Early primary repair of tetralogy of Fallot
1
ABSll?ACTS:ADDENOUM CARDIAC CATHETERIZATION AND SELECTIVE ANGIOGRAPHY IN INFANTS WITH A NEW FLOW-DIRECTED CATHETER. David C.Schwartz, M.D., F.A.C.C., and Samuel Kaplan, M.D., F.A.C.C., Division of Cardiology, Children's Hospital, Cincinnati, Ohio 45229 The overall risk of serious complication during cardiac catheterization in infants less than 30 days of age is reported to be as high as 15%. Cardiac perforation during catheter manipulation and selective angiography accounts for the majority of deaths in this age group. It is the purpose of this presentation to report the development and use of a prototype flow-directed infant angiography catheter* which minimizes the occurence of these complications. This double lumen 5F 60 cm. cathter combines both the flow directed (gas filled balloon) features of the standard Swan-Ganz catheter with the highflow contrast delivery characteristics of the standard NIH infant anaiography catheter. These features provide easy accessibility to all cardiac chambers and great vessels with virtually no risk of perforation and minimal arrhythmia as well as delivery of contrast at high flow rates through side holes proxfma to the balloon for selective angfography of diagnostic quality without fear of intramyocardfal injection. Preliminary experience with 16 infants demonstrates the value of this catheter in providing a safe and rapid method of R & L heart catheterization and selective angiography. *Edwards Laboratory, Santa Ana, California. EARLY PRIMARY REPAIR OF TETRALOGY OF FALLOT P. Venugopal, M.D., S. Subfamonian. M. B., F. R. C.S. Children’s Hospital, Buffalo, New York Thirty-three children under the oge of five years who have undergone corrective surgery for Tetralogy of Fallot in the lost four years are presented. In 22 children, (Grp. 1) pri- mary correction (no previous shunt procedure) was done with one death. There were no deaths in a group of eight infants under two yeors of age. Eleven children (Grp. 2) underwent secondary correction after one or more shunts and there were two deaths in this group. There was little patient selection in Grp. 1. All patients were moderately or severely cyanotic. some with cyanotic spells. In no instance was an acyanotic child operated to prevent “progression of the disease”. The only contraindication to primary correction was hypoplasia of the pulmonary artery branches. Hypo- plastic conus, severe infundibulor stenosis and onnulor hypoplasia do not preclude primary corrective surgery. The youngest patient who underwent successful primary repair 1 was five weeks old. It wos observed in the infant group (<two years) that the major determinant of successful outflow repoir was an annulus diometer >thon 12 mm. If preliminary inspection and measurement of the annulus revealed a diameter < 12mm. , an outflow patch of pericardium was used. Deep hypothermia and circulatory arrest in children 15Kg. in weight greatly faciiitated the operative technic. Heart block was not encountered and outflow aneurysm was seen in only one patient who hod residual distal obstruction. It is proposed that primary correction rather than two stage operation should be offered to infants and young children with Tetrology of Follot in view of the acceptable mortality and lack of long term morbidity. Young Investigators Awards Competltion Finalists INTMOCARDIAL PRESSURE: THE EFFECT OF PRELOAD ON THE TRANSMURAL DISTRIBUTION OF SYSTOLIC CORONARY nOh' Joseph P, Archie, Jr., Ph.D., M.D., University of Alabama Birmingham, Alabama Impairment of systolic coronary blood flow (CBF) may be medfated by intramyocardial pressure (PIM). However, the effect of systole on the magnitude and transmural distri- bution of CBF has not been investigated. The purpose of this study was to measure this and indirectly PIM. It is assumed that PIM acts on the coronary vessels as a Starling resistor, such that local CBF is determined by the equation: PC-PIM=R*CBF, where PC is coronary perfu- sion pressure and R resistance. This equation was inte- grated with respect to time and solved simultaneously for PIM and R by measuring regional CBF (radioactive micro- spheres) during maximal coronary vasodilitation in two states: beating and hypocalcemic diastolic arrest. Meas- urements were made in 7 to 16 concentric layers of the left ventricle (LV) of 16 dogs. PIM ranged from near zero to twice peak LV pressure. The transmural distribution of PIM and systolic CBF depended on preload. The transmural distribution of the ratio of PIM to Pc was not signifi- cantly different from one across the LV wall at low pre- load (O-4mmHg). At moderate to high preload (7-35mmHg) in the inner two l/5 of the LV wall this ratio was not dif- ferent from unity (mean 1.03 and 0.96), but in the middle and two outer l/5 this was significantly lower(mean 0.79, 0.64. 0.41 respectively). These data show that PIM shuts off systolic CBF across the entire LV wall at low preload and at high preload PIM determines a gradient of decreas- ing systolic CBF from the subepicardium to zero in the subendocardial layers. This suggests that dilated or failing LV receive systolic flow to the outer myocardial layers, where as, at low preload myocardial perfusion is entirely diastolic. REGIONAL WALL MOTION ABNORMALITIES OF ACUTE MYOCARDIAL ISCHEMIA: EFFECTS OF CORONARY REPERFUSION WITH AND WITH- OUT ALTERATIONS OF ARTERIAL PRESSURE AND HEART RATE. Richard E. Kerber, MD, U of Iowa Hosp. Iowa Cft 7' Iowa. The effect of alterations in blood pressure (AP and heart rate (HR) on segmental dyskinesis induced by acute coronary lfnatfon, and on the subsequent response to coronary reperfusion (CR) was evaluated in 77 open-chest dops. Wall motion was recorded by ultrasound reflected directly off the fschemfc muscle. Acute fschemfa (I) produced characteristic reqfonal wall mation abnormalf- ties: aneurysmal bulging durinq isometric contraction and markedly reduced wall velocity (WV) during ventricular e- jection. Durfnq 60 minutes of I the dogs underwent interventions to raise RP 25-50X: methoxamfne (M), phen- ylephrfne (P) or norepfnephrine (NE); ,other animals had BP lowered 25-503 with nftroprusside (NP) or hemorrhaqe (H) durfnn I, or underwent atria1 pacing (AP) to increase HR 25-50%. A control qroup (C) underwent no intervention durino I. Durfnq I WV was markedly reduced by M and fm- proved by NE. After cessation of druqs and 60 minutes af CR the relative order of improvement of WV was: NE: 11+2 mn/sec (ischemfa) to 24+3 mmfsec (reperfusfon), C: 12+5 to 20+3, NP: 13+2 to 2Oq, H: lo+2 to lBt2, AP: 14tl 70 20+2,-PE: 9tl tc 9t2, M?14+2 to72tl. The aneuryymal burgfng durTnp fsoi!ietric coiFtractloii also was reduced to a greater degree after NE than other interventions. The deleterious effects of increased afterload with M or PE thus outwefqhed the beneficial effects (increased coronary perfusion)and exacerbated the dyskfnesfs of the central portion of the fschemfc area durfnq the drug and after CR. NE, however, reduced dyskfnesfs, probably by decreasing ventricular size and wall tension. We con- clude that elevation of BP, although known to reduce in- farct size, may have deleterious effects on reofonal wall motion abnormalities dependinn on the pressor aaent used. March 1974 The AmericanJournal of CARDIOLOGY Volume33 451
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Transcript of Early primary repair of tetralogy of Fallot
ABSll?ACTS:ADDENOUM
CARDIAC CATHETERIZATION AND SELECTIVE ANGIOGRAPHY IN INFANTS WITH A NEW FLOW-DIRECTED CATHETER. David C.Schwartz, M.D., F.A.C.C., and Samuel Kaplan, M.D., F.A.C.C., Division of Cardiology, Children's Hospital, Cincinnati, Ohio 45229
The overall risk of serious complication during cardiac catheterization in infants less than 30 days of age is reported to be as high as 15%. Cardiac perforation during catheter manipulation and selective angiography accounts for the majority of deaths in this age group. It is the purpose of this presentation to report the development and use of a prototype flow-directed infant angiography catheter* which minimizes the occurence of these complications. This double lumen 5F 60 cm. cathter combines both the flow directed (gas filled balloon) features of the standard Swan-Ganz catheter with the highflow contrast delivery characteristics of the standard NIH infant anaiography catheter. These features provide easy accessibility to all cardiac chambers and great vessels with virtually no risk of perforation and minimal arrhythmia as well as delivery of contrast at high flow rates through side holes proxfma to the balloon for selective angfography of diagnostic quality without fear of intramyocardfal injection. Preliminary experience with 16 infants demonstrates the value of this catheter in providing a safe and rapid method of R & L heart catheterization and selective angiography.
*Edwards Laboratory, Santa Ana, California.
EARLY PRIMARY REPAIR OF TETRALOGY OF FALLOT
P. Venugopal, M.D., S. Subfamonian. M. B., F. R. C.S.
Children’s Hospital, Buffalo, New York
Thirty-three children under the oge of five years who have
undergone corrective surgery for Tetralogy of Fallot in the
lost four years are presented. In 22 children, (Grp. 1) pri-
mary correction (no previous shunt procedure) was done
with one death. There were no deaths in a group of eight
infants under two yeors of age. Eleven children (Grp. 2)
underwent secondary correction after one or more shunts and
there were two deaths in this group. There was little patient
selection in Grp. 1. All patients were moderately or severely
cyanotic. some with cyanotic spells. In no instance was an
acyanotic child operated to prevent “progression of the
disease”. The only contraindication to primary correction
was hypoplasia of the pulmonary artery branches. Hypo-
plastic conus, severe infundibulor stenosis and onnulor
hypoplasia do not preclude primary corrective surgery. The
youngest patient who underwent successful primary repair
1 was five weeks old. It wos observed in the infant group
(<two years) that the major determinant of successful outflow
repoir was an annulus diometer >thon 12 mm. If preliminary
inspection and measurement of the annulus revealed a
diameter < 12mm. , an outflow patch of pericardium was used.
Deep hypothermia and circulatory arrest in children 15Kg.
in weight greatly faciiitated the operative technic. Heart
block was not encountered and outflow aneurysm was seen in
only one patient who hod residual distal obstruction.
It is proposed that primary correction rather than two stage
operation should be offered to infants and young children
with Tetrology of Follot in view of the acceptable mortality
and lack of long term morbidity.
Young Investigators Awards Competltion Finalists
INTMOCARDIAL PRESSURE: THE EFFECT OF PRELOAD ON THE TRANSMURAL DISTRIBUTION OF SYSTOLIC CORONARY nOh' Joseph P, Archie, Jr., Ph.D., M.D., University of Alabama Birmingham, Alabama
Impairment of systolic coronary blood flow (CBF) may be medfated by intramyocardial pressure (PIM). However, the effect of systole on the magnitude and transmural distri- bution of CBF has not been investigated. The purpose of this study was to measure this and indirectly PIM. It is assumed that PIM acts on the coronary vessels as a Starling resistor, such that local CBF is determined by the equation: PC-PIM=R*CBF, where PC is coronary perfu- sion pressure and R resistance. This equation was inte- grated with respect to time and solved simultaneously for PIM and R by measuring regional CBF (radioactive micro- spheres) during maximal coronary vasodilitation in two states: beating and hypocalcemic diastolic arrest. Meas- urements were made in 7 to 16 concentric layers of the left ventricle (LV) of 16 dogs. PIM ranged from near zero to twice peak LV pressure. The transmural distribution of PIM and systolic CBF depended on preload. The transmural distribution of the ratio of PIM to Pc was not signifi- cantly different from one across the LV wall at low pre- load (O-4mmHg). At moderate to high preload (7-35mmHg) in the inner two l/5 of the LV wall this ratio was not dif- ferent from unity (mean 1.03 and 0.96), but in the middle and two outer l/5 this was significantly lower(mean 0.79, 0.64. 0.41 respectively). These data show that PIM shuts off systolic CBF across the entire LV wall at low preload and at high preload PIM determines a gradient of decreas- ing systolic CBF from the subepicardium to zero in the subendocardial layers. This suggests that dilated or failing LV receive systolic flow to the outer myocardial layers, where as, at low preload myocardial perfusion is entirely diastolic.
REGIONAL WALL MOTION ABNORMALITIES OF ACUTE MYOCARDIAL ISCHEMIA: EFFECTS OF CORONARY REPERFUSION WITH AND WITH- OUT ALTERATIONS OF ARTERIAL PRESSURE AND HEART RATE. Richard E. Kerber, MD, U of Iowa Hosp. Iowa Cft
7' Iowa.
The effect of alterations in blood pressure (AP and heart rate (HR) on segmental dyskinesis induced by acute coronary lfnatfon, and on the subsequent response to coronary reperfusion (CR) was evaluated in 77 open-chest dops. Wall motion was recorded by ultrasound reflected directly off the fschemfc muscle. Acute fschemfa (I) produced characteristic reqfonal wall mation abnormalf- ties: aneurysmal bulging durinq isometric contraction and markedly reduced wall velocity (WV) during ventricular e- jection. Durfnq 60 minutes of I the dogs underwent interventions to raise RP 25-50X: methoxamfne (M), phen- ylephrfne (P) or norepfnephrine (NE); ,other animals had BP lowered 25-503 with nftroprusside (NP) or hemorrhaqe (H) durfnn I, or underwent atria1 pacing (AP) to increase HR 25-50%. A control qroup (C) underwent no intervention durino I. Durfnq I WV was markedly reduced by M and fm- proved by NE. After cessation of druqs and 60 minutes af CR the relative order of improvement of WV was: NE: 11+2 mn/sec (ischemfa) to 24+3 mmfsec (reperfusfon), C: 12+5 to 20+3, NP: 13+2 to 2Oq, H: lo+2 to lBt2, AP: 14tl 70 20+2,-PE: 9tl tc 9t2, M?14+2 to72tl. The aneuryymal burgfng durTnp fsoi!ietric coiFtractloii also was reduced to a greater degree after NE than other interventions. The deleterious effects of increased afterload with M or PE thus outwefqhed the beneficial effects (increased coronary perfusion)and exacerbated the dyskfnesfs of the central portion of the fschemfc area durfnq the drug and after CR. NE, however, reduced dyskfnesfs, probably by decreasing ventricular size and wall tension. We con- clude that elevation of BP, although known to reduce in- farct size, may have deleterious effects on reofonal wall motion abnormalities dependinn on the pressor aaent used.
March 1974 The AmericanJournal of CARDIOLOGY Volume33 451
