Br Heart J 1992;67:204-7

LETTERS TOTHE EDITOR

* The British Heart Journal welcomes letterscomnenting on papers that it has publishedwithin the past six months.

* All letters must be typed with double spacingand signed by all authors.

* No letter should be more than 600 words.

* In general, no letter should contain morethan six references (also typed with doublespacing).

Balloon dilatation of supravalvar pul-monary stenosis after arterial switchprocedure for complete transposition

SIR,-I read with interest the article bySaxena et al on balloon dilatation ofsupravalvar pulmonary stenosis thatdeveloped after previous anatomical correc-tion of transposition of the great arteries.'They described the results of eight balloondilatations in five children. In none of thedilatations was there any improvement in thepressure gradient across the area of obstruc-tion nor was there any significant angiogra-phic change. Yet they went on to applyballoon angioplasty in five patients and inaddition repeated the procedure in threechildren. As they state, the residual obstruc-tion seems to be related to shrinkage andretraction of the pericardial patch used in theenlargement of neopulmonary artery at thetime ofinitial surgery. There is no theoreticalbasis why such lesions would respond toballoon dilatation. Zeevi et al's observationswere also similar when there was diffusenarrowing of the pulmonary artery.2 I havealso used balloon dilatation of supravalvarpulmonary stenosis that developed after aprevious arterial switch procedure.' Therewas excellent haemodynamic (fig 1) andangiographic (fig 2) improvement; however,the obstruction in my case was discrete (fig1A) and there is theoretical reason for balloondilatation to be effective discrete obstructionssuch as this.

I urge Saxena et al and others not to useballoon angioplasty if obstructive lesions ofthe pulmonary artery in children are diffuse,those described by Saxena and Zeevi.' Dis-crete lesions, however, can be dilated.

P SYAMASUNDAR RAODivision of Pediatric Cardiology,

University of Wisconsin Medical School,University of Wisconsin Children's Hospital,

Madison, WI S3792-0001, USA

1 Saxena A, Fong LV, Ogilvie BC, Keeton BR.Use of balloon dilatation to treat supravalvarpulmonary stenosis developing after anatomiccorrection for complete transposition. BrHeart J 1990;64:151-5.

2 Zeevi B, Keane JF, Perry SB, Lock JE. Balloondilatation of postoperative right ventricularoutflow obstructions. J Am Coll Cardiol1989;14:401-8.

3 Rao PS. Balloon angioplasty and valvuloplastyin infants, children and adolescents. CurrProbi Cardiol 1989;14:417-500.

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Figure I Pressure pullback tracings across the supravalvar stenosis showing a significant pressuregradient (A) that diminished considerably after balloon dilatation (B). Aortic pressure is alsoshown in B. Ao, aorta; DPA, distal pulmonary artery; PPA,. proximal pulmonary artery.Reproduced with permissionfrom the author and publisher: Rao PS. Curr Probl Cardiol1989;14:417-500.

This letter was shown to the authors, who replyasfollows:SIR,-Dr Rao has misinterpreted the natureof the stenotic lesions of the supravalvarpulmonary area that we attempted to dilateafter the arterial switch procedure. Theangiographic appearances of the cases,'showed a stenotic segment that seemed to belocalised to a short segment in the proximalpulmonary artery which was considerablynarrower than the distal pulmonary arterialsegment. The distal pulmonary artery mayhave looked smaller than expected, but it wascomparable to the more distal pulmonaryarterial tree, except where a further localisedstenosis occurred. It was this short segmentof proximal supravalvar pulmonary stenosisor discrete bifurcation stenosis that respon-ded poorly to balloon dilatation. Thesegments appeared amenable to balloondilatation, as judged by angiography, and didnot assume the appearance of diffuse narrow-ing that Dr Rao has described. It was con-cluded that these short localised segmentsthat responded poorly to balloon dilatationshould not be described as a discrete stenosis,as their appearance suggested, because theyresponded like short segments with hypo-plasia with both an intrinsic and post-surgicalaetiology. We agree with Dr Rao that diffusehypoplasia would not be amenable to balloondilatation. Progress in developing effectivetreatment for such stenotic lesions comes notonly from knowledge of successful trials, but

also from unsuccessful attempts, asanticipated by the use of endovascular stentsfor congenital heart disease.2

L V FONGDepartment of Cardiology,Royal Children's Hospital,

Flemington Road,Parkville, Victoria, 3052,

Melbourne, Australia

1 Saxena A, Fong LV, Ogilvie BC, Keeton BR.Use of balloon dilatation to treat supravalvarpulmonary stenosis developing afteranatomical correction for complete transposi-tion. Br Heart J 1990;64:151-5.

2 O'Laughlin MP, Perry SB, Lock JE, MullinsCE. Use of endovascular stents in congenitalheart disease. Circulation 1991;83:1923-39.

Balloon atrial septostomy via theumbilical vein

SIR,-We wish to point out that the "prac-ticability of cannulation via the umbilicalvein"' was first reported by us as an alter-native to the femoral route for balloon atrialseptostomy over two decades ago.2 Severalcentres have adopted the method and haveconfirmed the usefulness and advantages ofthis approach.' One report was published inthe British Heart Journal in 19746 with similarconclusions to ours. The incorporation ofechocardiographic imaging makes theumbilical route even more attractive. Wehighlighted the fact that transumbilical sep-

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Figure 2 Cineangiographicframesfrom lateral views ofpulmonary arteriograms showingsupravalvar pulmonary stenosis (arrow) after an arterial switch operation (A) that improvedconsiderably after angioplasty (B). Reproduced with permission from the author andpublisher:Rao PS. Curr Probl Cardiol 1989;4:417-500.

tostomy was not only less time-consumingbut spared the femoral vein for possiblefuture studies. At the time dissection of theinguinal fossa for balloon septostomies was

much more common than transcutaneouscatheterisations in the neonate.

EDWARD G ABINADERHeart Institute and CCU,Bnai Zion Medical Center,Technion Medical Faculty,

Haifa, Israel

1 Ashfaq M, Houston AB, Gnanapragasam JP,Lilley S, Murtagh EP. Balloon atrial septo-stomy under echocardiographic control: sixyears' experience and evaluation of the prac-ticability ofcannulation via the umbilical vein.Br Heart J 1991;65:148-51.

2 Abinader E, Zeltzer M, Riss E. Transumbilicalatrial septostomy in the newborn. Am J DisChild 1970;119:354-6.

3 Romney D, Katzuni E, Aygen MM. Transum-

bilical balloon atrial septostomy in a case oftranspositon of the great vessels with situsinversus totalis. Isr JMed Sci 1972;8:529-31.

4 Newfeld EA, Purcell C, Paul MH, Cole RB,Muster AJ. Transumbilical balloon atrial sep-tostomy in 16 infants with transposition ofthye great arteries. Pediatrics 1974;54:495-7.

5 Roguin N, Sujov P, Montag J, Zeltzer M, RissE. Transumbilical balloon atrial septostomyfor transposition ofthe great arteries in infantsunder the age of 60 hours. Am Heart J 1984;107:174-6.

6 Kaye HH, Tynan M. Balloon atrial septostomyvia the umbilical vein. Br Heart J 1974;36:1040-2.

SIR,-The report ofballoon atrial septostomyunder echocardiographic control by Ashfaqet al makes interesting reading but certainpoints need to be clarified before recommen-ding it as a procedure of choice.

On the basis of the size of the atrial septaldefect they created (as seen on echocardiogra-phic image or by colour flow mapping) Ash-faq et al claim that the procedure was success-ful. However, though they believe that such adefect can be "accurately measured" onechocardiography, they do not give the values(mean (SD)) of the defect size or flow jetwidth. In another study adequately palliatedneonates had a post-septostomy interatrialdefect of at least 12 mm in diameter asmeasured angiographically' or later at sur-gery or necropsy.2 In most of the previousseries, satisfactory early improvement afteratrial septostomy has been defined as eitheran increase in oxygen saturation of greaterthan 10% with reduction in interatrial meanpressure gradient to less than 2mm or arterialsaturations ofgreater than 50-75%.3 Satisfac-tory late improvement has been defined assurvival to six months with oxygen saturationat 60% or higher.3 It is surprising that none ofthese indices are mentioned in the resultsthough Ashfaq et al call their procedure "100per cent successful". It is possible that theseindices were not measured when theprocedure was performed as an emergencymeasure. But Ashfaq et al do not give a breakdown ofthe number ofprocedures performedin an equipped catheterisation laboratorycompared with those performed elsewhere orin the ward side room. The size of the post-septostomy inter-atrial defect can bemeasured only approximately by echocar-diography.' We were able to image a flappingtorn septum primum as an indication of anadequate septostomy. Because there are sofew data on the features and limitations ofechocardiography and colour flow mappingin evaluating the adequacy of post-septo-stomy interatrial defects, we expected thatAshfaq et al would have clarified these beforedrawing conclusions and inferences. At leastthe echocardiographic size ofthe defect couldhave been compared with the actualmeasurement at necropsy in the two patientswho died.Ashfaq et al seem to exaggerate the com-

plications related to fluoroscopically guidedseptostomy by quoting a single referencedating back to 1970 that describes 26 cases.5In a more recent series of 43 infants with d-transposition of the great arteries studiedover five years, fluoroscopy guided balloonatrial septostomy was not associated with anydeaths or mechanical complications.3Moreover, though they do not state theaverage procedure time, Ashfaq et al presumethat the echoguided procedure is less time-consuming.Thus balloon atrial septostomy under

echocardiographic guidance could be recom-mended during emergencies or in the cath-eterisation laboratory for facilitating theballoon positioning, especially in cases withcardiac malposition, but until our questionsare answered it should not be advocated as abetter alternative to fluoroscopy.

PRAFULLA G KERKARBHARAT V DALVI

Department of Cardiology,King Edward VII Memorial Hospital,

Parel, Bombay 400 012, India

1 Baker F, Baker L, Zoltun R, Zuberbuhler JR.Effectiveness of the Rashkind procedure intransposition of the great arteries in infants.Circulation 1971;43-44 (suppl I):1-6.

2 PowellTG, Dewey M, West CR, Arnold R. Fateof infants with transposition of the greatarteries in relation to balloon atrial septo-stomy. Br Heart J 1984;51:371-6.

3 Henry CG, Goldring D, Hartman AF, WeldonCS, Strauss AW. Treatment of d-transposi-

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tion of the great arteries: management ofhypoxemia after balloon atrial septostomy.Am J Cardiol 1981;47:299-306.

4 Allan LD, Leanage R, Wainwright R, JosephMC, Tynan M. Balloon atrial septostomyunder two dimensional echocardiographiccontrol. Br Heart J 1982;47:41-3.

5 Venables AW. Balloon atrial septostomy incomplete transposition of great arteries ininfancy. Br Heart J 1970;32:61-5.

These letters were shown to the authors, whoreply as follows:SIR,-We agree entirely with Dr Abinader'scomments. Neither the use of ultrasoundimaging nor the umbilical vein route are newtechniques for the performance of an atrialseptostomy and in our paper we did notintend to suggest that this was the case. Theinitial intention was to review our experiencewith the efficacy of ultrasound imaging. Inmost centres the umbilical route has not beenused routinely in the past because ofdifficultyin catheter manipulation where a full cath-eterisation is necessary to establish the diag-nosis. Catheterisation is now necessary onlyfor the performance of a septostomy and theumbilical route is ideal for this. We thought itappropriate to add our experience of the useof the umbilical route pioneered by Abinaderet al because we were aware that many centresstill did not use it.We referred in some detail to the different

workers who have commented on theultrasound technique, which has becomepopular only in recent years. The use of theumbilical vein technique has been known forover 20 years and indeed it was describedin 1985 in a major textbook on paediatriccardiology to which we referred.' We thusconsidered it was not necessary to refer indetail to the initial reports on this, and weagree it would have been appropriate to quotethe early paper on the subject.We would like to take the opportunity of

stating that we are no longer sure of theaccuracy of the comment that the ultrasoundimage is of little value in the manipulation ofthe catheter. In a newborn the heart was onlyentered after the image had been used toensure that the catheter was inserted with thebend aligned in a posterior and inferiordirection and then, at the appropriate point asdetermined from the image, it was turnedthrough a 180' angle to pass through theductus venosus and into the inferior vena cavaand thence the heart.Drs Kerkar and Dalvi question the validity

of our supposition that a septostomy per-formed under ultrasound is as effective as oneperformed under fluoroscopy. Ours was aretrospective study and the size of the defectwas not measured routinely. As their letterpoints out the "success" of a septostomy isdifficult to define and there is more to it thansimply the size of the defect. Because electivearterial switch procedures are performedwithin the first weeks oflife data on long-termfollow up can no longer be obtained. None ofour patients required "emergency" surgerybut in some prostaglandin therapy was con-tinued or started after septostomy. The com-ment that "the size . . . showed the procedurewas successful" was made on the basis ofseeing a tear, a flapping septum, and anincrease in the size of the defect. If thecriticism is related to the use of ultrasound Icannot accept that there is any reason that theresult could be different because the actualtechnique of pulling the catheter is nodifferent with ultrasound or screening. Wehave not compared the results of using theumbilical and femoral routes but both have

been accepted techniques for years. Thefacilities of a catheterisation laboratory arenot needed for septostomy under ultrasoundscreening. In our paper we stated that for 10months the ward side room was used whencatheterisation facilities were unavailable;thereafter we have used the catheterisationlaboratory routinely simply as a matter ofconvenience to the nursing staff; the x rayimaging facilities are not used. Where neces-sary septostomy is undertaken in the ward,intensive therapy unit, or maternity hospital.The location is simply a matter of personalchoice and hospital routine and again I cannotsuppose that there is any reason that the resultwould be different for ultrasound and fluoro-scopy.

I accept that in experienced hands the riskof mitral damage is almost negligible-butreports attest to the fact that damage doesoccur with fluoroscopy. I am unaware of thishappening with ultrasound screening. Inaddition I accept that there should be littledifference in the time of the procedurewhether ultrasound or fluoroscopy is used. Inthe past there might have been a potentialdelay in obtaining the services of a radiogra-pher or access to a catheterisation laboratoryin an emergency, but this is now of lessconcern because the infant can be maintainedon prostaglandins and the septostomy per-formed at a convenient time.Thus I agree with some ofDrs Kerkar and

Dalvi's comments but I disagree with theconclusion to their letter. In our centre thesimplicity and convenience of ultrasoundquickly made it the technique of choice. Apreference for ultrasound or fluoroscopy maysimply be a matter of personal choice,experience with ultrasound, and the hospitalfacilities available. However, my colleaguesand I firmly believe that it is correct toadvocate ultrasound as a more convenient andbetter imaging technique than fluoroscopy.

ALAN HOUSTONRoyal Hospitalfor Sick Children,

Yorkhill, Glasgow G3 8SJ

I Cardiac catheterisation and angiocardiography.In: Anderson RH, Macartney FJ, Shine-bourne EA, Tynan M, Paediatric cardiology.Edinburgh, London, Melbourne, New York:Churchill Livingstone, 1987:372.

Cardiac catheterisation with 5 Frenchcatheters

SIR,-In his letter commenting on the use of5F catheters for coronary angiography, DrRaphael calls for further randomised studiesto compare the latest 5F catheters with con-ventional 7F catheters (British Heart Journal1991;66:114). He and your readers may beinterested to know that such a trial wasundertaken in Bristol using the types of 5Fcatheter available in 1988 and 1989.' The fullresults of this trial are due to be publishedsoon in the International Journal of CardiacImaging; however, the main message of thetrial was that the 5F catheters available at thattime proved extremely unsatisfactory forcoronary angiography and could not berecommended for routine use. Catheterdesign has progressed rapidly, or at least sowe are told by the catheter manufacturers. Itmay be that the time is now right for a furtherrandomised study to compare the currentgeneration of 5F catheters with conventionalcatheters. Such a study will need to includenot only subjective assessments of catheterperformance but will also need to document

objective measures of catheter performancesuch as procedure time, injection pressures,and incidence of significant complications.

GEORGE G HARTNELLDepartment of Radiology,

New England Deaconess Hospital,185 Pilgrim Road,

Boston, Massachusetts 02215,USA

1 Brown E, Morris K, Wild RPH, Hartnell GG.Limitations in the performance of 5-F coron-ary catheters in routine angiography [abs-tract]. Clin Radiol 1989;40:648.

Genesis of Still's innocent systolicmurmur

SIR,-The recent publication of the paper onStill's innocent systolic murmur' promptedqueries about who Still was and whetherStill's disease commemorates the sameindividual.George Frederic Still was indeed the

author of early descriptions of both condi-tions. His personal history has been elegantlydescribed by Hamilton.2 Still was educated atCaius College, Cambridge, qualified inmedicine at Guy's Hospital in 1893 and, afterposts at the Hospital for Sick Children, GreatOrmond Street, was appointed to the firstchair of paediatrics in London, at King'sCollege Hospital, in 1906. His publicationsincluded five books and 108 papers,' amongthe earliest being his classic description oftheform of chronic arthritis in childhood thatbears his name.4

In his book Common Disorders and DiseasesofChildhood5 the innocent systolic murmur isreferred to as a "physiological bruit" whichmust be differentiated from the "sometimesmusical character of murmurs occurring inbacterial endocarditis". He describes theinnocent murmur in these terms: "It is heardusually just below the level of the nippie, andabout halfway between the left margin of thesternum and the vertical nipple line; it is notheard in the axilla nor behind; it is systolicand is often so small that only a carefulobserver would detect it; moreover, it is veryvariable in audibility...; its characteristicfeature is a twanging sound, very like thatmade by twanging a piece of tense string".This description remains accurate and auth-oritative to this day.

HYAM S JOFFECardiology Department,

Bristol Royal Children's Hospital,St Michael's Hill,Bristol BS2 8BJ

1 Gardiner HM, Joffe HS. Genesis of Still'smurmurs: a controlled Doppler echocar-diographic study. Br Heart J 1991;66:217-20.

2 Hamilton EBD. George Frederic Still. AnnRheum Dis 1986;45:1-5.

3 Franklin AW. A handlist of the writings ofGeorge Frederic Still. Arch Dis Child 1941;16:154-5.

4 Still GF. On a forn of chronic joint disease inchildren. Med-Chir Trans 1897;80:47-59.

5 Still GF. Common disorders and diseases ofchildhood. 3rd ed. London: Oxford Univer-sity Press, 1920:495.

Is cardiac rehabilitation necessary?

SIR,-Precise identification of the specificneeds of individual coronary patients forrehabilitative care and precise recommenda-tions regarding the components of this carewill enable precise assessment of the out-comes of these interventions.The occurrence of a coronary event and/or

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