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Biomedical subjects

R Juneja

Publications and source records attributed to R Juneja.

At least 91 records · Page 5Linked to original sources
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Routine cleft closure in repair of complete atrioventricular septal defects.

Thirty patients with complete atrioventricular septal defect were operated upon between 1989 and 1996 at our institute. Their ages ranged from two months to 24 years (mean age 2.81 years). All patients had severe pulmonary arterial hypertension except one who had associated pulmonic stenosis. Four patients had severe atrioventricular valve regurgitation and another six had moderate regurgitation. Five patients had Down's syndrome. The cleft in the left atrioventricular valve was closed in all but seven patients. There were five (16.66%) in-hospital deaths which included two patients in whom the cleft was left open. Follow-up ranged from three months to eight years. All patients were evaluated by 2D echocardiography in the immediate post-operative period and three to six monthly subsequently. One patient progressed to moderate and another to severe left atrioventricular valve regurgitation during follow-up. In both the patients the cleft had been left open. All other patients continue to have stable left atrioventricular valve status, that is, none or trivial to mild regurgitation. In view of late deterioration of the left atrioventricular valve regurgitation only in those patients where the cleft was left open, we suggest complete closure of the cleft in all complete atrioventricular canal defects.

Adolescent↗
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Mixed variety of total anomalous pulmonary venous connection: diagnosis by 2D echocardiography and Doppler colour flow imaging.

Of the many types of total anomalous pulmonary venous connection, mixed type is the least common. Its accurate non-invasive diagnosis by echocardiography poses a diagnostic challenge. We report our experience of echocardiography in 21 infants with mixed type of total anomalous pulmonary venous connection aged 25 days to one and half years. Multiple windows were used to identify individual pulmonary veins and various sites of drainage. Cardiac catheterisation and angiography were performed for 17 cases. In 11 of 21 cases, the left upper pulmonary vein was seen draining into vertical vein and the left lower and right-sided pulmonary veins were draining into the coronary sinus. Cardiac and supracardiac combinations of other types were seen in eight more cases. Both drainage sites were supracardiac in one case and supracardiac and infracardiac in another. On comparing echocardiographic findings with those obtained at cardiac catheterisation and/or surgery (carried out in 18 cases), there were three instances of error. In two cases (echocardiography performed without the use of colour flow imaging) the second site of drainage could not be defined. These patients were catheterised as all four pulmonary veins were not delineated by echo. The third error occurred in a case where although two sites of drainage were picked up by echo but at surgery, the right lower pulmonary vein was noted to have a double connection, both to coronary sinus and to vertical vein. We conclude that mixed type of total anomalous pulmonary venous connection can be accurately diagnosed by echocardiography and Doppler colour flow imaging. The diagnostic errors are rare and would not alter the surgical management.

Angiography↗
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Haemodynamic effects of leg raising in patients undergoing coronary artery bypass grafting.

Twenty patients undergoing elective coronary artery bypass grafting were studied prospectively to evaluate the haemodynamic effects of passive leg raising. The patients were divided into two groups: those having good left ventricular function with ejection fraction of 0.50 or more (group I, n = 10) and those having poor left ventricular function with ejection fraction of upto 0.35 (group II, n = 10). Morphine-based anaesthetic technique was used and standard haemodynamic measurements were obtained at following stages: (1) control--20 to 30 min after induction of anaesthesia; (2) one minute, and (3) five min after raising both the legs; (4) one min, and (5) five min after the legs were repositioned. In group I, heart rate decreased from 71 +/- 9 to 66 +/- 8 beats/min (p < 0.001) at stage 1 and persisted throughout the study period. This was accompanied by a decrease in cardiac index, although, the statistical significance was achieved at stage 3 and 4 only. The haemodynamic changes observed in group II were of more severe magnitude. The heart rate decreased from 90 +/- 13 to 84 +/- 13 beats/min at stage 1 (p < 0.05) and persisted throughout the study with maximum decrease of 14 percent occurring at stage 3. The cardiac index decreased significantly from 2.4 +/- 0.3 to 2.0 +/- 0.5 L/min/m2 (p < 0.05) at stage 1. This persisted throughout the study except that it recovered at stage 4. The maximum decrease in cardiac index (20%) occurred at stage 2. In addition, systemic vascular resistance increased significantly from 1458 +/- 255 to 1830 +/- 420 dyne.sec.cm-5 (p < 0.05) at stage 1 and persisted throughout the study period. We conclude that passive leg raising should be undertaken with caution in patients with coronary artery disease especially in those who have poor left ventricular function.

Aged↗
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Atrioventricular discordance in situs inversus.

We retrospectively analysed the records of 23 patients with atrioventricular discordance in situs inversus and compared them with 121 cases of atrioventricular discordance in situs solitus seen during preceding four years. One hundred and two (70.8%) patients were male. The mean age was 9.3 +/- 10.1 years (range 1 day-48 years). Overall, a ventricular septal defect with pulmonic stenosis (Fallot's physiology) was seen in 76 (56.7%) cases, ventricular septal defect without pulmonic stenosis in 26 (18.1%) cases, atrioventricular valve regurgitation in 25 (17.3%) cases and complete heart block in 13 (9%) cases. Double outlet right ventricle and Fallot's physiology were significantly more common (74.0% vs 32.3% and 91.3% vs 45.0%, respectively; p < 0.005), whereas atrioventricular valve regurgitation and complete heart block were less common (4.3% vs 19.8% and 0% vs 10.7%, respectively; p < 0.05) in patients with situs inversus and atrioventricular discordance as compared to patients with situs solitus. These differences may influence the natural history and treatment options selected for patients with atrioventricular discordance.

Adolescent↗
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Ambulatory 24-hour electrocardiographic monitoring following total cavopulmonary connection.

A total of 72 patients (53 males, 19 females) in the age range 1-22 years (mean 6.4 years) who underwent univentricular repair between April 1990 and May 1997 at our institute were followed up from six months to seven years (mean 3.6 years). Twenty-four hours ambulatory electrocardiographic Holter monitoring was done in all the patients. Thirty-four out of 40 patients (85%) who underwent fenestrated total cavopulmonary connection and 25 out of 32 patients (78%) who underwent non-fenestrated total cavopulmonary connection had normal Holter recording; thus 59 out of 72 (82%) patients had normal findings. Among the fenestrated total cavopulmonary connections, three patients each had atrial tachycardia and sinus bradycardia. In the non-fenestrated group, two patients had atrial tachycardia, three had supraventricular tachycardia, one sinus bradycardia and one had intermittent ventricular tachycardia. No correlation was found between age at surgery, pre-operative morphology, cross clamp time or cardiopulmonary bypass time with post-operative arrhythmia. To conclude, post-operative arrhythmias following total cavopulmonary connection were not related to age at surgery, pre-operative morphology, cross clamp or cardiopulmonary bypass time. However, a larger patient pool and longer follow-up is required for evaluation of any definitive correlation.

Adolescent↗
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Management of tetralogy of Fallot with absent pulmonary valve: early and mid-term results of a uniform approach.

The operative management of absent pulmonary valve syndrome remains controversial regarding palliative or one-stage correction, the need for pulmonary valve implantation and pulmonary arterioplasty. This retrospective report summarises the experience of a single centre with a view to provide some answers to this controversy. Forty-six consecutive patients including five infants, aged 2 months to 43 years, underwent primary surgical correction during the last 8.5 years. All the patients underwent two-dimensional echocardiography and cardiac catheterisation. Nine patients had mild and 10 moderate pulmonary artery hypertension. Repair consisted of patch closure of the ventricular septal defect and reconstruction of the right ventricular outflow tract. A valve was incorporated in the pulmonary position in 19 patients. Pulmonary arterioplasty was performed only in infants. Overall hospital mortality was 4 out of 46 patients (8.6%). Two out of five infants died accounting for 40 percent mortality. Forty-two survivors were followed up from 4 to 101 months; 40 patients are in functional class I and two in class II. Actuarial survival at 8.5 years was 91 percent. It is concluded that reconstruction of the right ventricular outflow tract with a transannular patch is sufficient in majority of patients. A selective approach to pulmonary valve insertion is recommended in patients with pulmonary hypertension or other anomalies. Pulmonary arterioplasty should be performed as the primary treatment in infants.

Adolescent↗
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Surgical considerations of univentricular heart with total anomalous pulmonary venous connection.

Out of the 600 patients undergoing univentricular repair during the last 11 years, 20 children had associated total anomalous pulmonary venous connection. The objective was to outline the clues to establish the diagnosis of this rare disease combination and the various surgical options available to manage the same. Bidirectional Glenn, bilateral bidirectional Glenn, total cavopulmonary connection and atriopulmonary connection were performed in combination with rechannelling of various types of total anomalous pulmonary venous connection in 20 children aged 6 months to 36 months (mean +/- SD 17.65 +/- 9.02 months). Diagnosis could be established pre-operatively in only 13 (65%) patients. Out of 6 early deaths (30%), 4 were directly attributable to missed diagnosis. No late deaths occurred over a follow-up period ranging from 1 month to 132 months. None of the surviving children required reoperation and all are in NYHA functional class I. Doppler echocardiography of the surviving children revealed unrestricted atrio/cavopulmonary anastomosis and pulmonary vein to atrium connection in all survivors. Our own experience, coupled with a review of the literature, indicates that a missed diagnosis increases the hospital mortality. Cross sectional 2D echocardiography is a superior method of detection of associated total anomalous pulmonary venous connection compared to angiocardiography. Exclusion of the diagnosis of anomalous pulmonary venous connection is imperative in all univentricular hearts pre-operatively and on operation table. Failure to recognise this disease combination results in formation of a closed systemic circuit after bidirectional Glenn or a modified Fontan of connection and is lethal as happened in our early experience. It is suggested that one-stage Fontan operation should be performed only if other criteria for Fontan procedure are satisfied.

Cardiac Surgical Procedures↗
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Two-catheter approach for ablation of accessory pathways in different locations.

Radiofrequency ablation is the treatment of choice for patients with Wolff-Parkinson-White syndrome and symptomatic tachyarrhythmias. The technique involves localising the pathway with multiple catheters at various sites followed by radiofrequency energy application at that site. Single catheter approach has been described for ablation of manifest left-sided accessory pathways. In this article, we report the ablation of accessory pathways in different locations in patients with Wolff-Parkinson-White syndrome by using a two-catheter approach. Twenty-three consecutive patients with symptomatic Wolff-Parkinson-White syndrome were taken up for radiofrequency ablation with this approach. Pathways could be successfully ablated in 11 out of 13 patients with left free wall, 5 out of 7 with right posteroseptal, one patient of left posteroseptal and each of the 2 patients of right mid septal locations giving an overall success in 19/23 (82.6%) patients. Hence, two-catheter approach can be used safely to ablate accessory pathways in different locations with high success rate, thus minimising the procedure time associated with conventional approach.

Adult↗
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Cardiac arrhythmias in surgically repaired total anomalous pulmonary venous connection: a follow-up study.

Twenty-five patients with diagnosis of total anomalous pulmonary venous connection, who had undergone corrective surgery, were studied at variable time period after surgery with 24-hour ambulatory electrocardiographic monitoring (Holter) and echocardiography. The aim of this study was to record arrhythmias, if any, and to correlate occurrence of arrhythmia with adequacy of repair and other related variables. All the patients were clinically asymptomatic. Twenty-four hours ambulatory electrocardiographic monitoring of these patients showed the presence of significant arrhythmias in 21 of the 25 patients. These included supraventricular ectopics in 19 patients, ventricular ectopics in 8, atrioventricular block in 2, right bundle branch block and atrial fibrillation 1 each and atrial tachycardia in 2 patients. There was no correlation between development of arrhythmia and age at repair, type of connection, operative approach and adequacy of repair. The study indicates that cardiac arrhythmias can occur in otherwise asymptomatic patients after correction for total anomalous pulmonary venous connection. Thus, these patients require long-term follow-up, even if they are asymptomatic.

Adolescent↗
PubMedDate not supplied

Immunosuppression in live-related donor renal transplantation.

BACKGROUND: Triple immunosuppression with cyclosporine, azathioprine and prednisolone is the most common regimen employed following renal transplantation. No information is available regarding its impact on the results of renal transplantation in India. The present study is an audit of a fixed-dose cyclosporine-based immunosuppressive regimen in an exclusively live-related donor transplant programme, with specific regard to graft and patient outcomes. METHODS: Patients transplanted over a 3-year period and receiving cyclosporine-based immunosuppression were studied. The relationship between immunosuppression and graft outcomes [rejection episodes (RE), graft function, graft survival], and patient outcomes (patient survival) was analysed in those receiving triple immunosuppression. Dosage schedules were audited. Cyclosporine trough level monitoring was employed at graft dysfunction episodes, or at dose reduction points. RESULTS: The median follow up was 14 months. Triple drug immunosuppression was used in 191 patients and double drug therapy in 26. The overall one-year patient survival rate was 91% and the corresponding graft survival rate was 90%. An audit of dosing schedules showed that over the first 6 months post-transplant, cumulatively, 20%-50% of patients received azathioprine, and 55%-60% received cyclosporine in doses below the protocol. The immunosuppressive doses (both of cyclosporine and azathioprine) in the first month were significantly related to the RE (p < 0.01) in the first month and the total number of RE in the first 6 months (p < 0.01). The other predictors were younger recipient age and older donor age. The sixth-month serum creatinine level was predicted by the donor age, the level of serum creatinine in the first month and the total number of RE in the first 6 months post-transplant. While no specific predictors of graft loss were identified in this cohort, diabetic nephropathy (p = 0.000) as the native renal disease, and the total number of RE were strongly related to patient mortality. The occurrence of > or = 2 RE in the first 6 months was an independent predictor, increasing the risk of death in the first 2 years post-transplant by 2.3 (p = 0.0001, 95% CI: 1.5-3.4). CONCLUSIONS: Sub-therapeutic baseline immunosuppression in the early post-transplant period predisposes to acute RE. This has an impact not only on graft function but also forms an important proximate marker of mortality, as seen in this cohort. Thus, immunosuppressive drug dosage should be optimized and therapeutic drug level monitoring strategies should be preemptive rather than event related, especially in the early post-transplant period. While fixed-dose immunosuppressive drug schedules are widely followed, it is possible to fall short of the target unless a specific effort is made to meet and sustain schedules.

Adolescent↗
PubMedDate not supplied

Does inhaled nitric oxide improve survival in operated congenital disease with severe pulmonary hypertension?

BACKGROUND: The present study aimed to assess the impact of inhaled nitric oxide on survival following correction of congenital heart defects with residual pulmonary arterial hypertension. METHODS AND RESULTS: Inhaled nitric oxide was utilized for the management of residual pulmonary hypertension in 24 children following surgical correction of their underlying heart defects. Their ages ranged from 15 days to 14 months (median 5 months). Pulmonary artery hypertension was diagnosed either by direct pulmonary artery pressure monitoring or by echocardiography. Inhaled nitric oxide was used electively in 22 patients when the ratio of the mean pulmonary arterial pressure and mean systemic arterial pressure exceeded 0.5. In the remaining 2 patients, nitric oxide was used only to manage a pulmonary hypertensive crisis. Inhaled nitric oxide was also used a second time in 2 patients who developed delayed pulmonary hypertensive crisis. Twenty-two patients showed an initial response to therapy and the pulmonary artery pressures dropped significantly. Of the patients on direct pulmonary artery pressure monitoring, a pulmonary artery to systemic artery pressure ratio below 0.3 on prolonged therapy was associated with a survival ratio of 4/6 (including 1 neurological death and one reoperation); that between 0.3 and 0.5 with a survival ratio of 3/4. Three out of four patients with sustained echocardiographic and clinical response also survived and were discharged from the hospital. All the patients who showed a lack of response to (n=2), tolerance to (n=1), or dependence on (n=6) the use of inhaled nitric oxide died. In addition, all 5 patients who had a pulmonary hypertensive crisis died, 3 in spite of successful resuscitation with nitric oxide. Thus, excluding one neurological death and one re-operation, only 9 (41%) out of 22 patients survived. CONCLUSIONS: Though inhaled nitric oxide is effective in lowering pulmonary pressure, it does not appear to improve the survival rate following repair of congenital heart disease in those with associated severe pulmonary hypertension. A randomized trial between the use and non-use of inhaled nitric oxide is warranted to determine its exact role in influencing survival in patients with residual pulmonary hypertension following surgical repair.

Administration, Inhalation↗
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Mechanical ventilation in the prone position: a strategy for acute respiratory failure after cardiac surgery.

Ventilation in the prone position, initially introduced in respiratory therapy to improve the drainage of secretions, has been used in intensive care to improve oxygenation. We report a case of an obese male patient who underwent elective coronary artery bypass grafting and had low PaO2 in the postoperative period. The PaO2 improved whenever the patient was ventilated in the prone position. On each occasion, oxygenation improved without any change in the hemodynamic parameters. The PaO2 increased from 57.8 to 249.7 mmHg on the first occasion, from 48.7 to 194.6 mmHg on the second and 62.5 to 199.7 mmHg on the third at an FIO2 of 1.0. The shunt fraction (Qva/Qt) decreased from 43.6% to 7.2% on the first occasion and from 46.7% to 12.5% on the second. Ventilation in the prone position can be an effective method for improving oxygenation in patients suffering from postoperative acute respiratory failure who are not responding to other ventilatory strategies.

Coronary Artery Bypass↗
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Aortic valve balloon dilatation in a newborn for critical aortic stenosis diagnosed during fetal life.

A young primigravida was diagnosed to have a fetus with critical aortic stenosis at 30 weeks' gestation. A decision to follow-up the fetus till term was taken as there was no evidence of congestive heart failure. Post-natal retrograde aortic valve balloon dilatation was performed 36 hours after birth. There was marked improvement in left ventricular function and the baby is doing well at 1-year follow-up. The need for accurate assessment of intracardiac anatomy during fetal life in critical aortic stenosis and its impact on therapeutic interventions is highlighted.

Adult↗
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Aneurysm of the vein of galen in neonates: report of four cases.

In neonates, aneurysm of the vein of Galen often masquerades as cyanotic congenital heart disease. We report 4 cases of neonates presenting with malformation of the vein of Galen at our insititution. An increased awareness of this entity seems warranted.

Cerebral Veins↗
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Graded balloon atrial septostomy in severe pulmonary hypertension.

BACKGROUND: The prognosis of patients with severe primary pulmonary hypertension is poor. The role of balloon atrial septostomy as a palliative procedure in these patients is not well defined. We retrospectively analyzed our data regarding the safety, clinical outcome and survival benefit of graded balloon atrial septostomy in patients with severe pulmonary hypertension. METHODS AND RESULTS: Eleven patients (7 males), aged 6 to 30 years (mean age 16.2+/-8.9 years), with severe pulmonary artery hypertension (mean pulmonary artery pressure of 76+/-16.9 mmHg) and refractory congestive heart failure and/or recurrent syncope underwent balloon atrial septostomy. Graded balloon dilatation under echocardiographic guidance and arterial oxygen saturation monitoring was done in all the patients. Procedure-related mortality was 18.2%. Significant acute hemodynamic improvement was seen in the survivors (pre-balloon atrial septostomy cardiac index 1.88+/-0.48 L/min/m2; post-balloon atrial septostomy cardiac index 2.18+/-0.37 L/min/m2, p<0.009). Patients were followed up for a mean period of 20.3 months after the procedure (range: 3 months-5 years). There was functional improvement and increased exercise tolerance in all the patients for a mean follow-up period of 14.6 months (NYHA functional class 3.62+/-0.69 to 2+/-0.50). The estimated probability of survival in this cohort at 1 year was only 48%; but 7 of 8 patients (87%) who survived the procedure were alive at 1 year. CONCLUSION: We conclude that balloon atrial septostomy improves clinical status, hemodynamic variables and possibly also improves survival in selected patients with severe pulmonary artery hypertension. It remains a definite palliative option for refractory primary pulmonary hypertension. However, the procedure-related risks are high in very sick patients and, therefore, balloon atrial septostomy may be advocated early in the course of the disease.

Adult↗