Garth S. Orsmond

Comparison of angioplasty and surgery for unoperated coarctation of the aorta.

BackgroundThe use of balloon coarctation angioplasty instead of surgery as treatment for unoperated coarctation of the aorta is controversial. The efficacy and complications of the two procedures have not been studied before in a prospective fashion. Methods and ResultsThirty-six patients were prospectively randomized to either angioplasty (20 patients) or surgery (16 patients). Immediate results and patient follow-up, including physical examination, angiograms, and magnetic resonance imaging, were compared between groups. Reduction in peak systolic pressure gradient across the coarctation was similar (86%) immediately after both balloon coarctation angioplasty and surgery. On follow-up, aneurysms were seen only in the angioplasty group (20%) and not in the surgery group (0%o). No aneurysms have shown progression or required surgery. The incidence of other complications was similar in both groups, although two patients experienced neurological complications after surgery. Although not statistically different, the incidence of restenosis (peak systolic pressure gradient 220 mm Hg) tended to be greater in the angioplasty group (25%) than in the surgery group (6%). Restenosis after angioplasty occurred more frequently in patients with an aortic isthmus/descending aorta diameter ratio <0.65 and was associated with an immediate catheterization residual peak systolic pressure gradient across the coarctation 212 mm Hg. ConclusionsImmediate gradient reduction is similar after balloon coarctation angioplasty and surgical treatment of unoperated coarctation of the aorta. The risks of aneurysm formation and possibly restenosis after angioplasty are higher than after surgery, although the risks of other complications are similar. Balloon coarctation angioplasty may provide an effective initial alternative to surgical repair of unoperated coarctation of the aorta in children beyond infancy, particularly in patients with a well-developed isthmus. Further follow-up is necessary to determine the long-term risks of postangioplasty aneurysms.

Mid-term results after bidirectional cavopulmonary shunts

Despite the increasing use of the bidirectional cavopulmonary shunt, little is known about the late results, the duration of palliation, and the frequency with which this procedure allows later successful conversion to a Fontan type of procedure. We reviewed our experience (1984 to 1992) in 38 consecutive children, ages 4 months to 16 years (mean, 4.0 years), who underwent a bidirectional cavopulmonary shunt procedure. All had a single functional ventricle and represented high risks for the performance of a Fontan procedure based on anatomic and hemodynamic criteria. The oxygen saturation in these patients improved from a preoperative value of 75% +/- 7% to 82% +/- 7% (p < 0.05) at late cardiac catheterization by a mean of 24 months after operation. The actuarial survival, including early deaths and that associated with all secondary procedures, was 86% at 1 year and 81% at 6 years. Early deaths occurred in 5.3% (2/38) and late deaths in 11% (4/36). Late follow-up ranged from 5 to 90 months (mean, 37 months). Conversion to a Fontan or fenestrated Fontan procedure was accomplished in 21 early survivors (21/36; 58%) by a mean of 26 months after the bidirectional cavopulmonary shunt procedure, with one operative and no late deaths (1/21; 4.8%). Three additional patients have undergone late reoperation, including 2 requiring cardiac transplantation and 1 undergoing the late creation of an axillary artery-to-vein fistula for the treatment of cyanosis. The midterm survival after a bidirectional cavopulmonary shunt procedure appears to be excellent, and it serves as a good staging procedure for patients who represent high risks for a Fontan procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon pulmonary valvotomy: Palliation for cyanotic heart disease

Balloon pulmonary valvotomy was attempted in eight children with cyanotic congenital heart disease and pulmonic stenosis who were scheduled for a palliative procedure (shunt). In seven patients the balloon could be positioned across the pulmonary anulus, and valvotomy was performed. Five of the patients had tetralogy of Fallot with multiple levels of pulmonary outflow obstruction. For all patients in whom the balloon could be properly positioned the valvotomy was successful, as judged by arterial hemoglobin saturation, which increased from 72% +/- 5% to 83% +/- 5% (p less than .005). Valvotomy was followed by an immediate rise in mean pulmonary artery pressure (12.6 +/- 2.8 to 18.3 +/- 4.8 mm Hg, p less than 0.05) and a decline in hematocrit level at 2 months (54% +/- 5% to 47% +/- 4%, p less than 0.05). There was no mortality or complication from the valvotomy, and the need for a systemic to pulmonary artery shunt was eliminated in six of eight patients. Follow-up has ranged from 0.5 to 2.8 years. This trial indicates that balloon pulmonary valvotomy can be safely performed and is effective palliation in selected patients with cyanotic heart disease that is not suitable for primary repair. The increased pulmonary flow may improve oxygenation and growth of the pulmonary arteries without the need of a systemic to pulmonary artery shunt.

Intra-aortic balloon pumping in children with dilated cardiomyopathy as a bridge to transplantation

Children with dilated cardiomyopathy awaiting transplantation who fail maximal pharmacologic therapy may benefit from intra-aortic balloon pumping. Between July 1993 and August 1999, a total of 4 children with dilated cardiomyopathy underwent pre-transplant balloon pumping for 6.0 +/- 5.8 (1 to 12) days. One child (pumped for 12 days) died awaiting transplant, and the remaining 3 were successfully transplanted. Intra-aortic balloon pumping timed precisely with M-mode echocardiographic markers offers a relatively simple and safe intermediate level of mechanical support for children with dilated cardiomyopathy who fail pharmacologic support.

Etiology and Outcome of Outpatient Fevers in Pediatric Heart Transplant Patients

We reviewed 74 outpatient febrile episodes in 22 pediatric heart transplant patients in order to determine etiologies, rates of serious and nonserious illness, and factors predictive of serious disease. Twenty-two febrile episodes (30%) resulted in hospital admission. Only three variables were predictive of serious illness: longer duration of fever, shorter time since transplant, and lower febrile episode number. We conclude that at least 70% of outpatient febrile episodes are nonserious and can be managed safely in an outpatient setting. The duration of fever may be predictive of serious disease but is not useful at initial presentation.

Reversal of flow in the left pulmonary artery after cavopulmonary connection

The postoperative course of a 15-month-old girl who underwent a bilateral bidirectional cavopulmonary connection was complicated by a left chylothorax and left hemidiaphragm paralysis. Two-dimensional and Doppler echocardiography revealed complete flow reversal in the left pulmonary artery. This flow abnormality was confirmed by angiography. Multiple aortopulmonary collaterals had also developed and were coil embolized at the time of catheterization. Coil embolization of the collaterals, combined with relief of the chylothorax and diaphragmatic plication, reestablished forward flow in the left pulmonary artery.