A retrospective cohort study of major adverse cardiac events in children affected by Kawasaki disease with coronary artery aneurysms in Thailand

Kawasaki disease (KD) is a common form of vasculitis in children that can be complicated by coronary artery aneurysms (CAAs). Data of long-term outcomes and major adverse cardiac events (MACE) in children with CAAs following KD in developing country are limited. Our aims were to determine the rates of MACE and identify risk factors associated with MACE in children with KD and CAAs in Thailand. We performed a retrospective analysis of data from 170 children diagnosed with KD and CAAs in two tertiary hospitals between 1994 and 2019. During a median (range) follow-up of 5.4 years (22 days to 23 years), 19 patients (11.2%) experienced MACE, that included 12 coronary artery bypass grafting, 2 percutaneous coronary intervention and 5 children with evidence of myocardial ischemia and coronary occlusion. Coronary interventions were performed at a median time of 4 years (0.01 to 9.5 years) after KD diagnosis. Forty-nine patients (28.8%) had giant CAAs. No MACE was reported in children with small CAAs. Independent risks of MACE were from the absence of intravenous immunoglobulin treatment (HR 7.22; 95% CI 2.21 to 23.59; p = 0.001), the presence of giant aneurysms (HR 13.59; 95% CI 2.43 to 76.09; p = 0.003), and CAAs that involved bilateral branches of coronary arteries (HR 6.19; 95% CI 1.24 to 30.92; p = 0.026). Among children with giant CAAs, the intervention-free rate was 93.8%, 78.7% and 52.2%, at 1, 5 and 10 years, respectively. Of note, 81% of the small CAAs regressed to a normal size, and for medium CAAs, 50% regressed to normal size. Overall, ~10% of children with CAAs following KD experienced MACE in this cohort. Timely IVIG treatment in children with KD following symptom onset will reduce the risk of MACE. Cautious surveillance to identify cardiac complications should be recommended for children once medium or giant CAAs develop.

Trial registration:TCTR20190125004.

Fetal and Neonatal Modified Myocardial Performance Indices in Preeclamptic versus Normotensive Pregnancies: A Prospective Cohort Study

Objective

To compare fetal and neonatal cardiac functions in terms of global, systolic, and diastolic function between the preeclampsia and normotensive blood pressure of pregnancies.

Methods

A prospective cohort study was conducted at a university hospital in Northeast Thailand. Twenty-nine pregnancies diagnosed as preeclampsia with or without severe features were compared with 29 normotensive pregnancies. Global cardiac, systolic, and diastolic function were assessed at prenatal and postnatal periods, by a professionally trained obstetrician and pediatric cardiologist, respectively.

Results

The fetal left modified myocardium performance index (Mod-MPI) in preeclampsia and normotensive blood pressure were 0.60±0.08 and 0.59±0.08 (p-value=0.341), respectively, while fetal right Mod-MPI were 0.57±0.16 and 0.54±0.21 (p-value=0.861), respectively. There were no statistically significant differences in terms of fetal isovolumic contraction time (ICT), isovolumic relaxation time (IRT), ejection time (ET), aortic peak systolic velocity (Ao PSV), pulmonary artery peak systolic velocity (PA PSV), mitral valve (MV) E:A ratio, or tricuspid valve (TV) E:A ratios between the two groups. Neonatal mitral valve E peak systolic velocity (MV-E PV) in preeclamptic and normotensive blood pressure groups were significantly different at 51.1±8.02 cm/s and 43.56±5.21cm/s (p-value=0.036), respectively, whereas neonatal left Mod-MPI, mitral valve A peak systolic velocity (MV-A PV), MV E:A ratio, and Ao PSV were not significantly different (p-value=0.436, 0.119, 0.379, and 0.709), respectively.

Conclusion

Neonatal MV-E PV of the preeclampsia group was significantly higher than the normotensive blood pressure group, while there were no statistically significant differences in terms of global cardiac and diastolic functions during the fetal period between two groups.

Historical assessment of diphtheritic myocarditis from a hospital in northeastern Thailand

Background: Although there have been many descriptive studies of diphtheria from resource limited countries, descriptions of the natural history of diphtheritic myocarditis in patients from these countries are scarce.

Objective: To present the natural history of diphtheritic myocarditis from a hospital in northeastern Thailand.

Methods: The clinical features of 38 patients with diphtheria admitted to the Khon Kaen University Hospital in northeastern Thailand between 1983 and 1996 were reviewed.

Results: Of the 38 cases of diphtheria, 10 progressed to diphtheritic myocarditis (26%). Electrocardiographic findings of the 10 patients with myocarditis were myocardial and conduction abnormalities. The presence of a clinically severe (toxic) type (P < 0.001) or a swollen neck (bull neck) (P = 0.001) was a predictor of the occurrence of myocarditis. Five (50%) of the 10 patients with myocarditis had conduction abnormalities (third-degree atrioventricular block 3, left bundle branch block 1, and right bundle branch block 1). Four patients with severe symptomatic bradyarrhythmia (third-degree atrioventricular block 3, and left bundle branch block 1) received ventricular pacing, and 3 patients died after this pacing. Echocardiographic abnormalities of left ventricular dilatation and myocardial hypertrophy were found in all 5 patients with conduction abnormalities. All 6 of 7 survivors of diphtheritic myocarditis had normal 12-lead electrocardiographic results at 1-month follow-up. A patient who was the survivor of third-degree AV block had an electrocardiographic finding of flat T waves, and with a complete echocardiographic normalization of left ventricular dilatation and myocardial hypertrophy.

Conclusion: The present study confirms that increasing diphtheria immunization coverage in the population remains the most important strategy for the control of diphtheria. In resource limited countries, clinical findings, electrocardiography, and sometimes where available, echocardiography are helpful in assessing the severity of diphtheritic myocarditis, decision making of acute management, and predicting fatal outcome.

Original article. Childhood infective endocarditis in Khon Kaen University Hospital from 1992 to 2011

Background: Infective endocarditis (IE) is an important cause of child morbidity and mortality, but the current burden of the disease in Thai children is unknown.

Objectives: To determine the current burden of IE in Thai children.

Patients and Methods: The records of all children aged <15 years admitted to Khon Kaen University Hospital from 1992 to 2011 were reviewed.

Results: Of 69,822 admissions, 56 patients fulfilled the modified Duke criteria for definite IE giving a rate of 0.8 cases per 1,000 admissions. Age at diagnosis was 7.9 ± 3.8 years (range, 8 days to 14.8 years). There was congenital heart disease in 38 (68%) patients, rheumatic heart disease (RHD) in 10 (18%), and no previous heart disease in 8 (14%). RHD was a less frequent underlying disease during the latter half (2002-2011) of the period studied (1/34 vs. 9/22, P < 0.001). Blood cultures were positive for pathogens in 34 (61%) patients with 11 cases of Streptococcus viridians and 8 cases of Staphylococcus aureus infections. Vegetations on echocardiography were present in 46 (82%) patients. For 8 embolic events, patients with large vegetations had a higher rate (4/6) than patients with small and no vegetations (4/50) (P < 0.003). In-hospital mortality was 11%. Eight patients with S. aureus infection had a higher mortality (5/8) than 26 patients (1/26) infected with other pathogens (P < 0.001).

Conclusion: The changing epidemiology of pediatric IE was toward fewer children with RHD. Mortality among children with IE was higher in those with S. aureus infection.

Rheumatic and congenital heart diseases among school children of Khon Kaen, Thailand: declining prevalence of rheumatic heart disease

Background: Rheumatic fever (RF), rheumatic heart disease (RHD), and congenital heart disease (CHD) are still major problems among Thai school children.

Objective: To examine trends in the prevalence of RF/RHD and CHD along with the socioeconomic status of school children in urban Khon Kaen, northeastern Thailand.

Methods: We conducted cross-sectional survey of 8,555 school children aged 5-15 years from 4 schools in urban Khon Kaen from January to March 2006. Pediatric cardiologists examined the school children and all cardiac diagnoses were confirmed by echocardiography. Socioeconomic data were also collected. Schools were divided into high and low socioeconomic status (SES) schools, based on the prevailing levels of parental education and household income. All positive cases of heart disease were followed and reviewed at a university hospital up to December 2013.

Results: Of 8,555 children examined, 2 had RF/RHD, and 10 had CHD. The prevalence of RF/RHD was 0.23 per 1,000 (95% CI 0.03-0.84), and the prevalence of CHD was 1.2 per 1,000 (95% CI 0.56-2.15). Prevalence of RF/RHD among urban school children in the center of northeastern Thailand had declined from 1.13 to 0.23 per 1,000 since 1986. The indices of socioeconomic development revealed marked improvement during this 20 year interim. The prevalence of RF/RHD was higher among low SES schools (4.6 per 1,000) compared with high SES schools (0 per 1,000).

Conclusion: There is a low prevalence of RHD in school children in this region compared with the period before 1986.

Assessment of Chromosome 22q11.2 Deletion in Patients with Isolated Cleft Palate: A Systematic Review of Prospective Studies

BACKGROUND

The prevalence of 22q11.2 deletion in patients presenting with isolated cleft palate has not been systematically assessed.

OBJECTIVE

To assess the evidence in the literature for the prevalence of 22q11.2 deletion in patients who were presenting with isolated cleft palate.

MATERIAL AND METHOD

A systematic literature search was conducted through PubMed between 1992 and June 2016 using search terms of 22q11.2 deletion OR 22q11 deletion AND cleft palate.

RESULTS

Of the six prospective studies reported, 328 patients with isolated cleft palate had been screened with FISH (Fluorescence In Situ Hybridization) test for 22q11.2 deletion. Among the 328 patients, there was one (0.3%) patient with positive FISH test for 22q11.2 deletion. This patient was clinically assessed and did not have an associated malformation or clinically recognized syndrome.

CONCLUSION

The prevalence of 22q11.2 deletion among patients with isolated cleft palate is rather low. Of more than 400 genetic disorders involving occurrences of isolated cleft palate, FISH testing for 22q11.2 deletion in a patient with isolated cleft palate is recommended on clinical suspicion of additional clinical presentations of 22q11.2 deletion syndrome such as conotruncal congenital heart diseases, dysmorphic facies, velopharyngeal insufficiencies, immune deficiencies, hypoparathyroidisms, and neuropsychiatric disorders.

Two-year survival, mental, and motor outcomes after cardiac extracorporeal life support at less than five years of age

OBJECTIVE

Comprehensive outcome assessment of children receiving cardiac extracorporeal life support.

METHODS

From 2000 to 2004, 39 consecutive children (aged 1 day to 4.4 years) had cardiac extracorporeal life support. Neurodevelopmental follow-up of all survivors was performed more than 6 months after life support (aged 53 +/- 12 months). Developmental delay was defined as a score of less than 70 on the Bayley Scales of Infant Development II or Wechsler Preschool and Primary Scale of Intelligence. Predictor variables for mortality (at 2 years' follow-up) and delay were examined by univariate and multivariate analyses.

RESULTS

Indications for extracorporeal life support were progressive low cardiac output in 14 (36%), failed weaning from cardiopulmonary bypass in 13 (33%), cardiac arrest in 9 (23%), and hypoxia in 3 (8%). Cardiac anatomy was single ventricle in 16 (41%), biventricular in 21 (54%), and myocarditis in 2 (5%). Survival was 18 (46%) at hospital discharge and 16 (41%) at 2 years. In survivors, mental score was 73 +/- 16 (normal 100 +/- 15), and 8 (50%) had mental delay. Initiating extracorporeal life support during cardiopulmonary resuscitation and duration of this resuscitation were not associated with death or mental delay. On multivariable Cox regression, lactate on admission to the pediatric intensive care unit (hazard rate 1.13; 95% confidence intervals 1.08-1.27) and single ventricle anatomy (hazard rate 3.93; 95% confidence intervals 1.62-9.49) were associated with death at 2 years. Stepwise multiple regression found time for lactate to normalize on extracorporeal life support, highest inotrope score during 120 hours of life support, and chromosomal abnormality explained 76.7% of the variance in mental score.

CONCLUSION

Cardiac extracorporeal life support had a 41% 2-year survival. Potentially modifiable variables (time for lactate to normalize and highest inotrope score early during extracorporeal life support) explained 69% of mental score variance.

Kawasaki disease in central area of Northeast Thailand

Kawasaki disease (KD) is a leading cause of acquired heart disease of childhood. The authors retrospectively reviewed cases of KD in major referral centers of central Northeast Thailand from July 1991 to June 2003. Seventy-three episodes occurring in 72 patients were diagnosed with KD by the American Heart Association criteria with a mean age of presentation of 27 +/- 19 months. The annual incidence was 2.2 per 100,000 children < 5 years of age. Coronary artery abnormalities (CAA) were found in 15 (20.5%) children. Nine patients (18%) who were diagnosed before 10 days were not treated with intravenous immunoglobulin (IVIG). Two (13%) of the 15 patients still had coronary lesions at the end of the follow-up period of 35.5 +/- 13.4 months. Index of suspicious should be maintained in children who had clinical signs of KD for early diagnosis and prompt treatment with IVIG.

Aortoesophageal fistula: a life-threatening cause of upper gastrointestinal hemorrhage in double aortic arch, a case report

The authors present the case of a 2-month-old infant with double aortic arch that developed massive bright red upper gastrointestinal hemorrhage from aortoesophageal fistula (AEF) after prolonged endotracheal and nasogastric intubation. Emergency thoracotomy with AEF and double aortic arch repaired were done successfully under cardiopulmonary bypass. Due to tracheomalacia and left phrenic nerve injury, tracheal extubation could not be done until 1 month after correction of the vascular ring. The endotracheal and nasogastric tube led to fistula formation by compression of the esophageal wall against an abnormal double aortic arch. When a double aortic arch is suspected, prolonged nasogastric intubation should be avoided.