Laszlo Kiraly - Academia.edu (original) (raw)

Papers by Laszlo Kiraly

Background: Fontan procedure is the final stage of a three-stage palliation process in patients b... more Background: Fontan procedure is the final stage of a three-stage palliation process in patients born with a univentricular heart as part of Hypoplastic Left Heart Syndrome (HLHS) or other types of Univentricular Heart. As essential as this procedure has proven to be for such cases, the Fontan physiology diminishes the cardiac output and expands systemic venous pressure which leads to venous congestion that can be complicated by Protein Losing Enteropathy (PLE). The aim of this retrospective research was to study the predictors of such complications in all patients who underwent completion of Fontan in our center in the past eight years. It involved the examination of medical records of patients who underwent completion of Fontan repair in our center since the inauguration of its cardiac surgery program. Exclusion criteria included the absence of any of the required predictors in a medical report. Included patients were divided into two groups: those who developed PLE and those who d...

Journal of Urology, 2001

We evaluated the clinical effectiveness of topical steroid application for balanitis xerotica obl... more We evaluated the clinical effectiveness of topical steroid application for balanitis xerotica obliterans in children and analyzed the association of any clinical response with histological findings. Our double-blind, placebo controlled, randomized study included 40 boys in whom balanitis xerotica obliterans was diagnosed clinically by cicatricial phimosis. The severity of phimosis was graded into 4 groups. Patients were randomized to receive the topical application of 0.05% mometasone furoate or placebo. After 5 weeks phimosis severity was reevaluated and all patients underwent circumcision. Surgical specimens were histologically typed as an early, intermediate or late form of balanitis xerotica obliterans. Seven patients were withdrawn from the study. In the steroid group 7 boys had clinical improvement and 10 had no change. Histological study showed an early, intermediate and late form of balanitis xerotica obliterans in 5, 5 and 7 cases, respectively. Of cases with clinical improvement 5 were the early and 2 the intermediate type. In the placebo group 5 cases worsened clinically and 11 did not change. Histological evaluation revealed an early, intermediate and late form of balanitis xerotica obliterans in 3, 7 and 6 boys, respectively. Of the 5 cases with histological worsening, disease was the early, intermediate and late type in 2, 2 and 1, respectively. Applying a potent topical steroid affects improvement in balanitis xerotica obliterans in the histologically early and intermediate stages of disease, and may inhibit further worsening in the late stage.

Reviews in Cardiovascular Medicine

Background: Aristotle's tripartite concept of man-body, soul and spirit-formed the basis of the G... more Background: Aristotle's tripartite concept of man-body, soul and spirit-formed the basis of the Galenic system that distinguished nurturing, vitalizing and animating tributary domains, governed by the liver, heart and brain, respectively. The Gothic cathedral structures into similar tripartite arrangements of nave, choir and sanctuary. We studied whether consistent parallels can be found between the Galenic concept of man, the Galenic heart itself and the structuring of the Gothic cathedral. Methods: Galenic literature along with scholastic texts were reviewed. Examples of Gothic cathedrals were visited and studied in locations. We used medieval analytical tools to compare characteristics of cathedral architecture and contemporary concepts on man and the heart. Results: Consistent parallels were found between the Galenic system and the structural parts of the Gothic cathedral. The principle of homology, intrinsic to both the Galenic system and Gothic architecture, identified the same tripartite organization in the Galenic heart itself and the segments could be projected onto the cathedral structure. Thus, the physical/nurturing domain was identified with the right ventricle inlet and the nave; the psychological/vitalizing domain corresponded with the right ventricle outlet/interventricular septum and the cathedral's choir; the animating/spiritual domain paralleled with the left ventricle/aortic valve and the sanctuary in the cathedral. Conclusions: The Aristotelian/Galenic tripartite concept appears consistent with Gothic architecture and both provided a comprehensive view of the world; their relationship stems in a common philosophical and symbolic foundation. The tripartite interpretation was so coherent that it effectively delayed recognition of circulation and the heart's role in it.

Journal of Humanitarian Cardio Vascular Medicine

Background/Objective. Establishment and development of tertiary-care centres for congenital heart... more Background/Objective. Establishment and development of tertiary-care centres for congenital heart disease (CHD) face multiple challenges as they need to be accessible, affordable/sustainable and provide the best possible outcomes. We report our experience of foundation a new tertiary-care CHD centre in the United Arab Emirates (UAE) and program development in Singapore. Methods. Prevalence and incidence of CHD in the context of local sociocultural environment was reviewed. Having established program elements of team, premises and workflow, quality assurance system was established. Outcome analysis, continuous audit modified internal therapeutic policies in accordance to international databases. Results. Consanguinity, segregated pattern of the population, high birth rate and low prenatal screening rate increased the incidence/prevalence and complexity of CHD in the UAE. Higher complexity/redo presentation and presence of associated anomalies were prevalent in Singapore at a lower bi...

The Egyptian Journal of Critical Care Medicine, 2016

The use of ECLS in the treatment of poisoned patients has been recently reviewed by de Lange et a... more The use of ECLS in the treatment of poisoned patients has been recently reviewed by de Lange et al. [1], but a case of aluminum phosphide poising supported by ECLS has not been described yet. We want to report a successful support with ECLS in a 6 year old child with severe cardiovascular failure due to aluminum phosphide poising

Journal of Cardiothoracic Surgery, 2021

Background Total anomalous pulmonary venous return (TAPVR) refers to an anomaly in which all of t... more Background Total anomalous pulmonary venous return (TAPVR) refers to an anomaly in which all of the pulmonary veins drain directly or indirectly to the systemic venous circulation. However, unusual types constitute approximately 5% or less of TAPVRs and there may be obstruction or discontinuity of pulmonary vein at various levels. Case presentation A 3-month-old infant was presented to us with history of poor feeding, respiratory distress and desaturations. The routine echocardiographic investigation initially confirmed the diagnosis of an atrial septal defect with dextrocardia. However, due to disproportionate severity of symptoms and congestive heart failure a cardiac computer tomography angiogram was done that revealed a rare finding of connection of pulmonary veins fused with the posterior atrium, but on the rightward side of the deviated atrial septum. Therefore, pulmonary veins entered a sinus that drains directly into the right atrial superior-posterior wall. During surgical ...

Kaleidoscope history

From the time immemorial, the heart was considered the seat of soul, repository of feelings and t... more From the time immemorial, the heart was considered the seat of soul, repository of feelings and the essence of human existence. Modern (Cartesian) science based on logical analysis and a mechanistic interpretation of physical nature grossly removed these qualities and reduced the heart to a mere pump. Discoverers of the autonomic nervous system adopted a view in which the organ, while it maintained its automatic contractions, was placed under the accelerator-brake control of the autonomic nervous system. The commanding hierarchy encompassed (1) the central autonomic network (CAN), (2) efferent drive via sympathetic and parasympathetic nerves and their ganglionic network. This rather mechanistic view has been challenged by deeper knowledge about the neuroendocrine system, establishing the heart as part of it, and by discoveries of large neural networks, 'little brains' in the gut andwe proposein the heart. These networks continuously accumulate physical and chemical information of the internal environment, interpret them and produce various messages for the brain and other organs. Apparently, there is dynamic two-way communication going on rather than one with a strictly hierarchical chain of command. This review provides a synopsis of the heart's little brain, the endocrine heart and explores the various avenues of the heart-brain dialogue The central autonomic network (CAN) is a complex functional entity in the brain that comprises of areas of the medial prefrontal cortex, anterior cingular cortex, prelimbic areas, insular cortex, basal ganglia, periaquaeductal gray matter in the midbrain, and multiple nuclei in the pons and medulla. CAN is the supreme commander of all autonomic functions including cardiovascular control. It engages in a dynamic dialogue with the cortex; thus, CAN is involved in all psychosomatic processes. On the thalamushypothalamus-pituitary gland axis, it is part of and presides over the neuroendocrine system. CAN communicates neural messages to and from the heart via vagal (parasympathetic) nerves and sympathetic nerves. Numerous cerebral pathologies can fundamentally affect the cardiac function leading to various arrhythmias, systolic and diastolic dysfunction, stress-cardiomyopathy and even to sudden death. Developing cardiomyocytes in the embryonic heart tube are set to motion by intrinsic cardiac adrenergic (ICA) cells producing catecholamines. The heart' is own conduction system (SA-node, AV-node, bundle of His, Purkinje fibers) quickly develops and it becomes functional even before the development i.e. septation, formation of valves of the embryonic heart would complete. Various origins and types of cells contribute to form the conduction system, e.g. cardiomyocytes, epithelium-derived cells and neural crest cells (NCC). NCCs emanate from the cranial terminal crest area of the embryo and reach the developing heart at the 5 th gestational week in humans. As they travel, they differentiate into foremen of septation of outflow tracts, contribute to almost all formation processes in the heart. NCCs are also the progenitors of the cardiac nerves, extracardiac ganglia (plexus cardiacus) and ganglionic network in and around the heart (intrinsic cardiac network). Parasympathetic innervation of the heart precedes sympathetic innervation. The intrinsic cardiac network reaches to the sinus venosus segment and spreads around the atria, pulmonary veins and

The Journal of Thoracic and Cardiovascular Surgery, 2007

Orvosi Hetilap, 2019

Bevezetés: A háromdimenziós (3D-s) modellezés és nyomtatás elősegíti a személyre szabott gyógyítá... more Bevezetés: A háromdimenziós (3D-s) modellezés és nyomtatás elősegíti a személyre szabott gyógyítást. A kongenitális szívsebészetben a 3D-modellek a vizuális és taktilis ingerek egyesítésével megkönnyítik a komplex anatómia megértését, hozzájárulnak a műtétek megtervezéséhez és elpróbálásához (virtuális műtét). Használatukkal javulhat a kommunikáció a multidiszciplináris gyógyító csapaton belül, illetve a betegek és hozzátartozóik felé. A 3D-modellek gyakran új anatómiai információt is nyújtanak, és alternatív műtéti megoldásokra sarkallnak. Célkitűzés: Mindezen lehetséges klinikai előnyök megvalósulását vizsgáltuk. Módszer: A komputertomográfiás-angiográfiás adatokból elkészült a szívnagyerek virtuális 3D-modellje, amelyből életnagyságú "vértérfogat"-(átlátszatlan anyagból) és egy 1,5×-es nagyítású "üreges" (rugalmas, áttetsző anyagból) 3D-nyomtatvány készült. A modellek pontosságát a műtéti viszonyokkal ellenőriztük. Eredmények: Tizenkét komplex veleszületett szívbeteg (6 fiú, 6 lány, medián életkor: 11 hónap; tartomány: 6,5-82) szívnagyereinek 3D virtuális és 3D nyomtatott modelljét készítettük el szívműtétre való előkészítés keretében. Az intraoperatív viszonyok milliméteres nagyságrendben igazolták a modellek pontosságát. Az atrioventricularis billentyűk 3D-nyomtatással való ábrázolására a módszer jelenleg nem alkalmas. A modellek 8 esetben pontosították a diagnózist, 6-ban új információt nyújtottak (rendellenes coronaria eredés/lefutás, korábban nem észlelt kommunikáció stb.); 6-ban megváltoztatták a műtéti tervet (például megnyitandó szívüreg, intracardialis korrekció mibenléte stb.), 10 esetben műtéttechnikai segítséget adtak. A 3D-modelleken elpróbált műtéti tervet (Aristotle-rizikó medián: 11; 10-14) minden esetben sikerült kivitelezni. A műtétek (10/12 tervezett reoperáció) során szövődmény, halálozás nem fordult elő. A 3D-modellek tetszési indexe, elfogadottsága mind a szakmai csapat, mind a betegek/hozzátartozók körében magas volt. Következtetés: A 3D nyomtatott szívmodellek válogatott esetekben nagymértékben növelhetik a komplex veleszületett szívhibák műtéteinek biztonságát. Számos előnyük mellett-jelenleg-hátrányuk, hogy az elkészítésükkel járó idő-és anyagi ráfordítás finanszírozására még nincs megfelelő biztosítási háttér.

With achievements in decreasing infant mortality rate, improving healthcare and somewhat declinin... more With achievements in decreasing infant mortality rate, improving healthcare and somewhat declining fertility rate, population growth remains at the highest in the Arab World. Extended family, where women carry subordinate status, expansion of religious attitudes into secular life have been proposed for the peculiarities in demography. Consanguinity is traditionally prevalent; some countries with significant immigrant subpopulation feature segregated reproductive groups. Religious considerations reduce open-access to family planning, birth control and cancel the possibility of termination of unwanted, defected pregnancies. These phenomena translate into a higher prevalence of birth defects, especially of congenital heart disease that present with higher complexity. Failure to integrate the youth bulge into their labour market led to serious consequences of radicalization, violence and migration in the Arab world. Majority of the countries experienced political instability ranging fro...

Journal of Cardiac Surgery

Fontan procedure is the preferred palliation for patients with single ventricles.

Kaleidoscope history

Interactivity and hands-on approach is key in modern day medical education, especially in the tra... more Interactivity and hands-on approach is key in modern day medical education, especially in the training of new generations of surgeons. Pediatric cardiac surgery requests detailed pathomorphological knowledge before embarking on any surgical procedure. Morphological archives of cardiac specimens greatly helped that task, however availability of these archives has become limited due to stiffened data protection rules, reduced number of autopsies, natural attrition of specimens and most importantly that patients with congenital heart disease survive. Transfer of morphological specimens on a 3D platform and creation of a virtual museum from clinical data could solve the problem. High-resolution is mandatory to preserve imaging information of delicate valvar structures. Availability of a 3D modelling and a virtual museum offers innumerable opportunities for training and education, presurgical planning and virtual surgery, patient-family education, etc. Inclusion of contour recognition and heart-cycle information may conjoin structure and function in the future. Augmented reality in the form of superimposed optical display of holograms or 3D-models onto the surgical field and/or any can be combined with robotics that may open a new horizon in surgery.

Kaleidoscope history

The heart fascinated humans since time immemorial as source and repository of our feelings, desir... more The heart fascinated humans since time immemorial as source and repository of our feelings, desires and demons. It also observed inner sensations, governed the psyche, vitalized the body, and presided over the parliament of organs. Modern scientific thinking reduced it to a mere pump. Rational intellectualism developed and spiritual insight declined. The mosque and the gothic cathedral relate to deeper symbolism; both apply a ritual of the heart. In the mosque, a niche with scallop-shaped canopy (mihrab) connects to man's heart of increasing levels of conscience. Prayer awakening the innermost pearl enables the heart to directly perceive God's word and light. Symbolism of the gothic cathedral presents physical and metaphysical worlds in unity. Its structure can be observed as different levels of conscience in which the nave is identified with the physical world, the choir with the soul and the sanctuary with the spiritual sphere. This classification is rooted in a tripartite system of the human being by Aristotle and Galen. According to Galen, the soul is governed by the heart that also affects neighbouring domains of the body and mind as much as the choir links the nave with sanctuary. This is the cathedral of the heart.

Biomolecules

Three-dimensional (3D) virtual modeling and printing advances individualized medicine and surgery... more Three-dimensional (3D) virtual modeling and printing advances individualized medicine and surgery. In congenital cardiac surgery, 3D virtual models and printed prototypes offer advantages of better understanding of complex anatomy, hands-on preoperative surgical planning and emulation, and improved communication within the multidisciplinary team and to patients. We report our single center team-learning experience about the realization and validation of possible clinical benefits of 3D-printed models in surgical planning of complex congenital cardiac surgery. CT-angiography raw data were segmented into 3D-virtual models of the heart-great vessels. Prototypes were 3D-printed as rigid “blood-volume” and flexible “hollow”. The accuracy of the models was evaluated intraoperatively. Production steps were realized in the framework of a clinical/research partnership. We produced 3D prototypes of the heart-great vessels for 15 case scenarios (nine males, median age: 11 months) undergoing co...

Pediatric Dermatology, 2005

This prospective study was designed to address the incidence and clinical and histologic characte... more This prospective study was designed to address the incidence and clinical and histologic characteristics of balanitis xerotica obliterans in a large random pediatric population with phimosis. We investigated 1178 boys who presented consecutively with phimosis between 1991 and 2001. All patients who underwent complete circumcision and surgical specimens were typed histologically as early, intermediate, or late forms of this disorder or as nonspecific chronic inflammation. Patients with balanitis xerotica obliterans were controlled at 1, 6, and 12 months postoperatively, then yearly. Balanitis xerotica obliterans was found in 471 of the 1178 patients (40%), with the highest incidence in boys aged 9 to 11 years (76%). Secondary phimosis occurred in 93% of boys with balanitis xerotica obliterans and in 32% of those without the disorder. In six instances of balanitis xerotica obliterans, meatotomy and in one meatoplasty was performed, as well as circumcision. On histologic evaluation, we found 19% had early, 60% intermediate, and 21% late form of balanitis xerotica obliterans. Glanular lesions disappeared completely within 6 months in 229 out of 231 patients. Our data strongly suggest that the true incidence of childhood balanitis xerotica obliterans is higher than previously assumed. Its incidence peaks in the 9 to 11 years age group, in whom secondary phimosis was almost exclusively caused by balanitis xerotica obliterans.

Pediatric Cardiology, 1991

The echocardiographic features and management of 10 children with right heart thrombus (RHT) are ... more The echocardiographic features and management of 10 children with right heart thrombus (RHT) are presented. The patients' ages ranged from 2 weeks to 12 years. Three patients were less than 3 weeks old. The echocardiographic diagnosis was confirmed in five patients by surgery or autopsy. The thrombus was detected in the right atrium (five patients), in the right ventricle (three), on the tricuspid valve or within the inferior vena cava, the superior vena cava, or its extension following Senning's operation for transposition of great arteries (TGA). Seven patients had structural heart disease: TGA in four, tricuspid atresia in three. In two of three patients with anatomically normal heart, the thrombus occurred as a complication of a ventriculoatrial and a iymphovenous shunt system. The third patient had no predisposing factor. Five patients were treated with anticoagulants or platelet anti-aggregating agents and four by surgery. Seven patients survived and were followed by echocardiography.

Pediatric Medicine

Objective: To provide a narrative review of the current outcomes and future trends in paediatric ... more Objective: To provide a narrative review of the current outcomes and future trends in paediatric and congenital cardiac surgery in a historical and multidisciplinary context. To present the paradigm shift in treating congenital heart disease that translate into improved outcomes. To identify current problems with directions of research. Background: Congenital heart disease (CHD) is the most common birth defect affecting approximately 1 neonate in every 120-166 births. More than half of CHD-patients need cardiac surgery in their lifetime; and half of the surgeries are required within the first six months of life. Methods: Narrative overview of the literature combining with current outcome data available from international databases is presented in comparison to the programme development of a newly-established tertiary-care centre. Conclusion: Congenital cardiac surgery is reconstructive surgery that aims for restoring biventricular circulation, when possible. Single-stage primary complete repair has become the central philosophy since the 1980s. In about thirty percent, physiologic and anatomical reasons do not permit repair by a single operation; these patients endure staged-repairs. Another 15% of CHD patients will require subsequent reoperationsmostly re-replacements of non-growing and/or deranged prostheses. Owing to advances of multidisciplinary treatment, CHD survival to adulthood now reaches 90-95% in high-income countries from less than 20% in the presurgical era. Treating CHD patients is a commitment for life. Research for viable and growing prostheses may solve the significant public health aspects currently associated with reoperations.

Micromachines

Despite significant advances in numerous fields of biofabrication, clinical application of biomat... more Despite significant advances in numerous fields of biofabrication, clinical application of biomaterials combined with bioactive molecules and/or cells largely remains a promise in an individualized patient settings. Three-dimensional (3D) printing and bioprinting evolved as promising techniques used for tissue-engineering, so that several kinds of tissue can now be printed in layers or as defined structures for replacement and/or reconstruction in regenerative medicine and surgery. Besides technological, practical, ethical and legal challenges to solve, there is also a gap between the research labs and the patients’ bedside. Congenital and pediatric cardiac surgery mostly deal with reconstructive patient-scenarios when defects are closed, various segments of the heart are connected, valves are implanted. Currently available biomaterials lack the potential of growth and conduits, valves derange over time surrendering patients to reoperations. Availability of viable, growing biomateri...

Journal of Urology, 2001

Reviews in Cardiovascular Medicine

Journal of Humanitarian Cardio Vascular Medicine

The Egyptian Journal of Critical Care Medicine, 2016

Journal of Cardiothoracic Surgery, 2021

Kaleidoscope history

The Journal of Thoracic and Cardiovascular Surgery, 2007

Orvosi Hetilap, 2019

Journal of Cardiac Surgery

Fontan procedure is the preferred palliation for patients with single ventricles.

Kaleidoscope history

Biomolecules

Pediatric Dermatology, 2005

Pediatric Cardiology, 1991

Pediatric Medicine

Micromachines