The intermittent ductus revisited: echocardiographic evidence and successful coil occlusion: a case report and review of literature

Intermittent occurrence of a large ductal shunt by physical examination and Doppler echocardiography is reported. Cineangiography confirmed a tubular ductus arteriosus with an angulated, narrow, pulmonary end. Presumably this angulation intermittently caused functional closure of the ductus. Trans-arterial delivery of coils resulted in complete occlusion.

Severe hemolysis following partial coil-occlusion of patent ductus arteriosus

Severe hemolysis occurred in a one-year-old boy following partial coil occlusion of a patent ductus arteriosus with a small but high-velocity residual shunt. Hemolysis abated rapidly and completely after placement of a second coil fully occluded the ductus.

Recovery from pulmonary hypertension in an adolescent with mixed connective tissue disease

This paper describes the case of an 11 year old girl who presented with mixed connective tissue disease which was complicated by the development of pulmonary hypertension. This case is unique with respect to the young age of onset, the serial non-invasive method used to follow the disease process, and the favourable response to treatment with vasodilator and anti-inflammatory drugs.

Transient third-degree atrioventricular block in a 4-year-old child with familial dysautonomia

The case of a transient third degree atrioventricular block in a 4-year-old patient with familial dysautonomia is reported. A review of the literature follows with analysis of the significance of arrhythmias in the natural history of the patient with familial dysautonomia.

Successful modified Fontan procedure in an adolescent after left pneumonectomy

We performed a Waterston's anastomosis on a patient with complicated tricuspid atresia when she was two months of age. At age 14 years she required left pneumonectomy for massive, idiopathic hemoptysis. Four months after the pneumonectomy we substituted a modified Fontan anastomosis for the Waterston anastomosis. Restudy when she was 17 years of age showed continued satisfactory function.

Congenital fistulous tract between aorta and right atrium presenting as heart failure in a newborn

A newborn with a fistulous communication between the right coronary sinus and right atrium had congestive heart failure on the first day of life. Medical management was unsuccessful and operative repair was performed using bypass surgery at 5 days of age. Echocardiographic evaluation preoperatively diagnosed the defect correctly and postoperatively confirmed a complete repair. Since aneurysms and/or fistulae can occur in other sinuses after an initial repair of the presenting lesion, the infant will continue to be followed with periodic echocardiographic and clinical evaluations.

Use of saphenous vein allografts for aortopulmonary artery anastomoses in neonates with complex cyanotic congenital heart disease

A saphenous vein allograft was used to create an aortopulmonary communication in 16 infants with cyanotic congenital heart disease and ductus-dependent pulmonary blood flow. These grafts measured from 3 to 8 mm in diameter and were placed between the aorta and main pulmonary artery in eight patients, between aorta and right pulmonary artery in eight, and between aorta and left pulmonary artery in one (one child had two grafts). Before heparin was used, early in the series, four of these grafts occluded and three of the four infants died during attempted revision. Another infant died early from renal failure. Late mortality has claimed four: one from cerebral hemorrhage, two from hypoxia, and one at open-heart surgery for repair. There are eight late survivors (50%). Most of the allografts were used before small diameter Gore-Tex was available; in more recent patients, 4- to 6-mm Gore-Tex grafts have been used. In our most recent patient, however, the attempt to place a Gore-Tex graft was unsuccessful, but the more pliable saphenous vein graft was readily placed and an adequate shunt obtained. Both the saphenous vein graft and the Gore-Tex have the advantage of providing pulmonary flow without the higher risk of congestive failure or pulmonary hypertension seen in patients with a Waterston or Potts anastomosis. They are easier to perform, require less anesthesia time than the Blalock-Taussig shunt, last as long as the Blalock-Taussig when done under similar conditions, and are easy to take down at the time of total repair.

Cardiac tamponade secondary to chylopericardium following cardiac surgery: case report and review of the literature

Only four instances of isolated chylopericardium following cardiac operation have been reported previously. We encountered this complication in a young patient who was operated on for infundibular pulmonary stenosis. The etiology appears to be related to a combination of intraoperative lymphatic injury and catheter-related subclavian vein thrombosis, the latter potentially elevating pressure within the thoracic duct and thereby resulting in an accumulation of chyle within the pericardial space. Therapy for this problem usually includes partial pericardiectomy with or without ligation of the thoracic duct.

Successful excision of an atrial fibroma in a four-month-old male infant

This report presents an infant who was initially admitted with a pericardial effusion. Subsequent evaluation led to the diagnosis of a primary cardiac tumor. Excision of the tumor which arose from the atrial septum was possible only by removing most of the free right atrial wall and a portion of the septal leaflet of the tricuspid valve. Reconstruction of the tricuspid valve leaflet by reattachment of chordae and a partial annuloplasty was done with the right atrial wall being replaced using pericardial tissue. The histology of the tumor was compatible with a fibroma, a type not previously reported in this location in the pediatric age group. Twenty-one months following operation, the child was restudied and the catheterization revealed mild to moderate tricuspid regurgitation and no recurrence of the tumor. The child is now 4 years of age and remains asymptomatic with normal growth and development and no evidence of fibromatosis.

Anomalous right ventricular muscle bundle: clinical pitfalls and extracardiac anomalies

Seven patients with anomalous right ventricular muscle bundle are presented to emphasize possible pitfalls in the clinical diagnosis as based on physical examination, chest x ray, and electrocardiogram. Echocardiography, on the other hand, revealed abnormalities in all four of the patients on whom the study was done. The echocardiogram was directly responsible for a change in diagnosis and referral for a cardiac catheterization in one patient who had been followed for 19 years with the clinical diagnosis of a small ventricular septal defect. Four of the seven patients with anomalous right ventricular muscle bundle had extracardiac anomalies, one girl with an absent left thumb, and three patients, one girl and two boys, with left-sided renal anomalies. This high incidence of renal anomalies has not been previously reported in clinical or postmortem series.

Echocardiography in duchenne muscular dystrophy

The cardiac function of 36 males with Duchenne muscular dystrophy was evaluated by echocardiography, and the results were compared with the results of other tests of cardiac involvement, including serum creatine kinase isoenzyme evaluation, electrocardiography, chest x-ray, and physical examination of the heart and lungs. Although correlation between the various methods of assessment was not impressive, the echocardiographic technique appeared to be useful in evaluating and following the cardiomyopathy in these patients. Several aspects of left ventricular function were abnormal in most patients, and only two of the 36 had normal left ventricular size and function. Electrocardiographic abnormalities were also apparent in all patients, although the changes were mild in four of the 36. Clinical evaluation, isoenzyme determinations, and chest x-rays have not been useful in assessing cardiac function. The echocardiographic data on these 36 patients are presented in detail and the patients will now be followed sequentially to attempt evaluation of ongoing changes.

Echocardiographic patterns after mitral annuloplasty

18 adolescents and children who underwent mitral annuloplasty for severe mitral regurgitation were evaluated by echocardiography. In 7 patients studied preoperatively, mitral valve excursion ranged from 25 to 56 mm with E-F slopes from 92 to 160 mm/sec. 5 of the 7 patients showed mitral valve prolapse. The left ventricle was dilated in 6 and the left atrium was dilated in 4 patients. Postoperatively, the mitral valve excursion decreased ( range 15-26 mm; p less than 0.01) as did the E-F slope (range 44-100 mm/sec; 0.10 greater than p greater than 0.05). The prolapse pattern disappeared and the left heart chambers decreased in size. In these 7 patients and in 11 others studied postoperatively only, a common echocardiographic pattern was that of early anterior motion of the posterior mitral valve leaflet, which was not present preoperatively and was, therefore, tentatively ascribed to the technique of annuloplasty repair. No calciferation and no definite mitral steosis has occurred in the follow-up of these patients to date. Persistent left atrial/left ventricular dilatation appeared related to residual mitral regurgitation with or without atrial fibrillation.

Use of contrast echocardiography in the diagnosis of partial anomalous pulmonary venous connection

Contrast echocardiography is useful in diagnosing the presence of partial anomalous pulmonary venous connection, particularly when it occurs in association with an atrial septal defect. Injections of saline solution, Cardiogreen or the patient's own blood were made in the inferior vena cava, left atrium and pulmonary veins of 27 patients. In all patients, the inferior vena caval injections showed only right heart clouding with no evidence of a right to left shunt. In 21 patients, the left atrial and pulmonary venous injections showed clouding of both the right and left heart structures, indicating a left to right atrial shunt and normal pulmonary venous connection. In six patients, the left artrial injections showed right and left heart clouding, but the right pulmonary venous injections showed only right heart structures, indicating a left to right atrial shunt with partial anomalous pulmonary venous connection. Contrast echocardiography proved to be a sensitive method of diagnosing the anomalous venous connection without the use of dye curves. The method is not useful when a right to left atrial shunt is present and may show false positive results for partial anomalous pulmonary venous connection it left atrial visualization is not adequate during injection into the pulmonary vein.

Postoperative responses in 'prepared' child after cardiac surgery

Postoperative reactions of children and adolescents realistically prepared for cardiac surgery were analysed for acute and long-term responses. No cases of delirium or psychoses occurred in the 60 children while they were in hospital. Fifty sets of parents and children answered questionnaires 6 months to 4 years after operation (36 under 1 year, 8 from 1 to 3 years, and 6 over 3 years) and assessment of these showed only long-term reaction. Evaluation of reactions is presented by age and in detail. The children aged 2 to 7 years had the greatest number of negative reactions and the only long-term reaction also came from this group. Children 8 to 11 years of age had the least number of negative reactions and the highest number of positive gains. Adolescents, 12 to 19 years of age, were often concerned with their body image (wanted to be considered 'well', resented the scar, etc). From the standpoint of emotional stability and after effects, the 8 to 11-year-old group seemed to do best.

Why does a child with a normal heart undergo cardiac catheterization?

Children who have no heart disease at cardiac catheterization have usually been referred because of signs or symptoms on the background of a basal flow murmur. The ECG and chest x-ray are sometimes spurious and may lead to catheterization. Advances in noninvasive testing are helping to screen this population. Only in rare instances should the risks involved with catheterization be taken in a child with a basal flow murmur and no other evidence of heart disease.

Masked abnormal drainage of the inferior vena cava into the left atrium

A 6 year old boy with a large atrial septal defect, partial anomalous pulmonary venous drainage and unrecognized anomalous insertion of the inferior vena cava into the left atrium had cyanosis after closure of the atrial defect. Repeat study revealed direct drainage of the inferior vena cava into the left atrium with moderate arterial oxygen desaturation. At repeat operation an unusual positioning of the inferior vena cava was seen. After reopening of the atrial defect, the pulmonary venous and systemic venous drainage anomalies were identified. A Dacron patch was inserted so as to divert flow to the proper atrium. Repeat catheterization 3 months after operation revealed a normal heart with no obstruction; arterial oxygen saturation was normal. The child has continued to do well 3 years after operation.

Echocardiographic findings in a patient with primary pulmonary hypertension

This is a report of the echocardiographic findings in a 9-year-old white female with primary pulmonary arterial hypertension confirmed by catheterization and later at autopsy. The reported findings of an absent "a" wave, a flat diastolic E to F slope, and a midsystolic closure of the pulmonic valve were observed. In addition, tricuspid valve prolapse was noted. Prolapse of the tricuspid valve may be part of the mechanism of tricuspid insufficiency in a patient with pulmonary hypertension.

Serial studies of pulmonary stenosis in infancy and childhood

Thirty-five children with pulmonary stenosis were catheterized from 1 day to 9 years of age and recatheterized after 2 weeks to 15 years. Right ventricular systolic pressure rose in 24 and the increase was greater in those under than over 5 years old. Pulmonary valve orifice area per square metre of body surface area increased in 12, but did not change in 3, and fell in 17; absolute decrease in calculated orifice area was usually associated with infundibular hypertrophy. Increase in right ventricular systolic pressure with age was thus caused by failure of the valve orifice to grow fast enough to keep pace with the increase of stroke volume. In the whole group, increasingly severe pulmonary stenosis was matched by increasing electrocardiographic evidence of right ventricular hypertrophy. However, in individual patients the electrocardiogram could suggest that right ventricular pressure had decreased when in fact it had risen considerably.

Pulmonary atresia with cyanosis. Report of two cases with ventricular septal defect and increased pulmonary blood flow

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