André Vliers

Long term outcome up to 30 years after the Mustard or Senning operation: a nationwide multicentre study in Belgium

Objective: To assess long term outcome of patients who underwent Mustard or Senning repair for transposition of the great arteries up to 30 years earlier. Design: Retrospective review of medical records. Setting: The six university hospitals in Belgium with paediatric cardiology departments. Patients: 339 patients were reviewed, of whom 124 underwent the Mustard procedure and 215 the Senning procedure. This represents almost the entire population of patients in Belgium with either simple or complex transposition. Main outcome measures: Mortality, morbidity, functional abilities, social integration. Results: Overall mortality was 24.2%. Early mortality (⩽ 30 days after surgery) accounted for 16.5%, late mortality for 7.7%. Actuarial survival of early survivors at 10, 20, and 30 years after surgery was 91.7%, 88.6%, and 79.3%, respectively. Patients in the Senning cohort had a slightly better survival rate than those in the Mustard cohort (NS). Baffle obstruction occurred more often after Mustard repair (15.3%) than after the Senning procedure (1.4%). Arrhythmia-free survival did not differ between the two cohorts, but was determined by the complexity of the transposition. Survivors of the Senning cohort had better functional status, and tended to engage in more sports activities. Conclusions: The long term outcome for patients surviving the Mustard or Senning operation was favourable in terms of late mortality, morbidity, functional, and social status. Overall mortality in the Senning cohort did not differ from the Mustard group, but Senning patients had better functional status, greater participation in sports activities, and fewer baffle related problems.

Early Balloon Dilatation of the Pulmonary Valve in Infants With Tetralogy of Fallot Risks and Benefits

BACKGROUND Balloon dilatation, an established treatment for pulmonary valve stenosis, remains a controversial procedure in tetralogy of Fallot. METHODS AND RESULTS Balloon dilatation of the pulmonary valve was performed in 19 infants with tetralogy of Fallot. Its effects on the severity of cyanosis, the growth of the pulmonary valve and pulmonary arteries, and the need for transannular patching were evaluated. Clinical, echographic, angiographic, hemodynamic, and operative data were analyzed. The procedure was safe in all, without significant complications. After balloon dilatation, systemic oxygen saturation increased from a mean value of 79% to 90%. This increase proved to be short-lasting in 4 patients, who required surgery before the age of 6 months. Balloon dilatation increased pulmonary annulus size in each case, from a mean value of 4.9 to 6.9 mm (P < .001). This gain in size remained stable over time, with a mean Z score of -4.8 SD before dilatation, -3.1 SD immediately after the procedure, and -2.7 SD at preoperative catheterization (P < .001). Pulmonary artery dimensions remained unchanged immediately after balloon dilatation but increased at follow-up from a Z score mean value of -2.5 to -0.06 SD and from -2.2 to 0.04 SD for right and left pulmonary arteries, respectively (P < .001). At the time of corrective surgery, the pulmonary annulus was considered large enough to avoid a transannular patch in 69% of the infants. This represented a 30% to 40% reduction in the need for a transannular patch compared with the incidence of transannular patch expected before balloon dilatation. CONCLUSIONS Pulmonary valve dilatation in infants with tetralogy of Fallot is a relatively safe procedure and appears to produce adequate palliation in most patients. It allowed the growth of the pulmonary annulus and of the pulmonary arteries, resulting in a mean gain of 2 SD for those structures.

Bacterial pericarditis in infancy and childhood

The authors report on a cooperative study of 43 cases of bacterial pericarditis observed in children. This disorder was suspected in patients with septicemia who developed symptoms and signs of pericarditis (precordial pain, muffled heart sounds, pericardial friction rub, cardiomegaly). Early diagnosis of this condition is now facilitated by echocardiography. A combination of medical and surgical treatments (appropriate antibiotic therapy after culture and sensitivity tests and early pericardial drainage) led to complete recovery in almost all of the cases (42 of 43). After long-term follow-up, no cases of constrictive pericarditis were observed.

Intravenous enalaprilat and oral enalapril in congestive heart failure secondary to ventricular septal defect in infancy.

Abstract Successful management of congestive heart failure (CHF) in infants with a left-to-right shunt is difficult and medical therapy with digoxin and a diuretic drug is not always of sufficient benefit.1–3 The magnitude of the shunt through a ventricular septal defect (VSD) is responsive to changes in systemic resistance, as shown in animals4 and in infants after using hydralazine as an afterload-reducing agent.5–7 The use of angiotensin-converting enzyme inhibitors for CHF of adults is well established,8 and clinical studies in infants with left-to-right shunt and CHF suggest a beneficial effect.9 Few hemodynamic data are available. We assessed the acute hemodynamic effects of enalaprilat given intravenously and the clinical benefits of oral enalapril in infants with a large VSD.

Ross procedure in congenital patients: results and left ventricular function.

METHODS From April 1990 to August 1995, 121 patients (median age 42 years) underwent aortic valve replacement with allografts (69 patients) or autografts (52 patients). In this latter group, 24 Ross procedures have been performed in congenital patients since November 1991 (median age 10 years, range five months to 27 years): aortic incompetence (n = 17), isolated aortic stenosis (n = 5), small stenotic prosthesis (n = 2). Transthoracic echocardiography was obtained preoperatively in all patients and serially after surgery with the aim of measuring aortic and pulmonary annuli and evaluate gradients and incompetence and to study the left ventricular function. Intraoperative transoesophageal echocardiography was routinely used. Complete root replacement was performed in all patients. RESULTS One patient died in the early postoperative period (4%). There was no late death. All survivors remained in NYHA class I and were free of complications and medications. No gradient nor any significant aortic incompetence could be demonstrated. In 17 patients with predominant aortic incompetence before surgery, the left ventricular function was followed prospectively, end-diastolic left ventricular dimensions diminished drastically from 2 +/- 3.4 S.D. above normal to -0.63 +/- 2.4 S.D. at one week postoperatively (day 10) to reach a normal value one to three months after surgery. Left ventricular mass remained abnormal at day 10 (from 4.7 +/- 3.3 S.D. to 5.3 +/- 3.8 S.D.) and diminished more progressively to reach a normal value (0.14 +/- 1.4 S.D.) at three months. This resulted in a significant decrease of end-systolic wall stress (-3.6 +/- 2.1 S.D.) and in a hyperdynamic function in the immediate postoperative days except in two patients. These two patients were characterized preoperatively by more severely dilated left ventricle (end diastolic dimension 5.3 +/- 0.03 versus 1.6 +/- 3 S.D.) with decreased left ventricular wall thickness (1.19 +/- 0.7 versus 3.44 +/- 1.9 S.D.), decreased ratio between end diastolic wall thickness and end diastolic dimension (0.14 +/- 0.06 versus 0.2 +/- 0.06) and a decreased velocity of shortening. Unlike the other 15 patients, the left ventricular function did not recover completely at mid term follow-up in those two patients. CONCLUSION The Ross operation is a safe procedure and allows us to suppress completely the abnormal loading conditions of the left ventricle, resulting in a complete recovery of left ventricular function in most patients.

Computer interpretation of pediatric orthogonal electrocardiograms: statistical and deterministic classification methods.

Statistical multivariate and conventional deterministic methods of computerized interpretation of the electrocardiogram (ECG) were compared in the analysis of 1711 pediatric orthogonal ECGs validated by nonelectrocardiographic criteria on the basis of clinical and anatomic diagnoses. Among 642 children catheterized for the evaluation of congenital heart disease, there were 140 patients with left ventricular hypertrophy, 299 with right ventricular hypertrophy, and 203 with biventricular hypertrophy. A group of 1069 obviously healthy school children was studied as a control. The overall accuracy of multigroup ECG diagnosis was 85% and 79% for the statistical and deterministic methods, respectively. The diagnostic performances of both methods expressed in terms of sensitivity and predictive value were the highest for normal children and those with right ventricular hypertrophy and lowest for children with biventricular hypertrophy. The statistical method was more sensitive in the diagnosis of left ventricular hypertrophy (74% vs 64%), right ventricular hypertrophy (86% vs 83%), and biventricular hypertrophy (62% vs 50%). Mutual agreement for a correct diagnosis by the two methods was 83% for normal children and 82% for those with right ventricular hypertrophy but only 61% for children with left ventricular hypertrophy and 39% for those with biventricular hypertrophy. In conclusion, better classification results are obtained with statistical multivariate techniques as compared with conventional deterministic analysis, but both methods of ECG interpretation are complementary and their combination in the same electrocardiographic computer program can improve diagnostic accuracy.

Influence of age on atrioventricular conduction intervals in children with and without atrial septal defect

His bundle electrograms were recorded in 42 patients with secundum atrial septal defects (ASD) and in 50 controls, aged 1 month to 16 years, in normal sinus rhythm and with normal PR intervals. Intervals PA (P less than 0.01) and PR (P less than 0.02) were found to be significantly prolonged in ASD patients. Analyzing the results according to age, a significant increase for intervals AH (P less than 0.05), HV (P less than 0.001) and PR (P less than 0.001) was noted in the oldest ASD children as compared to the younger ASD children, whereas in controls only the PR interval was found to be significantly prolonged (P less than 0.05) in the oldest subgroup. Under the age of three years, atrioventricular conduction intervals were not significantly different whether or not an ASD was present. However, in older children with ASD as compared to controls, a significant increase was noted for interval PA (P less than 0.03) in children four to eight years old and for intervals HV (P less than 0.01) and PR (P less than 0.001) in children 9 to 16 years old. ASD patients showed a more significant correlation with age for interval PR with a significantly steeper slope of the regression line. Results show the impact of ASD on AV conduction to be age-related, with involvement not only of the PA interval but also of the HV interval.

Atrioventricular-conduction and Right Atrial Volume in Children With and Without Secundum Atrial Septal-defects

Atrioventricular conduction intervals and right atrial end-diastolic volumes were studied in 43 patients (26 with secundum atrial septal defect and 17 controls) to test the hypothesis that the increase in intra-atrial conduction in atrial septal defect is due to right atrial dilatation. There was no relation between any of the atrioventricular conduction intervals and right atrial dilatation. The PH, PR, and AH intervals were, however, related to both age and the RR interval.

Evaluation cardiovasculaire de l'enfant sportif.

Although rare, sports related sudden cardiac deaths in children and adolescents justify the search for risk factors in any child or adolescent who wishes to practice sports. Each time that history and careful clinical cardiovascular examination point to a possible cardiovascular abnormality, an electrocardiogram and an echocardiography must be performed. Exercise testing is useful to appreciate the cardiovascular tolerance, either in normal subjects or in subjects with a cardiovascular abnormality; its interpretation requires good knowledge and understanding of hemodynamic responses to exercise. Indications, risks and procedures of exercise testing are discussed with reference to exercise physiology.