Role of balloons atrial septostomy in infants with transposition of the great arteries older than one month

Balloon atrial septostomy [BAS] is the initial line in management of severely hypoxic neonates with transposition of the great arteries [TGA] and is almost always successful in tearing the septum primum in the first 2 weeks of life. Moreover, it is only occasionally successful after the first month of life because the valve of the foramen oval becomes thicker. In Egypt, a large number of cases of TGA come to medical attention older than one month of age, where ideally BAS should be ineffective, and thus this study was done to evaluate its role in such cases. Twelve infants above one month of age with TGA were included in the study. The diagnosis was established by echocardiography and was confined by cardiac catheterization and angiography just before performing BAS. There were 8 males and 4 females. Their ages, at the time of BAS, ranged from 40 days to 64 days with a mean of 51.4 days. Their weights ranged from 3.5 kg to 6 kg with a mean of 4.75 kg. The mean aortic saturation increased by 22% and the average mean pressure gradient between both atria became 0.4 mmHg, following BAS, and cyanosis was clinically decreased. Doppler echocardiography, performed the next day in 9 infants, showed an atrial septal defect with free flapping of the inferior portion of the atrial septum, with increased left-to- right shunting across it. Three infants died after the procedure. Thus, BAS appears to be still effective in infants older than one month of age with TGA and should be offered to them as an initial palliative procedure

Value of intravenous streptokinase in treating femoral arterial thrombosis after pediatric cardiac catheterization

In order to evaluate the role of intravenous streptokinase in treating femoral arterial thrombosis after pediatric cardiac catheterization and its role in obviating vascular surgical thrombectomy, intravenous streptokinase in a loading dose of 1000 units/kg followed by an infusion at a rate of 1000 units/kg/hour was given to infants and children who developed femoral arterial thrombosis, after cardiac catheterization, not responding to 24 hours of adequate heparinization. A total of 520 consecutive children were catheterized between September 1989 and December 1992 at the Cardiology Department of Ain-Shams University. Out of the 520 patients, 240 patients had transarterial studies. Eighteen of these children had percutaneous balloon aortic valvuloplasty [PBAV] and 14 had percutaneous balloon coarctation angioplasty [PBCA]. There were 34 patients [14.1%] out of the total 240 patients who had a cool, pulseless extremity after catheterization. Nine patients [26.5%] improved with continued heparinization alone. The remaining 25 patients who did not respond to 24 hours of continuous heparinization, were treated with streptokinase and constituted the subjects of this study. In all of the 25 patients treated with streptokinase, except one 12-year-old female who underwent successful surgical femoral arterial thrombectomy, normal pulsations returned equal to those in the contralateral leg. Follow-up of 10 patients showed that the arterial pulsations in 50% of those treated with streptokinase were diminished as proven by Doppler vascular studies. Streptokinase is definitely effective in treating femoral arterial thrombosis not responding to heparinization after arterial catheterization, thus obviating the need for surgical thrombectomy in the majority of cases

Assessment of the effect of isoproterenol on pulmonary vasculature in patients with ventricular septal effect and elevated pulmonary vascular resistance.

The response of pulmonary vasculature to isoproterenol infusion during cardiac catheterization was studied in 30 patients with severe pulmonary hypertension secondary to large congenital ventricular septal defect [VSD]. The patients were divided into 2 groups. Group I included patients below 2 years of age and Group II included patients above 2 years of age. Isoproterenol was given in a dose of 0.14 Ug/kg/minute for 15 minutes IV during cardiac catheterization. Measurement of pulmonary and systemic flows and resistances were done before and after isoproterenol infusion. The pulmonary artery pressure, total pulmonary resistance, pulmonary vascular resistance, pulmonary/systemic vascular resistance ratio decreased significantly in all except 4 patients and the decrease was more in Group I than in Group II after isoproterenol infusion. Two of the 4 patients refractory to isoproterenol had lung biopsy which showed inoperable stages of pulmonary hypertension. Thus, isoproterenol can be used routinely for assessment of elevated pulmonary vascular resistance due to congenital large VSD