The role of a bidirectional cavopulmonary anastomosis in the correction and palliation of complex congenital cardiopathies

Between May 1990 and January 1998, 68 patients underwent bidirectional cavo-pulmonary anastomosis. We evaluated all patients in whom the bidirectional cavo-pulmonary anastomosis was associated with additional pulmonary flow (group A) and those in whom it was associated with biventricular repair (group B). Group A included 23 patients (33.8%), 14 males and 9 females, mean age 25 years and 6 months (range 4 months-16 years). Diagnoses were double outlet right ventricle (6), univentricular heart (6), tricuspid atresia (5), congenitally-corrected transposition of the great arteries with ventricular septal defect and pulmonary stenosis (3), right isomerism (2) and pulmonary atresia with atrioventricular canal (1). Group B included 13 patients (19.1%), 6 males and 7 females, mean age 13 years and 7 months (range 1 year-37 years). Diagnoses were pulmonary atresia with intact ventricular septum (4), Ebstein's anomaly (3), tetralogy of Fallot (3), atrioventricular canal (1), hypoplastic right ventricle (1), and pulmonary and tricuspid insufficiency (1). Four patients (17.3%) in group A died in the postoperative period, whereas there was no postoperative mortality in group B. Follow-up data were available in 31 patients (19 from group A, 13 from group B). Mean follow-up was 1 year and 6 months (range 30 days to 6 years). Evaluation was done by NYHA class functional status. In group A, 14 patients are doing well (NYHA I or II), while five patients (26.3%) underwent Fontan operation with one death. All group B patients are currently doing well (NYHA class I or II). In group A, complications were pericardial effusion (7), transient superior vena cava syndrome (5), pleural effusion (4), chylothorax (1) and rhythm disturbance (1). Complications in group B involved neurological events (2), pleural effusion (1) and rhythm disturbance (1). Bidirectional cavo-pulmonary anastomosis can be associated with additional pulmonary flow with good short- and intermediate-term outcome. Concern remains for the ability to properly regulate the amount of effective pulmonary blood flow. Bidirectional cavo-pulmonary anastomosis can be associated with biventricular repair in patients with diminutive right ventricles, amenable to anatomic complete correction, with good clinical outcome.     

Primary bidirectional superior cavopulmonary shunt in infants between 1 and 4 months of age

The performance of a primary bidirectional superior cavopulmonary shunt procedure in early infancy is attractive because it minimizes the number of operations needed before a Fontan procedure, avoids ventricular volume overload and its sequelae, and eliminates pulmonary artery distortion. However, concerns over elevated or labile pulmonary vascular resistance have limited its use in the first few months of life. Nine patients aged 1 to 4 months (5 patients, < 2 months) have undergone a primary bidirectional superior cavopulmonary shunt procedure between October 1992 and March 1994. Primary diagnoses were tricuspid atresia (n = 4), asplenia syndrome (n = 2), polysplenia syndrome (n = 1), double-outlet right ventricle (n = 1), and double-inlet left ventricle (n = 1). Associated lesions of immediate surgical importance were total anomalous pulmonary veins (n = 2), a restrictive atrial septum (n = 4), bilateral superior venae cavae (n = 5), and patent ductus arteriosus (n = 5). The surgical procedure consisted of unilateral (n = 4) or bilateral (n = 5) bidirectional superior cavopulmonary shunt and the repair of associated lesions. Of significance, in 4 of our first 5 patients a very limited additional source of pulmonary blood flow was provided because of a low arterial oxygen tension immediately after cardiopulmonary bypass. Pleural effusions developed in 2 of these 4 patients. In subsequent patients cardiopulmonary bypass was not used whenever possible or, if it was needed, use of an extra source of pulmonary blood flow was avoided.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bidirectional cavopulmonary shunt in patients with anomalies of systemic and pulmonary venous drainage

BACKGROUND: Bidirectional cavopulmonary shunt and Fontan repair are now commonly performed in patients with a variety of forms of complex single ventricle, including those with anomalies of systemic or pulmonary venous return. These anomalies are ideally dealt with during bidirectional cavopulmonary shunt, thereby minimizing the complexity of the eventual Fontan procedure. METHODS: Between March 1990 and December 1995, 36 patients with anomalous systemic or pulmonary venous drainage underwent bidirectional cavopulmonary shunt. A combination of anomalous systemic and pulmonary venous drainage was present in 12 patients, whereas 19 patients had anomalous drainage only from the systemic circulation and 5 patients had isolated anomalies of pulmonary venous return. Visceral heterotaxy syndrome was diagnosed in 18 patients. The median age at operation was 11 months, and bidirectional cavopulmonary shunt was the first surgical procedure performed in 10 of these patients. Techniques of repair are described. RESULTS: There were two early deaths and one bidirectional cavopulmonary shunt was taken down, for mortality and failure rates not significantly different than those for all patients undergoing bidirectional cavopulmonary shunt during this time period (n = 117). At a mean follow-up of 19.9 months, there have been three late deaths and 11 patients have undergone Fontan completion. Actuarial survival was 87% at 1 year and 81% at 3 years. Among all patients undergoing bidirectional cavopulmonary shunt during this time period, neither heterotaxy syndrome nor anomalies of systemic or pulmonary venous return were significantly associated with decreased survival or poor outcome. CONCLUSIONS: Bidirectional cavopulmonary shunt can be performed in patients with anomalous systemic or pulmonary venous drainage, including those with visceral heterotaxy syndrome, with morbidity and mortality rates that do not differ significantly from those achieved in all patients undergoing bidirectional cavopulmonary shunt. In this report, we describe our experience with this group of patients, primarily focusing on outcomes and technical issues that pertain to the use of bidirectional cavopulmonary shunt as a preparatory procedure for the extracardiac conduit Fontan operation.     

Longitudinal predictors of word reading development.

The authors review the scientific evidence regarding the prediction of reading development from six cognitive constructs: phonological awareness, phonological decoding, naming speed, orthographic processing, morphological awareness, and vocabulary. The authors describe the theoretical connexions amongst these indicators and word reading. The authors conclude that there is substantial evidence of each contributing to reading, and in most cases, this contribution is above and beyond that of the other predictor constructs. These findings have implications for early and regular cognitive assessment, and for curriculum development and teacher education. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Stenosis and thrombosis of the central venous tract as a cause of manifestations of venous hypertension after establishment of an arteriovenous anastomosis for hemodialysis

The authors draw attention to stenoses and occlusions of the central venous tract (subclavicular and brachiocephalic vein) which may be the cause of manifestations of venous hypertension on the upper extremity after establishment of an arteriovenous anastomosis for haemodialysis. In patients where this condition is suspected, careful preoperative examination of the venous circulation is essential. Possible treatment is discussed.     

Comparison of patterns of pulmonary venous blood flow in the functional single ventricle heart after operative aortopulmonary shunt versus superior cavopulmonary shunt

In this study we investigated the patterns of pulmonary venous flow in children with functional single ventricles to obtain a better understanding of the determinants of transpulmonary blood flow. Sixty-eight patients with functional single ventricles and aortopulmonary shunt (n = 34, group I), or superior cavopulmonary connection (n = 34, group II) underwent transesophageal Doppler echocardiographic assessment of flow in the left upper pulmonary vein before undergoing the next stage of surgery. Twelve patients from group II also underwent simultaneous evaluation of superior vena caval flow. Biphasic forward pulmonary venous flow was noted in 62 patients in sinus rhythm (S wave in systole, D wave in diastole); in 6 patients with junctional rhythm, significant early systolic reversal of flow was present. Both the S- and D-wave velocity-time integrals (VTI) were greater in group I than in group II (S(VTI) 9.9 +/- 4.2 vs 8.0 +/- 2.6, p = 0.02; D(VTI) 8.0 +/- 3.5 vs 4.2 +/- 2.6, p <0.001). In both groups, pulmonary venous flow was predominantly systolic; however, the proportion of flow during ventricular systole was significantly greater in group II than in group I (S(VTI)/D(VTI) group II: 2.4 +/- 1.5; group I 1.4 +/- 0.5, p = 0.001; percent systolic fraction of pulmonary venous flow group II = 67%, group I = 56%, p <0.001). Analysis of superior vena caval flow in group II revealed a single predominant wave with onset at early systole and peak in late systole at a mean of 150 ms after the pulmonary venous S-wave peak. Our data suggest that ventricular systole (i.e., atrial relaxation, atrioventricular valve descent) asserts great influence on transpulmonary blood flow in the functional single ventricle.     

An institutional experience with second- and third-stage palliative procedures for hypoplastic left heart syndrome: the impact of the bidirectional cavopulmonary shunt

Using pulsed-field gel electrophoresis(PFGE) with XbaI digestion, we analyzed 1,794 enterohemorrhagic Escherichia coli(EHEC) O157 isolates, which were derived from 16 outbreaks, sporadic cases, foods, beef fecal swabs, and environments in 1996 in Japan. They were classified into six types according to observed PFGE patterns. EHEC O157:H7 isolates from seven out of the 16 outbreaks showed very closely related patterns and those from other five outbreaks did the same pattern; in the former outbreaks, no common source could be identified, while in the latter outbreaks, radish sprout is thought to be the common cause of the infection. PFGE patterns of the remaining four outbreaks were not correlated to each other.     

Prevalence and predictors of the prone sleep position among inner-city infants

Total and lifestyle-related medical care costs for employees of a major corporation participating in a worksite health promotion (WHP) program over a three-year period were compared with the costs for non-participants in a cross-sectional study. The study population consisted of 8,334 active employees based in the Cincinnati headquarters of The Procter & Gamble Company. Adjusting for age and gender, participants (n = 3,993) had significantly lower health care costs (29% lower total and 36% lower lifestyle-related costs) when compared with non-participants (n = 4,341) in the third year of the program. Similarly, in the third year of the program, participants had significantly lower inpatient costs, fewer hospital admissions, and fewer hospital days of care when compared with non-participants. No significant differences in costs were found between participants and non-participants during the first two years of the WHP program. Conclusions drawn from this study are that long-term participation in a WHP that includes high-risk screening and intensive one-on-one counseling results in lower total and lifestyle-related health care costs, as well as lower utilization of hospital services.     

Studies of postnatal diabetes mellitus in women who had gestational diabetes. Part 2. Prevalence and predictors of diabetes mellitus after delivery

Diclofenac antiserum was previously developed and used to detect protein adducts of metabolites of dichlofenac in livers of mice and rats. In this study, the antibody has been used to facilitate the purification of a major 51 kDa microsomal adduct of diclofenac from the liver microsomes of male rats that were treated with diclofenac. The adduct was identified as male-specific cytochrome P4502C11 based on its N-terminal amino acid sequence, reaction with a cytochrome P4502C11 antibody, and by its absence from liver microsomes of diclofenac-treated female rats. When diclofenac was incubated with liver microsomes of control rats in the presence of NADPH, only the 51 kDa adduct was produced. The formation of the adduct was inhibited by a cytochrome P4502C11 monoclonal antibody, but not by reduced glutathione or N-alpha-acetyl-L-lysine. No adduct was detected when diclofenac was incubated with liver microsomes from female rats. Moreover, adduct formation in vivo appeared to lead to a 72% decrease in the activity of cytochrome P4502C11. The results indicate that cytochrome P4502C11 metabolizes diclofenac into a highly reactive product that covalently binds to this enzyme before it can diffuse away and react with other proteins.     

Angiographic predictors of graft patency and disease progression after coronary artery bypass grafting with arterial and venous grafts

BACKGROUND: There are few data about angiographic determinants of functional graft patency and native artery disease progression after coronary artery bypass grafting operation with arterial grafts compared with venous grafts. METHODS: Baseline and follow-up coronary angiograms at a mean of 2 years after operation in 91 patients with 194 arterial and 204 venous graft anastomoses were analyzed. RESULTS: Ninety-two percent of the arterial and 87% of the venous graft anastomoses were patent at follow-up angiography (p = 0.05, odds ratio = 2.63). Unlike that of arterial grafts, the patency rate of venous graft anastomoses correlated negatively with decreasing severity of the bypassed lesion. In contrast to venous grafts, in which angiographic graft function was basically dichotomous (fully patent or occluded), compromised flow of the arterial graft anastomoses was registered in 12%. Progression of the disease was more common in segments bypassed with venous grafts than with arterial grafts (p = 0.001, odds ratio = 2.03). CONCLUSIONS: Angiographic determinants of functional graft patency and progression of occlusive changes in the bypassed artery segments are different for arterial and venous grafts.     

Prevalence and predictors of posttraumatic stress in women undergoing an ovarian cancer investigation.

This study assessed posttraumatic stress disorder (PTSD) in women being investigated for an ovarian cancer diagnosis to determine prevalence and factors predicting PTSD in these patients. Participants (N = 75) were recruited from the Princess Margaret Hospital in Toronto, Ontario, after their initial clinic appointment and given a prediagnostic assessment that included measures of PTSD, depression, stress and pain. One month later, patients received an identical postdiagnostic assessment. No cases of clinical PTSD were detected, although 13.6% of participants were identified with subsyndromal PTSD. Multiple regression analyses showed that those participants reporting significant baseline depressive symptoms, definitively diagnosed with ovarian cancer, and with shorter treatment wait times were more likely to have a significant increase in PTSD symptoms. Supportive interventions aimed at reducing PTSD symptoms, launched prior to an ovarian cancer diagnosis, might optimally be directed at patients with baseline depressive symptoms and those with shorter treatment wait times. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in pulmonary artery size before and after total cavopulmonary connection

The aim of any abdominal wall reconstruction is maximal functional stability and adequate soft tissue coverage. The anatomy, elevation and clinical application of the myofascial tensor fasciae latae transposition flap and of the microvascular musculocutaneous latissimus dorsi free flap are presented. Repairing extensive fascial defects and recurrent hernias with the tensor fasciae latae transposition flap provides strong, dynamic, and functional reconstruction of fascial continuity to prevent a further recurrence. Adequate functional and aesthetic repair of a full-thickness abdominal wall defect can be optimally managed by the innervated microsurgical latissimus dorsi free flap.     

Naming speed and phonological awareness as predictors of reading development.

This article investigates how well kindergarten phonological awareness (PA) and naming speed (NS) account for reading development to Grade 5. The authors use regression analyses to predict reading development, with mental ability and prior achievement controlled, and follow the reading development of children having combinations of adequate or inadequate PA and NS. PA was most strongly related to reading in the first 2 years of school, and NS's initially weaker relationship increased with grade level. Children with weak PA and slow NS were most likely to develop reading difficulties by Grade 5, followed by children with slow NS alone. The authors discuss the roles of NS and PA in reading development and the need to clarify the constructs underlying NS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence, course, and predictors of multiple problem behaviors among gay and bisexual male adolescents.

Multiple problem behaviors, stress, and personal resources were assessed over 2 yrs among 136 mainly Black and Hispanic gay and bisexual male adolescents (aged 14–19 yrs). Whereas sexual risk acts, substance abuse, conduct problems, and emotional distress were common, the risk acts did not form a multiple problem behavior cluster, compared with previous findings with heterosexual youths. Problem behaviors were stable over time: Only 20–30% of the youths changed their pattern of problem behaviors over 2 yrs. For each individual, the pattern of change in one behavior problem was not related to patterns of change in other problem behaviors over 2 yrs. At baseline, personal resources were associated with less alcohol use and emotional distress, and stress was associated with delinquent behaviors. The pattern of results was similar whether youths labeled themselves as gay or bisexual, suggesting that problem behaviors among mainly Black and Hispanic gay and bisexual youths may follow different developmental pathways than among heterosexual youths. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment and autonomy as predictors of the development of social skills and delinquency during midadolescence.

This study examined adolescent attachment organization as a predictor of the development of social skills and delinquent behavior during midadolescence. Delinquent activity and skill levels were assessed for 117 moderately at-risk adolescents at ages 16 and 18, and maternal and adolescent attachment organization and autonomy in interactions were assessed at age 16. Adolescent attachment security predicted relative increases in social skills from age 16 to 18, whereas an insecure-preoccupied attachment organization predicted increasing delinquency during this period. In addition, preoccupied teens interacting with highly autonomous mothers showed greater relative decreases in skill levels and increases in delinquent activity over time, suggesting a heightened risk for deviance among preoccupied teens who may be threatened by growing autonomy in adolescent-parent interactions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Systemic and luminal influences on the perinatal development of the gut

At birth, the mammalian gastrointestinal tract (GIT) must be able to support a shift from mainly parenteral nutrition in the fetus (via the placenta) to enteral nutrition in the neonate. In the perinatal period the GIT therefore undergoes enhanced growth as well as morphological and functional differentiation, and this maturational programme is influenced by a complex interplay of local, systemic and luminal factors. This review shows how systemic and luminal factors may influence GIT development in the perinatal period of the pig and sheep, two long-gestation species. Adrenocortical hormones play a pivotal role in the prepartum maturation of the GIT in addition to their better known effects on the development of many other tissues and body systems. More particularly, in the fetal pig and sheep, the prenatal development of gastric acid and gastrin secretion, and of GIT hydrolase activities (chymosin, pepsin, amylase, lactase, aminopeptidases) is influenced by cortisol. Additionally, glucocorticoids exert effects throughout the GIT by influencing morphological, cytological, and functional differentiation. Since the GIT epithelial cells comprise a renewing cell population there are also changes in cell kinetics. In addition to systemic factors, the presence of growth factors, hormones and nutrients from swallowed amniotic fluid (fetus) and colostrum (neonate) may influence GIT development. In utero, fetal fluid ingestion has been shown to modulate tissue growth, macromolecule and immunoglobulin transport, enterocyte differentiation, cell turnover and activity of brush-border hydrolases. These effects may be mediated via regulatory peptides (e.g. insulin-like growth factor I, gastrin-releasing peptides, insulin, epidermal growth factor, gastrin). A physiological role of luminally derived growth factors is supported by a number of unique structural and functional adaptations of the GIT in the fetus and neonate (low luminal proteolysis, intestinal macromolecule transport). Thus, in the pig and sheep, both systemic and luminal factors appear to play critical roles in GIT development in the perinatal period.     

Prevalence and predictors of sexual dysfunction in long-term survivors of marrow transplantation

PURPOSE: To describe the prevalence of sexual difficulties in men and women after marrow transplantation (MT), and to define medical, demographic, sexual, and psychologic predictors of sexual dysfunction 3 years after MT. PATIENTS AND METHODS: Four hundred seven adult MT patients were assessed pretransplantation. Survivors repeated measures of psychologic and sexual functioning at 1 and 3 years posttransplantation. RESULTS: Data were analyzed from 102 event-free 3-year survivors who defined themselves as sexually active. Men and women did not differ in sexual satisfaction pretransplantation. At 1 and 3 years posttransplantation, women reported significantly more sexual dysfunction than men. Eighty percent of women and 29% of men reported at least one sexual problem by 3 years after MT. No pretransplantation variables were significant predictors of 3-year sexual satisfaction for women. For men, pretransplantation variables of older age, poorer psychologic function, not being married, and lower sexual satisfaction predicted sexual dissatisfaction at 3 years (R2=.28; P < .001). Women who were more dissatisfied 3 years after MT did not receive hormone replacement therapy (HRT) at 1 -year posttransplantation and were less satisfied at 1 year, but not pretransplantation (R2=.35; P < .001). CONCLUSION: Sexual problems are significant in the lives of MT survivors, particularly for women. Although HRT before 1 year posttransplantation improves sexual function, it does not ensure sexual quality of life. Intervention for women is needed to apply hormonal, mechanical, and behavioral methods to prevent sexual difficulties as early after transplantation as possible.     

Systemic collateral and pulmonary artery stenosis in patients with congenital pulmonary valve atresia and ventricular septal defect

Angiograms of 30 patients with congenital pulmonary valve atresia, ventricular septal defect, and large systemic-pulmonary collateral arteries (SPCAs) were evaluated. All had aortography, 28 had SPCA arteriography, and 26 had right ventriculography. Seventeen (65%) of 26 patients had a right ventricular infundibulum, 23 (77%) had a pulmonary artery confluence, and five of the nine patients without a right ventricular infundibulum had a confluence. Sixty-six SPCAs of aortic origin were seen; 28 (42%) had narrowing and 21 patients (70%) had one or more narrowed SPCAs. Five patients had collaterals from internal mammary, subclavian or innominate arteries. Fourteen (47%) had hilar pulmonary artery stenosis. Of these 14 patients mild peripheral stenosis was demonstrated in five. Right aortic arch was present in 15 patients (50%). Complete angiographic delineation of pulmonary vasculature is an essential procedure for preoperative detection of pulmonary and SPCA stenoses in these patients.     

Acute changes in preload, afterload, and systolic function after superior cavopulmonary connection

BACKGROUND: Superior cavopulmonary connection reduces the volume work of the single ventricle. METHODS: To determine the effects of superior cavopulmonary connection on preload, wall stress (or afterload), and systolic ventricular function, we studied 9 patients before and after operation, and at hospital discharge. Using echocardiography, preload was estimated by the ventricular end-diastolic area, and wall stress was calculated at end-systole and peak-systole. Ventricular function was represented by rate-corrected velocity of circumferential fiber shortening and fractional area change divided by rate-corrected ejection time. RESULTS: End-diastolic area and wall stress decreased postoperatively. Ventricular wall thickness increased with a concomitant decrease in cavity area. There was no change in mean blood pressure or heart rate or in rate-corrected velocity of circumferential fiber shortening or fractional area change divided by rate-corrected ejection time. These findings persisted at hospital discharge. CONCLUSIONS: In single ventricles, superior cavopulmonary correction results in an immediate decrease in preload and afterload. The decrease in afterload results primarily from alterations in ventricular geometry. Although no improvement in systolic function was noted, diminished work related to the reduction in loading conditions may have beneficial long-term effects on preserving myocardial performance.