Early and late results in pulmonary atresia and intact ventricular septum.

We examined the early and late results of operations in 29 consecutive neonates with pulmonary atresia and intact ventricular septum treated from 1980 to 1988. Transventricular pulmonary valvotomy and central aorta-pulmonary artery shunting were performed in 19 of 22 infants who had a patent infundibulum. Pulmonary valvotomy alone was performed in 3 of the 22 infants with a patent infundibulum, but 2 of these required subsequent systemic-pulmonary artery shunts. Primary shunting was used to palliate 7 infants who had absent infundibular portions of the right ventricle and a very diminutive right ventricular cavity. Tricuspid valve excision and atrial septectomy were also performed in 5 of these 7 infants to decompress large fistulous communications between the right ventricule and coronary artery. Two early deaths (2/29, 6.9%) occurred overall. Both were in infants who had a very small right ventricle. Definitive operation has been accomplished in 16 patients; 13 have had closure of residual interatrial communications and shunt ligation with no deaths, and 3 have undergone modified Fontan repair with 1 death. Actuarial survival rate for the entire group, including operative deaths, is 86% at 5 years. The technique of transventricular pulmonary valvotomy and systemic-pulmonary artery shunting offers a reliable means of palliating neonates with pulmonary atresia and intact ventricular septum and obtains good late right ventricular growth. Systemic-pulmonary shunting, tricuspid valvectomy, and atrial septectomy may offer a means of reducing or obliterating right ventricular-coronary artery fistulas.

The use of extracorporeal rewarming in a child submerged for 66 minutes.

A 2 1/2-year-old girl had a good neurologic recovery after submersion in cold water for at least 66 minutes; as far as we know, this is the longest time ever reported. Cardiopulmonary resuscitation was maintained for more than two hours before the initiation of extracorporeal rewarming in this child who had a core temperature of 19 degrees C. To our knowledge, this is the first successful use of extracorporeal rewarming in a child suffering from accidental hypothermia. Extension of this technique to children offers rapid rewarming and cardiovascular support for pediatric victims of severe hypothermia. We emphasize the importance of a coordinated response by the entire emergency medical system integrated with hospital-based personnel. Where it is geographically feasible, regionalization of triage and care for the pediatric victim of severe accidental hypothermia should be considered.