Biomedical subjects
Publications and source records attributed to F Butto.
A unique case of aortic atresia and tricuspid atresia associated with transposition of the great vessels is described in a newborn infant. The clinical, echocardiographic, and heart catheterization data are presented. The embryological and surgical implications are discussed.
Coarctation of the aorta is amenable to surgical correction or balloon dilatation. In a 6-month-old girl with multiple intracardiac anomalies, re-coarctation, which followed surgical repair at 16 days was successfully dilated.
Occult pulmonary artery is an uncommon cardiovascular defect. Associated symptoms include recurrent pulmonary infections and congestive heart failure. The authors describe a one-year-old boy initially diagnosed as having broncho-pulmonary dysplasia who developed severe failure to thrive, recurrent pneumonias, and pulmonary hypertension. The presence of an occult right pulmonary artery was suspected by lung perfusion scan and diagnosed by cardiac catheterization and angiography. After surgical repair, his clinical course improved and his growth and development were normal. This case demonstrates the importance of including occult pulmonary artery in the differential diagnosis of infants with failure to thrive associated with recurrent pulmonary infection.
Simultaneous inflation of two balloons may be necessary for balloon dilation valvuloplasty in patients with a large annulus. We examined the cardiovascular effects of dilating the pulmonary annulus with two balloons in 18 normal dogs using pulsed Doppler ultrasound and gross and microscopic examination. When the ratio of the cross-sectional area (CSA) during dilation to the CSA of the pulmonary annulus was between 1.04 and 1.28, there was valvar regurgitation in only one dog, in which catheter manipulation was complicated by heartworms, and damage was confined to intimal changes. (The dog was killed 24 hours after dilation.) With ratios between 1.67 and 1.76 (equal to the CSA of a single balloon with a diameter 33% greater than the annulus), there was trivial or mild tricuspid or pulmonary regurgitation, and anatomic changes were more prominent but still superficial. Two animals killed after nine days had resolution of valvar regurgitation and healing damage. With CSA ratios greater than 2.00 or with balloon rupture, myocardial damage and laceration of the pulmonary arteries resulted. Simultaneous inflation of two balloons within the right ventricular outflow tract with CSA ratios of up to 1.76 results in minimal cardiovascular trauma.
A major drawback of currently used exchange guide wires is insufficient stiffness, causing them to buckle or dislodge when used during catheter exchanges. A new heavy-duty exchange guide wire is described that facilitates catheter exchanges around sharp corners, such as those encountered during various cardiac interventional procedures. The wire was successfully used in experimental valvuloplasty and experimental dilation of the ductus arteriosus.
An introducer-sheath dilator is described, which was modified to protect the leading lip of the sheath during insertion, thus reducing arterial damage. The new sheath and a standard sheath were inserted into the femoral arteries of six dogs. Subsequent histologic examination of the arteries proved the new sheath to be both safe and effective.
Five cases are described in which noninflammatory pulmonary arterial aneurysmal disease existed. In each case, severe pulmonary hypertension had been present. In one (woman, age 50 years), the pulmonary hypertension was of the primary type, while in each of the others, congenital heart disease was an underlying condition (atrial septal defect in three cases; each woman, age range 35 to 56 years) and complete transposition in the remaining case (boy, age ten). In one case with atrial septal defect, saccular aneurysm involving each major pulmonary arterial branch was considered to have resulted from atherosclerotic disease. In each of the remaining cases, cystic medial necrosis was present, and the aneurysmal disease was the result of laceration of a major pulmonary arterial segment. In one of the cases with atrial septal defect, the laceration was recent and extended through the full thickness of the pulmonary trunk in a circumferential manner. In the remaining three cases, lacerations were usually old and had not extended through the full thickness of the involved arterial segments. Saccular aneurysm formation (usually multiple) had resulted from weakness of the wall as a result of laceration and retraction of tissue.
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Transesophageal study was used for diagnosis and treatment of 51 episodes of tachycardia in 13 patients with complete transposition of the great arteries who had undergone atrial baffle procedure. At the time of atrial baffle procedure, patients were 6 to 36 months old (mean 23). Tachycardia (1 to 17 episodes per patient) first occurred 1 to 23 days (4 patients) or 1.8 to 12 years (9 patients) after atrial baffle. Transesophageal study was performed using a bipolar silicone rubber-coated catheter. Tachycardia conversion was accomplished with stimulation bursts using 4 to 10 stimuli 9.9 ms in duration at 20 to 28 mA and an interstimulus interval of 50 to 100 ms less than the atrial cycle length. All tachycardia episodes had regular atrial cycle lengths ranging from 200 to 350 ms. In 12 patients, second-degree atrioventricular (AV) block was observed during tachycardia, suggesting primary atrial tachycardia. However, in 1 patient, occurrence of AV block always resulted in tachycardia termination, suggesting the presence of AV reentrant tachycardia. Transesophageal stimulation converted 48 of 51 tachycardia episodes to sinus/junctional rhythm. Ten tachycardia episodes in 6 patients were transiently converted to atrial fibrillation lasting 3 seconds to 28 minutes before spontaneous conversion to sinus junctional rhythm. Conversion attempts were unsuccessful on 3 occasions. Acceleration of ventricular rate after stimulation necessitated DC cardioversion on 1 occasion. Conversion was not achieved in 2 tachycardia episodes using stimuli less than 10 mA. Transesophageal study is a safe and effective minimally invasive technique for diagnosis and treatment of tachycardia in infants and children who have had atrial baffle for transposition of the great arteries.
Fifty-four specimens of heart with persistent truncus arteriosus (PTA) were reviewed anatomically. According to the Collett-Edwards classification there were 28 examples of type I and 26 type II. The sex distribution was equal. The number of the truncal cusps ranged from one to four (42% tricuspid, 30% bicuspid, 24% quadricuspid, and 4% unicommissural). A unicommissural truncal valve has not been previously reported. In 72% of cases, the truncal valve leaflets were thickened or dysplastic. Two valves were stenotic. The truncus arteriosus originated from both ventricles equally in 42% of the cases, predominantly from the right ventricle in 42%, and predominantly from the left ventricle in 16% of the cases. In unoperated cases of PTA originating predominantly from the right ventricle, it appeared to us that usual operative correction might result in left ventricular outflow obstruction. Variations in coronary arterial origins and patterns were present in nearly half of the cases. A single coronary artery was observed in ten cases (18.5%). Stenosis of the ostium of one coronary artery was seen in each of four cases (7%). High posterior origin of the left coronary artery was observed in ten cases (18.5%). Among the associated cardiovascular anomalies, the most common were right aortic arch (36%) and interruption of the aortic arch (11%). Three cases with the latter condition exhibited crossed pulmonary arteries. Isolated cases with tricuspid atresia, vascular sling (left pulmonary artery arising from right pulmonary artery), and persistent common atrioventricular canal were encountered.
A new technique for vascular embolization using two Gianturco steel coils is described. The authors used a "coil-in-coil" technique to embolize the arteries of 12 dogs. In this technique a large coil is introduced into the artery followed by a smaller coil, which is delivered with a special introducer into the lumen of the first coil. Two coils can therefore be introduced into a shorter length of vessel. This method was as effective as "packing" the vessel with two coils in a row. The coil-in-coil technique is especially advantageous for use in infants and children with short, anomalous vessels, minimizing the risk of coil dislodgment into normal peripheral vessels.
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