Biomedical subjects
Publications and source records attributed to R M Sade.
This is the first reported case of discrete fibrous subaortic stenosis in tetralogy of Fallot. Transaortic excision of the subaortic membrane was readily accomplished. To detect this and other forms of left ventricular outflow-tract obstruction in tetralogy of Fallot before surgery, routine selective left ventriculography is advocated.
Xenon-133 ventilation-perfusion scans and technetium-99m angiocardiograms were performed 47 times in 34 patients. All patients had ventricular septal defect (VSD), 17 with pulmonary artery band (PAB), 6 with isolated VSD, 4 with pulmonary valvar stenosis (PS), and 7 with transposition of the great arteries (d-TGA), VSD, and PAB. Patients with VSD had slightly depressed ventilation fraction of the left lung and slightly elevated perfusion fraction of the left lung, both before and after closure of the VSD. Patients with VSD and PAB had slightly depressed ventilation fraction of the left lung but perfusion fraction of the left lung that was either markedly elevated or markedly depressed. After closure of VSD and removal of PAB the perfusion abnormality returned toward normal in some patients but remained abnormal in most. The findings were similar in most patients with d-TGA. Ventilation-perfusion ratio was nearly normal in patients with VSD alone, both before and after closure of VSD. In patients with VSD with PAB the severe abnormality of ventilation-perfusion ratio returned toward normal after corrective operation but did not reach normal. There was no abnormality of distribution of perfusion along the cephalocaudal axis of the lung with the patient supine.
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Recent experience in the diagnosis and management of Hemophilus influenzae b pericarditis is described in five children. Anterior pericardectomy appears to be the preferred method of surgical drainage because it was associated with a shorter hospitalization than pericardiocentesis or closed or open pericardotomy and removed the risk of recurrent cardiac tamponade and constrictive pericarditis. Countercurrent immunoelectrophoresis of sera and pericardial fluid was used to rapidly identify the etiology of pericarditis in four of four patients tested. The observation that three children appeared to develop pericarditis in the absence of a contiguous infectious focus suggests that bacteremic seeding of the pericardium may be important in the pathogenesis of this disease.
Pulmonary artery sling is an uncommon and potentially lethal vascular anomaly that can produce airway obstruction. Despite the availability of a corrective operation, the mortality rate remains very high (50 per cent of surgically treated children) due to the high incidence of associated obstructive anormaliies of the tracheobronchial tree. The survivors of corrective operation have done well symptomatically. However, when restudied, most have been found to have no pulmonary blood flow to the left lung. Successful treatment requires early recognition of the anomaly, adequate preoperative investigation for associated anormalies (especially those of the tracheobronchial tree), a technically perfect vascular reconstruction, and meticulous postoperative respiratory therapy.
The historical development of the concept that an anatomic ventricle is not needed for the pulmonary circulation is reviewed. The application of this idea to surgical treatment of congenital heart disease has culminated in atriopulmonary bypass for tricuspid atresia, an operation that relieves cyanosis and creates a functionally normal circulation, but which may have late risk due to arrhythmias or valve failure.
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Intraoperative transesophageal echocardiography was compared with epicardial echocardiography after ventricular septal defect repair. This comparison was made in 18 children aged 7 to 137 months (median, 32 months), weighing 6.3 to 49.1 kg (median, 10.8 kg) from November 1989 to January 1991. Ventricular septal defect types were perimembranous (six), malalignment (seven), supracristal (three), midmuscular (one), and inlet (one). Eight children had isolated ventricular septal defects, four had tetralogy of Fallot, three had double outlet right ventricle, two had double chambered right ventricle, and one had pulmonary stenosis. Patch interrogation was complete in 17 of 18 transesophageal echocardiography and 16 of 18 epicardial echocardiography studies. Inability to fully interrogate the ventricular septal defect patch by epicardial echocardiography occurred in two children as a result of anterior ventricular septal defect location, limited epicardial exposure, and surgical hardware interference. Incomplete transesophageal echocardiography patch interrogation occurred in the child with the midmuscular ventricular septal defect. Seven residual ventricular septal defects were documented by color flow Doppler in six patients. Five of seven residual defects were demonstrated by both real-time transesophageal echocardiography and epicardial echocardiography imaging. Transesophageal echocardiography and epicardial echocardiography missed 1 and 7 defects, respectively. The missed defects were different with each technique and were confirmed by postoperative surface echocardiography. No residual defects of sufficient size to require reoperation were found as determined by combination color flow jet analysis and intraoperative oximetry (no pulmonary to systemic flow ratio was greater than 1.50). Patches caused two-dimensional and Doppler signal masking, but this was not limiting because all residual defects were found at the margins of the ventricular septal defect patch.(ABSTRACT TRUNCATED AT 250 WORDS)