Aortopulmonary window. Clinical and surgical assessment of 18 cases

OBJECTIVE

Aortopulmonary window (APW) is an uncommon congenital malformation. Its clinical presentation is dependent on the size of the defect and on the associated lesions. We evaluated our experience with this anomaly and compared it with 296 cases reported in the literature.

METHODS

Retrospective study of 18 patients diagnosed as having APW (age range from 13 days to 31 years, 13 (72.2%) females), divided into two groups: Group A (GA): 10 patients with isolated APW, and Group B (GB): 8 patients with associated lesions.

RESULTS

Heart failure occurred in 14 patients, and cyanosis in 3:2 from GB (tetralogy of Fallot--TF, and double outlet right ventricle--DORV), and one from GA with pulmonary hypertension. In 5 patients from GA the diagnosis of mitral regurgitation was made based on a systolic murmur and LV hypertrophy on the EKG. In GB, clinical findings were determined by the associated defect. Diagnosis was established by echocardiography in 11 (61.2%) of the patients. In 3 patients, a wrong diagnosis of mitral regurgitation was made, in 1 a patent ductus arteriosus was diagnosed and in 3 others, the diagnosis of APW was masked by other important associated defects (2 cases of DORV and 1 case of TF). The diagnosis was made by catheterization in 3 (16.6%) patients, by surgery in 3 (16.6%) and by necropsy in 1 (5.5%). Corrective surgery was performed in 14 (77.7%) patients, with one immediate death and good long-term follow-up in the remaining patients.

CONCLUSION

APW can be confused with other defects. Clinical findings, associated with an adequate echocardiogram can provide the information for the correct diagnosis.

Multiple rhabdomyomas in monozygotic twins

Rhabdomyoma is the most frequent primary cardiac tumor seen during infancy. We report multiple rhabdomyomas diagnosed in twins in the neo natal period. To the best of our knowledge, this is the first instance of this happening.

[Absence of right atrioventricular connection. Morphological and clinical presentation when the dominant ventricle is morphologically right]

Absent right atrioventricular connection, with the left atrium connected to a dominant left-sided morphologically right ventricle is a rare situation. We report five cases with these anatomical features, with emphasis on the morphological and clinical aspects. Although this combination of lesions is very uncommon, the sequential segmental analysis can easily provide an accurate description of the anomaly.

Double outlet right ventricle with intact atrial septum and restrictive ventricular septal defect: an analysis of two cases

Two cases of double outlet right ventricle with restrictive ventricular septal defect are described. This is an uncommon presentation that causes left ventricular dysfunction because of left ventricular outflow tract obstruction. The presence of an intact atrial septum leads to severe pulmonary hypertension, which tends to aggravate the right ventricular output. In the presence of a normal left ventricle, the authors suggest the possibility of enlargement of the ventricular septal defect in order to perform a biventricular repair. The association of a supramitral valve ring in both cases, and the isolation of the left subclavian artery and an aortopulmonary fenestration in one of these cases, are also discussed. In addition we explore factors that cause restrictive ventricular septal defects as well as the mechanisms that may lead to spontaneous closure of ventricular septal defect in a double outlet right ventricle.

[Hemodynamic evaluation and clinical outcome of children with severe dilated cardiomyopathy eligible for heart transplantation]

PURPOSE

To evaluate hemodynamic parameters and clinical outcome of children with severe cardiomyopathy who are candidates for heart transplantation.

METHODS

Twenty four children aged from 4 months to 10 years and 8 months (mean 3.7 +/- 2.5 years) from February 1992 to May 1996, were submitted to hemodynamic study and the following parameters were measured: cardiac output, mean pulmonary artery pressure (MPAP) and capillary wedge pressure. The pulmonary vascular resistance index (PVRI) and transpulmonary pressure gradient (TGP) were calculated.

RESULTS

Ten (41.6%) children were transplanted (group A), 5 (20.8%) are still waiting heart transplantation (group B) and 9 (37.6%) died (group C). The mean age of the B and C group were significantly different. The PVRI, MPAP and TPG were significant lower in group A than group C (p = 0.01; p = 0.044 and p = 0.023 respectively).

CONCLUSION

The profile of the hemodynamic parameters of children with severe dilated cardiomyopathy was compatible with the clinical findings. The age was the only difference comparing groups B and C. PVRI, MPAP and TPG were significant factors between group A and C. The older the patient, the worse was the prognosis.

Choreoathetosis after cardiac surgery with hypothermia and extracorporeal circulation

Eleven children, 4-48 months old, with congenital cyanotic heart defects developed choreoathetoid movements 2-12 days after cardiac surgery with hypothermia and extracorporeal circulation (ECC). The abnormal movements mainly involved the limbs, facial musculature, and tongue, leading to a severe dysphagia. The symptoms had an acute onset, after a period of apparent neurologic normality, and had a variable outcome. Of the nine children that survive, three had abnormal movements when last seen (41 days to 12 months of follow-up). The other six children had a complete regression of the choreoathetoid movements 1-4 weeks after onset. No specific finding was observed in the CT scans, cerebrospinal fluid examination, or EEG that could be related to the abnormal movements. Symptomatic therapy with haloperidol with or without benzodiazepines led to symptomatic improvement in six children, although there was no evidence that this treatment modified the evolution of the disease. The authors conclude that the choreoathetoid syndrome after cardiac surgery with deep hypothermia and ECC is an ill-defined entity requiring additional study to better understand its pathogenesis so that preventive measures can be taken to avoid a condition that can lead to permanent and incapacitating neurologic sequelae.

[Complete atrioventricular septal defect. Anatomo-functional correlation between patients with and without Down's syndrome]

PURPOSE

To compare clinical course, causes and symptoms beginning enset time in children with complete atrioventricular canal with and without Down's syndrome.

METHODS

Records of 80 patients < 2 years of age, were reviewed. There were 55 (69%) with Down's syndrome-group I (GI) and 25 (31%) without-group II (GII). Age at synpton enset intensity, functional class, clinical repercussion and anatomic variations in patients undergoing corrective surgery were evaluated.

RESULTS

Mean age at symptoms onset was similar for the two groups (50 +/- 75 days). Class II (NYHA) was more frequent in GI (31 patients-56.5%) and class III-IV (NYHA) in GII (19 patients-76%) p < 0.005. Clinical repercussion evaluation showed that congestive heart failure was present in 34 (62%) patients of GI and 21 (84%) of GII; and, pulmonary hypertension was in 21 (38%) patients of GI and 4 (16%) patients of GII p < 0.04. Mean pulmonary arterial pressure of 50 mmHg or more was present in 68% of children with Down's syndrome and in 35% of GII. Clinical course until surgical correction was down hill in 33 (60%) from GI and 21 (84%) from GII p < 0.03. Seventy seven patients underwent surgical correction. CAVC type A of the Rastelli classification was predominant in both groups, GI 37 (67%)-GII 25 (100%). There or more severe valvar morphologic lesions in group II (38%) than in group I (8%).

CONCLUSION

There seems to be a pulmonary vascular hyperreactivity predominance in Down's children and cardiac insufficiency signs in the normal genetic group.

[Pulmonary artery sling]

The authors present a case of a two-year-old boy with stridor since birth, and also recurrent episodes of pulmonary infections, due to mechanical compression of distal trachea by a left pulmonary artery sling. They discussed diagnostic approach, surgical management and review of the literature. To our knowledge, it is the first case of sling of the pulmonary artery reported in Brazil and the fifth in a latin language country.

[Systematic quantification of the arteries in lung biopsies of patients with congenital heart defects and its contribution to the therapeutic management]

PURPOSE

To determine the value of the quantitative analysis of lung biopsies from patients with congenital cardiac defects.

METHODS

Fourty nine biopsies were examined, from patients: 43 patients increased pulmonary blood flow, 3 with pulmonary atresia and large systemic-to-pulmonary collateral vessels, and 3 with decreased pulmonary flow. The degree of lesion was determined as in Heath-Edwards and of Rabinovitch and col.

RESULTS

The Heath and Edwards grade was determined in 41 cases; I in nine; II in 23; III in eight; IV in one; 3 biopsies showed evidence of reduced pulmonary flow and 5 had no signs of vascular disease. The Down patients (7) presented a greater proportion of severe lesions. Quantitative evaluation was obtained in 35 biopsies: 11 had grade B and 24 had grade C. Wall atrophy and dilatation of intraacinar arteries were detected in 7 cases, what suggested the existence of obstructive lesions in proximal vessels, even if not sampled. Medical thickness greater than 2 times the normal were observed in pre-acinar arteries from 14 biopsies.

CONCLUSION

The morphometric approach allowed us to detect severe lesions which the qualitative analysis alone would not indicate adequately. In the patients presenting decreased pulmonary flow, morphometry made possible to assess if the degree of arterial wall hypertrophy was compatible with a surgery of atrio-pulmonary anastomosis.

[Tetralogy of Fallot associated with left atrial isomerism]

The association of tetralogy of Fallot with atrial isomerism has been rarely reported. Eight cases (five with left isomerism and three with right isomerism) are known. This paper reports two other cases of tetralogy of Fallot with left atrial isomerism. The syndrome's defects were disguised and without clinical expression because of the presence of the right ventricular outlet obstruction of tetralogy of Fallot. These diagnostic elements, not recognized in one of the patients previous to surgical correction of tetralogy of Fallot, were present: junctional rhythm, bronchial isomerism, partial anomalous pulmonary vein connection, agenesy of inferior vena cava and abdominal heterotaxy; their identification previous to surgical correction of tetralogy of Fallot, is necessary for an adequate surgical management.

[Neonate and infant heart transplantation]

PURPOSE

Heart transplantation has offered children with complex congenital heart diseases and severe cardiomyopathies a chance for survival. The present article was written to show the three year experience of this procedure at the Instituto do Coração-HCFMUSP.

METHODS

The methodology used was based on heart transplant indication criteria, inclusion criteria for donors, postoperative management, immunosuppression and prophylaxis as well as treatment of potential complications.

RESULTS

From November 1992 to November 1995, 11 children, aged 12 days old to six years (mean 2.5 years) underwent transplantation. Sixty percent of recipients were male; weight ranged from 3.5 to 17.8 kg (mean 10.3 kg). The mean age of donors was 4.4 years (a range of three weeks to ten years), 80% male, weight ranging from 3.8 to 20 kg (median 14.3 kg). The survival rate was 91% and the remaining 10 children are doing well. The most important complications were systemic hypertension, acute rejection and infection. The number of rejections and infections per patient were 3.5 and 4.7 episodes, respectively. The follow-up was between one month to three years (average 16 months).

CONCLUSION

In this experience, heart transplantation has given an additional opportunity for children with complex congenital heart diseases and cardiomyopathies, with a survival rate of 91% in three years.

[Total anomalous pulmonary venous connection. Experience with 70 cases]

PURPOSE

To evaluate the clinical and surgical experience with consecutive patients with isolated total anomalous pulmonary venous connection admitted to the Heart Institute, São Paulo, Brasil.

METHODS

Hospital records of 70 consecutive patients (January 1985 to December 1993) were retrospectively reviewed. There were 28 girls and 42 boys whose ages ranged from two days to four years (mean 20.4 +/- 29 weeks). The following variables were selected for analysis: anatomic type, age at admission, clinical status, the presence of infection, restrictive atrial septal defect, and the presence of pulmonary venous obstruction. Univariate and multivariate analysis were used to identify possible risk factors for death.

RESULTS

The abnormal anatomical connection was supracardiac in 63%, cardiac in 17%, infracardiac in 8.5% and mixed in 11.5% of the cases. Eighteen (25.7%) patients were admitted in poor clinical condition. Infection, mainly pulmonar, was present in 31 (44%) patients. Pulmonary venous obstruction was present in 21% of the patients. Atrial septostomy was performed in 38 patients, 13 of them admitted in a poor clinical status. The preoperative mortality was 15.7% and the operative, 17%. Statistical analysis demonstrated that infection, poor clinical status and age were risk factors for death.

CONCLUSION

Surgical correction of total anomalous pulmonary venous drainage in infancy can be performed at low risk with good results. However early referral to a cardiac care center, agressive preoperative stabilization and postoperative care are important.

[Anomalous origin of the left coronary artery. Concomitant correction with valvar replacement for mitral insufficiency]

A four year-old boy with an anomalous origin of the left coronary artery (LCA) directly from the right pulmonary artery was reported. He had been underwent to mitral valve replacement by a St Judes no. 29, due to severe mitral insufficiency, secondary to an extensive myocardial infarction including the anterior and posterior papilary muscles, beside the implantation of the LCA in the aorta. Instead of this favorable outcome, it's emphasized the need for earlier recognition to avoid risk sequelae.

Epidemiologic investigation of an outbreak of coagulase-negative Staphylococcus primary bacteremia in a newborn intensive care unit

Infections due to coagulase-negative Staphylococcus (CNS) are an ever-increasing nosocomial problem, particularly in the pediatric population. The authors describe a cluster of three primary bloodstream infections due to CNS in a newborn intensive care unit that occurred between November 23 and December 2, 1992. Two children died as a direct consequence of the bacteremia; at autopsy, one had a large bacteria-containing thrombus extending from the insertion site of a central catheter to the superior vena cava. The children were placed in isolation, and the nursing and medical staff were given topical nasal mupirocin. Plasmid analysis performed later disclosed three different blood isolates that also were different from any of the staff's nasal isolates. The authors concluded that molecular methods such as plasmid analysis are important tools in identifying true outbreaks and can prevent needless interventions, such as those during this cluster.

[Pulmonary valve agenesis. Clinico-surgical evaluation of 32 patients]

PURPOSE

To study the surgical and clinical evolution of 32 cases with absent pulmonary valve to propose the ideal period of time for surgical correction.

METHODS

Clinical and laboratorial analysis were performed in 32 infants, under 12 months of age, between 1980 an 1993, in an evolutive character. From the clinical viewpoint, hypoxic and/or congestive features were considered in previous and late periods related to surgical repair. Laboratorial studies as ECG (cavities overload), chest X-ray (cardiac size and pulmonary vascular markings) and echocardiogram (associated defects, pressure gradients and anatomical aspects of pulmonary arteries) were also analyzed. Cardiac catheterization was performed in 15 patients.

RESULTS

Early cyanosis in 84% of cases and "to and for "murmur in 90% of them facilitate clinical diagnosis in whom tetralogy of Fallot was associated in 30 patients. Refractory respiratory and cardiac insufficiency were responsible for operative indication in 12 patients, half of them, operated on under 12 months of age, died. Survival patients were repaired between two to 11 years old. Four deaths occurred early in life, before any surgical consideration and the 16 remaining patients will electively be considered for an opportune repair.

CONCLUSION

Conservative clinical treatment is indicated, waiting for a more rigid bronchial wall can support the pressure of the dilated pulmonary arteries. This way, surgical repair is postponed for at least two years of age.

Favorable effects of immunosuppressive therapy in children with dilated cardiomyopathy and active myocarditis

Among 68 children with severe dilated cardiomyopathy, 43 (aged 10 months to 15 years) presented with active myocarditis, diagnosed by endomyocardial biopsy. They were divided into four treatment groups: I, controls: 9 patients submitted to conventional treatment (digitalis, diuretics, and vasodilators) for 8.1 +/- 0.7 (SD) months; II, prednisone: 12 patients received conventional therapy plus prednisone; III, azathioprine: 16 patients submitted to conventional therapy plus prednisone and azathioprine; IV, cyclosporine: 13 patients treated with conventional therapy plus prednisone and cyclosporine. Immunosuppressive therapy was maintained for a mean of 8.4 +/- 1.2 months. They were submitted to noninvasive (electrocardiogram, chest radiograph, Doppler echocardiogram, and radioisotopic scintigraphy) and invasive (hemodynamic) studies. In the control group only 2 of 9 patients showed clinical and hemodynamic improvement and 1 of 4, histologic regression of the myocarditis. Among patients submitted to conventional therapy plus prednisone, 3 of 12 presented clinical and hemodynamic improvement; 2 of 5 also showed histologic regression of inflammatory process. By contrast, patients treated with azathioprine or cyclosporine associated with prednisone had significantly better results: 13 of 16 and 10 of 13 patients, respectively, had clinical and hemodynamic improvement; all 6 patients in the azathioprine group and all 4 patients in the cyclosporine group had histologic regression of the myocarditis. Two patients in the prednisone group, one in the azathioprine group, and one in the cyclosporine group died during treatment, in cardiogenic shock. In our experience immunosuppressive therapy with azathioprine or cyclosporine associated with prednisone improves the prognosis of children with active myocarditis and severe ventricular dysfunction.

[Agenesis of the right pulmonary artery with severe pulmonary hypertension, attenuated by surgical correction]

A 22 months old infant with agenesis of right pulmonary artery, without other associated congenital heart defects, is reported. Reconstruction of pulmonary arteries by connecting them through a 7mm Goretex tube was performed, with clear clinical improvement in view of disappearance of signs of cardiac insufficiency and of hypoxemia. Contralateral pulmonary hypertension, at systemic level, decreased to 77% in the immediate postoperative period. So, this technique becomes the first option, before considering these cases for cardiopulmonary transplantation.

[Pulmonary atresia with intact ventricular septum. Natural development of the right ventricle]

A case of pulmonary atresia with intact ventricular septum and a hypoplastic right ventricle, with three wall formed portions, that became naturally well developed until 2 years of age, is related. A Blalock-Taussig shunt had been performed early in life. Z value of tricuspid valve of 0.3 and left ventricular in ECG has been changed to a well developed tricuspid annulus of 22 mm diameter and to a right ventricle overload after 2 years of follow-up, being possible surgical correction at that time. This observation, until today unknown, the natural increase of a congenitally hypoplastic cardiac chamber, favors the possibility to postpone the corrective operation to a better stage in this anomaly, when the risk becomes lower.

[Clinical manifestation of aortopulmonary window as mitral regurgitation caused by secondary dilatation of the valvar anulus]

Two patients with huge aortopulmonary window, both ten months-old, that showed curiously up at a clinical viewpoint, including echocardiography, as a mitral valve regurgitation with a dilated mitral ring secondary to the accentuated blood volume through it, were reported. Early signs of heart failure, accentuated systolic murmur at mitral area and overload of left heart cavities, characterized clinical impression of a congenital mitral insufficiency, in both cases. The correct diagnosis was established at operation and at necropsy study, bringing it to us the need to a more accurate analysis of the different diagnostic elements, especially in anomalies which clinical manifestations show great similarities.

Abnormal multimeric and oligomeric composition is associated with enhanced endothelial expression of von Willebrand factor in pulmonary hypertension

Abnormalities in endothelial von Willebrand factor (vWF) structure have been reported in pulmonary hypertension. These include loss of high molecular weight plasma multimers, resulting in decreased biologic activity. If endothelial processing of vWF is altered in this disorder, abnormalities in oligomeric composition may also be expected. We examined this possibility in ten adult patients with primary pulmonary hypertension. Enhanced endothelial vWF expression in these patients was indicated by increased plasma levels of vWF antigen (vWF:Ag) (214 +/- 91 vs 99 +/- 51 percent activity in controls, p < 0.001) and intense immunoperoxidase stain of pulmonary arterial endothelium for vWF (autopsy, 1 patient). Plasma from these patients also had a decreased capacity of inducing platelet aggregation in the presence of ristocetin, relative to vWF:Ag levels (57 +/- 20 percent activity). In addition to mild loss of the largest multimers, changes in oligomeric composition of plasma vWF were observed in most patients using both agarose and polyacrylamide gel electrophoresis. These included decreased concentration of dimeric (470 kDa) vWF in most patients, variable concentration of the 860-kDa fraction, and a relative decrease in subunit (223 kDa) density in subjects with elevated vWF:Ag. These findings provide additional information on the mechanisms responsible for endothelial production of dysfunctional vWF in patients with pulmonary hypertension.