digoxin and Coronary-Vessel-Anomalies

We report a case of a 33 yr old woman with pulmonary hypertension secondary to uncorrected right coronary artery to pulmonary artery fistula who underwent two successful operative deliveries under general anesthesia.. This woman underwent an emergency Caesarean section at 32 wk gestation because she presented in NYHA Class IV, heart failure and premature labour. She did not have antenatal follow-up. For her second pregnancy, she was managed from the first trimester of pregnancy by the cardiologist, obstetrician and anesthesiologist. She received oral furosemide and digoxin from eight weeks gestation. Pregnancy was managed to term before she progressed to NYHA Class IV and cardiac failure at 37 wk gestation. She had a Caesarean section under general anesthesia. She received rapid sequence induction of anesthesia and tracheal intubation with 0.1 mg x kg(-1) etomidate, 2 mg x kg(-1) succinylcholine and maintenance with nitrous oxide 50% in oxygen, isoflurane 1% and 0.1 mg x kg(-1) vecuronium. Fentanyl, 2 microg x kg(-1) helped to obtund the hypertensive response to intubation. Analgesia was provided with 1 mg x kg(-1) morphine. Glyceryl trinitrate infusion, 10-30 microg x min(-1) was used in addition to the anti-heart failure therapy. End-tidal capnography, electrocardiogram, pulse oximetry, continuous arterial blood pressure and pulmonary arterial catheter provided hemodynamic monitoring. The lungs were mechanically ventilated for 24 hr postoperatively. She received anti-heart failure therapy which she continued after discharge. She was NYHA class II upon discharge. She defaulted from further follow-up.. Although the literature advocates, in this situation, controlled vaginal delivery utilising epidural analgesia, we describe the successful outcome for operative delivery under general anesthesia in a patient with secondary pulmonary hypertension and heart failure.

Topics: Adult; Analgesics, Opioid; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthesia, Obstetrical; Arterio-Arterial Fistula; Blood Pressure; Cardiac Output, Low; Cardiotonic Agents; Cesarean Section; Coronary Vessel Anomalies; Digoxin; Diuretics; Female; Furosemide; Humans; Hypertension, Pulmonary; Intubation, Intratracheal; Morphine; Neuromuscular Blockade; Nitroglycerin; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Artery; Respiration, Artificial; Vasodilator Agents

Nine children and 1 adolescent with anomalous left coronary artery from the pulmonary trunk (ALCA) were studied between 1970 and 1982. Serial angiographic and hemodynamic data are compared with the clinical course. Four patients had separate conus coronary arteries with a major contribution to collateral flow. Eight patients survived various surgical procedures with 1 late death, 1 awaits operation, and 1 died in infancy. The authors' data show a significant potential for improvement in left ventricular function as shown by an increase in LV ejection fraction on medical therapy alone (5/6 patients), including all 4 with separate conus coronary arteries. The authors conclude that medical treatment alone may be indicated for a time in selected patients with ALCA, and a subgroup with a separate conus coronary artery may have a more favorable natural history.

Topics: Cardiac Catheterization; Child; Child, Preschool; Combined Modality Therapy; Coronary Angiography; Coronary Vessel Anomalies; Coronary Vessels; Digoxin; Diuretics; Electrocardiography; Humans; Infant

An infant with a symptomatic coronary artery fistula, documented by angiography, is presented. By age 5 years, clinical evidence of the fistula was no longer present. Repeat cardiac catheterization confirmed spontaneous closure of the coronary artery fistula. More information regarding the natural history of a coronary artery fistula is required before an elective surgical approach can be recommended in all asymptomatic children.

Topics: Cardiac Catheterization; Child, Preschool; Coronary Vessel Anomalies; Digoxin; Female; Heart Murmurs; Humans; Oxygen

Thallium-201 myocardial imaging was performed on six patients with an anomalous left coronary artery arising from the pulmonary artery. Initial images in three children (aged 4 months, 12 months and 2 1/2 years, respectively) demonstrated anterolateral perfusion defects in agreement with the electrocardiographic localization of infarction. Repeat imaging in two patients 2 to 3 months later, after clinical improvement with anticongestive therapy, demonstrated a reduction in the perfusion defect. In 3 other patients (aged 16, 16 and 20 years, respectively) thallium-201 scans performed during exercise stress demonstrated normal myocardial perfusion 7 to 15 years after operation (ligation of anomalous left coronary in two, ligation plus bypass graft in one). Thallium-201 imaging appears to be helpful in monitoring changes in myocardial perfusion before and after medical or surgical treatment of an anomalous left coronary artery, and may shed light on the pathophysiology of the defect. A possible practical limitation of thallium-201 imaging in this condition is the difficulty of imaging subendocardial infarction.

Topics: Adolescent; Child; Child, Preschool; Coronary Vessel Anomalies; Coronary Vessels; Digoxin; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Failure; Humans; Infant; Ligation; Male; Physical Exertion; Pulmonary Artery; Radioisotopes; Radionuclide Imaging; Thallium

Topics: Angiocardiography; Cardiomegaly; Child; Coronary Vessel Anomalies; Diagnosis, Differential; Digitalis; Digoxin; Drug Therapy; Electrocardiography; Endocardial Fibroelastosis; Glycogen Storage Disease; Humans; Infant; Mumps; Myocarditis; Skin Tests