Author + information
- Received December 7, 1988
- Revision received May 3, 1989
- Accepted June 14, 1989
- Published online November 15, 1989.
- Thomas P. Graham Jr., MD, FACC∗,
- Judith Burger, RN,
- Robert J. Boucek Jr., MD,
- James A. Johns, MD,
- Gordon A. Moreau, MD,
- John W. Hammon Jr., MD, FACC and
- Harvey W. Bender Jr., MD, FACC
- ↵∗Address for reprints: Thomas P. Graham, Jr., MD, Vanderbilt Medical Center, Division of Pediatric Cardiology, D-2217 MCN, Nashville, Tennessee 37232-2572.
Clinical characteristics and angiographic ventricular volume data were obtained in 25 infants aged 1 to 66 days who presented with coarctation of the aorta, ventricular septal defect and congestive heart failure to determine if left ventricular volume loading was present and if there were hemodynamic or volumetric variables that were predictive of operative mortality in this group.
Pulmonary to systemic flow ratio averaged 2.8 ±0.8 and right ventricular/left ventricular peak pressure ratio was 0.96 ± 0.12. Left ventricular end-diastolic volume averaged 116 ± 49% of normal and was less than the investigators' lower limit of normal in 5 (20%) of 25 patients. In contrast, right ventricular end-diastolic volume, measured in eight patients, averaged 173 ± 47% of normal and was greater than the investigators' upper limit of normal in seven (88%) of eight. Left ventricular ejection fraction averaged 0.47 ± 0.17 and was below normal (<0.55) in 14 (58%) of 24 patients. Preoperative volume and ejection fraction data did not differ in infants with coarctation plus ventricular septal defect and a similar group of 19 infants with isolated coarctation. Abnormal left ventricular operative volume distensibility was inferred by normal or decreased left ventricular end-diastolic volume and increased left ventricular end-diastolic pressure (>12 mm Hg) in 12 (55%) of 24 patients.
Early plus late mortality was related to left ventricular size: 3 of 5 patients with a small left ventricular end-diastolic volume died, compared with only 4 of 20 with a normal or increased volume (p < 0.05). Low left ventricular ejection fraction was not related to mortality; 2 of 14 patients with a low versus 3 of 10 with a normal ejection fraction died (p = NS). Repeat catheterization was carried out between 1.4 and 28 months after coarctation repair in 14 patients. Two patients with an initial small left ventricle had normal left ventricular size and five of seven patients with a prior low left ventricular ejection fraction had a normal ejection fraction. Left ventricular end-diastolic volume averaged 124 ± 60% of normal and left ventricular ejection fraction averaged 0.63 ± 0.11 (p < 0.01 versus preoperative value) for all 14 patients.
Despite a marked increase in pulmonary to systemic flow ratio, left ventricular end-diastolic volume remains normal or small in the majority of infants with coarctation and a large ventricular septal defect. Normal or low left ventricular end-diastolic volume in these patients in combination with increased right ventricular end-diastolic volume suggests a prominent atrial left to right shunt, which may partially be related to decreased left ventricular compliance. Abnormalities of left ventricular pump function are common in these patients but are primarily related to afterload mismatch or irreversible contractile function depression, or both.
- Received December 7, 1988.
- Revision received May 3, 1989.
- Accepted June 14, 1989.