Protrusion of the device: a complication of catheter closure of patent ductus arteriosus.

OBJECTIVE: To assess the medium term results of percutaneous transvenous closure of patent ductus arteriosus, in particular with regard to protrusion of the device with or without turbulence of the bloodflow. DESIGN: Clinical examination and echocardiographic study (cross sectional Doppler, and colour Doppler examination) within 24 hours of and at least 6 months after implantation (range 6-26 (mean 15) months). SETTING: Multicentre study at the departments of paediatric cardiology of three academic hospitals. Tertiary clinical care of the first group of patients in the Netherlands treated by the percutaneous transvenous method. PATIENTS: 36 patients (12 male, 24 female) mean age 8.2 years, (range 1.7-58.3), mean weight 25.5 kg (range 11-67.8 kg). The total group consisted of 46 patients. In one the implantation had failed and nine others were not available for regular follow up. All 36 patients underwent non-surgical closure of the patent ductus arteriosus with a Rashkind double umbrella prosthesis. MAIN OUTCOME MEASURES: Diagnosis or exclusion of protrusion of the Rashkind device with or without turbulence of the blood flow with follow up of changes in protrusion and turbulence. RESULTS: In 17 patients the prosthesis protruded into an arterial lumen: the aorta in 13 and the (left) pulmonary artery in four, with turbulence in seven and two cases respectively. After six months the aortic protrusion disappeared in three, including one who had had turbulent blood flow. At the end of follow up the prosthesis still protruded into the aorta in 10 but in three the turbulence had vanished. In two of the three remaining patients with turbulence in the descending aorta the degree of turbulence had decreased. There was no lessening of turbulence in the four patients in whom the device protruded into the pulmonary artery. CONCLUSIONS: The Rashkind double umbrella can protrude into the descending aorta and the left pulmonary artery without causing turbulent blood flow. Turbulence and the protrusion itself can disappear. Endocarditis prophylaxis may be required for as long as the device causes turbulence.

Anatomic correction for transposition of the great arteries: first follow-up (38 patients).

Between April 1983 and October 1985, 38 consecutive patients with transposition of the great arteries (TGA) underwent anatomic correction. Ages ranged from 1 day to 284 weeks (mean 26.2 weeks). Simple TGA was present in 17 patients, 17 had an associated ventricular septal defect, and the remaining four had a Taussig-Bing anomaly. Hospital mortality was 2 of 38, with 1 late death. Follow-up time varied from 6 to 35 months. Postoperative cardiac catheterization was performed in 34 of the 36 early survivors. Right ventricular outflow tract obstruction with a systolic gradient greater than 20 mmHg was found in four. A residual left-to-right shunt was found in nine; Qp/Qs exceeded 2.0 in only one. In four, the pulmonary-to-systemic resistance ratio calculated was greater than 0.3. All 35 survivors are in excellent condition. Only one patient has slight aortic insufficiency. Most pre- and postoperative electrocardiographic abnormalities disappeared in due course. Echocardiography revealed normal left ventricular dimensions and fractional shortening. The aortic root diameter showed in almost all a value above the 95th percentile of normal. Postoperatively, the aortic root has grown parallel to, but above, the 95th percentile and as yet has shown no tendency to normalization.

The concurrence of fetal supraventricular tachycardia and obstruction of the foramen ovale.

Fetal supraventricular tachycardia (FSVT) is a cardiac arrhythmia that bears a high mortality rate. In the majority of cases no morphological anomalies are found and death is caused by congestive heart failure. This report presents two cases of FSVT in which cross sectional echocardiography revealed obstruction of the foramen ovale with dilatation of the right heart without structural cardiac anomalies. After birth sinus rhythm re-established under digitalis medication in both cases. The association between premature obstruction of the foramen ovale and unexplained intrauterine death in the third trimester of gestation is suggested.

Ventricular septal defect associated with left ventricular outlfow tract obstruction below the defect.

Muscular subaortic stenosis associated with ventricular septal defect (VSD) is a rare but important anomaly. Two types of left ventricular outflow tract (LVOT) obstruction should be distinguished on the basis of morphologic as well as hemodynamic differences, depending on whether the stenosis is localized above (Type I) or below (Type II) the defect. The five cases presented are all in the latter category. In the first two cases the correct diagnosis was not made until after repair of the VSD. Two patients had previously undergone banding of the pulmonary artery (PAB). Marked carotid shudder and a vertical QRS axis in the frontal plane were presented in all cases. For the diagnosis to be established by catheterization, the catheter tip must be maneuvered into the apical part of the left ventricular cavity in order to detect the stenosis on the withdrawal curve. It is difficult to visualize the stenosis by angiography. The surgical approach through the VSD via a right atriotomy is highly recommended for Type II subaortic stenosis.

The postvalvulotomy propranolol test to determine reversibility of the residual gradient in pulmonary stenosis.

We advocate the use of propranolol in very low dosage at the end of operation to determine a prognosis of the long-term results to be expected after valvulotomy in diverse types of pulmonary stenosis.