Renal artery pseudoaneurysms are rare after blunt abdominal trauma; only 11 cases have been previously reported. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or automobile accidents. Patients may be asymptomatic for many years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. The patients in four untreated cases died. The diagnosis of renal artery pseudoaneurysm can be made by Doppler sonography, computerized tomography, renal perfusion imaging, or contrast angiography. Treatment requires either surgical or percutaneous intervention. Renal salvage was possible in five of the seven patients treated. We report two additional patients with successful outcomes after surgical intervention.

Background: Developing countries are profoundly affected by the burden of congenital heart disease (CHD) because of limited resources, poverty, cost, and inefficient governance. The outcome of pediatric cardiac surgery in developing countries is suboptimal, and the availability of sustainable programs is minimal. Aim: This study describes the establishment of a high quality in-situ pediatric cardiac surgery program in Lebanon, a limited resource country. Methods: We enrolled all patients operated for CHD at the Children's Heart Center at the American University of Beirut between January 2014 and December 2018. Financial information was obtained. We established a partnership between the state, private University hospital, and philanthropic organizations to support the program. Results: In 5 years, 856 consecutive patients underwent 993 surgical procedures. Neonates and infants constituted 22.5 and 22.6% of our cohort, respectively. Most patients (82.6%) underwent one cardiac procedure. Our results were similar to those of the Society of Thoracic Surgeons (STS) harvest and to the expected mortalities in RACHS-1 scores with an overall mortality of 2.8%. The government (Public) covered 43% of the hospital bill, the Philanthropic organizations covered 30%, and the Private hospital provided a 25% discount. The parents' out-of-pocket contribution included another 2%. The average cost per patient, including neonates, was $19,800. Conclusion: High standard pediatric cardiac surgery programs can be achieved in limited-resource countries, with outcome measures comparable to developed countries. We established a viable financial model through a tripartite partnership between Public, Private, and Philanthropy (3P system) to provide high caliber care to children with CHD.

The case of a traumatic tricuspid insufficiency in a child, due to an anterior and septal leaflet rupture at the annulus level is reported for the first time. The early diagnosis 2 months after the trauma enabled a rapid and simple tricuspid valvuloplasty by laeflet reinsertion on the annulus associated with annuloplasty with a good result 6 months after the repair.

Primary isolated chylopericardium is a rare entity. Its exact pathophysiology is still unknown. A case of chronic isolated primary pericardium diagnosed 12 years after the initial diagnosis of an asymptomatic pericardial effusion is reported. The diagnosis was established incidentally during surgery for resection of a papillary fibroelastoma of the aortic valve.

The thyroid function in full term newborn infants of 30 pregnant women given topical germicide providine-iodine (PVPI) during delivery was evaluated. For comparison 12 full term newborn infants of pregnant women using clorhexidine hydrochloride as germicide in selective cesarean section were designed as control. The two pregnant groups had similar median age (27.5 yr in PVPI group, range: 19-42 yr and 28.5 yr in control group, 19-40 yr) and gestational age (39 weeks, 38-42 weeks and 39.5 weeks, 38-42 weeks). Birth weight (3365 g, 2500-3860 g and 3265 g, 2850-4000 g) and the apgar score (9, 9-10 and 9, 8-10) of newborn were similar in both groups. Umbilical cord blood samples were taken after immediate clamping and serum total T3, total T4, free T4 and TSH concentrations were assayed by an immunofluorimetric method. T3, T4 and free T4 concentrations in the cord blood were not different in PVPI newborn infants (median values: 0.92 nmol/L, 135 nmol/L, and 15.9 pmol/L), in comparison to control newborns (0.97 mmol/L, 140.9 nmol/L and 17.3 pmol/L). In contrast, cord blood TSH concentration in newborn infants of PVPI pregnant women (median value: 6.47 mIU/L) was significantly higher (p < 0.01) than in control newborn infants (4.8 mIU/L). In PVPI exposed group 14 out of 30 newborn infants had TSH concentration above the upper value (6.7 mIU/L) observed in the control groups (X2 = 8.4, p < 0.01). These data suggest that fetal thyroid is susceptible even to acute iodine overload and support the recommendation that PVPI should be avoided during pregnancy.

BackgroundCongenital left atrial wall aneurysms are rare abnormalities that arise from a developmental weakness in the muscular wall. It may be misdiagnosed or go undetected and the delay in diagnosis can lead to catastrophic consequences.Case PresentationAn updated and comprehensive review of the literature was performed for all patients with this abnormality under the age of 18. A total of 15 cases including ours are presented in this article. We present a 10‐month‐old boy who was referred to our center for cardiomegaly. Workup revealed a large atrial wall aneurysm that was successfully corrected with surgery.ConclusionHistorically, left atrial aneurysms were uncommon in the absence of valvular heart disease or other cardiac conditions. Congenital aneurysms are rare phenomenon because they arise without an acquired cardiac disease and surgical correction is crucial for survival.

The term "posterior nutcracker phenomenon" refers to the compression of the retroaortic left renal vein between the aorta (A and B, arrowhead) and the vertebral column (A and B, arrow). This entity is better known through its anterior variant, the "anterior nutcracker phenomenon," where the anterior left renal vein is compressed between the aorta and the superior mesenteric artery.A retroaortic renal vein is a rare anomaly, with an incidence of 1% to 2.4%. Fewer than 20 cases of a posterior nutcracker phenomenon have been reported. 1,2 The resulting venous hypertension in the left renal vein is manifested by recurrent, intermittent left flank or abdominal pain, or both, and intermittent unilateral hematuria. The nutcracker phenomenon occurs in relatively young, healthy patients.This disorder is easily overlooked if routine diagnostic procedures are used alone. The natural history of this disease is characterized by repeated diagnostic procedures and delayed treatments. With the advent of multidetector computed tomography (MDCT), however, the precise anatomy of the renal vessels and the aorta can be delineated as well as the compression of the left renal vein and its delayed emptying into the vena cava (Cover). Contributing factors have been suggested, such as ptosis of the left kidney with the subsequent stretching of the vein, the presence of an abdominal aortic aneurysm, or pregnancy, but these factors are absent in most patients. 2 This 52-year-old man presented with flank pain and microscopic hematuria on urine analysis. The diagnosis was pointed out after MDCT: It revealed a posterior nutcracker phenomenon owing to the compression of his left retroaortic renal vein between the aorta and osteophytes bulging anteriorly out of the vertebral body (C). This patient had spontaneous resolution of flank pain and hematuria within 10 days and was treated conservatively. During a 12-month follow-up, he reported another isolated episode of flank pain that lasted for 5 days. To our knowledge, this is the first case of nutcracker phenomenon involving vertebral osteophytes. Osteophytes are extremely frequent in elderly individuals, and with the liberal use of multislice CT, these images may be more frequently encountered in older patients. REFERENCES1. Lau JL, Lo R, Chan FL, Wong KK. The posterior "nutcracker": hematuria secondary to retroaortic left renal vein. Urology 1986;28:437-9.

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