Efficacy of CVD risk factor modification in a lower-middle class community in Pakistan: the Metroville Health Study.

The Metroville Health Study aimed to reduce consumption of total cooking fats by 33%, salt by 25% and replace ghee with vegetable oil in a lower middle class urban community in Pakistan. Households (n=403) were randomly assigned to Intervention and Control groups. A baseline screening collected data on CVD risk factors, knowledge and attitudes and household consumption of cooking fats and salt. Intervention households received information about CVD and regular visits by social workers who measured cooking fats and salt and counselled cooks on the goals of intervention. Two years later, 291 households were re-screened. Intervention households reduced consumption of fats and salt compared to differences were total fat, 48% (p<0.0001); ghee, 37% (p=0.005); vegetable oil, 33% (p=0.0001); and salt, 41% (p=0.011). Household visits by trained social workers were effective in achieving reductions in consumption of cooking fat and salt in a lower class urban community.

Two-dimensional echocardiographic and angiocardiographic diagnosis of subpulmonary stenosis due to tricuspid valve pouch in complete transposition of the great arteries.

Two-dimensional echocardiograms and angiocardiograms were obtained in six infants and children, each with complete transposition of the great arteries, a ventricular septal defect and subvalvular pulmonary stenosis. In each case, the subpulmonary stenosis resulted from redundant tricuspid valve tissue which protruded through the ventricular septal defect and into the left ventricular outflow tract. Angio-echocardiographic correlations demonstrated features that allowed preoperative recognition of this unusual type of subpulmonary stenosis. The left ventricular angiogram in an anteroposterior orientation revealed a characteristic filling defect in the outflow tract during systole in each patient. Echocardiographic images of the left ventricular outflow tract and of the tricuspid valve demonstrated subpulmonary stenosis caused by protruding redundant tricuspid valve tissue (resembling a "pouch") in all six patients. These findings were contrasted with those from three patients with normally related great arteries and a similar, but nonobstructive, tricuspid valve pouch. Echocardiographic and angiocardiographic examination and correlation allowed preoperative diagnosis of this unusual form of subpulmonary stenosis in complete transposition of the great arteries. This is especially important because limited left ventricular intraoperative exploration may fail to reveal subpulmonary obstruction as the pouch may be flaccid in a relaxed arrested heart.

Two-dimensional echocardiographic features of interruption of the aortic arch.

The 2-dimensional echocardiographic features of interruption of the aortic arch are presented based on analysis of the echocardiograms and angiograms from 8 infants: 2 with type A and 6 with type B interruption. Each infant had a patent ductus arteriosus, 6 had a conoventricular septal defect with leftward deviation of the conal septum, 1 had truncus arteriosus with truncal valve stenosis, and 1 had a distal aortopulmonary septal defect with an intact ventricular septum. Echocardiographic images obtained from the suprasternal notch or from a high parasternal approach demonstrated the interruption of the aortic arch and continuation of the patent ductus arteriosus into the descending aorta. These findings were compared with those in infants with aortic atresia and a hypoplastic ascending aorta or discrete coarctation of the aorta with tubular hypoplasia of the aortic arch. Types A and B interruption of the aortic arch were easily differentiated and the caliber of the patent ductus arteriosus was assessed. The characteristic conoventricular septal defect was readily visualized froma an apex 2-chamber view or from a subcostal sagittal plane view. With this information subsequent angiography can be more expeditiously performed in this group of critically ill infants.

Prolonged prostaglandin E1 infusion: histologic effects on the patent ductus arteriosus.

An infant with Ebstein's malformation of the tricuspid valve and severe pulmonic stenosis underwent a 39-day course of prostaglandin E1 infusion, and a histologic study of the ductus arteriosus was undertaken after autopsy. There were marked alterations in the ductal and juxtaductal structures following this prolonged infusion of prostaglandin E1. The internal elastic lamella of the ductus was disrupted in many areas. The media showed widespread areas of disruption with cavity formation. The adventitia adjacent to the junction of the ductus with the pulmonary artery was thickened and infiltrated with mononuclear cells. The nerve trunks in the adventitia were markedly infiltrated with mononuclear cells and showed cavitation as well as considerable surrounding edema. Mucopolysaccharides were increased throughout the ductus. These changes produced increased fragility of the ductal and juxtaductal structures, thus increasing the likelihood of spontaneous aneurysms and rupture, or of tearing or rupture at the aortic and pulmonary junctions at the time of surgical closure of the ductus. Unusual fragility of the ductus, pulmonary artery, and aorta has been observed during ligation of the ductus following prostaglandin E infusions lasting seven and ten days. Additionally, another patient who had received prostaglandin E infusion for six days demonstrated aneurysmal fullness to the ductus arteriosus at autopsy. The histologic findings and intraoperative experience in this study suggest that there may be a real danger of spontaneous or surgically related rupture of the ductus arteriosus after prolonged infusion of prostaglandins.

Indomethacin treatment for symptomatic patent ductus arteriosus: a double-blind control study.

A double-blind control study was designed to determine the efficacy and safety of indomethacin treatment of patients with symptomatic patent ductus arteriosus. Infants with severe respiratory distress syndrome and symptomatic patent ductus arteriosus were eligible for the prospective study if the ratio of left atrial/aortic root diameter remained greater than or equal to 1.3:1 following a 24-hour period of medical management. Thirty-nine eligible infants were randomly assigned to the control or indomethacin group and given 0.2 mg/kg of enteral indomethacin or placebo in a double-blind manner. Second and third doses were administered at 24-hour intervals in phase 1 (17 patients), and at eight-hour intervals in phase 2 (22 patients). The 75% patent ductus arteriosus closure rate with indomethacin treatment in phase 1 was not statistically significant due to a 44% spontaneous closure rate in the control group. In phase 2, however, 85% of the indomethacin group demonstrated patent ductus arteriosus closure vs only 11% in the matched control group (P less than .01). Although no indomethacin side effects occurred in phase 1, in phase 2 indomethacin administration was associated with minimal, but statistically significant, transient impaired renal function and, in three infants (23%), mild upper gastrointestinal bleeding. In summary, enteral administration of three 0.2 mg/kg indomethacin doses at eight-hour intervals thus appears to be a safe and effective alternative to surgical closure.

Two dimensional echocardiographic evaluation of Mustard operation for d- transposition of the great arteries.

Two dimensional sector scan echocardiography was used to evaluate the morphologic characteristics of the surgically revised atria in 17 patients with d-transposition of the great arteries who had undergone the Mustard operation. Echocardiographic imaging of the atria was obtained from various planar projections. Dimensional measurements of various segments of the systemic and pulmonary venous atria were obtained in each patient. Correlative hemodynamic, angiographic, postmortem and echocardiographic data showed that seven patients (Group I) had no structural abnormalities of the atria. These 7 patients served as controls for 10 other patients with structural abnormalities of the surgically created atria. One patient (Group II) showed stenosis of the junction of the superior vena cava and systemic venous atrium compared with findings in the control group. Three patients (Group III) had significantly reduced echocardiographic dimensions of the junction of the anterior and posterior segments of the pulmonary venous atrium. Six patients (Group IV) had increased echocardiographic dimensions of all components of the pulmonary venous atrium due to tricuspid regurgitation. These data show that qualitative and quantitative two dimensional sector echocardiography can reliably detect structural abnormalities of the surgically revised atria after the Mustard operation.

Clinical manifestations of dynamic left ventricular outflow tract stenosis in infants with d-transposition of the great arteries with intact ventricular septum.

Four infants with d-transposition of the great arteries and intact ventricular septum who manifested early clinical symptoms and deterioration due to dynamic left ventricular outflow stenosis are presented. All four had an anatomically adequate atrial septal defect, made at the initial balloon atrial septostomy, that was later confirmed intraoperatively. Two infants continued to have a low arterial oxygen saturation level because of inadequate interatrial mixing, and one of these had severe persistent cyanosis and was treated with the Mustard operation at age 4 days. The other two infants subsequently presented with hypercyanotic spells at age 3 months. All four infants had features of dynamic left ventricular outflow stenosis on hemodynamic, angiocardiographic and echocardiographic studies. The left ventricular outflow pressure gradient was shown to increase after administration of isoproterenol in one infant, and relief of a cyanotic spell with reduction of left ventricular systolic pressure was achieved in another after intravenous administration of propranolol. The Mustard operation relieved symptoms in all infants. The effect of left ventricular outflow tract stenosis on the mechanisms responsible for interatrial mixing in d-transposition of the great arteries with intact ventricular septum is discussed.

Taussig-Bing anomaly with straddling mitral valve.

Five patients with the left-sided or intermediate type (Lev) of the Taussig-Bing anomaly were found to have an associated straddling of the mitral valve. In four patients the anomaly of the mitral valve was not recognized preoperatively, and all four died postoperatively. The persistent subpulmonic obstruction caused by the abnormal attachment of the anterior mitral leaflet is considered a significant factor in the poor operative outcome. Retrospective study of angiograms in these four patients revealed diagnostic clues of straddling mitral valve which enabled us to diagnose a fifth patient angiographically and confirm the diagnosis by cross-sectional echocardiography. A surgical approach to correct this association of abnormalities is proposed which avoids operating upon the mitral valve. Its function is thereby preserved, yet the hemodynamic problem caused by the straddling is bypassed. The fifth patient in this series was successfully treated by the proposed operative method.

Echocardiographic features of total anomalous pulmonary venous drainage into the coronary sinus.

Echocardiograms were obtained from five infants with total anomalous pulmonary venous drainage to the coronary sinus or the portal system or the superior vena cava and from one child with a secundum atrial septal defect and a large coronary sinus due to persistence of the left superior vena cava. The results demonstrate that an enlarged coronary sinus is positioned consistently posterior to the left atrium in approximately the same horizontal plane as the aortic valve. Echocardiographically the coronary sinus can be located as an echo complex behind the left atrium by using the aortic root as a reference point. The echo complex can be differentiated from the other spurious echoes in the left atrium by its characteristic phasic motions. The additional demonstration of the enlarged common pulmonary venous chamber behind the right atrium confirms the diagnosis of anomalous pulmonary venous drainage to the coronary sinus. For other types of anomalous pulmonary venous return, anatomic diagnosis with single crystal M mode echocardiography is not always possible because of the positional variability of the common pulmonary venous chamber in relation to the left atrium.

Echocardiographic assessment of the relation between left ventricular wall and cavity dimensions and peak systolic pressure in children with aortic stenosis.

Echocardiographic measurements of the left ventricular end diastolic minor axis and posterior and septal wall thickness were obtained in 19 children with congenital aortic stenosis with left ventricular peak systolic pressures ranging from 110 to 225 mm Hg at cardiac catheterization. From these measurements were derived (1) the left ventricular peak circumferential wall stress, (2)the end-diastolic h/r ratio (that is, mean of septal and posterior wall thickness (h) to minor semiaxis (r) ratio), and (3) the LVM/LVV ratio (that is, left ventricular mass (LVM) to left ventricular end-diastolic volume (LVV) ratio). The peak stress was found to be within the normal range and independent of the left ventricular peak systolic pressure. The end-diastolic h/r and LVM/LVV ratios had highly significant linear relations to the left ventricular peak systolic pressure. It is concluded that these easily determined echocardiographic measurements provide a useful noninvasive means of assessing left ventricular peak systolic pressure in patients with aortic stenosis without myocardial decompensation.

Bronchopulmonary circulation in d-transposition of the great arteries: possible role in genesis of accelerated pulmonary vascular disease.

Hemodynamic and angiograhic data from 209 patients with d-transposition of the great arteries were reviewed to estimate the incidence of prominent bronchopulmonary circulation and to explore its role in the genesis of accelerated pulmonary vascular disease in these patients. The degree of bronchopulmonary circulation was assessed visually by considering the extent of the pulmonary arterial opacification and the circulation to the left atrium. An initial survey study revealed a marked degree of collateral circulation in 20 of 138 patients with d-transposition having cardiac catheterization before age 2 years at the Hospital for Sick Children, Toronto, between 1967 and 1972. Detailed analysis of 71 additional patients with d-transposition aged 1 week to 72 months (mean 17 months) studied at Children's Memorial Hospital, Chicago, between 1967 and 1974 showed collateral circulation of marked degree in 23 and of mild degree in 14. The bronchopulmonary collateral vessels were more freqently demonstrated in the patients with intact ventricular septum than in those with ventricular septal defect or left ventricular outflow tract stenosis. In a prospective study in 12 of 15 patients during cardiac catheterization the functional patency of the bronchopulmonary collateral circulation was demonstrated by obstructing pulmonary blood flow in the right or left pulmonary artery, or both, with an inflated balloon and obtaining from the pulmonary arterial segment distal to the occlusion blood with an oxygen saturation similar to that of the aorta. A hypothesis is presented concerning the role of systemic hypoxemia and local pulmonary hypoxemia induced by way of the bronchopulmonary collateral vessels and the bronchial arterial vasovasorum in promoting pulmonary vasoconstriction. It is suggested that increased pulmonary blood flow and pressure due to the physiologic features of ventricular septal defect, patent ductus arteriosus or transposition of the great vessels, in the face of this regionally increased hypoxemia results in accelerated pulmonary vascular disease.

Echocardiographic detection of bacterial vegetations in a child with a ventricular septal defect.

A 13-year-old boy with a small ventricular septal defect was admitted with clinical manifestations of acute endocarditis. Coagulase-positive staphylococci were isolated from the blood. Definitive diagnosis was made by detecting bacterial vegetations in the right ventricle on the echocardiogram. Repeated embolization of these vegetations to the pulmonary circulation led to the death of the patient.

Variation in the size and distensibility of the pulmonary arteries in d-transposition of the great arteries.

The relative size of the main pulmonary artery was determined from cineangiograms of 117 patients with d-transposition of the great arteries by calculating the ration between the diameters of the main pulmonary artery and aorta. The pulmonary artery was largest in patients with ventricular septal defect or patent ductus arteriosus, or both, because of increased pulmonary arterial pressure and flow. In patients with an intact ventricular septum or with left ventricular outflow tract obstruction, or both, the main pulmonary artery was approximately the size of the aorta. Two cases of d-transposition and gross dilatation of the main pulmonary artery and hypoplastic first branch pulmonary arteries are presented. In these cases the ratio between the diameters of the main pulmonary artery and aorta was greater than in any of the other 117 cases studied...