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Biomedical subjects

D G Ritter

Publications and source records attributed to D G Ritter.

At least 73 records · Page 4Linked to original sources
PubMed1978

Clinical, angiographic, and hemodynamic assessment of late results after Mustard operation.

Since 1974, late results of the Mustard procedure for correcting complete transposition of the great arteries have been evaluated by cardiac catheterization, electrocardiography, roentgenography, history, and physical examination of 48 Mayo Clinic patients. Of these, 15 were studied 1 month to 2 years postoperatively because of clinical deterioration. The other 33 had been asymptomatic but were asked to return for hemodynamic reevaluation one-half to 11 years postoperatively. Of the asymptomatic group, 19 underwent exercise electrocardiography prior to catheterization and eight performed supine exercise during catheterization. Cardiac catheterization proved the most effective mode of study. Significant cardiovascular abnormalities (caval obstruction, residual pulmonary stenosis, etc.) were found in 35 of the 47 patients--including 20 of the 33 who were asymptomatic. Eight of the symptomatic group and three of the others have died since this restudy. These poor results warrant renewed effort to devise better methods for correcting complete transposition,

Cardiac Catheterization↗
PubMed1978

Echocardiographic spectrum of tricuspid atresia.

Standard M-mode and contrast echocardiographic features of 35 patients with tricuspid atresia are reported. These features included a single posteriorly located atrioventricular valve with large excursion, often demonstrating the pattern of systolic prolapse, mitral semilunar valve continuity, and small right ventricular chamber. Left ventricular dimension and left ventricular posterior wall thickness were usually increased. Ventricular septal and posterior wall excursion and percent thickening of the left ventricular posterior wall were in the normal range in most cases. However, fractional shortening of the left ventricular minor diameter was below normal in most patients (26/29, 90%) regardless of the age at presentation. A characteristic and reproducible flow pattern of contrast medium was also observed. After systemic venous injection of indocyanine green, the resultant echoes initially appeared in the left atrium and subsequently, via the mitral valve funnel, appeared in the left ventricular cavity. If a small right ventricular chamber could be recorded, this chamber filled with subsequent systole except in patients with intact ventricular septum. With the use of these M-mode echographic features, along with contrast studies, diagnosis of tricuspid atresia can confidently be established at the bedside and can readily be distinguished from other cyanotic congenital defects.

Adolescent↗
PubMed1978

Double-outlet right ventricle. Anatomic and angiocardiographic correlations.

A series of 72 patients with proved double-outlet right ventricle was studied with reference to the ability of angiocardiography to determine the location of a ventricular septal defect when it was associated with various great-artery relationships. Only 2 of the 72 patients had an intact ventricular septum. The other 70 patients had 16 possible anatomic variations based on four positions of the ventricular septal defect (subaortic, subpulmonary, subaortic and subpulmonary, and remote type) and four great-artery relationships (normal, side by side, dextromalposition, and levomalposition). Using the hemodynamic information regarding systemic and pulmonary arterial saturations, combined with biplane angiocardiographic data from the right ventricle (and if possible with left ventriculography), one can predict the location of ventricular septal defect. Because the different types of double-outlet right ventricle have different surgical approaches, this information can be important to the surgeon.

Angiocardiography↗
PubMed1978

Successful repair of double-outlet right ventricle, complete atrioventricular canal, and atrioventricular discordance associated with dextrocardia and pulmonary stenosis.

The association of complete atrioventricular canal with other complex congenital cardiac anomalies has represented a significant challenge for the cardiac surgion. The combination of double-outlet right ventricle with complete atrioventricular canal has been particularly difficult to correct, with no surgical successes having been reported until recently. This is a report of the first successful repair of double-outlet right ventricle, complete atrioventricular canal, and atrioventricular discordance (ventricular incersion) associated with common atrium, bilateral superior venae cavae, dextrocardia, and pulmonary stenosis. The specialized conduction tissue was identified by intracardiac electrophysiological mapping, and normal sinus rhythm was preserved. Postoperative cardiac catheterization showed excellent hemodynamics. One year postoperatively, the patient was attending school, playing swimming without difficulty, and taking no cardiac medications. This good result lends encouragement for considering total repair for similar patients with the combination of double-outlet right ventricle, complete atrioventricular canal, and other associated congenital cardiac anomalies.

Angiocardiography↗
PubMed1977

False aneurysm of the descending aorta: a complication of umbilical artery catheterization.

A patient had an aneurysm of the descending aorta secondary to aortitis arising from umbilical artery catheterization and in association with coarctation of the aorta. The aortitis probably was the direct result of bacterial contamination of the umbillicus and catheter with Staphylococcus aureus and the placement of the catheter tip just distal to a coarctation of the aorta. The patient required surgical resection of the coarctation and aneurysm of the descending aorta and placement of a tubular Dacron graft at 6 month of age. This is, to our knowledge, a hitherto unreported complication of umbilical artery catheterization.

Aneurysm, Infected↗
PubMed1977

Peripheral venous contrast echocardiography.

Contrast echocardiography is the technique of injecting various echo-producing agents into the bloodstream and, with standard echocardiographic techniques, observing the blood flow patterns as revealed by the resulting cloud of echoes. These techniques have only recently been utilized to evaluate various cardiac defects. Two physical properties of these agents characterize their usefulness: (1) clouds of echoes can be observed downstream as well as at the injection site, and (2) the echo-producing quality of these agents is completely lost with a single transit through either the pulmonary or the systemic capillary bed. Thus, detection of resultant echoes in both the venous and the arterial blood pool is indicative of abnormal shunting. In 60 patients with a spectrum of cardiac defects and a wide range in age of presentation, studies were made of (1) the feasibility of performing contrast echocardiography with superficial peripheral venous injections, and (2) the clinical usefulness of this relatively noninvasive technique in detecting and localizing intracardiac right ot left shunting. Most superficial peripheral veins could be utilized, and the resultant contrast echograms were reproducible and similar in quality to those obtained more central (caval) injections. Right to left shunts could be localized in the atrial, ventricular or intrapulmonary level. Characteristic flow patterns were also recognized for tricuspid atresia and common ventricle.

Adolescent↗
PubMed1977

Echocardiogram in common (single) ventricle: angiographic-anatomic correlation.

Common ventricle is a rare congenital anomaly in which the ventricular chamber receives blood from two separate atrioventricular (A-V) valves or a common A-V valve. Diagnosis of common ventricle was established in 55 patients aged 3 months to 33 years (mean 10 years) at cardiac catheterization in all 55 and at operation or autopsy in 24. In common ventricle with two angiographically demonstrable A-V valves (47 patients), the echocardiographic features included: (1) simultaneous recording (in the same sonic beam with the transducer held stationary) of the echoes of an anterior and a posterior A-V valve without an intervening septal echo (45 of 47 patients); (2) absence, on a base to apex scan, of the ventricular septal echo in the usual position separating the A-V valves (47 of 47 patients); (3) recording, in patients with common ventricle and outflow chamber, of this small outflow chamber anterior to the A-V valves (20 of 23 patients); and (4) recording of echographic continuity of the posterior A-V valve and great artery (27 of 31 patients). In common ventricle with a common A-V valve (8 patients), the echocardiographic features included: (1) a single demonstrable A-V valve, located posteriorly in the ventricle, which showed a large amplitude of excursion during diastole; and (2) absence of a second A-V valve echo or ventricular septal echo. Eight patients were studied postoperatively after surgical correction by ventricular septation. Echographic features included visualization of a prosthetic septum that produced a dense echo and divided the common ventricle into "right" and "left" ventricular chambers. This septum had a large excursion anteriorly during systole. Because common ventricle is now amenable to surgical correction, echocardiography should play an important role in assessment of ventricular anatomy in this complex congenital cardiac defect.

Abnormalities, Multiple↗
PubMed1977

Contrast echocardiography in single or common ventricle.

Common ventricle is a rare congenital anomaly in which the ventricular chamber receives blood from two separate atrioventricular valves or from a common atrioventricular valve. We used contrast echocardiography during cardiac catheterization to confirm ventricular anatomy and to characterize blood flow dynamics in 35 patients with common ventricle. After injections of dye, a cloud of echoes anterior to the mitral valve echo during the rapid inflow phase of ventricular diastole is indirect evidence of common ventricle with two atrioventricular valves. Common ventricle with an outflow chamber is characterized by a smaller ventricular chamber visualized anterior to both atrioventricular valves which opacifies with subsequent ventricular systole. The arrival of all dye posterior to the only recorded atrioventricular valve further established the presence of a single atrioventricular valve. These contrast flow patterns gave greater specificity to the standard M-mode echocardiographic assessment of patients suspected of having common ventricle.

Adolescent↗
PubMed1977

Truncus arteriosus with unilateral absence of a pulmonary artery. Criteria for operability and surgical results.

In 15 of 126 (12%) patients with truncus arteriosus who were catheterized at the Mayo Clinic from 1967 through 1975, natural agenesis of one pulmonary artery was present. Ten truncus patients with either natural or acquired absence of one pulmonary artery have undergone definitive operation. The criteria for operability, based on a calculation of pulmonary resistance, are different in patients with single pulmonary artery than in patients with two pulmonary arteries. Study revealed that, if the calculated pulmonary resistance in the patient with single pulmonary artery is halved, this new value provides a more reliable assessment of the reactivity of the pulmonary arteriolar bed than does the total calculated pulmonary resistance value. Follow-up information suggests that the patient with single pulmonary artery may be at potentially high risk of continued progression of pulmonary vascular disease after surgical correction, possibly because of the postoperative obligatory increased flow through the single pulmonary arteriolar bed as a result of the entire cardiac output passing through it. Surgical correction of truncus arteriosus during infancy, before significant pulmonary vascular disease has developed, appears to be particularly desirable in this subgroup of patients with single pulmonary artery.

Adolescent↗
PubMed1977

Systemic collateral and pulmonary artery stenosis in patients with congenital pulmonary valve atresia and ventricular septal defect.

Angiograms of 30 patients with congenital pulmonary valve atresia, ventricular septal defect, and large systemic-pulmonary collateral arteries (SPCAs) were evaluated. All had aortography, 28 had SPCA arteriography, and 26 had right ventriculography. Seventeen (65%) of 26 patients had a right ventricular infundibulum, 23 (77%) had a pulmonary artery confluence, and five of the nine patients without a right ventricular infundibulum had a confluence. Sixty-six SPCAs of aortic origin were seen; 28 (42%) had narrowing and 21 patients (70%) had one or more narrowed SPCAs. Five patients had collaterals from internal mammary, subclavian or innominate arteries. Fourteen (47%) had hilar pulmonary artery stenosis. Of these 14 patients mild peripheral stenosis was demonstrated in five. Right aortic arch was present in 15 patients (50%). Complete angiographic delineation of pulmonary vasculature is an essential procedure for preoperative detection of pulmonary and SPCA stenoses in these patients.

Adolescent↗
PubMed1977

Cardiac rhabdomyoma simulating mitral atresia.

Clinical, catheterization, and pathologic findings were recorded in a newborn infant with tuberous sclerosis and multiple cardiac rhabdomyomas that produced a clinical picture simulating mitral atresia and the hypoplastic left-heart syndrome. The clinical picture was due to a left atrial tumor that completely obstructed the mitral valvular orifice. Even if the diagnosis of left atrial tumor had been made, successful surgical correction was unlikely because of left ventricular rhabdomyomas, which produced severe subvalvular aortic stenosis and did not appear to be resectable. This case demonstrates the possibility that a hamartoma, such as a rhabdomyoma, occasionally can mimic the hypoplastic left-heart syndrome.

Abnormalities, Multiple↗
PubMed1977

Correction of the univentricular heart having two atrioventricular valves.

Problems associated with the early evolution of corrective operation (septation) for univentricular heart (single or common ventricle) are illustrated in a total experience of 36 such operations, 30 of which were recent. Complete heart block existed preoperatively in five of the 30 patients and developed at operation in another 10; only two of these 15 patients attained a satisfactory result. Associated pulmonary stenosis was present in 16 patients, and this seemed to influence the result favorably. An extracardiac conduit between the right-sided ventricular chamber and the distal pulmonary trunk was employed in 20 patients. The presence of associated anomalies, including function of the atrioventricular valves in seven, had a highly unfavorable influence on the result. Although all seven of the most favorable candidates attained a satisfactory result, only 13 (43 percent) in the total group of 30 attained a satisfactory result. Further evolution of this operation, as in previous operations for complex congenital heart disease, should provide more results that are satisfactory.

Adolescent↗
PubMed1977

Straddling right atrioventricular valve in criss-cross atrioventricular relationship.

Two cases of complex congenital heart disease are described in which systemic and pulmonary bloodstreams crossed at the atrioventricular level. Both patients were examined clinically, echocardiographically, and by cardiac catheterization, including angiography, and both underwent cardiac surgery and had intraoperative mapping of their conduction systems. Both patients were found to have levocardia and situs solitus of viscera and atria, large ventricular septal defect, and straddling right atrioventricular valve. One patient had atrioventricular discordance but with the left ventricle anterior and alightly on the right and with pulmonary atresia and dextromalposition of the aorta. The other patient had atrioventricular concordance but with the left ventricle inferior and slightly on the left and with ventricular-arterial concordance to normally related great arteries and banded pulmonary trunk. To our knowledge, this combination including straddling right atrioventricular valve has not been reported in the literature before. In both patients the straddling atrioventricular valve was thought to preclude corrective operation at that time. A unique palliative procedure--left ventricle-to-pulmonary trunk shunt--was successful in the first case and partial debanding of the pulmonary trunk in the second.

Cardiac Catheterization↗
PubMed1977

A criss-cross heart. Detailed anatomic description and discussion of morphogenesis.

Hearts with criss-cross atrioventricular connections are rare. Reports in the literature describe great anatomic variations with regard to the atrioventricular connections, spatial relationships of the ventricles, and connections and spatial relationships of the great arteries. In the example described in this report, the basic anatomic picture was that of transposition of the great arteries, but the criss-cross atrioventricular valves had resulted in atrioventricular discordance; hemodynamically, therefore, the situation resembled congenitally corrected transposition. One hypothesis for this anatomic configuration is that pronounced counterclockwise rotation (as viewed from below) brought the ventricular septum into a frontal plane and altered the respective positions of the pulmonary and aortic valves from those usually seen in congenitally corrected transposition and thereby resulted in crossed atrioventricular connections. An alternative hypothesis is that in this case one of the atrioventricular valves (the anteriorly positioned valve) may represent an anomalous communication that developed early in embryogenesis and connected the left atrial appendage to the right ventricular infundibulum.

Child↗
PubMed1976

Truncus arteriosus and previous pulmonary arterial banding: clinical and hemodynamic assessment.

Twenty-seven patients with truncus arteriosus and previous pulmonary arterial banding were evaluated 1 1/2 to 14 years (mean 7 years) after banding. Ages at the time of cardiac catheterization ranged from 3 to 18 years (mean 9 years). Current symptoms were severe in five patients and were related to truncal valve incompetence or decreased pulmonary blood flow (or both) rather than to age, duration of palliation or band location. Twenty-one of 22 patients with two pulmonary arteries were considered to be in a hemodynamically operable state at the time of study. The condition of three of five patients with a single pulmonary artery was subsequently found inoperable because of severe pulmonary vascular disease in the lung supplied by the single pulmonary artery. In patients with two pulmonary arteries, demonstration of low pressure in at least one normal-sized pulmonary artery established operability. Postoperative pressure measurements correlated well with preoperative prediction of operability, with 19 of 20 patients having a pulmonary arterial pressure less than 70 percent of systemic levels after repair. Bilateral pulmonary arterial binding may be more effective than central arterial banding (which frequently produces severe obstruction to the right pulmonary artery) in preventing pulmonary vascular obstructive disease in patients with truncus arteriosus who have two pulmonary arteries. Patients with truncus arteriosus and a single pulmonary artery with pulmonary arterial banding remain at high risk for the development of pulmonary vascular obstructive disease.

Adolescent↗
PubMed1976

Double outlet right ventricle: hemodynamic and anatomic correlations.

There are 16 possible variations of double outlet ventricle with regard to interrelations of the great arteries and to location of the ventricular septal defect. In a series of 62 cases, approximately two thirds of patients had the great arteries in a side by side relation, and most (28 of 41) had the ventricular septal defect in a subaortic position. In double outlet right ventricle with malposition of the great arteries, the ventricular septal defect was either subpulmonary or subaortic. Four of the 13 patients with subpulmonary ventricular septal defect had a supracristal defect with side by side relation of the great arteries (Taussig-Bing anomaly), and 9 patients had malposition of the great arteries with an infracristal ventricular septal defect. In all patients with subpulmonary ventricular septal defect, pulmonary arterial oxygen saturation was greater than systemic arterial saturation regardless of the relation of the great arteries. Forty patients had subaortic ventricular septal defect. In 24 of these patients, including 7 with malposition of the great arteries, systemic arterial oxygen saturation was greater than pulmonary arterial saturation. However, in 9 patients (25 percent) the reverse was true, as seen in complete transposition of the great arteries and in Taussig-Bing anomaly. Thus, pulmonary arterial oxygen saturation greater than systemic arterial saturation is not reliable evidence of a Taussig-Bing anomaly. Of the 25 patients with such saturation, only 4 had the Taussig-Bing anomaly.

Adolescent↗