Biomedical subjects
Publications and source records attributed to J A Tharakan.
A rare combination of tetralogy of Fallot, absent pulmonary valve and absent left pulmonary artery is described. The clinical and angiographic profile and the impact on management are discussed. The embryology is outlined.
In a 50 year old woman, transthoracic echocardiography showed a left atrial mass. Transoesophageal echocardiography delineated its attachment. Additionally, cystic spaces were seen arranged concentrically in the shape of a star in the centre of the tumour. Surgical excision followed. Histopathological examination confirmed myxoma with areas of haemorrhage and necrosis. This case highlights the acoustic property of myxomas in a rare and beautiful manner and emphasises the superior transoesophageal imaging of myxomas.
A young lady with post-subclavian coarctation and cranial hypertension is discussed. She had a jump graft from left subclavian artery to descending aorta, and presented 18 years later with hypertension, calcification of the graft with a gradient of 40 mmHg across it. In the meantime, she also developed moderate aortic regurgitation on a bicuspid aortic valve. Management strategies including trans-catheter options are discussed. We present our reservations on trans-catheter options in an occluded dacron graft.
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We studied 25 patients with coronary artery fistula between 1976 and 1994. Age ranged from 1 to 58 years. Twelve patients were symptomatic; seven had dyspnoea, four had angina, one had palpitation and one had syncope. Coronary arteries in four. Coronary artery fistula drained into right ventricle in 11, right atrium in nine, pulmonary artery in four and left ventricle in two. The Qp/Qs ranged from 1.0 to 2.6 with a mean of 1.39 +/- 0.38. Five patients had associated cardiac anomalies. Two had atrial septal defects, one had patent ductus arteriosus, one had atresia of proximal right coronary artery and in one patient, the right coronary was arising from left coronary artery. Five patients underwent surgery without any operative mortality. Thirteen patients were followed-up medically for a mean period of 6.1 +/- 5.1 years. There were no complications related to coronary artery fistula during follow-up. In one patient coronary artery fistula closed spontaneously.
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A retrospective cohort study was carried out in 61 patients (30 males, 31 females, age 24.6 +/- 11.8 years) with primary pulmonary hypertension diagnosed by strict clinical and hemodynamic criteria, to obtain an understanding of the natural history and prognostic markers. While 15 patients were alive, 46 patients (76%) had expired during the follow up period. Two, five and ten years survivals were 48%, 32% and 12% respectively. Median survival duration from time of diagnosis was 22 months. The survivors had significantly higher age of onset, cardiac index and significantly lower right atrial mean pressure, right ventricular end diastolic pressure, cardiothoracic ratio from chest rontgenogram and calculated pulmonary vascular resistance as compared to non survivors. While pulmonary artery systolic pressure was not significantly different, pulmonary artery diastolic and pulmonary artery mean pressures were significantly lower in survivors than in non-survivors. Lower New York Heart Association class, right atrial mean pressure < or = 7 mm Hg, right ventricular end diastolic pressure < or = 10 mmHg, cardiac index > 2.5 L/min/m2, pulmonary arterial oxygen saturation > 60%, were associated with significantly longer survival. The degree of pulmonary arterial hypertension had an indirect prognostic effect through the above parameters. Vasodilator therapy did not significantly alter the outcome of patients with primary pulmonary hypertension.
During a 7 year period from 1984 to 1991, 100 infants underwent either balloon atrial septostomy (BAS) (n = 92) or blade septostomy (BLS) (n = 8). The indication was complete transposition of the great arteries in all the patients. The mean age in the BAS group was 1.8 +/- 1.5 months while that in the infants requiring BLS due to a thick septum was 3.03 +/- 2.29 months. The degree of improvement in arterial oxygen saturation in both groups was satisfactory -27.16 +/- 14.06% in the BAS group vs 23.5 +/- 12.18% in the BLS group. There were no procedure related deaths in the BLS group, through only monoplane fluoroscopy was used in 6/8 patients. Three patients however died following balloon septostomy. We conclude that BLS is a safe and effective alternative to surgical septostomy when performed with due care. Two dimensional echocardiography during BAS enhances the speed and safety of the procedure and helps to identify patients who may require BLS due to a thick interatrial septum.
During 1992-93 12 patients (5 males, 7 females) with thrombosed prosthetic cardiac valves were treated with streptokinase on 13 occasions (one patient with prosthetic tricuspid valve had two thrombotic episodes). Their age ranged from 14 to 52 years (median 39). Two valves were in aortic position, six in mitral and four in tricuspid position. Eight were Bjork-Shiley prosthesis, three were Medtronic Hall valves and one was a St. Jude Valve. Timing of prosthetic valve thrombosis ranged from 3 months to 12 years after valve replacement surgery. Duration of symptoms due to valve thrombosis ranged from 1-4 months with tricuspid valve thrombosis and 1-14 days with left sided valve thrombosis. Five were in functional class II and four each were in functional class III and class IV. All patients were evaluated by echo Doppler and cine fluoroscopy. Loading dose of streptokinase was 2.5 lakh units in 4 patients and 1 lakh units in 9 patients. Maintenance infusion was at 1000 units/Kg/hour in 11 patients and 1 lakh units/hour in 2 patients. Duration of streptokinase infusion ranged from 3 hr to 38 hr. Thrombolytic therapy was successful (clinical, echo Doppler and fluoroscopy) in 12 out of 13 cases (92%). It was unsuccessful in a patient with valve at tricuspid position in whom infusion had to be stopped after 24 hour due to bleeding gums. One patient developed intracerebral bleed and expired. In conclusion streptokinase therapy is useful for prosthetic cardiac valve thrombosis.
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Bidirectional Glenn (BDG) shunt was carried out in 14 patients (age range 1.5-22 years; mean 9.3 years) for a variety of congenital cyanotic heart diseases with decreased pulmonary blood flow. Postoperative cardiac catheterisation was carried out in 10 patients including successful balloon angioplasty of the shunt and LPA in one patient. There was a significant improvement in oxygen saturation and a drop in haematocrit level at follow-up. Doppler echocardiography studies in 13 patients revealed functioning shunts in all cases with low velocity continuous flow. Thus BDG is a useful palliative procedure and could be undertaken as the first stage of total cavopulmonary connection in high-risk Fontan groups where biventricular repair is not feasible.