Hatem Hosny

Lessons from patient-specific 3D models of the cardiac chambers after the Mustard operation

The recent ability to create detailed 3D models of the atrial and ventricular chambers using CT, MRI and rapid prototyping offers unique opportunities to study the size and shape of the different cardiac chambers both before and following operation for complex cardiac anomalies. We here describe the techniques for creating detailed 3D models of the heart and demonstrate the utility of these techniques in a patient studied after the Mustard operation. This can give important insights into the changes in size and shape of the different chambers and the patterns of blood flow from the pulmonary and systemic veins to the ‘appropriate’ ventricle. This information in turn could be extremely helpful in understanding and optimizing the overall hemodynamic function after the Mustard operation.

Surgery for TGA in Developing Countries : The End of the Beginning∗

T he last 50 years have witnessed dramatic changes in the management of transposition of the great arteries (TGA). This has transformed the disease from being almost universally fatal to being compatible with normal or near normal survival and quality of life. Unfortunately, these changes have been limited to an extremely small proportion of the global community, with a large number of children with TGA born in developing countries continuing to suffer a dismal fate.

Giant Congenital Left Atrial Appendage Aneurysm

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 10-year-old girl presented with a 2-month history of atrial fibrillation. Chest x-ray film showed marked cardiomegaly (A) . Transthoracic echocardiography showed a giant (13 × 10 cm) saccular aneurysm

Predicting the future by looking at the past: necessary but not binding

In the complex field of cardiac surgery, risk stratification is important pre-operatively, to aid in a dispassionate prediction of outcome, and post-operatively, to allow adjustment for comparative audit. A good risk scoring system can help to put things in perspective for patients, healthcare providers, insurance companies, and, importantly, public opinion. Ranging in complexity from simple risk scores to sophisticated prediction calculators, many risk stratification models have been proposed for cardiac surgery (Table 1). In this issue of the journal, Dr Marco Ranucci and his colleagues from San Donato study the effectiveness of a simple risk score, utilizing age, creatinine, and ejection fraction (ACEF) and the addition of two parameters, namely anaemia and emergency surgery (ACEF II). The authors are to be congratulated for adding to the literature a simple risk score that surgeons can work out in their head. Their description of parsimonious may, actually, be its strength. As clinicians, we want to offer the best care for our patients and community. In the journey of climbing Mount Excellence, every effort is made to identify risks, prepare for the procedure, and then audit its outcomes. While audit of outcome is a major drive for quality, it can hinder the provision of care, especially for very sick patients. This is where risk stratification can be very helpful. As a clinician, it is important when applying a risk score to do so with an open mind, putting the patient first within his/her clinical context. It is a balancing act between patient individualization and standardization. For auditing outcomes and verifying risk assessment, surgeons and institutions have been using statistical techniques and forensic approaches. The statistical method, by means of data collection and numerical analysis, has advanced significantly in predicting surgical results. While adding a dispassionate indication of how the outcome will be, the clinical intricacies of each patient, inevitably, make this method defective. The forensic method, of reflection and explanation, is what puts statistical data in perspective to makes sense of the mathematical extrapolation. Working with the risk score proposed by the authors would exemplify statistical audit while discussion of case morbidity or mortality, individually or in series, would account for forensic audit. Various institutions have ’forensically’ audited their statistical risk scoring systems to find good correlation with prospective outcomes. In their construction, it should be identified that risk scores will remain a moving target. Components of these scores will change in size, shape, and, indeed, order of importance with time. Revision of our systems and validation of their calculations will be continuously required as we try to predict the future by looking at the past.

Three-dimensional transesophageal echocardiography incremental value in a rare case of a bileaflet tricuspid valve.

Detailed assessment of the tricuspid valve using two‐dimensional echocardiography is always challenging, as only two of three leaflets can be seen at a time. Three‐dimensional echocardiography can provide the enface view of the tricuspid valve that allows simultaneous visualization of all of the three leaflets. In a 42‐year‐old male patient scheduled for pulmonary endarterectomy, 3DTEE showed that the tricuspid valve is bileaflet, with one septal and another lateral leaflet. There were two commissures, one of them is anteriorly positioned and the other one is posterior. Our findings were confirmed intra‐operatively by direct surgical visualization of the tricuspid valve.

Repair of very severe tricuspid regurgitation following detachment of the tricuspid valve

We report on the case of 5-year-old girl with severe tricuspid regurgitation following previous repair of double outlet right ventricle with subaortic ventricular septal defect, performed through trans-atrial approach using detachment of tricuspid valve leaflet. The severe tricuspid regurgitation was found to be due to dehiscence at the site of the previous detachment and was repaired using a pericardial patch. In this report, we discuss the relative merits and risks of using this technique.

Double outlet right atrium with three atrioventricular valves

The atrioventricular (AV) valves are complex anatomical structures which perform sophisticated functions. 1 A wide spectrum of malformations of these valves can occur in patients with AV septal defects. We here describe the anatomic and functional abnormalities of a rare form of the disease, where two valves connected the right atrium to both the right and left ventricles, in addition to a third valve that connected the left atrium to the left ventricle, with no evidence of regurgitation or cyanosis in spite of the relatively large communication between the right atrium and the left ventricle. In addition, the patient had severe subaortic stenosis. The pathophysiology, hemodynamics and method of repair of the condition are discussed.

Antegrade flow in Anomalous Left Coronary Artery from Pulmonary Artery: Clinical implications

Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly that usually presents in childhood. It results in left ventricular (LV) ischemia with resulting LV dysfunction. This ischemia results from retrograde flow into the pulmonary artery which can act as a coronary steal. We here report antegrade flow detected in ALCAPA caused by severe pulmonary hypertension. Anatomic correction of ALCAPA is the preferred surgical option and should be performed as early as possible.

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis

Left main coronary artery (LMCA) disease is associated with increased morbidity and mortality. Coronary artery bypass grafting surgery (CABG) has always been the standard revascularization strategy for this group of patients. However, with the recent developments in stents design and medical therapy over the past decade, several trials have been designed to evaluate the safety and efficacy of percutaneous coronary intervention (PCI) as an alternative to CABG surgery in patients with LMCA disease. Recently, the results of two major trials, EXCEL and NOBLE, comparing CABG versus PCI in this patient population have been released. In fact, the results of both trials might appear contradictory at first glance. While the EXCEL trial showed that PCI was non-inferior to CABG surgery, the NOBLE trial suggested that CABG surgery is a better option. In the following review, we will discuss some of the similarities and contrasts between these two trials and conclude with lessons to be learned to our daily practice.

Surgery for TGA in Developing Countries

T he last 50 years have witnessed dramatic changes in the management of transposition of the great arteries (TGA). This has transformed the disease from being almost universally fatal to being compatible with normal or near normal survival and quality of life. Unfortunately, these changes have been limited to an extremely small proportion of the global community, with a large number of children with TGA born in developing countries continuing to suffer a dismal fate.