J. Deane Waldman

Surgical closure of the tricuspid valve for pulmonary atresia, intact ventricular septum, and right ventricle to coronary artery communications

SummaryA surgical approach is reported for a patient with pulmonary atresia, intact ventricular septum, and right ventricle to coronary artery communications through sinusoids. A shunt procedure was performed at two days of age; the right ventricular outflow tract was not opened. At subsequent catheterization, the tricuspid valve was temporarily closed with a balloon catheter and no change was seen in the ECG. At five months of age, the right ventricle was plicated and a patch was sewn over the tricuspid valve. One year after surgery, neither the right ventricular cavity nor the sinusoids could be demonstrated at angiocardiography; ECG changes of left ventricular ischemia have resolved, and the child is growing normally.

The Damus-Fontan procedure

The Damus-Kaye-Stansel operation is a useful technique for the treatment of complex cyanotic congenital heart disease when there is obstruction between the systemic ventricle and the aorta. Modifications of the technique include transection of the aorta and the pulmonary artery, anastomosis of the contiguous aortic and pulmonary walls, and connection of the distal aorta to the perimeter of the new bivalved proximal great artery. In addition, the bidirectional cavopulmonary shunt technique can be used with or without the Fontan procedure. Six patients underwent a Damus-Fontan operation, and all survived. Two patients underwent the Damus-cavopulmonary shunt (hemi-Fontan) procedure, and 1 survived. The postoperative status of the 7 survivors is good to excellent. Follow-up ranges from 2 months to 7 1/2 years.

Congenital heart disease and pulmonary artery hypertension. I. pulmonary vasoreactivity to 15% oxygen before and after surgery

Pulmonary vasoreactivity at sea level was studied in 22 children before and in 15 children after corrective cardiac surgery for congenital heart disease and pulmonary artery hypertension; 8 children were studied both before and after cardiac surgery. During cardiac catheterization in 28 children, pulmonary and systemic hemodynamics were determined in room air and during breathing of 15% oxygen, which corresponds to a maximal hypoxic level commonly encountered during airplane travel. Before surgery, 19 of 22 children tolerated 15% oxygen (O2), which caused the following hemodynamic changes from room air status: the ratio of pulmonary to systemic arterial pressure increased from 0.70 to 0.78 (p less than 0.05), the ratio of pulmonary to systemic flow decreased from 2.2 to 2.0 (p greater than 0.05) and the ratio of pulmonary to systemic vascular resistance increased from 0.33 to 0.40 (p less than 0.02). In two children, severe pulmonary vasoconstriction developed within 5 minutes of 15% oxygen administration, requiring immediate discontinuation of hypoxia; neither patient had lasting deleterious effects. There was no evidence of increased pulmonary vasoreactivity in children with Downs syndrome compared with genetically normal children. After corrective surgery in 15 children (including both of the hyperreactors), no significant pulmonary vascular response to 15% oxygen was found. It is concluded that, in a small number of children with unrepaired congenital heart disease and pulmonary artery hypertension, pulmonary vascular hyperreactivity can be induced by breathing 15% oxygen; this reaction is life-threatening but reversible with the administration of 100% oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)

Umbilical vascular catheters: localization by two-dimensional echocardio/aortography.

SummaryUmbilical vascular catheters are often necessary in the care of critically ill neonates. Position of the catheter tip is usually determined by roentgenography. Location of the umbilical arterial or venous catheter was determined by 2-dimensional echocardio/aortography in 55 consecutive infants and was compared to localization by thoraco-abdominal roentgenography. Most of the infants (76%) had respiratory distress syndrome or congenital heart disease.Echoaortographic localization of the umbilical arterial catheter correlated very closely (N = 50, r = .90) with roentgenographic determination. For localization of the tip of the umbilical venous catheters, echocardiography was more accurate than roentgenography (employing contrast echocardiography for confirmation of cardiac chamber position).Two-dimensional echocardio/aortographic localization of the tip of indwelling umbilical vascular catheters is as accurate as roentgenography in the arterial system and more accurate than x-ray for umbilical venous catheters. Echocardio/aortography is superior to roentgenography (in localizing the catheter tip) because it 1) avoids ionizing radiation, 2) makes positioning of the patient unnecessary, 3) allows visualization of the catheter in relation to cardiovascular structures, and 4) may allow demonstration of intraarterial thrombo-emboli.

Failure of balloon dilatation in mid-cavity obstruction of the systemic venous atrium after the Mustard operation.

SummaryMid-cavity obstruction of the systemic venous atrium developed after the Mustard operation in a child with transposition of the great arteries. Balloon dilatation (BD) was performed twice, to a maximum theoretical transverse diameter of 18 mm. Each time obstruction was initially relieved, but recurred within months. The usefulness of balloon dilatation therapy requires long-term follow-up. Results from currently reported experience do not suggest a major therapeutic role for this procedure in children.

Sedation for cardiac catheterization: A controlled study

SummaryIn a double-blind study we compared the effectiveness of a meperidine-promethazine-chlorpromazine combination (drug A) and a fentanyl citrate-droperidol combination (drug B) as sedatives for cardiac catheterization and angiography. The doses for drug A were meperidine, 1.84 mg/kg; promethazine, 0.46 mg/kg; and chlorpromazine, 0.46 mg/kg; for drug B they were fentanyl citrate, 1.25μg/kg; and droperidol, 62.5μg/kg. Drug A or B was assigned at random to each of 94 patients aged 3 to 34 years admitted for cardiac catheterization and was given intramuscularly 30 minutes before catheterization. Each patient who required additional sedation was given intravenously (IV) one fourth of the original dose of the same medication used for initial sedation. If still further sedation was required, diazepam, 1 to 2 mg IV, was administered. The effectiveness of sedation or need for additional medication in the group who received drug A were not significantly different from those in the group who received drug B: supplemental sedation was required in 8 of 47 (17%) with drug A and 8 of 47 (17%) with drug B. No significant differences between the two groups were noted for the mean values of heart rate, respiratory rate, oxygen consumption, cardiac index, left ventricular end-diastolic pressure, arterial oxygen saturation, pH,Po2, andPco2 measured during catheterization. No side effects were observed in either group, and all patients had a steady, uneventful recovery.We conclude that the meperidine-promethazine-chlorpromazine and the fentanyl-droperidol combinations were equally effective for precatheterization sedation with the dose used.

Psychological preparation of mothers of preschool children undergoing cardiac catheterization

Abstract Three methods of preparing mothers for the hospitalization of their preschool age children scheduled for cardiac catheterization were compared. Fifty mothers participated in varying combinations of education and hospital orientation, stress management training, and brief supportive psychotherapy. This design allowed for the measurement of both individual and cumulative effects. Behavioral responses of children and their mothers and self-reports of mothers were measured. Mothers who received stress management training and their children evidenced significantly more adaptive behaviors at key stress points and these children adapted more positively at home following the catheterization. Mothers who received education and hospital orientation reported significantly less anxiety and tension and expressed greater competence in caring for their children. Possible explanations for these results are discussed.

Twins in trouble: The need for system-wide reform of both healthcare and education

In the United States, both the healthcare (HC) and the educational (ED) systems are in crisis. The problems appear to be analogous, even identical, seeming to be twins in their troubles. We describe many of these problems-in-common such as: timeline and casuality; substrate and compliance; measurement of outcomes; micro- economic disconnection ; learning; contradictory incentive systems; corporate culture and organizational structure; change management. Possible solutions derive directly from the analysis, viz., measure what we really want rather than what we have measured in the past; develop incentives that encourage desired behaviors. We warn that there is no quick and easy fix. Effective sustainable solutions will be costly, painful and require decades.

The free routine postcatheterization urogram: a cost/benefit analysis

SummaryPostangiography urography has become routine procedure in most centers performing cardiac catheterization in children. We analyzed the x-radiation dosage and clinical yield of this procedure. Using lithium fluoride thermoluminescent dosimeters, radiation exposure to the abdomen and gonads was measured in 35 children during postangiography urography. Results of 334 consecutive routine postangiography cine-urograms were evaluated based on clinical significance and compared to previous reports on this subject.Averageabsorbed abdominal radiation dosage was 241 mR ±240 from cine-urography, 16 mR ±13 from fluoroscopy, and 107 mR ±111 from a single abdominal roentgenogram. Gonadal dosage averaged 8 mR and was uniformly less than 27 mR. Of 334 routine postangiography cineurograms, 282 (84%) were normal, 30 (9%) were technically inadequate, 12 (3%) had abnormalities that were clinically insignificant or were falsely “positive” and in 10 (3%), clinically significant urologic conditions were confirmed.Because of the low yield of clinically significant anomalies and the added radiation exposure, we no longer perform routine postangiography cine-urography in children. Following cardiac angiography, the upper renal collecting systems are examined fluoroscopically. If abnormalities are suspected or fluoroscopy is equivocal, a single abdominal roentgenogram is performed. Using this procedure, mean average absorbed abdominal radiation dose can be reduced from 241 mR to 30.5 mR.