Comparison of three techniques for internal jugular vein cannulation in infants.

Central venous cannulation allows accurate monitoring of right atrial pressure and infusion of drugs during the anaesthetic management of infants undergoing cardiopulmonary bypass. In this prospective, randomized study, we compared the success and speed of cannulation of the internal jugular vein in 45 infants weighing less than 10 kg using three modes of identification: auditory signals from internal ultrasound (SmartNeedle, SM), external ultrasound imaging (Imaging Method, IM) and the traditional palpation of the carotid pulsation and other landmarks (Landmarks Method, LM). The cannulation time, number of attempts with LM and SM techniques were greater than those with IM technique. The incidence of carotid artery puncture and the success rate were not significantly different among the three groups. In infants, a method based on visual ultrasound identification (IM) of the internal jugular vein is more precise and efficient than methods based on auditory (SM) and tactile perception (LM).

Early presentation of a congenital coronary artery fistula in a neonate.

A neonate developed severe congestive heart failure secondary to a congenital coronary artery fistula requiring emergent surgery. Intraoperative transesophageal echocardiography helped guide successful emergent closure of the fistula without complications.

Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method.

BACKGROUND: Percutaneous cannulation of the internal jugular vein in infants is technically more difficult and carries a higher risk of carotid artery puncture than in older children and adults. In this prospective study, the authors tested their hypothesis that using an ultrasound scanner would increase the success of internal jugular cannulation and decrease the incidence of carotid artery puncture in infants. METHODS: After approval from the institutional review board and receipt of written informed parental consent, 95 infants scheduled for cardiac surgery were randomized prospectively into two groups. In the landmarks group, the patients' internal jugular veins were cannulated using the traditional method of palpation of carotid pulsation and identification of other anatomic landmarks. In the ultrasound group, cannulation was guided using an ultrasound scanner image. The cannulation time, number of attempts, success rate, and incidence of complications were compared for the two groups. RESULTS: There were no significant differences between the two groups with regard to weight, age, and American Society of Anesthesiologists physical status classification. The success rate was 100% in the ultrasound group, with no carotid artery punctures, and 77% in the landmarks group, with a 25% incidence of carotid artery punctures. Both differences were significant (P > 0.0004). The cannulation time was less, the number of attempts was fewer, and the failure rate was significantly lower in the ultrasound group than in the landmark group. CONCLUSION: Ultrasonographic localization of the internal jugular vein was superior to the landmarks technique in terms of overall success, speed, and decreased incidence of carotid artery puncture.

Echocardiographic evidence for a ductal tissue sling causing discrete coarctation of the aorta in the neonate: case report.

A neonate presented to our institution with the physical findings of coarctation of the aorta. After starting prostaglandin E1 the signs and symptoms resolved despite persistent closure of the ductus arteriosus. We present echocardiographic evidence to support the contention that a ductal tissue sling contributes to the formation of juxtaductal coarctation of the aorta.

Impact of prolonged waiting times of neonates awaiting heart transplantation.

OBJECTIVES: This study analyzed waiting times and outcomes of neonates listed for heart transplantation at two medical centers from 1991 through 1994. STUDY DESIGN: Retrospective analysis was performed to examine waiting times, charges, morbidity, and outcomes. RESULTS: Of the 30 neonates listed for transplantation, 15 received hearts, with 10 late survivors. Waiting time increased from 25 +/- 8 days in 1991 and 1992 to 58 +/- 7 days in 1993 and 1994 (p < 0.01), and the hospital charge per patient increased from $118,300 +/- $31,500 to $198,700 +/- $25,400 (p < 0.05). Freedom from sepsis predicted receiving heart transplantation (p < 0.01). Lack of a preoperative central intravenous catheter, no preoperative mechanical ventilation, and A-negative blood type predicted heart transplantation survival (p < 0.05). The chances of receiving and surviving transplantation were the same in the two periods. There was a trend toward greater morbidity among neonates waiting more than 35 days. CONCLUSIONS: Waiting times and charges have increased significantly over the last 4 years. Patients who are free of sepsis, lack a preoperative central intravenous catheter, are not mechanically ventilated preoperatively, and have A-negative blood type have better outcomes.

Traumatic thoracic aortic rupture in the pediatric patient.

BACKGROUND: Traumatic thoracic aortic rupture is a rare injury in the pediatric patient. Experiences with thoracic aortic rupture in patients less than 17 years of age are needed to help identify factors that can influence injury occurrence, diagnosis, management, and outcome. METHODS: Between July 1989 and December 1995, 6 children were treated operatively for thoracic aortic rupture from blunt trauma at a level I pediatric trauma center. The average age was 13.2 years (range, 8 to 16 years). There were 4 females and 2 males. There were 5 motor vehicle accidents and 1 bicycle accident. Aortic injury was suspected based on the mechanism of injury and abnormal chest roentgenogram results, and was confirmed by aortography (3 cases) or chest computed tomography (2) and transesophageal echocardiography (3). Life-threatening central nervous system or gastrointestinal injuries were evaluated or treated first. Operative repair of the thoracic aorta was performed by cardiopulmonary bypass (2 patients) and clamp and sew technique (4). RESULTS: Aortic ruptures were complete transections at the ligamentum arteriosum in 5 of 6 (83%); the other case was a cervical arch pseudoaneurysm. Associated injuries included pulmonary contusion (100%), pelvic/long bone fractures (50%), visceral laceration/perforation (50%), central nervous system (33%), paraplegia (17%), and myocardial contusion (17%). There were no rib fractures. Four of 5 patients (80%) were not wearing seat belts, and 2 of these were ejected. The average time from injury to the operating room was 17.6 hours (range, 5 to 48 hours); the time from diagnosis to the operating room exceeded 5 hours with aortography and was less than 3 hours with chest computed tomography and transesophageal echocardiography. Each diagnostic modality accurately identified an aortic injury. The average time for cardiopulmonary bypass and for clamp and sew was 52 minutes (range, 49 to 55 minutes) and 34 minutes (range, 16 to 45 minutes), respectively. One patient with preoperative paraplegia regained partial function; there were no other patients with paraplegia. There were no deaths. All patients are alive 2 months to 7 years after repair. CONCLUSIONS: The multiply injured child with severe blunt trauma and an abnormal chest roentgenogram requires a search for aortic injury. We believe the most effective algorithm to follow for the diagnosis of traumatic thoracic aortic rupture in the child involves selective performance of chest computed tomography and transesophageal echocardiography. Our experience suggests that the mechanism of injury, the duration to diagnosis of an aortic injury, and failure to use seat belts may contribute to morbidity. A high index of suspicion and a systematic approach to the diagnosis and to the management strategy for injuries to the thoracic aorta can contribute to a good outcome in those few children who survive the injury.

Improved oxygenation with reduced recirculation during venovenous extracorporeal membrane oxygenation: evaluation of a test catheter.

OBJECTIVE: To determine whether modifications of the original design of a double-lumen, venovenous, extracorporeal membrane oxygenation (ECMO) catheter would reduce recirculation and improve oxygenation during venovenous ECMO. DESIGN: Prospective, interventional study. SETTING: The animal research laboratory at The Children's National Medical Center. SUBJECTS: Six newborn lambs, 1 to 7 days old and weighing 4.7 +/- 0.9 kg. INTERVENTIONS: Animals were anesthetized, intubated and ventilated. The ductus arteriosus was ligated. Femoral artery and vein, cephalic jugular vein, and pulmonary artery catheters were placed. After systemic heparinization, the test catheter (with venous drainage holes moved away from the arterial return holes) was placed in the right internal jugular vein and advanced into the right atrium. The animal was placed on ECMO and stabilized, with the ventilator settings decreased to a peak inspiratory pressure of 15 cm H2O, peak positive end-expiratory pressure of 5 cm H2O, respiratory rate of 15 breaths/min, and an FIO2 of 0.21. ECMO flows were increased in 100-mL increments from 200 to 600 mL/min, with measurements taken 15 mins after each change. The test catheter was removed, the double-lumen, venovenous ECMO catheter was placed, and the studies were repeated. MEASUREMENTS AND MAIN RESULTS: Heart rate, mean arterial pressure, PaO2, jugular cerebral oxygen saturation, pulmonary artery oxygen saturation, mixed venous oxygen saturation, and postmembrane circuit pressures were measured at each study period. The test catheter improved oxygenation significantly, with higher systemic PaO2, higher pulmonary artery and cerebral oxygen saturations, and lower mixed venous oxygen saturations (indicating less recirculation). With the test catheter, PaO2 levels ranged from 62 +/- 6 torr (8.3 +/- 0.8 kPa) to 112 +/- 12 torr (14.9 +/- 1.6 kPa), compared with 46 +/- 4 torr (6.1 +/- 0.5 kPa) to 59 +/- 2 torr (7.9 +/- 0.3 kPa) for the double-lumen, venovenous ECMO catheter (p < or = .001). These findings indicate that at all flow rates studied, less recirculation occurred with the test catheter than with the double-lumen, venovenous ECMO catheter. CONCLUSIONS: These findings indicate that the redesign of the double-lumen, venovenous ECMO catheter, as outlined in this study, resulted in a significant reduction of recirculation, thereby resulting in a significant improvement in oxygenation while on venovenous ECMO. This newly designed catheter makes venovenous ECMO more effective, and represents a design that could be used for pediatric and/or adult ECMO.

Recent advances in the diagnosis and treatment of coarctation of the aorta.

Although it has been the topic of intense medical and surgical attention for over 50 years, coarctation of the aorta continues to be a major cause of cardiovascular morbidity and mortality in infants and children. Refinements in established diagnostic modalities--primarily fetal, transesophageal, and intravascular echocardiography--have improved pre- and post-treatment assessments. Aggressive and early intervention, whether by surgery, catheter, or both, have been shown to increase initial success; the results of long-term follow-up are yet to be determined. The best possible outcome requires prompt recognition and effective treatment directed at immediate gradient relief, which will hopefully prevent or reduce the known late and long-term sequelae.

Anomalous pulmonary venous drainage of the right lung.

An unusual case of anomalous drainage of the right lung is described. The right superior pulmonary vein drained into the superior vena cava, and the middle and lower pulmonary veins drained into the inferior vena cava. Repair was achieved by creating a pericardial baffle that drained the inferior vein and the orifice of the superior vena cava through a surgically created atrial septal defect. The superior vena cava was transected and the distal portion anastomosed to the right atrial appendage.

Routine use of transesophageal echocardiography and color flow imaging in the evaluation and treatment of children with congenital heart disease.

We reviewed our experience with transesophageal echocardiography (TEE) and color flow imaging in 157 consecutive patients with known or suspected heart disease to ascertain the impact of this technology on patient care. TEE was performed for diagnostic purposes (22/157), during interventional cardiac catheterizations (13/157), and during operative procedures (122/157). Diagnostic studies were performed after transthoracic echocardiography (TTE) in 21 of 22 patients. TEE was performed because TTE was inconclusive (15/21) or failed to provide sufficient detail of an abnormality (6/21). TEE detected an abnormality in 6 of 15 inconclusive TTEs. TEE was helpful during interventional cardiac catheterizations, particularly during umbrella closure of septal defects and in patients with complex venous and atrial anatomy undergoing transseptal puncture. TEE studies performed before cardiac operations significantly changed the diagnosis in only 5 of 122 (4%) patients, but the information changed the surgical approach in 4 of 5 of these patients. Postoperative TEE assessment more frequently changed care and resulted in further surgical management in 9 of 122 (7%) or a change in medical management in 6 of 122 (5%) patients. TEE was discontinued because of complications before studies were completed in only 4 of 157 (3%) patients. TEE and color flow imaging is a useful adjunct to care of children with known or suspected congenital heart disease.

Closed technique for repair of right superior vena cava draining to left atrium.

A rare case of total anomalous drainage of a right superior vena cava to the left atrium is presented. The patient had an intact atrial septum and presented with cyanosis and a history of an earlier brain abscess. Complete repair was performed using a venoatrial shunt and without the use of cardiopulmonary bypass.

Pulsed Doppler echocardiographic and color flow imaging detection of retrograde filling of anomalous left coronary artery from the pulmonary artery.

We report a case in which pulsed wave Doppler echocardiography and color flow imaging of blood flow direction in an anomalous coronary artery from the pulmonary artery assisted in the correct diagnosis and confirmed the adequacy of the surgical correction. Low-velocity color scales were used to show retrograde filling of the left coronary artery before surgery and antegrade filling of the left coronary artery after surgery. Detecting direction of blood flow in coronary arteries should increase the accuracy of the noninvasive diagnosis of anomalous left coronary artery from the pulmonary artery.

Quantitative assessment of mesangial immunoglobulin A (IgA) accumulation, elevated circulating IgA immune complexes, and hematuria during vomitoxin-induced IgA nephropathy.

Extended dietary exposure to the trichothecene vomitoxin (deoxynivalenol), a naturally occurring fungal contaminant of cereal grains, induces elevated serum IgA and mesangial IgA accumulation in a manner similar to the human glomerulonephritis, IgA nephropathy. A 12-week feeding study was conducted in the B6C3F1 mouse to evaluate the effects of exposure to 25 ppm dietary vomitoxin over time on formation of IgA immune complexes (IgA-IC), hematuria, and mesangial deposition of IgA, IgG, IgM, and complement component C3. Both serum IgA and IgA-IC were significantly elevated in vomitoxin-exposed treatment groups compared to controls at weeks 4, 8, and 12, whereas serum IgG was unaffected. The incidence of hematuria was also significant in vomitoxin-exposed mice at weeks 4, 8, and 12. Quantitative immunofluorescence intensity measurements using interactive laser cytometer image analysis revealed significantly greater mesangial IgA accumulation in vomitoxin-fed mice compared to controls at weeks 4, 8, and 12. Although glomerular IgG and IgM deposition was present in both controls and treated mice, it was significantly lower in treated mice as compared to controls at week 12. Mesangial C3 deposition was not induced by vomitoxin feeding. Elevated IgA-IC, hematuria, and IgA mesangial accumulation occurring during exposure to vomitoxin mimicked human IgA nephropathy, whereas the absence of mesangial C3 represented a major difference between this toxin-induced immune dysregulation and the human disease.

The effect of inorganic phosphate on chick (Gallus domesticus) heart mitochondrial volume and cation content.

1. In the absence of exogenous Ca(II), Pi induces a swelling change that is kinetically first order with k = 1.08 +/- 0.1 min-1. The first-order rate constant is independent of [Pi] over the range of 0.5-45 mM. 2. In the presence of exogenous substrate, the volume change induced by Pi is monophasic and can be reversed by ADP. 3. The swelling process and the approach to steady state is accompanied by controlled losses of both K+ and Mg(II) from within the mitochondria. 4. The loss of K+ is biphasic as a function of time with ki = 14.1 +/- 1.6 and k2 = 4.4 +/- 0.34 nmol min-1 mg mitochondria-1. 5. The loss of Mg(II) is monophasic and the rate at which this cation is released decreases as a function of time. Ca(II) fluxes are not involved in the volume occurring secondary to Pi uptake. 6. In the absence of exogenous substrate, Pi induces a triphasic change in mitochondrial volume. 7. The sequence of volume changes corresponds to an initial first-order swelling secondary to the addition of Pi, a contraction apparently triggered by the loss of approximately 85% of total intra-mitochondrial Mg(II), and a second larger swelling phase that cannot be reversed with ADP. 8. The Pi-induced swelling of chick heart mitochondria is not inhibited by EGTA and does not depend on the provision of exogenous Ca(II). 9. The Ca(II) and Mg(II) ions released from within the mitochondria are responsible for activating divalent cation-dependent ATPases which cosediment with isolated chick heart mitochondria.

The results of a surgical program for interrupted aortic arch.

Seventy-one patients with interrupted arch entered the Boston Children's Hospital between Jan. 1, 1974, and Jan. 1, 1987, of whom 63 underwent an operation. Type B was the most prevalent form of interrupted arch, and ventricular septal defect alone was the commonest coexisting cardiac anomaly. Among the 63, the 30-day and the 1-, 5-, and 10-year survival rates were 61%, 52%, 48%, and 47%, respectively. The mortality rate declined strikingly during the experience, and by multivariate analysis in patients with coexisting ventricular septal defect operated on in 1986, the probability of death within 2 weeks of repair was only 7%. Also, preoperative therapy became progressively more intense and more prolonged. The complication of left ventricular outflow tract obstruction developed in eight of the 33 patients undergoing repair of interrupted arch and of isolated ventricular septal defect. The time-related freedom from this complication was 97%, 78%, and 58% at 1 month, 1 year, and 3 years, respectively. Seven of the eight patients underwent a surgical procedure directed against the left ventricular outflow tract obstruction, and all have survived. Recurrent or persistent aortic arch obstruction became evident after repair in 15 patients and appeared more frequently and earlier after direct anastomosis than after tube graft repair. All patients had either reoperation or balloon dilation, but all were alive at follow-up. Most surviving patients are active and without symptoms. Inferences: An aggressive surgical program can result in survival and a good clinical state for at least 10 years after birth of over 40% of patients born with interrupted arch. Multiple anatomic bases account for the development of left ventricular outflow tract obstruction in about 50% of the patients undergoing repair of interrupted arch with coexisting ventricular septal defect. Repair by direct anastomosis combined with repair of the coexisting defect whenever possible is optimal therapy.

Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement.

The incidence, preoperative and intraoperative diagnosis, methods, and the clinical and hemodynamic features of patients with and without tricuspid regurgitation associated with chronic mitral regurgitation were presented in Part I. This study (Part II) compares the early and late results in patients with chronic, pure mitral regurgitation undergoing isolated mitral valve replacement, mitral replacement and tricuspid valve annuloplasty, and mitral and tricuspid valve replacement. The mean follow-up interval was 6 years. Those with the longest duration of symptoms (18 years) required tricuspid and mitral valve replacement (11 patients), whereas those with the shortest duration (8.1 years) had only mitral replacement (22 patients). Eight patients had minimal tricuspid regurgitation by digital palpitation, with no procedure performed, and six had tricuspid valve annuloplasty, only one of whom received a ring support. Operative mortality rate was similar in all groups (13% to 18%). All but two of the surviving patients improved by at least one New York Heart Association functional class, and no statistically significant differences were found between preoperative and postoperative hemodynamic data. There were no statistically significant differences in survival at 1, 5, or 8 years (85%, 70%, and 60%, respectively) for patients with or without TR. Only two of the surviving five patients who underwent tricuspid valve annuloplasty were alive 3 years after operation, whereas 70% to 80% of those with mitral replacement or mitral and tricuspid replacement were alive after the same time interval. It is not clear whether or not the pathogenesis of tricuspid regurgitation resulting from mitral regurgitation is different from that of tricuspid regurgitation resulting from mitral stenosis. It is our contention that whether tricuspid regurgitation arises because of anatomic destruction of the tricuspid valve or because of right ventricular dilatation with tricuspid annular enlargement, the underlying mitral valve lesion may determine the preoperative and postoperative courses of these patients. Therefore, when tricuspid valve disease is being evaluated, we urge that patients be categorized by the nature of their underlying mitral or aortic valve lesions.

Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation.

Most reports of clinical experiences with palliation of acquired tricuspid regurgitation have failed to address the issue of coexisting disease of the mitral or aortic valve, or both. To accurately determine the natural history and the effect of operative interventions, we studied patients with chronic, pure mitral regurgitation who had surgical treatment at the National Heart, Lung, and Blood Institute from 1968 to 1984. Forty-seven patients fulfilled the criteria of a documented history of mitral regurgitation for more than 1.5 years, minimal mitral diastolic gradient, severe mitral regurgitation by angiography, and no prior mitral or tricuspid operative procedure. Twenty-five of the 47 patients (53%) had evidence of tricuspid regurgitation. No statistical differences in age, sex, mean duration of symptoms of congestive heart failure, or functional class were found between those patients with and those without tricuspid regurgitation. However, patients with symptoms of congestive heart failure for more than 6 years were more likely to have tricuspid regurgitation. This increased prevalence also correlated with higher elevations of left ventricular end-diastolic, systolic pulmonary artery, and mean right atrial pressures. The severity of tricuspid regurgitation estimated preoperatively did not correlate statistically with that determined by digital palpation, although the presence of tricuspid regurgitation was reliably confirmed. These data demonstrate that tricuspid regurgitation is frequently present in patients with chronic, pure mitral regurgitation and is associated with prolonged symptoms of congestive heart failure and significant alterations in right heart dynamics.

Healing of ischemic colonic anastomoses in the rat: role of antibiotic preparation.

In this study we evaluated the relative effects of ischemia with and without antibiotic bowel preparation on colonic wound healing. Thirty-two Sprague-Dawley rats (185 to 300 gm) were divided into five study groups: Groups I and II (n = 14) had no colonic ischemia, half receiving antibiotic bowel preparation before colocolostomy. Groups III, IV, and V (n = 18) had colonic ischemia induced by division of the marginal artery and ligation of the arteries to the splenic flexure and pelvic colon, assuring that all blood supply to the left side of the colon was intramural. Enteral (neomycin and erythromycin) antibiotic preparation was given in group III, no antibiotics were given in group IV, and parenteral (clindamycin and gentamicin) preparation was given in group V. The mid-left side of the colon was transected and an everting anastomosis was constructed with continuous 6.0 silk sutures. All animals were killed on the seventh postoperative day. Anastomotic healing in unprepared, ischemic rat colon was severely impaired, with an 83% dehiscence rate. In the colon prepared with enteral antibiotics, no adverse effect of ischemia was found. No animal had dehiscence, proximal dilation of the colon, or intra-abdominal abscess. This study may have clinical relevance in patients with ischemic intestinal disorders.