David Goldring

Dilated cardiomyopathy in infants and children.

The outcome of medical treatment of dilated cardiomyopathy in infants and children was reviewed to develop a predictive index for selection of patients likely to benefit from cardiac transplantation. The clinical findings, laboratory investigations, treatment and outcome of 20 patients (Group 1) less than 2 years of age at presentation and 12 patients (Group 2) greater than 2 years of age at onset were compared. Of 20 Group 1 patients, 5 (25%) died. Available autopsies (four patients) showed endocardial fibroelastosis. Of 15 survivors, 10 showed improvement in cardiac status and 5 remained unchanged. Ninety-three percent of survivors had dilated cardiomyopathy consistent with endocardial fibroelastosis by angiocardiography. All 12 Group 2 patients died. In addition to age at presentation and poor outcome, Group 2 differed from Group 1 in having a higher incidence of other family members with cardiomyopathy, more significant rhythm disturbances at presentation and a more rapid course to death. Risk factors of poor outcome in both groups included persistent cardiomegaly and the development of significant arrhythmias by Holter electrocardiographic monitoring. Cardiac transplantation is recommended for children with dilated cardiomyopathy presenting after age 2 years who survive 1 month. Those patients less than 2 years old at presentation whose condition has not improved after 1 year and who have persistent cardiomegaly or complex ventricular arrhythmias may also benefit from transplantation.

Effect of exercise training on the blood pressure and hemodynamic features of hypertensive adolescents

Twenty-five adolescents (aged 16 +/- 1 years) whose blood pressure (BP) was persistently above the 95th percentile for their age and sex were studied before and after 6 +/- 1 months of exercise training and again 9 +/- 1 months after the cessation of training. Maximal oxygen consumption (VO2) increased significantly with training. There was no change in body weight or sum of skinfolds. Both systolic and diastolic BP decreased significantly with training; however, complete BP normalization was not achieved. When the subjects were retested 9 +/- 1 months after cessation of training, systolic BP and VO2 max had returned to pretraining levels; however, diastolic BP was still below pretraining levels in the subjects who had diastolic hypertension initially. Except in subjects who initially had an elevated cardiac output, no consistent hemodynamic changes were found with training or cessation of training to account for the reductions in BP. The subjects whose resting cardiac outputs were high initially had significantly lower cardiac outputs after training as a result of decreases in both heart rate and stroke volume; however, vascular resistance remained unchanged. Sedentary control subjects with similar BP had no significant change in any of the variables measured over a similar period. These data indicate that moderate endurance exercise training can lower BP in otherwise healthy hypertensive adolescents as an initial therapeutic intervention.

Increased stiffness and persistent narrowing of the aorta after successful repair of coarctation of the aorta: relationship to left ventricular mass and blood pressure at rest and with exercise.

Fifteen children and adolescents who had repair of coarctation of the aorta before age 15, who were not hypertensive at rest, and who had resting arm-leg blood pressure gradients of less than 20 mm Hg underwent noninvasive evaluation of left ventricular structure and function, aortic stiffness, and residual coarctation as well as bicycle exercise testing. These results were compared with those in 15 age- and sex-matched control subjects. The mean resting age-related systolic blood pressure percentiles (63% versus 46%), transverse aortic stiffness measured by the elastic modulus (Ep) (42.1 versus 23.2 kPa), stiffness index beta (beta) (3.66 versus 2.17), echocardiographic left ventricular fractional shortening (0.42 versus 0.36), left ventricular mass index (99.3 versus 81.0 gm/m2), maximum exercise right arm systolic blood pressure (173 versus 156 mm Hg), and exercise arm-leg blood pressure gradient (35 versus 6 mm Hg) were significantly increased in the coarctectomy patients compared with controls. Univariate correlations in the coarctectomy group showed significant relationships of residual aortic narrowing with left ventricular mass index (r = 0.68, p less than 0.01) and resting systolic blood pressure percentile for age (r = 0.55, p less than 0.05). Residual aortic narrowing did not significantly correlate with aortic stiffness, resting blood pressure gradient, or exercise blood pressure gradient. Neither left ventricular mass index nor resting systolic blood pressure percentile significantly correlated with age of repair or years after repair. These results demonstrate persistent abnormalities in aortic stiffness and left ventricular mass and function after successful repair of coarctation of the aorta in childhood and adolescence.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of weight training on blood pressure and hemodynamics in hypertensive adolescents

Six adolescents with persistent essential hypertension were examined to determine the effect of weight training on their blood pressure and hemodynamics. Five had first completed an endurance training program; one subject trained only by weight lifting. All subjects were reevaluated after 5 +/- 2 months of weight training, and 12 +/- 2 months after cessation of training. Endurance training resulted in an increase in VO2max and decreases in systolic and diastolic blood pressure. After weight training, VO2max had decreased to the level found prior to endurance training, and body weight was significantly increased. Systolic blood pressure after weight training was 17 +/- 4 mm Hg lower than when measured initially (P less than 0.01). Weight training maintained the reduction in diastolic pressure elicited by endurance exercise in those who initially had diastolic hypertension. Cessation of all forms of training resulted in no change in body weight, body fat, or VO2max from the values measured after weight training. Systolic pressure increased significantly with the cessation of training to a value not different from that measured initially. Diastolic pressure also increased after cessation of training, but was still below the initial value. The only significant hemodynamic change found was a reduction in systemic vascular resistance in response to weight training. Weight training in hypertensive adolescents appears to maintain the reductions in blood pressure achieved by endurance training, and may even elicit further reductions in blood pressure.

Blood pressure in a high school population

This is a report on the initial findings from an ongoing study of blood pressure in ninth to twelfth grade students in the St. Louis metropolitan area. The purpose was to establish standards, to determine the. incidence of hypertension, and to examine the relationship of blood pressure to age, weight, height, sex, and race. Subjects with persistent hypertension were to be investigated and checked annually as long as long as they were in high school. Students in the ninth grade at the beginning of the project were to be screened each year for four years.

Recurrent coarctation of the aorta after successful repair in infancy

Abstract Twenty unselected infants who survived repair of coarctation of the aorta were restudied an average of 6.2 years postoperatively. Eight patients (40 percent) showed no significant difference in blood pressures between the arms and legs and had normal pressures in their arms. These patients have been followed up for an average of 5.1 years postoperatively. Another 8 patients (40 percent) had moderate blood pressure differences between the upper and lower limbs. These patients have been followed up for an average of 6.6 years postoperatively. Further follow-up of this group will be required to determine how many will need reoperation. Four patients (20 percent), although asymptomatic, had recurrent severe coarctation of the aorta that will require reoperation. These patients have been followed up for an average of 6.9 years postoperatively. The mechanism of the recurrent coarctation is not clear, but there is evidence that the coarctation is incompletely relieved in some and that it develops with growth in others. All infants surviving repair of coarctation of the aorta must be closely followed up for possible recurrent coarctation until they reach adult size.

Spontaneous closure of secundum atrial septal defect in infants and young children

The records of 264 pediatric patients with uncomplicated ostium secundum atrial septal defect (ASD) were reviewed. Eighty-seven patients were younger than age 4 years at the time of cardiac catheterization. Subnormal weight gain, frequent pneumonia, cyanosis or tachypnea were present in 26 patients (30%). Of the 36 infants at catheterization, 17 (48%) had the previously described symptoms, including 12 (33%) who had congestive heart failure. Eight of the 36 infants were found to have closed their defect at a subsequent catheterization. Six of 18 patients who underwent cardiac catheterization between 1 and 2 years of age also had spontaneously closed their ASD at subsequent study. Statistical analysis of hemodynamic data revealed no difference (except a smaller shunt size) between ASDs that closed and those that did not in patients who were less than 4 years at initial catheterization. Analysis of hemodynamic data revealed no statistical differences between groups of patients with an ASD who were younger than and those older than 4 years at time of diagnostic study. Patients with ASDs that closed were significantly different from patients with atrial level shunting thought to be secondary to a valve-incompetent foramen ovale with respect to age at initial study (11 versus 2 months, p less than 0.001), mean left atrial pressure (7.7 versus 12.3 mm Hg, p less than 0.02) and difference between mean right and left atrial pressures (1.0 versus 4.2 mm Hg, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The Two-Chambered Right Ventricle Report of Nine Cases

A relatively rare congenital cardiac malformation is described in nine patients and is characterized by aberrant hypertrophied muscular bands that divide the right ventricular cavity into two chambers. These hypertrophied muscular bands produce an effective stenosis and obstruct the outflow of blood from the right ventricle. An interventricular septal defect is usually seen in association with this abnormality. This cardiac malformation is anatomically distinct from the classic tetralogy of Fallot but may be mistakenly diagnosed as an acyanotic tetralogy of Fallot or an interventricular septal defect. The use of selective angiocardiography in conjunction with right-sided cardiac catheterization will establish the correct diagnosis. This congenital lesion is amenable to surgical correction, and five of the patients in this series were successfully operated upon with the aid of extracorporeal circulation. Surgery has been recommended for the remaining four patients because of the encouraging results.

Flush method for blood pressure determinations in newborn infants

Summary A visual method of determination of blood pressures in newborn infants is presented. The cuff is placed around the ankle or wrist in the usual manner and a piece of rubber sheeting or old rubber glove is wrapped snugly around the foot or hand, so that the blood is pressed from the extremity. The cuff is then inflated to a pressure slightly above the suspected systolic pressure, the rubber bandage is then removed and the pressure is slowly released from the cuff. The approximate systolic pressure is the reading at which blood suddenly re-enters the foot or hand, causing a flush.

High blood pressure in children: Problems and guidelines for evaluation and treatment☆

Evidence is presented from studies of the authors and of other investigators that primary hypertension is more common in children than was previously thought. Ninety-five percent of 131 asymptomatic children with incidental hypertension were considered to have primary hypertension after investigation for possible causes. The definition of hypertension was based on normal ranges of blood pressure for each age and sex. However, the definition of juvenile hypertension is still unsettled as is the question of treatment. Investigation of the effect of prolonged antihypertensive therapy on growth and development is needed. Primary hypertension in the young makes possible the study of the disease at its inception.