Univentricular repair. Early and midterm results

A total of 202 patients (62 with tricuspid atresia and 140 without tricuspid atresia) underwent univentricular repair at our unit from January 1990 to September 1994. Of these patients, 182 had nonfenestrated and 20 had fenestrated interatrial baffles. Early mortality was 15.9% (29/182) in the group with nonfenestrated baffles and 5% (1/20) in the group with fenestrated baffles. The follow-up period ranged from 2 to 58 months. Seven late deaths occurred, and five patients were lost to follow-up. Of 160 patients who have been evaluated in the outpatient department in the past 3 months, 142 (88.75%) required no cardiac medicines and were in functional class I. Risk factors analyzed for early mortality and significant effusion were age, preoperative diagnosis, type of Fontan modification, cardiopulmonary bypass time, aortic crossclamp time, pulmonary artery size, associated pulmonary arterioplasty, takedown of systemic-pulmonary artery shunt, and pulmonary artery debanding, along with the Fontan operation. Bypass time exceeding 120 minutes was associated with a higher early mortality (12/47 vs 18/155; p = 0.0187). Bypass time exceeding 120 minutes (p = 0.0456) and aortic crossclamp time exceeding 60 minutes (p = 0.0278) were associated with significant postoperative effusion. Other factors were not associated with any significantly increased risk for early mortality or postoperative effusions. Fenestration of the interatrial baffle appeared to decrease early mortality, although the numbers are too small to be statistically significant. The prevalence of effusions did not differ significantly between the group with fenestrated baffles and the group without fenestrated baffles.

Serial echocardiography for decision making in rapid two-stage arterial switch operation

BACKGROUND

Rapid two-stage arterial switch operation is advocated in infants with simple transposition presenting late. Accurate assessment of left ventricular preparation is crucial to successful outcome. The role of echocardiography alone in surgical decision making remains unclear.

METHODS

Seventeen patients with simple transposition (mean age, 4 months) underwent pulmonary artery banding and modified Blalock-Taussig shunt (first stage) to prepare the left ventricle for the arterial switch operation (second stage). Serial echocardiography was performed in the interval phase to assess left ventricular growth. Sixteen patients underwent arterial switch operation after a mean interval of 10.4 +/- 4 days, with 14 successful conversions. There was one mortality (5.9%) and two conversions to a Senning repair.

RESULTS

In all patients a mean increase in left ventricular mass (40.8 +/- 17.8 g/m2 to 81.4 +/- 25.4 g/m2) and posterior wall thickness (3.37 +/- 0.47 mm to 4.63 +/- 0.58 mm) was recorded. Left ventricular end-diastolic internal diameter increased in all except the two switch failures. In all the successful cases the left ventricle had assumed a circular shape on cross-section with the interventricular septum contracting in synergy with the left ventricular mass. In the two failures, however, the interventricular septum had remained flat.

CONCLUSIONS

Echocardiography can be used reliably in surgical decision making in rapid two-stage arterial switch operation. Increase in left ventricular mass, left ventricular posterior wall thickness, and left ventricular end-diastolic internal diameter toward normal combined with an acquisition of circular left ventricular configuration with the interventricular septum contracting in synergy with the left ventricular mass appear to best predict successful outcome.

The use of fluorophore-containing spin traps as potential probes to localize free radicals in cells with fluorescence imaging methods

Central to the study of free radical processes is the ability to identify and localize their cellular site of formation. Under the best of experimental conditions, spin trapping/ESR spectroscopy can only characterize intracellular production of specific free radicals and confocal microscopy can only localize the site of their formation. In this article, we report on the development of a fluorophore-containing nitrone, alpha-[4-[5-((2-carboxy)phenyl)-5-hydroxy-4-oxo-3-phenyl)-2-pyrrolin+ -1-yl]phenyl]-N-(tert-butyl)nitrone sodium salt (4). This nitrone (4) reacts with alpha-hydroxyethyl radical with a second order rate constant of 1.7 x 10(5) M-1 s-1 to give a characteristic ESR spectrum. However, we were unable to decrease the fluorescence emission, due in part to the small concentration of nitroxide generated from the reaction of alpha-hydroxyethyl radical with nitrone (4). Using the fluorophore-containing nitroxide (7) as a model, we found that only 12% of the nitroxide needs to be reduced to give an almost 400% increase in the fluorescent emission of (7). Our findings suggest new approaches to the development of various fluorophore-containing nitrones that can both characterize specific free radicals and localize their site of intracellular formation.

Orthotopic pulmonary valve replacement with a homograft

Eight pulmonary valve replacements (PVR) have been performed from January 1992 to October 1994. Three patients (mean age 7.7 years, range two to 16 years) had absent pulmonary valve with tetralogy of Fallot and underwent primary PVR at the time of surgical correction. Five other patients, who had correction of tetralogy of Fallot (four cases) and of double outlet right ventricle with ventricular septal defect and pulmonary stenosis (one case), were reoperated for pulmonary regurgitation with progressive right ventricular dysfunction. Mean age at the time of reoperation was 18 years (range seven to 34 years). There was no early death. Early postoperative recovery was satisfactory in all of them. The follow up ranges from six to 35 months (mean 19 months). Seven patients were in functional class I and one in functional class II when they were last evaluated in the out-patient department and five of them were off diuretics and vasodilator. In the presence of right ventricular dysfunction pulmonary regurgitation is poorly tolerated. A competent and non-obstructive pulmonary valve is often life saving in these critically ill patients.

Regional organisational audit of district departments of public health

Organisational audit of public health in the United Kingdom is rare. To provide a framework for a structured organisational audit in district public health departments in one region organisational factors contributing to efficient, high quality work were identified and compared between districts, enabling each department to identify its organisational strengths and weaknesses. A draft list of organisational factors, based on the King's Fund organisational audit programme, were rated by 52 public health physicians and trainees in 12 district public health departments in South East Thames region for their importance on a scale of 0 (not relevant) to 5 (vital). Factors with average ratings of > 4, judged to be "vital" and proxies for standards, were then used to compare each district's actual performance, as reported by its director of public health in a self reported questionnaire. In all, 37 responses were received to the rating questionnaire (response rate 71%) and 12 responses to the directors' questionnaire. Of the 54 factors identified as vital factors, 20(37%) were achieved in all 12 districts and 16(30%) in all but one district; 18 were not being achieved by two (33%) districts or more. Overall, vital factors were not being achieved in 9% of cases. The authors concluded that most departments are achieving most vital organisational factors most of the time, but improvement is still possible. The results have been used as a basis for planning the organisation of public health departments in several of the newly formed commissioning agencies. This was the first regional audit of public health of its kind performed in the region and it provided valuable experience for planning future regional audit activity.

A fluorophore-containing nitroxide as a probe to detect superoxide and hydroxyl radical generated by stimulated neutrophils

Toward the development of a fluorescence assay in combination with confocal microscopy to image free radicals generated by cells, we synthesized a fluorophore-nitroxide, 5-((2-carboxy)phenyl)-5-hydroxy-1-((2,2,5,5-tetramethyl-1-oxypyrrolid in-3- yl)methyl)-3-phenyl-2-pyrrolin-4-one sodium salt, and tested the applicability of this probe to detect oxygen-centered free radicals. The reaction of the fluorophore-nitroxide with superoxide (10 microM/min) generated either by the reaction of xanthine oxidase on xanthine or by PMA-activated neutrophils in the presence of cysteine (200 microM) resulted in a loss of electron spin resonance (ESR) signal intensity concurrent with an increase in fluorescence emission. The decrease in ESR signal and the augmentation in fluorescence emission were inhibited by the addition of superoxide dismutase. This fluorophore-nitroxide also reacted with methyl radical generated by the reaction of hydroxyl radical with DMSO (0.14 M). In this case a loss in ESR signal intensity concomitant with an increase in fluorescence emission which were inhibited by catalase (300 U/ml), was recorded. These results clearly demonstrated the feasibility of using fluorescence methodology in conjunction with a fluorophore-nitroxide to detect oxygen-centered free radicals in biological systems.

Cusp-level chordal shortening for rheumatic mitral regurgitation: early results

From February of 1987 through February of 1991, 25 patients with rheumatic mitral disease underwent cusp-level shortening of the chordae of the anterior mitral leaflet as part of the valvular reconstruction procedure at our institutions. All patients had moderate or severe mitral regurgitation, with prolapse of the anterior mitral leaflet. Seventeen patients also had mitral stenosis. Postoperative echocardiograms, both transthoracic and transesophageal, showed correction of leaflet prolapse and mitral regurgitation. This preliminary report suggests that the technique satisfactorily corrects mitral regurgitation in patients with elongated and thickened chordae characteristic of rheumatic mitral disease.

Profile of coronary arterial disease in diabetic patients undergoing coronary arterial bypass grafting

Diabetics are believed to have more extensive and diffuse lesions of the coronary arteries in presence of coronary arterial disease. We studied prospectively 52 diabetics with coronary arterial disease who underwent coronary arterial bypass grafting and evaluated their pre-operative symptomatology, angiographic appearance of coronary arteries, coronary arterial dimensions as assessed at surgery, and the post-operative complications. These were compared to 52 age and sex matched non-diabetic controls undergoing surgery during the same period. There was no statistically significant difference in the incidence of pre-operative symptomatology or frequency of myocardial infarction in the two groups. Left ventricular angiographic findings were also comparable, as was the observation on the extent and severity of coronary arterial disease as assessed by angiography and at surgery. Hence, we recommend coronary arterial bypass grafting to diabetics with the same criteria as are applied to non-diabetics, confident that there will be no added morbidity and mortality.

Immunohistochemical characterization of Aschoff nodules and endomyocardial inflammatory infiltrates in resected left atrial appendages

Presence of Aschoff nodules and other chronic inflammatory cells in the left atrial appendage even in the absence of rheumatic activity has been reported in a high percentage of patients with chronic rheumatic valvular heart disease. This study was conducted on 37 left atrial appendages resected at the time of closed mitral valvotomy. Aschoff nodules were present in 61.2 percent of resected appendages, positivity being 71.4 percent in the age group of 20 years of less and 53.3 percent in patients more than 20 years of age. The histological findings did not change significantly in the presence of activity. The frequency of Aschoff nodules and chronic inflammatory cells and their subtypes also did not show any correlation with age, sex, duration of symptoms or severity of mitral stenosis.

Mitral valve repair: techniques and results

From January 1986 to December 1989, seventy patients underwent mitral valve repair. Sixty-four patients had severe mitral stenosis (MS) and mitral regurgitation (MR), while six patients had severe mitral regurgitation (MR) only. The technique used was a combination of posterior semicircular annuloplasty, mitral commissurotomy and chordal shortening. There were two operative deaths. All except three of the surviving patients are asymptomatic. There has been no episode of thromboembolism. One patient has required valve replacement and two others have had a revision of the repair in the follow up period. Predischarge and late (3 months to 3 years) echocardiography suggests that the repair is satisfactory.

Fatal myocarditis with acute polymyositis in a young adult

A 21 year old woman presented with acute polymyositis associated with fatal myocarditis. The significance of cardiac involvement in polymyositis is discussed in relation to this unusually fulminant case.

Conformational studies of two isomeric ring-expanded purine nucleosides and their 5'-mono- and -diphosphate derivatives

The nucleosides Ia and IIa exist in syn and anti conformations, respectively, both in solid state and solution. Compound Ia undergoes significant conformational change, accompanied by increased population of the anti conformer, upon conversion to the corresponding 5'-mono- and- diphosphate derivatives, whereas conformation of IIa remains reasonably constant between nucleoside and nucleotides. While Ia possessed the C2'-endo-C3'-exo geometry, IIa had the opposite C2'-exo-C3'-endo conformation. The C5' of the two nucleosides bore axial and equatorial conformations, respectively.

Choledocho-duodenal fistula due to tuberculosis

An unusual case of caseating nodal tuberculosis causing a choledocho-duodenal fistula is reported. Anti-tubercular treatment led to closure of the fistula.

The combination of a left aortic arch, a right-sided descending thoracic aorta with a left-sided arterial duct

A nine-year-old male child presented with a history of recurrent chest infections and breathlessness. On investigation, he was found to have a left aortic arch with a right-sided descending thoracic aorta along with a left-sided arterial duct. He also had mild aortic stenosis with regurgitation. The duct was successfully ligated under controlled hypotensive anesthesia through a left posterolateral thoracotomy.

Erythema multiforme in a patient with T cell chronic lymphocytic leukemia

A patient with T4+ (helper-inducer) T cell chronic lymphocytic leukemia developed an erythema multiforme-like eruption, the diagnosis of which was supported by routine light microscopic findings. Immunopathologic studies using monoclonal antibodies demonstrate that despite an overwhelming majority of leukemic T4+ cells in the peripheral blood and dermal infiltrate, the predominant cells in the epidermal infiltrate are T8+ (cytotoxic-suppressor) cells. These findings are different from those seen in epidermotropic T cell leukemic infiltrates and are similar to those previously reported in erythema multiforme. Thus it is likely that the leukemic T4+ cells are participating in this cutaneous hypersensitivity reaction along with residual, normal T8+ cells.

Monoclonal antibodies to tissue-specific cell surface antigens. I. Characterization of an antibody to a prostate tissue antigen

Monoclonal antibodies were raised to PC-3 human prostate adenocarcinoma cells, and one hybridoma, designated F77-129, was extensively purified and used to characterize a PC-3 antigen. The F77-129 antibody also showed serological reactivity with the Du-145 prostate cancer line and with three of four breast carcinoma lines tested; it showed variable binding to a colon carcinoma line. Several other lines tested, including melanomas, fibrosarcomas, and leukemias, were completely negative. Immunoperoxidase staining of frozen surgical specimens showed binding to both normal and malignant prostate and breast tissue. Injection of radioiodinated F77-129 into tumor-bearing nude mice showed specific in vivo targeting to prostatic cancer implants. The antigen also showed surface modulation by bound antibody, suggesting possible clinical utility of this antibody in delivering immunotoxins to tumors.

Subunit function in cardiac myosin. Effects of binding phosphorylated and unphosphorylated myosin light chain 2 to light chain 2-deficient myosin

The 20,000-dalton light chain of cardiac muscle myosin can be specifically digested and thereby removed from the rest of the myosin molecule by incubation with a myofibrillar protease (Malhotra, A., Huang, S., and Bhan, A. (1979) Biochemistry 18, 461-467). In order to study the effects of phosphorylation of the 20,000-dalton myosin light chain, experiments were carried out with cardiac muscle myosin that was made deficient in this light chain following proteolysis. Both the phosphorylated and unphosphorylated isolated 20,000-dalton myosin light chain of cardiac muscle myosin were found to bind to light chain-deficient myosin. Prior to readdition of the isolated light chains, this light chain-deficient myosin was found to have a higher MgATPase activity in the presence and absence of actin, than native myosin. Binding of the unphosphorylated myosin light chain restored the MgATPase activity of light chain-deficient myosin to that of native cardiac myosin. In contrast, the binding of 2 mol of the previously phosphorylated myosin light chain did not lower the actin-activated MgATPase activity. The results suggest that while phosphorylation of the 20,000-dalton light chain of cardiac muscle myosin is not essential for the actin-activated MgATPase activity, it may have a modulatory role.