James A. Helmsworth

Congenital tracheo-esophageal fistula without esophageal atresia.

Summary A case of congenital tracheo-esophageal fistula without atresia in a 6-month-old boy is described. This diagnosis should be considered in all infants and children who have recurrent pneumonitis, whose coughing is related to the taking of food, and in whom meteorism is a prominent feature. Observation of the rapid increase of abdominal distention after feeding and coughing is a most helpful corroborative sign.

Syndrome of Left Ventricular-Right Atrial Shunt Resulting from High Interventricular Septal Defect Associated with Defective Septal Leaflet of the Tricuspid Valve

Two similar cases of unusual congenital anomalies of the heart are presented, in which there existed a direct communication between the left ventricle and the right auricle through a defect involving the membranous portion of the interventricular septum with defective formation of the medial leaflet of the tricuspid valve. Data obtained at catheterization, operative and postmortem findings are presented in each case. The differential diagnosis of this type of lesion is discussed.

Nitroprusside and Epinephrine for Treatment of Low Output in Children after Open-Heart Surgery

We evaluated the acute hemodynamic effects of treatment of the low output state with sodium nitroprusside and epinephrine in 13 children after intracardiac operation. The 13 patients were selected from a consecutive series of 106 children undergoing cardiopulmonary bypass. They had a cardiac index less than 2.0 L/min/m2, even after an increase in left ventricular filling pressure and during infusion of nitroprusside. Although the nitroprusside brought about a significant increase in cardiac output and decrease in systemic vascular resistance, the cardiac index remained critically low (less than 2 L/min/m2). Epinephrine resulted in a further significant increase in the cardiac index, without a significant change in systemic resistance. This study suggests that in selected patients the simultaneous use of both a vasodilator drug (sodium nitroprusside) and a positive inotropic agent (epinephrine) is advantageous in the short-term treatment of the low cardiac output state after intracardiac operation.

Repair of a Subvalvular Left Ventricular Aneurysm Following Mitral Valve Replacement

Left ventricular aneurysms are a frequent complication of myocardial infarction. Some aneurysms occur secondary to trauma, previous operation, or infection. This report presents the case of a patient with a posterior submitral left ventricular aneurysm, which occurred following mitral valve replacement. The complete obliteration of the pericardial sac due to previous cardiac operation and the posterior location made external dissection of the aneurysmal wall technically impossible. Closure of the defect through the valve orifice by placing a patch over the neck of the aneurysm was found to be a relatively simple and safe technique combined with replacement of the prosthetic valve. The possibility of injury to the circumflex coronary artery was reduced using this surgical approach.

Premature Infants with Patent Ductus Arteriosus and Respiratory Distress: Selection for Ductal Ligation

Abstract Operative treatment of patent ductus arteriosus (PDA) in premature infants with respiratory distress has been advocated when rapid and favorable response to medical management has not occurred. At Cincinnati Childrens Hospital from September, 1971, to January, 1975, 28 patients with respiratory distress syndrome (RDS) and PDA underwent ductal ligation after failing to respond to intensive medical management. There were 15 survivors and 13 deaths, for a survival rate of 53%. We have found the most reliable assessment of PDA and its response to medical management to be a reduction in left cardiac chamber size as evidenced by echocardiography. In 15 of the 28 infants who underwent ligation, echocardiography showed that they had failed to respond to medical management. Seven of the group survived. During the same period 15 infants with RDS and PDA responded favorably to medical management and showed return of left cardiac chamber size to normal by serial echocardiograms. Of these, 11 survived and 4 died of noncardiac causes. Clinical improvement was corroborated without exception by echocardiographic demonstration of a reduction in size of the left cardiac chamber. We believe that infants who follow this course should not have ductus ligation. We contend that the choice of surgical candidates should be more selective since a survival rate of only 50% has been obtained in this and other series. Further, we have found that only 8 of 14 long-term survivors in our series are free from pulmonary disease.

Leukopenic and Thrombocytopenic Effect of Hypothermia in Dogs

Summary 1. Attention is drawn to the complication of impaired coagulation encountered in experimental hypothermia in dogs. 2. The method used for anesthetizing and rapidly reducing the body temperature by packing in cracked ice is described. 3. The following changes were associated with hypothermia: The leukocyte count was reduced an average of 86%, the total eosinophil count was reduced an average of 86%; and the platelet count was reduced an average of 81%. 4. The coagulation mechanism was not studied directly, but data from these experiments suggest that the strong thrombocytopenic effect observed may be a factor in the impaired coagulation.

Experience with Anastomosis of Superior Vena Cava to Pulmonary Artery (Glenn Procedure)

Fifteen children with uncorrectable cyanotic heart disease were treated with the Glenn procedure. The hospital mortality was 20 per cent. Total and partial body perfusions were used in two cases to accomplish the anastomosis. The indications for perfusion have been discussed. Modifications in anesthesia were presented to reduce the high incidence of hypotension, bradycardia, and cardiac arrest.