Lynn C Graham

Piercing and tattooing in patients with congenital heart disease: patient and physician perspectives

PURPOSE The frequency and safety of ear piercing and tattooing were assessed in a group of children, adolescents, and adults with congenital heart disease (CHD). Also, a group of physicians who care for adolescents and adults with CHD were surveyed for opinions and experiences regarding piercing and tattooing. METHODS An eight-question survey was mailed to 445 patients (181 adults and 264 children) from one center. A different five-question survey was mailed to 176 physician members of the International Society of Adult Congenital Cardiac Disease. RESULTS The patient survey was completed by 152 of 445 (34%) patients (mean age +/- standard deviation 19.8 +/- 16.2 years; range 0.25-67 years). Eighty-eight of 152 (58%) patients were female. Ear piercing occurred in 65 of 152 (43%) patients (mean age 12.4 +/- 8.7 years; range 0.25-45 years). Prior to piercing, only 4 of 65 (6%) patients took antibiotics, but 15 of 65 (23%) had piercing-related infections. No patient had endocarditis. Infections occurred 1 week to 3 years after piercing. All were local skin infections. Tattoos were placed in 8 of 152 (5%) patients (median age 17.5 years; range 13-56 years). No antibiotic use or infections were reported in patients with tattoos. The physician survey was completed by 118 of 176 (67%) physicians. The majority of physicians did not approve of patients having piercing or tattooing performed. However, 60% of physicians believed that antibiotic prophylaxis is indicated for these procedures. CONCLUSIONS Despite the opinion of many physicians, most patients do not take antibiotic prophylaxis for piercing and tattooing. Patients apparently do not suffer serious sequelae. The efficacy of standard antibiotic regimes as applied to ear piercing and tattooing requires further study, since these procedures are increasingly popular in modern society.

Argatroban use during pediatric interventional cardiac catheterization

Argatroban is a synthetic direct thrombin inhibitor that does not interact with or induce heparin‐dependent antibodies. It is approved for use in adults for prevention and treatment of thrombosis associated with heparin‐induced thrombocytopenia (HIT). It has been administered safely in adults with HIT during coronary interventions. There are no reports of argatroban use for anticoagulation in pediatric patients. The present case describes the use of argatroban during coil embolization of a Fontan fenestration in a child with a history of HIT. The patient received a single bolus dose of 150 μg/kg of argatroban at the onset of the intervention. The fenestration was successfully occluded with a detachable coil. The activated clotting time (ACT) was > 200 sec throughout the procedure. The ACT returned to baseline 72 min after the bolus. No complications occurred. This case demonstrates the safe and successful use of argatroban during a transcatheter intervention in a pediatric patient with a history of HIT. The use of argatroban is promising for anticoagulation in children who require an alternative to heparin. Catheter Cardiovasc Interv 2004;61:147–149.

Simultaneous repair of pectus excavatum and congenital heart disease

Most repair of heart lesions and pectus deformity has been performed in adult patients using long incisions, sternal splits, excision of deformed cartilages, and sternal turnover operations that could result in poor cosmesis and chest growth in children because of sternal devascularization. We performed simultaneous pectus repair and atrial septal defect closure in 2 children using a short longitudinal incision and avoiding a transverse or longitudinal sternal split. After extraperichondrial excision of the deformed cartilages and mobilization of the sternum from the neurovascular bundles, a transverse wedge of sternum was removed at the level of the third cartilages, allowing cephalad retraction of the sternum and providing excellent exposure for the intracardiac operation. The cosmetic appearance remains excellent in both patients at 1 and 4 years postoperatively.

Extended end-to-end repair and enlargement of the entire arch in complex coarctation

BACKGROUND Treatment of hypoplasia of the entire arch in coarctation is a surgical challenge. The current approaches have technical difficulties, high recurrence rates, and increased morbidity and mortality. METHODS Over a 14-month period, a combined extended end-to-end repair with patch enlargement of the concavity of the entire arch was performed in 6 neonates and 1 infant. Through a midsternotomy and using cardiopulmonary bypass and hypothermia, extended end-to-end repair was performed initially leaving the proximal anastomosis open. The enlarging polytetrafluoroethylene patch was then sutured starting at the incised descending aorta distal to the extended end-to-end repair and continued retrogradely through the transverse arch to the ascending aorta proximal to the aortic cannulation site. One neonate had a patent ductus arteriosus and another had ventricular septal defect closure. One neonate had arterial switch and 3 had Norwood-type procedures performed with the enlarging patch extended to the pulmonary artery anastomosis. The remaining infant had arch enlargement performed after an arterial switch procedure and extended end-to-end repair. RESULTS All patients did well and showed no residual gradient up to 1 year follow-up. Two patients successfully had bidirectional Glenn shunt at 9 months of age, and one had closure of residual arterial septal defect at 8 months of age. CONCLUSION The combined extended end-to-end repair and arch enlargement procedure should minimize recurrence rates because of a tension-free enlargement of the entire aortic arch and elimination of the coarctation ridge and ductile tissues. Combined with the arterial switch and Norwood-type procedures, the approach results in a large neoaorta.

Cost-Effectiveness of Transaxillary Muscle-Sparing Same-Day Operative Closure of Patent Ductus Arteriosus

Transaxillary muscle-sparing patent ductus arteriosus closure performed as same-day surgery is described in 10 patients. This approach provides a superb cosmetic result while obviating the need for thoracostomy tube placement.

Large left atrial thrombus formation despite warfarin therapy after device closure of a patent foramen ovale

Appropriate anticoagulation after transcatheter device placement is controversial. Patients with no history of thromboembolism or neurologic event typically receive antiplatelet therapy for several months while the device endothelializes. For patients with a history of stroke, there are no established guidelines for postdevice anticoagulation. Most patients receive warfarin, antiplatelet therapy, or a combination. Thrombus formation after transcatheter device placement has been reported for most commercially available devices. We describe a patient who developed a left atrial thrombus after closure of a patent foramen ovale with a CardioSEAL device. The patient had a normal hypercoaguable laboratory evaluation prior to device placement. Thrombosis occurred despite warfarin therapy before and after device placement. The patients international normalized ratio was checked every 2 weeks after device placement and ranged between 2.0 and 2.8. She had no clinical arrhythmia during this time period. The left atrial thrombus was detected on routine follow‐up transthoracic echocardiogram performed 6 months after device deployment. A subsequent transesophageal echocardiogram demonstrated no residual shunt, appropriate positioning of the device, flat against the septum, and a 1 × 2 cm thrombus attached to the superior and posterior left atrial arm near the junction with the native septum. A fluoroscopic image demonstrated no arm fractures. The device and thrombus were subsequently removed at surgery without complication. This case is perplexing in that the patient received appropriate anticoagulation had a negative hypercoaguable work‐up, no residual shunt, and a well‐positioned device. Cathet Cardiovasc Intervent 2003;59:396–398.

Early detection of cardiac dysfunction: Use of the myocardial performance index in patients with anorexia nervosa

OVERVIEW Patients with anorexia nervosa have functional cardiac abnormalities secondary to their nutritionally depleted state. These abnormalities include decreased left ventricular (LV) mass and varying degrees of LV systolic dysfunction. Assessment of LV diastolic function and quantitative assessment of right ventricular function are not routinely performed. The myocardial performance index (MPI) is a relatively new, simple, quantitative measure of global myocardial function. The purpose of this study was to evaluate left and right ventricular function in 13 patients with anorexia nervosa with the MPI and compare it to more commonly used echocardiographic measures of ventricular function.

Gaining vascular access in pediatric patients: use of the P.D. access Doppler needle.

This article describes our initial experience with the P.D. Access Doppler needle for obtaining vascular access in pediatric patients. Patients were considered for use of the P.D. Access Doppler needle (Escalon Vascular Access, New Berlin, WI) if they had a history of difficult access or body habitus limitations to vascular access. An 18‐, a 20‐, or a 22‐gauge bare needle with an inserted Doppler stylet was utilized. The time from initial subcutaneous entry of the Doppler needle until wire placement into the vessel lumen was recorded. Initial attempts to cannulate were performed with standard Seldinger technique. If attempts with the standard technique were unsuccessful, then P.D. Access was utilized. However, P.D. Access was used primarily in small children for internal jugular vein cannulation or in patients with coarctation who had absent/diminished femoral pulses. P.D. Access cannulation was attempted 39 times (31 patients). Median age is 23 months (range, 1 day to 15 years). Median weight is 10.5 kg (range, 1.7–57 kg). These patients had a mean of two prior cardiac catheterizations and/or surgeries (range, 0–6 procedures). Use of P.D. Access resulted in successful cannulation in 35/39 (90%) attempts. In successful outcomes, the time from initial subcutaneous entry to cannulation is 6.5 ± 4.9 min. In unsuccessful outcomes, failure was due to prior hematoma formation, operator inexperience, or prior vessel occlusion. Successful use of P.D. Access shortens the duration of vascular access in difficult pediatric patients. In our cardiac catheterization laboratory, this technique has become the preferred initial entry technique for cannulation of the internal jugular vein in small children. In addition, this technique was particularly useful for femoral artery cannulation in patients with coarctation of the aorta with absent/diminished femoral pulses. Cathet. Cardiovasc. Intervent. 51:61–64, 2000.

DIASTOLIC FUNCTION IN CHILDREN WITH SICKLE CELL ANEMIA (SCA). 131

Left ventricular (LV) dilation and systolic dysfunction are recognized causes of mortality in patients with SCA. But, data evaluating diastolic function in children with SCA are limited. We used Doppler echocardiography(echo) to assess diastolic function in children with SCA.