Biomedical subjects
Publications and source records attributed to G R Westerman.
Double-outlet right ventricle and severe systemic outflow tract hypoplasia comprises a subset of patients in whom total correction or palliation requires complex surgical procedures in the neonatal period. Our experience with 3 patients illustrates the difficulties associated with treatment and suggests possible surgical options for this otherwise lethal variant of the Taussig-Bing syndrome.
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The child with congenital heart disease requiring permanent pacing presents a unique challenge with regard to the decision to pace, hardware, route, and unusual problems. Considerations of patient size, anatomy, insertion during and after complex intracardiac procedures, location of hardware, and unusual approaches are discussed including: placement of endocardial leads at open operation, closed transatrial endocardial technique, periprosthetic valvular endocardial placement, trans left superior vena cava placement and retromammary position via the axillary approach. Consideration of these unusual techniques may avoid frustration due to the complexities of the placement of pacing systems in these young patients.
Mitral valve replacement and bypass are high-risk operations in the infant with severe mitral stenosis. A palliative approach is presented that obviates the need for valve replacement in infancy.
To determine the effect of operations with cardiopulmonary bypass on the immunologic function of polymorphonuclear leukocytes in infants, we studied polymorphonuclear leukocyte function and immunologic profile in 16 infants undergoing repair of congenital heart lesions. An oxygen/air/high-dose fentanyl anesthetic was used for all patients. Absolute neutrophil count increased significantly (p less than 0.05) after bypass and remained increased 48 hours afterward. Chemotaxis, random migration of polymorphonuclear leukocytes, and phagocytic index were unaffected, but bactericidal capacity decreased significantly immediately after cardiopulmonary bypass and remained decreased 48 hours later. Serum opsonizing capacity to bacterial and fungal antigens was variably altered, and complement factors 3 and 4 decreased significantly after cardiopulmonary bypass. Total hemolytic complement decreased significantly immediately after cardiopulmonary bypass and returned to normal by 48 hours. These data suggest that operations with cardiopulmonary bypass in infants significantly affect the immunologic function of polymorphonuclear leukocytes and result in consumption of complement.
A young woman with double-outlet right ventricle, mitral stenosis, and high systemic pulmonary artery pressure is described. Pulmonary vascular morphometric analysis indicated considerably less pulmonary vascular obstructive disease than might otherwise have been expected. Total repair was performed and resulted in a marked fall in pulmonary artery pressure. Pulmonary vascular morphometry may be indicated in selected patients before palliative management is selected over complete repair.
The successful repair of double-outlet right atrium, tetralogy of Fallot, and common atrioventricular valve is reported. Double-outlet right atrium is reviewed and its pathoembryology and nomenclature are discussed.
The patient with a persistent left superior vena cava who requires permanent pacing presents difficulties if no right superior vena cava is present or if it is encountered unexpectedly at pacemaker implantation. A case is presented that illustrates potential problems and suggests a general approach to this situation. Successful transvenous universal pacemaker insertion through a persistent left superior vena cava is reported.
Two patients are presented who illustrate unusual venous anatomy allowing right-to-left shunting at the atrial level after Fontan repair.
The authors present two cases of septic complications after chemonucleolysis with chymopapain. One patient developed overt aortic valve failure. The second patient suffered an epidural abscess.
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From May, 1978, to July, 1982, 46 infants ranging in age from 12 days to 12 months and in weight from 2.1 to 8.4 kg underwent repair of dextrotransposition of the great arteries (D-TGA) and ventricular septal defect (VSD) using a Senning repair and closure of the VSD. Ventricular septal defects were classified as membranous (47.8%), malaligned (28.3%), atrioventricular (AV) canal type (13.0%), subarterial (2.2%), muscular (2.2%), and multiple (6.5%). Hospital mortality was 15.2% and late mortality, 5.1%. Postoperative complications included tricuspid regurgitation (mild in 3 and severe, requiring tricuspid valve replacement, in 3), residual VSD (pulmonary/systemic flow ratio of greater than 2:1) in 3 patients (2, AV canal type and 1, multiple VSDs), pulmonary venous obstruction in 3 patients, and permanent complete heart block in 4 patients (2, AV canal type of VSD also requiring tricuspid valve replacement). Lung biopsy studies showed reversible Heath-Edwards and morphometric changes. No patient was seen with Heath-Edwards III or greater changes. In 10 patients, right ventricular end-diastolic pressures and pulmonary artery pressures at rest were within normal limits one year after operation. As the operative mortality of atrial inversion and arterial switch operations for D-TGA with VSD tends to become comparable, more extensive follow-up data, including cardiac catheterization and coronary arteriography in a large number of patients, will be necessary to establish the superiority of one approach over the other.
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From August 1974 through April 1981, 23 patients, ages 5 months to 40 years (median 11 years) with corrected transposition of the great arteries (C-TGA), underwent repair of associated intracardiac defects: 20 for ventricular septal defect (VSD), 19 for pulmonary outflow tract obstruction, and five for anatomic tricuspid valve regurgitation. Segmental anatomy was [S,L,L] in 18 or [I,D,D] in 5. Pulmonary outflow tract obstruction was resected in 10 and bypassed with a left ventricle-to-main pulmonary artery conduit in nine patients. Hospital mortality was 9% (two of 23). One patient died from arrhythmia and one from sepsis and arrhythmia. The late mortality rate was 14% (three patients). Two patients died from severe pulmonary vascular obstructive disease (5 months and 2 years postoperatively) and one from arrhythmia (2 months postoperatively). Fourteen have undergone cardiac catheterization 3 days to 4 years (mean 12 months) postoperatively. Three had a small residual VDS (Qp/Qs less than 1.5). Five had residual pulmonary outflow tract obstruction (peak systolic ejection gradient 30-130 mm Hg) after resection or pulmonary valvotomy. One patient had reresection and four had placement of a secondary left ventricular-pulmonary artery conduit. Anatomic tricuspid valve regurgitation became severe in three patients after VSD closure, two of whom required valve replacement; the other died of coexisting pulmonary vascular obstructive disease. Five with [S,L,L] segmental anatomy had complete atrioventricular block preoperatively and six developed complete atrioventricular block at surgery. Eleven of 18 patients with [S,L,L] anatomy had atrioventricular spontaneous or iatrogenic complete block; none of the five patients with [I,D,D] anatomy had atrioventricular block. Pulmonary outflow tract obstruction in [S,L,L] segmental anatomy required conduit interposition in 12 of 14 of our patients to significantly decompress the ventricle. Postoperative development or exacerbation of anatomic tricuspid valve regurgitation occurs in TGA [S,L,L] and may be causally related to surgical complete atrioventricular block.