Stenting of the arterial duct combined with banding of the pulmonary arteries and atrial septectomy or septostomy: a new approach to palliation for the hypoplastic left heart syndrome

OBJECTIVE

To assess the feasibility of pulmonary artery banding, atrial septectomy or septostomy, and percutaneous stenting of the arterial duct in babies with the hypoplastic left heart syndrome.

PATIENTS

Four infants with hypoplastic left heart syndrome.

SETTING

Two supraregional paediatric cardiac centres.

METHODS

Ductal patency was maintained initially with prostaglandin E. Banding of the proximal branch pulmonary arteries was performed through a median sternotomy and open atrial septectomy was performed if balloon septostomy was not. Stainless steel stents (Johnson & Johnson) mounted in a balloon catheter were implanted into the arterial duct under radiographic control and expanded to a diameter of approximately 8 mm, prostaglandin treatment was then stopped.

RESULTS

All the patients survived the immediate postoperative period and maintenance of wide ductal patency was achieved in three of the four patients by stent implantation. Two weeks after the procedure two babies died of right ventricular failure and respiratory infection: some distal ductal constriction had occurred in one where the stent was not quite sufficiently distally placed. One child was discharged home 15 days after treatment and was well at follow up at age 16 weeks and one was stable but required diuretic therapy five weeks after the procedure.

CONCLUSIONS

This new approach is technically feasible. At least in the short term it seems to offer hope of effective palliation for the hypoplastic left heart syndrome and it warrants further study.

Cardiac abnormalities in end stage renal failure and anaemia

Thirteen anaemic children on dialysis were assessed to determine the incidence of cardiac changes in end stage renal failure. Nine children had an increased cardiothoracic ratio on radiography. The electrocardiogram was abnormal in every case but no child had left ventricular hypertrophy as assessed by voltage criteria. However, left ventricular hypertrophy, often gross, was found on echocardiography in 12 children and affected the interventricular septum disproportionately. Cardiac index was increased in 10 patients as a result of an increased left ventricular stroke volume rather than heart rate. Left ventricular hypertrophy was significantly greater in those on treatment for hypertension and in those with the highest cardiac index. Abnormal diastolic ventricular function was found in 6/11 children. Children with end stage renal failure have significant cardiac abnormalities that are likely to contribute to the high cardiovascular mortality in this group. Anaemia and hypertension, or its treatment, probably contribute to these changes. Voltage criteria on electrocardiogram are of no value in detecting left ventricular hypertrophy. Echocardiography must be performed, with the results corrected for age and surface area, in order to detect and follow these abnormalities.

Endocardial pacemakers in children: lead length and allowance for growth

Permanent endocardial pacing in small children is feasible but is limited by two problems: sufficient extra lead has to be left within the heart to allow for growth and the excess has to be coiled behind the pacemaker, limiting the benefit from smaller generators. The required intravascular lead length in 120 children and adults was measured on posteroanterior chest X ray and was correlated with standing height. Measurements were made from the mid-point of the left clavicle to the apex of the right ventricle in a curve simulating the usual endocardial lead position. In 60 children, aged 2.0-15.9 years, intravascular lead length (range 15.5-29.0 cm) correlated well with height (0.83-1.70 m), r = 0.91. In 60 adults, mean age 54.9 years, intravascular lead length (25.5-35.6 cm) also correlated well with height (1.45-1.85 m), r = 0.71. In 20 adults the excess extravascular lead length, measured during pacemaker implantation via the subclavian route, was 15.1-33.7 cm and was inversely correlated with height. A child's eventual adult height can be predicted and, using our data, the extra length of lead necessary to allow for growth can be computed. Available endocardial pacing leads are usually 58- to 64-cm long. The excess extravascular lead is a major practical difficulty in children. Shorter leads would avoid the problem of excess lead and facilitate long-term pacing in small children.

Extensive patch tracheoplasty with a silicon "T" tube stent in a 7-month-old infant

Congenital tracheal stenosis is difficult to manage. We describe the combination of an extensive patch tracheoplasty and silicon "T" tube stenting performed in a 7-month-old infant following classical repair of a coexisting pulmonary artery sling.

Endocarditis with acute mitral regurgitation caused by Fusobacterium necrophorum

Infective endocarditis is uncommon in young children, especially in the absence of structural heart disease. We report the case of a 2-year-old boy who presented with acute rupture of the mitral valve chordae 6 weeks after an episode of Fusobacterium necrophorum septicemia. His heart had been structurally normal before. Mitral valve replacement was successfully performed. This is the first recorded case of endocarditis in a child caused by necrobacillosis.

Aortic coarctation endarteritis and aneurysm: diagnosis by transoesophageal echocardiography

A 17-year-old girl developed infective endarteritis, caused by Staphylococcus aureus, at the site of a previously undiagnosed aortic coarctation. Transoesophageal echocardiography revealed a clinically unsuspected false aneurysm. Foreknowledge of the presence of the aneurysm proved to be life saving when an acute deterioration required emergency surgery.

Atrial flutter in the fetus and young infant: an association with accessory connections

OBJECTIVE

To highlight the association between atrial flutter and accessory connections in the fetus and young infant.

DESIGN

A retrospective review from January 1985 to January 1990.

PATIENTS

Fetuses, neonates, and young infants with atrial flutter.

RESULTS

Four fetuses and five infants presented with atrial flutter. In two fetuses and one infant sinus rhythm returned spontaneously. The other six required cardioversion. Three of them developed orthodromic atrioventricular re-entry tachycardia and each had evidence of an accessory connection.

CONCLUSIONS

Because atrial flutter in the fetus and neonate is rare, the high incidence of accessory connections in this group points to a possible aetiology of "idiopathic" atrial flutter in this age group.

Hypoplastic left heart syndrome: more potential transplant recipients than suitable donors

Neonatal cardiac transplantation offers the prospect of survival for babies with hypoplastic left heart syndrome--but only if suitable donors are available. In a retrospective survey in the Northern health region of England and Wales, the likely need for neonatal cardiac transplantation far outweighed the potential availability of donors. Over 8 years (1983-90) hypoplastic left heart syndrome was identified in 38 newborn babies and in 9 fetuses in utero. Of 41 live births (including 3 diagnosed prenatally) 31 would have been candidates for a cardiac transplant, but only 4 suitable donors could be identified (3 with anencephaly born alive during the same period and 1 who died between 1979 and 1986 after a head injury). Analysis of all infant deaths in 1987-89 revealed only 3 potential donors from 426 deaths in the 3 years. Although more widespread antenatal diagnosis may lead to fewer liveborn babies with hypoplastic left heart syndrome, these findings indicate that an alternative source of donors needs to be identified before neonatal cardiac transplantation can be widely used in the treatment of this disorder.

Fetal and infantile hypertension caused by unilateral renal arterial disease

Three children who presented with heart failure in infancy caused by severe hypertension as a result of unilateral renal arterial disease are described. One presented at 3 days of age with persistent fetal circulation and heart failure. He had abnormal great vessels that indicated that the hypertension was of long standing and therefore fetal; this has not been described previously. The other two children failed to thrive because of unrecognised hypertension and subsequently presented with heart failure. All three underwent unilateral nephrectomy which cured their hypertension, and all were thriving at the time of writing. The benefits of nephrectomy outweighed the operative risks and loss of renal function. Blood pressure should be measured in children who are failing to thrive as part of routine clinical practice.

Idiopathic infantile arterial calcification in two siblings: failure of treatment with diphosphonate

Two siblings with idiopathic infantile arterial calcification are reported. The fetal and postnatal echocardiographic features were a large pericardial effusion, thickened pulmonary and aortic valves, poor pulsation of the descending aorta, and calcification of the great vessels. In one patient calcification was first detected at 33 weeks' gestation. Despite treatment with disodium etidronate both children died.

Natural history of supravalvular aortic stenosis and pulmonary artery stenosis

Data from 35 patients with supravalvular aortic stenosis or pulmonary artery stenosis, or both, undergoing cardiac catheterization between 1973 and 1989 were analyzed retrospectively. Twenty-seven patients had supravalvular aortic stenosis: 11 required surgery after the first investigation and 8 (80%) of 10 others undergoing serial investigation showed an increase in the left ventricle to aorta pressure gradient. Angiographic measurements showed that the increase in the aortic pressure gradient was related to failure of normal growth of the ascending aorta lumen. Nineteen patients had pulmonary artery stenosis, with a right ventricular pressure greater than 33 mm Hg. At restudy, right ventricular pressure had decreased in 9 (82%) of 11 patients. This decrease in right ventricular pressure was associated with an increase in the systolic distensibility of the proximal pulmonary arteries, although there was no increase in the diastolic diameters. One patient had a rapid early increase in right ventricular pressure and no pulmonary artery growth. In two patients, multiple peripheral pulmonary artery stenoses became evident with time and produced persistent right ventricular hypertension. Supravalvular aortic stenosis is usually a progressive lesion, with an increase in left ventricular outflow tract pressure gradient related to poor growth of the ascending aorta. Pulmonary artery stenosis usually improves and only rarely limits prognosis.

Familial ventricular tachycardia: a report of four families

Four cases of familial ventricular tachycardia are presented. In each family the proband was an adolescent girl. Twelve members in the four families were affected and all were female. The clinical and electrocardiographic features were relatively constant within each family but there were striking differences between families. These differences argue against a common electrophysiological or pathophysiological basis for the ventricular tachycardia.

Supraventricular tachycardia in infants: response to initial treatment

All patients with supraventricular tachycardia during the first 12 months of life who presented between 1977 and 1988 were identified by a retrospective survey of records in this hospital and by a questionnaire sent to paediatricians in the Northern region. Twenty two of 29 patients (76%) were in heart failure and seven (24%) had cardiogenic shock. Seven patients (24%) were free of symptoms. All had narrow QRS tachycardia at 215-315 beats/minute (mean (SD) 292 (21)). Initial treatment included digoxin (effective in seven of 14 patients, with overdose in three), verapamil (effective in three of three but fatal in one), cardioversion (effective in all 10 who were treated in this way), iced water applied to the face (effective in all 16 patients on 53 of 59 occasions, 90%). Initial treatment in local hospitals was less effective and associated with more complications than that given in the regional referral centre. Digoxin is often ineffective, return to sinus rhythm is delayed, and overdosing is common. Cardioversion is effective but tachycardia often recurs. Iced water is safe and effective, and should become the treatment of choice for termination of supraventricular tachycardia in neonates and young infants.

Balloon valvotomy of calcified pulmonary valve stenosis

Successful balloon valvotomy in an adult with calcific pulmonic stenosis is described. The incidence of calcification, and the potential use of this technique in calcified pulmonary valves is discussed.

Coronary artery-left ventricular fistula and multiple ventricular septal defects due to blunt chest trauma

A 27 year old man developed multiple ventricular septal defects and a coronary artery ventricular fistula after a blunt injury. These were treated successfully by surgery, which was carried out four months after the injury to allow some healing of the defect to occur.

Truncus arteriosus with interrupted aortic arch: successful correction in a neonate

Truncus arteriosus (type II) with interrupted aortic arch (type B) was successfully repaired at 11 days of age using anterior translocation of the pulmonary arteries, resection of the ductus arteriosus, and direct anastomosis between the descending aorta and truncus. This technique permitted wide reconstruction of the aortic arch and minimized the number of suture lines. It also positioned the right ventricle-pulmonary artery conduit anteriorly, which may simplify its subsequent replacement.

Treatment of recoarctation: balloon dilation angioplasty

Balloon dilation of recoarctation of the aorta was performed 47 times in 44 patients 49 +/- 54 months after surgical repair. The initial operation was performed in the neonatal period in 29 patients (66%). The age at balloon dilation was 4.9 +/- 5.3 years (range 2 months to 20 years) and weight was 18 +/- 15 kg (range 2 to 72). Systolic pressure difference across the recoarctation site decreased from 37 +/- 16 to 14 +/- 11 mm Hg and coarctation/aortic diameter ratio increased from 0.45 +/- 0.14 to 0.85 +/- 0.16 immediately after balloon dilation regardless of the nature of the previous operation (subclavian flap [n = 12], resection with end to end anastomosis [n = 21], patch angioplasty [n = 4] or multiple operations [n = 5]). In the ascending aorta, systolic pressure decreased from 120 +/- 25 to 113 +/- 20 mm Hg. In the descending aorta, systolic pressure increased from 85 +/- 15 to 100 +/- 19 mm Hg and pulse pressure increased from 22 +/- 7 to 36 +/- 8 mm Hg. At repeat cardiac catheterization in 21 patients (48%) 12 +/- 8 months after balloon dilation, there was further reduction in systolic pressure difference from 17 +/- 11 to 12 +/- 9 mm Hg with no further change in coarctation/aortic diameter ratio. Aneurysm formation was evident in one patient (2%) immediately after balloon dilation; the aneurysm was unchanged at repeat study 15 months later. A "new" aneurysm was apparent in 2 (10%) of the other 20 patients restudied to date. The occurrence of aneurysm in these three patients was unrelated to balloon size. There were no procedure-related deaths. Three patients (7%) had femoral artery occlusion. Balloon dilation affords good relief of obstruction without adverse sequelae from aortic wall disruption at medium-term follow-up.

Acute myocardial infarction in infancy: unmasking of anomalous origin of the left coronary artery from the pulmonary artery by ligation of an arterial duct

Myocardial infarction and left ventricular failure developed within hours of ligation of a large arterial duct in a four week old infant. Anomalous origin of the left coronary artery from the pulmonary artery was confirmed by echocardiography. Despite emergency translocation of the anomalous coronary artery the patient died.

Cardiac abnormalities in the fragile X syndrome

Twenty three patients with fragile X syndrome underwent cardiovascular assessment. Echocardiography showed dilatation of the aortic root in 12 (52%) and mitral valve prolapse in five (22%), four of whom had an apical mid-systolic click on auscultation. Patients with fragile X syndrome have cardiac defects similar to those seen in other disorders of connective tissue such as Marfan's syndrome and Ehlers-Danlos syndrome. These, and other somatic features, suggest an underlying connective tissue dysplasia.

Balloon dilatation of the aortic valve for congenital aortic stenosis in childhood

Balloon dilatation of the aortic valve was attempted in 34 consecutive children aged 16 months to 17 years (median 7 years), weight range 9-60 (median 22) kg. Previous surgical valvotomy had been performed in two patients (twice in one of them). The valve was not crossed in one patient. In the remaining 33 patients the pressure difference between the left ventricle and the ascending aorta during systole was reduced from 71 (30) to 28 (19) mm Hg. In 24 patients recatheterisation 2-19 (mean 9) months later showed gradients that were similar to those immediately after balloon dilatation (35 (20) v 31 (20) mm Hg). The two patients with the highest residual gradients immediately after balloon dilatation showed a spontaneous reduction in gradient at repeat catheterisation, whereas the patient who had twice had previous surgical valvotomy showed an increase in gradient from 37 to 99 mm Hg over nine months and required aortic root replacement. Balloon dilatation was repeated in two patients and this caused a further reduction in gradient. New aortic regurgitation occurred in nine (27%) patients (grade I, 8; grade II, 1) and aortic regurgitation was exacerbated (grade I to II) in two of the nine with pre-existing aortic regurgitation. External iliac artery avulsion occurred in one (3%) patient and two (6%) required intravenous streptokinase because the femoral artery became occluded. There were no other complications. Open valvotomy was performed in the child in whom the valve was not crossed, but no other child required aortic valve operation. Balloon dilatation of the aortic valve gave reasonable short term palliation and was well tolerated. It is an alternative to surgical valvotomy for initial palliation of congenital aortic stenosis in many children.

Balloon dilatation of a stenosed bioprosthesis in the tricuspid valve position

Percutaneous balloon dilatation of a stenosed Ionescu-Shiley bioprosthesis in the tricuspid valve position was performed twice in a 19 year old woman. On each occasion there was a considerable improvement in symptoms and haemodynamic function but the effect lasted for only a few months. When the valve was excised it showed no evidence of the previous balloon dilatations.

Surgical unifocalization in pulmonary atresia and ventricular septal defect. A realistic goal?

Between 1979 and 1986, 26 patients with pulmonary atresia, ventricular septal defect, and multifocal pulmonary blood supply underwent surgery (median age, 2 years) to reconnect major aortopulmonary collateral arteries to other collateral arteries or to the central pulmonary arteries in an attempt to prepare the pulmonary circulation for complete repair. In four patients, central pulmonary arteries were found to be absent at exploratory thoracotomy, and therefore, the surgery aimed for optimal palliation. Four (15%) patients died perioperatively. The survivors had symptomatic improvement. At restudy 1 week-110 months (median time, 25 months) postoperatively, modest growth of central pulmonary arteries had occurred [right plus left pulmonary artery diameters/descending aortic diameter from 0.64 +/- 0.61 (mean +/- SD) preoperatively to 0.95 +/- 0.60 postoperatively (p less than 0.01)], with a greater number of bronchopulmonary segments connected to central pulmonary arteries [from 6.3 +/- 4.8 preoperatively to 10.0 +/- 4.5 postoperatively (p less than 0.001)]. However, only seven (27%) patients met the established criteria for repair, of whom three (12%) have undergone definitive surgery. Thirteen (50%) patients are unsuitable for repair, and two (8%) await restudy. Failure of anastomoses involving major aortopulmonary collateral arteries (13 of 33) was higher than for grafts from a systemic artery to the central pulmonary artery (1 of 22, p = 0.003). Failure was not related to the number of anastomoses per operation, suggesting that poor distal runoff may have been responsible. This surgical approach provided reasonable palliation but was rarely effective as a prelude to complete repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of respiratory syncytial virus antigen in nasopharyngeal secretions by Abbott Diagnostics enzyme immunoassay

We compared a rapid respiratory syncytial virus (RSV) antigen enzyme immunoassay (EIA) (Abbott Diagnostics, North Chicago, Ill.) with virus culture and with the indirect fluorescent-antibody test (FAT) by using nasopharyngeal washings from children with suspected RSV pneumonia or bronchiolitis. Fresh washings were used in all three tests. Specimens were inoculated into HEp-2 cells and human embryonic lung fibroblasts and observed for cytopathic effect. Cells in the centrifuged sediments of the nasal washes were examined for typical cytoplasmic fluorescence of RSV by FAT. The EIA cutoff was an optical density (OD) at 492 nm that was greater than the mean OD of the negative controls plus 0.1. An OD within +20% of the cutoff was considered borderline, and these specimens were retested. Of 289 specimens, 118 (41%) were positive by culture, 150 (52%) were positive by FAT, and 154 (53%) were positive by EIA. Eight borderline EIAs were all negative when the specimens were retested after storage at -70 degrees C. Of 17 specimens positive by EIA but negative by culture and FAT, 9 were blocked in a competitive EIA, indicating that they were true-positives and that the culture and FAT were falsely negative. The sensitivity, specificity, and predictive value (positive) of the EIA versus culture, FAT, or blocking assay were 90, 94, and 95%, respectively. We conclude that the Abbott RSV antigen EIA is highly sensitive and specific.

Maternal administration of flecainide to terminate and suppress fetal tachycardia

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Percutaneous balloon dilatation of aortic valve stenosis in neonates and infants

Percutaneous balloon dilatation of severe aortic valve stenosis was attempted in thirteen patients (seven neonates and six infants). In two the valve could not be crossed and both died during subsequent operation. Two patients died during manipulation of the balloon catheter. No significant benefit was obtained in another patient who later died during operation. Balloon dilatation was successful in the remaining eight patients, reducing the aortic valve pressure gradient from a mean of 63 mmHg (95% confidence interval 38 to 88 mmHg) to a mean of 23 mmHg (95% confidence interval 7 to 39 mmHg). Two of these patients subsequently died from heart failure related to other cardiac lesions. The six survivors have done well. At follow up the maximum Doppler velocities in the ascending aorta ranged from 1.9 to 4.0 m/s after 2-23 months, but despite this evidence of an increasing valve gradient there has been lasting clinical improvement.

Balloon dilatation of unoperated aortic coarctation: immediate results and one year follow up

Fifteen patients aged 1-19 years (mean 10.9) with previously unoperated aortic coarctation underwent percutaneous balloon angioplasty between January 1985 and February 1986. Nine (60%) were hypertensive at presentation. Under general anaesthetic the systolic coarctation gradient was 24-50 mm Hg (mean 29) and the coarctation diameter was 4-9 mm (mean 5.5). Meditech balloon catheters 8-18 mm in diameter were inflated 1-4 times at 410-760 kPa. After dilatation the systolic coarctation gradient decreased to 0-20 mm Hg (mean 6) and the coarctation diameter increased to 7-20 mm (mean 12). One patient developed a fusiform aneurysm of the aorta at the coarctation site immediately after the procedure. At reinvestigation 6-16 months (mean 12.5) after dilatation 14 of the 15 patients were normotensive. In 13 patients the residual coarctation gradient was 0-10 mm Hg (mean 3). Two patients had recoarctation with residual gradients of 20 and 24 mm Hg and underwent successful repeat dilatation. One patient had developed a small discrete aneurysm at the coarctation site. Balloon angioplasty is thus a safe and effective method of relieving unoperated aortic coarctation. The frequency of aortic aneurysm and recoarctation is small and probably related to balloon size. This early experience is encouraging, but long term results and further experience are required before this approach is used to treat coarctation generally.

His bundle tachycardia--arrhythmogenic and antiarrhythmic effects of therapy

His bundle tachycardia is a rare arrhythmia in infants and children and is resistant to therapy. There is now sufficient evidence from reported cases and a further patient reported below to suggest that drug management of this arrhythmia is a reasonable alternative to His bundle ablation with life-long pacing from infancy.

Cardiac rhythm in atrial isomerism

Standard electrocardiograms from 126 consecutive patients with atrial isomerism were reviewed. Of 67 patients with left isomerism, 49 had sinus rhythm, 8 nodal rhythm and 10 atrioventricular (AV) block. Fifty-eight of 59 patients with right isomerism had sinus rhythm. Complete AV block was significantly more frequent in association with AV septal defect in left isomerism (5 of 45 patients) than in right isomerism (0 of 47 patients, p = 0.049). The P-wave axis was superior in 49% of patients with left isomerism but did not correlate with abnormalities of systemic or pulmonary venous connection. A significant shift of P-wave axis (more than 90 degrees) was seen on a subsequent electrocardiogram in 14 of 44 patients (32%) with left isomerism and 2 of 16 (13%) with right isomerism. Ambulatory electrocardiographic monitoring in 17 patients (14 with left isomerism) showed that only 4 had sinus rhythm throughout 24 hours. Only 1 patient with complete AV block received a permanent pacemaker. Despite the high incidence of electrocardiographic abnormalities, significant arrhythmias appear to be rare. The arrhythmias apparently do not influence the natural history of this condition or affect the outcome of palliative or corrective surgery. The prognosis is determined mainly or solely by the associated anatomic abnormalities.

The response of paediatric arrhythmias to intravenous and oral flecainide

Flecainide acetate was administered intravenously and orally to 12 consecutive children, aged 1-15 years, presenting with arrhythmias that were life threatening or resistant to conventional medical treatment. Three children had arrhythmias related to Wolff-Parkinson-White syndrome, four had concealed accessory pathways, two had His bundle tachycardia, and three had ventricular tachycardia. Of seven patients who were given flecainide intravenously, four returned to sinus rhythm and in a fifth successful rate control of His bundle tachycardia was achieved. All 12 patients were given the drug orally: in nine it was successful in preventing recurrence of arrhythmia, in one satisfactory rate control was achieved, and in two it was withdrawn because it produced more frequent attacks of tachycardia. No other adverse effects occurred. The efficacy and low toxicity of treatment in this study suggests that flecainide acetate may have an important role in the management of selected paediatric arrhythmias.

Role of echocardiography in differential diagnosis of broad complex tachycardia

It is not always easy to distinguish between supraventricular tachycardia with aberration and ventricular tachycardia by electrocardiographic analysis alone. M mode echocardiography can often help by providing direct or indirect evidence of the relation between atrial and ventricular contraction. Sixteen consecutive patients with spontaneous sustained broad QRS complex tachycardia with heart rates of 120-225 beats/minute were examined. Echocardiographic evidence of 1:1 conduction was seen in three cases and 2:1 atrioventricular conduction in one (all four had supraventricular tachycardia, confirmed by intracardiac electrocardiography in three). Evidence of retrograde block was seen in 12 (all had ventricular tachycardia, with electrophysiological confirmation in 10). Satisfactory views of the mitral valve were obtained in all patients. Patients with ventricular tachycardia had a variable mitral valve opening time (range 42-110%) compared with those who had supraventricular tachycardia (9-15%). Aortic root and left atrial views gave direct evidence of atrial contraction in three cases, and subcostal right atrial wall views were diagnostic in four of five cases. Seven patients with ventricular tachycardia had been wrongly diagnosed elsewhere as having supraventricular tachycardia. This study confirms that echocardiography is a simple and rapid aid to accurate diagnosis in patients with broad QRS complex tachycardia.

Sinus node function in first three weeks after cardiac transplantation

Donor sinus node function was studied in 10 patients from day 4 to day 24 after cardiac transplantation. Cycle length, atrial arrhythmias, corrected sinus node recovery time, and estimated sinoatrial conduction time were recorded daily. Five patients had at least two sets of results suggesting sinus node dysfunction (group A) while five patients had no such abnormalities (group B). The prognosis in group A was poor, with four of the five patients dying within four months of the operation; one unexpected death from arrhythmias was recorded by ambulatory electrocardiographic monitoring. All five patients in group B survived for at least eight months. In nine patients sinus node function varied from day to day, with corrected sinus node recovery time reaching a peak at 11 to 18 days after operation. The longest corrected sinus node recovery time was 11 160 ms. Neither the differences between the patients, nor the day to day variation, could be explained solely by the degree of rejection as assessed by biopsy or by the ischaemia time of the heart during procurement. Sinus node dysfunction soon after transplantation is associated with a poorer prognosis and might be the terminal event in some cases.

Isolated interventricular septal tuberculoma causing complete heart block

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Endoscopic removal of a swallowed ball bearing from stomach of a 4-year-old child

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