Surgery - Cath: Rapid development of Veno-Venous Collateral after Glenn Operation

Dilawar, M. et al. Circulation 2001;104:e41-e42

Panel a: Preop. Angiogram

Panel b: 17th postop. day after Glenn operation
(Discharged home on Postop day 8 with 82% saturation in room air. Readmitted on postop. day 17 with 60% saturation)

Panel c: Closed using Amplatzer PDA device.


Cath: Magnification factor and Calibration

From Ing, F. Stenting branch pulmonary arteries p.100 in Complications during percutaneous interventions for congenital and structural heart disease. Ed. Hijazi, Z. et al. Informa health care, London, UK. 2008)


Cath: Caudo-cranial vs. Cranio-caudal projection

There is really no need for such terms as "caudo-cranial" and "cranio-caudal". But, these terms appears in textbooks (esp. the old ones). So, we need to cope with them. Here is an explanation...from one of the books. Does not necessarily mean that this is what is meant in a different text book!!!

From p.286 The Cardiac Catheterization Handbook. 3rd Ed. Edited by Morton J. Kern. Mosby, St Louis 1999)

Cath: Coronary Angiographic Views

Coronary angiographic views
Left coronary artery:

LMCA - PA or RAO 5-10°

LAD/LCX bifurcation - LAO 30-35°/Cr 20-30°

LCX & Marginals - RAO 30-40°/Caudal 20-30°

LAD & Diagnonals - RAO 5-30°/Cranial 20-45°

LAD/LCX bifurcation,
LCX & Marginals - LAO 50-60°/Caudal 10-20° (Spider view)

Bypass to LAD - Lateral (Optional)

Right coronary artery:

Prox, Mid, PDA - LAO 30-45°/Cr 15-20°

Prox, Mid, PDA - RAO 30-45°

Optional - Lateral

(From p. 288. The Cardiac Catheterization Handbook. 3rd edition. Ed. Morton J. Kern. Mosby, St Louis 1999).


CXR: Dextroposition & Dextrocardia/Situs inversus

CXRs from 4 different patients with 4 different combinations:

CXR: Pneumomediastinum

Hemodynamically stable, premie (920g). 24 hrs old. Transferred from outside hospital. This is the first CXR at this institution. How would you treat this?



EKG: Reading EKGs

An useful form to practice EKG reading. Click here to download.


Echo: Normal Echo Values Table

Small and Old data. But, useful in a hurry.
(Note: Don't know the source. We used this at Tufts. Advantage - fits in your pocket!)


Fredrickson Classification of Dyslipidemia (Circ 1965)

Loosely based on Fredrickson DS, Lees RS. Editorial: A system of phenotyping hyperlipoproteinemia. Circulation 1965;31:321-27.


EKG: Interpret this

6 month old baby s/p Arterial Switch Operation for d-TGA. He has residual moderate supravalvar PS and mild supravalvar AS. Comment about the EKG with specific reference to QRS and T waves lead V1.

(To view the clearest image of this EKG, double-click on the image. Alternatively, single-click will bring up a larger, but unclear image. Single-click again will bring the clearest image.)


Surgery: Multiple VSDs with TGA - Internal RV "band"

The Annals of Thoracic Surgery
Volume 91, Issue 1, January 2011, Pages 289-291

Case reportInternal Right Ventricular Band for Multiple Ventricular Septal Defects in a Neonate Undergoing Arterial Switch and Aortic Arch Repair
William W. Carroll, Girish S. Shirali and Scott M. Bradley

A neonate presented with d-transposition of the great arteries, aortic arch hypoplasia, aortic coarctation, and multiple ventricular septal defects. During the arterial switch procedure and the aortic arch repair, a fenestrated Gore-Tex disk (W.L. Gore & Assoc, Flagstaff, AZ) was sewn into the right ventricular outflow tract to restrict pulmonary blood flow. The internal right ventricular band successfully controlled the pulmonary blood flow, maintaining a systemic oxygen saturation of 88% to 92%, and allowing growth from 3.5 to 10.5 kg. At 8 months of age, the internal band in the patient was removed, and the ventricular septal defects were successfully closed.k


Cath: Angiogram of AVSD, Inlet VSD

Images from Radiology of Congenital Heart Disease by Kurt Amplatz & James H. Moller. Mosby Year Book, St. Louis, MO. 1993.
Appearance & Location of inlet VSD in LAO view angiogram.
Notice the distance from aortic valve to crest of ventricular septum (black arrow)

CXR: Obstructed Supracardiac TAPVR

"Snow storm in a cage"

History: The Azygos Factor

British Journal of Surgery 1953;40(164):616-21.
A.T.Andreasen & F.Watson

This paper and the one before this paper, from the same group showed that the dogs survived when both SVC and IVC were clamped with only azygos flow allowed to go into right atrium. After the experiment, all surviving dogs behaved "normally".

Later, Lillehei's group in Minnesota showed that the amount of flow via Azygos vein was 10% of the venous return. This formed the basis for cross-circulation surgeries performed using another human being as the cardiopulmonary support - prior to availability of cardio-pulmonary bypass machine.

Donor is cannulated in the groin. The blood from the donor goes through a pump that is set to pump a calculated volume (equivalent to the azygos factor) to the recipient. Open heart surgery was performed with this set up in 1953-54.


Enoxaparin (Lovenox) - Subcutaneous injection

From Lexi-Comp:

Neonates (<>
Prophylactic use: 0.75 mg/kg q12hrs
Therapeutic use: 1.5 mg/kg q12hrs

Infants (> 2 mo):
Prophylactic use: 0.5 mg/kg q12hrs
Therapeutic use: 1 mg/kg q12hrs

Then, check Antifactor Xa level and adjust to set maintenance dose:
< 0.35 U/ml → Increase by 20% - Check dose 4 hr after next dose
0.35-0.49 U/ml → Increase by 10% - Check dose 4 hr after next dose
0.5 - 1.0 U/ml → No change - Check level next day, 1 week later and monthly
1.1 - 1.5 U/ml → Decrease by 20% - Check level before next dose
1.6 - 2.0 U/ml → Hold dose for 3 hrs and Decrease by 30% - Check level before next dose and 4 hr after
? 2.0 U/ml → Hold doses until level is 0.5 U/ml, Resume with decreased dose by 40% - Check every 12 hrs until level < 0.5 U/ml. Then, before next dose.

CXR: Figure of 3

Courtesy Dr. Thapar.
Child with Coarctation of aorta.

CXR: Newborn, Egg on side

Courtesy Dr. Thapar.
Baby with d-transposition of great arteries.


Anticoagulation: Warfarin

From Lexi-Comp
To maintain INR 2-3:
Day 1: 0.2 mg/kg/day (0.1 mg/kg/day if liver dysfunction is present)
Day 2-4: Depends on daily INR
1.1 - 1.3 → Repeat same dose
1.4 - 3.0 → 50% of loading dose
3.1 - 3.5 → 25% of loading dose
> 3.5 → Hold until INR < 3.5. Then, start 50% of loading dose.

Maintenance (Day 5 & beyond): Depends on INR
1.1 -1.4 → Increase 20%
1.5 - 1.9 → Increase 10%
2-3 → No change
3.1 - 3.5 → Decrease 10%
> 3.5 → Hold until INR < 3.5. Then, start 20% lower than prior dose


ICU: Cardiopulmonary interaction, s/p Glenn operation

JTCVS 2003;126:1033-39
Scott Bradley et al.
Hypoventilation strategy to improve oxygenation after Glenn operation:
Protocol in Table 1, Response in other figures: