D F Dickinson

Congenital heart disease among 160 480 liveborn children in Liverpool 1960 to 1969. Implications for surgical treatment.

Among 160 480 children born alive between 1960 and 1969 in Liverpool, 884 patients with structural congenital heart disease were identified. Data on these patients have been reviewed in order to estimate the number likely to need cardiac surgery during childhood and adolescence. Though only 33.9% of patients had surgery, we estimate that if current policies for management were followed, 475 (53.7%) patients would not require surgery. Extrapolation of this data suggests that each year in England and Wales approximately 830 infants (1383 per million livebirths) will require cardiac surgery within the first year of life and a further 1424 operations (2374 per million livebirths) will be required in later childhood or adolescence. No attempt has been made to estimate the number of operations for congenital heart disease which may prove necessary in adult life.

Transcatheter occlusion of the arterial duct with Cook detachable coils: early experience.

OBJECTIVE: To assess the effectiveness of modified, controlled release Gianturco coils for transcatheter occlusion of the arterial duct. DESIGN: Prospective study, approved by local medical ethics committee. SETTING: Tertiary paediatric cardiac centre. PATIENTS: 43 patients with left to right shunting through the arterial duct, two of whom had a residual leak after surgical ligation and three had residual shunting after previous Rashkind umbrella implantation. INTERVENTION: Transcatheter delivery of one or more coils to the arterial duct. MAIN OUTCOME MEASURES: Complete occlusion of the arterial duct, based on intention to treat and judged by Doppler echocardiography. Absence of flow disturbance in the branch pulmonary arteries and the descending aorta following the procedure. Assessment of cost of the disposable items used. RESULTS: At a median follow up period of three months complete duct occlusion was achieved in 37 (86%) of the 43 patients. No flow disturbance in the branch pulmonary arteries or the descending aorta was detected in any patient. The median cost of disposable items used during the procedure was 342 pounds. CONCLUSIONS: The Cook detachable coil is an effective and financially attractive alternative to the Rashkind umbrella for closure of the arterial duct.

Laser valvotomy with balloon valvoplasty for pulmonary atresia with intact ventricular septum: five years' experience.

OBJECTIVE: To assess immediate and medium term results of transcatheter laser valvotomy with balloon valvoplasty in selected infants with pulmonary atresia and intact ventricular septum. DESIGN: Prospective study. SETTING: Tertiary cardiac unit. PATIENTS: All infants with pulmonary atresia and intact septum with no more than minor tricuspid valve hypoplasia referred between November 1990 and June 1995. Laser valvotomy was attempted in nine infants of median age 4-5 days and median weight 3.6 kg. INTERVENTION: The pulmonary valve was perforated using a 0.018 inch fibreoptic guidewire attached to a NdYag laser and introduced through a catheter positioned beneath the valve. After perforation the valve was dilated with progressively larger balloons. MAIN OUTCOME MEASURES: Successful laser valvotomy and balloon dilatation, complications, pulse oximetry, right ventricular outflow velocities, and need for surgical treatment. RESULTS: Valvotomy was successful in all but one case, the failure being due to laser breakdown. After perforation the valve was dilated to 6-8 mm diameter. Prostaglandin E was withdrawn immediately in six of the eight duct dependent infants, and 28 and 49 days later in two. No patient required an aortopulmonary shunt. Two patients had repeat valvoplasty at 20 days and three months of age, respectively; one required infundibular resection and closure of the atrial septum at age four and one is awaiting similar treatment. CONCLUSIONS: Laser valvotomy with balloon valvoplasty is safe and effective treatment for selected patients with pulmonary atresia and intact ventricular septum and should be considered as first line treatment in place of surgical valvotomy.

Normal intracardiac and great artery blood velocity measurements by pulsed Doppler echocardiography.

One hundred and 10 normal subjects were studied by pulsed Doppler velocimetry to determine the range of values of blood velocity across the cardiac valves and in the great vessels. Modal peak velocities of 1.55 m/s occurred in the left heart, but right heart peak velocities were lower. In most sites a statistically significant inverse relation between peak velocities and age or body surface area was found. Time to peak velcocity in the pulmonary artery and ascending aorta increased significantly with age and was shorter in the aorta than in the pulmonary artery. These data were developed to serve as standards for the assessment of values recorded in patients with congenital and acquired cardiac disease.

The normal ECG in childhood and adolescence

An electrocardiogram (ECG) may be requested as part of the investigation of a wide range of problems in paediatrics, often in patients who have no clinical evidence of cardiac disease. Frequently the request is made by practitioners with no particular expertise in cardiology. The basic principles of interpretation of the ECG in children are identical to those in adults, but the progressive changes in anatomy and physiology which take place between birth and adolescence result in some features which differ significantly from the normal adult pattern and vary according to the age of the child. Correct interpretation of the ECG is therefore potentially difficult and a detailed knowledge of these age dependent changes is critically important if errors are to be avoided. Extensive tables or centile charts of normal values in relation to age of patient are available.1–3 There is the potential for computer support in the interpretation of the paediatric ECG,4,5 sparing the interpreter the need to consult these tables or memorise large quantities of age dependant variables. However, there is published evidence6 which shows that some abnormalities are missed both by computer interpretation and by paediatric emergency department doctors. Equally, daily practice suggests that computer generated reports not infrequently identify an abnormality where none exists. Until recently the most comprehensive study of electrocardiographic variables in childhood was that of Davignon1 based on measurements made on 2141 white children in Quebec, Canada. Normal limits for 39 variables were presented as centile charts ranging from the 2nd to the 98th centile. These invaluable tables and charts are quoted in many major paediatric cardiology texts currently available, but some limitations must be recognised in the application of the data in practice today. Normal values for males and females were not separated. It may inappropriate to …

Left ventricular bands. A normal anatomical feature.

Discrete delicate fibromuscular structures crossing the cavity of the left ventricle were identified on morphological examination in 329 (48%) of 686 hearts from patients of all ages with congenital heart disease, acquired heart disease, or normal hearts. These structures were also present in 151 (95%) of 159 hearts from animals of six species. Cross sectional echocardiographic findings compatible with these structures were obtained in 39 (21.7%) of 179 children reviewed retrospectively and in three of 800 (0.4%) adults studied prospectively. These structures appear to be a normal anatomical finding.

Right ventricular outflow stent implantation: an alternative to palliative surgical relief of infundibular pulmonary stenosis.

OBJECTIVE: Preliminary assessment of the use of stents for palliative relief of right ventricular infundibular stenosis as an alternative to palliative surgical ventricular outflow enlargement. DESIGN: Descriptive clinical study. PATIENTS: Four patients with right ventricular outflow obstruction, aged between 2 and 15 years. One had had previous palliative surgery for pulmonary atresia, one had hypoplastic pulmonary arteries after palliative surgery for tetralogy of Fallot, one had multiple congenital abnormalities, and one had hypertrophic cardiomyopathy. SETTING: Tertiary paediatric cardiac centre. METHODS: After initial echocardiographic diagnosis the extent of right ventricular outflow obstruction was assessed by angiography. Balloon expandable stainless steel stents (Johnson & Johnson) were deployed in the right ventricular infundibulum. MAIN OUTCOME MEASURES: Improvement in right ventricular outflow assessed by ventriculography and change in right ventricular/ left ventricular pressure ratio, change in systemic oxygen saturation, freedom from arrhythmias, and sustained improvement in echocardiographic indices of obstruction. RESULTS: Mean right to left ventricular pressure ratio fell from 0.95 to 0.35 in the three patients with intact ventricular septum. Oxygen saturation increased from 76% to 91% in the patient with tetralogy. No arrhythmias were detected. Improvement was maintained at mean follow up of 9.7 months in three cases, but one patient required stent enlargement 17 months later because of neoendothelial proliferation within the stent. CONCLUSION: Stent implantation provides an effective alternative to palliative surgical enlargement of the right ventricular infundibulum. Neoendothelial proliferation causes reduction in lumen in some cases, but this may respond to redilatation.

Persistent fifth aortic arch. A report of two new cases and a review of the literature

Two new cases of persistent fifth aortic arch are described, one with a distal connexion to the pulmonary circulation and the other to the systemic circulation. The previously reported cases are reviewed and the advantages conferred clinically by persistence of this structure are noted.

Evaluation of an elliptical area technique for calculating mitral blood flow by Doppler echocardiography.

To evaluate a method for measuring blood flow through the mitral valve 18 normal subjects and 19 patients with cardiac disease in whom mitral and aortic blood flows were identical were studied. Initially the mitral ring area was planimetered from the echocardiographic image, but the results of area calculation using the mathematical formula for the area of an ellipse were found to approximate to within 8% of the planimetered result in most cases. The formula was therefore used if the ring appeared elliptical on the cross sectional echo image, and other shapes were planimetered. Mitral velocity, aligned with flow in three planes, was recorded just distal to the ring. Mitral flow calculated using the elliptical technique correlated closely with flow measured in the ascending aorta by the Doppler technique and also with systemic flow measured by the Fick method at cardiac catheterisation in 10 patients. The mitral flow technique that assumed a circular orifice correlated almost as well with Doppler aortic flow and with Fick flow but overestimated flow by a mean of 1446 ml, whereas the elliptical method had a mean error of only 138 ml. Both methods correlated well with standards, but the elliptical method was easy to apply and gave a better correlation with comparison reference values.

Residual and recurrent shunts after implantation of Cook detachable duct occlusion coils

Objective To assess the presence and outcome of Doppler detectable shunts following implantation of the Cook detachable PDA coil. Design Prospective study. Setting Tertiary paediatric cardiac centre. Patients 76 consecutive patients undergoing coil implantation (80 procedures). Main outcome measures Detection and colour Doppler echocardiographic appearance of residual or recurrent shunts, the timing of the appearance of recurrent shunts, and the time taken for spontaneous resolution of these shunts. Results Immediate occlusion was achieved in 52 patients. At one month 63 patients had complete occlusion and after three months the duct was completely occluded in 67 patients. In 27 cases small residual shunts were detected on echocardiography 10 minutes after the completion of the implantation procedure; 15 of these had resolved by 24 hours and 20 had resolved by three months. Recurrent shunts were detected after apparent initial complete occlusion in 11 cases 24 hours after coil implantation and in two cases one month after the procedure. Six recurrent shunts resolved on later follow up. Residual shunts appeared as single jets after implantation of a single coil, but up to three separate jets were detected after implantation of multiple coils. Conclusions Spontaneous resolution of small residual shunts occurs in most patients. The recurrence of small shunts after apparent complete occlusion suggests that recanalisation of the duct may occur in a small percentage of patients up to one month after occlusion. Residual shunts may take the form of multiple residual jets that may require implantation of further coils to achieve complete duct occlusion.