Arrhythmias and thromboembolic complications after the extracardiac Fontan operation.

BACKGROUND: Late morbidity and mortality after the Fontan operation are largely due to atrial arrhythmias, ventricular failure, and thrombus formation. The extracardiac Fontan procedure avoids extensive atrial manipulation and suture lines, theoretically minimizing the impetus for these events. We examined our experience with the extracardiac Fontan operation with particular attention to thromboembolism and arrhythmias. METHODS AND RESULTS: We retrospectively reviewed the medical and surgical records of all 16 patients who underwent an extracardiac Fontan operation between July 1993 and May 1996. Fifteen patients (94%) were in sinus rhythm before the operation. In the immediate postoperative period, seven (44%) had arrhythmias consisting of accelerated junctional rhythm and ectopic atrial rhythm. No associated hemodynamic compromise and no early deaths occurred. Patients were followed up for 3 to 34 months after the Fontan operation. Arrhythmias were detected in eight patients (50%) on surface electrocardiograms, and seven (44%) showed evidence of sinus node dysfunction on 24-hour Holter monitor studies. Thrombi were found in three patients (19%). All patients were asymptomatic, with no evidence of conduit obstruction by echocardiogram. CONCLUSIONS: The incidence of hemodynamically significant tachyarrhythmias appears to be reduced after the extracardiac Fontan operation. A significant percentage of patients have evidence of sinus node dysfunction, suggesting the presence of other surgical or nonsurgical factors responsible for this finding. Our incidence of thrombotic events is similar to previous reports with other Fontan modifications. It appears to be a reasonable option to maintain these patients on anticoagulation indefinitely.

Prostacyclin (prostaglandin I2) formation in lung tissues of infants in sudden infant death syndrome (SIDS), non-SIDS and adults.

SIDS lung tissues elaborated significantly (p less than 0.01) lower PGI2 as compared with non-SIDS and adults. Significant differences (p less than 0.01) between SIDS and non-SIDS were especially shown at 2-4 months of age, 16.46 +/- 6.86 vs. 28.39 +/- 8.86 ng PGI2/50 mg of lung tissue, respectively, for SIDS and non-SIDS. A highly significant difference (p less than 0.001) was shown for SIDS (16.46 +/- 6.86 ng PGI2/50 mg lung tissue) when compared to adults (33.50 +/- 5.60 ng PGI2/50 mg lung tissue). It is suggested that there is defective maturation in the development of prostacyclin synthetase in lung tissues of SIDS infants.

Characteristics of frequent pediatric emergency department users.

The purpose of this study was to examine the medical and demographic characteristics of patients who frequently seek emergency care at a pediatric emergency department (ED). Registration information of ED visits during the study period from 11/1/87 to 5/31/92 (4.6 years) was stored in a data base. Patients with 10 or more ED visits during this study period were considered to be "frequent" ED users. Outpatient and inpatient medical records of these patients were manually reviewed. Demographics, chronic conditions, and the acute conditions for each ED visit were coded and analyzed. During the study period, there were 79,049 ED patient visits under 21 years of age. Of the patients born after 1970, there were 47,451 visits by patients seen one or two times, 25,883 visits by patients seen three to nine times, and 5178 visits by 357 patients seen in the ED ten times or more. Ninety-nine patients were seen more than 15 times, 39 patients were seen more than 20 times, 17 patients were seen more than 25 times, and 10 patients were seen more than 30 times. Two hundred sixty-five of the 357 frequent ED users (74%) had chronic disease conditions. Two hundred and twenty-three of them had good functional status, 25 had mild or moderate impairment in carrying out activities of daily living, and 17 had severe impairment of function. The most common chronic medical conditions were recurrent wheezing (226), neurologic conditions (33), gastrointestinal conditions (13), cardiac conditions (12), and endocrine conditions (9). The other 92 were assessed as healthy children. Patients' immunization status were up to date as of the last ED visit during the study period in 329 patients (92%). Pediatricians were the primary care providers in 339 patients (95%). Medical insurance status of patients follows: private insurance (38%), military (0.3%), Medicaid or state assistance (60%), and no insurance (1.4%). Polynesian ethnic groups were over-represented in the cohort of frequent ED users. We conclude that cultural differences appeared to be an important factor associated with frequent ED use by healthy persons. Medical care resources as measured by immunizations, insurance, and identification of a primary care physician did not appear to be deficient in this cohort of frequent ED users. Since recurrent wheezing is a dominant chronic condition among frequent ED users, pediatric emergency medicine training programs may consider the inclusion of the chronic management of wheezing in their curriculum.