VSD enlargement (Surgery)

To enlarge the VSD without causing AV block...

D-loop ventricles - Raise the roof (Enlarge VSD in anterior-superior direction)

L-loop ventricles - Lower the floor (Enlarge VSD in posterior-inferior direction)

Without injuring the aortic valve in the process!

ICU: Postoperative AV block - Recovery

Study period: 1991-4. Boston Children's Hospital. n=2698 surgeries (73% on bypass).

Overall incidence of AV block was 3% (n=54).

Common diagnoses associated with development of AV block were VSD, Tetralogy, LVOTO repair, L-TGA and others. 

32 recovered conduction in 30 days after surgery (Graph below shows the postop. day at which conduction recovered in these 32 patients). 

9 did not recover conduction in 30 days after surgery. 

Weindling SN., et al. Duration of complete atrioventricular block after congenital heart surgery. Am J Cardiol 1998;82:525-527.

ICU: Arterial Line Artifact - "Standing Wave"

Pardon the poor quality images.

Newborn, s/p Norwood procedure.

Upper panel shows arterial pressure traces from 2 different lines - Right radial arterial (Red) and Umbilical arterial lines (White). There is a "standing wave" or "fling" in the red trace. This is secondary to being a small/distal vessel, smaller catheter, and state of peripheral vascular tone (vasoconstricted state).

Lower panel shows the same patient, approx. 30 min after the loading dose of Milrinone. Presumably, there is adequate vasodilation of the peripheral artery that the "standing wave" or "fling" is no longer evident or not as prominent as before!

(Click on the images to enlarge)

Echo artifacts

Five types of artifacts:
1) Mirror image artifact (Created by residual waves continuing to travel beyond the object of interest. Then, gets reflected back from interfaces beyond. These waves are once again reflected by the object giving rise to the second image.

 2) Reverberation artifact

 3) Side lobe artifact  (Produced by radial vibration of piezo electric crystals, instead of the longitudinal vibrations of the main beam)

4) Grating lobes artifact (no image) occurs in array transducers (?)

5) Acoustic shadowing (occurs due to highly reflective interface such as calcification).

(All images are from  TEE for congenital heart disease by Wong PC, Miller-Hance WC. Springer Verlog London. 2014.)

ICU - Antibiotics

Aortic arch anomalies - Vascular ring (Developmental basis)

Images are from Freedom's CHD Textbook of Angiography Vol. II (1997) p.948.

Based on Edwards Hypothetical Double Arch.

Numbers in lower diagram indicate possible sites of regression. Vascular anomalies occur according to the site of regression.

Normal left arch - 1, 7 regress.

Right arch with mirror-image branching - 2,8 regress.

Left arch with aberrant RSCA - 1, 3 regress.

Right arch with aberrant LSCA - 2,6 regresss.

Figure out other vascular anomalies...similarly:

   Double arch - both arches patent

   Double arch with atresia of a segement of left arch

   Double arch with atresia of a segement of right arch

   Left arch with right descending aorta

   Left arch with isolation of RSCA

   Right arch with left ductus (retroesophageal)

   Right arch with isolation of LSCA

   Right arch with aberrant left innominate artery

   Right arch with isolation of left innominate artery

Anti-Arrhythmic Sickness Video (+playlist)

Coarctation Prediction: Carotid-Subclavian Artery Index

Images are from Eur J Cardiothorac Surg 2008;34:1051-6.
CSA index was proposed in Dodge-Khatami et al. Ann Thorac Surg 2005;80:1852-7.
CSA index = Diameter of distal transverse aorta/Length of distal transverse aorta.

TPA (Alteplase) for Femoral Pulse Loss after Cardiac Catheterization

Am J Cardiol 2003;91:908-910

Alteplase:
Bolus 0.1 mg/kg over 5-10 min, followed by 0.5 mg/kg/hr x 2 hrs.
Resume Heparin at 17 Units/kg/hr for at least 4 hrs after Alteplase infusion completes.
(Heparin infusion may be continued without interruption during Alteplase infusion).

If there is no improvement at about 4-6 hrs from first dose of Alteplase, repeat dose may be given. Important to give heparin infusion for at least 4-6 hrs after completion of any dose of Alteplase. (To deal with increased thrombotic tendency after Alteplase therapy.

Normal Values for Term, Newborn

Click on the image to enlarge