Percutaneous balloon valvotomy was attempted in 27 patients (aged 6 days to 19 years, median 2 years, 11 months) with unoperated typical valvular pulmonary stenosis using a balloon 7 to 60% (mean 30%) larger than the valve anulus. One patient had undergone a previous balloon valvotomy elsewhere. To achieve an oversized dilation diameter in three larger patients, two balloons were inflated side by side. Their "effective dilation diameter" was determined by the diameter of the circle with the same area as that of the oval enveloping the two balloons. A significant reduction of the transvalvular gradient occurred in all patients (mean +/- SD = 74.3 +/- 14.7%, range 33 to 100%). The average gradient of 65.0 +/- 19.0 mm Hg (mean +/- SD) fell to 15.9 +/- 7.6 mm Hg (0 to 30 mm Hg). Twenty-five of 27 patients had a residual transvalvular gradient of less than 25 mm Hg. The calculated valve orifice area increased by an average of 183 +/- 80%. No significant complications occurred. It is concluded that percutaneous balloon valvotomy with a balloon 20 to 40% larger than the valve anulus is the treatment of choice for typical congenital valvular pulmonary stenosis.

Background Myocardial fibrosis is a hallmark of hypertrophic cardiomyopathy (HCM) and a risk factor for ventricular arrhythmia. Fibrosis can be reflected in circulating matrix remodeling protein concentrations. We explored differences in circulating markers of extracellular matrix turnover between young HCM patients with versus without history of serious arrhythmia. Methods and Results Using multiplexed and single ELISA, MMP 1,2,3,9; tissue inhibitor of metalloproteinase (TIMP) 1,2,4; and collagen I carboxyterminal peptide (CICP) were measured in plasma from 45 young HCM patients (80% male, median age 17 years[IQR 15-20]). Participants were grouped into serious ventricular arrhythmia history (VA) versus no ventricular arrhythmia history (NoVA). Differences in MMPs between groups were examined nonparametrically. Relationships between MMPs and ventricular arrhythmia were assessed with linear regression, adjusted for interventricular septal thickness, family history of sudden death, abnormal exercise blood pressure, and implantable cardioverter defibrillator (ICD). In post-hoc sensitivity analysis, age was substituted for ICD. The 14 VA patients were older than 31 NoVA patients (Median 19 vs. 17 years, p=0.03). All 14 VA and 12 NoVA patients had ICD. MMP3 concentration was significantly higher in the VA group (VA median 12.9 [IQR 5.7-16.7] mcg/mL vs. NoVA 5.8 [IQR 3.7-10.0 mcg/mL]; p=0.01). On multivariable analysis, VA was independently associated with increasing MMP3 (standardized b 0.37, p=0.01). Post hoc adjustment for age attenuated this association. Conclusions Circulating MMP3 may be a marker of ventricular arrhythmia in adolescent patients with HCM. Due to our role as pediatric providers, we cannot exclude age related confounding.

Application of suction to chest drains following non-pneumonectomy lung resection is common practice. Suction has an effect in hastening the removal of air and fluid in clinical experience but a policy of suction after lung resection has not been shown to offer improved clinical outcomes. Clinical practice is not aligned with Level 1a evidence.

Invasive coronary angiography (ICA) has long been the established gold standard in assessing graft patency following coronary artery bypass graft (CABG). Over the past decade or so however, improvements in computed tomography angiography (CTA) technology have allowed its emergence as a useful clinical tool in graft assessment. The recent introduction of 64-slice and now 128-slice scanners into widespread distribution, and the development of 320-detector row technology allowing volumetric imaging of the entire heart at single points in time within one cardiac cycle, has increased the potential of CTA to supersede ICA in this capacity. This study sought to examine the evidence surrounding this potential. A best evidence topic was constructed according to a structured protocol. The enquiry: In [patients who have undergone coronary artery bypass graft surgery] is [computed tomography angiography or invasive coronary angiography] superior in terms of [graft patency assessment, stenosis detection, radiation exposure and complication rate]? Four hundred and twenty-four articles were identified from the search strategy. Four additional articles were identified from references of key articles. Seventeen articles selected as best evidence were tabulated. The reliability of CTA as a tool in the detection of graft patency and stenosis has continued to improve with each successive generation of multislice technology. The latest 64- and 128-slice CTA techniques are able to detect graft patency and stenosis with very high sensitivities and specificities comparable with ICA, while remaining non-invasive procedures associated with fewer complications (ICA carries a 0.08% risk of myocardial infarction and 0.7% risk of minor complications in clinically stable patients). Present limitations of the technology include the accurate visualization of distal anastomoses and clip artefacts. In addition, the capacity of diagnostic ICA to be combined simultaneously with percutaneous coronary interventions is an important advantage and a further limitation of CTA alone. Recent developments, however, including the derivation of fractional flow reserve and perfusion assessment from CTA as functional measures of stenosis severity have given CTA at present the capacity to become a first-line tool in the assessment of patients with suspected graft dysfunction. Novel computer-automated diagnostic software, though currently in infancy, has shown promise in facilitating and speeding image interpretation. With further improvements in scanning technologies, CTA is likely to supersede ICA for graft assessment in the near future.

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