Herbert D. Ruttenberg

Disturbances of the transitional circulation: spectrum of pulmonary hypertension and myocardial dysfunction.

Thirteen neonates presented with central cyanosis due to right-to-left shunting across the foramen ovale or the ductus arteriosus or both. In three infants shunting occurred secondary to pulmonary vascular obstruction, presumably related to pulmonary vasospasm (persistence of the fetal or transitional circulation). In ten neonates right-to-left shunting was associated with heart failure; seven of these neonates had systemic hypotension.

Surgical treatment of patent ductus arteriosus in preterm infants

SummarySeventy-nine consecutive patent ductus arteriosus (PDA) ligations were performed in our newborn intensive care unit (NBICU) over a four-year period. Seven infants (9%) died within one month after surgery. The deaths were not attributed to the surgery but were associated with preexisting medical complications or new intracranial hemorrhages. Significant surgical morbidity was rare. We conclude that ligation of the PDA in the premature infant can be a safe and effective procedure, when pharmacologic closure is ineffective or contraindicated. Furthermore, PDA ligation may be safely performed in the NBICU.

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.

Pre- and Postoperative Exercise Testing of the Child with Coarctation of the Aorta

Abstract. Exercise studies in patients with coarctation of the aorta (CoA) are reviewed. A brief survey of the natural history of unoperated CoA, the pioneers who reported the first operative repair, and comments on blood pressure measurements are provided. Preoperative and postoperative (postop) exercise studies of patients with CoA are also reviewed. The various etiological factors which may contribute to hypertension found in some post-op CoA patients are discussed.

Ligation of the Patent Ductus Arteriosus in the Newborn Intensive Care Unit

During a two-year period, 21 premature infants (weight at birth, 680 to 2,340 gm) had operative closure of patent ductus arteriosus (PDA). The first 6 infants had ligation performed in the operating room (OR); the subsequent 15 had ligation in the Newborn Intensive Care Unit. There were no immediate postoperative deaths. Two infants died from problems presnet preoperatively within 30 days postoperatively. There were no infections. Technique in the unit utilizes an open warmer with local anesthesia and a paralyzing agent. By eliminating transportation to the OR one avoids problems with thermoregulation, loss of lines, malfunction of monitors, poorly controlled ventilation, and fluid overload. Additional advantages to ligation in the unit are that the infant is already monitored, intubated, and on a respirator, and that venous and usually umbilical arterial lines are in place. At the conclusion of operation, management is returned to the neonatologists for optimal continuity of care.

Deep hypothermia and circulatory arrest: effect on cerebrospinal fluid electrolytes in newborn lambs.

Abstract Cerebrospinal fluid (CSF) Na, K, and acid-base changes were studied in 13 new-born lambs anesthetized with α-chloralose (60 mg/kg) or diethylether during 90 min of normothermic (37 °C) or hypothermic (20 °C) circulatory arrest. CSF K concentration increased linearly from 3.1 to 23.2 meq/liter during 90 min of normothermic circulatory arrest. During hypothermic circulatory arrest, animals anesthetized with α-chloralose exhibited an exponential increase in CSF K concentration from 3.1 to 13.6 meq/liter and animals anesthetized with diethylether had an exponential increase in CSF K concentration from 3.3 to 12.7 meq/liter. The rate of increase in CSF K concentration in hypothermic and normothermic animals between 60 and 90 min of circulatory arrest was the same. CSF Na concentration decreased slightly in both hypothermic and normothermic animals, with a greater decrease in the normothermic group. Although CSF pH and bicarbonate were significantly decreased during normothermia as well as hypothermia, both CSF pH and bicarbonate showed greater decreases during normothermia. Mean pH values after 90 min of circulatory arrest were 6.34, 6.87, and 6.77, respectively, in the normothermic, α-chloralose-hypothermic, and diethylether-hypothermic groups; corresponding values for bicarbonate were 7.7, 13.8, and 12.2 meq/liter. CSF pCO2 increased linearly from 40.2 to 190.0 Torr during 90 min of normothermic circulatory arrest, from 28.6 to 92 Torr in the ether-hypothermic group, and from 28 to 81 Torr in the α-chloralose-hypothermic group.