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Clinical studies after fontan's operation for tricuspid atresia
ABSTRACTS
METABOLIC DYSFUNCTION OF CORONARY OCCLUDED AND NONOCCLDDED SEGMENTS OF THE HEART Samuel Meerbaum, PhD, FACC; Tzu-Wang Lang, MD, FACC; Costantino Costantini, MD; Steven Rubins, MD; Jules Osher, BA; Eliot Corday, MD, FACC, Cedars-Sinai Medical Center, Los Angeles, California. Studies were designed to determine progressive alterations in regional cardiac function following LAD coronary occlusion in closed chest dogs. Simultaneous lactate (LB) and potassium (KB) balances were determined in both the occluded (0) and nonoccluded (NO) myocardial segments. During three hours of occlusion, cardiac output (L/min) dropped from 2.70 ? 0.18 (mean f SEM) to 2.3 + 0.15, max LV dP/dt (mm Hg/sec) from 2840 + 135 to 2310 + 125. LVEDP (mm Hg) rose from 7 t 0.6 to 11 ? 0.9, and systemic vascular resistance (dynes set cm-5) increased from 3740 ? 240 to 4270 ?r295. The diastolic phase of pressure distal to occlusion rose from 16 to 18 mm Hg, indicating no significant increase in collateral supply to the ischemic zone within three hours. Regional metabolic measurements indicated severe dysfunction in 0. A significant reduction in LB, from 34.4 f 2.0 to 23.7 f 3.1% was noted in NO. This was accompanied by reduction in KB from -.04 + .02 to -.13 + .03 mEq/L. Of 34 dogs, NO lactate production was noted in seven and abnormal metabolism in 22. 0 showed lactate production 17 and abnormal LB in 17. A potassium loss greater than 0.5 mEq/L occurred in 0 in 11, and in NO in 12 dogs. A 6.8% increase in oxygen extraction in both 0 and NO was noted following the occlusion. Serious metabolic derangements are found in the nonoccluded segment following remote coronary occlusion. This finding is related to progressive deterioration of cardiac function which may result in clinical abnormalities such as cardiogenic shock.
THE EFFECT OF NITROGLYCERIN ON PREMATURE VENTRICULAR COMPLEXES IN ACUTE MYGCARDIAL INFARCTION Michael J. Mihalick, MD; Susan Rasmussen, RN; Suzanne B. Knoebel, MD, FACC, Indiana University, Indianapolis, Ind. Because of isolated clinical observations suggesting that nitroglycerin ('ING)may eliminate premature ventricular complexes (PVC) during acute ischemic chest pain, a study was designed to assess the effect of TNG on the incidence of PVC in patients with acute myocardial infarction (AMI). 46 patients with AM1 were studied. Every other patient was given l/150 gr TNG q 4 hr sublingually for 24 hr after admission to CCU. PVC were counted for 15 min prior to TNG and for the following 15 min. In the control group PVC were counted for identical time periods. Thus, during any 24 hr period, PVC were counted for 3 hr. The 23 patients receiving TNG had a total of 592 PVC prior to TNG and 276 after TNG (p
PRECATHETERIZATION IDENTIFICATION OF OPERABLE STENOSIS OF THE LEFT ANTERIOR DESCENDING CORONARY ARTERY. Richard R. Miller, MD; Dean T. Mason, MD, FACC; Louis A. Vismara, MD; Robert Zelis, MD, FACC and Ezra A. Amsterdam, MD, FACC. Univ. of Calif., Davis, Calif. Since left anterior descending coronary artery(LAD) stenosis(>75%:S) is considered specially life-threatening, elective selection of patients(pts) for coronary angio and bypass would be greatly facilitated if clinical evaluation allowed predictability of these pts suitable for CB. Although previous anterior myocardial infarction (MI) denotes LAD-S, elective CB of LAD is usually not performed with old anterior MI. Thus other criteria are required to identify operable LAD-S. 68 pts with proximal or mid LAD-S without anterior MI had shorter angina duration(2.5 vs 3.6 yrs, pc.05) and greater frequency of inferior MI(67% vs 42%, pc.05) than 54 proven coronary pts without LAD-S. There were no differences in pt age, sex or presence of risk factors. 52/68(76%) LAD-S pts had operable LAD(<50% distal stenosis). Operability of LAD-S correlated inversely with angina duration and directly with presence of inferior MI(57% vs 36% in 16/68 inoperable pts). Since these data suggested a relation between prior inferior MI to operable LAD-S, an additional 55 pts with inferior MI having coronary angios were evaluated: 26 pts(47%) had operable LAD-S; no factors other than cholesterol >260 mg% indicated operable LAD-S. Thus, despite lack of a relation to most clinical indices, this study demonstrates a predictive value of previous inferior MI and short duration of angina in the precatheterization detection of operable LAD stenosis. Furthermore, a rationale is provided for early coronary arteriographic study of selected pts with prior inferior MI in the detection of high risk LAD-S.
CLINICAL STUDIES AFTER FONTAN’S OPERATION FOR TRICUSPID ATRESIA Robert A. Miller, MD; Dev Pahlajani, MD; Maria Serratto, MD, FACC; Constantine Tatooles, MD, Cook County Children’s Hospital, Chicago, Illinois. Five children with tricuspid atresia have been operated upon using a modification of Fontan’s procedure: Superior vena cava - right pulmonary artery anastomosis, connection of right atrium to pulmonary artery by a graft containing a valve, insertion of a valve in the inferior vena cava at the right atria1 junction, tying off the pulmonary artery at its origin and closure of the interatrial communication. Criteria for selection for surgery included normal pulmonary vascular resistance, normal LA mean and LVEDP. LVEDP was 1OmmHg in the child that expired. All developed pleural effusion, hepatomegaly, Three cases and ascites in the immediate postop period. who did not have a prior SVC-RPA shunt developed a SVC syndrome which disappeared during the first postop week. Junctional tachycardia and other dysrhythmias were noted during the first 48 hours. Postop studies in three cases showed a marked elevation of right atria1 pressure with “ventricularized” tall A-waves, as high as 37mmHg in one patient. All cases showed arterial oxygen desaturation after surgery, 88.5%, 87%, 92%, and 77%. Angiocardiograms showed streaming of dye through multiple sites along the suture line in the atria1 septum in all three. A catheter could be passed from RA to LA and into pulmonPulmonary vein desaturation was ary veins in all cases. found in all three cases, severe (82%) in one. Although all 4 survivors were improved by the operation, three of them remarkably so, pleural effusion, right to left atria1 and intrapulmonary shunting have been consistshunting, ent problems in the early postoperative months.
January 1974
The American Journal of CARDIOLOGY
Volume 33
157
METABOLIC DYSFUNCTION OF CORONARY OCCLUDED AND NONOCCLDDED SEGMENTS OF THE HEART Samuel Meerbaum, PhD, FACC; Tzu-Wang Lang, MD, FACC; Costantino Costantini, MD; Steven Rubins, MD; Jules Osher, BA; Eliot Corday, MD, FACC, Cedars-Sinai Medical Center, Los Angeles, California. Studies were designed to determine progressive alterations in regional cardiac function following LAD coronary occlusion in closed chest dogs. Simultaneous lactate (LB) and potassium (KB) balances were determined in both the occluded (0) and nonoccluded (NO) myocardial segments. During three hours of occlusion, cardiac output (L/min) dropped from 2.70 ? 0.18 (mean f SEM) to 2.3 + 0.15, max LV dP/dt (mm Hg/sec) from 2840 + 135 to 2310 + 125. LVEDP (mm Hg) rose from 7 t 0.6 to 11 ? 0.9, and systemic vascular resistance (dynes set cm-5) increased from 3740 ? 240 to 4270 ?r295. The diastolic phase of pressure distal to occlusion rose from 16 to 18 mm Hg, indicating no significant increase in collateral supply to the ischemic zone within three hours. Regional metabolic measurements indicated severe dysfunction in 0. A significant reduction in LB, from 34.4 f 2.0 to 23.7 f 3.1% was noted in NO. This was accompanied by reduction in KB from -.04 + .02 to -.13 + .03 mEq/L. Of 34 dogs, NO lactate production was noted in seven and abnormal metabolism in 22. 0 showed lactate production 17 and abnormal LB in 17. A potassium loss greater than 0.5 mEq/L occurred in 0 in 11, and in NO in 12 dogs. A 6.8% increase in oxygen extraction in both 0 and NO was noted following the occlusion. Serious metabolic derangements are found in the nonoccluded segment following remote coronary occlusion. This finding is related to progressive deterioration of cardiac function which may result in clinical abnormalities such as cardiogenic shock.
THE EFFECT OF NITROGLYCERIN ON PREMATURE VENTRICULAR COMPLEXES IN ACUTE MYGCARDIAL INFARCTION Michael J. Mihalick, MD; Susan Rasmussen, RN; Suzanne B. Knoebel, MD, FACC, Indiana University, Indianapolis, Ind. Because of isolated clinical observations suggesting that nitroglycerin ('ING)may eliminate premature ventricular complexes (PVC) during acute ischemic chest pain, a study was designed to assess the effect of TNG on the incidence of PVC in patients with acute myocardial infarction (AMI). 46 patients with AM1 were studied. Every other patient was given l/150 gr TNG q 4 hr sublingually for 24 hr after admission to CCU. PVC were counted for 15 min prior to TNG and for the following 15 min. In the control group PVC were counted for identical time periods. Thus, during any 24 hr period, PVC were counted for 3 hr. The 23 patients receiving TNG had a total of 592 PVC prior to TNG and 276 after TNG (p
PRECATHETERIZATION IDENTIFICATION OF OPERABLE STENOSIS OF THE LEFT ANTERIOR DESCENDING CORONARY ARTERY. Richard R. Miller, MD; Dean T. Mason, MD, FACC; Louis A. Vismara, MD; Robert Zelis, MD, FACC and Ezra A. Amsterdam, MD, FACC. Univ. of Calif., Davis, Calif. Since left anterior descending coronary artery(LAD) stenosis(>75%:S) is considered specially life-threatening, elective selection of patients(pts) for coronary angio and bypass would be greatly facilitated if clinical evaluation allowed predictability of these pts suitable for CB. Although previous anterior myocardial infarction (MI) denotes LAD-S, elective CB of LAD is usually not performed with old anterior MI. Thus other criteria are required to identify operable LAD-S. 68 pts with proximal or mid LAD-S without anterior MI had shorter angina duration(2.5 vs 3.6 yrs, pc.05) and greater frequency of inferior MI(67% vs 42%, pc.05) than 54 proven coronary pts without LAD-S. There were no differences in pt age, sex or presence of risk factors. 52/68(76%) LAD-S pts had operable LAD(<50% distal stenosis). Operability of LAD-S correlated inversely with angina duration and directly with presence of inferior MI(57% vs 36% in 16/68 inoperable pts). Since these data suggested a relation between prior inferior MI to operable LAD-S, an additional 55 pts with inferior MI having coronary angios were evaluated: 26 pts(47%) had operable LAD-S; no factors other than cholesterol >260 mg% indicated operable LAD-S. Thus, despite lack of a relation to most clinical indices, this study demonstrates a predictive value of previous inferior MI and short duration of angina in the precatheterization detection of operable LAD stenosis. Furthermore, a rationale is provided for early coronary arteriographic study of selected pts with prior inferior MI in the detection of high risk LAD-S.
CLINICAL STUDIES AFTER FONTAN’S OPERATION FOR TRICUSPID ATRESIA Robert A. Miller, MD; Dev Pahlajani, MD; Maria Serratto, MD, FACC; Constantine Tatooles, MD, Cook County Children’s Hospital, Chicago, Illinois. Five children with tricuspid atresia have been operated upon using a modification of Fontan’s procedure: Superior vena cava - right pulmonary artery anastomosis, connection of right atrium to pulmonary artery by a graft containing a valve, insertion of a valve in the inferior vena cava at the right atria1 junction, tying off the pulmonary artery at its origin and closure of the interatrial communication. Criteria for selection for surgery included normal pulmonary vascular resistance, normal LA mean and LVEDP. LVEDP was 1OmmHg in the child that expired. All developed pleural effusion, hepatomegaly, Three cases and ascites in the immediate postop period. who did not have a prior SVC-RPA shunt developed a SVC syndrome which disappeared during the first postop week. Junctional tachycardia and other dysrhythmias were noted during the first 48 hours. Postop studies in three cases showed a marked elevation of right atria1 pressure with “ventricularized” tall A-waves, as high as 37mmHg in one patient. All cases showed arterial oxygen desaturation after surgery, 88.5%, 87%, 92%, and 77%. Angiocardiograms showed streaming of dye through multiple sites along the suture line in the atria1 septum in all three. A catheter could be passed from RA to LA and into pulmonPulmonary vein desaturation was ary veins in all cases. found in all three cases, severe (82%) in one. Although all 4 survivors were improved by the operation, three of them remarkably so, pleural effusion, right to left atria1 and intrapulmonary shunting have been consistshunting, ent problems in the early postoperative months.
January 1974
The American Journal of CARDIOLOGY
Volume 33
157