Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation.

From 1957 to 1984 direct and indirect isthmoplasty as described by Vossschulte has been the method of choice for surgical therapy of coarctation of the aorta in our hospital. A total of 317 patients have been so treated, 54 of whom were less than 12 months old at operation. The hospital mortality in this group was 15% and the mortality in patients older than 1 year was 3%. The early results were encouraging, but during follow-up an increasing number of postoperative aneurysms have been detected. During reinvestigation an aneurysm was diagnosed in 18 cases. Therefore, we have studied the cause of these aneurysms. To this point reoperation has been performed in 15 patients having late aneurysms. Extensive resection of a fibrous membrane of the aortic isthmus at the first intervention seems to be an essential predisposing factor for development of aneurysms. Microscopic examination of the aneurysmal wall revealed degeneration of the media in more than half of the patients. From our experience we conclude that the posterior fibrous ridge should no longer be excised and the Vossschulte operative technique should be viewed more critically.

[Systolic time intervals. 1st communication: normal values from children without heart diseases].

The concept of "systolic time intervals" was introduced into noninvasive cardiologic examination by Weissler et al.; in detail these are the following data: the total electromechanical systole = QS2, the left ventricular ejection time = LVET, the preejection period = PEP and the quotient PEP/LVET. These quantities are not in principle new parameters; in the German literature the QS2 is known as "Systolendauer", the LVET is identical to the "Austreibungszeit" and the PEP is identical to the "Anspannungszeit". The determination of PEP (= QS2-LVET) is preferable to the usual calculation of the "Anspannungszeit" nach Blumberger in so far as longer time intervals must be measured and therefore the statistical error decreases. From 96 children between 3 and 15 years polygraphic tracings were recorded and the STI were calculated and standard values were ascertained and were evaluated statistically. QS2 and LVET grow longer linearly with increasing age (p less than or equal to 0.001) and diminish linearly with increasing heart rate (p less than or equal to 0.001). For PEP only the inverse correlation with the heart rate was significant. PEP/LVET does not very significantly. Girls have longer PEP (+ 6 msec, p less than or equal to 0.01) and higher PEP/LVET (+ 0.04, p less than or equal to 0.001) than boys. The normal range of variation of the STI is relatively large (QS2: 278-386 msec, LVET: 200-285 MSEC, PEP: 65-114 msec, PEP/LVET: 0.27-0.47). For the examination of individual cases it is better to compare them with the standard values ascertained by the regression equations (table 3+4).

[The chest X-ray in children with pulmonic stenosis and intact ventricular septum (author's transl)]. / Das Nativröntgenbild der Pulmonalstenose mit intaktem Ventrikelseptum im Kindesalter.

Of 89 children with angiographically-documented pulmonic stenosis and intact ventricular septum (PST), 76 (85.4%) had valvular, 11 (12.4%) infundibular and 2 (2%) had supravalvular lesions. Standard, p. a. view, chest X-rays of children with a mean age of 6 7/12 years were evaluated with respect to 1. cardiac enlargement; 2. prominence of the pulmonic trunk; 3. diminished pulmonary vascular markings. The patients were divided into 3 groups according to the gradient measured across the pulmonic valve: Group 1: systolic pressure gradient less than 30 mm Hg (mild PST), 28 children; group 2: systolic pressure gradient between 30 and 80 mm Hg (moderate PST), 37 children; group 3: systolic pressure gradient greater than 80 mm Hg (severe PST), 24 children. Cardiac enlargement was found in a total of 56.2% of the children with no statistical difference in the severity of the lesion. A markedly ectatic pulmonary segment was observed in 12.5% of the children in group 3 but only in 2.7% of those in groups 1 and 2 respectively. Diminished pulmonary vascular markings were observed in a total of 9% with a distribution including no patient in group 1, 10.8% in group 2 and 16.6% in group 3. On combining all three of the radiologic criteria, 9% demonstrated completely normal findings of the heart and lungs, 5.6% showed cardiac enlargement with marked prominence of the pulmonic trunk and diminished pulmonary vascular markings. In the remaining patients, no statistically significant relationship between the constellation of findings and the severity of the stenosis was found. Thus, the results show that, in the individual case, the diagnosis of pulmonic stenosis with intact ventricular septum cannot be established from the standard chest X-ray.

[Pulmonary insufficiency in childhood. Contribution to diastolic murmurs (author's transl)]. / Pulmonalinsuffizienz im Kindesalter. Ein Beitrag zur Frage des diastolischen Geräusches.

Diastolic murmurs in childhood are in most cases due to pulmonary insufficiency. They may be functional (Graham-Steel-murmurs, for instance with idiopathic pulmonary ectasis or pulmonary hypertension), but are more and more the symptom of postoperative pulmonary insufficiency. Diastolic murmurs of pulmonary insufficiency were found after operations of valvular and infundibular pulmonary stenosis in 92,5% of the cases (40 children) and after total correction of tetralogy of Fallot in 89% of 27 children. The diastolic murmur of pulmonary insufficiency is very good recorded in phonocardiography; with postoperative heart catheterisations and angiocardiography there is good estimation of the degree of the pulmonary insufficiency. There is no doubt about the curative effort of operations in these congenital heart defects, and postoperative pulmonary insufficiency does not impair the operative improvement in childhood. Till now long term observations of these cases up to late adulthood cannot be possible; regular pediatric cardiologic examinations of these operated children are mandatory.

[The determination of heart minute volumes and systolic time intervals using echo- and Doppler echocardiography in severely ill premature infants]. / Zur Bestimmung von Herzminutenvolumina und systolischen Zeitintervallen mittels Echo- und Dopplerechokardiographie bei schwerkranken Frühgeborenen.

The here represented echo- and doppler-echocardiographic measurements of critically ill preterm infants demonstrate the possibility to watch closely to hemodynamic changes due to new treatments of these patients, thus to gather more information than with the usual monitoring of a neonatal intensive care unit. Using systolic time intervals and cardiac output, measured in the ascending aorta and the pulmonary truncus by echo- and doppler echocardiography, gives more ease and accuracy in actual therapeutic decisions. This is demonstrated with the use of dopamine, prostaglandin E1 and indomethacin.

[Cardiologic findings in incidental heart sounds in childhood]. / Kardiologische Befunde bei akzidentellen Herzgeräushcen im Kindesalter.

In a random sample of patients examined in the outpatient department of pediatric cardiology in Giessen, an innocent heart murmur was found in 1009 children. Results and methods of cardiological examination relevant to the practitioner were established by evaluating the individual diagnostic criteria. An anamnesis without any reference to heart disease is of special significance for the diagnosis of an innocent heart murmur. Another important factor is the experience of the examining doctor. Innocent murmurs are systolic and frequently of "musical quality", their intensity ranges from grade 1/6 to grade 3/6 (95.5%) and is greatest when the patient is supine (76%). Phonocardiography and the Amylnitrit-Test can give important hints. The electrocardiogram should be inconspicuous in terms of age. X-Ray and echocardiogram should be normal, but are not always necessary. Several examinations may be required to established a clear diagnosis. A diagnosis of an innocent heart murmur in children is possible in the practitioner's office, provided the doctor is familiar with the above mentioned criteria.

[Non-rheumatic carditis. A diagnostic study in a period of 11 years (author's transl)]. / Nichtrheumatische Karditis im Kindesalter. Eine diagnostische Studie über einen Zeitraum von 11 Jahren.

23 paediatric cases of non-rheumatic carditis seen in the period between 1965 and 1976 are reviewed. Neonatal carditis is very letal, but the prognosis improves with increasing age. Males and females are equally affected. There is a rise in frequency since 1971. 9 of the 23 cases ended letally. In further 9 cases congenital heart lesions occurred simultaneously, 3 of which were ventricle septal defects. The most important diagnostic feature is the cardiac enlargement (94% of our cases). Other important signs and symptoms are dyspnoea at rest tachycardia and fever. The ECG changes (89%) are non-specific. Very often, it is not possible to classify the disease into endo-, myo- or pericarditis; the term "carditis" is, therefore, preferred. Virological and bacteriological findings were found in only 35% of the cases.

["Left anterior hemiblock" or "extreme left axis deviation" in the ECG of children]. / "Linksanteriorer Hemiblock" oder "überdrehter Linkstyp" im EKG des Kindes.

A comprehensive study involving the use of ECG's from children at the Giessen University Children's Hospital was conducted with the specific intent of identifying all children with an extreme left-axis deviation. This study showed that, in a time period of five years, 212 out of 3618 children examined electrocardiographically had an extreme left-axis deviation according to very strict criteria, their ECG-types could be divided into three groups: 1. without heart defects, 2. with congenital heart anomalies, 3. after surgery for congenital heart problems. Measurement of the QRS-complex in eighty children without heart defect showed that fifty-nine of the children (73.8%) had a vector -QRS between -30 degrees to -90 degrees. Ih the 88 children with congenital heart defects, and in 20 with an extreme left-axis deviation previous to surgery, an angle of -60 degrees to -90 degrees was found, most often in children with complete A-V canals of Down's Syndrome (as well as in children with transposition of the great arteries, univentricular heart or other complicated malformations of the heart). And finally, an extreme left axis deviation was very often found after surgery to correct Tetralogy of Fallot, ventricular defect, or endocardial cushion defect. Since an extreme left-axis deviation often occurs in children without heart defects, we would like to suggest that the term "Left anterior Hemiblock" be reserved for cases where there is certainty that damage to the conduction system has occurred. In all other cases, we prefer the term "left-axis deviation" as a more appropriate because an anomaly in the conduction system is more likely than a "block" i.e. an interruption of the conduction of electrical impulses through the heart muscle.

[Left anterior hemiblock (left axis deviation) in the ECG of children before and after heart surgery]. / Linksanteriorer Hemiblock (überdrehter Linkstyp) in EKG bei Kindern vor und nach Herzoperationen.

In this study 18 248 ECG's were reviewed. In 212 children were found an extreme left axis deviation (or left anterior hemiblock) in ECG. In 44 (or 21%) exists an extreme left axis deviation before or after operation on congenital heart malformations. In 24 children this pathological deviation of the heart axis first appeared post-surgically. After critical analysis, however, it became apparent that it was factually correct to speak of a left anterior hemi-block in only 10 cases. This terminology was especially encountered after repair of ventricle-septal defects and total corrections of Tetralogy of Fallot, if at the same time a right bundle branch block existed in the sense of a bifascicular block. Some cases are especially difficult to judge; namely those in which on the basis of the heart defect itself, an extreme left axis deviation is likely to exist before surgery, as for example in endocardial cushion defects. Also, it is possible that an extreme left axis deviation could be reversed in the normal QRS-angle after operation.

[Problems in pacemaker therapy in childhood (author's transl)]. / Probleme bei der Herzschrittmacher-Behandlung im Kindesalter.

Over a period of 10 years, 16 children, aged 1.8 to 13 years underwent implantation of a cardiac pacemaker. The most common indication, in 11 cases, was a complete post-operative heart blockage. Two children died without it being able to be ascertained whether the pacemaker had in fact failed. There was a return of sinus rhythm in the case of 4 children. Pacemaker therapy over a period of 56 patient years produced 19 cases with such severe complications that renewed surgical treatment was necessary.