CORONARY ANGIOPLASTY THROUGH THE HAND

      Ritu Prakash Agarwal, a two-month-old girl baby hailing from Jhalna in Maharashtra, suffered from breathlessness because the left side of her heart was severly underdeveloped at birth. The left ventricle, the mitral valve, the ascending aorta and the arch of the aorta were unable to pump blood to the body and so blood that should return to the heart filled her lungs, leaving her breathless and unable to feed.

      Doctors at Jhalna had told her parents, Mr.Prakash Fakirchand Agarwal and Ms.Seema Agarwal, that the chances of her survival were remote. The normal procedure is to go for a heart transplant. Since they had already lost their first daughter within 13 hours of her birth about two and a half years ago, because of congenital heart malformation, the Agarwals decided to go ahead with the operation when Ritu was diagnosed as suffering from a similar defect, at the Madras Medical Mission where the doctors offered them some hope.

      Norwood procedure, a complex repair, was performed on Ritu for this serious congenital condition called Hypoplastic Left Heart Syndrome. Since the syndrome manifests in the form of low birth weight, severe breathlessness and sleeplessness among newborns, it is recommended that infants be operated in the first few months of life itself to avoid further complications. Subsequently, the baby will need to undergo two more surgeries.

      The Norwood procedure is to be done within five days of birth and the post-operative care is challenging, says Paediatric Cardiac Surgeon, Robert Coelho, who led the surgery team. The second part of the surgery is done when the child is five or six months old and the third, between three and five years of age. These surgeries ensure better oxygenation of blood. the surgery rearramges blood circulation from the heart to the body to enable the child to lead a normal life when she grows up. This procedure is performed in only few paediatric cardiological units in the world and MMM is proud to be one among these.

      Ritu has recovered well and her cheeks are beginning to fill out. The baby, weighing 2.7 kgs at birth, now weighs 3.5 kgs and will make two trips to Chennai to complete the process of correction.

      About three months ago, a 3-month-old infant was referred to the Department of Paediatric Surgery as a case of grossly enlarged right kidney. The parents complained that the baby had progressively increasing abdominal distension, vomiting and constipation. On examination the infant had a mass abdomen of variable consistency that was filling the entire abdomen. X-ray, ultra sound and CT scan all showed the kidneys were normal, but a tumour was arising from the retro peritoneum.

      A team comprising of Dr.Kumaravel, Paediatric Surgeon and Dr.Jayakumar, with Prof.Ramachandran providing anaesthetic support, operated on the infant.

      On laparotomy, there was found a huge mass that was free of kidney and liver but encircled by intestine and engulfing the blood supply of the entire intestine (Superior Mesentric Artery and Vein). The mass was removed completely after meticulously preserving the blood supply and the intestines. This mass was about one sixth of the weight of the baby.

      The mass on opening however revealed a well developd brain with choroid plexus, and cerebrospinal fluid, immature lung with bronchus (wind pipe) , stomach with intestine and pancreas, spine, cartilage and bone with bone marrow all pointing to an incompletely developed twin which lay buried inside the abdomen of the infant. Known as "Fetus in fetu". This is a situation in which an imperfect fetus is contained within the bodyof its well-developed twin. Complete excision is curative. Only about 100 such cases have been reported worldwide so far.

      The infant is well and thriving after the surgery.

      The Department of Paediatric surgery is now routinely receiving references from the surrounding Villupuram, Cudalore, Karaikal areas in addition to Pondicherry for many such unusual and rare surgical problems in newborns, infants and children.

Mr.Radhakrishanan N., Dr.Rajan S. and Dr.Ulhas M. Pandurangi

         Mr.Rugambwa Jean De Dieu, a 45-year-old national foot ball player from Rwanda, Africa, presented with a two-year history of progressive bereathlessness. At the time of admission, he was extremely sick with swelling of legs, abdomen and face. He was unable to lie down flat.

      His echocardiogram revealed dilatation of all the chambers of the heart with very poor pumping efficiency (EF: 20%). The contractile segments of the ventricles were found to be dyssynergic. Mitral valve was significantly leaking (severe MR). He had moderate renal insufficiency (Urea: 110mg/dl, Creatine 2.8 mg/dl, Potassium 5.2 mEQ/L). His electrocardiogram revealed sinus rhythum, wide QRS complex (190 ms) and frquent PVCs. Cardiac catheterization including coronary angiogram revealed significant lesion in the proximal left anterior descending artery (LAD) involving diagonal (DI) branch and severe pulmonary (mean PAP: 55 mmHg). The patient's symptoms did not improve significantly despite optimal medical therapy for two weeks during the hospital stay. The patient was enrolled in the cardiac transplantation registry and was waiting for a suitable donor. as the patient's condition deteriorated during the waiting period, he was offered very high-risk mitral valve repair / replacement with bypass graft surgery to LAD. It was also decided to put an epicardial to left ventricle lead during the surgery and if required in the postoperative period to utilize the lead for biventricular pacing.