Michael J. Cooper

A relaxation technique in the management of hypercholesterolemia.

Chronic sympathetic nervous system overactivity has been implicated as a factor capable of elevating and maintaining high serum cholesterol levels independent of dietary measures. We conducted a controlled trial to determine the effect of a relaxation technique. Transcendental Meditation, on serum cholesterol levels in hypercholesterolemic subjects. Serum cholesterol levels were measured at beginning and end of an 11-month period in 12 hypercholesterolemic subjects who regularly practiced meditation. Eleven hypercholesterolemic controls who did not practice the technique were similarly followed up for 13 months. Paired comparisons showed a significant (p less than 0.005) reduction in fasting serum cholesterol levels of those subjects who practiced meditation. These results suggest that the regular practice of a relaxation technique may contribute, most likely through a reduction in adrenergic activity, to the amelioration of hypercholesterolemia in certain subjects.

Critical pathway methodology: Effectiveness in congenital heart surgery

Critical pathway methodology has been demonstrated to provide producible reduction in average length of stay (ALOS) in adults in certain diagnostic-related groups and operations such as coronary artery bypass grafting. The efficacy of this approach in congenital heart surgery was explored. Two hundred eighty-six consecutive patients from a health maintenance organization treated by a single surgeon since the institution of diagnostic-related group coding at that health maintenance organization constituted the study group. One hundred fourteen patients were treated at a university hospital without critical pathway methodology (group 1) and 172, subsequently at the health maintenance organization institution using the methodology (group 2). Operation/lesion, age, and diagnostic-related group matching was possible in 61 pairs. Examination of the ALOS Hospital (operative and postoperative days) for the entire cohort revealed a 43.8% reduction in ALOS Hospital (p < 0.0001) and a 39.0% reduction in ALOS Intensive Care Unit (p < 0.0001). There was also significant reduction in ALOS Hospital and ALOS Intensive Care Unit in the operation/lesion-matched subsets. Outcome measures including operative and late mortality, readmission, unscheduled emergency room and clinic visits, and health maintenance organization family assessment survey demonstrated no improvement in outcome with increased hospital stay. Thus, critical pathway methodology when used in patients undergoing a congenital heart operation produces a significant reduction in hospital stay and intensive care unit stay as well as quality patient care with uniformity of outcome.

Pulmonary artery origin of the left coronary artery: Diagnosis by two-dimensional echocardiography, pulsed doppler ultrasound and color flow mapping

Five children, aged 0.2 to 6.7 years, with pulmonary artery origin of the left coronary artery proved by angiography underwent echocardiographic examination from 1985 through 1986. Prospective identification of this condition was achieved by two-dimensional echocardiography alone in two patients. Using a parasagittal plane from the second or third intercostal space, identification of the anomalous origin from the pulmonary artery was also possible in the other children on subsequent examination. In all of these studies the right coronary artery was considerably enlarged. The ratio of the diameters of the right coronary artery and the aortic root was 0.25 to 0.33 (normal 0.12 +/- 0.02). Flow mapping by color Doppler ultrasound in three children studied most recently and peripheral arterial or aortic root contrast echocardiography identified the site of entry of the coronary flow into the pulmonary artery. The flow disturbance was detected on the aortic surface of the pulmonary artery opposite the portion from where the flow from a patent ductus is usually identified. Pulsed Doppler ultrasound identified the flow disturbance in the pulmonary artery in only three of the children. The two youngest patients did not demonstrate turbulence on pulsed Doppler ultrasound, but they were not examined by color Doppler ultrasound. The accuracy of noninvasive detection of pulmonary artery origin of the left coronary artery by ultrasound is improved by the use of a combined echocardiographic approach.

Recognition of left coronary artery fistula to the left and right ventricles by contrast echocardiography

A coronary-cameral fistula was inspected clinically by two-dimensional and pulsed Doppler ultrasound. At cardiac catheterization a fistulous connection between the left coronary artery and the right ventricle was observed. Contrast echocardiography using agitated saline solution injected into the aortic catheter clearly showed the passage of microcavitations into the left and the right ventricles confirming the connection of the fistula to both chambers. Contrast echocardiography is a valuable technique that can help define the site of drainage of coronary artery fistulas.

Evaluation of the responsiveness of elevated pulmonary vascular resistance in children by Doppler echocardiography

Changes in the Doppler indexes, acceleration time (AcT), right ventricular ejection time (RVET), AcT/RVET ratio and pulmonary artery peak velocity were measured as were changes in pulmonary artery pressure and pulmonary vascular resistance in 21 children with pulmonary hypertension due to a large interventricular communication. In 11 children pulmonary vascular resistance was greater than 4.6 U/m2 (mean 8.6 +/- 1.6), whereas in 10 it was less than 4.5 U/m2 (mean 3.4 +/- 0.2). Although both groups demonstrated acceleration time and AcT/RVET values above normal, there were no significant differences in these values between the groups with high and low pulmonary vascular resistance. With administration of a pulmonary vasodilator pulmonary vascular resistance decreased in 11 responders by greater than 50% of baseline values (from 5.3 +/- 0.7 to 1.6 +/- 0.3 U/m2), whereas in the 10 nonresponders mean pulmonary vascular resistance decreased from 7.0 +/- 1.9 to 4.9 +/- 1.1 U/m2. There was no significant change in the Doppler indexes except for an increase in pulmonary artery peak velocity in the responders from 1.34 +/- 0.07 to 1.66 +/- 0.06 m/s (p less than 0.001). The results indicate that Doppler echocardiography cannot predict either the level of increased pulmonary vascular resistance or the degree of responsiveness sufficiently to obviate the need for cardiac catheterization in patients with interventricular communication and pulmonary hypertension.

Cardiovascular-radical outcome method is effective in complex congenital cardiac lesions

BACKGROUND The cardiovascular-radical outcome method is a proactive process of patient care that uses standard critical pathway methodology to reduce negative variation while encouraging positive variation to accelerate recovery. Its effectiveness in patients with complex congenital heart disease is explored. METHODS Two hundred fourteen consecutive patients with congenital heart disease were cared for using the cardiovascular radical outcome method. Age ranged from 2 days to 19 years (median age, 3 years). Cardiovascular radical outcome method data were compared with the pathway plan data for each patient. RESULTS Survival was 99% (211 patients) with an overall reduction in stay of 156 days (0.74 day/patient) (p < 0.0001). Only 10 patients (5%) exceeded the pathway plan; 201 (95%) reached the planned length of stay (critical pathway method), and 127 patients (60%) had a shorter length of stay than expected by the critical pathway method. One hundred forty-eight patients (70%), including 95 (64%) with more complex conditions, had a length of stay of 3 days and 18% achieved a 2-day length of stay, the maximal response. The process was most effective in the most complex groups, although preoperative comorbidities influenced outcomes. Outcome assessment demonstrated minimal morbidity and excellent family satisfaction. CONCLUSIONS The radical outcome method is effective in reducing the length of stay of patients with complex congenital heart disease. The power is in the process rather than the plan, and the method provides optimal patient care and family satisfaction.

Comparison of M-mode echocardiographic measurement of right ventricular wall thickness obtained by the subcostal and parasternal approach in children

Right ventricular (RV) wall thickness was measured from M-mode echocardiograms at end-diastole from both the parasternal and subcostal approaches in 50 children of various body surface areas (0.24 to 1.68 m2). The measurements were obtained from M-mode recordings generated from sector scans to ensure precise location and position. Twenty-three children had normal hearts, and 27 had various congenital heart defects that may be associated with RV hypertrophy. Corresponding measurements of the RV wall thickness at end-diastole from the 2 approaches were similar. Subcostal echocardiographic measurement of RV wall thickness was found to be a reliable alternative to parasternal measurement in children with normal hearts and in those with congenital heart disease and RV hypertrophy.

Contrast echocardiography in the diagnosis of anomalous left coronary artery arising from the pulmonary artery

SummaryWe have demonstrated an anomalous left coronary artery originating from the main pulmonary artery by saline contrast echocardiography. The anomalous vessel was easily identified using contrast injections into the ascending aorta at catheterization and into a radial artery cannula following catheterization. Contrast echocardiography may be useful in the diagnosis of this lesion when two-dimensional and Doppler echocardiography fail to show the anomalous vessel.

Usefulness of Doppler echocardiography for determining hemodynamic improvement with intravenous verapamil in hypertrophic cardiomyopathy

Abstract Verapamil is effective in the treatment of hypertrophic cardiomyopathy (HC). 1–4 Continuous-wave Doppler ultrasound is useful in the noninvasive assessment of high-velocity intracardiac blood flow. 5 We evaluated the hemodynamic response in a child with HC through intravenously administered verapamil during cardiac catheterization with simultaneous continuous-wave Doppler flow study for the noninvasive evaluation of changes in left ventricular (LV) outflow obstruction.