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Biomedical subjects

J Stark

Publications and source records attributed to J Stark.

At least 145 records · Page 8Linked to original sources
PubMed1985

Atrioventricular septal defect with balanced ventricles and malaligned atrial septum: double-outlet right atrium. Report of two cases.

An unusual form of atrioventricular septal defect was found at operation. The anatomy was that of a primum atrial septal defect with deviation of the atrial septum to the left. Thus from the right atrium both right and left atrioventricular valves could be seen. The left-sided valve was tricuspid. Repair was achieved by closure of the septal commissure of the left-sided valve ("cleft"), excision of the lower part of the atrial septum, and insertion of a pericardial patch. The lower part of the patch was sutured between the left and right atrioventricular valves. A specimen with similar anatomy is also described.

Child, Preschool↗
PubMed1984

Morphologic features of an intact ventricular septum susceptible to subpulmonary obstruction in complete transposition.

Twenty-five autopsy specimens of complete transposition of the great arteries with intact ventricular septum (VS) were categorized as "bulging" (11 cases) or " nonbulging " (14 cases) according to the curvature of the VS. A fibrous ridge was observed on the VS, especially at the site of mitral apposition in 82% of the bulging group. No fibrous ridge was seen in the nonbulging group. An objective index of anteroposteriorness was then designed to measure the distance between the midpoint of the nonfacing aortic cusp line and the left anterior descending coronary artery. In the bulging group, the aorta lay more anterior to the pulmonary trunk, whereas in the hearts with a straight VS, the aorta tended to lie side by side and to the right of the pulmonary trunk. The midmitral line is an imaginary line in the middle of the anterior mitral leaflet. The more the pulmonary valve is wedged toward the right atrioventricular junction, the more the midmitral line will pass through the nonfacing pulmonary cusp rather than right pulmonary cusp or the nonfacing /right commissure. This was so in 100% of the bulging group, but in only 36% of the nonbulging group. These differences between the groups in terms of anteroposterior index and extent of wedging were statistically significant. In conclusion, if the aorta lies more anterior and to the left of pulmonary trunk rather than side by side and to the right, the "wedged" subpulmonary area will be more susceptible to obstruction caused by septal bulging. Cross-sectional echocardiography is the best means of diagnosing these features.

Adolescent↗
PubMed1984

Experience with fibrin seal (Tisseel) in operations for congenital heart defects.

Tisseel (human fibrin seal) was used in 38 children with complex congenital heart defects (2.8% of all operations for congenital heart defects) between July, 1980, and August, 1983. Control of bleeding was excellent in 31 patients, good in 6 patients, and unsatisfactory in 1 patient. Best results were achieved when Tisseel was applied on collagen substrate. If bleeding was particularly difficult to control, a combination of Tisseel with pharmacological hypotension (sodium nitroprusside) was used. We recommend the use of Tisseel to preseal Dacron conduits and to control bleeding from multiple suture lines (conduits, arterial switch operations, complex reconstructions of the pulmonary arteries), near major coronary arteries, from Gore-Tex patches in high-pressure systems, and from the raw areas of the heart at reoperation.

Aprotinin↗
PubMed1984

"Fresh", antibiotic sterilized aortic homografts in extracardiac valved conduits. Long-term results.

Between 1971 and 1980, 65 children, aged 2 weeks to 15 years (mean 6.8 years) had "fresh" antibiotic sterilized aortic homografts inserted as a valved external conduit. Thirty-six patients (55%) had undergone previous palliations. Operations were performed on cardiopulmonary bypass, with hypothermia and cardioplegia. In selected young infants, deep hypothermia with circulatory arrest was used. Twenty-five patients (38%) died after the operation. Mortality was related to the complexity of the lesion, the condition of the child on admission, and the degree of pulmonary vascular disease. In addition, there were 7 late deaths. Twenty-one patients were recatheterized, either as a part of routine postoperative assessment (13) or because of symptoms (8). Satisfactory conduit performance, judged by the absence of significant gradients or regurgitation, was found in 18 out of 21 restudied patients. Calcification of the homograft aortic wall was seen on chest X-ray in 56% of patients. The aortic valve calcified in only one child, following an episode of subacute bacterial endocarditis. We conclude that fresh antibiotic preserved aortic homografts perform well in extracardiac valved conduits. They are easy to insert and better hemostasis can be achieved. Degeneration of the valved leaflets is extremely rare.

Adolescent↗
PubMed1984

Pulmonary artery sling in identical twins--report of two cases.

Pulmonary artery sling was successfully treated by division and reimplantation of the left pulmonary artery in identical twins. Long-term patency of the reimplanted pulmonary artery in both twins as well as in 4 other operated children was confirmed by lung perfusion scan. Early operative treatment of pulmonary artery sling is advocated.

Diseases in Twins↗
PubMed1984

Double outlet right ventricle. Cross sectional echocardiographic findings, their anatomical explanation, and surgical relevance.

The precise method of surgical repair of double outlet right ventricle depends both on the relation of the interventricular communication to the cardiac outlets and on the course and insertion of the atrioventricular valve tension apparatus. It may be difficult to connect the interventricular communication with one or other outlet or both either because the interventricular communication is too far from the outlets or because atrioventricular tension apparatus interposes between them. This study was carried out in order to establish whether these details could be recognised preoperatively using cross sectional echocardiography. Forty two echocardiograms were reviewed retrospectively from patients with double outlet right ventricle, excluding those with atrioventricular septal defects and atrioventricular discordance. Ten further such patients were studied prospectively. The diagnosis was confirmed at open heart surgery in 19 patients. The relation of the great arteries and their outlet tracts to each other and to the interventricular communication was readily and accurately predicted. Four patients (7.7%) had no infundibular septum. The remaining 48 had such a septum. In 27 (52%) the interventricular communication was overridden by a great artery. In 14 (27%) it was roofed by the ventriculoinfundibular fold, and in 11 (21%) it was confined to the inlet or trabecular septa. The insertion of chordae tendineae limited the possible surgical options in 12 patients (23.1%) who were distributed unpredictably among the above groups. Four patients had straddling atrioventricular valves. In five, tricuspid tension apparatus inserted into the underside of the infundibular septum and, in two, into the roof of the defect. In one patient the mitral valve inserted into the defect floor. Tricuspid tension apparatus inserted into the floor of the defect in a further nine patients, but this does not compromise surgery. Thus in double outlet right ventricle cross sectional echocardiography can provide unique information necessary for planning of rational surgical management.

Adolescent↗
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

Cardioplegic protection of the child's heart.

The advantages and limitations of cardioplegia as a mode of myocardial preservation in the pediatric cardiac surgical context are investigated. Review of early mortality related to ischemic time demonstrated no difference in overall mortality in consecutive series each of 200 patients, the first protected by reperfusion between intermittent periods of aortic cross-clamping and the second protected by cardioplegia. There was a tendency to accept longer ischemic time with cardioplegia (p less than 0.01). Mortality with cardioplegia increased sharply beyond 85 minutes of ischemia. Cytochemical and biophysical assessment of 129 pairs of right ventricular biopsy specimens taken before and after ischemia usually demonstrated deterioration of myocardium despite cardioplegia, and poor scores were predictive of hospital death. Use of a logistic analysis suggested that about half the hospital deaths were attributable to inadequate myocardial preservation despite cardioplegia.

Age Factors↗
PubMed1983

Surgical management of vascular ring.

Between 1968 and 1980, 51 children had an operation for various forms of vascular ring. Additional cardiac malformations were present in five patients, and six had noncardiac congenital anomalies. Although symptoms started within the first month of life in 39 infants, only 16 came to operation under three months of age, and a delay of more than six months occurred in 15. Stridor, often life-threatening, and recurrent infections were the most common symptoms, but dysphagia was also important. The reasons for delay in diagnosis are discussed. Barium swallow provided the diagnosis in 44 patients and suggested it in a further four patients. Innominate artery compression of the trachea was not diagnosed by barium swallow. Operations of various types were performed. Accuracy in diagnosis is important because not all patients could be treated through the classic left thoracotomy. Severe tracheomalacia was responsible for the only two deaths in the series; one of these had tracheostomy performed in the referring hospital, the second child also had Fallot's tetralogy. The large majority of the patients have done well, 76% being asymptomatic at follow-up. Minimal to moderate stridor persists among the remainder to the present time.

Aorta, Thoracic↗
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

Cryptic mediastinal masses causing airways obstruction.

In 3 infants, severe airways obstruction was caused by mediastinal lesions which were not evident on the antero-posterior chest radiograph. Their presence was demonstrated by barium swallow examination. Each infant had thoracotomy carried out urgently. Duplication cysts (without associated cervicodorsal vertebral anomalies) were present in 2 patients and neuroblastoma in the third.

Airway Obstruction↗
PubMed1983

[Indications for the surgical correction in patients with transposition of the great arteries, intact interventricular septum and organic or functional obstruction of the outflow tract of the left ventricle. Analysis of 53 cases operated on by the Mustard technic].

Between January 1965 and December 1979, in our Unit 53 patients underwent Mustard's operation for TGA, intact ventricular septum and LVOTO. There were 35 males and 18 females, ranging in age from 27 days to 12 years (mean = 26 months) and in weight from 3.7 to 26 kg (mean = 9.6 Kg). Twenty-one infants had undergone previous palliative procedures. The degree of LVOTO was mild in 26 cases, moderate in 10 and severe in 17 patients. In 28 cases no distinct anatomical obstructions were identified. In the other 25 patients the obstruction occurred at various level and it was determined by several anatomical structures. Subvalvular fibromuscular narrowing, redundant mitral valve, valvular stenosis and subvalvular fibrous shelf were the commonest forms encountered. The LVOTO was managed in several different ways. In 28 patients in whom the gradient was judged to be functional, no surgical intervention at the level of the LVOT was attempted. In 8 cases, all operated on at the beginning of this experience, an anatomic obstruction was present but was considered too difficult to be resected and, therefore, was left untreated. In 9 patients the LVOT was inspected either through the pulmonary valve or from below, through a left ventriculotomy. Pulmonary valvotomy was carried out in 5 of these cases, resection of the subvalvular fibrous shelf in 3 and subvalvular fibromuscular tunnel resection in 1. In 6 patients a left ventricle to pulmonary artery conduit was used to bypass the obstruction. A fibromuscular tunnel type of obstruction was present in 5 of these cases, while in one the obstruction was mainly due to a redundant mitral valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗
PubMed1983

[Indications for the surgical correction of patients with transposition of the great arteries associated with an interventricular defect. Analysis of 98 cases operated on using the Mustard technic].

At the Hospital for Sick Children, London, between Jan. 1965 and Jan. 1980, 98 patients, ranging in age from 22 days to 20.8 years (mean = 29.6 months), with a clinical diagnosis of transposition of the great arteries (TGA) associated with a ventricular septal defect (VSD) found at cardiac catheterization, underwent Mustard procedure at the atrial level, whether or not associated with the VSD closure. Twenty-nine other patients, with irreversible obstructive pulmonary vascular disease in whom a "palliative" Mustard was performed, have been excluded from this report. At operation, in 8 cases, the VSD was found to have closed spontaneously during the interval between the cardiac catheterization and the surgical repair, while, in 13 patients, the VSD was judged to be too small to influence the hemodynamic results and, accordingly, was left open. In 35 cases the VSD was closed with mattress stitches buttressed with dacron pledgets and in 42 patients a dacron patch was used. The defects were accessible through the tricuspid valve in all but 10 cases. There were 24 early deaths (24%) and these did not correlate either with the year of operation or with the age at the time of operation. The mortality rate was higher in the cases who had required previous pulmonary artery banding (37%), than in those who had not (21.5%), but this difference was not statistically significant. The early results were related to the size of the VSD. In the 21 patients in whom the VSD was partially or completely closed, the early mortality was 9.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
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↗