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Biomedical subjects

A J Muster

Publications and source records attributed to A J Muster.

At least 37 records · Page 2Linked to original sources
PubMed1991

Surgical management of the conal (supracristal) ventricular septal defect.

Surgical management of the conal (supracristal) ventricular septal defect differs significantly from the management of the perimembranous (infracristal) ventricular septal defect. The absence of a portion of the conal septum can lead to prolapse of the right cusp of the aortic valve, which predisposes these patients to aortic insufficiency. Between January 1980 and December 1989, 36 children with conal ventricular septal defect underwent intracardiac repair. Diagnosis was by echocardiography, cardiac catheterization, and intraoperative exploration. Preoperative evaluation showed that 26 patients (72%) had aortic valve prolapse and 16 (44%) had aortic insufficiency. Pulmonary-to-systemic flow ratios ranged from 1:1 to 3.5:1 (mean 2.0:1.0). Ten patients (27%) were believed to have clinical congestive heart failure. Age at the time of operation ranged from 2 weeks to 18 years (mean 5.5 years). Operative exposure was through the pulmonary artery (26), aorta (4), right ventricle (3), or right atrium (3). Simultaneous aortic valve suspension for aortic insufficiency was performed in four patients. Operative survival was 100%. Follow-up is complete in all patients and ranges from 0.5 to 9 years (mean 4.3 years). All patients are in normal sinus rhythm. No residual ventricular septal defects have been identified. Twenty-three of 36 patients (64%) have no evidence of aortic insufficiency; 12 of 36 (33%) have trivial or mild aortic insufficiency. One patient with initial severe aortic insufficiency underwent repeat aortic valvuloplasty 3 years after ventricular septal defect closure and aortic valve suspension. No patients have required aortic valve replacement. Surgical management of the conal ventricular septal defect differs from that of the perimembranous ventricular septal defect in two critical aspects. The operative approach should be through the pulmonary artery. This allows the best exposure of the remaining conal septum and the pulmonary and aortic valve leaflets, facilitating closure of the defect without injury to the valves or conduction system. Conal ventricular septal defects should undergo early closure, regardless of shunt volume, to prevent progressive aortic insufficiency.

Adolescent↗
PubMed1990

Balloon angioplasty--branch pulmonary artery stenosis: results from the Valvuloplasty and Angioplasty of Congenital Anomalies Registry.

Balloon angioplasty for branch pulmonary artery stenosis was reported from 27 institutions to the Valvuloplasty and Angioplasty of Congenital Anomalies Registry. One hundred eighty-two procedures were performed in 156 patients ranging in age from 0.2 to 46.2 years (mean 7.7). Short-term angiographic appearance, hemodynamic results and immediate complications were recorded. Vessel dimension at the site of stenosis increased from 4.5 +/- 2.0 (mean +/- standard deviation) to 6.8 +/- 3.0 mm (p less than 0.001) with greater increases in vessel dimension at the site of stenosis if the balloon diameter was greater than 3 X the original dimension of the stenosis. There was no significant benefit related to age or prior surgical intervention. The mean peak systolic pressure gradient was reduced from 49 +/- 25 to 37 +/- 26 mm Hg (p less than 0.001) and pressure proximal to the stenosis decreased from 69 +/- 25 to 63 +/- 24 mm Hg (p less than 0.001). Complications occurred in 21 patients and included vessel rupture and death in 2 patients, vessel perforation or rupture with survival in 3, cardiac arrest and death in 1, paradoxical embolism and death in 1 and low output and death in 1. Balloon angioplasty for branch pulmonary artery stenosis increases vessel dimension at the site of stenosis, reduces systolic pressure gradient and to a minor degree, reduces proximal pressure. Long-term outcome and potential complications are as yet uncertain.

Catheterization↗
PubMed1990

An alternative approach to the surgical management of physiologically corrected transposition with ventricular septal defect and pulmonary stenosis or atresia.

A modified approach to the surgical management of corrected transposition of the great vessels with ventricular septal defect and pulmonary stenosis or atresia was used successfully in two patients. The procedure consisted of performing a venous switch operation, directing the blood flow from the morphologically left ventricle (right-sided chamber) into the aorta through the ventricular septal defect and inserting a valved conduit between the left-sided morphologically right ventricle and the pulmonary artery. This approach has several advantages when compared with the traditional surgical management, which consists of closure of the ventricular septal defect and a left ventricular (right-sided chamber) to pulmonary artery conduit. It uses the morphologically left ventricle as the systemic pumping chamber, thereby minimizing long-term ventricular failure. It allows closure of the defect from the right ventricular side of the septum, thus decreasing the prevalence of complete atrioventricular block. It also avoids use of the tricuspid valve as the systemic atrioventricular valve and therefore decreases the chance of postoperative valve regurgitation.

Adult↗
PubMed1989

Direct tricuspid closure versus atrial partitioning in Fontan operation for complex lesions.

Thirty-three patients with complex lesions undergoing the Fontan operation needed either direct tricuspid closure (group 1, 14 patients) or atrial partitioning (group 2, 19 patients). In group 1, the tricuspid patch was sutured to the annulus leaving the coronary sinus draining to the systemic venous atrium. In group 2, atrial partitioning was accomplished with either a Dacron or a polytetrafluoroethylene patch, leaving the coronary sinus draining to the pulmonary venous atrium. Intraoperative distention of the left side was used to check for residual defects. In group 1, complete heart block developed in 5 patients (36%) and patch disruption, in 4 patients (29%). There were 3 late deaths (21%), which were due to sudden death, sepsis caused by Candida, and liver failure. In group 2, no patient had heart block, and patch disruption developed in 1 patient (5%). There was 1 early death (5%) and 2 late deaths (11%), which were due to sepsis caused by Candida and renal failure. Our experience suggests that atrial partitioning is a better approach than direct tricuspid patch closure in patients with complex lesions undergoing the Fontan operation.

Adolescent↗
PubMed1989

Transposition of the great arteries: a comparison of results of the mustard procedure versus the arterial switch.

Sixty infants with transposition of the great arteries and intact ventricular septum underwent primary surgical correction in the first 3 months of life. Twenty-three patients had a Mustard procedure (group 1) and 37 patients, an arterial switch operation (group 2). The mean age at the time of repair was 42 +/- 31 days for group 1 and 8 +/- 6 days for group 2 (p less than 0.001). The mean weight at the time of repair was 3.6 +/- 0.7 kg for group 1 and 3.4 +/- 0.5 kg for group 2 (p = not significant). Operative mortality was 8.7% (2/23) in group 1 and 8.1% (3/37) in group 2 (p = not significant). The incidence of arrhythmias in the early postoperative period was 39% (9/23) in group 1 and 11% (4/37) in group 2 (p less than 0.01). All patients were followed a mean of 4.8 +/- 2.4 years in group 1 and 2.6 +/- 1.4 years in group 2 (p less than 0.001). Postoperative catheterization has been performed in 86% (18/21) of group 1 operative survivors and 50% (17/34) of group 2 operative survivors. Ejection fraction of the systemic ventricle was 79% +/- 15% of predicted normal in group 1 and 98% +/- 6% in group 2 (p less than 0.005). The incidence of late arrhythmias was 57% (12/21) in group 1 and 3% (1/34) in group 2 (p less than 0.001). There have been 2 late deaths in group 1 and 1 late death in group 2 (p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias, Cardiac↗
PubMed1989

When should the hypoplastic right ventricle be used in a Fontan operation? An experimental and clinical correlation.

Eight anesthetized dogs underwent closure of the tricuspid valve and a Fontan procedure, and the right ventricular cavity was reduced in stepwise fashion. There was an increase in right atrial pressure from 9.3 +/- 2.2 to 14.1 +/- 2.4 mm Hg (p less than 0.001), a decrease in pulmonary artery pulse pressure from 10.8 +/- 2.2 to 6.8 +/- 2.2 mm Hg (p less than 0.01), and a decrease in cardiac index from 2.7 +/- 0.3 to 2.2 +/- 0.2 L/min/m2 (p less than 0.001) when the ventricular size was dropped from 50% to 25% of normal. The difference between mean pulmonary artery pressure and mean right atrial pressure, which reflects the positive stroke work index of the ventricle, disappeared once the right ventricular cavity was reduced to 25% of normal (15.0 +/- 6.1 versus 14.1 +/- 2.4 mm Hg; p = not significant). Experimental results were correlated with postoperative catheterization data from 19 patients with tricuspid atresia who had the Fontan operation. Mean right atrial pressure was 18 +/- 4.6 mm Hg and cardiac index was 2.35 +/- 0.65 L/min/m2 in patients with a direct atrium-pulmonary artery anastomosis or an atrioventricular anastomosis with a right ventricular cavity less than 30% of normal versus 13 +/- 3.2 mm Hg and 3.42 +/- 0.46 L/min/m2 for those with an atrioventricular connection and a right ventricular cavity greater than 30% of normal (p less than 0.05 and p less than 0.02, respectively). The right ventricle enlarged from 27% +/- 6% of normal preoperatively to 35% +/- 10% of normal on follow-up (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Anastomosis, Surgical↗
PubMed1989

Relation between preoperative left ventricular muscle mass and outcome of the Fontan procedure in patients with tricuspid atresia.

The relation between preoperative left ventricular muscle mass and clinical outcome of the Fontan procedure was evaluated retrospectively in 22 patients with tricuspid atresia who were selected for this physiologic surgical correction by conventional hemodynamic criteria. Patients were divided into two groups: group A (excellent or good outcome) and group B (poor outcome or death) based on the clinical course assessed up to 9.5 years postoperatively. Thirteen of 22 group A patients did not have prolonged, clinically significant, systemic venous hypertension and were not on long-term diuretic drug therapy. Nine of 22 group B patients either had clinically significant systemic venous hypertension, required long-term diuretic drug therapy or died (3 patients). Age at surgery, pulmonary arteriolar resistance, left ventricular ejection fraction, end-diastolic volume, end-diastolic pressure, systemic oxygen saturation and pulmonary to systemic blood flow ratio (Qp/Qs) were not statistically different between the two groups. Left ventricular muscle mass, both in group A patients (92 +/- 31 g/m2) and in group B patients (146 +/- 61 g/m2), was greater than the normal mean value (p less than 0.01 and p less than 0.001, respectively). Left ventricular muscle mass in group B was significantly greater than in group A (p less than 0.01). Furthermore, left ventricular muscle mass/end-diastolic volume (mass/volume) ratio, reflecting the extent of left ventricular hypertrophy relative to volume overload, was significantly greater in group B (1.1 +/- 0.28) than in group A (0.84 +/- 0.21) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

Tetralogy of Fallot with absent ductus arteriosus and absent collateral pulmonary circulation: diagnostic and surgical implications during the neonatal period.

A newborn infant with tetralogy of Fallot and presumed agenesis of the ductus arteriosus presented without the expected associated pulmonic regurgitation and aneurysmal pulmonary arteries. The presumption of agenesis of the ductus arteriosus was made because there was no reduction in cyanosis following prostaglandin E1 treatment and no remnant of ductus arteriosus could be demonstrated by angiography at 19 h of age. The fetal hemodynamics inferred in this infant are discussed with reference to the absence of aneurysmal pulmonary arteries. Closed transventricular pulmonary valvulotomy is recommended as emergency palliation for symptomatic newborns with this variant of tetralogy of Fallot because further reduction of pulmonary vascular bed, even temporarily, as in unilateral pulmonary artery cross-clamping for systemic-pulmonary anastomosis, may not be tolerated without the use of cardiopulmonary bypass.

Collateral Circulation↗
PubMed1988

Surgical management of patients with interrupted aortic arch and severe subaortic stenosis.

Ten patients underwent palliative surgery for interrupted aortic arch and severe subaortic obstruction due to posterior displacement of the conal septum. Their ages ranged between 4 and 28 days (mean, 11.0 +/- 7.7 days) and their weights, between 2.1 and 4.2 kg (mean, 2.85 +/- 0.6 kg). Preoperative echocardiography and cardiac catheterization were performed on all patients. The ratios of the left ventricular outflow tract diameters and the ascending aortic diameters to the descending aortic diameters were 0.56 +/- 0.03 and 0.56 +/- 0.06, respectively, compared with 0.81 +/- 0.12 and 0.95 +/- 0.17, respectively, in 20 patients with interrupted aortic arch but without obstruction (p less than 0.001). Four of the 10 patients underwent pulmonary artery banding and insertion of a bypass graft between the ascending and the descending aorta. All 4 died of low cardiac output soon after operation (100% operative mortality). The remaining 6 patients underwent banding and insertion of a graft between the main pulmonary artery proximal to the band, and the descending aorta. All of these patients survived, and all except 1 are doing well 3 months to 4 years postoperatively. The use of a pulmonary artery-descending aorta conduit and of distal pulmonary artery banding provides good palliation for patients with interrupted aortic arch and major subaortic stenosis.

Aorta, Thoracic↗
PubMed1988

Transposition of the great arteries with intact ventricular septum. Arterial switch in the first month of life.

Twenty-three infants with simple transposition of the great arteries and intact ventricular septum were operated on from October 1983 to October 1986. The age at operation in 22 infants ranged from 2 to 21 days and in one was 35 days (mean 9.82 +/- 6.86 days). The infants were evaluated with cardiac catheterization at 1 to 27 days of age. Twenty-two infants had balloon atrial septostomy, and 22 received prostaglandin E1 infusion. The left ventricular diastolic wall thickness, assessed by M-mode echocardiograms, varied between 2.8 and 4 mm. There were two hospital deaths in this group of 23 infants (mortality 8.6%), and there were no late deaths. All surviving patients are doing well clinically. One patient had asymptomatic nonsustained ventricular tachycardia necessitating phenytoin. Postoperative echocardiographic assessment performed on 15 patients at 0.93 +/- 0.61 years of age and cardiac catheterization and angiographic studies on seven patients at 1.07 +/- 0.13 years after operation revealed excellent ventricular performance, good semilunar valve function, and mild gradient at the right ventricular outflow with a mean right ventricular pressure of 37.4 +/- 4.1 torr.

Aorta↗
PubMed1988

Arterial switch in simple and complex transposition of the great arteries.

Arterial switch for repair of transposition of the great arteries was performed on 53 patients since October 1983. These patients were divided into three groups: group I, 25 infants with an intact ventricular septum who had primary repair in the first month of life (2 to 34 days of age, mean 9.7 +/- 6.6); group II, 13 patients with an intact ventricular septum who had anatomic repair after a preliminary procedure (pulmonary artery banding in 13, shunt in 10, atrial septectomy in 1); and group III, 15 infants with transposition of the great arteries and ventricular septal defect. In group III, six patients had Taussig-Bing abnormality, nine had previous pulmonary artery banding, three had coarctation of the aorta repaired earlier in life, and four were less than 2 weeks old. Overall early mortality was 9.4% (5/53: group I 8%, group II 7.6%, group III 13.3%). Two late deaths occurred in group II 10 and 12 weeks postoperatively after infection and high fever. A third late death 18 weeks postoperatively was due to aspiration in an infant with Goldenhar's syndrome. Mortality and morbidity decreased significantly after an initial learning period (no deaths from July 1985 to March 1987 overall, and none in the last 15 infants operated on in group I). The surviving 45 patients are doing well. All have normal sinus rhythm. Two had transient asymptomatic arrhythmias. Left and right ventricular function assessed by echocardiogram and postoperative cardiac catheterization were within normal ranges in all but two patients, one with pulmonary artery stenosis and one (Taussig-Bing abnormality with two large ventricular septal defects) with severe pulmonary vascular disease (9.6 units) observed before anatomic repair. The right ventricular pressure at catheterization ranged from 27 to 42 mm Hg in 12 patients and was 55 mm Hg in two. There was no aortic stenosis. Aortic insufficiency was trivial in three patients and mild in one. We conclude that excellent results can be obtained with arterial switch for transposition of the great arteries with or without ventricular septal defect, especially in neonates.

Cardiac Catheterization↗
PubMed1987

Recognition of coarctation of the aorta. A continuing challenge for the primary care physician.

Coarctation of the aorta (CoA) in its classic form presents with characteristic and distinctive physical findings. However, in our survey less than one third of 106 consecutive patients in whom CoA was ultimately diagnosed had the correct diagnosis made by the referring physician. Our survey suggests that in asymptomatic infants and children, an incomplete physical examination explains the diagnostic failure. However, in infants presenting with heart failure, the diagnostic signs of CoA may be obscured and more difficult to recognize even when specifically sought. This survey reaffirms the need for specific physical examination techniques in all infants and children to facilitate early recognition of CoA; these include the palpation of pulses and proper measurement of blood pressure.

Adolescent↗
PubMed1987

Surgical management of infants with complex cardiac anomalies associated with reduced pulmonary blood flow and total anomalous pulmonary venous drainage.

Eight infants with complex cardiac anomalies and pulmonary stenosis or atresia were noted to have obstructed total anomalous pulmonary venous drainage (TAPVD) either at the initial cardiac catheterization (Group 1; n = 2) or after creation of systemic-pulmonary artery shunts (Group 2; n = 6). The 2 patients in Group 1 underwent early repair of TAPVD (1 at 7 days, the other at 1 1/2 months of age) before any subsequent operation and are now doing well at 18 months of age. The 6 patients in Group 2 underwent repeat cardiac catheterization because of persistent severe cyanosis with faint or absent continuous murmur and were found to have patent shunts and obstructed TAPVD (1 mild, 5 severe). One patient who underwent repair of TAPVD at 2 1/2 months of age survived and is well at 2 years of age, whereas 4 patients who underwent repair at an average age of 6 months (age range, 3-16 months) subsequently died. The sixth patient, who did not undergo repair, remained severely cyanotic with hypoplastic pulmonary arteries in spite of repeated shunts. We feel that increased awareness of the possible association of TAPVD and reduced pulmonary blood flow in infants with complex cardiac defects, in combination with echocardiography, oxygen saturation studies, and angiography with prostaglandin E1 challenge, should lead to early diagnosis, avoidance of unnecessary systemic-pulmonary artery shunts, and increased survival rates in these infants.

Constriction, Pathologic↗
PubMed1987

Valve replacement in children: guidelines for selection of prosthesis and timing of surgical intervention.

One hundred fifty-nine patients ranging from 3 months to 18 years old (mean, 8.1 +/- 3.7 years) underwent 162 primary valve implantations. A porcine valve was used in 104 patients, a St. Jude Medical valve in 40, and a Björk-Shiley valve in 18. The valve replaced was the aortic in 25 patients, the mitral (systemic atrioventricular [AV] valve) in 43, the pulmonary in 71, and the tricuspid (pulmonary AV valve) in 23. Hospital mortality was 6%. Patients with a Björk-Shiley valve received warfarin sodium anticoagulation, and those with a St. Jude Medical valve were given salicylates and dipyridamole. Follow-up is available on all patients 0.6 to 12 years postoperatively (mean, 6.3 +/- 2.6 years). New York Heart Association Functional Class improved in 62% and remained unchanged in 38% of the patients. Thromboembolic complications occurred in only 8 (57%) of 14 patients with a St. Jude Medical valve in the right (pulmonary) side and in 3 (12%) of 26 with the valve in the left (systemic) side of the circulation. Bacterial endocarditis developed in 3 patients, all with porcine valves. Early valve replacement, less than 2 years after detection of hemodynamic deterioration, resulted in improvement in the ventricular ejection fraction in 25 of 29 patients (from 81 +/- 14% to 90 +/- 12% of normal; p less than 0.05). In contrast, the ejection fraction remained abnormal in all 22 patients with delayed valve insertion (more than 2 years) (81 +/- 16% of normal preoperatively and 80 +/- 10% of normal following operation; p = not significant).

Adolescent↗
PubMed1987

Preparation of the left ventricle for anatomical correction in patients with simple transposition of the great arteries. Surgical guidelines.

Pulmonary artery banding in combination with an aortopulmonary shunt was performed on 16 patients with simple transposition of the great arteries to prepare the left ventricle for anatomical correction. Three groups were identified after operation: Group I (four patients) had increased pulmonary blood flow and tight pulmonary artery banding; Group II (four patients) had increased pulmonary blood flow and moderate pulmonary artery banding; Group III (eight patients) had normal pulmonary blood flow and moderate pulmonary artery banding. Postoperative low cardiac output was present in all patients in Group I, whereas mild heart failure was present in two patients in Group II and in two in Group III. There was one hospital death (6%). The follow-up period was 125 patient-months. Left ventricular systolic pressure rose from 63 +/- 11 torr before the operation to 101 +/- 35 torr after the procedure in Group I (p less than 0.05), from 59 +/- 10 to 93 +/- 33 torr in Group II (p less than 0.05), and from 55 +/- 10 to 84 +/- 16 torr in Group III (p less than 0.005). The increase in left ventricular muscle mass was from 44 +/- 2 gm/m2 preoperatively to 108 +/- 12 gm/m2 after operation in Group I (p less than 0.01), from 43 +/- 3 to 93 +/- 8 gm/m2 in Group II (p less than 0.02), and from 46 +/- 3 to 55 +/- 14 gm/m2 in Group III (p = no statistically significant difference). The postoperative change in left ventricular end-diastolic volume was from 100% +/- 17% to 133% +/- 23% of normal in Groups I and II (p less than 0.05) and from 123% +/- 29% to 107% +/- 36% of normal in Group III (p = no statistically significant difference). In preparing the left ventricle for anatomical correction, avoidance of severe pulmonary artery banding decreases the incidence of postoperative myocardial dysfunction, a moderate degree of volume overload and pulmonary artery banding provides the most effective stimulus for ventricular growth, and a small to moderate atrial septal defect is advantageous because it ensures the volume preload necessary for the development of the left ventricle.

Arteriovenous Shunt, Surgical↗
PubMed1987

Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair. Surgical implications.

Postoperative cardiac catheterization data of 74 patients with pulmonary insufficiency after tetralogy repair were analyzed. Two groups were identified: Group A, 26 patients with normal right ventricular function (ejection fraction 95% +/- 5.5%, end-systolic volume 110% +/- 17% of predicted normal) and Group B, 48 patients with right ventricular dysfunction (ejection fraction 80% +/- 18% [p less than 0.001], and end-systolic volume 218% +/- 75% of predicted normal [p less than 0.001]). There was no significant difference between the two groups with respect to frequency of previous palliative procedures, age at operative repair, operative techniques, methods of myocardial protection, and follow-up period. Right ventricular dysfunction in Group B was associated with significant distal pulmonary stenosis (right ventricle-pulmonary artery pressure gradient 28 +/- 13 torr in Group A versus 55 +/- 20 torr in Group B, p less than 0.001), moderate pulmonary regurgitation (regurgitant fraction 18% +/- 11% in Group A versus 32% +/- 10% in Group B, p less than 0.001), and large transannular outflow patch (ratio of patch diameter to descending aorta diameter 1.31 +/- 0.16 in Group A versus 2.50 +/- 0.28 in Group B, p less than 0.001). Pulmonary valve insertion was performed in 42 patients in Group B. Eighteen had subsequent cardiac catheterization. Right ventricular function recovered completely (end-systolic volume 122% +/- 24%, and ejection fraction 92% +/- 7% of predicted) in five of six patients (83%) who had valve insertion within the first 2 years after tetralogy repair. In contrast, right ventricular function remained abnormal in all 12 patients who had valve insertion later than 2 years after tetralogy repair (p less than 0.05). Patients with residual pulmonary stenosis and/or a large transannular outflow patch are at risk for the development of right ventricular dysfunction from pulmonary insufficiency after tetralogy repair. Early correction of these residual lesions and control of pulmonary insufficiency may prevent long-term deterioration in right ventricular function.

Adolescent↗
PubMed1987

Experience with St. Jude Medical valve prosthesis in children. A word of caution regarding right-sided placement.

Thirty-six children aged 6 months to 18 years, underwent insertion of 37 St. Jude Medical cardiac prostheses. In 20, the valve was placed in the aortic or mitral position, and in 16 in the pulmonary or tricuspid position. There was one (2.8%) hospital death. All patients received maintenance doses of salicylates and dipyridamole after the operation. Follow-up data are available for all patients for 12 to 24 postoperative months. There was no incidence of valve dysfunction or thromboembolic complication in any of the 20 patients with valves in the systemic (left) side of the circulation, and all manifested improvement in their functional class. In contrast, six (37%) of the 16 patients with valves in the pulmonary (right) side of the circulation developed dysfunction of the prosthesis 1 to 6 months after insertion. Prosthesis failure was associated with fibrous tissue growing into the struts, leading to leaflet immobilization. At 2 years, the actuarial functional life was 100% for mitral and aortic valves and 70% for pulmonary and tricuspid valves. The data illustrate the excellent hemodynamic function of the St. Jude Medical valve in children. The absence of thromboembolic complications warrant continued implantation of the prosthesis in the left side without warfarin anticoagulation therapy, but the high incidence of valve dysfunction in the pulmonary position does not justify its continued use in the right side.

Adolescent↗