The modified Blalock-Taussig shunt: a 6-year experience from a developing country.

Since 1992 we have performed the modified Blalock-Taussig shunt (MBTS) for cyanotic children in Libya. This retrospective study reviews our results as a developing country, comparing them with those in the literature, and makes suggestions to improve our results. Between May 1992 and May 1998, 94 children (58 males and 36 females) underwent 100 MBTSs in Mesallata Cardiothoracic Centre, Libya. The age ranged from 4 days to 15 years, (median 12 months) and 25 patients were neonates. Patients' weights ranged from 3 to 31 kg (median 6.4 kg). Eighty-nine shunts were performed on the left side and 11 on the right. A 6-mm polytetrafluoroethylene graft was used in 68 children and a 4-mm graft in 32 cases. Tetralogy of Fallot (TOF) comprised the majority of cases (63; 67%), the remaining 31 (33%) included tricuspid atresia (13), pulmonary atresia (9), univentricular heart complex (6), and others (3). Acute shunt failure occurred in 3 cases (2 with 4-mm and 1 with 6-mm grafts), all of which had not received perioperative heparin. Hospital mortality was 6% (6 patients); risk factors were neonates, a diagnosis other than TOF, and emergency surgery. There were 12 late deaths, 6 of which were due to sepsis. Follow-up was achieved in 82 of 88 early survivors for a period of 2 to 60 months (median 26 months). All surviving patients had subjective and objective improvement. We conclude that MBTS is an excellent palliative procedure for children requiring a systemic-pulmonary shunt in developing as well as developed countries. This series shows an early mortality rate comparable to that of other studies, but the late mortality is higher, mainly due to sepsis, which warrants further attention.

Intracavitary cardiac hydatid cyst and the wall sign criteria.

Cardiac hydatid is rare at any age, accounting for less than 2% of all hydatid disease. The case is discussed of a 48-year-old female with a cardiac hydatid cyst attached intracavitary in the posterior wall of the right atrium. The Echinococcus cyst grows very slowly and, unless located in a critical anatomic site, it takes many years to evolve. Since the introduction of two-dimensional echocardiography, more cases are being diagnosed. The cyst was discovered incidentally by X-ray computed tomography and confirmed by trans-oesophageal echocardiography utilizing the wall-sign criteria developed by the authors. The cyst was removed surgically and the patient recovered by medical therapy.

Management of accidental kerosene ingestion.

Accidental kerosene ingestion is still a common problem in Libya. It causes considerable morbidity and occasionally mortality. The role and choice of antibacterial agents in its management remain unsettled. Pulmonary damage has been reported as resulting from aspiration. In aspiration pneumonia, anaerobic organisms may be important pathogens and metronidazole may have a place in therapy. The present randomized trial in 100 children with accidental kerosene ingestion assesses the role of ampicillin, carbenicillin and metronidazole in its management. The results are not conclusive but chemoprophylaxis appears to decrease morbidity. Of the various regimens used, the ampicillin/metronidazole combination was found to be slightly better than the others. Further study is recommended.

Hepatotoxicity of high dose salicylate therapy in acute rheumatic fever.

Liver function tests, including serum alanine aminotransferase (ALT) activity, serum bilirubin, alkaline phosphatase, serum proteins, blood ammonia levels and intravenous glucose utilization, were monitored in 50 children with acute rheumatic fever receiving anti-rheumatic doses of aspirin. There was a significant increase in blood ammonia levels and serum ALT after aspirin therapy. A significant fall in glucose utilization coefficient was also recorded. Serum alkaline phosphatase, bilirubin and total proteins did not change significantly. Twenty-two of the 50 children recorded a rise in serum ALT; in 12, the rise was five- to tenfold. These 12 children developed adverse symptoms to aspirin. Also, all had a marked rise in blood ammonia levels. The children improved clinically and biochemically on withdrawal of aspirin. There was no constant relationship between hepatocellular function and serum salicylate levels.

Cardiac hydatid cyst in a child.

Presentation of hydatid disease is uncommon in children, and cardiac hydatid cyst is rare at any age. The authors discuss a pediatric patient with cardiac hydatid cyst in the posterior wall of the left ventricle. The cyst was diagnosed by two-dimensional echocardiography and by serology. A 3 month course of mebendazole therapy was only partially effective. The patient remains asymptomatic 2 years after diagnosis. HYDATID DISEASE is endemic in the Middle East. In a study from a surgical hospital in eastern Libya, the disease accounted for 0.89 percent of all hospital admissions. The echinococcus cyst grows very slowly and unless located in a critical anatomic site, it takes many years to evolve. Consequently, presentation in pediatric patients is distinctly uncommon. In an epidemiologic study from Benghazi, only 11.7 percent of patients were under 10 years old. Cardiac hydatid disease is rare at any age, accounting for less than 2 percent of all hydatid disease. Since the introduction of two-dimensional echocardiography, more cases are being diagnosed. All the reports in the recent literature are in adult patients. We report here, however, a cardiac hydatid cyst in the left ventricular wall in a child.