Short-term outcome of polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of right ventricular outflow tract in tetralogy of fallot: a randomized controlled trial

Abstract Introduction: Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. Methods: Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. Results: The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. Conclusion: The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Incidence and predictors of super-response to cardiac resynchronization therapy

Objectives Cardiac resynchronization therapy (CRT) has significantly improved management of patients with heart failure with reduced ejection fraction (HFrEF). A significant number of patients have a dramatic response and have been termed “super-responders”. The characteristics of this subset of patients in Indian and Asian population have not been well studied. In this study, we sought to assess the prevalence and clinical characteristics of this cohort of patients. Methods This was a retrospective study involving patients undergoing CRT. Changes in ejection fraction and LVESV at the end of one year of follow-up following device implantation were assessed, and patients were stratified into non-responders, responders, and super-responders. Responders had a 15–29% decrease in LVESV while super-responders had a >30% decrease in LVESV. Results Of the 74 patients who had undergone CRT-P/CRT-D implantation, 16 patients did not have echocardiograms at the end of one year of follow-up and were excluded from the analysis. Thus, 58 patients were enrolled for analysis. We identified 16 patients (27.6%) to be super-responders, 26 patients (44.8%) to be responders, and 16 patients (27.6%) to be non-responders. Factors associated with a super-response were a diagnosis of dilated cardiomyopathy as against ischemic cardiomyopathy (93.7% vs 6.3%; p – 0.01), prior right ventricular (RV) apical pacing (25% vs 2.4%; p – 0.02) and absence of a prior history of myocardial infarction (MI) (0% vs 33.3%; p – 0.02). Conclusion In our study, 27.6% of patients were super-responders, and a diagnosis of dilated cardiomyopathy, absence of a prior history of MI and prior RV apical pacing predicted a super-response to CRT.

An Adolescent with Kawasaki Disease.

Kawasaki disease is an acute vasculitis of unknown etiology that predominantly affects children <5 years of age. The incidence and the severity of myocarditis in this disease is variable and depends upon the stage of the disease, acute or chronic. Acute-stage Kawasaki disease shows relatively high incidence of myocarditis, but almost all cases are clinically mild. We describe teenage boy presenting with atypical/incomplete manifestations of Kawasaki disease and developing fulminant myocarditis within a week of illness resulting in death. The case underscores the importance of suspecting Kawasaki disease in a young child presenting with features of myocardial ischemia.

Idiopathic spontaneous coronary artery dissection presenting as acute myocardial infarction in a young boy.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. It is more commonly seen in the younger age group particularly in women. We report a case of 14-year-old boy that presented with acute myocardial infarction (MI), with left ventricular (LV) dysfunction and was detected to have left main coronary artery dissection on coronary angiography. Myocardial perfusion imaging did not show any evidence of reversible ischemia. Patient was managed conservatively and was marginally improved. This case highlights one of the rare causes of myocardial infarction and the use of myocardial perfusion imaging in selecting treatment options for management of this rare entity.