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Biomedical subjects

F J Macartney

Publications and source records attributed to F J Macartney.

At least 55 records · Page 3Linked to original sources
PubMed1984

Continuous wave Doppler velocimetry as an adjunct to cross sectional echocardiography in the diagnosis of critical left heart obstruction in neonates.

If cross sectional echocardiography in isolation is used to diagnose critical left ventricular outflow obstruction in neonates, false positive and false negative diagnoses may result. Continuous wave Doppler velocimetry was used to measure blood flow velocity in the ascending and descending thoracic aorta in six neonates (aged less than 6 weeks) presenting with reduced or absent peripheral pulses in order to determine the important sites of obstruction. This technique demonstrated abnormal high velocity blood flow jets (three times higher than normal) in the ascending aorta in three patients with normal descending aortic flow velocity, suggesting aortic stenosis. In the other three patients velocity in the ascending aorta was normal but high in the descending aorta, suggesting coarctation. The Doppler diagnosis was confirmed in the five patients who required surgery. Two patients had residual high velocity jets after aortic valvotomy. Both had significant pressure gradients across the aortic valve at cardiac catheterisation with good agreement between actual gradients and those predicted by the Doppler technique. Thus a combined anatomical and physiological approach using cross sectional echocardiography and continuous wave Doppler velocimetry enables accurate non-invasive definition of the site of left ventricular outflow obstruction and may obviate the need for invasive investigation in these sick neonates.

Aortic Coarctation↗
PubMed1984

Effect of prostaglandin on early surgical mortality in obstructive lesions of the systemic circulation.

To examine the effect of preoperative prostaglandin infusion on surgical mortality the records of all patients aged less than or equal to 28 days operated between January 1979 and December 1981 for obstructive lesions of the systemic circulation were reviewed. Forty patients had coarctation of the aorta, five interrupted aortic arch, and seven critical aortic stenosis. Fourteen patients received intravenous prostaglandin before operation. Among preoperative variables low cardiac output was identified as a possible risk factor for hospital death, whereas the presence of a raised blood urea concentration was possibly significantly associated with hospital mortality only in patients not treated with prostaglandin. The preoperative administration of prostaglandin had a strongly favourable influence: 11 out of 38 (29.0%) patients who did not receive prostaglandin died compared with none of 14 treated with prostaglandin. The two groups were otherwise comparable with respect to the incidence of coagulopathy, urgency of operation, associated anomalies, and other medical treatment. Mean age at operation was younger and mean admission blood urea concentration higher in the group treated with prostaglandin, whereas the incidence of preoperative low cardiac output was probably higher. It is concluded that short term preoperative infusion of prostaglandin in associated with a significant reduction in early surgical mortality in this high risk group of infants.

Alprostadil↗
PubMed1984

Management of critical aortic stenosis in infancy.

Critical aortic valvular stenosis presents in infancy with severe congestive heart failure. Clinical assessment and electrocardiography are of value, but cardiac catheterization with angiography has been considered mandatory prior to surgical treatment. With cross-section echocardiography an accurate diagnosis of aortic stenosis and associated lesions is possible. Over the past 2 years, we have established a protocol according to which, if a clinical diagnosis of critical aortic stenosis is confirmed by cross-sectional echocardiography in the absence of major associated cardiac anomalies, infants are submitted for aortic valvotomy under inflow occlusion without invasive studies. This protocol was used in an effort to decrease the mortality rate by avoiding the preoperative stress of cardiac catheterization and angiography, as well as the hazards of cardiopulmonary bypass in the severely ill infant. Eight infants with critical aortic stenosis have been operated upon, five without prior cardiac catheterization. Ages at operation ranged from 2 days to 7 months, with six children less than 2 weeks of age. The noninvasive diagnosis was confirmed at operation in each case. There was one early postoperative death and one late death. No death has been related to the technique of inflow occlusion. A decision tree for the noninvasive assessment of suspected critical aortic stenosis based on the clinical features and echocardiographic findings is presented.

Aortic Valve↗
PubMed1984

The surgical anatomy of hearts with no direct communication between the right atrium and the ventricular mass--so-called tricuspid atresia.

Seventy-six hearts were studied having no direct communication between the right atrium and the ventricular mass. The different cardiac chamber combinations producing so-called "tricuspid atresia" were considered. The nature of the atrioventricular valve atresia, the morphology of the ventricular mass, the size and position of the interventricular communication, the ventriculoarterial connection, and the presence of subarterial outflow tract obstruction were all analyzed. The majority of cases were of the "classical" type, i.e., absent right atrioventricular connection with the left atrium connected to the left ventricle. In another group there was absence of the right atrioventricular connection but the left atrium drained into the morphologically right ventricle, which was left-sided. In a third group both atrial chambers connected with the ventricular mass but some structure, an imperforate valve or muscular partition, completely blocked the flow pathway through the right side of the heart. All the hearts described are candidates for the Fontan procedure with either an atrioventricular or an atriopulmonary conduit. The surgical options would not be affected by the observed variability at the atrioventricular junction but would be dictated by the feasibility of incorporating the subpulmonary ventricle within the pulmonary circulation.

Heart Atria↗
PubMed1983

Surgical anatomy of double-outlet right ventricle--a reappraisal.

In light of the recent developments in surgical treatment of double-outlet right ventricle, the anatomic observations on this lesion were reevaluated. For this review, double-outlet right ventricle was diagnosed when more than half of both arterial valves were connected to the same ventricle, although appreciating the reasons for using, in a clinical context, a "90% rule" rather than the "50% rule" used in this review. Although this ventriculo-arterial connection can exist with any segmental combination, most often it is found in the setting of usually arranged atrial chambers (solitus) and atrioventricular concordance. Categorization of this subset is then done on the basis of the relationships of the arterial trunks. Three main groups stand out: intertwining arterial trunks and "normally related" arterial valves, and parallel trunks, but with the aortic valve to the right side or left side. These groupings give information concerning the site of the ventricular septal defect, which in any group may be perimembranous, muscular or be doubly committed and subarterial. Infundibular morphology is also variable, and the proximity of the arterial valves to the roof of the defect is largely determined by the extent of the ventriculo-infundibular fold.

Heart Defects, Congenital↗
PubMed1983

Congenital heart disease in the neonate: results of surgical treatment.

All 212 neonates undergoing cardiac surgery at this hospital during the 5-year period from 1976 to 1980 inclusive were reviewed. Forty required open heart surgery with 23 (57%) deaths. One hundred and seventy-four neonates underwent non-bypass procedures and could be divided into three groups: group 1 (82 patients) had inadequate pulmonary blood flow, group 2 (33 patients) had increased pulmonary blood flow or inadequate mixing, and group 3 (59 patients) had coarctation of the aorta, alone or with associated lesions. Forty-four (25%) of the neonates undergoing non-bypass procedures died. Two required bypass surgery later in the first month of life. Metabolic acidosis and the need for preoperative respiratory support were appreciably greater in non-surviving patients. The spectrum of diagnoses encountered and types of operative procedures performed are analysed.

Cardiac Surgical Procedures↗
PubMed1983

Morphological characterisation of ventricular septal defects associated with coarctation of aorta by cross-sectional echocardiography.

Cross-sectional echocardiograms of 18 neonates and infants with coarctation of the aorta and ventricular septal defect were retrospectively assessed. With a combination of subcostal and precordial cuts the site and anatomical relations of the defects were determined. In one case there was a muscular trabecular ventricular septal defect. Three had a malalignment defect with associated left ventricular outflow tract obstruction. In two there was a doubly committed subarterial defect with associated malalignment of the point of continuity between the aortic and pulmonary valves and the crest of the trabecular septum. Twelve cases had a perimembranous defect, with varying degrees of extension into the inlet, trabecular, or outlet septum. In this group 10 had associated aortic override, with varying degrees of left ventricular outflow tract narrowing. Abnormal insertion of the tricuspid valve was observed in 10 cases, such that it partly obscured the ventricular septal defect. Thus in most cases of coarctation with ventricular septal defect, the morphology of the ventricular septal defect and ventricular outflow tracts is such that left ventricular ejection is directed towards the pulmonary artery rather than the aorta.

Aortic Coarctation↗
PubMed1983

Cross-sectional echocardiographic assessment of coarctation in the sick neonate and infant.

To establish an integrated non-invasive method for diagnosing coarctation, cross-sectional echocardiographic appearances of 48 neonates and infants with coarctation were combined with clinical information on the peripheral pulses. Measurements of the ascending aorta, aortic arch, and isthmus were made and compared with those from controls matched for weight and age. Confirmation of the coarctation was available in all cases. Angiocardiographic measurements were performed in 15 patients from either the group with coarctation or the controls. After the aortic arch had been analysed segment by segment 40 patients were found to have preductal coarctation, five juxtaductal coarctation, and three postductal coarctation. In one of the patients in the latter group the obstruction was situated in the abdominal aorta. Specific echocardiographic features were present in each subgroup. Echocardiographic measurements were about two thirds of those obtained by angiocardiography. By combining information on the peripheral pulses, isthmic size, and the presence of a discrete shelf in the aorta it was retrospectively possible to predict correctly the presence of coarctation in 45 out of 48 cases. Since the beginning of this study 29 patients have undergone surgery without prior invasive investigation. A combination of clinical assessment and cross-sectional echocardiographic features allows a reliable diagnosis of coarctation to be made in most cases.

Angiocardiography↗
PubMed1983

Use of a subpulmonary ventricular chamber in the Fontan circulation.

In order to study the usefulness of incorporating a subpulmonary ventricular chamber (SPVC) in the Fontan circulation, we compared the hemodynamics of 18 patients who underwent an atriopulmonary connection with those of 17 patients with an atrioventricular connection. Early postoperatively, regardless of whether an SPVC was incorporated or not, the mean pulmonary artery pressure was not higher than the mean right atrial pressure in any of our patients. The stroke work of the right heart was at best zero, and pressure tracings showed an a wave in the pulmonary artery (right atrium-dependent circulation). If an additional gradient was interposed between the right atrium and pulmonary artery, the effective stroke work of the right heart might be negative and the work curve have a negative slope. This can occur irrespective of the use of an SPVC. In the long term, if it grows sufficiently, an SPVC can sometimes provide a right ventricle-dependent pulmonary circulation with a more normal hemodynamic pattern (mean right atrial pressure less than mean pulmonary artery pressure). We concluded that an SPVC should be used in Fontan's circulation, provided that an obstruction-free atrioventricular connection can be established.

Adolescent↗
PubMed1983

Surgery for congenital heart defects diagnosed with cross-sectional echocardiography.

Between August 1980 and July 1982, 70 children were operated on for congenital heart defects without the use of cardiac catheterization and/or angiocardiography (7.5% of the total of 929 operations). The diagnosis was established by clinical examination, chest x-ray, electrocardiography, and comprehensive cross-sectional echocardiography. The following lesions were repaired: coarctation of the aorta in infancy (n = 28), total anomalous pulmonary venous drainage (n = 6), aortic valvular/subvalvular lesions (n = 11), mitral and tricuspid valve lesions (n = 4), simple transposition of the great arteries (n = 3), vegetations (n = 3), persistent truncus arteriosus (n = 2), and others (n = 13). Three diagnostic errors occurred, and in four children the initial diagnosis was not complete. No child died as a consequence of an error or incomplete diagnosis, and in only one instance was an inappropriate operation carried out (abdominal coarctation of the aorta). We conclude that operation on selected patients can be safely performed on the basis of noninvasive investigation.

Aortic Coarctation↗
PubMed1982

Assessment of atrioventricular septal defects by two dimensional echocardiography.

Ninety-six patients with an atrioventricular septal defect were assessed by two dimensional echocardiography. Forty-eight patients were judged as having two discrete valve orifices. In this group, 37 had an intact ventricular septum and 11 a ventricular septal defect. Two patterns of attachment of the valve leaflets to the interventricular septum were noted. Forty-eight patients had a common valve orifice. In 29 patients there was absence of tethering of the anterior bridging leaflet to the interventricular septum. A further 19 had varying degrees of tethering of the anterior bridging leaflet. A ventricular septal defect was identified under the anterior bridging leaflet in all cases. In 58 cases where the posterior bridging leaflet was identified, a ventricular septal defect was visualised in eight and missed in two. Seventy-eight patients had an ostium primum defect, 12 a common atrium, and a further six an intact interatrial septum. Two dimensional echocardiography provides in depth morphological information about the type of atrioventricular defect and can correctly identify the presence of a ventricular septal defect beneath the anterior or posterior bridging leaflet, unless it exists between short crowded chordae.

Child↗
PubMed1982

Two dimensional echocardiographic assessment of communications between ascending aorta and pulmonary trunk or individual pulmonary arteries.

The value of two dimensional echocardiography in identifying communications between the ascending aorta and pulmonary trunk or individual pulmonary arteries was assessed in 24 children, all of whom had either angiocardiographic and surgical or angiocardiographic confirmation alone. Fourteen cases had truncus arteriosus, four aortopulmonary window, four anomalous origin of the left pulmonary artery from the ascending aorta, and two anomalous origin of the right pulmonary artery from the ascending aorta. It was possible to identify reliably each individual abnormality with a combination of suprasternal, precordial, and subcostal cuts. Problems only arose in differentiating truncus arteriosus from pulmonary atresia and ventricular septal defect when the main pulmonary artery and infundibular region of the right ventricle were extremely hypoplastic.

Aorta↗
PubMed1982

Isolated anterior mitral cleft. Two dimensional echocardiographic assessment and differentiation from "clefts" associated with atrioventricular septal defect.

Five patients with isolated clefts in the anterior leaflet of the mitral valve, unassociated with atrioventricular septal defects, are described. All had significant mitral regurgitation, with the cleft being the only abnormality in three. Two patients had an associated ventricular septal defect, one with a straddling right atrioventricular valve. Angiocardiography in four showed moderate regurgitation, but was not able to delineate the aetiology. Two dimensional echocardiography showed a constant defect in the anterior leaflet, pointing towards the left ventricular outflow tract. This differed from 30 cases with atrioventricular septal defects where the "cleft" pointed towards the interventricular septum and was situated between the anterior and posterior bridging leaflets. All cases with isolated clefts had surgical correction, with minimal residual regurgitation on follow-up examination in two cases. Our current policy in patients with uncomplicated isolated cleft involves non-invasive assessment of these children and surgical correction if the regurgitation is significant.

Diagnosis, Differential↗
PubMed1982

Two dimensional echocardiographic diagnosis of situs.

At present there is no reliable method of recognising atrial isomerism by two dimensional echocardiography. We therefore used two dimensional echocardiography to examine 158 patients including 25 with atrial isomerism and four with situs inversus. Particular attention was paid to the short and long axis subcostal scans of the abdomen. Using the position of the inferior vena cava and the aorta with respect to the spine it was possible to separate those with situs solitus from the others. Two false positives for abnormal situs had exomphalos. In situs solitus the aorta lay to the left of the spine and the inferior vena cava lay to the right. One patient with situs solitus and azygos continuation of the inferior vena cava also had inferior vena cava to right atrial connection. In the four patients with situs inversus the mirror image of the normal pattern was present. In nine patients with right isomerism the inferior vena cava and aorta ran together on one or other side of the spine. The inferior vena cava, anterior to the aorta at the level of the diaphragm, received at least the right hepatic veins (normal or partial anomalous hepatic venous connection). Of the 16 patients with left isomerism, 14 had azygos continuation of the inferior vena cava which was visualised posterior to the aorta in all but two. All patients with left isomerism had total anomalous hepatic venous connection to one or both atria via one or two separate veins. Two dimensional echocardiography therefore provides the means of detecting abnormal atrial situs and of diagnosing right or left isomerism in the great majority of patients, if not all.

Adolescent↗