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Biomedical subjects

A R Castaneda

Publications and source records attributed to A R Castaneda.

At least 19 recordsLinked to original sources
PubMed1992

Temperature monitoring during CPB in infants: does it predict efficient brain cooling?

We examined jugular venous oxygen saturation data in 17 pediatric patients less than 1 year of age undergoing hypothermic cardiopulmonary bypass (CPB). Jugular venous oxygen saturations (JvO2SATS) were measured before bypass and during the active core cooling portion of CPB. The study intervals during CPB included 1 minute after initiation of CPB, at a tympanic membrane temperature of 15 degrees C, and at a rectal temperature of 15 degrees C. During these measurement intervals, there were no significant changes in mean arterial pressure, pump flow rate, arterial oxygen saturation, mixed venous oxygen saturation, carbon dioxide tension, or hematocrit. Six of the 17 patients (29%) demonstrated a significantly lower JvO2SAT (87.1% +/- 6.3% versus 98.1% +/- 0.9%) at a tympanic membrane temperature of 15 degrees C. Patients demonstrating jugular venous desaturation could not be predicted from continuous monitoring of tympanic membrane and rectal temperatures or through on-line measurements of mixed venous oxygen saturation. Low JvO2SAT suggests higher levels of cerebral metabolism and cerebral uptake of oxygen. In the presence of deep hypothermic CPB and stable anesthetic levels, the most likely cause of a low JvO2SAT is inadequate cerebral cooling. We believe JvO2SAT monitoring may be an important adjunct to conventional temperature monitoring in the patient undergoing deep hypothermic CPB or total circulatory arrest.

Body Temperature↗
PubMed1992

Clinical outcomes after the arterial switch operation for transposition. Patient, support, procedural, and institutional risk factors. Congenital Heart Surgeons Society.

BACKGROUND: As the probability increases that the arterial switch operation is optimal treatment for transposition, detailed information about outcomes and the circumstances in which they are suboptimal becomes important. METHODS AND RESULTS: A multi-institutional prospective study with annual detailed follow-up included 513 neonates with simple transposition or transposition and ventricular septal defect entering for diagnosis and treatment at < 15 days of age and undergoing an arterial switch repair. The 1-month and 1- and 5-year survivals were 84%, 82%, and 82%, respectively. The hazard function for death had a rapidly declining single phase that approached zero by 12 months after surgery. Among the eight patients who died > or = 3 months after the operation, four had severe ventricular dysfunction, probably related to imperfect coronary arterial transfer. Coexisting single ventricular septal defect was not a risk factor for death. Origin of the left main coronary artery or only the left anterior descending or the circumflex artery from the right posterior sinus (sinus 2) was a risk factor that was even stronger when an intramural course was present; multiplicity of ventricular septal defects was a risk factor. Longer global myocardial ischemic time and total circulatory arrest time were risk factors. Certain institutions were shown to be risk factors for death; the results in some improved with increasing experience, in some they did not, and in some they worsened. CONCLUSIONS: Good early and intermediate-term clinical outcomes can be obtained in neonates with simple transposition and transposition and ventricular septal defect by use of the arterial switch operation. Certain coronary artery patterns and certain institutions lessen the goodness of outcome.

Coronary Vessel Anomalies↗
PubMed1992

Effect of baffle fenestration on outcome of the modified Fontan operation.

BACKGROUND: 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. METHODS AND RESULTS: Patients having a modified Fontan operation with a cavocaval baffle and cavopulmonary anastomosis were retrospectively selected for study. Those with baffle fenestration (n = 91) were compared with those without baffle fenestration (n = 56) with respect to preoperative risk factors, age, anatomy, surgical date, and presence or absence of a previous bidirectional cavopulmonary anastomosis. Outcome variables were failure (death or take-down) and duration of postoperative pleural effusions and hospitalization. Survival and clinical status after hospital discharge were ascertained. The two groups did not appear to differ with respect to age or anatomic diagnosis. Patients having baffle fenestration were at significantly greater preoperative risk by univariate and multivariate analysis (p < 0.01). Operative failure was low in both groups (11% without and 7% with baffle fenestration, p = NS). Durations of pleural effusions and hospitalization were significantly shorter with baffle fenestration (p < 0.01). Neither date of surgery nor a previous bidirectional cavopulmonary anastomosis appeared to contribute to improved outcome. Patients with baffle fenestration had lower postoperative systemic venous pressure (p < 0.01). There were no late deaths. Functional status in both groups is good (82% in New York Heart Association class I). CONCLUSIONS: Baffle fenestration is associated with low mortality, significantly less pleural effusion, and significantly shorter hospitalization among high-risk patients having a modified Fontan operation.

Cardiac Surgical Procedures↗
PubMed1992

The fenestrated Fontan procedure.

In 90 patients with characteristics placing them at increased risk for a Fontan operation, a fenestration was created in the atrial baffle at the time of the Fontan repair. The rational was to allow a right to left shunt which would maintain cardiac output and limit right atrial pressure in the presence of conditions which limit pulmonary blood flow. Early mortality was 4/90 (4%), with an additional two patients having the Fontan repair taken down to a bidirectional cavopulmonary anastomosis. Postoperative right atrial pressures were low (average 13 mm Hg), as was the incidence of prolonged pleural effusions (13%). At short-term (average 13 months) follow-up, 77% of patients have had closure of the fenestration, and 92% are in New York Heart Association Class I. We conclude that baffle fenestration with subsequent transcatheter closure results in decreased mortality and morbidity among high risk patients undergoing a Fontan repair, and that the high functional level at short-term follow-up justifies continued aggressive management of such patients.

Adolescent↗
PubMed1992

Factors associated with choreoathetosis after cardiopulmonary bypass in children with congenital heart disease.

BACKGROUND: Choreoathetosis (CHO) after congenital heart surgery has been described since 1960. Risk factors and patient outcome have not been well defined. METHODS AND RESULTS: As our complexity of cases increased and management of pH on cardiopulmonary bypass (CPB) evolved, we noted the appearance of CHO among patients beginning in 1986. We reviewed the hospital course and follow-up of all 19 affected children, including eight younger patients (median age, 4.3 months) who developed a mild transient form of CHO, all of whom survived and had complete resolution of CHO; seven of these eight patients had deep hypothermic circulatory arrest (DHCA). Eleven older patients (median age, 16.8 months) developed severe persistent CHO; 11 had DHCA, 10 were cyanotic, seven had anatomic pulmonary atresia, and three others were physiologically analogous with a systemic to pulmonary artery shunt-dependent circulation. Five of six patients who had pertinent preoperative angiography had systemic to pulmonary collateral vessels arising from the head and neck arteries. Mortality in severe patients was 36% (four of 11); the seven survivors showed improvement, but only one had a normal neurological examination after 60 months of follow-up. When severe CHO patients were compared with 17 age- and diagnosis-matched patients without neurological complications, no differences were found in CPB or DHCA times, arterial blood gases, or hematocrits. Time from onset of CPB to onset of DHCA (time to shutoff) was shorter in the severe persistent CHO group than for comparison patients (22 +/- 7 versus 40 +/- 29 minutes, p = 0.053). CONCLUSIONS: Factors that may be associated with the development of severe persistent CHO include 1) age beyond early infancy, 2) cyanotic heart disease with systemic to pulmonary collaterals, particularly those arising from the head and neck vessels, and 3) the duration of the cooling period used in conjunction with deep hypothermic circulatory arrest. We advocate earlier reparative surgery, precise preoperative diagnosis and preoperative or intraoperative control of systemic to pulmonary artery collaterals, and further study of pH effects during CPB on development of CHO.

Athetosis↗
PubMed1992

From Glenn to Fontan. A continuing evolution.

BACKGROUND: Aristotle's and Galen's erroneous understanding of the circulation eventually was rectified, mostly by Colombo and Harvey, who in the 16th and 17th centuries, respectively, provided the foundation to our present knowledge of the pulmonary and systemic circulation. The "indispensability" of the right ventricle was not questioned until the 20th century. Rodbard, in 1948, for the first time successfully bypassed the canine right ventricle by anastomosing the right atrial appendage to the proximally ligated main pulmonary artery. This important experiment triggered a number of other studies that eventually led to the clinical introduction of the Glenn operation in 1959 and the Fontan operation in 1968. METHODS AND RESULTS: Clinical experience with modifications of the original Fontan operation at The Children's Hospital in Boston included 1) direct atrial-to-pulmonary artery connection (without valves), 2) cavocaval baffle-to-pulmonary artery connection, 3) bidirectional cavopulmonary artery anastomosis, and 4) fenestrated Fontan approach. The original surgical mortality of 20% has been reduced in 1990-1991 to 4%, including patients with complex pathology other than tricuspid atresia. The incidence of prolonged pleural effusions has also decreased from an earlier 40% to < 5% after bidirectional cavopulmonary artery anastomosis and to 11% after the fenestrated Fontan operation. CONCLUSIONS: Much progress has been made since Dr. Glenn's and Dr. Fontan's epic contributions. Ideally, a more appropriate selection of patients and some of the modifications of the original Fontan operation will have a more favorable impact on early and long-term results.

Animals↗
PubMed1992

Factors associated with marked reduction in mortality for Fontan operations in patients with single ventricle.

The Fontan operation was originally employed for patients with tricuspid atresia, but its application has been extended to those with a variety of complex defects in which there is functionally only a single ventricular chamber. The outcome of 225 modified Fontan operations carried out between 1984 and 1990 at the Children's Hospital, Boston, for patients with defects other than tricuspid atresia was reviewed. Overall 30 patients (13.3%) had failure of this operation (death or takedown). Results improved significantly during the period of the study, with failure rates of 6.5% (2 of 31) and 3.4% (2 of 59) in the last 2 years of the review. Multivariate analysis showed that pulmonary artery distortion, pulmonary artery pressure, age less than 3 years, use of a nonoxygenated glucose K+ cardioplegic solution, and cardiopulmonary bypass time greater than 180 minutes were associated with worse outcome, while "favorable" atrioventricular valve anatomy (non-left atrioventricular valve stenosis/atresia or common atrioventricular valve) and age greater than 9 years were associated with improved outcome. Excluding cardiopulmonary bypass time from the multivariate analysis, the technique of atrial partitioning for patients with left atrioventricular valve atresia/stenosis became the most important variable, followed by the others noted in the initial multivariate analysis except for age greater than 9 years. In the last 2 years of the study 31.1% of patients were less than 3 years of age. During the period of the study there was no significant decline in preoperative risk factors. These results show that modified Fontan operations can be carried out with a high likelihood of success in properly selected patients with complex defects in whom there is functionally a single ventricle.

Age Factors↗
PubMed1992

Morphologic and surgical determinants of outcome events after repair of tetralogy of Fallot and pulmonary stenosis. A two-institution study.

Survival after entry and survival after repair (94%, 91%, and 91% at 1 month, 1 year, and 5 years, respectively) were similar in two institutions treating 196 consecutive patients, and there was no advantage (and a possible disadvantage) of a protocol of preliminary shunting and later repair in very young patients. Size and configuration of the right and left pulmonary arteries had no demonstrable effect on survival, prevalence of transannular patching, or postrepair right ventricular-left ventricular pressure ratio. Small size of the pulmonary "anulus" and trunk were risk factors for death, transannular patching, and high postrepair pressure ratio. High postrepair pressure ratio was a risk factor for death after repair. Very young age (less than about 3 months) was a risk factor for death after repair, particularly when other risk factors coexisted. The prevalence of transannular patching in patients with mild infundibular and pulmonary anulus and trunk hypoplasia decreased across the time of the study, without ill effect. The usefulness of measuring postrepair right ventricular-left ventricular pressure ratio is emphasized by the data.

Female↗
PubMed1991

Tricuspid atresia or severe stenosis with partial common atrioventricular canal: anatomic data, clinical profile and surgical considerations.

The anatomic findings in 11 cases of tricuspid atresia and in two cases of severe tricuspid stenosis, both combined with partial common atrioventricular (AV) canal, are presented in detail. Twelve cases were documented by postmortem examination and the diagnosis was confirmed by echocardiography and surgical observation in the one living patient. Clinical data available in nine cases and cardiac catheterization data obtained in eight are included in this report. In three cases (23%)--two with tricuspid atresia and one with extreme tricuspid stenosis--the tricuspid valve and right ventricle exhibited characteristics seen in Ebstein's anomaly. In all 13 cases, the great arteries were normally related. The ventricular septal defect(s) in 10 (83%) of the 12 postmortem cases rapidly became smaller and this resulted in marked diminution of the pulmonary blood flow and severe hypoxia. Only three of the eight patients with available cardiac catheterization and angiocardiographic data showed the scooped-out appearance of the left ventricular septal surface characteristic of AV canal defects. By contrast, two-dimensional echocardiography, available in the three most recent cases, accurately demonstrated all the defects present and represents the diagnostic method of choice. Early surgical intervention to establish a systemic to pulmonary artery anastomosis is essential for survival. More definitive surgical treatment can be achieved later by an atriopulmonary or cavopulmonary anastomosis with or without replacement of the cleft and often regurgitant mitral valve. The one living patient exemplifies this approach. This is the largest series of this unusual type of tricuspid atresia reported to date.

Cardiac Catheterization↗
PubMed1991

Neonatal repair of tetralogy of Fallot with and without pulmonary atresia.

Our experience with the arterial switch operation for transposition of the great arteries has confirmed the attainability of excellent results with elective neonatal surgery. Up to this time, we have repaired tetralogy of Fallot during the neonatal period only when symptoms, either severe persistent cyanosis or cyanotic spells, have been present. This review assesses the results of such nonelective neonatal correction of tetralogy between 1973 and 1988. Twenty-seven neonates with either symptomatic tetralogy of Fallot or symptomatic tetralogy of Fallot with valvar pulmonary atresia underwent repair. Mean age at repair was 8 +/- 8.4 days and mean weight was 3.0 +/- 0.7 kg. Unsatisfactory palliative shunts had previously been placed elsewhere in four patients. Twenty-five transannular patches and two conduits were used for reconstruction of the right ventricular outflow tract. There were five deaths in the hospital, three of which were due to avoidable technical problems. All deaths occurred in patients with pulmonary artery (Nakata) index less than 150 mm2/m2. One premature child weighing 2.3 kg displayed an absent pulmonary valve-like syndrome after repair and died late of respiratory complications caused by aneurysmal branch pulmonary arteries. Actuarial survival at 5 years was 74%. There was a single rapidly declining hazard phase for death, with the hazard approaching zero at 1 1/2 years after repair. Actuarial freedom from need for reoperation was 76% at 5 years. Postoperative catheterization of 15 long-term survivors showed right ventricular pressure less than 70% systemic in 13 cases. All patients are symptomatically well and functioning in sinus rhythm 1 to 15 years after repair (mean, 5 +/- 4 years). This experience with neonates with symptoms suggests that, if mortality is lower in the absence of symptoms, elective repair of tetralogy of Fallot could be reasonably undertaken during the first months of life.

Abnormalities, Multiple↗
PubMed1991

Cognitive development of children following early repair of transposition of the great arteries using deep hypothermic circulatory arrest.

Twenty-eight children who underwent corrective cardiac surgery in early infancy had developmental evaluations to explore whether cardiopulmonary bypass perfusion variables are associated with later cognitive function. All had transposition of the great arteries repaired by the arterial switch operation using deep hypothermic circulatory arrest. The mean duration of deep hypothermic circulatory arrest was 64 +/- 10 minutes (mean +/- SD). Median age at repair was 4 days (range 1 to 125 days). Tests of development were administered at age 7 to 53 months: Bayley Scales for children younger than 30 months of age (n = 18) and McCarthy Scales for older children (n = 10). Overall cognitive development score was 101.2 +/- 11.1. Duration of deep hypothermic circulatory arrest was not associated with performance. However, for core cooling periods of less than 20 minutes' duration, shorter cooling periods were associated with lower scores (r = .85, n = 11, P less than .001). These data suggest that patients undergoing relatively long periods of deep hypothermic circulatory arrest may require some minimum time of cardiopulmonary bypass cooling to avoid central nervous system injury.

Child Development↗
PubMed1990

Long follow-up (to 43 years) of ventricular septal defect with audible aortic regurgitation.

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 subpulmonary VSD. The aortic valve was tricuspid in 90% and bicuspid in 10%. Prolapse was seen in 90% of those with subcristal VSD and in all with subpulmonary VSD. Pulmonary stenosis was seen in 46% of the patients with gradients ranging from 10 to 55 mm Hg. The incidence of infective endocarditis was 15 episodes/1,000 patient years. Among 20 patients followed medically, for 297 patient years, 1 died (1959) and most have been stable, including 2 followed for greater than 30 years. In the 72 patients operated on, there were 15 perioperative and 5 late deaths. Operations consisted of VSD closure alone in 7, VSD closure and valvuloplasty in 50 and VSD closure and aortic valve replacement in the other 15. Valvuloplasty was more effective in those operated on under age 10 compared to those older than 15 years (46 vs 14%). The durability of the valvuloplasty was 76% at 12 years and 51% at 18 years.

Actuarial Analysis↗
PubMed1990

Baffle fenestration with subsequent transcatheter closure. Modification of the Fontan operation for patients at increased risk.

Ventricular dysfunction, elevated pulmonary vascular resistance, and residual distal pulmonary artery distortion contribute to early mortality after a Fontan operation; they may be transient or reversible. A baffle fenestration, allowing right-to-left shunting, maintains cardiac output and limits right atrial pressure. A baffle fenestration was surgically created at the time of a modified Fontan repair in 20 consecutive patients. Risk factors included pulmonary artery pressure of 18 mm Hg or more, end-diastolic pressure of 12 mm Hg or more, valvar regurgitation, pulmonary artery distortion, pulmonary vascular resistance of 2 Woods' units or more, ventricular outflow obstruction, and complex anatomy. Nineteen of 20 patients survived. After the operation, mean arterial oxygen saturation was 86%, mean right atrial pressure was 15 mm Hg, and mean duration of pleural effusions was 6 days. Twelve of 19 survivors tolerated early test occlusion and had permanent transcatheter umbrella closure. Four patients failed early test occlusion, with a significant decrease in venous O2 saturation and a rise in central venous pressure, due to ventricular dysfunction, pulmonary artery distortion, or aortopulmonary collaterals. Three of four had successful late closure of the fenestration after correction of these abnormalities.

Cardiac Catheterization↗
PubMed1990

Bidirectional cavopulmonary anastomosis as interim palliation for high-risk Fontan candidates. Early results.

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 pressure (mean, greater than 18 mm Hg), atrioventricular valve regurgitation, systemic ventricular dysfunction, complex venous anatomy, and subaortic obstruction. There were no deaths, either early or late. Median arterial oxygen saturation increased from 79% to 84% (p less than 0.01). Median hospital stay was 8 days. No patient had pleural effusions after 7 days. Three patients had significant surgical complications. Five patients had inadequate relief of cyanosis; three of these had venous collaterals and two had severe ventricular dysfunction; the latter two patients subsequently had strokes. One of the patients with persistent cyanosis required a systemic-to-pulmonary artery shunt. We conclude that a bidirectional cavopulmonary shunt, with pulmonary artery reconstruction when indicated, provides adequate relief of cyanosis in most patients with single-ventricle lesions who are considered to be at increased risk for a Fontan repair. Relief of ventricular volume overload and pulmonary artery distortion may improve Fontan candidacy. Also, patients with persistent cyanosis after bidirectional cavopulmonary anastomosis should be catheterized for location and occlusion of venous collaterals. Further follow-up is necessary to determine the place of bidirectional cavopulmonary anastomosis in the management of patients at increased risk for a Fontan repair.

Anastomosis, Surgical↗
PubMed1990

Mitral valve replacement in the first year of life.

From 1973 through 1987 25 patients underwent mitral valve replacement in the first year of life for mitral stenosis and mitral regurgitation. The patients with mitral stenosis included two with mitral arcade, two with supravalvular mitral stenosis with hypoplastic mitral valve, and one with parachute mitral valve. Included in the group of patients with mitral regurgitation were 12 with atrioventricular canal defect, six with chordal and leaflet defects, one with Marfan's syndrome, and one with bacterial endocarditis. Prostheses included 12 Björk-Shiley (17 mm), seven St. Jude Medical (19 mm in four, 21 mm in three), five stent-mounted dura mater valves (12 mm to 16 mm), and one porcine xenograft (19 mm). In four patients the valves were placed in the left atrium in a supraannular location. There were nine operative (atrioventricular canal defect seven, mitral regurgitation two) and five late (atrioventricular canal defect four, mitral stenosis one) deaths, giving actuarial 1- and 5-year survival rates of 52% and 43%, respectively. All 6 patients with tissue valves died; the four with supraannular mitral valve replacement survived. Since 1983 operative mortality has been reduced to 0% (70% confidence limits 0% to 24%). Nine patients required a second mitral valve replacement for prosthetic stenosis 5 to 69 (mean 30) months after the original mitral valve replacement (one operative death). Because of improvements in repair of atrioventricular canal defect in infancy, the need for mitral valve replacement at atrioventricular canal defect repair has decreased. Although valvuloplasty has been advocated for repair of congenital mitral valve disease and is applicable in some infants with mitral regurgitation, mitral valve replacement is frequently unavoidable for congenital mitral disease and can now be accomplished at a low operative risk, even when the prosthesis has to be positioned supraannularly.

Age Factors↗
PubMed1990

Orthotopic heart transplantation for complex congenital heart disease.

Orthotopic heart transplantation has become standard therapy for end-stage cardiomyopathy in children and adults, but there has been much less experience with transplantation for complex congenital heart disease. In this report experience with orthotopic transplantation in seven children with various forms of complex congenital heart disease is reviewed. Diagnoses included hypoplastic left heart syndrome in two (after stage I palliation), left ventricular diverticulum in one, single ventricle in two (dextrocardia, atrial situs inversus, and total anomalous pulmonary venous return in one patient and post-Fontan repair in the second), D-transposition of the great arteries and ventricular septal defect (post-Senning repair and ventricular septal defect closure) in one, and Ebstein's anomaly with biventricular dysplasia in one. Six of the seven were hospital survivors and there has been one late death at 2 1/3 years. Modifications of the standard operative technique to fit the anatomic variations in these defects are reviewed.

Adolescent↗
PubMed1989

Truncus arteriosus.

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Abnormalities, Multiple↗