Lasya Gaur’s research while affiliated with Johns Hopkins Medicine and other places

Objective New platforms for patient imaging present opportunities for improved surgical planning in complex congenital heart disease (CHD). Virtual reality (VR) allows for interactive manipulation of high-resolution representations of patient-specific imaging data, as a supplement to traditional 2D visualizations and 3D printed heart models. Design We present the novel use of VR for the pre-surgical planning of cardiac surgery in two infants with complex CHD to demonstrate interactive real-time views of complex intra and extracardiac anatomy. Results The use of VR for cardiac pre-surgical planning is feasible using existing imaging data. The software was evaluated by both pediatric cardiac surgeons and pediatric cardiologists, and felt to be reliable and operated with a very short learning curve. Conclusions VR with controller-based interactive capability allows for interactive viewing of 3D models with complex intra and extracardiac anatomy. This serves as a useful complement to traditional pre-operative planning methods in terms of its potential for group based collaborative discussion, user defined illustrative views, cost-effectiveness and facility of use.

Objective: Abnormal cardiac axis and/or malposition prompts evaluation of congenital heart disease (CHD), however etiology may be difficult to clarify using obstetrical ultrasound (US) or fetal echocardiography (echo) alone. We aimed to use fetal magnetic resonance imaging (MRI) as a complementary tool to identify causes of cardiac malposition. Methods: Review of fetuses diagnosed with cardiac malposition by fetal US and echo was performed. Etiology was classified as either due to heterotaxy syndrome or extracardiac masses. Reclassification was then performed with fetal MRI findings. Results were compared with postnatal diagnoses. Results: Forty-two fetuses were identified as having abnormal cardiac axis and/or malposition. 23 of 42 cases (55%) had extracardiac anomalies while 19 (45%) were due to heterotaxy. 12 of 42 (29%) cases were reassigned by fetal MRI (5 in heterotaxy group and 7 in the lung anomaly group). Four cases (33%) had both cardiac disease and extracardiac masses, not previously recognized. Fetal MRI clarified heterotaxy subtype or removed heterotaxy diagnosis in 5 (26%) patients. Fetal MRI findings were confirmed in 8 of these 12 cases postnatally. Conclusion: Fetal MRI is a useful complementary tool to define etiology of cardiac malposition in complex cases for informative prenatal counseling and planning.

We thank Dr Sainathan for his eComment on our article [1, 2]. The author suggests an alternative strategy of placing bilateral branch pulmonary artery bands while leaving the aortopulmonary (AP) window intact as was used by Hosein et al. [3] for the management of patients with hypoplastic left heart syndrome (HLHS). While there may be different ways of managing rare complex anatomies such as tricuspid atresia and aortopulmonary window, in addition to the surgical strategy, we once again would like to highlight the interesting physiology in this patient, which we believe is related to ventricular volume unloading following AP window ligation leading to restriction at the level of the ventricular septal defect. We have successfully used bilateral branch pulmonary artery bands as a bridge to decision in high-risk patients with HLHS [4]. While this approach is to be recommended in certain selected patients, it is not a procedure free of problems, as Hosein et al. themselves in their report have accepted as ‘fundamentally flawed’ [2]. Conflict of interest: none declared

Tricuspid atresia and aortopulmonary window are rare congenital cardiac anomalies. The occurrence of both these anomalies in the same patient is extremely rare, with only 1 case reported in the literature. We report the surgical management of one such patient and discuss the management issues with respect to Stage 1 single ventricle palliation.