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ABSTRACT: Narrowing of the left ventricular outflow tract has been associated with partial atrioventricular septal defect (PAVSD) in about 3% of patients. Because of the predisposing anatomy, hemodynamically significant obstruction in the subaortic area may appear after repair of ostium primum atrial septal defects.
From 1984 to 1998, 40 patients underwent surgical correction of PAVSD by patch closure. The mean age at the initial repair was 5.8 years (range 3 months to 22 years).
Nine patients had 12 subsequent operations for hemodynamically significant subaortic obstruction. The mean age at PAVSD repair was 17 months (3 to 42 months) (p < 0.001 compared with others). Follow-up work-up was obtained due to symptoms in 5 patients and an abnormal echocardiogram in 4 asymptomatic patients. Subaortic stenosis developed at a mean of 5 years (range 4 months to 10 years), and 6 or more years in 4 patients. The mean age at subaortic stenosis repair was 6 years (range 2 to 12 years). Nine patients underwent subaortic fibromuscular resection. Of these, 4 developed recurrent stenosis and 2 have undergone additional operations.
Left ventricular outflow tract obstruction after PAVSD repair may be more frequent than reported. Because of the progressive nature of the process, echocardiography should be utilized liberally on patients to uncover subclinical stenosis. Long-term follow-up is essential for diagnosis due to delayed appearance and lack of reliable clinical signs.
The Annals of Thoracic Surgery 11/1999; 68(5):1723-6. · 3.74 Impact Factor
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ABSTRACT: A premature child with congenital complete heart block had an epicardial single-chamber pacemaker implanted at 2 days of
age. At 21 months of age, while sitting or standing, the patient's right anterior thigh muscles contracted at her pulse rate.
Surgical exploration revealed a free-floating pacemaker in her peritoneum. A new dual-chamber pacemaker was implanted into
the abdominal wall with resolution of the child's symptoms.
Pediatric Cardiology 02/1999; 20(2):164-166. · 1.30 Impact Factor
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ABSTRACT: Closure of a large ventricular septal defect (VSD) in children with elevated pulmonary vascular resistance is associated with significant morbidity and mortality. Pulmonary hypertensive episodes continue to be a major cause of postoperative morbidity and mortality. We designed a fenestrated flap valve double VSD patch in an effort to decrease the morbidity and mortality associated with the closure of a large VSD with elevated pulmonary vascular resistance.
Eighteen children (mean age, 5.7 years) with a large VSD and elevated pulmonary vascular resistance (mean, 11.4 Wood units) underwent double patch VSD closure using moderately hypothermic cardiopulmonary bypass and cardioplegic arrest. The routine VSD patch was fenestrated (4 to 6 mm) and on the left ventricular side of the patch, a second, smaller patch was attached to the fenestration along its superior margin before closure of the VSD.
All children survived operation and were weaned from inotropic and ventilator support within 48 hours postoperatively. Postoperative pulmonary artery pressures were significantly lower than preoperative values. One child died 9 months postoperatively.
Closure of a large VSD in children with elevated pulmonary vascular resistance can be performed with low morbidity and mortality when a flap valve double VSD patch is used.
The Annals of Thoracic Surgery 12/1998; 66(5):1533-8. · 3.74 Impact Factor
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ABSTRACT: Infants and children undergoing open cardiac operations have a high incidence of blood product transfusion. Ultrafiltration has been shown to reverse hemodilution and improve myocardial function and hemodynamics after cardiopulmonary bypass (CPB).
The effect of ultrafiltration on the amount of blood transfusion and hospital charge in 39 consecutive patients who underwent elective atrial septal defect repair was examined. Patients in group I (n=26) had a conventional cardiopulmonary circuit prime with blood, whereas 13 patients had bloodless prime (group II). Ultrafiltration was used immediately after weaning from CPB in group II. The patients in group I received blood products after discontinuation of CPB to achieve a hematocrit of 30%. The amount of blood product used, hematocrit immediately after CPB and on arrival in intensive care unit, postoperative hemodynamics and saturations, total operating room charge, blood charge, hospital stay, and hospital charge were compared.
Mean body weight (15.8 kg in group I versus 17.5 kg in group II) and preoperative hematocrit values (35.6% in group I versus 34.2% in group II) were similar. Mean hematocrit immediately after CPB was 22% and 14% in group I and II, respectively (p < 0.0001). The mean hematocrit upon arrival to the intensive care unit was 34% in group I and 22% in group II (p < 0.0001). The amount of blood product transfusion was 32 mL/kg in group I and 3 mL/kg in group II patients (p < 0.0001). The patients in group II had significantly less blood bank charges; however, operating room charges and total hospital charges were similar between the two groups.
Elective atrial septal defect repair was performed with no blood product transfusion without increased morbidity or hospital stay. Ultrafiltration can be used to reverse hemodilution resulting from a bloodless CPB prime without an increase in hospital charge.
The Annals of Thoracic Surgery 04/1998; 65(4):1105-8; discussion 1108-9. · 3.74 Impact Factor
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ABSTRACT: Limitation on health care resource use is stimulating critical evaluation of previous preoperative standards. We retrospectively reviewed the clinical and hospital financial records of all children admitted for patent ductus arteriosus ligation from July 1984 to April 1994 for age, perioperative length of stay, readmissions for postoperative surgical problem, and hospital charges adjusted to 1994 dollars. Patients with an isolated patent ductus arteriosus, greater than 3 months of age, without preoperative or postoperative complications were included in this study and stratified into two groups based on date of operation. Group I had operation before January 1, 1991, and group II had operation on or after January 1, 1991. Comparison of these two groups revealed a significant difference in perioperative length of stay (group I, 3.9 +/- 1.2 days [mean +/- standard deviation]; group II, 2.7 +/- 0.9 days; p < 0.0001) and in hospital charges (group I, $8,700 +/- $2,100; group II, $6,600 +/- $1,000; p < 0.0001). These data support the premise that children older than 3 months undergoing elective ligation of a patent ductus arteriosus have been treated with improved efficiency and less charge without an increase in postdischarge morbidity. Health care policy decisions have forced us to evaluate the standards of perioperative care more critically.
The Annals of Thoracic Surgery 04/1995; 59(4):822-4. · 3.74 Impact Factor
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American journal of diseases of children (1960) 04/1993; 147(3):262-3.
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ABSTRACT: From September 1984 through August 1989, 33 consecutive infants (mean age, 9 months; 13 male) received a single-stage intracardiac repair of complete atrioventricular septal defect. Preoperative evaluation of valvar morphology and function involved echocardiograms in 21% (7/33) and echocardiograms with cineangiograms in 79% (26/33). All infants operated on were included in the analysis. Patients with other complicating abnormalities were not excluded. All operations used a two-patch technique for closure of the atrioventricular septal defect in association with mitral valve repair. The newly formed septal leaflet of the mitral valve was repaired using unpledgeted interrupted sutures. Preoperative and postoperative echocardiograms were used to evaluate mitral valve regurgitation and left ventricular dysfunction as mild, moderate, or severe. The 30-day mortality was 6% (2/33). Follow-up ranged from 1 month to 60 months. Postoperative mitral valve insufficiency was mild in 84% versus 6% preoperatively, moderate in 3% versus 52% preoperatively, and severe in 13% versus 42% preoperatively. Mitral valve dysfunction necessitating reoperation occurred in 6% (2/31). Mitral valve function postoperatively was improved compared with preoperatively (p less than 0.001). The low 30-day operative mortality and the excellent late postoperative valvar function demonstrate the value of single-stage two-patch repair of atrioventricular septal defect early in life.
The Annals of Thoracic Surgery 08/1991; 52(1):33-5; discussion 35-7. · 3.74 Impact Factor
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Journal of Pediatrics 01/1991; 117(6):986-9. · 4.11 Impact Factor
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ABSTRACT: The decision to perform open lung biopsy in the evaluation of a diffuse pulmonary infiltrate is based on the probability that this examination will yield specific information that may lead to a change in treatment. The role of this procedure remains controversial and many clinicians are reluctant to allow this invasive procedure without assurances that results will lead to a change in therapy for a significant number. To evaluate the impact of open lung biopsy on diagnosis and treatment of diffuse pulmonary infiltrates, we conducted a retrospective review of 61 patients undergoing this procedure at three university-affiliated hospitals during a recent 7-year period. There were 37 men and 24 women; average age was 57 years. Biopsy yielded a specific diagnosis in 21 (34%) patients and a change in therapy in 33 (54%) patients. A complication developed in 11 (18%) patients, directly related to the biopsy procedure in six (10%). Eight patients died. The immune status in 22 (36%) patients was compromised. A specific diagnosis was obtained in 13 (59%) immunocompromised patients and a change in therapy occurred in 17 (77%) of these patients after biopsy. A specific diagnosis was obtained in only eight (21%) of the 39 noncompromised patients and therapy was changed in 16 (41%) patients in this group (p less than 0.02 compromised versus noncompromised). Morbidity and mortality were not significantly different between the two groups. A nonspecific diagnosis led to a change in therapy as frequently as a specific diagnosis in both compromised and noncompromised groups. Open lung biopsy in the patient with a diffuse pulmonary infiltrate is an accurate diagnostic tool and frequently leads to a change in patient treatment. The procedure can be performed with acceptable morbidity and mortality in immunocompromised and noncompromised patients.
Journal of Thoracic and Cardiovascular Surgery 05/1989; 97(4):534-40. · 3.41 Impact Factor
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ABSTRACT: Unilateral reexpansion pulmonary edema (RPE) is a rare complication of the treatment of lung collapse secondary to pneumothorax, pleural effusion, or atelectasis. Although RPE generally is believed to occur only when a chronically collapsed lung is rapidly reexpanded by evacuation of large amounts of air or fluid, in this review 15 of 47 cases of RPE available for assessment occurred when the pulmonary collapse was of short duration or when the lung was reexpanded without suction. The pathogenesis of RPE is unknown and is probably multifactorial. Implicated in the etiological process of RPE are chronicity of collapse, technique of reexpansion, increased pulmonary vascular permeability, airway obstruction, loss of surfactant, and pulmonary artery pressure changes. Since the outcome of RPE was fatal in 11 of 53 cases reviewed (20%), physicians treating lung collapse must be aware of the possible causes and endeavor to prevent the occurrence of this complication.
The Annals of Thoracic Surgery 04/1988; 45(3):340-5. · 3.74 Impact Factor
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The Annals of Thoracic Surgery 01/1988; 44(6):675-6. · 3.74 Impact Factor
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ABSTRACT: Anatomical complications of myocardial infarction include ventricular septal defect and mitral regurgitation. Another unusual complication of myocardial infarction is described, and its diagnosis and surgical management are discussed.
The Annals of Thoracic Surgery 12/1987; 44(5):550-1. · 3.74 Impact Factor
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The American Journal of Cardiology 09/1987; 60(4):405-7. · 3.37 Impact Factor
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ABSTRACT: Endoscopic treatment of broncholithiasis is controversial. From 1953 through 1984, 66 operations were performed on 40 patients with broncholithiasis in an endemic area for histoplasmosis. They are reviewed here retrospectively. All patients had cough; wheeze, hemoptysis, and lithoptysis were present in 60%, 45%, and 26%, respectively. Bronchoscopic stone removal was successful in 19%, whereas 21% of patients required no treatment. The 25 patients who were affected more severely required thoracotomy and operations varying from simple lung wedge resection to repair of a bronchoesophageal fistula. Optimum preservation of lung function was a major treatment guideline. All survived, and most have returned to normal preoperative activity. For selected patients, bronchoscopy and stone removal may be all that is required for broncholithiasis.
The Annals of Thoracic Surgery 10/1986; 42(3):255-7. · 3.74 Impact Factor
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ABSTRACT: Intraarterial digital subtraction angiography (IA-DSA) was performed in 80 pediatric patients. Forty-four underwent arterial injections with digital filming techniques. Of the 130 injections, DSA imaging was good or excellent in 121, often allowing resolution of vessels 1 mm in size. Thirty-six of the 80 patients underwent cardiac evaluation with intra-cardiac injections. Improved contrast resolution with IA-DSA allowed the use of smaller catheters (3-4F) and smaller amounts of contrast material. Immediate availability of subtracted images (no film processing delay) resulted in shorter total procedure time. Outpatient studies are possible. IA-DSA provides several notable advantages for the pediatric patient.
Pediatric Radiology 02/1986; 16(2):126-30. · 1.67 Impact Factor
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ABSTRACT: Two cases of discrete subaortic obstruction which developed in a previously normal left ventricular outflow tract of patients with congenital valvar aortic stenosis are described. These examples emphasize the need for careful scrutiny of the etiology of recurrent postoperative left ventricular outflow tract obstruction.
Pediatric Cardiology 15(2):91-4. · 1.30 Impact Factor
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ABSTRACT: A premature child with congenital complete heart block had an epicardial single-chamber pacemaker implanted at 2 days of age. At 21 months of age, while sitting or standing, the patient's right anterior thigh muscles contracted at her pulse rate. Surgical exploration revealed a free-floating pacemaker in her peritoneum. A new dual-chamber pacemaker was implanted into the abdominal wall with resolution of the child's symptoms.
Pediatric Cardiology 20(2):164-6. · 1.30 Impact Factor
