Day-case diagnostic and interventional peripheral angiography: 10-year experience in a radiology specialist nurse-led unit.

We describe a prospective evaluation of the safety of peripheral angiography procedures performed on day-case patients in a dedicated radiological nurse-led and administrated unit. Patients referred for peripheral vascular angiography, over a 10-year period, were pre-assessed by a radiology specialist nurse in a nurse-led clinic. Radiologists performed all procedures, whereas radiology specialist nurses were responsible for patient care before, during and after angiography and during the 24 h follow-up. Procedures were divided into diagnostic or interventional; complications were divided into immediate or delayed (24 h follow-up) either requiring hospital admission (major) or day-case unit management (minor). Patient acceptability was assessed using a standard questionnaire. Cost analysis was also performed. 401 day-case peripheral angiography procedures (144 diagnostic and 257 interventional) were performed in 310 patients. 109/401 (27.2%) procedures were performed on patients with diabetes mellitus. In diagnostic studies, 16/144 (11.1%) immediate and 6/144 (4.2%) delayed complications occurred whereas, in interventional studies, 65/257 (25.3%) immediate and 13/257 (5.1%) delayed complications were noted. A major complication occurred in 17/257 (6.6%) of patients in the interventional group and 3/144 (2.1%) in the diagnostic group. Puncture site haematoma was the most common complication. Nurse-led care was acceptable to the patient, with a high level of patient satisfaction seen. In conclusion, day-case diagnostic and interventional peripheral angiography procedures can be performed safely in a specialist nurse-led and administrated unit, with complication rates being within the accepted guidelines.

Anomalous origin of the right coronary artery from the pulmonary artery and mitral regurgitation in a newborn.

Anomalous origin of the right coronary artery (RCA) from the pulmonary artery (PA) is a rare congenital anomaly, and only 28 cases have been reported in the pediatric age group. We describe the case of an infant who had progressive mitral regurgitation and papillary muscle dysfunction in association with anomalous origin of the RCA from the PA. The diagnosis was made by color flow Doppler, confirmed by angiography, and the case was successfully corrected by reimplantation of the anomalous RCA to the aorta. This is only the second case of anomalous origin of the RCA from the PA diagnosed in infancy without an associated congenital anomaly of the heart and great vessels.

Congenital Heart Surgery Nomenclature and Database Project: double outlet right ventricle.

Double outlet right ventricle (DORV) is a type of ventriculoarterial connection in which both great vessels arise entirely or predominantly from the right ventricle. Although the presence of aortic-mitral discontinuity and bilateral coni are important descriptors, they should not serve as absolute prerequisites for the diagnosis of DORV. The morphology of DORV is encompassed by a careful description of the ventricular septal defect (VSD) with its relationship to the semilunar valves, the great artery relationships to each other, the coronary artery anatomy, the presence or absence of pulmonary outflow tract obstruction (POTO) and aortic outflow tract obstruction (AOTO), the tricuspid-pulmonary annular distance, and the presence or absence of associated cardiac lesions. The preferred surgical treatment involves the connection of the left ventricle to the systemic circulation by an intraventricular tunnel repair connecting the VSD to the systemic semilunar valve. This ideal surgical therapy is not always possible due to the presence of confounding anatomical barriers. A multitude of alternative surgical procedures has been devised to accommodate these more complex situations. A framework for the development of the DORV module for a pediatric cardiac surgical database is proposed.

Congenital Heart Surgery Nomenclature and Database Project: double outlet left ventricle.

Double outlet left ventricle (DOLV) is a type of ventriculoarterial connection in which both great arteries arise entirely or predominantly from the left ventricle. Although it was initially believed that bilateral absence of conus is a prerequisite for such diagnosis, all possible conal configurations have been described in this malformation. The morphology of DOLV is encompassed by a careful description of the ventricular septal defect (VSD) with its relationship to the semilunar valves, the presence or absence of pulmonary outflow tract obstruction (POTO) and aortic outflow tract obstruction (AOTO), and the presence or absence of associated cardiac lesions. The preferred surgical treatment involves the connection of the right ventricle to the pulmonary circulation by an intraventricular tunnel repair connecting the VSD to the pulmonary semilunar valve. This ideal surgical therapy is not always possible, because of the presence of confounding anatomical barriers. Several alternative surgical procedures have been devised to accommodate these more complex situations. A framework for the development of the DOLV module of a pediatric cardiac surgical database is proposed.

Risk factors for failure of aortic valvuloplasty in aortic insufficiency with ventricular septal defect.

BACKGROUND: Aortic insufficiency (AI) associated with ventricular septal defect (VSD) is often repaired using a modification of Trusler's aortic valvuloplasty technique. The purpose of this study was to identify the risk factors for failure of aortic valve (AV) repair in patients who underwent repair of associated VSD. METHODS: A univariate analysis was performed in this retrospective study to identify the possible risk factors for failure of the repair resulting in the need for AV replacement (AVR). RESULTS: The study included 24 patients, 15 (62%) boys and 9 (38%) girls, with a mean age of 9.1 +/- 1.2 (SEM) years. The VSD was perimembranous in 15 (62%) and subarterial in 9 (38%). The prolapsed aortic cusp was the right in 13 (54%), the noncoronary in 6 (25%), and both in 5 (21%). Plication was performed at one end of the free edge of the prolapsed cusp(s) in 12 (50%) and at more than one end in 12 (50%) of the patients. The VSD was closed by use of a patch in 21 (88%) and by direct suture closure in 3 (12%). At the mean follow up of 7.3 +/- 1.3 years, the degree of AI was none in 6 (25%), trivial in 5 (21%), mild in 9 (38%), moderate in 1 (4%), and severe in 3 (12%). The 15-year actuarial freedom from reoperation was 81% +/- 19% (95% confidence limit). By univariate analysis, the possible risk factors for AV repair failure were the degree of AI at hospital discharge (p = 0.004), direct closure of the VSD (p = 0.061), smaller size of the VSD (p = 0.081), and plication of more than one end of the prolapsed cusp(s) (p = 0.095). CONCLUSIONS: Trusler's AV repair is an effective and durable technique for the surgical treatment of patients with VSD-AI syndrome. The adequacy of the initial repair is the most important determinant of the long-term results.

Aortic root dilation after the Ross procedure.

This study evaluated changes in neoaortic root geometry in patients who underwent the Ross procedure. Serial postoperative echocardiographic measurements of the neoaortic root indexed to the square root of body surface area (centimeters divided by meters) were obtained from 30 patients (age range 3.1 to 31.4 years) and compared with paired preoperative and immediate postoperative values. Normal aortic root diameter Z scores were derived from root dimensions obtained from 217 healthy controls. Compared with preoperative values, an immediate stretch of the neoaortic versus pulmonary root (annulus and sinuses of valsalva) was observed at a mean follow-up period of 1 week. Additional aortic annular dilation from baseline prehospital discharge values was observed at 2 to 12 months (baseline vs follow-up annulus Z score: 1.4 vs 2.6, p <0.01, n = 16) and at 16 to 33 months follow-up (0.8 vs 2.0, p <0.05, n = 12). In a similar fashion, there was additional enlargement of the aortic sinus from its stretched state at hospital discharge at 2 to 12 months (baseline vs follow-up sinus Z score: 2.0 vs 3.3, p <0.01, n = 17) and at 16 to 33 months (1.7 vs 3.0, p <0.01, n = 13). There were no differences in root size between 2 to 12 and 16 to 33 months after surgery. There was a decrease in left ventricular size with no alteration in blood pressure or degree of aortic valve regurgitation. Thus, aortic root dilation occurs up to the first year after the Ross procedure but does not appear to progress beyond this time.

Technical report: Combined carotid bifurcation endarterectomy and intra-operative transluminal angioplasty of a proximal common carotid artery stenosis: an alternative to extrathoracic bypass.

A method of management of a dual stenoses affecting the proximal common carotid artery and the internal carotid artery, the tandem lesion, is described in two cases. The combination of a surgical endarterectomy of the internal carotid artery narrowing and percutaneous balloon dilatation of the more proximal common carotid artery narrowing, via the arteriotomy site, with clamping of the internal carotid artery was successfully employed to avoid an extrathoracic bypass procedure.

Arch growth after staged repair of interrupted aortic arch using carotid artery interposition.

BACKGROUND: Between 1980 and 1990, our practice was to perform carotid artery interposition as part of a staged repair of interrupted aortic arch with various associated cardiac defects. METHODS: This procedure was used in 16 patients with IAA type B. The median age at operation was 4.5 days and the median weight, 3.2 kg. Ten of the patients had an associated ventricular septal defect. Six more had complex anatomy. There were two death at carotid interposition, two interim deaths, and two deaths after intracardiac repair. Preoperative echocardiographic and angiographic studies were compared with postoperative studies in 11 survivors of arch repair to assess sequential growth of the interposed carotid artery. Measurements of the carotid artery were normalized to the descending aorta. RESULTS: Preoperatively, the left carotid artery had a median diameter of 3.7 mm and was 42.9% of the descending aortic diameter. Postoperative studies performed at a median age of 5.7 months disclosed that the interposed carotid artery had grown to a median diameter of 7.0 mm and was 69.6% of the diameter of the descending aorta (normal > or = 81%). On follow-up at a median time of 4 years, 6 of 9 patients have no gradient by blood pressure measurements or echocardiographic Doppler studies, and 3 have modest gradients. No patient has required revision of the arch repair. CONCLUSIONS: Survival is good after carotid artery interposition for interrupted aortic arch and growth of the carotid artery approaches that of a normal arch. Carotid artery interposition is a viable alternative for repair of this lesion should primary definitive repair not be feasible.

MnDPDP-enhanced MR imaging of the liver. Correlation with surgical findings.

PURPOSE: To compare lesion detection and characterisation predicted by MnDPDP-enhanced MR imaging with surgical excision and pathological examination. MATERIAL AND METHODS: Ninety patients were intravenously infused at a rate of 2 to 3 ml/min with 5 mumol/kg mangafodipir trisodium (MnDPDP, Teslascan). The patients were examined with spin-echo and gradient-echo T1-weighted MR imaging at 1 h and 24 h after the end of infusion. The results were compared with identical pre-contrast sequences. In 20 of these patients, the pre-operative MR findings were compared with intra-operative ultrasonography and histology of the resected liver specimens. RESULTS: In those with liver metastases, there was a good correlation between MR and the hepatic disease in 11 out of 14 cases. In the group with primary liver tumours, MR findings correlated with hepatic disease in 5 out of 6 cases. CONCLUSION: Liver lesion characterisation is possible with MnDPDP, and MR contrast enhancement with this agent is considered to be an important adjunct to the radiological assessment of patients with neoplastic liver disease where accurate decisions for surgical planning are imperative.

The Ross procedure in children and young adults with congenital aortic valve disease.

METHODS: Thirty-three children and young adults with congenital aortic valve disease underwent pulmonary autograft replacement of the aortic valve between October 1993 and March 1997. There wer six females and 27 males; at operation, median age was 16 years (range: 3 to 41 years) and median body weight 60 kg (range: 14 to 121 kg). Fifteen patients (46%) had undergone one or more previous cardiac surgical procedures. A bicuspid aortic valve was present in 31 patients (94%); moderate to severe aortic stenosis and regurgitation was present in 10 (30%) and 26 (79%), respectively. RESULTS: All patients underwent the Ross procedure while in NYHA class I (64%) or class II (36%). A preoperative shortening fraction of 41 +/- 1.4% suggested well-preserved systolic function, but the mean left ventricular end-diastolic pressure of 16.6 +/- 1.3 mmHg was consistent with preoperative left ventricular pressure and volume overload. The aortic root was replaced using an interrupted suture technique in two patients and with three separate running sutures in 31. The right ventricular outflow tract was reconstructed in all classes with a cryopreserved pulmonary homograft valved conduit (median diameter 23 mm; range 19 to 30 mm). Intraoperative complications included transient atrioventricular dissociation (one), permanent atrioventricular dissociation (one), and left coronary artery distortion relieved by shortening the distal ascending aorta (one). Postoperatively, postpericardiotomy syndrome developed in six patients (18%), supraventricular tachycardia in three (9%), and ventricular tachycardia in one (3%). At three days after surgery, one patient developed ischemic left ventricular dysfunction requiring repositioning of the distorted left coronary artery higher on the neo-aortic root. Hospital survival rate was 100%. During a median follow-up of 17 months (range: 1 to 41 months) one patient suffered a non-cardiac death due to blunt trauma. there has been a significant postoperative improvement in NYHA class among surviving patients (class I, 94%; class II, 6%; p = 0.004 versus preoperative). Postoperative aortic regurgitation was absent or trivial in 17 (60%) and mild in the remaining 11 (40%) patients for whom follow-up echocardiographic data are available. One patient required reoperation 16.5 months after the Ross procedure to replace a rapidly degenerating pulmonary homograft, and one with moderately severe homograft stenosis and five with mild homograft stenosis are being monitored. Postoperatively, a gradual early expansion in the diameter of the neo-aortic root and reduction in echocardiographic indices of left ventricular hypertrophy and dilatation occurred. CONCLUSIONS: Pulmonary autograft replacement of the aortic valve in young patients with congenital aortic valve disease has produced excellent short-term anatomic/physiologic results and symptomatic relief with no mortality. Indices of left ventricular dilatation and hypertrophy regress after repair when the Ross operation precedes important deterioration in preoperative ventricular function. Important technical considerations include: (i) the native distal ascending aorta should be sufficiently shortened before performing the distal aortic anastomosis; and (ii) the left coronary anastomosis should be positioned relatively high on the neo-aortic root with a slight amount of tension. Both of these maneuvers reduce the likelihood of coronary artery distortion. Rapid degeneration of the pulmonary homograft and the propensity towards progressive dilatation of the neo-aorta are important postoperative considerations. Until more is known about the etiology and natural history of these two potential complications, postoperative anti-inflammatory and/or immunosuppressive therapy and strict control of hypertension should be strongly considered.

Coil occlusion versus conventional surgical closure of patent ductus arteriosus.

This retrospective cohort study evaluated the clinical outcome and cost-effectiveness of 2 treatment strategies for children with an isolated restrictive patent ductus arteriosus. Results indicate a superior cost-effectiveness of transcatheter coil occlusion compared with conventional surgery for these patients.

Cardiac pacemaker dysfunction in children after thoracic drainage catheter manipulation.

Two children underwent placement of permanent, epicardial-lead, dual-chamber, unipolar pacemaker systems for complete heart block. Postoperatively, both patients demonstrated subcutaneous emphysema-in the area of their pulse generators-temporally related to thoracic catheter manipulation. Acutely, each situation was managed with manual compression of the pulse generator, ascertaining appropriate pacemaker sensing and pacing. Maintenance of compression with pressure dressings, vigilant observation/monitoring, and education of the care givers resulted in satisfactory pacemaker function without invasive intervention.

Bidirectional cavopulmonary anastomosis with intracardiac repair.

BACKGROUND: Patients with hypoplasia of the right ventricle and tricuspid valve have historically undergone a total cavopulmonary connection or a two-ventricle repair with atrial fenestration. METHODS: We reviewed our experience with 9 patients with hypoplasia of the right ventricle and tricuspid valve who underwent a bidirectional cavopulmonary anastomosis with intracardiac repair. Patient diagnoses included pulmonary atresia with intact ventricular septum (n = 3); hypoplastic right ventricle and tricuspid valve with atrial septal defect, ventricular septal defect, and right ventricular outflow tract obstruction (n = 3); unbalanced atrioventricular canal defect (n = 1); inlet ventricular septal defect with coarctation (n = 1); and tricuspid stenosis with atrial septal defect (n = 1). RESULTS: The median age at operation was 36 months. There was hypoplasia of the right ventricle and tricuspid valve in all patients. The tricuspid valve measured 56.5% of normal (range, 43.6% to 70.4%) by echocardiography, and the median ratio of the tricuspid valve to the mitral valve was 0.67 (range, 0.54 to 0.82). At operation, the median tricuspid valve annulus diameter was 65.6% of published autopsy normals (range, 57.8% to 78.5%) with a median Z value of -3.8 (range, -6.6 to -2.1). All patients survived operation. At a median follow-up of 16 months, 5 patients are asymptomatic, and 2 have occasional early-morning periorbital edema. Two patients are on a regimen of diuretics, 1 of whom is also taking an unloading agent. The patient with unbalanced atrioventricular canal died suddenly at home 6 months postoperatively. CONCLUSIONS: Bidirectional cavopulmonary anastomosis with intracardiac repair may avoid the long-term complications associated with the Fontan modifications and eliminates the need of atrial fenestration in most instances. This operation should be considered for select patients with hypoplasia of the right ventricle and tricuspid valve.

Steroid-eluting epicardial pacing electrodes: six year experience of pacing thresholds in a growing pediatric population.

Indications for pacemaker implantation in the pediatric population often include sinus or atrioventricular node dysfunction following surgery for congenital heart defects. However, patient size, cardiac defects, and vascular and valvular concerns may limit transvenous lead utilization. Since the epicardial surface of these patients often exhibits variable degrees of fibrosis from scar tissue formation or pericardial adhesions, chronic low output (2.5/1.6 V, 0.3 ms) epicardial pacing from implant is not currently recommended in children due to frequent threshold changes and electrode exit block. As a result, pacing in children is often viewed as a less efficient system than in adults. The addition of steroid combined with newer low threshold electrode designs however stabilizes the electrode-tissue interface and eliminates postimplant changes seen with standard smooth surface electrodes potentially permitting efficient chronic pacemaker application to all patient ages. The stability of chronic low output epicardial pacing with steroid-eluting electrodes was prospectively studied in 22 patients (ages 2 days-18.5 years, median 3.5 years) for up to 6 years. Chronic pulse width thresholds were compared according to implant site and association of prior cardiac surgery. A total of 26 pacing leads were implanted. The acute implant mean pulse width threshold (2.5 V) for all the electrodes studied was 0.10 ms +/- 0.05 ms. Stable low thresholds were maintained for up to 6 years without significant variation from implant. Mean ventricular pulse width thresholds (0.12 ms +/- 0.05 ms) were significantly higher (P < 0.001) than atrial thresholds (0.06 ms +/- 0.03 ms) at implant and throughout the study period. The thresholds in the patients following cardiac surgery were comparable to those without previous cardiac surgery (P = NS). Stable low thresholds may be chronically maintained for up to 6 years for epicardial steroid-eluting electrodes irrespective of pacing site or associated cardiac surgery.

Repair of an unusual type of total anomalous pulmonary venous connection.

A 9-day-old, 4.5-kg female infant was diagnosed with total anomalous pulmonary venous connections by echocardiography. The unusual nature of the pulmonary veins and their connections led to cardiac catheterization and angiography. Angiography demonstrated the left-sided veins connected, via a retropulmonary artery vertical vein, to the left inominate vein whereas the right-sided pulmonary veins connected to the right superior vena cava. We repaired this lesion uneventfully by creating a neo-common pulmonary vein and anastomosing this confluence to the left atrium.

Decreased incidence of postoperative pericardial effusions after cardiac surgery for congenital heart disease.

There has been a striking decrease in the incidence of postoperative pericardial effusion to 13.6%. A higher incidence of postoperative pericardial effusion was found in the winter months.

Coronary sinus ostial atresia with persistent left superior vena cava.

BACKGROUND: Atresia of the coronary sinus orifice with a persistent left superior vena cava is an intrinsically benign cardiac anomaly with important surgical implications. METHODS: THe medical records of 5 patients with atresia of the coronary sinus orifice with a persistent left superior vena cava were reviewed retrospectively, and a computer search of the world literature describing this cardiac malformation was undertaken. RESULTS: The 5 patients ranged in age from 9 months to 5 years. In 2, the diagnosis was made preoperatively by angiocardiography, and in 3, the abnormality was found incidentally at the time of cardiotomy for repair of associated congenital heart disease. Four of the 5 patients underwent repair of associated cardiac lesions. During operation, care was taken to avoid disruption of left superior vena cava flow to prevent coronary venous obstruction. All patients survived and are doing well at follow-up. CONCLUSIONS: Atresia of the coronary sinus orifice with persistent left superior vena cava is, in itself, a benign anomaly without physiologic consequence. However, the recognition of this lesion during repair of associated cardiac lesions is of vital importance to the cardiac surgeon. Interruption of this sole route of coronary venous drainage can potentially lead to myocardial ischemia and necrosis.