We performed a prospective, randomized, placebo-controlled, double-blind trial to assess the effi... more We performed a prospective, randomized, placebo-controlled, double-blind trial to assess the efficacy of aprotinin in 61 children (median age 3.7 yr) undergoing reoperative open heart surgery (OHS). Three demographically similar groups were studied: large-dose aprotinin (ALD), small-dose aprotinin (ASD), and placebo (P). Over the first 24 postoperative hours fewer patients in the aprotinin groups received packed red cells (ALD, 53%; ASD, 89%; and P, 95%; P = 0.001), platelets (ALD, 32%; ASD, 50%; and P, 65%; P = 0.04), and fresh frozen plasma (ALD, 16%; ASD, 17%; and P, 60%; P = 0.003) than placebo patients. Most importantly, aprotinin patients had fewer exposures to banked blood components (ALD, median 1 U; and ASD, median 2 U) than P (median 6 U; P = 0.001), with no difference in overall complication rate. Use of aprotinin was associated with a savings in the patient charges for blood components, operating room time, and duration of hospitalization. In conclusion, aprotinin decreased the number of units of banked blood components used during the first 24 postoperative hours in reoperative pediatric OHS. Aprotinin thus decreases the risks associated with exposure to banked blood components and reduces hospital charges.
Journal of the American Society of Echocardiography, 1995
Journal of the American Society of Echocardiography, Volume 8, Issue 3, Pages 402, May 1995, Auth... more Journal of the American Society of Echocardiography, Volume 8, Issue 3, Pages 402, May 1995, Authors:Ohad Ludomirsky; Achi Ludomirsky; Thomas Lloyd; Gerald Serwer; Roger P. Vermilion; Ralph Mosca; Ed Bove. ...
Journal of the American Society of Echocardiography, 1995
Available Doppler-echocardiographic methods of evaluation for mitral regurgitation (MR) suffer fr... more Available Doppler-echocardiographic methods of evaluation for mitral regurgitation (MR) suffer from several limitations. Variable morphology and direction of MR jets complicate visual appreciation from multiple cross-section views. We assessed the feasibility of dynamic three-dimensional (3D) reconstruction of turbulent MR jets and compared the results with conventional color Doppler (CD) imaging. Methods: 22 patients with MR were examined, by a modified multiplanar transesophageal 5 MHz transducer (Hewlett-Packard, Andover, MA) allowing computer-controlled rotation of the imaging plane by a stepper motor (TomTec, Munich, Germany). Gray-scale encoded color Doppler images were acquired at 2" increments over a 180 ~ rotation, Iransferred to a workstation, reformatted and integrated into data sets of cone-shaped voxei volumes. Various cutting planes through the 3D data set were then selected and multiple dynamic reconstruction of MR jets with mitral valve and left atrium were performed. Results: Dynamic 3D visualization of MR jets allowed good assessment of their extent in the left atrium in 19 cases. In 17 cases, 3D MR jets were graded equally severe as by CD method and in 5 cases less severe by one grade (mean grade 2.5+1.2 vs 2.8_+1.1 on a scale of 4). The 3D method was clearly superior for visualization of MR jet shape and spatial extent throughout systole. It revealed a greater number of distinct jets in 5 cases. Paravalvular regurgitation of mechanical prostheses could be easily distinguished from physiologic transvalvular jets.
The Journal of Thoracic and Cardiovascular Surgery, 1995
Since September 1991, 14 consecutive patients with tetralogy of Fallot, pulmonary atresia, and di... more Since September 1991, 14 consecutive patients with tetralogy of Fallot, pulmonary atresia, and diminutive pulmonary arteries have undergone staged repair. All patients had multiple aortopulmonary collateral arteries and the ductus arteriosus was absent in 11. Mean sizes of the right and left pulmonary arteries were 2.2 _+ 0.7 mm and 1.9 -+ 0.8 mm, respectively (range 0.5 to 3.0 mm). Eight patients (57%) have subsequently received complete repair. Age at initial procedure (shunt, right ventricle-pulmonary artery conduit, or direct aorta-puhnonary artery anastomosis) in this group was 5.3 -6.8 months. The number of operative procedures to achieve complete repair was 2.9 -0.8 per patient (range 2 to 4). Intraoperative postrepair peak right ventricle-left ventricle pressure ratio was 0.57 -0.17. Six of 8 patients (75%) required additional interventional procedures (mean 1.5 -+ 1.2 per patient) for angioplasty of peripheral pulmonary artery stenoses, coil embolization of aortopulmonary collateral arteries, or intraoperative insertion of intravascular pulmonary artery stents. Mean follow-up from complete repair was 8.7 _ 8.3 months (range 0.5 to 23.8 months) and is complete. There was one in-hospital death at 45 days, and one late cardiac death at 20.3 months. Six patients had initial palliative operations (unifocalization, right ventricle-pulmonary artery conduit, direct aorta-pulmonary artery anastomosis, or transannular outflow patch) but have not undergone complete repair. Age at initial procedure in this group was 27.9 -56.9 months (range 0.27 to 155 months), and mean follow-up from initial procedure was 10.9 -+ 11.2 months (range 0 to 31.4 months). The operative mortality rate was 33% (2 of 6 patients). There was one late noncardiac death at 5.3 months. Three patients are awaiting further intervention or repair. This experience suggests that complete repair is feasible even in patients with extremely diminutive pulmonary arteries (<3.0 mm). Pulmonary artery growth is facilitated by early (3 to 6 month) establishment of central pulmonary artery flow by right ventriclepulmonary artery conduit (pulmonary arteries >1.5 mm) or by direct ascending aorta-pulmonary artery anastomosis (pulmonary arteries <1.5 ram). Subsequent interventional catheterization and operative procedures as required for pulmonary artery stenoses and coil embolization of collateral arteries allow continued recruitment of central pulmonary arteries and may obviate or minimize the need for unifocalization procedures.
Although survival of patients with the hypoplastic left heart syndrome treated by staged surgical... more Although survival of patients with the hypoplastic left heart syndrome treated by staged surgical palliation has improved, hemodynamic data after fenestrated Fontan operation and after fenestration closure have not been reported in this patient population. We sought to describe the hemodynamic status of these patients at cardiac catheterization performed for the purpose of fenestration closure and to compare these data with data from contemporary patients with other forms of univentricular heart. Hemodynamic responses to fenestration closure during cardiac catheterization were reviewed in 40 consecutive patients, including 20 with the hypoplastic left heart syndrome and 20 with other forms of univentricular heart defects. Hemodynamics before fenestration closure (arterial saturation and pressure, Fontan baffle saturation and pressure, pulmonary capillary wedge pressure, systemic arteriovenous oxygen content difference, and right-to-left shunt fraction) were nearly identical between the two groups. Significant (p &lt; 0.05) changes after fenestration closure included increases in arterial saturation (9%), mean arterial pressure (3 mm Hg), and baffle pressure (1 mm Hg) and arteriovenous oxygen content difference (18 ml/L), with near elimination of right-to-left shunting. Cardiac output decreased by 21% and systemic oxygen transport by 13%, with no differences between the two patient groups. Mean baffle pressures were &lt;17 mm Hg in 32 patients (80%). Hemodynamics after fenestrated Fontan operation and responses to fenestration closure in patients with the hypoplastic left heart syndrome were remarkably similar to that in patients with other univentricular heart defects.
The Journal of Thoracic and Cardiovascular Surgery, 1995
The optimal treatment of critical aortic stenosis in the neonate and infant remains controversial... more The optimal treatment of critical aortic stenosis in the neonate and infant remains controversial. We compared transventricular dilation using normothermic cardiopulmonary bypass and percutaneous balloon aortic valvuloplasty with respect to early and late survival, relief of aortic stenosis, degree of aortic insufficiency, left ventricular function, and freedom from reintervention. Between July 1987 and July 1993, 30 neonates and infants underwent transventricular dilation or balloon aortic valvuloplasty for critical aortic stenosis. The patients in the transventricular dilation group (n = 21) ranged in age from 1 to 59 days (mean age 18.0 days -+ 19.1 days) and the balloon aortic valvuloplasty group (n = 9) from 1 to 31 days (mean age 10.0 days -9.0 days). There were n o significant differences in weight, body surface area, or aortic anulus diameter between the two groups (p = 1.0). Associated cardiovascular anomalies were more common in the transventricular dilation group (48%) than in the balloon aortic valvuloplasty group (11%). After intervention, the degree of residual aortic stenosis and insufficiency was equivalent in the two groups as assessed by postprocedural Doppler echocardiography. Ejection fraction improved within both groups (transventricular dilation 39% -20.2% versus 47% -22.0%; balloon aortic valvuloplasty 51% -+ 16.1% versus 62% -+ 8.4%), and there was no significant difference between groups. The left ventricular mass/volume ratio increased within both groups (p < 0.05) but with no significant difference between groups (transventricular dilation 1.4 -0.5 gm/ml versus 1.8 -0.6 gm/ml; balloon aortic valvuloplasty 1.1 -+ 0.6 gm/ml versus 1.7 -+ 0.4 gm/ml). Early mortality in the transventricular dilation group was 9.5% and in the balloon aortic valvuloplasty group, 11.1%. There was one late death in the transventricular dilation group. Four patients from the transventricular dilation group (19%) and two patients from the balloon aortic valvuloplasty group (22%) required reintervention for further relief of aortic stenosis. We conclude that both transventricular dilation and balloon aortic valvuloplasty provide adequate and equivalent relief of critical aortic stenosis. The treatment strategy adopted should depend on other factors, including associated cardiovascular anomalies, vascular access, preoperative condition, and the technical expertise available at each institution. (J THORAC CARDIOVASC SURG 1995;
Journal of the American College of Cardiology, 2001
We sought to examine the incidence and possible factors for inducible intra-atrial reentrant tach... more We sought to examine the incidence and possible factors for inducible intra-atrial reentrant tachycardia (IART) in a group of patients after two stages of the Fontan sequence but before the operation. BACKGROUND Intra-atrial reentrant tachycardia occurs in 10% to 40% of patients after the Fontan operation.
The outlook for newborns with hypoplastic left heart syndrome has been dramatically altered in th... more The outlook for newborns with hypoplastic left heart syndrome has been dramatically altered in the past decade with the successful application of staged reconstructive techniques. Once considered a uniformly fatal condition, refinements in operative technique and perioperative care have been largely responsible for this improved survival. The first stage in the reconstructive process, the Norwood procedure, continues to carry the most significant risk. The Nor-wood procedure must provide: unobstructed systemic and coronary blood flow from the right ventricle; unobstructed pulmonary venous return across the atria1 septum; and sufficient pulmonary blood flow without significant volume overload. Although the postoperative management of these patients must achieve the proper ratio of systemic and pulmonary vascular resistance, a properly performed reconstruction should result in a largely uncomplicated recovery. The second stage procedure, the hemi-Fontan operation, is performed between 4 and 6 months of age. This step results in removal of the ventricular volume overload imposed by the systemic shunt and the connection of the superior vena cava to the pulmonary arteries. Augmenting the central pulmonary arteries, avoiding conduction disturbances, and constructing a potential connection for the inferior vena cava to the pulmonary arteries are essential components of this procedure. The Fontan procedure is performed at approximately 1.52 years of age. Inferior vena cava return is channeled to the pulmonary arteries through the previously constructed atriocaval connection to complete the separation of the pulmonary and systemic circulations. Although the current techniques have resulted in substantial improvements in the quantity and quality of survival, efforts to refine each stage of the process continue to evolve with increasing follow-up and evaluation.
Repair of complete atrioventricular canal early in infancy has traditionally carried greater morb... more Repair of complete atrioventricular canal early in infancy has traditionally carried greater morbidity and mortality than repair performed later. However, an individualized anatomy-based repair may give young infants outcomes that are equivalent to older patients. We retrospectively reviewed 139 patients who underwent complete atrioventricular canal repair from January 2005 to December 2012. An individualized approach was used: 2-patch repair was performed in 98 patients for large ventricular septal defects and a modified single-patch ("Australian technique") was used in 41 for "shallow" ventricular septal defects. The average age was 25.5 ± 3.9 weeks, 50% were boys, and 78% had trisomy 21. Mean follow-up was 5.1 ± 0.2 years, with 100% completeness of data. There were 3 in-hospital deaths (2.1%) and 1 late death (0.7%). A permanent pacemaker was required in 2 patients (1.4%). The rate for left atrioventricular valve reoperation was 8% at a mean of 211 ± 238 days ...
Progress in transplantation (Aliso Viejo, Calif.), 2005
Heart transplantation with ABO blood type-incompatible donors has historically been contraindicat... more Heart transplantation with ABO blood type-incompatible donors has historically been contraindicated because of the high risk of an immediate hyperacute humoral graft rejection. The immature neonatal immune system presents an immunologic window that allows for breaching the ABO barrier before the natural development of anti-ABO antibodies. Information from a small series of neonates has demonstrated similar survival rates and posttransplant outcomes compared to ABO-compatible transplantations. In the posttransplant period, particular attention is placed on the surveillance of graft-specific antibody production and monitoring for immunologic signs and symptoms of early graft vasculopathy. This article presents a case study of a neonate with congenital heart disease who underwent one of the first successful ABO-incompatible heart transplantations in the United States.
Background. During induced ischemia for cardiac surgery inefficient anaerobic energy mechanisms p... more Background. During induced ischemia for cardiac surgery inefficient anaerobic energy mechanisms predominate. Sustaining aerobic metabolism with perfluorocarbon-supplemented blood cardioplegia theoretically could lead to improved postischemic recovery. Therefore we studied functional recovery after myocardial ischemia, comparing perflubron (CgF17Br) supplemented blood cardioplegia to standard blood cardiopleg~a. Methods. Nineteen dogs underwent 15 minutes of 37 ~ C global ischemia on cardiopulmonary bypass, followed by 90 minutes of cardioplegic arrest by use of blood cardiopleg~a with or without perflubron and then 30 minutes of 37 ~ C reperfusion. During ischemia myocardial oxygen tension, temperature, and pH were measured. Postischemic left ventricular recovery was assessed by means of preload recruitable stroke work, exponential end-diastolic stress-strain regression, and preservation of adenosine triphosphate and energy charge.
Changes in sexual function and hormone levels are commonly found in subjects addicted to narcotic... more Changes in sexual function and hormone levels are commonly found in subjects addicted to narcotics. In this study we examined 16 male and 3 female addicts who had been taking heroin (H) in the last year in doses higher than 150 mg/day. In these patients, who presented similar clinical problems, we assayed by RIA the plasma levels of heroin, testosterone, (T), dihydrotestosterone (DHT), androstenedione (A), luteinizing hormone (LH) and follicle-stimulating hormone (FSH) for periods of 150 min, 6 h and 9 h. We found a significant reduction of T and DHT concomitant with higher plasma concentrations of heroin but no relevant changes of A, LH and FSH. T and DHT returned to the initial levels after the decrease of heroin concentration. The GnRH test effectd on a female subject allowed us to make the diagnosis of hypothalamic amenorrhea. In the same patient no circadian rhythms for T, DHT and A were detected.
Journal of Cardiovascular Magnetic Resonance, 2000
Development of a mycotic aneurysm or pseudoaneurysm after subacute bacterial endarteritis is unco... more Development of a mycotic aneurysm or pseudoaneurysm after subacute bacterial endarteritis is uncommon. Nonetheless, patients with coarctation of the aorta are more likely to develop this complication. We describe a case of a large pseudoaneurysm discovered in a child with a previously undiagnosed aorta coarctation. Successful repair was performed with the aid of partial left heart bypass and the use of an interposition graft. A high index of suspicion is necessary to accurately diagnose this rare but life-threatening entity.
To determine the efficacy of decreasing cardiopulmonary bypass (CPB) prime volume for neonates an... more To determine the efficacy of decreasing cardiopulmonary bypass (CPB) prime volume for neonates and small infants by using low prime oxygenators, small diameter polyvinyl chloride (PVC) tubing and removing the arterial line filter (ALF) in an effort to reduce intraoperative exposure to multiple units of packed red blood cells (PRBC). Two retrospective database studies comparing neonatal CPB prime volume were undertaken: Study 1--A CPB circuit consisting of a 1/8 inch arterial line, a 3/16 inch venous line and a low prime oxygenator with 172 ml total circuit prime (n=74) was compared to a circuit with a 3/16 inch arterial line, a 1/4 inch venous line and a higher prime oxygenator with a 350 ml total circuit prime (n=74). Study 2--The 172 ml circuit (n=389) was compared to a circuit that included an ALF and had a total circuit prime volume of 218 ml (n=389). Study 1--of the 74 neonates and small infants whose CPB prime volume was 350 ml, 19 were exposed to two or more intraoperative ex...
We performed a prospective, randomized, placebo-controlled, double-blind trial to assess the effi... more We performed a prospective, randomized, placebo-controlled, double-blind trial to assess the efficacy of aprotinin in 61 children (median age 3.7 yr) undergoing reoperative open heart surgery (OHS). Three demographically similar groups were studied: large-dose aprotinin (ALD), small-dose aprotinin (ASD), and placebo (P). Over the first 24 postoperative hours fewer patients in the aprotinin groups received packed red cells (ALD, 53%; ASD, 89%; and P, 95%; P = 0.001), platelets (ALD, 32%; ASD, 50%; and P, 65%; P = 0.04), and fresh frozen plasma (ALD, 16%; ASD, 17%; and P, 60%; P = 0.003) than placebo patients. Most importantly, aprotinin patients had fewer exposures to banked blood components (ALD, median 1 U; and ASD, median 2 U) than P (median 6 U; P = 0.001), with no difference in overall complication rate. Use of aprotinin was associated with a savings in the patient charges for blood components, operating room time, and duration of hospitalization. In conclusion, aprotinin decreased the number of units of banked blood components used during the first 24 postoperative hours in reoperative pediatric OHS. Aprotinin thus decreases the risks associated with exposure to banked blood components and reduces hospital charges.
Journal of the American Society of Echocardiography, 1995
Journal of the American Society of Echocardiography, Volume 8, Issue 3, Pages 402, May 1995, Auth... more Journal of the American Society of Echocardiography, Volume 8, Issue 3, Pages 402, May 1995, Authors:Ohad Ludomirsky; Achi Ludomirsky; Thomas Lloyd; Gerald Serwer; Roger P. Vermilion; Ralph Mosca; Ed Bove. ...
Journal of the American Society of Echocardiography, 1995
Available Doppler-echocardiographic methods of evaluation for mitral regurgitation (MR) suffer fr... more Available Doppler-echocardiographic methods of evaluation for mitral regurgitation (MR) suffer from several limitations. Variable morphology and direction of MR jets complicate visual appreciation from multiple cross-section views. We assessed the feasibility of dynamic three-dimensional (3D) reconstruction of turbulent MR jets and compared the results with conventional color Doppler (CD) imaging. Methods: 22 patients with MR were examined, by a modified multiplanar transesophageal 5 MHz transducer (Hewlett-Packard, Andover, MA) allowing computer-controlled rotation of the imaging plane by a stepper motor (TomTec, Munich, Germany). Gray-scale encoded color Doppler images were acquired at 2" increments over a 180 ~ rotation, Iransferred to a workstation, reformatted and integrated into data sets of cone-shaped voxei volumes. Various cutting planes through the 3D data set were then selected and multiple dynamic reconstruction of MR jets with mitral valve and left atrium were performed. Results: Dynamic 3D visualization of MR jets allowed good assessment of their extent in the left atrium in 19 cases. In 17 cases, 3D MR jets were graded equally severe as by CD method and in 5 cases less severe by one grade (mean grade 2.5+1.2 vs 2.8_+1.1 on a scale of 4). The 3D method was clearly superior for visualization of MR jet shape and spatial extent throughout systole. It revealed a greater number of distinct jets in 5 cases. Paravalvular regurgitation of mechanical prostheses could be easily distinguished from physiologic transvalvular jets.
The Journal of Thoracic and Cardiovascular Surgery, 1995
Since September 1991, 14 consecutive patients with tetralogy of Fallot, pulmonary atresia, and di... more Since September 1991, 14 consecutive patients with tetralogy of Fallot, pulmonary atresia, and diminutive pulmonary arteries have undergone staged repair. All patients had multiple aortopulmonary collateral arteries and the ductus arteriosus was absent in 11. Mean sizes of the right and left pulmonary arteries were 2.2 _+ 0.7 mm and 1.9 -+ 0.8 mm, respectively (range 0.5 to 3.0 mm). Eight patients (57%) have subsequently received complete repair. Age at initial procedure (shunt, right ventricle-pulmonary artery conduit, or direct aorta-puhnonary artery anastomosis) in this group was 5.3 -6.8 months. The number of operative procedures to achieve complete repair was 2.9 -0.8 per patient (range 2 to 4). Intraoperative postrepair peak right ventricle-left ventricle pressure ratio was 0.57 -0.17. Six of 8 patients (75%) required additional interventional procedures (mean 1.5 -+ 1.2 per patient) for angioplasty of peripheral pulmonary artery stenoses, coil embolization of aortopulmonary collateral arteries, or intraoperative insertion of intravascular pulmonary artery stents. Mean follow-up from complete repair was 8.7 _ 8.3 months (range 0.5 to 23.8 months) and is complete. There was one in-hospital death at 45 days, and one late cardiac death at 20.3 months. Six patients had initial palliative operations (unifocalization, right ventricle-pulmonary artery conduit, direct aorta-pulmonary artery anastomosis, or transannular outflow patch) but have not undergone complete repair. Age at initial procedure in this group was 27.9 -56.9 months (range 0.27 to 155 months), and mean follow-up from initial procedure was 10.9 -+ 11.2 months (range 0 to 31.4 months). The operative mortality rate was 33% (2 of 6 patients). There was one late noncardiac death at 5.3 months. Three patients are awaiting further intervention or repair. This experience suggests that complete repair is feasible even in patients with extremely diminutive pulmonary arteries (<3.0 mm). Pulmonary artery growth is facilitated by early (3 to 6 month) establishment of central pulmonary artery flow by right ventriclepulmonary artery conduit (pulmonary arteries >1.5 mm) or by direct ascending aorta-pulmonary artery anastomosis (pulmonary arteries <1.5 ram). Subsequent interventional catheterization and operative procedures as required for pulmonary artery stenoses and coil embolization of collateral arteries allow continued recruitment of central pulmonary arteries and may obviate or minimize the need for unifocalization procedures.
Although survival of patients with the hypoplastic left heart syndrome treated by staged surgical... more Although survival of patients with the hypoplastic left heart syndrome treated by staged surgical palliation has improved, hemodynamic data after fenestrated Fontan operation and after fenestration closure have not been reported in this patient population. We sought to describe the hemodynamic status of these patients at cardiac catheterization performed for the purpose of fenestration closure and to compare these data with data from contemporary patients with other forms of univentricular heart. Hemodynamic responses to fenestration closure during cardiac catheterization were reviewed in 40 consecutive patients, including 20 with the hypoplastic left heart syndrome and 20 with other forms of univentricular heart defects. Hemodynamics before fenestration closure (arterial saturation and pressure, Fontan baffle saturation and pressure, pulmonary capillary wedge pressure, systemic arteriovenous oxygen content difference, and right-to-left shunt fraction) were nearly identical between the two groups. Significant (p &lt; 0.05) changes after fenestration closure included increases in arterial saturation (9%), mean arterial pressure (3 mm Hg), and baffle pressure (1 mm Hg) and arteriovenous oxygen content difference (18 ml/L), with near elimination of right-to-left shunting. Cardiac output decreased by 21% and systemic oxygen transport by 13%, with no differences between the two patient groups. Mean baffle pressures were &lt;17 mm Hg in 32 patients (80%). Hemodynamics after fenestrated Fontan operation and responses to fenestration closure in patients with the hypoplastic left heart syndrome were remarkably similar to that in patients with other univentricular heart defects.
The Journal of Thoracic and Cardiovascular Surgery, 1995
The optimal treatment of critical aortic stenosis in the neonate and infant remains controversial... more The optimal treatment of critical aortic stenosis in the neonate and infant remains controversial. We compared transventricular dilation using normothermic cardiopulmonary bypass and percutaneous balloon aortic valvuloplasty with respect to early and late survival, relief of aortic stenosis, degree of aortic insufficiency, left ventricular function, and freedom from reintervention. Between July 1987 and July 1993, 30 neonates and infants underwent transventricular dilation or balloon aortic valvuloplasty for critical aortic stenosis. The patients in the transventricular dilation group (n = 21) ranged in age from 1 to 59 days (mean age 18.0 days -+ 19.1 days) and the balloon aortic valvuloplasty group (n = 9) from 1 to 31 days (mean age 10.0 days -9.0 days). There were n o significant differences in weight, body surface area, or aortic anulus diameter between the two groups (p = 1.0). Associated cardiovascular anomalies were more common in the transventricular dilation group (48%) than in the balloon aortic valvuloplasty group (11%). After intervention, the degree of residual aortic stenosis and insufficiency was equivalent in the two groups as assessed by postprocedural Doppler echocardiography. Ejection fraction improved within both groups (transventricular dilation 39% -20.2% versus 47% -22.0%; balloon aortic valvuloplasty 51% -+ 16.1% versus 62% -+ 8.4%), and there was no significant difference between groups. The left ventricular mass/volume ratio increased within both groups (p < 0.05) but with no significant difference between groups (transventricular dilation 1.4 -0.5 gm/ml versus 1.8 -0.6 gm/ml; balloon aortic valvuloplasty 1.1 -+ 0.6 gm/ml versus 1.7 -+ 0.4 gm/ml). Early mortality in the transventricular dilation group was 9.5% and in the balloon aortic valvuloplasty group, 11.1%. There was one late death in the transventricular dilation group. Four patients from the transventricular dilation group (19%) and two patients from the balloon aortic valvuloplasty group (22%) required reintervention for further relief of aortic stenosis. We conclude that both transventricular dilation and balloon aortic valvuloplasty provide adequate and equivalent relief of critical aortic stenosis. The treatment strategy adopted should depend on other factors, including associated cardiovascular anomalies, vascular access, preoperative condition, and the technical expertise available at each institution. (J THORAC CARDIOVASC SURG 1995;
Journal of the American College of Cardiology, 2001
We sought to examine the incidence and possible factors for inducible intra-atrial reentrant tach... more We sought to examine the incidence and possible factors for inducible intra-atrial reentrant tachycardia (IART) in a group of patients after two stages of the Fontan sequence but before the operation. BACKGROUND Intra-atrial reentrant tachycardia occurs in 10% to 40% of patients after the Fontan operation.
The outlook for newborns with hypoplastic left heart syndrome has been dramatically altered in th... more The outlook for newborns with hypoplastic left heart syndrome has been dramatically altered in the past decade with the successful application of staged reconstructive techniques. Once considered a uniformly fatal condition, refinements in operative technique and perioperative care have been largely responsible for this improved survival. The first stage in the reconstructive process, the Norwood procedure, continues to carry the most significant risk. The Nor-wood procedure must provide: unobstructed systemic and coronary blood flow from the right ventricle; unobstructed pulmonary venous return across the atria1 septum; and sufficient pulmonary blood flow without significant volume overload. Although the postoperative management of these patients must achieve the proper ratio of systemic and pulmonary vascular resistance, a properly performed reconstruction should result in a largely uncomplicated recovery. The second stage procedure, the hemi-Fontan operation, is performed between 4 and 6 months of age. This step results in removal of the ventricular volume overload imposed by the systemic shunt and the connection of the superior vena cava to the pulmonary arteries. Augmenting the central pulmonary arteries, avoiding conduction disturbances, and constructing a potential connection for the inferior vena cava to the pulmonary arteries are essential components of this procedure. The Fontan procedure is performed at approximately 1.52 years of age. Inferior vena cava return is channeled to the pulmonary arteries through the previously constructed atriocaval connection to complete the separation of the pulmonary and systemic circulations. Although the current techniques have resulted in substantial improvements in the quantity and quality of survival, efforts to refine each stage of the process continue to evolve with increasing follow-up and evaluation.
Repair of complete atrioventricular canal early in infancy has traditionally carried greater morb... more Repair of complete atrioventricular canal early in infancy has traditionally carried greater morbidity and mortality than repair performed later. However, an individualized anatomy-based repair may give young infants outcomes that are equivalent to older patients. We retrospectively reviewed 139 patients who underwent complete atrioventricular canal repair from January 2005 to December 2012. An individualized approach was used: 2-patch repair was performed in 98 patients for large ventricular septal defects and a modified single-patch ("Australian technique") was used in 41 for "shallow" ventricular septal defects. The average age was 25.5 ± 3.9 weeks, 50% were boys, and 78% had trisomy 21. Mean follow-up was 5.1 ± 0.2 years, with 100% completeness of data. There were 3 in-hospital deaths (2.1%) and 1 late death (0.7%). A permanent pacemaker was required in 2 patients (1.4%). The rate for left atrioventricular valve reoperation was 8% at a mean of 211 ± 238 days ...
Progress in transplantation (Aliso Viejo, Calif.), 2005
Heart transplantation with ABO blood type-incompatible donors has historically been contraindicat... more Heart transplantation with ABO blood type-incompatible donors has historically been contraindicated because of the high risk of an immediate hyperacute humoral graft rejection. The immature neonatal immune system presents an immunologic window that allows for breaching the ABO barrier before the natural development of anti-ABO antibodies. Information from a small series of neonates has demonstrated similar survival rates and posttransplant outcomes compared to ABO-compatible transplantations. In the posttransplant period, particular attention is placed on the surveillance of graft-specific antibody production and monitoring for immunologic signs and symptoms of early graft vasculopathy. This article presents a case study of a neonate with congenital heart disease who underwent one of the first successful ABO-incompatible heart transplantations in the United States.
Background. During induced ischemia for cardiac surgery inefficient anaerobic energy mechanisms p... more Background. During induced ischemia for cardiac surgery inefficient anaerobic energy mechanisms predominate. Sustaining aerobic metabolism with perfluorocarbon-supplemented blood cardioplegia theoretically could lead to improved postischemic recovery. Therefore we studied functional recovery after myocardial ischemia, comparing perflubron (CgF17Br) supplemented blood cardioplegia to standard blood cardiopleg~a. Methods. Nineteen dogs underwent 15 minutes of 37 ~ C global ischemia on cardiopulmonary bypass, followed by 90 minutes of cardioplegic arrest by use of blood cardiopleg~a with or without perflubron and then 30 minutes of 37 ~ C reperfusion. During ischemia myocardial oxygen tension, temperature, and pH were measured. Postischemic left ventricular recovery was assessed by means of preload recruitable stroke work, exponential end-diastolic stress-strain regression, and preservation of adenosine triphosphate and energy charge.
Changes in sexual function and hormone levels are commonly found in subjects addicted to narcotic... more Changes in sexual function and hormone levels are commonly found in subjects addicted to narcotics. In this study we examined 16 male and 3 female addicts who had been taking heroin (H) in the last year in doses higher than 150 mg/day. In these patients, who presented similar clinical problems, we assayed by RIA the plasma levels of heroin, testosterone, (T), dihydrotestosterone (DHT), androstenedione (A), luteinizing hormone (LH) and follicle-stimulating hormone (FSH) for periods of 150 min, 6 h and 9 h. We found a significant reduction of T and DHT concomitant with higher plasma concentrations of heroin but no relevant changes of A, LH and FSH. T and DHT returned to the initial levels after the decrease of heroin concentration. The GnRH test effectd on a female subject allowed us to make the diagnosis of hypothalamic amenorrhea. In the same patient no circadian rhythms for T, DHT and A were detected.
Journal of Cardiovascular Magnetic Resonance, 2000
Development of a mycotic aneurysm or pseudoaneurysm after subacute bacterial endarteritis is unco... more Development of a mycotic aneurysm or pseudoaneurysm after subacute bacterial endarteritis is uncommon. Nonetheless, patients with coarctation of the aorta are more likely to develop this complication. We describe a case of a large pseudoaneurysm discovered in a child with a previously undiagnosed aorta coarctation. Successful repair was performed with the aid of partial left heart bypass and the use of an interposition graft. A high index of suspicion is necessary to accurately diagnose this rare but life-threatening entity.
To determine the efficacy of decreasing cardiopulmonary bypass (CPB) prime volume for neonates an... more To determine the efficacy of decreasing cardiopulmonary bypass (CPB) prime volume for neonates and small infants by using low prime oxygenators, small diameter polyvinyl chloride (PVC) tubing and removing the arterial line filter (ALF) in an effort to reduce intraoperative exposure to multiple units of packed red blood cells (PRBC). Two retrospective database studies comparing neonatal CPB prime volume were undertaken: Study 1--A CPB circuit consisting of a 1/8 inch arterial line, a 3/16 inch venous line and a low prime oxygenator with 172 ml total circuit prime (n=74) was compared to a circuit with a 3/16 inch arterial line, a 1/4 inch venous line and a higher prime oxygenator with a 350 ml total circuit prime (n=74). Study 2--The 172 ml circuit (n=389) was compared to a circuit that included an ALF and had a total circuit prime volume of 218 ml (n=389). Study 1--of the 74 neonates and small infants whose CPB prime volume was 350 ml, 19 were exposed to two or more intraoperative ex...
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Papers by Ralph Mosca