Reliability of echocardiography in the diagnosis of anomalous origin of the left coronary artery from the pulmonary trunk

Previous studies have indicated that the definitive diagnosis of anomalous origin of the left coronary artery from the pulmonary trunk (ALC) should be made by cardiac catheterization and angiography. This study evaluates echocardiography (two-dimensional, pulsed Doppler, and color flow mapping) as a method to establish the diagnosis of ALC. To diagnose ALC, a modified parasternal short-axis view was used to demonstrate continuity of the ALC with the pulmonary trunk and to detect the retrograde flow through the ALC into the pulmonary trunk. Absence of these imaging characteristics ruled out ALC. From June 1985 to January 1990, 16 patients who presented with or had previously had a dilated poorly contracting left ventricle were prospectively assessed by echocardiography to rule out ALC. Four patients had ALC (age 2 to 120 months, mean +/- 1SD = 32 +/- 59) and 12 patients (age 1 to 192 months, mean +/- 1SD = 57 +/- 80) had myocardiopathy. Two other patients with known ALC were evaluated by an observer unaware of the diagnosis. All coronary anatomy was confirmed by angiography, surgery, or autopsy. The correct diagnosis of coronary anatomy was obtained by echocardiography in all instances without false positive or false negative diagnosis of ALC. Three infants underwent surgical repair of ALC based only on the echocardiographic diagnosis. Echocardiography can be used to establish the diagnosis of ALC. Therefore surgical repair can be undertaken in some critically sick infants based on the echocardiographic diagnosis alone.

Pediatric cardiac rehabilitation

Sixteen patients participated in a Pediatric/Young Adult Cardiac Rehabilitation Program that included exercise training, education about cardiovascular diseases, dietary counseling, and counseling on stress management. Seven patients completed the program, and complete data were available on six. The subjects demonstrated significant changes in their hemodynamics and exercise tolerance after completing the program. Resting blood pressure decreased by 7%, from 119 +/- 12 to 111 +/- 10 mm Hg; peak oxygen consumption increased by 20%, from 31.9 +/- 4.3 mL/kg of body weight per minute to 38.4 +/- 6.0 mL/kg of body weight per minute; and exercise treadmill time increased by 21%, from 8.5 +/- 1.4 to 10.3 +/- 1.0 minutes. No complications occurred during exercise training or testing. Supervised exercise training at moderate intensity is safe and produces significant and beneficial changes in hemodynamics and exercise time in children with cardiac disease.

Clinical profile of congestive cardiomyopathy in children

The clinical profile of 23 children with congestive cardiomyopathy was reviewed to detect any factors that might be predictive for their survival. Factors examined include age at onset (less than 2 versus greater than 2 years), gender, severity of the clinical picture including data from the chest radiograph, electrocardiogram (ECG), echocardiogram, hemodynamic study and endomyocardial biopsy. Follow-up study ranged from 1 month to 14 years (mean 43 months). There were 12 survivors and 11 nonsurvivors; the 1 year mortality rate was 30% (7 of 23), and the 5 year mortality rate was 44% (10 of 23). Age at onset, gender, cardiothoracic ratio on chest radiograph, pattern of infarction, ST-T changes or arrhythmia on ECG and left ventricular end-diastolic pressure were nonpredictive of outcome. However, low shortening fraction (mean 11.5% in nonsurvivors versus 20.9% in survivors, p less than 0.01), familial cardiomyopathy and endocardial fibroelastosis indicated a very poor prognosis.

Detection of coronary artery abnormalities in tetralogy of Fallot by two-dimensional echocardiography

Patients with tetralogy of Fallot have a 5% to 19% incidence rate of abnormal distribution of coronary arteries. These abnormalities are usually detected by angiography and influence the timing and mortality rate of surgery. This study evaluates two-dimensional echocardiography as a method of assessing coronary artery distribution in tetralogy of Fallot. Forty-five consecutive patients with tetralogy of Fallot, aged 0.1 to 20.5 years (mean 5.7 +/- 4.3), had prospective two-dimensional echocardiographic studies to examine the branching patterns of the coronary arteries and to determine the presence or absence of a branch from the right or left coronary artery that crossed the right ventricular outflow tract. The first two patients had known coronary abnormalities and served as learning models. All other echocardiographic studies were performed without knowledge of angiographic or surgical findings. Twenty-two studies were completed before coronary angiography (group A) and 23 after angiography (group B). All eight patients (18%) with coronary abnormalities were correctly identified by two-dimensional echocardiography (five in group A and three in group B). Three had bilateral anterior descending coronary arteries originating from the left and right coronary arteries, two had the anterior descending artery originating from the right coronary artery, two had a large conal branch from the right coronary artery and one had origin of both left and right coronary arteries from a single left ostium. All abnormal coronary arteries were visualized crossing the right ventricular outflow tract, whereas all 21 small conal branches from the right coronary artery were not seen in the right ventricular outflow tract.(ABSTRACT TRUNCATED AT 250 WORDS)

Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up

From 1972 to 1987, seven patients, from two to 28 months of age, underwent left subclavian artery-left coronary artery anastomosis for anomalous origin of the left coronary artery from the pulmonary trunk. All of these infants, median age 4 months, had severe congestive heart failure caused by anterolateral myocardial infarctions. There were two hospital deaths (29% mortality rate) with no late deaths after an average 10-year follow-up. All survivors have good exercise tolerance New York Heart Association class I), reduction in heart size, and significant improvement or normalization of ventricular function by echocardiography. Patency of the subclavian-left coronary artery anastomosis has been documented in two of four patients who have undergone catheterization. In contrast to other revascularizing procedures for treatment of an anomalous origin of the left coronary artery, anastomosis of the left subclavian to the left coronary artery may be performed without cardiopulmonary bypass or aortic occlusion. Moreover, this procedure appears to have an acceptable mortality rate with excellent long-term functional results in critically ill infants.

Relations of moderate physical exercise to scores on hostility, aggression, and aggression, and trait-anxiety

100 male subjects were selected from a midwestern university and categorized into 5 jogging groups, advanced, intermediate, beginning, drop-out joggers and nonexercisers, who were administered the Commitment to Running Scale, the Buss-Durkee inventory measuring hostility and aggression, and the State-Trait Anxiety Inventory. Analysis of covariance with age as a covariate was performed using a 5 x 2 design with the 5 levels of jogging and status of the jogger (student/nonstudent) as independent variables. Fisher's LSD was used for multiple comparisons. Joggers scored higher than drop-outs or nonexercisers on the Commitment to Running Scale. Nonexercisers had higher mean scores on trait anxiety than advanced, intermediate, and drop-out joggers; advanced joggers had a lower mean trait-anxiety score than any other group. Nonexercisers had higher mean aggression and hostility scores than drop-out or advanced joggers; drop-out and advanced joggers did not differ significantly but their scores were significantly lower than those of other groups of joggers. These findings confirm that jogging affects trait anxiety, hostility, and aggression positively, which supports use of exercise preventively.

Aortico-right ventricular tunnel and critical pulmonary stenosis: diagnosis by two-dimensional and Doppler echocardiography and angiography

An infant with aortico-right ventricular (AO-RV) tunnel and critical pulmonary stenosis presented with severe distress at birth. We present the clinical, echocardiographic, and angiographic features, correlated with autopsy findings. Also we discuss the differentiation from other AO-RV communications and a theory for the embryogenesis. AO-RV tunnel should be considered in the differential diagnosis of a critically sick newborn with cyanosis, a "to and fro" murmur, and signs of right heart failure. The correct diagnosis can be made echocardiographically by demonstrating the two ends of the tunnel connecting the aorta and a dilated RV, two normal coronary arteries, and obtaining high-velocity systolic and diastolic Doppler flow signals in the tunnel. Surgical repair of this lesion is possible, and early diagnosis and a modification of the surgical procedure may help survival.

Dysrhythmias after the modified Fontan procedure

The cardiac rhythm before and after the modified Fontan procedure was reviewed in 24 patients. Transient atrial dysrhythmias were common in the immediate postoperative period. Late postoperative premature atrial contractions were detected by ambulatory monitoring in 20 of 23 patients; eight (34.8%) had supraventricular tachycardia. Late ventricular dysrhythmia was detected in 18 of 23 patients: ten had low-grade ventricular dysrhythmias and eight (34.8%) had multiform premature ventricular contractions. Five of the latter had couplets and one of these five plus another had ventricular tachycardia. Seven patients with supraventricular tachycardia and five patients with ventricular dysrhythmia required antiarrhythmic medication. Asymptomatic bradycardia was detected in five patients (21.7%). One patient had intermittent second-degree atrioventricular block. No specific risk factors predicted dysrhythmias. Thus, cardiac dysrhythmias were common in patients after the modified Fontan procedure, but were well tolerated in most patients. No sudden deaths or syncopal episodes have occurred during a mean follow-up of 5 years. One patient's death was related to severe left ventricular dysfunction. Permanent pacing has not been required in any patient.

Anomalous origin of the left coronary artery from the pulmonary trunk: repair after diagnostic cross sectional echocardiography

An infant with anomalous origin of the left coronary artery from the pulmonary trunk presented with congestive cardiomyopathy. Only cross sectional echocardiography gave a definitive diagnosis. The results of cardiac catheterisation and angiography were inconclusive. Surgical repair was performed successfully after the results of cross sectional echocardiography were known.

Concomitant valvotomy and subclavian-main pulmonary artery shunt in neonates with pulmonary atresia and intact ventricular septum

Our current approach to the management of neonates with pulmonary atresia and intact ventricular septum is to perform a transarterial pulmonary valvotomy through a left anterolateral thoracotomy followed by a polytetrafluoroethylene shunt between the left subclavian artery and the pulmonary trunk at the site of the pulmonary arteriotomy. From October, 1983, to December, 1985, 7 consecutive neonates with pulmonary atresia and intact ventricular septum were managed in this fashion. Mean age was 5.1 days (5 patients, less than 48 hours old), and mean weight was 3.3 kg (range, 2.5-4.3 kg). Right ventricular morphology was type I (tripartite) in 4 patients, type II (absent trabecular portion) in 2, and type III (absent trabecular and infundibular portions) in 1. The mean right ventricular to left ventricular peak systolic pressure ratio was 1.5. One patient who initially had valvotomy alone required a left subclavian-pulmonary trunk shunt the next day for hypoxemia. All other patients had a valvotomy and shunt during the same procedure. There were no operative or hospital deaths. Follow-up of 3.5 to 34 months (mean, 17.5 months) confirmed shunt patency in all patients. Three of 4 patients undergoing postoperative catheterization have shown good right ventricular growth; 2 have undergone successful repair at 10 and 23 months. There have been 3 late deaths at 3.5, 4, and 8 months. Two other patients are doing well and are awaiting postoperative catheterization. This procedure permits synchronous valvotomy and shunting without the need for cardiopulmonary bypass in these critically ill neonates.(ABSTRACT TRUNCATED AT 250 WORDS)

Carditis associated with Mycoplasma pneumoniae infection

A 16-year-old boy with acute perimyocarditis had serological evidence of Mycoplasma pneumoniae infection. The endomyocardial biopsy specimen showed grade 2 active lymphocytic myocarditis. A T-cell study suggested a cell-mediated immune process in the pathogenesis of carditis. Mycoplasma pneumoniae needs to be considered as a possible cause of acute carditis, and histological findings may influence management.

Two-dimensional echocardiographic assessment of adequacy of pulmonary artery banding

The goal of banding the pulmonary artery (PA) in children with complex heart disease is to reduce PA pressure and blood flow, relieve symptoms of circulatory congestion, and insure low pulmonary vascular resistance for future repair. To assess the hypothesis that two-dimensional echocardiography (E) measurements could be used to predict noninvasively the tightness of the PA band by measuring its diameter, we examined 15 patients with PA band. Of the 12 patients who underwent cardiac catheterization, nine with no symptoms of circulatory congestion had distal systolic PA pressure less than 0.5 systemic, and three symptomatic patients had distal PA pressure of more than 0.5 systemic. None had left ventricular outflow tract obstruction or pulmonary vascular disease. The E measurements were the internal diameter of the PA band (d), and PA annulus (D) in diastole. The d/D ratios correlated significantly with the ratios of measured distal to proximal PA systolic pressure (r = 0.98, P less than 0.001). Of the three patients not catheterized, one had a d/D ratio of less than or equal to 0.4 and two greater than 0.4. The former one had an excellent clinical improvement after banding, while the latter two remained in circulatory congestion. Doppler echocardiographic evaluation in five patients did not improve upon the data from the d/D ratios.(ABSTRACT TRUNCATED AT 250 WORDS)

Equilibrium radionuclide ventriculography in single ventricle

With the recent advances in pediatric cardiology and cardiovascular surgery, assessment of ventricular function in single ventricle complexes is becoming increasingly important. The serial assessment of ventricular function helps our understanding of the natural and unnatural history in these patients. Equilibrium radionuclide ventriculography is safe, easy to perform, and well-suited to the serial assessment of ventricular function. Fifteen nuclear studies were performed in 15 children with single ventricle complex. Nuclear studies were imaged in both the anterior and left anterior oblique views in each patient. The ventricular ejection fraction calculated from the anterior view (the view with the best atrial-ventricular separation) closely approximated the cineangiographic ejection fraction (54.0 vs 59.1%). Equilibrium radionuclide ventriculography is a valid method to calculate ventricular ejection fraction in single ventricle. The anterior view should be used for region of interest selection and subsequent ejection fraction analyses.

Repair of aortic coarctation in infants: experience with an intraluminal shunt

From 1962 to mid-1984, 63 infants underwent coarctation repair. Cardiac defects were present in 46 (73%). Repair was by subclavian aortoplasty in 35 patients, resection and end-to-end anastomosis in 19, and other techniques in 6. Three patients died before the repair was completed. In 15 patients, an intraluminal shunt was used during subclavian aortoplasty. Prostaglandin E1 (PGE1) was infused in 9 patients. Early (thirty-day) mortality was 16% (10 patients): 4 patients who underwent end-to-end anastomosis; 3 during attempted end-to-end anastomosis; 2 who received bypass grafts; and 1 who had subclavian aortoplasty without a shunt. None of the 15 patients who had subclavian aortoplasty with a shunt died. There were no early deaths among the last 25 patients seen. One patient who underwent subclavian aortoplasty without a shunt is paraplegic. There were 10 late deaths among the 53 patients followed from 1 month to 12 years (mean, 3 years). Arm-leg pressure gradients of 20 mm Hg or greater were found in 4 of the patients who had end-to-end anastomosis but not in any of the patients who had subclavian aortoplasty. Improved results of coarctation repair in infants in this study were attributed to PGE1, subclavian aortoplasty, and use of an intraluminal shunt.

Echocardiographic evaluation of left ventricular function, mass and wall stress in children with isolated ventricular septal defect

M-Mode echocardiography was performed in 22 normal children and 22 children with ventricular septal defects. Left ventricular and left atrial chamber dimensions and wall thicknesses were measured in all patients. Utilizing these data, indices of left ventricular function were derived: shortening fraction, velocity of fiber shortening, peak diastolic fiber lengthening, end-systolic wall stress, radius thickness ratio, and ventricular mass. The results showed that ventricular septal defect was associated with enlarged left ventricular and atrial dimensions and increased shortening fraction, but that velocity of shortening and early diastolic lengthening remained normal. Left ventricular mass was increased, thus maintaining normal wall stress and radius/thickness ratio. Cardiac failure complicating ventricular septal defect was associated with enlarged left ventricular and atrial dimensions (indexed for weight). Ventricular mass, wall stress and function, however, were similar in subjects with ventricular septal defect, with or without cardiac failure. Since left ventricular mass was adequate to maintain wall stress and function in subjects with heart failure, other factors were presumably responsible for heart failure complicating ventricular septal defect.

Fatal aortic rupture presenting as chest pain in an adolescent. The role of echocardiography in occult cystic medial necrosis

An adolescent female with occult cystic medial necrosis died following spontaneous aortic rupture. A large saccular aortic aneurysm that had ruptured into the pericardial space was demonstrated by two-dimensional echocardiography and confirmed at surgery. Echocardiographic screening of the patient's family members revealed a 13-year-old brother with unsuspected aortic root dilatation. He is now being followed for possible progression of his disease. This case demonstrates the role of echocardiography in cystic medial necrosis. It can aid the acute management of patients with aortic dissection or aneurysm. It can also define patients with occult disease who require serial follow-up and genetic counseling.

Ventricular dysrhythmias in children with Marfan's syndrome

A teenager with Marfan's syndrome required resuscitation and was found to have multiform premature ventricular contractions and ventricular tachycardia. Of 24 children with Marfan's syndrome, eight (33.3%) were found to have ventricular dysrhythmias, including three with ventricular tachycardia. Six of these eight patients had mitral valve prolapse, and five had prolonged QT or QTU intervals corrected for heart rate. However, only two patients had severe mitral regurgitation, five had only mild heart disease, and one had no detectable heart lesion. The role of mitral valve prolapse and/or delayed repolarization in the development of ventricular dysrhythmia was explored. Delayed repolarization, especially when combined with mitral valve prolapse, is associated with occurrence of ventricular dysrhythmia. Serious ventricular dysrhythmia can occur in children with Marfan's syndrome with or without substantial valve disease, and the dysrhythmia appears to progress with age.

Infantile cardiac fibromatosis: correlation of antemortem and necropsy findings

In the case presented here of a 2-month-old boy with symptoms of upper respiratory infection, the physical examination, chest X-ray film and electrocardiogram led us to suspect congestive heart failure caused by either a primary or infectious cardiomyopathy or by a structural left ventricular outflow tract obstruction. The echocardiographic findings were the first evidence to suggest the presence of an intracardiac tumor. A cardiac computerized axial tomography scan supported the findings. Operation was performed, but the tumor was unresectable. Biopsies of the mass revealed fibromatosis. The infant was discharged on diuretics, procainamide and propranolol. Approximately 3 weeks following discharge, while at rest, the child suddenly became unresponsive and could not be resuscitated. Postmortem examination verified the degree of precision that can be achieved by noninvasive techniques.

Normal thymus: CT characteristics in subjects under age 20

The chest computed tomographic (CT) scans of 40 subjects aged 20 or younger were analyzed retrospectively with special attention to the anterior mediastinum and the thymus. Thirty-four of the patients were considered to have normal CT appearances of the anterior mediastinum; neoplasm was suspected at this site in the other six. In the normal group, the gland was consistently identified as a characteristic anterior mediastinal structure. It had smooth, undulating, lateral contours tending to be convex laterally in the very young and concave laterally at an older age, although there was overlap in many in whom the shape of the lateral contours was a combination of convex, concave, or straight. A sharp angular contour to the lateral margin of the thymus was seen occasionally and is also thought to be characteristic of normal thymus. The posterior border of the gland molded to the heart and great vessels in all patients. The anterior contour was molded to the anterior chest wall or had a pointed shape directed toward the sternum. Molding to the mediastinum and chest wall was not found or was present to only a limited degree in the patients with anterior mediastinal tumor. Attenuation values varied between different normal glands and within the same gland on both pre- and postcontrast scans. Recognition of normal variation in the CT appearance of the thymus in young patients may prevent false-positive diagnosis of neoplasm.

The direct visualization of blood flow by real-time ultrasound: clinical observations and underlying mechanisms

The observation of spontaneous low-amplitude echoes from the blood in the larger blood vessels has not been satisfactorily explained. In vitro experiments were performed to study flowing and stationary blood by ultrasound. In both cases numerous low-level echoes were seen in blood and suspensions of washed red cells. No echoes were observed in plasma or solutions of hemoglobin. It was concluded that the red blood cells is the most likely scattering agent responsible for the contrast effect observed clinically.

Glenn shunt: long-term results and current role in congenital heart operations

Fifty cyanotic patients (aged 2 days to 22 years) underwent Glenn shunts for tricuspid atresia and other cyanotic heart defects. Thirteen of 15 operative deaths occurred in infants less than 4 months old, and only 1 death has occurred in the last 9 years. Results were poor in patients with Ebstein's anomaly, truncus arteriosus, transposition of the great vessels, and complex defects other than tricuspid atresia and univentricular heart. Of the 35 patients followed from 0.9 to 14.8 years, 12 were followed for more than 10 years. None of the 11 late deaths could be attributed to complications of the shunt. Minimal evidence of intrapulmonary shunting was found by angiography, pulmonary venous oximetry, or radioisotopic studies. Late deterioration due to venous collaterals and decreased flow to the opposite lung necessitated Blalock-Taussig shunts in 6 and Fontan procedures in 10. All survived the Fontan procedures with minimal morbidity. These data support the concept that Glenn shunts do not necessarily result in pulmonary abnormalities and may be indicated as a staged procedure in a few selected patients prior to a Fontan procedure.