Friday, September 17, 2010

Dr Kiran welcomes all the readers of this blog. Thanks for the responses I am receiving for book reviews. I have decided to continue the book-reviews till I get another flash! This week, let me introduce another “eye opener”! This would be followed by our regular features: Interesting learning scenarios and Pediatric cardiology pearls. By the way, anyone who has read and appreciated Dr Riesh Sukharamwala’s account in the last post- please reply. He would be encouraged to write more!

Let us get to the book first:

“Do you have Kiyosaki’s book?” asked my Boss one day.

“Yes, Sir. I do. Would you like to read it?”

“Please send it to me.”

When I read Robert Kiyosaki for the first time, only the novelty factor impressed me. However, over a period of time, I think I matured to the contents of book! It is something I would not hesitate recommending to anyone. It is titled “Rich Dad, Poor Dad: What the Rich Teach Their Kids about Money… That the Poor and Middle Class Do Not!”

The best part of the book is that it does not teach anything about market ventures, real-estate, dot com or anything similar. It concentrates on individual discipline and private attitudes towards money. When most of us equate money with wealth, Kiyosaki differs. He teaches us the difference between money and wealth. Money is a result of wealth or real value, and sometimes only a symbol of it. What is real is what has generated the money: a business with revenues greater than costs, a property with rent greater than mortgage, knowledge that earns royalties and so on.

The Rich Dad principle would be, “If you look for money and security, that’s all you’ll get.” You might get “money” but not find the source of money. The fundamental difference between the Rich Dad and Poor Dad is that the Rich Dad knows the difference between an asset and a liability. Anything that generates money—that actually puts it in your pocket—is an asset. Everything that takes money from your pocket without more returns is a liability! The job earnings are returns and not assets. The income coming from assets need not even have you to be around!

Kiyosaki maintains that unless one knows how to read a balance sheet, he is financial illiterate! Financial literacy, he says, is as important as word literacy. “Illiteracy, both in words and numbers, is the foundation of financial struggle.” His Sutra for getting rich is knowledge. Before making any investments, one should educate oneself on all the options and opportunities. “The more you know, the better your decisions will be!” Lack of financial education teamed with the desire for quick riches leads to disaster. “Most people, in their drive to get rich, are trying to build an Empire State Building on a 6-inch slab,” he says. The key to controlling money in his view is by controlling emotions. Becoming rich involves self-discipline and the ability to separate the emotions of fear and greed from a good investment decision.

This book makes the reader think a lot. It forces the reader to reflect not merely about their investments and assets, but about their whole attitude to work and life.

The stock market is always said to be driven by “fear and greed.” Kiyosaki claims that, for most of us, fear is the key influence in our personal economic lives. We are shaped by our attitude to money, and our attitude to money is shaped by our fear. If we could change our attitude to risk and wealth, we could begin to think, act, and live like the rich. But first we must become financially intelligent.

It is strongly advised to get hold of this book for all the simple yet strong principles it offers for enhancing your intelligence!

Please send your comments on the book and criticism on my writing on it!

Let us get back to our regular feature: Interesting learning scenarios


One of the most fascinating occurrences in pediatric cardiology is congenitally corrected transposition of great arteries (cTGA). Any student of medicine feels extremely fascinated when the anatomy is understood for first time. However, it takes lot many years to understand the lesion. Every child with cTGA teaches a different lesson. We had a 12-year-old with cTGA, intact IVS. The LV was obviously regressed. Cath showed LV pressure of 60mmHg against RV pressure of 120mmHg. There was a voice on PA banding and preparing LV for double switch. Surprisingly, few more people seemed to support this! I have no objective data on till what age such a venture is attempted. What is the maximum age you have come across in which such a surgery was fruitful? Is there a cut-off age till which we can attempt the 2-stage arterial switch? Please send me your opinions and experiences.


Continuing with cTGA, is it worth replacing the tricuspid valve in cases of cTGA with severe TR? We accept that the TV and RV are not physiologically fit enough to tolerate systemic pressures. Hence, they fail over a period of time and TR is a part of the natural history of cTGA. Is the problem with the TV or the chamber distal to it which is pumping against the systemic afterload?


We had a scenario that could not be explained by any of us. This 9-month-old came with a large ASD L to R, moderate VSD L to R and moderate PAH. The surprise in the picture was LA and LV dilatation in the presence of normal sized tricuspid and mitral valves. The RV did reach the apex nicely from subcostal views. We are still wondering how to explain the paradox. The classical teaching is that the sizable proximal shunt always overtakes distal. In this baby with a large ASD, it should invariably RA and RV dominance. How to explain this paradox? Is this seen earlier by any of the readership? Could you offer any explanation for this? I have asked for follow up as the baby was not much symptomatic. Please let me know your experiences and explanations on this issue.


Cath studies of borderline values always make a nice “cat(h) on the wall”! The data can be twisted in the most convincing manner depending upon individual moods! We often see the borderline PA pressures in single ventricle physiology either making it for BD Glenn or losing the case based on the individual mood of the day! “The data is collected when patient was continuously on oxygen, hence likely fallacious”, “The numbers are when the patient was sedated and would be more when the patient is walking and talking” are some of the explanations offered for rejecting a case. Similarly, “The PA pressures may come down once we offload the ventricles via BD Glenn”, “Once oxygenated blood starts circulating, the ventricular function is likely to improve” are some of the explanations given for accepting. The problem is: one can argue on either sides of the case. Can the relative non-objectability be replaced by better objective criteria in each case? Is there a way of telling if a child is fit or not-fit for the procedure? How different is the scenario in other places? Let me know your experiences on this critical issue.


“No TAPVC is inoperable” is the stand of one of our senior surgeons who must have done TAPVC rerouting in thousands of children and significant number of adults. But, objectively, how to p[rove this point? It is very clear that cath study is of no help in deciding operability, as denominator is indeterminable. Is the measurement of RV EDP useful? May be, but by itself, EDP cannot determine operability. Unlike other high Qp situations, pulmonary venous return is not an assessable entity here. Hence, only time can tell whether the decision of operating was appropriate. Fortunately, we do see some of the older patients with TAPVC successfully going through the scalpel and ending up with near normal PA pressures in post op phase. What is the experience of readership? Please inform the others if your views are similar or different.


76. In ASD, the P-R interval may be prolonged, especially in older patients, because of intra-atrial and sometimes H-V conduction delay, resulting in first-degree atrioventricular block (Shiku DJ, Stijns M, Lintermans JP, et al. Influence of age on atrioventricular conduction intervals in children with and without atrial septal defect. Journal of Electrocardiology in year 1982 page 9)

77. The cleft in the anterior mitral leaflet is directed toward the midportion of the ventricular septum, along the anteroinferior rim of the septal defect. In contrast, isolated mitral clefts (not otherwise associated with AVSD) are directed toward the aortic valve annulus (di Segni E, Edwards JE. Cleft anterior leaflet of the mitral valve with intact septa: A study of 20 cases. American Journal of Cardiology in year 1983 page 919)

78. With the perimembranous defect, there can be a variable degree of anterior malalignment between the infundibular septum and the anterior ventricular septum such that the aortic valve appears to override the defect. Such lesions cannot be called tetralogy of Fallot even if there is some RVOT obstruction. (Soto B, Becker AE, Moulaert AJ, et al. Classification of ventricular septal defects. British Heart Journal in year 1980 page 332)

79. In a PDA, due to increased return into the LA, left-to-right shunting through a stretched, incompetent foramen ovale secondary to left atrial dilation is a fairly common association. This should be evaluated correctly and the incidence of coexisting ASD should not be overestimated. (Rudolph AM, Mayer FE, Nadas AS, et al. Patent ductus arteriosus. A clinical and hemodynamic study of patients in the first year of life. AAP Pediatrics journal in year 1958 page 892)

80. Isolated anomalies of minimal significance are more frequent with bicuspid aortic valves (Baroldi G, Scomazzoni G. Coronary circulation in the normal and the pathologic heart. Washington, DC: Office of the Surgeon General, in year 1967)

Good news was the contribution from Dr Ritesh Sukharamwala, a consultant Pediatric Cardiologist from Surat, Gujarat. He was an alumnus of Narayana Hrudayalaya and a member of the team. You can find his early experience as an independent pediatric cardiologist in the previous post. He has promised me atleast one contribution every month from now on. Hope others would follow soon.

That brings us to the end of another post. Please send your comments and criticisms to or put them in the comments box below. I am thankful for the positive responses I am hearing for the book review. Also, as thought previously, planning a separate section for Pediatric PGs interested in cardiology. Please let me know your suggestions on structuring the section.




  1. I find your commitment to the profession highly comendable. This shows how much thinking time goes into each case analysis. Keep up the good work!
    there are flow probes that can measure blood flow in tubes. Development of a new type of transit time ultrasound flow probe (A-series probes, Transonic Systems, Ithaca, NY) has increased the accuracy of continuous measurements of blood flow in large vessels. are such probes available for use in the cath lab? if the blood coming out of the Common venous chamber can be measured and the pressure of the PA known then R=V/I. and reversibilty can be studied. Benedict.

  2. Dear Kiran ,
    my take on PA branch sizes,
    Might Be Fiction.
    we have good results whenever the PA size is >6mm in a kid >6 months and 6 Kg.
    The max PA dia we need is 10 mm even in an adult!
    so what do we have here?
    10-6 = 4 mm
    if all the kids and adults can flow full CO through 2x PAs differing by 4 mm, why is it that we check McGoons?
    Because we cant measure the PVRI and predict the outcome, we measure the distal most PA that escapes from developmental distortion and compare with the part of the aorta that is most predictable in dia.

  3. That was Dr Benedict Raj, one of the dynamic pediatric cardiac surgeons of NH. He belongs to the very rare breed of "Thinking surgeons"!

    Nice logic, Dr Benedict.
    However, the presumption needs a bit more elaboration.
    The 10mm logic is eminence based medicine; not evidence based.
    Going by the Z-score chart, 10mm PA is 0 SD for 22kg (0.8sq meters BSA)
    The standard adult size accepted is 1.6 to 1.7 Sq meters BSA as per convention.
    Though the mathematics appears logical, numbers need evidence.
    Please let us know if you find any supportive literature.

    I request the readers to be a part of this interesting discussion.