Higher Pulmonary Vein Index From Preoperative Computed
Angiography & Good Surgical Resection Ensures A Smooth Post-Operative
Recovery Sans Low Cardiac Output Syndrome in a TOF Child-Special
Emphasis On Indices Of Evaluation, Monocusp Preparation.
Author Information -
1) Vishal V. Bhende
Primary Author,
Consultant,Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel
Cardiac Centre,Shree Krishna Hospital,Gokal Nagar,Karamsad,Anand,Gujarat
- 388 325,India.
E
mail:drvishalbhende@gmail.com
Mobile : + 91 98453 83405
2) Tanishq S. Sharma,
Corresponding Author,
Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre,
Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:sharma.tanishqtask@gmail.com
Mobile : + 91 79902 43174
3) Deepakkumar V. Mehta
Professor & Head,Department of Radiodiagnosis & Imaging, Pramukhswami
Medical College & Shree Krishna Hospital, Bhaikaka
University,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:deepakvm@charutarhealth.org
Mobile : + 91 98791 67676
4) Krishnan Ganapathy Subramaniam
Consultant,Cardiac Surgeon,Mgm Healthcare, Aminjikarai, Chennai
E mail :
ganapathysubramaniamk@gmail.com
Mobile : 09600050895
5) Amit Kumar
Consultant,Pediatric Cardiac Intensivist, Bhanubhai and Madhuben Patel
Cardiac Centre,Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388
325,India.
E
mail:amitpaed2006@yahoo.com
Mobile : + 91 82380 10476
6) Bhadra Y. Trivedi
Consultant,Pediatric Interventional Cardiologist,Bhanubhai and Madhuben
Patel Cardiac Centre,Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388
325,India.
E mail:Bhadra81@gmail.com
Mobile : + 91 99877 18447
7) Jigar P. Thacker
Assistant Professor,Department Of Pediatrics, Pramukhswami Medical
College, Bhaikaka University, Karamsad
E mail: thackerjigar@yahoo.co.in
Mobile : 9426621883
8) Viral B. Patel
Professor,Department of Radiodiagnosis & Imaging, Pramukhswami Medical
College & Shree Krishna Hospital, Bhaikaka University,
Karamsad,Anand,Gujarat - 388 325,India.
E
mail:viralvp@charutarhealth.org
Mobile : + 91 98250 60977
9)Gurpreet Panesar
Consultant,Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac
Centre, Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:Panesar_preeti@yahoo.co.in
Mobile : + 91 98253 58661
10)Kunal Soni
Consultant,Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac
Centre, Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:drkunalsoni@gmail.com
Mobile : + 91 90999 21950
11)Kartik B. Dhami
Consultant,Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac
Centre, Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:kartikbdhami@yahoo.com
Mobile : + 91 91794 73521
12)Hardil P. Majmudar
Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre,Shree
Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E mail:
hardil.majmudar@gmail.com
Mobile : + 91 92659 03713
13)Nirja Patel
Fellow,Cardiac Anaesthesiology,Bhanubhai and Madhuben Patel Cardiac
Centre, Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:nirjapatel27@gmail.com
Mobile : + 91 75758 01142
14) Sohilkhan Pathan
Clinical Research Co-ordinator, Bhanubhai and Madhuben Patel Cardiac
Centre, Shree Krishna Hospital,Karamsad,Anand,Gujarat - 388 325,India.
E
mail:sohilrp@charutarhealth.org
Mobile : + 91 84600 63464
Abstract
Tetralogy of Fallot (TOF) is a common cyanotic congenital heart disease.
Its surgical correction requires ventricular septal defect (VSD) closure
and right ventricular outflow tract obstruction (RVOTO) relief, with
transannular patch enlargement (TAPE) of the pulmonary valve. The first
successful repair of TOF was reported in 1954 and consisted of closure
of the VSD through a large right ventriculotomy, and RVOTO relief with
TAPE of the pulmonary valve. To predict the intra-operative requirements
and post-operative course of patients with this condition, various
evaluation indices are available that can provide a good indication of
patient prognosis. In this case report, we describe a novel pulmonary
vein index (PVI) indicator that offers prognostic indications for
pediatric cardiac patients who have undergone surgical correction of
TOF.
KEYWORDS –
Tetralogy of Fallot, Pulmonary vein index, McGoon ratio, early outcomes,
congenital heart disease.
Introduction
Tetralogy of Fallot (TOF) is a cyanotic congenital heart disease seen in
pediatric patients. Successful surgical correction of TOF was first
performed in 1954 with the closure of the ventricular septal defect
(VSD) through a large right ventriculotomy and relief of RVOTO by
transannular patch enlargement (TAPE)
[1,2].
Since then, treatments for the correction of TOF have enjoyed tremendous
success
[3,4].
The peri-operative mortality rate has reduced to 1.5% and there are
good long-term outcomes due to the evolution of cardiopulmonary bypass
techniques and peri-operative management. Although TOF can be lethal if
untreated or incorrectly treated; it can have an excellent prognosis
with timely surgical intervention.
The ideal TOF repair removes RVOTO sufficiently to prevent the
progression of right ventricular hypertrophy. However, there are
remarkable clinical differences between TOF patients, which may lead to
overconfidence when formulating treatment decisions and predicting
prognoses. TOF patients can experience prolonged postoperative recovery
even when surgery is successful
[5,6].
Reduced pulmonary blood flow (Qp) is the main cause of hemodynamic
changes in TOF. Presently, preoperative evaluations of TOF children are
performed using the McGoon ratio and the Nakata index but these have
limitations. Both of these systems measure branch pulmonary arteries
(PAs), which can yield fallacious results as pulmonary arteries are not
typically cylindrical.Differences may be present as normal anatomic
variations,or as a result of factors that may increase the stiffness of
the vessels,and thus affect the ability of the PAs to alter their shape
in response to changing conditions. In addition, poststenotic dilatation
of branch PAs, the presence of major aortopulmonary collateral arteries
(MAPCAs), and malformations may lead to misjudgments of Qp and further
influence the mis-estimation of the patient’s condition and the
determination of poor treatment decisions.Thus,understanding of the
pulmonary artery anatomy is essential for all decisions -making in
pediatric cardiac surgery.
In this study, we aim to demonstrate that the sizes of individual
pulmonary veins (PVs) are a more accurate and sensitive indicator of Qp
than PA size, especially in TOF patients
[7,8].
The pulmonary vein index (PVI) is a new indicator based on the
morphology of pulmonary veins. As Qp and the severity of TOF are
inversely proportional, PVI may provide more precise predictions.
We review the case of a TOF patient who underwent complete repair in our
institution and compare the prognostic abilities of PVI and the McGoon
ratio and Nakata index in their predictions of early postoperative TOF
outcomes.
Case Presentation
Our study was approved by the Institutional Ethics Committee (IEC-2) of
the HM Patel Centre for Medical Care and Education, Anand,Gujarat vide
Approval No.IEC/BU/2021/Cr.54/296 dated 27.11.2021. Written informed
consent to use the patient’s data in this study was obtained from a
parent or guardian prior to surgery.
The patient was male,aged 1 year,9 months and 23 days;weighed 8.5
kgs.Weight at birth was 2.5 kgs.The patient presented with TOF and
confluent branch PAs,with a history of cyanotic spells.At surgery,the
patient’s pre-operative oxygen saturation was 75 %.The patient had
never undergone a surgical procedure prior to this.The Mc Goon ratio was
1.97,Nakata Index was 539.22 mm2/m2 and PVI was 368.12 mm2/m2.The
operative data comprised a cardiopulmonary bypass(CPB)time of 152
min.The surgical strategy included combination of four procedures -
Ventricular septal defect (VSD) closure, Right ventricular outflow tract
(RVOT) resection,Trans-annular patch enlargement(TAPE),Atrial Septal
Defect closure.A summary of the patient information is presented in
Table2.
A cardiac computed tomography dynamic study revealed confluent branch
PAs in our patient. The measurements for these were: right pulmonary
artery: proximal 9 mm, distal 8.3 mm; left pulmonary artery: proximal 11
mm, distal 12 mm; main pulmonary artery: proximal (supra-valvular
region) 7.7 mm, mid 9 mm, distal 12.2 mm.
Table – 1 Indices Used in the Evaluation of TOF Patients