The Ideal Timing of Bedside Surgical Ligation of Patent Ductus Arteriosus in Premature Babies Less Than 30 Gestational Weeks

Objective:

The aim of our study is to determine the relationship between exposure to hemodynamically significant patent ductus arteriosus and morbidities in premature babies, the optimal number of pharmacologic treatment cycles, and ideal ductus ligation timing.

Materials and Methods:

The study was a retrospective single-center study conducted in a 3-year period between July 2017 and June 2020. Premature babies, born ≤30 weeks of gestation and transferred to our unit for bedside ductus ligation, were included in the study. The subjects were divided into 2 groups; Group A consisted of the patients who received ≥3 pharmacologic treatment cycles, and group B consisted of the patients who received ≤2 cycles. The groups were compared according to preoperative and postoperative features. The main outcome of the study was the presence of severe bronchopulmonary dysplasia. The secondary outcomes were specified as the length of stay in the neonatal intensive care unit and the duration of invasive mechanical ventilation (MV).

Results:

The study group consisted of 24 patients. There were 10 patients in group A and 14 patients in group B. The mean gestational week and the mean birthweight were found to be 26,7 ± 2.2 weeks and 928 ± 190 g, respectively. The incidence of severe bronchopulmonary dysplasia was significantly higher in group A (70% vs. 14.3%; P = .019). Post-ligation invasive MV, duration, and length of stay in the intensive care unit were found to be significantly longer in group A. None of the patients had hemodynamic disturbances or complications during and after the operation.

Conclusions:

Bedside surgical ductus ligation is a safe procedure. Prolonging pharmacologic treatment in order to avoid surgery increases the risk of severe bronchopulmonary dysplasia and prolongs hospital stay.

Validation of the Vasoactive-Ventilation-Renal Score for Neonatal Heart Surgery

OBJECTIVES

 We aimed to validate the vasoactive-ventilation-renal (VVR) score and to compare it with other indices as a predictor of outcome in neonates recovering from surgery for critical congenital heart disease. We also sought to determine the optimal time at which the VVR score should be measured.

METHODS

We retrospectively reviewed neonates recovering from cardiac surgery between July 2017 and June 2020. The VVR score was calculated at admission, 24, 48, and 72 hours postoperatively. Max values, defined as the highest of the four scores, were also recorded. The main end result of interest was a composite outcome which included prolonged intensive care unit stay and mortality. Receiver operating characteristic curves were generated, and areas under the curve with 95% confidence intervals were calculated for all time points. Multivariable logistic regression modeling was also performed.

RESULTS

We reviewed 73 neonates and 21 of them showed composite outcomes. The area under the curve value for VVR score as a predictor of composite outcome was greatest at postoperative 72-hour max (AUC= 0.967; 95% confidence interval, (0.927-1). On multivariable regression analysis, the VVR max 72 hours remained a strong independent predictor of prolonged ICU stay and mortality (odds ratio, 1.452; 95% confidence interval, 1.036-2.035).

CONCLUSIONS

We validated the utility of the VVR score in neonatal cardiac surgery for critical congenital heart disease. The VVR follow-up in postoperative 72 hours is superior to other indices and especially the maximum VVR value is a potentially powerful clinical tool to predict ICU stay and mortality.

Ninety-two days of extracorporeal membrane oxygenation support following congenital heart surgery

We report on a case involving a 10-month-old infant who received prolonged ECMO therapy following cardiac surgery for multiple ventricular septal defects (VSD). The patient was successfully weaned from 92 days of ECMO support without any long-term deficits.

Bedside PDA ligation in premature infants less than 28 weeks and 1000 grams

Background

PDA(Patent ductus arteriosus) is a common and clinically important condition which is presented with a number of hemodynamic and respiratory problems such as intraventricular hemorrhage, pulmonary hemorrhage and necrotizing enterocolitis due to increased pulmonary blood flow and stealing from systemic circulation. The incidence of PDA among the infants that were born before the 28th gestational week is as high as 70 %; and spontaneous closure rates in very-low-birth-weight premature neonates(VLBWPN) is around 34 %. The onset, duration, and repeat number of consecutive courses of the prostaglandin synthesis inhibitor medication for PDA closure are still issues of debate. Bed-side PDA closure is a safe surgical procedure in both mature and premature babies. Here we aim to retrospectively present our 26 cases which were less than 28 weeks and 1000 grams that underwent bed-side PDA ligation.

Methods

This retrospective study included 26 VLBWPN with PDA that underwent bed-side ligation between 2012 and 2015. Babies were born before the 28th gestational week (23–27 weeks) and less than 1000 grams (489–970 gr). Of the 26, 15 were female and 11 were male. Indomethacin was administered to all of the cases as the medical closing agent. The medication was stopped due to unwanted effects in 6 cases. All of the patients took medical treatment before surgery.

Results

No surgical mortality occurred during our study. One case of pneumothorax was recorded as late surgical complication. Five of the 26 patients were lost, and the most common cause of mortality was sepsis (in 3 cases). The remaining 21 cases were discharged on days 86–238. The follow-up periods of the patients were 2 moths - 3 years. The most frequent problems encountered after discharge was chronic lung problems.

Conclusions

Bed side PDA ligation surgery in the ICU is a safe method for VLBWPN with clinically significant PDA.

Mid-Term Results of Congenital Supravalvar Mitral Ring Resection

BACKGROUND

Supravalvar mitral ring is a rare congenital anomaly leading to left ventricle inflow obstruction. We present our surgical experience and mid-term results in patients operated for supravalvar mitral ring and associated congenital heart defects.

MATERIALS AND METHODS

A retrospective analysis was performed in order to evaluate the cases surgically treated with the diagnosis of supravalvar mitral ring between 2001 and 2014. Ten patients were identified, seven of whom had accompanying congenital heart defects. Median age at the operation was 4.5 years.

RESULTS

Ventricular septal defects were encountered in half of the cases. Two of the patients had mitral annular hypoplasia, another two had the components of Shone's complex. The mean preoperative gradient across the supravalvar mitral ring decreased from 14.1 ± 4.2 mmHg to 4.6 ± 2.2 mmHg. All patients are alive and remain in a good clinical condition after a mean follow-up of five years.

CONCLUSION

Supravalvar mitral ring is a surgically treatable cause of left ventricular inflow obstruction. Although residual gradients may be encountered in patients with mitral annular hypoplasia, surgical resection of the ring is encouraged.

Inhaled iloprost in preterm infants with severe respiratory distress syndrome and pulmonary hypertension

OBJECTIVE

Many vasodilator drugs, including inhaled iloprost, are used to treat insufficient pulmonary vasodilatation, which is the main issue in pulmonary hypertension in newborns.

STUDY DESIGN

The safety and efficacy of inhaled iloprost for the treatment of pulmonary hypertension were evaluated retrospectively in 15 preterm infants diagnosed with respiratory distress syndrome and pulmonary hypertension.

RESULTS

The infants were unresponsive to surfactant and conventional mechanical ventilation and thus were treated with inhaled iloprost. Oxygenation parameters and hypoxemia improved rapidly after treatment. There was no decline in systemic blood pressure, no need for increased doses of vasopressor, and no side effects during treatment. One patient died of sepsis during treatment.

CONCLUSION

In the treatment of severely sick premature babies with pulmonary hypertension, inhaled iloprost has high tolerability and a low incidence of systemic side effects. Based on the benefits of inhaled iloprost in preterm infants with pulmonary hypertension in this case series, further studies are required to evaluate its efficacy and safety in the preterm population.

Inhaled iloprost in the treatment of pulmonary hypertension in very low birth weight infants: a report of two cases

We treated 2 very low birth weight (VLBW) infants with respiratory distress syndrome suffering from refractory hypoxic respiratory failure complicated with severe pulmonary hypertension with inhaled iloprost. The first infant was an 800 gram male and the second case was a 920 gram female. Echocardiography revealed a right to left shunt through patent duct in the first case; suprasystemic pulmonary arterial pressure was estimated by using tricuspid regurgitation of moderate severity in the second case. Inhaled iloprost was started in those infants when conventional therapies including the administration of exogenous surfactant and high-frequency oscillatory ventilation failed. After the commencement of therapy, the clinical condition of the infants improved dramatically. Pulmonary arterial pressure returned to normal levels within five days. We suggest that inhaled iloprost may be helpful by improving oxygenation and reducing the need for aggressive mechanical ventilation in some cases of severe hypoxaemic respiratory failure in VLBW infants.

Transcatheter device closure of a residual postmyocardial infarction ventricular septal defect

Postmyocardial infarction ventricular septal defect (VSD) carries a high mortality and, even after successful surgery, residual defect is common. A 75-year-old woman was admitted with the diagnosis of hyperacute anterior myocardial infarction. Primary percutaneous intervention was performed by stenting of a totally obstructed segment in the proximal left anterior descending artery. The patient's condition deteriorated on the second postprocedural day with a 3/6 pansystolic murmur at the mesocardium. Echocardiography revealed an apical anteroseptal VSD and moderate pulmonary hypertension. She underwent surgical VSD closure with a Gore-Tex patch and coronary artery bypass grafting to the left anterior descending and circumflex arteries. The patient's condition continued to be unstable due to septicemia and hemodynamically significant residual VSD. After medical management of septicemia, the residual defect was successfully closed using a 10-mm Cardio-O-Fix septal occluder under fluoroscopic and transesophageal echocardiographic guidance. The clinical condition of the patient was then stabilized and there was no significant residual shunt on echocardiography on the third postprocedural day.

Transthoracic echocardiographic guidance during transcatheter closure of atrial septal defects in children and adults

The purpose of this study was to evaluate the safety and efficacy of transcatheter atrial septal defect (ASD) closure guided by transthoracic echocardiography (TTE). Since 2004, ASD closure was performed successfully in total 337 patients. Transthoracic echocardiography guidance was used in 206 patients (61.1%) (group 1). Closure was guided by transesophageal echocardiography under general anesthesia in patients with poor transthoracic acoustic windows, defects with aneurysmatic septum and/or multiple defects in 131 patients (38.9%) (group 2). The median age (9 vs. 16 years, P < 0.001), mean defect diameter (14.9 ± 4 vs. 17.2 ± 5 mm, P < 0.001), ratio of complex atrial septal defect (14 vs. 34%, P = 0.01), the median balloon stretch dimensions (21 vs. 18.7 mm, P = 0.003) and the median device diameters (22 vs. 19 mm, P < 0.001) were significantly greater in group 2 compared to group 1. Both the median procedure time and the median fluoroscopy time was significantly shorter in group 1 (60 vs. 75; and 13 vs. 16.5 min; P < 0.0001 and P < 0.0001, respectively). The incidence of residual shunt did not differ significantly in two groups during follow up. Transthoracic echocardiography guidance during transcatheter ASD closure is safe and effective in children and in many adults. Even complex ASDs could be closed with TTE in patients with good acoustic windows. Performing the procedure under TTE guidance significantly reduces procedure time and also provides increased patient's comfort.

Atrial septal stenting to increase interatrial shunting in cyanotic congenital heart diseases: a report of two cases

Aiming to increase mixing at the atrial level, atrial septal stenting was performed in two pediatric cases with cyanotic congenital cardiac diseases. The first case was a 3-month-old male infant with transposition of the great arteries. The second case was an 18-month-old male infant with increased central venous pressure due to postoperative right ventricular outflow tract obstruction. Premounted bare stents of 8 mm in diameter were used in both cases. The length of the stent was 20 mm in the first case and 30 mm in the latter. The procedure was accomplished without any complications. In the first case, oxygen saturation increased approximately 20-25% with no significant interatrial gradient. In the latter, central venous pressure decreased from 16 to 8 mmHg immediately after the procedure. The patient was weaned from the ventilator on the second day and discharged from intensive care unit on the fifth day. Follow-up echocardiograms of both patients showed patent stents with good position relative to the atrial septum. Stenting of the atrial septum seems to be a safe and effective method to create a reliable, nonrestrictive interatrial communication.

Early Transient Neonatal Cyanosis Related to Interatrial Right-to-Left Shunting at an Altitude of 1890 Meters: A Report of Five Cases

BACKGROUND

We report five term neonates born at an altitude of 1890 meters with transient early neonatal cyanosis due to right-to-left shunting at atrial level through patent foramen ovale.

CASE PRESENTATION

The five neonates with no clinical sign or symptom other than marked cyanosis were examined in two neonatal units of Erzurum city. Hematologic and radiologic examinations were normal. Partial oxygen pressure (PO(2)) in the arterial blood samples was lower than 45 mmHg in all of the patients, and did not increase more than 15 mmHg in any of the patients after inhalation of 100% oxygen. Echocardiography revealed normal intracardiac structure. The right-to-left interatrial shunt at diastole was detected through a patent foramen ovale in all of these infants. By only observation with no treatment, diastolic right-to-left shunt disappeared in 40.15±9.52 hours. Oxygen saturation was increased from 69.80±9.55 percent to 90.40±8.80 percent. The patients were discharged from the hospital at 5.6±0.4 days of life. Follow up for 6 months revealed no clinical problem in any of the cases.

CONCLUSION

Transient cyanosis can be seen in the very early neonatal period because of interatrial right-to-left shunting in some healthy term neonates born at an altitude of 1890 meters. Decreased right atrial compliance due to relative hypoxia at that altitude can be speculated to be the causative mechanism.

[Our medium-term results with aortic balloon valvuloplasty and factors affecting development of aortic regurgitation]

OBJECTIVE

The objective of this study was to assess medium-term results of aortic balloon valvuloplasty (ABV) in congenital aortic stenosis and to determine factors affecting development of aortic regurgitation (AR).

METHODS

Between September 2003 and January 2010, 114 ABV procedures performed on 97 patients analyzed retrospectively. Patients were evaluated in terms of transvalvular gradients before and after procedure, development of new aortic insufficiency or increase in the current insufficiency and factors affecting the procedural success and development of aortic insufficiency. In addition, follow up results were also evaluated in terms of restenosis and increase or decrease of aortic regurgitation. Student's t-test, ANOVA for repeated measurements, linear discriminant and Kaplan-Meier survival analyses were used for statistical analysis.

RESULTS

The mean age was 6.63±6.33 year (2 days-21 years). Mean follow-up was 32.6±25.1 months (1 to 75 months). Thirty-seven patients were infant (<1 year) and 18 of them were newborn. The peak systolic pressure gradient decreased from 77.2±24.9 mmHg to 28.5±12.9 mmHg (p=0.0001). Eighty-two procedures were optimal, 29 suboptimal and 3 were unsuccessful. AR developed in totally 53 patients, 16 of them were significant degree. Balloon /annulus ratio and the percentage of reduction in gradient was meaningfully higher in patients with significant aortic regurgitation (p=0.02 and p=0.03, respectively). Infants show more significant AR (9/37, 24%) in comparison with bigger patients (7/77, 9%) (p=0.02). Four patients died after procedure at intensive care unit, three of them were newborn.

CONCLUSION

ABV is safe and effective palliative method for the treatment of congenital aortic stenosis. AR, which was the most common complication, incidence was increased in infancy and was related with high balloon/annulus ratio and high reduction in gradient.

[Arterial tortuosity syndrome in two cases]

Arterial tortuosity syndrome (ATS) is a rare autosomal recessive connective tissue disease characterized by elongation, tortuosity, aneurysmatic formation, and stenotic lesions in large and medium-size arteries. We present two cases of ATS diagnosed during cardiac examination for murmurs. The first was an 11-year-old boy who had an atypical facial appearance and hyperelasticity. He had a prior operation for inguinal hernia. Echocardiography showed aneurysmatic dilatation in the main pulmonary artery and peripheral stenotic lesions. Angiography and computed tomography angiography confirmed aneurysmatic formation in the main pulmonary artery and multiple stenotic lesions in peripheral arteries and showed elongation and tortuosity of the major branches of the aorta. Surgical reconstruction of the pulmonary arterial system was performed. The second was a 3-month-old girl with an atypical facial appearance, hyperelasticity, and marked hypotonia. The aortic arch could not be visualized during echocardiography. Angiographic examination showed mild bilateral stenosis of distal pulmonary arteries, elongation and tortuosity of the aortic arch and its main branches.

Anomalous origin of one pulmonary artery branch from the ascending aorta: experience of our center

OBJECTIVES

Anomalous origin of one pulmonary artery branch from the aorta in the presence of separate aortic and pulmonary valves is a rare but important entity necessitating early diagnosis and surgery to prevent irreversible vascular pulmonary disease. We evaluated our experience with seven infants having this anomaly.

STUDY DESIGN

Between December 2003 and 2009, a total of seven infants (2 girls, 5 boys, age range 4 days to 84 days) were diagnosed as having anomalous origin of one pulmonary artery branch from the aorta. Clinical records were reviewed for clinical features, operative procedures, and postoperative follow-up.

RESULTS

Common symptoms were dyspnea, tachypnea, and poor feeding. All the cases were diagnosed by echocardiography. The right pulmonary artery in six cases and the left pulmonary artery in one case originated from the ascending aorta. In addition, three patients had patent ductus arteriosus (PDA), five patients had patent foramen ovale, and one patient had interruption of the aortic arch and aortopulmonary window. All patients underwent surgical re-implantation of the anomalous pulmonary artery branch to the pulmonary trunk. Associated surgical procedures included PDA ligation in three patients, and total repair of interrupted aortic arch and aortopulmonary window in one patient. There were no in-hospital deaths. Two patients had prolonged intubation (10 and 16 days). All patients were discharged in good clinical condition. During a follow-up period ranging from two months to six years, only one patient developed stenosis at the site of anastomosis.

CONCLUSION

Prompt diagnosis at infancy, improved surgical technique, and good patient care decrease mortality and morbidity associated with anomalous origin of the pulmonary artery from the aorta.

The effect of low-carbohydrate diet on left ventricular diastolic function in obese children

BACKGROUND

This study was conducted to evaluate left ventricle (LV) functions using conventional and tissue Doppler imaging in childhood obesity and to identify the effects of diet on LV diastolic functions.

METHODS

Conventional and tissue Doppler echocardiographic measurements were compared in 34 obese children and 24 age- and gender-matched lean controls. Fasting plasma glucose, insulin and homeostatic model assessment of insulin resistance levels were also obtained. Thirty-one of the obese children were subjected to a low-carbohydrate diet and their follow-up measurements were obtained after 6 months.

RESULTS

Left atrial diameter, LV mass and LV mass index were higher in obese children than in lean controls. Lateral mitral myocardial early diastolic (E(m)) and peak E(m)/myocardial late diastolic (A(m)) were lower, and mitral E/E(m) and lateral mitral myocardial isovolumetric relaxation time were higher in obese subjects than in lean controls. Insulin and homeostatic model assessment of insulin resistance levels were higher in obese patients and decreased significantly after diet. After diet therapy, lateral mitral E(m) and peak E(m)/A(m), were increased, mitral E/E(m) and myocardial isovolumetric relaxation time were decreased.

CONCLUSIONS

Obesity predisposes children to increased preload reserve, left ventricular subclinical diastolic dysfunction and deterioration in diastolic filling. Weight reduction with a low-carbohydrate diet seems to be associated with significant improvement in LV diastolic function and a decrease in diastolic filling, as well as causing reversal in insulin resistance seen in obese children.

[Coexistence of partial anomalous pulmonary venous drainage and pulmonary atresia with ventricular septal defect: a report of two cases]

Coexistence of partial anomalous pulmonary venous drainage (PVD) and pulmonary atresia with ventricular septal defect (PA-VSD) is very rare with the exception of heterotaxy syndromes. We presented two cases of PA-VSD in which partial anomalous PVD was detected during pulmonary artery angiography. One was a six-month-old girl who underwent cardiac catheterization to evaluate the chance of unifocalization. There were true pulmonary arteries and three major aortopulmonary collaterals. It was noted that the right upper pulmonary vein was in direct continuity with the right atrium. The second case was a 12-year-old girl who was previously diagnosed as having PA-VSD and absence of true pulmonary arteries, for which she had undergone two subsequent aortopulmonary shunt operations four years before. During cardiac catheterization, confluent but hypoplastic true pulmonary arteries and multiple minor aortopulmonary collaterals were detected. The right and left upper pulmonary veins were draining to the right atrium. It should be known that, albeit very rare, partial anomalous PVD may be present in PA-VSD cases, requiring careful evaluation of pulmonary venous drainage during echocardiographic and angiographic studies.

Cardiac functions in children with coeliac disease during follow-up: insights from tissue Doppler imaging

BACKGROUND

The identification of a coeliac disease in patients with idiopathic dilated cardiomyopathy raises critical questions on the relationship between the two entities. But cardiac functions have not been studied in patients with coeliac disease. The present study was undertaken to assess cardiac functions by Tissue Doppler Echocardiography in patient with coeliac disease.

METHODS

We studied 45 clinically stable patients; twenty-five patients with positive serum IgA Antiendomysial Antibody levels (Group 1), twenty patients with negative serum IgA Antiendomysial Antibody levels (Group 2) at the time of echocardiographic study. Control group consisted of 30 healthy children free of any disease.

RESULTS

Myocardial systolic wave velocity of the mitral annulus was significantly lower (p<0.001), myocardial precontraction and contraction time were slightly longer in Group 2 when compared control group (p=0.015, p=0.044, respectively). There was a negative correlation between the serum IgA Antiendomysial Antibody levels titers and myocardial systolic wave levels of all patients included in the study (r = -0.633; p<0.001). A myocardial systolic wave velocity of <8.9 cm/s had a 92% sensitivity and 80% specificity in predicting serum IgA Antiendomysial Antibody levels positive patients.

CONCLUSIONS

We detected subclinical systolic dysfunction of the left ventricle in children with coeliac disease in whom serum IgA Antiendomysial Antibody reactivity is prominent. Tissue Doppler echocardiography provides a quantifiable indicator useful for cardiac monitoring of disease during follow up.

Tissue Doppler echocardiographic assessment of cardiac function in children with bronchial asthma

BACKGROUND

The aim of the present study was to evaluate the role of tissue Doppler echocardiography in assessment of ventricular function in pediatric patients with bronchial asthma (BA).

PATIENTS AND METHODS

Fifty-one pediatric patients with BA and 30 age- and sex-matched healthy subjects were studied. BA patients were divided into two groups: mild BA (n = 33) and moderate to severe BA (n = 18). All subjects were examined on conventional and tissue Doppler echocardiography, and 44 patients had pulmonary function tests on spirometry within 1 week of echocardiographic examination.

RESULTS

Conventional echocardiographic parameters were all similar in mild asthmatic patients and control subjects. Tricuspid E velocity, E/A ratio and isovolumetric relaxation time (IVRT) in moderate and severe cases differed significantly from mild cases and control subjects. E', A', E'/A' ratio and IVRT of the lateral tricuspid annulus, and IVRT of the medial and lateral mitral annuli were different between mild cases and control subjects. E' velocity and IVRT of the lateral tricuspid annulus and IVRT of the medial and lateral mitral annuli were also different between mild cases and moderate to severe cases. Pulmonary function tests correlated well with E', E'/A' and IVRT of lateral tricuspid annulus.

CONCLUSION

Patients with BA have subclinical right ventricular diastolic dysfunction even in the early stages. The severity of the functional impairment is parallel with the severity of the disease. Tissue Doppler echocardiography has a greater predictive value than conventional imaging, and is useful for evaluating ventricular function in patients with BA.

Stent implantation into the patent ductus arteriosus in cyanotic congenital heart disease with duct-dependent or diminished pulmonary circulation

We assessed the efficacy and safety of stent implantation into the ductus arteriosus in infants with cyanotic heart disease. Ten patients with duct-dependent or diminished pulmonary circulation underwent cardiac catheterization with the aim of stent implantation. Coronary stents of 3.5-4 mm in diameter were used and successfully implanted in eight. All patients in whom stent implantation was successful had adequate relief of their cyanosis and were discharged home. During a mean follow-up of 9.3 months (median 10 months), one patient had evidence of restenosis of the stent at five months. Re-dilatation of the stenosed stent was attempted but was unsuccessful and a modified left Blalock-Taussig shunt was placed surgically. Stent implantation of ductus arteriosus in neonates and infants with a duct-dependent pulmonary circulation is an effective and safe palliative procedure. It may be an alternative to surgical systemic-pulmonary artery shunt in a select group of patients.

Successful transcatheter balloon dilatation of coarctation of aorta and coil occlusion of patent ductus arteriosus in a single catheterization procedure

Simultaneous transcatheter coil occlusion of patent ductus arteriosus and balloon angioplasty of coarctation of aorta is avoided since intimal tearing after angioplasty is believed to increase the risk for dissection of the aorta during catheter manipulation. We report a 14-month-old boy, with weight of 7.6 kg, with aortic coarctation and patent ductus arteriosus with a large left-to-right shunt who underwent successful simultaneous balloon angioplasty of native coarctation and coil embolization of the patent ductus arteriosus. Coarctation gradient decreased from 30 to 4 mmHg after balloon angioplasty and complete occlusion of the ductus arteriosus was achieved without any complication.

Evaluation of cardiac function by tissue Doppler imaging in children with chronic hepatitis

OBJECTIVES

Pathoanatomic changes in cirrhosis result in impaired ventricular filling and diastolic dysfunction and were named as cirrhotic cardiomyopathy. However, cardiac functions have not been studied in patients with chronic hepatitis. We hypothesized that such patients might have subclinical ventricular dysfunction, detectable by tissue Doppler echocardiography and related to the severity of hepatic inflammation and fibrosis.

METHODS

We studied 63 clinically stable patients, 27 patients with mild chronic hepatitis (group 1), 22 patients with moderate chronic hepatitis (group 2) and 14 patients with severe chronic hepatitis (group 3) according to the scoring system of Knodell, and 36 age-matched healthy subjects.

RESULTS

Patients with severe chronic hepatitis had impaired right ventricular diastolic function. The early diastolic velocity of the tricuspid valve annulus was lower in patients from group 3 than in healthy subjects (P < 0.001). Patients in group 3 had a greater isovolumic relaxation time (P < 0.001), indicating right ventricular diastolic dysfunction. Comparing group 3 with the healthy subjects, the ratio of peak early myocardial tissue velocity and peak late (or atrial) myocardial tissue velocity was significantly decreased (P < 0.001), at 1.4 (0.7) and 1.9 (0.7), respectively. There was also a slightly lower peak early myocardial tissue velocity and peak late (or atrial) myocardial tissue velocity ratio and a slightly longer isovolumic relaxation time in patients from group 2 than in healthy subjects (P < 0.05).

CONCLUSIONS

We detected subclinical dysfunction of the right ventricle in children with chronic hepatitis in whom hepatic inflammation and fibrosis is prominent. Tissue Doppler echocardiography provides a quantifiable indicator useful for detection and monitoring of disease progression.

QT dispersion in acute rheumatic fever

BACKGROUND

Disturbances of conduction are well known in the setting of acute rheumatic fever. The aim of this study is to investigate the QT dispersion as seen in the surface electrocardiogram of children with acute rheumatic fever.

METHODS

QT dispersion was quantitatively evaluated in 88 children with acute rheumatic fever. Patients were divided into two groups based on the absence or presence of carditis. As a control group, we studied 36 healthy children free of any disease, and matched for age with both groups. Repeat echocardiographic examinations were routinely scheduled in all patients at 3 months after the initial attack to study the evolution of valvar lesions.

RESULTS

The mean QT dispersion was significantly higher in children with rheumatic carditis. But there was no statistical difference between children without carditis and normal children. Among the children with carditis, the mean dispersion was higher in those with significant valvar regurgitation. Dispersion of greater than 55 milliseconds had a sensitivity of 85%, and specificity of 70%, in predicting rheumatic carditis, while a value of 65 milliseconds or greater had sensitivity of 81% specificity of 85% in predicting severe valvar lesions in acute rheumatic carditis. At follow-up examination, a clear reduction on the QT dispersion was the main finding, reflecting an electrophysiological improvement.

CONCLUSIONS

These observations suggest that QT dispersion is increased in association with cardiac involvement in children with acute rheumatic fever.

Patient with the mesomelic dysplasia, Nievergelt syndrome, and cerebellovermian agenesis and cataracts

We describe a 33-day-old boy who had short and thick tibiae, symmetrical oligosyndactyly of the hands, and distinctive face. The patient was considered as a case of Nievergelt syndrome, a rare form of mesomelic dysplasia. Besides the characteristic mesomelic limb anomalies of Nievergelt syndrome, this patient exhibited two additional features: agenesis of the cerebellar vermis and cataracts, both of which have not been previously reported.

Effect of iron therapy on the whole blood platelet aggregation in infants with iron deficiency anemia

This study was performed to investigate the platelet aggregation alterations in whole blood samples of infants with iron deficiency anemia. Platelet aggregation induced by various concentrations of adenosine diphosphate (ADP) and collagen was studied with impedance aggregometry in 25 patients before and after oral iron therapy and in 12 children of the control group. The posttreatment mean maximum aggregation values were significantly higher (p<0.01) and the posttreatment mean aggregation times were significantly lower (p<0.01) in the study group at all concentrations of ADP and collagen. The aggregation time and maximum aggregation values revealed no significant difference except for the maximum aggregation value at 5 microM ADP (p<0.05) between the study group after therapy and the control group. The differences between the pretreatment and posttreatment mean platelet counts and mean platelet volume values in the study group were statistically significant (p<0.01), whereas those values in the study group after therapy and in the control group were not significantly different. We conclude that iron deficiency anemia in infants, even without clinically meaningful platelet abnormality, may cause dysfunction of the ex vivo whole blood platelet aggregation, and can be reversed by iron therapy. Further studies should be carried out at the enzymatic level to determine whether this platelet aggregation dysfunction in iron deficiency anemia is due to a deficiency in the activation of iron-containing enzymes.

Detection of early anthracycline-induced cardiotoxicity in childhood cancer with dobutamine stress echocardiography

Asymptomatic long-term survivors of childhood cancer treated with anthracyclines may have latent cardiac dysfunction which is undetected by commonly used echocardiographic methods. A more sensitive echocardiographic screening test, dobutamine stress echocardiography, was performed on 22 patients (mean age 9.10 +/- 3.79 years) treated with 75 to 450 mg/m2 of anthracyclines (mean 210.45 +/- 127.34) and results were compared with 22 healthy age-matched control subjects. Echocardiographic Doppler studies were performed after each dobutamine infusion of 0.5, 2.5, 5 and 10 micrograms/kg/min. Although left ventricular mass was decreased and end-systolic walls stress increased in the patient group when compared with the control subjects (p < 0.01 and p < 0.05, respectively), no differences were found between shortening fraction and ejection force in control subjects and patients, at rest and during each dobutamine infusion. A decreased mitral E/A ratio (ratio of early-to-late peak filling velocity) was demonstrated in anthracycline-treated patients only during dobutamine infusion (p < 0.01). Our data showed left ventricular diastolic dysfunction during intropic stimulation with dobutamine, and suggest that dobutamine stress echocardiography is a useful technique for evaluating the cardiac status of anthracycline-treated patients on a long-term basis.