Tarek Husayni

Choreoathetosis after deep hypothermia without circulatory arrest

In 8 of 758 patients undergoing an intracardiac operation under cardiopulmonary bypass and hypothermia, choreoathetosis developed 3 to 7 days postoperatively. Before the onset of choreoathetosis, varying degrees of neurological dysfunction were noted. Electroencephalography and neuroimaging failed to detect any responsible functional or structural changes. Six patients are alive 1 to 3 years postoperatively, and their condition is improving. Two patients died of aspiration or sepsis. All patients were grouped based on factors identified as being possibly causative: depth of hypothermia, cooling time, flow rate, and repeated hypothermia. The incidence of choreoathetosis was significantly different in group A (rectal temperature greater than 25 degrees C) compared with group B (rectal temperature less than or equal to 25 degrees C) (0/295 versus 8/463; p = 0.02). Based on cooling time, the incidence of choreoathetosis was significantly different in group B1 (cooling time less than 1 hour) compared with group B2 (cooling time greater than or equal to 1 hour) (1/220 versus 7/243; p = 0.05). Based on flow rate during cooling, group B2 was further divided into the low-flow group (less than 1,500 mL.min-1.m-2) and the high-flow group (greater than or equal to 1,500 mL.min-1.m-2). Although not significant, the incidence of choreoathetosis was higher in the high-flow group (6/153 versus 1/90; p = 0.22). In group B patients having reoperation, the incidence of choreoathetosis was higher than in patients operated on for the first time (5/54 versus 3/409; p less than or equal to 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Advantages of early relief of subaortic stenosis in single ventricle equivalents

Thirteen patients with single ventricle equivalents and subaortic stenosis underwent relief of the stenosis and subsequent Fontan operation. Nine patients, group 1, had the obstruction relieved at 3.6 +/- 1.6 years of age whenever the pressure gradient became apparent. Four patients, group 2, had the subaortic stenosis operated on at the neonatal period, 10.5 +/- 10 days old, before hemodynamic evidence of obstruction. Preoperative pressure gradient across the outflow tract was 44.2 +/- 4.7 mm Hg in group 1 versus 4.7 +/- 5 mm Hg in group 2 (p = 0.002). Ventricular muscle mass was 186% +/- 18% in group 1 versus 114% +/- 5% of normal in group 2 (p = 0.0001), and mass/volume ratio was 1.12 +/- 0.62 in group 1 versus 0.62 +/- 0.16 in group 2 (p = 0.003). Relief of subaortic stenosis was achieved by proximal pulmonary artery to ascending aorta or aortic arch anastomosis and by systemic to distal pulmonary artery shunt. There was no hospital mortality or complication related to the procedure. At evaluation before Fontan operation, 4.3 +/- 1.6 years after relief of subaortic stenosis in group 1 and 3.2 +/- 0.9 years in group 2, the pressure gradient across the ventricular outflow tract was 4 +/- 3 mm Hg in group 1 versus 3 +/- 2 mm Hg in group 2 (p = not significant), ventricular muscle mass was 184% +/- 31% in group 1 versus 114% +/- 5% of normal in group 2 (p = 0.003), and the mass/volume ratio was 1.17 +/- 0.2 in group 1 versus 0.62 +/- 0.2 in group 2 (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Extended aortic valvuloplasty: A new approach for the management of congenital valvar aortic stenosis

A new technique for the treatment of congenital valvar aortic stenosis is described. It consists of augmenting the aortic cusp by extending the commissurotomy incision into the aortic wall around the leaflet insertion, mobilizing the valve cusp attachment at the commissures, and freeing the aortic insertion of the rudimentary commissure. The results of standard valvotomy performed on 48 patients (group 1) were compared with those of the new extended valvuloplasty carried out on 16 patients (group 2). The two groups were comparable in age at operation (2.7 +/- 2.1 years for group 1 versus 2.1 +/- 1.7 years for group 2; p = not significant) and in preoperative pressure gradient (58 +/- 25 mm Hg for group 1 versus 61 +/- 36 mm Hg for group 2; p = not significant). There was no operative mortality in either group. Follow-up is available on all patients, with a mean of 4.3 +/- 2.6 years for group 1 versus 1.7 +/- 0.5 years for group 2 (p = 0.05). There was one late death in group 1. Postoperative gradient was 47 +/- 13 mm Hg in group 1 versus 19 +/- 13 mm Hg in group 2 (p = 0.05). Moderate or severe regurgitation was present in 18 patients (38%) in group 1 and 2 patients (13%) in group 2 (p = not significant). Reoperation was needed in 8 patients (17%) in group 1 versus 2 patients (13%) in group 2 (p = not significant). The described valvuloplasty procedure addresses the unique pathological features of valvar aortic stenosis and provides better relief of the obstruction than the presently available techniques. Longer follow-up is needed to determine the late results of this approach.

Use of an optical fiber scope to confirm endotracheal tube placement in pediatric patients.

ObjectiveTo determine the efficacy of a portable optical fiber scope to confirm endotracheal tube (ETT) placement. DesignA prospective, nonrandomized, blinded study. SettingPediatric intensive care unit in a children’s hospital. PatientsThirty mechanically ventilated patients with an ETT in place. InterventionsPatients entered into the study underwent ETT placement determination by chest roentgenogram (CXR) and by the optical fiber scope. Measurements and Main Results Thirty patients were entered into the study, for a total of 46 measurements (n = 46). ETT size ranged from 3.0 to 6.0 mm internal diameter. Distance from the ETT and the carina was determined by the scope and compared with the distance measured on the CXR. No statistical difference was found between the two methods. None of the patients experienced clinically significant side effects from the procedure. On three occasions, the presence of secretions in the ETT did not allow for the visualization of the carina by the scope. ConclusionThe use of a flexible optical fiber scope is an accurate, fast, and practical method to determine ETT placement in pediatric patients on mechanical ventilation.

Fetal Bifid Left Ventricular Diverticulum Presenting With Ventricular Ectopy

We report the diagnosis and outcome of a fetus with an unusual left ventricular wall defect. A 34-week fetus presented for echocardiographic evaluation because of an irregular cardiac rhythm. Fetal echocardiography revealed frequent ventricular ectopy and an “accessory” ventricular chamber diagnosed as a left ventricular diverticulum (LVD). The ectopy resolved in utero but recurred after delivery. Angiography revealed a “bifid” LVD. Inderal therapy suppressed the ventricular ectopy. The association between ventricular ectopy and LVD is unusual, but the prognosis of LVD even with arrhythmia is excellent.

Current Management of Hypoplastic Left Heart Syndrome

A diminutive, nonfunctional left ventricle with aortic atresia or severe aortic stenosis and hypoplasia of the ascending aorta constitutes the main structural abnormality in hypoplastic left heart syndrome. The syndrome often presents early with catastrophic hemodynamic decompensation. It is the most common cause of cardiac death in the first week of life1 and usually affects newborns who are otherwise normal.1,2 Hypoplastic left heart syndrome remains a major medical and surgical challenge.

CARDIAC SIZE AND FUNCTION IN SCHOOL ATHLETES AT REST AND AFTER EXERCISE

To determine the effect of high school athletics on cardiac structure and function, we performed 2-D directed M-Mode echos on students involved in isometric (IM) and isotonic (IT) sports and compared them to non-athletic controls (C). Measurements were made at rest and immediately after stage 4 treadmill exercise. Twenty students were included in each group. LV mass was greater in both in and IT compared to C (C 111±4, IM 132±3, IT 130±4 g/M2, p<0.05>. In IT LV diastole volume (LVDV) was increased with normal wall thickness/radius ration (t/r), whereas, in IM, LVDV was normal but, t/r was increased. Stroke index (SI) was increased in IT (C 44±1.7, IM 46±1.6, IT 52.3±2.0 ml/M2, p<0.02). Cardiac index (CI) and shortening fractions were similar among the three groups. After exercise LVDV and systolic volume decreased in both C and IT but, remained unchanged in IM. CI increased with exercise in all groups. Although resting systolic (S), diastolic (D), and mean (M), blood pressures (BP) were similar in all groups, after exercise both C and IT had an increase in SBP, (C 39%, IT 32%) and a fall in DBP, (C-26%), IT-27%) HBP remained unchanged. In IM, SBP rose less, 22%, and DBP fell less, −18%. These data suggest that students engaged in ordinary school sports can develop either eccentric or concentric LVH depending upon the type of sport. The IM athlete appears to have a thicker, less compliant LV and demonstrates less change in blood pressure with exercise.