Karen S. Rheuban

Usefulness of adenosine for arrhythmias in infants and children

Adenosine was administered to 25 infants and children (11 patients after presenting with a sustained arrhythmia, and 14 during a diagnostic electrophysiologic study) to determine its electrophysiologic effects. Adenosine was given as an intravenous bolus (starting dose 37.5 micrograms/kg, and increased by 37.5 micrograms/kg increments until an effect was seen). Adenosine caused tachycardia termination or transient increased atrioventricular (AV) block in all 25 patients. Seven patients had tachycardia requiring only the atria for perpetuation and developed increased AV nodal block (minimum effective adenosine dose range 37.5 to 350 micrograms/kg, mean 131). Thirteen had AV reciprocating tachycardia or AV node reentry tachycardia (minimum effective adenosine dose range 37.5 to 225 micrograms/kg, mean 114). Four other patients received adenosine to rule out preexcitation (minimum effective adenosine dose range 37.5 to 375 micrograms/kg, mean 165). One of the 25 patients had junctional ectopic tachycardia and adenosine administration caused retrograde AV block. Six of the 25 (24%) had noticeable but minor side effects. One patient had sustained bradycardia (2 to 3 minutes requiring temporary pacing). Adenosine is a safe and effective agent in the evaluation and treatment of infants and children with arrhythmias.

The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

National telemedicine initiatives: essential to healthcare reform.

Contributing authors: Elizabeth A. Krupinski, Ph.D.,3 Jim Grigsby, Ph.D.,4 Joseph C. Kvedar, M.D.,5 Ronald S. Weinstein, M.D.,3 Jay H. Sanders, M.D.,6 Karen S. Rheuban, M.D.,7 Thomas S. Nesbitt, M.D.,8 Dale C. Alverson, M.D.,9 Ronald C. Merrell, M.D.,10 Jonathan D. Linkous,11 A. Stewart Ferguson, Ph.D.,12 Robert J. Waters, J.D.,13 Max E. Stachura, M.D.,14 David G. Ellis, M.D.,15 Nina M. Antoniotti, Ph.D.,16 Barbara Johnston, M.S.N.,17 Charles R. Doarn, M.B.A.,18 Peter Yellowlees, M.D.,19 Steven Normandin,20 and Joseph Tracy 21

Incidence and risk of reintervention after coarctation repair

We examined the need for intervention after coarctation repair in a retrospective study of 197 procedures performed between 1967 and 1989. Reintervention was required in 23 patients. No technique of coarctation repair was free from complications. Although there were only two stenoses in the group receiving Dacron patch angioplasty, only seven of these procedures were performed in children under the age of 1 year. The risk of stenosis was inversely correlated to the age at primary repair, with children less than 1 year old being at greater risk than those more than 1 year of age (p less than 0.05). Subclavian flap angioplasty had a lower risk of reoperation than end-to-end anastomosis (p less than 0.02). Formation of true aneurysms was confined to the Dacron patch angioplasty group. The morbidity and mortality for reintervention was low in all groups, with only one procedure-related death and no incidence of paraplegia. Although no technique is free from risk, subclavian flap angioplasty leads to fewer reinterventions in younger patients.

Aortic aneurysm after patch angioplasty for aortic isthmic coarctation in childhood.

Abstract Repair of aortic coarctation, pioneered by Craaford and Nylin 1 and Gross and Hufnagel 2 in 1944, is an accepted procedure with relatively low morbidity and mortality rates. Repair was initially accomplished by excision of the aortic coarctation with end-to-end anastomosis of healthy aortic tissue. Newer techniques, such as patch angioplasty 3–5 and subclavian flap angioplasty, 6 were introduced to avoid the complications of stricture at anastomotic site and allow for further growth of the aorta. Reports of aneurysm formation in the region of the patch angioplasty 7–9 have raised concern as to long-term safety of this procedure. Development of a large true aneurysm of the aorta in 2 asymptomatic patients (Fig. 1) who underwent primary repair of coarctation by the technique of patch angioplasty (the subject of a previous report 10 ) prompted recall of all patients who underwent repair of coarctation of the aorta at the University of Virginia Hospital since 1971. This study assesses the incidence of aortic aneurysm in the pericoarctation region after surgical repair of coarctation of the aorta in childhood, and attempts to determine if the presence of aneurysmal dilatation was related to the type of operative procedure, age at operation or presence of residual gradient.

Pleuroperitoneal shunts for refractory chylothorax after operation for congenital heart disease

Between 1980 and 1990, 10 of 12 children with a symptomatic chylothorax after operation for congenital heart disease failed to respond to traditional medical therapy (thoracentesis, tube thoracostomy, low-fat diet). All 10 patients underwent placement of a pleuroperitoneal shunt, with complete resolution of the chylothorax in 9 patients (90%). Cardiac catheterization, performed before placement of the pleuroperitoneal shunt in 5 patients, demonstrated elevated right atrial pressure in all patients (range, 10 to 25 mm Hg). The pleuroperitoneal shunt functioned effectively in 4 patients with moderately elevated right atrial pressures (range, 10 to 16 mm Hg; median, 13.5 mm Hg) but not in 1 patient with a right atrial pressure of 25 mm Hg. Pleuroperitoneal shunting as treatment for chylothorax after operation for congenital heart disease is safe and effective, even in the face of moderate elevations in right atrial pressure.

Interrelationship of atrial natriuretic peptide, atrial volume, and renal function in premature infants.

Infants experience dramatic changes in fluid balance during the first few days of life, which provides an opportunity to observe the interrelationships of changing atrial size, atrial natriuretic peptide (ANP) secretion, and renal function during a relatively short period. To study these relationships, we examined nine infant boys (mean birth weight 1180 gm and gestational age 30 weeks) at 20 to 28 hours of age and then at four 24-hour intervals. Measurements included plasma ANP concentration, two-dimensional echocardiographic estimations of left and right atrial volumes, Doppler determination of ductus arteriosus patency, creatinine clearance, urine flow rate, urinary sodium excretion, and cyclic guanosine monophosphate (cGMP) excretion. Plasma ANP concentration was found to decrease with age and to correlate with decreasing size of the right atrium, closure of the ductus arteriosus, urinary cGMP excretion, and sodium excretion. We speculate that elevated plasma ANP values in a preterm neonate reflect an expanded volume state. As volume contraction, reflected by decreasing atrial volume and body weight occurs, ANP levels decrease, which may diminish diuresis. These findings are compatible with a significant role for ANP in volume homeostasis of newborn infants.

Intrapericardial teratoma causing nonimmune hydrops fetalis and pericardial tamponade: A case report

SummaryA case of fetal anasarca secondary to an intrapericardial teratoma is reported. The clinical, echocardiographic, and histologic features are described, along with a review of intrapericardial lesions.

Internal mammary artery bypass after the arterial switch operation

Myocardial ischemia may ensure after coronary artery translocation during the arterial switch operation. We report the successful use of a right internal mammary artery to right coronary artery bypass graft in an infant with angiographic documentation of persistent graft patency 6 months postoperatively.

Rupture of Postcoarctation Mycotic Aneurysms of the Aorta

Sudden and usually fatal rupture is a common complication of postcoarctation mycotic aneurysms. Prompt operative treatment is always indicated, and can be performed using one of three techniques depending on the adequacy of the collateral circulation and the presence or absence of active bacterial infection. Renal dysfunction commonly is associated with bacterial endarteritis and is secondary to an immune-complex glomerulonephritis. The patient reported here was treated successfully by the placement of an emergency axillofemoral bypass graft, removal of the infected portion of the descending thoracic aorta, and delayed intrathoracic reconstruction.