To determine if symptoms and electrocardiographic abnormalities relate to left ventricular mass, volume, and mass/volume ratio in children with aortic stenosis and/or insufficiency, we examined 42 patients (aged 11±6 years) with cross-sectional and Doppler echocardiography. Clinical symptoms included exertional chest pain, shortness of breath, exercise intolerance, congestive heart failure and syncope. Electrocardiographic abnormalities were defined as the presence of both left ventricular hypertrophy and ST-T wave changes. Left ventricular volumes and mass were measured from echocardiograms using paired orthogonal apical views and biplane Simpson's and truncated ellipsoid models, respectively. The peak and mean pressure gradients across the aortic valve, the aortic valvar area, and the degree of aortic insufficiency were determined using echo/Doppler techniques. Eighteen patients (ages 10±7 years) had pure aortic stenosis (peak gradient 52±29 mm Hg, mean gradient 28±18 mm Hg, and valve area 0.86±.46 cm2/m2). Of these 18, seven had symptoms and seven had an abnormal electrocardiogram. Twenty-four patients (aged 12±6 years) had aortic stenosis and aortic insufficiency (peak gradient 36±18 mm Hg, mean gradient 19±9 mm Hg, 18 with 1−2+ aortic insufficiency and six with 3−4+ aortic insufficiency). Of these 24, 10 had symptoms and 10 had an abnormal electrocardiogram. When symptomatic and asymptomatic patients were compared using an unpaired Student's t-test, symptomatic patients with pure aortic stenosis and combined aortic stenosis and insufficiency had left ventricular hypertrophy and inappropriately increased mass/volume ratios. However, due to differences in left ventricular volume, symptoms and electrocardiographic abnormalities occurred at a higher mass/ volume ratio in pure aortic stenosis (2.7±0.6) than in combined aortic stenosis and insufficiency (1.7±0.3).

HAPPY NEW YEAR! IT BECOMES INCREASINGLY EVI-dent that it is a truism that years go past quicker as we become older. Ironically, as time goes by faster, we must devote more of our attention to the future. For readers of Cardiology in the Young, as we enter our fifth year of publication, the future is indeed bright. As of this issue you join readers on six continents and scores of countries. As editors, we are most grateful for your continued support. You will notice changes that we are incorporating into this volume, beginning with a complete redesign of our cover and minor changes in the size of the journal. Further substantive editorial changes will be incorporated throughout the year, and we will keep you fully informed as we go. Exciting changes will occur as we augment participation from colleagues in Japan, China and throughout Asia. Please share with us your ideas, as we are amenable to any change or addition that will further improve the quality of Cardiology in the Young.

We evaluated the modulation of the viability of immature cardiac myocytes by cardiac fibroblasts after hypothermic preservation using three types of storage solutions—saline, University of Wisconsin solution, and MCDB 107 medium. Cardiac myocytes and fibroblasts were isolated from neonatal rat ventricles, and cultures of myocytes only or co-cultures with fibroblasts (myocyte: fibroblast 2:1) were established. On the fourth day of culture, the cultures were incubated at 4 °C for 6, 12, 18 and 24 hours in the different storage solutions. Enzymes were measured in the storage solutions immediately before and after hypothermic incubation. The cultures were then incubated for an additional 24 hours at 37 °C to evaluate the recovery of the myocyte beating rate. The myocyte beating rate in the co-culture groups showed significantly higher recovery ratios than the corresponding groups in which only myocytes were cultured. Complete recovery was observed in the group co-cultured in MCDB medium 24 hours after hypothermic incubation (83.4% of control—beating rate prior to hypothermic incubation) compared to the other co-cultured groups (15.4, 0%, respectively). Release of enzymes in the co-cultures was significantly suppressed compared to the cultured myocytes, and the greatest suppression was found after 24 hours of incubation in MCDB medium (CPK: 36.6 mIU/flask, LDH: 281.2 mIU/flask) compared to the other two co-cultured groups (CPK: 181.1, 281.1; LDH: 501.7, 773.2). Cardiac fibroblasts diminished myocytic injury after hypothermic preservation using various storage solutions, in which MCDB 107 medium showed the best overall protective effect. Thus, cardiac fibroblasts may play an important role in controlling myocytic viability under various hypothermic conditions.

BEFORE GOING INTO THE SPECIFIC AREAS OF PEDIATRIC cardiology and pediatric cardiac cardiology and pediatric cardiac surgery, an overview of the general health care organization in the Netherlands might be helpful. The Netherlands, a country with about 15 million inhabitants, spent 47 billion Dutch guilders (US$22 billion) for general health care in 1991. This is about 8.5% of the gross domestic product. Of this, 61% was spent on in-hospital costs, 39% on extramural costs, including the financing of organizations that deal with preventive (primary) medicine, such as clinics for infants and school children which were visited regularly. Almost all inhabitants, 99.6%, are covered for the expenses of health care, 60% through the “Sick Fund,” a state-insurance that is obliged for everyone with a yearly income of less than US$30,000. Employers of these people have to deduct an amount of money from the monthly salary to be paid to the “Sick Fund.” In case of unemployment this money is deducted from the amount paid by the social security office. The remaining 40% has some form of private insurance, that covers health care. Both diagnostic and therapeutic approaches as the timing of these are completely similar and independent from the type of insurance that applies for the individual patient.

Plasma leakage in polytetrafluoroethylene grafts arises through complex interactions between the prosthetic physical/chemical microstructure and patient environment. While many of the precipitating factors can be avoided by careful graft-handling and meticulous surgical technique, this unpredictable complication still contributes significant morbidity to shunt procedures. Protein sealing of the graft offers a possible solution to the problem.

The purpose of our study was to assess the effect of administration of erythropoietin on postoperative anemia in patients with congenital heart disease who had undergone open heart surgery without the use of homologous blood. One intravenous and one subcutaneous dose of 300 units of erythropoietin per kg body weight was given to 10 patients at a mean of five (3–8) days after surgery. Another group of 10 patients, who had undergone open heart surgery but were not given erythropoietin postoperatively, were used as controls. There was a significant fall in all patients in hemoglobin from 13.6±1.3 gm/dl prior to surgery to 9.8±1.6 gm/dl after surgery. In patients treated with erythropoietin, there was an immediate significant rise in hemoglobin and hematocrit. Hemoglobin rose by 14% on the seventh day after treatment (the twelfth day after surgery) and by 25% on the tenth day after treatment (the fifteenth day after surgery). It had increased by only 8% 15 days after surgery in the controls. These findings suggest a beneficial effect of administration of recombinant erythropoietin on postoperative anemia in children who had undergone open heart surgery without the use of homologous blood.

Outcome following the treatment of congenital heart disease continues to improve and interest has focused on reducing morbidity as well as mortality. One important aspect of this is the psychological effect of congenital heart disease and its treatment on both children and their parents. This review addresses the extent and nature of the psychological morbidity associated with this disease, in particular the impact of the diagnosis on the management of patient and family. The etiology of the high level of psychosocial morbidity remains poorly understood. Data from the 1960s concerned with pre-school and school-age children is now of little value given the dramatic changes in the treatment of congenital heart disease, which is now predominantly in the neonatal period. While theory from developmental and pediatric psychology may be usefully applied to this area, further research is required to define effective psychological care for patients and their families.

To determine the long-term results in patients with critical aortic stenosis who survive initial intervention, and to identify factors which predict prognosis, we studied patients who underwent intervention between 1979 and 1992 for critical aortic stenosis treated within the first three months of life. Patients with a hypoplastic left ventricle or mitral stenosis who were not considered for a biventricular repair were excluded. Follow-up examination included cross-sectional and Doppler echocardiography. All initial and subsequent patient data were reviewed. Of the 64 patients with critical aortic stenosis, 41 (64%) survived more than one month after initial intervention (surgical valvotomy in 39, balloon valvoplasty in two). These survivors constitute the study group. Mild or moderate residual aortic stenosis or regurgitation without further intervention was found in 28 patients at a median duration of 3.1 years (range 0.2–15.0 years). A poor result with re-intervention (n=6) or death (n=7) occurred in 13 patients. The diameter of the aortic valve at presentation was smaller (p<0.02) in patients with a poor result (median 5.5; range 5–15 mm), than in those with a satisfactory result (median 8.0; range 5–10 mm). Significant residual aortic stenosis was present from the time of initial intervention in nine of the 13 patients (69%) with a poor result. No difference was found in the incidence of a duct-dependent systemic circulation, associated cardiac lesions, mechanical ventilation, acidosis or the use of inotropes preoperatively between patients with a satisfactory or a poor late outcome. Of patients with critical aortic stenosis, 64% survived for more than a month after initial intervention. A small aortic valvar diameter at presentation ( 6 mm) and residual stenosis after initial intervention were important determinants of long-term prognosis.

Current procedural terminology codes generally do not distinguish between patients based on age or etiology of disease. As standardized payment schedules based upon such codes are being developed, the precise definition of a “typical” patient for each code becomes increasingly important. Since small size, young age, or presence of complex congenital disease could potentially render the work value of a physician's service different between children and adults, a study was jointly undertaken by the American College of Cardiology and the Cardiology Section of the American Academy of Pediatrics to compare relative work for the most commonly used Current Procedural Terminology codes in pediatric cardiology. A Technical Advisory Panel chose codes for evaluation and wrote clinical descriptors for each service. A separate rating panel of eight pediatric cardiologists (academic and private practice) and three adult cardiologists participated in a mail survey assigning work values to each service relative to current Health Care Financing Administration adult relative value units. The Panel then met and employed a modified Delphi process to arrive at consensus values. Of the 20 codes rated, only five were determined to be similar to adults. The pediatric median values were an average of 44% higher than the adult values (general cardiology codes 8% higher, echocardiography 90%, catheterization 49%, electrophysiology 35%). Thus, work values for cardiology were found to be different between children and adults in 75% of services assessed. The magnitude of these differences should be confirmed in a broader study. The Current Procedural Terminology Committee of the American Medical Association should consider, at a minimum, creating modifiers by specific age for certain procedures. Further study of the quantitative difference between services performed in adults and children is warranted.