Anomalous Anatomy Research Articles

Angiographic Profile of Coronary Artery Disease in Patients of Heart Failure Attending in BPKIHS, Nepal

INTRODUCTION Coronary Angiography in heart failure is one of the diagnostic modalities that acts as complementary tool in the management. Very few studies are conducted in Nepal regarding prevalence of CAD in HF. CAD has been one of the etiologies in 18% patients of Heart failure.1 On categorizing heart failure patients into ischemic and non-ischemic groups and knowing any anomalous anatomy would be feasible to intervene as essential and decrease in recurrent hospital admissions and improve quality of life. Our current study aimed to evaluate various characteristics and profiles of Coronary Arteries in the heart failure subjects after Coronary Angiography. METHODS It was a single center hospital based descriptive cross-sectional study conducted at BPKIHS from October 2022 to October 2023 in heart failure patients who underwent CAG. Heart failure patients were selected based on Framingham criteria. RESULTS Out of total 78 patients 64.15 were males and mean age was 62.4±13.69 years. There were 47.4% patients with HFrEF, 28.2% with HFmrEF and 24.4% were having HFpEF. Significant CAD was found in 70.5%, normal Coronary artery was present in 2.8%, 2.5% had anomalous coronary artery, minor CAD was found in 2.6% while 5.1% had moderate CAD. Prevalence of significant CAD was found in 70.3% patients with HFrEF, 68.2% in HFmrEF whereas HFpEF had significant CAD in 73.7% subjects. Significant CAD in males and females were 48.7% and 70.5% respectively. Smoking was the most common risk factor present in our study population. Most common presentation were Basal Lung Crepitations, Raised JVP, Hepatomegaly and Leg Swelling. CONCLUSION Our result suggests higher prevalence of CAD in HFpEF (73.7%) followed by HFrEF (70.3%) and HFmrEF (68.2%). Coronary anomaly was seen in 2.5% while angiographic profile revealed abnormal coronary artery to be more frequent in HF subjects which was quite comparable to other similar studies of Heart failure.

Sub-coronary aortic root replacement post-aortic valve dehiscence: a case report

This is a case report of a 78-year-old male who underwent a sub-coronary aortic valve and root replacement due to valve dehiscence and aortic root pseudoaneurysm. The patient had complex anomalous coronary anatomy and had undergone a previous tissue aortic valve replacement in 2013. The patient made an uneventful recovery and was discharged from the hospital five days later. The authors suggest that the sub-coronary root replacement technique should be considered in elderly patients and patients with complex coronary anatomy.

An institutional study on accuracy of freehand cervical C1 C2 screws placement by knock and drill technique in craniovertebral anomalous bony anatomy: An evaluation of more than 600 screws based on SGPGI screw accuracy criteria.

To assess the accuracy of freehand cervical C1 C2 screws placement by knock and drill (K and D) technique in craniovertebral anomalous bony anatomy. From January 2017 to December 2022, 682 consecutive C1 C2 screws in 215 patients with craniovertebral junction (CVJ) anomalies were enrolled. All patients underwent posterior fixation with K and D technique without any fluoroscopic guidance. The patient's demographic details, clinical details, radiological details, major intraoperative events, and postoperative complications were noted. The screws malposition grades and direction on CT images in the axial and sagittal plane were defined as new per proposed "SGPGI accuracy criteria." All patients had a clinical evaluation at 3-month follow-up. Total 682 C1, C2 screws were placed in 215 patients for CVJ anomalies using K and D technique. The accuracy of screws placement by freehand technique was 84.46% (576/682). So with technique explained the rate of malplacement in simple (16.35%) and complex (15.19%) groups were almost comparable and comparison difference was not significant (P = 0.7005). The freehand technique, as described, is effective in cases of anomalous bony anatomy, and it is mandatory in complex CVJ anomalies. The accuracy of screw placement and VA injury is comparable with major studies. This technique is supposedly cost-effective and less hazardous to both health-care workers and patients.

Unique Case of Anomalous Anatomy of the Right Coronary Artery from the Pulmnary Artery

Anomalous origin of the right coronary artery from the pulmonary artery is one of the rare congenital coronary diseases. The percentage of population damage is 0.002 %. In most cases this occurrence is asymptomatic and diagnosed accidentally like our case. Here, we report a 9-month-old female infant who was admitted with a diagnosis multiple muscle ventricular septal defects. For diagnostic we used echocardiogram, as a result an anomalous origin of the right coronary artery from the pulmonary artery was suspected. After that, coronary computed tomography angiography confirmed the diagnosis. The patient underwent surgical correction by redeployment of the coronary artery in aorta. The aim of our report is to describe the successful correction of a potentially fatal disease. Early diagnostic can provide effective treatment.
 
 

Visual Attention Toward Patients with Hemifacial Microsomia Reconstruction: A Prospective Eye-Tracking Study.

Facial areas attracting the most visual attention in Hemifacial Microsomia (HFM) are poorly understood. Further, it is not clear if and how visual attention changes from pre- to post-operatively. This study characterized layperson visual attention to pre- and post-reconstruction hemifacial microsomia (HFM) using eye-tracking technology. Visual fixations (Tobii Pro Nano) were recorded in four areas of interest from sixty participants completing two consecutive trials of 68 total images in each hemi-face of 17 patients with HFM pre- and post- orthognathic jaw reconstruction. Linear mixed effect models evaluated if visual fixations were affected by surgical reconstruction. 47,354 visual fixations were captured over 120 trials within defined AOIs. Linear mixed effect models revealed significantly decreased postoperative visual fixations in the mandible and chin region [716 (54.8%) pre-reconstruction, 591 (45.2%) post reconstruction; β = -0.198, SE = 0.056, z = -3.550, p < 0.001]. Analysis also revealed significantly increased postoperative visual fixations in the forehead and orbit region [11350 (48.6%) pre-reconstruction, 12000 (51.4%) post-reconstruction; β = 0.086, SE = 0.015, z = 5.664, p < 0.00001]. Following corrective jaw surgery for HFM, laypersons demonstrated significantly less visual attention to the mandible and chin and increased visual attention to the forehead and orbit. These findings suggest postoperative improvement towards aesthetic normalcy may reduce visual attention to previously anomalous anatomy.

Endoscopic Findings on Facial Nerve Anatomy During Exclusive Endoscopic Stapedotomy: Clinical Considerations and Impact on Surgical Results.

Variations along the facial nerve (FN) course present considerable challenges in the surgical treatment of otosclerosis, often complicating the procedure. Existing knowledge of its tympanic tract and its implications primarily comes from microscopical procedures. This study aims to assess endoscopic findings of FN anatomy in a healthy tympanic cavity and its impact on the stapedotomy procedure, focusing on the risk of complications and functional hearing outcomes. A retrospective study on exclusive endoscopic stapedotoplasties between October 2014 and October 2021 at our Otorhinolaryngology University Department was carried out. An evaluation of intraoperative endoscopic findings reviewed in surgical descriptive and/or video records was conducted to assess their potential negative impact on the surgery. Demographic data, preoperative and postoperative hearing thresholds, as well as intraoperative and postoperative complications were analyzed. One hundred fifty-seven subjects were included. A FN partially overhanging the oval window was observed in 7.3% (n=12): 10 prolapsing with bony canal dehiscence and 2 without any detected dehiscence. Each procedure was successfully completed without any issues related to the anomalous anatomy, and in no case, switching to the microscope for the handling of the prosthesis near the dehiscent nerve was required. No facial paralysis occurred, with an early- or long-term postoperative House-Brackman grade of 1 (n=157, 100%). Only 3/157 patients (1.9%) showed a sensorineural threshold reduction of ≥20 dB HL, but a significant air-bone gap improvement was observed (mean closure of 18.36 dB HL, P -lt; .0001). The endoscope promotes a concrete description of tympanic FN anatomy, and endoscopic stapes surgery appears to be a safe and viable option when dehiscent or prolapsed FNs reduce the footplate's exposure.

Outcomes of the Arterial Switch Operation in Patients With Dextrocardia

Patients with dextrocardia and d-transposition of the great arteries (d-TGA) present a technical challenge when performing the arterial switch operation (ASO). We sought to determine the long-term outcomes of this rare presentation. All patients who underwent the ASO with d-TGA and dextrocardia were identified from the hospital database. There were four patients with dextrocardia (4 of 844, 0.5%) patients; two patients had situs solitus and two patients had situs inversus. Three patients had a ventricular septal defect. Left ventricular outflow tract obstruction was present in one patient and one patient had a hypoplastic arch with severe coarctation of aorta. Anomalous coronary anatomy occurred in two patients. There was one early mortality and the cause of death was sepsis. One patient required late reoperation for severe neo-pulmonary valve regurgitation at 23 years after the ASO. At last follow-up, all three surviving patients were in New York Heart Association Class I. Patients with d-TGA and dextrocardia who undergo the ASO are extremely rare and require challenging operative management.

Ulnar Nerve Compression at the Elbow Secondary to Intramuscular Lipoma of the Flexor Carpi Ulnaris: A Case Report.

A 62-year-old right-hand-dominant woman presented with 1 year of persistent radiating pain, weakness, and paresthesias in her left forearm and hand. Electromyography findings were significant for ulnar neuropathy distal to the branch innervating the flexor carpi ulnaris (FCU), without superimposed cervical radiculopathy or other focal entrapment neuropathy. During open ulnar nerve neurolysis, an intramuscular lipoma was encountered within the FCU. Lipoma excision and cubital tunnel release with ulnar nerve transposition were performed with complete relief of neuropraxia. We demonstrate full neurologic recovery after intramuscular lipoma excision and cubital tunnel release. Although rare, anomalous anatomy and tissue overgrowth should remain on the differential for patients presenting with atypical neuropraxia.

Paediatric subarachnoid haemorrhage and severe vasospasm secondary to traumatic pseudoaneurysm of a fenestrated vertebral artery: a case report and review of the literature

Paediatric intracranial aneurysms are rare entities accounting for less than 5% of all age intracranial aneurysms. Traumatic aneurysms are more common in children and have an association with anatomical variations such as arterial fenestrations. Here, we present a case of a child initially presenting with traumatic subarachnoid haemorrhage who returned to baseline and was discharged home only to return within 2 weeks with diffuse subarachnoid and intraventricular re-haemorrhage. A dissecting aneurysm of a duplicated (fenestrated) V4 vertebral artery segment was identified as a rare cause of rebleeding. We describe a course complicated by severe vasospasm delaying aneurysm detection and treatment. Dissecting aneurysms in children should be considered in all cases of delayed post-traumatic cranial rebleeding, particularly where there is anomalous arterial anatomy.

Visual Attention, Bias, and Social Dispositions Toward People With Facial Anomalies: A Prospective Study With Eye-Tracking Technology.

Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. The purpose of this study was to determine associations of visual attention with bias and social dispositions toward people with facial anomalies. Sixty subjects completed tests evaluating implicit bias, explicit bias, and social dispositions before viewing publicly available images of preoperative and postoperative patients with hemifacial microsomia. Eye-tracking was used to register visual fixations. Participants with higher implicit bias scores fixated significantly less on the cheek and ear region preoperatively (P = 0.004). Participants with higher scores in empathic concern and perspective taking fixated more on the forehead and orbit preoperatively (P = 0.045) and nose and lips (P = 0.027) preoperativel. Participants with higher levels of implicit bias spent less visual attention on anomalous facial anatomy, whereas participants with higher levels of empathic concern and perspective taking spent more visual attention on normal facial anatomy. Levels of bias and social dispositions such as empathy may predict layperson gaze patterns toward those with facial anomalies and provide insights to neural mechanisms underlying the "anomalous is bad" paradigm.

Major Aortopulmonary Collaterals From Coronary Arteries and Dual Left Anterior Descending Artery in an Adult With Tetralogy of Fallot.

Major aortopulmonary collaterals (APCs) are more common with tetralogy of Fallot (TOF) with pulmonary atresia. Collateral arteries, when present, arise most commonly from the descending thoracic aorta, less commonly from the subclavian arteries, and rarely from the abdominal aorta or its branches or from the coronary arteries. Collaterals arising from the coronary arteries can cause myocardial ischemia due to coronary steal phenomenon. They can be addressed either by endovascular interventions like coiling or surgical ligation during the intracardiac repair. Coronary anomalies are seen in 5%-7% of TOF patients. In approximately 4% of TOF patients, the left anterior descending artery (LAD) or an accessory LAD takes origin from the right coronary artery or right coronary sinus and crosses the right ventricular outflow tract in its course toward the left ventricle. Presence of such anomalous coronary anatomy poses certain challenges during intracardiac repair of TOF.

Surgical treatment of craniovertebral junction instability in children with Down syndrome: a systematic review.

Down syndrome (DS) affects 1 in 700 live births and approximately one-third of patients develop craniovertebral junction (CVJ) instability, diagnosed by clinical examination and radiological measures such as the atlantodens interval (ADI) and space available for the cord (SAC). Patients with symptomatic CVJ instability are at increased risk for spinal cord injury. There are no guidelines for surgical management of CVJ instability in DS, the existing literature is sparse, and there is a lack of consistent pediatric data. This systematic review aimed to synthesize practice patterns of the surgical management of CVJ stability in pediatric DS patients to facilitate future standardization of care. Peer-reviewed studies reporting surgical management of CVJ instability in pediatric DS patients were systematically reviewed. Inclusion criteria were studies reporting primary data on patients younger than 18 years with DS, who had CVJ instability evaluation and underwent surgical treatment. Bias risk was assessed. Descriptive statistics of the independent patient data were presented. Interval variables were analyzed using the Wilcoxon rank-sum test. Of 1056 records, 38 studies were included. Of the included patients, 169 (6%) underwent surgery. The surgical indication was symptomatic, radiologically confirmed CVJ instability in 81% of the patients, presenting with myelopathy (30%), weakness (25%), abnormal gait (24%), torticollis (15%), and neck pain (14%). A cutoff of ADI ≥ 4 mm or SAC ≤ 14 mm, cord compression, cord signal change, and anomalous bony anatomy were used in diagnosing CVJ instability. Surgical approaches focused on internal fixation with posterior occipitocervical or atlantoaxial instrumented fusion in 57% and 44% of patients, respectively. Autograft, wiring, and allograft constructs were used in 48%, 45%, and 9% of patients. Anterior cervical approaches were performed in 6% of patients. Preoperative and postoperative external orthoses were used in approximately 50% of patients. The surgical mortality rate was 3%, and the complication rate was 36%. Assessment of CVJ instability in DS is based on radiographic and clinical factors. Surgery is recommended if symptoms are present, and the procedure type depends on patient factors, degree of instability, anomalous bony anatomy, and reduction results to relieve cord compression. Most commonly, posterior instrumented fusion is used. However, further research is required to determine the strength of evaluation methods, create standardized guidelines for evaluation and surgical treatment, and investigate the long-term results of different surgical techniques.

Biventricular repair in an infant with transposition of the great arteries and straddling of the tricuspid valve.

Biventricular repair is challenging in patients with transposition of the great arteries and straddling of the atrioventricular valves. Biventricular repair is the preferred option because of its anatomical and physiological advantages. However, in cases where biventricular repair carries operative risks that are too high or cases with unsuitable intracardiac anatomy, univentricular heart repair may have to be chosen. We report a five-month-old male patient with transposition of the great arteries, an inlet ventricular septal defect and anomalous coronary anatomy who had previously undergone a pulmonary banding operation and balloon atrial septostomy. Successful biventricular repair was performed while the patient had straddling of the tricuspid valve.

Once in a Blue Moon: Iatrogenic Coronary Dissection in Anomalous Coronary Artery

Coronary anomalies present as a rare phenomenon. One of the most observed coronary anomalies is the single coronary artery (SCA) originating from one coronary ostium and dividing into the coronary arteries in various configurations1Angelini P. Coronary artery anomalies: an entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (532) Google Scholar, classified by Lipton’s Classification.2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (414) Google Scholar A 38-year-old male patient was admitted to a community hospital with typical signs of non-ST-elevation myocardial infarction (NSTEMI) but without any known comorbidities. Urgent coronary angiography revealed a rare anomaly (incidence of 0.008%3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Google Scholar,4Mohanty A. Chandra S. A rare case of 'superdominant' single coronary artery.Indian Heart J. 2015; 67: 389-391Abstract Full Text Full Text PDF Google Scholar) of an SCA with the left coronary system originating from the right coronary periphery, posterior to the great vessels (Lipton’s Classification R-IP, table 1) and occlusion of the circumflex artery (CX) (figure 1a-b, video 1). A culprit-lesion percutaneous coronary intervention was attempted. However, despite the use of various flexible guidewires and angled microcatheters (90°) CX passage through the left main artery equivalent (LMA) was not achieved (video 2) and resulted in ST elevation. A prompt control demonstrated a dissection of the LMA (figure 1c, video 3). Further interventional approaches were waived and the patient was transferred for surgical revascularization.Table 1Lipton’s Single Coronary Artery Classification2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (414) Google ScholarCodeDescriptionOstial LocationRRight Sinus of ValsalvaLLeft Sinus of ValsalvaAnatomical DistributionIThe solitary domain vessel follows the course of either a normal right or left coronary arteryIIOne coronary artery arises from the proximal part of the normally located other coronary arteryIIILAD and CX arise separately from a common trunk originating from the right sinus of ValsalvaCourse of the Transverse TrunkAAnterior to the great vesselsBBetween the aorta and the pulmonary arteriesPPosterior to the great vesselsSSeptal Type: A part of the route passes through the interventricular septumCCombined Type: Combination of diverse routes Open table in a new tab Intraoperatively, coronary dissection could be confirmed, whereas the left anterior descending artery (LAD) and CX were identified in the typical locations. Coronary revascularization was performed by anastomosis of the left internal mammary artery to the LAD, and a saphenous vein graft to the CX in perfusion-assisted beating heart technique. The postoperative course remained uneventful and the patient was discharged on the 10th postoperative day. The main issue in SCA persists in the dependency on one system with fatal results in proximal occlusion. Since the overall incidence of coronary anomalies is very low3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Google Scholar, the treatment strategy for acute coronary syndromes in patients with anomalous coronary anatomy remains questionable. In particular, an interventional approach in complex coronary anatomy can result in coronary injury. Since in cases of myocardial infarction time matters most, a deep – even inter-hospital – heart team approach is crucial to maintain in-time life-saving treatments. •Lipton’s Classification R-IP is the rarest form of single coronary artery configuration with the left coronary system originating from the right coronary periphery.•Percutaneous coronary intervention of the left coronary system may be very challenging in Lipton’s Classification R-IP•Surgical revascularization is a reasonable strategy in particular when the coronary periphery location is in typical location.•A deep heart team approach is crucial to maintain in-time life-saving treatments in such critical and complex cases. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1ZWIwZTk5NTRiZWEzMDA2MGVlNzI5MmM4OTZjNDlmYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.My1bJvayG27S7R8PKVtQsWVd9XLKhwldpsEWqzuMHIzYxOz_VIFRiJulyjzbngC4CyNUqZMU_qmU-_r_3QPgVbNU2xkwNmcDVsxgXDGD3oSMx3rmyXQK-bNXjlY-qh_YzCrTQ4UEB8jH1qiVcNVpHyrGc-MtRjc7v89p3xEBD1aa_Ns-xk1OOfXUrdGlF9O7EQX7iWrHtaVkLbdCUhgxc55eQP4YI97gKqxSTzFKe4nOdxPc5K41oBsMkajdNYt83O5oDph59QzDCmbWJJDlinjzvGQqRFcavZjX7emVYeuqr5DOGxgmXTA36j331owW-wzHpdKn7wy_SAu2l1u30g Download .mp4 (3.49 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzYjhkMDgxYzg2OTRiYTM0MDZmYTgyZDcyYzcxMmI1NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.gH37xsv4GXLcsKMdb-SAuac7Xh_CpCm5C0UOpTzC6x5WB68zYxcjtSgpUhdMHve6TUbPHbeu4gyaKxxZOZFAyXhaMk3R4CzuIFQGSdNyQ3UbqN2MXekQOyGM0i6FNEiLMnWIlxCoQlwOvXWyQ1sI5cKCz5qIkr0f6r_5o2C3gv15nrn3mBIX3vPynprGA_1gHGfLtCQXAvMvVUwYfg-Ba-GOjt1NTSJ0ccCjlQefWR_6jSDTk7NX3BfZ5jU-ybtSzeAxEfALNpfSP2YHm960AaPVaXDNtI0CYb5bkGWLepuD3vzkGAahQrf2K23VUEfho5FELp_CpUVjx4EUMLZ3gA Download .mp4 (1.48 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2MTc2OTE5MTY2ZDM1OTQ1NTUzYTQ3MzcwOTc1OWJlNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.G5pvhhPUt-Kl_kxjdKfL-lOu-rH4hRhKzFlVwwANSrmNUjBoRc_thtwNvFupLmPpm1meakrWBTvBZ-JrBLOAlq6fW3AXl46Qy5drW5RxsehHs52zYd8GMPUQ9Trimxz6LG5NH50cVzlCWKi_iaZKUGpRueErVe1WFrp0YqXxkauvv-qmuoIW2pTQS1IpP-6E3u_z8OpKdj53TlaNfpGQJq3z28Uqw5FsY44sS9OP0k_A6uhflBqSRFLKU22pDTS3TPOUSqoxJAATd7yxU-H9QckIiu6lEHsAS2AKowXlAZiXHJnAcRaOBWAFkXx7eJ-MkLy7Eqms1glQNP6hxmoK4Q Download .mp4 (0.95 MB) Help with .mp4 files

Anomalous left coronary artery presenting with out-of-hospital cardiac arrest: a malignant outcome for a ‘benign’ variant

BackgroundAnomalous left coronary arteries are rare congenital defects. These are often detected incidentally unless they have a malignant course whereby patients present with acute coronary syndromes. We describe a rare presentation of a benign variant of this pathology and a proposed diagnostic and management plan.Case presentationA 41-year-old female was admitted following an out-of-hospital cardiac arrest. Cardiac imaging demonstrated an anomalous left main coronary artery arising from a single right coronary ostium with a trans-septal course and associated ischaemic changes on functional testing. Given her clinical presentation, she underwent successful left coronary reimplantation surgery.ConclusionsThis case highlights that even supposedly ‘benign’ variants can have malignant outcomes and that functional testing can be useful in further risk-stratifying anomalous coronary anatomy. Surgical reimplantation is a feasible and effective treatment for achieving optimal long-term results

Layperson Bias and Empathy Influence Visual Attention Toward Patients with Hemifacial Microsomia: A Prospective Eye-tracking Study

INTRODUCTION: Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. Previous work with functional magnetic resonance imaging (fMRI) has demonstrate implication of certain neuroanatomic structures in visual pathways when viewing others with facial anomalies. For example, laypersons with high levels of implicit bias toward those with facial anomalies demonstrated increased amygdala reactivity. This study aimed to characterize associations between visual attention patterns and implicit biases (attitudes toward groups of people without conscious awareness), explicit biases (attitudes toward groups of people with conscious awareness), and social dispositions toward people with facial anomalies. METHODS: Participants completed an implicit bias association test (IAT), an explicit bias questionnaire (EBQ), and several social disposition tests (e.g. empathic concern and perspective taking) prior to viewing publicly available images of pre- and postoperative patients with hemifacial microsomia (HFM). Eye-tracking was used to register visual fixations. Four areas of interest (AOIs) were defined on each face: cheek and ear, forehead and orbit, mandible and chin, and nose and lips. Linear mixed effects models (LMEMs) in R Studio tested whether locations of participant fixations were affected by surgical correction of HFM and influenced by IAT, EBQ, or social disposition scores. RESULTS: Sixty participants (38 women) were prospectively enrolled. LMEMs revealed participants with higher IAT scores fixated significantly less on the cheek and ear region preoperatively compared to postoperatively (β = 0.115, SE = 0.040, z = 2.855, p = 0.004). Participants with higher scores on empathic concern fixated more on the forehead and orbit preoperatively compared to postoperatively (β = -0.107, SE = 0.053, z = -2.007, p = 0.045) and participants with higher scores in perspective taking fixated more on the nose and lips (β = -0.085, SE = 0.038, z = -2.215, p = 0.027) preoperatively compared to postoperatively. EBQ scores and other social disposition scores did not significantly influence visual fixations in any AOIs based on better fit to the null models. CONCLUSION: Levels of biases, empathic concern, and other social dispositions may influence visual attention toward people with facial anomalies. Those with higher levels of implicit bias may avoid looking at anomalous anatomy, while those with higher levels of empathic concern and perspective taking do not show similar avoidance behaviors. These findings may have neural underpinnings with amygdala reactivity modulating visual activity in response to facial anomalies. This study has implications for the experience of patients with craniofacial anomalies and for characterizing neurologic mechanisms of the ‘beauty-is-good’ and ‘anomalous-is-bad’ biases.

Anomalous Course of the Brachial Plexus Identified During Ultrasound-Guided Brachial Plexus Nerve Block.

Knowledge of brachial plexus anatomy is essential when performing upper-extremity regional anaesthesia. Anomalous brachial plexus anatomy has been reported in up to 35% of patients. Variants include anomalous course of the roots anterior to, or within, the scalene musculature and abnormal separation of the cords around the subclavian artery. These anomalies have been detected with ultrasound, a valuable tool for delineating anatomy and providing imaging guidance during regional anaesthesia. We report a previously undescribed course of the brachial plexus relative to the subclavian artery within the supraclavicular fossa identified by ultrasound prior to peripheral nerve blockade.

Reintervention for Superior Vena Cava Obstruction After Heart Transplant

BackgroundChildren undergoing orthotopic heart transplant (OHT) may require complex reconstruction of superior vena cava (SVC) anomalies. SVC anatomy and mode of reconstruction are potential risk factors for SVC obstruction. MethodsA retrospective single-center review was conducted of patients undergoing initial OHT between January 1, 1990, and July 1, 2021. Simple SVC anatomy included a single right SVC to the right atrium or bilateral SVCs with a left SVC to an intact coronary sinus, without prior superior cavopulmonary connection. Presence of anomalous SVC anatomy, superior cavopulmonary connection, or previous atrial switch operation defined complex anatomy. Reconstructive strategies included atrial anastomosis; direct SVC-to-SVC anastomosis; and augmented SVC anastomosis using innominate vein, patch, cavopulmonary connection, or interposition graft. The primary outcome was reintervention for SVC obstruction. ResultsOf 288 patients, pretransplant diagnoses included congenital heart disease (n = 155 [54%]), cardiomyopathy (n = 125 [43%]), and other (n = 8 [3%]). Most (n = 208 [72%]) had simple SVC anatomy compared with complex SVC anatomy (80 [28%]). Reintervention for SVC obstruction occurred in 15 of 80 (19%) with complex anatomy and 1 of 208 (0.5%) with simple anatomy (P = .0001). Reintervention was more common when innominate vein or a patch was used (9/25 [36%]) compared with an interposition graft (1/7 [14%]) or direct anastomosis (6/82 [7%]; χ2 = 13.1; P = .001). Most reinterventions occurred within 30 days of OHT (14/16 [88%]). ConclusionsPatients with complex SVC anatomy have a higher rate of reintervention for SVC obstruction after OHT compared with those with simple SVC anatomy. In cases of complex SVC anatomy, interposition grafts may be associated with less reintervention compared with complex reconstructions using donor tissue.

Management of anomalous coronary anatomy during aortic valve repair.

Management of anomalous coronary anatomy during aortic valve repair.

Coronary anomalies associated with ventricular septal defect.

Coronary anomalies encompass different conditions in terms of anomalous origin, coursing, and branching, which are occasionally associated with congenital heart disease. This study aimed to explore coronary anomalies associated with ventricular septal defect that was a stereotypical congenital heart disease. We retrospectively reviewed angiographic findings in patients with ventricular septal defect who required corrective surgery, and identified coronary abnormalities, including anomalous origin, coursing, and branching of coronary arteries based on angiography. We studied the prevalence and types of coronary anomalies among them. A total of 998 patients with ventricular septal defect was studied. Age and weight were 2.0 (2.1-15.2) months and 5.7 (4.1-8.7) kg, respectively. There were 115 patients (12%) with syndrome or genetic disorder, and 34 patients (3%) with extracardiac major organ anomalies. The overall prevalence of coronary anomalies was 6.2%. All coronary anomalies were anomalous origin and coursing, among 3 patients accompanied anomalous intrinsic coronary anatomy. Originating within aortic root above the Valsalva sinus was the most common coronary anomaly. Coronary anomalies were independently correlated with bicuspid aortic valve (odds ratio [OR]: 8.02, 95% confidence interval [CI]: 2.34-23.4) and persistent left superior caval vein (OR: 5.02, 95% CI: 1.93-11.7). We showed the possibility that minor cardiac variants, such as bicuspid aortic valve and persistent left superior caval vein, contribute to higher prevalence of coronary anomalies in patients with ventricular septal defect.