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Biomedical subjects

C S Kleinman

Publications and source records attributed to C S Kleinman.

At least 73 records · Page 4Linked to original sources
PubMed1987

Persistent left superior vena cava causing subdivided left atrium: diagnosis, embryological implications, and surgical management.

A 3-month-old infant is described in whom a persistent left superior vena cava impinged on the posterior wall of the left atrium, producing a subdivided left atrium with left-to-right shunting and congestive heart failure. To our knowledge, this anomaly has not previously been reported. The preoperative diagnosis, surgical management, and embryological implications are discussed.

Echocardiography↗
PubMed1987

Combined echocardiographic and Doppler assessment of fetal congenital atrioventricular block.

Fetal heart rate monitoring was combined with fetal echocardiography for examination of atrial reactivity during labour in five fetuses with second or third degree heart block. Alterations in vagal tone accompanying uterine contraction influence atrial rate, even when the ventricle is not under atrial 'control'. Fetal echocardiography enabled diagnosis of the underlying basis of the arrhythmia and located the optimal position for recording atrial activity with an external heart rate monitor. External and internal monitoring of atrial activity demonstrated reactivity during labour. Two patients were delivered vaginally after monitoring throughout labour. One mother preferred elective caesarean delivery. Caesarean section was required in another for cephalopelvic disproportion and in the remaining woman for late decelerations. These monitoring techniques provide an assessment of fetal well-being in the presence of fetal bradycardia due to variable degrees of heart block.

Adult↗
PubMed1986

Fate of left-sided cardiac bioprosthesis valves in children.

To avoid anticoagulation and minimize thromboembolic phenomena, between 1975 and 1980 we used 18 porcine bioprosthetic valves (BPVs) to replace 11 aortic and seven mitral valves in 17 children ranging from 7 to 18 years of age (mean, 8.2 years). Ten BPVs (91%) in the aortic position had to be replaced one to six years (mean, 4.2 years) after insertion. Nine of these valves developed severe calcification with leaflet immobility and severe stenosis. The tenth valve became insufficient with a disrupted cusp. Six (86%) of seven BPVs inserted in the mitral position required replacement two to four years (mean, 3.1 years) after insertion. Massive mitral regurgitation developed in three, while in the other three mitral stenosis was prominent. All explanted BPVs exhibited calcification with disruption and loss of mobility of the leaflets. Hemodynamic deterioration often occurred catastrophically, with nine patients requiring emergency valve replacement. Elective valve replacement carried no hospital mortality, whereas emergency valve replacement carried a 33% mortality. The BPV failure rate of 94% within six years leads us to recommend against the use of biologic valves in the pediatric age group in the aortic or mitral position. Bioprosthetic valve failure may occur catastrophically and replacement should be carried out early to avoid the higher operative mortality associated with emergency surgery.

Adolescent↗
PubMed1986

Congenital heart disease and extracardiac anomalies: associations and indications for fetal echocardiography.

Fetal echocardiography is a well-established technique for the prenatal identification of congenital heart disease. One of the indications for its use is the presence of extracardiac anomalies, as such coexistent defects may have important implications for obstetric and neonatal management. We have reviewed the obstetric and pediatric literature to examine reported associations. If a fetus is suspected to have hydrocephalus, microcephaly, holoprosencephaly, agenesis of the corpus callosum, Meckel-Gruber syndrome, esophageal atresia, duodenal atresia, diaphragmatic hernia, omphalocele, or renal dysplasia, cardiac evaluation should be pursued. Furthermore, echocardiography may be of help in differential diagnosis of some anomalies (for instance, skeletal dysplasias). Maternal diabetes and phenylketonuria, as well as exposure to phenytoin, trimethadione, or isotretinoin, may result in multiple systemic defects, including congenital heart disease.

Abdominal Muscles↗
PubMed1986

The impact of fetal echocardiography on perinatal outcome.

Fetal echocardiograms were performed in 266 gravidae over a one-year period for a variety of previously identified indications. The largest group consisted of 112 patients referred because of other family members with congenital heart disease (CHD). Of these, only one fetus had CHD. The groups with the highest incidence of CHD were those suspected on general obstetrical scan to have structural cardiac disease (50% abnormal) and those scanned after extracardiac anomalies were found (26% abnormals). Forty rhythm abnormalities were encountered, 85% isolated premature atrial extra-systoles. We conclude that fetal echocardiography should be part of the prenatal evaluation of fetuses with extracardiac anomalies and of those with nonimmune hydrops. Any fetus suspected to have an abnormality of cardiac structure from the four-chamber view of the heart usually visualized while obtaining the abdominal circumference should also be evaluated.

Arrhythmias, Cardiac↗
PubMed1986

Accessory mitral valve tissue causing left ventricular outflow obstruction (two-dimensional echocardiographic diagnosis and surgical approach).

Accessory mitral valve tissue, a rare cause of left ventricular outflow tract obstruction, can be difficult to diagnose preoperatively and confusing even at surgery. The reported case illustrates how preoperative evaluation can be made using two-dimensional echocardiography combined with Doppler flow analysis. The intraoperative technique for removing the accessory tissue without causing damage to the native mitral valve is discussed.

Aortic Stenosis, Subvalvular↗
PubMed1986

Atrial dissociation: an electrophysiologic finding in a patient with transposition of the great arteries.

Complete interatrial block with two independent atrial rhythms is demonstrated by intracardiac electrograms in a patient with transposition of the great arteries who had undergone a Mustard operation. The atrial conduction abnormalities produced by the Mustard procedure with subsequent baffle revision are related to damaged anatomic interatrial connections and are similar to conduction abnormalities produced in experimental models of interatrial block.

Adult↗
PubMed1986

Prenatal diagnosis and management of intrauterine arrhythmias.

The antenatal diagnosis of fetal arrhythmias can be a difficult proposition. This paper reports 234 cases of fetal cardiac arrhythmias. One hundred and ninety-four of these were isolated extrasystoles which resolved spontaneously in all except 2 cases. There were 9 patients with complete heart block. Three of these patients had structural anomalies and hydrops. Four other patients with heart block had evidence of maternal collagen disease. Sustained supraventricular tachyarrhythmias are the most common clinical important arrhythmias. Most of these can be successfully controlled with digoxin alone or with verapamil or propranolol. Atrial flutter is more difficult to control than supraventricular tachycardia.

Anti-Arrhythmia Agents↗
PubMed1985

Treatment of fetal supraventricular tachyarrhythmias.

Supraventricular tachyarrhythmia has been encountered in 18 fetuses at the Yale-New Haven Medical Center during the past 4 years. Fourteen of these fetuses had supraventricular tachycardia and underwent in utero antiarrhythmic therapy with maternally administered digoxin either alone, or on combination with verapamil, propranolol, or procainamide. Thirteen of the 14 fetuses had successful in utero conversion of cardiac rhythm to normal sinus rhythm. The 14th patient underwent successful therapy after birth. All 14 fetuses survived despite severe fetal hydrops at the time of diagnosis in 13 of 14. The four remaining fetuses had either atrial flutter (3) or fibrillation. Two of the fetuses with atrial flutter died at birth, the 3rd survived after electrical cardioversion at birth. The fetus with atrial fibrillation converted to normal sinus rhythm and survived after maternal administration of digoxin. Using M-mode and pulsed Doppler echocardiography, the nature and electrophysiologic mechanism of the arrhythmia may be deduced. The latter information is reviewed along with the fetomaternal pharmacology of various antiarrhythmic agents to devise a rational antiarrhythmic treatment program.

Anti-Arrhythmia Agents↗
PubMed1985

Randomized indomethacin trial for prevention of intraventricular hemorrhage in very low birth weight infants.

We admitted 48 preterm neonates (600 to 1250 gm birth weight, normal 6-hour echoencephalograms) to a randomized prospective indomethacin or placebo trial for the prevention of neonatal intraventricular hemorrhage. Beginning at 6 postnatal hours, indomethacin or placebo was administered intravenously every 12 hours for a total of five doses. Cardiac ultrasound studies to assess the status of the ductus arteriosus were performed at 6 postnatal hours and on day 5. Urinary output, serum electrolytes, and renal and clotting functions were monitored. No differences in birth weight, gestational age, Apgar scores, or ventilatory needs were noted between the two groups. Six infants given indomethacin had intraventricular hemorrhage, compared to 14 control infants (P = 0.02). The indomethacin-treated group had significant decreases in serum prostaglandin values 30 hours after the initiation of therapy. The overall incidence of patent ductus arteriosus was 82% at 6 postnatal hours; 84% of the indomethacin-treated infants experienced closure of the ductus, compared to 60% of the placebo-treated patients. Closure of the ductus was not related to incidence of intraventricular hemorrhage. We speculate that indomethacin may provide some protection against neonatal intraventricular hemorrhage by acting on the cerebral microvasculature.

6-Ketoprostaglandin F1 alpha↗
PubMed1985

Ultrasonic assessment of cardiac function in the intact human fetus.

Echocardiography may provide information concerning the structural development of the fetal human heart. The information available from such studies, when interpreted in light of existing knowledge of developmental cardiac physiology, may give insight concerning in utero cardiac pump function. The quantitation of cardiac structural growth in utero has been used to provide growth curves for the chambers of the fetal heart. Disparity in the ratio of right ventricular/left ventricular size (normally 1.0 to 1.2) may suggest acute ventricular failure and dilation. Electromechanical analysis using M-mode techniques may be used to analyze and monitor the treatment of fetal cardiac arrhythmias and provide systolic time interval analysis. Doppler waveform analysis provides information concerning directional flow and vascular impedance and Doppler flowmetry has promise for the measurement of fetal aortic and umbilical venous blood flows. Such studies have increased our understanding of fetal circulatory function and have practical implications for the establishment of fetal cardiac diagnosis and treatment programs.

Arrhythmias, Cardiac↗
PubMed1985

Fetal atrioventricular valve insufficiency associated with nonimmune hydrops: a two-dimensional echocardiographic and pulsed Doppler ultrasound study.

Of 466 fetuses who underwent cardiac ultrasound examination with cross-sectional and M mode echocardiography and pulsed Doppler ultrasound and in whom we were able to follow the natural history, 12 were found to have atrioventricular valve insufficiency and nonimmune hydrops. Eleven fetuses (all of whom had structural heart disease) died either in utero or during the early postnatal period. In the one surviving hydropic fetus with supraventricular tachyarrhythmia and atrioventricular valve regurgitation but without structural heart disease, all the abnormalities disappeared on treatment with digoxin and verapamil. Seven fetuses who had atrioventricular valve insufficiency but did not develop nonimmune hydrops all survived pregnancy and the early neonatal period. The syndrome of atrioventricular valve insufficiency, nonimmune hydrops, and structural heart disease has a poor prognosis. The hydrops in this instance reflects fetal cardiac failure related to venous hypertension and low colloid oncotic pressure.

Echocardiography↗
PubMed1984

Communicating hydrocephalus secondary to superior vena caval obstruction. Occurrence after Mustard's operation for transposition of the great arteries.

Communicating hydrocephalus was observed on computed tomographic (CT) scans in two infants who had previously undergone Mustard's operation for transposition of the great arteries. Obstruction of the superior limb of the intracardiac baffle developed in these children, resulting in venous obstruction to the head and upper extremities that resulted in cranial enlargement. Radiologic clues included a bulging superior vena cava and a prominent azygous system on chest roentgenogram, split cranial sutures on skull films, and enlarged subarachnoid spaces and dilated ventricles on CT scans. Two-dimensional echocardiography showed the obstructed baffle, as well as signs of redirected blood flow. Angiography and measurement of venous pressures confirmed the obstruction, and surgical correction was successful. Follow-up CT scans showed resolution of the hydrocephalus. Increased venous pressure, leading to decreased CSF absorption and increased intraventricular and subarachnoid CSF accumulation in an infant with an expandable cranium, is a possible explanation for the development of cranial enlargement and hydrocephalus under these circumstances.

Echocardiography↗
PubMed1984

Intraventricular hemorrhage in the preterm neonate: timing and cerebral blood flow changes.

Serial cranial ultrasound studies, 133xenon inhalation cerebral blood flow determinations, and risk factor analyses were performed in 31 preterm neonates. Contrast echocardiographic studies were additionally performed in 16 of these 31 infants. Sixty-one percent were found to have germinal matrix or intraventricular hemorrhage. Seventy-four percent of all hemorrhages were detected by the thirtieth postnatal hour. The patients were divided into three groups: early GMH/IVH by the sixth postnatal hour (eight infants) interval GMH/IVH from 6 hours through 5 days (10), and no GMH/IVH (12). Cerebral blood flow values at 6 postnatal hours were significantly lower for the early GMH/IVH group than for the no GMH/IVH group (P less than 0.01). Progression of GMH/IVH was observed only in those infants with early hemorrhage, and these infants had a significantly higher incidence of neonatal mortality. Ventriculomegaly as determined by ultrasound studies was noted equally in infants with and without GMH/IVH (50%) and was not found to correlate with low cerebral blood flow. The patients with early hemorrhage were distinguishable by their need for more vigorous resuscitation at the time of birth and significantly higher ventilator settings during the first 36 postnatal hours, during which time they also had higher values of PCO2. An equal incidence of patent ductus arteriosus was found across all of the groups. We propose that early GMH/IVH may be related to perinatal events and that the significant decrease in cerebral blood flow found in infants with early GMH/IVH is secondary to the presence of the hemorrhage itself. Progression of early GMH/IVH and new interval GMH/IVH may be related to later neonatal events known to alter cerebral blood flow.

Blood Flow Velocity↗