Advocacy at the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery

The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery (WCPCCS) will be held in Washington DC, USA, from Saturday, 26 August, 2023 to Friday, 1 September, 2023, inclusive. The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery will be the largest and most comprehensive scientific meeting dedicated to paediatric and congenital cardiac care ever held. At the time of the writing of this manuscript, The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery has 5,037 registered attendees (and rising) from 117 countries, a truly diverse and international faculty of over 925 individuals from 89 countries, over 2,000 individual abstracts and poster presenters from 101 countries, and a Best Abstract Competition featuring 153 oral abstracts from 34 countries. For information about the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery, please visit the following website: [www.WCPCCS2023.org]. The purpose of this manuscript is to review the activities related to global health and advocacy that will occur at the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery.Acknowledging the need for urgent change, we wanted to take the opportunity to bring a common voice to the global community and issue the Washington DC WCPCCS Call to Action on Addressing the Global Burden of Pediatric and Congenital Heart Diseases. A copy of this Washington DC WCPCCS Call to Action is provided in the Appendix of this manuscript. This Washington DC WCPCCS Call to Action is an initiative aimed at increasing awareness of the global burden, promoting the development of sustainable care systems, and improving access to high quality and equitable healthcare for children with heart disease as well as adults with congenital heart disease worldwide.

Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Early Impact of the COVID-19 Pandemic on Congenital Heart Surgery Programs Across the World: Assessment by a Global Multi-Societal Consortium

The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the entire health care system with rapidly escalating morbidities and mortality. Although the infectious risk to the pediatric population appears low, the effects on children with congenital heart disease (CHD) remain poorly understood. The closure of congenital heart surgery programs worldwide to address the growing number of infected individuals could have an unintended impact on future health for COVID-19-negative patients with CHD. Pediatric and congenital heart surgeons, given their small numbers and close relationships, are uniquely positioned to collectively assess the impact of the pandemic on surgical practice and care of children with CHD. We present the results of an international survey sent to pediatric and congenital heart surgeons characterizing the early impact of COVID-19 on the care of patients with CHD.

Indian Guidelines for Indications and Timing of Intervention for Common Congenital Heart Diseases: Revised and Updated Consensus Statement of the Working Group on Management of Congenital Heart Diseases. Abridged Secondary Publication

JUSTIFICATION

A number of guidelines are available for management of congenital heart diseases from infancy to adult life. However, these guidelines are for patients living in high income countries. Separate guidelines, applicable to Indian children, are required when recommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and may have co-existing morbidities and malnutrition.

PROCESS

Guidelines emerged following expert deliberations at the National Consensus Meeting on Management of Congenital Heart Diseases in India, held on 10th and 11th of August 2018 at the All India Institute of Medical Sciences, New Delhi. The meeting was supported by Children's HeartLink, a non-governmental organization based in Minnesota, USA.

OBJECTIVES

To frame evidence based guidelines for (i) indications and optimal timing of intervention in common congenital heart diseases; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for congenital heart diseases.

RECOMMENDATIONS

Evidence based recommendations are provided for indications and timing of intervention in common congenital heart diseases, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus and others), obstructive lesions (pulmonary stenosis, aortic stenosis and coarctation of aorta) and cyanotic congenital heart diseases (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebstein anomaly and others). In addition, protocols for follow-up of post surgical patients are also described, disease wise.

Modulators of platelet function in aging

Platelets are small, anucleated effector cells that play an important role in linking the hemostatic and inflammatory processes in the body. Platelet function is known to be altered under various inflammatory conditions including aging. A gain in platelet function during aging can increase the risk of thrombotic events, such as stroke and acute myocardial infarction. Anti-platelet therapy is designed to reduce risk of serious cerebrovascular and cardiovascular events, but the adverse consequences of therapy, such as risk for bleeding increases with aging as well. Age-associated comorbidities such as obesity, diabetes, and hyperlipidemia also contribute to increased platelet activity and thus can enhance the risk of thrombosis. Therefore, identification of unique mechanisms of platelet dysfunction in aging and in age-associated comorbidities is warranted to design novel antiplatelet drugs. This review outlines some of the current areas of research on aging-related mechanisms of platelet hyperactivity and addresses the clinical urgency for designing anti-platelet therapies toward novel molecular targets in the aging population.

Indian guidelines for indications and timing of intervention for common congenital heart diseases: Revised and updated consensus statement of the Working group on management of congenital heart diseases

A number of guidelines are available for the management of congenital heart diseases (CHD) from infancy to adult life. However, these guidelines are for patients living in high-income countries. Separate guidelines, applicable to Indian children, are required when recommending an intervention for CHD, as often these patients present late in the course of the disease and may have coexisting morbidities and malnutrition. Guidelines emerged following expert deliberations at the National Consensus Meeting on Management of Congenital Heart Diseases in India, held on August 10 and 11, 2018, at the All India Institute of Medical Sciences. The meeting was supported by Children's HeartLink, a nongovernmental organization based in Minnesota, USA. The aim of the study was to frame evidence-based guidelines for (i) indications and optimal timing of intervention in common CHD; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for CHD; and (iii) indications for use of pacemakers in children. Evidence-based recommendations are provided for indications and timing of intervention in common CHD, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus, and others), obstructive lesions (pulmonary stenosis, aortic stenosis, and coarctation of aorta), and cyanotic CHD (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebstein's anomaly, and others). In addition, protocols for follow-up of postsurgical patients are also described, disease wise. Guidelines are also given on indications for implantation of permanent pacemakers in children.

Guidelines for the management of common congenital heart diseases in India: A consensus statement on indications and timing of intervention

INTRODUCTION

A number of guidelines are available for management of congenital heart diseases from infancy to adult life. However, these guidelines are for patients living in high-income countries. Separate guidelines, applicable to Indian children, are required when recommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and may have co-existing morbidities and malnutrition.

PROCESS

Guidelines emerged following expert deliberations at the National Consensus Meeting on Management of Congenital Heart Diseases in India, held on the 10th and 11th of August, 2018 at the All India Institute of Medical Sciences.

OBJECTIVES

The aim of the study was to frame evidence-based guidelines for (i) indications and optimal timing of intervention in common congenital heart diseases and (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for congenital heart diseases.

RECOMMENDATIONS

Evidence-based recommendations are provided for indications and timing of intervention in common congenital heart diseases, including left-to-right shunts, obstructive lesions, and cyanotic congenital heart diseases. In addition, protocols for follow-up of postsurgical patients are also described.

History of the World Society for Pediatric and Congenital Heart Surgery: The First Decade

The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) is the largest professional organization in the world dedicated to pediatric and congenital heart surgery. The purpose of this article is to document the first decade of the history of WSPCHS from its formation in 2006, to summarize the current status of WSPCHS, and to consider the future of WSPCHS. The WSPCHS was incorporated in Canada on April 7, 2011, with a head office in Montreal, Canada. The vision of the WSPCHS is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The mission of the WSPCHS is to promote the highest quality comprehensive cardiac care to all patients with congenital heart disease, from the fetus to the adult, regardless of the patient's economic means, with an emphasis on excellence in teaching, research, and community service.

Rare Combination of Pathologies Causing Mitral Stenosis and Mitral Regurgitation: A Case Report

A supramitral ring is a rare cause of mitral stenosis, while an isolated mitral valve cleft is a rare cause of congenital mitral regurgitation. Fortunately, both the lesions are known to have good outcomes after surgical correction. Although each is known to be associated with a variety of other structural heart defects, their coexistence has not been reported previously. We report a case of a three- and half-year-old boy detected to have a rare combination of supramitral ring producing severe mitral stenosis with a coexisting cleft in the anterior leaflet of mitral valve causing severe mitral regurgitation. The patient underwent successful surgical repair with resolution of both mitral stenosis and regurgitation.

Quantitative Dual-Energy Computed Tomography Supports a Vascular Etiology of Smoking-induced Inflammatory Lung Disease

RATIONALE

Endothelial dysfunction is of interest in relation to smoking-associated emphysema, a component of chronic obstructive pulmonary disease (COPD). We previously demonstrated that computed tomography (CT)-derived pulmonary blood flow (PBF) heterogeneity is greater in smokers with normal pulmonary function tests (PFTs) but who have visual evidence of centriacinar emphysema (CAE) on CT.

OBJECTIVES

We introduced dual-energy CT (DECT) perfused blood volume (PBV) as a PBF surrogate to evaluate whether the CAE-associated increased PBF heterogeneity is reversible with sildenafil.

METHODS

Seventeen PFT-normal current smokers were divided into CAE-susceptible (SS; n = 10) and nonsusceptible (NS; n = 7) smokers, based on the presence or absence of CT-detected CAE. DECT-PBV images were acquired before and 1 hour after administration of 20 mg oral sildenafil. Regional PBV and PBV coefficients of variation (CV), a measure of spatial blood flow heterogeneity, were determined, followed by quantitative assessment of the central arterial tree.

MEASUREMENTS AND MAIN RESULTS

After sildenafil administration, regional PBV-CV decreased in SS subjects but did not decrease in NS subjects (P < 0.05), after adjusting for age and pack-years. Quantitative evaluation of the central pulmonary arteries revealed higher arterial volume and greater cross-sectional area (CSA) in the lower lobes of SS smokers, which suggested arterial enlargement in response to increased peripheral resistance. After sildenafil, arterial CSA decreased in SS smokers but did not decrease in NS smokers (P < 0.01).

CONCLUSIONS

These results demonstrate that sildenafil restores peripheral perfusion and reduces central arterial enlargement in normal SS subjects with little effect in NS subjects, highlighting DECT-PBV as a biomarker of reversible endothelial dysfunction in smokers with CAE.

A semi-automatic framework of measuring pulmonary arterial metrics at anatomic airway locations using CT imaging

Pulmonary vascular dysfunction has been implicated in smoking-related susceptibility to emphysema. With the growing interest in characterizing arterial morphology for early evaluation of the vascular role in pulmonary diseases, there is an increasing need for the standardization of a framework for arterial morphological assessment at airway segmental levels. In this paper, we present an effective and robust semi-automatic framework to segment pulmonary arteries at different anatomic airway branches and measure their cross-sectional area (CSA). The method starts with user-specified endpoints of a target arterial segment through a custom-built graphical user interface. It then automatically detect the centerline joining the endpoints, determines the local structure orientation and computes the CSA along the centerline after filtering out the adjacent pulmonary structures, such as veins or airway walls. Several new techniques are presented, including collision-impact based cost function for centerline detection, radial sample-line based CSA computation, and outlier analysis of radial distance to subtract adjacent neighboring structures in the CSA measurement. The method was applied to repeat-scan pulmonary multirow detector CT (MDCT) images from ten healthy subjects (age: 21-48 Yrs, mean: 28.5 Yrs; 7 female) at functional residual capacity (FRC). The reproducibility of computed arterial CSA from four airway segmental regions in middle and lower lobes was analyzed. The overall repeat-scan intra-class correlation (ICC) of the computed CSA from all four airway regions in ten subjects was 96% with maximum ICC found at LB10 and RB4 regions.

Large Right Ventricular Clot in Pulmonary Atresia With Intact Ventricular Septum: In Defense of Biventricular Approach

Thrombus formation within the right ventricle (RV) in the setting of pulmonary atresia with intact ventricular septum (PAIVS) is not a very common occurrence and can be catastrophic. We present the case of a seven-month-old child with PAIVS and RV clot who successfully underwent biventricular repair. We discuss the interesting case and the rationale for management by means of biventricular repair over single ventricle repair when feasible in such a setting.

Paediatric cardiac surgery in low-income and middle-income countries: a continuing challenge

Despite advances in surgical and catheter-based treatment for congenital heart disease (CHD), there remain wide disparities across the globe. Ongoing international humanitarian and in-country programmes are working to address these issues with the ultimate goal to increase the quality and quantity of paediatric cardiac care, particularly in under-served regions of the world. This review aims to illustrate the reasons for these inequalities and suggests novel ways of improving access and sustainability of CHD programmes in low-income and middle-income countries.

A Robust and Efficient Curve Skeletonization Algorithm for Tree-Like Objects Using Minimum Cost Paths

Conventional curve skeletonization algorithms using the principle of Blum's transform, often, produce unwanted spurious branches due to boundary irregularities, digital effects, and other artifacts. This paper presents a new robust and efficient curve skeletonization algorithm for three-dimensional (3-D) elongated fuzzy objects using a minimum cost path approach, which avoids spurious branches without requiring post-pruning. Starting from a root voxel, the method iteratively expands the skeleton by adding new branches in each iteration that connects the farthest quench voxel to the current skeleton using a minimum cost path. The path-cost function is formulated using a novel measure of local significance factor defined by the fuzzy distance transform field, which forces the path to stick to the centerline of an object. The algorithm terminates when dilated skeletal branches fill the entire object volume or the current farthest quench voxel fails to generate a meaningful skeletal branch. Accuracy of the algorithm has been evaluated using computer-generated phantoms with known skeletons. Performance of the method in terms of false and missing skeletal branches, as defined by human experts, has been examined using in vivo CT imaging of human intrathoracic airways. Results from both experiments have established the superiority of the new method as compared to the existing methods in terms of accuracy as well as robustness in detecting true and false skeletal branches. The new algorithm makes a significant reduction in computation complexity by enabling detection of multiple new skeletal branches in one iteration. Specifically, this algorithm reduces the number of iterations from the number of terminal tree branches to the worst case performance of tree depth. In fact, experimental results suggest that, on an average, the order of computation complexity is reduced to the logarithm of the number of terminal branches of a tree-like object.

Reversible ventricular dysfunction in cyanotic heart disease

Ventricular dysfunction is a matter of concern for any preoperative cardiac patient. We describe 2 cases of cyanotic congenital heart disease (CCHD) awaiting on pump repair with hypoxia as a cause of ventricular dysfunction. Any Cyanotic Congenital heart disease presenting with ventricular dysfunction should be evaluated for treatable causes like hypoxia after exclusion of structural causes for the same.

Congenital internal jugular vein aneurysm in an infant: A rare entity

A 1-month old baby boy presented with a mass at the root of the neck. On investigation, a saccular aneurysm arising from the internal jugular vein was diagnosed. The aneurysm was excised after ligating the patent internal jugular vein above and below the origin of the aneurysm. Histopathology confirmed the diagnosis of a vascular malformation. Vascular malformation of the internal jugular vein, presenting as neck mass, is extremely rare with no case described in neonates. We present one such interesting case.

A New Approach of Arc Skeletonization for Tree-Like Objects Using Minimum Cost Path

Traditional arc skeletonization algorithms using the principle of Blum's transform, often, produce unwanted spurious branches due to boundary irregularities and digital effects on objects and other artifacts. This paper presents a new robust approach of extracting arc skeletons for three-dimensional (3-D) elongated fuzzy objects, which avoids spurious branches without requiring post-pruning. Starting from a root voxel, the method iteratively expands the skeleton by adding a new branch in each iteration that connects the farthest voxel to the current skeleton using a minimum-cost geodesic path. The path-cost function is formulated using a novel measure of local significance factor defined by fuzzy distance transform field, which forces the path to stick to the centerline of the object. The algorithm terminates when dilated skeletal branches fill the entire object volume or the current farthest voxel fails to generate a meaningful branch. Accuracy of the algorithm has been evaluated using computer-generated blurred and noisy phantoms with known skeletons. Performance of the method in terms of false and missing skeletal branches, as defined by human expert, has been examined using in vivo CT imaging of human intrathoracic airways. Experimental results from both experiments have established the superiority of the new method as compared to a widely used conventional method in terms of accuracy of medialness as well as robustness of true and false skeletal branches.

Lutembacher syndrome with unroofed left superior vena cava: a diagnostic dilemma

Lutembacher syndrome involving the association of congenital atrial septal defect (ASD), usually of the ostium secundum variety, and mitral valve disease is a well-known entity. Its association with a coronary sinus, ASD, and a persistent left superior vena cava (LSVC) draining into the left atrium (LA) (Raghib syndrome) is rarely described in the literature. This association in a 15-year-old boy erroneously deemed to be inoperable before referral to the authors' hospital due to cyanosis in the presence of atrial septal defect (ASD) and mitral stenosis is described in this report. Evaluation by echocardiography followed by cine angiography confirmed the cause of cyanosis to be drainage of the LSVC into the LA together with an ASD and rheumatic mitral stenosis, a combination of Raghib and Lutembacher syndromes. The boy underwent successful surgical correction. The authors believe this is the second such case to be reported in the English literature and the first of its kind to be managed by surgical intervention.

Unusual systemic venous Collateral channels to left atrium causing desaturation after Fontan operation closed percutaneously

We present an unusual cause of progressive cyanosis in a child appearing 2 years after successful Fontan surgery for tetralogy of Fallot with hypoplastic right ventricle. The cause of cyanosis was identified as one large venous channel draining into the left atrium. The channel was closed by Amplatzer vascular plug resulting in improvement of oxygen saturation.

Repeatability and Sample Size Assessment Associated with Computed Tomography-Based Lung Density Metrics

RATIONALE AND OBJECTIVES

Density-based metrics assess severity of lung disease but vary with lung inflation and method of scanning. The aim of this study was to evaluate the repeatability of single center, CT-based density metrics of the lung in a normal population and assess study sample sizes needed to detect meaningful changes in lung density metrics when scan parameters and volumes are tightly controlled.

MATERIALS AND METHODS

Thirty-seven subjects (normal smokers and non-smokers) gave consent to have randomly assigned repeated, breath-held scans at either inspiration (90% vital capacity: TLC) or expiration (20% vital capacity: FRC). Repeated scans were analyzed for: mean lung density (MLD), 15^th percentile point of the density histogram (P₁₅), low attenuation areas (LAA) and alpha (fractal measure of hole size distribution). Using inter-subject differences and previously reported bias, sample size was estimated from month or yearly change in density metrics obtained from published literature (i.e. meaningful change).

RESULTS

Inter-scan difference measurements were small for density metrics (ICC > 0.80) and average ICCs for whole lung alpha_-910 and alpha_-950 were 0.57 and 0.64, respectively. Power analyses demonstrated that, under the control conditions with minimal extrinsic variation, population sizes needed to detect meaningful changes in density measures for TLC or FRC repeated scans ranged from a few (20-40) to a few hundred subjects, respectively.

CONCLUSION

A meaningful sample size was predicted from this study using volume-controlled normal subjects in a controlled imaging environment. Under proper breath-hold conditions, high repeatability was obtained in cohorts of normal smokers and non-smokers.

Repeatability and Sample Size Assessment Associated with Computed Tomography-Based Lung Density Metrics

RATIONALE AND OBJECTIVES

Density-based metrics assess severity of lung disease but vary with lung inflation and method of scanning. The aim of this study was to evaluate the repeatability of single center, CT-based density metrics of the lung in a normal population and assess study sample sizes needed to detect meaningful changes in lung density metrics when scan parameters and volumes are tightly controlled.

MATERIALS AND METHODS

Thirty-seven subjects (normal smokers and non-smokers) gave consent to have randomly assigned repeated, breath-held scans at either inspiration (90% vital capacity: TLC) or expiration (20% vital capacity: FRC). Repeated scans were analyzed for: mean lung density (MLD), 15th percentile point of the density histogram (P15), low attenuation areas (LAA) and alpha (fractal measure of hole size distribution). Using inter-subject differences and previously reported bias, sample size was estimated from month or yearly change in density metrics obtained from published literature (i.e. meaningful change).

RESULTS

Inter-scan difference measurements were small for density metrics (ICC > 0.80) and average ICCs for whole lung alpha-910 and alpha-950 were 0.57 and 0.64, respectively. Power analyses demonstrated that, under the control conditions with minimal extrinsic variation, population sizes needed to detect meaningful changes in density measures for TLC or FRC repeated scans ranged from a few (20-40) to a few hundred subjects, respectively.

CONCLUSION

A meaningful sample size was predicted from this study using volume-controlled normal subjects in a controlled imaging environment. Under proper breath-hold conditions, high repeatability was obtained in cohorts of normal smokers and non-smokers.

Combined Bentall and modified Ravitch procedures in a patient with Marfan syndrome

Marfan syndrome is an inherited, connective-tissue disorder transmitted as an autosomal dominant trait. Cardinal features of the disorder include tall stature, ectopia lentis, mitral valve prolapse, aortic root dilatation, and aortic dissection. Pectus excavatum may exist as an isolated lesion or in association with a genetic syndrome such as Marfan syndrome. We report the successful management of a simultaneous correction of pectus excavatum and the underlying cardiovascular diseases.

Symptomatic giant left atrial aneurysm in a child: a rare entity

Isolated left atrial aneurysms are rare entities in clinical practice. Usually the condition is diagnosed in the second to fourth decades of life. The presence of such lesions in the pediatric age group is scantily described. We present a 2 year boy who presented with complaints of excessive irritability, respiratory distress and swelling of the feet. On examination, child was tachypnoeic with irregularly irregular rhythm. Echo showed a huge aneurysmal LA appendage with severe left ventricle dysfunction. The child underwent surgical resection for same. Findings were confirmed intraoperatively but he continued to have low cardiac output state after the surgery, with frequent arrhythmias and expired on day 7 of surgery. The case is reviewed and compared with the available English literature.

Baseline articular contact stress levels predict incident symptomatic knee osteoarthritis development in the MOST cohort

We studied whether contact stress estimates from knee magnetic resonance images (MRI) predict the development of incident symptomatic tibiofemoral osteoarthritis (OA) 15 months later in an at-risk cohort. This nested case-control study was conducted within a cohort of 3,026 adults, age 50 to 79 years. Thirty cases with incident symptomatic tibiofemoral OA by their 15 month follow-up visit were randomly selected and matched with 30 control subjects. Symptomatic tibiofemoral OA was defined as daily knee pain/stiffness and Kellgren-Lawrence Grade > or =2 on weight bearing, fixed-flexion radiographs. Tibiofemoral geometry was segmented on baseline knee MRI, and contact stresses were estimated using discrete element analysis. Linear mixed models for repeated measures were used to examine the association between articular contact stress and case/control status. No significant intergroup differences were found for age, sex, BMI, weight, height, or limb alignment. However, the maximum articular contact stress was 0.54 +/- 0.77 MPa (mean +/- SD) higher in incident OA cases compared to that in control knees (p = 0.0007). The interaction between case-control status and contact stress was significant above 3.20 MPa (p < 0.0001). The presence of differences in estimated contact stress 15 months prior to incidence suggests a biomechanical mechanism for symptomatic tibiofemoral OA and supports the ability to identify risk by subject-specific biomechanical modeling.

Unusual case of ruptured sinus of Valsalva: rupture into left ventricle cavity along with distortion of mitral valve requiring double valve replacement

We report a rare case of sinus of Valsalva aneurysm of left aortic sinus, which was bulging into left atrium (LA) distorting mitral valve and rupture into the left ventricle with severe aortic regurgitation in a 25 years old male patient. Due to the rupture, both aortic and mitral valves were irreparable and required a double valve replacement along with the closure of the neck of the aneurysmal cavity occupying the left atrial roof.

Pericardial cyst due to tuberculosis in an adolescent

Patient with a mediastinal mass may be diagnosed incidentally or following evaluation for the symptoms due to compressive effects on the adjoining structures. Pericardial cysts account to 6% of mediastinal masses. Echocardiography, computerised tomography and magnetic resonance imaging aid in accurate diagnosis and localization of these cysts. Anaesthesia for patients with these cysts may occasionally turn out to be catastrophic during induction or in postoperative period. Surgery is the preferred choice of treatment in these patients.

Rare variants of total anomalous pulmonary venous connection to coronary sinus-echocardiographic recognition and surgical correction

Total anomalous pulmonary venous connection (TAPVC) to the coronary sinus is a well-known entity but variations in connection sites are known to occur, the commonest among them is mixed connection. Here we describe two rare variants of TAPVC to coronary sinus. Group I (3 cases) in which there were dual sites of connection and group II (2 cases), TAPVC to coronary sinus was associated with a persistent left superior vena cava (LSVC). This was seen in total number of 45 cases of isolated TAPVC and 8 cases of TAPVC to coronary sinus between 2000 and December 2005 in our institute. All patients underwent surgical correction. In both of these groups, surgical correction may pose a challenge, which is discussed.

Coronary Artery Fistulas in Pulmonary Atresia and Ventricular Septal Defect

Pulmonary atresia with ventricular septal defect is an anomaly with highly variable anatomy. Rarely, a coronary artery-to-pulmonary artery fistula may contribute to pulmonary blood flow. Since 1996, we have treated 4 patients with coronary-pulmonary fistula associated with pulmonary atresia and ventricular septal defect. Two fistulas originated from the left coronary, one from the right coronary, and one from a right-sided solitary coronary system. All terminated in the main pulmonary artery, which was adequate in all cases. The fistulas were managed by direct internal closure. Total intracardiac repair was then accomplished in all patients at the same sitting. There was one death. In children with favorable anatomy, direct closure of the fistula from the pulmonary artery is adequate and allows single-stage intracardiac repair.

Total anomalous pulmonary venous connection to azygos vein: echocardiographic recognition of a rare variant

Total anomalous pulmonary venous connection to the azygos vein is a rare congenital malformation in which all the pulmonary veins drain anomalously to the azygous vein. Among 55 consecutive patients diagnosed as isolated total anomalous pulmonary venous connection by echocardiography at our institute between 1995 and January 2005, this anomaly was diagnosed in two patients. The malformation was diagnosed correctly in both the patients by echocardiography and the findings were confirmed on surgery. The importance of differentiating this condition from total anomalous pulmonary venous connection to superior vena cava by echocardiography and the differential diagnosis are discussed here.

Calcified ductal aneurysm with severe aortic regurgitation

A rare case of calcified aneurysm of the ductus arteriosus with severe aortic regurgitation is presented. We believe this is the first report of such a case in the English literature.

Identification of the structural and functional determinants of the extracellular domain of the human follicle stimulating hormone receptor

The extracellular domain (ECD) of the human follicle-stimulating hormone receptor (hFSHR) is believed to be the major determinant of hormone selectivity. Different discrete, discontinuous regions on the ECD of the hFSHR have been suggested to be crucial for hormone binding. However, the role of the ECD in signal transduction is not well understood. This study provides some insight into these aspects of the structure-function relationship of the ECD of hFSHR. Ten peptides were selected from the ECD on the basis of their ability to be surface oriented, synthesized by the solid-phase method using fluorenylmethyloxycarbonyl chemistry, purified and characterized. They were further studied for their ability to modulate both human follicle-stimulating hormone (hFSH)-FSHR binding and cAMP generation. Competitive inhibition studies showed that, of all the peptides studied, peptides 285-300 and 297-310 hFSHR were able to inhibit hFSH binding to FSHR. Both peptides function as weak competitive inhibitors of hFSH-FSHR binding. Peptides 285-300 hFSHR, 216-235 hFSHR, 184-195 hFSHR, 79-89 hFSHR and 15-31 hFSHR were observed to inhibit FSH-induced cAMP production. In summary, this study suggests that discrete, functional domains of the ECD have a role in hormone binding and signal transduction. Region 285-300 has been identified as a novel region crucial for both FSH binding and cAMP generation.