e36 SECTION XV Pediatric Critical Care Board Review Questions 8 A 3 year old child is brought to the emergency department with fever and increasing lethargy during the past 24 hours On initial evaluat[.]
e36 S E C T I O N XV Pediatric Critical Care: Board Review Questions A 3-year-old child is brought to the emergency department with fever and increasing lethargy during the past 24 hours On initial evaluation the child is minimally responsive and has poor distal perfusion with cool hands and feet Blood pressure is 70/30 mm Hg, and oxygen saturation is 85% in room air The child is intubated, central venous access is obtained, and intravenous fluids are administered An established goal of continued resuscitation for this child is which of the following? A Achieve a pulmonary artery occlusion pressure of greater than 15 mm Hg B Achieve a central venous pressure (CVP) of 15 mm Hg or higher C Achieve a mixed venous saturation of 70% or higher D Achieve a mean arterial pressure (MAP) of 80 mm Hg or higher Preferred response: C Rationale Achieving a mixed venous saturation of 70% or higher is one of the goals of early goal-directed therapy for persons with septic shock Early goal-directed therapy has been shown to decrease mortality in persons with septic shock Chapter 27: Assessment of Cardiovascular Function Two infants with dextro-transposition of the great arteries have had arterial switch operations earlier in the day Approximately hours postoperatively, infant A is on a milrinone infusion of 0.3 mg/kg/min with a mean arterial blood pressure of 45 mm Hg and a central venous pressure of cm H2O The last lactate level was 3.2 mmol/L (previously 4.5 mmol/L) and a recent mixed venous O2 saturation is 75% Infant B is on a milrinone infusion of 0.3 mg/kg/min with a mean arterial blood pressure of 45 mm Hg and a central venous pressure of cm H2O The last lactate is 3.2 mmol/L (previously 2.1 mmol/L) and a recent mixed venous saturation is 60% Infant B has received a total of 20 mL/kg of crystalloid in the last hours Both infants have 100% arterial oxygen saturations and identical mechanical ventilation parameters Based on the information above, which infant is at higher risk of clinical decompensation in the next hours: A Infant A B Infant B C Both are at equal risk based on the information provided Preferred response: B Rationale While both infants have identical vital signs and are on the same vasoactive infusions, infant B has received a higher “quantity of therapy” (QOT) due to the volume infusions in the last hours to maintain the hemodynamics listed In addition, infant B has a rising lactate and a lower mixed venous saturation (higher arteriovenous oxygen difference) which may signify inadequate oxygen delivery Infant B should be carefully monitored, and additional investigations into the cause for the higher QOT should be considered 2 A 6-month-old infant with tetralogy of Fallot is recovering in the intensive care unit after a complete surgical repair Approximately hours after the operation is completed, the central venous pressure (CVP) is 15 mm Hg The patient is hypotensive and receives 10 mL/kg of crystalloid Which of the following is the least likely to be observed in the physiology described? A Fluid accumulation in the thoracic and abdominal cavities B Increased chest wall stiffness C Increased intrathoracic pressures D Increased peripheral and pulmonary edema E Increased venous return Preferred response: E Rationale The patient described in this question with tetralogy of Fallot is likely to have significant right ventricular diastolic dysfunction resulting in high filling pressures (high CVP) Leaky vasculature as a result of inflammation due to cardiopulmonary bypass can result in significant third-spacing of fluid A fluid bolus for hypotension causes increased tissue edema and fluid accumulation in the thoracic and abdominal cavities which results in increased chest wall stiffness and increased intrathoracic pressure As a result, there is decreased venous return and therefore decreased preload to the right ventricle which results in further hypotension and diminished cardiac output An infant with hypoplastic left heart syndrome is recovering after a Norwood Stage I procedure with a modified BlalockTaussig shunt The patient’s arterial oxygen saturation and mean arterial blood pressure are within normal limits The infant has a lactate level that has been rising over the last hours and a wide arteriovenous O2 (AVO2) saturation difference Which of the following will not increase systemic oxygen delivery in this patient? A Addition of inhaled nitric oxide to improve pulmonary blood flow B Afterload reduction C Blood transfusion D Increased inotropic support with dobutamine E Sedation and paralysis Preferred response: A Rationale This patient with single ventricle physiology has complete mixing of systemic and pulmonary venous blood The rising lactate, minimal urine output, and widened AVO2 difference suggested compromised oxygen delivery despite a normal oxygen saturation and mean arterial blood pressure The addition of a pulmonary vasodilator to improve pulmonary blood flow would likely exacerbate the problem further by increasing pulmonary blood flow at the expense of systemic blood flow In other words, the Qp:Qs ratio would increase All of the other options would increase systemic oxygen delivery by improving Qs (options B and D), decreasing systemic oxygen demand (option E), or increasing oxygen carrying capacity and likely mixed venous saturation (option C) CHAPTER 136 Board Review Questions A 12-year-old girl is diagnosed with viral myocarditis and has an echocardiogram showing severely depressed biventricular systolic function Her blood pressure as measured by invasive monitoring is normal for age Which of the following factors is compatible with a relatively low quantity of therapy? A A central venous pressure of mm Hg B A lidocaine infusion to suppress ventricular tachycardia C An epinephrine infusion D Need for mechanical ventilation E Two sodium bicarbonate boluses due to metabolic acidosis Preferred response: A Rationale The patient is presenting with decreased systolic ventricular function in the setting of viral myocarditis The cardiac output is low; however, the patient’s blood pressure is normal due to the compensatory rise in systemic vascular resistance (SVR) As a result of these factors, one would expect that the patient might require increased filling pressures, a need of inotropic support, and/or mechanical ventilation to provide positive pressure ventilation to decrease oxygen demands and decrease left ventricular afterload In addition, a patient with myocarditis is at risk of ventricular arrhythmias due to the irritable myocardium The presence of a metabolic acidosis can also signify poor systemic oxygen delivery In this particular case, the presence of a low central venous pressure would be reassuring that the patient has not required fluid resuscitation and therefore a significant quantity of therapy All of the other options would signify a patient that is more critically ill In this scenario, it would be important to consider advanced therapies such as mechanical circulatory support if there are markers of poor oxygen delivery despite the interventions listed above What is a primary determinant of systemic oxygen delivery (Do2)? A Hemoglobin concentration B Intrathoracic pressure C Oxygen consumption D Pulmonary venous oxygen content Preferred response: A Rationale Do2 Cardiac output (CO) arterial content of oxygen (Cao2), where Cao2 (Sao2 Hgb 1.36) (Pao2 0.0031) Therefore because hemoglobin concentration is a key variable that determines systemic arterial O2 content, it also is a primary determinant of Do2 A 3-year-old child with hypoplastic left heart syndrome returns from the operating room following a lateral tunnel fenestrated Fontan procedure The initial postoperative arterial blood gas shows an oxygen saturation of 80% on a Fio2 1.0 via the mechanical ventilator Postoperative chest x-ray is unremarkable, and the echocardiogram shows good right ventricular systolic function, a patent 3-mm fenestration with right-to-left shunting, trace tricuspid regurgitation, no systemic outflow tract obstruction, and an unobstructed Fontan pathway with good flow to both pulmonary arteries The patient is mildly hypotensive in sinus rhythm with a hemoglobin level of 15 gm/dL and no postoperative bleeding What is the most appropriate initial management to improve blood pressure and oxygenation? A Cool the patient to decrease oxygen consumption B Remove the patient from positive pressure mechanical ventilation C Start an inotropic agent to improve myocardial contractility D Transfuse with red blood cells to increase hemoglobin Preferred response: B e37 Rationale Positive pressure mechanical ventilation decreases systemic venous return and increases pulmonary vascular resistance, both of which are detrimental to Fontan physiology Spontaneous respiration with negative intrathoracic pressure will provide the optimal conditions for systemic venous return and decreased pulmonary vascular resistance resulting in improved pulmonary blood flow (oxygenation), preload, and cardiac output A 3-year-old girl with history of a large ventriculoseptal defect is admitted to your pediatric intensive care unit after ventriculoseptal defect closure A chest radiograph shows that the cardiothoracic ratio is 0.4 The cardiac apex is displaced upward What is the most likely reason for these radiographic changes? A Large pericardial effusion B Left ventricular (LV) enlargement C Patent foramen ovale D Right ventricular (RV) enlargement Preferred response: D Rationale The cardiothoracic ratio gives a quantitative estimate of cardiac size, which is obtained by dividing the transverse measurement of the cardiac shadow in the posteroanterior view by the width of the thoracic cavity Cardiomegaly is present if this value is greater than 0.5 in adults and 0.6 in infants Although useful for assessing LV enlargement, the cardiothoracic ratio is not as sensitive to RV enlargement RV enlargement results in lateral and upward displacement of the cardiac apex on the posteroanterior view and filling of the retrosternal space on the lateral view It is perhaps more important to know what the chest x-ray may not reveal: significant cardiac problems, such as constrictive pericarditis, acute fulminant myocarditis, and even acute pericardial tamponade are often associated with a normal-sized heart on a chest radiograph A 1-year-old patient has a hemoglobin of mg/dL and arterial oxygen saturation of 86% The child’s arterial blood gas results reveal the following values: pH, 7.38; pco2, 53 mm Hg; and Pao2, 56 mm Hg Cardiac output is estimated to be 3.2 L/minute The child’s weight is 10 kg What is the approximate quantity of oxygen delivered to the tissues in minute (Do2)? A 10 mL O2/kg/min B 20 mL O2/kg/min C 30 mL O2/kg/min D 40 mL O2/kg/min Preferred response: C Rationale Tissue oxygenation is directly related to both Do2 and systemic arterial blood pressure Do2, the quantity of O2 delivered to the tissues per minute, is the product of systemic blood flow (SBF), which equals cardiac output except in patients with certain cardiac malformations, and arterial O2 content: L mL 10 CO D O2 minute minute mL CaO2 mL blood 100 e38 S E C T I O N XV Pediatric Critical Care: Board Review Questions where CO cardiac output or SBF in L/min or L/min/m2 and CaO2 quantity of O2 bound to hemoglobin plus the quantity of O2 dissolved in the plasma in arterial blood The O2 content of arterial blood (mL O2/dL blood) equals: CaO2 (SaO2 Hgb 1.36) (PaO2 0.003) where Sao2 arterial O2 saturation, Hgb hemoglobin concentration (g/dL), 1.36 (constant) amount of O2 bound per gram of hemoglobin (mL) at atmosphere of pressure, Pao2 arterial partial pressure of O2, and 0.003 (constant) amount of O2 dissolved in plasma at atmosphere The quantity of dissolved O2 is generally considered to be negligible in the normal range of Pao2 In this case, the Cao2 is (9 1.36 0.86) (0.0031 56) 10.53 0.17 10.7 mL O2/100 mL The Do2 is therefore 10 3.2 10.7 342.4 mL O2/min or 34.24 mL O2/k Chapter 28: Cardiac Failure and Ventricular Assist Devices A 5-year-old male has a 4-day history of persistent high fever (.38.5°C) and progressive lethargy Mother reports that today he stopped eating and became tachypneic resulting in the child being transported to the emergency department In triage, the child was noted to have the following vital signs: temperature, 38.8°C; heart rate, 140 beats per minute; respiration rate, 40 per minute; blood pressure, 75/60 mm Hg; Spo2, 85% in room air The child appears to be in shock, with pallor, cyanosis, cold extremities with thready pulses, and he has an audible S3/S4 gallop rhythm with bilateral diffuse rales and hepatomegaly The child was endotracheally intubated in the ED and ketamine and rocuronium were used during the procedure The ED physician contacts you for additional recommendations and admission to the PICU Your recommend the following NEXT IMPORTANT treatment for the child: A Begin vasopressin infusion to increase the child’s blood pressure to 100 mm Hg systolic B Begin epinephrine infusion to increase cardiac contractility, increase blood pressure to 85 mm Hg systolic, and improve central perfusion C Give an intravenous bolus of 20 mL/kg of normal saline D Start dexmedetomidine infusion to lower the child’s heart rate to ,100 beats/min Preferred response: B Rationale The patient is presenting in cardiogenic shock requiring increase in cardiac output that can be obtained by epinephrine use due to its B1 effects on contractility which should lower the heart rate and increase blood pressure without increasing systemic vascular resistance The above child arrives in the PICU endotracheally intubated with two peripheral large bore IVs infusing the treatment you recommended above, and has the following vital signs: temperature, 38°C (after IV acetaminophen); heart rate, 120 beats per minute; respirations, 25 per minute (intubated on ventilator with Fio2 of 0.50); blood pressure, 95/50 mm Hg; Spo2, 98% You immediately perform a point-of-care ultrasound (POCUS) of the heart from the apical four chamber view which reveals no tamponade but a left ventricular ejection fraction of 25% and normal proximal coronary arteries An arterial blood gas is obtained revealing: pH 7.20; pco2, 35 mm Hg; po2, 90 mm Hg; base excess, 29.0 mmol/L; lactate level, 8.2 mmol/L (normal: 1-2); B type natriuretic peptide level, 4675 pg/mL (normal: ,100 pg/mL) The complete blood count is normal The child has a positive nasal rapid antigen test for SARS-CoV-2 Over the next hours the child progresses downward with a worsening metabolic acidosis, increasing lactate level (12.4 mmol/L), lower mixed venous saturation level (,40%); anuria and decreased central and peripheral pulses A discussion with your pediatric cardiac surgeon and interventional cardiologist leads to the need for mechanical circulatory support for this child The best device choice for this child is: A Percutaneously inserted Abiomed Impella 2.5 through the right femoral artery B Thoratec Pediamag Right Ventricular Assist Device (RVAD) C Veno-venous extracorporeal life support (VV-ECLS) with a double lumen catheter in the right internal jugular vein D Veno-arterial extracorporeal life support (VA-ECLS) through the right internal jugular vein and carotid artery Preferred response: D Rationale Only VA ECMO will provide increased systemic cardiac output (Qs) in this patient with cardiogenic shock Theoretically, the Impella heart pump could provide LV assist in older adolescent but not in a 5-year-old The child stabilizes on the mechanical circulatory support you chose above but unfortunately after 10 days of aggressive therapy there is no recovery of cardiac function but all other organ function including neurologic status are intact Your next BEST OPTION for this child’s long term survival is to: A Continue on the current therapy for an additional weeks hoping for cardiac recovery B Continue on the current therapy but contact the heart transplant team to begin the process of listing the child status 1A C Convert the child over to a paracorporeal Berlin Heart Excor Biventricular Assist Device using two 25-mL pumps as a bridge to cardiac transplant D Speak to the family about the futility in continuing aggressive care and discontinue MCS Preferred response: C Rationale VA ECMO has stabilized the child with preservation of the child’s other vital organs but this therapy is limited to short term use (despite a few outliers) For the child to be listed and receive a heart transplant, continued support would likely run months Transitioning the child to a long term VAD is the best option for long term survival (to recovery or transplant) At this time ECLS/VAD are not futile or experimental therapies for this 5-year-old child A previously well 8-kg, 6-month-old girl is referred from an outside hospital with frequent episodes of new-onset polymorphic ventricular tachycardia She has been cardioverted several times and commenced on a lidocaine infusion The episodes are becoming more frequent and associated with significant hypotension Echocardiogram reveals extensive left ventricular noncompaction with an ejection fraction of 31% No intracardiac thrombus is reported A venous saturation of 51% is obtained CHAPTER 136 Board Review Questions from an existing right internal jugular central venous catheter What would be the appropriate subsequent management? A Cannulate for venoarterial (VA) extracorporeal membrane oxygenation (ECMO) until arrhythmia control is achieved B Maximize antiarrhythmic medication and initiate anticoagulation and milrinone infusion C Place a left ventricular assist device (LVAD) D Place on VA ECMO as a bridge to longer-term biventricular assist and heart transplantation Preferred response: D Rationale Refractory ventricular tachycardia with clinically significant hemodynamic compromise would necessitate biventricular support The patient has impaired ventricular function with evidence of inadequate tissue oxygen delivery The underlying disease process is not amenable to medical therapy alone, and the anticipated duration of mechanical support prior to orthotopic heart transplant would be in the order of weeks to months A 7-year-old, 22-kg boy is referred to the cardiology clinic with a 5-month history of increasing fatigue, exercise intolerance, anorexia, and dyspnea His parents comment that his color is gray on minimal exertion Echocardiography reveals a thin-walled, severely dilated left ventricle with an ejection fraction of 20% There is moderate mitral regurgitation with an otherwise structurally normal heart and vasculature A diagnosis of idiopathic dilated cardiomyopathy is made He is admitted, a central line is placed, and he is started on a milrinone infusion and diuretics He subsequently develops intermittent unifocal ventricular ectopy After 24 hours, his parents comment on the improvement in his color, energy levels, and appetite Listing for heart transplantation is considered Venous oxygen saturation from his central line is initially 63% Options for subsequent management include which of the following? A Discharge to home on milrinone with regular visits with the cardiologist B Place on left ventricular assist device (LVAD) as a bridge to transplant C Remain in the PICU with current regimen until a donor heart is available D Wait for evidence of end-organ dysfunction or worsening symptoms of heart failure before intervening Preferred response: A Rationale This is a case of a different disease process in an older child where potential clinical improvement can occur in more than 50% of patients Management will depend on response to initial therapy Failure to improve clinically in association with evidence of inadequate tissue oxygen delivery will determine the timing of institution of mechanical support The child’s size and expected duration of support precludes an adult VAD system or implantation of a short-term device You are caring for a newborn who underwent an arterial switch operation for d-transposition of the great vessels Eight hours after surgery, his vital signs are as follows: temperature, 37.8°C; heart rate, 165 beats per minute (sinus rhythm); left atrial pressure, 12 cm H2O; central venous pressure, 15 cm H2O; and blood pressure, 54/31 mm Hg On physical examination, he e39 has slightly cold extremities and pulses are 11, breath sounds are clear bilaterally, the abdomen is soft, and the liver edge is palpated cm below the right costal margin Urine output has been 0.49 mL/kg/h for the past hours Arterial blood gas values show the following: pH, 7.23; pco2, 37 mm Hg; Pao2, 65 mm Hg; base deficit, 6; and lactic acid, 3.7 mmol/L Which of the following interventions would potentially be detrimental to this patient? A Dopamine, 10 µg/kg/min B Epinephrine, 0.03 µg/kg/min C Fentanyl, µg/kg/h D Milrinone, 0.5 µg/kg/min Preferred response: A Rationale Low cardiac output state (LCOS) is commonly seen after cardiopulmonary bypass and is manifested by oliguria, followed by decreased perfusion, progressive acidosis, and hemodynamic compromise The goal in management of LCOS is to provide adequate oxygen delivery (Do2) to the tissues, which can be achieved by decreasing oxygen consumption or increasing Do2 Maintaining normothermia or mild hypothermia, providing adequate analgesia and sedation, and sometimes neuromuscular blockade are common interventions that will help decreased oxygen consumption Phosphodiesterase III inhibitors like milrinone are indicated in the postoperative management of LCOS Milrinone favors calcium transport into the cell by increasing intracellular cyclic adenosine monophosphate The increased intracellular calcium enhances the contractile state of the myocyte Milrinone decreases systemic and pulmonary vascular resistance and improves diastolic relaxation by increasing the rate of calcium reuptake after systole Although low-dose catecholamines are useful in improving contractility (via their b1-adrenergic effect), high-dose catecholamines (dopamine µg/kg/min, epinephrine 0.05 µg/ kg/min) will increase heart rate and increase systemic vascular resistance, leading to increased myocardial oxygen consumption, decreased cardiac output, and decreased Do2 If optimized medical management is unsuccessful in reverting LCOS, mechanical support would be indicated Chapter 29: Echocardiographic Imaging A patient undergoes surgical repair of tetralogy of Fallot with severe pulmonary stenosis The postoperative transesophageal echocardiogram demonstrates no residual obstruction in the RV outflow track, with severe pulmonary insufficiency, and a hypertrophied right ventricle On arrival to the ICU, the patient is noted to be cyanotic Breath sounds are equal with appropriate readings on ventilator monitors Which of the following would be an ideal early evaluation or intervention for this infant? A Increase the Fio2 on the ventilator to 100% and hope the cyanosis resolves B Obtain an echocardiogram to evaluate for right-to-left shunting at the atrial level C Request that the surgeon take the patient back to the operating room immediately D Request that an interventionalist take the infant to the catheterization laboratory for device occlusion of a presumed right-to-left shunt Preferred response: B e40 S E C T I O N XV Pediatric Critical Care: Board Review Questions Rationale Echocardiography is useful (and the modality of choice) in the evaluation of the cyanotic patient, can often be quickly and easily obtained, and gives immediate answers on residual shunts in the postoperative patient Prior to taking the infant back for revision of the operation, or to the catheterization laboratory for intervention, it is useful to understand the etiology of the cyanosis An atrial level communication is at times left intentionally to allow a “pop-off” for the stiff right ventricle in the immediate postoperative period A chest x-ray would be obtained prior to repositioning the ETT rather than assuming malposition in the setting of equal breath sounds Increasing the Fio2 to 100% is not a longterm solution Which of the following statements is true regarding echocardiography? A Echocardiography is limited to available acoustic windows B Echocardiography is uniquely a noninvasive modality C Echocardiography provides precise measurements of pulmonary arterial pressures D Echocardiography can provide histologic evaluation of cardiovascular tissues Preferred response: A Rationale Echocardiography is limited to the “windows” where the ultrasound beam can penetrate adequately to produce images It does not penetrate well through air This can be a major limitation to echocardiography The remaining statements are not true Transesophageal (TEE) and intracardiac echo (ICE) are examples of invasive echocardiography Echocardiography provides estimates of pulmonary arterial pressures, which can be inaccurate for many different reasons What is the earliest gestational age that cardiac echocardiography can be used to assess fetal cardiac anatomy reliably? A weeks B 14 weeks C 20 weeks D 28 weeks Preferred response: C Rationale Complete anatomic and physiologic assessment can be obtained in the neonate and in the fetus at 20 weeks of gestation Which of the following is the mainstay of the anatomic diagnosis of congenital heart disease? A Angiography B Cardiac catheterization C Computerized tomographic angiography D Echocardiography Preferred response: D Rationale The technique of echocardiography and the practice of echocardiology have changed the practice of pediatric cardiology by largely replacing the use of cardiac catheterization/angiography for the diagnosis of congenital malformations Combined with the use of prostaglandin for maintaining the patency of the ductus arteriosus, echocardiography has dramatically reduced the need for emergency cardiac catheterization in neonates Most patients with congenital heart disease that is detected in the neonatal period can undergo palliative surgery without cardiac catheterization Most definitive surgical repairs can be performed successfully without the risk of invasive studies Pulsed, continuous-wave, color, and tissue Doppler have added important capabilities for anatomic and functional assessment Intraoperative and postoperative management of congenital heart defects has been aided by the addition of transesophageal echocardiography Right ventricular pressure can be estimated with the use of echocardiography by the simplified Bernoulli equation, where v is peak velocity of which insufficiency jet? A Pulmonary insufficiency jet 4v B Pulmonary insufficiency jet 2v C Tricuspid insufficiency jet 4v2 D Tricuspid insufficiency jet 2v2 Preferred response: C Rationale Estimation of right ventricular systolic pressure by Doppler echocardiography is done with use of the maximum velocity (v) of the regurgitant tricuspid jet The systolic pressure gradient (delta P) between the right ventricle and the right atrium is calculated by using the simplified Bernoulli equation (delta P 4v2) Segmental analysis of cardiac disease is classically based on which of the following? A Great vessel arrangement, ventricular looping, situs B Situs, great vessel arrangement, ventricular looping C Situs, ventricular looping, great vessel arrangement D Ventricular looping, great vessel arrangement, situs Preferred response: C Rationale Comprehensive analysis of cardiovascular anatomy requires a step-by-step segmental approach A complete step-by-step approach to cardiac diagnosis includes the diagnosis of atrial situs; identification of the chambers and their interconnections; and systematic assessment of valves, septa, coronaries, systemic and pulmonary veins, and aortic anatomy Imaging of the thymus and diaphragm is part of the detailed echocardiographic examination The segmental approach is based on the principle that all aspects of abnormal cardiovascular morphology can be broken down into discrete, mutually exclusive descriptors, allowing unambiguous delineation of any complex congenital malformation The schema must include information on the presence, position, and connection of each cardiac segment Classically, three segments have been recognized: atria, ventricles, and great arteries By describing the anatomic segments and indicating the normality or abnormality of each, a complete description of the cardiac anatomy is possible It now is possible to code cardiac anatomic abnormalities by segmental analysis Determination of cardiac position and atrial-visceral situs is a standard portion of the echocardiographic assessment of congenital heart disease and is the foundation of the segmental approach Atrial situs and atrial morphology are diagnosed together, and four possibilities exist: solitus (normal), inversus, and heterotaxy that may be right atrial isomerism or left atrial isomerism Description of the connection of the atria and ventricles (i.e., AV connection) requires knowledge of both atrial and ventricular morphology Four patterns of AV connection exist: concordant (i.e., normal); discordant; univentricular through a single inlet ... interventional cardiologist leads to the need for mechanical circulatory support for this child The best device choice for this child is: A Percutaneously inserted Abiomed Impella 2.5 through the right... best option for long term survival (to recovery or transplant) At this time ECLS/VAD are not futile or experimental therapies for this 5-year-old child A previously well 8-kg, 6-month-old girl is... shadow in the posteroanterior view by the width of the thoracic cavity Cardiomegaly is present if this value is greater than 0.5 in adults and 0.6 in infants Although useful for assessing LV enlargement,