William J. Rashkind

Transcatheter treatment of congenital heart disease.

IN NORTHERN SPAIN, not far from Altamira with its magnificent polychrome frescoes and Stone Age animals, is the cave of Pindal. Located on a beautiful rocky rugged coast, it is nearly inaccessible and its entrance almost hidden. At first sight the cave is unprepossessing, leaving one unprepared to find what may well be mans first anatomical picture; for it was here that Aurignacian man, some 20,000 years ago, drew the outlines of a mammoth and, in red ochre, marked the heart (fig. 1). Of course, we can only speculate whether he really meant the heart; but, as a hunter, he certainly must have known that to strike the heart was the fastest and easiest way to achieve a kill. He stalked huge animals and was in great danger if his spear thrusts did not score a direct hit. Moreover, he would have to track the animal for many wearying miles or lose it completely. Paleontologists, based on the analysis of many cave drawings, have concluded that the arrows shown on these prehistoric pictographs (fig. 1)

Association of maternal systemic lupus erythematosus with congenital complete heart block.

Infants born to mothers with disseminated lupus erythematosus occasionally have transient manifestations of the maternal disease. In six infants with congenital heart block born to mothers with systemic lupus erythematosus we postulated a causative relation. In one of the infants a post-mortem study of the conduction system suggested faulty embryonic development of the atrioventricular node with an abnormally thick annulus fibrosus and the effects of early inflammatory changes. Two of the infants had a cardiomyopathy and three, associated congenital heart disease.

Transcatheter closure of patent ductus arteriosus

Summary1. A technique has been presented for transcatheter closure of a patent ductus arteriosus. 2. A 3.5-kg infant has been treated successfully in this manner. 3. The method should be considered in high-risk patients. 4. Further miniaturization of the system should make it suitable for use in premature infants critically ill as a result of ductal patency. 5. Increased experience will likely indicate that the technique is applicable to most patients who require ductus closure.

Transposition of the Great Arteries Results of Palliation by Balloon Atrioseptostomy in Thirty-one Infants

A nonsurgical method of creating atrial septal defects using a balloon catheter has been reviewed, and important procedural and technical details have been presented. The results of balloon atrioseptostomy in 31 infants with transposition of the great arteries have been reported and compared with those from the surgical creation of atrial septal defects. All 31 patients survived balloon atrioseptostomy without complications; 26 of them (84%) had effective immediate palliation, and 22 (71%) are long-term survivors. These results demonstrate that effective palliation of transposition of the great arteries, with or without associated ventricular septal defect, can be provided rapidly and safely by balloon atrioseptostomy. All patients with transposition and a large ventricular septal defect should have balloon atrioseptostomy and may also need pulmonary artery banding. For some of these patients banding may be postponed safely for many months, may occur spontaneously, or may be avoided completely.Atrioseptostomy by the balloon catheter technique requires neither sedation nor general anesthesia, and obviates the need for thoracotomy and cardiotomy. The rapidity with which it can be performed makes it particularly advantageous for the desperately hypoxic newborn with transposition of the great arteries who may be considered too sick to withstand major surgery.

Congenital left aortic sinus-left ventricle fistula and review of aortocardiac fistulas.

A fistula from the left aortic sinus to the left ventricle is reported that was successfully repaired using cardiopulmonary bypass. In addition, 175 cases of fistula to the heart from the aortic sinuses published in the English literature from 1839 through 1972 were studied, with particular emphasis on the 126 patients who underwent operative repair. The major cause of the fistulas (76%) was found to be rupture of a congenital aortic sinus aneurysm, usually during the third or fourth decade of life. The remainder of these fistulas to the heart consisted of simply a tract in an otherwise normal sinus. Ventricular septal defect was the most common associated defect and, when present, was nearly always related to a fistula arising from the right aortic sinus. Repair was successful in 86% of the 126 operated patients. The principles of operative treatment of these fistulas are reviewed.

EVALUATION OF A DISPOSABLE PLASTIC, LOW VOLUME, PUMPLESS OXYGENATOR AS A LUNG SUBSTITUTE.

A simple, disposable plastic device, with a total priming volume as low as 30 ml. (20 ml. per kilogram) has been tested as a lung substitute for prolonged periods. Primed with saline, it is interposed between a single femoral artery and vein, with cardiac action as the sole pumping mechanism. Asphyxiated puppies have been maintained for eight hours. Preliminary studies on moribund infants with the respiratory distress syndrome indicate sufficiently good chemical results to warrant further trial.

Normalization of the Blunted Ventilatory Response to Acute Hypoxia in Congenital Cyanotic Heart Disease

Patients with congenital cyanotic heart disease have a blunted ventilatory response to hypoxia, but the permanence of the blunting is disputed. To determine how early the blunted ventilatory response develops and whether it is reversible, we studied three groups of children and young adults: five (seven to 13 years of age) with acyanotic heart disease, eight (seven to 16) with cyanotic congenital heart disease (arterial oxygen saturation, 55 to 83 per cent), and 13 (seven to 17) whose cardiac defects were repaired (arterial oxygen saturation, 93 to 98 per cent). The ventilatory response to acute hypoxia was subnormal in the hypoxemic children in that their ventilation showed little increase when arterial oxygen saturation fell by 10 to 20 per cent, compared to a 150 to 300 per cent increase in the control subjects. This characteristic even appeared in a seven-year-old patient, indicating that the disorder occurs in early life. The appearance of blunted ventilatory response is delayed when hypoxia from birth is less severe. After operation, with return of the arterial hypoxemia to normal, the response was in the normal range. We conclude that the blunted response is reversible.

Interventional cardiac catheterization in congenital heart disease

Cardiac catheterization has proved its value as a major tool in the diagnosis of congenital cardiac defects. The advent of non-invasive imaging of various sorts has altered the role of diagnostic catheterization. Within the past two decades cardiac catheter instruments to provide therapy have been applied to many lesions. Improvements in design and methods will expand the use of therapeutic catheterization. It is inevitable that better results will be obtained for those defects currently being treated that way, and that the method will be applied to other conditions.

A Technic of Vascular Catheterization with Small Plastic Catheters Its Utilization to Measure the Arterial Pulse Wave Velocity in Man

A method of vascular catheterization is presented in which small polyvinyl catheters are introduced into peripheral vessels through 18 to 21 gage needles and then advanced into the central vascular bed. This technic has been utilized in the study of hemodynamic events occurring in the central arterial vessels in man. The results obtained from 31 arterial catheterizations done in 21 subjects are reported. Utilizing this technic, it has been impossible to catheterize the pulmonary artery in man. However, the method has proved useful in the study of right atrial and central venous pressure changes.

Comparison of Oxygen Poisoning of the Lung in Cyanotic and Acyanotic Dogs

Abstract Cyanosis was produced in dogs by the surgical creation of large intracardiac venoarterial shunts. Eight cyanotic and 10 acyanotic dogs were exposed, awake and unrestricted, to 1 atmosphere of 98 per cent to 100 per cent oxygen for two days. In each of the two groups of animals, a similar frequency and extent of pulmonary oxygen damage was found, as judged by the production of respiratory distress, atelectasis, alveolar edema and hemorrhage and abnormal surface tension of whole-lung extracts. Cyanosis did not protect against pulmonary injury from 100 per cent oxygen at 1 atmosphere for two days.