Vision and driving.
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Accidents, Traffic↗
Biomedical subjects
J F Taylor
Publications and source records attributed to J F Taylor.
Midshaft fractures of forearm bones in children.
Eighty midshaft fractures of the forearm bones in children are reviewed. These fractures occur predominantly in boys and are more frequent in the left forearm. The fractures can occur at any age, but the majority are seen between 6 and 8 years of age. They are divided into two groups: greenstick (Type 1) and displaced fractures (Type 2). Greenstick fractures (Type 1, 82.5 per cent) need only correction of the deformity without breaking the intact cortex, followed by supervized splintage for 6 weeks. Type 2(a) (3.8 per cent) fractures, where only one bone is displaced, were treated conservatively, but the displaced bone tends to heal with lateral angulation causing limited rotation unless adequately aligned surgically. Type 2(b) (13.7 per cent) fractures, where both bones are displaced, occur in young teenagers. The majority of these should be treated by internal fixation if adequate alignment cannot be achieved or maintained by conservative means.
Adolescent↗
Measurement of the oxidation-reduction equilibria of hemoglobin and myoglobin.
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Animals↗
Infradiaphragmatic total anomalous pulmonary venous drainage: surgical treatment and long-term results.
Since 1971, 20 infants (1 day to 3 months old) with infradiaphragmatic total anomalous pulmonary venous drainage (TAPVD) have undergone repair at The Hospital for Sick Children, Great Ormond Street, London. All patients were seen with severe cyanosis (mean partial pressure of arterial oxygen, 35.8 mm Hg) and pulmonary edema. All had a persistent ductus arteriosus. Right-sided pressures were equal to or greater than systemic in 17 patients. During surgical repair, the confluence of the pulmonary veins was anastomosed to the left atrium. The descending vein was ligated in 11, divided in 4, and left open in 5 patients. Atrial septal defects were closed with a patch in 6 and sutured in 14. Eight patients died (40%). Acidosis on admission was significantly greater among nonsurvivors (mean pH, 7.29 +/- 0.02) than survivors (mean ph, 7.37 +/- 0.02) (p less than 0.05). Twelve survivors are well four months to 8 years after operation. All are asymptomatic and none requires cardiac medication. Six have undergone repeat catheterization, demonstrating normal pressures and no shunts. We conclude that the mortality of patients with infradiaphragmatic TAPVD depends mainly on the condition of the child on admission.
Blood Pressure↗
Changes in ventricular depolarization in patients in sinus rhythm following closure of ventricular septal defect associated with atrioventricular discordance.
Closing the ventricular septal defect in patients with atrioventricular discordance with sutures placed through the defect onto the morphologically right septal surface should avoid production of complete heart block. To discover whether this procedure otherwise affects conduction, standard electrocardiogram (ECG) were compared preoperatively and postoperatively in 11 such patients. Operation had lengthened the PR interval in one and shortened it in another. The QRS interval remained unchanged in 5 patients thought 2 of these showed minor changes in QRS configuration. Four patients showed QRS prolongation (increase greater than 20 msec) with delayed conduction towards the right ventricle and the initial QRS vector preserved, i.e., morphologically right bundle branch block. Two patients showed QRS prolongation with initial QRS vector alteration and delayed conduction towards the left ventricle, i.e., morphologically left bundle branch block. Repair through the morphologically left ventricle invariably caused bundle branch block. Repair through a right atriotomy caused bundle branch block in only 3 of 8 patients. Therefore closure of a ventricular septal defect by this method, particularly transatrially, need not affect conduction. Morphologically left ventriculotomy rarely if ever causes morphologically left bundle branch block. When present, morphologically right bundle branch block presumably results from interruption of the proximal right bundle.
Adolescent↗
Correction of isolated secundum atrial septal defect in infancy.
Although it is a common congenital cardiac lesion, secundum atrial septal defect (ASD) rarely presents in infancy. Its natural history in the first two decades of life is generally benign. Reports of symptomatic ASD in early childhood stress the place of conservative management, and recommend that the operation should be deferred until school age. Few accounts of the indications for surgery in infancy exist. We present our experience of 6 patients who failed to respond adequately to conservative treatment and required operation for intractable heart failure due to isolated secundum ASD in the first year of life. As their presentation and physical signs were not typical of ASD seen in later childhood, they presented problems both of diagnosis and management.
Cardiac Catheterization↗
Rastelli procedure for transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction. Early and late results in 41 patients (1971 to 1978).
Forty-one children with transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction underwent a Rastelli operation between 1971 and 1978. A homograft valve preserved in an antibiotic solution and extended with A dacron tube was the conduit of choice. Alternatively, conduits with porcine heterografts or valves constructed from calf pericardium were used. They were positioned to the left of the aorta whenever possible. The intraventricular tunnel from the left ventricle to the aorta was constructed from Dacron velour. There were four early and seven late deaths. The last 13 consecutive patients have survived. Early deaths were related to unfavourable anatomy, conduit compression, and sepsis. Residual ventricular septal defects and postoperative infection were the main factors contributing to the late deaths.
Adolescent↗
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↗
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↗
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↗
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↗
Mechanical inefficiency of the thoracic cage in scoliosis.
The mechanism of impairment of ventilatory function in idiopathic scoliosis has been studied in 23 children, all girls, and compared with 27 normal children and 24 normal young adult females. The vital capacity, FEV 1, gas transfer factor, and the maximum static expiratory airway pressure were all significantly reduced. total lung capacity and the maximum inspiratory pressure were lower than in the normal subjects, but the difference was not significant. Restriction of thoracic cage movement by a belt showed that the thorax in the children with scoliosis was as mobile as in the normal subjects. The results are explained in terms of the characteristic deformity in scoliosis which causes one hemi-thorax to become relatively smaller than the other. It is concluded that this causes an inherent mechanical inefficiency of ventilation which is likely to contribute to respiratory failure in these subjects.
Adolescent↗
[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↗
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↗
Use of high kilovoltage filtered beam radiographs for detection of bronchial situs in infants and young children.
Determination of atrial situs is of cardinal importance in the analysis of complex congenital heart lesions, and is best predicted from bronchial situs. Previous methods for assessing bronchial morphology, however, are unsuited to the very young patient. To assess bronchial morphology, 100 consecutive patients under 18 months of age (medium 57.5 days) with suspected congenital heart disease were studied by high kilovoltage filtered beam radiographs, before cardiac catheterisation. This low radiation dose technique clearly defined bronchial anatomy in 95 patients. The lengths of the left and right main bronchi were compared and 10 cases (10%) had a ratio less than 1.5 suggesting bronchial isomerism. Discriminant function analysis based on tracheal width and bronchial length enabled clear distinction of right from left bronchi. Four patients had bilateral right and six had bilateral left bronchi. Four of these 10 cases died and had necropsy confirmation of the radiological diagnosis. Practical prediction about cardiac anatomy, particularly the systemic and pulmonary venous return, may be made when bronchial morphology is known.
Bronchi↗
Aortic atresia occurring with complete transposition of great arteries.
Aortic atresia occurring with complete transposition of the great arteries (ventriculoarterial discordance) has not previously been reported. A patient with this condition is described, who is alive and relatively well at the age of 6 years. This survival contrasts conspicuously with that of patients with the far commoner situation of aortic atresia with normally connected great arteries. It is suggested that this difference in longevity is a result of the greater ability of the left ventricle to supply both the systemic and pulmonary circulations.
Angiocardiography↗
Open heart surgery in the first year of life. Current state and future trends.
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Cardiac Surgical Procedures↗
Late results of surgical treatment of transposition of the great arteries.
In summary, many of these patients have achieved a normal working capacity, but as a group there is a statistically significant reduction when compared to healthy children (p < 0.01). There was no significant difference between the group of patients who had their Mustard operation in infancy and later. As yet, there is no suggestion that the older patients, or those with the longest time interval between the operation and the exercise test, have a progressive reduction in working capacity. The decreased working capacity and moderate increase in ventilation suggests restricted cardiac output on exercise. This could be related to the abnormal heart rate response rather than indicating poor ventricular function. Equally, a restricted cardiac output on exercise may be due to inefficiency of atrial transport, tricuspid regurgitation or unmasked pulmonary vascular obstructive disease. Further studies may clarify these points. This study demonstrated that the exercise performance of asymptomatic patients 6-13 years after Mustard's operation was somewhat diminished, compared with a group of normal children. Nevertheless, these patients did lead and enjoy a normal life. Only longitudinal studies may bring the final answer to the important question: How many patients will be alive with normal or near normal exercise tolerance 40-50 years after Mustard's operation? Until such an answer is available, we believe that the Mustard operation should be used in the treatment of TGA, while the alternative techniques are carefully explored.
Arrhythmias, Cardiac↗