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By: V. Tom, M.A.S., M.D.
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There is ongoing controversy regarding the advisability of For example blood pressure medication heart palpitations cheap 50mg tenormin fast delivery, Egan and Holzer from Nationwide Children’s balloon angioplasty for native coarctation blood pressure extremely low order cheap tenormin on-line. However blood pressure medication hair growth order tenormin 100 mg online, bal- Hospital concluded in a recent review, “balloon angioplasty loon angioplasty remains the standard of care for recurrent for (native) coarctation is effective in leading to an acute gra- coarctation following previous surgical repair. In contrast to dient reduction, but has been found to have a higher incidence the situation with a native coarctation, abnormal ductal tis- of recoarctation or aortic wall complications. In the set- before being able to make more frm recommendations upon ting of abnormal ductal tissue, this disruption of vessel wall the most appropriate treatment algorithm. One of the serious consequences of aneurysm formation is that subsequent surgical intervention carries a higher risk of CompariNg BallooN aNgioplasty, steNtiNg aNd paraplegia because there has been no ongoing stimulus for surgery iN the treatmeNt oF aortiC CoarCtatioN collateral formation though the risk of paraplegia after sur- In contrast to the situation with older infants and children, gery is apparently not high. Perhaps in the future it will be possible to timiNg oF surgery iN the asymptomatiC patieNt predict patients who are at risk of aneurysm formation. However, the presence of continuing fbrosis and maturation of a coarctation in the frst 1–2 months of life, it is probably not advisable to undertake symptoms which are unresponsive to medical therapy is an elective coarctation surgery in the asymptomatic infant dur- absolute indication for surgery for coarctation. However, there appears to be no important above under Pathophysiology and Clinical Presentation, the advantage in deferring surgery beyond the frst 2–3 months neonate with a critical coarctation will present with the signs of life. Beyond the neonatal period, there may be the usual certainly increases the risk of essential hypertension appear- signs and symptoms of congestive heart failure. However, if upper Following his success in achieving the frst successful clo- body blood pressure is greater than 2 standard deviations sure of a patent ductus arteriosus in 1938, Robert E. Gross above normal and if imaging studies confrm a diameter loss took up the challenge of pioneering the surgical correction of 50% or greater at the level of the coarctation, then surgery of coarctation of the aorta. Accordingly, in an era that predated Blood Pressure Gradient prosthetic vascular tube grafts, he investigated the use of The gradient across the coarctation whether measured by tubes of aortic homograft tissue as interposition grafts. Gross published the results of these studies in a landmark article in the New England Journal of Medicine setting of a coarctation that can be imaged to have a diameter in 1945. However, the frst successful repair in spite of important evidence of stenosis by imaging because of coarctation had already been performed by Craaford in of the presence of profuse collateral development. In Diameter Loss on Imaging Studies 1962, Schuster and Gross26 reported the results of their frst If there is greater than 50% stenosis at the level of the coarcta- 500 repairs of coarctation by resection and end-to-end anas- tion, surgery is indicated. They recommended that the optimal age for surgery should be about 10 years of age since by this time the child’s Abnormal Descending Aortic Flow aorta would have achieved 50% of adult size. Doppler echocardiographic assessment of fow in the In 1961, von Rueden12 proposed an isthmus plasty pro- descending aorta may provide additional information when cedure, as well as synthetic patch aortoplasty, with the goal imaging studies are equivocal in their assessment as to the being to avoid a circumferential anastomosis. However, this regarding growth of a circumferential anastomosis also led information alone should be used rarely to decide appropri- Waldhausen and Nahrwold31 in 1966 to propose the ingenious ateness of surgery. This procedure 296 Comprehensive Surgical Management of Congenital Heart Disease, Second Edition eliminated a circumferential anastomosis, but failed to elimi- is dissected free with careful visualization and preservation nate the abnormal ductal tissue. In 1987, Elliott33 proposed management of the hypoplas- The fnal area for dissection is the medial proximal tic arch associated with coarctation by extended end-to-end descending thoracic aorta. This area is left until last since anastomosis and radically extended end-to-end anastomosis. If injury to a collateral vessel did occur, one is now in Other innovative techniques that have been described a position to place clamps, transect the aorta and pursue the include the subclavian fap procedure with maintenance of left retracted bleeding collateral vessel. Clamps are applied after notifying the anesthesia team that they should anticipate a rise in blood pressure. Often for teChNiCal CoNsideratioNs proximal control it is useful to apply a C-clamp which will Resection and End-to-End Anastomosis include both the distal aortic arch, as well as the left sub- clavian artery. A straight or angled DeBakey clamp is often Resection and end-to-end anastomosis is currently the pre- appropriate for the descending thoracic aorta. Heparin is usu- ferred technique for management of coarctation at Children’s ally not given and is thought to be unnecessary because the National Medical Center (Video 16. An arterial monitor- vessels of young children are free of atherosclerotic disease. A Thus, this is not analogous to vascular surgery in an athero- urinary catheter is usually inserted. However, some centers choose to right lateral decubitus position (or slightly prone relative to infuse 1 mg/kg of heparin prior to clamp application.
In our large The mucosa is taken from the lateral nasal wall anterior to the series hypertension and renal failure buy tenormin on line amex, no such injuries occurred arrhythmia blogs purchase tenormin overnight. This expands the fat plug on the intracra- to gently introduce the fat plug through the defect young squage heart attack cheap 100 mg tenormin. This maneuver further pushes the fat plug into the introduce only a very small amount of fat through the defect defect and a little prolapse of fat through the defect is nor- with each maneuver. The patient is placed head up (15 degrees) and the free 12 Cerebrospinal Fluid Leak Closure 169 A B Fig. This expands the fat graft on the intracranial surface and pulls with each maneuver. The brain was adherent to the dura around the defect and needed to be carefully mobilized before the fascia lata graft was placed. No fuorescein can be seen and a solid the slightly protruding fat plug and skull base defect. This is especially true in defects larger than the mucosal surface facing the nasal cavity (Fig. Several is to use the suction bipolar forceps to shrink the brain tissue layers can be placed in this manner. The fascia lata graft is mea- Leak (Video 38) sured to be ,20 mm larger than the defect’s diameter so that there is at least 5 mm of graft to be slid into this space between The meninges and protruding brain tissue are resected up to brain and dura around the whole circumference of the defect. This is normally done with a powered microde- In some instances the two-surgeon approach can be useful. Once In smaller defects a free mucosal graft with the mucosa har- the bone of the skull base defect is clearly exposed and sur- vested from the middle turbinate or foor of the nose is placed rounding mucosa on the nasal surface gently removed from over this intracranial graft followed by fbrin glue. Defects the edges of the bony defect the prolapsing brain tissue can be from the posterior wall of the frontal sinus up to the anterior addressed. The brain tissue is shrunk using the suction bipolar face of the pituitary and from lamina papyracea to lamina until the stump of remaining brain tissue lies within the intra- papyracea have been successfully closed using this two- cranial cavity. At this point an assessment needs to be made as layer facia lata or septal fap approach. When large defects to whether the edges of the prolapsed brain tissue are in con- are closed, the fbrin glue is covered by Gelfoam and then a tact with the edges of the skull base defect and whether it is ad- nasal pack is placed in the nose for 5 days. This is often the case and is used in large defects as this is likely to result in air being in these patients a fat plug graft is not suitable because there sucked into the intracranial cavity rather than improving the is insufcient space on the intracranial surface of the defect to chances of a seal. The vidian nerve and pterygopalatine ganglion may need to be sacrifced during this exposure. This will usu- ally involve division of the sphenopalatine artery and other branches of the maxillary artery. Division of such a large ar- view of the skull base after a large defect was closed with the tery is preceded by cauterization with the suction bipolar two-layered fascia lata technique. The posterior wall of the pterygopalatine fossa is thick lage in the repair of large skull base defects but we have found and is resected with the high speed skull base diamond burr. If cartilage or bone is introduced intra- Care is taken not to injure the maxillary nerve as it traverses cranially, it pushes the fat plug or fascia away from the dura the pterygopalatine fossa. Once direct access is achieved in and bony rim of the defect and does not allow for a solid seal. In none of the patients who have undergone large defect reconstructions of Postoperative Care their skull base have we seen any recurrence of encephalo- celes over many years of follow-up. The argument that bone The patient is given broad-spectrum antibiotics for 5 days post- or cartilage is needed to provide stability to the skull base to operatively. Saline nasal spray is started immediately after the prevent encephalocele development is false. The patient is instructed not to blow their nose for at least 2 to 3 weeks postoperatively. If the lumbar drain drains more than 5 to 10 mL per hour it is raised above the shoulder to slow the drainage. After In this series there were four patients who had a defect in the 6 24 hours the lumbar drain is removed and the patient is slowly lateral wall of a very pneumatized sphenoid sinus. In three of the four patients multiple previous attempts at closure had been made at other institutions usually by at- Results tempting to obliterate the sphenoid with fat.
It then turns to the right behind the aorta and the thoracic duct to terminate into the azygos vein blood pressure keeps going down buy tenormin line. The left upper hemiazygos varies inversely with the size of the left superior intercostal vein arrhythmia natural cure safe 100 mg tenormin. It receives the left intercostal veins that did not drain into the left superior intercostal vein and the lower hemiazygos and terminates in the right azygos or the lower hemiazygos hypertension uptodate buy cheapest tenormin and tenormin. We prefer to use the term left azygos vein rather than hemiazygos to indicate the course and length of this vein. Normal Development of the Portal Vein Venous return of the primitive gut circulation is by way of the vitelline veins of the yolk sac that become confluent with the right and left omphalomesenteric veins, which enter the sinus venosus posteriorly (Fig. As the omphalomesenteric veins approach the heart, they lie adjacent to the developing liver. When the yolk sac disappears and the intestine grows, the omphalic (yolk sac) portion of these veins also disappears. The mesenteric part persists and grows to match the length and complexity of the growing intestine (6). By the sixth week of gestation, the paired mesenteric veins have formed anastomoses with each other. A week later, the left mesenteric vein involutes cephalad to the anastomosis, while the right mesenteric vein involutes caudal to the anastomosis. This results in the unpaired hepatic portal vein that connects the veins of the intestine and the spleen with the circulation of the liver. It descends in front of the aortic arch and the left pulmonary vessels and, after receiving the left superior intercostal vein, it penetrates the pericardium. When this anomaly accompanies other congenital cardiac malformations, it may pose diagnostic and technical difficulties during catheterization and cardiac surgery (16). The coronary sinus can be imaged from the subcostal, apical, and parasternal windows (Fig. B: The dilated coronary sinus is seen in the posterior left atrioventricular groove from the parasternal long-axis view. The left superior intercostal vein is a small systemic vein that can be followed toward the anterior chest wall. Typically, it is associated with severe left atrial outlet obstruction, such as mitral stenosis or atresia with a restrictive patent foramen ovale or an intact atrial septum, and provides an alternative egress for pulmonary venous blood (21). In patients with a normal septum primum and septum secundum, the orifice of the unroofed coronary sinus will function as an interatrial communication. In a study of 58 postmortem cases of visceral heterotaxy with asplenia, the incidence was 67%, and in 46 postmortem cases of polysplenia, the incidence was 13% (1). The reason for the high frequency of an unroofed coronary sinus in asplenia is not P. These patients exhibit varying degrees of cyanosis, clubbing of the nail beds, and polycythemia. They are at risk for complications of right-to-left shunting, including paradoxical emboli, brain abscess, strokes, and death. In some patients, the coronary sinus ostium is atretic and there is no significant interatrial communication. Patients with a significant interatrial communication exhibit signs and symptoms related to left-to-right shunting as well as cyanosis. The frontal axis of the P wave may be abnormal in patients with heterotaxy syndrome, reflecting a left sinoatrial node or an ectopic atrial rhythm. The posterior left atrioventricular groove is examined in detail to ascertain the extent of deficiency of the coronary sinus septum. A catheter inserted into the right femoral vein entered a left venous channel that crossed the diaphragm and entered the left side of a common atrium. In a study of 121 cases, we found that this anomaly occurred both in patients with structurally normal hearts (54%) and in patients with congenital heart defects (46%) (30). Rhythm disturbances without additional structural heart disease were reported in 29 patients (24%), including atrioventricular block, sinoatrial node dysfunction, ventricular tachycardia, left and right bundle-branch block, supraventricular tachycardia, and sudden death. A range of associated cardiovascular malformations with or without arrhythmia were found in 56 patients (46%). When the only associated cardiac anomaly is partial or complete unroofing of the coronary sinus (found in four patients), cyanosis dominates the clinical picture. Precise preoperative knowledge of the systemic venous anatomy is also crucial before surgery that includes cavopulmonary anastomosis and orthotopic heart transplantation.
As discussed pulse pressure 39 order tenormin with american express, late rejection young squage heart attack order tenormin 50 mg line, associated with poor outcome blood pressure glucose chart purchase 100mg tenormin otc, is often associated with nonadherence during adolescence (205). Older children return to school and a more normal lifestyle after transplantation and express an improvement in the quality of their lives. Rehabilitation of the pediatric heart transplant recipient depends on the age of the patient and the degree of illness before and after transplantation. In contrast to the experience with adult recipients, pediatric heart transplant recipients generally enjoy near-normal exercise capacity with low-normal oxygen consumption and just mildly reduced workload. Younger age at transplant is associated with greater exercise capacity (oxygen consumption). The persistence of some chronotropic incompetence may contribute to the lesser exercise capacity (221). Heart rate, systolic blood pressure response, and oxygen consumption all demonstrate significant incremental improvements with time after heart transplant, possibly providing supportive evidence for reinnervation of the allograft in many patients. Benefits include improved blood glucose control, increase in bone density, and potential psychological enrichment. Return to age- appropriate activities including a physical education class can be achieved in the majority of patients within the first 6 months after transplantation (223). Arrhythmias and Heart Rate Response Significant arrhythmias after transplantation are relatively uncommon and when they occur may be indicative of graft problems such as rejection. The occurrence of supraventricular and ventricular tachyarrhythmias always raise concern of rejection (224), although pediatric heart transplant recipients appear to be more prone to tachyarrhythmias than adult heart transplant recipients, and they are often not associated with rejection (225). Symptomatic sinus bradycardia and heart block after transplantation requiring pacemaker placement have been described in a small percentage of children (226). The heart rate response to exercise and heart rate recovery after exercise in pediatric heart transplant recipients are consistent with autonomic denervation after transplant and suggestive of late autonomic reinnervation of these hearts (227). Previous studies in adults have demonstrated that parasympathetic reinnervation is rather infrequent after heart transplant and occurs in only 5% to 10% of recipients (228). Sympathetic reinnervation occurs much more frequently, however, and has been described using both invasive and noninvasive approaches in adults (229). These include (a) measurement of norepinephrine levels from coronary sinus and heart rate response after intracoronary injection of tyramine; (b) kinetics after intravenous infusion of radiolabeled norepinephrine that includes coronary sinus catheterization; (c) histologic evidence of nerve endings on endomyocardial biopsy tissues using special staining; (d) scintigraphic techniques such as single- photon emission computerized tomography or positron emission tomography imaging using radioisotopes; and (e) heart rate variability studies (230,231,232,233). Late Rejection One of the most important factors in reducing the risk of and morbidity from rejection is to maintain regular and frequent routine office visits for all patients. Evidence of rejection in infants and small children ranges from no symptoms to a wide variety of nonspecific symptoms including tachycardia, tachypnea, lethargy, irritability, and poor feeding. Physical signs are similar to those in adults, including jugular venous distention, organomegaly, a new murmur, and gallop rhythm. Children who have no rejection in the first year after transplant may be at lower risk for hemodynamically compromising rejection later. Also “biopsy-negative” rejection—at times presenting with severe left ventricular dysfunction and negative cellular or immunohistochemical abnormality on biopsy—can occur late after transplantation. These patients can improve with augmented immunosuppression including plasmapheresis, cyclophosphamide, antilymphocyte therapy, and agents suppressing antibody production, but their long-term outcome remain guarded (234). In these cases, treatment strategies have included several immunosuppressant combinations and even total lymphoid irradiation (235). This is a complicated, multifactorial issue that needs further in-depth analysis to identify risk factors for late rejection, including social/behavioral environment, genetic polymorphisms that may present higher risk, and pharmacologic changes that could be targeted to specific patients over time (236). Generally, late rejection can be an ominous sign and may be predictive of graft loss. Episodes of late rejection with or without hemodynamic compromise always raise the concern of noncompliance. The Pediatric Heart Transplant Study reported the time-related risk of “serious” infection and death in a large pediatric heart transplant population from 22 participating centers in the United States (151). Often this infection consists of benign viremia and does not lead to clinically relevant disease. The risk of all types of infections is very low by 6 months after transplant, but a low risk persists indefinitely.
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Diastolic ventricular function in children: a Doppler echocardiographic study establishing normal values and predictors of increased ventricular end-diastolic pressure hypertension treatment guidelines jnc 7 order 50mg tenormin mastercard. Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography arrhythmia yahoo order generic tenormin online. Reversal of the pattern of respiratory variation of Doppler inflow velocities in constrictive pericarditis during mechanical ventilation blood pressure stroke range generic 50mg tenormin visa. Constrictive pericarditis without typical haemodynamic changes as a cause of oedema formation due to protein-losing enteropathy. Although relatively rare in children, this cardiac infection with protean manifestations continues to have a disproportionate influence on clinical practice. Reported mortality rates are much lower now than in the preantibiotic era; however, overall morbidity and the expense burden of prolonged and often intense medical and surgical therapies remain formidable. Major advances in understanding this disease process have been made over the years. Additionally, the development and refinement of echocardiographic techniques have contributed to better diagnosis and management of endocarditis. Endocarditis also can involve septal defects, the mural endocardium, or intravascular foreign devices such as intracardiac patches, surgically constructed shunts, and intravenous catheters. Infective endarteritis is a similar clinical illness involving arteries, including the ductus arteriosus, the great vessels, aneurysms, and arteriovenous shunts. At one time, endocarditis was classified as acute or subacute, but the recent tendency has been to avoid this terminology. Low-virulence organisms such as α-hemolytic streptococci, enterococci, or coagulase-negative staphylococci usually cause a prolonged subacute form of the illness. On the other hand, Staphylococcus aureus and other pyogenic bacteria, such as Streptococcus pneumoniae or b-hemolytic streptococci, are usually associated with a more virulent or acute clinical illness. In a review of several published studies between 1986 and 1995, the estimated incidence in children overall was 0. This is not true in developing countries, however, where endocarditis remains an important complicating factor in individuals with rheumatic heart disease. This reflects marked increases in cardiovascular interventions (surgical and nonsurgical) in newborns and young infants with concomitant increased use of prosthetic intravascular devices and insertion of long-term indwelling central venous catheters (6). In summary, patients with underlying cardiovascular disease may develop endocarditis at any age—in childhood, adolescence, or adulthood. Microorganisms Most cases of endocarditis are caused by a relatively small number of microorganisms (Table 62. Experimental data and clinical observations indicate that some bacteria are more commonly associated with endocarditis than others. One of the most logical and intriguing explanations relates to bacterial adherence. In contrast, gram-negative organisms, seldom responsible for endocarditis, adhere rather poorly in this in vitro system. Gram-positive cocci account for about 90% of recoverable bacteria in adult patients. Viridans group streptococci are still responsible for most cases of endocarditis in all age groups in developing countries where, as a predisposing condition, rheumatic heart disease is prevalent. Most of these children developed bacteremia from an infected intravascular device (15). Overall, enterococcal endocarditis occurs much less frequently in children than in adults. Rarely, Neisseria gonorrhoeae can cause endocarditis, presenting as an acute illness and affecting previously normal valves. In instances of prosthetic valve endocarditis, the infective organisms differ depending on whether endocarditis occurs early (<2 to 3 months after surgical procedure) or late. These infections often are implanted at the time of surgery and are seen ∼60 days after cardiac surgery, but coagulase-negative staphylococci may be present as late as 1 year after surgery. Some individuals with the clinical picture of endocarditis, but with sterile routine blood cultures, may be infected with anaerobic organisms, which are not readily recovered by the usual culture methods in the clinical laboratory. Fungal endocarditis is relatively unusual in children although it is one of the most feared forms of endocarditis. Candida species are the most common organisms recovered; Aspergillus species, Torulopsis glabrata, and some other fungi (Histoplasma, Coccidioides, Cryptococcus) also have been reported.