This is Dr Kiran welcoming you back to the present post of blog. The book review is being received well. Some of the issues written in the learning scenarios of last post had eyebrows of few people rising! But, as my colleague Dr Prem Alva put it, “What’s the purpose of blog if it does not even allow open discussion?” I agree with him. I have retained the post as it stood.

Let us get back to the present post. As usual, we shall see the book review, learn from few patient scenarios and the pearls.

This post, we shall see one of the massive best-sellers of contemporary literature. It is authored by Dr Richard Carlson. It was the number one bestselling book in the USA for two consecutive years. Yet, this is not a theoretical adage for perfection. It was a simple book with about 100 strategies and ideas for avoiding trouble whenever possible! Each idea is briefly elaborated in a short essay or anecdote. It has its basis from an ethereal spiritual law of Hinduism and Buddhism – of taking the path of least resistance whenever and wherever possible for betterment. These strategies have proven their worth for millions across the globe.

There is an interesting story behind the book. One of Dr Carlson’s books had a foreword written by best-selling author, Wayne Dyer. For his next book titled “You can Feel Good”, Dr Carlson requested Dyer to write another foreword. Somehow, it did not happen. But, by mistake, Dr Carlson’s overseas publisher used the previous book’s foreword of Dyer in the new book too! When the copy reached Dr Carlson, he was taken aback. He wrote a lengthy apology to Dyer and spoke of his efforts to get the copies taken off the shelves. In a few weeks time, he received a note from Dyer. It was simple two line letter which read:

“Richard. There are two rules for living in harmony. #1) Don’t sweat the small stuff and #2) It’s all small stuff. Let the quote stand. Love, Wayne.”

That started another super-seller for Dr Carlson!

Good heartedness is what one would appreciate in this book. The present day culture and wants have a crushing demand on our psyche. Lecture from a Guru or a meditation camp on a weekend do not have effects lasting for more than 2 days. What we need is the extension of that feeling for a longer time and possibly for a lifetime! How to do this? This is the question with which Dr Carlson starts. The refreshing approach that “Don’t Sweat the Small Stuff” takes is in not worrying about having bad feelings. “Don’t try to get rid of them, but do try to put them into a larger context” is one of the advices!

Some of the tips that really have amazing effects are:

• Rising early the day, long before the spouse and kids, would entitle oneself to “golden hour.” One can read, meditate, or think about the day in peace and solitude. This single act of becoming an early riser has revolutionized life for many people who practise this religiously!

• Do superachiev ners run through constant emergencies and never relax? On the contrary, Dr Carlson says, frantic thinking and constant movement leach motivation and real success from the lives. He emphasizes that peaceful and loving does not equate oneself to apathy! If inner peace becomes a habit, there is ease in the way one would achieve goals and serve others.

• Do you have the habit of interrupting others or finishing their sentences during conversation? Quit it! This simple measure puts you into lot of peace and happiness with yourself.

• John Lennon had said “Life is what happens when we are busy making other plans.” With attention to the present moment, fear—being associated mostly with an imaginary future—tends not to exist. Tomorrow’s troubles usually sort themselves out. This is a very powerful principle and repeatedly emphasized by people like William Osler and Dale Carnegie.

• If something really worries you a lot at the moment, please ask yourself “Would this matter to me in a year from now?” You may end up laughing at the problem immediately. All the energy that would have gone futile on thinking and getting angry would become more constructive and lively!

• What is the definition of accomplishment? Dr Carlson amazes you by telling that it is not an external thing. Just staying calm and composed during an adversity itself is an accomplishment. He advises to practice and recognise small but significant accomplishments everyday.

• How do you react when someone disapproves you? You may either become very angry and burst out or you may get very emotional and sob silently and get gloomy. Is there another way? Dr Carlson advices us to “respond” to the situation than “react”! He suggests acknowledging the disapproval and re-analyse. The retention of energy is a positive move and lets you take better decision.

• How do you measure your priorities? People who have read Randy Pausch (The Last Lecture) may have some ideas. Dr Carlson does a similar suggestion in his book: Imagining oneself at own funeral! Some relevant questioning at that moment might be - What sort of person was I? Did I do the things I loved and did I really love and cherish those close to me every day? And so on. That allows oneself to cut down the sweat on small things and concentrate on real issues of importance: love and happiness.

The best aspect of the book is its brevity. It is recommended for those who keep saying they don’t have time to read stuff. Feelings are the product of thoughts and by becoming more conscious of own thinking, one can get in a position to change thoughts and therefore feelings.

“Not sweating the small stuff” is simple to follow although many disagree in the first thought. A celebrated psychologist has recognized “Not sweating the small stuff” as a key feature of what he called the self-actualizing person, a person who has given up pettiness for an unusually wide view of the world and life. That is what the book emphasizes in a joyful way.

The beauty of the book is that any page can be opened and read. Though it has nearly 100 strategies all explained in a simple, brief way, practising even a couple of them might be worthwhile and may be life-changing.

Let me know your views on the book if you have read it. If you haven’t yet, I strongly recommend you to lay your hands on one and let me know how you feel after reading it. If you have any additional comments on the book, please post them in the comments section or to my email. I shall post them on your behalf.

With this, let us get back to our interesting learning scenarios.

SPLIT SECOND SOUND AND TETRALOGY

“Is it theoretically possible to get a split second sound in TOF physiology?” was one of the questions asked to me in class. I was taking a class for cardiology diploma students and this question popped up suddenly. I could not recall anytime when I had heard a split S2 in TOF. But, the question is hypothetical here. The logic tells us that any obstruction beyond the valve capable of producing a significant RVOT obstruction should be producing a split S2. Hence, a large VSD with significant bilateral branch pulmonary artery stenoses can theoretically produce the picture of TOF physiology with split S2! If any of the readers has seen such a picture, please enlighten rest of us!

AORTIC DOUBLE EDGE!

How can a dysplastic aortic valve with severe stenosis and moderate regurgitation in a 6-year-old tackled? We had this scenario recently. This dysplastic aortic valve is obviously not suited for ballooning. The difference in the annuli of aortic and pulmonary valves was too big for Ross. Repairing a dysplastic aortic valve is as certain as toss of ten coins at the same time! The fair option would be aortic valve replacement. But, the age was crucial. It is indeed a double edged sword situation. Since the patient was asymptomatic, we thought we could buy some time. How would one approach such scenarios? What is the experience of other institutes? Please let us know if you have handled such scenarios and your experiences on outcome.

OUTING McGOON

The surgeon friendly McGoon ratio may not be the favourite of everyone, but for the lack of anything simpler, it continues to be in use. The logic of measuring abdominal aorta diameter at diaphragm is well explained. However, are there any fallacies to it? We do McGoon ratio and Nakata index for all cath studies that require PA anatomy. The disparity is often striking, especially in VSD with pulmonary atresia. Does the hemodynamic logic applicable to two semilunar valves different from that of one semilunar valve? In other words, does the abdominal aorta get unduly dilated when both the ventricles drain into aorta? What is the observation in other centres? Please let us know.

APICAL VSD AND RV

“In a moderate sized apical VSD, along with LA and LV, even the RV increases in size” was the statement by one of our senior consultants. Is it correct? Just because blood traverses through the body of RV in systole, can the RV get dilated? My understanding is that ventricles get dilated only if they behave like capacitance chambers. In other words, unless the shunt blood stays in a ventricle during diastole, it cannot get dilated. Wherever may the location of VSD be, RV cannot be a capacitance chamber as blood entering into RV via VSD never stays there during diastole. Is there any literature or case study mentioning RV status in apical VSD? Any personal experiences in this regard? Please let us know.

FLOOD OR DROUGHT

Single pulmonary artery is another situation which leads to hair loss in cardiologist and surgeon (due to constant scratching of head!). We had a situation in which 11-year-old had virtual single pulmonary artery physiology. The RPA was about 8 mm and the LPA was hardly 3 mm at narrowest point, becoming 5 mm distally, looked hypoplastic overall. The child saturated 80% at rest. There were high pressure collaterals supplying lungs. One of our surgeons felt the need for a BTT shunt to RPA as possible final palliation. The supposed logic was the growth of PAs and symptomatic improvement. However, does this justify the risk/benefit ratio? There are existing high pressure pulmonary collaterals and tight stenosis of proximal LPA. Wouldn’t the BTT shunt flood right lung and accelerate PVRI there? The LPA is less likely to grow even with the BTT shunt to RPA. I felt that our surgeon had another explanation but could not express it then. I sought his time for further discussion of this scenario. In the meanwhile, what do you think of this scenario? Is the BTT shunt better or worse? Is future drought better than the present flood? Please enumerate your experiences about this condition.

PEDIATRIC CARDIOLOGY PEARLS

81. Nearly one fourth of patients with arch anomalies but without intracardiac defects have 22q11 deletion (McElhinney DB, Clark BJ III, Weinberg PM, et al. Association of chromosome 22q11 deletion with isolated anomalies of aortic arch laterality and branching. Journal of American College of Cardiology in year 2001 page 2114)

82. When PAPVC and ASD coexist, the hemodynamic picture may be similar to that of uncomplicated ASD. The left-to-right shunt may be large. This shunt is the result of anomalous drainage of most of the blood from the anomalously connected lung and of anomalous drainage of half or more of the blood from the normally connected lung via the ASD (Swan HJC, Hetzel PS, Burchell HB, et al. Relative contribution of blood from each lung to the left-to-right shunt in atrial septal defect. Circulation journal in year 1956 page 200)

83. The development of the left innominate vein at the 7th week of gestation usually is followed by the involution of the left SVC (LSVC), which becomes the ligament of Marshall (Marshall J. On the development of the great anterior veins in man and Mammalia. Philosophical Transactions of Royal Society of London in year 1850 page 133)

84. In tricuspid atresia, it is common for the VSD to decrease in size, thereby changing a patient's classification. (Rao PS. Natural history of the ventricular septal defect in tricuspid atresia and its surgical implications. British Heart Journal in year 1977 page 276)

85. In tricuspid atresia, ECG in patients with diminished pulmonary blood flow often shows small R waves with shallow Q waves (Davachi F, Lucas RV Jr, Moller JH. The electrocardiogram and vectorcardiogram in tricuspid atresia. Correlation with pathologic anatomy. Am J Cardiol 1970;25:18)

That brings us to the end of one more post. “Is it necessary to involve controversy to get more people reading your stuff?” is one of the most pertinent questions asked in many quarters. I feel the quality of content has longer lasting punch than the temporary titillation of controversy. Let us just keep up the former than the latter. This blog is meant for dissemination of meaningful knowledge. The contents and questions will always be kept in that way. Any contribution to improve the existing stuff is most welcome. Please use comments box or my email id drkiranvs@gmail.com Thank you all.

Regards

Kiran