Slim et al.'s paper provided an insight into the differences between repaired tetralogy of Fallot and isolated pulmonary regurgitation in their strain. Repaired tetralogy of Fallot had higher right ventricular circumferential strain, while isolated pulmonary regurgitation relied on longitudinal strain more. This allowed the authors to infer that repaired tetralogy of Fallot can withstand more chronic regurgitation before valve replacement is necessary. We highlighted new findings relevant to this paper. Arrhythmia in repaired tetralogy of Fallot is associated with a reduced global circumferential strain of the right ventricle. Specifically, a value of below -14% was associated with a 6.3 times increase in the risk for an arrhythmic event. We believe this would be beneficial for patients when considered for valve replacements, suggesting modification of current valve replacement guidelines to include strain thresholds alongside current volumetric thresholds.However, the data for isolated pulmonary regurgitation remains scarce. Further investigation is needed to provide clearer timelines for valve replacement. We emphasised the importance of exploring the underlying architecture of repaired tetralogy of Fallot patients' hearts and why they could generate more global circumferential strain. We acknowledged the broader effect of this paper and its specific benefit in our country, Egypt. This paper provided insights useful for broader global health impact, especially in low-income countries.

Unilateral absence of the pulmonary artery is a rare congenital defect requiring advanced imaging for diagnosis. We present two cases with a connection between a patent ductus arteriosus remnant and the left pulmonary artery. Therapeutic approaches, including imaging findings and management strategies, are discussed to highlight diagnostic and treatment considerations.

Coronary to pulmonary artery fistula is a rare malformation that can be detected incidentally because most cases are asymptomatic. Here, we present multiple micro coronary to pulmonary artery fistulas in a Fontan physiology adult patient, which leaded dyspnoea due to elevated pulmonary artery pressure and were successfully closed with vascular plugs from the pulmonary side.

Central venous catheter use is not standardised in paediatric cardiology, yet it is associated with additional morbidity. We aimed to characterise variation in central venous catheter use and complications across paediatric acute care cardiology units. This retrospective, multi-centre, and registry-based study examined all unique acute care cardiology encounters from February 2019 through September 2021 in the Paediatric Acute Care Cardiology Collaborative registry. Descriptive and comparative statistics were assessed for differences based on central venous catheter use. Multivariate logistic regression identified factors associated with increased line duration and use frequency. About 35,379 encounters from 24 institutions were assessed. About one in five encounters had at least one central venous catheter (n = 7,524, 21.3%). Neonates and post-operative cardiothoracic surgery patients were more likely to have central venous catheters than not (28.9% of neonates with, versus 11.4% without; 58.4% of post-operative patients with, versus 35.7% without; p < 0.001). Most patients after STAT 4 procedures retained central venous access for over half of the acute care cardiology stay. Institutions with overall "low" central venous catheter utilisation rates (<20%) also used central venous access most often on STAT 4 patients (p < 0.0001). Complication rates for venous thrombus and central line-associated bloodstream infection were low (1.9% and 0.2%). There is variable utilisation of central venous catheters across participating acute care cardiology units, though overall they are common vascular access modalities. Acute care cardiology units use central venous catheters more often in neonates, those after cardiac surgery, and in their higher-risk patients (i.e. after STAT 4 procedures).

We report a rare case of coronary sinus ostium atresia diagnosed due to impaired cardiac function caused by Marshall vein stenosis, which occurred during surgical treatment. Transcatheter perforation of the coronary sinus ostium and stenting of the Marshall vein stenosis improved ventricular function, enabling subsequent surgical enlargement. This staged strategy minimised surgical risks and demonstrated a reliable and effective treatment for such challenging conditions.

Severe dilated cardiomyopathy in children may uncommonly be caused by abnormal loading conditions such as mid-aortic pathology and renal artery stenosis. Refractory hypertension and left ventricular dilatation with hypertrophy are important clues to reversible causes. We present a case of dilated cardiomyopathy in a child secondary to mid-aortic syndrome with renal artery stenosis.

Congenital extrahepatic portosystemic shunt (CEPS) is an uncommon condition in which the portal vascular system drains into the systemic veins. We describe an unusual case of CEPS with congenital heart disease, presenting with aneurysmal enlargement of the pulmonary artery and symptoms of airway compression, highlighting the importance of evaluating for additional pathology in case of unexplained oxygenation defect or pulmonary hypertension.

Clinical outcomes of a standardised enhanced recovery after surgery protocol, including thoracic epidural analgesia, were studied in children undergoing trans-atrial cardiac surgery via the right mid-axillary thoracotomy approach. This single-centre retrospective study examined 42 paediatric patients who underwent trans-atrial cardiac surgeries via the mid-axillary approach (2018 to 2020), of whom 30 received epidural catheters. The standardised enhanced recovery after surgery protocol included transesophageal echo-guided thoracic epidural catheter placement, multimodal analgesia, reduced opioid use, and planned early extubation and discharge. Clinical outcomes assessed included extubation times, postoperative analgesic requirements, ICU pain scores, hospital length of stay, and any complications related to regional anaesthesia or surgery. Thirty patients received an epidural placed between the third and sixth thoracic interspace levels under transesophageal ultrasonography guidance. The median age was 42 months (range 3-156), and the median weight was 15.7 kg (range 4.9-61 kg). Epidural infusions were continued for a median of 52 hours postoperatively. The intraoperative fentanyl usage was a median of 4.5 mcg/kg (interquartile range (IQR) 2-9). Intraoperative extubation was achieved in 28 of the 30 patients. Median post-extubation pain scores in the first 6 and 12 hours were 0 (IQR 0), and postoperative rescue opioid requirements were low in epidural patients. There were no instances of tracheal reintubation, neuraxial blockade-related complications, or other anaesthesia-related adverse events. Through our standardised and reproducible anaesthetic protocol, we achieved excellent and nearly pain-free recovery in paediatric patients undergoing trans-atrial cardiac surgeries via the mid-axillary approach.

Scimitar syndrome is characterised by anomalous right pulmonary venous drainage to the inferior vena cava associated with right pulmonary artery hypoplasia. We present a case of an infant with Scimitar syndrome with a well-formed right pulmonary artery, in high Qp heart failure who was managed with right pulmonary artery banding after thorough haemodynamic evaluation.

Double-outlet right ventricle is a complex congenital cardiac anomaly in which both great arteries arise predominantly from the right ventricle. Accurate anatomical evaluation is critical for surgical planning. While transthoracic echocardiography is commonly used for intracardiac assessment, its limitations in visualising extracardiac structures highlight the need for additional imaging modalities like CT angiography. To compare the diagnostic accuracy and clinical utility of transthoracic echocardiography and CT angiography in the pre-operative evaluation and surgical planning of infants with double-outlet right ventricle. This retrospective, single-centre study included 78 infants diagnosed with double-outlet right ventricle. All patients underwent both transthoracic echocardiography and CT angiography before surgical intervention. Imaging findings were compared with intraoperative surgical results to assess sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for each modality. CT angiography was significantly more effective than transthoracic echocardiography in identifying extracardiac anomalies such as coronary artery anomalies (p = 0.014), aortic arch hypoplasia (p = 0.024), aortopulmonary collateral vessels (p = 0.039), anomalous pulmonary venous connections (p = 0.001), and persistent left superior vena cava (p = 0.001). In contrast, transthoracic echocardiography was more sensitive in detecting small ventricular septal defects (p = 0.035). Transthoracic echocardiography remains the first-line modality for intracardiac evaluation in double-outlet right ventricle, but CT angiography provides superior visualisation of extracardiac structures. The combined use of both imaging techniques improves diagnostic accuracy and surgical planning, supporting better outcomes in the management of CHD.