Intraperitoneal hemorrhage following femoral artery cannulation for intraoperative monitoring: an unusual complication.
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Adolescent↗
Biomedical subjects
G K Danielson
Publications and source records attributed to G K Danielson.
Pulmonary artery size and clinical outcome after the modified Fontan operation.
The maximum cross-sectional area of the central pulmonary arteries indexed to the body surface area (pulmonary artery index [PAI]) was measured preoperatively from angiograms in 173 patients evaluated for a Fontan-type operation between 1981 and June 1989. Of these, 34 patients underwent another palliative procedure, 8 primarily on the basis of small pulmonary arteries (PAI, 106 to 167 mm2/m2). The mean PAI of this group was significantly smaller than the mean PAI of the remaining 139 patients who underwent a Fontan operation (136 +/- 20 versus 310 +/- 113 mm2/m2) (p < 0.001). The patients who underwent a Fontan operation were evaluated according to three overlapping end points: (1) hospital death or takedown of repair (12.2%), (2) early failure (cumulative death or takedown of repair within 6 months of operation) (16.5%), and (3) early failure or persistent effusions (33.8%). With regard to these end points, no significant difference in pulmonary artery size could be found between patients having a favorable or unfavorable outcome. However, among a low-risk subset of 30 patients with tricuspid atresia, those with "early failure or persistent effusions" had significantly smaller pulmonary arteries than those with a good outcome (PAI, 185 +/- 47 versus 276 +/- 83 mm2/m2) (p < 0.01). The postoperative transpulmonary gradient of the 8 patients with the smallest pulmonary arteries who underwent a Fontan operation (all PAIs < 170 mm2/m2) was significantly greater than that of the rest of the study group (9.88 +/- 2.3 versus 8.13 +/- 2.3 mm Hg) (p < 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Congenital absence of the pericardium: displacement of the heart associated with tricuspid insufficiency.
This report describes a patient with congenital absence of the left pericardium with displacement of the heart into the left pleural space and associated tricuspid insufficiency. Excision of the ruptured chordae, plication of the flail anterior leaflet, and tricuspid annuloplasty rendered a competent tricuspid valve.
Adult↗
Cardiorespiratory response to exercise after the Fontan operation: a serial study.
OBJECTIVES: The purpose of this study was to assess whether there is deterioration of aerobic capacity over time after the Fontan operation in individual patients. BACKGROUND: We previously observed that maximal aerobic capacity after the Fontan operation was lower in older patients than in younger patients. It was unclear whether this represented a decrease in aerobic capacity with time after operation or was a function of studying patients of different ages at different times postoperatively. METHODS: All patients who had more than one postoperative exercise study were included. There were 25 patients (19 male, 6 female), aged 3.8 to 39 years at the time of the operation. The first exercise test was performed, on average, 2.2 years after the Fontan operation, and the last exercise test was performed, on average, 5.9 years (range 1.8 to 13) after the operation. In 11 patients, coronary sinus drainage was left on the pulmonary venous side. Five patients had had a previous Glenn operation. Exercise was performed to exhaustion with use of a 3-min incremental cycle protocol. RESULTS: Exercise duration, oxygen uptake, blood pressure, respiratory rate, minute ventilation, pulmonary blood flow index, exercise factor, ST-T wave changes and the prevalence of arrhythmias were similar during the first and last tests. Exercise systemic arterial blood oxygen saturation decreased from the first to the last postoperative test (p < 0.006) regardless of age. The percent of predicted heart rate, at rest and during maximal exercise, decreased more in older patients from the first to the last test (p < 0.05 for rest and exercise). CONCLUSIONS: In this select group of patients, exercise tolerance remained relatively unchanged over the range of 13 years after the Fontan operation. Heart rate at rest and during maximal exercise decreased more than predicted for age in older patients. A small but significant progressive decrease in systemic arterial blood oxygen saturation was found. The former might represent abnormal sinus node function in patients with functional single ventricle, and the latter might represent a tendency toward development of abnormal ventilation/perfusion patterns resulting from the development of small pulmonary arteriovenous fistulas or an effect of position of the coronary sinus postoperatively.
Adolescent↗
Aortopulmonary window: factors associated with early and late success after surgical treatment.
Between 1953 and 1990, 19 patients, who were from 7 weeks to 27 years old, underwent surgical correction of aortopulmonary window at the Mayo Clinic. Associated cardiac anomalies were present in nine patients (47%). At operation, extracorporeal circulation was used in all except one patient. In seven patients, division and primary closure were done. In four patients, the defect was closed by direct suture through a transpulmonary approach. In eight patients, the defect was closed with a patch through a transpulmonary or transaortic approach. Four deaths (21%) occurred intraoperatively or immediately postoperatively. All four patients had undergone division of the aortopulmonary window before 1962, and three of them had a pulmonary vascular resistance (Rp) that was 7.3 U.m2 or more and a ratio of Rp to systemic vascular resistance (Rp/Rs) that exceeded 0.6. One patient with an Rp of 11.8 U.m2 and an Rp/Rs of 0.72 died 16 years postoperatively. Statistical analysis of risk factors indicated that early year of operation (P = 0.022), division of the aortopulmonary window versus transaortic or transpulmonary closure (P = 0.009), and a high Rp/Rs (P = 0.021) were significantly associated with perioperative death. All patients with a preoperative Rp of 8 U.m2 or less, an Rp/Rs of less than 0.4, and no major associated cardiac anomalies were in functional class I (New York Heart Association) postoperatively. Our study confirms that infants with aortopulmonary window should undergo operation early, before irreversible pulmonary vascular changes have developed. Patients with an Rp/Rs that exceeds 0.4 should be thoroughly assessed to determine their operability.
Adolescent↗
Congenital partial and complete absence of the pericardium.
Between 1952 and 1991, 15 Mayo patients were found to have partial or complete absence of the pericardium at the time of a cardiovascular surgical procedure. One patient with complete absence of the left pericardium had symptoms possibly related to the pericardial abnormality. This 42-year-old man had severe insufficiency of the tricuspid valve attributable to chordal rupture of the anterior leaflet, possibly precipitated by complete displacement of the heart into the left pleural space. Excision of the ruptured chordae and plication of the anterior flail leaflet rendered a competent tricuspid valve. In two patients, a small defect in the pericardium was repaired. Three patients who underwent operation for complex congenital heart disease died: two early postoperatively and one late after a reoperation. In the other 12 patients, no early or late postoperative complications were encountered. Although rare and usually asymptomatic, complete and partial deficiency of the pericardium may lead to serious complications such as cardiac valvular insufficiency or incarceration of cardiac tissue.
Adult↗
Cor triatriatum: diagnosis, operative approach, and late results.
From May 1960 to January 1992, 13 patients with cor triatriatum underwent surgical correction at the Mayo Clinic. Their ages ranged from 7 months to 57 years. Four patients had isolated cor triatriatum; three others had an associated patent foramen ovale or atrial septal defect. Six patients had major associated cardiac anomalies. In patients who had isolated cor triatriatum or associated anomalies with high pulmonary blood flow, the mean gradient across the left atrial diaphragm was 24.4 mm Hg, in comparison with 11.6 mm Hg in patients who had cor triatriatum and a connection between the common pulmonary venous chamber and the right atrium or associated cardiac anomalies that restricted pulmonary blood flow. In all 11 patients who underwent angiography, echocardiography, or both at our institution, the correct diagnosis was established preoperatively. Currently, echocardiography is the procedure of choice for diagnosing cor triatriatum. The diaphragm was excised through a left atrial approach in seven patients and through a right atriotomy in six. All associated anomalies were corrected. One critically ill patient who underwent an emergency operation in 1963 died early postoperatively, and one patient with chromosomal abnormalities and multiple cardiac defects died 2 months after an uneventful postoperative course. At the time of follow-up of the 11 long-term survivors, 9 were in New York Heart Association functional class I, and 2 (both of whom had major associated cardiac anomalies) were in class II. Postoperative angiography or echocardiography (in nine patients) showed no residual interatrial shunt or recurrent left atrial diaphragm.
Adolescent↗
Surgical treatment of vascular rings: the Mayo Clinic experience.
From 1947 through 1992, 37 Mayo Clinic patients underwent operation for the relief of tracheoesophageal obstruction that resulted from vascular rings and related entities. Of the 37 patients, 18 had a double aortic arch, 11 had a right aortic arch with an aberrant left subclavian artery, 4 had a left aortic arch with an aberrant right subclavian artery, 2 had a pulmonary artery sling, 1 had a right aortic arch with mirror-image branching and a left ligamentum arteriosum, and 1 had a left aortic arch, a right descending aorta, and a right ductus arteriosus. Symptoms consisted of stridor, recurrent respiratory infections, and dysphagia. The anomaly was approached through a left thoracotomy in 31 patients, through a right thoracotomy in 4, and through a median sternotomy in 2. Only one early postoperative death (3%) and no late deaths occurred. At long-term follow-up (maximal duration, 45 years), three patients had residual symptomatic tracheomalacia, one of whom required right middle and lower lobectomy for recurrent pneumonia. Magnetic resonance imaging is the imaging technique of choice for accurate delineation of the vascular and tracheal anatomy. When patients are symptomatic, vascular ring should be repaired. The surgical risk is minimal, and the long-term results are excellent.
Adolescent↗
Dual chamber pacing for hypertrophic obstructive cardiomyopathy: has its time come?
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Cardiac Pacing, Artificial↗
Modified Fontan operation in the presence of anomalies of systemic and pulmonary venous connection.
BACKGROUND: The purpose of this report is to outline technical maneuvers dictated by anomalies of systemic and/or pulmonary venous connection in the performance of the Fontan procedure. METHODS AND RESULTS: Between 1975 and 1990, 104 patients (60 male, 44 female) with anomalies of systemic and/or pulmonary venous connection underwent a modified Fontan procedure at the Mayo Clinic. Mean age was 9.7 +/- 5.7 years. Isolated anomalies of the systemic venous connection were identified in 46 patients, isolated anomalous pulmonary venous connections in 4, and a combination of the two in 54. Previous palliative operations had been performed in 93 patients. Surgical repair was accomplished by atrial septation or placement of an intra-atrial conduit combined with cavopulmonary anastomosis if required. Survival by Kaplan-Meier, including operative mortality, was 55.7% at 10.3 years, not significantly different from the overall survival of the Fontan population. By the proportional hazards general linear model procedure, insufficiency of the systemic atrioventricular valve, preoperative mean pulmonary pressure greater than 15 mm Hg, and pulmonary artery resistance index greater than 4 U.m2 were associated with higher mortality. Five patients required reoperation for pulmonary venous obstruction (1 patient), revision of the atrial baffle (1 patient), revision of the intra-atrial conduit (2 patients), and replacement of the systemic atrioventricular valve (1 patient). CONCLUSIONS: We conclude that the modified Fontan operation can be successfully performed in this subset of patients, with long-term results comparable to those obtained in patients with normal systemic and pulmonary venous connection.
Cardiac Surgical Procedures↗
Surgical treatment of discrete and tunnel subaortic stenosis. Late survival and risk of reoperation.
BACKGROUND: Although membranectomy, with or without septal myotomy or myectomy, has been the accepted method for treatment of fixed subaortic stenosis, controversies remain regarding operative methods and uncertainties regarding recurrence of subaortic obstruction and development of aortic insufficiency after repair. METHODS AND RESULTS: To determine late survival and risk of reoperation, we reviewed 169 patients who, between 1957 and 1992, had repair of discrete (n = 108) and tunnel (n = 61) subaortic stenosis. One hundred fifty-four patients had their primary operation for subaortic stenosis at the Mayo Clinic, and 15 patients had their primary operation elsewhere. Among patients having initial repair at our institution, membranectomy was performed in 52 patients (33.8%), membranectomy plus myotomy in 24 patients (15.6%), membranectomy plus myectomy in 71 patients (46.1%), myectomy plus a Konno-Rastan procedure in 5 patients (3.2%), and myectomy plus a modified Konno-Rastan procedure in 2 patients (1.3%). For all patients, early mortality was 4.7% (2.7% since 1961), and during follow-up extending to 29 years, there have been 16 late deaths. Twenty-six patients underwent a second or third operation for recurrent left ventricular outflow obstruction, including 11 of the 154 who had their primary operation at the Mayo Clinic (7.1%). Among the 21 patients who had a discrete lesion at initial repair and required reoperation, 19 (92%) were noted to have tunnel obstruction at reoperation. At late follow-up, the left ventricular outflow tract gradient was higher in patients with tunnel versus discrete obstruction (33 +/- 5 versus 24 +/- 17 mm Hg, P < .04), and 10-year survival was poorer (79% versus 91%, P < .02). Ten-year survival was worse in patients with tunnel lesions and associated cardiac anomalies versus those with isolated tunnel subaortic stenosis (64% versus 92%, P < .005). Some degree of aortic valve insufficiency was seen at late follow-up in 26% of patients, but in most cases this was mild. For patients with discrete subaortic stenosis, risk of late aortic insufficiency was 38.6% after isolated membranectomy, 27.8% after membranectomy and myotomy, and only 7.3% after membranectomy and myectomy (P < .004). Progression of aortic insufficiency requiring aortic valve replacement occurred in only 6 patients. CONCLUSIONS: Our results support the use of myectomy in conjunction with membranectomy for discrete subaortic stenosis. For restenosis and tunnel obstruction, more complete relief of subaortic stenosis by extended resection or a modified or classical Konno-Rastan procedure may improve late survival and reduce the incidence of recurrent subaortic stenosis and late aortic valve insufficiency.
Adolescent↗
Pulmonary microthrombi. Caveat for successful modified Fontan operation.
We reviewed medical records from eight patients (4 to 29 years of age) with a functional single ventricle and pulmonary microthrombosis as observed on open lung biopsy specimens. Hemodynamic assessment before biopsy revealed pulmonary hypertension (mean pulmonary artery pressure 19 to 53 mm Hg) in the seven patients tested and severely increased pulmonary arteriolar resistance (6 to 13 U.m2) in three of the five patients in whom these measurements were performed. Pulmonary blood flow varied (< 4 L/min per square meter in two patients and > 5 L/min per square meter in four patients), and the pulmonary/systemic blood flow ratio was low or normal (0.6 to 1.1) in five of six cases. Hemoglobin values were increased (16.4 to 22 gm/dl) in seven of eight patients. Lung biopsy specimens revealed thrombotic obstructive lesions in 56% (range 28% to 96%) of muscular pulmonary arteries. Coexistent medial hypertrophy was absent or mild in all but one specimen, and none had features of plexogenic pulmonary arteriopathy. Microscopic pulmonary thrombi accounted for unexpected pulmonary hypertension, precluding the Fontan operation, in five patients and unsuccessful Fontan operation in two. Clinically significant thrombi should be considered in patients with severe polycythemia (hemoglobin value > 20 gm/dl) and unobtainable or unreliable pulmonary blood flow or pulmonary resistance determinations.
Adolescent↗
Late results of valve replacement with the Björk-Shiley valve (1973 to 1982)
Cardiac valve replacement with use of only the Björk-Shiley prosthesis was performed in 1253 patients between January 1973 and December 1982. There were 828 patients having aortic valve replacement, 280 patients having mitral valve replacement, and 145 patients having double valve replacement with aortic and mitral valve prostheses. Patient outcome was stratified according to multiple variables, including valve position and valve model (spherical versus convexo-concave discs). No valve failure due to strut fracture was identified in 26 high-risk patients (mitral valve replacement with greater than or equal to 29 mm implanted in patients less than or equal to 50 years of age) followed up for a mean of 10 years postoperatively. Fifteen patients had late thrombosis of their Björk-Shiley prosthesis (0.28 per 100 patient-years), but there was no significant difference in risk of valve thrombosis comparing the spherical and convexo-concave discs (0.27 per 100 patient-years versus 0.27 per 100 patient-years). One hundred two patients had 128 thromboembolic episodes; rates of thromboembolism after aortic valve replacement, mitral valve replacement, and double valve replacement were 2.1, 4.3, and 4.6 per 100 patient-years, respectively. Percentages of patients free from thromboemboli after aortic valve replacement, mitral valve replacement, and double valve replacement were 93% +/- 1%, 86% +/- 2%, and 89% +/- 3% at 5 years postoperatively and 87% +/- 2%, 79% +/- 5%, and 77% +/- 8% 10 years postoperatively. There was no significant difference in the rates of thromboemboli for spherical and convexo-concave discs for all patients and for each of the subgroups. Ten-year actuarial survival estimates for patients dismissed alive from the hospital after aortic valve replacement, mitral valve replacement, and double valve replacement with the Björk-Shiley valve were 65% +/- 4%, 63% +/- 5%, and 55% +/- 8%, respectively. Overall event-free survival (freedom from death, thromboembolism, anticoagulant-related bleeding, endocarditis, and reoperation) was similar for the three patient groups. Performance of the Björk-Shiley valve as judged by late patient follow-up is similar to other mechanical valves, and modifications in disc design do not appear to have reduced the threat of late valve thrombosis and thromboemboli. Evidence does not support elective explantation of this prosthesis.
Adolescent↗
Fixed subaortic stenosis in atrioventricular canal defect: a Doppler echocardiographic study.
OBJECTIVES: The objectives of this retrospective study were to describe the Doppler and echocardiographic features of fixed subaortic stenosis in the setting of atrioventricular (AV) canal defect and to document the de novo occurrence of subaortic stenosis and progression of this lesion over time on the basis of sequential echocardiographic studies. BACKGROUND: The coexistence of fixed subaortic and AV canal defect has been sporadically noted, but no single or multicenter experience with this constellation of abnormalities has been previously described. METHODS: All patients with a diagnosis of subaortic stenosis and complete or partial AV canal defect who had one or more Doppler echocardiographic examinations were identified from a computer data bank. Retrospective analysis was performed, including review of patients' charts, operative notes, recorded videotapes and hard copy recordings when available. RESULTS: Twenty-one patients with both subaortic stenosis and AV canal defect were identified over a 13-year period. Fifteen were female and the mean age at diagnosis of subaortic stenosis was 16 years. Fifteen patients had partial AV canal defect with prior repair in 10; 6 patients had complete AV canal defect with prior repair in 4. The mean interval from prior repair to recognition of subaortic stenosis was 6.8 years. In six patients, serial examinations demonstrated the de novo occurrence of subaortic obstruction over a period of 10 to 87 months. In five patients, progression of known subaortic stenosis was documented over a 10- to 59-month period. Surgical resection of subaortic stenosis was performed in 16 patients; the echocardiographic diagnosis was confirmed in 15 of the 16. CONCLUSIONS: In the largest reported echocardiographic series of this lesion complex, it is concluded that subaortic stenosis can occur de novo, is often recognized only after repair of the canal defect and is progressive. Doppler echocardiography is the method of choice for diagnosis and serial follow-up of these patients.
Adolescent↗
Fistulous pseudoaneurysm complicating surgical accessory pathway interruption for Wolff-Parkinson-White syndrome.
Pseudoaneurysms of the left ventricle are unusual operative complications that have commonly been associated with replacement of the mitral valve. In this report, we describe a 31-year-old man who was referred to our institution because of atypical chest pain. He had previously undergone three operations for ablation of an accessory pathway because of Wolff-Parkinson-White syndrome. A pseudoaneurysm of the left ventricle was noted on transesophageal echocardiography, biplanar left ventriculography, and ultrafast cine computed tomography of the heart. Elective surgical repair was successful. Although rare, this case demonstrates an unusual but potentially serious complication of surgical treatment of Wolff-Parkinson-White syndrome.
Adult↗
Aortic compression by transesophageal echocardiographic probe in infants and children undergoing cardiac surgery.
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Aorta, Thoracic↗
Five- to fifteen-year follow-up after Fontan operation.
BACKGROUND: The purpose of this study was to estimate survival and quality of outcome and assess factors associated with outcome for patients out 5 to 15 years from their Fontan operation. METHODS AND RESULTS: We studied 352 patients who had the Fontan operation prior to 1985. The overall 1-, 5-, and 10-year survival was 77%, 70%, and 60%, respectively. The following factors were significantly associated with lower survival: univentricular heart or complex congenital anomalies other than tricuspid atresia, early calendar year of operation, heterotaxia syndromes, early age at operation, increased pulmonary artery pressure, atrioventricular valve dysfunction, and higher (worse) New York Heart Association class. Reoperations were necessary for 103 of the 352 patients. At least 20% of the survivors have or have had cardiac arrhythmias requiring antiarrhythmic medication or mechanical pacemaker insertion. Between 7% and 10% of the patients have had or had protein-losing enteropathy/hypoproteinemia. At 5 years postoperatively, 122 patients (34.7%) were alive with a better New York Heart Association functional classification than preoperatively. Fifty-eight patients (16.5%) were alive and in the same functional classification, but 126 (35.8%) died within the first 5 years or were in a worse functional classification. Thirty-nine patients were doing excellently and 29 patients poorly 5 years after the operation. Of the surviving patients, 43% can do as much exercise as their peers, whereas 3% are incapable of exercise. CONCLUSIONS: To assure good functional long-term outcome in addition to survival, clinicians must exclude from selection for Fontan operation patients known to be at high risk for death or poor outcome.
Adolescent↗
Subaortic obstruction in hearts with a univentricular connection to a dominant left ventricle and an anterior subaortic outlet chamber. Results of a staged approach.
In 1984 we reported a 56% mortality after major cardiac operations for patients with univentricular connection to a dominant left ventricle, an anterior subaortic outlet chamber, and subaortic obstruction. Since then we have adopted a staged approach to this repair. Between 1984 and 1989 32 patients had such operations. The overall mortality has decreased (16%; p < 0.001). The current cohort was divided by subaortic gradient into three subgroups for comparison with the cohort reported in 1984. Staging improved the outcome in patients with gradients greater than 40 mm Hg (mortality of 17% compared with 67% from 1984; p = 0.05). Patients with gradients from 10 to 25 mm Hg who had a single-stage operation had the best outcome (mortality 6%). Survival has improved. Many factors, including increased awareness of the detrimental effects of subaortic obstruction, improved surgical techniques, better perioperative care, and the appropriate application of a staged repair, have contributed to this improvement. We recommend simultaneous relief of obstruction and a modified Fontan operation for patients with subaortic gradients less than 25 mm Hg. Those with gradients greater than 40 mm Hg should have repair in two stages. It is unclear whether a one-stage or two-stage approach is better for patients with gradients between these extremes.
Adolescent↗