Transcatheter device closure of patent ductus arteriosus.

OBJECTIVE: To determine the efficacy, safety and immediate complications encountered during percutaneous device closure of patent ductus arteriosus (PDA). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Paediatric Cardiology, AFIC/NIHD, Rawalpindi, from January 2005 to December 2010. METHODOLOGY: Consecutive 500 patients who underwent attempted transcatheter PDA device closure were included in the study. Device type position, success of closure and complications were described as frequency percentage. RESULTS: In 491 cases (98.2%), PDA was successfully occluded including 4 cases (0.8%) where devices were dislodged but retrieved and redeployed in Cath laboratory. PDA occluder devices used in 448 cases (91%) while coils (single or multiple) were used in 42 cases (8.5%) and in one case (0.2%) ASD occluder device was used to occlude the PDA. There were 09 (1.8%) unsuccessful cases, 06 (1.2%) were abandoned as ducts were considered unsuitable for device closure, 02 (0.4%) devices dislodged and needed surgical retrieval and one case (0.2%) was abandoned due to faulty equipment. The narrowest PDA diameter ranged from 0.5-14 mm with mean of 4.5±2.4 mm. There was a single (0.2%) mortality. CONCLUSION: Transcatheter occlusion of PDA by coil or occluder device is an effective therapeutic option with high success rate. Complication rate is low in the hands of skilled operators yet paediatric cardiac surgical back-up cover is mandatory.

Percutaneous transcatheter PDA device closure in infancy.

OBJECTIVE: To evaluate the results and complications associated with transcatheter closure of patent ductus arteriosus (PDA) in infants. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Paediatric Cardiology Department of Armed Forces Institute of Cardiology / National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi, from December 2010 to June 2012. METHODOLOGY: Infants undergoing transcatheter device closure of PDA were included. All patients were evaluated by experienced Paediatric Cardiologists with 2-D echocardiography and Doppler before the procedure. Success of closure and complications were recorded. RESULTS: The age of patients varied from 05 - 12 months and 31 (56.4%) were females. Out of the 55 infants, 3 (5.4%) were not offered device closure after aortogram (two large tubular type ducts and one tiny duct, considered unsuitable for device closure); while in 50 (96.1%) patients out of remaining 52, the duct was successfully closed with transcatheter PDA device or coil. In one infant, device deployment resulted in acquired coarctation, necessitating device retrieval by Snare followed by surgical duct interruption and another patient had non-fatal cardiac arrest during device deployment leading to abandonment of procedure and subsequent successful surgical interruption. Local vascular complications occurred in 12 (21.8%) of cases and all were satisfactorily treated. CONCLUSION: Transcatheter device closure of PDA in infants was an effective procedure in the majority of cases; however, here were considerable number of local access site vascular complications.

Safety and technical success of percutaneous left main coronary artery stenting.

OBJECTIVE: Critical stenosis of left main coronary artery (LMCA) has always remained a challenge for interventional cardiologists. Conventionally Coronary Artery Bypass Grafting (CABG) is done for these patients but recently Percutaneous Coronary Intervention (PCI) is also being tried more frequently, but data of PCI is scarce in this regard. Our objective was to determine the safety and technical success rate of percutaneous left main coronary artery stenting. METHODS: This was 12 month follow up study conducted at Pakistan Institute of Medical Sciences (PIMS), Islamabad from 11(th) Jan 2012 to 11(th) Jan 2013. All symptomatic patients who underwent coronary angiogram at PIMS and were found to have either isolated LMCA disease or coexisting osteal Left Anterior Descending (LAD) artery disease were potentially eligible for the study. Patients who had previous surgical treatment for coronary artery disease and those with renal dysfunction requiring dialysis were excluded. Patients were counselled in detail regarding the pros and cons of PCI versus CABG.Those who opted for PCI were included in the study. All these patients were treated with percutaneous left main coronary artery stenting with or without osteal LAD stenting. RESULTS: Seventy two patients had LMCA disease during angiogram. Fifteen patients opted for CABG. Four patients did not meet the inclusion criteria, whereas 53 patients were finally enrolled. Mean age of patients were 55.45±10.275 years. Twenty nine patients were with acute coronary syndrome and 22 presented with unstable angina.PCI with stenting was technically successful in all patients. One patient died three months after PCI, there was no other mortality. CONCLUSION: Our study showed that Percutaneous Coronary Intervention (PCI) to LMS has good technical success rate; the safety of the procedure is also acceptable.

Transthoracic echocardiography as a measuring and guiding tool for transcatheter device closure of secundum atrial septal defect in young children.

OBJECTIVE: To analyze the effectiveness of transthoracic echocardiography (TTE) for device closure of secundum atrial septal defect in children ≤5 years old. STUDY DESIGN: Quasiexperimental study. STUDY LOCATION AND DURATION: The study was conducted at Armed Forces Institute of Cardiology and National Institute of Heart Diseases from December 1, 2010 to December 31, 2012. PATIENTS AND METHODS: During the study period, a total of 48 children ≤5 years old underwent device closure of secundum atrial septal defect. The indications for closure were: elective closure in 31; parental anxiety in 10; frequent respiratory infection in 4; severe pulmonary stenosis in 2; and severe mitral stenosis in 1 patient. The procedure was carried out under general or local anesthesia with TTE and fluoroscopic guidance. TTE was the primary tool used for measurement of defect and estimation of occluder size as well as guiding equipment during device deployment in all patients. RESULTS: A total of 47/48 patients (97.9%) had successful closure of secundum atrial septal defect. The mean age was 4.1 ± .68 years (range, 2.5-5 years) and 28/48 patients (58.4%) were female. The defect size and occluders used were between 5-20 mm (mean, 12 ± 3.5 mm) and 8-22 mm (mean, 15 ± 3.9 mm), respectively. Three patients had simultaneous procedures comprising pulmonary balloon valvuloplasty in 2 patients and percutaneous transmitral commissurotomy in 1 patient. The device embolization occurred in 1 patient; the device was retrieved percutaneously and the patient was referred for surgical closure. The minor complications were residual leak (n = 1), transient bradycardia (n = 4), and first-degree heart block (n = 1). The median procedure time was 30 min (range, 15-100 min) and median fluoroscopic time was 6 min (range, 1.50-45 min). There were no emergency surgical explorations, cardiac perforations, vascular injuries, or deaths during this period. CONCLUSION: TTE can be used as a primary tool for the measurement of atrial septal defect and guidance during device deployment in young children by skilled and professional hands, yet more experience is awaited.

Successful surgical repair of pentalogy of cantrell at 14 months of age.

Pentalogy of Cantrell with ectopia cordis is a rare congenital anomaly, first described in 1958 by Cantrell, has a reported incidence of around 5-10 cases per one million live births with wide variety of clinical presentations. We are reporting a child with ectopia cordis along with cleft lower sternum, upper abdominal wall defect, ectopic umbilicus and diaphragmatic defect. Echocardiography in first month of life revealed a restrictive perimembranous ventricular septal defect and a small patent Foramen Ovale, both closed spontaneously in infancy. CT angiography at 10 months of age revealed a defect in the thoracic and abdominal walls along with herniation of left ventricular apex into epigastrium. The two ventriculi formed a tail that looked like a crocodile. This patient underwent surgical correction at our institution at 14 months of age and recovered well with no residual issue.

Pancarditis: a rare complication of tropical pyomyositis.

Tropical pyomyositis is a bacterial infection of the skeletal muscles leading to abscess formation, occurring in the tropical areas, often following minor trauma. We report a case of pancarditis as the direct complication of pyomyositis in a 10-year-old girl who presented with painful swelling of her right thigh, high grade fever and impaired consciousness. Echocardiography showed pericardial effusion with strands and a large vegetation in the left ventricle cavity. She was treated successfully with open heart surgical drainage and intravenous antibiotics. We emphasize early diagnosis and prompt treatment of pyomyositis to reduce its associated mortality and morbidities.

Percutaneous transluminal mitral commissurotomy for rheumatic mitral stenosis in a 5-year-old child.

We report a 5-year-old boy weighing 11 kg, with severe mitral valve stenosis of rheumatic aetiology, who underwent successful percutaneous transluminal mitral commissurotomy (PTMC) with valvuloplasty balloon. Postprocedural mean pressure gradient across the mitral valve decreased to 6 mmHg from an initially recorded value of 22 mmHg. In addition to symptomatic improvement, the mitral valvular area increased from 0.4 to 0.8 cm(2) without significant change in mitral regurgitation. At 1- and 3-month follow up, transthoracic echocardiography revealed further improvement with an increase in mitral valve area to 1.0 cm(2), a decrease in pulmonary arterial pressure, and a mean mitral valve pressure gradient of 8 mmHg with trivial mitral regurgitation. To best of our knowledge, this is the first successful PTMC procedure performed in the youngest and smallest ever reported child with rheumatic mitral stenosis (MS). We conclude that PTMC with valvuloplasty balloon could be a logical alternative to surgery in young patients with rheumatic MS.

Etiology of short stature in children.

OBJECTIVE: To determine the causes of short stature in children with special emphasis on growth hormone deficiency. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Paediatrics, Military Hospital, Rawalpindi and Combined Military Hospital, Multan from September 2004 to January 2007. METHODOLOGY: Two hundred and fourteen children (140 boys and 74 girls), ranging from 02 to 15 years presenting with short stature were studied. Height and weight were plotted on appropriate growth charts and centiles determined. Relevant hematological and biochemical investigations including thyroid profile were done. Bone age was determined in all cases. Growth hormone axis was investigated after excluding other causes. Karyotyping was done in selected cases. Data was analyzed by SPSS 10.0 by descriptive statistics. Mean values were compared using t-test. RESULTS: In this study, the five most common etiological factors in order of frequency were Constitutional Growth Delay (CGD), Familial Short Stature (FSS), malnutrition, coeliac disease and Growth Hormone Deficiency (GHD). In 37.4% of patients, the study revealed normal variants of growth - CGD, FSS or combination of both, 46.7% cases had nonendocrinological and 15.9% had endocrinological etiology. CGD (22.1%) in males and FSS (27%) in females were the most common etiology. GHD was found in 6.1% children and it comprised 38.2% of all endocrinological causes. Children with height falling below 0.4th centile were more likely to have a pathological short stature (79.2%) compared to 39.3% whose height was below 3rd centile but above 0.4th centile (p < 0.05). CONCLUSION: CGD and FSS are most common causes of short stature in boys and girls respectively, whereas, GHD is a relatively uncommon etiology.