Furosemide-associated fever.

We describe a 5-month-old infant who had fever of unknown origin leading to an exhaustive evaluation during a 7-week period. Fever caused by the use of furosemide was proved; the fever resolved after discontinuation of this medication and recurred after its reintroduction.

Long-term results after cavopulmonary anastomosis.

Brief case histories of three patients who underwent cavopulmonary anastomosis 28, 27, and 26 years ago, respectively, are presented. From this limited sample the following conclusions may be drawn. (1) Long-term survival with good functional results in patients with complex congenital anomalies who undergo cavopulmonary shunting at an early age is possible. (2) Secondary changes in the circulation of the right lung such as underperfusion of the upper lobe and the development of multiple arteriovenous connections in the lower lobe do occur, maybe more often than appreciated. (3) By 15 to 20 years after their initial operation, most of these patients require additional operations such as systemic-pulmonary artery shunt or, if possible, total repair of their underlying anomaly.

Stress testing for comparison of synthetic patch aortoplasty with resection and end to end anastomosis for repair of coarctation in childhood.

Excellent clinical results have been achieved by both resection with end to end anastomosis and synthetic patch aortoplasty for the repair of coarctation of the aorta in older children. Increasing experience with exercise stress testing in the postoperative evaluation of patients with coarctation has allowed the discovery of less obvious differences between the two procedures. To evaluate these differences further, the stress tests of 50 postoperative patients who underwent coarctation repair were reviewed: 26 patients with end to end anastomosis and 24 with synthetic patch aortoplasty. Twenty normal control subjects were similarly exercised. Systolic blood pressure in the arm and leg was evaluated before and after the test. Heart rate, electrocardiogram and arm blood pressure were monitored during the test. The mean arm systolic blood pressure was higher at all points of measurement in the patients who underwent repair by end to end anastomosis than in the group who underwent patch aortoplasty. These systolic pressure differences reached statistical significance only for standing arm blood pressure before exercise (p less than 0.05) and for supine arm systolic blood pressure immediately after exercise (p less than 0.01). There was no difference in arm-leg pressure gradient between the two study groups before exercise; however, after exercise the group with end to end anastomosis had significantly higher arm-leg pressure gradients (p less than 0.001). Significant differences between the two types of repair not apparent at rest were found immediately after exercise. The long-term prognostic importance of an exercise-induced arm-leg blood pressure gradient remains to be determined. However, exercise stress testing is sensitive in demonstrating these differences.

Growth of the aorta after prosthetic patch aortoplasty for coarctation in infants.

We have shown that patch aortoplasty relieves the aortic pressure gradient substantially better than resection with end-to-end anastomosis in infants with coarctation of the aorta. Growth of the intact posterior wall of the unresected coarctation after aortoplasty, however, has not yet been demonstrated to occur. We studied 21 infants less than 2 years of age who underwent prosthetic patch repair of coarctation after 1975. Associated lesions were present in 16 patients, and 12 had a concomitant procedure. Two patients died in the hospital, and 4 died later, all of causes unrelated to the coarctation repair. Systolic blood pressure in the right arm declined from 140 +/- 41 mm Hg (mean +/- standard deviation) preoperatively to 101 +/- 19 mm Hg postoperatively in the whole group and to 95 +/- 12 in 10 patients followed for more than 3 years. The right arm-left leg systolic pressure gradient declined from 66 +/- 22 mm Hg to 5 +/- 14 in all patients and to 4 +/- 13 in the group followed more than 3 years. Hypoplastic transverse arch was seen in all but 2 patients. Its relative diameter increased in 6 of 9 patients who underwent catheterization postoperatively and increased more than 50% in 3 patients. Two patients have evidence of narrowing of the aorta at the patch, but both have normal blood pressure in the right arm. In the patient with longest follow-up, an 8-month-old infant seen 8 years after operation, angiograms show the diameter of the aorta at the coarctation to be greater than that at the transverse arch and at the descending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

Discrete subaortic stenosis.

From 1971-1981, 18 patients with discrete subaortic stenosis were treated surgically at the Medical University of South Carolina. Echocardiography was diagnostic in 10 of 11 patients in whom it was used. Preoperative cardiac catheterization was performed in all patients. The preoperative left ventricular outflow systolic pressure gradient was 82.0 +/- 27.2 mmHg (mean +/- SD) (range 30-145). In 16 (88.8%) patients excision of the subaortic membrane was complete, and relief of left ventricular outflow obstruction was good. The excision was incomplete in 2 patients; one required reoperation for residual gradient and developed complete heart block, and the other had a residual gradient of 60 mmHg and was in New York Heart Association functional class II when lost to follow-up. These data suggest that complete excision of the discrete subaortic stenosis is important to achieve good relief of left ventricular outflow obstruction.

Kinetic and clinical observations in cyanotic children on propranolol therapy.

The kinetics of propranolol and its metabolite 4-hydroxypropranolol were determined together with heart rate and blood pressure responses in five cyanotic children on long-term propranolol therapy and after abrupt withdrawal. The daily dose range of propranolol was 2.4 to 4.4 mg/kg. Mean steady-state plasma propranolol concentrations, 16.5 to 114 ng/ml, were linearly related to dose (r = 0.93; p < 0.02) above a threshold dose of 1.8 mg/kg/day. There was excellent correlation (r = 0.96; p = 0.01) between concentrations and reduction in heart rate (delta HR, 14 to 27.5 beats/min), which also suggested a maximum heart rate response at plasma propranolol concentrations of 80 to 100 ng/ml. There was an inverse relationship between the plasma concentrations of 4-hydroxypropranolol and dose. On abrupt withdrawal of long-term propranolol therapy, plasma levels declined with a propranolol half-life (t1/2) of 3.9 to 6.4 hr, which correlated with the hemoglobin value. The 4-hydroxypropranolol t1/2 was 5.2 to 7.5 hr. Heart rates returned to normal after approximately 36 hr. Changes in blood pressure were minimal.

Orthoterminally corrective operation in the presence of severe hypoplasia of a pulmonary artery.

Hypoplasia of the pulmonary arteries has been cited as a contraindication to right vertricular bypass operations. We have successfully corrected a lesion in which the left pulmonary artery was severely hypoplastic and have documented a good hemodynamic result postoperatively. Size of pulmonary arteries is less important than pulmonary vascular resistance as a criterion for orthoterminal correction.

Tetralogy of Fallot associated with complete atrioventricular canal.

A 6-year-old girl had the clinical appearance of tetralogy of Fallot but was found at cardiac catheterization to have tetralogy of Fallot associated with complete atrioventricular canal. She underwent repair, and at recatherterization two years later, the hemodynamic result was excellent. Proper angiography is necessary to diagnose this combination, and correct preoperative diagnosis is necessary to plan a rational operative approach.

Blood pressure, heart rate, pressure-rate product and electrocardiographic changes in healthy children during treadmill exercise.

Heart rate, systolic and diastolic blood pressure, rate-pressure product and electrocardiographic changes were measured in 288 healthy children during treadmill exercise. A constant speed (3.5 miles/hour) protocol was used to facilitate the measurements of physiologic data during exercise. Because responses to exercise vary with size, the children were separated into four groups according to body surface area. Comparisons were also made between male and female and between black and white children. The values for heart rate and systolic pressure showed excellent reproducibility in repeated tests. These data establish for clinical use reference values for children during treadmill exercise.

Cardiac valve replacement in children: comparison of tissue with mechanical prostheses.

Replacement of cardiac valves in children has been associated with high rates of mortality and morbidity in the past. We have compared 24 children from 2 to 18 years of age who have received mechanical valves with 24 children who have received porcine valves. The groups were similar except that (1) there were more mitral operations in the mechanical valve group and more aortic operations in the porcine valve group; (2) more porcine than mechanical valves were implanted in recent years; and (3) the porcine valve group comprised more young patients under 8 years and required more complex operations. Early and late mortality rates were higher in the mechanical than in the porcine valve group. Major late complications were seen in 50 percent of the mechanical valve group and 13 percent of the porcine group. Implantation of an adult-sized aortic valve was made possible in all patients by the use of aortic augmentation annuloplasty. Higher operative mortality rates in the mechanical valve group may have been related more to technique of myocardial preservation during operation than to type of valve. Although differing rates of late morbidity and mortality may also have been related to myocardial preservation and other technical factors, the type of valve used seemed to be an important determinant of the better results in the porcine group. Despite unknown durability of the porcine valve, our data suggest that the safest prosthetic valve to use in children at this time is the glutaraldehyde-fixed porcine prosthesis.