Surgical strategy to prevent cardiac injury during reoperation in infants

<p>Abstract</p> <p>Introduction</p> <p>Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations. Since few technical options are available for re-entry cardiac injuries in small infants, we postulate that this technique may be equally helpful in those situations.</p> <p>Case Presentation</p> <p>We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1). In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion. Right atrial cannulation was obtained by dividing the anterior aspect of the diaphragm at the level of the xiphisternum, gaining easy access to the right atrial-inferior vena cava junction, without separating the sternal edges.</p> <p>Discussion and Evaluation</p> <p>All four infants successfully underwent their operations using SAC. In one case (2^ndstage palliation for hypoplastic left heart syndrome) a cardiac injury occurred upon sternal reentry, but utilizing SAC, this was repaired without consequence.</p> <p>Conclusion</p> <p>Simplified aortic cannulation and direct right atrial cannulation may be obtained without dividing the sternum in complex reoperative infant surgeries, without making additional incisions. This may be life-saving in reoperative cardiac injuries in small infants.</p

Effect of transannular patching on outcome after repair of tetralogy of Fallot.

Among 814 patients undergoing repair of tetralogy of Fallot with pulmonary stenosis between 1967 and May 1986, transannular patching in the current era was a weak risk factor for death early postoperatively (predicted 30-day mortality, 4\% with a transannular patch and 1.4\% without) and is not a risk factor for instantaneous risk of death late postoperatively (predicted 20-year survival including early death, 94\% with a transannular patch and 96.5\% without). Ninety-six percent of surviving patients were in New York Heart Association functional class I at last follow-up, and the slight decline in this percentage as the interval between operation and last follow-up lengthened could have been due to chance alone (p = 0.24) and was no different in patients with a transannular patch. Transannular patching was a risk factor for reoperation for pulmonary regurgitation late postoperatively, but only a 7\% incidence within 20 years is predicted when mild residual stenoses are beyond the patch: the incidence rises to about 20\% with important distal stenoses. Inferences from the study are relevant to the indications for transannular patching and insertion of allograft semilunar valves at the time of repair

Intermediate septal accessory pathways: Electrocardiographic characteristics, electrophysiologic observations and their surgical implications

AbstractIntermediate septal accessory pathways are located in close proximity to the atrioventricular (AV) node and His bundle, have unique features that distinguish them from typical anterior and posterior accessory pathways and have been associated with a high risk for unsuccessful pathway division and the production of complete AV block after surgery. Between July 1986 and May 1990, 4 of 70 patients (3 men and 1 woman; mean age 33 ± 13 years) undergoing surgery for accessory pathway division were found to have an intermediate septal accessory pathway. The presenting arrhythmia was atrial fibrillation with rapid anterograde conduction over the accessory pathway in two patients and recurrent orthodromic reciprocating tachycardia in two patients.In all patients, the delta wave on the electrocardiogram (ECG) was inversed in lead V1, but two patterns of delta wave configuration were observed. In three patients (type 1 intermediate septal accessory pathway), the delta wave was upright in lead II, inverted in lead III and isoelectric in lead aVF; the transition from a negative to an upright delta wave occurred in lead V2. The fourth patient exhibited a different delta wave pattern (type 2 intermediate septal accessory pathway). The delta wave was upright in each of leads II, III and aVF; the transition from a negative to an upright delta wave occurred at lead V3.Intraoperative electrophysiologic study localized the atrial insertion of type 1 pathways to the midpoint of Koch's triangle close to the AV node. In the one patient with a type 1 pathway in which both anterograde and retrograde accessory pathway conduction was present, preoperative catheter mapping demonstrated that earliest retrograde atrial activation occurred near the foramen ovale. Intraoperative mapping during anterograde conduction over the type 1 pathway demonstrated earliest epicardial ventricular activation to occur simultaneously at the crux and the base of the aorta. The atrial insertion of the type 2 intermediate septal accessory pathway was localized to the apex of Koch's triangle in close proximity to the bundle of His. Preoperative catheter mapping revealed that earliest retrograde atrial activation occurred on the His bundle electrogram. Intraoperative mapping during anterograde conduction over the type 2 pathway demonstrated that earliest epicardial ventricular activation occurred anteriorly at the base of the aorta.Intraoperative ablation of the intermediate septal accessory pathway was accomplished by cooling the endocardium at the site of pathway insertion on the atrial side of the tricuspid anulus with a 5 mm cryoprobe. Patients with a type 1 intermediate septal accessory pathway had preservation of AV conduction, but the patient with the type 2 pathway did not and required permanent pacing. At late follow-up study, no patient has had return of intermediate septal accessory pathway conduction. Distinguishing an intermediate septal accessory pathway close to the AV node (type 1) from one close to the His bundle (type 2) is useful to predict both surgical success and success without the production of permanent complete AV block

Homogeneous Modes of Cosmological Instantons

We discuss the O(4) invariant perturbation modes of cosmological instantons. These modes are spatially homogeneous in Lorentzian spacetime and thus not relevant to density perturbations. But their properties are important in establishing the meaning of the Euclidean path integral. If negative modes are present, the Euclidean path integral is not well defined, but may nevertheless be useful in an approximate description of the decay of an unstable state. When gravitational dynamics is included, counting negative modes requires a careful treatment of the conformal factor problem. We demonstrate that for an appropriate choice of coordinate on phase space, the second order Euclidean action is bounded below for normalized perturbations and has a finite number of negative modes. We prove that there is a negative mode for many gravitational instantons of the Hawking-Moss or Coleman-De Luccia type, and discuss the associated spectral flow. We also investigate Hawking-Turok constrained instantons, which occur in a generic inflationary model. Implementing the regularization and constraint proposed by Kirklin, Turok and Wiseman, we find that those instantons leading to substantial inflation do not possess negative modes. Using an alternate regularization and constraint motivated by reduction from five dimensions, we find a negative mode is present. These investigations shed new light on the suitability of Euclidean quantum gravity as a potential description of our universe.Comment: 16 pages, compressed and RevTex file, including one postscript figure fil

Student feedback on the use of paintings in Sparshanam, the Medical Humanities module at KIST Medical College, Nepal

<p>Abstract</p> <p>Background</p> <p>Paintings have been used in Medical Humanities modules in Nepal at Manipal College of Medical Sciences and KIST Medical College. Detailed participant feedback about the paintings used, the activities carried out, problems with using paintings and the role of paintings in future modules has not been previously done. Hence the present study was carried out.</p> <p>Methods</p> <p>The present module for first year medical students was conducted from February to August 2010 at KIST Medical College, Nepal. Paintings used were by Western artists and obtained from the Literature, Arts and Medicine database. The activities undertaken by the students include answering the questions 'What do you see' and 'What do you feel' about the painting, creating a story of 100 words about the scene depicted, and interpreting the painting using role plays and poems/songs. Feedback was not obtained about the last two activities. In August 2010 we obtained detailed feedback about the paintings used.</p> <p>Results</p> <p>Seventy-eight of the 100 students (78%) participated. Thirty-four students (43.6%) were male. The most common overall comments about the use of paintings were "they helped me feel what I saw" (12 respondents), "enjoyed the sessions" (12 respondents), "some paintings were hard to interpret" (10 respondents) and "were in tune with module objectives" (10 respondents). Forty-eight (61.5%) felt the use of western paintings was appropriate. Suggestions to make annotations about paintings more useful were to make them shorter and more precise, simplify the language and properly introduce the artist. Forty-one students (52.6%) had difficulty with the exercise 'what do you feel'. Seventy-four students (94.9%) wanted paintings from Nepal to be included.</p> <p>Conclusions</p> <p>Participant response was positive and they were satisfied with use of paintings in the module. Use of more paintings from Nepal and South Asia can be considered. Further studies may be required to understand whether use of paintings succeeded in fulfilling module objectives.</p

Why Does Inflation Start at the Top of the Hill?

We show why the universe started in an unstable de Sitter state. The quantum origin of our universe implies one must take a `top down' approach to the problem of initial conditions in cosmology, in which the histories that contribute to the path integral, depend on the observable being measured. Using the no boundary proposal to specify the class of histories, we study the quantum cosmological origin of an inflationary universe in theories like trace anomaly driven inflation in which the effective potential has a local maximum. We find that an expanding universe is most likely to emerge in an unstable de Sitter state, by semiclassical tunneling via a Hawking-Moss instanton. Since the top down view is forced upon us by the quantum nature of the universe, we argue that the approach developed here should still apply when the framework of quantum cosmology will be based on M-Theory.Comment: 21 pages, 1 figur

From Big Crunch to Big Bang

We consider conditions under which a universe contracting towards a big crunch can make a transition to an expanding big bang universe. A promising example is 11-dimensional M-theory in which the eleventh dimension collapses, bounces, and re-expands. At the bounce, the model can reduce to a weakly coupled heterotic string theory and, we conjecture, it may be possible to follow the transition from contraction to expansion. The possibility opens the door to new classes of cosmological models. For example, we discuss how it suggests a major simplification and modification of the recently proposed ekpyrotic scenario.Comment: 16 pages, compressed and RevTex file, including three postscript figure files. Minor changes, version to appear in Physical Review

Closed Universes from Cosmological Instantons

Current observational data is consistent with the universe being slightly closed. We investigate families of singular and non-singular closed instantons that could describe the beginning of a closed inflationary universe. We calculate the scalar and tensor perturbations that would be generated from singular instantons and compute the corresponding CMB power spectrum in a universe with cosmological parameters like our own. We investigate spatially homogeneous modes of the instantons, finding unstable modes which render the instantons sub-dominant contributions in the path integral. We show that a suitable condition may be imposed on singular closed instantons, constraining their instabilities. With this constraint these instantons can provide a suitable model of the early universe, and predict CMB power spectra in close agreement with the predictions of slow-roll inflation.Comment: 12 pages, 6 figure

Exsolution trends and co-segregation aspects of self-grown catalyst nanoparticles in perovskites

In perovskites, exsolution of transition metals has been proposed as a smart catalyst design for energy applications. Although there exist transition metals with superior catalytic activity, they are limited by their ability to exsolve under a reducing environment. When a doping element is present in the perovskite, it is often observed that the surface segregation of the doping element is changed by oxygen vacancies. However, the mechanism of co-segregation of doping element with oxygen vacancies is still an open question. Here we report trends in the exsolution of transition metal (Mn, Co, Ni and Fe) on the PrBaMn2O5+?? layered perovskite oxide related to the co-segregation energy. Transmission electron microscopic observations show that easily reducible cations (Mn, Co and Ni) are exsolved from the perovskite depending on the transition metal-perovskite reducibility. In addition, using density functional calculations we reveal that co-segregation of B-site dopant and oxygen vacancies plays a central role in the exsolution