Is this child with Eisenmenger operable or not ?
The answer to this question is debated for many decades . The old school of thought was grown with meticulous cath study (Pioneered by Paul wood and his team ) .Calculating PVR is academically fascinating . With so many variables, assumptions and too much dynamism in a circulatory system , It has never been proven as a gold standard .
The presence of following factors points to possible advantage for shunt closure .
- Pink Eisenengers ( Complete lack of clinical cyanosis )
- Clinically mild cyanosis but Oxygen saturation nearing 92 % (We have seen an occasional patient with 98 % )
- If Echo shows a dilated left atrium and left ventricle (VSD,PDA) it indicates a significant L-R shunt.
- Lack of septal bulge towards LV (This Indicates RV has still some useful life in it ! )
- Pulmonary flow velocity > 1.5m/sec indicates fairly good flow across RVOT (Qp/Qs calculation is almost impossible in bi-drectional shunt )
- Pulmonary artery diastolic pressure < 3o mmhg
- Pulmonary artery pulse pressure > 50mmhg
*Oxygen, Tolazoline test in cath lab has limited value.
**Temporary balloon occlusion and watching for reversibility is not useful (As fall in PAP and PVR is a long term affairs )
Scientific cardiologists may feel awkward to read this message .
- With mortality for shunt closure in Eisenmenger reaches nearly 50 % , it is essentially a 50-50 guess game !
- We often depend on our collective clinical acumen (Also called as Gut feeling . . .”I some how feel this child will do well ! “
- Most importantly surgeon’s experience and expertise would finally prevail over cardiologist !