Syncopy in seated position that is very important of Supine position Syncopy while driving you have history of palpitation before Syncopy these are all red flags where you need to look and rule out cardiac cause for Syncopy and very important is having Syncopy during exercise so if the child is exercising running and at that time has a Syncopy you need to think in terms of Arias while V Syncopy will be common after the child has stopped exercising and then has an episode of syn treatment of V synthy is very simple you give plenty of fluids you can add extra salt and sugar in it avoid starving for long duration as the child to have more frequent meals as I said episodes are common while standing in assembly so whenever they standing has the to bend the knees intermittently in the morning it is very common have Syncopy just while waking up from the bed so get up slowly from the bed stretch your muscle before getting off some kids pass urine and have a synal event in the washroom so always have ask them to have a breakfast before show slowly regulate the temperature of the sh and whenever they're giddy ask them to lie down and passively raise their leg rather than falling down by doing this most of the patient with Vis synop episodes are controlled very few of them require medication now coming from V Syncopy to this episode in a 9-year-old child where child had synal event while playing in the school uh child examine normally had normal first and second heart sound an adult cardiologist was shown and did a normal echo cardiogram and the op everything is fine nothing needs to be done child had one more episode at the Peri again sent for opinion to Pediatric Cardiologist and I said most important investigation was missed the first time that is the ECG we look at the ECG the QT interval is prolonged it is around close to7 millisecs uh that is Al around 700 millisecond so the child probably has a Long QT interal s of vac in between then after this dug into the history and there was a history of sudden death in the maternal Uncle so this is probably long syndrome child was started on beta blockers episode redu child is following up and doesn't have any episodes further so take away that most important in case of Syncopy is history if there are any red flags which had mentioned then you should think in terms of cardiac Syncopy if child is clinically normal no signs of cardiac failure no murmur normal first and second heart sound then that usually rules out structural heart problems so in those cases most important to have ECG as abnormal as Arias could be one of the common cause in these patients and always pay attention to the red flag before leveling any episode as V syn toy and coming to another OPD problem very commonly seen is the children complain of chest pain so you have an eight-year-old boy complain of chest pain on and off for two weeks there no aggravating or relieving factors pain is lasting only for a few seconds to minutes and self-resolving no Associated sweating change in color no family history of s death or death in early age group child is examining normally there's nothing clinically no signs at all this is the ECG which was completely normal echo which is normal so this is very common scenario where chest pain child comes with chest pain in the OPD by and large chest pain in pediatric age group is non-cardiac so it is not important to investigate always but if you have recurrent episode document a normal ACG document a normal structural heart in the heart the eoam just look whether the coronaries have been looked at the are normal there's no mital Val prolapse there's no pulmonary hypertension and also function normal most common cause in pediatric the chest pain is due to muscular scal cause or gastritis most of them do not require any further investigation unless there's a history of some cardiac surgery in the past history of recurrent chest pain history of Kawasaki disase in the past or famili idemia or there typical syr symptoms which is very rare to happen in pediatric AG so I'll end with my take-home message from this is look for if in a to pick up congenital heart disease Astic heart disease look for symptoms of slow weight gain fast breathing at risk suckr Cycles repeated low respir infection if the symptoms are continuously present then is more likely to be cardiac if the episodic more likely to be respiratory uh always use a saturation probe to look for low saturation that is less than 90% sinosis will be visible when s less than 85% any Mur that you hear on one more than one occasion should be investigate and evaluated If the child is symptomatic and has a murmur then don't wait for second examination just send for evaluation copy is more of a clinical diagnosis and most important investigation is ECG provided sign has no no signs and chest pain in Pediatric Group by and large non cardiac and origin whenever in doubt only that you investigate thank you for patient with me if you have any questions please put up in the chat box I'll be happy to answer them take e e good good afternoon everybody um so today guess somebody has a speaker on can we if you can mute yourself please thank you so much so uh good afternoon I'm Dr priia and uh I work in srcc as a consultant in pediatric cardiology and today I'm going to speak about Advanced Diagnostic Tools in pediatric cardiology so just now we spoke about the echo cardiogram but that is not it so a cardiologist also have to perform many other tests before uh we take the patient for any surgery or interventions many patients require a variety of tests so this uh though it's not tea time um it's time for P that's leoc cardiogram so what is a trans leoc cardiogram basically uh it's a test in which we pass on a ultrasound tip probe through the mouth of the patient and as you see in the diagram in the left side this probe goes from the mouth through the naso parins into the igus and the heart is just anterior to the probe the movements of the probe you can turn the probe clockwise anticlockwise you can make it anti Flex like you can turn it anteriorly take it posteriorly and in this way you can have different angles and different images of the heart so now what is the advantage of this test over the other traditional echo cardiogram so here the images are really very clear so you can see if there are small infective endocarditis poai you can see other structures like pulmonary veins or coronaries very well uh sometimes a surgeon also wants uh for the vssd routability so what is the routability is basically you to communicate the left ventricle to the Iota so in cases of large vsds or if there are malose great arteries then the surgeon needs to see exactly what route he has to take when he places his patch and hence this can be seen very well in the transal echocardiogram also when we do device closures we take a look at the defect in the trans echocardiogram so here this patient had multiple holes which is the interal sepal defect and we needed to see that we were not able to see that through the echo so we had to do a to very operatively we see whether the adequacy of surgery surgical closure is fine or even before the surgery of the surgeon wants to see any more details time required depends if it usually requires 15 to 20 minutes for the procedure uh patients are sedated for the procedure short uh IV sedation is required and uh this procedure can also be taken place in a daycare setup so this is just some pictures to for you to get an idea about how in the peroperative period uh we do the transpal cardiogram so this is in the operation theater the prog of the patient the surgeon is looking uh from the other side and we are looking at the pictures on the screen this another uh Imaging technique it's the echocardiogram which we call as epicardial echo in which we place the probe directly over the heart of the child so this again is done when uh sometimes the probe size is bigger for the child so very tiny babies the probe won't go through the esophagus it's too big for the baby so in those cases we perform a epicardial echocardiogram especially in patients with TVC TGA so these are all very tiny babies requiring surgeries in the first week of their life so next we go to the CT angiogram CT angiogram is basic a plain C is not very um useful for us in cardiology because we have to see more of the structural Anatomy which is best seen with angiography what is angiography is basically you give um an IV line to the child and you pass some contrast through the IV line and we see the structures of the heart so again uh in this way structural analysis is can be done much better in a CT scan than a traditional echocardiogram so extra cardiac structures like Branch pulmonary arteries major a pulmonary collaterals if there is any signs of Airway compression CT gives beautiful Imaging where what is the sight of the compression uh in case of rings Lings lung pathologist can be very well seen very small structures like coronary arteries pulmonary veins these are best seen in the CD scan and uh if any patient has poor transthoracic windows or if there is some uh metais like dextrocardia mesocardia in which the transc windows are not very good in those cases we need a CT scan requ 30 minutes of time patient may or may not need sedation even in the new bores we can just wrap and feed them and they can sleep through the procedure uh or else even in bigger children we can explain them the procedure and they do quite well serum creatinin test is required prior to the contrast injection um but here the only drawback is that the radiation dose is quite significant so you cannot keep on having repeated CT angiograms for patients also there's the thing about contrast allergy which we have to take care of um if the neonate has especially neonates or any child who has very high heart rates the Imaging may be a little suboptimal and of course it cannot be done in ch in pregnancy or children undergoing radiotherapy or the children who have heightened risk of cancer um so here is a image wherein um this is a patient paent so if you can see on the image B you can see the Iota and the pulmonary artery so Iota has to give rise to the coronary artery so if you can see coronary artery is coming from the Yota but the left coronary artery is absent only one coronary arter is coming from here so where is it coming from it's coming from the pulmonary artery so this is a case of alapa that's the abnormal abous origin of the left coronary artery from the pulmonary artery that was very well diagnosed because of the CT Scan Imaging the most regular cases which actually go for CT scan is the patients who have tetrology of phow in the first image you can see that there's a V and so the for before you go for complete repair we need to see the exact size and of the pulmanary branch pulmonary arteries okay kinking of the pulmonary arteries so all these very detailed information can can be only obtained from CT and you cannot see it in a normal transthoracic or transal cardiogram the next imag below is a patient with cooptation so even for interventions before we have to decide about the stent size uh CT is very important and it gives us very great Imaging and information about what size of St we need to choose the the other image here is a TC so we will discuss it more in the details it's basically all the pulmonary veins are anomalously draining through the innominate ve so this structure which is going up is the inom win and which is coming down on the right hand side which which is basically the left hand side of the screen is the right Superior vinava so it's a figure of eight which we on x-ray is seen on the CT here this is a very beautiful uh 3D reconstruct image of a patient who is just admitted in the ward and had his CT just yesterday so this is basically an arch anomaly if you can see the iotic arch comes from the right side and then from behind and it goes to the left side so it's a arch anomaly we can we call it as a circumflex Iota so CT uh of course prior to surgery many of the patients undergo CT Imaging to get more information about the anatomy next is uh MRI indications uh so in in cardiology we don't do MRIs very often but even then they have a very specific indication and very very useful in certain set of patients so for functional assessment if you need to know exactly what is the function of the ventricular Chambers especially when you have single ventricle conditions or cardiomyopathies to monitor them U volume assessment you can do for left ventricular or right ventricular volume so in case of tetrology of phop patients when they have a trans patch that means the valve has been cut open during the first surgery uh the valve has leakages which may lead to volume overload of the right ventricle and then as they grow up the right ventricular volume increases and we need to replace the pulmonary valve so in those cases when to actually the timing of the procedure can be decided upon serial M scans similar with iotic Val replacement so the timing of surgeries we can decide from the MRI sometimes even the iology of cardiomyopathies if you have decreased function of The myocardium uh you can if you do an M you can see there is uh if there's fibrosis or the storage disorders you can see the muscle uh looks different and that is how you can diagnose the pathology so mostly again requir sedation because it's a long procedure as opposed to CT which can be also performed without sedation uh here it requires around 2 hours there's no radiation Hazard but the machine is quite noisy and it becomes quite claustrophobic for patients and then there's another new modality which we use is the CMR wherein actually it's like an angiography through the MRI and here uh we can have very beautiful pictures we can also use this when we are doing cardiac catheterization so here your volume assessment pressure assessment can be done in this uh methodology so I'm going to show you a little bit of picture so what actually happens in an MRI if you see this the two dots so at different cardiac phases of the cardiac cycle we are studying about the volumes of the left ventricle here and we are getting the ejection fraction so systolic volume and diastolic volume if we know then we can get the exact ejection fraction of The ventricle this is another patient whose MRI did because if you can see this right ventricular outflow tract has an aneurysm here so this patient actually we would wanted to study for pulmonary Val replacement but we saw that there was this Conduit on the third picture which I'm playing right now you can see a cute which is quite loosen here and uh there's an aneurysm just below the cond which is causing a RV volume overload so helps in planning of procedures next testing uh next Advanced test is genetic testing see we all know that uh cardiac defects 20% of them as high as 20% are associated with some kind of other abnormalities they syndromic associations with cardiac defects so many patients uh also may not be syndromic but they may have genetic associations and hence it's very important for the overall outcome of the baby to know these genetic associations so it basically helps prediction and prognostication for that baby and then it also helps in uh give advising for the future pregnancy so if what conditions they are we can actually give them the incidence of of recurrence in the next pregnancy and the tests that they can do uh during the fetal uh from the amniocentesis to avoid those kind of problems in the subsequent pregnancies so whole exam sequencing is uh commonly advised very uh in case we don't we are not suspecting any particular problem otherwise we can do fish and cotype quite specific test so um we order them very routinely when we see certain type of heart diseases or if there is a family history or if there is syndromic Association and the sample can be either am notic fluid even the Buckle mucosa saliva blood but just the drawback is that the test takes time so it needs at least two to three weeks for the results to come up another very important test is the fetal Echo so fetal Echo is when we scan the heart of the child when he's in the womb and the mother uh we scan the mother and this is the indications so if not everybody requires a petal Echo but if the mother has a family history of congenital heart disease or metabolic disorders like diabetes if she's exposed to terens or is exposed to certain medications like IB pref salic acid certain kind of infections make you more prone for heart diseases like rubella autoimmune diseases like May predispose the baby to have a congenital heart blocker other and then there are family inherited disorders like the maans nans arar in initro fertilization is another indication because we see cardiac defects more common in these kind of pregnancies in the feter indication basically when uh they are doing a ultrasound scan for the mother if they notice that the radiologist notice any abnormal cardiac screening any abnormal heart or rate or rhythm in the baby or if they have found any fetal chromosome and anomaly extra anomalies like spinal bipa because again there are associations with these kind of anomalies with cardiac defects non highy drops if there's increased translucency as we see in the Down Syndrome cases in case of twins so timing best uh timing is after the anomaly scan that is the second trimester though we can also do an echo in the first trimester we can do a trans vaginal echo or a trans abdominal Echo but the cardiac vils May not be elicited well but by the second trimester is a good time and we can detect most of the anomalies uh which are quite Grievous anomalies so simple defects like an asdc these are the defects which will be present in a normal fetus for the fetal circulation like a PD and ASD but and other small defects can be missed but major defects like transposition of weight arteries tvcs which are going to be lifethreatening for the baby and which will require baby to be uh the birthing to happen at a particular place like a center where all the facilities are available for the baby a good Neal care is available and cardiologists are available on at Birth is very very essential since certain kind of duct dependent Legions uh if the PDA closes then that can be fetal the can lead to fetal morbidity or mortality so this uh procedure takes around 30 minutes to 2 hours there is no prerequisites like fasting in fact the wellfed mother is better because um the baby will be quiet and we get better Imaging um so this is how we do the fetal Echo we scan the baby's heart in different planes and like an example so there are some certain standard blues oh so it's not playing very well this uh which a radiologist performs the fetal echo in but for cardiologists we just um do it in our own way so we have to see the four chamber view the three vessel view the three vessel tra views the arch views the depal arch fetal Arch and all these structures now in this case there's an abnormal Echo and a normal Echo uh if you all can notice so this is a I'm not sure so this is basically the image a has a defect in the interventricular septum I'm going to play it again so uh it's Mark SE yes so this is the defect uh in the inter ventricular septum so this is a patient with the ventricular sepor defect and in this case in the image B you can see that it is normal there is no defect there this is how we diagnose fetal conditions in fetus by F next test I'm going to talk about is halter monitoring basically it's in ECG test which is done over 24 to 48 to 72 hours so where do we require this test this test is required when we suspect Rhythm abnormalities so if uh a patient has palpitations or as sh said Syncopy uh some with palpitations or any kind of cardiac problems with palpitations we always want to get an halter done for this child so this can be done for patients with heart blocks to see exactly what is the timing uh for intervention so not all hard blocks require pacemakers only if they fit into certain criterias in a halter V um advise them to do a faaker installation so this is a typical halter report wherein we see all the beads and how many supraventricular beads how many what was the average heart rate what was the minimum heart rate all that is given and this is how we screen the whole 24 hours ECG to see for any abnormal Rhythm so here in the right hand side picture you we have caught this abnormal Rhythm so this is a ventricular um abnormal ventricular techic cardia here for the patient and you give a diary to the patient so that we can correlate so during this time whether the patient was also having some symptoms another thing called as an event monitor so halter monitor when you have uh if the symptoms don't occur during the halter monitoring then we won't get any kind of diagnosis so for those cases we have this event monitor again it's a very uh modern device where in which you can stick it to the chest wall when the patient starts getting symptoms and it starts recording the ECG during that time and that helps us to diagnose the problems and manage accordingly so there are lot of abnormal Pathways which require electrophysiological studies or even abl of those abnormal Pathways all these can be diagnosed if not on the halter then on the event monitor so on the next test uh this is just a picture to give you a a hint about the next test which I'm going to talk about so it's basically the stress test the the lady is now going to be subjected to stress so this is how we do a stress test in our hospital we uh don't do the spirometry we just have ECG leads connected to the patient along with the blood pressure monitoring and even saturation monitoring and we make them run on a treadmill it can also be done on a bicycle uh in infants who cannot run so above five years most of the children can very well run on a treadmill but below that if we need so basically this test is done to see what happens at the peak of cardiac activity when you subject the heart to its maximum activity is it tolerating it well is the blood pressure response the heart rate response the saturation response appropriate or not so that is what is tested in the stress test uh can be U done in children as well with drugs like dobutamine which increase the cardiac contractility as well as the heart rate so here uh this test usually routine performed in patients with single ventricle for prognostication again conditions like pulmonary Val replacement or coronary abnormalities can be diagnosed even um coronary anomalies basically can be diagnosed with this problem so this test um if chat box open can anybody tell me what this test is so this test you can see here there's a table and it has been tilted til table test perfect ma'am so drali says it's still table test is perfect so this test uh is also performed uh in our hospital and we do it for patients especially with who complain of syntopy so what is better now next question is a positive tilt test better or negative tilt test better anybody so the answer lies in the next line basically U what we are going to try to do in the Tilt testes we want to postural call Madam postural hypertension patient and spents like six sinus syndrome like uh sure so uh on the right hand column we have given how we report a tilt table test so basically we want to see the blood pressure response the heart rate response and the heart rhythm response on passive standing so what happens uh in different conditions we can actually diagnose uh if we have we can mimic the Syncopy or if we have abnormal changes in the BP heart rate or Rhythm then we can actually predict what would be the cause of the Syncopy and that's how like as you said the vova Syncopy or ports that is the paradoxical orthostatic hypotension or you have these kind of cardio inhat vasod depressor or mixed kind of responses and then our treatment strategy changes with them uh whether we give a lot of water and salts in case of uh the PO syndrome or the baso depressor kinds and we also can sometimes give medications to the patients who have a very abnormal responses at even in very short time so this test usually takes 90 minutes because we we want to mimic the we want to cause that much of prolonged standing so that we can actually mimic a Syncopy if possible so it's always good to have responses so that we know whether actually this um Syncopy was caused because of the cardiac problem or if it was only a CNS problem so Syncopy can also be be caused by CNS like then we for that we then refer the patient for the E so this is the next test is the cardiac catheterization test um just because uh if this was interesting I put up a slide uh this is basically uh burner forcan and and uh he did the first cardia cathet himself so during his tea break he just passed his um urinary catheter through his cubal for and if you see on the right hand side you can see a line so this is the Ceta which is going right into his heart so he found out that you actually can measure the pressures or you can U go into the heart and measure the pressures there and that's how card catheterization began and with andri fedick who again then did a lot of techniques to measure cardiac out both of them together then won the Nobel Prize so what are the indications for cardiac catheterization uh it's done for hemodynamic assessment that means how are the pressures in various Chambers and what kind of uh output is there in the lungs what is the cardiac output systemic cardiac output what are the shun so we can quantify the right to left shun left to right shun we also do morphological assessment like if there are abnormal vessels in the heart this test for diagnosis takes around 1 to two hours can be done in sedation or general anesthesia so this is how we this a in a patient of vsd we need these calculations to see whether they are operable or not so we looked at lot of tests we asked are we really spoed for choice so no it's actually there's no spoil for Choice here because every uh indication for each test is very very unique so not one patient may require all the tests but he may require one test which is very important before the treatment or intervention or surgery is offered and that's how uh as we have so many tests for before diagnostic we also need so many people so it's not only a cardiologist or a cardiac surgeon who is important uh in the outcome but basically a very huge team is required with lot of technicians and other support staff and that is intensive is a key uh along with all the other Physicians and surgeons so this is our team and thank you from all of us and we are open for questions if you have anything even now or even after this talk we will have like a panel discussion uh so all of us are here there are intensiv here this cardiac surgeon and cardiologist so even in the end we can have a little bit of panel discussion and take up your questions at that time uh the next speaker I would like to invite Dr in with us talk hi good afternoon uh my name is suim s I'm a senior consultant in pediatric cardiology I hope you can hear me uh please let me know if anyone is having okay so discussing interventions in pediatric cardiology [Music] so in the present era a lot of structural interventions can be done in the catlab by minimally invasive techniques and these catlab procedures are as effective as surgery with quicker recovery in these specific situations so I'll just show you a few cases of interesting challenging work that we have done so this is quite a common uh case scenario for us this was a 10day old neate who was discharged from nursery on day four and then comes back on day 10 to the casualty with refusal to feed and respiratory distress and this was the ER assessment you can see the baby had Tachi cardia the femorals were not palpable and there was a soft ejection murmur on osculation the Venus blood gas showed severe metabolic acidosis so any idea what is the diagnosis here you can unmute eles and Shout out so uh this is a severe coact of orta with LV dysfunction and on Echo this is what it looks like so you can see this is the arch of the orta and there is a TI narrowing of the cooptation seen here when we put the Color Works the reason cooptation presents uh after a few days and not immediately mediately at Birth is because as you know that babies are born with a PDA and only once this PDA constricts will the flow of the lower body get affected as you can see on this schematic diagram and which is why the patients usually present at the end of the first week or the beginning of the second week of life so because this child had left ventricular dysfunction uh this CH for a balloon angioplasty you can see on the left that there was a tight narrowing and on the right you can see uh that we are dilating this with a balloon which opens up the coalation I would like to stress uh upon here that we only do a balloon anoplasty neonatal Coop if there is left ventricular dysfunction if the baby comes to us early with a normal function then we always send these patients for surgery the reason being that the recurrence rates are significantly higher with a balloon angioplasty compared to a surgical repair of qu so once you relieve this obstruction the babies have quite a dramatic recovery this particular patient had a normal LV function within 24 hours and we could discharge home after about three days so important learning points from this case is that in an Astic baby with an acute dation it's not always sepsis you should think of duct dependent conditions and metabolic acidosis with high lactates indicate an inadequate systemic circulation and you should think of causes other than sepsis in this I would like to also reiterate here that uh it is good to always palpate the femorals a second time before discharging a baby from Nursery I know that all pediatricians routinely palpate femorals at Birth but because the PDA is open at Birth you might miss a coact when the PDA constricts if you don't check a second time now the second case was a 14-day old baby weighing 3.1 kilg and this baby was sinos but had a quiet respiration SATs were only 60% uh there was no obvious murmur on osculation but an echo was warranted because you have sinosis with quiet respiration and the diagnosis here turned out to be vssd with pulmonary at treesia so as you know in pulmonary atesia the communication between the right ventricle and the pulmonary artery is absent and so the uh deoxygenated blood will mix at the vstd level go into the aorta and then through the PDA we have some flow into the lungs so the initial treatment of these patients is we start them on a prandin infusion and then we do a pation such as a PDS stenting or a BT shunt and at about one year of age we will do a complete repair where the surgeons will close the vssd and connect the right ventricle to the pulmonary artery with a tube or a conduit so all conditions where there is pulmonary atreia have a duct dependent circulation which means that they are supplied only by the PDA and all of them hence needs some sort of a pation where we can reestablish the connection reestablish the pulmonary blood flow which usually is with a PDS stent in our case so what we do at srcc is we have regularized the hybrid PD stting with the coted cut down and you can see here that the baby's turned with the head towards the foot end of the table and the first step is the surgeons give us the coted cutdown so uh this is the neck you can see it's a very small area which is exposed uh we do a small incision and then the common cored arter is entered with this small sheet and once the surgeons give us that access we have a direct view into the PDA so you can see the PDA just comes off the under surface of the eortic arch here these are the pulmonary arteries and so just by sorry I'll just go back just by pointing into the PDA we can cross it with a wire and once the wire is in good position we push in a stent in this case this was a the coronary stent and then we do a few check to check that we have covered both ends of the PDA and once we are happy with the position we can inflate the balloon and the stin is deployed so this procedure is known as PDA stenting and uh we take out the balloon first leaving the wire in and then the wire comes out and that's the final result so you can see the stent in position with good flow into the pulmonary opcs so we started doing the hybrid approach of this since 2020 uh and this is also with the flip technique which I showed you and so far we have done 37 such patients the median age at intervention is around 20 days mean weight of around 3 kgs and it takes about 20 20 minutes of fluoroscopy time and the whole procedure takes about 1 hour uh the hospital stays around 11 days me meanf of median followup we have for these patients is uh about 8 to nine months and we've not had any complications due to this vascular access uh since the last time of the last followup 25 of these 37 patients have undergone their corrective surgeries also so we had one early moris and one of the these cohort had late mortality due to covid uh 7 months after the procedure so uh this was our initial experience with hybrid stenting this was the first 11 patients and since then we have uh this has become a very routine and standard procedure for us the next patient uh similar new newborn baby 3 weeks old transferred from another hospital with sinosis you can see SATs were 74% and there was a hard systolic murmur in this child so we didn't have a diagnosis at the time of the transfer but when we did the echo this baby had a pulmonary atresia with an intact ventricular septum with a good sized right ventricle and a moderate PDA so this is what this condition looks like uh you can see here that the pulmonary valve plate here is uh not the valve doesn't go through so there is no flow across the pulmonary uh valve and uh basically the baby survive again on a PDA but because this is a discrete absence of the pulmonary valve known as pulmonary atesia we can perforate this so we are now in the right ventricle you can see there is this blind ending pulmonary valve plate so we aim our wire to this plate and we perforate the plate this is one of the highrisk procedures in neonatal pediatric cardiac interventions because instead of Perforating into the pulmonary artery if you perforate out of the heart you'll have massive Hemorrhage and tampon uh but if you do it carefully uh you can get a very nice result so you can see we have gone through the pulmonary valve here we have snared it out of the other side and once you have that pathway you can put in a balloon so we are gradually increasing the size of this pulmonary valve and we are putting in bigger balloons and making it uh the anti-gr flow better and this is the final result with very decent anti-gr flow so this patient was then shifted back to the Nic and we observed for the next seven days waited for the PDA to close completely and once we were happy that the saturations were adequate this patient was discharged and this child is now doing well at three years of age has not required a second procedure after that neonatal procedure the next case again highlights uh the teamwork approach which is needed in pediatric cardiac care so this was a seven and a half year old girl weighing 16 kilograms and you can see from the blood pressure difference that the Upper Limb blood pressure is slightly higher than the lower Lim blood pressure and the child also had a loud P2 and ejection systolic and an early diastolic murmur so the diagnosis here was a large PDA with a moderate long segment coact of aorta so so as you know generally in pediatric cardology if you just have a PDA PDA device closure is our routine uh procedure of choice but if you put a device when there's a coalation you're actually going to wasen the coalation so device closure was not a great option here we putting a balloon here through the PDA to see that this child uh is actually operable because they presented quite rate but we disc option would be to do a covered stent which would take care of the cooptation and also olude the PDA at the same time the only challenge then becomes that this was a child weighing only 16 kilograms and we would need a very large arterial sheet to put in this big stent so what we decided on was hybrid cooptation stenting and here the surgeons gave us a vascular access similar to an appendicectomy incision and you can see that the vessel size is much bigger there than the femoral artery so this is the common IC artery which has been exposed and then the procedure becomes much easier for us we have put in this very big sheath uh and we are checking angiograms to see the narrowing of the aorta there and this is the stent so this is in two planes this is lateral and this is anterior posterior and we are slowly inflating the stent and then we are doing angiograms to check that we have completely occluded the PDA you can see there is no filling of the PDA or the pulmonary ey and the uh aorta also has become larger in size than what we began with this is known as a 3D rotational angiogram where we are checking uh a 180° view to see that there is no heak or dissection anywhere after the stenting so hybrid interventions help us overcome size limitations of the conventional percutaneous access and it is also safer to maintain vascular patency the next case is a rare but very interest this was again and his only uh complain for severe sinosis saturations of only 56% the child had normal heart sounds the Baseline Echo done outside was also normal apart from a dilated right pulmonary artery so whenever we have this type of a presentation we do a contrast Echo where we take an IV access and we inject agitated saline into the vein and you can see here that the contrast Echo was strongly positive and what that means is that in a normal heart the right ventricle ejects into the pulmonary arteries and then there is a meical filtration at the the pulmonary capillary bed so any air bubbles in the right ventricle will not actually come to the left atrium while the pulmonary veins but if you have a short circuit which is known as a pulmonary AV malformation then you will bypass the pulmonary capillary bed and air bubbles from the right ventricle will come into the left side so that's what was happening in this case which is why the bubble contrast was positive and this child had a clinical diagnosis of pulmonary AR renous malformation this was the X-ray so there was a suspicion of the pulmonary AVM even on the X-ray we did a CD scan which confirmed it you can see this huge right pulmonary artery to left atrium AVM that is the RP on top left at the bottom and there is the pulmonary AVM so we took this child to the cathlab this is an injection into the right pulmonary artery ceter is through the AVM and then into the left atrium left ventricle and uh once we have our wire we have pulled the wire out of the aorta and out of the femoral artery to form a arterovenous loop and over the wire then we put in this big sheet so this sheath is going from the IVC R RV right pulmonary artery into the pulmonary AVM and then into the left a so this is our delivery sheet through which we are now putting in this big device so we are slowly adjusting the device so that it only obstructs the AVM and doesn't obstruct the surrounding structures and we are also doing a transis echo here while we are aligning the device so as you can see as we push out this device it reforms to take its uh original shape we do angiograms to check uh that we have got the device in the correct position and finally we unscrew the cable and the device is released so you'll see that this connecting cable will disconnect and the device sits there so this is the final result and this leads to an immediate Improvement in the saturations uh this child was observed in pic overnight discharged after two days and came to us for followup a couple of times after that this was 5 years ago the child is doing well and is absolutely normal so arterio venous malformations are a very rare cause of sinosis we should suspect them if there's nothing obvious on the Baseline x-ray or the Echo and this is something which needs to be treated to improve the saturations I'll also show you a couple of cases of double devices which just means that the child had two left to right shuns in the same patient and we uh treated both of them in the same sitting so the first first child was 4 years old 10 kilg with a moderate VST and a moderate PDA so this is the V angiogram you can see there is a v there and that is the autogram so there is the PDA which is connecting to the pulmonary artery so first we cross the uh VST we have gone through the VST into the right ventricle and into the pulmonary artery we then snar this wire out from the other side so we have taken a Venus catheter we will catch hold of this wire and snare it out to again form an arterio venous Loop and once you have an arterior Venus Loop then you can put in this big sheath so this is going from the right ventricle into the VST LV and a and then through this sheath we will put in our device this is the vssd device so the device is now being deployed so there is the first dis which is on the LV side of the VST and the second disc which is on the RV side and then on this angiogram you can see uh that the vsd device is nicely in position and there is no residual vsd flip but before releasing this device we will then do uh we will close the PD also so again we have gone from the the pulmonary artery across the PDA to the descending AA we have put a sheath over that then we put in the PDA device so when we deploy the PDA device the first dis is on the eotic end of the PDA and then this is the tail of the device which is side so here we doing an angiogram to check the PD device is in good position we have released the PDA device in this middle C flow and then the last step is releasing the VST device so transcatheter interventions uh versus open heart surgery have definite advantages these procedures have a quicker recovery there is less pain they discharged uh quicker and there is no surgical Scar and we don't have to expose or subject the patient to cardiopulmonary bypass but there are limitations not all congenital heart defects can be treated with trans cathet interventions surgery is the only option in many of these patients there are age and weight limitations and also we don't want to put in very large delivery sheet into a patient who is small because then you might damage the vessel but if possible we want to avoid this type of a morbidity because you have a very quick recovery with a trans catheter intervention as in this child who is One Day post VD closure so is there a minimum age of weight for cathlab interventions no for balloon anoplasty we have done uh procedures such as coati balloon and balloon pulmonary valvotomy even in children less than 1 kilogram of weight for PDA devices now we also have a special device which can be used Us in infants which is approved for vsd devices we generally want the patient to be five to six kilograms of weight and for ASD that's around 8 to 10 kges of weight for surgery there is no minimum age or weight limitations uh we can even do a 800 gram or 1 kg baby's surgery if it is really indicated I'll end with this routine case of a PDA device in our catlab just to show you what exactly happens in a device closure so we have and required for the cases the first step is the access so we do a vascular access with the percutan buinger technique uh we take an artery and a vein nowadays for smaller babies we routinely use ultrasound guided access which just makes the whole process a lot quicker uh so you can see here that we uh get the uh needle in and then we put in the guide wires over these wires then the sheets will go in so we have one arterial and one Venus sheet in a p device the first step then becomes the angiogram so as you saw in the case I showed you you do an a pram which looks like this and this is the aorta this is the PDA this pulmonary artery we then cross the PDA with a wire and then over that wire this delivery sheath is going in you can see we are pushing this sheath over the guide the long guide wire and we watch the fluoroscopy on the X-ray while we do this so we are going from right atrium right ventricle pulmonary artery and into the descending orta through the PDA so this is what the device looks like uh it has what is known as a shape memory so you can slenderize this into the loader and when you push it out it will retain its original shape so we are now uh flushing the system and pushing this into the delivery sheet and when we push the device out of the other end this is called the deployment you can see that it again reforms three diss of the device so we pull this into the PDA we do an angiogram to check that it is uh in the position we want it to be at and then as you saw in the previous cases we will unscrew this and the cable gets detached from the device so that's the principle of uh the catheter interventions we do in pediatric cardiology I want to stress that prognosis and long-term outcome of most chds is very good and recent advances in technology and increased operator experience means that with these minimally invasive techniques we are able to treat a large variety of complex CHD in the cat lab thank you if anyone has any questions you can ask or you can put it in the chat box I'll answer your questions it was well good afternoon everyone I'm Dr pradep Kosik cardiac surgeon at srcc Children's Hospital greetings from srcc it's a branch of narana Health which has exiled for more than two decades in the field of cardic surgery and all other specialities as well and srcc was uh uh started in 2017 with 207 beds we have separate an ICU p atric and cardiac ICU and all the services are 24/7 this is my brief particulars I'm associated with Nar hospital for last 18 years and we started the cardiac unit in 2017 along with the Inception of the hospital so I'll just talk to you all about what are the congenital heart disease and what is the surgical timing of intervention so congenital heart disease are any structural heart defects which are present since birth in which the equired effects we are not discussing which is Kawasaki or romatic and the incidence is about one per 100 live births in India so that takes the number to almost like two and a half lakh kids are born with congenital heart defect every year and all over the country whatever the intervention and surgical centers we can only treat we are only treating about 70,000 of the kids so you can imagine that hardly 1/4 are getting treated and all these are getting added to the next year pool of the new babies born the congenital heart effect so the work the volume of the uh congenital heart diseas is too much in India and already I think the Cardiology colleagues have discussed with the case scenario but theoretical discussion of Astic and CTIC so Astic in which the baby has conal heart defect but does not turn blue so they can have a shunt lesion but because the shunting is from the left heart which is oxygenated blood to the right side so the defect is there but because of the shunting of left to right the babies are not turning blue those are called as Astic the examples most common are ASD vsd and the PD if you have obstructive Legion like quation again the baby will not be blue and then common example of the CTIC lesion now if you see the right picture why the baby becomes cyanotic because there is again a shunt Legion but now the right heart pressure somehow is more and that's why the the shunting of the deoxygenated blood is more into the systemic circulation and that's why the baby's blue it can be either the wrong connection of the deoxygenated blood into the systemic side that also will lead to somebody turning blue so those are the typical example of CTIC lesions and uh let's discuss about what are the common timing what what time we do the surgery so this is a uh fiveyear old child which was just taken to OPD otherwise no symptoms and even if you leave the cardiac osculation the SATs are good there's no cardial and the echo diagnosis reveal atrial sepal defect so atrial sepal defect in asymptomatic child we operate between 2 to four years of age and all the ASDS are subjected if possible for a device closure in which the hospital stays about one to two days and there's no scar it is done by the Cardiology colleagues now if there are not enough margins then only the patients come for surgical closure now being considered as the simple uh among all the pediatric cardiac operations we try to give a u a minimal SCAR or a minimal invasive approach for these type of open heart surgery so we have done it by the right thoracotomy so the scar is not at all seen or else we do by Mini strot in which we do not open the whole of the Str so sorry SL J okay this is I think this mismatch so this is the uh scar which I was showing normally we have to give the incision right from the you're seeing the mosquito artery at the sural launch this the incision extends from there till the lower bottom but in this kid we have just done the lower half sternotomy and we could manage to do the ASD closure now this is the case to you can see this uh uh history of forhead sweating with SU cycle and fast beathing but the saturations are 98% now I'm leaving this cardiovascular examination or the oscitation on my Cardiology colleague but if we have this much symptoms we know that there is some Chun leion which is not turning the baby blue so it's it fits into a cytic congenital heart disease and again the diagnosis will be proved by the echo cardiography but if you see the clinical part which is henting towards uh uh towards the larger pressure sh so obviously it's not ASD and the diagnosis was vsd let's say for example it was PDA also which is the larger pressure shant so in vsd we do the surgery between 3 to six months until unless it is associated with any other congenital heart disease like Interruption of the arch or transposition of the great arteries which requires surgery in the neetal age then we do the vssd correction uh with that correction otherwise isolated vsd we wait on anti failure medications till 3 to 6 months of age again if the vsd is divisable and the weight is around kilos we we subject them for device if possible otherwise they undergo for open heart surgery case three is uh I think Dr Su has already discussed a baby who was discharged healthy and then re on day five with po feeding and you can see that the lower Lim pulses were feeble so obviously the first diagnosis goes um as the as the ductal might have shrunk so the quar has manifested but these can be the other differential diagnosis in such scenario a baby in low cardiac output or septic shock also you'll not have good peripheral pulses because of the peripheral shrinking so the diagnosis is again confirmed by by the uh these are the other examples of systemic circulation duug dependent but anyway this kid was having coarctation and quation if there's severe left ventricular dysfunction or the kid is not clinically looking good to subject for um for cardiac correction then we do catheter based intervention in the cardiac lab which is called as balloon anoplasty most often we have to still take them back later on after two three months once the kid is grown up gain some weight for uh Co repair now this is 48 newborn who has sinosis at Birth the most common diagnosis again goes for transposition great arteries in transposition what happens is as shown in the picture that the Iota is arising from the right ventricle normally it arises from the left ventricle so what happens is all the systemic Venus blood the deoxygenated blood comes from the body and travels back to the uh to the body through the aota because of the wrong connection so these baby obviously cannot sustain the circulation and they have to uh undergo arterial switch in which we trans the these transpose vessels have to be connected back to the uh correct ventricles if there is a vsd along with the transposition there is some mixing and these babies do have some better saturation as compared to without the VD common CTIC heart disease teratology of fellow again any hardly uh cardiovascular markings and in this there is a whole between the two lower Chambers you can see there's a communication and the pulmonary artery is narrow so the outflow from where the deoxygenated blood goes into the pulmonary artery is narrow and that's why the chant thing happens across the vsd and that's why these patients are blue so if you have tetrology of fellow but with minimal sinosis and there are patients who have Coptic spell or few patients are having balanced circulation so why I'm telling you all these three categories because the treatment is decided based upon the symptoms of the patient the spell uh which you might be encountering in your OPD practice again is agitation irritability not accepting the feeds and profound s sinosis obviously lead to syncopal attack so all these have to be treated the basic is again volume resuscitation oxygen morphine if you have beta blocker otherwise refer to the tary care center now surgical treatment U initially was U Lop which was a pallative sh to Pate the sinosis but nowaday we are moving towards uh the complete repair but if somebody has to do the palea sh two catheter based interventions are PD stand toxo as well mentioned and the rvot stand otherwise what surgically we do are B shant or a SOS shant and in B shant we connect artificial prosthetic tube graft from the innominate artery onto the epsal artery now what it does it it just increases the pulmonary blood flow so that you have more blood going to the lungs and comes back to oxygenated so the baby saturations are slightly better we gain some weight buy some more time and then then do the complete correction but there are couple of disadvantages of doing the shant because the patient has to come back for second surgery there are chances of shant thrombosis and the baby has to be on anti-platelet drug till the complete repair is being done similarly SOS shant is a conduit Place between the right ventricle and the pulmonary artery for uniformity of the growth onto the both side the shunt was done onto the one side uh our Hospital approach we as as an Institutional approach we try and prefer to do the complete repair at the time of diagnosis now it depends if the anatomy is suitable for complete repair let's say the branch pulmon Ary which is the most common determinant of the of the repair if they are good size we try and do the complete repair irrespective of age and weight so we have done couple of neetal complete repairs also and nowadays we routinely do about three months of age we do the complete repair but by and large if a kid is minimally sinos we can wait till 6 to 9 months for tety of fellow before we uh do the complete intracardiac repair if there's significant sinosis and the anatomy is not suitable for complet repair in those Cas cases we stage them and we do a PDS tent or a BT sh surgically now this chart shows what all surgeries and what all follow-ups you have to tell to the patients who might be asking you so if you go to the third table right from here uh ASD vssd PD and techology in which we have preserved the valve or the analyst those are lifetime correction they do not need any medications or long-term followup they can have any lifetime activity there's no restriction for physical U restriction or Diet restriction now the palea surgeries like BT shunt or a PA band or AAL sepy or any single ventricle surgeries they do require uh lifelong followup or multiple stage surgeries at some point in time now we come to the second uh the second paragraph in which the AV Canal or RTL switch and alopa repair they also need long of followups to see how the vales are functioning as the child is growing so these are the things the parents the common questions you might be ask they might be asking in your OPD practice this is the rare case uh in which we took the baby for TIY of fellow but there was impending you see this is impending aota dilated and impending rupture almost this white portion and so in tiies usually a is dilated but in this K there was anmal dilation and it could rupture any time so we could not leave it just like that just doing the try correction so we had to replace this uh ascending aota also along with the try correction in one go this was a rare case and that's why we we are presenting here so this is arrested heart and the sutures you can see that this is the vssd patch this is the how the vssd is closed and this is left ventricle right ventricle you cannot see these are the coronary arteries and the white one what I'm holding is the artificial tube which will be functioning as a and the black one is the arotic Val it's mechanical artificial prasis and the the surgery is called as bental this baby this is a lifetime process but the baby has to take anti cogul because of this mechanical processes uh all along the life this the final picture after the repair so another kid we have done open heart surgeries about 1.6 kgs we have done arterial switch the kid is now 5 years and these are the procedures just to name them we have done all spectrum of cardiac surgery and this is the age Spectrum major of if you see that we are doing the infant and the Neal work 50% of our work is about less than one year and similar is the weight if you see that uh less than 5 kilo uh comprises of almost 36% and less than 10 kilo is about 70% of our Spectrum our ICU stays about 1 to 4 days and we we have successfully sent about 98% patients uh back home after the surgery so as everybody has mentioned um it's a team effort and there's the team behind uh this is our group founder chairman Dr DVI shetti and his slogan we still carry forward that no child should be denied treatment now we conclude it here by saying that early identification of congenital heart disease the corrective treatment is possible in more than 80% and we have good results and late presenters can lead to IR ible complication and moreover the prognosis of surgical management nowadays is good and that's why they should be referred to Surgical Center now just for the visual Delight I have two short videos how we do the uh open heart surgery so for doing any open heart surgery we need cardiopulmonary bypass and this is how the cardiopulmonary bypass of the heart lung machine looks like it's quite complicated these are the roller pumps rolling around some tubings and these are going to the patient table and we'll just uh take you along initial process of how we so this is a schematic diagram of what heart lung machine does so all the blood from the heart the systemic Venus blood which is entering into the heart is diverted through the tubings into this heart lung machine which oxygenates and maintains the temperature and comes back and is given to the heart because for doing any heart surgery we have to stop the heart and now if the heart is pumping we cannot just stop it because rest of the body is functioning and the Brain kidney liver all require the oxygenation and the blood supply so all that is maintained by the heart lung machine and before we do that before we stop the heart we have to divert this function of the heart to the heart Lum machine which is maintained by the perfuses so this is how the patient is draped and we are starting a heart surgery so this is the patient is DED and you're seeing in suine position we give uh mid sternal incision so almost 99% surgeries are done by this approach pation coarctation or a B shunt are done by the toot approach now this is a saw which cuts the sternal bone and this is the sternal spreader which is spreaded and now still the we are dissecting the thymus and fat tissue over the pericardium the pericardium still is closed this is the electroc current boy which is helping us to achieve hemostasis as well as uh now the pericardium is getting opened and you'll start seeing how the heart looks like un likee the four chamber what we draw and show them here the pericard stays we make a pericard credle and this is uh the right angle is this is the right a you're seeing the gray color and that's that's the now you can see it very clearly so this is before the canulation and now we'll canate so that we can pass on the blood to the heart lung machine let me show you how we stop the heart so this is the culation we put various cand now this the heart is stopped you see is on a heart lung machine and the heart is stopped not beating anymore and we have opened the right atrium majority of the cardiac Corrections are done by the right atrium through the right atrial approach and all this Blood uh is sucked out and given to the heart lung machine which filters out and gives it back so all the patients who have to undergo heart surgery open heart surgery need blood transtion any procedure we do when the heart is arrested you can imagine that because of the cardiac SCH schia so we give some cardic drugs to maintain the heart alive but sleeping for uh few minutes and we have to do the cardiac correction within that much of time so this is the cardia delivery and showing the intra cardiac Anatomy this is a transposition vcle this is the right ventricle and the a is coming out from here normally the a should be coming out from the left ventricle this is uh another small pre-term 600 G baby we did recently for PD liation so the close heart surgery we have done about 600 grar but open heart Sur we done 1.6 kilo for a complete repair this the aial view of our hospital at Haj Junction thank you very much I think we'll take the questions at the end of the session and I would like to invite Dr Lupa now who is our intensivist and she will briefly about uh the intensive care approach for the cardiac Corrections e e you afternoon everyone I'm Dr lopa mudra I'm the cardiac anesthesiologist I do take care of OT as well as ICU today I'm going to talk about ICU management for our cardiac patients pediatric cardiac patients origin of the first dedicated Pediatric Intensive Care units in 1950s the field of Pediatric Intensive Care has been expanding and sprouting new Subs specialities but the concept of dedicated pediatric cardiac intensive care units originated because of this unique requirements for management of children after cardiac surgery in the early years of development of cardiac surgery pediatric cardiac surgeons have been primarily responsible for this care but since last first three decades other pediatric cardiac professionals like cardiologist cardiac anesthesiologist Critical Care Nursing respiratory therap therapist and others have started to contribute increasingly to this care so before discussing something else we should know why there is Need for this pediatric specific pediatric cardiac Intensive Care Unit with this facility Cas of accurate diagnosis and scope of complete correction more and more children are undergoing surgical treatment and so there is a lot of increasing the demand for this dedicated personel for the specialized intensive care of these critically ill children and it has been shown that dedicated team who are doing they are providing much better outcomes in several centers and nowadays this this train is towards early primary surgical repair like during early enany and newborn period which requires specially trained group of Physicians nurses and supportive staffs who can handle this very young population so our optimal post of care in ICU it requires accurate pre-operative assessment use of anotr sorry intraoperative findings and data careful patient risk stratification and meticulous anticipatory management so actual management what are the bedside facilities you should have usually in any cardiac ICU your patient area should be at least 15 to 200 square foot which can accommodate a ventilator like seing pumps area should be there to accumulate setting pumps IV poles and for neonates we need binat with overhead radiant warmers and for the kids it will be a big bed monitoring equipment should be W mounted to set physical space and to avoid overcrowding and there should be electrical power from an uninterrupted Source oxygen should be available Medical compressed air vacuum Outlets should be there in sufficient number so as intensest what should you know before your patient arrives in the ICU you should know have the knowledge of the preop conditions which allows you to anticipate the post of problems preop Anatomy you should know you should understand the preop physiology like whether it is a left right sh whe the patient is having pulmonary hypertension or any other rbot obstruction if there is any non-cardiac problems like failure to thrive or any a problems whether patient has syndrome having genetic problems very much malnourished or feeding having feeding intolerance you should know about this you should know about your past medical histories patients's recent illness or whether patient is on any medications if patient has undergone any past surgeries and having any complications because of that if patient has undergone any cat or CT you should know about that surgery before patient comes to your ICU you understood the physiology but you should understand the effect of cpb my colleague Dr Pradip explained you why cpb is needed but it it comes with a cost so when we put patient on cpb there is a abnormal circulatory environment it doesn't provide you pulsatile atrial flow it is always a nonpulsatile arrial flow there is blood trauma which gives rise to holis there are hemo dilation and there is exposure to the foreign surface so it activates your inflammatory mediators and coagulation Pathways and it gives rise to stress response as well important part is there is systemic inflammatory response and which activates and interacts many systems and cellular elements in the body so it activates or complement systems and it gives rise to your increase in the capillary permeability and patient may come with patient may develop intertial edema later on so once the patient comes to ICU very important it is very critical period when patient has been transferred from ODOT and you need to been done and you should get all those pertinent information so what should you get should find out what surgery has been done and how much time has been passed after separation from cpv you see what tube intubation what ventilation strategy was going on how much oxygenation was there whether there was any Arias what sort of lines tubes are there patient is on what medication what inotropic support whether there is chance of any concerns for bleeding and you should see how much like what are the lab values and vitals are maintained during intra period and what are the intra Eco findings it this is our Handover set what we use in in our I you it's in this paper we basically get all the informations and it helps us later on also once the patient reaches to you you should have your ECG monitoring attached this is the like monitor what we monitor in our ICU you should have continuously observe all invasive pressure lines and the you should make it zero and you should see that it is providing you accurate and normal way forms and ensure that all pressure transducers are continuously flushed and uh all pressure lines are labeled appropriately and if kids are if infants are less than 3 months 6 months then you should attach your Central and peripheral temperature monitoring because in cardiac ICU this temperature control is very very very important we try to keep the patient little bit hypothermic around 35 to 36 like that so that it decreases your metab demand and you should ensure your alarm limits what you want actually other it decreases your mental fake and what alarm you so that your sisters your nurses are acquainted with that so that they can inform you on timely manner and you should record your Vital Signs and invasive measures first initially half an hourly for first four hours then hourly thereafter if the patient is stable so in cardiac post of ICU low cardiac output syndrome is a common problem usually reported around 25% of the patients usually happens in first 6 to 12 hours after surgery so what are the factors We Believe to account for low cardiac output syndrome mainly if there is any hemodynamically significant residual Legion is there and mical dysfunction May probably result from prolonged periods of cardioplegia or mical esmia and reperfusion injury and post of also peroperative you can find out ventricular dysfunction so what are the signs of reduced cardiac output you can find that me may be takic cardia low blood pressure despite adequate CVP poor urine output and you may find C peripheries with four to toe temperature gap of more than 3° capillary refill time is more than 2 seconds B peripheral P reduced next Venus oxygen saturations increasing the trained in the lactate and nowadays if your institution is having nurse that is also helpful to find out uh whether there is decrease in oxygen saturation so it helps us to say that the patient is going into low cardiac output but before before treating it is always while you are managing it is always better to do a prevention so that's why it needs careful anticipation and aggressive cardiorespiratory treatment once patient is having low cardiac output in most of cardiac patients you may find arithmos they are very commonly found some childrens are at higher risk postoperatively so you should get your 12 Le ECG immediately after surgery and if patient has Arias prior you should get that thing there are you can see all type of Arias but in cardiac IUS this junctional ectopic takikardia is most common it is usually a narrow complex takikardia it often starts as a noal tardia and progress to a dissociation with ventricular rate greater than 170 beats per minute so first treatment is initiate simple cooling measures such as removing excess clothing and bedding inotropes should be reviewed to see that anything is PR precipitating that thing ensure your adequate analgesia and sedation check abgs to see that all electrolytes are fine if heart rate is less than 180 BP per minute sorry bits per minute you can think of overdrive pacing to get back your normal Rhythm if still it is not affecting so you can consider anti- arhythmic drug and amoden is the drug of choice so and you uh in cardiac ICU you find most of the like many patients particularly LA to WR SS they come with pulmonary hypertensions so uh elevated pbrr and resultant pulmonary hypertension is a common post of complications it can gives rise to in acutely elevated RV after load and which causes RV dysfunction and which then gives rise to cardiac arrest so always initial approach to postop pulmonary hypertension is prevention try to prevent increase in the pulmonary pressures so try to avoid noxia stimuli as much as possible give additional sedation analgesic neuromuscular blockage adjust your ventilation so that you should avoid hypocarbia avoid acidosis if this is not affecting then consider inhal nitric oxide nowadays medically we can start using some sop or bosentan as well that thing most of the patients and cardiac ISU comes on ventilator very rarely patient comes extubated but you will find they are coming on ventilator so you will find there is compromise on gas exchange that occurs because of endothelial dysfunction left ventricular failure pulmonary edema inadequate left heart decompression micro due to cpb Long collapse secretion trenic nve injury lot of in numbers so you should adapt strategies where it should provide adequate G gas exchange with minimizing the adverse effect on hemodynamics so if you think of cardiac who should be kept intubated cardiac CES so patients who have lung P pruns having poor elv dysfunctions if patients are hemodynamically unstable and having severe hypertension usually we ventilate them electively but some surg surgical patients who need early extubation those are the patient who have passive pulmonary blood flows like Glen and on time but before that you should know what s supposed to be that means which patient need how much saturation you should be well vered with that so in our uh institution we prefer early exbition so what helps like by doing early extubations we minimize the need for posto cations we reduce the length of ICU admissions reduce the incidence of nosocomial infections and it improves the family and patient satisfactions but in this our physiotherapist plays a great role because this kids who are unable to take out those secretions those who does lung collapse and all those things our physiotherapist helps them to maintain their Airway maintain the lung mechanics all the patients cardiac patient do come with drains they may have either mediastinal or both mediastinal and plural chest drains and you should monitor drains initial period ideally drain losses should be less than 2 ml per kg per hour in the first four hours after that it should be less than 1 ml per kg per hour subsequently if it is more you have to inform the surgeon to see whether is there any possibility of breeding and always we try to uh apply some the suction which is usually 2 kilopascal in each first day and later on we remove it coming to antibiotic profilaxis we do give prophylactic antibiotics according to the surgical antimicrobial prophylaxis guideline guideline which should be a broadspectrum antibiotic fever in the immediate postal period we usually uh like we treat it very aggressively with antibiotic agents and cooling devices so that it should not precipitate any Arias and it should by cooling also we reduce our oxygen conjuction if still fever persists after 48 hours then we send blood cultures to identify if there is any specific organisms patients with history of previous hospitalization neonet malar pent having low cardiac output syndrome for more prolonged period they are at more risk for of infections but always it is better is the preventive strategies to reduce this uh ICU infections by including strict adance to the sterile technique hand hyene and prpt removal of thees catheters and tubes we follow antibiotics towards a program in our hospital to prevent anti biotic resistance even if patients are having sign and symptoms we do send cultures and we upgrade our antibiotics the moment we get that culture is negative and or patient is like sensitive to some low antibiotics we do change them so that we try to prevent those antibiotic resistance nutritions plays an important role cardiovas cardiac surgery these patients particularly they are prone for malnourishment the preop conditions are like chronic heart failure cardiac CIA less functional metabolic Rees and they have Cathy and after surgery they may develop this endothelial dysfunctions of GI tract because of this cpb so they are prone for Mal nourishment if patient is malnourished they provide post worst post of outcome in form of like worse functional recovery higher rate of infections there is increase rate of pneumonia increase Hospital stay ICU stay and decrease discharge to the home rate and malish patients are have more incidence of increased mortality and morbidity so the moment patient comes to IU we prefer to start the ental nutrition within 24 hours after surgery if it is uh tolerating according to the Espen and Aspen guideline uh we start with 25 to 30 kilo calorie and 1.5 to 2.5 gram of protein per day per kg body weight for critically ill patientsite all the things despite uh good cardiac surgery still we have certain cases where we Face difficulties in the icus those are like all single ventricle patients pre and post stage one repair all patients with four ventricular functions all patients with pulmonary arrial PA bands and B sh with severe pulmonary hypertension patients on EO and patients coming with open chest so last one maybe ECMO so low cardiac output symptom syndrome which is refractory to the medical therapy their mechanical support should be considered and it is life saving for patients with refactory cardiac and respiratory flavor it also act as a bridge to recovery for transplantation or any decision making so suing my talk pediatric cardiac ICU it requires a comprehensive and multi-is disciplinary approach you should have clear understanding of cardiovascular physiology multiorgan system functions and on organ interactions in health as well as when patient is in disase so you should focus on a preemptive approach in preventing delous effects associated with cpb and intraoperative events if the patient is failing to progress along the projected course or patient is acutely decom sitting you should evaluate promptly with bedside assessment laboratory lab evaluations and echocardiography with that and call all of your team members think in One Direction and do for the best thank you yeah so we are just setting up for the panel discussion uh in the meantime if any of you have any questions please put it in the chat box or you can unmute yourself and yeah e so we heard STS from pediatric cardiologists Surge and we got to know all the small details about how uh usually patient Pati pathway is once they diagnosed to have a continental heart disease right from the diagnosis the investigations management interventions and then how the poost of course is but uh to go through little bit of nuances I would like the panel again to join in and we'll have a little bit of panel discussion please feel free to ask questions or stop me wherever you want more detailed answers so uh just to start like we as pediatric cardiologists we are doing so much of pediatric card work but in general practice uh how is the burden of the the disease is pediatric cardiac disease very very common so let us kind of get a little bit of glimpse of the burden of the problem and what kind of solutions are available presently in this country I'd like Dr to ask this question so as we know the general incidence of pediatric ofal heart defects is 8 to 10 per thousand life birs and in India looking at the birate that translates to 250,000 patients born every year with per heart effects now4 of these patients are estimated to require surgery or intervention during the first year of life meaning they have a critical CHD and of course we have a huge backlog of patients from before now pediatric cardiac Services started in India in the late 90s and since then we have progressed by leaves and grounds so today we have many centers in most of the Metropolitan City and also in some of the second year City so a lot of good quality high quality work is happening all over the country but obviously the number of train Specialists is much less than what is ideally required to take care of such a huge disease the bur is huge and as said that the cases keep piling up every year because we don't have enough Cent or enough person to take care of this problem uh so also you know as disease it's not we are not a hyper alert to diagnose pital heart disease so a lot of times children come to the emergency room and then they diagnosed as sepia or something else so I want to ask is what are the silent markers that you need to really be alert and to diagnose AAL heart disease because certain critical cases may have a heart problem which is treatable and that may be missed because we are not thinking about it so as we say what the Mind knows only that the eyes can see so what should our mind know for all the people who are listening what would be the silent things that they start of history and symptoms are very important any child in the first of come with tra infection failure to gain weight having fast breathing continuously typical Su C canit on exessive sweating on forehead any of those symptoms are should think term of also sometimes and uh these things are to be seen asked on history examination we usually osculate the heart directly now lot of people when the child come to the OPD is crying and don't have enough time to examine one important thing is consultation and palpation of pulses you need to palpate theal PSE of the make sure the child first and second so basically you to look for signs of cardiac failure is present te most of the time you will have some symptom of sign and you should have your eyes wide open to and try to investigate minimal of doubt you have should investigate sure so we should have a high risk of Suspicion basically is what he means to say it's back to the basics basically just oscilating maybe lot of us are very scared you know we may not be able to osculate well or because the child is crying we are not able to osculate so in those cases also just basic things you know just like Po Li saturation the blood pressure difference between the upper Li lower Lim palting pses all these things are quite crucial to diagnose anybody withal as I would like to ask Dr so how far do we go as in terms of cardiac surgical correction of these cardiac illnesses so how from when did we start like little bit of this IAL aspect you can and also if you can give us any insights about what looking next 10 years 20 years is this so the cardiac surgery started in 1943 when first of the P was done at that time there was no heart machine so open heart surgery was not done and so ear surgeries were bation 19 1956 to 60 the heart machine was kind of invented so we started doing the card surgery so we still say that card surgery is still in iny all around the world but if you consider from 1960 to now like it's almost 80 85 years many surgeries have been done and many evolutions and you have not also that surgeries last for how many years so we are still in the cardiac surgery and the techniques in pediatric cardiac surgery the the future I would say is that maybe some addition of the robotics for the minim inis but because everything is involved around handl machine so it might take some time and the babies have small chest but this is what we are looking at as far as the interventions are concerned obviously the cardiologist are doing like ear what we were doing now theying the PSS stands to all that in the ne AG so yeah as rightly said this is a very fast growing field we still in infancy and we are growing very very fast every new year we have some new therapies coming in some new drugs coming in new interventions coming in we all in the continuous cycle of learning unlearning and relearning so uh in the coming future we are very very optimistic like with regards to the life expectancy with regards to the quality of life we are very kind of we looking forward that these things will be normalized in patients withal heart diseas so coming to that point I would like to ask that currently what is the status once the child gets operated or gets an intervention or a device so how is their life after that and what kind of surgery do they require repeat surgeries and interventions in the future so can you just throw some light on that so most of the device closures and the trans interventions are done in patients with two good size ventricles and they have a normal life so suppose you do BD closure ASD closure P device closure they will have a normal life you keep seeing them at least for five years post procedure just to see that there is no complication but after that we discharge them from follow same goes for surgical patients who have had treatment of an Astic heart disease they will have a normal life expectancy normal exercise tolerance they can have kids and all issues now coming to the Coptic heart diseases if you have complete repair two ventricle repair such as an arterial switch operation most techologies those are also generally single the only caveat is when youology the surgeons are not able to preserve the pulmonary Val meaning you have a patient who does not have any obstruction in the pulmonary Ary but you have regurgitation then the subset of these patients within the second decade of Life require Val Plantation now that can be done either surgically and now since the last two decades we have now started doing trans so that's just one we tell the parents or the patients who Havey of that if you require rep you trans patch that Val will need replacement in the future now there is also subset of patients who have what is know as single ventricle circulation which means that they don't have two good size ventricles or their heart is formed in a way that we can't surgically separate it into separate right and left pumping chamber and these patients undergo a stage paliative procedure where we are trying to convert the heart to do the work only of the Left sided pumping chamber the left ventricle and we gradually take away the work of the right ventricle from the so these patients who undergo the Glen operation the font operation they don't have great long-term outcomes we have seen that usually they are all right for the first two to three decades of life but but but by the time they're about 20 25 years of age a lot of them will have heart fa so that is I would say one of the limitations we have in the present day and AG in terms of the spectrum we can treat so I would say 80 to 85% of our patients we are able to give them normal lifespan they have normal exercise tolerance and all but this 15% is the single ventricle subset where they will have some activity restriction single metrical people as Dr s said that they might have heart failure after 20 25 years of or even later 30 years some people can have a good life and after that starts so what after that so can Dr tell us what do we do after this this set of patients have their heart started paining are there any options that we can give them to extend the life so once the heart starts failing the option is medical management once the medical management also gets exhausted we have to consider always the patient for heart transplant heart transplantation needs quite a of work you have to see take the biopsy of the heart and once once the patient is listed there are certain categories in which the patient will be given the criteria before before the patient the recipient receives heart so more symptomatic or more sick or aing heart get the priority and until then we have to keep on medical management or there are certain assist devices but not many are available for smaller size of the heart of the babies those are mainly meant for the adults and that's why we do perative surgery or keep them on medical management till they 15 to 1 years at Le age so that we can get this better chances of getting the adult heart it's to get the ne of the Pediatric be heart even in the Western World so that's cardiac transplantation is available for such kind of patients though it is another disease it's not like the end of the trouble it's you have to be on monitoring as Dr said we need repeated biopsies and that heart which is transplanted also has a limited lifespan so it is not going to give you another 50 years of life maybe 10 20 years of so the condition or right now whatever present situation for a single ventrical disease is not as good as that for the patients with two ventricular disease so how do we know that if we can prevent this like Dr s said 8 to 10 of 1,000 child birs are going to have a conal heart problem naturally so this is a natural incidence so is there anything else that increases the risk of congenital heart disease and are there any ways to prevent that risk I like to stud conception pry anding at least for the first trimester help in reducing the incence ofal in addition what we recommend now is getting a though it's not done in everyone especially if the first child has had heart dis or the mother has had some heart disase is absolutely essential getting every patient so that at least pick them up critical conal heart disease early and we can avoid patients with single ventricle and complex heart where there are not many treatment options great treatment options available if you have say has just vsd which has a completely correctable Condition it's fine you can those kids do after birth but if you have a child single ventric we the have normal life better to pick them up early and the option that they can are there any infections or anything that the mother does does predispose infection mother some medications that the mother so do have to Be watchful to the medications to be mothers so that you can avoid these condition looking out for T infection tit mother can predict so as said most of theal AR there are very few ideologies which we can actually pinpoint but very significant so even like alcohol consumption can inrease risk of certain kind of syndromic associations again that can be picked with antinal ultrasounds like Sy they have high in ofal heart but again these are not we don't advise abortion to patients with simple heart problems only with complex heart problems this we can give the choice for the termination of pregnancy um according to uh Dr laa as she mentioned that good nutrition uh was quite predictable for good outcomes in the I is there anything else because when our doctors see patients with going to go for surgeries is there anything that they can do in the waiting period to make them better for the ICU care post so are there any measures that the doctors can take before this children Gove for please let us know you can hear okay yeah please the patient is admitted in the hospital and there is a time like we have we know that patient is having 7 to days in between prior we can't but in the hospital yes we can of like given patient is having cycle and patient is not taking properly we can put some and increase the cavity intake in those patients so that even if 100 or 200 g increase in the nutrition also it helps in our Immunity on it helps in tolerating the fs poop also and try to whoever sees the patient later on if we know that patient is now toting like it can go for next 2 three months we can advise that with only breastfeeding it is not happening and we should increase outside milk or outside protein and high calie diets you can think of and it will increase the weight and F Health early recovery and early and preventing the infection so very rightly said nutrition is the Keystone also prevention of infection so before they come to the hospital if you see a child who's going to go for surgery any surgery for that matter especially for cardiac surgeries most of the children with SH will always have some kind of respiratory infection there'll be cof so it's better to give antibiotics during that time we always you know as Peds we want to be safe and we want to only give antibiotics to proven bacterial infections but in this cases I would like to urge all of you to keep a low threshold so keep a low threshold for starting antibiotics with children which sh regions because that is going to prevent respiratory infections very susceptible to these respiratory infections and which may actually decrease the general condition and they will not which will affect the ISU State or the postoperative course so just on this topic a patient with has a ponia how long you before anesthetic clearance for patient for surgery so you have to actually check whether it is like pneumonia is actually because of the bacterial things some infection related or this is because of the cardiac issues sometimes we do take care sometimes it is because of the cardiac thing that's why that pneumonia is not getting cleared out so you have to check that thing you have to examine in that way the is the orig then I will for that and but find and high is high and and you find some patch on the x-rays then you think of no some amount of infection is there give some antibiotic wait for 4 to 5 days and see that the symptoms are improving x-ray wise and clinically as well then you can take the patient POS so basically if uh someone has we give antibiotic the patient gets better then we discharge and if press weeks of gap before we consider surgy Dr Lo mentioning supp the patient is already in hospital and respirat symptoms reing vation anding to from then in those conditions we have to go in and correct the C because that's the primary until unless we res the proba antibiotics will not have patient will always St and get further sub infection yeah so with regards to infection prevention is always better than cure so what about immunization should all is it contraindicated or is it indicated to give immunization or specific immunization schedules for any card patients we gen ad to in fact patients who have isia which is seen in some of these children with isomerism ambiguous subset of patients they are more prone to infections with capsulated organisms so vaccines very important once a child has had cardiac surgery we advise them not to be vaccinated for the next one month and that is because if a patient is put on card bypass there are some studies which sh that the immune response is suboptimal so if you give a vaccine in that one month you might not have an adequate protection for that vaccinating so we routinely see this that in primary healthare sectors when the child go with P heart disease is not growing well so they will see the growth and then they will say okay you have a heart problem we not immunizing you at this point time in fact it should be counterproductive for the child and we should in fact go and give up give the because that child needs that immunization more than other healthy child because of the low immunity so also I want to ask Dres how about the postoperative care so how long do the children need to be hospitalized when they go home can they play normally or when do they start schooling both in Cas of device closes or surgal what kind child go home couple of days time then can back to normal only we put in a inard device like as or device he need to be an as for 6 months and we need to avoid M for moning than that there no other restriction can do all theal go back to school they need to avoid contact SC on ASP they can have they caning BL Conta but normal sporting activity routin scholing everything can in case of surgical patient care need to be taken for the first month of post operative will be on medication first one mon of aftercharge andimar we need to avoid contact children they need special Avid Ley vegetables but most of them a normal life toool to work what about the post surgical patients like what kind of remal when do they need to come back to hospital how many times they need to come back to hospital after so once any patient is diagnosed with a heart we ad them and surgery do all the surgery work which includes blood investigation xay ECG and if any additional Imaging is required like ciaiac once everything is in place the blood also and then the pre check is after the surgery is done which rely takes about four to six hours for any open long second and after the surgery the babies are shifted into cardia where as for the recovery we keep them for 1 to 4 days the smaller the and the neonates are the less weight they take longer time in I to come out of that and after that we shift the baby back to the W with the mother and another 3 4 days we do a check next and then they go home so this is about roughly 7 to 10 days of stay after the surgery and we call them to to the hospital after one month for the first follow and that time we T of the card medication whatever going we use all the absorbable sutes that don't need to cut except for one or two chest sutes which can be cut at any peral Center or if the patient wish wish come here uh we we here it's just hardly and they can start taking shower with soap and water just after 15 there no more blessing or application is required because we remove the Sut that means the moood is dry and it's as good as the so when do they start scholing and we that they can start the school of private uh after two weeks but if they have they have very active uh school life or they have to climb stairs and all I would recommend anybody to go after four weeks by the time the bone usually heals the St B what cut and then there are less chances of it going that's the only recomendation otherwise routine like how they were living before there's not much of rest excellent so that was quite good to your that the recovery children is fast especially after stomy they do much better than what adults so for adults majority you have a restriction for many activities for six months but as Dr said the both healing is much faster in children so we don't usually ask them not to do certain things see if the baby has is a just a new or infant so they're going to learn new motor skills every they going to learn to sit they going to learn to stand walk so these things can happen normally and naturally even after a stomy there is no restriction for these things another like one thing I would like to note here is that we have Olympic players who had a as and they also play competitive Sports at that level so very good outcomes some kind ofal heart disease Legions have excellent outcomes and very good recovery I think uh from my side I I have tried to cover most of the points and try to give you a message regarding what work we do if you have any other questions other than these please feel free to ask and any comments by the panelists so I have coms about future DED [Music] of one is transor valves so the first cutaneous Val was done in 2020 and now it has become quite common in Wern countries we are perous ponary even in India but because of the cost it is still done in very few patients but as the cost come down and as hopefully insurance starts covering these complex procedures more and more patients with to get these done the second thing is vs so V ventricular assist devices have become progressively more compact in the last two decades and probably with new technologies of imization maybe in the next decade we will have vs which are specifically suited for children and some of these vs might even be an alternative to a transplantation so looking forward maybe 20 years down the line heart transplant will not be indicated in as many patients as it is indicated we can do a and of let the Child live normally also about like my topic was Advanced Imaging Technologies so you know every radiation is a hazard we are exposed to radiation even in the environment but especially in hospital situations when we subject children to angiography or to CD scans the ionizing radiation amount is quite high and this we have seen lot of studies showing that there's increased risk of cancers in this patient so this du advances we can do lot of device closures through nonionizing radiation techniques like the CMR or even ultrasound guided or we can superimpose the CD Scan Imaging or other other type of Imaging the C machines and then minimize the radiation exposure to the child so that is as well is a very new thing and it's growing very fast and in future maybe we'll have radiation minimal radiation exposure for device protes another thing before we close for all the doctors is about behavioral aspect of children postal heart disease treatments so that do you want to speak about it stud which have shown that proced child gr up may have [Music] ISS follow to have issu these are things which we need to watch out for and see how they evolve multi approach early pick up is essential so we need to involve development child behavior so we have to keep an eye for it very high defitely so since we started treating the children and sending them home successfully now we have more focus on the smaller aspects or the nuances of children with ConEd heart disease they are just like other children but they may have certain problems which are different from the normal children after they undergo this treatment even exposure to pain in newes and children to sever pain has shown to have a significant effect on their brain so we have to be on high alert with regards to behavioral behaviors in this children and they may need more of Behavioral therapies or stuff like that in the next the life after the Sur anything else any question yeah so uh I I'm just at the chat box I don't see any questions I think then I would like to conclude [Music] [Music] so goodbye fromard scien team of s thank you all of you for patient l and sping a good bit of your afternoon with us today thank thank