Factors influencing the structure and shape of stenotic and regurgitant jets: an in vitro investigation using Doppler color flow mapping and optical flow visualization.

To evaluate factors influencing the structure and shape of stenotic and regurgitant jets, Doppler color flow mapping and optical flow visualization studies were performed with use of a syringe model with a constant rate of ejection to simulate jets of valvular regurgitation and a pulsatile flow model of the right heart chambers to simulate jets of mild, moderate and severe valvular pulmonary stenosis. Ink-(0 to 40%) glycerol-water jets (viscosity 1 to 3.5 centiPoise) were produced by injecting the fluid at a constant rate into a 10 gallon rectangular reservoir of the same still fluid through 1.4 and 3.4 mm needles. The Doppler color flow scanners imaged the laminar jet length within 3 mm of actual jet length (2 to 6 cm) and the jet width within 2 to 3 mm of the actual jet width. Jet flows with Reynolds numbers ranging from 230 to 1,200 injected into still fluid yielded jet length/width ratios that decreased with increasing Reynolds numbers and leveled off to a length/width ratio of 5-6:1 at a Reynolds number near 600. When the fluid reservoir was swirled to better mimic the effect of flow entering the same cardiac chamber from a second source, the jets showed diminution of the jet length/width ratio and a clearly defined zone of turbulence. Studies of the pulsatile flow model were performed at cardiac outputs of 1 to 6 liters/min for the normal and each stenotic valve. Mild stenosis had an orifice area of 2.8 cm2, moderate stenosis an area of 1.0 cm2 and severe stenosis an area of 0.5 cm2. Laminar jet length represented the length of the total jet, which had a symmetric width and was measured from the valve opening to a region where the jet exhibited a spray effect. Laminar jet lengths (0.2 to 1.1 cm) were imaged by Doppler color flow mapping and optical visualization only in the moderate and severely stenotic valves and only at flows less than or equal to 3 liters/min (mean Reynolds numbers less than or equal to 3,470). Beyond this flow rate the jets exhibited a spray effect. Laminar jet length/width ratio approached unity with an increased amount of valvular stenosis and higher flow volumes (cardiac output). Proximal aliasing was present in each valve studied. the length of aliasing (0 to 3.2 cm) proximal to the valve was longer with increased flow rates and increased amounts of stenosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Elucidation of the natural history of ventricular septal defects by serial Doppler color flow mapping studies.

Two-dimensional echocardiography has provided information to aid in the diagnosis and management of infants with ventricular septal defect, but its inability to resolve very small ventricular septal defects and problems with defining ventricular septal defect orifice size (because of overlying muscle or tricuspid tissue) have made it unsuitable as a standard for defining the natural history of ventricular septal defect. In this study, 114 serial two-dimensional Doppler color flow mapping studies were performed to define ventricular septal defect anatomy, location and color flow diameter as an indicator of shunt size in 66 patients (over a 40 month period). Twenty-five patients first studied at 6 months of age (mean age at most recent study 15.9 months) had congestive heart failure and 41 (mean age 45 months) did not. In the congestive heart failure group, there were 24 perimembranous and 1 muscular ventricular septal defect and aneurysm formation was present in 17. Mean (+/- SD) color flow diameter was 8.2 +/- 1.9 mm and color flow diameter/aortic root diameter ratio was 0.63. In the 30 patients who underwent cardiac catheterization, color flow diameter bore a close relation to angiographic diameter (r = 0.96) and pulmonary/systemic flow ratio (Qp/Qs) (r = 0.88). In the patients with congestive heart failure, 4 of the 25 ventricular septal defects, all with aneurysm present or positioned adjacent to the tricuspid valve, became smaller but none closed. Of the 41 patients without congestive heart failure, 21 had a perimembranous defect (15 with aneurysm), 18 had a muscular ventricular septal defect and 2 had a supracristal ventricular septal defect.(ABSTRACT TRUNCATED AT 250 WORDS)

Rest and exercise hemodynamics in pulmonary stenosis: comparison of children and adults.

To better understand the hemodynamics of pulmonary stenosis (PS), 24 adults and 53 children with similar degrees of PS who had undergone cardiac catheterization at rest and during supine exercise were retrospectively studied. Three groups were defined. Group I consisted of 9 adults and 18 children with a pulmonary valve area of less than 0.5 cm2/m2; group II, 6 adults and 25 children with a pulmonary valve area of 0.5 to 1.0 cm2/m2; and group III, 9 adults and 10 children with pulmonary valve area of more than 1.0 cm2/m2. The mean ages of the adults were 29, 26 and 22 years for groups I, II, and III, respectively. The mean ages of the children were 11, 10 and 9 years for groups I, II and III, respectively. The pertinent data collected from catheterization included oxygen consumption, cardiac rate and index, arterial venous oxygen difference, stroke index, right ventricular (RV) systolic pressure and RV end-diastolic pressure. Adults and children in groups II and III had an appropriate response to exercise. Group I children responded abnormally by increasing their RV end-diastolic pressure and decreasing their stroke index. In group I adults both of these variables increased. Group I adults exhibited a significantly lower cardiac index at rest and exercise secondary to a significantly lower absolute cardiac rate. Long-standing severe PS results in hemodynamic compromise. Hence, early relief of PS is recommended.

Echocardiographic versus cardiac catheterization diagnosis of infants with congenital heart disease requiring cardiac surgery.

The success of noninvasive preoperative evaluation of infants with congenital heart disease using cardiac ultrasound depends not only on diagnostic accuracy, but also on risk of morbidity and mortality as compared with infants who undergo cardiac catheterization. Fifty-six infants (age 10 weeks or younger) with coarctation of the aorta (n = 16), coarctation with ventricular septal defect (n = 12), valvar aortic stenosis (n = 10) or total anomalous pulmonary venous connection (n = 18) were examined. Thirty-one underwent noninvasive preoperative assessment and 25 underwent evaluation including cardiac catheterization. Age, level and duration of support, pH, renal function, mortality, complications of cardiac catheterization and errors of diagnosis were compared. Significant differences between the 2 groups were more frequent preoperative use of prostaglandin E1 and shorter hospital stay in the noninvasively evaluated coarctation group. Of the infants with coarctation and ventricular septal defect, 1 who had cardiac catheterization required renal transplantation and 1 evaluated noninvasively required surgery at age 3 months for mitral stenosis not discovered on preoperative evaluation. One noninvasively evaluated infant with total anomalous pulmonary venous connection had a stenotic communication between the pulmonary venous confluence and the left atrium not detected by ultrasound. Surgery was successful in the latter 2 infants. Noninvasive preoperative diagnosis of some infants with congenital heart disease can be performed without increasing the risk of operative morbidity and mortality. Eliminating cardiac catheterization reduces hospital costs, decreases total numbers of catheterizations performed and influences the structure of training programs.

Echocardiographic-guided internal jugular venous cannulation in children with heart disease.

OBJECTIVE: To determine if cannulation of the internal jugular vein (IJV) with echocardiographic guidance increases the success and decreases the complications of the procedure when performed in children with heart disease. DESIGN: Twenty-five consecutive pediatric patients with heart disease who underwent IJV cannulation with echocardiographic guidance between September 1986 and March 1992. SETTING: University hospital referral center serving a four-state area. PATIENTS AND OTHER PARTICIPANTS: Ambulatory patients were admitted for this procedure and then discharged at its completion; others included hospitalized patients. All patients were between the ages of 6 weeks and 21.8 years. All patients underwent IJV cannulation performed by a member of the Pediatric Cardiology Division at the University of Minnesota, Minneapolis. All patients either underwent heart transplant, and IJV access was obtained to perform an endomyocardial biopsy or had congenital heart disease, and the IJV was cannulated to perform a heart catheterization. Written consent was obtained either from the patient, if 18 years of age or older, or a parent or legal guardian. INTERVENTION: Cannulation of the IJV using echocardiographic guidance. MAIN OUTCOME MEASURES: Would IJV cannulation with echocardiographic guidance improve safety and diminish complications of the procedure when performed in pediatric patients with heart disease? We compared the results of our evaluation with published results in which echocardiographic guidance was not used. RESULTS: Cannulation of the IJV with echocardiographic guidance was performed successfully on 138 occasions in 25 pediatric patients. There were no lasting complications and no deaths using this method of venous access. CONCLUSIONS: As in the adult population, IJV cannulation with the assistance of echocardiography increases the success of the procedure and decreases the number of complications. Furthermore, echocardiographic guidance allows for repeated IJV cannulation in pediatric patients, regardless of age.

Repair of multiple mycotic aortic aneurysms in a newborn.

Thoracoabdominal aortic and common and internal iliac artery mycotic aneurysms resulted from an umbilical arterial catheter in a 3 1/2-week-old boy. He underwent staged repair including an 8-mm Gore-tax tube graft, primary repair of the common iliac artery aneurysm, and resection of the internal iliac aneurysm. His operative and postoperative course was uneventful. He was asymptomatic at 17 months' follow-up, with equal blood pressure in the upper and lower extremities. Magnetic resonance imaging showed no stenoses or recurrent aneurysms at the anastomotic sites of the Gore-tex tube graft. Blood supply to his left leg came from collaterals, principally a large crossing vessel from the right iliac artery. This case represents the first successful aortic replacement in a 5 week old with extensive involvement of the thoracoabdominal aorta and its branch vessels.

Transcatheter closure of congenital coronary arterial fistula with a detachable balloon.

Coronary arterial fistulae are rare congenital cardiac defects that typically are treated by surgery. A case of transcatheter closure of a left anterior descending coronary artery to right ventricular fistula with a detachable balloon is described in a 16-month-old child. The fistula was easily occluded without complication. Follow-up 1.5 years later revealed normal ventricular function and no recurrence of the fistula. Detachable balloon occlusion of coronary arterial fistula is feasible in patients as young as 4 months.

Evaluation of coronary artery anatomy in patients with tetralogy of Fallot by two-dimensional echocardiography.

A major coronary artery crossing the right ventricular outflow tract in patients with tetralogy of Fallot interferes with a transannular patch, and preoperative detection of this artery is important. We evaluated the ability of two-dimensional echocardiography to define noninvasively the coronary artery anatomy in 37 consecutive patients (age range, 1 day to 18 years; mean age, 40.9 months). The origin and distribution of the right anterior descending and circumflex coronary arteries, as well as any anteriorly coursing vessel, were examined from parasternal views. Complete studies were obtained in 29 (78%) of the 37 patients. Coronary artery anatomy was determined to be normal by echocardiography in 20 (69%) of the 29 patients. An anterior vessel across the right ventricular outflow tract was detected in the remaining nine patients. Six patients had an anterior descending artery from the left main coronary artery (paired anterior descending arteries in three patients, a right anterior descending artery from the left main coronary artery in two patients, and a right coronary-to-pulmonary artery fistula in one patient). Three patients had no anterior descending artery from the left main coronary artery (anterior descending artery from the right main coronary artery in two patients, and anterior descending and circumflex arteries from the right main coronary artery in one patient). Angiography, surgery, or autopsy confirmed the diagnoses in all but the final patient in whom the anterior descending artery arose from the right main coronary artery as observed at surgery, but the circumflex artery was not seen. Accurate evaluation of coronary artery anatomy is possible by echocardiography in the majority of patients with tetralogy of Fallot. Noninvasive identification of a major coronary artery coursing anteriorly can influence the timing of cardiac catheterization and surgery and the need for angiography.

Dissecting transverse aortic arch aneurysm after percutaneous transluminal balloon dilation angioplasty of an aortic coarctation.

Percutaneous transluminal balloon dilation angioplasty of an aortic coarctation was done in a one-day-old boy. The infant died 10 h later during aortic valvotomy. A dissecting aneurysm of the aortic arch was present at autopsy.

A useful projection for demonstrating the bifurcation of the pulmonary artery.

The demonstration of the pulmonary bifurcation is important in order to exclude pulmonary branch stenoses. The origin of the right and left pulmonary arteries can be demonstrated in the anteroposterior plane if cranial angulation is used. Depending on the course of the left pulmonary artery, the origin of the left pulmonary artery may not be seen in spite of the maximal cranial angulation. On the lateral plane without tube angulation the origin left pulmonary artery is commonly superimposed on the origin of the right pulmonary artery. If maximum caudal angulation is added to the steep left anterior oblique view, not only the left, but also the origin of the right pulmonary artery can be seen.

Results of a right ventricular outflow patch for pulmonary atresia with intact ventricular septum.

BACKGROUND: Although overall outcome has improved, pulmonary atresia with intact septum remains a difficult surgical and clinical problem. To determine whether an early right ventricular outflow patch will result in biventricular repair for this lesion, we reviewed the long-term follow-up (5.8 +/- 0.8 years) of 19 newborns who underwent repair between 1979 and 1990. METHODS AND RESULTS: An early right ventricular outflow patch was placed in 15 of 19 newborns; in the remaining four, this was preceded by an aortopulmonary shunt. Prostaglandin E1 infusion postoperatively eliminated the need for shunt in 14 of 15. Coronary sinusoids were ligated in three newborns. Based on right ventricular morphology, the newborns were divided into two groups: group 1 (tripartite, n = 9) and group 2 (bipartite and monopartite, n = 10). Before surgery, group 1 had significantly larger right ventricular volumes (23.6 +/- 3.7 versus 5.2 +/- 1.1 ml/m2, p < 0.002). Five-year survival was 79% for the entire series. Four infants, all group 2, died within 12 months of their initial surgery. Fourteen of 15 survivors (nine group 1 and five group 2) currently are acyanotic and New York Heart Association functional class I. A biventricular repair was achieved in 12 of 15, and three other children are awaiting evaluation. All 15 survivors had significant right ventricular and tricuspid annulus growth. CONCLUSIONS: Our data suggest that early placement of a right ventricular outflow patch in infants with pulmonary atresia and intact ventricular septum, regardless of right ventricular anatomy, results in an excellent chance for biventricular repair.