The sequential segmental approach is essential for better understanding of cardiac anatomy in normal and malformed hearts. It is based on
a detailed analysis of the three main cardiac segments, namely atria, ventricles, and great vessels, and the two connecting segments, namely
atrioventricular and ventriculoarterial connections. Each segment is systematically defined based purely on its morphological characteristics.
In most cases, echocardiography is sufficient, but some cases necessitate the use of other imaging modalities. Systematic identification of
different segments, connections, and their abnormalities helps in making an accurate diagnosis of congenital heart disease (CHD). This review
provides a brief description of the sequential segmental approach for detecting CHD on echocardiography
A systematic segmental analysis of cardiovascular anatomy is
essential for optimal management of patients with congenital
heart disease (CHD). Understanding cardiac anatomy is integral
to the pediatric cardiology training, while it is much less
discussed among adult cardiologists and echocardiographers.
Nonetheless, it is not uncommon for an adult cardiologist and
echocardiographers to encounter a patient with unrepaired or
repaired CHD. Therefore, it is important to understand the
basics of sequential segmental approach. Besides, the uniform
use of such an approach helps in easy communication among
team members managing a patient with suspected CHD.
For obvious reasons, while most anatomic details are well
delineated on echocardiography, it is not always possible to
demonstrate all aspects of cardiac anatomy and necessitate the
use of other imaging modalities. In this article, we provide a
brief description of the sequential segmental approach to cardiacanatomy with an emphasis on echocardiographic evaluation.
A systematic segmental analysis of cardiovascular anatomy is
essential for optimal management of patients with congenital
heart disease (CHD). Understanding cardiac anatomy is integral
to the pediatric cardiology training, while it is much less
discussed among adult cardiologists and echocardiographers.
Nonetheless, it is not uncommon for an adult cardiologist and
echocardiographers to encounter a patient with unrepaired or
repaired CHD. Therefore, it is important to understand the
basics of sequential segmental approach. Besides, the uniform
use of such an approach helps in easy communication among
team members managing a patient with suspected CHD.
For obvious reasons, while most anatomic details are well
delineated on echocardiography, it is not always possible to
demonstrate all aspects of cardiac anatomy and necessitate the
use of other imaging modalities. In this article, we provide a
brief description of the sequential segmental approach to cardiacanatomy with an emphasis on echocardiographic evaluation.
Aortic aneurysm is a medical condition, in which aorta, gets enlarged. Abdominal and Thoracic are two categories of aortic aneurysm. These conditions can lead to abdominal pain, low blood pressure, loss of consciousness or even death. Endovascular aneurysm repair (EVAR) is a minimally invasive surgical method to treat abdominal and thoracic aortic aneurysm. It is an alternative to open surgery for abdominal aortic aneurysm (AAA), which makes it relatively safe and less time consuming. However, not all patients suffering from aneurysm are suitable for EVAR. Also, it is difficult to treat aneurysm near or on the kidney using EVAR.
The term “complete transposition of the great
arteries” (TGA) is traditionally used to name congenital
heart defects (CHDs) that are characterized by discordant
ventriculo-arterial connections. In such a situation, the
morphologically right ventricle is abnormally connected
to the ascending aorta while the morphologically left
ventricle is abnormally connected to the pulmonary trunk.
In the majority of cases, discordant ventriculo-arterial
connections are associated with parallel (non-spiraling)
arrangement of the arterial trunks, suggesting that the
condition may have resulted from abnormal development
of the outflow tract of the embryonic heart.[1,2] Parallel
arrangement (non-spiraling) of the great arterial trunks,
however, does not necessarily indicate the presence of
TGA. For example, a few cases have been reported in
which TGA occurred with normal spiraling of the arterial
trunks. Furthermore, in cases of CHDs with a solitary
ventricle of indeterminate morphology (“univentricular”
hearts), parallel great arterial trunks cannot be connected
in a discordant fashion to the ventricle since neither a
morphologically right nor a morphologically left ventricle
exists. Parallel arrangement (non-spiraling) of the great
arterial trunks, thus, should not be named TGA but
rather “malposition of the great arterial trunks”
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
Cardiology
From Wikipedia, the free encyclopedia
Jump to navigationJump to search
This article is about the medical specialty. For the album, see Cardiology (album). For the medical journal, see Cardiology (journal).
Cardiology
Heart diagram blood flow en.svg
Blood flow diagram of the human heart. Blue components indicate de-oxygenated blood pathways and red components indicate oxygenated blood pathways.
System Cardiovascular
Subdivisions Interventional, Nuclear
Significant diseases Heart disease, Cardiovascular disease, Atherosclerosis,
earning websites that make the most money
Aortic aneurysm is a medical condition, in which aorta, gets enlarged. Abdominal and Thoracic are two categories of aortic aneurysm. These conditions can lead to abdominal pain, low blood pressure, loss of consciousness or even death. Endovascular aneurysm repair (EVAR) is a minimally invasive surgical method to treat abdominal and thoracic aortic aneurysm. It is an alternative to open surgery for abdominal aortic aneurysm (AAA), which makes it relatively safe and less time consuming. However, not all patients suffering from aneurysm are suitable for EVAR. Also, it is difficult to treat aneurysm near or on the kidney using EVAR.
The term “complete transposition of the great
arteries” (TGA) is traditionally used to name congenital
heart defects (CHDs) that are characterized by discordant
ventriculo-arterial connections. In such a situation, the
morphologically right ventricle is abnormally connected
to the ascending aorta while the morphologically left
ventricle is abnormally connected to the pulmonary trunk.
In the majority of cases, discordant ventriculo-arterial
connections are associated with parallel (non-spiraling)
arrangement of the arterial trunks, suggesting that the
condition may have resulted from abnormal development
of the outflow tract of the embryonic heart.[1,2] Parallel
arrangement (non-spiraling) of the great arterial trunks,
however, does not necessarily indicate the presence of
TGA. For example, a few cases have been reported in
which TGA occurred with normal spiraling of the arterial
trunks. Furthermore, in cases of CHDs with a solitary
ventricle of indeterminate morphology (“univentricular”
hearts), parallel great arterial trunks cannot be connected
in a discordant fashion to the ventricle since neither a
morphologically right nor a morphologically left ventricle
exists. Parallel arrangement (non-spiraling) of the great
arterial trunks, thus, should not be named TGA but
rather “malposition of the great arterial trunks”
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
Cardiology
From Wikipedia, the free encyclopedia
Jump to navigationJump to search
This article is about the medical specialty. For the album, see Cardiology (album). For the medical journal, see Cardiology (journal).
Cardiology
Heart diagram blood flow en.svg
Blood flow diagram of the human heart. Blue components indicate de-oxygenated blood pathways and red components indicate oxygenated blood pathways.
System Cardiovascular
Subdivisions Interventional, Nuclear
Significant diseases Heart disease, Cardiovascular disease, Atherosclerosis,
earning websites that make the most money
Fragmented QRS Complex is associated with the Left Ventricular Remodeling in ...submissionclinmedima
A total of 140 patients with AMI were enrolled. Accoridng to the presence of fQRS in presenting electrocardiogram. The patients were divided into fQRS group and NonfQRS group. Real-time three-dimensional echocardiograph parameters measured in-hospital and 6-month follow-up period were collected.
FragmentedQRSComplexisassociatedwiththeLeftVentricular Remodeling in Patients...semualkaira
A total of 140 patients with AMI were enrolled. Accoridng to the presence of
fQRS in presenting electrocardiogram. The patients were divided into fQRS group and NonfQRS group. Real-time three-dimensional echocardiograph parameters measured in-hospital
and 6-month follow-up period were collected. The difference between two groups and the
influencing factors of left ventricular remodeling were analyzed.
The Association of Left Atrial Enlargement in Different Subtypes of Ischemic ...pateldrona
LAE related rhythm disturbance that characterize atrial fibrillation is also associated with other atrial derangement such as endothelial dysfunction and impaired myocyte function
The Association of Left Atrial Enlargement in Different Subtypes of Ischemic ...AnonIshanvi
LAE related rhythm disturbance that characterize atrial fibrillation is also associated with other atrial derangement such as endothelial dysfunction and impaired myocyte function. The role of LAE in acute cerebral infarction patient is not sufficiently described in literature.
The Association of Left Atrial Enlargement in Different Subtypes of Ischemic ...komalicarol
LAE related rhythm disturbance that characterize atrial fibrillation is
also associated with other atrial derangement such as endothelial dysfunction and impaired myocyte
function. The role of LAE in acute cerebral infarction patient is not sufficiently described in literature.
Hence of this study was undertaken to look for the frequency of left atrial enlargement in acute stroke
subtypes.
The International Journal of Engineering and Science (The IJES)theijes
The International Journal of Engineering & Science is aimed at providing a platform for researchers, engineers, scientists, or educators to publish their original research results, to exchange new ideas, to disseminate information in innovative designs, engineering experiences and technological skills. It is also the Journal's objective to promote engineering and technology education. All papers submitted to the Journal will be blind peer-reviewed. Only original articles will be published.
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Shakya, et al.: Sequential segmental approach to CHD
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging ¦ Volume 4 ¦ Issue 3 ¦ September-December 2020 245
In situs solitus or usual arrangement, the spleen, pancreas,
stomach, and sigmoid colon are located on the left, while the
liver, cecum, and appendix are on the right side.The left lung has
two lobes with a relatively longer bronchus that lies below the
left pulmonary artery (hyparterial). The right lung, in contrast,
has three lobes and a wider, shorter bronchus that lies above the
right pulmonary artery (eparterial) [Figure 1]. In some cases, the
arrangement is a mirror image of the normal. This arrangement
istermedassitusinversusalthoughthereisnoup‑downinversion
oforgans.However,foreaseofcommunication,wewillcontinue
to use the terms “situs solitus” and “situs inversus” in this article.
Sometimes, thoraco‑abdominal organs lack asymmetry, and the
arrangement is inconsistent. This arrangement, also known as
situs ambiguous or visceral heterotaxy, is commonly associated
with the isomerism of atrial appendages (see later) and has high
chances of CHD.[4]
Cardiac position
The position of the heart in the chest cavity provides important
clues about cardiac anatomy and underlying CHD. Most often,
the heart is left‑sided in the setting of situs solitus, whereas
it lies on the right side if there is situs inversus. The cardiac
position other than expected for the thoraco‑abdominal situs
is associated with a high likelihood of CHD.
The description of the cardiac position includes:
1. The position of the cardiac mass relative to the midline.
The heart can be left‑sided (levocardia), right‑sided
(dextrocardia), or lie in the midline (mesocardia)
2. The orientation of the long axis (base to apex) of the
heart.[5]
In most instances, the cardiac position and base‑to‑apex
orientation are concordant, and it is sufficient to describe
the cardiac position. The discrepancy on rare occasion
necessitates a description of both features separately.
Cardiac segments
Atrial situs
The identification of cardiac morphology starts from the
determination of which atrium is the right atrium (RA) and
which is the left atrium (LA). The atria are defined neither
by their venous connections nor by the side of the body on
which the atrium lies. Instead, it is the morphological features,
particularly of the atrial appendage, that defines a chamber as
morphologically RA or LA. Based on the morphology of the
atrial appendage, the atrial arrangement is classified as:
i. Usual arrangement or situs solitus: morphological RA
located to the right of the morphological LA
ii. Mirror image arrangement or situs inversus:
morphological RAlocated to the left of the morphological
LA. This is a left–right inverted arrangement compared
to situs solitus
iii. Atrial isomerism or situs ambiguous: both the atriums have
morphologically similar appendage. The arrangement
can be either right isomerism or left isomerism. This
arrangement is commonly associated with disorganized
left–right symmetry of abdominal organs and is also known
as heterotaxy syndrome.
In clinical practice, it is common to encounter difficulties in the
exact localization of atriums. In such a scenario, since a high
Figure 1: The arrangement of thoraco-abdominal organs in situs solitus, situs inversus, and situs ambiguous. Situs solitus has trilobed right lung
with eparterial bronchus, bilobed left lung with hyparterial, right-sided liver, and left-sided spleen and stomach. The arrangement in situs inversus is
a mirror image of situs solitus. In situs ambiguous or visceral heterotaxy, the liver is in the midline and splenic abnormalities are common. Both the
lungs are bilobed or trilobed in the setting of left or right isomerism, respectively
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246
concordance exists between thoraco‑abdominal, bronchial, and
atrial situs, the atrial situs is adjudged based on the relative
position of the inferior vena cava (IVC) and the aorta.[6]
In situs
solitus, the aorta is to the left of the spine, and the IVC lies
anterior and to the right of the aorta [Figures 2 and 3 and Video
1]. In cases with situs inversus, the aorta is to the right with the
IVC lying to its left and anterior. On most occasions, drainage
of a patent IVC identifies the RA, although rarely it can drain
anomalously to the LA.[7]
In the setting of left isomerism,
sometimes, the infrahepatic portion of the IVC is interrupted,
and instead, the blood from the lower body drains via azygos
vein, which runs posterior to aorta. The identification of the
arrangement of the abdominal situs is readily possible on
echocardiography. The assessment of bronchial situs, however,
mandates chest X‑ray or computed tomography.
In patients with a good acoustic window, it is possible to define
the morphology of the atrial appendage. Broadly speaking, an
atrium with a triangular appendage with a broad base and a
wide mouth is a morphological RA [Figure 4 and Videos 2 and
3]. The LA, on the other hand, has a long, tubular, finger‑like
appendage with a narrow orifice [Figure 5a and Video 4].
The parasternal short‑axis view is often sufficient to define
the LA appendage. The subcostal long‑axis view enables
visualization of the RA appendage. Some cases with complex
cardiac malformation or poor acoustic window mandate
transesophageal echocardiography or other cross‑sectional
cardiac imaging such as computed tomography or magnetic
resonance imaging.
Venoatrial connection
Apart from atrial situs, it is important to delineate the
venous connection to the atrial chambers. A combination
of subcostal, thoracic, and suprasternal views is generally
sufficient [Figure 4 and Video 2]. In some cases with difficulty
and suspicion of anomalous systemic venous connection,
a carefully performed and interpreted saline‑contrast
echocardiography is extremely useful.[7]
Compared to systemic
veins, the delineation of pulmonary veins is more challenging.
In children and adolescents with normal connections, a
modified high parasternal view, also known as crab view, is
most useful for defining the connection of all four pulmonary
veins. A similar modified parasternal short‑axis view also
provides details of the common chamber and pulmonary
veins in patients with supracardiac and cardiac forms of total
anomalous pulmonary venous connection. Obtaining these
views in adults is challenging, where the apical four‑chamber
view and subcostal view are used to delineate the connection
of pulmonary veins to LA.
Atrioventricular valve
Morphologically, the AV valve represents the ventricular
chamber and it is one of the features used to identify a ventricle
as right or left. In hearts with concordant AV connections, the
tricuspid valve guarding the rightAV junction has three leaflets
and is positioned distally (apical offsetting) compared to the
left‑sided bi‑leaflet mitral valve [Figure 6 and Videos 5 and 6].
Unlike the mitral valve, the tensor apparatus of the tricuspid
valve connects to the ventricular septum. These findings
are useful in echocardiographic identification of tricuspid
and mitral valves. In the setting of atrioventricular septal
defect (AVSD), the AV valve is common with no apical
offsetting of the left and the right components of the valve.[8]
Since the valve is common and does not possess characteristics
of a normal mitral or tricuspid valve, it is better to use the term
left and rightAV valves, instead of tricuspid and mitral valves.
The apical offsetting is also absent in cases with inlet type of
ventricular septal defect (VSD) and both AV valves are at the
same level [Figure 6c].
En face view of the AV valves in the subcostal short‑axis
and the left anterior oblique views helps in identifying the
morphology [Figure 7a andVideo 7].The parasternal short‑axis
view at the level of the mitral valve can also be used to study
the morphology of mitral valve leaflets [Figure 7b].A detailed
assessment of the AV valves and their tensor apparatus
necessitates imaging in multiple echocardiographic views.
Atrioventricular connection
The next step is to define the AV connection. In normal hearts
and most of the malformed hearts, each atrium connects to a
morphologically appropriate ventricle, an arrangement known
as concordant AV connection. Less commonly, the atrium
connects to morphologically inappropriate ventricle which
is called discordant AV connection. In the setting of atrial
isomerism with both atriums being either left or right, the
AV connection is anatomically mixed as one of the atriums
will mandatorily connect to morphologically inappropriate
ventricle. The connection, nevertheless, is not always
physiologically abnormal. For example, it is physiologically
normal in case morphologic right ventricle (RV) receives
Figure 2: The arrangement of abdominal viscera and vessels in situs solitus (a), inversus (b), and ambiguous (c)
a b c
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4. Shakya, et al.: Sequential segmental approach to CHD
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systemic venous blood and morphologic left ventricle (LV)
receives blood from the pulmonary veins, irrespective of
whether both the atriums are morphologically right or left.
Connection‑wise, as highlighted earlier, the AV valves are
usually committed fully to one of the ventricles, although, in
the setting of single‑ventricle physiology, one of the valves
may be atresia, e.g., tricuspid atresia and mitral atresia. In
some cases, mostly in the presence of a VSD, the AV valve
can be connected to both the ventricles. In this regard, the
term overriding is used if the valvular annulus overrides the
ventricular septum. The degree of override greater than 50%
assigns the valve to the ventricle, receiving a greater share
of the annulus. The AV valve is termed as straddling when
the tensor apparatus is supported by the other ventricle, in
addition to the ventricle with the dominant connection.[9,10]
The identification of straddling and overriding of AV valve
is important as it is often associated with hypoplasia of the
ipsilateral ventricle precluding biventricular surgical repair.
Rarely, theAV connection can have both atriums connected to
one ventricle (double‑inlet ventricle) or one atrium connecting
to both the ventricles (double‑outlet atrium) creating
single‑ventricle physiology. Figure 8 summarizes possible
variations in the AV connection.
Ventricles and ventricular looping
After the determination of the atrial situs, this is the most
important step of the segmental analysis. RV has more complex
geometry with an apically displaced tri‑leaflet tricuspid
valve having an attachment to the ventricular septum, coarse
trabeculations, and a distinctly trabeculated septal surface,
which includes septal and moderator bands [Figure 9 and
Videos 8 and 9]. A normal RV has an inlet, apical, and outlet
portions with the infundibulum separating the pulmonary
valve from the tricuspid valve. The LV is more elliptical and
has a smooth septal surface, fine trabeculations, two distinct
papillary muscles, and no attachment of bi‑leaflet mitral
valve to the ventricular septum. The LV has a more acute
angle between the mitral and aortic valves bringing both the
valves in continuity [Figure 10a]. Among all morphological
features, the morphology of the AV valve is most reliable in
identifying a ventricle as RV or LV.[11]
For obvious reasons,
as highlighted earlier, this cannot be used in cases with AVSD
and double‑inlet ventricle.
Once the ventricles are identified, the focus is shifted to
the ventricular topology or loop, which defines the spatial
relationship of the ventricles.[12,13]
The understanding of the
ventricular loop is clinically relevant as it determines the
pattern of coronary arteries and the conduction system. The
ventricular topology is a morphological concept based on
chirality. In d‑loop or right‑handed topology, the RV permits
the placement of the right hand so that the thumb is in the inflow
and fingers are in the outflow, while the palmar surface of the
hand faces the ventricular septum. This is expected in cases
with situs solitus and concordant AV connection. In contrast,
in the setting of l‑loop or left‑handed ventricular topology,
the morphological RV can accommodate only the left hand
in this fashion. This left‑handed topology is expected in the
setting of situs inversus and concordantAVconnection. Cardiac
Figure 3: Trans-thoracic echocardiogram in subcostal short-axis view
from a neonate with situs solitus. The IVC is to the right and Ao is to the
left of the vertebral body in situs solitus, while the reverse arrangement
is seen in patients with situs inversus [see Figure 2]. IVC: Inferior vena
cava, Ao: Aorta
Figure 4: Trans-thoracic echocardiogram in subcostal bicaval view
(a) showing the usual location of broad triangular RAA in a child with
an atrial septal defect (arrow). (b) Juxtaposed RAA in a neonate with
transposition of great arteries in which the RAA is abnormally located on
the left side. IVC: Inferior vena cava, LA: Left atrium. RA: Right atrium,
SVC: Superior vena cava, RAA: Right atrial appendage
a b
Figure 5: Trans-thoracic echocardiogram in parasternal short-axis
view (a) showing normal relation of great arteries with pulmonary valve
lying anterior and to the left of the Ao. A tubular, finger-like LAA (broken
lines) and origin of the right coronary artery (arrow) are also well seen.
(b) The circle and sausage appearance, with the Ao in the center and
PA with branching seen to the left of Ao. N: Noncoronary cusp, L: Left
coronary cusp, LPA: Left pulmonary artery, R: Right coronary cusp, RA:
Right atrium, RPA: Right pulmonary artery, Ao: Aorta, LAA: Left atrial
appendage, PA: Pulmonary artery
a b
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248
malformations related to faulty looping such as congenitally
corrected transposition of great arteries are common in
cases with discordance between the atrial arrangement and
ventricular looping. The concept of chirality is difficult to
demonstrate on echocardiography. Therefore, despite being
inaccurate in a minority of cases, the ventricular topology is
defined on the basis of the spatial orientation of the inlet of
the ventricles. Thus, for practical considerations, the tricuspid
valve lying to the right of the mitral valve is labeled as d‑loop
or right‑hand topology [Figure 9]. The left–right inversion
of this arrangement, with the tricuspid valve lying to the left
of the mitral valve, is termed as l‑loop or left‑hand topology.
Infundibulum
The infundibulum is the connecting segment between the
ventricles and the arterial trunks. In normal hearts, there is
a complete subpulmonary conus with muscular separation
between the pulmonary and the right‑sided tricuspid valves,
whereas the subaortic conus is absent, allowing fibrous
continuity between the left and noncoronary cusps of the aortic
valve and the base of the anterior mitral leaflet [Figure 10a]. In
some hearts, the aortic valve is separated from the mitral valve
when it is labeled as aorta–mitral discontinuity [Figure 10b and
Video 10]. In morphological terms, this indicates subaortic
conus. Any arrangement other than isolated subpulmonary
conus, i.e., bilateral conus, subaortic conus with absent
subpulmonary conus, and bilaterally absent conus, is
abnormal.[14]
A subpulmonary conus is typically absent in the
setting of transposition of great arteries (TGA), which in turn
results in continuity between the pulmonary valve and the
mitral valve, although this is not an essential morphological
feature to define TGA [Figure 11a and Video 11]. Similarly,
bilateral conus is commonly associated with a double‑outlet
RV but is not necessary for the diagnosis.
Thus, although the infundibulum provides an important clue
about cardiac anatomy, it is not the defining feature of either
ventricle or VA connection, and therefore, the morphology of
the infundibulum should not be used to define the ventricle
or VA connection.
Ventriculoarterial connection
Next, the outflow of the ventricles is examined to determine
from which cardiac chamber the great arteries originate. VA
connection also determines how the semilunar valves and their
respective great vessels align with the underlying ventricles.
Assessment of VA connection is easy in most hearts with
normal connections. The assessment may be is challenging in
the setting of CHDs, especially conotruncal malformations. In
cases with coexisting interventricular communication in the
outflow region, one of the semilunar valves can override the
ventricular septum. Again, in malformations with a possible
double outlet of a ventricle, the application of the so‑called
“50% rule” helps in assigning a valve to one of the ventricles.[15]
Like many other morphological principles, this “50% rule”
is not easily demonstrable on echocardiography due to the
complex three‑dimensional (3D) relationship of the ventricles
and the great arteries, curved sigmoid shape of the ventricular
septum, and rotational and translational cardiac motion.
Advanced 3D imaging techniques are superior, but the exact
delineation may still be challenging in some complex cases.
Like the analysis of other areas of the heart, the VA alignment
should also be solely assessed based on the connection and
spatial relationship between the semilunar valves and the
underlying ventricles and not on the variable characteristics
of ventricular outflow and infundibulum.
JustlikeAVconnection,theVAconnectioncanalsobeconcordant,
discordant, or absent. Unlike theAVconnection,VAconnection
cannot be mixed as isomerism of the ventricular chamber is
unknown. The connection can also be double outlet when
Figure 6: Trans-thoracic echocardiogram in apical four-chamber view (a) showing the normal apical displacement of the tricuspid valve compared to
the mitral valve. An excessive apical displacement (>8 mm/m2
in children and >15 mm in adults) of the tricuspid valve indicates Ebstein anomaly (b).
Panel c shows lack of apical offsetting of the tricuspid valve in the setting of an inlet ventricular septal defect (star). LA: Left atrium, LV: Left ventricle,
RA: Right atrium, RV: Right ventricle
a b c
Figure 7: Trans-thoracic echocardiogram in subcostal left anterior
oblique view (a) showing atrioventricular valves en face with anterior (A),
posterior (P), and septal (S) leaflets of the tricuspid valve and anterior
(A) and posterior (P) leaflets of the mitral valve. The septal attachment
of the tricuspid valve is also well seen. Parasternal short-axis view at
the level of the mitral valve (b) showing the anterior and posterior mitral
leaflets. AML: Anterior mitral leaflet, LV: Left ventricle, PML: Posterior
mitral leaflet, RV: Right ventricle
a b
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6. Shakya, et al.: Sequential segmental approach to CHD
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both arterial trunks arise from only one ventricle [Figure 12].
In most conditions, it is the RV that has a double outlet with
a minority having double outlet of the LV. There may also be
a single outlet from the heart. This group includes a common
arterial trunk and a single outlet with atresia of one semilunar
valve. In the common trunk, both ventricles are connected via
a common arterial valve to this trunk that directly provides
systemic, pulmonary, and coronary circulation [Figure 11b and
Video 12]. A single outlet with atresia of one semilunar valve
includes a single pulmonary trunk with aortic atresia or a single
aortic trunk with pulmonary atresia.
Semilunar valves and arterial trunks
In normal hearts, the pulmonary trunk is connected to the
RV, whereas the aorta arises from the LV and gives rise to the
coronary arteries and brachiocephalic vessels.
Although commonly thought to represent the spatial
relationship of the aorta and the pulmonary trunk, in reality,
the analysis is to clarify spatial relationships between the
aortic and pulmonary valves [Figures 13 and 14 and Video 4].
However, since the relationship of the proximal‑most part of
the arterial trunk is the same as the relationship of the valves,
these are commonly used interchangeably. The relationship
of semilunar valves is generally a reflection of VA connection
although there are many exceptions to this rule.
In the earlier version of the sequential analysis, the relationship
of the arterial trunks was depicted as “D” or “L” to indicate
the right or left position of the aorta relative to the pulmonary
Figure 8: The variations in atrioventricular connection. AV: Atrio-ventricular
Figure 10: Trans-thoracic echocardiogram in the parasternal long-axis view
showsaorto-mitralcontinuityinachildwithanormalheart(a)andaorto-mitral
discontinuity (b) with a wedge of tissue (broken line) between the base of the
AML and the annulus of the aortic valve in a child with double-outlet RV with
subaorticventricularseptaldefect(star).AML:Anteriormitralleaflet,Ao:Aorta,
LA:Leftatrium,LV:Leftventricle,PML:Posteriormitralleaflet,RV:Rightventricle
a b
Figure 9: Trans-thoracic echocardiogram in apical four-chamber view
(a) showing the MB, a characteristic morphologic feature of the RV.
(b) Subcostal short-axis view below the level of atrioventricular valves
showing a trabeculated RV side of the ventricular septum (arrows)
compared to a smooth surface on the LV side. Note right-hand topology
with the inlet of RV lying to the right of LV inflow. LA: Left atrium, RA:
Right atrium, MB: Moderator band, RV: Right ventricle, LV: Left ventricle
a b
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250
trunk.[16]
This notation, however, lacks crucial information
about relationships in the anteroposterior direction. Therefore,
it is better to provide a detailed description.
The term “normally related great arteries” is used when the
aortic valve is located to the right and posteriorly relative to
a b
Figure 11: Abnormal ventriculoarterial connections. (a) Parasternal long-
axis view from an infant with discordant ventriculoarterial connections
(transposition of great arteries) with a large subpulmonic ventricular
septal defect (star) with pulmonary stenosis. Note the presence of
continuity between the mitral valve and pulmonary valve (arrow). (b)
Subcostal short axis view in diastole from a child with a common arterial
trunk with sinusal origin of main pulmonary artery segment and a large
subtruncal ventricular septal defect (star). Ao: Aorta, LA: Left atrium, LV:
Left ventricle, PA: Pulmonary artery, RV: Right ventricle
Figure 12: Abnormalities of ventriculoarterial connection. CAT: Common arterial trunk; ccTGA: congenitally corrected transposition of great arteries;
DORV: Double outlet right ventricle; HRHS: Hypoplastic right heart syndrome; HLHS: Hypoplastic left heart syndrome, LV: Left ventricle, RV: Right
ventricle, TGA: Transposition of great arteries
the pulmonary valve. Any other relationship of the semilunar
valves is malposition of great arteries [Figure 13]. The
malposition is not the same as TGA. While malposition only
depicts an abnormal spatial relationship of semilunar valves
and arterial trunk, TGA is a type of discordant VA connection
in which the aorta arises from the RV and pulmonary trunk
arises from the LV [Figure 11a and Video 11].
The attention is then shifted to the aortic arch, its sidedness, and
its branching pattern.[17]
The aortic arch is left sided if it courses
over the left bronchus. In children, this assessment can be made
by sweeping the probe in the left‑to‑right direction to assess
the relationship with the trachea. This, however, is difficult to
visualize in older children and adults. In such cases, the arch
sidedness is assessed by analyzing the probe orientation that
permits the best visualization of the arch. A well‑visualized
aortic arch when the probe marker is pointed toward the left
shoulder indicates the left arch [Figure 14 and Video 13]. In
contrast, the right arch is better visualized when the probe
marker points toward the right shoulder.The pattern of the neck
vessels also provides important clues. Except in the presence
of isolated carotid or brachiocephalic artery, the first branch
contains a carotid artery opposite to the side of the aortic arch.
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Table 1: Summary of steps for sequential segmental analysis of cardiac anatomy
Steps Cardiac segments Assessment required
1 Thoraco-abdominal situs Are liver and spleen lateralized?
If yes, is it usual or mirror image arrangement?
If no, midline liver suggests visceral heterotaxy.
Is IVC patent or it continues as azygos vein behind aorta?
If IVC is patent, IVC to the right of the aorta - usual arrangement
IVC to the left of the aorta - mirror image arrangement
2 Cardiac position Is the heart left-sided, right-sided, or midline?
3 Atrial situs Is the atrial arrangement usual, mirror image, or isomeric?
If exact definition not possible then follow the abdominal situs
4 Venoatrial connection Do the inferior and superior vena cava drain to the right atrium?
Is there a left-sided SVC - if yes, where does it drain?
Are pulmonary veins draining normally to the left atrium?
Is there an anomaly of pulmonary venous drainage?
Presence, location, and size of the atrial septal defect
5 Atrioventricular valve Are there two patent valves?
If yes, identify and localize tricuspid and mitral valves
If no, is it a common valve or single valve with atresia of one valve?
6 Atrioventricular connection Is each atrium connecting to only one ventricle?
If yes, is AV connection concordant, discordant, or mixed?
If no, is there double inlet ventricle or double outlet atrium?
7 Ventricles and ventricular looping Morphology of ventricular chambers and looping - d-loop or l-loop?
Presence, location, size, and relationship of the ventricular septal defect
8 Infundibulum Is the pulmonary valve separated from the tricuspid valve (subpulmonary conus)?
Is aorta- mitral discontinuity (subaortic conus) present?
9 Ventriculoarterial connection Is each ventricle connected to one arterial trunk?
If yes, is the connection concordant or discordant?
If no, is there a double outlet, common outlet, single outlet with atresia of one valve?
The appearance of outflow tracts, presence, location, and severity of obstruction
10 Semilunar valves and arterial trunks Are there two semilunar valves?
If yes, are the valves normally related or malposed?
If no, is it a common valve or single valve with atresia of the other valve?
Appearance, orientation, and function of semilunar valves
Origins of coronary arteries
Size, position, and branching pattern of arterial trunks including sidedness of aortic arch
Presence and severity of obstruction - branch pulmonary stenosis, coarctation of the aorta
IVC: Inferior vena cava, AV: Atrioventricular, SVC: Superior vena cava
In the setting of the left aortic arch, the first vessel is the right
brachiocephalic artery, whereas in cases with the right aortic
arch, the first branch is the left brachiocephalic artery.
Defects and anomalies
Once the three main cardiac segments and the two connecting
segments have been evaluated and categorized, all associated
cardiac malformations are systematically examined and
described. The description can be either in the order of
hemodynamic significance or an anatomic order related to the
location of the abnormality within the heart.
Tips for Echocardiography in a Patient
Suspected to Have Congenital Heart Disease
Most of the cardiologists and echocardiographers dealing
with children are familiar with this step‑by‑step sequential
approach to cardiac morphology. Typically, unlike adult
echocardiography, which starts with a parasternal long‑axis
view, the echocardiography for suspected CHD starts with a
subcostal view for determination of the thoraco‑abdominal
and atrial situs.
Some modifications in the echocardiographic approach are
extremely useful while evaluating suspected CHD. The
assessment of all cardiac segments is greatly enhanced using
the “sweep” technique in which, depending upon views, the
echo probe is moved slowly from right to left or anterior to
posterior to create a series of images in a particular view.
Fundamentally, the technique is the same as that used in
assessing LV in the parasternal short‑axis view but is much
more detailed in the setting of CHD. This sweeping of echo
probe permits a detailed assessment of cardiac chambers and
their connections.
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9. Shakya, et al.: Sequential segmental approach to CHD
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252
Once the cardiac segments have been identified and the
connections have been described, then associated anomalies
are assessed and described using the same systematic approach.
The sequential segmental approach can be further condensed
to a 10‑step analysis [Table 1].
Conclusion
The sequential segmental approach includes the use of multiple
echocardiographic views and other imaging modalities for
systematic evaluation of cardiac anatomy. This stepwise
approach permits accurate detection of all morphologic aspects
relevant for managing a patient with suspected CHD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Figure 13: Possible variations in the relationship of the great arteries.
The Ao to the right and posterior to the MPA is the only arrangement
labeled as normally great vessel relationship (circles with solid outline).
All other arrangements indicate the malposition of great arteries. MPA:
Main pulmonary artery, Ao: Aorta
Figure 14: Trans-thoracic echocardiogram in suprasternal long-axis
view with the marker of the echo probe pointing toward the left shoulder
showing left aortic arch and its branches. Note the reducing caliber of neck
vessels with the first branch, the RBCA containing right subclavian and
right carotid artery, being the widest, and the LSCA being the narrowest.
The arch sidedness is assessed by the branching pattern of neck vessels.
Other than a few exceptions, the first branch from the aortic arch contains
contralateral carotid artery. A well-visualized aortic arch with the probe
marker pointing toward the left and right shoulders identifies the left and
right-sided aortic arch, respectively. DTA: Descending thoracic aorta,
LCCA: Left common carotid artery, RPA: Right pulmonary artery, RBCA:
Right brachiocephalic artery, LSCA: Left subclavian artery
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