Exercise assessment of cardiac function in children and young adults before and after bone marrow transplantation

Cardiac toxicity is a potential complication of bone marrow transplantation because recipients frequently receive cardiotoxic chemotherapy and/or irradiation before transplantation. Most studies indicate that transient cardiac toxicity occurs within weeks of transplantation, but few studies have evaluated either cardiac status before or late after transplantation. Cardiac performance was assessed via cycle ergometry in 20 children and young adults before transplantation and 31 other children and young adults after transplantation. Mean survival time in the group post-transplantation was 3.9 years with a range of 11 months to 12.1 years. Left ventricular size and shortening fraction at rest were assessed via echocardiography. Data were compared to those of 70 healthy subjects from our laboratory. Patients before and after transplantation had normal oxygen consumptions and cardiac indices at rest. During exercise, however, patients treated for cancer both before and after bone marrow transplantation had reduced exercise times, reduced maximal oxygen consumptions, and reduced ventilatory anaerobic thresholds. Cardiac reserve, as judged by the response of the cardiac output during exercise, was reduced severely. There were no significant differences between the groups tested before and after transplantation. Patients who had been treated for aplastic anemia, who had received less intensive therapy before transplantation, performed significantly better than did patients treated for cancer. Despite these findings, only four patients had abnormalities by echocardiography. In conclusion, before transplantation patients with oncologic diagnoses had serious limitations in exercise performance, most likely as a result of the effects of the cardiotoxic therapy given as part of their conventional cancer therapy. Long-term survivors of bone marrow transplantation also had similar abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoplastic left heart syndrome: hemodynamic and angiographic assessment after initial reconstructive surgery and relevance to modified Fontan procedure

After undergoing initial reconstructive surgery for hypoplastic left heart syndrome performed between August 1985 and March 1989, 59 patients (age range 3 to 27 months, mean 13.8 +/- 4.5) underwent elective cardiac catheterization in anticipation of a modified Fontan procedure. Five important hemodynamic and anatomic features considered to be components of successful reconstructive surgery were specifically addressed. 1) Interatrial communication: Only two patients had a measured pressure difference of greater than 4 mm Hg across the atrial septum. 2) Tricuspid valve function: Angiography demonstrated significant tricuspid valve regurgitation in only five patients (moderate in two and severe in three). 3) Aortic arch: Pressure tracings from the right ventricle to the descending aorta revealed a gradient greater than 25 mm Hg in only two patients. 4) Pulmonary vasculature: Ten patients had a calculated pulmonary vascular resistance greater than 4 U.m2; 51 (86%) of the 59 patients had no evidence of distortion (stenosis or hypoplasia) of either the left or the right pulmonary artery. 5) Right ventricular function: Five patients had an end-diastolic pressure in the right ventricle greater than 12 mm Hg and two patients had qualitative assessment of decreased ventricular function. Comparison of catheterization data between survivors and nonsurvivors of the subsequent modified Fontan procedure showed that only significant tricuspid regurgitation is a possible predictor of poor outcome. After first stage reconstructive surgery for hypoplastic left heart syndrome, most survivors have favorable anatomy and hemodynamics at follow-up cardiac catheterization for a subsequent Fontan procedure.

Pediatric exercise testing

The number of diagnostic modalities available to the pediatric cardiologist continues to escalate. However, with so many choices, it is often difficult to know what test is most efficacious in a given situation or how often to repeat it. This review summarizes the data from several exercise studies published within the past year. These studies address exercise as a diagnostic modality in children and adults with and without heart disease and compare exercise testing with other diagnostic modalities. They demonstrate some of the variables that should be routinely assessed during an exercise test, and they introduce many avenues for continued research.

Hypoplastic left heart syndrome. Outcome after initial reconstruction and before modified Fontan procedure

The outcome and clinical course before modified Fontan procedure were reviewed for 200 patients with hypoplastic left heart syndrome who underwent initial reconstructive surgery between August 1985 and March 1989. The median age at the time of initial reconstruction was 6 days (range, 1 day to 7.2 months). In 28 patients, a right modified Blalock-Taussig shunt was used; in 172 patients, a central shunt was placed. Additional procedures (n = 41) performed in 38 patients (median age, 5 months; range, 6 days to 17.5 months) were revision of systemic-to-pulmonary shunt (n = 15), arch reconstruction (n = 8), balloon angioplasty of arch obstruction (n = 7), atrial septectomy (n = 4), pulmonary artery angioplasty (n = 2), tricuspid valve annuloplasty or replacement (n = 4), and modified Glenn shunt (n = 1). There was no significant difference in the frequency of additional procedures performed more than 30 postoperative days in the survivors compared with the nonsurvivors. Actuarial survival rates were 0.66 (1 month), 0.48 (12 months), and 0.44 (18 months). Seventy percent of all deaths occurred during the initial admission, with 32% resulting from acute cardiovascular collapse during the first postoperative day. There was no statistical difference in actuarial survival when assessed by the type of shunt used or by anatomical subtype or when the influence of additional interventions was considered. Substantial improvement in outcome may be possible if immediate perioperative mortality can be reduced. We speculate that some of the intermediate mortality (30 days to 1 year) may be related to the effects of chronic exposure of the right ventricle to volume overload at systemic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective detection by Doppler color flow imaging of additional defects in infants with a large ventricular septal defect

The use of Doppler color flow imaging and axial contrast angiography in the preoperative detection of additional ventricular septal defects (in the setting of a known large defect) were compared in a prospective fashion. One hundred seventy-nine infants with two ventricles (each of at least normal size) and a large, nonrestrictive ventricular septal defect underwent reparative surgery before 2 years of age. The reference standard for the presence of additional defects was intraoperative verification or (in cases in which the surgeon did not visualize any additional defect) subsequent identification at postoperative angiography, postoperative color Doppler examination or reoperation. Only six patients (3%) had additional ventricular septal defects confirmed at the time of repair; an additional five (3%) had defects found only postoperatively. The negative predictive value of Doppler color flow imaging and angiography was 0.95 (168 of 176) and 0.97 (168 of 174), respectively. The sensitivity was 0.27 (3 of 11) and 0.45 (5 of 11), respectively. For certain malformations with a very low prevalence of additional muscular defects (such as perimembranous ventricular septal defect with normally aligned great arteries), a clinical trial of reparative surgery without prior invasive study appears reasonable.

Inflammatory aneurysms of the abdominal aorta

The treatment of inflammatory aneurysms of the abdominal aorta presents a formidable challenge to the surgeon. The retroperitoneal inflammatory reaction obliterates normal tissue planes, limiting access to the infrarenal aorta. During a 70-month period 25 (6%) of 439 patients operated on for abdominal aortic aneurysms were found to have the inflammatory type. These patients were more likely to be symptomatic than patients with noninflammatory aneurysms and they were more likely to be male. Although surgical repair of the aneurysms required longer aortic occlusion time and more blood replacement, the outcome was similar to that for patients treated for noninflammatory aneurysms.

Subcostal two-dimensional echocardiographic identification of anomalous attachment of septum primum in patients with left atrioventricular valve underdevelopment

Five variations of atrial septal morphology occur in hypoplastic left heart syndrome. One variety, termed anomalous attachment of septum primum, has been described only in necropsy series. Two-dimensional echocardiography was utilized to determine the incidence of this anomaly in patients with left atrioventricular (AV) valve underdevelopment, including those with other ventriculoarterial alignments, such as transposition of the great arteries. Forty-eight (37%) of 129 patients with normally aligned great arteries (and two ventricles) had anomalous attachment of septum primum. Ten (34%) of 29 patients with double outlet right ventricle and left AV valve underdevelopment had this anomaly. Four (50%) of eight patients with single ventricle exhibited this atrial septal variant. The most reliable view to identify anomalous attachment was the subcostal left oblique-equivalent cut. Recognition of atrial septal morphology has implications for preoperative and intraoperative management of patients with left AV valve underdevelopment. The similar prevalence of this atrial septal variant in patients with normally aligned great arteries, double outlet right ventricle and transposed great arteries suggests that there may be a common mechanism for left AV valve underdevelopment that is independent of the development of the arterial portion of the heart.

Pulmonary artery configuration after palliative operations for hypoplastic left heart syndrome

Pulmonary artery architecture and symmetry after palliative operations for hypoplastic left heart syndrome may affect subsequent suitability for a modified Fontan operation. Two-dimensional echocardiography was used to measure pulmonary artery diameter and assess symmetry after two types of systemic-pulmonary artery shunts: modified right Blalock-Taussig shunt (14 patients) and central shunt (from underside of aortic arch gusset to pulmonary artery confluence) (14 patients). Age, weight, preoperative diameter of right and left pulmonary arteries (proximal, middle, and distal segments), and mean interval between preoperative and postoperative echocardiographic studies (20.2 +/- 4.4 days in the Blalock shunt group; 19.1 +/- 6.8 days in the central shunt group) were similar. Early postoperatively, patients with a Blalock shunt showed a significant decrease in the diameter of all pulmonary artery segments except the distal right pulmonary artery. The diameters tapered from distal right to distal left pulmonary artery in this group. Patients with the central shunt had a significant decrease in the diameter of all pulmonary artery segments. There were no significant differences when cross comparisons were made of the various pulmonary arterial segments in patients after a central shunt. Similar findings persisted in 19 patients from both groups who had a late postoperative echocardiogram (mean interval between studies = 271 days in the group of 10 patients with Blalock shunt and 167 days in the group of nine patients with a central shunt). In conclusion, the central shunt preserves pulmonary artery symmetry, which may be important in candidates for the Fontan operation in infancy.

Two-dimensional and Doppler echocardiographic assessment of neonatal arterial repair for transposition of the great arteries

The arterial switch procedure has become an accepted reparative technique for transposition of the great arteries with or without ventricular septal defect. In this study the accuracy of prospective noninvasive imaging in detecting arterial tract obstruction and the prevalence and severity of arterial valvular regurgitation (as assessed by Doppler ultrasound) were evaluated in survivors of arterial repair. All 53 study patients underwent two-dimensional echocardiographic examination 2 days to 20 months (median 7 months) postoperatively; 43 patients also had pulsed and continuous wave Doppler studies. The accuracy of the noninvasive evaluation of arterial tract obstruction was determined by comparison of Doppler maximal instantaneous gradients with peak to peak gradients at nonsimultaneous catheterization in 26 patients. Twenty-one (81%) of the 26 patients underwent catheterization and successful pulsed and continuous wave Doppler examination of the right heart; 17 (81%) of these 21 had a maximal pressure gradient within 20 mm Hg of the peak to peak gradient obtained at catheterization. Echocardiographic identification of the stenotic site was correct in all eight of the patients in this group requiring reoperation. Twenty-three (88%) of the 26 patients who underwent catheterization had successful Doppler interrogation of the aortic tract; 22 (96%) of these 23 had a maximal instantaneous gradient within 20 mm Hg of the peak to peak catheterization gradient. Fourteen (32%) of 43 patients had mild or moderate pulmonary regurgitation by Doppler study. Three (7%) of the 43 had mild aortic regurgitation.

Hypoplastic left heart syndrome: lack of correlation between preoperative demographic and laboratory findings and survival following palliative surgery

To determine whether preoperative demographic and metabolic variables correlated with early or late survival following palliative surgery for hypoplastic left heart syndrome, we reviewed the charts of 89 patients operated upon from October 1984 to January 1987. The variables analyzed were age at operation, lowest preoperative pH and H2CO3, highest preoperative arterial oxygen saturation, the occurrence of a preoperative cardiorespiratory arrest, and location of birth relative to the surgical institution. The data were evaluated by chi-squared, multivariate, and life-table analyses to the end of the first postoperative year. None of the factors analyzed significantly correlated with either short-term (less than or equal to 30 days) or long-term (greater than 30 days) survival. Thus, neither demographic nor metabolic factors including prior cardiorespiratory arrest should be considered contraindications to surgical palliation for hypoplastic left heart syndrome.

The significance of tricuspid regurgitation in hypoplastic left-heart syndrome

Palliation of hypoplastic left-heart syndrome involves use of the morphologic right ventricle as the systemic ventricle and the tricuspid valve (in cases of mitral atresia/stenosis) or the common atrioventricular valve (in cases of malaligned atrioventricular canal) as the systemic atrioventricular valve. To determine the relationship between tricuspid or common atrioventricular valve function and the ultimate outcome of palliative surgery, 100 patients with hypoplastic left-heart syndrome were evaluated preoperatively by Doppler echocardiography to determine the degree of tricuspid regurgitation. These patients were then followed serially to assess changes with time in the functional status of the tricuspid or common atrioventricular valve and to determine the correlation of tricuspid or common atrioventricular valve regurgitation with survival. We discovered that tricuspid or common atrioventricular valve regurgitation is common in hypoplastic left-heart syndrome. Thirty-seven percent of the patients had mild, 13% had moderate, and 3% had severe tricuspid or common atrioventricular valve regurgitation on their preoperative Doppler echocardiograms. Throughout the first 2 postoperative years most patients had no significant change in the degree of tricuspid or common atrioventricular valve regurgitation when findings were compared to those of the preoperative echocardiogram. Patients with moderate or severe tricuspid or common atrioventricular valve regurgitation preoperatively had a significant reduction in their survival when contrasted with patients with no or mild atrioventricular valve regurgitation. We therefore conclude that tricuspid or common atrioventricular valve competence is a significant factor in long-term survival after palliative surgery for hypoplastic left-heart syndrome. This function, however, appears to be unaffected by palliation and remains relatively constant over the first 2 postoperative years.

Fate of the pulmonic valve after proximal pulmonary artery-to-ascending aorta anastomosis for aortic outflow obstruction

Transection of the main pulmonary artery and end-to-side anastomosis of the proximal pulmonary artery to the ascending aorta has been increasingly used in palliative surgery for cardiac malformations such as single ventricle with small outlet foramen (bulboventricular foramen) and hypoplastic left-heart syndrome. To evaluate pulmonary valve competence after this operation, we used color Doppler flow mapping to examine 45 survivors of pulmonary artery-to-ascending aorta anastomosis a median of 202 days postoperatively. Of 37 patients with hypoplastic left heart syndrome, mild regurgitation was detected in 9 (24%) and moderate regurgitation in 1 (3%). Of 8 with other lesions, mild regurgitation was observed in 2 and moderate regurgitation in 1. Seven of 11 patients imaged greater than or equal to 12 months postoperatively had regurgitation. In summary, one-fourth of survivors developed mild pulmonary regurgitation. Its presence should not be considered a contraindication to eventual application of Fontan's principle, although further follow-up appears warranted because the long-term fate of pulmonary valve function is not yet known.

Hemodynamic responses to isolated increments in heart rate by atrial pacing after a Fontan procedure

The physiologic role of the right ventricle has long been a subject of interest to physiologists. The Fontan operation provides a human model for studying the circulation in series devoid of a subpulmonic right ventricle. The hemodynamic response to isotonic exercise in this setting has been established, and differs appreciably from normal. However, the physiologic response to an increase in heart rate (atrial pacing) as an isolated variable has not been examined and compared to atrial pacing in hearts with two concordant subarterial ventricles. Accordingly, we compared the supine bicycle exercise response to rate-equivalent right atrial pacing in nine patients after atriopulmonary anastomoses (the Fontan operation) for single ventricle or tricuspid atresia. Cardiac index increased 77% with exercise (rest 2.6 L/min/m2; exercise 4.6 L/min/m2) but decreased 12% with atrial pacing (rest 2.5 L/min/m2; pacing 2.2 L/min/m2). Pulmonary arterial oxygen saturation declined significantly during exercise (rest 68%; exercise 31%) and during atrial pacing (control 72%; pacing 64%). The mean increment in pulmonary arterial pressure was 1.3 times greater with exercise (rest 14 mm Hg; exercise 20 mm Hg) than with pacing (control 12 mm Hg; pacing 16 mm Hg). Peak systemic arterial systolic pressure increased 14% with exercise but was unchanged by pacing. Systemic and pulmonary vascular resistances fell with exercise but changed insignificantly during atrial pacing. Stroke volume rose slightly with exercise but fell significantly with pacing.(ABSTRACT TRUNCATED AT 250 WORDS)

Palliative reconstructive surgery for hypoplastic left heart syndrome

From August, 1985, through August, 1987, 104 consecutive, nonselected neonates underwent palliation of hypoplastic left heart syndrome. The technique included pulmonary artery homograft augmentation of the diminutive ascending aorta and aortic arch, atrial septectomy, transection of the main pulmonary artery with patch closure of the distal main pulmonary artery, anastomosis of the proximal main pulmonary artery to the augmented ascending aorta, and a 4-mm, modified, right Blalock-Taussig (N = 21) or central (N = 83) shunt. There were 30 early and 11 late deaths. Early mortality was most commonly associated with hypoventilation. Complications included development of aortic arch obstruction (N = 11) and progressive hypoxemia (N = 11). Alterations in surgical techniques and perioperative management should permit continued improvement in early and long-term survival.

Positive and negative control observations for the in vivo/in vitro rat liver assay for unscheduled DNA synthesis (UDS)

Positive and negative control data are shown for greater than 50 experiments conducted using the in vivo/in vitro rat liver unscheduled DNA synthesis (UDS) assay. In this assay, animals are dosed with the test agent and the liver is subsequently assessed for UDS by autoradiography and grain counting. The combined corn-oil negative control gave a value of -2.54 +/- 1.4 net gains (NG +/- SD; n = 77) and the positive control agent 6-p-dimethylaminophenylazobenzothiazole (6BT, dosed in vivo, animals sampled at 12 h) gave a value of +28.3 +/- 16.0 NG (+/- SD; n = 51). These data are briefly discussed, as are the reasons why this laboratory employs an in vivo (as opposed to an in vitro) positive control in each experiment.

Subaortic obstruction in complex congenital heart disease: management by proximal pulmonary artery to ascending aorta end to side anastomosis

Six patients with univentricular heart and one patient with d-transposition of the great arteries had transection of the main pulmonary artery with an end to side anastomosis of the main pulmonary artery to the ascending aorta to relieve subaortic obstruction. Two operations were performed as a palliative procedure within the first 6 months of life and five were performed as part of a definitive repair (four modified Fontan procedures and one repair of transposition of the great arteries with ventricular septal defect). There was one surgical death (14%) occurring 1 day postoperatively from low cardiac output. The remaining six patients are doing well 1 to 19 months postoperatively (mean 11.4 months). The proximal pulmonary artery to ascending aorta end to side anastomosis is an effective means of bypassing subaortic obstruction associated with complex congenital heart disease.

Pulmonary atresia with ventricular septal defect: preoperative and postoperative responses to exercise

Between April 1982 and June 1984, maximal exercise testing was performed 35 times in 34 consecutive patients with pulmonary atresia and ventricular septal defect (14 studies in patients without repair, 11 studies in patients with partial repair [insertion of a right ventricle to pulmonary artery conduit without ventricular septal defect closure] and 10 studies in patients with complete repair [insertion of a conduit with septal defect closure]). Total work performed, maximal power achieved, exercise time and maximal oxygen uptake were significantly greater in patients after partial or complete repair than in patients without repair. Systemic arterial blood oxygen saturations at rest and during exercise were directly related to the degree of repair. Although heart rate at rest in the three study groups was similar to that in a separate group of normal control subjects, patients in all three study groups had a blunted heart rate response to exercise. The ventilatory equivalent for oxygen was increased both at rest and during exercise for patients without conduit repair and those with a right ventricle to pulmonary artery conduit without ventricular septal defect closure but was similar to that of control subjects in the group with conduit insertion and septal defect closure. This study indicates that patients with pulmonary atresia and ventricular septal defect have decreased exercise tolerance both before and after corrective surgery. Exercise tolerance improves significantly after placement of a conduit from the right ventricle to the pulmonary artery with or without ventricular septal defect closure. Although no further improvement in exercise tolerance occurs with closure of the septal defect, ventilatory function and systemic arterial blood oxygen saturation are improved.

Cardiorespiratory response to exercise in Ebstein's anomaly

Fourteen patients with unrepaired Ebstein's anomaly underwent maximal exercise testing between October 1982 and April 1984. Compared with control subjects, these patients had significantly lower values for total work performed, exercise time, maximal oxygen uptake, blood oxygen saturation at rest and during exercise, and heart rate and systolic blood pressure during maximal exercise. They had a significant increase in heart rate at rest. The ventilatory equivalent for oxygen was increased significantly both at rest and during exercise. Thus, patients with Ebstein's anomaly have decreased exercise tolerance owing to both cardiac and respiratory limitations.

Statistical prediction of cardiac risk in patients who undergo vascular surgery

Since August 1982, an extensive computerized data base has been developed on all patients admitted to the Division of Vascular Surgery at the Ottawa Civic Hospital. For each patient, 180 variables are recorded, including information about preoperative risk factors and postoperative complications. Since cardiac complications are a major cause of mortality and morbidity, the data file has been used to study postoperative cardiac complications in patients who undergo arterial reconstructive operations. Between August 1982 and December 1983, 353 artery repairs were performed, excluding ruptured aneurysms. Cardiac complications developed following surgery in 56 patients. Risk factors were initially studied using contingency table analysis. Four of these factors were found to be significant: electrocardiographic evidence of previous myocardial infarction (p = 0.0003), nonspecific ST-segment changes (p = 0.0007), New York Heart Association classification of symptoms (p = 0.0003) and age (p = 0.01). A further statistical study was based upon multiple logistic regression. The authors believe that the identification of a high-risk group, using these criteria, is helpful in selecting patients for intensive preoperative investigation, including coronary arteriography.

Surgical repair of univentricular heart (double inlet left ventricle) with obstructed anterior subaortic outlet chamber

The results of operation in all patients with univentricular heart and an obstructed anterior subaortic outlet chamber who were operated on utilizing extracorporeal circulation at the Mayo Clinic from 1973 through 1983 were reviewed. Ten of the 18 patients died during the immediate postoperative period and there was one late death. Factors significantly related to operative and immediate postoperative mortality were age at operation, cardiothoracic ratio on X-ray examination, degree of ST depression on electrocardiogram and pressure gradient across the outlet foramen at catheterization. Autopsy in eight cases revealed significant hypertrophy of ventricular myocardium and a small outlet foramen that was considered stenotic relative to either body surface area or aortic root area. The ventricular myocardium showed histologic changes of chronic ischemia that predated the surgical procedure.

The production and generalization of large-magnitude heart rate deceleration by contingently faded biofeedback

Eight subjects were taught to decrease their heart rates via biofeedback training. Four of these received contingently faded, beat-by-beat analogue feedback and contingent reinforcement each time their performance met a specified and adjusting criterion. The other four received continuous, beat-by-beat analogue feedback, but not the contingent reinforcement. Subjects in the two groups were yoked to ensure equal densities of reinforcement. Subjects in the first group were asked to decrease heart rates 15% from baseline and were then trained using only 75%, 50% and 25% of beat-by-beat feedback. It was hypothesized that the immediate reinforcement of appropriate behavior and the contingent fading (following mastery) of feedback would aid in the generalization of the response. Following completion of all criterion steps or 10 training sessions, whichever came first, all subjects were tested with no feedback and no contingent reinforcement. The group receiving contingently faded feedback training showed a significantly greater heart rate decrease in the training sessions and also the test session. These results were interpreted as indicating that biofeedback can be conceptualized as an operant conditioning paradigm, and that the use of operant techniques may help subjects produce clinically significant changes.