Delores Danilowicz

Left to right atrial shunts in infants

Abstract At cardiac catheterization, 24 infants less than 1 year old had a left to right atrial shunt without other major cardiac lesions. Only 6 infants had cardiac symptoms, and there was no relation between symptoms and the size of the shunt. Six infants (including 2 who were less than 1 week old and were asymptomatic) had a pulmonary to systemic flow ratio (Qp:Qs) greater than 3. Clinical features were often atypical. Fifteen had harsh grade 3–4 6 systolic murmurs; only 10 had wide fixed splitting of the second heart sound. Splitting of the second heart sound was unrelated to the Qp:Qs. Two infants with a large shunt had no cardiomegaly. Electrocardiograms were not typical of atrial septal defect. The shunt disappeared in 9 of 12 infants who underwent recatheterization and was not clinically detectable in 3 others whose shunt was large when under 2 weeks of age. Many shunts probably occurred through an incompetent foramen ovale, sometimes secondary to left-sided lesions. However, some children had a classic atrial septal defect that closed spontaneously. Since spontaneous closure of atrial septal defects occurs and there are many atypical features of these lesions in infants and younger children, it is possible that the incidence of this lesion is underestimated in infancy and early childhood.

Cardiac Tamponade Secondary to Chylopericardium Following Cardiac Surgery: Case Report and Review of the Literature

Only four instances of isolated chylopericardium following cardiac operation have been reported previously. We encountered this complication in a young patient who was operated on for infundibular pulmonary stenosis. The etiology appears to be related to a combination of intraoperative lymphatic injury and catheter-related subclavian vein thrombosis, the latter potentially elevating pressure within the thoracic duct and thereby resulting in an accumulation of chyle within the pericardial space. Therapy for this problem usually includes partial pericardiectomy with or without ligation of the thoracic duct.

Severe hemolysis following partial coil-occlusion of patent ductus arteriosus.

Severe hemolysis occurred in a one-year-old boy following partial coil occlusion of a patent ductus arteriosus with a small but high-velocity residual shunt. Hemolysis abated rapidly and completely after placement of a second coil fully occluded the ductus.

Saphenous Vein Graft Growth 13 Years After Coronary Bypass in a Child With Kawasaki Disease

The presumed limited growth potential of saphenous vein grafts has led many authorities to discourage their use in young children. We documented excellent growth and patency of a saphenous vein graft 13 years after operation in a 7-year-old child with coronary artery obstruction caused by Kawasaki disease.

Use of saphenous vein allografts for aortopulmonary artery anastomoses in neonates with complex cyanotic congenital heart disease

SummaryA saphenous vein allograft was used to create an aortopulmonary communication in 16 infants with cyanotic congenital heart disease and ductus-dependent pulmonary blood flow. These grafts measured from 3 to 8 mm in diameter and were placed between the aorta and main pulmonary artery in eight patients, between aorta and right pulmonary artery in eight, and between aorta and left pulmonary artery in one (one child had two grafts). Before heparin was used, early in the series, four of these grafts occluded and three of the four infants died during attempted revision. Another infant died early from renal failure. Late mortality has claimed four: one from cerebral hemorrhage, two from hypoxia, and one at open-heart surgery for repair. There are eight late survivors (50%).Most of the allografts were used before small diameter Gore-Tex was available; in more recent patients, 4- to 6-mm Gore-Tex grafts have been used. In our most recent patient, however, the attempt to place a Gore-Tex graft was unsuccessful, but the more pliable saphenous vein graft was readily placed and an adequate shunt obtained. Both the saphenous vein graft and the Gore-Tex have the advantage of providing pulmonary flow without the higher risk of congestive failure or pulmonary hypertension seen in patients with a Waterston or Potts anastomosis. They are easier to perform, require less anesthesia time than the Blalock-Taussig shunt, last as long as the Blalock-Taussig when done under similar conditions, and are easy to take down at the time of total repair.

Use of contrast echocardiography in the diagnosis of partial anomalous pulmonary venous connection

Contrast echocardiography is useful in diagnosing the presence of partial anomalous pulmonary venous connection, particularly when it occurs in association with an atrial septal defect. Injections of saline solution, Cardiogreen or the patients own blood were made in the inferior vena cava, left atrium and pulmonary veins of 27 patients. In all patients, the inferior vena caval injections showed only right heart clouding with no evidence of a right to left shunt. In 21 patients, the left atrial and pulmonary venous injections showed clouding of both the right and left heart structures, indicating a left to right atrial shunt and normal pulmonary venous connection. In six patients, the left artrial injections showed right and left heart clouding, but the right pulmonary venous injections showed only right heart structures, indicating a left to right atrial shunt with partial anomalous pulmonary venous connection. Contrast echocardiography proved to be a sensitive method of diagnosing the anomalous venous connection without the use of dye curves. The method is not useful when a right to left atrial shunt is present and may show false positive results for partial anomalous pulmonary venous connection it left atrial visualization is not adequate during injection into the pulmonary vein.

Congenital fistulous tract between aorta and right atrium presenting as heart failure in a newborn

SummaryA newborn with a fistulous communication between the right coronary sinus and right atrium had congestive heart failure on the first day of life. Medical management was unsuccessful and operative repair was performed using bypass surgery at 5 days of age. Echocardiographic evaluation preoperatively diagnosed the defect correctly and postoperatively confirmed a complete repair. Since aneurysms and/or fistulae can occur in other sinuses after an initial repair of the presenting lesion, the infant will continue to be followed with periodic echocardiographic and clinical evaluations.

Masked abnormal drainage of the inferior vena cava into the left atrium.

A 6 year old boy with a large atrial septal defect, partial anomalous pulmonary venous drainage and unrecognized anomalous insertion of the inferior vena cava into the left atrium had cyanosis after closure of the atrial defect. Repeat study revealed direct drainage of the inferior vena cava into the left atrium with moderate arterial oxygen desaturation. At repeat operation an unusual positioning of the inferior vena cava was seen. After reopening of the atrial defect, the pulmonary venous and systemic venous drainage anomalies were identified. A Dacron patch was inserted so as to divert flow to the proper atrium. Repeat catheterization 3 months after operation revealed a normal heart with no obstruction; arterial oxygen saturation was normal. The child has continued to do well 3 years after operation.

Salmonella septicemia after open heart surgery in an asymptomatic carrier

Abstract Nontyphoid salmonella septicemia (Salmonella oranienburg) developed in a 7 year old boy after open heart surgery for repair of a ventricular septal defect and aortic insufficiency. Investigation revealed that the patient and his younger brother were apparently asymptomatic carriers of this organism. The reasons for transformation of the carrier state Into septicemia are discussed and the danger of the carrier state in patients undergoing open heart surgery Is stressed. Since the mortality rate of salmonella endocarditis Is extremely high, preoperative cultures of patients at risk are indicated. The carrier state should be eradicated before open heart operation is performed.

Postcardiotomy psychosis in non-English-speaking patients.

This paper presents another causative or additive factor in the production of post-cardiotomy delirium. Comparison of two matched groups of patients from the National Heart Institute reveals a marked difference in the incidence of psychosis between the group that is from the United States and speaks English and the group that is foreign and has no ability to communicate in English. The United States group had two patients with psychosis (3.9 percent), while the foreign group had fifteen (29.4 percent) (p<0.001). A higher incidence of delirium occurred in men than women, and there was suggestive evidence that the group with psychoses had more medical complications, with resulting delays in discharge. The importance of language and culture in the determination of this delirium are considered and methods of mitigating this reaction are presented.