Question 1

What is the correct timing of surgery for a child with transposition of the great arteries (TGA) with a VSD and left ventricular outflow tract (LVOT) obstruction?

Dr. Aseem R. Srivastava · Accepted Answer

These children essentially have pulmonary stenosis with a VSD, and the timing of surgery depends on the child's oxygen saturation. They will go for either a Rastelli or a Nikaidoh operation, and both need an implant. The intent is to give them the biggest implant possible, because the smaller the implant, the earlier they come back for an implant change. If saturations are above 75 and the child is growing and doing well, they can wait and come for surgery at around one year of age. If saturations are below 75 and the child has significant failure to thrive, they should come for surgery at any age or weight.

Question 2

In a resource-limited country, diagnosis is often made late, including for simple shunt lesions, and families then panic and ask to go abroad for surgery. What do you recommend for these late presenters?

Dr. Aseem R. Srivastava · Accepted Answer

We are also a resource-limited country: four or five of us do this work across half of India, and we face children coming late every day or two. I have not yet found an answer, but my suggestion is education. We have started education programmes in different centres, and when I go for a CME I promote pulse oximeter screening. As a paediatric cardiologist you can take this up and help your paediatricians understand the significance of saturation measurements at birth, at 1 month and at 6 months after birth, so they refer for an echo early.

Among late presenters, PDAs are usually operable, and the blue heart conditions apart from TGA are usually operable even late, with slightly higher risk. Shunt lesions such as VSDs, unfortunately, become inoperable. Even so, when clinical judgement says a child is inoperable, a cardiac catheterisation often shows that a significant, though not large, proportion are operable, at high risk. I will always offer a late presenter a cardiac catheterisation to confirm. Once inoperability is confirmed, you can counsel the family to stop running around and stay with medical management: a child with an inoperable VSD who receives skilled medical care, with appropriately timed diuretics and pulmonary vasodilators, can still survive 25, 30 or 35 years, but without that care will die much earlier. Even when a child is not operable, you can prolong life and improve quality of life.

Question 3

What is the average cost of ASD closure?

Dr. Aseem R. Srivastava · Accepted Answer

Approximately 5,500 USD.

Question 4

Many referring doctors see patients who need surgery but whose families cannot afford it, and who must be managed medically at home. Can these doctors rely on you for guidance on local management?

Dr. Aseem R. Srivastava · Accepted Answer

Treating a child is not a one-time event. I have to make sure the child is safe before surgery, and that the doctors treating them have easy access to me after surgery. If I can help more children through you, it does not matter whether they come to me for surgery or go to another centre: I am still helping the referring physician, and I am always available, 24/7, even if I answer a little late when my schedule is tight.

Live Discussion with Dr. Aseem R. Srivastava

What is the correct timing of surgery for a child with transposition of the great arteries (TGA) with a VSD and left ventricular outflow tract (LVOT) obstruction?

In a resource-limited country, diagnosis is often made late, including for simple shunt lesions, and families then panic and ask to go abroad for surgery. What do you recommend for these late presenters?

What is the average cost of ASD closure?

Many referring doctors see patients who need surgery but whose families cannot afford it, and who must be managed medically at home. Can these doctors rely on you for guidance on local management?

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In This Series: Correct Timing for Congenital Heart Surgery