John F. Keane

Objective Our aim was to assess acute hemodynamic changes with stent insertion, outcomes, and factors associated with increased longevity of stented small diameter homograft conduits. Background Right ventricle‐to‐pulmonary artery (RV‐PA) homograft conduits are commonly used to palliate RV outflow tract obstruction. Bare metal stenting (BMS) and t...

In the last two decades, organization theorists have sought to apply complexity theories developed in the natural sciences to the study of organizations. This article develops a fictional approach for critically interrogating two important complexity concepts — order-through-fluctuations and autopoiesis. Using these concepts in a metaphorical sense...

The morphology of the large intrapulmonary arteries (PAs) in pulmonary hypertension (PH) has received limited attention. Dilation, pruning, abrupt tapering, and tortuosity of PAs occur, but whether different patients have distinct PA phenotypes is unknown. Pulmonary arteriograms from 41 pediatric patients with PH were blindly reviewed by four exper...

Fetal aortic valvuloplasty (FAV) is performed on the basis of the hypothesis that aortic stenosis leads to the impairment of left ventricular (LV) filling and growth. Given that most fetuses fail to exhibit normalization of LV growth even after successful FAV, better understanding of the associated LV myocardial pathology is indicated. Postnatal an...

Transcatheter balloon aortic valvuloplasty for critical aortic stenosis in neonates is routinely performed without recognized complication. Aortic wall injury has rarely been observed after balloon aortic valvuloplasty, although the incidence of this complication is unstudied. We reviewed single-center data to determine the incidence of aortic inju...

The purpose of this study was to validate and re-evaluate our previously reported scoring systems for predicting optimal management in neonates with aortic stenosis (AS). In 1991, we reported a multivariate discriminant equation and an ordinal scoring system for predicting which neonates with AS are suitable for biventricular repair and which are b...

Background: We sought to determine the rate of adverse events in pediatric cardiac catheterization procedures and determine patient and procedural characteristics predictive of events.

Background Group B streptococcus (GBS) is the leading cause of early-onset infections (EOI) in the developed world. Few data are available in Europe about incidence and clinical findings of neonatal disease. We reviewed cases occurred in the last 2 years in Emilia-Romagna (an area with about 4 500 000 million people).Methods Neonatal, pediatric dep...

Severe congenital mitral stenosis (MS) is a rare anomaly that is frequently associated with additional left heart obstructions. Anatomic treatments for congenital MS include balloon mitral valvuloplasty (BMVP), surgical mitral valvuloplasty (SMVP), and mitral valve replacement (MVR), although the optimal therapeutic strategy is unclear. Between 198...

Background - Transcatheter balloon aortic valvuloplasty (BAVP) has become the first-line treatment for critical aortic stenosis (AS) in neonates. However, little is known about the growth and function of left heart structures or about patterns of reintervention on the left heart after neonatal BAVP. Methods and Results - Between 1985 and 2002, 113...

Maintaining patent atrial septal communications or fenestrations can be vital in conditions requiring adequate decompression of the atria or Fontan baffle. We have recently deployed stents for this purpose, and the aim of this retrospective analysis is to describe our experience. All 26 patients undergoing such stent placement were retrospectively...

Transcatheter balloon aortic valvuloplasty (BAVP) has become the first-line treatment for critical aortic stenosis (AS) in neonates. However, little is known about the growth and function of left heart structures or about patterns of reintervention on the left heart after neonatal BAVP. Between 1985 and 2002, 113 patients underwent neonatal BAVP at...

The purpose of this study was to review our 35 years of experience with aortico-left ventricular tunnel (ALVT), with emphasis on diagnosis, surgical details, and follow-up. Aortico-left ventricular tunnel is a rare congenital anomaly. Neonatal surgery has been advocated in all due to long-term concern of valvar aortic regurgitation (AR). We identif...

OBJECTIVES We report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature. BACKGROUND Transcatheter closure of CAF has been advocated as a minimally invasive alternative to surgery. METHODS We reviewed al...

We report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature. Transcatheter closure of CAF has been advocated as a minimally invasive alternative to surgery. We reviewed all patients presenting with sig...

Objectives We report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature.

Aortic regurgitation after balloon dilation of congenital aortic stenosis may be treated with valve repair as an alternative to replacement. Charts and echocardiograms of all patients undergoing aortic valve operations after balloon dilation of congenital aortic stenosis at our institution between January 1988 and December 1999 were reviewed. Twent...

Mitral regurgitation (MR) represents the principal indication for reoperation in patients after repair of atrioventricular septal defects (AVSD). Reports of mitral valvuloplasty (MVP) in such patients are few; the alternative, mitral valve replacement (MVR), necessitates commitment to future valve replacement and long-term anticoagulation. We sough...

We reviewed the management and outcome of patients experiencing pulmonary artery (PA) trauma during balloon dilation (BD). Balloon dilation of the PA is important in the management of peripheral pulmonary stenosis. Successful BD requires a controlled tear of the PA; excessive tearing can produce complications ranging from pseudoaneurysms to rupture...

Background —Mitral regurgitation (MR) represents the principal indication for reoperation in patients after repair of atrioventricular septal defects (AVSD). Reports of mitral valvuloplasty (MVP) in such patients are few; the alternative, mitral valve replacement (MVR), necessitates commitment to future valve replacement and long-term anticoagulati...

Optimal timing and mode of treatment for patients with aortic coarctation remains controversial, particularly when the degree of obstruction is mild. Surgery, balloon dilatation, and stent implantation have all proven effective in the treatment of moderate or severe obstruction. In this report, we describe the use of stents to treat coarctation in...

A fundamental understanding of basic instrumentation and cardiovascular physiology is essential to competently assess the hemodynamic status of patients with congenital heart disease. The following is a very superficial view of these topics and readers should consult any of a number of more detailed texts 1–3. The contents of this chapter are prese...

Since the previous edition of this book, new technologies and techniques have been introduced to the field of pediatric interventional cardiology and much has been learned about established transcatheter therapies., The volume of published data on outcomes of transcatheter procedures in congenital and pediatric heart disease has grown and the role...

The strong association between congenital heart disease and spinal deformity is well established, but data on the risks and outcome of spinal fusion surgery in patients with congenital heart disease are scarce. The purpose of this study was to identify predictors of perioperative risk and outcome in a large series of children and adolescents with c...

While balloon dilation (BD) has become the initial treatment for congenital valvar aortic stenosis (CVAS) at many institutions, repeat BD for recurrent obstruction has been reported only in a few. Between January 1985 and December 1996, 298 patients (70 neonates) underwent BD, 34 of whom underwent a repeat BD without mortality. A greater proportion...

A newborn female infant was found to have a unique and previously unreported group of anomalies: (1) mitral and aortic atresia with a highly obstructive atrial septum; (2) hypoplasia of the right lung with a crossover segment involving the right lower lobe; (3) normally connected pulmonary veins, two from the left lung and one from the right; and (...

J Thorac Cardiovasc Surg 1998;115:1219-22

We sought to determine the frequency, etiology and progressive nature of midcavity obstruction in patients after primary repair of tetralogy of Fallot (TOF). Midcavity obstruction (double-chambered right ventricle [DCRV]) represents a significant portion of reoperations in patients who have had TOF repair. This group is still poorly defined. A retr...

Interventional therapy of congenital heart lesions at cardiac catheterization has greatly increased during the past decade. At the authors' institution, the frequency of such procedures among catheterizations has increased from 5% to more than 60%. The variety of lesions so treated continues to expand and equipment continues to improve. These proce...

We report the clinical course and unique hemodynamic findings after placement of a supraannular mitral valve prosthesis. Children with symptomatic mitral valve disease whose annulus is too small for the smallest prosthesis are difficult to manage. One option is valve replacement with a prosthesis positioned entirely within the left atrium (LA). We...

There are very few therapeutic options for severely symptomatic Fontan patients after spontaneous complete or virtual fenestration closure. Its reopening in 14 such patients led to dramatic hemodynamic improvement in most. The clinical experience with transcatheter fenestration creation and/or dilation in symptomatic Fontan patients is reported dem...

We evaluated our immediate and midterm (mean 4.3 years) results of balloon dilation of critical valvular aortic stenosis in 33 neonates. Balloon dilation has been used as an alternative to surgical treatment. Reports to date consist of small series (largest 16 babies) with short-term follow-up (longest 4.8 years). From 1985 to 1991, 33 neonates had...

After modified Fontan procedures with atriopulmonary anastomoses or right atrium–right ventricle conduits, some patients have progressive exercise intolerance, effusions, arrhythmias, or protein-losing enteropathy. Theoretic advantages of a lateral atrial tunnel cavopulmonary anastomosis and published clinical results suggest that conversion of oth...

We evaluated patient and procedural characteristics that influence the midterm success of balloon dilation of congenital aortic stenosis. Balloon dilation is a new treatment for congenital aortic stenosis. Factors that influence midterm success are unknown. We performed a retrospective review of 148 children >1 month old who underwent balloon dilat...

Right ventricle-to-pulmonary artery (RV-PA) homografts and bioprosthetic conduits are commonly used to palliate various types of complex congenital heart disease. These conduits frequently develop progressive obstruction and require surgical replacement. This report reviews our experience implanting balloon-expandable stents to relieve conduit obst...

The safety and efficacy of transcatheter clamshell occlusion of patent foramen ovale for relief of severe arterial desaturation and dyspnea in the upright position due to intracardiac shunting were examined in eight patients with excessive risk of surgical patent foramen ovale closure. All patients had successful reduction of intracardiac shunting...

Pulmonary arteriovenous malformations (PAVMs) are a known complication after some types of cavopulmonary anastomoses (CVPAs). Their cause is unknown, but they may be related to the absence of pulsatile flow or the presence or absence of circulating factors. These PAVMs are diffuse and are presumed to be progressive and irreversible. All patients wi...

Our aim was to determine the late fate of intraaortic spring coil loops after embolization of aortopulmonary vessels. In some aortopulmonary collateral vessels and patent ductus arteriosi, the narrowest segment is close to the aorta; coils used to close such vessels will "straddle" the lesion, allowing one or more coil loops to protrude into the ao...

Unlabelled: Intraatrial baffling procedures such as the Mustard or Senning repair of transposition of the great arteries have been associated with a high incidence of cardiac arrhythmias. These abnormalities are thought to arise from trauma to the sinus node and atrial muscle during the procedure. In the arterial switch operation, there is little...

A pseudoaneurysm of the right ventricle was diagnosed postoperatively in 8 patients between 1986 and 1992. One pseudoaneurysm formed after placement of a Carpentier-Edwards conduit and the other seven arose after placement of a homograft between the right ventricle and the pulmonary artery. Both aortic (n = 3) and pulmonary (n = 4) homografts had b...

Between 1985 and 1992, 36 consecutive neonates, aged 1–29 days, weight 2.4–5.0 kg, with critical valvar pulmonary stenosis underwent attempted balloon dilation (BD). At catheterization, 30 were on prostaglandin (PGE1) therapy and 20 were intubated. The valve was successfully crossed and dilated in 34/36 (94%), including three with an echocardiograp...

Frequently the definitive operation for patients with a right ventricle (RV) that is too small to support full cardiac output is a modified Fontan operation. However, other surgical options exist that incorporate a small RV in the atriopulmonary pathway when biventricular repair is not feasible because of RV or tricuspid valve hypoplasia. The risks...

Primum atrial septal defect (ASD) is a defect that is usually associated with few symptoms and can be electively repaired with good results. A review of our experience with primum ASD identified a subset of patients characterized by presentation with congestive heart failure (CHF) in the first months of life and a requirement for early operation. E...

Advances in interventional cardiac catheterization have necessitated technique modifications to ensure patient safety while allowing data acquisition. The use of cutoff pigtail catheters over guidewires for pressure recordings and angiography exemplifies such a modification. The primary purpose of this study was to ascertain contrast volume and flo...

This report describes transesophageal echocardiographic guidance of transcatheter closure of ventricular septal defects and its value as an adjunct to fluoroscopy and angiography in this procedure. Experience with transcatheter closure of ventricular septal defects has identified a diverse group of patients in whom it may be the procedure of choice...

Although balloon aortic valvuloplasty (BAV) is effective in the acute management of valvar aortic stenosis (AS), sustained benefit of this technique has been shown to vary in differing age groups. The role of BAV in the young adult with congenital, nondegenerative AS is poorly defined. The catheterization results and follow-up echocardiographic dat...

Despite current medical and surgical therapy, infants with symptomatic congenital mitral stenosis (CMS) continue to have high rates of morbidity and mortality. Catheter balloon dilation has been successful in relieving symptoms in a few older children with CMS but has not been evaluated in infants. We reviewed the records of 85 infants with CMS to...

Spontaneous closure of intra-atrial baffle fenestrations occurred early postoperatively following a Fontan procedure in three patients (ages 0.8–2 yr) and were reopened using transvenous balloon dilation. Following this clinical experience with this complication we studied the effects of high pressure balloons of different sizes on fenestrations cr...

Surgical repair of muscular ventricular septal defects (VSDs) has been associated with significant morbidity and mortality when the defects are multiple, associated with complex cardiac lesions, or requiring left ventriculotomy. Transcatheter VSD closure may be difficult in patients weighing less than 7 kg or those with limited vascular access. We...

D-transposition of the great arteries is infrequently associated with anomalies of the aortic arch. We report a rare case of double aortic arch associated with D-transposition of the great arteries. The diagnosis was made by angiography and transthoracic echocardiography. The patient underwent a successful simultaneous arterial switch operation and...

The clamshell double umbrella (Bard Clamshell Septal Umbrella, USCI Division, C. R. Bard, Billerica, MA) was developed to allow closure of septal defects, both atrial and ventricular. The device and delivery system and the techniques for implanting the device in atrial and ventricular defects are described in detail. Although fractures of the arms...

The "fenestrated Fontan" (surgical baffle fenestration followed by transcatheter test occlusion and permanent closure after postoperative recovery) was adopted in an effort to reduce perioperative mortality and morbidity. This study assesses the effect of baffle fenestration on outcome. Patients having a modified Fontan operation with a cavocaval b...

Our aim was to adapt the technique of transcatheter umbrella closure of intracardiac defects for closure of valvular and paravalvular defects. The double-umbrella device developed by Rashkind and Cuaso has been safely and effectively delivered across a host of intracardiac defects, but transcatheter closure of valvular and paravalvular leaks has no...

Transcatheter closure of a coronary artery fistula was undertaken in nine patients. There were three fistulas from the left circumflex coronary artery to the coronary sinus, three from the left anterior descending coronary artery to the right ventricular apex, two from the right coronary artery to the superior vena cava/right atrial junction and on...

Corrected transposition of the great arteries (C-TGA) in situs inversus [I,D,D] is a rare variant of C-TGA (5-8% of the cases). Few anatomic and surgical data on this anomaly have been published. Between 1974 and 1990, 13 such patients (mean age, 12.7 +/- 8.6 yr) underwent repair of associated cardiac anomalies, including ventricular septal defect...

In 14 patients undergoing transcatheter closure of a large (greater than 4 mm diameter) patent ductus arteriosus, occlusion was attempted with use of the Bard Clamshell septal umbrella. Patient age ranged from 0.7 to 30.4 years. Isolated patent ductus arteriosus was present in 11 patients; 3 had additional congenital heart lesions. Moderate or seve...

Nephropathy has long been recognized as a potential complication of cyanotic congenital heart disease (CHD).1 Previous studies have demonstrated that glomerular enlargement, mesangial hypercellularity, glomerular capillary congestion and segmental sclerosis occur in some patients with cyanotic CHD.1 Functional abnormalities including decreased rena...

Surgical repair of muscular ventricular septal defects, particularly those associated with complex heart lesions carries a higher risk of reoperation and death than the repair of membranous defects. Closing a muscular defect through an incision in the systemic ventricle may cause late ventricular dysfunction. In a collaborative approach to this pro...

Thirty-eight patients considered to be at increased risk for a Fontan repair underwent bidirectional cavopulmonary anastomosis. Twenty-one of the 38 had concurrent pulmonary artery reconstruction. Fontan risk factors included pulmonary artery distortion, elevated pulmonary artery resistance (greater than 2 Woods units) and/or pulmonary artery press...

Forty patients were catheterized for closure of atrial septal defects with the Rashkind patent ductus arteriosus umbrella device, a modified Rashkind umbrella device, and the newly designed Lock Clamshell Occluder. Patients weighed 8 kg or more (a requirement for transvenous access with the 11F delivery sheath) and had defects suitable for closure...

From 1946 to March 1989, 92 patients (33 women and 59 men) were seen with ventricular septal defect (VSD) and audible aortic regurgitation (AR). The VSD was subcristal in 62 patients, subpulmonary in 21 and unknown in the remaining 9. The median age of onset of AR was 5.3 years. The risk of developing AR was 2.5 times greater in those with a subpul...

We attempted balloon angioplasty in 9 children (ages 0.1 to 10 years) with congenital mitral stenosis. All were symptomatic with severe congestive heart failure and failure to thrive. Effective reduction in mitral gradient was initially achieved in 7 patients. For the entire group, mean valve gradient decreased from 14.8 ± 5.0 to 8.1 ± 6.7 mm (p =...

Two hundred eighteen balloon angioplasty procedures were performed in 135 patients with branch pulmonary artery stenoses from June 1984 to February 1989. Arteries were dilated in patients with tetralogy of Fallot (n = 49), tetralogy of Fallot/pulmonary atresia (n = 64), isolated peripheral pulmonary artery stenoses (n = 58) and “other” lesions (the...

We consider balloon angioplasty to be an established, highly useful procedure in the management of branch pulmonary artery stenosis. It is successful in approximately 60% of cases. Current figures would indicate a low but significant mortality rate (1%) and a risk of aneurym formation (3%). Patients undergoing balloon angioplasty in the acute postp...

Balloon aortic valvotomy (BAV) is an alternative to surgical valvotomy in infants and children. We compared BAV in 16 consecutive neonates (1985-1988) to surgical valvotomy in a prior group of 16 consecutive neonates (1978-1984). Both groups were comparable in terms of age, weight, hemodynamic data, left ventricular size, and associated lesions. Th...

Balloon dilation was attempted in 16 patients, aged 5 months to 19.5 years, with right ventricular outflow obstruction after repair of congenital heart defects. Stenosis of a valved conduit between the pulmonary ventricle and pulmonary artery was present in nine patients with a mean transvalvular peak systolic ejection gradient of 61.6 +/- 21.0 mm...

Recent experience with the spring-loaded patent ductus arteriosus (PDA) occluder has demonstrated several advantages of this device in the closure of intracardiac defects compared with previously described techniques. Pathologic and animal model studies were performed to identify which atrial septal defects (ASDs) might be suitable for device closu...

The current status of percutaneous balloon valvotomy for aortic, subaortic, and mitral stenosis and angioplasty of aortic arch obstructions are reviewed. Results from the authors and other laboratories are discussed in relation to technique and other factors such as patient age and underlying pathology. Current indications for these procedures are...

Gianturco coils were used to embolize 77 vessels in 54 patients: 58 aortopulmonary collateral vessels, 14 Blalock-Taussig shunts, 3 arteries involved in pulmonary sequestrations and 2 venae cavae. Embolization resulted in total occlusion in 53 (69%), subtotal occlusion in 19 (25%) and partial occlusion in 3 (1 intentional). Two embolizations failed...

Atrioventricular (AV) discordance with ventriculoarterial (VA) concordance is a rare form of congenital heart disease that consists of 5 different anatomic types. The salient therapeutic consideration uniting these 5 different anatomic entities is that anatomic correction can be achieved by an atrial switch procedure with closure of any associated...

Pectus excavatum and pectus carinatum usually exist as isolated abnormalities. Only 19 cases of associated congenital heart defects have been reported. Significant complications related to uncorrected pectus excavatum have been described either during or after cardiac operations. Therefore we reviewed our experience with these coexisting lesions to...

The currently available interventional cardiac procedures in neonates and infants are at various stages of development. We currently dilate neonates and infants with critical valvular pulmonary and aortic stenosis and postoperative aortic obstruction. We do not routinely dilate native coarctation of the aorta because of the possibility of aneurysm...

Catheterization complications following balloon dilation for peripheral pulmonary stenosis have been described previously, including pulmonary artery rupture and death.1,2 A previously unreported finding, transient unilateral pulmonary edema, occurred in 4 patients following successful dilations at 2 institutions. All 4 patients had an acute increa...

We evaluated dilation technique (n = 80) and aortic valve morphology by two-dimensional echocardiography (n = 58) in patients with congenital aortic valve stenosis to determine their influence on outcome. Patients' age (9 +/- 9 years; range, 1 day-39 years) and a history of surgical valvotomy did not influence outcome. The number of dilating balloo...

Between January and October, 1987, we attempted percutaneous transcatheter closure of seven ventricular septal defects (VSD) in six patients; none of the patients was a candidate for operative management. Patients' ages ranged from 8 months to 82 years (6.0-70 kg); diagnoses included postinfarction VSD (n = 4), congenital VSD (n = 1), and postopera...

Validation of a totally noninvasive method for estimating instantaneous left ventricular pressure and constructing a pressure waveform throughout ejection in patients with aortic stenosis is reported. In 20 patients (aged 8.75 +/- 10 years) with congenital aortic stenosis (measured peak left ventricular pressure 120 to 260 mm Hg; transvalvular grad...

Although the short-term results of atrial level repair of transposition of the great arteries (TGA) are satisfactory, longer follow-up has disclosed a significant incidence of systemic right ventricular dysfunction and rhythm disturbances. The arterial switch operation (ASO) may represent a major improvement by restoring the left ventricle as the s...

Between 1973 and 1985, 220 infants (age 1 day to 18 months, mean = 7 months) underwent repair of tetralogy of Fallot (TOF) or TOF/pulmonary atresia with 17 early deaths. Follow-up status was ascertained for 184 of 203 survivors (91%) at a postoperative interval of 2 to 185 months (mean = 60 months). Significant residual hemodynamic lesions included...

We have modified and applied to selected outpatients the transvenous approach to correction of patent ductus arteriosus (PDA) with the Rashkind PDA Occluder. Modifications included establishing the diagnosis and PDA anatomy before catheterization with echocardiography. The sedation/anesthetic regimen was altered to meet the needs with respect to tr...

The present status of catheter-directed therapy in pediatric congenital and acquired heart disease is reviewed. Balloon pulmonary valvotomy, established as the procedure of choice for children and adults with isolated pulmonary stenosis, has now been extended to neonates with critical pulmonary stenosis. Balloon mitral and aortic valvotomy are bein...

Although balloon dilation of valvular pulmonary stenosis is established in infants and children, the techniques for and results of balloon dilation in neonates with critical pulmonary stenosis remain largely unreported. Since January 1, 1985, six successive neonates with critical pulmonary stenosis (aged 1 to 6 days) underwent attempted balloon dil...

Although therapeutic catheter procedures for congenital heart disease are still developing, the number of procedures being performed allows statistically relevant review of the acute complications. Between January 1, 1984, and February 1, 1987, 417 such procedures were performed at The Children's Hospital, Boston; the age range of the patients was...

Cineurography is often performed after cineangiocardiography to look for occult congenital urinary tract disease. The accuracy of cineurography was investigated in 171 patients by comparing cineurograms with renal sonograms. One hundred fifteen cineurograms (67%) showed both kidneys well enough to allow assessment of renal structure and function an...

To evaluate the risks of and optimal method for valve dilation in aortic stenosis, balloons of different sizes were used to dilate the normal aortic root in 16 lambs and then stenotic valves in 15 children. In the lambs, inflated balloon to aortic anulus diameter ratios ranged from 0.9 to 1.5. These hearts were examined immediately after the proced...

Balloon dilation angioplasty (BDA) was attempted 29 times in 27 patients, aged 3 months to 22 years, with postoperative aortic obstructions. Previous operations included end-to-end anastomosis (n = 10), subclavian flap angioplasty (n = 7) and patch angioplasty (n = 3) for aortic coarctation, end-to-end anastomosis for interrupted aortic arch type B...