Question 1

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

Dr. Z S Meharwal · Accepted Answer

Tetralogy of Fallot repair is one of the commonest procedures in paediatric cardiac surgery, alongside repair of atrial and ventricular septal defects. It is very commonly performed, and any paediatric cardiac centre does it routinely. 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 not too late, because a patient referred late has accumulated comorbidities and the outcome may not be as good. For valve disease, there are definite guidelines for mitral and aortic valve disease on when a patient should be referred for cardiac surgery. A straightforward valve repair or replacement can be done locally; a case that looks challenging should be referred. The two key criteria are the patient's clinical symptoms, meaning the functional class (I, II, III or IV), and the echo findings: the severity of mitral or aortic stenosis or regurgitation, LV function, pulmonary artery pressures, and the overall impact of the valve pathology on the heart and body. Together these decide when the patient should be referred for surgery, locally or to another facility.

Question 3

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

Dr. Z S Meharwal · Accepted Answer

The cost depends mainly on two things. The first is the valve used: mechanical valves are significantly less expensive than tissue valves, and among tissue valves the range is wide; third-generation valves cost more than second-generation ones, while first-generation valves are no longer used or available. The second is the patient's course: a straightforward operation without a long hospital stay or many comorbidities costs less, and if the hospital stay lengthens for any reason, the cost rises. The final cost is determined once the patient is assessed in person.

Question 4

A 3-month-old infant has a non-obstructing mass of about 1.4 cm by 1 cm on the apical side of the heart, with no signs of heart failure and an otherwise normal echo; rhabdomyoma is the likely differential. Over one month the mass has decreased to about 1.2 cm. Should surgery be considered, and if so, when?

Dr. Z S Meharwal · Accepted Answer

Rhabdomyoma is not a very common pathology, although cardiac tumours are well known. The echo gives an idea of what the lesion may be, and an MRI and a CT should be done as well. Paediatric cardiac surgery is a separate subspecialty from the adult cardiac surgery I practise, and our institute has a dedicated paediatric cardiac surgical team, so the child's details should be sent to us to forward to them. 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 repair is one of the commonest cardiac operations, and the outcome depends on the exact anatomy, which must be delineated by a proper paediatric echo. Six years is not a very late stage: in India many patients are operated on at this age or even older. The outcome of tetralogy repair at six years is excellent, so this patient certainly needs surgical correction.

Question 6

For most international patients, excluding outliers, how long is the mandatory stay in India for cardiac surgery?

Dr. Z S Meharwal · Accepted Answer

For an adult patient having routine surgery, the hospital stay is about a week, typically 7 to 8 days. Patients are advised to stay in Delhi for at least a week after discharge, and if they recover well they can fly one to two weeks after discharge; most fly about two weeks after discharge, so the typical stay in India is about three weeks, and some patients fly after one week. Follow-up can then continue remotely through video or audio consultations.

Question 7

How should doctors handle complex cases where the patient clearly cannot travel or afford treatment abroad, but local management could benefit from an experienced surgeon's guidance?

Dr. Z S Meharwal · Accepted Answer

If the patient cannot travel for whatever reason, the best course is to connect the treating doctor locally with the team at Fortis Escorts to discuss the best course of treatment for that patient, and whatever advice is possible will be given. If the patient clearly needs surgery, medical treatment helps only to an extent and is limited beyond that, but consultation, advice and discussion can all be done remotely.

Question 8

An adult patient with myocardial bridging is on a beta blocker. Should surgery be done, and if not, what complications could follow?

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, a stress thallium test is done: if it is positive, we recommend surgery; if negative, which is what is seen most of the time, medical treatment alone is sufficient. Bridging normally occurs in the left anterior descending artery; if there is no stenosis elsewhere and the circumflex and right coronary arteries are normal, nothing further is needed unless the stress test is positive.

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