Frederick S. Sherman

Cardiovascular Reactivity to Stress and Left Ventricular Mass in Youth

We studied the relationships of cardiovascular reactivity during mental stress with left ventricular mass index in a group of prepubertal children 8 to 10 years old and in a group of peripubertal or postpubertal adolescents 15 to 17 years old. One hundred fifteen participants, varying in age group, sex, and race (black and white), took part in a laboratory stress protocol consisting of a reaction-time task, a mirror tracing task, a cold forehead challenge, and a stress interview. Cardiovascular measures included blood pressure and heart rate, as well as cardiac output, stroke volume, total peripheral resistance, and preejection period obtained noninvasively with impedance cardiography. Measures of left ventricular mass were made by echocardiography. Results indicated that across all participants, left ventricular mass index was associated with cardiovascular responses during the mirror tracing and cold forehead tasks, especially with those responses reflecting increased vasoconstriction. Subgroup analyses showed that these associations were significant for males and sometimes adolescents but not for females and children. As mirror tracing and cold forehead tasks most consistently produce alpha-adrenergic activation, the results suggest a model in which vasoconstriction due to mental stress is related to increased left ventricular mass in susceptible individuals, even at a young age.

To be or not to be a VSD

Abstract This study confirmed the fact that a large majority of isolated VSDs (74%) detected in utero will spontaneously close. Spontaneous closure rates were higher in utero than those detected in infants or children. Isolated VSDs detected in utero did not contribute to fetal morbidity and mortality. There is no correlation between the size of the defect and the probability of closure of the defect. Because of the high spontaneous closure rate of VSDs in utero and the lack of increased morbidity, parental anxiety can be allayed or minimized. For these reasons, close follow-up in utero is not necessary, and reevaluation can be done at birth.

Fetal echocardiographic findings are not predictive of death in twin-twin transfusion syndrome.

Objective. The purpose of this study was to determine whether fetal echocardiographic findings are predictive of prognosis in recipient fetuses with twin‐twin transfusion syndrome (TTTS). Methods. A cohort of 30 pregnancies with TTTS between 1990 and 2001 was included. Diagnosis and staging of TTTS were made according to the Quintero system. Fetal echocardiographic findings of cardiomegaly, right ventricular hypertrophy, and tricuspid regurgitation were evaluated for relationship with fetal death. Power analysis revealed an approximately 80% power to detect a 2‐fold increased risk of fetal death, with α = .05. Logistic regression was used to determine the relationship between echocardiographic findings and death. Results. Most pregnancies were Quintero stage 1, n = 13 (43%), and ranged in severity to Quintero stage 5, n = 4 (13%). Cardiac findings in the recipient fetus that were assessed for a relationship with death included cardiomegaly at the initial appearance of TTTS or at the most severe evaluation findings, right ventricular hypertrophy at initial appearance or at the most severe evaluation findings, or tricuspid regurgitation at initial appearance or at the most severe evaluation findings. Fetal or neonatal death in the recipient twin was not related to the presence of cardiac findings (odds ratio, 0.77; 95% confidence interval, 0.16–3.74). Conclusions. Fetal echocardiographic findings, whether evaluated at initial appearance or over the course of serial evaluations, were not related to fetal or neonatal death in recipient twins with TTTS.

Anesthetic care of parturients with single ventricle physiology

Understanding the management of the parturient with single ventricle physiology starts with knowledge of the lesion, the patients current stage of surgical palliation, her current functional status, and the impact of pregnancy and labor on her cardiac physiology. A multidisciplinary team approach, described in this article, is crucial to a positive outcome.

Totally anomalous pulmonary venous connection in an infant with tricuspid atresia

The occurrence of tricuspid atresia in association with totally anomalous pulmonary venous connection is a rare one. This combination has been described in the literature only twice previously. Such a case is presented with special regard to the therapeutic options and the need for cardiac catheterization.

Corrected QT interval and methadone dose and concentrations in pregnant and postpartum women

BACKGROUND Methadone is a standard treatment for opioid dependence in pregnancy; however, its impact on maternal corrected QT interval (QTc) has not been evaluated. We studied the association between methadone dose and enantiomer-specific plasma concentrations and QTc among pregnant and postpartum women and newborns. We assessed the relevance of QTc screening guidelines for pregnant women and infants. METHODS From 2006 to 2008, plasma methadone concentrations were measured during pregnancy, postpartum, and in cord blood in women treated for opioid dependence at a single treatment program. Electrocardiograms (ECGs) were obtained at peak methadone concentrations in mothers and within 48 hours of birth for infants. Pearson correlations were performed at each time point for QTc and R-methadone, S-methadone, and total methadone concentrations and ratio of R-methadone/S-methadone concentrations. RESULTS Mean (SD) daily methadone dose for the 25 women was 94.2 (39.1) mg during pregnancy and 112.5 (46.6) mg postpartum. During the third trimester, higher methadone dose and R-methadone concentration correlated with longer QTc (Pearson r = 0.67, P < .001 and Pearson r = 0.49, P = .02, respectively), while S-methadone concentration, R-methadone/S-methadone concentration ratio, and total methadone concentration did not. Postpartum, QTc did not significantly correlate with dose or enantiomer concentrations. Infant QTc did not correlate with maternal dose at delivery or enantiomer-specific cord methadone concentrations. In pregnant and postpartum women, 13% and 17%, respectively, had QTc ≥ 450 ms, as did 19% of infants. CONCLUSIONS QTc correlated with dose and R-methadone concentration during the third trimester. However, longer QTc was common among women during and after pregnancy. Given the relatively high rate of QTc > 450 ms, an ECG before and after methadone initiation is advisable for pregnant and postpartum women.