Results of heart-lung transplantation in children with cystic fibrosis

Children with cystic fibrosis represent the largest group referred for, and undergoing, heart-lung transplantation at our institute. Between June 1988 and July 1993, 76 patients were accepted for transplantation, of whom 25 were transplanted, while a further 36 died waiting. Those transplanted ranged from 5-18 years of age and included 13 males and 12 females. Organs were used from donors matched by ABO blood group, size and cytomegalovirus (CMV) status. Post-transplant maintenance immunosuppression comprised cyclosporin A, azathioprine and prednisolone. Anti-thymocyte globulin and high dose methylprednisolone were given peri-operatively and for acute rejection episodes. Actuarial survival was 67% at 1 year, 61% at 2 years and 54% at 3 years. Obliterative bronchiolitis (OB) has occurred in 13 patients (52%) and was the major cause of mortality and morbidity. In three patients, OB was associated with the development of tracheal anastomotic stenosis. Other complications included diabetes mellitus (n = 9), pancreatitis (n = 1) and hypertension (n = 8). Despite these problems, those surviving the first year post-transplant showed a mean FEV1 of 71% (compared to 29% pre-transplant) and enjoyed an overall improved quality of life.

Endothelium-dependent dilation in the systemic arteries of asymptomatic subjects relates to coronary risk factors and their interaction

OBJECTIVES

This study attempted to assess whether coronary risk factors are associated with endothelial dysfunction in the systemic arteries of asymptomatic men and women.

BACKGROUND

Endothelial dysfunction is present in adults with established atherosclerosis. It is not known whether risk factors interact to produce endothelial dysfunction in clinically well subjects early in the natural history.

METHODS

Using high resolution ultrasound, we measured arterial diameter at rest, after reactive hyperemia (with increased flow causing endothelium-dependent dilation) and after sublingual nitroglycerin (an endothelium-independent dilator). Arterial responses were studied noninvasively in 500 clinically well, nonhypertensive subjects (252 men, 248 women; mean [+/- SD] age 36 +/- 15 years, range 5 to 73), including 179 current and former smokers. The superficial femoral artery was studied in 46 subjects and the brachial artery in 454.

RESULTS

Flow-mediated dilation ranged from -1% to +17%. All arteries dilated in response to administration of nitroglycerin (17 +/- 6%), suggesting an abnormality of endothelial function in subjects with impaired flow-mediated dilation. On univariate analysis, reduced flow-mediated dilation was significantly related to hypercholesterolemia, cigarette smoking, higher blood pressure, male gender, older age, family history of premature vascular disease and larger vessel size (p < 0.01). By multiple stepwise regression analysis, reduced flow-mediated dilation was independently associated with cigarette smoking, older age, male gender and larger vessel size (p < 0.005) but not with total cholesterol level, blood pressure or family history. A composite risk factor score was independently related to flow-mediated dilation (r = -0.30, p < 0.0001), suggesting risk factor interaction.

CONCLUSIONS

Loss of endothelium-dependent dilation in the systemic arteries occurs in the preclinical phase of vascular disease and is associated with interaction of the same risk factors known to predispose to atherosclerosis and its complications in later life.

Thrombosis and embolism in long-term central venous access for parenteral nutrition

Although the use of silicone catheters for long-term central venous access is widespread, little is known about the incidence of pulmonary thromboembolic complications. We studied clinical events, lung perfusion scans, and echocardiographic screens in 34 children and adolescents with gut failure who had received cyclical parenteral nutrition for 2 months to 9 years. Major thrombosis and/or embolism was identified in 12 patients and 4 died as a consequence. Actuarial survival free from thrombosis was 53% at 5 years (95% Cl, 30-77%). Survival free from fatal pulmonary thromboembolic events was 74% at 5 years (48-99%). 3 patients required surgery to remove right atrial thrombus or pulmonary emboli. Major right atrial thrombosis and pulmonary embolism are common and potentially fatal complications of parenteral nutrition by long-term venous access in childhood. Anticoagulation is recommended.

Dilated cardiomyopathy in children: determinants of outcome

OBJECTIVE

To determine the outcome of dilated cardiomyopathy presenting in childhood and the features that might be useful for prognostic stratification.

SETTING

Supraregional paediatric cardiology unit.

DESIGN

Retrospective analysis.

BACKGROUND

The natural history of dilated cardiomyopathy in children is not well characterised. Previous studies have shown a variable relation between age at presentation and outcome, and sudden death has been infrequent.

METHODS

Retrospective study of 63 consecutive patients with idiopathic dilated cardiomyopathy presenting between 1979 and 1992. Survival curves were constructed by the Kaplan-Meier method.

RESULTS

Age at diagnosis ranged from 1 day to 15 years (median 12 months) and follow up ranged from 1 day to 13 years (median 19 months). Actuarial survival from presentation was 79% at one year (95% confidence interval (95% CI) 66%-88%) and 61% (44%-74%) at five years. Univariate analysis showed that mural thrombus, left ventricular end diastolic pressure > 20 mm Hg, and age at presentation > 2 years were predictors of adverse outcome, but on multivariate analysis only age at presentation was significant. Left ventricular echocardiographic indices either did not improve or deteriorated in 36 children (17 of whom died, four suddenly, and three were transplanted), partially improved in 16 (three of whom died, all suddenly), and returned to normal in 11 (all of whom have survived).

CONCLUSIONS

Older age at presentation and lack of improvement in systolic function are associated with an adverse outcome, and early transplantation should be considered in these patients. There is a persistent risk of late sudden death in those children in whom echocardiographic dimensions remain abnormal.

Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations

A pediatric cardiac surgeon performed 104 neonatal arterial switch operations for transposition of the great arteries with or without ventricular septal defect between June 1987 and February 1993. Initial euphoria on having only one death in the first 52 patients gave way to increasing concern when patients 53, 55, 59, 63, 64, 67, and 68 died. Sensing a problem, the surgeon visited a low-risk institution after patients 55 and 64 had died and then decided to re-train after patient 68 died. One death has occurred since. To find out whether the cluster of failures could have been related to chance alone, to variability of risk factors across time, or to suboptimal performance, we conducted the following analyses: First, identification of trends with the cumulative sum procedure was undertaken and actual mortality compared with the mortality predicted from an equation derived from a multi-institutional study. Second, logistic regression analysis of risk factors was done. If a mechanism of continuous monitoring had been in place, unfavorable trends and a need for change in protocol would have been detected earlier. Retrospective risk factor analysis suggested an excessive risk for patients with origin of the circumflex or left anterior descending coronary arteries from sinus 2 and a protective effect of phenoxybenzamine. However, about half of the risk associated with the cluster of failures was not accounted for by the variables analyzed. There was therefore an indication of suboptimal performance that appears to have been neutralized by retraining.

Outcome measures for the neonatal management of pulmonary atresia with intact ventricular septum

The outcome in 135 patients with pulmonary atresia with intact ventricular septum was reviewed in terms of actuarial survival and "suitability" for eventual definitive repair (defined as having a tricuspid valve diameter larger than 2.4 standard deviations below the mean normal beyond the neonatal period). Of patients who underwent an initial closed valvotomy, 50% were dead, 22% were alive and suitable, and the remaining 28% were alive but unsuitable for definitive repair at 5 years. None of 66 patients who underwent primary shunt alone achieved suitability and 52% were dead at 5 years. No mode of neonatal closed valvotomy was consistently satisfactory: in only 10 of 26 survivors with serial measurements did the neonatal valvotomy alone achieve decompression to subsystemic pressures. Only half of the decompressed ventricles achieved growth of the tricuspid valve disproportionate to somatic growth as a result of the neonatal procedure. Strategies for the neonatal treatment of pulmonary atresia with intact ventricular septum should not rely on closed operations on the pulmonary valve to optimized right ventricular growth.

Ebstein's anomaly: presentation and outcome from fetus to adult

OBJECTIVES

This study was conducted to investigate the presentation and outcome of patients with Ebstein's anomaly of the tricuspid valve.

BACKGROUND

Ebstin's anomaly may present at any age and has a highly variable clinical course. Previous natural history studies have been based on clinical and angiographic diagnosis and have included mainly older children and adults. Echocardiography, however, has facilitated fetal and neonatal diagnosis so that the natural history needs to be redefined.

METHODS

We reviewed 220 cases of Ebstein's anomaly presenting from fetal to adult life between 1958 and 1991, with 1 to 34 years of follow-up.

RESULTS

The most common presentation in each age group was abnormal routine prenatal scan for fetuses (86%), cyanosis for neonates (74%), heart failure for infants (43%), incidental murmur for children (63%) and arrhythmia for adolescents and adults (42%). Early presentation was frequently associated with other cardiac lesions, usually pulmonary stenosis or atresia. Surgery was undertaken at some stage in 86 (39%) of the 220 patients. Actuarial survival for all liveborn patients was 67% at 1 year and 59% at 10 years. There were 58 deaths, including 26 from heart failure, 19 perioperative and 8 sudden. Predictors of death included echocardiographic grade of severity at presentation (relative risk 2.7 for each increase in grade, 95% confidence limits 1.6 to 4.6), fetal presentation (6.9, confidence limits 1.6 to 16.5) and right ventricular outflow tract obstruction (2.1, confidence limits 1.1 to 4.4). Morbidity was mainly related to arrhythmias and late hemodynamic deterioration. Of 155 survivors, 129 (83%) were in functional class 1 and 104 (67%) were receiving no medical therapy.

CONCLUSIONS

In Ebstein's anomaly, fetal and neonatal presentation is associated with a poor outcome and can be predicted by the echocardiographic appearance and presence of associated lesions. In older children and adults, incidental findings and arrhythmia are common and the long-term outcome is superior.

Cigarette smoking is associated with dose-related and potentially reversible impairment of endothelium-dependent dilation in healthy young adults

BACKGROUND

Cigarette smoking is the most important modifiable risk factor for atherosclerosis. Endothelial dysfunction is an early event in atherogenesis, and we hypothesized that smoking might be associated with endothelial damage in the systemic arteries of otherwise healthy young adults.

METHODS AND RESULTS

We studied noninvasively the brachial arteries of 200 subjects aged 15 to 57 years, all normotensive, nondiabetic with cholesterol level < or = 240 mg/dL and no family history of premature vascular disease: 80 control subjects aged 16 to 56 years (mean, 35), 80 current smokers aged 15 to 55 years (mean, 33), and 40 former smokers aged 25 to 57 years (mean, 38). Total lifetime amount smoked varied from 1 to 75 pack years in the smokers. Using high-resolution ultrasound, vessel diameter was measured at rest, during reactive hyperemia (with flow increase causing endothelium-dependent dilation), and after sublingual glyceryl trinitrate (GTN, an endothelium-independent vasodilator). Flow-mediated dilation (FMD) was observed in all the control subjects (10 +/- 3.3%; range, 4% to 22%) but was impaired or absent in the smokers (4 +/- 3.9%; range, 0% to 17%; P < .0001). FMD in the smokers was inversely related to lifetime dose smoked (6.6 +/- 4.0% in very light smokers, 4.0 +/- 3.1% in light smokers, 3.2 +/- 3.2% in moderate smokers, and 2.6 +/- 1.2% in heavy smokers; P < .01). FMD for the former smokers was 5.1 +/- 4.1% (range, 0% to 15%). In a multivariate model adjusting for age, sex, cholesterol, smoking history, and vessel size, former smoking was associated with a higher FMD than current smoking (P = .07); when only male former and current smokers were considered, the higher FMD was significant (P = .0001) but not for female smokers (P = .24). GTN caused dilation in all subjects (control subjects, 20 +/- 5.2%; smokers, 17 +/- 5.8%; former smokers, 17.4 +/- 5.4%). Vessel diameter, baseline flow, and degree of reactive hyperemia (Doppler estimated) were similar in all groups.

CONCLUSIONS

Cigarette smoking is associated with dose-related and potentially reversible impairment of endothelium-dependent arterial dilation in asymptomatic young adults, consistent with endothelial dysfunction.

Incidence of obliterative bronchiolitis after heart-lung transplantation in children

Between June 1988 and February 1993, combined heart-lung transplantation was performed in 30 children and adolescents aged 3.6 to 18.6 years (mean, 12.2 years) at The Hospital for Sick Children in London. Original diagnoses included cystic fibrosis (n = 25), Eisenmenger's syndrome (n = 4), and chronic graft-versus-host disease of the lung (n = 1). Posttransplantation maintenance immunosuppression comprised a triple regimen, with methylprednisolone and antithymocyte globulin given perioperatively and for episodes of allograft rejection. Actuarial survival was 63% (95% confidence interval: 42%-78%) at 1 year and 48% (95% confidence interval: 27%-66%) at 3 years. Obliterative bronchiolitis has been diagnosed in 13 patients (43%). Actuarial freedom from obliterative bronchiolitis in survivors was 76%, 59%, and 37% at 12, 24, and 36 months after transplantation, respectively. Recipients in whom obliterative bronchiolitis developed within the first year (n = 6) had more episodes of pulmonary rejection during the first 6 months after transplantation (mean, 5.7 episodes per patient) than those in whom "premature" obliterative bronchiolitis did not develop (mean, 3.2 episodes per patient). Infection of the pulmonary allograft was implicated to a lesser extent in predisposing to obliterative bronchiolitis. At 2, 3, and 6 months, tracheal stenosis developed in three patients, all of whom died with obliterative bronchiolitis within 10 months of transplantation. Noncompliance with therapy was considered a contributory factor in producing obliterative bronchiolitis in four adolescent recipients. The high incidence of obliterative bronchiolitis observed in this pediatric cohort may have a multifactorial cause.

Outer membrane protein YadA of enteropathogenic yersiniae mediates specific binding to cellular but not plasma fibronectin

The binding of bacteria or bacterial products to host proteins of tissue extracellular matrix may be a mechanism of tissue adherence. We investigated interactions of the plasmid-encoded outer membrane protein YadA, which confers pathogenic functions on enteropathogenic yersiniae, with fibronectin. Attachment of YadA-positive and YadA-negative recombinant Yersinia enterocolitica strains to cartilage-derived human cellular fibronectin and human plasma fibronectin in the solid phase revealed that YadA mediates binding of yersiniae to cellular fibronectin in a saturable, concentration-dependent manner. The interaction could be inhibited by an anti-YadA-specific anti-serum. An anti-beta 1-integrin antibody and the synthetic peptide G-R-G-D-S-P, representing the binding site for alpha 5 beta 1-integrin on fibronectin, did not block attachment of YadA-positive yersiniae to cellular fibronectin, indicating a binding site for YadA on cellular fibronectin independent of the R-G-D-S-containing site. By contrast, YadA failed to mediate binding to plasma fibronectin immobilized on nitrocellulose or plastic surfaces. These observations provide evidence for the hypothesis that the binding region for YadA in cellular fibronectin is not present in plasma fibronectin. This study is the first report on differential binding of bacteria to splicing variants of fibronectin. Further experiments might answer the question whether binding of YadA to cellular fibronectin contributes to the pathogenesis of yersiniae, both to the initial adhesion of the bacteria to the matrices of the host and to the arthritogenic potential of enteropathogenic yersiniae.

Physiology of congenital heart disease

Images

Life-threatening pulmonary hypertensive crises occurring preoperatively

A 10-week-old infant with left atrial isomerism and a primum atrioventricular septal defect presented with life-threatening episodes of collapse. They proved due to paroxysmal pulmonary hypertension, although her pulmonary artery pressure was virtually normal between attacks. The pulmonary hypertensive crises persisted early but resolved late after surgical correction. Labile pulmonary vascular resistance may prove a problem preoperatively if the ventricular septum is intact.

Primary adjunctive whole abdominal radiotherapy in epithelial ovarian cancer: results of 10-years' experience

During a 10-year period from January 1, 1979, 59 patients out of a total of 203 undergoing definitive treatment for epithelial ovarian cancer were managed with primary adjuvant whole abdominal radiotherapy after initial cytoreductive surgery. The median survival of this group was 53 months. The serious morbidity rate was approximately 8% with 4 laparotomies for bowel complications and 1 death following radiation related liver failure. This form of adjuvant therapy in appropriately selected patients with minimal residual disease merits further evaluation against other forms of therapy such as systemic or intraperitoneal chemotherapy.

Recurrent genital infection in the guinea pig: differences between herpes simplex types 1 and 2

Recurrence rates of genital infections are significantly higher for herpes simplex virus (HSV) type 2 than HSV type 1. Reasons for this difference are not known. In this report, multiple strains of HSV-1 and HSV-2 were evaluated in the guinea-pig model. HSV-2 strains showed significantly higher genital lesion recurrence than HSV-1, including HSV-1 McKrae strain which is highly recurrent in ocular infections. HSV-2 strains were also associated with more frequent asymptomatic vaginal virus shedding. Further study showed that HSV-1 strains replicated as well as HSV-2 in both the genital tract and the nervous system during acute infection. In addition, no difference was detected between HSV-1 and HSV-2 in nervous system latency. Thus, a number of possible explanations for the observed difference in genital herpes recurrence rates were examined and excluded.

Herpes simplex types 1 and 2: latency in the genital tract of guinea pigs

Guinea pigs were infected with herpes simplex virus (HSV) intravaginally and then sacrificed during latent infection. Virus was recovered from the ganglia, spinal cord and genital tissues by co-cultivation after 1-6 weeks in culture. The virus could not be recovered from the genital tract during the first week of co-cultivation, nor from homogenized genital tissue. Cultivation of genital tissues with acyclovir did not reduce the recovery of HSV. Thus, HSV appeared to establish a truly latent infection in the genital tract and not a persistent infection as previously described.

Arrhythmias after the Fontan procedure. Comparison of total cavopulmonary connection and atriopulmonary connection

Arrhythmia was compared between 40 consecutive patients (pts) undergoing atriopulmonary connection (APC) and 40 undergoing total cavopulmonary connection (TCPC), between 1986 and 1990. Patients were not randomized, and those undergoing APC predominantly had tricuspid atresia (57.5% versus 15%) compared with pts undergoing TCPC who had more varied and complex cardiac defects. Before surgery there was no significant arrhythmia in either group. Hospital mortality was 15/40 and 6/40 for APC and TCPC, respectively (p less than 0.05). Early after APC nine pts developed atrial flutter (AFL) and eight died, while after TCPC only two developed AFL, and neither died (p less than 0.01). Fatal junctional ectopic tachycardia occurred in one pt in each group. During follow-up (38 +/- 8.5 months after APC versus 20 +/- 10 months after TCPC), new arrhythmia was uncommon (two AFL after APC with one death versus two AFL and one supraventricular tachycardia after TCPC with no deaths). Ambulatory ECG during follow-up showed arrhythmia in two APC and six TCPC pts (p = NS). The incidence of early arrhythmia and mortality associated with early arrhythmia appears to be less after TCPC compared with APC.

Limited small cell lung cancer: the effect of radiotherapy on local control following response to chemotherapy

The survival and rate of chest infield relapse was examined in 48 patients with limited disease small cell lung cancer (LSCLC) who had achieved complete (CR) or partial response (PR) following three courses of chemotherapy. During 1985-1986 chemotherapy consisted of carboplatin and etoposide and during 1986-1987, of etoposide, carboplatin, cyclophosphamide, and vincristine (ECCO). After three courses of chemotherapy, chest irradiation (50 Gy in 25 fractions over 5 weeks) was given to encompass the original tumor volume. Complete responders were also given prophylactic cranial irradiation, 30 Gy in 10 fractions over 2 weeks. Overall median survival of all patients receiving chest irradiation was 17 months from commencement of radiotherapy. The infield relapse-free survival at 24 months was 49% (95% confidence interval: 32-66%). Patients who had only achieved a PR at the time of irradiation were more likely to relapse in the chest than complete responders (p = 0.09). We conclude that local relapse remains a major cause of failure in patients with LSCLC in spite of sequential high dose radiotherapy given to patients who have responded to chemotherapy.

Pulmonary hypertensive crises following surgery for congenital heart defects in young children

In this clinical study, 20 high risk infants and neonates were monitored to identify and characterize pulmonary hypertensive crises following surgery for congenital cardiac defects. Monitoring included right ventricular or pulmonary artery pressure catheters and transcutaneous oximetry. Eleven patients also had continuous analog recording of hemodynamic data so that antecedents of crises and the sequence of events following treatment could be reconstructed. Eleven of the 20 patients had one or more crises. Six of these ultimately died whereas 5 patients survived with aggressive vasodilator therapy. Four patients without crises but with episodic pulmonary hypertension benefitted from pulmonary vasodilator therapy to ease weaning from ventilatory support. Typically, each crisis was associated with a stress event. Crises were difficult to ablate if not rapidly treated and multiple crises would often cluster following an initial event. High dose narcotic (fentanyl) analgesia was found to be important in the postoperative management. Tolazoline and oxygen were the most consistently useful vasodilators, but isoproterenol and nitrates also played a role. Five of the children who died were examined post mortem: histologically, there was increased pulmonary arterial muscularization in 2, in none were there changes of fixed pulmonary vascular disease. The postoperative management must be individualized on the basis of monitored responses of pulmonary circulation.

Natural history of supravalvular aortic stenosis and pulmonary artery stenosis

Data from 35 patients with supravalvular aortic stenosis or pulmonary artery stenosis, or both, undergoing cardiac catheterization between 1973 and 1989 were analyzed retrospectively. Twenty-seven patients had supravalvular aortic stenosis: 11 required surgery after the first investigation and 8 (80%) of 10 others undergoing serial investigation showed an increase in the left ventricle to aorta pressure gradient. Angiographic measurements showed that the increase in the aortic pressure gradient was related to failure of normal growth of the ascending aorta lumen. Nineteen patients had pulmonary artery stenosis, with a right ventricular pressure greater than 33 mm Hg. At restudy, right ventricular pressure had decreased in 9 (82%) of 11 patients. This decrease in right ventricular pressure was associated with an increase in the systolic distensibility of the proximal pulmonary arteries, although there was no increase in the diastolic diameters. One patient had a rapid early increase in right ventricular pressure and no pulmonary artery growth. In two patients, multiple peripheral pulmonary artery stenoses became evident with time and produced persistent right ventricular hypertension. Supravalvular aortic stenosis is usually a progressive lesion, with an increase in left ventricular outflow tract pressure gradient related to poor growth of the ascending aorta. Pulmonary artery stenosis usually improves and only rarely limits prognosis.

The natural and "unnatural" history of congenitally corrected transposition

The data available on 111 patients with congenitally corrected transposition and 2 adequate ventricles managed over the 20-year period to 1988 were reviewed retrospectively. The ages of survivors ranged from 1 to 58 years (median 20) and all but 10 had additional anatomic abnormalities. Tricuspid valve abnormalities were more prevalent in patients symptomatic with heart failure (26 of 43 patients) than those whose main problem was cyanosis (11 of 52 patients); all dysplastic or Ebstein valves were at least moderately incompetent. Intracardiac repair of the lesion was attempted in 51 patients with 11 early deaths; in multivariate models, the risk factors for early death or a bad early outcome or poor result 6 months later related to poor preoperative symptomatic status (especially from heart failure), impaired right ventricular function, heart block and younger age at surgery. Patients with more than mild preoperative tricuspid regurgitation whose valves were not replaced did very poorly. Thus, patients symptomatic from heart failure should probably be repaired early in the natural history of the disease, before the systemic right ventricles dilate. By contrast, the course of patients who were predominantly cyanosed was more stable in early childhood and their surgical outcome was less compromised by poor preoperative symptomatic status; their intracardiac repair can probably be delayed until symptoms become unacceptable.

Exercise responses in patients with congenital heart disease after Fontan repair: patterns and determinants of performance

After a Fontan repair for congenital heart disease, 42 patients underwent graded supine bicycle exercise tests at levels relevant to normal daily activities. Results were compared with those of 28 age-matched normal control subjects. At rest, the cardiac index, stroke index and systolic blood pressure were comparable in both groups, but increases with exercise were smaller in the patients with a Fontan circulation. The heart rate at rest was higher in the Fontan group, but this difference disappeared as soon as exercise started. To determine whether there are limitations intrinsic to the Fontan circulation at these levels of exercise, the 10 best performers were compared with 10 age-matched control subjects; no differences were found in cardiac index, stroke index, heart rate or blood pressure at any exercise level. Analysis of the determinants of cardiac output showed that at the other end of the spectrum poor performance after a Fontan operation did not result from inadequate levels of heart rate, but from an inability to increase or maintain stroke volume. Multivariate analysis demonstrated that impairment of ventricular contractility, only when severe, predicted limited performance. There was no evidence of increased afterload, particularly in the poor performers. Therefore, ventricular filling, which is determined primarily by the pulmonary vascular bed, appears to be a major determinant of functional result after a Fontan repair.

Etoposide, carboplatin, cyclophosphamide and vincristine in previously untreated patients with small-cell lung cancer

The efficacy and toxicity of 120 mg/m2 etoposide and 100 mg/m2 carboplatin given i.v. daily x 3 together with 750 mg/m2 cyclophosphamide and 1.4 mg/m2 vincristine given i.v. on day 1 (ECCO) in a regimen given every 28 days for 6 courses was assessed in 90 (40 limited stage, 50 extensive stage) previously untreated patients with small-cell lung cancer. Mediastinal irradiation using 50 Gy in 25 fractions was given to limited-stage patients without progression after 3 courses of chemotherapy. Cranial irradiation with 30 Gy in 10 fractions was given to all patients attaining a complete response (CR). Objective responses were seen in 83% [CR, 60%; partial response (PR), 23%] of patients with limited and 76% (CR, 22%; PR, 54%) of those with extensive disease. The median relapse-free survival for objective responders with limited disease was 13.4 months, with a median of 8.0 months for extensive-stage patients. The median relapse-free survival for patients achieving a CR was 13.4 months, with a median of 7.8 months for those undergoing a PR. The median survival was 13.3 months for patients with limited disease, with a median of 9.6 months for those with extensive disease. The median survival following a CR was 18.2 months, with a median survival of 9.9 months for those showing a PR. The combination was well tolerated, with either no nausea or nausea only (WHO grade 0 or 1) in 56% of patients and minimal mucositis, renal toxicity, neurotoxicity or ototoxicity. Neutropenia measuring less than 1.0 x 10(9) WBC/l (WHO grade 3 or 4) was seen in 74% of patients, with two deaths due to infection occurring during neutropenia. Thrombocytopenia of less than 50 x 10(9) platelets/l (WHO grade 3 or 4) occurred in 24% of patients. ECCO is a new, active, well-tolerated program for previously untreated patients with small-cell lung cancer.

Impact of Fontan operation on left ventricular size and contractility in tricuspid atresia

Left ventricular dimensions and contractility were determined by echocardiography in 33 patients with tricuspid atresia in 1985 and again in 1988. Eight patients remained palliated throughout the 3-year period; neither the left ventricular end-diastolic diameter (153 +/- 15% of normal vs. 157 +/- 19%, p = NS) nor a load-independent index of contractility (rate-corrected velocity of shortening [VCFc]/end-systolic meridional stress [ESSM]) changed. Eleven patients underwent a Fontan operation during the study and were reevaluated at least 6 months after surgery; left ventricular dimension decreased (130 +/- 15% vs. 114 +/- 19%, p less than 0.001), and the contractility index VCFc/ESSM improved (p less than 0.05). Fourteen patients had undergone a Fontan operation 0.9-9.5 years (mean, 4.2 years) before initial examination in 1985. Over the 3-year period, left ventricular dimensions did not change (121 +/- 17% vs. 118 +/- 11%, p = NS), but the contractility index showed significant improvement (p less than 0.01). Eight additional patients were studied just before and after a Fontan operation to examine the early effects of surgery. Left ventricular dimensions decreased from 130 +/- 14% to 100 +/- 13% by 10 days p less than 0.001) with no further change at 2 months. An inappropriate degree of ventricular hypertrophy was observed in only the early postoperative period. Successful Fontan repair results in rapid reduction of left ventricular size, followed by regression of hypertrophy to a normal mass-to-volume ratio. Operating at more favorable dimensions and loading conditions results in an early increase in left ventricular contractility, which further improves in the medium term follow-up.

Balloon dilation of pulmonary venous pathway obstruction after Mustard repair for transposition of the great arteries

Percutaneous balloon dilation was attempted in three patients with mid baffle pulmonary venous pathway obstruction after the Mustard operation for transposition of the great arteries. The procedure was unsuccessful in a 3 year old boy. Evidence for relief of obstruction in the other two patients (7 and 14 years old, respectively) consisted of angiographic demonstration of improved caliber at the site of the pulmonary venous pathway narrowing, improvement in the Doppler spectral signal at this site from an "obstructed" to a "normal" pattern as well as symptomatic improvement. Balloon dilation was performed twice in one of these patients. The Doppler and symptomatic improvement were sustained in both patients at short-term follow-up (5 and 6 months, respectively). This technique may offer effective relief of pulmonary venous pathway obstruction in some patients with this complication of the Mustard operation.