Dr Kiran welcomes the readership to the Pediatric Cardiology blog of Narayana Hrudayalaya, Bangalore. This post will see the review of one of the bestsellers of current generation, followed by interesting learning scenarios and the pearls. First: the book review.

“Sir, can you review ‘The Secret’ in your blog?” asked one of my students.

“Well; thanks for the suggestion, but I am not reviewing fiction”, I told him.

He looked a bit sad. “Sir, I mean Rhonda Byrne” he said slowly.

I did feel sorry for myself. It was stupid on my side to respond without the complete data. I should have asked him for complete details before discounting something as fiction.

“I am really sorry for the mistake. I will definitely review the book “The Secret” by Rhonda Byrne sometime in my blog. Thank you a lot for the suggestion.”

He felt happy. I felt lost out!

It is very common to make movies based on novels. But, this is rare- A book based on a movie! Rhonda Byrne achieved it in her own signature style. Both hits; one more than the other!

Most of the TV buffs would not forget the series “World’s Greatest Commercials”. This series was from Australia and many hooked on to it for the nice insight it provided for the creative genius and out-of-the-box thinking it provided. The concept and execution of programme was credited to Rhonda Byrne, a stoic lady with lots of common sense.

Despite all her credentials, she did find herself all time low at a point. Her business had unexpected changes and was at the brink of collapse. At the same time her father- her pillar of moral courage for years- passed away. Rhonda had hit a devastating low. It was at this time her daughter gave her a copy of the best seller titled “The Science of Getting Rich” by Wallace Wattles. The book was an anti-thesis for her. It seemed to counter everything she believed. Yet, there was a charm in the work and explanation. She could not stop thinking about it. She decided- “Why not? Anyway nothing else can go wrong. Why not implement the principle of this book in my life? Let us see the result, for I have nothing else to follow either!” The result was magical- both personal and financial.

During the process of reading and implementation, Rhonda felt that she had found a secret. She wanted to spread it. But how? She decided to make use of her existing contacts in television. Her modus operandi was simple. She would go to US and interview every teacher, write, scholar, Guru or professional speaker who was likely to know about the Secret. The interviews were compiled with background narration and edited sleekly. It was never meant for cinema halls or television, but for private circulation of like-minded people who were interested in the knowledge of Secret. It would be available on internet download in its partial version and on DVD on complete version. It was a runaway hit. Word-of-mouth publicity worked the best and the sales virtually exploded. There was no looking back for Rhonda.

When it was decided to make a book out of the movie, it was not a strategy to capitalize the success of the movie. Rhonda decided that the book should have its own soul independent of the movie. Those who have not seen the movie should also experience the book. Thus, “The Secret” remains a long homage to the thinkers and authors who inspired Rhonda: these included Charles Haanel,
Robert Collier, Wallace Wattles, Genevieve Behrend, Denis Waitley, Jack Canfield, and Neale Donald Walsch to name just a few. There are lot of narrations from the own experiences of author herself.

So, what IS the SECRET?

Rhonda says it is the “law of attraction”. To elaborate: whatever one thinks about or put attention into, becomes reality in life. You attract things, people, and situations that are of a similar “vibration” to you. The universe is essentially energy, and all energy vibrates at a certain frequency. And each person is vibrating at a particular frequency, existing as an energy field within larger energy fields.

Sounds Greek; but Rhonda explains.

Going by the contemporary logic, it is useful to imagine oneself as a transmission tower. The baseline vibration of the tower is determined by the thoughts and feelings of the person. The only difference is, unlike the regular tower, the human towers can broadcast these vibrations into the universe beyond space and time. By changing the vibrations by appropriate thoughts and feelings, one can attract better people and circumstances in life.

Let us see an example: People who are wealthy think only thoughts of more wealth. “They only know wealth, and nothing else exists in their minds.” Even most people who have made a fortune then lost it become wealthy again before long. This is because they remain focused on abundance all the time, despite current circumstances. The law of attraction MUST deliver to them the equivalent of their dominant thoughts.

So, there is a caveat. How about the negative things that often rule your thought process without your control? People who discover this law would worry more about the effects that their negative thoughts. So? But Rhonda is categorical: affirmative thoughts are many times more powerful than negative ones. “Just proclaim to the Universe that all your good thoughts are powerful, and that any negative thoughts are weak.” There is thankfully a time delay or buffer between your thoughts and their coming to fruition, which allows you some space to refine what you really want. It is only a matter of practice.

Rhonda advises the use of a 3-point creative process to get the best out of the Secret.

1. Ask the universe—you must be crystal clear about what you want.
2. Believe—act, speak, and think as though you have already received what you have asked for.
3. Receive—feel great that it is coming to you. Feeling good sets up the necessary vibration to manifest the desire.
Rhonda uses another simple example: It is as if placing an order in a restaurant. You place the order and wait for it to get delivered. There, you have the faith on humans. Can’t you develop a stronger faith on the “all-delivering” universe? Similarly, when you have placed an order in the restaurant, you would never go into the kitchen and find out how it is done. That takes away the entire purpose of “hassle-free” eating. You have to follow the same ideology here. Don’t worry how the universe provides it to you. Just have faith that it WILL provide it to you.

“The more time you invest in feeling good, the Secret works better for you”. How to do that? As Charles Haanel has put it in his masterpiece “The Master Key System”: Start living in a state of love and gratitude for everything around you. This is enough to create vibrations that that attract better things in life. It is vital to elevate how you feel in any moment, since when you have negative feelings you are blocking all the good that the universe wants to give you. The Secret should teach to make gratitude a way of your life. Affirming that you are surrounded by plenty ensures that plenty more comes your way. Give thanks for everything when you get up in the morning and before turning in at night, and watch your outlook on life and circumstances change. Instead of thinking that life is a struggle, start believing that things come easily to you

Is it all mystical rubbish? We would love to get cynical and discard the idea as pile of non-provable stuff. The Secret includes a quote attributed to Buddha: “All that we are is the result of what we have thought.” Again, this is a rational, rather than a mystical, concept. The circumstances you find yourself in today, if you are not happy with them, are not “you”! The only reason anyone is not living the life of their dreams is that they are thinking more thoughts about what they DON’T want than what it is they DO want.

The majority of people who buy The Secret probably do so with an improvement of their finances in mind. However, there are also chapters on health and relationships, and how using the law of attraction can change the world. The book and the film may be seen as works of marketing genius that have made their creator millions, but plenty of people testify to their powerful effect, attracting many intelligent people who are interested in the link between mind and physical manifestation.

Get your hands on the Book or the DVD. It will surely leave you with a “feel-good” sensation atleast!

With this review, I am winding up the book review part in the blog. I had a clear reason for the book reviews. I had gone back to some of these books when I was down with dejection for various reasons in the world. It is generally what most of us go through. Each of those reasons are like forced ‘bitter pills’ which depress you more than anything else. The list need not be produced!

In the early phase of the career, the concentration is on acquiring knowledge and skills with minimal concentration towards money. In the last phases, it is acquiring fame and power. It is the middle phase which is problematic. The financial needs do not match the earnings many times. Yet, despite all the personal issues, it is important to remain sane in medical profession. Letting the mind wander may come in the way of decision making. I have seen people who could beautifully isolate the work and personal/ professional problems. Somehow, I could never do it. I had to reach the books for the rescue. The books did a wonderful job for me. They gave me the solace that I badly wanted. I thought of generalising peace obtained. That was the whole reason why the reviews of these self-help books came up. However, I felt that the needs of the blog demand more scientific discussion. Hence, I am stopping the book reviews. Still, if someone has made any attempt to write a review on any book, please send it. I shall post those last ones for all. Thanks to my friends who did review a book for the blog and for the list of books that I have received. Sorry for letting few friends down! It is probably for the greater interest!!

With this, let us get back to the regular section: Interesting learning scenarios

PROSTINS AND ANTEGRADE FLOW

Is there a role of prostins when the antegrade flow into the pulmonary arteries is reasonable in cases of cyanotic hearts? We had a 2-month-old baby with Tetralogy. The antegrade flow PA was well documented. Despite this, the infant was desaturating. There were no pulmonary issues to explain the problem. On documentation of a restrictive PDA and no good reason for the desaturation, we considered a trial of Prostins; and it worked! The saturations did improve quite well, but desaturaion would ensue as soon as the supply of prostins tapered. That prompted us to go in for a BTT shunt. The question is: Is there a way to predict the need of additional blood flow into the lungs? As seen with this baby, the “visually sufficient” amount of antegrade flow was not enough to carry on with the saturations. Is there a thumb rule or a scientific way to predict the sufficiency of Qp in cyanotic hearts? Let us know your experiences.

ROSS WITH NO HOMOGRAFT?!

This one was an interesting. The question was brought up by our senior fellow, Dr Shweta. When a Ross procedure is done, we replace the pulmonary valve by an orthotopic homograft. How about leaving the RVOT without homograft and allowing free PR as in transannular patch repair of TOF? The annulus is still intact here unlike a severed annulus of TAP. So, the tolerance is likely to be better. This also ensures that the problems associated with homograft can be avoided. Why not extend the logic of TAP to this scenario and go on? I did not have the correct answer. The logic does not sound very good superficially, but not bad either! Is there any data or experience with this scenario? If anyone has thought of anything in similar lines, please let us know.

GOOD ONE OR BAD TWO?

Corrected Transpositions indeed create interesting discussions. As a convention, we have been using single ventricle repairs for cTGA with non-routable VSD with PS. Except for the issue of routability, the ventricles would have supported 2-pumps easily. Is the conventional repair of converting such anatomies to classical cTGA (VSD closure with LV to PA homograft) underutilised? One of our senior surgeons always quote that the best of single pump repair is inferior to any 2-pump repair. Is this analogy OK with cTGA also? It is said that the recent studies with insufficient numbers performed have reported minimal outcome differences between systemic LV and systemic RV. But, when the actual discussion comes to management plan, BD Glenn et al is decided! What is the experience in other centres? Please let us know.

RHEUMATIC CHAMBERS!?

We know the rheumatic involvement of heart valves for ages. Historically, development of the science of congenital heart passed through the route of rheumatic hearts. RHD still remains a major issue with developing countries. The pancarditis pathology of RHD is well understood. However, does it affect the overall geometry of chambers in a different way? For example, give the same quantity of mitral regurgitation, does the LV of RHD different from that of non-RHD etiology? When it comes to the management, we go by the LV volumes as a marker of progress. But the mitral valve of RHD has different operation technique and outcome compared to the non-RHD group. Are we extrapolating the volume analogy of MR for RHD cases also just for the lack of sufficient data? Are there any studies to understand the LV volume differences in RHD Vs non-RHD cases with same amount of regurgitation? If anyone has done any work on it, please enlighten us.

ENLARGING THE VSD

We had earlier discussed the issue of conal tissue resection as a part of VSD routing. Now, the question goes to the other side. The option of enlarging the VSD is considered by surgeons who tackle daring things like REV. It is definitely a risky business. We recently came across a 10-year-old who had undergone enlargement of VSD for routing issues. She was fine in the immediate post-operative period and was later lost for follow up. When she returned after 3 years, we were surprised to find a severe LVOT obstruction at the junction of IVS and its patch take-off. The VSD enlargement which was sufficient during the post-op period had outgrown somehow. Is this known? Can the enlarged VSD grow on its own? Is the natural history different for the native VSD against the enlarged VSD? Is this predictable? The amount of data we have is not adequate enough to draw conclusions. If anyone has seen these scenarios earlier, please let us know.

PEDIATRIC CARDIOLOGY PEARLS

91. Between the two papillary muscles of left ventricle, the medial papillary muscle is more vulnerable to ischemia. (Voci P, Bilotta F, Caretta Q, et al. Papillary muscle perfusion pattern. A hypothesis for ischemic papillary muscle dysfunction. Circulation journal in the year 1995 page 1714)

92. In 1916, in World War I England, Sir James Mackenzie presented a paper on Soldier’s heart- a form of heart trouble to which young soldiers were particularly susceptible, manifested in spare, thin young men with great vasomotor instability, easy fatigue, breathlessness, and pain over the region of the heart. Systolic murmurs were frequent, and heart size was normal. Exertion produced undue rapidity of the heart. During the latter part of World War I, the soldier's heart terminology was changed, and Thomas Lewis introduced the term effort syndrome into the British literature. In the US of A, they renamed the condition neurocirculatory asthenia, which became the official terminology in the U.S. Army and also was incorporated into the early nomenclature lists of the New York Heart Association. (Wooley CF. Where are the diseases of yesteryear? Da Costa's syndrome, soldier's heart, the effort syndrome, neurocirculatory asthenia, and the mitral valve prolapse syndrome. Circulation journal in year 1976 page 749)

93. When the degree of valvular pulmonary stenosis is severe enough to cause a decrease in fetal right ventricular output, a larger-than-normal atrial right-to-left shunt is established in utero. This condition has been termed critical pulmonary stenosis. (Freed MD, Rosenthal AR, Bernhard WF, et al. Critical pulmonary stenosis with diminutive right ventricle in neonates. Circulation Journal in year 1973 page 875)

94. In children with Pulmonary atresia with intact Interventricular septum, the tricuspid valve is invariably abnormal- may represent a continuation of the abnormality of distal structures, ranging from extreme stenosis to regurgitation. (Choi YH, Seo JW, Choi JY, et al. Morphology of tricuspid valve in pulmonary atresia with intact ventricular septum. Pediatric Cardiology journal in year 1998, page 38)

95. Infants of diabetic women have tenfold increased risk of developing Pulmonary Atresia with VSD. The infant of a mother with insulin-dependent diabetes had nearly a 20-fold increased risk of developing PA-VSD. (Ferencz C, Loffredo CA, Correa-Villasenor A, et al., eds. Malformations of the cardiac outflow tract in genetic and environmental risk factors of major cardiovascular malformations. The Baltimore-Washington Infant Study 1981 to 1989. Armonk, NY: Futura Publishing, 1997 page 102)
This brings us to the end of another post. Please let me know your comments and criticisms. I am planning to take up some of the controversies in pediatric cardiology and review of available literature about them with the current recommendations. There is another idea of reviewing one paper or anomaly with every post with the data as current as possible. One of these would replace the existing book-review section. Any fresh idea is welcome and would be duly acknowledged. Please use the comments link. Click on ‘comments’ to open a comments box and post your writing in it. Or you can also use my email id drkiranvs@gmail.com to put up your comments- both colourful and caustic are welcome!

Regards

Kiran