Trusler Rules for Pulmonary Artery Banding

Banding material: 4-mm wide band of Teflon with silicone rubber coating.

General rules: For infants < 1 year of age -

(i) Left to right shunting, no other intracardiac mixing disorders: Can have relatively tight band. Therefore, band circumference = 20 mm + 1 mm/kg body weight.
(Hopefully, the Qp/Qs will be close to 1:1)

(ii) If there is ASD or MPA diameter is large, band can be slightly looser.
Therefore, add 1 or 2 mm to the band circumference.
(Reasons: Presence of large ASD will cause too much cyanosis which will not be tolerated. When MPA is large, band causes folds of arterial wall which will decrease the lumen size and therefore, will be equivalent to a tighter band).

(iii) Bidirectional shunting is present, TGA, etc. - Looser band is needed.
Therefore, band circumference = 24 + 1 mm/kg of body weight.
(In these circumstances, pulmonary blood flow needs to be close to Qp/Qs of 2:1 than 1:1).

(iv) In the presence of pulmonary hypertension, PA band is usually looser than above. The PA band is tightened until distal PA pressure is 50% of systemic pressure. (This was performed in 17 of 209 patients. These 17 patients were excluded from the study).

Intraoperative adjustments to the PA band size: The band should be loosened if (i) distal PA collpases, (ii) cyanosis or (iii) bradycardia occurs.

PA band should be more distal in babies who will undergo arterial switch operation later.

Pulmonary Artery Banding. Albus RA, Trusler GA, Izukawa T and Williams WG. JTCVS 1984;88:645-653.

Preparing the band material - Letter to the editor. JTCVS 1984;88:792.

Trusler GA, Mustard WT. A method of banding the pulmonary artery for large isolated ventricular septal defect with and without TGA. Ann Thoracic Surg 1972;13:351-55.

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Development: Heart Tube & Looping

Images are from
An Introduction to Human Embryology for Medical Students by Inderbir Singh (5th ed).
MacMillan India Limited, Madras 1995.

(This 3rd figure is intentionally rotated to show in the same orientation as rest of the figures)


Statins classification by potency

(Click on the image to enlarge)
From JACC 2014;63:2889-934.

Atorvastatin - Lipitor
Rosuvastatin - Crestor
Simvastatin - Zocor
Pravastatin - Pravachol
Lovastatin - Mevacor
Fluvastatin - Lescol
Pitavastatin - Livalo


Reversal agent for Dabigatran (Pradaxa)

The US Food and Drug Administration (FDA) has granted accelerated approval to Praxbind (idarucizumab, Boehringer Ingelheim) to rapidly reverse the blood-thinning effects of the anticoagulant Pradaxa (dabigatran, Boehringer Ingelheim).

Link to Medscape news


Marfan Syndrome: Z-Score calculator

Link to Z-score calculator for Marfan syndrome: http://www.marfan.org/dx/zscore

(per Colan SD et al. J Am Coll Cardiol 2006;47:1858–65 - Using Systolic frame, Inner edge to Inner edge measurement of Aortic Sinus of Valsalva).

Courtesy: Ashish


EKG - PR interval

(Click on the image to enlarge)


Tissue Doppler Imaging - Mitral Lateral Annulus TDI

From Tighe DA, et al. Cardiac Ultrasound Today 2005;11(5):89-116.
(Click on the images to enlarge)

Normal TDI of Lateral Mitral Annulus
(S', E', A' velocities are measured in cm/sec)

Age-related change in Lateral Mitral Annulus TDI
(24 yr old on the left; 82 yr old on the right)

Lateral Mitral Annulus TDI
(Impaired Relaxation: E' velocity is lower than A' velocity)

Lateral Mitral Annulus TDI
(Restrictive Pattern: Both E' & A' velocities are reduced, E' velocity is higher than A' velocity though)

Diastolic Function by Doppler - Mitral Inflow, Pulmonary vein flow (Normals)

Mitral Inflow Doppler (Normal)
DT - DecelerationTime of E wave
Adur - A wave Duration

Pulmonary vein flow Doppler pattern
(S, D and Atrial reversal)

(From Tighe DA, et al. Cardiac Ultrasound Today 2005;11(5):89-116)

Diastolic Function: Echo parameters

Assessment of Diastolic Function using Echo Parameters
Tables from Wyman Lai's Pediatric Echocardiography Textbook (2009)
(Click on the image to enlarge)

Table 8.2: Inflow Doppler Values (Infants & Children)
Adapted from Eidem BW, et al. JASE 2004;17:212-21.

Table 8.3: Annular Doppler Tissue Imaging Values (Infants & Children)

Table 35.3: Echo parameters of diastolic function (Adult)
(Tam JW. et al. Curr Opin Cardiol 2002;17:470-7)

Table 35.4: Echo parameters for diastolic function (Child & Adult)
(Garcia MJ, et al. JACC 1998;32(4):866-75)

(Courtesy: Ashish)


PA-VSD Decision Tree

From Lofland GK. Progress in Pediatric Cardiology 2009;26:65-70
(Click on the image to enlarge)


Accessory Hemiazygos Vein

Accessory Hemiazygos Vein

Subclavian Steal - Mechansim

Arteries that form the basis for Subclavian Steal Syndrome


Oxygen Consumption (Lundell et al. Table)

Adapted from Lundell et al. Pediatr Cardiol 1996;17:207-13.

(Click on image to enlarge)


Diabolo Stent

Diabolo stent placement technique (Fontan Fenestration)
O.Stumper et al. Heart 2003;89:1227-30.

Technique: 3-4 mm diameter loop is created using temporary epicardial pacing wires as follows: The needle ends are removed. 5 cm of the wire tips are bared of its insulation. The 2 bare wire ends are tied in a loop. This provides ~90 cm long wire. A secure double-knot over a 10-14 French dilator.
The loop is paced over a 15-25 mm Valvuloplasty balloon (?low pressure). J&J P308 or P188/JoMed 17 mm stents are options. The stent is gently dilated using 10-14 French dilator and then, mounted on the balloon - keeping the knotted-loop over the center of balloon.
Deliver using 11-14 Fr Mullin sheath.