Quiz #5 Answers: WPW syndrome

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Questions:
1) What is the diagnosis?
2) Where is the pathway located?

Answers:
1) WPW syndrome (Short PR interval and Delta wave)
2) Right posteroseptal accessory pathway

Thanks to Dr. Numan for advice with interpretation.

There are several algorithms. Two are given below. None of them is perfect. But, they help.
(Click on the image to see a large image)
Bibliography:
Fitzpatrick et al. J Am Coll Cardiol. 1994 Jan;23(1):107-16, (Erratum in
J Am Coll Cardiol 1994 Apr;23(5):1272).
Fitzpatrick J Electrocardiol. 1993;26 Suppl:220-6.
Fitzpatrick PACE 1995.
Arruda et al. J Cardiovasc Electrophysiol 1998;9:2-12.
http://awolecg.blogspot.com/2009/10/wpw-localization-of-accessory-pathway.html
& there are many more!

Answer to Quiz #4: EKG - Pacemaker

Question: What's wrong?

Answer:

Ventricular wire is inserted into atrial outlet of the pacemaker and atrial wire into the ventricular outlet!

Finding in the EKG strip: In each beat, first pacing-spike elicits a QRS complex followed by the second pacing spike that elicits a P wave!

Answer to Quiz #3: Surgical anatomy - Arrangement of Atrial Appendages

Answer:
Arrangement shown is juxtaposition of atrial appendages. First figure is juxtapositioning of atrial appendages to the right side of great arteries. Second figure is juxtapositioning of atrial appendages to the left side of great arteries.

Left juxtapositioning (86%) is more common than right juxtaposition (14%) - based on autopsy study of 49 cases with juxtaposition.

Left juxtaposition is associated with complex heart defects more often than right juxtaposition.
Common associations with left juxtaposition are (i) Tricuspid atresia, (ii) Transposition and (iii) DORV.
Common associations with right juxtaposition are (i) Outflow tract obstruction, (ii) Anomalous venous return and (iii) DILV.

Ref:
1) Echocardiography in Pediatric Heart Disease by R. Snider et al. 2nd ed. 1997 (p.562)
2) Cardiovascular Pathology 2011; published online Apr 11, 2011

Answer to Quiz #2: Scimitar Syndrome

Answer:

Abdominal aortogram shows accessory pulmonary blood flow via aorto-pulmonary collateral arteries. The pulmonary venous return (at the end of the angiogram) returns to IVC-RA junction constituting partial anomalous pulmonary venous return.

This is scimitar syndrome.

Scimitar syndrome is characterized by (i) Lung sequestration (usually, right lower lobe), (ii) Accessory blood flow to the sequestered segment from abdominal aorta and (iii) Partial anomalous pulmonary venous return - drainage to IVC).

Pulmonary hypertension may occur in newborn and infants. Exact pathogenesis of pulmonary hypertension in Scimitar syndrome is unknown. Neonatal or infantile presentation with symptoms and presence of pulmonary hypertension is a bad prognostic signs.

Recurrent pneumonia in the sequestered lung segment is an indication for removal of the sequestered lung segment.

Transcatheter intervention: Coil occlusion of acc. pulmonary blood flow helps to reduce the vascularity. When the surgeon goes to remove the sequestered lung segment, prior coil occlusion of accessory blood flow to the sequestered segment saves the surgeon having to deal with ligating the blood vessels in the abdomen.

Journal article on Scimitar syndrome - 20 year experience from Toronto.