Identification and Analysis of Atrial-Bronchial-Abdominal Disharmony in Patients with Isomeric Atrial Appendages.

Ideally, the morphology of atrial appendages should solely be used to identify and differentiate patients with isomeric right and left atrial appendages. However, in clinical practice, the segregation is often indirectly based on the arrangement of thoraco-abdominal structures. The correlation between thoraco-abdominal arrangement and atrial appendages, however, is imperfect. In this study, we sought to clarify the cardiovascular malformations in patients with isomeric atrial appendages with an emphasis on atrial-thoracic-abdominal disharmony. A retrospective review of all patients who underwent cardiac CT angiography between January 2014 and June 2023 and identified to have isomeric atrial appendages was performed. Of the 366 cases (median age: 2 years [interquartile range: 11 months-7 years]), 247 (67.5%) patients had isomeric right atrial appendages while 119 (32.5%) patients had isomeric left atrial appendages. In 316 (86.3%) patients, the thoraco-abdominal arrangement was as per atrial appendage morphology while the remaining 50 (13.6%) patients had disharmonious patterns. Compared to isomeric left atrial appendages, the disharmonious pattern was more frequent with isomeric right atrial appendages (5.9% vs. 17.4%; p 0.003). Irrespective of the type of isomerism, disharmony was mostly confined to the level of the abdomen. Not all patients with isomeric atrial appendages have a harmonious thoraco-abdominal arrangement. The atrial-bronchial-abdominal disharmony is more frequent with isomeric right atrial appendages and is mostly present at the level of the abdomen. A detailed sequential segmental analysis with an independent description of each organ system is, therefore, essential for the complete evaluation of patients with isomeric atrial appendages.

Unravelling supravalvular aortic stenosis in a young patient: look beyond the valve.

A 16-year-old adolescent girl was referred to our tertiary care center for management of a failed aortic valve balloon dilatation procedure for congenital valvular aortic stenosis. The medical records revealed a residual peak-to-peak gradient of 80 mm Hg after 2 dilations with 16 x 6-mm Tyshak balloon (NuMed Inc.).

Ballerina foot in heart.

A 67-year-old woman with no known risk factors for coronary artery disease presented to the outpatient department with complaints of exertional fatigue and angina New York Heart Association class III.

Clarifying the Anatomy of Tetralogy of Fallot with S-shaped Ascending Aorta.

We recently encountered several cases of tetralogy of Fallot with an abnormally oriented S-shaped ascending aorta. In this retrospective study, we sought to clarify morphology of this unusual under-recognized variant. Databases were reviewed to identify all patients with tetralogy of Fallot having an S-shaped ascending aorta. Computed tomographic angiography was used for the assessment of cardiac morphology. Out of the 21 patients, 18 (86%) had a right aortic arch, 2 (9%) had a left aortic arch, and the remaining patient (5%) had a double aortic arch. Patients with a right aortic arch, compared to age and sex-matched patients with a right aortic arch but normally oriented ascending aorta, had lesser aortic override (29.3 ± 14% vs 54.8 ± 13.2%; p = 0.0001) and a wider ascending aorta (25.2 ± 6.9 vs 18.0 ± 3.2 mm; p = 0.0003). The S-shaped ascending aorta was located posteriorly, with a higher sterno-aortic distance (25.5 ± 7.7 vs 9.9 ± 4.5 mm; p = 0.0001). The ascending aorta among patients with tortuosity was longer (4.12 ± 1.7 vs 3.07 ± 0.82, p = 0.03) but with similar tortuosity index (1.22 ± 0.19 vs 1.15 ± 0.17, p = 0.23). Of the cases with right aortic arch and S-shaped ascending aorta, 16 (89%) had extrinsic compression of the right pulmonary artery (p = 0.0001), while 7 (39%) had crossed pulmonary arteries (p = 0.008), with no such findings among those with normally oriented ascending aorta. Tetralogy of Fallot with an S-shaped ascending aorta is a variant with lesser aortic override and a more posteriorly located ascending aorta. Compression of the right pulmonary artery and crossed pulmonary arteries is frequent in the presence of a right-sided aortic arch. These findings have important implications for optimal diagnosis and surgical repair.

Lipid clinical trials with special reference to Indian population.

Indians have a pattern of atherogenic dyslipidaemia characterised by not so high LDL-C but elevated small, dense LDL-C, elevated triglyceride levels and low HDL-C levels. In addition, different lipid-lowering drugs exhibit pharmacokinetic variability in Indians, which may have implications on the optimum doses required to achieve the desired LDL-C levels. Currently the management of dyslipidaemia in Indians are based on the landmark trials, which largely included western population. This review focusses on major clinical trials of lipid lowering drugs with special reference to the Indian population.

Transcatheter management of acquired atresia of aorta.

A 24-year-old man was referred to our tertiary care center for the management of uncontrolled hypertension secondary to severe coarctation of aorta.

Tubercular pseudoaneurysm of the axillary artery.

Tuberculous (TB) involvement of the vascular system has been reported in the preantibiotic era. We, hereby, report a case involving a teenage boy who presented to us with left upper limb pain followed by gradually progressive motor and sensory deficit over 1 month with preceding history of tuberculosis. Examination revealed a palpable, noncompressible, nonpulsatile swelling superior to the lateral third of the clavicle. Imaging through ultrasonography, computed tomography, and magnetic resonance imaging confirmed the presence of a pseudoaneurysm with compression of the underlying nerves. The child underwent surgical thrombectomy with pseudoaneurysm repair and arteriorrhaphy along with antitubercular medications with complete recovery at 6 months. The tissue staining, nucleic acid amplification tests, and histopathology confirmed TB etiology. Tuberculosis continues to remain a major health concern, especially in the developing world. High index of suspicion is necessary to diagnose such manifestations to avoid catastrophic sequelae.

Pulsating abdominal mass in a newborn - Pentalogy of Cantrell with left ventricular diverticulum.

Pentalogy of Cantrell is a rare congenital anomaly involving the anterior diaphragm, pericardium, sternum, peritoneum, and associated intracardiac defects. In this report, we describe a neonate with pentalogy of Cantrell evaluated with multimodality imaging and successfully managed by a multidisciplinary team.

Pediatric cardiology in India - In search of a holistic solution.

In response to the survey among early career pediatric cardiologists from India and the accompanying editorial, we invited comments and suggestions from thought leaders and senior functionaries in the field. We have summarized the thoughts and suggestions as a mini-symposium.