Public-Private Partnership for Treatment of Congenital Heart Diseases: Experiences From an Indian State.

Background: Treatment of congenital heart disease (CHD), being the most common congenital anomaly, puts immense financial burden in low- and middle-income countries (LMICs) and contributes significantly to infant mortality. We report experiences of treatment of CHD in the Indian state of West Bengal by a public-private partnership (PPP) model. Methods: Under the Rashtriya Bal Swasthya Karyakram, the government of the state of West Bengal in India launched a program called the "Sishu Sathi Scheme" to provide free treatment to children who need heart surgeries, irrespective of economic status. Treatment was provided in selected private hospitals and some public hospitals in a reimbursement model where government compensated the hospitals. Data were collected on such procedures from 2013 to 2022 and analyzed. Results: A total of 27,844 patients with CHD received treatment under the Sishu Sathi Scheme from August 2013 to December 2022. The average number of patients per year was 3,093. Detailed data of procedures from January 2016 to December 2022 showed a total of 22,572 procedures (6,249 device interventions, 4,840 cardiac catheterizations, and 11,483 surgical interventions). The in-hospital mortality of surgical procedures and catheterization lab procedures were 5.2% and 0.9%, respectively. Conclusions: A large number of patients with CHD were successfully treated under a PPP in the state of West Bengal in India. In spite of its inherent challenges, this model is of special relevance in LMICs where access and affordability for treatment of CHD always remain a challenge.

Comparison between Del Nido and conventional blood cardioplegia in pediatric open-heart surgery.

BACKGROUND: Del Nido cardioplegia (DNc) was designed for superior myocardial protection during cardiopulmonary bypass (CPB). We conducted a retrospective review to explore if DNc was associated with increase in systemic ventricle dysfunction (sVD) following pediatric CPB. METHODS AND RESULTS: This single-center, retrospective study included 1534 patients undergoing CPB between 2013 and 2016, 997 prior to center-wide conversion to DNc and 537 following. The primary outcome was new postoperative ≥moderate sVD by echocardiogram. Secondary outcomes included sVD of any severity and right ventricular dysfunction. Data was evaluated by interrupted time-series analysis. Groups had similar cardiac diagnoses and surgical complexity. Del Nido cardioplegia was associated with longer median (IQR) CPB [117 (84-158) vs 108 (81-154), p = 0.04], and aortic cross-clamp [83 (55-119) vs 76 (53-106), p = 0.03], and fewer cardioplegia doses [2 (1-2) vs 3 (2-4), p < 0.0001]. Mortality was similar in both groups. Frequency of sVD was unchanged following DNc, including predetermine subgroups (neonates, infants, and prolonged cross-clamp). Logistic regression showed a significant rise in right ventricular dysfunction (OR 5.886 [95% CI: 0.588, 11.185], p = 0.03) but similar slope. CONCLUSIONS: Use of DNc was not associated with increased in reported sVD, and provided similar myocardical protection to the systemic ventricle compared to conventional cardioplegia but may possibly impact right ventricular function. Studies evaluating quantitative systolic and diastolic function are needed.

Use of cardiopulmonary bypass machine in intensive care unit as a short term mechanical circulatory support for recovery of cardiac function.

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) is used as a bridge to recovery of cardiac function following completion of congenital cardiac surgeries where there is failure to wean from cardiopulmonary bypass (CPB) or severe low cardiac output states in the post operative periods. Although ECMO is a well-established form of mechanical circulatory support, the associated cost can be a huge financial burden on families. We are an ECMO center and use the same in post operative congenital cardiac surgeries for mechanical cardiovascular support if needed. However, a significant proportion of the children, whom we operate, are funded by government aides. The resources are limited in such circumstances. If needed, we use the same CPB circuit and cannulae used in the Operating Room (OR) and support them at a significantly lower cost compared to ECMO. METHODS: We report our experience of using conventional CPB machine as a short-term bridge to recovery of cardiac function in Intensive Care Unit where there was limitation of funds. Essentially same CPB circuit with roller pump is retained, by omitting cardiotomy suckers. We use D901 Lilliput 1 Oxygenator (Sorin, Italy) for children <5 kg and D902 Lilliput 2 (Sorin, Italy) Oxygenator for children >5 Kg. RESULTS: We supported nine patients on CPB between March 2019 and December 2021. During this time, 1392 congenital cardiac surgeries were performed. We could wean off three patients (33.3%) and discharge two patients (22.2%). Our support time ranged from 21 h to 60 h with a median of 48 h. Beyond 48 h of support, we experienced several CPB induced complications in our cohort. CONCLUSION: In resource-limited settings, conventional CPB machines can be used for short-term cardiac support. Although results may not be comparable to using ECMO, some patients can be definitely salvaged, who would otherwise die in the absence of institution of mechanical circulatory support.

Spectrum and outcome of the use of noninvasive ventilation in a pediatric cardiac intensive care unit: A single-center experience.

Background and Aims: The pediatric cardiac intensive care unit (PCICU) frequently uses noninvasive ventilation (NIV). There are several reasons for its use, including prophylactic use right after the patient has been extubated. It is also used when patients are experiencing acute respiratory failure due to either cardiac or noncardiac reasons but are still able to maintain their airways. The objective of this study was to understand the spectrum of use of NIV following congenital cardiac surgery and analyze the outcome. Methods and Results: A retrospective observational study was conducted in a 14-bed PCICU, reviewing data from August 2019 to August 2022. Among 1750 congenital cardiac surgeries, 523 patients (29.9%) received NIV. The median age of the population was 2.5 months. Factors such as higher Risk-Adjusted Classification for Congenital Heart Surgery-1 category, longer intraoperative cardiopulmonary bypass time, and aortic cross-clamp time were associated with increased NIV use. Preoperative ventilator needs, infections, genetic syndromes, diaphragmatic paralysis, high vasoactive inotrope score (VIS) in the first 24 h, neonatal age, and weight <5 kg were independently associated with increased NIV need. The NIV group had a longer intensive care unit (ICU) stay compared to non-NIV patients. The success rate of NIV was 84%, with 440 successful cases and 83 failures. The mortality rate in the success and failure groups was not significantly different (5.27% vs. 6.0%). Conclusions: NIV is widely used in PCICU, but it is associated with longer ICU stays. It proves beneficial after congenital cardiac surgery, especially for patients with specific risk factors. However, NIV may not directly impact mortality rates, suggesting that other factors contribute to patient survival.

Late presentation of aortopulmonary window: a contemporary series.

Late presentation of aortopulmonary window (APW) beyond infancy is uncommon and many of these cases are inoperable due to development of progressive pulmonary hypertension and Eisenmenger syndrome. Outcome data in this cohort is thus sparse and the aim of this study was to analyze the outcomes in patients with APW operable beyond 1 year of age. Between September 2016 and March 2020, in a single center, 12 consecutive patients older than 1 year, undergoing surgery for APW, were included in the study. The median age and weight at presentation were 7.5 years (interquartile range (IQR) 4-9.5) and 15 kg (IQR 11.7-19.5). Ten (83.3%) patients had type 1 APW (proximal type) and 2 (16.6%) had a type 2 APW (distal type). Eight (66.6%) patients had associated lesions. Transaortic patch closure of APW was done in all cases. Seven (58.3%) patients were extubated within 3.5 h of admission in intensive care. There were no early deaths or during follow-up. The median follow-up duration was 20.5 months (IQR 7.5-24), and all patients were in New York Heart Association (NYHA) class I at last follow-up. Follow-up echocardiography did not reveal any significant residual shunts necessitating any additional procedure and a consistent decrease in pulmonary artery pressures. Surgery in patients with APW beyond 1 year of age is possible in selected patients. The early and intermediate surgical outcomes in patients who remain operable are excellent.

Basics of extra corporeal membrane oxygenation: a pediatric intensivist's perspective.

Extra Corporeal membrane oxygenation (ECMO) is one of the most advanced forms of life support therapy in the Intensive Care Unit. It relies on the principle where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) within which blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. The goal of ECMO is to provide a physiologic milieu for recovery in refractory cardiac/respiratory failure. The technology is not a definitive treatment for a disease, but provides valuable time for the body to recover. In that way it can be compared to a bridge, where patients are initiated on ECMO as a bridge to recovery, bridge to decision making, bridge to transplant or bridge to diagnosis. The use of this modality in children is not backed by a lot of randomized controlled trials, but the use has increased dramatically in our country in last 10 years. This article is not intended to provide an in-depth overview of ECMO, but outlines the basic principles that a pediatric intensive care physician should know in order to manage a kid on ECMO support.

Atypical presentation of complete heart block in children with pediatric inflammatory multisystem syndrome: A case series of two patients.

In the midst of the COVID-19 pandemic, we report two cases of children presenting with typical diagnosis of pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) who suffered from complete heart block requiring pacemaker placement which is an unusual presentation of PIMS-TS. We also compared it with the already existing data with similar manifestations. PIMS-TS is reported to occur in children with predominantly gastrointestinal symptoms, hemodynamic instability, and myocardial dysfunction. The implications of development of atrioventricular block during critical illness in PIMS-TS are yet unknown. Both patients had an otherwise normal cardiac structure and had no gastrointestinal symptoms but suffered complete heart block without any other identifiable etiology, both requiring temporary pacemaker placement. While one child recovered completely with medical management, the other child required permanent pacemaker placement. While we cannot be certain that COVID-19 was the cause, complete heart block appeared to be temporally related to COVID-19 infection in both patients, and hence, it is important for pediatricians to be aware of the potential manifestation of this disease.

Surgical repair of total anomalous pulmonary venous connection: Lateral approach.

We describe the lateral approach to the surgical repair of a total anomalous pulmonary venous connection in this video tutorial. The goal of the operation is to create an unobstructed anastomosis between the pulmonary confluence and the left atrium, ligate the systemic venous connections, and close the atrial septal defect. After a median sternotomy and initial dissection of the structures surrounding the heart, cardiopulmonary bypass is initiated by aortobicaval cannulation. The patient is then cooled to attain mild hypothermia (30°C). The heart is arrested by a dose of antegrade cold cardioplegia. The right pleural cavity is opened widely. The heart is retracted and pushed into the right pleural cavity. The vertical vein is ligated near its connection with the innominate vein. An incision is made along the length of the confluence, stopping short of the individual pulmonary veins. The left atrial appendage is retracted, and the left atrium is opened in alignment with the opening in the confluence. The left atrium and the pulmonary confluence are anastomosed widely with 7-0 polypropylene suture material. The heart is put back into the mediastinum. Rewarming is started. The atrial septal defect is closed through the right atrium using a large untreated autologous pericardium patch. The patient is then weaned off cardiopulmonary bypass.

Congenital right ventricular diverticulum: An atypical presentation.

Congenital ventricular diverticulum is a rare congenital malformation of the heart. It remains mostly asymptomatic unless associated with other congenital cardiac defects. We present a case of a 4-month-old child who had dextrocardia, large inlet ventricular septal defect, amounting to single ventricle, and severe pulmonary artery hypertension. There was a right ventricular diverticulum which passed through the foramina of Morgagni to give rise to a pulsating lump in the epigastrium. Right ventricular diverticulum presenting with a pulsating mass in the abdomen is a rare entity. The confirmation of diverticulum was made with histopathology.

Developing nomogram to estimate birth weight from head circumference and mid-upper arm circumference.

BACKGROUND: Despite the huge proportion of the babies in the developing world being born low birthweight, only about half of the newborns are weighed at birth as weighing scales often tend to be either non-available or defective. OBJECTIVE: Designing a nomogram for estimation of birthweight from head circumference (HC) and mid-upper arm circumference (MUAC). METHOD: Birthweight, HC and MUAC of 500 newborns who were admitted in the baby nursery of Medical College and Hospital, Kolkata between July 2010 to December 2010 were measured. RESULTS: Multiple linear regression equation for prediction of birth weight from MUAC and HC was derived and a nomogram was constructed from the same. CONCLUSION: The birthweight estimation nomogram is an inexpensive and convenient tool for use in the community setting where weighing machines may not be always available and may thus allow prompt and early referral.

Unilateral basal-ganglia involvement likely due to valproate-induced hyperammonemic encephalopathy.

A male child suffering from generalized tonic clonic epilepsy, on treatment with valproate, developed fulminant hepatic failure, hyperammonemia and encephalopathy due to drug toxicity. The most extraordinary feature was his MRI (FLAIR image) of brain which showed unilateral hyperintensities in right putamen and caudate nucleus. The patient recovered on withdrawal of valproate with mild residual left sided athetotic movements during remission. Repeat investigation confirmed an improved MRI imaging and normalised blood ammonia levels. The case report is unique because of unilateral involvement of basal ganglia due to valproate-induced encephalopathy.

Rare magnetic resonance imaging findings in medium-chain acyl-coenzyme A dehydrogenase deficiency.

A 3-year-old boy receiving valproate for 1.5 months presented with sudden-onset unprovoked seizures and unconsciousness. Hypoketotic hypoglycemia, hyperammonemia, and deranged liver function were detected. Elevated medium-chain urinary acylglycines and plasma acylcarnitine were detected. His serum valproate level was elevated. Valproate toxicity had been precipitated in presence of medium-chain acyl-CoA dehydrogenase deficiency. Cranial magnetic resonance imaging brain indicated unilateral basal ganglia ischemia instead of the bilateral changes expected in metabolic disease.

Giant condyloma acuminata in pediatric HIV.

We report a 2 year 6 months old girl suffering from HIV infection and presenting with two giant condyloma acuminata of perianal and perivulvar region along with oral candidiasis.

Pediatric polysomnography: the patient and family perspective.

STUDY OBJECTIVES: The gold-standard test used to diagnose childhood obstructive sleep apnea is polysomnography. However, this test requires an overnight stay at a sleep laboratory and the attachment of multiple sensors to the patient. The long-term impact of this testing on the child and family are not known. We hypothesized that polysomnography does not precipitate acute or chronic psychological effects in children. METHODS: A consecutive cohort of children who had undergone sleep studies 2 to 4 months prior to the interview were administered a standardized questionnaire via telephone. RESULTS: Of the 118 families that were eligible to participate, 67% could be contacted and agreed to participate; 87% of respondents reported the experience to have been satisfactory (mean Likert score of 8.6 ± 2.0 [SD] on a scale of 1-10). Similar levels of satisfaction were reported by parents of children with developmental delay or those who were younger than 3 years. The night's sleep was considered typical in 68% of cases. Sleep was less likely to be typical in children younger than 3 years (47%, p = 0.043). Eight percent of children experienced pain during the study. By caregiver report, of those children who remembered the sleep study, memories were positive in 84%. No child had evidence of serious long-term psychological issues. CONCLUSIONS: The vast majority of children and families found the polysomnography experience to be satisfactory, with no psychological sequelae. However, many children, especially those younger than 3 years, demonstrated sleep patterns different from their usual sleep. The clinical relevance of this finding merits further study. Further research evaluating the generalizability of this study is also needed.

Designing colour-coded measuring tapes based on mid-arm and chest circumference to predict low birth weight in the field.

BACKGROUND: In developing countries, 80% of the births take place in the community. METHODS: Birthweight, mid-arm and chest circumferences were measured in 294 newborns admitted in a tertiary-level hospital in Kolkata between April and August 2010. Colour-coded measuring tapes were devised using receiver operating characteristic curves to calculate the most sensitive and specific cut-off values to identify birthweight <2.5 and 1.8 kg. RESULT: There is no significant difference in accuracy of Mid-arm circumference (MAC) and Chest circumference (CC) for prediction of low birth weight and birthweight <1.8 kg. The tape has three zones, green [weight (wt) > 2.5 kg, MAC > 8.4 cm, CC > 30 cm], yellow (wt 2.5-1.8 kg, MAC 8.4-6.7 cm, CC 30-25.5 cm) indicating some risk, and red (wt < 1.8 kg, MAC < 6.7 cm, CC < 25.5 cm) indicating babies needing referral and admission in Level II neonatal care unit.

Adolescents speak: why do we smoke?

OBJECTIVES: To assess the role of different factors that are associated with initiation and continuation of adolescent smoking. MATERIALS AND METHODS: A total of 2535 students (1465 males and 1070 females) between the age groups of 14 and 19 years were selected from four schools and two colleges of the city by two-stage cluster sampling design for this cross-sectional study. RESULTS: The prevalence of cigarette smoking was 21.58%. Smoking was found to be considerably influenced with having seen best friend, father, sibling and favorite movie star smoke and also with receiving pocket money. CONCLUSION: Experimentation of substance use, motivated by family members, peer groups and the surrounding environment is common among adolescents and starts early in life. Therefore, it is necessary to come up with health promotion programs directed toward students which encourage attitude shaping among them toward self-confidence and healthy life style.

Dengue infection with multi-organ involvement.

Fever, headache, body aches, retro-orbital pain, haemorrhage and shock are well known manifestations of dengue infection. We report the case of a 4-y-old child with dengue who presented with meningo-encephalitis and subsequently developed myelitis, hepatitis, glomerulonephritis and bone marrow suppression. Complete recovery occurred within 3 weeks.