Christine Boutin

Echocardiographic follow-up of atrial septal defect after catheter closure by double-umbrella device.

BackgroundTranscatheter device occlusion of atrial septal defects is an attractive approach, but its efficacy and place in patient management remain to be determined. Methods and ResultsTo evaluate the medium-term results of atrial septal defect device occlusion and factors influencing residual shunting, transesophageal and transthoracic echocardiograms of 49 patients were reviewed. Transesophageal echocardiograms on 48 patients immediately following surgical closure revealed residual shunting in 2% compared with 91% after device occlusion; this proportion decreased to 53% after a mean follow-up of 10 months. The actuarial analysis suggests a progressive resolution of shunting with time. One patient had residual shunting by transesophageal echocardiography immediately after surgical closure compared with 29 after a mean follow-up of 10 months after device occlusion. Residual shunting was not influenced by (1) dimension, location, or position with relation to the device as assessed by transesophageal echocardiography; (2) location of the defect; or (3) device size relative to the stretched dimension of the defect. In 15 patients, a poor correlation existed between transesophageal and transthoracic echocardiographic findings. Variability in serial transthoracic echocardiographic findings was observed in 14. Right ventricular dimension, heart size, and presence of a murmur at follow-up did not correlate with the presence or size of residual shunting after device occlusion. ConclusionThese results suggest that ongoing spontaneous resolution of residual shunting occurs after device insertion. Factors related to the defect or device could not predict eventual resolution of residual shunting. Transthoracic echocardiography in the follow-up of these patients may not be reliable in determining presence of residual shunting.

Morphologic and hemodynamic consequences after percutaneous balloon valvotomy for neonatal pulmonary stenosis: Medium-term follow-up

OBJECTIVESnThis study sought to evaluate ventricular and valvular morphologic changes, hemodynamic consequences and clinical outcomes of pulmonary balloon valvotomy performed in the neonatal period.nnnBACKGROUNDnPrevious studies support percutaneous balloon valvotomy as the management option of choice for infants and children with valvular pulmonary stenosis. Less information is available to define the impact of valvotomy on the clinical course when performed in the neonatal period.nnnMETHODSnPatient records, catheterization data, cineangiograms and selected echocardiograms (initial and most recent studies) of 37 consecutive neonates undergoing attempted balloon dilation were reviewed.nnnRESULTSnDilation was accomplished in 35 (94%) of 37 attempts. Immediately after dilation, the transvalvular peak to peak systolic gradient decreased from 60 +/- 22 mm Hg (mean +/- SD, range 20 to 100) to 11 +/- 10 mm Hg (range 0 to 45) (p < 0.0001), and the right ventricular/aortic systolic pressure ratio decreased from 1.25 +/- 0.43 (range 0.5 to 2.6) to 0.66 +/- 0.22 (range 0.2 to 1) (p < 0.0001). Oxygen saturation measured by percutaneous oximetry increased from 80 +/- 7% to 92 +/- 4% (p < 0.0001). Three patients died (8%), and two required repeat balloon dilation. At the follow-up visit (median 31 months, range 6 months to 8 years), the estimated peak instantaneous Doppler gradient was 15 +/- 9 mm Hg (range 6 to 36). Thickening of valve leaflets, initially present in 93% of patients, was found in only 4%, and leaflet mobility improved in all. Hypoplasia of the right ventricle, initially present in 31%, was found in only 4% at the latest evaluation. Pulmonary annulus diameter Z score increased from -3 +/- 1.0 to 0 +/- 0.1 (p < 0.0001). Freedom from reintervention was 90%, 84% and 84% at 1, 2 and 8 years, respectively.nnnCONCLUSIONSnThese data support the application of balloon valvotomy as the initial intervention in the treatment algorithm for neonates with critical pulmonary valve stenosis. Medium-term follow-up observations demonstrate sustained hemodynamic relief and support maturation of the right ventricle and pulmonary valve annulus, with the expectation of a good long-term outcome.

Clinical impact of transcatheter closure of secundum atrial septal defects with the double umbrella device

The clinical impact of transcatheter closure of the isolated secundum atrial septal defect was reviewed. Closure by echocardiographic evaluation was 23 +/- 14% at 6 months, 49 +/- 16% at 2 years, and 64 +/- 16% at 4 years, and right ventricular end-diastolic dimensions in patients without residual shunts did not differ significantly from those with residual shunts.

Does the degree of cyanosis affect myocardial adenosine triphosphate levels and function in children undergoing surgical procedures for congenital heart disease

OBJECTIVEnThe outcome of children with cyanosis after cardiac surgical procedures is inferior to that of children who are acyanotic. Animal studies indicated detrimental effects of chronic hypoxia on myocardial metabolism and function. We studied whether the presence or the degree of cyanosis adversely affected myocardial adenosine triphosphate, ventricular function, and clinical outcome in children.nnnMETHODSnForty-eight children who underwent repair of tetralogy of Fallot were divided according to their preoperative saturation: group I, 90% to 100% (n = 14 patients); group II, 80% to 89% (n = 16 patients); and group III, 65% to 79% (n = 18 patients). Adenosine triphosphate was measured from right ventricular biopsy specimens taken before ischemia, at 15 minutes of ischemia, at end-ischemia, and at 15 minutes of reperfusion. Ejection fraction was measured by echocardiography.nnnRESULTSnEven before surgical ischemia, compared with groups I and II, group III had lower preoperative ejection fraction (59% +/- 2.9% vs 67% +/- 1.7% and 68% +/- 1.0%; P <.01) and lower preischemic adenosine triphosphate levels (15.1 +/- 2.1 vs 19.1 +/- 1.9 and 21.4 +/- 1.5 micromol/g dry weight; P <.01). After 15 minutes of ischemia, group III had lower adenosine triphosphate levels (11.2 +/- 1.8 vs 14.77 +/- 2.3 and 17. 6 +/- 3.1 micromol/g dry weight; P <.01). With reperfusion, both cyanotic groups lost further adenosine triphosphate compared with partial recovery in the acyanotic group (-22% +/- 3.8%, -20% +/- 3. 1% vs +18% +/- 1.8%; P <.01). Children in group III had a more complicated postoperative course as evidenced by longer ventilatory support (85 +/- 25 hours vs 31 +/- 15 and 40 +/- 21 hours; P =.07), inotropic support (86 +/- 23 hours vs 38 +/- 12 and 36 +/- 4 hours; P <.01), and intensive care unit stay (160 +/- 35 hours vs 60 +/- 10 and 82 +/- 18 hours; P =.02).nnnCONCLUSIONSnThe degree of cyanosis adversely affects myocardial adenosine triphosphate, function, and clinical outcome of children who undergo cardiac operation. Children with cyanosis should be identified as a higher risk group that could be targeted for supportive interventions.

Should the routine use of atropine before succinylcholine in children be reconsidered

It is common practice to administer atropine before a first dose of succinylcholine in infants and children. However, the administration of succinylcholine without atropine has not been investigated in children. This study was designed to compare cardiovascular changes after the administration of either atropine with succinylcholine or succinylcholine alone. In 41 ASA I or II patients aged from 1 to 12 yr anaesthesia was induced with thiopentone 5 mg · kg−1. Patients were randomly allocated to receive either atropine 20μg · kg−1 and succinylcholine 1.5 mg · kg−1 (n = 20) or succinylcholine 1.5 mg · kg−1 alone (n = 21). Heart rate and rhythm were recorded continuously from two minutes before induction until two minutes after tracheal intubation. Blood pressure was measured non-invasively before and after induction of anaesthesia and both immediately and two minutes after laryngoscopy. One self-limiting episode of bradycardia was recorded during laryngoscopy in a child who received atropine. Heart rate increased in both groups compared with baseline values (108 ± 25), with a greater increase in patients who had received atropine (150 ± 13) than in those who had not (128 ± 18) (P < 0.05). There was no difference in mean arterial pressure or incidence of arrythmias between the two groups. No recorded arrythmias were judged to be clinically important by a cardiologist. The incidence of bradycardia after succinylcholine in the absence of atropine in children aged from 1 to 12 yr appears to be lower than previously estimated. The use of atropine before a single dose of succinylcholine in children deserves to be reconsidered.RésuméOn administre d’habitude de l’atropine avant la succinylcholine aux nourrissons et aux enfants. Toutefois, l’administration de succinylcholine sans atropine n’a jamais été étudiée chez ces enfants. Cette étude a été planifiée pour comparer les changements cardiovasculaires survenant après l’administration soit d’atropine et de succinylcholine soit de succinylcholine seulement. L’anesthésie de 41 enfants ASA I et II âgés de 1 à 12 ans a été induite avec du thiopentone 5 mg · kg−1. Les enfants ont été répartis au hasard de façon à recevoir soit de l’atropine 20 μg · kg−1 avec succinylcholine 1,5 mg · kg−1 (n = 20) soit de la succinylcholine 1,5 mg · kg−1 seulement (n = 21). La fréquence et le rythme cardiaque sont enregistrés continuellement deux minutes avant l’induction jusqu’à deux minutes après l’intubation de la trachée. La pression artérielle est mesurée par la méthode non effractive avant et après l’induction de l’anesthésie et immédiatement après la laryngoscopie et deux minutes plus tard. Un épisode de bradycardie est enregistré pendant la laryngoscopie chez un enfant qui a reçu de l’atropine. Comparativement aux videurs initiales, la fréquence cardiaque augmente dans les deux groupes (108 ± 25), avec une augmentation plus importante chez ceux qui ont reçu l’atropine (150 ± 13) que chez ceux qui ne l’ont pas reçue (128 ± 18) (P < 0,05). On ne note pas de différence pour ce qui est de la pression artérielle moyenne ou de l’incidence des arythmies entre les deux groupes. Aucune des arythmies enregistrées n’a été jugée importante par un cardiologiste. En absence d’atropine, l’incidence de la bradycardie après la succinylcholine chez des enfants âgés de 1 à 12 ans semble plus basse qu’on l’estimait auparavant. L’utilisation d’atropine avant une dose unique de succinylcholine mérite d’être revue.

Impact of dynamic 3D transoesoesophageal echoardiography in the assessment of atrial septal defects and occlusion by the double-umbrealla device(CardioSEAL)

Occlusion of the atrial septal defects in the oval fossa by interventional catheterization has progressed, but still has limitations. Three-dimensional (3D) echocardiography can provide unique views unavailable by cross-sectional imaging. The objective of this study was to define the clinical application of 3D echocardiography in the assessment and monitoring of transcatheter occlusion of atrial septal defects. Three-dimensional echocardiography was attempted prior to occlusion of atrial septal defects in 41 patients (median age 8.6 years). Serial cross-sectional images were acquired by multiplane transoesophageal echocardiography and displayed by means of computer reconstruction. Dynamic 3D echocardiographic images of defects in the oval fossa were obtained in 40 of 41 patients (98%). Volume-rendering demonstrated the anterosuperior rim in 36 (90%) and the inferoposterior rim in 24 (60%), but failed to reveal small additional fenestrations in six. Sizes measured by 3D echocardiography were significantly larger than those provided by cross-sectional transoesophageal echocardiography (p=0.007), but differed little from those obtained with balloon sizing (p=0.6). After occlusion, 3D echocardiography showed positions of all arms of the device in 20 of 24 cases. Location of any protruding arms, or residual defects, were also clearly revealed. Three-dimensional images obtained in 12 patients during deployment of the double-umbrella device were useful in monitoring its position (single-frame) and for explaining the mechanism of protrusion. Current 3D echocardiography provides clinically relevant information for selection of patients for closure of atrial septal defects by interventional catheterization and when monitoring during implantation. Information obtained by this technique can clarify the mechanism of deployment of the device and closure of the defect, therefore influencing outcomes.

Heart rate and cardiac output after atropine in anaesthetised infants and children

PurposeHeart rate is considered to be a major determinant of cardiac output in infants and small children but the relationships between age, heart, rate and cardiac output in humans have never been clearly established. This study was designed to determine the change in cardiac output following atropine iv to anaesthetised infants and small children. Methods: Following-,Institutional Ethics Committee approval and written-informed consent, 20 ASA l or ll unpremeditated patients aged from 1 to 36 mo were studied. Anaesthesia was induced with 5 mg · kg−1 thiopentone, 2 μg · kg−1 fentanyl and maintained with halothane 0.5% in nitrous oxide 66% in oxygen. Vecuronium, 0.1 mg · kg−1 was used to provide muscular relaxation. Cardiac output was measured by non-invasive transthoracic blind continuous-wave Doppler echocardiography before and after the administration of 0.02 mg·kg−1 atropine iv.ResulitsAtropine increased both heart rate and cardiac index by 31.1 ± 12.8% and 29.4 ± 17.3% respectively (P < 0.05). The cardiac index before atropine was 5.1 ± 1.2 L.min−1m−2 and the increase after atropine varied widely from 1,4 to 52.1%. Although atropine did not alter the overall stroke index the recorded changes ranged from -20.8 to + 18.0%. There was no association between age and either cardiac index or % change in cardiac index after atropine. However, there was a positive but weak correlation between percentage change in heart rate and cardiac output (r2=0.46).ConclusionAtropine causes a variable increase in cardiac output in infants and children aged between 1 and 36 mo. The change in cardiac,output, considering the limits of the transthoracic echocardiography methodology, suggests that this is related to the increase in heart rate but is not dependent of age.RésuméObjectifLa fréquence cardiaque est considérée comme un déterminant majeur du débit cardiaque chez les nourissons et les jeunes enfants mais la relation entre l’âge, la fréquence et le débit n’a jamais été nettement établie chez l’humain. Cette étude visait à déterminer l’importance des variations du débit cardiaque après l’administration iv d’atropine chez des nourissons et des jeunes enfants sous anesthésie.MéthodesAprès l’obtention de la sanction du comité d’éthique et d’un consentement éclairé par écrit, 20 patients ASA l et ll non prémédiqués âgés de un à 36 mois ont été recrutés pour cette étude. L’anesthésie était induite avec 5 mg · kg−1 de thiopentone, 2μg.kg−1 de fentanyl et maintenue avec de l’halothane 0,5% dans du protoxyde d’azote 66% en oxygène. Le vécuronium 0,1 mg · kg−1 assurait le relâchement musculaire. Le débit cardiaque était mesuré par échocardiographie Doppler transthoracique à ondes continues avant et après l’administration de 0,02 mg · kg−1 d’atropine iv.RésultatsL’atropinea fait augmenter la fréquence et le débit cardiaque respectivement de 31,1 ± 12,8% et 29,4 ± 17,3% (P < 0,05). Avant l’atropine, l’index cardiaque était de 5,1 ± 1,2 L · min−1·m−2 et son augmentation après atropine avarié largement-entre 1,4 et 52,1%. Bien que l’atropine n’ait pas modifié l’index systolique dans l’ensemble, des extrèmes de l’ordre de -20,8à+ 18% étaient enregistrés. ll n’y avait pas d’association entre l’âge et l’index cardiaque ou le pourcentage de changement de l’index cardiaque après l’atropine. Cependant, il existait une corrélation positive mais faible entre le pourcentage de changement pour la fréquence et le débit cardiaque (r2= 0,46).ConclusionLatropine provoque une augmentation variable du débit cardiaque chez les nourrissöns et les enfants âgés de un à 36 mois. Tout en tenant compte des limitations techniques de l’échocardiographie trânstho-, racique, la variabilité du débit cardiaque suggère que l’augmentation, est en rapport avec l’augmentation de la fréquence cardiaque mais qu’elle est indépendarite de l’âge.

904-48 Risk Factors for Venous Obstruction in Children with Transvenous Pacing Leads

To determine the incidence and risk factors for venous obstruction (OBST). we prospectively evaluated with echocardiography 63 of 70 eligible children who had transvenous pacing leads placed between 1985 and 1993. The median (range) age at initial implantation was 7.6 yrs (0.7, 16), and 8 patients had subsequent additional implants. OBST was defined as a combination of Doppler flow abnormalities in the SVC or innominate (InnV) vein and a 2D echo appearance of vessel narrowing and/or the clinical appearance of dilated superficial veins. OBST was noted in 13/63 (21%) patients, with location of OBST at the distal subclavian vein in 5, SVC in 4, InnV-SVC junction in 2, and multiple sites in 2. Venography in 11 of these patients (2 refused) showed that the severity of OBST (as defined by % luminal narrowing) was complete (100%) in 3 patients, severe (g90%) in 4, and moderate (60–90%) in 4. Of the 8 patients who had additional implants, 3 (38%) had OBST. Risk factors for OBST in the remaining 55 single implant patients (10 with OBST; 18%) were explored. Patients with vs. without OBST did not differ regarding date or duration of implant, number of leads, lead material or the presence of associated heart defects Or surgery. Patients with OBST were younger at implant (median 5.6 vs. 8.8 yrs; p l 0.05). Total cross-sectional area of lead(s) was related to body surface area at implant (RATIO). Patients with OBST had higher mean RATIO (7.6xa0±xa01.6xa0mm 2 /m 2 ) than patients without OBST (4.9xa0±xa02.0 mm 2 /m 2 ; pxa0lxa00.0002). After controlling for RATIO in multiple logistic regression, no other variable predicted OBST. Receiver-operator characteristic curves showed a RATIO of g6.6xa0mm 2 /m 2 to best predict OBST, with a sensitivity of 90% and specificity of 84%. Conclusion Since pacing is lifelong, sizing of transvenous leads to the child is important to prevent OBST and preserve venous access.

Obstructive rhabdomyoma and univentricular physiology: a rare combination.

We report the successful excision of a large left atrial rhabdomyoma producing complete obstruction of both inflow and outflow to the left ventricle. Systemic perfusion was dependent on anterograde ductual flow. The resultant univentricular physiology was initially managed medically, with spontaneous tumor regression contemplated as a means of possible long-term cure. Failure to achieve hemodynamic stability compelled urgent surgical excision. This neonate was successfully discharged home with an in-series biventricular circulation.

From functional pulmonary atresia to right ventricular restriction: Long term follow up of Uhl's anomaly

We report a 14 year old boy who presented as a neonate with functional pulmonary atresia due to Uhls disease with emphasis on the later detection of restrictive right ventricular physiology.