Images in cardiovascular medicine. Combined pulmonary artery angiography and tracheobronchography in pulmonary artery sling.
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Angiography↗
Biomedical subjects
T Paul
Publications and source records attributed to T Paul.
Extracorporeal support for intractable cardiorespiratory failure due to meningococcal disease.
BACKGROUND: Meningococcal disease is still associated with considerable mortality, despite the use of early antibiotics and management in specialised intensive care units, due principally to early refractory myocardial depression and hypotension as well as severe acute respiratory distress syndrome. Extracorporeal membrane oxygenation (ECMO) is a complex technology that uses a modified "heart-lung" machine to provide temporary cardiac and respiratory support. We reviewed the UK and Australian experience of the use of ECMO in patients with refractory cardiorespiratory failure due to meningococcal disease. METHODS: The records from all 12 known patients supported with ECMO for meningococcal disease in the UK and Australia since 1989 were reviewed. FINDINGS: 12 patients (aged 4 months to 18 years, median 26 months) with meningococcal disease received ECMO over 8 years. In seven patients, ECMO was required early for cardiac support for intractable shock within 36 h of admission to intensive care. In the other five patients, ECMO was indicated for respiratory failure due to severe adult respiratory distress syndrome, which tended to occur later in the disease. The paediatric risk of mortality score ranged from 13 to 40 (median 29, median predicted risk of mortality 72%). Six of the 12 patients required cardiopulmonary resuscitation before ECMO and the other six were deteriorating despite maximal conventional therapy. Overall, eight of the 12 patients survived, with six leading functionally normal lives at a median of 1 year (range 4 months to 4 years) of follow-up. INTERPRETATION: ECMO might be considered to support patients with intractable cardiorespiratory failure due to meningococcal disease who are not responding to conventional treatment.
Adolescent↗
[Severe stenosis of the right coronary artery in a 15-year-old girl with type IIa hypercholesterolemia: successful treatment with stent implantation].
Coronary artery stenosis with need for therapy is rarely seen in childhood. A 15-year-old girl with hypercholesterinaemia type II a was undergoing lipid aphereses therapy (once or twice a week) since she was 6 years old. The girl was seen in our hospital with stenocardia and depression of the ST-segment in the inferior ECG leads at rest. Myocardial scintigraphy with technetium 99 showed an ischemia of the infero-lateral left ventricular myocardium. During selective coronary angiography a 90% stenosis of the proximal right coronary artery over a distance of approximately 5 mm close to the ostium was found. Post stenotic dilatation of the vessel was obvious. In addition a diffuse 10% stenosis in the proximal and middle part of the right coronary artery was found. The left coronary artery appeared angiographically normal. After balloon dilatation, stent implantation was performed without complications with a 6 mm microstent. Reduction of the stenosis from 90% to 40% could be achieved. Ticlopidin 2 x 250 mg was started for thrombocyte aggregation inhibition. During the following 12 months the patient has been free of symptoms. Lipidaphareses has been continued as before. Stent implantation seems to be a successful treatment for coronary artery stenosis also in young patients.
Adolescent↗
Coronary artery involvement early and late after radiofrequency current application in young pigs.
Radiofrequency current (500 kHz) was delivered by temperature guidance (75 degrees C) over a 30-second period in 10 young piglets with a steerable 6F electrode catheter equipped with a thermistor at the 4 mm tip electrode. Lesions were created at the right atrial aspect of the tricuspid valve anulus, at the left ventricular myocardium under the lateral mitral valve anulus, and at the left ventricular apex. After 48 hours, five animals were randomly sacrificed. Lesions in the five animals appeared as transmural gray-white coagulation necrosis. Lymphocytic infiltration around the right atrial lesions extended into the layers of the right coronary artery in four of five animals. After 6 months, lesions consisted of compact fibrous tissue in the remaining five animals. Right atrial lesions extended to the layers of the right coronary artery in four of five pigs. In two animals the lumen of the right coronary artery was narrowed because of intimal thickening by 25% and 40%, respectively. No increase in the lesion size was observed with the growth of the animals. Effects on the right coronary artery as a late sequela after radiofrequency current application may also be possible in human beings and should be considered when radiofrequency current ablation procedures are proposed in infants and young children.
Animals↗
Individuals from multiplex insulin dependent diabetes mellitus families express higher levels of TCRBV2S1 than controls.
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Diabetes Mellitus, Type 1↗
Caries experience of 5-year-old children in Alkharj, Saudi Arabia.
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Child, Preschool↗
Generic database design for patient management information.
Patient management information tracks general facts about the location of the patient and the providers assigned to care for the patient. The Clinical Data Repository at Columbia Presbyterian Medical Center employs a generic schema to record patient management events. The schema is extremely simple, yet can support several different views of patient information, as required by different applications: a longitudinal view of patient visits, including both inpatient and outpatient encounters; a visit-oriented view, to record facts related to a current encounter; a location-based view to provide a census of a nursing ward; and a provider-based view to give a list of the patients currently being cared for by a given clinician. All of these views can be supported in a highly efficient manner by the use of appropriate indexes.
Databases as Topic↗
Enhanced release of nitric oxide causes increased cytotoxicity of S-nitroso-N-acetyl-DL-penicillamine and sodium nitroprusside under hypoxic conditions.
S-Nitroso-N-acetyl-DL-penicillamine (SNAP) and sodium nitroprusside (SNP), both of which are known to release nitric oxide (.NO), exhibited cytotoxicity against cultivated endothelial cells. Under hypoxic conditions 5 mM SNAP and 20 mM SNP induced a loss in cell viability of about 90% and 80% respectively, after an 8 h incubation. Under normoxic conditions, cell death was only 45% and 42% respectively within the same time period. Concentrations of .NO liberated from SNAP and SNP were measured by the oxyhaemoglobin method and by two of the recently developed nitric oxide cheletropic traps (NOCTs). The .NO concentrations from SNAP and SNP increased from 74 microM and 28 microM to 136 microM and 66 microM respectively within 15 min of hypoxic incubation, and then decreased to 36 microM and 28 microM. In the respective normoxic incubations the .NO levels from SNAP and SNP remained in the region of about 30 microM and 20 microM respectively. In contrast, spermine/NO adduct (spermineNONOate) was shown to be more toxic under normoxic than under hypoxic conditions. Under either of these conditions, the concentration of .NO liberated from 2 mM spermineNONOate was about 20 microM. The results demonstrate that the cytotoxicity of SNAP and SNP, but not of spermineNONOate, is significantly enhanced under hypoxic compared with normoxic incubations. Studies on the .NO-releasing behaviour of these compounds indicate that the increased toxicity of SNAP and SNP under hypoxic conditions is related to the influence of O2 on the chemical processes by which .NO is produced from the precursors, rather than to an increased sensitivity of the hypoxic cells towards .NO.
Animals↗
Familial idiopathic atrial fibrillation with bradyarrhythmia.
UNLABELLED: A 10-year-old boy is reported who presented with idiopathic atrial fibrillation and bradyarrhythmia. After history of intrauterine and postnatal bradycardia, atrial fibrillation was first documented electrocardiographically at 16 months of age. An underlying structural heart disease was not evident. At the age of 10 years, implantation of a permanent ventricular demand pacemaker was indicated after syncope due to severe bradyarrhythmia. The family history revealed five persons of four generations with bradyarrhythmias. Idiopathic atrial fibrillation known since childhood was documented in three close relatives. A high grade AV block resulting in bradyarrhythmias and the occurrence of ST-T-changes in precordial leads could be demonstrated in all affected family members suggesting a diffuse general conduction abnormality in these patients. In this family, idiopathic atrial fibrillation seems to be transmitted as an autosomal dominant trait. CONCLUSION: Atrial fibrillation without underlying heart disease is extremely rare in children. Careful electrocardiographic follow-up of these patients and the evaluation of ECG recordings of all family members is recommended.
Atrial Fibrillation↗
Lack of evidence of areas of slow conduction early after radiofrequency current application at porcine atrial myocardium.
Electrophysiological sequelae after creation of atrial myocardial lesions by radiofrequency current (RFC) application have not been studied in vitro. During general anesthesia, a steerable 6 French electrode catheter, equipped with a thermistor at the 4-mm tip electrode, was positioned at the lateral atrial aspect of the tricuspid valve annulus in 5 piglets (German Landrace, mean body weight 12.5 kg). Temperature-guided (75 degrees C) RFC (500 kHz) was delivered over 30 seconds. Forty-eight hours later, the hearts were removed and placed in ice-cold Turner's solution. The right atria were dissected, and the RFC lesions with surrounding tissue were cut out and transferred to an organ bath according to Steiert. Preparations were superfused with Turner's solution at 37 degrees C. Pacing of the viable tissue at the border of the preparations was accomplished at a cycle length of 500 ms. Whole atrial preparations were impaled (76 to 150 impalements per specimen) with KCl capillary microelectrodes containing 3 MKCl. In the surrounding viable tissue of the five preparations, mean maximum diastolic transmembrane potential ranged from -61.3 to -63.7 mV, mean action potential duration at 90% repolarization ranged from 135.2 to 156.1 ms, and mean maximum upstroke velocity of phase 0 of the action potential was between 104.7 and 112.9 V/sec. Statistical analysis revealed no significant differences among all 3 variables. No intracellular action potential was recorded from the surface of all 5 lesions. The surrounding tissue was sharply demarcated, with unaltered transmembrane action potential characteristics in the vicinity of the lesions. Areas of slow conduction were not observed. Lack of evidence of areas of slow conduction after RFC application to the atrial myocardium may imply that this technique is safe regarding occurrence of atrial tachyarrhythmias.
Action Potentials↗
[Therapy refractory continuous tachycardia of many years in a 40-year-old woman].
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Adult↗
[Atrial flutter in young patients after corrective operation of congenital heart defects: therapy by high frequency catheter ablation].
UNLABELLED: Radiofrequency catheter ablation has been used successfully in adult patients for treatment of atrial flutter. Three young patients (mean age 14.6 years) with common type atrial flutter (n = 2) and uncommon type atrial flutter (n = 1) underwent electrophysiologic study. Cardiac diagnoses included tricuspid atresia after Fontan operation, status after closure of an atrial septal defect of secundum type, and status after surgical valvotomy for valvular pulmonary stenosis, respectively. Indication for ablation were syncopal episodes in one and presyncopal episodes in two patients. Flutter cycle length ranged from 280 to 320 ms. Right atrial endocardial mapping revealed areas with local electrograms preceding the onset of the flutter-P-wave by 70 to 80 ms. In these regions pace mapping was performed with the intention to produce an identical P-wave morphology and short stimulus to P-wave interval. Radiofrequency current application (500 kHz) with 30 W for 30 s at theses sites terminated atrial flutter and prevented reinduction in all three patients. No complications were observed. Follow-up (7 to 11 months) revealed recurrence of uncommon type of atrial flutter in one patient who previously had had common type. The remaining two patients are in stable sinus rhythm. CONCLUSION: Radiofrequency catheter ablation appears to be an effective treatment of atrial flutter after surgery for congenital heart defects in young patients.
Adolescent↗
[Intermediate and long-term outcome after percutaneous balloon dilatation of valvular pulmonary stenoses in childhood].
Pulmonary balloon valvuloplasty was performed in 52 patients aged 7 days to 19 years (mean 5.5 years). Mean balloon/anulus ratio was 1.24. Mean right ventricular outflow tract (RVOT) systolic pressure gradient was 79.9 +/- 37.3 (x +/- SD) mm Hg before valvuloplasty and 37.2 +/- 29.6 mm Hg (p < 0.001) immediately after the procedure. 33 patients had residual RVOT-gradient < or = 36 (22 +/- 7) mm Hg, 19 patients had gradients > 36 (67.1 +/- 35.6) mm Hg. During intermediate follow-up (< 2 years) RVOT gradient assessed by catheterization or Doppler echocardiography improved without any additional intervention in 10/19 patients with RVOT gradient > 36 mm Hg early after valvuloplasty. 6/19 patients required additional reduction of RVOT gradient by repeated valvuloplasty (51 +/- 19 to 29 +/- 5 mm Hg; p < 0.01). 3/19 patients needed surgical resection of extremely thickened dysplastic valves. 49 patients had a mid- to long-term follow-up by echocardiography (mean 4.3, max. 9 years); the RVOT gradient decreased from 25.7 +/- 12.8 mm Hg during intermediate follow-up to 18.0 +/- 7.0 mm Hg during long-term follow-up. If pulmonary regurgitation was present after dilatation (n = 38), it was hemodynamically not significant and did not change during follow-up. Percutaneous balloon valvuloplasty was a safe and effective treatment for pulmonary valve stenosis in infancy and childhood. Long-term results confirm the value of this method.
Adolescent↗
[Permanent ventricular tachycardia in a 12-year-old boy: curative therapy by high frequency current ablation].
UNLABELLED: A 12-year old boy from Armenia presented with chronic permanent ventricular tachycardia (150/min) and reduced left ventricular shortening fraction (< 30%). Tachycardia was present > 20 h/day on several 24-h Holter monitorings. Diagnosis of ventricular tachycardia could be established on surface ECG by identification of atrioventricular dissociation and a right bundle branch block pattern with a R/S ratio < 1 in lead V6. Antiarrhythmic therapy with mexiletine and sotalol alone or in combination did not influence the presence of the dysrhythmia. During electrophysiological study, the dysrhythmia could not be terminated by administration of adenosine, ventricular extrastimuli, overdrive stimulation or direct current cardioversion. Endocardial mapping identified a region on the left ventricular surface of the anterior upper interventricular septum as the origin of the dysrhythmia. At this location stimulation at a cycle length shorter than the tachycardia produced a QRS complex nearly identical to the tachycardia QRS complex. Local ventricular electrogram preceded the onset of the tachycardia QRS complex on surface ECG by 23 ms. Radiofrequency current application with 30 W for 30 s resulted in permanent termination of the tachycardia. No complications occurred. Six months after the intervention, the boy is still in normal sinus rhythm. Left ventricular function normalized. CONCLUSION: Radiofrequency catheter ablation should be considered in young patients with drug-refractory chronic permanent ventricular tachycardia.
Bundle-Branch Block↗
[Coronary sinus defects: rare form of interatrial communication].
UNLABELLED: A coronary sinus defect results in a communication of variable size between the coronary sinus (CS) and the left atrium (LA). It is in most cases associated with a persistent left superior vena cava (l-SVC) and an atrial septal defect of the coronary sinus type and often part of a more complex cardiac malformation. If the CS to LA fenestration is the single cardiac defect, this anomaly provides the basis of an unusual form of interatrial communication, which may cause diagnostic difficulties. Two patients with this rare anomaly are reported. A 9-year-old boy presented with history of mild cyanosis pronounced after physical activity (SaO2 < 90%) since the age of 3. Comprehensive pulmonary and cardiological diagnostic procedures in the referring hospital yielded normal findings. Finally, a 1-SVC draining into a mildly dilated coronary sinus could be demonstrated echocardiographically. Contrast echocardiography revealed a right-to-left-shunt at atrial level. Diagnosis of a partially unroofed coronary sinus was subsequently confirmed during cardiac catheterization. The second patient was primarily diagnosed echocardiographically to have an atrial septal defect of the primum type (ASD I) in the first year of life. After pulmonary vascular markings on chest-x-ray had increased, she was assigned to our hospital for cardiac catheterization. Slight arterial desaturation (SaO2 88%) was present due to a large l-SVC anomalously draining into the LA, the innominate vein was missing. The roof of the coronary sinus was predominantly absent. Combined with a large atrial septal defect of the coronary sinus type, this resulted in significant left-to-right-shunt and right-to-left-shunt at atrial level due to a pure unroofed coronary sinus. CONCLUSION: A coronary sinus defect with partial or complete unroofing of the CS and a persistent l-SVC should be considered in the differential diagnosis of an otherwise unexplained systemic desaturation and in patients with both left-to-right-shunt and right-to-left-shunt at atrial level.
Cardiac Catheterization↗
Role of late potentials in identifying patients at risk for ventricular tachycardia after surgical correction of congenital heart disease.
This study evaluates the role of late potentials in identifying patients with sustained ventricular tachycardia (VT) after surgery for congenital heart defects using right ventriculotomy. Nine patients with early (1 to 12 months) or late VT (spontaneous in 7 [induced during electrophysiologic study in 6 of the 7] and induced in 2) and 104 patients without VT were studied. All patients had complete right bundle branch block. Late potentials were quantified by 3 time-domain parameters of the signal-averaged electrocardiogram: total filtered QRS duration, root-mean-square voltage in the last 40 ms, and low-amplitude signal duration of the terminal filtered QRS complex. Root-mean-square voltage filtered at 80 to 250 Hz was lower in patients with than without VT (9 +/- 6 vs 16 +/- 8 microV, p < 0.01). By multivariate analysis, more complex surgery (i.e., insertion of extracardiac conduits, Kawashima operation, etc.), lower root-mean-square voltage, and higher Lown grade (2 to 5) of ventricular arrhythmias on routine postoperative Holter recordings were the only independent predictors of VT (p < 0.001, < 0.05, and < 0.05, respectively). A combination of more complex surgery, root-mean-square voltage < 14 microV, and Lown grade 2 to 5 ventricular arrhythmias was highly predictive of VT (positive predictive value 75%). Conversely, patients without complex surgery and with root-mean-square voltage of > 13 microV were not likely to develop VT (negative predictive value 100%). Late potentials are an independent predictor of VT and may improve the identification of patients at low and high risk of VT after surgery for congenital heart defects using right ventriculotomy.
Action Potentials↗
Recurrent ventricular tachycardia in asymptomatic young children with an apparently normal heart.
UNLABELLED: Ventricular tachycardia without underlying heart disease is rare in infancy and childhood. Four young children (median age 8 months at initial presentation) with frequently recurrent episodes of asymptomatic and self-limiting ventricular tachycardia are reported. By noninvasive investigation no apparent heart disease has been found in all patients. Initially three of the four children had been treated with an anti-arrhythmic drug. Treatment was soon stopped in two patients for lack of symptoms and for lack of efficacy of therapy; one patient remained on beta-blocker therapy. One child did not receive anti-arrhythmic therapy. After a mean follow up of 32 months all patients continued to be asymptomatic despite frequently recurrent episodes of self-limiting ventricular tachycardia. CONCLUSION: Ventricular tachycardia in asymptomatic children with an otherwise normal heart carries a good prognosis. Invasive investigation (cardiac catheterization with electrophysiological study and right ventricular biopsy) can be withhold, as long as there are no symptoms. For lack of efficiency of antiarrhythmic drugs in suppressing ventricular tachycardia in asymptomatic children with apparently normal hearts, these patients may be left without therapy but have to be followed closely.
Anti-Arrhythmia Agents↗
Successful management of junctional tachycardia by hypothermia after cardiac operations in infants.
BACKGROUND: Junctional ectopic tachycardia is an early postoperative complication after intracardiac repair of congenital heart disease, especially in infants. Because of the high ventricular rate and the usually poor response to antiarrhythmic drugs, this condition is associated with a high morbidity and mortality. The purpose of this study was to assess the safety and efficacy of moderate body surface hypothermia in the treatment of postoperative junctional ectopic tachycardia in infants. METHODS: Six consecutive infants with postoperative junctional ectopic tachycardia (mean age at operation, 14 weeks) were treated with surface cooling. The decision to start treatment was based on the definition of a critical heart rate (180 to 200 beats/min) in the presence of junctional ectopic tachycardia diagnosed according to established criteria. Moderate hypothermia (rectal temperature between 32 degrees and 34 degrees C) was achieved by placing ice bags on the child's body surface. The patients were sedated, mechanically ventilated, and paralyzed. RESULTS: Mean interval between diagnosis of tachycardia and initiation of hypothermia was 4 hours. Rectal temperature was rapidly (within 1 hour) lowered to 32 degrees to 34 degrees C in all 6 patients. This significantly lowered the tachycardia rate from 219 +/- 27 beats/min to 165 +/- 25 beats/min (mean +/- standard deviation; p < 0.001). Three patients with signs of low cardiac output had restoration of stable hemodynamics once the tachycardia rate had been decreased by hypothermia. Cooling was maintained for a period of 24 to 88 hours (mean, 59 hours). No serious side effects were observed. CONCLUSIONS: Early institution of moderate hypothermia by body surface cooling was a safe and efficient measure to control ventricular rate in infants with postoperative junctional ectopic tachycardia.
Body Temperature↗