Fetal heterotaxy with tricuspid atresia, pulmonary atresia, and isomerism of the right atrial appendages at 22 weeks.

We report the accurate prenatal diagnosis at 22 weeks gestation of right atrial isomerism in association with tricuspid atresia. Several distinctive sonographic features of isomerism of the right atrial appendages were present in this fetus: complex cardiac abnormality, ventriculoarterial discordance, juxtaposition of the aorta and the inferior vena cava to the right side, pulmonary atresia, and anomalous pulmonary venous return to the morphological right atrium. Tricuspid atresia, which is an extremely rare lesion within heterotaxy spectrum disorders, was present. Postnatal investigations confirmed all prenatally diagnosed abnormalities, with additional findings of pulmonary atresia with discontinuous pulmonary arteries and bilateral arterial ducts, asplenia, and bilateral eparterial bronchi. To our knowledge, tricuspid atresia in the setting of isomerism of the right atrial appendages has not previously been diagnosed or reported prenatally. Because of the complexity of cardiac lesions that may be present in cases of atrial isomerism, these disorders should be considered even if sonographic findings are uncommon or atypical

Echocardiographic techniques for assessing normal and abnormal fetal cardiac anatomy

Diagnostic quality images of the fetal heart in utero can be obtained as early as 18 to 20 weeks of gestation. The cardiac structures can be imaged primarily by cross-sectional echocardiography and augmented by a combination of simultaneous M-mode echocardiography and range-gated pulsed Doppler ultrasonography. Cross-sectional images from planes through the fetal heart equivalent to planes that can be obtained after birth can be generated in utero. In a study of 168 pregnancies, 10 structural cardiac abnormalities have been defined. These abnormalities and others that have been reported indicate the potential for in utero cardiac diagnosis. The recognition of structural congenital heart disease in utero has been helpful in genetic counseling, planning the method of labor and delivery and making decisions regarding termination of pregnancy and planning postnatal care. Fetal echocardiography offers the potential to change the pattern of health care delivery to those with suspected congenital heart disease

Regression of tricuspid regurgitation after two-stage arterial switch operation for failing systemic ventricle after atrial inversion operation

AbstractThe cases of five patients with previous Senning ( n = 4) or Mustard ( n = 1) operations and failing systemic ventricles in whom banding of the pulmonary artery was performed as an interim step toward an arterial switch procedure are reported. The rise in the ratio of left to right mean systolic ventricular pressure, from 0.35 before operation to 0.90 during operation and 0.80 on the first postoperative day, caused a shift of the ventricular septum from a leftward to a midline or nearly midline position. This shift was associated with a reduction of tricuspid regurgitation. At a median interval of 5.1 months after pulmonary artery banding, the mean left ventricular posterior wall thickness had increased to 8.2 mm, versus 5 mm before operation, and the mean left ventricular myocardial mass index had increased to 90 gm/m2, versus 55.6 gm/m2 before operation. After the arterial switch operation, which was performed in four patients, the tricuspid regurgitation decreased to a trivial amount ( n = 1) or disappeared completely ( n = 3). (J THORAC CARDIOVASC SURG 1996;111:342-7

Accessory and anomalous atrioventricular valvar tissue causing outflow tract obstruction Surgical implications of a heterogeneous and complex problem

AbstractObjectives. The purpose of this study was to determine the effect of accessory or anomalous atrioventricular valvar apparatus on relief of outflow tract obstruction.Background. Outflow tract obstruction due to accessory tissue or anomalous attachments of the atrioventricular valvar apparatus is an unusual but well-recognized problem. In addition to obstruction, anomalous attachments of the atrioventricular valvar apparatus may interfere with procedures to relieve outflow tract obstruction or perform outflow tract reconstruction.Methods. Since 1992, we have operated on 21 patients (median age 4 years) with systemic (n = 13), pulmonary (n = 5) or bilateral (n = 3) outflow tract obstruction due to accessory atrioventricular valvar tissue and/or anomalous attachments of the subvalvar apparatus. Primary diagnoses were isolated obstruction of the systemic outflow tract or aortic arch (n = 7), transposition complexes (n = 6), previously repaired atrioventricular septal defect (n = 3), functionally single ventricle (n = 3) and ventricular septal defect with pulmonary outflow obstruction (n = 2). Outflow tract gradients ranged from 20–110 mm Hg (median 58 mm Hg).Results. Complete relief of obstruction due to atrioventricular valvar anomalies was possible in 14 patients. In six patients, the planned procedure either had to be modified or only partial relief of the obstruction was achieved. In the remaining patient, who had borderline functionally single ventricle heart disease (unbalanced atrioventricular septal defect) and systemic outflow obstruction due to accessory and functional valvar apparatus, support was withdrawn because the parents refused univentricular palliation and the valvar anomalies precluded a Ross-Konno procedure. There were two early deaths. At follow-up ranging from 1 to 66 months (median 27 months), there was one death, and there has been no recurrence of outflow tract obstruction or residual atrioventricular valvar tissue.Conclusions. Outflow tract obstruction caused by accessory or anomalous atrioventricular valvar structures is an uncommon and heterogeneous group of conditions that can have significant surgical implications. In the majority of cases, tailoring of surgical techniques will permit complete relief of obstruction. However, such anomalies may limit standard surgical options and necessitate an innovative approach in some patients

Surgical management of life threatening events caused by intermittent aortic insufficiency in a native valve: case report

We describe a case of a patient admitted with apparent life threatening events characterized by hypotension and bradycardia. The patient was ultimately found to have intermittent severe aortic insufficiency. Upon surgical exploration, abnormalities were discovered in the aortic valve, which had a small left coronary cusp with absence of the nodulus of Arantius. Following surgical repair of the valve, aimed at preventing the small cusp from becoming stuck in the open position, the patient has remained episode free for over one year

Additional experimental evidence for a solar influence on nuclear decay rates

Additional experimental evidence is presented in support of the recent hypothesis that a possible solar influence could explain fluctuations observed in the measured decay rates of some isotopes. These data were obtained during routine weekly calibrations of an instrument used for radiological safety at The Ohio State University Research Reactor using Cl-36. The detector system used was based on a Geiger-Mueller gas detector, which is a robust detector system with very low susceptibility to environmental changes. A clear annual variation is evident in the data, with a maximum relative count rate observed in January/February, and a minimum relative count rate observed in July/August, for seven successive years from July 2005 to June 2011. This annual variation is not likely to have arisen from changes in the detector surroundings, as we show here.Comment: 8 pages, 6 figure

Professional approaches in clinical judgements among senior and junior doctors: implications for medical education

<p>Abstract</p> <p>Background</p> <p>Clinical experience has traditionally been highly valued in medical education and clinical healthcare. On account of its multi-faceted nature, clinical experience is mostly difficult to articulate, and is mainly expressed in clinical situations as professional approaches. Due to retirement, hospitals in Scandinavia will soon face a substantial decrease in the number of senior specialist doctors, and it has been discussed whether healthcare will suffer an immense loss of experienced-based knowledge when this senior group leaves the organization. Both senior specialists and junior colleagues are often involved in clinical education, but the way in which these two groups vary in professional approaches and contributions to clinical education has not been so well described. Cognitive psychology has contributed to the understanding of how experience may influence professional approaches, but such studies have not included the effect of differences in position and responsibilities that junior and senior doctors hold in clinical healthcare. In the light of the discussion above, it is essential to describe the professional approaches of senior doctors in relation to those of their junior colleagues. This study therefore aims to describe and compare the professional approaches of junior and senior doctors when making clinical judgements.</p> <p>Methods</p> <p>Critical incident technique was used in interviews with nine senior doctors and nine junior doctors in internal medicine. The interviews were subjected to qualitative content analysis.</p> <p>Result</p> <p>Senior and junior doctors expressed a variety of professional approaches in clinical judgement as follows: use of theoretical knowledge, use of prior experience of cases and courses of events, use of ethical and moral values, meeting and communicating with the patient, focusing on available information, relying on their own ability, getting support and guidance from others and being directed by the organization.</p> <p>Conclusion</p> <p>The most prominent varieties of professional approaches were seen in use of knowledge and work-related experience. Senior doctors know how the organization has worked in the past and have acquired techniques with respect to long-term decisions and their consequences. Junior doctors, on the other hand, have developed techniques and expertise for making decisions based on a restricted amount of information, in relation to patients' wellbeing as well as organizational opportunities and constraints. This study contributes to medical education by elucidating the variation in professional approaches among junior and senior doctors, which can be used as a basis for discussion about clinical judgement, in both pre-clinical and clinical education. Further research is required to explain how these professional approaches are expressed and used in clinical education.</p