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Biomedical subjects

F J Macartney

Publications and source records attributed to F J Macartney.

At least 91 records · Page 5Linked to original sources
PubMed1981

Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. Effect of systemic pulmonary anastomosis.

In nine patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries, the effect of a systemic-pulmonary anastomosis on the lung was studied by comparison of pre- and postoperative cine angiograms. Selective injections into the collateral arteries were performed in all patients and the source of blood supply to each bronchopulmonary segment was sought. Central pulmonary arteries were present in six children and absent in three, as confirmed at thoracotomy. After insertion of a shunt, central pulmonary arteries increased in size, but the intrapulmonary vessels with which they connected remained abnormally small and were frequently stenosed. In addition, in each case the central pulmonary arteries increased flow to only five to 11 segments of lung. In the absence of central pulmonary arteries, shunting to a hilar or a lobar pulmonary artery increased perfusion to five to nine segments of lung per case. In all these three cases the pulmonary arteries at lobar level showed aneurysmal dilatation proximal to a severe stenosis. Sixty-eight per cent of collateral arteries were stenosed. The findings suggest that in this anomaly, when the central pulmonary arteries are hypoplastic, the intrapulmonary branches are also hypoplastic, emphasising the need for early surgical intervention to increase blood flow while the lung still has growth potential. Further, one collateral artery may connect with at least as many bronchopulmonary segments as does a central pulmonary artery, and the peripheral intrapulmonary arteries with which it connects may appear at least as normal angiographically as do vessels connected to central pulmonary arteries. These observations suggest that segments of lung connected to collaterals alone should, and sometimes can, be connected to central pulmonary arteries, the aim being to produce a unifocal blood supply as a prelude to total correction.

Adolescent↗
PubMed1981

Analysis of atrioventricular junction, ventricular mass, and ventriculoarterial junction in 43 specimens with atrial isomerism.

We have analysed the atrioventricular junction, ventricular mass, and ventriculoarterial junction in 43 hearts with isomeric atrial chambers. Of the hearts, 32 had atrial chambers of bilateral right morphology while 11 had atrial chambers with bilateral left atrial characteristics. Among the hearts with right atrial isomerism, there were 13 biventricular hearts, all with ambiguous atrioventricular connection. Eight had a common valve and five had two atrioventricular valves. In the other 19 hearts, the atrial chambers were connected to only one ventricular chamber, 18 having double inlet ventricle through a common valve and the other having absence of the left atrioventricular connection. In these univentricular hearts, all possible types of ventricular morphology were found. The ventriculoarterial junction among these hearts with right isomerism showed great variation. In the hearts with left atrial isomerism, nine hearts had two ventricles and two were univentricular. The biventricular hearts all had ambiguous atrioventricular connection, six via a common valve and three via two valves. The two univentricular hearts both had double inlet via a common valve, one to a chamber of right ventricular type and the other to a chamber of left ventricular type. Both had rudimentary chambers of complementary pattern. The ventriculoarterial junction again showed much variation. Statistical analysis showed that pulmonary obstruction and a univentricular heart were both significantly more frequent in association with right compared with left isomerism. Significant differences were also noted in the two groups in terms of ventriculoarterial connections and infundibular morphology.

Aorta↗
PubMed1981

Atresia of left atrioventricular orifice. Anatomical investigation in 62 cases.

Sixty-two hearts without a patent exit from the left atrium to the ventricular mass have been studied. All had situs solitus and laevocardia. The material consisted of 32 cases with coexistent aortic atresia and 30 cases with patent aortic root. Five hearts with aortic atresia were biventricular with atrioventricular concordance and imperforate left atrioventricular valves, and 27 hearts were univentricular of right ventricular type, with absent left atrioventricular connection. The anatomy of this group was uniform, with extreme hypoplasia of all the left cardiac segments. Among the cases with patent aortic root, five were biventricular, with atrioventricular concordance and imperforate left atrioventricular valves, and 24 had absent left atrioventricular connection, 15 with univentricular heart of right ventricular type and nine with univentricular heart of left ventricular type. The final heart had double inlet univentricular of left ventricular type with an imperforate left atrioventricular valve. In this second group the aorta was larger in cases with discordant ventriculoarterial connection or in those with double outlet from the main ventricular chamber. A normal sized aorta without aortic arch obstruction was observed in nine instances. These are of great interest in terms of surgical anatomy since definitive palliation may be feasible.

Aorta↗
PubMed1981

Factors influencing survival after balloon atrial septostomy for complete transposition of great arteries.

Despite balloon atrial septostomy within the first days of life, some patients with complete transposition of the great arteries die before reaching elective definitive surgery in the second six months of life. To discover why, we analysed the fate of 144 patients who had balloon atrial septostomy after 1966, using a modified logrank survival test with multivariate capability. Patients were withdrawn "alive" on reaching definitive surgery. The following largely independent factors were associated with a statistically significant excess mortality: pulmonary hypertension, the presence and size of a ventricular septal defect of persistent ductus arteriosus, relative anaemia, absence of left ventricular outflow tract obstruction, low arterial oxygen saturation, aortic stenosis and coarctation, and balloon atrial septostomy between 1 week and 1 month of life. Those of the above factors which can be determined at balloon atrial septostomy or at routine cardiac catheterisation at 3 months of age were then introduced into discriminant function analysis on survival to 6 months. Hence the probability of any individual patient dying in the first six months was calculated, allowing for these factors. This prediction was correct in 76 per cent of the patients studied. By offering earlier definitive correction to patients thus identified as being at high risk of premature death, it should prove possible to reduce overall mortality in transposition of the great arteries.

Age Factors↗
PubMed1981

Formalin infiltration of ductus arteriosus in cyanotic congenital heart disease.

Formalin infiltration of the ductus arteriosus was performed in 13 neonates with pulmonary atresia (three with ventricular septal defect, two with tricuspid atresia, and eight with intact ventricular septum, one of whom had Ebstein's anomaly) in an attempt to maintain duct patency. Nine patients had an additional retrograde pulmonary valvotomy and one a Blalock-Taussig shunt. The mean preoperative systemic PO2 was 31 mmHg and rose significantly to 46 mmHg after operation. However, the PO2 rose in only two of the four patients who had formalin infiltration alone. There were five early deaths and three had clinical evidence of duct closure. Four patients needed further surgery (systemic-pulmonary artery shunt) within eight days. Seven of eight surviving patients were shown to have a closed duct at repeat cardiac catheterisation (two to 13 months after operation). The eighth died before restudy. There were four late deaths, one following late reoperation and the other three within five months of early reoperation. These results suggest that formalin infiltration cannot ensure long-term duct patency. As short-term patency can be maintained more reliably by prostaglandin administration, we have abandoned the operation.

Ductus Arteriosus↗
PubMed1981

Two-dimensional echocardiographic assessment of common atrioventricular valves in univentricular hearts.

Twelve patients with univentricular heart and common atrioventricular valve were identified by two-dimensional echocardiography. Seven had an ostium primum atrial septal defect and five a common atrium. The common atrioventricular valve had the appearance of a free floating anterior leaflet flanked by two lateral leaflets. The position of the rudimentary chamber in relation to the atrioventricular valve was posterior in six and anterior in two; no chamber was identified in four. Two-dimensional echocardiography provides a reliable method for the identification of common atrioventricular valve in univentricular heart.

Child↗
PubMed1981

Detection and assessment of straddling and overriding atrioventricular valves by two dimensional echocardiography.

Sixteen patients with a straddling tricuspid and two with a straddling mitral valve were identified by two dimensional echocardiography. In all but one the atrioventricular valves appeared at the same level, indicating absence of the ventriculoatrial septum. A straddling valve was diagnosed by identifying subvalvular apparatus from one atrioventricular valve in both chambers, independent of whether they were ventricles or rudimentary chambers. Further confirmation was obtained during real time study where the valve leaflets appeared to fly through the ventricular septal defect. Overriding of the valve annulus was greater than 50% in 12 and less than 50% in five, with one other patient having none detectable. The relation of the central fibrous body to the tip of the interventricular septum was reliable in assessing overriding of greater than 50%, but where it was less than 50% other views were necessary to detect its presence. The diagnosis of straddling with or without overriding of an atrioventricular valve can be reliably made by two dimensional echocardiography, and carries important implications relating to the type of surgical intervention possible, and in those with a straddling tricuspid valve, the position of the atrioventricular node.

Echocardiography↗
PubMed1981

Duplicate sources of pulmonary blood supply in pulmonary atresia with ventricular septal defect.

In pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries, there is a tendency for each collateral artery to be the sole supply to a particular region of lung. On injection into a collateral artery, however, "wash-out" of contrast medium by non-opacified blood from a second source is sometimes seen. Alternatively, contrast medium may faintly "wash-in" to an adjacent lobar artery supplied from a second source. "Wash-in" and "wash-out" therefore show that a duplicate blood supply exists. To assess the importance of these phenomena, we reviewed the angiograms of 50 patients with this condition. Duplicate pulmonary blood supply not resulting from surgical shunts was found in 25 patients (50%), and in 24 of 37 patients (65%) who had selective collateral injections. In one patient two collaterals anastomosed with each other. Thirty-nine instances of duplicate supply occurred in the remaining 24. The duplicate connection was to a region of lung connected to a central pulmonary artery in 29 of 39 instances (74%). Determination of how much of the peripheral pulmonary vasculature is connected to central pulmonary arteries greatly affects decisions about palliative and corrective surgery. These results show that unless "wash-in" and "wash-out" are specifically looked for, the information obtained from angiography may be erroneous.

Aorta↗
PubMed1981

Surgical management of coarctation of aorta with ventricular septal defect. Multivariate analysis.

Optimal management of coarctation with ventricular septal defect is difficult. Should one treat the coarctation, the ventricular septal defect, or both? This dilemma was investigated by reviewing 39 successive patients, aged less than 4 months, undergoing coarctation repair without pulmonary artery banding. Twelve hospital deaths occurred. Ventricular septal defect size was graded "blind" according to preoperative angiocardiographic and haemodynamic findings. Of 14 patients classified as having a large ventricular septal defect, necropsy and operative findings in eight showed defects 7 to 12 mm in diameter. Factors associated univariately with significantly increased mortality were young age, raised atrial and ventricular end-diastolic pressures, low weight, high admission blood urea, preoperative ventilation, and a large ventricular septal defect. All but the last two were also closely associated with each other. A jack-knifed discriminant function based upon ventricular septal defect size, blood urea, pulmonary venous oxygen content, and inferior caval oxygen saturation correctly predicted outcome in 78.9% of patients. Combinations of these four giving a probability greater than 0.9 of survival were rare with blood ureas above 8 mmol/litre. Raised blood urea was associated with low descending aortic pressure and subsequent dialysis. Only patients with a large ventricular septal defect stand to benefit from pulmonary artery banding at initial operation. Preoperative treatment to increase renal blood flow (prostaglandins, dopamine) may improve overall survival.

Analysis of Variance↗
PubMed1981

Assessment of total anomalous pulmonary venous connection by two-dimensional echocardiography.

Twenty-three patients with total anomalous pulmonary venous connection were studied by two-dimensional echocardiography. In all cases the diagnosis was made before invasive procedures, with surgical or angiocardiographic confirmation. Eleven patients had supracardiac drainage (three to the coronary sinus, two to the right atrium,) and seven had infracardiac drainage. In the majority of cases the precise pattern of drainage could be identified by combining suprasternal, praecordial, and subcostal views. In 12 cases where the suprasternal cut was used a pulmonary venous confluence could be identified, having a cross-like structure in nine, with three others appearing as a dilated channel behind and separate from the left atrium. Thus, two-dimensional echocardiography reliably makes the diagnosis of total anomalous pulmonary venous connection and in the majority the precise pattern of drainage can be determined.

Echocardiography↗
PubMed1981

Modified Blalock-Taussig shunt. Use of subclavian artery orifice as flow regulator in prosthetic systemic-pulmonary artery shunts.

Between April, 1975, and December, 1979, 99 modified Blalock-Taussig shunts (MBTSs) were carried out at The Hospital for Sick Children, Great Ormond Street. The operation consists of interposing between the subclavian artery and the pulmonary artery a prosthesis of greater diameter than that of the subclavian artery. The first 13 operations were performed with a prosthesis of woven Dacron. Conduits of expanded polytetrafluorethylene (PTFE) were used for 86 MBTSs, and these form the basis of this report. Forty-four (51.1%) shunts were performed in infancy, 25 in patients under the age of 1 month (29.0%). Prostheses of 4 mm were used in 34 cases, 5 mm in 14, and 6 mm in 38. There were five shunt failures (5.8%) documented at postmortem or angiocardiographic investigation. Including two late deaths for which postmortem examinations were not obtained, the overall failure rate was 8.1% (seven patients). All these patients were operated upon in infancy, four of them in the neonatal period. Although a longer follow-up is necessary to assess the validity of these shunts, the early results are encouraging. We believe we can now recommend MBTS as an alternative when the classical Blalock-Taussig shunt is considered unsuitable.

Blood Vessel Prosthesis↗
PubMed1981

Hypoperfusion and hyperperfusion in the immature lung. Pulmonary arterial development following ligation of the left pulmonary artery in the newborn pig.

The left pulmonary artery and ductus arteriosus were ligated in 14 newborn pigs. Animals were put to death at intervals between 2 and 24 weeks of age. In each animal a cardiac catheterization was performed before sacrifice. Pulmonary arterial development in both lungs was studied by applying quantitative morphometric techniques to the infected and inflated specimens. In the right lung, pulmonary arterial pressure and resistance fell to normal after birth; however, structurally, muscularity remained high in arteries less than 75 mu in diameter. Size and number of intra-acinar arteries increased normally, not excessively, with age despite the abnormally high flow. After 16 weeks in all animals, muscularity increased significantly in arteries of all sizes; mean pulmonary arterial pressure was 20 to 35 mm Hg, the pulmonary--systemic pressure ratio was 0.21 or more, and total pulmonary vascular resistance was 0.16 to 0.4 torr (ml/min/kg) (normal, 0.08). In the left lung, the axial pulmonary artery and its branches were small, decreasing in size with age, and its elastic wall structure was disorganized. Small preacinar arteries showed obliterative change in the majority of animals put to death at 16 weeks or more. Within the acinus, however, the bronchial arterial blood supply ensured almost normal postnatal pulmonary arterial development, the vessels increasing in size and number although muscularity was reduced. Thus failure to perfuse one pulmonary artery in the immature animal changes growth and development of both lungs, and the findings are discussed in relation to the hyperperfused and hypoperfused lung in childhood.

Angiography↗
PubMed1981

Surgical anatomy of double-outlet right ventricle with situs solitus and atrioventricular concordance.

Sixty-three hearts with situs solitus, concordant atrioventricular connection, and more than half of both great arteries connected to the right ventricle have been studied to delineate their surgically important features. Specifically noted were the relationship of the arterial valves to each other and the type and position of the ventricular septal defect with special reference to the conduction tissue location. Infundibular morphology was ascertained and other congenital abnormalities were recorded. An estimate was made of the surgical options available given the various anatomic abnormalities present. The aorta was most commonly in the right posterior position but could be found anywhere in the arc extending to left anterior position. The septal defects were most frequently in subaortic position (34/65) and were usually of perimembranous type (45/65). Three hearts had two defects each and one heart had an intact ventricular septum. Identifying the type of defect was helpful in locating the conduction tissues. In addition, there were numerous associated anomalies, including 19 hearts with coronary artery malformations. Retrospective analysis of the surgical options suggested that 36% of the hearts would not have been operable during life. Approximately another third could have been corrected by use of an intraventricular tunnel from the ventricular septal defect to the aorta, and the remaining third would have needed more complex procedures. In the final analysis it was concluded that hearts with the ventriculoarterial connection of double-outlet right ventricle, though so varied as to preclude "standardization," did permit anatomic analysis and description in clear and consistent terms.

Coronary Vessels↗
PubMed1981

[Indications to the surgical treatment of patients with "simple" transposition of the great arteries. Analysis of 302 cases surgically treated according to mustard's technique (author's transl)].

Between January 1965 and December 1979, 302 patients underwent Mustard's operation for "simple" transposition of the great arteries (TGA). 31 cases who underwent Senning operation for "simple" TGA and 7 patients with "simple" TGA and severe pulmonary vascular disease, in whom Mustard's operation was performed and a ventricular septal defect created, have not been included in the present series. The patients analysed ranged in age from 3 days to 17 years (mean = 27,6 months) and in weight from 2.7 to 40 Kg (mean = 9.9 Kg). The technique originally described by Mustard was used, with some technical modifications. There were 26 early deaths (early mortality rate = 9%). The hospital mortality was 16% during the period 1965-1969, 75% between 1970 and 1974, while during the last 5 years it was 6%. The hospital mortality was lower among the infants between 6 and 12 months of age (6%), compared with an early mortality rate of 11% among those younger than 6 months and 9% in the age group over 1 year. There were 34 late deaths (12% of the survivors). Reoperation was performed in 42 cases. Forty patients required revision of the inter-atrial baffle for pulmonary and/or caval venous obstruction and 10 of them subsequently died. Post-operative venous obstructions were observed more frequently in patients with dumb-bell shaped dacron patch, which has been since 6 years abandoned. Since the introduction of Brom's trouser shape pericardial patch, venous obstructions are extremely rare. Both patients who underwent reoperation respectively for severe tricuspid valve incompetence and for occlusion of the left pulmonary artery, died early after reoperation. In our Unit, the actual management program for patients with "simple" TGA is the following. We keep to a minimum the degree of invasive investigations, 2 D ECHO diagnoses TGA with great accuracy. At the initial cardiac catheterization, a balloon atrial septostomy (BAS) is performed. A good inter-atrial mixing is usually obtained with balloons sized more than 2.5 ml. Angiocardiography is undertaken only when associated lesions, such as patent ductus arteriosus or aortic coarctation are suspected. If the child improves, complete investigation is performed at 3-4 months of age and the inter-atrial redirection of the venous inflow is scheduled for the age of 8-12 months. If the child fails to improve after BAS or deteriorates during the waiting period, restudy is performed immediately to ensure that additional lesions are not present and that the inter-atrial shunt is adequate. Rather than a surgical atrial septectomy, in this group of cases we prefer an early intracardial total repair, irrespective of age and weight.

Adolescent↗
PubMed1981

Aortic atresia associated with the right atrial isomeric form of situs ambiguus.

A case is described which had the right isomeric form of situs ambiguus. A common atrial chamber was found with bilateral appendages of right morphology and bilateral superior venae cavae entered the chamber. It communicated through a common atrioventricular valve with a sole ventricular chamber of morphologically right ventricular type which gave rise anteriorly to the pulmonary trunk. There was aortic atresia, the coronary arteries and head and arm arteries being fed in retrograde fashion by a ductus arteriosus. It is emphasized that while aortic atresia is exceedingly rare in situs ambiguus of right isomeric type, it can exist. The case also exhibits the advantages to be gained from categorizing atrial situs on the basis of atrial morphology.

Abnormalities, Multiple↗
PubMed1980

Postoperative angiographic assessment of modified Blalock-Taussig shunts using expanded polytetrafluoroethylene (Gore-Tex).

Thirty-six of 87 modified Blalock-Taussig shunts done with expanded polytetrafluoroethylene (Gore-Tex) were restudied angiocardiographically. In 7 patients the study was carried out within 1 month of the shunt operation because the patients failed to make satisfactory clinical progress. Two shunts were occluded and 1 ws stenosed; all 3 were in neonates. The remaining 29 patients were reinvestigated electively between 5 and 29 months postoperatively and had a 97% shunt patency rate. Because of the rather high incidence of irregular or stenosed shunts among neonates with 4 mm conduits, we now prefer to use a larger conduit even in this age group.

Arteriovenous Shunt, Surgical↗