Do children with supraventricular tachycardia treated with ablation therapy have similar quality of life as healthy children?

Introduction. There are a few available studies evaluating quality of life (QoL) in pediatric patients with supraventricular tachycardia (SVT) treated with ablation but they are based on small groups of patients. The aim of the paper was to compare the QoL in children with SVT treated with successful ablation with the group of healthy children.Materials and Methods. The study included 122 SVT children who underwent a successful ablation therapy and 83 healthy children. The Qol was assessed, using the WHOQOL-BREF and the Pediatric Arrhythmia Related Score (PARS) - a specific questionnaire developed by the authors, related to patients' own feelings and observations concerning arrhythmia.Results. On the basis of WHOQOL-BREF no significant differences were found in all the measured domains. On the basis of PARS in SVT-group the patients still reported significantly increased symptoms within physical domain in comparison with the healthy group (1.8 ± 0.5 vs 1.6 ± 0.3; p = 0.0195) as well as increased negative feelings within psychological domain (2.3 ± 0.7 vs 2.1 ± 0.6; p= 0.0172). Conclusions. On the basis of the general questionnaire all scores in SVT group are comparable with healthy children. When analyzing PARS questionnaire six months after the ablation procedure the physical and psychological functioning of SVT children was still worse than in the group of healthy children. On the basis of the performed analysis we believe that PARS questionnaire is a more useful and sensitive tool than WHOQOL-BREF when evaluating ablation influence on patients’ QoL.

Influence of ablation therapy on the quality of life in children with supraventricular tachycardia

OBJECTIVE

Numerous restrictions, which are imposed on children with arrhythmia, influence their quality of life (QoL) and may have a negative impact on their further development. Ablation is a highly successful treatment leaving patients free from arrhythmia and other related limitations. There are very few studies evaluating the influence of ablation on the QoL in children with arrhythmia, based on small groups of patients. The aim of this study was to evaluate the impact of ablation on the QoL in children with supraventricular tachycardia (SVT).

PATIENTS AND METHODS

We included 122 children with SVT who underwent a successful ablation. The Qol was assessed before and after the ablation, using the WHOQOL-BREF and the Pediatric Arrhythmia Related Score (PARS) - a specific questionnaire developed by the authors.

RESULTS

Six months after the ablation, WHOQOL-BREF showed a significant improvement in the QoL in the physical (Phd) (p < 0.0001), psychological (Psd) (p = 0.0014) and social relationships (SRD) (p = 0.0165) domains. PARS showed a significant improvement in the QoL in the Phd (p < 0.0001), Psd (p = 0.0307) and medical satisfaction domains (Msd) (p < 0.0001). No improvement in Psd was revealed in children who had been off medications before the ablation. In the youngest children, a significant improvement was observed in all the measured domains in both questionnaires (p < 0.05), while in older children the greatest improvement after the ablation was noted in the area of physical functioning.

CONCLUSIONS

Ablation in children with SVT significantly improved general satisfaction with health and with the QoL and had a positive impact on QoL scores. The youngest patients and those on antiarrhythmic medication before the ablation, benefit most from the procedure.

Evaluation of medical and psychological parameters of quality of life in supraventricular tachyarrhythmia children. A comparison with healthy children

INTRODUCTION

There are only a few available studies evaluating quality of life (QoL) in pediatric patients with cardiac arrhythmia. The aim of the study was to evaluate medical and psychological parameters of the QoL in children with a diagnosed supraventricular tachyarrhythmia (SVT) and to compare the obtained data with a group of healthy children (HC).

MATERIAL AND METHODS

Inclusion criteria: children aged 7-18 with SVT, treated at Poznan University of Medical Sciences, Department of Pediatric Cardiology. The evaluation tools were the WHOQOL-BREF instrument and a questionnaire related to the patient's feelings and observations concerning arrhythmia (Pediatric Arrhythmia Related Score - PARS), developed by the authors and adjusted to the group of arrhythmia patients.

RESULTS

The study included 180 SVT children and 83 HC. On the basis of WHOQOL-BREF the SVT group was found to have lower assessment values of QoL within the physical domain (Phd) (mean ± SD: 65.7 ±15.8 vs. 81.6 ±12.8; p < 0.0001) and psychological domain (Psd) (mean ± SD: 75.8 ±15.2 vs. 81.3 ±14.1; p < 0.005). No significant differences were found within the social relationships domain or the environment domain. On the basis of PARS in the SVT group the patients reported significantly increased symptoms within Phd (mean ± SD: 2.3 ±0.7 vs. 1.6 ± 0.3; p < 0.0001) as well as increased negative feelings within Psd (mean ± SD: 2.3 ±0.7 vs. 2.1 ± 0.6; p < 0.005).

CONCLUSIONS

Medical and psychological parameters of the QoL in SVT children are significantly lower in comparison with HC. A diagnosis of SVT has no influence on the social and environmental areas of QoL. The PARS appears to be a useful tool to supplement the generic questionnaire for QoL evaluation in SVT children.

Who is at higher risk of hypertension? Socioeconomic status differences in blood pressure among Polish adolescents: a population-based ADOPOLNOR study

In Poland, there is no data on parental socioeconomic status (SES) as a potent risk factor in adolescent elevated blood pressure, although social differences in somatic growth and maturation of children and adolescents have been recorded since the 1980s. This study aimed to evaluate the association between parental SES and blood pressure levels of their adolescent offspring. A cross-sectional survey was carried out between 2009 and 2010 on a sample of 4941 students (2451 boys and 2490 girls) aged 10-18, participants in the ADOPOLNOR study. The depended outcome variable was the level of blood pressure (optimal, pre- and hypertension) and explanatory variables included place of residence and indicators of parental SES: family size, parental educational attainments and occupation status, income adequacy and family wealth. The final selected model of the multiple multinomial logistic regression analysis (MLRA) with backward elimination procedure revealed the multifactorial dependency of blood pressure levels on maternal educational attainment, paternal occupation and income adequacy interrelated to urbanization category of the place of residence after controlling for family history of hypertension, an adolescent's sex, age and weight status. Consistent rural-to-urban and socioeconomic gradients were found in prevalence of elevated blood pressure, which increased with continuous lines from large cities through small- to medium-sized cities to villages and from high-SES to low-SES familial environments. The adjusted likelihood of developing systolic and diastolic hypertension decreased with each step increase in maternal educational attainment and increased urbanization category. The likelihood of developing prehypertension decreased with increased urbanization category, maternal education, paternal employment status and income adequacy. Weight status appeared to be the strongest confounder of adolescent blood pressure level and, at the same time, a mediator between their blood pressure and parental SES.

CONCLUSION

The findings of the present study confirmed socioeconomic disparities in blood pressure levels among adolescents. This calls for regularly performed blood pressure assessment and monitoring in the adolescent population. It is recommended to focus on obesity prevention and socioeconomic health inequalities by further trying to improve living and working conditions in adverse rural environments.

Percentile distribution of blood pressure readings in relation to body mass index: a populationbased cross-sectional study ADOPOLNOR

Recent upward trends toward elevated blood pressure and increased weight expressed in terms of body mass index in children and adolescents call for regular monitoring of their physical growth and age-related changes in blood pressure. This requires adequate tools - reference values of a normal blood pressure range. The main objective of this study was to provide sex- and BMI-specific percentile reference values for systolic and diastolic blood pressure based on the adolescent Polish population, participants in the ADOPOLNOR study. A cross-sectional survey was carried out on a representative, randomly selected cohort of 4,941; 2,451 male and 2,490 female students aged 10-18 years, residents in Wielkopolska province and its capital, the city of Poznań. All examinations were performed in school nursery rooms during morning hours according to standard procedures. Body height and weight were measured and BMI was calculated. Blood pressure was measured twice on each occasion on the right arm using a fully calibrated TECH MED TM-Z mercury gauge sphygmomanometer with sets of exchangeable cuffs and a clinical stethoscope. The blood pressure classification was determined using the surveillance method. For each participant, the mean of measurements taken on each of the three occasions was calculated and served as his/her final blood pressure value. Using the LMS method, fitted percentile curves were created for BMI-related systolic and diastolic blood pressure. The findings revealed that age related blood pressure pattern was similar in boys and girls. It showed a steady increase of systolic and diastolic blood pressure with age. There was a positive correlation between the systolic and diastolic blood pressure indicating that when systolic blood pressure increased so diastolic did (r=0.61 at p<0.01). Boys were likely to have relatively higher mean values of systolic and diastolic blood pressure and steeper slope for BMI-related change in blood pressure than girls. Similar pattern was found for age-related changes in BMI. The quotation of 3rd, 5th, 10th, 15th, 25th, 50th, 75th, 85th, 90th, 95th, and 97th at any given BMI between 12 kg/m2 and 35 kg/m2 provided indication of the entire variation in blood pressure of adolescent males and females aged 10-18 years. The sex- and BMI-specific reference values and charts for systolic and diastolic blood pressure may be a useful tool in monitoring blood pressure for early detection of its abnormal level and treatment of children and adolescents with high blood pressure.

[Paediatric echocardiography in clinical practice. 2012 Recommendations of the Echocardiography Working Group of the Polish Cardiac Society]

Echocardiography has become the primary imaging tool in the diagnosis and assessment of cardiological disorders in children. The purposes of this paper are to describe indications for paediatric echocardiography, define optimal instrumentation and laboratory setup for paediatric echocardiographic examinations and establish a baseline list of recommended measurements to be performed in a complete pediatric echocardiogram.

Stent implantation into the interatrial septum in patients with univentricular heart and a secondary restriction of interatrial communication

BACKGROUND

Presence of a restrictive interatrial communication in patients with univentricular anatomy significantly affects surgical outcomes. In patients with univentricular hearts, wide open atrial communication leads to lower pulmonary artery pressure, which is one of the most important factors influencing the success of bidirectional Glenn and Fontan operations. In some patients, recurrence of restricted interatrial communication can be observed despite initially successful interventional or surgical creation of unrestrictive interatrial communication.

AIM

To evaluate efficacy of stent implantation into the interatrial septum in patients with univentricular heart and a secondary restriction of interatrial communication.

METHODS

In 2006-2010, we created unrestrictive interatrial communication by stent implantation into the interatrial septum in 7 children with univentricular anatomy with systemic right ventricle (4 patients with hypoplastic left heart syndrome and 3 patients with mitral atresia). In all patients we diagnosed recurrent restriction of interatrial communication despite prior surgical or interventional creation of unrestrictive interatrial communication. Patient age at stent implantation was 3 to 30 months. Maximal systolic pressure gradient between the left and the right atrium was 6-29 mm Hg and left atrial pressure ranged from 20/17/19 mm Hg to 40/29/32 mm Hg. In all patients, we implanted a Palmaz-Genesis stent (length 18-29 mm) with subsequent balloon redilatation.

RESULTS

In all 7 patients, we created unrestrictive interatrial communication with mean pressure gradient reduction from 13.14 mm Hg to 0.86 mm Hg (p < 0.006). Mean interatrial communication diameter increased from 4.14 mm to 10.57 mm (p < 0.0001).

CONCLUSIONS

Percutaneous stent implantation into the interatrial septum in children with univentricular heart and secondary restriction of interatrial communication is a safe and effective method. Kardiol Pol 2011; 69, 11: 1137-1141.

[Radiofrequency ablation of accessory pathway from noncoronary cusp of aorta after failed cryoablation]

Successful ablation of atrial or ventricular arrhythmia from aortic sinuses of Valsalva has been well documented with low complication rate. Radiofrequency (RF) ablation of anteroseptal pathway is always challenging for the risk of atrioventricular block. Thus cryoablation is widely accepted approach. We present a 27 year-old patient with WPW syndrome and frequent palpitations referred for cryoablation of anteroseptal pathway. Extensive mapping from high anterseptal region and from noncoronary aortic cusp of aorta revealed a sharp pathway potential but several applications of cryomapping were unsuccessful. Finally, the pathway was permanently ablated with RF energy from noncoronary cusp of aorta. The mapping of aortic valve should be performed during difficult anteroseptal pathway ablation and unsuccessful cryomapping dose not preclude successful RF ablation at the same location.

Immunohistochemical detection of galectin-1 in renal biopsy specimens of children and its possible role in proteinuric glomerulopathies

AIMS

Galectin-1 is an endogenous lectin that specifically binds to beta-galactoside structures. It has been associated with developmental mechanisms ranging from differentiation to apoptosis and exerts immunoregulatory functions in autoimmune diseases. The aim was to determine the immunohistochemical expression of galectin-1 in renal biopsy specimens of children with primary idiopathic proteinuric glomerulopathies.

METHODS AND RESULTS

We examined 18 children with minimal change disease (MCD), 30 with diffuse mesangial proliferation (DMP) and 11 with focal segmental glomerulosclerosis (FSGS). An indirect immunohistochemical protocol using a polyclonal antibody directed against galectin-1 was applied. Galectin-1 was detected in renal podocytes in DMP and FSGS cases, while control glomeruli and MCD were negative. Galectin-1 immunoreactivity was found within parietal epithelial cells in patients with FSGS.

CONCLUSIONS

These results suggest a possible role for galectin-1 in the pathogenesis of primary glomerulopathies in children as a kind of podocyte-related self-protective activity and probably involvement of epithelial cells of Bowman's capsule in inflammatory processes. Immunohistochemistry using galectin-1 antibodies may further be helpful in histological distinction between MCD and DMP.

Mutation of the MYH7 gene in a child with hypertrophic cardiomyopathy and Wolff-Parkinson-White syndrome

Familial hypertrophic cardiomyopathy (HCM) displays autosomal dominant inheritance with incomplete penetration of defective genes. Data concerning the familial occurrence of ventricular preexcitation, i.e. Wolff-Parkinson-White (WPW) syndrome, also indicate autosomal dominant inheritance. In the literature, only a gene mutation on chromosome 7q3 has been described in familial HCM coexisting with WPW syndrome to date. The present paper describes the case of a 7-year-old boy with HCM and coexisting WPW syndrome. On his chromosome 14, molecular diagnostics revealed a C 9123 mutation (arginine changed into cysteine in position 453) in exon 14 in a copy of the gene for beta-myosin heavy chain (MYH7). It is the first known case of mutation of the MYH7 gene in a child with both HCM and WPW. Since no linkage between MYH7 mutation and HCM with WPW syndrome has been reported to date, we cannot conclude whether the observed mutation is a common cause for both diseases, or this patient presents an incidental co-occurrence of HCM (caused by MYH7 mutation) and WPW syndrome.

Difficult to treat recurrent stenosis of the aorta

The risk associated with repeated treatment of aortic stenosis is as high as 5% and increases to as much as 25% in complex heart diseases. Among the methods that are commonly accepted and used in the treatment of recurrent aortic stenosis are balloon dilatation and stent implantation. In this study we describe five patients with recurrent stenosis of the aorta treated with stent implantation. The short-term results of such treatment are promising. However, in some cases it is only palliative in character and does not completely resolve the problems arising from congenital heart disease. (Cardiol J 2007; 14: 186-192).

[The antioxidant therapy modulates intracellular lymphokine expression in children on dialysis]

Oxidative stress (SOX) is believed to be responsible for functional disabilities of lymphocytes in end-stage renal disease (ESRD). Therefore, we investigated the effect of antioxidant therapy with vitamin E and N-acetylcysteine (NAC) on SOX and cytokine synthesis in T cells in dialyzed children. Eighteen children (aged 2-20, mean 10.9 yr) treated with hemodialysis (n=5) and peritoneal dialysis (n=13) were enrolled into the study. Vitamin E and NAC were given orally for six months. Throughout the study, intracellular lymphokines [interleukin (IL)-2, interferon (IFN)-gamma, IL-4, IL-6] and SOX in T cells were measured by means of flow cytometry. In dialyzed children, mean fluorescence intensity (MFI), which reflected intracellular SOX, was significantly higher than in the controls in both CD3+ and CD3+CD4+ cells (p<0.05). We also found a cytokine dysregulation with a trend toward a predominant T helper (Th)-1 response compared to the controls. After 6 months of treatment with antioxidants, a significant reduction in MFI was noted compared to baseline values in CD3+ and CD3+CD4- cells (p<0.001). Interestingly, the therapy led to a decrease in IFN-gamma as well as an increase in IL-4 and IL-6 production. In addition, a gradual decline in IFN-gamma/IL-4 ratio in Th cells was noted.

CONCLUSIONS

Vitamin E and NAC used in combination are effective in reducing the intracellular SOX, and besides their action on cellular redox state, they modulate the cytokine profile in children on dialysis.

[New, successful treatment of urinary tract infection caused by Pseudomonas aeruginosa]

Urinary tract infection (UTI) is common in pediatric practice and an important cause of morbidity and mortality in children. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%) and Pseudomonas aeruginosa (9%) The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. Reinfections and relapses of urinary tract infections caused by PA are very frequent. The aim of the study was to evaluate the efficacy of combined clarithromycine and ceftazidime in terms of eradication of PA infection. We analyzed 20 out of 264 children with UTI where PA infection was confirmed with urine culture. Those children were treated for at least 14 days with the protocol used for PA infection in patients with mucoviscidosis. Short-term eradication was achieved in all patients. Long-term study revealed relapse in 25% of children, all with serious congenital malformations. 75% of children were treated with success. No side effects were observed. Conclusion. We conclude that an empirical combination treatment of clarithromycine and ceftazidime is appropriate and effective in children with UTI caused by PA. This therapy was clinically efficacious, well tolerated, and cost effective, and should prevent unnecessary development of antimicrobial resistance.

[Immunohistochemical analysis of podocytopathy with immature glomeruli and glomerulosclerosis in children with nephrotic syndrome]

Idiopathic nephrotic syndrome in children may be complicated by resistance to steroids with constant proteinuria in diffuse mesangial proliferation (DMP) and focal segmental glomerulosclerosis (FSGS). In our observation, sometimes in children with steroid-resistant nephrotic syndrome, the presence of immature renal glomeruli can be detected (hypercellularity and presence of a constant layer of cubical epithelial cells on the surface of glomerular tufts, without sclerosis, resembling M-stage of glomerulo-genesis). The aim of this study was immunohistochemical analysis of the podo-cyte-associated proteins, particularly ezrin, podocalyxin, synaptopodin and nephrin in glomeruli with and without signs of immaturity in children. In DMP with signs of immaturity podo-cytes situated in the central region of the glomerulus were immunohistochemically negative. The positive reaction was observed exclusively in the most superficial continuous 'layer' of podo-cytes. The unfavourable clinical course of nephrotic syndrome with signs of glomerular immaturity may be a consequence of decreased immunohistochemical expression of cytoskeleton-specific proteins.

Congenital heart defect with associated malformations in children

BACKGROUND

Children with multisystem involvement including congenital heart defect (CHD) are a very salient problem. The purpose of this study was to evaluate the incidence of CHD associated with malformations of other systems and to assess the modalities of treatment and perioperative mortality among patients referred to the department of pediatric cardiac surgery.

METHODS

The medical records of 1856 children were reviewed retrospectively from 1997 to 2002 to establish CHD and types of associated malformations. The connections between CHD and other lesions were investigated. Furthermore, the influence of patient and perioperative variables on mortality risk was scrutinized. Univariate and multivariate analyses were used.

RESULTS

Eighty-four children (4.53%) had CHD and associated malformations. The malformations of digestive (35.7%), urinary (22.4%), and nervous (14.3%) systems were the most frequently observed associated defects. No relation was found between CHD and concomitant lesions. The results of multivariate logistic regression showed significant influence of patient age, primary cardiac procedure, and CHD type on mortality (ca 19%) in children with multiorgan lesions.

CONCLUSIONS

The treatment of children with CHD and associated multiple lesions is connected with higher mortality risk. The following factors: younger age, urgency of surgical procedure, and primary surgical procedure had negative impact on patient's outcome. However, these risks in certain cases are inevitable. The cardiac procedure preceding the surgical operation may improve the overall effect of treatment because of circulatory stabilization, provided that the condition of the patient does not preclude any intervention at all.

[Ross operation using "contegra" conduit in a 5 year old girl with severe aortic valve insufficiency in Kawasaki disease coexisting with infective endocarditis--a case report]

A case of a 5-year-old girl with severe dysfunction of aortic valve in Kawasaki disease coexisting with endocarditis, is described. The role of Ross operation in the treatment of this condition is discussed. The 18-months follow-up showed good function of aortic valve and "Contegra" conduit (bovine jugular vein), but long-term follow-up of patients with "Contegra" conduit remains unknown. In conclusion, a Ross operation using "Contegra" conduit in pulmonary position could be effective method in the treatment of dysfunction of aortic valve in Kawasaki disease coexisting with endocarditis in children.

Abnormal Cytokine Synthesis as a Consequence of Increased Intracellular Oxidative Stress in Children Treated with Dialysis

BACKGROUND/AIM

End-stage renal disease (ESRD) induces a clinical state of immunodeficiency with a higher incidence of infections and higher mortality due to infectious complications compared with the normal population. The definite mechanism responsible for the host defense alterations is not well understood. The aim of the study was to investigate intracellularly the relationship between cytokine synthesis and oxidative stress in peripheral blood lymphocytes in children with ESRD.

METHODS

Twenty-one children (age 11.7 +/- 5.8 years) with ESRD treated with hemodialysis (HD; n = 10) and peritoneal dialysis (PD; n = 11) were studied. Nine healthy children of comparable age formed the control group. To determine intracellular oxidative stress we used dihydrorhodamine-123 (DHR), which after oxidation to rhodamine-123 (RHO) emitted a bright fluorescent signal. Intracellular oxidation of DHR in T lymphocytes reflected intracellular oxidative stress. The intracellular synthesis of cytokines (IL-2, IFN-gamma, IL-4, IL-6) was also measured. Both parameters were detected at a single-cell level by flow cytometry. Lymphocyte subsets were evaluated using the monoclonal antibodies conjugated with fluorochromes.

RESULTS

We found that in T lymphocytes the mean fluorescence intensity (MFI), which reflected intracellular oxidative stress, was increased in ESRD patients compared to the controls (CD3+: 34.77 +/- 11.55 vs. 22.55 +/- 4.97, p < 0.01; CD3+CD8+: 34.31 +/- 12.17 vs. 20.77 +/- 4.89, p < 0.01; CD3+CD4+: 36.06 +/- 6.98 vs. 24.44 +/- 7.68, p < 0.001). HD patients showed slightly higher MFI compared to PD patients in CD3+ cells (39.32 +/- 11.70 vs. 30.63 +/- 10.20, NS), in CD3+CD8+ cells (37.90 +/- 14.32 vs. 31.06 +/- 9.34, NS) and in CD3+CD4+ cells (40.10 +/- 2.28 vs. 29.33 +/- 7.06, p < 0.001). The intracellular synthesis of IL-2 was higher in ESRD patients compared to the controls, both in CD3+ cells (31.34 +/- 9.80 vs. 20.49 +/- 15.26%, p < 0.05) and in CD3+CD4+ cells (36.10 +/- 8.69 vs. 24.03 +/- 16.95%, p < 0.05). The intracellular synthesis of IFN-gamma, IL-4 and IL-6 was significantly lower in the ESRD group compared to the controls. Interestingly, in patients treated with HD, negative correlations between the degree of intracellular oxidative stress and intracellular cytokine synthesis in CD3+ lymphocytes were found.

CONCLUSION

Our results show that patients with ESRD, especially those treated with HD, present increased oxidative stress in T lymphocytes, which may lead to decreased cytokine synthesis and abnormal immune response.

Beneficial in vitro effect of N-acetyl-cysteine on oxidative stress and apoptosis

Chronic renal failure (CRF) is usually accompanied by abnormalities of both humoral and cellular immune response. The aim of the study was to investigate the influence of N-acetyl-cysteine (NAC) on intracellular oxidative stress and apoptosis rate of T lymphocytes in children with CRF. Twenty-two children (aged 4-16, mean 7.4) with CRF treated with dialysis were enrolled in the study. Intracellular reactive oxygen species (ROS) production was quantified by mean rhodamine 123 (RHO) fluorescence intensity with flow cytometry. Annexin V FITC was used for identifying apoptotic cells. Mean fluorescence intensity (MFI), which reflected intracellular oxidative stress in T lymphocytes, was increased in patients with CRF compared with the controls (CD3+: 31.58+/-11.58 vs 22.55+/-4.97, p = 0.043; CD3+CD4+: 32.50+/-8.59 vs 27.75+/-12.76, NS; CD3+CD8+: 32.10+/-11.85 vs 20.77+/- 4.89, p =0.012). Apoptotic T lymphocytes occurred more frequently in patients with CRF treated with hemodialysis (HD) (11.36+/-6.96%) than in the controls (6.14%+/-3.36%; p = 0.025). After 24 h incubation with NAC MFI and apoptosis rate decreased significantly in all subpopulations of lymphocytes. NAC, as a strong antioxidant, has a favorable effect on intracellular oxidative stress and apoptosis rate of T lymphocytes in patients with CRF. A decreased apoptosis rate may have positive effect on functional abnormalities of T cells already found in patients with CRF.

[The significance of cardiac symptoms in patients referred to pediatric cardiology outpatient clinics]

OBJECTIVE

To determine the significance of cardiac symptoms in patients referred to paediatric cardiology outpatient clinics.

MATERIAL AND METHODS

All patients above l month of age referred to paediatric cardiac outpatient clinics between 01-Apr-2004 and 31-Dec-2004. Data was collected prospectively in Internet data base. Patients were divided into 3 groups: patients referred by paediatricians to regional paediatric cardiology outpatient clinic (group 1, N=3383), patients referred to Academic Paediatric Cardiac outpatient clinics by paediatricians (group 2, N= 7461) and by cardiologists (group 2a, N=793).

RESULTS

Average age of patients was 6.4 +/- 5.8 years. The most common reasons for referral included cardiac murmur, chest pain, syncope, earlier diagnosed congenital heart disease (CHD). The proportion of patients referred by cardiologists and paediatricians because of murmur was 30% vs 56%, arrhythmia 12.6% vs 8% and CHD 44% vs 8%. The percentage of the significant cardiac pathology in all groups (l/ 2/ 2a) was 38/35/76; in patients with chest pain -- 9/18/0; with syncope -- 56/70/80; with murmur -- 19/21/43; with CHD -- 68/69/93 and with arrhythmia -- 57/80/92.

CONCLUSIONS

l. There were no significant differences between patients referred by paediatricians from regional and academic outpatient cardiology clinics. 2. Isolated cardiac symptoms such as chest pain, cardiac murmur and syncope were caused by significant cardiac pathology only in about 1/5 cases. 3. Cardiac murmur was the most common reason for referral to cardiac outpatient clinic in younger patients, in older group syncope and arrhythmia were more frequent.

Aortoventriculoplasty and left ventricle function: long-term follow-up

OBJECTIVE

Depressed cardiac function after aortoventriculoplasty is well known during the postoperative period. Little data exist concerning the long-term follow-up. The aim of this study is to determine whether septal incision has any permanent effect on the left ventricle function.

METHODS

From 1988 to 2002, 45 patients received aortic mechanical prosthesis. These patients were divided into two groups. Group A consisted of 26 patients 5-18 years old, who underwent simple aortic valve replacement. Group B consisted of 19 patients 4-20 years old, who underwent the Konno procedure. Systolic and diastolic functions of the left ventricle were analyzed using echocardiography. For the systolic function, the following parameters were assessed: pressure gradient between left ventricle and ascending aorta, shortening and ejection fraction of the left ventricle. For the diastolic function, left ventricle-filling parameters were assessed: ratio of early to late filling velocity, deceleration slope of the early filling velocity and left ventricular isovolumetric relaxation time. Furthermore the percentage fraction of the aortic valve index (AOVI%) was calculated and compared between these two groups.

RESULTS

After the surgery in group A, AOVI% dropped from 110+/-21 to 98+/-11%, while in group B it increased from 82+/-16 to 114+/-11%. As a result a higher residual pressure gradient across the aortic valve was noted in group A: 21.26+/-15 as compared to 11.17+/-5 mmHg in group B. A mean pressure above 30 mmHg appeared in group A 2 years after the surgery, while in group B this was obtained after 6 years. As for the diastolic function no significant difference was noted between these two groups. Overall there was one late death in group A, and in group B two early deaths, two reoperations because of excessive drainage and in two patients permanent pacemakers had to be implanted.

CONCLUSIONS

Improvement of the systolic function after the surgery was noted in both groups. In patients with low AOVI%, postsurgical pressure gradient, either residual or recurrent, appeared during the follow-up. As for the septal incision, it may have some transient effects on the left ventricle function in the postoperative period, but no permanent sequelae were observed in the long-term follow-up.

Transcatheter closure of perimembranous ventricular septal defect using an Amplatzer occluder--early results

BACKGROUND

Transcatheter closure of perimembranous ventricular septal defect with the use of an Amplatzer occluder was introduced in 1999, however, clinical experience with this method remains limited.

AIM

To assess short-term safety and efficacy of this technique in children.

METHODS

Since 2001, nine children underwent transcatheter closure of perimembranous ventricular septal defect in the cardiac centre in Bratislava (Slovak Republic) or in our centre. Patients were selected for the procedure based on the results of transesophageal echocardiography (TEE). Transcatheter closure using the Amplatzer occluder was guided by both TEE and angiography. The follow-up duration ranged from 3 to 22 months, mean 11.5 months. Control angiography was performed in order to detect any leakage through the aortic valve. The end-diastolic left ventricular diameter before and after the procedure as well as the function of the aortic, tricuspid and mitral valves were also assessed.

RESULTS

The procedure was effective in all patients. No damage to atrio-ventricular nor aortic valves was observed. Tricuspid regurgitation, present prior to the procedure, markedly decreased following the closure of the defect. The left ventricular end-diastolic diameter significantly (p=0.001) decreased after the procedure.

CONCLUSIONS

(1) Perimembranous ventricular septal defect can be safely and effectively closed using a transcatheter Amplatzer occluder. (2) Appropriate selection for the procedure as well as TEE and angiographic guidance during the procedure enable the avoidance of complications. (3) Tricuspid regurgitation is not an absolute contraindication to perform this procedure.

Aortic regurgitation in adults after surgical repair of tetralogy of Fallot

BACKGROUND

Total surgical repair of tetralogy of Fallot is usually associated with a favourable long-term outcome. However, complications or consequences of the defect such as dilatation of aortic root and aortic regurgitation are present in some patients.

AIM

To assess the prevalence of aortic regurgitation in relation to the timing of surgery and preceding palliative procedures as well as to examine its effects on left ventricular (LV) dimensions in adults after surgical repair of tetralogy of Fallot.

METHODS

The study group consisted of 63 patients in the mean age of 25.6+/-6.5 years who underwent surgery at the mean age of 7.4 years (mean 17.2 years ago). Echocardiographic assessment of the thickness of the inter-ventricular septum, posterior LV wall, end-diastolic LV diameter, left atrial dimension and aortic root diameter was performed. Aortic incompetence was examined using a colour Doppler method.

RESULTS

Aortic incompetence was found in 13 (20%) patients. Only four of them had undergone a palliative procedure prior to the repair of the defect. Patients with aortic regurgitation had significantly greater aortic root dimension (p=0.001), LV diameter (p=0.05) and were significantly older (p=0.005) than patients without aortic incompetence. A significant correlation was found between aortic root diameter and current age (p=0.02). A significant correlation was also observed between LV diameter and time elapsed after surgery (p=0.001), and between left atrial dimension and patients' current age (p=0.02) as well as time from the repair of the defect (p=0.003).

CONCLUSIONS

1. Minor aortic regurgitation and LV dilatation are present in 20% of adults who underwent repair of tetralogy of Fallot. 2. Aortic regurgitation is present in those who have dilated aortic root. 3. Aortic regurgitation is not associated with palliative surgery performed in the past. 4. Aortic regurgitation is more frequent in the elderly but is not associated with patient's age at surgery or time elapsed since repair.

Apoptosis and antioxidant defense in the nephrotic syndrome

Nephrotic syndrome (NS) is accompanied, and probably caused by, abnormalities in T lymphocyte function. The aim of this study was to investigate the antioxidant status of children with NS and its influence on the apoptosis of T cells. Fifty-seven children with NS were studied, aged 4-16 years (mean 7.4 years), 34 with a first episode (group I) and 23 in remission (>6 months) of NS (group II). The control group comprised 26 healthy children matched for age. Annexin V-FITC was used as a sensitive probe for identifying cells undergoing apoptosis. We found that apoptotic T lymphocytes occurred more frequently in patients with a first episode of NS than in children in remission and in the controls. In group I, total antioxidant status (TAS, plasma) was significantly reduced compared with controls (0.77+/-0.14 vs. 1.18+/-0.42 mmol/l, P<0.001). In group I children, glutathione reductase (GR, red blood cells) and glutathione peroxidase (GPX, red blood cells) activity was lower than in controls (GR 8.10+/-2.40 vs.10.55+/-3.81 U/g Hb, P<0.001) (GPX 28.65+/-6.99 vs. 33.84+/-13.11 U/g Hb, P=0.010). TAS levels and GR activity in group II were also lower than in the controls. A negative correlation between GR activity and the apoptosis rate of T lymphocytes was found. We conclude that in patients with NS, reduced antioxidant defense may contribute to an increase in the apoptosis rate of circulating lymphocytes.

Blood pressure, left ventricular mass and function in adult patients after successful repair of coarctation of the aorta

BACKGROUND

In spite of surgical correction, arterial hypertension may persist in a significant proportion of patients with aortic coarctation.

AIM

To asses arterial blood pressure (BP) and left ventricular (LV) mass and function in adult patients who underwent surgical repair of aortic coarctation.

METHODS

The study group consisted of 56 patients (27 females, 29 males, mean age 31.2+/-10 years), who underwent surgery due to aortic coarctation at the mean age of 11.53+/-8 years. The control group consisted of 61 healthy subjects. The following parameters were analysed: BP values, end-diastolic interventricular septum (IVS) and posterior wall (PW) thickness, end-diastolic LV diameter, residual stenosis of descending aorta, LV ejection fraction, LV mass (LVM), LVM index (LVMI) and parameters of diastolic LV function.

RESULTS

Hypertension was diagnosed in 55% of patients, particularly in those who underwent surgery in more advanced age. In 21 patients the residual pressure gradient through the descendent aorta exceeded 20 mmHg; 14 of them had hypertension. Echocardiography showed significantly higher values of PW thickness in patients than in controls, and significantly higher values of PW, IVS, LVM and LVMI in patients with rather than without hypertension. The most pronounced differences in these parameters were noted between controls and patients with hypertension. In patients with residual trans-aortic gradient, all the above mentioned parameters were similar to those obtained in patients without the gradient or controls. Also, both systolic and diastolic LV function were similar in patients and controls, in patients with or without hypertension, and in patients with or without residual aortic gradient. In the whole study group, a positive linear correlation between age at surgery and BP values was found (p=0.01) whereas no such correlation was found between BP and time which elapsed after surgery. There was a significant negative correlation between E/A and age at surgery (p=0.004) and a positive correlation between time from surgery and IVRT (p=0.025). IVRT positively correlated with BP (p=0.024). BP values correlated positively with PW (p=0.024) and IVS (p=0.04). Among patients with hypertension, a significant positive correlation between age at surgery and LVM (p=0.034) as well as LVMI (p=0.013) was noted. Diastolic LV function in the subgroup of patients with hypertension was characterised by a negative correlation between age at surgery and E/A (p=0.001) and a positive correlation between time from surgery, BP values and IVRT (p=0.045 and p=0.024, respectively). In patients without hypertension no significant correlation between the analysed parameters was found.

CONCLUSIONS

1. Hypertension is present in more than half of adult patients after surgical repair of aortic coarctation, is more frequent in patients who underwent surgery at a more advanced age, and in the majority of patients is not associated with the presence of residual trans-aortic gradient. 2. LV thickness, mass and index increase due to hypertension, regardless of the presence of gradient. 3. LV diastolic parameters are similar to those in healthy subjects, however, they become impaired as the time from surgery increases, particularly in patients who underwent repair at an advanced age and who have hypertension.

[Influence of autonomic nervous system on electrolyte abnormalities in children with mitral valve prolapse]

Measurement of the heart rate variability enables to assess the activity of the autonomous nervous system. The aim of the study was to evaluate the possible relationship between clinical status, serum sodium (Na), potassium (K), calcium (Ca), magnesium concentrations and HRV in children with mitral valve prolapse. The study group consisted of 151 children with MVP (age +/- SD: 12.2 +/- 3.1 years). Thirty patients out of the MVP group were symptomatic and 121 were asymptomatic. The total number of 165 healthy children (age +/- SD: 12.3 +/- 3.7 years) were included into the control group. We assessed power spectrum of HRV (low frequency component--LF, high frequency component--HF, and LF/HF ratio) from 5-minute recording during daytime and night. Serum Mg (p < 0.00001) and K (p < 0.03) concentrations were significantly lower in MVP group as compared to healthy children. A marked decrease in Mg concentration was observed in symptomatic children with MVP as compared to asymptomatic patients (p < 0.0001). A significant positive correlation was found between Mg concentration and HF and HF n.u. components (daytime and night) and significant negative correlation was observed between Mg concentration and LF and LF n.u. (daytime and night) parameters and LF/HF ratio (daytime and night). Symptomatic children with MVP had significantly higher LF n.u. and LF/HF ratio and a lower HF n.u. as compared to asymptomatic patients. The autonomic changes in MVP children (reduction in parasympathetic tone with sympathetic predominance) were associated with decreased serum Mg concentration and higher prevalence of clinical symptoms. Mg supplementation seems to be a prudent approach in symptomatic children with MVP.

[Pregnancy and labour in a patient after Fontan operation - a case report]

We present a case a 25-year-old pregnant female who had Fontan surgery performed 20 years ago due to a common ventricle of the left ventricular morphology. She had a history of three miscarriages and one successful pregnancy. This was a fifth pregnancy and she delivered normal healthy child. This is a second patient after Fontan procedure who had two successful deliveries. Clinical aspects of pregnancy in patients after Fontan procedure are described.

Echocardiographic parameters of left ventricular systolic and diastolic function in infants, children and adolescents before and after surgical correction of secundum atrial septal defect

BACKGROUND

Left ventricular (LV) dysfunction has been described in adults with secundum atrial septal defect (ASD II) and heart failure (CHF). This anomaly has been rarely regarded as a cause of CHF in pediatric patients with ASD II.

AIM

To assess LV systolic and diastolic function in patients with ASD II before and after cardiosurgery as well as to establish the prognostic value of these parameters in infants, children and adolescents with ASD II.

METHODS

LV systolic (LVEF) and diastolic function parameters (E/A, DCT, IVRT) were studied using Doppler echocardiography in 104 patients aged between 1-18 years with ASD II before cardiosurgery and 4 years afterwards. These parameters were compared with similar variables in 150 healthy infants, children and adolescents.

RESULTS

Before surgery LVEF was significantly lower only in infants with ASD II and CHF when compared with healthy controls. Relaxation abnormalities of LV diastolic function were observed before surgery in 40.4% of patients, especially in infants and adolescents with CHF. These disturbances were still present in about 20% of patients after surgery, especially in infants. Before and after surgery both LV and RV end-diastolic volumes were normal in about 6-10% of patients with LV diastolic dysfunction.

CONCLUSIONS

In patients with ASD II and CHF diastolic dysfunction of LV is more common than systolic dysfunction. RV volume overload mainly affects LV diastolic function but it is not the only cause of CHF in patients with ASD II, especially in infants and adolescents. After surgery, normalisation of LV diastolic function is not observed in about 20% of patients with ASD II, especially in those who had CHF before operation. Special monitoring of the circulatory system is necessary in patients with ASD II operated in infancy and adolescence.

A prospective study to determine the significance of ventricular late potentials in children with mitral valvar prolapse

We aimed prospectively to determine the incidence of ventricular arrhythmias and ventricular late potentials in children with mitral valvar prolapse, and to assess whether signal-averaged electrocardiography could identify which such children were at high risk of developing ventricular tachycardia. In all, we examined 151 children with mitral valvar prolapse, at an age of 12.2 +/- 3.1 years, and 164 healthy subjects aged 12.3 +/- 3.7 years. All children underwent 24-hour ambulatory Holter monitoring and echocardiography. The children with mitral valvar prolapse were followed prospectively for a mean of 64 months. There was a significantly higher prevalence of ventricular arrhythmias in those with prolapse than in the controls (p < 0.0001). Runs of ventricular tachycardia were observed in 3 children with mitral valvar prolapse compared with one from the control group. Late potentials were more frequently observed in the children with mitral valvar prolapse than in those who were healthy (p < 0.0001), and also in those with prolapse suffering ventricular arrhythmias compared with those without ventricular arrhythmias (p < 0.02). During follow-up, 24 children with prolapsing mitral valves developed non-sustained ventricular tachycardia, giving a frequency of 3.1/100 subject-years. The sensitivity of late potentials was low, at 52%, for the identification of children with mitral valvar prolapse who developed ventricular tachycardia, although the specificity was high at 90%. This gave a positive predictive value of 50%, and a negative predictive value of 91%. We conclude that prolapse of the mitral valve predisposes to the development of ventricular arrhythmias and late potentials in children. An abnormal signal-averaged electrocardiogram is a specific, but not very sensitive, predictor for the development of ventricular tachycardia in such children.

[Electrolyte abnormalities and ventricular arrhythmias in children with mitral valve prolapse]

The aim of this study was to determine plasma concentration of magnesium, potassium, calcium and sodium in children with mitral valve prolapse (MVP) and to establish the relation between electrolyte abnormalities and ventricular arrhythmias (VA). The study group consists of the 113 children with MVP (age +/- SD: 10.7 +/- 4.3 years). The 101 healthy children (age +/- SD: 13.0 +/- 3.2 years) were enrolled into the control group. All patients underwent clinical examination, standard ECG, 24 hr ECG Holter monitoring and echocardiography. Blood samples were taken 3 times in fasting state in separate days. All patients were in sinus rhythm. Cardiac arrhythmias were observed more frequently in children with MVP (53%) than in control group (31%, p < 0.0008). VA were recorded in 39% MVP patients, compared with 13% of the healthy children (p < 0.0001). There were no differences in K, Na and Ca concentrations in children with MVP comparing to control group. Serum Mg concentration was significantly lower in MVP group (0.88 +/- 0.08 mmol/l) comparing to healthy children (0.91 +/- 0.07 mmol/l, p < 0.002). A marked decrease in Mg concentration was recorded in patients with MVP and ventricular arrhythmias compared with those without ventricular arrhythmias (0.83 +/- 0.07 vs 0.90 +/- 0.06 mmol/l, p < 0.0001). This study demonstrates that potentially serious dysrhythmias are common in pediatric patients with MVP. It would appear that ambulatory ECG monitoring should be part of the complete evaluation of children with MVP. Since decreased plasma concentration, magnesium supplementation seems to be a prudent approach in children MVP with frequent ventricular premature beats and in children with ventricular tachycardia.

Potentiation of the antiproliferative effect in vitro of doxorubicin, cisplatin and genistein by new analogues of vitamin D

Numerous vitamin D3 analogues have been synthesised in recent years in order to obtain compounds with a favourable biological and therapeutic (antipsoriatic and/or antitumour) activity. Our results showed that pre-treatment for 72 hours of HL-60 human promyelocytic leukaemia cells with calcitriol or its new analogues significantly potentiated their sensitivity to the antiproliferative effect in vitro of cisplatin, doxorubicin or genistein. Moreover, for all cytotoxic agents tested a synergistic antiproliferative effect was observed. This effect was expressed as a significant decrease of the ID50 (inhibitory dose 50%) values for each cytotoxic agent applied after pretreatment with calcitriol or its analogues of HL-60 cells in comparison with the effect of cytotoxic agent applied alone. The observed in vitro potentiated antiproliferative effect of cytotoxic drugs used in combination with vitamin D or its analogues may raise the question as to whether such an effect could be expected in the in vivo situation.

Intravenous aminophylline increases the degree of saturation of urine with calcium phosphate and struvite

This study was designed to assess the effect of i.v. treatment with aminophylline (AMPH) on the risk of calcium phosphate and struvite stone formation. We administered AMPH in doses of 4 mg/kg body weight in 15-min i.v. infusions to 60 infants with clinical symptoms of obstructive bronchitis with dyspnoea. During 3 hours after infusion we observed a significant increase in urine saturation with brushite, octocalcium phosphate and struvite. This rise in urine saturation may increase the risk of kidney stone formation.

[Dysrhythmias documented by 48-hour electrocardiographic monitoring in children with mitral valve prolapse]

The association of dysrhythmias with mitral valve prolapse (MVP) in pediatric patients was examined by 48-hour ECG monitoring. Fifty unselected children with clinical diagnosis of MVP confirmed by echocardiography were studied. Eight (16%) patients manifested atrial dysrhythmias. Long runs of junctional rhythm with activity were recorded in one patient. Episodes of supraventricular tachycardia were recorded in 4 (8%) children. Seventeen (34%) patients had ventricular dysrhythmias. In 10 (20%) children, ventricular premature complexes (VPCs) were recorded. Four (8%) patients had frequent multifocal VPCs. Ventricular couplets were recorded several times in one patient (2%) and nonsustained ventricular tachycardia was recorded in two (4%) children. Clinical symptoms did not correlate with documented arrythmias. Although the prognostic implications of these findings are uncertain, this study demonstrated that potentially serious dysrhythmias are common in pediatric patients with MVP. It would appear that ambulatory ECG monitoring should be part of the complete evaluation of children with MVP.

[One center's experience with fibrinolytic treatment in children]

Fifteen children treated with fibrinolytic agents are presented. The most frequent indication was thromboembolic disease (TED). Eleven patients received streptokinase, 5-urokinase and 3-tissue plasminogen activator. Concomitant heparin was administered to 9 patients with TED. Total resolution was achieved in 9 children, partial improvement in 5; 1 child died during treatment without any improvement. Bleeding complications were observed in 6 patients, 1 of them died due to haemorrhagic stroke. According to the literature and our own experience, we recommend fibrinolytic agents as the treatment of choice for severe TED also in children.

[Symptomatic cytomegaly in a 6-month old infant]

The aim of our study is to present diagnostic and therapeutic problems in the case of 6-month old infant with cytomegaly infection. We observed typical symptoms of cytomegaly infection (central nervous system and liver damage, coagulopathy, anaemia) as well as electrolyte and serum lipid disturbances and urine densification abnormalities.

[Non-neoplastic tumors of the heart in newborn infants]

Two cases are reported of masses in the cardiac ventricles in newborns with a thrombus, in another case the changes disappeared completely. Despite the diagnosis of congenital heart disease. In one case autopsy examination demonstrated persistent heart disease. The condition of the child improved.