Cath: Contrast agents

Ionic, high osmolality: Hypaque (6-8x plasma osmolality)

Non-ionic, low osmolality: Omnique (2-3x plasma osmolality)

Cath: Ballon pulmonary angioplasty

Indications for intervention:
1) At least 50% stenosis by diameter
2) Lung perfusion scan showing more than 20% discrepancy between the two sides (Don't forget regional differences within the same lung)
3) RVSP >50% (or 70% by others)
4) Significant pulmonary regurgitation with moderate distal PA stenosis (Asso. RV enlargement)

Arbitrary definition of successful Balloon PA angioplasty:
1) More than 50% increase in diameter
2) 20% drop in RVSP


Anatomy: Terminology: Van Praagh's segmental formula

Original description: Van Praagh R. The segmental approach to diagnosis in congenital heart disease. Birth Defects;1972:8:4.
Then, Van Praagh R. Editorial. Terminonlogy of congenital heart disease. Glossary and Commentary. Circulation 1977;56:139-143
Later modified in 1985...

Later compromises...


Echo: Mitral Inflow Doppler

(Extract from JASE 2010;23:465-495)
1. Normal MV inflow Doppler:
2. Isovolumic Relaxation Time
(Duration between closure of AoV and Opening of MV)
Measured from CW Doppler trace that has both LVOT and MV flows.
3. Deceleration time
Deceleration time for E wave.
(Measured from PW Doppler of Mitral inflow) 4. Comparison of Ar duration (in PV Doppler) with A wave duration (in MV inflow Doppler):

Echo: Normal Pulmonary (&Systemic) Vein Doppler pattern

Normal Doppler Pattern in Pulmonary (& Systemic) Vein:
(Extract from JASE 2010;23:465-95; Pulmonary Vein PW Doppler)

Provides evaluation of Ventricular Diastolic Function and AV valve Function.
S wave: (Antergrade flow during Ventricular Systole)
Antegrade flow occurs because of both Atrial relaxation and Apical movement of AVV;
Biphasic if there is temporal dissociation of atrial relaxation and apical movement of AVV.
Abnormal retrograde flow occurs with AVV regurgitation & Atrial contraction against closed AVV.

D wave: (Antegrade flow during Ventricular Diastole)
Antegrade flow occurs because of Atrial and Ventricular filling & AVV patency.
Fast HR - leads to fusion of S and D peaks.
Ar wave: (Retrograde flow during Atrial systole)
Augmented when ventricular compliance is poor.
Ar wave duration exceeds MV inflow duration when LAP & LVEDP are elevated.
Respiratory variation:
During inspiration - D wave velocity increases. Ar wave velocity decreases.
So, measurements should be made over 3 consecutive cycles.


Atul Gawande: Professionalism

From "The Checklist Manifesto"

All learned occupations have a definition of professionalism, a code of conduct...But, they all have at least 3 common elements...
First, is an expectation of selflessness.
Second, is an expectation of skill.
Third, is an expectation of trustworthiness.
Aviators, however, add a fourth expectation, discipline; disciplinein following prudent procedure and in functioning with others...
In medicine, we hold up "autonomy" as a professional lodestar, a principle that stands in direct opposition to discipline...it rings more of protectionism than of excellence. The closest our profession comes to...is an occasional plea for "collegiality".
Discipline is hard, harder than trustworthiness and skill and perhaps even than selflessness. We are built on novelty and excitement,...Discipline is something we have to work at.


Cath - "Sleeping Bat View" to image distal end of Sano Shunt & Proximal branch PAs

From a poster presented at Cardiology 2010 (Orlando) by Shyam Sathanandam et al. Advocate Hope Children's Hospital, Chicago.
"Sleeping bat view" (35 degree caudal angulation in PA camera)

Hand injection 4 ml via Balloon wedge catheter

RAO 30 with caudal 35:

LAO 60 with caudal 35:

ICU strip

POD#1 (1 week old baby s/p Arterial Switch Operation for d-TGA):

(3 traces in the panel are EKG, Arterial line and Respiratory pleth)

Got a break next day...

Successfully, DC cardioverted to sinus rhythm.

EKG: EKGs in SVT and Sinus Rhythm

Where is the accessory pathway located?