Dissecting aneurysm of the ductus arteriosus with thromboembolism in the descending aorta and distal arteries, while rare, is a potentially fatal combination occurring mainly in the newborn period. The aneurysm and distal thromboses of a 6-day-old infant were demonstrated angiographically for the first time antemortem and correlated with the postmortem findings. The pathogenesis of the lesion and the possibility of antemortem recognition are disAneurysm of the ductus arteriosus ¿\. is a relatively rare lesion which is encountered most frequently in in¬ fants as an incidental finding at postmortem examination.1 Sponta¬ neous dissection and rupture of the aneurysm, as well as embolism and thrombosis of distal arteries, may oc¬ cur and are potentially lethal.-4 This report presents hemodynamic, angiographie, and pathologie findings from a case of a newborn infant in whom these complications were dem¬ onstrated angiographically and in whom, retrospectively, an angiogram performed prior to dissection showed the ductal aneurysm. Report of a CaseA girl was born at term at another hos¬ pital to a 23-year-old gravida 3, para 2, Rh positive mother following an uneventful pregnancy. The membranes were rup¬ tured artifically and labor induced with oxytocin (Pitocin). Delivery was spon¬ taneous from a vertex presentation and the birth weight was 2,690 gm (5 lb 15 oz).The infant was meconium stained with the umbilical cord wrapped around the neck. The Apgar score was 3 and resusci¬ tation was required. The infant was transferred to the Yale-New Haven Hos¬ pital at 4 hours of age because of per¬ sistent cyanosis. On admission, there was moderate generalized cyanosis, a respira¬ tory rate of 65 per minute, and heart rate 100 beats per minute. An enlarged tongue protruded slightly outside the mouth. The lungs were clear. A soft, grade 2, ejection, systolic murmur was heard at the left sternal border. The liver and spleen were not enlarged. A mag¬ nification chest roentgenogram revealed increased pulmonary vascularity bilateral¬ ly. There was a fine infiltrate in the right
From 1980 to 1990, 12 patients (mean age 2.5 years, range 5 months to 9 years) with anomalous origin of the left coronary artery from the pulmonary artery were treated surgically. Five infants were operated upon in the first year of life because of persistent symptoms of congestive heart failure. In all cases, a two-coronary system was constructed by direct aortic reimplantation of the anomalous vessel with no deaths early or late over a follow-up period of up to 10 years. The technique of reimplantation was facilitated by transection of the main pulmonary artery. One patient with severe mitral regurgitation underwent, in addition, a mitral annuloplasty. A pulmonary valvotomy was performed in another patient with associated pulmonary stenosis. Three patients are receiving medication. The reimplanted anomalous left coronary artery was patent in each reevaluated patient (10/12). Left ventricular function improved considerably in all cases. Patients with symptoms should undergo repair soon after diagnosis. Direct aortic reimplantation should be technically feasible in even the smallest infant. Operative mortality is related to preoperative conditions and severity of ischemic damage of the myocardium.
Neonatal heart surgery directed at the prompt anatomic and physiologic restoration of the patient who has congenital heart disease has largely developed in the past 2 decades. To obtain the best possible results and minimize the multiple risks involved with such surgery, various considerations must be taken into account, including the institution where the surgery occurs, the human resources available, and the particular characteristics of the newborn. An accurate statistical analysis of the surgical outcomes allows an intelligent examination of the risk factors, continuous improvement through responsiveness of the parts and the process, and valid comparisons with other institutions.
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