An assessment of Mustard's operation as a palliative procedure for transposition of the great vessels.

Ten patients in whom palliative Mustard operations have been performed for transposition of the great vessels with ventricular septal defect and elevated pulmonary vascular resistance are reported. There has been early or late mortality in this group of patients, and postoperative morbidity has been minimal. Five of them have been recatheterized, and the results indicate substantial improvement in postoperative arterial oxygen saturation with change in pulmonary vascular resistance. The operation is reserved for those patients in whom peripheral desaturation is the major cause of symptomatology. Clinical improvement has been gratifying, and the continued use of the operation in selected patients seen indicated.

Ionization collection efficiencies of some ionization chambers in pulsed and continuous radiation beams.

The most commonly used method of calibrating high-energy photon or electron beams consists in converting cavity ionization to dose by the application of the appropriate Clambda or CE multipled by the 60Co correction factor. The correct interpretation of calibration data for pulsed photon or electron beams requires a knowledge of the charge collection efficiencies of the ionization chambers used. The results are presented of efficiency measurements for both pulsed and continuous beams made with these chambers: 0.6-cm3 Farmer, 0.5-cm3 Spokas, 3-cm3 Shonka, 1-cm3 PTW, and 1-cm3 Memorial pancake. The dependence of collection efficiency on collection voltage, dose rate, and dose per pulse is demonstrated. These results are shown to agree with Boag's formulas for collection efficiency. Attention is drawn to the fact that several kinds of dosimeters provide only minimal collection voltages for efficient collection of charge at high dose rates, especially in Linac electron beams. It is recommended to check the collection efficiency of chambers which are to be used at high dose rates, and a simple method for this purpose is described.

Treatment planning for prostate implant with loose seeds.

A new method of treatment planning for the I-125 and Pd-103 permanent interstitial prostate implant is developed, which does not use the traditional nomograms but automatically generates optimized source configurations. An iterative algorithm is used that places one seed at a step. The volume dose of target is calculated at each step to determine the coldest spot where the next source is to be placed, so that the dose uniformity of target is best improved as source placement proceeds. At each step, the total activity required for the seed configuration as so established is calculated by normalizing the minimal dose to the prescribed dose. An optimized configuration is the one that takes the minimized total activity. Around its minimum the total activity has a very small variation with the number of seeds. Consequently multiple clinically acceptable seed configurations with similar total activity but different individual activities are generated simultaneously. In our computer generated treatment plans most of the seeds are distributed in the periphery of the target, similar to the Paterson-Parker pattern of a volume implant.

Measurements of diagnostic x-ray backscatter by a novel ion chamber method.

There is a major gap in backscatter information for diagnostic x-ray beams. Such information is increasingly needed for dose measurements and calculations, as well as for designing devices and techniques. We have therefore carried out measurements on both low Z materials and metals, using an ion chamber method designed specifically for the purpose. Lucite and two D.R. White tissue substitutes were studied extensively (BR 12 "average breast" and MS 11 "water"). Measured percent backscatter (BS) was greatest for Lucite and least for MS 11, with BR 12 in between. Backscatter buildup is rapid: 50% of full backscatter is achieved with 6 mm thickness for all three materials using mammographic beams and with about 12 mm using general diagnostic beams. A simple relationship between BS and field area permits close estimates of BS values for fields for which measured data is not available. Among metals tested, copper exhibited greatest backscatter (39% BS maximum), aluminum least, and lead in between--information of potential importance in cassette design and similar applications.

Comparison of ion chamber and TLD dosimetry in mammography.

An ionization chamber method has been developed to measure exposure vs depth in a uniform BR 12 "average breast" phantom. It employs a Memorial mammography chamber for exit exposure measurements; resulting data is then corrected for backscatter as well as for the exceptionally thin window of this chamber. A careful comparison has then been made with relative exposure vs depth curves obtained using TLD at several mammography beam qualities, for identical exposure factors and SSD values. Use of a correction for residual and background TL signals significantly improved agreement between TLD and ion chamber curves in the 28 to 35 kVp/0.03 mm Mo range of beam quality. Agreement was within +/- 5% for the Mo target tube, but TLD readings were 4%--8% higher than ion chamber values for the W/Mo target tube. At Xeromammography energies (45 kVp/1.6 mm Al), corrected TLD curve readings were 6% higher at depth than ion chamber curve values. TLD meaurements with 28 to 35 kVp/0.03 mm Mo beams tend to underestimate dosage to the midbreast parenchyma. For example, in a 5 cm "average breast", the underestimation ranges from 2%--10% for corrected, 10%--16% for uncorrected TLD readings.

Pacemaker therapy in children with complete heart block.

Permanent pacemaker therapy in children with complete heart block is necessary occasionally. Ten patients ranging in age from 8 months to 15 years were treated with an implanted P-wave, synchronous epicardial pacemaker. Indications for implantation were persisting postsurgical heart block, congestive failure, syncopal attacks, and arrhythmias. There were two deaths not attributed to pacemaker malfunction. The remaining eight children have been followed up for 38 to 108 months. There have been 27 pulse generator replacements. Twenty-three were for battery exhaustion, three for electromechanical failure, and one was due to arrhythmia. Rhythm disturbances have occurred on eight occasions. There have been no infections. It is concluded that the implanted P-wave synchronous pacemaker is an effective method of therapy when indicated for children with complete heart block.

A study of mammographic exposure and detail visibility using three systems: Xerox 125, Min-R, and Xonics XERG.

A breast phantom of novel design has been used to measure visibility of simulated calcific and soft-tissue fibrillar details in mammography, as well as to determine the roentgen exposure vs. depth. Exposure data were combined with a model of the breast as compressed during mammography to compute the mean exposure to the ductal parenchyma (MDE). Three different imaging systems were compared over a wide range of x-ray beam energies and breast characteristics. "Dosage" criteria other than the MDE are discussed.

The fontan procedure for tricuspid atresia.

A modified Fontan operation was performed on nine patients, ages 8--24 years (mean 14 years), with tricuspid atresia. The right atrium and right ventricle were connected with a valved conduit in five patients and directly in four. A porcine inferior vena caval valve was used in two patients. Prior operations had been performed in eight patients. There were no surgical deaths. Complications included pleural effusions, low-output syndrome, renal failure and atrioventricular block. There were two late deaths, only one of which was of cardiac origin. One patients required reoperation because of residual atrial septal defect at 1 month and again at 56 months for conduit stenosis. One patient required a pacemaker. Follow-up extends 6--65 months (mean 34 months). Survivors are clinically well and active, although four are taking medications. Postoperative cardiac catheterizations were done in six patients. Right atrial pressures were elevated in each, with no gradients across the conduit or pulmonary valve except in the one patient with conduit obstruction. Three patients had small residual ventricular septal defects and one a residual Blalock anastomosis. The Fontan procedure is an effective operation for tricuspid atresia. It may be further modified by establishing direct continuity between right atrium and right ventricle without a valve conduit in patients with a functioning pulmonary valve. The long-term ability of the right atrium to maintain adequate pulmonary flow and the effects of chronically elevated right atrial pressure on hepatic function and the cardiac conduction system must still be examined.

Long-term results of the Mustard procedure.

Over a 10-year period, 123 patients with transposition of the great vessels underwent the Mustard procedure. The hospital mortality for the series was 10.6%. There were seven late deaths, five of which were presumable due to arrhythmia. Sinus rhythm was noted postoperatively in 53% of the patients. Almost all the survivors had achieved catch-up growth when evaluated 6 months to 10 years later. A growth spurt was more consistently seen in the patients who were operated on under 2 years of age. Physical endurance and school performance were on a par with their normal peers or better in about half of the survivors. Severe neurologic problems were present in five patients. Postoperative catheterizations in 42 patients showed a rather high incidence of residual interatrial shunts, mild left ventricular outflow obstruction, and mild superior vena caval obstruction. Pulmonary venous obstruction and serious tricuspid regurgitation were not encountered.