Archives of Pediatrics & Adolescent Medicine, 1991
Page 1. Poverty and Cardiac Disease in Children Hugh D. Allen, MD; Kathryn A. Taubert, PhD; Richa... more Page 1. Poverty and Cardiac Disease in Children Hugh D. Allen, MD; Kathryn A. Taubert, PhD; Richard J. Deckelbaum, MD; David Driscoll, MD; Ann Dunnigan, MD; Samuel S. Gidding, MD; Paul Herndon, MD; Rae-Ellen W. Kavey ...
Journal of the American College of Cardiology, 1984
Fourteen patients, aged 1 month to 13 years, with congenital semilunar valve stenosis (11 pulmona... more Fourteen patients, aged 1 month to 13 years, with congenital semilunar valve stenosis (11 pulmonary and 3 aortic) were studied for orifice area quantification calculated from a Doppler echocardiographicequation: Area = SV/0.88 x V 2 x VET, where SV = stroke volume, V2 =maximal velocity and VET =ventricular ejection time. Results from individual measurements used in this formula and derived area were compared with individual results from cardiac catheterization and valve area derived from the Gorlin formula. Ventricular ejection time by cardiac catheterization ranged from 0.17 to 0.44 second (mean ± standard deviation [SD] 0.27 ± 0.09), and by Doppler study from 0.20 to 0.41 second (mean ± SD 0.29 ± 0.06) (r = 0.65, standard error of the estimate [SEE] = 0.03, y = 0.149 + 0.528x). Pressure gradient by catheterization ranged from 30 to 125 mm Hg (mean ± SD 56.6 ± 33.1), and by Doppler study from 17.6 to 100 mm Hg (mean ± SD 46.8 ± 27.9) (r = 0.91, SEE = 8.8, y = 1.23 + 0.904x). Stroke volume was measured by Doppler study simultaneously with cardiac catheterization in nine patients; results at cardiac catheterization with thermodilution measurements (cardiac outputlheart rate) Aortic and pulmonary valve stenosis has been noninvasively detected in patients by a variety of echocardiographic techniques that enable qualitative observations of valve images, thickening of ventricular walls and alterations in function (1-5). Doppler echocardiography has been used to diagnose the presence of semilunar valve stenosis by detection of flow disturbances in the aorta or pulmonary artery (6-8), and more recently, the pressure gradient across a stenotic
Real-time cross-sectional echocardiographic sector scan examinations were performed from a supras... more Real-time cross-sectional echocardiographic sector scan examinations were performed from a suprasternal notch location to image aortic anatomy in 15 children (ages 1 day to 21 years) who were subsequently shown at cardiac catheterization to have coarctation of the descending thoracic aorta. The resulting echocardiographic images of the ascending, transverse and descending aorta imaged juxtaductal coarctation in all 15 patients. Echocardiography predicted discrete coarctation of the aorta in eight, isthmic hypoplasia in two, hourglass type coarctation deformities in three and longer segment coarctation in four patients. Catheterization and angiography confirmed all of these anatomic observations. The control group, 100 patients with congenital heart disease but without angiographic coarctations, included four patients with right-sided aortic arch and six patients with dextrocardia. The ascending, transverse and descending aorta were adequately imaged in 94 of these and no descending ...
We developed and validated a mitral valve orifice method for Doppler cardiac output determination... more We developed and validated a mitral valve orifice method for Doppler cardiac output determination. In 15 open-chest dogs, cardiac output was controlled and measured by a roller pump interposed between the right atrium and pulmonary artery as a right-heart bypass. Left heart flows were measured in the open-chest dog model by Doppler measurements at the mitral valve orifice and compared not only to volume flow measured by the roller pump, but to electromagnetic flow meters as well. The maximum mitral valve orifice area was measured off short-axis two-dimensional echocardiographic views by planimetry. The maximal orifice was then adjusted for its diastolic variation in size by calculating a ratio of mean-to-maximal mitral valve separation on a derived M-mode echocardiogram. Flow was sampled parallel to mitral valve inflow in a four-chamber plane. The multiplication of mean flow throughout the cardiac cycle by the mean mitral valve area after correction for diastolic size variation yiel...
While echocardiography has been used to noninvasively document indirect effects on the heart of l... more While echocardiography has been used to noninvasively document indirect effects on the heart of left-to-right shunting through a patent ductus arteriosus, no noninvasive technique has been developed to image the duct itself. In this study, 35 sequential studies were performed on 28 patients with a mechanical sector scanner to image the distal pulmonary artery and its bifurcation by scanning along the axis of the right ventricular outflow tract. Cross-sectional imaging, just superior to the take-off of the right pulmonary artery, provided visualization of the patent ductus as a distal continuation of the pulmonary artery connecting to the descending aorta. Ductal visualization by cross-sectional echo was validated by saline echo contrast observations of right-to-left and left-to-right shunting through the duct in 14 patients, by surgical observations in 11, angiographic observations in 13 and autopsy observations in three. Angiographic size of the ductus arteriosus, whether constrict...
Recent studies suggest good prospective accuracy for two-dimensional echocardiographic imaging of... more Recent studies suggest good prospective accuracy for two-dimensional echocardiographic imaging of ventricular septal defects (VSD). We obtained two-dimensional images with high-frequency, high-resolution scanners from 36 patients proved by cardiac catheterization to have perimembranous VSD. In 20 patients, the VSD was an isolated lesion and in 16 it was associated with other forms of heart disease. VSDs were imaged in long-axis, apical four-chamber and subcostal echocardiographic views. The smallest VSD imaged was 2 mm in diameter on echo; the largest, 23 mm. The imaged size of VSDs was larger at end-diastole than at end-systole by paired t test on all views (all p less than 0.005). VSD size also varied between views, with no predictive relationship except between apical and subcostal four-chamber views in diastole (r = 0.71, p less than 0.005). This agreed with qualitative direct observations of an ellipsoid or irregularly shaped VSD in operated patients. Echocardiographically meas...
An echocardiographic evaluation of 77 members of a championship childhood swim team showed dimens... more An echocardiographic evaluation of 77 members of a championship childhood swim team showed dimensional variations from normal in most athletes. Cardiac walls were thicker than the 95th percentile of normal: right ventricular anterior wall exceeded the 95th percentile in 100%, interventricular septum in 83% and left ventricular posterior wall in 91%. The left ventricular and left atrial cavities in diastole had mean values at the 50th percentile of normal but showed considerable scatter. The left ventricular cavity in systole had a mean value less than the 5th percentile of normal and also showed wide scatter. The aortic root and the aortic intercusp dimension exceeded the 95th percentile of normal in most subjects, 74% and 77%, respectively. No correlation existed between the coach's estimate of championship ability and echocardiographic wall or chamber sizes. Children who participate extensively in athletic training programs such as swimming may have echocardiograms which are q...
IMAGING OF SUPRACARDIAC TOTAL ANOMALOUS PULMONARY VENOUS DRAINAGE 113 patient was one of acute ve... more IMAGING OF SUPRACARDIAC TOTAL ANOMALOUS PULMONARY VENOUS DRAINAGE 113 patient was one of acute ventricular failure with severe right upper abdominal quadrant pain due to liver distention, ascites, and edema. We suspect that the primary event was acute detachment of the semicircular suture, producing tricuspid regurgitation, acute right ventricular distention, increased tension of the papillary muscles, and chordae tendineae and tear of the latter structure. Probably the moderate pulmonary hypertension still present in this case increased further the stress on the subvalvular apparatus, contributing to rupture of the septal leaflet chordae tendineae and to the severity of right ventricular failure following this rupture. REFERENCES 1Arbulu A, Thomas NW, Wilson RF. Valvulectomy without prosthetic Replacement: a life-saving operation for tricuspid Pseudomonas endocarditis.
To evaluate the usefulness of two-dimensional echocardiography in asymptomatic or minimally sympt... more To evaluate the usefulness of two-dimensional echocardiography in asymptomatic or minimally symptomatic patients with significant aortic regurgitation and left ventricular enlargement, left ventricular size and function measurements obtained by a nongeometric technique, gated blood pool radionuclide angiography, were compared with measurements made by several two-dimensional echocardiographic methods in 20 patients. Left ventricular size was best assessed by an apical biplane modified Simpson's rule algorithm obtained by computer-assisted planimetry. For end-diastolic volume, r = 0.95 and standard error of the estimate = 25 ml; for end-systolic volume, r = 0.94 and standard error of the estimate = 16 ml. A newly introduced simplified two-dimensional method obviating the need for planimetry and using multiple axis measurements yielded satisfactory results, although volumes larger than 300 ml were markedly underestimated. Evaluation of volumes from a single minor axis measured directly from two-dimensional images and M-mode tracings obtained under two-dimensional echocardiographic control was inadequate for clinical use. Ejection fraction was correctly assessed by the modified Simpson's rule method as well as by the simplified two-dimensional method (r = 0.81 to 0.83, standard error of the estimate = 7%). However, when methods without planimetry were further simplified, a satisfactory correlation was no longer obtained. The M-mode approach using a corrected cube formula also provided an accurate estimation of ejection fraction, a finding that is attributed to the absence of regional wall motion abnormalities in this group of patients, the ability to locate the M-mode beam more adequately under two-dimensional control and the persistence of an ellipsoidal configuration and a circular cross section in the left ventricular chamber. The data indicate that two-dimensional echocardiography is a valuable approach to the assessment of left ventricular size and function in these patients. Moreover, this approach provides a practical and convenient way of improving M-mode evaluation of function and of determining left ventricular shape, thus permitting adequate selection of geometric algorithms for volume calculations.
D uring the last few years, pediatric cardiologists have witnessed a dramatic change in the utili... more D uring the last few years, pediatric cardiologists have witnessed a dramatic change in the utilization of the cardiac catheterization laboratory.1-21 Improved noninvasive diagnostic techniques have narrowed indications for diagnostic cardiac catheterizations while the laboratory is now increasingly being used for therapeutic procedures. Recently, numerous catheter techniques, increased numbers of persons and centers using these techniques, and the increased number of lesion types thought to be amenable to catheter therapy have caused concern about the appropriateness of some applications of pediatric therapeutic cardiac catheterization. Compared with diagnostic cardiac catheterization, therapeutic catheter procedures require more time and resources, are costlier and riskier, and demand more technical training and expertise. High levels of skill and expertise are required of the operator who performs the various therapeutic catheterization techniques. These procedures should only be performed in institutions with appropriate facilities, personnel, and programs.22 These considerations, combined with the rapid increase in the number of laboratories and cardiologists performing therapeutic catheterization procedures, cause concerns about hospital and physician credentialing, hospital and physician peer review, and human subjects investigational review. These concerns have prompted this report on the current status of pediatric therapeutic cardiac catheterization and its important new techniques as well as the development of guidelines for specific credentialing and review. "Guidelines for Pediatric Therapeutic Cardiac Catheterization" was approved by the American Heart Association Steering Committee on May 16, 1991. Requests for reprints should be sent to the Office of Scientific Affairs, American Heart Association,
To investigate the hypothesis that embryologic abnormalities in the venous valves may be associat... more To investigate the hypothesis that embryologic abnormalities in the venous valves may be associated with abnormal cardiac development, we examined the right atrial morphologic characteristics in 20 hearts with underdevelopment of the right heart and 17 normal hearts. In the study group, 16 (80%) of the patients had significantly enlarged eustachian valves, one (5%) was slightly enlarged, and three (15%) were smaller than expected. Five (25%) had cor triatriatum dexter. In comparison, eustachian valves in the control specimens were prominent in only one (6%), normal in five (29%), and almost absent in eight (47%). The thebesian valve was also more prominent in the study cohort when compared with controls (p < 0.05). No other morphologic features of the right atrium analyzed in this study differed from those found in normal specimens. We speculate that failure of the venous valves to regress appropriately may create abnormalities in fetal circulation that predispose the fetus to maldevelopment of the right heart structures.
Archives of Pediatrics & Adolescent Medicine, 1991
Page 1. Poverty and Cardiac Disease in Children Hugh D. Allen, MD; Kathryn A. Taubert, PhD; Richa... more Page 1. Poverty and Cardiac Disease in Children Hugh D. Allen, MD; Kathryn A. Taubert, PhD; Richard J. Deckelbaum, MD; David Driscoll, MD; Ann Dunnigan, MD; Samuel S. Gidding, MD; Paul Herndon, MD; Rae-Ellen W. Kavey ...
Journal of the American College of Cardiology, 1984
Fourteen patients, aged 1 month to 13 years, with congenital semilunar valve stenosis (11 pulmona... more Fourteen patients, aged 1 month to 13 years, with congenital semilunar valve stenosis (11 pulmonary and 3 aortic) were studied for orifice area quantification calculated from a Doppler echocardiographicequation: Area = SV/0.88 x V 2 x VET, where SV = stroke volume, V2 =maximal velocity and VET =ventricular ejection time. Results from individual measurements used in this formula and derived area were compared with individual results from cardiac catheterization and valve area derived from the Gorlin formula. Ventricular ejection time by cardiac catheterization ranged from 0.17 to 0.44 second (mean ± standard deviation [SD] 0.27 ± 0.09), and by Doppler study from 0.20 to 0.41 second (mean ± SD 0.29 ± 0.06) (r = 0.65, standard error of the estimate [SEE] = 0.03, y = 0.149 + 0.528x). Pressure gradient by catheterization ranged from 30 to 125 mm Hg (mean ± SD 56.6 ± 33.1), and by Doppler study from 17.6 to 100 mm Hg (mean ± SD 46.8 ± 27.9) (r = 0.91, SEE = 8.8, y = 1.23 + 0.904x). Stroke volume was measured by Doppler study simultaneously with cardiac catheterization in nine patients; results at cardiac catheterization with thermodilution measurements (cardiac outputlheart rate) Aortic and pulmonary valve stenosis has been noninvasively detected in patients by a variety of echocardiographic techniques that enable qualitative observations of valve images, thickening of ventricular walls and alterations in function (1-5). Doppler echocardiography has been used to diagnose the presence of semilunar valve stenosis by detection of flow disturbances in the aorta or pulmonary artery (6-8), and more recently, the pressure gradient across a stenotic
Real-time cross-sectional echocardiographic sector scan examinations were performed from a supras... more Real-time cross-sectional echocardiographic sector scan examinations were performed from a suprasternal notch location to image aortic anatomy in 15 children (ages 1 day to 21 years) who were subsequently shown at cardiac catheterization to have coarctation of the descending thoracic aorta. The resulting echocardiographic images of the ascending, transverse and descending aorta imaged juxtaductal coarctation in all 15 patients. Echocardiography predicted discrete coarctation of the aorta in eight, isthmic hypoplasia in two, hourglass type coarctation deformities in three and longer segment coarctation in four patients. Catheterization and angiography confirmed all of these anatomic observations. The control group, 100 patients with congenital heart disease but without angiographic coarctations, included four patients with right-sided aortic arch and six patients with dextrocardia. The ascending, transverse and descending aorta were adequately imaged in 94 of these and no descending ...
We developed and validated a mitral valve orifice method for Doppler cardiac output determination... more We developed and validated a mitral valve orifice method for Doppler cardiac output determination. In 15 open-chest dogs, cardiac output was controlled and measured by a roller pump interposed between the right atrium and pulmonary artery as a right-heart bypass. Left heart flows were measured in the open-chest dog model by Doppler measurements at the mitral valve orifice and compared not only to volume flow measured by the roller pump, but to electromagnetic flow meters as well. The maximum mitral valve orifice area was measured off short-axis two-dimensional echocardiographic views by planimetry. The maximal orifice was then adjusted for its diastolic variation in size by calculating a ratio of mean-to-maximal mitral valve separation on a derived M-mode echocardiogram. Flow was sampled parallel to mitral valve inflow in a four-chamber plane. The multiplication of mean flow throughout the cardiac cycle by the mean mitral valve area after correction for diastolic size variation yiel...
While echocardiography has been used to noninvasively document indirect effects on the heart of l... more While echocardiography has been used to noninvasively document indirect effects on the heart of left-to-right shunting through a patent ductus arteriosus, no noninvasive technique has been developed to image the duct itself. In this study, 35 sequential studies were performed on 28 patients with a mechanical sector scanner to image the distal pulmonary artery and its bifurcation by scanning along the axis of the right ventricular outflow tract. Cross-sectional imaging, just superior to the take-off of the right pulmonary artery, provided visualization of the patent ductus as a distal continuation of the pulmonary artery connecting to the descending aorta. Ductal visualization by cross-sectional echo was validated by saline echo contrast observations of right-to-left and left-to-right shunting through the duct in 14 patients, by surgical observations in 11, angiographic observations in 13 and autopsy observations in three. Angiographic size of the ductus arteriosus, whether constrict...
Recent studies suggest good prospective accuracy for two-dimensional echocardiographic imaging of... more Recent studies suggest good prospective accuracy for two-dimensional echocardiographic imaging of ventricular septal defects (VSD). We obtained two-dimensional images with high-frequency, high-resolution scanners from 36 patients proved by cardiac catheterization to have perimembranous VSD. In 20 patients, the VSD was an isolated lesion and in 16 it was associated with other forms of heart disease. VSDs were imaged in long-axis, apical four-chamber and subcostal echocardiographic views. The smallest VSD imaged was 2 mm in diameter on echo; the largest, 23 mm. The imaged size of VSDs was larger at end-diastole than at end-systole by paired t test on all views (all p less than 0.005). VSD size also varied between views, with no predictive relationship except between apical and subcostal four-chamber views in diastole (r = 0.71, p less than 0.005). This agreed with qualitative direct observations of an ellipsoid or irregularly shaped VSD in operated patients. Echocardiographically meas...
An echocardiographic evaluation of 77 members of a championship childhood swim team showed dimens... more An echocardiographic evaluation of 77 members of a championship childhood swim team showed dimensional variations from normal in most athletes. Cardiac walls were thicker than the 95th percentile of normal: right ventricular anterior wall exceeded the 95th percentile in 100%, interventricular septum in 83% and left ventricular posterior wall in 91%. The left ventricular and left atrial cavities in diastole had mean values at the 50th percentile of normal but showed considerable scatter. The left ventricular cavity in systole had a mean value less than the 5th percentile of normal and also showed wide scatter. The aortic root and the aortic intercusp dimension exceeded the 95th percentile of normal in most subjects, 74% and 77%, respectively. No correlation existed between the coach's estimate of championship ability and echocardiographic wall or chamber sizes. Children who participate extensively in athletic training programs such as swimming may have echocardiograms which are q...
IMAGING OF SUPRACARDIAC TOTAL ANOMALOUS PULMONARY VENOUS DRAINAGE 113 patient was one of acute ve... more IMAGING OF SUPRACARDIAC TOTAL ANOMALOUS PULMONARY VENOUS DRAINAGE 113 patient was one of acute ventricular failure with severe right upper abdominal quadrant pain due to liver distention, ascites, and edema. We suspect that the primary event was acute detachment of the semicircular suture, producing tricuspid regurgitation, acute right ventricular distention, increased tension of the papillary muscles, and chordae tendineae and tear of the latter structure. Probably the moderate pulmonary hypertension still present in this case increased further the stress on the subvalvular apparatus, contributing to rupture of the septal leaflet chordae tendineae and to the severity of right ventricular failure following this rupture. REFERENCES 1Arbulu A, Thomas NW, Wilson RF. Valvulectomy without prosthetic Replacement: a life-saving operation for tricuspid Pseudomonas endocarditis.
To evaluate the usefulness of two-dimensional echocardiography in asymptomatic or minimally sympt... more To evaluate the usefulness of two-dimensional echocardiography in asymptomatic or minimally symptomatic patients with significant aortic regurgitation and left ventricular enlargement, left ventricular size and function measurements obtained by a nongeometric technique, gated blood pool radionuclide angiography, were compared with measurements made by several two-dimensional echocardiographic methods in 20 patients. Left ventricular size was best assessed by an apical biplane modified Simpson&amp;amp;amp;amp;#39;s rule algorithm obtained by computer-assisted planimetry. For end-diastolic volume, r = 0.95 and standard error of the estimate = 25 ml; for end-systolic volume, r = 0.94 and standard error of the estimate = 16 ml. A newly introduced simplified two-dimensional method obviating the need for planimetry and using multiple axis measurements yielded satisfactory results, although volumes larger than 300 ml were markedly underestimated. Evaluation of volumes from a single minor axis measured directly from two-dimensional images and M-mode tracings obtained under two-dimensional echocardiographic control was inadequate for clinical use. Ejection fraction was correctly assessed by the modified Simpson&amp;amp;amp;amp;#39;s rule method as well as by the simplified two-dimensional method (r = 0.81 to 0.83, standard error of the estimate = 7%). However, when methods without planimetry were further simplified, a satisfactory correlation was no longer obtained. The M-mode approach using a corrected cube formula also provided an accurate estimation of ejection fraction, a finding that is attributed to the absence of regional wall motion abnormalities in this group of patients, the ability to locate the M-mode beam more adequately under two-dimensional control and the persistence of an ellipsoidal configuration and a circular cross section in the left ventricular chamber. The data indicate that two-dimensional echocardiography is a valuable approach to the assessment of left ventricular size and function in these patients. Moreover, this approach provides a practical and convenient way of improving M-mode evaluation of function and of determining left ventricular shape, thus permitting adequate selection of geometric algorithms for volume calculations.
D uring the last few years, pediatric cardiologists have witnessed a dramatic change in the utili... more D uring the last few years, pediatric cardiologists have witnessed a dramatic change in the utilization of the cardiac catheterization laboratory.1-21 Improved noninvasive diagnostic techniques have narrowed indications for diagnostic cardiac catheterizations while the laboratory is now increasingly being used for therapeutic procedures. Recently, numerous catheter techniques, increased numbers of persons and centers using these techniques, and the increased number of lesion types thought to be amenable to catheter therapy have caused concern about the appropriateness of some applications of pediatric therapeutic cardiac catheterization. Compared with diagnostic cardiac catheterization, therapeutic catheter procedures require more time and resources, are costlier and riskier, and demand more technical training and expertise. High levels of skill and expertise are required of the operator who performs the various therapeutic catheterization techniques. These procedures should only be performed in institutions with appropriate facilities, personnel, and programs.22 These considerations, combined with the rapid increase in the number of laboratories and cardiologists performing therapeutic catheterization procedures, cause concerns about hospital and physician credentialing, hospital and physician peer review, and human subjects investigational review. These concerns have prompted this report on the current status of pediatric therapeutic cardiac catheterization and its important new techniques as well as the development of guidelines for specific credentialing and review. "Guidelines for Pediatric Therapeutic Cardiac Catheterization" was approved by the American Heart Association Steering Committee on May 16, 1991. Requests for reprints should be sent to the Office of Scientific Affairs, American Heart Association,
To investigate the hypothesis that embryologic abnormalities in the venous valves may be associat... more To investigate the hypothesis that embryologic abnormalities in the venous valves may be associated with abnormal cardiac development, we examined the right atrial morphologic characteristics in 20 hearts with underdevelopment of the right heart and 17 normal hearts. In the study group, 16 (80%) of the patients had significantly enlarged eustachian valves, one (5%) was slightly enlarged, and three (15%) were smaller than expected. Five (25%) had cor triatriatum dexter. In comparison, eustachian valves in the control specimens were prominent in only one (6%), normal in five (29%), and almost absent in eight (47%). The thebesian valve was also more prominent in the study cohort when compared with controls (p < 0.05). No other morphologic features of the right atrium analyzed in this study differed from those found in normal specimens. We speculate that failure of the venous valves to regress appropriately may create abnormalities in fetal circulation that predispose the fetus to maldevelopment of the right heart structures.
Uploads
Papers by Hugh Allen