Congenital Cardiac Anesthesia Society
A Section of the the Society for Pediatric Anesthesia

{“questions”:{“3gf66”:{“id”:”3gf66″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Pedro Solorzano, MD and Destiny F. Chau, MD – Arkansas Children\u2019s Hospital\/University of Arkansas for Medical Sciences, Little Rock, AR \r\n\r\nA 4-year-old child with Kleefstra syndrome and obstructive sleep apnea presents for tonsillectomy and adenoidectomy. Which of the following cardiac defect is MOST commonly associated with Kleefstra syndrome? “,”desc”:”EXPLANATION \r\nKleefstra Syndrome, previously \u201c9q subtelomere deletion syndrome\u201d, is a rare disorder linked to microdeletions or mutations on 9q34.3, which is related to the Euchromatin Histone Methyl Transferase 1 (EHMT1) gene. This gene encodes a histone methyltransferase enzyme involved in chromatin remodeling. Although most reported cases to date involve de novo mutations, autosomal dominant familial inheritance occurs in cases of balanced translocations or somatic mosaicism. \r\n\r\n\r\nThe phenotype for Kleefstra syndrome includes microcephaly, arched eyebrows, synophrism (unibrow), hypertelorism, anteverted nares, mid-face hypoplasia, macroglossia, and prognathism. Typical facial features of a patient with Kleefstra syndrome are illustrated in the picture below. \r\n\r\n\r\n\r\nFigure: Phenotypical features of Kleefstra syndrome. Karlak et al. Creative Commons License\r\n\r\n\r\nMajor associated defects include congenital heart disease (40%), urogenital disease (50%), recurrent infections (60%), intellectual disability (100%), behavioral problems (75%), obesity (40%), hearing deficits (25%), and seizures (25%). The behavioral\/ psychiatric issues have been observed to worsen after puberty. An increasing number of EHMT1<\/em> mutations have been detected in patients with the Kleefstra syndrome phenotype in recent years. \r\n\r\nAnalysis of the two largest known Kleefstra syndrome registries has demonstrated a 40% prevalence of cardiovascular abnormalities including atrial septal defects (14%), ventricular septal defects (12%), Tetralogy of Fallot with pulmonary valve stenosis (8%), cardiomyopathy (1%) and vascular malformations (9%). It also revealed a prevalence (8%) of early-onset arrhythmias including atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia, in the absence of structural heart disease. Pulmonary hypertension (PH) in patients with repaired congenital heart disease with severity out of proportion to the preoperative pathophysiology has been observed in patients with Kleefstra syndrome. Concurrent sleep apnea likely contributes to the severity of PH in some patients with this syndrome. \r\n\r\n\r\nPatients with Kleefstra syndrome present for a range of procedures necessitating anesthetic care. A thorough multisystem preoperative evaluation is essential for delineating anesthetic considerations and comprehensive perioperative planning. In addition to congenital heart disease, cardiovascular assessment should include screening for pulmonary hypertension and malignant arrhythmias, even in the absence of structural heart disease. Phenotypical facial features may cause difficulty with airway management. Associated congenital cardiac lesions warrant anesthetic management tailored to the specific cardiac defect. \r\n\r\n\r\nOf the three choices listed, this patient is most likely to have had an atrial septal defect (ASD). ASDs and ventricular septal defects are the most prevalent congenital cardiac lesions associated with Kleefstra syndrome. At present, left sided heart defects such as coarctation of the aorta and hypoplastic left heart syndrome are rarely reported in patients with Kleefstra syndrome. \r\n\r\n\r\n\r\n\r\n \r\n\r\nREFERENCES \r\n\r\nKleefstra Syndrome UK. Accessed November 14, 2023. https:\/\/www.kleefstrasyndrome.org\/ \r\n\r\n\r\nKarlak V, Jankowski J, Kolasi\u0144ska J, Nijakowski K. Kleefstra Syndrome\u2014Dental Manifestations and Needs: A Case Report with a Literature Review. Case Rep Dent<\/em>. 2023;2023:2478465. doi: 10.1155\/2023\/2478465\r\n\r\n \r\nWillemsen MH, Vulto-van Silfhout AT, Nillesen WM et al. Update on Kleefstra Syndrome. Mol Syndromol<\/em>. 2012;2(3-5):202-212. doi: 10.1159\/000335648\r\n \r\n\r\nVolkan Okur, Nees SN, Chung WK, Krishnan U. Pulmonary hypertension in patients with 9q34.3 microdeletion-associated Kleefstra syndrome. Am J Med Genet A<\/em>. 2018;176(8):1773-1777. doi: 10.1002\/ajmg.a.38852\r\n \r\n\r\nVasireddi SK, Draksler TZ, Bouman A et al. PO-04- 124 arrhythmias including atrial fibrillation in KLEEFSTRA syndrome: A possible epigenetic link. Heart Rhythm<\/em>. 2023;20(5): S597-S598. doi:10.1016\/j.hrthm.2023.03.1263\r\n\r\n\r\nCampbell CL, Collins RT, Zarate YA. Severe neonatal presentation of Kleefstra syndrome in a patient with hypoplastic left heart syndrome and 9q34.3 microdeletion. Birth Defects Res A Clin Mol Teratol<\/em>. 2014;100(12):985-990. doi:10.1002\/bdra.23324\r\n\r\n”,”hint”:””,”answers”:{“qo9cu”:{“id”:”qo9cu”,”image”:””,”imageId”:””,”title”:”A. Atrial septal defect “,”isCorrect”:”1″},”2t8qd”:{“id”:”2t8qd”,”image”:””,”imageId”:””,”title”:”B. Coarctation of the aorta”},”iypkr”:{“id”:”iypkr”,”image”:””,”imageId”:””,”title”:”C. Hypoplastic left heart syndrome “}}}}}

{“questions”:{“cgrip”:{“id”:”cgrip”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Nicholas Houska, DO – University of Colorado, Children\u2019s Hospital Colorado \r\n\r\nAccording to recent data, which of the following percentages reflects the proportion of pediatric cardiac anesthesia programs in the United States that are actively recruiting more faculty? \r\n\r\n”,”desc”:”EXPLANATION \r\nIn the last decade there has been increasing focus on the training and workforce of pediatric cardiac anesthesiologists domestically and worldwide. While the recent addition of the subspecialty to the Accreditation Council for Graduate Medical Education (ACGME) aims to formalize education and training, there is still a question of the adequacy of the current and future workforce. In 2022, to address this dearth of information, Nasr et al. conducted a survey of 113 pediatric cardiac anesthesiology programs in the United States. Analysis of the fifty-nine respondent programs with complete data provides insight into the current practice of pediatric cardiac anesthesiology in the United States. \r\n\r\nInstitutions that took part in the survey provided data for 50,463 cases of the Society of Thoracic Surgeons Congenital Surgery Database (STS-CHD) over the two year time frame (before the COVID pandemic) representing 63% of the STS-CHD reported cases for the study. Across the fifty-nine institutions, the total practicing pediatric cardiac anesthesiologists numbered 307, with a median of five per institution. Pediatric cardiac anesthesiologists reported spending 35% of their time in the cardiac operating room (OR), 25% of their time in the catheterization lab, and 25% of their time in imaging\/other sites. The respondents reported that the median number of OR cases per year with and without cardiopulmonary bypass was 60 and 26 respectively. \r\n\r\nThe predominant practice model for pediatric cardiac anesthesiology was an academic institution with trainees (71.4%) at free-standing children\u2019s hospitals (42.9%). The staffing model for OR cases was overwhelmingly (90%) 1:1 supervision while 2:1 supervision was more common in the catheterization labs (40%). Supervised providers were most commonly pediatric anesthesia fellows (59.3%) followed by nurse anesthetists (54.2%), residents (33.9%), and pediatric cardiac anesthesia fellows (25.4%). \r\n\r\nThirty-eight percent of pediatric anesthesiologists caring for children with congenital heart disease reported having completed a fellowship in pediatric cardiac anesthesia. An additional 17% pursued other training pathways such as adult cardiac anesthesiology fellowships and pediatric critical care fellowships. The remaining 44% learned the practice through on the job training. Thirty-four percent of institutions had a pediatric cardiac anesthesia fellowship at the time of the survey.\r\n\r\nNearly half (49.2%) of the fifty-nine institutions surveyed reported they were actively recruiting pediatric cardiac anesthesiologists. Impending retirement of staff was reported by 10 (17%) of 59 institutions. About one third of institutions expected no immediate changes in staffing levels.\r\n\r\nThis survey helps to illustrate the heterogeneity of the practice, training, and staffing of the pediatric cardiac anesthesiology workforce in the United States. It also shows that there is a current and future need for anesthesiologists trained in the care of children with congenital heart disease. The combination of decreasing pediatric anesthesiology fellowship applicants and the pediatric cardiac anesthesiology subspecialty combined with impending retirement of senior practitioners may soon lead to a workforce crisis in the field. \r\n\r\n\r\n\r\n \r\nREFERENCES \r\nNasr VG, Staffa SJ, Vener DF, et al. The practice of pediatric cardiac anesthesiology in the United States. Anesth Analg<\/em>. 2022;134(3):532-539.\r\n”,”hint”:””,”answers”:{“i5hxl”:{“id”:”i5hxl”,”image”:””,”imageId”:””,”title”:”A.\t25%”},”6sa7u”:{“id”:”6sa7u”,”image”:””,”imageId”:””,”title”:”B.\t50%”,”isCorrect”:”1″},”mukf3″:{“id”:”mukf3″,”image”:””,”imageId”:””,”title”:”C.\t75%”}}}}}

{“questions”:{“vi0mc”:{“id”:”vi0mc”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Nicholas Fawley, DO – Children\u2019s Hospital Los Angeles \r\n\r\nA 21-year-old female with Trisomy 21, who underwent complete atrioventricular canal (CAVC) repair as an infant, presents with fatigue and progressive dyspnea on exertion. A transthoracic echocardiogram demonstrates an estimated right ventricular systolic pressure of 64 mmHg. Which of the following medications improves exercise capacity in adults with Trisomy 21 and pulmonary hypertension? \r\n”,”desc”:”EXPLANATION \r\nChildren with Trisomy 21 (T21) have an increased incidence of pulmonary hypertension (PH). There are a variety of risk factors that contribute to the development of pulmonary hypertension in these patients, including congenital heart disease. However, there are other genetic, pulmonary, vascular and metabolic factors that also contribute to the overall risk of developing PH. The most frequent congenital heart defects found in patients with T21 include atrioventricular septal defects and ventricular septal defects. Both defects are associated with left-to-right intracardiac shunting of blood, leading to increased pulmonary blood flow, increased pulmonary arterial pressure and increased arterial wall shear stress. Ultimately, over time, the result is endothelial dysfunction, altered vasoactive mediator expression, and vascular remodeling. Progressive endothelial intimal fibrosis leads to arterial narrowing and further shear stress. The vascular remodeling associated with increased pulmonary blood flow is a key component in the timing of corrective surgery. Although early surgical repair can prevent continued hemodynamic stress on the pulmonary vasculature, elevated pulmonary arterial pressures may persist after repair. There is some evidence to suggest intrinsic endothelial dysfunction is present in patients with T21. This is supported in this patient population with evidence of elevated endothelial vasoconstrictors such as endothelin-1, impaired production of nitric oxide, and an imbalance of vasoactive eicosanoid to prostacyclin ratios. Furthermore, upregulation of proinflammatory genes in patients with T21 contributes to endothelial dysfunction and impaired nitric oxide production. \r\n\r\nRespiratory disorders are prevalent in children with T21 and may contribute to the development of PH. Functional and anatomic upper airway obstruction, obstructive and central sleep apnea, chronic aspiration, and recurrent lower airway infections can lead to increased pulmonary vascular resistance secondary to hypoxic pulmonary vasoconstriction. Small studies in children with T21 provide evidence of pulmonary hypoplasia with reduced vascular surface area and impaired microvascular development. Pulmonary hypoplasia contributes to hypoxemia during periods of increased oxygen demand. Additionally, pulmonary vein stenosis may be underdiagnosed in this population, which results in pulmonary venous hypertension and upstream pulmonary arterial hypertension. Early identification of respiratory disorders, with intervention, can potentially circumvent the development of PH. Despite early resolution, subsequent respiratory disease can cause recurrence of PH later in life. \r\n\r\nPharmacologic treatment of PH in infants and children with T21 may be accompolished through targeted monotherapy or combination therapy. In 2023, Hopper and colleagues studied data from patients with T21 in the Pediatric Pulmonary Hypertension Network Registry and found that prescribing practices are similar for pediatric patients with and without T21. Unfortunately, there are few studies comparing the efficacy of PH pharmacotherapies in pediatric patients with T21. Due to upregulated endothelial vasoconstrictors and endothelial dysfunction in T21, there may be particular benefit of endothelin receptor antagonists (ERAs), such as bosentan. In adults with T21 and PH, D\u2019Alto and colleagues found that bosentan improved WHO functional classification, exercise capacity, and pulmonary hemodynamics. \r\n\r\nOther targeted PH pharmacotherapies include phosphodiesterase type V inhibitors (sildenafil), prostacyclins (treprostinil), calcium channel blockers, and selective prostacyclin receoptor agonists (selexipag). Sildenafil is a widely prescribed therapy in infants and children with PH and has been studied in the STARTS-1 and STARTS-2 trials. However, a STARTS-1 trial sub-analysis by Beghetti and colleagues demonstrated that when comparing children with T21 compared to those without T21, sildenafil was well-tolerated but did not lead to meaningful improvements in pulmonary vascular resistance or mean pulmonary pressure. There is a lack of strong evidence-based recommendations for prostacyclin therapy in children with T21, but reduced prostacyclin production in patients with T21 suggests a possible role in pharmacotherapy. In guidelines from the American Heart Association and American Thoracic Society (AHA-ATS) on pediatric pulmonary hypertension, prostacyclin pharmacotherapy is recommended for pediatric patients with higher-risk disease severity of PH, defined by the following features: clinical evidence of right ventricular (RV) failure, WHO functional class of III & IV, recurrent syncope, significant RV enlargement\/dysfunction by echocardiography, pulmonary vascular resistance index > 20 WU.m^{2 <\/sup>, cardiac index of less than 2.0 L\/min\/m2<\/sup>, pulmonary vascular resistance\/systemic vascular resistance ratio > 1, significantly elevated brain natriuretic peptide, shorter 6-minute walk distance, and peak VO_{2<\/sub> < 15 ml\/kg\/min. Bosentan is approved for pediatric patients aged 3 to 17 years, while sildenafil is approved for ages 1 to 17 years by the Federal Drug Administration for the treatment of pulmonary arterial hypertension. \r\n\r\nAlthough studies of targeted PH therapy in children and adults with Trisomy 21 are lacking, D\u2019Alto and colleagues demonstrated that bosentan improves WHO functional classification, exercise capacity, and pulmonary hemodynamics in adults with PH and Trisomy 21. \r\n\r\n\r\n \r\nREFERENCES \r\n\r\nAbman SH, Hansmann G, Archer SL, et al. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation <\/em>. 2015; 132: 2037-99. \r\n\r\nBarst RJ, Ivy D, Gaitan G, et al. A Randomized, Double-Blind, Placebo-Controlled, Dose-Ranging Study of Oral Sildenafil Citrate in Treatment-Na\u00efve Children With Pulmonary Arterial Hypertension. Circulation <\/em>. 2012; 125(2): 324-34. \r\n\r\nBarst RJ, Beghetti M, Tomas P, et al. STARTS-2: Long-Term Survival With Oral Sildenafil Monotherapy in Treatment-Na\u00efve Pediatric Pulmonary Arterial Hypertension. Circulation<\/em>. 2014; 129(13): 1914-23. \r\n\r\nBeghetti M, Rudzinski A, Zhang M. Efficacy and safety of oral sildenafil in children with Down syndrome and pulmonary hypertension. BMC Cardiovasc Disord<\/em>. 2017; 17(1): 177. \r\n\r\nBush D, Galambos C, Dunbar D. Pulmonary hypertension in children with Down Syndrome. Pediatr Pulmonol<\/em>. 2021; 56: 621-29. \r\n\r\nD\u2019Alto M, Romeo E, Argiento P, et al. Therapy for pulmonary arterial hypertension due to congenital heart disease and Down\u2019s syndrome. Int J Cardiology<\/em>. 2013; 164: 323-6. \r\n\r\nHopper RK, Abman SH, Elia EG, et al. Pulmonary Hypertension in Children with Down Syndrome: Results from the Pediatric Pulmonary Hypertension Network Registry. J Pediatr<\/em>. 2023; 252: 131-40.\r\n”,”hint”:””,”answers”:{“vb5ri”:{“id”:”vb5ri”,”image”:””,”imageId”:””,”title”:”A.\tSildenafil”},”jrr1s”:{“id”:”jrr1s”,”image”:””,”imageId”:””,”title”:”B.\tBosentan”,”isCorrect”:”1″},”xdusv”:{“id”:”xdusv”,”image”:””,”imageId”:””,”title”:”C.\tTreprostinil”}}}}}}}

{“questions”:{“2ga6s”:{“id”:”2ga6s”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Nicholas Houska, DO – University of Colorado – Children\u2019s Hospital Colorado \r\n\r\nA 2-year-old child with decompensated heart failure and multi-organ dysfunction secondary to myocarditis is placed on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) via neck cannulation. Four hours after initiation of ECMO, the patient has increasing airway pressures and pink frothy secretions with tracheal suctioning. Transthoracic echocardiography shows severely diminished biventricular dysfunction, lack of aortic valve excursion, and a distended left atrium. Which of the following interventions is the BEST course of action?\r\n”,”desc”:”EXPLANATION \r\nExtracorporeal membrane oxygenation (ECMO) is increasingly utilized as a therapy in children with severe cardiovascular and\/or pulmonary dysfunction. However, it is not without adverse effects on the heart, lungs and other organ systems. In cases of cardiac failure, one of the primary goals of ECMO is to facilitate myocardial recovery, which can be hindered by the physiologic effects of ECMO itself. Specifically, ECMO can increase left ventricular (LV) afterload, thus increasing LV volume and pressure and simultaneously decreasing transmural myocardial perfusion. These untoward effects can inhibit cardiac recovery. Further adverse effects are seen in severe cardiac dysfunction in which the LV is not able to generate enough pressure to open the aortic valve and eject blood. In such cases, left atrial (LA) and pulmonary venous hypertension will be the end result. Pulmonary venous hypertension can lead to pulmonary edema, pulmonary hemorrhage, and impaired gas exchange, which may further delay separation from mechanical support. Stasis of blood in the left ventricle due to lack of aortic valve opening increases the risk of thrombosis, which may be difficult to prevent and treat with typical anticoagulants. \r\n\r\nIn cases where there is either clinical or echocardiographic evidence of left atrial hypertension, decompression may be indicated to reduce further cardiopulmonary complications. Decompression of the left atrium can be achieved through a variety of methods. In cases of central cannulation, a surgical LA vent may be feasible. Balloon atrial septostomy is an alternative option to achieve LA decompression in cases of peripheral ECMO cannulation or complex anatomy circumventing surgical LA vent placement. This is most commonly achieved percutaneously in the cardiac catheterization lab or bedside with echocardiographic guidance. More recently, temporary ventricular assist devices, such as the Impella, have been used to decompress the left ventricle and atrium. A retrospective study by Sperotto and colleagues demonstrated that 279 (18%) out of a total of 1,508 children with biventricular physiology required LA decompression during VA ECMO support due to failure to wean from cardiopulmonary bypass. This study also demonstrated that LA decompression was protective against in hospital adverse events. Further studies investigating the risk\/benefit profile of LA decompression during ECMO support in children are warranted. \r\n\r\nDiagnostic bronchoscopy may temporarily improve pulmonary function by clearing secretions but does not address the underlying problem. Similarly, increasing ECMO flows is likely to worsen LA hypertension by further increasing left ventricular afterload, and therefore, is not beneficial. \r\n\r\n\r\n \r\nREFERENCES \r\nSperotto F, Polito A, Amigoni A, Maschietto N, Thiagarajan RR. Left atrial decompression in pediatric patients supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass: a propensity\u2010weighted analysis. J Am Heart Assoc <\/em>. 2022;11(23):e023963.\r\n\r\nBhaskar P, Davila S, Hoskote A, Thiagarajan R. Use of ECMO for cardiogenic shock in pediatric population. J Clin Med <\/em>. 2021;10(8):1573.\r\n\r\nBrown G, Moynihan KM, Deatrick KB, et al. Extracorporeal life support organization (ELSO): guidelines for pediatric cardiac failure. ASAIO J<\/em>. 2021;67(5):463-475.\r\n\r\n\r\n”,”hint”:””,”answers”:{“cx9b5”:{“id”:”cx9b5″,”image”:””,”imageId”:””,”title”:”A.\tTranscatheter balloon atrial septostomy”,”isCorrect”:”1″},”d1inr”:{“id”:”d1inr”,”image”:””,”imageId”:””,”title”:”B.\tDiagnostic bronchoscopy”},”wm1kr”:{“id”:”wm1kr”,”image”:””,”imageId”:””,”title”:”C.\tIncrease ECMO flow\r\n\r\n”}}}}}

{“questions”:{“jb8lj”:{“id”:”jb8lj”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Nicholas Houska, DO – University of Colorado, Children\u2019s Hospital Colorado \r\n\r\nA 2023 consensus statement endorsed by sixteen professional societies, including the Congenital Cardiac Anesthesia Society, recommends a two-tier classification of pediatric heart surgery programs. To optimize high-complexity pediatric heart surgery, what is the minimum number of congenital heart surgeons recommended for Comprehensive Care Centers? \r\n”,”desc”:”EXPLANATION \r\nThe Congenital Heart Surgeon\u2019s Society has recently developed consensus recommendations for centers performing pediatric cardiac surgery in the United States, which were endorsed by fifteen other societies representing healthcare professionals caring for children and adults with congenital heart disease. The current system of healthcare delivery for pediatric heart surgery in the United States consists of a multitude of centers with wide variability in location, volume, and case complexity. Pediatric cardiac surgical outcomes differ widely after low and high complexity procedures and when compared across different care centers. This is likely related to wide variability in staffing models, program structure, resources, and perioperative care practices and processes between centers. Numerous studies have shown an association between surgical volume and outcomes, with low volume centers having higher mortality. Furthermore, studies have shown that both high performing and low performing centers have the potential for improvement in outcomes. National efforts have been made to reduce variability and improve outcomes, including public reporting, quality improvement networks, disseminating best practices, and developing consensus-based standards and guidelines for care. \r\n\r\n\r\n\r\nThe consensus statement settled on two tiers of recommendations. The first tier is termed \u201cEssential\u201d and consists of recommendations for fundamental components to promote high-quality care for any pediatric heart surgery program. The second tier is termed \u201cComprehensive\u201d and consists of recommendations to optimize high-complexity pediatric heart surgery. Per the consensus statement, at least three surgeons are recommended in a Comprehensive Care Center to optimize high complexity pediatric cardiac surgery. The consensus statement also highlights that these are recommendations, and that individual center variability may be deemed necessary as appropriate. \r\n\r\n\r\n\r\n \r\nREFERENCES \r\n\r\nBacker CL, Overman DM, Dearani JA, et al. Recommendations for centers performing pediatric heart surgery in the United States. J Thorac Cardiovasc Surg <\/em>. 2023. https:\/\/doi.org\/10.1016\/j.jtcvs.2023.09.001 Published online September 2023 \r\n”,”hint”:””,”answers”:{“bowuy”:{“id”:”bowuy”,”image”:””,”imageId”:””,”title”:”A.\tTwo surgeons”},”eafl0″:{“id”:”eafl0″,”image”:””,”imageId”:””,”title”:”B.\tThree surgeons”,”isCorrect”:”1″},”j576o”:{“id”:”j576o”,”image”:””,”imageId”:””,”title”:”C.\tFive surgeons”}}}}}