Effectiveness of the Rashkind procedure in transposition of the great arteries in infants

The immediate and long-term efficacy of the balloon atrial septostomy (BAS) was appraised in a series of 43 patients with transposition of the great arteries. Early effectiveness was gauged by changes in oxygen saturation and atrial pressures, and by balloon catheter measurement of the interatrial opening immediately following BAS. BAS was initially effective in 31 cases. In 20 patients the size of the interatrial opening was measured by balloon catheter from three months to three years after initially successful BAS. In 13 of these the opening was less than 12 mm; 7 subsequently required surgical septectomy, and each of the remaining 6 had a ventricular septal defect. In the other 7, the opening was greater than 12 mm; none have required surgical septectomy. A total of 13 patients required late septectomy, with only one death. In contrast, there was a 40% (17/44) surgical mortality with surgical septectomy in a similar group of patients between 1959 and 1966. It is concluded that balloon atrial septostomy is initially effective and relatively safe, but that, particularly in those with intact ventricular septum, surgical septectomy is often required. Balloon catheter measurement of the interatrial opening has been helpful in predicting the necessity for surgical septectomy.

Metabolic homeostasis in juvenile diabetes mellitus. II. Increased ketone responsiveness to epinephrine

A series of epinephrine infusions were performed to study the possible role of catecholamines in the observed metabolic lability of juvenile diabetics. The data obtained in twenty insulin dependent juvenile diabetics were compared with the results obtained in eleven normal children.

Glucose and free fatty acid concentrations rose sharply in the diabetic group at the start of the epinephrine infusion, despite initial concentrations that were markedly elevated. The most striking difference between the diabetic children and the normal group, however, was seen in the blood ketone response. There appeared to be an increased ketone responsiveness to epinephrine stimulation in the diabetic child documented by the rate and magnitude of the ketone elevation, and by the absence of any lag period between the start of the epinephrine infusion and the rise of the blood ketone concentration.

Increased ketone responsiveness to epinephrine would appear to be an important characteristic of the juvenile diabetic. The ketone rise can be blocked by acute beta adrenergic blockade, indicating the dependence of the ketone rise on free fatty acid mobilization. The possible importance of hepatic triglycerides in diabetic ketosis is discussed.