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Dr. Gaurav Agrawal

Dr. Gaurav Agrawal
Associate Consultant
Paediatric Cardiology
BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

Waiting For The Right Time

Not every abnormal heart needs to go under the knife

THE CASES

A 7-month-old boy from Zimbabwe was brought to BLK Super Speciality Hospital for Patent Ductus Arteriosus (PDA) closure. The patient’s history showed increased respiratory rate since birth. The child used to sleep day and night most of the times and was diagnosed with Down’s Syndrome. On clinical assessment, the child showed respiratory distress with subcostal and intercostal retractions. Saturation in upper limb was 78% and 55% in lower limb. First heart sound was normal and second heart sound was normally split with loud P2.

Echocardiography showed 2.8 mm PDA, shunting purely right to left with dilated RA and RV with severe RV dysfunction. As the patient had severe respiratory distress along with severe PAH and increased PA pressures, he was admitted in PICU for evaluation and management of high PA pressure.

THE PROCEDURE

Basic lab investigations for Pulmonary Hypertension were normal with mild increase in reticulocyte count. Peripheral blood smear was not showing evidence of haemolysis. Sickle cell test was negative. Initial VBG was showing high pCO2 (>70). He was kept on 2 litres of oxygen via nasal cannula. Within 1 hour of oxygen, his RV function improved significantly along with normal size of RV and PDA was shunting mainly left to right.

CT scan of chest showed consolidation of left lower lobe, lower 1/3rd of the right lung. As the child had basal consolidation and slept most of the times, Paediatric Pulmonology opinion was sought and sleep study was advised. Sleep study showed severe apnea even during awake phase, the frequency of which increased during sleep. Hence, diagnosis of severe obstructive apnea was made. Paediatric Neurology opinion was sought for assessment of neuromuscular status as the boy was a known case of Down’s Syndrome. CPK level was normal. MRI brain was advised but could not be possible as the patient was desaturating as soon as sedation was given.

THE RESULT

As the boy had severe OSA, BiPAP support with 3 litres of oxygen both during day and night was advised. PDA closure was not done due to high PA pressures. Patient was advised for a follow up visit after 6 months for assessing PA pressures and possible PDA closure at that time.