Surgical versus balloon therapy for aortic coarctation in infants < or = 3 months old.

OBJECTIVES: This study compared the efficacy and safety of balloon angioplasty with surgical correction of native aortic coarctation in infants < or = 3 months old. BACKGROUND: There is a controversy with regard to the role of balloon angioplasty in the treatment of aortic coarctation, especially in young infants. METHODS: Data from 29 infants < or = 3 months old undergoing therapy for aortic coarctation during the decade ending 1992 were analyzed. Fourteen infants underwent surgery, and 15 had balloon angioplasty. The sole criterion for allotment to the balloon group was the availability of an interventional cardiologist at the time of presentation of the infant. RESULTS: The surgical and balloon groups were comparable (p > 0.1) with regard to age (27 +/- 35 [mean +/- SD] vs. 29 +/- 27 days), weight (3.5 +/- 0.9 vs. 3.8 +/- 1.0 kg) and prevalence (7 of 14 vs. 8 of 15) and type of associated defects. Operative (1 of 14 vs. 1 of 15) and late (3 of 13 vs. 3 of 14) mortality, immediate gradient relief (36 +/- 25 to 10 +/- 9 mm Hg vs. 41 +/- 14 to 6 +/- 6 mm Hg) and follow-up gradient (27 +/- 27 vs. 24 +/- 19 mm Hg) were similar (p > 0.1). Infants with a gradient > 20 mm Hg at follow-up (6 of 13 vs. 7 of 14) and need for reintervention (6 of 13 vs. 7 of 14) were also similar (p > 0.1) in both groups. Duration of hospital stay during the first intervention was higher (p < 0.05) in the surgical (32 +/- 37 days) than the balloon (7 +/- 6 days) group. Similarly, duration of endotracheal intubation and mechanical ventilation was longer (p < 0.05) in the surgical (12 +/- 16 days) than the balloon (2 +/- 3 days) group. Complications after surgical intervention (0.86 events/patient) were higher (p < 0.01) than those seen after balloon angioplasty (0.27 events/patient). However, the lack of significant differences observed for mortality rates and residual gradients may be due to low statistical power to detect differences (16% to 49%), implying that this may be due to either actual lack of statistical difference or small sample size. CONCLUSIONS: The data indicate that the degree of relief from aortic coarctation and the frequency with which reintervention is needed are similar in both groups. However, the morbidity and complication rates are lower with balloon than with surgical therapy. These data suggest that balloon angioplasty may be an acceptable alternative to surgical correction in the treatment of symptomatic aortic coarctation in infants < or = 3 months old.

Transcatheter closure of atrial septal defect by "buttoned" devices.

During a 21-month period ending in August 1991, 12 patients underwent transcatheter closure of atrial septal defect (ASD) with a "buttoned" device through an 8Fr sheath, using an institutional review board-approved, custom-made device protocol initially, and Food and Drug Administration-approved clinical trials subsequently. Ten children had left-to-right shunts across the ASD and 2 adults had their patent foramen ovale closed to prevent recurrent paradoxical embolism (including cerebrovascular accidents). The device dislodged in 1 of the 4 patients in whom a first-generation device was used, and retrieval of the device, and surgical closure of the ASD were performed without incident. In the remaining 11 patients (age range 7 months to 45 years, weight 3.6 to 64 kg), the device remained intact, and pulmonary-to-systemic flow ratio decreased from 2.1 +/- 0.3 to 1.04 +/- 0.06. Follow-up chest x-ray and echo-Doppler studies were available in all patients 0.5 to 18 months after the procedure. The device was intact in all patients. Small residual shunt detected by color Doppler was seen in 2 children. Right ventricular size decreased (23 +/- 6 to 17 +/- 3 mm; p less than 0.01), and paradoxical septal motion disappeared in all patients. There was no recurrence of paradoxical embolism in the 2 adults. No complications occurred during follow-up. It is concluded that transcatheter closure of ASD with the buttoned device is feasible, effective and safe, and can be accomplished with small, 8Fr sheaths (even in infants weighing 3.6 kg), follow-up results are excellent, and clinical trials on a larger number of patients are needed.

Transcatheter closure of atrial septal defect or patent foramen ovale with the buttoned device for prevention of recurrence of paradoxic embolism.

Transcatheter occlusion of patent foramina ovalia and atrial septal defects in 10 patients with presumptive paradoxic embolic stroke using the buttoned device appears to be encouraging, with safety and efficacy demonstrated during a follow-up of up to 60 months. Anticoagulation should be continued until complete disappearance of the right-to-left atrial shunt.

Intermediate-term follow-up results of balloon aortic valvuloplasty in infants and children with special reference to causes of restenosis.

Sixteen infants and children with valvular aortic stenosis underwent percutaneous balloon aortic valvuloplasty over a 36-month period ending August 1988. The mean systolic pressure gradient across the aortic valve decreased from 72 +/- 21 (mean +/- standard deviation) to 28 +/- 13 mm Hg (p less than 0.001) immediately after valvuloplasty; the degree of aortic insufficiency did not significantly increase. Follow-up catheterization (in 10 patients) and Doppler data (in all 16 patients) were available 3 to 32 months (mean 12 months) after valvuloplasty and revealed a residual aortic valvular gradient of 37 +/- 23 mm Hg, which continues to be significantly lower (p less than 0.001) than that before valvuloplasty. There was no increase in aortic insufficiency. On the basis of follow-up data, the 16 children were divided into 2 groups: group I with good results (gradients less than or equal to 49 mm Hg), 12 patients; and group II with poor results (gradients greater than or equal to 50 mm Hg), 4 patients. All 4 patients in group II required repeat balloon valvuloplasty or surgical valvotomy; none from group I required these procedures. Seventeen general, anatomic, physiologic and technical variables were examined by a multivariate logistic regression analysis to identify factors associated with restenosis; these risk factors were: age less than or equal to 3 years; and immediate aortic valvular gradient after valvuloplasty greater than or equal to 30 mm Hg. The immediate and intermediate-term follow-up results of balloon aortic valvuloplasty are encouraging. Recognition of the risk factors may help identify potential candidates for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety, tolerance, and efficacy of adenosine as an additive to blood cardioplegia in humans during coronary artery bypass surgery.

Myocardial stunning after heart surgery is associated with increased morbidity and mortality in patients with severe multivessel disease and reduced myocardial function. The purpose of this study was to evaluate the safety, tolerance, and efficacy of adenosine as a cardioprotective agent when added to blood cardioplegia in patients undergoing coronary artery bypass surgery. Sixty-one patients were randomized to standard cold-blood cardioplegia, or cold-blood cardioplegia containing 1 of 5 adenosine doses (100 microM, 500 microM, 1 mM, 2 mM, and 2 mM with a preischemic infusion of 140 microg/kg/min of adenosine). Invasive and noninvasive measurements of ventricular performance and rhythm were obtained preoperatively, prebypass, and then at 1, 2, 4, 8, 16, and 24 hours postbypass. Use of inotropic agents and vasoactive drugs pastoperatively was recorded; blood samples were collected for measurement of nucleoside levels. High-dose adenosine treatment was associated with a 249-fold increase in the plasma adenosine concentration and a 69-fold increase in the combined levels of adenosine, inosine, and hypoxanthine (p <0.05). Increasing doses of the adenosine additive were also associated with lower requirements of dopamine (p = 0.003) and nitroglycerine (p = 0.001). The 24-hour average doses for dopamine and nitroglycerine in the placebo group were 28-fold and 2.6-fold greater than their respective high-dose adenosine treatment cohorts. Finally, the placebo- and 100 microM-adenosine group was associated with a lower ejection fraction when compared to patients receiving the intermediate dose or high-dose treatment. These findings are consistent with the hypothesis that adenosine is effective in attenuating myocardial stunning in humans.

Long-term follow-up of partial atrioventricular septal defect repair in adults.

Patients presenting with partial atrioventricular septal (PAVC) defects in adulthood are rare. Eight adult patients with this congenital heart defect who had surgical repair are described, along with their long-term postoperative follow-up data. Average age at operation was 48 years, and average follow-up was 13.4 years. There was no operative mortality. All but one patient were in NYHA functional class 1 or 2 postoperatively. Three patients had suffered late onset of progressive mitral regurgitation leading to severe congestive heart failure 15 to 25 years postoperatively. The number of adult patients with repaired PAVC defects who have eventual mitral valve deterioration may be higher than estimated in the current literature. Because of the unpredictability of mitral valve function, lifelong follow-up should be stressed in these patients.

Pre- and postoperative pulmonary function abnormalities in coronary artery revascularization surgery.

Pulmonary function studies were conducted one to two days prior to, two weeks after, and an average of 116 days after coronary artery revascularization surgery. Preoperation it was found that 11 of 19 patients had mild to moderate obstruction, 8 of 17 had diffusing capacity less than 80 percent of predicted, and 9 of 17 had mild hypoxemia. Many of these abnormalities seemed related to smoking. After surgery, significant reductions in volumes, diffusion and PaO2 were found at two weeks. By the last study, there was improvement in volumes and diffusion, but they remained significantly reduced in comparison to preoperative levels. Arterial oxygen tension (PaO2) had returned to preoperative levels. Correction of diffusion for volume showed there to be no change in any of the study periods suggesting chest wall alteration is a major component of the abnormality. It is concluded that close monitoring of pulmonary function is indicated before and after operation in this patient population even if the patient is asymptomatic.

Delayed presentation of anomalous circumflex coronary artery arising from pulmonary artery following repair of aortopulmonary window in infancy.

Anomalous origin of the circumflex coronary artery is extremely rare and may cause serious perioperative myocardial injury associated with correction of coexisting congenital malformations. We describe a 15-year-old female patient who underwent surgical correction of an aortopulmonary window at 13 months. Fourteen years later, she presented with dyspnea on exertion associated with angina. On cardiac catheterization, she was noted to have a step-up in oxygen saturation in the pulmonary artery and retrograde filling of the circumflex coronary artery from the left anterior descending coronary artery, with drainage into the pulmonary artery. The patient underwent surgical bypass of the anomalous circumflex coronary artery and ligation of its anomalous origin in the pulmonary artery. Her postoperative course was uneventful, with complete relief of symptoms. We have reviewed this rare congenital anomaly and its therapeutic options.

The fate of aortic valve homografts 12 to 17 years after implantation.

Results of long-term follow-up of an early cohort of patients receiving aortic valve homografts for aortic stenosis and aortic insufficiency are presented. All patients were operated upon by a single surgeon from 1966 to 1971. Eighty-three patients underwent insertion of 85 homograft aortic valves. Homografts were sterilized with either betapropiolactone (39 valves) or gamma irradiation (41 valves) and were inserted following storage in nutrient medium (16 valves) or after cryopreservation (51 valves). All homograft valves were sutured in the subcoronary position using a freehand technique. There was a 55 percent 15-year actuarial patient survival and a 16 percent 15-year actuarial homograft survival in this cohort. Homograft valve failure occurred gradually allowing the patients to be observed until they developed hemodynamic compromise at which time elective valve replacement was performed.

Prolonged perfusion with a membrane oxygenator in awake ponies.

Prolonged extracorporeal membrane oxygenation (PEMO) was performed in 6 adult ponies with the membrane oxygenator in vein-to-artery bypass circuit. A flow rate equal to 46 per cent of control cardiac output was diverted through the PEMO circuit of 10 to 24 hours. Three of the 6 ponies were perfused for at least 20 hours and developed no complications. Immediately following initiation of PEMO, left ventricular output decreased; however, in the interval between 6 and 24 hours, left ventricular output was increased above control levels. Aortic pressure and left ventricular work were markedly elevated during PEMO. Pulmonary ventilation and oxygen uptake also decreased initially but were elevated during later stages of bypass. Pulmonary compliance did not change, except in those studies in which problems were encountered with perfusion techniques. Hepatic glycolysis and hyperglycemia occurred and were more severe in ponies with catheter-produced thrombi. Marked diuresis, which could be attributed only partially to the hyperglycemia, was present throughout PEMO. Based on the minimal morphologic changes observed in the ponies, extracorporeal circulation diverting one half of the cardiac output through a membrane oxygenator can be safely performed for up to 24 hours.

Diagnosis and management of the hypothyroid patient with chest pain.

A retrospective analysis of 38 patients undergoing cardiac catheterization with the diagnoses of hypothyroidism and chest pain revealed 23 to be euthyroid while receiving replacement therapy and 15 to be hypothyroid. Cardiac index was significantly reduced (p less than 0.01) in hypothyroid and euthyroid patients with thyroxine values between 4 and 7 micrograms/dl (2.8 +/- 0.7 and 3.0 +/- 0.9 L/min/m2, respectively), compared to euthyroid patients with thyroxine values greater than 7 micrograms/dl with or without coronary artery disease (4.0 +/- 1.2 and 4.0 +/- 0.7 L/min/m2, respectively). Ten hypothyroid patients underwent coronary artery bypass. There were no deaths, and only one patient required prolonged postoperative intubation. With a mean follow-up of 36 months, there have been no myocardial infarctions and one late death, which occurred at 7 years secondary to stroke. We conclude that preoperative thyroid replacement therapy is theoretically dangerous and may not significantly improve hemodynamics until full replacement is achieved. Coronary bypass grafting can be performed safely despite hypothyroidism with excellent early results.

Computerized fluoroscopy: new technique for the noninvasive evaluation of the aorta, coronary artery bypass grafts, and left ventricular function.

A computerized fluoroscopy system has been developed on the basis of real-time digital processing of x-ray transmission data from traditional image-intensified fluoroscopy equipment. High-quality visualization of any part of the arterial system is obtained following intravenous injection of 0.5 to 0.75 ml/kg of iodinated contrast materials. This report describes the use of this technique to evaluate the aortic arch, left ventricular function, and coronary artery bypass graft patency. Fifty intravenous studies were performed in 25 patients. Among 20 patients with coronary artery bypass grafts, computerized fluoroscopy correctly identified 11 of 15 patent grafts and 11 of 11 occluded grafts as confirmed by standard coronary arteriography in 11 of these patients. Unlike computerized tomography, our technique gives a longitudinal view of the bypass graft much like direct coronary angiography. Aortic arch studies included demonstration of a right aortic arch with a small left subclavian artery, a coarctation, and a normal aortic arch in a trauma patient with a wide mediastinum. Segmental wall motion abnormalities were clearly identified by a modification of the technique which produces a negative outline on the ventriculogram in dyskinetic segments. Ejection fractions may be calculated by determining the amount of iodine in the ventricle in systole and diastole. This technique may also be used to evaluate carotid disease and peripheral vascular disease in patients undergoing coronary artery bypass procedures. Computerized fluoroscopy, therefore, allows evaluation of the entire cardiovascular system by the relatively noninvasive technique of intravenous angiography.

Digital subtraction angiography as a method of screening for coronary artery disease during peripheral vascular angiography.

Since myocardial infarction is the major cause of perioperative and postoperative death following peripheral vascular surgery, an accurate method of screening for coronary artery disease in this group of patients is needed. Digital subtraction angiography (DSA) with the use of intra-arterial aortic root injection of contrast material was evaluated as a method of screening for coronary artery disease in patients undergoing angiography for peripheral vascular disease. The feasibility of this method was demonstrated in animal experiments. Fifteen milliliters of Renografin-76 was power injected into the aortic root of seven anesthetized 20 kg mongrel dogs. Normal coronary artery anatomy was clearly demonstrated with DSA, and a series of iatrogenically created stenoses and occlusions were accurately identified. Excellent definition of patent grafts to the left anterior descending and circumflex coronary arteries was obtained in two dogs that had undergone previous coronary artery bypass grafting. A balloon occluder on one graft was used to demonstrate partial and near-total obstruction of the bypass graft. We are currently studying the use of aortic root injections using DSA to determine coronary artery disease in patients having standard angiography for peripheral vascular disease. Adequate visualization of coronary arteries and bypass grafts with only 20 ml of contrast has been obtained. The potential ability of this technique to identify and allow treatment of life-threatening coronary artery lesions in patients prior to or simultaneously with peripheral vascular surgery may result in reduced mortality.

Comparison of survival in cardiac surgery at a Veterans Administration hospital and its affiliated university hospital.

Survival data were reviewed for 3330 open cardiac procedures from 1975 through 1984 at the William S. Middleton Memorial Veterans Hospital, Madison, Wis, and the University of Wisconsin Hospitals and Clinics, Madison. Respective operative survivals were 98.6% and 98.7% for myocardial revascularizations with vein graft or internal mammary artery (CABG), 96.2% and 96.8% for CABG reoperation, 97.8% and 95.9% for aortic valve replacement, 96.3% and 90.3% for aortic valve replacement plus CABG, 100.0% and 94.9% for mitral valve replacement, and 100.0% and 82.9% for mitral valve replacement plus CABG. There were no significant differences in six-year survival curves between hospitals despite threefold differences in average annual caseload (88 vs 294). This suggest that residency-directed cardiac surgery programs can function equally as well at a Veterans Administration hospital as at an affiliated university hospital.

Carpentier ring annuloplasty in severe noncalcific mitral insufficiency.

Sixteen patients have undergone Carpentier ring annuloplasty for severe mitral insufficiency (MI) since 1974. Our criteria were clinical and angiographic evidence of severe noncalcific MI, a dilated mitral anulus, absence of severe subvalvular chordal thickening, and no major loss of leaflet substance. Carpentier annuloplasty has been successful in eliminating MI in every patient except one. There have been no embolic problems and no early or late deaths. From 1971 to 1974, a similar group of 20 patients with the same diagnosis underwent prosthetic valve replacement. Even though all patients were receiving anticoagulant drugs, three had emboli and there were one early and three late deaths. In patients with severe noncalcific MI who meet our criteria, Carpentier ring annuloplasty is preferable to valve replacement, thus eliminating the hazards of a prosthesis and of long-term anticoagulant therapy.

The Blalock-Hanlon operation: an anachronism?

Some surgeons advocate early correction of dextrotransposition of the great arteries (D-TGA) using hypothermic circulatory arrest when Rashkind balloon atrial septostomy is inadequate. An alternative procedure is a Blalock-Hanlon closed atrial septectomy. From 1971 to 1985, 19 patients underwent the latter procedure for D-TGA at our institution. Three had it as the first procedure, and 16 had undergone Rashkind balloon atrial septostomy, which was unsuccessful. Age at performance of the Blalock-Hanlon closed atrial septectomy ranged from 1 day to 5 months (mean, 2.51 months). There were no operative deaths. Subsequently, 18 children have had a Mustard procedure, and 1, a Rastelli procedure (average age at definitive repair, 25.31 months). One death followed definitive repair (combined mortality, 5%). On room air, average partial pressure of arterial oxygen rose from 23.25 mm Hg prior to closed atrial septectomy to 31.45 mm Hg at discharge. Average hematocrit fell from 58.37% prior to closed atrial septectomy to 53.94% prior to definitive repair. At the time of definitive repair, percentile height ranged from the 3rd to the 95th percentile (mean, 44th percentile) and weight ranged from the 3rd to the 90th percentile (mean, 32.5th percentile). In 1 infant, transient neurological symptoms developed three days following Blalock-Hanlon atrial septectomy. The symptoms were due to multiple cerebral infarctions thought to be caused by emboli. No permanent neurological deficit resulted. We believe that the infant with an inadequate Rashkind balloon atrial septostomy prior to age 6 months should undergo a Blalock-Hanlon septectomy followed by definitive repair timed on the basis of the baby's growth, associated anomalies, and evidence of pulmonary hypertension.

Role of balloon angioplasty in the treatment of aortic coarctation.

Since the initial report of coarctation balloon angioplasty in 1982, several groups have used this technique for native coarctations in neonates, infants, and children and for postoperative recoarctations. However, recommendations for use of balloon angioplasty as a treatment procedure of choice are clouded by reports of aneurysm development at the site of coarctation. Here we review our experience as well as that published in the literature, including Valvuloplasty and Angioplasty of Congenital Anomalies Registry data, and present evidence in support of balloon angioplasty as a therapeutic procedure of choice for treating native and recurrent postoperative aortic coarctations. Balloon angioplasty of native aortic coarctations in 20 neonates and infants 1 year old or less reduced peak systolic pressure gradient across the coarctation from 40 +/- 12 mm Hg (mean +/- standard deviation) to 11 +/- 8 mm Hg (p less than 0.001); no patient required immediate surgical intervention. The residual gradient at follow-up (mean follow-up, 12 months) in 16 infants was 18 +/- 16 mm Hg, a significant improvement (p less than 0.01) compared with preangioplasty values. In none of the patients did an aneurysm develop. Recoarctation developed in 5 (31%) of the 16 infants and was successfully treated either by surgical resection (in 2) or by repeat balloon angioplasty (in 3). A comparison of mortality and recurrence rates between the balloon angioplasty and surgical groups was made with the help of data pooled from the literature published since 1980. The initial (7% versus 23%) and late (2% versus 25%) mortality and recoarctation (11% versus 18%) rates were higher (p less than 0.025) after surgical intervention than after balloon therapy. When only reports in which patients were operated on after 1979 were included in this type of analysis, the initial and late mortality rates remained higher (p less than 0.01) after operation than after angioplasty, and the recoarctation rates became similar (p greater than 0.1). Thirty-two children (greater than 1 year old) underwent balloon angioplasty of native coarctation with a resultant reduction in peak systolic pressure gradient from 48 +/- 19 mm Hg to 10 +/- 9 mm Hg (p less than 0.001), which continued to remain low (14 +/- 11 mm Hg; p less than 0.001) at follow-up catheterization in 24 children 13 months (mean) later. There were no immediate or late deaths. A small aneurysm developed in 1 patient (4%) but did not require intervention. Recoarctation developed in 2 patients (8%), and in both, repeat balloon angioplasty was performed with good results.(ABSTRACT TRUNCATED AT 400 WORDS)

Intrapulmonary steal complicating repair of tetralogy of Fallot.

A patient with total occlusion of the distal right pulmonary artery secondary to the performance of a Waterston shunt is reported. A nearly fatal intrapulmonary steal occurred at the time of corrective operation when an attempt was made to revascularize both pulmonary arteries.

Pericardial cyst with partial erosion of the right ventricular wall.

A case of pericardial cyst with partial erosion into the anterior wall of the right ventricle is presented. Cardiopulmonary bypass was necessary for excision of the cyst. This report helps to alert surgeons of the possible need for cardiopulmonary bypass during the removal of some pericardial cysts, especially in patients with signs and symptoms of infection and in whom preoperative imaging fails to show distinct margins between the cyst and cardiac structures.

The Blalock-Taussig operation: the procedure of choice in the hypoxic infant with tetralogy of Fallot.

From 1971 to 1975, 17 consecutive patients aged 1 day to 4 years underwent Blalock-Taussig shunts for severe tetralogy of Fallot. Three infants were under 6 weeks of age and 7 (41%) under 1 year. There were no hospital deaths. Modification of the shunt technique adapts it to any size infant. The subclavian artery is divided at its major branches and the end spatulated to enlarge it. The artery is occluded while the shunt is constructed. No intraoperative complications were encountered; all patients have a shunt murmur with no early or late closure. No child has had heart failure or hypoxic spells. Flows measured at operation equaled one-quarter to one-half of the child's normal cardiac output. Ligation of the shunt at subsequent repair is uncomplicated. One child died three years later at correction from causes unrelated to the shunt. With appropriate modifications in technique, the Blalock-Taussig shunt is the operation of choice, at any age, for palliation of severe tetralogy of Fallot.