Significant intraoperative right ventricular outflow gradients after repair for tetralogy of Fallot: to revise or not to revise?

BACKGROUND: This study was performed to define alternative parameters for the management of intraoperative residual right ventricular outflow obstruction (RVOTO) after transatrial repair of tetralogy of Fallot (ToF) in order to differentiate those requiring immediate revision from those who do not. METHODS: Since October 1995, 166 patients of ToF underwent transatrial repair. Postbypass residual RVOTO was assessed by surgeon's subjective impression, direct intracardiac pressure measurements, and intraoperative echocardiography (IOE). RVOTO was labeled "significant" whenever it exceeded a gradient of 40 mm Hg on IOE or right ventricular to left ventricular pressure ratio (pRV/LV) exceeded 0.85. Further, on IOE, significant RVOTO was defined "fixed", if there was no change in RVOT dimensions during the cardiac cycle, along with the presence of anatomic substrate for obstruction, and "dynamic" if RVOT dimensions increased appreciably in diastole. Postoperative course and follow-up echocardiograms of all patients were analyzed. RESULTS: Significant RVOTO was detected in 58 (35%) patients (mean gradient 54 mm Hg). Seven (12%) of them with fixed obstruction (mean 46 mm Hg) underwent immediate surgical revision, while the remaining 51 patients with mean gradient of 78 mm Hg (including 10 patients with pRV/LV ratio of > or = 1.0) with dynamic obstruction did not undergo revision. There were six (3.6%) early deaths. Operative mortality and postoperative morbidity were not related to higher residual gradients, although the first 15 such patients had longer intensive care stay and inotropic support, in which this was done electively. On follow-up (mean 18.5 months), outflow gradients declined sharply (mean 16 mm Hg) irrespective of the severity of intraoperative gradients (p < 0.001). There were no reoperations or late deaths. CONCLUSIONS: This study shows that: 1) existing parameters for immediate revision of residual RVOTO possibly need to be reviewed; 2) intraoperative echocardiography helps in differentiating "fixed" from "dynamic" obstruction and helps obviate needless revisions; and 3) dynamic RVOT gradients decline significantly irrespective of their severity after transatrial repair of ToF.

Relationship of maternal serum ferritin with foetal serum ferritin, birth weight and gestation.

Haemoglobin and ferritin estimations employing the micro-ELISA technique were done in 308 random selected mothers in labour and their newborns. The values of haemoglobin and serum ferritin as well as birth weight and gestation of babies born to iron depleted, and mildly and moderately anaemic mothers were no different from those of newborns of non-anaemic women. However, the values of serum ferritin per se in all these newborns were much lower than what are generally reported from the western countries. Babies born to severely anaemic women, on the other hand, showed elevated levels of haemoglobin and serum ferritin, and lower birth weights and gestation. Thus, mild to moderate iron deficiency in the mother does contribute to lower iron reserves in the foetus, if not frank iron depletion, and severe iron deficiency anaemia to lower birth weight and gestation.

Scurvy--the eternal masquerader.

Osseous involvement in scurvy is unusual in older children even though classical bony changes are well recognized in the infantile variety. This report describes two children with scurvy, aged 6 and 8 years, both of whom presented with bone pains and associated swelling. One child also had a pathological telescoping diaphyseal fracture--a complication not previously described in association with scurvy.

An unusual manifestation of tuberculous hypersensitivity.

This report describes a 6-year-old boy with symmetrical, painful soft tissue swelling of all the fingers and toes, without apparent joint involvement. The Mantoux test was strongly positive. A dramatic response was observed with anti-tuberculosis chemotherapy.

Low birthweight: aetiology and prevention in India.

Low weight at birth continues to remain a major public health problem in India in contrast to what is observed in most developed and many developing countries of the world (Table I) (1). This raises several issues relating to the persistently high infant mortality and the difficulties in providing adequate care for these "at risk" infants because of the vastness of the country and its marked geographic, cultural, religious and socio-economic variations. Despite these numerous unresolved problems, those concerned with delivery of health care are faced with the stupendous task of achieving a reduction in low birthweight rate from the present estimated 30% to 10% by 2000 A.D. The present communication deals with an overall view of the problem of low birthweight (LBW) in India and suggests possible areas of action for its prevention.

Delivery of perinatal care in India: priorities and policies.

Delivery of appropriate perinatal care at primary, secondary and tertiary levels is becoming an urgent and important issue in countries of the Third World where maternal, perinatal and neonatal mortality rates remain at an unacceptably high level. A recent WHO report on perinatal morbidity and mortality in the South-east Asian region (Table I) shows the current state of the problem in this region (1). In India, the perinatal mortality rate (PNMR) varies from 12.5 to 147.2/1000 (2), with most centres reporting rates of 70-90/1000 (Table II) (2-5). Ghosh et al. (6) have reported intranatal asphyxia, pulmonary conditions, cerebral birth trauma and neonatal infections as the leading necropsy causes of perinatal death. Several studies have also documented low birth weight as a major contributory factor in perinatal and neonatal mortality. In India a large proportion of perinatal deaths are preventable. High fetal and childhood mortality adversely affect the acceptance of family planning (7). Therefore, perinatal care is important for India and must form an integral part of national goals of "health for all" by 2000 AD.