1. Managing VSDs: Specific Challenges in the Low Resource Environment
Krishna Kumar
AIMS, Cochin
India

2. VSD Common Surgical Correction Rewarding Immediate Intermediate
Long-term

3. LMICs
This slide shows the human development indices in various parts of the world. The purpose here is to show the fact that an overwhelming majority of the world’s population lives in regions that have relatively low HDI.
The Demic Atlas Project: Toward a Non-State-Based Approach to Mapping Global Economic and Social Development, by Martin W. Lewis, Jake Coolidge, and Anne Fredell
Source:

4. Worldmapper Population Cartogram
This worldmapper cartogram depicts the area of a region in proportion to population and again demonstrates that the vast majority of the worlds population are in “emerging economies

5. Estimated proportion of infants and newborns with critical CHD undergoing surgery within the first year of life in India
Number undergoing surgery in the first year of life
Estimated number of infants with critical CHD
2012

6. The Indian Situation Barriers to timely care of CHD: Poverty Treatment
Ignorance
Socio-cultural (gender bias)
Geographic
Treatment N~
Top 5-10% of the economic pyramid?
The Indian Situation
Timely referral
N = ?
Detection
N = ?
Total CHD population at birth
N = 80, ,000

7. Specific Challenges in LMICs
Undernutrition
Pneumonia
Pulmonary hypertension

8. Photograph obtained and reproduced with permission from family
1999
Baby A: Large VSD and ASD
Birth Weight of 3.07 Kg; 2.5 Kg at 6 months!
Photograph obtained and reproduced with permission from family

9. (J Pediatr 2002;140:736-41)

10. (J Pediatr 2002;140:736-41)

11. Weight Z Scores > -3: 73; <-3: 125; < -4: 68; < -5: 27
Infant VSDs (Year ) – 198 (19.3% of all infant heart operations)
Weight Z Scores > -3: 73; <-3: 125; < -4: 68; < -5: 27

12. 3 months after discharge 

13. 90 from original cohort; follow up of 52.3 􏰀± 15.5 months
Nutritional Recovery
90 from original cohort; follow up of 52.3 􏰀± 15.5 months
J Pediatr 2006;149:205-9;

14. J Pediatr 2006;149:205-9;

15. VSD in LMICs: Challenge #2

16. When does one intervene? What outcomes can be expected?
VSD with Severe Respiratory Infections Requiring Mechanical Ventilation
Questions:
Band vs. Repair?
When does one intervene?
What outcomes can be expected?

17. VSD with Severe Respiratory Infections
Bhatt M, Roth S, Kumar RK, Gauvreau K, Chengode S, Nair, SG, Shivaprakasha K, Rao SG, Management of infants with large, unrepaired left-to-right shunts and respiratory infection requiring mechanical ventilation, Journal of Thoracic and Cardiovascular Surgery 2004;127:

18. Institutional criteria for VSD closure in ventilated infants
No fever for 48 hours or longer
Decreasing leukocyte counts, if initially increased, and increasing platelet counts, if initially reduced
At least partial radiologic clearance of lung infiltrates
Improved arterial blood gases (PaO2 >􏰁60 mm Hg and PaCO2 <􏰂50 mm Hg on a fraction of inspired oxygen of 􏰂0.4 using pressure-controlled ventilation with maximum peak inspiratory pressures of mm Hg and tidal volumes of 10 mL/kg)
Unequivocal documentation of predominant left-to-right systolic shunting on color Doppler echocardiography
Documentation of negative bacterial cultures and normalization of gas exchange, although desirable, were not mandatory.

19. VSD with Severe Respiratory Infections
Bhatt M, Roth S, Kumar RK, Gauvreau K, Chengode S, Nair, SG, Shivaprakasha K, Rao SG, Management of infants with large, unrepaired left-to-right shunts and respiratory infection requiring mechanical ventilation, Journal of Thoracic and Cardiovascular Surgery 2004;127:

20. VSD with severe respiratory infections
Correction is feasible and should be pursued aggressively
Potential to save lives
Significant morbidity
Postoperative sepsis
Prolonged ICU and hospital stay

21. Specific Challenges in LMICs
Undernutrition
Pneumonia
Pulmonary hypertension

22. VSD with PAH
Generally operable if there is evidence of a significant shunt in the basal state irrespective of PA pressure
Age is an important variable and some benefit of doubt must be given to younger patients.
However, when in significant doubt, do not operate

23. Clinical Spectrum of PAH in CHD
Operable
Clear evidence of a large L-R shunt
Typically younger patients
Borderline situation: PVR elevated ; operability uncertain.
Inoperable: Eisenmenger physiology
Shunt reversal
Typically older patients

25. Clearly Operable: Cath not requiredLV RV LA LV RA RV
Clearly Operable: Cath not required

26. 26 year old
Blue
Single loud S2

27. Clearly Inoperable: Cath not requiredRV LV RA LA
Clearly Inoperable: Cath not required

28. Clinical spectrum of post-tricuspid shunts with PAH
Operable
Failure to thrive,  precordial activity, mid diastolic murmur at apex,
Cardiac enlargement, pulmonary blood flow
Q in lateral leads on ECG, good LV forces
LA/LV enlargement, exclusively L-R flows across the defect
Clear clinical /noninvasive evidence of a large left – right shunt
Borderline clinical non-invasive data: uncertain operability
Cyanosis, quiet precordium, no MDM
Normal heart size, peripheral pruning
No Q in lateral leads, predominent RV forces
No LA LV enlargement, significant R-L flows across the defect
Clear evidence of shunt reversal resulting from high PVR.
Inoperable

29. Opportunity to refine data further using the IQIC database
Conclusions
Large VSDs pose significant challenges in resource limited environments
Contextually relevant data available from LMICs to formulate simple guidelines
Opportunity to refine data further using the IQIC database

30. Acknowledgements Patients and their families
Former and current members of the AIMS pediatric heart program
AIMS administration
Children’s Heartlink
Steve Roth
Children’s Boston
Kathy and IQIC