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A double-outlet left ventricle (DOLV) is a congenital cardiac anomaly that rarely is encountered. This case report demonstrates the echocardiographic features of DOLV in the form of the pulmonary artery arising completely from the left ventricle with D-looped ventricles, especially when evaluated by intraoperative transesophageal echocardiography (TEE), along with the correlation of characteristic features with cardiac computerized tomography. The features pertinent to the differentiation of DOLV from double-outlet right ventricle and congenitally corrected transposition of the great arteries by echocardiography have been described. To the authors' knowledge, this was the first report of intraoperative TEE in the case of DOLV. In addition, the use of intraoperative echocardiography to rule out coronary compression as a cause for post-repair ventricular tachycardia, by use of TEE to rule out ventricular dysfunction and regional wall motion abnormalities, as well as epicardial echocardiography to demonstrate normal coronary blood flow, has been reported.

Heart failure in tetralogy of Fallot in the newborn period is rare and is usually due to either large aortopulmonary collaterals or absent pulmonary valve syndrome with severe pulmonary regurgitation. Pink tetralogy of Fallot and tetralogy of Fallot with disconnected pulmonary arteries from the aorta may present beyond the newborn period with heart failure when Pulmonary vascular resistance (PVR) falls. We describe the diagnostic and therapeutic pathway in a rare case of heart failure in newborn with tetralogy of Fallot.

Background Transthoracic intracardiac catheters inserted under direct vision in the pulmonary artery and left atrium during cardiac surgery play major roles in the management of patients with complex congenital heart disease. We aimed to analyze the utility of transthoracic intracardiac catheters in the perioperative management of pediatric cardiac surgery patients and review catheter-related morbidity. Methods The computerized register of all pediatric cardiac surgery patients in whom transthoracic intracardiac catheters were inserted from 2012 to 2019 in a tertiary referral center were reviewed. Results Transthoracic pulmonary artery and left atrial catheters were inserted in 89 and 71 patients, respectively. The most common indications for pulmonary artery and left atrial catheters were total anomalous pulmonary venous connection (52%) and total cavopulmonary connection (58%) respectively. The most common reason for elevated pulmonary artery and left atrial pressure after cardiopulmonary bypass was left ventricular dysfunction. Transthoracic pulmonary artery catheters helped in diagnosing pulmonary hypertensive crisis (29%), surgical decision-making (14%), and ventilator therapy (16%). Left atrial catheters helped in the diagnosis of left ventricular dysfunction (54%). The incidence of morbidity was 8.9% for transthoracic pulmonary artery catheters and 9.8% for left atrial catheters. Conclusion Transthoracic pulmonary artery catheters help in the diagnosis and management of pulmonary hypertensive crisis, for making perioperative surgical decisions, and during ventilator therapy. Transthoracic left atrial catheters help in the diagnosis of left ventricular dysfunction in the perioperative period. The diagnostic and treatment benefits provided by transthoracic intracardiac catheters outweigh the minor adverse events, supporting their continued use in the perioperative period.

Aortic valve endocarditis can lead to secondary involvement of aorto mitral curtain and the adjacent anterior mitral leaflet (AML). The secondary damage to AML is often caused by the infected diastolic jet of aortic regurgitation hitting the ventricular surface of the anterior mitral leaflet, or by the pronounced bacterial vegetation that prolapses from the aortic valve into the left ventricular outflow tract. This is called “kissing lesion”. We describe a case of infective endocarditis of aortic valve in a 13-year-old child causing secondary mitral valve involvement with AML perforation and aneurysm formation.

Myxomas are the most common primary intra-cardiac tumors in adults. Myxoma occurring in a preschooler is very rare, and cardiac surgery in acute stroke is a challenging decision. We present a rare case of acute cardio-embolic stroke in a 3-year-old child due to left atrial myxoma which was successfully treated.

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. 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. 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. 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.

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. Keywords: Congenital heart disease, Intervention, Surgery

OBJECTIVES The study objective was to evaluate the cardiac, neurodevelopmental, psycho-social and health-related quality of life (HRQOL) outcomes of children who underwent an arterial switch operation (ASO). METHODS Children who underwent ASO were evaluated on follow-up at 3–5 years with cardiovascular, neurodevelopmental and HRQOL assessment using validated tools. Children with developmental delay, attention-deficit hyperactivity disorder, autism spectrum disorder, neuromotor and speech and language impairment were considered to have neurodevelopmental disorder (NDD). The impact of socioeconomic status (Kuppuswamy classification), perioperative cardiac, nutritional and psycho-social factors on outcomes was analysed. RESULTS There were 61 (89.7%) survivors at a mean follow-up of 50.9 ± 7.6 months. The median age at surgery was 41 days (22–74.5). One-third of patients had growth restriction. Two children had residual cardiovascular lesions requiring intervention. The mean HRQOL score was >90 in all scales of the Paediatric Quality of Life Inventory™ 3.0 Cardiac Module. Neurological abnormalities were seen in 19 patients (31.1%) of whom 17 (27.9%) patients had NDD and 12 had developmental delay. Speech and language impairment, attention-deficit hyperactivity disorder, and neuromotor impairment were found in 16.4%, 3.3% and 6.7% patients, respectively. On multivariate analysis, increasing time to lactate normalization and low socioeconomic status were associated with developmental delay after ASO. CONCLUSIONS While intermediate-term cardiac outcomes and HRQOL after ASO were fairly satisfactory, NDD was identified in one-fourth of these children. Increasing time to lactate normalization after ASO and low socioeconomic status were associated with suboptimal intermediate neurodevelopment outcomes after ASO.

Objective To assess the feasibility and accuracy of intraoperative three-dimensional (3D) epicardial en face images of ventricular septal defects (VSD) in children using the 3D transesophageal echocardiography (TEE) probe as an epicardial probe. Design This was a prospective nonrandomized blinded observational study. Setting The study was conducted at a single tertiary cardiac care center. Participants Fifty pediatric patients, weighing between 5.0 kg and 20 kg, who were scheduled for elective surgical closure of their VSDs, prospectively were recruited for this study. Interventions Epicardial 3D images were acquired using the full-volume mode. VSD location and size were determined from the 3D data sets using multiplanar reconstruction mode (QLAB 9) by a blinded investigator. The accuracy in terms of location and size was compared with surgical findings. Measurements and Main Results In 50 study subjects, 54 VSDs were located by epicardial 3D echocardiography (3DE): 12 perimembranous, 17 inlet, eight muscular, 15 malaligned, and two outlet. Average image acquisition time was 4.96 (±1.47) minutes. Average image reconstruction time was 6.18 (±1.93) minutes. Good en face views of the VSD could be rendered in all patients (100% feasibility). The highest image quality was for perimembranous and malaligned VSDs. The location of VSD by 3DE corresponded precisely with surgical findings (100% accuracy). With linear regression analysis, excellent correlation was observed between the diameters measured by surgery and that measured by 3DE from the right ventricle side (r2 = 0.97, p Conclusions The authors’ study demonstrated that diagnostic quality 3D en face images of VSD can be obtained intraoperatively using 3D epicardial echocardiography. The short acquisition and reconstruction times make this technique clinically applicable.

Background Double-outlet left ventricle (DOLV) is a rare congenital cardiac anomaly. The aorta and the main pulmonary arterial trunk arises predominantly from the left ventricle and is associated with a malaligned ventricular septal defect, various degrees of hypoplasia of the right ventricle, and presence, or absence of pulmonary stenosis. Bi-ventricular repair is the preferred treatment option whenever possible. Multiple techniques for bi-ventricular repair have been described. The best option for DOLV correction is by translocating the pulmonary root from the left ventricle to the right ventricle. In this series, we report four patients who underwent biventricular repair of DOLV with excellent outcomes. Methods This is a retrospective study of four patients who underwent surgical correction of DOLV between January 2014 and December 2018. We collected all patient details from the institute patient record system. Echocardiographic data were obtained from the records. Intraoperative charts were reviewed for further information on the surgical procedure and cardiopulmonary bypass. Postoperative data included survival, functional status, and followup echocardiography. Results Of the four children, three underwent pulmonary root translocation, and one child underwent a Reparation al etage Ventriculaire (REV) procedure. There was no mortality in our series, and all children are in a stable clinical condition in the recent follow-up, and no re-operations or interventions were required following primary surgical correction. Conclusion DOLV is anatomically and surgically a challenging subset. Pulmonary root translocation in this anatomy is technically challenging but safe and superior option when compared to other alternative surgical procedures. Pulmonary root translocation can be performed with excellent results, even in infants.

Double-outlet left ventricle (DOLV) is a rare congenital cardiac anomaly. The aorta and the main pulmonary arterial trunk arises predominantly from the left ventricle(LV) and is associated with a malaligned ventricular septal defect(VSD), various degrees of hypoplasia of the right ventricle, and presence or absence of pulmonary stenosis. Bi-ventricular repair is the preferred treatment option whenever possible. Various techniques for bi-ventricular repair have been described. The best option for DOLV correction is by translocating the pulmonary root to the right ventricle(RV)[1]. In this series, we report four patients who underwent biventricular repair of DOLV in our institute with excellent outcomes. All patient details were collected from the institute patient record system. Echocardiographic data were obtained from the records. Intraoperative charts were reviewed for further information on the surgical procedure and cardiopulmonary bypass. Postoperative data included survival, functional status and followup echocardiography. Of the four children, three underwent pulmonary root translocation and one child underwent Reparation al etage Ventriculaire(REV) procedure. There was no mortality and all children are in stable clinical condition in the recent follow-up and no re-operations or interventions were required following primary surgical correction. Thus DOLV is anatomically and surgically a challenging subset. Pulmonary root translocation in this anatomy is technically challenging but safe and superior option when compared to other alternative surgical procedures and it can be performed with excellent results, even in infants.

Anomalous origin of left coronary artery from pulmonary artery (ALCAPA) accounts for 0.4% of the congenital heart diseases. Comprehensive 2D and 3D transesophageal echocardiographic imaging of a well-collateralized subset of ALCAPA is described. A nonstandard short-axis view of both aorta and pulmonary arteries showed the origin of left coronary artery from the posterior sinus of the pulmonary artery and right coronary artery in its usual position. Pulse-wave interrogation of the coronary arteries showed the direction of flow in opposite directions. Using the real time-3D, the en-face views of the origins of both coronaries were also demonstrated.

Mitral inflow obstruction caused by dilated coronary sinus is a rare congenital cardiac anomaly that must be differentiated from other causes of left ventricular inflow obstruction such as cor triatriatum, supramitral membrane, and supramitral ridge, because their surgical repair is different. Although preoperative transthoracic echocardiography is the primary imaging modality for diagnosis, intraoperative transesophageal echocardiography has a higher sensitivity and specificity over transthoracic echocardiography in differentiating these lesions. We report 2 cases of supramitral obstruction where the intraoperative transesophageal echocardiography has refined the preoperative diagnosis and changed the course of surgical repair.

Pulmonary atresia with ventricular septal defect and coronary-dependent pulmonary circulation arising from both major coronary arteries is rare. Dependence of pulmonary blood flow on the coronaries and the risk of early development of pulmonary vascular obstructive disease warrant early surgical repair in these patients. We report a case of a ten-month-old infant with pulmonary atresia with ventricular septal defect and coronary artery-to-main pulmonary artery connections who was successfully managed with ligation of the coronary fistulas and intracardiac repair.

Submitral aneurysms are rare clinical entities occurring predominantly in young adults of African descent. A host of etiologies have been proposed for this entity. We present a unique case of submitral aneurysm which developed after pulmonary artery banding in a three-year-old girl with complex congenital heart disease. The aneurysmal sac was burrowing into the interatrial septum.

Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals that result in leakage of excessive serum proteins and lymphocytes into the gastrointestinal (GI) tract culminating in protein-losing enteropathy. The GI loss of protein and possible antithrombin III (AT-III) loss creates a prothrombotic environment. The surgical management of congenital heart disease (CHD) in presence of PIL can present with altered heparin response and can impose problems in instituting cardiopulmonary bypass (CPB). We report a case of surgical closure of ventricular septal defect with PIL with altered heparin response. Such an association of PIL with altered heparin response in CHD has not been reported in literature.

Total anomalous pulmonary venous connection (TAPVC) with direct connection of the pulmonary veins to the morphologically right atrium is exceedingly rare other than in the setting of isomerism of the right atrial appendages. We present an interesting case of TAPVC in a patient with situs solitus that connected to the right atrium via a broad-mouthed common chamber. Resumo: As variantes de retorno venoso pulmonar anómalo total (RVPAT) que resultam de conexão e de drenagem direta das veias pulmonares à aurícula morfologicamente direita são extremamente raras, exceto no caso de presença de isomerismo direito. Apresentamos um caso de RVPAT, com drenagem à aurícula direita através de um coletor comum, num doente com situs solitus. Keywords: Total anomalous pulmonary venous connection, Cardiac total anomalous pulmonary venous connection, Supracardiac total anomalous pulmonary venous connection, Palavras-chave: Conexão anómala total das veias pulmonares, Conexão anómala total de veias pulmonares cardíaca, Conexão anómala total de veias pulmonares supracardíaca

Objectives Mitral regurgitation (MR) in the majority of infants with an anomalous left coronary artery from the pulmonary artery (ALCAPA) has been shown to improve without concomitant mitral valve repair. However, the outcome of MR in older children with ALCAPA is unclear. The purpose of this study was to compare the outcome of MR following the ALCAPA repair in infants and older children. Methods Forty-six patients (34 were younger than 1 year and 12 were aged 1-12 years) underwent the repair for ALCAPA in our institution from June 2006 to June 2016. Baseline and follow-up data were collected from records, and the latest echocardiogram was performed for all surviving patients from June 2017 to August 2017. Results Of the 34 infants, 82% had moderate-to-severe ventricular dysfunction, and 47% had significant MR at presentation. Fifty-seven percent of the older age group had MR, though none of them had ventricular dysfunction. Two infants and 3 older children underwent concomitant mitral valve repair. There were 2 early deaths in the infantile group. On follow-up, ventricular function normalized in 88% of infants; 12.5% of the infants had moderate-to-severe MR on follow-up, and 50% of the older children had moderate-to-severe MR on follow-up. Conclusions The ALCAPA repair has excellent survival outcomes in all age groups. MR improves in the majority of infants with revascularization alone. MR worsens or persists in a significant number of older children following the ALCAPA repair, and they are more likely to require reinterventions for the mitral valve on follow-up.

A 7-year-old girl with severe mitral regurgitation and pulmonary artery hypertension with good ventricular function was planned for mitral valve repair, but was subsequently diagnosed to have anomalous left coronary artery from pulmonary artery. We describe the pitfalls in the diagnosis of this rare anomaly, particularly in the presence of severe pulmonary artery hypertension and absence of circumstantial evidence of coronary steal and ventricular dysfunction.

A baby with pulmonary atresia with intact ventricular septum and hypoplastic right ventricle, with suspected right ventricle to coronary communications, was operated on for placing an aortopulmonary shunt. Postoperatively, the baby deteriorated with features of myocardial ischemia. Postmortem examination revealed anomalous origin of left coronary artery from pulmonary artery that caused significant coronary ischemia on ligation of the ductus arteriosus. Although coronary anomalies, including right ventricle dependent coronary circulation, has been well described, this is the first report of anomalous origin of coronary artery from pulmonary artery in a baby with pulmonary atresia and intact ventricular septum.

BSTEIN’S ANOMALY is a complex congenital cardiac condition associated with structural changes in the tricuspid valve (TV) and functional derangement of the right ventricle (RV). Cone procedure is a new modality of surgical correction of abnormal TV and is performed aiming for a biventricular repair. 1 Utility of intraoperative two-dimensional echocardiography (2DE) has been reported during the surgical repair of Ebstein’s anomaly. 2 Real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) has been found to provide better information than 2DE during cardiac surgery in adult patients, especially for evaluation of left ventricular function 3 and mitral valve repair. 4 However, its role in the intraoperative monitoring of congenital heart lesions is not widely popular, mainly because of unavailability of appropriate probes as well as difficult image acquisition in children who have inherently high heart rates. This case report describes the utility of RT-3D-TEE in an adult patient who had surgery for Ebstein's anomaly of the TV. CASE REPORT A 21-year-old female patient, with a diagnosed case of Ebstein’s anomaly with severe tricuspid regurgitation (TR), had surgery for cone repair of the TV. She presented with history of 3 episodes of syncope and was evaluated in the electrophysiology laboratory for the presence of any aberrant cardiac conduction pathways, which turned out to be negative. Preoperative transthoracic echocardiogram found Ebstein’s anomaly of the TV with moderate-to-severe TR and an 18-mm 23-mm atrial septal defect (ASD), predominantly shunting left-to-right. Examination of the TV leaflets showed a 5-cm long and freely mobile anterior tricuspid leaflet (ATL) and a restricted septal tricuspid leaflet (STL). The morphology of the posterior tricuspid leaflet (PTL) was unclear. On the morning of surgery, routine monitoring was established, including invasive cannulation of the left radial artery. Anesthesia was induced with 300 μg of fentanyl, 5 mg of midazolam, and 8 mg of etomidate, and muscle relaxation was achieved with 9 mg of vecuronium. After tracheal intubation, a 3D-TEE probe was inserted in the esophagus, and the heart was inspected using an ultrasound system (IE 33; Philips Medical Systems, Bothell, WA). Initial 2DE examination confirmed the findings of the transthoracic echocardiogram (Fig 1, Video 1). The 2DE features were a 10-mm/m 2 apical displacement of the STL, moderate-to-severe TR with an eccentric and wallhugging jet, a second TR jet arising through the ATL near the lateral portion of the annulus, and a crescent-shaped left ventricle, which had adequate systolic function. The TV was inspected through virtual right atriotomy and right ventriculotomy using RT-3D-TEE after acquiring full-volume data and zoomed images from midesophageal windows. The PTL was rudimentary and stuck to the right ventricular wall when seen through the RV (Fig 2, Video 2). A fenestration was noticed in the ATL near the lateral aspect of the TV annulus on enfacedzoomed view after cropping through the right atrium (Fig 3). After systemic heparinization, cardiopulmonary bypass was established and electromechanical quiescence of the heart was achieved with antegrade administration of cold blood cardioplegia. The rudimentary nature of the PTL and the presence of fenestration in the ATL were confirmed by the surgeon after right atriotomy. During surgery, the STL and ATL were detached from the RV wall and the annulus, respectively. Cone repair was performed by rotating the ATL toward the STL and suturing their free margins together. Suture annuloplasty of the TV was performed along with closure of the fenestration and plication of the atrialized segment of the RV. The ASD was made restrictive. The patient was weaned from cardiopulmonary bypass with inotropic infusions of milrinone 0.5 μg/kg/min, and norepinephrine, 0.05 μg/kg/min. The TEE examination found a coneshaped TV that had its base at the atrioventricular junction and apex in the RV cavity, with a mean inflow gradient of 2 mmHg (Fig 4, Video 3). The apical area of the cone, which was about 2.4 cm 2 , could be measured in the enface view via virtual right ventriculotomy. The mitral valve and tricuspid valve were inspected side-by-side using RT-3D-TEE (Fig 5, Video 4), which showed the difference in the shape of the apparatus of both valves. Both the valves had simultaneous closure at the end of diastole. The patient was transferred to the intensive care unit and artificially ventilated for 10 hours. She had an uneventful recovery in the postoperative period and was discharged from the intensive care unit on the second postoperative day.

In the current scenario the costs of performing minimally invasive cardiac surgery are very high primarily due to the high cost of hardware used, limiting its widespread usage especially in a developing country like ours. The aim of our study was to test the feasibility and safety of performing minimally invasive surgery to repair simple congenital cardiac defects using standard equipment. From July 2011 to March 2012, 59 patients, weighing between 7 kg to 32 kg underwent closure of their defects via lower ministernotomy. Forty six cases were Ostium Secundum Atrial Septal Defect (OSASD), four cases had OSASD with Valvar Pulmonary Stenosis (PS), five cases of moderate Ventricular Septal Defect (VSD), three cases of Sinus Venosus Atrial Septal Defect (SVASD) and one case of Partial AtrioVentricular Canal Defect (PAVCD). All patients underwent central canulation of aorta and vena cava. Standard cannula and instruments were used during the procedure. The length of the postoperative scar measured ranged from 3.5 to 8 cm. One SVASD was converted to complete sternotomy because of high drainage of the Partial Anomalous Partial Venous Connection (PAPVC). None of the patients had any emergency conversion, re-exploration or neurological side effects. One patient had a tiny residual VSD and another patient had a pericardial effusion that required drainage. Repair of most simple congenital cardiac defects can be safely performed through a lower ministernotomy approach. The procedure resulted in a cosmetically appealing scar and decreased patient morbidity without using any special expensive instruments.

Origin of a common carotid artery from a pulmonary artery is extremely rare, but isolated origin of an internal carotid artery from a pulmonary artery with intracardiac anomaly has not been reported before. We report a case of the left internal carotid artery arising from the left pulmonary artery in a case of tetralogy of Fallot. The possible embryologic mechanism and the surgical management of this unique lesion are described.

The aim of this study was to investigate a rare subset of adult patients with double-chambered right ventricle, pertaining to clinical presentation, rhythm disturbances, surgical approach, and results of surgical repair. A retrospective review of our records revealed that 14 adults had undergone surgical repair of double-chambered right ventricle from 1990 to 2010. Their median age was 25.5 years, and their median weight was 50 kg. Patients presented with various symptoms, the most common being dyspnea on exertion. The mean systolic pressure gradient across the obstruction was 69.8 ± 23.1 mm Hg. The most common associated anomaly was ventricular septal defect. Significant rhythm disturbances were present in 4 patients. Transatrial repair was undertaken in 5 patients, a combined transatrial and transpulmonary approach was used in 4, and a right ventriculotomy in 5. There was no mortality at a median follow-up of 5.1 years. A mild right ventricular outflow tract gradient was noted in 2 patients. Medical management was required for rhythm disturbances in 2 patients. Double-chambered right ventricle can present in adulthood, often with vague symptoms. The midterm results of surgical correction are satisfactory. Long-term follow-up is necessary to detect late arrhythmias.

TRIAL SEPTAL DEFECTS (ASDs) are usually repaired through a median sternotomy under general anesthesia and cardiopulmonary bypass (CPB). However, a right anterolateral thoracotomy 1 or right-limited posterior thoracotomy 2 approach can be used for cosmetic reasons for closure of an ASD. The anesthetic management is similar to any other cardiac surgical procedure; however, tracheal intubation with a left-sided double-lumen endobronchial tube (DLT) is preferred (if feasible) to permit collapse of the right lung and to facilitate surgical exposure.1 In the lateral thoracotomy position, in a paralyzed patient during two-lung ventilation, the dependent lung receives more perfusion and the nondependent lung receives more ventilation, whereas during one-lung ventilation the dependent lung is well ventilated and well perfused. 3 Airway collapse in the dependent lung during two-lung or onelung ventilation would be expected to result in severe ventilation-perfusion mismatch (desaturation) and increased afterload to the right ventricle. A repeated failure of weaning from CPB after ASD closure is described in a child operated through a right limited posterior thoracotomy who developed collapse of the dependent lung because of complete obstruction of the left bronchus with very thick secretions. The left lung could not be expanded despite repeated tracheal suctioning and washing under fiberoptic bronchoscopy. The patient was finally weaned from CPB after reducing tidal volume to one third of the required tidal volume. The pathophysiology of the intraoperative complications, management, and implications of these complications for cardiac surgical procedures approached through a right thoracotomy are discussed. CASE REPORT*

OBJECTIVES Balloon atrial septostomy (BAS) is an effective palliative procedure in children with transposition of the great arteries and poor intercirculatory mixing. While the subpulmonary left ventricle (LV) is known to regress with time in these newborns due to the declining afterload, it has not been studied how it behaves following BAS and a consequent decrease in preload. The study was designed to examine the effects of BAS on the LV in infants with simple d-transposition of the great arteries by serial 2D echocardiographic monitoring. METHODS This was a prospective echocardiographic follow-up study of all consecutive children with simple d-transposition of the great arteries who underwent BAS for restrictive interatrial communication and oxygen saturation below 75% between January 2014 and June 2015. Left ventricular mass estimation was done by M-mode transthoracic echocardiography before balloon septostomy and serially on follow-up till surgery. RESULTS The median age of the 25 children studied was 4 days (1-95 days) when they underwent BAS. Twenty patients underwent arterial switch operation at a mean of 9 days from balloon septostomy. The mean baseline left ventricular mass was 47.9 g/m2, which decreased to 38.5, 36.2, 32.1, 32.4, 25.7 and 25.2 g/m2 on Days 1, 3, 6, 9, 12 and 15, respectively. The left ventricular mass decreased by 1.5 g/m2 every day during the first 2 weeks following balloon septostomy adjusted for the age of the child in days. Children who underwent BAS beyond 3 weeks of life had faster LV regression than those who underwent the procedure earlier (unstandardized regression coefficient β 0.892, P < 0.001). CONCLUSIONS BAS is associated with accelerated regression of the LV in infants with simple d-transposition of the great arteries in the first 2 weeks after the procedure. Regression of the LV is faster in children who underwent BAS after 3 weeks of age.

Objectives The incidence of endotracheal tube (ETT) malposition in children with various described methods is 15% to 30%. Chest x-ray (CXR) is the gold standard for confirming appropriate ETT position. The aim of this study was to measure the accuracy of a preoperative CXR-based method in determining depth of insertion of ETTs and to compare it with methods based on the intubation depth mark or formulae (age, height, and ETT internal diameter) in children undergoing cardiac surgery. Design Prospective observational study. Setting University-affiliated tertiary care hospital. Participants Sixty-six consecutive children scheduled for elective pediatric cardiac surgery. Interventions None. Measurements and Main Results The distance from carina to mid-trachea was measured for each child preoperatively on the CXR displayed as a computed radiography image in a picture archival and communications system computer. Following intubation, ETTs deliberately were pushed endobronchially and then pulled back to the carina; they were further withdrawn by the previously measured carina to mid-tracheal distance and secured. CXRs postoperatively were repeated to confirm ETT position. The ETT position was measured with other methods using the picture archival and communications system ruler on the postoperative CXR and compared with the CXR method. The proportion of appropriate ETT position with the CXR method was 98.5% (p≤0.001 v other methods). In children younger than 3 years, the appropriate proportion was 97.4%. Conclusion The appropriate positioning of ETTs in the trachea by the CXR method is superior to other methods.