Showing papers on "Pulmonary artery published in 1974"

Right ventricular infarction. Clinical and hemodynamic features.

Abstract: Six patients with acute myocardial infarction presented with hemodynamic evidence of predominant right ventricular failure, characterized by a mean right atrial pressure averaging 20.2 mm Hg and left ventricular filling pressure averaging 16.3 mm Hg. Autopsy in two cases revealed extensive involvement of the right as well as the left ventricle. Clinically the patients usually had evidence of diaphragmatic wall infarction, distended neck veins, hypotension and heart block. Pressure contours and mean pressure often showed no significant change as the catheter was advanced from the right atrium to the pulmonary artery. Shock in three patients was effectively treated with plasma volume expansion, to increase further right-sided pressure, or the administration of sodium nitroprusside, to reduce left-sided filling pressure. It is suggested that when right ventricular infarction accompanies left ventricular infarction, a unique clinical and hemodynamic syndrome occurs because the ability of the right ventricle to maintain adequate left ventricular filling is impaired. Recognition of this syndrome is vital if appropriate therapy is to be instituted.

Pulmonary arteriovenous fistulas

Abstract: Previously reported from our institution has been a series of 63 patients with pulmonary arteriovenous fistula who were seen from Jan. 1, 1952, through Dec. 31, 1972. Subsequently, we have seen 38 additional patients during the 8 1/2-year period from Jan. 1, 1973, through June 1981. The series includes three patients with hereditary telangiectasia who had bilateral pulmonary arteriovenous fistulas removed at two separate thoracotomies. Our report also includes a brief description of five additional patients with acquired systemic artery-to-pulmonary artery fistula who underwent miniballoon occlusion of the fistula. We are including these five cases because we believe this therapeutic catheterization technique may be of particular value in patients with multiple or bilateral pulmonary arteriovenous malformations and may obviate extensive pulmonary resection and repeat thoracotomy. Pulmonary arteriovenous fistula is believed to occur most often in middle-aged women who have associated Rendu-Osler-Weber syndrome, but most of our patients did not have hereditary hemorrhagic telangiectasia. Twenty-three (36.5%) of the 63 patients in a previous Mayo Clinic series and 18 (47%) of the 38 in the present series had associated Rendu-Osler-Weber syndrome. A logical workup of a patient with pulmonary arteriovenous fistula includes, in sequential fashion based on priority, chest roentgenography and tomography, arterial blood gas measurements, contrast echocardiography with indocyanine green dye, angiography, and measurement of differential pulmonary venous oxygen content.

Anomalous origin of the left coronary artery from the pulmonary artery. A new method of surgical repair.

Abstract: Anomalous origin of the left coronary artery from the pulmonary artery has been surgically corrected by means of a technique that avoids direct suturing of the coronary artery itself. The anomalous left coronary artery is removed from the pulmonary artery with a cuff of pulmonary artery tissue about its orifice. In a five-and-one-half-year-old patient the anomalous coronary artery was anastomosed directly to the aorta using this technique. In another patient, seven months of age, the anomalous coronary artery could not be anastomosed directly to the aorta and a segment of the patient's subclavian artery was interposed between the left coronary artery and the aorta to complete the anastomosis. In the latter patient, profound hypothermia and circulatory arrest were used during construction of the anastomosis in an attempt to minimize further myocardial damage. The establishment of a two coronary artery system has been demonstrated to be feasible in the infant or young child with this anomaly.

Pulmonary complications of the flow-directed balloon-tipped catheter.

Abstract: Retrospective analysis of the course of 125 patients in whom flow-directed balloon-tipped catheters were employed showed that in nine (7.2 per cent), pulmonary ischemic lesions appeared to have occurred as a direct result of the use of the catheter. Mechanisms of the pulmonary ischemia included persistent wedging of the catheter tip in a peripheral artery (six cases), obstruction of a more central pulmonary artery by an inflated balloon (one case), and pulmonary embolism from venous thrombosis developing around the catheter (two cases). Awareness of the tendency for spontaneous wedging of the catheter to occur and of the possibility of air remaining in the balloon after use should reduce the frequency of these complications. (N Engl J Med 290:927–931, 1974)

Echocardiographic Evaluation of Pulmonary Hypertension

Abstract: Echocardiographic studies of the pulmonary valve were obtained in 63 adults. Patients with normal pulmonary artery pressure (22 cases) showed an oblique position of the valve images in diastole, slow valve opening slopes (≤ 300 mm/sec), sizable (> 2 mm) posterior displacement of the cusp echoes with atrial systole (`a' dip), and a relatively short right ventricular pre-ejection period. In contrast, pulmonary valves in pulmonary hypertension (mean pressure > 20 mm Hg, 41 cases) appeared straight in diastole with rapid opening slopes (> 350 mm/sec) and prolonged pre-ejection periods (P 40 mm Hg) when uncomplicated by severe right heart failure. In the latter instance rapid valve opening slopes were associated with large `a' dips. Echocardiography appears to ...

Dimensional changes of the left ventricle during acute pulmonary arterial hypertension in dogs

Abstract: Left ventricular dimensions and volumes were measured by an endocardial marker technique in eight closed chest dogs during progressive increases of 10 mm Hg in mean pulmonary arterial pressure. Right ventricular volumes were measured by biplane cineanglography. Increasing mean pulmonary arterial pressure caused a progressive increase in right ventricular volume; at a mean pulmonary arterial pressure of 60 mm Hg, right ventricular end-diastolic volume increased by 48 percent and end-systolic volume by 50 percent. Left ventricular volumes began to decrease significantly at a mean pulmonary arterial pressure of 30 mm Hg, and when a mean pulmonary arterial pressure of 60 mm Hg was reached, left ventricular end-diastolic volume had decreased by 30 percent and left ventricular end-systolic volume by 19 percent. Changes in ventricular filling pressure dlrectionally followed the volume changes of the respective ventricle. Left ventricular stroke volume decreased 45 percent at a mean pulmonary arterial pressure of 60 mm Hg but increasing heart rate prevented a decrease in cardiac output. The decrease in left ventricular volume as pulmonary arterial pressure was Increased was associated with a disproportionate reduction in the left ventricular septal-lateral axis. At end-diastole, this dimension decreased by 22 percent at a mean pulmonary arterial pressure of 60 mm Hg, the anterior-posterior axis decreased by 8 percent and the base-apex axis by 4 percent. A similar disproportionate decrease of the septal-lateral axis occurred at end-systole. Even at the modest increase in mean pulmonary arterial pressure to 20 mm Hg, only the septal-lateral dimension was significantly shortened, and the right ventricular end-diastolic volume had increased by 17 percent but left ventricular end-diastolic volume was not significantly changed. Thus, during acute pulmonary hypertension, the right ventricle progressively dilates resulting in a distinctive change in the shape of the left ventricle that suggests septal buiging and that may impair left ventricular function.

Use of an ultrasonic contrast method in the diagnosis of valvular regurgitation and intracardiac shunts.

Abstract: Injection of normal saline solution or indocyanine green dye through intracardiac catheters results in ultrasonic reflections from the site of injection. To evaluate the diagnostic usefulness of this observation, ultrasonic transducers were first placed directly on the pulmonary artery or ascending aorta of six open chest dogs. The rapid injection of 5 ml of normal saline solution into the femoral vein or left atrium produced a “cloud” of contrast echoes filling the pulmonary artery or ascending aorta. Thus, the echo-reflecting phenomenon persists during the passage of blood across two cardiac valves. Sixty-two patients aged 2 months to 70 years were then studied during cardiac catheterization; recordings were made during injection of indocyanine green dye or normal saline solution. Contrast echoes appeared in the left atrium after left ventricular injection in 14 of 16 patients with mitral regurgitation. Aortic root injection produced contrast echoes in the left ventricle in 13 of 16 patients with aortic regurgitation. Valvular regurgitation as small as 10 percent by angiographic determination was detected. Shunting was detected In patients with atrial and ventricular septal defects, patent ductus arteriosus and tetralogy of Fallot. Catheter-induced mitral regurgitation was demonstrated in one patient. This method is a sensitive and accurate qualitative technique for detecting intracardiac shunts and valvular regurgitation.

Relation between fetal flow patterns, coarctation of the aorta, and pulmonary blood flow.

Abstract: Intracardiac anomalies cause disturbances in fetal flow patterns which in turn influence dimensions of the great vessels. At birth the aortic isthmus, which receives 25 per cent of the combinedfetal ventricular output, is normally 25 to 30 per cent narrower than the descending aorta. A shelf-like indentation of the posterior aortic wall opposite the ductus characterizes thejunction of the isthmus with descending aorta. In tetralogy of Fallot, pulmonary atresia, and tricuspid atresia, when pulmonary blood flow is reduced from birth, the main pulmonary artery is decreased and ascending aorta increased in size. Conversely in intracardiac anomalies where blood is diverted awayfrom the aorta to the pulmonary artery, isthmal narrowing or the posterior indentation may be exaggerated. Analysis of I62 patients with coarctation of the aorta showed 83 with an intracardiac anomaly resulting in increased pulmonary bloodflow and 21 with left-sided lesions present from birth. In contrast no patients with coarctation were found with diminished pulmonary flow or right-sided obstructive lesions. From this evidence the hypothesis is developed that coarctation is prevented whenflow in the main pulmonary artery is reduced in thefetus.

Ventricular septal defect with increased pulmonary vascular resistance: Late results of surgical closure

Abstract: The fate of 57 children who underwent surgical closure of ventricular septal defect in the presence of increased pulmonary vascular resistance was analyzed. Eighteen (32 percent) died at or immediately after operation. Seven late deaths, due to the Eisenmenger syndrome, occurred 1 to 7 years after operation. Follow-up studies, including cardiac catheterization, were performed in 25 survivors, 1 to 11 years (mean 5 years) after operation. In patients operated on after age 2 years, the degree of preoperative elevation of pulmonary vascular resistance largely determined the prognosis: The condition of patients with mild elevation (pulmonary vascular resistance less than one third the systemic level) returned to normal after operation, with one exception. Patients with more severe elevation (pulmonary vascular resistance more than one third the systemic level) most often showed progressive pulmonary vascular disease; the condition of a few remained unchanged and that of only one returned to normal after operation. Operative mortality rate was high in children with elevated pulmonary vascular resistance during the second year of life who were operated on before age 2 years, but pulmonary vascular resistance returned to normal in the three survivors. When pulmonary vascular resistance was increased in the first year of life, it generally decreased spontaneously (independently of operation); the early increase in these cases is believed to represent delayed maturation of the pulmonary vascular bed rather than pulmonary vascular disease. The overall results of surgery in ventricular septal defect associated with a high level of pulmonary vascular resistance are unfavorable and call for interruption of the natural history before significant pulmonary vascular obstructive changes have taken place; this can be achieved by surgical closure before age 2 years or pulmonary artery banding in infancy.

Haemodynamic and anatomical characteristics of pulmonary blood supply in pulmonary atresia with ventricular septal defect - including a case of persistent fifth aortic arch.

Abstract: Eight children with congenital pulmonary atresia with ventricular septal defect were investigated. The anatomy ofpulmonary blood supply was established by aortography and multiple selective injections of contrast medium into aortopulmonary anastomoses or pulmonary arteries. All patients were shown to have central pulmonary arteries (derived from the embryological sixth aortic arches). In 4 (group I) the central pulmonary arteries had been supplied via a persistent ductus arteriosus alone (3 subsequently had surgical aortopulmonary shunts). In 3 (group 2), the central pulmonary arteries were supplied via major aortopulmonary collateral arteries alone, and in I patient (group 3) pulmonary blood supply was derived both from collateral arteries and a persistent left fifth aortic arch. Systolic pressure gradients of 28 to 8I mmHg were demonstrated in each patient at the pulmonary artery end of the aortopulmonary anastomosis, whatever its nature. All patients in group I, and I patient in group 2 had unifocal pulmonary blood supply, i.e. the sixth aortic arch asasto,nosed with, and provided a singlefocus for, all systemic sources ofpulmonary blood supply. Pulmonary resistance relative to sixth aortic arch pressure rangedfrom 1`4 to 6.4 units M2. The remaining patients had multifocalpulmonary blood supply, i.e. one or more aortopulmonary collateral arteries provided pulmonary blood supply independent of the sixth aortic arch. In this group the minimum pulmonary resistance relative to the sixth aortic arch rangedfrom 3-9 to I2-i5 units M2. The latterfigure suggested the presence of severe pulmonary vascular disease. Thus stenoses at the aortopulmonary collateral/pulmonary artery junction usually, but not invariably, protect the pulmonary vascular bedfrom the effects ofperfusion at aortic pressure.

The pathology of pulmonary veno-occlusive disease

Abstract: The histopathology of the lungs is described in 13 patients with pulmonary veno-occlusive disease. The patients were mostly children or young adults and there was no sex preference as is seen in primary pulmonary hypertension.

Sound Pressure Correlates of the Second Heart Sound: An Intracardiac Sound Study

Abstract: The sound pressure correlates of the second heart sound were studied in 22 patients during diagnostic cardiac catheterization. Simultaneous right ventricular and pulmonary artery pressures were recorded with equisensitive catheter-tip micromanometers together with the external phonocardiogram and ECG. In 12 patients having normal pulmonary vascular resistance (group 1), pulmonic closure sound was coincident with the incisura of the pulmonary artery pressure curve which in turn was separated from the right ventricular pressure trace by an interval denoted hangout. The duration of this interval varied (33-89 msec), was independent of pulmonary artery pressure or resistance and was felt to be primarily a reflection of the capacitance of the pulmonary vascular tree. The absolute value of this interval during inspiration was very similar to the splitting interval and, when subtracted from the Q-P 2 interval, the remaining interval (QRV) was almost identical to the Q-A 2 interval, indicating that the actual duration of right and left ventricular systole is nearly equal. Awareness of the existence of the hangout interval and its hemodynamic determinants offers a reasonable mechanism to explain the audible expiratory splitting of the second heart sound found in patients with idiopathic dilatation of the pulmonary artery following atrial septal defect repair and in one additional patient studied with mild valvular pulmonic stenosis. In nine patients with elevated pulmonary vascular resistance approaching systemic levels (group 2), the absolute value of the hangout interval was markedly reduced (15-28 msec) consistent with the decrease in capacitance of the pulmonary vascular bed and the increased pulmonary vascular resistance known to occur in pulmonary hypertension. In those patients where the duration of right and left ventricular systole were nearly equal, narrow splitting of the second heart sound was present. In those patients where selective prolongation of right ventricular systole occurred, the narrow hangout interval persisted, but the splitting interval was prolonged proportionate to the increased duration of right ventricular systole.

Normal Contractile State of Hypertrophied Myocardium after Pulmonary Artery Constriction in the Cat

Abstract: The contractile function of right ventricular papillary muscles from normal cats and cats in which the pulmonary artery had been constricted for 6 or 24 wk was examined. Acute pulmonary artery constriction reduced cross-sectional area by an average of 70%, resulting in a 30% mortality from congestive heart failure, all such deaths occurring within the first 3 wk after banding. The increase in right ventricular mass in animals surviving for 6 or 24 wk was similar, averaging 70%. No banded animals had evidence of congestive heart failure at the time of sacrifice, and cardiac output and right atrial pressures were similar to those in control animals.6 wk after banding, the active length-tension curve, maximal rate of rise of isometric force, force-velocity relations, and isometric force with paired stimulation and norepinephrine were all significantly depressed when compared to their respective values in control animals. In contrast, none of these variables was significantly different from control values in animals banded for 24 wk. These observations indicate that depressed contractile state is not a fundamental characteristic of pressure-induced hypertrophied myocardium and reemphasize the important temporal relationship between contractile state and the imposition of sudden sustained loads.

Anomalous Origin of One Pulmonary Artery from the Ascending Aorta Diagnostic, Physiological and Surgical Considerations

Abstract: Six patients with origin of one pulmonary artery from the ascending aorta are presented. Two are alive: a 21-year-old female, unoperated, with bilateral pulmonary vascular obstructive disease (PVO) and a 4-year-old girl who underwent successful correction at age 5 months. In addition, the data are reviewed from previous reports of 44 patients with this anomaly. Among the total of 50 patients, 42 had congestive heart failure in infancy. The right pulmonary artery arose anomalously in 44. A patent ductus arteriosus was present in 38 cases. At cardiac catheterization, pressure in both pulmonary arteries was generally at systemic level and the diagnosis was confirmed by aortography. Histologically, no significant PVO was observed in the majority of 18 infants who died, while significant changes, mainly in the "systemic" lung, were observed in 6 of 10 older children. Twenty-two patients have been operated on with 13 survivors. Anastomosis of the aberrant pulmonary artery to the main pulmonary artery directly o...

Hemodynamic evaluation of 221 patients after intracardiac repair of tetralogy of Fallot

Abstract: Cardiac catheterization and angiocardiographic studies were performed in 221 patients an average of 2 years (range 2 weeks to 10 years) after intracardiac repair of tetralogy of Fallot. The group represented 32.5 percent of the postoperative survivors. The postoperative result was classified as “excellent” (43 percent), “good” (35 percent), “satisfactory” (7 percent) or “unsatisfactory” (14 percent) on the basis of right ventricular peak systolic pressure, right ventricle to pulmonary artery peak systolic gradient and presence of a persistent large or small left to right shunt at the ventricular level. Unsatisfactory results were associated with obstructive pulmonary vascular disease (four patients), severe malformations with obstruction of the right ventricular outflow tract and/or a left to right shunt with a Qp:Qs ratio of greater than 1.5:1 or with currently uncorrectable obstructive anomalies of the right ventricular outflow tract or pulmonary arteries. The postoperative result depended upon the amount of reconstruction of the right ventricular outflow tract and the caliber of the pulmonary arteries. Patients who required a systemic to pulmonary artery anastomosis before total correction and those who required a prosthetic patch for the right ventricular outflow tract fared worse than younger patients who had minimal resection of the right ventricular outflow tract. Pulmonary insufficiency was detected in 94 percent of patients with a right ventricular outflow tract prosthesis and in 10 percent of those who had infundibulectomy alone. The insufficiency was well tolerated clinically and hemodynamically unless there was distal obstruction of the pulmonary artery or its branches. Postoperative catheterization is necessary to assess the immediate and long-term operative results in patients with tetralogy of Fallot. Total correction of tetralogy of Fallot as a primary procedure provides acceptable hemodynamic results even in children less than 4 years of age, providing that the right ventricular outflow tract obstruction can be relieved and that pulmonary insufficiency is not aggravated by increased main pulmonary arterial pressure.

Selection of Patients with Truncus Arteriosus for Surgical Correction Anatomic and Hemodynamic Considerations

Abstract: Six years have passed since the first successful surgical correction of truncus arteriosus. A review of our experience enables some conclusions regarding the operation. Patients with mild or moderate truncal valve incompetence do not need truncal valve replacement. Patients with severe truncal valve incompetence require valve replacement, which is associated with a significantly increased surgical mortality. The surgical mortality is not increased in hemodynamically favorable patients who have only one pulmonary artery. However, these patients are especially likely to have early development of severe pulmonary vascular disease. The surgical mortality for the patient with uncomplicated disease and two pulmonary arteries, with pulmonary resistance of less than 8.0 units m2, is 10%. In patients with pulmonary resistance between 8.0 and 12 units m2, the mortality is approximately three times greater. Patients with pulmonary resistances greater than 12.0 units m2 are probably inoperable. Different hemodynamic ...

Arterial changes in Crotalaria spectabilis-induced pulmonary hypertension in rats.

Abstract: Pulmonary hypertension has been induced in rats by feeding them the seeds of Crotalaria spectabilis for 34 days, when some were killed and others left to recover for 14, 31 or 54 days. By 34 days and after pulmonary arterial injection, right ventricular hypertrophy was demonstrated with an increase in pulmonary arterial medial muscle, a reduced number of small arteries and “ghost” arteries. With recovery, right ventricular hypertrophy had regressed by 31 days and by 54 days the arterial muscle was decreased. There was no increase in number of small arteries although “ghost” arteries had disappeared by 31 days. Similar features have recently been described in human primary pulmonary hypertension.

Pulsatile flow in pulmonary artery, capillary, and vein in the dog.

Abstract: The temporal relationship of flow pulses in the pulmonary artery, capillaries, and veins was investigated in 10 chronic dog preparations with pulsed ultrasonic flowmeters and a nitrous oxide-body plethysmograph for capillary flow. Implanted pressure transducers in the left atrium provided reference to the conventional atrial pulses: A, C, X-descent, V, and Y-descent. Left atrial contraction produced an A-wave pressure transient followed by retrograde flow up the veins. The C-pressure pulse occasionally produced a minimal trough in the venous flow pattern. Early in ventricular systole, X-descent in left atrial pressure preceded a venous flow pulse of modest amplitude, which began prior to the onset of the pulse of capillary flow. On average, right ventricular ejection was followed in 37 msec by the major flow pulse in the capillaries, which in turn was followed 68 msec later by the onset of venous flow. This venous flow pulse was simultaneous with a rise in left atrial pressure, the V-wave. With the onset of diastole, the Y-descent in atrial pressure preceded a major venous flow pulse. With accelerated heart rate, separation of the V and Y venous flow pulses was lost, and a monophasic pulse was found.

Hemodynamic observations in patients with unstable angina pectoris.

Abstract: Brachial and pulmonary arterial pressures were monitored for 48 hours in 26 patients with unstable angina pectoris and documented occlusive coronary artery disease. The circulatory response during 56 episodes of spontaneous anginal pain permitted the division of responses into three distinctive hemodynamic subsets. Patients in group I had an increased heart rate only with the spontaneous attack of angina; patients in group II had associated increases in brachial arterial pressure and slight increases in heart rate during the episodes of pain; patients in group III demonstrated increases in both brachial and pulmonary arterial diastolic pressures with minimal changes in heart rate. Resting hemodynamic data during pain-free periods were normal in 25 of 26 patients. Patients in all groups who had more than one episode of pain had similar hemodynamic responses to the first and later episodes. Although myocardial hypoxemia appears to be responsible for the spontaneous attack of angina, the hemodynamic responses to the attack varied but were highly specific for any one patient. Our observations suggest that there may be various pathogenic mechanisms for “spontaneous” or resting angina in patients with occlusive coronary artery disease but that the mechanism and associated hemodynamic changes may be specific for individual patients.

Afferent fibres from pulmonary arterial baroreceptors in the left cardiac sympathetic nerve of the cat.

Abstract: 1. Afferent discharges were recorded from the left cardiac sympathetic nerve or the third sympathetic ramus communicans of anaesthetized cats. Twenty-one single units with baroreceptor activity were obtained. 2. The receptors of each unit were localized to the extrapulmonary part of the pulmonary artery, determined by direct mechanical probing of the wall of the pulmonary artery after death of the animals. Conduction velocity of the fibres ranged from 2·5 to 15·7 m/sec. 3. Afferent discharges occurred irregularly under artificial ventilation. The impulse activity was increased when pulmonary arterial pressure was raised by an intravenous infusion of Locke solution, or by occlusion of lung roots, and decreased by bleeding the animal from the femoral artery. 4. Above a threshold pressure, discharges occurred synchronously with the systolic pressure pulse in the pulmonary artery. A progressive further rise in pressure did not produce an increase in the number of impulses per heart beat. Occlusion of lung roots initially elicited a burst of discharges but the number of impulses for each cardiac cycle gradually decreased. 5. The receptors responded to repetitive mechanical stimuli up to a frequency of 10/sec, but failed to respond to stimuli delivered at 20/sec. 6. The results provide further evidence for the presence of afferent fibres in the cardiac sympathetic nerve. These afferent fibres are likely to provide the spinal cord with specific information only on transient changes in pulmonary arterial pressure.

Ventilation-perfusion lung scanning for pulmonary emboli.

Abstract: The conventional method of lung scanning detects defects of pulmonary artery perfusion. False positive results occur because regions of hypoventilation, such as are present in obstructive airways disease, also cause defects of perfusion. The converse is not true, however, as defects of perfusion continue to be ventilated. Thus in pulmonary embolism ventilation-perfusion discrepancy (normal ventilation and impaired perfusion) occurs.We have assessed the clinical value of this discrepancy. Out of 18 patients with ventilation-perfusion discrepancy 14 had a final diagnosis of pulmonary emboli, whereas in none of the 34 patients without the discrepancy was this final diagnosis made. We conclude that combined ventilation-perfusion lung scanning distinguishes pulmonary emboli from other lung conditions such as asthma and bronchitis which cause impaired pulmonary perfusion. The false positive rate was only 4% overall and 7.7% in patients with perfusion defects.

Aortopulmonary fenestration and aortic atresia. Report of an infant with ventricular septal defect, persistent ductus arteriosus, and interrupted aortic arch.

Abstract: Most reported cases of aortopulmonary fenestration are discrete openings between the main pulmonary artery and the aorta, distal to the outflow valves, and thus are amenable to surgical correction using cardiopulmonary bypass (Bosher and McCue, I962; Deverall et al., I969; Gross, I952; Gasul, Fell, and Casas, I951; Hurwitz, Ruttenberg, and Fonkalsrud, I967; Kalter et al., 1970; Meisner et al., 1968; Morrow, Greenfield, and Braunwald, I962; Neufeld et al., I962; Putnam and Gross, I966; Reis et al., I965; Stanley et al., I969; Wright, Freeman, and Johnston, I968). Some cases are more difficult to correct because the fenestration is so large that there is either no truncal septum separating the aorta from the main pulmonary artery with only a very small cuff or rim above the separate valves, or an aortopulmonary fenestration that perches above both valves with no rim of tissue above the valves (Dadds and Hoyle, 1949; Sprengel and Brown, 1954). Such cases have sometimes been classified as truncus arteriosus because one great vessel leads to pulmonary, systemic, and coronary circulations (Van Praagh and Van Praagh, I965). The present case report concerns an infant with aortopulmonary fenestration, aortic atresia, interrupted aortic arch, persistent ductus arteriosus, and ventricular septal defect. Because of the aortic atresia, blood flow across the fenestration was the reverse of that usually seen in aortopulmonary defects.

The effect of ketamine on pulmonary artery pressure. An experimental and clinical study.

Abstract: Anaesthesia for cardiac catheterisation in infants and children remains a challenge to the anaesthetist. A wide variety of methods has been advocated' but none of these has proved completely satisfactory, nor is there, as yet, a single well-recognised technique which is accepted in all centres. It is generally agreed that there should be minimal fluctuations in physiological parameters during cardiac catheterisation if false data is not to be obtained from the procedure; alterations in oxygen tension in the inspired air and intermittent positive pressure ventilation should, therefore, be avoided as far as is possible.* The introduction of ketamine has provided an anaesthetic which has proved to have advantages over others currently employed for cardiac catheterisation ; its use as a sole agent for this purpose has been described by several a ~ t h o r s . ~ ~ The advantages claimed for ketamine include its ease of administration, the rapidity of induction, the ease in maintaining an unobstructed airway and the minimal respiratory depression. Anaesthesia can be maintained for extended periods without endotracheal intubation and with the patient breathing air rather than unphysiological gas mixtures. Certain characteristic cardiovascular responses to ketamine administration have been observed and reported in both humans and anirnak6 These include an increased cardiac output, hypertension and tachycardia with little or no change in the systemic peripheral re~istance.~ These haemodynamic changes have also been noted by the authors when using ketamine in the diagnostic cardiac catheterisation Iaboratory over the past 4 years. The studies in animals and children described in this paper were undertaken to determine whether or not the observed rise in systemic blood pressure following the injection of ketamine is accompanied by a concomitant increase in pulmonary artery pressure. If such a rise in pulmonary artery pressure occurred it might result in erroneous data being obtained from the catheterisation study. It might also be

Ascending Aorta to Right Pulmonary Artery Anastomosis Immediate Results in 123 Patients and One Month to Six Year Follow-up in 74 Patients

Abstract: An intrapericardial ascending aorta-to-right pulmonary artery anastomosis was performed in 123 patients with cyanotic congenital heart disease associated with pulmonary stenosis or atresia during the eight year period from 1964 through 1971. While there were 20 early postoperative deaths (16%), 90% (93 patients) of the 103 survivors were symptomatically improved. In the postoperative evaluation, 74 patients (72% of the survivors) returned for follow-up examination, which included cardiac catheterization in 57. The anastomosis was nonfunctioning in ten (13.5%) of these 74 patients and in an additional 13 (17.5%) patients, clinically silent right pulmonary artery stenosis was demonstrated angiographically at the anastomosis site. Clinical improvement had been maintained in the 64 patients with an open anastomosis (audible continuous murmur or angiographically demonstrated patency) including the 13 patients with acquired pulmonary stenosis at the operative site. Persistent right pulmonary artery stenosis was...