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Dye Dilution Curves After the Artificial Atrial Septostomy in Three Infants with the Transposition of the Great Vessels

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Dye Dilution Curves After the Artificial Atrial Septostomy in Three Infants with the Transposition of the Great Vessels Pohoku J. exp. Med., 1970, 100, 39-46 Dye Dilution Curves after the Artificial Atrial Septostomy in Three Infants with the Transposition of the Great Vessels Hiroshi Onoki, Tetsuo Sato, Ichiki Kano and Keiko Mochizuki Department of Pediatrics (Prof. Ts. Arakawa), Faculty of Medicine, Tohoku University, Sendai Hemodynamic consequences after the Rashkind and Miller balloon atrial septostomy were successfully evaluated by means of the dye dilution technic in three infants with the complete transposition of the great vessels. The complete transposition of the great vessels has been the most common cause of death in infants born with congenital malformations of the heart; accord ing to Boesen1 forty-two per cent of the patients with this anomaly succumbed within one month of life and seventy-three per cent within the first three months of life. In 1964 Mustard2 reported a case of the transposition of the great vessels in which the successful result of the radical operation was obtained by adopting a two-stage correction technic; that is, creation of an atrial septal defect was done by Blalock-Hanlon's procedure with thoracotomy when 20 days of life, then successful radical operation was carried out at the age of 18 months. In 1966 Rashkind and Miller3 devised a method for the creation of an atrial septal defect without thoracotomy as a palliative approach to the complete transposi tion of the great vessels. Then in 1968, Rashkind and Miller4 reported thirty-one infants with the transposition of the great vessels who were subjected to the balloon atrial septostomy of theirs with a marked improvement in the interatrial blood commu nication. When the successful balloon atrial septostomy was done, a marked improve ment in clinical conditions, i.e., a decrease in cyanosis, etc., was observed. The abolition of the pressure gradient between the atria and the sampling of highly oxy genated blood from the right atrium were further evidences for the presence of an adequate interatrial blood communication after the balloon atrial septostomy.5,6 Our present study was an attempt to use the dye dilution technics7,8 after the artificial balloon atrial septostomy as a method for estimating the interatrial blood communication induced by the procedure. Receivedfor publication, September 3, 1969. 39 40 H. Onoki et al. CASES EXAMINED Case 1. M.A., a female was born on October 9, 1968, weighing 2,800g . The child was cyanosed at rest which became more remarkable when she was crying or taking feedings. Physical examination, when 4 months old, revealed a cyanotic and thin girl, there were moist rales all over the lungs. X-ray films of the chest showed cardiac enlargement and increased pulmonary vascularity (cf. Fig. 1). Electrocardiograms revealed bilateral hypertrophy of both the ventricles and atria (cf. Fig. 2). Phonocardiograms showed the presence of faint systolic murmurs at the pulmonic area (cf. Fig. 3). Fig. 1. A chest roentgenogram of Case 1. The result of angiocardiography established a diagnosis of the complete transposition of the great vessels with no evidence of either interventricular or interauricular blood communication. When 4 months old, the balloon atrial septostomy was carried out according to Rashkind and Miller's method by using the catheter 4F . The amount of the contrast material infused into the balloon was one ml . After the procedure, dye dilution curves were recorded with a result showing a marked improvement in the interatrial blood communication (cf. Fig. 4). Case 2. Y.K., a 12-day-old male was admitted to the University Hospital because of deep cyanosis soon after birth . His delivery was uneventful, with a birth weight of 3,960g. Physical examination revealed a boy with cyanosis and tachypnea. The liver was palpable 5cm below the costal margin . There were Dye Dilution Curves after Artificial Atrial Septostomy 41 Fig. 2. Fip. 3. Fig. 2. An electroardiogram of Case; 1. Fig. 3. A paonocardiogram of Case 1. Fig. 4. A dye dilution curve after the balloon atrial septostomy in Case 1. rales all over the lungs. No cardiac murmurs were recorded in phonocardiograms (cf. Fig. 7). Chest X-ray films revealed the cardiac enlargement and pulmonary congestion (cf. Fig. 5). Electrocardiograms showed a remarkable right ventricular hypertrophy (cf. Fig. 6). A diagnosis of the transposition of the great vessels without interatrial or interventricular septal defect was established by angiocardiographic findings. 42 Ti. Onoki et al. Fig. 5. The chest roentgenogram of Case 2. Fig. 6. Fig. 7. Fig. 6. An electrocardiogram of Case 2, showing remarkable right ventricular hypertrophy. Fig. 7. A phonocardiogram of Case 2. Dye Dilution Curves after Artificial Atrial Septostomy 43 When 13 days old, the balloon atrial septostomy was done with use of Rashkind's single lumen catheter 4F. The balloon was inflated with 1.5ml of the contrast medium. The dye dilution curves were recorded before and after the balloon atrial septostomy, showing that a marked improvement in the interatrial blood com munication was achieved by the Rashkind's procedure (cf. Figs. 8A and 8B). Fig. 8A. A dye dilution curve of Case 2 before the balloon atrial septostomy. Fig. 8B. A dye dilution curve of Case 2 after the balloon atrial septostomy. Case 3. T.O., an 11-day-old male was admitted to the University Hospital because of cyanosis and tachypnea soon after birth. The birth weight was 3,100g. The liver was palpable 3cm below the costal margin. There was suprasternal retraction on inspiration. X-ray films of the chest demonstrated cardiac enlargement and pulmonary overvascularity (cf. Fig. 9). On phonocardiograms apical systolic cardiac murmurs were recorded (cf. Fig. 11). Electrocardiograms showed a remarkable hypertrophy of the right ventricle (cf. Fig. 10). An angiocardiography taken on the 12 days of life gave definite evidences for the complete transposition of the great vessels without interauricular or interventri cular septal defect. The balloon atrial septostomy was performed, where the balloon was inflated with 1.5ml of the contrast medium. 44 H. Onoki et at. Fig. 9. A chest roentgenogram of Case 3 on admission. Fig. 10. Fig. 11. Fig. 10. An electrocardiogram of Case 3. Fig. 11. A phonocardiogram of Case 3. Dye Dilution Curves after Artificial Atrial Septostomy 45 Dye dilution curves were recorded before and immediately after the Rashkind septostomy, showing a striking increase in the interatrial blood mixing after the balloon atrial septostomy (cf. Figs. 12A and 12B). A marked decrease in the cardiothoracic ratio was observed 10 days after the balloon atrial septostomy (cf. Fig. 13). Fig 12A. A dye dilution curve before the balloon atrial septostomy. Fig. 12B. A dye dilution curve after the balloon atrial septostomy. Fig. 13. A chest roentgenogram of Case 3, taken 10 days after the balloon atrial septostomy. 46 H. Onoki et al. DISCUSSION The result of our present study revealed that the effective balloon atrial septostomy could be evaluated on the basis of the dye dilution curves recorded before and after the procedure. The evidences for the presence of artificial interatrial blood communication were consisting of the following findings in the dye dilution curves obtained after the procedure: 1) An occurrence of an abnormal hump in the down slope, 2) the prolongation of the disappearance time, 3) loss or diminution of the recirculation curve, 4) a decrease in the peak concen tration, and 5) a decrease in the gradient of the down slope. References 1) Boesen, I. Complete transposition of the great vessels: Importance of septal defects and patent ductus arteriosus. Analysis of 132 patients dying before age 4. Circulation, 1963, 28, 885-887. 2) Mustard, W.T. Successful two-stage correction of transposition of the great vessels. Surgery, 1964, 55, 469-472. 3) Rashkind, W.J. & Miller, W.W. Creation of an atrial septal defect without thoracotomy. A palliative approach to complete transposition of the great arteries. J. Amer. med. Ass., 1966, 196, 991-992. 4) Rashkind, W.J. & Miller, W.W. Transposition of the great arteries. Results of palliation by balloon atrioseptostomy in thirty-one infants. Circulation, 1968, 38, 453-462. 5) Jordan, S.C. & McCarthy, C. Hemodynamic consequences of atrial septostomy without thoracotomy in an infant with transposition of the great arteries. Lancet , 1967, 1, 310-311. 6) Watson, H. & Rashkind, W.J. Creation of atrial septal defects by balloon catheter in babies with transposition of the great arteries. Lancet, 1967, 1, 403-405. 7) Sato, T., Onoki, H., Yamauchi, N & Kano, I. Earpiece dye-dilution technics for estimation of the left-to-right shunt in infants and children. Tohoku J. exp. Med., 1969, 97, 329-335. 8) Sato, T., Onoki, H., Yamauchi, N. & Kano, I. A simplified method for calculation of the left-to-right shunt from a single earpiece dye-dilution curve. Tohoku J . exp. Med., 1969, 97, 337-346..
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