Important Anatomical Variations Research Articles

Coeliaco-Mesenteric Trunk-- A Rare Anomaly of the Coeliac Trunk

Abstract The Coeliaco-mesenteric trunk, characterized by the shared origin of the coeliac trunk and the superior mesenteric artery, represents a rare but clinically important anatomical variation within the abdominal vasculature. Knowledge of variations of the abdominal vascular system and their origins is of great importance to surgeons to ensure optimal patient outcomes and also to mitigate the potential complications that may arise due to this lack of knowledge. Present case: During routine dissection for 1st year MBBS (2022-23), of the abdominal region of a 60 year-old male cadaver, there was an unusual presentation of multiple blood vessels at the level of origin of the coeliac trunk. Upon further dissection, the superior mesenteric artery was found to be originating from this group of arteries. This artery was found to be passing through mesentery upto transverse colon. No other distinct blood vessel was found at the level where the superior mesenteric artery usually originates. Conclusion: This case underscores the importance of thorough pre-operative assessment and awareness of anatomical anomalies to facilitate safe and effective management strategies.

Evaluation of the Prevalence of Radix Entomolaris in First and Second Mandibular Molars in Yazd Population Using Cone-Beam Computed Tomography

Introduction: The third root of mandibular molar teeth is the most important normal anatomical variation in these teeth. Failure to recognize the presence of this root is one of the most common reasons for treatment failure in these teeth. Therefore, the aim of this study was to investigate the prevalence of Radix Entomolaris in the mandibular first and second molars in the population of Yazd City using CBCT imaging.
 Methods: In this study, 217 CBCT images prepared in an oral and maxillofacial radiology clinic were examined. The presence of the third root in the first and second molar teeth of the mandible was investigated according to the gender of the patients and the side of the tooth placement. Data were analyzed using SPSS16 software and Chi-Square statistical test. 
 Results: The prevalence of Radix Entomolaris in the present study in first molar and second molar teeth was recorded 5.1% and 1.8%, respectively. It was reported that its bilateral prevalence was 1.4%. In unilateral cases it was observed more on the right side. The occurrence of Radix Entomolaris had no statistically significant relationship with gender (P>0.05).
 Conclusion: The overall frequency of Radix Entomolaris in the population of Yazd City is 6.9%. Its frequency is more likely to be unilateral, mostly in the first molar and without the influence of gender.

An uncommon anatomic variation of the sartorius muscle in a domestic dog (Canis lupus familiaris)

The sartorius muscle is located in the pelvic limb of the dog and is divided into a cranial and caudal part. There is no report describing of the three parts of the sartorius muscle. The aim of the present report was to describe the presence of a third part of the sartorius muscle in a dog. Although it does not represent a malformation, it is an important anatomical variation to consider for didactic purposes of dissection and in surgeries of the pelvic limb, as in this case there is a need to move the muscles apart to maintain their integrity. Furthermore, this anatomical description is relevant for comparative purposes in this animal species.

RADIOLOGICAL CLASSIFICATION OF THE PELVIS: A TOOL FOR TRAUMA SURGERY PLANNING

Variations in pelvic anatomy are a major risk factor for misplaced percutaneous sacroiliac screws used to treat unstable posterior pelvic ring injuries. A better understanding of pelvic morphology improves preoperative planning and therefore minimises the risk of malpositioned screws, neurological or vascular injuries, failed fixation or malreduction. Hence a classification system which identifies the clinically important anatomical variations of the sacrum would improve communication among pelvic surgeons and inform treatment strategy.300 Pelvic CT scans from skeletally mature trauma patients that did not have pre-existing posterior pelvic pathology were identified. Axial and coronal transosseous corridor widths at both S1 and S2 were recorded. Additionally, the S1 lateral mass angle were also calculated. Pelvises were classified based upon the sacroiliac joint (SIJ) height using the midpoint of the anterior cortex of L5 as a reference point. Four distinct types could be identified:Type-A – SIJ height is above the midpoint of the anterior cortex of the L5 vertebra.Type-B – SIJ height is between the midpoint and the lowest point of the anterior cortex of the L5 vertebra.Type-C – SIJ height is below the lowest point of the anterior cortex of the L5 vertebra.Type-D – a subgroup for those with a lumbosacral transitional vertebra, in particular a sacralised L5.Differences in transosseous corridor widths and lateral mass angles between classification types were assessed using two-way ANOVAs.Type-B was the most common pelvic type followed by Type-A, Type-C, and Type-D. Significant differences in the axial and coronal corridors was observed for all pelvic types at each level. Lateral mass angles increased from Types-A to C, but were smaller in Type-D.This classification system offers a guide to surgeons navigating variable pelvic anatomy and understanding how it is associated with the differences in transosseous sacral corridors. It can assist surgeons’ preoperative planning of screw position, choice of fixation or the need for technological assistance.

Evaluation of Anatomical Variations with Morphological Measurements and Their Relationship to Meniscal Injury and Ligament Damage.

The purpose of this study was to reveal the anatomical risk factors for anterior and posterior cruciate ligament (ACL and PCL) injuries and menisci injury. We aim to investigate whether there are significant relationships between tibial tubercle-trochlear groove (TT-TG) distance, patella angle, trochlear sulcus angle (TSA), trochlear groove depth (TGD), medial and lateral trochlea length (MT and LT), MT/LT ratio, lateral patellar tilt angle (LPTA), patella-patellar tendon angle (P-PTA), quadriceps-patellar tendon angle (QPA), Insall-Salvati index (ISI), medial and lateral trochlear inclination (MTI and LTI) measurements and important common pathologies such as ACL, PCL, medial and lateral meniscal injuries (MM and LM), peripatellar fat pad edema, chondromalacia, and effusion. Thus, the mechanisms of injury will be better understood by revealing important anatomical variations for meniscus and ligament damage. Three hundred eighty patients with knee magnetic resonance imaging examination were included in this study. Our patients who underwent knee magnetic resonance imaging were divided into groups according to the presence of MM tear, LM tear, ACL tear, PCL tear, peripatellar fat pad edema, chondromalacia and effusion. TT-TG distance, patella angle, TSA, TGD, MT, LT, MT/LT ratio, LPTA, P-PTA, QPA, ISI, MTI, and LTI were measured. In patients with ACL tear, age, LT, ML/LT ratio, and QPA measurements were found to be significantly higher. There was no significant difference between the participants' LPTA value and the presence of ACL tear, MM and LM injury. MT and ML/LT ratio were found to be significantly lower in the group with MM tear (p <0.001). The TT-TG distance was found to be significantly lower in the group with LM tear. Increased age, LT, ML/LT ratio, and QPA are predisposed risk for ACL tear. Decreased MT and ML/LT ratio are among the risk factors for MM tear. The anatomical variations are associated with ligament and meniscal injury.

Assessing the Value of a Pre-operative CT Sinus Anatomy Review Tool.

Performing endoscopic sinus surgery requires an intricate understanding of the anatomy of the paranasal sinuses, orbits and skull base. Avoidance of adverse events requires careful review of pre-operative computed tomography (CT) images to recognize potential areas of safety concern. Using a preoperative checklist may aid surgeons in identifying these features. The objective of this study is to determine the educational value of a pre-operative CT sinus review tool and todetermine if itsuse improves identification of important anatomical features.Otolaryngologists from varying practice levels reviewed 2 preoperative sinus CTs, with and without the tool. A 6-item Likert scale questionnaire assessed the operator experience with the tool. The number of high-risk features identified, determination of overall safety risk and difficulty, and time needed for review were compared between the two groups.A total of 18 participants reviewed 36 CT scans. The use of the CT review tool improved identification of important anatomical feature from 47% to 74% on average. All participants agreed that the tool was useful in capturing important anatomical variations in an organized manner and enabled overall assessment of surgical risk and difficulty. The checklist required significantly more time to complete.A preoperative CT sinus tool is perceived to be a useful tool by surgeons who perform endoscopicsinus surgery. The tool requires more time, but increases the number and consistency of high-risk features identified.

Endodontic Management of C-shaped Root Canal Configuration using Different Obturation Systems: Case Series

C-shaped canal is one of the most difficult situations with which the dentist is confronted during endodontic treatment of teeth. Recognition of unusual variation in the canal configuration is critical because it has been established that the root with a single tapering canal and apical foramen is the exception rather than rule. The early recognition of these configurations facilitates cleaning, shaping and obturation of the root canal system. “C” configuration, which is an important anatomic variation, presents a thin fin connecting the root canals. The present case series reports the successful management of C-shaped canals in mandibular second molars using cone-beam computed tomography(CBCT), sonic irrigation activation and different thermoplasticized gutta percha obturating techniques.

The Nomenclature of Chiari Malformations.

The current nomenclature of Chiari malformations includes the standard designations, Chiari 1-4, which were described by Hans Chiari in the late nineteenth century, and more recent additions, Chiari 0, 0.5, and 1.5, which emerged when the standard nomenclature failed to include important anatomical variations. The authors describe these entities and propose that to best optimize clinical care and research, it would be wise to place less focus on the eponyms and more effort on developing a descriptive or pathophysiological nomenclature.

Clinical Significance of Körner's Septum in Relation to Occurrence of Squamous Chronic Otitis Media.

The Körner's septum (KS), persistent petrosquamosal lamina, is a bony lamina (developmental remnant) that extends from the articular fossa to the mastoid apex, above the middle ear, and runs inferiorly and laterally to the facial nerve canal. The petrous and squamous bones meet at this septum. The anatomical structure of KS, which most frequently occurs at the level of the head of the malleus and/or the anterior semicircular canal, is described in depth in this work. The embryological elements of the temporal bone development that result in the formation of KS are taken into consideration. Clinically KS is consideredan important anatomical variation, in the development of chronic diseases of the ear like chronic otitis media, especially attic retraction pockets, and cholesteatoma as it can contributeto attic blockage. Also, studies have found a significant association between tympanosclerosis and KS. High-resolution computed tomography (HRCT) and cone-beam computed tomography are the two imaging methods most commonly used to identify KS. It is observed that KS was associated with an increased risk for chronic otitis media, and residual cholesteatoma. The purpose of this review article is to provide a general overview of the KS and its clinical implication, as well as to summarize and discuss the latest clinical data regarding this entity.

컴퓨터단층촬영을 이용한 비중격 만곡증 환자의 안와벽 결손 유병률에 대한 연구

Background and Objectives: The orbit contains important structures such as the eyeball, optic nerve, and extra-ocular muscles. A defect the orbital wall is a clinically important anatomical variation because it can cause serious complications during nasal surgery. The authors investigated the incidence of orbital defects in patients of chronic sinusitis with nasal septal deviation and found out whether there is a relationship between chronic sinusitis and orbital defects to help the surgical treatment of these patients. Materials and Methods: The computed tomography (CT) and medical records of 247 patients with chronic sinusitis with septal deviation (study group) and 470 patients with septal deviation only (control group) were analyzed retrospectively. The average age of patients was 34.05 years for males and 33.67 years for females. Results: The incidence of orbital defects was statistically higher with 22 out of 247 subjects in the study group (8.9%) than 22 out of 470 subjects in the control group (4.7%)(Chi-square verification result, significance level 0.05). In both groups, the direction and degree of nasal septal deviation did not significantly affect the incidence of orbital defects, and medial orbital defects were the most common in both groups (study group, 90.9%, 20/22, control group, 86.4%, 19/22). Conclusions: About 9% of patients with chronic sinusitis with septal deviation showed defects of the orbital wall, which is easy to be damaged in sinus surgery and can lead to permanent complications. We should prevent such complications through evaluating CT and detailed medical history of the patient before surgery. (J Clinical Otolaryngol 2021;32:118-124)

The accessory heads of the muscles flexor pollicis longus and flexor digitorum profundus (Gantzer muscle) – An anatomical study in Brazilian cadavers

An important accessory anatomical variation, exclusively human, and related to the muscular ventres of the flexor pollicis longus and flexor digitorum profundus is frequently denominated Gantzer. These variations have close relations with the anterior interosseous nerve (AIN), which provides, for many authors, by direct compression, one of the rare neuropathic syndromes. In this work, thirty-four forearms were dissected from the collections of the Medical School of the Federal University of Minas Gerais and the Department of Basic Sciences of the Federal University of Juiz de Fora, with a prevalence of 50% of the 34 forearms studied for the Gantzer muscle. The muscle relationship was mainly with the flexor pollicis longus muscle and only one occurrence related to the flexor digitorum profundus muscle, described as a rare occurrence of unilateral double formation of Gantzer muscle. Bilaterality was observed in 88.23% of the findings and the dominant innervation for this muscle variation occurred in 82.35% by the anterior interosseous nerve (AIN). The type morphological in all forms found was the fusiform, with 10.5cm of total length and an average of 0.3cm in diameter and all related, as origin, in the medial aspect of the coronoid process of the ulna, next to the origin of the flexor digitorum superficialis muscle. Our work largely reflected the findings of most publications and, considering the controversy of the occurrence of a compressive neuropathy, the data were not sufficient, from a strictly anatomical point of view, to confirm or refute the hypothesis.

Rare association of anatomical variations of the atlas and the occipital in a case with cranial deformation.

The paracondylar process is an exostosis, situated lateral to the occipital condyles, which expands towards the transverse process of the atlas. The epitransverse process of the atlas is a bony outgrowth that extends from the transverse process towards the occiput. Ponticulus posterior is a bony bridge that spans from the lateral mass of the atlas towards the posterior extremity of the vertebral artery groove. They are important anatomical variations. In this article, we analyze a rare situation of concomitant presence of ponticulus posterior, foramen arcuate, paracondylar process and epitransverse process, all of them situated on the right side of an individual with artificial cranial deformation from the fifth century AD. The paracondylar process and the epitransverse process form an accessory atlantooccipital joint. The expression of these variations, though under genetic influence, might have also been influenced by artificial cranial deformation. To our knowledge, this association has not been reported. The epitransverse process and the ponticulus posterior are important because of the positional relationship with the vertebral artery on which they may exert compression effects generating blood flow disorders. The paracondylar process is located at the insertion of rectus capitis lateralis, an important surgical landmark, which could be affected by the presence of the paracondylar process, thus leading to possible difficulties in orientation and iatrogenic trauma. This case contributes to extending the knowledge regarding anatomical variations, being of great use to the contemporary medical field, especially surgery.

Important anatomical variations of the superior posterior alveolar artery: Studied by cone beam computed tomography.

The knowledge of anatomical variations of the posterior superior alveolar artery (PSAA) is very important in surgeries for maxillary sinus (MS) elevation and subsequent insertion of dental implants, avoiding common and serious surgical complications. The main objective of this study was to analyse important anatomical variations of the PSAA by means of cone beam computed tomography (CBCT) examinations. 180 tomographic CBCT were analysed, and MS was divided into three equal regions: (I) anterior, (II) intermediate and (III) posterior. Variables evaluated were the visualisation of the artery, distance from the artery to the ridge crest, distance from the artery to the sinus floor, alveolar ridge height and arterial diameter. The PSAA visualisation was more prevalent in males and region III (76.7%). The distance from the artery to the sinus floor presented no significant difference between regions II and III, with both regions showing significantly lower values than region I. A significant difference was observed in the diameter of the arteries with higher prevalence of diameters >1.0mm in males and <1.0mm in females. The PSAA can be well visualised frequently with a CBCT, and differences in artery diameter were observed in relation to gender (males>females). Additional care is recommended when it is necessary to extend surgeries to the posterior MS region, avoiding haemorrhages that are associated with failures in these procedures.

Cranial Base Structures Geometric Morphometry and Description of a Clinical Relevant Anatomical Variation

The foramen magnum is a large median oval opening in the occipital bone in the base of the skull, which leads into the posterior fossa. The foramen magnum has a forwarded shift of its anterior border in humans causing a shortening of the cranial base. The foramen is described as oval, wider posteriorly than anteriorly, and its antero‐posterior diameter exceeds the transversal one. Anteriorly, the margin of the foramen magnum is slightly covered, on each side, by an occipital condyle. These condyles, oval in shape, are located obliquely, so that their anterior end is closer to the median plane. Thirty dry skulls, from adult individuals, present in the anatomy laboratory of our institution were evaluated and a study of the dimensional anatomy of the foramen magnum and the occipital condyles was performed. With the aid of an analog caliper (precision of 0.05mm), the antero‐posterior and transverse diameters of the foramen magnum (posterior to the occipital condyles) and occipital condyles were obtained. Our results showed that the mean antero‐posterior diameter of the foramen magnum was 36.1 ± 0.5 mm and the transverse diameter was 30.0 ± 0.4 mm. The mean antero‐posterior diameter of the right occipital condyle was significantly smaller than that of the left, being 22.2 ± 0.4 mm and 23.1 ± 0.4 mm, respectively. The mean transverse diameter of the right occipital condyle was also statistically smaller than that of the left, being 12.6 ± 0.2 mm and 13.2 ± 0.2 mm, respectively. One of the skulls studied (excluded from the previous statistic) showed anatomical variation in the shape and size of the foramen magnum. This foramen was narrow, with an antero‐posterior diameter of 26.75 mm and a transverse diameter of 22.50 mm. In addition, the occipital condyles were asymmetrical, with the right condyle being practically transverse in relation to the foramen magnum, making a protrusion into its interior, contributing to the transverse narrowing of this foramen. The left condyle presented antero‐posterior (22.95 mm) and transversal (15.95 mm) diameters larger than the right (19.35 mm and 13.10 mm respectively). There were no signs of fractures or previous craniotomies in this particular skull. The present study reports the geometric morphometry of some striking structures at the base of the skull, in addition to describing an important anatomical variation of these structures. We did not find reports of significant difference between the right and left condylar diameters in the literature. The anatomy of the skull base is useful for estimating the race and sex of individuals in forensic medicine. Furthermore, geometric morphometry is an important tool in primatology and anthropology.Support or Funding InformationFAPESP, CNPq, CAPES and FAEPA

Circumaortic left renal vein: a rare but important anatomical variation to consider prior to a radical nephrectomy.

Circumaortic left renal vein: a rare but important anatomical variation to consider prior to a radical nephrectomy.

High-resolution, real-time, and nonfluoroscopic 3-dimensional cardiac imaging and catheter navigation in humans using a novel dielectric-based system

Catheter navigation and 3-dimensional (3D) cardiac mapping are essential components of minimally invasive electrophysiological procedures. The purpose of this study was to develop a novel 3D mapping system (KODEX - EPD, EPD Solutions, Best, The Netherlands) that measures changing electric field gradients induced on intracardiac electrodes to enable catheter localization and real-time 3D cardiac mapping. We first validated the accuracy of the system's measurement and localization capabilities by comparing known and KODEX - EPD-measured distances and locations at 12 anatomical landmarks in both the atria and ventricles of 4 swine. Next, invivo images of 3D porcine cardiac anatomy generated by KODEX - EPD and widely used CARTO 3 system (Biosense Webster, Inc., Diamond Bar, CA) were compared with gold standard computed tomography images acquired from the same animals. Finally, 3D maps of atrial anatomy were created for 22 patients with paroxysmal atrial fibrillation (Dielectric Unravelling of Radiofrequency ABLation Effectiveness trial). First, the mean error between known and measured distances was 1.08 ± 0.11 mm (P < .01) and the overall standard deviation between known and measured locations in 12 areas of the porcine heart was 0.35 mm (P < .01). Second, an expert comparison of 3D image quality revealed that KODEX - EPD is noninferior to CARTO 3. Third, the system enabled 3D imaging of atrial anatomy in humans, provided real-time images of atrioventricular valves, and detected important anatomical variations in a subset of patients. The KODEX - EPD system is a novel 3D mapping system that accurately detects catheter location and can generate high-resolution images without the need for preacquired imaging, specialty catheters, or a point-by-point mapping procedure.

The Presence of a Variant Obturator Artery: The Corona Mortis

INTRODUCTIONThe obturator artery (OA) is a vessel of variable origin with anterior‐lateral direction on the wall of the pelvis. It is followed by the obturator vein and nerve leaving the pelvis through the obturator canal1. This vessel is often a branch of the internal iliac artery, however, it is subject to important anatomical and surgical variations 2,3. The most important variation is referred to corona mortis4 (Crown of Death). The aim of this study is to verify and quantify the OA different origins and to determine the presence of conora mortis.METHODForty cadavers of Brazilian decent (27males and 13 females) were dissected in order to observe the presence or absence of anatomical variations of OA. The study was conducted in the Laboratory of Anatomy of the Estácio de Sá University (Joao Uchoa Campus), Rio de Janeiro, Brazil. The data analysis was conducted using SPSS software.RESULTSThe corona mortis (Figures 1 and 2) was found in 22.5% of subjects (55,6% Males and 44,4% females) (Tables 1 and 2). The external iliac artery had a common trunk that originated the obturator and inferior epigastric arteries.DISCUSSIONThe presence of the corona mortis is very relevant for surgery because it is a common variation of the obturator artery. The knowledge of this variation is important because of the possibility of injury during surgical interventions especially when staples are used for endoscopic repair of inguinal and femoral hernias2,3,4,5,6.CONCLUSIONThe presence of corona mortis variation was significant, demonstrating that the knowledge of this variation, is important to surgery.Support or Funding InformationOwn financing and support from Estácio de Sá UniversityThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Case report of an arc of Bühler pancreatic variant in a Brazilian cadaver

The present study concerns the persistence of an arc of Bühler pancreatic variant in a Brazilian cadáver. The arc of Bühler, reported by Bühler and Tandler in 1904, is an important and rare vascular anatomical variation of the abdominal cavity. Although the first description dates back more than a century, it is estimated that this variation represents only 1% to 4% of all variations found worldwide, and its presence is often admitted as controversial, because it is not the arc of Bühler per se, but a similar collateral variation. In this context, the aim of the present study is to examine the role of this variation in clinical and surgical presentations of the abdominal cavity, punctuating both the benefits and harms of the presence of this vasculature variant of considerable caliber. The importance of adequately classifying similar structures with different functions is demonstrated, given different medical practice situations. Possible pathologies created exclusively by the presence of this anatomical variation are also highlighted. It is concluded that knowledge concerning the present structure reaffirms the study of human anatomy as one of the foundations of medicine and of its safe, resolutive and inclusive practice within medical aspects. The study was carried out within the parameters established by decree No. 8.501, of November 30, 1992, of the Federative Republic of Brazil1,on the use of unclaimed cadavers for study or scientific research purposes. Support or Funding Information The work had funding from the present authors and support from college of medicine, Campus João Uchôa, Universidade Estácio de Sá. Anterior view of the abdominal cavity, exposing the larger omentum. Anterior view of the upper abdomen.-Blue: Left gastric artery.- White: Splenic artery.- Red: Hepatic Artery Proper.- Green: Arc of Bühler. Lateral view. Arc of Bühler contouring the SMA and performing anastomosis on the posterior side. Morphometric analysis of the Arc of Bühler -Anterior view of the abdominal cavity. This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Morphological approach of the sternal foramen: an anatomic study and a short review of the literature.

The sternal foramen (SF) constitutes a specific anatomic defect in sternum, indicating an impaired fusion of ossificated segments, which occurs either in an anatomical part of the sternum or in sternal joints. The aim of this article is to provide baseline statistical data about the variations of the SF, to present a short review of the relevant literature and to compare results with other studies and populations. We review relevant literature, and we present data obtai-ned from skeletal samples of known population and sex. A total of 35 well-preserved dried sterna from the prefecture of Eastern Macedonia and Thrace, Greece, were selected: 20 men and 15 women with a mean age of 55 ± 6 years old. Measurements were made with a sliding calliper and photographic documentation. The incidence of the SF in the 35 dried specimens was 14.2%, 4 men (20% of male sample) and 1 woman (6.6% of female sample) and 80% of sternal foramina were observed in male individuals. The SF was found in the sternum body (2 cases, 40% of foramina), in xiphoid process (2 cases, 40% of foramina) and in sternoxiphoidal junction (1 case, 20% of foramina). All of the sterna presented 1 single visible SF. Two anatomically unique cases were identified throughout these 5 sterna, both belonging in male subjects. The SF constitutes a relatively common variation with great radiological, clinical, and forensic significance. Presence of a SF with irregular bony margins complicates considerably radiological differential diagnosis. Awareness of this important anatomic variation is fundamental for clinicians and autopsy pathologists, in order to avoid severe fatal complications and elucidate the exact cause of death, respectively.

Introduction to the Congenital Heart Defects: Anatomy of the Conduction System.

The position and course of the conduction system in congenital heart disease are intricately tied to the underlying congenital malformation. Although only subtle differences exist between the anatomy of the conduction axis for simple congenital heart lesions and normal anatomy, almost every patient with congenital heart disease harbors some important anatomic variation. This article summarizes the body of literature by retaining original classical concepts and by attempting to translate the available knowledge into useful points for the congenital heart disease specialist. This discussion spans the entire spectrum of simple to complex congenital heart disease.