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

{“questions”:{“dmrgw”:{“id”:”dmrgw”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: M.Gangadharan, MD, FAAP, FASA Children\u2019s Memorial Hermann Hospital, University of Texas Health Science Center, Houston, TX AND K.L. Richards, MD, Children\u2019s Hospital of Los Angeles, Univ. of Southern California, Keck School of Medicine, Los Angeles, CA \r\n\r\nThe echocardiogram of a newborn boy with clinical features of Trisomy 21 reveals a complete atrioventricular septal defect. The superior bridging leaflet of the atrioventricular valve has no chordal attachments to either ventricle. According to the Rastelli classification, what type of morphology BEST describes this atrioventricular valve?\r\n”,”desc”:”EXPLANATION \r\n Atrioventricular septal defects (AVSD) occur at a frequency of 2 per 10,000 live births and constitute about 3% of cardiac malformations. The defect is characterized by the combination of an ostium primum atrial septal defect (ASD), an inlet ventricular septal defect (VSD), and an abnormal atrioventricular valve (AVV) straddling the left and right chambers of the heart. It results from the failure of endocardial cushions to fuse in the fifth week of intrauterine development. The abnormal atrioventricular valve usually has five leaflets: the superior bridging leaflet (SBL), the inferior bridging leaflet (IBL), the right mural leaflet, the right antero-superior leaflet, and the left mural leaflet. The valve may have a single orifice, or two orifices as shown in Figure 1 below.\r\n\r\n The pattern of the chordal septal attachments of the superior bridging leaflet (SBL) described by Rastelli is used to classify the morphology of the common atrioventricular valve into three subtypes. Rastelli type A, the most common subtype occurring in 75% of cases, consists of a superior bridging leaflet which is attached to the left ventricular septum through multiple chordal attachments. The AVV in type A is divided at the septum into left and right components. Rastelli type B, the rarest subtype, is characterized by a large SBL that extends across the interventricular septum and is attached to the right ventricle through an anomalous papillary muscle. The Rastelli type C atrioventricular valve consists of a very large SBL which is \u201cfree-floating\u201d and unattached. The Rastelli classification may be used to determine the type of approach through either a one-patch or a two-patch technique.\r\n\r\n\r\n \r\nFigure 1. AVSD. (Rigby M. Atrioventricular Septal Defect: What Is in a Name?. J Cardiovasc Dev Dis<\/em>. 2021;8(2):19. Distributed under Creative Commons Attribution License ) \r\n\r\nIn addition to complete atrioventricular septal defect, there are also partial and transitional atrioventricular septal defects. Partial AVSDs consist of an ostium primum ASD and a gap at the zone of apposition between the left side of the SBL and IBL, which is often called a cleft. Transitional AVSDs consist of an ostium primum ASD, a restrictive VSD below the common atrioventricular valve, and a cleft. \r\n\r\n Several cardiac malformations may occur with AVSD such as left ventricular inflow tract and outflow tract obstruction, tetralogy of Fallot, persistent left superior vena cava, coarctation of aorta, and heterotaxy. The common atrioventricular valve may open predominantly into the left or right ventricle resulting in an unbalanced AVSD and single ventricle physiology. Rastelli type A is associated with a narrow left ventricular outflow tract, often described as a \u201cgooseneck deformity.\u201d Rastelli type C is associated with tetralogy of Fallot. Complete diagnosis in the newborn period is usually possible with transthoracic echocardiography. \r\n\r\n Multiple chromosomal anomalies have been associated with complete atrioventricular septal defects. It occurs in approximately 20% of infants and children with Trisomy 21 and is also commonly associated with tetralogy of Fallot. Complete AVSD occurs in almost all patients with asplenia and 25% of patients with polysplenia. In addition, 8p deletion syndrome, Trisomy 9, and Trisomy 18 are also associated with CAVSD.\r\n\r\nThe superior bridging leaflet of the atrioventricular valve described in the stem has no attachments, which describes the Rastelli type C morphology, unlike Rastelli type A and B. \r\n\r\n \r\nREFERENCES \r\nWalker SG. Anesthesia for Left-to-Right Shunt Lesions. In: Andropoulos DB, Mossad EB, Gottlieb EA. Anesthesia for Congenital Heart Disease<\/em>. 4th Edition. Hoboken, NJ: John Wiley & Sons Ltd, Blackwell Publishing; 2023:636-637.\r\n\r\nRigby M. Atrioventricular Septal Defect: What Is in a Name? J Cardiovasc Dev Dis<\/em>. 2021;8(2):19. doi:10.3390\/jcdd8020019 \r\n\r\nCalabr\u00f2 R, Limongelli G. Complete atrioventricular canal. Orphanet J Rare Dis<\/em>. 2006;1:8. doi:10.1186\/1750-1172-1-8 \r\n\r\nMarino B, Vairo U, Corno A, et al. Atrioventricular canal in Down syndrome. Prevalence of associated cardiac malformations compared with patients without Down syndrome. Am J Dis Child<\/em>. 1990;144(10):1120-1122. doi:10.1001\/archpedi.1990.02150340066025\r\n\r\n”,”hint”:””,”answers”:{“fi84k”:{“id”:”fi84k”,”image”:””,”imageId”:””,”title”:”A)\tRastelli type A”},”9hm3l”:{“id”:”9hm3l”,”image”:””,”imageId”:””,”title”:”B)\tRastelli type B”},”fyu21″:{“id”:”fyu21″,”image”:””,”imageId”:””,”title”:”C)\tRastelli type C\r\n\r\n”,”isCorrect”:”1″}}}}}

{“questions”:{“zyhh8”:{“id”:”zyhh8″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Meera Gangadharan MBBS, FAAP, FASA, University of Texas Health Science Center at Houston\/Children\u2019s Memorial Hermann Hospital AND Destiny F. Chau MD, University of Arkansas for Medical Sciences\/Arkansas Children\u2019s Hospital, Little Rock, AR \r\n\r\nWhich of the following coronary artery arrangements is MOST commonly associated with D-transposition of the great arteries?\r\n\r\n\r\n\r\n\r\nCreative Commons Licensing from Gittenberger-de Groot et al. J Thorac Cardiovasc Surg<\/em>. 2018;156(6):2260-2269″,”desc”:”EXPLANATION \r\nDextro transposition of the great arteries (D-TGA) is characterized by ventriculoarterial discordance and atrioventricular concordance. D-TGA comprises approximately 5% of all congenital heart lesions and is one of the most common cyanotic congenital heart diseases to present in the newborn period with an incidence of roughly 3 per 10,000 live births. The aorta arises from the morphologic right ventricle and the pulmonary artery from the morphologic left ventricle. Patients usually have levocardia, situs solitus, and D-looped ventricles. The relative position of the aortic valve to the pulmonary valve may vary. Still, the most common arrangement is the aortic valve orifice to the right and anterior to the pulmonary valve orifice. The ventricular septum may be intact or there may be a ventricular septal defect. Left ventricular outflow tract obstruction may also be present. \r\n\r\n\r\nCoronary artery anomalies are another hallmark of transposition of the great arteries and efforts have been made to describe the coronary artery configurations in a standardized manner. Due to variations in the relative positions of the aortic and pulmonary valves to each other, the aortic valve orifice may be side-by-side, right and anterior to, or directly anterior to the pulmonary valve. The origin and subsequent course of the coronary arteries result in several different patterns. The two most common systems for describing the coronary artery configuration in D-TGA are the Yacoub classification described in 1978 and the more common Leiden Convention. The Leiden Convention was originally published in the early 1980s and was modified in 2018. It places the observer in the non-coronary cusp facing the pulmonary artery, with the right hand labeled \u201csinus 1\u201d and the left hand labeled \u201csinus 2\u201d. The classification then describes from which sinus each of the three major coronary arteries arise (Fig.1). \r\n\r\n\r\n \r\n \r\nFigure 1: Illustration of Leiden nomenclature determination. [Creative Commons Licensing from Gittenberger-de Groot et al. J Thorac Cardiovasc Surg<\/em>. 2018;156(6):2260-2269.] \r\n\r\n\r\nThe most common surgery performed for D-TGA in the current era is the Jatene arterial switch operation (ASO). This involves transecting the pulmonary artery and aorta, a few millimeters distal to their valves and anastomosing the pulmonary artery segment to the aortic root and the aorta to the pulmonary root. The operation also requires that the coronaries be translocated to the neo-aortic (pulmonary) root. From a surgical perspective, coronary artery patterns can be grouped into three main categories: (1) the \u201cusual\u201d coronary pattern (70% of cases), as depicted in answer option (A), where the left and right coronaries originate from separate sinuses with the left coronary dividing into left anterior descending and circumflex branches. Coronary transfer is usually straightforward and associated with excellent outcomes; (2) coronary arteries with an anterior or posterior loop (25% of cases), in which the coronary transfer may be difficult; and (3) coronary artery pattern with a single origin or where the coronaries course between the major arterial trunks, which may be associated with an intramural segment. Coronary transfer is usually difficult and represents a high risk for morbidity and mortality. Hence a detailed description of coronary artery anatomy before surgery is critical to avoid kinking, stretching, or placing tension on the coronary arteries when they are translocated. \r\n\r\n\r\nThe most common (\u201cusual\u201d) coronary artery pattern present in approximately 70% of cases of D-TGA is shown in answer option A. The other two patterns are much less commonly associated with D-TGA. \r\n\r\n\r\n\r\n \r\nREFERENCES \r\n\r\nGittenberger-de Groot AC, Koenraadt WMC, Bartelings MM, et al. Coding of coronary arterial origin and branching in congenital heart disease: The modified Leiden Convention. J Thorac Cardiovasc Surg<\/em>. 2018;156(6):2260-2269. doi:10.1016\/j.jtcvs.2018.08.009\r\n\r\n\r\nYacoub MH, Radley-Smith R. Anatomy of the coronary arteries in transposition of the great arteries and methods for their transfer in anatomical correction. Thorax<\/em>. 1978;33(4):418-424. doi:10.1136\/thx.33.4.418\r\n\r\n\r\nQureshi AM, Justino H, Heinle JS. Transposition of the Great Arteries. In: Shaddy R, Penny D, Feltes T, Cetta F, Mital S. Moss & Adams heart disease in infants, children, and adolescents: Including the fetus and young adult<\/em>. 10th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2022: 1122-1142. \r\n\r\n\r\nAhlstr\u00f6m L, Odermarsky M, Malm T, Johansson Ramgren J, Liuba P. Preoperative coronary anatomy assessment with echocardiography and morbidity after arterial switch operation of transposition of the great arteries. Pediatr Cardiol<\/em>. 2018;39(8):1620-1626. doi:10.1007\/s00246-018-1939-z\r\n\r\n”,”hint”:””,”answers”:{“m0krq”:{“id”:”m0krq”,”image”:””,”imageId”:””,”title”:”A. Image A Above “,”isCorrect”:”1″},”kptwb”:{“id”:”kptwb”,”image”:””,”imageId”:””,”title”:”B. Image B Above”},”zhdhm”:{“id”:”zhdhm”,”image”:””,”imageId”:””,”title”:”C. Image C Above “}}}}}

{“questions”:{“6kwwk”:{“id”:”6kwwk”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Cori Banerdt, MD – Vanderbilt Children\u2019s Hospital\/Vanderbilt University Medical Center, Nashville, TN AND\r\nDestiny F. Chau, MD – Arkansas Children\u2019s Hospital\/University of Arkansas for Medical Sciences, Little Rock, AR \r\n\r\nA 17-year-old patient with dilated cardiomyopathy is Status 1A on the heart transplantation list. The isohemagglutinin titer, drawn two days prior, is 1:32. According to the Organ Procurement and Transplantation Network (OPTN) policy changes in 2023, which of the following listing criteria MOST likely disqualifies this patient for ABO-incompatible heart transplantation?\r\n”,”desc”:”EXPLANATION \r\nPediatric patients with refractory heart failure placed on the cardiac transplantation waiting list have significant mortality due to long wait times related to the scarcity of donor organs. Furthermore, a proportion of patients with certain ABO blood types have even longer waitlist times. Specifically, recipients with type O blood have the longest waitlist time and can only receive O-type donor organs because of the presence of both anti-A and anti-B antibodies (isohemagglutinins). The immaturity of the immune system in infants prompted the first incompatible blood type (ABOi) heart transplantations in the 1990s. \r\n\r\nCurrently, ABOi heart transplants in young children are routinely performed. Reports in the literature indicate that the long-term outcomes of both compatibility groups are similar. In July 2016, the Organ Procurement and Transplantation Network (OPTN) expanded the candidacy for ABOi heart transplantation from patients younger than one year of age to include patients one to two years of age, as well as increasing the isohemagglutinin titers from 1:4 to 1:16 in this age group. After this policy change, a study using the Scientific Registry of Transplant Recipients database demonstrated that the percentage of ABOi transplantations increased by 2.7-fold, and the waiting times decreased by 68% for children listed for ABOi transplants compared to those listed for ABO compatible (ABOc) transplants. The survival rates were similar in children who received an ABOi versus ABOc heart transplant.\r\n\r\nIn March 2023, the OPTN Executive Committee approved further policy changes, which allowed transplant programs to indicate they were willing to accept an ABOi donor heart and\/or donor heart-lung for status 1A and 1B candidates placed on the waiting list before their 18th birthday. Transplant programs must report isohemagglutinin titers equal to or less than 1:16 to the OPTN every 30 days on behalf of such candidates. Previously, candidates had to be registered before their 2nd birthday. \r\n \r\nPediatric status assignments include status 1A, 1B, 2, and inactive. To be listed status 1A, a pediatric candidate must be less than 18 years of age at the time of registration and require therapy with one or more of the following: 1) continuous mechanical ventilation; 2) an intra-aortic balloon pump; 3) a stent or prostaglandin infusion to maintain ductal-dependent circulation; 4) multiple inotropic infusions or a single inotrope at high dose to treat hemodynamically unstable heart failure; or 5) a mechanical circulatory support device. Pediatric status 1A must be recertified every 14 days. \r\n\r\nThe correct answer is B. The patient described in the stem is 17 years old, status 1A, and has a recent isohemagglutinin titer of 1:32. Although the other criteria set by the most current OPTN policy are met, the isohemagglutinin titer is greater than 1:16. Therefore, this patient is a candidate for an ABOc, but not ABOi heart transplantation. \r\n\r\n \r\nREFERENCES \r\nBansal N, West LJ, Simmonds J, Urschel S. ABO-incompatible heart transplantation-evolution of a revolution. J Heart Lung Transplant<\/em>. 2024. 43(9):1514-1520. \r\n\r\nMilligan C, Daly KP. ABO-Incompatible heart transplantation: where science, society, and policy collide. J Card Fail<\/em>. 2024;30(3):486-487. \r\n\r\nAmdani S, Deshpande SR, Liu W, Urschel S. Impact of the pediatric ABO policy change on listings, transplants, and outcomes for children younger than 2 years listed for heart transplantation in the United States. J Card Fail<\/em>. 2024;30(3):476-485. \r\n\r\nOrgan Procurement and Transplantation Network. Notice of OPTN Policy Changes. Modify heart policy for intended incompatible blood type (ABOi) offers to pediatric candidates. Updated June 26, 2023. Accessed July 27 2024.\r\nhttps:\/\/optn.transplant.hrsa.gov\/media\/05vnqa0k\/optn_heart_aboi-offers_pn_june-2023.pdf\r\n\r\nOrgan Procurement and Transplantation Network Policies. Updated July 25, 2024. Accessed July 30, 2024. https:\/\/optn.transplant.hrsa.gov\/media\/eavh5bf3\/optn_policies.pdf\r\n\r\n”,”hint”:””,”answers”:{“wceai”:{“id”:”wceai”,”image”:””,”imageId”:””,”title”:”A.\tAge”},”zz0ks”:{“id”:”zz0ks”,”image”:””,”imageId”:””,”title”:”B.\tIsohemagglutinin titer “,”isCorrect”:”1″},”iiq2x”:{“id”:”iiq2x”,”image”:””,”imageId”:””,”title”:”C.\tListing status”}}}}}

{“questions”:{“elmq8”:{“id”:”elmq8″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Vera Winograd-Gomez, MD \u2013 Cincinnati Children\u2019s Hospital and Medical Center, Cincinnati, OH AND\r\nDestiny F. Chau, MD – Arkansas Children\u2019s Hospital\/University of Arkansas for Medical Sciences, Little Rock, AR \r\n\r\nA 2-month-old infant with cor triatriatum sinister is to undergo surgical repair. Which of the following hemodynamic goals is MOST appropriate during the pre-bypass period? \r\n”,”desc”:”EXPLANATION \r\nCor triatriatum (\u201ctriatrial heart\u201d), a rare cardiac anomaly found in approximately 1 in 1000 patients with congenital heart disease, describes the anatomical finding of a membrane dividing the left atrium (sinister) or right atrium (dexter) into two chambers. Cor triatriatum sinister results from an inadequate merging of the common pulmonary vein with the left atrium during heart development. In this malformation, a fibromuscular membrane with one or more orifices separates the atrium into an upper chamber, with the pulmonary veins, and a lower chamber with the left atrial appendage and the mitral valve. The degree of obstruction to blood flow through the orifices in the membrane determines the severity of the patient\u2019s symptoms. Significant obstruction may result in severe left atrial hypertension, low cardiac output, and pulmonary venous hypertension. The symptoms and pathophysiology are similar to severe mitral stenosis. Most patients develop symptoms during the first year of life, or earlier if severe obstruction is present. There are also reports of completely asymptomatic adult patients with multiperforated membranes. Cor triatriatum sinister is usually associated with other congenital cardiac malformations including hypoplastic left heart syndrome, left superior vena cava, and anomalous pulmonary venous drainage.\r\n\r\nAnesthetic considerations and goals are similar to mitral stenosis, which include the following: 1) preservation of contractility and normal sinus rhythm; 2) low to low-normal heart rate to enhance left ventricular filling time in the presence of inflow obstruction; 3) maintenance of adequate preload (central venous pressure[CVP]) to minimize the functional obstruction to left ventricular (LV) filling; and 4) adequate afterload for maintenance of systemic and coronary artery perfusion. Maneuvers to decrease pulmonary vascular resistance (PVR) before relieving pulmonary venous obstruction can result in the worsening of pulmonary venous hypertension. Conversely, after repair, pulmonary arterial hypertension may indicate a need for inhaled nitric oxide during the postoperative period. \r\nIn this case scenario, during the pre-bypass period, the hemodynamic goals are normal sinus rhythm, low to low-normal heart rate, maintenance of adequate preload (CVP) and afterload (mean arterial pressure (MAP)), and avoidance of low PVR. Decreased afterload can result in coronary artery hypoperfusion in the setting of a reduced MAP pressure in a patient with impaired left ventricular filling\/stroke volume. Excessive preload or high central venous pressure (CVP) can exacerbate left atrial hypertension and pulmonary edema, whereas low preload and CVP can further reduce stroke volume (LV end-diastolic volume) and cardiac output. Left atrial hypertension and pulmonary venous hypertension with secondary pulmonary arterial hypertension may require initiation of inhaled nitrous oxide post-operatively. \r\n\r\n\r\n \r\nREFERENCES \r\n\r\nSpaeth J, Loepke A. Anesthesia for left-sided obstructive lesions. In: Andropoulos DB, Mossad EB, Gottlieb EA, eds. Anesthesia for Congenital Heart Disease<\/em>. 4th ed. Hoboken, NJ; Wiley-Blackwell. 2023: 513-514.\r\n\r\nStout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA\/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2019 May 14;73(18):2361]. J Am Coll Cardiol. 2019;73(12):1494-1563. doi:10.1016\/j.jacc.2018.08.1028\r\n”,”hint”:””,”answers”:{“mlgrq”:{“id”:”mlgrq”,”image”:””,”imageId”:””,”title”:”A. Heart rate 100 to 140 bpm”,”isCorrect”:”1″},”1ih89″:{“id”:”1ih89″,”image”:””,”imageId”:””,”title”:”B. Mean arterial pressure 35 to 45 mmHg”},”zauyj”:{“id”:”zauyj”,”image”:””,”imageId”:””,”title”:”C. Central venous pressure 3-5 mmHg”}}}}}

{“questions”:{“74dah”:{“id”:”74dah”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: David Fitzgerald, MD and Destiny F. Chau, MD – Arkansas Children\u2019s Hospital\/University of Arkansas for Medical Sciences, Little Rock, AR \r\n\r\nA 1-month-old boy who is born with multiple intracavitary left ventricular tumors presents for follow-up cardiac evaluation. A transthoracic echocardiogram demonstrates multiple masses of homogeneous appearance without inflow or outflow obstruction that are reduced in size from previous imaging. Delta waves are noted on the electrocardiogram. Which of the following cardiac tumors is the MOST likely diagnosis?”,”desc”:”EXPLANATION \r\nPrimary cardiac tumors in children are rare with a reported incidence of up to 0.4%, excluding inflammatory masses, thrombi, and vegetations. Although most congenital cardiac tumors are benign (90%), the degree of involvement with or invasion into surrounding cardiac structures can lead to detrimental physiologic consequences. \r\n\r\nThe most common type of cardiac tumor in children is rhabdomyoma, accounting for over 60% of cases. Morphologically, these tumors are well circumscribed, multiple, and often located in the ventricles, either in an intramural or intracavitary position. On echocardiographic images, rhabdomyomas appear echogenic and homogenous. As many of these tumors regress spontaneously, an initial conservative, observational approach to management is appropriate unless the tumors cause hemodynamically significant sequelae. Both atrial and ventricular arrhythmias can occur in 40% of cases. Specifically, the incidence of Wolff-Parkinson-White syndrome is ten-fold that of the general population. Rhabdomyomas are known to be associated with tuberous sclerosis, an autosomal dominant multi-systemic disease affecting the brain, kidney, liver, and lungs. The drugs sirolimus and everolimus have been shown to reduce tumor size in the heart and brain, thus offering a potential alternative to surgical resection.\r\n\r\n\r\nThe second most common type of cardiac tumor in children is fibroma, accounting for 10-25% of cases. Unlike rhabdomyomas, fibromas are solitary tumors that typically do not regress. They tend to grow slowly, typically reaching maximal size in late gestation and early infancy. They are usually located in the interventricular septum or on the ventricular free wall. Fibromas are echogenic, well circumscribed, and often have areas of calcification or cystic degeneration. Fibromas often grow into the conduction system and may cause ventricular tachycardia or sudden death. \r\n\r\nMyxomas are rare in neonates but account for approximately 10% of cardiac tumors in older children. They are the most common cardiac tumor in adults. They are most commonly located in the left atrium arising from the fossa ovalis. Morphologically they appear sessile or pedunculated and lobular with frond like projections. Myxomas do not recede but rather require resection. The morphological appearance, typical location in the left atrium and later presentation in life tend to make these lesions easily identifiable. Clinically significant, intermittent obstruction of left ventricular inflow across the mitral valve can occur, as can embolization. \r\n\r\nIn the stem, the patient has multiple tumors with a characteristic echocardiographic appearance and history of regression over time that is most consistent with a cardiac rhabdomyoma. Fibromas may have a cystic appearance, are solitary and do not regress. Myxomas are usually present in older children, are typically located in the left atrium, and do not recede.\r\n\r\n\r\n \r\nREFERENCES \r\nUzun O, Wilson DG, Vujanic GM, Parsons JM, De Giovanni JV. Cardiac tumours in children. Orphanet J Rare Dis<\/em>. 2007;2:11. \r\n\r\nMarx G, Moran A. Cardiac tumors. In: Shaddy R, Penny D, Feltes T, Cetta F, Mital S, eds. Moss & Adams\u2019 Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult<\/em>. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2022:1639-1644\r\n\r\nMcKenzie I, Markakis Zestos M, Stayer S, Kamiski E, Davies P, Andropoulos D. In: Andropoulos D, Mossad E, Gottlieb E, eds. Anesthesia for miscellaneous lesions. Anesthesia for Congenital Heart Disease<\/em>. 4th ed. New Jersey: John Wiley & Sons, Inc.; 2023: 816-820.\r\n\r\n\r\n”,”hint”:””,”answers”:{“f9oqu”:{“id”:”f9oqu”,”image”:””,”imageId”:””,”title”:”A.\tFibroma”},”ldlpv”:{“id”:”ldlpv”,”image”:””,”imageId”:””,”title”:”B.\tRhabdomyoma”,”isCorrect”:”1″},”urfik”:{“id”:”urfik”,”image”:””,”imageId”:””,”title”:”C.\tMyxoma\r\n\r\n”}}}}}