INNOVATIVE TECHNIQUE/ IDEA

Prof Brig Gen Nurun Nahar Fatema Begum, Armed Forces Medical College, Dhaka

  • Scope
  • The new innovation in intervention for 1. Simplification 2. bailing out.
  • The new innovation in a treatment protocol
  • The new innovation in special sign in various syndrome

New innovation – intervention

  • Coarctoplasty in newborn
  • VSD device closure in retrograde approach
  • VSD coil occlusion
  • Closure of longest slender PDA
  • Snare assisted PDA device closure
  • Minimalistic approach in ASD device closure
  • PDA device with RFV technique
  • Device closure of large tubular PDA ( Spl design)
  • PDA device in high PHT cases
  • PFO closure in migraine
  • RVOT stenting
  • ASD device closure in patient with small LA/Floppy rim
  • BVP for critical PS /PA

New invention- treatment protocol

Pharmacological protocol

  1. PPHN treatment protocol (NNF Protocol)
  2. Use of sildenafil in children
  3. Management protocol in cyanotic spell (NNF )

Diagnostic technique

  1. Collection of sweat for sweat chloride test

New invention of special sign in various  syndrome

  • Round face in DORV, VSD, PS
  • Characteristic whorl in CRS

Coarctoplasty in newborn (1999)

Year : 1999

Name: Manha,   Age: 1.5 month,      Wt : 3.5 Kg

VSD device closure in retrograde approach 2012

  • Perimembranous VSD  closed by ADO II device from retrograde approach is practiced in 100% cases of small VSD’s including DC VSD,s.
  • This method was innovated by pediatric cardiac team of Armed Forces Pediatric Cardiac Center spontaneously while doing an adult female case in 2012. Named as Fatema,s technique by Little Heart

 

 

Closure of long slender PDA (2013)

Tamim , S/O Sgt Kamal,  Age: 01 Yrs ,  07 Kg 23 mm long

Closed with 5 x 4 mm  Cook Coil 

Snare assisted PDA device closure (2004)

 

The minimalistic approach in ASD device closure (2005)

  • In minimalistic approach, we can reduce the procedure time by avoiding many steps like reducing sedation time & also reducing the radiation of the patient, operators & cath lab staffs.
  • Cocktail sedation is used instead of general anesthesia.
  • Transthoracic Echocardiography is used instead of Transesophageal Echo.
  • Diagnostic cath is not done
  • Balloon sizing is done to stop the flow

PDA device with RFV technique (2006)

 

Name: Nasifa

Age: 2 months, Weight: 2.2kg

Dis: Large PDA with reverse shunt, Severe PHT

Device closure done with 6/6 ADO I device

Device closure of large tubular PDA ( Spl design)

 

Device configuration for cylindrical PDA

 

Aortic end of the device was pulled inside the PDA and a round shape configuration created which was pressed against the PDA wall and secured the device inside PDA. Other ends of the device released inside the pulmonary artery.

PDA device in high PHT cases . Ref Asean heart Journal 2006;14(1):12-15

PFO closure in migraine (2013)

RVOT stenting (2006)

  • Year: 2006
  • Sneha, 7 mo old baby presented with severe cyanotic spell,
  • Diagnosis: DORV, VSD, severe infundibular & valvular PS
  • Surgeon refused to do BT shunt due to less body wt ( 3 Kg)
  • Pt was taken to cath lab for life saving purpose.

ASD device closure in  patient with small LA

ASD device closure in  patient with floppy rims with double disc in LA

ASD device closure in Small LA

BVP for critical PS (2001) PVA (2005)

  • Name: Rafi
  • Age: 1 month, Weight: 3.5 kg
  • Disease: Severe pulmonary valve stenosis
  • Procedure: Balloon valvoplasty is done 6×3 Balloon

First ever  MFO Device Closure in Bangladesh
at NNF Lab. 28.10.18

  • Sanzam, 4.6 Yrs, 16 Kg
  • Disease: Small PM VSD
  • Device: 6 x 4 MFO Device
  • No AR, VSD Flow after  deployment of Device

 

New treatment protocol

PPHN treatment protocol (NNF Protocol) Ref:
Notes on basic paedi cardiology.

Protocol formulated by us for Persistent Pulmonary Hypertension in 2001 has success rate > 99%

First line treatment:

  • High flow oxygen therapy for 72 hours
  • Tab Cardopril
  • Inj Frusemide
  • Inj Digoxin

PPHN treatment protocol (NNF Protocol)

Second line treatment:

  • Tab Sildenafil
  • Some of the patients required ventilator support due to profound hypoxemia and acidosis.
  • Some of the patients require ionotropic support with Dopamine and/ dobutamine.
  • In preterm patients with significant PDA without right to left shunt Inj Indomethacin or Syp Ibuprofen or Paracetamol may be used to close the ductus
  • Third line management: Inhaled Nitric Oxide (iNO) and ECMO if available

Use of sildenafil in children

Management protocol in cyanotic spell
(NNF protocol) Ref, Notes on Basis Ped Cardiology

1ststep:

  • O2 inhalation
  • Keep the baby calm and quiet
  • Do not irritate the baby by giving IV line
  • Inj. Diazepam 0.5 mg/kg PR stat
  • Mother should be encouraged to sedate the baby

2nd step:

  • Inj. Hartman solution/FFP-10 ml/kg IV stat
  • Inj. Morphine 0.1 mg/kg IV or SC stat
  • Inj. Esmolol 0.5 mg/kg IV in one minute
  • Inj. Sodium bicarbonate 1-2 mEq/kg diluted with an equal amount of 5% DBS in 1 hour

3rd step:

  • Artificial ventilation

4th step:

  • RVOT stenting in the young infant.
  • BT shunt.
  • PDA stenting if PDA is present.

Note: Inj Esmolol in the cyanotic spell: 0.5 mg/kg in 5 minutes. Then 50 µgm/kg/min over 4 minutes. If no response: 0.5 mg/kg over 5 min again. Then 50-200 µgm/kg/min up to 48 hours

Special Prophylaxis for Tetralogy of Fallot (TOF)

Special note:

Phenobarbitone is used in the author’s center since 1998 for a severe form of infundibular stenosis to avoid hypoxic convulsion and oxygen consumption.

Collection of sweat for sweat chloride test

Improvised technique for collection of sweat for sweat chloride test

Ref: NNF chest and heart Journal 2005 ; 29(1): 65-70.

A new clinical sign of the various syndrome

Characteristic whorl of hair in Congenital Rubella Syndrome

Round face in DORV , VSD with PS

Conclusion

Medicine is the science which is evidence-based. Evidence comes out usually from the experience of the physician and surgeons. Some of the experience is achieved during managing complication from a normal procedure and bailing out from that in a safe way. Many of our new innovation in cath lab was achieved during such a bailout procedure. Medical management protocol was designed on the basis of necessity as a low resource country and the syndrome was identified on the basis of experience.

 

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