Question 1

What is the place of surgery in children with tetralogy of Fallot?

Dr. Z S Meharwal · Accepted Answer

Tetralogy of Fallot is one of the commonest procedures in paediatric cardiac surgery, alongside ASD and VSD repair. It is a very commonly performed procedure with excellent outcomes — any paediatric cardiac centre does this routinely, and the clinical outcomes are excellent.

Question 2

What is the most common dilemma doctors practising in resource-constrained environments like Africa face: how do they decide whether a case should be handled locally or referred across the border for specialist intervention?

Dr. Z S Meharwal · Accepted Answer

The patient should be referred for further evaluation at the appropriate time — not too early, but also not too late, because if it is too late the patient develops more comorbidities and the outcome may not be as good. For valve disease specifically, there are definite guidelines for mitral and aortic valve disease on when a patient should be referred for cardiac surgery; whether it can be done locally depends on whether it looks like a straightforward repair or replacement, or a more challenging one. The two important criteria are the patient's clinical symptoms — which functional class (1, 2, 3, or 4) — and the echo findings, which show the severity of stenosis or regurgitation, LV function, and pulmonary artery pressures. Together these decide whether the patient should be referred for surgical treatment, locally or elsewhere.

Question 3

What is the financial implication of these surgeries, whether mechanical or tissue-based valve replacement?

Dr. Z S Meharwal · Accepted Answer

Cost primarily depends on two things: which valve is used — mechanical valves are significantly less expensive than tissue valves, and among tissue valves, third-generation valves cost more than second-generation ones — and the patient's clinical course, since a straightforward surgery without a long hospital stay or comorbidities costs less. The average cost generally starts from $9,000 and goes up to $15,000–$16,000.

Question 4

For a child born with a non-obstructing mass over the apical side of the heart, around 1.4 cm by 1 cm, with no sign of heart failure — the baby is now 3 months old, echo is otherwise normal except for the mass, which is likely a rhabdomyoma on differential, and has shown some decrease in size (from 1.4x1 cm to 1.2x0 cm over a month) — should we consider surgical management, or when should surgical management be considered?

Dr. Z S Meharwal · Accepted Answer

Cardiac tumours in children are well known, though this exact pathology is not very common. The echo gives us an idea, but I would suggest also doing an MRI and a CT to further delineate it. I would like the details of this patient sent to our institute so we can forward it to our paediatric cardiac surgeon, since paediatric cardiac surgery is a separate subspecialty from the adult cardiac surgery I practise, and we do have a dedicated paediatric cardiac surgical team. This child needs very close follow-up and further investigation.

Question 5

For a tetralogy of Fallot patient where surgery was not done at an early age and the patient is now around 6 years old, what is the survival rate if surgery is not done, and what is the success rate of surgery done now?

Dr. Z S Meharwal · Accepted Answer

Tetralogy of Fallot is one of the commonest surgical procedures, and the outcome depends on the exact anatomy delineated by a proper paediatric echo, but six years is not a very late stage — in India a lot of patients are operated on at this age or even older. The outcome of tetralogy repair even at 6 years is excellent, so this patient certainly needs surgical correction.

Question 6

An adult patient with myocardial bridging is on a beta blocker — should surgery be done, and if surgery is not done, what are the possible negative complications?

Dr. Z S Meharwal · Accepted Answer

Myocardial bridging is not uncommon and is often seen on angiography. If it is asymptomatic, nothing needs to be done. If it is symptomatic, we normally do a stress thallium test — if positive, we recommend surgery; if negative, which is most of the time, only medical treatment is needed. If it is only myocardial bridging with no stenosis involved in other arteries (the circumflex or right coronary artery are normal), nothing needs to be done, but if the stress test is positive, surgery is recommended.

Advances in Cardiac Surgeries

Questions Doctors Asked Dr. Z S Meharwal

What is the place of surgery in children with tetralogy of Fallot?

What is the most common dilemma doctors practising in resource-constrained environments like Africa face: how do they decide whether a case should be handled locally or referred across the border for specialist intervention?

What is the financial implication of these surgeries, whether mechanical or tissue-based valve replacement?

For a tetralogy of Fallot patient where surgery was not done at an early age and the patient is now around 6 years old, what is the survival rate if surgery is not done, and what is the success rate of surgery done now?

An adult patient with myocardial bridging is on a beta blocker — should surgery be done, and if surgery is not done, what are the possible negative complications?

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