome measures included in-hospital mortality, prolonged ventilation (>48 hours), and bloodstream infection (BSI) after surgery. Preoperative variables that showed significant individual association with outcome measures were entered into a logistic regression model. Weight at birth was low in 224 infants (21.8%), and failure to thrive was common (mean-weight Z score at surgery was 2.72 ± 1.7). Preoperatively, 525 infants (51%) needed intensive care, 69 infants (6.7%) were ventilated, and 80 infants (7.8%) had BSI. In-hospital mortality (4.1%) was significantly associated with risk adjustment for congenital heart surgery-1 (RACHS-1) risk category (P < 0.001). Neonatal status, preoperative BSI, and requirement of preoperative intensive care and ventilation had significant individual association with adverse outcomes, whereas low birth weight, prematurity, and severe failure to thrive (weight Z score <-3) were not associated with adverse outcomes. On multivariable logistic regression analysis, preoperative sepsis (odds ratio = 2.86; 95% CI: 1.32-6.21; P = 0.008) was associated with mortality. Preoperative intensive care unit stay, ventilation, BSI, and RACHS-1 category were associated with prolonged postoperative ventilation and postoperative sepsis. Neonatal age group was additionally associated with postoperative sepsis. Although severe failure to thrive was common, it did not adversely affect outcomes. In conclusions, preoperative BSI, preoperative intensive care, and mechanical ventilation are strongly associated with adverse outcomes after infant cardiac surgery in this large single-center experience from a developing country. Failure to thrive and low birth weight do not appear to adversely affect surgical outcomes.

Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: a single center experience in a developing economy

Background:

The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world.

Objective:

We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution.

Methods:

The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection.

Results:

The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance.

Conclusions:

The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.

Cardiac spectrum, cytogenetic analysis and thyroid profile of 418 children with Down syndrome from South India: a cross-sectional study

OBJECTIVE

To describe the spectrum of congenital heart disease in children with Down syndrome and their cytogenetic profile (and that of parents of those with translocation), and thyroid profile.

METHODS

A cross sectional study was conducted in 418 consecutive patients with Down syndrome attending the Department of Pediatric Genetics from a tertiary care centre in Kerala with a comprehensive Pediatric Cardiac Program, from November 2005 through April 2012. All children were offered cytogenetic analysis and were subjected to echocardiography. Parental karyotyping was offered for children with translocation type of Down syndrome. The thyroid profiles of all children were checked at the first visit and once every 6 mo during follow up.

RESULTS

Congenital heart disease was present in 256 (63.4 %) of 404 children with Down syndrome. Ventricular septal defect (72; 28.1 %) was the commonest, followed by atrio-ventricular septal defect (70; 27.3 %) and patent ductus arteriosus (43; 16.8 %). Surgical correction was accomplished in 104 (40.6 %) with excellent intermediate-term outcomes. Three hundred eighty seven of 418 children (92.6 %) underwent cytogenetic tests. The abnormalities included non-disjunction (340, 87.8 %), translocation (33, 8.5 %) and mosaicism (12, 3.1 %). Hypothyroidism was detected in 57 children (13.6 %).

CONCLUSIONS

The prevalence of congenital heart disease in children with Down syndrome in Kerala is the highest reported (63.4 %). Ventricular septal defect is the most common heart disease in the present study. The results highlight the changing attitudes of families towards the surgical correction of congenital heart disease in children with Down syndrome. Prevalence of hypothyroidism in Down syndrome in Kerala is 13.6 %.

Two-ventricle repair for complex congenital heart defects palliated towards single-ventricle repair

OBJECTIVES

Complex congenital heart defects that present earlier in life are sometimes channelled towards single-ventricle repair, because of anatomical or logistic challenges involved in two-ventricle correction. Given the long-term functional and survival advantage, we have been consciously exploring the feasibility of a biventricular repair in these patients when they present later for Fontan completion.

METHODS

Since June 2009, 71 patients were referred for staged completion of the Fontan procedure. Following detailed evaluation that included three-dimensional echocardiography and magnetic resonance imaging, 10 patients (Group 1-median age 6 years) were identified and later underwent complex biventricular repair with takedown of Glenn shunt, while completion of extracardiac Fontan repair was done in 61 patients (Group 2-median age 7 years).

RESULTS

Two-ventricle repair was accomplished in all the 10 Group 1 patients. One patient developed complete heart block requiring permanent pacemaker insertion. Late patch dehiscence occurred in another (awaiting repair). At a median follow-up of 15 months, there was no mortality among the Group 1 patients and all except for 1 patient were symptom free. There were 2 early deaths (3.3%) in the Group 2 patients.

CONCLUSIONS

Two-ventricular repair, although surgically challenging, should be considered in all patients with two functional ventricles who come for Fontan completion. Comprehensive preoperative imaging and meticulous planning helps in identifying suitable candidates.

Understanding the physiology of complex congenital heart disease using cardiac magnetic resonance imaging

Complex congenital heart diseases are often associated with complex alterations in hemodynamics. Understanding these key hemodynamic changes is critical to making management decisions including surgery and postoperative management. Existing tools for imaging and hemodynamic assessment like echocardiography, computed tomography and cardiac catheterization have inherent limitations. Cardiac magnetic resonance imaging (MRI) is emerging as a powerful bouquet of tools that allow not only excellent imaging, but also a unique insight into hemodynamics. This article introduces the reader to cardiac MRI and its utility through the clinical example of a child with a complex congenital cyanotic heart disease.

Characterization of a distinct lethal arteriopathy syndrome in twenty-two infants associated with an identical, novel mutation in FBLN4 gene, confirms fibulin-4 as a critical determinant of human vascular elastogenesis

BACKGROUND

Vascular elasticity is crucial for maintaining hemodynamics. Molecular mechanisms involved in human elastogenesis are incompletely understood. We describe a syndrome of lethal arteriopathy associated with a novel, identical mutation in the fibulin 4 gene (FBLN4) in a unique cohort of infants from South India.

METHODS

Clinical characteristics, cardiovascular findings, outcomes and molecular genetics of twenty-two infants from a distinct population subgroup, presenting with characteristic arterial dilatation and tortuosity during the period August 2004 to June 2011 were studied.

RESULTS

Patients (11 males, 11 females) presented at median age of 1.5 months, belonging to unrelated families from identical ethno-geographical background; eight had a history of consanguinity. Cardiovascular features included aneurysmal dilatation, elongation, tortuosity and narrowing of the aorta, pulmonary artery and their branches. The phenotype included a variable combination of cutis laxa (52%), long philtrum-thin vermillion (90%), micrognathia (43%), hypertelorism (57%), prominent eyes (43%), sagging cheeks (43%), long slender digits (48%), and visible arterial pulsations (38%). Genetic studies revealed an identical c.608A > C (p. Asp203Ala) mutation in exon 7 of the FBLN4 gene in all 22 patients, homozygous in 21, and compound heterozygous in one patient with a p. Arg227Cys mutation in the same conserved cbEGF sequence. Homozygosity was lethal (17/21 died, median age 4 months). Isthmic hypoplasia (n = 9) correlated with early death (≤4 months).

CONCLUSIONS

A lethal, genetic disorder characterized by severe deformation of elastic arteries, was linked to novel mutations in the FBLN4 gene. While describing a hitherto unreported syndrome in this population subgroup, this study emphasizes the critical role of fibulin-4 in human elastogenesis.

Variation in prevalence of chromosome 22q11 deletion in subtypes of conotruncal defect in 254 children

AIM

To determine the frequency of chromosomal aberrations particularly 22q11 deletion in Indian children ≤2 years with different types of conotruncal malformations and their association with abnormal aortic arch. Additionally, extracardiac features were also studied.

METHODS

Conventional cytogenetic and fluorescence in situ hybridization analyses were performed in 254 patients with conotruncal defects. Multivariable logistic regression analysis was performed to ascertain extracardiac features helpful in identifying high-risk patients with deletion.

RESULTS

Chromosomal abnormalities were identified in 52 (21%) children, of whom 49 (94%) showed 22q11 deletion and 3 (6%) had abnormalities of chromosome 6, 2 and X. None of the 11/254 children with tetralogy of Fallot with absent pulmonary valve showed deletion. The association of 22q11 deletion with right sidedness of the aortic arch varied with the type of conotruncal defect. The eight extracardiac features in combination showed 93.5% agreement with the presence of deletion.

CONCLUSION

The extracardiac features along with specific type of conotruncal defect and associated cardiovascular anomaly should alert the clinician for 22q11 deletion testing. However, if deletion analysis is not possible, specific extracardiac features (six dysmorphic facial features, thin long fingers and hypocalcemia) can help to identify an increased risk of 22q11 deletion in patients with conotruncal defect.

Sly Disease: Mucopolysaccharidosis Type VII

A 6 month-old infant presenting with severe mitral regurgitation was found to have hepatosplenomegaly, corneal clouding, and Alder-Reilly granules in the leucocytes. Extremely low levels of beta glucuronidase confirmed the diagnosis of Sly disease (Mucopolysaccharidosis VII). This is the first case of MPS VII reported from India.